A Multicenter, Open-label Extension Study to Evaluate the Long-term Safety and Clinical Activity of Subcutaneously Administered ALN-AS1 in Patients With Acute Intermittent Porphyria Who Have Completed a Previous Clinical Study With ALN-AS1
Phase: PHASE1
Conditions: Acute Intermittent Porphyria
Sponsor: Alnylam Pharmaceuticals

Clinical Study Protocol ALN-AS1-002 
givosiran (ALN-AS1) 
Amendment 8, 29 March 2021 
Alnylam Pharmaceuticals 
Confidential 
1 
CLINICAL STUDY PROTOCOL 
ALN-AS1-002 
Protocol Title: 
A Multicenter, Open-label Extension Study to Evaluate the Long-term 
Safety and Clinical Activity of Subcutaneously Administered 
ALN-AS1 in Patients with Acute Intermittent Porphyria who have 
Completed a Previous Clinical Study with ALN-AS1 
Investigational Drug: 
ALN-AS1 (givosiran) 
EudraCT Number: 
2016-002638-54 
IND Number: 
126094 
Protocol Date: 
Original Protocol 19 July 2016 
Protocol Amendment 0.1 (Sweden) 20 September 2016 
Protocol Amendment 1 10 November 2016 
Protocol Amendment 2 01 December 2016 
Protocol Amendment 3 03 February 2017 
Protocol Amendment 4 02 August 2017 
Protocol Amendment 5 03 May 2018  
Protocol Amendment 6 28 May 2019 
Protocol Amendment 7 29 April 2020 
Protocol Amendment 8 29 March 2021 
Sponsor: 
Alnylam Pharmaceuticals, Inc. 
300 Third Street 
Cambridge, MA  02142 USA 
Telephone:  
 
Sponsor Contact:  
 
The concepts and information contained in this document or generated during the study are considered 
proprietary and may not be disclosed in whole or in part without expressed written authorization of 
Alnylam Pharmaceuticals, Inc. 
PPD
PPD

Clinical Stujdy Protocol ALN-ASl-002 
Amendmen 8, 29 March 2021 
SPONSOR PROTOCOL APPROVAL 
Date 
Alnylam Ph rmaceuticals 
Confidential 
givosiran (ALN-ASl) 
2 
PPD

Clinical Study Protocol ALN-AS1-002 
givosiran (ALN-AS1) 
Amendment 8, 29 March 2021 
Alnylam Pharmaceuticals 
Confidential 
3 
 
 
INVESTIGATOR’S AGREEMENT 
 
I have read the ALN-AS1-002 protocol and agree to conduct the study as outlined.  I agree to 
maintain the confidentiality of all information received or developed in connection with this 
protocol. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Printed Name of Investigator 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signature of Investigator 
 
 
 
 
 
 
 
 
Date 

Clinical Study Protocol ALN-AS1-002 
givosiran (ALN-AS1) 
Amendment 8, 29 March 2021 
Alnylam Pharmaceuticals 
Confidential 
4 
 
 
PROTOCOL SYNOPSIS 
Protocol Title 
A Multicenter, Open-label Extension Study to Evaluate the Long-term Safety and Clinical Activity of 
Subcutaneously Administered ALN-AS1 in Patients with Acute Intermittent Porphyria who have 
Completed a Previous Clinical Study with ALN-AS1 
Product Name 
ALN-AS1 (givosiran) 
Indication 
Patients with acute intermittent porphyria (AIP) who experience recurrent porphyria attacks 
Phase 
1/2 
Study center(s)   
The study will be conducted at up to 8 clinical study centers worldwide. 
Objectives 
Primary 
• 
Evaluate the long-term safety and tolerability of ALN-AS1 in patients with AIP 
Secondary 
• 
Assess the pharmacodynamic (PD) effect of ALN-AS1 over time 
• 
Assess the clinical activity of ALN-AS1 over time 
Exploratory 
• 
Characterize the pharmacokinetic (PK) profile of ALN-AS1 and incidence of antidrug antibodies 
(ADA) over time 
• 
Assess changes in health-related quality of life (QOL) 
• 
Characterize analytes related to targeting the heme biosynthesis pathway 
Endpoints 
Primary 
• 
Patient incidence of adverse events (AEs) 
Secondary 
• 
Change in urine delta-aminolevulinic acid (ALA) and porphobilinogen (PBG) levels 
• 
Frequency and characteristics of porphyria attacks 
• 
Change in hemin administration 
Exploratory 
• 
Change in circulating 5-aminolevulinic acid synthase 1 (ALAS1) mRNA levels 
• 
Concentrations of ALN-AS1 and ADA 
• 
Duration and treatment of porphyria attacks 
• 
Number and duration of visits to a health care facility for acute porphyria care 
• 
EQ-5D-5L questionnaire scores 
• 
Pain assessment and narcotic use as recorded in a patient diary 

Clinical Study Protocol ALN-AS1-002 
givosiran (ALN-AS1) 
Amendment 8, 29 March 2021 
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• Exploratory biomarkers related to the target pathway, such as urine porphyrins, vitamin D binding 
protein 
Study Design 
This is a multicenter, open-label extension study to evaluate the long-term safety and clinical activity 
of ALN-AS1 in patients with AIP who completed study ALN-AS1-001. 
The last assessments performed, determining previous study (ALN-AS1-001) completion, will serve as 
the Screening/Baseline assessments in this study.  If more than 60 days have elapsed since the last 
assessment, safety assessments will be repeated before administration of ALN-AS1.  It is anticipated 
that patients will begin ALN-AS1 administration in this study within 6 months after the last dose of 
study drug in the previous study.  Eligibility will be confirmed before administration of the first dose of 
ALN-AS1 (Day 1).  Patients will undergo assessments at the clinical study center every month for the 
first 3 months.  Then, through Month 6, and according to the dosing regimen selected, assessments will 
take place at the clinical study center or via a phone contact (for an every month dosing regimen, visits 
will be every month; for an every 3 months dosing regimen, visits will be every 3 months).  After a 
patient has completed 12 months of ALN-AS1 administration in this study (6 months in an every 
month dosing regimen), and where applicable country and local regulations and infrastructure allow, 
study procedures, including ALN-AS1 administration, may take place at the patient’s home by a 
healthcare professional.  If the patient is unable to come to the study site, and a visit by a home 
healthcare professional is not possible due to circumstances related to the COVID-19 pandemic, ALN-
AS1 may be administered by the patient or the caregiver under the oversight of the Investigator, and 
following consultation with the medical monitor, as allowed by applicable country and local 
regulations.  Study procedures may occur at the patient’s home at the discretion of the Investigator, 
based on safety and tolerability; however, patients are required to complete at least 1 visit at the clinical 
study center every 3 months for the first year, and thereafter every 6 months through the end of the 
treatment period.  Additional visits to collect clinical laboratory samples may occur at home at any 
point during the treatment period, within 14 days prior to scheduled dose administration.  Patients will 
return to the clinical study center for a posttreatment follow-up visit after administration of the last 
dose of ALN-AS1.  An ALA/PBG Monitoring/EOS visit will be conducted either at the clinical study 
center or via phone contact, unless treatment continues with ALN-AS1. 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, 
and narcotic use.  Patients will also be provided with laboratory sample collection kits and instructions 
for collecting and sending urine samples to the clinical study center. 
Patients may receive ALN-AS1 as long as they do not fulfill any of the study discontinuation criteria or 
until ALN-AS1 is commercially available in the patient’s territory or the ALN-AS1 development 
program is discontinued (whichever comes first). 
A Safety Review Committee (SRC) will review safety and tolerability data collected during the study 
with the primary purpose of protecting the safety of patients participating in the study. 
Number of Planned Patients 
Up to 24 patients are planned for enrollment in this study (including optional cohorts in 
ALN-AS1-001). 
Diagnosis and Main Eligibility Criteria 
Patients with AIP, who have completed Part C of study ALN-AS1-001, will be eligible for screening in 
this study.  Eligible patients will not be on a scheduled regimen of hemin to prevent porphyria attacks 
at Screening.  Patients with alanine transaminase ≥2.0× upper limit of normal, total bilirubin ≥2 mg/dL 
(unless bilirubin elevation is due to Gilbert’s syndrome), or estimated glomerular filtration rate ≤30 
mL/min/1.73 m2 (using the Modification of Diet in Renal Disease formula) at Screening are not 
eligible for this study. 

Clinical Study Protocol ALN-AS1-002 
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Investigational Product, Dose, and Mode of Administration 
ALN-AS1 Solution for Injection (subcutaneous use [SC]) is comprised of a synthetic, small interfering 
RNA targeting ALAS1 and bearing a triantennary N-acetyl galactosamine ligand conjugated to the 
sense strand, formulated in phosphate buffer. 
The study starting dose and regimen of ALN-AS1 is 5.0 mg/kg as an SC injection administered every 
3 months.  Based on emerging clinical data, the SRC may approve changes to the dosing regimen, 
including decreases in the dose level and changes in the dosing frequency.  However any dose and 
dosing regimen will not exceed a previously explored dose level or frequency that was determined to 
be safe and well-tolerated in study ALN-AS1-001, SRC, Health Authority and Ethics Committee 
approval must be sought prior to dose escalation above 5.0 mg/kg in accordance with local Regulatory 
requirements.  
Reference Therapy, Dose, and Mode of Administration 
Not applicable 
Duration of Treatment and Study 
The duration of treatment is up to 48 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 56 months. 
Statistical Methods 
Statistical analyses will be primarily descriptive.  Incidence of AEs will be summarized by maximum 
severity and relationship to ALN-AS1.  Incidence of and serious adverse events (SAEs) and AEs 
leading to discontinuation will also be tabulated.  By-patient listings will be provided for deaths, SAEs, 
and events leading to discontinuation.  
Laboratory shift tables from baseline to worst values will be presented.  Abnormal physical 
examination findings and electrocardiogram data will be presented in by-patient listings.  Descriptive 
statistics will be provided for electrocardiogram interval data and presented as both actual values and 
changes from baseline relative to each on study evaluation and to the last evaluation on-study. 
Clinical activity of ALN-AS1 will be summarized primarily by descriptive statistics.  The clinical 
activity of ALN-AS1 will be evaluated by the frequency and characteristics of porphyria attacks 
including duration, treatment, and severity of porphyria attacks and number and duration of visits to a 
health care setting for acute porphyria care.  Patient diary recordings, including BPI-SF questionnaire 
scores, will also be summarized.   
PD analysis will include the evaluation of change in ALA, PBG, and ALAS mRNA levels.  Descriptive 
statistics (eg, mean and standard error of the mean) for observed levels of PD parameters and the 
relative change from baseline will be presented for each of the postdose follow-up time points. 
The PK concentration of ALN-AS1 will be determined.  Antidrug antibody results will be tabulated 
overall and by previous treatment in the previous study (ALN-AS1-001).  A by-patient listing will also 
be provided. 
Additional exploratory analyses may be conducted on analytes related to targeting the heme 
biosynthesis pathway.  Quality of life scores will also be summarized. 

Clinical Study Protocol ALN-AS1-002 
givosiran (ALN-AS1) 
Amendment 8, 29 March 2021 
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 Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8 
M9 
M10/ 
M11 
M12 
M13/ 
M14 
M15b 
M16/ 
M17 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History/Disease 
Historyc 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/ 
Exclusion Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examinationd 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
 
 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
Vital Signsf 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Triplicate 12-Lead ECGg 
X 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Clinical Laboratory 
Assessmenth 
X 
Xa 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Study Drug Administrationj 
 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl 
 
X 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 

Clinical Study Protocol ALN-AS1-002 
givosiran (ALN-AS1) 
Amendment 8, 29 March 2021 
Alnylam Pharmaceuticals 
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 Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8 
M9 
M10/ 
M11 
M12 
M13/ 
M14 
M15b 
M16/ 
M17 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Blood Sample for PK 
Analysism 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Antidrug Antibodiesn 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
Porphyria Attack Kit 
Dispensationo 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EQ-5D-5L Questionnairep 
X 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Diary Review  
(including BPI-SF)q 
 
 
X 
Phone Contactr 
 
 
 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
AEs 
 
Continuous 
Concomitant Medicationss 
 
Continuous 
 Abbreviations:  AE=adverse event; ALAS1=5-aminolevulinic acid synthase 1; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain 
Inventory-Short Form; D=day; ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of life; 
SC=subcutaneous. 
Notes:   
• 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
• 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
a Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study (ALN-AS1-001) were completed within 60 days 
of administration of the first dose of ALN-AS1 in this study.  If more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs 
will be repeated before administration of ALN-AS1.  Results should be available and deemed acceptable before the administration of the first dose of ALN-
AS1.  On Day 1, results from hematology, chemistry (including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the 

Clinical Study Protocol ALN-AS1-002 
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Amendment 8, 29 March 2021 
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Investigator before study drug administration.  If results from within the prior 14 days are not available at a dosing visit, locally analyzed predose assessments 
may be used for review in order to allow same day study drug administration and additional samples for central analysis must also be collected. 
b After a patient has completed 12 months of ALN-AS1 administration in this study, and where applicable country and local regulations and infrastructure allow, 
study procedures, including ALN-AS1 administration, may take place at the patient’s home by a healthcare professional.  Study procedures may occur at the 
patient’s home at the discretion of the Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit at the clinical 
study center Q6M.  Additional visits to collect clinical laboratory samples may occur at home at any point during the treatment period, within 14 days prior to 
scheduled dose administration. 
c See Section 7.1 for details on the interval medical history/disease history to be recorded at Screening/Baseline.  Ongoing AEs from the previous study 
(ALN-AS1-001) will be captured as medical history. 
d A complete physical examination will be performed at Screening/Baseline, and D1.  At all other visits, a targeted physical examination will be performed.  On 
dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any time 
during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On D1, vital signs will be collected within 1 hour predose; and 2 hours 
(±10 minutes) postdose.  On all other dosing days, vital signs will be collected within 1 hour predose.  On days when ALN-AS1 is not administered, vital signs 
can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position (should be consistent for each patient), after the 
patient has rested comfortably for at least 10 minutes. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at least 5 
minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose at a minimum of 2 
of the following visits:  D1, Month 3, Month 6, Month 9, Month 12, Month 15 (only if visit is done at clinic), or Month 18.  In patients receiving >2.5 mg/kg 
ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose at a minimum of two of the following visits:  D1, Month 3, 
Month 6, Month 9, Month 12, Month 15 (only if visit is done at clinic), or Month 18.  On all other dosing days, ECGs will be collected within 1 hour predose 
(see Section 7.5.4 for ECG assessment details).   
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  On 
days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. On dosing days, results from hematology, chemistry 
(including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the Investigator before study drug administration.  If results 
from within the prior 14 days are not available at a dosing visit, locally analyzed predose assessments may be used for review in order to allow same day study 
drug administration and additional samples for central analysis  must  also be collected. 
i A serum pregnancy test will be performed at Screening/Baseline; thereafter, urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  For 
weight-based dosing, weight measured at the current study center visit (dosing day) will be used to calculate the dose of ALN-AS1 through M12.  After M12, 
weight measured at either the previous study center visit or the current study center visit may be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1).  Blood sample collection for PK analysis at 
Month 9 and Month 15 is only necessary if ECG will be performed at same visit. 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o Porphyria attack laboratory sample collection kits should be dispensed at the screening visit along with instructions for use. For any attack that occurs through 
M37, urine samples should be collected within 24 hours of the start of clinical intervention (eg, hemin or glucose administration) and within 24 hours of the end 
of clinical intervention.  If patients are unable to report to the clinical study center during a porphyria attack, laboratory sample collection kits will be provided 

Clinical Study Protocol ALN-AS1-002 
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that contain instructions for collecting and sending urine samples to the clinical study center, if possible.  These urine samples may also be analyzed for 
exploratory biomarkers. 
p In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but not more than once in a 6 month period), if possible.  
q Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, and narcotic use on a daily basis through M9; 
thereafter, acute porphyria attacks will be recorded in the diary.  The BPI will be completed on a weekly basis as part of the patient diary through M9, then 
Q3M. 
r Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack. 
s Medications that are ongoing from the previous study (ALN-AS1-001), started between the previous study and this study, and started after signing informed 
consent in this study, will be captured as concomitant medication(s). 
 

Clinical Study Protocol ALN-AS1-002 
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Table 2: 
Schedule of Assessments:  Month 19 through Month 36 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through Month 36) 
M19/ 
M20 
M21a 
M22/ 
M23 
M24 
M25/ 
M26 
M27a 
M28/ 
M29 
M30 
M31/ 
M32 
M33a 
M34/ 
M35 
M36 
Study Visit (D±Visit Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
Physical Examinationb 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Body Weight, BMI, and Heightc 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Vital Signsd 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Triplicate 12-Lead ECGe 
 
 
 
X 
 
 
 
 
 
 
 
 
Clinical Laboratory Assessmentf 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Pregnancy Testg 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Study Drug Administrationh 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Urine Sample for PBG, ALA, and 
Creatinine Analysisi 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Blood and Urine Sample for 
Exploratory Biomarker Analysisj 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Blood Sample for PK Analysisk 
 
 
 
X 
 
 
 
 
 
 
 
 
Antidrug Antibodiesl 
 
 
 
X 
 
 
 
 
 
 
 
X 
EQ-5D-5L Questionnairem 
 
 
 
X 
 
 
 
X 
 
 
 
X 

Clinical Study Protocol ALN-AS1-002 
givosiran (ALN-AS1) 
Amendment 8, 29 March 2021 
Alnylam Pharmaceuticals 
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Table 2: 
Schedule of Assessments:  Month 19 through Month 36 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through Month 36) 
M19/ 
M20 
M21a 
M22/ 
M23 
M24 
M25/ 
M26 
M27a 
M28/ 
M29 
M30 
M31/ 
M32 
M33a 
M34/ 
M35 
M36 
Study Visit (D±Visit Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
Diary Review (including BPI-SF)n 
X 
Phone Contacto 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of life; SC=subcutaneous. 
Notes:   
• 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
• 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
a Where applicable country and local regulations and infrastructure allow, study procedures, including ALN-AS1 administration, may take place at the patient’s 
home by a healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the Investigator, based on safety and tolerability; 
however, patients are required to complete at least 1 visit at the clinical study center Q6M.  
b A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed.  
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 
c Height will be measured at Screening/Baseline only. 
d Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for at least 10 minutes. 
e Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at least 
5 minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose .  In patients 

Clinical Study Protocol ALN-AS1-002 
givosiran (ALN-AS1) 
Amendment 8, 29 March 2021 
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receiving >2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose.  See Section 7.5.4 for ECG assessment 
details. 
f Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  .  
On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. 
g Urine pregnancy tests will be performed.  Results must be available before dosing. 
h ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured at either the previous study center visit or the current study center visit may be used to calculate the weight-based dose of ALN-AS1. 
i Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
j On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
k Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1). 
l On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
m In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but, not more than once in a 6 month period), if possible.  
n Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
o Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack. 
 

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Table 3: 
Schedule of Assessments:  Month 37 through End of Study (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 37 through EOS) 
EOS/ 
ETb 
Safety Follow-
upc 
 
M37/ 
M38a 
M39a 
M40/ 
M41a 
M42 
M43/ 
M44a 
M45a 
M46/ 
M47a 
M48/ 
EOT 
M49 
 
Study Visit (D±Visit Window) 
1111±7/1141±7 
1171±10 
1201±7/1231±7 
1261±10 
1291±7/1321±7 
1351±10 
1381±7/1411±7 
1441±10 
1471±10 
 
Physical Examinationd 
 
 
 
X 
 
 
 
X 
X 
X 
Body Weight, BMI, and Heighte 
 
 
 
X 
 
 
 
 
X 
 
Vital Signsf 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGg 
 
 
 
X 
 
 
 
 
X 
 
Clinical Laboratory Assessmenth 
X 
X 
X 
X 
 
X 
 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationj 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Urine Sample for PBG, ALA, and 
Creatinine Analysisk 
 
X 
 
X 
 
X 
 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker Analysisl 
 
 
 
X 
 
 
 
X 
X 
 
Antidrug Antibodiesn 
 
 
 
X 
 
 
 
X 
X 
 
EQ-5D-5L Questionnaireo 
 
 
 
X 
 
 
 
X 
X 
 

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Table 3: 
Schedule of Assessments:  Month 37 through End of Study (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 37 through EOS) 
EOS/ 
ETb 
Safety Follow-
upc 
 
M37/ 
M38a 
M39a 
M40/ 
M41a 
M42 
M43/ 
M44a 
M45a 
M46/ 
M47a 
M48/ 
EOT 
M49 
 
Study Visit (D±Visit Window) 
1111±7/1141±7 
1171±10 
1201±7/1231±7 
1261±10 
1291±7/1321±7 
1351±10 
1381±7/1411±7 
1441±10 
1471±10 
 
Diary Review (including BPI-SF)p 
X 
 
Phone Contactq 
X 
 
X 
 
X 
 
X 
 
 
 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; EOS = End of Study; EOT = End of Treatment; ET = Early Termination; M=month; PBG= porphobilinogen; 
PK=pharmacokinetics; Q=every; QOL=quality of life; SC=subcutaneous. 
Notes:   
• 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
• 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
a Where applicable country and local regulations and infrastructure allow, study procedures, including ALN-AS1 administration, may take place at the patient’s 
home by a healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the Investigator, based on safety and tolerability; 
however, patients are required to complete at least 1 visit at the clinical study center Q6M.  
b Patients who complete all scheduled treatment with ALN-AS1 through Month 48 will return for an end of study (EOS) visit at Month 49.  Patients who 
discontinue treatment will be asked to complete an early termination (ET) visit at which all Month 37 visit procedures will be performed; the patient must also 
return for a safety-follow-up visit at 3 months (84 [+7] days) after his/her last dose of ALN-AS1.   
c The safety follow-up visit is only required for patients who discontinue prior to study completion.  The visit should be conducted  3 months (84 [+7 days]) 
following the last dose of ALN-AS1. 
d A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed.  
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 

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e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for at least 10 minutes. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at least 
5 minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose .  In patients 
receiving >2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose.  See Section 7.5.4 for ECG assessment 
details. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  .  
On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. 
i Urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured at either the previous study center visit or the current study center visit may be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA analysis (also including possible biomarkers and homocysteine levels) will be collected within 
1 hour predose.   
m Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but, not more than once in a 6 month period), if possible.  
p Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
q Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack. 
 

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TABLE OF CONTENTS 
SPONSOR PROTOCOL APPROVAL ...........................................................................................2 
INVESTIGATOR’S AGREEMENT ...............................................................................................3 
PROTOCOL SYNOPSIS ................................................................................................................4 
TABLE OF CONTENTS ...............................................................................................................17 
LIST OF TABLES .........................................................................................................................20 
LIST OF FIGURES .......................................................................................................................21 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS ................................................22 
1. 
INTRODUCTION ......................................................................................................24 
1.1. 
Disease Overview .......................................................................................................24 
1.1.1. 
Epidemiology ..............................................................................................................24 
1.1.2. 
Current Management and Unmet Medical Need ........................................................25 
1.2. 
RNA Interference ........................................................................................................26 
1.3. 
ALN-AS1 ....................................................................................................................26 
1.4. 
Study Design Rationale ..............................................................................................26 
1.5. 
Dose Rationale ............................................................................................................26 
1.6. 
Clinical Data Summary ...............................................................................................27 
1.6.1. 
Clinical Pharmacodynamics .......................................................................................27 
1.6.2. 
Clinical Activity ..........................................................................................................27 
1.6.3. 
Clinical Safety ............................................................................................................29 
1.6.4. 
Drug-Drug Interactions ...............................................................................................30 
1.7. 
Benefit-Risk Assessment ............................................................................................30 
2. 
OBJECTIVES .............................................................................................................31 
2.1. 
Primary Objective .......................................................................................................31 
2.2. 
Secondary Objectives .................................................................................................31 
2.3. 
Exploratory Objectives ...............................................................................................31 
3. 
ENDPOINTS ..............................................................................................................31 
3.1. 
Primary Endpoint ........................................................................................................31 
3.2. 
Secondary Endpoints ..................................................................................................31 
3.3. 
Exploratory Endpoints ................................................................................................32 
4. 
INVESTIGATIONAL PLAN .....................................................................................32 
4.1. 
Summary of Study Design ..........................................................................................32 

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4.2. 
Duration of Treatment and Study ...............................................................................34 
4.3. 
Number of Patients .....................................................................................................34 
4.4. 
Method of Assigning Patients to Treatment Groups ..................................................34 
4.5. 
Blinding ......................................................................................................................34 
4.6. 
Safety Review Committee ..........................................................................................34 
5. 
SELECTION AND WITHDRAWAL OF PATIENTS ..............................................34 
5.1. 
Inclusion Criteria ........................................................................................................34 
5.2. 
Exclusion Criteria .......................................................................................................35 
5.3. 
Discontinuation of Study Drug and/or Study .............................................................35 
5.3.1. 
Discontinuation of Study Drug ...................................................................................36 
5.3.2. 
Discontinuation from the Study ..................................................................................36 
5.3.3. 
Withdrawal of Consent to Collect and Process the Patient’s Personal Data ..............37 
5.3.4. 
Replacement of Patients .............................................................................................37 
6. 
TREATMENTS ..........................................................................................................37 
6.1. 
Treatments Administered ............................................................................................37 
6.2. 
Investigational Study Drug .........................................................................................38 
6.2.1. 
Description ..................................................................................................................38 
6.2.2. 
Dose and Administration ............................................................................................38 
6.2.3. 
Dose Modifications .....................................................................................................39 
6.2.3.1. 
Study Population Dose Modifications ........................................................................39 
6.2.3.2. 
Individual Dose Modifications ...................................................................................39 
6.2.4. 
Preparation, Handling, and Storage ............................................................................40 
6.2.5. 
Packaging and Labeling ..............................................................................................40 
6.2.6. 
Accountability .............................................................................................................40 
6.3. 
Concomitant Medications ...........................................................................................41 
6.4. 
Contraceptive Requirements .......................................................................................42 
6.5. 
Treatment Compliance ................................................................................................43 
7. 
STUDY ASSESSMENTS ..........................................................................................43 
7.1. 
Screening/Baseline Assessments ................................................................................43 
7.2. 
Clinical Activity Assessments ....................................................................................43 
7.2.1. 
Patient Diary ...............................................................................................................43 
7.2.2. 
Brief Pain Inventory-Short Form Questionnaire ........................................................43 
7.3. 
Pharmacodynamic Assessments .................................................................................43 

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7.4. 
Pharmacokinetic Assessments ....................................................................................44 
7.5. 
Safety Assessments .....................................................................................................44 
7.5.1. 
Vital Signs ..................................................................................................................44 
7.5.2. 
Weight and Height ......................................................................................................44 
7.5.3. 
Physical Examination .................................................................................................44 
7.5.4. 
Electrocardiogram .......................................................................................................45 
7.5.5. 
Clinical Laboratory Assessments ...............................................................................45 
7.5.5.1. 
Immunogenicity ..........................................................................................................48 
7.5.5.2. 
Pregnancy Testing ......................................................................................................48 
7.5.6. 
Adverse Events ...........................................................................................................48 
7.5.6.1. 
Definitions ..................................................................................................................48 
7.5.6.2. 
Eliciting and Recording Adverse Events ....................................................................50 
7.5.6.3. 
Serious Adverse Events Require Immediate Reporting to Sponsor/Designee ...........51 
7.5.6.4. 
Sponsor Safety Reporting to Regulatory Authorities .................................................51 
7.5.6.5. 
Serious Adverse Event Notification to the Institutional Review 
Board/Independent Ethics Committee ........................................................................52 
7.5.6.6. 
Pregnancy Reporting ..................................................................................................52 
7.5.6.7. 
Overdose Reporting ....................................................................................................53 
7.6. 
Exploratory Assessments ............................................................................................53 
7.7. 
Other Assessments ......................................................................................................53 
7.7.1. 
EQ-5D-5L Questionnaire ............................................................................................53 
7.8. 
COVID-19 Data Collection ........................................................................................53 
8. 
STATISTICS ..............................................................................................................53 
8.1. 
Determination of Sample Size ....................................................................................53 
8.2. 
Statistical Methodology ..............................................................................................54 
8.2.1. 
Populations to be Analyzed ........................................................................................54 
8.2.2. 
Examination of Subgroups .........................................................................................54 
8.2.3. 
Handling of Missing Data ...........................................................................................54 
8.2.4. 
Baseline Evaluations ...................................................................................................54 
8.2.5. 
Clinical Activity Analyses ..........................................................................................54 
8.2.6. 
Pharmacodynamic Analysis........................................................................................55 
8.2.7. 
Pharmacokinetic Analysis ..........................................................................................55 
8.2.8. 
Safety Analyses ..........................................................................................................55 

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8.2.9. 
Other Analyses ............................................................................................................55 
9. 
STUDY ADMINISTRATION ...................................................................................56 
9.1. 
Ethical and Regulatory Considerations ......................................................................56 
9.1.1. 
Informed Consent .......................................................................................................56 
9.1.2. 
Ethical Review ............................................................................................................56 
9.1.3. 
Serious Breach of Protocol .........................................................................................57 
9.1.4. 
Study Documentation, Confidentiality, and Records Retention .................................57 
9.1.5. 
End of the Study .........................................................................................................57 
9.1.6. 
Discontinuation of the Clinical Study.........................................................................57 
9.2. 
Data Quality Control and Quality Assurance .............................................................58 
9.2.1. 
Data Handling .............................................................................................................58 
9.2.2. 
Study Monitoring ........................................................................................................58 
9.2.3. 
Audits and Inspections ................................................................................................58 
9.3. 
Publication Policy .......................................................................................................58 
10. 
LIST OF REFERENCES ............................................................................................59 
11. 
APPENDICES ............................................................................................................62 
11.1. 
Pharmacokinetic Assessment Time Points .................................................................62 
11.2. 
Schedules of Assessments for Every Month Dosing Regimen ..................................63 
11.3. 
Anaphylactic Reactions ..............................................................................................73 
LIST OF TABLES 
Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 
Months Dosing Regimen) .............................................................................................7 
Table 2: 
Schedule of Assessments:  Month 19 through Month 36 (Every 3 Months 
Dosing Regimen) ........................................................................................................11 
Table 3: 
Schedule of Assessments:  Month 37 through End of Study (Every 3 Months 
Dosing Regimen) ........................................................................................................14 
Table 4: 
Pharmacokinetic Time Points .....................................................................................62 
Table 5: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 
Month Dosing Regimen) ............................................................................................63 
Table 6: 
Schedule of Assessments:  Month 19 through Month 36 (Every Month 
Dosing Regimen) ........................................................................................................67 
Table 7: 
Schedule of Assessments:  Month 37 through End of Study (Every Month 
Dosing Regimen) ........................................................................................................70 
Table 8: 
 Sampson Criteria for Anaphylactic Reactions ...........................................................73 

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LIST OF FIGURES 
Figure 1: 
Part C Cohort 1 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in .........................................................................................................................28 
Figure 2: 
Part C Cohort 2 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in .........................................................................................................................28 
Figure 3: 
Study Design ...............................................................................................................33 
 

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LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
Abbreviation 
Definition 
AE 
Adverse event 
AHP 
Acute hepatic porphyria 
AIP 
Acute intermittent porphyria 
ALA 
Delta-aminolevulinic acid 
ALAS1 
5-aminolevulinic acid synthase 1 
ALP 
Alkaline phosphatase 
ASGPR 
Asialoglycoprotein receptor 
ASHE 
Asymptomatic high excreters 
BPI-SF 
Brief Pain Inventory-Short Form 
cERD 
Circulating extracellular RNA detection assay 
COVID-19 
Coronavirus disease 2019 
CRF 
Case report form 
CYP 
Cytochrome P450 
DDI 
Drug-drug interaction 
ECG 
Electrocardiogram 
eCRF 
Electronic case report form 
eGFR 
Estimated Glomerular Filtration Rate 
EDC 
Electronic data capture 
EOS 
End of study 
EU 
European Union 
GalNAc 
N-acetyl galactosamine 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practice 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
IEC 
Independent Ethics Committee 
IRB 
Institutional Review Board 
ISR 
Injection site reaction 
IV 
Intravenous 
LFT 
Liver function test 
mRNA 
Messenger RNA 

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Abbreviation 
Definition 
NHP 
Nonhuman primate 
NOAEL 
No observed adverse effect level 
NOEL 
No observed effect level 
OTC 
Over the counter 
PBG 
Porphobilinogen 
PBGD 
Porphobilinogen deaminase 
PD 
Pharmacodynamic(s) 
PK 
Pharmacokinetic(s) 
QOL 
Quality of life 
RNA 
Ribonucleic acid 
RNAi 
RNA interference 
SAE 
Serious adverse event 
SAP 
Statistical Analysis Plan 
SC 
Subcutaneous 
siRNA 
Small interfering RNA 
SRC 
Safety Review Committee 
SUSAR 
Suspected unexpected serious adverse reaction 
ULN 
Upper limit of normal 
US 
United States 
WOCBP 
Woman of child-bearing potential 
 

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1. 
INTRODUCTION 
1.1. 
Disease Overview 
The porphyrias are a family of rare metabolic disorders predominately caused by a genetic 
mutation in 1 of the 8 enzymes responsible for heme synthesis.(1)  The 2 major categories are 
erythropoietic and hepatic, depending on the major site of expression of the underlying enzyme 
deficiency.(2)  In addition, the porphyrias are classified as acute if patients present with 
neurovisceral symptoms (eg, abdominal pain and neurologic symptoms) or cutaneous if they 
present with dermal blistering or photosensitivity.(3, 4) 
This study will include patients with acute intermittent porphyria (AIP), the most common acute 
hepatic porphyria (AHP).  AIP occurs as a result of an autosomal dominant mutation leading to 
partial deficiency of porphobilinogen deaminase (PBGD), the third enzyme in the heme 
biosynthesis pathway.(5)  The rate limiting step in heme synthesis is the upstream enzyme 
5-aminolevulinic acid synthase 1 (ALAS1), which is controlled by feedback repression via the 
end-product heme.  In response to a decrease in endogenous heme in the liver, as can occur with 
fasting, hormonal alterations, or with cytochrome P450 (CYP) inducing drugs, ALAS1 is 
induced, resulting in increased flux through the heme synthesis pathway.  In patients with AIP, 
this can result in the marked accumulation of the toxic heme intermediates porphobilinogen 
(PBG) and delta aminolevulinic acid (ALA) in the blood and urine due to the deficiency in the 
downstream PBGD.  Clinically, this manifests as acute attacks characterized by severe 
abdominal pain, cardiovascular as well as neurologic and psychiatric dysfunction.(6) 
1.1.1. 
Epidemiology 
Over 370 mutations have been identified in the PBGD gene, which in most instances result in its 
reduction by approximately 50%.  The exact prevalence of AIP is unknown due to under 
diagnosis, variation by geographic region, and the differences in penetrance observed for the 
different mutations.(2)  However, it is estimated that the prevalence of AIP is 5 to 10 per 100,000 
people in Western countries, while in Sweden it occurs in 1 in 1,000 people due to a founder 
effect associated with the resultant G593A mutation.(7-10)  AIP shows incomplete penetrance 
and on average only 10% to 50% of carriers with a mutation present with clinical symptoms.(11)  
It has been proposed that unknown inherited co-factors, in addition to PBGD mutations, may 
explain why a small percentage of patients present with much more severe disease while the 
majority remain asymptomatic. 
Patients with AIP present with acute attacks characterized by neurovisceral symptoms and signs 
including severe abdominal pain, nausea, vomiting, constipation, or less commonly diarrhea, 
hypertension, tachycardia, fever, muscle weakness, as well as neurological (eg, neuropathy, 
seizures) and psychiatric (eg, anxiety and confusion) manifestations.(12)  AIP attacks typically 
start after puberty and can be triggered by exogenous factors such as medications (especially 
barbiturates, sulfonamides, and hydantoins), stress, exogenous hormones, nutritional status, and 
infection.  Clinically active disease is more common in women, where attacks often occur around 
the menstrual cycle and are likely precipitated by hormonal changes. 
Many AIP patients remain undiagnosed given that the disease is rare and characterized by 
non-specific symptoms (eg, abdominal pain and nausea).(2)  The initial diagnosis involves 
demonstrating elevated urinary PBG (typically 20-50 × normal reference range) and ALA 

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(typically 5-20 × normal reference range) when the patient is having acute attack symptoms.  
Once a test is positive for elevated ALA and PBG and porphyria is suspected, genetic testing for 
a PBGD mutation is performed.   
There are 4 main clinical phenotypes of AIP.  Latent gene carriers have never had an acute attack 
and are biochemically inactive (normal urinary ALA and PBG).  Asymptomatic high excreters 
(ASHE) do not have current acute attacks, but are biochemically active (increased urinary ALA 
and PBG).  The increased levels of ALA and PBG in ASHE patients are lower than those in AIP 
patients during an acute attack, but are still significantly higher than normal reference values.(6-
8)  Sporadic attack patients have infrequent acute attacks.  Recurrent attack patients have ≥4 
attacks per year requiring hospitalization or treatment by a medical professional.(7) 
1.1.2. 
Current Management and Unmet Medical Need 
Management of acute attacks often requires hospitalization.  Patients are initially treated with 
supportive care and carbohydrate loading, analgesics and anti-emetics, and removal of known 
precipitating factors.(13)  In patients with moderate to severe attacks, or who fail to respond to 
supportive measures, treatment with intravenous (IV) hemin (daily for 3-5 days) is commenced.  
Symptoms typically begin to improve after 2 to 5 days of hemin treatment, accompanied by a 
lowering of urinary ALA and PBG levels to below or at the upper limit of normal (ULN) 
reference value; however, in some patients attacks can last several weeks, requiring prolonged 
hemin use and hospitalization.(14)  With prolonged and severe attacks, cranial nerve 
involvement can occur, leading to bulbar paralysis, respiratory failure, and death.(15) 
Hemin, a blood derived therapy, was approved as Normosang® (heme arginate) in the European 
Union (EU) and as Panhematin® (lyophilised hematin) in the United States (US) in 1999 and 
1983, respectively.(16, 17)  In the EU, heme arginate is indicated for the treatment of acute 
attacks of hepatic porphyria (eg, AIP, variegate porphyria, and hereditary coproporphyria); 
whereas, in the US lyophilized hemin is limited to the amelioration of recurrent attacks of AIP 
temporally related to the menstrual cycle.  Approval of both products was based on biochemical 
efficacy (ie, lowering of ALA and PBG) as well as data from uncontrolled case series and case 
reports.(18-22)  Hemin side effects include thrombophlebitis, transient anticoagulation, and in 
rare cases, anaphylaxis or renal failure.(22-24)  In addition, hemin administration requires a large 
vein for administration, often necessitating central venous access. 
While the majority of patients who experience attacks have them sporadically, it is estimated that 
up to 1,000 AIP patients experience recurrent attacks (typically defined as ≥4 per year) in the US 
and EU combined.(25)  While hemin is currently only approved to ameliorate acute attacks, it is 
administered prophylactically in some patients with recurrent attacks (eg, administered every 1-2 
weeks).(26)  Potential problems associated with chronic hemin administration include infusion 
site phlebitis, iron overload, and the need for chronic IV access and associated complications (eg, 
risk of infection or occlusion).(5)  In addition, there have been reports of a decrease in efficacy 
with chronic hemin administration, as evidenced by the need to increase the frequency or dosage 
of hemin prophylaxis over time in attempt to maintain a clinical effect.(27)  In patients with very 
severe recurrent attacks, or in whom hemin treatment is not effective, liver transplantation can be 
curative; however, organ transplantation is a high-risk procedure and is rarely used as a treatment 
option.  Given the significant morbidity and mortality, there remains a significant unmet need for 
an efficacious, simple, fast-acting and better tolerated treatment for acute or prevent recurrent 

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attacks in patients with AIP. 
1.2. 
RNA Interference 
RNA interference (RNAi) is a naturally occurring cellular mechanism mediated by small 
interfering RNAs (siRNAs) for regulating gene expression.  Typically, synthetic siRNAs are 19 
to 25 base pair double stranded oligonucleotides in a staggered duplex with a 2-nucleotide 
overhang at both or 1 of the 3’ ends.(28)  Such siRNAs can be designed to target an endogenous 
messenger RNA (mRNA) transcript of a given gene.  When introduced into cells, the net effect 
of an RNAi-based pharmacological approach is the binding of the siRNA to its complementary 
mRNA sequence, cleavage of this target mRNA, and reduction of synthesis of the target protein, 
resulting in a decrease of the target protein levels.(29)  The ability to selectively and potently 
degrade the mRNA encoding the ALAS1 protein (thereby decreasing accumulation of the toxic 
intermediates ALA and PBG) using an siRNA is a novel approach for the prevention and 
treatment of acute attacks in patients with AIP.   
1.3. 
ALN-AS1 
ALN-AS1 (givosiran) comprises a synthetic siRNA covalently linked to a GalNAc containing 
ligand (ALN60519), specific for ALAS1 and formulated for administration via subcutaneous 
(SC) injection. ALN-60519 has a target region between nucleotide 918 to 937 of the ALAS1 
mRNA. Attachment to a triantennary GalNAc ligand to the siRNA enables its distribution to the 
liver (which is the primary site of ALAS1 synthesis), followed by intracellular delivery to 
hepatocytes via ASGPR, resulting in engagement of the RNAi pathway and suppression of 
hepatic ALAS1 protein synthesis. 
ALN-AS1 is currently in development for treatment of acute attacks in patients with AIP, the 
most common AHP. 
Further information on ALN-AS1, including the clinical and nonclinical experience to date, is 
available in in the current version of the Investigator’s Brochure (IB). 
1.4. 
Study Design Rationale 
This is a multicenter, open-label extension study designed to evaluate the long-term safety and 
clinical activity of subcutaneously administered ALN-AS1 in patients with AIP who have 
completed clinical study ALN-AS1-001.  The primary endpoint for the study is the incidence of 
AEs. 
1.5. 
Dose Rationale 
Clinical data from Part A and Part B of the ongoing study ALN-AS1-001 demonstrate that single 
(0.035-2.5 mg/kg) and multiple (0.35-1.0 mg/kg) doses of ALN-AS1 have been generally 
well-tolerated in patients with AIP who are ASHE.  Additionally, data from this study indicate 
that a single dose of 2.5 mg/kg ALN-AS1 results in near normalization of urine ALA and PBG 
levels, which is sustained for approximately 14 weeks.   
Patients in Part C of the ongoing study ALN-AS1-001 who are eligible for participation in this 
study will likely require a higher dose of ALN-AS1 to normalize ALA and PBG as they have 
higher levels of ALAS1 upregulation and higher baseline levels of ALA and PBG, when 

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compared to patients with AIP who are ASHE.(30)  For example, based on preliminary data in 
Part A and Part B of the ALN-AS1-001 study, the mean PBG level of patients who are ASHE is 
21.9 mmol/mol Cr (N=28); whereas, in Part C of this study in patients with AHP who have 
recurrent porphyria attacks, the mean PBG level is approximately 49.3 mmol/mol Cr (N=12). 
The study starting dose and regimen of ALN-AS1 is 5.0 mg/kg as an SC injection administered 
every 3 months.  Based on emerging clinical data, the SRC may approve changes to the ALN-
AS1 dosing regimen, including decreases in the dose level and changes in dosing frequency.  
However, any dosing regimen will not exceed a previously explored dose level or frequency that 
was determined to be safe and well-tolerated in study ALN-AS1-001. SRC, Health Authority and 
Ethics Committee approval must be sought prior to dose level escalation above 5.0 mg/kg in 
accordance with local Regulatory requirements. 
The study starting dose and regimen was selected based on the benefit:risk profile of ALN-AS1 
in Part C of the ongoing ALN-AS1-001 study.  Preliminary data to date indicate that 
administration of 5.0 mg/kg ALN-AS1 has been generally well-tolerated.  There have been no 
study drug-related serious adverse events (SAEs), severe AEs, or clinically significant changes in 
safety parameters.  While a single 2.5 mg/kg dose of ALN-AS1 has also been generally well-
tolerated when administered to patients in Part A and Part C of study ALN-AS1-001, this dose 
has not resulted in near normalization of ALA and PBG levels.  In addition, while emerging data 
from Part C indicate that an every 3 months dose of 2.5 mg/kg ALN-AS1 demonstrated some 
clinical activity (eg, decrease in attack frequency and decrease in heme use), some patients 
continued to experience breakthrough porphyria attacks during the treatment period, indicating 
that a higher dose may be required. 
The duration of dosing in this study is supported by the overall favorable safety profile of 
ALN-AS1 in the ongoing clinical study ALN-AS1-001 and the absence of new findings in 
nonclinical studies with ALN-AS1. 
1.6. 
Clinical Data Summary 
1.6.1. 
Clinical Pharmacodynamics  
Dosing has been completed in Part A and Part B of the study.  In both Parts A and B of the study, 
durable and dose-dependent reductions of ALAS1 mRNA (up to 66% in the 2.5 mg/kg dose 
group) as measured by cERD were observed after ALN-AS1 treatment.  ALAS1 reductions were 
highly correlated with reductions in ALA (mean maximal 86%) PBG (mean maximal 95%) 
levels in a dose-dependent manner and were sustained for ≥180 days.  
Dosing is currently ongoing in Part C of the study. The mean maximal reduction in ALAS1 
mRNA relative to baseline in ALN-AS1-treated patients in Cohort 1 (2.5 mg/kg Q3M) was 39% 
and in Cohort 2 (2.5 mg/kg Q1M) 66%.  All patients treated with ALN-AS1 also had decreases 
in their peak ALA and PBG levels in the treatment period compared to the run-in period, along 
with reduced fluctuations in these levels in the treatment period (data not shown). No reductions 
were observed in the placebo-treated patients.  
1.6.2. 
Clinical Activity 
Clinical activity was not evaluated in Parts A and B of the study because ASHE patients included 
in this study were not actively experiencing attacks of porphyria. 

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Dosing is currently ongoing in Part C of the study. All patients in Cohorts 1 and 2 were enrolled 
in a run-in phase for 10-15 weeks that was followed by a treatment phase for up to 24 weeks.  No 
investigational product was administered during the run-in phase.  Therefore, each patient acted 
as their own control, allowing for individual ALA / PBG levels, and overall attack rate while on 
ALN-AS1 treatment to be compared to that observed in the run-in phase.   
Figure 1 shows in Cohort 1 ALN-AS1-treated patients there was a 74% mean decrease in the 
annualized attack rate for the treatment period versus the run-in period (range: 63-94% 
reduction), compared with a 23% decrease in the annualized attack rate for the placebo-treated 
patient.  In ALN-AS1-treated patients this was accompanied by an approximate 76% mean 
decrease in annualized acute hemin usage (range 52-95%) and a 10.3 times increase in the 
maximal attack free interval compared to run-in period (range 4.2-16.3). 
Figure 1: 
Part C Cohort 1 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in 
 
Figure 2 shows in Cohort 2 ALN-AS1-treated patients, there was a 58% mean decrease in the 
annualized attack rate for the treatment period versus the run-in period (range: 45-76% 
reduction).  This compares favorably with data from the placebo-treated patient who showed a 
34% reduction in the annualized attack rate for the treatment period versus the run-in period.  In 
ALN-AS1-treated patients, the reduction in attack rate was accompanied by a 92% mean 
decrease in annualized hemin usage (range 84-100%) and a 2.7x increase in the mean maximal 
attack free interval compared to run-in period (range 2.1-3.2). 
Figure 2: 
Part C Cohort 2 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in 
 

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1.6.3. 
Clinical Safety 
In Part A and Part B of Study ALN-AS1-001, a total of 11 patients (11/13; 85.0%) who received 
ALN-AS1 reported at least 1 AE.  All 5 placebo-treated patients (5/5; 100%) reported at least 1 
AE.  AEs considered possibly or definitely related to ALN-AS1 were reported in 5 patients 
(5/13; 38%): diarrhoea, dyspepsia, hematochezia, injection site erythema, injection site pain, 
blood creatinine increased, glomerular filtration rate decreased, and hypoesthesia (each AE 
reported only by an individual patient; 1/13; 8% each).  There were 2 SAEs of abdominal pain: 1 
patient each in the 0.035 mg/kg and 0.1 mg/kg ALN-AS1 dose groups.  Both were considered to 
be not related and resolved without sequelae.  There were no AEs leading to discontinuation.  All 
AEs were mild or moderate in severity, except for 1 of the SAEs of abdominal pain (0.10 mg/kg 
dose group), which was considered severe. Adverse events related to abnormal laboratory values 
were seen in 1 patient in the 0.35 mg/kg ALN-AS1 dose group who had AEs of ALT increased 
and AST increased, which were moderate and considered by the Investigator to be unrelated to 
ALN-AS1.  No clinically significant findings were observed with routine monitoring of CRP and 
a panel of 9 proinflammatory cytokines collected predose and up to 24 hours post-dose.  There 
were no other clinically significant laboratory abnormalities related to study drug or changes in 
vital signs, or ECGs in patients who were administered ALN AS1 or placebo. 
Dosing is ongoing in Part C of the study. All patients who received ALN-AS1 in cohort 1 and 2 
reported at least 1 AE.  AEs that were reported in at least 2 subjects were nausea in 3 patients 
(50%) and abdominal pain, vomiting, nasopharyngitis, headache, cough and oropharyngeal pain 
in 2 patients (33.3%) each.  All AEs were mild or moderate in severity.  AEs considered possibly 
or definitely related to ALN-AS1 were reported in 4 patients (66.6%), 1 each:  renal impairment 
in Cohort 1 and injection site reaction, myalgia, and headache in Cohort 2. Both placebo-treated 
patients reported AEs.  No AE was experienced in more than 1 patient.  
In Part C, Cohort 1 or 2, there were no SAEs or AEs leading to discontinuation in patients 
administered ALN-AS1 or placebo. No clinically significant laboratory abnormalities related to 
study drug or changes in vital signs, ECG, or physical exam findings were observed in patients 
administered ALN-AS1 or placebo. 
Part C Cohort 3 5.0 mg/kg SC monthly dosing is ongoing.  In this cohort there was one fatal 
SAE of acute pancreatitis, which was determined to be unlikely related to study drug or placebo 
by the Investigator due to the presence of gall bladder sludge found at the time of her 
presentation.  Contributors to this patient's adverse clinical course included: pre-existing chronic 
debilitation from recurrent AIP attacks requiring monthly hospitalization, porphyria-attributed 
quadriplegia requiring nursing home care, delay in hospital admission and complications from 
thromboembolism (multiple risk factors included pancreatitis, obesity, immobilisation from 
quadriparesis and recent hospitalization for infected portacath removal).  Serum lipase was added 
to all scheduled laboratory assessments in November 2016 as part of additional safety 
monitoring. To date, all lipase results (available in 11 of 15 subjects) have been at or below the 
upper limit of normal with no trends seen with dosing of study drug or placebo. 
Further information on the safety, efficacy, PK and PD of ALN-AS1 are available in the 
Investigator’s Brochure. 

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1.6.4. 
Drug-Drug Interactions  
An open-label drug-drug interaction (DDI) study (ALN-AS1-004) was conducted in AIP patients 
who are ASHE to evaluate the effect of a single dose of 2.5 mg/kg ALN-AS1 administered SC 
on the pharmacokinetics of probe substrates for 5 major CYP enzymes that account for the 
metabolism of approximately 80% of prescribed drugs.(31, 32)  Results from this study 
demonstrated that ALN-AS1 treatment resulted in weak to moderate reduction in the metabolic 
activity of some of the 5 CYP enzymes studied, thereby leading to higher concentrations of some 
substrates and their metabolites.  Treatment with ALN-AS1 resulted in an approximately 3-fold 
increase in exposure (as measured by AUC) of caffeine (a sensitive substrate for CYP1A2) and 
an approximately 2-fold increase in exposure of dextromethorphan (a sensitive substrate for 
CYP2D6).  Exposure of midazolam (a sensitive substrate for CYP3A4) and omeprazole (a 
sensitive substrate for CYP2C19) increased less than 2-fold after treatment with ALN-AS1.  
There was no effect of ALN-AS1 treatment on losartan (a sensitive substrate for CYP2C9). 
1.7. 
Benefit-Risk Assessment 
Patients participating in this study may experience a reduced number or severity of porphyria 
attacks, reduced treatment with IV hemin, and/or reduced requirement for pain medication.  As 
presented in Section 1.6, emerging data demonstrate that patients given ALN-AS1 experienced 
reduced ALA/PBG levels, decreased attack frequency and reduced heme usage in the 24-week 
treatment period compared to the 12-week run-in period in Study ALN-AS1-001 
As detailed in Section 1.6, a fatal SAE of hemorrhagic pancreatitis was reported but deemed to 
be unlikely related to study drug.  However, the potentially non-adverse nonclinical finding of 
angiectasis in the islets of Langerhans (endocrine, not exocrine region) of the rat pancreas (see 
Investigator Brochure), do not exclude a potential association between ALN-AS1 and the SAE of 
hemorrhagic pancreatitis. 
The important potential risks associated with administration of ALN-AS1 in patients with AIP 
are as follows: 
• Injection site reactions (ISRs):  ALN-AS1 is administered by SC injection.  In the 
ongoing ALN-AS1 clinical study, AEs of ISRs have been infrequently reported and 
have been mild to moderate in severity with single dosing.  Injection site rotation and 
close monitoring have been implemented in ALN-AS1 clinical studies to reduce the 
potential for ISRs.  
• Pancreatitis: Since an association between ALN-AS1 and the fatal SAE of 
hemorrhagic pancreatitis can not be ruled out, patients will undergo routine 
monitoring of systemic and pancreatic inflammation and coagulation throughout the 
study.  Hematology, chemistry and coagulation results are required to be available 
prior to each dose. 
• Liver transaminase abnormalities:  As ALN-AS1 is targeted for delivery to the liver, 
and reversible hepatic changes were observed in some animal species, there is a 
potential for development of liver function test (LFT) abnormalities.  To minimize the 
potential for LFT abnormalities, patients are required to have adequate liver function 
at study entry and LFTs are monitored during the study. 

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• Anaphylactic reactions:  There is a potential risk of developing a severe allergic 
reaction with ALN-AS1 administration.  In the present study, one patient in the 
2.5 mg/kg monthly dose group with a history of asthma and multiple allergies 
experienced an SAE of anaphylactic reaction that was determined by the Investigator 
to be definitely related to study drug given the temporal relationship of ALN-AS1 
treatment to the onset of the reaction (within minutes).  The patient was treated and 
recovered and was discontinued from the study.  Guidance on dose administration 
and monitoring for anaphylactic reactions has been included in this protocol.The 
complete summary of the clinical and nonclinical data relevant to the investigational 
drug and its study in human subjects is provided in the Investigator’s Brochure. 
• Homocysteine elevations:  Blood homocysteine levels may be increased in patients 
with AHP, vitamin deficiencies, or chronic kidney disease.(33-35)  During treatment 
with ALN-AS1, increases in blood homocysteine levels have been observed 
compared to levels before treatment.  The clinical relevance of the elevations in blood 
homocysteine during ALN-AS1 treatment is unknown.  The protocol includes 
monitoring for changes in blood homocysteine levels during treatment with 
ALN-AS1.  Vitamin B6 supplementation is recommended for patients with elevated 
homocysteine levels (see Section 6.3).  
2. 
OBJECTIVES 
2.1. 
Primary Objective 
• Evaluate the long-term safety and tolerability of ALN-AS1 in patients with AIP 
2.2. 
Secondary Objectives 
• Assess the PD effect of ALN-AS1 over time 
• Assess the clinical activity of ALN-AS1 over time 
2.3. 
Exploratory Objectives 
• Characterize the PK profile of ALN-AS1 and incidence of ADA over time 
• Assess changes in health-related quality of life (QOL) 
• Characterize analytes related to targeting the heme biosynthesis pathway 
3. 
ENDPOINTS 
3.1. 
Primary Endpoint 
• Patient incidence of AEs 
3.2. 
Secondary Endpoints 
• Change in urine ALA and PBG levels 

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• Frequency and characteristics of porphyria attacks 
• Change in hemin administration 
3.3. 
Exploratory Endpoints 
• Change in circulating ALAS1 mRNA levels 
• Concentrations of ALN-AS1 and ADA  
• Duration and treatment of porphyria attacks 
• Number and duration of visits to a health care facility for acute porphyria care 
• EQ-5D-5L questionnaire scores 
• Pain assessment and narcotic use as recorded in a patient diary 
• Exploratory biomarkers related to the target pathway, such as urine porphyrins, 
vitamin D binding protein 
4. 
INVESTIGATIONAL PLAN 
4.1. 
Summary of Study Design 
This is a Phase 1/2 multicenter, open-label extension study to evaluate the long-term safety and 
clinical activity of ALN-AS1 in patients with AIP who completed study ALN-AS1-001.  The 
study will be conducted at up to 8 clinical study centers worldwide. 
The last assessments performed, determining previous study (ALN-AS1-001) completion, will 
serve as the Screening/Baseline assessments in this study.  If more than 60 days have elapsed 
since the last assessment, safety assessments (eg, ECG and clinical laboratory tests) will be 
repeated before administration of ALN-AS1.  It is anticipated that patients will begin ALN-AS1 
administration in this study within 6 months after the last dose of study drug in the previous 
study.  Eligibility will be confirmed during Screening/Baseline and before administration of the 
first dose of ALN-AS1 (Day 1).  Patients will undergo assessments at the clinical study center 
every month for the first 3 months.  Then, through Month 6, and according to the dosing regimen 
selected, assessments will take place at the clinical study center or via a phone contact (for an 
every month dosing regimen, visits will be every month; for an every 3 months dosing regimen, 
visits will be every 3 months; see Section 6.2.2).  After a patient has completed 12 months of 
ALN-AS1 administration in this study (6 months in an every month dosing regimen), and where 
applicable country and local regulations and infrastructure allow, study procedures, including 
ALN-AS1 administration, may take place at the patient’s home by a healthcare professional (as 
indicated in the Schedules of Assessments in Table 1, Table 2, and Table 3; and Table 5, Table 6, 
and Table 7 in Appendix Section 11.2).  If the patient is unable to come to the study site, and a 
visit by a home healthcare professional is not possible due to circumstances related to the 
COVID-19 pandemic, ALN-AS1 may be administered by the patient or the caregiver under the 
oversight of the Investigator, and following consultation with the medical monitor, as allowed by 
applicable country and local regulations.  In such cases, the patient or caregiver must receive 
appropriate training on ALN-AS1 administration and the use of epinephrine (epi pen or 

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equivalent) prior to dosing.  This measure is intended to remain in effect only during periods of 
time when the COVID-19 pandemic impedes the ability of patients to travel to the study site or 
healthcare professionals to go to patients' homes for dosing.  Study procedures may occur at the 
patient’s home at the discretion of the Investigator, based on safety and tolerability; however, 
patients are required to complete at least 1 visit at the clinical study center every 3 months for the 
first year, and thereafter every 6 months through the end of the treatment period.  Additional 
visits to collect clinical laboratory samples may occur at home at any point during the treatment 
period, within 14 days prior to scheduled dose administration.  Patients will return to the clinical 
study center for a posttreatment follow-up visit after administration of the last dose of ALN-AS1.  
An ALA/PBG Monitoring/EOS visit will be conducted either at the clinical study center or via 
phone contact, unless treatment continues with ALN-AS1. 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain 
assessments, and narcotic use.  Additionally, patients will be encouraged to report to the clinical 
study center if they experience a porphyria attack through Month 49.  In the event that patients 
are unable to report to the clinical study center during a porphyria attack, laboratory sample 
collection kits containing instructions for collecting and sending urine samples to the clinical 
study center, if possible, will be provided.  Patients will be contacted by phone after a porphyria 
attack to record attack details.  If patients are experiencing signs and symptoms of a porphyria 
attack when ALN-AS1 administration is scheduled, the Investigator will determine whether 
administration of ALN-AS1 is appropriate.  If patients are treated for a porphyria attack at a 
health care facility (eg, hospital, emergency department, infusion center, or outpatient clinic) 
other than the clinical study center, copies of medical records, including discharge summaries, 
will be requested.   
A Safety Review Committee (SRC) will review safety and tolerability data collected during the 
study with the primary purpose of protecting the safety of patients participating in the study (see 
Section 4.6). 
Patients may receive ALN-AS1 as long as they do not fulfill any of the study discontinuation 
criteria (see Section 5.3) or until ALN-AS1 is commercially available in the patient’s territory or 
the ALN-AS1 development program is discontinued (whichever comes first).  
All patients are asked to participate in a Posttreatment Follow-up visit after they have received 
their last dose of ALN-AS1. 
Figure 3: 
Study Design 
 
a Patients who discontinue treatment will be asked to complete an early termination (ET) visit at which all Month 49 
visit procedures will be performed; they must also return for a safety-follow-up visit 3 months (84 [+14] days) 
after their last dose of ALN-AS1. 
Screening
(Day -60 to -1)
Treatment Period
(up to 48 Months)a
End of Study
(Month 49)

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4.2. 
Duration of Treatment and Study 
The duration of treatment is up to 48 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 56 months.   
4.3. 
Number of Patients 
Up to 24 patients are planned for enrollment in this study (including optional cohorts in 
ALN-AS1-001). 
4.4. 
Method of Assigning Patients to Treatment Groups 
This is an open-label study; all patients will receive ALN-AS1.  A combination of the clinical 
study center number and screening number will create the unique patient identifier.  The clinical 
study center number will be assigned by the Sponsor.  Upon signing the Informed Consent Form 
(ICF), the patient will be assigned a screening number by the clinical study site, which will be 
the same unique patient identifier assigned in the previous study (ALN-AS1-001).  The 
Investigator, or delegate, will confirm that the patient fulfills all the inclusion criteria and none of 
the exclusion criteria. 
4.5. 
Blinding 
This is an open-label study, and all patients will receive ALN-AS1. 
4.6. 
Safety Review Committee 
An SRC will be involved in the conduct of this study.  The SRC has the responsibility for 
monitoring the safety of the study participants.  The SRC will perform periodic reviews of safety 
and tolerability data during the course of the clinical study at least every 3 months for the first 6 
months of the study and thereafter at least every 6 months.  The SRC may also meet on an ad hoc 
basis for review of emergent safety and tolerability data, as defined in the SRC Charter for this 
clinical study.  The SRC will not stop the study for efficacy. 
The SRC will be comprised of the following members:  Principal Investigator(s), or designee(s), 
the Sponsor Medical Monitor, and the Study Medical Monitor. 
The membership of the SRC and reporting structure are further defined in the SRC Charter. 
5. 
SELECTION AND WITHDRAWAL OF PATIENTS 
5.1. 
Inclusion Criteria 
Each patient must meet all of the following inclusion criteria to be eligible for enrollment in this 
study: 
1. Completed and, in the opinion of the Investigator, tolerated study drug dosing in Part C 
of study ALN-AS1-001 
2. Not on a scheduled regimen of hemin to prevent porphyria attacks at Screening 

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3. Women of child-bearing potential (WOCBP) must have a negative serum pregnancy test, 
cannot be breast feeding, and must be willing to use acceptable methods of contraception 
14 days before first dose, throughout study participation, and for 90 days after last dose 
administration.  Acceptable methods include hormonal methods along with an additional 
barrier method (eg, condom, diaphragm, or cervical cap), or a double barrier method of 
contraception for those WOCBP for whom a hormonal method of contraception is 
medically contraindicated due to underlying disease (see Section 6.4 for acceptable 
methods of contraception).   
4. Willing and able to comply with the study requirements and to provide written informed 
consent 
5.2. 
Exclusion Criteria 
Each patient must not meet any of the following exclusion criteria to be eligible for enrollment in 
this study: 
1. Alanine transaminase ≥2.0×ULN or total bilirubin ≥2 mg/dL (unless bilirubin elevation is 
due to Gilbert’s syndrome) 
2. Estimated glomerular filtration rate ≤30 mL/min/1.73 m2 (using the Modification of Diet 
in Renal Disease formula) 
3. History of multiple drug allergies or history of allergic reaction to an oligonucleotide or 
to N-acetyl galactosamine ligand (GalNAc) 
4. Received an investigational agent, other than ALN-AS1, or who are in follow-up of 
another clinical study of an investigational agent within 90 days before study drug 
administration 
5. Other medical conditions or comorbidities which, in the opinion of the Investigator, 
would interfere with study compliance or data interpretation 
5.3. 
Discontinuation of Study Drug and/or Study 
Patients or their legal guardians (in the case that the patient is a minor) are free to discontinue 
treatment and/or study or withdraw their consent at any time and for any reason, without penalty 
to their continuing medical care.  Any discontinuation of treatment or of the study must be fully 
documented in the electronic case report form (eCRF), and should be followed up by the 
Investigator.  The Investigator may withdraw a patient from the study at any time if this is 
considered to be in the patient’s best interest. 
Discontinuation of study drug and withdrawal from the study are described in Section 5.3.1 and 
Section 5.3.2, respectively.  If a patient stops participation from the study or withdraws consent 
from the study, he/she will not be able to re-enroll in the study. 

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5.3.1. 
Discontinuation of Study Drug 
The Investigator or designee may discontinue dosing in a patient if the patient: 
• Is in violation of the protocol 
• Experiences a SAE considered to be possibly or definitely related to the study drug or 
an intolerable AE  
• Becomes pregnant 
• Is found to be considerably noncompliant with the protocol-requirements 
Patients who are pregnant will be discontinued from study drug dosing immediately (see 
Section 7.5.6.6 for reporting and follow-up of pregnancy).  A positive urine pregnancy test 
should be confirmed by a serum pregnancy test prior to discontinuing the study drug. 
If a patient discontinues dosing due to a serious adverse event (SAE), the SAE should be 
followed as described in Section 7.5.6.  When a patient discontinues study drug dosing, the 
primary reason must be recorded in the electronic case report form (eCRF).  Patients who 
discontinue study drug and remain on study may receive treatment consistent with local standard 
practice for their disease per Investigator judgement, as applicable. 
Patients who discontinue treatment will be asked to complete an early termination (ET) visit at 
which all Month 49 visit procedures will be performed; they must also return for a safety-follow-
up visit 3 months (84 [+14] days) after their last dose of ALN-AS1. 
5.3.2. 
Discontinuation from the Study 
A patient or their legal guardian may decide to stop the patient’s participation in the study at any 
time.  Patients considering to stop the study should be informed that they can discontinue 
treatment and complete study assessments including follow-up, as per the SOA, or alternatively 
may complete any minimal assessments for which the patient consents. The Investigator may 
withdraw a patient at any time if this is considered to be in the patient’s best interest. 
However, study integrity and interpretation is best maintained if all randomized patients continue 
study assessments and follow-up.  Stopping study participation could mean: 
• If a patient discontinues from the study, he/she will be asked to complete an early 
termination (ET) visit at which all Month 49 visit procedures will be performed; the 
patient must also return for a safety-follow-up visit at 3 months (84 [+14] days) after 
his/her last dose of ALN-AS1. 
• A patient can stop taking the study drug and stop study-related visits, but allow the 
investigator and study team to review the patient’s medical records, public records or 
be contacted in order to receive information about the patient’s health 
When a patient stops the study, the discontinuation and reason for discontinuation must be 
recorded in the appropriate section of the electronic case report form (eCRF) and all efforts will 
be made to complete and report the observations as thoroughly as possible.  If a patient stops the 
study due to an adverse event (AE), including an SAE, the AE should be followed as described 
in Section 7.5.6. 
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writing or in any other form that may be locally required. The personal data already collected 
during the study, including patient’s biological samples, will still be used together with the data 
collected on other patients in the study according to the informed consent and applicable laws. 
In addition to stopping participation in the study, the patient could decide to withdraw his/her 
consent as explained in Section 5.3.3 
5.3.3. 
Withdrawal of Consent to Collect and Process the Patient’s Personal Data 
The patient may decide to withdraw his/her consent informing the study doctor at any time in 
writing, or in any other form that may be locally required.  This means that the patient wants to 
stop participation in the study and any further collection of his/her personal data.  
• The sponsor will continue to keep and use a patient's study information (including 
any data resulting from the analysis of the patient's biological samples until time of 
withdrawal) according to applicable law.  This is done to guarantee the validity of the 
study, determine the effects of the study treatment, and ensure completeness of study 
documentation. 
• The patient can also request that collected samples be destroyed or returned (to the 
extent it is permitted by applicable law) at any time. 
• Patients who withdraw their consent to collect and use personal data should 
understand that public records may be reviewed to determine the patient’s survival 
status as allowed per local and national regulations.    
In US and Japan, otherwise, samples not yet analyzed at the time of withdrawal may still be used 
for further testing/analysis in accordance with the terms of the protocol and of the informed 
consent form. 
In EU and rest of world, in any event, samples not yet analyzed at the time of withdrawal will 
not be used any longer, unless permitted by applicable law. They will be stored or destroyed 
according to applicable legal requirements. 
5.3.4. 
Replacement of Patients 
Patients discontinuing from study drug or withdrawing from the study will not be replaced. 
6. 
TREATMENTS 
6.1. 
Treatments Administered 
ALN-AS1 Solution for Injection (SC use) is a clear, colorless to pale yellow solution essentially 
free of particulates.  ALN-AS1 will be supplied by the Sponsor as a sterile solution for SC 
injection. 
Study drug supplied for this study must not be used for any purpose other than the present study 
and must not be administered to any person not enrolled in the study.  Study drug that has been 
dispensed to a patient and returned unused must not be re-dispensed to a different patient. 

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6.2. 
Investigational Study Drug 
Detailed information describing the preparation, handling, and storage, packaging and labeling, 
as well as study drug accountability for ALN-AS1 is provided in the Pharmacy Manual. 
6.2.1. 
Description 
ALN-AS1 Solution for Injection (SC use) is comprised of a synthetic, siRNA targeting ALAS1 
and bearing a triantennary GalNAc ligand conjugated to the sense strand, formulated in 
phosphate buffer.  
6.2.2. 
Dose and Administration 
The study starting dose of ALN-AS1 is 5.0 mg/kg ALN-AS1 as an SC injection administered 
every 3 months (Table 1, Table 2, and Table 3). Based on emerging clinical data, the SRC may 
approve changes to the ALN-AS1 dosing regimen, including decreases in the dose level and 
changes in dosing frequency (Table 5, Table 6, and Table 7 in Section 11.2).  However, any dose 
and dosing regimen will not exceed a previously explored dose level or frequency that was 
determined to be safe and well-tolerated in study ALN-AS1-001. SRC, Health Authority and 
Ethics Committee approval must be sought prior to dose level escalation above 5.0 mg/kg in 
accordance with local Regulatory requirements.  See Section 6.2.3 for details on dose 
modifications. 
The study drug should be injected into the abdomen or upper arms or thighs.  Detailed 
instructions for study drug administration are presented in the Pharmacy Manual. As is consistent 
with good medical practice for subcutaneous drug administration, patients will be observed for a 
minimum of 20 minutes after each injection.   Treatment for anaphylactic reactions should be 
readily available where patients are being dosed, and follow country and/or local hospital 
treatment guidelines as shown in Table 8.(36) 
ALN-AS1 will be administered by a qualified and authorized health care professional trained in 
the recognition and management of anaphylactic reactions.  After a patient has completed 12 
months of ALN-AS1 administration in this study (6 months in an every month dosing regimen), 
study drug administration may be conducted at a location other than the study center by a home 
healthcare professional, where applicable country and local regulations and infrastructure allow, 
after consultation with the medical monitor, during particular study visits, as specified in the 
Schedules of Assessments.  If the patient is unable to come to the study site, and a visit by a 
home healthcare professional is not possible due to circumstances related to the COVID-19 
pandemic, ALN-AS1 may be administered by the patient or the caregiver under the oversight of 
the Investigator, and following consultation with the medical monitor, as allowed by applicable 
country and local regulations.  In such cases, the patient or caregiver must receive appropriate 
training on ALN-AS1 administration and the use of epinephrine (epi pen or equivalent) prior to 
dosing.  This measure is intended to remain in effect only during periods of time when the 
COVID-19 pandemic impedes the ability of patients to travel to the study site or healthcare 
professionals to go to patients' homes for dosing.  However, study drug administration at the 
study center should be considered for patients who have ongoing study drug-related AEs or 
known risk factors for developing anaphylactic reaction, including but not limited to: a prior 
history of anaphylactic reaction to food, medications or due to unknown etiology, worsening 
injection site reactions with repeat dosing, or anyone in the opinion of the investigator that would 

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benefit from clinical observation following dosing.  Patients are required to complete at least 1 
visit at the clinical study center every 3 months for the first year, and thereafter every 6 months 
through the end of the treatment period.  Additional visits to collect clinical laboratory samples 
may occur at home at any point during the treatment period, within 14 days prior to scheduled 
dose administration. 
If a patient does not receive a dose of ALN-AS1 within the specified dosing window, the 
Investigator should contact the Medical Monitor.  After such consultation, the dose may be 
administered or considered missed and not administered. 
Patients will be permitted to miss an occasional dose of study drug; however, if a patient misses 
2 consecutive doses, the Investigator, in consultation with the Medical Monitor, will discuss 
whether the patient will be able to continue on the study.  
Detailed instructions for study drug administration are found in the Pharmacy Manual.  In 
addition, instructions and procedures related to administration of ALN-AS1 by a patient or 
caregiver will be provided in the Patient/Caregiver Storage and Administration Instructions. 
6.2.3. 
Dose Modifications 
6.2.3.1. 
Study Population Dose Modifications 
During the study, dose modifications are permitted for the study population, or based on the dose 
cohort into which patients were originally randomized in study ALN-AS1-001.  Following SRC 
review of emerging safety and tolerability data from Part C of study ALN-AS1-001, or from this 
study (ALN-AS1-002), the dose and dosing regimen may be modified.  However, the dose and 
dosing regimen of ALN-AS1 will not exceed a previously explored dose and dosing regimen that 
was determined to be safe and well-tolerated in study ALN-AS1-001.  Patients enrolling in this 
study after a dose modification decision has been implemented may start at the newly identified 
dose and regimen. 
6.2.3.2. 
Individual Dose Modifications 
Dose modifications are permitted for individual patients.  If a patient has a study drug related AE 
of a recurrent ISR, severe ISR, or clinically significant LFT abnormality and the Investigator has 
concerns regarding further ALN-AS1 administration, the Medical Monitor and Investigator will 
review all available safety data for the patient.  Based on this review, a dose reduction to half the 
previously administered dose (eg, a 5.0 mg/kg dose would be reduced to a 2.5 mg/kg dose) or a 
reduction in dosing frequency from monthly to every 3 months is permitted.  Subsequent ALN-
AS1 administration at the previous dose may be considered based on the judgment of the 
Investigator and Medical Monitor. 
6.2.3.2.1. Monitoring and Dosing Rules in Patients with Potential Cases of Anaphylactic 
Reaction   
An anaphylactic reaction is a severe, potentially fatal, systemic allergic reaction with acute onset 
(minutes to hours).  For reference see Section 11.3.(36) 
Stop administering the study medication immediately if an anaphylactic reaction to the study 
medication is suspected.  Study medication must be permanently discontinued in patients for 

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whom an anaphylactic reaction is assessed as related to the study medication. 
Laboratory testing: Obtain blood sample for tryptase, total IgE, and ADA antidrug antibodies 
(ADA) ideally within 15 minutes to 3 hours after the onset of a suspected anaphylactic reaction; 
however, up to 6 hours is acceptable.  An additional blood sample to assess tryptase, total IgE, 
and ADA should be obtained between 1 to 2 weeks from onset of event.  Local laboratory may 
be used to analyze samples; however, parallel samples should be sent to the central laboratory for 
analysis.  Sample collection and shipping instructions are included in the Laboratory Manual. 
Reporting: The PI or designee must notify the sponsor or designee within 24 hours of the 
occurrence of a suspected case of anaphylactic reaction or being informed of the case as required 
for AEs of Clinical Interest (AECI) and SAEs, per AE reporting requirements (Section 7.5.6.1,  
Section 7.5.6.2 and 7.5.6.3). 
6.2.4. 
Preparation, Handling, and Storage 
Staff at each clinical study center, or the home healthcare professional, will be responsible for 
preparation of ALN-AS1 doses, according to procedures detailed in the Pharmacy Manual.  In 
cases where ALN-AS1 is administered at home by a patient/caregiver, dosing may be prepared 
and administered by the patient/caregiver according to procedures detailed in the 
Patient/Caregiver Storage and Administration Instructions.  No special procedures for the safe 
handling of study drug are required. 
Study drug will be stored upright and refrigerated at approximately 5±3°C. 
A Sponsor representative or designee will be permitted, upon request, to audit the supplies, 
storage, dispensing procedures, and records. 
Additional storage and preparation details are provided in the Pharmacy Manual and the 
Patient/Caregiver Storage and Administration Instructions 
6.2.5. 
Packaging and Labeling 
All packaging, labeling, and production of study drug will be in compliance with current Good 
Manufacturing Practice specifications, as well as applicable local regulations.  Study drug labels 
and external packaging will include all appropriate information as per local labeling 
requirements. 
Additional details will be available in the Pharmacy Manual. 
6.2.6. 
Accountability 
The Investigator or designee will maintain accurate records of receipt and the condition of the 
study drug supplied for this study, including dates of receipt.  In addition, accurate records will 
be kept of when and how much study drug is dispensed and administered to each patient in the 
study.  Any reasons for departure from the protocol dispensing regimen must also be recorded. 
At the completion of the study, there will be a final reconciliation of all study drugs.  All used, 
partially used, and unused study drug will be returned to the Sponsor (or designee) or destroyed 
at the clinical study center according to applicable regulations.   
Further instructions about drug accountability are detailed in the Pharmacy Manual. 
 

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6.3. 
Concomitant Medications 
Use of concomitant medications will be recorded on the patient’s case report form (CRF) as 
indicated in the Schedules of Assessments (Table 1, Table 2, and Table 3; and Table 5, Table 6, 
and Table 7 in Appendix Section 11.2).  This includes all prescription medications, herbal 
preparations, over the counter (OTC) medications, vitamins, and minerals.  Any changes in 
medications during the study will also be recorded on the CRF. 
Any concomitant medication that is required for the patient’s welfare may be administered by the 
Investigator.  However, it is the responsibility of the Investigator to ensure that details regarding 
the medication are recorded on the eCRF.  Concomitant medication will be coded using an 
internationally recognized and accepted coding dictionary. 
During treatment with ALN-AS1, blood homocysteine levels may show an increase compared to 
levels before treatment.  Blood homocysteine levels will be assessed as indicated in the Schedule 
of Assessments (see Table 3 or Table 7).  It is recommended that patients with increased blood 
homocysteine levels receive a supplement containing vitamin B6.  All vitamin supplements 
should be recorded on the concomitant medications eCRF. 
Patients with porphyria could have altered hepatic heme synthesis, and treatment with ALN-AS1 
could also modulate this pathway and secondarily impact CYP enzyme activity.  Results from a 
DDI study in AIP patients who are ASHE are presented in Section 1.6.4.  The DDI study 
demonstrated that ALN-AS1 treatment resulted in weak to moderate reduction in activity in 
some of the CYP enzymes resulting in corresponding low to moderate increase in the plasma 
levels of drugs that are metabolized by these CYP enzymes.  Based on the moderate decrease in 
CYP2D6 or CYP1A2 activity, investigators will review all concomitant medications that are 
primarily metabolized by these enzymes and monitor the patient’s clinical response to these 
medications during the study.  Medications metabolized primarily by CYP2D6 and CYP1A2 
with a narrow therapeutic index (ie that require regular laboratory monitoring) may need to be 
monitored more frequently to determine if a dose adjustment of the concomitant medication is 
required.  For patients who require new medications while on study, selection of medications that 
are not primarily metabolized by CYP2D6 or CYP1A2 should be considered.  Refer to the 
individual product’s prescription information to determine if there is a need to monitor 
concomitant medications for differences in safety or efficacy of the medication based on reported 
DDIs with CYP2D6 or CYP1A2.  For more detailed and up-to-date information on CYP 
substrates, see: 
https://www.fda.gov/drugs/developmentapprovalprocess/developmentresources/druginteractionsl
abeling/ucm093664.htm. 
Patients are not permitted to be on hemin prophylaxis at Screening; however, patients are 
permitted to receive concomitant hemin treatment for the management of acute porphyria 
attacks.  Patients experiencing significant breakthrough attacks while enrolled in this study, 
necessitating frequent hemin treatment, may receive hemin prophylaxis if in the Investigator’s 
judgment this is clinically beneficial to the patient.  The Investigator should contact with the 
Sponsor and Medical Monitor before prophylactic hemin treatment.  The dose, regimen, and 
dates of administration will be recorded on the patient’s eCRF.   
Pain medication (eg, opiates, opioids, narcotic analgesics) and glucose administration are 
permitted for the management of porphyria and for acute porphyria attacks. 

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If patients use nonsteroidal anti-inflammatory medications intermittently or chronically, they 
must have been able to tolerate them with no previous side effects (eg, gastric distress or 
bleeding).   
Standard vitamins and topical medications are permitted; however, topical steroids must not be 
applied anywhere near the injection site(s) unless medically indicated. 
6.4. 
Contraceptive Requirements 
No data are available on the use of ALN-AS1 in pregnancy; however, there is no suspicion of 
human teratogenicity based on class effects or genotoxic potential.  ALN-AS1 was neither 
genotoxic nor clastogenic in in vitro and in vivo studies.   
WOCBP must be willing to use acceptable methods of contraception 14 days before first dose, 
throughout study participation, and for 90 days after last dose administration.   
Birth control methods which may be considered as acceptable include: 
• Established use of oral, implantable, injectable, transdermal hormonal, or intrauterine 
hormone-releasing system as methods of contraception.  WOCBP using hormonal 
methods of contraception must also use a barrier method (condom or occlusive cap 
[diaphragm or cervical/vault cap] in conjunction with spermicide [eg, foam, gel, film, 
cream, or suppository]). 
• If hormonal methods of contraception are medically contraindicated for WOCBP due 
to underlying disease, a double-barrier method (combination of male condom with 
either cap, diaphragm, or sponge, in conjunction with spermicide) is also considered 
an acceptable method of contraception. 
• Placement of an intrauterine device  
• Bilateral tubal occlusion 
• Surgical sterilization of male partner (with the appropriate post-vasectomy 
documentation of the absence of sperm in the ejaculate; for female patients on the 
study, the vasectomized male partner should be the sole partner for that patient) 
• Sexual abstinence, when this is in line with the preferred and usual lifestyle of the 
patient, is considered an acceptable method only if defined as refraining from 
heterosexual intercourse during the entire period of risk associated with the study 
drug (defined above).  Periodic abstinence (eg, calendar, ovulation, symptothermal, 
post-ovulation methods) and withdrawal are not considered sexual abstinence and do 
not meet criteria for an acceptable method of birth control.  As determined by the 
investigator, the reliability of sexual abstinence needs to be evaluated in relation to 
the duration of the clinical trial and the preferred and usual lifestyle of the patient.  
Abstinent patients must agree to use 1 of the abovementioned contraceptive methods 
if they start a heterosexual relationship during the study and continue to do so for the 
entire period of risk associated with the study drug (defined above). 
• WOCBP includes any female patient who has experienced menarche and who is not 
postmenopausal or permanently sterilized (eg, bilateral tubal occlusion, hysterectomy, 
or bilateral salpingectomy).  Postmenopausal state is defined as no menses for 12 

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months without an alternative medical cause, confirmed by follicle stimulating 
hormone level within the postmenopausal range. 
6.5. 
Treatment Compliance 
Compliance with study drug administration will be verified through observation by study 
personnel or trained home healthcare professionals.  
7. 
STUDY ASSESSMENTS 
The schedules of study assessments are provided in Table 1, Table 2, and Table 3; and Table 5, 
Table 6, and Table 7. 
Where applicable country and local regulations and infrastructure allow for home healthcare, 
healthcare may take place at a location other than the clinical trial site to perform study 
assessments including targeted physical exam/body system assessment, assessments for vital 
signs, and collection of blood and urine samples for safety laboratory assessments, and PD 
assessments, at all timepoints as specified in the Schedule of Assessments. 
7.1. 
Screening/Baseline Assessments 
Informed consent, patient demographic data, and eligibility criteria will be confirmed at 
Screening/Baseline.  An interval medical history/disease history will be obtained at 
Screening/Baseline.  The last assessments performed, determining previous study 
(ALN-AS1-001) completion, will serve as the Screening/Baseline assessments in this study.  If 
more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs will 
be repeated before administration of ALN-AS1. 
7.2. 
Clinical Activity Assessments 
The clinical activity of ALN-AS1 will be assessed by the frequency and characteristics of 
porphyria attacks including, but not limited to, duration, treatment, and severity of porphyria 
attacks and number and duration of visits to a health care setting for acute porphyria care (eg, 
hospital, emergency department, infusion center, or outpatient clinic).  Concomitant hemin 
administration will also be recorded. 
7.2.1. 
Patient Diary 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain 
assessments, and narcotic use. 
7.2.2. 
Brief Pain Inventory-Short Form Questionnaire 
The Brief Pain Inventory-Short Form (BPI-SF) questionnaire will be used to evaluate pain.(37)  
The BPI will be completed as part of the patient diary. 
7.3. 
Pharmacodynamic Assessments 
Blood and urine samples will be collected for assessment of ALN-AS1 PD parameters.  The PD 
effect of ALN-AS1 will be evaluated by urine ALA and PBG levels.  Blood and urine samples 

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will be collected for assessment of circulating ALAS1 mRNA levels in serum and in urine.  
Analysis for blood and urine PD parameters will take place at a central laboratory.   
Details regarding the processing and aliquoting of samples for storage and analyses will be 
provided in the Laboratory Manual. 
7.4. 
Pharmacokinetic Assessments 
Blood samples will be collected to evaluate the PK profile of ALN-AS1 at the time points in the 
Schedule of Assessments.  A detailed schedule of time points for the collection of blood samples 
for PK analysis is in Table 4 in Appendix Section 11.1). 
The concentration of ALN-AS1 will be determined using a validated assay.  Details regarding 
the processing, shipping, and analysis of the samples will be provided in the Laboratory Manual. 
7.5. 
Safety Assessments 
The assessment of safety during the course of the study will consist of the surveillance and 
recording of AEs including SAEs, recording of concomitant medications and measurements of 
vital signs, physical examination, and ECG findings and clinical laboratory evaluations. 
Safety will be monitored over the course of the study by an SRC as described in Section 4.6. 
7.5.1. 
Vital Signs 
Vital sign measurements include blood pressure, heart rate, body temperature, and respiratory 
rate.  Vital signs will be measured in the seated or supine position (should be consistent for each 
patient), after the patient has rested comfortably for at least 10 minutes.  Blood pressure should 
be taken using the same arm throughout the study.  Body temperature will be obtained in degrees 
Celsius, heart rate will be counted for a full minute and recorded in beats per minute, and 
respiration rate will be counted for a full minute and recorded in breaths per minute. 
For the safety of the patient, additional vital sign assessments may be added at the discretion of 
the Investigator. 
7.5.2. 
Weight and Height 
Height will be measured in centimeters at the Screening/Baseline visit only.  Body weight will be 
measured in kilograms.  Body mass index will be calculated in the database. 
Body weight measured on the dosing day will be used to calculate the dose of ALN-AS1 through 
M12.  After M12, weight obtained within 6 months during a study center visit or offsite may be 
used for dosing calculations. 
7.5.3. 
Physical Examination 
Complete physical examinations will include the examination of the following:  general 
appearance, head, eyes, ears, nose and throat, chest/respiratory, heart/cardiovascular, 
gastrointestinal/liver, musculoskeletal/extremities, dermatological/skin, thyroid/neck, lymph 
nodes, and neurological/psychiatric. 

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Targeted physical examinations will include the examination of the following:  general 
appearance, chest/respiratory, heart/cardiovascular, gastrointestinal/liver, and 
neurological/psychiatric. 
7.5.4. 
Electrocardiogram 
Triplicate standard 12-lead ECGs will be performed using central ECG equipment, with readings 
approximately 1 minute apart and recorded as specified in the Schedule of Assessments.  Patients 
should be seated or supine for at least 5 minutes before each ECG is obtained.  The 
electrophysiological parameters assessed will be rhythm, ventricular rate, PR interval, QRS 
duration, QT interval, ST and T waves, Bazett-corrected QT interval (QTcB), and Fridericia 
corrected QT interval (QTcF). 
When ECG and blood sample collection occur at the same time, ECGs should be performed 
before blood samples are drawn. 
Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine 
position after the patient has rested comfortably for at least 5 minutes.   
In all patients receiving ≤2.5 mg/kg ALN-AS1, it is required that ECGs will be obtained on at 
least 2 separate clinic visits (D1, and Months 3, 6, 9, 12, 15, or 18), each of which will include 
same day predose and 2-hour (±15 minutes) postdose readings, paired with PK timepoints 
(Table 4) as specified in the Schedule of Assessments.   
Similarly, in all patients receiving >2.5 mg/kg ALN-AS1, it is required that ECGs will be 
obtained on at least 2 separate clinic visits (D1, and Months 3, 6, 9, 12, 15, or 18), each of which 
will include same day predose and 4-hour (±20 minutes) postdose readings, paired with PK 
timepoints (Table 4), as specified in the Schedule of Assessments.  
The Investigator or designee is responsible for reviewing the ECGs to assess whether the results 
have changed since the Screening/Baseline visit and to determine the clinical relevance of the 
results.  These assessments will be recorded on the eCRF.  For any clinically relevant ECG 
changes from the Screening/Baseline visit (eg, ischemic ECG changes, wave/interval changes, or 
arrhythmia), the Investigator must contact the Medical Monitor to discuss continued participation 
of the patient in the study. 
7.5.5. 
Clinical Laboratory Assessments 
The following clinical laboratory tests will be evaluated by a central laboratory.   
On dosing days up to the Month 18 visit, results from hematology, chemistry, and coagulation 
tests collected within the prior 14 days must be reviewed by the Investigator before study drug 
administration.  These results can be analyzed centrally or at a local laboratory.  If results from 
within the prior 14 days are not available at a dosing visit (at visits from D1 to Month 18), 
locally analyzed assessments must be reviewed to allow same day study drug administration and 
additional samples for central analysis must also be collected.  On dosing days from Month 19 
through Month 48, a review of laboratory results within 14 days is not required. 
In the event of an unexplained clinically relevant abnormal laboratory test occurring after study 
drug administration, the test should be repeated and followed up at the discretion of the 

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Investigator until it has returned to the normal range or stabilized, and/or a diagnosis is made to 
adequately explain the abnormality. 
At any point during the study, and based on Investigator judgment, if a patient experiences 
uncharacteristic signs and symptoms during a porphyria attack, lipase testing should be 
performed and imaging evaluations (eg, right upper quadrant ultrasound and/or other testing, 
based on Investigator judgment) should be considered by the Investigator.  Signs and symptoms 
include, but are not limited to, uncharacteristic abdominal pain and worsening nausea and 
vomiting. 
Imaging is required for any serum lipase result of ≥3× the upper limit of normal, or as clinically 
indicated. 

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Hematology 
Complete blood count with differential 
 
Serum Chemistry 
Sodium 
Potassium 
BUN 
Phosphate 
Creatinine and eGFRa 
Albumin 
Uric acid 
Calcium 
Total protein 
Carbon dioxide 
Glucose 
Chloride 
Lipase 
Bicarbonate 
Liver Function Tests 
 
AST 
ALP 
ALT 
Bilirubin (total and direct) 
GGT 
 
Urinalysis 
Visual inspection for appearance and color 
Bilirubin 
pH (dipstick) 
Nitrite 
Specific gravity 
RBCs 
Ketones 
Urobilinogen 
Albumin 
Leukocytes 
Glucose 
Microscopy (if clinically indicated) 
Protein 
 
Immunogenicity 
Antidrug antibodies 
Coagulation 
Prothrombin time 
International Normalized Ratio 
Pregnancy Testing (WOCBP only) 
β-human chorionic gonadotropin 
 
Inflammation 
 
C-reactive protein 
 
Abbreviations:  AST=aspartate transaminase; ALP=alkaline phosphatase; ALT=alanine transaminase; 
BUN=blood urea nitrogen; eGFR=estimated glomerular filtration rate; GGT=gamma-glutamyltransferase; 
WOCBP=women of child bearing potential. 
a eGFR will be calculated using the Modification of Diet in Renal Disease formula.(38) 

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7.5.5.1. 
Immunogenicity 
Blood samples will be collected to evaluate antidrug antibodies.  On days when ALN-AS1 is 
administered, blood samples for antidrug antibody testing must be collected before ALN-AS1 is  
administered. 
Sample collection for patients who experience a potential anaphylactic reaction is discussed in 
Section 6.2.3.2.1. 
Details regarding the processing, shipping, and analysis of the samples will be provided in the 
Laboratory Manual. 
7.5.5.2. 
Pregnancy Testing 
A pregnancy test will be performed for WOCBP only.  A serum pregnancy test will be 
performed at Screening/Baseline and urine pregnancy tests will be performed thereafter per the 
Schedule of Assessments and any time pregnancy is suspected.  Urine pregnancy tests may also 
be performed more frequently (eg, monthly) based on local country requirements.  The results of 
the pregnancy test must be known before study drug administration.  Patients who are pregnant 
are not eligible for study participation.  Any woman with a positive pregnancy test during the 
study will be discontinued from study drug, but will continue to be followed for safety.  Patients 
determined to be pregnant while on study will be followed until the pregnancy outcome is known 
(see Section 7.5.6.6 for follow-up instructions).  
7.5.6. 
Adverse Events 
7.5.6.1. 
Definitions 
Adverse Event 
According to the ICH E2A guideline Definitions and Standards for Expedited Reporting, and 21 
Code of Federal Regulations 312.32, Investigational New Drug Safety Reporting, an AE is any 
untoward medical occurrence in a patient or clinical investigational subject administered a 
medicinal product and which does not necessarily have a causal relationship with this treatment. 
Serious Adverse Event 
An SAE is any untoward medical occurrence that at any dose: 
• Results in death 
• Is life-threatening (An event which places the patient at immediate risk of death from 
the event as it occurred.  It does not include an event that had it occurred in a more 
severe form might have caused death) 
• Requires in-patient hospitalization or prolongation of existing hospitalization 
• Results in persistent or significant disability or incapacity 
• Is a congenital anomaly or birth defect 
• Is an important medical event that may not be immediately life-threatening or result 
in death or hospitalization but may jeopardize the patient and may require 
intervention to prevent one of the other outcomes listed in the definition above (eg, 

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events include allergic bronchospasm requiring intensive treatment in an emergency 
room or at home, blood dyscrasias, convulsions, or the development of drug 
dependency or abuse). 
Adverse Event Severity 
Adverse events are to be graded according to the categories detailed below: 
Mild: 
Mild events are those which are easily tolerated with no disruption of normal 
daily activity. 
Moderate: 
Moderate events are those which cause sufficient discomfort to interfere with 
normal daily activities. 
Severe: 
Severe events are those which incapacitate and prevent usual activity. 
Changes in severity should be documented in the medical record to allow assessment of the 
duration of the event at each level of severity.  AEs characterized as intermittent require 
documentation of the start and stop of each incidence.  When changes in the severity of an AE 
occur more frequently than once a day, the maximum severity for the experience that day should 
be noted.  If the severity category changes over a number of days, then those changes should be 
recorded separately (with distinct onset dates) 
AE severity and seriousness are assessed independently.  ‘Severity’ characterizes the intensity of 
an AE.  ‘Serious’ is a regulatory definition and serves as a guide to the Sponsor for defining 
regulatory reporting obligations (see definition for Serious Adverse Event). 
Relationship of the Adverse Event to Study Treatment 
The relationship of each AE to study treatment should be evaluated by the Investigator using the 
following criteria:  
Definitely related: 
A clinical event, including laboratory test abnormality, occurring in a 
plausible time relationship to the medication administration, and which 
cannot be explained by concurrent disease or other drugs or chemicals.  
The response to withdrawal of the drug should be clinically plausible. 
Possibly related: 
A clinical event, including laboratory test abnormality, with a 
reasonable time sequence to the medication administration, but which 
could also be explained by concurrent disease or other drugs or 
chemicals.  Information on the drug withdrawal may be lacking or 
unclear. 
Unlikely related: 
A clinical event, including laboratory test abnormality, with little or no 
temporal relationship to medication administration, and which other 
drugs, chemicals, or underlying disease provide plausible explanations. 
Not related: 
A clinical event, including laboratory test abnormality that has no 
temporal relationship to the medication or has more likely alternative 
etiology. 

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Adverse Events of Clinical Interest 
The following events are considered to be adverse events of clinical interest: 
• ISRs 
• Hepatic AEs, including LFT abnormalities considered clinically significant by the 
Investigator. 
• Lipase >3×ULN (or >3× the baseline lipase measurement if baseline is >ULN) 
• Anaphylactic Reactions. Anaphylactic reaction is a severe, potentially fatal, systemic 
allergic reaction with acute onset (minutes to hours).  Symptoms of an anaphylactic 
reaction may include skin or mucosal tissue (e.g. generalized hives, pruritus, 
angioedema), respiratory compromise (e.g. wheezing, bronchospasm, hypoxia), 
reduced blood pressure or associated symptoms (e.g. syncope, hypotonia).  See 
Section 11.3 (Table 8) for guidance on diagnosing anaphylactic reactions.(36) 
7.5.6.2. 
Eliciting and Recording Adverse Events 
Eliciting Adverse Events 
The patient should be asked about medically relevant changes in his/her health since the last 
visit.  The patient should also be asked if he/she has been hospitalized, had any accidents, used 
any new medications, or changed concomitant medication routines (both prescription and OTC).  
In addition to patient observations, AEs will be documented from any clinically relevant 
laboratory findings, physical examination findings, ECG changes, or other findings that are 
relevant to patient safety. 
Recording Adverse Events 
The Investigator is responsible for recording non-serious AEs that are observed or reported by 
the patient after administration of the first dose of study drug regardless of their relationship to 
study drug through the end of study.  Non-serious AEs will be followed until the end of study.  
The Investigator is responsible for recording SAEs that are observed or reported by the patient 
after the time when the informed consent is signed regardless of their relationship to study drug 
through the end of study.  SAEs will be followed until satisfactory resolution, until baseline level 
is reached, or until the SAE is considered by the Investigator to be chronic or the patient is 
stable, as appropriate. 
All AEs must be recorded in the source records for the clinical study center and in the eCRF for 
the patient, whether or not they are considered to be drug-related.  Each AE must be described in 
detail:  onset time and date, description of event, severity, relationship to investigational drug, 
action taken, and outcome (including time and date of resolution, if applicable). 
For SAEs, record the event(s) on the eCRF.  If the electronic data capture (EDC) system is 
unavailable, complete the backup SAE form. 
For AEs that are considered AEs of clinical interest, the Sponsor or its designee should be 
notified within 24 hours using a supplemental AEs of clinical interest (AECI) eCRF.  Additional 
clinical and laboratory information may be collected based upon the severity or nature of the 
event. 

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If a patient has ISRs meeting any of the following criteria, the Investigator or delegate should 
contact the Medical Monitor and submit a supplemental ISR eCRF: 
• ISRs that are recurrent and/or demonstrate a pattern of increasing severity 
• Any ISR that is determined to be severe and/or a cause for study drug discontinuation  
• Any ISR which, in the opinion of the Investigator, requires further medical evaluation 
or treatment 
In some cases, where it is medically appropriate, further evaluation may include photographs, 
referral to a dermatologist, skin biopsy, or other laboratory testing.  If a biopsy was obtained, the 
Sponsor may request that the biopsy also be reviewed by a central dermatopathologist.  To better 
understand the safety profile of the study drug, additional analysis of biopsy tissue may be 
performed according to local regulations. 
For patients with hepatic AEs, additional information, including, clinical history, course of event, 
and local laboratory results to monitor LFT levels or other laboratory parameters, may be 
collected. 
7.5.6.3. 
Serious Adverse Events Require Immediate Reporting to Sponsor/Designee 
An assessment of the seriousness of each AE will be made by the Investigator.  Any AE and 
laboratory abnormality that meets the SAE criteria in Section 7.5.6.1 must be reported to the 
Sponsor or designee within 24 hours from the time that clinical study center personnel first 
learns of the event.  All SAEs must be reported regardless of the relationship to study drug. 
The initial report should include at least the following information: 
• Patient’s study number 
• Description and date of onset of the event 
• Criterion for serious 
• Preliminary assignment of relationship to study drug 
• Investigator/clinical study center information 
To report the SAE, complete the eCRF.  If the EDC system is unavailable, complete the backup 
SAE form.  Within 24 hours of receipt of follow-up information, the Investigator must update the 
report.  SAEs must be reported using the contact information provided in the Study Manual. 
Appropriate remedial measures should be taken by the Investigator using his/her best medical 
judgment to treat the SAE.  These measures and the patient’s response to these measures should 
be recorded.  All SAEs, regardless of relationship to study drug, will be followed by the 
Investigator until satisfactory resolution or the Investigator deems the SAE to be chronic or 
stable.  Clinical, laboratory, and diagnostic measures should be employed by the Investigator as 
needed to adequately determine the etiology of the event. 
7.5.6.4. 
Sponsor Safety Reporting to Regulatory Authorities 
The Sponsor or its representative is required to report certain study events in an expedited 
manner to the Food and Drug Administration, the European Medicines Agency’s EudraVigilance 

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electronic system according to Directive 2001/20/EC, and to all country Regulatory Authorities 
where the study is being conducted, according to local applicable regulations. 
The following describes the safety reporting timeline requirements for suspected unexpected 
serious adverse reactions (SUSARs) and other reportable events: 
Immediately and within 7 calendar days 
• Any suspected adverse reaction that is associated with the use of the study drug, 
unexpected, and fatal or life threatening.  Follow-up information must be reported in 
the following 8 days. 
Immediately and within 15 calendar days 
• Any suspected adverse reaction that is associated with the use of the study drug, 
unexpected, and serious, but not fatal or life threatening, and there is evidence to 
suggest a causal relationship between the study drug and the reaction. 
• Any finding from tests in laboratory animals that suggest a significant risk for human 
patients including reports of mutagenicity, teratogenicity, or carcinogenicity. 
• Any event in connection with the conduct of the study or the development of the 
study drug that may affect the safety of the trial patients. 
In addition, periodic safety reporting to regulatory authorities will be performed by the Sponsor 
or its representative according to national and local regulations. 
7.5.6.5. 
Serious Adverse Event Notification to the Institutional Review 
Board/Independent Ethics Committee 
SUSARs will be reported to the Institutional Review Board (IRB)/Independent Ethics 
Committee (IEC) per their institutional policy by the Investigator or Sponsor (or Sponsor 
designee) according to country requirements.  Copies of each report and documentation of 
IRB/IEC notification and acknowledgement of receipt will be kept in the Investigator’s study 
file. 
7.5.6.6. 
Pregnancy Reporting 
If a female patient becomes pregnant during the course of this study through 90 days following 
the last dose of study drug, the Investigator must report the pregnancy to the Sponsor or designee 
within 24 hours of being notified of the pregnancy.  Details of the pregnancy will be recorded on 
the pregnancy reporting form.  The patient should receive any necessary counseling regarding 
the risks of continuing the pregnancy and the possible effects on the fetus. 
The pregnancy should be followed by the Investigator until completion.  At the completion of the 
pregnancy, the Investigator will document the outcome of the pregnancy.  If the outcome of the 
pregnancy results in a postpartum complication, spontaneous abortion, stillbirth, neonatal death, 
or congenital anomaly, then the Investigator should follow the procedures for reporting an SAE 
as outlined in Section 7.5.6.3.   

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7.5.6.7. 
Overdose Reporting 
An overdose is defined as any dose administered to or taken by a patient (accidentally or 
intentionally) that exceeds the highest daily dose, or is at a higher frequency, than included in the 
protocol.  It is up to the investigator to decide whether a dose is to be considered an overdose, in 
consultation with the Sponsor.  Overdose must be recorded in the eCRF. 
All reports of overdose (with or without an AE) must be reported within 24 hours to the Sponsor 
or designee.   
7.6. 
Exploratory Assessments 
Blood and urine samples will be collected for exploratory analyses.  Aliquots of samples will be 
obtained and frozen, to permit future analysis of the effect of ALN-AS1 on exploratory 
biomarkers.  Samples may also be used for testing homocysteine levels. 
Where local regulations allow, biologic samples will be retained on behalf of the Sponsor for a 
maximum of 15 years following the last patient’s last visit in the study.  Details regarding the 
collection, processing, storage, and shipping of samples will be in the Laboratory Manual. 
7.7. 
Other Assessments 
7.7.1. 
EQ-5D-5L Questionnaire 
QOL will be assessed through the use of the 5-level EQ-5D (EQ-5D-5L), a standardized 
questionnaire measuring health outcomes.(39)  In addition to the time points indicated, the 
EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a 
porphyria attack (but, not more than once in a 6 month period), if possible. 
7.8. 
COVID-19 Data Collection 
Information on the coronavirus disease 2019 (COVID-19) infection status of the patient, if 
known, and other information on the impact of the COVID-19 pandemic on the patient's 
participation in the study will be collected. 
8. 
STATISTICS 
A detailed Statistical Analysis Plan (SAP) will be written after finalizing the protocol and before 
database lock.  The plan will detail the implementation of all the statistical analyses in 
accordance with the principle features stated in the protocol. 
8.1. 
Determination of Sample Size 
This is a Phase 1/2 multicenter, open-label extension study to evaluate the long-term safety and 
clinical activity of ALN-AS1 in patients with AIP who completed study ALN-AS1-001.  Safety, 
tolerability, PK, and PD of ALN-AS1 will be investigated.  The sample size was not determined 
based on statistical considerations.  Up to 24 patients are planned for this study (including 
optional cohorts in ALN-AS1-001). 

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8.2. 
Statistical Methodology 
The statistical and analytical plans presented below summarize the more complete plans to be 
detailed in the SAP.  Any changes to the methods described in the final SAP will be described 
and justified as needed in the clinical study report. 
Statistical analyses will be primarily descriptive in nature.  Descriptive statistics (eg, mean, 
standard deviation, median, minimum, and maximum) will be presented for continuous 
variables.  Frequencies and percentages will be presented for categorical and ordinal variables. 
Analyses will be performed using SAS® (Version 9.2, or higher). 
8.2.1. 
Populations to be Analyzed 
The populations (analysis sets) are defined as follows:  
Safety Analysis Set: 
All patients who received any amount of study drug. 
Clinical Activity Analysis 
Set: 
All patients who received any amount of study drug and have 
both a baseline and at least 1 postdose assessment. 
PK Analysis Set: 
All patients who received any amount of study drug and have at 
least 1 postdose blood sample for PK and who have evaluable 
PK data. 
PD Analysis Set: 
All patients who received any amount of study drug and who 
have at least 1 postdose blood sample for the determination of 
ALN-AS1 will be included in the PD analyses. 
Safety will be analyzed using the Safety Analysis Set.  The PK and PD Analysis Sets will be 
used to conduct PK and PD analyses, respectively.  The population used to evaluate clinical 
activity will be the Clinical Activity Analysis Set.   
8.2.2. 
Examination of Subgroups 
Subgroup analyses may be conducted for selected endpoints.  Detailed methodology will be 
provided in the SAP. 
8.2.3. 
Handling of Missing Data 
Unrecorded values will be treated as missing.  The appropriateness of the method(s) described 
for handling missing data may be reassessed and documented in the SAP before database lock.  
Depending on the extent of missing values, further investigation may be made into the sensitivity 
of the analysis results to the method(s) specified. 
8.2.4. 
Baseline Evaluations 
Demographics, medical history, disease-specific information, and other baseline characteristics 
collected in this study will be summarized.   
8.2.5. 
Clinical Activity Analyses 
Clinical activity of ALN-AS1 will be summarized primarily by descriptive statistics.  The 
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attacks including duration, treatment, and severity of porphyria attacks and number and duration 
of visits to a health care setting for acute porphyria care. 
Patient diary recordings, including BPI-SF questionnaire scores, will also be summarized. 
8.2.6. 
Pharmacodynamic Analysis 
PD analyses will include the evaluation of change in ALA, PBG, and ALAS mRNA levels.  
Descriptive statistics (eg, mean and standard error of the mean) for observed levels of PD 
parameters and the relative change from baseline will be presented for each of the postdose 
follow-up time points. 
8.2.7. 
Pharmacokinetic Analysis 
The PK concentration of ALN-AS1 will be determined. 
Antidrug antibody results will be tabulated.  A by-patient data listing will also be provided. 
8.2.8. 
Safety Analyses 
Extent of exposure will be summarized.  AEs will be summarized by the Medical Dictionary for 
Regulatory Activities System Organ Class and Preferred Term.  Prior and concomitant 
medications will be classified according to the World Health Organization drug dictionary. 
Incidence of AEs (those events that started after exposure to study drug or worsened in severity 
after dosing) will be presented.  Incidence of AEs will also be presented by maximum severity 
and relationship to study treatment.  The incidence of SAEs and AEs leading to discontinuation 
of treatment will also be tabulated.  By-patient listings will be provided for deaths, SAEs, and 
AEs leading to discontinuation of treatment.   
Descriptive statistics will be provided for clinical laboratory data and vital signs data, presented 
as both actual values and changes from baseline relative to each on-study evaluation and to the 
last evaluation on study.  Laboratory shift tables from baseline to worst values will be presented.  
Abnormal physical examination findings and 12-lead ECG data will be presented in a by-patient 
data listing. 
Descriptive statistics will be provided for ECG interval data and presented as both actual values 
and changes from baseline relative to each on-study evaluation and to the last evaluation on 
study.  Details of any abnormalities will be included in patient listings. 
Concomitant hemin administration will also be recorded. 
8.2.9. 
Other Analyses 
Possible associations between PD parameters (ALA, PBG, and ALAS1 mRNA levels) and 
clinical activity parameters may also be explored. 
Additional exploratory analyses may be conducted on analytes related to targeting the heme 
biosynthesis pathway. 
QOL scores on the EQ-5D-5L questionnaire will also be summarized. 
Additional data summaries to help understand any impact of the COVID-19 pandemic on 
efficacy, PK, PD, and safety assessments will be performed, as appropriate. 

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9. 
STUDY ADMINISTRATION 
9.1. 
Ethical and Regulatory Considerations 
This study will be conducted in accordance with the protocol, all applicable regulatory 
requirements, and the guidelines of Good Clinical Practice (GCP).  Compliance with GCP 
provides public assurance that the rights, safety, and well-being of study patients are protected 
consistent with the principles that have their origin in the Declaration of Helsinki. 
9.1.1. 
Informed Consent 
The Investigator will ensure that the patient is given full and adequate oral and written 
information about the nature, purpose, possible risk and benefit of the study.  Patients must also 
be notified that they are free to withdraw from the study at any time.  The patient should be given 
the opportunity to ask questions and allowed time to consider the information provided. 
The patient’s signed and dated informed consent must be obtained before conducting any study 
procedures. 
The Investigator must maintain the original, signed ICF.  A copy of the signed ICF must be 
given to the patient. 
The Investigator will inform the patient/legal guardian if new information becomes available that 
may be relevant to the patient’s/legal guardian’s willingness to continue participation in the 
study.  Communication of this information should be documented. 
9.1.2. 
Ethical Review 
The final study protocol, including the final version of the ICF, must be approved or given a 
favorable opinion in writing by an IRB or IEC, as appropriate.  The Investigator must submit 
written approval before he or she can enroll any patient into the study. 
The Investigator is responsible for informing the IRB or IEC of any amendment to the protocol 
in accordance with local requirements.  In addition, the IRB or IEC must approve all patient 
materials for the study (except those that support the need to remove an apparent immediate 
hazard to the patient).  The protocol must be reapproved by the IRB or IEC upon receipt of 
amendments and annually, as local regulations require. 
Initial IRB approval of the protocol, and all materials approved by the IRB for this study 
including the patient consent form and recruitment materials must be maintained by the 
Investigator and made available for inspection. 
The Investigator will submit reports of SAEs as outlined in Section 7.5.6.  In addition, the 
Investigator agrees to submit progress reports to the IRB or IEC per their local reporting 
requirements, or at least annually and at the conclusion of the study.  The reports will be made 
available to the Sponsor or designee. 
Any communications from regulatory agencies in regard to inspections, other studies that impact 
this protocol or the qualifications of study personnel should be promptly reported to the Sponsor 
or its designee. 

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The Investigator is also responsible for providing the IRB with reports of any reportable serious 
adverse drug reactions from any other study conducted with the investigational drug.  The 
Sponsor or designee will provide this information to the Investigator. 
Major changes in this research activity, except those to remove an apparent immediate hazard to 
the patient, must be reviewed and approved by the Sponsor and the IRB or IEC that approved the 
study.  Amendments to the protocol must be submitted in writing to the Investigator’s IRB or 
IEC and the Regulatory Authority for approval before patients are enrolled under the amended 
protocol. 
9.1.3. 
Serious Breach of Protocol 
Investigators must notify the Medical Monitor within 24 hours of becoming aware of a potential 
serious breach of the protocol.  A serious breach is a breach that is likely to affect to a significant 
degree the safety and rights of a study participant or the reliability and robustness of the data 
generated in the clinical trial. 
9.1.4. 
Study Documentation, Confidentiality, and Records Retention 
All documentation relating to the study should be retained for the period of time required by 
applicable local law.  If it becomes necessary for the Sponsor, the Sponsor’s designee, applicable 
IRB/IEC, or applicable regulatory authorities to review or audit any documentation relating to 
the study, the Investigator must permit direct access to all source documents/data.  Records will 
not be destroyed without informing the Sponsor in writing and giving the Sponsor the 
opportunity to store the records for a longer period of time at the Sponsor’s expense.   
The Investigator must ensure that the patients’ confidentiality will be maintained.  On the CRFs 
or other documents submitted to the Sponsor or designees, patients should not be identified by 
their names, but by the assigned patient number and initials.  If patient names are included on 
copies of documents submitted to the Sponsor or designees, the names (except for initials) will 
be obliterated and the assigned patient number added to the document.  Documents not for 
submission to the Sponsor (eg, signed ICFs) should be maintained by the Investigator in strict 
confidence. 
The Investigator must treat all of the information related to the study and the compiled data as 
confidential, whose use is for the purpose of conducting the study.  The Sponsor must approve 
any transfer of information not directly involved in the study. 
In compliance with local and/or regional regulations, this clinical study may be registered and 
study results may be posted on public registries, such as ClinicalTrials.gov. 
9.1.5. 
End of the Study 
The end of the study is defined as last patient last visit. 
9.1.6. 
Discontinuation of the Clinical Study 
The Sponsor reserves the right to discontinue the study for clinical or administrative reasons at 
any time.  If the clinical study center does not recruit at a reasonable rate, the study may be 
discontinued at that clinical study center.  Should the study be terminated and/or the clinical 
study center closed for whatever reason, all documentation and study drug pertaining to the study 

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must be returned to the Sponsor or its representative, and the Investigators, IEC/IRB and 
Regulatory Authorities will be promptly informed of the termination and the reason for the 
decision.  The Investigator should promptly inform the patients and assure appropriate therapy 
and follow-up.  Patients should then be withdrawn from the study.   
9.2. 
Data Quality Control and Quality Assurance 
9.2.1. 
Data Handling 
Study data must be recorded on case report forms (paper and/or electronic) provided by the 
Sponsor or designee on behalf of the Sponsor.  Case report forms must be completed only by 
persons designated by the Investigator.  If eCRFs are used, study data must be entered by trained 
clinical study center personnel with access to a valid and secure eCRF system.  All data entered 
into the eCRF must also be available in the source documents.  Corrections on paper CRFs must 
be made so as to not obliterate the original data and must be initialed and dated by the person 
who made the correction. 
9.2.2. 
Study Monitoring 
The clinical monitor, as a representative of the Sponsor, has an obligation to closely follow the 
study conduct at the clinical study center.  The monitor will visit the Investigator and clinical 
study center periodically and will maintain frequent telephone and written contact.  The monitor 
will maintain current personal knowledge of the study through observation, review of study 
records and source documentation, and discussion of the conduct of the study with the 
Investigator and personnel. 
The monitor will review source documents, systems and CRFs to ensure overall quality and 
completeness of the data and to confirm study procedures are complied with the requirements in 
the study protocol.  The Sponsor, or its designee, will be allowed to conduct clinical study center 
visits to the investigation facilities for the purpose of monitoring any aspect of the study.  The 
Investigator agrees to allow the monitor to inspect the drug storage area, study drug stocks, drug 
accountability records, patient charts and study source documents, and other records relative to 
study conduct. 
9.2.3. 
Audits and Inspections 
Periodically, the Sponsor or its authorized representatives audit clinical investigative study 
centers as an independent review of core trial processes and documents to determine whether 
these activities were conducted, and data were recorded, analyzed, and accurately reported 
according to the protocol, GCP guidelines of the ICH, and any applicable regulatory 
requirements.  A regulatory authority, an IEC or an IRB may visit the clinical study center to 
perform audits or inspections, including source data verification.  The Investigator should contact 
the Sponsor, or its designee, immediately if contacted by a regulatory agency about an 
inspection. 
9.3. 
Publication Policy 
It is intended that after completion of the study, the data are to be submitted for publication in a 
scientific journal and/or for reporting at a scientific meeting.  A copy of any proposed manuscript 
must be provided and confirmed received at the Sponsor at least 30 days before its submission, 
and according to any additional publication details in the Investigator Agreement. 

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10. 
LIST OF REFERENCES 
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5. Puy H, Gouya L, Deybach JC. Porphyrias. Lancet. 2010;375(9718):924-37. 
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Plasma and Urine from Asymptomatic Carriers of the Acute Intermittent Porphyria Gene with 
Increased Porphyrin Precursor Excretion. Clinical Chemistry. 2006;52(4):701-7. 
7. Anderson K. Disorders of Heme Biosynthesis. 2001. 
8. Dowman JK, Gunson BK, Mirza DF, Bramhall SR, Badminton MN, Newsome PN. Liver 
transplantation for acute intermittent porphyria is complicated by a high rate of hepatic artery 
thrombosis. Liver Transplantation. 2012;18(2):195-200. 
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Inherit Metab Dis. 2005;28(3):277-86. 
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Porphyrin Handbook. Amsterdam: Academic Press; 2003. p. 23-41. 
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northern Sweden: a population-based study. Scand J Clin Lab Invest. 2009;69(5):612-8. 
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15. Bonkovsky HL. Neurovisceral porphyrias: what a hematologist needs to know. Hematology 
Am Soc Hematol Educ Program. 2005:24-30. 

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16. PanhematinPI. Panhematin Prescribing Information. 2017. 
17. NormosangSmPC. Normosang Summary of Product Characteristics. 2017. 
18. Watson CJ, Pierach CA, Bossenmaier I, Cardinal R. Postulated deficiency of hepatic heme 
and repair by hematin infusions in the "inducible" hepatic porphyrias. Proc Natl Acad Sci U S A. 
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19. Mustajoki P, Nordmann Y. Early administration of heme arginate for acute porphyric attacks. 
Arch Intern Med. 1993;153(17):2004-8. 
20. Bonkovsky HL, Singh RH, Jafri IH, Fiellin DA, Smith GS, Simon D, et al. A randomized, 
controlled trial of treatment of alcoholic hepatitis with parenteral nutrition and oxandrolone. II. 
Short-term effects on nitrogen metabolism, metabolic balance, and nutrition. Am J Gastroenterol. 
1991;86(9):1209-18. 
21. Herrick AL, McColl KE, Moore MR, Cook A, Goldberg A. Controlled trial of haem arginate 
in acute hepatic porphyria. Lancet. 1989;1(8650):1295-7. 
22. Bissell DM. Treatment of acute hepatic porphyria with hematin. J Hepatol. 1988;6(1):1-7. 
23. Green D, Ts'ao CH. Hematin: effects on hemostasis. J Lab Clin Med. 1990;115(2):144-7. 
24. Daimon M, Susa S, Igarashi M, Kato T, Kameda W. Administration of heme arginate, but 
not hematin, caused anaphylactic shock. Am J Med. 2001;110(3):240. 
25. Elder G, Harper P, Badminton M, Sandberg S, Deybach JC. The incidence of inherited 
porphyrias in Europe. J Inherit Metab Dis. 2013;36(5):849-57. 
26. Anderson KE, Egger NG, Goeger DE. Heme arginate for prevention of acute porphyric 
attacks. Acta Haematologica. 1997;98:120. 
27. Bonkovsky HL, Guo JT, Hou W, Li T, Narang T, Thapar M. Porphyrin and heme 
metabolism and the porphyrias. Compr Physiol. 2013;3(1):365-401. 
28. Vaishnaw AK, Gollob J, Gamba-Vitalo C, Hutabarat R, Sah D, Meyers R, et al. A status 
report on RNAi therapeutics. Silence. 2010;1(1):14. 
29. Elbashir SM, Harborth J, Lendeckel W, Yalcin A, Weber K, Tuschl T. Duplexes of 21-
nucleotide RNAs mediate RNA interference in cultured mammalian cells. Nature. 
2001;411(6836):494-8. 
30. Kauppinen R, von und zu Fraunberg M. Molecular and biochemical studies of acute 
intermittent porphyria in 196 patients and their families. Clin Chem. 2002;48(11):1891-900. 
31. Ryu JY, Song IS, Sunwoo YE, Shon JH, Liu KH, Cha IJ, et al. Development of the "Inje 
cocktail" for high-throughput evaluation of five human cytochrome P450 isoforms in vivo. Clin 
Pharmacol Ther. 2007;82(5):531-40. 

Clinical Study Protocol ALN-AS1-002 
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32. Williams D, Tao X, Zhu L, Stonier M, Lutz JD, Masson E, et al. Use of a cocktail probe to 
assess potential drug interactions with cytochrome P450 after administration of belatacept, a 
costimulatory immunomodulator. Br J Clin Pharmacol. 2017;83(2):370-80. 
33. Ventura P, Corradini E, Di Pierro E, Marchini S, Marcacci M, Cuoghi C, et al. 
Hyperhomocysteinemia in patients with acute porphyrias: A potentially dangerous metabolic 
crossroad? Eur J Intern Med. 2020;79:101-7. 
34. To-Figueras J, Lopez RM, Deulofeu R, Herrero C. Preliminary report: 
hyperhomocysteinemia in patients with acute intermittent porphyria. Metabolism. 
2010;59(12):1809-10. 
35. Maron BA, Loscalzo J. The treatment of hyperhomocysteinemia. Annu Rev Med. 
2009;60:39-54. 
36. Sampson HA, Munoz-Furlong A, Campbell RL, Adkinson NF, Jr., Bock SA, Branum A, et 
al. Second symposium on the definition and management of anaphylaxis: summary report--
second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis 
Network symposium. Ann Emerg Med. 2006;47(4):373-80. 
37. Atkinson TM, Mendoza TR, Sit L, Passik S, Scher HI, Cleeland C, et al. The Brief Pain 
Inventory and its "pain at its worst in the last 24 hours" item: clinical trial endpoint 
considerations. Pain Med. 2010;11(3):337-46. 
38. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF, 3rd, Feldman HI, et al. A new 
equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150(9):604-12. 
39. Herdman M, Gudex C, Lloyd A, Janssen M, Kind P, Parkin D, et al. Development and 
preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res. 
2011;20(10):1727-36. 
 

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11. 
APPENDICES 
11.1. 
Pharmacokinetic Assessment Time Points 
Table 4 contains a detailed schedule for the collection of blood samples for PK analysis. 
Table 4: 
Pharmacokinetic Time Points 
Study Day 
 
Protocol Time 
(hh:mm) 
PK Blood 
Day 1 and 
Month 12 (D361) ±10 
days 
 
Predose (within 60 
minutes before dosing) 
X 
 
02:00 (±15 minutes)b 
X 
 
06:00 (±20 minutes) 
X 
Month 1 (Day 14) ±2 
days 
 
Anytime during visit 
X 
Month 1 (Day 31) ±7 
days,a  
Month 3 (Day 91) ±7 
days, 
Month 6 (Day 181) ±7 
days, 
Month 9 (Day 271) ±10 
daysd, 
Month 15 (Day 451) ±10 
daysd, 
Month 18 (Day 541) ±10 
days  
Month 24 (Day 721) ±10 
days 
 
Predose (within 60 
minutes before dosing) 
X 
 
02:00 (±15 minutes)b 
X 
 
04:00 (±20 minutes)c 
Abbreviations:  hh=hours; mm=minutes; PK=pharmacokinetic. 
a At the Day 31, Month 1 visit, if the dosing regimen is every 3 months, ALN-AS1 is not administered and a 
single time point blood sample for PK analysis should be collected. 
b Only in patients receiving ≤2.5 mg/kg ALN-AS1; paired with ECG (for ECG details, see Section 7.5.4).  
c Only in patients receiving >2.5 mg/kg ALN-AS1; paired with ECG (for ECG details, see Section 7.5.4). 
d Blood sample collection for PK analysis at Month 9 and Month 15 is only necessary if ECG will be performed 
at same visit. 

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11.2. 
Schedules of Assessments for Every Month Dosing Regimen 
 Table 5: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14 ±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical 
History/Disease 
Historyc 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/ 
Exclusion Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examinationd 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
 
 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
X 
Vital Signsf 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead 
ECGg 
X 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Clinical Laboratory 
Assessmenth 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug 
Administrationj 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 

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 Table 5: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14 ±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Blood and Urine 
Sample for Exploratory 
Biomarker Analysisl 
 
X 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Blood Sample for PK 
Analysism 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Antidrug Antibodiesn 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
Porphyria Attack Kit 
Dispensationo 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EQ-5D-5L 
Questionnairep 
X 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Diary Review 
(including BPI-SF)q 
 
 
X 
AEs 
 
Continuous 
Concomitant 
Medicationsr 
 
Continuous 
 
Abbreviations:  AE=adverse event; ALAS1=5-aminolevulinic acid synthase 1; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief 
Pain Inventory-Short Form; D=day; ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of 
life; SC=subcutaneous. 
Notes:   
• 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may 
be conducted while the patient is at home. 
• 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical 
examinations and blood/urine sample collections. 

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a Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study (ALN-AS1-001) were completed within 60 days 
of administration of the first dose of ALN-AS1 in this study.  If more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs 
will be repeated before administration of ALN-AS1.  Results should be available and deemed acceptable before the administration of the first dose of ALN-
AS1. 
b After a patient has completed 6 months of ALN-AS1 administration in this study, and where applicable country and local regulations and infrastructure allow, 
study procedures, including ALN-AS1 administration, may take place at the patient’s home by a healthcare professional.  Study procedures may occur at the 
patient’s home at the discretion of the Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit at the clinical 
study center Q3M through M12, and thereafter Q6M. Additional visits to collect clinical laboratory samples may occur at home at any point during the 
treatment period, within 14 days prior to scheduled dose administration. 
c See Section 7.1 for details on the interval medical history/disease history to be recorded at Screening/Baseline.  Ongoing AEs from the previous study 
(ALN-AS1-001) will be captured as medical history. 
d A complete physical examination will be performed at Screening/Baseline, and D1.  At all other visits, a targeted physical examination will be performed.  On 
dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any time 
during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On D1, vital signs will be collected within 1 hour predose; and 2 hours 
(±10 minutes) postdose.  On all other dosing days, vital signs will be collected within 1 hour predose.  On days when ALN-AS1 is not administered, vital signs 
can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position (should be consistent for each patient), after the 
patient has rested comfortably for 10 minutes. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at least 5 
minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1 ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose at a minimum of 2 
of the following visits:  D1, Month 3, Month 6, Month 9, Month 12, Month 15 (only if visit is done at clinic), or Month 18.  In patients receiving >2.5 mg/kg 
ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose at a minimum of two of the following visits:  D1, Month 3, 
Month 6, Month 9, Month 12, Month 15 (only if visit is done at clinic), or Month 18.  On all other dosing days, ECGs will be collected within 1 hour predose 
(see Section 7.5.4  for ECG assessment details). 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  On 
days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. On dosing days up to the Month 18 visit,results from 
hematology, chemistry (including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the Investigator before study drug 
administration.  If results from within the prior 14 days are not available at a dosing visit (at visits from D1 to Month 18), locally analyzed predose assessments 
may be used for review in order to allow same day study drug administration, and additional samples for central analysis must also be collected. 
i A serum pregnancy test will be performed at Screening/Baseline; thereafter, urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  For weight-
based dosing, weight measured at the current study center visit (dosing day) will be used to calculate the dose of ALN-AS1.  After M12, weight measured at 
either the previous study center visit or on current study center visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1).  Blood sample collection for PK analysis at 
Month 9 and Month 15 is only necessary if ECG will be performed at same visit. 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 

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o Porphyria attack laboratory sample collection kits should be dispensed at the screening visit along with instructions for use. For any attack that occurs through 
M37, urine samples should be collected within 24 hours of the start of clinical intervention (eg, hemin or glucose administration) and within 24 hours of the end 
of clinical intervention.  If patients are unable to report to the clinical study center during a porphyria attack, laboratory sample collection kits should be used 
for collecting and sending urine samples to the clinical study center, if possible.  These urine samples may also be analyzed for exploratory biomarkers. 
p In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but not more than once in a 6 month period), if possible.  
q Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, and narcotic use on a daily basis through M9; 
thereafter, acute porphyria attacks will be recorded in the diary.  The BPI will be completed on a weekly basis as part of the patient diary through M9, then 
Q3M. 
r Medications that are ongoing from the previous study (ALN-AS1-001), started between the previous study and this study, and started after signing informed 
consent in this study, will be captured as concomitant medication(s). 
 

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Table 6: 
Schedule of Assessments:  Month 19 through Month 36 (Every Month Dosing Regimen) 
 
Treatment Period 
(Month 19 through Month 36) 
M19/ 
M20a 
M21a 
M22/ 
M23a 
M24 
M25/ 
M26a 
M27a 
M28/ 
M29a 
M30 
M31/ 
M32a 
M33a 
M34/ 
M35a 
M36 
Study Visit (D±Visit Window) 
571±14/601±14 
631±14 
661±14/691±14 
721±14 
751±14/781±14 
811±14 
841±14/871±14 
901±14 
931±14/961±14 
991±14 
1021±14/1051±14 
1081±14 
Physical Examinationb 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Body Weight, BMI, and Heightc 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Vital Signsd 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGe 
 
 
 
 
 
 
 
 
 
 
 
 
Clinical Laboratory Assessmentf 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Pregnancy Testg 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationh 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine Sample for PBG, ALA, and 
Creatinine Analysisi 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Blood and Urine Sample for 
Exploratory Biomarker Analysisj  
 
 
 
X 
 
 
 
X 
 
 
 
X 
Blood Sample for PK Analysisk 
 
 
 
X 
 
 
 
 
 
 
 
 
Antidrug Antibodiesl 
 
 
 
X 
 
 
 
 
 
 
 
X 

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Table 6: 
Schedule of Assessments:  Month 19 through Month 36 (Every Month Dosing Regimen) 
 
Treatment Period 
(Month 19 through Month 36) 
M19/ 
M20a 
M21a 
M22/ 
M23a 
M24 
M25/ 
M26a 
M27a 
M28/ 
M29a 
M30 
M31/ 
M32a 
M33a 
M34/ 
M35a 
M36 
Study Visit (D±Visit Window) 
571±14/601±14 
631±14 
661±14/691±14 
721±14 
751±14/781±14 
811±14 
841±14/871±14 
901±14 
931±14/961±14 
991±14 
1021±14/1051±14 
1081±14 
EQ-5D-5L Questionnairem 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Diary Review (including 
BPI-SF)n 
X 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; M=month; PBG=porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of life; SC=subcutaneous. 
Notes:   
• 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may 
be conducted while the patient is at home. 
• 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical 
examinations and blood/urine sample collections. 
• 
In situations where a study visit cannot be completed at the study center or offsite by a home healthcare professional visit, the study 
Investigator (or delegate) may verbally contact the patient within the study visit window to assess for any AEs, concomitant medications 
(including hemin use), hospitalizations/procedures, and porphyria attacks. 
a Where applicable country and local regulations and infrastructure allow, study procedures, including ALN-AS1 administration,  may take place at the patient’s 
home by a healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the Investigator, based on safety and tolerability; 
however, patients are required to complete at least 1 visit at the clinical study center Q6M.   
b A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed.  
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  Targeted physical examinations/body system assessments may be conducted offsite at all time points, where applicable country and local 
regulations and infrastructure allow.  See Section 7.5.3 for details on the physical examination. 
c Height will be measured at Screening/Baseline only. 

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d Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for 10 minutes.  Vital sign measurements may be conducted offsite at all time 
points, where applicable country and local regulations and infrastructure allow. 
e Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at least 
5 minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose . At Month 24, 
ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose, when paired with PK timepoints, otherwise ECGs will be collected 
predose.  In patients receiving >2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose.  See Section 7.5.4 
for ECG assessment details.  With the implementation of Amendment 7, ECGs are no longer required. 
f Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  On 
days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit.  Collection of blood and urine samples for safety 
laboratory assessments may be conducted offsite at all time points, where applicable country and local regulations and infrastructure allow. 
g Urine pregnancy tests will be performed.  Results must be available before dosing. 
h ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
obtained within 6 months during a study center visit or offsite will be used to calculate the weight-based dose of ALN-AS1. 
i Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose.  Collection of 
samples for PD assessments may be conducted offsite at all time points, where applicable country and local regulations and infrastructure allow. 
j On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
k Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1).  
l On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose.  Antidrug antibody assessments that cannot be 
collected in the intended visit window may be completed within 6 months at the next study center visit. 
m In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but, not more than once in a 6 month period), if possible. In situations where a planned study visit cannot be completed at the study center, the patient will 
complete the EQ-5D-5L questionnaire at home. 
n Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 

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Table 7: 
Schedule of Assessments:  Month 37 through End of Study (Every Month Dosing Regimen) 
 
Treatment Period 
(Month 37 through EOS) 
EOS/ 
ETb 
Safety 
Follow-upc 
Study Visit (M) 
M37/ 
M38a 
M39a 
M40/ 
M41a 
M42 
M43/ 
M44a 
M45a 
M46/ 
M47a 
M48/ 
EOT 
M49 
 
Study Visit (D±Visit Window) 
1111±14/1141±14 
1171±14 
1201±14/1231±14 
1261±14 
1291±14/1321±14 
1351±14 
1381±14/1411±14 
1441±14 
1471±14 
 
Physical Examinationd 
 
 
 
X 
 
 
 
X 
X 
X 
Body Weight, BMI, and Heighte 
 
 
 
X 
 
 
 
X 
X 
 
Vital Signsf 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGg 
 
 
 
 
 
 
 
 
 
 
Clinical Laboratory Assessmenth 
 
X 
 
X 
 
X 
 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationj 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Urine Sample for PBG, ALA, and 
Creatinine Analysisk 
 
X 
 
X 
 
X 
 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker Analysisl  
 
 
 
X 
 
 
 
X 
X 
 
Antidrug Antibodiesm 
 
 
 
 
 
 
 
X 
X 
 

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Table 7: 
Schedule of Assessments:  Month 37 through End of Study (Every Month Dosing Regimen) 
 
Treatment Period 
(Month 37 through EOS) 
EOS/ 
ETb 
Safety 
Follow-upc 
Study Visit (M) 
M37/ 
M38a 
M39a 
M40/ 
M41a 
M42 
M43/ 
M44a 
M45a 
M46/ 
M47a 
M48/ 
EOT 
M49 
 
Study Visit (D±Visit Window) 
1111±14/1141±14 
1171±14 
1201±14/1231±14 
1261±14 
1291±14/1321±14 
1351±14 
1381±14/1411±14 
1441±14 
1471±14 
 
EQ-5D-5L Questionnairen 
 
 
 
X 
 
 
 
X 
X 
 
Diary Review (including BPI-SF)o 
X 
 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; EOS=End of Study; EOT=End of Treatment; ET=early termination; M=month; PBG=porphobilinogen; PK=pharmacokinetics; 
Q=every; QOL=quality of life; SC=subcutaneous. 
Notes:   
• 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
• 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
• 
In situations where a study visit cannot be completed at the study center or offsite by a home healthcare professional visit, the study Investigator (or 
delegate) may verbally contact the patient within the study visit window to assess for any AEs, concomitant medications (including hemin use), 
hospitalizations/procedures, and porphyria attacks. 
a Where applicable country and local regulations and infrastructure allow, study procedures, including ALN-AS1 administration,  may take place at the patient’s 
home by a healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the Investigator, based on safety and tolerability; 
however, patients are required to complete at least 1 visit at the clinical study center Q6M.   
b Patients who complete all scheduled doses ALN-AS1 through Month 48 will return for an end of study (EOS) visit at Month 49.  Patients who discontinue 
treatment prior to Month 48 will be asked to complete an early termination (ET) visit at which all Month 49 visit procedures will be performed; they must also 
return 3 months (84 [+14] days) after their last dose of ALN-AS1 for a safety-follow-up visit.   
c The safety follow-up visit is only required for patients who discontinue prior to study completion.  The visit should be conducted  3 months (84 [+14 days]) 
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d A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed.  
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  Targeted physical examinations/body system assessments may be conducted offsite at all time points, where applicable country and local 
regulations and infrastructure allow.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for 10 minutes.  Vital sign measurements may be conducted offsite at all time 
points, where applicable country and local regulations and infrastructure allow. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at least 
5 minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose . At Month 24, 
ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose, when paired with PK timepoints, otherwise ECGs will be collected 
predose.  In patients receiving >2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose.  See Section 7.5.4 
for ECG assessment details.  With the implementation of Amendment 7, ECGs are no longer required. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  On 
days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit.  Collection of blood and urine samples for safety 
laboratory assessments may be conducted offsite at all time points, where applicable country and local regulations and infrastructure allow.  
i Urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
obtained within 6 months during a study center visit or offsite will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose.  Collection of 
samples for PD assessments may be conducted offsite at all time points, where applicable country and local regulations and infrastructure allow. 
l On dosing days, blood and urine samples for ALAS1 mRNA analysis (also including possible biomarkers and homocysteine levels) will be collected will be 
collected within 1 hour predose. 
m On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose.  Antidrug antibody assessments that cannot be 
collected in the intended visit window may be completed within 6 months at the next study center visit. 
n In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but, not more than once in a 6 month period), if possible. In situations where a planned study visit cannot be completed at the study center, the patient will 
complete the EQ-5D-5L questionnaire at home. 
o Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 

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11.3. 
Anaphylactic Reactions 
Table 8: 
 
Sampson Criteria for Anaphylactic Reactions 
 
Adapted from Sampson et al. 2006 (36) 
 

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ALN-AS1-002 PROTOCOL AMENDMENT 8 
SUMMARY OF CHANGES DATED 29 MARCH 2021 
A Multicenter, Open-label Extension Study to Evaluate the Long-term Safety and Clinical 
Activity of Subcutaneously Administered ALN-AS1 in Patients with Acute Intermittent 
Porphyria who have Completed a Previous Clinical Study with ALN-AS1 
1. 
RATIONALE FOR PROTOCOL AMENDMENT 
The purpose of this protocol amendment is to recommend testing of blood homocysteine levels.  
In addition, it is recommended that patients with increased blood homocysteine levels receive a 
supplement containing vitamin B6. 
 
These recommendations are being made because during ALN-AS1 treatment, increases in blood 
homocysteine levels have been observed compared to levels before ALN-AS1 treatment.  Thus, 
monitoring for changes in blood homocysteine levels during treatment with ALN-AS1 has been 
incorporated into the protocol.  Blood homocysteine levels may also be increased in patients with 
acute hepatic porphyria (AHP), vitamin deficiencies, or chronic kidney disease.  The clinical 
relevance of the elevations in blood homocysteine during ALN-AS1 treatment is unknown.  
Detailed reasons for each change are provided in Section 2.  Corrections to typographical errors, 
punctuation, grammar, abbreviations, and formatting are not detailed. 
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2. 
PROTOCOL AMENDMENT 8 DETAILED SUMMARY OF CHANGES 
The primary section(s) of the protocol affected by the changes in Protocol Amendment 8 are indicated.  The corresponding text has 
been revised throughout the protocol.  Deleted text is indicated by strikeout and added text is indicated by bold font, relevant to each 
purpose described. 
Purpose:  Add measuring blood homocysteine levels as part of the exploratory biomarker assessment. 
The primary change occurs in Section 7.6 Exploratory Biomarkers  
Revised text:  (in the first paragraph) 
Blood and urine samples will be collected for exploratory analyses.  Aliquots of samples will be obtained and frozen, to permit future 
analysis of the effect of ALN-AS1 on exploratory biomarkers.  Samples may also be used for testing homocysteine levels.   
Section(s) also reflecting this change:  
• Table 3, Schedule of Assessments:  Month 37 through End of Study (Every 3 Months Dosing Regimen) (footnote l) 
• Table 7, Schedule of Assessments:  Month 37 through End of Study (Every 3 Months Dosing Regimen) (footnote l) 
Purpose:  To add increases in blood homocysteine levels to the benefit-risk assessment, noting the unknown clinical relevance, and to 
inform the Investigator about the possibility to supplement with vitamin B6 should increases in homocysteine levels occur.  
The primary change occurs in Section 1.7 Benefit-Risk Assessment 
Added text:  (added 4th bullet point) 
The important potential risks associated with administration of ALN-AS1 in patients with AIP are as follows: 
• Homocysteine elevations:  Blood homocysteine levels may be increased in patients with AHP, vitamin deficiencies, 
or chronic kidney disease.(33-35)  During treatment with ALN-AS1, increases in blood homocysteine levels have 
been observed compared to levels before treatment.  The clinical relevance of the elevations in blood homocysteine 
during ALN-AS1 treatment is unknown.  The protocol includes monitoring for changes in blood homocysteine 
levels during treatment with ALN-AS1.  Vitamin B6 supplementation is recommended for patients with elevated 
homocysteine levels (see Section 6.3).  
 
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Purpose:  To add that vitamin B6 supplementation is an accepted potential concomitant medication if increases in blood homocysteine 
levels are observed. 
The changes include the revisions to Section 6.3 Concomitant Medications 
Added text: (3rd paragraph) 
During treatment with ALN-AS1, blood homocysteine levels may show an increase compared to levels before treatment.  
Blood homocysteine levels will be assessed as indicated in the Schedule of Assessments (see Table 3 or Table 7).  It is 
recommended that patients with increased blood homocysteine levels receive a supplement containing Vitamin B6.  All 
vitamin supplements should be recorded on the concomitant medications eCRF. 
 
 
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CLINICAL STUDY PROTOCOL 
ALN-AS1-002 
Protocol Title: 
A Multicenter, Open-label Extension Study to Evaluate the Long-term 
Safety and Clinical Activity of Subcutaneously Administered 
ALN-AS1 in Patients with Acute Intermittent Porphyria who have 
Completed a Previous Clinical Study with ALN-AS1 
Investigational Drug: 
ALN-AS1 (givosiran) 
EudraCT Number: 
2016-002638-54 
IND Number: 
126094 
Protocol Date: 
Original Protocol 19 July 2016 
Protocol Amendment 0.1 (Sweden) 20 September 2016 
Protocol Amendment 1 10 November 2016 
Protocol Amendment 2 01 December 2016 
Protocol Amendment 3 03 February 2017 
Protocol Amendment 4 02 August 2017 
Protocol Amendment 5 03 May 2018  
Protocol Amendment 6 28 May 2019 
Protocol Amendment 7 29 April 2020 
Sponsor: 
Alnylam Pharmaceuticals, Inc. 
300 Third Street 
Cambridge, MA  02142 USA 
Telephone:  
 
Sponsor Contact:  
 
The concepts and information contained in this document or generated during the study are considered 
proprietary and may not be disclosed in whole or in part without expressed written authorization of 
Alnylam Pharmaceuticals, Inc. 
77
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PPD

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INVESTIGATOR’S AGREEMENT 
 
I have read the ALN-AS1-002 protocol and agree to conduct the study as outlined.  I agree to 
maintain the confidentiality of all information received or developed in connection with this 
protocol. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Printed Name of Investigator 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signature of Investigator 
 
 
 
 
 
 
 
 
Date 
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PROTOCOL SYNOPSIS 
Protocol Title 
A Multicenter, Open-label Extension Study to Evaluate the Long-term Safety and Clinical Activity of 
Subcutaneously Administered ALN-AS1 in Patients with Acute Intermittent Porphyria who have 
Completed a Previous Clinical Study with ALN-AS1 
Product Name 
ALN-AS1 (givosiran) 
Indication 
Patients with acute intermittent porphyria (AIP) who experience recurrent porphyria attacks 
Phase 
1/2 
Study center(s)   
The study will be conducted at up to 8 clinical study centers worldwide. 
Objectives 
Primary 
• 
Evaluate the long-term safety and tolerability of ALN-AS1 in patients with AIP 
Secondary 
• 
Assess the pharmacodynamic (PD) effect of ALN-AS1 over time 
• 
Assess the clinical activity of ALN-AS1 over time 
Exploratory 
• 
Characterize the pharmacokinetic (PK) profile of ALN-AS1 and incidence of antidrug antibodies 
(ADA) over time 
• 
Assess changes in health-related quality of life (QOL) 
• 
Characterize analytes related to targeting the heme biosynthesis pathway 
Endpoints 
Primary 
• 
Patient incidence of adverse events (AEs) 
Secondary 
• 
Change in urine delta-aminolevulinic acid (ALA) and porphobilinogen (PBG) levels 
• 
Frequency and characteristics of porphyria attacks 
• 
Change in hemin administration 
Exploratory 
• 
Change in circulating 5-aminolevulinic acid synthase 1 (ALAS1) mRNA levels 
• 
Concentrations of ALN-AS1 and ADA 
• 
Duration and treatment of porphyria attacks 
• 
Number and duration of visits to a health care facility for acute porphyria care 
• 
EQ-5D-5L questionnaire scores 
• 
Pain assessment and narcotic use as recorded in a patient diary 
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• Exploratory biomarkers related to the target pathway, such as urine porphyrins, vitamin D binding 
protein 
Study Design 
This is a multicenter, open-label extension study to evaluate the long-term safety and clinical activity 
of ALN-AS1 in patients with AIP who completed study ALN-AS1-001. 
The last assessments performed, determining previous study (ALN-AS1-001) completion, will serve as 
the Screening/Baseline assessments in this study.  If more than 60 days have elapsed since the last 
assessment, safety assessments will be repeated before administration of ALN-AS1.  It is anticipated 
that patients will begin ALN-AS1 administration in this study within 6 months after the last dose of 
study drug in the previous study.  Eligibility will be confirmed before administration of the first dose of 
ALN-AS1 (Day 1).  Patients will undergo assessments at the clinical study center every month for the 
first 3 months.  Then, through Month 6, and according to the dosing regimen selected, assessments will 
take place at the clinical study center or via a phone contact (for an every month dosing regimen, visits 
will be every month; for an every 3 months dosing regimen, visits will be every 3 months).  After a 
patient has completed 12 months of ALN-AS1 administration in this study (6 months in an every 
month dosing regimen), and where applicable country and local regulations and infrastructure allow, 
study procedures, including ALN-AS1 administration, may take place at the patient’s home by a 
healthcare professional.  If the patient is unable to come to the study site, and a visit by a home 
healthcare professional is not possible due to circumstances related to the COVID-19 pandemic, ALN-
AS1 may be administered by the patient or the caregiver under the oversight of the Investigator, and 
following consultation with the medical monitor, as allowed by applicable country and local 
regulations.  Study procedures may occur at the patient’s home at the discretion of the Investigator, 
based on safety and tolerability; however, patients are required to complete at least 1 visit at the clinical 
study center every 3 months for the first year, and thereafter every 6 months through the end of the 
treatment period.  Additional visits to collect clinical laboratory samples may occur at home at any 
point during the treatment period, within 14 days prior to scheduled dose administration.  Patients will 
return to the clinical study center for a posttreatment follow-up visit after administration of the last 
dose of ALN-AS1.  An ALA/PBG Monitoring/EOS visit will be conducted either at the clinical study 
center or via phone contact, unless treatment continues with ALN-AS1. 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, 
and narcotic use.  Patients will also be provided with laboratory sample collection kits and instructions 
for collecting and sending urine samples to the clinical study center. 
Patients may receive ALN-AS1 as long as they do not fulfill any of the study discontinuation criteria or 
until ALN-AS1 is commercially available in the patient’s territory or the ALN-AS1 development 
program is discontinued (whichever comes first). 
A Safety Review Committee (SRC) will review safety and tolerability data collected during the study 
with the primary purpose of protecting the safety of patients participating in the study. 
Number of Planned Patients 
Up to 24 patients are planned for enrollment in this study (including optional cohorts in 
ALN-AS1-001). 
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Diagnosis and Main Eligibility Criteria 
Patients with AIP, who have completed Part C of study ALN-AS1-001, will be eligible for screening in 
this study.  Eligible patients will not be on a scheduled regimen of hemin to prevent porphyria attacks 
at Screening.  Patients with alanine transaminase ≥2.0× upper limit of normal, total bilirubin ≥2 mg/dL 
(unless bilirubin elevation is due to Gilbert’s syndrome), or estimated glomerular filtration rate ≤30 
mL/min/1.73 m2 (using the Modification of Diet in Renal Disease formula) at Screening are not 
eligible for this study. 
Investigational Product, Dose, and Mode of Administration 
ALN-AS1 Solution for Injection (subcutaneous use [SC]) is comprised of a synthetic, small interfering 
RNA targeting ALAS1 and bearing a triantennary N-acetyl galactosamine ligand conjugated to the 
sense strand, formulated in phosphate buffer. 
The study starting dose and regimen of ALN-AS1 is 5.0 mg/kg as an SC injection administered every 3 
months.  Based on emerging clinical data, the SRC may approve changes to the dosing regimen, 
including decreases in the dose level and changes in the dosing frequency.  However any dose and 
dosing regimen will not exceed a previously explored dose level or frequency that was determined to 
be safe and well-tolerated in study ALN-AS1-001, SRC, Health Authority and Ethics Committee 
approval must be sought prior to dose escalation above 5.0 mg/kg in accordance with local Regulatory 
requirements.  
Reference Therapy, Dose, and Mode of Administration 
Not applicable 
Duration of Treatment and Study 
The duration of treatment is up to 48 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 56 months. 
Statistical Methods 
Statistical analyses will be primarily descriptive.  Incidence of AEs will be summarized by maximum 
severity and relationship to ALN-AS1.  Incidence of and serious adverse events (SAEs) and AEs 
leading to discontinuation will also be tabulated.  By-patient listings will be provided for deaths, SAEs, 
and events leading to discontinuation.  
Laboratory shift tables from baseline to worst values will be presented.  Abnormal physical 
examination findings and electrocardiogram data will be presented in by-patient listings.  Descriptive 
statistics will be provided for electrocardiogram interval data and presented as both actual values and 
changes from baseline relative to each on study evaluation and to the last evaluation on-study. 
Clinical activity of ALN-AS1 will be summarized primarily by descriptive statistics.  The clinical 
activity of ALN-AS1 will be evaluated by the frequency and characteristics of porphyria attacks 
including duration, treatment, and severity of porphyria attacks and number and duration of visits to a 
health care setting for acute porphyria care.  Patient diary recordings, including BPI-SF questionnaire 
scores, will also be summarized.   
PD analysis will include the evaluation of change in ALA, PBG, and ALAS mRNA levels.  Descriptive 
statistics (eg, mean and standard error of the mean) for observed levels of PD parameters and the 
relative change from baseline will be presented for each of the postdose follow-up time points. 
The PK concentration of ALN-AS1 will be determined.  Antidrug antibody results will be tabulated 
overall and by previous treatment in the previous study (ALN-AS1-001).  A by-patient listing will also 
be provided. 
Additional exploratory analyses may be conducted on analytes related to targeting the heme 
biosynthesis pathway.  Quality of life scores will also be summarized. 
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 Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8 
M9 
M10/ 
M11 
M12 
M13/ 
M14 
M15b 
M16/ 
M17 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History/Disease 
Historyc 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/ 
Exclusion Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examinationd 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
 
 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
Vital Signsf 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Triplicate 12-Lead ECGg 
X 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Clinical Laboratory 
Assessmenth 
X 
Xa 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Study Drug Administrationj 
 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl 
 
X 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
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 Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8 
M9 
M10/ 
M11 
M12 
M13/ 
M14 
M15b 
M16/ 
M17 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Blood Sample for PK 
Analysism 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Antidrug Antibodiesn 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
Porphyria Attack Kit 
Dispensationo 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EQ-5D-5L Questionnairep 
X 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Diary Review  
(including BPI-SF)q 
 
 
X 
Phone Contactr 
 
 
 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
AEs 
 
Continuous 
Concomitant Medicationss 
 
Continuous 
 Abbreviations:  AE=adverse event; ALAS1=5-aminolevulinic acid synthase 1; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain 
Inventory-Short Form; D=day; ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of life; 
SC=subcutaneous. 
Notes:   
• 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
• 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
a Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study (ALN-AS1-001) were completed within 60 days 
of administration of the first dose of ALN-AS1 in this study.  If more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs 
will be repeated before administration of ALN-AS1.  Results should be available and deemed acceptable before the administration of the first dose of ALN-
AS1.  On Day 1, results from hematology, chemistry (including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the 
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Investigator before study drug administration.  If results from within the prior 14 days are not available at a dosing visit, locally analyzed predose assessments 
may be used for review in order to allow same day study drug administration and additional samples for central analysis must also be collected. 
b After a patient has completed 12 months of ALN-AS1 administration in this study, and where applicable country and local regulations and infrastructure allow, 
study procedures, including ALN-AS1 administration, may take place at the patient’s home by a healthcare professional.  Study procedures may occur at the 
patient’s home at the discretion of the Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit at the clinical 
study center Q6M.  Additional visits to collect clinical laboratory samples may occur at home at any point during the treatment period, within 14 days prior to 
scheduled dose administration. 
c See Section 7.1 for details on the interval medical history/disease history to be recorded at Screening/Baseline.  Ongoing AEs from the previous study 
(ALN-AS1-001) will be captured as medical history. 
d A complete physical examination will be performed at Screening/Baseline, and D1.  At all other visits, a targeted physical examination will be performed.  On 
dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any time 
during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On D1, vital signs will be collected within 1 hour predose; and 2 hours 
(±10 minutes) postdose.  On all other dosing days, vital signs will be collected within 1 hour predose.  On days when ALN-AS1 is not administered, vital signs 
can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position (should be consistent for each patient), after the 
patient has rested comfortably for at least 10 minutes. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at least 5 
minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose at a minimum of 2 
of the following visits:  D1, Month 3, Month 6, Month 9, Month 12, Month 15 (only if visit is done at clinic), or Month 18.  In patients receiving >2.5 mg/kg 
ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose at a minimum of two of the following visits:  D1, Month 3, 
Month 6, Month 9, Month 12, Month 15 (only if visit is done at clinic), or Month 18.  On all other dosing days, ECGs will be collected within 1 hour predose 
(see Section 7.5.4 for ECG assessment details).   
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  On 
days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. On dosing days, results from hematology, chemistry 
(including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the Investigator before study drug administration.  If results 
from within the prior 14 days are not available at a dosing visit, locally analyzed predose assessments may be used for review in order to allow same day study 
drug administration and additional samples for central analysis  must  also be collected. 
i A serum pregnancy test will be performed at Screening/Baseline; thereafter, urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  For 
weight-based dosing, weight measured at the current study center visit (dosing day) will be used to calculate the dose of ALN-AS1 through M12.  After M12, 
weight measured at either the previous study center visit or the current study center visit may be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1).  Blood sample collection for PK analysis at 
Month 9 and Month 15 is only necessary if ECG will be performed at same visit. 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o Porphyria attack laboratory sample collection kits should be dispensed at the screening visit along with instructions for use. For any attack that occurs through 
M37, urine samples should be collected within 24 hours of the start of clinical intervention (eg, hemin or glucose administration) and within 24 hours of the end 
of clinical intervention.  If patients are unable to report to the clinical study center during a porphyria attack, laboratory sample collection kits will be provided 
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that contain instructions for collecting and sending urine samples to the clinical study center, if possible.  These urine samples may also be analyzed for 
exploratory biomarkers. 
p In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but not more than once in a 6 month period), if possible.  
q Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, and narcotic use on a daily basis through M9; 
thereafter, acute porphyria attacks will be recorded in the diary.  The BPI will be completed on a weekly basis as part of the patient diary through M9, then 
Q3M. 
r Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack. 
s Medications that are ongoing from the previous study (ALN-AS1-001), started between the previous study and this study, and started after signing informed 
consent in this study, will be captured as concomitant medication(s). 
 
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Table 2: 
Schedule of Assessments:  Month 19 through Month 36 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through Month 36) 
M19/ 
M20 
M21a 
M22/ 
M23 
M24 
M25/ 
M26 
M27a 
M28/ 
M29 
M30 
M31/ 
M32 
M33a 
M34/ 
M35 
M36 
Study Visit (D±Visit Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
Physical Examinationb 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Body Weight, BMI, and Heightc 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Vital Signsd 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Triplicate 12-Lead ECGe 
 
 
 
X 
 
 
 
 
 
 
 
 
Clinical Laboratory Assessmentf 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Pregnancy Testg 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Study Drug Administrationh 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Urine Sample for PBG, ALA, and 
Creatinine Analysisi 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Blood and Urine Sample for 
Exploratory Biomarker Analysisj 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Blood Sample for PK Analysisk 
 
 
 
X 
 
 
 
 
 
 
 
 
Antidrug Antibodiesl 
 
 
 
X 
 
 
 
 
 
 
 
X 
EQ-5D-5L Questionnairem 
 
 
 
X 
 
 
 
X 
 
 
 
X 
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Table 2: 
Schedule of Assessments:  Month 19 through Month 36 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through Month 36) 
M19/ 
M20 
M21a 
M22/ 
M23 
M24 
M25/ 
M26 
M27a 
M28/ 
M29 
M30 
M31/ 
M32 
M33a 
M34/ 
M35 
M36 
Study Visit (D±Visit Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
Diary Review (including BPI-SF)n 
X 
Phone Contacto 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of life; SC=subcutaneous. 
Notes:   
• 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
• 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
a Where applicable country and local regulations and infrastructure allow, study procedures, including ALN-AS1 administration, may take place at the patient’s 
home by a healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the Investigator, based on safety and tolerability; 
however, patients are required to complete at least 1 visit at the clinical study center Q6M.  
b A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed.  
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 
c Height will be measured at Screening/Baseline only. 
d Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for at least 10 minutes. 
e Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at least 
5 minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose .  In patients 
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receiving >2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose.  See Section 7.5.4 for ECG assessment 
details. 
f Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  .  
On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. 
g Urine pregnancy tests will be performed.  Results must be available before dosing. 
h ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured at either the previous study center visit or the current study center visit may be used to calculate the weight-based dose of ALN-AS1. 
i Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
j On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
k Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1). 
l On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
m In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but, not more than once in a 6 month period), if possible.  
n Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
o Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack. 
 
 
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Table 3: 
Schedule of Assessments:  Month 37 through End of Study (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 37 through EOS) 
EOS/ 
ETb 
Safety Follow-
upc 
 
M37/ 
M38a 
M39a 
M40/ 
M41a 
M42 
M43/ 
M44a 
M45a 
M46/ 
M47a 
M48/ 
EOT 
M49 
 
Study Visit (D±Visit Window) 
1111±7/1141±7 
1171±10 
1201±7/1231±7 
1261±10 
1291±7/1321±7 
1351±10 
1381±7/1411±7 
1441±10 
1471±10 
 
Physical Examinationd 
 
 
 
X 
 
 
 
X 
X 
X 
Body Weight, BMI, and Heighte 
 
 
 
X 
 
 
 
 
X 
 
Vital Signsf 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGg 
 
 
 
X 
 
 
 
 
X 
 
Clinical Laboratory Assessmenth 
X 
X 
X 
X 
 
X 
 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationj 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Urine Sample for PBG, ALA, and 
Creatinine Analysisk 
 
X 
 
X 
 
X 
 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker Analysisl 
 
 
 
X 
 
 
 
X 
X 
 
Antidrug Antibodiesn 
 
 
 
X 
 
 
 
X 
X 
 
EQ-5D-5L Questionnaireo 
 
 
 
X 
 
 
 
X 
X 
 
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Table 3: 
Schedule of Assessments:  Month 37 through End of Study (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 37 through EOS) 
EOS/ 
ETb 
Safety Follow-
upc 
 
M37/ 
M38a 
M39a 
M40/ 
M41a 
M42 
M43/ 
M44a 
M45a 
M46/ 
M47a 
M48/ 
EOT 
M49 
 
Study Visit (D±Visit Window) 
1111±7/1141±7 
1171±10 
1201±7/1231±7 
1261±10 
1291±7/1321±7 
1351±10 
1381±7/1411±7 
1441±10 
1471±10 
 
Diary Review (including BPI-SF)p 
X 
 
Phone Contactq 
X 
 
X 
 
X 
 
X 
 
 
 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; EOS = End of Study; EOT = End of Treatment; ET = Early Termination; M=month; PBG= porphobilinogen; 
PK=pharmacokinetics; Q=every; QOL=quality of life; SC=subcutaneous. 
Notes:   
• 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
• 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
a Where applicable country and local regulations and infrastructure allow, study procedures, including ALN-AS1 administration, may take place at the patient’s 
home by a healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the Investigator, based on safety and tolerability; 
however, patients are required to complete at least 1 visit at the clinical study center Q6M.  
b Patients who complete all scheduled treatment with ALN-AS1 through Month 48 will return for an end of study (EOS) visit at Month 49.  Patients who 
discontinue treatment will be asked to complete an early termination (ET) visit at which all Month 37 visit procedures will be performed; the patient must also 
return for a safety-follow-up visit at 3 months (84 [+7] days) after his/her last dose of ALN-AS1.   
c The safety follow-up visit is only required for patients who discontinue prior to study completion.  The visit should be conducted  3 months (84 [+7 days]) 
following the last dose of ALN-AS1. 
d A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed.  
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 
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e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for at least 10 minutes. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at least 
5 minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose .  In patients 
receiving >2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose.  See Section 7.5.4 for ECG assessment 
details. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  .  
On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. 
i Urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured at either the previous study center visit or the current study center visit may be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but, not more than once in a 6 month period), if possible.  
p Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
q Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack. 
 
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TABLE OF CONTENTS 
SPONSOR PROTOCOL APPROVAL ...........................................................................................2 
INVESTIGATOR’S AGREEMENT ...............................................................................................3 
PROTOCOL SYNOPSIS ................................................................................................................4 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS ................................................22 
1. 
INTRODUCTION ......................................................................................................24 
1.1. 
Disease Overview .......................................................................................................24 
1.1.1. 
Epidemiology ..............................................................................................................24 
1.1.2. 
Current Management and Unmet Medical Need ........................................................25 
1.2. 
RNA Interference ........................................................................................................26 
1.3. 
ALN-AS1 ....................................................................................................................26 
1.4. 
Study Design Rationale ..............................................................................................26 
1.5. 
Dose Rationale ............................................................................................................26 
1.6. 
Clinical Data Summary ...............................................................................................27 
1.6.1. 
Clinical Pharmacodynamics .......................................................................................27 
1.6.2. 
Clinical Activity ..........................................................................................................28 
1.6.3. 
Clinical Safety ............................................................................................................29 
1.6.4. 
Drug-Drug Interactions ...............................................................................................30 
1.7. 
Benefit-Risk Assessment ............................................................................................30 
2. 
OBJECTIVES .............................................................................................................31 
2.1. 
Primary Objective .......................................................................................................31 
2.2. 
Secondary Objectives .................................................................................................31 
2.3. 
Exploratory Objectives ...............................................................................................31 
3. 
ENDPOINTS ..............................................................................................................32 
3.1. 
Primary Endpoint ........................................................................................................32 
3.2. 
Secondary Endpoints ..................................................................................................32 
3.3. 
Exploratory Endpoints ................................................................................................32 
4. 
INVESTIGATIONAL PLAN .....................................................................................32 
4.1. 
Summary of Study Design ..........................................................................................32 
4.2. 
Duration of Treatment and Study ...............................................................................34 
4.3. 
Number of Patients .....................................................................................................34 
4.4. 
Method of Assigning Patients to Treatment Groups ..................................................34 
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4.5. 
Blinding ......................................................................................................................34 
4.6. 
Safety Review Committee ..........................................................................................34 
5. 
SELECTION AND WITHDRAWAL OF PATIENTS ..............................................35 
5.1. 
Inclusion Criteria ........................................................................................................35 
5.2. 
Exclusion Criteria .......................................................................................................35 
5.3. 
Discontinuation of Study Drug and/or Study .............................................................35 
5.3.1. 
Discontinuation of Study Drug ...................................................................................36 
5.3.2. 
Discontinuation from the Study ..................................................................................36 
5.3.3. 
Withdrawal of Consent to Collect and Process the Patient’s Personal Data ..............37 
5.3.4. 
Replacement of Patients .............................................................................................37 
6. 
TREATMENTS ..........................................................................................................38 
6.1. 
Treatments Administered ............................................................................................38 
6.2. 
Investigational Study Drug .........................................................................................38 
6.2.1. 
Description ..................................................................................................................38 
6.2.2. 
Dose and Administration ............................................................................................38 
6.2.3. 
Dose Modifications .....................................................................................................39 
6.2.3.1. 
Study Population Dose Modifications ........................................................................39 
6.2.3.2. 
Individual Dose Modifications ...................................................................................39 
6.2.4. 
Preparation, Handling, and Storage ............................................................................40 
6.2.5. 
Packaging and Labeling ..............................................................................................40 
6.2.6. 
Accountability .............................................................................................................41 
6.3. 
Concomitant Medications ...........................................................................................41 
6.4. 
Contraceptive Requirements .......................................................................................42 
6.5. 
Treatment Compliance ................................................................................................43 
7. 
STUDY ASSESSMENTS ..........................................................................................43 
7.1. 
Screening/Baseline Assessments ................................................................................43 
7.2. 
Clinical Activity Assessments ....................................................................................43 
7.2.1. 
Patient Diary ...............................................................................................................43 
7.2.2. 
Brief Pain Inventory-Short Form Questionnaire ........................................................44 
7.3. 
Pharmacodynamic Assessments .................................................................................44 
7.4. 
Pharmacokinetic Assessments ....................................................................................44 
7.5. 
Safety Assessments .....................................................................................................44 
7.5.1. 
Vital Signs ..................................................................................................................44 
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7.5.2. 
Weight and Height ......................................................................................................44 
7.5.3. 
Physical Examination .................................................................................................45 
7.5.4. 
Electrocardiogram .......................................................................................................45 
7.5.5. 
Clinical Laboratory Assessments ...............................................................................45 
7.5.5.1. 
Immunogenicity ..........................................................................................................48 
7.5.5.2. 
Pregnancy Testing ......................................................................................................48 
7.5.6. 
Adverse Events ...........................................................................................................48 
7.5.6.1. 
Definitions ..................................................................................................................48 
7.5.6.2. 
Eliciting and Recording Adverse Events ....................................................................50 
7.5.6.3. 
Serious Adverse Events Require Immediate Reporting to Sponsor/Designee ...........51 
7.5.6.4. 
Sponsor Safety Reporting to Regulatory Authorities .................................................51 
7.5.6.5. 
Serious Adverse Event Notification to the Institutional Review 
Board/Independent Ethics Committee ........................................................................52 
7.5.6.6. 
Pregnancy Reporting ..................................................................................................52 
7.5.6.7. 
Overdose Reporting ....................................................................................................53 
7.6. 
Exploratory Assessments ............................................................................................53 
7.7. 
Other Assessments ......................................................................................................53 
7.7.1. 
EQ-5D-5L Questionnaire ............................................................................................53 
7.8. 
COVID-19 Data Collection ........................................................................................53 
8. 
STATISTICS ..............................................................................................................53 
8.1. 
Determination of Sample Size ....................................................................................53 
8.2. 
Statistical Methodology ..............................................................................................54 
8.2.1. 
Populations to be Analyzed ........................................................................................54 
8.2.2. 
Examination of Subgroups .........................................................................................54 
8.2.3. 
Handling of Missing Data ...........................................................................................54 
8.2.4. 
Baseline Evaluations ...................................................................................................54 
8.2.5. 
Clinical Activity Analyses ..........................................................................................54 
8.2.6. 
Pharmacodynamic Analysis........................................................................................55 
8.2.7. 
Pharmacokinetic Analysis ..........................................................................................55 
8.2.8. 
Safety Analyses ..........................................................................................................55 
8.2.9. 
Other Analyses ............................................................................................................55 
9. 
STUDY ADMINISTRATION ...................................................................................56 
9.1. 
Ethical and Regulatory Considerations ......................................................................56 
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9.1.1. 
Informed Consent .......................................................................................................56 
9.1.2. 
Ethical Review ............................................................................................................56 
9.1.3. 
Serious Breach of Protocol .........................................................................................57 
9.1.4. 
Study Documentation, Confidentiality, and Records Retention .................................57 
9.1.5. 
End of the Study .........................................................................................................57 
9.1.6. 
Discontinuation of the Clinical Study.........................................................................57 
9.2. 
Data Quality Control and Quality Assurance .............................................................58 
9.2.1. 
Data Handling .............................................................................................................58 
9.2.2. 
Study Monitoring ........................................................................................................58 
9.2.3. 
Audits and Inspections ................................................................................................58 
9.3. 
Publication Policy .......................................................................................................58 
10.
LIST OF REFERENCES ............................................................................................59
11.
APPENDICES ............................................................................................................62
11.1. 
Pharmacokinetic Assessment Time Points .................................................................62 
11.2. 
Schedules of Assessments for Every Month Dosing Regimen ..................................63 
11.3. 
Anaphylactic Reactions ..............................................................................................74 
LIST OF TABLES 
Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 
Months Dosing Regimen) .............................................................................................7 
Table 2: 
Schedule of Assessments:  Month 19 through Month 36 (Every 3 Months 
Dosing Regimen) ........................................................................................................11 
Table 3: 
Schedule of Assessments:  Month 37 through End of Study (Every 3 Months 
Dosing Regimen) ........................................................................................................14 
Table 4: 
Pharmacokinetic Time Points .....................................................................................62 
Table 5: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 
Month Dosing Regimen) ............................................................................................63 
Table 6: 
Schedule of Assessments:  Month 19 through Month 36 (Every Month 
Dosing Regimen) ........................................................................................................68 
Table 7: 
Schedule of Assessments:  Month 37 through End of Study (Every Month 
Dosing Regimen) ........................................................................................................71 
Table 8: 
 Sampson Criteria for Anaphylactic Reactions ...........................................................74 
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LIST OF FIGURES 
Figure 1: 
Part C Cohort 1 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in .........................................................................................................................28 
Figure 2: 
Part C Cohort 2 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in .........................................................................................................................29 
Figure 3: 
Study Design ...............................................................................................................34 
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LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
Abbreviation 
Definition 
AE 
Adverse event 
AHP 
Acute hepatic porphyria 
AIP 
Acute intermittent porphyria 
ALA 
Delta-aminolevulinic acid 
ALAS1 
5-aminolevulinic acid synthase 1 
ALP 
Alkaline phosphatase 
ASGPR 
Asialoglycoprotein receptor 
ASHE 
Asymptomatic high excreters 
BPI-SF 
Brief Pain Inventory-Short Form 
cERD 
Circulating extracellular RNA detection assay 
COVID-19 
Coronavirus disease 2019 
CRF 
Case report form 
CYP 
Cytochrome P450 
DDI 
Drug-drug interaction 
ECG 
Electrocardiogram 
eCRF 
Electronic case report form 
eGFR 
Estimated Glomerular Filtration Rate 
EDC 
Electronic data capture 
EOS 
End of study 
EU 
European Union 
GalNAc 
N-acetyl galactosamine 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practice 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
IEC 
Independent Ethics Committee 
IRB 
Institutional Review Board 
ISR 
Injection site reaction 
IV 
Intravenous 
LFT 
Liver function test 
mRNA 
Messenger RNA 
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Abbreviation 
Definition 
NHP 
Nonhuman primate 
NOAEL 
No observed adverse effect level 
NOEL 
No observed effect level 
OTC 
Over the counter 
PBG 
Porphobilinogen 
PBGD 
Porphobilinogen deaminase 
PD 
Pharmacodynamic(s) 
PK 
Pharmacokinetic(s) 
QOL 
Quality of life 
RNA 
Ribonucleic acid 
RNAi 
RNA interference 
SAE 
Serious adverse event 
SAP 
Statistical Analysis Plan 
SC 
Subcutaneous 
siRNA 
Small interfering RNA 
SRC 
Safety Review Committee 
SUSAR 
Suspected unexpected serious adverse reaction 
ULN 
Upper limit of normal 
US 
United States 
WOCBP 
Woman of child-bearing potential 
 
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1. 
INTRODUCTION 
1.1. 
Disease Overview 
The porphyrias are a family of rare metabolic disorders predominately caused by a genetic 
mutation in 1 of the 8 enzymes responsible for heme synthesis.(1)  The 2 major categories are 
erythropoietic and hepatic, depending on the major site of expression of the underlying enzyme 
deficiency.(2)  In addition, the porphyrias are classified as acute if patients present with 
neurovisceral symptoms (eg, abdominal pain and neurologic symptoms) or cutaneous if they 
present with dermal blistering or photosensitivity.(3, 4) 
This study will include patients with acute intermittent porphyria (AIP), the most common acute 
hepatic porphyria (AHP).  AIP occurs as a result of an autosomal dominant mutation leading to 
partial deficiency of porphobilinogen deaminase (PBGD), the third enzyme in the heme 
biosynthesis pathway.(5)  The rate limiting step in heme synthesis is the upstream enzyme 
5-aminolevulinic acid synthase 1 (ALAS1), which is controlled by feedback repression via the 
end-product heme.  In response to a decrease in endogenous heme in the liver, as can occur with 
fasting, hormonal alterations, or with cytochrome P450 (CYP) inducing drugs, ALAS1 is 
induced, resulting in increased flux through the heme synthesis pathway.  In patients with AIP, 
this can result in the marked accumulation of the toxic heme intermediates porphobilinogen 
(PBG) and delta aminolevulinic acid (ALA) in the blood and urine due to the deficiency in the 
downstream PBGD.  Clinically, this manifests as acute attacks characterized by severe 
abdominal pain, cardiovascular as well as neurologic and psychiatric dysfunction.(6) 
1.1.1. 
Epidemiology 
Over 370 mutations have been identified in the PBGD gene, which in most instances result in its 
reduction by approximately 50%.  The exact prevalence of AIP is unknown due to under 
diagnosis, variation by geographic region, and the differences in penetrance observed for the 
different mutations.(2)  However, it is estimated that the prevalence of AIP is 5 to 10 per 100,000 
people in Western countries, while in Sweden it occurs in 1 in 1,000 people due to a founder 
effect associated with the resultant G593A mutation.(7-10)  AIP shows incomplete penetrance 
and on average only 10% to 50% of carriers with a mutation present with clinical symptoms.(11)  
It has been proposed that unknown inherited co-factors, in addition to PBGD mutations, may 
explain why a small percentage of patients present with much more severe disease while the 
majority remain asymptomatic. 
Patients with AIP present with acute attacks characterized by neurovisceral symptoms and signs 
including severe abdominal pain, nausea, vomiting, constipation, or less commonly diarrhea, 
hypertension, tachycardia, fever, muscle weakness, as well as neurological (eg, neuropathy, 
seizures) and psychiatric (eg, anxiety and confusion) manifestations.(12)  AIP attacks typically 
start after puberty and can be triggered by exogenous factors such as medications (especially 
barbiturates, sulfonamides, and hydantoins), stress, exogenous hormones, nutritional status, and 
infection.  Clinically active disease is more common in women, where attacks often occur around 
the menstrual cycle and are likely precipitated by hormonal changes. 
Many AIP patients remain undiagnosed given that the disease is rare and characterized by 
non-specific symptoms (eg, abdominal pain and nausea).(2)  The initial diagnosis involves 
demonstrating elevated urinary PBG (typically 20-50 × normal reference range) and ALA 
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(typically 5-20 × normal reference range) when the patient is having acute attack symptoms.  
Once a test is positive for elevated ALA and PBG and porphyria is suspected, genetic testing for 
a PBGD mutation is performed.   
There are 4 main clinical phenotypes of AIP.  Latent gene carriers have never had an acute attack 
and are biochemically inactive (normal urinary ALA and PBG).  Asymptomatic high excreters 
(ASHE) do not have current acute attacks, but are biochemically active (increased urinary ALA 
and PBG).  The increased levels of ALA and PBG in ASHE patients are lower than those in AIP 
patients during an acute attack, but are still significantly higher than normal reference values.(6-
8)  Sporadic attack patients have infrequent acute attacks.  Recurrent attack patients have ≥4 
attacks per year requiring hospitalization or treatment by a medical professional.(7) 
1.1.2. 
Current Management and Unmet Medical Need 
Management of acute attacks often requires hospitalization.  Patients are initially treated with 
supportive care and carbohydrate loading, analgesics and anti-emetics, and removal of known 
precipitating factors.(13)  In patients with moderate to severe attacks, or who fail to respond to 
supportive measures, treatment with intravenous (IV) hemin (daily for 3-5 days) is commenced.  
Symptoms typically begin to improve after 2 to 5 days of hemin treatment, accompanied by a 
lowering of urinary ALA and PBG levels to below or at the upper limit of normal (ULN) 
reference value; however, in some patients attacks can last several weeks, requiring prolonged 
hemin use and hospitalization.(14)  With prolonged and severe attacks, cranial nerve 
involvement can occur, leading to bulbar paralysis, respiratory failure, and death.(15) 
Hemin, a blood derived therapy, was approved as Normosang® (heme arginate) in the European 
Union (EU) and as Panhematin® (lyophilised hematin) in the United States (US) in 1999 and 
1983, respectively.(16, 17)  In the EU, heme arginate is indicated for the treatment of acute 
attacks of hepatic porphyria (eg, AIP, variegate porphyria, and hereditary coproporphyria); 
whereas, in the US lyophilized hemin is limited to the amelioration of recurrent attacks of AIP 
temporally related to the menstrual cycle.  Approval of both products was based on biochemical 
efficacy (ie, lowering of ALA and PBG) as well as data from uncontrolled case series and case 
reports.(18-22)  Hemin side effects include thrombophlebitis, transient anticoagulation, and in 
rare cases, anaphylaxis or renal failure.(22-24)  In addition, hemin administration requires a large 
vein for administration, often necessitating central venous access. 
While the majority of patients who experience attacks have them sporadically, it is estimated that 
up to 1,000 AIP patients experience recurrent attacks (typically defined as ≥4 per year) in the US 
and EU combined.(25)  While hemin is currently only approved to ameliorate acute attacks, it is 
administered prophylactically in some patients with recurrent attacks (eg, administered every 1-2 
weeks).(26)  Potential problems associated with chronic hemin administration include infusion 
site phlebitis, iron overload, and the need for chronic IV access and associated complications (eg, 
risk of infection or occlusion).(5)  In addition, there have been reports of a decrease in efficacy 
with chronic hemin administration, as evidenced by the need to increase the frequency or dosage 
of hemin prophylaxis over time in attempt to maintain a clinical effect.(27)  In patients with very 
severe recurrent attacks, or in whom hemin treatment is not effective, liver transplantation can be 
curative; however, organ transplantation is a high-risk procedure and is rarely used as a treatment 
option.  Given the significant morbidity and mortality, there remains a significant unmet need for 
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an efficacious, simple, fast-acting and better tolerated treatment for acute or prevent recurrent 
attacks in patients with AIP. 
1.2. 
RNA Interference 
RNA interference (RNAi) is a naturally occurring cellular mechanism mediated by small 
interfering RNAs (siRNAs) for regulating gene expression.  Typically, synthetic siRNAs are 19 
to 25 base pair double stranded oligonucleotides in a staggered duplex with a 2-nucleotide 
overhang at both or 1 of the 3’ ends.(28)  Such siRNAs can be designed to target an endogenous 
messenger RNA (mRNA) transcript of a given gene.  When introduced into cells, the net effect 
of an RNAi-based pharmacological approach is the binding of the siRNA to its complementary 
mRNA sequence, cleavage of this target mRNA, and reduction of synthesis of the target protein, 
resulting in a decrease of the target protein levels.(29)  The ability to selectively and potently 
degrade the mRNA encoding the ALAS1 protein (thereby decreasing accumulation of the toxic 
intermediates ALA and PBG) using an siRNA is a novel approach for the prevention and 
treatment of acute attacks in patients with AIP.   
1.3. 
ALN-AS1 
ALN-AS1 (givosiran) comprises a synthetic siRNA covalently linked to a GalNAc containing 
ligand (ALN60519), specific for ALAS1 and formulated for administration via subcutaneous 
(SC) injection. ALN-60519 has a target region between nucleotide 918 to 937 of the ALAS1 
mRNA. Attachment to a triantennary GalNAc ligand to the siRNA enables its distribution to the 
liver (which is the primary site of ALAS1 synthesis), followed by intracellular delivery to 
hepatocytes via ASGPR, resulting in engagement of the RNAi pathway and suppression of 
hepatic ALAS1 protein synthesis. 
ALN-AS1 is currently in development for treatment of acute attacks in patients with AIP, the 
most common AHP. 
Further information on ALN-AS1, including the clinical and nonclinical experience to date, is 
available in in the current version of the Investigator’s Brochure (IB). 
1.4. 
Study Design Rationale 
This is a multicenter, open-label extension study designed to evaluate the long-term safety and 
clinical activity of subcutaneously administered ALN-AS1 in patients with AIP who have 
completed clinical study ALN-AS1-001.  The primary endpoint for the study is the incidence of 
AEs. 
1.5. 
Dose Rationale 
Clinical data from Part A and Part B of the ongoing study ALN-AS1-001 demonstrate that single 
(0.035-2.5 mg/kg) and multiple (0.35-1.0 mg/kg) doses of ALN-AS1 have been generally 
well-tolerated in patients with AIP who are ASHE.  Additionally, data from this study indicate 
that a single dose of 2.5 mg/kg ALN-AS1 results in near normalization of urine ALA and PBG 
levels, which is sustained for approximately 14 weeks.   
Patients in Part C of the ongoing study ALN-AS1-001 who are eligible for participation in this 
study will likely require a higher dose of ALN-AS1 to normalize ALA and PBG as they have 
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higher levels of ALAS1 upregulation and higher baseline levels of ALA and PBG, when 
compared to patients with AIP who are ASHE.(30)  For example, based on preliminary data in 
Part A and Part B of the ALN-AS1-001 study, the mean PBG level of patients who are ASHE is 
21.9 mmol/mol Cr (N=28); whereas, in Part C of this study in patients with AHP who have 
recurrent porphyria attacks, the mean PBG level is approximately 49.3 mmol/mol Cr (N=12). 
The study starting dose and regimen of ALN-AS1 is 5.0 mg/kg as an SC injection administered 
every 3 months.  Based on emerging clinical data, the SRC may approve changes to the ALN-
AS1 dosing regimen, including decreases in the dose level and changes in dosing frequency.  
However, any dosing regimen will not exceed a previously explored dose level or frequency that 
was determined to be safe and well-tolerated in study ALN-AS1-001. SRC, Health Authority and 
Ethics Committee approval must be sought prior to dose level escalation above 5.0 mg/kg in 
accordance with local Regulatory requirements. 
The study starting dose and regimen was selected based on the benefit:risk profile of ALN-AS1 
in Part C of the ongoing ALN-AS1-001 study.  Preliminary data to date indicate that 
administration of 5.0 mg/kg ALN-AS1 has been generally well-tolerated.  There have been no 
study drug-related serious adverse events (SAEs), severe AEs, or clinically significant changes in 
safety parameters.  While a single 2.5 mg/kg dose of ALN-AS1 has also been generally well-
tolerated when administered to patients in Part A and Part C of study ALN-AS1-001, this dose 
has not resulted in near normalization of ALA and PBG levels.  In addition, while emerging data 
from Part C indicate that an every 3 months dose of 2.5 mg/kg ALN-AS1 demonstrated some 
clinical activity (eg, decrease in attack frequency and decrease in heme use), some patients 
continued to experience breakthrough porphyria attacks during the treatment period, indicating 
that a higher dose may be required. 
The duration of dosing in this study is supported by the overall favorable safety profile of 
ALN-AS1 in the ongoing clinical study ALN-AS1-001 and the absence of new findings in 
nonclinical studies with ALN-AS1. 
1.6. 
Clinical Data Summary 
1.6.1. 
Clinical Pharmacodynamics  
Dosing has been completed in Part A and Part B of the study.  In both Parts A and B of the study, 
durable and dose-dependent reductions of ALAS1 mRNA (up to 66% in the 2.5 mg/kg dose 
group) as measured by cERD were observed after ALN-AS1 treatment.  ALAS1 reductions were 
highly correlated with reductions in ALA (mean maximal 86%) PBG (mean maximal 95%) 
levels in a dose-dependent manner and were sustained for ≥180 days.  
Dosing is currently ongoing in Part C of the study. The mean maximal reduction in ALAS1 
mRNA relative to baseline in ALN-AS1-treated patients in Cohort 1 (2.5 mg/kg Q3M) was 39% 
and in Cohort 2 (2.5 mg/kg Q1M) 66%.  All patients treated with ALN-AS1 also had decreases 
in their peak ALA and PBG levels in the treatment period compared to the run-in period, along 
with reduced fluctuations in these levels in the treatment period (data not shown). No reductions 
were observed in the placebo-treated patients.  
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1.6.2. 
Clinical Activity 
Clinical activity was not evaluated in Parts A and B of the study because ASHE patients included 
in this study were not actively experiencing attacks of porphyria. 
Dosing is currently ongoing in Part C of the study. All patients in Cohorts 1 and 2 were enrolled 
in a run-in phase for 10-15 weeks that was followed by a treatment phase for up to 24 weeks.  No 
investigational product was administered during the run-in phase.  Therefore, each patient acted 
as their own control, allowing for individual ALA / PBG levels, and overall attack rate while on 
ALN-AS1 treatment to be compared to that observed in the run-in phase.   
Figure 1 shows in Cohort 1 ALN-AS1-treated patients there was a 74% mean decrease in the 
annualized attack rate for the treatment period versus the run-in period (range: 63-94% 
reduction), compared with a 23% decrease in the annualized attack rate for the placebo-treated 
patient.  In ALN-AS1-treated patients this was accompanied by an approximate 76% mean 
decrease in annualized acute hemin usage (range 52-95%) and a 10.3 times increase in the 
maximal attack free interval compared to run-in period (range 4.2-16.3). 
Figure 1: 
Part C Cohort 1 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in 
 
Figure 2 shows in Cohort 2 ALN-AS1-treated patients, there was a 58% mean decrease in the 
annualized attack rate for the treatment period versus the run-in period (range: 45-76% 
reduction).  This compares favorably with data from the placebo-treated patient who showed a 
34% reduction in the annualized attack rate for the treatment period versus the run-in period.  In 
ALN-AS1-treated patients, the reduction in attack rate was accompanied by a 92% mean 
decrease in annualized hemin usage (range 84-100%) and a 2.7x increase in the mean maximal 
attack free interval compared to run-in period (range 2.1-3.2). 
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Figure 2: 
Part C Cohort 2 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in 
 
1.6.3. 
Clinical Safety 
In Part A and Part B of Study ALN-AS1-001, a total of 11 patients (11/13; 85.0%) who received 
ALN-AS1 reported at least 1 AE.  All 5 placebo-treated patients (5/5; 100%) reported at least 1 
AE.  AEs considered possibly or definitely related to ALN-AS1 were reported in 5 patients 
(5/13; 38%): diarrhoea, dyspepsia, hematochezia, injection site erythema, injection site pain, 
blood creatinine increased, glomerular filtration rate decreased, and hypoesthesia (each AE 
reported only by an individual patient; 1/13; 8% each).  There were 2 SAEs of abdominal pain: 1 
patient each in the 0.035 mg/kg and 0.1 mg/kg ALN-AS1 dose groups.  Both were considered to 
be not related and resolved without sequelae.  There were no AEs leading to discontinuation.  All 
AEs were mild or moderate in severity, except for 1 of the SAEs of abdominal pain (0.10 mg/kg 
dose group), which was considered severe. Adverse events related to abnormal laboratory values 
were seen in 1 patient in the 0.35 mg/kg ALN-AS1 dose group who had AEs of ALT increased 
and AST increased, which were moderate and considered by the Investigator to be unrelated to 
ALN-AS1.  No clinically significant findings were observed with routine monitoring of CRP and 
a panel of 9 proinflammatory cytokines collected predose and up to 24 hours post-dose.  There 
were no other clinically significant laboratory abnormalities related to study drug or changes in 
vital signs, or ECGs in patients who were administered ALN AS1 or placebo. 
Dosing is ongoing in Part C of the study. All patients who received ALN-AS1 in cohort 1 and 2 
reported at least 1 AE.  AEs that were reported in at least 2 subjects were nausea in 3 patients 
(50%) and abdominal pain, vomiting, nasopharyngitis, headache, cough and oropharyngeal pain 
in 2 patients (33.3%) each.  All AEs were mild or moderate in severity.  AEs considered possibly 
or definitely related to ALN-AS1 were reported in 4 patients (66.6%), 1 each:  renal impairment 
in Cohort 1 and injection site reaction, myalgia, and headache in Cohort 2. Both placebo-treated 
patients reported AEs.  No AE was experienced in more than 1 patient.  
In Part C, Cohort 1 or 2, there were no SAEs or AEs leading to discontinuation in patients 
administered ALN-AS1 or placebo. No clinically significant laboratory abnormalities related to 
study drug or changes in vital signs, ECG, or physical exam findings were observed in patients 
administered ALN-AS1 or placebo. 
Part C Cohort 3 5.0 mg/kg SC monthly dosing is ongoing.  In this cohort there was one fatal 
SAE of acute pancreatitis, which was determined to be unlikely related to study drug or placebo 
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by the Investigator due to the presence of gall bladder sludge found at the time of her 
presentation.  Contributors to this patient's adverse clinical course included: pre-existing chronic 
debilitation from recurrent AIP attacks requiring monthly hospitalization, porphyria-attributed 
quadriplegia requiring nursing home care, delay in hospital admission and complications from 
thromboembolism (multiple risk factors included pancreatitis, obesity, immobilisation from 
quadriparesis and recent hospitalization for infected portacath removal).  Serum lipase was added 
to all scheduled laboratory assessments in November 2016 as part of additional safety 
monitoring. To date, all lipase results (available in 11 of 15 subjects) have been at or below the 
upper limit of normal with no trends seen with dosing of study drug or placebo. 
Further information on the safety, efficacy, PK and PD of ALN-AS1 are available in the 
Investigator’s Brochure. 
1.6.4. 
Drug-Drug Interactions  
An open-label drug-drug interaction (DDI) study (ALN-AS1-004) was conducted in AIP patients 
who are ASHE to evaluate the effect of a single dose of 2.5 mg/kg ALN-AS1 administered SC 
on the pharmacokinetics of probe substrates for 5 major CYP enzymes that account for the 
metabolism of approximately 80% of prescribed drugs.(31, 32)  Results from this study 
demonstrated that ALN-AS1 treatment resulted in weak to moderate reduction in the metabolic 
activity of some of the 5 CYP enzymes studied, thereby leading to higher concentrations of some 
substrates and their metabolites.  Treatment with ALN-AS1 resulted in an approximately 3-fold 
increase in exposure (as measured by AUC) of caffeine (a sensitive substrate for CYP1A2) and 
an approximately 2-fold increase in exposure of dextromethorphan (a sensitive substrate for 
CYP2D6).  Exposure of midazolam (a sensitive substrate for CYP3A4) and omeprazole (a 
sensitive substrate for CYP2C19) increased less than 2-fold after treatment with ALN-AS1.  
There was no effect of ALN-AS1 treatment on losartan (a sensitive substrate for CYP2C9). 
1.7. 
Benefit-Risk Assessment 
Patients participating in this study may experience a reduced number or severity of porphyria 
attacks, reduced treatment with IV hemin, and/or reduced requirement for pain medication.  As 
presented in Section 1.6, emerging data demonstrate that patients given ALN-AS1 experienced 
reduced ALA/PBG levels, decreased attack frequency and reduced heme usage in the 24-week 
treatment period compared to the 12-week run-in period in Study ALN-AS1-001 
As detailed in Section 1.6, a fatal SAE of hemorrhagic pancreatitis was reported but deemed to 
be unlikely related to study drug.  However, the potentially non-adverse nonclinical finding of 
angiectasis in the islets of Langerhans (endocrine, not exocrine region) of the rat pancreas (see 
Investigator Brochure), do not exclude a potential association between ALN-AS1 and the SAE of 
hemorrhagic pancreatitis. 
The important potential risks associated with administration of ALN-AS1 in patients with AIP 
are as follows: 
• Injection site reactions (ISRs):  ALN-AS1 is administered by SC injection.  In the 
ongoing ALN-AS1 clinical study, AEs of ISRs have been infrequently reported and 
have been mild to moderate in severity with single dosing.  Injection site rotation and 
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close monitoring have been implemented in ALN-AS1 clinical studies to reduce the 
potential for ISRs.  
• Pancreatitis: Since an association between ALN-AS1 and the fatal SAE of 
hemorrhagic pancreatitis can not be ruled out, patients will undergo routine 
monitoring of systemic and pancreatic inflammation and coagulation throughout the 
study.  Hematology, chemistry and coagulation results are required to be available 
prior to each dose. 
• Liver transaminase abnormalities:  As ALN-AS1 is targeted for delivery to the liver, 
and reversible hepatic changes were observed in some animal species, there is a 
potential for development of liver function test (LFT) abnormalities.  To minimize the 
potential for LFT abnormalities, patients are required to have adequate liver function 
at study entry and LFTs are monitored during the study. 
• Anaphylactic reactions:  There is a potential risk of developing a severe allergic 
reaction with ALN-AS1 administration.  In the present study, one patient in the 
2.5 mg/kg monthly dose group with a history of asthma and multiple allergies 
experienced an SAE of anaphylactic reaction that was determined by the Investigator 
to be definitely related to study drug given the temporal relationship of ALN-AS1 
treatment to the onset of the reaction (within minutes).  The patient was treated and 
recovered and was discontinued from the study.  Guidance on dose administration 
and monitoring for anaphylactic reactions has been included in this protocol. 
The complete summary of the clinical and nonclinical data relevant to the investigational drug 
and its study in human subjects is provided in the Investigator’s Brochure. 
2. 
OBJECTIVES 
2.1. 
Primary Objective 
• Evaluate the long-term safety and tolerability of ALN-AS1 in patients with AIP 
2.2. 
Secondary Objectives 
• Assess the PD effect of ALN-AS1 over time 
• Assess the clinical activity of ALN-AS1 over time 
2.3. 
Exploratory Objectives 
• Characterize the PK profile of ALN-AS1 and incidence of ADA over time 
• Assess changes in health-related quality of life (QOL) 
• Characterize analytes related to targeting the heme biosynthesis pathway 
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3. 
ENDPOINTS 
3.1. 
Primary Endpoint 
• Patient incidence of AEs 
3.2. 
Secondary Endpoints 
• Change in urine ALA and PBG levels 
• Frequency and characteristics of porphyria attacks 
• Change in hemin administration 
3.3. 
Exploratory Endpoints 
• Change in circulating ALAS1 mRNA levels 
• Concentrations of ALN-AS1 and ADA  
• Duration and treatment of porphyria attacks 
• Number and duration of visits to a health care facility for acute porphyria care 
• EQ-5D-5L questionnaire scores 
• Pain assessment and narcotic use as recorded in a patient diary 
• Exploratory biomarkers related to the target pathway, such as urine porphyrins, 
vitamin D binding protein 
4. 
INVESTIGATIONAL PLAN 
4.1. 
Summary of Study Design 
This is a Phase 1/2 multicenter, open-label extension study to evaluate the long-term safety and 
clinical activity of ALN-AS1 in patients with AIP who completed study ALN-AS1-001.  The 
study will be conducted at up to 8 clinical study centers worldwide. 
The last assessments performed, determining previous study (ALN-AS1-001) completion, will 
serve as the Screening/Baseline assessments in this study.  If more than 60 days have elapsed 
since the last assessment, safety assessments (eg, ECG and clinical laboratory tests) will be 
repeated before administration of ALN-AS1.  It is anticipated that patients will begin ALN-AS1 
administration in this study within 6 months after the last dose of study drug in the previous 
study.  Eligibility will be confirmed during Screening/Baseline and before administration of the 
first dose of ALN-AS1 (Day 1).  Patients will undergo assessments at the clinical study center 
every month for the first 3 months.  Then, through Month 6, and according to the dosing regimen 
selected, assessments will take place at the clinical study center or via a phone contact (for an 
every month dosing regimen, visits will be every month; for an every 3 months dosing regimen, 
visits will be every 3 months; see Section 6.2.2).  After a patient has completed 12 months of 
ALN-AS1 administration in this study (6 months in an every month dosing regimen), and where 
applicable country and local regulations and infrastructure allow, study procedures, including 
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ALN-AS1 administration, may take place at the patient’s home by a healthcare professional (as 
indicated in the Schedules of Assessments in Table 1, Table 2, and Table 3; and Table 5, Table 6, 
and Table 7 in Appendix Section 11.2).  If the patient is unable to come to the study site, and a 
visit by a home healthcare professional is not possible due to circumstances related to the 
COVID-19 pandemic, ALN-AS1 may be administered by the patient or the caregiver under the 
oversight of the Investigator, and following consultation with the medical monitor, as allowed by 
applicable country and local regulations.  In such cases, the patient or caregiver must receive 
appropriate training on ALN-AS1 administration and the use of epinephrine (epi pen or 
equivalent) prior to dosing.  This measure is intended to remain in effect only during periods of 
time when the COVID-19 pandemic impedes the ability of patients to travel to the study site or 
healthcare professionals to go to patients' homes for dosing.  Study procedures may occur at the 
patient’s home at the discretion of the Investigator, based on safety and tolerability; however, 
patients are required to complete at least 1 visit at the clinical study center every 3 months for the 
first year, and thereafter every 6 months through the end of the treatment period.  Additional 
visits to collect clinical laboratory samples may occur at home at any point during the treatment 
period, within 14 days prior to scheduled dose administration.  Patients will return to the clinical 
study center for a posttreatment follow-up visit after administration of the last dose of ALN-AS1.  
An ALA/PBG Monitoring/EOS visit will be conducted either at the clinical study center or via 
phone contact, unless treatment continues with ALN-AS1. 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain 
assessments, and narcotic use.  Additionally, patients will be encouraged to report to the clinical 
study center if they experience a porphyria attack through Month 49.  In the event that patients 
are unable to report to the clinical study center during a porphyria attack, laboratory sample 
collection kits containing instructions for collecting and sending urine samples to the clinical 
study center, if possible, will be provided.  Patients will be contacted by phone after a porphyria 
attack to record attack details.  If patients are experiencing signs and symptoms of a porphyria 
attack when ALN-AS1 administration is scheduled, the Investigator will determine whether 
administration of ALN-AS1 is appropriate.  If patients are treated for a porphyria attack at a 
health care facility (eg, hospital, emergency department, infusion center, or outpatient clinic) 
other than the clinical study center, copies of medical records, including discharge summaries, 
will be requested.   
A Safety Review Committee (SRC) will review safety and tolerability data collected during the 
study with the primary purpose of protecting the safety of patients participating in the study (see 
Section 4.6). 
Patients may receive ALN-AS1 as long as they do not fulfill any of the study discontinuation 
criteria (see Section 5.3) or until ALN-AS1 is commercially available in the patient’s territory or 
the ALN-AS1 development program is discontinued (whichever comes first).  
All patients are asked to participate in a Posttreatment Follow-up visit after they have received 
their last dose of ALN-AS1. 
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Figure 3: 
Study Design 
 
a Patients who discontinue treatment will be asked to complete an early termination (ET) visit at which all Month 49 
visit procedures will be performed; they must also return for a safety-follow-up visit 3 months (84 [+14] days) 
after their last dose of ALN-AS1. 
4.2. 
Duration of Treatment and Study 
The duration of treatment is up to 48 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 56 months.   
4.3. 
Number of Patients 
Up to 24 patients are planned for enrollment in this study (including optional cohorts in 
ALN-AS1-001). 
4.4. 
Method of Assigning Patients to Treatment Groups 
This is an open-label study; all patients will receive ALN-AS1.  A combination of the clinical 
study center number and screening number will create the unique patient identifier.  The clinical 
study center number will be assigned by the Sponsor.  Upon signing the Informed Consent Form 
(ICF), the patient will be assigned a screening number by the clinical study site, which will be 
the same unique patient identifier assigned in the previous study (ALN-AS1-001).  The 
Investigator, or delegate, will confirm that the patient fulfills all the inclusion criteria and none of 
the exclusion criteria. 
4.5. 
Blinding 
This is an open-label study, and all patients will receive ALN-AS1. 
4.6. 
Safety Review Committee 
An SRC will be involved in the conduct of this study.  The SRC has the responsibility for 
monitoring the safety of the study participants.  The SRC will perform periodic reviews of safety 
and tolerability data during the course of the clinical study at least every 3 months for the first 6 
months of the study and thereafter at least every 6 months.  The SRC may also meet on an ad hoc 
basis for review of emergent safety and tolerability data, as defined in the SRC Charter for this 
clinical study.  The SRC will not stop the study for efficacy. 
The SRC will be comprised of the following members:  Principal Investigator(s), or designee(s), 
the Sponsor Medical Monitor, and the Study Medical Monitor. 
The membership of the SRC and reporting structure are further defined in the SRC Charter. 
Screening
(Day -60 to -1)
Treatment Period
(up to 48 Months)a
End of Study
(Month 49)
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5. 
SELECTION AND WITHDRAWAL OF PATIENTS 
5.1. 
Inclusion Criteria 
Each patient must meet all of the following inclusion criteria to be eligible for enrollment in this 
study: 
1. Completed and, in the opinion of the Investigator, tolerated study drug dosing in Part C 
of study ALN-AS1-001 
2. Not on a scheduled regimen of hemin to prevent porphyria attacks at Screening 
3. Women of child-bearing potential (WOCBP) must have a negative serum pregnancy test, 
cannot be breast feeding, and must be willing to use acceptable methods of contraception 
14 days before first dose, throughout study participation, and for 90 days after last dose 
administration.  Acceptable methods include hormonal methods along with an additional 
barrier method (eg, condom, diaphragm, or cervical cap), or a double barrier method of 
contraception for those WOCBP for whom a hormonal method of contraception is 
medically contraindicated due to underlying disease (see Section 6.4 for acceptable 
methods of contraception).   
4. Willing and able to comply with the study requirements and to provide written informed 
consent 
5.2. 
Exclusion Criteria 
Each patient must not meet any of the following exclusion criteria to be eligible for enrollment in 
this study: 
1. Alanine transaminase ≥2.0×ULN or total bilirubin ≥2 mg/dL (unless bilirubin elevation is 
due to Gilbert’s syndrome) 
2. Estimated glomerular filtration rate ≤30 mL/min/1.73 m2 (using the Modification of Diet 
in Renal Disease formula) 
3. History of multiple drug allergies or history of allergic reaction to an oligonucleotide or 
to N-acetyl galactosamine ligand (GalNAc) 
4. Received an investigational agent, other than ALN-AS1, or who are in follow-up of 
another clinical study of an investigational agent within 90 days before study drug 
administration 
5. Other medical conditions or comorbidities which, in the opinion of the Investigator, 
would interfere with study compliance or data interpretation 
5.3. 
Discontinuation of Study Drug and/or Study 
Patients or their legal guardians (in the case that the patient is a minor) are free to discontinue 
treatment and/or study or withdraw their consent at any time and for any reason, without penalty 
to their continuing medical care.  Any discontinuation of treatment or of the study must be fully 
documented in the electronic case report form (eCRF), and should be followed up by the 
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Investigator.  The Investigator may withdraw a patient from the study at any time if this is 
considered to be in the patient’s best interest. 
Discontinuation of study drug and withdrawal from the study are described in Section 5.3.1 and 
Section 5.3.2, respectively.  If a patient stops participation from the study or withdraws consent 
from the study, he/she will not be able to re-enroll in the study. 
5.3.1. 
Discontinuation of Study Drug 
The Investigator or designee may discontinue dosing in a patient if the patient: 
• Is in violation of the protocol 
• Experiences a SAE considered to be possibly or definitely related to the study drug or 
an intolerable AE  
• Becomes pregnant 
• Is found to be considerably noncompliant with the protocol-requirements 
Patients who are pregnant will be discontinued from study drug dosing immediately (see 
Section 7.5.6.6 for reporting and follow-up of pregnancy).  A positive urine pregnancy test 
should be confirmed by a serum pregnancy test prior to discontinuing the study drug. 
If a patient discontinues dosing due to a serious adverse event (SAE), the SAE should be 
followed as described in Section 7.5.6.  When a patient discontinues study drug dosing, the 
primary reason must be recorded in the electronic case report form (eCRF).  Patients who 
discontinue study drug and remain on study may receive treatment consistent with local standard 
practice for their disease per Investigator judgement, as applicable. 
Patients who discontinue treatment will be asked to complete an early termination (ET) visit at 
which all Month 49 visit procedures will be performed; they must also return for a safety-follow-
up visit 3 months (84 [+14] days) after their last dose of ALN-AS1. 
5.3.2. 
Discontinuation from the Study 
A patient or their legal guardian may decide to stop the patient’s participation in the study at any 
time.  Patients considering to stop the study should be informed that they can discontinue 
treatment and complete study assessments including follow-up, as per the SOA, or alternatively 
may complete any minimal assessments for which the patient consents. The Investigator may 
withdraw a patient at any time if this is considered to be in the patient’s best interest. 
However, study integrity and interpretation is best maintained if all randomized patients continue 
study assessments and follow-up.  Stopping study participation could mean: 
• If a patient discontinues from the study, he/she will be asked to complete an early 
termination (ET) visit at which all Month 49 visit procedures will be performed; the 
patient must also return for a safety-follow-up visit at 3 months (84 [+14] days) after 
his/her last dose of ALN-AS1. 
• A patient can stop taking the study drug and stop study-related visits, but allow the 
investigator and study team to review the patient’s medical records, public records or 
be contacted in order to receive information about the patient’s health 
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When a patient stops the study, the discontinuation and reason for discontinuation must be 
recorded in the appropriate section of the electronic case report form (eCRF) and all efforts will 
be made to complete and report the observations as thoroughly as possible.  If a patient stops the 
study due to an adverse event (AE), including an SAE, the AE should be followed as described 
in Section 7.5.6. 
If the patient wants to stop participation in the study, he/she should notify the study doctor in 
writing or in any other form that may be locally required. The personal data already collected 
during the study, including patient’s biological samples, will still be used together with the data 
collected on other patients in the study according to the informed consent and applicable laws. 
In addition to stopping participation in the study, the patient could decide to withdraw his/her 
consent as explained in Section 5.3.3 
5.3.3. 
Withdrawal of Consent to Collect and Process the Patient’s Personal Data 
The patient may decide to withdraw his/her consent informing the study doctor at any time in 
writing, or in any other form that may be locally required.  This means that the patient wants to 
stop participation in the study and any further collection of his/her personal data.  
• The sponsor will continue to keep and use a patient's study information (including 
any data resulting from the analysis of the patient's biological samples until time of 
withdrawal) according to applicable law.  This is done to guarantee the validity of the 
study, determine the effects of the study treatment, and ensure completeness of study 
documentation. 
• The patient can also request that collected samples be destroyed or returned (to the 
extent it is permitted by applicable law) at any time. 
• Patients who withdraw their consent to collect and use personal data should 
understand that public records may be reviewed to determine the patient’s survival 
status as allowed per local and national regulations.    
In US and Japan, otherwise, samples not yet analyzed at the time of withdrawal may still be used 
for further testing/analysis in accordance with the terms of the protocol and of the informed 
consent form. 
In EU and rest of world, in any event, samples not yet analyzed at the time of withdrawal will 
not be used any longer, unless permitted by applicable law. They will be stored or destroyed 
according to applicable legal requirements. 
5.3.4. 
Replacement of Patients 
Patients discontinuing from study drug or withdrawing from the study will not be replaced. 
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6. 
TREATMENTS 
6.1. 
Treatments Administered 
ALN-AS1 Solution for Injection (SC use) is a clear, colorless to pale yellow solution essentially 
free of particulates.  ALN-AS1 will be supplied by the Sponsor as a sterile solution for SC 
injection. 
Study drug supplied for this study must not be used for any purpose other than the present study 
and must not be administered to any person not enrolled in the study.  Study drug that has been 
dispensed to a patient and returned unused must not be re-dispensed to a different patient. 
6.2. 
Investigational Study Drug 
Detailed information describing the preparation, handling, and storage, packaging and labeling, 
as well as study drug accountability for ALN-AS1 is provided in the Pharmacy Manual. 
6.2.1. 
Description 
ALN-AS1 Solution for Injection (SC use) is comprised of a synthetic, siRNA targeting ALAS1 
and bearing a triantennary GalNAc ligand conjugated to the sense strand, formulated in 
phosphate buffer.  
6.2.2. 
Dose and Administration 
The study starting dose of ALN-AS1 is 5.0 mg/kg ALN-AS1 as an SC injection administered 
every 3 months (Table 1, Table 2, and Table 3). Based on emerging clinical data, the SRC may 
approve changes to the ALN-AS1 dosing regimen, including decreases in the dose level and 
changes in dosing frequency (Table 5, Table 6, and Table 7 in Section 11.2).  However, any dose 
and dosing regimen will not exceed a previously explored dose level or frequency that was 
determined to be safe and well-tolerated in study ALN-AS1-001. SRC, Health Authority and 
Ethics Committee approval must be sought prior to dose level escalation above 5.0 mg/kg in 
accordance with local Regulatory requirements.  See Section 6.2.3 for details on dose 
modifications. 
The study drug should be injected into the abdomen or upper arms or thighs.  Detailed 
instructions for study drug administration are presented in the Pharmacy Manual. As is consistent 
with good medical practice for subcutaneous drug administration, patients will be observed for a 
minimum of 20 minutes after each injection.   Treatment for anaphylactic reactions should be 
readily available where patients are being dosed, and follow country and/or local hospital 
treatment guidelines as shown in Table 8.(33) 
ALN-AS1 will be administered by a qualified and authorized health care professional trained in 
the recognition and management of anaphylactic reactions.  After a patient has completed 12 
months of ALN-AS1 administration in this study (6 months in an every month dosing regimen), 
study drug administration may be conducted at a location other than the study center by a home 
healthcare professional, where applicable country and local regulations and infrastructure allow, 
after consultation with the medical monitor, during particular study visits, as specified in the 
Schedules of Assessments.  If the patient is unable to come to the study site, and a visit by a 
home healthcare professional is not possible due to circumstances related to the COVID-19 
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pandemic, ALN-AS1 may be administered by the patient or the caregiver under the oversight of 
the Investigator, and following consultation with the medical monitor, as allowed by applicable 
country and local regulations.  In such cases, the patient or caregiver must receive appropriate 
training on ALN-AS1 administration and the use of epinephrine (epi pen or equivalent) prior to 
dosing.  This measure is intended to remain in effect only during periods of time when the 
COVID-19 pandemic impedes the ability of patients to travel to the study site or healthcare 
professionals to go to patients' homes for dosing.  However, study drug administration at the 
study center should be considered for patients who have ongoing study drug-related AEs or 
known risk factors for developing anaphylactic reaction, including but not limited to: a prior 
history of anaphylactic reaction to food, medications or due to unknown etiology, worsening 
injection site reactions with repeat dosing, or anyone in the opinion of the investigator that would 
benefit from clinical observation following dosing.  Patients are required to complete at least 1 
visit at the clinical study center every 3 months for the first year, and thereafter every 6 months 
through the end of the treatment period.  Additional visits to collect clinical laboratory samples 
may occur at home at any point during the treatment period, within 14 days prior to scheduled 
dose administration. 
If a patient does not receive a dose of ALN-AS1 within the specified dosing window, the 
Investigator should contact the Medical Monitor.  After such consultation, the dose may be 
administered or considered missed and not administered. 
Patients will be permitted to miss an occasional dose of study drug; however, if a patient misses 
2 consecutive doses, the Investigator, in consultation with the Medical Monitor, will discuss 
whether the patient will be able to continue on the study.  
Detailed instructions for study drug administration are found in the Pharmacy Manual.  In 
addition, instructions and procedures related to administration of ALN-AS1 by a patient or 
caregiver will be provided in the Patient/Caregiver Storage and Administration Instructions. 
6.2.3. 
Dose Modifications 
6.2.3.1. 
Study Population Dose Modifications 
During the study, dose modifications are permitted for the study population, or based on the dose 
cohort into which patients were originally randomized in study ALN-AS1-001.  Following SRC 
review of emerging safety and tolerability data from Part C of study ALN-AS1-001, or from this 
study (ALN-AS1-002), the dose and dosing regimen may be modified.  However, the dose and 
dosing regimen of ALN-AS1 will not exceed a previously explored dose and dosing regimen that 
was determined to be safe and well-tolerated in study ALN-AS1-001.  Patients enrolling in this 
study after a dose modification decision has been implemented may start at the newly identified 
dose and regimen. 
6.2.3.2. 
Individual Dose Modifications 
Dose modifications are permitted for individual patients.  If a patient has a study drug related AE 
of a recurrent ISR, severe ISR, or clinically significant LFT abnormality and the Investigator has 
concerns regarding further ALN-AS1 administration, the Medical Monitor and Investigator will 
review all available safety data for the patient.  Based on this review, a dose reduction to half the 
previously administered dose (eg, a 5.0 mg/kg dose would be reduced to a 2.5 mg/kg dose) or a 
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reduction in dosing frequency from monthly to every 3 months is permitted.  Subsequent ALN-
AS1 administration at the previous dose may be considered based on the judgment of the 
Investigator and Medical Monitor. 
6.2.3.2.1. Monitoring and Dosing Rules in Patients with Potential Cases of Anaphylactic 
Reaction   
An anaphylactic reaction is a severe, potentially fatal, systemic allergic reaction with acute onset 
(minutes to hours).  For reference see Section 11.3.(33) 
Stop administering the study medication immediately if an anaphylactic reaction to the study 
medication is suspected.  Study medication must be permanently discontinued in patients for 
whom an anaphylactic reaction is assessed as related to the study medication. 
Laboratory testing: Obtain blood sample for tryptase, total IgE, and ADA antidrug antibodies 
(ADA) ideally within 15 minutes to 3 hours after the onset of a suspected anaphylactic reaction; 
however, up to 6 hours is acceptable.  An additional blood sample to assess tryptase, total IgE, 
and ADA should be obtained between 1 to 2 weeks from onset of event.  Local laboratory may 
be used to analyze samples; however, parallel samples should be sent to the central laboratory for 
analysis.  Sample collection and shipping instructions are included in the Laboratory Manual. 
Reporting: The PI or designee must notify the sponsor or designee within 24 hours of the 
occurrence of a suspected case of anaphylactic reaction or being informed of the case as required 
for AEs of Clinical Interest (AECI) and SAEs, per AE reporting requirements (Section 7.5.6.1,  
Section 7.5.6.2 and 7.5.6.3). 
6.2.4. 
Preparation, Handling, and Storage 
Staff at each clinical study center, or the home healthcare professional, will be responsible for 
preparation of ALN-AS1 doses, according to procedures detailed in the Pharmacy Manual.  In 
cases where ALN-AS1 is administered at home by a patient/caregiver, dosing may be prepared 
and administered by the patient/caregiver according to procedures detailed in the 
Patient/Caregiver Storage and Administration Instructions.  No special procedures for the safe 
handling of study drug are required. 
Study drug will be stored upright and refrigerated at approximately 5±3°C. 
A Sponsor representative or designee will be permitted, upon request, to audit the supplies, 
storage, dispensing procedures, and records. 
Additional storage and preparation details are provided in the Pharmacy Manual and the 
Patient/Caregiver Storage and Administration Instructions 
6.2.5. 
Packaging and Labeling 
All packaging, labeling, and production of study drug will be in compliance with current Good 
Manufacturing Practice specifications, as well as applicable local regulations.  Study drug labels 
and external packaging will include all appropriate information as per local labeling 
requirements. 
Additional details will be available in the Pharmacy Manual. 
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6.2.6. 
Accountability 
The Investigator or designee will maintain accurate records of receipt and the condition of the 
study drug supplied for this study, including dates of receipt.  In addition, accurate records will 
be kept of when and how much study drug is dispensed and administered to each patient in the 
study.  Any reasons for departure from the protocol dispensing regimen must also be recorded. 
At the completion of the study, there will be a final reconciliation of all study drugs.  All used, 
partially used, and unused study drug will be returned to the Sponsor (or designee) or destroyed 
at the clinical study center according to applicable regulations.   
Further instructions about drug accountability are detailed in the Pharmacy Manual. 
 
6.3. 
Concomitant Medications 
Use of concomitant medications will be recorded on the patient’s case report form (CRF) as 
indicated in the Schedules of Assessments (Table 1, Table 2, and Table 3; and Table 5, Table 6, 
and Table 7 in Appendix Section 11.2).  This includes all prescription medications, herbal 
preparations, over the counter (OTC) medications, vitamins, and minerals.  Any changes in 
medications during the study will also be recorded on the CRF. 
Any concomitant medication that is required for the patient’s welfare may be administered by the 
Investigator.  However, it is the responsibility of the Investigator to ensure that details regarding 
the medication are recorded on the eCRF.  Concomitant medication will be coded using an 
internationally recognized and accepted coding dictionary. 
Patients with porphyria could have altered hepatic heme synthesis, and treatment with ALN-AS1 
could also modulate this pathway and secondarily impact CYP enzyme activity.  Results from a 
DDI study in AIP patients who are ASHE are presented in Section 1.6.4.  The DDI study 
demonstrated that ALN-AS1 treatment resulted in weak to moderate reduction in activity in 
some of the CYP enzymes resulting in corresponding low to moderate increase in the plasma 
levels of drugs that are metabolized by these CYP enzymes.  Based on the moderate decrease in 
CYP2D6 or CYP1A2 activity, investigators will review all concomitant medications that are 
primarily metabolized by these enzymes and monitor the patient’s clinical response to these 
medications during the study.  Medications metabolized primarily by CYP2D6 and CYP1A2 
with a narrow therapeutic index (ie that require regular laboratory monitoring) may need to be 
monitored more frequently to determine if a dose adjustment of the concomitant medication is 
required.  For patients who require new medications while on study, selection of medications that 
are not primarily metabolized by CYP2D6 or CYP1A2 should be considered.  Refer to the 
individual product’s prescription information to determine if there is a need to monitor 
concomitant medications for differences in safety or efficacy of the medication based on reported 
DDIs with CYP2D6 or CYP1A2.  For more detailed and up-to-date information on CYP 
substrates, see: 
https://www.fda.gov/drugs/developmentapprovalprocess/developmentresources/druginteractionsl
abeling/ucm093664.htm. 
Patients are not permitted to be on hemin prophylaxis at Screening; however, patients are 
permitted to receive concomitant hemin treatment for the management of acute porphyria 
attacks.  Patients experiencing significant breakthrough attacks while enrolled in this study, 
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necessitating frequent hemin treatment, may receive hemin prophylaxis if in the Investigator’s 
judgment this is clinically beneficial to the patient.  The Investigator should contact with the 
Sponsor and Medical Monitor before prophylactic hemin treatment.  The dose, regimen, and 
dates of administration will be recorded on the patient’s eCRF.   
Pain medication (eg, opiates, opioids, narcotic analgesics) and glucose administration are 
permitted for the management of porphyria and for acute porphyria attacks. 
If patients use nonsteroidal anti-inflammatory medications intermittently or chronically, they 
must have been able to tolerate them with no previous side effects (eg, gastric distress or 
bleeding).   
Standard vitamins and topical medications are permitted; however, topical steroids must not be 
applied anywhere near the injection site(s) unless medically indicated. 
6.4. 
Contraceptive Requirements 
No data are available on the use of ALN-AS1 in pregnancy; however, there is no suspicion of 
human teratogenicity based on class effects or genotoxic potential.  ALN-AS1 was neither 
genotoxic nor clastogenic in in vitro and in vivo studies.   
WOCBP must be willing to use acceptable methods of contraception 14 days before first dose, 
throughout study participation, and for 90 days after last dose administration.   
Birth control methods which may be considered as acceptable include: 
• Established use of oral, implantable, injectable, transdermal hormonal, or intrauterine 
hormone-releasing system as methods of contraception.  WOCBP using hormonal 
methods of contraception must also use a barrier method (condom or occlusive cap 
[diaphragm or cervical/vault cap] in conjunction with spermicide [eg, foam, gel, film, 
cream, or suppository]). 
• If hormonal methods of contraception are medically contraindicated for WOCBP due 
to underlying disease, a double-barrier method (combination of male condom with 
either cap, diaphragm, or sponge, in conjunction with spermicide) is also considered 
an acceptable method of contraception. 
• Placement of an intrauterine device  
• Bilateral tubal occlusion 
• Surgical sterilization of male partner (with the appropriate post-vasectomy 
documentation of the absence of sperm in the ejaculate; for female patients on the 
study, the vasectomized male partner should be the sole partner for that patient) 
• Sexual abstinence, when this is in line with the preferred and usual lifestyle of the 
patient, is considered an acceptable method only if defined as refraining from 
heterosexual intercourse during the entire period of risk associated with the study 
drug (defined above).  Periodic abstinence (eg, calendar, ovulation, symptothermal, 
post-ovulation methods) and withdrawal are not considered sexual abstinence and do 
not meet criteria for an acceptable method of birth control.  As determined by the 
investigator, the reliability of sexual abstinence needs to be evaluated in relation to 
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the duration of the clinical trial and the preferred and usual lifestyle of the patient.  
Abstinent patients must agree to use 1 of the abovementioned contraceptive methods 
if they start a heterosexual relationship during the study and continue to do so for the 
entire period of risk associated with the study drug (defined above). 
• WOCBP includes any female patient who has experienced menarche and who is not 
postmenopausal or permanently sterilized (eg, bilateral tubal occlusion, hysterectomy, 
or bilateral salpingectomy).  Postmenopausal state is defined as no menses for 12 
months without an alternative medical cause, confirmed by follicle stimulating 
hormone level within the postmenopausal range. 
6.5. 
Treatment Compliance 
Compliance with study drug administration will be verified through observation by study 
personnel or trained home healthcare professionals.  
7. 
STUDY ASSESSMENTS 
The schedules of study assessments are provided in Table 1, Table 2, and Table 3; and Table 5, 
Table 6, and Table 7. 
Where applicable country and local regulations and infrastructure allow for home healthcare, 
healthcare may take place at a location other than the clinical trial site to perform study 
assessments including targeted physical exam/body system assessment, assessments for vital 
signs, and collection of blood and urine samples for safety laboratory assessments, and PD 
assessments, at all timepoints as specified in the Schedule of Assessments. 
7.1. 
Screening/Baseline Assessments 
Informed consent, patient demographic data, and eligibility criteria will be confirmed at 
Screening/Baseline.  An interval medical history/disease history will be obtained at 
Screening/Baseline.  The last assessments performed, determining previous study 
(ALN-AS1-001) completion, will serve as the Screening/Baseline assessments in this study.  If 
more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs will 
be repeated before administration of ALN-AS1. 
7.2. 
Clinical Activity Assessments 
The clinical activity of ALN-AS1 will be assessed by the frequency and characteristics of 
porphyria attacks including, but not limited to, duration, treatment, and severity of porphyria 
attacks and number and duration of visits to a health care setting for acute porphyria care (eg, 
hospital, emergency department, infusion center, or outpatient clinic).  Concomitant hemin 
administration will also be recorded. 
7.2.1. 
Patient Diary 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain 
assessments, and narcotic use. 
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7.2.2. 
Brief Pain Inventory-Short Form Questionnaire 
The Brief Pain Inventory-Short Form (BPI-SF) questionnaire will be used to evaluate pain.(34)  
The BPI will be completed as part of the patient diary. 
7.3. 
Pharmacodynamic Assessments 
Blood and urine samples will be collected for assessment of ALN-AS1 PD parameters.  The PD 
effect of ALN-AS1 will be evaluated by urine ALA and PBG levels.  Blood and urine samples 
will be collected for assessment of circulating ALAS1 mRNA levels in serum and in urine.  
Analysis for blood and urine PD parameters will take place at a central laboratory.   
Details regarding the processing and aliquoting of samples for storage and analyses will be 
provided in the Laboratory Manual. 
7.4. 
Pharmacokinetic Assessments 
Blood samples will be collected to evaluate the PK profile of ALN-AS1 at the time points in the 
Schedule of Assessments.  A detailed schedule of time points for the collection of blood samples 
for PK analysis is in Table 4 in Appendix Section 11.1). 
The concentration of ALN-AS1 will be determined using a validated assay.  Details regarding 
the processing, shipping, and analysis of the samples will be provided in the Laboratory Manual. 
7.5. 
Safety Assessments 
The assessment of safety during the course of the study will consist of the surveillance and 
recording of AEs including SAEs, recording of concomitant medications and measurements of 
vital signs, physical examination, and ECG findings and clinical laboratory evaluations. 
Safety will be monitored over the course of the study by an SRC as described in Section 4.6. 
7.5.1. 
Vital Signs 
Vital sign measurements include blood pressure, heart rate, body temperature, and respiratory 
rate.  Vital signs will be measured in the seated or supine position (should be consistent for each 
patient), after the patient has rested comfortably for at least 10 minutes.  Blood pressure should 
be taken using the same arm throughout the study.  Body temperature will be obtained in degrees 
Celsius, heart rate will be counted for a full minute and recorded in beats per minute, and 
respiration rate will be counted for a full minute and recorded in breaths per minute. 
For the safety of the patient, additional vital sign assessments may be added at the discretion of 
the Investigator. 
7.5.2. 
Weight and Height 
Height will be measured in centimeters at the Screening/Baseline visit only.  Body weight will be 
measured in kilograms.  Body mass index will be calculated in the database. 
Body weight measured on the dosing day will be used to calculate the dose of ALN-AS1 through 
M12.  After M12, weight obtained within 6 months during a study center visit or offsite may be 
used for dosing calculations. 
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7.5.3. 
Physical Examination 
Complete physical examinations will include the examination of the following:  general 
appearance, head, eyes, ears, nose and throat, chest/respiratory, heart/cardiovascular, 
gastrointestinal/liver, musculoskeletal/extremities, dermatological/skin, thyroid/neck, lymph 
nodes, and neurological/psychiatric. 
Targeted physical examinations will include the examination of the following:  general 
appearance, chest/respiratory, heart/cardiovascular, gastrointestinal/liver, and 
neurological/psychiatric. 
7.5.4. 
Electrocardiogram 
Triplicate standard 12-lead ECGs will be performed using central ECG equipment, with readings 
approximately 1 minute apart and recorded as specified in the Schedule of Assessments.  Patients 
should be seated or supine for at least 5 minutes before each ECG is obtained.  The 
electrophysiological parameters assessed will be rhythm, ventricular rate, PR interval, QRS 
duration, QT interval, ST and T waves, Bazett-corrected QT interval (QTcB), and Fridericia 
corrected QT interval (QTcF). 
When ECG and blood sample collection occur at the same time, ECGs should be performed 
before blood samples are drawn. 
Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine 
position after the patient has rested comfortably for at least 5 minutes.   
In all patients receiving ≤2.5 mg/kg ALN-AS1, it is required that ECGs will be obtained on at 
least 2 separate clinic visits (D1, and Months 3, 6, 9, 12, 15, or 18), each of which will include 
same day predose and 2-hour (±15 minutes) postdose readings, paired with PK timepoints 
(Table 4) as specified in the Schedule of Assessments.   
Similarly, in all patients receiving >2.5 mg/kg ALN-AS1, it is required that ECGs will be 
obtained on at least 2 separate clinic visits (D1, and Months 3, 6, 9, 12, 15, or 18), each of which 
will include same day predose and 4-hour (±20 minutes) postdose readings, paired with PK 
timepoints (Table 4), as specified in the Schedule of Assessments.  
The Investigator or designee is responsible for reviewing the ECGs to assess whether the results 
have changed since the Screening/Baseline visit and to determine the clinical relevance of the 
results.  These assessments will be recorded on the eCRF.  For any clinically relevant ECG 
changes from the Screening/Baseline visit (eg, ischemic ECG changes, wave/interval changes, or 
arrhythmia), the Investigator must contact the Medical Monitor to discuss continued participation 
of the patient in the study. 
7.5.5. 
Clinical Laboratory Assessments 
The following clinical laboratory tests will be evaluated by a central laboratory.   
On dosing days up to the Month 18 visit, results from hematology, chemistry, and coagulation 
tests collected within the prior 14 days must be reviewed by the Investigator before study drug 
administration.  These results can be analyzed centrally or at a local laboratory.  If results from 
within the prior 14 days are not available at a dosing visit (at visits from D1 to Month 18), 
locally analyzed assessments must be reviewed to allow same day study drug administration and 
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additional samples for central analysis must also be collected.  On dosing days from Month 19 
through Month 48, a review of laboratory results within 14 days is not required. 
In the event of an unexplained clinically relevant abnormal laboratory test occurring after study 
drug administration, the test should be repeated and followed up at the discretion of the 
Investigator until it has returned to the normal range or stabilized, and/or a diagnosis is made to 
adequately explain the abnormality. 
At any point during the study, and based on Investigator judgment, if a patient experiences 
uncharacteristic signs and symptoms during a porphyria attack, lipase testing should be 
performed and imaging evaluations (eg, right upper quadrant ultrasound and/or other testing, 
based on Investigator judgment) should be considered by the Investigator.  Signs and symptoms 
include, but are not limited to, uncharacteristic abdominal pain and worsening nausea and 
vomiting. 
Imaging is required for any serum lipase result of ≥3× the upper limit of normal, or as clinically 
indicated. 
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Hematology 
Complete blood count with differential 
 
Serum Chemistry 
Sodium 
Potassium 
BUN 
Phosphate 
Creatinine and eGFRa 
Albumin 
Uric acid 
Calcium 
Total protein 
Carbon dioxide 
Glucose 
Chloride 
Lipase 
Bicarbonate 
Liver Function Tests 
 
AST 
ALP 
ALT 
Bilirubin (total and direct) 
GGT 
 
Urinalysis 
Visual inspection for appearance and color 
Bilirubin 
pH (dipstick) 
Nitrite 
Specific gravity 
RBCs 
Ketones 
Urobilinogen 
Albumin 
Leukocytes 
Glucose 
Microscopy (if clinically indicated) 
Protein 
 
Immunogenicity 
Antidrug antibodies 
Coagulation 
Prothrombin time 
International Normalized Ratio 
Pregnancy Testing (WOCBP only) 
β-human chorionic gonadotropin 
 
Inflammation 
 
C-reactive protein 
 
Abbreviations:  AST=aspartate transaminase; ALP=alkaline phosphatase; ALT=alanine transaminase; 
BUN=blood urea nitrogen; eGFR=estimated glomerular filtration rate; GGT=gamma-glutamyltransferase; 
WOCBP=women of child bearing potential. 
a eGFR will be calculated using the Modification of Diet in Renal Disease formula.(35) 
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7.5.5.1. 
Immunogenicity 
Blood samples will be collected to evaluate antidrug antibodies.  On days when ALN-AS1 is 
administered, blood samples for antidrug antibody testing must be collected before ALN-AS1 is  
administered. 
Sample collection for patients who experience a potential anaphylactic reaction is discussed in 
Section 6.2.3.2.1. 
Details regarding the processing, shipping, and analysis of the samples will be provided in the 
Laboratory Manual. 
7.5.5.2. 
Pregnancy Testing 
A pregnancy test will be performed for WOCBP only.  A serum pregnancy test will be 
performed at Screening/Baseline and urine pregnancy tests will be performed thereafter per the 
Schedule of Assessments and any time pregnancy is suspected.  Urine pregnancy tests may also 
be performed more frequently (eg, monthly) based on local country requirements.  The results of 
the pregnancy test must be known before study drug administration.  Patients who are pregnant 
are not eligible for study participation.  Any woman with a positive pregnancy test during the 
study will be discontinued from study drug, but will continue to be followed for safety.  Patients 
determined to be pregnant while on study will be followed until the pregnancy outcome is known 
(see Section 7.5.6.6 for follow-up instructions).  
7.5.6. 
Adverse Events 
7.5.6.1. 
Definitions 
Adverse Event 
According to the ICH E2A guideline Definitions and Standards for Expedited Reporting, and 21 
Code of Federal Regulations 312.32, Investigational New Drug Safety Reporting, an AE is any 
untoward medical occurrence in a patient or clinical investigational subject administered a 
medicinal product and which does not necessarily have a causal relationship with this treatment. 
Serious Adverse Event 
An SAE is any untoward medical occurrence that at any dose: 
• Results in death 
• Is life-threatening (An event which places the patient at immediate risk of death from 
the event as it occurred.  It does not include an event that had it occurred in a more 
severe form might have caused death) 
• Requires in-patient hospitalization or prolongation of existing hospitalization 
• Results in persistent or significant disability or incapacity 
• Is a congenital anomaly or birth defect 
• Is an important medical event that may not be immediately life-threatening or result 
in death or hospitalization but may jeopardize the patient and may require 
intervention to prevent one of the other outcomes listed in the definition above (eg, 
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events include allergic bronchospasm requiring intensive treatment in an emergency 
room or at home, blood dyscrasias, convulsions, or the development of drug 
dependency or abuse). 
Adverse Event Severity 
Adverse events are to be graded according to the categories detailed below: 
Mild: 
Mild events are those which are easily tolerated with no disruption of normal 
daily activity. 
Moderate: 
Moderate events are those which cause sufficient discomfort to interfere with 
normal daily activities. 
Severe: 
Severe events are those which incapacitate and prevent usual activity. 
Changes in severity should be documented in the medical record to allow assessment of the 
duration of the event at each level of severity.  AEs characterized as intermittent require 
documentation of the start and stop of each incidence.  When changes in the severity of an AE 
occur more frequently than once a day, the maximum severity for the experience that day should 
be noted.  If the severity category changes over a number of days, then those changes should be 
recorded separately (with distinct onset dates) 
AE severity and seriousness are assessed independently.  ‘Severity’ characterizes the intensity of 
an AE.  ‘Serious’ is a regulatory definition and serves as a guide to the Sponsor for defining 
regulatory reporting obligations (see definition for Serious Adverse Event). 
Relationship of the Adverse Event to Study Treatment 
The relationship of each AE to study treatment should be evaluated by the Investigator using the 
following criteria:  
Definitely related: 
A clinical event, including laboratory test abnormality, occurring in a 
plausible time relationship to the medication administration, and which 
cannot be explained by concurrent disease or other drugs or chemicals.  
The response to withdrawal of the drug should be clinically plausible. 
Possibly related: 
A clinical event, including laboratory test abnormality, with a 
reasonable time sequence to the medication administration, but which 
could also be explained by concurrent disease or other drugs or 
chemicals.  Information on the drug withdrawal may be lacking or 
unclear. 
Unlikely related: 
A clinical event, including laboratory test abnormality, with little or no 
temporal relationship to medication administration, and which other 
drugs, chemicals, or underlying disease provide plausible explanations. 
Not related: 
A clinical event, including laboratory test abnormality that has no 
temporal relationship to the medication or has more likely alternative 
etiology. 
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Adverse Events of Clinical Interest 
The following events are considered to be adverse events of clinical interest: 
• ISRs 
• Hepatic AEs, including LFT abnormalities considered clinically significant by the 
Investigator. 
• Lipase >3×ULN (or >3× the baseline lipase measurement if baseline is >ULN) 
• Anaphylactic Reactions. Anaphylactic reaction is a severe, potentially fatal, systemic 
allergic reaction with acute onset (minutes to hours).  Symptoms of an anaphylactic 
reaction may include skin or mucosal tissue (e.g. generalized hives, pruritus, 
angioedema), respiratory compromise (e.g. wheezing, bronchospasm, hypoxia), 
reduced blood pressure or associated symptoms (e.g. syncope, hypotonia).  See 
Section 11.3 (Table 8) for guidance on diagnosing anaphylactic reactions.(33) 
7.5.6.2. 
Eliciting and Recording Adverse Events 
Eliciting Adverse Events 
The patient should be asked about medically relevant changes in his/her health since the last 
visit.  The patient should also be asked if he/she has been hospitalized, had any accidents, used 
any new medications, or changed concomitant medication routines (both prescription and OTC).  
In addition to patient observations, AEs will be documented from any clinically relevant 
laboratory findings, physical examination findings, ECG changes, or other findings that are 
relevant to patient safety. 
Recording Adverse Events 
The Investigator is responsible for recording non-serious AEs that are observed or reported by 
the patient after administration of the first dose of study drug regardless of their relationship to 
study drug through the end of study.  Non-serious AEs will be followed until the end of study.  
The Investigator is responsible for recording SAEs that are observed or reported by the patient 
after the time when the informed consent is signed regardless of their relationship to study drug 
through the end of study.  SAEs will be followed until satisfactory resolution, until baseline level 
is reached, or until the SAE is considered by the Investigator to be chronic or the patient is 
stable, as appropriate. 
All AEs must be recorded in the source records for the clinical study center and in the eCRF for 
the patient, whether or not they are considered to be drug-related.  Each AE must be described in 
detail:  onset time and date, description of event, severity, relationship to investigational drug, 
action taken, and outcome (including time and date of resolution, if applicable). 
For SAEs, record the event(s) on the eCRF.  If the electronic data capture (EDC) system is 
unavailable, complete the backup SAE form. 
For AEs that are considered AEs of clinical interest, the Sponsor or its designee should be 
notified within 24 hours using a supplemental AEs of clinical interest (AECI) eCRF.  Additional 
clinical and laboratory information may be collected based upon the severity or nature of the 
event. 
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If a patient has ISRs meeting any of the following criteria, the Investigator or delegate should 
contact the Medical Monitor and submit a supplemental ISR eCRF: 
• ISRs that are recurrent and/or demonstrate a pattern of increasing severity 
• Any ISR that is determined to be severe and/or a cause for study drug discontinuation  
• Any ISR which, in the opinion of the Investigator, requires further medical evaluation 
or treatment 
In some cases, where it is medically appropriate, further evaluation may include photographs, 
referral to a dermatologist, skin biopsy, or other laboratory testing.  If a biopsy was obtained, the 
Sponsor may request that the biopsy also be reviewed by a central dermatopathologist.  To better 
understand the safety profile of the study drug, additional analysis of biopsy tissue may be 
performed according to local regulations. 
For patients with hepatic AEs, additional information, including, clinical history, course of event, 
and local laboratory results to monitor LFT levels or other laboratory parameters, may be 
collected. 
7.5.6.3. 
Serious Adverse Events Require Immediate Reporting to Sponsor/Designee 
An assessment of the seriousness of each AE will be made by the Investigator.  Any AE and 
laboratory abnormality that meets the SAE criteria in Section 7.5.6.1 must be reported to the 
Sponsor or designee within 24 hours from the time that clinical study center personnel first 
learns of the event.  All SAEs must be reported regardless of the relationship to study drug. 
The initial report should include at least the following information: 
• Patient’s study number 
• Description and date of onset of the event 
• Criterion for serious 
• Preliminary assignment of relationship to study drug 
• Investigator/clinical study center information 
To report the SAE, complete the eCRF.  If the EDC system is unavailable, complete the backup 
SAE form.  Within 24 hours of receipt of follow-up information, the Investigator must update the 
report.  SAEs must be reported using the contact information provided in the Study Manual. 
Appropriate remedial measures should be taken by the Investigator using his/her best medical 
judgment to treat the SAE.  These measures and the patient’s response to these measures should 
be recorded.  All SAEs, regardless of relationship to study drug, will be followed by the 
Investigator until satisfactory resolution or the Investigator deems the SAE to be chronic or 
stable.  Clinical, laboratory, and diagnostic measures should be employed by the Investigator as 
needed to adequately determine the etiology of the event. 
7.5.6.4. 
Sponsor Safety Reporting to Regulatory Authorities 
The Sponsor or its representative is required to report certain study events in an expedited 
manner to the Food and Drug Administration, the European Medicines Agency’s EudraVigilance 
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electronic system according to Directive 2001/20/EC, and to all country Regulatory Authorities 
where the study is being conducted, according to local applicable regulations. 
The following describes the safety reporting timeline requirements for suspected unexpected 
serious adverse reactions (SUSARs) and other reportable events: 
Immediately and within 7 calendar days 
• Any suspected adverse reaction that is associated with the use of the study drug, 
unexpected, and fatal or life threatening.  Follow-up information must be reported in 
the following 8 days. 
Immediately and within 15 calendar days 
• Any suspected adverse reaction that is associated with the use of the study drug, 
unexpected, and serious, but not fatal or life threatening, and there is evidence to 
suggest a causal relationship between the study drug and the reaction. 
• Any finding from tests in laboratory animals that suggest a significant risk for human 
patients including reports of mutagenicity, teratogenicity, or carcinogenicity. 
• Any event in connection with the conduct of the study or the development of the 
study drug that may affect the safety of the trial patients. 
In addition, periodic safety reporting to regulatory authorities will be performed by the Sponsor 
or its representative according to national and local regulations. 
7.5.6.5. 
Serious Adverse Event Notification to the Institutional Review 
Board/Independent Ethics Committee 
SUSARs will be reported to the Institutional Review Board (IRB)/Independent Ethics 
Committee (IEC) per their institutional policy by the Investigator or Sponsor (or Sponsor 
designee) according to country requirements.  Copies of each report and documentation of 
IRB/IEC notification and acknowledgement of receipt will be kept in the Investigator’s study 
file. 
7.5.6.6. 
Pregnancy Reporting 
If a female patient becomes pregnant during the course of this study through 90 days following 
the last dose of study drug, the Investigator must report the pregnancy to the Sponsor or designee 
within 24 hours of being notified of the pregnancy.  Details of the pregnancy will be recorded on 
the pregnancy reporting form.  The patient should receive any necessary counseling regarding 
the risks of continuing the pregnancy and the possible effects on the fetus. 
The pregnancy should be followed by the Investigator until completion.  At the completion of the 
pregnancy, the Investigator will document the outcome of the pregnancy.  If the outcome of the 
pregnancy results in a postpartum complication, spontaneous abortion, stillbirth, neonatal death, 
or congenital anomaly, then the Investigator should follow the procedures for reporting an SAE 
as outlined in Section 7.5.6.3.   
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7.5.6.7. 
Overdose Reporting 
An overdose is defined as any dose administered to or taken by a patient (accidentally or 
intentionally) that exceeds the highest daily dose, or is at a higher frequency, than included in the 
protocol.  It is up to the investigator to decide whether a dose is to be considered an overdose, in 
consultation with the Sponsor.  Overdose must be recorded in the eCRF. 
All reports of overdose (with or without an AE) must be reported within 24 hours to the Sponsor 
or designee.   
7.6. 
Exploratory Assessments 
Blood and urine samples will be collected for exploratory analyses.  Aliquots of samples will be 
obtained and frozen, to permit future analysis of the effect of ALN-AS1 on exploratory 
biomarkers.   
Where local regulations allow, biologic samples will be retained on behalf of the Sponsor for a 
maximum of 15 years following the last patient’s last visit in the study.  Details regarding the 
collection, processing, storage, and shipping of samples will be in the Laboratory Manual. 
7.7. 
Other Assessments 
7.7.1. 
EQ-5D-5L Questionnaire 
QOL will be assessed through the use of the 5-level EQ-5D (EQ-5D-5L), a standardized 
questionnaire measuring health outcomes.(36)  In addition to the time points indicated, the 
EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a 
porphyria attack (but, not more than once in a 6 month period), if possible. 
7.8. 
COVID-19 Data Collection 
Information on the coronavirus disease 2019 (COVID-19) infection status of the patient, if 
known, and other information on the impact of the COVID-19 pandemic on the patient's 
participation in the study will be collected. 
8. 
STATISTICS 
A detailed Statistical Analysis Plan (SAP) will be written after finalizing the protocol and before 
database lock.  The plan will detail the implementation of all the statistical analyses in 
accordance with the principle features stated in the protocol. 
8.1. 
Determination of Sample Size 
This is a Phase 1/2 multicenter, open-label extension study to evaluate the long-term safety and 
clinical activity of ALN-AS1 in patients with AIP who completed study ALN-AS1-001.  Safety, 
tolerability, PK, and PD of ALN-AS1 will be investigated.  The sample size was not determined 
based on statistical considerations.  Up to 24 patients are planned for this study (including 
optional cohorts in ALN-AS1-001). 
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8.2. 
Statistical Methodology 
The statistical and analytical plans presented below summarize the more complete plans to be 
detailed in the SAP.  Any changes to the methods described in the final SAP will be described 
and justified as needed in the clinical study report. 
Statistical analyses will be primarily descriptive in nature.  Descriptive statistics (eg, mean, 
standard deviation, median, minimum, and maximum) will be presented for continuous 
variables.  Frequencies and percentages will be presented for categorical and ordinal variables. 
Analyses will be performed using SAS® (Version 9.2, or higher). 
8.2.1. 
Populations to be Analyzed 
The populations (analysis sets) are defined as follows:  
Safety Analysis Set: 
All patients who received any amount of study drug. 
Clinical Activity Analysis 
Set: 
All patients who received any amount of study drug and have 
both a baseline and at least 1 postdose assessment. 
PK Analysis Set: 
All patients who received any amount of study drug and have at 
least 1 postdose blood sample for PK and who have evaluable 
PK data. 
PD Analysis Set: 
All patients who received any amount of study drug and who 
have at least 1 postdose blood sample for the determination of 
ALN-AS1 will be included in the PD analyses. 
Safety will be analyzed using the Safety Analysis Set.  The PK and PD Analysis Sets will be 
used to conduct PK and PD analyses, respectively.  The population used to evaluate clinical 
activity will be the Clinical Activity Analysis Set.   
8.2.2. 
Examination of Subgroups 
Subgroup analyses may be conducted for selected endpoints.  Detailed methodology will be 
provided in the SAP. 
8.2.3. 
Handling of Missing Data 
Unrecorded values will be treated as missing.  The appropriateness of the method(s) described 
for handling missing data may be reassessed and documented in the SAP before database lock.  
Depending on the extent of missing values, further investigation may be made into the sensitivity 
of the analysis results to the method(s) specified. 
8.2.4. 
Baseline Evaluations 
Demographics, medical history, disease-specific information, and other baseline characteristics 
collected in this study will be summarized.   
8.2.5. 
Clinical Activity Analyses 
Clinical activity of ALN-AS1 will be summarized primarily by descriptive statistics.  The 
clinical activity of ALN-AS1 will be evaluated by the frequency and characteristics of porphyria 
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attacks including duration, treatment, and severity of porphyria attacks and number and duration 
of visits to a health care setting for acute porphyria care. 
Patient diary recordings, including BPI-SF questionnaire scores, will also be summarized. 
8.2.6. 
Pharmacodynamic Analysis 
PD analyses will include the evaluation of change in ALA, PBG, and ALAS mRNA levels.  
Descriptive statistics (eg, mean and standard error of the mean) for observed levels of PD 
parameters and the relative change from baseline will be presented for each of the postdose 
follow-up time points. 
8.2.7. 
Pharmacokinetic Analysis 
The PK concentration of ALN-AS1 will be determined. 
Antidrug antibody results will be tabulated.  A by-patient data listing will also be provided. 
8.2.8. 
Safety Analyses 
Extent of exposure will be summarized.  AEs will be summarized by the Medical Dictionary for 
Regulatory Activities System Organ Class and Preferred Term.  Prior and concomitant 
medications will be classified according to the World Health Organization drug dictionary. 
Incidence of AEs (those events that started after exposure to study drug or worsened in severity 
after dosing) will be presented.  Incidence of AEs will also be presented by maximum severity 
and relationship to study treatment.  The incidence of SAEs and AEs leading to discontinuation 
of treatment will also be tabulated.  By-patient listings will be provided for deaths, SAEs, and 
AEs leading to discontinuation of treatment.   
Descriptive statistics will be provided for clinical laboratory data and vital signs data, presented 
as both actual values and changes from baseline relative to each on-study evaluation and to the 
last evaluation on study.  Laboratory shift tables from baseline to worst values will be presented.  
Abnormal physical examination findings and 12-lead ECG data will be presented in a by-patient 
data listing. 
Descriptive statistics will be provided for ECG interval data and presented as both actual values 
and changes from baseline relative to each on-study evaluation and to the last evaluation on 
study.  Details of any abnormalities will be included in patient listings. 
Concomitant hemin administration will also be recorded. 
8.2.9. 
Other Analyses 
Possible associations between PD parameters (ALA, PBG, and ALAS1 mRNA levels) and 
clinical activity parameters may also be explored. 
Additional exploratory analyses may be conducted on analytes related to targeting the heme 
biosynthesis pathway. 
QOL scores on the EQ-5D-5L questionnaire will also be summarized. 
Additional data summaries to help understand any impact of the COVID-19 pandemic on 
efficacy, PK, PD, and safety assessments will be performed, as appropriate. 
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9. 
STUDY ADMINISTRATION 
9.1. 
Ethical and Regulatory Considerations 
This study will be conducted in accordance with the protocol, all applicable regulatory 
requirements, and the guidelines of Good Clinical Practice (GCP).  Compliance with GCP 
provides public assurance that the rights, safety, and well-being of study patients are protected 
consistent with the principles that have their origin in the Declaration of Helsinki. 
9.1.1. 
Informed Consent 
The Investigator will ensure that the patient is given full and adequate oral and written 
information about the nature, purpose, possible risk and benefit of the study.  Patients must also 
be notified that they are free to withdraw from the study at any time.  The patient should be given 
the opportunity to ask questions and allowed time to consider the information provided. 
The patient’s signed and dated informed consent must be obtained before conducting any study 
procedures. 
The Investigator must maintain the original, signed ICF.  A copy of the signed ICF must be 
given to the patient. 
The Investigator will inform the patient/legal guardian if new information becomes available that 
may be relevant to the patient’s/legal guardian’s willingness to continue participation in the 
study.  Communication of this information should be documented. 
9.1.2. 
Ethical Review 
The final study protocol, including the final version of the ICF, must be approved or given a 
favorable opinion in writing by an IRB or IEC, as appropriate.  The Investigator must submit 
written approval before he or she can enroll any patient into the study. 
The Investigator is responsible for informing the IRB or IEC of any amendment to the protocol 
in accordance with local requirements.  In addition, the IRB or IEC must approve all patient 
materials for the study (except those that support the need to remove an apparent immediate 
hazard to the patient).  The protocol must be reapproved by the IRB or IEC upon receipt of 
amendments and annually, as local regulations require. 
Initial IRB approval of the protocol, and all materials approved by the IRB for this study 
including the patient consent form and recruitment materials must be maintained by the 
Investigator and made available for inspection. 
The Investigator will submit reports of SAEs as outlined in Section 7.5.6.  In addition, the 
Investigator agrees to submit progress reports to the IRB or IEC per their local reporting 
requirements, or at least annually and at the conclusion of the study.  The reports will be made 
available to the Sponsor or designee. 
Any communications from regulatory agencies in regard to inspections, other studies that impact 
this protocol or the qualifications of study personnel should be promptly reported to the Sponsor 
or its designee. 
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The Investigator is also responsible for providing the IRB with reports of any reportable serious 
adverse drug reactions from any other study conducted with the investigational drug.  The 
Sponsor or designee will provide this information to the Investigator. 
Major changes in this research activity, except those to remove an apparent immediate hazard to 
the patient, must be reviewed and approved by the Sponsor and the IRB or IEC that approved the 
study.  Amendments to the protocol must be submitted in writing to the Investigator’s IRB or 
IEC and the Regulatory Authority for approval before patients are enrolled under the amended 
protocol. 
9.1.3. 
Serious Breach of Protocol 
Investigators must notify the Medical Monitor within 24 hours of becoming aware of a potential 
serious breach of the protocol.  A serious breach is a breach that is likely to affect to a significant 
degree the safety and rights of a study participant or the reliability and robustness of the data 
generated in the clinical trial. 
9.1.4. 
Study Documentation, Confidentiality, and Records Retention 
All documentation relating to the study should be retained for the period of time required by 
applicable local law.  If it becomes necessary for the Sponsor, the Sponsor’s designee, applicable 
IRB/IEC, or applicable regulatory authorities to review or audit any documentation relating to 
the study, the Investigator must permit direct access to all source documents/data.  Records will 
not be destroyed without informing the Sponsor in writing and giving the Sponsor the 
opportunity to store the records for a longer period of time at the Sponsor’s expense.   
The Investigator must ensure that the patients’ confidentiality will be maintained.  On the CRFs 
or other documents submitted to the Sponsor or designees, patients should not be identified by 
their names, but by the assigned patient number and initials.  If patient names are included on 
copies of documents submitted to the Sponsor or designees, the names (except for initials) will 
be obliterated and the assigned patient number added to the document.  Documents not for 
submission to the Sponsor (eg, signed ICFs) should be maintained by the Investigator in strict 
confidence. 
The Investigator must treat all of the information related to the study and the compiled data as 
confidential, whose use is for the purpose of conducting the study.  The Sponsor must approve 
any transfer of information not directly involved in the study. 
In compliance with local and/or regional regulations, this clinical study may be registered and 
study results may be posted on public registries, such as ClinicalTrials.gov. 
9.1.5. 
End of the Study 
The end of the study is defined as last patient last visit. 
9.1.6. 
Discontinuation of the Clinical Study 
The Sponsor reserves the right to discontinue the study for clinical or administrative reasons at 
any time.  If the clinical study center does not recruit at a reasonable rate, the study may be 
discontinued at that clinical study center.  Should the study be terminated and/or the clinical 
study center closed for whatever reason, all documentation and study drug pertaining to the study 
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must be returned to the Sponsor or its representative, and the Investigators, IEC/IRB and 
Regulatory Authorities will be promptly informed of the termination and the reason for the 
decision.  The Investigator should promptly inform the patients and assure appropriate therapy 
and follow-up.  Patients should then be withdrawn from the study.   
9.2. 
Data Quality Control and Quality Assurance 
9.2.1. 
Data Handling 
Study data must be recorded on case report forms (paper and/or electronic) provided by the 
Sponsor or designee on behalf of the Sponsor.  Case report forms must be completed only by 
persons designated by the Investigator.  If eCRFs are used, study data must be entered by trained 
clinical study center personnel with access to a valid and secure eCRF system.  All data entered 
into the eCRF must also be available in the source documents.  Corrections on paper CRFs must 
be made so as to not obliterate the original data and must be initialed and dated by the person 
who made the correction. 
9.2.2. 
Study Monitoring 
The clinical monitor, as a representative of the Sponsor, has an obligation to closely follow the 
study conduct at the clinical study center.  The monitor will visit the Investigator and clinical 
study center periodically and will maintain frequent telephone and written contact.  The monitor 
will maintain current personal knowledge of the study through observation, review of study 
records and source documentation, and discussion of the conduct of the study with the 
Investigator and personnel. 
The monitor will review source documents, systems and CRFs to ensure overall quality and 
completeness of the data and to confirm study procedures are complied with the requirements in 
the study protocol.  The Sponsor, or its designee, will be allowed to conduct clinical study center 
visits to the investigation facilities for the purpose of monitoring any aspect of the study.  The 
Investigator agrees to allow the monitor to inspect the drug storage area, study drug stocks, drug 
accountability records, patient charts and study source documents, and other records relative to 
study conduct. 
9.2.3. 
Audits and Inspections 
Periodically, the Sponsor or its authorized representatives audit clinical investigative study 
centers as an independent review of core trial processes and documents to determine whether 
these activities were conducted, and data were recorded, analyzed, and accurately reported 
according to the protocol, GCP guidelines of the ICH, and any applicable regulatory 
requirements.  A regulatory authority, an IEC or an IRB may visit the clinical study center to 
perform audits or inspections, including source data verification.  The Investigator should contact 
the Sponsor, or its designee, immediately if contacted by a regulatory agency about an 
inspection. 
9.3. 
Publication Policy 
It is intended that after completion of the study, the data are to be submitted for publication in a 
scientific journal and/or for reporting at a scientific meeting.  A copy of any proposed manuscript 
must be provided and confirmed received at the Sponsor at least 30 days before its submission, 
and according to any additional publication details in the Investigator Agreement. 
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10. 
LIST OF REFERENCES 
1. Anderson KE, Bloomer JR, Bonkovsky HL, Kushner JP, Pierach CA, Pimstone NR, et al. 
Recommendations for the diagnosis and treatment of the acute porphyrias. Ann Intern Med. 
2005;142(6):439-50. 
2. Siegesmund M, van Tuyll van Serooskerken AM, Poblete-Gutierrez P, Frank J. The acute 
hepatic porphyrias: current status and future challenges. Best Pract Res Clin Gastroenterol. 
2010;24(5):593-605. 
3. Poblete-Gutierrez P, Wiederholt T, Merk HF, Frank J. The porphyrias: clinical presentation, 
diagnosis and treatment. Eur J Dermatol. 2006;16(3):230-40. 
4. Balwani M, Desnick RJ. The porphyrias: advances in diagnosis and treatment. Blood. 
2012;120(23):4496-504. 
5. Puy H, Gouya L, Deybach JC. Porphyrias. Lancet. 2010;375(9718):924-37. 
6. Floderus Y. Variations in Porphobilinogen and 5-Aminolevulinic Acid Concentrations in 
Plasma and Urine from Asymptomatic Carriers of the Acute Intermittent Porphyria Gene with 
Increased Porphyrin Precursor Excretion. Clinical Chemistry. 2006;52(4):701-7. 
7. Anderson K. Disorders of Heme Biosynthesis. 2001. 
8. Dowman JK, Gunson BK, Mirza DF, Bramhall SR, Badminton MN, Newsome PN. Liver 
transplantation for acute intermittent porphyria is complicated by a high rate of hepatic artery 
thrombosis. Liver Transplantation. 2012;18(2):195-200. 
9. Badminton MN, Elder GH. Molecular mechanisms of dominant expression in porphyria. J 
Inherit Metab Dis. 2005;28(3):277-86. 
10. Deybach JC. Acute Intermittent Porphyria: From Clinical to Molecular Aspects.  The 
Porphyrin Handbook. Amsterdam: Academic Press; 2003. p. 23-41. 
11. Bylesjo I, Wikberg A, Andersson C. Clinical aspects of acute intermittent porphyria in 
northern Sweden: a population-based study. Scand J Clin Lab Invest. 2009;69(5):612-8. 
12. James MF, Hift RJ. Porphyrias. Br J Anaesth. 2000;85(1):143-53. 
13. Chemmanur AT, Bonkovsky HL. Hepatic porphyrias: diagnosis and management. Clin Liver 
Dis. 2004;8(4):807-38, viii. 
14. Stein P, Badminton M, Barth J, Rees D, Stewart MF, British, et al. Best practice guidelines 
on clinical management of acute attacks of porphyria and their complications. Ann Clin 
Biochem. 2013;50(Pt 3):217-23. 
15. Bonkovsky HL. Neurovisceral porphyrias: what a hematologist needs to know. Hematology 
Am Soc Hematol Educ Program. 2005:24-30. 
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16. PanhematinPI. Panhematin Prescribing Information. 2017. 
17. NormosangSmPC. Normosang Summary of Product Characteristics. 2017. 
18. Watson CJ, Pierach CA, Bossenmaier I, Cardinal R. Postulated deficiency of hepatic heme 
and repair by hematin infusions in the "inducible" hepatic porphyrias. Proc Natl Acad Sci U S A. 
1977;74(5):2118-20. 
19. Mustajoki P, Nordmann Y. Early administration of heme arginate for acute porphyric attacks. 
Arch Intern Med. 1993;153(17):2004-8. 
20. Bonkovsky HL, Singh RH, Jafri IH, Fiellin DA, Smith GS, Simon D, et al. A randomized, 
controlled trial of treatment of alcoholic hepatitis with parenteral nutrition and oxandrolone. II. 
Short-term effects on nitrogen metabolism, metabolic balance, and nutrition. Am J Gastroenterol. 
1991;86(9):1209-18. 
21. Herrick AL, McColl KE, Moore MR, Cook A, Goldberg A. Controlled trial of haem arginate 
in acute hepatic porphyria. Lancet. 1989;1(8650):1295-7. 
22. Bissell DM. Treatment of acute hepatic porphyria with hematin. J Hepatol. 1988;6(1):1-7. 
23. Green D, Ts'ao CH. Hematin: effects on hemostasis. J Lab Clin Med. 1990;115(2):144-7. 
24. Daimon M, Susa S, Igarashi M, Kato T, Kameda W. Administration of heme arginate, but 
not hematin, caused anaphylactic shock. Am J Med. 2001;110(3):240. 
25. Elder G, Harper P, Badminton M, Sandberg S, Deybach JC. The incidence of inherited 
porphyrias in Europe. J Inherit Metab Dis. 2013;36(5):849-57. 
26. Anderson KE, Egger NG, Goeger DE. Heme arginate for prevention of acute porphyric 
attacks. Acta Haematologica. 1997;98:120. 
27. Bonkovsky HL, Guo JT, Hou W, Li T, Narang T, Thapar M. Porphyrin and heme 
metabolism and the porphyrias. Compr Physiol. 2013;3(1):365-401. 
28. Vaishnaw AK, Gollob J, Gamba-Vitalo C, Hutabarat R, Sah D, Meyers R, et al. A status 
report on RNAi therapeutics. Silence. 2010;1(1):14. 
29. Elbashir SM, Harborth J, Lendeckel W, Yalcin A, Weber K, Tuschl T. Duplexes of 21-
nucleotide RNAs mediate RNA interference in cultured mammalian cells. Nature. 
2001;411(6836):494-8. 
30. Kauppinen R, von und zu Fraunberg M. Molecular and biochemical studies of acute 
intermittent porphyria in 196 patients and their families. Clin Chem. 2002;48(11):1891-900. 
31. Ryu JY, Song IS, Sunwoo YE, Shon JH, Liu KH, Cha IJ, et al. Development of the "Inje 
cocktail" for high-throughput evaluation of five human cytochrome P450 isoforms in vivo. Clin 
Pharmacol Ther. 2007;82(5):531-40. 
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32. Williams D, Tao X, Zhu L, Stonier M, Lutz JD, Masson E, et al. Use of a cocktail probe to 
assess potential drug interactions with cytochrome P450 after administration of belatacept, a 
costimulatory immunomodulator. Br J Clin Pharmacol. 2017;83(2):370-80. 
33. Sampson HA, Munoz-Furlong A, Campbell RL, Adkinson NF, Jr., Bock SA, Branum A, et 
al. Second symposium on the definition and management of anaphylaxis: summary report--
second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis 
Network symposium. Ann Emerg Med. 2006;47(4):373-80. 
34. Atkinson TM, Mendoza TR, Sit L, Passik S, Scher HI, Cleeland C, et al. The Brief Pain 
Inventory and its "pain at its worst in the last 24 hours" item: clinical trial endpoint 
considerations. Pain Med. 2010;11(3):337-46. 
35. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF, 3rd, Feldman HI, et al. A new 
equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150(9):604-12. 
36. Herdman M, Gudex C, Lloyd A, Janssen M, Kind P, Parkin D, et al. Development and 
preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res. 
2011;20(10):1727-36. 
 
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11. 
APPENDICES 
11.1. 
Pharmacokinetic Assessment Time Points 
Table 4 contains a detailed schedule for the collection of blood samples for PK analysis. 
Table 4: 
Pharmacokinetic Time Points 
Study Day 
 
Protocol Time 
(hh:mm) 
PK Blood 
Day 1 and 
Month 12 (D361) ±10 
days 
 
Predose (within 60 
minutes before dosing) 
X 
 
02:00 (±15 minutes)b 
X 
 
06:00 (±20 minutes) 
X 
Month 1 (Day 14) ±2 
days 
 
Anytime during visit 
X 
Month 1 (Day 31) ±7 
days,a  
Month 3 (Day 91) ±7 
days, 
Month 6 (Day 181) ±7 
days, 
Month 9 (Day 271) ±10 
daysd, 
Month 15 (Day 451) ±10 
daysd, 
Month 18 (Day 541) ±10 
days  
Month 24 (Day 721) ±10 
days 
 
Predose (within 60 
minutes before dosing) 
X 
 
02:00 (±15 minutes)b 
X 
 
04:00 (±20 minutes)c 
Abbreviations:  hh=hours; mm=minutes; PK=pharmacokinetic. 
a At the Day 31, Month 1 visit, if the dosing regimen is every 3 months, ALN-AS1 is not administered and a 
single time point blood sample for PK analysis should be collected. 
b Only in patients receiving ≤2.5 mg/kg ALN-AS1; paired with ECG (for ECG details, see Section 7.5.4).  
c Only in patients receiving >2.5 mg/kg ALN-AS1; paired with ECG (for ECG details, see Section 7.5.4). 
d Blood sample collection for PK analysis at Month 9 and Month 15 is only necessary if ECG will be performed 
at same visit. 
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11.2. 
Schedules of Assessments for Every Month Dosing Regimen 
 
 Table 5: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14 ±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical 
History/Disease 
Historyc 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/ 
Exclusion Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examinationd 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
 
 
X 
Body Weight, BMI, 
and Heighte 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
X 
Vital Signsf 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead 
ECGg 
X 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Clinical Laboratory 
Assessmenth 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
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 Table 5: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14 ±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Study Drug 
Administrationj 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine Sample for 
PBG, ALA, and 
Creatinine Analysisk 
 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
Blood and Urine 
Sample for 
Exploratory 
Biomarker Analysisl 
 
X 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Blood Sample for PK 
Analysism 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Antidrug Antibodiesn 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
Porphyria Attack Kit 
Dispensationo 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EQ-5D-5L 
Questionnairep 
X 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Diary Review 
(including BPI-SF)q 
 
 
X 
AEs 
 
Continuous 
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 Table 5: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14 ±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Concomitant 
Medicationsr 
 
Continuous 
 Abbreviations:  AE=adverse event; ALAS1=5-aminolevulinic acid synthase 1; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-
SF=Brief Pain Inventory-Short Form; D=day; ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; 
QOL=quality of life; SC=subcutaneous. 
Notes:   
• 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit 
that may be conducted while the patient is at home. 
• 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical 
examinations and blood/urine sample collections. 
a Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study (ALN-AS1-001) were completed within 
60 days of administration of the first dose of ALN-AS1 in this study.  If more than 60 days have elapsed since the last assessment, clinical laboratory 
tests and ECGs will be repeated before administration of ALN-AS1.  Results should be available and deemed acceptable before the administration of 
the first dose of ALN-AS1. 
b After a patient has completed 6 months of ALN-AS1 administration in this study, and where applicable country and local regulations and 
infrastructure allow, study procedures, including ALN-AS1 administration, may take place at the patient’s home by a healthcare professional.  Study 
procedures may occur at the patient’s home at the discretion of the Investigator, based on safety and tolerability; however, patients are required to 
complete at least 1 visit at the clinical study center Q3M through M12, and thereafter Q6M. Additional visits to collect clinical laboratory samples 
may occur at home at any point during the treatment period, within 14 days prior to scheduled dose administration. 
c See Section 7.1 for details on the interval medical history/disease history to be recorded at Screening/Baseline.  Ongoing AEs from the previous study 
(ALN-AS1-001) will be captured as medical history. 
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d A complete physical examination will be performed at Screening/Baseline, and D1.  At all other visits, a targeted physical examination will be 
performed.  On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical 
examination can occur at any time during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On D1, vital signs will be collected within 1 hour predose; and 2 
hours (±10 minutes) postdose.  On all other dosing days, vital signs will be collected within 1 hour predose.  On days when ALN-AS1 is not 
administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position (should be 
consistent for each patient), after the patient has rested comfortably for 10 minutes. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at 
least 5 minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1 ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose at a 
minimum of 2 of the following visits:  D1, Month 3, Month 6, Month 9, Month 12, Month 15 (only if visit is done at clinic), or Month 18.  In patients 
receiving >2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose at a minimum of two of the 
following visits:  D1, Month 3, Month 6, Month 9, Month 12, Month 15 (only if visit is done at clinic), or Month 18.  On all other dosing days, ECGs 
will be collected within 1 hour predose (see Section 7.5.4  for ECG assessment details). 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected 
predose.  On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. On dosing days up to the Month 18 
visit,results from hematology, chemistry (including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the 
Investigator before study drug administration.  If results from within the prior 14 days are not available at a dosing visit (at visits from D1 to Month 
18), locally analyzed predose assessments may be used for review in order to allow same day study drug administration, and additional samples for 
central analysis must also be collected. 
i A serum pregnancy test will be performed at Screening/Baseline; thereafter, urine pregnancy tests will be performed.  Results must be available before 
dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  For 
weight-based dosing, weight measured at the current study center visit (dosing day) will be used to calculate the dose of ALN-AS1.  After M12, 
weight measured at either the previous study center visit or on current study center visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1).  Blood sample collection for PK analysis 
at Month 9 and Month 15 is only necessary if ECG will be performed at same visit. 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o Porphyria attack laboratory sample collection kits should be dispensed at the screening visit along with instructions for use. For any attack that occurs 
through M37, urine samples should be collected within 24 hours of the start of clinical intervention (eg, hemin or glucose administration) and within 
24 hours of the end of clinical intervention.  If patients are unable to report to the clinical study center during a porphyria attack, laboratory sample 
collection kits should be used for collecting and sending urine samples to the clinical study center, if possible.  These urine samples may also be 
analyzed for exploratory biomarkers. 
p In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria 
attack (but not more than once in a 6 month period), if possible.  
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q Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, and narcotic use on a daily basis through M9; 
thereafter, acute porphyria attacks will be recorded in the diary.  The BPI will be completed on a weekly basis as part of the patient diary through M9, 
then Q3M. 
r Medications that are ongoing from the previous study (ALN-AS1-001), started between the previous study and this study, and started after signing 
informed consent in this study, will be captured as concomitant medication(s). 
 
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Table 6: 
Schedule of Assessments:  Month 19 through Month 36 (Every Month Dosing Regimen) 
 
Treatment Period 
(Month 19 through Month 36) 
M19/ 
M20a 
M21a 
M22/ 
M23a 
M24 
M25/ 
M26a 
M27a 
M28/ 
M29a 
M30 
M31/ 
M32a 
M33a 
M34/ 
M35a 
M36 
Study Visit (D±Visit Window) 
571±14/601±14 
631±14 
661±14/691±14 
721±14 
751±14/781±14 
811±14 
841±14/871±14 
901±14 
931±14/961±14 
991±14 
1021±14/1051±14 
1081±14 
Physical Examinationb 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Body Weight, BMI, and Heightc 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Vital Signsd 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGe 
 
 
 
 
 
 
 
 
 
 
 
 
Clinical Laboratory Assessmentf 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Pregnancy Testg 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationh 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine Sample for PBG, ALA, and 
Creatinine Analysisi 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Blood and Urine Sample for 
Exploratory Biomarker Analysisj  
 
 
 
X 
 
 
 
X 
 
 
 
X 
Blood Sample for PK Analysisk 
 
 
 
X 
 
 
 
 
 
 
 
 
Antidrug Antibodiesl 
 
 
 
X 
 
 
 
 
 
 
 
X 
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Table 6: 
Schedule of Assessments:  Month 19 through Month 36 (Every Month Dosing Regimen) 
 
Treatment Period 
(Month 19 through Month 36) 
M19/ 
M20a 
M21a 
M22/ 
M23a 
M24 
M25/ 
M26a 
M27a 
M28/ 
M29a 
M30 
M31/ 
M32a 
M33a 
M34/ 
M35a 
M36 
Study Visit (D±Visit Window) 
571±14/601±14 
631±14 
661±14/691±14 
721±14 
751±14/781±14 
811±14 
841±14/871±14 
901±14 
931±14/961±14 
991±14 
1021±14/1051±14 
1081±14 
EQ-5D-5L Questionnairem 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Diary Review (including 
BPI-SF)n 
X 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; M=month; PBG=porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of life; SC=subcutaneous. 
Notes:   
• 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
• 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
• 
In situations where a study visit cannot be completed at the study center or offsite by a home healthcare professional visit, the study Investigator (or 
delegate) may verbally contact the patient within the study visit window to assess for any AEs, concomitant medications (including hemin use), 
hospitalizations/procedures, and porphyria attacks. 
a Where applicable country and local regulations and infrastructure allow, study procedures, including ALN-AS1 administration,  may take place at the 
patient’s home by a healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the Investigator, based on safety 
and tolerability; however, patients are required to complete at least 1 visit at the clinical study center Q6M.   
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b A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be 
performed.  On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical 
examination can occur at any time during the visit.  Targeted physical examinations/body system assessments may be conducted offsite at all time 
points, where applicable country and local regulations and infrastructure allow.  See Section 7.5.3 for details on the physical examination. 
c Height will be measured at Screening/Baseline only. 
d Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On dosing days, vital signs will be collected within 1 hour 
predose.  On days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the 
seated or supine position (should be consistent for each patient), after the patient has rested comfortably for 10 minutes.  Vital sign measurements may 
be conducted offsite at all time points, where applicable country and local regulations and infrastructure allow. 
e Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at 
least 5 minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose . At 
Month 24, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose, when paired with PK timepoints, otherwise ECGs will 
be collected predose.  In patients receiving >2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose.  
See Section 7.5.4 for ECG assessment details.  With the implementation of Amendment 7, ECGs are no longer required. 
f Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected 
predose.  On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit.  Collection of blood and urine 
samples for safety laboratory assessments may be conducted offsite at all time points, where applicable country and local regulations and 
infrastructure allow. 
g Urine pregnancy tests will be performed.  Results must be available before dosing. 
h ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  
Weight obtained within 6 months during a study center visit or offsite will be used to calculate the weight-based dose of ALN-AS1. 
i Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose.  
Collection of samples for PD assessments may be conducted offsite at all time points, where applicable country and local regulations and 
infrastructure allow. 
j On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
k Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1).  
l On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose.  Antidrug antibody assessments that cannot 
be collected in the intended visit window may be completed within 6 months at the next study center visit. 
m In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a 
porphyria attack (but, not more than once in a 6 month period), if possible. In situations where a planned study visit cannot be completed at the study 
center, the patient will complete the EQ-5D-5L questionnaire at home. 
n Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
 
 
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Table 7: 
Schedule of Assessments:  Month 37 through End of Study (Every Month Dosing Regimen) 
 
Treatment Period 
(Month 37 through EOS) 
EOS/ 
ETb 
Safety 
Follow-upc 
Study Visit (M) 
M37/ 
M38a 
M39a 
M40/ 
M41a 
M42 
M43/ 
M44a 
M45a 
M46/ 
M47a 
M48/ 
EOT 
M49 
 
Study Visit (D±Visit Window) 
1111±14/1141±14 
1171±14 
1201±14/1231±14 
1261±14 
1291±14/1321±14 
1351±14 
1381±14/1411±14 
1441±14 
1471±14 
 
Physical Examinationd 
 
 
 
X 
 
 
 
X 
X 
X 
Body Weight, BMI, and Heighte 
 
 
 
X 
 
 
 
X 
X 
 
Vital Signsf 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGg 
 
 
 
 
 
 
 
 
 
 
Clinical Laboratory Assessmenth 
 
X 
 
X 
 
X 
 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationj 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Urine Sample for PBG, ALA, and 
Creatinine Analysisk 
 
X 
 
X 
 
X 
 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker Analysisl  
 
 
 
X 
 
 
 
X 
X 
 
Antidrug Antibodiesm 
 
 
 
 
 
 
 
X 
X 
 
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Table 7: 
Schedule of Assessments:  Month 37 through End of Study (Every Month Dosing Regimen) 
 
Treatment Period 
(Month 37 through EOS) 
EOS/ 
ETb 
Safety 
Follow-upc 
Study Visit (M) 
M37/ 
M38a 
M39a 
M40/ 
M41a 
M42 
M43/ 
M44a 
M45a 
M46/ 
M47a 
M48/ 
EOT 
M49 
 
Study Visit (D±Visit Window) 
1111±14/1141±14 
1171±14 
1201±14/1231±14 
1261±14 
1291±14/1321±14 
1351±14 
1381±14/1411±14 
1441±14 
1471±14 
 
EQ-5D-5L Questionnairen 
 
 
 
X 
 
 
 
X 
X 
 
Diary Review (including BPI-SF)o 
X 
 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; EOS=End of Study; EOT=End of Treatment; ET=early termination; M=month; PBG=porphobilinogen; PK=pharmacokinetics; 
Q=every; QOL=quality of life; SC=subcutaneous. 
Notes:   
• 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
• 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
• 
In situations where a study visit cannot be completed at the study center or offsite by a home healthcare professional visit, the study Investigator (or 
delegate) may verbally contact the patient within the study visit window to assess for any AEs, concomitant medications (including hemin use), 
hospitalizations/procedures, and porphyria attacks. 
a Where applicable country and local regulations and infrastructure allow, study procedures, including ALN-AS1 administration,  may take place at the 
patient’s home by a healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the Investigator, based on safety 
and tolerability; however, patients are required to complete at least 1 visit at the clinical study center Q6M.   
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b Patients who complete all scheduled doses ALN-AS1 through Month 48 will return for an end of study (EOS) visit at Month 49.  Patients who 
discontinue treatment prior to Month 48 will be asked to complete an early termination (ET) visit at which all Month 49 visit procedures will be 
performed; they must also return 3 months (84 [+14] days) after their last dose of ALN-AS1 for a safety-follow-up visit.   
c The safety follow-up visit is only required for patients who discontinue prior to study completion.  The visit should be conducted  3 months (84 [+14 
days]) following the last dose of ALN-AS1. 
d A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be 
performed.  On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical 
examination can occur at any time during the visit.  Targeted physical examinations/body system assessments may be conducted offsite at all time 
points, where applicable country and local regulations and infrastructure allow.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On dosing days, vital signs will be collected within 1 hour 
predose.  On days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the 
seated or supine position (should be consistent for each patient), after the patient has rested comfortably for 10 minutes.  Vital sign measurements may 
be conducted offsite at all time points, where applicable country and local regulations and infrastructure allow. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at 
least 5 minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose . At 
Month 24, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose, when paired with PK timepoints, otherwise ECGs will 
be collected predose.  In patients receiving >2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose.  
See Section 7.5.4 for ECG assessment details.  With the implementation of Amendment 7, ECGs are no longer required. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected 
predose.  On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit.  Collection of blood and urine 
samples for safety laboratory assessments may be conducted offsite at all time points, where applicable country and local regulations and 
infrastructure allow.  
i Urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  
Weight obtained within 6 months during a study center visit or offsite will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose.  
Collection of samples for PD assessments may be conducted offsite at all time points, where applicable country and local regulations and 
infrastructure allow. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose.  Antidrug antibody assessments that cannot 
be collected in the intended visit window may be completed within 6 months at the next study center visit. 
n In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria 
attack (but, not more than once in a 6 month period), if possible. In situations where a planned study visit cannot be completed at the study center, the 
patient will complete the EQ-5D-5L questionnaire at home. 
o Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
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11.3. 
Anaphylactic Reactions 
Table 8: 
 
Sampson Criteria for Anaphylactic Reactions 
 
Adapted from Sampson et al. 2006 (33) 
 
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ALN-AS1-002 PROTOCOL AMENDMENT 7  
SUMMARY OF CHANGES DATED 29 APRIL 2020 
A Multicenter, Open-label Extension Study to Evaluate the Long-term Safety and Clinical 
Activity of Subcutaneously Administered ALN AS1 in Patients with Acute Intermittent 
Porphyria who have Completed a Previous Clinical Study with ALN-AS1 
1. 
RATIONALE FOR PROTOCOL AMENDMENT 
The purpose of this protocol amendment is to incorporate Urgent Safety Measures (USMs) that 
were communicated to investigators in a Dear Investigator Letter to assure the safety of study 
participants while minimizing risks to study integrity amid the COVID-19 pandemic. These 
changes are in line with guidance from both the European Medicines Agency and the United 
States Food and Drug Administration on the conduct of clinical trials during the COVID-19 
pandemic.[EMA 2020; FDA 2020] 
The USM modifications and new procedures are outlined below, and a detailed summary of the 
specific protocol changes is provided in Section 2. These changes should be adopted 
immediately per the Dear Investigator Letter dated 07 April 2020. 
• ALN-AS1 (givosiran) Dosing Outside the Study Center by Patient or Caregiver 
Following appropriate training on ALN-AS1 administration and the use of 
epinephrine (epi pen or equivalent), dosing will be permitted at a location other than 
the study center (eg, at home) by the patient or caregiver at all time points under the 
oversight of the Investigator and following consultation with the medical monitor.  
This measure is intended to remain in effect only during periods of time when the 
COVID-19 pandemic impedes the ability of patients to travel to the study site or 
healthcare professionals to go to patients' homes for dosing. 
ALN-AS1-002 is a dedicated open-label extension study.  One patient in the 
ALN-AS1-002 study had an anaphylactic reaction within minutes of receiving her 3rd 
dose of givosiran and was successfully treated with epinephrine. This patient 
discontinued from the study. To date, all current study patients have been stable on 
treatment with givosiran for a median duration of 36 months, with monthly dosing 
occurring both at the study site and offsite by home healthcare professionals.  
Detailed instructions and procedures related to administration of givosiran by a 
patient or caregiver will be provided in the Patient/Caregiver Storage and 
Administration Instructions. 
• Study Visit Window 
Except for assessments with other specified timing requirements, study assessments 
and dosing are to be performed within a visit window of ±14 days (previously 
±7 days). Study drug doses must be administered at least 14 days apart, and this is 
expected to be tolerated based on safety data from the Phase 1 study (ALN-AS1-001), 
which evaluated dosing at 5.0 mg/kg monthly (twice the therapeutic dose of 
2.5◦mg/kg monthly). 
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• Assessments of Adverse Events, Concomitant Medications (including hemin use), 
Hospitalizations/Procedures, and Porphyria Attacks 
In situations where a study visit cannot be completed at the study center or offsite by 
a healthcare professional visit, the study Investigator (or delegate) may verbally 
contact the patient within the study visit window to assess for any adverse events 
(AEs), concomitant medications (including hemin use), hospitalizations/procedures, 
and porphyria attacks. 
• Time Period to Obtain Weight for Dose Determination 
Dose will be based on weight obtained within 6 months (previously at the current or 
prior study visit) prior to dosing.  Dosing weight may be collected during clinical 
study center visits or offsite. 
Given the expanded use of offsite administration, use of a prior weight permits 
accurate determination of dose and volume without manual calculations or verbal 
orders.  All patients are adult; therefore, substantial fluctuations in body weight over a 
6-month period are not expected.  Prior analyses of the study data have shown mean 
body weight to be stable over time. 
• EQ-5D-5L Assessments 
In situations where a planned study visit cannot be completed at the study center, the 
patient will complete the 5-level EQ-5D (EQ-5D-5L) questionnaire at home. 
• Assessment of ECG 
Further assessment of ECG is no longer warranted, because no clinically significant 
ECG findings, including QT interval prolongation, have been observed following 
comprehensive analyses across ALN-AS1-002 and the Phase 3 study ALN-AS1-003 
to date.  To minimize exposure to COVID-19, decrease the burden on patients and 
trial sites, and align with the US and EU prescribing information, which do not 
require ECG assessment for dosing, ECGs are no longer required in this study.  For 
further information, refer to the givosiran (ALN-AS1) Investigator’s Brochure. 
• Assessments Required to be Performed at Study Center Visits 
Where applicable country and local regulations and infrastructure allow for home 
healthcare, healthcare may take place at a location other than the clinical trial site to 
perform study assessments including targeted physical exam/body system assessment, 
assessments for vital signs, and collection of blood and urine samples for safety 
laboratory assessments, and PD assessments, at all timepoints as specified in the 
Schedule of Assessments. 
• Antidrug Antibody Assessments Required to be Performed at Study Center 
Visits 
Given the expanded use of offsite dosing, antidrug antibody (ADA) assessments that 
cannot be collected in the intended visit window may be completed within 6 months 
at the next study center visit (previously at the clinical study center visit). 
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The incidence of ADAs due to ALN-AS1 has been very low across clinical studies of 
ALN-AS1.  There have been no treatment-emergent ADAs in the current study.  In 
the Phase 3 study ALN-AS1-003, there has been only 1 case of treatment-emergent 
ADAs due to ALN-AS1.  The antibody titer was low and transient, with the patient 
subsequently testing negative.  Based on the collective evidence to date, ALN-AS1 is 
considered to have a very low risk of eliciting an immune response. 
• Collection of Information Related to COVID-19 
Information related to the impact of the COVID-19 pandemic on patient participation 
in the study will be collected for each patient.  Additional information regarding 
collection of this information, including completion of a new case report form 
specific to COVID-19, will be provided separately. 
This change is implemented to enable analysis of the impact of the COVID-19 global 
pandemic on clinical trial data. 
• Updates to Study Administration 
Text was updated to provide clarification on Investigator responsibilities regarding 
communication of new study information to patients and Institutional Review Boards 
(IRBs)/Independent Ethics Committees (IECs). 
 
References: 
FDA Guidance on Conduct of Clinical Trials of Medical Products during COVID-19 Pandemic: 
Guidance for Industry, Investigators, and Institutional Review Boards. 
https://www.fda.gov/regulatory-information/search-fda-guidance-documents/fda-guidance-
conduct-clinical-trials-medical-products-during-covid-19-pandemic 
Guidance on the Management of Clinical Trials during the COVID-19 (Coronavirus) Pandemic, 
Version 1.0 (20/03/2020). https://www.ema.europa.eu/en/news/guidance-sponsors-how-manage-
clinical-trials-during-covid-19-pandemic 
 
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2. 
PROTOCOL AMENDMENT 7 DETAILED SUMMARY OF CHANGES 
The primary section(s) of the protocol affected by the changes in Protocol Amendment 7 are indicated.  The corresponding text has 
been revised throughout the protocol.  Deleted text is indicated by strikeout and added text is indicated by bold font, relevant to each 
purpose described. 
Purpose:  To expand the use of offsite administration to include ALN-AS1 dosing by the patient or caregiver. 
The primary change occurs in Section 6.2.2, Dose and Administration 
Revised text: 
2nd paragraph 
ALN-AS1 will be administered by a qualified and authorized health care professional trained in the recognition and management of 
anaphylactic reactions.  The study drug should be injected into the abdomen or upper arms or thighs.  Detailed instructions for study 
drug administration are presented in the Pharmacy Manual. As is consistent with good medical practice for subcutaneous drug 
administration, patients will be observed for a minimum of 20 minutes after each injection.   Treatment for anaphylactic reactions 
should be readily available where patients are being dosed, and follow country and/or local hospital treatment guidelines as shown in 
Table 8 (33). 
3rd paragraph 
ALN-AS1 will be administered by a qualified and authorized health care professional trained in the recognition and 
management of anaphylactic reactions.  After a patient has completed 12 months of ALN-AS1 administration in this study 
(6 months in an every month dosing regimen), study drug administration may be conducted at a location other than the study center by 
a home healthcare professional, where applicable country and local regulations and infrastructure allow, after consultation with the 
medical monitor, during particular study visits, as specified in the Schedules of Assessments.  If the patient is unable to come to the 
study site, and a visit by a home healthcare professional is not possible due to circumstances related to the COVID-19 
pandemic, ALN-AS1 may be administered by the patient or the caregiver under the oversight of the Investigator, and 
following consultation with the medical monitor, as allowed by applicable country and local regulations.  In such cases, the 
patient or caregiver must receive appropriate training on ALN-AS1 administration and the use of epinephrine (epi pen or 
equivalent) prior to dosing.  This measure is intended to remain in effect only during periods of time when the COVID-19 
pandemic impedes the ability of patients to travel to the study site or healthcare professionals to go to patients' homes for 
dosing.  However, study drug administration at the study center should be considered for patients who have ongoing study drug-
related AEs or known risk factors for developing anaphylactic reaction, including but not limited to: a prior history of anaphylactic 
reaction to food, medications or due to unknown etiology, worsening injection site reactions with repeat dosing, or anyone in the 
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opinion of the investigator that would benefit from clinical observation following dosing.  Patients are required to complete at least 1 
visit at the clinical study center every 3 months for the first year, and thereafter every 6 months through the end of the treatment 
period.  Additional visits to collect clinical laboratory samples may occur at home at any point during the treatment period, within 14 
days prior to scheduled dose administration. 
Last paragraph: 
Detailed instructions for study drug administration are found in the Pharmacy Manual.  In addition, instructions and procedures 
related to administration of ALN-AS1 by a patient or caregiver will be provided in the Patient/Caregiver Storage and 
Administration Instructions. 
Section(s) also reflecting this change:  
• Synopsis 
• Section 4.1 
• Section 6.2.4 
Purpose:  To expand the study visit windows. 
The primary changes occur in Table 6, Schedule of Assessments:  Month 19 through Month 36 (Every Month Dosing Regimen), and 
Table 7, Schedule of Assessments:  Month 37 through End of Study (Every Month Dosing Regimen). 
Revised text:  In Tables 6 and 7, the visit window was changed to ±14 days for all visits (previously either ±7 or ±10 days). 
Section(s) also reflecting this change:   
• Section 4.1 
• Section 5.3.1 
• Section 5.3.2 
Purpose:  To allow the study Investigator (or delegate) to verbally contact the patient within the study visit window to assess for any 
AEs, concomitant medications (including hemin use), hospitalizations/procedures, and porphyria attacks. 
The change is added as a third bullet point following Table 6, Schedule of Assessments:  Month 19 through Month 36 (Every Month 
Dosing Regimen), and Table 7, Schedule of Assessments:  Month 37 through End of Study (Every Month Dosing Regimen). 
Added text: 
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• In situations where a study visit cannot be completed at the study center or offsite by a home healthcare 
professional visit, the study Investigator (or delegate) may verbally contact the patient within the study visit window 
to assess for any AEs, concomitant medications (including hemin use), hospitalizations/procedures, and porphyria 
attacks. 
Purpose: To increase the window for obtaining body weight for dose determination. 
The change primarily occurs in Section 7.5.2, Weight and Height, 2nd paragraph 
Revised text:  Body weight measured on the dosing day will be used to calculate the dose of ALN-AS1 through M12.  After M12, 
weight obtained within 6 months during a measured at either the previous study center visit or current study center visit or offsite 
may be used for dosing calculations. 
Section(s) also reflecting this change:   
• Table 6, footnote h 
• Table 7, footnote j 
Purpose: To allow for remote completion of the EQ-5D-5L questionnaires. 
The changes occur in Table 6, Schedule of Assessments:  Month 19 through Month 36 (Every Month Dosing Regimen), and Table 7, 
Schedule of Assessments:  Month 37 through End of Study (Every Month Dosing Regimen). 
Revised text: 
Table 6, footnote m 
m In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a 
patient has a porphyria attack (but, not more than once in a 6 month period), if possible. In situations where a planned study visit 
cannot be completed at the study center, the patient will complete the EQ-5D-5L questionnaire at home. 
Table 7, footnote n 
n In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a 
patient has a porphyria attack (but, not more than once in a 6 month period), if possible. In situations where a planned study visit 
cannot be completed at the study center, the patient will complete the EQ-5D-5L questionnaire at home. 
Purpose: To remove the requirement for ECGs. 
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The changes occur in Table 6, Schedule of Assessments:  Month 19 through Month 36 (Every Month Dosing Regimen), and Table 7, 
Schedule of Assessments:  Month 37 through End of Study (Every Month Dosing Regimen). 
Revised text: 
Table 6, footnote e 
e Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested 
comfortably for at least 5 minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 
2 hours (±15 minutes) postdose . At Month 24, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose, 
when paired with PK timepoints, otherwise ECGs will be collected predose.  In patients receiving >2.5 mg/kg ALN-AS1, ECGs will 
be performed within 1 hour predose and 4 hours (±20 minutes) postdose.  See Section 7.5.4 for ECG assessment details.  With the 
implementation of Amendment 7, ECGs are no longer required. 
Table 7, footnote g 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested 
comfortably for at least 5 minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 
2 hours (±15 minutes) postdose . At Month 24, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose, 
when paired with PK timepoints, otherwise ECGs will be collected predose.  In patients receiving >2.5 mg/kg ALN-AS1, ECGs will 
be performed within 1 hour predose and 4 hours (±20 minutes) postdose.  See Section 7.5.4 for ECG assessment details.  With the 
implementation of Amendment 7, ECGs are no longer required. 
Purpose: To allow certain study visit assessments to be performed offsite by a health care professional and provide a window for 
safety laboratory assessments prior to dosing by the patient or caregiver. 
The change occurs in Section 7, Study Assessments. 
Revised text:  The schedules of study assessments are provided in Table 1, Table 2, and Table 3; and Table 5, Table 6, and Table 7. 
Where applicable country and local regulations and infrastructure allow for home healthcare, healthcare may take place at a 
location other than the clinical trial site to perform study assessments including targeted physical exam/body system 
assessment, assessments for vital signs, and collection of blood and urine samples for safety laboratory assessments, and PD 
assessments, at all timepoints as specified in the Schedule of Assessments. 
Other section(s) also reflecting these changes: 
• Table 6, footnotes b, d, f, and i 
• Table 7, footnotes d, f, h, and k 
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• Section 7.5.5 
Purpose: To broaden the window for ADA assessments required to be performed at study center visits. 
The changes occur in Table 6, Schedule of Assessments:  Month 19 through Month 36 (Every Month Dosing Regimen), and Table 7, 
Schedule of Assessments:  Month 37 through End of Study (Every Month Dosing Regimen). 
Revised text: 
Table 6, footnote l 
l On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose.  Antidrug antibody 
assessments that cannot be collected in the intended visit window may be completed within 6 months at the next study center 
visit. 
Table 7, footnote m 
m On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose.  Antidrug antibody 
assessments that cannot be collected in the intended visit window may be completed within 6 months at the next study center 
visit. 
Purpose: To collect information related to the impact of the COVID-19 pandemic on patient participation in the study. 
The primary change occurs in a newly added Section 7.8, COVID-19 Data Collection. 
Added text: 
7.8  
COVID-19 Data Collection 
Information on the coronavirus disease 2019 (COVID-19) infection status of the patient, if known, and other information on 
the impact of the COVID-19 pandemic on the patient's participation in the study will be collected. 
Section(s) also reflecting this change: 
• Section 8.2.9 
Purpose: To provide clarification on Investigator responsibilities regarding communication of new study information to patients and 
IRB/IECs. 
These changes occur in Section 9.1.1, Informed Consent, and Section 9.1.2, Ethical Review. 
Added text: 
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Section 9.1.1, 4th paragraph 
The Investigator will inform the patient/legal guardian if new information becomes available that may be relevant to the 
patient’s/legal guardian’s willingness to continue participation in the study.  Communication of this information should be 
documented. 
Revised text: 
Section 9.1.2, 2nd paragraph 
The Investigator is responsible for informing the IRB or IEC of any amendment to the protocol in accordance with local requirements.  
In addition, the IRB or IEC must approve all advertising used to recruit patients patient materials for the study (except those that 
support the need to remove an apparent immediate hazard to the patient).  The protocol must be reapproved by the IRB or IEC 
upon receipt of amendments and annually, as local regulations require. 
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CLINICAL STUDY PROTOCOL 
ALN-AS1-002 
 
Protocol Title: 
A Multicenter, Open-label Extension Study to Evaluate the Long-term 
Safety and Clinical Activity of Subcutaneously Administered 
ALN-AS1 in Patients with Acute Intermittent Porphyria who have 
Completed a Previous Clinical Study with ALN-AS1 
Investigational Drug: 
ALN-AS1 (givosiran) 
EudraCT Number: 
2016-002638-54 
IND Number: 
126094 
Protocol Date: 
Original Protocol 19 July 2016 
 
Protocol Amendment 0.1 (Sweden) 20 September 2016 
 
Protocol Amendment 1 10 November 2016 
 
Protocol Amendment 2 01 December 2016 
 
Protocol Amendment 3 03 February 2017 
 
Protocol Amendment 4 02 August 2017 
 
Protocol Amendment 5 03 May 2018  
 
Protocol Amendment 6 28 May 2019 
Sponsor: 
Alnylam Pharmaceuticals, Inc. 
300 Third Street 
Cambridge, MA  02142 USA 
Telephone:  
 
Sponsor Contact:   
 
 
 
The concepts and information contained in this document or generated during the study are considered 
proprietary and may not be disclosed in whole or in part without expressed written authorization of 
Alnylam Pharmaceuticals, Inc. 
 
160
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SPONSOR PROTOCOL APPROVAL 
I have read this protocol and I approve the design of this study. 
 
 
 
 
 
 
 
 
 
.2"1. 
HA\ 2.-o\"i. 
Date 
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INVESTIGATOR’S AGREEMENT 
 
I have read the ALN-AS1-002 protocol and agree to conduct the study as outlined.  I agree to 
maintain the confidentiality of all information received or developed in connection with this 
protocol. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Printed Name of Investigator 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signature of Investigator 
 
 
 
 
 
 
 
 
Date 
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PROTOCOL SYNOPSIS 
Protocol Title 
A Multicenter, Open-label Extension Study to Evaluate the Long-term Safety and Clinical Activity of 
Subcutaneously Administered ALN-AS1 in Patients with Acute Intermittent Porphyria who have 
Completed a Previous Clinical Study with ALN-AS1 
Product Name 
ALN-AS1 (givosiran) 
Indication 
Patients with acute intermittent porphyria (AIP) who experience recurrent porphyria attacks 
Phase 
1/2 
Study center(s)   
The study will be conducted at up to 8 clinical study centers worldwide. 
Objectives 
Primary 
 
Evaluate the long-term safety and tolerability of ALN-AS1 in patients with AIP 
Secondary 
 
Assess the pharmacodynamic (PD) effect of ALN-AS1 over time 
 
Assess the clinical activity of ALN-AS1 over time 
Exploratory 
 
Characterize the pharmacokinetic (PK) profile of ALN-AS1 and incidence of antidrug antibodies 
(ADA) over time 
 
Assess changes in health-related quality of life (QOL) 
 
Characterize analytes related to targeting the heme biosynthesis pathway 
Endpoints 
Primary 
 
Patient incidence of adverse events (AEs) 
Secondary 
 
Change in urine delta-aminolevulinic acid (ALA) and porphobilinogen (PBG) levels 
 
Frequency and characteristics of porphyria attacks 
 
Change in hemin administration 
Exploratory 
 
Change in circulating 5-aminolevulinic acid synthase 1 (ALAS1) mRNA levels 
 
Concentrations of ALN-AS1 and ADA 
 
Duration and treatment of porphyria attacks 
 
Number and duration of visits to a health care facility for acute porphyria care 
 
EQ-5D-5L questionnaire scores 
 
Pain assessment and narcotic use as recorded in a patient diary 
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 Exploratory biomarkers related to the target pathway, such as urine porphyrins, vitamin D binding 
protein 
Study Design 
This is a multicenter, open-label extension study to evaluate the long-term safety and clinical activity 
of ALN-AS1 in patients with AIP who completed study ALN-AS1-001. 
The last assessments performed, determining previous study (ALN-AS1-001) completion, will serve as 
the Screening/Baseline assessments in this study.  If more than 60 days have elapsed since the last 
assessment, safety assessments will be repeated before administration of ALN-AS1.  It is anticipated 
that patients will begin ALN-AS1 administration in this study within 6 months after the last dose of 
study drug in the previous study.  Eligibility will be confirmed before administration of the first dose of 
ALN-AS1 (Day 1).  Patients will undergo assessments at the clinical study center every month for the 
first 3 months.  Then, through Month 6, and according to the dosing regimen selected, assessments will 
take place at the clinical study center or via a phone contact (for an every month dosing regimen, visits 
will be every month; for an every 3 months dosing regimen, visits will be every 3 months).  After a 
patient has completed 12 months of ALN-AS1 administration in this study (6 months in an every 
month dosing regimen), and where applicable country and local regulations and infrastructure allow, 
study procedures, including ALN-AS1 administration, may take place at the patient’s home by a 
healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the 
Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit 
at the clinical study center every 3 months for the first year, and thereafter every 6 months through the 
end of the treatment period.  Additional visits to collect clinical laboratory samples may occur at home 
at any point during the treatment period, within 14 days prior to scheduled dose administration.  
Patients will return to the clinical study center for a posttreatment follow-up visit after administration 
of the last dose of ALN-AS1.  An ALA/PBG Monitoring/EOS visit will be conducted either at the 
clinical study center or via phone contact, unless treatment continues with ALN-AS1. 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, 
and narcotic use.  Patients will also be provided with laboratory sample collection kits and instructions 
for collecting and sending urine samples to the clinical study center. 
Patients may receive ALN-AS1 as long as they do not fulfill any of the study discontinuation criteria or 
until ALN-AS1 is commercially available in the patient’s territory or the ALN-AS1 development 
program is discontinued (whichever comes first). 
A Safety Review Committee (SRC) will review safety and tolerability data collected during the study 
with the primary purpose of protecting the safety of patients participating in the study. 
Number of Planned Patients 
Up to 24 patients are planned for enrollment in this study (including optional cohorts in 
ALN-AS1-001). 
Diagnosis and Main Eligibility Criteria 
Patients with AIP, who have completed Part C of study ALN-AS1-001, will be eligible for screening in 
this study.  Eligible patients will not be on a scheduled regimen of hemin to prevent porphyria attacks 
at Screening.  Patients with alanine transaminase ≥2.0× upper limit of normal, total bilirubin ≥2 mg/dL 
(unless bilirubin elevation is due to Gilbert’s syndrome), or estimated glomerular filtration rate ≤30 
mL/min/1.73 m2 (using the Modification of Diet in Renal Disease formula) at Screening are not 
eligible for this study. 
Investigational Product, Dose, and Mode of Administration 
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ALN-AS1 Solution for Injection (subcutaneous use [SC]) is comprised of a synthetic, small interfering 
RNA targeting ALAS1 and bearing a triantennary N-acetyl galactosamine ligand conjugated to the 
sense strand, formulated in phosphate buffer. 
The study starting dose and regimen of ALN-AS1 is 5.0 mg/kg as an SC injection administered every 3 
months.  Based on emerging clinical data, the SRC may approve changes to the dosing regimen, 
including decreases in the dose level and changes in the dosing frequency.  However any dose and 
dosing regimen will not exceed a previously explored dose level or frequency that was determined to 
be safe and well-tolerated in study ALN-AS1-001, SRC, Health Authority and Ethics Committee 
approval must be sought prior to dose escalation above 5.0 mg/kg in accordance with local Regulatory 
requirements.  
Reference Therapy, Dose, and Mode of Administration 
Not applicable 
Duration of Treatment and Study 
The duration of treatment is up to 48 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 56 months. 
Statistical Methods 
Statistical analyses will be primarily descriptive.  Incidence of AEs will be summarized by maximum 
severity and relationship to ALN-AS1.  Incidence of and serious adverse events (SAEs) and AEs 
leading to discontinuation will also be tabulated.  By-patient listings will be provided for deaths, SAEs, 
and events leading to discontinuation.  
Laboratory shift tables from baseline to worst values will be presented.  Abnormal physical 
examination findings and electrocardiogram data will be presented in by-patient listings.  Descriptive 
statistics will be provided for electrocardiogram interval data and presented as both actual values and 
changes from baseline relative to each on study evaluation and to the last evaluation on-study. 
Clinical activity of ALN-AS1 will be summarized primarily by descriptive statistics.  The clinical 
activity of ALN-AS1 will be evaluated by the frequency and characteristics of porphyria attacks 
including duration, treatment, and severity of porphyria attacks and number and duration of visits to a 
health care setting for acute porphyria care.  Patient diary recordings, including BPI-SF questionnaire 
scores, will also be summarized.   
PD analysis will include the evaluation of change in ALA, PBG, and ALAS mRNA levels.  Descriptive 
statistics (eg, mean and standard error of the mean) for observed levels of PD parameters and the 
relative change from baseline will be presented for each of the postdose follow-up time points. 
The PK concentration of ALN-AS1 will be determined.  Antidrug antibody results will be tabulated 
overall and by previous treatment in the previous study (ALN-AS1-001).  A by-patient listing will also 
be provided. 
Additional exploratory analyses may be conducted on analytes related to targeting the heme 
biosynthesis pathway.  Quality of life scores will also be summarized. 
 
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Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea
Treatment Period 
(Screening/Baseline through Month 18) 
M1 
M2 
M3 
M4/ 
M5 
M6
M7/ 
M8 
M9 
M10/ 
M11 
M12 
M13/ 
M14 
M15b 
M16/ 
M17 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Informed Consent 
X 
Medical History/Disease 
Historyc
X 
X 
Demographics 
X 
Inclusion/ 
Exclusion Criteria 
X 
X 
Physical Examinationd
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Body Weight, BMI, and 
Heighte
X 
X 
X 
X 
X 
X 
X 
Vital Signsf
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGg 
X 
X 
X 
X 
X 
X 
X 
X 
Clinical Laboratory 
Assessmenth
X 
Xa 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationj
X 
X 
X 
X 
X 
X 
X 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl
X 
X 
X 
X 
X 
X 
X 
X 
X 
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Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8 
M9 
M10/ 
M11 
M12 
M13/ 
M14 
M15b 
M16/ 
M17 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Blood Sample for PK 
Analysism 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Antidrug Antibodiesn 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
Porphyria Attack Kit 
Dispensationo 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EQ-5D-5L Questionnairep 
X 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Diary Review  
(including BPI-SF)q 
 
 
X 
Phone Contactr 
 
 
 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
AEs 
 
Continuous 
Concomitant Medicationss 
 
Continuous 
 
Abbreviations:  AE=adverse event; ALAS1=5-aminolevulinic acid synthase 1; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief 
Pain Inventory-Short Form; D=day; ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of 
life; SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may 
be conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical 
examinations and blood/urine sample collections. 
a Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study (ALN-AS1-001) were completed within 60 days 
of administration of the first dose of ALN-AS1 in this study.  If more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs 
will be repeated before administration of ALN-AS1.  Results should be available and deemed acceptable before the administration of the first dose of ALN-
AS1.  On Day 1, results from hematology, chemistry (including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the 
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Investigator before study drug administration.  If results from within the prior 14 days are not available at a dosing visit, locally analyzed predose assessments 
may be used for review in order to allow same day study drug administration and additional samples for central analysis must also be collected. 
b After a patient has completed 12 months of ALN-AS1 administration in this study, and where applicable country and local regulations and infrastructure allow, 
study procedures, including ALN-AS1 administration, may take place at the patient’s home by a healthcare professional.  Study procedures may occur at the 
patient’s home at the discretion of the Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit at the clinical 
study center Q6M.  Additional visits to collect clinical laboratory samples may occur at home at any point during the treatment period, within 14 days prior to 
scheduled dose administration. 
c See Section 7.1 for details on the interval medical history/disease history to be recorded at Screening/Baseline.  Ongoing AEs from the previous study 
(ALN-AS1-001) will be captured as medical history. 
d A complete physical examination will be performed at Screening/Baseline, and D1.  At all other visits, a targeted physical examination will be performed.  On 
dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any time 
during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On D1, vital signs will be collected within 1 hour predose; and 2 hours 
(±10 minutes) postdose.  On all other dosing days, vital signs will be collected within 1 hour predose.  On days when ALN-AS1 is not administered, vital signs 
can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position (should be consistent for each patient), after the 
patient has rested comfortably for at least 10 minutes. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at least 5 
minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose at a minimum of 2 
of the following visits:  D1, Month 3, Month 6, Month 9, Month 12, Month 15 (only if visit is done at clinic), or Month 18.  In patients receiving >2.5 mg/kg 
ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose at a minimum of two of the following visits:  D1, Month 3, 
Month 6, Month 9, Month 12, Month 15 (only if visit is done at clinic), or Month 18.  On all other dosing days, ECGs will be collected within 1 hour predose 
(see Section 7.5.4 for ECG assessment details).   
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  On 
days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. On dosing days, results from hematology, chemistry 
(including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the Investigator before study drug administration.  If results 
from within the prior 14 days are not available at a dosing visit, locally analyzed predose assessments may be used for review in order to allow same day study 
drug administration and additional samples for central analysis  must  also be collected. 
i A serum pregnancy test will be performed at Screening/Baseline; thereafter, urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  For 
weight-based dosing, weight measured at the current study center visit (dosing day) will be used to calculate the dose of ALN-AS1 through M12.  After M12, 
weight measured at either the previous study center visit or the current study center visit may be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1).  Blood sample collection for PK analysis at 
Month 9 and Month 15 is only necessary if ECG will be performed at same visit. 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o Porphyria attack laboratory sample collection kits should be dispensed at the screening visit along with instructions for use. For any attack that occurs through
M37, urine samples should be collected within 24 hours of the start of clinical intervention (eg, hemin or glucose administration) and within 24 hours of the end
of clinical intervention.  If patients are unable to report to the clinical study center during a porphyria attack, laboratory sample collection kits will be provided
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that contain instructions for collecting and sending urine samples to the clinical study center, if possible.  These urine samples may also be analyzed for 
exploratory biomarkers. 
p In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but not more than once in a 6 month period), if possible.  
q Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, and narcotic use on a daily basis through M9; 
thereafter, acute porphyria attacks will be recorded in the diary.  The BPI will be completed on a weekly basis as part of the patient diary through M9, then 
Q3M. 
r Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack. 
s Medications that are ongoing from the previous study (ALN-AS1-001), started between the previous study and this study, and started after signing informed 
consent in this study, will be captured as concomitant medication(s). 
 
 
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Table 2: 
Schedule of Assessments:  Month 19 through Month 36 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through Month 36) 
M19/ 
M20 
M21a
M22/ 
M23 
M24 
M25/ 
M26 
M27a
M28/ 
M29 
M30 
M31/ 
M32 
M33a
M34/ 
M35 
M36 
Study Visit (D±Visit Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
Physical Examinationb
X 
X 
X 
Body Weight, BMI, and Heightc
X 
X 
X 
Vital Signsd
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGe
X 
Clinical Laboratory Assessmentf
X 
X 
X 
X 
X 
X 
Pregnancy Testg 
X 
X 
X 
X 
X 
X 
Study Drug Administrationh
X 
X 
X 
X 
X 
X 
Urine Sample for PBG, ALA, and 
Creatinine Analysisi
X 
X 
X 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker Analysisj
X 
X 
X 
Blood Sample for PK Analysisk
X 
Antidrug Antibodiesl
X 
X 
EQ-5D-5L Questionnairem 
X 
X 
X 
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Table 2: 
Schedule of Assessments:  Month 19 through Month 36 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through Month 36) 
M19/ 
M20 
M21a 
M22/ 
M23 
M24 
M25/ 
M26 
M27a 
M28/ 
M29 
M30 
M31/ 
M32 
M33a 
M34/ 
M35 
M36 
Study Visit (D±Visit Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
Diary Review (including BPI-SF)n 
X 
Phone Contacto 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of life; SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
a Where applicable country and local regulations and infrastructure allow, study procedures, including ALN-AS1 administration, may take place at the patient’s 
home by a healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the Investigator, based on safety and tolerability; 
however, patients are required to complete at least 1 visit at the clinical study center Q6M.  
b A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed.  
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 
c Height will be measured at Screening/Baseline only. 
d Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for at least 10 minutes. 
e Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at least 
5 minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose .  In patients 
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receiving >2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose.  See Section 7.5.4 for ECG assessment 
details. 
f Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  .  
On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. 
g Urine pregnancy tests will be performed.  Results must be available before dosing. 
h ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured at either the previous study center visit or the current study center visit may be used to calculate the weight-based dose of ALN-AS1. 
i Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
j On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
k Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1). 
l On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
m In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but, not more than once in a 6 month period), if possible.  
n Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
o Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack. 
 
 
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Table 3: 
Schedule of Assessments:  Month 37 through End of Study (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 37 through EOS) 
EOS/ 
ETb 
Safety Follow-
upc 
M37/ 
M38a 
M39a
M40/ 
M41a 
M42 
M43/ 
M44a 
M45a
M46/ 
M47a 
M48/ 
EOT 
M49 
Study Visit (D±Visit Window) 
1111±7/1141±7 
1171±10 
1201±7/1231±7 
1261±10 
1291±7/1321±7 
1351±10 
1381±7/1411±7 
1441±10 
1471±10 
Physical Examinationd
X 
X 
X 
X 
Body Weight, BMI, and Heighte
X 
X 
Vital Signsf
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGg 
X 
X 
Clinical Laboratory Assessmenth
X 
X 
X 
X 
X 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationj
X 
X 
X 
X 
X 
X 
X 
X 
Urine Sample for PBG, ALA, and 
Creatinine Analysisk
X 
X 
X 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker Analysisl
X 
X 
X 
Antidrug Antibodiesn
X 
X 
X 
EQ-5D-5L Questionnaireo
X 
X 
X
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Table 3: 
Schedule of Assessments:  Month 37 through End of Study (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 37 through EOS) 
EOS/ 
ETb 
Safety Follow-
upc 
 
M37/ 
M38a 
M39a 
M40/ 
M41a 
M42 
M43/ 
M44a 
M45a 
M46/ 
M47a 
M48/ 
EOT 
M49 
 
Study Visit (D±Visit Window) 
1111±7/1141±7 
1171±10 
1201±7/1231±7 
1261±10 
1291±7/1321±7 
1351±10 
1381±7/1411±7 
1441±10 
1471±10 
 
Diary Review (including BPI-SF)p 
X 
 
Phone Contactq 
X 
 
X 
 
X 
 
X 
 
 
 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; EOS = End of Study; EOT = End of Treatment; ET = Early Termination; M=month; PBG= porphobilinogen; 
PK=pharmacokinetics; Q=every; QOL=quality of life; SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
a Where applicable country and local regulations and infrastructure allow, study procedures, including ALN-AS1 administration, may take place at the patient’s 
home by a healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the Investigator, based on safety and tolerability; 
however, patients are required to complete at least 1 visit at the clinical study center Q6M.  
b Patients who complete all scheduled treatment with ALN-AS1 through Month 48 will return for an end of study (EOS) visit at Month 49.  Patients who 
discontinue treatment will be asked to complete an early termination (ET) visit at which all Month 37 visit procedures will be performed; the patient must also 
return for a safety-follow-up visit at 3 months (84 [+7] days) after his/her last dose of ALN-AS1.   
c The safety follow-up visit is only required for patients who discontinue prior to study completion.  The visit should be conducted  3 months (84 [+7 days]) 
following the last dose of ALN-AS1. 
d A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed.  
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 
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e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for at least 10 minutes. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at least 
5 minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose .  In patients 
receiving >2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose.  See Section 7.5.4 for ECG assessment 
details. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  .  
On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. 
i Urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured at either the previous study center visit or the current study center visit may be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but, not more than once in a 6 month period), if possible.  
p Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
q Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack. 
 
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TABLE OF CONTENTS 
PROTOCOL SYNOPSIS ................................................................................................................4 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS ................................................22 
1. 
INTRODUCTION ......................................................................................................24 
1.1. 
Disease Overview .......................................................................................................24 
1.1.1. 
Epidemiology ..............................................................................................................24 
1.1.2. 
Current Management and Unmet Medical Need ........................................................25 
1.2. 
RNA Interference ........................................................................................................26 
1.3. 
ALN-AS1 ....................................................................................................................26 
1.4. 
Study Design Rationale ..............................................................................................26 
1.5. 
Dose Rationale ............................................................................................................26 
1.6. 
Clinical Data Summary ...............................................................................................27 
1.6.1. 
Clinical Pharmacodynamics .......................................................................................27 
1.6.2. 
Clinical Activity ..........................................................................................................28 
1.6.3. 
Clinical Safety ............................................................................................................29 
1.6.4. 
Drug-Drug Interactions ...............................................................................................30 
1.7. 
Benefit-Risk Assessment ............................................................................................30 
2. 
OBJECTIVES .............................................................................................................31 
2.1. 
Primary Objective .......................................................................................................31 
2.2. 
Secondary Objectives .................................................................................................31 
2.3. 
Exploratory Objectives ...............................................................................................31 
3. 
ENDPOINTS ..............................................................................................................32 
3.1. 
Primary Endpoint ........................................................................................................32 
3.2. 
Secondary Endpoints ..................................................................................................32 
3.3. 
Exploratory Endpoints ................................................................................................32 
4. 
INVESTIGATIONAL PLAN .....................................................................................32 
4.1. 
Summary of Study Design ..........................................................................................32 
4.2. 
Duration of Treatment and Study ...............................................................................34 
4.3. 
Number of Patients .....................................................................................................34 
4.4. 
Method of Assigning Patients to Treatment Groups ..................................................34 
4.5. 
Blinding ......................................................................................................................34 
4.6. 
Safety Review Committee ..........................................................................................34 
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5. 
SELECTION AND WITHDRAWAL OF PATIENTS ..............................................34 
5.1. 
Inclusion Criteria ........................................................................................................34 
5.2. 
Exclusion Criteria .......................................................................................................35 
5.3. 
Discontinuation of Study Drug and/or Study .............................................................35 
5.3.1. 
Discontinuation of Study Drug ...................................................................................36 
5.3.2. 
Discontinuation from the Study ..................................................................................36 
5.3.3. 
Withdrawal of Consent to Collect and Process the Patient’s Personal Data ..............37 
5.3.4. 
Replacement of Patients .............................................................................................37 
6. 
TREATMENTS ..........................................................................................................37 
6.1. 
Treatments Administered ............................................................................................37 
6.2. 
Investigational Study Drug .........................................................................................38 
6.2.1. 
Description ..................................................................................................................38 
6.2.2. 
Dose and Administration ............................................................................................38 
6.2.3. 
Dose Modifications .....................................................................................................39 
6.2.3.1. 
Study Population Dose Modifications ........................................................................39 
6.2.3.2. 
Individual Dose Modifications ...................................................................................39 
6.2.4. 
Preparation, Handling, and Storage ............................................................................40 
6.2.5. 
Packaging and Labeling ..............................................................................................40 
6.2.6. 
Accountability .............................................................................................................40 
6.3. 
Concomitant Medications ...........................................................................................40 
6.4. 
Contraceptive Requirements .......................................................................................41 
6.5. 
Treatment Compliance ................................................................................................42 
7. 
STUDY ASSESSMENTS ..........................................................................................42 
7.1. 
Screening/Baseline Assessments ................................................................................42 
7.2. 
Clinical Activity Assessments ....................................................................................43 
7.2.1. 
Patient Diary ...............................................................................................................43 
7.2.2. 
Brief Pain Inventory-Short Form Questionnaire ........................................................43 
7.3. 
Pharmacodynamic Assessments .................................................................................43 
7.4. 
Pharmacokinetic Assessments ....................................................................................43 
7.5. 
Safety Assessments .....................................................................................................43 
7.5.1. 
Vital Signs ..................................................................................................................44 
7.5.2. 
Weight and Height ......................................................................................................44 
7.5.3. 
Physical Examination .................................................................................................44 
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7.5.4. 
Electrocardiogram .......................................................................................................44 
7.5.5. 
Clinical Laboratory Assessments ...............................................................................45 
7.5.5.1. 
Immunogenicity ..........................................................................................................47 
7.5.5.2. 
Pregnancy Testing ......................................................................................................47 
7.5.6. 
Adverse Events ...........................................................................................................47 
7.5.6.1. 
Definitions ..................................................................................................................47 
7.5.6.2. 
Eliciting and Recording Adverse Events ....................................................................49 
7.5.6.3. 
Serious Adverse Events Require Immediate Reporting to Sponsor/Designee ...........50 
7.5.6.4. 
Sponsor Safety Reporting to Regulatory Authorities .................................................50 
7.5.6.5. 
Serious Adverse Event Notification to the Institutional Review 
Board/Independent Ethics Committee ........................................................................51 
7.5.6.6. 
Pregnancy Reporting ..................................................................................................51 
7.5.6.7. 
Overdose Reporting ....................................................................................................51 
7.6. 
Exploratory Assessments ............................................................................................52 
7.7. 
Other Assessments ......................................................................................................52 
7.7.1. 
EQ-5D-5L Questionnaire ............................................................................................52 
8. 
STATISTICS ..............................................................................................................52 
8.1. 
Determination of Sample Size ....................................................................................52 
8.2. 
Statistical Methodology ..............................................................................................52 
8.2.1. 
Populations to be Analyzed ........................................................................................53 
8.2.2. 
Examination of Subgroups .........................................................................................53 
8.2.3. 
Handling of Missing Data ...........................................................................................53 
8.2.4. 
Baseline Evaluations ...................................................................................................53 
8.2.5. 
Clinical Activity Analyses ..........................................................................................53 
8.2.6. 
Pharmacodynamic Analysis........................................................................................53 
8.2.7. 
Pharmacokinetic Analysis ..........................................................................................54 
8.2.8. 
Safety Analyses ..........................................................................................................54 
8.2.9. 
Other Analyses ............................................................................................................54 
9. 
STUDY ADMINISTRATION ...................................................................................54 
9.1. 
Ethical and Regulatory Considerations ......................................................................54 
9.1.1. 
Informed Consent .......................................................................................................55 
9.1.2. 
Ethical Review ............................................................................................................55 
9.1.3. 
Serious Breach of Protocol .........................................................................................55 
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9.1.4. 
Study Documentation, Confidentiality, and Records Retention .................................56 
9.1.5. 
End of the Study .........................................................................................................56 
9.1.6. 
Discontinuation of the Clinical Study.........................................................................56 
9.2. 
Data Quality Control and Quality Assurance .............................................................56 
9.2.1. 
Data Handling .............................................................................................................56 
9.2.2. 
Study Monitoring ........................................................................................................57 
9.2.3. 
Audits and Inspections ................................................................................................57 
9.3. 
Publication Policy .......................................................................................................57 
10. 
LIST OF REFERENCES ............................................................................................58 
11. 
APPENDICES ............................................................................................................61 
11.1. 
Pharmacokinetic Assessment Time Points .................................................................61 
11.2. 
Schedules of Assessments for Every Month Dosing Regimen ..................................62 
11.3. 
Anaphylactic Reactions ..............................................................................................72 
 
LIST OF TABLES 
Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 
Months Dosing Regimen) .............................................................................................7 
Table 2: 
Schedule of Assessments:  Month 19 through Month 36 (Every 3 Months 
Dosing Regimen) ........................................................................................................11 
Table 3: 
Schedule of Assessments:  Month 37 through End of Study (Every 3 Months 
Dosing Regimen) ........................................................................................................14 
Table 4: 
Pharmacokinetic Time Points .....................................................................................61 
Table 5: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 
Month Dosing Regimen) ............................................................................................62 
Table 6: 
Schedule of Assessments:  Month 19 through Month 36 (Every Month 
Dosing Regimen) ........................................................................................................66 
Table 7: 
Schedule of Assessments:  Month 37 through End of Study (Every Month 
Dosing Regimen) ........................................................................................................69 
Table 8: 
 Sampson Criteria for Anaphylactic Reactions ...........................................................72 
 
LIST OF FIGURES 
Figure 1: 
Part C Cohort 1 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in .........................................................................................................................28 
Figure 2: 
Part C Cohort 2 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in .........................................................................................................................29 
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Figure 3: 
Study Design ...............................................................................................................33 
 
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LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
Abbreviation 
Definition 
AE 
Adverse event 
AHP 
Acute hepatic porphyria 
AIP 
Acute intermittent porphyria 
ALA 
Delta-aminolevulinic acid 
ALAS1 
5-aminolevulinic acid synthase 1 
ALP 
Alkaline phosphatase 
ASGPR 
Asialoglycoprotein receptor 
ASHE 
Asymptomatic high excreters 
BPI-SF 
Brief Pain Inventory-Short Form 
cERD 
Circulating extracellular RNA detection assay 
CRF 
Case report form 
CYP 
Cytochrome P450 
DDI 
Drug-drug interaction 
ECG 
Electrocardiogram 
eCRF 
Electronic case report form 
eGFR 
Estimated Glomerular Filtration Rate 
EDC 
Electronic data capture 
EOS 
End of study 
EU 
European Union 
GalNAc 
N-acetyl galactosamine 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practice 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
IEC 
Independent Ethics Committee 
IRB 
Institutional Review Board 
ISR 
Injection site reaction 
IV 
Intravenous 
LFT 
Liver function test 
mRNA 
Messenger RNA 
NHP 
Nonhuman primate 
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Abbreviation 
Definition 
NOAEL 
No observed adverse effect level 
NOEL 
No observed effect level 
OTC 
Over the counter 
PBG 
Porphobilinogen 
PBGD 
Porphobilinogen deaminase 
PD 
Pharmacodynamic(s) 
PK 
Pharmacokinetic(s) 
QOL 
Quality of life 
RNA 
Ribonucleic acid 
RNAi 
RNA interference 
SAE 
Serious adverse event 
SAP 
Statistical Analysis Plan 
SC 
Subcutaneous 
siRNA 
Small interfering RNA 
SRC 
Safety Review Committee 
SUSAR 
Suspected unexpected serious adverse reaction 
ULN 
Upper limit of normal 
US 
United States 
WOCBP 
Woman of child-bearing potential 
 
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1.
INTRODUCTION
1.1. 
Disease Overview
The porphyrias are a family of rare metabolic disorders predominately caused by a genetic 
mutation in 1 of the 8 enzymes responsible for heme synthesis.(1)  The 2 major categories are 
erythropoietic and hepatic, depending on the major site of expression of the underlying enzyme 
deficiency.(2)  In addition, the porphyrias are classified as acute if patients present with 
neurovisceral symptoms (eg, abdominal pain and neurologic symptoms) or cutaneous if they 
present with dermal blistering or photosensitivity.(3, 4) 
This study will include patients with acute intermittent porphyria (AIP), the most common acute 
hepatic porphyria (AHP).  AIP occurs as a result of an autosomal dominant mutation leading to 
partial deficiency of porphobilinogen deaminase (PBGD), the third enzyme in the heme 
biosynthesis pathway.(5)  The rate limiting step in heme synthesis is the upstream enzyme 
5-aminolevulinic acid synthase 1 (ALAS1), which is controlled by feedback repression via the 
end-product heme.  In response to a decrease in endogenous heme in the liver, as can occur with 
fasting, hormonal alterations, or with cytochrome P450 (CYP) inducing drugs, ALAS1 is 
induced, resulting in increased flux through the heme synthesis pathway.  In patients with AIP, 
this can result in the marked accumulation of the toxic heme intermediates porphobilinogen 
(PBG) and delta aminolevulinic acid (ALA) in the blood and urine due to the deficiency in the 
downstream PBGD.  Clinically, this manifests as acute attacks characterized by severe 
abdominal pain, cardiovascular as well as neurologic and psychiatric dysfunction.(6) 
1.1.1. 
Epidemiology 
Over 370 mutations have been identified in the PBGD gene, which in most instances result in its 
reduction by approximately 50%.  The exact prevalence of AIP is unknown due to under 
diagnosis, variation by geographic region, and the differences in penetrance observed for the 
different mutations.(2)  However, it is estimated that the prevalence of AIP is 5 to 10 per 100,000 
people in Western countries, while in Sweden it occurs in 1 in 1,000 people due to a founder 
effect associated with the resultant G593A mutation.(7-10)  AIP shows incomplete penetrance 
and on average only 10% to 50% of carriers with a mutation present with clinical symptoms.(11)  
It has been proposed that unknown inherited co-factors, in addition to PBGD mutations, may 
explain why a small percentage of patients present with much more severe disease while the 
majority remain asymptomatic. 
Patients with AIP present with acute attacks characterized by neurovisceral symptoms and signs 
including severe abdominal pain, nausea, vomiting, constipation, or less commonly diarrhea, 
hypertension, tachycardia, fever, muscle weakness, as well as neurological (eg, neuropathy, 
seizures) and psychiatric (eg, anxiety and confusion) manifestations.(12)  AIP attacks typically 
start after puberty and can be triggered by exogenous factors such as medications (especially 
barbiturates, sulfonamides, and hydantoins), stress, exogenous hormones, nutritional status, and 
infection.  Clinically active disease is more common in women, where attacks often occur around 
the menstrual cycle and are likely precipitated by hormonal changes. 
Many AIP patients remain undiagnosed given that the disease is rare and characterized by 
non-specific symptoms (eg, abdominal pain and nausea).(2)  The initial diagnosis involves 
demonstrating elevated urinary PBG (typically 20-50 × normal reference range) and ALA 
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(typically 5-20 × normal reference range) when the patient is having acute attack symptoms.  
Once a test is positive for elevated ALA and PBG and porphyria is suspected, genetic testing for 
a PBGD mutation is performed.   
There are 4 main clinical phenotypes of AIP.  Latent gene carriers have never had an acute attack 
and are biochemically inactive (normal urinary ALA and PBG).  Asymptomatic high excreters 
(ASHE) do not have current acute attacks, but are biochemically active (increased urinary ALA 
and PBG).  The increased levels of ALA and PBG in ASHE patients are lower than those in AIP 
patients during an acute attack, but are still significantly higher than normal reference values.(6-
8)  Sporadic attack patients have infrequent acute attacks.  Recurrent attack patients have ≥4 
attacks per year requiring hospitalization or treatment by a medical professional.(7) 
1.1.2. 
Current Management and Unmet Medical Need 
Management of acute attacks often requires hospitalization.  Patients are initially treated with 
supportive care and carbohydrate loading, analgesics and anti-emetics, and removal of known 
precipitating factors.(13)  In patients with moderate to severe attacks, or who fail to respond to 
supportive measures, treatment with intravenous (IV) hemin (daily for 3-5 days) is commenced.  
Symptoms typically begin to improve after 2 to 5 days of hemin treatment, accompanied by a 
lowering of urinary ALA and PBG levels to below or at the upper limit of normal (ULN) 
reference value; however, in some patients attacks can last several weeks, requiring prolonged 
hemin use and hospitalization.(14)  With prolonged and severe attacks, cranial nerve 
involvement can occur, leading to bulbar paralysis, respiratory failure, and death.(15) 
Hemin, a blood derived therapy, was approved as Normosang® (heme arginate) in the European 
Union (EU) and as Panhematin® (lyophilised hematin) in the United States (US) in 1999 and 
1983, respectively.(16, 17)  In the EU, heme arginate is indicated for the treatment of acute 
attacks of hepatic porphyria (eg, AIP, variegate porphyria, and hereditary coproporphyria); 
whereas, in the US lyophilized hemin is limited to the amelioration of recurrent attacks of AIP 
temporally related to the menstrual cycle.  Approval of both products was based on biochemical 
efficacy (ie, lowering of ALA and PBG) as well as data from uncontrolled case series and case 
reports.(18-22)  Hemin side effects include thrombophlebitis, transient anticoagulation, and in 
rare cases, anaphylaxis or renal failure.(22-24)  In addition, hemin administration requires a large 
vein for administration, often necessitating central venous access. 
While the majority of patients who experience attacks have them sporadically, it is estimated that 
up to 1,000 AIP patients experience recurrent attacks (typically defined as ≥4 per year) in the US 
and EU combined.(25)  While hemin is currently only approved to ameliorate acute attacks, it is 
administered prophylactically in some patients with recurrent attacks (eg, administered every 1-2 
weeks).(26)  Potential problems associated with chronic hemin administration include infusion 
site phlebitis, iron overload, and the need for chronic IV access and associated complications (eg, 
risk of infection or occlusion).(5)  In addition, there have been reports of a decrease in efficacy 
with chronic hemin administration, as evidenced by the need to increase the frequency or dosage 
of hemin prophylaxis over time in attempt to maintain a clinical effect.(27)  In patients with very 
severe recurrent attacks, or in whom hemin treatment is not effective, liver transplantation can be 
curative; however, organ transplantation is a high-risk procedure and is rarely used as a treatment 
option.  Given the significant morbidity and mortality, there remains a significant unmet need for 
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an efficacious, simple, fast-acting and better tolerated treatment for acute or prevent recurrent 
attacks in patients with AIP. 
1.2. 
RNA Interference 
RNA interference (RNAi) is a naturally occurring cellular mechanism mediated by small 
interfering RNAs (siRNAs) for regulating gene expression.  Typically, synthetic siRNAs are 19 
to 25 base pair double stranded oligonucleotides in a staggered duplex with a 2-nucleotide 
overhang at both or 1 of the 3’ ends.(28)  Such siRNAs can be designed to target an endogenous 
messenger RNA (mRNA) transcript of a given gene.  When introduced into cells, the net effect 
of an RNAi-based pharmacological approach is the binding of the siRNA to its complementary 
mRNA sequence, cleavage of this target mRNA, and reduction of synthesis of the target protein, 
resulting in a decrease of the target protein levels.(29)  The ability to selectively and potently 
degrade the mRNA encoding the ALAS1 protein (thereby decreasing accumulation of the toxic 
intermediates ALA and PBG) using an siRNA is a novel approach for the prevention and 
treatment of acute attacks in patients with AIP.   
1.3. 
ALN-AS1 
ALN-AS1 (givosiran) comprises a synthetic siRNA covalently linked to a GalNAc containing 
ligand (ALN60519), specific for ALAS1 and formulated for administration via subcutaneous 
(SC) injection. ALN-60519 has a target region between nucleotide 918 to 937 of the ALAS1 
mRNA. Attachment to a triantennary GalNAc ligand to the siRNA enables its distribution to the 
liver (which is the primary site of ALAS1 synthesis), followed by intracellular delivery to 
hepatocytes via ASGPR, resulting in engagement of the RNAi pathway and suppression of 
hepatic ALAS1 protein synthesis. 
ALN-AS1 is currently in development for treatment of acute attacks in patients with AIP, the 
most common AHP. 
Further information on ALN-AS1, including the clinical and nonclinical experience to date, is 
available in in the current version of the Investigator’s Brochure (IB). 
1.4. 
Study Design Rationale 
This is a multicenter, open-label extension study designed to evaluate the long-term safety and 
clinical activity of subcutaneously administered ALN-AS1 in patients with AIP who have 
completed clinical study ALN-AS1-001.  The primary endpoint for the study is the incidence of 
AEs. 
1.5. 
Dose Rationale 
Clinical data from Part A and Part B of the ongoing study ALN-AS1-001 demonstrate that single 
(0.035-2.5 mg/kg) and multiple (0.35-1.0 mg/kg) doses of ALN-AS1 have been generally 
well-tolerated in patients with AIP who are ASHE.  Additionally, data from this study indicate 
that a single dose of 2.5 mg/kg ALN-AS1 results in near normalization of urine ALA and PBG 
levels, which is sustained for approximately 14 weeks.   
Patients in Part C of the ongoing study ALN-AS1-001 who are eligible for participation in this 
study will likely require a higher dose of ALN-AS1 to normalize ALA and PBG as they have 
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higher levels of ALAS1 upregulation and higher baseline levels of ALA and PBG, when 
compared to patients with AIP who are ASHE.(30)  For example, based on preliminary data in 
Part A and Part B of the ALN-AS1-001 study, the mean PBG level of patients who are ASHE is 
21.9 mmol/mol Cr (N=28); whereas, in Part C of this study in patients with AHP who have 
recurrent porphyria attacks, the mean PBG level is approximately 49.3 mmol/mol Cr (N=12). 
The study starting dose and regimen of ALN-AS1 is 5.0 mg/kg as an SC injection administered 
every 3 months.  Based on emerging clinical data, the SRC may approve changes to the ALN-
AS1 dosing regimen, including decreases in the dose level and changes in dosing frequency.  
However, any dosing regimen will not exceed a previously explored dose level or frequency that 
was determined to be safe and well-tolerated in study ALN-AS1-001. SRC, Health Authority and 
Ethics Committee approval must be sought prior to dose level escalation above 5.0 mg/kg in 
accordance with local Regulatory requirements. 
The study starting dose and regimen was selected based on the benefit:risk profile of ALN-AS1 
in Part C of the ongoing ALN-AS1-001 study.  Preliminary data to date indicate that 
administration of 5.0 mg/kg ALN-AS1 has been generally well-tolerated.  There have been no 
study drug-related serious adverse events (SAEs), severe AEs, or clinically significant changes in 
safety parameters.  While a single 2.5 mg/kg dose of ALN-AS1 has also been generally well-
tolerated when administered to patients in Part A and Part C of study ALN-AS1-001, this dose 
has not resulted in near normalization of ALA and PBG levels.  In addition, while emerging data 
from Part C indicate that an every 3 months dose of 2.5 mg/kg ALN-AS1 demonstrated some 
clinical activity (eg, decrease in attack frequency and decrease in heme use), some patients 
continued to experience breakthrough porphyria attacks during the treatment period, indicating 
that a higher dose may be required. 
The duration of dosing in this study is supported by the overall favorable safety profile of 
ALN-AS1 in the ongoing clinical study ALN-AS1-001 and the absence of new findings in 
nonclinical studies with ALN-AS1. 
1.6. 
Clinical Data Summary 
1.6.1. 
Clinical Pharmacodynamics  
Dosing has been completed in Part A and Part B of the study.  In both Parts A and B of the study, 
durable and dose-dependent reductions of ALAS1 mRNA (up to 66% in the 2.5 mg/kg dose 
group) as measured by cERD were observed after ALN-AS1 treatment.  ALAS1 reductions were 
highly correlated with reductions in ALA (mean maximal 86%) PBG (mean maximal 95%) 
levels in a dose-dependent manner and were sustained for ≥180 days.  
Dosing is currently ongoing in Part C of the study. The mean maximal reduction in ALAS1 
mRNA relative to baseline in ALN-AS1-treated patients in Cohort 1 (2.5 mg/kg Q3M) was 39% 
and in Cohort 2 (2.5 mg/kg Q1M) 66%.  All patients treated with ALN-AS1 also had decreases 
in their peak ALA and PBG levels in the treatment period compared to the run-in period, along 
with reduced fluctuations in these levels in the treatment period (data not shown). No reductions 
were observed in the placebo-treated patients.  
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1.6.2. 
Clinical Activity 
Clinical activity was not evaluated in Parts A and B of the study because ASHE patients included 
in this study were not actively experiencing attacks of porphyria. 
Dosing is currently ongoing in Part C of the study. All patients in Cohorts 1 and 2 were enrolled 
in a run-in phase for 10-15 weeks that was followed by a treatment phase for up to 24 weeks.  No 
investigational product was administered during the run-in phase.  Therefore, each patient acted 
as their own control, allowing for individual ALA / PBG levels, and overall attack rate while on 
ALN-AS1 treatment to be compared to that observed in the run-in phase.   
Figure 1 shows in Cohort 1 ALN-AS1-treated patients there was a 74% mean decrease in the 
annualized attack rate for the treatment period versus the run-in period (range: 63-94% 
reduction), compared with a 23% decrease in the annualized attack rate for the placebo-treated 
patient.  In ALN-AS1-treated patients this was accompanied by an approximate 76% mean 
decrease in annualized acute hemin usage (range 52-95%) and a 10.3 times increase in the 
maximal attack free interval compared to run-in period (range 4.2-16.3). 
Figure 1: 
Part C Cohort 1 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in 
 
Figure 2 shows in Cohort 2 ALN-AS1-treated patients, there was a 58% mean decrease in the 
annualized attack rate for the treatment period versus the run-in period (range: 45-76% 
reduction).  This compares favorably with data from the placebo-treated patient who showed a 
34% reduction in the annualized attack rate for the treatment period versus the run-in period.  In 
ALN-AS1-treated patients, the reduction in attack rate was accompanied by a 92% mean 
decrease in annualized hemin usage (range 84-100%) and a 2.7x increase in the mean maximal 
attack free interval compared to run-in period (range 2.1-3.2). 
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Figure 2: 
Part C Cohort 2 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in 
 
1.6.3. 
Clinical Safety 
In Part A and Part B of Study ALN-AS1-001, a total of 11 patients (11/13; 85.0%) who received 
ALN-AS1 reported at least 1 AE.  All 5 placebo-treated patients (5/5; 100%) reported at least 1 
AE.  AEs considered possibly or definitely related to ALN-AS1 were reported in 5 patients 
(5/13; 38%): diarrhoea, dyspepsia, hematochezia, injection site erythema, injection site pain, 
blood creatinine increased, glomerular filtration rate decreased, and hypoesthesia (each AE 
reported only by an individual patient; 1/13; 8% each).  There were 2 SAEs of abdominal pain: 1 
patient each in the 0.035 mg/kg and 0.1 mg/kg ALN-AS1 dose groups.  Both were considered to 
be not related and resolved without sequelae.  There were no AEs leading to discontinuation.  All 
AEs were mild or moderate in severity, except for 1 of the SAEs of abdominal pain (0.10 mg/kg 
dose group), which was considered severe. Adverse events related to abnormal laboratory values 
were seen in 1 patient in the 0.35 mg/kg ALN-AS1 dose group who had AEs of ALT increased 
and AST increased, which were moderate and considered by the Investigator to be unrelated to 
ALN-AS1.  No clinically significant findings were observed with routine monitoring of CRP and 
a panel of 9 proinflammatory cytokines collected predose and up to 24 hours post-dose.  There 
were no other clinically significant laboratory abnormalities related to study drug or changes in 
vital signs, or ECGs in patients who were administered ALN AS1 or placebo. 
Dosing is ongoing in Part C of the study. All patients who received ALN-AS1 in cohort 1 and 2 
reported at least 1 AE.  AEs that were reported in at least 2 subjects were nausea in 3 patients 
(50%) and abdominal pain, vomiting, nasopharyngitis, headache, cough and oropharyngeal pain 
in 2 patients (33.3%) each.  All AEs were mild or moderate in severity.  AEs considered possibly 
or definitely related to ALN-AS1 were reported in 4 patients (66.6%), 1 each:  renal impairment 
in Cohort 1 and injection site reaction, myalgia, and headache in Cohort 2. Both placebo-treated 
patients reported AEs.  No AE was experienced in more than 1 patient.  
In Part C, Cohort 1 or 2, there were no SAEs or AEs leading to discontinuation in patients 
administered ALN-AS1 or placebo. No clinically significant laboratory abnormalities related to 
study drug or changes in vital signs, ECG, or physical exam findings were observed in patients 
administered ALN-AS1 or placebo. 
Part C Cohort 3 5.0 mg/kg SC monthly dosing is ongoing.  In this cohort there was one fatal 
SAE of acute pancreatitis, which was determined to be unlikely related to study drug or placebo 
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by the Investigator due to the presence of gall bladder sludge found at the time of her 
presentation.  Contributors to this patient's adverse clinical course included: pre-existing chronic 
debilitation from recurrent AIP attacks requiring monthly hospitalization, porphyria-attributed 
quadriplegia requiring nursing home care, delay in hospital admission and complications from 
thromboembolism (multiple risk factors included pancreatitis, obesity, immobilisation from 
quadriparesis and recent hospitalization for infected portacath removal).  Serum lipase was added 
to all scheduled laboratory assessments in November 2016 as part of additional safety 
monitoring. To date, all lipase results (available in 11 of 15 subjects) have been at or below the 
upper limit of normal with no trends seen with dosing of study drug or placebo. 
Further information on the safety, efficacy, PK and PD of ALN-AS1 are available in the 
Investigator’s Brochure. 
1.6.4. 
Drug-Drug Interactions 
An open-label drug-drug interaction (DDI) study (ALN-AS1-004) was conducted in AIP patients 
who are ASHE to evaluate the effect of a single dose of 2.5 mg/kg ALN-AS1 administered SC 
on the pharmacokinetics of probe substrates for 5 major CYP enzymes that account for the 
metabolism of approximately 80% of prescribed drugs.(31, 32)  Results from this study 
demonstrated that ALN-AS1 treatment resulted in weak to moderate reduction in the metabolic 
activity of some of the 5 CYP enzymes studied, thereby leading to higher concentrations of some 
substrates and their metabolites.  Treatment with ALN-AS1 resulted in an approximately 3-fold 
increase in exposure (as measured by AUC) of caffeine (a sensitive substrate for CYP1A2) and 
an approximately 2-fold increase in exposure of dextromethorphan (a sensitive substrate for 
CYP2D6).  Exposure of midazolam (a sensitive substrate for CYP3A4) and omeprazole (a 
sensitive substrate for CYP2C19) increased less than 2-fold after treatment with ALN-AS1.  
There was no effect of ALN-AS1 treatment on losartan (a sensitive substrate for CYP2C9). 
1.7. 
Benefit-Risk Assessment 
Patients participating in this study may experience a reduced number or severity of porphyria 
attacks, reduced treatment with IV hemin, and/or reduced requirement for pain medication.  As 
presented in Section 1.6, emerging data demonstrate that patients given ALN-AS1 experienced 
reduced ALA/PBG levels, decreased attack frequency and reduced heme usage in the 24-week 
treatment period compared to the 12-week run-in period in Study ALN-AS1-001 
As detailed in Section 1.6, a fatal SAE of hemorrhagic pancreatitis was reported but deemed to 
be unlikely related to study drug.  However, the potentially non-adverse nonclinical finding of 
angiectasis in the islets of Langerhans (endocrine, not exocrine region) of the rat pancreas (see 
Investigator Brochure), do not exclude a potential association between ALN-AS1 and the SAE of 
hemorrhagic pancreatitis. 
The important potential risks associated with administration of ALN-AS1 in patients with AIP 
are as follows: 

Injection site reactions (ISRs):  ALN-AS1 is administered by SC injection.  In the
ongoing ALN-AS1 clinical study, AEs of ISRs have been infrequently reported and
have been mild to moderate in severity with single dosing.  Injection site rotation and
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close monitoring have been implemented in ALN-AS1 clinical studies to reduce the 
potential for ISRs.  
 Pancreatitis: Since an association between ALN-AS1 and the fatal SAE of 
hemorrhagic pancreatitis can not be ruled out, patients will undergo routine 
monitoring of systemic and pancreatic inflammation and coagulation throughout the 
study.  Hematology, chemistry and coagulation results are required to be available 
prior to each dose. 
 Liver transaminase abnormalities:  As ALN-AS1 is targeted for delivery to the liver, 
and reversible hepatic changes were observed in some animal species, there is a 
potential for development of liver function test (LFT) abnormalities.  To minimize the 
potential for LFT abnormalities, patients are required to have adequate liver function 
at study entry and LFTs are monitored during the study. 
 Anaphylactic reactions:  There is a potential risk of developing a severe allergic 
reaction with ALN-AS1 administration.  In the present study, one patient in the 
2.5 mg/kg monthly dose group with a history of asthma and multiple allergies 
experienced an SAE of anaphylactic reaction that was determined by the Investigator 
to be definitely related to study drug given the temporal relationship of ALN-AS1 
treatment to the onset of the reaction (within minutes).  The patient was treated and 
recovered and was discontinued from the study.  Guidance on dose administration 
and monitoring for anaphylactic reactions has been included in this protocol. 
The complete summary of the clinical and nonclinical data relevant to the investigational drug 
and its study in human subjects is provided in the Investigator’s Brochure. 
2. 
OBJECTIVES 
2.1. 
Primary Objective 
 Evaluate the long-term safety and tolerability of ALN-AS1 in patients with AIP 
2.2. 
Secondary Objectives 
 Assess the PD effect of ALN-AS1 over time 
 Assess the clinical activity of ALN-AS1 over time 
2.3. 
Exploratory Objectives 
 Characterize the PK profile of ALN-AS1 and incidence of ADA over time 
 Assess changes in health-related quality of life (QOL) 
 Characterize analytes related to targeting the heme biosynthesis pathway 
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3. 
ENDPOINTS 
3.1. 
Primary Endpoint 
 Patient incidence of AEs 
3.2. 
Secondary Endpoints 
 Change in urine ALA and PBG levels 
 Frequency and characteristics of porphyria attacks 
 Change in hemin administration 
3.3. 
Exploratory Endpoints 
 Change in circulating ALAS1 mRNA levels 
 Concentrations of ALN-AS1 and ADA  
 Duration and treatment of porphyria attacks 
 Number and duration of visits to a health care facility for acute porphyria care 
 EQ-5D-5L questionnaire scores 
 Pain assessment and narcotic use as recorded in a patient diary 
 Exploratory biomarkers related to the target pathway, such as urine porphyrins, 
vitamin D binding protein 
4. 
INVESTIGATIONAL PLAN 
4.1. 
Summary of Study Design 
This is a Phase 1/2 multicenter, open-label extension study to evaluate the long-term safety and 
clinical activity of ALN-AS1 in patients with AIP who completed study ALN-AS1-001.  The 
study will be conducted at up to 8 clinical study centers worldwide. 
The last assessments performed, determining previous study (ALN-AS1-001) completion, will 
serve as the Screening/Baseline assessments in this study.  If more than 60 days have elapsed 
since the last assessment, safety assessments (eg, ECG and clinical laboratory tests) will be 
repeated before administration of ALN-AS1.  It is anticipated that patients will begin ALN-AS1 
administration in this study within 6 months after the last dose of study drug in the previous 
study.  Eligibility will be confirmed during Screening/Baseline and before administration of the 
first dose of ALN-AS1 (Day 1).  Patients will undergo assessments at the clinical study center 
every month for the first 3 months.  Then, through Month 6, and according to the dosing regimen 
selected, assessments will take place at the clinical study center or via a phone contact (for an 
every month dosing regimen, visits will be every month; for an every 3 months dosing regimen, 
visits will be every 3 months; see Section 6.2.2).  After a patient has completed 12 months of 
ALN-AS1 administration in this study (6 months in an every month dosing regimen), and where 
applicable country and local regulations and infrastructure allow, study procedures, including 
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ALN-AS1 administration, may take place at the patient’s home by a healthcare professional (as 
indicated in the Schedules of Assessments in Table 1, Table 2, and Table 3; and Table 5, Table 6, 
and Table 7 in Appendix Section 11.2).  Study procedures may occur at the patient’s home at the 
discretion of the Investigator, based on safety and tolerability; however, patients are required to 
complete at least 1 visit at the clinical study center every 3 months for the first year, and 
thereafter every 6 months through the end of the treatment period.  Additional visits to collect 
clinical laboratory samples may occur at home at any point during the treatment period, within 
14 days prior to scheduled dose administration.  Patients will return to the clinical study center 
for a posttreatment follow-up visit after administration of the last dose of ALN-AS1.  An 
ALA/PBG Monitoring/EOS visit will be conducted either at the clinical study center or via 
phone contact, unless treatment continues with ALN-AS1. 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain 
assessments, and narcotic use.  Additionally, patients will be encouraged to report to the clinical 
study center if they experience a porphyria attack through Month 49.  In the event that patients 
are unable to report to the clinical study center during a porphyria attack, laboratory sample 
collection kits containing instructions for collecting and sending urine samples to the clinical 
study center, if possible, will be provided.  Patients will be contacted by phone after a porphyria 
attack to record attack details.  If patients are experiencing signs and symptoms of a porphyria 
attack when ALN-AS1 administration is scheduled, the Investigator will determine whether 
administration of ALN-AS1 is appropriate.  If patients are treated for a porphyria attack at a 
health care facility (eg, hospital, emergency department, infusion center, or outpatient clinic) 
other than the clinical study center, copies of medical records, including discharge summaries, 
will be requested.   
A Safety Review Committee (SRC) will review safety and tolerability data collected during the 
study with the primary purpose of protecting the safety of patients participating in the study (see 
Section 4.6). 
Patients may receive ALN-AS1 as long as they do not fulfill any of the study discontinuation 
criteria (see Section 5.3) or until ALN-AS1 is commercially available in the patient’s territory or 
the ALN-AS1 development program is discontinued (whichever comes first).  
All patients are asked to participate in a Posttreatment Follow-up visit after they have received 
their last dose of ALN-AS1. 
Figure 3: 
Study Design 
 
a Patients who discontinue treatment will be asked to complete an early termination (ET) visit at which all Month 49 
visit procedures will be performed; they must also return for a safety-follow-up visit 3 months (84 [+ 7] days) after 
their last dose of ALN-AS1. 
Screening
(Day -60 to -1)
Treatment Period
(up to 48 Months)a
End of Study
(Month 49)
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4.2. 
Duration of Treatment and Study 
The duration of treatment is up to 48 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 56 months.   
4.3. 
Number of Patients 
Up to 24 patients are planned for enrollment in this study (including optional cohorts in 
ALN-AS1-001). 
4.4. 
Method of Assigning Patients to Treatment Groups 
This is an open-label study; all patients will receive ALN-AS1.  A combination of the clinical 
study center number and screening number will create the unique patient identifier.  The clinical 
study center number will be assigned by the Sponsor.  Upon signing the Informed Consent Form 
(ICF), the patient will be assigned a screening number by the clinical study site, which will be 
the same unique patient identifier assigned in the previous study (ALN-AS1-001).  The 
Investigator, or delegate, will confirm that the patient fulfills all the inclusion criteria and none of 
the exclusion criteria. 
4.5. 
Blinding 
This is an open-label study, and all patients will receive ALN-AS1. 
4.6. 
Safety Review Committee 
An SRC will be involved in the conduct of this study.  The SRC has the responsibility for 
monitoring the safety of the study participants.  The SRC will perform periodic reviews of safety 
and tolerability data during the course of the clinical study at least every 3 months for the first 6 
months of the study and thereafter at least every 6 months.  The SRC may also meet on an ad hoc 
basis for review of emergent safety and tolerability data, as defined in the SRC Charter for this 
clinical study.  The SRC will not stop the study for efficacy. 
The SRC will be comprised of the following members:  Principal Investigator(s), or designee(s), 
the Sponsor Medical Monitor, and the Study Medical Monitor. 
The membership of the SRC and reporting structure are further defined in the SRC Charter. 
5. 
SELECTION AND WITHDRAWAL OF PATIENTS 
5.1. 
Inclusion Criteria 
Each patient must meet all of the following inclusion criteria to be eligible for enrollment in this 
study: 
1. Completed and, in the opinion of the Investigator, tolerated study drug dosing in Part C 
of study ALN-AS1-001 
2. Not on a scheduled regimen of hemin to prevent porphyria attacks at Screening 
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3. Women of child-bearing potential (WOCBP) must have a negative serum pregnancy test, 
cannot be breast feeding, and must be willing to use acceptable methods of contraception 
14 days before first dose, throughout study participation, and for 90 days after last dose 
administration.  Acceptable methods include hormonal methods along with an additional 
barrier method (eg, condom, diaphragm, or cervical cap), or a double barrier method of 
contraception for those WOCBP for whom a hormonal method of contraception is 
medically contraindicated due to underlying disease (see Section 6.4 for acceptable 
methods of contraception).   
4. Willing and able to comply with the study requirements and to provide written informed 
consent 
5.2. 
Exclusion Criteria 
Each patient must not meet any of the following exclusion criteria to be eligible for enrollment in 
this study: 
1. Alanine transaminase ≥2.0×ULN or total bilirubin ≥2 mg/dL (unless bilirubin elevation is 
due to Gilbert’s syndrome) 
2. Estimated glomerular filtration rate ≤30 mL/min/1.73 m2 (using the Modification of Diet 
in Renal Disease formula) 
3. History of multiple drug allergies or history of allergic reaction to an oligonucleotide or 
to N-acetyl galactosamine ligand (GalNAc) 
4. Received an investigational agent, other than ALN-AS1, or who are in follow-up of 
another clinical study of an investigational agent within 90 days before study drug 
administration 
5. Other medical conditions or comorbidities which, in the opinion of the Investigator, 
would interfere with study compliance or data interpretation 
5.3. 
Discontinuation of Study Drug and/or Study 
Patients or their legal guardians (in the case that the patient is a minor) are free to discontinue 
treatment and/or study or withdraw their consent at any time and for any reason, without penalty 
to their continuing medical care.  Any discontinuation of treatment or of the study must be fully 
documented in the electronic case report form (eCRF), and should be followed up by the 
Investigator.  The Investigator may withdraw a patient from the study at any time if this is 
considered to be in the patient’s best interest. 
Discontinuation of study drug and withdrawal from the study are described in Section 5.3.1 and 
Section 5.3.2, respectively.  If a patient stops participation from the study or withdraws consent 
from the study, he/she will not be able to re-enroll in the study. 
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5.3.1. 
Discontinuation of Study Drug 
The Investigator or designee may discontinue dosing in a patient if the patient: 
 Is in violation of the protocol 
 Experiences a SAE considered to be possibly or definitely related to the study drug or 
an intolerable AE  
 Becomes pregnant 
 Is found to be considerably noncompliant with the protocol-requirements 
Patients who are pregnant will be discontinued from study drug dosing immediately (see 
Section 7.5.6.6 for reporting and follow-up of pregnancy).  A positive urine pregnancy test 
should be confirmed by a serum pregnancy test prior to discontinuing the study drug. 
If a patient discontinues dosing due to a serious adverse event (SAE), the SAE should be 
followed as described in Section 7.5.6.  When a patient discontinues study drug dosing, the 
primary reason must be recorded in the electronic case report form (eCRF).  Patients who 
discontinue study drug and remain on study may receive treatment consistent with local standard 
practice for their disease per Investigator judgement, as applicable. 
Patients who discontinue treatment will be asked to complete an early termination (ET) visit at 
which all Month 49 visit procedures will be performed; they must also return for a safety-follow-
up visit 3 months (84 [+ 7] days) after their last dose of ALN-AS1. 
5.3.2. 
Discontinuation from the Study 
A patient or their legal guardian may decide to stop the patient’s participation in the study at any 
time.  Patients considering to stop the study should be informed that they can discontinue 
treatment and complete study assessments including follow-up, as per the SOA, or alternatively 
may complete any minimal assessments for which the patient consents. The Investigator may 
withdraw a patient at any time if this is considered to be in the patient’s best interest. 
However, study integrity and interpretation is best maintained if all randomized patients continue 
study assessments and follow-up.  Stopping study participation could mean: 
 If a patient discontinues from the study, he/she will be asked to complete an early 
termination (ET) visit at which all Month 49 visit procedures will be performed; 
the patient must also return for a safety-follow-up visit at 3 months (84 [+7] days) 
after his/her last dose of ALN-AS1. 
 A patient can stop taking the study drug and stop study-related visits, but allow 
the investigator and study team to review the patient’s medical records, public 
records or be contacted in order to receive information about the patient’s health 
When a patient stops the study, the discontinuation and reason for discontinuation must be 
recorded in the appropriate section of the electronic case report form (eCRF) and all efforts will 
be made to complete and report the observations as thoroughly as possible.  If a patient stops the 
study due to an adverse event (AE), including an SAE, the AE should be followed as described 
in Section 7.5.6. 
If the patient wants to stop participation in the study, he/she should notify the study doctor in 
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writing or in any other form that may be locally required. The personal data already collected 
during the study, including patient’s biological samples, will still be used together with the data 
collected on other patients in the study according to the informed consent and applicable laws. 
In addition to stopping participation in the study, the patient could decide to withdraw his/her 
consent as explained in Section 5.3.3 
5.3.3. 
Withdrawal of Consent to Collect and Process the Patient’s Personal Data 
The patient may decide to withdraw his/her consent informing the study doctor at any time in 
writing, or in any other form that may be locally required.  This means that the patient wants to 
stop participation in the study and any further collection of his/her personal data.  
 The sponsor will continue to keep and use a patient's study information (including 
any data resulting from the analysis of the patient's biological samples until time 
of withdrawal) according to applicable law.  This is done to guarantee the validity 
of the study, determine the effects of the study treatment, and ensure 
completeness of study documentation. 
 The patient can also request that collected samples be destroyed or returned (to 
the extent it is permitted by applicable law) at any time. 
 Patients who withdraw their consent to collect and use personal data should 
understand that public records may be reviewed to determine the patient’s 
survival status as allowed per local and national regulations.    
In US and Japan, otherwise, samples not yet analyzed at the time of withdrawal may still be used 
for further testing/analysis in accordance with the terms of the protocol and of the informed 
consent form. 
In EU and rest of world, in any event, samples not yet analyzed at the time of withdrawal will 
not be used any longer, unless permitted by applicable law. They will be stored or destroyed 
according to applicable legal requirements. 
5.3.4. 
Replacement of Patients 
Patients discontinuing from study drug or withdrawing from the study will not be replaced. 
6. 
TREATMENTS 
6.1. 
Treatments Administered 
ALN-AS1 Solution for Injection (SC use) is a clear, colorless to pale yellow solution essentially 
free of particulates.  ALN-AS1 will be supplied by the Sponsor as a sterile solution for SC 
injection. 
Study drug supplied for this study must not be used for any purpose other than the present study 
and must not be administered to any person not enrolled in the study.  Study drug that has been 
dispensed to a patient and returned unused must not be re-dispensed to a different patient. 
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6.2. 
Investigational Study Drug 
Detailed information describing the preparation, handling, and storage, packaging and labeling, 
as well as study drug accountability for ALN-AS1 is provided in the Pharmacy Manual. 
6.2.1. 
Description 
ALN-AS1 Solution for Injection (SC use) is comprised of a synthetic, siRNA targeting ALAS1 
and bearing a triantennary GalNAc ligand conjugated to the sense strand, formulated in 
phosphate buffer.  
6.2.2. 
Dose and Administration 
The study starting dose of ALN-AS1 is 5.0 mg/kg ALN-AS1 as an SC injection administered 
every 3 months (Table 1, Table 2, and Table 3). Based on emerging clinical data, the SRC may 
approve changes to the ALN-AS1 dosing regimen, including decreases in the dose level and 
changes in dosing frequency (Table 5, Table 6, and Table 7 in Section 11.2).  However, any dose 
and dosing regimen will not exceed a previously explored dose level or frequency that was 
determined to be safe and well-tolerated in study ALN-AS1-001. SRC, Health Authority and 
Ethics Committee approval must be sought prior to dose level escalation above 5.0 mg/kg in 
accordance with local Regulatory requirements.  See Section 6.2.3 for details on dose 
modifications. 
ALN-AS1 will be administered by a qualified and authorized health care professional trained in 
the recognition and management of anaphylactic reactions.  The study drug should be injected 
into the abdomen or upper arms or thighs.  Detailed instructions for study drug administration are 
presented in the Pharmacy Manual. As is consistent with good medical practice for subcutaneous 
drug administration, patients will be observed for a minimum of 20 minutes after each injection.   
Treatment for anaphylactic reactions should be readily available where patients are being dosed, 
and follow country and/or local hospital treatment guidelines as shown in Table 8.(33) 
After a patient has completed 12 months of ALN-AS1 administration in this study (6 months in 
an every month dosing regimen), study drug administration may be conducted at a location other 
than the study center by a home healthcare professional, where applicable country and local 
regulations and infrastructure allow, after consultation with the medical monitor, during 
particular study visits, as specified in the Schedules of Assessments.  However, study drug 
administration at the study center should be considered for patients who have ongoing study 
drug-related AEs or known risk factors for developing anaphylactic reaction, including but not 
limited to: a prior history of anaphylactic reaction to food, medications or due to unknown 
etiology, worsening injection site reactions with repeat dosing, or anyone in the opinion of the 
investigator that would benefit from clinical observation following dosing.  Patients are required 
to complete at least 1 visit at the clinical study center every 3 months for the first year, and 
thereafter every 6 months through the end of the treatment period.  Additional visits to collect 
clinical laboratory samples may occur at home at any point during the treatment period, within 
14 days prior to scheduled dose administration. 
If a patient does not receive a dose of ALN-AS1 within the specified dosing window, the 
Investigator should contact the Medical Monitor.  After such consultation, the dose may be 
administered or considered missed and not administered. 
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Patients will be permitted to miss an occasional dose of study drug; however, if a patient misses 
2 consecutive doses, the Investigator, in consultation with the Medical Monitor, will discuss 
whether the patient will be able to continue on the study.  
Detailed instructions for study drug administration are found in the Pharmacy Manual. 
6.2.3. 
Dose Modifications 
6.2.3.1. 
Study Population Dose Modifications 
During the study, dose modifications are permitted for the study population, or based on the dose 
cohort into which patients were originally randomized in study ALN-AS1-001.  Following SRC 
review of emerging safety and tolerability data from Part C of study ALN-AS1-001, or from this 
study (ALN-AS1-002), the dose and dosing regimen may be modified.  However, the dose and 
dosing regimen of ALN-AS1 will not exceed a previously explored dose and dosing regimen that 
was determined to be safe and well-tolerated in study ALN-AS1-001.  Patients enrolling in this 
study after a dose modification decision has been implemented may start at the newly identified 
dose and regimen. 
6.2.3.2. 
Individual Dose Modifications 
Dose modifications are permitted for individual patients.  If a patient has a study drug related AE 
of a recurrent ISR, severe ISR, or clinically significant LFT abnormality and the Investigator has 
concerns regarding further ALN-AS1 administration, the Medical Monitor and Investigator will 
review all available safety data for the patient.  Based on this review, a dose reduction to half the 
previously administered dose (eg, a 5.0 mg/kg dose would be reduced to a 2.5 mg/kg dose) or a 
reduction in dosing frequency from monthly to every 3 months is permitted.  Subsequent ALN-
AS1 administration at the previous dose may be considered based on the judgment of the 
Investigator and Medical Monitor. 
6.2.3.2.1. Monitoring and Dosing Rules in Patients with Potential Cases of Anaphylactic 
Reaction   
An anaphylactic reaction is a severe, potentially fatal, systemic allergic reaction with acute onset 
(minutes to hours).  For reference see Section 11.3.(33) 
Stop administering the study medication immediately if an anaphylactic reaction to the study 
medication is suspected.  Study medication must be permanently discontinued in patients for 
whom an anaphylactic reaction is assessed as related to the study medication. 
Laboratory testing: Obtain blood sample for tryptase, total IgE, and ADA antidrug antibodies 
(ADA) ideally within 15 minutes to 3 hours after the onset of a suspected anaphylactic reaction; 
however, up to 6 hours is acceptable.  An additional blood sample to assess tryptase, total IgE, 
and ADA should be obtained between 1 to 2 weeks from onset of event.  Local laboratory may 
be used to analyze samples; however, parallel samples should be sent to the central laboratory for 
analysis.  Sample collection and shipping instructions are included in the Laboratory Manual. 
Reporting: The PI or designee must notify the sponsor or designee within 24 hours of the 
occurrence of a suspected case of anaphylactic reaction or being informed of the case as required 
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for AEs of Clinical Interest (AECI) and SAEs, per AE reporting requirements (Section 7.5.6.1,  
Section 7.5.6.2 and 7.5.6.3). 
6.2.4. 
Preparation, Handling, and Storage 
Staff at each clinical study center or the home healthcare professional will be responsible for 
preparation of ALN-AS1 doses, according to procedures detailed in the Pharmacy Manual.  No 
special procedures for the safe handling of study drug are required. 
Study drug will be stored upright and refrigerated at approximately 5±3°C.  Any deviation from 
the recommended storage conditions should be reported to the Sponsor and use of the study drug 
halted until authorization for its continued use has been provided by the Sponsor or designee. 
A Sponsor representative or designee will be permitted, upon request, to audit the supplies, 
storage, dispensing procedures, and records. 
6.2.5. 
Packaging and Labeling 
All packaging, labeling, and production of study drug will be in compliance with current Good 
Manufacturing Practice specifications, as well as applicable local regulations.  Study drug labels 
and external packaging will include all appropriate information as per local labeling 
requirements. 
Additional details will be available in the Pharmacy Manual. 
6.2.6. 
Accountability 
The Investigator or designee will maintain accurate records of receipt and the condition of the 
study drug supplied for this study, including dates of receipt.  In addition, accurate records will 
be kept of when and how much study drug is dispensed and administered to each patient in the 
study.  Any reasons for departure from the protocol dispensing regimen must also be recorded. 
At the completion of the study, there will be a final reconciliation of all study drugs.  All used, 
partially used, and unused study drug will be returned to the Sponsor (or designee) or destroyed 
at the clinical study center according to applicable regulations.   
Further instructions about drug accountability are detailed in the Pharmacy Manual. 
6.3. 
Concomitant Medications 
Use of concomitant medications will be recorded on the patient’s case report form (CRF) as 
indicated in the Schedules of Assessments (Table 1, Table 2, and Table 3; and Table 5, Table 6, 
and Table 7 in Appendix Section 11.2).  This includes all prescription medications, herbal 
preparations, over the counter (OTC) medications, vitamins, and minerals.  Any changes in 
medications during the study will also be recorded on the CRF. 
Any concomitant medication that is required for the patient’s welfare may be administered by the 
Investigator.  However, it is the responsibility of the Investigator to ensure that details regarding 
the medication are recorded on the eCRF.  Concomitant medication will be coded using an 
internationally recognized and accepted coding dictionary. 
Patients with porphyria could have altered hepatic heme synthesis, and treatment with ALN-AS1 
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could also modulate this pathway and secondarily impact CYP enzyme activity.  Results from a 
DDI study in AIP patients who are ASHE are presented in Section 1.6.4.  The DDI study 
demonstrated that ALN-AS1 treatment resulted in weak to moderate reduction in activity in 
some of the CYP enzymes resulting in corresponding low to moderate increase in the plasma 
levels of drugs that are metabolized by these CYP enzymes.  Based on the moderate decrease in 
CYP2D6 or CYP1A2 activity, investigators will review all concomitant medications that are 
primarily metabolized by these enzymes and monitor the patient’s clinical response to these 
medications during the study.  Medications metabolized primarily by CYP2D6 and CYP1A2 
with a narrow therapeutic index (ie that require regular laboratory monitoring) may need to be 
monitored more frequently to determine if a dose adjustment of the concomitant medication is 
required.  For patients who require new medications while on study, selection of medications that 
are not primarily metabolized by CYP2D6 or CYP1A2 should be considered.  Refer to the 
individual product’s prescription information to determine if there is a need to monitor 
concomitant medications for differences in safety or efficacy of the medication based on reported 
DDIs with CYP2D6 or CYP1A2.  For more detailed and up-to-date information on CYP 
substrates, see: 
https://www.fda.gov/drugs/developmentapprovalprocess/developmentresources/druginteractionsl 
abeling/ucm093664.htm. 
Patients are not permitted to be on hemin prophylaxis at Screening; however, patients are 
permitted to receive concomitant hemin treatment for the management of acute porphyria 
attacks.  Patients experiencing significant breakthrough attacks while enrolled in this study, 
necessitating frequent hemin treatment, may receive hemin prophylaxis if in the Investigator’s 
judgment this is clinically beneficial to the patient.  The Investigator should contact with the 
Sponsor and Medical Monitor before prophylactic hemin treatment.  The dose, regimen, and 
dates of administration will be recorded on the patient’s eCRF.   
Pain medication (eg, opiates, opioids, narcotic analgesics) and glucose administration are 
permitted for the management of porphyria and for acute porphyria attacks. 
If patients use nonsteroidal anti-inflammatory medications intermittently or chronically, they 
must have been able to tolerate them with no previous side effects (eg, gastric distress or 
bleeding).   
Standard vitamins and topical medications are permitted; however, topical steroids must not be 
applied anywhere near the injection site(s) unless medically indicated. 
6.4. 
Contraceptive Requirements 
No data are available on the use of ALN-AS1 in pregnancy; however, there is no suspicion of 
human teratogenicity based on class effects or genotoxic potential.  ALN-AS1 was neither 
genotoxic nor clastogenic in in vitro and in vivo studies.   
WOCBP must be willing to use acceptable methods of contraception 14 days before first dose, 
throughout study participation, and for 90 days after last dose administration.   
Birth control methods which may be considered as acceptable include: 

Established use of oral, implantable, injectable, transdermal hormonal, or intrauterine
hormone-releasing system as methods of contraception.  WOCBP using hormonal
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methods of contraception must also use a barrier method (condom or occlusive cap 
[diaphragm or cervical/vault cap] in conjunction with spermicide [eg, foam, gel, film, 
cream, or suppository]). 
 If hormonal methods of contraception are medically contraindicated for WOCBP due 
to underlying disease, a double-barrier method (combination of male condom with 
either cap, diaphragm, or sponge, in conjunction with spermicide) is also considered 
an acceptable method of contraception. 
 Placement of an intrauterine device  
 Bilateral tubal occlusion 
 Surgical sterilization of male partner (with the appropriate post-vasectomy 
documentation of the absence of sperm in the ejaculate; for female patients on the 
study, the vasectomized male partner should be the sole partner for that patient) 
 Sexual abstinence, when this is in line with the preferred and usual lifestyle of the 
patient, is considered an acceptable method only if defined as refraining from 
heterosexual intercourse during the entire period of risk associated with the study 
drug (defined above).  Periodic abstinence (eg, calendar, ovulation, symptothermal, 
post-ovulation methods) and withdrawal are not considered sexual abstinence and do 
not meet criteria for an acceptable method of birth control.  As determined by the 
investigator, the reliability of sexual abstinence needs to be evaluated in relation to 
the duration of the clinical trial and the preferred and usual lifestyle of the patient.  
Abstinent patients must agree to use 1 of the abovementioned contraceptive methods 
if they start a heterosexual relationship during the study and continue to do so for the 
entire period of risk associated with the study drug (defined above). 
 WOCBP includes any female patient who has experienced menarche and who is not 
postmenopausal or permanently sterilized (eg, bilateral tubal occlusion, hysterectomy, 
or bilateral salpingectomy).  Postmenopausal state is defined as no menses for 12 
months without an alternative medical cause, confirmed by follicle stimulating 
hormone level within the postmenopausal range. 
6.5. 
Treatment Compliance 
Compliance with study drug administration will be verified through observation by study 
personnel or trained home healthcare professionals.  
7. 
STUDY ASSESSMENTS 
The schedules of study assessments are provided in Table 1, Table 2, and Table 3; and Table 5, 
Table 6, and Table 7.  
7.1. 
Screening/Baseline Assessments 
Informed consent, patient demographic data, and eligibility criteria will be confirmed at 
Screening/Baseline.  An interval medical history/disease history will be obtained at 
Screening/Baseline.  The last assessments performed, determining previous study 
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(ALN-AS1-001) completion, will serve as the Screening/Baseline assessments in this study.  If 
more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs will 
be repeated before administration of ALN-AS1. 
7.2. 
Clinical Activity Assessments 
The clinical activity of ALN-AS1 will be assessed by the frequency and characteristics of 
porphyria attacks including, but not limited to, duration, treatment, and severity of porphyria 
attacks and number and duration of visits to a health care setting for acute porphyria care (eg, 
hospital, emergency department, infusion center, or outpatient clinic).  Concomitant hemin 
administration will also be recorded. 
7.2.1. 
Patient Diary 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain 
assessments, and narcotic use. 
7.2.2. 
Brief Pain Inventory-Short Form Questionnaire 
The Brief Pain Inventory-Short Form (BPI-SF) questionnaire will be used to evaluate pain.(34)  
The BPI will be completed as part of the patient diary. 
7.3. 
Pharmacodynamic Assessments 
Blood and urine samples will be collected for assessment of ALN-AS1 PD parameters.  The PD 
effect of ALN-AS1 will be evaluated by urine ALA and PBG levels.  Blood and urine samples 
will be collected for assessment of circulating ALAS1 mRNA levels in serum and in urine.  
Analysis for blood and urine PD parameters will take place at a central laboratory.   
Details regarding the processing and aliquoting of samples for storage and analyses will be 
provided in the Laboratory Manual. 
7.4. 
Pharmacokinetic Assessments 
Blood samples will be collected to evaluate the PK profile of ALN-AS1 at the time points in the 
Schedule of Assessments.  A detailed schedule of time points for the collection of blood samples 
for PK analysis is in Table 4 in Appendix Section 11.1). 
The concentration of ALN-AS1 will be determined using a validated assay.  Details regarding 
the processing, shipping, and analysis of the samples will be provided in the Laboratory Manual. 
7.5. 
Safety Assessments 
The assessment of safety during the course of the study will consist of the surveillance and 
recording of AEs including SAEs, recording of concomitant medications and measurements of 
vital signs, physical examination, and ECG findings and clinical laboratory evaluations. 
Safety will be monitored over the course of the study by an SRC as described in Section 4.6. 
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7.5.1. 
Vital Signs 
Vital sign measurements include blood pressure, heart rate, body temperature, and respiratory 
rate.  Vital signs will be measured in the seated or supine position (should be consistent for each 
patient), after the patient has rested comfortably for at least 10 minutes.  Blood pressure should 
be taken using the same arm throughout the study.  Body temperature will be obtained in degrees 
Celsius, heart rate will be counted for a full minute and recorded in beats per minute, and 
respiration rate will be counted for a full minute and recorded in breaths per minute. 
For the safety of the patient, additional vital sign assessments may be added at the discretion of 
the Investigator. 
7.5.2. 
Weight and Height 
Height will be measured in centimeters at the Screening/Baseline visit only.  Body weight will be 
measured in kilograms.  Body mass index will be calculated in the database. 
Body weight measured on the dosing day will be used to calculate the dose of ALN-AS1 through 
M12.  After M12, weight measured at either the previous study center visit or current study 
center visit may be used for dosing calculations. 
7.5.3. 
Physical Examination 
Complete physical examinations will include the examination of the following:  general 
appearance, head, eyes, ears, nose and throat, chest/respiratory, heart/cardiovascular, 
gastrointestinal/liver, musculoskeletal/extremities, dermatological/skin, thyroid/neck, lymph 
nodes, and neurological/psychiatric. 
Targeted physical examinations will include the examination of the following:  general 
appearance, chest/respiratory, heart/cardiovascular, gastrointestinal/liver, and 
neurological/psychiatric. 
7.5.4. 
Electrocardiogram 
Triplicate standard 12-lead ECGs will be performed using central ECG equipment, with readings 
approximately 1 minute apart and recorded as specified in the Schedule of Assessments.  Patients 
should be seated or supine for at least 5 minutes before each ECG is obtained.  The 
electrophysiological parameters assessed will be rhythm, ventricular rate, PR interval, QRS 
duration, QT interval, ST and T waves, Bazett-corrected QT interval (QTcB), and Fridericia 
corrected QT interval (QTcF). 
When ECG and blood sample collection occur at the same time, ECGs should be performed 
before blood samples are drawn. 
Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine 
position after the patient has rested comfortably for at least 5 minutes.   
In all patients receiving ≤2.5 mg/kg ALN-AS1, it is required that ECGs will be obtained on at 
least 2 separate clinic visits (D1, and Months 3, 6, 9, 12, 15, or 18), each of which will include 
same day predose and 2-hour (±15 minutes) postdose readings, paired with PK timepoints 
(Table 4) as specified in the Schedule of Assessments.   
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Similarly, in all patients receiving >2.5 mg/kg ALN-AS1, it is required that ECGs will be 
obtained on at least 2 separate clinic visits (D1, and Months 3, 6, 9, 12, 15, or 18), each of which 
will include same day predose and 4-hour (±20 minutes) postdose readings, paired with PK 
timepoints (Table 4), as specified in the Schedule of Assessments.  
The Investigator or designee is responsible for reviewing the ECGs to assess whether the results 
have changed since the Screening/Baseline visit and to determine the clinical relevance of the 
results.  These assessments will be recorded on the eCRF.  For any clinically relevant ECG 
changes from the Screening/Baseline visit (eg, ischemic ECG changes, wave/interval changes, or 
arrhythmia), the Investigator must contact the Medical Monitor to discuss continued participation 
of the patient in the study. 
7.5.5. 
Clinical Laboratory Assessments 
The following clinical laboratory tests will be evaluated by a central laboratory.  
On dosing days up to the Month 18 visit, results from hematology, chemistry, and coagulation 
tests collected within the prior 14 days must be reviewed by the Investigator before study drug 
administration.  These results can be analyzed centrally or at a local laboratory.  If results from 
within the prior 14 days are not available at a dosing visit (at visits from D1 to Month 18), 
locally analyzed assessments must be reviewed to allow same day study drug administration and 
additional samples for central analysis must also be collected.  On dosing days from Month 19 
through Month 48, a review of laboratory results within 14 days is not required.   
In the event of an unexplained clinically relevant abnormal laboratory test occurring after study 
drug administration, the test should be repeated and followed up at the discretion of the 
Investigator until it has returned to the normal range or stabilized, and/or a diagnosis is made to 
adequately explain the abnormality. 
At any point during the study, and based on Investigator judgment, if a patient experiences 
uncharacteristic signs and symptoms during a porphyria attack, lipase testing should be 
performed and imaging evaluations (eg, right upper quadrant ultrasound and/or other testing, 
based on Investigator judgment) should be considered by the Investigator.  Signs and symptoms 
include, but are not limited to, uncharacteristic abdominal pain and worsening nausea and 
vomiting. 
Imaging is required for any serum lipase result of ≥3× the upper limit of normal, or as clinically 
indicated. 
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Hematology 
Complete blood count with differential 
 
Serum Chemistry 
Sodium 
Potassium 
BUN 
Phosphate 
Creatinine and eGFRa 
Albumin 
Uric acid 
Calcium 
Total protein 
Carbon dioxide 
Glucose 
Chloride 
Lipase 
Bicarbonate 
Liver Function Tests 
 
AST 
ALP 
ALT 
Bilirubin (total and direct) 
GGT 
 
Urinalysis 
Visual inspection for appearance and color 
Bilirubin 
pH (dipstick) 
Nitrite 
Specific gravity 
RBCs 
Ketones 
Urobilinogen 
Albumin 
Leukocytes 
Glucose 
Microscopy (if clinically indicated) 
Protein 
 
Immunogenicity 
Antidrug antibodies 
Coagulation 
Prothrombin time 
International Normalized Ratio 
Pregnancy Testing (WOCBP only) 
β-human chorionic gonadotropin 
 
Inflammation 
 
C-reactive protein 
 
Abbreviations:  AST=aspartate transaminase; ALP=alkaline phosphatase; ALT=alanine transaminase; 
BUN=blood urea nitrogen; eGFR=estimated glomerular filtration rate; GGT=gamma-glutamyltransferase; 
WOCBP=women of child bearing potential. 
a eGFR will be calculated using the Modification of Diet in Renal Disease formula.(35) 
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7.5.5.1. 
Immunogenicity 
Blood samples will be collected to evaluate antidrug antibodies.  On days when ALN-AS1 is 
administered, blood samples for antidrug antibody testing must be collected before ALN-AS1 is  
administered. 
Sample collection for patients who experience a potential anaphylactic reaction is discussed in 
Section 6.2.3.2.1. 
Details regarding the processing, shipping, and analysis of the samples will be provided in the 
Laboratory Manual. 
7.5.5.2. 
Pregnancy Testing 
A pregnancy test will be performed for WOCBP only.  A serum pregnancy test will be 
performed at Screening/Baseline and urine pregnancy tests will be performed thereafter per the 
Schedule of Assessments and any time pregnancy is suspected.  Urine pregnancy tests may also 
be performed more frequently (eg, monthly) based on local country requirements.  The results of 
the pregnancy test must be known before study drug administration.  Patients who are pregnant 
are not eligible for study participation.  Any woman with a positive pregnancy test during the 
study will be discontinued from study drug, but will continue to be followed for safety.  Patients 
determined to be pregnant while on study will be followed until the pregnancy outcome is known 
(see Section 7.5.6.6 for follow-up instructions).  
7.5.6. 
Adverse Events 
7.5.6.1. 
Definitions 
Adverse Event 
According to the ICH E2A guideline Definitions and Standards for Expedited Reporting, and 21 
Code of Federal Regulations 312.32, Investigational New Drug Safety Reporting, an AE is any 
untoward medical occurrence in a patient or clinical investigational subject administered a 
medicinal product and which does not necessarily have a causal relationship with this treatment. 
Serious Adverse Event 
An SAE is any untoward medical occurrence that at any dose: 
 Results in death 
 Is life-threatening (An event which places the patient at immediate risk of death from 
the event as it occurred.  It does not include an event that had it occurred in a more 
severe form might have caused death) 
 Requires in-patient hospitalization or prolongation of existing hospitalization 
 Results in persistent or significant disability or incapacity 
 Is a congenital anomaly or birth defect 
 Is an important medical event that may not be immediately life-threatening or result 
in death or hospitalization but may jeopardize the patient and may require 
intervention to prevent one of the other outcomes listed in the definition above (eg, 
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events include allergic bronchospasm requiring intensive treatment in an emergency 
room or at home, blood dyscrasias, convulsions, or the development of drug 
dependency or abuse). 
Adverse Event Severity 
Adverse events are to be graded according to the categories detailed below: 
Mild: 
Mild events are those which are easily tolerated with no disruption of normal 
daily activity. 
Moderate: 
Moderate events are those which cause sufficient discomfort to interfere with 
normal daily activities. 
Severe: 
Severe events are those which incapacitate and prevent usual activity. 
Changes in severity should be documented in the medical record to allow assessment of the 
duration of the event at each level of severity.  AEs characterized as intermittent require 
documentation of the start and stop of each incidence.  When changes in the severity of an AE 
occur more frequently than once a day, the maximum severity for the experience that day should 
be noted.  If the severity category changes over a number of days, then those changes should be 
recorded separately (with distinct onset dates) 
AE severity and seriousness are assessed independently.  ‘Severity’ characterizes the intensity of 
an AE.  ‘Serious’ is a regulatory definition and serves as a guide to the Sponsor for defining 
regulatory reporting obligations (see definition for Serious Adverse Event). 
Relationship of the Adverse Event to Study Treatment 
The relationship of each AE to study treatment should be evaluated by the Investigator using the 
following criteria:  
Definitely related: 
A clinical event, including laboratory test abnormality, occurring in a 
plausible time relationship to the medication administration, and which 
cannot be explained by concurrent disease or other drugs or chemicals.  
The response to withdrawal of the drug should be clinically plausible. 
Possibly related: 
A clinical event, including laboratory test abnormality, with a 
reasonable time sequence to the medication administration, but which 
could also be explained by concurrent disease or other drugs or 
chemicals.  Information on the drug withdrawal may be lacking or 
unclear. 
Unlikely related: 
A clinical event, including laboratory test abnormality, with little or no 
temporal relationship to medication administration, and which other 
drugs, chemicals, or underlying disease provide plausible explanations. 
Not related: 
A clinical event, including laboratory test abnormality that has no 
temporal relationship to the medication or has more likely alternative 
etiology. 
Adverse Events of Clinical Interest 
The following events are considered to be adverse events of clinical interest: 
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 ISRs 
 Hepatic AEs, including LFT abnormalities considered clinically significant by the 
Investigator. 
 Lipase >3×ULN (or >3× the baseline lipase measurement if baseline is >ULN) 
 Anaphylactic Reactions. Anaphylactic reaction is a severe, potentially fatal, systemic 
allergic reaction with acute onset (minutes to hours).  Symptoms of an anaphylactic 
reaction may include skin or mucosal tissue (e.g. generalized hives, pruritus, 
angioedema), respiratory compromise (e.g. wheezing, bronchospasm, hypoxia), 
reduced blood pressure or associated symptoms (e.g. syncope, hypotonia).  See 
Section 11.3 (Table 8) for guidance on diagnosing anaphylactic reactions.(33) 
7.5.6.2. 
Eliciting and Recording Adverse Events 
Eliciting Adverse Events 
The patient should be asked about medically relevant changes in his/her health since the last 
visit.  The patient should also be asked if he/she has been hospitalized, had any accidents, used 
any new medications, or changed concomitant medication routines (both prescription and OTC).  
In addition to patient observations, AEs will be documented from any clinically relevant 
laboratory findings, physical examination findings, ECG changes, or other findings that are 
relevant to patient safety. 
Recording Adverse Events 
The Investigator is responsible for recording non-serious AEs that are observed or reported by 
the patient after administration of the first dose of study drug regardless of their relationship to 
study drug through the end of study.  Non-serious AEs will be followed until the end of study.  
The Investigator is responsible for recording SAEs that are observed or reported by the patient 
after the time when the informed consent is signed regardless of their relationship to study drug 
through the end of study.  SAEs will be followed until satisfactory resolution, until baseline level 
is reached, or until the SAE is considered by the Investigator to be chronic or the patient is 
stable, as appropriate. 
All AEs must be recorded in the source records for the clinical study center and in the eCRF for 
the patient, whether or not they are considered to be drug-related.  Each AE must be described in 
detail:  onset time and date, description of event, severity, relationship to investigational drug, 
action taken, and outcome (including time and date of resolution, if applicable). 
For SAEs, record the event(s) on the eCRF.  If the electronic data capture (EDC) system is 
unavailable, complete the backup SAE form. 
For AEs that are considered AEs of clinical interest, the Sponsor or its designee should be 
notified within 24 hours using a supplemental AEs of clinical interest (AECI) eCRF.  Additional 
clinical and laboratory information may be collected based upon the severity or nature of the 
event. 
If a patient has ISRs meeting any of the following criteria, the Investigator or delegate should 
contact the Medical Monitor and submit a supplemental ISR eCRF: 
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 ISRs that are recurrent and/or demonstrate a pattern of increasing severity 
 Any ISR that is determined to be severe and/or a cause for study drug discontinuation  
 Any ISR which, in the opinion of the Investigator, requires further medical evaluation or 
treatment 
In some cases, where it is medically appropriate, further evaluation may include photographs, 
referral to a dermatologist, skin biopsy, or other laboratory testing.  If a biopsy was obtained, the 
Sponsor may request that the biopsy also be reviewed by a central dermatopathologist.  To better 
understand the safety profile of the study drug, additional analysis of biopsy tissue may be 
performed according to local regulations. 
For patients with hepatic AEs, additional information, including, clinical history, course of event, 
and local laboratory results to monitor LFT levels or other laboratory parameters, may be 
collected. 
7.5.6.3. 
Serious Adverse Events Require Immediate Reporting to Sponsor/Designee 
An assessment of the seriousness of each AE will be made by the Investigator.  Any AE and 
laboratory abnormality that meets the SAE criteria in Section 7.5.6.1 must be reported to the 
Sponsor or designee within 24 hours from the time that clinical study center personnel first 
learns of the event.  All SAEs must be reported regardless of the relationship to study drug. 
The initial report should include at least the following information: 
 Patient’s study number 
 Description and date of onset of the event 
 Criterion for serious 
 Preliminary assignment of relationship to study drug 
 Investigator/clinical study center information 
To report the SAE, complete the eCRF.  If the EDC system is unavailable, complete the backup 
SAE form.  Within 24 hours of receipt of follow-up information, the Investigator must update the 
report.  SAEs must be reported using the contact information provided in the Study Manual. 
Appropriate remedial measures should be taken by the Investigator using his/her best medical 
judgment to treat the SAE.  These measures and the patient’s response to these measures should 
be recorded.  All SAEs, regardless of relationship to study drug, will be followed by the 
Investigator until satisfactory resolution or the Investigator deems the SAE to be chronic or 
stable.  Clinical, laboratory, and diagnostic measures should be employed by the Investigator as 
needed to adequately determine the etiology of the event. 
7.5.6.4. 
Sponsor Safety Reporting to Regulatory Authorities 
The Sponsor or its representative is required to report certain study events in an expedited 
manner to the Food and Drug Administration, the European Medicines Agency’s EudraVigilance 
electronic system according to Directive 2001/20/EC, and to all country Regulatory Authorities 
where the study is being conducted, according to local applicable regulations. 
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The following describes the safety reporting timeline requirements for suspected unexpected 
serious adverse reactions (SUSARs) and other reportable events: 
Immediately and within 7 calendar days 
 Any suspected adverse reaction that is associated with the use of the study drug, 
unexpected, and fatal or life threatening.  Follow-up information must be reported in 
the following 8 days. 
Immediately and within 15 calendar days 
 Any suspected adverse reaction that is associated with the use of the study drug, 
unexpected, and serious, but not fatal or life threatening, and there is evidence to 
suggest a causal relationship between the study drug and the reaction. 
 Any finding from tests in laboratory animals that suggest a significant risk for human 
patients including reports of mutagenicity, teratogenicity, or carcinogenicity. 
 Any event in connection with the conduct of the study or the development of the 
study drug that may affect the safety of the trial patients. 
In addition, periodic safety reporting to regulatory authorities will be performed by the Sponsor 
or its representative according to national and local regulations. 
7.5.6.5. 
Serious Adverse Event Notification to the Institutional Review 
Board/Independent Ethics Committee 
SUSARs will be reported to the Institutional Review Board (IRB)/Independent Ethics 
Committee (IEC) per their institutional policy by the Investigator or Sponsor (or Sponsor 
designee) according to country requirements.  Copies of each report and documentation of 
IRB/IEC notification and acknowledgement of receipt will be kept in the Investigator’s study 
file. 
7.5.6.6. 
Pregnancy Reporting 
If a female patient becomes pregnant during the course of this study through 90 days following 
the last dose of study drug, the Investigator must report the pregnancy to the Sponsor or designee 
within 24 hours of being notified of the pregnancy.  Details of the pregnancy will be recorded on 
the pregnancy reporting form.  The patient should receive any necessary counseling regarding 
the risks of continuing the pregnancy and the possible effects on the fetus. 
The pregnancy should be followed by the Investigator until completion.  At the completion of the 
pregnancy, the Investigator will document the outcome of the pregnancy.  If the outcome of the 
pregnancy results in a postpartum complication, spontaneous abortion, stillbirth, neonatal death, 
or congenital anomaly, then the Investigator should follow the procedures for reporting an SAE 
as outlined in Section 7.5.6.3.   
7.5.6.7. 
Overdose Reporting 
An overdose is defined as any dose administered to or taken by a patient (accidentally or 
intentionally) that exceeds the highest daily dose, or is at a higher frequency, than included in the 
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protocol.  It is up to the investigator to decide whether a dose is to be considered an overdose, in 
consultation with the Sponsor.  Overdose must be recorded in the eCRF. 
All reports of overdose (with or without an AE) must be reported within 24 hours to the Sponsor 
or designee.   
7.6. 
Exploratory Assessments 
Blood and urine samples will be collected for exploratory analyses.  Aliquots of samples will be 
obtained and frozen, to permit future analysis of the effect of ALN-AS1 on exploratory 
biomarkers.   
Where local regulations allow, biologic samples will be retained on behalf of the Sponsor for a 
maximum of 15 years following the last patient’s last visit in the study.  Details regarding the 
collection, processing, storage, and shipping of samples will be in the Laboratory Manual. 
7.7. 
Other Assessments 
7.7.1. 
EQ-5D-5L Questionnaire 
QOL will be assessed through the use of the 5-level EQ-5D (EQ-5D-5L), a standardized 
questionnaire measuring health outcomes.(36)  In addition to the time points indicated, the 
EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a 
porphyria attack (but, not more than once in a 6 month period), if possible. 
8. 
STATISTICS 
A detailed Statistical Analysis Plan (SAP) will be written after finalizing the protocol and before 
database lock.  The plan will detail the implementation of all the statistical analyses in 
accordance with the principle features stated in the protocol. 
8.1. 
Determination of Sample Size 
This is a Phase 1/2 multicenter, open-label extension study to evaluate the long-term safety and 
clinical activity of ALN-AS1 in patients with AIP who completed study ALN-AS1-001.  Safety, 
tolerability, PK, and PD of ALN-AS1 will be investigated.  The sample size was not determined 
based on statistical considerations.  Up to 24 patients are planned for this study (including 
optional cohorts in ALN-AS1-001). 
8.2. 
Statistical Methodology 
The statistical and analytical plans presented below summarize the more complete plans to be 
detailed in the SAP.  Any changes to the methods described in the final SAP will be described 
and justified as needed in the clinical study report. 
Statistical analyses will be primarily descriptive in nature.  Descriptive statistics (eg, mean, 
standard deviation, median, minimum, and maximum) will be presented for continuous 
variables.  Frequencies and percentages will be presented for categorical and ordinal variables. 
Analyses will be performed using SAS® (Version 9.2, or higher). 
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8.2.1. 
Populations to be Analyzed 
The populations (analysis sets) are defined as follows:  
Safety Analysis Set: 
All patients who received any amount of study drug. 
Clinical Activity Analysis 
Set: 
All patients who received any amount of study drug and have 
both a baseline and at least 1 postdose assessment. 
PK Analysis Set: 
All patients who received any amount of study drug and have at 
least 1 postdose blood sample for PK and who have evaluable 
PK data. 
PD Analysis Set: 
All patients who received any amount of study drug and who 
have at least 1 postdose blood sample for the determination of 
ALN-AS1 will be included in the PD analyses. 
Safety will be analyzed using the Safety Analysis Set.  The PK and PD Analysis Sets will be 
used to conduct PK and PD analyses, respectively.  The population used to evaluate clinical 
activity will be the Clinical Activity Analysis Set.   
8.2.2. 
Examination of Subgroups 
Subgroup analyses may be conducted for selected endpoints.  Detailed methodology will be 
provided in the SAP. 
8.2.3. 
Handling of Missing Data 
Unrecorded values will be treated as missing.  The appropriateness of the method(s) described 
for handling missing data may be reassessed and documented in the SAP before database lock.  
Depending on the extent of missing values, further investigation may be made into the sensitivity 
of the analysis results to the method(s) specified. 
8.2.4. 
Baseline Evaluations 
Demographics, medical history, disease-specific information, and other baseline characteristics 
collected in this study will be summarized.   
8.2.5. 
Clinical Activity Analyses 
Clinical activity of ALN-AS1 will be summarized primarily by descriptive statistics.  The 
clinical activity of ALN-AS1 will be evaluated by the frequency and characteristics of porphyria 
attacks including duration, treatment, and severity of porphyria attacks and number and duration 
of visits to a health care setting for acute porphyria care. 
Patient diary recordings, including BPI-SF questionnaire scores, will also be summarized. 
8.2.6. 
Pharmacodynamic Analysis 
PD analyses will include the evaluation of change in ALA, PBG, and ALAS mRNA levels.  
Descriptive statistics (eg, mean and standard error of the mean) for observed levels of PD 
parameters and the relative change from baseline will be presented for each of the postdose 
follow-up time points. 
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8.2.7. 
Pharmacokinetic Analysis 
The PK concentration of ALN-AS1 will be determined. 
Antidrug antibody results will be tabulated.  A by-patient data listing will also be provided. 
8.2.8. 
Safety Analyses 
Extent of exposure will be summarized.  AEs will be summarized by the Medical Dictionary for 
Regulatory Activities System Organ Class and Preferred Term.  Prior and concomitant 
medications will be classified according to the World Health Organization drug dictionary. 
Incidence of AEs (those events that started after exposure to study drug or worsened in severity 
after dosing) will be presented.  Incidence of AEs will also be presented by maximum severity 
and relationship to study treatment.  The incidence of SAEs and AEs leading to discontinuation 
of treatment will also be tabulated.  By-patient listings will be provided for deaths, SAEs, and 
AEs leading to discontinuation of treatment.   
Descriptive statistics will be provided for clinical laboratory data and vital signs data, presented 
as both actual values and changes from baseline relative to each on-study evaluation and to the 
last evaluation on study.  Laboratory shift tables from baseline to worst values will be presented.  
Abnormal physical examination findings and 12-lead ECG data will be presented in a by-patient 
data listing. 
Descriptive statistics will be provided for ECG interval data and presented as both actual values 
and changes from baseline relative to each on-study evaluation and to the last evaluation on 
study.  Details of any abnormalities will be included in patient listings. 
Concomitant hemin administration will also be recorded. 
8.2.9. 
Other Analyses 
Possible associations between PD parameters (ALA, PBG, and ALAS1 mRNA levels) and 
clinical activity parameters may also be explored. 
Additional exploratory analyses may be conducted on analytes related to targeting the heme 
biosynthesis pathway. 
QOL scores on the EQ-5D-5L questionnaire will also be summarized. 
9. 
STUDY ADMINISTRATION 
9.1. 
Ethical and Regulatory Considerations 
This study will be conducted in accordance with the protocol, all applicable regulatory 
requirements, and the guidelines of Good Clinical Practice (GCP).  Compliance with GCP 
provides public assurance that the rights, safety, and well-being of study patients are protected 
consistent with the principles that have their origin in the Declaration of Helsinki. 
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9.1.1. 
Informed Consent 
The Investigator will ensure that the patient is given full and adequate oral and written 
information about the nature, purpose, possible risk and benefit of the study.  Patients must also 
be notified that they are free to withdraw from the study at any time.  The patient should be given 
the opportunity to ask questions and allowed time to consider the information provided. 
The patient’s signed and dated informed consent must be obtained before conducting any study 
procedures. 
The Investigator must maintain the original, signed ICF.  A copy of the signed ICF must be 
given to the patient. 
9.1.2. 
Ethical Review 
The final study protocol, including the final version of the ICF, must be approved or given a 
favorable opinion in writing by an IRB or IEC, as appropriate.  The Investigator must submit 
written approval before he or she can enroll any patient into the study. 
The Investigator is responsible for informing the IRB or IEC of any amendment to the protocol 
in accordance with local requirements.  In addition, the IRB or IEC must approve all advertising 
used to recruit patients for the study.  The protocol must be reapproved by the IRB or IEC upon 
receipt of amendments and annually, as local regulations require. 
Initial IRB approval of the protocol, and all materials approved by the IRB for this study 
including the patient consent form and recruitment materials must be maintained by the 
Investigator and made available for inspection. 
The Investigator will submit reports of SAEs as outlined in Section 7.5.6.  In addition, the 
Investigator agrees to submit progress reports to the IRB or IEC per their local reporting 
requirements, or at least annually and at the conclusion of the study.  The reports will be made 
available to the Sponsor or designee. 
Any communications from regulatory agencies in regard to inspections, other studies that impact 
this protocol or the qualifications of study personnel should be promptly reported to the Sponsor 
or its designee. 
The Investigator is also responsible for providing the IRB with reports of any reportable serious 
adverse drug reactions from any other study conducted with the investigational drug.  The 
Sponsor or designee will provide this information to the Investigator. 
Major changes in this research activity, except those to remove an apparent immediate hazard to 
the patient, must be reviewed and approved by the Sponsor and the IRB or IEC that approved the 
study.  Amendments to the protocol must be submitted in writing to the Investigator’s IRB or 
IEC and the Regulatory Authority for approval before patients are enrolled under the amended 
protocol. 
9.1.3. 
Serious Breach of Protocol 
Investigators must notify the Medical Monitor within 24 hours of becoming aware of a potential 
serious breach of the protocol.  A serious breach is a breach that is likely to affect to a significant 
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degree the safety and rights of a study participant or the reliability and robustness of the data 
generated in the clinical trial. 
9.1.4. 
Study Documentation, Confidentiality, and Records Retention 
All documentation relating to the study should be retained for the period of time required by 
applicable local law.  If it becomes necessary for the Sponsor, the Sponsor’s designee, applicable 
IRB/IEC, or applicable regulatory authorities to review or audit any documentation relating to 
the study, the Investigator must permit direct access to all source documents/data.  Records will 
not be destroyed without informing the Sponsor in writing and giving the Sponsor the 
opportunity to store the records for a longer period of time at the Sponsor’s expense.   
The Investigator must ensure that the patients’ confidentiality will be maintained.  On the CRFs 
or other documents submitted to the Sponsor or designees, patients should not be identified by 
their names, but by the assigned patient number and initials.  If patient names are included on 
copies of documents submitted to the Sponsor or designees, the names (except for initials) will 
be obliterated and the assigned patient number added to the document.  Documents not for 
submission to the Sponsor (eg, signed ICFs) should be maintained by the Investigator in strict 
confidence. 
The Investigator must treat all of the information related to the study and the compiled data as 
confidential, whose use is for the purpose of conducting the study.  The Sponsor must approve 
any transfer of information not directly involved in the study. 
In compliance with local and/or regional regulations, this clinical study may be registered and 
study results may be posted on public registries, such as ClinicalTrials.gov. 
9.1.5. 
End of the Study 
The end of the study is defined as last patient last visit. 
9.1.6. 
Discontinuation of the Clinical Study 
The Sponsor reserves the right to discontinue the study for clinical or administrative reasons at 
any time.  If the clinical study center does not recruit at a reasonable rate, the study may be 
discontinued at that clinical study center.  Should the study be terminated and/or the clinical 
study center closed for whatever reason, all documentation and study drug pertaining to the study 
must be returned to the Sponsor or its representative, and the Investigators, IEC/IRB and 
Regulatory Authorities will be promptly informed of the termination and the reason for the 
decision.  The Investigator should promptly inform the patients and assure appropriate therapy 
and follow-up.  Patients should then be withdrawn from the study.   
9.2. 
Data Quality Control and Quality Assurance 
9.2.1. 
Data Handling 
Study data must be recorded on case report forms (paper and/or electronic) provided by the 
Sponsor or designee on behalf of the Sponsor.  Case report forms must be completed only by 
persons designated by the Investigator.  If eCRFs are used, study data must be entered by trained 
clinical study center personnel with access to a valid and secure eCRF system.  All data entered 
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into the eCRF must also be available in the source documents.  Corrections on paper CRFs must 
be made so as to not obliterate the original data and must be initialed and dated by the person 
who made the correction. 
9.2.2. 
Study Monitoring 
The clinical monitor, as a representative of the Sponsor, has an obligation to closely follow the 
study conduct at the clinical study center.  The monitor will visit the Investigator and clinical 
study center periodically and will maintain frequent telephone and written contact.  The monitor 
will maintain current personal knowledge of the study through observation, review of study 
records and source documentation, and discussion of the conduct of the study with the 
Investigator and personnel. 
The monitor will review source documents, systems and CRFs to ensure overall quality and 
completeness of the data and to confirm study procedures are complied with the requirements in 
the study protocol.  The Sponsor, or its designee, will be allowed to conduct clinical study center 
visits to the investigation facilities for the purpose of monitoring any aspect of the study.  The 
Investigator agrees to allow the monitor to inspect the drug storage area, study drug stocks, drug 
accountability records, patient charts and study source documents, and other records relative to 
study conduct. 
9.2.3. 
Audits and Inspections 
Periodically, the Sponsor or its authorized representatives audit clinical investigative study 
centers as an independent review of core trial processes and documents to determine whether 
these activities were conducted, and data were recorded, analyzed, and accurately reported 
according to the protocol, GCP guidelines of the ICH, and any applicable regulatory 
requirements.  A regulatory authority, an IEC or an IRB may visit the clinical study center to 
perform audits or inspections, including source data verification.  The Investigator should contact 
the Sponsor, or its designee, immediately if contacted by a regulatory agency about an 
inspection. 
9.3. 
Publication Policy 
It is intended that after completion of the study, the data are to be submitted for publication in a 
scientific journal and/or for reporting at a scientific meeting.  A copy of any proposed manuscript 
must be provided and confirmed received at the Sponsor at least 30 days before its submission, 
and according to any additional publication details in the Investigator Agreement.
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transplantation for acute intermittent porphyria is complicated by a high rate of hepatic artery 
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Porphyrin Handbook. Amsterdam: Academic Press; 2003. p. 23-41. 
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15. Bonkovsky HL. Neurovisceral porphyrias: what a hematologist needs to know. Hematology 
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21. Herrick AL, McColl KE, Moore MR, Cook A, Goldberg A. Controlled trial of haem arginate 
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22. Bissell DM. Treatment of acute hepatic porphyria with hematin. J Hepatol. 1988;6(1):1-7. 
23. Green D, Ts'ao CH. Hematin: effects on hemostasis. J Lab Clin Med. 1990;115(2):144-7. 
24. Daimon M, Susa S, Igarashi M, Kato T, Kameda W. Administration of heme arginate, but 
not hematin, caused anaphylactic shock. Am J Med. 2001;110(3):240. 
25. Elder G, Harper P, Badminton M, Sandberg S, Deybach JC. The incidence of inherited 
porphyrias in Europe. J Inherit Metab Dis. 2013;36(5):849-57. 
26. Anderson K, Egger N, Goeger D. Heme arginate for prevention of acute porphyric attacks. 
Acta Haematologica. 1997;98:120. 
27. Bonkovsky HL, Guo JT, Hou W, Li T, Narang T, Thapar M. Porphyrin and heme 
metabolism and the porphyrias. Compr Physiol. 2013;3(1):365-401. 
28. Vaishnaw AK, Gollob J, Gamba-Vitalo C, Hutabarat R, Sah D, Meyers R, et al. A status 
report on RNAi therapeutics. Silence. 2010;1(1):14. 
29. Elbashir SM, Harborth J, Lendeckel W, Yalcin A, Weber K, Tuschl T. Duplexes of 21-
nucleotide RNAs mediate RNA interference in cultured mammalian cells. Nature. 
2001;411(6836):494-8. 
30. Kauppinen R, von und zu Fraunberg M. Molecular and biochemical studies of acute 
intermittent porphyria in 196 patients and their families. Clin Chem. 2002;48(11):1891-900. 
31. Ryu JY, Song IS, Sunwoo YE, Shon JH, Liu KH, Cha IJ, et al. Development of the "Inje 
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cocktail" for high-throughput evaluation of five human cytochrome P450 isoforms in vivo. Clin 
Pharmacol Ther. 2007;82(5):531-40. 
32. Williams D, Tao X, Zhu L, Stonier M, Lutz JD, Masson E, et al. Use of a cocktail probe to 
assess potential drug interactions with cytochrome P450 after administration of belatacept, a 
costimulatory immunomodulator. Br J Clin Pharmacol. 2017;83(2):370-80. 
33. Sampson HA, Munoz-Furlong A, Campbell RL, Adkinson NF, Jr., Bock SA, Branum A, et 
al. Second symposium on the definition and management of anaphylaxis: summary report--
second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis 
Network symposium. Ann Emerg Med. 2006;47(4):373-80. 
34. Atkinson TM, Mendoza TR, Sit L. The Brief Pain Inventory and its “pain at its worst in the 
last 24 hours” item: Clinical trial endpoint considerations. Pain Medicine. 2010;11(3):337-46. 
35. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF, 3rd, Feldman HI, et al. A new 
equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150(9):604-12. 
36. Herdman M, Gudex C, Lloyd A, Janssen M, Kind P, Parkin D, et al. Development and 
preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res. 
2011;20(10):1727-36. 
 
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11.
APPENDICES
11.1. 
Pharmacokinetic Assessment Time Points 
Table 4 contains a detailed schedule for the collection of blood samples for PK analysis. 
Table 4: 
Pharmacokinetic Time Points 
Study Day 
Protocol Time 
(hh:mm) 
PK Blood 
Day 1 and 
Month 12 (D361) ±10 days 
Predose (within 60 minutes 
before dosing) 
X 
02:00 (±15 minutes)b 
X 
06:00 (±20 minutes) 
X 
Month 1 (Day 14) ±2 days 
Anytime during visit 
X 
Month 1 (Day 31) ±7 days,a  
Month 3 (Day 91) ±7 days, 
Month 6 (Day 181) ±7 days, 
Month 9 (Day 271) ±10 daysd, 
Month 15 (Day 451) ±10 daysd, 
Month 18 (Day 541) ±10 days  
Month 24 (Day 721) ±10 days
Predose (within 60 minutes 
before dosing) 
X 
02:00 (±15 minutes)b 
X 
04:00 (±20 minutes)c 
Abbreviations:  hh=hours; mm=minutes; PK=pharmacokinetic. 
a  At the Day 31, Month 1 visit, if the dosing regimen is every 3 months, ALN-AS1 is not administered and 
a single time point blood sample for PK analysis should be collected. 
b  Only in patients receiving ≤2.5 mg/kg ALN-AS1; paired with ECG (for ECG details, see Section 7.5.4).  
c  Only in patients receiving >2.5 mg/kg ALN-AS1; paired with ECG (for ECG details, see Section 7.5.4). 
d. Blood sample collection for PK analysis at Month 9 and Month 15 is only necessary if ECG will be
performed at same visit. 
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11.2. 
Schedules of Assessments for Every Month Dosing Regimen 
 
 Table 5: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14 ±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical 
History/Disease 
Historyc 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/ 
Exclusion Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examinationd 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
 
 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
X 
Vital Signsf 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead 
ECGg 
X 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Clinical Laboratory 
Assessmenth 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug 
Administrationj 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
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 Table 5: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14 ±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
Blood and Urine 
Sample for Exploratory 
Biomarker Analysisl 
 
X 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Blood Sample for PK 
Analysism 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Antidrug Antibodiesn 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
Porphyria Attack Kit 
Dispensationo 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EQ-5D-5L 
Questionnairep 
X 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Diary Review 
(including BPI-SF)q 
 
 
X 
AEs 
 
Continuous 
Concomitant 
Medicationsr 
 
Continuous 
 
Abbreviations:  AE=adverse event; ALAS1=5-aminolevulinic acid synthase 1; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief 
Pain Inventory-Short Form; D=day; ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of 
life; SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may 
be conducted while the patient is at home. 
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 Table 5: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14 ±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical 
examinations and blood/urine sample collections. 
a Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study (ALN-AS1-001) were completed within 60 days 
of administration of the first dose of ALN-AS1 in this study.  If more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs 
will be repeated before administration of ALN-AS1.  Results should be available and deemed acceptable before the administration of the first dose of ALN-
AS1. 
b After a patient has completed 6 months of ALN-AS1 administration in this study, and where applicable country and local regulations and infrastructure allow, 
study procedures, including ALN-AS1 administration, may take place at the patient’s home by a healthcare professional.  Study procedures may occur at the 
patient’s home at the discretion of the Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit at the clinical 
study center Q3M through M12, and thereafter Q6M. Additional visits to collect clinical laboratory samples may occur at home at any point during the 
treatment period, within 14 days prior to scheduled dose administration. 
c See Section 7.1 for details on the interval medical history/disease history to be recorded at Screening/Baseline.  Ongoing AEs from the previous study 
(ALN-AS1-001) will be captured as medical history. 
d A complete physical examination will be performed at Screening/Baseline, and D1.  At all other visits, a targeted physical examination will be performed.  On 
dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any time 
during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On D1, vital signs will be collected within 1 hour predose; and 2 hours 
(±10 minutes) postdose.  On all other dosing days, vital signs will be collected within 1 hour predose.  On days when ALN-AS1 is not administered, vital signs 
can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position (should be consistent for each patient), after the 
patient has rested comfortably for 10 minutes. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at least 5 
minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1 ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose at a minimum of 2 
of the following visits:  D1, Month 3, Month 6, Month 9, Month 12, Month 15 (only if visit is done at clinic), or Month 18.  In patients receiving >2.5 mg/kg 
ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose at a minimum of two of the following visits:  D1, Month 3, 
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Month 6, Month 9, Month 12, Month 15 (only if visit is done at clinic), or Month 18.  On all other dosing days, ECGs will be collected within 1 hour predose 
(see Section 7.5.4  for ECG assessment details). 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  On 
days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. On dosing days up to the Month 18 visit,results from 
hematology, chemistry (including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the Investigator before study drug 
administration.  If results from within the prior 14 days are not available at a dosing visit (at visits from D1 to Month 18), locally analyzed predose assessments 
may be used for review in order to allow same day study drug administration, and additional samples for central analysis must also be collected. 
i A serum pregnancy test will be performed at Screening/Baseline; thereafter, urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  For weight-
based dosing, weight measured at the current study center visit (dosing day) will be used to calculate the dose of ALN-AS1.  After M12, weight measured at 
either the previous study center visit or on current study center visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1).  Blood sample collection for PK analysis at 
Month 9 and Month 15 is only necessary if ECG will be performed at same visit. 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o Porphyria attack laboratory sample collection kits should be dispensed at the screening visit along with instructions for use. For any attack that occurs through 
M37, urine samples should be collected within 24 hours of the start of clinical intervention (eg, hemin or glucose administration) and within 24 hours of the end 
of clinical intervention.  If patients are unable to report to the clinical study center during a porphyria attack, laboratory sample collection kits should be used 
for collecting and sending urine samples to the clinical study center, if possible.  These urine samples may also be analyzed for exploratory biomarkers. 
p In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but not more than once in a 6 month period), if possible.  
q Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, and narcotic use on a daily basis through M9; 
thereafter, acute porphyria attacks will be recorded in the diary.  The BPI will be completed on a weekly basis as part of the patient diary through M9, then 
Q3M. 
r Medications that are ongoing from the previous study (ALN-AS1-001), started between the previous study and this study, and started after signing informed 
consent in this study, will be captured as concomitant medication(s). 
 
 
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Table 6: 
Schedule of Assessments:  Month 19 through Month 36 (Every Month Dosing Regimen) 
 
Treatment Period 
(Month 19 through Month 36) 
M19/ 
M20a 
M21a 
M22/ 
M23a 
M24 
M25/ 
M26a 
M27a 
M28/ 
M29a 
M30 
M31/ 
M32a 
M33a 
M34/ 
M35a 
M36 
Study Visit (D±Visit Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
Physical Examinationb 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Body Weight, BMI, and Heightc 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Vital Signsd 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGe 
 
 
 
X 
 
 
 
 
 
 
 
 
Clinical Laboratory Assessmentf 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Pregnancy Testg 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationh 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine Sample for PBG, ALA, and 
Creatinine Analysisi 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Blood and Urine Sample for 
Exploratory Biomarker Analysisj  
 
 
 
X 
 
 
 
X 
 
 
 
X 
Blood Sample for PK Analysisk 
 
 
 
X 
 
 
 
 
 
 
 
 
Antidrug Antibodiesl 
 
 
 
X 
 
 
 
 
 
 
 
X 
EQ-5D-5L Questionnairem 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Diary Review (including 
BPI-SF)n 
X 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; M=month; PBG=porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of life; SC=subcutaneous. 
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Table 6: 
Schedule of Assessments:  Month 19 through Month 36 (Every Month Dosing Regimen) 
 
Treatment Period 
(Month 19 through Month 36) 
M19/ 
M20a 
M21a 
M22/ 
M23a 
M24 
M25/ 
M26a 
M27a 
M28/ 
M29a 
M30 
M31/ 
M32a 
M33a 
M34/ 
M35a 
M36 
Study Visit (D±Visit Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
a Where applicable country and local regulations and infrastructure allow, study procedures, including ALN-AS1 administration,  may take place at the patient’s 
home by a healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the Investigator, based on safety and tolerability; 
however, patients are required to complete at least 1 visit at the clinical study center Q6M.   
b A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed.  
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 
c Height will be measured at Screening/Baseline only. 
d Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On a dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for 10 minutes. 
e Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at least 
5 minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose . At Month 24, 
ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose, when paired with PK timepoints, otherwise ECGs will be collected 
predose.  In patients receiving >2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose.  See Section 7.5.4 
for ECG assessment details. 
f Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  On 
days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit.   
g Urine pregnancy tests will be performed.  Results must be available before dosing. 
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h ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured at either the at the previous study center visit or current study center visit will be used to calculate the weight-based dose of ALN-AS1. 
i Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
j On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
k Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1).  
l On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
m In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but, not more than once in a 6 month period), if possible.  
n Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
 
 
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Table 7: 
Schedule of Assessments:  Month 37 through End of Study (Every Month Dosing Regimen) 
 
Treatment Period 
(Month 37 through EOS) 
EOS/ 
ETb 
Safety 
Follow-upc 
Study Visit (M) 
M37/ 
M38a 
M39a 
M40/ 
M41a 
M42 
M43/ 
M44a 
M45a 
M46/ 
M47a 
M48/ 
EOT 
M49 
 
Study Visit (D±Visit Window) 
1111±7/1141±7 
1171±10 
1201±7/1231±7 
1261±10 
1291±7/1321±7 
1351±10 
1381±7/1411±7 
1441±10 
1471±10 
 
Physical Examinationd 
 
 
 
X 
 
 
 
X 
X 
X 
Body Weight, BMI, and Heighte 
 
 
 
X 
 
 
 
X 
X 
 
Vital Signsf 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGg 
 
 
 
X 
 
 
 
 
X 
 
Clinical Laboratory Assessmenth 
 
X 
 
X 
 
X 
 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationj 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Urine Sample for PBG, ALA, and 
Creatinine Analysisk 
 
X 
 
X 
 
X 
 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker Analysisl  
 
 
 
X 
 
 
 
X 
X 
 
Antidrug Antibodiesm 
 
 
 
 
 
 
 
X 
X 
 
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Table 7: 
Schedule of Assessments:  Month 37 through End of Study (Every Month Dosing Regimen) 
 
Treatment Period 
(Month 37 through EOS) 
EOS/ 
ETb 
Safety 
Follow-upc 
Study Visit (M) 
M37/ 
M38a 
M39a 
M40/ 
M41a 
M42 
M43/ 
M44a 
M45a 
M46/ 
M47a 
M48/ 
EOT 
M49 
 
Study Visit (D±Visit Window) 
1111±7/1141±7 
1171±10 
1201±7/1231±7 
1261±10 
1291±7/1321±7 
1351±10 
1381±7/1411±7 
1441±10 
1471±10 
 
EQ-5D-5L Questionnairen 
 
 
 
X 
 
 
 
X 
X 
 
Diary Review (including BPI-SF)o 
X 
 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; EOS=End of Study; EOT=End of Treatment; ET=early termination; M=month; PBG=porphobilinogen; PK=pharmacokinetics; 
Q=every; QOL=quality of life; SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
a Where applicable country and local regulations and infrastructure allow, study procedures, including ALN-AS1 administration,  may take place at the patient’s 
home by a healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the Investigator, based on safety and tolerability; 
however, patients are required to complete at least 1 visit at the clinical study center Q6M.   
b Patients who complete all scheduled doses ALN-AS1 through Month 48 will return for an end of study (EOS) visit at Month 49.  Patients who discontinue 
treatment prior to Month 48 will be asked to complete an early termination (ET) visit at which all Month 49 visit procedures will be performed; they must also 
return 3 months (84 [+ 7] days) after their last dose of ALN-AS1 for a safety-follow-up visit.   
c The safety follow-up visit is only required for patients who discontinue prior to study completion.  The visit should be conducted  3 months (84 [+7 days]) 
following the last dose of ALN-AS1. 
d A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed.  
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 
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e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On a dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for 10 minutes. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at least 
5 minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose . At Month 24, 
ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose, when paired with PK timepoints, otherwise ECGs will be collected 
predose.  In patients receiving >2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose.  See Section 7.5.4 
for ECG assessment details. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  On 
days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit.   
i Urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured at either the at the previous study center visit or current study center visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
n In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but, not more than once in a 6 month period), if possible.  
o Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
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11.3. 
Anaphylactic Reactions 
Table 8: 
 
Sampson Criteria for Anaphylactic Reactions 
 
Adapted from Sampson et al. 2006 (33) 
 
 
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ALN-AS1-002 PROTOCOL AMENDMENT 6 
SUMMARY OF CHANGES DATED 28 MAY 2019 
A Multicenter, Open-label Extension Study to Evaluate the Long-term Safety and Clinical 
Activity of Subcutaneously Administered ALN AS1 in Patients with Acute Intermittent 
Porphyria who have Completed a Previous Clinical Study with ALN-AS1 
Rationale for Protocol Amendment 
The primary purpose for this protocol amendment is to provide updated information from a 
recently completed drug-drug interaction study (ALN-AS1-004) performed in AIP patients who 
are asymptomatic high excreters in the concomitant medications section (Section 6.3).  The 
results of the study indicated that ALN-AS1 treatment resulted in moderate reduction in 
CYP1A2 and CYP2D6 activity, weak reduction in CYP3A4 and CYP2C19 activity, and no 
change in the activity of CYP2C9. 
This amendment also extends the treatment period to 48 months to continue the study until 
ALN-AS1 is anticipated to be commercially available in the countries where the study sites are 
located. 
Additional updates are being implemented as noted below:  clarification that patients may 
continue to receive ALN-AS1 until it is commercially available in the patient’s territory, addition 
of guidance for serious breaches of protocol, and deletion of Section 11.3, List of Sensitive 
CYP3A substrates and those with a Narrow Therapeutic Range. 
A detailed summary of changes is provided in Table 1.  Corrections to typographical errors, 
punctuation, grammar, abbreviations, and formatting (including administrative changes between 
protocol amendments 5 and 6) are not detailed. 
 
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Table 1: 
Protocol Amendment 6 Detailed Summary of Changes 
The primary section(s) of the protocol affected by the changes in Protocol Amendment 6 are indicated.  The corresponding text has 
been revised throughout the protocol.  Deleted text is indicated by strikeout; added text is indicated by bold font. 
Purpose:  Updated Section 1.6, Clinical Data Summary, with results of the open-label drug-drug interaction study (ALN-AS1-004) to support 
changes in Section 6.3, Concomitant Medications. 
The primary change is the addition of Section 1.2.2.3, Drug-drug Interaction Study ALN-AS1-004 
Added text: 
1.6.4 
Drug-drug Interaction Study ALN-AS1-004 
An open-label drug-drug interaction (DDI) study (ALN-AS1-004) was conducted in AIP patients who are 
ASHE to evaluate the effect of a single dose of 2.5 mg/kg ALN-AS1 administered SC on the 
pharmacokinetics of probe substrates for 5 major CYP enzymes that account for the metabolism of 
approximately 80% of prescribed drugs.(31, 32)  Results from this study demonstrated that ALN-AS1 
treatment resulted in weak to moderate reduction in the metabolic activity of some of the 5 CYP 
enzymes studied, thereby leading to higher concentrations of some substrates and their metabolites.  
Treatment with ALN-AS1 resulted in an approximately 3-fold increase in exposure (as measured by 
AUC) of caffeine (a sensitive substrate for CYP1A2) and an approximately 2-fold increase in exposure of 
dextromethorphan (a sensitive substrate for CYP2D6).  Exposure of midazolam (a sensitive substrate for 
CYP3A4) and omeprazole (a sensitive substrate for CYP2C19) increased less than 2-fold after treatment 
with ALN-AS1.  There was no effect of ALN-AS1 treatment on losartan (a sensitive substrate for 
CYP2C9). 
Purpose:  Clarify that subjects may continue until givosiran is commercially available or the givosiran development program is discontinued. 
The primary change is the addition of 2 sentences to Section 4.1, Summary of Study Design. 
Added text: 
Patients may receive ALN-AS1 as long as they do not fulfill any of the study discontinuation criteria (see 
Section 5.3) or until ALN-AS1 is commercially available in the patient’s territory or the ALN-AS1 development
program is discontinued (whichever comes first). 
All patients are asked to participate in a Posttreatment Follow-up visit after they have received their last dose of 
ALN-AS1. 
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Section(s) also containing this change: 

Synopsis, Study Design
Purpose:  Updated concomitant medications to indicate that givosiran treatment could affect drugs that are metabolized primarily by CYP2D6 
and CYP1A2. 
The primary change occurs in Section 6.3, Concomitant Medications 
Formerly read: 
Drug-drug interaction studies in NHP, could not exclude the potential for ALN-AS1 to alter the clearance of 
drugs metabolized by the CYP3A enzymes.  Therefore, patients on medications metabolized by CYP3A, 
especially those with narrow therapeutic ranges, may require monitoring for their drug levels or drug response.  
ALN-AS1 could potentially increase the clearance of drugs metabolized by the CYP3A isoform.   
Investigators will review all medications at study start and monitor response to these medications during the 
study.  For patients who require new medications while on study, selection of medications that are not mainly 
metabolized by the CYP3A isoform is recommended.  A list of medications that are sensitive CYP3A 
substrates is included in Table 6 Appendix Section 11.3.  In addition, a more detailed and current list of 
sensitive CYP3A-metabolized medications and CYP3A-metabolized medications with a narrow therapeutic 
range is available at the Indiana University, Division of Clinical Pharmacology, website 
(http://medicine.iupui.edu/clinpharm/ddis/clinical-table/).[31] 
Now reads: 
Drug-drug interaction studies in NHP, could not exclude the potential for ALN-AS1 to alter the clearance of 
drugs metabolized by the CYP3A enzymes.  Therefore, patients on medications metabolized by CYP3A, 
especially those with narrow therapeutic ranges, may require monitoring for their drug levels or drug response.  
ALN-AS1 could potentially increase the clearance of drugs metabolized by the CYP3A isoform.   Investigators 
will review all medications at study start and monitor response to these medications during the study.  For 
patients who require new medications while on study, selection of medications that are not mainly metabolized 
by the CYP3A isoform is recommended.  A list of medications that are sensitive CYP3A substrates is included 
in Table 6 Appendix Section 11.3.  In addition, a more detailed and current list of sensitive CYP3A-
metabolized medications and CYP3A-metabolized medications with a narrow therapeutic range is available at 
the Indiana University, Division of Clinical Pharmacology, website 
(http://medicine.iupui.edu/clinpharm/ddis/clinical-table/).[31] 
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Patients with porphyria could have altered hepatic heme synthesis, and treatment with ALN-AS1 could 
also modulate this pathway and secondarily impact CYP enzyme activity.  Results from a DDI study in 
AIP patients who are ASHE are presented in Section 1.6.4.  The DDI study demonstrated that ALN-AS1 
treatment resulted in weak to moderate reduction in activity in some of the CYP enzymes resulting in 
corresponding low to moderate increase in the plasma levels of drugs that are metabolized by these CYP 
enzymes.  Based on the moderate decrease in CYP2D6 or CYP1A2 activity, investigators will review all 
concomitant medications that are primarily metabolized by these enzymes and monitor the patient’s 
clinical response to these medications during the study.  Medications metabolized primarily by CYP2D6 
and CYP1A2 with a narrow therapeutic index (ie that require regular laboratory monitoring) may need 
to be monitored more frequently to determine if a dose adjustment of the concomitant medication is 
required.  For patients who require new medications while on study, selection of medications that are not 
primarily metabolized by CYP2D6 or CYP1A2 should be considered.  Refer to the individual product’s 
prescription information to determine if there is a need to monitor concomitant medications for 
differences in safety or efficacy of the medication based on reported DDIs with CYP2D6 or CYP1A2.  
For more detailed and up-to-date information on CYP substrates, see: 
https://www.fda.gov/drugs/developmentapprovalprocess/developmentresources/
druginteractionslabeling/ucm093664.htm. 
Purpose:  Extend treatment duration so that patients may continue on treatment for up to 48 months. 
The primary change occurs in Section 4.2, Duration of Treatment and Study. 
Formerly read: 
The duration of treatment is up to 36 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 44 months. 
Now reads: 
The duration of treatment is up to 4836 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 4456 months.  
Section(s) also containing this change: 

Synopsis, Duration of Treatment and Study

Synopsis, Table 2 (Table 3 added)

Section 4.1, Summary of Study design and Figure 3

Section 5.3.1 Discontinuation of Study Drug

Section 5.3.2 Discontination from the Study
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
Section 6.2.2, Dose and Administration

Section 6.3, Concomitant Medications

Section 7, Study Assessments

Section 7.5.5, Clinical Laboratory Assessments

Section 11.2, Table 5 (Table 6 added)
Purpose:  Section 9.1.3, Serious Breach of Protocol, was added to align with the process for the reporting potential serious breaches of protocol. 
The primary change is the addition of Section 9.1.3, Serious Breach of Protocol 
Added text: 
9.1.3. Serious Breach of Protocol 
Investigators must notify the Medical Monitor within 24 hours of becoming aware of a potential serious breach of 
the protocol.  A serious breach is a breach that is likely to affect to a significant degree the safety and rights of a 
study participant or the reliability and robustness of the data generated in the clinical trial.  
Purpose:  Because data from the human drug-drug interaction study showed that givosiran treatment resulted in a moderate (>2-fold) reduction 
of CYP2D6 and CYP1A2 metabolic activity, the guidance for investigators in Section 6.3 was updated to recommend that medications metabolized 
primarily by CYP2D6 and CYP1A2 with a narrow therapeutic index may need to be monitored more frequently to determine if a dose adjustment 
of the concomitant medication is required.  In the absence of comprehensive lists of products metabolized by CYP2D6 and CYP1A2, Section 6.3 
now directs the Investigator to the product information of any concomitant medication required and to the Table of Substrates for CYP enzymes on 
the FDA Website to determine if concomitant medications metabolized primarily by CYP2D6 and CYP1A2 need to be monitored more frequently.   
Section 11.2, List of Sensitive CYP3A Substrates and Those with a Narrow Therapeutic Range, was deleted because , based on the results from the 
human drug-drug interaction study, givosiran treatment results in only a weak (<2-fold) reduction of CYP3A4 metabolic activity, and the 
recommendation to monitor the drug response in patients on medications primarily metabolized by CYP3A4 was not considered necessary. 
The primary change occurs in Section 11.3, List of Sensitive CYP3A Substrates and Those with a Narrow Therapeutic Range. 
Section 11.3 was deleted. 
Purpose:  Correct typographical errors, punctuation, grammar, abbreviations, and formatting 
These changes are not listed individually. 
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CLINICAL STUDY PROTOCOL 
ALN-AS1-002 
Protocol Title: 
A Multicenter, Open-label Extension Study to Evaluate the Long-term 
Safety and Clinical Activity of Subcutaneously Administered 
ALN-AS1 in Patients with Acute Intermittent Porphyria who have 
Completed a Previous Clinical Study with ALN-AS1 
Investigational Drug: 
ALN-AS1 (givosiran) 
EudraCT Number: 
2016-002638-54 
IND Number: 
126094 
Protocol Date: 
Original Protocol 19 July 2016 
Protocol Amendment 0.1 (Sweden) 20 September 2016 
Protocol Amendment 1 10 November 2016 
Protocol Amendment 2 01 December 2016 
Protocol Amendment 3 03 February 2017 
Protocol Amendment 4 02 August 2017 
Protocol Amendment 5 03 May 2018 
Sponsor: 
Alnylam Pharmaceuticals, Inc. 
300 Third Street 
Cambridge, MA  02142 USA 
Telephone:  
 
Sponsor Contact:  
 
 
The concepts and information contained in this document or generated during the study are considered 
proprietary and may not be disclosed in whole or in part without expressed written authorization of 
Alnylam Pharmaceuticals, Inc. 
237
PPD
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SPONSOR PROTOCOL APPROVAL 
I have read this protocol and I approve the design of this study. 
Date 
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INVESTIGATOR’S AGREEMENT 
 
I have read the ALN-AS1-002 protocol and agree to conduct the study as outlined.  I agree to 
maintain the confidentiality of all information received or developed in connection with this 
protocol. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Printed Name of Investigator 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signature of Investigator 
 
 
 
 
 
 
 
 
Date 
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PROTOCOL SYNOPSIS 
Protocol Title 
A Multicenter, Open-label Extension Study to Evaluate the Long-term Safety and Clinical Activity of 
Subcutaneously Administered ALN-AS1 in Patients with Acute Intermittent Porphyria who have 
Completed a Previous Clinical Study with ALN-AS1 
Product Name 
ALN-AS1 (givosiran) 
Indication 
Patients with acute intermittent porphyria (AIP) who experience recurrent porphyria attacks 
Phase 
1/2 
Study center(s)   
The study will be conducted at up to 8 clinical study centers worldwide. 
Objectives 
Primary 
 
Evaluate the long-term safety and tolerability of ALN-AS1 in patients with AIP 
Secondary 
 
Assess the pharmacodynamic (PD) effect of ALN-AS1 over time 
 
Assess the clinical activity of ALN-AS1 over time 
Exploratory 
 
Characterize the pharmacokinetic (PK) profile of ALN-AS1 and incidence of antidrug antibodies 
(ADA) over time 
 
Assess changes in health-related quality of life (QOL) 
 
Characterize analytes related to targeting the heme biosynthesis pathway 
Endpoints 
Primary 
 
Patient incidence of adverse events (AEs) 
Secondary 
 
Change in urine delta-aminolevulinic acid (ALA) and porphobilinogen (PBG) levels 
 
Frequency and characteristics of porphyria attacks 
 
Change in hemin administration 
Exploratory 
 
Change in circulating 5-aminolevulinic acid synthase 1 (ALAS1) mRNA levels 
 
Concentrations of ALN-AS1 and ADA 
 
Duration and treatment of porphyria attacks 
 
Number and duration of visits to a health care facility for acute porphyria care 
 
EQ-5D-5L questionnaire scores 
 
Pain assessment and narcotic use as recorded in a patient diary 
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 Exploratory biomarkers related to the target pathway, such as urine porphyrins, vitamin D binding 
protein 
Study Design 
This is a multicenter, open-label extension study to evaluate the long-term safety and clinical activity 
of ALN-AS1 in patients with AIP who completed study ALN-AS1-001. 
The last assessments performed, determining previous study (ALN-AS1-001) completion, will serve as 
the Screening/Baseline assessments in this study.  If more than 60 days have elapsed since the last 
assessment, safety assessments will be repeated before administration of ALN-AS1.  It is anticipated 
that patients will begin ALN-AS1 administration in this study within 6 months after the last dose of 
study drug in the previous study.  Eligibility will be confirmed before administration of the first dose of 
ALN-AS1 (Day 1).  Patients will undergo assessments at the clinical study center every month for the 
first 3 months.  Then, through Month 6, and according to the dosing regimen selected, assessments will 
take place at the clinical study center or via a phone contact (for an every month dosing regimen, visits 
will be every month; for an every 3 months dosing regimen, visits will be every 3 months).  After a 
patient has completed 12 months of ALN-AS1 administration in this study (6 months in an every 
month dosing regimen), and where applicable country and local regulations and infrastructure allow, 
study procedures, including ALN-AS1 administration, may take place at the patient’s home by a 
healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the 
Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit 
at the clinical study center every 3 months for the first year, and thereafter every 6 months through the 
end of the treatment period.  Additional visits to collect clinical laboratory samples may occur at home 
at any point during the treatment period, within 14 days prior to scheduled dose administration.  
Patients will return to the clinical study center for a posttreatment follow-up visit after administration 
of the last dose of ALN-AS1.  An ALA/PBG Monitoring/EOS visit will be conducted either at the 
clinical study center or via phone contact, unless treatment continues with ALN-AS1. 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, 
and narcotic use.  Patients will also be provided with laboratory sample collection kits and instructions 
for collecting and sending urine samples to the clinical study center. 
A Safety Review Committee (SRC) will review safety and tolerability data collected during the study 
with the primary purpose of protecting the safety of patients participating in the study. 
Number of Planned Patients 
Up to 24 patients are planned for enrollment in this study (including optional cohorts in 
ALN-AS1-001). 
Diagnosis and Main Eligibility Criteria 
Patients with AIP, who have completed Part C of study ALN-AS1-001, will be eligible for screening in 
this study.  Eligible patients will not be on a scheduled regimen of hemin to prevent porphyria attacks 
at Screening.  Patients with alanine transaminase ≥2.0× upper limit of normal, total bilirubin ≥2 mg/dL 
(unless bilirubin elevation is due to Gilbert’s syndrome), or estimated glomerular filtration rate ≤30 
mL/min/1.73 m2 (using the Modification of Diet in Renal Disease formula) at Screening are not 
eligible for this study. 
Investigational Product, Dose, and Mode of Administration 
ALN-AS1 Solution for Injection (subcutaneous use [SC]) is comprised of a synthetic, small interfering 
RNA targeting ALAS1 and bearing a triantennary N-acetyl galactosamine ligand conjugated to the 
sense strand, formulated in phosphate buffer.   
The study starting dose and regimen of ALN-AS1 is 5.0 mg/kg as an SC injection administered every 3 
months.  Based on emerging clinical data, the SRC may approve changes to the dosing regimen, 
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including decreases in the dose level and changes in the dosing frequency.  However any dose and 
dosing regimen will not exceed a previously explored dose level or frequency that was determined to 
be safe and well-tolerated in study ALN-AS1-001, SRC, Health Authority and Ethics Committee 
approval must be sought prior to dose escalation above 5.0 mg/kg in accordance with local Regulatory 
requirements.  
Reference Therapy, Dose, and Mode of Administration 
Not applicable 
Duration of Treatment and Study 
The duration of treatment is up to 36 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 44 months. 
Statistical Methods 
Statistical analyses will be primarily descriptive.  Incidence of AEs will be summarized by maximum 
severity and relationship to ALN-AS1.  Incidence of and serious adverse events (SAEs) and AEs 
leading to discontinuation will also be tabulated.  By-patient listings will be provided for deaths, SAEs, 
and events leading to discontinuation.  
Laboratory shift tables from baseline to worst values will be presented.  Abnormal physical 
examination findings and electrocardiogram data will be presented in by-patient listings.  Descriptive 
statistics will be provided for electrocardiogram interval data and presented as both actual values and 
changes from baseline relative to each on study evaluation and to the last evaluation on-study. 
Clinical activity of ALN-AS1 will be summarized primarily by descriptive statistics.  The clinical 
activity of ALN-AS1 will be evaluated by the frequency and characteristics of porphyria attacks 
including duration, treatment, and severity of porphyria attacks and number and duration of visits to a 
health care setting for acute porphyria care.  Patient diary recordings, including BPI-SF questionnaire 
scores, will also be summarized.   
PD analysis will include the evaluation of change in ALA, PBG, and ALAS mRNA levels.  Descriptive 
statistics (eg, mean and standard error of the mean) for observed levels of PD parameters and the 
relative change from baseline will be presented for each of the postdose follow-up time points. 
The PK concentration of ALN-AS1 will be determined.  Antidrug antibody results will be tabulated 
overall and by previous treatment in the previous study (ALN-AS1-001).  A by-patient listing will also 
be provided. 
Additional exploratory analyses may be conducted on analytes related to targeting the heme 
biosynthesis pathway.  Quality of life scores will also be summarized. 
 
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Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8 
M9 
M10/ 
M11 
M12 
M13/ 
M14 
M15b 
M16/ 
M17 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History/Disease 
Historyc 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/ 
Exclusion Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examinationd 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
 
 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
Vital Signsf 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Triplicate 12-Lead ECGg 
X 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Clinical Laboratory 
Assessmenth 
X 
Xa 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Study Drug Administrationj 
 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl 
 
X 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
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Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8 
M9 
M10/ 
M11 
M12 
M13/ 
M14 
M15b 
M16/ 
M17 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Blood Sample for PK 
Analysism 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Antidrug Antibodiesn 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
Porphyria Attack Kit 
Dispensationo 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EQ-5D-5L Questionnairep 
X 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Diary Review  
(including BPI-SF)q 
 
 
X 
Phone Contactr 
 
 
 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
AEs 
 
Continuous 
Concomitant Medicationss 
 
Continuous 
 
Abbreviations:  AE=adverse event; ALAS1=5-aminolevulinic acid synthase 1; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief 
Pain Inventory-Short Form; D=day; ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of 
life; SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may 
be conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical 
examinations and blood/urine sample collections. 
a Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study (ALN-AS1-001) were completed within 60 days 
of administration of the first dose of ALN-AS1 in this study.  If more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs 
will be repeated before administration of ALN-AS1.  Results should be available and deemed acceptable before the administration of the first dose of ALN-
AS1.  On Day 1, results from hematology, chemistry (including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the 
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Investigator before study drug administration.  If results from within the prior 14 days are not available at a dosing visit, locally analyzed predose assessments 
may be used for review in order to allow same day study drug administration and additional samples for central analysis must also be collected. 
b After a patient has completed 12 months of ALN-AS1 administration in this study, and where applicable country and local regulations and infrastructure allow, 
study procedures, including ALN-AS1 administration, may take place at the patient’s home by a healthcare professional.  Study procedures may occur at the
patient’s home at the discretion of the Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit at the clinical
study center Q6M.  Additional visits to collect clinical laboratory samples may occur at home at any point during the treatment period, within 14 days prior to 
scheduled dose administration. 
c See Section 7.1 for details on the interval medical history/disease history to be recorded at Screening/Baseline.  Ongoing AEs from the previous study 
(ALN-AS1-001) will be captured as medical history. 
d A complete physical examination will be performed at Screening/Baseline, and D1.  At all other visits, a targeted physical examination will be performed.  On 
dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any time 
during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On D1, vital signs will be collected within 1 hour predose; and 2 hours 
(±10 minutes) postdose.  On all other dosing days, vital signs will be collected within 1 hour predose.  On days when ALN-AS1 is not administered, vital signs 
can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position (should be consistent for each patient), after the 
patient has rested comfortably for at least 10 minutes. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at least 5 
minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose at a minimum of 2
of the following visits:  D1, Month 3, Month 6, Month 9, Month 12, Month 15 (only if visit is done at clinic), or Month 18.  In patients receiving >2.5 mg/kg 
ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose at a minimum of two of the following visits:  D1, Month 3, 
Month 6, Month 9, Month 12, Month 15 (only if visit is done at clinic), or Month 18.  On all other dosing days, ECGs will be collected within 1 hour predose 
(see Section 7.5.4 for ECG assessment details).   
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  On 
days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. On dosing days, results from hematology, chemistry 
(including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the Investigator before study drug administration.  If results 
from within the prior 14 days are not available at a dosing visit, locally analyzed predose assessments may be used for review in order to allow same day study 
drug administration and additional samples for central analysis  must  also be collected. 
i A serum pregnancy test will be performed at Screening/Baseline; thereafter, urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  For 
weight-based dosing, weight measured at the current study center visit (dosing day) will be used to calculate the dose of ALN-AS1 through M12.  After M12, 
weight measured at either the previous study center visit or the current study center visit may be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 3 (Appendix Section 11.1).  Blood sample collection for PK analysis at 
Month 9 and Month 15 is only necessary if ECG will be performed at same visit. 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o Porphyria attack laboratory sample collection kits should be dispensed at the screening visit along with instructions for use. For any attack that occurs through
M37, urine samples should be collected within 24 hours of the start of clinical intervention (eg, hemin or glucose administration) and within 24 hours of the end
of clinical intervention.  If patients are unable to report to the clinical study center during a porphyria attack, laboratory sample collection kits will be provided
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that contain instructions for collecting and sending urine samples to the clinical study center, if possible.  These urine samples may also be analyzed for 
exploratory biomarkers. 
p In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but not more than once in a 6 month period), if possible.  
q Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, and narcotic use on a daily basis through M9; 
thereafter, acute porphyria attacks will be recorded in the diary.  The BPI will be completed on a weekly basis as part of the patient diary through M9, then 
Q3M. 
r Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack. 
s Medications that are ongoing from the previous study (ALN-AS1-001), started between the previous study and this study, and started after signing informed 
consent in this study, will be captured as concomitant medication(s). 
 
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Table 2: 
Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
EOS/ 
ETb 
Safety 
Follow-
upc 
M19/ 
M20 
M21a 
M22/ 
M23 
M24 
M25/ 
M26 
M27a 
M28/ 
M29 
M30 
M31/ 
M32 
M33a 
M34/ 
M35 
M36/ 
EOT 
M37 
 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Physical Examinationd 
 
 
 
X 
 
 
 
X 
 
 
 
X 
X 
X 
Body Weight, BMI, and 
Heighte 
 
 
 
X 
 
 
 
X 
 
 
 
 
X 
 
Vital Signsf 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
Triplicate 12-Lead ECGg 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
 
Clinical Laboratory 
Assessmenth 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
Pregnancy Testi 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
Study Drug Administrationj 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl 
 
 
 
X 
 
 
 
X 
 
 
 
X 
X 
 
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Table 2: 
Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
EOS/ 
ETb 
Safety 
Follow-
upc 
M19/ 
M20 
M21a 
M22/ 
M23 
M24 
M25/ 
M26 
M27a 
M28/ 
M29 
M30 
M31/ 
M32 
M33a 
M34/ 
M35 
M36/ 
EOT 
M37 
 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Blood Sample for PK 
Analysism 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
Antidrug Antibodiesn 
 
 
 
X 
 
 
 
 
 
 
 
X 
X 
 
EQ-5D-5L Questionnaireo 
 
 
 
X 
 
 
 
X 
 
 
 
X 
X 
 
Diary Review (including 
BPI-SF)p 
X 
 
Phone Contactq 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; EOS = End of Study; EOT = End of Treatment; ET = Early Termination; M=month; PBG= porphobilinogen; 
PK=pharmacokinetics; Q=every; QOL=quality of life; SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
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a Where applicable country and local regulations and infrastructure allow, study procedures, including ALN-AS1 administration, may take place at the patient’s 
home by a healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the Investigator, based on safety and tolerability;
however, patients are required to complete at least 1 visit at the clinical study center Q6M.  
b Patients who complete all scheduled treatment with ALN-AS1 through Month 36 will return for an end of study (EOS) visit at Month 37.  Patients who 
discontinue treatment will be asked to complete an early termination (ET) visit at which all Month 37 visit procedures will be performed; the patient must also 
return for a safety-follow-up visit at 3 months (84 [+7] days) after his/her last dose of ALN-AS1.   
c The safety follow-up visit is only required for patients who discontinue prior to study completion.  The visit should be conducted  3 months (84 [+7 days]) 
following the last dose of ALN-AS1. 
d A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed. 
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for at least 10 minutes. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at least 
5 minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose .  In patients
receiving >2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose.  See Section 7.5.4 for ECG assessment 
details. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  . 
On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. 
i Urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured at either the previous study center visit or the current study center visit may be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 3 (Appendix Section 11.1).   
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack
(but, not more than once in a 6 month period), if possible.
p Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
q Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack.
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TABLE OF CONTENTS 
PROTOCOL SYNOPSIS ................................................................................................................4 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS ................................................18 
1. 
INTRODUCTION ......................................................................................................20 
1.1. 
Disease Overview .......................................................................................................20 
1.1.1. 
Epidemiology ..............................................................................................................20 
1.1.2. 
Current Management and Unmet Medical Need ........................................................21 
1.2. 
RNA Interference ........................................................................................................22 
1.3. 
ALN-AS1 ....................................................................................................................22 
1.4. 
Study Design Rationale ..............................................................................................22 
1.5. 
Dose Rationale ............................................................................................................22 
1.6. 
Clinical Data Summary ...............................................................................................23 
1.6.1. 
Clinical Pharmacodynamics .......................................................................................23 
1.6.2. 
Clinical Activity ..........................................................................................................24 
1.6.3. 
Clinical Safety ............................................................................................................25 
1.7. 
Benefit-Risk Assessment ............................................................................................26 
2. 
OBJECTIVES .............................................................................................................27 
2.1. 
Primary Objective .......................................................................................................27 
2.2. 
Secondary Objectives .................................................................................................27 
2.3. 
Exploratory Objectives ...............................................................................................27 
3. 
ENDPOINTS ..............................................................................................................27 
3.1. 
Primary Endpoint ........................................................................................................27 
3.2. 
Secondary Endpoints ..................................................................................................27 
3.3. 
Exploratory Endpoints ................................................................................................27 
4. 
INVESTIGATIONAL PLAN .....................................................................................28 
4.1. 
Summary of Study Design ..........................................................................................28 
4.2. 
Duration of Treatment and Study ...............................................................................29 
4.3. 
Number of Patients .....................................................................................................29 
4.4. 
Method of Assigning Patients to Treatment Groups ..................................................29 
4.5. 
Blinding ......................................................................................................................29 
4.6. 
Safety Review Committee ..........................................................................................29 
5. 
SELECTION AND WITHDRAWAL OF PATIENTS ..............................................30 
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5.1. 
Inclusion Criteria ........................................................................................................30 
5.2. 
Exclusion Criteria .......................................................................................................30 
5.3. 
Discontinuation of Study Drug and/or Study .............................................................31 
5.3.1. 
Discontinuation of Study Drug ...................................................................................31 
5.3.2. 
Discontinuation from the Study ..................................................................................31 
5.3.3. 
Withdrawal of Consent to Collect and Process the Patient’s Personal Data ..............32 
5.3.4. 
Replacement of Patients .............................................................................................33 
6. 
TREATMENTS ..........................................................................................................33 
6.1. 
Treatments Administered ............................................................................................33 
6.2. 
Investigational Study Drug .........................................................................................33 
6.2.1. 
Description ..................................................................................................................33 
6.2.2. 
Dose and Administration ............................................................................................33 
6.2.3. 
Dose Modifications .....................................................................................................34 
6.2.3.1. 
Study Population Dose Modifications ........................................................................34 
6.2.3.2. 
Individual Dose Modifications ...................................................................................34 
6.2.4. 
Preparation, Handling, and Storage ............................................................................35 
6.2.5. 
Packaging and Labeling ..............................................................................................35 
6.2.6. 
Accountability .............................................................................................................35 
6.3. 
Concomitant Medications ...........................................................................................36 
6.4. 
Contraceptive Requirements .......................................................................................37 
6.5. 
Treatment Compliance ................................................................................................37 
7. 
STUDY ASSESSMENTS ..........................................................................................38 
7.1. 
Screening/Baseline Assessments ................................................................................38 
7.2. 
Clinical Activity Assessments ....................................................................................38 
7.2.1. 
Patient Diary ...............................................................................................................38 
7.2.2. 
Brief Pain Inventory-Short Form Questionnaire ........................................................38 
7.3. 
Pharmacodynamic Assessments .................................................................................38 
7.4. 
Pharmacokinetic Assessments ....................................................................................38 
7.5. 
Safety Assessments .....................................................................................................39 
7.5.1. 
Vital Signs ..................................................................................................................39 
7.5.2. 
Weight and Height ......................................................................................................39 
7.5.3. 
Physical Examination .................................................................................................39 
7.5.4. 
Electrocardiogram .......................................................................................................39 
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7.5.5. 
Clinical Laboratory Assessments ...............................................................................40 
7.5.5.1. 
Immunogenicity ..........................................................................................................42 
7.5.5.2. 
Pregnancy Testing ......................................................................................................42 
7.5.6. 
Adverse Events ...........................................................................................................42 
7.5.6.1. 
Definitions ..................................................................................................................42 
7.5.6.2. 
Eliciting and Recording Adverse Events ....................................................................44 
7.5.6.3. 
Serious Adverse Events Require Immediate Reporting to Sponsor/Designee ...........45 
7.5.6.4. 
Sponsor Safety Reporting to Regulatory Authorities .................................................45 
7.5.6.5. 
Serious Adverse Event Notification to the Institutional Review 
Board/Independent Ethics Committee ........................................................................46 
7.5.6.6. 
Pregnancy Reporting ..................................................................................................46 
7.5.6.7. 
Overdose Reporting ....................................................................................................46 
7.6. 
Exploratory Assessments ............................................................................................47 
7.7. 
Other Assessments ......................................................................................................47 
7.7.1. 
EQ-5D-5L Questionnaire ............................................................................................47 
8. 
STATISTICS ..............................................................................................................47 
8.1. 
Determination of Sample Size ....................................................................................47 
8.2. 
Statistical Methodology ..............................................................................................47 
8.2.1. 
Populations to be Analyzed ........................................................................................48 
8.2.2. 
Examination of Subgroups .........................................................................................48 
8.2.3. 
Handling of Missing Data ...........................................................................................48 
8.2.4. 
Baseline Evaluations ...................................................................................................48 
8.2.5. 
Clinical Activity Analyses ..........................................................................................48 
8.2.6. 
Pharmacodynamic Analysis........................................................................................48 
8.2.7. 
Pharmacokinetic Analysis ..........................................................................................49 
8.2.8. 
Safety Analyses ..........................................................................................................49 
8.2.9. 
Other Analyses ............................................................................................................49 
9. 
STUDY ADMINISTRATION ...................................................................................49 
9.1. 
Ethical and Regulatory Considerations ......................................................................49 
9.1.1. 
Informed Consent .......................................................................................................50 
9.1.2. 
Ethical Review ............................................................................................................50 
9.1.3. 
Study Documentation, Confidentiality, and Records Retention .................................50 
9.1.4. 
End of the Study .........................................................................................................51 
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9.1.5. 
Discontinuation of the Clinical Study.........................................................................51 
9.2. 
Data Quality Control and Quality Assurance .............................................................51 
9.2.1. 
Data Handling .............................................................................................................51 
9.2.2. 
Study Monitoring ........................................................................................................51 
9.2.3. 
Audits and Inspections ................................................................................................52 
9.3. 
Publication Policy .......................................................................................................52 
10. 
LIST OF REFERENCES ............................................................................................53 
11. 
APPENDICES ............................................................................................................56 
11.1. 
Pharmacokinetic Assessment Time Points .................................................................56 
11.2. 
Schedules of Assessments for Every Month Dosing Regimen ..................................57 
11.3. 
List of Sensitive CYP3A Substrates and those with a Narrow Therapeutic 
Range ..........................................................................................................................64 
11.4. 
Anaphylactic Reactions ..............................................................................................65 
 
LIST OF TABLES 
Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 
Months Dosing Regimen) .............................................................................................7 
Table 2: 
Schedule of Assessments:  Month 19 through End of Study (Every 3 Months 
Dosing Regimen) ........................................................................................................11 
Table 3: 
Pharmacokinetic Time Points .....................................................................................56 
Table 4: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 
Month Dosing Regimen) ............................................................................................57 
Table 5: 
Schedule of Assessments:  Month 19 through End of Study (Every Month 
Dosing Regimen) ........................................................................................................61 
Table 6: 
List of Sensitive CYP3A Substrates and those with a Narrow Therapeutic 
Range ..........................................................................................................................64 
Table 7: 
 Sampson Criteria for Anaphylactic Reactions ...........................................................65 
 
LIST OF FIGURES 
Figure 1: 
Part C Cohort 1 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in .........................................................................................................................24 
Figure 2: 
Part C Cohort 2 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in .........................................................................................................................25 
Figure 3: 
Study Design ...............................................................................................................29 
 
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LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
Abbreviation 
Definition 
AE 
Adverse event 
AHP 
Acute hepatic porphyria 
AIP 
Acute intermittent porphyria 
ALA 
Delta-aminolevulinic acid 
ALAS1 
5-aminolevulinic acid synthase 1 
ALP 
Alkaline phosphatase 
ASGPR 
Asialoglycoprotein receptor 
ASHE 
Asymptomatic high excreters 
BPI-SF 
Brief Pain Inventory-Short Form 
cERD 
Circulating extracellular RNA detection assay 
CRF 
Case report form 
CYP 
Cytochrome P450 
ECG 
Electrocardiogram 
eCRF 
Electronic case report form 
eGFR 
Estimated Glomerular Filtration Rate 
EDC 
Electronic data capture 
EOS 
End of study 
EU 
European Union 
GalNAc 
N-acetyl galactosamine 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practice 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
IEC 
Independent Ethics Committee 
IRB 
Institutional Review Board 
ISR 
Injection site reaction 
IV 
Intravenous 
LFT 
Liver function test 
mRNA 
Messenger RNA 
NHP 
Nonhuman primate 
NOAEL 
No observed adverse effect level 
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Abbreviation 
Definition 
NOEL 
No observed effect level 
OTC 
Over the counter 
PBG 
Porphobilinogen 
PBGD 
Porphobilinogen deaminase 
PD 
Pharmacodynamic(s) 
PK 
Pharmacokinetic(s) 
QOL 
Quality of life 
RNA 
Ribonucleic acid 
RNAi 
RNA interference 
SAE 
Serious adverse event 
SAP 
Statistical Analysis Plan 
SC 
Subcutaneous 
siRNA 
Small interfering RNA 
SRC 
Safety Review Committee 
SUSAR 
Suspected unexpected serious adverse reaction 
ULN 
Upper limit of normal 
US 
United States 
WOCBP 
Woman of child-bearing potential 
 
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1. 
INTRODUCTION 
1.1. 
Disease Overview 
The porphyrias are a family of rare metabolic disorders predominately caused by a genetic 
mutation in 1 of the 8 enzymes responsible for heme synthesis.[1]  The 2 major categories are 
erythropoietic and hepatic, depending on the major site of expression of the underlying enzyme 
deficiency.[2]  In addition, the porphyrias are classified as acute if patients present with 
neurovisceral symptoms (eg, abdominal pain and neurologic symptoms) or cutaneous if they 
present with dermal blistering or photosensitivity.[3, 4]   
This study will include patients with acute intermittent porphyria (AIP), the most common acute 
hepatic porphyria (AHP).  AIP occurs as a result of an autosomal dominant mutation leading to 
partial deficiency of porphobilinogen deaminase (PBGD), the third enzyme in the heme 
biosynthesis pathway.[5]  The rate limiting step in heme synthesis is the upstream enzyme 
5-aminolevulinic acid synthase 1 (ALAS1), which is controlled by feedback repression via the 
end-product heme.  In response to a decrease in endogenous heme in the liver, as can occur with 
fasting, hormonal alterations, or with cytochrome P450 (CYP) inducing drugs, ALAS1 is 
induced, resulting in increased flux through the heme synthesis pathway.  In patients with AIP, 
this can result in the marked accumulation of the toxic heme intermediates porphobilinogen 
(PBG) and delta aminolevulinic acid (ALA) in the blood and urine due to the deficiency in the 
downstream PBGD.  Clinically, this manifests as acute attacks characterized by severe 
abdominal pain, cardiovascular as well as neurologic and psychiatric dysfunction.[6] 
1.1.1. 
Epidemiology 
Over 370 mutations have been identified in the PBGD gene, which in most instances result in its 
reduction by approximately 50%.  The exact prevalence of AIP is unknown due to under 
diagnosis, variation by geographic region, and the differences in penetrance observed for the 
different mutations.[2]  However, it is estimated that the prevalence of AIP is 5 to 10 per 100,000 
people in Western countries, while in Sweden it occurs in 1 in 1,000 people due to a founder 
effect associated with the resultant G593A mutation.[7-10]  AIP shows incomplete penetrance 
and on average only 10% to 50% of carriers with a mutation present with clinical symptoms.[11]  
It has been proposed that unknown inherited co-factors, in addition to PBGD mutations, may 
explain why a small percentage of patients present with much more severe disease while the 
majority remain asymptomatic. 
Patients with AIP present with acute attacks characterized by neurovisceral symptoms and signs 
including severe abdominal pain, nausea, vomiting, constipation, or less commonly diarrhea, 
hypertension, tachycardia, fever, muscle weakness, as well as neurological (eg, neuropathy, 
seizures) and psychiatric (eg, anxiety and confusion) manifestations.[12]  AIP attacks typically 
start after puberty and can be triggered by exogenous factors such as medications (especially 
barbiturates, sulfonamides, and hydantoins), stress, exogenous hormones, nutritional status, and 
infection.  Clinically active disease is more common in women, where attacks often occur around 
the menstrual cycle and are likely precipitated by hormonal changes. 
Many AIP patients remain undiagnosed given that the disease is rare and characterized by 
non-specific symptoms (eg, abdominal pain and nausea).[2]  The initial diagnosis involves 
demonstrating elevated urinary PBG (typically 20-50 × normal reference range) and ALA 
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(typically 5-20 × normal reference range) when the patient is having acute attack symptoms.  
Once a test is positive for elevated ALA and PBG and porphyria is suspected, genetic testing for 
a PBGD mutation is performed.   
There are 4 main clinical phenotypes of AIP.  Latent gene carriers have never had an acute attack 
and are biochemically inactive (normal urinary ALA and PBG).  Asymptomatic high excreters 
(ASHE) do not have current acute attacks, but are biochemically active (increased urinary ALA 
and PBG).  The increased levels of ALA and PBG in ASHE patients are lower than those in AIP 
patients during an acute attack, but are still significantly higher than normal reference values.[6-
8]  Sporadic attack patients have infrequent acute attacks.  Recurrent attack patients have ≥4 
attacks per year requiring hospitalization or treatment by a medical professional.[7] 
1.1.2. 
Current Management and Unmet Medical Need 
Management of acute attacks often requires hospitalization.  Patients are initially treated with 
supportive care and carbohydrate loading, analgesics and anti-emetics, and removal of known 
precipitating factors.[13]  In patients with moderate to severe attacks, or who fail to respond to 
supportive measures, treatment with intravenous (IV) hemin (daily for 3-5 days) is commenced.  
Symptoms typically begin to improve after 2 to 5 days of hemin treatment, accompanied by a 
lowering of urinary ALA and PBG levels to below or at the upper limit of normal (ULN) 
reference value; however, in some patients attacks can last several weeks, requiring prolonged 
hemin use and hospitalization.[14]  With prolonged and severe attacks, cranial nerve 
involvement can occur, leading to bulbar paralysis, respiratory failure, and death.[15]  
Hemin, a blood derived therapy, was approved as Normosang® (heme arginate) in the European 
Union (EU) and as Panhematin® (lyophilised hematin) in the United States (US) in 1999 and 
1983, respectively.[16, 17]  In the EU, heme arginate is indicated for the treatment of acute 
attacks of hepatic porphyria (eg, AIP, variegate porphyria, and hereditary coproporphyria); 
whereas, in the US lyophilized hemin is limited to the amelioration of recurrent attacks of AIP 
temporally related to the menstrual cycle.  Approval of both products was based on biochemical 
efficacy (ie, lowering of ALA and PBG) as well as data from uncontrolled case series and case 
reports.[18-22]  Hemin side effects include thrombophlebitis, transient anticoagulation, and in 
rare cases, anaphylaxis or renal failure.[22-24]  In addition, hemin administration requires a large 
vein for administration, often necessitating central venous access. 
While the majority of patients who experience attacks have them sporadically, it is estimated that 
up to 1,000 AIP patients experience recurrent attacks (typically defined as ≥4 per year) in the US 
and EU combined.[25]  While hemin is currently only approved to ameliorate acute attacks, it is 
administered prophylactically in some patients with recurrent attacks (eg, administered every 1-2 
weeks).[26]  Potential problems associated with chronic hemin administration include infusion 
site phlebitis, iron overload, and the need for chronic IV access and associated complications (eg, 
risk of infection or occlusion).[5]  In addition, there have been reports of a decrease in efficacy 
with chronic hemin administration, as evidenced by the need to increase the frequency or dosage 
of hemin prophylaxis over time in attempt to maintain a clinical effect.[27]  In patients with very 
severe recurrent attacks, or in whom hemin treatment is not effective, liver transplantation can be 
curative; however, organ transplantation is a high-risk procedure and is rarely used as a treatment 
option [34].  Given the significant morbidity and mortality, there remains a significant unmet 
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need for an efficacious, simple, fast-acting and better tolerated treatment for acute or prevent 
recurrent attacks in patients with AIP. 
1.2. 
RNA Interference 
RNA interference (RNAi) is a naturally occurring cellular mechanism mediated by small 
interfering RNAs (siRNAs) for regulating gene expression.  Typically, synthetic siRNAs are 19 
to 25 base pair double stranded oligonucleotides in a staggered duplex with a 2-nucleotide 
overhang at both or 1 of the 3’ ends.[28]  Such siRNAs can be designed to target an endogenous 
messenger RNA (mRNA) transcript of a given gene.  When introduced into cells, the net effect 
of an RNAi-based pharmacological approach is the binding of the siRNA to its complementary 
mRNA sequence, cleavage of this target mRNA, and reduction of synthesis of the target protein, 
resulting in a decrease of the target protein levels.[29]  The ability to selectively and potently 
degrade the mRNA encoding the ALAS1 protein (thereby decreasing accumulation of the toxic 
intermediates ALA and PBG) using an siRNA is a novel approach for the prevention and 
treatment of acute attacks in patients with AIP.   
1.3. 
ALN-AS1 
ALN-AS1 (givosiran) comprises a synthetic siRNA covalently linked to a GalNAc containing 
ligand (ALN60519), specific for ALAS1 and formulated for administration via subcutaneous 
(SC) injection. ALN-60519 has a target region between nucleotide 918 to 937 of the ALAS1 
mRNA. Attachment to a triantennary GalNAc ligand to the siRNA enables its distribution to the 
liver (which is the primary site of ALAS1 synthesis), followed by intracellular delivery to 
hepatocytes via ASGPR, resulting in engagement of the RNAi pathway and suppression of 
hepatic ALAS1 protein synthesis. 
ALN-AS1 is currently in development for treatment of acute attacks in patients with AIP, the 
most common AHP. 
Further information on ALN-AS1, including the clinical and nonclinical experience to date, is 
available in in the current version of the Investigator’s Brochure (IB). 
1.4. 
Study Design Rationale 
This is a multicenter, open-label extension study designed to evaluate the long-term safety and 
clinical activity of subcutaneously administered ALN-AS1 in patients with AIP who have 
completed clinical study ALN-AS1-001.  The primary endpoint for the study is the incidence of 
AEs. 
1.5. 
Dose Rationale 
Clinical data from Part A and Part B of the ongoing study ALN-AS1-001 demonstrate that single 
(0.035-2.5 mg/kg) and multiple (0.35-1.0 mg/kg) doses of ALN-AS1 have been generally 
well-tolerated in patients with AIP who are ASHE.  Additionally, data from this study indicate 
that a single dose of 2.5 mg/kg ALN-AS1 results in near normalization of urine ALA and PBG 
levels, which is sustained for approximately 14 weeks.   
Patients in Part C of the ongoing study ALN-AS1-001 who are eligible for participation in this 
study will likely require a higher dose of ALN-AS1 to normalize ALA and PBG as they have 
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higher levels of ALAS1 upregulation and higher baseline levels of ALA and PBG, when 
compared to patients with AIP who are ASHE.[30]  For example, based on preliminary data in 
Part A and Part B of the ALN-AS1-001 study, the mean PBG level of patients who are ASHE is 
21.9 mmol/mol Cr (N=28); whereas, in Part C of this study in patients with AHP who have 
recurrent porphyria attacks, the mean PBG level is approximately 49.3 mmol/mol Cr (N=12). 
The study starting dose and regimen of ALN-AS1 is 5.0 mg/kg as an SC injection administered 
every 3 months.  Based on emerging clinical data, the SRC may approve changes to the ALN-
AS1 dosing regimen, including decreases in the dose level and changes in dosing frequency.  
However, any dosing regimen will not exceed a previously explored dose level or frequency that 
was determined to be safe and well-tolerated in study ALN-AS1-001. SRC, Health Authority and 
Ethics Committee approval must be sought prior to dose level escalation above 5.0 mg/kg in 
accordance with local Regulatory requirements. 
The study starting dose and regimen was selected based on the benefit:risk profile of ALN-AS1 
in Part C of the ongoing ALN-AS1-001 study.  Preliminary data to date indicate that 
administration of 5.0 mg/kg ALN-AS1 has been generally well-tolerated.  There have been no 
study drug-related serious adverse events (SAEs), severe AEs, or clinically significant changes in 
safety parameters.  While a single 2.5 mg/kg dose of ALN-AS1 has also been generally well-
tolerated when administered to patients in Part A and Part C of study ALN-AS1-001, this dose 
has not resulted in near normalization of ALA and PBG levels.  In addition, while emerging data 
from Part C indicate that an every 3 months dose of 2.5 mg/kg ALN-AS1 demonstrated some 
clinical activity (eg, decrease in attack frequency and decrease in heme use), some patients 
continued to experience breakthrough porphyria attacks during the treatment period, indicating 
that a higher dose may be required. 
The duration of dosing in this study is supported by the overall favorable safety profile of 
ALN-AS1 in the ongoing clinical study ALN-AS1-001 and the absence of new findings in 
nonclinical studies with ALN-AS1. 
1.6. 
Clinical Data Summary 
1.6.1. 
Clinical Pharmacodynamics 
Dosing has been completed in Part A and Part B of the study.  In both Parts A and B of the study, 
durable and dose-dependent reductions of ALAS1 mRNA (up to 66% in the 2.5 mg/kg dose 
group) as measured by cERD were observed after ALN-AS1 treatment.  ALAS1 reductions were 
highly correlated with reductions in ALA (mean maximal 86%) PBG (mean maximal 95%) 
levels in a dose-dependent manner and were sustained for ≥180 days. 
Dosing is currently ongoing in Part C of the study. The mean maximal reduction in ALAS1 
mRNA relative to baseline in ALN-AS1-treated patients in Cohort 1 (2.5 mg/kg Q3M) was 39% 
and in Cohort 2 (2.5 mg/kg Q1M) 66%.  All patients treated with ALN-AS1 also had decreases 
in their peak ALA and PBG levels in the treatment period compared to the run-in period, along 
with reduced fluctuations in these levels in the treatment period (data not shown). No reductions 
were observed in the placebo-treated patients.  
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1.6.2. 
Clinical Activity 
Clinical activity was not evaluated in Parts A and B of the study because ASHE patients included 
in this study were not actively experiencing attacks of porphyria. 
Dosing is currently ongoing in Part C of the study. All patients in Cohorts 1 and 2 were enrolled 
in a run-in phase for 10-15 weeks that was followed by a treatment phase for up to 24 weeks.  No 
investigational product was administered during the run-in phase.  Therefore, each patient acted 
as their own control, allowing for individual ALA / PBG levels, and overall attack rate while on 
ALN-AS1 treatment to be compared to that observed in the run-in phase.   
Figure 1 shows in Cohort 1 ALN-AS1-treated patients there was a 74% mean decrease in the 
annualized attack rate for the treatment period versus the run-in period (range: 63-94% 
reduction), compared with a 23% decrease in the annualized attack rate for the placebo-treated 
patient.  In ALN-AS1-treated patients this was accompanied by an approximate 76% mean 
decrease in annualized acute hemin usage (range 52-95%) and a 10.3 times increase in the 
maximal attack free interval compared to run-in period (range 4.2-16.3). 
Figure 1: 
Part C Cohort 1 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in 
 
Figure 2 shows in Cohort 2 ALN-AS1-treated patients, there was a 58% mean decrease in the 
annualized attack rate for the treatment period versus the run-in period (range: 45-76% 
reduction).  This compares favorably with data from the placebo-treated patient who showed a 
34% reduction in the annualized attack rate for the treatment period versus the run-in period.  In 
ALN-AS1-treated patients, the reduction in attack rate was accompanied by a 92% mean 
decrease in annualized hemin usage (range 84-100%) and a 2.7x increase in the mean maximal 
attack free interval compared to run-in period (range 2.1-3.2). 
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Figure 2: 
Part C Cohort 2 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in 
 
1.6.3. 
Clinical Safety 
In Part A and Part B of Study ALN-AS1-001, a total of 11 patients (11/13; 85.0%) who received 
ALN-AS1 reported at least 1 AE.  All 5 placebo-treated patients (5/5; 100%) reported at least 1 
AE.  AEs considered possibly or definitely related to ALN-AS1 were reported in 5 patients 
(5/13; 38%): diarrhoea, dyspepsia, hematochezia, injection site erythema, injection site pain, 
blood creatinine increased, glomerular filtration rate decreased, and hypoesthesia (each AE 
reported only by an individual patient; 1/13; 8% each).  There were 2 SAEs of abdominal pain: 1 
patient each in the 0.035 mg/kg and 0.1 mg/kg ALN-AS1 dose groups.  Both were considered to 
be not related and resolved without sequelae.  There were no AEs leading to discontinuation.  All 
AEs were mild or moderate in severity, except for 1 of the SAEs of abdominal pain (0.10 mg/kg 
dose group), which was considered severe. Adverse events related to abnormal laboratory values 
were seen in 1 patient in the 0.35 mg/kg ALN-AS1 dose group who had AEs of ALT increased 
and AST increased, which were moderate and considered by the Investigator to be unrelated to 
ALN-AS1.  No clinically significant findings were observed with routine monitoring of CRP and 
a panel of 9 proinflammatory cytokines collected predose and up to 24 hours post-dose.  There 
were no other clinically significant laboratory abnormalities related to study drug or changes in 
vital signs, or ECGs in patients who were administered ALN AS1 or placebo. 
Dosing is ongoing in Part C of the study. All patients who received ALN-AS1 in cohort 1 and 2 
reported at least 1 AE.  AEs that were reported in at least 2 subjects were nausea in 3 patients 
(50%) and abdominal pain, vomiting, nasopharyngitis, headache, cough and oropharyngeal pain 
in 2 patients (33.3%) each.  All AEs were mild or moderate in severity.  AEs considered possibly 
or definitely related to ALN-AS1 were reported in 4 patients (66.6%), 1 each:  renal impairment 
in Cohort 1 and injection site reaction, myalgia, and headache in Cohort 2. Both placebo-treated 
patients reported AEs.  No AE was experienced in more than 1 patient.  
In Part C, Cohort 1 or 2, there were no SAEs or AEs leading to discontinuation in patients 
administered ALN-AS1 or placebo. No clinically significant laboratory abnormalities related to 
study drug or changes in vital signs, ECG, or physical exam findings were observed in patients 
administered ALN-AS1 or placebo. 
Part C Cohort 3 5.0 mg/kg SC monthly dosing is ongoing.  In this cohort there was one fatal 
SAE of acute pancreatitis, which was determined to be unlikely related to study drug or placebo 
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by the Investigator due to the presence of gall bladder sludge found at the time of her 
presentation.  Contributors to this patient's adverse clinical course included: pre-existing chronic 
debilitation from recurrent AIP attacks requiring monthly hospitalization, porphyria-attributed 
quadriplegia requiring nursing home care, delay in hospital admission and complications from 
thromboembolism (multiple risk factors included pancreatitis, obesity, immobilisation from 
quadriparesis and recent hospitalization for infected portacath removal).  Serum lipase was added 
to all scheduled laboratory assessments in November 2016 as part of additional safety 
monitoring. To date, all lipase results (available in 11 of 15 subjects) have been at or below the 
upper limit of normal with no trends seen with dosing of study drug or placebo. 
Further information on the safety, efficacy, PK and PD of ALN-AS1 are available in the 
Investigator’s Brochure. 
1.7. 
Benefit-Risk Assessment 
Patients participating in this study may experience a reduced number or severity of porphyria 
attacks, reduced treatment with IV hemin, and/or reduced requirement for pain medication.  As 
presented in Section 1.6, emerging data demonstrate that patients given ALN-AS1 experienced 
reduced ALA/PBG levels, decreased attack frequency and reduced heme usage in the 24-week 
treatment period compared to the 12-week run-in period in Study ALN-AS1-001 
As detailed in Section 1.6, a fatal SAE of hemorrhagic pancreatitis was reported but deemed to 
be unlikely related to study drug.  However, the potentially non-adverse nonclinical finding of 
angiectasis in the islets of Langerhans (endocrine, not exocrine region) of the rat pancreas (see 
Investigator Brochure), do not exclude a potential association between ALN-AS1 and the SAE of 
hemorrhagic pancreatitis. 
The important potential risks associated with administration of ALN-AS1 in patients with AIP 
are as follows: 
 Injection site reactions (ISRs):  ALN-AS1 is administered by SC injection.  In the 
ongoing ALN-AS1 clinical study, AEs of ISRs have been infrequently reported and 
have been mild to moderate in severity with single dosing.  Injection site rotation and 
close monitoring have been implemented in ALN-AS1 clinical studies to reduce the 
potential for ISRs.  
 Pancreatitis: Since an association between ALN-AS1 and the fatal SAE of 
hemorrhagic pancreatitis can not be ruled out, patients will undergo routine 
monitoring of systemic and pancreatic inflammation and coagulation throughout the 
study.  Hematology, chemistry and coagulation results are required to be available 
prior to each dose. 
 Liver transaminase abnormalities:  As ALN-AS1 is targeted for delivery to the liver, 
and reversible hepatic changes were observed in some animal species, there is a 
potential for development of liver function test (LFT) abnormalities.  To minimize the 
potential for LFT abnormalities, patients are required to have adequate liver function 
at study entry and LFTs are monitored during the study. 
 Anaphylactic reactions:  There is a potential risk of developing a severe allergic 
reaction with ALN-AS1 administration.  In the present study, one patient in the 
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2.5 mg/kg monthly dose group with a history of asthma and multiple allergies 
experienced an SAE of anaphylactic reaction that was determined by the Investigator 
to be definitely related to study drug given the temporal relationship of ALN-AS1 
treatment to the onset of the reaction (within minutes).  The patient was treated and 
recovered and was discontinued from the study.  Guidance on dose administration 
and monitoring for anaphylactic reactions has been included in this protocol. 
The complete summary of the clinical and nonclinical data relevant to the investigational drug 
and its study in human subjects is provided in the Investigator’s Brochure. 
2. 
OBJECTIVES 
2.1. 
Primary Objective 
 Evaluate the long-term safety and tolerability of ALN-AS1 in patients with AIP 
2.2. 
Secondary Objectives 
 Assess the PD effect of ALN-AS1 over time 
 Assess the clinical activity of ALN-AS1 over time 
2.3. 
Exploratory Objectives 
 Characterize the PK profile of ALN-AS1 and incidence of ADA over time 
 Assess changes in health-related quality of life (QOL) 
 Characterize analytes related to targeting the heme biosynthesis pathway 
3. 
ENDPOINTS 
3.1. 
Primary Endpoint 
 Patient incidence of AEs 
3.2. 
Secondary Endpoints 
 Change in urine ALA and PBG levels 
 Frequency and characteristics of porphyria attacks 
 Change in hemin administration 
3.3. 
Exploratory Endpoints 
 Change in circulating ALAS1 mRNA levels 
 Concentrations of ALN-AS1 and ADA  
 Duration and treatment of porphyria attacks 
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 Number and duration of visits to a health care facility for acute porphyria care 
 EQ-5D-5L questionnaire scores 
 Pain assessment and narcotic use as recorded in a patient diary 
 Exploratory biomarkers related to the target pathway, such as urine porphyrins, 
vitamin D binding protein 
4. 
INVESTIGATIONAL PLAN 
4.1. 
Summary of Study Design 
This is a Phase 1/2 multicenter, open-label extension study to evaluate the long-term safety and 
clinical activity of ALN-AS1 in patients with AIP who completed study ALN-AS1-001.  The 
study will be conducted at up to 8 clinical study centers worldwide. 
The last assessments performed, determining previous study (ALN-AS1-001) completion, will 
serve as the Screening/Baseline assessments in this study.  If more than 60 days have elapsed 
since the last assessment, safety assessments (eg, ECG and clinical laboratory tests) will be 
repeated before administration of ALN-AS1.  It is anticipated that patients will begin ALN-AS1 
administration in this study within 6 months after the last dose of study drug in the previous 
study.  Eligibility will be confirmed during Screening/Baseline and before administration of the 
first dose of ALN-AS1 (Day 1).  Patients will undergo assessments at the clinical study center 
every month for the first 3 months.  Then, through Month 6, and according to the dosing regimen 
selected, assessments will take place at the clinical study center or via a phone contact (for an 
every month dosing regimen, visits will be every month; for an every 3 months dosing regimen, 
visits will be every 3 months; see Section 6.2.2).  After a patient has completed 12 months of 
ALN-AS1 administration in this study (6 months in an every month dosing regimen), and where 
applicable country and local regulations and infrastructure allow, study procedures, including 
ALN-AS1 administration, may take place at the patient’s home by a healthcare professional (as 
indicated in the Schedules of Assessments in Table 1 and Table 2 ; and Table 4 and Table 5 in 
Appendix Section 11.2).  Study procedures may occur at the patient’s home at the discretion of 
the Investigator, based on safety and tolerability; however, patients are required to complete at 
least 1 visit at the clinical study center every 3 months for the first year, and thereafter every 6 
months through the end of the treatment period.  Additional visits to collect clinical laboratory 
samples may occur at home at any point during the treatment period, within 14 days prior to 
scheduled dose administration.  Patients will return to the clinical study center for a 
posttreatment follow-up visit after administration of the last dose of ALN-AS1.  An ALA/PBG 
Monitoring/EOS visit will be conducted either at the clinical study center or via phone contact, 
unless treatment continues with ALN-AS1. 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain 
assessments, and narcotic use.  Additionally, patients will be encouraged to report to the clinical 
study center if they experience a porphyria attack through Month 37.  In the event that patients 
are unable to report to the clinical study center during a porphyria attack, laboratory sample 
collection kits containing instructions for collecting and sending urine samples to the clinical 
study center, if possible, will be provided.  Patients will be contacted by phone after a porphyria 
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attack to record attack details.  If patients are experiencing signs and symptoms of a porphyria 
attack when ALN-AS1 administration is scheduled, the Investigator will determine whether 
administration of ALN-AS1 is appropriate.  If patients are treated for a porphyria attack at a 
health care facility (eg, hospital, emergency department, infusion center, or outpatient clinic) 
other than the clinical study center, copies of medical records, including discharge summaries, 
will be requested.   
A Safety Review Committee (SRC) will review safety and tolerability data collected during the 
study with the primary purpose of protecting the safety of patients participating in the study (see 
Section 4.6). 
Figure 3: 
Study Design 
 
4.2. 
Duration of Treatment and Study 
The duration of treatment is up to 36 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 44 months.   
4.3. 
Number of Patients 
Up to 24 patients are planned for enrollment in this study (including optional cohorts in 
ALN-AS1-001). 
4.4. 
Method of Assigning Patients to Treatment Groups 
This is an open-label study; all patients will receive ALN-AS1.  A combination of the clinical 
study center number and screening number will create the unique patient identifier.  The clinical 
study center number will be assigned by the Sponsor.  Upon signing the Informed Consent Form 
(ICF), the patient will be assigned a screening number by the clinical study site, which will be 
the same unique patient identifier assigned in the previous study (ALN-AS1-001).  The 
Investigator, or delegate, will confirm that the patient fulfills all the inclusion criteria and none of 
the exclusion criteria. 
4.5. 
Blinding 
This is an open-label study, and all patients will receive ALN-AS1. 
4.6. 
Safety Review Committee 
An SRC will be involved in the conduct of this study.  The SRC has the responsibility for 
monitoring the safety of the study participants.  The SRC will perform periodic reviews of safety 
and tolerability data during the course of the clinical study at least every 3 months for the first 6 
Complete Study
ALN-AS1-001
Screening
(Day -60 to -1)
Treatment Period
(36 Months)
Posttreatment 
Follow-up
(3 months)
End of Study
(Month 42)
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months of the study and thereafter at least every 6 months.  The SRC may also meet on an ad hoc 
basis for review of emergent safety and tolerability data, as defined in the SRC Charter for this 
clinical study.  The SRC will not stop the study for efficacy. 
The SRC will be comprised of the following members:  Principal Investigator(s), or designee(s), 
the Sponsor Medical Monitor, and the Study Medical Monitor. 
The membership of the SRC and reporting structure are further defined in the SRC Charter. 
5. 
SELECTION AND WITHDRAWAL OF PATIENTS 
5.1. 
Inclusion Criteria 
Each patient must meet all of the following inclusion criteria to be eligible for enrollment in this 
study: 
1. Completed and, in the opinion of the Investigator, tolerated study drug dosing in Part C 
of study ALN-AS1-001 
2. Not on a scheduled regimen of hemin to prevent porphyria attacks at Screening 
3. Women of child-bearing potential (WOCBP) must have a negative serum pregnancy test, 
cannot be breast feeding, and must be willing to use acceptable methods of contraception 
14 days before first dose, throughout study participation, and for 90 days after last dose 
administration.  Acceptable methods include hormonal methods along with an additional 
barrier method (eg, condom, diaphragm, or cervical cap), or a double barrier method of 
contraception for those WOCBP for whom a hormonal method of contraception is 
medically contraindicated due to underlying disease (see Section 6.4 for acceptable 
methods of contraception).   
4. Willing and able to comply with the study requirements and to provide written informed 
consent 
5.2. 
Exclusion Criteria 
Each patient must not meet any of the following exclusion criteria to be eligible for enrollment in 
this study: 
1. Alanine transaminase ≥2.0×ULN or total bilirubin ≥2 mg/dL (unless bilirubin elevation is 
due to Gilbert’s syndrome) 
2. Estimated glomerular filtration rate ≤30 mL/min/1.73 m2 (using the Modification of Diet 
in Renal Disease formula) 
3. History of multiple drug allergies or history of allergic reaction to an oligonucleotide or 
to N-acetyl galactosamine ligand (GalNAc) 
4. Received an investigational agent, other than ALN-AS1, or who are in follow-up of 
another clinical study of an investigational agent within 90 days before study drug 
administration 
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5. Other medical conditions or comorbidities which, in the opinion of the Investigator, 
would interfere with study compliance or data interpretation 
5.3. 
Discontinuation of Study Drug and/or Study 
Patients or their legal guardians (in the case that the patient is a minor) are free to discontinue 
treatment and/or study or withdraw their consent at any time and for any reason, without penalty 
to their continuing medical care.  Any discontinuation of treatment or of the study must be fully 
documented in the electronic case report form (eCRF), and should be followed up by the 
Investigator.  The Investigator may withdraw a patient from the study at any time if this is 
considered to be in the patient’s best interest. 
Discontinuation of study drug and withdrawal from the study are described in Section 5.3.1 and 
Section 5.3.2, respectively.  If a patient stops participation from the study or withdraws consent 
from the study, he/she will not be able to re-enroll in the study. 
5.3.1. 
Discontinuation of Study Drug 
The Investigator or designee may discontinue dosing in a patient if the patient: 
 Is in violation of the protocol 
 Experiences a SAE considered to be possibly or definitely related to the study drug or 
an intolerable AE  
 Becomes pregnant 
 Is found to be considerably noncompliant with the protocol-requirements 
Patients who are pregnant will be discontinued from study drug dosing immediately (see 
Section 7.5.6.6 for reporting and follow-up of pregnancy).  A positive urine pregnancy test 
should be confirmed by a serum pregnancy test prior to discontinuing the study drug. 
If a patient discontinues dosing due to a serious adverse event (SAE), the SAE should be 
followed as described in Section 7.5.6.  When a patient discontinues study drug dosing, the 
primary reason must be recorded in the electronic case report form (eCRF).  Patients who 
discontinue study drug and remain on study may receive treatment consistent with local standard 
practice for their disease per Investigator judgement, as applicable. 
Patients who discontinue treatment will be asked to complete an early termination (ET) visit at 
which all Month 37 visit procedures will be performed; they must also return for a safety-follow-
up visit 3 months (84 [+ 7] days) after their last dose of ALN-AS1. 
5.3.2. 
Discontinuation from the Study 
A patient or their legal guardian may decide to stop the patient’s participation in the study at any 
time.  Patients considering to stop the study should be informed that they can discontinue 
treatment and complete study assessments including follow-up, as per the SOA, or alternatively 
may complete any minimal assessments for which the patient consents. The Investigator may 
withdraw a patient at any time if this is considered to be in the patient’s best interest. 
However, study integrity and interpretation is best maintained if all randomized patients continue 
study assessments and follow-up.  Stopping study participation could mean: 
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 If a patient discontinues from the study, he/she will be asked to complete an early 
termination (ET) visit at which all Month 37 visit procedures will be performed; 
the patient must also return for a safety-follow-up visit at 3 months (84 [+7] days) 
after his/her last dose of ALN-AS1. 
 A patient can stop taking the study drug and stop study-related visits, but allow 
the investigator and study team to review the patient’s medical records, public 
records or be contacted in order to receive information about the patient’s health 
When a patient stops the study, the discontinuation and reason for discontinuation must be 
recorded in the appropriate section of the electronic case report form (eCRF) and all efforts will 
be made to complete and report the observations as thoroughly as possible.  If a patient stops the 
study due to an adverse event (AE), including an SAE, the AE should be followed as described 
in Section 7.5.6. 
If the patient wants to stop participation in the study, he/she should notify the study doctor in 
writing or in any other form that may be locally required. The personal data already collected 
during the study, including patient’s biological samples, will still be used together with the data 
collected on other patients in the study according to the informed consent and applicable laws. 
In addition to stopping participation in the study, the patient could decide to withdraw his/her 
consent as explained in Section 5.3.3 
5.3.3. 
Withdrawal of Consent to Collect and Process the Patient’s Personal Data 
The patient may decide to withdraw his/her consent informing the study doctor at any time in 
writing, or in any other form that may be locally required.  This means that the patient wants to 
stop participation in the study and any further collection of his/her personal data.  
 The sponsor will continue to keep and use a patient's study information (including 
any data resulting from the analysis of the patient's biological samples until time 
of withdrawal) according to applicable law.  This is done to guarantee the validity 
of the study, determine the effects of the study treatment, and ensure 
completeness of study documentation. 
 The patient can also request that collected samples be destroyed or returned (to 
the extent it is permitted by applicable law) at any time. 
 Patients who withdraw their consent to collect and use personal data should 
understand that public records may be reviewed to determine the patient’s 
survival status as allowed per local and national regulations.    
In US and Japan, otherwise, samples not yet analyzed at the time of withdrawal may still be used 
for further testing/analysis in accordance with the terms of the protocol and of the informed 
consent form. 
In EU and rest of world, in any event, samples not yet analyzed at the time of withdrawal will 
not be used any longer, unless permitted by applicable law. They will be stored or destroyed 
according to applicable legal requirements. 
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5.3.4. 
Replacement of Patients 
Patients discontinuing from study drug or withdrawing from the study will not be replaced. 
6. 
TREATMENTS 
6.1. 
Treatments Administered 
ALN-AS1 Solution for Injection (SC use) is a clear, colorless to pale yellow solution essentially 
free of particulates.  ALN-AS1 will be supplied by the Sponsor as a sterile solution for SC 
injection. 
Study drug supplied for this study must not be used for any purpose other than the present study 
and must not be administered to any person not enrolled in the study.  Study drug that has been 
dispensed to a patient and returned unused must not be re-dispensed to a different patient. 
6.2. 
Investigational Study Drug 
Detailed information describing the preparation, handling, and storage, packaging and labeling, 
as well as study drug accountability for ALN-AS1 is provided in the Pharmacy Manual. 
6.2.1. 
Description 
ALN-AS1 Solution for Injection (SC use) is comprised of a synthetic, siRNA targeting ALAS1 
and bearing a triantennary GalNAc ligand conjugated to the sense strand, formulated in 
phosphate buffer.  
6.2.2. 
Dose and Administration 
The study starting dose of ALN-AS1 is 5.0 mg/kg ALN-AS1 as an SC injection administered 
every 3 months (Table 1 and Table 2). Based on emerging clinical data, the SRC may approve 
changes to the ALN-AS1 dosing regimen, including decreases in the dose level and changes in 
dosing frequency (Table 4 and Table 5 in Appendix Section 11.2).  However, any dose and 
dosing regimen will not exceed a previously explored dose level or frequency that was 
determined to be safe and well-tolerated in study ALN-AS1-001. SRC, Health Authority and 
Ethics Committee approval must be sought prior to dose level escalation above 5.0 mg/kg in 
accordance with local Regulatory requirements.  See Section 6.2.3 for details on dose 
modifications. 
ALN-AS1 will be administered by a qualified and authorized health care professional trained in 
the recognition and management of anaphylactic reactions.  The study drug should be injected 
into the abdomen or upper arms or thighs.  Detailed instructions for study drug administration are 
presented in the Pharmacy Manual. As is consistent with good medical practice for subcutaneous 
drug administration, patients will be observed for a minimum of 20 minutes after each injection.   
Treatment for anaphylactic reactions should be readily available where patients are being dosed, 
and follow country and/or local hospital treatment guidelines as shown in Table 7.[35] 
After a patient has completed 12 months of ALN-AS1 administration in this study (6 months in 
an every month dosing regimen), study drug administration may be conducted at a location other 
than the study center by a home healthcare professional, where applicable country and local 
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regulations and infrastructure allow, after consultation with the medical monitor, during 
particular study visits, as specified in the Schedules of Assessments.  However, study drug 
administration at the study center should be considered for patients who have ongoing study 
drug-related AEs or known risk factors for developing anaphylactic reaction, including but not 
limited to: a prior history of anaphylactic reaction to food, medications or due to unknown 
etiology, worsening injection site reactions with repeat dosing, or anyone in the opinion of the 
investigator that would benefit from clinical observation following dosing.  Patients are required 
to complete at least 1 visit at the clinical study center every 3 months for the first year, and 
thereafter every 6 months through the end of the treatment period.  Additional visits to collect 
clinical laboratory samples may occur at home at any point during the treatment period, within 
14 days prior to scheduled dose administration. 
If a patient does not receive a dose of ALN-AS1 within the specified dosing window, the 
Investigator should contact the Medical Monitor.  After such consultation, the dose may be 
administered or considered missed and not administered. 
Patients will be permitted to miss an occasional dose of study drug; however, if a patient misses 
2 consecutive doses, the Investigator, in consultation with the Medical Monitor, will discuss 
whether the patient will be able to continue on the study.  
Detailed instructions for study drug administration are found in the Pharmacy Manual. 
6.2.3. 
Dose Modifications 
6.2.3.1. 
Study Population Dose Modifications 
During the study, dose modifications are permitted for the study population, or based on the dose 
cohort into which patients were originally randomized in study ALN-AS1-001.  Following SRC 
review of emerging safety and tolerability data from Part C of study ALN-AS1-001, or from this 
study (ALN-AS1-002), the dose and dosing regimen may be modified.  However, the dose and 
dosing regimen of ALN-AS1 will not exceed a previously explored dose and dosing regimen that 
was determined to be safe and well-tolerated in study ALN-AS1-001.  Patients enrolling in this 
study after a dose modification decision has been implemented may start at the newly identified 
dose and regimen. 
6.2.3.2. 
Individual Dose Modifications 
Dose modifications are permitted for individual patients.  If a patient has a study drug related AE 
of a recurrent ISR, severe ISR, or clinically significant LFT abnormality and the Investigator has 
concerns regarding further ALN-AS1 administration, the Medical Monitor and Investigator will 
review all available safety data for the patient.  Based on this review, a dose reduction to half the 
previously administered dose (eg, a 5.0 mg/kg dose would be reduced to a 2.5 mg/kg dose) or a 
reduction in dosing frequency from monthly to every 3 months is permitted.  Subsequent ALN-
AS1 administration at the previous dose may be considered based on the judgment of the 
Investigator and Medical Monitor. 
6.2.3.2.1. Monitoring and Dosing Rules in Patients with Potential Cases of Anaphylactic 
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Reaction   
An anaphylactic reaction is a severe, potentially fatal, systemic allergic reaction with acute onset 
(minutes to hours).  For reference see Section 11.4.[35] 
Stop administering the study medication immediately if an anaphylactic reaction to the study 
medication is suspected.  Study medication must be permanently discontinued in patients for 
whom an anaphylactic reaction is assessed as related to the study medication. 
Laboratory testing: Obtain blood sample for tryptase, total IgE, and ADA antidrug antibodies 
(ADA) ideally within 15 minutes to 3 hours after the onset of a suspected anaphylactic reaction; 
however, up to 6 hours is acceptable.  An additional blood sample to assess tryptase, total IgE, 
and ADA should be obtained between 1 to 2 weeks from onset of event.  Local laboratory may 
be used to analyze samples; however, parallel samples should be sent to the central laboratory for 
analysis.  Sample collection and shipping instructions are included in the Laboratory Manual. 
Reporting: The PI or designee must notify the sponsor or designee within 24 hours of the 
occurrence of a suspected case of anaphylactic reaction or being informed of the case as required 
for AEs of Clinical Interest (AECI) and SAEs, per AE reporting requirements (Section 7.5.6.1,  
Section 7.5.6.2 and 7.5.6.3). 
6.2.4. 
Preparation, Handling, and Storage 
Staff at each clinical study center or the home healthcare professional will be responsible for 
preparation of ALN-AS1 doses, according to procedures detailed in the Pharmacy Manual.  No 
special procedures for the safe handling of study drug are required. 
Study drug will be stored upright and refrigerated at approximately 5±3°C.  Any deviation from 
the recommended storage conditions should be reported to the Sponsor and use of the study drug 
halted until authorization for its continued use has been provided by the Sponsor or designee. 
A Sponsor representative or designee will be permitted, upon request, to audit the supplies, 
storage, dispensing procedures, and records. 
6.2.5. 
Packaging and Labeling 
All packaging, labeling, and production of study drug will be in compliance with current Good 
Manufacturing Practice specifications, as well as applicable local regulations.  Study drug labels 
and external packaging will include all appropriate information as per local labeling 
requirements. 
Additional details will be available in the Pharmacy Manual. 
6.2.6. 
Accountability 
The Investigator or designee will maintain accurate records of receipt and the condition of the 
study drug supplied for this study, including dates of receipt.  In addition, accurate records will 
be kept of when and how much study drug is dispensed and administered to each patient in the 
study.  Any reasons for departure from the protocol dispensing regimen must also be recorded. 
At the completion of the study, there will be a final reconciliation of all study drugs.  All used, 
partially used, and unused study drug will be returned to the Sponsor (or designee) or destroyed 
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at the clinical study center according to applicable regulations.   
Further instructions about drug accountability are detailed in the Pharmacy Manual. 
 
6.3. 
Concomitant Medications 
Use of concomitant medications will be recorded on the patient’s case report form (CRF) as 
indicated in the Schedules of Assessments (Table 1 and Table 2; and Table 4 and Table 5 in 
Appendix Section 11.2).  This includes all prescription medications, herbal preparations, over the 
counter (OTC) medications, vitamins, and minerals.  Any changes in medications during the 
study will also be recorded on the CRF. 
Any concomitant medication that is required for the patient’s welfare may be administered by the 
Investigator.  However, it is the responsibility of the Investigator to ensure that details regarding 
the medication are recorded on the eCRF.  Concomitant medication will be coded using an 
internationally recognized and accepted coding dictionary. 
Drug-drug interaction studies in NHP, could not exclude the potential for ALN-AS1 to alter the 
clearance of drugs metabolized by the CYP3A enzymes.  Therefore, patients on medications 
metabolized by CYP3A, especially those with narrow therapeutic ranges, may require 
monitoring for their drug levels or drug response.  ALN-AS1 could potentially increase the 
clearance of drugs metabolized by the CYP3A isoform.   Investigators will review all 
medications at study start and monitor response to these medications during the study.  For 
patients who require new medications while on study, selection of medications that are not 
mainly metabolized by the CYP3A isoform is recommended.  A list of medications that are 
sensitive CYP3A substrates is included in Table 6 Appendix Section 11.3.  In addition, a more 
detailed and current list of sensitive CYP3A-metabolized medications and CYP3A-metabolized 
medications with a narrow therapeutic range is available at the Indiana University, Division of 
Clinical Pharmacology, website (http://medicine.iupui.edu/clinpharm/ddis/clinical-table/).[31] 
Patients are not permitted to be on hemin prophylaxis at Screening; however, patients are 
permitted to receive concomitant hemin treatment for the management of acute porphyria 
attacks.  Patients experiencing significant breakthrough attacks while enrolled in this study, 
necessitating frequent hemin treatment, may receive hemin prophylaxis if in the Investigator’s 
judgment this is clinically beneficial to the patient.  The Investigator should contact with the 
Sponsor and Medical Monitor before prophylactic hemin treatment.  The dose, regimen, and 
dates of administration will be recorded on the patient’s eCRF.   
Pain medication (eg, opiates, opioids, narcotic analgesics) and glucose administration are 
permitted for the management of porphyria and for acute porphyria attacks. 
If patients use nonsteroidal anti-inflammatory medications intermittently or chronically, they 
must have been able to tolerate them with no previous side effects (eg, gastric distress or 
bleeding).   
Standard vitamins and topical medications are permitted; however, topical steroids must not be 
applied anywhere near the injection site(s) unless medically indicated. 
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6.4. 
Contraceptive Requirements 
No data are available on the use of ALN-AS1 in pregnancy; however, there is no suspicion of 
human teratogenicity based on class effects or genotoxic potential.  ALN-AS1 was neither 
genotoxic nor clastogenic in in vitro and in vivo studies.   
WOCBP must be willing to use acceptable methods of contraception 14 days before first dose, 
throughout study participation, and for 90 days after last dose administration.   
Birth control methods which may be considered as acceptable include: 
 Established use of oral, implantable, injectable, transdermal hormonal, or intrauterine 
hormone-releasing system as methods of contraception.  WOCBP using hormonal 
methods of contraception must also use a barrier method (condom or occlusive cap 
[diaphragm or cervical/vault cap] in conjunction with spermicide [eg, foam, gel, film, 
cream, or suppository]). 
 If hormonal methods of contraception are medically contraindicated for WOCBP due 
to underlying disease, a double-barrier method (combination of male condom with 
either cap, diaphragm, or sponge, in conjunction with spermicide) is also considered 
an acceptable method of contraception. 
 Placement of an intrauterine device  
 Bilateral tubal occlusion 
 Surgical sterilization of male partner (with the appropriate post-vasectomy 
documentation of the absence of sperm in the ejaculate; for female patients on the 
study, the vasectomized male partner should be the sole partner for that patient) 
 Sexual abstinence, when this is in line with the preferred and usual lifestyle of the 
patient, is considered an acceptable method only if defined as refraining from 
heterosexual intercourse during the entire period of risk associated with the study 
drug (defined above).  Periodic abstinence (eg, calendar, ovulation, symptothermal, 
post-ovulation methods) and withdrawal are not considered sexual abstinence and do 
not meet criteria for an acceptable method of birth control.  As determined by the 
investigator, the reliability of sexual abstinence needs to be evaluated in relation to 
the duration of the clinical trial and the preferred and usual lifestyle of the patient.  
Abstinent patients must agree to use 1 of the abovementioned contraceptive methods 
if they start a heterosexual relationship during the study and continue to do so for the 
entire period of risk associated with the study drug (defined above). 
 WOCBP includes any female patient who has experienced menarche and who is not 
postmenopausal or permanently sterilized (eg, bilateral tubal occlusion, hysterectomy, 
or bilateral salpingectomy).  Postmenopausal state is defined as no menses for 12 
months without an alternative medical cause, confirmed by follicle stimulating 
hormone level within the postmenopausal range. 
6.5. 
Treatment Compliance 
Compliance with study drug administration will be verified through observation by study 
personnel or trained home healthcare professionals.  
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7. 
STUDY ASSESSMENTS 
The schedule of study assessments is provided in Table 1.  
7.1. 
Screening/Baseline Assessments 
Informed consent, patient demographic data, and eligibility criteria will be confirmed at 
Screening/Baseline.  An interval medical history/disease history will be obtained at 
Screening/Baseline.  The last assessments performed, determining previous study 
(ALN-AS1-001) completion, will serve as the Screening/Baseline assessments in this study.  If 
more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs will 
be repeated before administration of ALN-AS1. 
7.2. 
Clinical Activity Assessments 
The clinical activity of ALN-AS1 will be assessed by the frequency and characteristics of 
porphyria attacks including, but not limited to, duration, treatment, and severity of porphyria 
attacks and number and duration of visits to a health care setting for acute porphyria care (eg, 
hospital, emergency department, infusion center, or outpatient clinic).  Concomitant hemin 
administration will also be recorded. 
7.2.1. 
Patient Diary 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain 
assessments, and narcotic use. 
7.2.2. 
Brief Pain Inventory-Short Form Questionnaire 
The Brief Pain Inventory-Short Form (BPI-SF) questionnaire will be used to evaluate pain.[32]  
The BPI will be completed as part of the patient diary. 
7.3. 
Pharmacodynamic Assessments 
Blood and urine samples will be collected for assessment of ALN-AS1 PD parameters.  The PD 
effect of ALN-AS1 will be evaluated by urine ALA and PBG levels.  Blood and urine samples 
will be collected for assessment of circulating ALAS1 mRNA levels in serum and in urine.  
Analysis for blood and urine PD parameters will take place at a central laboratory.   
Details regarding the processing and aliquoting of samples for storage and analyses will be 
provided in the Laboratory Manual. 
7.4. 
Pharmacokinetic Assessments 
Blood samples will be collected to evaluate the PK profile of ALN-AS1 at the time points in the 
Schedule of Assessments.  A detailed schedule of time points for the collection of blood samples 
for PK analysis is in Table 3 in Appendix Section 11.1). 
The concentration of ALN-AS1 will be determined using a validated assay.  Details regarding 
the processing, shipping, and analysis of the samples will be provided in the Laboratory Manual. 
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7.5. 
Safety Assessments 
The assessment of safety during the course of the study will consist of the surveillance and 
recording of AEs including SAEs, recording of concomitant medications and measurements of 
vital signs, physical examination, and ECG findings and clinical laboratory evaluations. 
Safety will be monitored over the course of the study by an SRC as described in Section 4.6. 
7.5.1. 
Vital Signs 
Vital sign measurements include blood pressure, heart rate, body temperature, and respiratory 
rate.  Vital signs will be measured in the seated or supine position (should be consistent for each 
patient), after the patient has rested comfortably for at least 10 minutes.  Blood pressure should 
be taken using the same arm throughout the study.  Body temperature will be obtained in degrees 
Celsius, heart rate will be counted for a full minute and recorded in beats per minute, and 
respiration rate will be counted for a full minute and recorded in breaths per minute. 
For the safety of the patient, additional vital sign assessments may be added at the discretion of 
the Investigator. 
7.5.2. 
Weight and Height 
Height will be measured in centimeters at the Screening/Baseline visit only.  Body weight will be 
measured in kilograms.  Body mass index will be calculated in the database. 
Body weight measured on the dosing day will be used to calculate the dose of ALN-AS1 through 
M12.  After M12, weight measured at either the previous study center visit or current study 
center visit may be used for dosing calculations. 
7.5.3. 
Physical Examination 
Complete physical examinations will include the examination of the following:  general 
appearance, head, eyes, ears, nose and throat, chest/respiratory, heart/cardiovascular, 
gastrointestinal/liver, musculoskeletal/extremities, dermatological/skin, thyroid/neck, lymph 
nodes, and neurological/psychiatric. 
Targeted physical examinations will include the examination of the following:  general 
appearance, chest/respiratory, heart/cardiovascular, gastrointestinal/liver, and 
neurological/psychiatric. 
7.5.4. 
Electrocardiogram 
Triplicate standard 12-lead ECGs will be performed using central ECG equipment, with readings 
approximately 1 minute apart and recorded as specified in the Schedule of Assessments (Table 
1).  Patients should be seated or supine for at least 5 minutes before each ECG is obtained.  The 
electrophysiological parameters assessed will be rhythm, ventricular rate, PR interval, QRS 
duration, QT interval, ST and T waves, Bazett-corrected QT interval (QTcB), and Fridericia 
corrected QT interval (QTcF). 
When ECG and blood sample collection occur at the same time, ECGs should be performed 
before blood samples are drawn. 
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Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine 
position after the patient has rested comfortably for at least 5 minutes.   
In all patients receiving ≤2.5 mg/kg ALN-AS1, it is required that ECGs will be obtained on at 
least 2 separate clinic visits (D1, and Months 3, 6, 9, 12, 15, or 18), each of which will include 
same day predose and 2-hour (±15 minutes) postdose readings, paired with PK timepoints (Table 
3) as specified in the Schedule of Assessments (Table 1).   
Similarly, in all patients receiving >2.5 mg/kg ALN-AS1, it is required that ECGs will be 
obtained on at least 2 separate clinic visits (D1, and Months 3, 6, 9, 12, 15, or 18), each of which 
will include same day predose and 4-hour (±20 minutes) postdose readings, paired with PK 
timepoints (Table 3), as specified in the Schedule of Assessments (Table 1).  
The Investigator or designee is responsible for reviewing the ECGs to assess whether the results 
have changed since the Screening/Baseline visit and to determine the clinical relevance of the 
results.  These assessments will be recorded on the eCRF.  For any clinically relevant ECG 
changes from the Screening/Baseline visit (eg, ischemic ECG changes, wave/interval changes, or 
arrhythmia), the Investigator must contact the Medical Monitor to discuss continued participation 
of the patient in the study. 
7.5.5. 
Clinical Laboratory Assessments 
The following clinical laboratory tests will be evaluated by a central laboratory.   
On dosing days up to the Month 18 visit, results from hematology, chemistry, and coagulation 
tests collected within the prior 14 days must be reviewed by the Investigator before study drug 
administration.  These results can be analyzed centrally or at a local laboratory.  If results from 
within the prior 14 days are not available at a dosing visit (at visits from D1 to Month 18), 
locally analyzed assessments must be reviewed to allow same day study drug administration and 
additional samples for central analysis must also be collected.  On dosing days from Month 19 
through Month 36, a review of laboratory results within 14 days is not required.   
In the event of an unexplained clinically relevant abnormal laboratory test occurring after study 
drug administration, the test should be repeated and followed up at the discretion of the 
Investigator until it has returned to the normal range or stabilized, and/or a diagnosis is made to 
adequately explain the abnormality. 
At any point during the study, and based on Investigator judgment, if a patient experiences 
uncharacteristic signs and symptoms during a porphyria attack, lipase testing should be 
performed and imaging evaluations (eg, right upper quadrant ultrasound and/or other testing, 
based on Investigator judgment) should be considered by the Investigator.  Signs and symptoms 
include, but are not limited to, uncharacteristic abdominal pain and worsening nausea and 
vomiting. 
Imaging is required for any serum lipase result of ≥3× the upper limit of normal, or as clinically 
indicated. 
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Hematology 
Complete blood count with differential 
 
Serum Chemistry 
Sodium 
Potassium 
BUN 
Phosphate 
Creatinine and eGFRa 
Albumin 
Uric acid 
Calcium 
Total protein 
Carbon dioxide 
Glucose 
Chloride 
Lipase 
Bicarbonate 
Liver Function Tests 
 
AST 
ALP 
ALT 
Bilirubin (total and direct) 
GGT 
 
Urinalysis 
Visual inspection for appearance and color 
Bilirubin 
pH (dipstick) 
Nitrite 
Specific gravity 
RBCs 
Ketones 
Urobilinogen 
Albumin 
Leukocytes 
Glucose 
Microscopy (if clinically indicated) 
Protein 
 
Immunogenicity 
Antidrug antibodies 
Coagulation 
Prothrombin time 
International Normalized Ratio 
Pregnancy Testing (WOCBP only) 
β-human chorionic gonadotropin 
 
Inflammation 
 
C-reactive protein 
 
Abbreviations:  AST=aspartate transaminase; ALP=alkaline phosphatase; ALT=alanine transaminase; 
BUN=blood urea nitrogen; eGFR=estimated glomerular filtration rate; GGT=gamma-glutamyltransferase; 
WOCBP=women of child bearing potential. 
a eGFR will be calculated using the Modification of Diet in Renal Disease formula.[33] 
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7.5.5.1. 
Immunogenicity 
Blood samples will be collected to evaluate antidrug antibodies.  On days when ALN-AS1 is 
administered, blood samples for antidrug antibody testing must be collected before ALN-AS1 is  
administered. 
Sample collection for patients who experience a potential anaphylactic reaction is discussed in 
Section 6.2.3.2.1. 
Details regarding the processing, shipping, and analysis of the samples will be provided in the 
Laboratory Manual. 
7.5.5.2. 
Pregnancy Testing 
A pregnancy test will be performed for WOCBP only.  A serum pregnancy test will be 
performed at Screening/Baseline and urine pregnancy tests will be performed thereafter per the 
Schedule of Assessments and any time pregnancy is suspected.  Urine pregnancy tests may also 
be performed more frequently (eg, monthly) based on local country requirements.  The results of 
the pregnancy test must be known before study drug administration.  Patients who are pregnant 
are not eligible for study participation.  Any woman with a positive pregnancy test during the 
study will be discontinued from study drug, but will continue to be followed for safety.  Patients 
determined to be pregnant while on study will be followed until the pregnancy outcome is known 
(see Section 7.5.6.6 for follow-up instructions).  
7.5.6. 
Adverse Events 
7.5.6.1. 
Definitions 
Adverse Event 
According to the ICH E2A guideline Definitions and Standards for Expedited Reporting, and 21 
Code of Federal Regulations 312.32, Investigational New Drug Safety Reporting, an AE is any 
untoward medical occurrence in a patient or clinical investigational subject administered a 
medicinal product and which does not necessarily have a causal relationship with this treatment. 
Serious Adverse Event 
An SAE is any untoward medical occurrence that at any dose: 
 Results in death 
 Is life-threatening (An event which places the patient at immediate risk of death from 
the event as it occurred.  It does not include an event that had it occurred in a more 
severe form might have caused death) 
 Requires in-patient hospitalization or prolongation of existing hospitalization 
 Results in persistent or significant disability or incapacity 
 Is a congenital anomaly or birth defect 
 Is an important medical event that may not be immediately life-threatening or result 
in death or hospitalization but may jeopardize the patient and may require 
intervention to prevent one of the other outcomes listed in the definition above (eg, 
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events include allergic bronchospasm requiring intensive treatment in an emergency 
room or at home, blood dyscrasias, convulsions, or the development of drug 
dependency or abuse). 
Adverse Event Severity 
Adverse events are to be graded according to the categories detailed below: 
Mild: 
Mild events are those which are easily tolerated with no disruption of normal 
daily activity. 
Moderate: 
Moderate events are those which cause sufficient discomfort to interfere with 
normal daily activities. 
Severe: 
Severe events are those which incapacitate and prevent usual activity. 
Changes in severity should be documented in the medical record to allow assessment of the 
duration of the event at each level of severity.  AEs characterized as intermittent require 
documentation of the start and stop of each incidence.  When changes in the severity of an AE 
occur more frequently than once a day, the maximum severity for the experience that day should 
be noted.  If the severity category changes over a number of days, then those changes should be 
recorded separately (with distinct onset dates) 
AE severity and seriousness are assessed independently.  ‘Severity’ characterizes the intensity of 
an AE.  ‘Serious’ is a regulatory definition and serves as a guide to the Sponsor for defining 
regulatory reporting obligations (see definition for Serious Adverse Event). 
Relationship of the Adverse Event to Study Treatment 
The relationship of each AE to study treatment should be evaluated by the Investigator using the 
following criteria:  
Definitely related: 
A clinical event, including laboratory test abnormality, occurring in a 
plausible time relationship to the medication administration, and which 
cannot be explained by concurrent disease or other drugs or chemicals.  
The response to withdrawal of the drug should be clinically plausible. 
Possibly related: 
A clinical event, including laboratory test abnormality, with a 
reasonable time sequence to the medication administration, but which 
could also be explained by concurrent disease or other drugs or 
chemicals.  Information on the drug withdrawal may be lacking or 
unclear. 
Unlikely related: 
A clinical event, including laboratory test abnormality, with little or no 
temporal relationship to medication administration, and which other 
drugs, chemicals, or underlying disease provide plausible explanations. 
Not related: 
A clinical event, including laboratory test abnormality that has no 
temporal relationship to the medication or has more likely alternative 
etiology. 
Adverse Events of Clinical Interest 
The following events are considered to be adverse events of clinical interest: 
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 ISRs 
 Hepatic AEs, including LFT abnormalities considered clinically significant by the 
Investigator. 
 Lipase >3×ULN (or >3× the baseline lipase measurement if baseline is >ULN) 
 Anaphylactic Reactions. Anaphylactic reaction is a severe, potentially fatal, systemic 
allergic reaction with acute onset (minutes to hours).  Symptoms of an anaphylactic 
reaction may include skin or mucosal tissue (e.g. generalized hives, pruritus, 
angioedema), respiratory compromise (e.g. wheezing, bronchospasm, hypoxia), 
reduced blood pressure or associated symptoms (e.g. syncope, hypotonia).  See 
Section 11.4 (Table 7) for guidance on diagnosing anaphylactic reactions.[35] 
7.5.6.2. 
Eliciting and Recording Adverse Events 
Eliciting Adverse Events 
The patient should be asked about medically relevant changes in his/her health since the last 
visit.  The patient should also be asked if he/she has been hospitalized, had any accidents, used 
any new medications, or changed concomitant medication routines (both prescription and OTC).  
In addition to patient observations, AEs will be documented from any clinically relevant 
laboratory findings, physical examination findings, ECG changes, or other findings that are 
relevant to patient safety. 
Recording Adverse Events 
The Investigator is responsible for recording non-serious AEs that are observed or reported by 
the patient after administration of the first dose of study drug regardless of their relationship to 
study drug through the end of study.  Non-serious AEs will be followed until the end of study.  
The Investigator is responsible for recording SAEs that are observed or reported by the patient 
after the time when the informed consent is signed regardless of their relationship to study drug 
through the end of study.  SAEs will be followed until satisfactory resolution, until baseline level 
is reached, or until the SAE is considered by the Investigator to be chronic or the patient is 
stable, as appropriate. 
All AEs must be recorded in the source records for the clinical study center and in the eCRF for 
the patient, whether or not they are considered to be drug-related.  Each AE must be described in 
detail:  onset time and date, description of event, severity, relationship to investigational drug, 
action taken, and outcome (including time and date of resolution, if applicable). 
For SAEs, record the event(s) on the eCRF.  If the electronic data capture (EDC) system is 
unavailable, complete the backup SAE form. 
For AEs that are considered AEs of clinical interest, the Sponsor or its designee should be 
notified within 24 hours using a supplemental AEs of clinical interest (AECI) eCRF.  Additional 
clinical and laboratory information may be collected based upon the severity or nature of the 
event. 
If a patient has ISRs meeting any of the following criteria, the Investigator or delegate should 
contact the Medical Monitor and submit a supplemental ISR eCRF: 
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 ISRs that are recurrent and/or demonstrate a pattern of increasing severity 
 Any ISR that is determined to be severe and/or a cause for study drug discontinuation  
 Any ISR which, in the opinion of the Investigator, requires further medical evaluation or 
treatment 
In some cases, where it is medically appropriate, further evaluation may include photographs, 
referral to a dermatologist, skin biopsy, or other laboratory testing.  If a biopsy was obtained, the 
Sponsor may request that the biopsy also be reviewed by a central dermatopathologist.  To better 
understand the safety profile of the study drug, additional analysis of biopsy tissue may be 
performed according to local regulations. 
For patients with hepatic AEs, additional information, including, clinical history, course of event, 
and local laboratory results to monitor LFT levels or other laboratory parameters, may be 
collected. 
7.5.6.3. 
Serious Adverse Events Require Immediate Reporting to Sponsor/Designee 
An assessment of the seriousness of each AE will be made by the Investigator.  Any AE and 
laboratory abnormality that meets the SAE criteria in Section 7.5.6.1 must be reported to the 
Sponsor or designee within 24 hours from the time that clinical study center personnel first 
learns of the event.  All SAEs must be reported regardless of the relationship to study drug. 
The initial report should include at least the following information: 
 Patient’s study number 
 Description and date of onset of the event 
 Criterion for serious 
 Preliminary assignment of relationship to study drug 
 Investigator/clinical study center information 
To report the SAE, complete the eCRF.  If the EDC system is unavailable, complete the backup 
SAE form.  Within 24 hours of receipt of follow-up information, the Investigator must update the 
report.  SAEs must be reported using the contact information provided in the Study Manual. 
Appropriate remedial measures should be taken by the Investigator using his/her best medical 
judgment to treat the SAE.  These measures and the patient’s response to these measures should 
be recorded.  All SAEs, regardless of relationship to study drug, will be followed by the 
Investigator until satisfactory resolution or the Investigator deems the SAE to be chronic or 
stable.  Clinical, laboratory, and diagnostic measures should be employed by the Investigator as 
needed to adequately determine the etiology of the event. 
7.5.6.4. 
Sponsor Safety Reporting to Regulatory Authorities 
The Sponsor or its representative is required to report certain study events in an expedited 
manner to the Food and Drug Administration, the European Medicines Agency’s EudraVigilance 
electronic system according to Directive 2001/20/EC, and to all country Regulatory Authorities 
where the study is being conducted, according to local applicable regulations. 
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The following describes the safety reporting timeline requirements for suspected unexpected 
serious adverse reactions (SUSARs) and other reportable events: 
Immediately and within 7 calendar days 
 Any suspected adverse reaction that is associated with the use of the study drug, 
unexpected, and fatal or life threatening.  Follow-up information must be reported in 
the following 8 days. 
Immediately and within 15 calendar days 
 Any suspected adverse reaction that is associated with the use of the study drug, 
unexpected, and serious, but not fatal or life threatening, and there is evidence to 
suggest a causal relationship between the study drug and the reaction. 
 Any finding from tests in laboratory animals that suggest a significant risk for human 
patients including reports of mutagenicity, teratogenicity, or carcinogenicity. 
 Any event in connection with the conduct of the study or the development of the 
study drug that may affect the safety of the trial patients. 
In addition, periodic safety reporting to regulatory authorities will be performed by the Sponsor 
or its representative according to national and local regulations. 
7.5.6.5. 
Serious Adverse Event Notification to the Institutional Review 
Board/Independent Ethics Committee 
SUSARs will be reported to the Institutional Review Board (IRB)/Independent Ethics 
Committee (IEC) per their institutional policy by the Investigator or Sponsor (or Sponsor 
designee) according to country requirements.  Copies of each report and documentation of 
IRB/IEC notification and acknowledgement of receipt will be kept in the Investigator’s study 
file. 
7.5.6.6. 
Pregnancy Reporting 
If a female patient becomes pregnant during the course of this study through 90 days following 
the last dose of study drug, the Investigator must report the pregnancy to the Sponsor or designee 
within 24 hours of being notified of the pregnancy.  Details of the pregnancy will be recorded on 
the pregnancy reporting form.  The patient should receive any necessary counseling regarding 
the risks of continuing the pregnancy and the possible effects on the fetus. 
The pregnancy should be followed by the Investigator until completion.  At the completion of the 
pregnancy, the Investigator will document the outcome of the pregnancy.  If the outcome of the 
pregnancy results in a postpartum complication, spontaneous abortion, stillbirth, neonatal death, 
or congenital anomaly, then the Investigator should follow the procedures for reporting an SAE 
as outlined in Section 7.5.6.3.   
7.5.6.7. 
Overdose Reporting 
An overdose is defined as any dose administered to or taken by a patient (accidentally or 
intentionally) that exceeds the highest daily dose, or is at a higher frequency, than included in the 
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protocol.  It is up to the investigator to decide whether a dose is to be considered an overdose, in 
consultation with the Sponsor.  Overdose must be recorded in the eCRF. 
All reports of overdose (with or without an AE) must be reported within 24 hours to the Sponsor 
or designee.   
7.6. 
Exploratory Assessments 
Blood and urine samples will be collected for exploratory analyses.  Aliquots of samples will be 
obtained and frozen, to permit future analysis of the effect of ALN-AS1 on exploratory 
biomarkers.   
Where local regulations allow, biologic samples will be retained on behalf of the Sponsor for a 
maximum of 15 years following the last patient’s last visit in the study.  Details regarding the 
collection, processing, storage, and shipping of samples will be in the Laboratory Manual. 
7.7. 
Other Assessments 
7.7.1. 
EQ-5D-5L Questionnaire 
QOL will be assessed through the use of the 5-level EQ-5D (EQ-5D-5L), a standardized 
questionnaire measuring health outcomes.[34]  In addition to the time points indicated, the 
EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a 
porphyria attack (but, not more than once in a 6 month period), if possible. 
8. 
STATISTICS 
A detailed Statistical Analysis Plan (SAP) will be written after finalizing the protocol and before 
database lock.  The plan will detail the implementation of all the statistical analyses in 
accordance with the principle features stated in the protocol. 
8.1. 
Determination of Sample Size 
This is a Phase 1/2 multicenter, open-label extension study to evaluate the long-term safety and 
clinical activity of ALN-AS1 in patients with AIP who completed study ALN-AS1-001.  Safety, 
tolerability, PK, and PD of ALN-AS1 will be investigated.  The sample size was not determined 
based on statistical considerations.  Up to 24 patients are planned for this study (including 
optional cohorts in ALN-AS1-001). 
8.2. 
Statistical Methodology 
The statistical and analytical plans presented below summarize the more complete plans to be 
detailed in the SAP.  Any changes to the methods described in the final SAP will be described 
and justified as needed in the clinical study report. 
Statistical analyses will be primarily descriptive in nature.  Descriptive statistics (eg, mean, 
standard deviation, median, minimum, and maximum) will be presented for continuous 
variables.  Frequencies and percentages will be presented for categorical and ordinal variables. 
Analyses will be performed using SAS® (Version 9.2, or higher). 
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8.2.1. 
Populations to be Analyzed 
The populations (analysis sets) are defined as follows:  
Safety Analysis Set: 
All patients who received any amount of study drug. 
Clinical Activity Analysis 
Set: 
All patients who received any amount of study drug and have 
both a baseline and at least 1 postdose assessment. 
PK Analysis Set: 
All patients who received any amount of study drug and have at 
least 1 postdose blood sample for PK and who have evaluable 
PK data. 
PD Analysis Set: 
All patients who received any amount of study drug and who 
have at least 1 postdose blood sample for the determination of 
ALN-AS1 will be included in the PD analyses. 
Safety will be analyzed using the Safety Analysis Set.  The PK and PD Analysis Sets will be 
used to conduct PK and PD analyses, respectively.  The population used to evaluate clinical 
activity will be the Clinical Activity Analysis Set.   
8.2.2. 
Examination of Subgroups 
Subgroup analyses may be conducted for selected endpoints.  Detailed methodology will be 
provided in the SAP. 
8.2.3. 
Handling of Missing Data 
Unrecorded values will be treated as missing.  The appropriateness of the method(s) described 
for handling missing data may be reassessed and documented in the SAP before database lock.  
Depending on the extent of missing values, further investigation may be made into the sensitivity 
of the analysis results to the method(s) specified. 
8.2.4. 
Baseline Evaluations 
Demographics, medical history, disease-specific information, and other baseline characteristics 
collected in this study will be summarized.   
8.2.5. 
Clinical Activity Analyses 
Clinical activity of ALN-AS1 will be summarized primarily by descriptive statistics.  The 
clinical activity of ALN-AS1 will be evaluated by the frequency and characteristics of porphyria 
attacks including duration, treatment, and severity of porphyria attacks and number and duration 
of visits to a health care setting for acute porphyria care. 
Patient diary recordings, including BPI-SF questionnaire scores, will also be summarized. 
8.2.6. 
Pharmacodynamic Analysis 
PD analyses will include the evaluation of change in ALA, PBG, and ALAS mRNA levels.  
Descriptive statistics (eg, mean and standard error of the mean) for observed levels of PD 
parameters and the relative change from baseline will be presented for each of the postdose 
follow-up time points. 
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8.2.7. 
Pharmacokinetic Analysis 
The PK concentration of ALN-AS1 will be determined. 
Antidrug antibody results will be tabulated.  A by-patient data listing will also be provided. 
8.2.8. 
Safety Analyses 
Extent of exposure will be summarized.  AEs will be summarized by the Medical Dictionary for 
Regulatory Activities System Organ Class and Preferred Term.  Prior and concomitant 
medications will be classified according to the World Health Organization drug dictionary. 
Incidence of AEs (those events that started after exposure to study drug or worsened in severity 
after dosing) will be presented.  Incidence of AEs will also be presented by maximum severity 
and relationship to study treatment.  The incidence of SAEs and AEs leading to discontinuation 
of treatment will also be tabulated.  By-patient listings will be provided for deaths, SAEs, and 
AEs leading to discontinuation of treatment.   
Descriptive statistics will be provided for clinical laboratory data and vital signs data, presented 
as both actual values and changes from baseline relative to each on-study evaluation and to the 
last evaluation on study.  Laboratory shift tables from baseline to worst values will be presented.  
Abnormal physical examination findings and 12-lead ECG data will be presented in a by-patient 
data listing. 
Descriptive statistics will be provided for ECG interval data and presented as both actual values 
and changes from baseline relative to each on-study evaluation and to the last evaluation on 
study.  Details of any abnormalities will be included in patient listings. 
Concomitant hemin administration will also be recorded. 
8.2.9. 
Other Analyses 
Possible associations between PD parameters (ALA, PBG, and ALAS1 mRNA levels) and 
clinical activity parameters may also be explored. 
Additional exploratory analyses may be conducted on analytes related to targeting the heme 
biosynthesis pathway. 
QOL scores on the EQ-5D-5L questionnaire will also be summarized. 
9. 
STUDY ADMINISTRATION 
9.1. 
Ethical and Regulatory Considerations 
This study will be conducted in accordance with the protocol, all applicable regulatory 
requirements, and the guidelines of Good Clinical Practice (GCP).  Compliance with GCP 
provides public assurance that the rights, safety, and well-being of study patients are protected 
consistent with the principles that have their origin in the Declaration of Helsinki. 
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9.1.1. 
Informed Consent 
The Investigator will ensure that the patient is given full and adequate oral and written 
information about the nature, purpose, possible risk and benefit of the study.  Patients must also 
be notified that they are free to withdraw from the study at any time.  The patient should be given 
the opportunity to ask questions and allowed time to consider the information provided. 
The patient’s signed and dated informed consent must be obtained before conducting any study 
procedures. 
The Investigator must maintain the original, signed ICF.  A copy of the signed ICF must be 
given to the patient. 
9.1.2. 
Ethical Review 
The final study protocol, including the final version of the ICF, must be approved or given a 
favorable opinion in writing by an IRB or IEC, as appropriate.  The Investigator must submit 
written approval before he or she can enroll any patient into the study. 
The Investigator is responsible for informing the IRB or IEC of any amendment to the protocol 
in accordance with local requirements.  In addition, the IRB or IEC must approve all advertising 
used to recruit patients for the study.  The protocol must be reapproved by the IRB or IEC upon 
receipt of amendments and annually, as local regulations require. 
Initial IRB approval of the protocol, and all materials approved by the IRB for this study 
including the patient consent form and recruitment materials must be maintained by the 
Investigator and made available for inspection. 
The Investigator will submit reports of SAEs as outlined in Section 7.5.6.  In addition, the 
Investigator agrees to submit progress reports to the IRB or IEC per their local reporting 
requirements, or at least annually and at the conclusion of the study.  The reports will be made 
available to the Sponsor or designee. 
Any communications from regulatory agencies in regard to inspections, other studies that impact 
this protocol or the qualifications of study personnel should be promptly reported to the Sponsor 
or its designee. 
The Investigator is also responsible for providing the IRB with reports of any reportable serious 
adverse drug reactions from any other study conducted with the investigational drug.  The 
Sponsor or designee will provide this information to the Investigator. 
Major changes in this research activity, except those to remove an apparent immediate hazard to 
the patient, must be reviewed and approved by the Sponsor and the IRB or IEC that approved the 
study.  Amendments to the protocol must be submitted in writing to the Investigator’s IRB or 
IEC and the Regulatory Authority for approval before patients are enrolled under the amended 
protocol. 
9.1.3. 
Study Documentation, Confidentiality, and Records Retention 
All documentation relating to the study should be retained for the period of time required by 
applicable local law.  If it becomes necessary for the Sponsor, the Sponsor’s designee, applicable 
IRB/IEC, or applicable regulatory authorities to review or audit any documentation relating to 
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the study, the Investigator must permit direct access to all source documents/data.  Records will 
not be destroyed without informing the Sponsor in writing and giving the Sponsor the 
opportunity to store the records for a longer period of time at the Sponsor’s expense.   
The Investigator must ensure that the patients’ confidentiality will be maintained.  On the CRFs 
or other documents submitted to the Sponsor or designees, patients should not be identified by 
their names, but by the assigned patient number and initials.  If patient names are included on 
copies of documents submitted to the Sponsor or designees, the names (except for initials) will 
be obliterated and the assigned patient number added to the document.  Documents not for 
submission to the Sponsor (eg, signed ICFs) should be maintained by the Investigator in strict 
confidence. 
The Investigator must treat all of the information related to the study and the compiled data as 
confidential, whose use is for the purpose of conducting the study.  The Sponsor must approve 
any transfer of information not directly involved in the study. 
In compliance with local and/or regional regulations, this clinical study may be registered and 
study results may be posted on public registries, such as ClinicalTrials.gov. 
9.1.4. 
End of the Study 
The end of the study is defined as last patient last visit. 
9.1.5. 
Discontinuation of the Clinical Study 
The Sponsor reserves the right to discontinue the study for clinical or administrative reasons at 
any time.  If the clinical study center does not recruit at a reasonable rate, the study may be 
discontinued at that clinical study center.  Should the study be terminated and/or the clinical 
study center closed for whatever reason, all documentation and study drug pertaining to the study 
must be returned to the Sponsor or its representative, and the Investigators, IEC/IRB and 
Regulatory Authorities will be promptly informed of the termination and the reason for the 
decision.  The Investigator should promptly inform the patients and assure appropriate therapy 
and follow-up.  Patients should then be withdrawn from the study.   
9.2. 
Data Quality Control and Quality Assurance 
9.2.1. 
Data Handling 
Study data must be recorded on case report forms (paper and/or electronic) provided by the 
Sponsor or designee on behalf of the Sponsor.  Case report forms must be completed only by 
persons designated by the Investigator.  If eCRFs are used, study data must be entered by trained 
clinical study center personnel with access to a valid and secure eCRF system.  All data entered 
into the eCRF must also be available in the source documents.  Corrections on paper CRFs must 
be made so as to not obliterate the original data and must be initialed and dated by the person 
who made the correction. 
9.2.2. 
Study Monitoring 
The clinical monitor, as a representative of the Sponsor, has an obligation to closely follow the 
study conduct at the clinical study center.  The monitor will visit the Investigator and clinical 
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study center periodically and will maintain frequent telephone and written contact.  The monitor 
will maintain current personal knowledge of the study through observation, review of study 
records and source documentation, and discussion of the conduct of the study with the 
Investigator and personnel. 
The monitor will review source documents, systems and CRFs to ensure overall quality and 
completeness of the data and to confirm study procedures are complied with the requirements in 
the study protocol.  The Sponsor, or its designee, will be allowed to conduct clinical study center 
visits to the investigation facilities for the purpose of monitoring any aspect of the study.  The 
Investigator agrees to allow the monitor to inspect the drug storage area, study drug stocks, drug 
accountability records, patient charts and study source documents, and other records relative to 
study conduct. 
9.2.3. 
Audits and Inspections 
Periodically, the Sponsor or its authorized representatives audit clinical investigative study 
centers as an independent review of core trial processes and documents to determine whether 
these activities were conducted, and data were recorded, analyzed, and accurately reported 
according to the protocol, GCP guidelines of the ICH, and any applicable regulatory 
requirements.  A regulatory authority, an IEC or an IRB may visit the clinical study center to 
perform audits or inspections, including source data verification.  The Investigator should contact 
the Sponsor, or its designee, immediately if contacted by a regulatory agency about an 
inspection. 
9.3. 
Publication Policy 
It is intended that after completion of the study, the data are to be submitted for publication in a 
scientific journal and/or for reporting at a scientific meeting.  A copy of any proposed manuscript 
must be provided and confirmed received at the Sponsor at least 30 days before its submission, 
and according to any additional publication details in the Investigator Agreement.
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10. 
LIST OF REFERENCES 
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Recommendations for the diagnosis and treatment of the acute porphyrias. Ann Intern Med. 2005 
Mar 15;142(6):439-50. 
2. Siegesmund M, van Tuyll van Serooskerken AM, Poblete-Gutierrez P, Frank J. The acute 
hepatic porphyrias: current status and future challenges. Best Pract Res Clin Gastroenterol. 2010 
Oct;24(5):593-605. 
3. Poblete-Gutierrez P, Wiederholt T, Merk HF, Frank J. The porphyrias: clinical presentation, 
diagnosis and treatment. Eur J Dermatol. 2006 May-Jun;16(3):230-40. 
4. Balwani M, Desnick RJ. The porphyrias: advances in diagnosis and treatment. Blood. 2012 
Nov 29;120(23):4496-504. 
5. Puy H, Gouya L, Deybach JC. Porphyrias. Lancet. 2010 Mar 13;375(9718):924-37. 
6. Floderus Y, Sardh E, Moller C, Andersson C, Rejkjaer L, Andersson DE, et al. Variations in 
porphobilinogen and 5-aminolevulinic acid concentrations in plasma and urine from 
asymptomatic carriers of the acute intermittent porphyria gene with increased porphyrin 
precursor excretion. Clin Chem. 2006 Apr;52(4):701-7. 
7. Anderson K. Disorders of heme biosynthesis. 8th ed. CR S, editor: McGraw-Hill, New York 
2001. 
8. Dowman JK, Gunson BK, Mirza DF, Bramhall SR, Badminton MN, Newsome PN. Liver 
transplantation for acute intermittent porphyria is complicated by a high rate of hepatic artery 
thrombosis. Liver Transpl. 2012 Feb;18(2):195-200. 
9. Badminton MN, Elder GH. Molecular mechanisms of dominant expression in porphyria. J 
Inherit Metab Dis. 2005;28(3):277-86. 
10. Deybach J-C, Puy H. 86 - Acute Intermittent Porphyria: From Clinical to Molecular Aspects. 
In: Guilard KMKMS, editor. The Porphyrin Handbook. Amsterdam: Academic Press; 2003. p. 
23-41. 
11. Bylesjo I, Wikberg A, Andersson C. Clinical aspects of acute intermittent porphyria in 
northern Sweden: a population-based study. Scand J Clin Lab Invest. 2009;69(5):612-8. 
12. James MF, Hift RJ. Porphyrias. Br J Anaesth. 2000 Jul;85(1):143-53. 
13. Chemmanur AT, Bonkovsky HL. Hepatic porphyrias: diagnosis and management. Clin Liver 
Dis. 2004 Nov;8(4):807-38, viii. 
14. Stein P, Badminton M, Barth J, Rees D, Stewart MF. Best practice guidelines on clinical 
management of acute attacks of porphyria and their complications. Ann Clin Biochem. 2013 
May;50(Pt 3):217-23. 
15. Bonkovsky HL. Neurovisceral porphyrias: what a hematologist needs to know. Hematology 
Am Soc Hematol Educ Program. 2005:24-30. 
16. Panhematin. (hemin for injection). 2013. 
17. Normosang. (human hemin). 2007. 
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18. Watson CJ, Pierach CA, Bossenmaier I, Cardinal R. Postulated deficiency of hepatic heme
and repair by hematin infusions in the "inducible" hepatic porphyrias. Proc Natl Acad Sci U S A. 
1977 May;74(5):2118-20. 
19. Mustajoki P, Nordmann Y. Early administration of heme arginate for acute porphyric attacks.
Arch Intern Med. 1993 Sep 13;153(17):2004-8. 
20. Bonkovsky HL, Singh RH, Jafri IH, Fiellin DA, Smith GS, Simon D, et al. A randomized,
controlled trial of treatment of alcoholic hepatitis with parenteral nutrition and oxandrolone. II. 
Short-term effects on nitrogen metabolism, metabolic balance, and nutrition. Am J Gastroenterol. 
1991 Sep;86(9):1209-18. 
21. Herrick AL, McColl KE, Moore MR, Cook A, Goldberg A. Controlled trial of haem arginate
in acute hepatic porphyria. Lancet. 1989 Jun 10;1(8650):1295-7. 
22. Bissell DM. Treatment of acute hepatic porphyria with hematin. J Hepatol. 1988 Feb;6(1):1-
7. 
23. Green D, Ts'ao CH. Hematin: effects on hemostasis. J Lab Clin Med. 1990 Feb;115(2):144-
7. 
24. Daimon M, Susa S, Igarashi M, Kato T, Kameda W. Administration of heme arginate, but
not hematin, caused anaphylactic shock. Am J Med. 2001 Feb 15;110(3):240. 
25. Elder G, Harper P, Badminton M, Sandberg S, Deybach JC. The incidence of inherited
porphyrias in Europe. J Inherit Metab Dis. 2013 Sep;36(5):849-57. 
26. Anderson K. Heme arginate for prevention of acute porphyric attacks (abstract). Acta
Haematologica. 1997;98((suppl 1):120). 
27. Bonkovsky HL, Guo JT, Hou W, Li T, Narang T, Thapar M. Porphyrin and heme
metabolism and the porphyrias. Compr Physiol. 2013 Jan;3(1):365-401. 
28. Vaishnaw AK, Gollob J, Gamba-Vitalo C, Hutabarat R, Sah D, Meyers R, et al. A status
report on RNAi therapeutics. Silence. 2010;1(1):14. 
29. Elbashir SM, Harborth J, Lendeckel W, Yalcin A, Weber K, Tuschl T. Duplexes of 21-
nucleotide RNAs mediate RNA interference in cultured mammalian cells. Nature. 2001 May 
24;411(6836):494-8. 
30. Kauppinen R, von und zu Fraunberg M. Molecular and biochemical studies of acute
intermittent porphyria in 196 patients and their families. Clin Chem. 2002 Nov;48(11):1891-900. 
31. Division of Clinical Pharmacology, Indiana University, P450 Drug Interaction Table.  2013 [
Accessed 06 February 2015]; Available from: http://medicine.iupui.edu/clinpharm/ddis/main-
table/. 
32. Atkinson TM M, TR, Sit L, Passik P, Scher, HI, Cleeland C, and Basch E. The Brief Pain
Inventory and its “Pain at its Worst in the last 24 Hours” Item: Clinical Trial Endpoint 
Considerations. Pain Med. 2010 March;11(3):337–46.
33. Levey AS SL, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, Kusek JW, Eggers P,
Van Lente F, Greene T, Coresh J; CKD-EPI (Chronic Kidney Disease Epidemiology 
Collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med. 
2009;150(9):604-12. 
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34. Herdman M GC, Lloyd A, Janssen M, Kind P, Parkin D, Bonsel G, Badia X. Development 
and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res. 
2011;20(10):1727-36. 
35. Sampson HA, Muñoz-Furlong A, Campbell RL, et al. Second symposium on the definition 
and management of anaphylaxis: summary report--Second National Institute of Allergy and 
Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol 
2006; 117:391. 
 
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11.
APPENDICES
11.1. 
Pharmacokinetic Assessment Time Points 
Table 3 contains a detailed schedule for the collection of blood samples for PK analysis. 
Table 3: 
Pharmacokinetic Time Points 
Study Day 
Protocol Time 
(hh:mm) 
PK Blood 
Day 1 and 
Month 12 (D361) ±10 days 
Predose (within 60 minutes 
before dosing) 
X 
02:00 (±15 minutes)b 
X 
06:00 (±20 minutes) 
X 
Month 1 (Day 14) ±2 days 
Anytime during visit 
X 
Month 1 (Day 31) ±7 days,a  
Month 3 (Day 91) ±7 days, 
Month 6 (Day 181) ±7 days, 
Month 9 (Day 271) ±10 daysd, 
Month 15 (Day 451) ±10 daysd, 
Month 18 (Day 541) ±10 days  
Month 24 (Day 721) ±10 days
Predose (within 60 minutes 
before dosing) 
X 
02:00 (±15 minutes)b 
X 
04:00 (±20 minutes)c 
Abbreviations:  hh=hours; mm=minutes; PK=pharmacokinetic. 
a  At the Day 31, Month 1 visit, if the dosing regimen is every 3 months, ALN-AS1 is not administered and 
a single time point blood sample for PK analysis should be collected. 
b  Only in patients receiving ≤2.5 mg/kg ALN-AS1; paired with ECG (for ECG details, see Section 7.5.4).
c  Only in patients receiving >2.5 mg/kg ALN-AS1; paired with ECG (for ECG details, see Section 7.5.4). 
d. Blood sample collection for PK analysis at Month 9 and Month 15 is only necessary if ECG will be
performed at same visit. 
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11.2. 
Schedules of Assessments for Every Month Dosing Regimen 
 
 Table 4: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14 ±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical 
History/Disease 
Historyc 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/ 
Exclusion Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examinationd 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
 
 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
X 
Vital Signsf 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead 
ECGg 
X 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Clinical Laboratory 
Assessmenth 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug 
Administrationj 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
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 Table 4: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14 ±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
Blood and Urine 
Sample for Exploratory 
Biomarker Analysisl 
 
X 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Blood Sample for PK 
Analysism 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Antidrug Antibodiesn 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
Porphyria Attack Kit 
Dispensationo 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EQ-5D-5L 
Questionnairep 
X 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Diary Review 
(including BPI-SF)q 
 
 
X 
AEs 
 
Continuous 
Concomitant 
Medicationsr 
 
Continuous 
 
Abbreviations:  AE=adverse event; ALAS1=5-aminolevulinic acid synthase 1; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief 
Pain Inventory-Short Form; D=day; ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of 
life; SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may 
be conducted while the patient is at home. 
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 Table 4: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14 ±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical 
examinations and blood/urine sample collections. 
a Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study (ALN-AS1-001) were completed within 60 days 
of administration of the first dose of ALN-AS1 in this study.  If more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs 
will be repeated before administration of ALN-AS1.  Results should be available and deemed acceptable before the administration of the first dose of ALN-
AS1. 
b After a patient has completed 6 months of ALN-AS1 administration in this study, and where applicable country and local regulations and infrastructure allow, 
study procedures, including ALN-AS1 administration, may take place at the patient’s home by a healthcare professional.  Study procedures may occur at the 
patient’s home at the discretion of the Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit at the clinical 
study center Q3M through M12, and thereafter Q6M. Additional visits to collect clinical laboratory samples may occur at home at any point during the 
treatment period, within 14 days prior to scheduled dose administration. 
c See Section 7.1 for details on the interval medical history/disease history to be recorded at Screening/Baseline.  Ongoing AEs from the previous study 
(ALN-AS1-001) will be captured as medical history. 
d A complete physical examination will be performed at Screening/Baseline, and D1.  At all other visits, a targeted physical examination will be performed.  On 
dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any time 
during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On D1, vital signs will be collected within 1 hour predose; and 2 hours 
(±10 minutes) postdose.  On all other dosing days, vital signs will be collected within 1 hour predose.  On days when ALN-AS1 is not administered, vital signs 
can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position (should be consistent for each patient), after the 
patient has rested comfortably for 10 minutes. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at least 5 
minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1 ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose at a minimum of 2 
of the following visits:  D1, Month 3, Month 6, Month 9, Month 12, Month 15 (only if visit is done at clinic), or Month 18.  In patients receiving >2.5 mg/kg 
ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose at a minimum of two of the following visits:  D1, Month 3, 
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Month 6, Month 9, Month 12, Month 15 (only if visit is done at clinic), or Month 18.  On all other dosing days, ECGs will be collected within 1 hour predose 
(see Section 7.5.4  for ECG assessment details). 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  On 
days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. On dosing days up to the Month 18 visit,results from 
hematology, chemistry (including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the Investigator before study drug 
administration.  If results from within the prior 14 days are not available at a dosing visit (at visits from D1 to Month 18), locally analyzed predose assessments 
may be used for review in order to allow same day study drug administration, and additional samples for central analysis must also be collected. 
i A serum pregnancy test will be performed at Screening/Baseline; thereafter, urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  For weight-
based dosing, weight measured at the current study center visit (dosing day) will be used to calculate the dose of ALN-AS1.  After M12, weight measured at 
either the previous study center visit or on current study center visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 3 (Appendix Section 11.1).  Blood sample collection for PK analysis at 
Month 9 and Month 15 is only necessary if ECG will be performed at same visit. 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o Porphyria attack laboratory sample collection kits should be dispensed at the screening visit along with instructions for use. For any attack that occurs through 
M37, urine samples should be collected within 24 hours of the start of clinical intervention (eg, hemin or glucose administration) and within 24 hours of the end 
of clinical intervention.  If patients are unable to report to the clinical study center during a porphyria attack, laboratory sample collection kits should be used 
for collecting and sending urine samples to the clinical study center, if possible.  These urine samples may also be analyzed for exploratory biomarkers. 
p In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but not more than once in a 6 month period), if possible.  
q Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, and narcotic use on a daily basis through M9; 
thereafter, acute porphyria attacks will be recorded in the diary.  The BPI will be completed on a weekly basis as part of the patient diary through M9, then 
Q3M. 
r Medications that are ongoing from the previous study (ALN-AS1-001), started between the previous study and this study, and started after signing informed 
consent in this study, will be captured as concomitant medication(s). 
 
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Table 5: 
Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
EOS/ 
ETb 
Safety 
Follow-
upc 
M19/ 
M20a 
M21a 
M22/ 
M23a 
M24 
M25/ 
M26a 
M27a 
M28/ 
M29a 
M30 
M31/ 
M32a 
M33a 
M34/ 
M35a 
M36/ 
EOT 
M37 
 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Physical Examinationd 
 
 
 
X 
 
 
 
X 
 
 
 
X 
X 
X 
Body Weight, BMI, and 
Heighte 
 
 
 
X 
 
 
 
X 
 
 
 
 
X 
 
Vital Signsf 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGg 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
 
Clinical Laboratory 
Assessmenth 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationj 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl  
 
 
 
X 
 
 
 
X 
 
 
 
X 
X 
 
Blood Sample for PK 
Analysism 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
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Table 5: 
Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
EOS/ 
ETb 
Safety 
Follow-
upc 
M19/ 
M20a 
M21a 
M22/ 
M23a 
M24 
M25/ 
M26a 
M27a 
M28/ 
M29a 
M30 
M31/ 
M32a 
M33a 
M34/ 
M35a 
M36/ 
EOT 
M37 
 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Antidrug Antibodiesn 
 
 
 
X 
 
 
 
 
 
 
 
X 
X 
 
EQ-5D-5L Questionnaireo 
 
 
 
X 
 
 
 
X 
 
 
 
X 
X 
 
Diary Review (including 
BPI-SF)pq 
X 
 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; EOS=End of Study; EOT=End of Treatment; ET=early termination; M=month; PBG=porphobilinogen; PK=pharmacokinetics; 
Q=every; QOL=quality of life; SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
a Where applicable country and local regulations and infrastructure allow, study procedures, including ALN-AS1 administration,  may take place at the patient’s 
home by a healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the Investigator, based on safety and tolerability; 
however, patients are required to complete at least 1 visit at the clinical study center Q6M.   
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b Patients who complete all scheduled doses ALN-AS1 through Month 36 will return for an end of study (EOS) visit at Month 37.  Patients who discontinue 
treatment prior to Month 36 will be asked to complete an early termination (ET) visit at which all Month 37 visit procedures will be performed; they must also 
return 3 months (84 [+ 7] days) after their last dose of ALN-AS1 for a safety-follow-up visit.   
c The safety follow-up visit is only required for patients who discontinue prior to study completion.  The visit should be conducted  3 months (84 [+7 days]) 
following the last dose of ALN-AS1. 
d A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed.  
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On a dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for 10 minutes. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for at least 
5 minutes.  For patients receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose . At Month 24, 
ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose, when paired with PK timepoints, otherwise ECGs will be collected 
predose.  In patients receiving >2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose.  See Section 7.5.4 
for ECG assessment details. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  On 
days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit.   
i Urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured at either the at the previous study center visit or current study center visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 3 (Appendix Section 11.1).  
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but, not more than once in a 6 month period), if possible.  
p Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
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11.3. 
List of Sensitive CYP3A Substrates and those with a Narrow 
Therapeutic Range 
A list of medications that are sensitive CYP3A substrates and those with a narrow therapeutic 
range is in Table 6.  
Table 6: 
List of Sensitive CYP3A Substrates and those with a Narrow Therapeutic 
Range 
Sensitive CYP3A Substrates 
 
CYP3A Substrates With A Narrow 
Therapeutic Range 
alfentanil 
fluticasone 
 
Alfentanil 
aprepitant 
lopinavir 
 
Astemizole 
budesonide 
lovastatin 
 
Cisapride 
buspirone 
lurasidone 
 
Cyclosporine 
conivaptan 
maraviroc 
 
Diergotamine 
darifenacin 
midazolam 
 
Dihydroergotamine 
darunavir 
nisoldipine 
 
Ergotamine 
dasatinib 
quetiapine 
 
Fentanyl 
dronedarone 
saquinavir 
 
Irinotecan 
eletriptan 
sildenafil 
 
Pimozide 
eplerenone 
simvastatin 
 
Quinidine 
everolimus 
sirolimus 
 
Sirolimus 
felodipine 
tolvaptan 
 
Tacrolimus 
imatinib 
tipranavir 
 
Terfenadine 
indinavir 
triazolam 
 
 
 
vardenafil 
 
 
Note:  This is not an exhaustive list and availability of medications may differ between countries.  For more 
information about clinically relevant drugs that are CYP3A substrates, see the Indiana University Division of 
Pharmacology website for reference: http://medicine.iupui.edu/clinpharm/ddis/clinical-table/. 
 
 
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11.4. 
Anaphylactic Reactions 
Table 7: 
 
Sampson Criteria for Anaphylactic Reactions 
 
Adapted from Sampson et al. 2006 [35] 
 
 
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ALN-AS1-002 Protocol Amendment 5 
Summary of Changes (dated 03 May 2018)  
compared to Protocol Amendment 4 (dated 02 August 2017) 
A Multicenter, Open-label Extension Study to Evaluate the Long-term Safety and Clinical 
Activity of Subcutaneously Administered ALN AS1 in Patients with Acute Intermittent 
Porphyria who have Completed a Previous Clinical Study with ALN-AS1 
 
Rationale for Protocol Amendment 
 
The purpose of the amendment is to: 
 Include clinical data on a single case of anaphylactic reaction, information regarding the 
potential risk for anaphylactic reactions, and provide updated guidance for dosing and 
monitoring.  The event of anaphylactic reaction was previously reported to applicable 
regulatory authorities and Institutional Review Boards/Ethics Committees. 
 Benefit-Risk Assessment (Section 1.7) modified to align with potential risks in the 
Investigator’s Brochure.  Information on reproductive health moved to Contraceptive 
Requirements (Section 6.4) and CYP inhibition moved to Concomitant Medications 
(Section 6 3). 
 Update guidance and procedures on patient withdrawal from study. 
 Schedule of Assessments footnotes were updated to: 
o Update end of study visit, early termination visit, and safety follow-up visit timing 
and assessments. 
o Clarify clinical laboratory testing required prior to dosing 
o Clarify timing of ECG assessments for patients administered ≤ 2.5 mg/kg and 
>2.5 mg/kg ALN-AS1 
 provide the following clarifications:  
o patient withdrawal details regarding subsequent visits and data collection 
o definition of sexual abstinence 
o contraception with an intrauterine hormone-releasing system also requires use of a 
barrier method   
A detailed summary of the changes is provided in Table 1.  Corrections to typographical errors 
and formatting are not detailed. 
 
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Table 1: 
Protocol Amendment 5 Detailed Summary of Changes 
The primary section(s) of the protocol affected by the changes in the protocol amendment are indicated.  The corresponding text has 
been revised throughout the protocol.  Deleted text is indicated by strikeout; added text is indicated by bold font. 
 
Purpose: Provide details of an anaphylactic reaction reported in Study ALN-AS1-002 and add anaphylactic reaction to potential risk 
The primary change occurs in Section 1.7 Benefit-Risk Assessment 
Added text: 
Anaphylactic reactions:  There is a potential risk of developing a severe allergic reaction with givosiran 
administration.  In the present study, one patient in the 2.5 mg/kg monthly dose group with a history of asthma 
and multiple allergies experienced an SAE of anaphylactic reaction that was determined by the Investigator to be 
definitely related to study drug given the temporal relationship of ALN-AS1 treatment to the onset of the reaction 
(within minutes).  The patient was treated and recovered and was discontinued from the study.Guidance on dose 
administration and monitoring for anaphylactic reactions has been included in this protocol. 
Section(s) also containing similar or related changes 
 Section 6.2.2 Dose Administration 
 Section 6.2.3.2 Indivdual Dose Modifications 
 
Purpose: Updated labels of two potential risks to align with ALN-AS1 Invesigator’s Brochure 
The primary change occurs in Section 1.7 Benefit-Risk Assessment 
Now reads: 
Serum chemistry and coagulation change Pancreatitis:  
Liver function test abnormalities Liver transaminase abnormalities: 
 
 
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Purpose: Clarified that only important potential risks are listed in Section 1.7.  To align with the Investigator’s Brochure, removed 
discussion of Reproductive Health and CYP Inhibition from important risks and, instead included details in respective sections in the 
protocol (reproductive health information moved to Section 6.4, Contraception Requirements and CYP inhibition information moved 
to Section 6.3, Concomitant Medication.   
The primary change occurs in Section 1.7 Benefit-Risk Assessment 
Now reads:  
The important potential risks associated with administration of ALN-AS1 in patients with AIP are as follows: 
Removed text: 
 Reproductive health:  No data are available on the use of ALN-AS1 in pregnancy; however, there is 
no suspicion of human teratogenicity based on class effects or genotoxic potential.  ALN-AS1 was 
neither genotoxic nor clastogenic in in vitro and in vivo studies.  Women of child bearing potential 
(WOCBP) must have a negative pregnancy test, cannot be breastfeeding, and must be willing to use 
acceptable methods of contraception during studies with ALN-AS1.  
 CYP inhibition:  A study in NHP demonstrated that ALN-AS1 dosing could potentially increase the 
clearance of drugs metabolized by the CYP3A isoform.  As contraceptive hormones are metabolized 
via CYP3A, WOCBP must use a barrier method of contraception, in addition to hormonal 
contraception, during study participation.  Additionally, Investigators will review all patient 
medications at study start and monitor responses to these medications during the study.  A list of 
medications that are sensitive CYP3A substrates is in Table 7 in Appendix Section 11.3.In addition, 
a list of medications that are sensitive CYP3A substrates is available at the Indiana University, 
Division of Clinical Pharmacology, website.[31] 
Section(s) also containing similar or related changes 
 Section 6.3 Concomitant Medications (moved information from Section 1.7 that was not already included in Section 6.3) 
 Section 6.4 Contraceptive Requirements (moved information from Section 1.7 that was not already included in Section 6.3) 
 
 
 
 
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Purpose: Updated exploratory PK objective to reflect corresponding exploratory endpoint (added “incidence of ADA”) 
The primary change occurs in Section 2.3 – Exploratory Objectives 
Now reads: 
Characterize the PK profile of ALN-AS1 and incidence of ADA over time 
Section(s) also containing this change: 
Protocol synopsis 
 
Purpose:  Updated section title and wording to reflect current company language 
The primary change occurs in Section 5.3 – Discontinuation of Study Drug and/or Study (new title) 
Now reads: 
Patients or their legal guardians (in the case that the patient is a minor) are free to discontinue study drug 
treatment and/or study or withdraw from the study  their consent at any time and for any reason, without 
penalty to their continuing medical care.  Any discontinuation of treatment or withdrawal from of the study 
must be fully documented in the electronic case report form (eCRF), and should be followed up by the 
Investigator.  The Investigator may withdraw a patient from the study at any time if this is considered to be in 
the patient’s best interest of the patient. 
Procedures for the discontinuationDiscontinuation of study drug and withdrawal from the study are described 
in Section 5.3.1 and Section 5.3.2 , respectively. , respectively.  If a patient stops participation from the 
study or withdraws consent from the study, he/she will not be able to re-enroll in the study. 
 
 
 
 
 
 
 
 
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Purpose:  Updated to reflect complete instructions to align with current Company language    
The primary change occurs in Section 5.3.1 – Discontinuation of Study Drug 
Now reads: 
The Investigator or designee may discontinue dosing in a patient if the patient: 
 Is in violation of the protocol 
 Experiences a SAE considered to be possibly or definitely related to the study drug or an intolerable 
AE  
 Becomes pregnant 
 Is found to be considerably noncompliant with the protocol-requirements 
Patients who are pregnant will be discontinued from study drug dosing immediately (see Section7.5.6.6 for 
reporting and follow-up of pregnancy).  Patients who discontinue treatment will be asked to complete the 
Month 39 visit assessments.  A positive urine pregnancy test should be confirmed by a serum pregnancy 
test prior to discontinuing the study drug. 
If a patient discontinues dosing due to a serious adverse event (SAE), the SAE should be followed as 
described in Section 7.5.6.  When a patient discontinues study drug dosing, the primary reason must be 
recorded in the electronic case report form (eCRF).  Patients who discontinue study drug and remain on 
study may receive treatment consistent with local standard practice for their disease per Investigator 
judgement, as applicable. 
Patients who discontinue treatment will be asked to complete an early termination (ET) visit at which all 
Month 37 visit procedures will be performed; they must also return for a safety-follow-up visit at 3 months 
(84 [+7] days) after their last dose of ALN-AS1.  
 
 
 
 
 
 
 
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Purpose:  Current section was replaced with more detailed information regarding premature discontinuation study drug and to align 
protocol text with sample Informed Consent Form.  
The primary change occurs in Section 5.3.2 – Discontinuation from the Study 
Now reads: 
A patient or their legal guardian may decide to stop the patient’s participation in the study at any time.  
Patients considering to stop the study should be informed that they can discontinue treatment and 
complete study assessments including follow-up, as per the SOA, or alternatively may complete any 
minimal assessments for which the patient consents. The Investigator may withdraw a patient at any 
time if this is considered to be in the patient’s best interest. 
However, study integrity and interpretation is best maintained if all randomized patients continue study 
assessments and follow-up.  Stopping study participation could mean: 
 If a patient discontinues from the study, he/she will be asked to complete an early 
termination (ET) visit at which all Month 37 visit procedures will be performed; the 
patient must also return for a safety-follow-up visit 3 months (84 [+7] days) after his/her 
last dose of ALN-AS1. 
 A patient can stop taking the study drug and stop study-related visits, but allow the 
investigator and study team to review the patient’s medical records, public records or be 
contacted in order to receive information about the patient’s health 
When a patient withdraws fromstops the study, the discontinuation and reason for study 
withdrawaldiscontinuation must be recorded in the appropriate section of the electronic case report form 
(eCRF) and all efforts will be made to complete and report the observations as thoroughly as possible.  If a 
patient withdrawsstops the study due to an adverse event (AE), including an SAE, the SAEAE should be 
followed as described in Section 7.5.6. 
If the patient wants to stop participation in the study, he/she should notify the study doctor in writing or 
in any other form that may be locally required. The personal data already collected during the study, 
including patient’s biological samples, will still be used together with the data collected on other patients 
in the study according to the informed consent and applicable laws. 
In addition to stopping participation in the study, the patient could decide to withdraw his/her consent as 
explained in Section 5.3.3.   
 
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Purpose: New section added to discuss withdrawal of consent    
The primary change occurs in Section 5.3.3 (new section)– Withdrawal of Consent to Collect and Process the Patient’s Personal Data 
New text: 
The patient may decide to withdraw his/her consent informing the study doctor at any time in writing, or in any 
other form that may be locally required.  This means that the patient wants to stop participation in the study and 
any further collection of his/her personal data.  
 The sponsor will continue to keep and use a patient's study information (including any data 
resulting from the analysis of the patient's biological samples until time of withdrawal) according 
to applicable law.  This is done to guarantee the validity of the study, determine the effects of the 
study treatment, and ensure completeness of study documentation. 
 The patient can also request that collected samples be destroyed or returned (to the extent it is 
permitted by applicable law) at any time. 
 Patients who withdraw their consent to collect and use Personal Data should understand that 
public records may be reviewed to determine the patient’s survival status as allowed per local 
and national regulations.    
In US and Japan, otherwise, samples not yet analyzed at the time of withdrawal may still be used for further 
testing/analysis in accordance with the terms of the protocol and of the informed consent form. 
In EU and rest of world, in any event, samples not yet analyzed at the time of withdrawal will not be used any 
longer, unless permitted by applicable law. They will be stored or destroyed according to applicable legal 
requirements. 
 
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Purpose: Revise details of requirements for study drug administration due to potential risk of anaphylactic reactions  
The primary change occurs in Section 6.2.2 Dose and Administration 
Now reads: 
ALN-AS1 will be administered by a qualified and authorized staff at the study center.  In the event that a 
patient is unable to come to the study center for a scheduled clinical study visit, health care professional 
trained in the recognition and management of anaphylactic reactions.  The study drug should be injected 
into the abdomen or upper arms or thighs.  Detailed instructions for study drug administration are 
presented in the Pharmacy Manual. As is consistent with good medical practice for subcutaneous drug 
administration, patients will be observed for a minimum of 20 minutes after each injection.  Treatment 
for anaphylactic reactions should be readily available where patients are being dosed, and follow country 
and/or local hospital treatment guidelines.[36]. 
After a patient has completed 12 months of ALN-AS1 administration in this study (6 months in an every month 
dosing regimen), study drug administration may be conducted at a location other than the study center by a 
home healthcare professional, where applicable country and local regulations and infrastructure allow, after 
consultation with the medical monitor.  For, during particular study visits, as specified in the Schedules of 
Assessments), dosing may also be performed.  However, study drug administration at a location other 
thanthe study center by a qualified home healthcare professional where applicable country and local regulations 
and infrastructure allow. The study drug should be injected intoconsidered for patients who have ongoing 
study drug-related AEs or known risk factors for developing anaphylactic reaction, including but not 
limited to: a prior history of an anaphylactic reaction to food, medications or unknown etiology, 
worsening injection site reactions with repeat dosing, or anyone in the abdomen or upper arms or thighs.  
Patients must demonstrate that they can tolerate doseopinion of the investigator that would benefit from 
clinical observation following dosing. at a location other than the study center is permitte Patients are required 
to complete at least 1 visit at the clinical study center every 3 months for the first year, and thereafter every 6 
months through the end of the treatment period.  Additional visits to collect clinical laboratory samples may 
occur at home at any point during the treatment period, within 14 days prior to scheduled dose administration. 
 
 
 
 
 
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Purpose: Add instructions regarding management of potential cases of anaphylactic reaction  
The primary change occurs in Section 6.2.3.2.1 Monitoring and Dosing Rules in Patients with Potential Cases of Anaphylactic 
Reactions 
New text: 
An anaphylactic reaction is a severe, potentially fatal, systemic allergic reaction with acute onset (minutes to 
hours).  For reference see Section 11.4.[35] 
Stop administering the study medication immediately if an anaphylactic reaction to the study medication is 
suspected.  Study medication must be permanently discontinued in patients for whom anaphylactic reactions is 
assessed as related to the study medication. 
Laboratory testing: Obtain blood sample for tryptase, total IgE, and ADA antidrug antibodies (ADA) ideally 
within 15 minutes to 3 hours after the onset of a suspected anaphylactic reaction; however, up to 6 hours is 
acceptable.  An additional blood sample to assess tryptase, total IgE, and ADA should be obtained between 1 to 
2 weeks from onset of event.  Local laboratory may be used to analyze samples; however, parallel samples 
should be sent to the central laboratory for analysis.  Sample collection and shipping instructions are included in 
the Laboratory Manual. 
Reporting: The PI or designee must notify the sponsor or designee within 24 hours of the occurrence of a 
suspected case of anaphylactic reaction or being informed of the case as required for AEs of Clinical Interest 
(AECI) and SAEs, per AE reporting requirements (Section Error! Reference source not found.,  
Section Error! Reference source not found. and 7.5.6.3). 
 
Purpose: To make the language on packaging and labeling more general and provide a reference to the Pharmacy Manual, where such 
language is easier to update and maintain.  
The primary change occurs in Section 6.2.5- Packaging and Labeling 
Now reads:  
ALN-AS1 Solution for Injection (SC use) is packaged in 2 mL glass vials with a fill volume of no less than 
0.55 mL.  The container closure system consists of a Type I glass vial, a Teflon faced bromobutyl 13 mm 
stopper and a flip-off Truedge aluminum seal 
All packaging, labeling, and production of study drug will be in compliance with current Good 
Manufacturing Practice specifications, as well as applicable local regulations.  Study drug labels and 
external packaging will include all appropriate information as per local labeling requirements. 
Additional details will be available in the Pharmacy Manual. 
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Purpose:  Revised definition of sexual abstinence to align with current standards and clarified that intrauterine hormone releasing 
system is a method requiring a barrier method 
Benefit-Risk Assessment (Section 1.7) modified to align with potential risks in the Investigator’s Brochure.  Information on reproductive health 
moved to Contraceptive Requirements (Section 6.4) and CYP inhibition moved to Concomitant Medications (Section 6.3) 
The primary change occurs in Section 6.4– Contraceptive Requirements 
Now reads 
Sexual abstinence, when this is in line with the preferred and usual lifestyle of the patient, is considered an 
acceptable method only if defined as refraining from heterosexual intercourse during the entire period of 
risk associated with the study drug (defined above).  Periodic abstinence (eg, calendar, ovulation, 
symptothermal, post-ovulation methods) and withdrawal are not acceptable methods of contraception. 
considered sexual abstinence and do not meet criteria for an acceptable method of birth control.  As 
determined by the investigator, the reliability of sexual abstinence needs to be evaluated in relation to the 
duration of the clinical trial and the preferred and usual lifestyle of the patient.  Abstinent patients must 
agree to use 1 of the abovementioned contraceptive methods if they start sexual relationships a heterosexual 
relationship during the study and continue to do so for 3 months after their last dose administration.the entire 
period of risk associated with the study drug (defined above). 
 
 
 
 
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Purpose:  Revised definition of sexual abstinence to align with current standards and clarified that intrauterine hormone releasing 
system is a method requiring a barrier method 
The primary change occurs in Section 6.4 – Contraceptive Requirements 
Now reads 
Sexual abstinence, when this is in line with the preferred and usual lifestyle of the patient, is considered an 
acceptable method only if defined as refraining from heterosexual intercourse during the entire period of 
risk associated with the study drug (defined above).  Periodic abstinence (eg, calendar, ovulation, 
symptothermal, post-ovulation methods) and withdrawal are not acceptable methods of contraception. 
considered sexual abstinence and do not meet criteria for an acceptable method of birth control.  As 
determined by the investigator, the reliability of sexual abstinence needs to be evaluated in relation to the 
duration of the clinical trial and the preferred and usual lifestyle of the patient.  Abstinent patients must 
agree to use 1 of the abovementioned contraceptive methods if they start sexual relationships a heterosexual 
relationship during the study and continue to do so for 3 months after their last dose administration.the entire 
period of risk associated with the study drug (defined above). 
Now reads 
Established use of oral, implantable, injectable, or transdermal hormonal, or intrauterine hormone-releasing 
system as methods of contraception:  Women of child-bearing potential using hormonal methods of 
contraception must also use a barrier method (condom or occlusive cap [diaphragm or cervical/vault cap] in 
conjunction with spermicide [eg, foam, gel, film, cream, or suppository]). 
 
Purpose:  For consistency across documents, elevated lipase (see below)  was added to the list of adverse events of clinical interest. 
The primary change occurs in Section7.5.6.1 - Definitions 
Added text: 
Lipase >3×ULN (or >3× the baseline lipase measurement if baseline is >ULN) 
 
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Purpose:  Update instructions for Pharmacokinetic Assessments at Month 9 and Month 15  
The primary change occurs in Section 11.1, Table 4:  Pharmacokinetic Time Points Footnotes 
New text: 
d.  Blood sample collection for PK analysis at Month 9 and Month 15 is only necessary if ECG will be performed at same visit. 
Section(s) also containing similar or related changes 
 Table 2: Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen) 
 Table 6: Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen) 
 
Purpose: Added anaphylactic reactions to list of Adverse Events of Clinical Interest 
The primary change occurs in Section 7.5.6.1 – Definitions 
Added text: 
Anaphylactic Reactions. Anaphylactic reaction is a severe, potentially fatal, systemic allergic reaction with 
acute onset (minutes to hours).  Symptoms of an anaphylactic reaction may include skin or mucosal tissue (e.g. 
generalized hives, pruritus, angioedema), respiratory compromise (e.g. wheezing, bronchospasm, hypoxia), 
reduced blood pressure or associated symptoms (e.g. syncope, hypotonia).  See Section 11.4 for guidance on 
diagnosing anaphylactic reactions.[35]  
 
 
 
 
 
 
 
 
 
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Purpose: Clarify clinical laboratory testing required prior to dosing 
The primary change occurs in Table 1, Schedule of Assessments 
Now reads:  
a Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study 
(ALN-AS1-001) were completed within 60 days of administration of the first dose of ALN-AS1 in this study.  
If more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs will be 
repeated before administration of ALN-AS1.  Results should be available and deemed acceptable before the 
administration of the first dose of ALN-AS1.  On Day 1, results from hematology, chemistry (including 
LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the Investigator 
before study drug administration.  If results from within the prior 14 days are not available at a dosing 
visit, locally analyzed predose assessments may be used for review in order to allow same day study 
drug administration and additional samples for central analysis must also be collected. 
 
 
Purpose: Clarify timing of ECG assessments for patients administered ≤ 2.5 mg/kg and >2.5 mg/kg ALN-AS1 
The primary change occurs in Table 1 and Table 2, Schedule of Assessments 
Now reads: 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after 
the patient has rested comfortably for at least 5 minutes.  On at least two of the following visits For patients 
receiving ≤2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) 
postdose at a minimum of 2 of the following visits:  D1, Month 3, Month 6, Month 9, Month 12, Month 15 
(only if visit is done at clinic), or Month 18.  In patients receiving >2.5 mg/kg ALN-AS1, ECGs will be 
performed within 1 hour predose and 4 hours (±20 minutes) postdose on at least a minimum of two of the 
following visits:  D1, Month 3, Month 6, Month 9, Month 12, Month 15 (only if visit is done at clinic), or 
Month 18.  On all other dosing days, ECGs will be collected within 1 hour predose (see Section 7.5.4 for ECG 
assessment details).   
 
 
 
 
 
 
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Purpose: to update the guidance on weight collection for dosing calculations 
The Primary change occurs in Table 1, Schedule of Assessments 
Now reads:  
j  ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for 
ALN-AS1 dose and dosing regimen.  For weight-based dosing, weight measured on the dosing dayat the 
current study center visit (dosing day) will be used to calculate the dose of ALN-AS1 through M12.  After 
M12, weight measured at either the previous study center visit or the current study center visit on the 
nearest previous clinic visitmay be used to calculate the weight-based dose of ALN-AS1. 
Section(s) also containing similar or related changes 
Table 1, Schedule of Assessments 
Section 7.5.2 – Weight and Height 
Table 4 – Schedule of Assessments: Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Table 5- Schedule of Assessments: Month 19 through End of Study (Every Month Dosing Regimen) 
 
 
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Purpose:  Update end of study visit, early termination visit, and safety follow-up visit timing and assessments 
The primary change occurs in Table 2 and Table 5 
Now reads 
Posttreatment Follow-upEOS/ ETb 
ALA/PBG 
Monitoring/EOSc  Safety Follow-upc 
M39b 
M37 
M42 
Now Reads 
b Patients who complete all scheduled treatment with ALN-AS1 through Month 36 will return for an end 
of study (EOS) visit at Month 37.  Patients who discontinue treatment will be asked to complete an early 
termination (ET) visit at which all Month 37 visit procedures will be performed; the M39 visit 
assessments.  If a patient chooses to withdraw from the study, every effort should be made to conduct the 
assessments performed at the.  See Section  for details on removal from treatment or assessment. 
c 
The ALA/PBG Monitoring/EOSa safety-follow-up visit will be conducted at the clinical study center or via 
phone contact, unless treatment continues with ALN-AS1.  Patients will be provided with laboratory sample 
collection kits and instructions for collecting and sending urine samples to the clinical study center.; the patient 
must also return for a safety follow-up visit 3 months (84 [+7] days) after his/her last dose of ALN-AS1.   
Section(s) also containing similar or related changes 
 Section 4.1 : Summary of Study Design 
 Section 5.3.1: Discontinuation of Study Drug 
 
 
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Purpose: Add  guidance for diagnosing anaphylactic reactions  
The primary change occurs in Section 11.4 (new section) – Anaphylactic Reactions 
Added text: 
Table 2 
Sampson Criteria for Anaphylactic Reactions 
 
Adapted from Sampson et al. 2006 [35] 
 
 
 
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CLINICAL STUDY PROTOCOL 
ALN-AS1-002 
 
Protocol Title: 
A Multicenter, Open-label Extension Study to Evaluate the Long-term 
Safety and Clinical Activity of Subcutaneously Administered 
ALN-AS1 in Patients with Acute Intermittent Porphyria who have 
Completed a Previous Clinical Study with ALN-AS1 
Investigational Drug: 
ALN-AS1 
EudraCT Number: 
2016-002638-54 
IND Number: 
126094 
Protocol Date: 
Original Protocol 19 July 2016 
 
Protocol Amendment 0.1 (Sweden) 20 September 2016 
 
Protocol Amendment 1 10 November 2016 
 
Protocol Amendment 2 01 December 2016 
 
Protocol Amendment 3 03 February 2017 
 
Protocol Amendment 4 02 August 2017 
 
 
Sponsor: 
Alnylam Pharmaceuticals, Inc. 
300 Third Street 
Cambridge, MA  02142 USA 
Telephone:  
 
Sponsor Contact:   
 
 
 
 
The concepts and information contained in this document or generated during the study are considered 
proprietary and may not be disclosed in whole or in part without expressed written authorization of 
Alnylam Pharmaceuticals, Inc. 
 
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SPONSOR PROTOCOL APPROVAL 
I haread this protocol and I approve the design of this study. 
Date 
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INVESTIGATOR’S AGREEMENT 
 
I have read the ALN-AS1-002 protocol and agree to conduct the study as outlined.  I agree to 
maintain the confidentiality of all information received or developed in connection with this 
protocol. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Printed Name of Investigator 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signature of Investigator 
 
 
 
 
 
 
 
 
Date 
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PROTOCOL SYNOPSIS 
Protocol Title 
A Multicenter, Open-label Extension Study to Evaluate the Long-term Safety and Clinical Activity of 
Subcutaneously Administered ALN-AS1 in Patients with Acute Intermittent Porphyria who have 
Completed a Previous Clinical Study with ALN-AS1 
Product Name 
ALN-AS1 
Indication 
Patients with acute intermittent porphyria (AIP) who experience recurrent porphyria attacks 
Phase 
1/2 
Study center(s)   
The study will be conducted at up to 8 clinical study centers worldwide. 
Objectives 
Primary 
 
Evaluate the long-term safety and tolerability of ALN-AS1 in patients with AIP 
Secondary 
 
Assess the pharmacodynamic (PD) effect of ALN-AS1 over time 
 
Assess the clinical activity of ALN-AS1 over time 
Exploratory 
 
Characterize the pharmacokinetic (PK) profile of ALN-AS1 over time 
 
Assess changes in health-related quality of life (QOL) 
 
Characterize analytes related to targeting the heme biosynthesis pathway 
Endpoints 
Primary 
 
Patient incidence of adverse events (AEs) 
Secondary 
 
Change in urine delta-aminolevulinic acid (ALA) and porphobilinogen (PBG) levels 
 
Frequency and characteristics of porphyria attacks 
 
Change in hemin administration 
Exploratory 
 
Change in circulating 5-aminolevulinic acid synthase 1 (ALAS1) mRNA levels 
 
Concentrations of ALN-AS1 and antidrug antibodies  
 
Duration and treatment of porphyria attacks 
 
Number and duration of visits to a health care facility for acute porphyria care 
 
EQ-5D-5L questionnaire scores 
 
Pain assessment and narcotic use as recorded in a patient diary 
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 
Exploratory biomarkers related to the target pathway, such as urine porphyrins, vitamin D binding 
protein 
Study Design 
This is a multicenter, open-label extension study to evaluate the long-term safety and clinical activity 
of ALN-AS1 in patients with AIP who completed study ALN-AS1-001. 
The last assessments performed, determining previous study (ALN-AS1-001) completion, will serve as 
the Screening/Baseline assessments in this study.  If more than 60 days have elapsed since the last 
assessment, safety assessments will be repeated before administration of ALN-AS1.  It is anticipated 
that patients will begin ALN-AS1 administration in this study within 6 months after the last dose of 
study drug in the previous study.  Eligibility will be confirmed before administration of the first dose of 
ALN-AS1 (Day 1).  Patients will undergo assessments at the clinical study center every month for the 
first 3 months.  Then, through Month 6, and according to the dosing regimen selected, assessments will 
take place at the clinical study center or via a phone contact (for an every month dosing regimen, visits 
will be every month; for an every 3 months dosing regimen, visits will be every 3 months).  After a 
patient has completed 12 months of ALN-AS1 administration in this study (6 months in an every 
month dosing regimen), and where applicable country and local regulations and infrastructure allow, 
study procedures, including ALN-AS1 administration, may take place at the patient’s home by a 
healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the 
Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit 
at the clinical study center every 3 months for the first year, and thereafter every 6 months through the 
end of the treatment period.  Additional visits to collect clinical laboratory samples may occur at home 
at any point during the treatment period, within 14 days prior to scheduled dose administration.  
Patients will return to the clinical study center for a posttreatment follow-up visit after administration 
of the last dose of ALN-AS1.  An ALA/PBG Monitoring/EOS visit will be conducted either at the 
clinical study center or via phone contact, unless treatment continues with ALN-AS1. 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, 
and narcotic use.  Patients will also be provided with laboratory sample collection kits and instructions 
for collecting and sending urine samples to the clinical study center. 
A Safety Review Committee (SRC) will review safety and tolerability data collected during the study 
with the primary purpose of protecting the safety of patients participating in the study. 
Number of Planned Patients 
Up to 24 patients are planned for enrollment in this study (including optional cohorts in 
ALN-AS1-001). 
Diagnosis and Main Eligibility Criteria 
Patients with AIP, who have completed Part C of study ALN-AS1-001, will be eligible for screening in 
this study.  Eligible patients will not be on a scheduled regimen of hemin to prevent porphyria attacks 
at Screening.  Patients with alanine transaminase ≥2.0× upper limit of normal, total bilirubin ≥2 mg/dL 
(unless bilirubin elevation is due to Gilbert’s syndrome), or estimated glomerular filtration rate 
≤30 mL/min/1.73 m2 (using the Modification of Diet in Renal Disease formula) at Screening are not 
eligible for this study. 
Investigational Product, Dose, and Mode of Administration 
ALN-AS1 Solution for Injection (subcutaneous use [SC]) is comprised of a synthetic, small interfering 
RNA targeting ALAS1 and bearing a triantennary N-acetyl galactosamine ligand conjugated to the 
sense strand, formulated in phosphate buffer.   
The study starting dose and regimen of ALN-AS1 is 5.0 mg/kg as an SC injection administered every 
3 months.  Based on emerging clinical data, the SRC may approve changes to the dosing regimen, 
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including decreases in the dose level and changes in the dosing frequency.  However any dose and 
dosing regimen will not exceed a previously explored dose level or frequency that was determined to 
be safe and well-tolerated in study ALN-AS1-001, SRC, Health Authority and Ethics Committee 
approval must be sought prior to dose escalation above 5.0 mg/kg in accordance with local Regulatory 
requirements.  
Reference Therapy, Dose, and Mode of Administration 
Not applicable 
Duration of Treatment and Study 
The duration of treatment is up to 36 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 44 months. 
Statistical Methods 
Statistical analyses will be primarily descriptive.  Incidence of AEs will be summarized by maximum 
severity and relationship to ALN-AS1.  Incidence of and serious adverse events (SAEs) and AEs 
leading to discontinuation will also be tabulated.  By-patient listings will be provided for deaths, SAEs, 
and events leading to discontinuation.  
Laboratory shift tables from baseline to worst values will be presented.  Abnormal physical 
examination findings and electrocardiogram data will be presented in by-patient listings.  Descriptive 
statistics will be provided for electrocardiogram interval data and presented as both actual values and 
changes from baseline relative to each on study evaluation and to the last evaluation on-study. 
Clinical activity of ALN-AS1 will be summarized primarily by descriptive statistics.  The clinical 
activity of ALN-AS1 will be evaluated by the frequency and characteristics of porphyria attacks 
including duration, treatment, and severity of porphyria attacks and number and duration of visits to a 
health care setting for acute porphyria care.  Patient diary recordings, including BPI-SF questionnaire 
scores, will also be summarized.   
PD analysis will include the evaluation of change in ALA, PBG, and ALAS mRNA levels.  Descriptive 
statistics (eg, mean and standard error of the mean) for observed levels of PD parameters and the 
relative change from baseline will be presented for each of the postdose follow-up time points. 
The PK concentration of ALN-AS1 will be determined.  Antidrug antibody results will be tabulated 
overall and by previous treatment in the previous study (ALN-AS1-001).  A by-patient listing will also 
be provided. 
Additional exploratory analyses may be conducted on analytes related to targeting the heme 
biosynthesis pathway.  Quality of life scores will also be summarized. 
 
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Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8 
M9 
M10/ 
M11 
M12 
M13/ 
M14 
M15b 
M16/ 
M17 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History/Disease 
Historyc 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/ 
Exclusion Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examinationd 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
 
 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
Vital Signsf 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Triplicate 12-Lead ECGg 
X 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Clinical Laboratory 
Assessmenth 
X 
 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Study Drug Administrationj 
 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl 
 
X 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
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Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8 
M9 
M10/ 
M11 
M12 
M13/ 
M14 
M15b 
M16/ 
M17 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Blood Sample for PK 
Analysism 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Antidrug Antibodiesn 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
Porphyria Attack Kit 
Dispensationo 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EQ-5D-5L Questionnairep 
X 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Diary Review (including 
BPI-SF)q 
 
 
X 
Phone Contactr 
 
 
 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
AEs 
 
Continuous 
Concomitant Medicationss 
 
Continuous 
 
Abbreviations:  AE=adverse event; ALAS1=5-aminolevulinic acid synthase 1; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief 
Pain Inventory-Short Form; D=day; ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of life; 
SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may 
be conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical 
examinations and blood/urine sample collections. 
a Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study (ALN-AS1-001) were completed within 60 days 
of administration of the first dose of ALN-AS1 in this study.  If more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs 
will be repeated before administration of ALN-AS1.  Results should be available and deemed acceptable before the administration of the first dose of ALN-
AS1. 
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b After a patient has completed 12 months of ALN-AS1 administration in this study, and where applicable country and local regulations and infrastructure allow, 
study procedures, including ALN-AS1 administration, may take place at the patient’s home by a healthcare professional.  Study procedures may occur at the
patient’s home at the discretion of the Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit at the clinical
study center Q6M.  Additional visits to collect clinical laboratory samples may occur at home at any point during the treatment period, within 14 days prior to 
scheduled dose administration. 
c See Section 7.1 for details on the interval medical history/disease history to be recorded at Screening/Baseline.  Ongoing AEs from the previous study 
(ALN-AS1-001) will be captured as medical history. 
d A complete physical examination will be performed at Screening/Baseline, and D1.  At all other visits, a targeted physical examination will be performed.  On 
dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any time 
during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On D1, vital signs will be collected within 1 hour predose; and 2 hours 
(±10 minutes) postdose.  On all other dosing days, vital signs will be collected within 1 hour predose.  On days when ALN-AS1 is not administered, vital signs 
can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position (should be consistent for each patient), after the 
patient has rested comfortably for 10 minutes. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 5 minutes. 
On at least two of the following visits, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose:  D1, Month 3, Month 6, Month 9, 
Month 12, Month 15, or Month 18.  In patients receiving >2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) 
postdose on at least two of the following visits:  D1, Month 3, Month 6, Month 12, Month 15, or Month 18.  On all other dosing days, ECGs will be collected 
within 1 hour predose (see Section 7.5.4 for ECG assessment details). 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  On 
days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. On dosing days, results from hematology, chemistry 
(including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the Investigator before study drug administration.  If results 
from within the prior 14 days are not available at a dosing visit, locally analyzed predose assessments may be used for review in order to allow same day study 
drug administration, but additional samples for central analysis must also be collected. 
i A serum pregnancy test will be performed at Screening/Baseline; thereafter, urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  For 
weight-based dosing, weight measured on the dosing day will be used to calculate the dose of ALN-AS1.  After M12, weight measured on the nearest previous 
visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1).  Blood sample collection for PK analysis at 
Month 9 and Month 15 is only necessary if ECG will be performed at same visit. 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o Porphyria attack laboratory sample collection kits should be dispensed at the screening visit along with instructions for use. For any attack that occurs through
M39, urine samples should be collected within 24 hours of the start of clinical intervention (eg, hemin or glucose administration) and within 24 hours of the end
of clinical intervention.  If patients are unable to report to the clinical study center during a porphyria attack, laboratory sample collection kits will be provided
that contain instructions for collecting and sending urine samples to the clinical study center, if possible.  These urine samples may also be analyzed for
exploratory biomarkers.
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p In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but not more than once in a 6 month period), if possible.  
q Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, and narcotic use on a daily basis through M9; 
thereafter, acute porphyria attacks will be recorded in the diary.  The BPI will be completed on a weekly basis as part of the patient diary through M9, then 
Q3M. 
r Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack. 
s Medications that are ongoing from the previous study (ALN-AS1-001), started between the previous study and this study, and started after signing informed 
consent in this study, will be captured as concomitant medication(s). 
 
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Table 2: 
Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20 
M21a 
M22/ 
M23 
M24 
M25/ 
M26 
M27a 
M28/ 
M29 
M30 
M31/ 
M32 
M33a 
M34/ 
M35 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Physical Examinationd 
 
 
 
X 
 
 
 
X 
 
 
 
X 
X 
 
Body Weight, BMI, and 
Heighte 
 
 
 
X 
 
 
 
X 
 
 
 
 
X 
 
Vital Signsf 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
 
Triplicate 12-Lead ECGg 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
 
Clinical Laboratory 
Assessmenth 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
 
Pregnancy Testi 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
 
Study Drug Administrationj 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl 
 
 
 
X 
 
 
 
X 
 
 
 
X 
X 
 
Blood Sample for PK 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
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Table 2: 
Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20 
M21a 
M22/ 
M23 
M24 
M25/ 
M26 
M27a 
M28/ 
M29 
M30 
M31/ 
M32 
M33a 
M34/ 
M35 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Analysism 
Antidrug Antibodiesn 
 
 
 
X 
 
 
 
 
 
 
 
X 
 
 
EQ-5D-5L Questionnaireo 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
Diary Review (including 
BPI-SF)p 
X 
 
Phone Contactq 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
X 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; EOS = End of Study; EOT = End of Treatment; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality 
of life; SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
a Where applicable country and local regulations and infrastructure allow, study procedures, including ALN-AS1 administration, may take place at the patient’s 
home by a healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the Investigator, based on safety and tolerability; 
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however, patients are required to complete at least 1 visit at the clinical study center Q6M. Additional visits to collect clinical laboratory samples may occur at 
home at any point during the treatment period, within 14 days prior to scheduled dose administration. 
b Patients who discontinue treatment will be asked to complete the M39 visit assessments.  If a patient chooses to withdraw from the study, every effort should 
be made to conduct early the assessments performed at the M39 visit.  See Section 5.3 for details on removal from treatment or assessment. 
c The ALA/PBG Monitoring/EOS visit will be conducted at the clinical study center or via phone contact, unless treatment continues with ALN-AS1.  Patients 
will be provided with laboratory sample collection kits and instructions for collecting and sending urine samples to the clinical study center. 
d A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed. 
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for 10 minutes. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 5 minutes. 
ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose.  In patients receiving >2.5 mg/kg ALN-AS1, ECGs will be performed 
within 1 hour predose and 4 hours (±20 minutes) postdose.  See Section 7.5.4 for ECG assessment details. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  . 
On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit.  On dosing days, results from hematology, chemistry 
(including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the Investigator before study drug administration.  If results 
from within the prior 14 days are not available at a dosing visit, locally analyzed predose assessments may be used for review in order to allow same day study 
drug administration, but additional samples for central analysis must also be collected. 
i Urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured on the nearest previous visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack
(but, not more than once in a 6 month period), if possible.
p Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
q Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack.
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TABLE OF CONTENTS 
PROTOCOL SYNOPSIS ................................................................................................................4 
TABLE OF CONTENTS ...............................................................................................................14 
LIST OF TABLES .........................................................................................................................17 
LIST OF FIGURES .......................................................................................................................18 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS ................................................19 
1. 
INTRODUCTION ......................................................................................................21 
1.1. 
Disease Overview .......................................................................................................21 
1.1.1. 
Epidemiology ..............................................................................................................21 
1.1.2. 
Current Management and Unmet Medical Need ........................................................22 
1.2. 
RNA Interference ........................................................................................................23 
1.3. 
ALN-AS1 ....................................................................................................................23 
1.4. 
Study Design Rationale ..............................................................................................23 
1.5. 
Dose Rationale ............................................................................................................23 
1.6. 
Clinical Data Summary ...............................................................................................24 
1.6.1. 
Clinical Pharmacodynamics .......................................................................................25 
1.6.2. 
Clinical Activity ..........................................................................................................25 
1.6.3. 
Clinical Safety ............................................................................................................26 
1.7. 
Benefit-Risk Assessment ............................................................................................27 
2. 
OBJECTIVES .............................................................................................................28 
2.1. 
Primary Objective .......................................................................................................28 
2.2. 
Secondary Objectives .................................................................................................28 
2.3. 
Exploratory Objectives ...............................................................................................29 
3. 
ENDPOINTS ..............................................................................................................29 
3.1. 
Primary Endpoint ........................................................................................................29 
3.2. 
Secondary Endpoints ..................................................................................................29 
3.3. 
Exploratory Endpoints ................................................................................................29 
4. 
INVESTIGATIONAL PLAN .....................................................................................29 
4.1. 
Summary of Study Design ..........................................................................................29 
4.2. 
Duration of Treatment and Study ...............................................................................31 
4.3. 
Number of Patients .....................................................................................................31 
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4.4. 
Method of Assigning Patients to Treatment Groups ..................................................31 
4.5. 
Blinding ......................................................................................................................31 
4.6. 
Safety Review Committee ..........................................................................................31 
5. 
SELECTION AND WITHDRAWAL OF PATIENTS ..............................................31 
5.1. 
Inclusion Criteria ........................................................................................................31 
5.2. 
Exclusion Criteria .......................................................................................................32 
5.3. 
Removal from Treatment or Assessment ...................................................................32 
5.3.1. 
Discontinuation of Study Drug ...................................................................................32 
5.3.2. 
Withdrawal from Study ..............................................................................................33 
5.3.3. 
Replacement of Patients .............................................................................................33 
6. 
TREATMENTS ..........................................................................................................33 
6.1. 
Treatments Administered ............................................................................................33 
6.2. 
Investigational Study Drug .........................................................................................33 
6.2.1. 
Description ..................................................................................................................33 
6.2.2. 
Dose and Administration ............................................................................................33 
6.2.3. 
Dose Modifications .....................................................................................................34 
6.2.3.1. 
Study Population Dose Modifications ........................................................................34 
6.2.3.2. 
Individual Dose Modifications ...................................................................................34 
6.2.4. 
Preparation, Handling, and Storage ............................................................................35 
6.2.5. 
Packaging and Labeling ..............................................................................................35 
6.2.6. 
Accountability .............................................................................................................35 
6.3. 
Concomitant Medications ...........................................................................................35 
6.4. 
Contraceptive Requirements .......................................................................................36 
6.5. 
Treatment Compliance ................................................................................................37 
7. 
STUDY ASSESSMENTS ..........................................................................................37 
7.1. 
Screening/Baseline Assessments ................................................................................37 
7.2. 
Clinical Activity Assessments ....................................................................................37 
7.2.1. 
Patient Diary ...............................................................................................................37 
7.2.2. 
Brief Pain Inventory-Short Form Questionnaire ........................................................37 
7.3. 
Pharmacodynamic Assessments .................................................................................37 
7.4. 
Pharmacokinetic Assessments ....................................................................................38 
7.5. 
Safety Assessments .....................................................................................................38 
7.5.1. 
Vital Signs ..................................................................................................................38 
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7.5.2. 
Weight and Height ......................................................................................................38 
7.5.3. 
Physical Examination .................................................................................................38 
7.5.4. 
Electrocardiogram .......................................................................................................38 
7.5.5. 
Clinical Laboratory Assessments ...............................................................................39 
7.5.5.1. 
Immunogenicity ..........................................................................................................41 
7.5.5.2. 
Pregnancy Testing ......................................................................................................41 
7.5.6. 
Adverse Events ...........................................................................................................41 
7.5.6.1. 
Definitions ..................................................................................................................41 
7.5.6.2. 
Eliciting and Recording Adverse Events ....................................................................43 
7.5.6.3. 
Serious Adverse Events Require Immediate Reporting to Sponsor/Designee ...........44 
7.5.6.4. 
Sponsor Safety Reporting to Regulatory Authorities .................................................44 
7.5.6.5. 
Serious Adverse Event Notification to the Institutional Review 
Board/Independent Ethics Committee ........................................................................45 
7.5.6.6. 
Pregnancy Reporting ..................................................................................................45 
7.5.6.7. 
Overdose Reporting ....................................................................................................45 
7.6. 
Exploratory Assessments ............................................................................................46 
7.7. 
Other Assessments ......................................................................................................46 
7.7.1. 
EQ-5D-5L Questionnaire ............................................................................................46 
8. 
STATISTICS ..............................................................................................................46 
8.1. 
Determination of Sample Size ....................................................................................46 
8.2. 
Statistical Methodology ..............................................................................................46 
8.2.1. 
Populations to be Analyzed ........................................................................................47 
8.2.2. 
Examination of Subgroups .........................................................................................47 
8.2.3. 
Handling of Missing Data ...........................................................................................47 
8.2.4. 
Baseline Evaluations ...................................................................................................47 
8.2.5. 
Clinical Activity Analyses ..........................................................................................47 
8.2.6. 
Pharmacodynamic Analysis........................................................................................47 
8.2.7. 
Pharmacokinetic Analysis ..........................................................................................48 
8.2.8. 
Safety Analyses ..........................................................................................................48 
8.2.9. 
Other Analyses ............................................................................................................48 
9. 
STUDY ADMINISTRATION ...................................................................................48 
9.1. 
Ethical and Regulatory Considerations ......................................................................48 
9.1.1. 
Informed Consent .......................................................................................................49 
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9.1.2. 
Ethical Review ............................................................................................................49 
9.1.3. 
Study Documentation, Confidentiality, and Records Retention .................................49 
9.1.4. 
End of the Study .........................................................................................................50 
9.1.5. 
Discontinuation of the Clinical Study.........................................................................50 
9.2. 
Data Quality Control and Quality Assurance .............................................................50 
9.2.1. 
Data Handling .............................................................................................................50 
9.2.2. 
Study Monitoring ........................................................................................................50 
9.2.3. 
Audits and Inspections ................................................................................................51 
9.3. 
Publication Policy .......................................................................................................51 
10. 
LIST OF REFERENCES ............................................................................................52 
11. 
APPENDICES ............................................................................................................55 
11.1. 
Pharmacokinetic Assessment Time Points .................................................................55 
11.2. 
Schedules of Assessments for Every Month Dosing Regimen ..................................56 
11.3. 
List of Sensitive CYP3A Substrates and those with a Narrow Therapeutic 
Range ..........................................................................................................................63 
 
LIST OF TABLES 
Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 
Months Dosing Regimen) .............................................................................................7 
Table 2: 
Schedule of Assessments:  Month 19 through End of Study (Every 3 Months 
Dosing Regimen) ........................................................................................................11 
Table 3: 
Status of ALN-AS1 Clinical Studies as of 07 November 2016..................................24 
Table 4: 
Pharmacokinetic Time Points .....................................................................................55 
Table 5: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 
Month Dosing Regimen) ............................................................................................56 
Table 6: 
Schedule of Assessments:  Month 19 through End of Study (Every Month 
Dosing Regimen) ........................................................................................................60 
Table 7: 
List of Sensitive CYP3A Substrates and those with a Narrow Therapeutic 
Range ..........................................................................................................................63 
 
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LIST OF FIGURES 
Figure 1: 
Part C Cohort 1 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in .........................................................................................................................26 
Figure 2: 
Part C Cohort 2 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in .........................................................................................................................26 
Figure 3: 
Study Design ...............................................................................................................30 
 
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LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
Abbreviation 
Definition 
AE 
Adverse event 
AHP 
Acute hepatic porphyria 
AIP 
Acute intermittent porphyria 
ALA 
Delta-aminolevulinic acid 
ALAS1 
5-aminolevulinic acid synthase 1 
ALP 
Alkaline phosphatase 
ASGPR 
Asialoglycoprotein receptor 
ASHE 
Asymptomatic high excreters 
BPI-SF 
Brief Pain Inventory-Short Form 
cERD 
Circulating extracellular RNA detection assay 
CRF 
Case report form 
CYP 
Cytochrome P450 
ECG 
Electrocardiogram 
eCRF 
Electronic case report form 
eGFR 
Estimated Glomerular Filtration Rate 
EDC 
Electronic data capture 
EOS 
End of study 
EU 
European Union 
GalNAc 
N-acetyl galactosamine 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practice 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
IEC 
Independent Ethics Committee 
IRB 
Institutional Review Board 
ISR 
Injection site reaction 
IV 
Intravenous 
LFT 
Liver function test 
mRNA 
Messenger RNA 
NHP 
Nonhuman primate 
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Abbreviation 
Definition 
NOAEL 
No observed adverse effect level 
NOEL 
No observed effect level 
OTC 
Over the counter 
PBG 
Porphobilinogen 
PBGD 
Porphobilinogen deaminase 
PD 
Pharmacodynamic(s) 
PK 
Pharmacokinetic(s) 
QOL 
Quality of life 
RNA 
Ribonucleic acid 
RNAi 
RNA interference 
SAE 
Serious adverse event 
SAP 
Statistical Analysis Plan 
SC 
Subcutaneous 
siRNA 
Small interfering RNA 
SRC 
Safety Review Committee 
SUSAR 
Suspected unexpected serious adverse reaction 
ULN 
Upper limit of normal 
US 
United States 
WOCBP 
Woman of child-bearing potential 
 
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1. 
INTRODUCTION 
1.1. 
Disease Overview 
The porphyrias are a family of rare metabolic disorders predominately caused by a genetic 
mutation in 1 of the 8 enzymes responsible for heme synthesis.[1]  The 2 major categories are 
erythropoietic and hepatic, depending on the major site of expression of the underlying enzyme 
deficiency.[2]  In addition, the porphyrias are classified as acute if patients present with 
neurovisceral symptoms (eg, abdominal pain and neurologic symptoms) or cutaneous if they 
present with dermal blistering or photosensitivity.[3, 4]   
This study will include patients with acute intermittent porphyria (AIP), the most common acute 
hepatic porphyria (AHP).  AIP occurs as a result of an autosomal dominant mutation leading to 
partial deficiency of porphobilinogen deaminase (PBGD), the third enzyme in the heme 
biosynthesis pathway.[5]  The rate limiting step in heme synthesis is the upstream enzyme 
5-aminolevulinic acid synthase 1 (ALAS1), which is controlled by feedback repression via the 
end-product heme.  In response to a decrease in endogenous heme in the liver, as can occur with 
fasting, hormonal alterations, or with cytochrome P450 (CYP) inducing drugs, ALAS1 is 
induced, resulting in increased flux through the heme synthesis pathway.  In patients with AIP, 
this can result in the marked accumulation of the toxic heme intermediates porphobilinogen 
(PBG) and delta aminolevulinic acid (ALA) in the blood and urine due to the deficiency in the 
downstream PBGD.  Clinically, this manifests as acute attacks characterized by severe 
abdominal pain, cardiovascular as well as neurologic and psychiatric dysfunction.[6] 
1.1.1. 
Epidemiology 
Over 370 mutations have been identified in the PBGD gene, which in most instances result in its 
reduction by approximately 50%.  The exact prevalence of AIP is unknown due to under 
diagnosis, variation by geographic region, and the differences in penetrance observed for the 
different mutations.[2]  However, it is estimated that the prevalence of AIP is 5 to 10 per 
100,000 people in Western countries, while in Sweden it occurs in 1 in 1,000 people due to a 
founder effect associated with the resultant G593A mutation.[7-10]  AIP shows incomplete 
penetrance and on average only 10% to 50% of carriers with a mutation present with clinical 
symptoms.[11]  It has been proposed that unknown inherited co-factors, in addition to PBGD 
mutations, may explain why a small percentage of patients present with much more severe 
disease while the majority remain asymptomatic. 
Patients with AIP present with acute attacks characterized by neurovisceral symptoms and signs 
including severe abdominal pain, nausea, vomiting, constipation, or less commonly diarrhea, 
hypertension, tachycardia, fever, muscle weakness, as well as neurological (eg, neuropathy, 
seizures) and psychiatric (eg, anxiety and confusion) manifestations.[12]  AIP attacks typically 
start after puberty and can be triggered by exogenous factors such as medications (especially 
barbiturates, sulfonamides, and hydantoins), stress, exogenous hormones, nutritional status, and 
infection.  Clinically active disease is more common in women, where attacks often occur around 
the menstrual cycle and are likely precipitated by hormonal changes. 
Many AIP patients remain undiagnosed given that the disease is rare and characterized by 
non-specific symptoms (eg, abdominal pain and nausea).[2]  The initial diagnosis involves 
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demonstrating elevated urinary PBG (typically 20-50 × normal reference range) and ALA 
(typically 5-20 × normal reference range) when the patient is having acute attack symptoms.  
Once a test is positive for elevated ALA and PBG and porphyria is suspected, genetic testing for 
a PBGD mutation is performed.   
There are 4 main clinical phenotypes of AIP.  Latent gene carriers have never had an acute attack 
and are biochemically inactive (normal urinary ALA and PBG).  Asymptomatic high excreters 
(ASHE) do not have current acute attacks, but are biochemically active (increased urinary ALA 
and PBG).  The increased levels of ALA and PBG in ASHE patients are lower than those in AIP 
patients during an acute attack, but are still significantly higher than normal reference values.[6-
8]  Sporadic attack patients have infrequent acute attacks.  Recurrent attack patients have 
≥4 attacks per year requiring hospitalization or treatment by a medical professional.[7] 
1.1.2. 
Current Management and Unmet Medical Need 
Management of acute attacks often requires hospitalization.  Patients are initially treated with 
supportive care and carbohydrate loading, analgesics and anti-emetics, and removal of known 
precipitating factors.[13]  In patients with moderate to severe attacks, or who fail to respond to 
supportive measures, treatment with intravenous (IV) hemin (daily for 3-5 days) is commenced.  
Symptoms typically begin to improve after 2 to 5 days of hemin treatment, accompanied by a 
lowering of urinary ALA and PBG levels to below or at the upper limit of normal (ULN) 
reference value; however, in some patients attacks can last several weeks, requiring prolonged 
hemin use and hospitalization.[14]  With prolonged and severe attacks, cranial nerve 
involvement can occur, leading to bulbar paralysis, respiratory failure, and death.[15]  
Hemin, a blood derived therapy, was approved as Normosang® (heme arginate) in the European 
Union (EU) and as Panhematin® (lyophilised hematin) in the United States (US) in 1999 and 
1983, respectively.[16, 17]  In the EU, heme arginate is indicated for the treatment of acute 
attacks of hepatic porphyria (eg, AIP, variegate porphyria, and hereditary coproporphyria); 
whereas, in the US lyophilized hemin is limited to the amelioration of recurrent attacks of AIP 
temporally related to the menstrual cycle.  Approval of both products was based on biochemical 
efficacy (ie, lowering of ALA and PBG) as well as data from uncontrolled case series and case 
reports.[18-22]  Hemin side effects include thrombophlebitis, transient anticoagulation, and in 
rare cases, anaphylaxis or renal failure.[22-24]  In addition, hemin administration requires a large 
vein for administration, often necessitating central venous access. 
While the majority of patients who experience attacks have them sporadically, it is estimated that 
up to 1,000 AIP patients experience recurrent attacks (typically defined as ≥4 per year) in the US 
and EU combined.[25]  While hemin is currently only approved to ameliorate acute attacks, it is 
administered prophylactically in some patients with recurrent attacks (eg, administered every 
1-2 weeks).[26]  Potential problems associated with chronic hemin administration include 
infusion site phlebitis, iron overload, and the need for chronic IV access and associated 
complications (eg, risk of infection or occlusion).[5]  In addition, there have been reports of a 
decrease in efficacy with chronic hemin administration, as evidenced by the need to increase the 
frequency or dosage of hemin prophylaxis over time in attempt to maintain a clinical effect.[27]  
In patients with very severe recurrent attacks, or in whom hemin treatment is not effective, liver 
transplantation can be curative; however, organ transplantation is a high-risk procedure and is 
rarely used as a treatment option [34].  Given the significant morbidity and mortality, there 
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remains a significant unmet need for an efficacious, simple, fast-acting and better tolerated 
treatment for acute or prevent recurrent attacks in patients with AIP. 
1.2. 
RNA Interference 
RNA interference (RNAi) is a naturally occurring cellular mechanism mediated by small 
interfering RNAs (siRNAs) for regulating gene expression.  Typically, synthetic siRNAs are 
19 to 25 base pair double stranded oligonucleotides in a staggered duplex with a 2-nucleotide 
overhang at both or 1 of the 3’ ends.[28]  Such siRNAs can be designed to target an endogenous 
messenger RNA (mRNA) transcript of a given gene.  When introduced into cells, the net effect 
of an RNAi-based pharmacological approach is the binding of the siRNA to its complementary 
mRNA sequence, cleavage of this target mRNA, and reduction of synthesis of the target protein, 
resulting in a decrease of the target protein levels.[29]  The ability to selectively and potently 
degrade the mRNA encoding the ALAS1 protein (thereby decreasing accumulation of the toxic 
intermediates ALA and PBG) using an siRNA is a novel approach for the prevention and 
treatment of acute attacks in patients with AIP.   
1.3. 
ALN-AS1 
ALN-AS1 comprises a synthetic siRNA covalently linked to a GalNAc containing ligand 
(ALN60519), specific for ALAS1 and formulated for administration via subcutaneous (SC) 
injection. ALN-60519 has a target region between nucleotide 918 to 937 of the ALAS1 mRNA. 
Attachment to a triantennary GalNAc ligand to the siRNA enables its distribution to the liver 
(which is the primary site of ALAS1 synthesis), followed by intracellular delivery to hepatocytes 
via ASGPR, resulting in engagement of the RNAi pathway and suppression of hepatic ALAS1 
protein synthesis. 
ALN-AS1 is currently in development for treatment of acute attacks in patients with AIP, the 
most common AHP. 
Further information on ALN-AS1, including the clinical and nonclinical experience to date, is 
available in in the current version of the Investigator’s Brochure (IB). 
1.4. 
Study Design Rationale 
This is a multicenter, open-label extension study designed to evaluate the long-term safety and 
clinical activity of subcutaneously administered ALN-AS1 in patients with AIP who have 
completed clinical study ALN-AS1-001.  The primary endpoint for the study is the incidence of 
AEs. 
1.5. 
Dose Rationale 
Clinical data from Part A and Part B of the ongoing study ALN-AS1-001 demonstrate that single 
(0.035-2.5 mg/kg) and multiple (0.35-1.0 mg/kg) doses of ALN-AS1 have been generally 
well-tolerated in patients with AIP who are ASHE.  Additionally, data from this study indicate 
that a single dose of 2.5 mg/kg ALN-AS1 results in near normalization of urine ALA and PBG 
levels, which is sustained for approximately 14 weeks.   
Patients in Part C of the ongoing study ALN-AS1-001 who are eligible for participation in this 
study will likely require a higher dose of ALN-AS1 to normalize ALA and PBG as they have 
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higher levels of ALAS1 upregulation and higher baseline levels of ALA and PBG, when 
compared to patients with AIP who are ASHE.[30]  For example, based on preliminary data in 
Part A and Part B of the ALN-AS1-001 study, the mean PBG level of patients who are ASHE is 
21.9 mmol/mol Cr (N=28); whereas, in Part C of this study in patients with AHP who have 
recurrent porphyria attacks, the mean PBG level is approximately 49.3 mmol/mol Cr (N=12). 
The study starting dose and regimen of ALN-AS1 is 5.0 mg/kg as an SC injection administered 
every 3 months.  Based on emerging clinical data, the SRC may approve changes to the 
ALN-AS1 dosing regimen, including decreases in the dose level and changes in dosing 
frequency.  However, any dosing regimen will not exceed a previously explored dose level or 
frequency that was determined to be safe and well-tolerated in study ALN-AS1-001. SRC, 
Health Authority and Ethics Committee approval must be sought prior to dose level escalation 
above 5.0 mg/kg in accordance with local Regulatory requirements. 
The study starting dose and regimen was selected based on the benefit:risk profile of ALN-AS1 
in Part C of the ongoing ALN-AS1-001 study.  Preliminary data to date indicate that 
administration of 5.0 mg/kg ALN-AS1 has been generally well-tolerated.  There have been no 
study drug-related SAEs, severe AEs, or clinically significant changes in safety parameters.  
While a single 2.5 mg/kg dose of ALN-AS1 has also been generally well-tolerated when 
administered to patients in Part A and Part C of study ALN-AS1-001, this dose has not resulted 
in near normalization of ALA and PBG levels.  In addition, while emerging data from Part C 
indicate that an every 3 months dose of 2.5 mg/kg ALN-AS1 demonstrated some clinical activity 
(eg, decrease in attack frequency and decrease in heme use), some patients continued to 
experience breakthrough porphyria attacks during the treatment period, indicating that a higher 
dose may be required. 
The duration of dosing in this study is supported by the overall favorable safety profile of 
ALN-AS1 in the ongoing clinical study ALN-AS1-001 and the absence of new findings in 
nonclinical studies with ALN-AS1. 
1.6. 
Clinical Data Summary 
Table 3 shows the current status of the 2 ongoing ALN-AS1 studies, as of 07 November 2016. 
Clinical data presented in this section are as of 07 November 2016, unless otherwise noted. 
Table 3: 
Status of ALN-AS1 Clinical Studies as of 07 November 2016 
Study 
Number 
Study Description 
Dose, Route, and 
Regimen 
Patients Treateda 
ALN-AS1-
001 
Phase 1, randomized (3:1 
[ALN-AS1: 
placebo]) single-blind 
SAD and MAD, and 
double-blind 
multiple-dose safety, 
tolerability, PK, and PD 
study 
Part A:  0.035-2.5 
mg/kg; SC; single dose 
Part B:  0.35-1.0 
mg/kg; SC; 2 doses 28 
days apart   
Part C:  2.5 or 5.0 
mg/kg; SC; either 2 
doses quarterly or 4 
Part A in ASHE: 
15 ALN-AS1; 
5 placebo 
Part B in ASHE: 
6 ALN-AS1; 
2 placebo 
Part C in AIP patients with 
recurrent attacks:  
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Study 
Number 
Study Description 
Dose, Route, and 
Regimen 
Patients Treateda 
doses monthly 
11 ALN-AS1; 
4 placebo 
ALN-AS1-
002 
OLE study for subjects 
completing Part C of 
study ALN-AS1-001 
2.5 or 5.0 mg/kg; SC; 
monthly or quarterly 
dosing 
A total of 2 patients have been 
dosed at 5 mg/kg quarterly x 1 
dose 
a 5 subjects had >1 treatment assignment: 2 subjects repeated Part A; 3 subjects enrolled in Part A and 
Part B 
1.6.1. 
Clinical Pharmacodynamics 
Dosing has been completed in Part A and Part B of the study.  In both Parts A and B of the study, 
durable and dose-dependent reductions of ALAS1 mRNA (up to 66% in the 2.5 mg/kg dose 
group) as measured by cERD were observed after ALN-AS1 treatment.  ALAS1 reductions were 
highly correlated with reductions in ALA (mean maximal 86%) PBG (mean maximal 95%) 
levels in a dose-dependent manner and were sustained for ≥180 days. 
Dosing is currently ongoing in Part C of the study. The mean maximal reduction in ALAS1 
mRNA relative to baseline in ALN-AS1-treated patients in Cohort 1 (2.5 mg/kg Q3M) was 39% 
and in Cohort 2 (2.5 mg/kg Q1M) 66%.   All patients treated with ALN-AS1 also had decreases 
in their peak ALA and PBG levels in the treatment period compared to the run-in period, along 
with reduced fluctuations in these levels in the treatment period (data not shown). No reductions 
were observed in the placebo-treated patients.  
1.6.2. 
Clinical Activity 
Clinical activity was not evaluated in Parts A and B of the study because ASHE patients included 
in this study were not actively experiencing attacks of porphyria. 
Dosing is currently ongoing in Part C of the study. All patients in Cohorts 1 and 2 were enrolled 
in a run-in phase for 10-15 weeks that was followed by a treatment phase for up to 24 weeks.  No 
investigational product was administered during the run-in phase.  Therefore, each patient acted 
as their own control, allowing for individual ALA / PBG levels, and overall attack rate while on 
ALN-AS1 treatment to be compared to that observed in the run-in phase.  
Figure 1 shows in Cohort 1 ALN-AS1-treated patients there was a 74% mean decrease in the 
annualized attack rate for the treatment period versus the run-in period (range: 63-94% 
reduction), compared with a 23% decrease in the annualized attack rate for the placebo-treated 
patient.  In ALN-AS1-treated patients this was accompanied by an approximate 76% mean 
decrease in annualized acute hemin usage (range 52-95%) and a 10.3 times increase in the 
maximal attack free interval compared to run-in period (range 4.2-16.3). 
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Figure 1: 
Part C Cohort 1 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in 
 
Figure 2 shows in Cohort 2 ALN-AS1-treated patients, there was a 58% mean decrease in the 
annualized attack rate for the treatment period versus the run-in period (range: 45-76% 
reduction).  This compares favorably with data from the placebo-treated patient who showed a 
34% reduction in the annualized attack rate for the treatment period versus the run-in period.  In 
ALN-AS1-treated patients, the reduction in attack rate was accompanied by a 92% mean 
decrease in annualized hemin usage (range 84-100%) and a 2.7x increase in the mean maximal 
attack free interval compared to run-in period (range 2.1-3.2). 
Figure 2: 
Part C Cohort 2 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in 
 
1.6.3. 
Clinical Safety 
In Part A and Part B of the study, a total of 11 patients (11/13; 85.0%) who received ALN-AS1 
reported at least 1 AE.  All 5 placebo-treated patients (5/5; 100%) reported at least 1 AE.  AEs 
considered possibly or definitely related to ALN-AS1 were reported in 5 patients (5/13; 38%): 
diarrhoea, dyspepsia, hematochezia, injection site erythema, injection site pain, blood creatinine 
increased, glomerular filtration rate decreased, and hypoesthesia (each AE reported only by an 
individual patient; 1/13; 8% each).  There were 2 SAEs of abdominal pain: 1 patient each in the 
0.035 mg/kg and 0.1 mg/kg ALN-AS1 dose groups.  Both were considered to be not related and 
resolved without sequelae.  There were no AEs leading to discontinuation.  All AEs were mild or 
moderate in severity, except for 1 of the SAEs of abdominal pain (0.10 mg/kg dose group), 
which was considered severe. Adverse events related to abnormal laboratory values were seen in 
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1 patient in the 0.35 mg/kg ALN-AS1 dose group who had AEs of ALT increased and AST 
increased, which were moderate and considered by the Investigator to be unrelated to ALN-AS1.  
No clinically significant findings were observed with routine monitoring of CRP and a panel of 9 
proinflammatory cytokines collected predose and up to 24 hours post-dose.  There were no other 
clinically significant laboratory abnormalities related to study drug or changes in vital signs, or 
ECGs in patients who were administered ALN AS1 or placebo. 
Dosing is ongoing in Part C of the study. All patients who received ALN-AS1 in cohort 1 and 2 
reported at least 1 AE.  AEs that were reported in at least 2 subjects were nausea in 3 patients 
(50%) and abdominal pain, vomiting, nasopharyngitis, headache, cough and oropharyngeal pain 
in 2 patients (33.3%) each.  All AEs were mild or moderate in severity.  AEs considered possibly 
or definitely related to ALN-AS1 were reported in 4 patients (66.6%), 1 each:  renal impairment 
in Cohort 1 and injection site reaction, myalgia, and headache in Cohort 2. Both placebo-treated 
patients reported AEs.  No AE was experienced in more than 1 patient. 
In Part C, Cohort 1 or 2, there were no SAEs or AEs leading to discontinuation in patients 
administered ALN-AS1 or placebo. No clinically significant laboratory abnormalities related to 
study drug or changes in vital signs, ECG, or physical exam findings were observed in patients 
administered ALN-AS1 or placebo. 
Part C Cohort 3 5.0 mg/kg SC monthly dosing is ongoing.  In this cohort there was one fatal 
SAE of acute pancreatitis, which was determined to be unlikely related to study drug or placebo 
by the Investigator due to the presence of gall bladder sludge found at the time of her 
presentation.  Contributors to this patient's adverse clinical course included: pre-existing chronic 
debilitation from recurrent AIP attacks requiring monthly hospitalization, porphyria-attributed 
quadriplegia requiring nursing home care, delay in hospital admission and complications from 
thromboembolism (multiple risk factors included pancreatitis, obesity, immobilisation from 
quadriparesis and recent hospitalization for infected portacath removal).  Serum lipase was added 
to all scheduled laboratory assessments in November 2016 as part of additional safety 
monitoring. To date, all lipase results (available in 11 of 15 subjects) have been at or below the 
upper limit of normal with no trends seen with dosing of study drug or placebo. 
1.7. 
Benefit-Risk Assessment 
Patients participating in this study may experience a reduced number or severity of porphyria 
attacks, reduced treatment with IV hemin, and/or reduced requirement for pain medication.  As 
presented in Section 1.6, emerging data demonstrate that patients given ALN-AS1 experienced 
reduced ALA/PBG levels, decreased attack frequency and reduced heme usage in the 24-week 
treatment period compared to the 12-week run-in period in Study ALN-AS1-001 
As detailed in Section 1.6, a fatal SAE of hemorrhagic pancreatitis was reported but deemed to 
be unlikely related to study drug.  However, the potentially non-adverse nonclinical finding of 
angiectasis in the islets of Langerhans (endocrine, not exocrine region) of the rat pancreas (see 
Investigator Brochure), do not exclude a potential association between ALN-AS1 and the SAE of 
hemorrhagic pancreatitis. 
The potential risks associated with administration of ALN-AS1 in patients with AIP are as 
follows: 
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 Injection site reactions (ISRs):  ALN-AS1 is administered by SC injection.  In the 
ongoing ALN-AS1 clinical study, AEs of ISRs have been infrequently reported and 
have been mild to moderate in severity with single dosing.  Injection site rotation and 
close monitoring have been implemented in ALN-AS1 clinical studies to reduce the 
potential for ISRs.  
 Serum chemistry and coagulation changes: Since an association between ALN-AS1 
and the fatal SAE of hemorrhagic pancreatitis can not be ruled out, patients will 
undergo routine monitoring of systemic and pancreatic inflammation and coagulation 
throughout the study.  Hematology, chemistry and coagulation results are required to 
be available prior to each dose. 
 Liver function test abnormalities:  As ALN-AS1 is targeted for delivery to the liver, 
and reversible hepatic changes were observed in some animal species, there is a 
potential for development of LFT abnormalities.  To minimize the potential for LFT 
abnormalities, patients are required to have adequate liver function at study entry and 
LFTs are monitored during the study. 
 Reproductive health:  No data are available on the use of ALN-AS1 in pregnancy; 
however, there is no suspicion of human teratogenicity based on class effects or 
genotoxic potential.  ALN-AS1 was neither genotoxic nor clastogenic in in vitro and 
in vivo studies.  Women of child bearing potential (WOCBP) must have a negative 
pregnancy test, cannot be breastfeeding, and must be willing to use acceptable 
methods of contraception during studies with ALN-AS1.  
 CYP inhibition:  A study in NHP demonstrated that ALN-AS1 dosing could 
potentially increase the clearance of drugs metabolized by the CYP3A isoform.  As 
contraceptive hormones are metabolized via CYP3A, WOCBP must use a barrier 
method of contraception, in addition to hormonal contraception, during study 
participation.  Additionally, Investigators will review all patient medications at study 
start and monitor responses to these medications during the study.  A list of 
medications that are sensitive CYP3A substrates is in Table 7 in Appendix 
Section 11.3.  In addition, a list of medications that are sensitive CYP3A substrates is 
available at the Indiana University, Division of Clinical Pharmacology, website.[31] 
The complete summary of the clinical and nonclinical data relevant to the investigational drug 
and its study in human subjects is provided in the Investigator’s Brochure. 
2. 
OBJECTIVES 
2.1. 
Primary Objective 
 Evaluate the long-term safety and tolerability of ALN-AS1 in patients with AIP 
2.2. 
Secondary Objectives 
 Assess the PD effect of ALN-AS1 over time 
 Assess the clinical activity of ALN-AS1 over time 
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2.3. 
Exploratory Objectives 
 Characterize the PK profile of ALN-AS1 over time 
 Assess changes in health-related quality of life (QOL) 
 Characterize analytes related to targeting the heme biosynthesis pathway 
3. 
ENDPOINTS 
3.1. 
Primary Endpoint 
 Patient incidence of AEs 
3.2. 
Secondary Endpoints 
 Change in urine ALA and PBG levels 
 Frequency and characteristics of porphyria attacks 
 Change in hemin administration 
3.3. 
Exploratory Endpoints 
 Change in circulating ALAS1 mRNA levels 
 Concentrations of ALN-AS1 and antidrug antibodies  
 Duration and treatment of porphyria attacks 
 Number and duration of visits to a health care facility for acute porphyria care 
 EQ-5D-5L questionnaire scores 
 Pain assessment and narcotic use as recorded in a patient diary 
 Exploratory biomarkers related to the target pathway, such as urine porphyrins, 
vitamin D binding protein 
4. 
INVESTIGATIONAL PLAN 
4.1. 
Summary of Study Design 
This is a Phase 1/2 multicenter, open-label extension study to evaluate the long-term safety and 
clinical activity of ALN-AS1 in patients with AIP who completed study ALN-AS1-001.  The 
study will be conducted at up to 8 clinical study centers worldwide. 
The last assessments performed, determining previous study (ALN-AS1-001) completion, will 
serve as the Screening/Baseline assessments in this study.  If more than 60 days have elapsed 
since the last assessment, safety assessments (eg, ECG and clinical laboratory tests) will be 
repeated before administration of ALN-AS1.  It is anticipated that patients will begin ALN-AS1 
administration in this study within 6 months after the last dose of study drug in the previous 
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study.  Eligibility will be confirmed during Screening/Baseline and before administration of the 
first dose of ALN-AS1 (Day 1).  Patients will undergo assessments at the clinical study center 
every month for the first 3 months.  Then, through Month 6, and according to the dosing regimen 
selected, assessments will take place at the clinical study center or via a phone contact (for an 
every month dosing regimen, visits will be every month; for an every 3 months dosing regimen, 
visits will be every 3 months; see Section 6.2.2).  After a patient has completed 12 months of 
ALN-AS1 administration in this study (6 months in an every month dosing regimen), and where 
applicable country and local regulations and infrastructure allow, study procedures, including 
ALN-AS1 administration, may take place at the patient’s home by a healthcare professional (as 
indicated in the Schedules of Assessments in Table 1 and Table 2; and Table 5 and Table 6 in 
Appendix Section 11.2).  Study procedures may occur at the patient’s home at the discretion of 
the Investigator, based on safety and tolerability; however, patients are required to complete at 
least 1 visit at the clinical study center every 3 months for the first year, and thereafter every 6 
months through the end of the treatment period.  Additional visits to collect clinical laboratory 
samples may occur at home at any point during the treatment period, within 14 days prior to 
scheduled dose administration.  Patients will return to the clinical study center for a 
posttreatment follow-up visit after administration of the last dose of ALN-AS1.  An ALA/PBG 
Monitoring/EOS visit will be conducted either at the clinical study center or via phone contact, 
unless treatment continues with ALN-AS1. 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain 
assessments, and narcotic use.  Additionally, patients will be encouraged to report to the clinical 
study center if they experience a porphyria attack through Month 39.  In the event that patients 
are unable to report to the clinical study center during a porphyria attack, laboratory sample 
collection kits containing instructions for collecting and sending urine samples to the clinical 
study center, if possible, will be provided.  Patients will be contacted by phone after a porphyria 
attack to record attack details.  If patients are experiencing signs and symptoms of a porphyria 
attack when ALN-AS1 administration is scheduled, the Investigator will determine whether 
administration of ALN-AS1 is appropriate.  If patients are treated for a porphyria attack at a 
health care facility (eg, hospital, emergency department, infusion center, or outpatient clinic) 
other than the clinical study center, copies of medical records, including discharge summaries, 
will be requested.   
A Safety Review Committee (SRC) will review safety and tolerability data collected during the 
study with the primary purpose of protecting the safety of patients participating in the study (see 
Section 4.6). 
Figure 3: 
Study Design 
 
Complete Study
ALN-AS1-001
Screening
(Day -60 to -1)
Treatment Period
(36 Months)
Posttreatment 
Follow-up
(3 months)
End of Study
(Month 42)
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4.2. 
Duration of Treatment and Study 
The duration of treatment is up to 36 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 44 months.   
4.3. 
Number of Patients 
Up to 24 patients are planned for enrollment in this study (including optional cohorts in 
ALN-AS1-001). 
4.4. 
Method of Assigning Patients to Treatment Groups 
This is an open-label study; all patients will receive ALN-AS1.  A combination of the clinical 
study center number and screening number will create the unique patient identifier.  The clinical 
study center number will be assigned by the Sponsor.  Upon signing the Informed Consent Form 
(ICF), the patient will be assigned a screening number by the clinical study site, which will be 
the same unique patient identifier assigned in the previous study (ALN-AS1-001).  The 
Investigator, or delegate, will confirm that the patient fulfills all the inclusion criteria and none of 
the exclusion criteria. 
4.5. 
Blinding 
This is an open-label study, and all patients will receive ALN-AS1. 
4.6. 
Safety Review Committee 
An SRC will be involved in the conduct of this study.  The SRC has the responsibility for 
monitoring the safety of the study participants.  The SRC will perform periodic reviews of safety 
and tolerability data during the course of the clinical study at least every 3 months for the first 
6 months of the study and thereafter at least every 6 months.  The SRC may also meet on an ad 
hoc basis for review of emergent safety and tolerability data, as defined in the SRC Charter for 
this clinical study.  The SRC will not stop the study for efficacy. 
The SRC will be comprised of the following members:  Principal Investigator(s), or designee(s), 
the Sponsor Medical Monitor, and the Study Medical Monitor. 
The membership of the SRC and reporting structure are further defined in the SRC Charter. 
5. 
SELECTION AND WITHDRAWAL OF PATIENTS 
5.1. 
Inclusion Criteria 
Each patient must meet all of the following inclusion criteria to be eligible for enrollment in this 
study: 
1. Completed and, in the opinion of the Investigator, tolerated study drug dosing in Part C 
of study ALN-AS1-001 
2. Not on a scheduled regimen of hemin to prevent porphyria attacks at Screening 
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3. WOCBP must have a negative serum pregnancy test, cannot be breast feeding, and must 
be willing to use acceptable methods of contraception 14 days before first dose, 
throughout study participation, and for 90 days after last dose administration.  Acceptable 
methods include hormonal methods along with an additional barrier method (eg, condom, 
diaphragm, or cervical cap), or a double barrier method of contraception for those 
WOCBP for whom a hormonal method of contraception is medically contraindicated due 
to underlying disease (see Section 6.4 for acceptable methods of contraception).   
4. Willing and able to comply with the study requirements and to provide written informed 
consent 
5.2. 
Exclusion Criteria 
Each patient must not meet any of the following exclusion criteria to be eligible for enrollment in 
this study: 
1. Alanine transaminase ≥2.0×ULN or total bilirubin ≥2 mg/dL (unless bilirubin elevation is 
due to Gilbert’s syndrome) 
2. Estimated glomerular filtration rate ≤30 mL/min/1.73 m2 (using the Modification of Diet 
in Renal Disease formula) 
3. History of multiple drug allergies or history of allergic reaction to an oligonucleotide or 
to N-acetyl galactosamine ligand (GalNAc) 
4. Received an investigational agent, other than ALN-AS1, or who are in follow-up of 
another clinical study of an investigational agent within 90 days before study drug 
administration 
5. Other medical conditions or comorbidities which, in the opinion of the Investigator, 
would interfere with study compliance or data interpretation 
5.3. 
Removal from Treatment or Assessment 
Patients are free to discontinue treatment or withdraw from the study at any time and for any 
reason, without penalty to their continuing medical care.  Any discontinuation of treatment or 
withdrawal from the study must be fully documented in the electronic case report form (eCRF), 
and should be followed up by the Investigator.  The Investigator may withdraw a patient at any 
time if this is considered to be in the best interest of the patient. 
Discontinuation of study drug and withdrawal from the study are described in Section 5.3.1 and 
Section 5.3.2, respectively. 
5.3.1. 
Discontinuation of Study Drug 
The Investigator or designee may discontinue dosing in a patient if the patient: 
 Is in violation of the protocol 
 Experiences a SAE considered to be possibly or definitely related to the study drug or 
an intolerable AE  
 Becomes pregnant 
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
Is found to be considerably noncompliant with the protocol-requirements
Patients who are pregnant will be discontinued from study drug dosing immediately (see 
Section 7.5.6.6 for reporting and follow-up of pregnancy).  Patients who discontinue treatment 
will be asked to complete the Month 39 visit assessments. 
5.3.2. 
Withdrawal from Study 
A patient may withdraw from the study at any time.  If a patient chooses to withdraw from the 
study, every effort should be made to conduct early the assessments performed at the Month 39 
visit.  When a patient withdraws from the study, the primary reason for study withdrawal must be 
recorded in the appropriate section of the eCRF and all efforts made to complete and report the 
observations as thoroughly as possible.  If a patient withdraws due to a SAE, the SAE should be 
followed as described in Section 7.5.6. 
5.3.3. 
Replacement of Patients 
Patients discontinuing from study drug or withdrawing from the study will not be replaced. 
6. 
TREATMENTS 
6.1. 
Treatments Administered 
ALN-AS1 Solution for Injection (SC use) is a clear, colorless to pale yellow solution essentially 
free of particulates.  ALN-AS1 will be supplied by the Sponsor as a sterile solution for SC 
injection. 
Study drug supplied for this study must not be used for any purpose other than the present study 
and must not be administered to any person not enrolled in the study.  Study drug that has been 
dispensed to a patient and returned unused must not be re-dispensed to a different patient. 
6.2. 
Investigational Study Drug 
Detailed information describing the preparation, handling, and storage, packaging and labeling, 
as well as study drug accountability for ALN-AS1 is provided in the Pharmacy Manual. 
6.2.1. 
Description 
ALN-AS1 Solution for Injection (SC use) is comprised of a synthetic, siRNA targeting ALAS1 
and bearing a triantennary GalNAc ligand conjugated to the sense strand, formulated in 
phosphate buffer.  
6.2.2. 
Dose and Administration 
The study starting dose of ALN-AS1 is 5.0 mg/kg ALN-AS1 as an SC injection administered 
every 3 months (Table 1 and Table 2). Based on emerging clinical data, the SRC may approve 
changes to the ALN-AS1 dosing regimen, including decreases in the dose level and changes in 
dosing frequency (Table 5 and Table 6 in Appendix Section 11.2). However, any dose and 
dosing regimen will not exceed a previously explored dose level or frequency that was 
determined to be safe and well-tolerated in study ALN-AS1-001. SRC, Health Authority and 
Ethics Committee approval must be sought prior to dose level escalation above 5.0 mg/kg in 
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accordance with local Regulatory requirements.  See Section 6.2.3 for details on dose 
modifications. 
The study drug will be administered under the supervision of a healthcare professional.  After a 
patient has completed 12 months of ALN-AS1 administration in this study (6 months in an every 
month dosing regimen), and where applicable country and local regulations and infrastructure 
allow, study procedures, including ALN-AS1 administration, may take place at the patient’s 
home by a healthcare professional.  Study procedures may occur at the patient’s home at the 
discretion of the Investigator, based on safety and tolerability; however, patients are required to 
complete at least 1 visit at the clinical study center every 3 months for the first year, and 
thereafter every 6 months through the end of the treatment period.  Additional visits to collect 
clinical laboratory samples may occur at home at any point during the treatment period, within 
14 days prior to scheduled dose administration. 
If a patient does not receive a dose of ALN-AS1 within the specified dosing window, the 
Investigator should contact the Medical Monitor.  After such consultation, the dose may be 
administered or considered missed and not administered. 
Patients will be permitted to miss an occasional dose of study drug; however, if a patient misses 
2 consecutive doses, the Investigator, in consultation with the Medical Monitor, will discuss 
whether the patient will be able to continue on the study.  
Detailed instructions for study drug administration are found in the Pharmacy Manual. 
6.2.3. 
Dose Modifications 
6.2.3.1. 
Study Population Dose Modifications 
During the study, dose modifications are permitted for the study population, or based on the dose 
cohort into which patients were originally randomized in study ALN-AS1-001.  Following SRC 
review of emerging safety and tolerability data from Part C of study ALN-AS1-001, or from this 
study (ALN-AS1-002), the dose and dosing regimen may be modified.  However, the dose and 
dosing regimen of ALN-AS1 will not exceed a previously explored dose and dosing regimen that 
was determined to be safe and well-tolerated in study ALN-AS1-001.  Patients enrolling in this 
study after a dose modification decision has been implemented may start at the newly identified 
dose and regimen. 
6.2.3.2. 
Individual Dose Modifications 
Dose modifications are permitted for individual patients.  If a patient has a study drug related AE 
of a recurrent ISR, severe ISR, or clinically significant LFT abnormality and the Investigator has 
concerns regarding further ALN-AS1 administration, the Medical Monitor and Investigator will 
review all available safety data for the patient.  Based on this review, a dose reduction to half the 
previously administered dose (eg, a 5.0 mg/kg dose would be reduced to a 2.5 mg/kg dose) or a 
reduction in dosing frequency from monthly to every 3 months is permitted.  Subsequent 
ALN-AS1 administration at the previous dose may be considered based on the judgment of the 
Investigator and Medical Monitor. 
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6.2.4. 
Preparation, Handling, and Storage 
Staff at each clinical study center or the home healthcare professional will be responsible for 
preparation of ALN-AS1 doses, according to procedures detailed in the Pharmacy Manual.  No 
special procedures for the safe handling of study drug are required. 
Study drug will be stored upright and refrigerated at approximately 5±3°C.  Any deviation from 
the recommended storage conditions should be reported to the Sponsor and use of the study drug 
halted until authorization for its continued use has been provided by the Sponsor or designee. 
A Sponsor representative or designee will be permitted, upon request, to audit the supplies, 
storage, dispensing procedures, and records. 
6.2.5. 
Packaging and Labeling 
ALN-AS1 Solution for Injection (SC use) is packaged in 2 mL glass vials with a fill volume of 
no less than 0.55 mL.  The container closure system consists of a Type I glass vial, a Teflon 
faced bromobutyl 13 mm stopper and a flip-off Truedge aluminum seal. 
6.2.6. 
Accountability 
The Investigator or designee will maintain accurate records of receipt and the condition of the 
study drug supplied for this study, including dates of receipt.  In addition, accurate records will 
be kept of when and how much study drug is dispensed and administered to each patient in the 
study.  Any reasons for departure from the protocol dispensing regimen must also be recorded. 
At the completion of the study, there will be a final reconciliation of all study drugs.  All used, 
partially used, and unused study drug will be returned to the Sponsor (or designee) or destroyed 
at the clinical study center according to applicable regulations.   
6.3. 
Concomitant Medications 
Use of concomitant medications will be recorded on the patient’s case report form (CRF) as 
indicated in the Schedules of Assessments (Table 1 and Table 2; and Table 5 and Table 6 in 
Appendix Section 11.2).  This includes all prescription medications, herbal preparations, over the 
counter (OTC) medications, vitamins, and minerals.  Any changes in medications during the 
study will also be recorded on the CRF. 
Any concomitant medication that is required for the patient’s welfare may be administered by the 
Investigator.  However, it is the responsibility of the Investigator to ensure that details regarding 
the medication are recorded on the eCRF.  Concomitant medication will be coded using an 
internationally recognized and accepted coding dictionary. 
ALN-AS1 could potentially increase the clearance of drugs metabolized by the CYP3A isoform.   
Investigators will review all medications at study start and monitor response to these medications 
during the study.  For patients who require new medications while on study, selection of 
medications that are not mainly metabolized by the CYP3A isoform is recommended.  A list of 
medications that are sensitive CYP3A substrates is included in Table 7 Appendix Section 11.3.  
In addition, a more detailed and current list of sensitive CYP3A-metabolized medications and 
CYP3A-metabolized medications with a narrow therapeutic range is available at the Indiana 
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University, Division of Clinical Pharmacology, website 
(http://medicine.iupui.edu/clinpharm/ddis/clinical-table/).[31] 
Patients are not permitted to be on hemin prophylaxis at Screening; however, patients are 
permitted to receive concomitant hemin treatment for the management of acute porphyria 
attacks.  Patients experiencing significant breakthrough attacks while enrolled in this study, 
necessitating frequent hemin treatment, may receive hemin prophylaxis if in the Investigator’s 
judgment this is clinically beneficial to the patient.  The Investigator should contact with the 
Sponsor and Medical Monitor before prophylactic hemin treatment.  The dose, regimen, and 
dates of administration will be recorded on the patient’s eCRF.   
Pain medication (eg, opiates, opioids, narcotic analgesics) and glucose administration are 
permitted for the management of porphyria and for acute porphyria attacks. 
If patients use nonsteroidal anti-inflammatory medications intermittently or chronically, they 
must have been able to tolerate them with no previous side effects (eg, gastric distress or 
bleeding).   
Standard vitamins and topical medications are permitted; however, topical steroids must not be 
applied anywhere near the injection site(s) unless medically indicated. 
6.4. 
Contraceptive Requirements 
WOCBP must be willing to use acceptable methods of contraception 14 days before first dose, 
throughout study participation, and for 90 days after last dose administration.  Birth control 
methods which may be considered as acceptable include: 
 Established use of oral, implantable, injectable, or transdermal hormonal methods of 
contraception.  WOCBP using hormonal methods of contraception must also use a 
barrier method (condom or occlusive cap [diaphragm or cervical/vault cap] in 
conjunction with spermicide [eg, foam, gel, film, cream, or suppository]).  If 
hormonal methods of contraception are medically contraindicated for WOCBP due to 
underlying disease, a double-barrier method (combination of male condom with 
either cap, diaphragm, or sponge, in conjunction with spermicide) is also considered 
an acceptable method of contraception. 
 Placement of an intrauterine device  
 Placement of an intrauterine hormone-releasing system  
 Bilateral tubal occlusion 
 Surgical sterilization of male partner (with the appropriate post-vasectomy 
documentation of the absence of sperm in the ejaculate; for female patients on the 
study, the vasectomized male partner should be the sole partner for that patient) 
 True sexual abstinence, when in line with the preferred and usual lifestyle of the 
patient.  Periodic abstinence (eg, calendar, ovulation, symptothermal, post-ovulation 
methods) and withdrawal are not acceptable methods of contraception.  Abstinent 
patients must agree to use 1 of the abovementioned contraceptive methods, if they 
start sexual relationships during the study and for 90 days after last dose 
administration. 
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WOCBP includes any female patient who has experienced menarche and who is not 
postmenopausal or permanently sterilized (eg, bilateral tubal occlusion, hysterectomy, or 
bilateral salpingectomy).  Postmenopausal state is defined as no menses for 12 months without 
an alternative medical cause, confirmed by follicle stimulating hormone level within the 
postmenopausal range. 
6.5. 
Treatment Compliance 
Compliance with study drug administration will be verified through observation by study 
personnel or trained home healthcare professionals.  
7. 
STUDY ASSESSMENTS 
The schedule of study assessments is provided in Table 1.  
7.1. 
Screening/Baseline Assessments 
Informed consent, patient demographic data, and eligibility criteria will be confirmed at 
Screening/Baseline.  An interval medical history/disease history will be obtained at 
Screening/Baseline.  The last assessments performed, determining previous study 
(ALN-AS1-001) completion, will serve as the Screening/Baseline assessments in this study.  If 
more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs will 
be repeated before administration of ALN-AS1. 
7.2. 
Clinical Activity Assessments 
The clinical activity of ALN-AS1 will be assessed by the frequency and characteristics of 
porphyria attacks including, but not limited to, duration, treatment, and severity of porphyria 
attacks and number and duration of visits to a health care setting for acute porphyria care (eg, 
hospital, emergency department, infusion center, or outpatient clinic).  Concomitant hemin 
administration will also be recorded. 
7.2.1. 
Patient Diary 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain 
assessments, and narcotic use. 
7.2.2. 
Brief Pain Inventory-Short Form Questionnaire 
The Brief Pain Inventory-Short Form (BPI-SF) questionnaire will be used to evaluate pain.[32]  
The BPI will be completed as part of the patient diary. 
7.3. 
Pharmacodynamic Assessments 
Blood and urine samples will be collected for assessment of ALN-AS1 PD parameters.  The PD 
effect of ALN-AS1 will be evaluated by urine ALA and PBG levels.  Blood and urine samples 
will be collected for assessment of circulating ALAS1 mRNA levels in serum and in urine.  
Analysis for blood and urine PD parameters will take place at a central laboratory.   
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Details regarding the processing and aliquoting of samples for storage and analyses will be 
provided in the Laboratory Manual. 
7.4. 
Pharmacokinetic Assessments 
Blood samples will be collected to evaluate the PK profile of ALN-AS1 at the time points in the 
Schedule of Assessments.  A detailed schedule of time points for the collection of blood samples 
for PK analysis is in Table 4 in Appendix Section 11.1). 
The concentration of ALN-AS1 will be determined using a validated assay.  Details regarding 
the processing, shipping, and analysis of the samples will be provided in the Laboratory Manual. 
7.5. 
Safety Assessments 
The assessment of safety during the course of the study will consist of the surveillance and 
recording of AEs including SAEs, recording of concomitant medications and measurements of 
vital signs, physical examination, and ECG findings and clinical laboratory evaluations. 
Safety will be monitored over the course of the study by an SRC as described in Section 4.6. 
7.5.1. 
Vital Signs 
Vital sign measurements include blood pressure, heart rate, body temperature, and respiratory 
rate.  Vital signs will be measured in the seated or supine position (should be consistent for each 
patient), after the patient has rested comfortably for 10 minutes.  Blood pressure should be taken 
using the same arm throughout the study.  Body temperature will be obtained in degrees Celsius, 
heart rate will be counted for a full minute and recorded in beats per minute, and respiration rate 
will be counted for a full minute and recorded in breaths per minute. 
For the safety of the patient, additional vital sign assessments may be added at the discretion of 
the Investigator. 
7.5.2. 
Weight and Height 
Height will be measured in centimeters at the Screening/Baseline visit only.  Body weight will be 
measured in kilograms.  Body mass index will be calculated in the database. 
7.5.3. 
Physical Examination 
Complete physical examinations will include the examination of the following:  general 
appearance, head, eyes, ears, nose and throat, chest/respiratory, heart/cardiovascular, 
gastrointestinal/liver, musculoskeletal/extremities, dermatological/skin, thyroid/neck, lymph 
nodes, and neurological/psychiatric. 
Targeted physical examinations will include the examination of the following:  general 
appearance, chest/respiratory, heart/cardiovascular, gastrointestinal/liver, and 
neurological/psychiatric. 
7.5.4. 
Electrocardiogram 
Triplicate standard 12-lead ECGs will be performed using central ECG equipment, with readings 
approximately 1 minute apart and recorded as specified in the Schedule of Assessments 
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(Table 1).  Patients should be seated or supine for at least 5 minutes before each ECG is 
obtained.  The electrophysiological parameters assessed will be rhythm, ventricular rate, PR 
interval, QRS duration, QT interval, ST and T waves, Bazett-corrected QT interval (QTcB), and 
Fridericia corrected QT interval (QTcF). 
When ECG and blood sample collection occur at the same time, ECGs should be performed 
before blood samples are drawn. 
In all patients receiving ≤2.5 mg/kg ALN-AS1, it is required that ECGs will be obtained on at 
least 2 separate clinic visits (D1, and Months 3, 6, 9, 12, 15, or 18), each of which will include 
same day predose and 2-hour (±15 minutes) postdose readings, paired with PK timepoints 
(Table 4) as specified in the Schedule of Assessments (Table 1).   
Similarly, in all patients receiving >2.5 mg/kg ALN-AS1, it is required that ECGs will be 
obtained on at least 2 separate clinic visits (D1, and Months 3, 6, 9, 12, 15, or 18), each of which 
will include same day predose and 4-hour (±20 minutes) postdose readings, paired with PK 
timepoints (Table 4), as specified in the Schedule of Assessments (Table 1).   
The Investigator or designee is responsible for reviewing the ECGs to assess whether the results 
have changed since the Screening/Baseline visit and to determine the clinical relevance of the 
results.  These assessments will be recorded on the eCRF.  For any clinically relevant ECG 
changes from the Screening/Baseline visit (eg, ischemic ECG changes, wave/interval changes, or 
arrhythmia), the Investigator must contact the Medical Monitor to discuss continued participation 
of the patient in the study. 
7.5.5. 
Clinical Laboratory Assessments 
The following clinical laboratory tests will be evaluated by a central laboratory.   
On dosing days up to the Month 18 visit, results from hematology, chemistry, and coagulation 
tests collected within the prior 14 days must be reviewed by the Investigator before study drug 
administration.  These results can be analyzed centrally or at a local laboratory.  If results from 
within the prior 14 days are not available at a dosing visit (at visits from D1 to Month 18), 
locally analyzed assessments may be reviewed to allow same day study drug administration, but 
additional samples for central analysis must also be collected. 
In the event of an unexplained clinically relevant abnormal laboratory test occurring after study 
drug administration, the test should be repeated and followed up at the discretion of the 
Investigator until it has returned to the normal range or stabilized, and/or a diagnosis is made to 
adequately explain the abnormality. 
At any point during the study, and based on Investigator judgment, if a patient experiences 
uncharacteristic signs and symptoms during a porphyria attack, lipase testing should be 
performed and imaging evaluations (eg, right upper quadrant ultrasound and/or other testing, 
based on Investigator judgment) should be considered by the Investigator.  Signs and symptoms 
include, but are not limited to, uncharacteristic abdominal pain and worsening nausea and 
vomiting. 
Imaging is required for any serum lipase result of ≥3× the upper limit of normal, or as clinically 
indicated. 
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Hematology 
Complete blood count with differential 
 
Serum Chemistry 
Sodium 
Potassium 
BUN 
Phosphate 
Creatinine and eGFRa 
Albumin 
Uric acid 
Calcium 
Total protein 
Carbon dioxide 
Glucose 
Chloride 
Lipase 
Bicarbonate 
Liver Function Tests 
 
AST 
ALP 
ALT 
Bilirubin (total and direct) 
GGT 
 
Urinalysis 
Visual inspection for appearance and color 
Bilirubin 
pH (dipstick) 
Nitrite 
Specific gravity 
RBCs 
Ketones 
Urobilinogen 
Albumin 
Leukocytes 
Glucose 
Microscopy (if clinically indicated) 
Protein 
 
Immunogenicity 
Antidrug antibodies 
Coagulation 
Prothrombin time 
International Normalized Ratio 
Pregnancy Testing (WOCBP only) 
β-human chorionic gonadotropin 
 
Inflammation 
 
C-reactive protein 
 
Abbreviations:  AST=aspartate transaminase; ALP=alkaline phosphatase; ALT=alanine transaminase; BUN=blood 
urea nitrogen; eGFR=estimated glomerular filtration rate; GGT=gamma-glutamyltransferase; WOCBP=women of 
child bearing potential. 
a eGFR will be calculated using the Modification of Diet in Renal Disease formula.[33] 
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7.5.5.1. 
Immunogenicity 
Blood samples will be collected to evaluate antidrug antibodies.  On days when ALN-AS1 is 
administered, blood samples for antidrug antibody testing must be collected before ALN-AS1 is  
administered. 
Details regarding the processing, shipping, and analysis of the samples will be provided in the 
Laboratory Manual. 
7.5.5.2. 
Pregnancy Testing 
A pregnancy test will be performed for WOCBP only.  A serum pregnancy test will be 
performed at Screening/Baseline and urine pregnancy tests will be performed thereafter per the 
Schedule of Assessments and any time pregnancy is suspected.  Urine pregnancy tests may also 
be performed more frequently (eg, monthly) based on local country requirements.  The results of 
the pregnancy test must be known before study drug administration.  Patients who are pregnant 
are not eligible for study participation.  Any woman with a positive pregnancy test during the 
study will be discontinued from study drug, but will continue to be followed for safety.  Patients 
determined to be pregnant while on study will be followed until the pregnancy outcome is known 
(see Section 7.5.6.6 for follow-up instructions).  
7.5.6. 
Adverse Events 
7.5.6.1. 
Definitions 
Adverse Event 
According to the ICH E2A guideline Definitions and Standards for Expedited Reporting, and 
21 Code of Federal Regulations 312.32, Investigational New Drug Safety Reporting, an AE is 
any untoward medical occurrence in a patient or clinical investigational subject administered a 
medicinal product and which does not necessarily have a causal relationship with this treatment. 
Serious Adverse Event 
An SAE is any untoward medical occurrence that at any dose: 
 Results in death 
 Is life-threatening (An event which places the patient at immediate risk of death from 
the event as it occurred.  It does not include an event that had it occurred in a more 
severe form might have caused death) 
 Requires in-patient hospitalization or prolongation of existing hospitalization 
 Results in persistent or significant disability or incapacity 
 Is a congenital anomaly or birth defect 
 Is an important medical event that may not be immediately life-threatening or result 
in death or hospitalization but may jeopardize the patient and may require 
intervention to prevent one of the other outcomes listed in the definition above (eg, 
events include allergic bronchospasm requiring intensive treatment in an emergency 
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room or at home, blood dyscrasias, convulsions, or the development of drug 
dependency or abuse). 
Adverse Event Severity 
Adverse events are to be graded according to the categories detailed below: 
Mild: 
Mild events are those which are easily tolerated with no disruption of normal 
daily activity. 
Moderate: 
Moderate events are those which cause sufficient discomfort to interfere with 
normal daily activities. 
Severe: 
Severe events are those which incapacitate and prevent usual activity. 
Changes in severity should be documented in the medical record to allow assessment of the 
duration of the event at each level of severity.  AEs characterized as intermittent require 
documentation of the start and stop of each incidence.  When changes in the severity of an AE 
occur more frequently than once a day, the maximum severity for the experience that day should 
be noted.  If the severity category changes over a number of days, then those changes should be 
recorded separately (with distinct onset dates) 
AE severity and seriousness are assessed independently.  ‘Severity’ characterizes the intensity of 
an AE.  ‘Serious’ is a regulatory definition and serves as a guide to the Sponsor for defining 
regulatory reporting obligations (see definition for Serious Adverse Event). 
Relationship of the Adverse Event to Study Treatment 
The relationship of each AE to study treatment should be evaluated by the Investigator using the 
following criteria:  
Definitely related: 
A clinical event, including laboratory test abnormality, occurring in a 
plausible time relationship to the medication administration, and which 
cannot be explained by concurrent disease or other drugs or chemicals.  
The response to withdrawal of the drug should be clinically plausible. 
Possibly related: 
A clinical event, including laboratory test abnormality, with a 
reasonable time sequence to the medication administration, but which 
could also be explained by concurrent disease or other drugs or 
chemicals.  Information on the drug withdrawal may be lacking or 
unclear. 
Unlikely related: 
A clinical event, including laboratory test abnormality, with little or no 
temporal relationship to medication administration, and which other 
drugs, chemicals, or underlying disease provide plausible explanations. 
Not related: 
A clinical event, including laboratory test abnormality that has no 
temporal relationship to the medication or has more likely alternative 
etiology. 
Adverse Events of Clinical Interest 
The following events are considered to be adverse events of clinical interest: 
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 ISRs 
 Hepatic AEs, including LFT abnormalities considered clinically significant by the 
Investigator. 
7.5.6.2. 
Eliciting and Recording Adverse Events 
Eliciting Adverse Events 
The patient should be asked about medically relevant changes in his/her health since the last 
visit.  The patient should also be asked if he/she has been hospitalized, had any accidents, used 
any new medications, or changed concomitant medication routines (both prescription and OTC).  
In addition to patient observations, AEs will be documented from any clinically relevant 
laboratory findings, physical examination findings, ECG changes, or other findings that are 
relevant to patient safety. 
Recording Adverse Events 
The Investigator is responsible for recording non-serious AEs that are observed or reported by 
the patient after administration of the first dose of study drug regardless of their relationship to 
study drug through the end of study.  Non-serious AEs will be followed until the end of study.  
The Investigator is responsible for recording SAEs that are observed or reported by the patient 
after the time when the informed consent is signed regardless of their relationship to study drug 
through the end of study.  SAEs will be followed until satisfactory resolution, until baseline level 
is reached, or until the SAE is considered by the Investigator to be chronic or the patient is 
stable, as appropriate. 
All AEs must be recorded in the source records for the clinical study center and in the eCRF for 
the patient, whether or not they are considered to be drug-related.  Each AE must be described in 
detail:  onset time and date, description of event, severity, relationship to investigational drug, 
action taken, and outcome (including time and date of resolution, if applicable). 
For SAEs, record the event(s) on the eCRF.  If the electronic data capture (EDC) system is 
unavailable, complete the backup SAE form. 
For AEs that are considered AEs of clinical interest, additional clinical information may be 
collected based upon the severity or nature of the event. 
If a patient has ISRs meeting any of the following criteria, the Investigator or delegate should 
contact the Medical Monitor and submit a supplemental ISR eCRF: 
 ISRs that are recurrent and/or demonstrate a pattern of increasing severity 
 Any ISR that is determined to be severe and/or a cause for study drug discontinuation  
 Any ISR which, in the opinion of the Investigator, requires further medical evaluation or 
treatment 
In some cases, where it is medically appropriate, further evaluation may include photographs, 
referral to a dermatologist, skin biopsy, or other laboratory testing.  If a biopsy was obtained, the 
Sponsor may request that the biopsy also be reviewed by a central dermatopathologist.  To better 
understand the safety profile of the study drug, additional analysis of biopsy tissue may be 
performed according to local regulations. 
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For patients with hepatic AEs, additional information, including, clinical history, course of event, 
and local laboratory results to monitor LFT levels or other laboratory parameters, may be 
collected. 
7.5.6.3. 
Serious Adverse Events Require Immediate Reporting to Sponsor/Designee 
An assessment of the seriousness of each AE will be made by the Investigator.  Any AE and 
laboratory abnormality that meets the SAE criteria in Section 7.5.6.1 must be reported to the 
Sponsor or designee within 24 hours from the time that clinical study center personnel first 
learns of the event.  All SAEs must be reported regardless of the relationship to study drug. 
The initial report should include at least the following information: 
 Patient’s study number 
 Description and date of onset of the event 
 Criterion for serious 
 Preliminary assignment of relationship to study drug 
 Investigator/clinical study center information 
To report the SAE, complete the eCRF.  If the EDC system is unavailable, complete the backup 
SAE form.  Within 24 hours of receipt of follow-up information, the Investigator must update the 
report.  SAEs must be reported using the contact information provided in the Study Manual. 
Appropriate remedial measures should be taken by the Investigator using his/her best medical 
judgment to treat the SAE.  These measures and the patient’s response to these measures should 
be recorded.  All SAEs, regardless of relationship to study drug, will be followed by the 
Investigator until satisfactory resolution or the Investigator deems the SAE to be chronic or 
stable.  Clinical, laboratory, and diagnostic measures should be employed by the Investigator as 
needed to adequately determine the etiology of the event. 
7.5.6.4. 
Sponsor Safety Reporting to Regulatory Authorities 
The Sponsor or its representative is required to report certain study events in an expedited 
manner to the Food and Drug Administration, the European Medicines Agency’s EudraVigilance 
electronic system according to Directive 2001/20/EC, and to all country Regulatory Authorities 
where the study is being conducted, according to local applicable regulations. 
The following describes the safety reporting timeline requirements for suspected unexpected 
serious adverse reactions (SUSARs) and other reportable events: 
Immediately and within 7 calendar days 
 Any suspected adverse reaction that is associated with the use of the study drug, 
unexpected, and fatal or life threatening.  Follow-up information must be reported in 
the following 8 days. 
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Immediately and within 15 calendar days 
 Any suspected adverse reaction that is associated with the use of the study drug, 
unexpected, and serious, but not fatal or life threatening, and there is evidence to 
suggest a causal relationship between the study drug and the reaction. 
 Any finding from tests in laboratory animals that suggest a significant risk for human 
patients including reports of mutagenicity, teratogenicity, or carcinogenicity. 
 Any event in connection with the conduct of the study or the development of the 
study drug that may affect the safety of the trial patients. 
In addition, periodic safety reporting to regulatory authorities will be performed by the Sponsor 
or its representative according to national and local regulations. 
7.5.6.5. 
Serious Adverse Event Notification to the Institutional Review 
Board/Independent Ethics Committee 
SUSARs will be reported to the Institutional Review Board (IRB)/Independent Ethics 
Committee (IEC) per their institutional policy by the Investigator or Sponsor (or Sponsor 
designee) according to country requirements.  Copies of each report and documentation of 
IRB/IEC notification and acknowledgement of receipt will be kept in the Investigator’s study 
file. 
7.5.6.6. 
Pregnancy Reporting 
If a female patient becomes pregnant during the course of this study through 90 days following 
the last dose of study drug, the Investigator must report the pregnancy to the Sponsor or designee 
within 24 hours of being notified of the pregnancy.  Details of the pregnancy will be recorded on 
the pregnancy reporting form.  The patient should receive any necessary counseling regarding 
the risks of continuing the pregnancy and the possible effects on the fetus. 
The pregnancy should be followed by the Investigator until completion.  At the completion of the 
pregnancy, the Investigator will document the outcome of the pregnancy.  If the outcome of the 
pregnancy results in a postpartum complication, spontaneous abortion, stillbirth, neonatal death, 
or congenital anomaly, then the Investigator should follow the procedures for reporting an SAE 
as outlined in Section 7.5.6.3.   
7.5.6.7. 
Overdose Reporting 
An overdose is defined as any dose administered to or taken by a patient (accidentally or 
intentionally) that exceeds the highest daily dose, or is at a higher frequency, than included in the 
protocol.  It is up to the investigator to decide whether a dose is to be considered an overdose, in 
consultation with the Sponsor.  Overdose must be recorded in the eCRF. 
All reports of overdose (with or without an AE) must be reported within 24 hours to the Sponsor 
or designee.   
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7.6. 
Exploratory Assessments 
Blood and urine samples will be collected for exploratory analyses.  Aliquots of samples will be 
obtained and frozen, to permit future analysis of the effect of ALN-AS1 on exploratory 
biomarkers.   
Where local regulations allow, biologic samples will be retained on behalf of the Sponsor for a 
maximum of 15 years following the last patient’s last visit in the study.  Details regarding the 
collection, processing, storage, and shipping of samples will be in the Laboratory Manual. 
7.7. 
Other Assessments 
7.7.1. 
EQ-5D-5L Questionnaire 
QOL will be assessed through the use of the 5-level EQ-5D (EQ-5D-5L), a standardized 
questionnaire measuring health outcomes.[34]  In addition to the time points indicated, the 
EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a 
porphyria attack (but, not more than once in a 6 month period), if possible. 
8. 
STATISTICS 
A detailed Statistical Analysis Plan (SAP) will be written after finalizing the protocol and before 
database lock.  The plan will detail the implementation of all the statistical analyses in 
accordance with the principle features stated in the protocol. 
8.1. 
Determination of Sample Size 
This is a Phase 1/2 multicenter, open-label extension study to evaluate the long-term safety and 
clinical activity of ALN-AS1 in patients with AIP who completed study ALN-AS1-001.  Safety, 
tolerability, PK, and PD of ALN-AS1 will be investigated.  The sample size was not determined 
based on statistical considerations.  Up to 24 patients are planned for this study (including 
optional cohorts in ALN-AS1-001). 
8.2. 
Statistical Methodology 
The statistical and analytical plans presented below summarize the more complete plans to be 
detailed in the SAP.  Any changes to the methods described in the final SAP will be described 
and justified as needed in the clinical study report. 
Statistical analyses will be primarily descriptive in nature.  Descriptive statistics (eg, mean, 
standard deviation, median, minimum, and maximum) will be presented for continuous 
variables.  Frequencies and percentages will be presented for categorical and ordinal variables. 
Analyses will be performed using SAS® (Version 9.2, or higher). 
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8.2.1. 
Populations to be Analyzed 
The populations (analysis sets) are defined as follows:  
Safety Analysis Set: 
All patients who received any amount of study drug. 
Clinical Activity Analysis 
Set: 
All patients who received any amount of study drug and have 
both a baseline and at least 1 postdose assessment. 
PK Analysis Set: 
All patients who received any amount of study drug and have at 
least 1 postdose blood sample for PK and who have evaluable 
PK data. 
PD Analysis Set: 
All patients who received any amount of study drug and who 
have at least 1 postdose blood sample for the determination of 
ALN-AS1 will be included in the PD analyses. 
Safety will be analyzed using the Safety Analysis Set.  The PK and PD Analysis Sets will be 
used to conduct PK and PD analyses, respectively.  The population used to evaluate clinical 
activity will be the Clinical Activity Analysis Set.   
8.2.2. 
Examination of Subgroups 
Subgroup analyses may be conducted for selected endpoints.  Detailed methodology will be 
provided in the SAP. 
8.2.3. 
Handling of Missing Data 
Unrecorded values will be treated as missing.  The appropriateness of the method(s) described 
for handling missing data may be reassessed and documented in the SAP before database lock.  
Depending on the extent of missing values, further investigation may be made into the sensitivity 
of the analysis results to the method(s) specified. 
8.2.4. 
Baseline Evaluations 
Demographics, medical history, disease-specific information, and other baseline characteristics 
collected in this study will be summarized.   
8.2.5. 
Clinical Activity Analyses 
Clinical activity of ALN-AS1 will be summarized primarily by descriptive statistics.  The 
clinical activity of ALN-AS1 will be evaluated by the frequency and characteristics of porphyria 
attacks including duration, treatment, and severity of porphyria attacks and number and duration 
of visits to a health care setting for acute porphyria care. 
Patient diary recordings, including BPI-SF questionnaire scores, will also be summarized. 
8.2.6. 
Pharmacodynamic Analysis 
PD analyses will include the evaluation of change in ALA, PBG, and ALAS mRNA levels.  
Descriptive statistics (eg, mean and standard error of the mean) for observed levels of PD 
parameters and the relative change from baseline will be presented for each of the postdose 
follow-up time points. 
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8.2.7. 
Pharmacokinetic Analysis 
The PK concentration of ALN-AS1 will be determined. 
Antidrug antibody results will be tabulated.  A by-patient data listing will also be provided. 
8.2.8. 
Safety Analyses 
Extent of exposure will be summarized.  AEs will be summarized by the Medical Dictionary for 
Regulatory Activities System Organ Class and Preferred Term.  Prior and concomitant 
medications will be classified according to the World Health Organization drug dictionary. 
Incidence of AEs (those events that started after exposure to study drug or worsened in severity 
after dosing) will be presented.  Incidence of AEs will also be presented by maximum severity 
and relationship to study treatment.  The incidence of SAEs and AEs leading to discontinuation 
of treatment will also be tabulated.  By-patient listings will be provided for deaths, SAEs, and 
AEs leading to discontinuation of treatment.   
Descriptive statistics will be provided for clinical laboratory data and vital signs data, presented 
as both actual values and changes from baseline relative to each on-study evaluation and to the 
last evaluation on study.  Laboratory shift tables from baseline to worst values will be presented.  
Abnormal physical examination findings and 12-lead ECG data will be presented in a by-patient 
data listing. 
Descriptive statistics will be provided for ECG interval data and presented as both actual values 
and changes from baseline relative to each on-study evaluation and to the last evaluation on 
study.  Details of any abnormalities will be included in patient listings. 
Concomitant hemin administration will also be recorded. 
8.2.9. 
Other Analyses 
Possible associations between PD parameters (ALA, PBG, and ALAS1 mRNA levels) and 
clinical activity parameters may also be explored. 
Additional exploratory analyses may be conducted on analytes related to targeting the heme 
biosynthesis pathway. 
QOL scores on the EQ-5D-5L questionnaire will also be summarized. 
9. 
STUDY ADMINISTRATION 
9.1. 
Ethical and Regulatory Considerations 
This study will be conducted in accordance with the protocol, all applicable regulatory 
requirements, and the guidelines of Good Clinical Practice (GCP).  Compliance with GCP 
provides public assurance that the rights, safety, and well-being of study patients are protected 
consistent with the principles that have their origin in the Declaration of Helsinki. 
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9.1.1. 
Informed Consent 
The Investigator will ensure that the patient is given full and adequate oral and written 
information about the nature, purpose, possible risk and benefit of the study.  Patients must also 
be notified that they are free to withdraw from the study at any time.  The patient should be given 
the opportunity to ask questions and allowed time to consider the information provided. 
The patient’s signed and dated informed consent must be obtained before conducting any study 
procedures. 
The Investigator must maintain the original, signed ICF.  A copy of the signed ICF must be 
given to the patient. 
9.1.2. 
Ethical Review 
The final study protocol, including the final version of the ICF, must be approved or given a 
favorable opinion in writing by an IRB or IEC, as appropriate.  The Investigator must submit 
written approval before he or she can enroll any patient into the study. 
The Investigator is responsible for informing the IRB or IEC of any amendment to the protocol 
in accordance with local requirements.  In addition, the IRB or IEC must approve all advertising 
used to recruit patients for the study.  The protocol must be reapproved by the IRB or IEC upon 
receipt of amendments and annually, as local regulations require. 
Initial IRB approval of the protocol, and all materials approved by the IRB for this study 
including the patient consent form and recruitment materials must be maintained by the 
Investigator and made available for inspection. 
The Investigator will submit reports of SAEs as outlined in Section 7.5.6.  In addition, the 
Investigator agrees to submit progress reports to the IRB or IEC per their local reporting 
requirements, or at least annually and at the conclusion of the study.  The reports will be made 
available to the Sponsor or designee. 
Any communications from regulatory agencies in regard to inspections, other studies that impact 
this protocol or the qualifications of study personnel should be promptly reported to the Sponsor 
or its designee. 
The Investigator is also responsible for providing the IRB with reports of any reportable serious 
adverse drug reactions from any other study conducted with the investigational drug.  The 
Sponsor or designee will provide this information to the Investigator. 
Major changes in this research activity, except those to remove an apparent immediate hazard to 
the patient, must be reviewed and approved by the Sponsor and the IRB or IEC that approved the 
study.  Amendments to the protocol must be submitted in writing to the Investigator’s IRB or 
IEC and the Regulatory Authority for approval before patients are enrolled under the amended 
protocol. 
9.1.3. 
Study Documentation, Confidentiality, and Records Retention 
All documentation relating to the study should be retained for the period of time required by 
applicable local law.  If it becomes necessary for the Sponsor, the Sponsor’s designee, applicable 
IRB/IEC, or applicable regulatory authorities to review or audit any documentation relating to 
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the study, the Investigator must permit direct access to all source documents/data.  Records will 
not be destroyed without informing the Sponsor in writing and giving the Sponsor the 
opportunity to store the records for a longer period of time at the Sponsor’s expense.   
The Investigator must ensure that the patients’ anonymity will be maintained.  On the CRFs or 
other documents submitted to the Sponsor or designees, patients should not be identified by their 
names, but by the assigned patient number and initials.  If patient names are included on copies 
of documents submitted to the Sponsor or designees, the names (except for initials) will be 
obliterated and the assigned patient number added to the document.  Documents not for 
submission to the Sponsor (eg, signed ICFs) should be maintained by the Investigator in strict 
confidence. 
The Investigator must treat all of the information related to the study and the compiled data as 
confidential, whose use is for the purpose of conducting the study.  The Sponsor must approve 
any transfer of information not directly involved in the study. 
In compliance with local and/or regional regulations, this clinical study may be registered and 
study results may be posted on public registries, such as ClinicalTrials.gov. 
9.1.4. 
End of the Study 
The end of the study is defined as last patient last visit. 
9.1.5. 
Discontinuation of the Clinical Study 
The Sponsor reserves the right to discontinue the study for clinical or administrative reasons at 
any time.  If the clinical study center does not recruit at a reasonable rate, the study may be 
discontinued at that clinical study center.  Should the study be terminated and/or the clinical 
study center closed for whatever reason, all documentation and study drug pertaining to the study 
must be returned to the Sponsor or its representative, and the Investigators, IEC/IRB and 
Regulatory Authorities will be promptly informed of the termination and the reason for the 
decision.  The Investigator should promptly inform the patients and assure appropriate therapy 
and follow-up.  Patients should then be withdrawn from the study.   
9.2. 
Data Quality Control and Quality Assurance 
9.2.1. 
Data Handling 
Study data must be recorded on case report forms (paper and/or electronic) provided by the 
Sponsor or designee on behalf of the Sponsor.  Case report forms must be completed only by 
persons designated by the Investigator.  If eCRFs are used, study data must be entered by trained 
clinical study center personnel with access to a valid and secure eCRF system.  All data entered 
into the eCRF must also be available in the source documents.  Corrections on paper CRFs must 
be made so as to not obliterate the original data and must be initialed and dated by the person 
who made the correction. 
9.2.2. 
Study Monitoring 
The clinical monitor, as a representative of the Sponsor, has an obligation to closely follow the 
study conduct at the clinical study center.  The monitor will visit the Investigator and clinical 
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study center periodically and will maintain frequent telephone and written contact.  The monitor 
will maintain current personal knowledge of the study through observation, review of study 
records and source documentation, and discussion of the conduct of the study with the 
Investigator and personnel. 
The monitor will review source documents, systems and CRFs to ensure overall quality and 
completeness of the data and to confirm study procedures are complied with the requirements in 
the study protocol.  The Sponsor, or its designee, will be allowed to conduct clinical study center 
visits to the investigation facilities for the purpose of monitoring any aspect of the study.  The 
Investigator agrees to allow the monitor to inspect the drug storage area, study drug stocks, drug 
accountability records, patient charts and study source documents, and other records relative to 
study conduct. 
9.2.3. 
Audits and Inspections 
Periodically, the Sponsor or its authorized representatives audit clinical investigative study 
centers as an independent review of core trial processes and documents to determine whether 
these activities were conducted, and data were recorded, analyzed, and accurately reported 
according to the protocol, GCP guidelines of the ICH, and any applicable regulatory 
requirements.  A regulatory authority, an IEC or an IRB may visit the clinical study center to 
perform audits or inspections, including source data verification.  The Investigator should contact 
the Sponsor, or its designee, immediately if contacted by a regulatory agency about an 
inspection. 
9.3. 
Publication Policy 
It is intended that after completion of the study, the data are to be submitted for publication in a 
scientific journal and/or for reporting at a scientific meeting.  A copy of any proposed manuscript 
must be provided and confirmed received at the Sponsor at least 30 days before its submission, 
and according to any additional publication details in the Investigator Agreement.
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10. 
LIST OF REFERENCES 
1. Anderson KE, Bloomer JR, Bonkovsky HL, Kushner JP, Pierach CA, Pimstone NR, et al. 
Recommendations for the diagnosis and treatment of the acute porphyrias. Ann Intern Med. 2005 
Mar 15;142(6):439-50. 
2. Siegesmund M, van Tuyll van Serooskerken AM, Poblete-Gutierrez P, Frank J. The acute 
hepatic porphyrias: current status and future challenges. Best Pract Res Clin Gastroenterol. 2010 
Oct;24(5):593-605. 
3. Poblete-Gutierrez P, Wiederholt T, Merk HF, Frank J. The porphyrias: clinical presentation, 
diagnosis and treatment. Eur J Dermatol. 2006 May-Jun;16(3):230-40. 
4. Balwani M, Desnick RJ. The porphyrias: advances in diagnosis and treatment. Blood. 2012 
Nov 29;120(23):4496-504. 
5. Puy H, Gouya L, Deybach JC. Porphyrias. Lancet. 2010 Mar 13;375(9718):924-37. 
6. Floderus Y, Sardh E, Moller C, Andersson C, Rejkjaer L, Andersson DE, et al. Variations in 
porphobilinogen and 5-aminolevulinic acid concentrations in plasma and urine from 
asymptomatic carriers of the acute intermittent porphyria gene with increased porphyrin 
precursor excretion. Clin Chem. 2006 Apr;52(4):701-7. 
7. Anderson K. Disorders of heme biosynthesis. 8th ed. CR S, editor: McGraw-Hill, New York 
2001. 
8. Dowman JK, Gunson BK, Mirza DF, Bramhall SR, Badminton MN, Newsome PN. Liver 
transplantation for acute intermittent porphyria is complicated by a high rate of hepatic artery 
thrombosis. Liver Transpl. 2012 Feb;18(2):195-200. 
9. Badminton MN, Elder GH. Molecular mechanisms of dominant expression in porphyria. J 
Inherit Metab Dis. 2005;28(3):277-86. 
10. Deybach J-C, Puy H. 86 - Acute Intermittent Porphyria: From Clinical to Molecular Aspects. 
In: Guilard KMKMS, editor. The Porphyrin Handbook. Amsterdam: Academic Press; 2003. p. 
23-41. 
11. Bylesjo I, Wikberg A, Andersson C. Clinical aspects of acute intermittent porphyria in 
northern Sweden: a population-based study. Scand J Clin Lab Invest. 2009;69(5):612-8. 
12. James MF, Hift RJ. Porphyrias. Br J Anaesth. 2000 Jul;85(1):143-53. 
13. Chemmanur AT, Bonkovsky HL. Hepatic porphyrias: diagnosis and management. Clin Liver 
Dis. 2004 Nov;8(4):807-38, viii. 
14. Stein P, Badminton M, Barth J, Rees D, Stewart MF. Best practice guidelines on clinical 
management of acute attacks of porphyria and their complications. Ann Clin Biochem. 2013 
May;50(Pt 3):217-23. 
15. Bonkovsky HL. Neurovisceral porphyrias: what a hematologist needs to know. Hematology 
Am Soc Hematol Educ Program. 2005:24-30. 
16. Panhematin. (hemin for injection). 2013. 
17. Normosang. (human hemin). 2007. 
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18. Watson CJ, Pierach CA, Bossenmaier I, Cardinal R. Postulated deficiency of hepatic heme
and repair by hematin infusions in the "inducible" hepatic porphyrias. Proc Natl Acad Sci U S A. 
1977 May;74(5):2118-20. 
19. Mustajoki P, Nordmann Y. Early administration of heme arginate for acute porphyric attacks.
Arch Intern Med. 1993 Sep 13;153(17):2004-8. 
20. Bonkovsky HL, Singh RH, Jafri IH, Fiellin DA, Smith GS, Simon D, et al. A randomized,
controlled trial of treatment of alcoholic hepatitis with parenteral nutrition and oxandrolone. II. 
Short-term effects on nitrogen metabolism, metabolic balance, and nutrition. Am J Gastroenterol. 
1991 Sep;86(9):1209-18. 
21. Herrick AL, McColl KE, Moore MR, Cook A, Goldberg A. Controlled trial of haem arginate
in acute hepatic porphyria. Lancet. 1989 Jun 10;1(8650):1295-7. 
22. Bissell DM. Treatment of acute hepatic porphyria with hematin. J Hepatol. 1988 Feb;6(1):1-
7. 
23. Green D, Ts'ao CH. Hematin: effects on hemostasis. J Lab Clin Med. 1990 Feb;115(2):144-
7. 
24. Daimon M, Susa S, Igarashi M, Kato T, Kameda W. Administration of heme arginate, but
not hematin, caused anaphylactic shock. Am J Med. 2001 Feb 15;110(3):240. 
25. Elder G, Harper P, Badminton M, Sandberg S, Deybach JC. The incidence of inherited
porphyrias in Europe. J Inherit Metab Dis. 2013 Sep;36(5):849-57. 
26. Anderson K. Heme arginate for prevention of acute porphyric attacks (abstract). Acta
Haematologica. 1997;98((suppl 1):120). 
27. Bonkovsky HL, Guo JT, Hou W, Li T, Narang T, Thapar M. Porphyrin and heme
metabolism and the porphyrias. Compr Physiol. 2013 Jan;3(1):365-401. 
28. Vaishnaw AK, Gollob J, Gamba-Vitalo C, Hutabarat R, Sah D, Meyers R, et al. A status
report on RNAi therapeutics. Silence. 2010;1(1):14. 
29. Elbashir SM, Harborth J, Lendeckel W, Yalcin A, Weber K, Tuschl T. Duplexes of 21-
nucleotide RNAs mediate RNA interference in cultured mammalian cells. Nature. 2001 May 
24;411(6836):494-8. 
30. Kauppinen R, von und zu Fraunberg M. Molecular and biochemical studies of acute
intermittent porphyria in 196 patients and their families. Clin Chem. 2002 Nov;48(11):1891-900. 
31. Division of Clinical Pharmacology, Indiana University, P450 Drug Interaction Table.  2013 [
Accessed 06 February 2015]; Available from: http://medicine.iupui.edu/clinpharm/ddis/main-
table/. 
32. Atkinson TM M, TR, Sit L, Passik P, Scher, HI, Cleeland C, and Basch E. The Brief Pain
Inventory and its “Pain at its Worst in the last 24 Hours” Item: Clinical Trial Endpoint 
Considerations. Pain Med. 2010 March;11(3):337–46.
33. Levey AS SL, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, Kusek JW, Eggers P,
Van Lente F, Greene T, Coresh J; CKD-EPI (Chronic Kidney Disease Epidemiology 
Collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med. 
2009;150(9):604-12. 
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34. Herdman M GC, Lloyd A, Janssen M, Kind P, Parkin D, Bonsel G, Badia X. Development 
and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res. 
2011;20(10):1727-36. 
 
 
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11. 
APPENDICES 
11.1. 
Pharmacokinetic Assessment Time Points 
Table 4 contains a detailed schedule for the collection of blood samples for PK analysis. 
Table 4: 
Pharmacokinetic Time Points 
Study Day 
Protocol Time 
(hh:mm) 
PK Blood 
Day 1 and 
Month 12 (D361) ±10 days 
Predose (within 60 minutes 
before dosing) 
X 
02:00 (±15 minutes)b 
X 
06:00 (±20 minutes) 
X 
Month 1 (Day 14) ±2 days 
Anytime during visit 
X 
Month 1 (Day 31) ±7 days,a  
Month 3 (Day 91) ±7 days, 
Month 6 (Day 181) ±7 days, 
Month 9 (Day 271) ±10 days, 
Month 15 (Day 451) ±10 days, 
Month 18 (Day 541) ±10 days  
Month 24 (Day 721) ±10 days 
Predose (within 60 minutes 
before dosing) 
X 
02:00 (±15 minutes)b 
X 
04:00 (±20 minutes)c 
Abbreviations:  hh=hours; mm=minutes; PK=pharmacokinetic. 
a  At the Day 31 1 visit, if the dosing regimen is every 3 months, ALN-AS1 is not administered and a single 
time point blood sample for PK analysis should be collected. 
b  Only in patients receiving ≤2.5 mg/kg ALN-AS1; paired with ECG (for ECG details, see Section 7.5.4).  
c  Only in patients receiving >2.5 mg/kg ALN-AS1; paired with ECG (for ECG details, see Section 7.5.4). 
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11.2. 
Schedules of Assessments for Every Month Dosing Regimen 
 
 
Table 5: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14 ±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History/Disease 
Historyc 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/ 
Exclusion Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examinationd 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
 
 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
X 
Vital Signsf 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGg 
X 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Clinical Laboratory 
Assessmenth 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationj 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
Blood and Urine Sample for 
 
X 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
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Table 5: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14 ±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Exploratory Biomarker 
Analysisl 
Blood Sample for PK 
Analysism 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Antidrug Antibodiesn 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
Porphyria Attack Kit 
Dispensationo 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EQ-5D-5L Questionnairep 
X 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Diary Review (including 
BPI-SF)q 
 
 
X 
AEs 
 
Continuous 
Concomitant Medicationsr 
 
Continuous 
 
Abbreviations:  AE=adverse event; ALAS1=5-aminolevulinic acid synthase 1; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief 
Pain Inventory-Short Form; D=day; ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of life; 
SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may 
be conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical 
examinations and blood/urine sample collections. 
a Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study (ALN-AS1-001) were completed within 60 days 
of administration of the first dose of ALN-AS1 in this study.  If more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs 
will be repeated before administration of ALN-AS1.  Results should be available and deemed acceptable before the administration of the first dose of ALN-
AS1. 
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b After a patient has completed 6 months of ALN-AS1 administration in this study, and where applicable country and local regulations and infrastructure allow, 
study procedures, including ALN-AS1 administration, may take place at the patient’s home by a healthcare professional.  Study procedures may occur at the 
patient’s home at the discretion of the Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit at the clinical 
study center Q3M through M12, and thereafter Q6M. Additional visits to collect clinical laboratory samples may occur at home at any point during the 
treatment period, within 14 days prior to scheduled dose administration. 
c See Section 7.1 for details on the interval medical history/disease history to be recorded at Screening/Baseline.  Ongoing AEs from the previous study 
(ALN-AS1-001) will be captured as medical history. 
d A complete physical examination will be performed at Screening/Baseline, and D1.  At all other visits, a targeted physical examination will be performed.  On 
dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any time 
during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On D1, vital signs will be collected within 1 hour predose; and 2 hours 
(±10 minutes) postdose.  On all other dosing days, vital signs will be collected within 1 hour predose.  On days when ALN-AS1 is not administered, vital signs 
can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position (should be consistent for each patient), after the 
patient has rested comfortably for 10 minutes. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 5 minutes.  
On at least two of the following visits, ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose:  D1, Month 3, Month 6, Month 9, 
Month 12, Month 15, or Month 18.  In patients receiving >2.5 mg/kg ALN-AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) 
postdose on at least two of the following visits:  D1, Month 3, Month 6, Month 12, Month 15, or Month 18.  On all other dosing days, ECGs will be collected 
within 1 hour predose (see Section 7.5.4 for ECG assessment details). 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  On 
days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. On dosing days up to the Month 18 visit,results from 
hematology, chemistry (including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the Investigator before study drug 
administration.  If results from within the prior 14 days are not available at a dosing visit (at visits from D1 to Month 18), locally analyzed predose assessments 
may be used for review in order to allow same day study drug administration, but additional samples for central analysis must also be collected. 
i A serum pregnancy test will be performed at Screening/Baseline; thereafter, urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  For weight-
based dosing, weight measured on the dosing day will be used to calculate the dose of ALN-AS1.  After M12, weight measured on the nearest previous visit 
will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1).  Blood sample collection for PK analysis at 
Month 9 and Month 15 is only necessary if ECG will be performed at same visit. 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o Porphyria attack laboratory sample collection kits should be dispensed at the screening visit along with instructions for use. For any attack that occurs through 
M39, urine samples should be collected within 24 hours of the start of clinical intervention (eg, hemin or glucose administration) and within 24 hours of the end 
of clinical intervention.  If patients are unable to report to the clinical study center during a porphyria attack, laboratory sample collection kits should be used 
for collecting and sending urine samples to the clinical study center, if possible.  These urine samples may also be analyzed for exploratory biomarkers. 
p In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but not more than once in a 6 month period), if possible.  
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q Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, and narcotic use on a daily basis through M9; 
thereafter, acute porphyria attacks will be recorded in the diary.  The BPI will be completed on a weekly basis as part of the patient diary through M9, then 
Q3M. 
r Medications that are ongoing from the previous study (ALN-AS1-001), started between the previous study and this study, and started after signing informed 
consent in this study, will be captured as concomitant medication(s). 
 
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Table 6: 
Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20a 
M21a 
M22/ 
M23a 
M24 
M25/ 
M26a 
M27a 
M28/ 
M29a 
M30 
M31/ 
M32a 
M33a 
M34/ 
M35a 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Physical Examinationd 
X 
X 
X 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
X 
Vital Signsf 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGg 
X 
X 
Clinical Laboratory 
Assessmenth 
X 
X 
X 
X 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationj 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
X 
X 
X 
X 
X 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl  
X 
X 
X 
X 
Blood Sample for PK 
Analysism 
X 
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Table 6: 
Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20a 
M21a 
M22/ 
M23a 
M24 
M25/ 
M26a 
M27a 
M28/ 
M29a 
M30 
M31/ 
M32a 
M33a 
M34/ 
M35a 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Antidrug Antibodiesn 
 
 
 
X 
 
 
 
 
 
 
 
X 
 
 
EQ-5D-5L Questionnaireo 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
Diary Review (including 
BPI-SF)p 
X 
 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; EOS = End of Study; EOT = End of Treatment; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality 
of life; SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
a Where applicable country and local regulations and infrastructure allow, study procedures, including ALN-AS1 administration,  may take place at the patient’s 
home by a healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the Investigator, based on safety and tolerability; 
however, patients are required to complete at least 1 visit at the clinical study center Q6M. Additional visits to collect clinical laboratory samples may occur at 
home at any point during the treatment period, within 14 days prior to scheduled dose administration. 
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b Patients who discontinue treatment will be asked to complete the M39 visit assessments.  If a patient chooses to withdraw from the study, every effort should 
be made to conduct early the assessments performed at the M39 visit.  See Section 5.3 for details on removal from treatment or assessment. 
c The ALA/PBG Monitoring/EOS visit will be conducted at the clinical study center or via phone contact, unless treatment continues with ALN-AS1.  Patients 
will be provided with laboratory sample collection kits and instructions for collecting and sending urine samples to the clinical study center.  Urine samples 
should not be collected during a porphyria attack. 
d A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed.  
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On a dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for 10 minutes. 
g Using central ECG equipment, triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 5 minutes.  
ECGs will be performed within 1 hour predose and 2 hours (±15 minutes) postdose.  In patients receiving >2.5 mg/kg ALN-AS1, ECGs will be performed 
within 1 hour predose and 4 hours (±20 minutes) postdose (see Section 7.5.4 for ECG assessment details). 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  On 
days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. On dosing days, results from hematology, chemistry 
(including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the Investigator before study drug administration.  If results 
from within the prior 14 days are not available at a dosing visit, locally analyzed predose assessments may be used for review in order to allow same day study 
drug administration, but additional samples for central analysis must also be collected. 
i Urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured on the nearest previous visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but, not more than once in a 6 month period), if possible.  
p Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
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11.3. 
List of Sensitive CYP3A Substrates and those with a Narrow 
Therapeutic Range 
A list of medications that are sensitive CYP3A substrates and those with a narrow therapeutic 
range is in Table 7.  
Table 7: 
List of Sensitive CYP3A Substrates and those with a Narrow Therapeutic 
Range 
Sensitive CYP3A Substrates 
 
CYP3A Substrates With A Narrow 
Therapeutic Range 
alfentanil 
fluticasone 
 
Alfentanil 
aprepitant 
lopinavir 
 
Astemizole 
budesonide 
lovastatin 
 
Cisapride 
buspirone 
lurasidone 
 
Cyclosporine 
conivaptan 
maraviroc 
 
Diergotamine 
darifenacin 
midazolam 
 
Dihydroergotamine 
darunavir 
nisoldipine 
 
Ergotamine 
dasatinib 
quetiapine 
 
Fentanyl 
dronedarone 
saquinavir 
 
Irinotecan 
eletriptan 
sildenafil 
 
Pimozide 
eplerenone 
simvastatin 
 
Quinidine 
everolimus 
sirolimus 
 
Sirolimus 
felodipine 
tolvaptan 
 
Tacrolimus 
imatinib 
tipranavir 
 
Terfenadine 
indinavir 
triazolam 
 
 
 
vardenafil 
 
 
Note:  This is not an exhaustive list and availability of medications may differ between countries.  For more 
information about clinically relevant drugs that are CYP3A substrates, see the Indiana University Division of 
Pharmacology website for reference: http://medicine.iupui.edu/clinpharm/ddis/clinical-table/. 
 
 
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 Amendment 4 Summary of Changes_02 August 2017 
 
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ALN-AS1-002 Protocol Amendment 4 
Summary of Changes (dated 02 August 2017)  
compared to Protocol Amendment 3 (dated 03 February 2017) 
A Multicenter, Open-label Extension Study to Evaluate the Long-term Safety and Clinical 
Activity of Subcutaneously Administered ALN AS1 in Patients with Acute Intermittent 
Porphyria who have Completed a Previous Clinical Study with ALN-AS1 
 
Rationale for Protocol Amendment 
This protocol is being amended to update the ECG assessments to obtain triplicate 12-lead ECGs 
using central equipment and paired with plasma PK at times corresponding to nominal maximum 
concentration (Cmax). 
Also, Schedule of Assessments footnotes and related text were updated to define the visit range 
in which previously noted predose interpretation of hematology, coagulation, and chemistry test 
results are required. 
A detailed summary of the changes is provided in Table 1.  Corrections to typographical errors 
and formatting are not detailed. 
 
 
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Table 1: 
Protocol Amendment 4 Detailed Summary of Changes 
The primary section(s) of the protocol affected by the changes in the protocol amendment are indicated.  The corresponding text has 
been revised throughout the protocol.  Deleted text is indicated by strikeout; added text is indicated by bold font. 
Purpose: To update text to require that same day predose and postdose ECG readings will be obtained from at least 2 separate clinic 
visits.  
The primary change occurs in Section 7.5.4 Electrocardiogram 
Added text: 
Triplicate standard 12-lead ECGECGs will be performed using central ECG equipment, with readings 
approximately 2 minutes apart, will be recorded.  Additional ECGs may be collected at the discretion of the 
Investigator.  Standard computerized 12-lead ECG recordings will be obtained.  Each lead shall be recorded for 
at least 3 beats at a speed of 25 mm/s.  Recordings will be obtained, after the patient has rested comfortably for 
approximately 10 minutes1 minute apart and recorded as specified in the Schedule of Assessments (Table 
1).  Patients should be seated or supine for at least 5 minutes before each ECG is obtained.  The 
electrophysiological parameters assessed includewill be rhythm, ventricular rate, PR interval, QRS duration, 
QT interval, ST and T waves, Bazett-corrected QT interval (QTcB), and Fridericia- corrected QT interval 
(QTcF). 
When ECG and blood sample collection occur at the same time, ECGs should be performed before blood 
samples are drawn. 
In all patients receiving ≤2.5 mg/kg ALN-AS1, it is required that ECGs will be obtained on at least 2 
separate clinic visits (D1, and Months 3, 6, 9, 12, 15, or 18), each of which will include same day predose 
and 2-hour (±15 minutes) postdose readings, paired with PK timepoints (Table 4) as specified in the 
Schedule of Assessments (Table 1).   
Similarly, in all patients receiving >2.5 mg/kg ALN-AS1, it is required that ECGs will be obtained on at 
least 2 separate clinic visits (D1, and Months 3, 6, 9, 12, 15, or 18), each of which will include same day 
predose and 4-hour (±20 minutes) postdose readings, paired with PK timepoints (Table 4), as specified in 
the Schedule of Assessments (Table 1).   
The Investigator or designee is responsible for reviewing the ECGs to assess whether the results have changed 
since the Screening/Baseline visit and to determine the clinical relevance of the results.  These assessments will 
be recorded on the eCRF.  For any clinically relevant ECG changes from the Screening/Baseline visit (eg, 
ischemic ECG changes, wave/interval changes, or arrhythmia), the Investigator must contact the Medical 
Monitor to discuss continued participation of the patient in the study. 
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Section(s) also containing similar or related changes 
 Footnote to Table 1: Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
 Footnote to Table 2: Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen) 
 Footnote to Table 5: Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
 Footnote to Table 6: Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen) 
 Table 4:  Pharmacokinetic Timepoints; revision applied to table and table footnotes. 
Purpose: To revise Schedule of Assessments table, Pharmacokinetics table, and related footnotes to create additional timepoints for 
performing ECGs, and also to pair with PK timepoints. 
The primary change occurs in footnote to Table 1: Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months 
Dosing Regimen) 
Now reads: 
Revised footnotes: 
 
g Using central ECG equipment, Ttriplicate 12-lead ECGs will be performed in the seated or supine 
position after the patient has rested comfortably for 105 minutes.  On D1,at least two of the following visits, 
ECGs will be performed within 1 hour predose and 2 hours (±10 minutes) postdose.15 minutes) postdose:  D1, 
Month 3, Month 6, Month 9,  Month 12, Month 15, or Month 18.  In patients receiving >2.5 mg/kg ALN-
AS1, ECGs will be performed within 1 hour predose and 4 hours (±20 minutes) postdose on at least two 
of the following visits:  D1, Month 3, Month 6, Month 12, Month 15, or Month 18.  On all other dosing 
days, ECGs will be collected within 1 hour predose (see Section 7.5.4 for ECG assessment details). 
 
m   Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 
11.1).  Blood sample collection for PK analysis at Month 9 and Month 15 is only necessary if ECG will be 
performed at same visit. 
Section(s) also containing similar or related changes 
 Footnote to Table 2: Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen) 
 Footnote to Table 5: Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
 Footnote to Table 6: Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen) 
 Section 7.5.4 Electrocardiogram 
 Table 4:  Pharmacokinetic Timepoints; revision applied to table and table footnotes. 
 
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CLINICAL STUDY PROTOCOL 
ALN-AS1-002 
 
Protocol Title: 
A Multicenter, Open-label Extension Study to Evaluate the Long-term 
Safety and Clinical Activity of Subcutaneously Administered 
ALN-AS1 in Patients with Acute Intermittent Porphyria who have 
Completed a Previous Clinical Study with ALN-AS1 
Investigational Drug: 
ALN-AS1 
EudraCT Number: 
2016-002638-54 
IND Number: 
126094 
Protocol Date: 
Original Protocol 19 July 2016 
 
Protocol Amendment 0.1 (Sweden) 20 September 2016 
 
Protocol Amendment 1 10 November 2016 
 
Protocol Amendment 2 01 December 2016 
Protocol Amendment 3 03 February 2017 
 
 
Sponsor: 
Alnylam Pharmaceuticals, Inc. 
300 Third Street 
Cambridge, MA  02142 USA 
Telephone:  
 
Sponsor Contact:   
 
 
 
 
 
The concepts and information contained in this document or generated during the study are considered 
proprietary and may not be disclosed in whole or in part without expressed written authorization of 
Alnylam Pharmaceuticals, Inc. 
 
384
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Clinical Study Protocol ALN-ASl-002 
Amendment 3 03 February 2017 
SPONSOR PROTOCOL APPROVAL 
I have read this protocol and I approve the design of this study. 
 
 
 
Date 
Alnylam Pharmaceuticals 
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P
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Amendment 3_03 February 2017 
 
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INVESTIGATOR’S AGREEMENT 
 
I have read the ALN-AS1-002 protocol and agree to conduct the study as outlined.  I agree to 
maintain the confidentiality of all information received or developed in connection with this 
protocol. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Printed Name of Investigator 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signature of Investigator 
 
 
 
 
 
 
 
 
Date 
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PROTOCOL SYNOPSIS 
Protocol Title 
A Multicenter, Open-label Extension Study to Evaluate the Long-term Safety and Clinical Activity of 
Subcutaneously Administered ALN-AS1 in Patients with Acute Intermittent Porphyria who have 
Completed a Previous Clinical Study with ALN-AS1 
Product Name 
ALN-AS1 
Indication 
Patients with acute intermittent porphyria (AIP) who experience recurrent porphyria attacks 
Phase 
1/2 
Study center(s)   
The study will be conducted at up to 8 clinical study centers worldwide. 
Objectives 
Primary 
 
Evaluate the long-term safety and tolerability of ALN-AS1 in patients with AIP 
Secondary 
 
Assess the pharmacodynamic (PD) effect of ALN-AS1 over time 
 
Assess the clinical activity of ALN-AS1 over time 
Exploratory 
 
Characterize the pharmacokinetic (PK) profile of ALN-AS1 over time 
 
Assess changes in health-related quality of life (QOL) 
 
Characterize analytes related to targeting the heme biosynthesis pathway 
Endpoints 
Primary 
 
Patient incidence of adverse events (AEs) 
Secondary 
 
Change in urine delta-aminolevulinic acid (ALA) and porphobilinogen (PBG) levels 
 
Frequency and characteristics of porphyria attacks 
 
Change in hemin administration 
Exploratory 
 
Change in circulating 5-aminolevulinic acid synthase 1 (ALAS1) mRNA levels 
 
Concentrations of ALN-AS1 and antidrug antibodies  
 
Duration and treatment of porphyria attacks 
 
Number and duration of visits to a health care facility for acute porphyria care 
 
EQ-5D-5L questionnaire scores 
 
Pain assessment and narcotic use as recorded in a patient diary 
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 
Exploratory biomarkers related to the target pathway, such as urine porphyrins, vitamin D binding 
protein 
Study Design 
This is a multicenter, open-label extension study to evaluate the long-term safety and clinical activity 
of ALN-AS1 in patients with AIP who completed study ALN-AS1-001. 
The last assessments performed, determining previous study (ALN-AS1-001) completion, will serve as 
the Screening/Baseline assessments in this study.  If more than 60 days have elapsed since the last 
assessment, safety assessments will be repeated before administration of ALN-AS1.  It is anticipated 
that patients will begin ALN-AS1 administration in this study within 6 months after the last dose of 
study drug in the previous study.  Eligibility will be confirmed before administration of the first dose of 
ALN-AS1 (Day 1).  Patients will undergo assessments at the clinical study center every month for the 
first 3 months.  Then, through Month 6, and according to the dosing regimen selected, assessments will 
take place at the clinical study center or via a phone contact (for an every month dosing regimen, visits 
will be every month; for an every 3 months dosing regimen, visits will be every 3 months).  After a 
patient has completed 12 months of ALN-AS1 administration in this study (6 months in an every 
month dosing regimen), and where applicable country and local regulations and infrastructure allow, 
study procedures, including ALN-AS1 administration, may take place at the patient’s home by a 
healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the 
Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit 
at the clinical study center every 3 months for the first year, and thereafter every 6 months through the 
end of the treatment period.  Additional visits to collect clinical laboratory samples may occur at home 
at any point during the treatment period, within 14 days prior to scheduled dose administration.  
Patients will return to the clinical study center for a posttreatment follow-up visit after administration 
of the last dose of ALN-AS1.  An ALA/PBG Monitoring/EOS visit will be conducted either at the 
clinical study center or via phone contact, unless treatment continues with ALN-AS1. 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, 
and narcotic use.  Patients will also be provided with laboratory sample collection kits and instructions 
for collecting and sending urine samples to the clinical study center. 
A Safety Review Committee (SRC) will review safety and tolerability data collected during the study 
with the primary purpose of protecting the safety of patients participating in the study. 
Number of Planned Patients 
Up to 24 patients are planned for enrollment in this study (including optional cohorts in 
ALN-AS1-001). 
Diagnosis and Main Eligibility Criteria 
Patients with AIP, who have completed Part C of study ALN-AS1-001, will be eligible for screening in 
this study.  Eligible patients will not be on a scheduled regimen of hemin to prevent porphyria attacks 
at Screening.  Patients with alanine transaminase ≥2.0× upper limit of normal, total bilirubin ≥2 mg/dL 
(unless bilirubin elevation is due to Gilbert’s syndrome), or estimated glomerular filtration rate 
≤30 mL/min/1.73 m2 (using the Modification of Diet in Renal Disease formula) at Screening are not 
eligible for this study. 
Investigational Product, Dose, and Mode of Administration 
ALN-AS1 Solution for Injection (subcutaneous use [SC]) is comprised of a synthetic, small interfering 
RNA targeting ALAS1 and bearing a triantennary N-acetyl galactosamine ligand conjugated to the 
sense strand, formulated in phosphate buffer.   
The study starting dose and regimen of ALN-AS1 is 5.0 mg/kg as an SC injection administered every 
3 months.  Based on emerging clinical data, the SRC may approve changes to the dosing regimen, 
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including decreases in the dose level and changes in the dosing frequency.  However any dose and 
dosing regimen will not exceed a previously explored dose level or frequency that was determined to 
be safe and well-tolerated in study ALN-AS1-001, SRC, Health Authority and Ethics Committee 
approval must be sought prior to dose escalation above 5.0 mg/kg in accordance with local Regulatory 
requirements.  
Reference Therapy, Dose, and Mode of Administration 
Not applicable 
Duration of Treatment and Study 
The duration of treatment is up to 36 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 44 months. 
Statistical Methods 
Statistical analyses will be primarily descriptive.  Incidence of AEs will be summarized by maximum 
severity and relationship to ALN-AS1.  Incidence of and serious adverse events (SAEs) and AEs 
leading to discontinuation will also be tabulated.  By-patient listings will be provided for deaths, SAEs, 
and events leading to discontinuation.  
Laboratory shift tables from baseline to worst values will be presented.  Abnormal physical 
examination findings and electrocardiogram data will be presented in by-patient listings.  Descriptive 
statistics will be provided for electrocardiogram interval data and presented as both actual values and 
changes from baseline relative to each on study evaluation and to the last evaluation on-study. 
Clinical activity of ALN-AS1 will be summarized primarily by descriptive statistics.  The clinical 
activity of ALN-AS1 will be evaluated by the frequency and characteristics of porphyria attacks 
including duration, treatment, and severity of porphyria attacks and number and duration of visits to a 
health care setting for acute porphyria care.  Patient diary recordings, including BPI-SF questionnaire 
scores, will also be summarized.   
PD analysis will include the evaluation of change in ALA, PBG, and ALAS mRNA levels.  Descriptive 
statistics (eg, mean and standard error of the mean) for observed levels of PD parameters and the 
relative change from baseline will be presented for each of the postdose follow-up time points. 
The PK concentration of ALN-AS1 will be determined.  Antidrug antibody results will be tabulated 
overall and by previous treatment in the previous study (ALN-AS1-001).  A by-patient listing will also 
be provided. 
Additional exploratory analyses may be conducted on analytes related to targeting the heme 
biosynthesis pathway.  Quality of life scores will also be summarized. 
 
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Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8 
M9 
M10/ 
M11 
M12 
M13/ 
M14 
M15b 
M16/ 
M17 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History/Disease 
Historyc 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/ 
Exclusion Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examinationd 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
 
 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
Vital Signsf 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Triplicate 12-Lead ECGg 
X 
X 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
Clinical Laboratory 
Assessmenth 
X 
 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Study Drug Administrationj 
 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl 
 
X 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Blood Sample for PK 
 
X 
X 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
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Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8 
M9 
M10/ 
M11 
M12 
M13/ 
M14 
M15b 
M16/ 
M17 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Analysism 
Antidrug Antibodiesn 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
Porphyria Attack Kit 
Dispensationo 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EQ-5D-5L Questionnairep 
X 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Diary Review (including 
BPI-SF)q 
 
 
X 
Phone Contactr 
 
 
 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
AEs 
 
Continuous 
Concomitant Medicationss 
 
Continuous 
 
Abbreviations:  AE=adverse event; ALAS1=5-aminolevulinic acid synthase 1; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief 
Pain Inventory-Short Form; D=day; ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of life; 
SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may 
be conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical 
examinations and blood/urine sample collections. 
a Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study (ALN-AS1-001) were completed within 60 days 
of administration of the first dose of ALN-AS1 in this study.  If more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs 
will be repeated before administration of ALN-AS1.  Results should be available and deemed acceptable before the administration of the first dose of ALN-
AS1. 
b After a patient has completed 12 months of ALN-AS1 administration in this study, and where applicable country and local regulations and infrastructure allow, 
study procedures, including ALN-AS1 administration, may take place at the patient’s home by a healthcare professional.  Study procedures may occur at the 
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patient’s home at the discretion of the Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit at the clinical 
study center Q6M.  Additional visits to collect clinical laboratory samples may occur at home at any point during the treatment period, within 14 days prior to 
scheduled dose administration. 
c See Section 7.1 for details on the interval medical history/disease history to be recorded at Screening/Baseline.  Ongoing AEs from the previous study 
(ALN-AS1-001) will be captured as medical history. 
d A complete physical examination will be performed at Screening/Baseline, and D1.  At all other visits, a targeted physical examination will be performed.  On 
dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any time 
during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On D1, vital signs will be collected within 1 hour predose; and 2 hours 
(±10 minutes) postdose.  On all other dosing days, vital signs will be collected within 1 hour predose.  On days when ALN-AS1 is not administered, vital signs 
can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position (should be consistent for each patient), after the 
patient has rested comfortably for 10 minutes. 
g Triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 10 minutes.  On D1, ECGs will be 
performed within 1 hour predose and 2 hours (±10 minutes) postdose.  On all other dosing days, ECGs will be collected within 1 hour predose. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  On 
days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. On dosing days, results from hematology, chemistry 
(including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the Investigator before study drug administration.  If results 
from within the prior 14 days are not available at a dosing visit, locally analyzed predose assessments may be used for review in order to allow same day study 
drug administration, but additional samples for central analysis must also be collected. 
i A serum pregnancy test will be performed at Screening/Baseline; thereafter, urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  For 
weight-based dosing, weight measured on the dosing day will be used to calculate the dose of ALN-AS1.  After M12, weight measured on the nearest previous 
visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o Porphyria attack laboratory sample collection kits should be dispensed at the screening visit along with instructions for use. For any attack that occurs through
M39, urine samples should be collected within 24 hours of the start of clinical intervention (eg, hemin or glucose administration) and within 24 hours of the end
of clinical intervention.  If patients are unable to report to the clinical study center during a porphyria attack, laboratory sample collection kits will be provided
that contain instructions for collecting and sending urine samples to the clinical study center, if possible.  These urine samples may also be analyzed for
exploratory biomarkers.
p In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but not more than once in a 6 month period), if possible.  
q Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, and narcotic use on a daily basis through M9; 
thereafter, acute porphyria attacks will be recorded in the diary.  The BPI will be completed on a weekly basis as part of the patient diary through M9, then 
Q3M. 
r Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack. 
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s Medications that are ongoing from the previous study (ALN-AS1-001), started between the previous study and this study, and started after signing informed 
consent in this study, will be captured as concomitant medication(s). 
 
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Table 2: 
Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20 
M21a 
M22/ 
M23 
M24 
M25/ 
M26 
M27a 
M28/ 
M29 
M30 
M31/ 
M32 
M33a 
M34/ 
M35 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Physical Examinationd 
 
 
 
X 
 
 
 
X 
 
 
 
X 
X 
 
Body Weight, BMI, and 
Heighte 
 
 
 
X 
 
 
 
X 
 
 
 
 
X 
 
Vital Signsf 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
 
Triplicate 12-Lead ECGg 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
 
Clinical Laboratory 
Assessmenth 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
 
Pregnancy Testi 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
 
Study Drug Administrationj 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl 
 
 
 
X 
 
 
 
X 
 
 
 
X 
X 
 
Blood Sample for PK 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
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Table 2: 
Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20 
M21a 
M22/ 
M23 
M24 
M25/ 
M26 
M27a 
M28/ 
M29 
M30 
M31/ 
M32 
M33a 
M34/ 
M35 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Analysism 
Antidrug Antibodiesn 
 
 
 
X 
 
 
 
 
 
 
 
X 
 
 
EQ-5D-5L Questionnaireo 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
Diary Review (including 
BPI-SF)p 
X 
 
Phone Contactq 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
X 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; EOS = End of Study; EOT = End of Treatment; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality 
of life; SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
a Where applicable country and local regulations and infrastructure allow, study procedures, including ALN-AS1 administration, may take place at the patient’s 
home by a healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the Investigator, based on safety and tolerability; 
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however, patients are required to complete at least 1 visit at the clinical study center Q6M. Additional visits to collect clinical laboratory samples may occur at 
home at any point during the treatment period, within 14 days prior to scheduled dose administration. 
b Patients who discontinue treatment will be asked to complete the M39 visit assessments.  If a patient chooses to withdraw from the study, every effort should 
be made to conduct early the assessments performed at the M39 visit.  See Section 5.3 for details on removal from treatment or assessment. 
c The ALA/PBG Monitoring/EOS visit will be conducted at the clinical study center or via phone contact, unless treatment continues with ALN-AS1.  Patients 
will be provided with laboratory sample collection kits and instructions for collecting and sending urine samples to the clinical study center. 
d A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed.  
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On a dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for 10 minutes. 
g Triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 10 minutes.  On dosing days, ECGs will 
be collected within 1 hour predose. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  .  
On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit.  On dosing days, results from hematology, chemistry 
(including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the Investigator before study drug administration.  If results 
from within the prior 14 days are not available at a dosing visit, locally analyzed predose assessments may be used for review in order to allow same day study 
drug administration, but additional samples for central analysis must also be collected. 
i Urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured on the nearest previous visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but, not more than once in a 6 month period), if possible.  
p Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
q Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack.
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TABLE OF CONTENTS 
PROTOCOL SYNOPSIS ................................................................................................................4 
TABLE OF CONTENTS ...............................................................................................................14 
LIST OF TABLES .........................................................................................................................17 
LIST OF FIGURES .......................................................................................................................18 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS ................................................19 
1. 
INTRODUCTION ......................................................................................................21 
1.1. 
Disease Overview .......................................................................................................21 
1.1.1. 
Epidemiology ..............................................................................................................21 
1.1.2. 
Current Management and Unmet Medical Need ........................................................22 
1.2. 
RNA Interference ........................................................................................................23 
1.3. 
ALN-AS1 ....................................................................................................................23 
1.4. 
Study Design Rationale ..............................................................................................23 
1.5. 
Dose Rationale ............................................................................................................23 
1.6. 
Clinical Data Summary ...............................................................................................24 
1.6.1. 
Clinical Pharmacodynamics .......................................................................................25 
1.6.2. 
Clinical Activity ..........................................................................................................25 
1.6.3. 
Clinical Safety ............................................................................................................26 
1.7. 
Benefit-Risk Assessment ............................................................................................27 
2. 
OBJECTIVES .............................................................................................................28 
2.1. 
Primary Objective .......................................................................................................28 
2.2. 
Secondary Objectives .................................................................................................28 
2.3. 
Exploratory Objectives ...............................................................................................29 
3. 
ENDPOINTS ..............................................................................................................29 
3.1. 
Primary Endpoint ........................................................................................................29 
3.2. 
Secondary Endpoints ..................................................................................................29 
3.3. 
Exploratory Endpoints ................................................................................................29 
4. 
INVESTIGATIONAL PLAN .....................................................................................29 
4.1. 
Summary of Study Design ..........................................................................................29 
4.2. 
Duration of Treatment and Study ...............................................................................31 
4.3. 
Number of Patients .....................................................................................................31 
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4.4. 
Method of Assigning Patients to Treatment Groups ..................................................31 
4.5. 
Blinding ......................................................................................................................31 
4.6. 
Safety Review Committee ..........................................................................................31 
5. 
SELECTION AND WITHDRAWAL OF PATIENTS ..............................................31 
5.1. 
Inclusion Criteria ........................................................................................................31 
5.2. 
Exclusion Criteria .......................................................................................................32 
5.3. 
Removal from Treatment or Assessment ...................................................................32 
5.3.1. 
Discontinuation of Study Drug ...................................................................................32 
5.3.2. 
Withdrawal from Study ..............................................................................................33 
5.3.3. 
Replacement of Patients .............................................................................................33 
6. 
TREATMENTS ..........................................................................................................33 
6.1. 
Treatments Administered ............................................................................................33 
6.2. 
Investigational Study Drug .........................................................................................33 
6.2.1. 
Description ..................................................................................................................33 
6.2.2. 
Dose and Administration ............................................................................................33 
6.2.3. 
Dose Modifications .....................................................................................................34 
6.2.3.1. 
Study Population Dose Modifications ........................................................................34 
6.2.3.2. 
Individual Dose Modifications ...................................................................................34 
6.2.4. 
Preparation, Handling, and Storage ............................................................................35 
6.2.5. 
Packaging and Labeling ..............................................................................................35 
6.2.6. 
Accountability .............................................................................................................35 
6.3. 
Concomitant Medications ...........................................................................................35 
6.4. 
Contraceptive Requirements .......................................................................................36 
6.5. 
Treatment Compliance ................................................................................................37 
7. 
STUDY ASSESSMENTS ..........................................................................................37 
7.1. 
Screening/Baseline Assessments ................................................................................37 
7.2. 
Clinical Activity Assessments ....................................................................................37 
7.2.1. 
Patient Diary ...............................................................................................................37 
7.2.2. 
Brief Pain Inventory-Short Form Questionnaire ........................................................37 
7.3. 
Pharmacodynamic Assessments .................................................................................37 
7.4. 
Pharmacokinetic Assessments ....................................................................................38 
7.5. 
Safety Assessments .....................................................................................................38 
7.5.1. 
Vital Signs ..................................................................................................................38 
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7.5.2. 
Weight and Height ......................................................................................................38 
7.5.3. 
Physical Examination .................................................................................................38 
7.5.4. 
Electrocardiogram .......................................................................................................38 
7.5.5. 
Clinical Laboratory Assessments ...............................................................................39 
7.5.5.1. 
Immunogenicity ..........................................................................................................41 
7.5.5.2. 
Pregnancy Testing ......................................................................................................41 
7.5.6. 
Adverse Events ...........................................................................................................41 
7.5.6.1. 
Definitions ..................................................................................................................41 
7.5.6.2. 
Eliciting and Recording Adverse Events ....................................................................43 
7.5.6.3. 
Serious Adverse Events Require Immediate Reporting to Sponsor/Designee ...........44 
7.5.6.4. 
Sponsor Safety Reporting to Regulatory Authorities .................................................44 
7.5.6.5. 
Serious Adverse Event Notification to the Institutional Review 
Board/Independent Ethics Committee ........................................................................45 
7.5.6.6. 
Pregnancy Reporting ..................................................................................................45 
7.5.6.7. 
Overdose Reporting ....................................................................................................45 
7.6. 
Exploratory Assessments ............................................................................................46 
7.7. 
Other Assessments ......................................................................................................46 
7.7.1. 
EQ-5D-5L Questionnaire ............................................................................................46 
8. 
STATISTICS ..............................................................................................................46 
8.1. 
Determination of Sample Size ....................................................................................46 
8.2. 
Statistical Methodology ..............................................................................................46 
8.2.1. 
Populations to be Analyzed ........................................................................................47 
8.2.2. 
Examination of Subgroups .........................................................................................47 
8.2.3. 
Handling of Missing Data ...........................................................................................47 
8.2.4. 
Baseline Evaluations ...................................................................................................47 
8.2.5. 
Clinical Activity Analyses ..........................................................................................47 
8.2.6. 
Pharmacodynamic Analysis........................................................................................47 
8.2.7. 
Pharmacokinetic Analysis ..........................................................................................48 
8.2.8. 
Safety Analyses ..........................................................................................................48 
8.2.9. 
Other Analyses ............................................................................................................48 
9. 
STUDY ADMINISTRATION ...................................................................................48 
9.1. 
Ethical and Regulatory Considerations ......................................................................48 
9.1.1. 
Informed Consent .......................................................................................................49 
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9.1.2. 
Ethical Review ............................................................................................................49 
9.1.3. 
Study Documentation, Confidentiality, and Records Retention .................................49 
9.1.4. 
End of the Study .........................................................................................................50 
9.1.5. 
Discontinuation of the Clinical Study.........................................................................50 
9.2. 
Data Quality Control and Quality Assurance .............................................................50 
9.2.1. 
Data Handling .............................................................................................................50 
9.2.2. 
Study Monitoring ........................................................................................................50 
9.2.3. 
Audits and Inspections ................................................................................................51 
9.3. 
Publication Policy .......................................................................................................51 
10. 
LIST OF REFERENCES ............................................................................................52 
11. 
APPENDICES ............................................................................................................55 
11.1. 
Pharmacokinetic Assessment Time Points .................................................................55 
11.2. 
Schedules of Assessments for Every Month Dosing Regimen ..................................56 
11.3. 
List of Sensitive CYP3A Substrates and those with a Narrow Therapeutic 
Range ..........................................................................................................................63 
 
LIST OF TABLES 
Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 
Months Dosing Regimen) .............................................................................................7 
Table 2: 
Schedule of Assessments:  Month 19 through End of Study (Every 3 Months 
Dosing Regimen) ........................................................................................................11 
Table 3: 
Status of ALN-AS1 Clinical Studies as of 07 November 2016..................................24 
Table 4: 
Pharmacokinetic Time Points .....................................................................................55 
Table 5: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 
Month Dosing Regimen) ............................................................................................56 
Table 6: 
Schedule of Assessments:  Month 19 through End of Study (Every Month 
Dosing Regimen) ........................................................................................................60 
Table 7: 
List of Sensitive CYP3A Substrates and those with a Narrow Therapeutic 
Range ..........................................................................................................................63 
 
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LIST OF FIGURES 
Figure 1: 
Part C Cohort 1 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in .........................................................................................................................26 
Figure 2: 
Part C Cohort 2 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in .........................................................................................................................26 
Figure 3: 
Study Design ...............................................................................................................30 
 
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LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
Abbreviation 
Definition 
AE 
Adverse event 
AHP 
Acute hepatic porphyria 
AIP 
Acute intermittent porphyria 
ALA 
Delta-aminolevulinic acid 
ALAS1 
5-aminolevulinic acid synthase 1 
ALP 
Alkaline phosphatase 
ASGPR 
Asialoglycoprotein receptor 
ASHE 
Asymptomatic high excreters 
BPI-SF 
Brief Pain Inventory-Short Form 
cERD 
Circulating extracellular RNA detection assay 
CRF 
Case report form 
CYP 
Cytochrome P450 
ECG 
Electrocardiogram 
eCRF 
Electronic case report form 
eGFR 
Estimated Glomerular Filtration Rate 
EDC 
Electronic data capture 
EOS 
End of study 
EU 
European Union 
GalNAc 
N-acetyl galactosamine 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practice 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
IEC 
Independent Ethics Committee 
IRB 
Institutional Review Board 
ISR 
Injection site reaction 
IV 
Intravenous 
LFT 
Liver function test 
mRNA 
Messenger RNA 
NHP 
Nonhuman primate 
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Abbreviation 
Definition 
NOAEL 
No observed adverse effect level 
NOEL 
No observed effect level 
OTC 
Over the counter 
PBG 
Porphobilinogen 
PBGD 
Porphobilinogen deaminase 
PD 
Pharmacodynamic(s) 
PK 
Pharmacokinetic(s) 
QOL 
Quality of life 
RNA 
Ribonucleic acid 
RNAi 
RNA interference 
SAE 
Serious adverse event 
SAP 
Statistical Analysis Plan 
SC 
Subcutaneous 
siRNA 
Small interfering RNA 
SRC 
Safety Review Committee 
SUSAR 
Suspected unexpected serious adverse reaction 
ULN 
Upper limit of normal 
US 
United States 
WOCBP 
Woman of child-bearing potential 
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1. 
INTRODUCTION 
1.1. 
Disease Overview 
The porphyrias are a family of rare metabolic disorders predominately caused by a genetic 
mutation in 1 of the 8 enzymes responsible for heme synthesis.[1]  The 2 major categories are 
erythropoietic and hepatic, depending on the major site of expression of the underlying 
enzyme deficiency.[2]  In addition, the porphyrias are classified as acute if patients present 
with neurovisceral symptoms (eg, abdominal pain and neurologic symptoms) or cutaneous if 
they present with dermal blistering or photosensitivity.[3, 4]   
This study will include patients with acute intermittent porphyria (AIP), the most common acute 
hepatic porphyria (AHP).  AIP occurs as a result of an autosomal dominant mutation leading to 
partial deficiency of porphobilinogen deaminase (PBGD), the third enzyme in the heme 
biosynthesis pathway.[5]  The rate limiting step in heme synthesis is the upstream enzyme 
5-aminolevulinic acid synthase 1 (ALAS1), which is controlled by feedback repression via the 
end-product heme.  In response to a decrease in endogenous heme in the liver, as can occur with 
fasting, hormonal alterations, or with cytochrome P450 (CYP) inducing drugs, ALAS1 is 
induced, resulting in increased flux through the heme synthesis pathway.  In patients with AIP, 
this can result in the marked accumulation of the toxic heme intermediates porphobilinogen 
(PBG) and delta aminolevulinic acid (ALA) in the blood and urine due to the deficiency in the 
downstream PBGD.  Clinically, this manifests as acute attacks characterized by severe 
abdominal pain, cardiovascular as well as neurologic and psychiatric dysfunction.[6] 
1.1.1. 
Epidemiology 
Over 370 mutations have been identified in the PBGD gene, which in most instances result in its 
reduction by approximately 50%.  The exact prevalence of AIP is unknown due to under 
diagnosis, variation by geographic region, and the differences in penetrance observed for the 
different mutations.[2]  However, it is estimated that the prevalence of AIP is 5 to 10 per 
100,000 people in Western countries, while in Sweden it occurs in 1 in 1,000 people due to a 
founder effect associated with the resultant G593A mutation.[7-10]  AIP shows incomplete 
penetrance and on average only 10% to 50% of carriers with a mutation present with clinical 
symptoms.[11]  It has been proposed that unknown inherited co-factors, in addition to PBGD 
mutations, may explain why a small percentage of patients present with much more severe 
disease while the majority remain asymptomatic. 
Patients with AIP present with acute attacks characterized by neurovisceral symptoms and signs 
including severe abdominal pain, nausea, vomiting, constipation, or less commonly diarrhea, 
hypertension, tachycardia, fever, muscle weakness, as well as neurological (eg, neuropathy, 
seizures) and psychiatric (eg, anxiety and confusion) manifestations.[12]  AIP attacks typically 
start after puberty and can be triggered by exogenous factors such as medications (especially 
barbiturates, sulfonamides, and hydantoins), stress, exogenous hormones, nutritional status, and 
infection.  Clinically active disease is more common in women, where attacks often occur around 
the menstrual cycle and are likely precipitated by hormonal changes. 
Many AIP patients remain undiagnosed given that the disease is rare and characterized by 
non-specific symptoms (eg, abdominal pain and nausea).[2]  The initial diagnosis involves 
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demonstrating elevated urinary PBG (typically 20-50 × normal reference range) and ALA 
(typically 5-20 × normal reference range) when the patient is having acute attack symptoms.  
Once a test is positive for elevated ALA and PBG and porphyria is suspected, genetic testing for 
a PBGD mutation is performed.   
There are 4 main clinical phenotypes of AIP.  Latent gene carriers have never had an acute attack 
and are biochemically inactive (normal urinary ALA and PBG).  Asymptomatic high excreters 
(ASHE) do not have current acute attacks, but are biochemically active (increased urinary ALA 
and PBG).  The increased levels of ALA and PBG in ASHE patients are lower than those in AIP 
patients during an acute attack, but are still significantly higher than normal reference values.[6-
8] Sporadic attack patients have infrequent acute attacks.  Recurrent attack patients have
≥4 attacks per year requiring hospitalization or treatment by a medical professional.[7] 
1.1.2. 
Current Management and Unmet Medical Need 
Management of acute attacks often requires hospitalization.  Patients are initially treated with 
supportive care and carbohydrate loading, analgesics and anti-emetics, and removal of known 
precipitating factors.[13]  In patients with moderate to severe attacks, or who fail to respond to 
supportive measures, treatment with intravenous (IV) hemin (daily for 3-5 days) is commenced.  
Symptoms typically begin to improve after 2 to 5 days of hemin treatment, accompanied by a 
lowering of urinary ALA and PBG levels to below or at the upper limit of normal (ULN) 
reference value; however, in some patients attacks can last several weeks, requiring prolonged 
hemin use and hospitalization.[14]  With prolonged and severe attacks, cranial nerve 
involvement can occur, leading to bulbar paralysis, respiratory failure, and death.[15]  
Hemin, a blood derived therapy, was approved as Normosang® (heme arginate) in the European 
Union (EU) and as Panhematin® (lyophilised hematin) in the United States (US) in 1999 and 
1983, respectively.[16, 17]  In the EU, heme arginate is indicated for the treatment of acute 
attacks of hepatic porphyria (eg, AIP, variegate porphyria, and hereditary coproporphyria); 
whereas, in the US lyophilized hemin is limited to the amelioration of recurrent attacks of AIP 
temporally related to the menstrual cycle.  Approval of both products was based on biochemical 
efficacy (ie, lowering of ALA and PBG) as well as data from uncontrolled case series and case 
reports.[18-22]  Hemin side effects include thrombophlebitis, transient anticoagulation, and in 
rare cases, anaphylaxis or renal failure.[22-24]  In addition, hemin administration requires a large 
vein for administration, often necessitating central venous access. 
While the majority of patients who experience attacks have them sporadically, it is estimated that 
up to 1,000 AIP patients experience recurrent attacks (typically defined as ≥4 per year) in the US 
and EU combined.[25]  While hemin is currently only approved to ameliorate acute attacks, it is 
administered prophylactically in some patients with recurrent attacks (eg, administered every 
1-2 weeks).[26]  Potential problems associated with chronic hemin administration include 
infusion site phlebitis, iron overload, and the need for chronic IV access and associated 
complications (eg, risk of infection or occlusion).[5]  In addition, there have been reports of a 
decrease in efficacy with chronic hemin administration, as evidenced by the need to increase the 
frequency or dosage of hemin prophylaxis over time in attempt to maintain a clinical effect.[27]  
In patients with very severe recurrent attacks, or in whom hemin treatment is not effective, liver 
transplantation can be curative; however, organ transplantation is a high-risk procedure and is 
rarely used as a treatment option [34].  Given the significant morbidity and mortality, there 
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remains a significant unmet need for an efficacious, simple, fast-acting and better tolerated 
treatment for acute or prevent recurrent attacks in patients with AIP. 
1.2. 
RNA Interference 
RNA interference (RNAi) is a naturally occurring cellular mechanism mediated by small 
interfering RNAs (siRNAs) for regulating gene expression.  Typically, synthetic siRNAs are 
19 to 25 base pair double stranded oligonucleotides in a staggered duplex with a 2-nucleotide 
overhang at both or 1 of the 3’ ends.[28]  Such siRNAs can be designed to target an endogenous 
messenger RNA (mRNA) transcript of a given gene.  When introduced into cells, the net effect 
of an RNAi-based pharmacological approach is the binding of the siRNA to its complementary 
mRNA sequence, cleavage of this target mRNA, and reduction of synthesis of the target 
protein, resulting in a decrease of the target protein levels.[29]  The ability to selectively and 
potently degrade the mRNA encoding the ALAS1 protein (thereby decreasing accumulation of 
the toxic intermediates ALA and PBG) using an siRNA is a novel approach for the prevention 
and treatment of acute attacks in patients with AIP.   
1.3. 
ALN-AS1 
ALN-AS1 comprises a synthetic siRNA covalently linked to a GalNAc containing ligand 
(ALN60519), specific for ALAS1 and formulated for administration via subcutaneous (SC) 
injection. ALN-60519 has a target region between nucleotide 918 to 937 of the ALAS1 mRNA. 
Attachment to a triantennary GalNAc ligand to the siRNA enables its distribution to the liver 
(which is the primary site of ALAS1 synthesis), followed by intracellular delivery to hepatocytes 
via ASGPR, resulting in engagement of the RNAi pathway and suppression of hepatic ALAS1 
protein synthesis. 
ALN-AS1 is currently in development for treatment of acute attacks in patients with AIP, the 
most common AHP. 
Further information on ALN-AS1, including the clinical and nonclinical experience to date, is 
available in in the current version of the Investigator’s Brochure (IB). 
1.4. 
Study Design Rationale 
This is a multicenter, open-label extension study designed to evaluate the long-term safety and 
clinical activity of subcutaneously administered ALN-AS1 in patients with AIP who have 
completed clinical study ALN-AS1-001.  The primary endpoint for the study is the incidence of 
AEs. 
1.5. 
Dose Rationale 
Clinical data from Part A and Part B of the ongoing study ALN-AS1-001 demonstrate that single 
(0.035-2.5 mg/kg) and multiple (0.35-1.0 mg/kg) doses of ALN-AS1 have been generally 
well-tolerated in patients with AIP who are ASHE.  Additionally, data from this study indicate 
that a single dose of 2.5 mg/kg ALN-AS1 results in near normalization of urine ALA and PBG 
levels, which is sustained for approximately 14 weeks.   
Patients in Part C of the ongoing study ALN-AS1-001 who are eligible for participation in this 
study will likely require a higher dose of ALN-AS1 to normalize ALA and PBG as they have 
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higher levels of ALAS1 upregulation and higher baseline levels of ALA and PBG, when 
compared to patients with AIP who are ASHE.[30]  For example, based on preliminary data in 
Part A and Part B of the ALN-AS1-001 study, the mean PBG level of patients who are ASHE is 
21.9 mmol/mol Cr (N=28); whereas, in Part C of this study in patients with AHP who have 
recurrent porphyria attacks, the mean PBG level is approximately 49.3 mmol/mol Cr (N=12). 
The study starting dose and regimen of ALN-AS1 is 5.0 mg/kg as an SC injection administered 
every 3 months.  Based on emerging clinical data, the SRC may approve changes to the 
ALN-AS1 dosing regimen, including decreases in the dose level and changes in dosing 
frequency.  However, any dosing regimen will not exceed a previously explored dose level or 
frequency that was determined to be safe and well-tolerated in study ALN-AS1-001. SRC, 
Health Authority and Ethics Committee approval must be sought prior to dose level escalation 
above 5.0 mg/kg in accordance with local Regulatory requirements. 
The study starting dose and regimen was selected based on the benefit:risk profile of ALN-AS1 
in Part C of the ongoing ALN-AS1-001 study.  Preliminary data to date indicate that 
administration of 5.0 mg/kg ALN-AS1 has been generally well-tolerated.  There have been no 
study drug-related SAEs, severe AEs, or clinically significant changes in safety parameters.  
While a single 2.5 mg/kg dose of ALN-AS1 has also been generally well-tolerated when 
administered to patients in Part A and Part C of study ALN-AS1-001, this dose has not resulted 
in near normalization of ALA and PBG levels.  In addition, while emerging data from Part C 
indicate that an every 3 months dose of 2.5 mg/kg ALN-AS1 demonstrated some clinical activity 
(eg, decrease in attack frequency and decrease in heme use), some patients continued to 
experience breakthrough porphyria attacks during the treatment period, indicating that a higher 
dose may be required. 
The duration of dosing in this study is supported by the overall favorable safety profile of 
ALN-AS1 in the ongoing clinical study ALN-AS1-001 and the absence of new findings in 
nonclinical studies with ALN-AS1. 
1.6. 
Clinical Data Summary 
Table 3 shows the current status of the 2 ongoing ALN-AS1 studies, as of 07 November 2016. 
Clinical data presented in this section are as of 07 November 2016, unless otherwise noted. 
Table 3: 
Status of ALN-AS1 Clinical Studies as of 07 November 2016 
Study 
Number 
Study Description 
Dose, Route, and 
Regimen 
Patients Treateda 
ALN-AS1-
001 
Phase 1, randomized (3:1 
[ALN-AS1: 
placebo]) single-blind 
SAD and MAD, and 
double-blind 
multiple-dose safety, 
tolerability, PK, and PD 
study 
Part A:  0.035-2.5 
mg/kg; SC; single dose 
Part B:  0.35-1.0 
mg/kg; SC; 2 doses 28 
days apart   
Part C:  2.5 or 5.0 
mg/kg; SC; either 2 
doses quarterly or 4 
Part A in ASHE: 
15 ALN-AS1; 
5 placebo 
Part B in ASHE: 
6 ALN-AS1; 
2 placebo 
Part C in AIP patients with 
recurrent attacks:  
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Study 
Number 
Study Description 
Dose, Route, and 
Regimen 
Patients Treateda 
doses monthly 
11 ALN-AS1; 
4 placebo 
ALN-AS1-
002 
OLE study for subjects 
completing Part C of 
study ALN-AS1-001 
2.5 or 5.0 mg/kg; SC; 
monthly or quarterly 
dosing 
A total of 2 patients have been 
dosed at 5 mg/kg quarterly x 1 
dose 
a 5 subjects had >1 treatment assignment: 2 subjects repeated Part A; 3 subjects enrolled in Part A and 
Part B 
1.6.1. 
Clinical Pharmacodynamics 
Dosing has been completed in Part A and Part B of the study.  In both Parts A and B of the study, 
durable and dose-dependent reductions of ALAS1 mRNA (up to 66% in the 2.5 mg/kg dose 
group) as measured by cERD were observed after ALN-AS1 treatment.  ALAS1 reductions were 
highly correlated with reductions in ALA (mean maximal 86%) PBG (mean maximal 95%) 
levels in a dose-dependent manner and were sustained for ≥180 days.  
Dosing is currently ongoing in Part C of the study. The mean maximal reduction in ALAS1 
mRNA relative to baseline in ALN-AS1-treated patients in Cohort 1 (2.5 mg/kg Q3M) was 39% 
and in Cohort 2 (2.5 mg/kg Q1M) 66%.   All patients treated with ALN-AS1 also had decreases 
in their peak ALA and PBG levels in the treatment period compared to the run-in period, along 
with reduced fluctuations in these levels in the treatment period. No reductions were observed 
in the placebo-treated patients.  
1.6.2. 
Clinical Activity 
Clinical activity was not evaluated in Parts A and B of the study because ASHE patients included 
in this study were not actively experiencing attacks of porphyria. 
Dosing is currently ongoing in Part C of the study. All patients in Cohorts 1 and 2 were enrolled 
in a run-in phase for 10-15 weeks that was followed by a treatment phase for up to 24 weeks.  No 
investigational product was administered during the run-in phase.  Therefore, each patient acted 
as their own control, allowing for individual ALA / PBG levels, and overall attack rate while on 
ALN-AS1 treatment to be compared to that observed in the run-in phase.  
Figure 1 shows in Cohort 1 ALN-AS1-treated patients there was a 74% mean decrease in the 
annualized attack rate for the treatment period versus the run-in period (range: 63-94% 
reduction), compared with a 23% decrease in the annualized attack rate for the placebo-treated 
patient.  In ALN-AS1-treated patients this was accompanied by an approximate 76% mean 
decrease in annualized acute hemin usage (range 52-95%) and a 10.3 times increase in the 
maximal attack free interval compared to run-in period (range 4.2-16.3). 
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Figure 1: 
Part C Cohort 1 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in 
 
Figure 2 shows in Cohort 2 ALN-AS1-treated patients, there was a 58% mean decrease in the 
annualized attack rate for the treatment period versus the run-in period (range: 45-76% 
reduction).  This compares favorably with data from the placebo-treated patient who showed a 
34% reduction in the annualized attack rate for the treatment period versus the run-in period.  In 
ALN-AS1-treated patients, the reduction in attack rate was accompanied by a 92% mean 
decrease in annualized hemin usage (range 84-100%) and a 2.7x increase in the mean maximal 
attack free interval compared to run-in period (range 2.1-3.2). 
Figure 2: 
Part C Cohort 2 Summary of Treatment Period Clinical Efficacy Relative to 
Run-in 
 
1.6.3. 
Clinical Safety 
In Part A and Part B of the study, a total of 11 patients (11/13; 85.0%) who received ALN-AS1 
reported at least 1 AE.  All 5 placebo-treated patients (5/5; 100%) reported at least 1 AE.  AEs 
considered possibly or definitely related to ALN-AS1 were reported in 5 patients (5/13; 38%): 
diarrhoea, dyspepsia, hematochezia, injection site erythema, injection site pain, blood creatinine 
increased, glomerular filtration rate decreased, and hypoesthesia (each AE reported only by an 
individual patient; 1/13; 8% each).  There were 2 SAEs of abdominal pain: 1 patient each in the 
0.035 mg/kg and 0.1 mg/kg ALN-AS1 dose groups.  Both were considered to be not related and 
resolved without sequelae.  There were no AEs leading to discontinuation.  All AEs were mild or 
moderate in severity, except for 1 of the SAEs of abdominal pain (0.10 mg/kg dose group), 
which was considered severe. Adverse events related to abnormal laboratory values were seen in 
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1 patient in the 0.35 mg/kg ALN-AS1 dose group who had AEs of ALT increased and AST 
increased, which were moderate and considered by the Investigator to be unrelated to ALN-AS1.  
No clinically significant findings were observed with routine monitoring of CRP and a panel of 9 
proinflammatory cytokines collected predose and up to 24 hours post-dose.  There were no other 
clinically significant laboratory abnormalities related to study drug or changes in vital signs, or 
ECGs in patients who were administered ALN AS1 or placebo. 
Dosing is ongoing in Part C of the study. All patients who received ALN-AS1 in cohort 1 and 2 
reported at least 1 AE.  AEs that were reported in at least 2 subjects were nausea in 3 patients 
(50%) and abdominal pain, vomiting, nasopharyngitis, headache, cough and oropharyngeal pain 
in 2 patients (33.3%) each.  All AEs were mild or moderate in severity.  AEs considered possibly 
or definitely related to ALN-AS1 were reported in 4 patients (66.6%), 1 each:  renal impairment 
in Cohort 1 and injection site reaction, myalgia, and headache in Cohort 2. Both placebo-treated 
patients reported AEs.  No AE was experienced in more than 1 patient. 
In Part C, Cohort 1 or 2, there were no SAEs or AEs leading to discontinuation in patients 
administered ALN-AS1 or placebo. No clinically significant laboratory abnormalities related to 
study drug or changes in vital signs, ECG, or physical exam findings were observed in patients 
administered ALN-AS1 or placebo. 
Part C Cohort 3 5.0 mg/kg SC monthly dosing is ongoing.  In this cohort there was one fatal 
SAE of acute pancreatitis, which was determined to be unlikely related to study drug or placebo 
by the Investigator due to the presence of gall bladder sludge found at the time of her 
presentation.  Contributors to this patient's adverse clinical course included: pre-existing chronic 
debilitation from recurrent AIP attacks requiring monthly hospitalization, porphyria-attributed 
quadriplegia requiring nursing home care, delay in hospital admission and complications from 
thromboembolism (multiple risk factors included pancreatitis, obesity, immobilisation from 
quadriparesis and recent hospitalization for infected portacath removal).  Serum lipase was added 
to all scheduled laboratory assessments in November 2016 as part of additional safety 
monitoring. To date, all lipase results (available in 11 of 15 subjects) have been at or below the 
upper limit of normal with no trends seen with dosing of study drug or placebo. 
1.7. 
Benefit-Risk Assessment 
Patients participating in this study may experience a reduced number or severity of porphyria 
attacks, reduced treatment with IV hemin, and/or reduced requirement for pain medication.  
As presented in Section 1.6, emerging data demonstrate that patients given ALN-AS1 
experienced reduced ALA/PBG levels, decreased attack frequency and reduced heme usage in 
the 24-week treatment period compared to the 12-week run-in period in Study ALN-AS1-001 
As detailed in Section 1.6, a fatal SAE of hemorrhagic pancreatitis was reported but deemed to 
be unlikely related to study drug.  However, the potentially non-adverse nonclinical finding of 
angiectasis in the islets of Langerhans (endocrine, not exocrine region) of the rat pancreas (see 
Investigator Brochure), do not exclude a potential association between ALN-AS1 and the SAE of 
hemorrhagic pancreatitis. 
The potential risks associated with administration of ALN-AS1 in patients with AIP are as 
follows: 
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
Injection site reactions (ISRs):  ALN-AS1 is administered by SC injection.  In the
ongoing ALN-AS1 clinical study, AEs of ISRs have been infrequently reported and
have been mild to moderate in severity with single dosing.  Injection site rotation and
close monitoring have been implemented in ALN-AS1 clinical studies to reduce the
potential for ISRs.

Serum chemistry and coagulation changes: Since an association between ALN-AS1
and the fatal SAE of hemorrhagic pancreatitis can not be ruled out, patients will
undergo routine monitoring of systemic and pancreatic inflammation and coagulation
throughout the study.  Hematology, chemistry and coagulation results are required to
be available prior to each dose.

Liver function test abnormalities:  As ALN-AS1 is targeted for delivery to the liver,
and reversible hepatic changes were observed in some animal species, there is a
potential for development of LFT abnormalities.  To minimize the potential for LFT
abnormalities, patients are required to have adequate liver function at study entry and
LFTs are monitored during the study.

Reproductive health:  No data are available on the use of ALN-AS1 in pregnancy;
however, there is no suspicion of human teratogenicity based on class effects or
genotoxic potential.  ALN-AS1 was neither genotoxic nor clastogenic in in vitro and
in vivo studies.  Women of child bearing potential (WOCBP) must have a negative
pregnancy test, cannot be breastfeeding, and must be willing to use acceptable
methods of contraception during studies with ALN-AS1.

CYP inhibition:  A study in NHP demonstrated that ALN-AS1 dosing could 
potentially increase the clearance of drugs metabolized by the CYP3A isoform.  As 
contraceptive hormones are metabolized via CYP3A, WOCBP must use a barrier 
method of contraception, in addition to hormonal contraception, during study 
participation.  Additionally, Investigators will review all patient medications at study 
start and monitor responses to these medications during the study.  A list of 
medications that are sensitive CYP3A substrates is in Table 7 in Appendix
Section 11.3.  In addition, a list of medications that are sensitive CYP3A substrates is 
available at the Indiana University, Division of Clinical Pharmacology, website.[31]
The complete summary of the clinical and nonclinical data relevant to the investigational drug 
and its study in human subjects is provided in the Investigator’s Brochure. 
2. 
OBJECTIVES 
2.1. 
Primary Objective 

Evaluate the long-term safety and tolerability of ALN-AS1 in patients with AIP
2.2. 
Secondary Objectives 

Assess the PD effect of ALN-AS1 over time

Assess the clinical activity of ALN-AS1 over time
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2.3. 
Exploratory Objectives 
 Characterize the PK profile of ALN-AS1 over time 
 Assess changes in health-related quality of life (QOL) 
 Characterize analytes related to targeting the heme biosynthesis pathway 
3. 
ENDPOINTS 
3.1. 
Primary Endpoint 
 Patient incidence of AEs 
3.2. 
Secondary Endpoints 
 Change in urine ALA and PBG levels 
 Frequency and characteristics of porphyria attacks 
 Change in hemin administration 
3.3. 
Exploratory Endpoints 
 Change in circulating ALAS1 mRNA levels 
 Concentrations of ALN-AS1 and antidrug antibodies  
 Duration and treatment of porphyria attacks 
 Number and duration of visits to a health care facility for acute porphyria care 
 EQ-5D-5L questionnaire scores 
 Pain assessment and narcotic use as recorded in a patient diary 
 Exploratory biomarkers related to the target pathway, such as urine porphyrins, 
vitamin D binding protein 
4. 
INVESTIGATIONAL PLAN 
4.1. 
Summary of Study Design 
This is a Phase 1/2 multicenter, open-label extension study to evaluate the long-term safety and 
clinical activity of ALN-AS1 in patients with AIP who completed study ALN-AS1-001.  The 
study will be conducted at up to 8 clinical study centers worldwide. 
The last assessments performed, determining previous study (ALN-AS1-001) completion, will 
serve as the Screening/Baseline assessments in this study.  If more than 60 days have elapsed 
since the last assessment, safety assessments (eg, ECG and clinical laboratory tests) will be 
repeated before administration of ALN-AS1.  It is anticipated that patients will begin ALN-AS1 
administration in this study within 6 months after the last dose of study drug in the previous 
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study.  Eligibility will be confirmed during Screening/Baseline and before administration of the 
first dose of ALN-AS1 (Day 1).  Patients will undergo assessments at the clinical study center 
every month for the first 3 months.  Then, through Month 6, and according to the dosing regimen 
selected, assessments will take place at the clinical study center or via a phone contact (for an 
every month dosing regimen, visits will be every month; for an every 3 months dosing regimen, 
visits will be every 3 months; see Section 6.2.2).  After a patient has completed 12 months of 
ALN-AS1 administration in this study (6 months in an every month dosing regimen), and where 
applicable country and local regulations and infrastructure allow, study procedures, including 
ALN-AS1 administration, may take place at the patient’s home by a healthcare professional (as 
indicated in the Schedules of Assessments in Table 1 and Table 2; and Table 5 and Table 6 in 
Appendix Section 11.2).  Study procedures may occur at the patient’s home at the discretion of 
the Investigator, based on safety and tolerability; however, patients are required to complete at 
least 1 visit at the clinical study center every 3 months for the first year, and thereafter every 6 
months through the end of the treatment period.  Additional visits to collect clinical laboratory 
samples may occur at home at any point during the treatment period, within 14 days prior to 
scheduled dose administration.  Patients will return to the clinical study center for a 
posttreatment follow-up visit after administration of the last dose of ALN-AS1.  An ALA/PBG 
Monitoring/EOS visit will be conducted either at the clinical study center or via phone contact, 
unless treatment continues with ALN-AS1. 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain 
assessments, and narcotic use.  Additionally, patients will be encouraged to report to the clinical 
study center if they experience a porphyria attack through Month 39.  In the event that patients 
are unable to report to the clinical study center during a porphyria attack, laboratory sample 
collection kits containing instructions for collecting and sending urine samples to the clinical 
study center, if possible, will be provided.  Patients will be contacted by phone after a porphyria 
attack to record attack details.  If patients are experiencing signs and symptoms of a porphyria 
attack when ALN-AS1 administration is scheduled, the Investigator will determine whether 
administration of ALN-AS1 is appropriate.  If patients are treated for a porphyria attack at a 
health care facility (eg, hospital, emergency department, infusion center, or outpatient clinic) 
other than the clinical study center, copies of medical records, including discharge summaries, 
will be requested.   
A Safety Review Committee (SRC) will review safety and tolerability data collected during the 
study with the primary purpose of protecting the safety of patients participating in the study (see 
Section 4.6). 
Figure 3: 
Study Design 
 
Complete Study
ALN-AS1-001
Screening
(Day -60 to -1)
Treatment Period
(36 Months)
Posttreatment 
Follow-up
(3 months)
End of Study
(Month 42)
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4.2. 
Duration of Treatment and Study 
The duration of treatment is up to 36 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 44 months.   
4.3. 
Number of Patients 
Up to 24 patients are planned for enrollment in this study (including optional cohorts in 
ALN-AS1-001). 
4.4. 
Method of Assigning Patients to Treatment Groups 
This is an open-label study; all patients will receive ALN-AS1.  A combination of the clinical 
study center number and screening number will create the unique patient identifier.  The clinical 
study center number will be assigned by the Sponsor.  Upon signing the Informed Consent Form 
(ICF), the patient will be assigned a screening number by the clinical study site, which will be 
the same unique patient identifier assigned in the previous study (ALN-AS1-001).  The 
Investigator, or delegate, will confirm that the patient fulfills all the inclusion criteria and none of 
the exclusion criteria. 
4.5. 
Blinding 
This is an open-label study, and all patients will receive ALN-AS1. 
4.6. 
Safety Review Committee 
An SRC will be involved in the conduct of this study.  The SRC has the responsibility for 
monitoring the safety of the study participants.  The SRC will perform periodic reviews of safety 
and tolerability data during the course of the clinical study at least every 3 months for the first 
6 months of the study and thereafter at least every 6 months.  The SRC may also meet on an ad 
hoc basis for review of emergent safety and tolerability data, as defined in the SRC Charter for 
this clinical study.  The SRC will not stop the study for efficacy. 
The SRC will be comprised of the following members:  Principal Investigator(s), or designee(s), 
the Sponsor Medical Monitor, and the Study Medical Monitor. 
The membership of the SRC and reporting structure are further defined in the SRC Charter. 
5. 
SELECTION AND WITHDRAWAL OF PATIENTS 
5.1. 
Inclusion Criteria 
Each patient must meet all of the following inclusion criteria to be eligible for enrollment in this 
study: 
1. Completed and, in the opinion of the Investigator, tolerated study drug dosing in Part C 
of study ALN-AS1-001 
2. Not on a scheduled regimen of hemin to prevent porphyria attacks at Screening 
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3. WOCBP must have a negative serum pregnancy test, cannot be breast feeding, and must 
be willing to use acceptable methods of contraception 14 days before first dose, 
throughout study participation, and for 90 days after last dose administration.  Acceptable 
methods include hormonal methods along with an additional barrier method (eg, condom, 
diaphragm, or cervical cap), or a double barrier method of contraception for those 
WOCBP for whom a hormonal method of contraception is medically contraindicated due 
to underlying disease (see Section 6.4 for acceptable methods of contraception).   
4. Willing and able to comply with the study requirements and to provide written informed 
consent 
5.2. 
Exclusion Criteria 
Each patient must not meet any of the following exclusion criteria to be eligible for enrollment in 
this study: 
1. Alanine transaminase ≥2.0×ULN or total bilirubin ≥2 mg/dL (unless bilirubin elevation is 
due to Gilbert’s syndrome) 
2. Estimated glomerular filtration rate ≤30 mL/min/1.73 m2 (using the Modification of Diet 
in Renal Disease formula) 
3. History of multiple drug allergies or history of allergic reaction to an oligonucleotide or 
to N-acetyl galactosamine ligand (GalNAc) 
4. Received an investigational agent, other than ALN-AS1, or who are in follow-up of 
another clinical study of an investigational agent within 90 days before study drug 
administration 
5. Other medical conditions or comorbidities which, in the opinion of the Investigator, 
would interfere with study compliance or data interpretation 
5.3. 
Removal from Treatment or Assessment 
Patients are free to discontinue treatment or withdraw from the study at any time and for any 
reason, without penalty to their continuing medical care.  Any discontinuation of treatment or 
withdrawal from the study must be fully documented in the electronic case report form (eCRF), 
and should be followed up by the Investigator.  The Investigator may withdraw a patient at any 
time if this is considered to be in the best interest of the patient. 
Discontinuation of study drug and withdrawal from the study are described in Section 5.3.1 and 
Section 5.3.2, respectively. 
5.3.1. 
Discontinuation of Study Drug 
The Investigator or designee may discontinue dosing in a patient if the patient: 
 Is in violation of the protocol 
 Experiences a SAE considered to be possibly or definitely related to the study drug or 
an intolerable AE  
 Becomes pregnant 
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
Is found to be considerably noncompliant with the protocol-requirements
Patients who are pregnant will be discontinued from study drug dosing immediately (see 
Section 7.5.6.6 for reporting and follow-up of pregnancy).  Patients who discontinue treatment 
will be asked to complete the Month 39 visit assessments. 
5.3.2. 
Withdrawal from Study 
A patient may withdraw from the study at any time.  If a patient chooses to withdraw from the 
study, every effort should be made to conduct early the assessments performed at the Month 39 
visit.  When a patient withdraws from the study, the primary reason for study withdrawal must be 
recorded in the appropriate section of the eCRF and all efforts made to complete and report the 
observations as thoroughly as possible.  If a patient withdraws due to a SAE, the SAE should be 
followed as described in Section 7.5.6. 
5.3.3. 
Replacement of Patients 
Patients discontinuing from study drug or withdrawing from the study will not be replaced. 
6. 
TREATMENTS 
6.1. 
Treatments Administered 
ALN-AS1 Solution for Injection (SC use) is a clear, colorless to pale yellow solution essentially 
free of particulates.  ALN-AS1 will be supplied by the Sponsor as a sterile solution for SC 
injection. 
Study drug supplied for this study must not be used for any purpose other than the present study 
and must not be administered to any person not enrolled in the study.  Study drug that has been 
dispensed to a patient and returned unused must not be re-dispensed to a different patient. 
6.2. 
Investigational Study Drug 
Detailed information describing the preparation, handling, and storage, packaging and labeling, 
as well as study drug accountability for ALN-AS1 is provided in the Pharmacy Manual. 
6.2.1. 
Description 
ALN-AS1 Solution for Injection (SC use) is comprised of a synthetic, siRNA targeting ALAS1 
and bearing a triantennary GalNAc ligand conjugated to the sense strand, formulated in 
phosphate buffer.  
6.2.2. 
Dose and Administration 
The study starting dose of ALN-AS1 is 5.0 mg/kg ALN-AS1 as an SC injection administered 
every 3 months (Table 1 and Table 2). Based on emerging clinical data, the SRC may approve 
changes to the ALN-AS1 dosing regimen, including decreases in the dose level and changes in 
dosing frequency (Table 5 and Table 6 in Appendix Section 11.2). However, any dose and 
dosing regimen will not exceed a previously explored dose level or frequency that was 
determined to be safe and well-tolerated in study ALN-AS1-001. SRC, Health Authority and 
Ethics Committee approval must be sought prior to dose level escalation above 5.0 mg/kg in 
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accordance with local Regulatory requirements.  See Section 6.2.3 for details on dose 
modifications. 
The study drug will be administered under the supervision of a healthcare professional.  After a 
patient has completed 12 months of ALN-AS1 administration in this study (6 months in an every 
month dosing regimen), and where applicable country and local regulations and infrastructure 
allow, study procedures, including ALN-AS1 administration, may take place at the patient’s 
home by a healthcare professional.  Study procedures may occur at the patient’s home at the 
discretion of the Investigator, based on safety and tolerability; however, patients are required to 
complete at least 1 visit at the clinical study center every 3 months for the first year, and 
thereafter every 6 months through the end of the treatment period.  Additional visits to collect 
clinical laboratory samples may occur at home at any point during the treatment period, within 
14 days prior to scheduled dose administration. 
If a patient does not receive a dose of ALN-AS1 within the specified dosing window, the 
Investigator should contact the Medical Monitor.  After such consultation, the dose may be 
administered or considered missed and not administered. 
Patients will be permitted to miss an occasional dose of study drug; however, if a patient misses 
2 consecutive doses, the Investigator, in consultation with the Medical Monitor, will discuss 
whether the patient will be able to continue on the study.  
Detailed instructions for study drug administration are found in the Pharmacy Manual. 
6.2.3. 
Dose Modifications 
6.2.3.1. 
Study Population Dose Modifications 
During the study, dose modifications are permitted for the study population, or based on the dose 
cohort into which patients were originally randomized in study ALN-AS1-001.  Following SRC 
review of emerging safety and tolerability data from Part C of study ALN-AS1-001, or from this 
study (ALN-AS1-002), the dose and dosing regimen may be modified.  However, the dose and 
dosing regimen of ALN-AS1 will not exceed a previously explored dose and dosing regimen that 
was determined to be safe and well-tolerated in study ALN-AS1-001.  Patients enrolling in this 
study after a dose modification decision has been implemented may start at the newly identified 
dose and regimen. 
6.2.3.2. 
Individual Dose Modifications 
Dose modifications are permitted for individual patients.  If a patient has a study drug related AE 
of a recurrent ISR, severe ISR, or clinically significant LFT abnormality and the Investigator has 
concerns regarding further ALN-AS1 administration, the Medical Monitor and Investigator will 
review all available safety data for the patient.  Based on this review, a dose reduction to half the 
previously administered dose (eg, a 5.0 mg/kg dose would be reduced to a 2.5 mg/kg dose) or a 
reduction in dosing frequency from monthly to every 3 months is permitted.  Subsequent 
ALN-AS1 administration at the previous dose may be considered based on the judgment of the 
Investigator and Medical Monitor. 
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6.2.4. 
Preparation, Handling, and Storage 
Staff at each clinical study center or the home healthcare professional will be responsible for 
preparation of ALN-AS1 doses, according to procedures detailed in the Pharmacy Manual.  No 
special procedures for the safe handling of study drug are required. 
Study drug will be stored upright and refrigerated at approximately 5±3°C.  Any deviation from 
the recommended storage conditions should be reported to the Sponsor and use of the study drug 
halted until authorization for its continued use has been provided by the Sponsor or designee. 
A Sponsor representative or designee will be permitted, upon request, to audit the supplies, 
storage, dispensing procedures, and records. 
6.2.5. 
Packaging and Labeling 
ALN-AS1 Solution for Injection (SC use) is packaged in 2 mL glass vials with a fill volume of 
no less than 0.55 mL.  The container closure system consists of a Type I glass vial, a Teflon 
faced bromobutyl 13 mm stopper and a flip-off Truedge aluminum seal. 
6.2.6. 
Accountability 
The Investigator or designee will maintain accurate records of receipt and the condition of the 
study drug supplied for this study, including dates of receipt.  In addition, accurate records will 
be kept of when and how much study drug is dispensed and administered to each patient in the 
study.  Any reasons for departure from the protocol dispensing regimen must also be recorded. 
At the completion of the study, there will be a final reconciliation of all study drugs.  All used, 
partially used, and unused study drug will be returned to the Sponsor (or designee) or destroyed 
at the clinical study center according to applicable regulations.   
6.3. 
Concomitant Medications 
Use of concomitant medications will be recorded on the patient’s case report form (CRF) as 
indicated in the Schedules of Assessments (Table 1 and Table 2; and Table 5 and Table 6 in 
Appendix Section 11.2).  This includes all prescription medications, herbal preparations, over the 
counter (OTC) medications, vitamins, and minerals.  Any changes in medications during the 
study will also be recorded on the CRF. 
Any concomitant medication that is required for the patient’s welfare may be administered by the 
Investigator.  However, it is the responsibility of the Investigator to ensure that details regarding 
the medication are recorded on the eCRF.  Concomitant medication will be coded using an 
internationally recognized and accepted coding dictionary. 
ALN-AS1 could potentially increase the clearance of drugs metabolized by the CYP3A isoform.   
Investigators will review all medications at study start and monitor response to these medications 
during the study.  For patients who require new medications while on study, selection of 
medications that are not mainly metabolized by the CYP3A isoform is recommended.  A list of 
medications that are sensitive CYP3A substrates is included in Table 7 Appendix Section 11.3.  
In addition, a more detailed and current list of sensitive CYP3A-metabolized medications and 
CYP3A-metabolized medications with a narrow therapeutic range is available at the Indiana 
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University, Division of Clinical Pharmacology, website 
(http://medicine.iupui.edu/clinpharm/ddis/clinical-table/).[31] 
Patients are not permitted to be on hemin prophylaxis at Screening; however, patients are 
permitted to receive concomitant hemin treatment for the management of acute porphyria 
attacks.  Patients experiencing significant breakthrough attacks while enrolled in this study, 
necessitating frequent hemin treatment, may receive hemin prophylaxis if in the Investigator’s 
judgment this is clinically beneficial to the patient.  The Investigator should contact with the 
Sponsor and Medical Monitor before prophylactic hemin treatment.  The dose, regimen, and 
dates of administration will be recorded on the patient’s eCRF.   
Pain medication (eg, opiates, opioids, narcotic analgesics) and glucose administration are 
permitted for the management of porphyria and for acute porphyria attacks. 
If patients use nonsteroidal anti-inflammatory medications intermittently or chronically, they 
must have been able to tolerate them with no previous side effects (eg, gastric distress or 
bleeding).   
Standard vitamins and topical medications are permitted; however, topical steroids must not be 
applied anywhere near the injection site(s) unless medically indicated. 
6.4. 
Contraceptive Requirements 
WOCBP must be willing to use acceptable methods of contraception 14 days before first dose, 
throughout study participation, and for 90 days after last dose administration.  Birth control 
methods which may be considered as acceptable include: 

Established use of oral, implantable, injectable, or transdermal hormonal methods of
contraception.  WOCBP using hormonal methods of contraception must also use a
barrier method (condom or occlusive cap [diaphragm or cervical/vault cap] in
conjunction with spermicide [eg, foam, gel, film, cream, or suppository]).  If
hormonal methods of contraception are medically contraindicated for WOCBP due to
underlying disease, a double-barrier method (combination of male condom with
either cap, diaphragm, or sponge, in conjunction with spermicide) is also considered
an acceptable method of contraception.

Placement of an intrauterine device

Placement of an intrauterine hormone-releasing system

Bilateral tubal occlusion

Surgical sterilization of male partner (with the appropriate post-vasectomy
documentation of the absence of sperm in the ejaculate; for female patients on the
study, the vasectomized male partner should be the sole partner for that patient)

True sexual abstinence, when in line with the preferred and usual lifestyle of the
patient.  Periodic abstinence (eg, calendar, ovulation, symptothermal, post-ovulation
methods) and withdrawal are not acceptable methods of contraception.  Abstinent
patients must agree to use 1 of the abovementioned contraceptive methods, if they
start sexual relationships during the study and for 90 days after last dose
administration.
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WOCBP includes any female patient who has experienced menarche and who is not 
postmenopausal or permanently sterilized (eg, bilateral tubal occlusion, hysterectomy, or 
bilateral salpingectomy).  Postmenopausal state is defined as no menses for 12 months without 
an alternative medical cause, confirmed by follicle stimulating hormone level within the 
postmenopausal range. 
6.5. 
Treatment Compliance 
Compliance with study drug administration will be verified through observation by study 
personnel or trained home healthcare professionals.  
7. 
STUDY ASSESSMENTS 
The schedule of study assessments is provided in Table 1. 
7.1. 
Screening/Baseline Assessments 
Informed consent, patient demographic data, and eligibility criteria will be confirmed at 
Screening/Baseline.  An interval medical history/disease history will be obtained at 
Screening/Baseline.  The last assessments performed, determining previous study 
(ALN-AS1-001) completion, will serve as the Screening/Baseline assessments in this study.  If 
more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs will 
be repeated before administration of ALN-AS1. 
7.2. 
Clinical Activity Assessments 
The clinical activity of ALN-AS1 will be assessed by the frequency and characteristics of 
porphyria attacks including, but not limited to, duration, treatment, and severity of porphyria 
attacks and number and duration of visits to a health care setting for acute porphyria care (eg, 
hospital, emergency department, infusion center, or outpatient clinic).  Concomitant hemin 
administration will also be recorded. 
7.2.1. 
Patient Diary 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain 
assessments, and narcotic use. 
7.2.2. 
Brief Pain Inventory-Short Form Questionnaire 
The Brief Pain Inventory-Short Form (BPI-SF) questionnaire will be used to evaluate pain.[32]  
The BPI will be completed as part of the patient diary. 
7.3. 
Pharmacodynamic Assessments 
Blood and urine samples will be collected for assessment of ALN-AS1 PD parameters.  The PD 
effect of ALN-AS1 will be evaluated by urine ALA and PBG levels.  Blood and urine samples 
will be collected for assessment of circulating ALAS1 mRNA levels in serum and in urine.  
Analysis for blood and urine PD parameters will take place at a central laboratory.   
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Details regarding the processing and aliquoting of samples for storage and analyses will be 
provided in the Laboratory Manual. 
7.4. 
Pharmacokinetic Assessments 
Blood samples will be collected to evaluate the PK profile of ALN-AS1 at the time points in the 
Schedule of Assessments.  A detailed schedule of time points for the collection of blood samples 
for PK analysis is in Table 4 in Appendix Section 11.1). 
The concentration of ALN-AS1 will be determined using a validated assay.  Details regarding 
the processing, shipping, and analysis of the samples will be provided in the Laboratory Manual. 
7.5. 
Safety Assessments 
The assessment of safety during the course of the study will consist of the surveillance and 
recording of AEs including SAEs, recording of concomitant medications and measurements of 
vital signs, physical examination, and ECG findings and clinical laboratory evaluations. 
Safety will be monitored over the course of the study by an SRC as described in Section 4.6. 
7.5.1. 
Vital Signs 
Vital sign measurements include blood pressure, heart rate, body temperature, and respiratory 
rate.  Vital signs will be measured in the seated or supine position (should be consistent for each 
patient), after the patient has rested comfortably for 10 minutes.  Blood pressure should be taken 
using the same arm throughout the study.  Body temperature will be obtained in degrees Celsius, 
heart rate will be counted for a full minute and recorded in beats per minute, and respiration rate 
will be counted for a full minute and recorded in breaths per minute. 
For the safety of the patient, additional vital sign assessments may be added at the discretion of 
the Investigator. 
7.5.2. 
Weight and Height 
Height will be measured in centimeters at the Screening/Baseline visit only.  Body weight will be 
measured in kilograms.  Body mass index will be calculated in the database. 
7.5.3. 
Physical Examination 
Complete physical examinations will include the examination of the following:  general 
appearance, head, eyes, ears, nose and throat, chest/respiratory, heart/cardiovascular, 
gastrointestinal/liver, musculoskeletal/extremities, dermatological/skin, thyroid/neck, lymph 
nodes, and neurological/psychiatric. 
Targeted physical examinations will include the examination of the following:  general 
appearance, chest/respiratory, heart/cardiovascular, gastrointestinal/liver, and 
neurological/psychiatric. 
7.5.4. 
Electrocardiogram 
Triplicate 12-lead ECG, with readings approximately 2 minutes apart, will be recorded.  
Additional ECGs may be collected at the discretion of the Investigator.  Standard computerized 
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12-lead ECG recordings will be obtained.  Each lead shall be recorded for at least 3 beats at a 
speed of 25 mm/s.  Recordings will be obtained, after the patient has rested comfortably for 
approximately 10 minutes.  The electrophysiological parameters assessed include rhythm, 
ventricular rate, PR interval, QRS duration, QT interval, ST and T waves, Bazett-corrected QT 
interval (QTcB) and Fridericia-corrected QT interval (QTcF). 
The Investigator or designee is responsible for reviewing the ECGs to assess whether the results 
have changed since the Screening/Baseline visit and to determine the clinical relevance of the 
results.  These assessments will be recorded on the eCRF.  For any clinically relevant ECG 
changes from the Screening/Baseline visit (eg, ischemic ECG changes, wave/interval changes, or 
arrhythmia), the Investigator must contact the Medical Monitor to discuss continued participation 
of the patient in the study. 
7.5.5. 
Clinical Laboratory Assessments 
The following clinical laboratory tests will be evaluated by a central laboratory.   
On dosing days, results from hematology, chemistry, and coagulation tests collected within the 
prior 14 days must be reviewed by the Investigator before study drug administration. These 
results can be analyzed centrally or at a local laboratory.  If results from within the prior 14 days 
are not available at a dosing visit, locally analyzed assessments may be reviewed to allow same 
day study drug administration, but additional samples for central analysis must also be collected. 
In the event of an unexplained clinically relevant abnormal laboratory test occurring after study 
drug administration, the test should be repeated and followed up at the discretion of the 
Investigator until it has returned to the normal range or stabilized, and/or a diagnosis is made to 
adequately explain the abnormality. 
At any point during the study, and based on Investigator judgment, if a patient experiences 
uncharacteristic signs and symptoms during a porphyria attack, lipase testing should be 
performed and imaging evaluations (eg, right upper quadrant ultrasound and/or other testing, 
based on Investigator judgment) should be considered by the Investigator.  Signs and symptoms 
include, but are not limited to, uncharacteristic abdominal pain and worsening nausea and 
vomiting. 
Imaging is required for any serum lipase result of ≥3× the upper limit of normal, or as clinically 
indicated. 
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Hematology 
Complete blood count with differential 
Serum Chemistry 
Sodium 
Potassium 
BUN 
Phosphate 
Creatinine and eGFRa 
Albumin 
Uric acid 
Calcium 
Total protein 
Carbon dioxide 
Glucose 
Chloride 
Lipase 
Bicarbonate 
Liver Function Tests 
AST 
ALP 
ALT 
Bilirubin (total and direct) 
GGT 
Urinalysis 
Visual inspection for appearance and color 
Bilirubin 
pH (dipstick) 
Nitrite 
Specific gravity 
RBCs 
Ketones 
Urobilinogen 
Albumin 
Leukocytes 
Glucose 
Microscopy (if clinically indicated) 
Protein 
Immunogenicity 
Antidrug antibodies 
Coagulation 
Prothrombin time 
International Normalized Ratio 
Pregnancy Testing (WOCBP only) 
β-human chorionic gonadotropin 
Inflammation 
C-reactive protein 
Abbreviations:  AST=aspartate transaminase; ALP=alkaline phosphatase; ALT=alanine transaminase; BUN=blood 
urea nitrogen; eGFR=estimated glomerular filtration rate; GGT=gamma-glutamyltransferase; WOCBP=women of 
child bearing potential. 
a eGFR will be calculated using the Modification of Diet in Renal Disease formula.[33] 
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7.5.5.1. 
Immunogenicity 
Blood samples will be collected to evaluate antidrug antibodies.  On days when ALN-AS1 is 
administered, blood samples for antidrug antibody testing must be collected before ALN-AS1 is  
administered. 
Details regarding the processing, shipping, and analysis of the samples will be provided in the 
Laboratory Manual. 
7.5.5.2. 
Pregnancy Testing 
A pregnancy test will be performed for WOCBP only.  A serum pregnancy test will be 
performed at Screening/Baseline and urine pregnancy tests will be performed thereafter per the 
Schedule of Assessments and any time pregnancy is suspected.  Urine pregnancy tests may also 
be performed more frequently (eg, monthly) based on local country requirements.  The results of 
the pregnancy test must be known before study drug administration.  Patients who are pregnant 
are not eligible for study participation.  Any woman with a positive pregnancy test during the 
study will be discontinued from study drug, but will continue to be followed for safety.  Patients 
determined to be pregnant while on study will be followed until the pregnancy outcome is known 
(see Section 7.5.6.6 for follow-up instructions).  
7.5.6. 
Adverse Events 
7.5.6.1. 
Definitions 
Adverse Event 
According to the ICH E2A guideline Definitions and Standards for Expedited Reporting, and 
21 Code of Federal Regulations 312.32, Investigational New Drug Safety Reporting, an AE is 
any untoward medical occurrence in a patient or clinical investigational subject administered a 
medicinal product and which does not necessarily have a causal relationship with this treatment. 
Serious Adverse Event 
An SAE is any untoward medical occurrence that at any dose: 
 Results in death 
 Is life-threatening (An event which places the patient at immediate risk of death from 
the event as it occurred.  It does not include an event that had it occurred in a more 
severe form might have caused death) 
 Requires in-patient hospitalization or prolongation of existing hospitalization 
 Results in persistent or significant disability or incapacity 
 Is a congenital anomaly or birth defect 
 Is an important medical event that may not be immediately life-threatening or result 
in death or hospitalization but may jeopardize the patient and may require 
intervention to prevent one of the other outcomes listed in the definition above (eg, 
events include allergic bronchospasm requiring intensive treatment in an emergency 
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room or at home, blood dyscrasias, convulsions, or the development of drug 
dependency or abuse). 
Adverse Event Severity 
Adverse events are to be graded according to the categories detailed below: 
Mild: 
Mild events are those which are easily tolerated with no disruption of normal 
daily activity. 
Moderate: 
Moderate events are those which cause sufficient discomfort to interfere with 
normal daily activities. 
Severe: 
Severe events are those which incapacitate and prevent usual activity. 
Changes in severity should be documented in the medical record to allow assessment of the 
duration of the event at each level of severity.  AEs characterized as intermittent require 
documentation of the start and stop of each incidence.  When changes in the severity of an AE 
occur more frequently than once a day, the maximum severity for the experience that day should 
be noted.  If the severity category changes over a number of days, then those changes should be 
recorded separately (with distinct onset dates) 
AE severity and seriousness are assessed independently.  ‘Severity’ characterizes the intensity of 
an AE.  ‘Serious’ is a regulatory definition and serves as a guide to the Sponsor for defining 
regulatory reporting obligations (see definition for Serious Adverse Event). 
Relationship of the Adverse Event to Study Treatment 
The relationship of each AE to study treatment should be evaluated by the Investigator using the 
following criteria:  
Definitely related: 
A clinical event, including laboratory test abnormality, occurring in a 
plausible time relationship to the medication administration, and which 
cannot be explained by concurrent disease or other drugs or chemicals.  
The response to withdrawal of the drug should be clinically plausible. 
Possibly related: 
A clinical event, including laboratory test abnormality, with a 
reasonable time sequence to the medication administration, but which 
could also be explained by concurrent disease or other drugs or 
chemicals.  Information on the drug withdrawal may be lacking or 
unclear. 
Unlikely related: 
A clinical event, including laboratory test abnormality, with little or no 
temporal relationship to medication administration, and which other 
drugs, chemicals, or underlying disease provide plausible explanations. 
Not related: 
A clinical event, including laboratory test abnormality that has no 
temporal relationship to the medication or has more likely alternative 
etiology. 
Adverse Events of Clinical Interest 
The following events are considered to be adverse events of clinical interest: 
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 ISRs 
 Hepatic AEs, including LFT abnormalities considered clinically significant by the 
Investigator. 
7.5.6.2. 
Eliciting and Recording Adverse Events 
Eliciting Adverse Events 
The patient should be asked about medically relevant changes in his/her health since the last 
visit.  The patient should also be asked if he/she has been hospitalized, had any accidents, used 
any new medications, or changed concomitant medication routines (both prescription and OTC).  
In addition to patient observations, AEs will be documented from any clinically relevant 
laboratory findings, physical examination findings, ECG changes, or other findings that are 
relevant to patient safety. 
Recording Adverse Events 
The Investigator is responsible for recording non-serious AEs that are observed or reported by 
the patient after administration of the first dose of study drug regardless of their relationship to 
study drug through the end of study.  Non-serious AEs will be followed until the end of study.  
The Investigator is responsible for recording SAEs that are observed or reported by the patient 
after the time when the informed consent is signed regardless of their relationship to study drug 
through the end of study.  SAEs will be followed until satisfactory resolution, until baseline level 
is reached, or until the SAE is considered by the Investigator to be chronic or the patient is 
stable, as appropriate. 
All AEs must be recorded in the source records for the clinical study center and in the eCRF for 
the patient, whether or not they are considered to be drug-related.  Each AE must be described in 
detail:  onset time and date, description of event, severity, relationship to investigational drug, 
action taken, and outcome (including time and date of resolution, if applicable). 
For SAEs, record the event(s) on the eCRF.  If the electronic data capture (EDC) system is 
unavailable, complete the backup SAE form. 
For AEs that are considered AEs of clinical interest, additional clinical information may be 
collected based upon the severity or nature of the event. 
If a patient has ISRs meeting any of the following criteria, the Investigator or delegate should 
contact the Medical Monitor and submit a supplemental ISR eCRF: 
 ISRs that are recurrent and/or demonstrate a pattern of increasing severity 
 Any ISR that is determined to be severe and/or a cause for study drug discontinuation  
 Any ISR which, in the opinion of the Investigator, requires further medical evaluation or 
treatment 
In some cases, where it is medically appropriate, further evaluation may include photographs, 
referral to a dermatologist, skin biopsy, or other laboratory testing.  If a biopsy was obtained, the 
Sponsor may request that the biopsy also be reviewed by a central dermatopathologist.  To better 
understand the safety profile of the study drug, additional analysis of biopsy tissue may be 
performed according to local regulations. 
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For patients with hepatic AEs, additional information, including, clinical history, course of event, 
and local laboratory results to monitor LFT levels or other laboratory parameters, may be 
collected. 
7.5.6.3. 
Serious Adverse Events Require Immediate Reporting to Sponsor/Designee 
An assessment of the seriousness of each AE will be made by the Investigator.  Any AE and 
laboratory abnormality that meets the SAE criteria in Section 7.5.6.1 must be reported to the 
Sponsor or designee within 24 hours from the time that clinical study center personnel first 
learns of the event.  All SAEs must be reported regardless of the relationship to study drug. 
The initial report should include at least the following information: 
 Patient’s study number 
 Description and date of onset of the event 
 Criterion for serious 
 Preliminary assignment of relationship to study drug 
 Investigator/clinical study center information 
To report the SAE, complete the eCRF.  If the EDC system is unavailable, complete the backup 
SAE form.  Within 24 hours of receipt of follow-up information, the Investigator must update the 
report.  SAEs must be reported using the contact information provided in the Study Manual. 
Appropriate remedial measures should be taken by the Investigator using his/her best medical 
judgment to treat the SAE.  These measures and the patient’s response to these measures should 
be recorded.  All SAEs, regardless of relationship to study drug, will be followed by the 
Investigator until satisfactory resolution or the Investigator deems the SAE to be chronic or 
stable.  Clinical, laboratory, and diagnostic measures should be employed by the Investigator as 
needed to adequately determine the etiology of the event. 
7.5.6.4. 
Sponsor Safety Reporting to Regulatory Authorities 
The Sponsor or its representative is required to report certain study events in an expedited 
manner to the Food and Drug Administration, the European Medicines Agency’s EudraVigilance 
electronic system according to Directive 2001/20/EC, and to all country Regulatory Authorities 
where the study is being conducted, according to local applicable regulations. 
The following describes the safety reporting timeline requirements for suspected unexpected 
serious adverse reactions (SUSARs) and other reportable events: 
Immediately and within 7 calendar days 
 Any suspected adverse reaction that is associated with the use of the study drug, 
unexpected, and fatal or life threatening.  Follow-up information must be reported in 
the following 8 days. 
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Immediately and within 15 calendar days 
 Any suspected adverse reaction that is associated with the use of the study drug, 
unexpected, and serious, but not fatal or life threatening, and there is evidence to 
suggest a causal relationship between the study drug and the reaction. 
 Any finding from tests in laboratory animals that suggest a significant risk for human 
patients including reports of mutagenicity, teratogenicity, or carcinogenicity. 
 Any event in connection with the conduct of the study or the development of the 
study drug that may affect the safety of the trial patients. 
In addition, periodic safety reporting to regulatory authorities will be performed by the Sponsor 
or its representative according to national and local regulations. 
7.5.6.5. 
Serious Adverse Event Notification to the Institutional Review 
Board/Independent Ethics Committee 
SUSARs will be reported to the Institutional Review Board (IRB)/Independent Ethics 
Committee (IEC) per their institutional policy by the Investigator or Sponsor (or Sponsor 
designee) according to country requirements.  Copies of each report and documentation of 
IRB/IEC notification and acknowledgement of receipt will be kept in the Investigator’s study 
file. 
7.5.6.6. 
Pregnancy Reporting 
If a female patient becomes pregnant during the course of this study through 90 days following 
the last dose of study drug, the Investigator must report the pregnancy to the Sponsor or designee 
within 24 hours of being notified of the pregnancy.  Details of the pregnancy will be recorded on 
the pregnancy reporting form.  The patient should receive any necessary counseling regarding 
the risks of continuing the pregnancy and the possible effects on the fetus. 
The pregnancy should be followed by the Investigator until completion.  At the completion of the 
pregnancy, the Investigator will document the outcome of the pregnancy.  If the outcome of the 
pregnancy results in a postpartum complication, spontaneous abortion, stillbirth, neonatal death, 
or congenital anomaly, then the Investigator should follow the procedures for reporting an SAE 
as outlined in Section 7.5.6.3.   
7.5.6.7. 
Overdose Reporting 
An overdose is defined as any dose administered to or taken by a patient (accidentally or 
intentionally) that exceeds the highest daily dose, or is at a higher frequency, than included in the 
protocol.  It is up to the investigator to decide whether a dose is to be considered an overdose, in 
consultation with the Sponsor.  Overdose must be recorded in the eCRF. 
All reports of overdose (with or without an AE) must be reported within 24 hours to the Sponsor 
or designee.   
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7.6. 
Exploratory Assessments 
Blood and urine samples will be collected for exploratory analyses.  Aliquots of samples will be 
obtained and frozen, to permit future analysis of the effect of ALN-AS1 on exploratory 
biomarkers.   
Where local regulations allow, biologic samples will be retained on behalf of the Sponsor for a 
maximum of 15 years following the last patient’s last visit in the study.  Details regarding the 
collection, processing, storage, and shipping of samples will be in the Laboratory Manual. 
7.7. 
Other Assessments 
7.7.1. 
EQ-5D-5L Questionnaire 
QOL will be assessed through the use of the 5-level EQ-5D (EQ-5D-5L), a standardized 
questionnaire measuring health outcomes.[34]  In addition to the time points indicated, the 
EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a 
porphyria attack (but, not more than once in a 6 month period), if possible. 
8. 
STATISTICS 
A detailed Statistical Analysis Plan (SAP) will be written after finalizing the protocol and before 
database lock.  The plan will detail the implementation of all the statistical analyses in 
accordance with the principle features stated in the protocol. 
8.1. 
Determination of Sample Size 
This is a Phase 1/2 multicenter, open-label extension study to evaluate the long-term safety and 
clinical activity of ALN-AS1 in patients with AIP who completed study ALN-AS1-001.  Safety, 
tolerability, PK, and PD of ALN-AS1 will be investigated.  The sample size was not determined 
based on statistical considerations.  Up to 24 patients are planned for this study (including 
optional cohorts in ALN-AS1-001). 
8.2. 
Statistical Methodology 
The statistical and analytical plans presented below summarize the more complete plans to be 
detailed in the SAP.  Any changes to the methods described in the final SAP will be described 
and justified as needed in the clinical study report. 
Statistical analyses will be primarily descriptive in nature.  Descriptive statistics (eg, mean, 
standard deviation, median, minimum, and maximum) will be presented for continuous 
variables.  Frequencies and percentages will be presented for categorical and ordinal variables. 
Analyses will be performed using SAS® (Version 9.2, or higher).
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8.2.1. 
Populations to be Analyzed 
The populations (analysis sets) are defined as follows:  
Safety Analysis Set: 
All patients who received any amount of study drug. 
Clinical Activity Analysis 
Set: 
All patients who received any amount of study drug and have 
both a baseline and at least 1 postdose assessment. 
PK Analysis Set: 
All patients who received any amount of study drug and have at 
least 1 postdose blood sample for PK and who have evaluable 
PK data. 
PD Analysis Set: 
All patients who received any amount of study drug and who 
have at least 1 postdose blood sample for the determination of 
ALN-AS1 will be included in the PD analyses. 
Safety will be analyzed using the Safety Analysis Set.  The PK and PD Analysis Sets will be 
used to conduct PK and PD analyses, respectively.  The population used to evaluate clinical 
activity will be the Clinical Activity Analysis Set.   
8.2.2. 
Examination of Subgroups 
Subgroup analyses may be conducted for selected endpoints.  Detailed methodology will be 
provided in the SAP. 
8.2.3. 
Handling of Missing Data 
Unrecorded values will be treated as missing.  The appropriateness of the method(s) described 
for handling missing data may be reassessed and documented in the SAP before database lock.  
Depending on the extent of missing values, further investigation may be made into the sensitivity 
of the analysis results to the method(s) specified. 
8.2.4. 
Baseline Evaluations 
Demographics, medical history, disease-specific information, and other baseline characteristics 
collected in this study will be summarized.   
8.2.5. 
Clinical Activity Analyses 
Clinical activity of ALN-AS1 will be summarized primarily by descriptive statistics.  The 
clinical activity of ALN-AS1 will be evaluated by the frequency and characteristics of porphyria 
attacks including duration, treatment, and severity of porphyria attacks and number and duration 
of visits to a health care setting for acute porphyria care. 
Patient diary recordings, including BPI-SF questionnaire scores, will also be summarized. 
8.2.6. 
Pharmacodynamic Analysis 
PD analyses will include the evaluation of change in ALA, PBG, and ALAS mRNA levels.  
Descriptive statistics (eg, mean and standard error of the mean) for observed levels of PD 
parameters and the relative change from baseline will be presented for each of the postdose 
follow-up time points. 
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8.2.7. 
Pharmacokinetic Analysis 
The PK concentration of ALN-AS1 will be determined. 
Antidrug antibody results will be tabulated.  A by-patient data listing will also be provided. 
8.2.8. 
Safety Analyses 
Extent of exposure will be summarized.  AEs will be summarized by the Medical Dictionary for 
Regulatory Activities System Organ Class and Preferred Term.  Prior and concomitant 
medications will be classified according to the World Health Organization drug dictionary. 
Incidence of AEs (those events that started after exposure to study drug or worsened in severity 
after dosing) will be presented.  Incidence of AEs will also be presented by maximum severity 
and relationship to study treatment.  The incidence of SAEs and AEs leading to discontinuation 
of treatment will also be tabulated.  By-patient listings will be provided for deaths, SAEs, and 
AEs leading to discontinuation of treatment.   
Descriptive statistics will be provided for clinical laboratory data and vital signs data, presented 
as both actual values and changes from baseline relative to each on-study evaluation and to the 
last evaluation on study.  Laboratory shift tables from baseline to worst values will be presented.  
Abnormal physical examination findings and 12-lead ECG data will be presented in a by-patient 
data listing. 
Descriptive statistics will be provided for ECG interval data and presented as both actual values 
and changes from baseline relative to each on-study evaluation and to the last evaluation on 
study.  Details of any abnormalities will be included in patient listings. 
Concomitant hemin administration will also be recorded. 
8.2.9. 
Other Analyses 
Possible associations between PD parameters (ALA, PBG, and ALAS1 mRNA levels) and 
clinical activity parameters may also be explored. 
Additional exploratory analyses may be conducted on analytes related to targeting the heme 
biosynthesis pathway. 
QOL scores on the EQ-5D-5L questionnaire will also be summarized. 
9. 
STUDY ADMINISTRATION 
9.1. 
Ethical and Regulatory Considerations 
This study will be conducted in accordance with the protocol, all applicable regulatory 
requirements, and the guidelines of Good Clinical Practice (GCP).  Compliance with GCP 
provides public assurance that the rights, safety, and well-being of study patients are protected 
consistent with the principles that have their origin in the Declaration of Helsinki. 
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9.1.1. 
Informed Consent 
The Investigator will ensure that the patient is given full and adequate oral and written 
information about the nature, purpose, possible risk and benefit of the study.  Patients must also 
be notified that they are free to withdraw from the study at any time.  The patient should be given 
the opportunity to ask questions and allowed time to consider the information provided. 
The patient’s signed and dated informed consent must be obtained before conducting any study 
procedures. 
The Investigator must maintain the original, signed ICF.  A copy of the signed ICF must be 
given to the patient. 
9.1.2. 
Ethical Review 
The final study protocol, including the final version of the ICF, must be approved or given a 
favorable opinion in writing by an IRB or IEC, as appropriate.  The Investigator must submit 
written approval before he or she can enroll any patient into the study. 
The Investigator is responsible for informing the IRB or IEC of any amendment to the protocol 
in accordance with local requirements.  In addition, the IRB or IEC must approve all advertising 
used to recruit patients for the study.  The protocol must be reapproved by the IRB or IEC upon 
receipt of amendments and annually, as local regulations require. 
Initial IRB approval of the protocol, and all materials approved by the IRB for this study 
including the patient consent form and recruitment materials must be maintained by the 
Investigator and made available for inspection. 
The Investigator will submit reports of SAEs as outlined in Section 7.5.6.  In addition, the 
Investigator agrees to submit progress reports to the IRB or IEC per their local reporting 
requirements, or at least annually and at the conclusion of the study.  The reports will be made 
available to the Sponsor or designee. 
Any communications from regulatory agencies in regard to inspections, other studies that impact 
this protocol or the qualifications of study personnel should be promptly reported to the Sponsor 
or its designee. 
The Investigator is also responsible for providing the IRB with reports of any reportable serious 
adverse drug reactions from any other study conducted with the investigational drug.  The 
Sponsor or designee will provide this information to the Investigator. 
Major changes in this research activity, except those to remove an apparent immediate hazard to 
the patient, must be reviewed and approved by the Sponsor and the IRB or IEC that approved the 
study.  Amendments to the protocol must be submitted in writing to the Investigator’s IRB or 
IEC and the Regulatory Authority for approval before patients are enrolled under the amended 
protocol. 
9.1.3. 
Study Documentation, Confidentiality, and Records Retention 
All documentation relating to the study should be retained for the period of time required by 
applicable local law.  If it becomes necessary for the Sponsor, the Sponsor’s designee, applicable 
IRB/IEC, or applicable regulatory authorities to review or audit any documentation relating to 
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the study, the Investigator must permit direct access to all source documents/data.  Records will 
not be destroyed without informing the Sponsor in writing and giving the Sponsor the 
opportunity to store the records for a longer period of time at the Sponsor’s expense.   
The Investigator must ensure that the patients’ anonymity will be maintained.  On the CRFs or 
other documents submitted to the Sponsor or designees, patients should not be identified by their 
names, but by the assigned patient number and initials.  If patient names are included on copies 
of documents submitted to the Sponsor or designees, the names (except for initials) will be 
obliterated and the assigned patient number added to the document.  Documents not for 
submission to the Sponsor (eg, signed ICFs) should be maintained by the Investigator in strict 
confidence. 
The Investigator must treat all of the information related to the study and the compiled data as 
confidential, whose use is for the purpose of conducting the study.  The Sponsor must approve 
any transfer of information not directly involved in the study. 
In compliance with local and/or regional regulations, this clinical study may be registered and 
study results may be posted on public registries, such as ClinicalTrials.gov. 
9.1.4. 
End of the Study 
The end of the study is defined as last patient last visit. 
9.1.5. 
Discontinuation of the Clinical Study 
The Sponsor reserves the right to discontinue the study for clinical or administrative reasons at 
any time.  If the clinical study center does not recruit at a reasonable rate, the study may be 
discontinued at that clinical study center.  Should the study be terminated and/or the clinical 
study center closed for whatever reason, all documentation and study drug pertaining to the study 
must be returned to the Sponsor or its representative, and the Investigators, IEC/IRB and 
Regulatory Authorities will be promptly informed of the termination and the reason for the 
decision.  The Investigator should promptly inform the patients and assure appropriate therapy 
and follow-up.  Patients should then be withdrawn from the study.   
9.2. 
Data Quality Control and Quality Assurance 
9.2.1. 
Data Handling 
Study data must be recorded on case report forms (paper and/or electronic) provided by the 
Sponsor or designee on behalf of the Sponsor.  Case report forms must be completed only by 
persons designated by the Investigator.  If eCRFs are used, study data must be entered by trained 
clinical study center personnel with access to a valid and secure eCRF system.  All data entered 
into the eCRF must also be available in the source documents.  Corrections on paper CRFs must 
be made so as to not obliterate the original data and must be initialed and dated by the person 
who made the correction. 
9.2.2. 
Study Monitoring 
The clinical monitor, as a representative of the Sponsor, has an obligation to closely follow the 
study conduct at the clinical study center.  The monitor will visit the Investigator and clinical 
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study center periodically and will maintain frequent telephone and written contact.  The monitor 
will maintain current personal knowledge of the study through observation, review of study 
records and source documentation, and discussion of the conduct of the study with the 
Investigator and personnel. 
The monitor will review source documents, systems and CRFs to ensure overall quality and 
completeness of the data and to confirm study procedures are complied with the requirements in 
the study protocol.  The Sponsor, or its designee, will be allowed to conduct clinical study center 
visits to the investigation facilities for the purpose of monitoring any aspect of the study.  The 
Investigator agrees to allow the monitor to inspect the drug storage area, study drug stocks, drug 
accountability records, patient charts and study source documents, and other records relative to 
study conduct. 
9.2.3. 
Audits and Inspections 
Periodically, the Sponsor or its authorized representatives audit clinical investigative study 
centers as an independent review of core trial processes and documents to determine whether 
these activities were conducted, and data were recorded, analyzed, and accurately reported 
according to the protocol, GCP guidelines of the ICH, and any applicable regulatory 
requirements.  A regulatory authority, an IEC or an IRB may visit the clinical study center to 
perform audits or inspections, including source data verification.  The Investigator should contact 
the Sponsor, or its designee, immediately if contacted by a regulatory agency about an 
inspection. 
9.3. 
Publication Policy 
It is intended that after completion of the study, the data are to be submitted for publication in a 
scientific journal and/or for reporting at a scientific meeting.  A copy of any proposed manuscript 
must be provided and confirmed received at the Sponsor at least 30 days before its submission, 
and according to any additional publication details in the Investigator Agreement.
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10. 
LIST OF REFERENCES 
1. Anderson KE, Bloomer JR, Bonkovsky HL, Kushner JP, Pierach CA, Pimstone NR, et al. 
Recommendations for the diagnosis and treatment of the acute porphyrias. Ann Intern Med. 2005 
Mar 15;142(6):439-50. 
2. Siegesmund M, van Tuyll van Serooskerken AM, Poblete-Gutierrez P, Frank J. The acute 
hepatic porphyrias: current status and future challenges. Best Pract Res Clin Gastroenterol. 2010 
Oct;24(5):593-605. 
3. Poblete-Gutierrez P, Wiederholt T, Merk HF, Frank J. The porphyrias: clinical presentation, 
diagnosis and treatment. Eur J Dermatol. 2006 May-Jun;16(3):230-40. 
4. Balwani M, Desnick RJ. The porphyrias: advances in diagnosis and treatment. Blood. 2012 
Nov 29;120(23):4496-504. 
5. Puy H, Gouya L, Deybach JC. Porphyrias. Lancet. 2010 Mar 13;375(9718):924-37. 
6. Floderus Y, Sardh E, Moller C, Andersson C, Rejkjaer L, Andersson DE, et al. Variations in 
porphobilinogen and 5-aminolevulinic acid concentrations in plasma and urine from 
asymptomatic carriers of the acute intermittent porphyria gene with increased porphyrin 
precursor excretion. Clin Chem. 2006 Apr;52(4):701-7. 
7. Anderson K. Disorders of heme biosynthesis. 8th ed. CR S, editor: McGraw-Hill, New York 
2001. 
8. Dowman JK, Gunson BK, Mirza DF, Bramhall SR, Badminton MN, Newsome PN. Liver 
transplantation for acute intermittent porphyria is complicated by a high rate of hepatic artery 
thrombosis. Liver Transpl. 2012 Feb;18(2):195-200. 
9. Badminton MN, Elder GH. Molecular mechanisms of dominant expression in porphyria. J 
Inherit Metab Dis. 2005;28(3):277-86. 
10. Deybach J-C, Puy H. 86 - Acute Intermittent Porphyria: From Clinical to Molecular Aspects. 
In: Guilard KMKMS, editor. The Porphyrin Handbook. Amsterdam: Academic Press; 2003. p. 
23-41. 
11. Bylesjo I, Wikberg A, Andersson C. Clinical aspects of acute intermittent porphyria in 
northern Sweden: a population-based study. Scand J Clin Lab Invest. 2009;69(5):612-8. 
12. James MF, Hift RJ. Porphyrias. Br J Anaesth. 2000 Jul;85(1):143-53. 
13. Chemmanur AT, Bonkovsky HL. Hepatic porphyrias: diagnosis and management. Clin Liver 
Dis. 2004 Nov;8(4):807-38, viii. 
14. Stein P, Badminton M, Barth J, Rees D, Stewart MF. Best practice guidelines on clinical 
management of acute attacks of porphyria and their complications. Ann Clin Biochem. 2013 
May;50(Pt 3):217-23. 
15. Bonkovsky HL. Neurovisceral porphyrias: what a hematologist needs to know. Hematology 
Am Soc Hematol Educ Program. 2005:24-30. 
16. Panhematin. (hemin for injection). 2013. 
17. Normosang. (human hemin). 2007. 
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18. Watson CJ, Pierach CA, Bossenmaier I, Cardinal R. Postulated deficiency of hepatic heme
and repair by hematin infusions in the "inducible" hepatic porphyrias. Proc Natl Acad Sci U S A. 
1977 May;74(5):2118-20. 
19. Mustajoki P, Nordmann Y. Early administration of heme arginate for acute porphyric attacks.
Arch Intern Med. 1993 Sep 13;153(17):2004-8. 
20. Bonkovsky HL, Singh RH, Jafri IH, Fiellin DA, Smith GS, Simon D, et al. A randomized,
controlled trial of treatment of alcoholic hepatitis with parenteral nutrition and oxandrolone. II. 
Short-term effects on nitrogen metabolism, metabolic balance, and nutrition. Am J Gastroenterol. 
1991 Sep;86(9):1209-18. 
21. Herrick AL, McColl KE, Moore MR, Cook A, Goldberg A. Controlled trial of haem arginate
in acute hepatic porphyria. Lancet. 1989 Jun 10;1(8650):1295-7. 
22. Bissell DM. Treatment of acute hepatic porphyria with hematin. J Hepatol. 1988 Feb;6(1):1-
7. 
23. Green D, Ts'ao CH. Hematin: effects on hemostasis. J Lab Clin Med. 1990 Feb;115(2):144-
7. 
24. Daimon M, Susa S, Igarashi M, Kato T, Kameda W. Administration of heme arginate, but
not hematin, caused anaphylactic shock. Am J Med. 2001 Feb 15;110(3):240. 
25. Elder G, Harper P, Badminton M, Sandberg S, Deybach JC. The incidence of inherited
porphyrias in Europe. J Inherit Metab Dis. 2013 Sep;36(5):849-57. 
26. Anderson K. Heme arginate for prevention of acute porphyric attacks (abstract). Acta
Haematologica. 1997;98((suppl 1):120). 
27. Bonkovsky HL, Guo JT, Hou W, Li T, Narang T, Thapar M. Porphyrin and heme
metabolism and the porphyrias. Compr Physiol. 2013 Jan;3(1):365-401. 
28. Vaishnaw AK, Gollob J, Gamba-Vitalo C, Hutabarat R, Sah D, Meyers R, et al. A status
report on RNAi therapeutics. Silence. 2010;1(1):14. 
29. Elbashir SM, Harborth J, Lendeckel W, Yalcin A, Weber K, Tuschl T. Duplexes of 21-
nucleotide RNAs mediate RNA interference in cultured mammalian cells. Nature. 2001 May 
24;411(6836):494-8. 
30. Kauppinen R, von und zu Fraunberg M. Molecular and biochemical studies of acute
intermittent porphyria in 196 patients and their families. Clin Chem. 2002 Nov;48(11):1891-900. 
31. Division of Clinical Pharmacology, Indiana University, P450 Drug Interaction Table.  2013 [
Accessed 06 February 2015]; Available from: http://medicine.iupui.edu/clinpharm/ddis/main-
table/. 
32. Atkinson TM M, TR, Sit L, Passik P, Scher, HI, Cleeland C, and Basch E. The Brief Pain
Inventory and its “Pain at its Worst in the last 24 Hours” Item: Clinical Trial Endpoint 
Considerations. Pain Med. 2010 March;11(3):337–46. 
33. Levey AS SL, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, Kusek JW, Eggers P,
Van Lente F, Greene T, Coresh J; CKD-EPI (Chronic Kidney Disease Epidemiology 
Collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med. 
2009;150(9):604-12. 
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34. Herdman M GC, Lloyd A, Janssen M, Kind P, Parkin D, Bonsel G, Badia X. Development 
and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res. 
2011;20(10):1727-36. 
 
 
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11. 
APPENDICES 
11.1. 
Pharmacokinetic Assessment Time Points 
Table 4 contains a detailed schedule for the collection of blood samples for PK analysis. 
Table 4: 
Pharmacokinetic Time Points 
Study Day 
Protocol Time 
(hh:mm) 
PK Blood 
Day 1 and 
Month 12 (D361) ±10 days 
Predose (within 60 minutes 
before dosing) 
X 
02:00 (±5 minutes) 
X 
06:00 (±20 minutes) 
X 
Month 1 (Day 14) ±2 days 
Anytime during visit 
X 
Month 1 (Day 31) ±7 days,a  
Month 3 (Day 91) ±7 days, 
Month 6 (Day 181) ±7 days, 
Month 18 (Day 541) ±10, and 
Month 24 (Day 721) ±10 days 
Predose (within 60 minutes 
before dosing) 
X 
02:00 (±5 minutes) 
X 
Abbreviations:  hh=hours; mm=minutes; PK=pharmacokinetic. 
a  At the Day 31 1 visit, if the dosing regimen is every 3 months, ALN-AS1 is not administered and a single 
time point blood sample for PK analysis should be collected. 
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11.2. 
Schedules of Assessments for Every Month Dosing Regimen 
 
 
Table 5: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14 ±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History/Disease 
Historyc 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/ 
Exclusion Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examinationd 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
 
 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
X 
Vital Signsf 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGg 
X 
X 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
Clinical Laboratory 
Assessmenth 
X 
 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationj 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
Blood and Urine Sample for 
 
X 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
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Table 5: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14 ±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Exploratory Biomarker 
Analysisl 
Blood Sample for PK 
Analysism 
 
X 
X 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
Antidrug Antibodiesn 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
Porphyria Attack Kit 
Dispensationo 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EQ-5D-5L Questionnairep 
X 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Diary Review (including 
BPI-SF)q 
 
 
X 
AEs 
 
Continuous 
Concomitant Medicationsr 
 
Continuous 
 
Abbreviations:  AE=adverse event; ALAS1=5-aminolevulinic acid synthase 1; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief 
Pain Inventory-Short Form; D=day; ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of life; 
SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may 
be conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical 
examinations and blood/urine sample collections. 
a Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study (ALN-AS1-001) were completed within 60 days 
of administration of the first dose of ALN-AS1 in this study.  If more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs 
will be repeated before administration of ALN-AS1.  Results should be available and deemed acceptable before the administration of the first dose of ALN-
AS1. 
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b After a patient has completed 6 months of ALN-AS1 administration in this study, and where applicable country and local regulations and infrastructure allow, 
study procedures, including ALN-AS1 administration, may take place at the patient’s home by a healthcare professional.  Study procedures may occur at the 
patient’s home at the discretion of the Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit at the clinical 
study center Q3M through M12, and thereafter Q6M. Additional visits to collect clinical laboratory samples may occur at home at any point during the 
treatment period, within 14 days prior to scheduled dose administration. 
c See Section 7.1 for details on the interval medical history/disease history to be recorded at Screening/Baseline.  Ongoing AEs from the previous study 
(ALN-AS1-001) will be captured as medical history. 
d A complete physical examination will be performed at Screening/Baseline, and D1.  At all other visits, a targeted physical examination will be performed.  On 
dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any time 
during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On D1, vital signs will be collected within 1 hour predose; and 2 hours 
(±10 minutes) postdose.  On all other dosing days, vital signs will be collected within 1 hour predose.  On days when ALN-AS1 is not administered, vital signs 
can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position (should be consistent for each patient), after the 
patient has rested comfortably for 10 minutes. 
g Triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 10 minutes.  On D1, ECGs will be 
performed within 1 hour predose and 2 hours (±10 minutes) postdose.  On all other dosing days, ECGs will be collected within 1 hour predose. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  On 
days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. On dosing days, results from hematology, chemistry 
(including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the Investigator before study drug administration.  If results 
from within the prior 14 days are not available at a dosing visit, locally analyzed predose assessments may be used for review in order to allow same day study 
drug administration, but additional samples for central analysis must also be collected. 
i A serum pregnancy test will be performed at Screening/Baseline; thereafter, urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  For weight-
based dosing, weight measured on the dosing day will be used to calculate the dose of ALN-AS1.  After M12, weight measured on the nearest previous visit 
will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o Porphyria attack laboratory sample collection kits should be dispensed at the screening visit along with instructions for use. For any attack that occurs through 
M39, urine samples should be collected within 24 hours of the start of clinical intervention (eg, hemin or glucose administration) and within 24 hours of the end 
of clinical intervention.  If patients are unable to report to the clinical study center during a porphyria attack, laboratory sample collection kits should be used 
for collecting and sending urine samples to the clinical study center, if possible.  These urine samples may also be analyzed for exploratory biomarkers. 
p In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but not more than once in a 6 month period), if possible.  
q Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, and narcotic use on a daily basis through M9; 
thereafter, acute porphyria attacks will be recorded in the diary.  The BPI will be completed on a weekly basis as part of the patient diary through M9, then 
Q3M. 
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r Medications that are ongoing from the previous study (ALN-AS1-001), started between the previous study and this study, and started after signing informed 
consent in this study, will be captured as concomitant medication(s). 
 
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Table 6: 
Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20a 
M21a 
M22/ 
M23a 
M24 
M25/ 
M26a 
M27a 
M28/ 
M29a 
M30 
M31/ 
M32a 
M33a 
M34/ 
M35a 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Physical Examinationd 
 
 
 
X 
 
 
 
X 
 
 
 
X 
X 
 
Body Weight, BMI, and 
Heighte 
 
 
 
X 
 
 
 
X 
 
 
 
 
X 
 
Vital Signsf 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Triplicate 12-Lead ECGg 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
 
Clinical Laboratory 
Assessmenth 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Study Drug Administrationj 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl  
 
 
 
X 
 
 
 
X 
 
 
 
X 
X 
 
Blood Sample for PK 
Analysism 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
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Table 6: 
Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20a 
M21a 
M22/ 
M23a 
M24 
M25/ 
M26a 
M27a 
M28/ 
M29a 
M30 
M31/ 
M32a 
M33a 
M34/ 
M35a 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Antidrug Antibodiesn 
 
 
 
X 
 
 
 
 
 
 
 
X 
 
 
EQ-5D-5L Questionnaireo 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
Diary Review (including 
BPI-SF)p 
X 
 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; EOS = End of Study; EOT = End of Treatment; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality 
of life; SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
a Where applicable country and local regulations and infrastructure allow, study procedures, including ALN-AS1 administration,  may take place at the patient’s 
home by a healthcare professional.  Study procedures may occur at the patient’s home at the discretion of the Investigator, based on safety and tolerability; 
however, patients are required to complete at least 1 visit at the clinical study center Q6M. Additional visits to collect clinical laboratory samples may occur at 
home at any point during the treatment period, within 14 days prior to scheduled dose administration. 
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b Patients who discontinue treatment will be asked to complete the M39 visit assessments.  If a patient chooses to withdraw from the study, every effort should 
be made to conduct early the assessments performed at the M39 visit.  See Section 5.3 for details on removal from treatment or assessment. 
c The ALA/PBG Monitoring/EOS visit will be conducted at the clinical study center or via phone contact, unless treatment continues with ALN-AS1.  Patients 
will be provided with laboratory sample collection kits and instructions for collecting and sending urine samples to the clinical study center.  Urine samples 
should not be collected during a porphyria attack. 
d A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed.  
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On a dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for 10 minutes. 
g Triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 10 minutes.  On dosing days, ECGs will 
be collected within 1 hour predose. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected predose.  On 
days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. On dosing days, results from hematology, chemistry 
(including LFTs), and coagulation tests collected within the prior 14 days must be reviewed by the Investigator before study drug administration.  If results 
from within the prior 14 days are not available at a dosing visit, locally analyzed predose assessments may be used for review in order to allow same day study 
drug administration, but additional samples for central analysis must also be collected. 
i Urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured on the nearest previous visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 4 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but, not more than once in a 6 month period), if possible.  
p Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
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11.3. 
List of Sensitive CYP3A Substrates and those with a Narrow 
Therapeutic Range 
A list of medications that are sensitive CYP3A substrates and those with a narrow therapeutic 
range is in Table 7.  
Table 7: 
List of Sensitive CYP3A Substrates and those with a Narrow Therapeutic 
Range 
Sensitive CYP3A Substrates 
 
CYP3A Substrates With A Narrow 
Therapeutic Range 
alfentanil 
fluticasone 
 
Alfentanil 
aprepitant 
lopinavir 
 
Astemizole 
budesonide 
lovastatin 
 
Cisapride 
buspirone 
lurasidone 
 
Cyclosporine 
conivaptan 
maraviroc 
 
Diergotamine 
darifenacin 
midazolam 
 
Dihydroergotamine 
darunavir 
nisoldipine 
 
Ergotamine 
dasatinib 
quetiapine 
 
Fentanyl 
dronedarone 
saquinavir 
 
Irinotecan 
eletriptan 
sildenafil 
 
Pimozide 
eplerenone 
simvastatin 
 
Quinidine 
everolimus 
sirolimus 
 
Sirolimus 
felodipine 
tolvaptan 
 
Tacrolimus 
imatinib 
tipranavir 
 
Terfenadine 
indinavir 
triazolam 
 
 
 
vardenafil 
 
 
Note:  This is not an exhaustive list and availability of medications may differ between countries.  For more 
information about clinically relevant drugs that are CYP3A substrates, see the Indiana University Division of 
Pharmacology website for reference: http://medicine.iupui.edu/clinpharm/ddis/clinical-table/. 
 
 
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Amendment 3 Summary of Changes_03 February 2017 
 
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ALN-AS1-002 Protocol Amendment 3 
Summary of Changes (dated 03 February 2017)  
compared to Protocol Amendment 2 (dated 01 December 2016) 
A Multicenter, Open-label Extension Study to Evaluate the Long-term Safety and Clinical 
Activity of Subcutaneously Administered ALN AS1 in Patients with Acute Intermittent 
Porphyria who have Completed a Previous Clinical Study with ALN-AS1 
 
Rationale for Protocol Amendment 
The purpose of this amendment is to update the risk-benefit assessment of the study protocol to 
align with the current Investigator's Brochure, to add regular monitoring of prothrombin time 
(PT), International Normalized Ratio (INR), and c-reactive protein (CRP), and to clarify the 
timing of the review of clinical laboratory assessments prior to scheduled dosing. 
This amendment includes the following changes: 
 Updated dose rationale and risk-benefit sections to align with current IB including 
preliminary clinical results from Part C of Study ALN-AS1-001 and nonclinical findings 
from the rat and NHP chronic toxicology studies  
 Added assessments of PT, INR and CRP to regularly scheduled clinical laboratory draws 
 Clarified that hematology, chemistry (including LFTs), and coagulation results must be 
reviewed prior to each dose, and that the interval between the blood sample collection 
and dosing should not exceed 14 days 
A detailed summary of the changes is provided in Table 1.  Corrections to typographical errors 
and formatting are not detailed. 
 
 
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Table 1: 
Protocol Amendment 3 Detailed Summary of Changes 
The primary section(s) of the protocol affected by the changes in the protocol amendment are indicated.  The corresponding text has 
been revised throughout the protocol.  Deleted text is indicated by strikeout; added text is indicated by bold font. 
Purpose: To update the benefit-risk assessment with recent nonclinical and clinical data  
The primary change occurs in Section 1.7 Benefit-Risk Assessment 
Added text: 
Patients participating in this study may experience a reduced number or severity of porphyria attacks, reduced 
treatment with IV hemin, and/or reduced requirement for pain medication.  As presented in Section 1.6, emerging 
data demonstrate that patients given ALN-AS1 experienced reduced ALA/PBG levels, decreased attack 
frequency and reduced heme usage in the 24-week treatment period compared to the 12-week run-in period 
in Study ALN-AS1-001 
As detailed in Section 1.6, a fatal SAE of hemorrhagic pancreatitis was reported but deemed to be unlikely 
related to study drug.  However, the potentially non-adverse nonclinical findings of angiectasis in the islets 
of Langerhans (endocrine, not exocrine region) of the rat pancreas (see Investigator’s Brochure), do not 
exclude a potential association between ALN-AS1 and the SAE of hemorrhagic pancreatitis. 
Purpose: To clarifiy procedures on predose clinical laboratory review 
The primary change occurs in Section 7.5.5 Clinical Laboratory Assessments 
Now reads: 
ResultsOn dosing days, results from clinical laboratoryhematology, chemistry, and coagulation tests collected 
on dosing days are not required before study drug administration; however if results for clinical laboratory tests 
from within the previous study visit are not available or are deemed clinically significant, then clinical laboratory 
assessments prior 14 days must be repeated and the results must be deemed acceptable reviewed by the 
Investigator before study drug administration. These results can be analyzed centrally or at a local laboratory.  
If results from within the prior 14 days are not available at a dosing visit, locally analyzed assessments may 
be reviewed to allow same day study drug administration, but additional samples for central analysis must 
also be collected. 
Section(s) also containing this change or similar changes: 
 
Table 1 Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen), footnote h 
 
Table 2 Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen), footnote h 
 
Table 5 Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen), footnote h 
 
Table 6 Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen), footnote h 
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Purpose: To add summary of ALN-AS1 clinical data to align with current version of the Investigator’s Brochure  
The primary change occurs in Section 1.6 Clinical Data Summary 
Added text:  
Section 1.6 has been added, which summarizes the results to date on the safety, pharmacodynamics, and clinical 
activity of ALN-AS1. 
Purpose: To clarify the details for visits taking place at a patient’s home  
The primary change occurs in Section 4.1 Summary of Study Design 
Now reads:  
After a patient has completed 12 months of ALN-AS1 administration in this study (6 months in an every month 
dosing regimen), and where applicable country and local regulations and infrastructure allow, study visits and 
procedures, including ALN-AS1 administration, may take place at the patient’s home by a healthcare professional 
(as indicated in the Schedules of Assessments in Table 1 and Table 2; and Table 5 and Table 6 in Appendix 
Section 11.2).  Home visitsStudy procedures may occur at the patient’s home at the discretion of the 
Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit at the 
clinical study center every 3 months for the first year, and thereafter every 6 months through the end of the 
treatment period.  Additional visits to collect clinical laboratory samples may occur at home at any point 
during the treatment period, within 14 days prior to scheduled dose administration. 
Section(s) also containing this change or similar changes: 
 
Synopsis, Study Design 
 
Table 1 Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen), footnote b 
 
Table 2 Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen), footnote a 
 
Section 6.2.2 Dose and Administration 
 
Table 5 Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen), footnote b 
 
Table 6 Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen), footnote a 
Purpose: To add serum chemistry and coagulation changes as a potential risk in the benefit-risk analysis  
The primary change occurs in Section 1.7 Benefit-Risk Assessment 
Added text: 
 
Serum chemistry and coagulation changes: Since an association between ALN-AS1 and the fatal SAE 
of hemorrhagic pancreatitis, complicated by a pulmonary embolism, can not be ruled out, patients will 
undergo routine monitoring of systemic and pancreatic inflammation and coagulation throughout the 
study.  Hematology, chemistry and coagulation results are required to be available prior to each dose. 
Purpose: To expand clinical laboratory assessment to include coagulation tests and c-reactive protein evaluation 
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The primary change occurs in Section 7.5.5 Clinical Laboratory Assessments 
Added text: 
Added rows to the clinical laboratory assessment table for coagulation tests (prothrombin time and International 
Normalized Ratio), and inflammation (c-reactive protein). 
Purpose: To add GGT to the battery of liver function tests, per clarification letter dated 01 December 2016. 
The primary change occurs in Section 7.5.5 Clinical Laboratory Assessments 
Added text: 
Added row to the clinical laboratory assessment table for gamma-glutamyltransferase (GGT) 
 
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CLINICAL STUDY PROTOCOL 
ALN-AS1-002 
Protocol Title: 
A Multicenter, Open-label Extension Study to Evaluate the Long-term 
Safety and Clinical Activity of Subcutaneously Administered 
ALN-AS1 in Patients with Acute Intermittent Porphyria who have 
Completed a Previous Clinical Study with ALN-AS1 
Investigational Drug: 
ALN-AS1 
EudraCT Number: 
2016-002638-54 
IND Number: 
126094 
Protocol Date: 
Original Protocol 19 July 2016 
Protocol Amendment 0.1 (Sweden) 20 September 2016 
Protocol Amendment 1 10 November 2016 
Protocol Amendment 2 01 December 2016 
Sponsor: 
Alnylam Pharmaceuticals, Inc. 
300 Third Street 
Cambridge, MA  02142 USA 
Telephone:  
 
Sponsor Contact:  
 
The concepts and information contained in this document or generated during the study are considered 
proprietary and may not be disclosed in whole or in part without expressed written authorization of 
Alnylam Pharmaceuticals, Inc. 
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Amendment 2 01 December 2016 
SPONSOR PROTOCOL APPROVAL 
I have read this protocol and I approve the design of this study. 
Date 
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PPD

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Amendment 2_01 December 2016 
 
INVESTIGATOR’S AGREEMENT 
 
I have read the ALN-AS1-002 protocol and agree to conduct the study as outlined.  I agree to 
maintain the confidentiality of all information received or developed in connection with this 
protocol. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Printed Name of Investigator 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signature of Investigator 
 
 
 
 
 
 
 
 
Date 
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Amendment 2_01 December 2016 
PROTOCOL SYNOPSIS 
Protocol Title 
A Multicenter, Open-label Extension Study to Evaluate the Long-term Safety and Clinical Activity of 
Subcutaneously Administered ALN-AS1 in Patients with Acute Intermittent Porphyria who have 
Completed a Previous Clinical Study with ALN-AS1 
Product Name 
ALN-AS1 
Indication 
Patients with acute intermittent porphyria (AIP) who experience recurrent porphyria attacks 
Phase 
1/2 
Study center(s)   
The study will be conducted at up to 8 clinical study centers worldwide. 
Objectives 
Primary 
•
Evaluate the long-term safety and tolerability of ALN-AS1 in patients with AIP
Secondary 
•
Assess the pharmacodynamic (PD) effect of ALN-AS1 over time
•
Assess the clinical activity of ALN-AS1 over time
Exploratory 
•
Characterize the pharmacokinetic (PK) profile of ALN-AS1 over time
•
Assess changes in health-related quality of life (QOL)
•
Characterize analytes related to targeting the heme biosynthesis pathway
Endpoints 
Primary 
•
Patient incidence of adverse events (AEs)
Secondary 
•
Change in urine delta-aminolevulinic acid (ALA) and porphobilinogen (PBG) levels
•
Frequency and characteristics of porphyria attacks
•
Change in hemin administration
Exploratory 
•
Change in circulating 5-aminolevulinic acid synthase 1 (ALAS1) mRNA levels
•
Concentrations of ALN-AS1 and antidrug antibodies
•
Duration and treatment of porphyria attacks
•
Number and duration of visits to a health care facility for acute porphyria care
•
EQ-5D-5L questionnaire scores
•
Pain assessment and narcotic use as recorded in a patient diary
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• 
Exploratory biomarkers related to the target pathway, such as urine porphyrins, vitamin D binding 
protein 
Study Design 
This is a multicenter, open-label extension study to evaluate the long-term safety and clinical activity 
of ALN-AS1 in patients with AIP who completed study ALN-AS1-001. 
The last assessments performed, determining previous study (ALN-AS1-001) completion, will serve as 
the Screening/Baseline assessments in this study.  If more than 60 days have elapsed since the last 
assessment, safety assessments will be repeated before administration of ALN-AS1.  It is anticipated 
that patients will begin ALN-AS1 administration in this study within 6 months after the last dose of 
study drug in the previous study.  Eligibility will be confirmed before administration of the first dose of 
ALN-AS1 (Day 1).  Patients will undergo assessments at the clinical study center every month for the 
first 3 months.  Then, through Month 6, and according to the dosing regimen selected, assessments will 
take place at the clinical study center or via a phone contact (for an every month dosing regimen, visits 
will be every month; for an every 3 months dosing regimen, visits will be every 3 months).  After a 
patient has completed 6 months of ALN-AS1 administration in this study  (6 months in an every month 
dosing regimen), and where applicable country and local regulations and infrastructure allow, study 
visits and ALN-AS1 administration may take place at the patient’s home by a healthcare professional.  
Home visits may occur at the discretion of the Investigator, based on safety and tolerability; however, 
patients are required to complete at least 1 visit at the clinical study center every 3 months for the first 
year, and thereafter every 6 months through the end of the treatment period.  Patients will return to the 
clinical study center for a posttreatment follow-up visit after administration of the last dose of 
ALN-AS1.  An ALA/PBG Monitoring/EOS visit will be conducted either at the clinical study center or 
via phone contact, unless treatment continues with ALN-AS1. 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, 
and narcotic use.  Patients will also be provided with laboratory sample collection kits and instructions 
for collecting and sending urine samples to the clinical study center. 
A Safety Review Committee (SRC) will review safety and tolerability data collected during the study 
with the primary purpose of protecting the safety of patients participating in the study. 
Number of Planned Patients 
Up to 24 patients are planned for enrollment in this study (including optional cohorts in 
ALN-AS1-001). 
Diagnosis and Main Eligibility Criteria 
Patients with AIP, who have completed Part C of study ALN-AS1-001, will be eligible for screening in 
this study.  Eligible patients will not be on a scheduled regimen of hemin to prevent porphyria attacks 
at Screening.  Patients with alanine transaminase ≥2.0× upper limit of normal, total bilirubin ≥2 mg/dL 
(unless bilirubin elevation is due to Gilbert’s syndrome), or estimated glomerular filtration rate 
≤30 mL/min/1.73 m2 (using the Modification of Diet in Renal Disease formula) at Screening are not 
eligible for this study. 
Investigational Product, Dose, and Mode of Administration 
ALN-AS1 Solution for Injection (subcutaneous use [SC]) is comprised of a synthetic, small interfering 
RNA targeting ALAS1 and bearing a triantennary N-acetyl galactosamine ligand conjugated to the 
sense strand, formulated in phosphate buffer.   
The study starting dose and regimen of ALN-AS1 is 5.0 mg/kg as an SC injection administered every 
3 months.  Based on emerging clinical data, the SRC may approve changes to the dosing regimen, 
including decreases in the dose level and changes in the dosing frequency.  However any dose and 
dosing regimen will not exceed a previously explored dose level or frequency that was determined to 
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be safe and well-tolerated in study ALN-AS1-001, SRC, Health Authority and Ethics Committee 
approval must be sought prior to dose escalation above 5.0 mg/kg in accordance with local Regulatory 
requirements.  
Reference Therapy, Dose, and Mode of Administration 
Not applicable 
Duration of Treatment and Study 
The duration of treatment is up to 36 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 44 months. 
Statistical Methods 
Statistical analyses will be primarily descriptive.  Incidence of AEs will be summarized by maximum 
severity and relationship to ALN-AS1.  Incidence of and serious adverse events (SAEs) and AEs 
leading to discontinuation will also be tabulated.  By-patient listings will be provided for deaths, SAEs, 
and events leading to discontinuation.  
Laboratory shift tables from baseline to worst values will be presented.  Abnormal physical 
examination findings and electrocardiogram data will be presented in by-patient listings.  Descriptive 
statistics will be provided for electrocardiogram interval data and presented as both actual values and 
changes from baseline relative to each on study evaluation and to the last evaluation on-study. 
Clinical activity of ALN-AS1 will be summarized primarily by descriptive statistics.  The clinical 
activity of ALN-AS1 will be evaluated by the frequency and characteristics of porphyria attacks 
including duration, treatment, and severity of porphyria attacks and number and duration of visits to a 
health care setting for acute porphyria care.  Patient diary recordings, including BPI-SF questionnaire 
scores, will also be summarized.   
PD analysis will include the evaluation of change in ALA, PBG, and ALAS mRNA levels.  Descriptive 
statistics (eg, mean and standard error of the mean) for observed levels of PD parameters and the 
relative change from baseline will be presented for each of the postdose follow-up time points. 
The PK concentration of ALN-AS1 will be determined.  Antidrug antibody results will be tabulated 
overall and by previous treatment in the previous study (ALN-AS1-001).  A by-patient listing will also 
be provided. 
Additional exploratory analyses may be conducted on analytes related to targeting the heme 
biosynthesis pathway.  Quality of life scores will also be summarized. 
 
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Clinical Study Protocol ALN-AS1-002 
Amendment 2_01 December 2016 
 
Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8 
M9 
M10/ 
M11 
M12 
M13/ 
M14 
M15b 
M16/ 
M17 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History/Disease 
Historyc 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/ 
Exclusion Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examinationd 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
 
 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
Vital Signsf 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Triplicate 12-Lead ECGg 
X 
X 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
Clinical Laboratory 
Assessmenth 
X 
 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Study Drug Administrationj 
 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl 
 
X 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Blood Sample for PK 
 
X 
X 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
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Clinical Study Protocol ALN-AS1-002 
Amendment 2_01 December 2016 
 
Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8 
M9 
M10/ 
M11 
M12 
M13/ 
M14 
M15b 
M16/ 
M17 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Analysism 
Antidrug Antibodiesn 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
Porphyria Attack Kit 
Dispensationo 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EQ-5D-5L Questionnairep 
X 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Diary Review (including 
BPI-SF)q 
 
 
X 
Phone Contactr 
 
 
 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
AEs 
 
Continuous 
Concomitant Medicationss 
 
Continuous 
 
Abbreviations:  AE=adverse event; ALAS1=5-aminolevulinic acid synthase 1; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief 
Pain Inventory-Short Form; D=day; ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of life; 
SC=subcutaneous. 
Notes:   
• 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may 
be conducted while the patient is at home. 
• 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical 
examinations and blood/urine sample collections. 
a Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study (ALN-AS1-001) were completed within 60 days 
of administration of the first dose of ALN-AS1 in this study.  If more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs 
will be repeated before administration of ALN-AS1.  Results should be available and deemed acceptable before the administration of the first dose of ALN-
AS1. 
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b After a patient has completed 12 months of ALN-AS1 administration in this study, and where applicable country and local regulations and infrastructure allow, 
study visits and ALN-AS1 administration may take place at the patient’s home by a healthcare professional.  Home visits may occur at the discretion of the 
Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit at the clinical study center Q6M. 
c See Section 7.1 for details on the interval medical history/disease history to be recorded at Screening/Baseline.  Ongoing AEs from the previous study 
(ALN-AS1-001) will be captured as medical history. 
d A complete physical examination will be performed at Screening/Baseline, and D1.  At all other visits, a targeted physical examination will be performed.  On 
dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any time 
during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On D1, vital signs will be collected within 1 hour predose; and 2 hours 
(±10 minutes) postdose.  On all other dosing days, vital signs will be collected within 1 hour predose.  On days when ALN-AS1 is not administered, vital signs 
can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position (should be consistent for each patient), after the 
patient has rested comfortably for 10 minutes. 
g Triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 10 minutes.  On D1, ECGs will be 
performed within 1 hour predose and 2 hours (±10 minutes) postdose.  On all other dosing days, ECGs will be collected within 1 hour predose. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected within 1 hour 
predose.  Results from clinical laboratory tests collected on dosing days are not required before study drug administration; however, if results for clinical 
laboratory tests from the previous study visit are not available or are deemed clinically significant, then clinical laboratory assessments must be repeated and 
the results must be deemed acceptable by the Investigator before study drug administration.  On days when ALN-AS1 is not administered, blood samples can 
be collected at any time during the visit. 
i A serum pregnancy test will be performed at Screening/Baseline; thereafter, urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  For 
weight-based dosing, weight measured on the dosing day will be used to calculate the dose of ALN-AS1.  After M12, weight measured on the nearest previous 
visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 3 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o Porphyria attack laboratory sample collection kits should be dispensed at the screening visit along with instructions for use. For any attack that occurs through 
M39, urine samples should be collected within 24 hours of the start of clinical intervention (eg, hemin or glucose administration) and within 24 hours of the end 
of clinical intervention.  If patients are unable to report to the clinical study center during a porphyria attack, laboratory sample collection kits will be provided 
that contain instructions for collecting and sending urine samples to the clinical study center, if possible.  These urine samples may also be analyzed for 
exploratory biomarkers. 
p In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but not more than once in a 6 month period), if possible.  
q Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, and narcotic use on a daily basis through M9; 
thereafter, acute porphyria attacks will be recorded in the diary.  The BPI will be completed on a weekly basis as part of the patient diary through M9, then 
Q3M. 
r Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack. 
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s Medications that are ongoing from the previous study (ALN-AS1-001), started between the previous study and this study, and started after signing informed 
consent in this study, will be captured as concomitant medication(s). 
 
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ALN-AS1  
 
Clinical Study Protocol ALN-AS1-002 
Amendment 2_01 December 2016 
 
Table 2: 
Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20 
M21a 
M22/ 
M23 
M24 
M25/ 
M26 
M27a 
M28/ 
M29 
M30 
M31/ 
M32 
M33a 
M34/ 
M35 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Physical Examinationd 
 
 
 
X 
 
 
 
X 
 
 
 
X 
X 
 
Body Weight, BMI, and 
Heighte 
 
 
 
X 
 
 
 
X 
 
 
 
 
X 
 
Vital Signsf 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
 
Triplicate 12-Lead ECGg 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
 
Clinical Laboratory 
Assessmenth 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
 
Pregnancy Testi 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
 
Study Drug Administrationj 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl 
 
 
 
X 
 
 
 
X 
 
 
 
X 
X 
 
Blood Sample for PK 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
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ALN-AS1  
 
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Table 2: 
Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20 
M21a 
M22/ 
M23 
M24 
M25/ 
M26 
M27a 
M28/ 
M29 
M30 
M31/ 
M32 
M33a 
M34/ 
M35 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Analysism 
Antidrug Antibodiesn 
 
 
 
X 
 
 
 
 
 
 
 
X 
 
 
EQ-5D-5L Questionnaireo 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
Diary Review (including 
BPI-SF)p 
X 
 
Phone Contactq 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
X 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; EOS = End of Study; EOT = End of Treatment; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality 
of life; SC=subcutaneous. 
Notes:   
• 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
• 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
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ALN-AS1  
 
Clinical Study Protocol ALN-AS1-002 
Amendment 2_01 December 2016 
a Where applicable country and local regulations and infrastructure allow, study visits and ALN-AS1 administration may take place at the patient’s home by a 
healthcare professional.  Home visits may occur at the discretion of the Investigator, based on safety and tolerability; however, patients are required to complete 
at least 1 visit at the clinical study center Q6M. 
b Patients who discontinue treatment will be asked to complete the M39 visit assessments.  If a patient chooses to withdraw from the study, every effort should 
be made to conduct early the assessments performed at the M39 visit.  See Section 5.3 for details on removal from treatment or assessment. 
c The ALA/PBG Monitoring/EOS visit will be conducted at the clinical study center or via phone contact, unless treatment continues with ALN-AS1.  Patients 
will be provided with laboratory sample collection kits and instructions for collecting and sending urine samples to the clinical study center. 
d A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed.  
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On a dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for 10 minutes. 
g Triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 10 minutes.  On dosing days, ECGs will 
be collected within 1 hour predose. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected within 1 hour 
predose.  Results from clinical laboratory tests collected on dosing days are not required before study drug administration; however, if results for clinical 
laboratory tests from the previous study visit are not available or are deemed clinically significant, then clinical laboratory assessments must be repeated and 
the results must be deemed acceptable by the Investigator before study drug administration.  On days when ALN-AS1 is not administered, blood samples can 
be collected at any time during the visit. 
i Urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured on the nearest previous visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 3 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but, not more than once in a 6 month period), if possible.  
p Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
q Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack.
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ALN-AS1 
 
 Clinical Study Protocol ALN-AS1-002 
Amendment 2_01 December 2016 
TABLE OF CONTENTS 
PROTOCOL SYNOPSIS ................................................................................................................4 
TABLE OF CONTENTS ...............................................................................................................14 
LIST OF TABLES .........................................................................................................................17 
LIST OF FIGURES .......................................................................................................................17 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS ................................................18 
1. 
INTRODUCTION ......................................................................................................20 
1.1. 
Disease Overview .......................................................................................................20 
1.1.1. 
Epidemiology ..............................................................................................................20 
1.1.2. 
Current Management and Unmet Medical Need ........................................................21 
1.2. 
RNA Interference ........................................................................................................22 
1.3. 
ALN-AS1 ....................................................................................................................22 
1.4. 
Study Design Rationale ..............................................................................................22 
1.5. 
Dose Rationale ............................................................................................................22 
1.6. 
Benefit-Risk Assessment ............................................................................................23 
2. 
OBJECTIVES .............................................................................................................24 
2.1. 
Primary Objective .......................................................................................................24 
2.2. 
Secondary Objectives .................................................................................................24 
2.3. 
Exploratory Objectives ...............................................................................................24 
3. 
ENDPOINTS ..............................................................................................................25 
3.1. 
Primary Endpoint ........................................................................................................25 
3.2. 
Secondary Endpoints ..................................................................................................25 
3.3. 
Exploratory Endpoints ................................................................................................25 
4. 
INVESTIGATIONAL PLAN .....................................................................................25 
4.1. 
Summary of Study Design ..........................................................................................25 
4.2. 
Duration of Treatment and Study ...............................................................................26 
4.3. 
Number of Patients .....................................................................................................26 
4.4. 
Method of Assigning Patients to Treatment Groups ..................................................27 
4.5. 
Blinding ......................................................................................................................27 
4.6. 
Safety Review Committee ..........................................................................................27 
5. 
SELECTION AND WITHDRAWAL OF PATIENTS ..............................................27 
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5.1. 
Inclusion Criteria ........................................................................................................27 
5.2. 
Exclusion Criteria .......................................................................................................28 
5.3. 
Removal from Treatment or Assessment ...................................................................28 
5.3.1. 
Discontinuation of Study Drug ...................................................................................28 
5.3.2. 
Withdrawal from Study ..............................................................................................28 
5.3.3. 
Replacement of Patients .............................................................................................29 
6. 
TREATMENTS ..........................................................................................................29 
6.1. 
Treatments Administered ............................................................................................29 
6.2. 
Investigational Study Drug .........................................................................................29 
6.2.1. 
Description ..................................................................................................................29 
6.2.2. 
Dose and Administration ............................................................................................29 
6.2.3. 
Dose Modifications .....................................................................................................30 
6.2.3.1. 
Study Population Dose Modifications ........................................................................30 
6.2.3.2. 
Individual Dose Modifications ...................................................................................30 
6.2.4. 
Preparation, Handling, and Storage ............................................................................30 
6.2.5. 
Packaging and Labeling ..............................................................................................31 
6.2.6. 
Accountability .............................................................................................................31 
6.3. 
Concomitant Medications ...........................................................................................31 
6.4. 
Contraceptive Requirements .......................................................................................32 
6.5. 
Treatment Compliance ................................................................................................32 
7. 
STUDY ASSESSMENTS ..........................................................................................33 
7.1. 
Screening/Baseline Assessments ................................................................................33 
7.2. 
Clinical Activity Assessments ....................................................................................33 
7.2.1. 
Patient Diary ...............................................................................................................33 
7.2.2. 
Brief Pain Inventory-Short Form Questionnaire ........................................................33 
7.3. 
Pharmacodynamic Assessments .................................................................................33 
7.4. 
Pharmacokinetic Assessments ....................................................................................33 
7.5. 
Safety Assessments .....................................................................................................34 
7.5.1. 
Vital Signs ..................................................................................................................34 
7.5.2. 
Weight and Height ......................................................................................................34 
7.5.3. 
Physical Examination .................................................................................................34 
7.5.4. 
Electrocardiogram .......................................................................................................34 
7.5.5. 
Clinical Laboratory Assessments ...............................................................................35 
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 Clinical Study Protocol ALN-AS1-002 
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7.5.5.1. 
Immunogenicity ..........................................................................................................36 
7.5.5.2. 
Pregnancy Testing ......................................................................................................37 
7.5.6. 
Adverse Events ...........................................................................................................37 
7.5.6.1. 
Definitions ..................................................................................................................37 
7.5.6.2. 
Eliciting and Recording Adverse Events ....................................................................39 
7.5.6.3. 
Serious Adverse Events Require Immediate Reporting to Sponsor/Designee ...........40 
7.5.6.4. 
Sponsor Safety Reporting to Regulatory Authorities .................................................40 
7.5.6.5. 
Serious Adverse Event Notification to the Institutional Review 
Board/Independent Ethics Committee ........................................................................41 
7.5.6.6. 
Pregnancy Reporting ..................................................................................................41 
7.5.6.7. 
Overdose Reporting ....................................................................................................41 
7.6. 
Exploratory Assessments ............................................................................................42 
7.7. 
Other Assessments ......................................................................................................42 
7.7.1. 
EQ-5D-5L Questionnaire ............................................................................................42 
8. 
STATISTICS ..............................................................................................................42 
8.1. 
Determination of Sample Size ....................................................................................42 
8.2. 
Statistical Methodology ..............................................................................................42 
8.2.1. 
Populations to be Analyzed ........................................................................................43 
8.2.2. 
Examination of Subgroups .........................................................................................43 
8.2.3. 
Handling of Missing Data ...........................................................................................43 
8.2.4. 
Baseline Evaluations ...................................................................................................43 
8.2.5. 
Clinical Activity Analyses ..........................................................................................43 
8.2.6. 
Pharmacodynamic Analysis........................................................................................43 
8.2.7. 
Pharmacokinetic Analysis ..........................................................................................44 
8.2.8. 
Safety Analyses ..........................................................................................................44 
8.2.9. 
Other Analyses ............................................................................................................44 
9. 
STUDY ADMINISTRATION ...................................................................................44 
9.1. 
Ethical and Regulatory Considerations ......................................................................44 
9.1.1. 
Informed Consent .......................................................................................................45 
9.1.2. 
Ethical Review ............................................................................................................45 
9.1.3. 
Study Documentation, Confidentiality, and Records Retention .................................45 
9.1.4. 
End of the Study .........................................................................................................46 
9.1.5. 
Discontinuation of the Clinical Study.........................................................................46 
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 Clinical Study Protocol ALN-AS1-002 
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9.2. 
Data Quality Control and Quality Assurance .............................................................46 
9.2.1. 
Data Handling .............................................................................................................46 
9.2.2. 
Study Monitoring ........................................................................................................46 
9.2.3. 
Audits and Inspections ................................................................................................47 
9.3. 
Publication Policy .......................................................................................................47 
10.
LIST OF REFERENCES ............................................................................................48
11.
APPENDICES ............................................................................................................51
11.1. 
Pharmacokinetic Assessment Time Points .................................................................51 
11.2. 
Schedules of Assessments for Every Month Dosing Regimen ..................................52 
11.3. 
List of Sensitive CYP3A Substrates and those with a Narrow Therapeutic 
Range ..........................................................................................................................58 
LIST OF TABLES 
Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 
Months Dosing Regimen) .............................................................................................7 
Table 2: 
Schedule of Assessments:  Month 19 through End of Study (Every 3 Months 
Dosing Regimen) ........................................................................................................11 
Table 3: 
Pharmacokinetic Time Points .....................................................................................51 
Table 4: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 
Month Dosing Regimen) ............................................................................................52 
Table 5: 
Schedule of Assessments:  Month 19 through End of Study (Every Month 
Dosing Regimen) ........................................................................................................55 
Table 6: 
List of Sensitive CYP3A Substrates and those with a Narrow Therapeutic 
Range ..........................................................................................................................58 
LIST OF FIGURES 
Figure 1: 
Study Design ...............................................................................................................26 
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 Clinical Study Protocol ALN-AS1-002 
Amendment 2_01 December 2016 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
Abbreviation 
Definition 
AE 
Adverse event 
AHP 
Acute hepatic porphyria 
AIP 
Acute intermittent porphyria 
ALA 
Delta-aminolevulinic acid 
ALAS1 
5-aminolevulinic acid synthase 1 
ALP 
Alkaline phosphatase 
ASGPR 
Asialoglycoprotein receptor 
ASHE 
Asymptomatic high excreters 
BPI-SF 
Brief Pain Inventory-Short Form 
cERD 
Circulating extracellular RNA detection assay 
CRF 
Case report form 
CYP 
Cytochrome P450 
ECG 
Electrocardiogram 
eCRF 
Electronic case report form 
eGFR 
Estimated Glomerular Filtration Rate 
EDC 
Electronic data capture 
EOS 
End of study 
EU 
European Union 
GalNAc 
N-acetyl galactosamine 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practice 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
IEC 
Independent Ethics Committee 
IRB 
Institutional Review Board 
ISR 
Injection site reaction 
IV 
Intravenous 
LFT 
Liver function test 
mRNA 
Messenger RNA 
NHP 
Nonhuman primate 
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Abbreviation 
Definition 
NOAEL 
No observed adverse effect level 
NOEL 
No observed effect level 
OTC 
Over the counter 
PBG 
Porphobilinogen 
PBGD 
Porphobilinogen deaminase 
PD 
Pharmacodynamic(s) 
PK 
Pharmacokinetic(s) 
QOL 
Quality of life 
RNA 
Ribonucleic acid 
RNAi 
RNA interference 
SAE 
Serious adverse event 
SAP 
Statistical Analysis Plan 
SC 
Subcutaneous 
siRNA 
Small interfering RNA 
SRC 
Safety Review Committee 
SUSAR 
Suspected unexpected serious adverse reaction 
ULN 
Upper limit of normal 
US 
United States 
WOCBP 
Woman of child-bearing potential 
 
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1. 
INTRODUCTION 
1.1. 
Disease Overview 
The porphyrias are a family of rare metabolic disorders predominately caused by a genetic 
mutation in 1 of the 8 enzymes responsible for heme synthesis.[1]  The 2 major categories are 
erythropoietic and hepatic, depending on the major site of expression of the underlying enzyme 
deficiency.[2]  In addition, the porphyrias are classified as acute if patients present with 
neurovisceral symptoms (eg, abdominal pain and neurologic symptoms) or cutaneous if they 
present with dermal blistering or photosensitivity.[3, 4]   
This study will include patients with acute intermittent porphyria (AIP), the most common acute 
hepatic porphyria (AHP).  AIP occurs as a result of an autosomal dominant mutation leading to 
partial deficiency of porphobilinogen deaminase (PBGD), the third enzyme in the heme 
biosynthesis pathway.[5]  The rate limiting step in heme synthesis is the upstream enzyme 
5-aminolevulinic acid synthase 1 (ALAS1), which is controlled by feedback repression via the 
end-product heme.  In response to a decrease in endogenous heme in the liver, as can occur with 
fasting, hormonal alterations, or with cytochrome P450 (CYP) inducing drugs, ALAS1 is 
induced, resulting in increased flux through the heme synthesis pathway.  In patients with AIP, 
this can result in the marked accumulation of the toxic heme intermediates porphobilinogen 
(PBG) and delta aminolevulinic acid (ALA) in the blood and urine due to the deficiency in the 
downstream PBGD.  Clinically, this manifests as acute attacks characterized by severe 
abdominal pain, cardiovascular as well as neurologic and psychiatric dysfunction.[6] 
1.1.1. 
Epidemiology 
Over 370 mutations have been identified in the PBGD gene, which in most instances result in its 
reduction by approximately 50%.  The exact prevalence of AIP is unknown due to under 
diagnosis, variation by geographic region, and the differences in penetrance observed for the 
different mutations.[2]  However, it is estimated that the prevalence of AIP is 5 to 10 per 
100,000 people in Western countries, while in Sweden it occurs in 1 in 1,000 people due to a 
founder effect associated with the resultant G593A mutation.[7-10]  AIP shows incomplete 
penetrance and on average only 10% to 50% of carriers with a mutation present with clinical 
symptoms.[11]  It has been proposed that unknown inherited co-factors, in addition to PBGD 
mutations, may explain why a small percentage of patients present with much more severe 
disease while the majority remain asymptomatic. 
Patients with AIP present with acute attacks characterized by neurovisceral symptoms and signs 
including severe abdominal pain, nausea, vomiting, constipation, or less commonly diarrhea, 
hypertension, tachycardia, fever, muscle weakness, as well as neurological (eg, neuropathy, 
seizures) and psychiatric (eg, anxiety and confusion) manifestations.[12]  AIP attacks typically 
start after puberty and can be triggered by exogenous factors such as medications (especially 
barbiturates, sulfonamides, and hydantoins), stress, exogenous hormones, nutritional status, and 
infection.  Clinically active disease is more common in women, where attacks often occur around 
the menstrual cycle and are likely precipitated by hormonal changes. 
Many AIP patients remain undiagnosed given that the disease is rare and characterized by 
non-specific symptoms (eg, abdominal pain and nausea).[2]  The initial diagnosis involves 
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demonstrating elevated urinary PBG (typically 20-50 × normal reference range) and ALA 
(typically 5-20 × normal reference range) when the patient is having acute attack symptoms.  
Once a test is positive for elevated ALA and PBG and porphyria is suspected, genetic testing for 
a PBGD mutation is performed.   
There are 4 main clinical phenotypes of AIP.  Latent gene carriers have never had an acute attack 
and are biochemically inactive (normal urinary ALA and PBG).  Asymptomatic high excreters 
(ASHE) do not have current acute attacks, but are biochemically active (increased urinary ALA 
and PBG).  The increased levels of ALA and PBG in ASHE patients are lower than those in AIP 
patients during an acute attack, but are still significantly higher than normal reference values.[6-
8]  Sporadic attack patients have infrequent acute attacks.  Recurrent attack patients have 
≥4 attacks per year requiring hospitalization or treatment by a medical professional.[7] 
1.1.2. 
Current Management and Unmet Medical Need 
Management of acute attacks often requires hospitalization.  Patients are initially treated with 
supportive care and carbohydrate loading, analgesics and anti-emetics, and removal of known 
precipitating factors.[13]  In patients with moderate to severe attacks, or who fail to respond to 
supportive measures, treatment with intravenous (IV) hemin (daily for 3-5 days) is commenced.  
Symptoms typically begin to improve after 2 to 5 days of hemin treatment, accompanied by a 
lowering of urinary ALA and PBG levels to below or at the upper limit of normal (ULN) 
reference value; however, in some patients attacks can last several weeks, requiring prolonged 
hemin use and hospitalization.[14]  With prolonged and severe attacks, cranial nerve 
involvement can occur, leading to bulbar paralysis, respiratory failure, and death.[15]  
Hemin, a blood derived therapy, was approved as Normosang® (heme arginate) in the European 
Union (EU) and as Panhematin® (lyophilised hematin) in the United States (US) in 1999 and 
1983, respectively.[16, 17]  In the EU, heme arginate is indicated for the treatment of acute 
attacks of hepatic porphyria (eg, AIP, variegate porphyria, and hereditary coproporphyria); 
whereas, in the US lyophilized hemin is limited to the amelioration of recurrent attacks of AIP 
temporally related to the menstrual cycle.  Approval of both products was based on biochemical 
efficacy (ie, lowering of ALA and PBG) as well as data from uncontrolled case series and case 
reports.[18-22]  Hemin side effects include thrombophlebitis, transient anticoagulation, and in 
rare cases, anaphylaxis or renal failure.[22-24]  In addition, hemin administration requires a large 
vein for administration, often necessitating central venous access. 
While the majority of patients who experience attacks have them sporadically, it is estimated that 
up to 1,000 AIP patients experience recurrent attacks (typically defined as ≥4 per year) in the US 
and EU combined.[25]  While hemin is currently only approved to ameliorate acute attacks, it is 
administered prophylactically in some patients with recurrent attacks (eg, administered every 
1-2 weeks).[26]  Potential problems associated with chronic hemin administration include 
infusion site phlebitis, iron overload, and the need for chronic IV access and associated 
complications (eg, risk of infection or occlusion).[5]  In addition, there have been reports of a 
decrease in efficacy with chronic hemin administration, as evidenced by the need to increase the 
frequency or dosage of hemin prophylaxis over time in attempt to maintain a clinical effect.[27]  
In patients with very severe recurrent attacks, or in whom hemin treatment is not effective, liver 
transplantation can be curative; however, organ transplantation is a high-risk procedure and is 
rarely used as a treatment option [34].  Given the significant morbidity and mortality, there 
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remains a significant unmet need for an efficacious, simple, fast-acting and better tolerated 
treatment for acute or prevent recurrent attacks in patients with AIP. 
1.2. 
RNA Interference 
RNA interference (RNAi) is a naturally occurring cellular mechanism mediated by small 
interfering RNAs (siRNAs) for regulating gene expression.  Typically, synthetic siRNAs are 
19 to 25 base pair double stranded oligonucleotides in a staggered duplex with a 2-nucleotide 
overhang at both or 1 of the 3’ ends.[28]  Such siRNAs can be designed to target an endogenous 
messenger RNA (mRNA) transcript of a given gene.  When introduced into cells, the net effect 
of an RNAi-based pharmacological approach is the binding of the siRNA to its complementary 
mRNA sequence, cleavage of this target mRNA, and reduction of synthesis of the target protein, 
resulting in a decrease of the target protein levels.[29]  The ability to selectively and potently 
degrade the mRNA encoding the ALAS1 protein (thereby decreasing accumulation of the toxic 
intermediates ALA and PBG) using an siRNA is a novel approach for the prevention and 
treatment of acute attacks in patients with AIP.   
1.3. 
ALN-AS1 
ALN-AS1 comprises a synthetic siRNA covalently linked to a GalNAc containing ligand 
(ALN60519), specific for ALAS1 and formulated for administration via subcutaneous (SC) 
injection. ALN-60519 has a target region between nucleotide 918 to 937 of the ALAS1 mRNA. 
Attachment to a triantennary GalNAc ligand to the siRNA enables its distribution to the liver 
(which is the primary site of ALAS1 synthesis), followed by intracellular delivery to hepatocytes 
via ASGPR, resulting in engagement of the RNAi pathway and suppression of hepatic ALAS1 
protein synthesis. 
ALN-AS1 is currently in development for treatment of acute attacks in patients with AIP, the 
most common AHP. 
Further information on ALN-AS1, including the clinical and nonclinical experience to date, is 
available in in the current version of the Investigator’s Brochure (IB). 
1.4. 
Study Design Rationale 
This is a multicenter, open-label extension study designed to evaluate the long-term safety and 
clinical activity of subcutaneously administered ALN-AS1 in patients with AIP who have 
completed clinical study ALN-AS1-001.  The primary endpoint for the study is the incidence of 
AEs. 
1.5. 
Dose Rationale 
Clinical data from Part A and Part B of the ongoing study ALN-AS1-001 demonstrate that single 
(0.035-2.5 mg/kg) and multiple (0.35-1.0 mg/kg) doses of ALN-AS1 have been generally 
well-tolerated in patients with AIP who are ASHE.  Additionally, data from this study indicate 
that a single dose of 2.5 mg/kg ALN-AS1 results in near normalization of urine ALA and PBG 
levels, which is sustained for approximately 14 weeks.   
Patients in Part C of the ongoing study ALN-AS1-001 who are eligible for participation in this 
study will likely require a higher dose of ALN-AS1 to normalize ALA and PBG as they have 
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higher levels of ALAS1 upregulation and higher baseline levels of ALA and PBG, when 
compared to patients with AIP who are ASHE.[30]  For example, based on preliminary data in 
Part A and Part B of the ALN-AS1-001 study, the mean PBG level of patients who are ASHE is 
21.9 mmol/mol Cr (N=28); whereas, in Part C of this study in patients with AHP who have 
recurrent porphyria attacks, the mean PBG level is approximately 49.3 mmol/mol Cr (N=12). 
The study starting dose and regimen of ALN-AS1 is 5.0 mg/kg as an SC injection administered 
every 3 months.  Based on emerging clinical data, the SRC may approve changes to the 
ALN-AS1 dosing regimen, including decreases in the dose level and changes in dosing 
frequency.  However, any dosing regimen will not exceed a previously explored dose level or 
frequency that was determined to be safe and well-tolerated in study ALN-AS1-001. SRC, 
Health Authority and Ethics Committee approval must be sought prior to dose level escalation 
above 5.0 mg/kg in accordance with local Regulatory requirements. 
The study starting dose and regimen was selected based on the benefit:risk profile of ALN-AS1 
in Part C of the ongoing ALN-AS1-001 study.  Preliminary data to date indicate that 
administration of 5.0 mg/kg ALN-AS1 has been generally well-tolerated.  There have been no 
study drug-related SAEs, severe AEs, or clinically significant changes in safety parameters.  
While a single 2.5 mg/kg dose of ALN-AS1 has also been generally well-tolerated when 
administered to patients in Part A and Part C of study ALN-AS1-001, this dose has not resulted 
in near normalization of ALA and PBG levels.  In addition, while emerging data from Part C 
indicate that an every 3 months dose of 2.5 mg/kg ALN-AS1 demonstrated some clinical activity 
(eg, decrease in attack frequency and decrease in heme use), some patients continued to 
experience breakthrough porphyria attacks during the treatment period, indicating that a higher 
dose may be required. 
The duration of dosing in this study is supported by the overall favorable safety profile of 
ALN-AS1 in the ongoing clinical study ALN-AS1-001 and the absence of new findings in 
nonclinical studies with ALN-AS1. 
1.6. 
Benefit-Risk Assessment 
Patients participating in this study may experience a reduced number or severity of porphyria 
attacks, reduced treatment with IV hemin, and/or reduced requirement for pain medication. 
The potential risks associated with administration of ALN-AS1 in patients with AIP are as 
follows: 
• Injection site reactions (ISRs):  ALN-AS1 is administered by SC injection.  In the 
ongoing ALN-AS1 clinical study, AEs of ISRs have been infrequently reported and 
have been mild to moderate in severity with single dosing.  Injection site rotation and 
close monitoring have been implemented in ALN-AS1 clinical studies to reduce the 
potential for ISRs.  
• Liver function test abnormalities:  As ALN-AS1 is targeted for delivery to the liver, 
and reversible hepatic changes were observed in some animal species, there is a 
potential for development of LFT abnormalities.  To minimize the potential for LFT 
abnormalities, patients are required to have adequate liver function at study entry and 
LFTs are monitored during the study. 
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• Reproductive health:  No data are available on the use of ALN-AS1 in pregnancy; 
however, there is no suspicion of human teratogenicity based on class effects or 
genotoxic potential.  ALN-AS1 was neither genotoxic nor clastogenic in in vitro and 
in vivo studies.  Based on preliminary data from rat fertility/embryofetal development 
and rabbit embryofetal development studies, it is unlikely that ALN-AS1 
administration to pregnant women poses a risk to embryofetal development.  In a rat 
fertility/embryofetal development study at daily dose levels up to 16.5 mg/kg, no test 
article-related effects on female fertility or developmental endpoints were observed.  
In a rabbit embryofetal development study, maternal toxicity was observed at daily 
doses of >3 mg/kg (7.8-fold higher than the clinical monthly dose of 5.0 mg/kg).  No 
terata were observed in this range finding embryo fetal development study.  Women 
of child bearing potential (WOCBP) must have a negative pregnancy test, cannot be 
breastfeeding, and must be willing to use acceptable methods of contraception during 
studies with ALN-AS1.  
• CYP inhibition:  A study in NHP demonstrated that ALN-AS1 dosing could 
potentially increase the clearance of drugs metabolized by the CYP3A isoform.  As 
contraceptive hormones are metabolized via CYP3A, WOCBP must use a barrier 
method of contraception, in addition to hormonal contraception, during study 
participation.  Additionally, Investigators will review all patient medications at study 
start and monitor responses to these medications during the study.  A list of 
medications that are sensitive CYP3A substrates is in Table 6 in Appendix 
Section 11.3.  In addition, a list of medications that are sensitive CYP3A substrates is 
available at the Indiana University, Division of Clinical Pharmacology, website.[31] 
The complete summary of the clinical and nonclinical data relevant to the investigational drug 
and its study in human subjects is provided in the Investigator’s Brochure. 
2. 
OBJECTIVES 
2.1. 
Primary Objective 
• Evaluate the long-term safety and tolerability of ALN-AS1 in patients with AIP 
2.2. 
Secondary Objectives 
• Assess the PD effect of ALN-AS1 over time 
• Assess the clinical activity of ALN-AS1 over time 
2.3. 
Exploratory Objectives 
• Characterize the PK profile of ALN-AS1 over time 
• Assess changes in health-related quality of life (QOL) 
• Characterize analytes related to targeting the heme biosynthesis pathway 
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3. 
ENDPOINTS 
3.1. 
Primary Endpoint 
• Patient incidence of AEs 
3.2. 
Secondary Endpoints 
• Change in urine ALA and PBG levels 
• Frequency and characteristics of porphyria attacks 
• Change in hemin administration 
3.3. 
Exploratory Endpoints 
• Change in circulating ALAS1 mRNA levels 
• Concentrations of ALN-AS1 and antidrug antibodies  
• Duration and treatment of porphyria attacks 
• Number and duration of visits to a health care facility for acute porphyria care 
• EQ-5D-5L questionnaire scores 
• Pain assessment and narcotic use as recorded in a patient diary 
• Exploratory biomarkers related to the target pathway, such as urine porphyrins, 
vitamin D binding protein 
4. 
INVESTIGATIONAL PLAN 
4.1. 
Summary of Study Design 
This is a Phase 1/2 multicenter, open-label extension study to evaluate the long-term safety and 
clinical activity of ALN-AS1 in patients with AIP who completed study ALN-AS1-001.  The 
study will be conducted at up to 8 clinical study centers worldwide. 
The last assessments performed, determining previous study (ALN-AS1-001) completion, will 
serve as the Screening/Baseline assessments in this study.  If more than 60 days have elapsed 
since the last assessment, safety assessments (eg, ECG and clinical laboratory tests) will be 
repeated before administration of ALN-AS1.  It is anticipated that patients will begin ALN-AS1 
administration in this study within 6 months after the last dose of study drug in the previous 
study.  Eligibility will be confirmed during Screening/Baseline and before administration of the 
first dose of ALN-AS1 (Day 1).  Patients will undergo assessments at the clinical study center 
every month for the first 3 months.  Then, through Month 6, and according to the dosing regimen 
selected, assessments will take place at the clinical study center or via a phone contact (for an 
every month dosing regimen, visits will be every month; for an every 3 months dosing regimen, 
visits will be every 3 months; see Section 6.2.2).  After a patient has completed 12 months of 
ALN-AS1 administration in this study (6 months in an every month dosing regimen), and where 
applicable country and local regulations and infrastructure allow, study visits and ALN-AS1 
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administration may take place at the patient’s home by a healthcare professional (as indicated in 
the Schedules of Assessments in Table 1 and Table 2; and Table 4 and Table 5 in Appendix 
Section 11.2).  Home visits may occur at the discretion of the Investigator, based on safety and 
tolerability; however, patients are required to complete at least 1 visit at the clinical study center 
every 3 months for the first year, and thereafter every 6 months through the end of the treatment 
period.  Patients will return to the clinical study center for a posttreatment follow-up visit after 
administration of the last dose of ALN-AS1.  An ALA/PBG Monitoring/EOS visit will be 
conducted either at the clinical study center or via phone contact, unless treatment continues with 
ALN-AS1. 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain 
assessments, and narcotic use.  Additionally, patients will be encouraged to report to the clinical 
study center if they experience a porphyria attack through Month 39.  In the event that patients 
are unable to report to the clinical study center during a porphyria attack, laboratory sample 
collection kits containing instructions for collecting and sending urine samples to the clinical 
study center, if possible, will be provided.  Patients will be contacted by phone after a porphyria 
attack to record attack details.  If patients are experiencing signs and symptoms of a porphyria 
attack when ALN-AS1 administration is scheduled, the Investigator will determine whether 
administration of ALN-AS1 is appropriate.  If patients are treated for a porphyria attack at a 
health care facility (eg, hospital, emergency department, infusion center, or outpatient clinic) 
other than the clinical study center, copies of medical records, including discharge summaries, 
will be requested.   
A Safety Review Committee (SRC) will review safety and tolerability data collected during the 
study with the primary purpose of protecting the safety of patients participating in the study (see 
Section 4.6). 
Figure 1: 
Study Design 
 
4.2. 
Duration of Treatment and Study 
The duration of treatment is up to 36 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 44 months.   
4.3. 
Number of Patients 
Up to 24 patients are planned for enrollment in this study (including optional cohorts in 
ALN-AS1-001). 
Complete Study
ALN-AS1-001
Screening
(Day -60 to -1)
Treatment Period
(36 Months)
Posttreatment 
Follow-up
(3 months)
End of Study
(Month 42)
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4.4. 
Method of Assigning Patients to Treatment Groups 
This is an open-label study; all patients will receive ALN-AS1.  A combination of the clinical 
study center number and screening number will create the unique patient identifier.  The clinical 
study center number will be assigned by the Sponsor.  Upon signing the Informed Consent Form 
(ICF), the patient will be assigned a screening number by the clinical study site, which will be 
the same unique patient identifier assigned in the previous study (ALN-AS1-001).  The 
Investigator, or delegate, will confirm that the patient fulfills all the inclusion criteria and none of 
the exclusion criteria. 
4.5. 
Blinding 
This is an open-label study, and all patients will receive ALN-AS1. 
4.6. 
Safety Review Committee 
An SRC will be involved in the conduct of this study.  The SRC has the responsibility for 
monitoring the safety of the study participants.  The SRC will perform periodic reviews of safety 
and tolerability data during the course of the clinical study at least every 3 months for the first 
6 months of the study and thereafter at least every 6 months.  The SRC may also meet on an ad 
hoc basis for review of emergent safety and tolerability data, as defined in the SRC Charter for 
this clinical study.  The SRC will not stop the study for efficacy. 
The SRC will be comprised of the following members:  Principal Investigator(s), or designee(s), 
the Sponsor Medical Monitor, and the Study Medical Monitor. 
The membership of the SRC and reporting structure are further defined in the SRC Charter. 
5. 
SELECTION AND WITHDRAWAL OF PATIENTS 
5.1. 
Inclusion Criteria 
Each patient must meet all of the following inclusion criteria to be eligible for enrollment in this 
study: 
1. Completed and, in the opinion of the Investigator, tolerated study drug dosing in Part C 
of study ALN-AS1-001 
2. Not on a scheduled regimen of hemin to prevent porphyria attacks at Screening 
3. WOCBP must have a negative serum pregnancy test, cannot be breast feeding, and must 
be willing to use acceptable methods of contraception 14 days before first dose, 
throughout study participation, and for 90 days after last dose administration.  Acceptable 
methods include hormonal methods along with an additional barrier method (eg, condom, 
diaphragm, or cervical cap), or a double barrier method of contraception for those 
WOCBP for whom a hormonal method of contraception is medically contraindicated due 
to underlying disease (see Section 6.4 for acceptable methods of contraception).   
4. Willing and able to comply with the study requirements and to provide written informed 
consent 
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5.2. 
Exclusion Criteria 
Each patient must not meet any of the following exclusion criteria to be eligible for enrollment in 
this study: 
1. Alanine transaminase ≥2.0×ULN or total bilirubin ≥2 mg/dL (unless bilirubin elevation is 
due to Gilbert’s syndrome) 
2. Estimated glomerular filtration rate ≤30 mL/min/1.73 m2 (using the Modification of Diet 
in Renal Disease formula) 
3. History of multiple drug allergies or history of allergic reaction to an oligonucleotide or 
to N-acetyl galactosamine ligand (GalNAc) 
4. Received an investigational agent, other than ALN-AS1, or who are in follow-up of 
another clinical study of an investigational agent within 90 days before study drug 
administration 
5. Other medical conditions or comorbidities which, in the opinion of the Investigator, 
would interfere with study compliance or data interpretation 
5.3. 
Removal from Treatment or Assessment 
Patients are free to discontinue treatment or withdraw from the study at any time and for any 
reason, without penalty to their continuing medical care.  Any discontinuation of treatment or 
withdrawal from the study must be fully documented in the electronic case report form (eCRF), 
and should be followed up by the Investigator.  The Investigator may withdraw a patient at any 
time if this is considered to be in the best interest of the patient. 
Discontinuation of study drug and withdrawal from the study are described in Section 5.3.1 and 
Section 5.3.2, respectively. 
5.3.1. 
Discontinuation of Study Drug 
The Investigator or designee may discontinue dosing in a patient if the patient: 
• Is in violation of the protocol 
• Experiences a SAE considered to be possibly or definitely related to the study drug or 
an intolerable AE  
• Becomes pregnant 
• Is found to be considerably noncompliant with the protocol-requirements 
Patients who are pregnant will be discontinued from study drug dosing immediately (see 
Section 7.5.6.6 for reporting and follow-up of pregnancy).  Patients who discontinue treatment 
will be asked to complete the Month 39 visit assessments. 
5.3.2. 
Withdrawal from Study 
A patient may withdraw from the study at any time.  If a patient chooses to withdraw from the 
study, every effort should be made to conduct early the assessments performed at the Month 39 
visit.  When a patient withdraws from the study, the primary reason for study withdrawal must be 
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recorded in the appropriate section of the eCRF and all efforts made to complete and report the 
observations as thoroughly as possible.  If a patient withdraws due to a SAE, the SAE should be 
followed as described in Section 7.5.6. 
5.3.3. 
Replacement of Patients 
Patients discontinuing from study drug or withdrawing from the study will not be replaced. 
6.
TREATMENTS
6.1. 
Treatments Administered
ALN-AS1 Solution for Injection (SC use) is a clear, colorless to pale yellow solution essentially 
free of particulates.  ALN-AS1 will be supplied by the Sponsor as a sterile solution for SC 
injection. 
Study drug supplied for this study must not be used for any purpose other than the present study 
and must not be administered to any person not enrolled in the study.  Study drug that has been 
dispensed to a patient and returned unused must not be re-dispensed to a different patient. 
6.2. 
Investigational Study Drug 
Detailed information describing the preparation, handling, and storage, packaging and labeling, 
as well as study drug accountability for ALN-AS1 is provided in the Pharmacy Manual. 
6.2.1. 
Description 
ALN-AS1 Solution for Injection (SC use) is comprised of a synthetic, siRNA targeting ALAS1 
and bearing a triantennary GalNAc ligand conjugated to the sense strand, formulated in 
phosphate buffer.  
6.2.2. 
Dose and Administration 
The study starting dose of ALN-AS1 is 5.0 mg/kg ALN-AS1 as an SC injection administered 
every 3 months (Table 1 and Table 2). Based on emerging clinical data, the SRC may approve 
changes to the ALN-AS1 dosing regimen, including decreases in the dose level and changes in 
dosing frequency (Table 4 and Table 5 in Appendix Section 11.2). However, any dose and 
dosing regimen will not exceed a previously explored dose level or frequency that was 
determined to be safe and well-tolerated in study ALN-AS1-001. SRC, Health Authority and 
Ethics Committee approval must be sought prior to dose level escalation above 5.0 mg/kg in 
accordance with local Regulatory requirements.  See Section 6.2.3 for details on dose 
modifications. 
The study drug will be administered under the supervision of a healthcare professional.  After a 
patient has completed 12 months of ALN-AS1 administration in this study (6 months in an every 
month dosing regimen), and where applicable country and local regulations and infrastructure 
allow, study visits and ALN-AS1 administration may take place at the patient’s home by a 
healthcare professional.  Home visits may occur at the discretion of the Investigator, based on 
safety and tolerability; however, patients are required to complete at least 1 visit at the clinical 
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study center every 3 months for the first year, and thereafter every 6 months through the end of 
the treatment period.   
If a patient does not receive a dose of ALN-AS1 within the specified dosing window, the 
Investigator should contact the Medical Monitor.  After such consultation, the dose may be 
administered or considered missed and not administered. 
Patients will be permitted to miss an occasional dose of study drug; however, if a patient misses 
2 consecutive doses, the Investigator, in consultation with the Medical Monitor, will discuss 
whether the patient will be able to continue on the study.  
Detailed instructions for study drug administration are found in the Pharmacy Manual. 
6.2.3. 
Dose Modifications 
6.2.3.1. 
Study Population Dose Modifications 
During the study, dose modifications are permitted for the study population, or based on the dose 
cohort into which patients were originally randomized in study ALN-AS1-001.  Following SRC 
review of emerging safety and tolerability data from Part C of study ALN-AS1-001, or from this 
study (ALN-AS1-002), the dose and dosing regimen may be modified.  However, the dose and 
dosing regimen of ALN-AS1 will not exceed a previously explored dose and dosing regimen that 
was determined to be safe and well-tolerated in study ALN-AS1-001.  Patients enrolling in this 
study after a dose modification decision has been implemented may start at the newly identified 
dose and regimen. 
6.2.3.2. 
Individual Dose Modifications 
Dose modifications are permitted for individual patients.  If a patient has a study drug related AE 
of a recurrent ISR, severe ISR, or clinically significant LFT abnormality and the Investigator has 
concerns regarding further ALN-AS1 administration, the Medical Monitor and Investigator will 
review all available safety data for the patient.  Based on this review, a dose reduction to half the 
previously administered dose (eg, a 5.0 mg/kg dose would be reduced to a 2.5 mg/kg dose) or a 
reduction in dosing frequency from monthly to every 3 months is permitted.  Subsequent 
ALN-AS1 administration at the previous dose may be considered based on the judgment of the 
Investigator and Medical Monitor. 
6.2.4. 
Preparation, Handling, and Storage 
Staff at each clinical study center or the home healthcare professional will be responsible for 
preparation of ALN-AS1 doses, according to procedures detailed in the Pharmacy Manual.  No 
special procedures for the safe handling of study drug are required. 
Study drug will be stored upright and refrigerated at approximately 5±3°C.  Any deviation from 
the recommended storage conditions should be reported to the Sponsor and use of the study drug 
halted until authorization for its continued use has been provided by the Sponsor or designee. 
A Sponsor representative or designee will be permitted, upon request, to audit the supplies, 
storage, dispensing procedures, and records. 
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6.2.5. 
Packaging and Labeling 
ALN-AS1 Solution for Injection (SC use) is packaged in 2 mL glass vials with a fill volume of 
no less than 0.55 mL.  The container closure system consists of a Type I glass vial, a Teflon 
faced bromobutyl 13 mm stopper and a flip-off Truedge aluminum seal. 
6.2.6. 
Accountability 
The Investigator or designee will maintain accurate records of receipt and the condition of the 
study drug supplied for this study, including dates of receipt.  In addition, accurate records will 
be kept of when and how much study drug is dispensed and administered to each patient in the 
study.  Any reasons for departure from the protocol dispensing regimen must also be recorded. 
At the completion of the study, there will be a final reconciliation of all study drugs.  All used, 
partially used, and unused study drug will be returned to the Sponsor (or designee) or destroyed 
at the clinical study center according to applicable regulations.   
6.3. 
Concomitant Medications 
Use of concomitant medications will be recorded on the patient’s case report form (CRF) as 
indicated in the Schedules of Assessments (Table 1 and Table 2; and Table 4 and Table 5 in 
Appendix Section 11.2).  This includes all prescription medications, herbal preparations, over the 
counter (OTC) medications, vitamins, and minerals.  Any changes in medications during the 
study will also be recorded on the CRF. 
Any concomitant medication that is required for the patient’s welfare may be administered by the 
Investigator.  However, it is the responsibility of the Investigator to ensure that details regarding 
the medication are recorded on the eCRF.  Concomitant medication will be coded using an 
internationally recognized and accepted coding dictionary. 
ALN-AS1 could potentially increase the clearance of drugs metabolized by the CYP3A isoform.   
Investigators will review all medications at study start and monitor response to these medications 
during the study.  For patients who require new medications while on study, selection of 
medications that are not mainly metabolized by the CYP3A isoform is recommended.  A list of 
medications that are sensitive CYP3A substrates is included in Table 6 Appendix Section 11.3.  
In addition, a more detailed and current list of sensitive CYP3A-metabolized medications and 
CYP3A-metabolized medications with a narrow therapeutic range is available at the Indiana 
University, Division of Clinical Pharmacology, website 
(http://medicine.iupui.edu/clinpharm/ddis/clinical-table/).[31] 
Patients are not permitted to be on hemin prophylaxis at Screening; however, patients are 
permitted to receive concomitant hemin treatment for the management of acute porphyria 
attacks.  Patients experiencing significant breakthrough attacks while enrolled in this study, 
necessitating frequent hemin treatment, may receive hemin prophylaxis if in the Investigator’s 
judgment this is clinically beneficial to the patient.  The Investigator should contact with the 
Sponsor and Medical Monitor before prophylactic hemin treatment.  The dose, regimen, and 
dates of administration will be recorded on the patient’s eCRF.   
Pain medication (eg, opiates, opioids, narcotic analgesics) and glucose administration are 
permitted for the management of porphyria and for acute porphyria attacks. 
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If patients use nonsteroidal anti-inflammatory medications intermittently or chronically, they 
must have been able to tolerate them with no previous side effects (eg, gastric distress or 
bleeding).   
Standard vitamins and topical medications are permitted; however, topical steroids must not be 
applied anywhere near the injection site(s) unless medically indicated. 
6.4. 
Contraceptive Requirements 
WOCBP must be willing to use acceptable methods of contraception 14 days before first dose, 
throughout study participation, and for 90 days after last dose administration.  Birth control 
methods which may be considered as acceptable include: 
• Established use of oral, implantable, injectable, or transdermal hormonal methods of 
contraception.  WOCBP using hormonal methods of contraception must also use a 
barrier method (condom or occlusive cap [diaphragm or cervical/vault cap] in 
conjunction with spermicide [eg, foam, gel, film, cream, or suppository]).  If 
hormonal methods of contraception are medically contraindicated for WOCBP due to 
underlying disease, a double-barrier method (combination of male condom with 
either cap, diaphragm, or sponge, in conjunction with spermicide) is also considered 
an acceptable method of contraception. 
• Placement of an intrauterine device  
• Placement of an intrauterine hormone-releasing system  
• Bilateral tubal occlusion 
• Surgical sterilization of male partner (with the appropriate post-vasectomy 
documentation of the absence of sperm in the ejaculate; for female patients on the 
study, the vasectomized male partner should be the sole partner for that patient) 
• True sexual abstinence, when in line with the preferred and usual lifestyle of the 
patient.  Periodic abstinence (eg, calendar, ovulation, symptothermal, post-ovulation 
methods) and withdrawal are not acceptable methods of contraception.  Abstinent 
patients must agree to use 1 of the abovementioned contraceptive methods, if they 
start sexual relationships during the study and for 90 days after last dose 
administration. 
WOCBP includes any female patient who has experienced menarche and who is not 
postmenopausal or permanently sterilized (eg, bilateral tubal occlusion, hysterectomy, or 
bilateral salpingectomy).  Postmenopausal state is defined as no menses for 12 months without 
an alternative medical cause, confirmed by follicle stimulating hormone level within the 
postmenopausal range. 
6.5. 
Treatment Compliance 
Compliance with study drug administration will be verified through observation by study 
personnel or trained home healthcare professionals.  
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7. 
STUDY ASSESSMENTS 
The schedule of study assessments is provided in Table 1.  
7.1. 
Screening/Baseline Assessments 
Informed consent, patient demographic data, and eligibility criteria will be confirmed at 
Screening/Baseline.  An interval medical history/disease history will be obtained at 
Screening/Baseline.  The last assessments performed, determining previous study 
(ALN-AS1-001) completion, will serve as the Screening/Baseline assessments in this study.  If 
more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs will 
be repeated before administration of ALN-AS1. 
7.2. 
Clinical Activity Assessments 
The clinical activity of ALN-AS1 will be assessed by the frequency and characteristics of 
porphyria attacks including, but not limited to, duration, treatment, and severity of porphyria 
attacks and number and duration of visits to a health care setting for acute porphyria care (eg, 
hospital, emergency department, infusion center, or outpatient clinic).  Concomitant hemin 
administration will also be recorded. 
7.2.1. 
Patient Diary 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain 
assessments, and narcotic use. 
7.2.2. 
Brief Pain Inventory-Short Form Questionnaire 
The Brief Pain Inventory-Short Form (BPI-SF) questionnaire will be used to evaluate pain.[32]  
The BPI will be completed as part of the patient diary. 
7.3. 
Pharmacodynamic Assessments 
Blood and urine samples will be collected for assessment of ALN-AS1 PD parameters.  The PD 
effect of ALN-AS1 will be evaluated by urine ALA and PBG levels.  Blood and urine samples 
will be collected for assessment of circulating ALAS1 mRNA levels in serum and in urine.  
Analysis for blood and urine PD parameters will take place at a central laboratory.   
Details regarding the processing and aliquoting of samples for storage and analyses will be 
provided in the Laboratory Manual. 
7.4. 
Pharmacokinetic Assessments 
Blood samples will be collected to evaluate the PK profile of ALN-AS1 at the time points in the 
Schedule of Assessments.  A detailed schedule of time points for the collection of blood samples 
for PK analysis is in Table 3 in Appendix Section 11.1). 
The concentration of ALN-AS1 will be determined using a validated assay.  Details regarding 
the processing, shipping, and analysis of the samples will be provided in the Laboratory Manual. 
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7.5. 
Safety Assessments 
The assessment of safety during the course of the study will consist of the surveillance and 
recording of AEs including SAEs, recording of concomitant medications and measurements of 
vital signs, physical examination, and ECG findings and clinical laboratory evaluations. 
Safety will be monitored over the course of the study by an SRC as described in Section 4.6. 
7.5.1. 
Vital Signs 
Vital sign measurements include blood pressure, heart rate, body temperature, and respiratory 
rate.  Vital signs will be measured in the seated or supine position (should be consistent for each 
patient), after the patient has rested comfortably for 10 minutes.  Blood pressure should be taken 
using the same arm throughout the study.  Body temperature will be obtained in degrees Celsius, 
heart rate will be counted for a full minute and recorded in beats per minute, and respiration rate 
will be counted for a full minute and recorded in breaths per minute. 
For the safety of the patient, additional vital sign assessments may be added at the discretion of 
the Investigator. 
7.5.2. 
Weight and Height 
Height will be measured in centimeters at the Screening/Baseline visit only.  Body weight will be 
measured in kilograms.  Body mass index will be calculated in the database. 
7.5.3. 
Physical Examination 
Complete physical examinations will include the examination of the following:  general 
appearance, head, eyes, ears, nose and throat, chest/respiratory, heart/cardiovascular, 
gastrointestinal/liver, musculoskeletal/extremities, dermatological/skin, thyroid/neck, lymph 
nodes, and neurological/psychiatric. 
Targeted physical examinations will include the examination of the following:  general 
appearance, chest/respiratory, heart/cardiovascular, gastrointestinal/liver, and 
neurological/psychiatric. 
7.5.4. 
Electrocardiogram 
Triplicate 12-lead ECG, with readings approximately 2 minutes apart, will be recorded.  
Additional ECGs may be collected at the discretion of the Investigator.  Standard computerized 
12-lead ECG recordings will be obtained.  Each lead shall be recorded for at least 3 beats at a 
speed of 25 mm/s.  Recordings will be obtained, after the patient has rested comfortably for 
approximately 10 minutes.  The electrophysiological parameters assessed include rhythm, 
ventricular rate, PR interval, QRS duration, QT interval, ST and T waves, Bazett-corrected QT 
interval (QTcB) and Fridericia-corrected QT interval (QTcF). 
The Investigator or designee is responsible for reviewing the ECGs to assess whether the results 
have changed since the Screening/Baseline visit and to determine the clinical relevance of the 
results.  These assessments will be recorded on the eCRF.  For any clinically relevant ECG 
changes from the Screening/Baseline visit (eg, ischemic ECG changes, wave/interval changes, or 
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arrhythmia), the Investigator must contact the Medical Monitor to discuss continued participation 
of the patient in the study. 
7.5.5. 
Clinical Laboratory Assessments 
The following clinical laboratory tests will be evaluated by a central laboratory.   
Results from clinical laboratory tests collected on dosing days are not required before study drug 
administration; however, if results for clinical laboratory tests from the previous study visit are 
not available or are deemed clinically significant, then clinical laboratory assessments must be 
repeated and the results must be deemed acceptable by the Investigator before study drug 
administration. 
In the event of an unexplained clinically relevant abnormal laboratory test occurring after study 
drug administration, the test should be repeated and followed up at the discretion of the 
Investigator until it has returned to the normal range or stabilized, and/or a diagnosis is made to 
adequately explain the abnormality. 
At any point during the study, and based on Investigator judgment, if a patient experiences 
uncharacteristic signs and symptoms during a porphyria attack, lipase testing should be 
performed and imaging evaluations (eg, right upper quadrant ultrasound and/or other testing, 
based on Investigator judgment) should be considered by the Investigator.  Signs and symptoms 
include, but are not limited to, uncharacteristic abdominal pain and worsening nausea and 
vomiting. 
Imaging is required for any serum lipase result of ≥3× the upper limit of normal, or as clinically 
indicated. 
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Hematology 
Complete blood count with differential 
 
Serum Chemistry 
Sodium 
Potassium 
BUN 
Phosphate 
Creatinine and eGFRa 
Albumin 
Uric acid 
Calcium 
Total protein 
Carbon dioxide 
Glucose 
Chloride 
Lipase 
Bicarbonate 
Liver Function Tests 
 
AST 
ALP 
ALT 
Bilirubin (total and direct) 
Urinalysis 
Visual inspection for appearance and color 
Bilirubin 
pH (dipstick) 
Nitrite 
Specific gravity 
RBCs 
Ketones 
Urobilinogen 
Albumin 
Leukocytes 
Glucose 
Microscopy (if clinically indicated) 
Protein 
 
Immunogenicity 
Antidrug antibodies 
Pregnancy Testing (WOCBP only) 
β-human chorionic gonadotropin 
Abbreviations:  AST=aspartate transaminase; ALP=alkaline phosphatase; ALT=alanine transaminase; BUN=blood 
urea nitrogen; eGFR=estimated glomerular filtration rate; WOCBP=women of child bearing potential. 
a eGFR will be calculated using the Modification of Diet in Renal Disease formula.[33] 
7.5.5.1. 
Immunogenicity 
Blood samples will be collected to evaluate antidrug antibodies.  On days when ALN-AS1 is 
administered, blood samples for antidrug antibody testing must be collected before ALN-AS1 is  
administered. 
Details regarding the processing, shipping, and analysis of the samples will be provided in the 
Laboratory Manual. 
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7.5.5.2. 
Pregnancy Testing 
A pregnancy test will be performed for WOCBP only.  A serum pregnancy test will be 
performed at Screening/Baseline and urine pregnancy tests will be performed thereafter per the 
Schedule of Assessments and any time pregnancy is suspected.  Urine pregnancy tests may also 
be performed more frequently (eg, monthly) based on local country requirements.  The results of 
the pregnancy test must be known before study drug administration.  Patients who are pregnant 
are not eligible for study participation.  Any woman with a positive pregnancy test during the 
study will be discontinued from study drug, but will continue to be followed for safety.  Patients 
determined to be pregnant while on study will be followed until the pregnancy outcome is known 
(see Section 7.5.6.6 for follow-up instructions).  
7.5.6. 
Adverse Events 
7.5.6.1. 
Definitions 
Adverse Event 
According to the ICH E2A guideline Definitions and Standards for Expedited Reporting, and 
21 Code of Federal Regulations 312.32, Investigational New Drug Safety Reporting, an AE is 
any untoward medical occurrence in a patient or clinical investigational subject administered a 
medicinal product and which does not necessarily have a causal relationship with this treatment. 
Serious Adverse Event 
An SAE is any untoward medical occurrence that at any dose: 
• Results in death 
• Is life-threatening (An event which places the patient at immediate risk of death from 
the event as it occurred.  It does not include an event that had it occurred in a more 
severe form might have caused death) 
• Requires in-patient hospitalization or prolongation of existing hospitalization 
• Results in persistent or significant disability or incapacity 
• Is a congenital anomaly or birth defect 
• Is an important medical event that may not be immediately life-threatening or result 
in death or hospitalization but may jeopardize the patient and may require 
intervention to prevent one of the other outcomes listed in the definition above (eg, 
events include allergic bronchospasm requiring intensive treatment in an emergency 
room or at home, blood dyscrasias, convulsions, or the development of drug 
dependency or abuse). 
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Adverse Event Severity 
Adverse events are to be graded according to the categories detailed below: 
Mild: 
Mild events are those which are easily tolerated with no disruption of normal 
daily activity. 
Moderate: 
Moderate events are those which cause sufficient discomfort to interfere with 
normal daily activities. 
Severe: 
Severe events are those which incapacitate and prevent usual activity. 
Changes in severity should be documented in the medical record to allow assessment of the 
duration of the event at each level of severity.  AEs characterized as intermittent require 
documentation of the start and stop of each incidence.  When changes in the severity of an AE 
occur more frequently than once a day, the maximum severity for the experience that day should 
be noted.  If the severity category changes over a number of days, then those changes should be 
recorded separately (with distinct onset dates) 
AE severity and seriousness are assessed independently.  ‘Severity’ characterizes the intensity of 
an AE.  ‘Serious’ is a regulatory definition and serves as a guide to the Sponsor for defining 
regulatory reporting obligations (see definition for Serious Adverse Event). 
Relationship of the Adverse Event to Study Treatment 
The relationship of each AE to study treatment should be evaluated by the Investigator using the 
following criteria:  
Definitely related: 
A clinical event, including laboratory test abnormality, occurring in a 
plausible time relationship to the medication administration, and which 
cannot be explained by concurrent disease or other drugs or chemicals.  
The response to withdrawal of the drug should be clinically plausible. 
Possibly related: 
A clinical event, including laboratory test abnormality, with a 
reasonable time sequence to the medication administration, but which 
could also be explained by concurrent disease or other drugs or 
chemicals.  Information on the drug withdrawal may be lacking or 
unclear. 
Unlikely related: 
A clinical event, including laboratory test abnormality, with little or no 
temporal relationship to medication administration, and which other 
drugs, chemicals, or underlying disease provide plausible explanations. 
Not related: 
A clinical event, including laboratory test abnormality that has no 
temporal relationship to the medication or has more likely alternative 
etiology. 
Adverse Events of Clinical Interest 
The following events are considered to be adverse events of clinical interest: 
•
ISRs
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•
Hepatic AEs, including LFT abnormalities considered clinically significant by the
Investigator.
7.5.6.2. 
Eliciting and Recording Adverse Events 
Eliciting Adverse Events 
The patient should be asked about medically relevant changes in his/her health since the last 
visit.  The patient should also be asked if he/she has been hospitalized, had any accidents, used 
any new medications, or changed concomitant medication routines (both prescription and OTC).  
In addition to patient observations, AEs will be documented from any clinically relevant 
laboratory findings, physical examination findings, ECG changes, or other findings that are 
relevant to patient safety. 
Recording Adverse Events 
The Investigator is responsible for recording non-serious AEs that are observed or reported by 
the patient after administration of the first dose of study drug regardless of their relationship to 
study drug through the end of study.  Non-serious AEs will be followed until the end of study.  
The Investigator is responsible for recording SAEs that are observed or reported by the patient 
after the time when the informed consent is signed regardless of their relationship to study drug 
through the end of study.  SAEs will be followed until satisfactory resolution, until baseline level 
is reached, or until the SAE is considered by the Investigator to be chronic or the patient is 
stable, as appropriate. 
All AEs must be recorded in the source records for the clinical study center and in the eCRF for 
the patient, whether or not they are considered to be drug-related.  Each AE must be described in 
detail:  onset time and date, description of event, severity, relationship to investigational drug, 
action taken, and outcome (including time and date of resolution, if applicable). 
For SAEs, record the event(s) on the eCRF.  If the electronic data capture (EDC) system is 
unavailable, complete the backup SAE form. 
For AEs that are considered AEs of clinical interest, additional clinical information may be 
collected based upon the severity or nature of the event. 
If a patient has ISRs meeting any of the following criteria, the Investigator or delegate should 
contact the Medical Monitor and submit a supplemental ISR eCRF: 
•
ISRs that are recurrent and/or demonstrate a pattern of increasing severity
•
Any ISR that is determined to be severe and/or a cause for study drug discontinuation
•
Any ISR which, in the opinion of the Investigator, requires further medical evaluation or
treatment
In some cases, where it is medically appropriate, further evaluation may include photographs, 
referral to a dermatologist, skin biopsy, or other laboratory testing.  If a biopsy was obtained, the 
Sponsor may request that the biopsy also be reviewed by a central dermatopathologist.  To better 
understand the safety profile of the study drug, additional analysis of biopsy tissue may be 
performed according to local regulations. 
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For patients with hepatic AEs, additional information, including, clinical history, course of event, 
and local laboratory results to monitor LFT levels or other laboratory parameters, may be 
collected. 
7.5.6.3. 
Serious Adverse Events Require Immediate Reporting to Sponsor/Designee 
An assessment of the seriousness of each AE will be made by the Investigator.  Any AE and 
laboratory abnormality that meets the SAE criteria in Section 7.5.6.1 must be reported to the 
Sponsor or designee within 24 hours from the time that clinical study center personnel first 
learns of the event.  All SAEs must be reported regardless of the relationship to study drug. 
The initial report should include at least the following information: 
•
Patient’s study number
•
Description and date of onset of the event
•
Criterion for serious
•
Preliminary assignment of relationship to study drug
•
Investigator/clinical study center information
To report the SAE, complete the eCRF.  If the EDC system is unavailable, complete the backup 
SAE form.  Within 24 hours of receipt of follow-up information, the Investigator must update the 
report.  SAEs must be reported using the contact information provided in the Study Manual. 
Appropriate remedial measures should be taken by the Investigator using his/her best medical 
judgment to treat the SAE.  These measures and the patient’s response to these measures should 
be recorded.  All SAEs, regardless of relationship to study drug, will be followed by the 
Investigator until satisfactory resolution or the Investigator deems the SAE to be chronic or 
stable.  Clinical, laboratory, and diagnostic measures should be employed by the Investigator as 
needed to adequately determine the etiology of the event. 
7.5.6.4. 
Sponsor Safety Reporting to Regulatory Authorities 
The Sponsor or its representative is required to report certain study events in an expedited 
manner to the Food and Drug Administration, the European Medicines Agency’s EudraVigilance 
electronic system according to Directive 2001/20/EC, and to all country Regulatory Authorities 
where the study is being conducted, according to local applicable regulations. 
The following describes the safety reporting timeline requirements for suspected unexpected 
serious adverse reactions (SUSARs) and other reportable events: 
Immediately and within 7 calendar days 
•
Any suspected adverse reaction that is associated with the use of the study drug,
unexpected, and fatal or life threatening.  Follow-up information must be reported in
the following 8 days.
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Immediately and within 15 calendar days 
•
Any suspected adverse reaction that is associated with the use of the study drug,
unexpected, and serious, but not fatal or life threatening, and there is evidence to
suggest a causal relationship between the study drug and the reaction.
•
Any finding from tests in laboratory animals that suggest a significant risk for human
patients including reports of mutagenicity, teratogenicity, or carcinogenicity.
•
Any event in connection with the conduct of the study or the development of the
study drug that may affect the safety of the trial patients.
In addition, periodic safety reporting to regulatory authorities will be performed by the Sponsor 
or its representative according to national and local regulations. 
7.5.6.5. 
Serious Adverse Event Notification to the Institutional Review 
Board/Independent Ethics Committee 
SUSARs will be reported to the Institutional Review Board (IRB)/Independent Ethics 
Committee (IEC) per their institutional policy by the Investigator or Sponsor (or Sponsor 
designee) according to country requirements.  Copies of each report and documentation of 
IRB/IEC notification and acknowledgement of receipt will be kept in the Investigator’s study 
file. 
7.5.6.6. 
Pregnancy Reporting 
If a female patient becomes pregnant during the course of this study through 90 days following 
the last dose of study drug, the Investigator must report the pregnancy to the Sponsor or designee 
within 24 hours of being notified of the pregnancy.  Details of the pregnancy will be recorded on 
the pregnancy reporting form.  The patient should receive any necessary counseling regarding 
the risks of continuing the pregnancy and the possible effects on the fetus. 
The pregnancy should be followed by the Investigator until completion.  At the completion of the 
pregnancy, the Investigator will document the outcome of the pregnancy.  If the outcome of the 
pregnancy results in a postpartum complication, spontaneous abortion, stillbirth, neonatal death, 
or congenital anomaly, then the Investigator should follow the procedures for reporting an SAE 
as outlined in Section 7.5.6.3.   
7.5.6.7. 
Overdose Reporting 
An overdose is defined as any dose administered to or taken by a patient (accidentally or 
intentionally) that exceeds the highest daily dose, or is at a higher frequency, than included in the 
protocol.  It is up to the investigator to decide whether a dose is to be considered an overdose, in 
consultation with the Sponsor.  Overdose must be recorded in the eCRF. 
All reports of overdose (with or without an AE) must be reported within 24 hours to the Sponsor 
or designee.   
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7.6. 
Exploratory Assessments 
Blood and urine samples will be collected for exploratory analyses.  Aliquots of samples will be 
obtained and frozen, to permit future analysis of the effect of ALN-AS1 on exploratory 
biomarkers.   
Where local regulations allow, biologic samples will be retained on behalf of the Sponsor for a 
maximum of 15 years following the last patient’s last visit in the study.  Details regarding the 
collection, processing, storage, and shipping of samples will be in the Laboratory Manual. 
7.7. 
Other Assessments 
7.7.1. 
EQ-5D-5L Questionnaire 
QOL will be assessed through the use of the 5-level EQ-5D (EQ-5D-5L), a standardized 
questionnaire measuring health outcomes.[34]  In addition to the time points indicated, the 
EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a 
porphyria attack (but, not more than once in a 6 month period), if possible. 
8.
STATISTICS
A detailed Statistical Analysis Plan (SAP) will be written after finalizing the protocol and before 
database lock.  The plan will detail the implementation of all the statistical analyses in 
accordance with the principle features stated in the protocol. 
8.1. 
Determination of Sample Size 
This is a Phase 1/2 multicenter, open-label extension study to evaluate the long-term safety and 
clinical activity of ALN-AS1 in patients with AIP who completed study ALN-AS1-001.  Safety, 
tolerability, PK, and PD of ALN-AS1 will be investigated.  The sample size was not determined 
based on statistical considerations.  Up to 24 patients are planned for this study (including 
optional cohorts in ALN-AS1-001). 
8.2. 
Statistical Methodology 
The statistical and analytical plans presented below summarize the more complete plans to be 
detailed in the SAP.  Any changes to the methods described in the final SAP will be described 
and justified as needed in the clinical study report. 
Statistical analyses will be primarily descriptive in nature.  Descriptive statistics (eg, mean, 
standard deviation, median, minimum, and maximum) will be presented for continuous 
variables.  Frequencies and percentages will be presented for categorical and ordinal variables. 
Analyses will be performed using SAS® (Version 9.2, or higher). 
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8.2.1. 
Populations to be Analyzed 
The populations (analysis sets) are defined as follows:  
Safety Analysis Set: 
All patients who received any amount of study drug. 
Clinical Activity Analysis 
Set: 
All patients who received any amount of study drug and have 
both a baseline and at least 1 postdose assessment. 
PK Analysis Set: 
All patients who received any amount of study drug and have at 
least 1 postdose blood sample for PK and who have evaluable 
PK data. 
PD Analysis Set: 
All patients who received any amount of study drug and who 
have at least 1 postdose blood sample for the determination of 
ALN-AS1 will be included in the PD analyses. 
Safety will be analyzed using the Safety Analysis Set.  The PK and PD Analysis Sets will be 
used to conduct PK and PD analyses, respectively.  The population used to evaluate clinical 
activity will be the Clinical Activity Analysis Set.   
8.2.2. 
Examination of Subgroups 
Subgroup analyses may be conducted for selected endpoints.  Detailed methodology will be 
provided in the SAP. 
8.2.3. 
Handling of Missing Data 
Unrecorded values will be treated as missing.  The appropriateness of the method(s) described 
for handling missing data may be reassessed and documented in the SAP before database lock.  
Depending on the extent of missing values, further investigation may be made into the sensitivity 
of the analysis results to the method(s) specified. 
8.2.4. 
Baseline Evaluations 
Demographics, medical history, disease-specific information, and other baseline characteristics 
collected in this study will be summarized.   
8.2.5. 
Clinical Activity Analyses 
Clinical activity of ALN-AS1 will be summarized primarily by descriptive statistics.  The 
clinical activity of ALN-AS1 will be evaluated by the frequency and characteristics of porphyria 
attacks including duration, treatment, and severity of porphyria attacks and number and duration 
of visits to a health care setting for acute porphyria care. 
Patient diary recordings, including BPI-SF questionnaire scores, will also be summarized. 
8.2.6. 
Pharmacodynamic Analysis 
PD analyses will include the evaluation of change in ALA, PBG, and ALAS mRNA levels.  
Descriptive statistics (eg, mean and standard error of the mean) for observed levels of PD 
parameters and the relative change from baseline will be presented for each of the postdose 
follow-up time points. 
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8.2.7. 
Pharmacokinetic Analysis 
The PK concentration of ALN-AS1 will be determined. 
Antidrug antibody results will be tabulated.  A by-patient data listing will also be provided. 
8.2.8. 
Safety Analyses 
Extent of exposure will be summarized.  AEs will be summarized by the Medical Dictionary for 
Regulatory Activities System Organ Class and Preferred Term.  Prior and concomitant 
medications will be classified according to the World Health Organization drug dictionary. 
Incidence of AEs (those events that started after exposure to study drug or worsened in severity 
after dosing) will be presented.  Incidence of AEs will also be presented by maximum severity 
and relationship to study treatment.  The incidence of SAEs and AEs leading to discontinuation 
of treatment will also be tabulated.  By-patient listings will be provided for deaths, SAEs, and 
AEs leading to discontinuation of treatment.   
Descriptive statistics will be provided for clinical laboratory data and vital signs data, presented 
as both actual values and changes from baseline relative to each on-study evaluation and to the 
last evaluation on study.  Laboratory shift tables from baseline to worst values will be presented.  
Abnormal physical examination findings and 12-lead ECG data will be presented in a by-patient 
data listing. 
Descriptive statistics will be provided for ECG interval data and presented as both actual values 
and changes from baseline relative to each on-study evaluation and to the last evaluation on 
study.  Details of any abnormalities will be included in patient listings. 
Concomitant hemin administration will also be recorded. 
8.2.9. 
Other Analyses 
Possible associations between PD parameters (ALA, PBG, and ALAS1 mRNA levels) and 
clinical activity parameters may also be explored. 
Additional exploratory analyses may be conducted on analytes related to targeting the heme 
biosynthesis pathway. 
QOL scores on the EQ-5D-5L questionnaire will also be summarized. 
9.
STUDY ADMINISTRATION
9.1. 
Ethical and Regulatory Considerations
This study will be conducted in accordance with the protocol, all applicable regulatory 
requirements, and the guidelines of Good Clinical Practice (GCP).  Compliance with GCP 
provides public assurance that the rights, safety, and well-being of study patients are protected 
consistent with the principles that have their origin in the Declaration of Helsinki. 
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9.1.1. 
Informed Consent 
The Investigator will ensure that the patient is given full and adequate oral and written 
information about the nature, purpose, possible risk and benefit of the study.  Patients must also 
be notified that they are free to withdraw from the study at any time.  The patient should be given 
the opportunity to ask questions and allowed time to consider the information provided. 
The patient’s signed and dated informed consent must be obtained before conducting any study 
procedures. 
The Investigator must maintain the original, signed ICF.  A copy of the signed ICF must be 
given to the patient. 
9.1.2. 
Ethical Review 
The final study protocol, including the final version of the ICF, must be approved or given a 
favorable opinion in writing by an IRB or IEC, as appropriate.  The Investigator must submit 
written approval before he or she can enroll any patient into the study. 
The Investigator is responsible for informing the IRB or IEC of any amendment to the protocol 
in accordance with local requirements.  In addition, the IRB or IEC must approve all advertising 
used to recruit patients for the study.  The protocol must be reapproved by the IRB or IEC upon 
receipt of amendments and annually, as local regulations require. 
Initial IRB approval of the protocol, and all materials approved by the IRB for this study 
including the patient consent form and recruitment materials must be maintained by the 
Investigator and made available for inspection. 
The Investigator will submit reports of SAEs as outlined in Section 7.5.6.  In addition, the 
Investigator agrees to submit progress reports to the IRB or IEC per their local reporting 
requirements, or at least annually and at the conclusion of the study.  The reports will be made 
available to the Sponsor or designee. 
Any communications from regulatory agencies in regard to inspections, other studies that impact 
this protocol or the qualifications of study personnel should be promptly reported to the Sponsor 
or its designee. 
The Investigator is also responsible for providing the IRB with reports of any reportable serious 
adverse drug reactions from any other study conducted with the investigational drug.  The 
Sponsor or designee will provide this information to the Investigator. 
Major changes in this research activity, except those to remove an apparent immediate hazard to 
the patient, must be reviewed and approved by the Sponsor and the IRB or IEC that approved the 
study.  Amendments to the protocol must be submitted in writing to the Investigator’s IRB or 
IEC and the Regulatory Authority for approval before patients are enrolled under the amended 
protocol. 
9.1.3. 
Study Documentation, Confidentiality, and Records Retention 
All documentation relating to the study should be retained for the period of time required by 
applicable local law.  If it becomes necessary for the Sponsor, the Sponsor’s designee, applicable 
IRB/IEC, or applicable regulatory authorities to review or audit any documentation relating to 
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the study, the Investigator must permit direct access to all source documents/data.  Records will 
not be destroyed without informing the Sponsor in writing and giving the Sponsor the 
opportunity to store the records for a longer period of time at the Sponsor’s expense.   
The Investigator must ensure that the patients’ anonymity will be maintained.  On the CRFs or 
other documents submitted to the Sponsor or designees, patients should not be identified by their 
names, but by the assigned patient number and initials.  If patient names are included on copies 
of documents submitted to the Sponsor or designees, the names (except for initials) will be 
obliterated and the assigned patient number added to the document.  Documents not for 
submission to the Sponsor (eg, signed ICFs) should be maintained by the Investigator in strict 
confidence. 
The Investigator must treat all of the information related to the study and the compiled data as 
confidential, whose use is for the purpose of conducting the study.  The Sponsor must approve 
any transfer of information not directly involved in the study. 
In compliance with local and/or regional regulations, this clinical study may be registered and 
study results may be posted on public registries, such as ClinicalTrials.gov. 
9.1.4. 
End of the Study 
The end of the study is defined as last patient last visit. 
9.1.5. 
Discontinuation of the Clinical Study 
The Sponsor reserves the right to discontinue the study for clinical or administrative reasons at 
any time.  If the clinical study center does not recruit at a reasonable rate, the study may be 
discontinued at that clinical study center.  Should the study be terminated and/or the clinical 
study center closed for whatever reason, all documentation and study drug pertaining to the study 
must be returned to the Sponsor or its representative, and the Investigators, IEC/IRB and 
Regulatory Authorities will be promptly informed of the termination and the reason for the 
decision.  The Investigator should promptly inform the patients and assure appropriate therapy 
and follow-up.  Patients should then be withdrawn from the study.   
9.2. 
Data Quality Control and Quality Assurance 
9.2.1. 
Data Handling 
Study data must be recorded on case report forms (paper and/or electronic) provided by the 
Sponsor or designee on behalf of the Sponsor.  Case report forms must be completed only by 
persons designated by the Investigator.  If eCRFs are used, study data must be entered by trained 
clinical study center personnel with access to a valid and secure eCRF system.  All data entered 
into the eCRF must also be available in the source documents.  Corrections on paper CRFs must 
be made so as to not obliterate the original data and must be initialed and dated by the person 
who made the correction. 
9.2.2. 
Study Monitoring 
The clinical monitor, as a representative of the Sponsor, has an obligation to closely follow the 
study conduct at the clinical study center.  The monitor will visit the Investigator and clinical 
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study center periodically and will maintain frequent telephone and written contact.  The monitor 
will maintain current personal knowledge of the study through observation, review of study 
records and source documentation, and discussion of the conduct of the study with the 
Investigator and personnel. 
The monitor will review source documents, systems and CRFs to ensure overall quality and 
completeness of the data and to confirm study procedures are complied with the requirements in 
the study protocol.  The Sponsor, or its designee, will be allowed to conduct clinical study center 
visits to the investigation facilities for the purpose of monitoring any aspect of the study.  The 
Investigator agrees to allow the monitor to inspect the drug storage area, study drug stocks, drug 
accountability records, patient charts and study source documents, and other records relative to 
study conduct. 
9.2.3. 
Audits and Inspections 
Periodically, the Sponsor or its authorized representatives audit clinical investigative study 
centers as an independent review of core trial processes and documents to determine whether 
these activities were conducted, and data were recorded, analyzed, and accurately reported 
according to the protocol, GCP guidelines of the ICH, and any applicable regulatory 
requirements.  A regulatory authority, an IEC or an IRB may visit the clinical study center to 
perform audits or inspections, including source data verification.  The Investigator should contact 
the Sponsor, or its designee, immediately if contacted by a regulatory agency about an 
inspection. 
9.3. 
Publication Policy 
It is intended that after completion of the study, the data are to be submitted for publication in a 
scientific journal and/or for reporting at a scientific meeting.  A copy of any proposed manuscript 
must be provided and confirmed received at the Sponsor at least 30 days before its submission, 
and according to any additional publication details in the Investigator Agreement.
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10. 
LIST OF REFERENCES 
1. Anderson KE, Bloomer JR, Bonkovsky HL, Kushner JP, Pierach CA, Pimstone NR, et al. 
Recommendations for the diagnosis and treatment of the acute porphyrias. Ann Intern Med. 2005 
Mar 15;142(6):439-50. 
2. Siegesmund M, van Tuyll van Serooskerken AM, Poblete-Gutierrez P, Frank J. The acute 
hepatic porphyrias: current status and future challenges. Best Pract Res Clin Gastroenterol. 2010 
Oct;24(5):593-605. 
3. Poblete-Gutierrez P, Wiederholt T, Merk HF, Frank J. The porphyrias: clinical presentation, 
diagnosis and treatment. Eur J Dermatol. 2006 May-Jun;16(3):230-40. 
4. Balwani M, Desnick RJ. The porphyrias: advances in diagnosis and treatment. Blood. 2012 
Nov 29;120(23):4496-504. 
5. Puy H, Gouya L, Deybach JC. Porphyrias. Lancet. 2010 Mar 13;375(9718):924-37. 
6. Floderus Y, Sardh E, Moller C, Andersson C, Rejkjaer L, Andersson DE, et al. Variations in 
porphobilinogen and 5-aminolevulinic acid concentrations in plasma and urine from 
asymptomatic carriers of the acute intermittent porphyria gene with increased porphyrin 
precursor excretion. Clin Chem. 2006 Apr;52(4):701-7. 
7. Anderson K. Disorders of heme biosynthesis. 8th ed. CR S, editor: McGraw-Hill, New York 
2001. 
8. Dowman JK, Gunson BK, Mirza DF, Bramhall SR, Badminton MN, Newsome PN. Liver 
transplantation for acute intermittent porphyria is complicated by a high rate of hepatic artery 
thrombosis. Liver Transpl. 2012 Feb;18(2):195-200. 
9. Badminton MN, Elder GH. Molecular mechanisms of dominant expression in porphyria. J 
Inherit Metab Dis. 2005;28(3):277-86. 
10. Deybach J-C, Puy H. 86 - Acute Intermittent Porphyria: From Clinical to Molecular Aspects. 
In: Guilard KMKMS, editor. The Porphyrin Handbook. Amsterdam: Academic Press; 2003. p. 
23-41. 
11. Bylesjo I, Wikberg A, Andersson C. Clinical aspects of acute intermittent porphyria in 
northern Sweden: a population-based study. Scand J Clin Lab Invest. 2009;69(5):612-8. 
12. James MF, Hift RJ. Porphyrias. Br J Anaesth. 2000 Jul;85(1):143-53. 
13. Chemmanur AT, Bonkovsky HL. Hepatic porphyrias: diagnosis and management. Clin Liver 
Dis. 2004 Nov;8(4):807-38, viii. 
14. Stein P, Badminton M, Barth J, Rees D, Stewart MF. Best practice guidelines on clinical 
management of acute attacks of porphyria and their complications. Ann Clin Biochem. 2013 
May;50(Pt 3):217-23. 
15. Bonkovsky HL. Neurovisceral porphyrias: what a hematologist needs to know. Hematology 
Am Soc Hematol Educ Program. 2005:24-30. 
16. Panhematin. (hemin for injection). 2013. 
17. Normosang. (human hemin). 2007. 
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18. Watson CJ, Pierach CA, Bossenmaier I, Cardinal R. Postulated deficiency of hepatic heme 
and repair by hematin infusions in the "inducible" hepatic porphyrias. Proc Natl Acad Sci U S A. 
1977 May;74(5):2118-20. 
19. Mustajoki P, Nordmann Y. Early administration of heme arginate for acute porphyric attacks. 
Arch Intern Med. 1993 Sep 13;153(17):2004-8. 
20. Bonkovsky HL, Singh RH, Jafri IH, Fiellin DA, Smith GS, Simon D, et al. A randomized, 
controlled trial of treatment of alcoholic hepatitis with parenteral nutrition and oxandrolone. II. 
Short-term effects on nitrogen metabolism, metabolic balance, and nutrition. Am J Gastroenterol. 
1991 Sep;86(9):1209-18. 
21. Herrick AL, McColl KE, Moore MR, Cook A, Goldberg A. Controlled trial of haem arginate 
in acute hepatic porphyria. Lancet. 1989 Jun 10;1(8650):1295-7. 
22. Bissell DM. Treatment of acute hepatic porphyria with hematin. J Hepatol. 1988 Feb;6(1):1-
7. 
23. Green D, Ts'ao CH. Hematin: effects on hemostasis. J Lab Clin Med. 1990 Feb;115(2):144-
7. 
24. Daimon M, Susa S, Igarashi M, Kato T, Kameda W. Administration of heme arginate, but 
not hematin, caused anaphylactic shock. Am J Med. 2001 Feb 15;110(3):240. 
25. Elder G, Harper P, Badminton M, Sandberg S, Deybach JC. The incidence of inherited 
porphyrias in Europe. J Inherit Metab Dis. 2013 Sep;36(5):849-57. 
26. Anderson K. Heme arginate for prevention of acute porphyric attacks (abstract). Acta 
Haematologica. 1997;98((suppl 1):120). 
27. Bonkovsky HL, Guo JT, Hou W, Li T, Narang T, Thapar M. Porphyrin and heme 
metabolism and the porphyrias. Compr Physiol. 2013 Jan;3(1):365-401. 
28. Vaishnaw AK, Gollob J, Gamba-Vitalo C, Hutabarat R, Sah D, Meyers R, et al. A status 
report on RNAi therapeutics. Silence. 2010;1(1):14. 
29. Elbashir SM, Harborth J, Lendeckel W, Yalcin A, Weber K, Tuschl T. Duplexes of 21-
nucleotide RNAs mediate RNA interference in cultured mammalian cells. Nature. 2001 May 
24;411(6836):494-8. 
30. Kauppinen R, von und zu Fraunberg M. Molecular and biochemical studies of acute 
intermittent porphyria in 196 patients and their families. Clin Chem. 2002 Nov;48(11):1891-900. 
31. Division of Clinical Pharmacology, Indiana University, P450 Drug Interaction Table.  2013 [ 
Accessed 06 February 2015]; Available from: http://medicine.iupui.edu/clinpharm/ddis/main-
table/. 
32. Atkinson TM M, TR, Sit L, Passik P, Scher, HI, Cleeland C, and Basch E. The Brief Pain 
Inventory and its “Pain at its Worst in the last 24 Hours” Item: Clinical Trial Endpoint 
Considerations. Pain Med. 2010 March;11(3):337–46. 
33. Levey AS SL, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, Kusek JW, Eggers P, 
Van Lente F, Greene T, Coresh J; CKD-EPI (Chronic Kidney Disease Epidemiology 
Collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med. 
2009;150(9):604-12. 
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34. Herdman M GC, Lloyd A, Janssen M, Kind P, Parkin D, Bonsel G, Badia X. Development
and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res. 
2011;20(10):1727-36. 
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11.
APPENDICES
11.1. 
Pharmacokinetic Assessment Time Points 
Table 3 contains a detailed schedule for the collection of blood samples for PK analysis. 
Table 3: 
Pharmacokinetic Time Points 
Study Day 
Protocol Time 
(hh:mm) 
PK Blood 
Day 1 and 
Month 12 (D361) ±10 days 
Predose (within 60 minutes 
before dosing) 
X 
02:00 (±5 minutes) 
X 
06:00 (±20 minutes) 
X 
Month 1 (Day 14) ±2 days 
Anytime during visit 
X 
Month 1 (Day 31) ±7 days,a  
Month 3 (Day 91) ±7 days, 
Month 6 (Day 181) ±7 days, 
Month 18 (Day 541) ±10, and 
Month 24 (Day 721) ±10 days 
Predose (within 60 minutes 
before dosing) 
X 
02:00 (±5 minutes) 
X 
Abbreviations:  hh=hours; mm=minutes; PK=pharmacokinetic. 
a  At the Day 31 1 visit, if the dosing regimen is every 3 months, ALN-AS1 is not administered and a single 
time point blood sample for PK analysis should be collected. 
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11.2. 
Schedules of Assessments for Every Month Dosing Regimen 
Table 4: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14 ±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Informed Consent 
X 
Medical History/Disease 
Historyc 
X
X 
Demographics 
X
Inclusion/ 
Exclusion Criteria 
X
X 
Physical Examinationd 
X
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Vital Signsf 
X 
X 
X 
X 
X 
X
X
X
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGg 
X 
X 
X 
X 
Clinical Laboratory 
Assessmenth 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationj 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood and Urine Sample for 
X 
X 
X 
X 
X 
X 
X 
X 
X 
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Table 4: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D14 ±2 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Exploratory Biomarker 
Analysisl 
Blood Sample for PK 
Analysism 
X 
X 
X 
X 
X 
X 
X 
Antidrug Antibodiesn 
X 
X 
X 
X 
X 
X 
Porphyria Attack Kit 
Dispensationo 
X 
EQ-5D-5L Questionnairep 
X 
X 
X 
X 
Diary Review (including 
BPI-SF)q 
X 
AEs 
Continuous 
Concomitant Medicationsr 
 
Continuous 
Abbreviations:  AE=adverse event; ALAS1=5-aminolevulinic acid synthase 1; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief 
Pain Inventory-Short Form; D=day; ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of life; 
SC=subcutaneous. 
Notes:   
•
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may
be conducted while the patient is at home.
•
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical
examinations and blood/urine sample collections.
a Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study (ALN-AS1-001) were completed within 60 days 
of administration of the first dose of ALN-AS1 in this study.  If more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs 
will be repeated before administration of ALN-AS1.  Results should be available and deemed acceptable before the administration of the first dose of ALN-
AS1. 
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b After a patient has completed 6 months of ALN-AS1 administration in this study, and where applicable country and local regulations and infrastructure allow, 
study visits and ALN-AS1 administration may take place at the patient’s home by a healthcare professional.  Home visits may occur at the discretion of the 
Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit at the clinical study center Q3M through M12, and 
thereafter Q6M. 
c See Section 7.1 for details on the interval medical history/disease history to be recorded at Screening/Baseline.  Ongoing AEs from the previous study 
(ALN-AS1-001) will be captured as medical history. 
d A complete physical examination will be performed at Screening/Baseline, and D1.  At all other visits, a targeted physical examination will be performed.  On 
dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any time 
during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On D1, vital signs will be collected within 1 hour predose; and 2 hours 
(±10 minutes) postdose.  On all other dosing days, vital signs will be collected within 1 hour predose.  On days when ALN-AS1 is not administered, vital signs 
can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position (should be consistent for each patient), after the 
patient has rested comfortably for 10 minutes. 
g Triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 10 minutes.  On D1, ECGs will be 
performed within 1 hour predose and 2 hours (±10 minutes) postdose.  On all other dosing days, ECGs will be collected within 1 hour predose. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected within 1 hour 
predose.  Results from clinical laboratory tests collected on dosing days are not required before study drug administration; however, if results for clinical 
laboratory tests from the previous study visit are not available or are deemed clinically significant, then clinical laboratory assessments must be repeated and 
the results must be deemed acceptable by the Investigator before study drug administration.  On days when ALN-AS1 is not administered, blood samples can 
be collected at any time during the visit. 
i A serum pregnancy test will be performed at Screening/Baseline; thereafter, urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  For weight-
based dosing, weight measured on the dosing day will be used to calculate the dose of ALN-AS1.  After M12, weight measured on the nearest previous visit 
will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 3 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o Porphyria attack laboratory sample collection kits should be dispensed at the screening visit along with instructions for use. For any attack that occurs through
M39, urine samples should be collected within 24 hours of the start of clinical intervention (eg, hemin or glucose administration) and within 24 hours of the end
of clinical intervention.  If patients are unable to report to the clinical study center during a porphyria attack, laboratory sample collection kits should be used
for collecting and sending urine samples to the clinical study center, if possible.  These urine samples may also be analyzed for exploratory biomarkers.
p In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but not more than once in a 6 month period), if possible.  
q Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, and narcotic use on a daily basis through M9; 
thereafter, acute porphyria attacks will be recorded in the diary.  The BPI will be completed on a weekly basis as part of the patient diary through M9, then 
Q3M. 
r Medications that are ongoing from the previous study (ALN-AS1-001), started between the previous study and this study, and started after signing informed 
consent in this study, will be captured as concomitant medication(s). 
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Table 5: 
Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20a 
M21a 
M22/ 
M23a 
M24 
M25/ 
M26a 
M27a 
M28/ 
M29a 
M30 
M31/ 
M32a 
M33a 
M34/ 
M35a 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Physical Examinationd 
X 
X 
X 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
X 
Vital Signsf 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGg 
X 
X 
Clinical Laboratory 
Assessmenth 
X 
X 
X 
X 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationj 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
X 
X 
X 
X 
X 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl  
X 
X 
X 
X 
Blood Sample for PK 
Analysism 
X 
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Table 5: 
Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20a 
M21a 
M22/ 
M23a 
M24 
M25/ 
M26a 
M27a 
M28/ 
M29a 
M30 
M31/ 
M32a 
M33a 
M34/ 
M35a 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Antidrug Antibodiesn 
X 
X 
EQ-5D-5L Questionnaireo 
X 
X 
X 
Diary Review (including 
BPI-SF)p 
X 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; EOS = End of Study; EOT = End of Treatment; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality 
of life; SC=subcutaneous. 
Notes:   
•
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be
conducted while the patient is at home.
•
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations
and blood/urine sample collections.
a Where applicable country and local regulations and infrastructure allow, study visits and ALN-AS1 administration may take place at the patient’s home by a 
healthcare professional.  Home visits may occur at the discretion of the Investigator, based on safety and tolerability; however, patients are required to complete 
at least 1 visit at the clinical study center Q6M. 
b Patients who discontinue treatment will be asked to complete the M39 visit assessments.  If a patient chooses to withdraw from the study, every effort should 
be made to conduct early the assessments performed at the M39 visit.  See Section 5.3 for details on removal from treatment or assessment. 
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c The ALA/PBG Monitoring/EOS visit will be conducted at the clinical study center or via phone contact, unless treatment continues with ALN-AS1.  Patients 
will be provided with laboratory sample collection kits and instructions for collecting and sending urine samples to the clinical study center.  Urine samples 
should not be collected during a porphyria attack. 
d A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed.  
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On a dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for 10 minutes. 
g Triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 10 minutes.  On dosing days, ECGs will 
be collected within 1 hour predose. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected within 1 hour 
predose  Results from clinical laboratory tests collected on dosing days are not required before study drug administration; however, if results for clinical 
laboratory tests from the previous study visit are not available or are deemed clinically significant, then clinical laboratory assessments must be repeated and 
the results must be deemed acceptable by the Investigator before study drug administration.  On days when ALN-AS1 is not administered, blood samples can 
be collected at any time during the visit. 
i Urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured on the nearest previous visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 3 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but, not more than once in a 6 month period), if possible.  
p Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
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11.3. 
List of Sensitive CYP3A Substrates and those with a Narrow 
Therapeutic Range 
A list of medications that are sensitive CYP3A substrates and those with a narrow therapeutic 
range is in Table 6.  
Table 6: 
List of Sensitive CYP3A Substrates and those with a Narrow Therapeutic 
Range 
Sensitive CYP3A Substrates 
CYP3A Substrates With A Narrow 
Therapeutic Range 
alfentanil 
fluticasone 
Alfentanil 
aprepitant 
lopinavir 
Astemizole 
budesonide 
lovastatin 
Cisapride 
buspirone 
lurasidone 
Cyclosporine 
conivaptan 
maraviroc 
Diergotamine 
darifenacin 
midazolam 
Dihydroergotamine 
darunavir 
nisoldipine 
Ergotamine 
dasatinib 
quetiapine 
Fentanyl 
dronedarone 
saquinavir 
Irinotecan 
eletriptan 
sildenafil 
Pimozide 
eplerenone 
simvastatin 
Quinidine 
everolimus 
sirolimus 
Sirolimus 
felodipine 
tolvaptan 
Tacrolimus 
imatinib 
tipranavir 
Terfenadine 
indinavir 
triazolam 
vardenafil 
Note:  This is not an exhaustive list and availability of medications may differ between countries.  For more 
information about clinically relevant drugs that are CYP3A substrates, see the Indiana University Division of 
Pharmacology website for reference: http://medicine.iupui.edu/clinpharm/ddis/clinical-table/. 
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Clinical Study Protocol ALN-AS1-002 
 
Amendment 2 Summary of Changes_01 December 2016 
 
ALN-AS1-002 Protocol Amendment 2 
Summary of Changes (dated 01 December 2016)  
compared to Protocol Amendment 1 (dated 10 November 2016) 
A Multicenter, Open-label Extension Study to Evaluate the Long-term Safety and Clinical 
Activity of Subcutaneously Administered ALN AS1 in Patients with Acute Intermittent 
Porphyria who have Completed a Previous Clinical Study with ALN-AS1 
 
Rationale for Protocol Amendment 
The primary purpose of this amendment is to implement additional safety monitoring; 
specifically to require lipase monitoring and review of recent clinical laboratory results prior to 
dosing.  These changes are being made in accordance with the study's Safety Review Committee 
recommendation pursuant to an unlikely related SAE of hemorrhagic pancreatitis with fatal 
outcome. This amendment includes the following changes: 
• A Day 14 clinic visit has been added to allow safety assessment approximately 2 weeks 
following the first study drug dose. 
• Lipase has been added to the battery of serum chemistry parameters regularly collected 
throughout the study 
• Laboratory results from the previous clinical visit are now required to be available prior 
to each dose. If results from the previous visit are clinically significant or are not 
available, assessments must be repeated and the results must be deemed acceptable by the 
Investigator before study drug administration 
• Lipase testing is now required, and imaging should be considered by the Investigator, 
when a patient experiences uncharacteristic signs and symptoms during a porphyria 
attack. 
• Imaging is now required following a clinical laboratory test result of serum lipase ≥3× the 
upper limit of normal. 
Additionally, out of date text describing the nonclinical and clinical experience with ALN-AS1 
has been removed and replaced with a reference to the current Investigator's Brochure, which has 
been updated to include a description of the aforementioned unlikely related fatal SAE. 
A detailed summary of the changes is provided in Table 1.  Corrections to typographical errors 
and formatting are not detailed. 
 
 
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Amendment 2 Summary of Changes_01 December 2016 
Table 1: 
Protocol Amendment 2 Detailed Summary of Changes 
The primary section(s) of the protocol affected by the changes in the protocol amendment are indicated.  The corresponding text has 
been revised throughout the protocol.  Deleted text is indicated by strikeout; added text is indicated by bold font. 
Purpose: To add a clinic visit approximately 2 weeks following the first dose of study drug 
The primary change occurs in Table 1, Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
Added text: 
A column has been added to the schedule of assessments reflecting a Day 14 visit during which safety 
assessments will be collected. 
Section(s) also containing this change or similar changes: 
• 
Table 3, Pharmacokinetic Time Points 
• 
Table 4, Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Purpose: To clarify that safety assessments must be available and deemed acceptable prior to administration of the first dose of study drug. 
The primary change occurs in Table 1, Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen), 
Footnote a 
Now reads: 
a. Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study (ALN-AS1-
001) were completed within 60 days of administration of the first dose of ALN-AS1 in this study.  If more than 60 days have 
elapsed since the last assessment, clinical laboratory tests and ECGs will be repeated before administration of ALN-AS1.  
Results should be available and deemed acceptable before the administration of the first dose of ALN-AS1. 
Section(s) also containing this change or similar changes: 
• 
Table 4, Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Purpose: To require review of clinical laboratory tests from previous visit prior to each study drug administration. 
The primary change occurs in Table 1, Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen), 
Footnote h 
Now reads: 
h. Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory 
evaluations will be collected within 1 hour predose; results are not required before dosing.  Results from clinical laboratory 
tests collected on dosing days are not required before study drug administration; however, if results for clinical 
laboratory tests from the previous study visit are not available or are deemed clinically significant, then clinical 
laboratory assessments must be repeated and the results must be deemed acceptable by the Investigator before study 
drug administration.  On days when ALN-AS1 is not administered, blood samples can be collected at any time during the 
visit. 
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Clinical Study Protocol ALN-AS1-002 
 
Amendment 2 Summary of Changes_01 December 2016 
Section(s) also containing this change or similar changes: 
• 
Table 2, Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen) 
• 
Section 7.5.5 Clinical Laboratory Assessments 
• 
Table 4, Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
• 
Table 5, Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen) 
Purpose: To streamline the protocol introduction by removing out of date text describing the nonclinical and clinical experience with ALN-AS1.  
The primary change occurs in Section 1 INTRODUCTION 
Now reads: 
Section 1.3.1 Nonclinical Summary and Section 1.3.2 Clinical Summary have been removed.  
Subsequent sections have been renumbered appropriately. Section 1.3 now reads: 
ALN-AS1 comprises a synthetic siRNA covalently linked to a GalNAc containing ligand 
(ALN60519), specific for ALAS1 and formulated for administration via subcutaneous (SC) 
injection. ALN-60519 has a target region between nucleotide 918 to 937 of the ALAS1 mRNA. 
Attachment to a triantennary GalNAc ligand to the siRNA enables its distribution to the liver 
(which is the primary site of ALAS1 synthesis), followed by intracellular delivery to hepatocytes 
via ASGPR, resulting in engagement of the RNAi pathway and suppression of hepatic ALAS1 
protein synthesis. 
ALN-AS1 is currently in development for treatment of acute attacks in patients with AIP, the 
most common AHP. 
Further information on ALN-AS1, including the clinical and nonclinical experience to date, is 
available in in the current version of the Investigator’s Brochure (IB). 
Purpose: To require clinical laboratory tests and consider imaging when a patient experiences uncharacteristic signs and symptoms during a 
porphyria attack. 
The primary change occurs in Section 7.5.5 Clinical Laboratory Assessments 
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Amendment 2 Summary of Changes_01 December 2016 
Added text: 
At any point during the study, and based on Investigator judgment, if a patient experiences 
uncharacteristic signs and symptoms during a porphyria attack, lipase testing should be 
performed and imaging evaluations (eg, right upper quadrant ultrasound and/or other testing, 
based on Investigator judgment) should be considered by the Investigator.  Signs and symptoms 
include, but are not limited to, uncharacteristic abdominal pain and worsening nausea and 
vomiting. 
Purpose: To require imaging following a result of serum lipase ≥3× the upper limit of normal 
The primary change occurs in Section 7.5.5 Clinical Laboratory Assessments 
Added text: 
Imaging is required for any serum lipase result of ≥3× the upper limit of normal, or as clinically 
indicated. 
Purpose: To add lipase to the serum chemistry battery as well as inadvertently omitted bicarbonate. 
The primary change occurs in Section 7.5.5 Clinical Laboratory Assessments 
Added text: 
Lipase and bicarbonate have been added to the list of serum chemistry parameters to be collected as part of 
clinical laboratory tests. 
Purpose:  Correct typographical and formatting. 
These changes are not listed individually. 
 
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Clinical Study Protocol ALN-AS1-002 
Amendment 1_10 November 2016 
 
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CLINICAL STUDY PROTOCOL 
ALN-AS1-002 
 
Protocol Title: 
A Multicenter, Open-label Extension Study to Evaluate the Long-term 
Safety and Clinical Activity of Subcutaneously Administered 
ALN-AS1 in Patients with Acute Intermittent Porphyria who have 
Completed a Previous Clinical Study with ALN-AS1 
Investigational Drug: 
ALN-AS1 
EudraCT Number: 
2016-002638-54 
IND Number: 
126094 
Protocol Date: 
Original Protocol 19 July 2016 
 
Protocol Amendment 0.1 (Sweden) 20 September 2016 
 
Protocol Amendment 1 10 November 2016 
Sponsor: 
Alnylam Pharmaceuticals, Inc. 
300 Third Street 
Cambridge, MA  02142 USA 
Telephone:
 
Sponsor Contact:   
 
  
 
 
The concepts and information contained in this document or generated during the study are considered 
proprietary and may not be disclosed in whole or in part without expressed written authorization of 
Alnylam Pharmaceuticals, Inc. 
 
513
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Clinical Study Protocol ALN-AS1-002 
Amendment 1 10 November 2016 
SPONSOR PROTOCOL APPROVAL 
I have read this protocol and I approve the design of this study. 
Date 
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PPD

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Clinical Study Protocol ALN-AS1-002 
Amendment 1_10 November 2016 
 
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INVESTIGATOR’S AGREEMENT 
 
I have read the ALN-AS1-002 protocol and agree to conduct the study as outlined.  I agree to 
maintain the confidentiality of all information received or developed in connection with this 
protocol. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Printed Name of Investigator 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signature of Investigator 
 
 
 
 
 
 
 
 
Date 
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PROTOCOL SYNOPSIS 
Protocol Title 
A Multicenter, Open-label Extension Study to Evaluate the Long-term Safety and Clinical Activity of 
Subcutaneously Administered ALN-AS1 in Patients with Acute Intermittent Porphyria who have 
Completed a Previous Clinical Study with ALN-AS1 
Product Name 
ALN-AS1 
Indication 
Patients with acute intermittent porphyria (AIP) who experience recurrent porphyria attacks 
Phase 
1/2 
Study center(s)   
The study will be conducted at up to 8 clinical study centers worldwide. 
Objectives 
Primary 
 
Evaluate the long-term safety and tolerability of ALN-AS1 in patients with AIP 
Secondary 
 
Assess the pharmacodynamic (PD) effect of ALN-AS1 over time 
 
Assess the clinical activity of ALN-AS1 over time 
Exploratory 
 
Characterize the pharmacokinetic (PK) profile of ALN-AS1 over time 
 
Assess changes in health-related quality of life (QOL) 
 
Characterize analytes related to targeting the heme biosynthesis pathway 
Endpoints 
Primary 
 
Patient incidence of adverse events (AEs) 
Secondary 
 
Change in urine delta-aminolevulinic acid (ALA) and porphobilinogen (PBG) levels 
 
Frequency and characteristics of porphyria attacks 
 
Change in hemin administration 
Exploratory 
 
Change in circulating 5-aminolevulinic acid synthase 1 (ALAS1) mRNA levels 
 
Concentrations of ALN-AS1 and antidrug antibodies  
 
Duration and treatment of porphyria attacks 
 
Number and duration of visits to a health care facility for acute porphyria care 
 
EQ-5D-5L questionnaire scores 
 
Pain assessment and narcotic use as recorded in a patient diary 
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 
Exploratory biomarkers related to the target pathway, such as urine porphyrins, vitamin D binding 
protein 
Study Design 
This is a multicenter, open-label extension study to evaluate the long-term safety and clinical activity 
of ALN-AS1 in patients with AIP who completed study ALN-AS1-001. 
The last assessments performed, determining previous study (ALN-AS1-001) completion, will serve as 
the Screening/Baseline assessments in this study.  If more than 60 days have elapsed since the last 
assessment, safety assessments will be repeated before administration of ALN-AS1.  It is anticipated 
that patients will begin ALN-AS1 administration in this study within 6 months after the last dose of 
study drug in the previous study.  Eligibility will be confirmed before administration of the first dose of 
ALN-AS1 (Day 1).  Patients will undergo assessments at the clinical study center every month for the 
first 3 months.  Then, through Month 6, and according to the dosing regimen selected, assessments will 
take place at the clinical study center or via a phone contact (for an every month dosing regimen, visits 
will be every month; for an every 3 months dosing regimen, visits will be every 3 months).  After a 
patient has completed 6 months of ALN-AS1 administration in this study  (6 months in an every month 
dosing regimen), and where applicable country and local regulations and infrastructure allow, study 
visits and ALN-AS1 administration may take place at the patient’s home by a healthcare professional.  
Home visits may occur at the discretion of the Investigator, based on safety and tolerability; however, 
patients are required to complete at least 1 visit at the clinical study center every 3 months for the first 
year, and thereafter every 6 months through the end of the treatment period.  Patients will return to the 
clinical study center for a posttreatment follow-up visit after administration of the last dose of 
ALN-AS1.  An ALA/PBG Monitoring/EOS visit will be conducted either at the clinical study center or 
via phone contact, unless treatment continues with ALN-AS1. 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, 
and narcotic use.  Patients will also be provided with laboratory sample collection kits and instructions 
for collecting and sending urine samples to the clinical study center. 
A Safety Review Committee (SRC) will review safety and tolerability data collected during the study 
with the primary purpose of protecting the safety of patients participating in the study. 
Number of Planned Patients 
Up to 24 patients are planned for enrollment in this study (including optional cohorts in 
ALN-AS1-001). 
Diagnosis and Main Eligibility Criteria 
Patients with AIP, who have completed Part C of study ALN-AS1-001, will be eligible for screening in 
this study.  Eligible patients will not be on a scheduled regimen of hemin to prevent porphyria attacks 
at Screening.  Patients with alanine transaminase ≥2.0× upper limit of normal, total bilirubin ≥2 mg/dL 
(unless bilirubin elevation is due to Gilbert’s syndrome), or estimated glomerular filtration rate 
≤30 mL/min/1.73 m2 (using the Modification of Diet in Renal Disease formula) at Screening are not 
eligible for this study. 
Investigational Product, Dose, and Mode of Administration 
ALN-AS1 Solution for Injection (subcutaneous use [SC]) is comprised of a synthetic, small interfering 
RNA targeting ALAS1 and bearing a triantennary N-acetyl galactosamine ligand conjugated to the 
sense strand, formulated in phosphate buffer.   
The study starting dose and regimen of ALN-AS1 is 5.0 mg/kg as an SC injection administered every 
3 months.  Based on emerging clinical data, the SRC may approve changes to the dosing regimen, 
including decreases in the dose level and changes in the dosing frequency.  However any dose and 
dosing regimen will not exceed a previously explored dose level or frequency that was determined to 
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be safe and well-tolerated in study ALN-AS1-001, SRC, Health Authority and Ethics Committee 
approval must be sought prior to dose escalation above 5.0 mg/kg in accordance with local Regulatory 
requirements.  
Reference Therapy, Dose, and Mode of Administration 
Not applicable 
Duration of Treatment and Study 
The duration of treatment is up to 36 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 44 months. 
Statistical Methods 
Statistical analyses will be primarily descriptive.  Incidence of AEs will be summarized by maximum 
severity and relationship to ALN-AS1.  Incidence of and serious adverse events (SAEs) and AEs 
leading to discontinuation will also be tabulated.  By-patient listings will be provided for deaths, SAEs, 
and events leading to discontinuation.  
Laboratory shift tables from baseline to worst values will be presented.  Abnormal physical 
examination findings and electrocardiogram data will be presented in by-patient listings.  Descriptive 
statistics will be provided for electrocardiogram interval data and presented as both actual values and 
changes from baseline relative to each on study evaluation and to the last evaluation on-study. 
Clinical activity of ALN-AS1 will be summarized primarily by descriptive statistics.  The clinical 
activity of ALN-AS1 will be evaluated by the frequency and characteristics of porphyria attacks 
including duration, treatment, and severity of porphyria attacks and number and duration of visits to a 
health care setting for acute porphyria care.  Patient diary recordings, including BPI-SF questionnaire 
scores, will also be summarized.   
PD analysis will include the evaluation of change in ALA, PBG, and ALAS mRNA levels.  Descriptive 
statistics (eg, mean and standard error of the mean) for observed levels of PD parameters and the 
relative change from baseline will be presented for each of the postdose follow-up time points. 
The PK concentration of ALN-AS1 will be determined.  Antidrug antibody results will be tabulated 
overall and by previous treatment in the previous study (ALN-AS1-001).  A by-patient listing will also 
be provided. 
Additional exploratory analyses may be conducted on analytes related to targeting the heme 
biosynthesis pathway.  Quality of life scores will also be summarized. 
 
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Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8 
M9 
M10/ 
M11 
M12 
M13/ 
M14 
M15b 
M16/ 
M17 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History/Disease 
Historyc 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/ 
Exclusion Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examinationd 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
 
 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
 
 
X 
 
X 
 
X 
 
X 
 
 
 
X 
Vital Signsf 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Triplicate 12-Lead ECGg 
X 
X 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
Clinical Laboratory 
Assessmenth 
X 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Study Drug Administrationj 
 
X 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Urine Sample for PBG, ALA, 
and Creatinine Analysisk 
 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl 
 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Blood Sample for PK 
Analysism 
 
X 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
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Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8 
M9 
M10/ 
M11 
M12 
M13/ 
M14 
M15b 
M16/ 
M17 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Antidrug Antibodiesn 
 
X 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
Porphyria Attack Kit 
Dispensationo 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EQ-5D-5L Questionnairep 
X 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Diary Review (including 
BPI-SF)q 
 
X 
Phone Contactr 
 
 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
AEs 
 
Continuous 
Concomitant Medicationss 
Continuous 
Abbreviations:  AE=adverse event; ALAS1=5-aminolevulinic acid synthase 1; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain 
Inventory-Short Form; D=day; ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of life; 
SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations and 
blood/urine sample collections. 
a Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study (ALN-AS1-001) were completed within 60 days 
of administration of the first dose of ALN-AS1 in this study.  If more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs 
will be repeated before administration of ALN-AS1.  Results should be available before the administration of the first dose of ALN-AS1. 
b After a patient has completed 12 months of ALN-AS1 administration in this study, and where applicable country and local regulations and infrastructure allow, 
study visits and ALN-AS1 administration may take place at the patient’s home by a healthcare professional.  Home visits may occur at the discretion of the 
Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit at the clinical study center Q6M. 
c See Section 7.1 for details on the interval medical history/disease history to be recorded at Screening/Baseline.  Ongoing AEs from the previous study 
(ALN-AS1-001) will be captured as medical history. 
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d A complete physical examination will be performed at Screening/Baseline, and D1.  At all other visits, a targeted physical examination will be performed.  On 
dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any time 
during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On D1, vital signs will be collected within 1 hour predose; and 2 hours 
(±10 minutes) postdose.  On all other dosing days, vital signs will be collected within 1 hour predose.  On days when ALN-AS1 is not administered, vital signs 
can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position (should be consistent for each patient), after the 
patient has rested comfortably for 10 minutes. 
g Triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 10 minutes.  On D1, ECGs will be 
performed within 1 hour predose and 2 hours (±10 minutes) postdose.  On all other dosing days, ECGs will be collected within 1 hour predose. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected within 1 hour 
predose; results are not required before dosing.  On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. 
i A serum pregnancy test will be performed at Screening/Baseline; thereafter, urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  For 
weight-based dosing, weight measured on the dosing day will be used to calculate the dose of ALN-AS1.  After M12, weight measured on the nearest previous 
visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 3 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o Porphyria attack laboratory sample collection kits should be dispensed at the screening visit along with instructions for use. For any attack that occurs through 
M39, urine samples should be collected within 24 hours of the start of clinical intervention (eg, hemin or glucose administration) and within 24 hours of the end 
of clinical intervention.  If patients are unable to report to the clinical study center during a porphyria attack, laboratory sample collection kits will be provided 
that contain instructions for collecting and sending urine samples to the clinical study center, if possible.  These urine samples may also be analyzed for 
exploratory biomarkers. 
p In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but not more than once in a 6 month period), if possible.  
q Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, and narcotic use on a daily basis through M9; 
thereafter, acute porphyria attacks will be recorded in the diary.  The BPI will be completed on a weekly basis as part of the patient diary through M9, then 
Q3M. 
r Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack. 
s Medications that are ongoing from the previous study (ALN-AS1-001), started between the previous study and this study, and started after signing informed 
consent in this study, will be captured as concomitant medication(s). 
 
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Table 2: 
Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20 
M21a 
M22/ 
M23 
M24 
M25/ 
M26 
M27a 
M28/ 
M29 
M30 
M31/ 
M32 
M33a 
M34/ 
M35 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Physical Examinationd 
 
 
 
X 
 
 
 
X 
 
 
 
X 
X 
 
Body Weight, BMI, and 
Heighte 
 
 
 
X 
 
 
 
X 
 
 
 
 
X 
 
Vital Signsf 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
 
Triplicate 12-Lead ECGg 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
 
Clinical Laboratory 
Assessmenth 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
 
Pregnancy Testi 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
 
Study Drug Administrationj 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl 
 
 
 
X 
 
 
 
X 
 
 
 
X 
X 
 
Blood Sample for PK 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
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Table 2: 
Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20 
M21a 
M22/ 
M23 
M24 
M25/ 
M26 
M27a 
M28/ 
M29 
M30 
M31/ 
M32 
M33a 
M34/ 
M35 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Analysism 
Antidrug Antibodiesn 
 
 
 
X 
 
 
 
 
 
 
 
X 
 
 
EQ-5D-5L Questionnaireo 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
Diary Review (including 
BPI-SF)p 
X 
 
Phone Contactq 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
X 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; EOS = End of Study; EOT = End of Treatment; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality 
of life; SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
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a Where applicable country and local regulations and infrastructure allow, study visits and ALN-AS1 administration may take place at the patient’s home by a 
healthcare professional.  Home visits may occur at the discretion of the Investigator, based on safety and tolerability; however, patients are required to complete 
at least 1 visit at the clinical study center Q6M. 
b Patients who discontinue treatment will be asked to complete the M39 visit assessments.  If a patient chooses to withdraw from the study, every effort should 
be made to conduct early the assessments performed at the M39 visit.  See Section 5.3 for details on removal from treatment or assessment. 
c The ALA/PBG Monitoring/EOS visit will be conducted at the clinical study center or via phone contact, unless treatment continues with ALN-AS1.  Patients 
will be provided with laboratory sample collection kits and instructions for collecting and sending urine samples to the clinical study center. 
d A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed.  
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On a dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for 10 minutes. 
g Triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 10 minutes.  On dosing days, ECGs will 
be collected within 1 hour predose. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected within 1 hour 
predose; results are not required before dosing.  On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. 
i Urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured on the nearest previous visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 3 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but, not more than once in a 6 month period), if possible.  
p Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
q Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack.
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TABLE OF CONTENTS 
PROTOCOL SYNOPSIS ................................................................................................................4 
TABLE OF CONTENTS ...............................................................................................................13 
LIST OF TABLES .........................................................................................................................16 
LIST OF FIGURES .......................................................................................................................16 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS ................................................17 
1. 
INTRODUCTION ......................................................................................................19 
1.1. 
Disease Overview .......................................................................................................19 
1.1.1. 
Epidemiology ..............................................................................................................19 
1.1.2. 
Current Management and Unmet Medical Need ........................................................20 
1.2. 
RNA Interference ........................................................................................................21 
1.3. 
ALN-AS1 ....................................................................................................................21 
1.3.1. 
Nonclinical Summary .................................................................................................21 
1.3.2. 
Clinical Summary .......................................................................................................22 
1.4. 
Study Design Rationale ..............................................................................................23 
1.5. 
Dose Rationale ............................................................................................................23 
1.6. 
Benefit-Risk Assessment ............................................................................................24 
2. 
OBJECTIVES .............................................................................................................25 
2.1. 
Primary Objective .......................................................................................................25 
2.2. 
Secondary Objectives .................................................................................................25 
2.3. 
Exploratory Objectives ...............................................................................................25 
3. 
ENDPOINTS ..............................................................................................................25 
3.1. 
Primary Endpoint ........................................................................................................25 
3.2. 
Secondary Endpoints ..................................................................................................25 
3.3. 
Exploratory Endpoints ................................................................................................26 
4. 
INVESTIGATIONAL PLAN .....................................................................................26 
4.1. 
Summary of Study Design ..........................................................................................26 
4.2. 
Duration of Treatment and Study ...............................................................................27 
4.3. 
Number of Patients .....................................................................................................27 
4.4. 
Method of Assigning Patients to Treatment Groups ..................................................27 
4.5. 
Blinding ......................................................................................................................27 
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4.6. 
Safety Review Committee ..........................................................................................28 
5. 
SELECTION AND WITHDRAWAL OF PATIENTS ..............................................28 
5.1. 
Inclusion Criteria ........................................................................................................28 
5.2. 
Exclusion Criteria .......................................................................................................28 
5.3. 
Removal from Treatment or Assessment ...................................................................29 
5.3.1. 
Discontinuation of Study Drug ...................................................................................29 
5.3.2. 
Withdrawal from Study ..............................................................................................29 
5.3.3. 
Replacement of Patients .............................................................................................29 
6. 
TREATMENTS ..........................................................................................................30 
6.1. 
Treatments Administered ............................................................................................30 
6.2. 
Investigational Study Drug .........................................................................................30 
6.2.1. 
Description ..................................................................................................................30 
6.2.2. 
Dose and Administration ............................................................................................30 
6.2.3. 
Dose Modifications .....................................................................................................31 
6.2.3.1. 
Study Population Dose Modifications ........................................................................31 
6.2.3.2. 
Individual Dose Modifications ...................................................................................31 
6.2.4. 
Preparation, Handling, and Storage ............................................................................31 
6.2.5. 
Packaging and Labeling ..............................................................................................31 
6.2.6. 
Accountability .............................................................................................................31 
6.3. 
Concomitant Medications ...........................................................................................32 
6.4. 
Contraceptive Requirements .......................................................................................32 
6.5. 
Treatment Compliance ................................................................................................33 
7. 
STUDY ASSESSMENTS ..........................................................................................33 
7.1. 
Screening/Baseline Assessments ................................................................................33 
7.2. 
Clinical Activity Assessments ....................................................................................34 
7.2.1. 
Patient Diary ...............................................................................................................34 
7.2.2. 
Brief Pain Inventory-Short Form Questionnaire ........................................................34 
7.3. 
Pharmacodynamic Assessments .................................................................................34 
7.4. 
Pharmacokinetic Assessments ....................................................................................34 
7.5. 
Safety Assessments .....................................................................................................34 
7.5.1. 
Vital Signs ..................................................................................................................34 
7.5.2. 
Weight and Height ......................................................................................................35 
7.5.3. 
Physical Examination .................................................................................................35 
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7.5.4. 
Electrocardiogram .......................................................................................................35 
7.5.5. 
Clinical Laboratory Assessments ...............................................................................35 
7.5.5.1. 
Immunogenicity ..........................................................................................................36 
7.5.5.2. 
Pregnancy Testing ......................................................................................................37 
7.5.6. 
Adverse Events ...........................................................................................................37 
7.5.6.1. 
Definitions ..................................................................................................................37 
7.5.6.2. 
Eliciting and Recording Adverse Events ....................................................................39 
7.5.6.3. 
Serious Adverse Events Require Immediate Reporting to Sponsor/Designee ...........40 
7.5.6.4. 
Sponsor Safety Reporting to Regulatory Authorities .................................................40 
7.5.6.5. 
Serious Adverse Event Notification to the Institutional Review 
Board/Independent Ethics Committee ........................................................................41 
7.5.6.6. 
Pregnancy Reporting ..................................................................................................41 
7.5.6.7. 
Overdose Reporting ....................................................................................................41 
7.6. 
Exploratory Assessments ............................................................................................42 
7.7. 
Other Assessments ......................................................................................................42 
7.7.1. 
EQ-5D-5L Questionnaire ............................................................................................42 
8. 
STATISTICS ..............................................................................................................42 
8.1. 
Determination of Sample Size ....................................................................................42 
8.2. 
Statistical Methodology ..............................................................................................42 
8.2.1. 
Populations to be Analyzed ........................................................................................43 
8.2.2. 
Examination of Subgroups .........................................................................................43 
8.2.3. 
Handling of Missing Data ...........................................................................................43 
8.2.4. 
Baseline Evaluations ...................................................................................................43 
8.2.5. 
Clinical Activity Analyses ..........................................................................................43 
8.2.6. 
Pharmacodynamic Analysis........................................................................................43 
8.2.7. 
Pharmacokinetic Analysis ..........................................................................................44 
8.2.8. 
Safety Analyses ..........................................................................................................44 
8.2.9. 
Other Analyses ............................................................................................................44 
9. 
STUDY ADMINISTRATION ...................................................................................44 
9.1. 
Ethical and Regulatory Considerations ......................................................................44 
9.1.1. 
Informed Consent .......................................................................................................45 
9.1.2. 
Ethical Review ............................................................................................................45 
9.1.3. 
Study Documentation, Confidentiality, and Records Retention .................................45 
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9.1.4. 
End of the Study .........................................................................................................46 
9.1.5. 
Discontinuation of the Clinical Study.........................................................................46 
9.2. 
Data Quality Control and Quality Assurance .............................................................46 
9.2.1. 
Data Handling .............................................................................................................46 
9.2.2. 
Study Monitoring ........................................................................................................46 
9.2.3. 
Audits and Inspections ................................................................................................47 
9.3. 
Publication Policy .......................................................................................................47 
10. 
LIST OF REFERENCES ............................................................................................48 
11. 
APPENDICES ............................................................................................................51 
11.1. 
Pharmacokinetic Assessment Time Points .................................................................51 
11.2. 
Schedules of Assessments for Every Month Dosing Regimen ..................................52 
11.3. 
List of Sensitive CYP3A Substrates and those with a Narrow Therapeutic 
Range ..........................................................................................................................58 
 
LIST OF TABLES 
Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 
Months Dosing Regimen) .............................................................................................7 
Table 2: 
Schedule of Assessments:  Month 19 through End of Study (Every 3 Months 
Dosing Regimen) ........................................................................................................10 
Table 3: 
Pharmacokinetic Time Points .....................................................................................51 
Table 4: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 
Month Dosing Regimen) ............................................................................................52 
Table 5: 
Schedule of Assessments:  Month 19 through End of Study (Every Month 
Dosing Regimen) ........................................................................................................55 
Table 6: 
List of Sensitive CYP3A Substrates and those with a Narrow Therapeutic 
Range ..........................................................................................................................58 
 
LIST OF FIGURES 
Figure 1: 
Study Design ...............................................................................................................27 
 
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LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
Abbreviation 
Definition 
AE 
Adverse event 
AHP 
Acute hepatic porphyria 
AIP 
Acute intermittent porphyria 
ALA 
Delta-aminolevulinic acid 
ALAS1 
5-aminolevulinic acid synthase 1 
ALP 
Alkaline phosphatase 
ASGPR 
Asialoglycoprotein receptor 
ASHE 
Asymptomatic high excreters 
BPI-SF 
Brief Pain Inventory-Short Form 
cERD 
Circulating extracellular RNA detection assay 
CRF 
Case report form 
CYP 
Cytochrome P450 
ECG 
Electrocardiogram 
eCRF 
Electronic case report form 
eGFR 
Estimated Glomerular Filtration Rate 
EDC 
Electronic data capture 
EOS 
End of study 
EU 
European Union 
GalNAc 
N-acetyl galactosamine 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practice 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
IEC 
Independent Ethics Committee 
IRB 
Institutional Review Board 
ISR 
Injection site reaction 
IV 
Intravenous 
LFT 
Liver function test 
mRNA 
Messenger RNA 
NHP 
Nonhuman primate 
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Abbreviation 
Definition 
NOAEL 
No observed adverse effect level 
NOEL 
No observed effect level 
OTC 
Over the counter 
PBG 
Porphobilinogen 
PBGD 
Porphobilinogen deaminase 
PD 
Pharmacodynamic(s) 
PK 
Pharmacokinetic(s) 
QOL 
Quality of life 
RNA 
Ribonucleic acid 
RNAi 
RNA interference 
SAE 
Serious adverse event 
SAP 
Statistical Analysis Plan 
SC 
Subcutaneous 
siRNA 
Small interfering RNA 
SRC 
Safety Review Committee 
SUSAR 
Suspected unexpected serious adverse reaction 
ULN 
Upper limit of normal 
US 
United States 
WOCBP 
Woman of child-bearing potential 
 
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1. 
INTRODUCTION 
1.1. 
Disease Overview 
The porphyrias are a family of rare metabolic disorders predominately caused by a genetic 
mutation in 1 of the 8 enzymes responsible for heme synthesis.[1]  The 2 major categories are 
erythropoietic and hepatic, depending on the major site of expression of the underlying enzyme 
deficiency.[2]  In addition, the porphyrias are classified as acute if patients present with 
neurovisceral symptoms (eg, abdominal pain and neurologic symptoms) or cutaneous if they 
present with dermal blistering or photosensitivity.[3, 4]   
This study will include patients with acute intermittent porphyria (AIP), the most common acute 
hepatic porphyria (AHP).  AIP occurs as a result of an autosomal dominant mutation leading to 
partial deficiency of porphobilinogen deaminase (PBGD), the third enzyme in the heme 
biosynthesis pathway.[5]  The rate limiting step in heme synthesis is the upstream enzyme 
5-aminolevulinic acid synthase 1 (ALAS1), which is controlled by feedback repression via the 
end-product heme.  In response to a decrease in endogenous heme in the liver, as can occur with 
fasting, hormonal alterations, or with cytochrome P450 (CYP) inducing drugs, ALAS1 is 
induced, resulting in increased flux through the heme synthesis pathway.  In patients with AIP, 
this can result in the marked accumulation of the toxic heme intermediates porphobilinogen 
(PBG) and delta aminolevulinic acid (ALA) in the blood and urine due to the deficiency in the 
downstream PBGD.  Clinically, this manifests as acute attacks characterized by severe 
abdominal pain, cardiovascular as well as neurologic and psychiatric dysfunction.[6] 
1.1.1. 
Epidemiology 
Over 370 mutations have been identified in the PBGD gene, which in most instances result in its 
reduction by approximately 50%.  The exact prevalence of AIP is unknown due to under 
diagnosis, variation by geographic region, and the differences in penetrance observed for the 
different mutations.[2]  However, it is estimated that the prevalence of AIP is 5 to 10 per 
100,000 people in Western countries, while in Sweden it occurs in 1 in 1,000 people due to a 
founder effect associated with the resultant G593A mutation.[7-10]  AIP shows incomplete 
penetrance and on average only 10% to 50% of carriers with a mutation present with clinical 
symptoms.[11]  It has been proposed that unknown inherited co-factors, in addition to PBGD 
mutations, may explain why a small percentage of patients present with much more severe 
disease while the majority remain asymptomatic. 
Patients with AIP present with acute attacks characterized by neurovisceral symptoms and signs 
including severe abdominal pain, nausea, vomiting, constipation, or less commonly diarrhea, 
hypertension, tachycardia, fever, muscle weakness, as well as neurological (eg, neuropathy, 
seizures) and psychiatric (eg, anxiety and confusion) manifestations.[12]  AIP attacks typically 
start after puberty and can be triggered by exogenous factors such as medications (especially 
barbiturates, sulfonamides, and hydantoins), stress, exogenous hormones, nutritional status, and 
infection.  Clinically active disease is more common in women, where attacks often occur around 
the menstrual cycle and are likely precipitated by hormonal changes. 
Many AIP patients remain undiagnosed given that the disease is rare and characterized by 
non-specific symptoms (eg, abdominal pain and nausea).[2]  The initial diagnosis involves 
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demonstrating elevated urinary PBG (typically 20-50 × normal reference range) and ALA 
(typically 5-20 × normal reference range) when the patient is having acute attack symptoms.  
Once a test is positive for elevated ALA and PBG and porphyria is suspected, genetic testing for 
a PBGD mutation is performed.   
There are 4 main clinical phenotypes of AIP.  Latent gene carriers have never had an acute attack 
and are biochemically inactive (normal urinary ALA and PBG).  Asymptomatic high excreters 
(ASHE) do not have current acute attacks, but are biochemically active (increased urinary ALA 
and PBG).  The increased levels of ALA and PBG in ASHE patients are lower than those in AIP 
patients during an acute attack, but are still significantly higher than normal reference values.[6-
8] Sporadic attack patients have infrequent acute attacks.  Recurrent attack patients have
≥4 attacks per year requiring hospitalization or treatment by a medical professional.[7] 
1.1.2. 
Current Management and Unmet Medical Need 
Management of acute attacks often requires hospitalization.  Patients are initially treated with 
supportive care and carbohydrate loading, analgesics and anti-emetics, and removal of known 
precipitating factors.[13]  In patients with moderate to severe attacks, or who fail to respond to 
supportive measures, treatment with intravenous (IV) hemin (daily for 3-5 days) is commenced.  
Symptoms typically begin to improve after 2 to 5 days of hemin treatment, accompanied by a 
lowering of urinary ALA and PBG levels to below or at the upper limit of normal (ULN) 
reference value; however, in some patients attacks can last several weeks, requiring prolonged 
hemin use and hospitalization.[14]  With prolonged and severe attacks, cranial nerve 
involvement can occur, leading to bulbar paralysis, respiratory failure, and death.[15]  
Hemin, a blood derived therapy, was approved as Normosang® (heme arginate) in the European
Union (EU) and as Panhematin® (lyophilised hematin) in the United States (US) in 1999 and
1983, respectively.[16, 17]  In the EU, heme arginate is indicated for the treatment of acute 
attacks of hepatic porphyria (eg, AIP, variegate porphyria, and hereditary coproporphyria); 
whereas, in the US lyophilized hemin is limited to the amelioration of recurrent attacks of AIP 
temporally related to the menstrual cycle.  Approval of both products was based on biochemical 
efficacy (ie, lowering of ALA and PBG) as well as data from uncontrolled case series and case 
reports.[18-22]  Hemin side effects include thrombophlebitis, transient anticoagulation, and in 
rare cases, anaphylaxis or renal failure.[22-24]  In addition, hemin administration requires a large 
vein for administration, often necessitating central venous access. 
While the majority of patients who experience attacks have them sporadically, it is estimated that 
up to 1,000 AIP patients experience recurrent attacks (typically defined as ≥4 per year) in the US 
and EU combined.[25]  While hemin is currently only approved to ameliorate acute attacks, it is 
administered prophylactically in some patients with recurrent attacks (eg, administered every 
1-2 weeks).[26]  Potential problems associated with chronic hemin administration include 
infusion site phlebitis, iron overload, and the need for chronic IV access and associated 
complications (eg, risk of infection or occlusion).[5]  In addition, there have been reports of a 
decrease in efficacy with chronic hemin administration, as evidenced by the need to increase the 
frequency or dosage of hemin prophylaxis over time in attempt to maintain a clinical effect.[27]  
In patients with very severe recurrent attacks, or in whom hemin treatment is not effective, liver 
transplantation can be curative; however, organ transplantation is a high-risk procedure and is 
rarely used as a treatment option [34].  Given the significant morbidity and mortality, there 
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remains a significant unmet need for an efficacious, simple, fast-acting and better tolerated 
treatment for acute or prevent recurrent attacks in patients with AIP. 
1.2. 
RNA Interference 
RNA interference (RNAi) is a naturally occurring cellular mechanism mediated by small 
interfering RNAs (siRNAs) for regulating gene expression.  Typically, synthetic siRNAs are 
19 to 25 base pair double stranded oligonucleotides in a staggered duplex with a 2-nucleotide 
overhang at both or 1 of the 3’ ends.[28]  Such siRNAs can be designed to target an endogenous 
messenger RNA (mRNA) transcript of a given gene.  When introduced into cells, the net effect 
of an RNAi-based pharmacological approach is the binding of the siRNA to its complementary 
mRNA sequence, cleavage of this target mRNA, and reduction of synthesis of the target protein, 
resulting in a decrease of the target protein levels.[29]  The ability to selectively and potently 
degrade the mRNA encoding the ALAS1 protein (thereby decreasing accumulation of the toxic 
intermediates ALA and PBG) using an siRNA is a novel approach for the prevention and 
treatment of acute attacks in patients with AIP.   
1.3. 
ALN-AS1 
ALN-AS1 is a synthetic RNAi therapeutic currently in development for treatment of acute 
attacks in patients with AIP, the most common AHP. 
1.3.1. 
Nonclinical Summary 
The pharmacology, safety pharmacology, drug metabolism and pharmacokinetics and toxicology 
of ALN-AS1 were evaluated in a series of in vitro and in vivo nonclinical studies. 
ALN-AS1 is pharmacologically active in rodents and nonhuman primates (NHP) due to 
conservation within the siRNA target sequence.  Transfection assays in human liver carcinoma 
cell line-G2 cells showed dose-dependent inhibition of endogenous ALAS1 mRNA levels with 
an half-maximal inhibitory concentration of approximately 26 pM of ALN-AS1.  In multiple 
studies in the mouse, rat, and NHP, potent and dose-dependent pharmacologic activity has been 
demonstrated with subcutaneous (SC) administration of ALN-AS1, which results in consistent 
reduction of ALAS1 mRNA in liver.  After single dose administration, ALAS1 mRNA 
suppression in liver is durable depending on the dose administered (1-4 weeks) and correlates 
with the extent of ALAS1 mRNA suppression observed in serum or urine.  Dose dependent, 
steady-state ALAS1 mRNA reduction has also been demonstrated with repeat-dose regimens.  
Studies in rodent AIP models have confirmed that ALAS1 mRNA reduction with ALN-AS1 
treatment correlates with decreases in ALA and PBG heme intermediates. 
A Good Laboratory Practice (GLP)-compliant safety pharmacology study conducted in NHPs 
showed no functional cardiovascular or respiratory effects, with a no observed effect level 
(NOEL) of 150 mg/kg.  Neurological assessments were conducted as part of a 13-week repeat 
dose GLP toxicity study in NHPs (weekly dosing); no ALN-AS1-related neurobehavioral 
observations occurred, with a NOEL for neurological effects of 150 mg/kg (highest dose tested).  
Genetic toxicity studies (bacterial reverse mutation, human peripheral blood lymphocyte 
chromosomal aberrations, and rat bone marrow micronucleus) assays were all negative at 
International Conference on Harmonization (ICH) S2 (R1) limit doses. 
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Two to 4-week exploratory (non-GLP) dose-range finding toxicology studies were conducted 
with ALN-AS1 in mice, rats, and NHPs.  In all 3 species, no dose-limiting toxicity was observed 
up to the highest dose evaluated (300 mg/kg weekly SC dose), with the rat appearing to be the 
most sensitive species.  These studies were followed by 13-week GLP toxicology studies in rats 
and NHPs where ALN-AS1 was administered daily (100 mg/kg) and weekly at doses of 0, 3, 10, 
and 30 mg/kg in the rat and weekly at doses of 0, 15, 50, and 150 mg/kg in the NHP.  The no 
observed adverse effect levels (NOAELs) were 30 mg/kg in the rat and 150 mg/kg in the NHP 
(highest dose tested in each species).   
Preliminary results from 26-week and 39-week GLP chronic toxicity studies conducted in rats 
and NHPs, respectively, support long-term clinical dosing.  The repeat-dose toxicity study in rats 
included assessment of male fertility and early embryonic development.  ALN-AS1 was 
administered weekly at doses of 0, 3, 10, or 30 mg/kg for up to 26 weeks.  Weekly doses of 
30 mg/kg resulted in adverse hepatocellular single cell necrosis and vacuolation in the liver, 
associated with mild increases in liver function tests (LFTs) at the conclusion of the dosing 
period.  Angiectasis was observed in the islets of Langerhans, possibly a secondary change to 
hepatic changes, which is not considered adverse.  Combined male fertility assessments did not 
indicate adverse reproductive or developmental findings up to the highest dose evaluated 
(30 mg/kg weekly SC dose).  In the 39-week repeat-dose toxicity study in NHP, ALN-AS1 was 
administered weekly at doses of 0, 10, 30, or 100 mg/kg for up to 39 weeks.  Weekly doses of 
100 mg/kg were the lowest-observed-adverse-effect level based on single cell necrosis combined 
with increased alanine transaminase (approximately 2-fold above control).  The NOAELs were 
10 mg/kg in the rat and 30 mg/kg in the NHP.  The 13-week recovery data in the rat and NHP 
studies is pending. 
1.3.2. 
Clinical Summary 
ALN-AS1 is being investigated in an ongoing, Phase 1 study (ALN-AS1-001) to evaluate the 
safety, tolerability, pharmacokinetics (PK), and pharmacodynamics (PD) of ALN-AS1 
administered subcutaneously in patients with AIP.  The study is being conducted in 3 parts.  
Part A and Part B are single-blind, placebo-controlled portions of the study in patients with AIP 
who are ASHE.  Patients are randomized in a 3:1 ratio to receive either a single dose (Part A) or 
multiple doses (Part B; 2 doses 28 days apart) of ALN-AS1 or placebo.  Patients who participate 
in Part A and Part B are not eligible to participate in this study.  In Part C, patients with AIP who 
have recurrent porphyria attacks will receive multiple doses of ALN-AS1 dosing over a 12-week 
period in a randomized, double-blind, placebo-controlled part of the study.  This study will enroll 
patients who completed Part C of study ALN-AS1-001. 
Dosing has been completed in Part A (0.035-2.5 mg/kg) and Part B of the study 
(0.35-1.0 mg/kg).  A total of 23 unique patients with AIP who are ASHE have received at least 
1 dose of study drug (20 patients received at least 1 dose of ALN-AS1 and 3 patients received 
placebo only).  ALN-AS1 has been generally well-tolerated.  Adverse Events (AEs) in patients 
administered ALN-AS1, which were reported in 2 patients each, were abdominal pain, diarrhea, 
and hypoaesthesia in Part A; and nasopharyngitis, pruritus, and rash in Part B.  In Part A, AEs 
considered possibly or definitely related to ALN-AS1 were reported in 5 patients:  diarrhea, 
dyspepsia, haematochezia, injection site erythema, injection site pain, blood creatinine increased, 
glomerular filtration rate decreased, and hypoesthesia (1 patient each).  In Part B, AEs 
considered possibly or definitely related to ALN-AS1 were reported in 3 patients:  pruritus and 
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rash (2 patients each); and rash macular and rash pruritic (1 patient each).  There were 2 SAEs of 
abdominal pain in Part A, 1 patient each in the 0.035 mg/kg and 0.10 mg/kg dose groups, which 
were not considered to be related to study drug or due to AIP.  Across Part A and Part B, all AEs 
were mild or moderate in severity, except for 1 serious adverse event (SAE) of abdominal pain 
(0.10 mg/kg dose group), which was considered severe.  There were no dose-related trends in 
AEs and no AEs leading to discontinuation.   
Overall, a dose-dependent reduction of urinary ALA and PBG as well as ALAS1 mRNA was 
observed following single and multiple doses of ALN-AS1.  Preliminary data demonstrate that 
administration of a single dose of ALN-AS1 at ≥1.0 mg/kg lowered ALA and PBG levels ≥80% 
and ALAS1 mRNA levels ≥50% when compared to baseline levels in patients with AIP who are 
ASHE.  Similarly, administration of multiple doses of ALN-AS1 at ≥0.35 mg/kg lowered ALA 
and PBG levels ≥80%.  ALAS1 mRNA levels were reduced ≥50% in the 1.0 mg/kg dose group 
when compared to baseline levels in patients with AIP who are ASHE.  ALA and PBG levels in 
the 1.0 mg/kg dose group in Part A were sustained for ≥180 days and in both dose groups in 
Part B for ≥160 days.  Specifically, the maximum mean reduction from baseline of urinary ALA 
and PBG reached 93% in the 2.5 mg/kg dose group, which were sustained for approximately 
14 weeks.  The maximum mean reduction in ALAS1 mRNA relative to baseline of 66% was 
demonstrated in the 2.5 mg/kg dose group which was maintained beyond 42 days. 
Cumulatively, nonclinical and clinical data to date support long-term administration of 
ALN-AS1 in patients with AIP. 
1.4. 
Study Design Rationale 
This is a multicenter, open-label extension study designed to evaluate the long-term safety and 
clinical activity of subcutaneously administered ALN-AS1 in patients with AIP who have 
completed clinical study ALN-AS1-001.  The primary endpoint for the study is the incidence of 
AEs. 
1.5. 
Dose Rationale 
Clinical data from Part A and Part B of the ongoing study ALN-AS1-001 demonstrate that single 
(0.035-2.5 mg/kg) and multiple (0.35-1.0 mg/kg) doses of ALN-AS1 have been generally 
well-tolerated in patients with AIP who are ASHE.  Additionally, data from this study indicate 
that a single dose of 2.5 mg/kg ALN-AS1 results in near normalization of urine ALA and PBG 
levels, which is sustained for approximately 14 weeks.   
Patients in Part C of the ongoing study ALN-AS1-001 who are eligible for participation in this 
study will likely require a higher dose of ALN-AS1 to normalize ALA and PBG as they have 
higher levels of ALAS1 upregulation and higher baseline levels of ALA and PBG, when 
compared to patients with AIP who are ASHE.[30]  For example, based on preliminary data in 
Part A and Part B of the ALN-AS1-001 study, the mean PBG level of patients who are ASHE is 
21.9 mmol/mol Cr (N=28); whereas, in Part C of this study in patients with AHP who have 
recurrent porphyria attacks, the mean PBG level is approximately 49.3 mmol/mol Cr (N=12). 
The study starting dose and regimen of ALN-AS1 is 5.0 mg/kg as an SC injection administered 
every 3 months.  Based on emerging clinical data, the SRC may approve changes to the 
ALN-AS1 dosing regimen, including decreases in the dose level and changes in dosing 
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frequency.  However, any dosing regimen will not exceed a previously explored dose level or 
frequency that was determined to be safe and well-tolerated in study ALN-AS1-001. SRC, 
Health Authority and Ethics Committee approval must be sought prior to dose level escalation 
above 5.0 mg/kg in accordance with local Regulatory requirements. 
The study starting dose and regimen was selected based on the benefit:risk profile of ALN-AS1 
in Part C of the ongoing ALN-AS1-001 study.  Preliminary data to date indicate that 
administration of 5.0 mg/kg ALN-AS1 has been generally well-tolerated.  There have been no 
study drug-related SAEs, severe AEs, or clinically significant changes in safety parameters.  
While a single 2.5 mg/kg dose of ALN-AS1 has also been generally well-tolerated when 
administered to patients in Part A and Part C of study ALN-AS1-001, this dose has not resulted 
in near normalization of ALA and PBG levels.  In addition, while emerging data from Part C 
indicate that an every 3 months dose of 2.5 mg/kg ALN-AS1 demonstrated some clinical activity 
(eg, decrease in attack frequency and decrease in heme use), some patients continued to 
experience breakthrough porphyria attacks during the treatment period, indicating that a higher 
dose may be required. 
The duration of dosing in this study is supported by the overall favorable safety profile of 
ALN-AS1 in the ongoing clinical study ALN-AS1-001 and the absence of new findings in 
nonclinical studies with ALN-AS1. 
1.6. 
Benefit-Risk Assessment 
Patients participating in this study may experience a reduced number or severity of porphyria 
attacks, reduced treatment with IV hemin, and/or reduced requirement for pain medication. 
The potential risks associated with administration of ALN-AS1 in patients with AIP are as 
follows: 
 Injection site reactions (ISRs):  ALN-AS1 is administered by SC injection.  In the 
ongoing ALN-AS1 clinical study, AEs of ISRs have been infrequently reported and 
have been mild to moderate in severity with single dosing.  Injection site rotation and 
close monitoring have been implemented in ALN-AS1 clinical studies to reduce the 
potential for ISRs.  
 Liver function test abnormalities:  As ALN-AS1 is targeted for delivery to the liver, 
and reversible hepatic changes were observed in some animal species, there is a 
potential for development of LFT abnormalities.  To minimize the potential for LFT 
abnormalities, patients are required to have adequate liver function at study entry and 
LFTs are monitored during the study. 
 Reproductive health:  No data are available on the use of ALN-AS1 in pregnancy; 
however, there is no suspicion of human teratogenicity based on class effects or 
genotoxic potential.  ALN-AS1 was neither genotoxic nor clastogenic in in vitro and 
in vivo studies.  Based on preliminary data from rat fertility/embryofetal development 
and rabbit embryofetal development studies, it is unlikely that ALN-AS1 
administration to pregnant women poses a risk to embryofetal development.  In a rat 
fertility/embryofetal development study at daily dose levels up to 16.5 mg/kg, no test 
article-related effects on female fertility or developmental endpoints were observed.  
In a rabbit embryofetal development study, maternal toxicity was observed at daily 
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doses of >3 mg/kg (7.8-fold higher than the clinical monthly dose of 5.0 mg/kg).  No 
terata were observed in this range finding embryo fetal development study.  Women 
of child bearing potential (WOCBP) must have a negative pregnancy test, cannot be 
breastfeeding, and must be willing to use acceptable methods of contraception during 
studies with ALN-AS1.  
 CYP inhibition:  A study in NHP demonstrated that ALN-AS1 dosing could 
potentially increase the clearance of drugs metabolized by the CYP3A isoform.  As 
contraceptive hormones are metabolized via CYP3A, WOCBP must use a barrier 
method of contraception, in addition to hormonal contraception, during study 
participation.  Additionally, Investigators will review all patient medications at study 
start and monitor responses to these medications during the study.  A list of 
medications that are sensitive CYP3A substrates is in Table 6 in Appendix 
Section 11.3.  In addition, a list of medications that are sensitive CYP3A substrates is 
available at the Indiana University, Division of Clinical Pharmacology, website.[31] 
The complete summary of the clinical and nonclinical data relevant to the investigational drug 
and its study in human subjects is provided in the Investigator’s Brochure. 
2. 
OBJECTIVES 
2.1. 
Primary Objective 
 Evaluate the long-term safety and tolerability of ALN-AS1 in patients with AIP 
2.2. 
Secondary Objectives 
 Assess the PD effect of ALN-AS1 over time 
 Assess the clinical activity of ALN-AS1 over time 
2.3. 
Exploratory Objectives 
 Characterize the PK profile of ALN-AS1 over time 
 Assess changes in health-related quality of life (QOL) 
 Characterize analytes related to targeting the heme biosynthesis pathway 
3. 
ENDPOINTS 
3.1. 
Primary Endpoint 
 Patient incidence of AEs 
3.2. 
Secondary Endpoints 
 Change in urine ALA and PBG levels 
 Frequency and characteristics of porphyria attacks 
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 Change in hemin administration 
3.3. 
Exploratory Endpoints 
 Change in circulating ALAS1 mRNA levels 
 Concentrations of ALN-AS1 and antidrug antibodies  
 Duration and treatment of porphyria attacks 
 Number and duration of visits to a health care facility for acute porphyria care 
 EQ-5D-5L questionnaire scores 
 Pain assessment and narcotic use as recorded in a patient diary 
 Exploratory biomarkers related to the target pathway, such as urine porphyrins, 
vitamin D binding protein 
4. 
INVESTIGATIONAL PLAN 
4.1. 
Summary of Study Design 
This is a Phase 1/2 multicenter, open-label extension study to evaluate the long-term safety and 
clinical activity of ALN-AS1 in patients with AIP who completed study ALN-AS1-001.  The 
study will be conducted at up to 8 clinical study centers worldwide. 
The last assessments performed, determining previous study (ALN-AS1-001) completion, will 
serve as the Screening/Baseline assessments in this study.  If more than 60 days have elapsed 
since the last assessment, safety assessments (eg, ECG and clinical laboratory tests) will be 
repeated before administration of ALN-AS1.  It is anticipated that patients will begin ALN-AS1 
administration in this study within 6 months after the last dose of study drug in the previous 
study.  Eligibility will be confirmed during Screening/Baseline and before administration of the 
first dose of ALN-AS1 (Day 1).  Patients will undergo assessments at the clinical study center 
every month for the first 3 months.  Then, through Month 6, and according to the dosing regimen 
selected, assessments will take place at the clinical study center or via a phone contact (for an 
every month dosing regimen, visits will be every month; for an every 3 months dosing regimen, 
visits will be every 3 months; see Section 6.2.2).  After a patient has completed 12 months of 
ALN-AS1 administration in this study (6 months in an every month dosing regimen), and where 
applicable country and local regulations and infrastructure allow, study visits and ALN-AS1 
administration may take place at the patient’s home by a healthcare professional (as indicated in 
the Schedules of Assessments in Table 1 and Table 2; and Table 4 and Table 5 in Appendix 
Section 11.2).  Home visits may occur at the discretion of the Investigator, based on safety and 
tolerability; however, patients are required to complete at least 1 visit at the clinical study center 
every 3 months for the first year, and thereafter every 6 months through the end of the treatment 
period.  Patients will return to the clinical study center for a posttreatment follow-up visit after 
administration of the last dose of ALN-AS1.  An ALA/PBG Monitoring/EOS visit will be 
conducted either at the clinical study center or via phone contact, unless treatment continues with 
ALN-AS1. 
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Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain 
assessments, and narcotic use.  Additionally, patients will be encouraged to report to the clinical 
study center if they experience a porphyria attack through Month 39.  In the event that patients 
are unable to report to the clinical study center during a porphyria attack, laboratory sample 
collection kits containing instructions for collecting and sending urine samples to the clinical 
study center, if possible, will be provided.  Patients will be contacted by phone after a porphyria 
attack to record attack details.  If patients are experiencing signs and symptoms of a porphyria 
attack when ALN-AS1 administration is scheduled, the Investigator will determine whether 
administration of ALN-AS1 is appropriate.  If patients are treated for a porphyria attack at a 
health care facility (eg, hospital, emergency department, infusion center, or outpatient clinic) 
other than the clinical study center, copies of medical records, including discharge summaries, 
will be requested.   
A Safety Review Committee (SRC) will review safety and tolerability data collected during the 
study with the primary purpose of protecting the safety of patients participating in the study (see 
Section 4.6). 
Figure 1: 
Study Design 
 
4.2. 
Duration of Treatment and Study 
The duration of treatment is up to 36 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 44 months.   
4.3. 
Number of Patients 
Up to 24 patients are planned for enrollment in this study (including optional cohorts in 
ALN-AS1-001). 
4.4. 
Method of Assigning Patients to Treatment Groups 
This is an open-label study; all patients will receive ALN-AS1.  A combination of the clinical 
study center number and screening number will create the unique patient identifier.  The clinical 
study center number will be assigned by the Sponsor.  Upon signing the Informed Consent Form 
(ICF), the patient will be assigned a screening number by the clinical study site, which will be 
the same unique patient identifier assigned in the previous study (ALN-AS1-001).  The 
Investigator, or delegate, will confirm that the patient fulfills all the inclusion criteria and none of 
the exclusion criteria. 
4.5. 
Blinding 
This is an open-label study, and all patients will receive ALN-AS1. 
Complete Study
ALN-AS1-001
Screening
(Day -60 to -1)
Treatment Period
(36 Months)
Posttreatment 
Follow-up
(3 months)
End of Study
(Month 42)
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4.6. 
Safety Review Committee 
An SRC will be involved in the conduct of this study.  The SRC has the responsibility for 
monitoring the safety of the study participants.  The SRC will perform periodic reviews of safety 
and tolerability data during the course of the clinical study at least every 3 months for the first 
6 months of the study and thereafter at least every 6 months.  The SRC may also meet on an ad 
hoc basis for review of emergent safety and tolerability data, as defined in the SRC Charter for 
this clinical study.  The SRC will not stop the study for efficacy. 
The SRC will be comprised of the following members:  Principal Investigator(s), or designee(s), 
the Sponsor Medical Monitor, and the Study Medical Monitor. 
The membership of the SRC and reporting structure are further defined in the SRC Charter. 
5. 
SELECTION AND WITHDRAWAL OF PATIENTS 
5.1. 
Inclusion Criteria 
Each patient must meet all of the following inclusion criteria to be eligible for enrollment in this 
study: 
1. Completed and, in the opinion of the Investigator, tolerated study drug dosing in Part C 
of study ALN-AS1-001 
2. Not on a scheduled regimen of hemin to prevent porphyria attacks at Screening 
3. WOCBP must have a negative serum pregnancy test, cannot be breast feeding, and must 
be willing to use acceptable methods of contraception 14 days before first dose, 
throughout study participation, and for 90 days after last dose administration.  Acceptable 
methods include hormonal methods along with an additional barrier method (eg, condom, 
diaphragm, or cervical cap), or a double barrier method of contraception for those 
WOCBP for whom a hormonal method of contraception is medically contraindicated due 
to underlying disease (see Section 6.4 for acceptable methods of contraception).   
4. Willing and able to comply with the study requirements and to provide written informed 
consent 
5.2. 
Exclusion Criteria 
Each patient must not meet any of the following exclusion criteria to be eligible for enrollment in 
this study: 
1. Alanine transaminase ≥2.0×ULN or total bilirubin ≥2 mg/dL (unless bilirubin elevation is 
due to Gilbert’s syndrome) 
2. Estimated glomerular filtration rate ≤30 mL/min/1.73 m2 (using the Modification of Diet 
in Renal Disease formula) 
3. History of multiple drug allergies or history of allergic reaction to an oligonucleotide or 
to N-acetyl galactosamine ligand (GalNAc) 
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4. Received an investigational agent, other than ALN-AS1, or who are in follow-up of 
another clinical study of an investigational agent within 90 days before study drug 
administration 
5. Other medical conditions or comorbidities which, in the opinion of the Investigator, 
would interfere with study compliance or data interpretation 
5.3. 
Removal from Treatment or Assessment 
Patients are free to discontinue treatment or withdraw from the study at any time and for any 
reason, without penalty to their continuing medical care.  Any discontinuation of treatment or 
withdrawal from the study must be fully documented in the electronic case report form (eCRF), 
and should be followed up by the Investigator.  The Investigator may withdraw a patient at any 
time if this is considered to be in the best interest of the patient. 
Discontinuation of study drug and withdrawal from the study are described in Section 5.3.1 and 
Section 5.3.2, respectively. 
5.3.1. 
Discontinuation of Study Drug 
The Investigator or designee may discontinue dosing in a patient if the patient: 
 Is in violation of the protocol 
 Experiences a SAE considered to be possibly or definitely related to the study drug or 
an intolerable AE  
 Becomes pregnant 
 Is found to be considerably noncompliant with the protocol-requirements 
Patients who are pregnant will be discontinued from study drug dosing immediately (see 
Section 7.5.6.6 for reporting and follow-up of pregnancy).  Patients who discontinue treatment 
will be asked to complete the Month 39 visit assessments. 
5.3.2. 
Withdrawal from Study 
A patient may withdraw from the study at any time.  If a patient chooses to withdraw from the 
study, every effort should be made to conduct early the assessments performed at the Month 39 
visit.  When a patient withdraws from the study, the primary reason for study withdrawal must be 
recorded in the appropriate section of the eCRF and all efforts made to complete and report the 
observations as thoroughly as possible.  If a patient withdraws due to a SAE, the SAE should be 
followed as described in Section 7.5.6. 
5.3.3. 
Replacement of Patients 
Patients discontinuing from study drug or withdrawing from the study will not be replaced. 
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6. 
TREATMENTS 
6.1. 
Treatments Administered 
ALN-AS1 Solution for Injection (SC use) is a clear, colorless to pale yellow solution essentially 
free of particulates.  ALN-AS1 will be supplied by the Sponsor as a sterile solution for SC 
injection. 
Study drug supplied for this study must not be used for any purpose other than the present study 
and must not be administered to any person not enrolled in the study.  Study drug that has been 
dispensed to a patient and returned unused must not be re-dispensed to a different patient. 
6.2. 
Investigational Study Drug 
Detailed information describing the preparation, handling, and storage, packaging and labeling, 
as well as study drug accountability for ALN-AS1 is provided in the Pharmacy Manual. 
6.2.1. 
Description 
ALN-AS1 Solution for Injection (SC use) is comprised of a synthetic, siRNA targeting ALAS1 
and bearing a triantennary GalNAc ligand conjugated to the sense strand, formulated in 
phosphate buffer.  
6.2.2. 
Dose and Administration 
The study starting dose of ALN-AS1 is 5.0 mg/kg ALN-AS1 as an SC injection administered 
every 3 months (Table 1 and Table 2). Based on emerging clinical data, the SRC may approve 
changes to the ALN-AS1 dosing regimen, including decreases in the dose level and changes in 
dosing frequency (Table 4 and Table 5 in Appendix Section 11.2). However, any dose and 
dosing regimen will not exceed a previously explored dose level or frequency that was 
determined to be safe and well-tolerated in study ALN-AS1-001. SRC, Health Authority and 
Ethics Committee approval must be sought prior to dose level escalation above 5.0 mg/kg in 
accordance with local Regulatory requirements.  See Section 6.2.3 for details on dose 
modifications. 
The study drug will be administered under the supervision of a healthcare professional.  After a 
patient has completed 12 months of ALN-AS1 administration in this study (6 months in an every 
month dosing regimen), and where applicable country and local regulations and infrastructure 
allow, study visits and ALN-AS1 administration may take place at the patient’s home by a 
healthcare professional.  Home visits may occur at the discretion of the Investigator, based on 
safety and tolerability; however, patients are required to complete at least 1 visit at the clinical 
study center every 3 months for the first year, and thereafter every 6 months through the end of 
the treatment period.   
If a patient does not receive a dose of ALN-AS1 within the specified dosing window, the 
Investigator should contact the Medical Monitor.  After such consultation, the dose may be 
administered or considered missed and not administered. 
Patients will be permitted to miss an occasional dose of study drug; however, if a patient misses 
2 consecutive doses, the Investigator, in consultation with the Medical Monitor, will discuss 
whether the patient will be able to continue on the study.  
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Detailed instructions for study drug administration are found in the Pharmacy Manual. 
6.2.3. 
Dose Modifications 
6.2.3.1. 
Study Population Dose Modifications 
During the study, dose modifications are permitted for the study population, or based on the dose 
cohort into which patients were originally randomized in study ALN-AS1-001.  Following SRC 
review of emerging safety and tolerability data from Part C of study ALN-AS1-001, or from this 
study (ALN-AS1-002), the dose and dosing regimen may be modified.  However, the dose and 
dosing regimen of ALN-AS1 will not exceed a previously explored dose and dosing regimen that 
was determined to be safe and well-tolerated in study ALN-AS1-001.  Patients enrolling in this 
study after a dose modification decision has been implemented may start at the newly identified 
dose and regimen. 
6.2.3.2. 
Individual Dose Modifications 
Dose modifications are permitted for individual patients.  If a patient has a study drug related AE 
of a recurrent ISR, severe ISR, or clinically significant LFT abnormality and the Investigator has 
concerns regarding further ALN-AS1 administration, the Medical Monitor and Investigator will 
review all available safety data for the patient.  Based on this review, a dose reduction to half the 
previously administered dose (eg, a 5.0 mg/kg dose would be reduced to a 2.5 mg/kg dose) or a 
reduction in dosing frequency from monthly to every 3 months is permitted.  Subsequent 
ALN-AS1 administration at the previous dose may be considered based on the judgment of the 
Investigator and Medical Monitor. 
6.2.4. 
Preparation, Handling, and Storage 
Staff at each clinical study center or the home healthcare professional will be responsible for 
preparation of ALN-AS1 doses, according to procedures detailed in the Pharmacy Manual.  No 
special procedures for the safe handling of study drug are required. 
Study drug will be stored upright and refrigerated at approximately 5±3°C.  Any deviation from 
the recommended storage conditions should be reported to the Sponsor and use of the study drug 
halted until authorization for its continued use has been provided by the Sponsor or designee. 
A Sponsor representative or designee will be permitted, upon request, to audit the supplies, 
storage, dispensing procedures, and records. 
6.2.5. 
Packaging and Labeling 
ALN-AS1 Solution for Injection (SC use) is packaged in 2 mL glass vials with a fill volume of 
no less than 0.55 mL.  The container closure system consists of a Type I glass vial, a Teflon 
faced bromobutyl 13 mm stopper and a flip-off Truedge aluminum seal. 
6.2.6. 
Accountability 
The Investigator or designee will maintain accurate records of receipt and the condition of the 
study drug supplied for this study, including dates of receipt.  In addition, accurate records will 
be kept of when and how much study drug is dispensed and administered to each patient in the 
study.  Any reasons for departure from the protocol dispensing regimen must also be recorded. 
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At the completion of the study, there will be a final reconciliation of all study drugs.  All used, 
partially used, and unused study drug will be returned to the Sponsor (or designee) or destroyed 
at the clinical study center according to applicable regulations.   
6.3. 
Concomitant Medications 
Use of concomitant medications will be recorded on the patient’s case report form (CRF) as 
indicated in the Schedules of Assessments (Table 1 and Table 2; and Table 4 and Table 5 in 
Appendix Section 11.2).  This includes all prescription medications, herbal preparations, over the 
counter (OTC) medications, vitamins, and minerals.  Any changes in medications during the 
study will also be recorded on the CRF. 
Any concomitant medication that is required for the patient’s welfare may be administered by the 
Investigator.  However, it is the responsibility of the Investigator to ensure that details regarding 
the medication are recorded on the eCRF.  Concomitant medication will be coded using an 
internationally recognized and accepted coding dictionary. 
ALN-AS1 could potentially increase the clearance of drugs metabolized by the CYP3A isoform.   
Investigators will review all medications at study start and monitor response to these medications 
during the study.  For patients who require new medications while on study, selection of 
medications that are not mainly metabolized by the CYP3A isoform is recommended.  A list of 
medications that are sensitive CYP3A substrates is included in Table 6 Appendix Section 11.3.  
In addition, a more detailed and current list of sensitive CYP3A-metabolized medications and 
CYP3A-metabolized medications with a narrow therapeutic range is available at the Indiana 
University, Division of Clinical Pharmacology, website 
(http://medicine.iupui.edu/clinpharm/ddis/clinical-table/).[31] 
Patients are not permitted to be on hemin prophylaxis at Screening; however, patients are 
permitted to receive concomitant hemin treatment for the management of acute porphyria 
attacks.  Patients experiencing significant breakthrough attacks while enrolled in this study, 
necessitating frequent hemin treatment, may receive hemin prophylaxis if in the Investigator’s 
judgment this is clinically beneficial to the patient.  The Investigator should contact with the 
Sponsor and Medical Monitor before prophylactic hemin treatment.  The dose, regimen, and 
dates of administration will be recorded on the patient’s eCRF.   
Pain medication (eg, opiates, opioids, narcotic analgesics) and glucose administration are 
permitted for the management of porphyria and for acute porphyria attacks. 
If patients use nonsteroidal anti-inflammatory medications intermittently or chronically, they 
must have been able to tolerate them with no previous side effects (eg, gastric distress or 
bleeding).   
Standard vitamins and topical medications are permitted; however, topical steroids must not be 
applied anywhere near the injection site(s) unless medically indicated. 
6.4. 
Contraceptive Requirements 
WOCBP must be willing to use acceptable methods of contraception 14 days before first dose, 
throughout study participation, and for 90 days after last dose administration.  Birth control 
methods which may be considered as acceptable include: 
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 Established use of oral, implantable, injectable, or transdermal hormonal methods of 
contraception.  WOCBP using hormonal methods of contraception must also use a 
barrier method (condom or occlusive cap [diaphragm or cervical/vault cap] in 
conjunction with spermicide [eg, foam, gel, film, cream, or suppository]).  If 
hormonal methods of contraception are medically contraindicated for WOCBP due to 
underlying disease, a double-barrier method (combination of male condom with 
either cap, diaphragm, or sponge, in conjunction with spermicide) is also considered 
an acceptable method of contraception. 
 Placement of an intrauterine device  
 Placement of an intrauterine hormone-releasing system  
 Bilateral tubal occlusion 
 Surgical sterilization of male partner (with the appropriate post-vasectomy 
documentation of the absence of sperm in the ejaculate; for female patients on the 
study, the vasectomized male partner should be the sole partner for that patient) 
 True sexual abstinence, when in line with the preferred and usual lifestyle of the 
patient.  Periodic abstinence (eg, calendar, ovulation, symptothermal, post-ovulation 
methods) and withdrawal are not acceptable methods of contraception.  Abstinent 
patients must agree to use 1 of the abovementioned contraceptive methods, if they 
start sexual relationships during the study and for 90 days after last dose 
administration. 
WOCBP includes any female patient who has experienced menarche and who is not 
postmenopausal or permanently sterilized (eg, bilateral tubal occlusion, hysterectomy, or 
bilateral salpingectomy).  Postmenopausal state is defined as no menses for 12 months without 
an alternative medical cause, confirmed by follicle stimulating hormone level within the 
postmenopausal range. 
6.5. 
Treatment Compliance 
Compliance with study drug administration will be verified through observation by study 
personnel or trained home healthcare professionals.  
7. 
STUDY ASSESSMENTS 
The schedule of study assessments is provided in Table 1.  
7.1. 
Screening/Baseline Assessments 
Informed consent, patient demographic data, and eligibility criteria will be confirmed at 
Screening/Baseline.  An interval medical history/disease history will be obtained at 
Screening/Baseline.  The last assessments performed, determining previous study 
(ALN-AS1-001) completion, will serve as the Screening/Baseline assessments in this study.  If 
more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs will 
be repeated before administration of ALN-AS1. 
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7.2. 
Clinical Activity Assessments 
The clinical activity of ALN-AS1 will be assessed by the frequency and characteristics of 
porphyria attacks including, but not limited to, duration, treatment, and severity of porphyria 
attacks and number and duration of visits to a health care setting for acute porphyria care (eg, 
hospital, emergency department, infusion center, or outpatient clinic).  Concomitant hemin 
administration will also be recorded. 
7.2.1. 
Patient Diary 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain 
assessments, and narcotic use. 
7.2.2. 
Brief Pain Inventory-Short Form Questionnaire 
The Brief Pain Inventory-Short Form (BPI-SF) questionnaire will be used to evaluate pain.[32]  
The BPI will be completed as part of the patient diary. 
7.3. 
Pharmacodynamic Assessments 
Blood and urine samples will be collected for assessment of ALN-AS1 PD parameters.  The PD 
effect of ALN-AS1 will be evaluated by urine ALA and PBG levels.  Blood and urine samples 
will be collected for assessment of circulating ALAS1 mRNA levels in serum and in urine.  
Analysis for blood and urine PD parameters will take place at a central laboratory.   
Details regarding the processing and aliquoting of samples for storage and analyses will be 
provided in the Laboratory Manual. 
7.4. 
Pharmacokinetic Assessments 
Blood samples will be collected to evaluate the PK profile of ALN-AS1 at the time points in the 
Schedule of Assessments.  A detailed schedule of time points for the collection of blood samples 
for PK analysis is in Table 3 in Appendix Section 11.1). 
The concentration of ALN-AS1 will be determined using a validated assay.  Details regarding 
the processing, shipping, and analysis of the samples will be provided in the Laboratory Manual. 
7.5. 
Safety Assessments 
The assessment of safety during the course of the study will consist of the surveillance and 
recording of AEs including SAEs, recording of concomitant medications and measurements of 
vital signs, physical examination, and ECG findings and clinical laboratory evaluations. 
Safety will be monitored over the course of the study by an SRC as described in Section 4.6. 
7.5.1. 
Vital Signs 
Vital sign measurements include blood pressure, heart rate, body temperature, and respiratory 
rate.  Vital signs will be measured in the seated or supine position (should be consistent for each 
patient), after the patient has rested comfortably for 10 minutes.  Blood pressure should be taken 
using the same arm throughout the study.  Body temperature will be obtained in degrees Celsius, 
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heart rate will be counted for a full minute and recorded in beats per minute, and respiration rate 
will be counted for a full minute and recorded in breaths per minute. 
For the safety of the patient, additional vital sign assessments may be added at the discretion of 
the Investigator. 
7.5.2. 
Weight and Height 
Height will be measured in centimeters at the Screening/Baseline visit only.  Body weight will be 
measured in kilograms.  Body mass index will be calculated in the database. 
7.5.3. 
Physical Examination 
Complete physical examinations will include the examination of the following:  general 
appearance, head, eyes, ears, nose and throat, chest/respiratory, heart/cardiovascular, 
gastrointestinal/liver, musculoskeletal/extremities, dermatological/skin, thyroid/neck, lymph 
nodes, and neurological/psychiatric. 
Targeted physical examinations will include the examination of the following:  general 
appearance, chest/respiratory, heart/cardiovascular, gastrointestinal/liver, and 
neurological/psychiatric. 
7.5.4. 
Electrocardiogram 
Triplicate 12-lead ECG, with readings approximately 2 minutes apart, will be recorded.  
Additional ECGs may be collected at the discretion of the Investigator.  Standard computerized 
12-lead ECG recordings will be obtained.  Each lead shall be recorded for at least 3 beats at a 
speed of 25 mm/s.  Recordings will be obtained, after the patient has rested comfortably for 
approximately 10 minutes.  The electrophysiological parameters assessed include rhythm, 
ventricular rate, PR interval, QRS duration, QT interval, ST and T waves, Bazett-corrected QT 
interval (QTcB) and Fridericia-corrected QT interval (QTcF). 
The Investigator or designee is responsible for reviewing the ECGs to assess whether the results 
have changed since the Screening/Baseline visit and to determine the clinical relevance of the 
results.  These assessments will be recorded on the eCRF.  For any clinically relevant ECG 
changes from the Screening/Baseline visit (eg, ischemic ECG changes, wave/interval changes, or 
arrhythmia), the Investigator must contact the Medical Monitor to discuss continued participation 
of the patient in the study. 
7.5.5. 
Clinical Laboratory Assessments 
The following clinical laboratory tests will be evaluated by a central laboratory.  In the event of 
an unexplained clinically relevant abnormal laboratory test occurring after study drug 
administration, the test should be repeated and followed up at the discretion of the Investigator 
until it has returned to the normal range or stabilized, and/or a diagnosis is made to adequately 
explain the abnormality. 
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Hematology 
Complete blood count with differential 
 
Serum Chemistry 
Sodium 
Potassium 
BUN 
Phosphate 
Creatinine and eGFRa 
Albumin 
Uric acid 
Calcium 
Total protein 
Carbon dioxide 
Glucose 
Chloride 
Liver Function Tests 
 
AST 
ALP 
ALT 
Bilirubin (total and direct) 
Urinalysis 
Visual inspection for appearance and color 
Bilirubin 
pH (dipstick) 
Nitrite 
Specific gravity 
RBCs 
Ketones 
Urobilinogen 
Albumin 
Leukocytes 
Glucose 
Microscopy (if clinically indicated) 
Protein 
 
Immunogenicity 
Antidrug antibodies 
Pregnancy Testing (WOCBP only) 
β-human chorionic gonadotropin 
Abbreviations:  AST=aspartate transaminase; ALP=alkaline phosphatase; ALT=alanine transaminase; BUN=blood 
urea nitrogen; eGFR=estimated glomerular filtration rate; WOCBP=women of child bearing potential. 
a eGFR will be calculated using the Modification of Diet in Renal Disease formula.[33] 
7.5.5.1. 
Immunogenicity 
Blood samples will be collected to evaluate antidrug antibodies.  On days when ALN-AS1 is 
administered, blood samples for antidrug antibody testing must be collected before ALN-AS1 is  
administered. 
Details regarding the processing, shipping, and analysis of the samples will be provided in the 
Laboratory Manual. 
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7.5.5.2. 
Pregnancy Testing 
A pregnancy test will be performed for WOCBP only.  A serum pregnancy test will be 
performed at Screening/Baseline and urine pregnancy tests will be performed thereafter per the 
Schedule of Assessments and any time pregnancy is suspected.  Urine pregnancy tests may also 
be performed more frequently (eg, monthly) based on local country requirements.  The results of 
the pregnancy test must be known before study drug administration.  Patients who are pregnant 
are not eligible for study participation.  Any woman with a positive pregnancy test during the 
study will be discontinued from study drug, but will continue to be followed for safety.  Patients 
determined to be pregnant while on study will be followed until the pregnancy outcome is known 
(see Section 7.5.6.6 for follow-up instructions).  
7.5.6. 
Adverse Events 
7.5.6.1. 
Definitions 
Adverse Event 
According to the ICH E2A guideline Definitions and Standards for Expedited Reporting, and 
21 Code of Federal Regulations 312.32, Investigational New Drug Safety Reporting, an AE is 
any untoward medical occurrence in a patient or clinical investigational subject administered a 
medicinal product and which does not necessarily have a causal relationship with this treatment. 
Serious Adverse Event 
An SAE is any untoward medical occurrence that at any dose: 
 Results in death 
 Is life-threatening (An event which places the patient at immediate risk of death from 
the event as it occurred.  It does not include an event that had it occurred in a more 
severe form might have caused death) 
 Requires in-patient hospitalization or prolongation of existing hospitalization 
 Results in persistent or significant disability or incapacity 
 Is a congenital anomaly or birth defect 
 Is an important medical event that may not be immediately life-threatening or result 
in death or hospitalization but may jeopardize the patient and may require 
intervention to prevent one of the other outcomes listed in the definition above (eg, 
events include allergic bronchospasm requiring intensive treatment in an emergency 
room or at home, blood dyscrasias, convulsions, or the development of drug 
dependency or abuse). 
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Adverse Event Severity 
Adverse events are to be graded according to the categories detailed below: 
Mild: 
Mild events are those which are easily tolerated with no disruption of normal 
daily activity. 
Moderate: 
Moderate events are those which cause sufficient discomfort to interfere with 
normal daily activities. 
Severe: 
Severe events are those which incapacitate and prevent usual activity. 
Changes in severity should be documented in the medical record to allow assessment of the 
duration of the event at each level of severity.  AEs characterized as intermittent require 
documentation of the start and stop of each incidence.  When changes in the severity of an AE 
occur more frequently than once a day, the maximum severity for the experience that day should 
be noted.  If the severity category changes over a number of days, then those changes should be 
recorded separately (with distinct onset dates) 
AE severity and seriousness are assessed independently.  ‘Severity’ characterizes the intensity of 
an AE.  ‘Serious’ is a regulatory definition and serves as a guide to the Sponsor for defining 
regulatory reporting obligations (see definition for Serious Adverse Event). 
Relationship of the Adverse Event to Study Treatment 
The relationship of each AE to study treatment should be evaluated by the Investigator using the 
following criteria:  
Definitely related: 
A clinical event, including laboratory test abnormality, occurring in a 
plausible time relationship to the medication administration, and which 
cannot be explained by concurrent disease or other drugs or chemicals.  
The response to withdrawal of the drug should be clinically plausible. 
Possibly related: 
A clinical event, including laboratory test abnormality, with a 
reasonable time sequence to the medication administration, but which 
could also be explained by concurrent disease or other drugs or 
chemicals.  Information on the drug withdrawal may be lacking or 
unclear. 
Unlikely related: 
A clinical event, including laboratory test abnormality, with little or no 
temporal relationship to medication administration, and which other 
drugs, chemicals, or underlying disease provide plausible explanations. 
Not related: 
A clinical event, including laboratory test abnormality that has no 
temporal relationship to the medication or has more likely alternative 
etiology. 
Adverse Events of Clinical Interest 
The following events are considered to be adverse events of clinical interest: 
 ISRs 
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 Hepatic AEs, including LFT abnormalities considered clinically significant by the 
Investigator. 
7.5.6.2. 
Eliciting and Recording Adverse Events 
Eliciting Adverse Events 
The patient should be asked about medically relevant changes in his/her health since the last 
visit.  The patient should also be asked if he/she has been hospitalized, had any accidents, used 
any new medications, or changed concomitant medication routines (both prescription and OTC).  
In addition to patient observations, AEs will be documented from any clinically relevant 
laboratory findings, physical examination findings, ECG changes, or other findings that are 
relevant to patient safety. 
Recording Adverse Events 
The Investigator is responsible for recording non-serious AEs that are observed or reported by 
the patient after administration of the first dose of study drug regardless of their relationship to 
study drug through the end of study.  Non-serious AEs will be followed until the end of study.  
The Investigator is responsible for recording SAEs that are observed or reported by the patient 
after the time when the informed consent is signed regardless of their relationship to study drug 
through the end of study.  SAEs will be followed until satisfactory resolution, until baseline level 
is reached, or until the SAE is considered by the Investigator to be chronic or the patient is 
stable, as appropriate. 
All AEs must be recorded in the source records for the clinical study center and in the eCRF for 
the patient, whether or not they are considered to be drug-related.  Each AE must be described in 
detail:  onset time and date, description of event, severity, relationship to investigational drug, 
action taken, and outcome (including time and date of resolution, if applicable). 
For SAEs, record the event(s) on the eCRF.  If the electronic data capture (EDC) system is 
unavailable, complete the backup SAE form. 
For AEs that are considered AEs of clinical interest, additional clinical information may be 
collected based upon the severity or nature of the event. 
If a patient has ISRs meeting any of the following criteria, the Investigator or delegate should 
contact the Medical Monitor and submit a supplemental ISR eCRF: 
 ISRs that are recurrent and/or demonstrate a pattern of increasing severity 
 Any ISR that is determined to be severe and/or a cause for study drug discontinuation  
 Any ISR which, in the opinion of the Investigator, requires further medical evaluation or 
treatment 
In some cases, where it is medically appropriate, further evaluation may include photographs, 
referral to a dermatologist, skin biopsy, or other laboratory testing.  If a biopsy was obtained, the 
Sponsor may request that the biopsy also be reviewed by a central dermatopathologist.  To better 
understand the safety profile of the study drug, additional analysis of biopsy tissue may be 
performed according to local regulations. 
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For patients with hepatic AEs, additional information, including, clinical history, course of event, 
and local laboratory results to monitor LFT levels or other laboratory parameters, may be 
collected. 
7.5.6.3. 
Serious Adverse Events Require Immediate Reporting to Sponsor/Designee 
An assessment of the seriousness of each AE will be made by the Investigator.  Any AE and 
laboratory abnormality that meets the SAE criteria in Section 7.5.6.1 must be reported to the 
Sponsor or designee within 24 hours from the time that clinical study center personnel first 
learns of the event.  All SAEs must be reported regardless of the relationship to study drug. 
The initial report should include at least the following information: 
 Patient’s study number 
 Description and date of onset of the event 
 Criterion for serious 
 Preliminary assignment of relationship to study drug 
 Investigator/clinical study center information 
To report the SAE, complete the eCRF.  If the EDC system is unavailable, complete the backup 
SAE form.  Within 24 hours of receipt of follow-up information, the Investigator must update the 
report.  SAEs must be reported using the contact information provided in the Study Manual. 
Appropriate remedial measures should be taken by the Investigator using his/her best medical 
judgment to treat the SAE.  These measures and the patient’s response to these measures should 
be recorded.  All SAEs, regardless of relationship to study drug, will be followed by the 
Investigator until satisfactory resolution or the Investigator deems the SAE to be chronic or 
stable.  Clinical, laboratory, and diagnostic measures should be employed by the Investigator as 
needed to adequately determine the etiology of the event. 
7.5.6.4. 
Sponsor Safety Reporting to Regulatory Authorities 
The Sponsor or its representative is required to report certain study events in an expedited 
manner to the Food and Drug Administration, the European Medicines Agency’s EudraVigilance 
electronic system according to Directive 2001/20/EC, and to all country Regulatory Authorities 
where the study is being conducted, according to local applicable regulations. 
The following describes the safety reporting timeline requirements for suspected unexpected 
serious adverse reactions (SUSARs) and other reportable events: 
Immediately and within 7 calendar days 
 Any suspected adverse reaction that is associated with the use of the study drug, 
unexpected, and fatal or life threatening.  Follow-up information must be reported in 
the following 8 days. 
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Immediately and within 15 calendar days 
 Any suspected adverse reaction that is associated with the use of the study drug, 
unexpected, and serious, but not fatal or life threatening, and there is evidence to 
suggest a causal relationship between the study drug and the reaction. 
 Any finding from tests in laboratory animals that suggest a significant risk for human 
patients including reports of mutagenicity, teratogenicity, or carcinogenicity. 
 Any event in connection with the conduct of the study or the development of the 
study drug that may affect the safety of the trial patients. 
In addition, periodic safety reporting to regulatory authorities will be performed by the Sponsor 
or its representative according to national and local regulations. 
7.5.6.5. 
Serious Adverse Event Notification to the Institutional Review 
Board/Independent Ethics Committee 
SUSARs will be reported to the Institutional Review Board (IRB)/Independent Ethics 
Committee (IEC) per their institutional policy by the Investigator or Sponsor (or Sponsor 
designee) according to country requirements.  Copies of each report and documentation of 
IRB/IEC notification and acknowledgement of receipt will be kept in the Investigator’s study 
file. 
7.5.6.6. 
Pregnancy Reporting 
If a female patient becomes pregnant during the course of this study through 90 days following 
the last dose of study drug, the Investigator must report the pregnancy to the Sponsor or designee 
within 24 hours of being notified of the pregnancy.  Details of the pregnancy will be recorded on 
the pregnancy reporting form.  The patient should receive any necessary counseling regarding 
the risks of continuing the pregnancy and the possible effects on the fetus. 
The pregnancy should be followed by the Investigator until completion.  At the completion of the 
pregnancy, the Investigator will document the outcome of the pregnancy.  If the outcome of the 
pregnancy results in a postpartum complication, spontaneous abortion, stillbirth, neonatal death, 
or congenital anomaly, then the Investigator should follow the procedures for reporting an SAE 
as outlined in Section 7.5.6.3.   
7.5.6.7. 
Overdose Reporting 
An overdose is defined as any dose administered to or taken by a patient (accidentally or 
intentionally) that exceeds the highest daily dose, or is at a higher frequency, than included in the 
protocol.  It is up to the investigator to decide whether a dose is to be considered an overdose, in 
consultation with the Sponsor.  Overdose must be recorded in the eCRF. 
All reports of overdose (with or without an AE) must be reported within 24 hours to the Sponsor 
or designee.   
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7.6. 
Exploratory Assessments 
Blood and urine samples will be collected for exploratory analyses.  Aliquots of samples will be 
obtained and frozen, to permit future analysis of the effect of ALN-AS1 on exploratory 
biomarkers.   
Where local regulations allow, biologic samples will be retained on behalf of the Sponsor for a 
maximum of 15 years following the last patient’s last visit in the study.  Details regarding the 
collection, processing, storage, and shipping of samples will be in the Laboratory Manual. 
7.7. 
Other Assessments 
7.7.1. 
EQ-5D-5L Questionnaire 
QOL will be assessed through the use of the 5-level EQ-5D (EQ-5D-5L), a standardized 
questionnaire measuring health outcomes.[34]  In addition to the time points indicated, the 
EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a 
porphyria attack (but, not more than once in a 6 month period), if possible. 
8. 
STATISTICS 
A detailed Statistical Analysis Plan (SAP) will be written after finalizing the protocol and before 
database lock.  The plan will detail the implementation of all the statistical analyses in 
accordance with the principle features stated in the protocol. 
8.1. 
Determination of Sample Size 
This is a Phase 1/2 multicenter, open-label extension study to evaluate the long-term safety and 
clinical activity of ALN-AS1 in patients with AIP who completed study ALN-AS1-001.  Safety, 
tolerability, PK, and PD of ALN-AS1 will be investigated.  The sample size was not determined 
based on statistical considerations.  Up to 24 patients are planned for this study (including 
optional cohorts in ALN-AS1-001). 
8.2. 
Statistical Methodology 
The statistical and analytical plans presented below summarize the more complete plans to be 
detailed in the SAP.  Any changes to the methods described in the final SAP will be described 
and justified as needed in the clinical study report. 
Statistical analyses will be primarily descriptive in nature.  Descriptive statistics (eg, mean, 
standard deviation, median, minimum, and maximum) will be presented for continuous 
variables.  Frequencies and percentages will be presented for categorical and ordinal variables. 
Analyses will be performed using SAS® (Version 9.2, or higher).
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8.2.1. 
Populations to be Analyzed 
The populations (analysis sets) are defined as follows:  
Safety Analysis Set: 
All patients who received any amount of study drug. 
Clinical Activity Analysis 
Set: 
All patients who received any amount of study drug and have 
both a baseline and at least 1 postdose assessment. 
PK Analysis Set: 
All patients who received any amount of study drug and have at 
least 1 postdose blood sample for PK and who have evaluable 
PK data. 
PD Analysis Set: 
All patients who received any amount of study drug and who 
have at least 1 postdose blood sample for the determination of 
ALN-AS1 will be included in the PD analyses. 
Safety will be analyzed using the Safety Analysis Set.  The PK and PD Analysis Sets will be 
used to conduct PK and PD analyses, respectively.  The population used to evaluate clinical 
activity will be the Clinical Activity Analysis Set.   
8.2.2. 
Examination of Subgroups 
Subgroup analyses may be conducted for selected endpoints.  Detailed methodology will be 
provided in the SAP. 
8.2.3. 
Handling of Missing Data 
Unrecorded values will be treated as missing.  The appropriateness of the method(s) described 
for handling missing data may be reassessed and documented in the SAP before database lock.  
Depending on the extent of missing values, further investigation may be made into the sensitivity 
of the analysis results to the method(s) specified. 
8.2.4. 
Baseline Evaluations 
Demographics, medical history, disease-specific information, and other baseline characteristics 
collected in this study will be summarized.   
8.2.5. 
Clinical Activity Analyses 
Clinical activity of ALN-AS1 will be summarized primarily by descriptive statistics.  The 
clinical activity of ALN-AS1 will be evaluated by the frequency and characteristics of porphyria 
attacks including duration, treatment, and severity of porphyria attacks and number and duration 
of visits to a health care setting for acute porphyria care. 
Patient diary recordings, including BPI-SF questionnaire scores, will also be summarized. 
8.2.6. 
Pharmacodynamic Analysis 
PD analyses will include the evaluation of change in ALA, PBG, and ALAS mRNA levels.  
Descriptive statistics (eg, mean and standard error of the mean) for observed levels of PD 
parameters and the relative change from baseline will be presented for each of the postdose 
follow-up time points. 
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8.2.7. 
Pharmacokinetic Analysis 
The PK concentration of ALN-AS1 will be determined. 
Antidrug antibody results will be tabulated.  A by-patient data listing will also be provided. 
8.2.8. 
Safety Analyses 
Extent of exposure will be summarized.  AEs will be summarized by the Medical Dictionary for 
Regulatory Activities System Organ Class and Preferred Term.  Prior and concomitant 
medications will be classified according to the World Health Organization drug dictionary. 
Incidence of AEs (those events that started after exposure to study drug or worsened in severity 
after dosing) will be presented.  Incidence of AEs will also be presented by maximum severity 
and relationship to study treatment.  The incidence of SAEs and AEs leading to discontinuation 
of treatment will also be tabulated.  By-patient listings will be provided for deaths, SAEs, and 
AEs leading to discontinuation of treatment.   
Descriptive statistics will be provided for clinical laboratory data and vital signs data, presented 
as both actual values and changes from baseline relative to each on-study evaluation and to the 
last evaluation on study.  Laboratory shift tables from baseline to worst values will be presented.  
Abnormal physical examination findings and 12-lead ECG data will be presented in a by-patient 
data listing. 
Descriptive statistics will be provided for ECG interval data and presented as both actual values 
and changes from baseline relative to each on-study evaluation and to the last evaluation on 
study.  Details of any abnormalities will be included in patient listings. 
Concomitant hemin administration will also be recorded. 
8.2.9. 
Other Analyses 
Possible associations between PD parameters (ALA, PBG, and ALAS1 mRNA levels) and 
clinical activity parameters may also be explored. 
Additional exploratory analyses may be conducted on analytes related to targeting the heme 
biosynthesis pathway. 
QOL scores on the EQ-5D-5L questionnaire will also be summarized. 
9. 
STUDY ADMINISTRATION 
9.1. 
Ethical and Regulatory Considerations 
This study will be conducted in accordance with the protocol, all applicable regulatory 
requirements, and the guidelines of Good Clinical Practice (GCP).  Compliance with GCP 
provides public assurance that the rights, safety, and well-being of study patients are protected 
consistent with the principles that have their origin in the Declaration of Helsinki. 
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9.1.1. 
Informed Consent 
The Investigator will ensure that the patient is given full and adequate oral and written 
information about the nature, purpose, possible risk and benefit of the study.  Patients must also 
be notified that they are free to withdraw from the study at any time.  The patient should be given 
the opportunity to ask questions and allowed time to consider the information provided. 
The patient’s signed and dated informed consent must be obtained before conducting any study 
procedures. 
The Investigator must maintain the original, signed ICF.  A copy of the signed ICF must be 
given to the patient. 
9.1.2. 
Ethical Review 
The final study protocol, including the final version of the ICF, must be approved or given a 
favorable opinion in writing by an IRB or IEC, as appropriate.  The Investigator must submit 
written approval before he or she can enroll any patient into the study. 
The Investigator is responsible for informing the IRB or IEC of any amendment to the protocol 
in accordance with local requirements.  In addition, the IRB or IEC must approve all advertising 
used to recruit patients for the study.  The protocol must be reapproved by the IRB or IEC upon 
receipt of amendments and annually, as local regulations require. 
Initial IRB approval of the protocol, and all materials approved by the IRB for this study 
including the patient consent form and recruitment materials must be maintained by the 
Investigator and made available for inspection. 
The Investigator will submit reports of SAEs as outlined in Section 7.5.6.  In addition, the 
Investigator agrees to submit progress reports to the IRB or IEC per their local reporting 
requirements, or at least annually and at the conclusion of the study.  The reports will be made 
available to the Sponsor or designee. 
Any communications from regulatory agencies in regard to inspections, other studies that impact 
this protocol or the qualifications of study personnel should be promptly reported to the Sponsor 
or its designee. 
The Investigator is also responsible for providing the IRB with reports of any reportable serious 
adverse drug reactions from any other study conducted with the investigational drug.  The 
Sponsor or designee will provide this information to the Investigator. 
Major changes in this research activity, except those to remove an apparent immediate hazard to 
the patient, must be reviewed and approved by the Sponsor and the IRB or IEC that approved the 
study.  Amendments to the protocol must be submitted in writing to the Investigator’s IRB or 
IEC and the Regulatory Authority for approval before patients are enrolled under the amended 
protocol. 
9.1.3. 
Study Documentation, Confidentiality, and Records Retention 
All documentation relating to the study should be retained for the period of time required by 
applicable local law.  If it becomes necessary for the Sponsor, the Sponsor’s designee, applicable 
IRB/IEC, or applicable regulatory authorities to review or audit any documentation relating to 
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the study, the Investigator must permit direct access to all source documents/data.  Records will 
not be destroyed without informing the Sponsor in writing and giving the Sponsor the 
opportunity to store the records for a longer period of time at the Sponsor’s expense.   
The Investigator must ensure that the patients’ anonymity will be maintained.  On the CRFs or 
other documents submitted to the Sponsor or designees, patients should not be identified by their 
names, but by the assigned patient number and initials.  If patient names are included on copies 
of documents submitted to the Sponsor or designees, the names (except for initials) will be 
obliterated and the assigned patient number added to the document.  Documents not for 
submission to the Sponsor (eg, signed ICFs) should be maintained by the Investigator in strict 
confidence. 
The Investigator must treat all of the information related to the study and the compiled data as 
confidential, whose use is for the purpose of conducting the study.  The Sponsor must approve 
any transfer of information not directly involved in the study. 
In compliance with local and/or regional regulations, this clinical study may be registered and 
study results may be posted on public registries, such as ClinicalTrials.gov. 
9.1.4. 
End of the Study 
The end of the study is defined as last patient last visit. 
9.1.5. 
Discontinuation of the Clinical Study 
The Sponsor reserves the right to discontinue the study for clinical or administrative reasons at 
any time.  If the clinical study center does not recruit at a reasonable rate, the study may be 
discontinued at that clinical study center.  Should the study be terminated and/or the clinical 
study center closed for whatever reason, all documentation and study drug pertaining to the study 
must be returned to the Sponsor or its representative, and the Investigators, IEC/IRB and 
Regulatory Authorities will be promptly informed of the termination and the reason for the 
decision.  The Investigator should promptly inform the patients and assure appropriate therapy 
and follow-up.  Patients should then be withdrawn from the study.   
9.2. 
Data Quality Control and Quality Assurance 
9.2.1. 
Data Handling 
Study data must be recorded on case report forms (paper and/or electronic) provided by the 
Sponsor or designee on behalf of the Sponsor.  Case report forms must be completed only by 
persons designated by the Investigator.  If eCRFs are used, study data must be entered by trained 
clinical study center personnel with access to a valid and secure eCRF system.  All data entered 
into the eCRF must also be available in the source documents.  Corrections on paper CRFs must 
be made so as to not obliterate the original data and must be initialed and dated by the person 
who made the correction. 
9.2.2. 
Study Monitoring 
The clinical monitor, as a representative of the Sponsor, has an obligation to closely follow the 
study conduct at the clinical study center.  The monitor will visit the Investigator and clinical 
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study center periodically and will maintain frequent telephone and written contact.  The monitor 
will maintain current personal knowledge of the study through observation, review of study 
records and source documentation, and discussion of the conduct of the study with the 
Investigator and personnel. 
The monitor will review source documents, systems and CRFs to ensure overall quality and 
completeness of the data and to confirm study procedures are complied with the requirements in 
the study protocol.  The Sponsor, or its designee, will be allowed to conduct clinical study center 
visits to the investigation facilities for the purpose of monitoring any aspect of the study.  The 
Investigator agrees to allow the monitor to inspect the drug storage area, study drug stocks, drug 
accountability records, patient charts and study source documents, and other records relative to 
study conduct. 
9.2.3. 
Audits and Inspections 
Periodically, the Sponsor or its authorized representatives audit clinical investigative study 
centers as an independent review of core trial processes and documents to determine whether 
these activities were conducted, and data were recorded, analyzed, and accurately reported 
according to the protocol, GCP guidelines of the ICH, and any applicable regulatory 
requirements.  A regulatory authority, an IEC or an IRB may visit the clinical study center to 
perform audits or inspections, including source data verification.  The Investigator should contact 
the Sponsor, or its designee, immediately if contacted by a regulatory agency about an 
inspection. 
9.3. 
Publication Policy 
It is intended that after completion of the study, the data are to be submitted for publication in a 
scientific journal and/or for reporting at a scientific meeting.  A copy of any proposed manuscript 
must be provided and confirmed received at the Sponsor at least 30 days before its submission, 
and according to any additional publication details in the Investigator Agreement.
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10. 
LIST OF REFERENCES 
1. Anderson KE, Bloomer JR, Bonkovsky HL, Kushner JP, Pierach CA, Pimstone NR, et al. 
Recommendations for the diagnosis and treatment of the acute porphyrias. Ann Intern Med. 2005 
Mar 15;142(6):439-50. 
2. Siegesmund M, van Tuyll van Serooskerken AM, Poblete-Gutierrez P, Frank J. The acute 
hepatic porphyrias: current status and future challenges. Best Pract Res Clin Gastroenterol. 2010 
Oct;24(5):593-605. 
3. Poblete-Gutierrez P, Wiederholt T, Merk HF, Frank J. The porphyrias: clinical presentation, 
diagnosis and treatment. Eur J Dermatol. 2006 May-Jun;16(3):230-40. 
4. Balwani M, Desnick RJ. The porphyrias: advances in diagnosis and treatment. Blood. 2012 
Nov 29;120(23):4496-504. 
5. Puy H, Gouya L, Deybach JC. Porphyrias. Lancet. 2010 Mar 13;375(9718):924-37. 
6. Floderus Y, Sardh E, Moller C, Andersson C, Rejkjaer L, Andersson DE, et al. Variations in 
porphobilinogen and 5-aminolevulinic acid concentrations in plasma and urine from 
asymptomatic carriers of the acute intermittent porphyria gene with increased porphyrin 
precursor excretion. Clin Chem. 2006 Apr;52(4):701-7. 
7. Anderson K. Disorders of heme biosynthesis. 8th ed. CR S, editor: McGraw-Hill, New York 
2001. 
8. Dowman JK, Gunson BK, Mirza DF, Bramhall SR, Badminton MN, Newsome PN. Liver 
transplantation for acute intermittent porphyria is complicated by a high rate of hepatic artery 
thrombosis. Liver Transpl. 2012 Feb;18(2):195-200. 
9. Badminton MN, Elder GH. Molecular mechanisms of dominant expression in porphyria. J 
Inherit Metab Dis. 2005;28(3):277-86. 
10. Deybach J-C, Puy H. 86 - Acute Intermittent Porphyria: From Clinical to Molecular Aspects. 
In: Guilard KMKMS, editor. The Porphyrin Handbook. Amsterdam: Academic Press; 2003. p. 
23-41. 
11. Bylesjo I, Wikberg A, Andersson C. Clinical aspects of acute intermittent porphyria in 
northern Sweden: a population-based study. Scand J Clin Lab Invest. 2009;69(5):612-8. 
12. James MF, Hift RJ. Porphyrias. Br J Anaesth. 2000 Jul;85(1):143-53. 
13. Chemmanur AT, Bonkovsky HL. Hepatic porphyrias: diagnosis and management. Clin Liver 
Dis. 2004 Nov;8(4):807-38, viii. 
14. Stein P, Badminton M, Barth J, Rees D, Stewart MF. Best practice guidelines on clinical 
management of acute attacks of porphyria and their complications. Ann Clin Biochem. 2013 
May;50(Pt 3):217-23. 
15. Bonkovsky HL. Neurovisceral porphyrias: what a hematologist needs to know. Hematology 
Am Soc Hematol Educ Program. 2005:24-30. 
16. Panhematin. (hemin for injection). 2013. 
17. Normosang. (human hemin). 2007. 
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18. Watson CJ, Pierach CA, Bossenmaier I, Cardinal R. Postulated deficiency of hepatic heme 
and repair by hematin infusions in the "inducible" hepatic porphyrias. Proc Natl Acad Sci U S A. 
1977 May;74(5):2118-20. 
19. Mustajoki P, Nordmann Y. Early administration of heme arginate for acute porphyric attacks. 
Arch Intern Med. 1993 Sep 13;153(17):2004-8. 
20. Bonkovsky HL, Singh RH, Jafri IH, Fiellin DA, Smith GS, Simon D, et al. A randomized, 
controlled trial of treatment of alcoholic hepatitis with parenteral nutrition and oxandrolone. II. 
Short-term effects on nitrogen metabolism, metabolic balance, and nutrition. Am J Gastroenterol. 
1991 Sep;86(9):1209-18. 
21. Herrick AL, McColl KE, Moore MR, Cook A, Goldberg A. Controlled trial of haem arginate 
in acute hepatic porphyria. Lancet. 1989 Jun 10;1(8650):1295-7. 
22. Bissell DM. Treatment of acute hepatic porphyria with hematin. J Hepatol. 1988 Feb;6(1):1-
7. 
23. Green D, Ts'ao CH. Hematin: effects on hemostasis. J Lab Clin Med. 1990 Feb;115(2):144-
7. 
24. Daimon M, Susa S, Igarashi M, Kato T, Kameda W. Administration of heme arginate, but 
not hematin, caused anaphylactic shock. Am J Med. 2001 Feb 15;110(3):240. 
25. Elder G, Harper P, Badminton M, Sandberg S, Deybach JC. The incidence of inherited 
porphyrias in Europe. J Inherit Metab Dis. 2013 Sep;36(5):849-57. 
26. Anderson K. Heme arginate for prevention of acute porphyric attacks (abstract). Acta 
Haematologica. 1997;98((suppl 1):120). 
27. Bonkovsky HL, Guo JT, Hou W, Li T, Narang T, Thapar M. Porphyrin and heme 
metabolism and the porphyrias. Compr Physiol. 2013 Jan;3(1):365-401. 
28. Vaishnaw AK, Gollob J, Gamba-Vitalo C, Hutabarat R, Sah D, Meyers R, et al. A status 
report on RNAi therapeutics. Silence. 2010;1(1):14. 
29. Elbashir SM, Harborth J, Lendeckel W, Yalcin A, Weber K, Tuschl T. Duplexes of 21-
nucleotide RNAs mediate RNA interference in cultured mammalian cells. Nature. 2001 May 
24;411(6836):494-8. 
30. Kauppinen R, von und zu Fraunberg M. Molecular and biochemical studies of acute 
intermittent porphyria in 196 patients and their families. Clin Chem. 2002 Nov;48(11):1891-900. 
31. Division of Clinical Pharmacology, Indiana University, P450 Drug Interaction Table.  2013 [ 
Accessed 06 February 2015]; Available from: http://medicine.iupui.edu/clinpharm/ddis/main-
table/. 
32. Atkinson TM M, TR, Sit L, Passik P, Scher, HI, Cleeland C, and Basch E. The Brief Pain 
Inventory and its “Pain at its Worst in the last 24 Hours” Item: Clinical Trial Endpoint 
Considerations. Pain Med. 2010 March;11(3):337–46. 
33. Levey AS SL, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, Kusek JW, Eggers P, 
Van Lente F, Greene T, Coresh J; CKD-EPI (Chronic Kidney Disease Epidemiology 
Collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med. 
2009;150(9):604-12. 
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34. Herdman M GC, Lloyd A, Janssen M, Kind P, Parkin D, Bonsel G, Badia X. Development 
and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res. 
2011;20(10):1727-36. 
 
 
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11. 
APPENDICES 
11.1. 
Pharmacokinetic Assessment Time Points 
Table 3 contains a detailed schedule for the collection of blood samples for PK analysis. 
Table 3: 
Pharmacokinetic Time Points 
Study Day 
Protocol Time 
(hh:mm) 
PK Blood 
Day 1 and 
Month 12 (D361) ±10 days 
Predose (within 60 minutes 
before dosing) 
X 
02:00 (±5 minutes) 
X 
06:00 (±20 minutes) 
X 
Month 1 (Day 31) ±7 days,a  
Month 3 (Day 91) ±7 days, 
Month 6 (Day 181) ±7 days, 
Month 18 (Day 541) ±10, and 
Month 24 (Day 721) ±10 days 
Predose (within 60 minutes 
before dosing) 
X 
02:00 (±5 minutes) 
X 
Abbreviations:  hh=hours; mm=minutes; PK=pharmacokinetic. 
a  At the Month 1 visit, if the dosing regimen is every 3 months, ALN-AS1 is not administered and a single 
time point blood sample for PK analysis should be collected. 
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11.2. 
Schedules of Assessments for Every Month Dosing Regimen 
 
Table 4: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History/Disease 
Historyc 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/ 
Exclusion Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examinationd 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
 
 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
X 
Vital Signsf 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGg 
X 
X 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
Clinical Laboratory 
Assessmenth 
X 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationj 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine Sample for PBG, ALA, 
and Creatinine Analysisk 
 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl 
 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
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Table 4: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Blood Sample for PK 
Analysism 
 
X 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
Antidrug Antibodiesn 
 
X 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
Porphyria Attack Kit 
Dispensationo 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EQ-5D-5L Questionnairep 
X 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Diary Review (including 
BPI-SF)q 
 
X 
AEs 
 
Continuous 
Concomitant Medicationsr 
Continuous 
Abbreviations:  AE=adverse event; ALAS1=5-aminolevulinic acid synthase 1; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain 
Inventory-Short Form; D=day; ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of life; 
SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations and 
blood/urine sample collections. 
a Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study (ALN-AS1-001) were completed within 60 days 
of administration of the first dose of ALN-AS1 in this study.  If more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs 
will be repeated before administration of ALN-AS1.  Results should be available before the administration of the first dose of ALN-AS1. 
b After a patient has completed 6 months of ALN-AS1 administration in this study, and where applicable country and local regulations and infrastructure allow, 
study visits and ALN-AS1 administration may take place at the patient’s home by a healthcare professional.  Home visits may occur at the discretion of the 
Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit at the clinical study center Q3M through M12, and 
thereafter Q6M. 
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c See Section 7.1 for details on the interval medical history/disease history to be recorded at Screening/Baseline.  Ongoing AEs from the previous study 
(ALN-AS1-001) will be captured as medical history. 
d A complete physical examination will be performed at Screening/Baseline, and D1.  At all other visits, a targeted physical examination will be performed.  On 
dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any time 
during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On D1, vital signs will be collected within 1 hour predose; and 2 hours 
(±10 minutes) postdose.  On all other dosing days, vital signs will be collected within 1 hour predose.  On days when ALN-AS1 is not administered, vital signs 
can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position (should be consistent for each patient), after the 
patient has rested comfortably for 10 minutes. 
g Triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 10 minutes.  On D1, ECGs will be 
performed within 1 hour predose and 2 hours (±10 minutes) postdose.  On all other dosing days, ECGs will be collected within 1 hour predose. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected within 1 hour 
predose; results are not required before dosing.  On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. 
i A serum pregnancy test will be performed at Screening/Baseline; thereafter, urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  For weight-
based dosing, weight measured on the dosing day will be used to calculate the dose of ALN-AS1.  After M12, weight measured on the nearest previous visit 
will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 3 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o Porphyria attack laboratory sample collection kits should be dispensed at the screening visit along with instructions for use. For any attack that occurs through 
M39, urine samples should be collected within 24 hours of the start of clinical intervention (eg, hemin or glucose administration) and within 24 hours of the end 
of clinical intervention.  If patients are unable to report to the clinical study center during a porphyria attack, laboratory sample collection kits should be used 
for collecting and sending urine samples to the clinical study center, if possible.  These urine samples may also be analyzed for exploratory biomarkers. 
p In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but not more than once in a 6 month period), if possible.  
q Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, and narcotic use on a daily basis through M9; 
thereafter, acute porphyria attacks will be recorded in the diary.  The BPI will be completed on a weekly basis as part of the patient diary through M9, then 
Q3M. 
r Medications that are ongoing from the previous study (ALN-AS1-001), started between the previous study and this study, and started after signing informed 
consent in this study, will be captured as concomitant medication(s). 
 
 
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Table 5: 
Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20a 
M21a 
M22/ 
M23a 
M24 
M25/ 
M26a 
M27a 
M28/ 
M29a 
M30 
M31/ 
M32a 
M33a 
M34/ 
M35a 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Physical Examinationd 
 
 
 
X 
 
 
 
X 
 
 
 
X 
X 
 
Body Weight, BMI, and 
Heighte 
 
 
 
X 
 
 
 
X 
 
 
 
 
X 
 
Vital Signsf 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Triplicate 12-Lead ECGg 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
 
Clinical Laboratory 
Assessmenth 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Study Drug Administrationj 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl  
 
 
 
X 
 
 
 
X 
 
 
 
X 
X 
 
Blood Sample for PK 
Analysism 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
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Table 5: 
Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20a 
M21a 
M22/ 
M23a 
M24 
M25/ 
M26a 
M27a 
M28/ 
M29a 
M30 
M31/ 
M32a 
M33a 
M34/ 
M35a 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Antidrug Antibodiesn 
 
 
 
X 
 
 
 
 
 
 
 
X 
 
 
EQ-5D-5L Questionnaireo 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
Diary Review (including 
BPI-SF)p 
X 
 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; EOS = End of Study; EOT = End of Treatment; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality 
of life; SC=subcutaneous. 
Notes:   
 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations 
and blood/urine sample collections. 
a Where applicable country and local regulations and infrastructure allow, study visits and ALN-AS1 administration may take place at the patient’s home by a 
healthcare professional.  Home visits may occur at the discretion of the Investigator, based on safety and tolerability; however, patients are required to complete 
at least 1 visit at the clinical study center Q6M. 
b Patients who discontinue treatment will be asked to complete the M39 visit assessments.  If a patient chooses to withdraw from the study, every effort should 
be made to conduct early the assessments performed at the M39 visit.  See Section 5.3 for details on removal from treatment or assessment. 
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c The ALA/PBG Monitoring/EOS visit will be conducted at the clinical study center or via phone contact, unless treatment continues with ALN-AS1.  Patients 
will be provided with laboratory sample collection kits and instructions for collecting and sending urine samples to the clinical study center.  Urine samples 
should not be collected during a porphyria attack. 
d A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed.  
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, body temperature, and respiratory rate.  On a dosing days, vital signs will be collected within 1 hour predose.  On 
days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position 
(should be consistent for each patient), after the patient has rested comfortably for 10 minutes. 
g Triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 10 minutes.  On dosing days, ECGs will 
be collected within 1 hour predose. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected within 1 hour 
predose; results are not required before dosing.  On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. 
i Urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured on the nearest previous visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 3 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but, not more than once in a 6 month period), if possible.  
p Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
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11.3. 
List of Sensitive CYP3A Substrates and those with a Narrow 
Therapeutic Range 
A list of medications that are sensitive CYP3A substrates and those with a narrow therapeutic 
range is in Table 6.  
Table 6: 
List of Sensitive CYP3A Substrates and those with a Narrow Therapeutic 
Range 
Sensitive CYP3A Substrates 
 
CYP3A Substrates With A Narrow 
Therapeutic Range 
alfentanil 
fluticasone 
 
Alfentanil 
aprepitant 
lopinavir 
 
Astemizole 
budesonide 
lovastatin 
 
Cisapride 
buspirone 
lurasidone 
 
Cyclosporine 
conivaptan 
maraviroc 
 
Diergotamine 
darifenacin 
midazolam 
 
Dihydroergotamine 
darunavir 
nisoldipine 
 
Ergotamine 
dasatinib 
quetiapine 
 
Fentanyl 
dronedarone 
saquinavir 
 
Irinotecan 
eletriptan 
sildenafil 
 
Pimozide 
eplerenone 
simvastatin 
 
Quinidine 
everolimus 
sirolimus 
 
Sirolimus 
felodipine 
tolvaptan 
 
Tacrolimus 
imatinib 
tipranavir 
 
Terfenadine 
indinavir 
triazolam 
 
 
 
vardenafil 
 
 
Note:  This is not an exhaustive list and availability of medications may differ between countries.  For more 
information about clinically relevant drugs that are CYP3A substrates, see the Indiana University Division of 
Pharmacology website for reference: http://medicine.iupui.edu/clinpharm/ddis/clinical-table/. 
 
 
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ALN-AS1-002 Protocol Amendment 1 
Summary of Changes (dated 10 November 2016)  
compared to Original Protocol (dated 19 July 2016) 
 
A Multicenter, Open-label Extension Study to Evaluate the Long-term Safety and Clinical 
Activity of Subcutaneously Administered ALN-AS1 in Patients with Acute Intermittent 
Porphyria who have Completed a Previous Clinical Study with ALN-AS1 
 
Rationale for Protocol Amendment 
The primary purpose of this protocol amendment is to define the starting dose in study 
ALN-AS1-002, and to clarify criteria for determining individual dose modifications.  
The following changes are being implemented as outlined: 
 Based on review of data from the ALN-AS1-001 study, the SRC has determined the 
study starting dose and dosing regimen for administration in ALN-AS1-002 to be 
5.0 mg/kg administered every 3 months.  
 If a patient has a study drug-related adverse event (AE) of a recurrent injection site 
reaction (ISR), severe ISR, or clinically significant liver function test (LFT) abnormality 
and the Investigator and Medical Monitor have concerns regarding further ALN-AS1 
administration, a dose reduction to half the previously administered dose or a reduction in 
dosing frequency will be permitted. Subsequent ALN-AS1 administration at the previous 
dose may be considered based on the judgment of the Investigator and Medical Monitor. 
 The benefit-risk profile remains unchanged; however, the potential risks associated with 
administration of ALN-AS1 in patients with acute intermittent porphyria (AIP) on 
reproductive health were updated to include preliminary nonclinical data.  Based on these 
data, ALN-AS1 administration to pregnant women is unlikely to pose a risk to 
embryofetal development.   
 While contraceptive requirements for patients enrolling in study ALN-AS1-002 remain 
unchanged from those in study ALN-AS1-001, wording of the inclusion criterion for 
WOCBP was clarified such that if hormonal methods of contraception are medically 
contraindicated, a double-barrier method will be considered an acceptable method of 
contraception.  
 Since ALN-AS1 could increase the clearance of drugs metabolized by the CYP3A 
isoform, a list of medications that are CYP3A substrates is now included in the protocol. 
 To support dosing for up to 36-months, preliminary nonclinical data from 26-week and 
39-week Good Laboratory Practice (GLP) chronic toxicity studies conducted in rats and 
nonhuman primates (NHPs) have been updated. 
 Clarified that a single blood sample for pharmacokinetic (PK) analysis will be collected 
at the Month 1 visit for patients with an every 3 month dosing regimen 
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
Made minor changes to schedules of assessment to increase consistency and clarity
A detailed summary of changes is provided in Table 1.  Corrections to typographical errors, 
punctuation, grammar, abbreviations, and formatting, as well as those indicated in administrative 
change letter 1 (dated 18 August 2016), are not detailed.
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Table 1: 
Protocol Amendment 1 Detailed Summary of Changes 
The primary section(s) of the protocol affected by the changes in the protocol amendment are indicated.  The corresponding text has 
been revised throughout the protocol.  Deleted text is indicated by strikeout; added text is indicated by bold font. 
Purpose:  Updated preliminary nonclinical data from 26-week and 39-week GLP chronic toxicity studies conducted in rats and NHPs 
The primary change occurs in Section 1.3.1, Nonclinical Summary 
Added text: 
Preliminary results from 26-week and 39-week GLP chronic toxicity studies conducted in rats and NHPs, 
respectively, support long-term clinical dosing.  The repeat-dose toxicity study in rats included assessment of male 
fertility and early embryonic development.  ALN-AS1 was administered weekly at doses of 0, 3, 10, or 30 mg/kg for 
up to 26 weeks.  Weekly doses of 30 mg/kg resulted in adverse hepatocellular single cell necrosis and vacuolation in 
the liver, associated with mild increases in liver function tests (LFTs) at the conclusion of the dosing period.  
Angiectasis was observed in the islets of Langerhans, possibly a secondary change to hepatic changes, which is not 
considered adverse.  Combined male fertility assessments did not indicate adverse reproductive or developmental 
findings up to the highest dose evaluated (30 mg/kg weekly SC dose).  In the 39-week repeat-dose toxicity study in 
NHP, ALN-AS1 was administered weekly at doses of 0, 10, 30, or 100 mg/kg for up to 39 weeks.  Weekly doses of 
100 mg/kg were the lowest-observed-adverse-effect level based on single cell necrosis combined with increased 
alanine transaminase (approximately 2-fold above control).  The NOAELs were 10 mg/kg in the rat and 30 mg/kg 
in the NHP.  The 13-week recovery data in the rat and NHP studies is pending. 
Section(s) also containing this change: 

Section 1.5, Dose Rationale
Purpose:  Specified the starting dose level and frequency for administration in study ALN-AS1-002 as 5.0 mg/kg every 3 months and added 
preliminary clinical data from study ALN-AS1-001 supporting this starting dose level and frequency 
The primary change occurs in Section 1.5, Dose Rationale 
Added text 
The study starting dose and regimen of ALN-AS1 is 5.0 mg/kg as an SC injection administered every 3 months.  
Based on emerging clinical data, the SRC may approve changes to the ALN-AS1 dosing regimen, including 
decreases in the dose level and changes in dosing frequency.  However, any dose and dosing regimen will not 
exceed a previously explored dose level or frequency that was determined to be safe and well-tolerated in study 
ALN-AS1-001. SRC, Health Authority and Ethics Committee approval must be sought prior to dose level 
escalation above 5.0 mg/kg in accordance with local Regulatory requirements. 
The study starting dose and regimen was selected based on the benefit:risk profile of ALN-AS1 in Part C of the 
ongoing ALN AS1 001 study.  Preliminary data to date indicate that administration of 5.0 mg/kg ALN AS1 has 
been generally well-tolerated.  There have been no study drug related SAEs, severe AEs, or clinically significant 
changes in safety parameters.  While a single 2.5 mg/kg dose of ALN-AS1 has also been generally well-tolerated 
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when administered to patients in Part A and Part C of study ALN-AS1-001, this dose has not resulted in near 
normalization of ALA and PBG levels.  In addition, while emerging data from Part C indicate that an every 3 
months dose of 2.5 mg/kg ALN-AS1 demonstrated some clinical activity (eg, decrease in attack frequency and 
decrease in heme use), some patients continued to experience breakthrough porphyria attacks during the 
treatment period, indicating that a higher dose may be required. 
Section(s) also containing this change: 
 
Synopsis 
 
Section 6.2.2, Dose and Administration 
Purpose:  Updated potential risks associated with administration of ALN-AS1 on reproductive health to include preliminary nonclinical data 
The primary change occurs in Section 1.6, Benefit-Risk Assessment 
Now reads: 
Reproductive health: No data are available on the use of ALN-AS1 in pregnancy; however, there is no suspicion of 
human teratogenicity based on class effects or genotoxic potential. ALN-AS1 was neither genotoxic nor clastogenic in in 
vitro and in vivo studies. Based on preliminary data from rat fertility/embryofetal development and rabbit 
embryofetal development studies, it is unlikely that ALN-AS1 administration to pregnant women or animals poses a 
risk to embryofetal development; however, in the absence of data from embryofetal developmental toxicity studies with 
ALN-AS1,. In a rat fertility/embryofetal development study at daily dose levels up to 16.5 mg/kg, no test article-
related effects on female fertility or developmental endpoints were observed. In a rabbit embryofetal development 
study, maternal toxicity was observed at daily doses of >3 mg/kg (7.8 fold higher than the clinical monthly dose of 
5.0 mg/kg). No terata were observed in this range-finding embryofetal development study. Women of child bearing 
potential (WOCBP) must have a negative pregnancy test, cannot be breastfeeding, and must be willing to use acceptable 
methods of contraception during studies with ALN-AS1. 
Purpose:  Clarified the inclusion criterion for WOCBP when hormonal methods of contraception are medically contraindicated  and removed 
reference to low-dose gestagens 
The primary change occurs in Section 5.1, Inclusion Criteria 
Now reads: 
3. WOCBP must have a negative serum pregnancy test, cannot be breast feeding, and must be willing to use 1 highly 
effective method acceptable methods of contraception 14 days before first dose, throughout study participation, and for 
90 days after last dose administration.  Acceptable methods include hormonal methods along with an additional 
barrier method (eg, condom, diaphragm, or cervical cap), or a double barrier method of contraception for those 
WOCBP for whom a hormonal method of contraception is medically contraindicated due to underlying disease 
(see Section 6.4 for acceptable methods of contraception). 
Section(s) also containing this change: 
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
Section 6.4, Contraceptive Requirements
Purpose:  Clarified the criteria for individual dose modifications based on study drug-related AEs 
The primary change occurs in Section 6.2.3.2, Individual Dose Modifications 
Now reads: 
Dose modifications are permitted for individual patients. If a patient has an AE that is related to a study drug (eg,related 
AE of a recurrent ISR, or severe orISRs, or clinically significant LFT abnormalities)abnormality and the Investigator 
has concerns regarding further ALN-AS1 administration, the Medical Monitor and Investigator will review all available 
safety data for the patient. Based on this review, it may be determined that the patient is a candidate for a dose reduction. 
Dose reduction to a dose, which was found to be safe and well-tolerated by the SRC,a dose reduction to half the 
previously administered dose (eg, a 5.0 mg/kg dose would be reduced to a 2.5 mg/kg dose) or a reduction in dosing 
frequency from monthly to every 3 months is permitted. Subsequent ALN-AS1 administration at the previous, or 
higher, dose may be considered based on the judgment of the Investigator and Medical Monitor. 
Purpose: While it was previously listed in the protocol in the Benefit -Risk Assessment that ALN-AS1 could increase clearance of drugs 
metabolized by the CYP3A isoform, it has been added to the concomitant medications section for clarification. 
The primary change occurs in Section 6.3, Concomitant Medications 
Added text: 
ALN-AS1 could potentially increase the clearance of drugs metabolized by the CYP3A isoform.   Investigators will 
review all medications at study start and monitor response to these medications during the study.  For patients 
who require new medications while on study, selection of medications that are not mainly metabolized by the 
CYP3A isoform is recommended.  A list of medications that are sensitive CYP3A substrates is in Table 6 Appendix 
Section 11.3.  In addition, a more detailed and current list of sensitive CYP3A-metabolized medications and 
CYP3A-metabolized medications with a narrow therapeutic range is available at the Indiana University, Division 
of Clinical Pharmacology, website (http://medicine.iupui.edu/clinpharm/ddis/clinical-table/).[31] 
Section(s) also containing this change: 

Section 1.6, Benefit-Risk Assessment

Table 6, List of Sensitive CYP3A Substrates and those with a Narrow Therapeutic Range, in Appendix Section 11.3
Purpose:  Clarified that a single blood sample for pharmacokinetic (PK) analysis will be collected at the Month 1 visit for patients with an every 3 
month dosing regimen 
The primary change occurs in Table 3, Pharmacokinetic Time Points, in Appendix Section 11.1, Pharmacokinetic Assessment Time Points 
Added text: 
Footnote ‘a’:  At the Month 1 visit, if the dosing regimen is every 3 months, ALN-AS1 is not administered and a 
single time point blood sample for PK analysis should be collected. 
Purpose:  Made minor changes to schedules of assessment to increase consistency in procedures across the protocol 
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The changes occur in Table 1, Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) and Table 4, 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Now reads: 
Adjustments to Table 1 and 4 have been made to indicate that at the Month 15 visit,  Body Weight, BMI, and height will 
not be collected but Blood and Urine Sample for Exploratory Biomarker Analysis will be collected. 
Purpose: To clarify the procedures for dispensing and using porphyria sample attack kits 
The changes occur in Table 1, Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) and Table 4, 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Now reads: 
Porphyria attack laboratory sample collection kits should be dispensed at the screening visit along with 
instructions for use. For any attack that occurs through M39, Uurine samples should be collected within 24 hours of 
the start of clinical intervention for a porphyria attack(eg, hemin or glucose administration) and within 24 hours of the end 
of clinical intervention for a porphyria attack through M39.  If patients are unable to report to the clinical study center 
during a porphyria attack, laboratory sample collection kits will be provided that contain instructions for collecting and 
sending urine samples to the clinical study center, if possible.  These urine samples may also be analyzed for exploratory 
biomarkers. 
Purpose:  To allow flexibility in method of collecting body temperature 
The primary change occurs in Section 7.5.1, Vital Signs 
Deleted text: 
Vital sign measurements include blood pressure, heart rate, oral body temperature, and respiratory rate. Vital signs will be 
measured in the seated or supine position (should be consistent for each patient), after the patient has rested comfortably 
for 10 minutes.  Blood pressure should be taken using the same arm throughout the study.  Oral bBody temperature will 
be obtained in degrees Celsius, heart rate will be counted for a full minute and recorded in beats per minute, and 
respiration rate will be counted for a full minute and recorded in breaths per minute. 
Section(s) also containing this change: 

Table 1, Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen)

Table 2, Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen)

Table 4, Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen)

Table 5, Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen)
Purpose:  Correct typographical errors, punctuation, grammar, abbreviations, and formatting, and incorporated administrative change letter 1 
(dated 18 August 2016) 
These changes are not listed individually. 
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ALN-AS1-002 Protocol Amendment 1 
Summary of Changes (dated 10 November 2016)  
Compared to Amendment 0.1 (Sweden) dated 20 September 2016 
A Multicenter, Open-label Extension Study to Evaluate the Long-term Safety and Clinical 
Activity of Subcutaneously Administered ALN-AS1 in Patients with Acute Intermittent 
Porphyria who have Completed a Previous Clinical Study with ALN-AS1 
Rationale for Protocol Amendment 
The primary purpose for this protocol amendment is to clarify that based on review of data from 
the ongoing ALN-AS1-001 study, the Safety Review Committee (SRC) has determined the study 
starting dose and dosing regimen for administration in study ALN-AS1-002 is to be 5.0 mg/kg 
administered every 3 months.  
Additionally, minor changes were made to schedules of assessment to increase consistency and 
clarity. 
A detailed summary of changes is provided in Table 1.  Corrections to typographical errors, 
punctuation, grammar, abbreviations, and formatting are not detailed.
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Table 1: 
Protocol Amendment 1 Detailed Summary of Changes 
The primary section(s) of the protocol affected by the changes in the protocol amendment are indicated.  The corresponding text has 
been revised throughout the protocol.  Deleted text is indicated by strikeout; added text is indicated by bold font. 
Purpose:  Specified the starting dose and dosing regimen for administration in study ALN-AS1-002. 
The primary change occurs in Section 1.5, Dose Rationale 
Now reads: 
The study starting dose of ALN-AS1 is 5.0 mg/kg ALN-AS1 as an SC injection administered every month 3 months 
(Table 1 and Table 2). Based on emerging study clinical data, the SRC may approve implementation of a lower changes 
to the ALN-AS1 dosinge, less frequent regimen regimen, or a fixed dose equivalent of ALN-AS1 including decreases in 
the dose level and changes in dosing frequency. However, any dosing regimen will not exceed a previously explored 
dose level or frequency that was determined to be safe and well-tolerated in Study ALN-AS1-001. SRC, Health 
AuthorityRegulatory and Ethics Committee approval must be sought prior to dose level escalation above 5.0 mg/kg in 
accordance with local Regulatory requirements.or implementation of a more frequent dosing regimen.  
Section(s) also containing this change: 

Synopsis

Section 6.2.2, Dose and Administration
Purpose:  Made minor changes to schedules of assessment to increase consistency in procedures across the protocol 
The changes occur in Table 1, Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) and Table 4, 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Now reads: 
Adjustments to Table 1 and 4 have been made to indicate that at the Month 15 visit, Body Weight, BMI, and height will 
not be collected but Blood and Urine Sample for Exploratory Biomarker Analysis will be collected. 
Purpose: To clarify the procedures for dispensing and using porphyria sample attack kits 
The changes occur in Table 1, Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) and Table 4, 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Now reads: 
Porphyria attack laboratory sample collection kits should be dispensed at the screening visit along with 
instructions for use. For any attack that occurs through M39, Uurine samples should be collected within 24 hours of 
the start of clinical intervention for a porphyria attack(eg, hemin or glucose administration) and within 24 hours of the end 
of clinical intervention for a porphyria attack through M39.  If patients are unable to report to the clinical study center 
during a porphyria attack, laboratory sample collection kits will be provided that contain instructions for collecting and 
sending urine samples to the clinical study center, if possible.  These urine samples may also be analyzed for exploratory 
biomarkers. 
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Purpose:  To allow flexibility in method of collecting body temperature 
The primary change occurs in Section 7.5.1, Vital Signs 
Deleted text: 
Vital sign measurements include blood pressure, heart rate, oral body temperature, and respiratory rate. Vital signs will be 
measured in the seated or supine position (should be consistent for each patient), after the patient has rested comfortably 
for 10 minutes.  Blood pressure should be taken using the same arm throughout the study.  Oral bBody temperature will 
be obtained in degrees Celsius, heart rate will be counted for a full minute and recorded in beats per minute, and 
respiration rate will be counted for a full minute and recorded in breaths per minute. 
Section(s) also containing this change: 
 
Table 1, Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
 
Table 2, Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen) 
 
Table 4, Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
 
Table 5, Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen) 
Purpose:  Correct typographical errors, punctuation, grammar, abbreviations, and formatting 
These changes are not listed individually. 
 
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CLINICAL STUDY PROTOCOL 
ALN-AS1-002 
Protocol Title: 
A Multicenter, Open-label Extension Study to Evaluate the Long-term 
Safety and Clinical Activity of Subcutaneously Administered 
ALN-AS1 in Patients with Acute Intermittent Porphyria who have 
Completed a Previous Clinical Study with ALN-AS1 
Investigational Drug: 
ALN-AS1 
EudraCT Number: 
2016-002638-54 
IND Number: 
126094 
Protocol Date: 
Original protocol 19 July 2016 
Sponsor: 
Alnylam Pharmaceuticals, Inc. 
300 Third Street 
Cambridge, MA  02142 USA 
Telephone:  
 
Sponsor Contact:  
 
The concepts and information contained in this document or generated during the study are considered 
proprietary and may not be disclosed in whole or in part without expressed written authorization of 
Alnylam Pharmaceuticals, Inc. 
580
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19 July 2016 
SPONSOR PROTOCOL APPROVAL 
I have read this protocol and I approve the design of this study. 
Date 
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3 
INVESTIGATOR’S AGREEMENT 
 
I have read the ALN-AS1-002 protocol and agree to conduct the study as outlined.  I agree to 
maintain the confidentiality of all information received or developed in connection with this 
protocol. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Printed Name of Investigator 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signature of Investigator 
 
 
 
 
 
 
 
 
Date 
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PROTOCOL SYNOPSIS 
Protocol Title 
A Multicenter, Open-label Extension Study to Evaluate the Long-term Safety and Clinical Activity of 
Subcutaneously Administered ALN-AS1 in Patients with Acute Intermittent Porphyria who have 
Completed a Previous Clinical Study with ALN-AS1 
Product Name 
ALN-AS1 
Indication 
Patients with acute intermittent porphyria (AIP) who experience recurrent porphyria attacks 
Phase 
1/2 
Study center(s)   
The study will be conducted at up to 8 clinical study centers worldwide. 
Objectives 
Primary 
•
Evaluate the long-term safety and tolerability of ALN-AS1 in patients with AIP
Secondary 
•
Assess the pharmacodynamic (PD) effect of ALN-AS1 over time
•
Assess the clinical activity of ALN-AS1 over time
Exploratory 
•
Characterize the pharmacokinetic (PK) profile of ALN-AS1 over time
•
Assess changes in health-related quality of life (QOL)
•
Characterize analytes related to targeting the heme biosynthesis pathway
Endpoints 
Primary 
•
Patient incidence of adverse events (AEs)
Secondary 
•
Change in urine delta-aminolevulinic acid (ALA) and porphobilinogen (PBG) levels
•
Frequency and characteristics of porphyria attacks
•
Change in hemin administration
Exploratory 
•
Change in circulating 5-aminolevulinic acid synthase 1 (ALAS1) mRNA levels
•
Concentrations of ALN-AS1 and antidrug antibodies
•
Duration and treatment of porphyria attacks
•
Number and duration of visits to a health care facility for acute porphyria care
•
EQ-5D-5L questionnaire scores
•
Pain assessment and narcotic use as recorded in a patient diary
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•
Exploratory biomarkers related to the target pathway, such as urine porphyrins, vitamin D binding
protein
Study Design 
This is a multicenter, open-label extension study to evaluate the long-term safety and clinical activity 
of ALN-AS1 in patients with AIP who completed study ALN-AS1-001. 
The last assessments performed, determining previous study (ALN-AS1-001) completion, will serve as 
the Screening/Baseline assessments in this study.  If more than 60 days have elapsed since the last 
assessment, safety assessments will be repeated before administration of ALN-AS1.  It is anticipated 
that patients will begin ALN-AS1 administration in this study within 6 months after the last dose of 
study drug in the previous study.  Eligibility will be confirmed before administration of the first dose of 
ALN-AS1 (Day 1).  Patients will undergo assessments at the clinical study center every month for the 
first 3 months.  Then, through Month 6, and according to the dosing regimen selected, assessments will 
take place at the clinical study center or via a phone contact (for an every month dosing regimen, visits 
will be every month; for an every 3 months dosing regimen, visits will be every 3 months).  After a 
patient has completed 6 months of ALN-AS1 administration in this study  (6 months in an every month 
dosing regimen), and where applicable country and local regulations and infrastructure allow, study 
visits and ALN-AS1 administration may take place at the patient’s home by a healthcare professional.  
Home visits may occur at the discretion of the Investigator, based on safety and tolerability; however, 
patients are required to complete at least 1 visit at the clinical study center every 3 months for the first 
year, and thereafter every 6 months through the end of the treatment period.  Patients will return to the 
clinical study center for a posttreatment follow-up visit after administration of the last dose of 
ALN-AS1.  An ALA/PBG Monitoring/EOS visit will be conducted either at the clinical study center or 
via phone contact, unless treatment continues with ALN-AS1. 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, 
and narcotic use.  Patients will also be provided with laboratory sample collection kits and instructions 
for collecting and sending urine samples to the clinical study center. 
A Safety Review Committee will review safety and tolerability data collected during the study with the 
primary purpose of protecting the safety of patients participating in the study. 
Number of Planned Patients 
Up to 24 patients are planned for enrollment in this study (including optional cohorts in 
ALN-AS1-001). 
Diagnosis and Main Eligibility Criteria 
Patients with AIP, who have completed Part C of study ALN-AS1-001, will be eligible for screening in 
this study.  Eligible patients will not be on a scheduled regimen of hemin to prevent porphyria attacks 
at Screening.  Patients with alanine transaminase ≥2.0× upper limit of normal, total bilirubin ≥2 mg/dL 
(unless bilirubin elevation is due to Gilbert’s syndrome), or estimated glomerular filtration rate 
≤30 mL/min/1.73 m2 (using the Modification of Diet in Renal Disease formula) at Screening are not 
eligible for this study. 
Investigational Product, Dose, and Mode of Administration 
ALN-AS1 Solution for Injection (subcutaneous use [SC]) is comprised of a synthetic, small interfering 
RNA targeting ALAS1 and bearing a triantennary N-acetyl galactosamine ligand conjugated to the 
sense strand, formulated in phosphate buffer.   
The planned starting dose of ALN-AS1 is 2.5 mg/kg ALN-AS1 as an SC injection administered every 
3 months.  Before initiating dosing in this study, the actual dose and dosing regimen administered will 
be determined based on SRC review of emerging data in Part C of study ALN-AS1-001.  Based on 
SRC review, a higher dose of ALN-AS1 may be administered and/or the dosing regimen adjusted to 
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every month.  Either fixed or weight-based doses may be administered.  The dose and dosing regimen 
of ALN-AS1 administered in this study will not exceed a previously explored dose and dosing regimen 
that was determined to be safe and well-tolerated in study ALN-AS1-001.  Further, the dose 
administered in this study will not exceed the maximum dose permitted in Part C of study 
ALN-AS1-001. 
Reference Therapy, Dose, and Mode of Administration 
Not applicable 
Duration of Treatment and Study 
The duration of treatment is up to 36 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 44 months. 
Statistical Methods 
Statistical analyses will be primarily descriptive.  Incidence of AEs will be summarized by maximum 
severity and relationship to ALN-AS1.  Incidence of and serious adverse events (SAEs) and AEs 
leading to discontinuation will also be tabulated.  By-patient listings will be provided for deaths, SAEs, 
and events leading to discontinuation.  
Laboratory shift tables from baseline to worst values will be presented.  Abnormal physical 
examination findings and electrocardiogram data will be presented in by-patient listings.  Descriptive 
statistics will be provided for electrocardiogram interval data and presented as both actual values and 
changes from baseline relative to each on study evaluation and to the last evaluation on-study. 
Clinical activity of ALN-AS1 will be summarized primarily by descriptive statistics.  The clinical 
activity of ALN-AS1 will be evaluated by the frequency and characteristics of porphyria attacks 
including duration, treatment, and severity of porphyria attacks and number and duration of visits to a 
health care setting for acute porphyria care.  Patient diary recordings, including BPI-SF questionnaire 
scores, will also be summarized.   
PD analysis will include the evaluation of change in ALA, PBG, and ALAS mRNA levels.  Descriptive 
statistics (eg, mean and standard error of the mean) for observed levels of PD parameters and the 
relative change from baseline will be presented for each of the postdose follow-up time points. 
The PK concentration of ALN-AS1 will be determined.  Antidrug antibody results will be tabulated 
overall and by previous treatment in the previous study (ALN-AS1-001).  A by-patient listing will also 
be provided. 
Additional exploratory analyses may be conducted on analytes related to targeting the heme 
biosynthesis pathway.  Quality of life scores will also be summarized. 
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Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8 
M9 
M10/ 
M11 
M12 
M13/ 
M14 
M15b 
M16/ 
M17 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Informed Consent 
X 
Medical History/Disease 
Historyc 
X
X
Demographics 
X
Inclusion/ 
Exclusion Criteria 
X
X 
Physical Examinationd 
X
X
X 
X 
X 
X 
X 
X 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
X 
X 
X 
X 
X 
X 
Vital Signsf 
X 
X 
X 
X 
X
X
X 
X 
X 
X 
Triplicate 12-Lead ECGg 
X 
X 
X 
X 
Clinical Laboratory 
Assessmenth 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationj 
X 
X 
X 
X 
X 
X 
X 
Urine Sample for PBG, ALA, 
and Creatinine Analysisk 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood Sample for PK 
Analysism 
X 
X 
X 
X 
X 
X 
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 8 
Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8 
M9 
M10/ 
M11 
M12 
M13/ 
M14 
M15b 
M16/ 
M17 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Antidrug Antibodiesn 
 
X 
X 
 
X 
 
X 
 
 
 
X 
 
 
 
X 
Porphyria Attack Laboratory 
Sample Collection Kit and 
Instructionso 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EQ-5D-5L Questionnairep 
X 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Diary Review (including 
BPI-SF)q 
 
X 
Phone Contactr 
 
 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
AEs 
 
Continuous 
Concomitant Medicationss 
Continuous 
Abbreviations:  AE=adverse event; ALAS1=5-aminolevulinic acid synthase 1; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain 
Inventory-Short Form; D=day; ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of life; 
SC=subcutaneous. 
Notes:   
• 
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be 
conducted while the patient is at home. 
• 
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations and 
blood/urine sample collections. 
a Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study (ALN-AS1-001) were completed within 60 days 
of administration of the first dose of ALN-AS1 in this study.  If more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs 
will be repeated before administration of ALN-AS1.  Results should be available before the administration of the first dose of ALN-AS1. 
b After a patient has completed 12 months of ALN-AS1 administration in this study, and where applicable country and local regulations and infrastructure allow, 
study visits and ALN-AS1 administration may take place at the patient’s home by a healthcare professional.  Home visits may occur at the discretion of the 
Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit at the clinical study center Q6M. 
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c See Section 7.1 for details on the interval medical history/disease history to be recorded at Screening/Baseline.  Ongoing AEs from the previous study 
(ALN-AS1-001) will be captured as medical history. 
d A complete physical examination will be performed at Screening/Baseline, and D1.  At all other visits, a targeted physical examination will be performed.  On 
dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any time 
during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, oral body temperature, and respiratory rate.  On D1, vital signs will be collected within 1 hour predose; and 
2 hours (±10 minutes) postdose.  On all other dosing days, vital signs will be collected within 1 hour predose.  On days when ALN-AS1 is not administered, 
vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position (should be consistent for each patient), 
after the patient has rested comfortably for 10 minutes. 
g Triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 10 minutes.  On D1, ECGs will be 
performed within 1 hour predose and 2 hours (±10 minutes) postdose.  On all other dosing days, ECGs will be collected within 1 hour predose. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected within 1 hour 
predose; results are not required before dosing.  On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. 
i A serum pregnancy test will be performed at Screening/Baseline; thereafter, urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  For 
weight-based dosing, weight measured on the dosing day will be used to calculate the dose of ALN-AS1.  After M12, weight measured on the nearest previous 
visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 3 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o Urine samples should be collected within 24 hours of the start of clinical intervention for a porphyria attack (eg, hemin or glucose administration) and within
24 hours of the end of clinical intervention for a porphyria attack through M39.  If patients are unable to report to the clinical study center during a porphyria
attack, laboratory sample collection kits will be provided that contain instructions for collecting and sending urine samples to the clinical study center, if
possible.  These urine samples may also be analyzed for exploratory biomarkers.
p In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but not more than once in a 6 month period), if possible.  
q Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, and narcotic use on a daily basis through M9; 
thereafter, acute porphyria attacks will be recorded in the diary.  The BPI will be completed on a weekly basis as part of the patient diary through M9, then 
Q3M. 
r Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack. 
s Medications that are ongoing from the previous study (ALN-AS1-001), started between the previous study and this study, and started after signing informed 
consent in this study, will be captured as concomitant medication(s). 
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Table 2: 
Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20 
M21a 
M22/ 
M23 
M24 
M25/ 
M26 
M27a 
M28/ 
M29 
M30 
M31/ 
M32 
M33a 
M34/ 
M35 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Physical Examinationd 
X 
X 
X 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
X 
Vital Signsf 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGg 
X 
X 
Clinical Laboratory 
Assessmenth 
X 
X 
X 
X 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationj 
X 
X 
X 
X 
X 
X 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
X 
X 
X 
X 
X 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl 
X 
X 
X 
X 
Blood Sample for PK 
X 
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Table 2: 
Schedule of Assessments:  Month 19 through End of Study (Every 3 Months Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20 
M21a 
M22/ 
M23 
M24 
M25/ 
M26 
M27a 
M28/ 
M29 
M30 
M31/ 
M32 
M33a 
M34/ 
M35 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Analysism 
Antidrug Antibodiesn 
X 
X 
EQ-5D-5L Questionnaireo 
X 
X 
X 
Diary Review (including 
BPI-SF)p 
X 
Phone Contactq 
X 
X 
X 
X 
X 
X 
X 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; EOS = End of Study; EOT = End of Treatment; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality 
of life; SC=subcutaneous. 
Notes:   
•
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be
conducted while the patient is at home.
•
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations
and blood/urine sample collections.
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a Where applicable country and local regulations and infrastructure allow, study visits and ALN-AS1 administration may take place at the patient’s home by a 
healthcare professional.  Home visits may occur at the discretion of the Investigator, based on safety and tolerability; however, patients are required to complete 
at least 1 visit at the clinical study center Q6M. 
b Patients who discontinue treatment will be asked to complete the M39 visit assessments.  If a patient chooses to withdraw from the study, every effort should 
be made to conduct early the assessments performed at the M39 visit.  See Section 5.3 for details on removal from treatment or assessment. 
c The ALA/PBG Monitoring/EOS visit will be conducted at the clinical study center or via phone contact, unless treatment continues with ALN-AS1.  Patients 
will be provided with laboratory sample collection kits and instructions for collecting and sending urine samples to the clinical study center.  Urine samples 
should not be collected during a porphyria attack.   
d A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed. 
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, oral body temperature, and respiratory rate.  On a dosing days, vital signs will be collected within 1 hour predose. 
On days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine 
position (should be consistent for each patient), after the patient has rested comfortably for 10 minutes. 
g Triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 10 minutes.  On dosing days, ECGs will 
be collected within 1 hour predose. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected within 1 hour 
predose; results are not required before dosing.  On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. 
i Urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured on the nearest previous visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 3 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack
(but, not more than once in a 6 month period), if possible.
p Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
q Patients will be contacted by phone to collect AEs and concomitant medications.  Patients will also be reminded to collect and send urine samples to the clinical 
study center, if possible, if they are unable to report to the clinical study center during a porphyria attack.
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TABLE OF CONTENTS 
PROTOCOL SYNOPSIS ................................................................................................................4 
TABLE OF CONTENTS ...............................................................................................................13 
LIST OF TABLES .........................................................................................................................16 
LIST OF FIGURES .......................................................................................................................16 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS ................................................17 
1. 
INTRODUCTION ......................................................................................................19 
1.1. 
Disease Overview .......................................................................................................19 
1.1.1. 
Epidemiology ..............................................................................................................19 
1.1.2. 
Current Management and Unmet Medical Need ........................................................20 
1.2. 
RNA Interference ........................................................................................................21 
1.3. 
ALN-AS1 ....................................................................................................................21 
1.3.1. 
Nonclinical Summary .................................................................................................21 
1.3.2. 
Clinical Summary .......................................................................................................22 
1.4. 
Study Design Rationale ..............................................................................................23 
1.5. 
Dose Rationale ............................................................................................................23 
1.6. 
Benefit-Risk Assessment ............................................................................................24 
2. 
OBJECTIVES .............................................................................................................24 
2.1. 
Primary Objective .......................................................................................................24 
2.2. 
Secondary Objectives .................................................................................................25 
2.3. 
Exploratory Objectives ...............................................................................................25 
3. 
ENDPOINTS ..............................................................................................................25 
3.1. 
Primary Endpoint ........................................................................................................25 
3.2. 
Secondary Endpoints ..................................................................................................25 
3.3. 
Exploratory Endpoints ................................................................................................25 
4. 
INVESTIGATIONAL PLAN .....................................................................................25 
4.1. 
Summary of Study Design ..........................................................................................25 
4.2. 
Duration of Treatment and Study ...............................................................................27 
4.3. 
Number of Patients .....................................................................................................27 
4.4. 
Method of Assigning Patients to Treatment Groups ..................................................27 
4.5. 
Blinding ......................................................................................................................27 
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4.6. 
Safety Review Committee ..........................................................................................27 
5. 
SELECTION AND WITHDRAWAL OF PATIENTS ..............................................28 
5.1. 
Inclusion Criteria ........................................................................................................28 
5.2. 
Exclusion Criteria .......................................................................................................28 
5.3. 
Removal from Treatment or Assessment ...................................................................28 
5.3.1. 
Discontinuation of Study Drug ...................................................................................28 
5.3.2. 
Withdrawal from Study ..............................................................................................29 
5.3.3. 
Replacement of Patients .............................................................................................29 
6. 
TREATMENTS ..........................................................................................................29 
6.1. 
Treatments Administered ............................................................................................29 
6.2. 
Investigational Study Drug .........................................................................................29 
6.2.1. 
Description ..................................................................................................................29 
6.2.2. 
Dose and Administration ............................................................................................30 
6.2.3. 
Dose Modifications .....................................................................................................30 
6.2.3.1. 
Study Population Dose Modifications ........................................................................30 
6.2.3.2. 
Individual Dose Modifications ...................................................................................30 
6.2.4. 
Preparation, Handling, and Storage ............................................................................31 
6.2.5. 
Packaging and Labeling ..............................................................................................31 
6.2.6. 
Accountability .............................................................................................................31 
6.3. 
Concomitant Medications ...........................................................................................31 
6.4. 
Contraceptive Requirements .......................................................................................32 
6.5. 
Treatment Compliance ................................................................................................33 
7. 
STUDY ASSESSMENTS ..........................................................................................33 
7.1. 
Screening/Baseline Assessments ................................................................................33 
7.2. 
Clinical Activity Assessments ....................................................................................33 
7.2.1. 
Patient Diary ...............................................................................................................33 
7.2.2. 
Brief Pain Inventory-Short Form Questionnaire ........................................................33 
7.3. 
Pharmacodynamic Assessments .................................................................................33 
7.4. 
Pharmacokinetic Assessments ....................................................................................34 
7.5. 
Safety Assessments .....................................................................................................34 
7.5.1. 
Vital Signs ..................................................................................................................34 
7.5.2. 
Weight and Height ......................................................................................................34 
7.5.3. 
Physical Examination .................................................................................................34 
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7.5.4. 
Electrocardiogram .......................................................................................................34 
7.5.5. 
Clinical Laboratory Assessments ...............................................................................35 
7.5.5.1. 
Immunogenicity ..........................................................................................................36 
7.5.5.2. 
Pregnancy Testing ......................................................................................................37 
7.5.6. 
Adverse Events ...........................................................................................................37 
7.5.6.1. 
Definitions ..................................................................................................................37 
7.5.6.2. 
Eliciting and Recording Adverse Events ....................................................................39 
7.5.6.3. 
Serious Adverse Events Require Immediate Reporting to Sponsor/Designee ...........40 
7.5.6.4. 
Sponsor Safety Reporting to Regulatory Authorities .................................................40 
7.5.6.5. 
Serious Adverse Event Notification to the Institutional Review 
Board/Independent Ethics Committee ........................................................................41 
7.5.6.6. 
Pregnancy Reporting ..................................................................................................41 
7.5.6.7. 
Overdose Reporting ....................................................................................................41 
7.6. 
Exploratory Assessments ............................................................................................42 
7.7. 
Other Assessments ......................................................................................................42 
7.7.1. 
EQ-5D-5L Questionnaire ............................................................................................42 
8. 
STATISTICS ..............................................................................................................42 
8.1. 
Determination of Sample Size ....................................................................................42 
8.2. 
Statistical Methodology ..............................................................................................42 
8.2.1. 
Populations to be Analyzed ........................................................................................43 
8.2.2. 
Examination of Subgroups .........................................................................................43 
8.2.3. 
Handling of Missing Data ...........................................................................................43 
8.2.4. 
Baseline Evaluations ...................................................................................................43 
8.2.5. 
Clinical Activity Analyses ..........................................................................................43 
8.2.6. 
Pharmacodynamic Analysis........................................................................................43 
8.2.7. 
Pharmacokinetic Analysis ..........................................................................................44 
8.2.8. 
Safety Analyses ..........................................................................................................44 
8.2.9. 
Other Analyses ............................................................................................................44 
9. 
STUDY ADMINISTRATION ...................................................................................44 
9.1. 
Ethical and Regulatory Considerations ......................................................................44 
9.1.1. 
Informed Consent .......................................................................................................45 
9.1.2. 
Ethical Review ............................................................................................................45 
9.1.3. 
Study Documentation, Confidentiality, and Records Retention .................................45 
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9.1.4. 
End of the Study .........................................................................................................46 
9.1.5. 
Discontinuation of the Clinical Study.........................................................................46 
9.2. 
Data Quality Control and Quality Assurance .............................................................46 
9.2.1. 
Data Handling .............................................................................................................46 
9.2.2. 
Study Monitoring ........................................................................................................46 
9.2.3. 
Audits and Inspections ................................................................................................47 
9.3. 
Publication Policy .......................................................................................................47 
10.
LIST OF REFERENCES ............................................................................................48
11.
APPENDICES ............................................................................................................51
11.1. 
Pharmacokinetic Assessment Time Points .................................................................51 
11.2. 
Schedules of Assessments for Every Month Dosing Regimen ..................................52 
LIST OF TABLES 
Table 1: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 3 
Months Dosing Regimen) .............................................................................................7 
Table 2: 
Schedule of Assessments:  Month 19 through End of Study (Every 3 Months 
Dosing Regimen) ........................................................................................................10 
Table 3: 
Pharmacokinetic Time Points .....................................................................................51 
Table 4: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every 
Month Dosing Regimen) ............................................................................................52 
Table 5: 
Schedule of Assessments:  Month 19 through End of Study (Every Month 
Dosing Regimen) ........................................................................................................55 
LIST OF FIGURES 
Figure 1: 
Study Design ...............................................................................................................27 
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LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
Abbreviation 
Definition 
AE 
Adverse event 
AHP 
Acute hepatic porphyria 
AIP 
Acute intermittent porphyria 
ALA 
Delta-aminolevulinic acid 
ALAS1 
5-aminolevulinic acid synthase 1 
ALP 
Alkaline phosphatase 
ASGPR 
Asialoglycoprotein receptor 
ASHE 
Asymptomatic high excreters 
BPI-SF 
Brief Pain Inventory-Short Form 
cERD 
Circulating extracellular RNA detection assay 
CRF 
Case report form 
CYP 
Cytochrome P450 
ECG 
Electrocardiogram 
eCRF 
Electronic case report form 
eGFR 
Estimated Glomerular Filtration Rate 
EDC 
Electronic data capture 
EOS 
End of study 
EU 
European Union 
GalNAc 
N-acetyl galactosamine 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practice 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
IEC 
Independent Ethics Committee 
IRB 
Institutional Review Board 
ISR 
Injection site reaction 
IV 
Intravenous 
LFT 
Liver function test 
mRNA 
Messenger RNA 
NHP 
Nonhuman primate 
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Abbreviation 
Definition 
NOAEL 
No observed adverse effect level 
NOEL 
No observed effect level 
OTC 
Over the counter 
PBG 
Porphobilinogen 
PBGD 
Porphobilinogen deaminase 
PD 
Pharmacodynamic(s) 
PK 
Pharmacokinetic(s) 
QOL 
Quality of life 
RNA 
Ribonucleic acid 
RNAi 
RNA interference 
SAE 
Serious adverse event 
SAP 
Statistical Analysis Plan 
SC 
Subcutaneous 
siRNA 
Small interfering RNA 
SRC 
Safety Review Committee 
SUSAR 
Suspected unexpected serious adverse reaction 
ULN 
Upper limit of normal 
US 
United States 
WOCBP 
Woman of child-bearing potential 
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1.
INTRODUCTION
1.1. 
Disease Overview
The porphyrias are a family of rare metabolic disorders predominately caused by a genetic 
mutation in 1 of the 8 enzymes responsible for heme synthesis.[1]  The 2 major categories are 
erythropoietic and hepatic, depending on the major site of expression of the underlying enzyme 
deficiency.[2]  In addition, the porphyrias are classified as acute if patients present with 
neurovisceral symptoms (eg, abdominal pain and neurologic symptoms) or cutaneous if they 
present with dermal blistering or photosensitivity.[3, 4]   
This study will include patients with acute intermittent porphyria (AIP), the most common acute 
hepatic porphyria (AHP).  AIP occurs as a result of an autosomal dominant mutation leading to 
partial deficiency of porphobilinogen deaminase (PBGD), the third enzyme in the heme 
biosynthesis pathway.[5]  The rate limiting step in heme synthesis is the upstream enzyme 
5-aminolevulinic acid synthase 1 (ALAS1), which is controlled by feedback repression via the 
end-product heme.  In response to a decrease in endogenous heme in the liver, as can occur with 
fasting, hormonal alterations, or with cytochrome P450 (CYP) inducing drugs, ALAS1 is 
induced, resulting in increased flux through the heme synthesis pathway.  In patients with AIP, 
this can result in the marked accumulation of the toxic heme intermediates porphobilinogen 
(PBG) and delta aminolevulinic acid (ALA) in the blood and urine due to the deficiency in the 
downstream PBGD.  Clinically, this manifests as acute attacks characterized by severe 
abdominal pain, cardiovascular as well as neurologic and psychiatric dysfunction.[6] 
1.1.1. 
Epidemiology 
Over 370 mutations have been identified in the PBGD gene, which in most instances result in its 
reduction by approximately 50%.  The exact prevalence of AIP is unknown due to under 
diagnosis, variation by geographic region, and the differences in penetrance observed for the 
different mutations.[2]  However, it is estimated that the prevalence of AIP is 5 to 10 per 
100,000 people in Western countries, while in Sweden it occurs in 1 in 1,000 people due to a 
founder effect associated with the resultant G593A mutation.[7-10]  AIP shows incomplete 
penetrance and on average only 10% to 50% of carriers with a mutation present with clinical 
symptoms.[11]  It has been proposed that unknown inherited co-factors, in addition to PBGD 
mutations, may explain why a small percentage of patients present with much more severe 
disease while the majority remain asymptomatic. 
Patients with AIP present with acute attacks characterized by neurovisceral symptoms and signs 
including severe abdominal pain, nausea, vomiting, constipation, or less commonly diarrhea, 
hypertension, tachycardia, fever, muscle weakness, as well as neurological (eg, neuropathy, 
seizures) and psychiatric (eg, anxiety and confusion) manifestations.[12]  AIP attacks typically 
start after puberty and can be triggered by exogenous factors such as medications (especially 
barbiturates, sulfonamides, and hydantoins), stress, exogenous hormones, nutritional status, and 
infection.  Clinically active disease is more common in women, where attacks often occur around 
the menstrual cycle and are likely precipitated by hormonal changes. 
Many AIP patients remain undiagnosed given that the disease is rare and characterized by 
non-specific symptoms (eg, abdominal pain and nausea).[2]  The initial diagnosis involves 
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demonstrating elevated urinary PBG (typically 20-50 × normal reference range) and ALA 
(typically 5-20 × normal reference range) when the patient is having acute attack symptoms.  
Once a test is positive for elevated ALA and PBG and porphyria is suspected, genetic testing for 
a PBGD mutation is performed.   
There are 4 main clinical phenotypes of AIP.  Latent gene carriers have never had an acute attack 
and are biochemically inactive (normal urinary ALA and PBG).  Asymptomatic high excreters 
(ASHE) do not have current acute attacks, but are biochemically active (increased urinary ALA 
and PBG).  The increased levels of ALA and PBG in ASHE patients are lower than those in AIP 
patients during an acute attack, but are still significantly higher than normal reference values.[6-
8] Sporadic attack patients have infrequent acute attacks.  Recurrent attack patients have
≥4 attacks per year requiring hospitalization or treatment by a medical professional.[7] 
1.1.2. 
Current Management and Unmet Medical Need 
Management of acute attacks often requires hospitalization.  Patients are initially treated with 
supportive care and carbohydrate loading, analgesics and anti-emetics, and removal of known 
precipitating factors.[13]  In patients with moderate to severe attacks, or who fail to respond to 
supportive measures, treatment with intravenous (IV) hemin (daily for 3-5 days) is commenced.  
Symptoms typically begin to improve after 2 to 5 days of hemin treatment, accompanied by a 
lowering of urinary ALA and PBG levels to below or at the upper limit of normal (ULN) 
reference value; however, in some patients attacks can last several weeks, requiring prolonged 
hemin use and hospitalization.[14]  With prolonged and severe attacks, cranial nerve 
involvement can occur, leading to bulbar paralysis, respiratory failure, and death.[15]  
Hemin, a blood derived therapy, was approved as Normosang® (heme arginate) in the European 
Union (EU) and as Panhematin® (lyophilised hematin) in the United States (US) in 1999 and 
1983, respectively.[16, 17]  In the EU, heme arginate is indicated for the treatment of acute 
attacks of hepatic porphyria (eg, AIP, variegate porphyria, and hereditary coproporphyria); 
whereas, in the US lyophilized hemin is limited to the amelioration of recurrent attacks of AIP 
temporally related to the menstrual cycle.  Approval of both products was based on biochemical 
efficacy (ie, lowering of ALA and PBG) as well as data from uncontrolled case series and case 
reports.[18-22]  Hemin side effects include thrombophlebitis, transient anticoagulation, and in 
rare cases, anaphylaxis or renal failure.[22-24]  In addition, hemin administration requires a large 
vein for administration, often necessitating central venous access. 
While the majority of patients who experience attacks have them sporadically, it is estimated that 
up to 1,000 AIP patients experience recurrent attacks (typically defined as ≥4 per year) in the US 
and EU combined.[25]  While hemin is currently only approved to ameliorate acute attacks, it is 
administered prophylactically in some patients with recurrent attacks (eg, administered every 
1-2 weeks).[26]  Potential problems associated with chronic hemin administration include 
infusion site phlebitis, iron overload, and the need for chronic IV access and associated 
complications (eg, risk of infection or occlusion).[5]  In addition, there have been reports of a 
decrease in efficacy with chronic hemin administration, as evidenced by the need to increase the 
frequency or dosage of hemin prophylaxis over time in attempt to maintain a clinical effect.[27]  
In patients with very severe recurrent attacks, or in whom hemin treatment is not effective, liver 
transplantation can be curative; however, organ transplantation is a high-risk procedure and is 
rarely used as a treatment option [34].  Given the significant morbidity and mortality, there 
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remains a significant unmet need for an efficacious, simple, fast-acting and better tolerated 
treatment for acute or prevent recurrent attacks in patients with AIP. 
1.2. 
RNA Interference 
RNA interference (RNAi) is a naturally occurring cellular mechanism mediated by small 
interfering RNAs (siRNAs) for regulating gene expression.  Typically, synthetic siRNAs are 
19 to 25 base pair double stranded oligonucleotides in a staggered duplex with a 2-nucleotide 
overhang at both or 1 of the 3’ ends.[28]  Such siRNAs can be designed to target an endogenous 
messenger RNA (mRNA) transcript of a given gene.  When introduced into cells, the net effect 
of an RNAi-based pharmacological approach is the binding of the siRNA to its complementary 
mRNA sequence, cleavage of this target mRNA, and reduction of synthesis of the target protein, 
resulting in a decrease of the target protein levels.[29]  The ability to selectively and potently 
degrade the mRNA encoding the ALAS1 protein (thereby decreasing accumulation of the toxic 
intermediates ALA and PBG) using an siRNA is a novel approach for the prevention and 
treatment of acute attacks in patients with AIP.   
1.3. 
ALN-AS1 
ALN-AS1 is a synthetic RNAi therapeutic currently in development for treatment of acute 
attacks in patients with AIP, the most common AHP. 
1.3.1. 
Nonclinical Summary 
The pharmacology, safety pharmacology, drug metabolism and pharmacokinetics and toxicology 
of ALN-AS1 were evaluated in a series of in vitro and in vivo nonclinical studies. 
ALN-AS1 is pharmacologically active in rodents and nonhuman primates (NHP) due to 
conservation within the siRNA target sequence.  Transfection assays in human liver carcinoma 
cell line-G2 cells showed dose-dependent inhibition of endogenous ALAS1 mRNA levels with 
an half-maximal inhibitory concentration of approximately 26 pM of ALN-AS1.  In multiple 
studies in the mouse, rat, and NHP, potent and dose-dependent pharmacologic activity has been 
demonstrated with subcutaneous (SC) administration of ALN-AS1, which results in consistent 
reduction of ALAS1 mRNA in liver.  After single dose administration, ALAS1 mRNA 
suppression in liver is durable depending on the dose administered (1-4 weeks) and correlates 
with the extent of ALAS1 mRNA suppression observed in serum or urine.  Dose dependent, 
steady-state ALAS1 mRNA reduction has also been demonstrated with repeat-dose regimens.  
Studies in rodent AIP models have confirmed that ALAS1 mRNA reduction with ALN-AS1 
treatment correlates with decreases in ALA and PBG heme intermediates. 
A Good Laboratory Practice (GLP)-compliant safety pharmacology study conducted in NHPs 
showed no functional cardiovascular or respiratory effects, with a no observed effect level 
(NOEL) of 150 mg/kg.  Neurological assessments were conducted as part of a 13-week repeat 
dose GLP toxicity study in NHPs (weekly dosing); no ALN-AS1-related neurobehavioral 
observations occurred, with a NOEL for neurological effects of 150 mg/kg (highest dose tested).  
Genetic toxicity studies (bacterial reverse mutation, human peripheral blood lymphocyte 
chromosomal aberrations, and rat bone marrow micronucleus) assays were all negative at 
International Conference on Harmonization (ICH) S2 (R1) limit doses. 
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Two to 4-week exploratory (non-GLP) dose-range finding toxicology studies were conducted 
with ALN-AS1 in mice, rats, and NHPs.  In all 3 species, no dose-limiting toxicity was observed 
up to the highest dose evaluated (300 mg/kg weekly SC dose), with the rat appearing to be the 
most sensitive species.  These studies were followed by 13-week GLP toxicology studies in rats 
and NHPs where ALN-AS1 was administered daily (100 mg/kg) and weekly at doses of 0, 3, 10, 
and 30 mg/kg in the rat and weekly at doses of 0, 15, 50, and 150 mg/kg in the NHP.  The no 
observed adverse effect levels were 30 mg/kg in the rat and 150 mg/kg in the NHP (highest dose 
tested in each species).  GLP chronic toxicity studies (26 weeks in the rat and 39 weeks in the 
NHP) have been conducted and are currently in the reporting phase.  Results of these studies will 
be available to support the clinical dosing. 
1.3.2. 
Clinical Summary 
ALN-AS1 is being investigated in an ongoing, Phase 1 study (ALN-AS1-001) to evaluate the 
safety, tolerability, pharmacokinetics (PK), and pharmacodynamics (PD) of ALN-AS1 
administered subcutaneously in patients with AIP.  The study is being conducted in 3 parts.  
Part A and Part B are single-blind, placebo-controlled portions of the study in patients with AIP 
who are ASHE.  Patients are randomized in a 3:1 ratio to receive either a single dose (Part A) or 
multiple doses (Part B; 2 doses 28 days apart) of ALN-AS1 or placebo.  Patients who participate 
in Part A and Part B are not eligible to participate in this study.  In Part C, patients with AIP who 
have recurrent attacks will receive multiple doses of ALN-AS1 dosing over a 12-week period in 
a randomized, double-blind, placebo-controlled part of the study.  This study will enroll patients 
who completed Part C of study ALN-AS1-001. 
Dosing has been completed in Part A (0.035-2.5 mg/kg) and Part B of the study 
(0.35-1.0 mg/kg).  A total of 23 unique patients with AIP who are ASHE have received at least 
1 dose of study drug (20 patients received at least 1 dose of ALN-AS1 and 3 patients received 
placebo only).  ALN-AS1 has been generally well-tolerated.  Adverse Events (AEs) in patients 
administered ALN-AS1, which were reported in 2 patients each, were abdominal pain, diarrhea, 
and hypoaesthesia in Part A; and nasopharyngitis, pruritus, and rash in Part B.  In Part A, AEs 
considered possibly or definitely related to ALN-AS1 were reported in 5 patients:  diarrhea, 
dyspepsia, haematochezia, injection site erythema, injection site pain, blood creatinine increased, 
glomerular filtration rate decreased, and hypoesthesia (1 patient each).  In Part B, AEs 
considered possibly or definitely related to ALN-AS1 were reported in 3 patients:  pruritus and 
rash (2 patients each); and rash macular and rash pruritic (1 patient each).  There were 2 SAEs of 
abdominal pain in Part A, 1 patient each in the 0.035 mg/kg and 0.10 mg/kg dose groups, which 
were not considered to be related to study drug or due to AIP.  Across Part A and Part B, all AEs 
were mild or moderate in severity, except for 1 serious adverse event (SAE) of abdominal pain 
(0.10 mg/kg dose group), which was considered severe.  There were no dose-related trends in 
AEs and no AEs leading to discontinuation.   
Overall, a dose-dependent reduction of urinary ALA and PBG as well as ALAS1 mRNA was 
observed following single and multiple doses of ALN-AS1.  Preliminary data demonstrate that 
administration of a single dose of ALN-AS1 at ≥1.0 mg/kg lowered ALA and PBG levels ≥80% 
and ALAS1 mRNA levels ≥50% when compared to baseline levels in patients with AIP who are 
ASHE.  Similarly, administration of multiple doses of ALN-AS1 at ≥0.35 mg/kg lowered ALA 
and PBG levels ≥80%.  ALAS1 mRNA levels were reduced ≥50% in the 1.0 mg/kg dose group 
when compared to baseline levels in patients with AIP who are ASHE.  ALA and PBG levels in 
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the 1.0 mg/kg dose group in Part A were sustained for ≥180 days and in both dose groups in 
Part B for ≥160 days.  Specifically, the maximum mean reduction from baseline of urinary ALA 
and PBG reached 93% in the 2.5 mg/kg dose group, which were sustained for approximately 
14 weeks.  The maximum mean reduction in ALAS1 mRNA relative to baseline of 66% was 
demonstrated in the 2.5 mg/kg dose group which was maintained beyond 42 days. 
Cumulatively, nonclinical and clinical data to date support long-term administration of 
ALN-AS1 in patients with AIP. 
1.4. 
Study Design Rationale 
This is a multicenter, open-label extension study designed to evaluate the long-term safety and 
clinical activity of subcutaneously administered ALN-AS1 in patients with AIP who have 
completed clinical study ALN-AS1-001.  The primary endpoint for the study is the incidence of 
AEs. 
1.5. 
Dose Rationale 
Clinical data from Part A and Part B of the ongoing study ALN-AS1-001 demonstrate that single 
(0.035-2.5 mg/kg) and multiple (0.35-1.0 mg/kg) doses of ALN-AS1 have been generally 
well-tolerated in patients with AIP who are ASHE.  Additionally, data from this study indicate 
that a single dose of 2.5 mg/kg ALN-AS1 results in near normalization of urine ALA and PBG 
levels, which is sustained for approximately 14 weeks.   
Patients in Part C of the ongoing study ALN-AS1-001 who are eligible for participation in this 
study will likely require a higher dose of ALN-AS1 to normalize ALA and PBG as they have 
higher levels of ALAS1 upregulation and higher baseline levels of ALA and PBG, when 
compared to patients with AIP who are ASHE.[30]  For example, based on preliminary data in 
Part A and Part B of the ALN-AS1-001 study, the mean PBG level of patients who are ASHE is 
21.9 mmol/mol Cr (N=28); whereas, in Part C of this study in patients with AHP who have 
recurrent porphyria attacks, the mean PBG level is approximately 49.3 mmol/mol Cr (N=12). 
The planned starting dose of ALN-AS1 is 2.5 mg/kg ALN-AS1 as an SC injection administered 
every 3 months, which is also the initial dose administered to patients with AIP in Part C of 
study ALN-AS1-001.  Before initiating dosing in this study, the actual dose and dosing regimen 
administered will be determined based on SRC review of emerging data in Part C of study 
ALN-AS1-001.  Based on SRC review, a higher dose of ALN-AS1 may be administered and/or 
the dosing regimen adjusted to every month.  Either fixed or weight-based doses may be 
administered.  The dose and dosing regimen of ALN-AS1 administered in this study will not 
exceed a previously explored dose and dosing regimen that was determined to be safe and 
well-tolerated in study ALN-AS1-001.  Further, the dose administered in this study will not 
exceed the maximum dose permitted in Part C of study ALN-AS1-001.   
The duration of dosing in this study is supported by the overall favorable safety profile of 
ALN-AS1 in the ongoing clinical study ALN AS1-001 and the absence of new findings in 
nonclinical studies with ALN-AS1.  GLP chronic toxicity studies (26 weeks in the rat and 
39 weeks in the NHP) have been conducted and are currently in the reporting phase.  Results of 
these studies will be available to support the clinical dosing. 
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1.6. 
Benefit-Risk Assessment 
Patients participating in this study may experience a reduced number or severity of porphyria 
attacks, reduced treatment with IV hemin, and/or reduced requirement for pain medication. 
The potential risks associated with administration of ALN-AS1 in patients with AIP are as 
follows: 
•
Injection site reactions (ISRs):  ALN-AS1 is administered by SC injection.  In the
ongoing ALN-AS1 clinical study, AEs of ISRs have been infrequently reported and
have been mild to moderate in severity with single dosing.  Injection site rotation and
close monitoring have been implemented in ALN-AS1 clinical studies to reduce the
potential for ISRs.
•
Liver function test (LFT) abnormalities:  As ALN-AS1 is targeted for delivery to the
liver, and reversible hepatic changes were observed in some animal species, there is a
potential for development of LFT abnormalities.  To minimize the potential for LFT
abnormalities, patients are required to have adequate liver function at study entry and
LFTs are monitored during the study.
•
Reproductive health:  No data are available on the use of ALN-AS1 in pregnancy;
however, there is no suspicion of human teratogenicity based on class effects or
genotoxic potential.  ALN-AS1 was neither genotoxic nor clastogenic in in vitro and
in vivo studies.  It is unlikely ALN-AS1 administration to pregnant women or animals
poses a risk to embryofetal development; however, in the absence of data from
embryofetal developmental toxicity studies with ALN-AS1, women of child bearing
potential (WOCBP) must have a negative pregnancy test, cannot be breastfeeding,
and must be willing to use an acceptable method of contraception during studies with
ALN-AS1.
•
CYP inhibition:  A study in NHP demonstrated that ALN-AS1 dosing could
potentially increase the clearance of drugs metabolized by the CYP3A isoform.  As
contraceptive hormones are metabolized via CYP3A, WOCBP must use a barrier
method of contraception, in addition to hormonal contraception, during study
participation.  Additionally, Investigators will review all patient medications at study
start and monitor responses to these medications during the study.  A list of
medications that may be CYP3A inhibitors and inducers is available at the Indiana
University, Division of Clinical Pharmacology, website.[31]
The complete summary of the clinical and nonclinical data relevant to the investigational drug 
and its study in human subjects is provided in the Investigator’s Brochure. 
2.
OBJECTIVES
2.1. 
Primary Objective
•
Evaluate the long-term safety and tolerability of ALN-AS1 in patients with AIP
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2.2. 
Secondary Objectives 
•
Assess the PD effect of ALN-AS1 over time
•
Assess the clinical activity of ALN-AS1 over time
2.3. 
Exploratory Objectives
•
Characterize the PK profile of ALN-AS1 over time
•
Assess changes in health-related quality of life (QOL)
•
Characterize analytes related to targeting the heme biosynthesis pathway
3.
ENDPOINTS
3.1. 
Primary Endpoint
•
Patient incidence of AEs
3.2. 
Secondary Endpoints
•
Change in urine ALA and PBG levels
•
Frequency and characteristics of porphyria attacks
•
Change in hemin administration
3.3. 
Exploratory Endpoints
•
Change in circulating ALAS1 mRNA levels
•
Concentrations of ALN-AS1 and antidrug antibodies
•
Duration and treatment of porphyria attacks
•
Number and duration of visits to a health care facility for acute porphyria care
•
EQ-5D-5L questionnaire scores
•
Pain assessment and narcotic use as recorded in a patient diary
•
Exploratory biomarkers related to the target pathway, such as urine porphyrins,
vitamin D binding protein
4.
INVESTIGATIONAL PLAN
4.1. 
Summary of Study Design
This is a Phase 1/2 multicenter, open-label extension study to evaluate the long-term safety and 
clinical activity of ALN-AS1 in patients with AIP who completed study ALN-AS1-001.  The 
study will be conducted at up to 8 clinical study centers worldwide. 
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The last assessments performed, determining previous study (ALN-AS1-001) completion, will 
serve as the Screening/Baseline assessments in this study.  If more than 60 days have elapsed 
since the last assessment, safety assessments (eg, ECG and clinical laboratory tests) will be 
repeated before administration of ALN-AS1.  It is anticipated that patients will begin ALN-AS1 
administration in this study within 6 months after the last dose of study drug in the previous 
study.  Eligibility will be confirmed during Screening/Baseline and before administration of the 
first dose of ALN-AS1 (Day 1).  Patients will undergo assessments at the clinical study center 
every month for the first 3 months.  Then, through Month 6, and according to the dosing regimen 
selected, assessments will take place at the clinical study center or via a phone contact (for an 
every month dosing regimen, visits will be every month; for an every 3 months dosing regimen, 
visits will be every 3 months; see Section 6.2.2).  After a patient has completed 12 months of 
ALN-AS1 administration in this study (6 months in an every month dosing regimen), and where 
applicable country and local regulations and infrastructure allow, study visits and ALN-AS1 
administration may take place at the patient’s home by a healthcare professional (as indicated in 
the Schedules of Assessments in Table 1 and Table 2; and Table 4 and Table 5 in Appendix 
Section 11.2).  Home visits may occur at the discretion of the Investigator, based on safety and 
tolerability; however, patients are required to complete at least 1 visit at the clinical study center 
every 3 months for the first year, and thereafter every 6 months through the end of the treatment 
period.  Patients will return to the clinical study center for a posttreatment follow-up visit after 
administration of the last dose of ALN-AS1.  An ALA/PBG Monitoring/EOS visit will be 
conducted either at the clinical study center or via phone contact, unless treatment continues with 
ALN-AS1. 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain 
assessments, and narcotic use.  Additionally, patients will be encouraged to report to the clinical 
study center if they experience a porphyria attack through Month 39.  In the event that patients 
are unable to report to the clinical study center during a porphyria attack, laboratory sample 
collection kits containing instructions for collecting and sending urine samples to the clinical 
study center, if possible, will be provided.  Patients will be contacted by phone after a porphyria 
attack to record attack details.  If patients are experiencing signs and symptoms of a porphyria 
attack when ALN-AS1 administration is scheduled, the Investigator will determine whether 
administration of ALN-AS1 is appropriate.  If patients are treated for a porphyria attack at a 
health care facility (eg, hospital, emergency department, infusion center, or outpatient clinic) 
other than the clinical study center, copies of medical records, including discharge summaries, 
will be requested.   
A Safety Review Committee (SRC) will review safety and tolerability data collected during the 
study with the primary purpose of protecting the safety of patients participating in the study (see 
Section 4.6). 
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Figure 1: 
Study Design 
 
4.2. 
Duration of Treatment and Study 
The duration of treatment is up to 36 months.  The estimated total time on study, inclusive of 
Screening/Baseline, for each patient is up to 44 months.   
4.3. 
Number of Patients 
Up to 24 patients are planned for enrollment in this study (including optional cohorts in 
ALN-AS1-001). 
4.4. 
Method of Assigning Patients to Treatment Groups 
This is an open-label study; all patients will receive ALN-AS1.  A combination of the clinical 
study center number and screening number will create the unique patient identifier.  The clinical 
study center number will be assigned by the Sponsor.  Upon signing the Informed Consent Form 
(ICF), the patient will be assigned a screening number by the clinical study site, which will be 
the same unique patient identifier assigned in the previous study (ALN-AS1-001).  The 
Investigator, or delegate, will confirm that the patient fulfills all the inclusion criteria and none of 
the exclusion criteria. 
4.5. 
Blinding 
This is an open-label study, and all patients will receive ALN-AS1. 
4.6. 
Safety Review Committee 
An SRC will be involved in the conduct of this study.  The SRC has the responsibility for 
monitoring the safety of the study participants.  The SRC will perform periodic reviews of safety 
and tolerability data during the course of the clinical study at least every 3 months for the first 
6 months of the study and thereafter at least every 6 months.  The SRC may also meet on an ad 
hoc basis for review of emergent safety and tolerability data, as defined in the SRC Charter for 
this clinical study.  The SRC will not stop the study for efficacy. 
The SRC will be comprised of the following members:  Principal Investigator(s), or designee(s), 
the Sponsor Medical Monitor, and the Study Medical Monitor. 
The membership of the SRC and reporting structure are further defined in the SRC Charter. 
Complete Study
ALN-AS1-001
Screening
(Day -60 to -1)
Treatment Period
(36 Months)
Posttreatment 
Follow-up
(3 months)
End of Study
(Month 42)
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5.
SELECTION AND WITHDRAWAL OF PATIENTS
5.1. 
Inclusion Criteria
Each patient must meet all of the following inclusion criteria to be eligible for enrollment in the 
study: 
1. Completed and, in the opinion of the Investigator, tolerated study drug dosing in Part C
of study ALN-AS1-001
2. Not on a scheduled regimen of hemin to prevent porphyria attacks at Screening
3. WOCBP must have a negative serum pregnancy test, cannot be breast feeding, and must
be willing to use 1 highly effective method of contraception 14 days before first dose,
throughout study participation, and for 90 days after last dose administration
4. Willing and able to comply with the study requirements and to provide written informed
consent
5.2. 
Exclusion Criteria 
Each patient must not meet any of the following exclusion criteria to be eligible for enrollment in 
the study: 
1. Alanine transaminase ≥2.0×ULN or total bilirubin ≥2 mg/dL (unless bilirubin elevation is
due to Gilbert’s syndrome)
2. Estimated glomerular filtration rate ≤30 mL/min/1.73 m2 (using the Modification of Diet
in Renal Disease formula)
3. History of multiple drug allergies or history of allergic reaction to an oligonucleotide or
to N-acetyl galactosamine ligand (GalNAc)
4. Received an investigational agent, other than ALN-AS1, or who are in follow-up of
another clinical study of an investigational agent within 90 days before study drug
administration
5. Other medical conditions or comorbidities which, in the opinion of the Investigator,
would interfere with study compliance or data interpretation
5.3. 
Removal from Treatment or Assessment 
Patients are free to discontinue treatment or withdraw from the study at any time and for any 
reason, without penalty to their continuing medical care.  Any discontinuation of treatment or 
withdrawal from the study must be fully documented in the electronic case report form (eCRF), 
and should be followed up by the Investigator.  The Investigator may withdraw a patient at any 
time if this is considered to be in the best interest of the patient. 
Discontinuation of study drug and withdrawal from the study are described in Section 5.3.1 and 
Section 5.3.2, respectively. 
5.3.1. 
Discontinuation of Study Drug 
The Investigator or designee may discontinue dosing in a patient if the patient: 
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•
Is in violation of the protocol
•
Experiences a SAE considered to be possibly or definitely related to the study drug or
an intolerable AE
•
Becomes pregnant
•
Is found to be considerably noncompliant with the protocol-requirements
Patients who are pregnant will be discontinued from study drug dosing immediately (see 
Section 7.5.6.6 for reporting and follow-up of pregnancy).  Patients who discontinue treatment 
will be asked to complete the Month 39 visit assessments. 
5.3.2. 
Withdrawal from Study 
A patient may withdraw from the study at any time.  If a patient chooses to withdraw from the 
study, every effort should be made to conduct early the assessments performed at the Month 39 
visit.  When a patient withdraws from the study, the primary reason for study withdrawal must be 
recorded in the appropriate section of the eCRF and all efforts made to complete and report the 
observations as thoroughly as possible.  If a patient withdraws due to a SAE, the SAE should be 
followed as described in Section 7.5.6. 
5.3.3. 
Replacement of Patients 
Patients discontinuing from study drug or withdrawing from the study will not be replaced. 
6.
TREATMENTS
6.1. 
Treatments Administered
ALN-AS1 Solution for Injection (SC use) is a clear, colorless to pale yellow solution essentially 
free of particulates.  ALN-AS1 will be supplied by the Sponsor as a sterile solution for SC 
injection. 
Study drug supplied for this study must not be used for any purpose other than the present study 
and must not be administered to any person not enrolled in the study.  Study drug that has been 
dispensed to a patient and returned unused must not be re-dispensed to a different patient. 
6.2. 
Investigational Study Drug 
Detailed information describing the preparation, handling, and storage, packaging and labeling, 
as well as study drug accountability for ALN-AS1 is provided in the Pharmacy Manual. 
6.2.1. 
Description 
ALN-AS1 Solution for Injection (SC use) is comprised of a synthetic, siRNA targeting ALAS1 
and bearing a triantennary GalNAc ligand conjugated to the sense strand, formulated in 
phosphate buffer.  
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6.2.2. 
Dose and Administration 
The planned starting dose of ALN-AS1 is 2.5 mg/kg ALN-AS1 as an SC injection administered 
every 3 months (Table 1 and Table 2).  Before initiating dosing in this study, the actual dose and 
dosing regimen administered will be determined based on SRC review of emerging data in 
Part C of study ALN-AS1-001.  Based on SRC review, a higher dose of ALN-AS1 may be 
administered and/or the dosing regimen adjusted to every month (Table 4 and Table 5 in 
Appendix Section 11.2).  Either fixed or weight-based doses may be administered.  The dose and 
dosing regimen of ALN-AS1 administered in this study will not exceed a previously explored 
dose and dosing regimen that was determined to be safe and well-tolerated in study 
ALN-AS1-001.  Further, the dose administered in this study will not exceed the maximum dose 
permitted in Part C of study ALN-AS1-001.  See Section 6.2.3 for details on dose modifications. 
The study drug will be administered under the supervision of a healthcare professional.  After a 
patient has completed 12 months of ALN-AS1 administration in this study (6 months in an every 
month dosing regimen), and where applicable country and local regulations and infrastructure 
allow, study visits and ALN-AS1 administration may take place at the patient’s home by a 
healthcare professional.  Home visits may occur at the discretion of the Investigator, based on 
safety and tolerability; however, patients are required to complete at least 1 visit at the clinical 
study center every 3 months for the first year, and thereafter every 6 months through the end of 
the treatment period.   
If a patient does not receive a dose of ALN-AS1 within the specified dosing window, the 
Investigator should contact the Medical Monitor.  After such consultation, the dose may be 
administered or considered missed and not administered. 
Patients will be permitted to miss an occasional dose of study drug; however, if a patient misses 
2 consecutive doses, the Investigator, in consultation with the Medical Monitor, will discuss 
whether the patient will be able to continue on the study.  
Detailed instructions for study drug administration are found in the Pharmacy Manual. 
6.2.3. 
Dose Modifications 
6.2.3.1. 
Study Population Dose Modifications 
During the study, dose modifications are permitted for the study population, or based on the dose 
cohort into which patients were originally randomized in study ALN-AS1-001.  Following SRC 
review of emerging safety and tolerability data from Part C of study ALN-AS1-001, or from this 
study (ALN-AS1-002), the dose and dosing regimen may be modified.  However, the dose and 
dosing regimen of ALN-AS1 will not exceed a previously explored dose and dosing regimen that 
was determined to be safe and well-tolerated in study ALN-AS1-001.  Patients enrolling in this 
study after a dose modification decision has been implemented may start at the newly identified 
dose and regimen. 
6.2.3.2. 
Individual Dose Modifications 
Dose modifications are permitted for individual patients.  If a patient has an AE that is related to 
study drug (eg, recurrent or severe ISRs, or clinically significant LFT abnormalities) and the 
Investigator has concerns regarding further ALN-AS1 administration, the Medical Monitor and 
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Investigator will review all available safety data for the patient.  Based on this review, it may be 
determined that the patient is a candidate for a dose reduction.  Dose reduction to a dose, which 
was found to be safe and well-tolerated by the SRC, is permitted.  Subsequent ALN-AS1 
administration at the previous, or higher, dose may be considered based on the judgment of the 
Investigator and Medical Monitor. 
6.2.4. 
Preparation, Handling, and Storage 
Staff at each clinical study center or the home healthcare professional will be responsible for 
preparation of ALN-AS1 doses, according to procedures detailed in the Pharmacy Manual.  No 
special procedures for the safe handling of study drug are required. 
Study drug will be stored upright and refrigerated at approximately 5±3°C.  Any deviation from 
the recommended storage conditions should be reported to the Sponsor and use of the study drug 
halted until authorization for its continued use has been provided by the Sponsor or designee. 
A Sponsor representative or designee will be permitted, upon request, to audit the supplies, 
storage, dispensing procedures, and records. 
6.2.5. 
Packaging and Labeling 
ALN-AS1 Solution for Injection (SC use) is packaged in 2 mL glass vials with a fill volume of 
no less than 0.55 mL.  The container closure system consists of a Type I glass vial, a Teflon 
faced bromobutyl 13 mm stopper and a flip-off Truedge aluminum seal. 
6.2.6. 
Accountability 
The Investigator or designee will maintain accurate records of receipt and the condition of the 
study drug supplied for this study, including dates of receipt.  In addition, accurate records will 
be kept of when and how much study drug is dispensed and administered to each patient in the 
study.  Any reasons for departure from the protocol dispensing regimen must also be recorded. 
At the completion of the study, there will be a final reconciliation of all study drugs.  All used, 
partially used, and unused study drug will be returned to the Sponsor (or designee) or destroyed 
at the clinical study center according to applicable regulations.   
6.3. 
Concomitant Medications 
Use of concomitant medications will be recorded on the patient’s case report form (CRF) as 
indicated in the Schedules of Assessments (Table 1 and Table 2; and Table 4 and Table 5 in 
Appendix Section 11.2).  This includes all prescription medications, herbal preparations, over the 
counter (OTC) medications, vitamins, and minerals.  Any changes in medications during the 
study will also be recorded on the CRF. 
Any concomitant medication that is required for the patient’s welfare may be administered by the 
Investigator.  However, it is the responsibility of the Investigator to ensure that details regarding 
the medication are recorded on the eCRF.  Concomitant medication will be coded using an 
internationally recognized and accepted coding dictionary. 
Patients are not permitted to be on hemin prophylaxis at Screening; however, patients are 
permitted to receive concomitant hemin treatment for the management of acute porphyria 
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attacks.  Patients experiencing significant breakthrough attacks while enrolled in this study, 
necessitating frequent hemin treatment, may receive hemin prophylaxis if in the Investigator’s 
judgment this is clinically beneficial to the patient.  The Investigator should contact with the 
Sponsor and Medical Monitor before prophylactic hemin treatment.  The dose, regimen, and 
dates of administration will be recorded on the patient’s eCRF.   
Pain medication (eg, opiates, opioids, narcotic analgesics) and glucose administration are 
permitted for the management of porphyria and for acute porphyria attacks. 
If patients use nonsteroidal anti-inflammatory medications intermittently or chronically, they 
must have been able to tolerate them with no previous side effects (eg, gastric distress or 
bleeding).   
Standard vitamins and topical medications are permitted; however, topical steroids must not be 
applied anywhere near the injection site(s) unless medically indicated. 
6.4. 
Contraceptive Requirements 
WOCBP must be willing to use a highly effective method of contraception 14 days before first 
dose, throughout study participation, and for 90 days after last dose administration.  Highly 
effective methods of birth control result in a low failure rate (ie, less than 1% per year).  Birth 
control methods which may be considered as highly effective include: 
• Established use of oral (except low-dose gestagens [eg, lynestrenol and 
norethisterone]), implantable, injectable, or transdermal hormonal methods of 
contraception.  WOCBP using hormonal methods of contraception must also use a 
barrier method (condom or occlusive cap [diaphragm or cervical/vault cap] in 
conjunction with spermicide [eg, foam, gel, film, cream, or suppository]).  If 
hormonal methods of contraception are medically contraindicated for WOCBP due to 
underlying disease, a double-barrier method (combination of male condom with 
either cap, diaphragm, or sponge, in conjunction with spermicide) is also considered 
an acceptable method of contraception. 
• Placement of an intrauterine device  
• Placement of an intrauterine hormone-releasing system  
• Bilateral tubal occlusion 
• Surgical sterilization of male partner (with the appropriate post-vasectomy 
documentation of the absence of sperm in the ejaculate; for female patients on the 
study, the vasectomized male partner should be the sole partner for that patient) 
• True sexual abstinence, when in line with the preferred and usual lifestyle of the 
patient.  Periodic abstinence (eg, calendar, ovulation, symptothermal, post-ovulation 
methods) and withdrawal are not acceptable methods of contraception.  Abstinent 
patients must agree to use 1 of the abovementioned contraceptive methods, if they 
start sexual relationships during the study and for 90 days after last dose 
administration. 
WOCBP includes any female patient who has experienced menarche and who is not 
postmenopausal or permanently sterilized (eg, bilateral tubal occlusion, hysterectomy, or 
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bilateral salpingectomy).  Postmenopausal state is defined as no menses for 12 months without 
an alternative medical cause, confirmed by follicle stimulating hormone level within the 
postmenopausal range. 
6.5. 
Treatment Compliance 
Compliance with study drug administration will be verified through observation by study 
personnel or trained home healthcare professionals.  
7. 
STUDY ASSESSMENTS 
The schedule of study assessments is provided in Table 1.  
7.1. 
Screening/Baseline Assessments 
Informed consent, patient demographic data, and eligibility criteria will be confirmed at 
Screening/Baseline.  An interval medical history/disease history will be obtained at 
Screening/Baseline.  The last assessments performed, determining previous study 
(ALN-AS1-001) completion, will serve as the Screening/Baseline assessments in this study.  If 
more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs will 
be repeated before administration of ALN-AS1. 
7.2. 
Clinical Activity Assessments 
The clinical activity of ALN-AS1 will be assessed by the frequency and characteristics of 
porphyria attacks including, but not limited to, duration, treatment, and severity of porphyria 
attacks and number and duration of visits to a health care setting for acute porphyria care (eg, 
hospital, emergency department, infusion center, or outpatient clinic).  Concomitant hemin 
administration will also be recorded. 
7.2.1. 
Patient Diary 
Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain 
assessments, and narcotic use. 
7.2.2. 
Brief Pain Inventory-Short Form Questionnaire 
The Brief Pain Inventory-Short Form (BPI-SF) questionnaire will be used to evaluate pain.[32]  
The BPI will be completed as part of the patient diary. 
7.3. 
Pharmacodynamic Assessments 
Blood and urine samples will be collected for assessment of ALN-AS1 PD parameters.  The PD 
effect of ALN-AS1 will be evaluated by urine ALA and PBG levels.  Blood and urine samples 
will be collected for assessment of circulating ALAS1 mRNA levels in serum and in urine.  
Analysis for blood and urine PD parameters will take place at a central laboratory.   
Details regarding the processing and aliquoting of samples for storage and analyses will be 
provided in the Laboratory Manual. 
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7.4. 
Pharmacokinetic Assessments 
Blood samples will be collected to evaluate the PK profile of ALN-AS1 at the time points in the 
Schedule of Assessments.  A detailed schedule of time points for the collection of blood samples 
for PK analysis is in Table 3 in Appendix 11.1). 
The concentration of ALN-AS1 will be determined using a validated assay.  Details regarding 
the processing, shipping, and analysis of the samples will be provided in the Laboratory Manual. 
7.5. 
Safety Assessments 
The assessment of safety during the course of the study will consist of the surveillance and 
recording of AEs including SAEs, recording of concomitant medications and measurements of 
vital signs, physical examination, and ECG findings and clinical laboratory evaluations. 
Safety will be monitored over the course of the study by an SRC as described in Section 4.6. 
7.5.1. 
Vital Signs 
Vital sign measurements include blood pressure, heart rate, oral body temperature, and 
respiratory rate.  Vital signs will be measured in the seated or supine position (should be 
consistent for each patient), after the patient has rested comfortably for 10 minutes.  Blood 
pressure should be taken using the same arm throughout the study.  Oral body temperature will 
be obtained in degrees Celsius, heart rate will be counted for a full minute and recorded in beats 
per minute, and respiration rate will be counted for a full minute and recorded in breaths per 
minute. 
For the safety of the patient, additional vital sign assessments may be added at the discretion of 
the Investigator. 
7.5.2. 
Weight and Height 
Height will be measured in centimeters at the Screening/Baseline visit only.  Body weight will be 
measured in kilograms.  Body mass index will be calculated in the database. 
7.5.3. 
Physical Examination 
Complete physical examinations will include the examination of the following:  general 
appearance, head, eyes, ears, nose and throat, chest/respiratory, heart/cardiovascular, 
gastrointestinal/liver, musculoskeletal/extremities, dermatological/skin, thyroid/neck, lymph 
nodes, and neurological/psychiatric. 
Targeted physical examinations will include the examination of the following:  general 
appearance, chest/respiratory, heart/cardiovascular, gastrointestinal/liver, and 
neurological/psychiatric. 
7.5.4. 
Electrocardiogram 
Triplicate 12-lead ECG, with readings approximately 2 minutes apart, will be recorded.  
Additional ECGs may be collected at the discretion of the Investigator.  Standard computerized 
12-lead ECG recordings will be obtained.  Each lead shall be recorded for at least 3 beats at a 
speed of 25 mm/s.  Recordings will be obtained, after the patient has rested comfortably for 
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approximately 10 minutes.  The electrophysiological parameters assessed include rhythm, 
ventricular rate, PR interval, QRS duration, QT interval, ST and T waves, Bazett-corrected QT 
interval (QTcB) and Fridericia-corrected QT interval (QTcF). 
The Investigator or designee is responsible for reviewing the ECGs to assess whether the results 
have changed since the Screening/Baseline visit and to determine the clinical relevance of the 
results.  These assessments will be recorded on the eCRF.  For any clinically relevant ECG 
changes from the Screening/Baseline visit (eg, ischemic ECG changes, wave/interval changes, or 
arrhythmia), the Investigator must contact the Medical Monitor to discuss continued participation 
of the patient in the study. 
7.5.5. 
Clinical Laboratory Assessments 
The following clinical laboratory tests will be evaluated by a central laboratory.  In the event of 
an unexplained clinically relevant abnormal laboratory test occurring after study drug 
administration, the test should be repeated and followed up at the discretion of the Investigator 
until it has returned to the normal range or stabilized, and/or a diagnosis is made to adequately 
explain the abnormality. 
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Hematology 
Complete blood count with differential 
Serum Chemistry 
Sodium 
Potassium 
BUN 
Phosphate 
Creatinine and eGFRa 
Albumin 
Uric acid 
Calcium 
Total protein 
Carbon dioxide 
Glucose 
Chloride 
Liver Function Tests 
AST 
ALP 
ALT 
Bilirubin (total and direct) 
Urinalysis 
Visual inspection for appearance and color 
Bilirubin 
pH (dipstick) 
Nitrite 
Specific gravity 
RBCs 
Ketones 
Urobilinogen 
Albumin 
Leukocytes 
Glucose 
Microscopy (if clinically indicated) 
Protein 
Immunogenicity 
Antidrug antibodies 
Pregnancy Testing (WOCBP only) 
β-human chorionic gonadotropin 
Abbreviations:  AST=aspartate transaminase; ALP=alkaline phosphatase; ALT=alanine transaminase; BUN=blood 
urea nitrogen; eGFR=estimated glomerular filtration rate; WOCBP=women of child bearing potential. 
a eGFR will be calculated using the Modification of Diet in Renal Disease formula.[33] 
7.5.5.1. 
Immunogenicity 
Blood samples will be collected to evaluate antidrug antibodies.  On days when ALN-AS1 is 
administered, blood samples for antidrug antibody testing must be collected before ALN-AS1 is 
administered. 
Details regarding the processing, shipping, and analysis of the samples will be provided in the 
Laboratory Manual. 
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7.5.5.2. 
Pregnancy Testing 
A pregnancy test will be performed for WOCBP only.  A serum pregnancy test will be 
performed at Screening/Baseline and urine pregnancy tests will be performed thereafter per the 
Schedule of Assessments and any time pregnancy is suspected.  Urine pregnancy tests may also 
be performed more frequently (eg, monthly) based on local country requirements.  The results of 
the pregnancy test must be known before study drug administration.  Patients who are pregnant 
are not eligible for study participation.  Any woman with a positive pregnancy test during the 
study will be discontinued from study drug, but will continue to be followed for safety.  Patients 
determined to be pregnant while on study will be followed until the pregnancy outcome is known 
(see Section 7.5.6.6 for follow-up instructions).  
7.5.6. 
Adverse Events 
7.5.6.1. 
Definitions 
Adverse Event 
According to the ICH E2A guideline Definitions and Standards for Expedited Reporting, and 
21 Code of Federal Regulations 312.32, Investigational New Drug Safety Reporting, an AE is 
any untoward medical occurrence in a patient or clinical investigational subject administered a 
medicinal product and which does not necessarily have a causal relationship with this treatment. 
Serious Adverse Event 
An SAE is any untoward medical occurrence that at any dose: 
• Results in death 
• Is life-threatening (An event which places the patient at immediate risk of death from 
the event as it occurred.  It does not include an event that had it occurred in a more 
severe form might have caused death) 
• Requires in-patient hospitalization or prolongation of existing hospitalization 
• Results in persistent or significant disability or incapacity 
• Is a congenital anomaly or birth defect 
• Is an important medical event that may not be immediately life-threatening or result 
in death or hospitalization but may jeopardize the patient and may require 
intervention to prevent one of the other outcomes listed in the definition above (eg, 
events include allergic bronchospasm requiring intensive treatment in an emergency 
room or at home, blood dyscrasias, convulsions, or the development of drug 
dependency or abuse). 
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Adverse Event Severity 
Adverse events are to be graded according to the categories detailed below: 
Mild: 
Mild events are those which are easily tolerated with no disruption of normal 
daily activity. 
Moderate: 
Moderate events are those which cause sufficient discomfort to interfere with 
normal daily activities. 
Severe: 
Severe events are those which incapacitate and prevent usual activity. 
Changes in severity should be documented in the medical record to allow assessment of the 
duration of the event at each level of severity.  AEs characterized as intermittent require 
documentation of the start and stop of each incidence.  When changes in the severity of an AE 
occur more frequently than once a day, the maximum severity for the experience that day should 
be noted.  If the severity category changes over a number of days, then those changes should be 
recorded separately (with distinct onset dates) 
AE severity and seriousness are assessed independently.  ‘Severity’ characterizes the intensity of 
an AE.  ‘Serious’ is a regulatory definition and serves as a guide to the Sponsor for defining 
regulatory reporting obligations (see definition for Serious Adverse Event). 
Relationship of the Adverse Event to Study Treatment 
The relationship of each AE to study treatment should be evaluated by the Investigator using the 
following criteria:  
Definitely related: 
A clinical event, including laboratory test abnormality, occurring in a 
plausible time relationship to the medication administration, and which 
cannot be explained by concurrent disease or other drugs or chemicals.  
The response to withdrawal of the drug should be clinically plausible. 
Possibly related: 
A clinical event, including laboratory test abnormality, with a 
reasonable time sequence to the medication administration, but which 
could also be explained by concurrent disease or other drugs or 
chemicals.  Information on the drug withdrawal may be lacking or 
unclear. 
Unlikely related: 
A clinical event, including laboratory test abnormality, with little or no 
temporal relationship to medication administration, and which other 
drugs, chemicals, or underlying disease provide plausible explanations. 
Not related: 
A clinical event, including laboratory test abnormality that has no 
temporal relationship to the medication or has more likely alternative 
etiology. 
Adverse Events of Clinical Interest 
The following events are considered to be adverse events of clinical interest: 
• ISRs 
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• Hepatic AEs, including LFT abnormalities considered clinically significant by the 
Investigator. 
7.5.6.2. 
Eliciting and Recording Adverse Events 
Eliciting Adverse Events 
The patient should be asked about medically relevant changes in his/her health since the last 
visit.  The patient should also be asked if he/she has been hospitalized, had any accidents, used 
any new medications, or changed concomitant medication routines (both prescription and OTC).  
In addition to patient observations, AEs will be documented from any clinically relevant 
laboratory findings, physical examination findings, ECG changes, or other findings that are 
relevant to patient safety. 
Recording Adverse Events 
The Investigator is responsible for recording non-serious AEs that are observed or reported by 
the patient after administration of the first dose of study drug regardless of their relationship to 
study drug through the end of study.  Non-serious AEs will be followed until the end of study.  
The Investigator is responsible for recording SAEs that are observed or reported by the patient 
after the time when the informed consent is signed regardless of their relationship to study drug 
through the end of study.  SAEs will be followed until satisfactory resolution, until baseline level 
is reached, or until the SAE is considered by the Investigator to be chronic or the patient is 
stable, as appropriate. 
All AEs must be recorded in the source records for the clinical study center and in the eCRF for 
the patient, whether or not they are considered to be drug-related.  Each AE must be described in 
detail:  onset time and date, description of event, severity, relationship to investigational drug, 
action taken, and outcome (including time and date of resolution, if applicable). 
For SAEs, record the event(s) on the eCRF.  If the electronic data capture (EDC) system is 
unavailable, complete the backup SAE form. 
For AEs that are considered AEs of clinical interest, additional clinical information may be 
collected based upon the severity or nature of the event. 
If a patient has ISRs meeting any of the following criteria, the Investigator or delegate should 
contact the Medical Monitor and submit a supplemental ISR eCRF: 
• ISRs that are recurrent and/or demonstrate a pattern of increasing severity 
• Any ISR that is determined to be severe and/or a cause for study drug discontinuation  
• Any ISR which, in the opinion of the Investigator, requires further medical evaluation or 
treatment 
In some cases, where it is medically appropriate, further evaluation may include photographs, 
referral to a dermatologist, skin biopsy, or other laboratory testing.  If a biopsy was obtained, the 
Sponsor may request that the biopsy also be reviewed by a central dermatopathologist.  To better 
understand the safety profile of the study drug, additional analysis of biopsy tissue may be 
performed according to local regulations. 
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For patients with hepatic AEs, additional information, including, clinical history, course of event, 
and local laboratory results to monitor LFT levels or other laboratory parameters, may be 
collected. 
7.5.6.3. 
Serious Adverse Events Require Immediate Reporting to Sponsor/Designee 
An assessment of the seriousness of each AE will be made by the Investigator.  Any AE and 
laboratory abnormality that meets the SAE criteria in Section 7.5.6.1 must be reported to the 
Sponsor or designee within 24 hours from the time that clinical study center personnel first 
learns of the event.  All SAEs must be reported regardless of the relationship to study drug. 
The initial report should include at least the following information: 
• Patient’s study number 
• Description and date of onset of the event 
• Criterion for serious 
• Preliminary assignment of relationship to study drug 
• Investigator/clinical study center information 
To report the SAE, complete the eCRF.  If the EDC system is unavailable, complete the backup 
SAE form.  Within 24 hours of receipt of follow-up information, the Investigator must update the 
report.  SAEs must be reported using the contact information provided in the Study Manual. 
Appropriate remedial measures should be taken by the Investigator using his/her best medical 
judgment to treat the SAE.  These measures and the patient’s response to these measures should 
be recorded.  All SAEs, regardless of relationship to study drug, will be followed by the 
Investigator until satisfactory resolution or the Investigator deems the SAE to be chronic or 
stable.  Clinical, laboratory, and diagnostic measures should be employed by the Investigator as 
needed to adequately determine the etiology of the event. 
7.5.6.4. 
Sponsor Safety Reporting to Regulatory Authorities 
The Sponsor or its representative is required to report certain study events in an expedited 
manner to the Food and Drug Administration, the European Medicines Agency’s EudraVigilance 
electronic system according to Directive 2001/20/EC, and to all country Regulatory Authorities 
where the study is being conducted, according to local applicable regulations. 
The following describes the safety reporting timeline requirements for suspected unexpected 
serious adverse reactions (SUSARs) and other reportable events: 
Immediately and within 7 calendar days 
• Any suspected adverse reaction that is associated with the use of the study drug, 
unexpected, and fatal or life threatening.  Follow-up information must be reported in 
the following 8 days. 
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Immediately and within 15 calendar days 
• Any suspected adverse reaction that is associated with the use of the study drug, 
unexpected, and serious, but not fatal or life threatening, and there is evidence to 
suggest a causal relationship between the study drug and the reaction. 
• Any finding from tests in laboratory animals that suggest a significant risk for human 
patients including reports of mutagenicity, teratogenicity, or carcinogenicity. 
• Any event in connection with the conduct of the study or the development of the 
study drug that may affect the safety of the trial patients. 
In addition, periodic safety reporting to regulatory authorities will be performed by the Sponsor 
or its representative according to national and local regulations. 
7.5.6.5. 
Serious Adverse Event Notification to the Institutional Review 
Board/Independent Ethics Committee 
SUSARs will be reported to the Institutional Review Board (IRB)/Independent Ethics 
Committee (IEC) per their institutional policy by the Investigator or Sponsor (or Sponsor 
designee) according to country requirements.  Copies of each report and documentation of 
IRB/IEC notification and acknowledgement of receipt will be kept in the Investigator’s study 
file. 
7.5.6.6. 
Pregnancy Reporting 
If a female patient becomes pregnant during the course of this study through 90 days following 
the last dose of study drug, the Investigator must report the pregnancy to the Sponsor or designee 
within 24 hours of being notified of the pregnancy.  Details of the pregnancy will be recorded on 
the pregnancy reporting form.  The patient should receive any necessary counseling regarding 
the risks of continuing the pregnancy and the possible effects on the fetus. 
The pregnancy should be followed by the Investigator until completion.  At the completion of the 
pregnancy, the Investigator will document the outcome of the pregnancy.  If the outcome of the 
pregnancy results in a postpartum complication, spontaneous abortion, stillbirth, neonatal death, 
or congenital anomaly, then the Investigator should follow the procedures for reporting an SAE 
as outlined in Section 7.5.6.3.   
7.5.6.7. 
Overdose Reporting 
An overdose is defined as any dose administered to or taken by a patient (accidentally or 
intentionally) that exceeds the highest daily dose, or is at a higher frequency, than included in the 
protocol.  It is up to the investigator to decide whether a dose is to be considered an overdose, in 
consultation with the Sponsor.  Overdose must be recorded in the eCRF. 
All reports of overdose (with or without an AE) must be reported within 24 hours to the Sponsor 
or designee.   
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7.6. 
Exploratory Assessments 
Blood and urine samples will be collected for exploratory analyses.  Aliquots of samples will be 
obtained and frozen, to permit future analysis of the effect of ALN-AS1 on exploratory 
biomarkers.   
Where local regulations allow, biologic samples will be retained on behalf of the Sponsor for a 
maximum of 15 years following the last patient’s last visit in the study.  Details regarding the 
collection, processing, storage, and shipping of samples will be in the Laboratory Manual. 
7.7. 
Other Assessments 
7.7.1. 
EQ-5D-5L Questionnaire 
QOL will be assessed through the use of the 5-level EQ-5D (EQ-5D-5L), a standardized 
questionnaire measuring health outcomes.[34]  In addition to the time points indicated, the 
EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a 
porphyria attack (but, not more than once in a 6 month period), if possible. 
8. 
STATISTICS 
A detailed Statistical Analysis Plan (SAP) will be written after finalizing the protocol and before 
database lock.  The plan will detail the implementation of all the statistical analyses in 
accordance with the principle features stated in the protocol. 
8.1. 
Determination of Sample Size 
This is a Phase 1/2 multicenter, open-label extension study to evaluate the long-term safety and 
clinical activity of ALN-AS1 in patients with AIP who completed study ALN-AS1-001.  Safety, 
tolerability, PK, and PD of ALN-AS1 will be investigated.  The sample size was not determined 
based on statistical considerations.  Up to 24 patients are planned for this study (including 
optional cohorts in ALN-AS1-001). 
8.2. 
Statistical Methodology 
The statistical and analytical plans presented below summarize the more complete plans to be 
detailed in the SAP.  Any changes to the methods described in the final SAP will be described 
and justified as needed in the clinical study report. 
Statistical analyses will be primarily descriptive in nature.  Descriptive statistics (eg, mean, 
standard deviation, median, minimum, and maximum) will be presented for continuous 
variables.  Frequencies and percentages will be presented for categorical and ordinal variables. 
Analyses will be performed using SAS® (Version 9.2, or higher). 
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8.2.1. 
Populations to be Analyzed 
The populations (analysis sets) are defined as follows:  
Safety Analysis Set: 
All patients who received any amount of study drug. 
Clinical Activity Analysis 
Set: 
All patients who received any amount of study drug and have 
both a baseline and at least 1 postdose assessment. 
PK Analysis Set: 
All patients who received any amount of study drug and have at 
least 1 postdose blood sample for PK and who have evaluable 
PK data. 
PD Analysis Set: 
All patients who received any amount of study drug and who 
have at least 1 postdose blood sample for the determination of 
ALN-AS1 will be included in the PD analyses. 
Safety will be analyzed using the Safety Analysis Set.  The PK and PD Analysis Sets will be 
used to conduct PK and PD analyses, respectively.  The population used to evaluate clinical 
activity will be the Clinical Activity Analysis Set.   
8.2.2. 
Examination of Subgroups 
Subgroup analyses may be conducted for selected endpoints.  Detailed methodology will be 
provided in the SAP. 
8.2.3. 
Handling of Missing Data 
Unrecorded values will be treated as missing.  The appropriateness of the method(s) described 
for handling missing data may be reassessed and documented in the SAP before database lock.  
Depending on the extent of missing values, further investigation may be made into the sensitivity 
of the analysis results to the method(s) specified. 
8.2.4. 
Baseline Evaluations 
Demographics, medical history, disease-specific information, and other baseline characteristics 
collected in this study will be summarized.   
8.2.5. 
Clinical Activity Analyses 
Clinical activity of ALN-AS1 will be summarized primarily by descriptive statistics.  The 
clinical activity of ALN-AS1 will be evaluated by the frequency and characteristics of porphyria 
attacks including duration, treatment, and severity of porphyria attacks and number and duration 
of visits to a health care setting for acute porphyria care. 
Patient diary recordings, including BPI-SF questionnaire scores, will also be summarized. 
8.2.6. 
Pharmacodynamic Analysis 
PD analyses will include the evaluation of change in ALA, PBG, and ALAS mRNA levels.  
Descriptive statistics (eg, mean and standard error of the mean) for observed levels of PD 
parameters and the relative change from baseline will be presented for each of the postdose 
follow-up time points. 
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8.2.7. 
Pharmacokinetic Analysis 
The PK concentration of ALN-AS1 will be determined. 
Antidrug antibody results will be tabulated.  A by-patient data listing will also be provided. 
8.2.8. 
Safety Analyses 
Extent of exposure will be summarized.  AEs will be summarized by the Medical Dictionary for 
Regulatory Activities System Organ Class and Preferred Term.  Prior and concomitant 
medications will be classified according to the World Health Organization drug dictionary. 
Incidence of AEs (those events that started after exposure to study drug or worsened in severity 
after dosing) will be presented.  Incidence of AEs will also be presented by maximum severity 
and relationship to study treatment.  The incidence of SAEs and AEs leading to discontinuation 
of treatment will also be tabulated.  By-patient listings will be provided for deaths, SAEs, and 
AEs leading to discontinuation of treatment.   
Descriptive statistics will be provided for clinical laboratory data and vital signs data, presented 
as both actual values and changes from baseline relative to each on-study evaluation and to the 
last evaluation on study.  Laboratory shift tables from baseline to worst values will be presented.  
Abnormal physical examination findings and 12-lead ECG data will be presented in a by-patient 
data listing. 
Descriptive statistics will be provided for ECG interval data and presented as both actual values 
and changes from baseline relative to each on-study evaluation and to the last evaluation on 
study.  Details of any abnormalities will be included in patient listings. 
Concomitant hemin administration will also be recorded. 
8.2.9. 
Other Analyses 
Possible associations between PD parameters (ALA, PBG, and ALAS1 mRNA levels) and 
clinical activity parameters may also be explored. 
Additional exploratory analyses may be conducted on analytes related to targeting the heme 
biosynthesis pathway. 
QOL scores on the EQ-5D-5L questionnaire will also be summarized. 
9. 
STUDY ADMINISTRATION 
9.1. 
Ethical and Regulatory Considerations 
This study will be conducted in accordance with the protocol, all applicable regulatory 
requirements, and the guidelines of Good Clinical Practice (GCP).  Compliance with GCP 
provides public assurance that the rights, safety, and well-being of study patients are protected 
consistent with the principles that have their origin in the Declaration of Helsinki. 
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9.1.1. 
Informed Consent 
The Investigator will ensure that the patient is given full and adequate oral and written 
information about the nature, purpose, possible risk and benefit of the study.  Patients must also 
be notified that they are free to withdraw from the study at any time.  The patient should be given 
the opportunity to ask questions and allowed time to consider the information provided. 
The patient’s signed and dated informed consent must be obtained before conducting any study 
procedures. 
The Investigator must maintain the original, signed ICF.  A copy of the signed ICF must be 
given to the patient. 
9.1.2. 
Ethical Review 
The final study protocol, including the final version of the ICF, must be approved or given a 
favorable opinion in writing by an IRB or IEC, as appropriate.  The Investigator must submit 
written approval before he or she can enroll any patient into the study. 
The Investigator is responsible for informing the IRB or IEC of any amendment to the protocol 
in accordance with local requirements.  In addition, the IRB or IEC must approve all advertising 
used to recruit patients for the study.  The protocol must be reapproved by the IRB or IEC upon 
receipt of amendments and annually, as local regulations require. 
Initial IRB approval of the protocol, and all materials approved by the IRB for this study 
including the patient consent form and recruitment materials must be maintained by the 
Investigator and made available for inspection. 
The Investigator will submit reports of SAEs as outlined in Section 7.5.6.  In addition, the 
Investigator agrees to submit progress reports to the IRB or IEC per their local reporting 
requirements, or at least annually and at the conclusion of the study.  The reports will be made 
available to the Sponsor or designee. 
Any communications from regulatory agencies in regard to inspections, other studies that impact 
this protocol or the qualifications of study personnel should be promptly reported to the Sponsor 
or its designee. 
The Investigator is also responsible for providing the IRB with reports of any reportable serious 
adverse drug reactions from any other study conducted with the investigational drug.  The 
Sponsor or designee will provide this information to the Investigator. 
Major changes in this research activity, except those to remove an apparent immediate hazard to 
the patient, must be reviewed and approved by the Sponsor and the IRB or IEC that approved the 
study.  Amendments to the protocol must be submitted in writing to the Investigator’s IRB or 
IEC and the Regulatory Authority for approval before patients are enrolled under the amended 
protocol. 
9.1.3. 
Study Documentation, Confidentiality, and Records Retention 
All documentation relating to the study should be retained for the period of time required by 
applicable local law.  If it becomes necessary for the Sponsor, the Sponsor’s designee, applicable 
IRB/IEC, or applicable regulatory authorities to review or audit any documentation relating to 
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the study, the Investigator must permit direct access to all source documents/data.  Records will 
not be destroyed without informing the Sponsor in writing and giving the Sponsor the 
opportunity to store the records for a longer period of time at the Sponsor’s expense.   
The Investigator must ensure that the patients’ anonymity will be maintained.  On the CRFs or 
other documents submitted to the Sponsor or designees, patients should not be identified by their 
names, but by the assigned patient number and initials.  If patient names are included on copies 
of documents submitted to the Sponsor or designees, the names (except for initials) will be 
obliterated and the assigned patient number added to the document.  Documents not for 
submission to the Sponsor (eg, signed ICFs) should be maintained by the Investigator in strict 
confidence. 
The Investigator must treat all of the information related to the study and the compiled data as 
confidential, whose use is for the purpose of conducting the study.  The Sponsor must approve 
any transfer of information not directly involved in the study. 
In compliance with local and/or regional regulations, this clinical study may be registered and 
study results may be posted on public registries, such as ClinicalTrials.gov. 
9.1.4. 
End of the Study 
The end of the study is defined as last patient last visit. 
9.1.5. 
Discontinuation of the Clinical Study 
The Sponsor reserves the right to discontinue the study for clinical or administrative reasons at 
any time.  If the clinical study center does not recruit at a reasonable rate, the study may be 
discontinued at that clinical study center.  Should the study be terminated and/or the clinical 
study center closed for whatever reason, all documentation and study drug pertaining to the study 
must be returned to the Sponsor or its representative, and the Investigators, IEC/IRB and 
Regulatory Authorities will be promptly informed of the termination and the reason for the 
decision.  The Investigator should promptly inform the patients and assure appropriate therapy 
and follow-up.  Patients should then be withdrawn from the study.   
9.2. 
Data Quality Control and Quality Assurance 
9.2.1. 
Data Handling 
Study data must be recorded on case report forms (paper and/or electronic) provided by the 
Sponsor or designee on behalf of the Sponsor.  Case report forms must be completed only by 
persons designated by the Investigator.  If eCRFs are used, study data must be entered by trained 
clinical study center personnel with access to a valid and secure eCRF system.  All data entered 
into the eCRF must also be available in the source documents.  Corrections on paper CRFs must 
be made so as to not obliterate the original data and must be initialed and dated by the person 
who made the correction. 
9.2.2. 
Study Monitoring 
The clinical monitor, as a representative of the Sponsor, has an obligation to closely follow the 
study conduct at the clinical study center.  The monitor will visit the Investigator and clinical 
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study center periodically and will maintain frequent telephone and written contact.  The monitor 
will maintain current personal knowledge of the study through observation, review of study 
records and source documentation, and discussion of the conduct of the study with the 
Investigator and personnel. 
The monitor will review source documents, systems and CRFs to ensure overall quality and 
completeness of the data and to confirm study procedures are complied with the requirements in 
the study protocol.  The Sponsor, or its designee, will be allowed to conduct clinical study center 
visits to the investigation facilities for the purpose of monitoring any aspect of the study.  The 
Investigator agrees to allow the monitor to inspect the drug storage area, study drug stocks, drug 
accountability records, patient charts and study source documents, and other records relative to 
study conduct. 
9.2.3. 
Audits and Inspections 
Periodically, the Sponsor or its authorized representatives audit clinical investigative study 
centers as an independent review of core trial processes and documents to determine whether 
these activities were conducted, and data were recorded, analyzed, and accurately reported 
according to the protocol, GCP guidelines of the ICH, and any applicable regulatory 
requirements.  A regulatory authority, an IEC or an IRB may visit the clinical study center to 
perform audits or inspections, including source data verification.  The Investigator should contact 
the Sponsor, or its designee, immediately if contacted by a regulatory agency about an 
inspection. 
9.3. 
Publication Policy 
It is intended that after completion of the study, the data are to be submitted for publication in a 
scientific journal and/or for reporting at a scientific meeting.  A copy of any proposed manuscript 
must be provided and confirmed received at the Sponsor at least 30 days before its submission, 
and according to any additional publication details in the Investigator Agreement.
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10.
LIST OF REFERENCES
1. Anderson KE, Bloomer JR, Bonkovsky HL, Kushner JP, Pierach CA, Pimstone NR, et al.
Recommendations for the diagnosis and treatment of the acute porphyrias. Ann Intern Med. 2005 
Mar 15;142(6):439-50. 
2. Siegesmund M, van Tuyll van Serooskerken AM, Poblete-Gutierrez P, Frank J. The acute
hepatic porphyrias: current status and future challenges. Best Pract Res Clin Gastroenterol. 2010 
Oct;24(5):593-605. 
3. Poblete-Gutierrez P, Wiederholt T, Merk HF, Frank J. The porphyrias: clinical presentation,
diagnosis and treatment. Eur J Dermatol. 2006 May-Jun;16(3):230-40. 
4. Balwani M, Desnick RJ. The porphyrias: advances in diagnosis and treatment. Blood. 2012
Nov 29;120(23):4496-504. 
5. Puy H, Gouya L, Deybach JC. Porphyrias. Lancet. 2010 Mar 13;375(9718):924-37.
6. Floderus Y, Sardh E, Moller C, Andersson C, Rejkjaer L, Andersson DE, et al. Variations in
porphobilinogen and 5-aminolevulinic acid concentrations in plasma and urine from 
asymptomatic carriers of the acute intermittent porphyria gene with increased porphyrin 
precursor excretion. Clin Chem. 2006 Apr;52(4):701-7. 
7. Anderson K. Disorders of heme biosynthesis. 8th ed. CR S, editor: McGraw-Hill, New York
2001. 
8. Dowman JK, Gunson BK, Mirza DF, Bramhall SR, Badminton MN, Newsome PN. Liver
transplantation for acute intermittent porphyria is complicated by a high rate of hepatic artery 
thrombosis. Liver Transpl. 2012 Feb;18(2):195-200. 
9. Badminton MN, Elder GH. Molecular mechanisms of dominant expression in porphyria. J
Inherit Metab Dis. 2005;28(3):277-86. 
10. Deybach J-C, Puy H. 86 - Acute Intermittent Porphyria: From Clinical to Molecular Aspects.
In: Guilard KMKMS, editor. The Porphyrin Handbook. Amsterdam: Academic Press; 2003. p. 
23-41. 
11. Bylesjo I, Wikberg A, Andersson C. Clinical aspects of acute intermittent porphyria in
northern Sweden: a population-based study. Scand J Clin Lab Invest. 2009;69(5):612-8. 
12. James MF, Hift RJ. Porphyrias. Br J Anaesth. 2000 Jul;85(1):143-53.
13. Chemmanur AT, Bonkovsky HL. Hepatic porphyrias: diagnosis and management. Clin Liver
Dis. 2004 Nov;8(4):807-38, viii. 
14. Stein P, Badminton M, Barth J, Rees D, Stewart MF. Best practice guidelines on clinical
management of acute attacks of porphyria and their complications. Ann Clin Biochem. 2013 
May;50(Pt 3):217-23. 
15. Bonkovsky HL. Neurovisceral porphyrias: what a hematologist needs to know. Hematology
Am Soc Hematol Educ Program. 2005:24-30. 
16. Panhematin. (hemin for injection). 2013.
17. Normosang. (human hemin). 2007.
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18. Watson CJ, Pierach CA, Bossenmaier I, Cardinal R. Postulated deficiency of hepatic heme
and repair by hematin infusions in the "inducible" hepatic porphyrias. Proc Natl Acad Sci U S A. 
1977 May;74(5):2118-20. 
19. Mustajoki P, Nordmann Y. Early administration of heme arginate for acute porphyric attacks.
Arch Intern Med. 1993 Sep 13;153(17):2004-8. 
20. Bonkovsky HL, Singh RH, Jafri IH, Fiellin DA, Smith GS, Simon D, et al. A randomized,
controlled trial of treatment of alcoholic hepatitis with parenteral nutrition and oxandrolone. II. 
Short-term effects on nitrogen metabolism, metabolic balance, and nutrition. Am J Gastroenterol. 
1991 Sep;86(9):1209-18. 
21. Herrick AL, McColl KE, Moore MR, Cook A, Goldberg A. Controlled trial of haem arginate
in acute hepatic porphyria. Lancet. 1989 Jun 10;1(8650):1295-7. 
22. Bissell DM. Treatment of acute hepatic porphyria with hematin. J Hepatol. 1988 Feb;6(1):1-
7. 
23. Green D, Ts'ao CH. Hematin: effects on hemostasis. J Lab Clin Med. 1990 Feb;115(2):144-
7. 
24. Daimon M, Susa S, Igarashi M, Kato T, Kameda W. Administration of heme arginate, but
not hematin, caused anaphylactic shock. Am J Med. 2001 Feb 15;110(3):240. 
25. Elder G, Harper P, Badminton M, Sandberg S, Deybach JC. The incidence of inherited
porphyrias in Europe. J Inherit Metab Dis. 2013 Sep;36(5):849-57. 
26. Anderson K. Heme arginate for prevention of acute porphyric attacks (abstract). Acta
Haematologica. 1997;98((suppl 1):120). 
27. Bonkovsky HL, Guo JT, Hou W, Li T, Narang T, Thapar M. Porphyrin and heme
metabolism and the porphyrias. Compr Physiol. 2013 Jan;3(1):365-401. 
28. Vaishnaw AK, Gollob J, Gamba-Vitalo C, Hutabarat R, Sah D, Meyers R, et al. A status
report on RNAi therapeutics. Silence. 2010;1(1):14. 
29. Elbashir SM, Harborth J, Lendeckel W, Yalcin A, Weber K, Tuschl T. Duplexes of 21-
nucleotide RNAs mediate RNA interference in cultured mammalian cells. Nature. 2001 May 
24;411(6836):494-8. 
30. Kauppinen R, von und zu Fraunberg M. Molecular and biochemical studies of acute
intermittent porphyria in 196 patients and their families. Clin Chem. 2002 Nov;48(11):1891-900. 
31. Division of Clinical Pharmacology, Indiana University, P450 Drug Interaction Table.  2013 [
Accessed 06 February 2015]; Available from: http://medicine.iupui.edu/clinpharm/ddis/main-
table/. 
32. Atkinson TM M, TR, Sit L, Passik P, Scher, HI, Cleeland C, and Basch E. The Brief Pain
Inventory and its “Pain at its Worst in the last 24 Hours” Item: Clinical Trial Endpoint 
Considerations. Pain Med. 2010 March;11(3):337–46. 
33. Levey AS SL, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, Kusek JW, Eggers P,
Van Lente F, Greene T, Coresh J; CKD-EPI (Chronic Kidney Disease Epidemiology 
Collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med. 
2009;150(9):604-12. 
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34. Herdman M GC, Lloyd A, Janssen M, Kind P, Parkin D, Bonsel G, Badia X. Development
and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res. 
2011;20(10):1727-36. 
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11.
APPENDICES
11.1. 
Pharmacokinetic Assessment Time Points 
Table 3 contains a detailed schedule for the collection of blood samples for PK analysis. 
Table 3: 
Pharmacokinetic Time Points 
Study Day 
Protocol Time 
(hh:mm) 
PK Blood 
Day 1 and 
Month 12 (D361) ±10 days 
Predose (within 60 minutes 
before dosing) 
X 
02:00 (±5 minutes) 
X 
06:00 (±20 minutes) 
X 
Month 1 (Day 31) ±7 days,  
Month 3 (Day 91) ±7 days, 
Month 6 (Day 181) ±7 days, 
Month 18 (Day 541) ±10, and 
Month 24 (Day 721) ±10 days 
Predose (within 60 minutes 
before dosing) 
X 
02:00 (±5 minutes) 
X 
Abbreviations:  hh=hours; mm=minutes; PK=pharmacokinetic. 
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11.2. 
Schedules of Assessments for Every Month Dosing Regimen 
Table 4: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Informed Consent 
X 
Medical History/Disease 
Historyc 
X
X
Demographics 
X
Inclusion/ 
Exclusion Criteria 
X
X 
Physical Examinationd 
X
X
X 
X 
X 
X 
X 
X 
X 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Vital Signsf 
X 
X 
X 
X 
X
X
X
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGg 
X 
X 
X 
X 
Clinical Laboratory 
Assessmenth 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationj 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine Sample for PBG, ALA, 
and Creatinine Analysisk 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl 
X 
X 
X 
X 
X 
X 
X 
X 
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Table 4: 
Schedule of Assessments:  Screening/Baseline through Month 18 (Every Month Dosing Regimen) 
Study Visit (M) 
Screening/ 
Baselinea 
Treatment Period 
(Screening/Baseline through Month 18) 
M1 
M2 
M3 
M4/ 
M5 
M6  
M7/ 
M8b 
M9 
M10/ 
M11b 
M12 
M13/ 
M14b 
M15b 
M16/ 
M17b 
M18 
Study Visit (D±Visit 
Window) 
-60 to -1 
D1 
D31±7 
D61±7 
D91±7 
D121±7/ 
D151±7 
D181±7 
211±7/ 
241±7 
271±10 
301±7/ 
331±7 
361±10 
391±7/ 
421±7 
451±10 
481±7/ 
511±7 
541±10 
Blood Sample for PK 
Analysism 
X 
X 
X 
X 
X 
X 
Antidrug Antibodiesn 
X 
X 
X 
X 
X 
X 
Porphyria Attack Laboratory 
Sample Collection Kit and 
Instructionso 
X 
EQ-5D-5L Questionnairep 
X 
X 
X 
X 
Diary Review (including 
BPI-SF)q 
X 
AEs 
Continuous 
Concomitant Medicationsr 
Continuous 
Abbreviations:  AE=adverse event; ALAS1=5-aminolevulinic acid synthase 1; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain 
Inventory-Short Form; D=day; ECG=electrocardiogram; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality of life; 
SC=subcutaneous. 
Notes:   
•
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be
conducted while the patient is at home.
•
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations and
blood/urine sample collections.
a Patients are not required to complete Screening/Baseline assessments if the assessments in the previous study (ALN-AS1-001) were completed within 60 days 
of administration of the first dose of ALN-AS1 in this study.  If more than 60 days have elapsed since the last assessment, clinical laboratory tests and ECGs 
will be repeated before administration of ALN-AS1.  Results should be available before the administration of the first dose of ALN-AS1. 
b After a patient has completed 6 months of ALN-AS1 administration in this study, and where applicable country and local regulations and infrastructure allow, 
study visits and ALN-AS1 administration may take place at the patient’s home by a healthcare professional.  Home visits may occur at the discretion of the 
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Investigator, based on safety and tolerability; however, patients are required to complete at least 1 visit at the clinical study center Q3M through M12, and 
thereafter Q6M. 
c See Section 7.1 for details on the interval medical history/disease history to be recorded at Screening/Baseline.  Ongoing AEs from the previous study 
(ALN-AS1-001) will be captured as medical history. 
d A complete physical examination will be performed at Screening/Baseline, and D1.  At all other visits, a targeted physical examination will be performed.  On 
dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any time 
during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, oral body temperature, and respiratory rate.  On D1, vital signs will be collected within 1 hour predose; and 
2 hours (±10 minutes) postdose.  On all other dosing days, vital signs will be collected within 1 hour predose.  On days when ALN-AS1 is not administered, 
vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine position (should be consistent for each patient), 
after the patient has rested comfortably for 10 minutes. 
g Triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 10 minutes.  On D1, ECGs will be 
performed within 1 hour predose and 2 hours (±10 minutes) postdose.  On all other dosing days, ECGs will be collected within 1 hour predose. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected within 1 hour 
predose; results are not required before dosing.  On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. 
i A serum pregnancy test will be performed at Screening/Baseline; thereafter, urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  For weight-
based dosing, weight measured on the dosing day will be used to calculate the dose of ALN-AS1.  After M12, weight measured on the nearest previous visit 
will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 3 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o Urine samples should be collected within 24 hours of the start of clinical intervention for a porphyria attack (eg, hemin or glucose administration) and within
24 hours of the end of clinical intervention for a porphyria attack through M39.  If patients are unable to report to the clinical study center during a porphyria
attack, laboratory sample collection kits will be provided that contain instructions for collecting and sending urine samples to the clinical study center, if
possible.  These urine samples may also be analyzed for exploratory biomarkers.
p In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack 
(but not more than once in a 6 month period), if possible.  
q Patients or caregivers will be provided with a diary to record acute porphyria attacks, pain assessments, and narcotic use on a daily basis through M9; 
thereafter, acute porphyria attacks will be recorded in the diary.  The BPI will be completed on a weekly basis as part of the patient diary through M9, then 
Q3M. 
r Medications that are ongoing from the previous study (ALN-AS1-001), started between the previous study and this study, and started after signing informed 
consent in this study, will be captured as concomitant medication(s). 
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Table 5: 
Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20a 
M21a 
M22/ 
M23a 
M24 
M25/ 
M26a 
M27a 
M28/ 
M29a 
M30 
M31/ 
M32a 
M33a 
M34/ 
M35a 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Physical Examinationd 
X 
X 
X 
X 
Body Weight, BMI, and 
Heighte 
X 
X 
X 
Vital Signsf 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Triplicate 12-Lead ECGg 
X 
X 
Clinical Laboratory 
Assessmenth 
X 
X 
X 
X 
X 
X 
X 
Pregnancy Testi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Drug Administrationj 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine Sample for PBG, 
ALA, and Creatinine 
Analysisk 
X 
X 
X 
X 
X 
X 
X 
X 
Blood and Urine Sample for 
Exploratory Biomarker 
Analysisl  
X 
X 
X 
X 
Blood Sample for PK 
Analysism 
X 
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Table 5: 
Schedule of Assessments:  Month 19 through End of Study (Every Month Dosing Regimen) 
Study Visit (M) 
Treatment Period 
(Month 19 through EOS) 
Posttreatment 
Follow-up 
ALA/PBG 
Monitoring/
EOSc 
M19/ 
M20a 
M21a 
M22/ 
M23a 
M24 
M25/ 
M26a 
M27a 
M28/ 
M29a 
M30 
M31/ 
M32a 
M33a 
M34/ 
M35a 
M36/ 
EOT 
M39b 
M42 
Study Visit (D±Visit 
Window) 
571±7/601±7 
631±10 
661±7/691±7 
721±10 
751±7/781±7 
811±10 
841±7/871±7 
901±10 
931±7/961±7 
991±10 
1021±7/1051±7 
1081±10 
1171±10 
1351±10 
Antidrug Antibodiesn 
X 
X 
EQ-5D-5L Questionnaireo 
X 
X 
X 
Diary Review (including 
BPI-SF)p 
X 
AEs 
Continuous 
Concomitant Medications 
Continuous 
Abbreviations:  AE=adverse event; ALA=delta-aminolevulinic acid; BMI=body mass index; BPI-SF=Brief Pain Inventory-Short Form; D=day; 
ECG=electrocardiogram; EOS = End of Study; EOT = End of Treatment; M=month; PBG= porphobilinogen; PK=pharmacokinetics; Q=every; QOL=quality 
of life; SC=subcutaneous. 
Notes:   
•
White boxes represent visits to the clinical study center or when patients will be contacted by phone; grey boxes represent study visit that may be
conducted while the patient is at home.
•
When scheduled at the same time points, assessments of vital signs and 12-lead ECGs should be performed first, before the physical examinations
and blood/urine sample collections.
a Where applicable country and local regulations and infrastructure allow, study visits and ALN-AS1 administration may take place at the patient’s home by a 
healthcare professional.  Home visits may occur at the discretion of the Investigator, based on safety and tolerability; however, patients are required to complete 
at least 1 visit at the clinical study center Q6M. 
b Patients who discontinue treatment will be asked to complete the M39 visit assessments.  If a patient chooses to withdraw from the study, every effort should 
be made to conduct early the assessments performed at the M39 visit.  See Section 5.3 for details on removal from treatment or assessment. 
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c The ALA/PBG Monitoring/EOS visit will be conducted at the clinical study center or via phone contact, unless treatment continues with ALN-AS1.  Patients 
will be provided with laboratory sample collection kits and instructions for collecting and sending urine samples to the clinical study center.  Urine samples 
should not be collected during a porphyria attack. 
d A complete physical examination will be performed at the posttreatment follow-up visit.  At all other visits, a targeted physical examination will be performed. 
On dosing days, the physical examination will be performed predose.  On days when ALN-AS1 is not administered, the physical examination can occur at any 
time during the visit.  See Section 7.5.3 for details on the physical examination. 
e Height will be measured at Screening/Baseline only. 
f Vital signs include blood pressure, heart rate, oral body temperature, and respiratory rate.  On a dosing days, vital signs will be collected within 1 hour predose. 
On days when ALN-AS1 is not administered, vital signs can be collected at any time during the visit.  Vital signs will be measured in the seated or supine 
position (should be consistent for each patient), after the patient has rested comfortably for 10 minutes. 
g Triplicate 12-lead ECGs will be performed in the seated or supine position after the patient has rested comfortably for 10 minutes.  On dosing days, ECGs will 
be collected within 1 hour predose. 
h Clinical laboratory parameters are described in Section 7.5.5.  On dosing days, blood samples for clinical laboratory evaluations will be collected within 1 hour 
predose; results are not required before dosing.  On days when ALN-AS1 is not administered, blood samples can be collected at any time during the visit. 
i Urine pregnancy tests will be performed.  Results must be available before dosing. 
j ALN-AS1 will be administered by SC injection according to the Pharmacy Manual.  See Section 6.2.2 for ALN-AS1 dose and dosing regimen.  Weight 
measured on the nearest previous visit will be used to calculate the weight-based dose of ALN-AS1. 
k Spot urine samples will be collected for measurement of ALA, PBG, and creatinine levels.  On dosing days, samples should be collected predose. 
l On dosing days, blood and urine samples for ALAS1 mRNA (and possible biomarker) analysis will be collected within 1 hour predose. 
m Blood samples for PK analysis will be collected at the time points listed in Table 3 (Appendix Section 11.1). 
n On dosing days, blood samples for antidrug antibody analysis should be collected within 1 hour predose. 
o In addition to the time points indicated, the EQ-5D-5L questionnaire should be completed once during the treatment period if a patient has a porphyria attack
(but, not more than once in a 6 month period), if possible.
p Patients or caregivers will be provided with a diary to record acute porphyria attacks.  The BPI will be completed as part of the patient diary Q3M. 
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