A Phase 3, Open-label Study to Evaluate the Efficacy and Safety of REPLAGAL® in Treatment-naïve Subjects With Fabry Disease
Phase: PHASE3
Conditions: Fabry Disease
Sponsor: Shire

NCT Number: NCT04840667
Title: A Phase 3, Open-label Study to Evaluate the Efficacy and Safety of 
REPLAGAL® in Treatment-naïve Subjects with Fabry Disease 
Study Number: SHP675-301
Document Version and Date: Amendment 06 (17 February 2022)
Certain information within this document has been redacted (i.e., specific content is 
masked irreversibly from view) to protect either personally identifiable information or 
company confidential information.
Clinical Study Protocol

PROTOCOL: SHP675-301
TITLE:
A Phase 3, Open-label Study to Evaluate the Efficacy and Safety of 
REPLAGAL® in Treatment-naïve Subjects with Fabry Disease 
SHORT TITLE:
A Phase 3, Open-label Study to Evaluate the Efficacy and Safety of 
REPLAGAL® in Treatment-naïve Subjects with Fabry Disease
STUDY PHASE:
3
ACRONYM:
Not Applicable 
DRUG:
REPLAGAL® (SHP675) 
IND NUMBER:
Non-IND 
EUDRACT 
NUMBER:
2018-004689-32
OTHER 
NUMBER:
Not Applicable
SPONSOR:
Shire Human Genetic Therapies, Inc., a wholly owned subsidiary of 
Takeda Pharmaceutical Company Limited
300 Shire Way, Lexington, MA 02421 USA
PRINCIPAL/
COORDINATING
INVESTIGATOR:
Not Applicable
PROTOCOL 
HISTORY:
Amendment 6: 17 February 2022
Amendment 5: 22 July 2021
Amendment 4: 24 June 2021
Amendment 3: 30 April 2021
Amendment 2: 21 January 2021
Amendment 1: 01 April 2020
Original Protocol: 17 January 2019 
This document contains confidential and proprietary information of Shire and is disclosed pursuant to 
confidentiality and nondisclosure obligations. This information should be used solely for the purposes for which 
it was provided and should not be copied, shared with, or disclosed to any third party without the express written 
consent of Shire.
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CONFIDENTIAL
Page 2
SHP675-301 Protocol Amendment 6
REPLAGAL® (agalsidase alfa) 
17 Feb 2022
SUMMARY OF CHANGES FROM PREVIOUS PROTOCOL VERSION
The table below provides an overview of the changes from the previous version (dated 
22 July 2021) to the current version of the protocol (Amendment 6).
The reasons for this amendment are to correct the conversion of the protein/creatinine ratio units 
in exclusion criterion 3, clarify the process of rescreening of subjects with prior approval of the 
sponsor medical monitor, clarify early termination and End of Treatment visit procedures for 
subjects who discontinue the study or IP treatment, specify SAE reporting procedures, and to 
remove references to paper assessments as a back-up to record PRO assessments.
Grammatical, typographical, or minor edits for clarity, administrative, and general formatting 
revisions are not identified. 
Protocol Amendment
Summary of Changes Since the Last Version of the Approved Protocol
Amendment Number
6
Amendment Date
17 Feb 2022
Global
Sections Affected by Change
Description of Each Change
Rationale for Change
Protocol Signature Page, 
Emergency Contact Information
Updated signatory and contact 
information
Personnel and procedural 
updates.
Section 1.1 Synopsis, Section 5.2
Corrected Exclusion Criterion #3 
regarding protein-creatinine ratio
To correct the conversion 
after changing the urine 
protein/creatinine ratio units 
from mg/mmol to mg/mg in 
Amendment 1.
Section 1.1 Synopsis, Section 4.4
Updated study duration
Updated year of study start.
Table 1 (footnote g), Section 7.3, 
Section 8.1.3.4
Clarified procedures for subjects 
who discontinue treatment 
To specify that subjects who 
discontinue treatment but 
remain in the study should 
complete the EoT 
assessments within 
10-21 days of the subject’s
last dose.
Table 1 (footnote a), Section 7.3, 
Section 8.1.3.4
Clarified rescreening procedures
To clarify circumstances 
under which subjects could 
be rescreened, and to clarify 
that some procedures may 
not need to be repeated for 
rescreening.
Section 6.7, Section 7.1, Section 8.1.1
Clarified that rescreening of 
subjects requires prior approval by 
sponsor medical monitor and this 
process is not limited solely to 
COVID-19 related issues
To ensure subjects
appropriate for the study are 
not excluded. 
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CONFIDENTIAL
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SHP675-301 Protocol Amendment 6
REPLAGAL® (agalsidase alfa) 
17 Feb 2022
Protocol Amendment
Summary of Changes Since the Last Version of the Approved Protocol
Amendment Number
6
Amendment Date
17 Feb 2022
Global
Sections Affected by Change
Description of Each Change
Rationale for Change
Section 6.2.3, Section 6.7, Section 8.2.4.3, 
Appendix 5
Removed references to paper 
back-up assessments for PRO data 
collection if patient would not be 
able to attend clinic visit. Added 
new text about web-based data 
collection in case of device 
unavailability.
Paper back-ups were added 
incorrectly; they will not be 
used for this study
Appendix 3.4, Appendix 3.5
Changed SAE reporting process
To include and specify 
processes for reporting 
SAEs to the electronic data 
capture system
Appendix 3.8
Changed pregnancy reporting 
process
To include and specify 
processes for reporting 
pregnancy events 
See Appendix 7 for protocol history, including all amendments.
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CONFIDENTIAL
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SHP675-301 Protocol Amendment 6
REPLAGAL® (agalsidase alfa) 
17 Feb 2022
PROTOCOL SIGNATURE PAGE
Sponsor’s (Shire) Approval
Signature:
Date:
Clinical Science, Marketed Products Group
Investigator’s Acknowledgement
I have read this protocol for Study SHP675-301.
Title: A Phase 3, Open-label Study to Evaluate the Efficacy and Safety of REPLAGAL® in 
Treatment-naïve Subjects with Fabry Disease
I have fully discussed the objective(s) of this study and the contents of this protocol with the 
sponsor’s representative.
I understand that the information in this protocol is confidential and should not be disclosed, 
other than to those directly involved in the execution or the scientific/ethical review of the study, 
without written authorization from the sponsor. It is, however, permissible to provide the 
information contained herein to a subject in order to obtain their consent to participate.
I agree to conduct this study according to this protocol and to comply with its requirements, 
subject to ethical and safety considerations and guidelines, and to conduct the study in 
accordance with International Council for Harmonisation of Technical Requirements for 
Registration of Pharmaceuticals for Human Use guidelines on Good Clinical Practice and with 
the applicable regulatory requirements.
I understand that failure to comply with the requirements of the protocol may lead to the 
termination of my participation as an investigator for this study.
I understand that the sponsor may decide to suspend or prematurely terminate the study at any
time for whatever reason; such a decision will be communicated to me in writing. Conversely, 
should I decide to withdraw from execution of the study I will communicate my intention 
immediately in writing to the sponsor.
Investigator Name and Address:
(please handprint or type)
Signature:
Date:
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Shire
CONFIDENTIAL
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SHP675-301 Protocol Amendment 6
REPLAGAL® (agalsidase alfa) 
17 Feb 2022
EMERGENCY CONTACT INFORMATION
If a subject experiences a serious adverse event (SAE) requiring expedited reporting per the 
protocol, the investigator must report the event to the sponsor’s Global Patient Safety Evaluation 
department within 24 hours of awareness, by transmitting an electronic data capture (EDC) SAE 
report, the preferred method of reporting SAEs.
If access to EDC is not feasible within 24 hours of receiving notice of the event, the relevant 
form (provided separately from this protocol):
Sponsor "Safety Report” or “Pregnancy Report” should be submitted using the fax
number or email address below.
Fax number: +1-484-595-8155 (Use the email below to request a confirmation that the faxed 
SAE report was received.)
Email: drugsafety@shire.com
Sponsor medical monitor:
 MD, PhD, 
 Clinical Science
Marketed Products Group
Email: 
PPD
PPD
PPD
For non-commercial use only
C
ercia
no

Shire
CONFIDENTIAL
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SHP675-301 Protocol Amendment 6
REPLAGAL® (agalsidase alfa) 
17 Feb 2022
PRODUCT QUALITY COMPLAINTS
Investigators are required to report any investigational product quality complaints or nonmedical 
complaints to Shire within 24 hours. If requested, defective product(s) will be returned to the 
sponsor for inspection and analysis.
A product quality complaint includes any instances where there is an allegation or report relating 
to Shire licensed or investigational products, received in writing, electronically, or orally, which 
indicates an impact to a product’s strength, identity, safety, purity, or quality, or which suggests 
that a product did not meet the criteria defined in the regulatory applications, licenses, or 
marketing authorizations for the product. Examples of investigational product quality complaints 
include, but are not limited to, the following:
Unit issues

Capsule fill empty or overage

Bottle/vial fill shortage or overage

Capsule/tablet damaged/broken

Syringe/vial cracked/broken

Syringe leakage

Missing components

Product discoloration

Device malfunction
Labeling

Label missing

Leaflet or Instructions For Use
(IFU) missing

Label illegible

Incomplete, inaccurate, or 
misleading labeling

Lot number or serial number 
missing
Packaging

Damaged packaging (eg, 
secondary, primary, bag/pouch)

Tampered seals

Inadequate or faulty closure

Missing components within 
package
Foreign
material

Contaminated product

Particulate in bottle/vial

Particulate in packaging
Please report the product quality complaint using the “Product Complaint Data Collection Form” 
via the following email address:
PQC@shire.com
For instructions on reporting AEs related to product complaints, see Appendix 3.4.
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CONFIDENTIAL
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SHP675-301 Protocol Amendment 6
REPLAGAL® (agalsidase alfa) 
17 Feb 2022
TABLE OF CONTENTS
SUMMARY OF CHANGES FROM PREVIOUS PROTOCOL VERSION..................................2
PROTOCOL SIGNATURE PAGE .................................................................................................4
EMERGENCY CONTACT INFORMATION................................................................................5
PRODUCT QUALITY COMPLAINTS..........................................................................................6
TABLE OF CONTENTS.................................................................................................................7
LIST OF TABLES.........................................................................................................................11
LIST OF FIGURES .......................................................................................................................11
LIST OF APPENDICES................................................................................................................11
1
PROTOCOL SUMMARY......................................................................................................12
1.1
Synopsis ...................................................................................................................12
1.2
Schedule of Activities ..............................................................................................20
2
INTRODUCTION..................................................................................................................25
2.1
Indication and Current Treatment Options...............................................................25
2.2
Product Background, Clinical Information, and Risk Benefit .................................26
2.3
Study Rationale ........................................................................................................28
2.4
Compliance Statement..............................................................................................28
3
OBJECTIVES AND ENDPOINTS........................................................................................29
3.1
Study Objectives ......................................................................................................29
3.1.1
Primary Objective..................................................................................................29
3.1.2
Secondary Objectives.............................................................................................29
3.1.3
Exploratory Objectives ..........................................................................................29
3.1.4
Rationale for the Selection of the Primary Endpoints ...........................................29
3.2
Study Endpoints .......................................................................................................30
4
STUDY DESIGN ...................................................................................................................33
4.1
Overall Design..........................................................................................................33
4.2
Scientific Rationale for the Reference-Controlled Study Design ............................34
4.3
Justification for Dose ...............................................................................................37
4.4
Duration of Subject Participation and Study Completion Definition ......................37
4.5
Sites and Regions .....................................................................................................37
5
STUDY POPULATION.........................................................................................................38
5.1
Inclusion Criteria......................................................................................................38
5.2
Exclusion Criteria.....................................................................................................39
5.3
Restrictions...............................................................................................................40
5.4
Reproductive Potential .............................................................................................40
5.4.1
Female Contraception............................................................................................40
5.4.2
Male Contraception................................................................................................40
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6
STUDY INTERVENTION ....................................................................................................41
6.1
Investigational Product.............................................................................................41
6.1.1
Identity of Investigational Product.........................................................................41
6.1.2
Blinding the Treatment Assignment......................................................................41
6.2
Administration of Investigational Product ...............................................................41
6.2.1
Infusions of REPLAGAL in the Home Setting .........................................................41
6.2.2
Management of Infusion-related Reactions...........................................................42
6.2.3
Interactive Response Technology for Investigational Product Management ........42
6.2.4
Allocation of Subjects to Treatment ......................................................................43
6.2.5
Dosing....................................................................................................................43
6.2.6
Dose Modification .................................................................................................43
6.3
Labeling, Packaging, Storage, and Handling of Investigational Product.................44
6.3.1
Labeling .................................................................................................................44
6.3.2
Packaging...............................................................................................................44
6.3.3
Storage ...................................................................................................................44
6.3.4
Handling.................................................................................................................44
6.4
Drug Accountability.................................................................................................45
6.5
Subject Compliance..................................................................................................46
6.6
Prior and Concomitant Therapy ...............................................................................46
6.6.1
Prior Treatment ......................................................................................................46
6.6.2
Concomitant Treatment .........................................................................................46
6.6.3
Prohibited Treatment .............................................................................................46
6.7
COVID-19-related Protocol Considerations ............................................................47
7
SCREEN FAILURE, WITHDRAWAL FROM THE STUDY, DISCONTINUATION 
OF STUDY TREATMENT, AND LOST TO FOLLOW-UP...........................................48
7.1
Screen Failure...........................................................................................................48
7.2
Withdrawal from the Study......................................................................................48
7.3
Discontinuation of Study Treatment ........................................................................49
7.4
Lost to Follow-up.....................................................................................................51
8
STUDY ASSESSMENTS AND PROCEDURES..................................................................52
8.1
Study Periods............................................................................................................52
8.1.1
Screening Period (Day -50 through Day -8)..........................................................52
8.1.1.1
Screening Visit(s)...................................................................................52
8.1.2
Baseline Period (Day -7 to Day 0/Week 0) ...........................................................53
8.1.3
Treatment Period (Day 0/Week 0 through Week 104 or Early Termination) .......55
8.1.3.1
Every Other Week Visits........................................................................55
8.1.3.2
Week 12, Week 40, Week 64, and Week 92 Visits ...............................56
8.1.3.3
Week 26, Week 52, and Week 78 Visits................................................57
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8.1.3.4
Week 104 Visit (End of Treatment) or Early Termination ....................58
8.1.4
Follow-up Period ...................................................................................................59
8.1.5
Additional Care of Subjects after the Study ..........................................................59
8.2
Study Assessments ...................................................................................................60
8.2.1
Demographic and Other Baseline Characteristics .................................................60
8.2.1.1
Demographics.........................................................................................60
8.2.1.2
Confirmation of Study Eligibility ..........................................................60
8.2.1.3
Confirmation of Fabry Disease (GLA Activity and Genotyping)..........60
8.2.1.4
Medical History......................................................................................60
8.2.2
Efficacy..................................................................................................................61
8.2.2.1
Cardiac Magnetic Resonance Imaging (cMRI)......................................61
8.2.2.2
Estimated Glomerular Filtration Rate (eGFR).......................................61
8.2.2.3
Proteinuria ..............................................................................................61
8.2.3
Safety .....................................................................................................................61
8.2.3.1
Physical Examination.............................................................................61
8.2.3.2
Height.....................................................................................................62
8.2.3.3
Weight ....................................................................................................62
8.2.3.4
Adverse Events.......................................................................................62
8.2.3.5
Vital Signs..............................................................................................62
8.2.3.6
Clinical Laboratory Tests (Serum Chemistry, Hematology, and 
Urinalysis) ..............................................................................................63
8.2.3.7
Pregnancy Test .......................................................................................63
8.2.3.8
Electrocardiogram ..................................................................................64
8.2.3.9
Anti-drug Antibody Testing...................................................................64
8.2.3.10
Prior/Concomitant Medications, Therapies, and Medical/Surgical 
Interventions Assessments .....................................................................64
8.2.3.11
Viral Testing...........................................................................................64
8.2.4
Other ......................................................................................................................65
8.2.4.1
Investigational Product Administration .................................................65
8.2.4.2
Pharmacodynamics.................................................................................65
8.2.4.3
Health-related QoL Assessments ...........................................................65
8.2.5
Retention of Testing Samples................................................................................67
8.2.6
Volume of Blood to Be Drawn From Each Subject ..............................................67
9
STATISTICAL CONSIDERATIONS ...................................................................................68
9.1
Statistical Analysis Process......................................................................................68
9.2
Planned Interim Analysis, Adaptive Design, and Data Monitoring Committee......68
9.3
Sample Size and Power Considerations...................................................................68
9.4
Statistical Analysis Sets ...........................................................................................70
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9.5
Efficacy Analyses.....................................................................................................70
9.5.1
Primary Efficacy Endpoint ....................................................................................70
9.5.2
Secondary Efficacy Endpoints...............................................................................72
9.5.3
Multiplicity Adjustment.........................................................................................73
9.5.4
Control of Type I Error..........................................................................................73
9.5.5
Exploratory Efficacy Endpoints.............................................................................73
9.6
Safety Analyses........................................................................................................73
9.7
Other Analyses .........................................................................................................74
9.7.1
Health-related Quality of Life Analyses................................................................74
9.7.2
Sensitivity Analysis ...............................................................................................75
9.8
Missing, Unused, and Spurious Data .......................................................................75
10 REFERENCES .......................................................................................................................77
11
SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS .........81
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LIST OF TABLES
Table 1
Schedule of Activities....................................................................................20
Table 2
Objectives and Endpoints..............................................................................31
Table 3
Assessments for Physical Examinations .......................................................62
Table 4
Schedule for Recording of Vital Signs at Infusion........................................63
Table 5
Volume of Blood to Be Drawn From Each Subject......................................67
LIST OF FIGURES
Figure 1
Study Design Flow Chart ..............................................................................34
LIST OF APPENDICES
Appendix 1
Regulatory, Ethical, and Study Oversight Considerations ............................82
Appendix 2
Clinical Laboratory Tests ..............................................................................89
Appendix 3
Adverse Events: Definitions and Procedures for Recording, 
Evaluating, Follow-Up, and Reporting .........................................................90
Appendix 4
Contraceptive Guidance ................................................................................99
Appendix 5
Scales and Assessments...............................................................................100
Appendix 6
Abbreviations ..............................................................................................122
Appendix 7
Protocol History...........................................................................................125
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1
PROTOCOL SUMMARY
1.1
Synopsis 
Protocol number: SHP675-301
Drug: Agalsidase alfa (REPLAGAL®; SHP675)
Title of the study: A Phase 3, Open-label Study to Evaluate the Efficacy and Safety of REPLAGAL® in 
Treatment-naïve Subjects with Fabry Disease
Short title: A Phase 3, Open-label Study to Evaluate the Efficacy and Safety of REPLAGAL® in Treatment-naïve 
Subjects with Fabry Disease
Study phase: 3
Number of subjects: It is anticipated that at least 45 subjects will need to be enrolled in the study in order to 
obtain 36 evaluable subjects, ie, subjects who have not discontinued from investigational product and who have 
valid, nonmissing values of primary efficacy endpoints (estimated glomerular filtration rate [eGFR] and left 
ventricular mass index [LVMI]) for baseline and Week 104 assessments (completers set).
In efforts to achieve equal representation, the study will target approximately 40% females and 40% males for 
enrollment.
Investigator(s): This is an international, multicenter study.
Site(s) and Region(s): This study is expected to be conducted at up to 50 sites globally.
Study period (planned): The planned study duration 
is approximately 6 years from the first subject enrolled 
(2022).
Clinical phase: 3
Objectives:
Primary Objective: 
The primary objective is to evaluate the efficacy of REPLAGAL (0.2 mg/kg every other week [EOW] for up to
104 weeks) on renal (eGFR) and cardiac (LVMI) parameters in subjects with a confirmed diagnosis of Fabry 
disease and who are naïve to any Fabry-specific treatment. 
Secondary Objectives: 
The secondary objectives are:

To evaluate the efficacy of REPLAGAL 0.2 mg/kg EOW on other renal and cardiac variables and 
pharmacodynamic (PD) markers

To assess the safety and tolerability of REPLAGAL over the study period.
Exploratory Objectives: 
The exploratory objectives are:

To evaluate the effect of REPLAGAL on inflammatory biomarkers relevant to Fabry disease

To assess the effect of REPLAGAL on the subject’s overall rating of pain, fatigue, severity of Fabry 
symptoms and quality of life

To evaluate the effects of REPLAGAL on gastrointestinal (GI) symptoms of Fabry disease.
Rationale:
This Phase 3 study will be conducted to confirm the efficacy of REPLAGAL 0.2 mg/kg EOW for up to 104 weeks 
of treatment in subjects with Fabry disease who are naïve to any Fabry-specific treatment.
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Investigational product, dose, and mode of administration:
REPLAGAL (agalsidase alfa) will be administered at the globally approved dose of 0.2 mg/kg EOW by intravenous 
(IV) infusion over 40 minutes (±10 minutes).
Methodology:
This is a global, Phase 3, multicenter, nonrandomized, open-label, single-arm, baseline-controlled study.
Eligible participants will be male and female adult subjects who are treatment naïve and who have a confirmed 
diagnosis of Fabry disease with left ventricular hypertrophy. Subjects with or without renal involvement may 
qualify for the study if their eGFR is 45 to 120 mL/min/1.73 m2, as calculated by the Chronic Kidney 
Disease-Epidemiology (CKD-EPI) formula.
The study will include 1 arm, comprising subjects prospectively treated with REPLAGAL for up to 104 weeks. The 
change from baseline to Week 104 in eGFR and LVMI will be compared with reference values of patients with 
Fabry disease from the published literature (Schiffmann et al., 2009; Kampmann et al., 2008) who had similar
baseline demographic and disease characteristics to the study subjects (Schiffmann et al., 2009) and who 
remained untreated for 2 years.
It is anticipated that at least 45 adult subjects with Fabry disease will need to be enrolled in order to obtain 
36 evaluable subjects. To be considered evaluable, a subject must not have discontinued from investigational 
product and must have valid, nonmissing values of the primary efficacy endpoints (eGFR and LVMI) for both 
baseline and Week 104.
Potential subjects will participate in a screening period, which can last up to 42 days, to determine eligibility. 
After completion of baseline procedures and assessments, eligible subjects will receive 0.2 mg/kg REPLAGAL by 
IV infusion over 40 minutes EOW for 104 weeks and will have site visits approximately every 12 to 14 weeks 
during the 104-week treatment period. Subjects who discontinue from study treatment will continue to have study 
visits if they consent to do so. Approximately 14 days (-4 days/+7 days) after the last infusion or study visit, a 
safety follow-up contact or visit will occur to confirm the subject’s safety.
Inclusion and Exclusion Criteria:
Inclusion Criteria:
The subject will not be considered eligible for the study without meeting all of the criteria below:
1.
The subject must voluntarily sign an Institutional Review Board/Independent Ethics Committee/Research 
Ethics Board approved informed consent form after all relevant aspects of the study have been explained and 
discussed with the subject. 
2.
The subject has Fabry disease as confirmed at screening by the following criteria using a dried blood spot 
assay:

For male subjects, Fabry disease is confirmed by a deficiency of -galactosidase A (GLA) activity 
and a mutation in the GLA gene. 

For female subjects, Fabry disease is confirmed by a mutation in the GLA gene.
3.
The subject is 18 to 65 years of age, inclusive.
4.
Female subjects must have a negative pregnancy test at screening. 
5.
Female subjects of child-bearing potential must agree to use a medically acceptable method of contraception 
at all times during the study and for at least 14 days after the final study infusion; the methods of acceptable 
contraception are listed in the protocol. 
6.
The subject is deemed, as determined by the investigator, to have adequate general health to undergo the 
specified protocol-related procedures and to have no safety or medical contraindications for participation.
7.
The subject has not received any treatment (approved or investigational) specific to Fabry disease, such as 
enzyme replacement therapy (ERT), chaperone therapy, or substrate reduction therapy. 
8.
The subject must have an eGFR of 45 to 120 mL/min/1.73 m2; eGFR will be calculated by a 
Shire-designated laboratory using the Chronic Kidney Disease Epidemiology (CKD-EPI) formula. If the 
eGFR measurement at screening is not within the stipulated range, a second eGFR measurement may be 
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completed and, if in range, used as the screening value. If a second measurement is taken, a minimum of 
1 week and maximum of 30 days should separate it from the first measurement. This inclusion criterion 
follows the European Guidelines for Treatment of Fabry Disease (Biegstraaten et al., 2015) and Kidney 
Disease Improving Global Outcomes guidelines for classification of renal disease (Kidney Disease
Improving Global Outcomes [KDIGO], 2013).
9.
The subject has left ventricular hypertrophy (LVH), where LVH is defined as left ventricular mass index 
(LVMI) >50 g/m2.7 confirmed by cardiac magnetic resonance imaging (cMRI) at screening. The cMRI value 
at screening will serve as the baseline value. 
Exclusion Criteria:
The subject will be excluded from the study if any of the following exclusion criteria are met: 
1.
In the opinion of the investigator, the subject’s life expectancy is ≤5 years.
2.
The subject has undergone or is scheduled to undergo kidney transplantation or is currently on dialysis, or 
has any signs or symptoms of end stage renal disease.
3.
Urine protein/creatinine ratio (PCR) >1.5 mg/mg.
4.
Subjects who have clinically relevant history of allergy or signs or symptoms of severe hypersensitivity 
(including hypersensitivity to the REPLAGAL active substance or any of the excipients), which in the 
investigator’s judgment, will substantially increase the subject’s risk if he or she participates in the study.
5.
Cardiac fibrosis involving more than 2 segments, as determined by cMRI at screening.
6.
In the opinion of the investigator, the subject has non-Fabry disease-related cause of end-organ (renal, 
cardiac, central nervous system) dysfunction/failure or is receiving medications that may affect the rate of 
disease progression, as assessed by cardiac and/or renal measures. 
7.
The subject has a positive test at screening for hepatitis B surface antigen, positive test for hepatitis B core 
antibody, positive test for hepatitis C (HCV) antibody with confirmation by HCV-ribonucleic acid 
polymerase chain reaction testing, or positive test for human immunodeficiency virus antibody.
8.
Treatment with REPLAGAL at any time prior to the study
9.
Prior treatment with any of the following medications:

FABRAZYME® (agalsidase beta) and its biosimilars 

GLYSET® (miglitol)

ZAVESCA® (miglustat)

CERDELGA® (eliglustat)

GALAFOLD® (migalastat)

Any investigational product for treatment of Fabry disease

Chloroquine

Amiodarone

Monobenzone

Gentamicin.
10. The subject is pregnant or lactating.
11. The subject has a body mass index >39 kg/m2. (BMI = kg/m2)
12. The subject is treated or has been treated with any investigational drug within 30 days prior to study start.
13. The subject is unable to understand the nature, scope, and possible consequences of the study. 
14. The subject is unable to comply with the protocol, eg, uncooperative with protocol schedule, refusal to agree 
to all of the study procedures, inability to return for evaluations, or is otherwise unlikely to complete the 
study, as determined by the investigator.
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Maximum duration of subject participation in the study:
The maximum duration of participation is expected to be 112 weeks as follows:

Planned duration of screening period: up to 42 days

Planned duration of treatment period (baseline visit to end of treatment visit): up to 104 weeks

Planned duration of safety follow-up period: 14 days (-4 days/+7 days).
Statistical analysis:
Endpoints and statistical analysis:
Subject Populations 

The intent-to-treat (ITT) set (those subjects who are considered enrolled in the study) will include 
all subjects who sign informed consent form and are eligible for the study based on the defined 
inclusion/exclusion criteria. There is a possibility that a subject is enrolled in the study but does not 
receive a dose of investigational product

The modified intent-to-treat (mITT) set will include all enrolled subjects (all subjects from the 
ITT) who have received at least 1 dose of investigational product and completed at least 1 efficacy 
assessment of the endpoints being analyzed. 

The safety set will include all subjects in the ITT set who receive at least 1 dose of investigational 
product. The safety set will be used for the analysis of safety endpoints.

The per-protocol (PP) set will include all subjects in the ITT excluding subjects with major 
protocol deviations. The PP set will be identified by a team consisting of, at a minimum, a physician 
and a statistician from Shire. 

The completers set will include all subjects in the ITT who have valid values of primary efficacy 
endpoints (eGFR and LVMI) for both baseline and Week 104 assessments. 
Primary Efficacy Endpoints:
The primary efficacy endpoints are:

Change from baseline at Week 104 in renal function, assessed by eGFR (using the CKD-EPI 
formula)

Change from baseline at Week 104 in cardiac structure, assessed by LVMI using cMRI.
Secondary Efficacy Endpoints:
The secondary efficacy endpoints are:

Annualized rate of change in eGFR

Annualized rate of change in LVMI 

Change over time in eGFR

Change over time in LVMI

Change over time in proteinuria, measured by PCR

Change over time of the number of fibrotic segments suggestive of cardiac fibrosis as assessed by 
volume of fibrosis, measured by cMRI

Change over time in interventricular septal end-diastolic thickness and posterior wall thickness in 
diastole, measured by cMRI

Change over time in plasma globotriaosylsphingosine (lyso-Gb3).
Exploratory Efficacy Endpoints: 
The exploratory efficacy endpoints will include the change over time in serum levels of inflammatory biomarkers 
including but not limited to Interleukin 1 Beta (INTLK1β), Tumor Necrosis Factor (TNF-α), Vascular Cell 
Adhesion Molecule 1 (VCAM1), and Intercellular Adhesion Molecule 1 (ICAM1). 
Safety Endpoints:
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The safety and tolerability of REPLAGAL will be analyzed as a secondary endpoint. The safety endpoints include:

Adverse events (AEs)

Antidrug antibody (ADA) assessments including neutralizing antibodies (NAbs) 

Clinical laboratory tests (serum chemistry, hematology, and urinalysis)

Electrocardiography (ECG)

Vital signs.
Patient Reported Outcome Endpoints:
The change over time in subject rating of pain, fatigue, severity of global Fabry symptoms and quality of life will 
be analyzed as exploratory endpoints using the following patient-reported outcome (PRO) measures, respectively:

The Brief Pain Inventory-Short Form

The Brief Fatigue Inventory 

The Patient Global Impression of Fabry Symptom Severity 

The Short Form-36 Health Survey.

The change over time in subject rating of GI symptoms as assessed by the Gastrointestinal 
Symptom Rating Scale. 
Statistical Methodology for the Primary Efficacy Endpoints:
The primary efficacy endpoints are the change from baseline at Week 104 in eGFR and LVMI. 
The primary analysis for change from baseline at Week 104 in eGFR will be based on a mixed-effects model for 
repeated measures (MMRM) with multiple imputation under the assumption that the missing is not at random 
(MNAR) using the ITT population. A Bonferroni adjustment will be used to control the overall one-sided type I 
error rate of 0.025 for two primary endpoints. The primary null hypothesis to be tested for eGFR is that the mean 
change from baseline in eGFR at Week 104 of treated subjects will be less than or equal to -6 mL/min/1.73 m2, 
the reference value from untreated subjects. The alternative hypothesis is that the mean change in eGFR is greater 
than -6 mL/min/1.73 m2 , the reference value of untreated subjects. A one-sided p-value to test if the mean change 
is greater than -6 mL/min/1.73 m2 from MMRM model will be used to interpret that there is sufficient evidence to 
reject the null hypothesis. The model will include visit as the fixed effect; with adjustment for sex (male versus 
female), age at baseline and baseline eGFR. In the model, visit will be treated as a class variable, assuming an 
unstructured covariance matrix to model the within subject variability.
The primary analysis for change from baseline at Week 104 in LVMI will be based on a MMRM with imputation 
under the assumption that the missing is not at random using the ITT population. The primary null hypothesis to 
be tested for LVMI is that the mean change from baseline in LVMI at Week 104 of treated subjects will be
greater than or equal to 10 g/m2.7 , the reference value from untreated subjects. The alternative hypothesis is that 
the mean change in LVMI is less than 10 g/m2.7, the reference value of untreated subjects. A one-sided p-value to 
test if the mean change is less than 10 g/m2.7 from MMRM model will be used to interpret that there is sufficient 
evidence to reject the null hypothesis. The model will include visit as the fixed effect; with adjustment for sex 
(male versus female), age at baseline and baseline LVMI. In the model, visit will be treated as a class variable, 
assuming an unstructured covariance matrix to model the within subject variability.
Missing eGFR and LVMI data due to intercurrent event or other reasons will be handled according to the 
treatment policy strategy. 
Treatment policy strategy is defined as the strategy that considers “The occurrence of the intercurrent event is 
irrelevant: the value for the variable of interest is used regardless of whether or not the intercurrent event occurs.” 
(per ICH E9 R1 Addendum). Intercurrent events can include but are not limited to the following: (1) 
discontinuation of study drug, (2) discontinuation of the study, or (3) initiation of a new treatment. In a situation 
that missingness of the eGFR or LVMI data cannot be predicted solely based on subject’s observed data, such 
missingness will not be considered as missing at random, but rather as MNAR. The missing pattern will be 
evaluated and subjects with and without missing data will be compared to gain understanding of the nature of the 
missingness. Pattern-mixture models and Monte Carlo Markov Chain methodology will be implemented in 
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17 Feb 2022
multiple imputation with a list of observed variables and covariates to impute missing eGFR and LVMI data with 
the assumption of MNAR. The covariates can be variables related to missingness identified in the comparison of 
subjects with and without missing data, the covariate can also be variables related to eGFR or LVMI based on 
medical input. 
The analyses of the primary endpoints will be performed with all available data through Week 104. The repeated 
measure analyses will be based on the restricted maximum likelihood method assuming an unstructured 
covariance matrix to model the within-subject errors. If the analysis fails to converge, a compound symmetry 
covariance structure will be used to model the within-subject errors. Denominator degrees of freedom for the 
F test for fixed effects will be estimated using the Kenward-Roger approximation.
The following analyses will be performed for the primary endpoints to evaluate the robustness of the results from 
the primary analysis methods:

MMRM analysis using the completers set 

MMRM analysis using the PP set.

The eGFR and LVMI annualized rate of change and 95% CI will be estimated for subjects using the 
random intercept and slope model. Baseline eGFR or baseline LVMI, age at baseline, sex, and 
treatment duration on investigational product in year will be included in the model. 

Tipping point analysis with multiple imputation approach in ITT and mITT sets.
Descriptive summary statistics including the number of subjects (n) and mean (standard deviation [SD]) for each 
of raw values of the primary endpoints and change from baseline at each visit will be presented by visit.
Descriptive summary statistics for each of the primary endpoints will also be provided by sex subgroups.
Statistical Methodology for Secondary Efficacy Endpoints:
The same model used for the primary endpoints will be used.
For other secondary efficacy endpoints, summary statistics of the raw values and change from baseline will be 
provided descriptively by visit. Simple summary statistics will be produced initially. Continuous variables will be 
summarized using the following descriptive statistics: mean, SD, median, first and third quartiles, minimum and 
maximum. The number and percentage of observed levels will be reported for all categorical measures. 
Subsequently, MMRM will be performed to explore the changes of the secondary efficacy endpoints over the 
course of follow-up. MMRM will be calculated using unstructured covariance (subject level) and restricted 
maximum likelihood estimation (REML). The MMRM will include the fixed effect of visit. Significance tests 
will be based on least-squares means. Further on, if considered necessary, the MMRM will be repeated for each 
secondary efficacy endpoint to account for any prespecified possible baseline confounder.
All analyses related to secondary efficacy endpoints will be performed using the ITT and mITT sets.
Statistical Methodology for Exploratory Efficacy Endpoints:
Concentrations of inflammatory biomarkers will be summarized using descriptive statistics: mean, SD, median, 
first and third quartiles, minimum and maximum. Initially, simple summary statistics will be produced for each 
inflammatory biomarker. Subsequently, MMRM will be performed to explore the changes of INTLK1β, TNF-α, 
VCAM1, and ICAM1 over the course of follow-up. 
MMRM will be built using unstructured covariance (subject level) and REML. The MMRM will include the 
fixed effect of visit. Significance tests will be based on least-squares means. Further on, if considered necessary, 
the MMRM will be repeated for each inflammatory biomarker to account for any prespecified possible baseline 
confounder.
All analyses related to inflammatory biomarkers will be performed using the ITT and mITT sets.
Statistical Methodology for Safety Endpoints:
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REPLAGAL® (agalsidase alfa) 
17 Feb 2022
All safety analyses will be presented for the safety set. Safety measures including vital signs, clinical laboratory 
results (hematology, chemistry, urinalysis), ECG, and ADA (including NAb) assessments will be summarized 
descriptively at baseline and for each postbaseline visit. Shift from baseline will be provided, if applicable.
Treatment emergent adverse events (TEAEs) are defined as AEs that start or deteriorate during or after the first 
dose of investigational product through the safety follow-up visit/contact. The number of events, incidence, and 
percentage of TEAEs will be summarized overall and by system organ class and preferred term at both subject 
level and AE level. TEAEs will be further summarized by severity and relationship to investigational product. 
Multiple events of the same type will be combined for each subject and, when doing this, the worst severity or 
outcome for each event type will be presented for the analysis. When calculating event rates, the denominator 
will be the number of subjects commencing follow-up in the relevant analysis population, irrespective of dropouts 
during the course of follow-up. Adverse events related to investigational product including infusion-related 
reactions, AEs leading to withdrawal, SAEs, and deaths will be similarly summarized/listed.
Statistical Methodology for Health-related Quality of Life Endpoints:
Initially, simple summary statistics will be produced for the overall score and (if available) any subscale score of 
each PRO measure. Continuous variables will be summarized using the following descriptive statistics: mean, 
SD, median, first and third quartiles, minimum and maximum. The number and percentage of observed levels 
will be reported for all categorical measures. Subsequently, MMRM will be performed to explore the changes of 
PRO measures over the course of follow-up. MMRM will be calculated using unstructured covariance (subject
level) and REML. The MMRM will include the fixed effect of visit. Significance tests will be based on 
least-squares means. Further on, if considered necessary, the MMRM will be repeated for each PRO measure to 
account for any prespecified possible baseline confounder.
All analyses related to PRO measures will be performed using the ITT and mITT sets.
Sample Size Justification
The primary endpoints for this study are change in eGFR and LVMI from baseline at Week 104.
Two publications by Schiffmann et al. (Schiffmann et al., 2009) and Kampmann et al. (Kampmann et al., 2008) 
are acknowledged as landmark references reporting on the natural history of renal and cardiac function disease 
progression in untreated subjects with Fabry disease, respectively. The results of these studies are used across the 
Fabry disease medical community as a reference for the assessment of therapeutic expectations and the response 
of treatment. Use of these published, aggregate data as reference values for untreated changes in the endpoints 
have some limitations, as the adjustment for bias in patient baseline characteristics is not feasible without access 
to individual patient data. Nonetheless, this relevant publicly available data will provide necessary information to 
evaluate the REPLAGAL efficacy benefit.
Beck et al. (Beck et al., 2015) describes the disease progression in cardiac and renal function for untreated 
subjects with Fabry disease based on the data reported by Schiffmann et al. (Schiffmann et al., 2009) and 
Kampmann et al. (Kampmann et al., 2008), respectively. In this untreated population, the mean weighted 
annualized rate of change for eGFR and LVMI is approximately -3 mL/min/1.73 m2 and +5 g/m2.7, respectively, 
which is equivalent to a change of -6 mL/min/1.73 m2 and +10 g/m2.7, respectively over a period of 104 weeks. 
Based on the clinical document of Summary of Clinical Efficacy provided by Shire in the REPLAGAL New Drug 
Submission for Health Canada, the standard deviation for change in eGFR and LVMI in ERT-naïve subjects 
following 24-month treatment with REPLAGAL is 7 mL/min/1.73 m2 and 15 g/m2.7, respectively. 
The null hypothesis for eGFR is that the mean change from baseline in eGFR at Week 104 of the treated subjects 
is less than or equal to -6 mL/min/1.73 m2, the mean change of untreated patients. 
The alternative hypothesis states that the mean change in eGFR is greater than this reference value of -6 
mL/min/1.73 m2. The null hypothesis for LVMI is that the mean change from baseline in LVMI at Week 104 for 
the treated subjects is greater than or equal to +10 g/m2.7, as the untreated patients. The alternative hypothesis 
states that mean change in LVMI is smaller than this reference value of +10 g/m2.7.
The Bonferroni adjustment to control the type I error rate for the 2 primary endpoints is incorporated in the 
sample size determination. The Bonferroni adjustment does not make any assumptions of the primary endpoints. 
For eGFR, with 36 evaluable subjects, the study has at least 90% power to detect a decrease after 104 weeks of 
treatment of -1.7 mL/min/1.73 m2 compared with a reference untreated change of -6 mL/min/1.73 with SD=7 
(effect size of 0.61) using a 1-sided one sample t-test at significance level of 0.0125. For LVMI, with 
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SHP675-301 Protocol Amendment 6
REPLAGAL® (agalsidase alfa) 
17 Feb 2022
36 evaluable subjects, the study has at least 90% power to detect an increase after 104 weeks of treatment of 
0.64 g/m2.7 compared with a reference untreated change of 10 g/m2.7 with SD=15 (effect size of 0.62) using a 
1-sided one sample t-test at significance level of 0.0125.
It is anticipated that 45 subjects will need to be enrolled in the study in order to obtain 36 evaluable subjects, ie, 
subjects who have not discontinued from investigational product and who have valid, nonmissing values of 
primary efficacy endpoints (eGFR and LVMI) for baseline and Week 104 assessments (completers set).
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17 Feb 2022
1.2
Schedule of Activities
Table 1
Schedule of Activities
Study 
Assessments and 
Procedures
Screening 
Perioda
Baseline 
Periodb
Treatment Periodc
Safety Follow-up 
Period
EOW 
REPLAGAL
Infusiond
(±7 days) 
at (Week 2 
-Week 50) 
and
(±14 days) 
at (Week 
52-Week
104)
Site Visitse
Telephone 
Contact/Visitf
Day -50 to 
Day -8
(up to 42 
days)
Day -7 
to Day 0 
(Day 0 
=
Week 
0)d
Week
2
(±7 
days)
Week
4
(±7 
days)
Week 
12
(±7 
days)
Week 
26
(±7 
days)
Week 
40
(±7 
days)
Week 
52
(±14 
days)
Week 64
(±14 days)
Week 78
(±14 days)
Week 92
(±14 days)
Week 104
(±14 days)
EOT or 
Early 
Terminationg
14 Days
(-4 days/ +7 days) 
from EOT or Last 
Infusion for 
Discontinued 
Subjects
Informed consenth
•
Review of 
inclusion/exclusion 
criteria
•
•
Confirmation of 
Fabry diseasei
•
Demography
•
Medical history
•
Physical 
examination
•
•
•
•
•
Vital signsj
•
•
•
•
•
•
•
•
•
•
•
•
•
Heightk
•
•
•
Weight
•
•
•
•
•
•
•
•
•
•
Dose calculationl
•
•
•
•
•
•
•
•
REPLAGAL
infusionm
•
•
•
•
•
•
•
•
•
•
•
•g
cMRI
•
•
•
12-lead ECG
•
•
•
•
•
•
eGFR calculationn
•
•
•
•
•
•
•
•
•
•
Pregnancy testo
•
•
•
•
•
•
•
•
•
•
•
•
•
Serum chemistryp
•
•
•
•
•
•
•
•
•
•
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CONFIDENTIAL
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SHP675-301 Protocol Amendment 6
REPLAGAL® (agalsidase alfa) 
17 Feb 2022
Table 1
Schedule of Activities
Study 
Assessments and 
Procedures
Screening 
Perioda
Baseline 
Periodb
Treatment Periodc
Safety Follow-up 
Period
EOW 
REPLAGAL
Infusiond
(±7 days) 
at (Week 2 
-Week 50) 
and
(±14 days) 
at (Week 
52-Week
104)
Site Visitse
Telephone 
Contact/Visitf
Day -50 to 
Day -8
(up to 42 
days)
Day -7 
to Day 0 
(Day 0 
=
Week 
0)d
Week
2
(±7 
days)
Week
4
(±7 
days)
Week 
12
(±7 
days)
Week 
26
(±7 
days)
Week 
40
(±7 
days)
Week 
52
(±14 
days)
Week 64
(±14 days)
Week 78
(±14 days)
Week 92
(±14 days)
Week 104
(±14 days)
EOT or 
Early 
Terminationg
14 Days
(-4 days/ +7 days) 
from EOT or Last 
Infusion for 
Discontinued 
Subjects
Hematologyq
•
•
•
•
•
•
•
•
•
•
Serum 
inflammatory 
biomarkersr
•
•
•
•
•
•
•
Serum ADA & 
NAbss
•
•
•
•
•
•
•
•
•
Plasma lyso-Gb3
•
•
•
•
•
•
•
Urinalysis
•
•
•
•
•
•
•
•
•
•
Proteinuriat
•
•
•
•
•
•
•
•
•
•
Viral testingu
•
Short Form-36 
Health Survey (SF-
36v2)
•
•
•
•
•
•
•
•
•
Brief Pain 
Inventory Short 
Form (BPI-SF)
•
•
•
•
•
•
•
•
•
Patient Global 
Impression of 
Fabry Symptom 
Severity (PGI-S)
•
•
•
•
•
•
•
•
•
Brief Fatigue
Inventory (BFI)
•
•
•
•
•
•
•
•
•
Gastrointestinal 
Symptom Rating 
Scale (GSRS)
•
•
•
•
•
•
•
•
•
Review of AEs
•
•
•
•
•
•
•
•
•
•
•
•
•
•
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CONFIDENTIAL
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REPLAGAL® (agalsidase alfa) 
17 Feb 2022
Table 1
Schedule of Activities
Study 
Assessments and 
Procedures
Screening 
Perioda
Baseline 
Periodb
Treatment Periodc
Safety Follow-up 
Period
EOW 
REPLAGAL
Infusiond
(±7 days) 
at (Week 2 
-Week 50) 
and
(±14 days) 
at (Week 
52-Week
104)
Site Visitse
Telephone 
Contact/Visitf
Day -50 to 
Day -8
(up to 42 
days)
Day -7 
to Day 0 
(Day 0 
=
Week 
0)d
Week
2
(±7 
days)
Week
4
(±7 
days)
Week 
12
(±7 
days)
Week 
26
(±7 
days)
Week 
40
(±7 
days)
Week 
52
(±14 
days)
Week 64
(±14 days)
Week 78
(±14 days)
Week 92
(±14 days)
Week 104
(±14 days)
EOT or 
Early 
Terminationg
14 Days
(-4 days/ +7 days) 
from EOT or Last 
Infusion for 
Discontinued 
Subjects
Prior/concomitant 
medications, 
therapies, and 
medical/surgical 
interventionsv
•
•
•
•
•
•
•
•
•
•
•
•
•
•
ADA=antidrug antibody; AE=adverse event; β-hCG=beta-human chorionic gonadotropin; cMRI=cardiac magnetic resonance imaging; ECG=electrocardiography; 
eGFR=estimated glomerular filtration rate; EOI=end of infusion; EOT=end of treatment; EOW=every other week; GLA=α-galactosidase A; HCV=hepatitis C virus; 
IP=investigational product; IRR=infusion-related reaction; lyso-Gb3=globotriaosylsphingosine; SAE=serious adverse event
a Screening procedures can be performed over multiple days within a period of up to 42 days following the subject’s signature of the informed consent form. The value obtained 
for cMRI at Screening will serve as the baseline value. Subjects who screen failed or could not be enrolled during the screening period, due to circumstances including, but not 
limited to, COVID-19 related issues, may be rescreened with prior approval from the sponsor medical monitor. Some procedures, such as cMRI, may not need to be repeated 
for rescreening, with prior agreement of the sponsor medical monitor.
b All baseline assessments and procedures are to be performed at the clinical site. The baseline assessments may be completed over a period of 7 days as long as all baseline 
assessments and procedures are completed prior to the first REPLAGAL infusion. The day of the first REPLAGAL infusion is considered Day 0/Week 0 and all future study visits 
and windows should be timed from the first infusion.
c During the treatment period all study assessments and procedures should be completed on the day of the scheduled visit (ie, day of infusion) with the exception of visits where a 
cMRI will be performed (Screening, Week 52, and Week 104 Visits). On visits where a cMRI assessment will be performed, all study assessments should occur on the day of 
infusion; however, to accommodate the scheduling of cMRI, this assessment may be performed within ±7 days of the infusion day for Week 52 and ±14 days of the infusion 
day for Week 104.
d The first 3 REPLAGAL infusions (Day 0/Week 0 first infusion, EOW second infusion, and EOW third infusion) are to be administered at the clinical site. After the first 3 
infusions, subjects who have not experienced a treatment-related serious adverse event (SAE) or a moderate or severe infusion-related reaction (IRR) may receive their 
subsequent infusions at home by qualified and trained medical personnel, per the discretion and direction of the investigator.
If at any point during home infusions subjects experience a treatment-related SAE or a moderate or severe IRR, their next infusion should be administered at the clinical site. 
Infusions should continue at the clinical site until no further moderate or severe IRRs are reported, at which point subjects may be re-evaluated for consideration to retransition 
to home infusions. 
e Procedures and evaluations to be performed at site visits will occur at the clinical site. 
f The safety follow-up period is 14 days (-4 days/+7 days) following end of treatment (EOT) infusion (or the last infusion for early discontinued subjects). At the end of this 
period there will be a telephone call initiated by the site staff to query for adverse events (AEs), SAEs and concomitant medications. Subjects who experienced SAEs, or 
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Shire
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REPLAGAL® (agalsidase alfa) 
17 Feb 2022
Table 1
Schedule of Activities
Study 
Assessments and 
Procedures
Screening 
Perioda
Baseline 
Periodb
Treatment Periodc
Safety Follow-up 
Period
EOW 
REPLAGAL
Infusiond
(±7 days) 
at (Week 2 
-Week 50) 
and
(±14 days) 
at (Week 
52-Week
104)
Site Visitse
Telephone 
Contact/Visitf
Day -50 to 
Day -8
(up to 42 
days)
Day -7 
to Day 0 
(Day 0 
=
Week 
0)d
Week
2
(±7 
days)
Week
4
(±7 
days)
Week 
12
(±7 
days)
Week 
26
(±7 
days)
Week 
40
(±7 
days)
Week 
52
(±14 
days)
Week 64
(±14 days)
Week 78
(±14 days)
Week 92
(±14 days)
Week 104
(±14 days)
EOT or 
Early 
Terminationg
14 Days
(-4 days/ +7 days) 
from EOT or Last 
Infusion for 
Discontinued 
Subjects
mild-worsening, moderate or severe AEs will be requested to report to the clinical site for further examination. All AEs and SAEs that are not resolved at the time of this 
contact will be followed to closure.
g For subjects who discontinue the study early, all ET assessments and procedures should be completed as soon as possible after the subject’s last dose. For subjects who 
discontinue study treatment but remain in the study, the End of Treatment (EOT) Visit should occur within 10-21 days after the subject’s last IP dose. These subjects will also 
have either a Week 104 Visit (if completing the study) or an ET Visit (if withdrawing from the study prior to Week 104).
h Informed consent must be obtained prior to performing any study related procedures.
i Fabry disease diagnosis will be confirmed at screening using a dried blood assay. For male subjects, Fabry disease will be confirmed by a deficiency of α-galactosidase A 
(GLA) activity and a mutation in the GLA gene. For female subjects, Fabry disease will be confirmed by a mutation in the GLA gene. Measurement of serum GLA activity will 
also be done for female subjects however, serum GLA activity is not an inclusion criterion for female subjects.
j The following vital signs will be collected at all study visits (screening and infusion visits): pulse, blood pressure, respiratory rate, and temperature. On infusion visits (baseline, 
EOW, and the site visits), vital signs should be obtained as follows: 1) within 10 minutes prior to starting the infusion; 2) 20 minutes (±5 minutes) after the start of the infusion 
3) 10 minutes (±5 minutes) post infusion; and 4) 30 minutes (±5 minutes) post infusion. In the event that a scheduled infusion does not occur on a visit, the vital signs collected 
within 10 minutes prior to the start of the expected infusion should be documented in the electronic case report form. If no infusion-related reactions (IRRs) are observed during 
the first 3 infusions, the observation and vital signs post infusion can be omitted at the discretion of the investigator.
k Subject height and weight must be measured and collected at Screening, Week 52 and Week 104 (or early termination) visits for all subjects. 
l The first dose of REPLAGAL will be based on the subject’s weight at Baseline. Change in subject weight of ≥±5% from baseline, or the last weight used to recalculate the dose, 
will require a recalculation of the dose by the clinical site. Weight will be measured approximately every 12 to 14 weeks, with any dosing adjustments completed prior to the 
next dose.
m REPLAGAL will be administered as an intravenous infusion over 40 minutes (±10 minutes) every other week (EOW) (±7 days) starting at the baseline visit up to Week 52 when 
EOW visits will have windows of ±14 days. All study procedures, assessments (except for postinfusion vital signs), and sample collection should be completed prior to 
administering an infusion.
n If the eGFR measurement at screening is not within the range, a second eGFR measurement may be completed and, if in range, used as the screening value. If a second 
measurement is taken, a minimum of 1 week and maximum of 30 days should separate it from the first measurement.
o Female subjects of childbearing potential will have a pregnancy test administered at each study visit. At screening, pregnancy testing will be performed using a urine test and a 
serum human beta-human chorionic gonadotropin (β-hCG) test. The urine pregnancy test should be administered by the clinical site before any other screening procedures 
(except for signature of informed consent) are completed. If the urine pregnancy test is negative, screening procedures (including the serum pregnancy test) will be completed. 
If the urine test is positive, a blood sample will be collected for serum β-hCG testing and sent to the central laboratory for analysis. No additional screening procedures should 
be completed until the result of the serum pregnancy test is available. Female subjects of childbearing potential must have a negative β-hCG serum test at screening to be 
eligible for the study. A positive β-hCG serum test would result in the subject being a screen failure. At baseline, the urine pregnancy test should be administered by the clinical 
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Table 1
Schedule of Activities
Study 
Assessments and 
Procedures
Screening 
Perioda
Baseline 
Periodb
Treatment Periodc
Safety Follow-up 
Period
EOW 
REPLAGAL
Infusiond
(±7 days) 
at (Week 2 
-Week 50) 
and
(±14 days) 
at (Week 
52-Week
104)
Site Visitse
Telephone 
Contact/Visitf
Day -50 to 
Day -8
(up to 42 
days)
Day -7 
to Day 0 
(Day 0 
=
Week 
0)d
Week
2
(±7 
days)
Week
4
(±7 
days)
Week 
12
(±7 
days)
Week 
26
(±7 
days)
Week 
40
(±7 
days)
Week 
52
(±14 
days)
Week 64
(±14 days)
Week 78
(±14 days)
Week 92
(±14 days)
Week 104
(±14 days)
EOT or 
Early 
Terminationg
14 Days
(-4 days/ +7 days) 
from EOT or Last 
Infusion for 
Discontinued 
Subjects
site before any other baseline procedures are completed. If the urine test is positive, a blood sample will be collected for serum β-hCG testing and sent to the central laboratory 
for analysis. No additional baseline procedures will be completed until the result of the serum pregnancy test is available. If the serum β-hCG result is positive, the subject will 
not be dosed with REPLAGAL and would be considered a screen failure. At all other visits during the treatment period (EOW and site visits), a urine pregnancy test will be 
performed prior to the completion of any study procedures. 
If the urine test is positive, a blood sample will be collected for serum β-hCG testing and sent to the central laboratory for analysis. The subject will not receive any additional 
REPLAGAL infusions until the result of the serum pregnancy test is available. If the serum β-hCG result is positive, no additional doses of REPLAGAL are to be administered.
p Serum chemistry laboratory tests: sodium (Na+), potassium (K+), chloride (Cl-), bicarbonate, calcium, magnesium (Mg2+), phosphate, creatinine, urea nitrogen, glucose, 
albumin, bilirubin, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, triglycerides, cholesterol, LDL cholesterol, and HDL cholesterol.
q Hematology laboratory tests include complete blood count: hematocrit [Hct]; hemoglobin [Hb]; RBC; WBC; platelets; basophils; basophils/total cells; eosinophils; 
eosinophils/total cells; immature granulocyte/leukocytes; lymphocytes; lymphocytes/total cells; monocytes; monocytes/total cells; neutrophils; and neutrophils/total cells. 
r Serum inflammatory biomarkers include but are not limited to Interleukin 1 Beta, Tumor Necrosis Factor, Vascular Cell Adhesion Molecule 1, and Intercellular Adhesion 
Molecule 1.
s Antidrug antibody (ADA) samples to be collected prior to infusion; any samples that are confirmed positive for ADA will also be tested for neutralizing antibodies (NAbs).
t Proteinuria (measured by protein creatinine ratio) to be performed as part of urinalysis. 
u Hepatitis B surface antigen, Hepatitis B core antibody, Hepatitis C (HCV) antibody with confirmation by HCV-ribonucleic acid polymerase chain reaction testing, human 
immunodeficiency virus antibody.
v The following medications and treatments are prohibited at any time prior and throughout the course of the study: FABRAZYME® (agalsidase beta) and its biosimilars, GLYSET®
(miglitol), ZAVESCA® (miglustat), CERDELGA® (eliglustat), GALAFOLD® (migalastat), and any investigational product for treatment of Fabry disease. Treatment at any time 
during the study with the following medications is prohibited: Chloroquine, Amiodarone, Monobenzone, and Gentamicin.
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2
INTRODUCTION
2.1
Indication and Current Treatment Options 
Indication
Fabry disease is a rare, lifelong, slowly progressive, X-linked glycosphingolipid storage 
disorder with a global incidence estimated at 1:50,000 male live births (Spada et al. 2006).
According to the census bureau’s population, there are an estimated 11,000 patients with 
Fabry disease in the US. 
Fabry disease results from a mutation in the α-galactosidase A gene located on chromosome 
Xq22.1, which leads to a partial or full loss of the activity of the lysosomal enzyme 
α-galactosidase A (GLA) (Garman and Garboczi 2004). More than 400 mutations have 
been identified in the GLA gene. These consist mainly of missense mutations, but 
nonsense mutations in addition to single amino acid deletions and insertions were also 
reported (Mehta et al. 2010). Most of these mutations are “private”, having been identified 
only in individual families (Mehta et al. 2010). As an X-linked disorder, females may inherit 
an X-linked Fabry mutation from either parent accounting for twice the number of 
carriers (heterozygotes) as males (hemizygotes). Female carriers are not necessarily 
asymptomatic. 
Alpha-galactosidase A is a lysosomal hydrolase enzyme that catalyzes the removal of 
terminal alpha-galactosyl moieties during the catabolism of glycolipids and glycoproteins. 
Partially active or deficient GLA results in abnormal accumulation of glycolipids 
(globotriaosylceramide [Gb3]) in cells throughout the body, including capillary endothelial, 
renal (podocytes, tubular cells, glomerular endothelial, mesangial, and interstitial cells), 
cardiac (cardiomyocytes and fibroblasts) and nerve cells. Abnormal Gb3 concentrations in 
membranous structures may impair intracellular trafficking processes, cellular activation, 
intercellular communication, and cellular homeostasis. This results in inflammatory changes 
and cytokine release, ultimately leading to apoptosis and eventual organ dysfunction and/or 
failure (Brady 1967; Desnick 1995; deVeber et al. 1992; Kahn 1973; Kaye et al. 1988; 
Schaefer et al. 2009). 
Fabry disease is characterized by a range of phenotypes that generally correlates with the 
degree of residual enzymatic activity. The threshold level of alpha-Gal A activity below 
which clinically significant Fabry disease occurs is thought to be 30 to 35 percent of 
the mean normal control (Schiffmann et al. 2016). Phenotype presentation becomes more 
evident during childhood and young adulthood, and as the patient advances in age organ 
function deterioration intensifies ultimately leading to organ failure and early death. Most 
patients display multiple clinical manifestations of the disease, many of which may occur 
before 10 years of age in males (Deegan et al. 2006). In females, alpha-Gal A activity is 
most often higher than in males (Arends et al. 2017) and the onset of symptoms and time 
of diagnosis can be variable, occurring approximately 10 years later compared with males 
(Eng et al. 2007; Kruger et al. 2010). The clinical presentation of the disease varies widely 
among patients, but neuropathic pain and acroparesthesia are typically the first and most 
frequent symptoms to manifest. 
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Other clinical manifestations of Fabry disease include angiokeratomas, gastrointestinal 
problems, proteinuria, progressive renal impairment leading to renal failure, hypertrophic 
cardiomyopathy with arrhythmias, corneal dystrophy, hypohidrosis, and microvascular cerebral 
events including transient ischemic attacks, stroke, and dolichoectasia (Deegan et al. 2006; 
Schiffmann and Ries 2005). Vital organs, especially the heart, kidneys, and brain, are 
progressively affected with advancing age (Ries and Schiffmann 2005). As a consequence, 
physical and functional well-being and quality of life (QoL) are significantly reduced in patients 
with Fabry disease compared with the general population and patients with other chronic 
nongenetic disorders (Gold et al. 2002; Miners et al. 2002).
Patients with Fabry disease have a shortened life expectancy with men and women affected by 
the disorder living 20 years (MacDermot et al. 2001b) and 15 years (Barbey et al. 2004; 
MacDermot et al. 2001a; Mehta et al. 2004) less than those in the general population, 
respectively. Prior to the introduction of enzyme replacement therapy (ERT) in 2001, the leading 
cause of death in patients with Fabry disease was renal disease (Mehta et al. 2009). Since then, 
significant improvements have been made in supportive care of renal function and cardiac 
disease is now the primary cause of death (Mehta et al. 2009; Waldek et al. 2009).
Current Treatment Options
Two ERT products have been approved for patients with a confirmed diagnosis of Fabry disease: 
agalsidase alfa (marketed under the trade name of REPLAGAL® in countries outside the United 
States [US] by Shire) and agalsidase beta (FABRAZYME; Genzyme). REPLAGAL is approved in 
59 countries worldwide as of December 2017, including Canada. More recently in May 2016, 
migalastat (GALAFOLD) was granted approval in Europe and the US as the first chaperone 
therapy for the long-term treatment of Fabry disease in adults and adolescents aged 16 or older 
with an amenable mutation in GLA.
2.2
Product Background, Clinical Information, and Risk Benefit
Product Background
Always refer to the latest version of the REPLAGAL investigator’s brochure for the overall 
risk/benefit assessment and the most accurate and current information regarding the drug 
metabolism, pharmacokinetics, efficacy, and safety of REPLAGAL.
Alpha-galactosidase A is a homodimer consisting of 2 approximately 50 kDa subunits; 
α-galactosidase A is targeted to its lysosomal site of action by mannose-6-phosphate (M6P) 
moieties, which bind to their cognate receptors in the Golgi directing the enzyme to the 
prelysosomal compartments. Any enzyme that escapes this routing system is secreted by the cell 
via the constitutive secretory pathway and is often recaptured by cell surface M6P receptors to be
rerouted to the lysosome by the endocytic pathway (Kornfeld and Mellman 1989). The 
M6P-mediated lysosomal targeting is the key mechanism that made ERT a feasible 
treatment strategy for lysosomal storage diseases as it enables the targeting of exogenously 
administered lysosomal enzymes to the appropriate subcellular compartment for their optimal 
activity. 
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REPLAGAL (agalsidase alfa) is human GLA produced by genetic engineering technology. 
REPLAGAL is manufactured using an aseptic filling process in a facility in compliance with 
current Good Manufacturing Practice and regulations. REPLAGAL is formulated as a sterile 
product suitable for parenteral administration. The formulation of REPLAGAL includes sodium 
phosphate as a buffering agent, polysorbate 20 as a stabilizing agent, and sodium chloride as an 
isotonic agent.
REPLAGAL is intended for use as an ERT for patients with Fabry disease. Replacement of the 
absent or deficient enzyme contributes to the correction of the deficient enzymatic activity and 
allows for improved metabolism of the natural substrate of the enzyme. Over time, chronic 
replacement of the deficient enzyme could theoretically alter the natural history of Fabry disease, 
with concomitant improvements in renal and cardiac function, metabolism, neuropathic pain, and 
QoL.
Clinical Information and Benefit/Risk
Clinical studies of REPLAGAL have been conducted in Australia, Brazil, Canada, Europe, Japan, 
Paraguay, and the US. The clinical development program was designed to evaluate the safety and 
efficacy of REPLAGAL in subjects with Fabry disease and includes early phase safety studies, 
placebo-controlled safety and efficacy studies, and open-label extension studies. Additionally, 
studies in special populations have been conducted: pediatric subjects, female subjects, dialysis 
and renal-transplant subjects, and 1 compassionate-use study. A manufacturing change led to 
additional studies, such as bioequivalence pharmacokinetic (PK)/pharmacodynamic (PD) studies. 
One open-label, treatment protocol study (HGT-REP-081) evaluating the long-term safety of 
REPLAGAL in subjects with Fabry disease following a manufacturing change from roller bottle 
(RB) to bioreactor, animal-free (AF) process was completed in Canada (2018).
Data collected in clinical studies to date indicate that REPLAGAL remains safe and well-tolerated 
during long-term use. As with other intravenous (IV)-administered protein therapeutics, the 
identified and potential risks of treatment with REPLAGAL include occurrence of infusion-related 
reactions (IRRs) and potential development of neutralizing antibodies (NAbs) that may 
compromise efficacy. IRRs are idiosyncratic allergic-type hypersensitivity signs or symptoms 
experienced by patients during the infusion of REPLAGAL or on the first day of its administration. 
Infusion-related reactions are the most commonly observed ADRs associated with REPLAGAL.
The onset of IRRs generally occurs within the first 2 to 4 months after initiation of treatment 
with REPLAGAL, although later onset (after 1 year) has been reported. The frequency of these 
events has decreased over time as the number of infusions increased. The clinical and 
commercial experience has indicated that IRRs can be mitigated with a combination of 
infusion-rate control and pretreatment with medications such as antihistamines, antipyretics or 
low-dose corticosteroids. Cardiac ischemic events and arrhythmias triggered by IRRs have been 
also reported as risks associated with REPLAGAL treatment in patients with pre-existing cardiac 
manifestations of Fabry disease. The majority of these events were mild in severity, nonserious 
and resolved. Cardiac events triggered by IRRs are possibly due to the hemodynamic stress 
caused by infusion. Lack of efficacy due to development of NAbs against agalsidase alfa remains 
a potential risk but has not been reported during treatment with REPLAGAL.
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To date, there is no apparent evidence for a loss of efficacy due to NAbs. Borderline 
immunoglobulins E (IgE) antibody positivity not associated with anaphylaxis has been reported 
in clinical studies. Additionally, clinical and postmarketing experience has reflected a safety 
profile for REPLAGAL that continues to support administration in the home setting.
In summary, the cumulative clinical and postmarketing experience indicates that the benefit-risk 
profile of agalsidase alfa for the treatment of Fabry disease remains favorable supported by the 
following:

A high disease burden with life-threatening/debilitating complications

Alternative treatments are limited and are also associated with significant adverse reactions

Demonstrated benefit in pain reduction, improvement or stabilization of cardiac and renal 
function, and reduction in accumulation of Gb3

Well established safety profile with the main identified risks of IRRs, cardiac events 
triggered by IRRs, and immunogenicity.
The efficacy profile of REPLAGAL was evaluated in clinical studies and REPLAGAL received 
initial regulatory approval in the European Union (EU) in 2001 based on reduction of pain in 
patients with Fabry disease. Additionally, the registration studies evaluated important clinical 
outcome benefits such as QoL, renal function, cardiac structure, and PD (Gb3) measures. 
The benefit-risk for this study is in alignment with the overall clinical program benefit-risk 
assessment. Investigators will follow site-specific standards for the mitigation of impact from 
COVID-19 and will manage any AEs related to COVID-19 per study procedures for the 
reporting and treatment of AEs.
2.3
Study Rationale
Initial approval for REPLAGAL was granted in Canada in 2004. At that time, REPLAGAL was 
manufactured using an RB technology. In March 2009, Shire submitted a Supplemental New 
Drug Submission for REPLAGAL manufactured using a new bioreactor method intended to 
eliminate animal-sourced raw materials from the manufacturing process but approval was not 
granted. On 10 Feb 2017, REPLAGAL manufactured using the AF process received conditional 
approval in Canada under a Notice of Compliance with Conditions mandating that efficacy of 
REPLAGAL be confirmed in patients with Fabry disease. This Phase 3 study will be conducted to 
fulfill the postmarketing commitment to confirm the efficacy of REPLAGAL in a population of 
treatment-naïve subjects with a confirmed diagnosis of Fabry disease.
2.4
Compliance Statement
This study will be conducted in accordance with this protocol, the International Council for 
Harmonisation Guideline for Good Clinical Practice E6 (ICH GCP, 1996; E6 R2, 2017), Title 21 
of the US Code of Federal Regulations (US CFR), the EU Directives (2001/20/EC; 2005/28/EC), 
and applicable national and local regulatory requirements.
The responsibilities of the study sponsor and investigator(s) are described fully in Appendix 1.
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3
OBJECTIVES AND ENDPOINTS
3.1
Study Objectives
3.1.1
Primary Objective
The primary objective is to evaluate the efficacy of REPLAGAL (0.2 mg/kg every other week 
[EOW] up to 104 weeks) on renal (estimated glomerular filtration rate [eGFR]) and cardiac (left 
ventricular mass index [LVMI]) parameters in subjects with a confirmed diagnosis of Fabry 
disease and who are naïve to any Fabry-specific treatment. 
3.1.2
Secondary Objectives
The secondary objectives of this study are: 

To evaluate the efficacy of REPLAGAL 0.2 mg/kg EOW on other renal and cardiac 
variables and PD markers

To assess the safety and tolerability of REPLAGAL over the study period. 
3.1.3
Exploratory Objectives
The exploratory objectives of this study are: 

To evaluate the effect of REPLAGAL on inflammatory biomarkers relevant to Fabry 
disease

To assess the effect of REPLAGAL on the subject’s overall rating of pain, fatigue, 
severity of Fabry symptoms and quality of life

To evaluate the effects of REPLAGAL on gastrointestinal (GI) symptoms of Fabry 
disease.
3.1.4
Rationale for the Selection of the Primary Endpoints
A number of clinical and PD measures have been evaluated as endpoints in previous clinical 
studies of Fabry disease, including renal function, cardiac involvement, pain, Gb3 and lyso-Gb3
levels and occurrence of sentinel events (renal, cardiac, or cerebrovascular events, or death). 
Sentinel events, such as hospitalizations and death events are infrequent, often unpredictable (eg, 
arrhythmias, stroke) and occur over a protracted period during the progressive course of Fabry 
disease and therefore precludes their use as practical endpoints for disease progression in a 
clinical study setting.
Measures of renal and cardiac involvement have been more consistently used to assess disease 
progression across clinical studies based on the progressive impairment of the kidney and the 
heart during the disease evolution (Branton et al. 2002; Kampmann et al. 2008; 
Schaefer et al. 2009; Schiffmann et al. 2009). Over time, progressive deterioration of renal and 
cardiac function results in the occurrence of clinical events such as myocardial infarction, 
arrhythmia, dialysis, left ventricular hypertrophy, and end-stage renal disease (dialysis and renal 
transplantation), and may finally lead to death related to cardiac or renal failures.
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The clinical relevance of renal and cardiac parameters, as disease progression markers, is 
highlighted by their inclusion in global treatment guidelines and in the Canadian Fabry 
Disease Treatment Guidelines 2017, as key criteria informing initiation of enzyme replacement 
therapy (ERT) for the stabilization or improvement of renal and cardiac function decline 
(Eng et al. 2006; Schiffmann et al. 2010; Sirrs et al. 2018; West et al. 2012). Based on the current 
literature, the Canadian Fabry Disease Treatment Guidelines 2017 confirmed that there is 
evidence of improvement with ERT as disease specific therapy, as follows:

Stabilization of Fabry nephropathy with stable proteinuria and glomerular filtration 
rate

Stabilization of Fabry cardiomyopathy with stable or declining left ventricular mass 
index or left ventricular wall thickness.
Renal and cardiac disease manifestations are also considered as the primary criteria for ERT 
initiation in patients with Fabry disease and are assigned a higher level of evidence to justify 
ERT treatment relative to neurologic, neuropathic, and gastrointestinal manifestations. In this 
sense, the renal disease evidence has the level of evidence 1 - Grade B, while the cardiac disease 
evidence has the level of evidence 2 - Grade B (Sirrs et al. 2018).
Considering the clinical relevance of renal and cardiac involvement in Fabry disease, it is 
appropriate to look at measures of renal and cardiac function as relevant clinical endpoints when 
assessing the efficacy of Fabry disease treatments. The same renal and cardiac parameters were 
also used as primary endpoints by other sponsors for studying the efficacy of their molecules on 
Fabry disease (eg, FABRAZYME, Genzyme [(Fabrazyme 2003)]; GALAFOLD, Amicus 
[(Galafold 2018)]; and pegunigalsidase alfa [PRX-102], Protalix). 
3.2
Study Endpoints
The study endpoints are summarized and mapped to their corresponding objective in Table 2. A 
detailed description of the statistical analysis of each endpoint is provided in Section 8.2.6. 
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Table 2
Objectives and Endpoints 
Objective
Endpoint(s)
Primary
To evaluate the efficacy of 
REPLAGAL (0.2 mg/kg every EOW 
up to 104 weeks) on renal (eGFR) 
and cardiac (LVMI) parameters in 
subjects with a confirmed diagnosis 
of Fabry disease and who are naïve 
to any Fabry-specific treatment 

Change from baseline at Week 104 in renal function, assessed by 
eGFR (using the Chronic Kidney Disease Epidemiology [CKD-EPI] 
formula)

Change from baseline at Week 104 in cardiac structure, assessed by 
LVMI using cardiac magnetic resonance imaging (cMRI).
Secondary
To evaluate the efficacy of 
REPLAGAL 0.2 mg/kg EOW on 
other renal and cardiac variables 
and PD markers. 

Annualized rate of change in eGFR

Annualized rate of change in LVMI

Change over time in eGFR

Change over time in LVMI

Change over time in proteinuria, measured by protein/creatinine ratio
(PCR)

Change over time of the number of fibrotic segments suggestive of 
cardiac fibrosis as assessed by volume of fibrosis, measured by cMRI

Change over time in interventricular septal end-diastolic thickness 
(IVSTd) and posterior wall thickness in diastole (PWTd), measured 
by cMRI

Change over time in plasma globotriaosylsphingosine (lyso-Gb3) 
To assess the safety and tolerability 
of REPLAGAL over the study period.

Adverse events (AEs)

Antidrug antibody (ADA) assessments including NAbs

Clinical laboratory tests (serum chemistry, hematology, and 
urinalysis)

Electrocardiography 

Vital signs
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Table 2
Objectives and Endpoints 
Objective
Endpoint(s)
Exploratory
To evaluate the effect of REPLAGAL
on inflammatory biomarkers 
relevant to Fabry disease.

Change over time in serum and levels of inflammatory biomarkers, 
including but not limited to Interleukin 1 Beta (INTLK1β), Tumor 
Necrosis Factor (TNF-α), Vascular Cell Adhesion Molecule 1 
(VCAM1), and Intercellular Adhesion Molecule 1 (ICAM1). 
To assess the effect of REPLAGAL
on the subject’s overall rating of 
pain, fatigue, severity of Fabry 
symptoms and quality of life.

Change over time in the following patient-reported outcome (PRO) 
measures: 
o
Patient-reported pain assessed by the Brief Pain 
Inventory-Short Form (BPI-SF)
o
Patient-reported fatigue assessed by the Brief Fatigue 
Inventory (BFI)
o
Patient-reported disease severity assessed by the Patient 
Global Impression of Fabry Symptom Severity (PGI-S)
o
Patient-reported QoL assessed by the Short Form-36 Health 
Survey (SF-36v2)
To evaluate the effects of 
REPLAGAL on gastrointestinal 
symptoms of Fabry disease. 

Change over time in GI symptoms as assessed by the Gastrointestinal 
Symptom Rating Scale (GSRS)
ADA=antidrug antibody; AE=adverse event; AUC=area under the plasma concentration-time curve; BFI=Brief Fatigue 
Inventory; BPI-SF=Brief Pain Inventory-Short Form; CKD-EPI=Chronic Kidney Disease-Epidemiology; cMRI=cardiac 
magnetic resonance imaging; eGFR=estimated glomerular filtration rate; EOW=every-other-week; GSRS=Gastrointestinal 
Symptom Rating Scale; ICAM1=Intercellular Adhesion Molecule 1; INTLK1β =Interleukin 1 Beta; IVSTd=interventricular 
septal end-diastolic thickness; LVMI=left ventricular mass index; lyso-Gb3=globotriaosylsphingosine; NAb=neutralizing 
antibody; PCR=protein/creatinine ratio; PD=pharmacodynamic; PGI-S=Patient Global Impression of Fabry Symptom 
Severity; PRO=patient-reported outcome; PWTd=posterior wall thickness in diastole; QoL=quality of life; SF-36v2=Short 
Form-36 Health Survey; TNF-α=Tumor Necrosis Factor; VCAM1=Vascular Cell Adhesion Molecule 1 
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STUDY DESIGN
4.1
Overall Design 
This is a global, Phase 3, multicenter, nonrandomized, open-label, single-arm, and 
baseline-controlled study. 
Eligible participants will be male and female adult subjects who are treatment naïve and who 
have a confirmed diagnosis of Fabry disease with left ventricular hypertrophy. Subjects with or 
without renal involvement may qualify for the study if their eGFR is 45 to 120 mL/min/1.73 m2, 
as calculated by the Chronic Kidney Disease-Epidemiology (CKD-EPI) formula.
The study will include 1 arm, comprising subjects prospectively treated with REPLAGAL for 
104 weeks. The change from baseline to Week 104 in eGFR and LVMI will be compared with 
values of patients with Fabry disease from the published literature (Schiffmann et al. 2009);
(Kampmann et al. 2008) who had similar baseline demographic and disease characteristics as the 
study subjects (Schiffmann et al. 2009) and who remained untreated for 2 years.
It is expected that at least 45 adult subjects with Fabry disease will need to be enrolled in order to 
obtain at least 36 evaluable subjects. To be considered evaluable, a subject must not have 
discontinued from investigational product and must have valid, nonmissing values of the primary 
efficacy endpoints (eGFR and LVMI) for both baseline and Week 104. 
Potential subjects will participate in a screening period, which can last up to 42 days, to 
determine eligibility. After completion of baseline procedures and assessments, eligible subjects 
will receive 0.2 mg/kg REPLAGAL by IV infusion EOW for 104 weeks and will have study visits 
approximately every 12 to 14 weeks during the 104-week treatment period. Subjects who 
discontinue from study treatment may continue to have study visits if they consent to do so. 
Approximately 14 days (-4 days/+7 days) after the last infusion or study visit, a safety follow-up 
contact or visit will occur to ensure the subject's safety.
Subject participation is expected to be approximately 112 weeks, as follows (Figure 1):

Screening period: up to 42 days 

Treatment period: 104 weeks

Safety follow-up period: 14 days (-4 days/+7 days).
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Figure 1
Study Design Flow Chart
4.2
Scientific Rationale for the Reference-Controlled Study Design
This study intends to confirm the efficacy of REPLAGAL in treatment-naïve subjects who have a 
confirmed diagnosis of Fabry disease. These criteria pose a challenge for subject recruitment, 
precluding the feasibility of a randomized placebo-controlled design recommended for Phase 3 
studies as detailed below.
Fabry disease is a rare disease and recruitment of sufficient number of subjects to conduct 
clinical studies has been a longstanding challenge throughout the clinical development of 
REPLAGAL. Following approval of ERT for Fabry disease (REPLAGAL and Fabrazyme) in 2001, 
treatment was indicated for patients with more advanced disease manifestations and subsequent 
treatment guidelines encouraged the initiation of treatment at the time of diagnosis in males and 
at the time of development of significant symptoms in females (Schiffmann et al. 2010); 
(Eng et al. 2006; Sirrs et al. 2018; West et al. 2012). As such, patients with Fabry disease who 
remain naïve to treatment in countries where ERT is commercially available are typically those 
who do not show evidence of severe organ involvement. The rarity of Fabry disease and the 
recommended guidelines for the management of its symptoms limit the availability of the 
clinical population targeted for this study, posing challenges for the recruitment of a sufficient 
number of naïve subjects.
The Canadian Fabry Disease Treatment Guidelines (Sirrs et al. 2018) outline when patients 
qualify for disease specific therapy based on available data and recommend regular follow-up of 
patients who do not yet meet the criteria for treatment (Sirrs et al. 2018). According to the 
guidelines, patients with renal and cardiac manifestations are all eligible for treatment, which 
limits the number of available ERT-naïve patients and has implications on the study design. 
The small global pool of patients who are potentially eligible for this study limits the feasibility 
of an adequately powered 2-arm, randomized, placebo-controlled phase 3 study, to detect 
between-arm differences in the primary endpoints. Due to the recruitment and ethical limitations 
associated with the 2-arm, placebo-controlled study design, the focus has shifted towards a 
design whereby the efficacy of REPLAGAL will be confirmed by comparing the dataset from the 
prospectively treated cohort enrolled in this study with an external, reference dataset of untreated 
patients (FDA Guidance for Industry: E10 Choice of Control Group and Related Issues in 
Clinical Trials). 
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More specifically, eGFR and LVMI change over the 2-year treatment period will be compared 
with reported literature values for patients with Fabry disease who remained untreated for 2 years 
and who demonstrate similar baseline demographic and disease severity characteristics as those 
in the treatment arm. 
Study designs relying on comparisons with reference datasets from untreated patients have 
become increasingly common for studies aiming to investigate the benefits of ERT for the 
treatment of Fabry disease. Except for one long-term, placebo-controlled Phase IV study 
conducted with agalsidase beta (Banikazemi et al. 2007), none of the long-term studies 
performed after the approval and marketing of ERT have used a concurrent, untreated study arm. 
Access to ERT treatment has changed the treatment paradigm for patients with Fabry disease and 
limited the availability of data in treatment-naïve patients to the timeframe before approval of 
ERTs. Summaries of selected studies examining the effects of ERT in patients with Fabry 
disease by comparing outcomes from a treated cohort with reference data from untreated patients 
are provided below to support the validity of this approach. For each study summary, the focus is 
on the reasons justifying the use of a reference dataset from untreated patients as a comparator 
and on the criteria used for patient selection to ensure that the treated and the untreated patients 
have similar baseline characteristics to allow for a valid comparison. 

Rombach et al., 2013: this prospective Dutch study sought to examine the long-term 
benefits of ERT (Rombach et al. 2013). Renal, cardiac, and cerebrovascular measures 
were collected from 75 ERT-treated patients with Fabry disease between 1999 and 
2010 and compared with data from a natural history cohort. The natural history cohort 
data were obtained from the medical records of 28 patients with Fabry disease who 
had a history of complications before ERT became available or who had an indication 
for ERT but remained untreated after treatment became available. Among the 
untreated patients, only those meeting the Dutch Fabry Guidelines criteria for 
treatment defined as the presence of chronic kidney disease (CKD), left ventricular 
hypertrophy, or cerebral white matter lesions were selected. The selection criteria set 
for the historical control were intended to create an untreated cohort of patients who 
matched those in the treatment arm by disease severity, in order to prevent 
confounding result interpretation due to bias by indication (Rombach et al. 2013).

Weidemann et al., 2013: this study conducted in Germany aimed to examine the 
effects of ERT on the progression towards “hard” clinical endpoints including 
stroke, end-stage renal disease and initiation of dialysis, and Fabry disease-related 
death in patients with Fabry disease (Weidemann et al. 2013). The treatment 
cohort data was collected from 40 patients with Fabry disease registered in the 
Wurzburg Fabry disease Centre (established in 2001) who have been receiving ERT 
for at least 5 years (or died during the observation period). Patients in treatment 
were relatively old with advanced disease progression at baseline because ERT was 
not available prior 2001. The authors noted that after approval of ERT, it was 
inappropriate to conduct a prospective study enrolling untreated subjects for ethical 
considerations. Therefore, historical, registry data from untreated subjects were used 
for comparison. 
Forty patients from the Fabry Registry, a database that monitors the natural history of 
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Fabry disease and outcomes of patients, were selected to match those in the treatment 
group with respect to age, gender, previous transient ischemic attacks, and CKD 
stage. These patients remained untreated due to ERT reimbursement issues in their 
countries of residence (Weidemann et al. 2013). 

Beck et al., 2015: this retrospective study was conducted to investigate the long-term 
benefits of ERT treatment on renal function, cardiomyopathy, morbidity and 
mortality in patients with Fabry disease (Beck et al. 2015). The outcomes evaluated 
were annualized rate of change in eGFR and LVMI, as well as time to and age at 
composite morbidity endpoints and death. Data for the treated cohort was collected 
from 740 patients enrolled in the Fabry Outcome Survey (FOS) registry. The authors 
highlighted that selection of an untreated cohort from FOS patients resulted in a 
biased comparison group, as untreated patients within the registry tend to be less 
affected by the disease than those receiving treatment and were predominantly 
females. Only 10% of FOS untreated patients could be matched for comparison 
resulting in a sample too small to allow for valid conclusions. As a result, data from 
FOS were extracted to provide cohorts of treated patients as comparable as possible 
to untreated cohorts from published studies with respect to inclusion/exclusion 
criteria and available data. Data from the FOS evaluable treated renal cohort were 
compared with those from untreated patients reported in a natural history study by 
Schiffman et al. (Schiffmann et al. 2009) as the two groups were broadly comparable 
in terms of age and renal characteristics. The FOS evaluable treated cardiac cohort 
was compared with an untreated cohort of patient with Fabry disease from a natural 
history study by Kampmann et al. (Kampmann et al. 2008), as the two cohorts were 
closely similar in terms of patient number, age, and relevant clinical factors. 
Two untreated comparators from the literature were used to evaluate 
morbidity-related outcomes: one was a natural history cohort (Schiffmann et al. 2009)
while the other was a placebo-treated cohort from a randomized clinical study of 
agalsidase beta (Banikazemi et al. 2007).
In the proposed SHP675-301 study design, each subject is their own control and the assessment 
will be made by comparing their postbaseline results with their own baseline results for eGFR 
and LVMI. To determine treatment benefits, the change in eGFR and LVMI in the prospectively 
treated cohort over the 2-year treatment period will be compared with reference control values of 
untreated patients with similar baseline demographic and disease characteristics from the 
published literature. While use of reference control values is not optimal, and elimination of bias 
in subject baseline characteristics is challenging, every effort to facilitate meaningful matches 
will be made. After a comprehensive review of published/available data, the following values 
from nontreated reference cohorts have been selected as comparators and will be used in the 
statistical analysis of the primary endpoints (refer to Section 9.5.1 for more details on the 
statistical analysis of the primary endpoints):

For the value of the weighted annualized rate of change in eGFR from natural history 
patients (-3 mL/min/1.73 m2) refer to analysis by Schiffmann et al. 
(Schiffmann et al. 2009)
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
For the value of the weighted annualized rate of change in LVMI from natural history 
patients (+5 g/m2.7) refer to analysis Kampmann et al. (Kampmann et al. 2008).
4.3
Justification for Dose
REPLAGAL 1 mg/mL concentrate solution for infusion is approved in 63 countries worldwide as 
of January 2020. The approved dose for REPLAGAL in these countries is 0.2 mg/kg of body 
weight EOW by IV infusion over 40 minutes (±10 minutes). This is the dose to be used for this 
study. 
4.4
Duration of Subject Participation and Study Completion Definition
A subject’s maximum duration of participation is approximately 112 weeks. This includes the 
screening period (up to 42 days), the treatment period (104 weeks), and the safety follow-up 
period (14 days [-4 days/+7 days] from the end of treatment [EOT] infusion, or the last infusion 
for subjects who withdraw early from the study). A subject is considered enrolled in the study 
when he or she signs informed consent and passes the inclusion/exclusion criteria.
The overall planned study duration is approximately 6 years. The first subject is expected to be 
enrolled in 2022. The Study Completion Date is defined as the date on which the last subject in 
the study completes the final protocol-defined assessment(s). This includes the follow-up visit or 
contact, whichever is later (refer to Section 8.1.4 for the defined follow-up period for this 
protocol).
4.5
Sites and Regions
This study is expected to be conducted at up to 50 sites globally. 
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5
STUDY POPULATION
Each subject must participate in the informed consent process and provide written informed 
consent/assent before any procedures specified in the protocol are performed.
5.1
Inclusion Criteria
The subject will not be considered eligible for the study without meeting all of the criteria below:
1. The subject must voluntarily sign an Institutional Review Board (IRB)/Independent 
Ethics Committee/Research Ethics Board approved informed consent form after all 
relevant aspects of the study have been explained and discussed with the subject. 
2. The subject has Fabry disease as confirmed at screening by the following criteria using a 
dried blood spot (DBS) assay:

For male subjects, Fabry disease is confirmed by a deficiency of GLA activity and a 
mutation in the GLA gene.

For female subjects, Fabry disease is confirmed by a mutation in the GLA gene.
3. The subject is 18 to 65 years of age, inclusive.
4. Female subjects must have a negative pregnancy test at screening. 
5. Female subjects of child-bearing potential must agree to use a medically acceptable 
method of contraception at all times during the study and for at least 14 days after the 
final study infusion; the methods of acceptable contraception are listed in the protocol. 
6. The subject is deemed, as determined by the investigator, to have adequate general health 
to undergo the specified protocol-related procedures and to have no safety or medical 
contraindications for participation.
7. The subject has not received any treatment (approved or investigational) specific to Fabry 
disease, such as ERT, chaperone therapy, or substrate reduction therapy.
8. The subject must have an eGFR of 45 to 120 mL/min/1.73 m2; eGFR will be calculated 
by a Shire-designated laboratory using the CKD-EPI formula. If the eGFR measurement 
at screening is not within the stipulated range, a second eGFR measurement may be 
completed and, if in range, used as the screening value. If a second measurement is taken, 
a minimum of 1 week and maximum of 30 days should separate it from the first 
measurement. This inclusion criterion follows the European Guidelines for Treatment of 
Fabry Disease (Biegstraaten et al. 2015) and Kidney Disease Improving Global 
Outcomes guidelines for classification of renal disease 
(Kidney Disease Improving Global Outcomes (KDIGO) 2013).
9. The subject has left ventricular hypertrophy (LVH), where LVH is defined as left 
ventricular mass index (LVMI) >50 g/m2.7 confirmed by cardiac magnetic resonance 
imaging (cMRI) at screening. The cMRI value at screening will serve as the baseline 
value.
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5.2
Exclusion Criteria
The subject will be excluded from the study if any of the following exclusion criteria are met:
1. In the opinion of the investigator, the subject’s life expectancy is ≤5 years.
2. The subject has undergone or is scheduled to undergo kidney transplantation or is 
currently on dialysis, or has any signs or symptoms of end stage renal disease.
3. Urine protein/creatinine ratio (PCR) >1.5 mg/mg.
4. Subjects who have clinically relevant history of allergy or signs or symptoms of severe 
hypersensitivity (including hypersensitivity to the REPLAGAL active substance or any of 
the excipients), which in the investigator’s judgment, will substantially increase the 
subject’s risk if he or she participates in the study.
5. Cardiac fibrosis involving more than 2 segments, as determined by cMRI at screening.
6. In the opinion of the investigator, the subject has non-Fabry disease-related cause of 
end-organ (renal, cardiac, central nervous system) dysfunction/failure or is receiving 
medications that may affect the rate of disease progression, as assessed by cardiac and/or 
renal measures. 
7. The subject has a positive test at screening for hepatitis B surface antigen (HBsAg), 
positive test for hepatitis B core antibody (HBcAb), positive test for hepatitis C (HCV) 
antibody with confirmation by HCV-ribonucleic acid polymerase chain reaction testing, 
or positive test for human immunodeficiency virus (HIV) antibody.
8. Treatment with REPLAGAL at any time prior to the study.
9. Prior treatment with any of the following medications:

FABRAZYME (agalsidase beta) and its biosimilars

GLYSET® (MIGLITOL)

ZAVESCA® (MIGLUSTAT)

CERDELGA® (ELIGLUSTAT)

GALAFOLD® (MIGALASTAT)

ANY INVESTIGATIONAL PRODUCT FOR TREATMENT OF FABRY DISEASE

CHLOROQUINE

AMIODARONE

MONOBENZONE 

GENTAMICIN.
10. The subject is pregnant or lactating.
11. The subject has a body mass index >39 kg/m2. (BMI = kg/m2)
12. The subject is treated or has been treated with any other investigational drug within 
30 days of prior to study start.
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13. The subject is unable to understand the nature, scope, and possible consequences of the 
study. 
14. The subject is unable to comply with the protocol, eg, uncooperative with protocol 
schedule, refusal to agree to all of the study procedures, inability to return for 
evaluations, or is otherwise unlikely to complete the study, as determined by the 
investigator.
5.3
Restrictions 
Not applicable.
5.4
Reproductive Potential
5.4.1
Female Contraception
Sexually active females of childbearing potential should be using an acceptable form of 
contraception. Females of childbearing potential must be advised to use acceptable 
contraceptives throughout the study period and for 14 days following the last dose of 
investigational product. If hormonal contraceptives are used, they should be administered 
according to the package insert. Females of childbearing potential who are not currently sexually 
active must agree to use acceptable contraception, as defined below, if they become sexually 
active during the period of the study and 14 days following the last dose of investigational 
product. 
Female subjects should be either:

Postmenopausal (12 consecutive months of spontaneous amenorrhea and age ≥51 years) 

Surgically sterile (having undergone one of the following surgical acts: hysterectomy, 
bilateral tubal ligation, bilateral oophorectomy, or bilateral salpingectomy) and at least 
6 weeks post sterilization, or

Females of child-bearing potential with a negative urine and/or serum beta-human chorionic 
gonadotropin (-hCG) pregnancy test as described in Section 8.2.3.7. Females of 
childbearing potential must agree to abstain from sexual activity that could result in 
pregnancy or agree to use acceptable methods of contraception.
Acceptable methods of contraception are listed in Appendix 4. 
5.4.2
Male Contraception
Not applicable. 
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6
STUDY INTERVENTION
6.1
Investigational Product
6.1.1
Identity of Investigational Product
The test product is REPLAGAL, which will be supplied as a sterile, clear, colorless concentrate for 
dilution for IV infusion. REPLAGAL will be provided in single-use, 5 mL vials containing 3.5 mL 
of concentrate at a concentration of 1 mg/mL.
Additional information is provided in the current REPLAGAL investigator’s brochure. 
6.1.2
Blinding the Treatment Assignment
Not applicable.
6.2
Administration of Investigational Product
REPLAGAL infusions may occur at the clinical site, in a home setting, or at a qualified satellite 
treatment center at the investigator’s discretion. Subjects must complete all baseline assessments 
and procedures before the first infusion of REPLAGAL. Subjects will receive REPLAGAL at a dose 
of 0.2 mg/kg body weight administered as an IV infusion over 40 minutes (±10 minutes) EOW 
(±7 days). Refer to the instruction manual provided separately from this protocol that outlines all 
operating procedures to be followed for this study including drug transport, reconstitution, and 
the required subject assessments before, during, and after infusion of REPLAGAL.
6.2.1
Infusions of REPLAGAL in the Home Setting
Please note that allowing for subjects to have home infusions is not a study requirement. This is 
an option available to the investigator as per their discretion and/or in accordance with regulatory 
requirements per country.
For those sites choosing to allow subjects to dose in a home setting, the first 3 REPLAGAL
infusions (baseline infusion [Day 0/Week 0], Week 2/EOW infusion 2, and Week 4/EOW 
infusion 3) are to be administered at the clinical site. After the first 3 infusions, subjects who 
have not experienced a treatment-related serious adverse event (SAE) or a moderate or severe 
IRR (refer to Appendix 3.1 for a definition of IRR) may have their subsequent EOW infusions 
administered by qualified and trained medical personnel at home, per the discretion and direction 
of the investigator. Subjects receiving REPLAGAL as home therapy will be required to return to 
the clinical site to receive their infusion at Week 12/EOW infusion 7, Week 26/EOW
infusion 14, Week 40/EOW infusion 21, Week 52/EOW infusion 27, Week 64/EOW 
infusion 33, Week 78/EOW infusion 40, Week 92/EOW infusion 47, and Week 104 visits/EOW 
infusion 53. A total of 11 REPLAGAL infusions are required to be performed at the clinical site.
If at any point during home infusions subjects experience a treatment-related SAE or a moderate 
or severe IRR, their next infusion should be administered at the clinical site. Infusions should 
continue at the clinical site until no further moderate or severe IRRs are reported, at which point 
subjects may be re-evaluated for consideration to retransition to home infusions. 
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Home therapy can only resume at subsequent infusions after agreement is reached by the 
investigator and the Shire medical monitor.
In the home setting, vital signs and documentation of AEs will be collected at each visit. The 
qualified, trained medical personnel will evaluate and report to the study site the occurrence of 
AEs. Study site personnel will report SAEs as described in the Emergency Contact Information 
and Appendix 3.4. If a SAE or moderate or severe IRR occur while a subject is receiving 
treatment at home, the qualified, trained medical personnel will maintain contact with the 
investigator for treatment advice. 
At each home visit, a urine pregnancy test will be conducted for women of childbearing potential 
prior to the completion of any study procedures. If the result is positive, the infusion will not be 
administered, and a blood sample will be collected for serum β-hCG pregnancy testing. The next 
infusion of REPLAGAL will not be administered until the results of the serum pregnancy test are 
received. If the serum β-hCG result is also positive, no additional doses of the investigational 
product are to be administered. Pregnancy should be reported to Shire Global Patient Safety 
Evaluation, and the Shire medical monitor (or designee) within 24 hours of becoming aware of 
the pregnancy. For more details on pregnancy reporting refer to Appendix 3.8.
If there are no IRRs during the first 3 infusions the observation and vital signs post infusion can 
be omitted at the discretion of the investigator. 
The qualified, trained medical personnel will follow the instruction manual provided separately 
from this protocol that outlines all operating procedures to be followed for this study including 
drug transport, reconstitution, and the required subject assessments before, during, and after 
infusion of REPLAGAL. Clinical evaluations will remain under the medical supervision of the 
investigator. Appropriate medical support, including adequately trained personnel in emergency 
measures, should be readily available when REPLAGAL is administered. If anaphylactic or other 
acute severe reactions occur, immediately discontinue the infusion and initiate appropriate 
medical treatment.
6.2.2
Management of Infusion-related Reactions
For guidance on the management of IRRs, refer to Appendix 3.1.
6.2.3
Interactive Response Technology for Investigational Product Management
An interactive response technology (IRT) will be used for investigational product management 
tasks including investigational product supply management, inventory management and supply 
ordering, investigational product expiration tracking, destruction at site tracking, and return of 
investigational product. Please refer to the instruction manual provided separately from this 
protocol that outlines the operating procedures regarding the IRT. 
At relevant visits during the baseline and treatment periods, patient-facing assessments including 
the SF-36, BPI-SF, PGI-S, BFI, and GSRS will be collected via an electronic device. These 
assessments will be captured and transmitted to a third-party database where site staff will have 
access to the patient data via a restricted website. 
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In the case of an unplanned event that disallows/prevents the administration of the PRO on a 
device, for reasons including but not limited to, device outage or other technical limitation, 
subjects may record their responses on a web back-up version of the assessments that is provided 
by the CRO or PRO vendor. Sites will be provided with access to the web back-up assessments 
as a preventative measure.
6.2.4
Allocation of Subjects to Treatment 
This is an open-label, nonrandomized study where all subjects will be enrolled to receive 
REPLAGAL at 0.2 mg/kg EOW. Individual subject numbers are automatically assigned to all 
subjects via the IRT as they consent to take part in the study.
6.2.5
Dosing
REPLAGAL will be administered at a dose of 0.2 mg/kg body weight as an IV infusion over 
40 minutes (±10 minutes) EOW. The first dose of REPLAGAL will be based on the subject’s 
weight at baseline. 
The appropriate dose calculation is obtained as follows: multiply the subject’s weight in kg by 
0.2 mg/kg. (Round up or down to the 1/10th decimal place from the 1/100th decimal place using 
>0.05 to round up). This will give the number of mL of drug required since the concentration is 
1 mg/mL.
To determine the number of vials required, divide the number of mL determined above by 
3.5 mL. Round up to the whole number and this is the number of vials required to withdraw the 
number of mL needed (refer to the Pharmacy Manual).
All study procedures, assessments (except for postinfusion vital signs), and sample collection 
should be completed prior to administering an infusion.
Ideally, REPLAGAL infusions should occur on the same day of the week, EOW (ie, every 
14 days), but may occur every 14 days (±7 days) of the target day in order to facilitate subject 
scheduling. If at all possible, missed infusions should be avoided. If a subject is not dosed within 
21 days from the scheduled dose, the subject should receive the next infusion as soon as possible. 
It may be acceptable to give the next infusion as early as 7 days after the previous infusion. 
Subsequent infusions will return to the original schedule which should be based on the subject’s 
first infusion.
Dosing guidance will be provided in a separate study manual.
6.2.6
Dose Modification
The first dose of REPLAGAL will be based on the subject’s weight at baseline. If the subject’s 
weight changes ≥±5% from baseline weight, (or the weight last used for dose recalculation), then 
the subject’s dose, should be recalculated based on the new weight. Weight for dose 
management, should be taken at the Site Visits (Weeks 12, 26, 40, 52, 64, 78, 92) as outlined in
the Schedule of Activities (Table 1). 
Percent weight change formula: (((W1-W0)/W0) *100)
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Dose adjustments should occur as soon as possible after a weight change of ±5% is identified, 
but no later than the next bi-weekly infusion visit. If the dose can be adjusted prior to the 
infusion on the day a weight change of ±5% is identified, the dose adjustment should be made 
and the updated dose should be given to the subject. If the dose cannot be adjusted on the same 
day the weight change of ±5% is identified, the updated dose may be given at the next bi-weekly 
infusion. 
6.3
Labeling, Packaging, Storage, and Handling of Investigational Product
6.3.1
Labeling
Investigational product labels will contain information necessary to meet the applicable 
regulatory requirements. 
6.3.2
Packaging
Investigational product will be packaged in the following labeled containers: single-use, 5 mL 
vials containing 3.5 mL of concentrate at a concentration of 1 mg/mL. Changes to 
sponsor-supplied packaging prior to dosing may not occur without full agreement in advance by 
the sponsor.
6.3.3
Storage
REPLAGAL will be provided by the sponsor (or designee) to the clinical sites, qualified satellite 
sites, or other approved location, in a temperature-controlled, monitored container. The vials 
should be stored in a refrigerator at 2 to 8°C (36–46°F). A minute amount of fine particulate 
matter, causing the solution to appear slightly hazy, may be present during storage.
Investigational product at the clinical sites, hospitals, infusion centers, etc. must be stored in a 
locked refrigerator, or in a refrigerator in a locked room, with access limited to authorized study 
personnel.
Investigational product must be stored in accordance with labeled storage conditions. 
Temperature monitoring is required at the storage location to ensure that the investigational 
product is maintained within the established temperature range. The sponsor, or designee, must 
be notified of any temperature that fall out of the accepted range. Detailed guidance on storage 
requirements and issue reporting will be outlined in the Infusion and Pharmacy Manuals.
The sponsor should be notified immediately if there are any changes to the storage area of the 
investigational product that could affect the integrity of the product(s), eg, fumigation of a 
storage room.
6.3.4
Handling
REPLAGAL should be handled as follows:

REPLAGAL vials should be stored in a refrigerator at 2 to 8°C (36–46°F). A minute 
amount of fine particulate matter, causing the solution to appear slightly hazy, may be 
present during storage.
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
REPLAGAL is intended for IV use only.

REPLAGAL for subject administration should be prepared by slowly mixing the 
appropriate amount of REPLAGAL into 100 mL of normal saline (0.9% sodium 
chloride) suitable for IV administration.

Once diluted into normal saline, the solution should be rocked gently, but not shaken.

REPLAGAL should be prepared on the day of infusion. As the product does not contain
preservatives, REPLAGAL should be used as soon as possible after diluting with 
normal saline. Do not store above 25°C (77°F). It is recommended that infusion of the 
product be initiated within 24 hours of dilution.

The diluted REPLAGAL must be administered via an IV line that contains a standard 
filter.

Do not mix with or administer in conjunction with other drug solutions.

REPLAGAL vials are intended for one time use only (3.5 mL maximum). Remaining 
drug product (overfill or unused drug) left in a vial after withdrawing the subject’s 
assigned dose is NOT to be used for subsequent doses (refer to Pharmacy Manual).
6.4
Drug Accountability
Investigators, or designee, will be provided with sufficient amounts of the investigational product 
to carry out this protocol for the agreed number of subjects.
The investigator or designee will acknowledge receipt of the investigational product, 
documenting shipment content and condition. Accurate records of all investigational product 
dispensed, used, returned, and/or destroyed must be maintained for the duration of the study.
As instructed by the sponsor, at the end of the study all unused stock, and empty/used 
investigational product packaging may be destroyed at the site or a local facility. In this case, 
destruction records identifying what was destroyed, when and how, must be obtained with copies 
provided to the sponsor. Destruction of investigational product must be in accordance with local, 
state, and national laws.
In the event that a site is not allowed to destroy investigational product, all unused stock and 
empty/used investigational product packaging are to be sent to a nominated contractor on behalf 
of the sponsor. Investigational product being returned to the sponsor’s designated contractors 
must be counted and verified by the clinical site personnel and the sponsor or their designee. The 
sponsor, or designee, should be contacted for authorization to return any investigational product 
prior to shipment. Shipment of all returned investigational product must comply with local, state, 
and national laws.
All investigational product should be accounted for, and the identified discrepancies should be 
investigated and documented to the sponsor’s satisfaction. Additional guidance on drug 
accountability will be included in a separate study plan. 
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6.5
Subject Compliance
For this study, REPLAGAL is administered under controlled conditions; therefore, subject
compliance with study treatment is anticipated to be high.
6.6
Prior and Concomitant Therapy
All nonstudy treatment (including but not limited to herbal treatments, vitamins, behavioral 
treatment, nonpharmacological treatment, such as psychotherapy, as appropriate) received within 
30 days prior to screening period through the end of the follow-up period must be recorded in the
subject’s source documentation. 
6.6.1
Prior Treatment
Prior treatment includes all treatment (including but not limited to herbal treatments, vitamins, 
behavioral treatment, nonpharmacological treatment such as psychotherapy) received within 
30 days prior to screening period through the date of first dose of investigational product. Prior 
treatment information must be recorded on the subject’s source documentation.
6.6.2
Concomitant Treatment 
Concomitant treatment refers to all treatment taken between the dates of the first dose of 
investigational product and the end of the follow-up period, inclusive. Concomitant treatment 
information must be recorded in the subject’s source documentation.
6.6.3
Prohibited Treatment
The following medications and treatments are prohibited at any time prior and throughout the 
course of the study:

FABRAZYME (agalsidase beta) and its biosimilars

GLYSET (miglitol)

ZAVESCA (miglustat) 

CERDELGA (eliglustat)

GALAFOLD (migalastat)

Any investigational product for treatment of Fabry disease.
The following medications should not be administered at any time during this study because 
these substances have the potential to inhibit intracellular GLA:

Chloroquine

Amiodarone

Monobenzone 

Gentamicin
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6.7
COVID-19-related Protocol Considerations
On a temporary basis, in order to maintain subject safety, confidentiality, and study integrity in 
the context of healthcare delivery challenges presented by the COVID-19 pandemic, subjects 
who may be impacted should contact study sites and investigators to determine the best course of 
action. Depending on the impact, in some cases it may be possible to arrange for alternative 
solutions as permitted by local regulations. Any decision on procedural changes should be made 
on a case-by-case basis by the principal investigator in consultation with the study team and the 
medical monitor, while maintaining subject safety and confidentiality as the priority.
Missing data, remote visits, changes to assessment approaches, and altered visit windows during 
the COVID-19 public health emergency may affect the study results. Thus, it is important to 
identify all protocol deviations and altered data collection or assessment methods. It is crucial 
that any deviations related to COVID-19 be clearly identified as such in the eCRF.
The following procedural changes may be considered:

If necessary, informed consent from a potential or current trial participant may be obtained 
via electronic informed consent capabilities, or an electronic face-to-face consent interview 
when potential participants are unable to travel to the site. 

Subjects who discontinued from screening due to COVID-19-related factors may be 
rescreened if the medical monitor agrees

Options for additional investigational dosing in the home setting to prevent missed doses at 
site visits (see Section 6.2.1)

Remote checks instead of site visits (if appropriate) may be performed as a safety check on 
subject well-being

Transfer to investigational sites away from risk zones to complete required visits
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7
SCREEN FAILURE, WITHDRAWAL FROM THE STUDY, DISCONTINUATION 
OF STUDY TREATMENT, AND LOST TO FOLLOW-UP
7.1
Screen Failure
A screen failure is a subject who has given informed consent but who fails to meet the inclusion 
and/or exclusion criteria and has not been administered investigational product(s). 
Subjects who screen failed or could not be enrolled during the screening period, due to 
circumstances including, but not limited to, COVID-19 related issues, may be rescreened with 
prior approval from the sponsor medical monitor. Some procedures, such as cMRI, may not need 
to be repeated for rescreening, with prior agreement of the sponsor medical monitor.
7.2
Withdrawal from the Study
A subject may withdraw from the study at any time and for any reason, without prejudice to 
his/her future medical care by the physician or at the institution, or may be withdrawn at any 
time at the discretion of the investigator or sponsor (eg, in the interest of subject safety). The 
investigator is encouraged to discuss withdrawal of a subject with the medical monitor when 
possible. Withdrawal from the study means that the subject is no longer taking study treatment 
and does not return for further study visits. A subject who is withdrawn from the study does not 
meet the criteria to be part of the “completer set” for statistical analysis.
The investigator should make a reasonable effort to ascertain the reason(s) for withdrawal, while 
fully respecting the subject’s right to do so. The reason for withdrawal should be recorded in the 
subject’s source documentation. If a subject is withdrawn for more than 1 reason, each reason 
should be documented in the source documentation and the most clinically relevant reason 
should be indicated. 
Reasons for withdrawal from the study may include, but are not limited to:

Adverse event

Protocol deviation

Withdrawal by subject

Lost to follow-up

Lack of efficacy

Death

Pregnancy
Subjects wishing to completely withdraw from the study should be encouraged to complete the 
Week 104 (end of treatment or early termination visit) and safety follow-up assessments to 
ensure subject safety. Comments (spontaneous or elicited) or complaints made by the subject 
must be recorded in the source documents. The reason for withdrawal, date of stopping 
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investigational product, and the total amount of investigational product taken must be recorded in 
the source documents.
7.3
Discontinuation of Study Treatment
Premature Closure of the Treatment Protocol
Treatment Protocol Termination
If the sponsor or an investigator discovers conditions arising during the treatment protocol that 
indicate that the clinical investigation should be halted due to an unacceptable patient risk, the 
treatment protocol may be terminated after appropriate consultation between Shire and the 
investigators. 
In addition, a decision on the part of Shire to suspend or discontinue development of the test 
material may be made at any time.
Options for Subjects upon Discontinuation from Study Treatment
In an effort to collect information on key outcomes for participants who discontinue from study 
treatment, all enrolled subjects who have received at least 1 dose of investigational product, and 
who have completed at least 1 efficacy assessment of the endpoints being analyzed, may consent 
to return to the clinic site for assessments conducted at the site visits. During the initial informed 
consent process, subjects should be reminded that, even if they choose to discontinue study 
treatment, their continued participation in the study is beneficial for data collection and analysis.
If for any reason investigational product is discontinued, the subject should be given the 
opportunity to consent to continuing study visits without being on study treatment. Subjects in 
this situation should review and sign a “Withdrawal of Informed Consent” document, and select 
from a list of options regarding their study participation. Options may include, but are not limited 
to:

No longer willing/able to receive REPLAGAL study treatment, but willing to attend 
study visits

No longer willing/able to receive REPLAGAL study treatment, and not willing to attend 
further visits, but willing to allow medical records to be consulted in future to obtain 
clinical information to assess the safety and efficacy of REPLAGAL

No longer willing/able to receive REPLAGAL study treatment, and not willing to attend 
further visits or allow medical records to be consulted in future to obtain clinical 
information for REPLAGAL.
The reason for discontinuation of study treatment should be determined by the investigator and 
recorded in the subject’s source documentation. If a subject discontinues study treatment for 
more than 1 reason, each reason should be documented in the source documentation and the most 
clinically relevant reason should be indicated. If the subject has consented to continuing in the 
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study, without study treatment, this outcome should also be documented in the subject’s source 
documentation.
Reasons for discontinuation from study treatment may include, but are not limited to:

Adverse event

Withdrawal by subject

Lack of efficacy

Pregnancy

Other (If “Other” is selected, the investigator must specify in the source document).
For subjects who discontinue study treatment but remain in the study, the End of Treatment 
(EOT) Visit should occur within 10-21 days after the subject’s last IP dose. These subjects will 
also have either a Week 104 Visit (if completing the study) or an ET Visit (if withdrawing from 
the study prior to Week 104). Following the EOT visit, these subjects will continue with their 
remaining site visits as originally scheduled. Subjects should be encouraged to complete all study 
visits through Week 104 (end of treatment visit). The safety follow-up assessment is not 
necessary because the subject will already have been off study treatment, and will have had site 
visits at which safety has been assessed. Subjects who discontinue study treatment and complete 
visits through Week 104 do not meet the criteria to be part of the “completer set” for statistical 
analysis.
Subjects who have discontinued study treatment, and who have consented to continuing to attend 
study visits, can decide to withdraw from study participation at any time and for any reason, 
without prejudice to his/her future medical care by the physician or at the institution, or may be 
withdrawn at any time at the discretion of the investigator or sponsor.
Site Termination
A specific site may be terminated separate from the general treatment protocol for, but not 
limited to, the following conditions:

The discovery of an unexpected, significant, or unacceptable risk to the patients 
enrolled at the site

Insufficient adherence by the investigator to protocol or regulatory requirements
Safety Related Study Stopping Rules
The study will be considered as completed when the last participant in the study completes 
his/her last study assessments.
The entire study may be prematurely terminated/discontinued for the following reasons:
1. Sponsor’s decision in the following cases:

If the information on the product leads to doubt as to the benefit/risk ratio;
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
Comprehensive deficiency in the recorded data or protocol compliance so that the 
study cannot be reliably assessed;

In the event of breach by the investigator of a fundamental obligation under this 
agreement, including but not limited to breach of the clinical study protocol, breach 
of the applicable laws and regulations, or breach of the ICH guidelines for GCP.
In any case, the Sponsor will notify the investigator of its decision by written notice.
2. Investigator’s decision in the following case:

Occurrence of undesired experiences or AEs necessitating termination.
The investigator must notify the sponsor of his/her decision and give the reason in writing for 
premature termination/discontinuation. In all cases (decided by the sponsor or by the 
investigator, the IEC and Health Authorities should be informed according to applicable 
regulatory requirements. The principal investigator and the sponsor, if appropriate, will jointly 
decide premature termination with the Ethics Committee.
7.4
Lost to Follow-up
A subject is considered lost to follow-up if, after a minimum of 3 documented attempts, the site 
personnel are unable to make contact with the subject after their most recent study contact (site 
visit, infusion visit, telephone contact, etc). At least 1 of these documented attempts must include 
a written communication sent to the subject’s last known address via courier or mail (with an 
acknowledgement of receipt request) asking that the subject return to the clinical site for final 
safety assessments. 
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8
STUDY ASSESSMENTS AND PROCEDURES
Prior to performing any study-related procedures (including those related to screening), the 
investigator or his/her designee must obtain written informed consent from the subject (as per 
local requirements). There must be documentation of consent (as per local requirements) 
indicating that the subject is aware of the investigational nature of the study and the required 
procedures and restrictions, prior to performing any study-related procedures.
8.1
Study Periods
Refer to Table 1 for the schedule of study activities. Study assessments are detailed in 
Section 8.2.
8.1.1
Screening Period (Day -50 through Day -8)
The screening period starts when subjects sign informed consent. The duration of the screening 
period is up to 42 days where study subjects will undergo all procedures listed for the screening 
period in Table 1. The screening period can occur over multiple days to allow for the evaluation 
of subject’s eligibility for inclusion in the study. Subjects who screen failed or could not be 
enrolled during the screening period, due to circumstances including, but not limited to,
COVID-19 related issues, may be rescreened with prior approval from the sponsor medical 
monitor. Some procedures, such as cMRI, may not need to be repeated for rescreening, with 
prior approval from the sponsor medical monitor.
Screen failure is defined in Section 7.1.
8.1.1.1
Screening Visit(s) 
Informed consent must be obtained before any screening procedures are performed. Screening 
procedures can be performed over several days. Assessments and procedures to be performed 
during the screening visit(s) are outlined in Table 1 and listed below.

Obtain subject consent

Administer pregnancy test (for women of childbearing potential only). At screening 
both the urine and serum β-hCG tests should be performed. The urine pregnancy test 
should be administered by the clinical site before any other screening procedures 
(except for signature of informed consent) are completed. 

Review eligibility criteria (inclusion/exclusion criteria) 

Collect samples for GLA genotyping and measurement of GLA activity for 
confirmation of Fabry disease (see Section 8.2.1.3)

Collect demographic information

Review medical history

Perform physical examination

Record vital signs (pulse, blood pressure, respiratory rate, and temperature)
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
Measure and collect height

Measure weight

Perform cMRI (will serve as the baseline value)

Perform 12-lead ECG

eGFR (to be calculated by a Shire-designated laboratory; if the eGFR measurement at 
screening is not within the range, a second eGFR measurement may be completed 
and, if in range, used as the screening value. If a second measurement is taken, a 
minimum of 1 week and maximum of 30 days should separate it from the first.

Collect blood samples to perform serum chemistry (sodium [Na+], potassium [K+], 
chloride [Cl-], bicarbonate [HCO3-], calcium [Ca2+], magnesium [Mg2+], 
phosphate, creatinine, urea nitrogen [BUN], glucose, albumin, bilirubin, alkaline 
phosphatase, alanine aminotransferase [ALT], aspartate aminotransferase [AST], 
triglycerides, cholesterol, LDL cholesterol, HDL cholesterol, and hematology 
(complete blood count: hematocrit [Hct]; hemoglobin [Hb]; RBC; WBC; platelets; 
basophils; basophils/total cells; eosinophils; eosinophils/total cells; immature 
granulocytes; lymphocytes; lymphocytes/total cells; monocytes; monocytes/total 
cells; neutrophils; and neutrophils/total cells) laboratory tests 

Collect urine samples for urinalysis (including proteinuria)

Perform viral testing (including HBsAg, HBcAb, HCV antibody with confirmation by 
HCV-ribonucleic acid polymerase chain reaction testing, and HIV antibody)

Record AEs

Review of prior and concomitant medications, therapies, and medical/surgical 
interventions.
8.1.2
Baseline Period (Day -7 to Day 0/Week 0)
All baseline assessments and procedures are to be performed at the clinical site. The baseline 
assessments may be completed over a period of 7 days as long as all baseline assessments and 
procedures are completed prior to the first REPLAGAL infusion. The day of the first REPLAGAL
infusion is considered Day 0/Week 0 and all future study visits and windows should be timed 
from the first infusion.
Baseline assessments and procedures are outlined in Table 1 and listed below:

Review of inclusion/exclusion criteria

Administer urine pregnancy test (for women of childbearing potential only). The 
urine pregnancy test should be administered by the clinical site before any other 
procedures are completed. If the urine test is positive, a blood sample will be 
collected for serum β-hCG testing and sent to the central laboratory for analysis. 

Measure weight

Perform 12-lead ECG
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
Collect blood samples to perform serum chemistry (sodium [Na+], potassium [K+], 
chloride [Cl-], bicarbonate [HCO3-], calcium [Ca2+], magnesium [Mg2+], 
phosphate, creatinine, urea nitrogen [BUN], glucose, albumin, bilirubin, alkaline 
phosphatase, alanine aminotransferase [ALT], aspartate aminotransferase [AST], 
triglycerides, cholesterol, LDL cholesterol, HDL cholesterol, and hematology 
(complete blood count: hematocrit [Hct]; hemoglobin [Hb]; RBC; WBC; platelets; 
basophils; basophils/total cells; eosinophils; eosinophils/total cells; immature 
granulocytes; lymphocytes; lymphocytes/total cells; monocytes; monocytes/total 
cells; neutrophils; and neutrophils/total cells) laboratory tests 

eGFR (to be calculated by a Shire-designated laboratory; if the eGFR measurement at 
screening is not within the range, a second eGFR measurement may be completed 
and, if in range, used as the screening value. If a second measurement is taken, a 
minimum of 1 week and maximum of 30 days should separate it from the first.

Collect blood samples for ADA testing

Collect blood samples for evaluation of plasma lyso-Gb3 levels

Collect blood samples for assessments of levels of inflammatory biomarkers

Collect urine samples for urinalysis

Administer the following questionnaires: 
o
SF-36v2 
o
BPI-SF
o
PGI-S
o
BFI
o
GSRS

Record AEs

Review of prior and concomitant medications, therapies, and medical/surgical 
interventions 

Record vital signs (pulse, blood pressure, respiratory rate, and temperature) as 
follows: 1) within 10 minutes prior to starting the infusion; 2) 20 minutes 
(±5 minutes) after the start of the infusion 3) 10 minutes (±5 minutes) post infusion; 
and 4) 30 minutes (±5 minutes) post infusion. In the event that a scheduled infusion 
does not occur, vital signs should still be collected. The vital signs that were taken 
within 10 minutes prior to the start of the expected infusion should be recorded in the 
subject’s source documentation.

Calculate the dose of REPLAGAL based on the subject’s weight at baseline

Administer REPLAGAL. REPLAGAL is administered EOW (±7 days) as an IV infusion 
over 40 minutes (±10 minutes) after all other assessments (except for postinfusion 
vital signs assessment), procedures and sample collection have been completed. 
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8.1.3
Treatment Period (Day 0/Week 0 through Week 104 or Early Termination)
The treatment period will begin after all baseline assessments and procedures are completed, and 
it is confirmed the subject continues to meet all inclusion/exclusion criteria. The treatment period 
will comprise 104 weeks during which subjects will receive every other week (EOW) IV 
injections of REPLAGAL. The first 3 infusions should be performed at the clinical site. (Refer to 
Section 6.2.1 for guidance regarding transition to home infusions.)
During the treatment period all study assessments and procedures should be completed on the 
day of the scheduled visit (ie, day of infusion) with the exception of visits where a cMRI will be 
performed (Baseline, Week 52 and Week 104 visits). On visits where a cMRI assessment will be 
performed, all study assessments should occur on the day of infusion; however, to accommodate 
the scheduling of cMRI, this assessment may be performed within ±7 days of the infusion day 
for Week 52 and ±14 days of the infusion day for Week 104.
Study visit windows should be calculated off of the date of the subject's first infusion of 
REPLAGAL. 
During the Treatment Period, subjects will undergo the study procedures outlined in Table 1 and 
listed in the sections below. 
8.1.3.1
Every Other Week Visits 
The subject's first REPLAGAL infusions should be performed at the clinical site. (Refer to 
Section 6.2.1 for guidance regarding transition to home infusions.) Every other week visit 
windows should be calculated from the date of the subject's first infusion of REPLAGAL. 
EOW assessments and procedures are outlined in Table 1 and listed below: 

Administer urine pregnancy test (for women of childbearing potential only). The 
urine pregnancy test should be administered by the clinical site before any other 
procedures are completed. If the urine test is positive, the infusion should not be 
given, and a blood sample should be collected for serum β-hCG testing and sent to 
the central laboratory for analysis.

Record AEs

Review concomitant medications, therapies, and medical/surgical interventions

Record vital signs (pulse, blood pressure, respiratory rate, and temperature) as 
follows: 1) within 10 minutes prior to starting the infusion; 2) 20 minutes 
(±5 minutes) after the start of the infusion 3) 10 minutes (±5 minutes) post infusion; 
and 4) 30 minutes (±5 minutes) post infusion. In the event that a scheduled infusion 
does not occur, vital signs should still be collected. The vital signs that were taken 
within 10 minutes prior to the start of the expected infusion should be recorded in the 
source documentation.

Administer REPLAGAL. REPLAGAL is administered EOW (±7 days) as an IV infusion 
over 40 minutes (±10 minutes) after all other assessments (except for postinfusion 
vital signs assessment), procedures and sample collection have been completed. 
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8.1.3.2
Week 12, Week 40, Week 64, and Week 92 Visits 
Assessments and procedures at these visits are to be performed at the clinical site. These 
assessments and procedures are outlined in Table 1 and listed below:

Administer urine pregnancy test (for women of childbearing potential only). The 
urine pregnancy test should be administered by the clinical site before any procedures 
are completed. If the urine test is positive, the infusion should not be given, and a 
blood sample should be collected and sent to the central laboratory for analysis. 

Measure weight

Calculate REPLAGAL dose based on subject’s weight

eGFR (to be calculated by a Shire-designated laboratory)

Collect blood samples to perform serum chemistry (sodium [Na+], potassium [K+], 
chloride [Cl-], bicarbonate [HCO3-], calcium [Ca2+], magnesium [Mg2+], 
phosphate, creatinine, urea nitrogen [BUN], glucose, albumin, bilirubin, alkaline 
phosphatase, alanine aminotransferase [ALT], aspartate aminotransferase [AST], 
triglycerides, cholesterol, LDL cholesterol, HDL cholesterol, and hematology 
(complete blood count: hematocrit [Hct]; hemoglobin [Hb]; RBC; WBC; platelets; 
basophils; basophils/total cells; eosinophils; eosinophils/total cells; immature 
granulocytes; lymphocytes; lymphocytes/total cells; monocytes; monocytes/total 
cells; neutrophils; and neutrophils/total cells) laboratory tests 

Collect blood samples for ADA testing 

Collect blood samples for evaluation of plasma lyso-Gb3 levels 

Collect blood samples for assessments of inflammatory biomarkers

Collect urine samples for urinalysis (including proteinuria)

Administer the following questionnaires:
o
SF-36v2
o
BPI-SF
o
PGI-S 
o
BFI 
o
GSRS 

Record AEs

Review concomitant medications, therapies, and medical/surgical interventions

Record vital signs (pulse, blood pressure, respiratory rate, and temperature) as 
follows: 1) within 10 minutes prior to starting the infusion; 2) 20 minutes 
(±5 minutes) after the start of the infusion 3) 10 minutes (±5 minutes) post infusion; 
and 4) 30 minutes (±5 minutes) post infusion. In the event that a scheduled infusion 
does not occur, vital signs should still be collected. 
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The vital signs that were taken within 10 minutes prior to the start of the expected 
infusion should be recorded in the source documentation.

Administer REPLAGAL. REPLAGAL is administered as an IV infusion over 40 minutes 
(±10 minutes) at the clinical site after all other assessments (except for postinfusion 
vital signs assessment), procedures and sample collection have been completed.
8.1.3.3
Week 26, Week 52, and Week 78 Visits
Assessments and procedures at these visits are to be performed at the clinical site. These 
assessments and procedures are outlined in Table 1 and listed below:

Administer urine pregnancy test (for women of childbearing potential only). The 
urine pregnancy test should be administered by the clinical site before any other 
procedures are completed. If the urine test is positive, the infusion should not be 
given, and a blood sample should be collected and sent to the central laboratory for 
analysis.

Perform physical examination

Measure height at Week 52

Measure weight 

Calculate dose of REPLAGAL based on subject’s weight

Perform cMRI for LVMI assessment (Week 52 visit, only) 

Perform 12-lead ECG

eGFR (to be calculated by a Shire-designated laboratory)

Collect blood samples to perform serum chemistry (Sodium [Na+], Potassium [K+], 
Chloride [Cl-], Bicarbonate [HCO3-], Calcium [Ca2+], Magnesium [Mg2+], 
Phosphate, Creatinine, Urea Nitrogen [BUN], Glucose, Albumin, Bilirubin, Alkaline 
Phosphatase, Alanine Aminotransferase [ALT], Aspartate Aminotransferase [AST], 
Triglycerides, Cholesterol, LDL Cholesterol, HDL Cholesterol, and hematology 
(complete blood count: Hematocrit [Hct]; Hemoglobin [Hb]; RBC; WBC; Platelets; 
Basophils; Basophils/Total Cells; Eosinophils; Eosinophils/Total Cells; Immature 
Granulocytes; Lymphocytes; Lymphocytes/Total Cells; Monocytes; Monocytes/Total 
Cells; Neutrophils; Neutrophils/Total Cells) laboratory tests 

Collect blood samples for ADA testing 

Collect blood samples for evaluation of plasma lyso-Gb3 levels 

Collect blood samples for assessment of inflammatory biomarkers

Collect urine samples for urinalysis (including proteinuria)

Administer the following questionnaires: 
o
SF-36v2
o
BPI-SF
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o
PGI-S 
o
BFI
o
GSRS 

Record AEs

Review concomitant medications, therapies, and medical/surgical interventions

Record vital signs (pulse, blood pressure, respiratory rate, and temperature) as 
follows: 1) within 10 minutes prior to starting the infusion; 2) 20 minutes 
(±5 minutes) after the start of the infusion 3) 10 minutes (±5 minutes) post infusion; 
and 4) 30 minutes (±5 minutes) post infusion. In the event that a scheduled infusion 
does not occur, vital signs should still be collected. The vital signs that were taken 
within 10 minutes prior to the start of the expected infusion should be recorded in the 
source documentation.

Administer REPLAGAL. REPLAGAL is administered as an IV infusion over 40 minutes 
(±10 minutes) at the clinical site after all other assessments (except for postinfusion 
vital signs assessment), procedures and sample collection have been completed.
8.1.3.4
Week 104 Visit (End of Treatment) or Early Termination 
The assessments and procedures outlined in Table 1 and listed below are to be performed at the 
clinical site for completers (EOT visit) or for subjects who discontinue early (early termination 
visit). For subjects who discontinue early, all assessments and procedures should be completed 
except for REPLAGAL infusion. For subjects who discontinue study treatment but remain in the 
study, the End of Treatment (EOT) Visit should occur within 10-21 days after the subject’s last 
IP dose. These subjects will also have either a Week 104 Visit (if completing the study) or an ET 
Visit (if withdrawing from the study prior to Week 104).

Administer urine pregnancy test (for women of childbearing potential only). The 
urine pregnancy test should be administered by the clinical site before any other 
procedures are completed. If the urine test is positive, the infusion should not be 
given, and a blood sample should be collected and sent to the central laboratory for 
analysis. 

Perform physical examination

Subject height and weight must be measured 

Perform cMRI for LVMI assessment 

Perform 12-lead ECG

eGFR (to be calculated by a Shire-designated laboratory)

Collect blood samples to perform serum chemistry (Sodium [Na+], Potassium [K+], 
Chloride [Cl-], Bicarbonate [HCO3-], Calcium [Ca2+], Magnesium [Mg2+], 
Phosphate, Creatinine, Urea Nitrogen [BUN], Glucose, Albumin, Bilirubin, Alkaline 
Phosphatase, Alanine Aminotransferase [ALT], Aspartate Aminotransferase [AST],
Triglycerides, Cholesterol, LDL Cholesterol, HDL Cholesterol, and hematology 
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(complete blood count: Hematocrit [Hct]; Hemoglobin [Hb]; RBC; WBC; Platelets; 
Basophils; Basophils/Total Cells; Eosinophils; Eosinophils/Total Cells; Immature 
Granulocytes; Lymphocytes; Lymphocytes/Total Cells; Monocytes; Monocytes/Total 
Cells; Neutrophils; Neutrophils/Total Cells) laboratory tests 

Collect blood samples for ADA testing

Collect blood samples for evaluation of plasma lyso-Gb3 levels 

Collect blood samples for assessment of inflammatory biomarkers

Collect urine samples for urinalysis (including proteinuria)

Administer the following questionnaires: 
o
SF-36v2
o
BPI-SF
o
PGI-S 
o
BFI
o
GSRS

Record AEs

Review concomitant medications, therapies, and medical/surgical interventions

Record vital signs (pulse, blood pressure, respiratory rate, and temperature) as 
follows: 1) within 10 minutes prior to starting the infusion; 2) 20 minutes 
(±5 minutes) after the start of the infusion 3) 10 minutes (±5 minutes) post infusion; 
and 4) 30 minutes (±5 minutes) post infusion. In the event that a scheduled infusion 
does not occur, vital signs should still be collected. The vital signs that were taken 
within 10 minutes prior to the start of the expected infusion should be recorded in the 
source documentation.

Administer REPLAGAL (except for subjects who discontinue early). REPLAGAL is 
administered as an IV infusion over 40 minutes (±10 minutes) at the clinical site after 
all other assessments (except for postinfusion vital signs assessment) procedures and 
sample collection have been completed. 
8.1.4
Follow-up Period
The safety follow-up period is 14 days (-4 days/+7 days) following EOT infusion (or the last 
infusion for subjects who have withdrawn from the study). At the end of this period there will be 
a telephone call initiated by the site staff to query for AEs, SAEs, and concomitant medications.
Subjects who experienced SAEs, or mild-worsening, moderate or severe AEs will be requested 
to report to the clinical site for further examination. All AEs and SAEs that are not resolved at 
the time of this contact will be followed to closure (see Appendix 3.2).
8.1.5
Additional Care of Subjects after the Study
No aftercare is planned for this study. 
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8.2
Study Assessments 
Detailed descriptions of subject procedures and evaluations required for this protocol are 
described in this section. The timing for the performance of these evaluations is specified in the 
Schedule of Activities (Table 1).
8.2.1
Demographic and Other Baseline Characteristics
8.2.1.1
Demographics
Subject demographic information including gender, age, and race will be collected prior to the 
subject receiving the first dose of investigational product. 
8.2.1.2
Confirmation of Study Eligibility
At screening, each subject will be reviewed for eligibility against the study inclusion/exclusion 
criteria. Subjects who do not meet the study entrance criteria will not be allowed to participate in 
the study, and the reason(s) for the subject’s ineligibility will be documented; the subject will be 
considered a screen failure. If the eGFR measurement at screening is not within the range, a 
second eGFR measurement may be completed and, if in the stipulated range, used as the 
screening value. If a second measurement is taken, a minimum of 1 week and maximum of 
30 days should separate it from the first measurement.
Subject eligibility will be confirmed at baseline on the basis of review of the study entrance 
criteria. Subjects should not be administered study medication unless they continue to meet all 
inclusion/exclusion criteria at the time of dosing. For any subjects who do not continue to meet 
the study entrance criteria, the reason(s) for the subject’s ineligibility for the study will be 
documented and the subject will be considered a screen failure.
8.2.1.3
Confirmation of Fabry Disease (GLA Activity and Genotyping)
Subjects will undergo evaluations at screening to confirm that they have Fabry disease. Male 
subjects will provide a blood sample for measurement of serum GLA activity and for genotyping 
of the GLA gene. Female subjects will provide a blood sample for measurement of serum GLA 
activity and for genotyping of the GLA gene. However, serum GLA activity is not an inclusion 
criterion for female subjects. Blood samples will be analyzed using a DBS assay.
8.2.1.4
Medical History
Medical history will be collected and recorded in the subject’s source documents. Medical 
history will include a review of the subject’s medical status, documentation of current and prior 
medical procedures, and documentation of current and prior medication usage (for details on 
prior medication refer to Section 6.6.1). The subject will be queried on the following:

Relevant intercurrent illness and chronic disease update

Disease-specific review of symptoms, including:
o
Head, neck, and thyroid
o
Eyes, ears, nose, and throat
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o
Chest and lungs
o
Heart
o
Lymph nodes
o
Abdomen
o
Anorectal
o
Genitourinary
o
Skin
o
Musculoskeletal
o
Endocrine
o
Neurological
o
Other.
8.2.2
Efficacy
8.2.2.1
Cardiac Magnetic Resonance Imaging (cMRI)
Cardiac magnetic resonance imaging will be used to assess cardiac fibrotic segments, LVMI, 
interventricular septal end-diastolic thickness (IVSTd), and posterior wall thickness in diastole 
(PWTd). Reading of images will be performed by a central reader. Image collection, preparation, 
and transfer instructions will be provided to the clinical sites.
8.2.2.2
Estimated Glomerular Filtration Rate (eGFR)
Estimated glomerular filtration rate will be calculated by a Shire designated laboratory from 
serum creatinine using the CKD-EPI equation. The CKD-EPI equation, expressed as a single
equation, is:
eGFR = 141 * min(Scr/κ,1)α * max(Scr/κ, 1)-1.209 * 0.993Age * 1.018 [if female] * 1.159 [if black]
Where Scr is serum creatinine (mg/dL), κ is 0.7 for females and 0.9 for males, α is -0.329 for 
females and -0.411 for males; min indicates the minimum of Scr/κ or 1, and max indicates the 
maximum of Scr/κ or 1.
8.2.2.3
Proteinuria 
Proteinuria will be measured based on PCR. Measurement of proteinuria will be performed as 
part of urinalysis (see Appendix 2 for details on urinalysis). 
8.2.3
Safety
8.2.3.1
Physical Examination 
A full physical examination will be performed by the investigator with a thorough review of 
body systems on the visits specified in the Schedule of Activities (Table 1). Physical 
examinations will include a review of the subject’s general appearance as well as evaluation of 
the body systems listed in Table 3. Any abnormal change in findings will be recorded as an AE 
on the subject’s source documentation. 
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Table 3
Assessments for Physical Examinations
Assessment
Assessment
General appearance
Endocrine
Head and neck
Cardiovascular
Eyes
Abdomen
Ears
Genitourinary
Nose
Skin
Throat
Musculoskeletal
Chest and lungs
Neurological
8.2.3.2
Height
Subject height must be measured and collected at Screening, Week 52 and Week 104 (or early 
termination) visits for all subjects.
8.2.3.3
Weight
Weight is a critical measurement as it determines the dosing of REPLAGAL. Weight is initially 
collected at screening and again at baseline. The first dose of REPLAGAL will be based on the 
subject’s weight at baseline. A change in subject weight of ≥±5% from baseline, or the last 
weight used to recalculate the dose, will require a recalculation of the dose by the clinical site. 
Weight will be measured every 12 weeks, as specified in the Schedule of Activities (Table 1), 
with any dosing adjustments completed prior to the next dose.
8.2.3.4
Adverse Events
Subjects will be questioned in a general way to ascertain if AEs have occurred since the previous 
visit (eg, “Have you had any health problems since your last visit?”). Adverse events are 
collected from the time informed consent is signed. Refer to Appendix 3 for AE definitions, 
assessment, collection time frame, and reporting procedures. 
8.2.3.5
Vital Signs 
The following vital signs will be collected at all study visits: pulse, blood pressure, respiratory 
rate, and temperature. On visits where a subject is scheduled to receive an infusion (baseline, 
EOW, and the site visits), vital signs should be recorded as outlined in (Table 4). In the event 
that a scheduled infusion does not occur at one of these visits, vital signs should still be 
collected. The vital signs that were taken within 10 minutes prior to the start of the expected 
infusion should be recorded in the subject’s source documentation.
If there are no IRRs reported during the first 3 infusions, the observation and vital signs post 
infusion can be omitted at the discretion of the investigator.
The investigator will assess whether a change from baseline visit in vital signs is clinically 
significant, and whether the change should be considered and recorded as an AE.
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Table 4
Schedule for Recording of Vital Signs at Infusion
Timing Relative to Infusion
Schedule of Assessments
Start of Infusion
Within 10 minutes prior to start of infusion
During Infusion
20 minutes (±5 minutes) after start of infusion
After Infusiona
10 minutes (±5 minutes) after completing the infusion
30 minutes (±5 minutes) after completing the infusion
a If there are no infusion-related reactions during the first 3 infusions, the observation and vital signs post infusion can be 
omitted at the discretion of the investigator. 
8.2.3.6
Clinical Laboratory Tests (Serum Chemistry, Hematology, and 
Urinalysis)
All clinical laboratory tests will be performed according to the laboratory’s standard procedures. 
Reference ranges will be supplied by the laboratory and used to assess the results for clinical 
significance and out-of-range changes which may be associated with, or constitute, an AE. The 
investigator should assess out-of-range clinical laboratory values for clinical significance, 
indicating if the value(s) is/are not clinically significant or clinically significant. Abnormal 
clinical laboratory values, which are unexpected or not explained by the subject’s clinical 
condition, may, at the discretion of the investigator or sponsor, be repeated as soon as possible 
until confirmed, explained, or resolved.
A complete list of the clinical laboratory tests (serum chemistry, hematology, and urinalysis) to 
be performed is provided in Appendix 2.
8.2.3.7
Pregnancy Test 
Female subjects of childbearing potential will have a pregnancy test administered at each study 
visit. 
At screening, pregnancy testing will be performed using a urine test and a serum human β-hCG 
test. The urine pregnancy test should be administered by the clinical site before any other 
screening procedures (except for signature of informed consent) are completed. If the urine 
pregnancy test is negative, screening procedures (including the serum pregnancy test) will be 
completed as outlined in Table 1. If the urine test is positive, a blood sample will be collected for 
serum β-hCG testing and sent to the central laboratory for analysis. No additional screening 
procedures should be completed until the result of the serum pregnancy test is available. Female 
subjects of childbearing potential must have a negative β-hCG serum test at screening to be 
eligible for the study. A positive β-hCG serum test would result in the subject being a screen 
failure. 
At baseline, the urine pregnancy test should be administered by the clinical site before any other 
baseline procedures are completed. If the urine test is positive, a blood sample will be collected 
for serum β-hCG testing and sent to the central laboratory for analysis. No additional baseline 
procedures will be completed until the result of the serum pregnancy test is available. If the 
serum β-hCG result is positive, the subject will not be dosed with REPLAGAL and would be 
considered a screen failure. 
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At all other visits during the treatment period (EOW and site visits), a urine pregnancy test will 
be performed prior to the completion of any study procedures. If the urine test is positive, a 
blood sample will be collected for serum β-hCG testing and sent to the central laboratory for 
analysis. The subject will not receive any additional REPLAGAL infusions until the result of the 
serum pregnancy test is available. If the serum β-hCG result is positive, no additional doses of 
the investigational product are to be administered. Pregnancy should be reported to Shire Global 
Patient Safety Evaluation, and the Shire medical monitor (or designee) within 24 hours of 
becoming aware of the pregnancy. For more details on pregnancy reporting refer to 
Appendix 3.8.
8.2.3.8
Electrocardiogram 
Twelve-lead ECGs will be performed in accordance with the clinical site’s standard practice(s). 
ECG recordings will be read locally at the clinical site by the investigator or a qualified designee. 
ECGs will include assessment of heart rate, sinus rhythm, atrial or ventricular hypertrophy, and 
assessment of PR, QRS, QT, and corrected QT intervals (Bazetts and Fridericia). Identification 
of any clinically significant findings and/or conduction abnormalities will be recorded in the 
source documentation.
8.2.3.9
Anti-drug Antibody Testing
Blood samples will be collected for all subjects for the determination of anti-agalsidase alfa 
antibodies prior to the subject receiving the REPLAGAL infusion at time points specified in 
the Schedule of Activities (Table 1). Blood samples collected for anti-agalsidase alfa 
antibody determination will be evaluated at a research laboratory designated by the Sponsor. 
These samples will be analyzed for anti-agalsidase alfa binding antibodies. Confirmed 
antibody-positive samples will undergo assessment for NAbs. Sample collection, processing, 
and shipping instructions will be detailed in the study laboratory manual.
8.2.3.10
Prior/Concomitant Medications, Therapies, and Medical/Surgical 
Interventions Assessments
Prior medications received within 30 days prior to screening through the date of first dose of 
investigational will be reviewed and recorded in the subject’s source documentation (refer to 
Section 6.6.1 for full details on prior treatments). 
All medications, therapies/interventions administered to and medical/surgical procedures 
performed on the study subjects from the time of first dose investigational product through the 
end of the safety follow-up period are regarded as concomitant and will be recorded on the 
subject’s source documentation (Refer to Section 6.6.2 for full details on collection of 
concomitant treatments).
8.2.3.11
Viral Testing
Viral testing will be performed at screening to ensure that subjects do not present with viral 
infections that might compromise their ability to safely complete the study and confound later 
interpretation of the study findings. Viral tests include HBsAg, HBcAb, HCV antibody with 
confirmation by HCV-ribonucleic acid polymerase chain reaction testing, and HIV antibody.
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8.2.4
Other 
8.2.4.1
Investigational Product Administration
Prior to the first infusion of REPLAGAL, all baseline assessments and procedures must be 
completed. REPLAGAL’s administration will occur as described in Section 6.2 at the visits
specified in Schedule of Activities (Table 1) after all other assessments (except for post-infusion 
vital signs) procedures and sample collection have been completed. 
The first 3 REPLAGAL infusions (including baseline infusion) as well as infusions at Week 12, 
Week 26, Week 40, Week 52, Week 64, Week 78, Week 92, and Week 104 visits are to be 
administered at the clinical site. After the first 3 doses, subjects who have not experienced a 
treatment-related SAE or a moderate or severe IRR may receive their subsequent infusions at 
home by qualified and trained medical personnel, per the discretion and direction of the 
investigator. If at any point during home infusions subjects experience a treatment-related SAE 
or a moderate or severe IRR, their next infusion should be administered at the clinical site. 
Infusions should continue at the clinical site until no further moderate or severe IRRs are 
reported, at which point subjects may be re-evaluated for consideration to retransition to home 
infusions (for more details on home infusions refer to Section 6.2.1).
8.2.4.2
Pharmacodynamics 
Globotriaosylsphingosine (Lyso-Gb3)
Pharmacodynamic assessment will be performed by measuring lyso-Gb3 levels in plasma. 
Lyso-Gb3 plasma samples will be analyzed at a Shire-designated laboratory using a validated 
assay.
Inflammatory Biomarkers 
In order to assess the impact of REPLAGAL on serum levels of inflammatory biomarkers relevant 
to Fabry disease, samples will be collected and tested including but not limited to INTLK1β, 
TNF-α, VCAM1, and ICAM1.
8.2.4.3
Health-related QoL Assessments
The study will include the following a health-related QoL assessment which will be administered 
at the baseline, Week 12, Week 26, Week 40, Week 52, Week 64, Week 78, Week 92, and 
Week 104 visits. In the case of an unplanned event that disallows/prevents the administration of 
the PRO on a device, for reasons including but not limited to, device outage or other technical 
limitation, subjects may record their responses on a web back-up version of the assessments that 
is provided by the CRO or PRO vendor. Sites will be provided with access to the web back-up 
assessments as a preventative measure.
Further information concerning these assessments is provided in Appendix 5.
Short Form-36 Health Survey (SF-36v2)
The SF-36v2 is a multipurpose, valid, short-form health survey comprising 36 questions. It 
consists of eight scaled scores, which are the weighted sums of the questions in their section. 
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Each scale is directly transformed into a 0 to 100 scale on the assumption that each question 
carries equal weight. 
The higher the score the less disability ie, a score of zero is equivalent to maximum disability 
and a score of 100 is equivalent to no disability. The 8 domains assessed are: physical 
functioning, role limitations due to physical problems functioning, bodily pain, general health 
perceptions, vitality, physical role functioning, social role functioning, role-limitations due to 
emotional problems role functioning, and mental health. The questionnaire is expected to take 
5 minutes to be completed (Ware and Sherbourne 1992).
Brief Pain Inventory-Short Form (BPI-SF)
The BPI-SF is a 9-item self-administered questionnaire that will be used to evaluate the severity 
of a subject's pain and the impact of this pain on the subject's daily functioning. The subject will 
be asked to rate their worst, least, average, and current pain intensity, list current treatments and 
their perceived efficacy, and rate the degree that pain interferes with general activity, mood, 
walking ability, normal work, relations with other persons, sleep, and enjoyment of life on a 
10-point scale. The questionnaire is expected to take about 5 minutes to be completed 
(Keller et al. 2004).
Patient Global Impression of Fabry Symptom Severity (PGI-S)
The PGI-S is a validated 1-item questionnaire designed to assess subjects’ impression of Fabry 
symptom severity. The subject has to select the one response from the response options that 
gives the most accurate description of his/her state of health (overall status). The questionnaire is 
expected to take about 5 minutes to be completed (Farrar et al. 2001; Guy 1976). 
Brief Fatigue Inventory (BFI)
The BFI is a 9-item questionnaire developed to assess the severity of fatigue and its impact on 
daily functioning. Each question asks the respondent to rate the level of their experienced fatigue 
on an 11-point (0–10) scale. The first question measures fatigue severity at current level while 
the following two questions rate usual and worst fatigue levels over the past 24 hours. In these 
3 questions 0 indicates “no fatigue” and 10 indicates fatigue “as bad as you can imagine”. The 
following six questions assess the level of fatigue interference with daily activities including 
general activity, mood, walking ability, normal work (both inside and outside the home), 
relations with other people, and enjoyment of life. A score of 0 corresponds to no interference 
while a score of 10 indicates complete interference. The questionnaire is expected to take 
5 minutes to be completed (Mendoza et al. 1999). 
Gastrointestinal Symptom Rating Scale (GSRS)
The GSRS is a disease-specific instrument based on a previous week recall period. It comprises 
15 items that combine into five symptom clusters: reflux, abdominal pain, indigestion, diarrhea, 
and constipation. Each item is rated on a 7-point Likert scale. The reliability and validity of the 
GSRS are well-documented across a wide variety of GI conditions, and norm values for a 
general population are available. The questionnaire is expected to take about 5 minutes to be 
completed (Dimenäs et al. 1993; Dimenäs et al. 1995; Kulich et al. 2008; Svedlund et al. 1988). 
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8.2.5
Retention of Testing Samples
Antibody and biomarker analyses may be performed at a research laboratory designated by the 
Sponsor. Collection and processing of samples will be performed as specified in the Laboratory 
and/or Study Operations Manuals. Samples will be stored securely to ensure subject 
confidentiality. Samples obtained for this study may be stored for up to 10 years after the end of 
the study and may be used for further analyses. Thereafter, samples will be destroyed.
8.2.6
Volume of Blood to Be Drawn From Each Subject
Table 5
Volume of Blood to Be Drawn From Each Subject
Assessment
Sample Volume (mL)
Number of 
Samples
Total Volume (mL)
Safety
Biochemistry 
6 
10
60
Hematology
2 
10
20
-hCGa
2 
1
2
ADAb
4
9
36
Viral testing 
(HBsAg, HIV, 
HCV)
6 
1
6
Confirmation of Fabry disease 
(GLA activity and genotyping) 
1
1
1
Inflammatory biomarkers 
(INTLK1β, TNF-α, VCAM1, 
ICAM1)
5
7
35
Lyso-Gb3
3
7
21
Total (mL)
29
181
ADA=antidrug antibody; -hCG=beta-human chorionic gonadotropin; GLA=α-galactosidase A; HBsAg=hepatitis B surface 
antigen; HCV=hepatitis C virus; HIV=human immunodeficiency virus; ICAM1=Intercellular Adhesion Molecule 1; 
INTLK1β=Interleukin 1 Beta; lyso-Gb3=globotriaosylsphingosine; TNF-α=Tumor Necrosis Factor; VCAM1=Vascular Cell 
Adhesion Molecule 1
a -hCG testing for females only.
b Any samples that are confirmed positive for ADA will also be tested for neutralizing antibodies (NAbs).
During this study, it is expected that approximately 181 mL of blood will be drawn from all 
subjects, regardless of sex.
Note: The amount of blood to be drawn for each assessment is an estimate. The amount of blood 
to be drawn may vary according to the instructions provided by the manufacturer or laboratory 
for an individual assessment; however, the total volume drawn over the course of the study 
should be approximately 181 mL. When more than 1 blood assessment is to be done at the time 
point/period, if they require the same type of tube, the assessments may be combined. 
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9
STATISTICAL CONSIDERATIONS
9.1
Statistical Analysis Process
The study will be analyzed by the sponsor or its agent. 
The statistical analysis plan (SAP) will provide the statistical methods and definitions for the 
analysis of the efficacy and safety data, as well as describe the approaches to be taken for 
summarizing other study information such as subject disposition, demographics and baseline 
characteristics, investigational product exposure, and prior and concomitant medications. The 
SAP will also include a description of how missing, unused, and spurious data will be addressed. 
The first version of the SAP will be finalized before the enrollment of the first patient. To 
preserve the integrity of the statistical analysis and study conclusions, the SAP will be finalized 
prior to database lock.
All statistical analyses will be performed using SASsoftware (SAS Institute, Cary, NC 27513) 
version 9.3 or higher. 
9.2
Planned Interim Analysis, Adaptive Design, and Data Monitoring Committee
No interim analysis, adaptive design, or data monitoring committee is planned for this study.
9.3
Sample Size and Power Considerations
The primary endpoints for this study are change in eGFR and LVMI from baseline up to 
Week 104. Two publications by Schiffmann et al. (Schiffmann et al. 2009) and Kampmann et al. 
(Kampmann et al. 2008) are acknowledged as landmark references reporting on the natural 
history of renal and cardiac function disease progression in untreated subjects with Fabry 
disease, respectively. The results of these studies are used across the Fabry disease medical 
community as a reference for the assessment of therapeutic expectations and the response of 
treatment. Use of these published, aggregate data as reference values for untreated changes in the 
endpoints have some limitations, as the adjustment for bias in patient baseline characteristics is 
not feasible without access to individual patient data. Nonetheless, this relevant publicly 
available data will provide necessary information to evaluate the REPLAGAL efficacy benefit.
Beck et al. (Beck et al. 2015) describes the disease progression in cardiac and renal function for 
untreated subjects with Fabry disease based on the data reported by Schiffmann et al. 
(Schiffmann et al. 2009) and Kampmann et al. (Kampmann et al. 2008), respectively. In this 
untreated population, the mean weighted annualized rate of change for eGFR and LVMI is 
approximately -3 mL/min/1.73 m2 and +5 g/m2.7, respectively, which is equivalent to a change 
of -6 mL/min/1.73 m2 and +10 g/m2.7, respectively over a period of 104 weeks. Based on the 
clinical document of Summary of Clinical Efficacy provided by Shire in the REPLAGAL New 
Drug Submission for Health Canada, the standard deviation for change in eGFR and LVMI in 
ERT-naïve subjects following 24-month treatment with REPLAGAL is 7 mL/min/1.73 m2 and 
15 g/m2.7, respectively. 
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The null hypothesis for eGFR is that the mean change from baseline in eGFR at Week 104 of the 
treated subjects is less than or equal to -6 mL/min/1.73 m2, the mean change of untreated 
subjects. The alternative hypothesis states that the mean change in eGFR is greater than this 
reference value of -6 mL/min/1.73 m2. The null hypothesis for LVMI is that the mean change 
from baseline in LVMI at Week 104 of the treated subjects is greater than or equal to +10 g/m2.7, 
the mean change of untreated subjects. The alternative hypothesis states that the mean change in 
LVMI is smaller than this reference value of 10 g/m2.7.
The Bonferroni adjustment to control the type I error rate for the 2 primary endpoints is 
incorporated in the sample size determination. The Bonferroni adjustment does not require any 
assumptions of the two primary endpoints. If both endpoints are significant at the 
0.025 significance level, then the power will be large than quoted below.
For eGFR, with 36 evaluable subjects, the study has at least 90% power to detect a decrease after 
104 weeks of treatment of 1.7 mL/min/1.73 m2 compared with a reference untreated change 
of -6 mL/min/1.73 m2 with SD=7 (effect size of 0.61) using a 1-sided one sample t-test at 
significance level of 0.0125. For LVMI, with 36 evaluable subjects, the study has at least 90% 
power to detect an increase after 104 weeks of treatment of 0.64 g/m2.7 compared with a 
reference untreated change of 10 g/m2.7 with SD=15 (effect size of 0.62) using a 1-sided 
one sample t-test at significance level of 0.0125. 
It is anticipated that 45 subjects will need to be enrolled in the study in order to obtain 
36 evaluable subjects, ie, subjects who have not discontinued from investigational product and 
who have valid, nonmissing values of primary efficacy endpoints (eGFR and LVMI) for baseline 
and Week 104 assessments. The anticipated percentage of subjects enrolled who will not meet 
the criteria to be considered as part of the completers set (approximately 20%) is based on data 
from previous Shire-sponsored studies with REPLAGAL, studies with competitor drugs in the 
Fabry disease area, and other figures reported in published literature. 
In a recently completed Shire-sponsored study (HGT-REP-081) with REPLAGAL, 27 of 
167 enrolled subjects discontinued from the study, representing a drop-out rate of 16%. 
Two other recently published studies, ATTRACT and FACETS, provide recent discontinuation 
data in patients with Fabry disease. In ATTRACT (Hughes et al. 2017), a 9% drop-out rate was 
observed at 18 months, but a much higher rate of 16% was reported in patients who entered the 
12-month open-label extension. In FACETS (Germain et al. 2016), a 20% drop-out rate was 
noted among migalastat-randomized patients after 24 months of treatment. Although not specific 
to Fabry disease, a review (Wood et al. 2004) of 71 randomized clinical studies published in 
leading medical journals found that 18% of the studies had a drop-out rate of 20% or higher (ie, 
studies published in specialist journals show that the drop-out rate is likely to be higher). 
It is anticipated that the majority of subjects who do not meet the criteria to be considered as part 
of the completers set will have data that can be meaningful for analysis. Enrolled subjects who 
have received at least 1 dose of investigational product and who have completed at least 
1 efficacy assessment of the endpoints being analyzed will be part of the modified intent-to-treat 
(mITT) set (see Section 9.4). The mITT set will be used for all analyses related to primary 
efficacy, secondary efficacy, inflammatory biomarker, and PRO endpoints.
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The study population will target approximately 40% females and 40% males for enrollment.
9.4
Statistical Analysis Sets
The statistical analysis will include the following analysis sets:

The intent-to-treat (ITT) set (those subjects who are considered enrolled in the 
study) will include all subjects who sign informed consent form and are eligible for 
the study based on the defined inclusion exclusion criteria. There is a possibility that 
a subject is enrolled in the study but does not receive a dose of investigational 
product.

The modified intent-to-treat (mITT) set will include all enrolled subjects (all 
subjects from the ITT) who have received at least 1 dose of investigational product 
and completed at least 1 efficacy assessment of the endpoints being analyzed. 

The safety set will include all subjects in the ITT set who receive at least 1 dose of 
investigational product. The safety set will be used for the analysis of safety endpoints.

The per-protocol (PP) set will include all subjects in the ITT excluding subjects with 
major protocol deviations. The PP set will be identified by a team consisting of, at a 
minimum, a physician and a statistician from Shire. 

The completers set will include all subjects in the ITT who have valid, values of primary 
efficacy endpoints (eGFR and LVMI) for both baseline and Week 104 assessments. 
9.5
Efficacy Analyses
9.5.1
Primary Efficacy Endpoint
The primary efficacy endpoints are:

Change from baseline at Week 104 in renal function, assessed by eGFR (using the 
CKD-EPI formula)

Change from baseline at Week 104 in cardiac structure, assessed by LVMI using 
cMRI.
The primary analysis for change from baseline at Week 104 in eGFR will be based on a 
mixed-effects model for repeated measures (MMRM) with multiple imputation under the 
assumption missing is not at random using the ITT population. A Bonferroni adjustment will be 
used to control the overall one-sided type I error rate of 0.025 for 2 primary endpoints. The 
primary null hypothesis to be tested for eGFR is that the mean change from baseline in eGFR at 
Week 104 of treated subjects is less than or equal to -6 mL/min/1.73 m2 , the mean change of 
reference untreated subjects. The alternative hypothesis is that the mean change in eGFR is 
greater than -6 mL/min/1.73 m2 , the mean change of the reference untreated subjects. A 
one-sided p-value to test if the mean change is greater than -6 mL/min/1.73 m2 from MMRM 
model will be used to interpret that there is sufficient evidence to reject the null hypothesis. The 
model will include visit as the fixed effect; with adjustment for sex (male versus female), age at 
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baseline and baseline eGFR. In the model, visit will be treated as a class variable, assuming an 
unstructured covariance matrix to model the within subject variability.
The primary analysis for change from baseline at Week 104 in LVMI will be based on a MMRM 
with multiple imputation under the assumption that missing is not at random (MNAR) using the 
ITT population. The primary null hypothesis to be tested for LVMI is that the mean change from 
baseline in LVMI at Week 104 of treated subjects is greater than or equal to 10 g/m2.7 , the mean 
change of the reference untreated subjects. The alternative hypothesis is that the mean change in 
LVMI is less than 10 g/m2.7, the reference value of untreated subjects. A one-sided p-value to test 
if the mean change is less than 10 g/m2.7 from MMRM model will be used to interpret that there 
is sufficient evidence to reject the null hypothesis. The model will include visit as the fixed 
effect; with adjustment for sex (male versus female), age at baseline and baseline LVMI. In the 
model, visit will be treated as a class variable, assuming an unstructured covariance matrix to 
model the within subject variability. 
Missing eGFR and LVMI data due to intercurrent event or other reasons will be handled 
according to the treatment policy strategy. Treatment policy strategy is defined as the strategy 
that considers “The occurrence of the intercurrent event is irrelevant: the value for the variable of 
interest is used regardless of whether or not the intercurrent event occurs.” (per ICH E9 R1 
Addendum). Intercurrent events can include but are not limited to the following: (1) 
discontinuation of study drug, (2) discontinuation of the study, or (3) initiation of a new 
treatment. In a situation that missingness of the eGFR or LVMI data cannot be predicted solely 
based on subject’s observed data, such missingness will not be considered as missing at random, 
but rather as MNAR. The missing pattern will be evaluated and subjects with and without 
missing data will be compared to gain understanding of the nature of the missingness. 
Pattern-mixture models and Monte Carlo Markov Chain methodology will be implemented in 
multiple imputation with a list of observed variables and covariates to impute missing eGFR and 
LVMI data with the assumption of MNAR. The covariates can be variables related to 
missingness identified in the comparison of subjects with and without missing data, the covariate 
can also be variables related to eGFR or LVMI based on medical input.
The analyses of the primary endpoints will be performed with all available data through 
Week 104. The repeated measure analyses will be based on the restricted maximum likelihood 
method assuming an unstructured covariance matrix to model the within-subject errors. If the 
analysis fails to converge, a compound symmetry covariance structure will be used to model the 
within-subject errors. Denominator degrees of freedom for the F test for fixed effects will be 
estimated using the Kenward-Roger approximation.
The following analyses will be performed for the primary endpoints to evaluate the robustness of 
the results from the primary analysis methods:

MMRM analyses using the completers set

MMRM using the PP set

The eGFR and LVMI annualized rate of change and 95% CI will be estimated for 
subjects using the random intercept and slope model. Baseline eGFR or baseline 
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LVMI, age at baseline, sex, and treatment duration on investigational product in year 
will be included in the model. 

Tipping point analysis with multiple imputation approach will be conducted for 
analyses of change from baseline in eGFR or LVMI at week 104 in ITT.
Descriptive summary statistics including the number of subjects (n) and mean (standard 
deviation [SD]) of raw values of each the primary endpoints and change from baseline at each 
visit will be presented by visit. The analysis of efficacy endpoints should be based primarily on 
the ITT and mITT sets, and subsequently on completers and PP sets.
Descriptive summary statistics for each of the primary endpoints will also be provided by sex 
subgroups. 
9.5.2
Secondary Efficacy Endpoints
The same model used for the primary endpoints will be used. The secondary efficacy endpoints 
are:

Annualized rate of change in eGFR

Annualized rate of change in LVMI

Change over time in eGFR

Change over time in LVMI

Change over time in proteinuria, measured by PCR

Change over time of the number of fibrotic segments suggestive of cardiac fibrosis as 
assessed by volume of fibrosis, measured by cMRI 

Change over time in IVSTd and PWTd, measured by cMRI 

Change over time in plasma lyso-Gb3.
For other secondary efficacy endpoints, summary statistics of the raw values and change from 
baseline will be provided descriptively by visit. Simple summary statistics will be produced 
initially. Continuous variables will be summarized using the following descriptive statistics: 
mean, SD, median, first and third quartiles, minimum and maximum. The number and 
percentage of observed levels will be reported for all categorical measures. Subsequently, 
MMRM will be performed to explore the changes of the secondary efficacy endpoints over the 
course of follow-up. MMRM will be calculated using unstructured covariance (subject level) and 
restricted maximum likelihood estimation (REML). The MMRM will include the fixed effect of 
visit. Significance tests will be based on least-squares means. Further on, if considered 
necessary, the MMRM will be repeated for each secondary efficacy endpoint to account for any 
prespecified possible baseline confounder.
All analyses related to secondary efficacy endpoints will be performed using the ITT and mITT 
sets.
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9.5.3
Multiplicity Adjustment
The following strategies will be employed to alleviate the issue of multiple testing in this study:

Defining several primary endpoints creates a multiplicity problem. Testing each 
endpoint separately at α=0.05 would inflate the Type I error and overstate the 
statistical significance. Therefore, failure to account for multiplicity can lead to false 
inference regarding the effects of a drug. To address the multiplicity problem, a 
Bonferroni adjustment will be implemented. 

Apart from the two primary endpoints, all other endpoints will be considered to be 
secondary, and any significant finding amongst these outcomes will not therefore be 
interpreted as confirmatory.

Prespecification of analysis populations, subgroups of interest, methods for 
calculating and analyzing each outcome, would reduce the potential for multiplicity. 
To this end, all these issues will be described and documented in the SAP prior to any 
statistical analysis.
9.5.4
Control of Type I Error
A Bonferroni adjustment will be used to control the overall one-sided type I error rate. 
9.5.5
Exploratory Efficacy Endpoints
The exploratory efficacy endpoint is the change over time in serum levels of inflammatory 
biomarkers including but not limited to INTLK1β, TNF-α, VCAM1, and ICAM1.
Concentrations of inflammatory biomarkers will be summarized using descriptive statistics: 
mean, SD, median, first and third quartiles, minimum and maximum. Initially, simple summary 
statistics will be produced for each inflammatory biomarker. Subsequently, MMRM will be 
performed to explore the changes of INTLK1β, TNF-α, VCAM1, and ICAM1 over the course of 
follow-up. MMRM will be calculated using unstructured covariance (subject level) and REML. 
The MMRM will include the fixed effect of visit. Significance tests will be based on 
least-squares means. Further on, if considered necessary, the MMRM will be repeated for each 
inflammatory biomarker to account for any prespecified possible baseline confounder.
All analyses related to inflammatory biomarkers will be performed using the ITT and mITT sets.
9.6
Safety Analyses
The safety endpoints include:

AEs

ADA assessments, including NAbs for samples confirmed positive for ADA

Clinical laboratory tests (serum chemistry, hematology, and urinalysis)

Electrocardiography 

Vital signs.
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All safety analyses will be presented for the safety set. All safety measures including, vital signs, 
clinical laboratory results (hematology, chemistry, urinalysis), ECG, and ADA (including NAbs) 
assessments will be summarized descriptively at baseline and for each postbaseline visit. Shift 
from baseline will be provided, if applicable. 
Treatment emergent adverse events (TEAEs) are defined as AEs that start or deteriorate during
or after the first dose of investigational product through the safety follow up visit/contact. The 
number of events, incidence, and percentage of TEAEs will be calculated overall and by system
organ class and preferred term at both subject level and adverse event level. TEAEs will be 
further summarized by severity and relationship to investigational product. Multiple events of the 
same type will be combined for each subject and, when doing this, the worst severity or outcome 
for each event type will be presented for the analysis. When calculating event rates, the 
denominator will be the number of subjects commencing follow-up in the relevant analysis 
population, irrespective of dropouts during the course of follow-up. Adverse events related to 
investigational product including IRRs, AEs leading to withdrawal, SAEs, and deaths will be 
similarly summarized/listed. 
9.7
Other Analyses
9.7.1
Health-related Quality of Life Analyses
The change over time in subject rating of pain, fatigue, severity of global Fabry symptoms and 
quality of life will be analyzed as exploratory endpoints using the following PRO measures, 
respectively:
o
SF-36v2 
o
BPI-SF
o
PGI-S
o
BFI
o
GSRS
Initially, simple summary statistics will be produced for the overall score and (if available) any 
subscale score of each PRO measure. Continuous variables will be summarized using the 
following descriptive statistics: mean, SD, median, first and third quartiles, minimum and 
maximum. The number and percentage of observed levels will be reported for all categorical 
measures. Subsequently, MMRM will be performed to explore the changes of PRO measures 
over the course of follow-up. MMRM will be calculated using unstructured covariance (subject 
level) and REML. The MMRM will include the fixed effect of visit. Significance tests will be 
based on least-squares means. Further on, if considered necessary, the MMRM will be repeated 
for each PRO measure to account for any prespecified possible baseline confounder.
All analyses related to PRO measures will be performed using the ITT and mITT set.
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9.7.2
Sensitivity Analysis
The assumption of normality in continuous endpoints will be assessed, and, in case of deviations, 
a sensitivity analysis will be conducted using log-transformed values. Regarding outliers, the 
primary endpoints are expected to be within the following ranges: (a) eGFR: 
5-200 mL/min/1.73m², (b) LVMI: 10-150 g/m2.7. Depending on the extent of outliers, a 
sensitivity analysis might be considered necessary. Subgroup analyses aiming to assess whether 
the observed effect is consistent across underlying patient subgroups can be viewed as some 
form of sensitivity analysis (ie, robustness across subgroups). Such analyses are planned to be 
conducted according to key baseline characteristics (eg, age, gender). These subgroup analyses 
will be performed through inclusion of an interaction term (ie, of the subgroup variable x main 
exposure variable) in the regression models. If, after performing sensitivity analyses, the findings 
are consistent with those from the primary analysis and lead to reasonably similar estimates, this 
provides assurance on the robustness of the results and lead to the conclusion that the underlying 
factors had little or no influence or impact on the primary estimates.
9.8
Missing, Unused, and Spurious Data
Some degree of missing data is expected for both baseline characteristics and outcomes for this 
study. Subjects may withdraw from the study prior to completion of the intended follow-up 
period for reasons such as death, severe intercurrent illness, withdrawal of consent, and loss to 
follow-up. For each case of premature termination, detailed information will be obtained and 
documented in the final report explaining circumstances leading to the termination. Nevertheless, 
with a sample size of 45 subjects, losing a significant percentage of the data can have drastic 
effects on statistical power and vastly increase Type-II error rates. 
For each endpoint, a decision will be made as to whether special methods of analysis need to be 
employed to handle missing data on an endpoint-by-endpoint basis, and this will be documented 
in the SAP before the final analysis. The decision will be based upon the extent of missing data, 
the likelihood of bias occurring as a result of missing data, and the importance of each endpoint. 
Specific rules will be applied to impute missing dates depending on whether whole date (year, 
month, and day) is missing or date is partially missing (month or day); start date or ad-hoc date is 
missing. All different scenarios of missing dates imputation will be presented in detail in the 
SAP.
Providing that the missing data are not extensive, and that data are not missing selectively, the 
mixed-effects model for repeated measures (MMRM) will be employed to enable all continuous 
endpoints or scores assessed at several time points to be included in the analysis, rather than only 
subjects with nonmissing values for all time points. In the presence of missing repeated measures 
for a subject, the MMRM analysis does not exclude this subject from the analysis; instead, it uses 
all the available data. If missing data are substantial, the data will be analyzed, in addition to the 
prespecified methods, with multiple imputation (MI), a Monte Carlo technique in which the 
missing values are replaced by m>1 simulated versions, where m is typically small (eg, 3-10). 
The question of how to obtain valid inferences from imputed data will be addressed according to 
Rubin's method for `repeated imputation' inference. The advantage of the method is that once the 
imputed data set has been generated, the analysis can be carried out using standard statistical 
procedures in virtually any statistical package. 
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If results obtained from models using different missing mechanisms (eg, multiple imputation 
versus MMRM) are not similar, full details of the differences between these models should be 
provided in the final report. In any case the impact different settings of a model have on the 
results obtained will be explained in detail. The sponsor acknowledges that both procedures 
(MMRM and MI) assume that the missing data are missing at random (MAR), an assumption 
that should be generally checked for plausibility before its use. Nevertheless, it would be difficult 
to test or to verify a systematic pattern for a MNAR mechanism in the context of the current 
study. To address this issue, and in case the amount of missing data is substantial, subjects with 
missing versus subjects with nonmissing primary endpoints will be compared in terms of 
demographic and baseline characteristics such as gender, age, and relevant clinical factors, and 
(if any) noteworthy differences will be documented and investigated. 
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10
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Waldek, S., Patel, M. R., Banikazemi, M., Lemay, R. and Lee, P. 2009. Life expectancy and 
cause of death in males and females with Fabry disease: findings from the Fabry 
Registry. Genet Med, 11(11), 790-6.
Ware, J. E., Jr. and Sherbourne, C. D. 1992. The MOS 36-item short-form health survey (SF-36). 
I. Conceptual framework and item selection. Med Care, 30(6), 473-83.
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Weidemann, F., Niemann, M., Stork, S., Breunig, F., Beer, M., Sommer, C., et al. 2013. Long-
term outcome of enzyme-replacement therapy in advanced Fabry disease: evidence for 
disease progression towards serious complications. J Intern Med, 274(4), 331-41.
West, M., Robin, C., Clark, J., Iwanochko, M., Moore, D. F. and Sirrs, S. 2012. Canadian Fabry 
Disease Treatment Guidelines.
Wood, A. M., White, I. R. and Thompson, S. G. 2004. Are missing outcome data adequately 
handled? A review of published randomized controlled trials in major medical journals. 
Clin Trials, 1(4), 368-76.
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11
SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS
Appendix 1
Regulatory, Ethical, and Study Oversight Considerations
Appendix 2
Clinical Laboratory Tests
Appendix 3
Adverse Events: Definitions and Procedures for Recording, Evaluating, Follow 
Up, and Reporting
Appendix 4
Contraceptive Guidance
Appendix 5
Scales and Assessments
Appendix 6
Abbreviations
Appendix 7
Protocol History
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Appendix 1
Regulatory, Ethical, and Study Oversight Considerations
Appendix 1.1
Regulatory and Ethical Considerations
This study is conducted in accordance with current applicable regulations including ICH E6, as 
well as other country and local ethical and legal requirements, and all updates.
Compliance with these regulations and guidelines also constitutes compliance with the ethical 
principles described in the Declaration of Helsinki.
The name and address of each third-party vendor (eg, CRO) used in this study will be maintained 
in the investigator’s and sponsor’s files, as appropriate.
Appendix 1.2
Sponsor’s Responsibilities
Good Clinical Practice Compliance
The study sponsor and any third party to whom aspects of the study management or monitoring 
have been delegated will undertake their assigned roles for this study in compliance with all 
applicable industry regulations, current ICH GCP Guidelines, as well as all applicable national 
and local laws and regulations.
Visits to sites are conducted by representatives of the study sponsor and/or the company 
organizing/managing the research on behalf of the sponsor to inspect study data, subjects’ 
medical records, and eCRFs in accordance with current GCP and the respective local and 
(inter)national government regulations and guidelines. Records and data may additionally be 
reviewed by auditors or by regulatory authorities.
The sponsor ensures that local regulatory authority requirements are met before the start of the 
study. The sponsor (or a nominated designee) is responsible for the preparation, submission, and 
confirmation of receipt of any regulatory authority approvals required prior to release of 
investigational product for shipment to the site.
Indemnity/Liability and Insurance
The sponsor of this research adheres to the recommendations of the Association of British 
Pharmaceutical Industry Guidelines. If appropriate, a copy of the indemnity document is 
supplied to the investigator before study initiation, per local country guidelines.
The sponsor ensures that suitable clinical study insurance coverage is in place prior to the start of 
the study. An insurance certificate is supplied to the applicable parties as necessary.
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Public Posting of Study Information
The sponsor is responsible for posting appropriate study information on applicable websites. 
Information included in clinical study registries may include participating investigators’ names 
and contact information.
The timing for study registration and results summary posting must be in accordance with 
applicable local and national requirements.
Submission of Summary of Clinical Study Report to Competent Authorities of Member 
States Concerned and Ethics Committees
The sponsor will provide a summary of the clinical study report to the competent authority of the 
member state(s) concerned as required by regulatory requirement(s) and to comply with the 
Community guideline on GCP. This requirement will be fulfilled within 24 weeks of study 
completion date for pediatric studies and within 1 year for nonpediatric studies as per guidance. 
The sponsor will provide the ECs with a copy of the same summary.
Study Suspension, Termination, and Completion
The sponsor may suspend or terminate the study, or part of the study, at any time for any reason. 
If the study is suspended or terminated, the sponsor will ensure that applicable sites, regulatory 
agencies, and IRBs/ECs are notified as appropriate. Additionally, the discontinuation of a 
registered clinical study which has been posted to a designated public website will be updated 
accordingly.
The sponsor will make an end-of-study declaration to the relevant competent authority as 
required by Article 10 (c) of Directive 2001/20/EC.
Appendix 1.3
Investigator’s Responsibilities
Good Clinical Practice Compliance
The investigator must undertake to perform the study in accordance with ICH GCP Guideline E6 
(1996) and E6 R2 (2017), EU Directive 2001/20/EC, and applicable regulatory requirements and 
guidelines.
It is the investigator’s responsibility to ensure that adequate time and appropriately trained 
resources are available at the site prior to commitment to participate in this study. The 
investigator should also be able to estimate or demonstrate a potential for recruiting the required 
number of suitable subjects within the agreed recruitment period.
The investigator will maintain a list of appropriately qualified persons to whom the investigator 
has delegated significant study-related tasks, and shall, upon request of the sponsor, provide 
documented evidence of any licenses and certifications necessary to demonstrate such 
qualification. Curriculum vitae for investigators and subinvestigators are provided to the study 
sponsor (or designee) before starting the study.
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If a potential research subject has a primary care physician, the investigator should, with the 
subject’s consent, inform them of the subject’s participation in the study. 
Protocol Adherence and Investigator Agreement
The investigator and any subinvestigators must adhere to the protocol as detailed in this 
document. The investigator is responsible for enrolling only those subjects who have met 
protocol eligibility criteria. Investigators are required to sign an investigator agreement to 
confirm acceptance and willingness to comply with the study protocol.
If the investigator suspends or terminates the study at their site, the investigator will promptly 
inform the sponsor and the IRB/EC and provide them with a detailed written explanation. The 
investigator will also return all investigational product, containers, and other study materials to 
the sponsor. Upon study completion, the investigator will provide the sponsor, IRB/EC, and 
regulatory agency with final reports and summaries as required by (inter)national regulations.
Communication with local IRBs/ECs, to ensure accurate and timely information is provided at 
all phases during the study, may be done by the sponsor, applicable CRO, investigator, or for 
multicenter studies, the coordinating principal investigator according to national provisions and 
will be documented in the investigator agreement.
Documentation and Retention of Records
Case Report Forms
Electronic Case Report Forms will be completed for each subject and should be handled in 
accordance with instructions from the sponsor or designee.
The investigator is responsible for maintaining adequate and accurate medical records from 
which accurate information is recorded into eCRFs. The eCRFs have been designed to record all 
observations and other data pertinent to the clinical investigation. The clinical research associate 
(CRA)/study monitor will verify the contents of the eCRFs against the source data per the 
monitoring plan. If data is unclear or contradictory, queries are sent for corrections or 
verification of data.
Case report forms must be completed by the investigator or designee as stated in the site 
delegation log. The investigator is required to sign the eCRF after all data have been captured for 
each subject. 
Recording, Access, and Retention of Source Data and Study Documents
Original source data to be reviewed during this study will include, but are not limited to,
subject’s medical file, original clinical laboratory reports, and imaging reports. 
All key data must be recorded in the subject’s source documents.
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The investigator must permit authorized representatives of the sponsor; the respective national, 
local, or foreign regulatory authorities; the IRB/EC; and auditors to inspect facilities and to have 
direct access to original source records relevant to this study, regardless of media.
The CRA/study monitor (and auditors, IRB/EC, or regulatory inspectors) may check the eCRF 
entries against the source documents. The consent form includes a statement by which the 
subject agrees to the monitor/auditor from the sponsor or its representatives, national or local 
regulatory authorities, or the IRB/EC, having access to source data (eg, subject’s medical file, 
appointment books, original laboratory reports, X-rays etc).
These records must be made available within reasonable times for inspection and duplication, if 
required, by a properly authorized representative of any regulatory agency (eg, the US Food and 
Drug Administration [FDA], European Medicines Agency [EMA], United Kingdom [UK] 
Medicines and Healthcare products Regulatory Agency) or an auditor.
Essential documents must be maintained according to ICH GCP requirements and may not be 
destroyed without written permission from the sponsor.
Audit/Inspection
To ensure compliance with relevant regulations, data generated by this study must be available 
for inspection upon request by representatives of, for example, the US FDA (as well as other US 
national and local regulatory authorities), the EMA, the Medicines and Healthcare products 
Regulatory Agency, other regulatory authorities, the sponsor or its representatives, and the 
IRB/EC for each site.
Appendix 1.4
Data Management Considerations
Data Collection
This study will be monitored according to GCP. 
The investigators’ authorized site personnel must enter the information required by the study 
eCRF Completion Guidelines or similar for all data requiring transcription of the source. A study 
monitor will visit each site in accordance with the monitoring plan and review the eCRF data 
against the source data for completeness and accuracy. Discrepancies between source data and 
data entered on the eCRF will be addressed by qualified site personnel. When a data discrepancy 
warrants correction, the correction will be made by authorized site personnel. Data collection 
procedures will be discussed with the site at the site initiation visit and/or at the investigator’s 
meeting. The study will be monitored according to Good Clinical Practice.
At each visit during the baseline and treatment periods, patient-facing assessments including the 
SF-36, BPI-SF, PGI-S, BFI, and GSRS will be collected via an electronic device. These 
assessments will be captured on the device and transmitted to a third-party database where site 
staff will have access to the patient data via a restricted website.
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Data Management
Data are to be entered into a clinical database as specified in the CRO’s data management plan or 
similar. Quality control and data validation procedures are applied to ensure the validity and 
accuracy of the clinical database.
Data are to be reviewed and checked for omissions, errors, and values requiring further 
clarification using computerized and manual procedures. Data queries requiring clarification are 
to be communicated to the site for resolution. Only authorized personnel will make corrections to 
the clinical database, and all corrections are documented in an auditable manner.
Data Handling
No special data handling will be performed for this study.
Appendix 1.5
Ethical Considerations
Informed Consent
It is the responsibility of the investigator to obtain written informed consent from all study 
subjects prior to any study-related procedures including screening assessments. All consent 
documentation must be in accordance with applicable regulations and GCP. Each subject or the 
subject’s legally authorized representative, as applicable, is requested to sign and date the subject 
informed consent form or a certified translation if applicable, after the subject has received and 
read (or been read) the written subject information and received an explanation of what the study 
involves, including but not limited to: the objectives, potential benefits and risk, inconveniences, 
and the subject’s rights and responsibilities. A copy of the informed consent documentation (ie, a 
complete set of subject information sheets and fully executed signature pages) must be given to 
the subject or the subject’s legally authorized representative, as applicable. This document may 
require translation into the local language. Signed consent forms must remain in each subject’s 
study file and must be available for verification at any time.
The principal investigator provides the sponsor with a copy of the consent form that was 
reviewed by the IRB/EC and received their favorable opinion/approval. A copy of the IRB/EC’s 
written favorable opinion/approval of these documents must be provided to the sponsor prior to 
the start of the study unless it is agreed to and documented (abiding by regulatory guidelines and 
national provisions) prior to study start that another party (ie, sponsor or coordinating principal 
investigator) is responsible for this action. Additionally, if the IRB/EC requires modification of 
the sample subject information and consent document provided by the sponsor, the 
documentation supporting this requirement must be provided to the sponsor.
Institutional Review Board or Ethics Committee
For sites outside the EU, it is the responsibility of the investigator to submit this protocol, the 
informed consent document (approved by the sponsor or their designee), relevant supporting 
information and all types of subject recruitment information to the IRB/ Ethics Committee (EC) 
for review, and all must be approved prior to site initiation.
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The applicant for an EC opinion can be the sponsor or investigator for sites within the EU; for 
multicenter studies, the applicant can be the coordinating principal investigator or sponsor, 
according to national provisions.
Responsibility for coordinating with IRBs/ECs is defined in the investigator agreement. 
Investigational product supplies will not be released until the sponsor, or designee has received 
written IRB/EC approval.
Prior to implementing changes in the study, the sponsor and the IRB/EC must approve any 
revisions of all informed consent documents and amendments to the protocol unless there is a 
subject safety issue. If required by local law, substantial amendments to the protocol must also 
be approved by the appropriate regulatory agency prior to implementation.
For sites outside the EU, the investigator is responsible for keeping the IRB/EC apprised of the 
progress of the study and of any changes made to the protocol at least annually or more 
frequently in accordance with the requirements, policies, and procedures established by the 
IRB/EC. This can be the responsibility of the sponsor or investigator for sites within the EU; or 
for multicenter studies, the coordinating principal investigator, according to national provisions. 
The investigator must also keep the local IRB/EC informed of any serious and significant AEs as 
required by IRB/EC procedures.
Privacy and Confidentiality
All US-based sites and laboratories or entities providing support for this study, must, where 
applicable, comply with the Health Insurance Portability and Accountability Act (HIPAA) of 
1996. A site that is not a covered entity as defined by HIPAA must provide documentation of 
this fact to the sponsor or designee.
The confidentiality of records that may be able to identify subjects will be protected in 
accordance with applicable laws, regulations, and guidelines.
After subjects have consented to take part in the study, the sponsor and/or its representatives 
reviews their medical records and data collected during the study. These records and data may, in 
addition, be reviewed by others including the following: independent auditors who validate the 
data on behalf of the sponsor; third parties with whom the sponsor may develop, register, or 
market Replagal; national or local regulatory authorities; and the IRB(s)/EC(s) which gave 
approval for the study to proceed. The sponsor and/or its representatives accessing the records 
and data will take all reasonable precautions in accordance with applicable laws, regulations, and 
guidelines to maintain the confidentiality of subjects’ identities. Subjects are assigned a unique 
identifying number; however, their initials and date of birth may also be collected, if permitted 
under local laws governing privacy. 
The results of studies containing subjects’ unique identifying number, relevant medical records, 
and possibly initials and dates of birth, where allowed per local law, may be transferred to, and 
used in, other countries which may not afford the same level of protection that applies within the 
countries where this study is conducted. The purpose of any such transfer would include: to
support regulatory submissions, to conduct new data analyses to publish or present the study 
results, or to answer questions asked by regulatory or health authorities.
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Study Results/Publication Policy
The term “Publication” shall mean any paper, article, manuscript, report, poster, internet posting, 
presentation slides, abstract, outline, video, instructional material, presentation (in the form of a 
written summary), or other public disclosure of the study results, in printed, electronic, oral, or 
other form. The parties understand and agree that participation in the study may involve a 
commitment to publish the data from all sites participating in the study in a cooperative 
publication with other investigators prior to publication or oral presentations of the study results 
on an individual basis. The site agrees not to publish or present the site’s study results until such 
time as either the aggregate multisite study results are published in a cooperative publication or 
for a period of one (1) year after termination or completion of the study at all participating sites, 
whichever shall first occur. After that time, the site may publish the site’s study results in 
scientific journals or present the study results at symposia or other professional meetings in 
accordance with the following provisions:
If the study is part of a multicenter study, the first publication of the study results shall be made 
by the sponsor in conjunction with the sponsor’s presentation of a joint, multicenter publication 
of the compiled and analyzed study results. If such a multicenter publication is not submitted to a 
journal for publication by the sponsor within an 18-month period after conclusion, abandonment, 
or termination of the study at all sites, or after the sponsor confirms there shall be no multicenter 
study publication of the study results, an investigator may individually publish the study results 
from the specific site in accordance with this section. The investigator must, however, 
acknowledge in the publication the limitations of the single site data being presented.
At least sixty (60) days prior to submitting an abstract, manuscript, or other document for 
publication, a copy of the proposed publication will be provided to the sponsor by the site for 
review. Upon the sponsor’s request, the site agrees to remove any and all confidential 
information (expressly excluding study results) identified in the publication and to delay such 
submission or presentation for an additional sixty (60) day period in order to allow the sponsor 
time to file any patent application(s). All publications of the study results shall appropriately 
reference the multisite study publication, if any, or the fact that the study results are a subset of 
data resulting from a larger multisite study.
Shire is committed to transparent dissemination of all scientific, technical, and medical 
manuscripts generated from Shire-supported research. Therefore, after January 1, 2018, Shire 
will require the submission of all Shire-supported research manuscripts to journals that offer 
public availability via Open Access (including publisher platforms/repositories and 
self-archiving). Open Access refers to the free at point of entry, online availability of published 
research output with, where available, rights of reuse according to an End User License.
Unless otherwise required by the journal in which the publication appears, or the forum in which 
it is made, authorship will comply with the International Committee of Medical Journal Editors 
(ICMJE) Recommendation for the Conduct, Reporting, Editing and Publication of Scholarly
Work in Medical journals. Participation as an investigator does not confer any rights to 
authorship of publications.
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Appendix 2
Clinical Laboratory Tests
The following clinical laboratory assessments will be performed: 
Serum Chemistry

Sodium 

Glucose

Potassium 

Albumin

Chloride 

Bilirubin

Bicarbonate

Alkaline phosphatase 

Calcium

Alanine Aminotransferase

Magnesium 

Aspartate Aminotransferase 

Phosphate

Triglycerides

Creatinine

Cholesterol

LDL Cholesterol

HDL Cholesterol

Urea Nitrogen
Hematology

Hemoglobin

RBC

Hematocrit

White blood cell count with differential

Platelets
Urinalysis

pH

Albumin

Creatinine

Protein
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Appendix 3
Adverse Events: Definitions and Procedures for Recording, Evaluating, 
Follow-Up, and Reporting
Appendix 3.1
Adverse Event Definitions
An AE is any untoward medical occurrence in a clinical investigation subject administered a 
pharmaceutical product and that does not necessarily have a causal relationship with this 
investigational product or medicinal product. An AE can therefore be any unfavorable and 
unintended sign (including a clinically significant laboratory finding), symptom, or disease 
temporally associated with the use of a medicinal (investigational) product, whether or not 
causality is suspected (ICH Guidance E2A 1995).
Treatment-emergent Adverse Event
A TEAE is defined as any event emerging or manifesting at or after the initiation of treatment 
with an investigational product or medicinal product or any existing event that worsens in either 
intensity or frequency following exposure to the investigational product or medicinal product.
Serious Adverse Event
A SAE is any untoward clinical manifestation of signs, symptoms or outcomes whether 
considered related to investigational product or not and at any dose:

Results in death

Is life-threatening. Note: The term “life-threatening” in the definition of “serious” refers 
to an event in which the subject was at risk of death at the time of the event; it does not 
refer to an event which hypothetically might have caused death if it was more severe.

Requires inpatient hospitalization or prolongation of hospitalization. Note: 
Hospitalizations that are the result of elective or previously scheduled investigations 
procedures or surgery for pre-existing conditions and have not worsened after initiation 
of treatment should not be classified as SAEs. 
For example, an admission for a previously scheduled ventral hernia repair would not be 
classified as an SAE; however, complication(s) resulting from a hospitalization for an 
elective or previously scheduled surgery that meet(s) serious criteria must be reported as 
SAE(s).

Results in persistent or significant disability/incapacity

Results in a congenital abnormality/birth defect

Is an important medical event. Note: Important medical events that may not result in 
death, be life-threatening, or require hospitalization may be considered an SAE when, 
based upon appropriate medical judgment, they may jeopardize the subject and may 
require medical or surgical intervention to prevent 1 of the outcomes listed in this 
definition. Examples of such medical events include bronchospasm associated with 
anaphylaxis requiring intensive treatment in an emergency room or at home; blood 
dyscrasias or convulsions that do not result in inpatient hospitalization; the development 
of drug dependency or drug abuse; and reviewed and confirmed seroconversion for 
human immunodeficiency virus (HIV), hepatitis A virus (HAV), hepatitis B virus (HBV), 
hepatitis C virus (HCV), hepatitis E virus (HEV), or parvovirus B19 (B19V).
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Unexpected Adverse Event
An unexpected adverse event is an AE whose nature, severity, specificity, or outcome is not 
consistent with the term, representation, or description used in the Reference Safety Information 
(RSI). “Unexpected” also refers to the AEs that are mentioned in the investigator’s brochure as 
occurring with a class of drugs or as anticipated from the pharmacological properties of the 
product, but are not specifically mentioned as occurring with the particular product under 
investigation.
The expectedness of AEs will be determined by the sponsor using the investigator’s brochure as 
the RSI. This determination will include considerations such as the number of AEs previously 
observed, but not on the basis of what might be anticipated form the pharmacological properties 
of a product.
Suspected Unexpected Serious Adverse Reaction 
A Suspected Unexpected Serious Adverse Reaction is defined as any suspected adverse reaction 
to study treatment (ie, including active comparators) that is both serious and unexpected.
The event(s) must meet all of the following:

Suspected adverse reaction

Serious

Unexpected

Assessed as related to study treatment.
Infusion-Related Reactions
Definition of Infusion-Related Reactions
Infusion-related reactions will be defined as an AE that 1) begins either during or within 
24 hours after the start of the infusion and 2) is judged as related to study treatment. Adverse 
events that are considered IRRs will be noted as such in the subject’s source documentation.
Other AEs that occur prior to an infusion, along with AEs associated with protocol-defined 
testing and assessments (laboratory testing and physical examinations) that were performed prior 
to an infusion will not be defined as IRRs.
A list of the most common IRRs that have been reported in patients with Fabry disease during 
REPLAGAL infusions is included in the current version of the REPLAGAL investigator’s brochure.
Management of Infusion-Related Reactions
The management of IRRs should be based on the severity of the reaction, and at the discretion of 
the investigator. If mild or moderate acute infusion reactions occur, medical attention must be 
sought immediately, and appropriate actions instituted. The infusion can be temporarily 
interrupted (5 to 10 minutes) until symptoms subside and the infusion may then be restarted, or 
the infusion rate can be slowed. Some mild and transient effects may not require medical 
treatment or discontinuation of the infusion. 
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Oral or IV pretreatment with antihistamines and/or corticosteroids, from 1 to 24 hours prior to 
infusion, may prevent subsequent reactions in those cases where symptomatic treatment was 
previously required. Pretreatment of infusion reactions is left to the clinical judgment of the 
investigator.
If further analysis of IRRs is necessary, additional clinical laboratory samples may be collected 
at the discretion of the investigator and in consultation with the study medical monitor. 
Symptoms of the Disease under Study
Symptoms of the disease under study should not be classed as AEs as long as they are within the 
normal day-to-day fluctuation or expected disease progression and are part of the efficacy or 
efficacy data collected in the study. Significant worsening of symptoms should be recorded as an 
AE.
Preexisting conditions prior to initiation of study medication are described in the medical history, 
and those that manifest with the same severity, frequency, or duration after drug exposure, are 
not to be recorded as AEs. However, when there is an increase in the severity, duration or 
frequency of a preexisting condition, the event must be described in the subject’s source 
documentation.
Clinical Laboratory and Other Safety Assessment
A change in the value of a clinical laboratory parameter, vital sign measure, or ECG assessment 
can represent an AE if the change is clinically relevant or if, during administration of 
investigational product, a shift of a parameter is observed from a value in the normative range to 
a value that is outside the normal range and considered clinically significant, or a further 
worsening of an already clinically significant value. When evaluating such changes, the extent of 
deviation from the reference range, the duration until return to the reference range, either while 
continuing administration or after the end of administration with the investigational product, and 
the range of variation of the respective parameter within its reference range, should also be 
considered.
If, at the end of the treatment phase, there are abnormal clinical laboratory (such as hematology 
panel or clinical chemistry panel), vital sign, or ECG values which were not present at the 
pretreatment evaluation observed closest to the start of study treatment, further investigations 
should be performed until the values return to within the reference range or until a plausible 
explanation (eg, concomitant disease or expected disease evolution) is found for the abnormal 
values.
The investigator should assess, based on the above criteria and the clinical condition of the 
subject, whether a change in a clinical laboratory value, vital sign, or ECG parameter is clinically 
significant and represents an AE.
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Appendix 3.2
Collection of Adverse Events 
All AEs/SAEs are collected from the time the informed consent document is signed until the 
defined follow-up period stated in Section 8.1.4. This includes events occurring during the 
screening phase of the study, regardless of whether or not investigational product is 
administered.
All AEs/SAEs must be followed to closure (the subject’s health has returned to his/her baseline 
status or all variables have returned to baseline), regardless of whether the subject is still 
participating in the study. Closure indicates that an outcome is reached, stabilization achieved 
(the investigator does not expect any further improvement or worsening of the event), or the 
event is otherwise explained.
Appendix 3.3
Assessment of Adverse Events
Severity Categorization
The severity of AEs must be recorded during the course of the event including the start and stop 
dates for each change in severity. An event that changes in severity is captured as a new event. 
Worsening medical conditions, signs or symptoms present prior to initiation of investigational 
product, must be recorded as new AEs.
For example, if a subject reports mild intermittent dyspepsia prior to initiation of dosing with the 
investigational product, and the dyspepsia becomes severe and more frequent after first dose a 
new AE of severe dyspepsia (with the appropriate date of onset) should be documented in the 
source.
The medical assessment of severity is determined by using the following definitions:

Mild: A type of AE that is usually transient and may require only minimal treatment 
or therapeutic intervention. The event does not generally interfere with usual 
activities of daily living.

Moderate: A type of AE that is usually alleviated with specific therapeutic 
intervention. The event interferes with usual activities of daily living, causing 
discomfort but poses no significant or permanent risk of harm to the research subject.

Severe: A type of AE that interrupts usual activities of daily living, or significantly 
affects clinical status, or may require intensive therapeutic intervention.
Relationship Categorization
A physician/investigator must make the assessment of relationship to investigational product for 
each AE. The investigator should decide whether, in his or her medical judgment, there is a 
reasonable possibility that the event may have been caused by the investigational product. If 
there is no valid reason for suggesting a relationship, then the AE should be classified as “not 
related”. Otherwise, if there is any valid reason, even if undetermined or untested, for suspecting 
a possible cause-and-effect relationship between the investigational product and the occurrence 
of the AE, then the AE should be considered “related”. The causality assessment must be 
documented in the source.
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The following additional guidance may be helpful:
Table A1
Adverse Event Relationship Categorization
Related
The temporal relationship between the event and the administration of 
the investigational product is compelling enough and/or follows a 
known or suspected response pattern to that product, and the event 
cannot be explained by the subject’s medical condition, other 
therapies, or accident.
Not related
The event can be readily explained by other factors such as the 
subject’s underlying medical condition, concomitant therapy, or 
accident and no plausible temporal or biologic relationship exists 
between the investigational product and the event.
Outcome Categorization
The outcome of AEs must be documented in the source during the course of the study. Outcomes 
are as follows:

Fatal

Not Recovered/Not Resolved

Recovered/Resolved

AE Recovered/Resolved With Sequelae

Recovering/Resolving

Unknown.
If applicable, action taken (ie, dose increased, dose not changed, dose reduced, drug interrupted, 
drug withdrawn, not applicable, or unknown) should also be recorded in the source 
documentation. 
Appendix 3.4
Safety Reporting
Reference Safety Information
The RSI for this study is the investigator’s brochure which the sponsor has provided under 
separate cover to all investigators. 
Reporting Procedures
All initial and follow-up SAE reports must be reported by the investigator to the sponsor Global
Patient Safety Evaluation (GPSE) Department (see details below) and the sponsor medical
monitor within 24 hours of becoming aware of the event. This will be done by transmitting an
EDC SAE report, the preferred method of reporting SAEs. If access to EDC is not feasible
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within 24 hours of receiving the event, the paper SAE forms should be submitted via fax or
email. If a fax is used for transmission, site personnel must make every effort to confirm
successful transmission of all pages and include an e-mail address on the fax cover sheet so that
an acknowledgment of receipt can be returned via e-mail within 1 business day.
Global Patient Safety Evaluation E-mail: drugsafety@shire.com
Global Patient Safety Evaluation Fax Number: 1-484-595-8155 
If e-mail submission of scanned SAE forms is used, site personnel must make every effort to
confirm successful transmission by awaiting acknowledgment of receipt via e-mail within 1 
business day.
If SAEs are reported via fax or by email, EDC must be updated as soon as possible with the 
appropriate information. Information in the SAE report form must be consistent with the data 
provided on the eCRF.
Note: The 24-hour reporting requirement for SAEs does not apply to reports of abuse, misuse, 
overdose, or medication errors (see Appendix 3.9) unless they result in an SAE.
Appendix 3.5
Serious Adverse Event Collection Time Frame
All SAEs (regardless of relationship to investigational product) are collected from the time the 
subject signs the informed consent until the defined follow-up period stated in Section 8.1.4 and 
must be reported to the sponsor Global Patient Safety Evaluation within 24 hours of the first 
awareness of the event. Any SAE considered related to study participation that is reported to the 
investigator following the AE collection period should be reported to the sponsor within 24 hours 
of first awareness of the event.
Appendix 3.6
Serious Adverse Event Onset and Resolution Dates
The onset date of the SAE is defined as the date the event meets serious criteria. The resolution 
date is the date the event no longer meets serious criteria, the date the symptoms resolve, or the 
event is considered chronic. In the case of hospitalizations, the hospital admission and discharge 
dates are considered the onset and resolution dates, respectively.
In addition, any signs or symptoms reported by the subject after signing the informed consent 
form, or leading up to the onset date of the SAE, or following the resolution date of the SAE, 
must be recorded as an AE, if appropriate.
Appendix 3.7
Fatal Outcome
Any SAE that results in the subject’s death (eg, the SAE was noted as the primary cause of 
death) must have fatal checked as an outcome with the date of death recorded as the resolution 
date. For all other events ongoing at the time of death that did not contribute to the subject’s 
death, the outcome should be considered not resolved, without a resolution date recorded.
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For any SAE that results in the subject’s death or any ongoing events at the time of death, unless 
another investigational product action was previously taken (eg, drug interrupted, reduced, 
withdrawn), the action taken with the investigational product should be recorded as “dose not 
changed” or “not applicable” (if the subject never received investigational product). The 
investigational product action of withdrawn should not be selected solely as a result of the 
subject’s death.
Appendix 3.8
Pregnancy 
All pregnancies are to be reported from the time informed consent is signed until the defined 
follow-up period stated in Section 8.1.4.
Any report of pregnancy for any female study participant must be reported within 24 hours to the 
sponsor Global Patient Safety Evaluation using the sponsor Pregnancy Report Form. 
A copy of the sponsor Pregnancy Report Form (and any applicable follow-up reports) must also
be sent to the CRO/sponsor medical monitor using the details specified in the emergency contact
information section of the protocol. The pregnant female study participant must be withdrawn 
from the study. 
Every effort should be made to gather information regarding the pregnancy outcome and 
condition of the infant. It is the responsibility of the investigator to obtain this information within 
30 calendar days after the initial notification and approximately 30 calendar days postpartum.
Pregnancy complications such as spontaneous abortion/miscarriage or congenital abnormality 
are considered SAEs and must be reported using the SAE eCRF. Note: An elective abortion is 
not considered an SAE.
In addition to the above, if the investigator determines that the pregnancy meets serious criteria, 
it must be reported as an SAE using the SAE eCRF as well as the Sponsor Pregnancy Report 
Form. The test date of the first positive serum/urine -hCG test or ultrasound result will 
determine the pregnancy onset date.
Appendix 3.9
Abuse, Misuse, Overdose and Medication Error
Abuse, misuse, overdose, or medication error (as defined below) must be reported to the sponsor 
according to the SAE reporting procedure whether or not they result in an AE/SAE as described 
in Appendix 3.1.
Note: The 24-hour reporting requirement for SAEs does not apply to reports of abuse, misuse, 
overdose, or medication errors unless these result in an SAE.
The categories below are not mutually exclusive; the event can meet more than 1 category.

Abuse – Persistent or sporadic intentional intake of investigational product when used 
for a nonmedical purpose (eg, to alter one’s state of consciousness or get high) in a 
manner that may be detrimental to the individual and/or society
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
Misuse – Intentional use of investigational product other than as directed or indicated 
at any dose (Note: this includes a situation where the investigational product is not 
used as directed at the dose prescribed by the protocol)

Overdose – Intentional or unintentional intake of a dose of investigational product 
higher than the protocol-prescribed dose

Medication Error – An error made in prescribing, dispensing, administration, and/or 
use of an investigational product. For studies, medication errors are reportable to the 
sponsor only as defined below.
Cases of subjects missing doses of the investigational product are not considered reportable as 
medication errors. Medication errors should be collected/reported for all products under 
investigation. The administration and/or use of an expired investigational product, errors relating 
to rate of drug administration dilution, use of inappropriate diluent, and longer than 
recommended time frames within which drug must be used after dilution should be considered as 
reportable medication errors. 
Appendix 3.10
Urgent Safety Measures 
An urgent safety measure is an immediate action taken, which is not defined by the protocol, in 
order to protect subjects participating in a clinical study from immediate harm, these do not 
constitute de facto deviation from the protocol. Urgent safety measures may be taken by the 
sponsor or clinical investigator, and may include any of the following:

Immediate change in study design or study procedures

Temporary or permanent halt of a given clinical study or studies

Any other immediate action taken in order to protect clinical study participants from 
immediate hazard to their health and safety.
The investigator may implement urgent safety measures to protect study subjects from 
immediate hazard to their health or safety. The measures should implement immediately and 
does not require prior authorization from the sponsor. In the event(s) of an apparent direct hazard 
to the subject, the investigator will notify the sponsor immediately by telephone and confirm 
notification to the sponsor in writing as soon as possible, and within 1 calendar day after the 
change is implemented. The sponsor will also ensure the responsible EC(s) and relevant 
competent authority(s) are notified of the urgent safety measures taken in such cases according to 
local regulations.
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Appendix 3.11
Regulatory Agency, Institutional Review Board, Ethics Committee and 
Site Reporting
The sponsor or designee is responsible for notifying the relevant regulatory authorities of related, 
unexpected SAEs. 
In addition, the sponsor is responsible for notifying active sites of all related, unexpected SAEs 
occurring during all interventional studies across the REPLAGAL® program.
The investigator is responsible for notifying the local IRB/EC of SAEs or significant safety 
findings that occur at his or her site as required by IRB/EC procedures (see Appendix 1.5).
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Appendix 4
Contraceptive Guidance 
Female participants of childbearing potential are eligible to participate if they agree to use a 
highly effective method of contraception consistently and correctly as described below.
Highly Effective Contraceptive Methods That Are User Dependenta
Failure rate of <1% per year when used consistently and correctly.
Combined (estrogen- and progestogen-containing) hormonal contraception associated with 
inhibition of ovulation

Oral 

Intravaginal 

Transdermal
Progestogen-only hormonal contraception associated with inhibition of ovulation

Oral 

Injectable
Highly Effective Methods That Are User Independenta
Implantable progestogen only hormonal contraception associated with inhibition of ovulation

Intrauterine device (IUD)

Intrauterine hormone-releasing system (IUS).
Bilateral tubal occlusion
Vasectomized partner 
A vasectomized partner is a highly effective contraception method provided that the partner is 
the sole male sexual partner of the women of childbearing potential (WOCBP) and the absence 
of sperm has been confirmed. If not, an additional highly effective method of contraception 
should be used. 
Sexual abstinence 
Sexual abstinence is considered a highly effective method only if defined as refraining from 
heterosexual intercourse during the entire period of risk associated with the study treatment. 
The reliability of sexual abstinence needs to be evaluated in relation to the duration of the 
study and the preferred and usual lifestyle of the participant. 
NOTES: 
a)
Typical use failure rates may differ from those when used consistently and correctly. Use 
should be consistent with local regulations regarding the use of contraceptive methods for 
participants participating in clinical studies. 
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Appendix 5
Scales and Assessments
The following scales/assessments will be utilized in this study. In the case of an unplanned event 
that disallows/prevents the administration of the PRO on a device, for reasons including but not 
limited to, device outage or other technical limitation, subjects may record their responses on a 
web back-up version of the assessments that is provided by the CRO or PRO vendor. Sites will 
be provided with access to the web back-up assessments as a preventative measure.
Full Title of Scale/Assessment
Appendix 5.1 Short Form-36 Health Survey (SF-36v2) 
Appendix 5.2 Brief Pain Inventory-Short Form (BPI-SF)
Appendix 5.3 Patient Global Impression of Fabry Symptom Severity (PGI-S)
Appendix 5.4 Brief Fatigue Inventory (BFI)
Appendix 5.5 Gastrointestinal Symptom Rating Scale (GSRS)
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Appendix 5.1
Short Form-36 Health Survey (SF-36v2)
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Appendix 5.2
Brief Pain Inventory Short Form (BPI-SF)
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Appendix 5.3
Patient Global Impression of Fabry Symptom Severity (PGI-S)
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Appendix 5.4
Brief Fatigue Inventory (BFI)
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Appendix 5.5
Gastrointestinal Symptom Rating Scale (GSRS)
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Appendix 6
Abbreviations 
Abbreviation
Definition
ADA
antidrug antibody
AE
adverse event
AF
animal-free
ALT
alanine aminotransferase
AST
aspartate aminotransferase
AUC
area under the plasma concentration-time curve
B19V
parvovirus B19
-hCG
beta-human chorionic gonadotropin
BFI
Brief Fatigue Inventory 
BPI-SF
Brief Pain Inventory-Short Form
BUN
blood urea nitrogen
CFR
Code of Federal Regulations
CKD-EPI
Chronic Kidney Disease Epidemiology
CI
confidence interval
CKD
chronic kidney disease
cMRI
cardiac magnetic resonance imaging
CRA
clinical research associate
CRO 
contract research organization
CSR
clinical study report
DBS
dried blood spot
EC
ethics committee
ECG
electrocardiography
eCRF
electronic case report form
EDC
electronic data capture
eGFR
estimated glomerular filtration rate
EMA
European Medicines Agency
EOT
end of treatment
EOW
every other week
ERT
enzyme replacement therapy
EU
European Union
FDA
Food and Drug Administration
FOS
Fabry Outcome Survey
Gb3
globotriaosylceramide
GCP
Good Clinical Practice
GI
gastrointestinal
GLA
α-galactosidase A
GSRS
Gastrointestinal Symptom Rating Scale
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Abbreviation
Definition
HAV
hepatitis A virus
HBcAb
hepatitis B core antibody 
HBsAg
hepatitis B surface antigen 
HBV
hepatitis B virus
HCV
hepatitis C virus
HDL
high-density lipoprotein
HEV
hepatitis E virus
HIPAA
Health Insurance Portability and Accountability Act
HIV
human immunodeficiency virus
ICAM1
Intercellular Adhesion Molecule 1
ICH
International Council for Harmonisation
ICMJE
International Committee of Medical Journal Editors
IgE
immunoglobulins E
INTLK1β
Interleukin 1 Beta
IRB
Institutional Review Board
IRR
infusion-related reaction
IRT
interactive response technology
mITT
modified intent-to-treat
IV
intravenous
IVSTd
interventricular septal end-diastolic thickness
KDIGO
Kidney Disease Improving Global Outcomes
LDL
low-density lipoprotein
LVH
left ventricular hypertrophy
LVMI
left ventricular mass index
lyso-Gb3
globotriaosylsphingosine
M6P
mannose-6-phosphate
MI
multiple imputation
MMRM
mixed-effects model for repeated measures
MNAR
missing not at random
NAb
neutralizing antibody
PCR
protein/creatinine ratio 
PD
pharmacodynamic
PGI-S
Patient Global Impression of Fabry Symptom Severity
PK
pharmacokinetic(s) 
PP
per-protocol
PRO
patient-reported outcome
PWTd
posterior wall thickness in diastole
QoL
quality of life
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Abbreviation
Definition
RB
roller bottle
REML
restricted maximum likelihood estimation
RSI
Reference Safety Information
SAE
serious adverse event
SAP
statistical analysis plan
SD
standard deviation
SF-36v2
Short Form-36 Health Survey
TEAE
Treatment emergent adverse events
TNF-α
Tumor Necrosis Factor
UK
United Kingdom
US
United States
VCAM1
Vascular Cell Adhesion Molecule 1
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Appendix 7
Protocol History 
Document
Date
Global/Country/Site Specific
Amendment 6
17 Feb 2022
Global
Amendment 5
22 Jul 2021
Global
Amendment 4
24 Jun 2021
Global
Amendment 3
30 Apr 2021
Global
Amendment 2
21 Jan 2021
Global
Amendment 1
01 Apr 2020
Global
Original Protocol
17 Jan 2019 
Global
Protocol Amendment
Summary of Change(s) Since the Last Version of the Approved Protocol
Amendment Number
1
Amendment Date
01 Apr 2020
Global
Protocol Amendment Summary and Rationale:
The protocol was updated to reflect feedback from Health Canada.
Section(s) Affected by Change
Description of Each Change
Rationale for Change
All
Made minor updates to text and 
formatting throughout the protocol
Edited for clarity and consistency
All
Updated “effectiveness” to 
“efficacy” throughout the protocol
This is a confirmatory study of 
efficacy, so the term “efficacy” is 
appropriate
All
Changed time points from Month to 
Week and adjusted duration of study 
treatment in weeks
This change corrects study treatment 
duration from 96 weeks to 104 
weeks, which is required in order to 
have subject treatment data for 2 
years
All
Changed “12-week Interval Visits” 
to “Site Visits”
The study visits are not exactly at 
12-week intervals, so “site visits” is 
more accurate
All
Removed pulse oximetry from vital 
sign collection
Assessed as not needed
Emergency Contact Information
Updated the emergency contact
New emergency contact
Section 1.1, Synopsis
Updated synopsis to reflect changes 
in the protocol body
Edited for consistency
Section 1.1, Synopsis
Deleted study design figure
Deleted to reduce the length of the 
synopsis
Section 1.2, Schedule of Activities
Section 3.1.4, Study Endpoints
Section 5.2, Exclusion Criteria
Section 8.1, Study Periods (and 
subsections)
Removed the option to use 
echocardiogram to assess cardiac 
structure 
Left ventricular hypertrophy is now 
an inclusion criterion, so all subjects 
must have cardiac magnetic 
resonance imaging performed; 
echocardiogram is therefore 
redundant
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Protocol Amendment
Summary of Change(s) Since the Last Version of the Approved Protocol
Amendment Number
1
Amendment Date
01 Apr 2020
Global
Protocol Amendment Summary and Rationale:
The protocol was updated to reflect feedback from Health Canada.
Section(s) Affected by Change
Description of Each Change
Rationale for Change
Section 1.2, Schedule of Activities
Section 5.1, Inclusion Criteria
Section 8.1, Study Periods (and 
subsections)
Section 8.2.2, Efficacy
Section 9.5, Efficacy Analyses 
(and subsections)
Added that estimated glomerular 
filtration rate will be calculated by a 
Shire-designated laboratory
Clarification that this will not be 
calculated by the site staff
Section 1.2, Schedule of Activities
Section 8.1.2, Baseline Visit
Removed proteinuria assessment at 
baseline
To help alleviate the assessments 
burden. The screening value will be 
used so the baseline value would be 
redundant
Section 1.2, Schedule of Activities
Section 8.1.2, Baseline Visit
Section 8.1.3, Treatment Period
Removed cMRI from baseline visit 
and Week 78 and extended the 
window for screening assessment to 
42 days
To help alleviate the assessments 
burden on subjects and study 
personnel. Extending the assessment 
window allows for cMRI screening 
results to be used for the baseline 
comparison
Section 1.2, Schedule of Activities
Section 8.1.3, Treatment Period
Added Day0/Week 0 to the Schedule 
of Activities within the Baseline 
Period to indicate the first infusion 
of REPLAGAL
Clarifies that the first dose of 
REPLAGAL will be at Day 0/Week 0 
and will be after all baseline 
assessments and procedures are 
completed
Section 1.2, Schedule of Activities
Section 8.1.1, Screening Period
Section 8.1.2, Baseline Period
Moved height, weight, and dose 
calculation from screening to 
baseline
To streamline assessments
Section 1.2, Schedule of Activities
Section 8.1.3.4, Week 104 Visit
Added a footnote to the EOT visit to 
indicate all but the REPLAGAL
infusion is to be completed at this 
visit for subjects who discontinue 
early
Allows for the EOT visit to serve as 
end of study for all subjects 
regardless of whether they complete 
or discontinue the study early
Section 1.2, Schedule of Activities
Section 8.2.1.3, Confirmation of 
Fabry Disease (GLA Activity and 
Genotyping)
Added GLA activity for female 
subjects with clarification that this 
will not be used as an inclusion 
criterion
For completeness of data
Section 2.2, Product Background 
and Clinical Information
Deleted data on exposure to 
commercial REPLAGAL and some 
text on the efficacy of REPLAGAL
Deletions suggested by Health 
Canada and in order to ensure the 
most accurate and current 
information for safety and efficacy, 
the latest edition of the REPLAGAL
investigator’s brochure should be the 
source referenced
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Protocol Amendment
Summary of Change(s) Since the Last Version of the Approved Protocol
Amendment Number
1
Amendment Date
01 Apr 2020
Global
Protocol Amendment Summary and Rationale:
The protocol was updated to reflect feedback from Health Canada.
Section(s) Affected by Change
Description of Each Change
Rationale for Change
Section 4.1, Overall Design
Section 7.2, Withdrawal From the 
Study
Section 7.3, Discontinuation of 
Study Treatment
Added that subjects who discontinue 
from study treatment will continue to 
have study visits if they consent to 
do so
Added in line with guidance from 
the US National Research Council 
guidance on The Prevention and 
Treatment of Missing Data in 
Clinical Trials
Section 4.1, Study Design
Section 9.3, Sample Size and 
Power Considerations
Section 9.4, Statistical Analysis 
Sets
Updated definition of evaluable 
subjects to require that subjects must 
not have discontinued from 
investigational product
Updated to reflect that data will still 
be collected from subjects who 
discontinue treatment but continue 
study assessments. 
Section 4.3, Justification for Dose
Updated the number of countries 
where REPLAGAL is approved
Updated numbers
Section 6.2.6, Dose Modification
Section 8.2.4, Other
Moved dosing information from 
Section 8.2.4 to Section 6.2.6
Consolidates dosing information in 
one location
Section 5.1, Inclusion Criteria
Added left ventricular hypertrophy 
as an inclusion criterion
Added to increase the similarity 
between the study subjects and the 
historical control patients per the 
suggestions from Health Canada
Section 5.2, Exclusion Criteria
Updated exclusion criterion #3 to 
remove proteinuria 
>1000 mg/24 hour
Standardized to protein/creatinine 
ratio to reduce operational burden
Section 5.4.1 Female 
Contraception
Appendix 4, Contraceptive 
Guidance
Updated contraceptive guidance, 
including definition of 
postmenopausal 
Updated to reflect most recent 
protocol template
Section 7.1 Screen Failure
Moved definition of screen failure 
from Section 8.1.1 to Section 7
Updated for clarity
Section 8.2.5, Volume of Blood to 
Be Drawn From Each Subject
Increased volume of blood to be 
taken for antidrug antibody samples 
from 3 mL to 4 mL, and updated 
total blood volume accordingly
Volume increased to ensure 
adequate sample volume for the 
assay
Section 9.3, Sample Size and 
Power Considerations
Added details of drop-out rates in 
previous studies
Justification of the estimated drop-
out rate in this study
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Protocol Amendment
Summary of Change(s) Since the Last Version of the Approved Protocol
Amendment Number
1
Amendment Date
01 Apr 2020
Global
Protocol Amendment Summary and Rationale:
The protocol was updated to reflect feedback from Health Canada.
Section(s) Affected by Change
Description of Each Change
Rationale for Change
Section 9.3, Sample Size and 
Power Considerations
Section 9.4, Statistical Analysis 
Sets
Section 9.5, Efficacy Analyses 
(and subsections)
Section 9.7.1, Health-related 
Quality of Life Analyses
Added modified intent-to-treat set
The intent-to-treat set may include 
subjects who were enrolled in the 
study but did not receive 
investigational product. The 
modified intent-to-treat set will 
consist of all enrolled subjects who 
have received at least 1 dose of 
investigational product and 
completed at least 1 efficacy 
assessment of the endpoints being 
analyzed.
Section 9.7.2, Sensitivity Analysis
New section added
Details how data will be managed 
regarding sensitivity and outliers
Section 9.8, Missing, Unused, and 
Spurious Data
Added section on missing, unused, 
and spurious data
Clarification of how missing data 
will be treated
Investigator’s Responsibilities
Deleted Financial Disclosure 
information
This is a non-IND study and is not 
being conducted at any US sites
Data Management Considerations
Added that patient-facing 
assessments including the SF-36, 
BPI-SF, PGI-S, BFI, and GSRS will 
be collected via an electronic tablet
This helps to clarify data collection 
for these assessments
Adverse Event Definitions
Deleted suggestion that 
electrocardiograms should be 
performed in triplicate and 
conducted by a central laboratory
Electrocardiograms will not be done 
by a central laboratory
Appendix 5, Scales and 
Assessments
Updated sample scales and 
assessments
Updated to provide the most recent 
versions
Section 10, References 
Moved Section up from 11 to 10
Updated to current submission 
standards
Section 11, Supporting 
Documentation and Operational 
Considerations
Moved Section down from 10 to 11
Updated to current submission 
standards
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Shire
CONFIDENTIAL
Page 129
SHP675-301 Protocol Amendment 6
REPLAGAL® (agalsidase alfa) 
17 Feb 2022
Protocol Amendment
Summary of Change(s) Since the Last Version of the Approved Protocol
Amendment Number
2
Amendment Date
21 Jan 2021
Global
Section(s) Affected by Change
Description of Each Change
Rationale for Change
Title Page
The title page was updated to state 
that Shire is now a wholly owned 
subsidiary of Takeda Pharmaceutical 
Company Limited.
This change was made to provide 
updated and accurate information for 
the sponsor.
Protocol Signature Page, 
Emergency Contact Information
The medical monitor information for 
this study was updated as follows: 
Marketed Products.
This change was made to provide 
updated and accurate information.
Emergency Contact Information, 
Section 6.2.1, Section 8.2.3.7, 
Appendix 3.4, Appendix 3.5, 
Appendix 3.8
The name of the Global Drug Safety 
department was updated to Global 
Patient Safety Evaluation.
This change was made to provide 
updated and accurate information.
Section 1.1 Synopsis, 
Section 3.1.1, Section 3.2
The primary objective was updated 
to indicate that efficacy will be 
evaluated every other week (EOW) 
for up to 104 weeks.
This change was made to provide 
updated and accurate information.
Section 1.1 Synopsis, Section 4.5
Sites and Regions have been updated 
to indicate that the study is expected 
to be conducted in up to 50 sites 
globally.
This change was made to provide 
updated and accurate information.
Section 1.1 Synopsis, Section 4.4
The planned study duration of 
approximately 6 years has been 
updated to indicate the first subject 
enrolled is anticipated in 2021 and 
the last subject completed is 
anticipated to be in 2027.
This change was made to provide 
updated and accurate information.
Section 1.1 Synopsis, Section 4.1, 
Section 4.2, Section 9.3
Updates have been made to indicate 
that the study will use reference 
values of patients with Fabry disease 
from published literature instead of 
historical controls.
Historical controls are not available 
for this study and reference values 
from published literature will be 
used.
Section 1.1 Synopsis, Section 5.1
Inclusion criterion 3 was revised as 
follows: “The subject is 18 to 
65 years of age, inclusive.”
This change was made because the 
upper limit of age for inclusion as 
REPLAGAL has not been tested in 
subjects over 65 years of age.
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Shire
CONFIDENTIAL
Page 130
SHP675-301 Protocol Amendment 6
REPLAGAL® (agalsidase alfa) 
17 Feb 2022
Protocol Amendment
Summary of Change(s) Since the Last Version of the Approved Protocol
Amendment Number
2
Amendment Date
21 Jan 2021
Global
Section(s) Affected by Change
Description of Each Change
Rationale for Change
Section 1.1 Synopsis, Section 5.2
Exclusion criterion #4 was revised as 
follows: “Subjects who have 
clinically relevant history of allergy 
or signs or symptoms of severe 
hypersensitivity (including 
hypersensitivity to the REPLAGAL
active substance or any of the 
excipients), which in the 
investigator’s judgment, will 
substantially increase the subject’s 
risk if he or she participates the 
study.”
This change was made to ensure that 
patients with hypersensitivity to any 
components in REPLAGAL are not 
enrolled.
Section 1.1 Synopsis, Section 5.2, 
Section 6.6.3, Table 1 Schedule of 
Activities footnote v
Content from exclusion criteria 
(formerly 10 and 11) 9 and 10 as 
added to Section 6.6.3 Prohibited 
Treatment and footnote v in Table 1 
Schedule of Activities; these 
2 exclusion criteria were combined 
into a single exclusion criterion.
This content was combined to 
streamline the eligibility and was 
also added to the prohibited 
treatments and medications and 
footnote “v” in Table 1 for 
consistency.
Section 1.1 Synopsis, Section 9.3
The details for sample size and 
power considerations was revised to 
read: “The null hypothesis for eGFR 
is that there is no difference in mean 
change from baseline in eGFR at 
Week 104 between the treated 
subjects and the untreated patients
reference change of -
6 mL/min/1.73 m2. The alternative 
hypothesis states that the mean 
decline in eGFR is smaller than this 
reference value. The null hypothesis 
for LVMI is that there is no 
difference in mean change from 
baseline in LVMI at Week 104 
between the treated subjects and the 
untreated patients reference change 
of +10 g/m2.7. The alternative 
hypothesis states that mean increase 
in LVMI is smaller than this 
reference value.
The Hochberg procedure to control 
the type I error rate for the 2 primary 
endpoints is incorporated in the
sample size determination. The 
Hochberg procedure does not require 
the order of testing. Below is the 
sample size justification assuming 
The details have been modified to 
align with the new approach to 
statistical analysis.
For non-commercial use only

Shire
CONFIDENTIAL
Page 131
SHP675-301 Protocol Amendment 6
REPLAGAL® (agalsidase alfa) 
17 Feb 2022
Protocol Amendment
Summary of Change(s) Since the Last Version of the Approved Protocol
Amendment Number
2
Amendment Date
21 Jan 2021
Global
Section(s) Affected by Change
Description of Each Change
Rationale for Change
only one of the dual endpoints will 
be determined to be significant. If 
both endpoints are significant at the 
0.025 significance level, then the 
power will be large than quoted 
below.
For eGFR, with 36 evaluable 
subjects, the study has at least 90% 
power to detect a decrease after 
104 weeks of treatment of 
1.7 mL/min/1.73 m2 compared with 
a reference untreated change 
of -6 mL/min/1.73 m2 with SD=7 
(effect size of 0.61) using a 1-sided 
one sample t-test at significance 
level of 0.0125. For LVMI, with 
36 evaluable subjects, the study has 
at least 90% power to detect an 
increase after 104 weeks of 
treatment of 0.64 g/m2.7 compared 
with a reference untreated change of 
10 g/m2.7 with SD=15 (effect size of 
0.62) using a 1-sided one sample 
t-test at significance level of 
0.0125.” 
Section 1.1 Synopsis, Section 9.4, 
Section 9.5.1, Section 9.5.2
The intent to treat (ITT) population 
was removed and the modified intent 
to treat (mITT) population was 
revised. The mixed-effects model for 
repeated measures (MMRM) will 
use the mITT population for both 
primary and secondary analyses.
Revised to ensure the subject 
receives at least one dose of 
investigational product so that data is 
more meaningful.
Section 1.1 Synopsis, Section 9.4
A new subject population was 
added: the completers set 
This subject population was added to 
ensure analysis can be conducted for 
a larger proportion of the subject 
population.
Section 1.1 Synopsis, 
Section 9.5.1, Section 9.5.2
The following was added to the 
sensitivity analysis: “The eGFR and 
LVMI annualized rate of change and 
95% CI will be estimated for 
subjects using the random intercept 
and slope model. Baseline eGFR or 
baseline LVMI, age at baseline, sex, 
and treatment duration on 
investigational product in year will 
be included in the model.”
Statistically it is more appropriate to 
use this information in the sensitivity 
analysis.
For non-commercial use only

Shire
CONFIDENTIAL
Page 132
SHP675-301 Protocol Amendment 6
REPLAGAL® (agalsidase alfa) 
17 Feb 2022
Protocol Amendment
Summary of Change(s) Since the Last Version of the Approved Protocol
Amendment Number
2
Amendment Date
21 Jan 2021
Global
Section(s) Affected by Change
Description of Each Change
Rationale for Change
Section 1.1 Synopsis, 
Section 9.5.1
The analyses of the primary 
endpoints were revised to indicate 
that the most appropriate data (vs all 
available data) will be used.
This is a clarification to indicate 
analysis will be conducted with the 
most appropriate data.
Table 1 Schedule of Activities
Proteinuria was added to baseline as 
an assessment to be completed.
This was removed in amendment 1 
to ease subject burden but is 
reconsidered to be important to the 
study.
Table 1 Schedule of Activities 
footnote q, Section 8.1.1, 
Section 8.1.2, Section 8.1.3.2
Details of the complete blood count 
assessment were added.
Added for completeness and clarity
Table 1 Schedule of Activities
Schedule of Activities Table revised 
to correct visit windows and clarify 
site visits
Added for clarity
Section 2.1, Section 10
New statements added with new 
reference publications: 
“The threshold level of alpha-Gal A 
activity below which clinically 
significant Fabry disease occurs is 
thought to be 30 to 35 percent of the 
mean normal control Schiffmann et 
al., 2016.” And
“In females, alpha-Gal A activity is 
most often higher than in males 
Arends et al., 2017.”
To enhance information provided 
about the indication under study.
Section 2.2
New information on infusion-related 
reactions (IRRs) was added 
including the description of the 
observed events’ onset, timing, 
mitigation, and treatment. Newly 
added information on IRRs is 
analyzed in the context of 
benefit/risk which still remains 
positive. A summary of the 
benefit/risk conclusions was added.
A statement was added that 
investigators will follow site-specific 
standards for the mitigation of 
impact from COVID-19 and will 
manage any AEs related to 
COVID-19 per study procedures for 
the reporting and treatment of AEs.
Added to inform on observed IRRs, 
the most commonly observed ADRs 
associated with REPLAGAL, and to 
provide detailed guidance on 
mitigation, potential causes, and 
treatment. Conclusions and rationale 
added to confirm benefit/risk is still 
favorable.
Statement added to inform that 
investigators will follow site-specific 
standards and AE reporting if there 
is impact from COVID-19.
Section 6.2.1
A statement that home infusions are 
optional and not mandatory was 
added.
To provide clarity.
For non-commercial use only

Shire
CONFIDENTIAL
Page 133
SHP675-301 Protocol Amendment 6
REPLAGAL® (agalsidase alfa) 
17 Feb 2022
Protocol Amendment
Summary of Change(s) Since the Last Version of the Approved Protocol
Amendment Number
2
Amendment Date
21 Jan 2021
Global
Section(s) Affected by Change
Description of Each Change
Rationale for Change
Section 6.2.1
Each EOW Infusion mentioned in 
this section was updated to include 
the corresponding infusion number.
To provide clarity.
Section 6.2.3, Section 8.2.4.3, 
Appendix 5
A statement that patient-reported 
outcome (PRO) assessments may be 
completed via electronic device or 
provided paper assessment was 
added.
Added as a preventative measure in 
the event that there are technology 
issues preventing electronic devise 
use or if the subject is unable to 
travel to the site. 
Section 6.7
A new section was added for 
COVID-19-related protocol 
considerations.
Added to ensure subject safety and 
maintain study data integrity due to 
any impact due to the COVID-19 
pandemic.
Section 7.3
The content for discontinuation of 
study treatment was expanded and 
new study stopping rules were 
added. 
Additional detail added for 
clarification and enhancement of 
safety precautions.
Section 8.1.2
An assessment was added: 
“Calculate the dose of REPLAGAL
based on the subject’s weight at 
baseline.”
This assessment was inadvertently 
omitted from the description of stud 
assessments and procedures 
performed at baseline in the prior 
amendment.
Section 8.2.1.2
The following text was added: “If 
the eGFR measurement at screening 
is not within the range, a second 
eGFR measurement may be 
completed and, if in the stipulated 
range, used as the screening value. If 
a second measurement is taken, a 
minimum of 1 week and maximum 
of 30 days should separate it from 
the first measurement.”
This text was already in inclusion 
criterion #8 and screening sections 
and has been added to the section on 
eligibility to confirm allowance and 
for consistency.
Section 9.7.1
The assessment of GSRS was added.
These assessments were 
inadvertently omitted from the prior 
amendment.
Protocol Amendment
Summary of Change(s) Since the Last Version of the Approved Protocol
Amendment Number
3
Amendment Date
30 April 2021
Global
Section(s) Affected by Change
Description of Each Change
Rationale for Change
Section 1.1
The analyses of the primary endpoints 
were revised to indicate that all available 
Takeda acknowledges that the revised 
wording in the protocol amendment 2 
For non-commercial use only

Shire
CONFIDENTIAL
Page 134
SHP675-301 Protocol Amendment 6
REPLAGAL® (agalsidase alfa) 
17 Feb 2022
Protocol Amendment
Summary of Change(s) Since the Last Version of the Approved Protocol
Amendment Number
3
Amendment Date
30 April 2021
Global
Section(s) Affected by Change
Description of Each Change
Rationale for Change
Section 9.5.1
data (vs most appropriate data) will be 
used.
from “all available data” to “the most 
appropriate data” could alter the 
interpretation of the statement. This 
change was an oversight during editorial 
review of the protocol and was not 
intended to suggest a change in the 
approach to the assessment of primary 
endpoints. 
Table 1
For all subjects 18 to 65 years inclusive: 
height and weight must be collected at 
Screening. Height must also be measured 
and collected at Week 52.
Subject height and weight must be 
collected at Screening, Week 52 and 
Week 104 (or early termination) visits as 
required for Cardiac MRI procedure.
Section 8.1.1.1
For all Subjects 18 to 65 years inclusive 
height and weight are measured at 
Screening.
Subject height and weight must be 
measured at Screening as required for 
Cardiac MRI procedure.
Section 8.1.2 
Remove “Measure height” at Baseline.
Subject height must be measured and 
collected at Screening as required for 
Cardiac MRI procedure.
Table 1
Section 8.1.3.3
Section 8.1.3.4
Section 8.2.3.2
Subject height must be measured at 
Screening, Week 52 and Week 104 (or 
early termination) visits for all subjects.
Subject height must be measured at 
Screening, Week 52 and Week 104 (or 
early termination) for all subjects as 
required for Cardiac MRI procedure.
Table 1
Section 8.2.3.3
Subject weight must be measured at 
Screening.
Subject weight must be measured at 
Screening as required for Cardiac MRI 
procedure.
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Shire
CONFIDENTIAL
Page 135
SHP675-301 Protocol Amendment 6
REPLAGAL® (agalsidase alfa) 
17 Feb 2022
Protocol Amendment
Summary of Change(s) Since the Last Version of the Approved Protocol
Amendment Number
4
Amendment Date
24 June 2021
Global
Section(s) Affected by Change
Description of Each Change
Rationale for Change
Synopsis
Section 9.4, Statistical Analysis Sets
An intent-to-treat (ITT) subject 
population was added. The safety set, 
per protocol set, and completers set 
will be drawn from the ITT set instead 
of the mITT set.
The analysis will be based 
on the ITT population to 
include all enrolled 
patients.
Synopsis
Section 9.3 Sample Size and Power Considerations
Section 9.5.1, Primary Efficacy Endpoints
Section 9.5.3 Multiplicity Adjustment
Section 9.5.4, Control of Type I Error
Hochberg procedure replaced by 
Bonferroni adjustment, ITT set instead 
of mITT set, the primary null 
hypothesis was updated to include the 
mean change from baseline in eGFR at 
Week 104 for treated subjects will be 
less than or equal 
to -6 mL/min/1.73 m2, the reference 
value from untreated subjects (instead 
of no difference), and the alternate 
hypothesis is that the mean change in 
eGFR is greater 
than -6 mL/min/1.73 m2, the reference 
value (instead of change in absolute 
value) from untreated subjects.
The mean change from baseline in 
LVMI at Week 104 of treated subjects 
will be greater than or equal to 
10 g/m2.7, the reference value from 
untreated subjects (instead of no 
difference), and the alternate 
hypothesis is that the mean change in 
LVMI will be less than 10 g/m2.7, the 
reference value (instead of change in 
absolute value) from untreated 
subjects.
A tipping point analysis was added for 
the ITT and mITT sets
Addition of ITT analysis set to 
analyses
Changes to the statistical 
analysis sections were 
made pursuant to a request 
from a regulatory authority
to define the limits used to 
test the corresponding null 
hypotheses for the 
2 primary endpoints 
(change from baseline at 
Week 104 below or above 
specific limit)
Section 4.2, Scientific Rationale for the Reference 
Controlled Study Design
Reference data clarified from 
“historical control” to “natural history” 
patients 
Clarification of source data
Section 9.1 
Text added to specify the timing of the 
SAP added.
The first version of the SAP 
will be finalized before the 
enrollment of the first 
patient.
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Shire
CONFIDENTIAL
Page 136
SHP675-301 Protocol Amendment 6
REPLAGAL® (agalsidase alfa) 
17 Feb 2022
Protocol Amendment
Summary of Change(s) Since the Last Version of the Approved Protocol
Amendment Number
5
Amendment Date
22 July 2021
Global
Section(s) Affected by Change
Description of Each Change
Rationale for Change
Section 1.1, Synopsis- Statistical Methodology 
for the Primary Efficacy Endpoints 
Section 9.5 Efficacy Analysis
Section 9.5.1 Primary Efficacy Endpoint
Includes information regarding 
statistical method for handling 
missing estimated glomerular 
filtration rate (eGFR) and left 
ventricular mass index (LVMI) 
data.
Clarification of methods 
for missing eGFR and 
LVMI data.
Appendix 6
Includes abbreviation for 
assumption that the missing data is 
not at random (MNAR).
For non-commercial use only