A Randomized, Double-blinded, Placebo-controlled, Clinical Study of the Effects of a Nutraceutical Combination on LDL Cholesterol Levels in Subjects With Sub-optimal Blood Cholesterol Levels
Phase: NA
Conditions: Hypercholesterolemia
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l.

              Menarini Group 
                         
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 1 of 52 
 
  
 
 
 
 
 
 
CLINICAL STUDY PROTOCOL 
 
 
Title: A randomized, double-blinded, placebo-controlled, clinical study of the effects of a 
nutraceutical combination on LDL cholesterol levels in subjects with sub-optimal blood 
cholesterol levels. (Acronym: NATCOL) 
 
Study code: MEIF/16/MOF-Col/001 
 
Study type and design: A clinical, exploratory, monocentric, interventional, non-drug, 
randomized, placebo-controlled, double-blinded, parallel-group study. 
Amended Protocol version n°: 4.0               Release Date: 16.04.2018 
 
 
Principal Investigator: 
  
Prof. Claudio Borghi 
Ambulatorio Dislipidemie e Aterosclerosi/Ambulatorio per la Diagnosi 
e Cura dell’Ipertensione  
Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater 
Studiorum Università di Bologna 
Phone: +39.051.2142843 - Fax: +39.051.391320 
 
CRO:   
 
 
 
OPIS s.r.l. 
Via Matteotti 10, 20832 Desio (MB), Italy 
Phone: + 39 0362 6331 - Fax: +39.0362.633633 
E-mail: office@opis.it 
 
Sponsor: 
 
 
 
A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
Offices: Via dei Sette Santi 3, 50131 Firenze  
Phone: +39.055.5680.1 – Fax: +39.055.58.27.71 
 
 
CONFIDENTIALITY STATEMENT 
The information in this document contains trade secrets and commercial information that are privileged or confidential and may not 
be disclosed unless such disclosure is required by law. In any event, persons to whom the information is disclosed must be informed 
that the information is privileged or confidential and may not be further disclosed by them. These restrictions on disclosure will apply 
equally to all future information supplied to you that is indicated as privileged or confidential. 
 

              Menarini Group 
                         
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 2 of 52 
 
  
 
 
 
 
 
 
SUMMARY OF CHANGES 
Amendment 3 (non-substantial amendment) 
Amendment rationale 
The purpose of this non-substantial amendment is to no longer use a portable device (4 in 1 Mission 
Cholesterol Meter) for the evaluation of inclusion criteria LDL-C 115 – 190 mg/dL and TG < 400 mg/dL 
during Visit 2 - Baseline. The protocol originally called for the use of a portable device (4 in 1 Mission 
Cholesterol Meter) that provided immediate results and thus allowed the confirmation of eligibility and 
subsequent randomization at the same visit. The results from the portable device were however found to 
be inconsistent with those of the laboratory run on blood drawn during the same visit and led to patients 
being incorrectly excluded from the study due to screening failure. LDL-C and TG eligibility criteria will now 
be confirmed only through the blood sample evaluated by local laboratory at Visit 2 - Baseline. If eligibility 
is confirmed, the patient will be asked to return no later than 3 days after V2 for randomization and treatment 
dispensation. 
Changes to the protocol 
Changes to specific sections of the protocol are shown in the track changes version of the protocol using 
strike through font for deletions and underlined font for insertions.  
Section 6, Section 9, Section 11, the flow chart in Section 2.2 and the Protocol Synopsis in Section 2 have 
been modified to reflect the changes described in the amendment rationale. 
A typographic error in the eGFR value that defines chronic renal failure has also been corrected in Section 
7.2 and Protocol Synopsis. 
The changes in the protocol affect the Informed Consent. Therefore, a revised Informed Consent that 
reflects the changes described in this protocol amendment will be provided. None of the changes made are 
due to safety concerns and none have an impact on the conduct of the trial or alter in any way the treatment 
of study subjects. Based on these premises, the amendment will be submitted to the Ethics Committee as 
a non-substantial amendment. 
 
Amendment 2 (non-substantial amendment) 
Amendment rationale 
The purpose of this non-substantial amendment was to correct errors in the “General Guidelines for a Proper 
Mediterranean Style Diet”. 
Changes to the protocol 
The “General Guidelines for a Proper Mediterranean Style Diet” in Appendix 1 were modified. 
 
Amendment 1 (non-substantial amendment) 
Amendment rationale 
The purpose of this non-substantial amendment was to provide detailed diet guidelines so that the diets 
among patients in the two treatment groups could be as similar as possible. 
Changes to the protocol 
The “General Guidelines for a Proper Mediterranean Style Diet” were added to the protocol as Appendix 1. 

              Menarini Group 
                         
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 3 of 52 
 
  
 
 
 
 
 
 
 
T AB L E  O F  C O N T E N T S  
1.
RESPONSIBILITIES ..................................................................................................................................... 5
2.
PROTOCOL SYNOPSIS ............................................................................................................................... 6
2.1
STUDY SCHEME: ............................................................................................................................................. 12
2.2
STUDY FLOW CHART ....................................................................................................................................... 13
3.
ABBREVIATIONS ....................................................................................................................................... 14
4.
BACKGROUND INFORMATION ............................................................................................................. 15
5.
TRIAL OBJECTIVES AND PURPOSE ..................................................................................................... 16
6.
STUDY DESIGN ........................................................................................................................................... 17
7.
SELECTION AND WITHDRAWAL OF SUBJECTS .............................................................................. 19
7.1
INCLUSION CRITERIA ........................................................................................................................................ 20
7.2
EXCLUSION CRITERIA ....................................................................................................................................... 20
7.3
WITHDRAWAL CRITERIA ................................................................................................................................... 21
8.
TREATMENT OF SUBJECTS ................................................................................................................... 22
8.1
TREATMENTS .................................................................................................................................................. 22
8.2
BLINDING PROCEDURES ................................................................................................................................... 22
8.3
METHOD OF ASSIGNING PATIENTS TO TREATMENT GROUP .................................................................................. 23
8.4
PACKAGING, LABELING AND STORAGE ............................................................................................................... 23
8.5
TREATMENT ACCOUNTABILITY AND COMPLIANCE ............................................................................................... 24
8.6
CONCOMITANT MEDICATIONS ........................................................................................................................... 24
9.
ASSESSMENT OF PRIMARY AND SECONDARY VARIABLES ........................................................ 24
9.1
LABORATORY PARAMETERS ............................................................................................................................. 24
9.2
ENDOTHELIAL REACTIVITY (ENDOCHECK®) ........................................................................................................ 25
9.3
OTHER VARIABLES ........................................................................................................................................... 25
10. ASSESSMENT OF SAFETY ....................................................................................................................... 26
10.1
ADVERSE EVENTS (AE).................................................................................................................................... 26
10.2
MANAGEMENT OF ANY LABORATORY ABNORMALITY .......................................................................... 27
10.3
MANAGEMENT OF PREGNANCY EXPOSURE CASES ............................................................................................. 27
11. STATISTICS ................................................................................................................................................. 28
11.1
STATISTICAL METHODS (BLINDING AND RANDOMIZATION) ................................................................................... 28

              Menarini Group 
                         
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 4 of 52 
 
  
 
 
 
 
 
 
11.2
DETERMINATION OF SAMPLE SIZE ..................................................................................................................... 29
11.3
ANALYSIS POPULATIONS .................................................................................................................................. 29
11.4
ANALYSIS VARIABLES ....................................................................................................................................... 30
11.5
STATISTICAL ANALYSIS .................................................................................................................................... 30
11.6
SUBGROUP ANALYSIS ...................................................................................................................................... 33
11.7
PROTOCOL VIOLATIONS AND BLIND REVIEW ....................................................................................................... 33
11.8
STATISTICAL ANALYSIS PLAN ............................................................................................................................ 33
12. DIRECT ACCESS TO SOURCE DATA/DOCUMENTS ......................................................................... 34
13. QUALITY CONTROL AND QUALITY ASSURANCE ........................................................................... 34
13.1
DATA QUALITY CONTROL/STUDY MONITORING ................................................................................................. 34
13.2
CASE REPORT FORMS ..................................................................................................................................... 34
13.3
QUALITY ASSURANCE ...................................................................................................................................... 34
14. ETHICAL ASPECTS ................................................................................................................................... 35
14.1
ETHICS COMMITTEES....................................................................................................................................... 35
14.2
INSURANCE ..................................................................................................................................................... 35
15. DATA PROTECTION LAWS COMPLIANCE ........................................................................................ 35
16. DATA HANDLING AND RECORDS KEEPING ..................................................................................... 38
17. PUBLICATION POLICY AND RESULTS ............................................................................................... 38
18. REFERENCES .............................................................................................................................................. 39
19. PUBLIC PROTOCOL APPROVAL PAGE ............................................................................................... 41
20. INVESTIGATOR’S APPROVAL PAGE ................................................................................................... 42
21. APPENDICES ............................................................................................................................................... 43
21.1
APPENDIX 1: GENERAL GUIDELINES FOR A PROPER MEDITERRANEAN STYLE DIET ............................................. 43
21.2
APPENDIX 2: DECLARATION OF HELSINKI .......................................................................................................... 46
 
 
 

              Menarini Group 
                         
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 5 of 52 
 
  
 
 
 
 
 
 
1. RESPONSIBILITIES 
 
Sponsor:  
 
 
 
A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
Offices: Via dei Sette Santi 3, 50131 Firenze  
Phone: +39.055.5680.1 – Fax: +39.055.58.27.71 
 
Clinical Trial Coordinator: 
  
Dr. Matteo Molli 
 
  
A. Menarini Farmaceutica Internazionale S.r.L. 
 
  
Via Sette Santi 1, 50131 Florence 
 
  
Phone: +39.055.5680.7626 – Mobile: +39.329.1728.707 
 
  
mmolli@menarini.it 
 
Study Medical Expert (SME):  
Dr. Meto Suada 
 
  
A. Menarini Farmaceutica Internazionale S.r.L. 
 
  
Via Sette Santi 1, 50131 Florence 
                   Phone: +39.055.5680.7893 – Fax: +39.055.5680.9710 
 
E-mail: smeto@menarini.it 
 
Principal Investigator:  
  
Prof. Claudio Borghi 
Ambulatorio Dislipidemie e Aterosclerosi/Ambulatorio per 
la Diagnosi e Cura dell’Ipertensione  
Dipartimento di Scienze mediche e chirurgiche, Alma 
Mater Studiorum Università di Bologna 
Phone: +39.051.2142843 – Fax: +39.051.391320 
 
CRO:  
  
OPIS s.r.l. 
 
  
Dr. Laura Ambrosoli – Medical Director 
 
  
Via Matteotti, 10, 20832 Desio (MB), Italy 
 
  
Phone: + 39.0362.6331 – Fax: +39.0362.633.633 
 
  
E-mail: laura.ambrosoli@opis.it 
 
Statistician:  
  
Dr. Chiara Costantini 
 
  
OPIS s.r.l. 
 
  
Via Matteotti, 10, 20832 Desio (MB), Italy 
 
Phone: +39 0362 633403 – Fax: 39.0362.633655 
 
E-mail: chiara.costantini@opis.it 

              Menarini Group 
                         
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 6 of 52 
 
  
 
 
 
 
 
 
 
  
2. PROTOCOL SYNOPSIS 
 
Title 
 
 
Study Code: 
A randomized, double-blinded, placebo-controlled, clinical study of the effects 
of a nutraceutical combination on LDL cholesterol levels in subjects with sub-
optimal blood cholesterol levels. 
 
MEIF/16/MOF-Col/001 
Investigational Product 
Reference Therapy 
(comparator) 
Dose Regimen 
Phytosterols 800 mg + DIF1STAT® (containing fermented red rice titrated in 5 
mg monacolin K).  
Placebo for oral administration identical in appearance, size, shape, weight 
and taste to the active product.  
Both administered as one tablet, per os, per day in the evening. 
Study Type and Design 
This is an exploratory, monocentric, interventional, non-drug, randomized, 
double-blinded, placebo-controlled, parallel-group study. 
Background and 
Rationale 
High cholesterol is one of the major controllable risk factors for coronary heart 
disease. 
Numerous preclinical and clinical studies have demonstrated that drugs that 
reduce the intestinal absorption of cholesterol (ex. ezetimibe), or block the 
hepatic synthesis of cholesterol (statins) or the association of both can reduce 
cholesterolemia and are associated with reduced rate of cardiovascular 
events.  
The search for natural alternatives to this approach includes the evaluation of 
the single and associated effects of nutritional inhibitors of dietary cholesterol 
absorption and endogenous hepatic synthesis. 
Phytosterols are plant sterols structurally similar to cholesterol that act in the 
intestine to lower cholesterol absorption and effectively reduce LDL-
cholesterolemia.  
Since they have very low systemic absorption, increasing the intake of 
phytosterols may be a practical way to reduce cholesterol levels.  
Chinese red yeast rice is a dietary supplement made by fermenting the yeast, 
Monascus purpureus, over rice. Monascus yeast produces a family of 
substances called monacolins, including monacolin K.  

              Menarini Group 
                         
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 7 of 52 
 
  
 
 
 
 
 
 
Monacolins act as reversible inhibitors of the 3-hydroxy-3-methyl-glutaryl-
coenzyme A (HMG-CoA) reductase, a key enzyme in cholesterol 
biosynthesis. Besides the inhibition of HMG-CoA reductase, red yeast rice has 
been found to contain sterols, isoflavones and isoflavone glycosides, and 
monounsaturated fatty acids, all capable of lowering LDL cholesterol. 
Aim of the Study 
The purpose of this study is to evaluate the effect of a combination of 
phytosterols and DIF1STAT® (fermented red rice titrated in 5 mg monacolin 
K), on modulation of lipid profile and other biomarkers in subjects with sub-
optimal blood cholesterol levels. 
Primary Objective 
To evaluate the effect of a nutraceutical combination over an 8-weeks period, 
on blood LDL-cholesterol levels in subjects with sub-optimal blood cholesterol 
levels. 
Secondary Objectives 
To evaluate the effect of a nutraceutical combination on the following 
parameters following 8-weeks treatment, in subjects with sub-optimal blood 
cholesterol levels: 
• 
Total blood cholesterol levels 
• 
Blood HDL-cholesterol levels 
• 
Blood non-HDL cholesterol levels 
• 
Blood triglyceride levels 
• 
Apolipoprotein B levels 
• 
TC/HDL and LDL-C/HDL risk ratios 
• 
Endothelial reactivity (Endocheck®) 
• 
Glycemia, ALT, AST gamma-GT, creatinine, uric acid, CPK 
Number and 
characteristics of Patients 
Ninety (90) subjects with sub-optimal blood LDL-cholesterol levels. 
Number of Centers & 
Countries  
One Italian center  
Study Duration (specify 
different study phases) 
 
Enrollment period: 6 months  
Screening period: 2 weeks 
Treatment period: 8 weeks 
The study will last 10 weeks per patient. 

              Menarini Group 
                         
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 8 of 52 
 
  
 
 
 
 
 
 
Study Procedures  
The study is made up of four visits distributed over a 10-weeks period: 
V 1 (day -14) – Screening: Subjects will be enrolled into the study within their 
normal health-care program. After providing written informed consent, tests 
will be run in order to check the subject’s eligibility for the study. Subjects will 
also be given suggestions regarding their diet (a Mediterranean-style diet is 
to be maintained for the entire duration of the study – see Appendix 1 of the 
protocol). 
V2 (baseline) and Day 0 (randomization): After confirmation of the subject’s 
eligibility (LDL-C and TG criteria confirmed with blood test results), eligible 
subjects will be randomized within 3 days to one of the two treatment groups 
(phytosterols 800 mg + DIF1STAT® or placebo). During this visit (Visit 2 - 
baseline) an endothelial reactivity test (Endocheck®) will be performed.  
V3 (28 ±3 days after Day 0) – Intermediate: Blood will be drawn for tests and 
compliance with treatment will be assessed.  
V4 (28 ± 3 days after Visit 3) – End of study: Blood tests and an endothelial 
reactivity test (Endocheck®) will be performed and treatment compliance will 
be assessed. 
Weight, waist circumference, Index of Central Obesity (ICO) and Body Mass 
Index (BMI), Hepatic Steatosis Index (HSI) and Lipid Accumulation Product 
(LAP) will be measured/calculated at each visit, height at Visit 1.  
Heart rate and blood pressure will be measured at each visit. 
This study will be conducted in a double-blinded manner. Patients will be 
assigned to a treatment according to a computer-generated randomization list 
produced by the trial statistician. Code break cards will be kept at the study 
center and may be opened to reveal what treatment the patient is taking in 
case of emergency. 
Inclusion Criteria 
Subjects must meet all of the following inclusion criteria: 
• 
Age 30-75 years 
• 
LDL-cholesterol = 115 -190 mg/dL 
• 
Triglycerides < 400 mg/dL 
• 
Any cardiovascular therapy should be stable for type and dose for at 
least three months 
• 
Signed, written informed consent 
Exclusion Criteria 
Subjects must meet none of the following exclusion criteria: 

              Menarini Group 
                         
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 9 of 52 
 
  
 
 
 
 
 
 
• 
Intolerance to any ingredient of dietary supplement 
• 
Patients already suffering from cardiovascular diseases or at high risk of 
developing cardiovascular diseases 
• 
Myopathies 
• 
Uncontrolled diabetes mellitus based on PI judgment 
• 
Chronic renal failure (defined as eGFR <60ml/min/1.73m2) or liver failure 
(defined as AST and /or ALT>3 ULN) 
• 
Body Mass Index > 32 kg/m2 
• 
Therapy with statins or other drugs or supplements with effects on lipid 
metabolism 
• 
Patients with acquired immunodeficiency 
• 
Treatment with immunosuppressants 
• 
Pregnant or breastfeeding women 
• 
Women of childbearing potential not willing to use effective birth control 
methods 
• 
Patients participating or having participated in another clinical trial within 
the previous 3 months 
• 
Current or recent history of drug or alcohol addiction based on PI 
judgment 
Study Variables 
• 
Primary Variable: 
The primary variable of the study is the change in blood LDL cholesterol level 
from baseline (V2) to Week 8 (V4). 
• 
Secondary Variables 
The secondary variables of the study are defined as the change from baseline 
(V2) to Week 8 (V4) in the following parameters: 
o Total blood cholesterol level 
o Blood HDL cholesterol level 
o Blood non-HDL cholesterol level 
o Blood triglycerides level 
o Apolipoprotein B level 

              Menarini Group 
                         
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 10 of 52 
 
  
 
 
 
 
 
 
o Total cholesterol /HDL cholesterol ratio 
o LDL cholesterol/HDL cholesterol ratio 
o Pulse Volume (PV) waveform (endothelial reactivity) 
o Glycemia, AST, ALT, Gamma-GT, serum creatinine, serum uric acid, 
CPK 
• 
Other Variables 
o Change from baseline at each assessment time point for each 
laboratory parameter  
o Adverse Events 
o Vital Signs 
o Weight 
o Height 
o Waist Circumference 
o Index of Central Obesity (ICO) 
o Body Mass Index (BMI) 
o Hepatic Steatosis Index (HSI) 
o 
Lipid Accumulation Product (LAP) 
Statistical Assumptions 
Patients will be randomized to one of the two treatment arms in a 1:1 ratio 
(phytosterols 800 mg + DIF1STAT® or placebo). 
A patient randomization list, and its respective randomization cards, will be 
generated by means of a validated computerized system. Patients, 
investigators, site personnel, and data analysis will remain blinded to the 
identity of the treatment administered from the time of randomization until 
database lock. Unblinding will only occur in case of patient emergencies and 
at the conclusion of the study. 
Justification of Sample Size 
Considering the primary endpoint of the study as the reduction from baseline 
to week 8 in LDL cholesterol level and the data available from literature 
[Phytomedicine. 2016 Oct 15; 23(11):1113-8], a reduction of LDL level of 
approximately 10% is expected after the intake of the nutraceutical, the total 
number of patients to be evaluated should be 35 per treatment arm in a 1:1 
ratio (NQuery Advisor, 7.0). Allowing for an approximate 20% dropout rate, at 
least 88 patients should be randomized: 44 patients in each treatment group.

              Menarini Group 
                         
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 11 of 52 
 
  
 
 
 
 
 
 
 
Analysis populations: 
Full Analysis Set (FAS): all patients to whom study treatment has been 
assigned by randomization and who have the assessment for LDL cholesterol 
at visit 4 (week 8). The primary and secondary analyses will be based on the 
FAS. 
Per Protocol (PP) Set: all patients in the FAS who have no major protocol 
deviations. Results of the primary analysis conducted in the PP set will be 
considered as supportive. 
Tolerability Set: all patients who received at least one dose of study 
medication. Patients will be analyzed according to the treatment they actually 
received.  
Statistical analyses  
Summary statistics of raw data and change from baseline at each assessment 
time point for LDL cholesterol level will be presented overall and by treatment 
group. An analysis of covariance (ANCOVA) model will be estimated on the 
changes from baseline to Week 8 in LDL cholesterol levels considering 
treatment group as factor and baseline value of LDL cholesterol as continuous 
covariate. Results will be reported as Least-Square Means together with 
associated two-tailed 95% CI and p-value. If the assumption of normality of 
residuals is violated, the ANCOVA model will be fitted on rank transformed 
data. 
No alpha level adjustment for multiplicity will be adopted. 
The same statistical models described for the analysis of the primary variable 
will be applied to the secondary variables. 
No technique for missing data imputation will be adopted. 
 
 
 
 
 
 
 
 

              Menarini Group 
                         
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 12 of 52 
 
  
 
 
 
 
 
 
2.1 
Study Scheme:   
  
 
 
 
Treatment A  
  
 
 
      (Phytosterols/DIF1STAT®) ------------------------------------------------ 
 Screening ---- // Randomization        
  
 
 
 
Treatment B  
  
 
 
 
   (Placebo) --------------------------------------------------------- 
      V1  
 
 
V2 
 
 
    V3 
 
 
    V4 
      I 
----- 2 wks ----  
I 
 ----4 wks ----          I         ---- 4 wks ---         I 

              Menarini Group 
                         
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 13 of 52 
 
  
 
 
 
 
 
 
2.2 
Study Flow Chart 
 
Day -14 
 
Day 0 
 
Day 28 (± 3) 
Day 56 (± 3) 
Visit 1^ 
Visit 2^§ 
Visit 3^ 
Visit 4^ 
Screening 
Baseline 
Intermediate  
End of study  
Informed consent 
 
 
 
Inclusion/exclusion criteria 
 
 
 
Medical history  
 
 
 
Weight, height&,  
waist circumference,  
Index of Central Obesity (ICO),  
Body Mass Index (BMI),  
Hepatic Steatosis Index (HSI),  
Lipid Accumulation Product (LAP) 
 
 
 
 
Heart rate,  
blood pressure# 
 
 
 
 
Hematology/clinical chemistry* 

 
 

Urine Pregnancy Test (dipstick) 
 
 
Endothelial reactivity (Endocheck) 
 
 
Diet evaluation+ 

 
 

Randomization/Dispensation 
of treatment 
 
° 
 
 
Compliance with treatment 
 
 
 
Concomitant medications 

 
 

Adverse events (AE) 
† 
 
 
 
^ Visits to take place in the morning. Participants will be asked to fast overnight 12h before the visits. 
# Orthostatic and clinostatic, diastolic and systolic blood pressure (average of three measurements). 
* Full lipid panel (total cholesterol, LDL-cholesterol, HDL and non-HDL cholesterol, triglycerides, risk ratio, B 
apolipoproteins, LDL-C/Apo B), glycemia, ALT, AST, gamma-GT, CPK, uric acid, creatinine, eGFR with MDRD 
formula.  
§ During Visit 2 – Baseline evaluation – the LDL-C and TG values will be confirmed through a blood test analysis. If 
the eligibility was confirmed, the patient will be asked to return no later than 3 days after V2 for randomization and 
treatment dispensation. 
† Collection of AEs occurred after signature of informed consent. 
& Height only at Visit 1. 
+ See Appendix 1 of the protocol for diet guidelines. 
° Randomization and dispensation of treatment will take place within 3 days from Visit 2^ - Baseline evaluation and 
will be considered as “Day 0”.  
 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 14 of 52 
 
  
 
 
 
 
 
 
3. ABBREVIATIONS 
 
AE 
Adverse Events 
ALT 
Alanine Aminotransferase 
ANCOVA 
Analysis of Covariance 
AST 
Aspartate Aminotransferase 
BMI 
Body Mass Index 
CHD 
Coronary Heart Disease 
CPK 
Creatinine Phosphokinase 
CRF 
Case Report Form 
CRO 
Contract Research Organization 
EC 
Ethics Committee 
eGFR 
Estimated Glomerular Filtration Rate 
FAS 
Full Analysis Set 
HDL 
High-Density Lipoprotein 
HSI 
Hepatic Steatosis Index 
ICF 
Informed Consent Form 
ICO 
Index of Central Obesity 
LAP 
Lipid Accumulation Product 
LDL 
Low-Density Lipoprotein 
LDL-C 
Low-Density Lipoprotein-Cholesterol 
MDRD 
Modification of Diet in Renal Disease 
PP 
Per Protocol 
PV 
Pulse Volume 
SAE 
Serious Adverse Event 
SD 
Standard Deviation 
TC 
Total Cholesterol 
TG 
Triglycerides 
ULN 
Upper Limit of Normal 
 
 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 15 of 52 
 
  
 
 
 
 
 
 
4. BACKGROUND INFORMATION 
High cholesterol is one of the major controllable risk factors for coronary heart disease 
(CHD), heart attack and stroke. Dietary cholesterol has been associated with cardiovascular 
disease (1), leading the 2010 Dietary Guidelines Advisory Committee to recommend no 
more than 300 mg/d of cholesterol intake for healthy populations in the United States (2). 
The International Atherosclerosis Society also recommends decreasing dietary cholesterol 
as a strategy for lowering Low-Density-Lipoprotein (LDL) cholesterol (3). In contrast to 
dietary guidelines in the United States, other developed and developing countries do not 
define an upper limit on cholesterol intake but focus on controlling the intake of saturated 
and trans fat, which are major determinants of blood cholesterol concentrations (4). 
The relationship between raised plasma cholesterol and atherosclerotic vascular disease 
has been clearly demonstrated and the evidence that reducing plasma cholesterol is 
associated with reduced CV risk is equally unequivocal. A 10% proportional reduction in all-
cause mortality and 20% proportional reduction in CAD death per 1.0 mmol/L (40 mg/dL) 
LDL-C reduction is reported from a large number of meta-analyses. The risk of major 
coronary events was reduced by 23% and the risk of stroke was reduced by 17% per 1 
mmol/L (40 mg/dL) LDL-C reduction. The benefits were similar in all subgroups examined. 
The benefits were significant within the first year but were greater in subsequent years (5). 
A relatively large number of dietary supplements and nutraceuticals have been studied for 
their supposed or demonstrated ability to reduce cholesterolemia in humans. 
Antioxidants are natural substances that exist as vitamins, minerals and other compounds 
in foods. They are believed to help preventing disease by fighting free radicals that cause 
cellular damage, leading to the oxidation of low-density lipoproteins and contributing to 
atherosclerosis. A meta-analysis reviewing the results from seven large randomized trials of 
vitamin E, alone or in combination with other antioxidants, concluded that vitamin E did not 
provide any benefit in lowering mortality compared to control treatments, and did not 
significantly decrease the risk of cardiovascular death or stroke. The lack of any beneficial 
effect was seen consistently regardless of the doses of vitamins used and the diversity of 
the patient populations (6).  
Numerous preclinical and clinical studies have demonstrated that drugs that reduce the 
intestinal absorption of cholesterol (ex. ezetimibe), others that block the hepatic synthesis 
of cholesterol (statins) or the association of both besides reducing lipid profile, also reduce 
the rate of cardiovascular events (7).  
The search for natural alternatives to this approach includes the evaluation of the single and 
associated effects of nutritional inhibitors of dietary cholesterol absorption and endogenous 
hepatic synthesis. 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
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Phytosterols are plant sterols structurally similar to cholesterol that act in the intestine to 
lower cholesterol absorption and effectively reduce LDL-cholesterol. Since they have very 
low systemic absorption, increasing the intake of phytosterols may be a practical way to 
reduce cholesterol levels (8).  
Chinese red yeast rice is a dietary supplement made by fermenting the yeast, Monascus 
purpureus, over rice. Monascus yeast produces a family of substances called monacolins, 
including monacolin K.  
Monacolins act as reversible inhibitors of the 3-hydroxy-3-methyl-glutaryl-coenzyme A 
(HMG-CoA) reductase, a key enzyme in cholesterol biosynthesis. In addition to the inhibition 
of HMG-CoA reductase, red yeast rice has been found to contain sterols (-sitosterol, 
campesterol, stigmasterol, and sapogenin), isoflavones and isoflavone glycosides, and 
monounsaturated fatty acids (9, 10), all capable of lowering LDL cholesterol (11). 
A recent double-blinded, placebo-controlled, randomized clinical trial carried out on 25 
moderately hypercholesterolemic, nonsmoking, pharmacologically untreated subjects found 
that a product containing 10 mg of monacolins from M. purpureus and a mix of antioxidants 
appears to safely reduce cholesterolemia, hs-CRP, and endothelial dysfunction in 
moderately hypercholesterolemic subjects (12). 
5. TRIAL OBJECTIVES AND PURPOSE 
The purpose of this study is to evaluate the modulation of lipids, lipoproteins, and other 
biomarkers using a combination of phytosterols and DIF1STAT® (fermented red rice titrated 
in 5 mg monacolin K). 
The primary objective of this study is to evaluate the effect of this nutraceutical combination 
on blood LDL-cholesterol levels over an 8-week period in subjects with sub-optimal blood 
cholesterol levels. 
The secondary objective is to evaluate in subjects with sub-optimal blood cholesterol levels 
the effect of this nutraceutical combination on the following parameters over an 8-week 
period: 
• Total blood cholesterol (TC) 
• Blood High Density Lipoprotein (HDL)-cholesterol  
• Blood non-HDL cholesterol  
• Blood triglycerides (TG) 
• Apolipoprotein B  
• TC/HDL and LDL-C/HDL risk ratios 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
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• Pulse Volume (PV) waveform (Endothelial reactivity) 
• Glycemia, ALT, AST, gamma-GT, serum creatinine, serum uric acid, Creatinine 
Phosphokinase (CPK) 
6. STUDY DESIGN 
This is an exploratory, monocentric, interventional, non-drug, randomized, placebo-
controlled, double-blinded, parallel-group study.  
The study duration will be of approximately ten weeks for each subject. Four study visits are 
planned and will take place in the morning; participants will be asked to fast overnight (12 
hours) prior to the visit. 
 
Visit 1 (screening) (Day -14) 
Subjects will be enrolled into the study within their normal health-care program. Those who 
provide written informed consent will undergo screening assessments to evaluate 
compliance with inclusion/exclusion criteria and eligibility for the study. Patients will be 
assigned a patient number made up of five-digits; the first two correspond to the center 
number and the last three to the patient. Visit 1 includes: 
Medical history  
Weight, height, waist circumference, Index of Central Obesity (ICO), Body Mass Index (BMI),  
Hepatic Steatosis Index (HSI), Lipid Accumulation Product (LAP) 
Heart rate, blood pressure (average of three measurements) 
Hematology/clinical chemistry in fasting condition (total cholesterol, LDL-cholesterol, HDL and 
non-HDL cholesterol, triglycerides, risk ratio, B apolipoproteins, LDL-C/Apo B, glycemia, ALT, 
AST, gamma-GT, CPK, uric acid, creatinine, eGFR with MDRD formula 
Concomitant medication 
Subjects will also be given standard dietary suggestions to correct unhealthy habits (a 
Mediterranean-style diet is to be maintained for the entire duration of the study – see 
Appendix 1 for diet guidelines). 
 
Visit 2 (baseline evaluation) and Day 0 (randomization) 
During this visit, LDL-C and TG values will be confirmed through a blood test analysis in 
fasting condition to evaluate compliance with inclusion criteria (LDL-cholesterol = 115 -190 
mg/dL, Triglycerides < 400 mg/dL).  

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
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Once inclusion/exclusion criteria are confirmed, eligible patients will be asked to return no 
later than 3 days after Visit 2 for randomization and treatment dispensation. The day of 
randomization will be considered as Day 0. 
Weight, waist circumference, Index of Central Obesity (ICO), Body Mass Index (BMI),  
Hepatic Steatosis Index (HSI), Lipid Accumulation Product (LAP) 
Heart rate, blood pressure (average of three measurements) 
Hematology/clinical chemistry in fasting condition (total cholesterol, LDL-cholesterol, HDL and 
non-HDL cholesterol, triglycerides, risk ratio, B apolipoproteins, LDL-C/Apo B, glycemia, ALT, 
AST, gamma-GT, CPK, uric acid, creatinine, eGFR with MDRD formula
Endothelial reactivity test (Endocheck®) 
Urine Pregnancy Test (dipstick) 
Diet evaluation (see Appendix 1) 
Dispensation of treatment 
Concomitant medication 
Adverse events 
Eligible patients will be randomly assigned to one of the two groups in a 1:1 ratio (45 subjects 
per group) and treated with phytosterols 800 mg + DIF1STAT® or placebo, one tablet a day 
for 8 weeks.  
 
Visit 3 (Day 28) (intermediate) will take place 28 ± 3 days after Day 0.  
During V3, the following evaluations are performed: 
Weight, waist circumference, Index of Central Obesity (ICO), Body Mass Index (BMI),  
Hepatic Steatosis Index (HSI), Lipid Accumulation Product (LAP) 
Heart rate, blood pressure (average of three measurements) 
Hematology/clinical chemistry in fasting condition (total cholesterol, LDL-cholesterol, HDL and 
non-HDL cholesterol, triglycerides, risk ratio, B apolipoproteins, LDL-C/Apo B, glycemia, ALT, 
AST, gamma-GT, CPK, uric acid, creatinine, eGFR with MDRD formula 
Diet evaluation (see Appendix 1) 
Concomitant medication 
Accountability and compliance with treatment 
Treatment tolerability evaluation (adverse events, if any) 
 
 
Visit 4 (Day 56) (end of study) will take place 28 ± 3 days after V3.  
During the last visit the following evaluations are performed: 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 19 of 52 
 
  
 
 
 
 
 
 
Weight, waist circumference, Index of Central Obesity (ICO), Body Mass Index (BMI),  
Hepatic Steatosis Index (HSI), Lipid Accumulation Product (LAP) 
Heart rate, blood pressure (average of three measurements) 
Hematology/clinical chemistry in fasting condition (total cholesterol, LDL-cholesterol, HDL and 
non-HDL cholesterol, triglycerides, risk ratio, B apolipoproteins, LDL-C/Apo B, glycemia, ALT, 
AST, gamma-GT, CPK, uric acid, creatinine, eGFR with MDRD formula 
Endothelial reactivity (Endocheck) 
Urine Pregnancy Test (dipstick) 
Diet evaluation (see Appendix 1) 
Concomitant medication 
Accountability and compliance with treatment 
Treatment tolerability evaluation (adverse events, if any) 
This study will be conducted in a double-blinded manner; the investigator, study staff, 
subjects and monitors will remain blinded to the treatment until study closure. Patients will 
be assigned to a treatment according to a computer-generated randomization list produced 
by the trial statistician. Code break cards will be kept at the study center and may be opened 
to reveal what treatment the patient is taking in case of emergency. 
7. SELECTION AND WITHDRAWAL OF SUBJECTS 
This study will randomize 90 male/female subjects, aged 30-75 years, with sub-optimal 
blood LDL-cholesterol levels (LDL-cholesterol = 115 -190 mg/dL and Triglycerides < 400 
mg/dL. It will take place at one center located in Italy.  
Informed Consent Process 
Prior to the subject’s enrolment in the study and before performing any study-related 
procedures, the Investigator or authorized delegate shall obtain the subject’s written, dated 
and signed informed consent to participate in the study and to the confidential disclosure, 
processing and transfer of necessary documentation of the subject’s health and personal 
data to the CRO, Sponsor and its Affiliates, the competent Health Authorities and any other 
institutions (even if located outside the European Economic Area), as legally required and 
in accordance with applicable privacy laws. 
Institution and Investigator undertake to duly inform patients about personal data processing 
and relevant applicable privacy rights before their participation in the study. 
Prior to submittal to the patient, the Informed Consent form must be approved in the 
corresponding local language and in accordance with local laws and regulations by the 
Ethics Committee (EC). 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 20 of 52 
 
  
 
 
 
 
 
 
In the patient information section, patients will be given information and a comprehensive 
explanation in easily understandable terms of the study procedures, benefits, restrictions, 
discomforts, and risks in taking part in the study, the properties of the nutraceutical product, 
and the method of assignment to treatments. 
Patients will also be informed about the measures taken to ensure their confidentiality 
according to pertinent legislation. The Investigator shall provide the patient with an 
emergency telephone number. 
After being duly informed and interviewed by the Investigator, the patient has to date and 
sign the 2 copies of Informed Consent Form (ICF) before being enrolled in the study and 
before undergoing any study procedure. One signed copy of the ICF will be stored by the 
Investigator in the Investigator’s File, the other will be given to the patient. 
Should a protocol amendment affect the terms of the ICF, it will be revised to reflect the 
protocol change and be submitted to the EC for approval.  
The Investigator will ensure that this new consent form is signed by both new patients 
subsequently entered in the study and those already enrolled. 
 
7.1 
Inclusion criteria  
Subjects must meet all the following inclusion criteria: 
• Age 30-75 years 
• LDL-cholesterol = 115-190 mg/dL 
• Triglycerides < 400 mg/dL 
• Any cardiovascular therapy should be stable for type and dose for at least three months 
• Signed, written informed consent 
 
7.2 
Exclusion criteria  
Subjects must meet none of the following exclusion criteria: 
• Intolerance to any ingredient of dietary supplement 
• Patients already suffering from cardiovascular diseases or at high risk of developing 
cardiovascular diseases 
• Myopathies 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
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• Uncontrolled diabetes mellitus based on PI judgment 
• Chronic renal failure (defined as eGFR<60ml/min/1.73m2) or liver failure (defined as 
AST and /or ALT>3 Upper Limit of Normal) (ULN) 
• Body Mass Index > 32 kg/m2 
• Therapy with statins or other drugs or supplements with effects on lipid metabolism 
• Patients with acquired immunodeficiency 
• Treatment with immunosuppressants 
• Pregnant or breastfeeding women 
• Women of childbearing potential not willing to use effective birth control methods 
• Patients participating in or having participated in another clinical trial within the previous 
3 months 
• Current or recent history of drug or alcohol addiction based on PI judgment 
 
7.3 
Withdrawal criteria 
The patient may withdraw from the study at any time without explanation, without losing the 
right to future medical care. The participation of the patient may be terminated by the 
Investigator at any moment, if considered appropriate. 
Treatment with the study product must be terminated during the study for any of the following 
reasons: 
• Request of the patient 
• Pregnancy 
• Investigator deems it to be in the best interest of the patient to discontinue 
• Failure to comply adequately with the dosing, evaluations, or other requirements of 
the study. 
If possible, and after the permanent discontinuation of treatment, the patients will be 
assessed using the procedures normally planned for the last visit. 
If patients fail to return to the site, the Investigator should make every effort to recontact the 
patient and determine his/her health status. Attempts to contact such patients must be 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 22 of 52 
 
  
 
 
 
 
 
 
documented in the patient’s records (times and dates of attempted telephone contact, 
receipt for sending a registered letter).  
Patients who have withdrawn from the study cannot be re-randomized (treated) in the study, 
and their random numbers must not be reused.  
The reason for the withdrawal must be well documented in the CRF. 
8. TREATMENT OF SUBJECTS 
8.1 
Treatments 
Patients will be randomized with a 1:1 ratio to one of the following two treatment arms: 
1. Phytosterols 800 mg, + DIF1STAT®. 1,300 mg film-coated tablets. Ingredients: 
phytosterols (61.5%) bulking agent: microcrystalline cellulose, cross-linked sodium 
carboxymethyl cellulose, fermented red rice titrated at 3% in monacolin K (Monascus 
purpureus went, seed), niacin, anti-caking agents: fatty acid magnesium salts, silicon 
dioxide; policosanols titrated to 60% octacosanol; coating agents: polyvinyl alcohol, 
talcum, polyethylene glycol, polysorbate 80; colorants: E120, E172. 
Nutritional information: each tablet contains phytosterols (800 mg), Monascus pupureus 
(167 mg) titrated at 3% in monacolin k (5mg), niacin (27 mg), linear aliphatic alcohols 
titrated to 60% octacosanol. 
One tablet per os, per day to be taken in the evening. 
2. Placebo tablets for oral administration identical in appearance, size, shape, weight and 
taste to the active product. 1,300 mg film-coated tablets. Ingredients: bulking agent: 
microcrystalline cellulose, cross-linked sodium carboxymethyl cellulose; colorants: red 
beet, elder extract plv, anti-caking agents: fatty acid magnesium salts, silicon dioxide; 
coating agents: polyvinyl alcohol, talcum, polyethylene glycol, polysorbate 80; colorants: 
E120, E172. 
One tablet per os, per day to be taken in the evening. 
Patients will be treated for 8 weeks. 
8.2 
Blinding procedures 
Patients, Investigator staff, personnel performing the study assessments and data analysts 
will remain blinded to the identity of the treatment from the time of randomization until 
database lock using the following methods: 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 23 of 52 
 
  
 
 
 
 
 
 
• The two treatments will be identical in packaging, labeling, administration schedule, 
appearance, taste and odor. 
• Randomization data will be kept strictly confidential until the time of unblinding and 
will not be accessible by anyone involved in the study. 
Unblinding will occur only in case of patient emergencies by opening the code break cards 
stored at the center, and at the conclusion of the study.  
Health Authorities will be granted access to unblinded data if needed.  
 
8.3 
Method of assigning patients to treatment group 
A computer-generated randomization list produced by the trial statistician will randomize 
patients to one of the two treatment groups (phytosterols 800 mg + DIF1STAT® or placebo) 
in a 1:1 ratio. Paper based randomization procedure will assign a randomization number to 
the patient, which will be used to link the patient to a treatment arm and will specify a unique 
kit number for the package of treatment to be dispensed to the patient. The randomization 
numbers will be generated using a procedure to ensure that treatment assignment is 
unbiased (further details are available in the randomization document).  
 
8.4 
Packaging, labeling and storage 
Each patient will receive one bottle containing 80 film-tablets of either the study product or 
placebo. The product bottles should be kept in a cool, dry place. Shelf life of the product is 
24 months. 
Two-part labels will be computer-generated for this blinded study. One part of the label is 
attached to the container, whereas the other part is a tear-off portion to be removed at the 
time of dispensing and attached to the Drug Label Page. 
The label contains the following information: 
• Name of the Sponsor (A. Menarini Industrie Farmaceutiche Riunite S.r.l.). 
• Name of the study: NATCOL. 
• Batch number and expiration date. 
• One bottle contains 80 1,300 mg film-tablets: phytosterols 800 mg + DIF1STAT® or 
placebo. 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
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• Take one tablet per os per day. 
• Kit number. 
• Random number. 
• Store in a dry, cool place. The expiration date applies to undamaged, properly stored 
product. 
• This sample product is to be used exclusively during the clinical study. Return bottle 
and all unused tablets. 
The Principal Investigator or other authorized persons (Pharmacists) is responsible for 
storing treatments in a secure and safe place in accordance with local regulations, labeling 
specifications, policies, and procedures. 
 
8.5 
Treatment accountability and compliance 
Patients will be asked to return all unused tablets at Visit 3 and Visit 4. Compliance will be 
assessed at Visit 3 and Visit 4 by counting unused tablets. A subject Treatment 
Accountability Log for dispensed and returned treatment will be kept for each patient.  
The Investigator will be responsible for ensuring that an accurate record of the treatment 
issued and returned is maintained through a Site Treatment Accountability Log. Destruction 
of all study products (used or unused) shall be carried out following the Sponsor’s written 
authorization. 
 
8.6 
Concomitant medications 
The use of any concomitant medication should be reported at each visit and reported in 
CRF.  
The use of statins or other drugs/products that affect lipid metabolism is prohibited during 
the study.  
9. ASSESSMENT OF PRIMARY AND SECONDARY VARIABLES 
9.1 
Laboratory parameters 
The following laboratory parameters will be assessed at baseline and over the 8-week 
treatment period (Visits 2, 3 and 4): 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 25 of 52 
 
  
 
 
 
 
 
 
• Blood LDL cholesterol 
• Total blood cholesterol 
• Blood HDL-cholesterol  
• Blood non-HDL cholesterol 
• Blood triglycerides 
• Apolipoprotein B  
• TC/HDL and LDL-C/HDL risk ratios 
• Glycemia, ALT, AST, gamma-GT, creatinine, uric acid, CPK,  
 
9.2 
Endothelial reactivity (Endocheck®) 
Endothelial function will be evaluated through Endocheck® (BC Biomedical Laboratories Ltd, 
Vancouver, BC, Canada), a non-invasive method embedded within the Vicorder® device 
(PRN Vascular, Fall River, MA, USA), which records brachial pulse volume (PV) waveforms, 
at baseline and during reactive hyperemia.  
Reactive hyperemia is provoked through PV displacement, obtained by inflating a cuff 
positioned distally around the forearm. After a 10-minute rest, brachial blood pressure is 
evaluated, and PV waveforms recorded at baseline for 10 seconds. Then, the cuff is inflated 
to 200 mmHg for 5 minutes, and PV waveforms are recorded for 3 minutes after cuff release. 
PV displacement is then calculated as a percent change in the PV waveform area, 
comparing waveforms during and before hyperemia through the equation PV2/PV1, where 
PV1 represents PV at baseline and PV2 represents PV during hyperemia (12).  
The endothelial reactivity test will be performed at baseline (Visit 2) and Visit 4. 
 
9.3 
Other variables  
Heart rate, blood pressure 
Heart rate, diastolic and systolic blood pressure in orthostatic and clinostatic position 
(average of three measurements) will be measured at all visits. 
Weight, height, waist circumference, Index of Central Obesity (ICO), Body Mass Index 
(BMI), Hepatic Steatosis Index (HSI), Lipid Accumulation Product (LAP) 
Weight, Height (only at V1), Waist Circumference, Index of Central Obesity (ICO), Body 
Mass Index (BMI) Hepatic Steatosis Index (HSI) and Lipid Accumulation Product (LAP) will 
be evaluated at all visits. Here below the corresponding formulas: 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 26 of 52 
 
  
 
 
 
 
 
 
• BMI = Weight (kg) / Height 2(m) 
• ICO = Ratio of Waist Circumference and Height (cm) (13) 
• HSI = 8 x (ALT/AST ratio)+BMI (+2, if female; +2, if diabetes mellitus) (14) 
• LAP for men = (waist circumference [cm] − 65) × (triglyceride concentration [mmol/l]) (15) 
• LAP for women = (waist circumference [cm] − 58) × (triglyceride concentration [mmol/l] 
(15) 
10. ASSESSMENT OF SAFETY 
10.1 Adverse events (AE) 
An adverse event (AE) is as any untoward medical occurrence in a patient administered the 
product and which does not necessarily have to have a causal relationship with the product. 
Adverse events should be recorded in the Adverse Events CRF under the signs, symptoms 
or diagnosis associated with them accompanied by the following information. 
• severity grade 
o mild: usually transient in nature and generally not interfering with normal activities 
o moderate: sufficiently discomforting to interfere with normal activities 
o severe: prevents normal activities 
• Relationship to the investigational product (no/yes) 
• Duration (start and end dates) or if the event is ongoing an outcome of not recovered/not 
resolved should be reported. 
• Action taken regarding investigational treatment  
• Whether other medication or therapies have been taken 
• Outcome (not recovered/not resolved; recovered/resolved; recovering/resolving, 
recovered/resolved with sequelae; fatal; or unknown) 
• Whether it constitutes a serious adverse event (SAE)  
A serious adverse event (SAE) is any untoward medical occurrence that at any dose: 
• Results in death, or 
• Is life-threatening, or 
• Requires inpatient hospitalization or prolongation of existing hospitalization, or 
• Results in persistent or significant disability/incapacity, or 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
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• Is a congenital anomaly/birth defect, or 
• Is a medically important event. 
Should an SAE occur, the Investigator or any designees must complete and send the SAE 
form signed and dated by fax or e-mail within 24 hours following awareness to the 
Pharmacovigilance Officer whose fax number and e-mail address appear below. 
The Investigator should take appropriate measures to follow all AEs (both serious and not 
serious) until clinical recovery is complete and laboratory results have returned to normal, 
or until progression has been stabilized to ensure the safety of the patients. This may imply 
that observations will continue beyond the last planned visit per protocol, and that additional 
investigations may be requested by the monitoring team up to as noticed by the Sponsor. 
Any follow-up information of SAEs should be transmitted by fax or email as described above. 
 
 
CRO Pharmacovigilance Officer: Dr Riccardo Chisci, OPIS s.r.l. 
 
Email: all_phv@opis.it 
 
Fax: +39 0362 633622 
 
Tel: +39 0362 633312 
 
Mobile: +39 348 6440813 
 
 
10.2 MANAGEMENT OF ANY LABORATORY ABNORMALITY 
Any laboratory test abnormality that is considered by the Investigator as an AE is to be 
managed as detailed above (see 10.1). 
10.3 Management of pregnancy exposure cases 
The Investigator is expected to record any case of pregnancy exposure occurring in a female 
patient or in a male patient’s partner during the study on the pregnancy form and send it to 
the Sponsor by fax to the address indicated in Section 10.1. 
The Investigator is requested to follow each case of pregnancy exposure until the outcome. 
 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 28 of 52 
 
  
 
 
 
 
 
 
11. STATISTICS 
11.1 Statistical methods (blinding and randomization) 
 
Randomization 
Patients will be randomized to one of the two treatment arms in a 1:1 ratio (phytosterols 800 
mg + DIF1STAT® or placebo). 
The randomization numbers will be generated to ensure that treatment assignment is 
unbiased and concealed from patients and investigator staff. A patient randomization list, 
and its respective randomization cards, will be generated by the CRO by means of a 
validated computerized system that automates the random assignment of randomization 
numbers to the different treatment arms. Prior to dosing, all patients who fulfill all 
inclusion/exclusion criteria will be randomized, by means of randomization cards, to one of 
the two treatment arms. The investigator or his/her delegate will use the first available 
randomization card, which will assign a randomization number to the patient that will be 
used to link the patient to a treatment arm and will specify a unique medication number for 
the package of study treatment to be dispensed to the patient. 
 
Blinding 
Patients, investigators, site personnel, and data analysts will remain blinded to the identity 
of the treatment administered from the time of randomization until database lock. 
Randomization data are kept strictly confidential until the time of unblinding and will not be 
accessible by anyone else involved in the study. The identity of the treatments will be 
concealed by the use of study treatments that are all identical in packaging, labeling, 
schedule of administration and appearance. 
Unblinding will only occur in case of patient emergencies and at the conclusion of the study. 
 
Interim Analysis 
No interim analyses are planned. 
 
General methodology 
All data collected in the study will be listed and summarized as appropriate as described 
below in Section 11.5. Continuous data will be summarized by means of common descriptive 
statistics: mean, standard deviation (SD), median, first and third quartiles, minimum and 
maximum. Categorical data will be presented by absolute and relative frequencies (n and %) 
or contingency tables. 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
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Patients will be included in each analysis based on available assessments, after the data 
handling conventions have been applied. The prevalence approach, if not differently 
indicated, will be applied. 
Unless stated otherwise, two-sided p-values <0.05 will be considered statistically significant. 
All statistical tables, listings, figures and analyses will be generated using SAS® release 9.4 
or later (SAS Institute Inc., Cary NC, USA). 
Further details about data analysis will be provided in the Statistical Analysis Plan document. 
11.2 Determination of sample size 
Considering the primary endpoint of the study as the reduction from baseline to week 8 in 
LDL cholesterol level and the data available from literature [Phytomedicine. 2016 Oct 15; 
23(11):1113-8], a reduction of LDL level of approximately 10% is expected after the intake 
of the nutraceutical. Therefore, a mean difference of 15 mg/dL in the reduction of LDL 
cholesterol level at week 8 between the nutraceutical treatment group and the placebo group 
is considered clinically significant. 
Assuming a baseline LDL level of 145 ±19 mg/dL, a power of 90% and a 5% two-sided alpha 
level to detect a difference in mean change in LDL from baseline to week 8 equal to 15 
mg/dL between the nutraceutical and the placebo group, the total number of patients to be 
evaluated should be 35 per treatment arm in a 1:1 ratio (NQuery Advisor, 7.0). Allowing for 
an approximate 20% dropout rate, at least 88 patients should be randomized: 44 patients in 
each treatment group. 
11.3 Analysis populations 
Patients without a valid or adequately obtained Informed Consent Form (ICF) will be 
excluded from any analysis population. 
The following analysis populations will be defined for statistical analyses: 
• Full Analysis Set (FAS): All patients to whom study treatment has been assigned by 
randomization and who have the assessment for LDL cholesterol at visit 4 (week 8). 
According to the intent-to-treat principle, patients will be analyzed according to the 
treatment they have been assigned to during the randomization procedure. The 
primary and secondary analysis will be based on the FAS. 
• Per Protocol (PP) Set: All patients in the FAS who have no major protocol deviations. 
All major protocol deviations leading to exclusion from the PP set will be detailed in 
the analysis plan. Results of the analysis of the primary variable conducted in the PP 
set will be considered as supportive. 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
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• Tolerability Set: All patients who received at least one dose of investigational 
product. Patients will be analyzed according to the treatment actually received (if 
different from treatment assigned through randomization). 
11.4 Analysis variables 
• The primary variable of the study is the change from baseline to Week 8 in LDL 
cholesterol levels
• The secondary variables of the study are defined as change from baseline to Week 8 
in:
o Total blood cholesterol 
o Blood HDL-cholesterol  
o Blood non-HDL cholesterol 
o Blood triglycerides 
o Apolipoprotein B  
o TC/HDL and LDL-C/HDL risk ratios 
o Pulse Volume (PV) waveform (endothelial reactivity) 
o Glycemia, ALT, AST, gamma-GT, creatinine, uric acid, CPK 
• Other variables are as follows: 
o Change from baseline at each assessment time point for each laboratory parameter 
o Adverse Events 
o Vital Signs 
o Weight 
o Height 
o Waist Circumference 
o Index of Central Obesity (ICO) 
o Body Mass Index (BMI) 
o Hepatic Steatosis Index (HSI) 
o Lipid Accumulation Product (LAP) 
11.5 Statistical analysis 
Patient demographics and other baseline characteristics 
All data about patient demographics and baseline characteristics will be summarized in the 
FAS, overall and by treatment group, by means of summary descriptive statistics. 
The number and percentages of subjects meeting all eligibility criteria at screening will be 
provided. The analysis populations will be described and the reasons for excluding a patient 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 31 of 52 
 
  
 
 
 
 
 
 
from any particular population will be provided with the number of protocol deviators per 
each criterion. 
A complete description of patients’ disposition will be provided, overall and by treatment 
group specifying the number of randomized patients, the number of patients at each visit, 
the number of completed and discontinued patients and the reason for the discontinuation. 
Medical history data will be presented by MedDRA dictionary system organ class and 
preferred term, overall and by treatment group. 
Treatments (study treatment, concomitant therapies, compliance) 
The Tolerability set will be used for the analyses on treatment administration, compliance, 
concomitant medications and adverse events. 
Extent of exposure is defined as the difference in days between the date of last treatment 
administration and the date of first treatment administration plus one, regardless of 
unplanned intermittent discontinuations. 
Overall treatment compliance is defined as the actual number of capsules taken compared 
to the planned treatment duration (i.e. extent of exposure). 
Extent of exposure and treatment compliance will be summarized by means of descriptive 
statistics, overall and by treatment group. The percentage of patients per compliance level 
will be also summarized: 
• 80% 
• >80% and 120% 
• >120% 
A subject that has taken at least 80% and no more than 120% of the required treatment will be 
considered compliant. 
Dose reductions and dose interruptions (including the reasons) will be listed and 
summarized overall and by treatment group. 
Concomitant medications and significant non-drug therapies prior to and after the start of 
the study treatment will be presented by WHO Drug Dictionary ATC class and preferred 
term, overall and by treatment group. 
Primary variable 
The statistical analysis of the primary variable will be performed on the FAS population and 
on the PP population as supportive. 
No alpha level adjustment for multiplicity will be adopted.  
All data available will be used for analysis and no technique for missing data imputation will 
be adopted. 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 32 of 52 
 
  
 
 
 
 
 
 
Summary statistics of raw data and change from baseline at each assessment time point for 
LDL cholesterol levels will be presented overall and by treatment group. 
An analysis of covariance (ANCOVA) model will be estimated on the changes from baseline 
to Week 8 in LDL cholesterol levels considering treatment group as factor and baseline value 
of LDL cholesterol as continuous covariate. Results will be reported as Least-Square Means 
together with associated two-tailed 95% CI and p-value. If the assumption of normality of 
residuals is violated, the ANCOVA model will be fitted on rank transformed data. 
Secondary variables 
The statistical analyses of the secondary variables will be performed on the FAS population. 
Given the exploratory nature of the secondary objectives of the study, no alpha level 
adjustment for multiplicity will be adopted. 
The prevalence approach will be applied, and therefore no technique for missing data 
imputation will be adopted. 
The same statistical models described for the analysis of the primary variable will be applied. 
Other variables 
All the other analyses will be performed on the Tolerability set. 
No missing data handling approach will be applied. 
Adverse Events 
The incidence of Adverse Events (AEs) and Serious Adverse Events (SAEs) recorded 
throughout the study will be presented. 
According to the onset date of the event, AEs will be defined as follows: 
• treatment-emergent AE, those events with an onset date after treatment initiation 
• non-treatment-emergent AE, those events with an onset date between informed 
consent and treatment initiation  
Non treatment-emergent AEs will be listed only. 
Treatment-emergent AEs will be summarized by MedDRA dictionary system organ class 
and preferred term. A summary of treatment-emergent AEs by preferred term and severity 
will be also provided. For analysis purposes, all treatment-emergent AEs defined as 
‘‘certain”, ‘‘probable’’, ‘‘possible’’ or “unassessable” will be considered as product related. If 
the relationship to study treatment is missing, the treatment-emergent AE will be considered 
treatment-related. All related treatment-emergent AEs, treatment-emergent AEs with an 
outcome of death, treatment-emergent AEs leading to discontinuation of treatment will be 
summarized by MedDRA dictionary system organ class and preferred term and will also be 
listed. Serious treatment-emergent AEs will be summarized similarly. Percentages will be 
based on the number of subjects in the Tolerability set. 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 33 of 52 
 
  
 
 
 
 
 
 
Laboratory parameters 
Summary statistics of raw data and change from baseline at each assessment time point for 
each laboratory parameter will be presented overall and by treatment group. 
Laboratory test results will be classified by the low/normal/high classification based on local 
laboratory normal ranges. A frequency table for low/normal/high classification will be 
presented overall and by treatment group for each laboratory parameter. A listing of all out 
of range laboratory parameters will be provided with values flagged to show the classification 
relative to the laboratory normal ranges. 
Vital signs, weight, waist circumference, Index of Central Obesity (ICO), Body Mass Index 
(BMI), Hepatic Steatosis Index (HSI), Lipid Accumulation Product (LAP). 
Heart rate and blood pressure will be measured in orthostatic and clinostatic position. 
Summary statistics of raw data and change from baseline at each assessment time point for 
each parameter will be presented overall and by treatment group. 
Deaths 
All deaths occurred will be listed together with all their details. 
Pregnancy test results 
Any pregnancies reported will be listed. 
11.6 Subgroup analysis 
No subgroup analyses are currently planned. 
11.7 Protocol violations and blind review 
Protocol deviations will be detected throughout the study and reported by means of a 
specific form. All cases of prospectively defined protocol deviations (PD) will be identified 
prior to clinical database lock/unblinding and included in the clinical database. Certain 
deviations may stipulate that data collected from the patients will be excluded from analysis 
population(s). All exceptional cases and the final decisions on the allocation of patients to 
populations will be fully defined, documented and approved by the Sponsor study team 
during the blind review meeting, which will be held before data base lock and before breaking 
the blind. 
11.8 Statistical analysis plan 
Further details about data analysis will be provided in the Statistical Analysis Plan. 
The document will have to be finalized before the database lock. Any deviation from the 
original statistical plan, as reported in the study protocol, will be properly documented and 
justified in the Statistical Analysis Plan. 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 34 of 52 
 
  
 
 
 
 
 
 
12. DIRECT ACCESS TO SOURCE DATA/DOCUMENTS 
The investigator/Institution will permit trial related monitoring, audits, IRB/IEC review, and 
regulatory inspections, providing direct access to source data/documents. 
13. QUALITY CONTROL AND QUALITY ASSURANCE 
13.1 Data Quality Control/Study Monitoring 
The study will be monitored according to the details specified in the Monitoring Plan. 
The Investigator will be contacted by the study monitor on a regular basis. The monitor will 
have the responsibility of reviewing the ongoing study with the Investigator to verify 
adherence to the protocol and to deal with any problems. CRFs will be checked for 
completeness and consistency with the source data and special attention will be dedicated 
to patient enrolment, obtaining signed informed consent, occurrence of AEs, product 
accountability, and accurate recording of variables. The confidentiality of study related 
documents shall be maintained at all times. The Investigator agrees to allow access to all 
study materials needed for the proper review of study conduct. The Investigator agrees to 
assist the monitor in resolving any problem that may be detected during the monitoring visit 
or data cleaning process.  
13.2 Case Report Forms 
Data collected during the study will be recorded in the Case Report Form (CRF). Data 
reported on the CRF have to be consistent with the source documents. The Investigator 
must ensure the accuracy, completeness and the consistency of the data entered in the 
CRF. 
On the CRF, patients will be identified by a patient number, assigned at the Screening Visit. 
The patient number will be composed of a two-digit center number followed by a three-digit 
patient identification number (01-001 for the first patient). 
During the conduct of the study, the CRF must be available and up-to-date so that it always 
reflects the latest observations on the respective patient. 
The Investigator will be responsible for entering study data into the CRF in accordance with 
the CRF user guidelines.  
13.3 Quality Assurance 
An independent quality audit/inspection at the study site may take place at any time during 
or after the study. The independent audit/inspection can be carried out by the Sponsor’s 
independent Quality Assurance (QA), by a Health Authorities or an Ethics Committee (EC). 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 35 of 52 
 
  
 
 
 
 
 
 
14. ETHICAL ASPECTS 
This study will be carried out in compliance with the study protocol, the recommendations 
on biomedical research on human subjects of the Declaration of Helsinki, International 
Conference of Harmonization – Good Clinical Practice (ICH-GCP) Guidelines, EU-Directive 
2001/20 and national requirements. 
All clinical work conducted under this protocol is subject to Good Clinical Practice (GCP) 
rules. 
14.1 Ethics Committees 
Before starting the study at a study site, study protocol and relevant documentation (Patient 
information leaflet, informed consent form) must be submitted to and approved by the Ethics 
Committees and the Competent Authorities. 
In addition, all local national legal requirements for the conduct of a clinical study have to be 
met prior to the start of the study. Any amendment to the protocol will be submitted to the 
EC for approval before implementation, after prior discussion between the Sponsor and 
Principal Investigator. 
The Competent Authorities and EC will be informed of any changes in the study protocol, 
the end of the study or premature study termination as appropriate and within the requested 
time. 
14.2 Insurance 
The Sponsor has stipulated an insurance policy for patients participating in the study in 
accordance with local regulatory requirements. 
Details of the insurance company, the insurance policy number and conditions will be made 
available to patients in the information sheet and/or provided as a separate document, in 
accordance with national requirements. 
A copy of the insurance certificate will be provided to the Investigator and will be filed in the 
Investigator’s File at the site and in the study’s Trial Master File (TMF). 
The Investigator must notify the Sponsor of any claims or lawsuits immediately. 
15. DATA PROTECTION LAWS COMPLIANCE 
By signing the study protocol, the Institution and the Principal Investigator (including their 
appointed staff) acknowledge that the performance of the study will imply the processing of 
personal data. Personal data processing is regulated by the Sponsor’s national legislation 
as well as local laws (i.e. the country where the study is conducted): such provisions will 
apply mandatorily. The Sponsor clarifies that strict compliance with the applicable data 
protection laws by any parties and relevant employees who take part in the study is an 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 36 of 52 
 
  
 
 
 
 
 
 
essential condition for the appointment of, and the collaboration with, research institutions, 
investigators, Contract Research Organization (CRO), etc. 
The parties shall acknowledge that according to the applicable privacy laws, Sponsor and 
Institution/s will act as independent data controllers, while CRO and Principal Investigator/s 
will act as data processors. Before the beginning of the Study, the Institution will appoint in 
writing its Principal Investigator as its data processor, and the Sponsor will appoint in writing 
the CRO as its data processor. In addition, the Institution will appoint any Investigators other 
than the Principal Investigator as “persons in charge of the processing of personal data” 
(“incaricato del trattamento”), pursuant to art. 30 of the Italian Legislative Decree 196/2003 
(“Codice in material di protezione dei dati personali”).  
Principal Investigator and Institution (including their personnel) shall comply with the 
applicable privacy laws and Sponsor’s instructions concerning the protection of personal 
data. Such obligations will include, by way of example:  
(i) 
the duty to provide the subjects involved in the Study with adequate, law-
compliant information notices (based on the “information notice and consent form 
to process personal data” supplied by the Sponsor), where the nature of the study 
and the personal data processing operations it implies will duly be described;  
(ii) 
the duty to collect the informed consent of the patients involved in the Study prior 
to their participation; such consent will include the possibility to transfer personal 
data outside the EEA (including to countries which do not ensure a level of 
protection of personal data comparable to that afforded by EU Law);  
(iii) 
the duty to respect the data privacy rights of any data subjects - particularly of 
patients- as established by applicable privacy laws (including, by way of example, 
the right to have one’s personal data amended, corrected or deleted, and  to 
withdraw from the study);  
(iv) 
the duty to adopt all physical, logical, organizational, technical and IT security 
measures in accordance with applicable privacy laws. 
Given the sensitive nature of data processed in the Study, the parties undertake to 
implement adequate safety measures (physical, logical, organizational, technical, etc.) to 
warrant that data are always processed safely and in compliance with local privacy laws, 
and in particular with the Italian Data Protection Authority’s “Guidelines on Personal Data 
Processing in the context of Clinical Trials” (“Linee guida per i trattamenti di dati personali 
nell'ambito delle sperimentazioni cliniche di medicinali”) of 24.07.2008. Specifically:  
a) 
The CRO, Sponsor, Principal Investigator and Institution must ensure that data is 
safely processed and stored in a way that minimizes the risk of theft and 
unauthorized access. To this extent, patients’ personal data shall be securely 
stored in restricted areas, accessible only to those individuals who need to retrieve 
patients’ data for professional purposes and should also be password-protected 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 37 of 52 
 
  
 
 
 
 
 
 
(in the case of electronic documents) or key-locked (in the case of paper 
documents). In addition, the password of any electronic database containing 
patients’ personal data (including the centralized database held by the CRO) shall 
be at least 8 characters long and updated at least every three months, and should 
have adequate cryptographic protection measures in place to prevent data 
breaches (such as, for example, file system or database cryptography, or any 
other equivalent IT measure which renders data unintelligible to those who are 
not authorized to access them); 
b) 
The Principal Investigator must ensure that each patient’s anonymity is 
safeguarded and will therefore “pseudonymize” patients’ personal data (i.e., the 
patient’s name and surname shall never be reported in the study documentation; 
instead, only the patient number described under section 13.2 of this Protocol will 
be used). The Principal Investigator will keep a separate log of patients’ names, 
addresses and telephone numbers, and of the “key” to link this information to the 
respective patient numbers. Such data shall be securely stored as described 
under point a) above and shall be kept separate from the study documents that 
have been “pseudonymized” as described above. The Principal Investigator will 
keep these records for the longest time allowed by own institution and in any case 
until further communication from Sponsor. 
c) 
All the parties that transfer patients’ personal data through internet and/or through 
the centralised database(s) used to process the study’s data or to generate 
statistical analyses shall implement secure protocols based on cryptographic 
standards which make data unintelligible to unauthorized individuals; this applies 
also to the CRO’s centralized database;
d) 
The centralised database held by the CRO shall be accessible to authorized users 
by means of authentication methods which permit access to each specific set of 
subjects’ data only to those for whom access is essential in the context of their 
work for the study;
e) 
The CRO and Institution shall ensure that any member of staff/collaborator 
involved in the study have received proper training on data protection issues.
Upon request of the CRO or the Sponsor, the Institution and Investigator will provide a 
detailed description of the measures adopted to comply with the requirements of the 
applicable data protection laws. In addition, all actions related to the implementation of the 
afore mentioned-measures shall be provided by the Sponsor and/or the CRO to the 
competent authorities (including data protection authorities) and Ethics Committees if and 
when requested. If such authorities or the Sponsor consider the implementation of the afore-
mentioned measures insufficient to guarantee an adequate level of protection of the patients’ 
personal data, the parties undertake to adopt all the necessary activities to overcome such 
remarks to assure the full compliance with the data protection laws. 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 38 of 52 
 
  
 
 
 
 
 
 
16. DATA HANDLING AND RECORDS KEEPING 
The Investigator should keep all study-related documents, as specified in ICH/GCP Section 
8 “Essential Documents for the Conduct of a Clinical Trial” and all study documents as 
specified by applicable regulatory requirements, in the Investigator's Trial Center File. 
The Investigator will take measures to prevent accidental or premature destruction of these 
documents. 
Essential documents must be retained in a secure place as long as needed to comply with 
national and international regulations. 
If the responsible Investigator retires, relocates, or for other reasons withdraws from the 
responsibility of keeping the study records, custody must be transferred to a person who will 
accept the responsibility.  
The Sponsor must be notified in writing of the name and address of the new custodian.  
If it becomes necessary for the Sponsor and/or a Regulatory Authority to review any 
documentation related to this study, the Investigator must permit access to such 
documentation. 
Any difficulty in storing original documents should be discussed with Sponsor personnel prior 
to initiation of the study. 
17. PUBLICATION POLICY AND RESULTS 
By signing the study protocol, the Investigator (and his/her appointed staff) states that any 
information and all the study documents provided by the Sponsor will be maintained strictly 
confidential. 
None of this material may be disclosed to any party not directly involved in the study without 
written permission from Sponsor. 
The Investigator will supply the Sponsor with all the data/results from the study.  
All information concerning the study, the product as well as data and results of the study are 
confidential and property of the Sponsor. The Sponsor will prepare the final report, including 
the statistical and clinical evaluations. The Investigator’s agreement and signature will be 
obtained and a copy will be provided to the Investigator. 
Sponsor reserves the exclusive right to publish and present data and results of the present 
study at scientific meetings, or to submit these clinical trial data to national and international 
Regulatory Authorities. The Investigator may not use the results of this study for publication 
or presentation without written authorization from Sponsor. 
 
 
 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 39 of 52 
 
  
 
 
 
 
 
 
18. REFERENCES 
1. Houston DK, Ding J, Lee JS et al. Dietary fat and cholesterol and risk of cardiovascular 
disease in older adults: the Health ABC Study. Nutr Metab Cardiovasc Dis 2011;21:430–
7. 
2. USDA and US Department of Health and Human Services. Dietary guidelines for 
Americans. 7th ed. 2010. Washington (DC): US Government Printing Office; 2010 
3. Expert Dyslipidemia Panel of the International Atherosclerosis Society Panel members. 
An International Atherosclerosis Society Position Paper: global recommendations for the 
management of dyslipidemia—full report. J Clin Lipidol 2014;8:29–60 
4. Graham I, Atar D, Borch-Johnsen K, et al. European guidelines on cardiovascular 
disease prevention in clinical practice: executive summary: Fourth Joint Task Force of 
the European Society of Cardiology and Other Societies on Cardiovascular Disease 
Prevention in Clinical Practice. Eur Heart J 2007;28:2375–414. 
5. 2016 ESC/EAS Guidelines for the Management of Dyslipidaemias, European Heart 
Journal doi:10.1093/eurheartj/ehw272. 
6. Vivekananthan DP, Penn MS, Sapp SK et al. Use of antioxidant vitamins for the 
prevention of cardiovascular disease: meta-analysis of randomised trials 2003. Lancet 
2003;361:2017–23. 
7. Cannon CP, Blazing MA, Giugliano RP et al. Ezetimibe added to statin therapy after 
acute coronary syndromes. N Engl J Med 2015; 372:2387-2397. 
8. Ostlund RE Jr. Phytosterols and cholesterol metabolism. Curr Opin Lipidol. 2004 
Feb;15(1):37-41. 
9. Heber D, Lembertas A, Lu QY et al. An analysis of nine proprietary Chinese red yeast 
rice dietary supplements: implications of variability in chemical profile and contents. J 
Altern Complement Med. 2001;7(2):133–139. 
10. Ma J, Li Y, Ye Q, et al. Constituents of red yeast rice, a traditional Chinese food and 
medicine. J Agric Food Chem. 2000;48(11):5220–5225. 
11. Goldstein MR. Effects of dietary phytosterols on cholesterol metabolism and 
atherosclerosis. Am J Med. 2000;109(1):72–73. 
12. Cicero AFG, Morbini M, Parini A et al. Effect of red yeast rice combined with antioxidants 
on 
lipid 
pattern, 
hs-CRP 
level, 
and 
endothelial 
function 
in 
moderately 
hypercholesterolemic subjects. Ther Clin Manag. 2016;12:281-286. 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 40 of 52 
 
  
 
 
 
 
 
 
13. Wenshu L., Zhirong G, Ming w et al. Index of central obesity as a parameter to replace 
waist circumference for the definition of metabolic syndrome in predicting cardiovascular 
disease. J Cardiovasc Med (Hagerstown) 2014 Oct;15(10):738-44. 
14. Lee JH, Kim D, Kim HJ, Lee CH, Yang JI, Kim W, Kim YJ, Yoon JH, Cho SH, Sung MW, 
Lee HS (2010) Hepatic steatosis index: a simple screening tool reflecting nonalcoholic 
fatty liver disease. Dig Liver Dis 42:503–508. 
15. Bedogni G, Kahn HS, Bellentani S, Tiribelli C (2010) A simple index of lipid over 
accumulation is a good marker of liver steatosis. BMC Gastroenterol 10:98. 
 
 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
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20. Investigator’s approval Page  
 
INVESTIGATOR’S APPROVAL PAGE 
(original to be kept in the Trial Center File) 
 
 
 
I understand that all information concerning the product Phytosterols 800 mg + DIF1STAT® supplied by A. 
Menarini Industrie Farmaceutiche Riunite S.r.l. in connection with this study protocol are confidential 
information. This information includes: Protocol, Investigator’s Brochure, Case Report Form, Other documents 
in the context of this study. 
 
I understand that any change in this study protocol must be approved in writing by the Sponsor the Co-ordinating 
Investigator and the Ethics Committee before implementation, except where necessary to eliminate apparent 
immediate hazard to patients. 
 
I confirm that I will conduct the study according to this protocol (except when mutually agreed to in writing with 
the Sponsor, the Good Clinical Practice (GCP), the Declaration of Helsinki and laws and regulations in the Country 
where the study is to be conducted. 
 
I confirm that I will record and report all adverse events occurring during the study, according to this protocol. 
I confirm that I am informed about the need of data records retention, according to current regulations and that no 
data can be destroyed without the written consent of the Sponsor. 
I confirm that I will transfer adequate ownership of my responsibilities for the trial and will inform the Sponsor, in 
case I retire from my PI role. 
I confirm that in case the Trial Center File is stolen or anyhow damaged, I will promptly inform the Sponsor and 
declare it to the Competent Authorities. 
 
 
Principal Investigator: ____________________________________________________ 
 
Signature & Date: _________________________________________________________    
 
 
 
 
 
 
 
 
 
 
                         

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 43 of 52 
 
  
 
 
 
 
 
 
 
 
21. APPENDICES 
21.1 Appendix 1: General Guidelines for a Proper Mediterranean Style Diet 
 
GENERAL DIETARY SUGGESTIONS: 
- Keep meal times constant (3 main meals, 2 snacks between meals). 
- Avoid large meals and feeling full. 
- Avoid associating bread and pasta/rice, bread and potatoes, pasta/rice and potatoes during a 
single meal. 
- Try to eat pasta/rice at lunch and meat/fish at dinner.  
- If possible, start your meal with vegetables, possibly raw (without limits), with an oil, lemon and 
vinegar dressing. 
- Do not lie down immediately after meals, but do regular physical activity.  
 
Type of food 
Avoid 
Limit (= acceptable if 
not in excess)
Preferred 
Carbohydrates
(Pasta, bread, 
etc.) 
Egg pasta, soft wheat pasta, 
rice pasta, gluten-free pasta, 
corn pasta, toast, bread 
containing lard (even if whole 
wheat!), boiled brown rice, 
French fries, mashed 
potatoes; packaged bakery 
products containing 
transesterified fatty acids (on 
the label indicated as 
“hydrogenated fats” or 
“partially hydrogenated fats”)  
Boiled partial whole 
grain rice, potatoes 
(even boiled and 
baked!), polenta (grits)
Partial whole wheat or 
whole wheat bread 
without lard, durum 
wheat pasta cooked until 
just firm (better long 
pasta than short pasta), 
pasta with added fiber, 
boiled partial whole grain 
rice cooked until just 
firm, soups with cereals 
(oats and barley)  
Meat 
 
Offal, tongue, liver, pig 
trotters, cotechino, capocollo 
(cured pork shoulder), fatty 
meat, lamb, canned meat, 
lard, sausage, salami, 
bologna, greaves, bacon, and 
in general all fatty cold cuts. 
Eggs: 2 per week 
(including “hidden” 
eggs in egg pasta, 
cream etc.) 
Bresaola or cold cuts 
from which fat can be 
removed such as ham 
or speck 
Lean meat: poultry 
(cooked without skin!), 
pork (lean cuts with fat 
removed before cooking; 
ex.: filet, shoulder), beef 
(lean cuts with fat 
removed before 
cooking), rabbit, guinea 
fowl, pheasant, quail, 
horse meat, goat meat 
(kid), frog. 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 44 of 52 
 
  
 
 
 
 
 
 
Preferred cooking is 
grilled with extra-virgin 
olive oil and spices. 
Fish 
Eel, roe, crustaceans (shrimp, 
scampi, lobster), clams, 
mussels, oysters and other 
shellfish 
Fish in oil 
 
Sardines, mackerel, 
sole, bass, sea bream, 
trout, tuna, salmon, 
cuttlefish squid (not 
fried!)
Dairy products 
Medium-fat cheeses (fontina, 
edamer, emmenthal) and 
high-fat cheeses (asiago, 
gorgonzola, camembert, brie, 
bleu), and buffalo mozzarella 
Seasoned cheeses 
(parmesan, pecorino), 
used on pasta or as 
shavings after a meal 
Low-fat cheeses (ricotta, 
spreadable light cheeses 
or shavings of light 
cheeses, light cow 
mozzarella), skimmed 
milk. 
Whole milk, whole goat milk, 
cream (liquid and whipped)  
 
Low-fat milk (2%) 
 
Whole milk yogurt 
Low-fat yogurt 
Yogurt from skimmed 
milk
Dressings and 
seasoning 
Butter, lard, margarine 
containing animal fat, peanut 
oil, palm oil, coconut oil, 
mixed seed oil 
Mayonnaise (in 
moderate doses), 
olives, margarine 
100% vegetable 
Extra-virgin olive oil, 
corn oil, rice oil, vinegar, 
lemon, spices (pepper, 
chili peppers, saffron, 
curry, herbs)
Vegetables 
None 
Carrots, zucchini, 
squash (especially 
cooked) 
All legumes, green leafy 
vegetables, better if raw. 
Fruit 
Fruit in syrup, grapes, 
bananas, figs, pineapple, 
coconuts, avocados, 
macadamia nuts, cashew 
nuts, pecans, peanuts, dried 
fruit (dates, dried figs), 
candied fruit 
Unsweetened canned 
fruit and fruit juice 
Fresh seasonal fruit with 
skin (not more than 200 
grams per meal). Dried 
fruit such as almonds, 
walnuts or hazelnuts (not 
more than 20 grams 
shelled a day). 
Beverages 
Strong beer, liquor, strong 
wine, sweet cider, sparkling 
wine, sweetened beverages 
and fruit juice, syrups, 
“energy drinks,” mineral 
supplements containing 
glucose (read label!!!) 
Unsweetened 
beverages and fruit 
juice (carbonated and 
non) (not more than 
one glass a day), dry 
cider, low alcohol beer 
(1 can) or wine (1 
glass) with meals
Spring water, still or 
sparkling 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 45 of 52 
 
  
 
 
 
 
 
 
Dessert 
Cakes with cream, pastries, 
ice cream, sorbets, fruit 
gelatin with sugar, sweetened 
breakfast cereals, caramel, 
milk chocolate, coconut, 
honey, packaged bakery 
products containing 
transesterified fatty acids (on 
the label indicated as 
“hydrogenated fats” or 
“partially hydrogenated fats”). 
2 bars of extra dark 
chocolate with low 
quantity of sugar, 
Uno low-fat yogurt 
with 2-3 nuts and one 
spoonful of honey, 
spreadable hazelnut 
cream without added 
sugar (max. 1 
tablespoon) 
An exception as 
“gratification” or special 
occasions is allowed 
within an acceptable 
quantity. 
Artificial sweeteners for 
coffee without milk (max. 
3 times a day) and tea.  
 
 
 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 46 of 52 
 
  
 
 
 
 
 
 
21.2 Appendix 2: Declaration of Helsinki 
 
Adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964 
and amended by the: 
29th WMA General Assembly, Tokyo, Japan, October 1975 
35th WMA General Assembly, Venice, Italy, October 1983 
41st WMA General Assembly, Hong Kong, September 1989 
48th WMA General Assembly, Somerset West, Republic of South Africa, October 1996 
52nd WMA General Assembly, Edinburgh, Scotland, October 2000  
53rd WMA General Assembly, Washington DC, USA, October 2002 (Note of 
Clarification added) 
55th WMA General Assembly, Tokyo, Japan, October 2004 (Note of Clarification added) 
59th WMA General Assembly, Seoul, Republic of Korea, October 2008 
64th WMA General Assembly, Fortaleza, Brazil, October 2013 
Preamble 
1.         The World Medical Association (WMA) has developed the Declaration of Helsinki as a 
statement of ethical principles for medical research involving human subjects, including research on 
identifiable human material and data. 
            The Declaration is intended to be read as a whole and each of its constituent paragraphs should 
be applied with consideration of all other relevant paragraphs. 
2.         Consistent with the mandate of the WMA, the Declaration is addressed primarily to physicians. 
The WMA encourages others who are involved in medical research involving human subjects to adopt 
these principles.  
General Principles 
3.         The Declaration of Geneva of the WMA binds the physician with the words, “The health of my 
patient will be my first consideration,” and the International Code of Medical Ethics declares that, “A 
physician shall act in the patient's best interest when providing medical care.” 
4.         It is the duty of the physician to promote and safeguard the health, well-being and rights of 
patients, including those who are involved in medical research. The physician's knowledge and 
conscience are dedicated to the fulfilment of this duty. 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 47 of 52 
 
  
 
 
 
 
 
 
5.         Medical progress is based on research that ultimately must include studies involving human 
subjects. 
6.         The primary purpose of medical research involving human subjects is to understand the causes, 
development and effects of diseases and improve preventive, diagnostic and therapeutic interventions 
(methods, procedures and treatments). Even the best proven interventions must be evaluated continually 
through research for their safety, effectiveness, efficiency, accessibility and quality. 
7.         Medical research is subject to ethical standards that promote and ensure respect for all human 
subjects and protect their health and rights. 
8.         While the primary purpose of medical research is to generate new knowledge, this goal can never 
take precedence over the rights and interests of individual research subjects. 
9.         It is the duty of physicians who are involved in medical research to protect the life, health, dignity, 
integrity, right to self-determination, privacy, and confidentiality of personal information of research 
subjects. The responsibility for the protection of research subjects must always rest with the physician 
or other health care professionals and never with the research subjects, even though they have given 
consent. 
10.       Physicians must consider the ethical, legal and regulatory norms and standards for research 
involving human subjects in their own countries as well as applicable international norms and standards. 
No national or international ethical, legal or regulatory requirement should reduce or eliminate any of 
the protections for research subjects set forth in this Declaration. 
11.       Medical research should be conducted in a manner that minimises possible harm to the 
environment. 
12.       Medical research involving human subjects must be conducted only by individuals with the 
appropriate ethics and scientific education, training and qualifications. Research on patients or healthy 
volunteers requires the supervision of a competent and appropriately qualified physician or other health 
care professional. 
13.       Groups that are underrepresented in medical research should be provided appropriate access to 
participation in research. 
14.       Physicians who combine medical research with medical care should involve their patients in 
research only to the extent that this is justified by its potential preventive, diagnostic or therapeutic value 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 48 of 52 
 
  
 
 
 
 
 
 
and if the physician has good reason to believe that participation in the research study will not adversely 
affect the health of the patients who serve as research subjects. 
15.       Appropriate compensation and treatment for subjects who are harmed as a result of participating 
in research must be ensured. 
Risks, Burdens and Benefits  
16.       In medical practice and in medical research, most interventions involve risks and burdens. 
           Medical research involving human subjects may only be conducted if the importance of the 
objective outweighs the risks and burdens to the research subjects. 
17.       All medical research involving human subjects must be preceded by careful assessment of 
predictable risks and burdens to the individuals and groups involved in the research in comparison with 
foreseeable benefits to them and to other individuals or groups affected by the condition under 
investigation. 
           Measures to minimise the risks must be implemented. The risks must be continuously monitored, 
assessed and documented by the researcher.  
18.       Physicians may not be involved in a research study involving human subjects unless they are 
confident that the risks have been adequately assessed and can be satisfactorily managed. 
           When the risks are found to outweigh the potential benefits or when there is conclusive proof of 
definitive outcomes, physicians must assess whether to continue, modify or immediately stop the 
study.            
Vulnerable Groups and Individuals 
19.       Some groups and individuals are particularly vulnerable and may have an increased likelihood 
of being wronged or of incurring additional harm. 
           All vulnerable groups and individuals should receive specifically considered protection. 
20.       Medical research with a vulnerable group is only justified if the research is responsive to the 
health needs or priorities of this group and the research cannot be carried out in a non-vulnerable group. 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 49 of 52 
 
  
 
 
 
 
 
 
In addition, this group should stand to benefit from the knowledge, practices or interventions that result 
from the research. 
Scientific Requirements and Research Protocols  
21.       Medical research involving human subjects must conform to generally accepted scientific 
principles, be based on a thorough knowledge of the scientific literature, other relevant sources of 
information, and adequate laboratory and, as appropriate, animal experimentation. The welfare of 
animals used for research must be respected. 
22.       The design and performance of each research study involving human subjects must be clearly 
described and justified in a research protocol. 
           The protocol should contain a statement of the ethical considerations involved and should indicate 
how the principles in this Declaration have been addressed. The protocol should include information 
regarding funding, sponsors, institutional affiliations, potential conflicts of interest, incentives for 
subjects and information regarding provisions for treating and/or compensating subjects who are harmed 
as a consequence of participation in the research study. 
           In clinical trials, the protocol must also describe appropriate arrangements for post-trial provisions. 
Research Ethics Committees 
23.       The research protocol must be submitted for consideration, comment, guidance and approval to 
the concerned research ethics committee before the study begins. This committee must be transparent in 
its functioning, must be independent of the researcher, the sponsor and any other undue influence and 
must be duly qualified. It must take into consideration the laws and regulations of the country or 
countries in which the research is to be performed as well as applicable international norms and standards 
but these must not be allowed to reduce or eliminate any of the protections for research subjects set forth 
in this Declaration.  
           The committee must have the right to monitor ongoing studies. The researcher must provide 
monitoring information to the committee, especially information about any serious adverse events. No 
amendment to the protocol may be made without consideration and approval by the committee. After 
the end of the study, the researchers must submit a final report to the committee containing a summary 
of the study’s findings and conclusions.  
 
 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 50 of 52 
 
  
 
 
 
 
 
 
Privacy and Confidentiality  
24.       Every precaution must be taken to protect the privacy of research subjects and the confidentiality 
of their personal information. 
Informed Consent  
25.       Participation by individuals capable of giving informed consent as subjects in medical research 
must be voluntary. Although it may be appropriate to consult family members or community leaders, no 
individual capable of giving informed consent may be enrolled in a research study unless he or she freely 
agrees. 
26.       In medical research involving human subjects capable of giving informed consent, each potential 
subject must be adequately informed of the aims, methods, sources of funding, any possible conflicts of 
interest, institutional affiliations of the researcher, the anticipated benefits and potential risks of the study 
and the discomfort it may entail, post-study provisions and any other relevant aspects of the study. The 
potential subject must be informed of the right to refuse to participate in the study or to withdraw consent 
to participate at any time without reprisal. Special attention should be given to the specific information 
needs of individual potential subjects as well as to the methods used to deliver the information. 
           After ensuring that the potential subject has understood the information, the physician or another 
appropriately qualified individual must then seek the potential subject’s freely-given informed consent, 
preferably in writing. If the consent cannot be expressed in writing, the non-written consent must be 
formally documented and witnessed.       
           All medical research subjects should be given the option of being informed about the general 
outcome and results of the study. 
27.       When seeking informed consent for participation in a research study the physician must be 
particularly cautious if the potential subject is in a dependent relationship with the physician or may 
consent under duress. In such situations the informed consent must be sought by an appropriately 
qualified individual who is completely independent of this relationship. 
28.       For a potential research subject who is incapable of giving informed consent, the physician must 
seek informed consent from the legally authorised representative. These individuals must not be included 
in a research study that has no likelihood of benefit for them unless it is intended to promote the health 
of the group represented by the potential subject, the research cannot instead be performed with persons 
capable of providing informed consent, and the research entails only minimal risk and minimal burden. 

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 51 of 52 
 
  
 
 
 
 
 
 
29.       When a potential research subject who is deemed incapable of giving informed consent is able 
to give assent to decisions about participation in research, the physician must seek that assent in addition 
to the consent of the legally authorised representative. The potential subject’s dissent should be 
respected. 
30.       Research involving subjects who are physically or mentally incapable of giving consent, for 
example, unconscious patients, may be done only if the physical or mental condition that prevents giving 
informed consent is a necessary characteristic of the research group. In such circumstances the physician 
must seek informed consent from the legally authorised representative. If no such representative is 
available and if the research cannot be delayed, the study may proceed without informed consent 
provided that the specific reasons for involving subjects with a condition that renders them unable to 
give informed consent have been stated in the research protocol and the study has been approved by a 
research ethics committee. Consent to remain in the research must be obtained as soon as possible from 
the subject or a legally authorised representative. 
31.       The physician must fully inform the patient which aspects of their care are related to the research. 
The refusal of a patient to participate in a study or the patient’s decision to withdraw from the study must 
never adversely affect the patient-physician relationship. 
32.       For medical research using identifiable human material or data, such as research on material or 
data contained in biobanks or similar repositories, physicians must seek informed consent for its 
collection, storage and/or reuse. There may be exceptional situations where consent would be impossible 
or impracticable to obtain for such research. In such situations the research may be done only after 
consideration and approval of a research ethics committee. 
Use of Placebo 
33.       The benefits, risks, burdens and effectiveness of a new intervention must be tested against those 
of the best proven intervention(s), except in the following circumstances: 
           Where no proven intervention exists, the use of placebo, or no intervention, is acceptable; or 
           Where for compelling and scientifically sound methodological reasons the use of any intervention 
less effective than the best proven one, the use of placebo, or no intervention is necessary to determine 
the efficacy or safety of an intervention  
           and the patients who receive any intervention less effective than the best proven one, placebo, or 
no intervention will not be subject to additional risks of serious or irreversible harm as a result of not 
receiving the best proven intervention.  

              Menarini Group 
                    
 
 
Sponsor: A. Menarini Industrie Farmaceutiche Riunite S.r.l. 
 
Study Code: MEIF/16/MOF-Col/001 
 
Amended Protocol Version 4.0 of 16.04.2018 
  
 
 
 
CONFIDENTIAL                                                                                                                                   Page 52 of 52 
 
  
 
 
 
 
 
 
           Extreme care must be taken to avoid abuse of this option. 
Post-Trial Provisions 
34.       In advance of a clinical trial, sponsors, researchers and host country governments should make 
provisions for post-trial access for all participants who still need an intervention identified as beneficial 
in the trial. This information must also be disclosed to participants during the informed consent process. 
Research Registration and Publication and Dissemination of Results 
35.       Every research study involving human subjects must be registered in a publicly accessible 
database before recruitment of the first subject. 
36.       Researchers, authors, sponsors, editors and publishers all have ethical obligations with regard to 
the publication and dissemination of the results of research. Researchers have a duty to make publicly 
available the results of their research on human subjects and are accountable for the completeness and 
accuracy of their reports. All parties should adhere to accepted guidelines for ethical reporting. Negative 
and inconclusive as well as positive results must be published or otherwise made publicly available. 
Sources of funding, institutional affiliations and conflicts of interest must be declared in the publication. 
Reports of research not in accordance with the principles of this Declaration should not be accepted for 
publication. 
Unproven Interventions in Clinical Practice 
37.       In the treatment of an individual patient, where proven interventions do not exist or other known 
interventions have been ineffective, the physician, after seeking expert advice, with informed consent 
from the patient or a legally authorised representative, may use an unproven intervention if in the 
physician's judgement it offers hope of saving life, re-establishing health or alleviating suffering. This 
intervention should subsequently be made the object of research, designed to evaluate its safety and 
efficacy. In all cases, new information must be recorded and, where appropriate, made publicly available.