Effects of A3309, an Ileal Bile Acid Transport Inhibitor, on Gastrointestinal and Colonic Motor Functions in Female Patients With Functional Constipation
Phase: PHASE2
Conditions: Functional Constipation
Sponsor: Michael Camilleri, MD

 
Effects of A3309, an Ileal Bile 
Acid Transport Inhibitor, on 
Gastrointestinal and Colonic 
Motor Functions in Female 
Patients with Functional 
Constipation 
 
NCT# 01038687 
 
June 7, 2010 

 
Albireo 
1(89) 
07 June 2010 
 
 
 
Clinical Study Protocol  
 
Investigational Product 
A3309 
 
Study code 
A3309-003 
 
Protocol Version 
1.3 
 
Date 
07 June 2010 
 
STUDY TITLE 
 
 
Effects of A3309, an Ileal Bile Acid Transport Inhibitor, on Gastrointestinal 
and Colonic Motor Functions in Female Patients with Functional 
Constipation 
Development phase 
II 
 
 
Design  
 
 
A single-center, randomized, parallel group, double-blind, placebo-
controlled, dose response, pharmacodynamic and pharmacokinetic 
study.  
 
 
Investigational product and 
dosage  
Oral tablets of A3309, 15 or 20 mg once daily  
 
 
Comparator product  
Placebo 
 
 
Duration of treatment  
A3309 or matching placebo will be administered orally once 
daily for fourteen (14) consecutive days. 
 
Sponsor Signatory 
Hans Graffner, MD 
Albireo AB 
Arvid Wallgrens Backe 20 
413 46 Göteborg, Sweden 
Telephone: +46 31 741 1480 
email: hans.graffner@albireopharma.com  
 
 
Principal Investigator  
Michael Camilleri, MD                                                        
Gastroenterology and Hepatology  
Charlton 8 GI  
Mayo Clinic  
200 First Street Southwest  
Rochester, Minnesota 55905, US 
Phone: (507) 266-2305 Cindy 
email: camilleri.michael@mayo.edu 
 
Amendment No:1 
 
Date of Amendment :07 June 2010 
 
Amendment No: 
 
Date of Amendment : 
 

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PROTOCOL SYNOPSIS 
Study Title 
Effects of A3309, an Ileal Bile Acid Transport Inhibitor, on Gastrointestinal and Colonic Motor 
Functions in Patients with Functional Constipation 
Study code 
A3309-003 
 
 Principal Investigator  
Michael Camilleri M.D.  
Professor of Medicine and Physiology,  
Division of Gastroenterology and Hepatology,  
Medical Director, Strategic Alliances, Mayo Clinic 
Study period 
Estimated date of first patient enrolled:  January 2010 
 
Estimated date of last patient completed:  November 2010  
Phase of development 
 
 
 
II 
Study design 
This is a single-center, randomized, parallel group, double-blind, placebo-controlled, dose response, 
pharmacodynamic and pharmacokinetic study evaluating the effects of A3309 on gastric, intestinal 
and colonic transit in patients with functional constipation. Doses of 15 or 20 mg A3309 or matching 
placebo will be administered orally once daily for fourteen (14) consecutive days.  
 
Aim  
To assess the dose related effects of A3309 on small bowel and overall colonic transit and bowel 
function in patients with functional constipation.    
Primary endpoint: 
Colonic geometric center at 24 h as measured by scintigraphy, as compared to placebo. 
 
Secondary endpoints:  
1. Colonic filling at 6 h measured by scintigraphy, as compared to placebo. 
2. T1/2 
3. Colonic geometric center at 48 h measured by scintigraphy, as compared to placebo. 
of ascending colon emptying measured by scintigraphy, as compared to placebo. 
4. T1/2
5. Assess the effects on stool frequency and consistency based on the Bowel Pattern Diary and effects  
 of gastric emptying of solid 
    on symptom parameters coupled to constipation as well as the overall treatment effect, as  
    compared to placebo based on a six question survey given at the end of the pre-treatment period  
    and the post-treatment period. 
6. Evaluate the pharmacokinetic (PK) and pharmacodynamic characteristics for each dose of A3309. 
7. Assess the safety and tolerability of A3309 administered as an oral tablet. 
 
Number of patients planned 
Twelve female patients with functional constipation in each treatment group for a total  
of 36 patients. 
Diagnosis and main eligibility criteria 
Patients with diagnosed functional constipation will be recruited from the local community by public 
advertisement placed within areas of Mayo Clinic or by a targeted mailing of an informational letter.  

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Methodology 
Female patients with functional constipation will be screened for eligibility and informed about the 
study during pre-screening dialogue and also at the initial Visit 1 screen. 
Within seven (7) to fourteen (14) days of Visit 1, eligible patients will return for an abbreviated 
scintigraphy test with images obtained only at 4 and 24 hours post In111
A urine pregnancy test will be performed for all females of child bearing potential at Visit 1 and again 
within the 48 hours prior to the receipt of radiation for both the abbreviated and post-study 
medication transit scintigraphy tests at Visit 2 and Visit 4. Note that females who are status post 
bilateral tubal ligation, hysterectomy or postmenopausal are exempted from this test.  
 capsule ingestion. A 
geometric center at 24 hours must be less than 2.30, the median of normal colonic transit in normal 
healthy volunteers (as determined by analysis of a compilation of prior Camilleri studies), to qualify 
for randomization to study medication, either 15 or 20 mg A3309 or placebo administered orally once 
daily for fourteen (14) consecutive days. The allocation to treatment group will be concealed.  
Study medication will be administered at the Charlton 7 Clinical Research Unit (CRU) at Visit 4, 5, 
and 6, the days of scintigraphic assessment of gastric, small bowel and colonic transit of solids 
performed over a 48 hour period.  
Within seven (7) to ten (10) days of Visit 6, patients will return to the Charlton 7 CRU for final safety 
monitoring and an exit physical examination and interview with study staff. 
 
Investigational product, dosage and mode of administration 
 
Patients will take 15 or 20 mg of A3309 or placebo administered orally for eleven (11) consecutive 
days and report for post-study medication transit scintigraphy on day twelve (12) of dosing. Study 
medication will be administered once with the In111
 
 capsule on Visit 4 and once immediately before 
the camera images obtained on Visits 5 and 6.  Study medication will be administered at Charlton 7 
CRU by CRU nurses. 
Duration of treatment 
A3309 or matching placebo will be administered orally once daily for fourteen (14) consecutive days. 
 
Duration of patients involvement in the study 
 
Each patient will attend seven (7) visits at the clinic during a period of about thirty-one (31) to forty-
one (41) days.  
 
Efficacy assessments  
 
• 
Scintigraphic small bowel and colonic transit 
• 
Assessment of stool frequency and consistency using the Bowel Pattern Diary 
• 
Symptoms of constipation 
• 
Overall treatment effects 
 
Pharmacokinetic and pharmacodynamic analysis 
Blood samples for analysis of pharmacokinetic (PK) parameters will be collected at Visit 4, before 
dosing and at 30, 60, 90, 120, 180, 240, 360, 480 minutes post dosing. Pharmacodynamic parameters 
(C4, total cholesterol, HDL, LDL and triglycerides) will be collected at Visit 1, Visit 4 and Visit 7. 

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PK parameters will be analyzed using conventional analyses by Covance, UK 
 
Safety assessments  
 
The following safety assessments will be performed: 
 
• 
Laboratory safety tests, including a complete blood count (CBC), a comprehensive metabolic 
panel (CMP), coagulation studies and a urinalysis (UA) performed at Visit 1 study entry, 
Visit 4 transit scintigraphy and Visit 7 study completion.  A urine screen for drugs of abuse 
will be performed once at Visit 1 study entry. 
• 
A 12-lead ECG performed at Visit 1 study entry, Visit 4 and Visit 7 study completion. 
• 
A physical examination by a study physician at Visit 1 study entry, Visit 6 and Visit 7 study 
completion and as necessary throughout the study. 
• 
Weight and vital signs (including temperature, pulse, blood pressure and respiration rate) at 
every visit   
• 
Urine pregnancy tests performed at Visit 1 study entry and within 48 hours prior to receipt of 
radiation during the abbreviated transit scintigraphy and post-study medication transit 
scintigraphy at Visit 2 and Visit 4, respectively   
• 
Interview for concomitant medications and adverse events at every visit 
 
Statistical methods 
An analysis of covariance (ANCOVA) will be used to compare transit parameters and patient bowel 
pattern diary summaries (ie, stool frequency, mean stool consistency and mean ease of passage 
scores) among the treatment groups. The covariates considered for inclusion in the analyses are age, 
body mass index (BMI) and the corresponding baseline (pre-treatment) bowel pattern diary 
summaries. If necessary a suitable transformation for potential skewness in the distributions of 
measured responses or heterogenous variation among treatment groups may be used (e.g., ANCOVA 
on ranks or square root, transformed stool frequency.) 
If the ANCOVA test for overall treatment effects for a given response has  a p value less than or 
equal to 0.10, then both the 15 mg and 20 mg doses will be compared to placebo using Dunnett’s test. 
Since each of the primary endpoints assesses a separate hypothesis regarding the effects of A3309, no 
adjustment in the alpha level for testing multiple types of endpoints is anticipated, and a two-sided 
significance level of 0.05 will be used in each ANCOVA model.  
Statistical Power 
 
Based on data acquired using the same methods in the laboratory, the sample size of 12 patients per 
group provides 80% power to detect differences of approximately 27% to 37%  in colonic transit, the 
primary endpoints.  This magnitude of change is considered clinically significant. 
 
Pharmacokinetic and Pharmacodynamic analyses 
Plasma concentration of A3309 vs time curves will be plotted for each subject, on both linear/linear 
and log10/linear scales. Mean plasma concentration vs time curves will also be presented by dose, PK  
and PD parameters.. Exploratory analyses of the PD variables will be conducted and described in the 
Statistical Analysis Plan (SAP).  

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Efficacy analyses 
Exploratory analyses of the efficacy variables will be conducted and described in the Statistical 
Analysis Plan (SAP).  
 
Analysis data sets  
The primary analyses will follow the intent to treat (ITT) paradigm with all patients randomized 
included in the analyses. Those patients with missing response values will have their missing values 
imputed via the overall (patients with non-missing data) mean and a corresponding adjustment in the 
ANCOVA residual error variance degrees of freedom (subtracting one for each missing value 
imputed). 
Safety data will be presented for all patients receiving investigational product. 
 
3 
TABLE OF CONTENTS 
 
 
STUDY TITLE
 
 ....................................................................................................................................... 1
2 
PROTOCOL SYNOPSIS
 
 ..................................................................................................... 2
3 
TABLE OF CONTENTS
 
 ..................................................................................................... 5
4 
ABBREVIATIONS AND TERMS
 
 ...................................................................................... 8
5 
ETHICS
 
 ................................................................................................................................. 9
5.1 
Ethical review
 
 ..................................................................................................................... 9
5.2 
Ethical conduct of the study
 
 ............................................................................................... 9
5.3 
Patient information and consent
 
 ......................................................................................... 9
5.4 
Patient data protection
 
 ...................................................................................................... 10
5.5 
Risks and Precautions
 
 ....................................................................................................... 10
6 
INVESTIGATOR(S) AND STUDY ADMINISTRATIVE STRUCTURE
 
 ................... 11
6.1 
Signature page
 
 .................................................................................................................. 13
7 
INTRODUCTION
 
 .............................................................................................................. 14
7.1 
Background
 
 ...................................................................................................................... 14
7.2 
Current Approaches to Treatment of Constipation and C-IBS
 
 ......................................... 14
7.3 
Natural Laxation by Endogenous Bile Acids
 
 ................................................................... 14
7.4 
Safety of Delivering Higher Concentrations of Bile Acids to the Colon in  Humans
 
 ...... 15
7.5 
Unmet Clinical Need and Potential Indications for a A3309
 
 ........................................... 15
8 
DESCRIPTION OF A3309
 
 ................................................................................................ 15
8.1 
Chemistry
 
 ......................................................................................................................... 15
8.2 
Pharmacology
 
 ................................................................................................................... 16
8.3 
Safety Pharmacology
 
 ........................................................................................................ 18
8.4 
Pharmacodynamics in Animals
 
 ........................................................................................ 19
8.5 
Pharmacokinetics and drug metabolism in animals
 
 ......................................................... 19

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8.6 
Toxicology and Safety Pharmacology
 
 .............................................................................. 20
8.7 
Reproductive Toxicology
 
 ................................................................................................. 21
8.8 
Effects in Humans
 
 ............................................................................................................ 21
9 
STUDY AIMS AND ENDPOINTS
 
 ................................................................................... 23
9.1 
Aim
 
 ................................................................................................................................... 23
9.2 
Primary endpoint:
 
 ............................................................................................................. 23
9.3 
Secondary endpoints:
 
 ....................................................................................................... 23
10 
RESEARCH DESIGN AND METHODS
 
......................................................................... 23
11 
OVERALL STUDY DESIGN AND SCHEDULE OF EVENTS
 
 ................................... 23
11.1 
Study Design
 
 .................................................................................................................... 23
11.2 
Schedule of events
 
 ............................................................................................................ 24
11.3 
Schedule of Visits
 
 ............................................................................................................. 25
12 
RATIONALE FOR STUDY DESIGN
 
 .............................................................................. 27
12.1 
Strengths and limitations
 
 .................................................................................................. 27
12.2 
Anticipated results and significance
 
 ................................................................................. 28
12.3 
Feasibility and timeframe
 
 ................................................................................................. 28
12.4 
Selection of study population
 
 ........................................................................................... 28
13 
INCLUSION CRITERIA
 
 .................................................................................................. 28
14 
EXCLUSION CRITERIA
 
 ................................................................................................. 29
15 
GENDER/MINORITY MIX
 
 ............................................................................................. 29
16 
RESTRICTIONS
 
 ................................................................................................................ 30
17 
STUDY WITHDRAWAL
 
 .................................................................................................. 30
18 
SCREENING AND ENROLLMENT LOG
 
 ..................................................................... 30
19 
INVESTIGATIONAL PRODUCT
 
 ................................................................................... 30
19.1 
Packaging, labeling and storage of Investigational Product
 
 ............................................. 30
19.2 
Doses and treatment regimens
 
 .......................................................................................... 31
19.3 
Product accountability
 
 ...................................................................................................... 32
20 
RANDOMIZATION METHODS
 
 ..................................................................................... 33
20.1 
Blinding
 
 ............................................................................................................................ 33
20.2 
Emergency decoding of blinded treatment
 
 ....................................................................... 33
20.3 
Prior and concomitant therapy
 
 ......................................................................................... 33
20.4 
Continuation of treatment
 
 ................................................................................................. 33
20.5 
Treatment Compliance
 
 ..................................................................................................... 33
21 
STUDY ASSESSMENTS
 
 ................................................................................................... 33
21.1 
Demographics
 
 ................................................................................................................... 33
21.2 
Clinical efficacy assessments
 
 ........................................................................................... 33
21.3 
Laboratory safety assessments
 
 ......................................................................................... 34
21.4 
Clinical safety assessments
 
 .............................................................................................. 35

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22 
ADVERSE EVENTS
 
 .......................................................................................................... 35
22.1 
Definitions
 
 ........................................................................................................................ 35
22.2 
Evaluations
 
 ....................................................................................................................... 36
22.3 
Reporting of SAEs
 
............................................................................................................ 37
22.4 
Exceptions from expedited reporting of SAEs
 
 ................................................................. 37
22.5 
Follow-up period after an AE
 
 ........................................................................................... 37
22.6 
Procedures in case of pregnancy
 
 ...................................................................................... 37
22.7 
Procedures in case of overdose
 
......................................................................................... 38
23 
DATA QUALITY ASSURANCE
 
 ...................................................................................... 38
23.1 
Monitoring and auditing procedures
 
 ................................................................................ 38
23.2 
Case Report Forms (CRFs)
 
 .............................................................................................. 38
23.3 
Source Data
 
 ...................................................................................................................... 39
23.4 
Training of study staff
 
 ...................................................................................................... 39
24 
STATISTICAL METHODS
 
 .............................................................................................. 39
24.1 
Statistical considerations
 
 .................................................................................................. 39
24.2 
Analysis data sets
 
 ............................................................................................................. 40
24.3 
Demographics
 
 ................................................................................................................... 40
24.4 
Analysis of efficacy
 
 .......................................................................................................... 40
24.5 
Transit data analysis
 
 ......................................................................................................... 40
24.6 
Stool frequency and stool consistency
 
 ............................................................................. 41
24.7 
Analysis of pharmacokinetic and pharmacodynamic data
 
 ............................................... 41
24.8 
Analysis of safety
 
 ............................................................................................................. 41
24.9 
Assessment of sample size
 
 ............................................................................................... 42
24.10 
Data Management
 
............................................................................................................. 42
24.11 
Changes in the approved study protocol
 
 .......................................................................... 42
25 
EMERGENCY PROCEDURES
 
 ....................................................................................... 43
25.1 
Emergency contacts
 
 .......................................................................................................... 43
25.2 
Procedures in case of medical emergency
 
 ........................................................................ 43
26 
STUDY TIME TABLE
 
 ...................................................................................................... 43
27 
DISCONTINUATION OF THE STUDY
 
 ......................................................................... 43
28 
FINAL STUDY REPORT AND PUBLICATION OF STUDY RESULTS
 
 .................. 43
29 
RECORD RETENTION
 
 .................................................................................................... 43
30 
DISCLOSURE AND CONFIDENTIALITY
 
 ................................................................... 44
31 
INSURANCE/INDEMNITY
 
 ............................................................................................. 44
32 
STUDY AGREEMENTS
 
 ................................................................................................... 44
33 
REFERENCES
 
 ................................................................................................................... 44
34 
APPENDICES
 
 .................................................................................................................... 46
34.1 
Study Flow Chart
 
.............................................................................................................. 46

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34.2 
Bristol Stool Scale
 
 ............................................................................................................ 48
34.3 
Laboratory Test Panels
 
 ..................................................................................................... 50
34.4 
Patient informed consent form
 
 ......................................................................................... 52
34.5 
Patient bowel pattern diary
 
 ............................................................................................... 62
34.6 
Survey of Constipation Symptoms and Treatment Efficacy
 
 ............................................ 63
34.7 
Protocol amendment 1: List of changes
 
 ........................................................................... 71
             
4 
 ABBREVIATIONS AND TERMS 
Abbreviation/Term  
Definition  
A3309 
Investigative drug substance code 
A3309-14
Carbon-labeled drug substance 
C 
AE 
Adverse event 
ALT 
Alanine aminotransferase 
ANCOVA 
Analysis of covariance 
ANOVA 
Analysis of variance 
AP 
Alkaline phosphatase 
aPPT 
Activated partial thromboplastin time 
AST 
Aspartate aminotransferase 
BM 
Bowel movement: A single defecation event with a beginning and end (as 
interpreted by the patient), which may include single or multiple stools. 
BMI 
Body mass index 
bp 
Blood pressure 
C4 
7α-hydroxy-4-cholesten-3-one 
CIC 
Chronic idiopathic constipation 
C
Maximum plasma concentration observed post-dose 
max 
CRO 
Contract research organization 
CSBM 
Complete spontaneous bowel movement: A spontaneous bowel movement 
that is accompanied by the patient reporting a feeling of 
complete evacuation. 
CV 
Cardiovascular   
CYP
Cytochrome P
450 
ECG 
450 
Electrocardiogram  
GCP 
Good Clinical Practice 
GI 
Gastrointestinal 
HbA
Glycosylated hemoglobin 
1c 
IB 
Investigator’s Brochure 
IBAT 
Ileal bile acid transporter 
IBS 
Irritable bowel syndrome 
IC
Concentration for 50% inhibition of the effect 
50 
ICF 
Informed consent form 

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Abbreviation/Term  
Definition  
IRB 
Institutional Review Board 
ITT 
Intent to treat analysis 
i.v. 
Intravenous 
LDL-C 
Low density lipoprotein cholesterol 
NOAEL 
No observed adverse effect level 
NOEL 
No observed effect level 
PD 
Pharmacodynamic 
PK 
Pharmacokinetic 
SAE 
Serious adverse event 
SBM 
Spontaneous bowel movement: A bowel movement that occurs in the 
absence of a laxative/enema use or manual disimpaction. For the purpose 
of this protocol, bowel movements that occur within 24 hours of 
laxative/enema use will not be considered spontaneous bowel movements. 
SAP 
Statistical Analysis Plan 
t
Half-life 
½ 
t
Time to maximum observed plasma concentration  
max 
 
5 
ETHICS 
5.1 
 Ethical review 
Necessary approvals of the study protocol and the informed consent form (ICF) must be obtained before 
enrollment of any patient into the study. It is the responsibility of the Principal Investigator (PI) to keep 
the Institutional Review Board (IRB) informed of any Serious Adverse Events (SAEs) and any substantial 
amendments to the protocol during the study period.  
The written approval from the IRB, including study identification and the date of review will be filed at 
the study site together with a list of the IRB members, their titles or occupation, and their institutional 
affiliations. All correspondence with the IRB should be filed both at the Sponsor and at the study site. 
5.2 
Ethical conduct of the study 
The study will be performed in accordance with the recommendations guiding physicians in biomedical 
research involving human subjects that were adopted in 1964 by the 18th World Medical Assembly, in 
Helsinki, Finland, with later revisions. 
5.3 
Patient information and consent 
Informed consent will be obtained by the Investigator or study coordinator following both a review of the 
written ICF and a conversation outlining the risks, benefits, and goals of the investigation.  The patient 
will be informed about the right to withdraw from the study at any time and should be allowed sufficient 
time for consideration of the proposal. Documentation will be recorded with signatures of the study 
participant and the individual obtaining consent (on the standard informed consent document) before any 
study-specific procedures are performed, including screening procedures. 

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The official Mayo IRB reviewed and approved version of the ICF must be used to obtain and document 
patient consent.  The ICF must not be changed without permission from the sponsor Albireo AB and 
subsequent review and approval by Mayo IRB. 
5.4 
Patient data protection 
The Investigator must file a patient identification list which includes sufficient information to link 
records, i.e. the Case Report Form (CRF) and the electronic medical record (EMR). This list will be 
preserved for possible future inspections/audits but should not be made available to the Sponsor except 
for monitoring or auditing purposes. 
All data retrieved during the study will be used specifically for research purposes.  Results will be 
maintained in Excel spreadsheets and SAS datasets stored electronically and will be password protected.  
Mayo Clinic IRB guidelines for anonymizing data will be strictly adhered to.  Only de-identified data will 
be permitted to be sent outside of Mayo Clinic.  The ICF specifies that authorized representatives from 
the Sponsor, the IRB, FDA and other regulatory authorities will be granted access to the patient’s medical 
record in a limited capacity for the purpose of verification of clinical study procedures. 
5.5 
Risks and Precautions 
Data from two prior phase I studies using up to 5 mg in healthy volunteers and up to 10 mg in patients 
with functional constipation suggest that the study medication is well tolerated. In 26 normal healthy 
volunteers, the adverse events observed were: flatulence (27 percent), abdominal distension (19 percent), 
abdominal pain and nasopharyngitis (12 percent each), and diarrhea, nausea and headache, (2 percent 
each). In 25 constipation patients, the adverse events observed were: abdominal distension, nausea and 
headache (8 percent each). There was no relation of AEs to the dose levels tested. Further information is 
available in the Investigator´s Brochure Section 6.1 
A Data Safety Monitoring Plan (DSMP) for this study has been established in accordance with 
recommendation by the Mayo IRB and CRU.  We justify the proposal on the following rationale, that the 
study involves the use of radiation that is within limits permissible for patients with functional 
constipation. The study drug safety to date in healthy volunteers and patients with constipation has been 
excellent. 
Radiation exposure in this study comes from the 99mTc and 111
 
In used to measure gut transit. These 
exposures conform to previously approved levels of radiation exposure approved by the Radiation Safety 
Committee at Mayo Clinic. The radiation dosimetry and organ exposures (in mrad) are listed below: 
TRANSIT SCINTIGRAPHY 
Radiopharmaceutical 
Activity mCi 
Body 
Gonads 
Breast 
Red marrow 
Lung 
Thyroid 
111InCl
0.1 
3 
20 
140 
 
20 
 
 
99m
1.0 
Tc sulfur 
20 
90 
 
20 
 
 
 
Radiopharmaceutical 
Bone 
ULI 
Colon 
Stomach 
Bladder 
Liver 
Esophagus 
Other 
111InCl
 
3 
380 
740 
60 
40 
10 
 
160 
99m
 
Tc sulfur 
420 
300 
130 
20 
10 
 
220 
(mrad=radiation absorbed dose to organs) 
 

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He 
 
or the radiation effective dose to the body summarizes the risk to the whole body as the individual 
doses to each of the organs; effective dose is used to compare risks among various types of x-ray and 
radionuclide studies: 
111InCl
  0.1 mCi   
3 
He     142 mrem 
99mTc sulfur colloid
  1.0 mCi    
    
He        
 
90  mrem 
(mrem= radiation equivalent dose) 
 
In summary, A3309 has a good safety profile, and the most commonly reported adverse events (AEs) in 
previous studies have been of gastrointestinal origin presumably reflecting the Mechanism of Action of 
A3309 and the subject cohort studied.  The risks to the participants are reasonable since most procedures 
are noninvasive and there is no obvious risk of any significant morbidity or mortality.  
6 
INVESTIGATOR(S) AND STUDY ADMINISTRATIVE STRUCTURE 
The study will be performed at the Division of Gastroenterology and Hepatology at the Mayo Clinic in 
Rochester, Minnesota. The study will be conducted under an Albireo sponsored IND, IND number  
103,060 and the Investigational Product (IP) will be provided by Albireo.  
 
Sponsor 
Albireo AB 
Arvid Wallgrens Backe 20 
413 46 Goteborg, Sweden 
 
Responsible Medical Officer 
Hans Graffner, MD  
Telephone: +46 31 741 1485 
email: hans.graffner@albireopharma.com 
CRO 
Icon 
 
Responsible Medical Officer 
Michael Gallagher, MD 
Office Phone Number 
215-616-3371 
Office Fax Number 
215-699-6288 
email: Michael.Gallagher@iconplc.com 
 
 
Project Manager, Clinical Operations 
Jeff White 
Office Phone Number 
312-706-6257 
Office Fax Number 
312-533-4442 
Email: Jeff.White@iconplc.com 
 
 
Study center 
Mayo Clinic 
Division of Gastroenterology and 
Hepatology 
Rochester Minnesota 
Principal Investigator 
Michael Camilleri, MD  
 
Co-investigators 
Maria Vazquez Roque, MD 
Banny Wong, MD 
Archana Rao, MD 
 
Study coordinators 

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Sanna McKinzie, MS 
Irene Busciglio, BS 
Deborah Eckert, RN 
 
 
Technicians 
Duane Burton 
Michael Ryks 
Sara Linker Nord, LPN 
 
Statistician/Co-investigator 
Alan R. Zinsmeister, PhD 
 
 
Laboratory analysis 
GI Physiology Core Laboratory at the Charlton 7 CRU, Mayo Clinic  
Pharmacokinetic analysis 
 
Pharmacodynamic analysis 
Covance 
Karolinska University Hospital 
SE-141 86 Huddinge, Sweden 
Manufacturer of Active 
Pharmaceutical Ingredient (API) 
Syngene International Ltd 
Biacon Park Plot no 2 &3 
Bommasandra IV Phase 
Jigani Link Road 
Bangalore 560 099 INDIA 
Packaging and labeling of API, 
IP quality control 
Galenica AB 
Medeon Science park 
SE-205 12 Malmo, Sweden 
Individual patient dose IP 
preparation, quality control and 
labeling 
Mayo Research Pharmacy 
 

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6.1 
Signature page 
 
Protocol 
A3309-003 
Title 
Effects of A3309, an Ileal Bile Acid Transport Inhibitor, on Gastrointestinal and Colonic  
 
Motor Functions in Female Patients with Functional Constipation 
 
Reviewed by the following: 
 
 
______________________________ 
 
 
_______________ 
 
Hans Graffner, MD 
 
 
 
             Date 
Chief Medical Office, 
Albireo AB 
 
 
______________________________ 
 
 
_______________ 
 
Michael Camilleri, MD 
 
 
 
             Date 
Principal Investigator, 
Mayo Clinic 
Division of Gastroenterology and Hepatology 
Rochester Minnesota 
 
 
 
______________________________ 
 
 
_______________ 
 
Jeff White 
 
 
 
             
             Date 
Project Manager, Clinical Operations 
ICON Clinical Research 
 
 
 
 
______________________________ 
 
 
_______________ 
 
Michael Gallagher, MD 
 
 
 
              Date 
Director, Medical Affairs 
ICON Clinical Research 
 
 

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7 
INTRODUCTION 
7.1 
   Background 
Constipation and C-IBS are very common clinical problems. A questionnaire study in Olmsted County, 
Minnesota demonstrated that up to 20% of patients report constipation (1) and up to 16% have some form 
of irritable bowel syndrome. Clinical practice suggests that patients transition between these two 
diagnoses, and it is also evident that the symptoms of these disorders overlap those of evacuation 
disorders such as pelvic floor dyssynergia. Thus, approximately 40% of patients with functional 
constipation have historical evidence of needing to strain excessively to pass bowel movements.  These 
features might suggest that they also have a component of an evacuation disorder, although the 
questionnaire-based data did not allow a sufficient distinction between an evacuation problem and slow 
transit constipation.  In a tertiary center study, 50% of 70 patients with severe, unresponsive constipation 
referred to a single gastroenterologist over a 3-year period had impaired evacuation, and the remainder of 
patients had either normal or slow transit constipation (2). Moreover, the cardinal "Manning" criterion of 
sense of incomplete rectal evacuation is conceivably a manifestation of a disturbance of rectal evacuation. 
In clinical practice, it is essential to identify the presence of an evacuation disorder, particularly since the 
management of constipation should be modified by its presence (3).  Biofeedback-based physical therapy 
is more effective than any other form of therapy when spastic pelvic floor disorders are identified.  
Therefore, patients with an evacuation disorder will be excluded from participating in this study. 
A subgroup of patients (3,4) has functional or chronic idiopathic constipation (CIC), in which there is no 
evacuation disorder and colonic transit is slow or normal, but is not accelerated at baseline.  This group of 
patients has a variable component of pain in association with constipation, and hence overlaps in time 
with C-IBS. 
The cause of abnormal colonic transit in functional constipation, CIC and C-IBS is still incompletely 
understood; over the last three decades, histological studies have suggested that there may be quantitative 
differences in the number of interstitial cells of Cajal (ICCs), substance P (excitatory nerves reduced) and 
VIP or nitrergic (inhibitory nerves increased) neurons in the myenteric plexus of resected specimens of 
colons from patients with severe constipation.  However, these results have not been consistently 
reported.   
 
7.2 
Current Approaches to Treatment of Constipation and C-IBS 
Patients with constipation tend to benefit from fiber, osmotic laxatives (magnesium salts, PEG 3350 
solutions), and stimulant laxatives (e.g., bisacodyl), although the efficacy of these in treatment of CIC, C-
IBS and functional constipation is limited, even with recently approved medications such as lubiprostone. 
Prokinetics such as tegaserod have been withdrawn from the market.  There is a spectrum of potential 
medications such as 5-HT4 agonists, and guanylate cyclase C agonists that are being tested but none are 
yet approved by the FDA. Given the fact that these conditions are not life-threatening, safety is of 
paramount importance and, hence, local activity within the gastrointestinal tract is beneficial in 
development of drugs for these indications. 
 
7.3 
Natural Laxation by Endogenous Bile Acids   
Bile acids have a variety of physiologic functions and are actively reabsorbed (up to 95%) in the terminal 
ileum (5). Disruption of the enterohepatic circulation of bile acids due to ileal disease (e.g., Crohn’s or 

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radiation ileitis) or idiopathic bile acid malabsorption (BAM) causes chronic diarrhea [see systematic 
summary (6)]. Conjugated and non-conjugated bile acids induce secretion in the human colon (7,8) by 
activating intracellular secretory mechanisms [e.g. adenylate cyclase (9)] or by detergent effects resulting 
in mucus secretion (10), increased mucosal permeability (11) and inhibition of apical Cl-/OH- exchange 
(12). In addition, bile acids may induce propulsive contractions in canine [>20mM (13)] and human colon 
[1mM (14) or 5mM (15)]. In humans, there is a relationship between the fecal bile acid excretion and 
colonic motility; however, this relationship is complicated by associated steatorrhea (15) since the 
delivery of fatty acids to the colon may also accelerate colonic transit (16). Bile acid concentration in 
stool of patients with ileal resection may reach 21mM chenodeoxycholate [CDC (17)].  However, fecal 
concentrations of bile acids in diarrhea-predominant irritable bowel syndrome (IBS-D) or functional 
diarrhea are unknown, and up-regulation of the ileal active transporter (18) as a result of chronic loss of 
bile acids may reduce the bile acids reaching the colon. In studies of gallstone dissolution with 750-
1000mg CDC per day (19), diarrhea occurred in 40% of patients (20). Therefore, an approach that results 
in the passage of higher concentrations of endogenous bile acids into the colon has the potential to 
provide a useful treatment for constipation and related conditions. Structure activity studies show that 
several primary and secondary bile acids are secretagogues in the mammalian colon (11).  
 
7.4 
Safety of Delivering Higher Concentrations of Bile Acids to the Colon in 
Humans 
The literature on gallstone dissolution shows that 37% of patients treated with typical CDC doses of 14-
15 mg per kg per day had effectively dissolved gallstones (21) and had hypertransaminasemia (within 3 
times upper limit of normal) in the first 6 months of treatment (22). On the other hand, doses of 7-20 mg 
CDC kg-1 day-1 were not hepatotoxic in humans (23). Among patients with gallstones treated with CDC 
(over 1000mg day-1 for several months), and patients who underwent partial ileal bypass for 
hyperlipidemia, there are no reports of colon cancer (24). 
 
7.5 
Unmet Clinical Need and Potential Indications for a A3309 
Given the insufficient efficacy of OTC agents for CIC, FC and C-IBS, an approach that results in the 
delivery of endogenous bile acids to the colon is an attractive way to relieve constipation, especially with 
a locally acting agent that inhibits reuptake of bile acids by the apical bile acid transporter in the ileum.  
Such an agent is A3309.  From an academic perspective, this study also provides the opportunity to prove 
the principle that endogenous bile acids are effective laxatives to normalize bowel function, and also they 
provide proof of concept that bile acid malabsorption may be very relevant (and therefore targets for 
therapy) for patients with chronic diarrhea.
 
     
 
8 
DESCRIPTION OF A3309 
8.1 
Chemistry 
A3309 is a stereochemically pure enantiomer with a molecular weight of 695.9 g/mol.  It is an acid with 
an acid dissociation constant (pKa) of approximately 4, the pH at which half of the molecules are ionized.  
As aqueous solubility is pH dependent, higher pH results in increased solubility. 
 

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The expected short half-life (t½
The molecular formula of A3309 is C
) of A3309 in humans is <4 hours.   
36H45N3O7S2
The chemical structure of A3309 is:  
. 
 
 
  
Bile acids are mainly absorbed by a specific ileal bile acid transporter in the ileum (IBAT) and are 
returned to the liver, completing enterohepatic circulation (25).  A3309 is a small molecule known to be 
an inhibitor of the IBAT that interrupts the enterohepatic circulation of bile acids by decreasing intestinal 
bile acid reabsorption, which results in an increased bile acid load to the colon.  This stimulates increased 
fluid secretion in the colon and colonic motility; both effects are expected to benefit patients with 
constipation (7).  Additionally, given the mode of action of A3309, beneficial effects on bile acid 
synthesis and cholesterol levels are anticipated (25). Bile acid reabsorption from the intestine is a very 
efficient process whereby 95% of the secreted bile acids are reabsorbed and IBAT, an integral brush 
border membrane glycoprotein that co-transports sodium and bile acid, appears to be a major regulator of 
the bile acid pool in animals and man. IBAT inhibitors prevent the reabsorption of bile acids from the 
ileum and their return to the liver.  The liver compensates for this decrease in bile acid level by 
upregulating cholesterol 7α-hydroxylase, the rate-limiting enzyme for bile acid synthesis(26, 27).
8.2 
Pharmacology 
  
 
A3309 is a small molecule known to be an inhibitor of the ileal bile acid transporter (IBAT), [synonym: 
Apical sodium dependent bile acid transporter (ASBT)]. It has previously been evaluated for the 
treatment in dyslipidemia and is currently being evaluated for the treatment of constipation. The expected 
short half-life (t½
 
) of A3309 in humans is <4 hours.   
Non-clinical studies 
 
 
The species and strains of the animals used in the studies are presented in Table 1.   
 
Table 1. 
The species and the strains used in the pharmacology, pharmacokinetic and 
toxicology evaluations of A3309 
Species 
Strain 
Type of study 
Rat 
Wistar 
Toxicology Safety Pharmacology 
Rat 
Long Evans black hooded 
Quantitative whole body autoradiography (QWBA) 
Dog 
Rabbit 
Beagle 
New Zealand White 
Toxicology. Primary and Safety Pharmacology 
Reproductive toxicity 

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Species 
Strain 
Type of study 
Mouse 
CD1 
Toxicology 
Mouse 
ApoE knock out 
Pharmacology 
Mouse 
ApoE/LDL-receptor knock out 
Pharmacology 
Guinea pig 
Duncan Hartley 
Safety Pharmacology 
 
 
Non-Clinical Pharmacology 
 
Table 2. 
Primary pharmacology 
Effect studied 
Species (sex) 
No of 
animals 
Admin. 
route 
Duration of 
treatment 
Doses mg/kg 
(µmol/kg) 
Effect on bile acid 
absorption 
Mouse (F) 
3 
Oral 
Single 
0.11, 0.43, 1.7 (0.16, 
0.63, 2.5) 
Duration of action 
Mouse(F) 
3-4 
Oral 
Single  
1.7 (2.5) 
Effect on cholesterol 
lowering 
Mouse (F) 
7 
Oral 
7 days 
1.7, 7 (2.5, 10) 
Effect cholesterol 
metabolism 
Rat (M&F) 
3
Oral 
a 
28 days 
3.5, 35, 350 (5, 50, 
500) 
Effect cholesterol 
metabolism 
Dog (M&F) 
3
Oral 
a 
28 days 
 
3.5, 17, 140 (5, 25, 
200) 
Inhibition of bile acid uptake 
in HEK293 cells 
Effect on constipation 
Human, mouse 
and canine IBAT 
Dog (M&F) 
3
 
b 
28 
In vitro 
 
Oral 
 
 
3 days 
 
 
1, 3.5, 10, 35 (1.5, 5, 
15, 50) 
a  number of animals sampled at each time point at each dose level each day of exposure monitoring, 
for rats satellite groups were used (one month study) 
 
b
 
M=male F=female 
  No. of experiments. 
 
 
A3309 is a potent inhibitor of the ileal bile acid transporter in human, mouse and canine IBAT-transfected 
cells as demonstrated by inhibition of bile acid uptake in this cell model (IC50
 
=0.53, 0.13 and 5.8 nM 
respectively). 
Orally administered A3309 showed a dose-dependent inhibitory effect on the intestinal bile acid 
absorption in mouse with an ED50
 
 value of 0.3 mg/kg. Moreover, A3309 showed a dose-dependent 
reduction (maximal effect 38%) of plasma cholesterol in the ApoE/LDLr KO mouse (transgenic mouse 
model showing a human-like lipoprotein profile). The cholesterol reduction was seen within the 
chylomicron/VLDL and LDL-fractions, whereas HDL-cholesterol fraction was increased. 
The pharmacodynamic effect of A3309 was investigated in the one-month toxicity studies in rat and in 
dog by measuring the plasma concentration of 7α-hydroxy-4-cholesten-3-one (C4), a biomarker for bile 
acid synthesis. An increase of C4 in plasma was observed already after single doses in the dog. A dose 
dependent increase of C4 was observed in dog (3 to 7 times) and in rat (5 to 8 times) after the one month 
treatment period. 
 
The effects of A3309 on GI motility and feces output were investigated in constipated beagle dogs. An 
increase in feces output was identified already at the lowest dose (1 mg/kg) tested and the magnitude of 
increase was similar to administration of tegaserod (0.3 mg/kg); a reference substance with known effects 
on GI motility in man. It was concluded that A3309 ameliorate meat-induced constipation in dogs. 

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The predicted therapeutic oral dose in man for A3309 is approximately 10 mg but, given scarcity of data, 
may be within the range of 5 to 20 mg, calculated from in vitro potency in human IBAT transfected cells 
and the in vitro and in vivo potency in mouse, dog and in man and from the results of the studies in 
healthy volunteers and in patients with chronic idiopathic constipation.  
 
8.3 
Safety Pharmacology 
 
Table 3. 
Overview of safety pharmacology studies 
Effect studied 
Species 
(sex) 
No. of 
animals 
Admin. 
route 
Duration of treatment 
Doses mg/kg (µmol/kg) 
Cardiovascular function 
Guinea pig 
(M) 
4 
i.v. 
Single 
0.070, 0.41, 1.1, 2.5 
(0.1, 0.6, 1.6, 3.6) 
Motor coordination 
Rat (M) 
10 
Oral 
Single 
3.5, 35, 350  (5, 50, 500)  
Locomotor activity 
Rat (M) 
8 
Oral 
Single 
3.5, 35, 350  (5, 50, 500)  
Irwin test, body 
temperature 
Rat (M) 
8 
Oral 
Single 
3.5, 35, 350  (5, 50, 500)  
Hemodynamics and ECG 
Dog (F) 
6 
i.v. 
Bolus followed by 
infusion
0.0035, 0.035, 0.35, 3.5  
a 
(0.005, 0.05, 0.5, 5)  
Cardiovascular function 
Rat (M) 
8 
Oral 
Single 
3.5, 35, 350 (5, 50, 500) 
Respiratory function 
Rat (M) 
8 
Oral 
Single 
3.5, 35, 350 (5, 50, 500) 
Intestinal transit 
Rat (M) 
8 
Oral 
Single 
3.5, 35, 350 (5, 50, 500) 
Renal function 
Rat (M) 
8 
Oral 
Single 
3.5, 35, 350 (5, 50, 500) 
Effect on potassium 
channel 
hERG 
assay on 
human 
cells 
6
In vitro 
b 
 
0.70 (1)  
Enzymatic and binding 
assays 
Tissue 
models 
3
In vitro 
 b 
 
0.070, 0.70, 7.0, 70 
(0.1, 1, 10, 100) 
a 
Cumulative dose during 30 min 
b
 
  
No. of experiments 
 
Table 4. 
Plasma concentrations of A3309 (nmol/L). Compiled data from all safety pharmacology 
studies conducted in rat 
Dose  
mg/kg 
(µmol/kg)  
Sampling time post dose (hours) 
po 
1 
1.5 
2 
3 
4 
6 
24 
30 
 
(n=3) 
(n=8) 
(n=3) 
(n=6) 
(n=11) 
(n=9) 
(n=32) 
(n=8) 
3.5 (5) 
26.0±3.0 
40.6±19.5 
20.7±5.6 
12.2±6.1 
6.8±2.1 
4.0±1.9 
nc 
Nc 
35 (50) 
198±90 
145±82 
103±20 
51.4±18.4 
67.7±20.0 
31.8±9.5 
6.4±8.0 
Nc 
350 (500) 
471±182 
496±127 
671±212 
284±90 
284±124 
246±100 
30±34 
7.1±10.4 
Nc = Not calculated, no mean was calculated if more than 40% of the concentrations were below LOQ. Mean 
values ± SD. 

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At the doses of A3309 studied in the rat, no evidence was found for any biologically relevant 
interaction with the central nervous system, respiratory function and there were no effects on arterial 
blood pressure, heart rate and body temperature observed. The only significant effect observed was on 
renal function (decrease in urinary excretion of sodium and increase in urinary concentration of urea) and 
on gastrointestinal motility (decreased) after the highest dose (350 mg/kg) given, which is more than 1000 
times higher than predicted dose in man. 
 
A3309 intravenously infused in the anesthetised dog at the doses of 0.0035, 0.035, 0.35, 3.5 
mg/kg did not cause any pharmacologically relevant action on cardiovascular parameters. The only 
statistically significant change was a slight decrease in mean coronary blood flow and increase in 
coronary resistance. However, in the absence of any other hemodynamic effects, even at plasma 
concentration of 10,000 nmol/L, the effect on coronary flow is considered to be of no biological 
significance. 
 
In addition, no cardiovascular effects were observed in the three-month toxicity study in dog 
at doses up to 140 mg/kg (520 times a human dose of 20 mg). A3309 had low effect in vitro in a variety 
of tissue models, enzyme/binding assay and on the hERG potassium channel; IC50 > 2000 fold higher 
than IC50 in the human IBAT transfected cell assay. 
 
8.4 
Pharmacodynamics in Animals 
 
A3309 is an inhibitor of the ileal bile acid transporter in human, mouse and canine IBAT-transfected 
cells. 
 
Orally administered A3309 showed a dose-dependent inhibitory effect on the intestinal bile acid 
absorption in mouse with an ED50 value of 0.3 mg/kg and a dose-dependent reduction (maximal effect 
38%) of plasma cholesterol in a transgenic mouse model showing a human-like lipoprotein profile. 
 
After oral administration of A3309,  a dose dependent increase in plasma of 7α-hydroxy-4-cholesten-3-
one (C4), a biomarker for bile acid synthesis, was observed in dog (3 to 7 times) and in rat (5 to 8 times).  
 
In a study of the effects of A3309 on feces output in a dog model of meat-induced constipation, animals 
were dosed orally once daily for 3 days at 1.5, 5, 15, or 50 μmol/kg or  with tegaserod (a compound 
previously used to treat constipation in humans) at dose levels of  0.3, 1.0, 66 μmol/kg. A3309 
ameliorates meat-induced constipation in dogs already at the dose of 1.5 μmol/kg, with a statistically 
significant effect at a dose of 15μmol/kg. Tegaserod also reversed constipation in this dog model 
validating the method.The predicted therapeutic oral dose in man for A3309 is in the range of 5 mg to 20 
mg with a predicted therapeutic target dose of approximately 10-15 mg/day, calculated from in vitro 
potency in human IBAT transfected cells and the in vitro and in vivo potency in mouse, dog, 
gastrointestinal effects on motility in healthy volunteers and in patients with chronic idiopathic 
constipation. 
 
8.5 
Pharmacokinetics and drug metabolism in animals 
 
Orally administered A3309 appears to be minimally absorbed from the gastrointestinal tract. Following an 
oral dose of A3309-14C, most of the dose was found in the stomach and intestine and no radioactivity 
was detected in the blood in an autoradiography study in rats. The oral bioavailability in the dog was only 

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2%. Cmax is generally reached within 2 hours after oral administration to rat and dog and is eliminated 
from plasma with a half-life < 2 hours.  
 
A3309 is highly bound to plasma proteins, >99.5%. The tissue distribution of A3309-14C    was limited 
after an oral dose, and the radioactivity was rapidly eliminated; 24 hours after dose, compound related 
material was only seen in the gastrointestinal tract. 
 
Upon repeated oral dosing of A3309 there is no evidence of time dependence or accumulation in either rat 
or dog. The exposure increased proportional with dose except at the highest doses in the toxicity studies, 
where the exposure increased more than dose proportional in the rat (AUC) while less than dose 
proportional in the dog.  
 
A3309 does not inhibit heterologously expressed human CYP1A2, CYP2C19 and CYP2D6 up to 20 µM. 
It inhibits CYP2C9 and CYP3A4 exhibiting IC50 values of 10.3 and 6.0 µM respectively. That the 
absorption of A3309 is low indicates a low risk of drug-drug interactions with these enzymes after oral 
dosing.  
 
8.6 
Toxicology and Safety Pharmacology 
 
At the doses of A3309 in the safety studies (3.5-350 mg/kg) in the rat, no evidence was found for any 
biologically relevant effect on central nervous system and respiratory function and there were no effects 
on arterial blood pressure, heart rate or body temperature. The only significant effect observed was on 
renal function (decrease in urinary excretion of sodium and increase in urinary concentration of urea) and 
on gastrointestinal motility (decreased) after the highest dose (350 mg/kg) given, which is more than 1000 
times higher than a clinical dose of 20 mg. A3309 intravenously infused in the anesthetised dog at the 
doses of 0.0035, 0.035, 0.35 and 3.5 mg/kg did not cause any pharmacologically relevant action on 
cardiovascular parameters. The only statistically significant change was a slight decrease in mean 
coronary blood flow and increase in coronary resistance.  However, in the absence of any other 
hemodynamic effects, even at plasma concentration of 10,000 nmol/L, the effect on coronary flow is 
considered to be of no biological significance. 
 
The acute toxicity of A3309 is considered to be low after oral administration. The minimum lethal dose 
after oral administration in rats and mice is >2000 mg/kg.  Dogs were given single oral ascending doses 
of A3309 at 8.4, 17, 35, 70 and 140 mg/kg. The animals were necropsied 14 days after completion of 
dosing.  Clinical signs observed after treatment were loose stool, diarrhea and emesis. The frequency and 
severity increased with dose starting at 17 mg/kg. There were no histopathology changes that could be 
attributed to A3309. 
 
In a preliminary rat study, enteritis of the caecum was observed in most animals dosed at 200 or 1000 
mg/kg for 7 days. However, the toxicological significance of this finding is unclear since rats dosed with 
up to 350 mg/kg/day of A3309 for one or three months showed no effects in the gastrointestinal tract. 
 
In both the one- and the three-month toxicity study in rats, groups of 10 males and 10 females were given 
A3309 orally once a day at 0, 3.5, 35 and 350 mg/kg for 28 days and 13 weeks respectively. None of the 
changes seen in A3309-treated rats were considered to be of toxicological significance. NOAEL (no 
observable adverse effect level) in rats was at least 350 mg/kg/day in both studies.  
 
In a one-month toxicity study in dogs, groups of 3 males and 3 females were given A3309 orally once 
daily for 28 days at 0, 3.5, 17 and 140 mg/kg/day. The only blood chemistry change considered 

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noteworthy at these dose levels was a slightly reduced level of plasma triglycerides. For all other 
parameters, including histopathology, there were no toxicologically significant, treatment-related 
changes.  Based on the findings of emesis and soft/fluid feces at 17 and 140 mg/kg the NOAEL in dogs 
was considered to be 3.5 mg/kg/day. However, excluding these signs of mild gastrointestinal intolerance 
there were no effects of toxicological significance at doses up to and including 140 mg/kg. 
In a three-month toxicity study in dogs, groups of 4 males and 4 females were given A3309 orally once 
daily for 13 weeks at 0, 3.5, 17.5 and 140 mg/kg/day. Dose related liquid feces were seen in all groups 
treated with A3309. An increase in liver weight and minor changes in red blood cell parameters at high 
dose was not considered toxicologically significant. NOAEL for males was 140 mg/kg/day but in females 
17.5 mg/kg/day based upon emesis occurring at the higher dose.  
Thus, the main target organ for A3309 in the toxicology studies appears to be the gastrointestinal tract. It 
is most likely that the effects seen in the gastrointestinal tract are related to the pharmacological activity 
of A3309, e.g. increased colon motility. Based on the available toxicological documentation, it is 
concluded that A3309 can be given orally to man up to three months of duration in the proposed clinical 
trials with sufficient safety. 
8.7 
Reproductive Toxicology 
No adverse effects on fertility or embryo-fetal development were seen in the repro-toxicity studies in rat 
and rabbit. The doses of A3309 used exceeded a clinical dose of 20 mg by about 600- 4000 fold. In a 
fertility and embryo-fetal study in rats, groups of 22 males and 22 female rats were given A3309 at 0, 
175, 350 or 1000 mg/kg/day for 2 weeks prior pairing and continued until day 17 (females) and day 20 
(males) of gestation. The NOAEL was 1000 mg/kg/day. In an embryo-fetal study in rabbits, groups of 24 
mated females were given daily oral doses of A3309 at 0, 20, 55 and 150 mg/kg/day from day 7 to day 19 
of gestation. The NOEL was 150 mg/kg/day.  
8.8 
Effects in Humans 
There have been two main studies to date in humans: a single and repeated-dose, single-blind, 
randomized, placebo-controlled, Phase I study to assess the tolerability, safety and pharmacokinetics of 
A3309 after single escalating oral doses and repeated doses in healthy male subjects (D1240C00001)  
1. The single doses were 0.1, 0.5, 2.5 and 5 mg. The repeated dose was 0.25 mg daily for seven days. In 
total, 38 subjects were randomized; thirty subjects to single doses of A3309 or placebo and eight subjects 
to repeated doses or placebo. Tolerability was monitored by global physical examination, 12-lead ECGs, 
safety laboratory assessments and recording of adverse events. In addition, specific evaluation of 
gastrointestinal symptoms (Gastrointestinal Symptom Rating Scale – GSRS), bowel movement frequency 
and stool consistency were evaluated. Pharmacodynamic markers of dyslipidemia and bile acid synthesis 
evaluated were campesterol/sitosterol, lanosterol and 7α-hydroxy-4-cholesten-3-one (C4). No effect on 
lipid profiles was noted. However, this is not expected after a single dose. There was an effect on C4 in 
the 2.5 and 5 mg single dose cohorts. Pharmacokinetic samples were scheduled throughout the 24 hour 
observation period in the single dose groups. No measurable plasma or urine concentrations of A3309 
were detected; neither in the single ascending dose part (up to and including 5 mg) or in the multiple dose 
group (0.25 mg daily for seven days). In 26 normal healthy volunteers, the adverse events observed were: 
flatulence (27 percent), abdominal distension (19 percent), abdominal pain (12 percent), and diarrhea, 
nausea and headache, (2 percent each).Adverse events, other than gastrointestinal problems, were few and 
in most cases mild in intensity and did not cause any reason for concern. One 25 year old male developed 
bloating, passage of mucus and had proctitis on colonoscopy 6 weeks later. There were no clinically 
relevant changes in clinical chemistry, hematology, coagulation, vital signs, weight, ECG, physical 
observations, GSRS, or stool appearance during the study. 

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2. A double-blind, randomized, placebo-controlled, phase Ib, dose-escalating study to assess the safety, 
tolerability and systemic exposure of A3309 capsules after repeated once daily administration to patients 
with chronic idiopathic constipation (Study A3309-001). Eligible patients should have had at least a 12 
month history of constipation (defined as < 3 BMs per week) with symptoms and no more than 5 
spontaneous complete bowel movements (SCBMs) during the 14 days preceding randomization. The 
initial screening evaluation included flexible sigmoidoscopy, colon transit measurement and a 14 day 
period to evaluate frequency of BMs and to calculate baseline data for GI symptoms. The primary 
objective of this study was to assess the safety and tolerability of A3309 after repeated oral doses to 
patients with chronic idiopathic constipation (CIC). Secondary objectives of the study were to assess: 1/ 
changes in (SCBM) and Bristol Stool Form score after repeated oral doses of A3309, 2/ to investigate 
colon transit and systemic availability of A3309 during escalating oral repeated doses and 3/ to evaluate 
the effect of A3309 by analysis of plasma glucose or HbA1c, triglycerides (TG), plasma lipid parameters, 
FGF19, FGF21 and C4. Patients were randomized in a 5:1 ratio to receive one of five sequential dose 
levels (0.1 mg, 0.3 mg, 1.0 mg, 3.0 mg or 10 mg) of A3309 or placebo, orally administered. A blinded 
safety assessment was performed between each dose level. The safety evaluation do not indicate any 
apparent effects on physical examination findings, vital signs, safety laboratory or 12-lead ECGs and no 
serious adverse events were reported. In 25 constipation patients, the adverse events observed were: 
abdominal distension, nausea and headache (8 percent each). The small number of subjects and events do 
not permit conclusions about any difference between groups in the nature, severity or incidence of 
adverse events. No deaths were reported and no adverse events led to treatment or study discontinuation. 
Pharmacokinetics: A3309 was detected in plasma in the picomolar range at doses of 1-10 mg. The highest 
individual levels at 10 mg were 0.33-0.76 nmol/L, seen 2 hours after 14 days of treatment. Cmax occurs 
within 4 h after dose. There is no obvious accumulation of neither A3309 or any metabolite since there 
were no detectable levels 24 hours after dose. The pharmacodynamic analyses provided evidence of 
biological activity consistent with the mechanism of action of A3309: 
• 
C4, a biomarker of bile acid synthesis, showed a dose-dependent increase from baseline to end of 
treatment (p=0.0042). Values returned to baseline at the follow-up 30 days after end of treatment. 
• 
Total cholesterol showed a dose-dependent decrease from baseline to end of treatment (p=0.0305) 
and a similar trend was observed for LDL cholesterol (p=0.0536). 
• 
This study was not powered to show an effect on clinical endpoints, or a comparison to placebo.  
 
However, pre-planned as exploratory analyses, the following parameters indicate therapeutic effect with 
A3309: 
• 
Colon transit in Days comparing baseline with an evaluation on last day of treatment; p=0.0129 
(test for trend over increasing dose) 
• 
Change from Baseline to Week 1 for number of spontaneous bowel movements (SBMs); p= 
0.0285 (test for trend over increasing dose) 
• 
Most of the observed signals of clinical effect were identified in the 10 mg group.  
 
The overall conclusions from the dose levels tested: 
• 
Very low systemic exposure (picomolar range in highest dose groups) was observed.  
• 
Administration of A3309 was found to be safe and tolerable across the dose levels tested with no 
serious adverse events or discontinuations. 
• 
Clear biological effect on C4, total cholesterol and LDL cholesterol and colon transit.  
• 
Preliminary descriptive evidence of clinical efficacy: bowel movement frequency. 

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9 
STUDY AIMS AND ENDPOINTS 
9.1 
Aim 
To assess the dose related effects of A3309 on small bowel and overall colonic transit and bowel function 
in patients with functional constipation.    
9.2 
Primary endpoint: 
Colonic geometric center at 24 h as measured by scintigraphy, as compared to placebo. 
9.3 
Secondary endpoints:  
1. Colonic filling at 6 h measured by scintigraphy, as compared to placebo. 
2. T1/2 
3. Colonic geometric center at 48 h measured by scintigraphy, as compared to placebo. 
of ascending colon emptying measured by scintigraphy, as compared to placebo. 
4. T1/2
5. Assess the effects on stool frequency and consistency based on the Bowel Pattern Diary and effects  
 of gastric emptying of solid 
    on symptom parameters coupled to constipation as well as the overall treatment effect, as  
    compared to placebo based on a six question survey given at the end of the pre-treatment period  
    and the post-treatment period. 
6. Evaluate the pharmacokinetic (PK) characteristics and pharmacodynamic effects for each dose A3309. 
7. Symptoms of constipation 
 
10 RESEARCH DESIGN AND METHODS   
 
This is a randomized, single-center, parallel-group, dose-response, multiple-administration, double-blind, 
placebo-controlled study evaluating the effects of A3309 on gastrointestinal and colonic transit in patients 
with functional constipation. Following an initial screening (visit 1), patients will have baseline transit 
measurement over 24 hours to ensure they fulfill entry criteria for transit. Subsequently, they will be 
randomized to one dose of A3309 or placebo per day for 14 days, and will undergo scintigraphic 
assessment of gastric, small bowel and colonic transit of solids starting on day 12.  These studies will be 
undertaken on over a 48 hour period, days 12 to 14, (visits 4-6). Participants will undergo a safety follow-
up visit (visit 7) 7-10 days after the last day of study medication. Three treatment arms will be included in 
the study.  As stated above, participants will be randomly assigned and allocation will be concealed. 
 
11 OVERALL STUDY DESIGN AND SCHEDULE OF EVENTS 
11.1 
Study Design  
This is a single-center, randomized, parallel group, double-blind, placebo-controlled, dose response, 
pharmacodynamic and pharmacokinetic study to evaluate the effects A3309 on gastrointestinal and 
colonic transit in patients with functional constipation. Patients with functional constipation will be 
screened for eligibility and informed about the study during pre-screening dialogue and also at the initial 
Visit 1 screen. 

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Within seven (7) to fourteen (14) days of Visit 1, eligible patients will return for an abbreviated 
scintigraphy test with images obtained only at 4 and 24 hours post In111
A urine pregnancy test will be performed for all females of child bearing potential at Visit 1 and again 
within the 48 hours prior to the receipt of radiation for both the abbreviated and post-study medication 
transit scintigraphy tests at Visit 2 and Visit 4. Note that females who are status post bilateral tubal 
ligation, hysterectomy or postmenopausal are exempted from this test.  
 capsule ingestion. A geometric 
center at 24 hours must be less than 2.30, the median of normal colonic transit in normal healthy 
volunteers (as determined by analysis of a compilation of prior Camilleri studies),  to qualify for 
randomization to study medication, either 15 or 20 mg A3309 or placebo administered orally once daily 
for fourteen (14) consecutive days. The allocation to treatment group will be concealed.  
Study medication will be administered at the Charlton 7 Clinical Research Unit (CRU) at Visit 4, 5, and 
6, the days of scintigraphic assessment of gastric, small bowel and colonic transit of solids performed 
over a 48 hour period.  
Within seven (7) to ten (10) days of Visit 6, patients will return to the Charlton 7 CRU for final safety 
monitoring and an exit physical examination and interview with study staff. 
11.2 
Schedule of events 
 
Study assessments are described in the chart below. 
 
Table 5 
Study assessments. 
 
 
    
V1 
 
V2 
 
V3 
V4-V6 
 
V7 
Event 
Screen 
Baseline  
Transit 
(V1 + 7-14 days) 
Randomization  
(V2 + 0-3 days) 
Final 
Transit 
(days 12-14 of 
study med) 
Follow-up 
(V6 + 7-10 days) 
x 
Patient information 
 
 
 
 
x 
Informed consent 
 
 
 
 
x 
Inclusion/exclusion criteria 
 
 
 
 
x 
Demographics 
 
 
 
 
x 
Medical history 
 
 
 
 
Physical examination
x 
1 
 
 
x 
x 
x 
Height/Weight 
 
 
 
x 
Vital signs
x 
2 
x 
x 
x 
x 
Med history/adverse events
x 
3 
x 
x 
x 
x 
x 
Concomitant medication 
x 
x 
x 
x 
Laboratory safety tests
x 
4 
 
 
x 
x 
Pharmacodynamics
x 
5 
 
 
x 
x 
Pregnancy test
x 
6 
x 
 
x 
 
x 
12-lead ECG 
 
 
x 
x 

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V1 
 
V2 
 
V3 
V4-V6 
 
V7 
Event 
Screen 
Baseline  
Transit 
(V1 + 7-14 days) 
Randomization  
(V2 + 0-3 days) 
Final 
Transit 
(days 12-14 of 
study med) 
Follow-up 
(V6 + 7-10 days) 
x 
Long BDQ 
 
 
 
 
x (out) 
Bowel pattern diary  
 
 
 
X (in) 
Symptom and efficacy survey
 
7 
 
x 
x 
 
Scintigraphy
 
8 
x 
 
x 
 
Randomization
 
9 
 
x 
 
 
Pharmacokinetics
x 
10 
 
 
x 
x 
 
Administration of study med 
 
x 
x 
 
1 A rectal exam to be performed at Visit 1 to exclude the possibility of an evacuation disorder if a normal exam not 
documented within 2 years by a qualified gastroenterologist. A patient may defer the rectal exam at Visit 6 and 7 if 
not clinically indicated.. 
2 Includes temperature, blood pressure, pulse and respiratory rate 
3 Adverse events occurring prior to administration of study medication are classified as medical history 
4 Laboratory safety assessments include clinical chemistry (ALT; Albumin; Alkaline phosphatase; AST; Bilirubin, 
total; Calcium;  Chloride; C-Reactive Protein; Creatinine; GGT; Glucose; Potassium; Protein, total; Sodium; Urea; 
Uric acid), hematology (hemoglobin; hematocrit; MCV; platelet count; RBC count; WBC count with differential), 
coagulation studies (Activated partial prothrombin time aPPT; Prothrombin time PT), urinalysis (blood; glucose; 
ketones; leukocytes; nitrites; pH; protein), drugs of abuse urine screen (alcohol; amphetamines; barbiturates; 
benzodiazepines; cocaine; opiates; phencyclidine; tetrohydrocannibinol). The drugs of abuse urine screen is 
performed once at Visit 1; the other laboratory tests are performed at Visit 1, Visit 6 and Visit 7. 
5 Blood samples for pharmacodynamics including C4 and a lipid panel of total cholesterol, HDL, LDL and 
triglycerides are obtained at Visits 1, 4 and 7. 
6Females of child bearing potential are required to have a negative pregnancy test result within 48 hours prior to the 
receipt of radiation. Females who are status post-tubal ligation, post-hysterectomy or post-menopause are exempted 
from this requirement 
7 A six question survey concerning constipation symptoms and treatment efficacy will be given at Visit 3, the end of 
the pre-treatment period, and again at Visit 6, the end of the treatment period. 
8An abbreviated transit scintigraphy with scans obtained at 4 and 24h is performed at Visit 2. A full transit with 
scans obtained at 0, 30 min, 60 min, 90 min, 2, 3, 4, 5, 6, 7 and 8 hours after taking study medication for 12 
consecutive days at Visits 4-6. 
9
 
Criteria for randomization is defined as a geometric center < 2.30 at 24h, the median of normal colonic transit 
in normal healthy volunteers (as determined by analysis of a compilation of prior Camilleri studies) 
10
11.3 
Schedule of Visits  
Blood samples for pharmacokinetics are obtained at Visit 4 at pre-dose, 30, 60, 90, 120, 180, 240, 360, 480 
minutes after study medication.  One blood sample for pharmacokinetics is obtained at Visit 1 and Visit 7 as well. 
Visit 1 Study Entry 
Potential study patients will arrive at the Charlton 7 CRU fasting for the previous eight hours. Patients 
will be required to sign the ICF after review and explanation of the study and after all questions have been 
answered. Inclusion and exclusion criteria will be accurately reviewed.   
After reviewing and signing a patient ICF, they will have a brief interview (including demographics, 
medical history and current medications) and a physical examination performed by a study physician. If 
the results of a normal rectal examination to exclude the possibility of an evacuation disorder are not 
documented within the previous two years by a qualified gastroenterologist, this exam will be performed 

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at this time. Height, weight and vital signs including temperature, pulse, blood pressure, and respiration 
rate will be obtained.  
Blood and urine samples will be obtained to perform standard laboratory safety tests including a CBC, 
CMP, coagulation studies, UA, urine screen for drugs of abuse and a urine pregnancy test for females of 
childbearing potential. Note that females who are status post bilateral tubal ligation, hysterectomy or 
postmenopausal are exempted from this test. Blood samples will also be obtained for pharmacodynamics 
(C4, total cholesterol, LDL, HDL, and triglycerides) and one solitary pharmacokinetic sample. The total 
amount of blood obtained for the standard laboratory tests is about 30 mL. A 12-lead ECG will be 
performed. 
Patients will review the study instructions and schedule with the study coordinator.  The Long Bowel 
Disease Questionnaire (BDQ) will be completed to confirm patients have functional constipation. The 
Bowel Pattern Diary will be dispensed and reviewed.   
Prior to Visit 2  
Females of child bearing potential must have a negative urine pregnancy test performed within forty-eight 
hours prior to receipt of radiation in the abbreviated transit scintigraphy test. Females who have 
experienced a bilateral tubal ligation, hysterectomy or menopause will not need the pregnancy test.  
 
Visit 2 Abbreviated Transit Scintigraphy 
Within 7-14 days of Visit 1, patients will return to Charlton 7 CRU fasting for the previous eight hours, 
no food or drink allowed. Vital signs (pulse, blood pressure, respiration rate and temperature) will be 
measured. They will be given a capsule containing a small amount of In111
 
 radioactivity and asked not to 
eat anything for the next two hours and to return four hours later for one five minute camera picture.  
Patients will return the following morning at the same time the capsule was taken for one final five 
minute camera image.  If the camera indicates a state of constipation by showing a geometric center at 24 
hours to be less than 2.30, , the median of normal colonic transit in normal healthy volunteers (as 
determined by analysis of a compilation of prior Camilleri studies ,the patient will continue in the study 
and be randomized to the study medication.  If the camera does not indicate a state of constipation by 
showing a geometric center equal to or greater than 2.30, the patient will end the study at this time. 
Visit 3 Randomization and Administration of Study Medication 
The patient will complete a six question survey of constipation symptoms and treatment efficacy at the 
end of the pre-treatment period, before receiving study medication. The patient will then be randomized 
to a dose of the study medication which is either a placebo (an inactive substance) or a 15 mg or 20 mg 
dose of A3309 study medication taken orally once daily for a total of fourteen consecutive days, eleven 
doses at home and three at the Charlton CRU during the final transit scintigraphy test, Visit 4 to Visit 6.  
Patients will dose at home and record the dosing of study medication in their Bowel Pattern Diaries. 
 
Prior to Visit 4 
Females of child bearing potential must have a negative urine pregnancy test performed within forty-eight 
hours prior to receipt of radiation in the abbreviated transit scintigraphy test. Females who have 
experienced a bilateral tubal ligation, hysterectomy or menopause will not need the pregnancy test.  
 
Visit 4 Final Transit Scintigraphy and Pharmacokinetic Sampling 
Patients will return to Charlton 7 CRU fasting for the previous eight hours, no food or drink allowed. 
Vital signs (pulse, blood pressure, respiration rate and temperature) will be measured. Patients will be 
asked about adverse events and concomitant medications by the study staff and the CRU nurses. 
The study medication and a capsule containing a small amount of In111 radioactivity will be given. About 
one hour after taking the capsule, the first anterior and posterior images will be obtained. The patient will 
be given a scrambled egg breakfast meal; the eggs contain a small amount of Tc99 radioactivity. Images 
will be obtained immediately after the egg breakfast; this image is considered the start of the imaging 

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procedure or the ‘zero hour’ image. Images will be obtained at 30, 60 and 90 minutes later and at 2, 3, 4, 
5, 6, 7, and 8 hours after the ‘zero hour’ image. An intravenous line will be placed in the forearm or hand 
to obtain small volume blood samples for pharmacokinetic (pk) analysis. Small volume blood samples 
will be drawn immediately before the administration of the study medication and at 30, 60, 90, 120, 180, 
240, 360, 480 minutes after study medication. Blood and urine samples will also be obtained to perform 
standard laboratory safety tests including a CBC, CMP, coagulation studies, and UA. Blood samples will 
also be obtained for pharmacodynamics (C4, total cholesterol, LDL, HDL, and triglycerides) at this time. 
The total amount of blood taken will be about 75 mL. A 12-lead ECG will be performed.  About four 
hours after the breakfast, a standard chicken breast lunch meal is given. Images will be obtained at five, 
six and seven hours. About eight hours after the breakfast, a standard roast beef sandwich snack, will be 
given followed by a final camera image. These standardized meals ensure that all participants in this 
study eat the same type and same amount of food this day. Patients are asked not to eat or drink anything 
other than these standardized meals. 
 
Visit 5 Transit Scintigraphy 
The following morning, patients will return to the Charlton 7 CRU fasting for the previous eight hours, no 
food or drink allowed, to receive the study medication followed by one five minute camera image. Vital 
signs (pulse, blood pressure, respiration rate and temperature) will be measured. Patients will be asked 
about adverse events and concomitant medications by the study staff and the CRU nurses. 
 
Visit 6 Transit Scintigraphy 
The following morning, patients will return to the Charlton 7 CRU fasting for the previous eight hours, no 
food or drink allowed, to receive the study medication followed by one five minute camera image. A brief 
physical exam will be performed by a study physician. Patients may defer the rectal exam if not clinically 
indicated. Vital signs (pulse, blood pressure, respiration rate and temperature) will be measured. Patients 
will be asked about adverse events and concomitant medications by the study staff and the CRU nurses. 
Patients will complete a six question survey of constipation symptoms and treatment efficacy. 
 
Visit 7 Study Completion 
Within seven to ten days after Visit 6, patients will return to Charlton 7 CRU fasting for the previous 
eight hours, no food or drink allowed. Height, weight and vital signs (pulse, blood pressure, respiration 
rate and temperature) will be measured. Blood and urine samples will be obtained to perform standard 
laboratory safety tests including a CBC, CMP, coagulation studies and urinalysis. Blood samples will also 
be obtained for pharmacodynamics (C4, total cholesterol, LDL, HDL, and triglycerides) and one solitary 
pharmacokinetic sample. The total amount of blood obtained for the standard laboratory tests is about 30 
mL. A 12-lead ECG will be performed. The Bowel Pattern Diary will be turned in.  A physical exam will 
be performed by the study doctor; the patients may defer the rectal exam if not clinically indicated.An exit 
interview will be done with study staff.  
 
12 RATIONALE FOR STUDY DESIGN 
12.1 
Strengths and limitations 
Major strengths of this study include the ability to noninvasively measure gastrointestinal transit and the 
resources available in the Charlton 7 CRU at the Mayo Clinic Rochester. Therefore, completion of this 
study is highly feasible.  The study team has a well-established track record using these techniques in 
healthy volunteers in previous studies.  The study has sufficient power to detect clinically relevant 
differences between the treatment groups. Variability in body size and weight may present pitfalls in the 
analysis of the data.  

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12.2 
Anticipated results and significance 
We anticipate decreased colonic transit without significant effects upon stomach and small bowel transit. 
We expect no serious adverse events, though the efficacy of the medication being relief of constipation 
may result in diarrhea, gas and bloating. We also expect a minor decrease in LDL cholesterol and a slight 
increase in C4, also consistent with the pharmacologic actions of the medication. 
12.3 
Feasibility and timeframe 
This study requiring four days of investigation in female patients with functional constipation is feasible.  
Based on past experience, recruitment of study subjects should be uncomplicated.  
12.4 
Selection of study population  
Thirty-six female patients with diagnosed functional constipation will be recruited from the local 
community by public advertisement placed within areas of Mayo Clinic or by a targeted mailing of an 
informational letter. They will be screened by means of the Long BDQ to confirm the diagnosis of 
functional constipation.  
This study will reflect the population of Olmsted County, Minnesota with 90% Caucasian, 5% Asian and 
5% other.  Previous experience would suggest an age range of patients from 18-65 years old, with a mean 
age of approximately 30 years. No subpopulations or special classes of subjects are involved in this study.  
 
13 INCLUSION CRITERIA  
    1. Females aged 18 to 65 years old inclusive 
 
 
 
 
 
 
 
    2. An adaption of Rome II criteria for functional constipation will be used. Eligible patients must  
        have functional constipation for the previous three months with symptom onset at least six 
        months prior to diagnosis with less than three complete spontaneous bowel movements per week  
        with two or more of the following:   
 
 
           a. hard or lumpy stools at least 25 % of the time 
           b. straining during a bowel movement at least 25 % of the time 
           c. sensation of incomplete evacuation at least 25 % of the time 
           d. sensation of anorectal obstruction/blockage at least 25 % of the time 
 
   3. A normal rectal exam result on file within the past 2 years or performed at Visit 1 screen by a 
qualified gastroenterologist to exclude the possibility of an evacuation disorder. Examination must 
exclude findings suggestive of an evacuation disorder such as high sphincter tone at rest, failure of 
perineal descent and spasm, tenderness or paradoxical contraction of the puborectalis muscles. 
 
   4. Females of child-bearing potential (those who have not experienced a bilateral tubal ligation,   
       hysterectomy or menopause) must use an acceptable method of contraception during the study.  
       Acceptable methods are surgical sterilization, hormonal methods such as oral contraceptives,  
       Norplant and Depo-Provera, double barrier method such as a condom and spermicide, and an IUD.    
       Abstinent females may participate if they agree to use the double barrier method should they become   
       sexually active during the study. 
 
   5. Able to provide written informed consent prior to any study procedures being performed 
 

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14 EXCLUSION CRITERIA 
 
   1. Female patients who are pregnant or breast feeding 
 
 
 
 
 
 
   2. Structural or metabolic diseases/conditions that affect the gastrointestinal system or functional    
       gastrointestinal disorders other than constipation. The long version BDQ will be used to confirm   
       patients have constipation. 
 
   
3. Taking any medication  that in the opinion of the principal investigator has a potential to alter GI 
transit. This includes but is not limited to osmotic or stimulant laxatives, magnesium or aluminum-
containing antacids, prokinetics, erythromycin, narcotics, anticholinergics, selective norepinephrine 
reuptake inhibitors (SNRIs), opiates, GABAergic agents and benzodiazepines. 
 
Note: Selective serotonin reuptake inhibitor (SSRI) antidepressants are permissible at low, stable 
doses. Analgesics such as Tylenol, ibuprofen, naproxen and aspirin are permissible. All 
medications shall be reviewed by the principal investigator on a case by case basis. 
 
 
4. Clinical evidence (including but not limited to a clinically significant abnormal physical exam, ECG or  
    laboratory test result in the past medical record) or current clinically significant abnormal physical  
    exam or laboratory test result that could indicate significant cardiovascular, respiratory, renal, hepatic,  
    gastrointestinal, hematological, neurological, psychiatric or other diseases that interfere with the  
    objectives of the study. If a laboratory test result is abnormal and clinically significant, it may be     
    repeated once at the discretion of the PI. If the laboratory test result remains abnormal and clinically  
    significant, the patient will be discontinued from the study and referred to a primary care physician for  
    further evaluation. 
 
5. Patients who are considered by the PI to be alcoholics not in remission or known substance abusers. 
 
6. Patients who have participated in another clinical study in the past 30 days. 
 
 
15 GENDER/MINORITY MIX 
We justify restricting enrollment to only female patients with functional constipation by the following: 
 
1. The clinical population presenting with functional constipation is greater than 90 percent female. 
2. The clinical population potentially receiving A3309 as a treatment for functional constipation is 
mostly female. 
3. This is a non-therapeutic study; therefore, we are not depriving males of a potential therapy for 
functional constipation. 
 
It is anticipated that the racial/ethnic characteristics of the group will reflect the communities in Olmsted 
County, Minnesota and are anticipated to be 90% Caucasian, 5% Asian and 5% other minorities.  The 
prevalence of IBS among whites, blacks and Hispanics in the U.S. is very similar.  
There are no known ethnic or gender differences in bioavailability of A3309.  Hence, we anticipate the 
results of our study will be generalizable. 

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16 RESTRICTIONS  
Patients must report to Charlton 7 CRU fasting for the previous eight hours for all study visits, Visits 1 to 
7.   
Rescue medications (Milk of Magnesia, Dulcolax and Fleets/tap water enemas) may be used but only 
under the direction of the PI. Rescue medications must not be used within the seven days prior to both the 
abbreviated and full transit scintigraphy tests.  Since each patient’s schedule will differ, each patient will 
be instructed as to when rescue medication may not be taken.   
 
17 STUDY WITHDRAWAL 
A study patient should be withdrawn from the study treatment if, in the opinion of the Investigator, it is 
medically necessary, or if it is the expressed wish of the patient. 
Irrespective of the reason for withdrawal and whenever possible, the patient should be examined. 
Relevant laboratory test samples should be obtained and all relevant assessments should be completed, 
preferably according to the scheme for the final assessment. The CRF should be completed as far as 
possible and collected by the Monitor. 
A withdrawn patient is not allowed to re-enter into the study. 
 
18 SCREENING AND ENROLLMENT LOG 
The site will keep a log of all patients screened and included. The reason for screen failure should be 
stated for all patients screened but not included. The reason for withdrawal should be stated for all 
patients included but not completed. 
 
19 INVESTIGATIONAL PRODUCT 
Investigational Product (IP) will be provided by Albireo. The study will be performed under an IND held 
by Albireo, IND number 103,060. 
The active pharmaceutical ingredient (API) in A3309 is manufactured by Syngene as a white to off-white 
powder. The IP will be shipped from Galenica to the Mayo Research Pharmacy.  
19.1 
Packaging, labeling and storage of Investigational Product 
The A3309 tablets will be delivered to the Mayo Research Pharmacy in aluminium sachets. The sachets 
are packed in HDPE containers (DUMA Twist-Off) with childproof polypropylene caps (DUMA Twist-
Off cap). 
The label of the sachets (primary container) will include: 
Content: A3309 tablets and/ or Placebo tablets 
Protocol Number: A3309-003  

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Storage: Room Temperature (preferably 20 – 25˚C) 
Batch No: 96202-YYMM-XX 
Use by: YYYY-MM-DD 
Caution: 
Sponsor: Albireo AB, Arvid Wallgrens backe 20, SE-413 46 Gothenburg, Sweden 
New drug - Limited by Federal (USA) Law to Investigational Use 
Keep Out of Reach of Children. 
Take both tablets orally daily before breakfast 
 
 
The label of the HDPE containers (secondary container) will include: 
 
18 sachets containing two tablets each. 
Content: A3309 tablets and/or Placebo tablets 
Protocol Number: A3309-003  
Patient no: XXXX 
Storage: Room Temperature (preferably 20 – 25˚C) 
Batch No: 96202-YYMM-XX 
Use by: YYYY-MM-DD 
Caution: 
Sponsor: Albireo AB, Arvid Wallgrens backe 20, SE-413 46 Gothenburg, Sweden 
New drug - Limited by Federal (USA) Law to Investigational Use 
Manufactured by: Galenica AB, Medeon, SE-205 12 Malmoe, Sweden 
Clinical site: Mayo Clinics, xxxxxxxxxxx, phone: xxxxxx 
Keep Out of Reach of Children. 
Take both tablets from one sachet orally daily before breakfast. 
 
19.2 
Doses and treatment regimens 
Patients will receive placebo or 15 mg or 20 mg A3309 tablets taken orally once daily for eleven 
consecutive days at home and once daily for three consecutive days of the final transit scintigraphy test at 
the Charlton 7 CRU. Study medication will be administered at Charlton 7 CRU by CRU nurses. 
 Based on the effect on the biomarker C4, data on colon transit, and results of patient-reported outcomes 
in study A3309-001, the protocol design includes two dose levels: 15 and 20 mg.  
 
These dose estimations are based on the following findings from preclinical studies: 
• 
PD effects of A3309 tested in several species in both in vitro and in vivo experiments.  The in 
vitro potency in human IBAT-transfected cells, as well as the in vitro and in vivo potency in the 
mouse and the dog were used to approximate an effective dose in humans from 0.25 to 0.5 
µmol/kg. 
• 
A dose of A3309 0.16 µmol/kg resulted in twice the fecal excretion of 75
• 
Evaluation of the results of the A3309-001 study showed: 
SeHCAT in the mouse 
than in humans over a 24-hour period; mouse IBAT showed a 3-fold greater potency than human 
IBAT.  In the dog, a clear increase of C4 and in diarrhea was observed and a reversal of meat-
induced constipation was detected at 5 µmol/kg (the canine IBAT has a 10-fold less potency than 
human IBAT).  As diarrhea was observed in the dog at 5 µmol/kg in the 3 month toxicology 
study, this dose is probably too high for use in patients with constipation. 

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o A minor signal on C4 and on lipid parameters observed at the 3 mg and the 10 mg dose levels 
produced a stronger signal; 
o Efficacy signals (colon transit, stool form scale (28), and frequency of BMs) evident in the 10 
mg dose group.  However, no diarrhea or incapacitating “very loose stools” were observed in 
the 10 mg dose group. 
Given the paucity of data, the therapeutic oral dose range in man is difficult to estimate but may be in the 
range of 5 to 20 mg, as calculated from in vitro potency in human IBAT-transfected cells and from in 
vitro and in vivo potency in the mouse, dog, and man.  
 
Previous experience with A3309 does not include dose levels greater than 10 mg.  Evaluating  15 mg and 
a 20 mg dose level is adequate given: 
• 
The large safety window in the preclinical toxicology package.  The only dose-limiting effect 
identified was emesis in female dogs given high dose.  The preliminary NOAEL in the rat was 
350 mg/kg, 140 mg/kg in the male dog, and 17.5 mg/kg in the female dog, giving an approximate 
safety margins of approximately 520 to 1300-fold differences for a 20 mg dose (see Section 
1.2.6). 
• 
The extremely low systemic exposure (picomolar exposure) of both A3309 and its metabolites  
• 
The high protein binding (approximately 99.5 %), and 
• 
The benign safety profile in the Phase Ib study 
The available toxicological documentation indicates that A3309 can be given orally to humans for up to 3 
months duration at doses of 15 mg and potentially within the range of 1 to 20 mg for up to 90 days. In 
parallel with this study a Phase IIb study (A3309-002) is ongoing in the US including three dose levels (5, 
10 and 15 mg) and with a treatment duration of 8 weeks. Based on the results of that study and the results 
of this study data will be evaluated and a decision taken whether to continue into a Phase 3 program.
19.3 
Product accountability 
  
The IP will be released to the study site after approvals of the study protocol have been received from the 
IRB and the Regulatory Authority. The IP will be stored at and dispensed by the Mayo Research 
Pharmacy and administered by the Charlton 7 CRU nurses.  
The Mayo Research Pharmacy will be responsible for keeping detailed dispensation records, which show 
the quantity of IP that is stored, removed from the place of storage, prepared for delivery to Charlton 7 
CRU and any unused product returned from Charlton 7 CRU.  Any discrepancies between dispensed and 
returned IP must be explained and documented. 
The CRU will keep record of IP administered to the patients. 
IPs deliberately and/or accidentally destroyed by the Research Pharmacy or the dispensing nurses must 
also be accounted for. 
The Monitor will perform IP accountability and make sure that all unused IP is adequately 
destroyed/returned and documented. 
 

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20 RANDOMIZATION METHODS  
Randomization will be stratified on BMI (< 25, > = 25 kg/m2
20.1 
Blinding 
). IP doses will be randomly assigned in 
fixed block sizes according to a schedule provided by the study statistician. Mayo Clinic Research 
Pharmacy will maintain the randomization schedule.  
The different doses of IP and placebo will be of identical appearance. Only pharmacy personnel will be 
allowed to see the randomization schedule and know the block size to avoid the possibility of predication 
by the Investigators and study staff. All study personnel (including the study statistician) will remain 
blinded to the assignments until the study is completed and the analysis data set is finalized. 
20.2 
Emergency decoding of blinded treatment 
Breaking the code must only be done in emergency situations and should only be used when knowledge 
of the treatment is necessary for the proper management of the patient. If the treatment code is broken, the 
reason and the date must be documented. Decoding of the blinded treatment must be reported to the 
Albireo AB, the CRO Icon and Mayo IRB. 
20.3 
Prior and concomitant therapy 
Rescue medications and other medications considered necessary for the patient’s welfare may be given at 
the discretion of the Investigator. 
All concomitant therapy used during and within 30 days of study entry must be recorded in the CRF. No 
other drug under investigation may be used concomitantly with the study medication. 
20.4 
Continuation of treatment 
Continuation of treatment with the IP after the study period will not be offered. 
20.5 
Treatment Compliance 
Treatment compliance of greater than 80% is required and will be assessed by the patient’s record of 
dosing contained in the Bowel Pattern Diary. 
 
21 STUDY ASSESSMENTS 
21.1 
Demographics  
At Visit 1 the following information will be collected and registered in the CRF: age, height, weight, 
BMI, gender and ethnic origin.  
21.2 
Clinical efficacy assessments  
1. Gastrointestinal and Colonic Transit 

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An adaptation of our established scintigraphic method will be used to measure gastrointestinal and 
colonic transit. Briefly, 111In absorbed on activated charcoal particles is delivered to the colon by means 
of a methacrylate-coated, delayed-release capsule. The capsule is ingested following an overnight fast. 
Colonic transit measurements will be performed by means of the delayed release capsule. After the 
capsule emptied from the stomach (documented by its position relative to radioisotopic markers placed on 
the anterior iliac crests), the study medication is given immediately before a standard radiolabeled 
breakfast meal is ingested. In this meal, 99m
Relative to the time of consumption of breakfast meal, abdominal camera images are initially obtained 
every 30 minutes for the first two hours, then hourly for the next six hours. At about 4 hours, a standard 
chicken breast lunch will be given. Camera images will be taken at 5, 6, and at 8 hours post breakfast 
meal.  At about 8 hours, the standard roast beef sandwich snack will be given. The patient will leave the 
CRU after the completion of the 8 hour image and will return the following two mornings in order to 
receive study medication and obtain 24 and 48 hour scans fifteen minutes later.  The performance 
characteristics of this test are summarized elsewhere. Please see relevant references on the methods 
(
Tc-sulfur colloid is used to label two scrambled eggs that will 
be eaten with one slice of whole wheat bread and one glass of skim milk.  This meal facilitates 
measurement of gastric and small bowel transit.  
29,30). 
 
2. Assessment of stool frequency and consistency  
During the study, patients will complete a daily Bowel Pattern Diary to record their bowel habits.  The 
Bowel Pattern Diary will be dispensed at Visit 1 and will be collected at the completion of the study at 
Visit 7.  
 
3. Pharmacokinetic (PK) and pharmacodynamic (PD) assessments  
a. Sample collection and handling 
Blood samples for analysis of PK parameters will be collected at Visit 4, before dosing and at 30, 60,      
90, 120, 180, 240, 360 and 480 minutes post-dose. One solitary sample to measure a baseline level at 
Visit 1 and one sample to measure a post treatment level at Visit 7 will be obtained. The samples will be 
drawn from an IV line into a lavender EDTA collection tube, centrifuged at  3000 rpm for 15 minutes and 
the plasma transferred to an anonymized polypropylene tube labeled only with a study number and patient 
initials as identifiers.  The samples will be frozen at -70 degrees Celsius until they are batch shipped to 
Covance UK for analysis after the end of the study. One 5-mL pharmacodynamic sample to determine 
levels of C4 is taken at Visit 1, 4 and 7 and stored in the refrigerator for 30-60 min and thereafter serum is 
separated by centrifugation. The serum obtained is aliquoted into a cryo tube equipped with a screw-cap 
lid with a rubber o-ring.  Samples are thereafter frozen at -70 degrees Celsius until they are batch shipped 
to Karolinska Institue, Sweden for analysis after end of the study. The total amount of blood drawn for 
these pharmacokinetic and pharmacodynamic samples is about 75 mL. 
 
b. Pharmacokinetic analysis 
PK parameters will be analyzed using conventional analyses by Covance, UK: 
21.3 
Laboratory safety assessments 
Blood and urine samples will be obtained for the standard laboratory tests safety assessments of CBC, 
CMP, coagulation studies and UA at Visit 1, Visit 6 and Visit 7. A urine screen for drugs of abuse will be 
performed at Visit 1. These laboratory panels are further described in Appendix 3.  The total amount of 
blood drawn will be approximately 20 mL on each visit for a total of 60 mL. Urine pregnancy tests will 
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radiation for both the abbreviated and full transit scintigraphy tests performed at Visit 2 and Visit 4, 
respectively. The laboratory analysis will be performed at Mayo Clinic. 
21.4 
Clinical safety assessments 
A physical examination will be performed at the Visit 1 study entry and Visit 7 study completion and if 
necessary throughout the study. 
Vital signs (including temperature, pulse, blood pressure and respiration rate) will be recorded at all visits.  
Patients will be interviewed about adverse events and concomitant medications at every visit.  
 
22 ADVERSE EVENTS 
22.1 
Definitions  
Any untoward medical occurrence in a patient or clinical investigation subject administered a 
pharmaceutical product and which does not necessarily have to have a causal relationship with this 
treatment. AE can therefore be any unfavorable and unintended sign (including e.g. an abnormal 
laboratory finding), symptom or disease temporally associated with the use of a medicinal product, 
whether or not considered related to the product. 
Adverse Events (AE) 
 
Any untoward medical occurrence or effect that at any dose 
Serious Adverse Event (SAE) 
• 
results in death 
• 
is life-threatening 
• 
requires patient’s hospitalization or prolongation of existing hospitalization 
• 
results in persistent or significant disability or incapacity 
• 
is a congenital anomaly/birth defect 
• 
is regarded as medically important without meeting the above mentioned criteria.  
 
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. 
Hospitalization is defined as an unplanned overnight stay. Note however that the subject must be formally 
admitted. Waiting in outpatient clinic or emergency room would not count. A planned hospital stay does 
not count as SAE, nor does staying in hospital for social reasons (e.g. respite care, the fact that there is no-
one at home to care for the patient). 
 
Any adverse drug experience, the specificity or severity of which is not consistent with the current 
Investigator Brochure (IB); or, if an IB is not required or available, the specificity or severity of which is 
not consistent with the risk information described in the general investigational plan or elsewhere in the 
current application, as amended. 
Unexpected Adverse Drug experience 
 

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Mild means awareness of symptoms or signs, but easily tolerated (acceptable)  
Intensity 
Moderate means discomfort enough to interfere with usual activity (disturbing)  
Severe means incapacity to work or to do usual activity (unacceptable) 
 
Certain - A clinical event, including laboratory test abnormality, occurring in a plausible time 
relationship to drug administration, and which cannot be explained by concurrent disease or other drugs 
or chemicals. The response to withdrawal of the drug (dechallenge) should be clinically plausible. The 
event must be definitive pharmacologically or phenomenologically, using a satisfactory rechallenge 
procedure if necessary. 
Causality 
Probable - A clinical event - including laboratory test abnormality - with a reasonable time sequence to 
use of the product, unlikely to be attributed to concurrent disease or other drugs or chemicals, and which 
follows a clinically reasonable response on withdrawal (dechallenge). Rechallenge information is not 
required.  
Possible - A clinical event - including laboratory test abnormality - with a reasonable time sequence to 
use of the product, but which could also be explained by concurrent disease or other drugs or chemicals. 
Information on drug withdrawal may be lacking or unclear. 
Unlikely - A clinical event - including laboratory test abnormality - with a temporal relationship with use 
of the product which makes a causal relationship improbable, and in which other drugs, chemicals or 
underlying disease provide plausible explanations. 
 Not related - Evidence exists that the AE has an etiology other than the study drug (e.g., pre-existing 
condition, underlying disease, intercurrent illness, or concomitant medication). 
An adverse event will be considered associated with the use of a study drug if the attribution is certain, 
probable or possible. 
22.2 
Evaluations  
All AEs, serious and non-serious, should be recorded in the CRF. If no AE has occurred during the study 
period, this should also be recorded in the CRF. 
The following evaluations are to be done by the Investigator in connection with the AE: 
• 
type of event 
• 
seriousness 
• 
degree of severity 
• 
duration (start - end) 
• 
action taken 
• 
causality with study product 
• 
outcome of the adverse event 
For AE reporting purposes no distinction should be made between the IP and any reference/comparator 
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22.3 
Reporting of SAEs 
All SAEs must be reported by the Investigator using phone or fax within 24 hours of knowledge of the 
event to the Monitor or other members of the staff at the CRO Icon, regardless of the time that may have 
elapsed from the time the event occurred to when the Investigator first learns of it. The Initial Report 
should contain as a minimum the following information: 
• 
subject identification 
• 
treatment specification 
• 
adverse event diagnosis 
• 
time specification for the medical event 
• 
name of the original reporter 
 
A Serious Adverse Event Report Form must also be completed, signed by the Investigator and submitted 
to the CRO Icon no later than five calendar days after the initial information was received. Apart from the 
information above, this Follow-up Report should also contain the following information: 
• 
assessment of severity 
• 
assessment of causality 
No distinction should be made between the IP and the reference product regarding reporting of SAEs as 
long as the code is not broken.  
SAEs should be reported to the CRO Icon even after the clinical study has been finished, if, in the 
judgment of the Investigator, there might be an association between the event and the previous use of the 
study product(s) or as a result of the study procedures. This post-study observation period will be up to 30 
days after administration of last dose of study product. 
An SAE may qualify for reporting to the FDA by the Sponsor or Sponsor’s representative if the AE is 
both serious and unexpected based upon the current Investigator’s Brochure.  In this case, all 
Investigators will receive a formal notification describing the SAE in the form of an IND safety report.  
22.4 
Exceptions from expedited reporting of SAEs 
An event need not to be reported as an SAE if it represents only a relapse or an expected change, or 
progression of a pre-existing condition and is without any other symptoms or signs than those present 
before treatment. This event needs only to be reported as an AE and should be described in the Study 
Protocol. 
22.5 
Follow-up period after an AE 
If a study patient is withdrawn due to an AE, or if an AE persists at the end of the study treatment period, 
this should be followed up by a physician until the condition has ceased or until the subject is under 
professional medical care and a potential causality between the investigational drug and the AE has been 
penetrated. An outcome assessment should be performed when an AE persists. 
22.6 
Procedures in case of pregnancy 
In case of pregnancy or suspicion of possible pregnancy, the study treatment must be stopped 
immediately, and the patient discontinued from participation in the study. Pregnancy itself is not regarded 

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as an AE unless there is a suspicion that the IP may have interfered with the effectiveness of the 
contraceptive medication. However, the outcome of all pregnancies (spontaneous miscarriage, elective 
termination, normal birth or congenital abnormality) must be followed up and documented even after the 
patient was discontinued from the study. 
All events of congenital abnormalities/birth defects are SAEs. Spontaneous miscarriages should also be 
reported and handled as AEs. All outcomes of pregnancy must be reported to the CRO Icon on the 
pregnancy outcomes report form. 
22.7 
Procedures in case of overdose 
 
Overdose is defined as any dose greater than the highest daily dose in the protocol-defined doses, ie, 20 
mg. Any overdose must be recorded in the study medication section of the CRF. At least 12 hours should 
elapse between consecutive calendar days and no more than one dose should be taken per calendar day. In 
case of overdose, appropriate treatment should be given and hospitalization for observation should be 
considered. Though an overdose may not be considered an SAE, any case of reported overdose must be 
reported to the sponsor and CRO in the same expedited manner as an SAE using an SAE form. If the PI 
and/or sponsor and CRO consider the overdose to be medically significant, it would then be reported as 
an SAE. 
 
23 DATA QUALITY ASSURANCE 
23.1 
Monitoring and auditing procedures 
The study site will be visited by the Monitor and/or the Project Manager periodically at times agreed on 
by the Investigator and the Monitor. It is the function of the Monitor to ascertain that all aspects of the 
Study Protocol are complied with and that the conduct of the study conforms to applicable regulatory 
requirements and established rules for Good Clinical Practice (GCP).  
At the time of each monitoring visit, the Monitor will review the completed CRFs to ascertain that all 
items have been completed and that the data provided are accurate and obtained in the manner specified 
in the protocol.  
The Monitor will also check that the data in the CRF are consistent with the clinical records (Source Data 
Verification) and that study results are recorded completely and correctly. The Monitor will check on the 
reporting of SAEs and the procedures for IP accountability and record keeping. For this purpose the 
Monitor must be given direct access to clinical records, original laboratory data, etc., as far as these relate 
to the study and without jeopardizing subject integrity. CRFs for all included subjects must be made 
available to the Monitor for review.  
The study site may also be subject to quality assurance audit by the Sponsor or someone appointed for 
this task by the Sponsor. A Regulatory Authority may request to make an inspection of the study site. The 
procedures of such a visit would be similar to those of a monitoring visit, and data already checked by the 
Monitor may be checked again. The Investigator is required to inform the Sponsor immediately of an 
inspection requested by a Regulatory Authority. 
23.2 
Case Report Forms (CRFs) 
CRFs of a design mutually agreed upon by the Sponsor, the CRO and the PI will be developed by the 
Mayo Clinic.  

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A CRF must be completed and signed for each included subject. All data and information on the CRFs 
are to be neatly and legibly recorded in black or blue
The completed CRFs should be made available for checking of completeness and accuracy before 
collection by the Monitor as agreed in advance. The original CRFs are the sole property of the Sponsor 
and should not be copied or made available in any form to a third party, with the exception of authorized 
representatives of local Regulatory Authorities, without the written permission from the Sponsor. 
 ball-point ink to ensure legibility of self-copying and 
photocopied pages. Corrections on the CRFs must be made by one single line through the incorrect data, 
leaving the corrected data clearly visible. The revised entry should be made alongside, initialed and dated 
by a member of the PI’s research team who is authorized to initial CRF changes for the Investigator. This 
authorization must be documented in writing. Correction fluids are not permitted. 
23.3 
Source Data  
Source documents will be the Mayo Clinic EMR, original laboratory results and original electronic data 
generated from the scintigraphic investigations. Relevant EMR for study patients will be printed in 
certified hardcopies prior to the monitoring visit and used for SDV. 
The extent of SDV to be performed will be described in the study specific monitoring instructions prior to 
initiation of the study. 
The source of derived information appearing in the CRF will be included in each individual CRF binder 
for monitoring purposes. The SDV process will be performed continuously during the monitoring visits at 
the clinic. 
23.4 
Training of study staff  
It is the responsibility of the PI to ensure that all personnel involved in the study are fully informed of all 
relevant aspects of the study, and have a detailed knowledge of and training in the procedures that are to 
be executed by them. 
All Investigators and staff carrying out observations of primary or other major efficacy variables involved 
in the study should provide a Curriculum Vitae (CV). The PI will keep a list of all personnel involved in 
the study together with their function and study related duties delegated. He/she will ensure that 
appropriate study related training is given to all of these staff, and that any new information of relevance 
to the performance of this study is forwarded to the staff involved. 
Before inclusion of subjects the Monitor and/or Project Manager will perform a study initiation visit to 
inform and train relevant study staff. 
24 STATISTICAL METHODS 
24.1 
Statistical considerations 
An analysis of covariance (ANCOVA) will be used to compare transit parameters and patient bowel 
pattern diary summaries (i.e., stool frequency, mean stool consistency and mean ease of passage scores) 
among the treatment groups. The covariates considered for inclusion in the analyses are age, body mass 
index (BMI) and the corresponding baseline (pre-treatment) bowel pattern diary summaries. If necessary 
a suitable transformation for potential skewness in the distributions of measured responses or 
heterogenous variation amongst the treatment groups may be used (i.e., ANCOVA on ranks or square root 
transformed stool frequency. 
 

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If the ANCOVA test for overall treatment effects for a given response has a p value less than or equal to 
0.10, then both the 15 mg and 20 mg doses will be compared to placebo using Dunnett’s Test.  
 Since each of the primary endpoints assesses a separate hypothesis regarding the effects of A3309, no 
adjustment in the alpha level for testing multiple types of endpoints is anticipated, and a two-sided 
significance level of 0.05 will be used in each ANCOVA model.  
24.2 
Analysis data sets  
The primary analyses will follow the intent to treat (ITT) paradigm with all patients randomized included 
in the analyses. Those patients with missing response values will have their missing values imputed via 
the overall (patients with non-missing data) mean and a corresponding adjustment in the ANCOVA 
residual error variance degrees of freedom (subtracting one for each missing value imputed). A per 
protocol analysis of transit data will also be performed. The per protocol population consists of all 
patients having at least 80 % compliance with study drug and having participated in the transit evaluation. 
Safety data will be presented for all patients receiving investigational product. 
24.3 
Demographics  
The following baseline values and patient characteristics will be summarized descriptively in order to 
describe the study population: age, gender and ethnic origin.  
24.4 
Analysis of efficacy  
Primary endpoint: 
Colonic geometric center at 24 h as measured by scintigraphy, as compared to placebo. 
 
Secondary endpoints:  
1. Colonic filling at 6 h measured by scintigraphy, as compared to placebo. 
2. T1/2 
3. Colonic geometric center at 48 h measured by scintigraphy, as compared to placebo. 
of ascending colon emptying measured by scintigraphy, as compared to placebo. 
4. T1/2
5. Assess the effects on stool frequency and consistency based on the Bowel Pattern Diary and treatment     
 of gastric emptying of solids 
     effects on symptom responses specific to constipation, overall and for active treatment compared to   
      placebo.  
6. Evaluate the pharmacokinetic (PK) characteristics for each dose of A3309. 
7. Assess the safety and tolerability of A3309 administered as an oral tablet. 
 
24.5 
Transit data analysis 
A variable region of interest program is used to quantitate the counts in the stomach and each of four 
colonic regions: ascending, transverse, descending, and combined sigmoid and rectum.  These counts 
were corrected for isotope decay, tissue attenuation, and downscatter of 111 In counts in the 99m
Data will be analyzed as in previous studies. 
Tc window. 
1. Geometric mean of counts in anterior and posterior gastric regions of interest will be used to 
estimate by power exponential analysis of the proportionate emptying over time of counts 
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the colon at 6 hours will also be estimated as a measure of orocecal (and a surrogate for 
small bowel) transit. 
2. Geometric center of colonic counts for solids at 4, 24 and 48 hours will be estimated using 
geometric mean of counts in ascending, transverse, descending and rectosigmoid colon and 
stool (weighted by factors of 1 to 5 respectively). The primary variable of interest in overall 
colonic transit is the geometric center at 24 hours.  
3. Ascending colon emptying t1/2 will be estimated by power exponential analysis of the 
proportionate emptying over time of counts from the colon.  The primary data for this 
analysis will be the proportion of decay and depth-corrected counts in the ascending colon 
on the hourly scans on the first day of transit measurement and the 24 h data.  
The primary summaries obtained for comparison of transit profiles will be the  colonic geometric 
center at 24 hours and the ascending colon emptying t½.  The geometric center is the weighted 
average of counts in the different colonic regions: ascending (AC), transverse (TC), descending (DC), 
rectosigmoid (RS), and stool.  At any time, the portion of colonic counts in each colonic region is 
multiplied by its weighting factors as follows: (%AC x 1 + %TC x 2 + %DC x 3 + %RS x 4 + %stool 
x 5)/100 = geometric center. Thus, a high geometric center implies faster colonic transit.  A geometric 
center of 1 implies that all isotope is in the ascending colon and a geometric center of 5 implies that 
all isotope is in the stool. The t½ of ascending colon emptying is also estimated by plotting the 
activity-time curve for percent residing in the ascending colon; linear interpolation is used to connect 
points. 
24.6 
Stool frequency and stool consistency  
Patients are asked to keep a daily bowel pattern diary documenting the number of stools and the 
consistency (Bristol Stool Scale (28)) of each stool. These are averaged as number of bowel movements 
or consistency of bowel movements per day per patient. Number of bowel movements and consistency 
are subsequently averaged over the study periods (i.e. run-in and treatment) per patient. The ANCOVA 
will be used to assess treatment effects on each of these two measures separately, using the corresponding 
run-in values as covariates.  In addition, treatment effects on specific constipation symptoms , considered 
as discrete categorical responses, will be evaluated by a contingency table analysis of the post-treatment 
responses based on the final post-treatment bowel pattern diaries and questionnaires concerning 
constipation symptoms and treatment efficacy.  
24.7 
Analysis of pharmacokinetic and pharmacodynamic data  
 Pharmacokinetic and pharmacodynamic parameters will be analyzed as described in the SAP. 
24.8 
Analysis of safety  
All safety variables and AEs will be presented, when possible, by treatment, with summary statistics.  
All continuous variables will be described using standard statistical measures, i.e. number of 
observations, number of missing observations, mean, standard deviation, minimum and maximum value, 
median, 1st and 3rd quartile. All categorical variables will be summarized by absolute and relative 
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24.9 
Assessment of sample size 
Table 1 below summarizes data for the primary response measures and uses the (relative) variation, 
(CV%) to estimate the effect size detectable with 80% power based on a two sample t-test  at a two-sided 
alpha level of 0.05. The effect size is the difference in group means as a percentage of the overall mean 
for each response and assumes 12 subjects per group. The ANCOVA should provide 80% power to detect 
similar (pairwise) differences using a pooled estimate of variation across all three groups and potentially 
even smaller effect sizes by adjusting for important covariates. The data from the scintigraphic transit  
studies are based on the same methods proposed for this study. There is no planned adjustment for 
dropouts. In these types of studies, we expect less than five percent dropouts.  Missing data will be 
handled by standard imputation methods (e.g. use of mean data for all participants for that specific 
missing data), with appropriate adjustment of the degrees of freedom for each data imputed. 
 
Table 6 
Primary Response Measurement Summary 
‡   Effect Size is the difference between means as a percentage of listed mean  
† *  Based on data from previous studies (31,32,33) using similar methods to those proposed here. Transit 
data† 
24.10 
Data Management 
from C-IBS studies (e.g. Renzapride, prucalopride, Tegaserod).  
Standardized CRFs and patient diaries will be developed in accordance with the study protocol. The PI 
will ensure that all data from patient visits including details of AEs and concomitant medications are 
entered promptly in the CRFs in accordance with specific instructions given. The PI must sign each CRF 
to verify the integrity of the data recorded.  All scintigraphy data, laboratory values and patient diary data 
will be provided to the Sponsor electronically in the form of Excel spreadsheets.   
The PI, Statistician and nuclear medicine technician will quality check the scintigraphy data before 
database lock. Audits of data may be conducted at the discretion of the sponsor Albireo AB by its 
representatives and/or regulatory agencies such as the FDA and Mayo IRB. 
The database will be locked when clean file has been declared. Any changes to the database after that 
time can only be made by joint written agreement between the Sponsor, the Statistician and the PI.  
The computerized data processing and the statistical analysis will be performed by the Mayo Clinic. Data 
will be processed in agreement with local legislations. 
24.11 
Changes in the approved study protocol 
Any proposed change to the study protocol version reviewed and approved by FDA and IRB (including 
appendices) will be documented in a written and numbered protocol amendment. All amendments must 
be submitted to Mayo IRB and Regulatory Authority for approval, according to applicable national 
regulations. A substantial protocol amendment should be signed and dated by the same parties who 
signed the Final Study Protocol, as applicable. 
 
 Assuming n=12/ group 
Effect Size‡ 
Detectable(N=12 per group)  with: 
(%)  
Response Type 
CV% 
80%Power (α=0.05) 
GE solids t1/2 min†
25 
  
27 
GC @ 24 hrs
35 
 † 
37 

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25 EMERGENCY PROCEDURES 
25.1 
Emergency contacts 
In case of an emergency the Investigator should contact the Monitor at the CRO Icon or the Project 
Manager at Albireo. 
25.2 
Procedures in case of medical emergency 
The PI is responsible for ensuring that there are procedures and expertise available to cope with medical 
emergencies during the study. 
26 STUDY TIME TABLE 
The first patient will be screened during January 2010 and the last patient will be completed during 
November/December 2010. The end of the clinical phase of the study will be defined as the last patient’s 
last study visit. The final closure of the study will be declared when Clinical Study Report has been 
finalized at Albireo AB and Mayo IRB has reviewed and approved a Final Progress Report which will not 
occur until a manuscript has been accepted for publication.  
27 DISCONTINUATION OF THE STUDY 
The Sponsor reserves the right to discontinue the study at any time, but intends only to exercise this right 
for valid scientific or administrative reasons. 
After such a decision, the Investigator must call in all participating subjects within one month and inform 
the subjects as well as perform relevant assessments, preferably according to the scheme for the final 
assessments. All delivered and unused IPs and other study materials must be returned and all CRFs 
completed as far as possible. 
Investigator(s) will be reimbursed for reasonable expenses incurred, in the event this becomes necessary. 
28 FINAL STUDY REPORT AND PUBLICATION OF STUDY RESULTS 
After conclusion of the study, Mayo will analyze the data and write a manuscript for publication in a 
peer-reviewed scientific journal. The Sponsor will have the opportunity to review the study data 
according to the conditions stipulated in the contract developed by Mayo's legal section. Publication 
rights are specifically identified in the Mayo Legal Section contracts. 
A Clinical Study Report, in compliance with ICH E3; Structure and content of Clinical Study Reports, 
describing the conduct of the study, the statistical analysis performed and the results obtained will be 
prepared by the Sponsor or designee. 
A summarizing report will be submitted to Regulatory Authorities and IRB within 12 months from end of 
study. The Final study Report will be submitted to Regulatory Authorities when available.  
29 RECORD RETENTION 
The Investigator must arrange for retention at the investigational site of a list of the subjects and their 
identifying code, subject files and other study documents. The archiving period must be adapted to 

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regulations in force and should not be shorter than ten years after the termination of the study and the 
presentation of the final report.   
It is the responsibility of the Sponsor to inform the investigator/institution as to when these documents no 
longer need to be retained. 
30 DISCLOSURE AND CONFIDENTIALITY 
All unpublished information concerning the test product and research carried out by the Sponsor, 
including patent applications, manufacturing processes, basic scientific data, etc., is considered 
confidential and the sole property of the Sponsor. Disclosure to third parties must be limited to those 
undertaking legitimate peer review of the scientific and ethical aspects of the study and to those 
participating, including the recipients of drugs, so that customary medical care and informed consent can 
be achieved. 
31 INSURANCE/INDEMNITY       
As described in the Research Agreement between Albireo AB and the Mayo Clinic, each party agrees to 
maintain, at its own expense, insurance in quantities and types, or self-insurance, sufficient to meet its 
legal obligations hereunder.  All policies shall be issued by financial secure companies and shall be 
written as primary coverage.  Such insurance shall provide for 30 days’ prior written notice of 
cancellation or material change.  Upon request, each party shall provide the other party with certificates of 
insurance evidence coverage. 
32 STUDY AGREEMENTS 
The Principal Investigator at the investigational site must comply with all the terms, conditions, and 
obligations of the Research Agreement for this study. In the event of any inconsistency between the Study 
Protocol and the Research Agreement, the Research Agreement shall prevail. Financial terms and 
conditions are specified in an exhibit to the Research Agreement. A separate financial agreement between 
Albireo AB and Mayo Clinic will be filed with Research Administration and a legal contract with the 
Mayo Legal Department as per standard protocol.  The Principal Investigator is required to maintain an 
updated Regulatory Binder which includes all required documents as per the Mayo Office of Research 
Compliance. 
33 REFERENCES   
 
1. Talley NJ, Weaver AL, Zinsmeister AR, Melton LJ, 3rd
2. Surrenti E, Rath DM, Pemberton JH, Camilleri M. Audit of constipation in a tertiary referral 
gastroenterology practice.  Am J Gastroenterol. 1995:90(9):1471-5. 
. Functional constipation and outlet delay: 
a population-based study. Gastroenterology. 1993;105(3):781-90. 
3. Camilleri M, Thompson WG, Fleshman JW, Pemberton JH. Clinical management of intractable 
constipation. Ann Intern Med. 1994:121(7):520-8. 
4. Thompson WG, Longstreth GF, Drossman DA, Heaton KW, Irvine EJ, Muller-Lissner SA. 
Functional bowel disorders and functional abdominal pain. Gut. 1999:45 Suppl 2:II43-7. 
5. Hofmann AF. The continuing importance of bile acids in liver and intestinal disease. Arch Intern 
Med 1999:159:2647-2658. 

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6. Wedlake L, A’hern R, Russell D, Thomas K, Walters J, Andreyev H. Systematic review: the 
prevalence of idiopathic bile acid malabsorption (I-BAM) as diagnosed by SeHCAT scanning in 
patients with diarrhoea-predominant irritable bowel syndrome (IBS). Aliment Pharmacol Ther 
2009 Jun 30. [Epub ahead of print]. 
7. Mekhjian HS, Phillips SF, Hofmann AF. Colonic secretion of water and electrolytes induced by 
bile acids: perfusion studies in man. J Clin Invest 1971;50:1569-1577. 
8. Wingate DL, Phillips SF, Hofmann AF. Effect of glycine-conjugated bile acids with and without 
lecithin on water and glucose absorption in perfused human jejunum. J Clin Invest 1973;52:1230-
1236. 
9. Conley DR, Coyne MJ, Bonorris GG, Chung A, Schoenfield LJ. Bile acid stimulation of colonic 
adenylate cyclase and secretion in the rabbit. Am J Dig Dis 1976;21:453-458. 
10. Camilleri M, Murphy R, Chadwick VS, Dose-related effects of chemodeoxycholic acid in the 
rabbit colon. Dig Dis Sci 1980;25:433-438. 
11. Chadwick VS, Gaginella TS, Carlson GL, Debongnie JC, Phillips SF, Hofmann AF. Effect of 
molecular structure on bile acid-induced alterations in absorptive function, permeability, and 
morphology in the perfused rabbit colon. J Lab Clin Med 1979;94:661-674. 
12. Alrefai WA, Saksena S, Tyagi S, Gill RK, Ramaswamy K, Dudeja PK.  Taurodeoxycholate 
modulates apical Cl-/OH- exchange activity in Caco2 cells. Dig Dis Sci 2007;52:1270-1278.   
13. Kruis W, Haddad A, Phillips SF. Chenodeoxycholic and ursodeoxycholic acids alter motility and 
fluid transit in the canine ileum. Digestion 1986;34:185-195. 
14. Bampton PA, Dinning PG, Kennedy ML, Lubowski DZ, Cook IJ. The proximal colonic motor 
response to rectal mechanical and chemical stimulation. Am J Physiol 2002;282:G443-G449. 
 
15. Kirwan WO, Smith AN, Mitchell WD, Falconer JD, Eastwood MA. Bile acids and colonic 
motility in the rabbit and the human. Gut 1975;16:894-902. 
 
16. Spiller RC, Brown ML, Phillips SF. Decreased fluid tolerance, accelerated transit, and abnormal 
motility of the human colon induced by oleic acid. Gastroenterology 1986;91:100-107. 
17. Mitchell WD, Findlay JM, Prescott RJ, Eastwood MA, Horn DB. Bile acids in the diarrhoea of 
ileal resection. Gut 1973;14:348-353. 
 
18. van Tilburg AJ, de Rooij FW, van Blankenstein M, van den Berg JW, Bosman-Jacobs EP.  Na+-
dependent bile acid transport in the ileum: the balance between diarrhea and constipation. 
Gastroenterology 1990;98:25-32. 
19. Schoenfield LJ, Lachin JM. Chenodiol (chenodeoxycholic acid) for dissolution of gallstones: the 
National Cooperative Gallstone Study. A controlled trial of efficacy and safety. Ann Intern Med 
1981;95:257-282. 
20. Mok HY, Bell GD, Dowling RH. Effect of different doses of chenodeoxycholic acid on bile-lipid 
composition and on frequency of side-effects in patients with gallstones. Lancet 1974;304:253-
257. 
21. Iser JH, Dowling H, Mok HY, Bell GD. Chenodeoxycholic acid treatment of gallstones. A 
follow-up report and analysis of factors influencing response to therapy. N Engl J Med 
1975;293:378-383. 
22. Meredith TJ, Williams GV, Maton PN, Murphy GM, Saxton HM, Dowling RH. Retrospective 
comparison of 'Cheno' and 'Urso' in the medical treatment of gallstones. Gut 1982;23:382-389. 

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23. Bell GD, Mok HY, Thwe M, Murphy GM, Henry K, Dowling RH. Liver structure and function in 
cholelithiasis: effect of chenodeoxycholic acid. Gut 1974;15:165-172. 
24. Buchwald H, Varco RL, Bowen JR, Williams SE, Hansen BJ, Campos CT, Campbell GS, Pearce 
MB, Yellin AE, Edmiston WA, Smink RD Jr, Sawin HS Jr. Effective lipid modification by 
partial ileal bypass reduced long-term coronary heart disease mortality and morbidity: five-year 
post-trial follow-up report from the POSCH, Program on the Surgical Control of the 
Hyperlipidemias. Arch Intern Med 1998;158:1253-1261. 
25. Angelin B, Eriksson M, Rudling M. Bile acids and lipoprotein metabolism: a renaissance for bile 
acids in the post-statin era? Curr Opin Lipidology 1999;10:269-74. 
26. Naoumova RP, O’Neill FH, Dunn S, Neuwirth CKY, Taylor GW, et al. Effect of inhibiting HM-
CoA reductase on 7α-hydroxy-4-cholesten-3-one, a marker of bile acid synthesis: contrasting 
findings in patients with and without prior up-regulation of the latter pathway. Eur J Clin Investig 
1999;29:404-12. 
27. Bertolotti M, Zambianchi L, Carulli L, Simonini MS, DelPuppo M, et al. Bile acid synthesis 
during chronic inhibition of bile acid absorption. Hepatology 2003;38:939-46. 
28. Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J 
Gastroenterol 1997;32(9):920-4. 
29. Burton DD, Camilleri M, Mullan BP, Forstrom LA, Hung JC.  Colonic transit scintigraphy 
labeled activated charcoal compared with ion exchange pellets.  J Nucl Med 38: 1807-1810, 1997. 
30. Cremonini F, Mullan BP, Camilleri M, Burton DD, Rank MR.  Performance characteristics of 
scintigraphic transit measurements for studies of experimental therapies.  Aliment Pharmacol 
Ther 16: 1781-1790, 2002. 
31. Bouras EP, Camilleri M, Burton DD, Thomforde G, McKinzie S, Zinsmeister AR:  Prucalopride 
accelerates gastrointestinal and colonic transit in patients with constipation without a rectal 
evacuation disorder.  Gastroenterology 120:354-360, 2001 
32. Camilleri M, McKinzie S, Fox J, Foxx-Orenstein A, Burton D, Thomforde G, Baxter K, 
Zinsmeister AR:  Effect of renzapride on transit in constipation-predominant irritable bowel 
syndrome.  Clin Gastroenterol Hepatol 2:895-904, 2004 
33. Andresen V, Camilleri M, Busciglio I, Grudell A, Burton D, McKinzie S, Foxx-Orenstein A, 
Kurtz CB, Sharma V, Johnston JM, Currie MG, Zinsmeister AR:  Effect of 5 days linaclotide on 
transit and bowel function in females with constipation-predominant irritable bowel syndrome.  
Gastroenterology
34 APPENDICES 
 133:761-768, 2007 
34.1 
Study Flow Chart 
 
Study assessments are described in the chart below. 
 
 
    
V1 
 
V2 
 
V3 
V4-V6 
 
V7 
Event 
Screen 
Baseline  
Transit 
(V1 + 7-14 days) 
Randomization  
(V2 + 0-3 days) 
Final 
Transit 
(days 12-14 of 
study med) 
Follow-up 
(V6 + 7-10 days) 

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x 
Patient information 
 
 
 
 
x 
Informed consent 
 
 
 
 
x 
Inclusion/exclusion criteria 
 
 
 
 
x 
Demographics 
 
 
 
 
x 
Medical history 
 
 
 
 
Physical examination
x 
1 
 
 
x 
x 
x 
Height/Weight 
 
 
 
x 
Vital signs
x 
2 
x 
x 
x 
x 
Med history/adverse events
x 
3 
x 
x 
x 
x 
x 
Concomitant medication 
x 
x 
x 
x 
Laboratory safety tests
x 
4 
 
 
x 
x 
Pharmacodynamics
x 
5 
 
 
x 
x 
Pregnancy test
x 
6 
x 
 
x 
 
x 
12-lead ECG 
 
 
x 
x 
x 
Long BDQ 
 
 
 
 
x (out) 
Bowel pattern diary  
 
 
 
x (in) 
Symptom and efficacy survey
 
7 
 
x 
x 
 
Scintigraphy
 
8 
x 
 
x 
 
Randomization
 
9 
 
x 
 
 
Pharmacokinetics
x 
10 
 
 
x 
x 
 
Administration of study med 
 
x 
x 
 
 
 
1 A rectal exam to be performed at Visit 1 to exclude the possibility of an evacuation disorder if a normal exam not 
documented within 2 years by a qualified gastroenterologist A patient may defer the rectal exam at Visit 6 and 7 if 
not clinically indicated. 
2 Includes temperature, blood pressure, pulse and respiratory rate 
3 Adverse events occurring prior to administration of study medication are classified as medical history 
4 Laboratory safety assessments include clinical chemistry (ALT; Albumin; Alkaline phosphatase; AST; Bilirubin, 
total; Calcium;  Chloride; C-Reactive Protein; Creatinine; GGT; Glucose; Potassium; Protein, total; Sodium; Urea; 
Uric acid), hematology (hemoglobin; hematocrit; MCV; platelet count; RBC count; WBC count with differential), 
coagulation studies (Activated partial prothrombin time aPPT; Prothrombin time PT), urinalysis (blood; glucose; 
ketones; leukocytes; nitrites; pH; protein), drugs of abuse urine screen (alcohol; amphetamines; barbiturates; 
benzodiazepines; cocaine; opiates; phencyclidine; tetrohydrocannibinol). The drugs of abuse urine screen is 
performed once at Visit 1; the other laboratory tests are performed at Visit 1, Visit 6 and Visit 7. 
5 Blood samples for pharmacodynamics including C4 and a lipid panel of total cholesterol, HDL, LDL and 
triglycerides are obtained at Visits 1, 4 and 7. 
6Females of child bearing potential are required to have a negative pregnancy test result within 48 hours prior to the 
receipt of radiation. Females who are status post-tubal ligation, post-hysterectomy or post-menopause are exempted 
from this requirement 
7 A six question survey concerning constipation symptoms and treatment efficacy will be given at Visit 3, the end of 
the pre-treatment period, and again at Visit 6, the end of the treatment period. 

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8An abbreviated transit scintigraphy with scans obtained at 4 and 24h is performed at Visit 2. A full transit with 
scans obtained at 0, 30 min, 60 min, 90 min, 2, 3, 4, 5, 6, 7 and 8 hours after taking study medication for 12 
consecutive days at Visits 4-6. 
9
 
Criteria for randomization is defined as a geometric center < 2.30 at 24h, the median of normal colonic transit 
in normal healthy volunteers (as determined by analysis of a compilation of prior Camilleri studies) 
10
 
Blood samples for pharmacokinetics are obtained at Visit 4 at pre-dose, 30, 60, 90, 120, 180, 240, 360, 480 
minutes after study medication.  One blood sample for pharmacokinetics is obtained at Visit 1 and Visit 7 as well. 
 
34.2 
Bristol Stool Scale 
     
 
Ease of Passage: 
 
1. Manual disimpaction required 
2. Enema or suppository required to initiate bowel movement 
3. Some straining necessary to pass bowel movement 
4. Easy normal passage of stool without straining 
5. Urgent need to pass bowel movement spontaneously; no abdominal pain or discomfort present 

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6. Urgent need to pass bowel movement spontaneously; abdominal pain or cramping present 
7. Incontinent of bowel movements 

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34.3 
Laboratory Test Panels 
 
Test 
Complete Blood Count (CBC) 
Normal ranges 
Units 
Hemoglobin 
12.0 - 15.5 
g/dL 
Hematocrit 
34.9 - 44.5 
% 
Erythrocytes 
3.90 - 5.03 
x 1012
MCV 
/L 
81.6 - 98.3  
fL 
RBC Distrb Wid 
11.9 - 15.5 
% 
Leukocytes 
3.5 -10.5 
x 109
Platelet Count 
/L 
150 - 450 
x 109
 Neutrophils 
/L 
1.7 - 7.0 
x 109
 Lymphocytes 
/L 
0.9 - 2.9 
x 109
 Monocytes 
/L 
0.3 - 0.9 
x 109
 Eosinophils 
/L 
0.05 - 0.50 
x 109
 Basophils 
/L 
0 - 0.3 
x 109
 
/L 
Test 
Comprehensive Metabolic Panel (CMP) 
 
Normal ranges 
Units 
Sodium 
 
135 - 145 
mmol/L 
Potassium 
 
3.6 - 5.2 
mmol/L 
Calcium 
 
8.9 - 10.1 
mg/dL 
Protein,Total 
 
6.3 - 7.9 
g/dL 
Glucose  
 
70 - 100 
mg/dL 
Alk Phosphatase 
Age 
Age dependent 
U/L 
 
16 
61 - 264 
 
 
23 
52 - 144 
 
 
45 
37 - 98 
 
 
50 
39 - 100 
 
 
55 
41 - 108 
 
 
60 
46 - 118 
 
 
65 
50 - 130 
 
AST (GOT) 
 
8 - 43 
U/L 
ALT (GPT) 
 
7 - 45 
U/L 
Bilirubin,Total 
 
0.1 - 1.0 
mg/dL 
Creatinine 
 
0.6 - 1.1 
mg/dL 
Albumin 
 
3.5 - 5.0 
g/dL 
BUN  
 
6 - 21 
mg/dL 
Chloride 
 
100 - 108 
mmol/L 
Bicarbonate 
 
22 - 29 
mmol/L 
 

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Test 
Other Blood Values 
Normal ranges 
Units 
C-reactive protein 
< = 8.0 
mg/L 
GGT 
6 -29 
U/L 
Uric acid 
2.7 – 6.1 
mg/dL 
aPTT 
21 - 33 
sec 
PT 
8.3 – 10.8  
sec 
Cholesterol 
< 230 
mg/dL 
HDL cholesterol 
> 40  
mg/dL 
LDL cholesterol 
< 159  
mg/dL 
Triglycerides 
< 199 
mg/dL 
 
Test 
Dipstick Urinalysis (UA) 
Normal ranges 
Units 
pH 
5.0 – 8.0 
pH units 
Glucose 
Neg 
 
Protein 
Neg 
 
Hemoglobin 
Neg 
 
Ketones 
Neg 
 
Leukocytes 
Neg 
 
Nitrites 
Neg 
 
 
 
Test 
Drugs of Abuse urine screen (DAUS) 
Normal ranges 
Units 
Alcohol 
< 30 
mg/dL 
Amphetamine 
< 1000 
ng/mL 
Barbiturates 
< 200 
ng/mL 
Benzodiazepines 
< 200 
ng/dL 
Cocaine 
< 300 
ng/mL 
Opiates 
< 300 
ng/mL 
Phencyclidine 
< 25 
ng/mL 
Tetrahydrocannabinol 
< 20 
ng/mL 
 
 

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34.4 
Patient informed consent form 
 
Name and Clinic Number 
 
IRB # _____________ 
Consent form approved                   ; 
This consent valid through                   ; 
 
1. General Information About This Research 
Study  
Study Title:  A Phase II, Double Blind, Randomized, Placebo Controlled Study of the Effects of A 3309, 
an Ileal Bile Acid Transport Inhibitor, on Small Bowel and Colonic Motor Functions in Female Patients 
with Functional Constipation. 
 
Name of Principal Investigator on this Study: Dr Michael Camilleri and Colleagues 
 
A.  Study Eligibility and Purpose 
 
You are being asked to take part in this research study because we are studying the effects of an 
investigational (not FDA approved) medication, A3309, on the movement of food through the stomach, 
small intestine and colon in females with constipation.  
   
As you read this form describing the study, ask any questions you have.  Take your time to decide.  Feel 
free to discuss the study with your family, friends, and healthcare provider before you decide.  If you 
decide to participate, you may stop participating at any time during the study.  You may decide not to 
participate.  If so, none of your current benefits or normal health care will be affected in any way.  When 
you feel comfortable that all your questions have been answered, and you wish to take part in this study, 
sign this form in order to begin your participation.  Your signature means you have been told about the 
study and what the risks are. Your signature on this form also means that you want to take part in this 
study.  
 
B.  Number of Participants 
 
The plan is to have 36 female participants with constipation take part in this study at Mayo Clinic.  
 
C.  Additional Information You Should Know 
 
Albireo AB is funding the study.  Albireo AB will pay your study doctor or the institution to cover costs 
related to running the study.  
 
 
2. What Will Happen To You While You Are In 
This Research Study? 

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The study will last up to about forty-one (41) days from the date of the first visit, but the actual testing 
will be done over five (5) days on two (2) separate occasions in the Charlton 7 Clinical Research Unit 
(CRU).   
 
If you agree to be in the study, you will be asked to participate in the following activities:  
 
Visit 1 – You will be asked to report to the Charlton 7 CRU fasting for the previous eight (8) hours, no 
food or drink allowed. You will be asked to review and sign an informed consent form. You will have an 
interview with and a brief physical examination performed by a study physician. If you have not had a 
normal rectal exam to rule out a possible evacuation disorder documented within the past two (2) years, 
this exam will be performed at this time. You will have your height, weight and vital signs (pulse, blood 
pressure, respiration rate and temperature) measured. You will be asked to have an electrocardiogram 
(ECG), a recording of the heart rhythm, performed. Blood and urine samples will be obtained to perform 
standard laboratory safety tests including hematology, chemistry, coagulation studies, urinalysis, urine 
screen for drugs of abuse and a urine pregnancy test for females of childbearing potential. You will be 
told the results of the pregnancy test. If it is positive, you will not be able to take part in the study Note 
that females who are status post bilateral tubal ligation, hysterectomy or postmenopausal do not need this 
test. Blood samples will also be obtained for pharmacodynamics (C4, total cholesterol, LDL, HDL, and 
triglycerides) and one solitary pharmacokinetic sample. The total volume of blood obtained for the 
standard laboratory tests is about two tablespoons. You will be asked to complete one (1) questionnaire, 
the long Bowel Disease questionnaire (BDQ) to confirm the diagnosis of constipation. This questionnaire 
requires about ten (10) to twenty (20) minutes total to complete. You will be given a bowel pattern diary 
and instructed in its completion. You will record numbers in this bowel pattern diary beginning today 
through Visit 7, the final day of the study for a maximum of 41 days. This visit will require approximately 
45 to 75 minutes total. 
 
During the study, you will be asked to refrain from donating blood; participating in other research studies 
or taking any additional over-the-counter or prescription medications or herbal supplements that have not 
been reviewed and approved by the physician or the study coordinator until the study has been completed. 
 
Prior to Visit 2 - Females who may become pregnant must have a negative urine pregnancy test within 
forty-eight hours prior to receipt of radiation in the abbreviated transit scintigraphy test. You will be told 
the results of the pregnancy test. If it is positive, you will not be able to take part in the study. Females 
who have experienced a bilateral tubal ligation, hysterectomy or menopause will not need the pregnancy 
test. You may leave a urine sample at Desk Charlton 7 CRU the day prior to Visit 2 or bring in a sample 
with you should Visit 2 fall on a Monday. 
 
 
Visit 2 – Within 7-14 days of Visit 1, you will be asked to return to Charlton 7 CRU fasting for the 
previous eight (8) hours, no food or drink allowed, to have your vital signs (pulse, blood pressure, 
respiration rate and temperature) measured. You will be given a capsule containing a small amount of 
radioactivity. This allows the movement of food particles through the colon to be measured using an 
external camera.  You will be asked not to eat anything for the next two (2) hours and to return four (4) 
hours later for one five (5) minute camera picture.  You will be asked to return the following morning at 
the same time you took the capsule for another five (5) minute camera image.  If the camera indicates a 
state of constipation, you will continue in the study and receive the study medication.  If the camera does 
not indicate a state of constipation, the study will be ended at this time. 
 
Visit 3 – You will be asked to return to Charlton 7 CRU fasting for the previous eight (8) hours, no food 
or drink allowed, to have your vital signs (pulse, blood pressure, respiratiorn rate and temperature) 

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measured. You will be complete a six (6) question survey of constipation symptoms and treatment 
effectiveness before you receive the study medication.  This survey will require less than five (5) minutes. 
You will be assigned to the study medication which is either a placebo (an inactive substance) or a 15 mg 
or 20 mg dose of A3309 study medication taken orally once daily for a total of fourteen (14) consecutive 
days, eleven (11) doses at home and three (3) at the Charlton CRU during the final transit scintigraphy 
test, Visit 4 to Visit 6.  You will be put into one of these three (3) groups by chance (as in the flip of a 
coin). There is a two in three (2/3) chance that you would receive the A3309 study medication and a one 
in three (1/3) chance you would receive placebo. Neither you nor the research team will know what study 
medication you receive. However, in case of emergency, the physician would be able to find out.  This 
study will require about fifteen minutes total. 
 
Prior to Visit 4 - Females who may become pregnant must have a negative urine pregnancy test within 
forty-eight hours prior to receipt of radiation in the abbreviated transit scintigraphy test. You will be told 
the results of the pregnancy test. If it is positive, you will not be able to take part in the study. Females 
who have experienced a bilateral tubal ligation, hysterectomy or menopause will not need the pregnancy 
test. You may leave a urine sample at Desk Charlton 7 CRU the day prior to Visit 2 or bring in a sample 
with you should Visit 2 fall on a Monday. 
 
Visit 4 - You will be asked to return to Charlton 7 CRU fasting for the previous eight (8) hours, no food 
or drink allowed, to have your vital signs (pulse, blood pressure, respiration rate and temperature) 
measured. A 12-lead ECG will be performed. You will be given the study medication and a capsule 
containing a small amount of radioactivity. This allows the movement of food particles through the colon 
to be measured using an external camera. About one hour after taking the capsule, you will stand in front 
of a special camera and an anterior and posterior image will be obtained. You will be given a scrambled 
egg breakfast meal; the eggs also contain a small amount of radioactivity. Images will be obtained 
immediately after the egg breakfast; this image is considered the start of the imaging procedure or the 
‘zero hour’ image. Images will be obtained at 30, 60 and 90 minutes later and at 2, 3, 4, 5, 6, 7, and 8 
hours after the ‘zero hour’ image. An intravenous line (a small sterile plastic catheter) will be placed in 
your forearm or hand to obtain small volume blood samples for pharmacokinetic (pk) analysis (the 
amount of study medication present in the blood sample). Small volume blood samples will be drawn 
immediately before the administration of the study medication and at 30, 60, 90, 120, 180, 240, 360 and 
480 minutes after the administration of the study medication.  Blood and urine samples will also be 
obtained to perform standard laboratory safety tests including hematology, chemistry, coagulation studies, 
and a urinalysis. Blood samples will also be obtained for pharmacodynamics (C4, total cholesterol, LDL, 
HDL, and triglycerides) at this time. The total amount of blood taken will be about five (5) tablespoons.  
About four (4) hours after the breakfast, you will eat a standard chicken breast lunch meal. You will have 
camera images taken at five (5),  six (6) and seven (7) hours. You will eat a standard roast beef sandwich 
snack, about eight (8) hours after the breakfast followed by a final camera image. These standard meals 
are not radioactive, they are supplied only so all participants in this study eat the same type and same 
amount of food this day. You will be asked not to eat or drink anything while you are having the transit 
test performed today other than what you are given. After the eight (8) hour image is completed, you will 
be instructed to return to the Charlton 7 CRU at specific times on the following two (2) mornings for 
administration of study medication and to obtain one five (5) minute camera image. This visit will require 
about nine to ten (9 to 10) hours total. 
 
 
Visit 5 – The following morning, you will be asked to return to the Charlton 7 CRU fasting for the 
previous eight (8) hours, no food or drink allowed. You will receive the study medication and one five (5) 
minute camera image will be obtained. This visit will require fifteen (15) to twenty-five (25) minutes 
total. 
 

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Visit 6 – The following morning, you will be asked to return to the Charlton 7 CRU fasting for the 
previous eight (8) hours, no food or drink allowed, to receive the study medication. One five (5) minute 
camera image will be obtained. A study physician will perform a brif physical exam. You will be asked to 
complete a six (6) question survey of constipation symptoms and treatment effectiveness. This survey will 
require less than five (5) minutes. This visit will require fifteen (15) to twenty-five (25) minutes total. 
 
Visit 7 – Within seven (7) to ten (10) days after completing Visit 6, you will return to Charlton 7 CRU 
fasting for the previous eight (8) hours, no food or drink, to have your height, weight and vital signs 
(pulse, blood pressure, respiration rate and temperature) measured. Blood and urine samples will be 
obtained to perform standard laboratory safety tests including hematology, chemistry, coagulation studies 
and a urinalysis. Blood samples will also be obtained for pharmacodynamics (C4, total cholesterol, LDL, 
HDL, and triglycerides) and one solitary pharmacokinetic sample. The total amount of blood obtained for 
the standard laboratory tests is about two (2) tablespoons.  A 12-lead ECG will be performed. You will be 
asked to turn in your completed bowel pattern diary. You will have a physical exam by the study doctor 
and an exit interview with study staff. This visit will require about twenty (20) to forty-five (45) minutes. 
 
3. How Long Will You Be in This Research 
Study? 
 
You will be in the study for a maximum of about forty-one (41) days.   
 
4. Why You Might Want To Take Part In This 
Research Study 
This study will not make your health better. It is for the benefit of research. 
 
 
5. What Are the Risks Of This Research Study? 
Data from two prior phase I studies using up to 5 mg in healthy volunteers and up to 10 mg in patients 
with functional constipation suggest that the study medication is well tolerated. In 26 normal healthy 
volunteers, the adverse events observed were: flatulence (27 percent), abdominal distension (19 percent), 
abdominal pain and nasopharyngitis (12 percent each), and diarrhea, nausea and headache, (2 percent 
each). In 25 constipation patients, the adverse events observed were: abdominal distension, nausea and 
headache (8 percent each).  
 
As with any medication, allergic reactions are a possibility.   
 
The risks of drawing blood include pain, bruising, or rarely, infection at the site of the needle stick. 
 
You will be exposed to radiation in this study.  The amount of radiation you will receive has a low risk of 
harmful effects.  
 
Some questions you will be asked to answer in the study questionnaire(s) may make you feel 
uncomfortable.  You may choose not to answer any questions that make you feel uncomfortable. 
 

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Pregnancy and Birth Control:  
1) Will women of child-bearing-potential be allowed to participate in this study? 
Yes:  Women of child-bearing-potential will be able to participate in this study if they have a 
negative pregnancy test and agree to use acceptable birth control (see # 4) since the risks to an 
unborn child are either unknown or potentially serious. 
 
2)   Will pregnant and/or nursing women be allowed to participate in this study?  
      No:  There is not enough medical information to know what the risks might be to    an unborn 
child carried by a woman who takes part in this study. 
 
3)   Do you need to have a pregnancy test done to be part of the study?   
      Yes: As part of this study a pregnancy test is required for all women who are able   to become 
pregnant. A urine pregnancy test will be done. You will be told the results of the pregnancy test.  
If the pregnancy test is positive, you will not be able to take part in the study. 
 
4)  What types of birth control are acceptable?  
Surgical sterilization 
Approved hormonal contraceptives (such as birth control pills, Depo-Provera) 
Barrier methods (such as a condom or diaphragm) used with a spermicide 
An intrauterine device (IUD) 
Abstinence 
 
Risk summary  
Many side effects go away shortly after the A3309 study medication is stopped, but in some cases side 
effects can be serious, long lasting, or may never go away.  Some side effects may not be known.  Side 
effects may range from mild to life-threatening. Other drugs may be given to make side effects less 
serious and less uncomfortable.  Talk to the researcher and/or your healthcare provider about side effects 
and ask any other questions. 
 
6. What Other Choices Do You Have If You 
Don’t Take Part In This Research Study? 
 
This study is only being done to gather information.  You may choose not to take part in this study. 
 
7. Are There Reasons You Might Leave This 
Research Study Early? 
 
Taking part in this research study is voluntary.  You may decide to stop at any time.  You should tell the 
researcher if you decide to stop and you will be advised whether any additional tests may need to be done 
for your safety.  
 
In addition, the researchers, Albireo or Mayo may stop you from taking part in this study at any time: 
o 
if it is in your best clinical interest,  
o 
if you do not follow the study procedures  ,  
o 
if the study is stopped.  

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8. Will You Need To Pay For Any Of The Tests 
And Procedures? 
 
You will not need to pay for tests and procedures which are done just for this research study.  These tests 
and procedures are: 
 
• 
Height, weight and vital signs 
• 
Physical exams 
• 
Urine pregnancy tests 
• 
Laboratory tests including chemistry, hematology, coagulation studies, urinalysis and urine 
screen for drugs of abuse 
• 
Electrocardiograms (ECGs) 
• 
Blood draws for laboratory tests and pk samples 
• 
Camera imaging studies 
• 
Study medication (A3309 or placebo) 
• 
Study meals 
 
 
However, you and/or your health plan will need to pay for all other tests and procedures that you would 
normally have as part of your regular clinical care. 
 
If you have study related questions regarding billing, insurance or reimbursement, stop by or call: 
Admission and Business Services office, or call Patient Account Services at (507) 287-1819 
 
9. Will You Be Paid For Participating In This 
Research Study? 
 
If you finish the study, you will receive $600.  This money is for the time you spend in this study.  If you 
start the study but stop before finishing the study, you will receive part of this money. 
 
 
10. What Happens If You Are Injured Or Ill 
Because You Were In This Research Study? 
 
If you have side effects from taking part in this study, you need to report them to the researcher and your 
regular physician, and you will be treated as needed.  Mayo will give medical services for treatment for 
any bad side effects from taking part in this study.  Such services will be free if not covered by a health 
plan or insurance. No additional money will be offered. 
 

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If you have injuries directly resulting from the proper application of the study drug, whether at Mayo or 
another institution, the sponsor Albireo will pay for appropriate medical treatment beyond that covered by 
your health insurance or other third party or government programs, at no cost to you.  Your study doctor 
can help you obtain this reimbursement.  The sponsor will not be responsible for deductibles and co-pays.  
The sponsor Albireo will not offer to pay you for lost wages, disability, or discomfort due to any such 
side effects or injuries. 
 
 
11. What Are Your Rights If You Are In This 
Research Study? 
 
Taking part in this research study will not change your rights and benefits.  Taking part in this research 
study does not give you any special privileges.  If you decide to not participate in this study, or stop in the 
middle of the study, no benefits are taken away from you.  Specifically, you do not have to be in this 
research study to receive or continue to receive medical care from Mayo Clinic. 
 
You will be told of important new findings or any changes in the study or procedures that may affect you 
or your willingness to continue in the study. 
 
12. What About Your Privacy? 
 
Authorization To Use And Disclose Protected Health Information 
 
Your privacy is important to us, and we want to protect it as much as possible.  By signing this form, you 
authorize Mayo Clinic and the investigators to use and disclose any information created or collected in the 
course of your participation in this research protocol.  This information might be in different places, 
including your original medical record, but we will only disclose information that is related to this 
research protocol for the purposes listed below. 
 
This information will be given out for the proper monitoring of the study, checking the accuracy of study 
data, analyzing the study data, and other purposes necessary for the proper conduct and reporting of this 
study.  If some of the information is reported in published medical journals or scientific discussions, it 
will be done in a way that does not directly identify you. 
 
This information may be given to other researchers in this study, representatives of the company 
sponsoring the study, Albireo, including representatives in the USA or other countries, or private, state or 
federal government parties or regulatory authorities in the USA and other countries responsible for 
overseeing this research.  These may include the Food and Drug Administration, the Office for Human 
Research Protections, or other offices within the Department of Health and Human Services, and the 
Mayo Clinic Office for Human Research Protections or other Mayo groups involved in protecting 
research subjects. 
 
Information Disclosed to Study Sponsor 
The study data sent by the study doctor to the sponsor does not include your name, address, social 
security number, or other information that directly identifies you.  Instead, the study doctor assigns a code 

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number to the study data and may use your initials.  Some study data sent to the sponsor may contain 
information that could be used (perhaps in combination with other information) to identify you (eg, date 
of birth). If you have questions about the specific health information that will be sent to the sponsor, you 
should ask the study doctor. 
 
If this information is given out to anyone outside of Mayo, the information may no longer be protected by 
federal privacy regulations and may be given out by the person or entity that receives the information.  
However, Mayo will take steps to help other parties understand the need to keep this information 
confidential. 
 
This authorization lasts until the end of the study. The study does not end until all data has been collected, 
checked (or audited) and analyzed.  Sometimes this can be years after your study visits have ended.  For 
example, this could happen if the results of the study are filed with a regulatory agency like the Food and 
Drug Administration 
 
You may stop this authorization at any time by writing to the following address: 
 
Mayo Clinic 
Office for Human Research Protection 
ATTN:  Notice of Revocation of Authorization 
200 1st Street SW 
Rochester, MN  55905 
 
If you stop authorization, Mayo may continue to use your information already collected as part of this 
study, but will not collect any new information.  
 
12 a. Additional Information About Your 
Privacy 
What Other Things Might the Sponsor do with Study Data? 
In addition to the uses listed above, companies that sponsor studies often use study data for other 
purposes that are not part of the study.  For example, the company might use the study data for research 
purposes to support the scientific objectives of the study described in this consent document, to learn 
more about the effects (good and bad) of any drug, device or treatment included in the study, to better 
understand the disease(s) included in the study, or to improve the design of future studies.  Also, the 
company might share the study data with other companies it does business with.  The company might do 
these things during the study, or after the study has ended, and would not have to ask for your permission 
to do so.  The sponsor might still use study data, even after you stop your authorization, or the 
authorization expires, as long as the study data was collected before your authorization stopped or 
expired.  The ways in which the study data could be used in the future may not be known now, so we 
can’t give you the details. 
 
13. What Will Happen to Your Samples? 
 
Your samples obtained for pharmacokinetic measurements and for evaluation of biological effects of the 
drug will be sent to the sponsor or the sponsor’s designee.  The sponsor can use your samples solely for 
research purposes as described in the research study.  Your sample will be returned to Mayo or destroyed 

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upon termination or expiration of the research study.  Your sample will be sent to the sponsor in a coded 
format, which protects your identity.  Mayo has the right to end storage of the sample without telling you 
Your samples obtained for standard safety assessments (chemistry, hematology, coagulation studies, 
urinalysis and urine screen for drugs of abuse) will be used as described for this study.  When the study is 
done, they will be destroyed. 
 
14. Who Can Answer Your Questions? 
 
You can call … 
At … 
 If you have questions or concerns about 
… 
Principal Investigator: 
Michael Camilleri, MD 
 
Study Coordinator: 
Sanna McKinzie, MS 
 
Phone: 6-2305 
 
 
Phone: 6-8627 
 
 
Questions about the study tests and 
procedures 
 
Research-related injuries or emergencies 
 
Any research-related concerns or 
complaints 
Mayo Clinic IRB  
 
Research Subject 
Advocate:  
Shari Brumm  
 
Phone: 
507-266-4000 
 
Toll-Free: 
866-273-4681 
Rights of a research subject 
 
Use of Protected Health Information 
 
Any research-related concerns or 
complaints 
Research Billing  
Rochester: 
507-287-1819 
 
Billing / Insurance 
Questions 
 
 
15. Summary and Enrollment Signatures 
 
You have been asked to take part in a research study, at Mayo Clinic.  The information about this study 
has been provided to you to inform you about this study. 
 
• 
I have read the whole consent form, and all of my questions have been answered to my 
satisfaction. 
 
• 
I am satisfied that I have been given enough information about the purpose, methods, risks, and 
possible benefits of the study to decide if I want to join. 
 
• 
I know that joining the study is voluntary and I agree to join the study. 
 
 
• 
I know that I can call the investigator and research staff at any time with any questions or to tell 
them about side effects. 
 
• 
I know that I may withdraw from the study at any time. 
 
A copy of this form will be put in my medical records and I will be given a copy of this completed 
form. 

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Please sign and date to show that you have read all of the above guidelines.  Please do not sign unless you 
have read this entire consent form.  If you do not want to sign, you don’t have to, but if you don’t you 
cannot participate in this research study.  
 
 
 
 
______________ 
_______________________________________________________________ 
______________   
__________________________________________    ________________ 
(Date / Time) 
(Printed Name of Participant) 
(Clinic Number) 
 
 
_____________________________________________ 
 
(Signature of Participant) 
 
 
______________ 
_______________________________________________ 
(Date / Time) 
(Printed Name of Individual Obtaining Consent) 
 
 
 _______________________________________________ 
(Signature of Individual Obtaining Consent) 
 

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34.5 
Patient bowel pattern diary 
 
Daily Diary
Date
Please record the time the study medication was taken   ____:____ am  
If you had no bowel movements today, please check this box:
no bowel movement today
1
Hard lumps
1
Manual Disimpaction
1
Not al all
1
No
1
No
2
Lumpy sausage
2
Enema needed
2
A little bit
2
Yes
2
Yes
3
Cracked sausage
3
Straining needed
3
More straining than not
4
Smooth sausage
4
Normal
4
A great deal
5
Soft lumps
5
Urgent wo/pain
5
An extreme amount
6
Mushy
6
Urgent w/pain
7
watery
7
Incontinent
am
1
pm
am
2
pm
am
3
pm
am
4
pm
am
5
pm
am
6
pm
am
7
pm
am
8
pm
No
Yes
(complete below)
Event
Mild  /  Moderate  /  Severe
Resolved  /  Ongoing
Event
Mild  /  Moderate  /  Severe
Resolved  /  Ongoing
Event
Mild  /  Moderate  /  Severe
Resolved  /  Ongoing
No
Yes
(complete below)
Medication
Medication
Medication
Dose
Dose
Dose
Time(s)
Time(s)
Time(s)
hr.
Describe the consistency 
of bowel movement
min
hr.
min
hr.
min
hr.
min
Did you feel like you had a 
sensation of obstruction and/or 
blockage during the bowel 
movement?
hr.
hr.
min
min
Describe the ease of passage 
of bowel movement
Did you feel like you 
completely emptied your 
bowels?
How much did you strain 
during the bowel movement?
hr.
min
   Have you had any unusual events today?
   Have you taken any atypical medications today?
hr.
min
 
 
 
 
 
 
 
 
 
 

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34.6 
Survey of Constipation Symptoms and Treatment Efficacy 
 
1. On average, how would you rate your constipation during the past 7 days? 
 
1 = None 
 
2 = Mild 
 
3 = Moderate 
 
4 = Severe 
 
5 = Very severe 
 
2. Compared to before you started this study, how would you rate your constipation during the  
    past 7 days? 
 
1 = Completely relieved 
 
2 = Considerably relieved 
 
3 = Somewhat relieved 
 
4 = Unchanged 
 
5 = Somewhat worse 
 
6 = Considerably worse 
 
7 = As bad as I can imagine 
 
3. Compared to before you started this study, how would you rate the treatment effectiveness 
    during the past 7 days? 
 
1 = Not at all effective 
 
2 = A little bit effective 
 
3 = Moderately effective 
 
4 = Quite a bit effective 
 
5 = Extremely effective 
 
4. How would you rate your abdominal discomfort over the last 24 hours? 
 
1 = None 
 
2 = Mild 
 
3 = Moderate 
 
4 = Severe 
 
5 = Very severe 
 
5. How would you rate your abdominal pain over the last 24 hours? 
 
1 = None 
 
2 = Mild 
 
3 = Moderate 
 
4 = Severe 
 
5 = Very severe 
 
6. How would you rate your bloating over the last 24 hours? 
 
1 = None 
 
2 = Mild 
 
3 = Moderate 
 
4 = Severe 
 
5 = Very severe 
 
 
 
Data and Safety Monitoring Plan 

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Mayo Clinic  
CTSA – Research Resources 
 
Protocol Application - Data and Safety Monitoring Plan Template (DSMP) 
 
IRB #:  
09-00618
Protocol Title: Effects of A3309, an Ileal Bile Acid Transport Inhibitor, on Small Bowel and Colonic 
Motor Functions in Female Patients with Functional Constipation 
 
 
 
PI: M. Camilleri, MD 
 
Person Completing This Form: S. McKinzie, MS 
 
Date of Completion/Revision: 10/20/2009 
 
Introduction 
Please use the following template to develop or reflect your Data and Safety Monitoring Plan (DSMP). 
All protocols conducted on the Clinical Research Unit (CRU) or use any CTSA – Research Resources are 
required to have a DSMP.  
 
Please include the DSMP with your protocol submission to the CTSA – Research Resources. The 
DSMP also requires IRB approval and may be submitted to the IRB with your new protocol at the 
time of submission or to the appropriate IRB review board with a modification form if the protocol 
is already IRB approved. 
 
The specifics of the DSMP will depend on the nature, size, complexity, and risk of the research 
study. Your DSMP is one aspect of your protocol and the completed template is to be included 
with your protocol submission to both the CTSA – Research Resources and IRB. 
 
The DSMP template includes the following steps: 
1. Risk assessment 
2. Data and Safety Monitoring Elements 
• 
Safety contact 
• 
Safety assessment (identify risks, assessment measures, individual doing assessments, frequency 
of assessments, and interventions to respond to risks) 
• 
Monitoring/reviewing of data and safety issues/trends (by whom and at what frequency) 
• 
Adverse event-grading and attribution 
3. Implementation Plan 
• 
Reports, response to subject withdrawal/dropout, and decision making criteria for continuation, 
modification, or termination of protocol 
 
Please contact one of the following for assistance with your DSMP: 
Bettie Lechtenberg 
 
 
 
 
 
 
CTSA – Research Resources 
Administrative Office Manager/Protocol Specialist 
Lechtenberg.bettie@mayo.edu 
 
 
 
  
Eric L. Matteson, M.D. 
CTSA – Research Resources 
Research Resources Safety Committee Chair 
 
Director of Research Subject Advocacy and Compliance 
matteson.eric@mayo.edu 
 

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Protocol Application – Data and Safety Monitoring Plan Template 
 
A. Rank risks associated with participant characteristics that may increase participant’s      
vulnerability to unanticipated or undesired response (check all that apply). 
STEP 1: PROTOCOL RISK ASSESSMENT 
 
Category of Risk 
 
Low 
Medium 
High 
Notes 
Age of Subjects 
x 
 
 
Patients aged 18-65 only 
Childbearing Status 
x 
 
 
Pregnant and breast-feeding 
females not allowed; use of 
contraception required; urine 
pregnancy tests required for 
females of child bearing 
potential 
Health/Disease Status 
x 
 
 
Stable, otherwise healthy 
constipation patients 
Concurrent Stressors 
x 
 
 
Not anticipated 
Communication Difficulties 
x 
 
 
Not anticipated 
Cognitive Difficulties 
x 
 
 
Not anticipated 
Other 
 
 
 
 
 
B. 
Rank risks associated with procedures (check all that apply). 
Please note, procedural risks may increase when additional stimuli occurs prior to or during 
procedures. Risk may be related to the procedure’s complexity, instrumentation, magnitude or 
interaction with other procedures. 
 
Category of Risk 
 
Minimal 
Risk 
Minor 
Increase 
over 
Minimal 
More Than 
a Minor 
Increase 
over 
Minimal 
Significant 
Risk 
Notes 
Anthropomorphic evaluations 
x 
 
 
 
 
Blood pressure measurement 
x 
 
 
 
Vital signs 
Blood draws 
x 
 
 
 
Safety labs x 3 
Electrocardiogram (EKG) 
x 
 
 
 
Safety labs x 3 
GI transit study 
x 
 
 
 
Low dose isotope 
*Investigational drug (IND) 
x 
 
 
 
A3309, an IBAT  
Radiation 
x 
 
 
 
Transit studies 
Venipuncture 
x 
 
 
 
Safety labs x 3 
Venous lines 
x 
 
 
 
pk sampling once 

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Step 2: Data and Safety Monitoring Plan Elements 
 
Method of data and safety monitoring:  
Note: A Date and Safety Monitoring Board (DSMB) may be appropriate if any of the research 
procedures or participant characteristics are noted as “more than minor increase over minimal 
risk” and/or
 
 any of the items below are applicable to the study (mark all that apply). 
 Phase I or II clinical trial 
 Phase III clinical trial 
 Multi-site 
X Blinded (masked) 
X Randomized 
X Placebo-controlled 
 
 
Questions: 
 
1. Does this protocol require a DSMB?  
 Yes 
      X No 
 
2. Who will provide the data and safety monitoring? 
 An “external” DSMB funded by the 
protocol   
     sponsor(s). Complete Questions 3 and 4  
     below. 
X PI or designee. Omit Question 3 and 
complete  
      Question 4 below. 
 An “internal” DSMB or committee 
organized and funded by the investigator. 
Complete Questions 3 and 4 below. 
 Other. Describe: 
 No DSMB needed – Justification is 
attached. 
      
 
 
Identify who will review (monitor) data and safety assessment activities at Mayo (PI, Research 
Study Coordinator, etc.). [Specific safety assessment activities are listed in Section C.] 
Name 
Role on Project 
Frequency of Review 
Michael Camilleri, 
MD 
PI 
Monthly or as necessary for adverse events 
Archana Rao, MD 
CI 
Monthly or as necessary for adverse events 
Sanna McKinzie, MS 
SC 
As necessary for adverse events 
 
Safety contact information 
Who will be available on-call if an unexpected event including after-hour patient safety  
concerns would occur? At least one (1) person must be identified.  
Name (degree/license) 
Role on Project 
Contact Information 
(telephone, pager, e-mail) 
Michael Camilleri, MD 
Staff Prinicipal Investigator 
46218 pager 266-2305 secy 
camilleri.michael@mayo.edu 
Archana Rao, MD 
Fellow, available on call 
127-13968 
rao.archana@mayo.edu 
 
 
Safety Assessments – Risks and AEs (Please focus on level II, III, and primary 
procedures). See example below. 
 
 

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Please complete the following table and include risks and adverse events noted in the 
consent form, emphasizing those greater than minimal risk. 
 
Risks and/or 
Anticipated 
Adverse Events 
Assessment 
measures 
Individual doing
Assessment 
intervals or 
frequency 
 
assessment 
Interventions to 
decrease or respond 
to risks 
Radiation 
exposure 
Documentation of 
radiation exposure 
GI technologists 
Prior to dosing 
Monthly monitoring of 
dosing log by PI 
Bruising at IV or 
venipuncture or 
injection sites 
Patient 
observation 
CRU nurses,  
study staff 
At time of 
procedure 
Treatment with 
pressure and ice 
Infection at IV or 
venipuncture or 
injection sites 
Patient 
observation 
CRU nurses,  
study staff  
Patient instructed 
to contact study 
staff 
Performed by trained 
personnel 
Flatulence 
Patient 
observation 
CRU nurses,  
study staff  
Patient instructed 
to contact study 
staff 
None due to short half-
life of medication 
Abdominal 
bloating 
Patient 
observation 
CRU nurses,  
study staff 
Patient instructed 
to contact study 
staff 
None due to short half-
life of medication 
Abdominal pain 
Patient 
observation 
CRU nurses,  
study staff 
Patient instructed 
to contact study 
staff 
Assessment by study 
physician 
Diarrhea 
Patient 
CRU nurses,  
Patient instructed 
Study physician 
2.1 
EXAMPLES  
Example 1: 
Risks and/or 
Anticipated 
Adverse Events 
Assessment 
measures 
Individual doing 
assessment 
Assessment intervals or 
frequency 
Interventions to decrease 
or respond to risks 
a. Biopsy- 
 
 
 
 
 
Pain 
Subject 
communication 
Physician, Study 
Coordinator, RN 
At time of procedure, 
when subject leaves, and 
weekly by questionnaire. 
Expected-Informed and 
support provided- Lidocane 
used at time of procedure 
and cataminophen for 
residual discomfort 
 
Bruising 
Subject 
Observation 
Study Coordinator, 
RN 
As above 
Expected-Informed  
Decreased with pressure 
and ice 
 
Infection 
Subject 
symptoms/vital 
signs 
Study Coordinator, 
RN 
Participant instructed to 
call SC or PI 
Performed by trained 
personnel 
b. Study drug-
Hu-901 
See protocol, 
page 16. 
Study Coordinator, 
RN 
Daily review of lab 
reports and observe for 2 
hours post infusion 
Acetaminophen given for 
discomfort 
 
Example 2:  
As a Level I/II risk protocol, monitoring will occur on the first three (3) subjects with future monitoring intervals determined 
and/or adjusted on the results of the first three (3) subjects.  
 
Example 3: 
We have a small, Level III risk protocol and will monitor all responses of the first three (3) subjects and every 1-2 subjects 
thereafter.  
 

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observation 
study staff 
to contact study 
staff 
assessment, advise 
regarding fluid intake, 
IV rehydration if 
severe 
Nausea 
Patient 
observation 
CRU nurses,   
study staff 
Patient instructed 
to contact study 
staff 
Study physician 
assessment 
Headache 
Patient 
observation 
CRU nurses,   
study staff 
Patient instructed 
to contact study 
staff 
Tylenol permitted, 
study physician 
assessment if severe 
 
Note: Assessment findings are monitored
 
 by the individuals identified in Question #1. 
D. Grading method for adverse event reporting 
 
The PI must identify what scale will be used to grade adverse events (AEs) and 
indicate how the relationship between the adverse event and the protocol/intervention 
will be scaled. Each protocol may have a unique approach to grading AEs and the PI 
should consult the parent protocol and/or funding source for specific grading scales. 
Suggested guidelines for the grading of AEs are available below: 
 
 
 
 
 
 
 
 
 
Identify the scale used to grade the severity of adverse events in this study: 
 
 AEs will be graded according to CTEP Common Toxicity Criteria (CTC II) 
 AEs will be graded according to CTEP Common Terminology Criteria (CTC III) 
 AEs will be graded according to the 0-5 scale shown above 
X 
AEs will be graded using another system (specify): 
 
AEs will be graded as per protocol (page 33) : 
Mild means awareness of symptoms or signs, but easily tolerated (acceptable)  
Moderate means discomfort enough to interfere with usual activity (disturbing)  
Example 1:  
Cancer Therapy Evaluation Program (CTEP) Common Toxicity Criteria (CTC II) 
available for viewing at http://ctep.info.nih.govi (see “Reporting Guidelines, Common 
Toxicity Criteria”) 
 
Example 2: 
Cancer Therapy Evaluation Program (CTEP) Common Terminology Criteria (CTC III) 
 
Example 3: 
Common grading scale 
0 
No adverse event or within normal limits or not clinical significant 
1 
Mild - did not require treatment 
2 
Moderate - resolved with treatment 
3 
Severe - resulted in inability to carry on normal activities and required professional 

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Severe means incapacity to work or to do usual activity (unacceptable) 
 
Identify the attribution scale to be used in this study: 
 
The PI will determine the relationship of AEs to the test procedure/device/agent as 
definitely related, probably related, possibly related, unrelated, or unknown. 
X 
 The PI will use an alternative attribution scale (specify): 
 
AEs will be attributed as per protocol (page 33): 
Certain - A clinical event, including laboratory test abnormality, occurring in a 
plausible time relationship to drug administration, and which cannot be explained 
by concurrent disease or other drugs or chemicals. The response to withdrawal of 
the drug (dechallenge) should be clinically plausible. The event must be definitive 
pharmacologically or phenomenologically, using a satisfactory rechallenge 
procedure if necessary. 
Probable - A clinical event - including laboratory test abnormality - with a 
reasonable time sequence to use of the product, unlikely to be attributed to 
concurrent disease or other drugs or chemicals, and which follows a clinically 
reasonable response on withdrawal (dechallenge). Rechallenge information is not 
required.  
Possible - A clinical event - including laboratory test abnormality - with a 
reasonable time sequence to use of the product, but which could also be explained 
by concurrent disease or other drugs or chemicals. Information on drug 
withdrawal may be lacking or unclear. 
Unlikely - A clinical event - including laboratory test abnormality - with a 
temporal relationship with use of the product which makes a causal relationship 
improbable, and in which other drugs, chemicals or underlying disease provide 
plausible explanations. 
Not related - A clinical event - including laboratory test abnormality - with a 
temporal relationship with use of the product which makes a causal relationship 
impossible, and in which other drugs, chemicals or underlying disease provide a 
more probable explanations. 
 
Step 3: Implementing the Data and Safety Monitoring Plan 
 
 
A. 
Reporting of Adverse Events 
 
B. 
Refer to the Mayo Institutional Review Board (IRB) web site for guidelines on 
reporting adverse events at (http://researchweb.mayo.edu/irb/index.html ).  Please 
check all reporting requirements that apply for this protocol: 
 
 National Institutes of Health (NIH) 
 Food and Drug Administration (FDA) 
X   IRB 
X   CTSA – Research Resources 

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X   Sponsor (specify): Albireo 
 
 
C. 
Subject withdrawals/dropouts 
 
Describe how subject withdrawals/dropouts prior to study completion will be 
accommodated and reported. Include examples of reasons that may prompt subject 
withdrawal/dropout. 
Description: Patient withdrawals or discontinuations prior to study completion will be described in an 
annual report to Mayo’s IRB and copied to the CRU, FDA and sponsor. Reasons for withdrawal include 
abnormal laboratory test result, concomitant illness or withdrawal of consent by patient. 
 
D. 
Decision making criteria – Stopping rules 
 
Describe criteria for decision-making regarding continuation, modification, or 
termination of the clinical study (e.g. Review summarized data to determine response to 
procedure after 10% of subjects have been seen). 
Description: A patient will be withdrawn from the study if she develops diarrhea severe enough to 
require IV rehydration. The study will be discontinued if greater than 40 percent of patients develop 
diarrhea severe enough to require IV rehydration. 
 
E. 
Study meetings/discussions 
 
Identify method for documenting study discussions and meeting minutes, as well as 
follow-up communications. 
 
Method: Decisions that alter the study procedures or the human studies aspects will be communicated to 
the IRB, CRU and sponsor and the review minutes will be documented in the regulatory binder. 
 
Please note: 
All DSMP’s are subject to ongoing review and modification as new information 
concerning data integrity and safety issues become available. Proposals for revision of 
DSMP’s may come from any source, including the PI of the study, the study coordinator, 
CRU nursing staff, or the CTSA – Research Resources Program Director. Revisions of 
the DSMP may be expedited per the decision of the Program Director or the Research 
Resources Review Panel (RRRP) Chair but requires approval by the RRRP at its regular 
meeting.  

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34.7 
Protocol amendment 1: List of changes 
The protocol for the study is to be changed as follows:  
 
Throughout the document links from ToC and to references as well as minor lay-out 
changes have been made and identified errors in the reference list have been corrected. 
 
 
TITLE PAGE 
Previous text: 
 
Clinical Study Protocol 
 
Investigational Product 
A3309 
Study code 
A3309-003 
Protocol Version 
1.2 
Date 
10 Nov 2009 
 
Amendment No: 
 
Date of Amendment : 
 
Amendment No: 
 
Date of Amendment : 
 
 
 
Revised text: 
 
Clinical Study Protocol 
 
Investigational Product 
A3309 
Study code 
A3309-003 
Protocol Version 
1.3 
Date 
07 June 2010 
 
Amendment No:1 
 
Date of Amendment :07 June 2010 
 
Amendment No: 
 
Date of Amendment : 
 
 
Reason for change: 
 
Protocol Amendment 1 processing and administration. 
 

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(Please note that the Table of Contents has been updated to account for the amendment 
processing.) 
 
 
 
PROTOCOL SYNOPSIS, Number of patients planned 
Previous text: 
Twelve completed female patients with functional constipation in each treatment group for a total  
of 36 patients. 
 
 
Revised text: 
 
Twelve completed
of 36 patients. 
 female patients with functional constipation in each treatment group for a total  
 
Reason for change: Patients not completing the study has not been planned to be 
replaced 
 
PROTOCOL SYNOPSIS, Methodology (2nd
 
 paragraph) 
Previous text: 
 
Within seven (7) to fourteen (14) days of Visit 1, eligible patients will return for an abbreviated 
scintigraphy test with images obtained only at 4 and 24 hours post In111
 
 capsule ingestion. A 
geometric center at 24 hours must be less than or equal to 2.30, the median of normal colonic 
transit in normal healthy volunteers (as determined by analysis of a compilation of prior Camilleri 
studies), to qualify for randomization to study medication, either 15 or 20 mg A3309 or placebo 
administered orally once daily for fourteen (14) consecutive days. The allocation to treatment 
group will be concealed. 
Revised text: 
 
Within seven (7) to fourteen (14) days of Visit 1, eligible patients will return for an abbreviated 
scintigraphy test with images obtained only at 4 and 24 hours post In111 capsule ingestion. A 
geometric center at 24 hours must be less than or equal to
 
 2.30, the median of normal colonic 
transit in normal healthy volunteers (as determined by analysis of a compilation of prior Camilleri 
studies), to qualify for randomization to study medication, either 15 or 20 mg A3309 or placebo 
administered orally once daily for fourteen (14) consecutive days. The allocation to treatment 
group will be concealed. 
Reason for change: In the previous protocol different  descriptions of this criterion appeared. 
In the amendment a consistent definition has been inserted throughout the protocol. 
 
 
 
Section 7.3 Natural Laxation by Endogenous Bile Acids 
Previous text: 

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Bile acids have a variety of physiologic functions and are actively reabsorbed (up to 95%) in the 
terminal ileum (5). Disruption of the enterohepatic circulation of bile acids due to ileal disease 
(e.g., Crohn’s or radiation ileitis) or idiopathic bile acid malabsorption (BAM) causes chronic 
diarrhea [see systematic summary (6)]. Conjugated and non-conjugated bile acids induce 
secretion in the human colon (7,8) by activating intracellular secretory mechanisms [e.g. 
adenylate cyclase (9)] or by detergent effects resulting in mucus secretion (10), increased mucosal 
permeability (11) and inhibition of apical Cl-/OH- exchange (12). In addition, bile acids may 
induce propulsive contractions in canine [>20mM (13)] and human colon [1mM or 5mM (15)]. In 
humans, there is a relationship between the fecal bile acid excretion and colonic motility; 
however, this relationship is complicated by associated steatorrhea since the delivery of fatty 
acids to the colon may also accelerate colonic transit (16). Bile acid concentration in stool of 
patients with ileal resection may reach 21mM chenodeoxycholate [CDC (17)].  However, fecal 
concentrations of bile acids in diarrhea-predominant irritable bowel syndrome (IBS-D) or 
functional diarrhea are unknown, and up-regulation of the ileal active transporter (18) as a result 
of chronic loss of bile acids may reduce the bile acids reaching the colon. In studies of gallstone 
dissolution with 750-1000mg CDC per day (19), diarrhea occurred in 40% of patients. Therefore, 
an approach that results in the passage of higher concentrations of endogenous bile acids into the 
colon has the potential to provide a useful treatment for constipation and related conditions. 
Structure activity studies show that several primary and secondary bile acids are secretagogues in 
the mammalian colon.  
 
Revised text: 
 
Bile acids have a variety of physiologic functions and are actively reabsorbed (up to 95%) in the 
terminal ileum (5). Disruption of the enterohepatic circulation of bile acids due to ileal disease 
(e.g., Crohn’s or radiation ileitis) or idiopathic bile acid malabsorption (BAM) causes chronic 
diarrhea [see systematic summary (6)]. Conjugated and non-conjugated bile acids induce 
secretion in the human colon (7,8) by activating intracellular secretory mechanisms [e.g. 
adenylate cyclase (9)] or by detergent effects resulting in mucus secretion (10), increased mucosal 
permeability (11) and inhibition of apical Cl-/OH- exchange (12). In addition, bile acids may 
induce propulsive contractions in canine [>20mM (13)] and human colon [1mM (14) or 5mM 
(15)]. In humans, there is a relationship between the fecal bile acid excretion and colonic motility; 
however, this relationship is complicated by associated steatorrhea (15) since the delivery of fatty 
acids to the colon may also accelerate colonic transit (16). Bile acid concentration in stool of 
patients with ileal resection may reach 21mM chenodeoxycholate [CDC (17)].  However, fecal 
concentrations of bile acids in diarrhea-predominant irritable bowel syndrome (IBS-D) or 
functional diarrhea are unknown, and up-regulation of the ileal active transporter (18) as a result 
of chronic loss of bile acids may reduce the bile acids reaching the colon. In studies of gallstone 
dissolution with 750-1000mg CDC per day (19), diarrhea occurred in 40% of patients (20). 
Therefore, an approach that results in the passage of higher concentrations of endogenous bile 
acids into the colon has the potential to provide a useful treatment for constipation and related 
conditions. Structure activity studies show that several primary and secondary bile acids are 
secretagogues in the mammalian colon (11).  
 
Reason for change: Previous protocol had some inconsistencies in the literature references. 
This has now been corrected throughout the protocol 
Section 8.1 Chemistry (5th paragraph) 

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Previous text: 
 
Bile acids are mainly absorbed by a specific ileal bile acid transporter in the ileum (IBAT) and 
are returned to the liver, completing enterohepatic circulation (1).  A3309 is a small molecule 
known to be an inhibitor of the IBAT that interrupts the enterohepatic circulation of bile acids by 
decreasing intestinal bile acid reabsorption, which results in an increased bile acid load to the 
colon.  This stimulates increased fluid secretion in the colon and colonic motility; both effects are 
expected to benefit patients with constipation (2).  Additionally, given the mode of action of 
A3309, beneficial effects on bile acid synthesis and cholesterol levels are anticipated (2,3). Bile 
acid reabsorption from the intestine is a very efficient process whereby 95% of the secreted bile 
acids are reabsorbed and IBAT, an integral brush border membrane glycoprotein that 
co-transports sodium and bile acid, appears to be a major regulator of the bile acid pool in 
animals and man. IBAT inhibitors prevent the reabsorption of bile acids from the ileum and their 
return to the liver.  The liver compensates for this decrease in bile acid level by upregulating 
cholesterol 7α-hydroxylase, the rate-limiting enzyme for bile acid synthesis(4,5).
 
  
Revised text: 
 
Bile acids are mainly absorbed by a specific ileal bile acid transporter in the ileum (IBAT) and 
are returned to the liver, completing enterohepatic circulation (125).  A3309 is a small molecule 
known to be an inhibitor of the IBAT that interrupts the enterohepatic circulation of bile acids by 
decreasing intestinal bile acid reabsorption, which results in an increased bile acid load to the 
colon.  This stimulates increased fluid secretion in the colon and colonic motility; both effects are 
expected to benefit patients with constipation (27).  Additionally, given the mode of action of 
A3309, beneficial effects on bile acid synthesis and cholesterol levels are anticipated (2,325). Bile 
acid reabsorption from the intestine is a very efficient process whereby 95% of the secreted bile 
acids are reabsorbed and IBAT, an integral brush border membrane glycoprotein that 
co-transports sodium and bile acid, appears to be a major regulator of the bile acid pool in 
animals and man. IBAT inhibitors prevent the reabsorption of bile acids from the ileum and their 
return to the liver.  The liver compensates for this decrease in bile acid level by upregulating 
cholesterol 7α-hydroxylase, the rate-limiting enzyme for bile acid synthesis(4,526,27).
 
  
Reason for change: Previous protocol had some inconsistencies in the literature references. 
This has now been corrected throughout the protocol. 
 
Section 11.1 Study Design (2nd
 
 paragraph) 
Previous text: 
Within seven (7) to fourteen (14) days of Visit 1, eligible patients will return for an abbreviated 
scintigraphy test with images obtained only at 4 and 24 hours post In111
 
 capsule ingestion. A 
geometric center at 24 hours must be less than or equal to 2.30, the median of normal colonic 
transit in normal healthy volunteers (as determined by analysis of a compilation of prior Camilleri 
studies),  to qualify for randomization to study medication, either 15 or 20 mg A3309 or placebo 
administered orally once daily for fourteen (14) consecutive days. The allocation to treatment 
group will be concealed.  
Revised text: 

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Within seven (7) to fourteen (14) days of Visit 1, eligible patients will return for an abbreviated 
scintigraphy test with images obtained only at 4 and 24 hours post In111 capsule ingestion. A 
geometric center at 24 hours must be less than or equal to
Reason for change: In the previous protocol different descriptions of this criterion appeared. 
In the amendment a consistent definition has been inserted throughout the protocol. 
 2.30, the median of normal colonic 
transit in normal healthy volunteers (as determined by analysis of a compilation of prior Camilleri 
studies),  to qualify for randomization to study medication, either 15 or 20 mg A3309 or placebo 
administered orally once daily for fourteen (14) consecutive days. The allocation to treatment 
group will be concealed.  
 
 
Section 11.2 Schedule of events 
Previous text: 
 
1
 
 A rectal exam to be performed to exclude evacuation disorder if a normal exam not documented within 2 
years. 
Revised text: 
 
1
 
 A rectal exam to be performed at Visit 1 to exclude the possibility of an evacuation disorder if a normal 
exam not documented within 2 years by a qualified gastroenterologist. A patient may defer the rectal exam 
at Visits 6 and 7 if not clinically indicated. 
Reason for change: To ensure adequately trained physician and, as per clinical convention, 
rectal exam will only be performed based on clinical symptoms at visits 6 and 7. 
 
Section 11.3 Schedule of Visits, Visit 1 Study Entry (2nd
 
 paragraph) 
Previous text: 
 
After reviewing and signing a patient ICF, they will have a brief interview (including 
demographics, medical history and current medications) and a physical examination performed 
by a study physician. If the results of a normal rectal examination to exclude the possibility of an 
evacuation disorder are not documented within the previous two years, this exam will be 
performed at this time. Height, weight and vital signs including temperature, pulse, blood 
pressure, and respiration rate will be obtained.  
Revised text: 
 
After reviewing and signing a patient ICF, they will have a brief interview (including 
demographics, medical history and current medications) and a physical examination performed 
by a study physician. If the results of a normal rectal examination to exclude the possibility of an 
evacuation disorder are not documented within the previous two years by a qualified 
gastroenterologist, this exam will be performed at this time. Height, weight and vital signs 
including temperature, pulse, blood pressure, and respiration rate will be obtained.  
 
Reason for change: To ascertain that this exam is made by an appropriately trained physician. 
 

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Section 11.3  Schedule of Visits, Visit 4 Final Transit Scintigraphy and 
Pharmacokinetic Sampling  
Previous text: 
 
Patients will return to Charlton 7 CRU fasting for the previous eight hours, no food or drink 
allowed. Vital signs (pulse, blood pressure, respiration rate and temperature) will be measured. 
Patients will be asked about adverse events and concomitant medications by the study staff and 
the CRU nurses. 
The study medication and a capsule containing a small amount of In111 radioactivity will be 
given. About one hour after taking the capsule, the first anterior and posterior images will be 
obtained. The patient will be given a scrambled egg breakfast meal; the eggs contain a small 
amount of Tc99
 
 radioactivity. Images will be obtained immediately after the egg breakfast; this 
image is considered the start of the imaging procedure or the ‘zero hour’ image. Images will be 
obtained at 30, 60 and 90 minutes later and at 2, 3, 4, 5, 6, 7, and 8 hours after the ‘zero hour’ 
image. An intravenous line will be placed in the forearm or hand to obtain small volume blood 
samples for pharmacokinetic (pk) analysis. Small volume blood samples will be drawn 
immediately before the administration of the study medication and at 30, 60, 90, 120, 180, 240, 
360, 480 minutes after study medication. Blood and urine samples will also be obtained to 
perform standard laboratory safety tests including a CBC, CMP, coagulation studies, and UA. 
Blood samples will also be obtained for pharmacodynamics (C4, total cholesterol, LDL, HDL, 
and triglycerides) at this time. The total amount of blood taken will be about 75 mL. A 12-lead 
ECG will be performed. Four hours after the breakfast, a standard lunch meal consisting of 
chicken breast, baked potato and vanilla pudding is given. Images will be obtained at five, six and 
seven hours. Eight hours after the lunch, a standard dinner of a roast beef sandwich, sugar cookie 
and milk will be given followed by a final camera image. These standardized meals ensure that 
all participants in this study eat the same type and same amount of food this day. Patients are 
asked not to eat or drink anything other than these standardized meals. 
Revised text: 
 
Patients will return to Charlton 7 CRU fasting for the previous eight hours, no food or drink 
allowed. Vital signs (pulse, blood pressure, respiration rate and temperature) will be measured. 
Patients will be asked about adverse events and concomitant medications by the study staff and 
the CRU nurses. 
The study medication and a capsule containing a small amount of In111 radioactivity will be 
given. About one hour after taking the capsule, the first anterior and posterior images will be 
obtained. The patient will be given a scrambled egg breakfast meal; the eggs contain a small 
amount of Tc99 radioactivity. Images will be obtained immediately after the egg breakfast; this 
image is considered the start of the imaging procedure or the ‘zero hour’ image. Images will be 
obtained at 30, 60 and 90 minutes later and at 2, 3, 4, 5, 6, 7, and 8 hours after the ‘zero hour’ 
image. An intravenous line will be placed in the forearm or hand to obtain small volume blood 
samples for pharmacokinetic (pk) analysis. Small volume blood samples will be drawn 
immediately before the administration of the study medication and at 30, 60, 90, 120, 180, 240, 
360, 480 minutes after study medication. Blood and urine samples will also be obtained to 
perform standard laboratory safety tests including a CBC, CMP, coagulation studies, and UA. 
Blood samples will also be obtained for pharmacodynamics (C4, total cholesterol, LDL, HDL, 
and triglycerides) at this time. The total amount of blood taken will be about 75 mL. A 12-lead 
ECG will be performed.  About fFour hours after the breakfast, a standard chicken breast lunch 
meal consisting of chicken breast, baked potato and vanilla pudding is given. Images will be 

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obtained at five, six and seven hours. About Eeight hours after the lunch breakfast, a standard 
dinner of a roast beef sandwich snack, sugar cookie and milk
 
 will be given followed by a final 
camera image. These standardized meals ensure that all participants in this study eat the same 
type and same amount of food this day. Patients are asked not to eat or drink anything other than 
these standardized meals. 
Reason for change: To correct a fault in regard to description of food intake during the visit. 
 
 
Section 11.3 Schedule of Visits, Visit 6 Transit Scintigraphy 
Previous text: 
 
The following morning, patients will return to the Charlton 7 CRU fasting for the previous eight 
hours, no food or drink allowed, to receive the study medication followed by one five minute 
camera image. A brief physical exam will be performed by a study physician. Vital signs (pulse, 
blood pressure, respiration rate and temperature) will be measured. Patients will be asked about 
adverse events and concomitant medications by the study staff and the CRU nurses. Patients will 
complete a six question survey of constipation symptoms and treatment efficacy. 
 
Revised text: 
 
The following morning, patients will return to the Charlton 7 CRU fasting for the previous eight 
hours, no food or drink allowed, to receive the study medication followed by one five minute 
camera image. A brief physical exam will be performed by a study physician. Patients may defer 
the rectal exam if not clinically indicated. Vital signs (pulse, blood pressure, respiration rate and 
temperature) will be measured. Patients will be asked about adverse events and concomitant 
medications by the study staff and the CRU nurses. Patients will complete a six question survey 
of constipation symptoms and treatment efficacy. 
 
Reason for change: As per clinical convention, rectal exam will only be performed based on 
clinical symptoms at visits 6 and 7. 
 
 
Section 11.3 Schedule of Visits, Visit 7 Study Completion 
Previous text: 
 
Within seven to ten days after Visit 6, patients will return to Charlton 7 CRU fasting for the 
previous eight  hours, no food or drink allowed. Height, weight and vital signs (pulse, blood 
pressure, respiration rate and temperature) will be measured. Blood and urine samples will be 
obtained to perform standard laboratory safety tests including a CBC, CMP, coagulation studies 
and urinalysis. Blood samples will also be obtained for pharmacodynamics (C4, total cholesterol, 
LDL, HDL, and triglycerides) and one solitary pharmacokinetic sample. The total amount of 
blood obtained for the standard laboratory tests is about 30 mL. A 12-lead ECG will be 
performed. The Bowel Pattern Diary will be turned in.  A physical exam will be performed by the 
study doctor and an exit interview done with study staff.  
Revised text: 
 

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Within seven to ten days after Visit 6, patients will return to Charlton 7 CRU fasting for the 
previous eight  hours, no food or drink allowed. Height, weight and vital signs (pulse, blood 
pressure, respiration rate and temperature) will be measured. Blood and urine samples will be 
obtained to perform standard laboratory safety tests including a CBC, CMP, coagulation studies 
and urinalysis. Blood samples will also be obtained for pharmacodynamics (C4, total cholesterol, 
LDL, HDL, and triglycerides) and one solitary pharmacokinetic sample. The total amount of 
blood obtained for the standard laboratory tests is about 30 mL. A 12-lead ECG will be 
performed. The Bowel Pattern Diary will be turned in.  A physical exam will be performed by the 
study doctor; the patients may defer the rectal exam if not clinically indicated and a
 
. An exit 
interview will be done with study staff.  
Reason for change: As per clinical convention, rectal exam will only be performed based on 
clinical symptoms at visits 6 and 7. 
 
 
Section 13  INCLUSION CRITERIA (#3) 
Previous text: 
 
3. A normal rectal exam result on file within the past 2 years or performed at screen to exclude 
the possibility of an evacuation disorder. Examination must exclude findings suggestive of an 
evacuation disorder such as high sphincter tone at rest, failure of perineal descent and spasm, 
tenderness or paradoxical contraction of the puborectalis muscles. 
 
Revised text: 
 
3.  A normal rectal exam result on file within the past 2 years or performed at Visit 1 screen by a 
qualified gastroenterologist to exclude the possibility of an evacuation disorder. Examination 
must exclude findings suggestive of an evacuation disorder such as high sphincter tone at rest, 
failure of perineal descent and spasm, tenderness or paradoxical contraction of the 
puborectalis muscles. 
 
Reason for change: To ascertain that this exam is made by an appropriately trained physician 
either within the past two years or at Visit 1. 
 
 
 
Section 14  EXCLUSION CRITERIA (#3) 
Previous text: 
 
3.     Unable to withdraw all medications 48 hours prior to Visit 1; any medication that alters GI 
transit including but not limited to laxatives, magnesium or aluminum containing antacids, 
prokinetics, erythromycin, narcotics, anticholinergics, tricyclic antidepressants and SNRIs; 
analgesic drugs including opiates, NSAIDs and COX 2 inhibitors (Note: Tylenol is 
permitted), GABAergic agents and benzodiazepines. 
 
Note: All other concomitant medications will be reviewed on a case by case basis by 
the study physicians. 
 
Revised text: 

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3.     
 
Unable to withdraw all medications 48 hours prior to Visit 1; any medication that alters GI 
transit including but not limited to laxatives, magnesium or aluminum containing antacids, 
prokinetics, erythromycin, narcotics, anticholinergics, tricyclic antidepressants and SNRIs; 
analgesic drugs including opiates, NSAIDs and COX 2 inhibitors (Note: Tylenol is 
permitted), GABAergic agents and benzodiazepines. 
 
Note: All other concomitant medications will be reviewed on a case by case basis by 
the study physicians. 
Taking any medication that in the opinion of the principal investigator has a potential to 
alter GI transit. This includes but is not limited to osmotic or stimulant laxatives, magnesium 
or aluminum-containing antacids, prokinetics, erythromycin, narcotics, anticholinergics, 
selective norepinephrine reuptake inhibitors (SNRIs), opiates, GABAergic agents and 
benzodiazepines. 
 
Note: Selective serotonin reuptake inhibitor (SSRI) antidepressants are permissible at 
low, stable doses. Analgesics such as Tylenol, ibuprofen, naproxen and aspirin 
are permissible. All medications shall be reviewed by the principal investigator 
on a case by case basis. 
 
Reason for change: To ensure that the principal investigator is reviewing all medications. The 
list has been slightly modified based on current knowledge of potential for transit changes. 
 
Section 19.1 Packaging, labeling and storage of Investigational Product (5th
 
 
paragraph) 
Previous text: 
 
18 sachets containing two tablets each. 
Content: A3309 tablets and/or Placebo tablets 
Protocol Number: A3309-002  
Patient no: XXXX 
Storage: Room Temperature (preferably 20 – 25˚C) 
Batch No: 96202-YYMM-XX 
Use by: YYYY-MM-DD 
Caution: 
Sponsor: Albireo AB, Arvid Wallgrens backe 20, SE-413 46 Gothenburg, Sweden 
New drug - Limited by Federal (USA) Law to Investigational Use 
Manufactured by: Galenica AB, Medeon, SE-205 12 Malmoe, Sweden 
Clinical site: Mayo Clinics, xxxxxxxxxxx, phone: xxxxxx 
Keep Out of Reach of Children. 
Take both tablets from one sachet orally daily before breakfast. 
 
Revised text: 
 
18 sachets containing two tablets each. 
Content: A3309 tablets and/or Placebo tablets 
Protocol Number: A3309-002
Patient no: XXXX 
3  
Storage: Room Temperature (preferably 20 – 25˚C) 

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Batch No: 96202-YYMM-XX 
Use by: YYYY-MM-DD 
Caution: 
Sponsor: Albireo AB, Arvid Wallgrens backe 20, SE-413 46 Gothenburg, Sweden 
New drug - Limited by Federal (USA) Law to Investigational Use 
Manufactured by: Galenica AB, Medeon, SE-205 12 Malmoe, Sweden 
Clinical site: Mayo Clinics, xxxxxxxxxxx, phone: xxxxxx 
Keep Out of Reach of Children. 
Take both tablets from one sachet orally daily before breakfast. 
 
Reason for change: Correction of typographic error 
 
Section 19.2 Doses and treatment regimens (3rd
 
 bullet) 
Previous text: 
 
• 
Evaluation of the results of the A3309-001 study showed: 
o A minor signal on C4 and on lipid parameters observed at the 3 mg and the 10 mg 
dose levels produced a stronger signal; 
o Efficacy signals (colon transit, stool form scale, and frequency of BMs) evident in the 
10 mg dose group.  However, no diarrhea or incapacitating “very loose stools” were 
observed in the 10 mg dose group. 
Revised text: 
 
• 
Evaluation of the results of the A3309-001 study showed: 
o A minor signal on C4 and on lipid parameters observed at the 3 mg and the 10 mg 
dose levels produced a stronger signal; 
o Efficacy signals (colon transit, stool form scale (28), and frequency of BMs) evident 
in the 10 mg dose group.  However, no diarrhea or incapacitating “very loose stools” 
were observed in the 10 mg dose group. 
 
Reason for change: Update of reference list 
 
Section 21.2  Clinical efficacy assessment (#1 2nd
 
 paragraph) 
Previous text: 
Relative to the time of consumption of breakfast meal, abdominal camera images are initially 
obtained every 30 minutes for the first two hours, then hourly for the next six hours. At 4 hours, a 
standard lunch (chicken breast, potato, pudding and milk, the “Stanghellini” meal, 550 kcal) will 
be given. Camera images will be taken at 5, 6, and at 8 hours post breakfast meal.  At 8 hours, the 
standard dinner (roast beef sandwich, sugar cookie and milk, the “Greydanus” meal, 750 kcal) 
will be given. The patient will leave the CRU after the completion of the 8 hour image and will 
return the following two mornings in order to receive study medication and obtain 24 and 48 hour 
scans fifteen minutes later.  The performance characteristics of this test are summarized 
elsewhere. Please see relevant references on the methods (6,7,8,9,10). 

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Revised text: 
Relative to the time of consumption of breakfast meal, abdominal camera images are initially 
obtained every 30 minutes for the first two hours, then hourly for the next six hours. At about 4 
hours, a standard chicken breast lunch (chicken breast, potato, pudding and milk, the 
“Stanghellini” meal, 550 kcal) will be given. Camera images will be taken at 5, 6, and at 8 hours 
post breakfast meal.  At about 8 hours, the standard dinner (roast beef sandwich snack, sugar 
cookie and milk, the “Greydanus” meal, 750 kcal) will be given. The patient will leave the CRU 
after the completion of the 8 hour image and will return the following two mornings in order to 
receive study medication and obtain 24 and 48 hour scans fifteen minutes later.  The performance 
characteristics of this test are summarized elsewhere. Please see relevant references on the 
methods (6,7,8,9,10
  
 29,30). 
Reason for change: To correct a fault in regard to description of food intake during the visit. 
Update of reference list. 
 
 
 
Section 24.2 Analysis data sets 
Previous text: 
The primary analyses will follow the intent to treat (ITT) paradigm with all patients randomized 
included in the analyses. Those patients with missing response values will have their missing 
values imputed via the overall (patients with non-missing data) mean and a corresponding 
adjustment in the ANCOVA residual error variance degrees of freedom (subtracting one for each 
missing value imputed).  
Safety data will be presented for all patients receiving investigational product. 
 
Revised text: 
The primary analyses will follow the intent to treat (ITT) paradigm with all patients randomized 
included in the analyses. Those patients with missing response values will have their missing 
values imputed via the overall (patients with non-missing data) mean and a corresponding 
adjustment in the ANCOVA residual error variance degrees of freedom (subtracting one for each 
missing value imputed). A per protocol analysis of transit data will also be performed. The per 
protocol population consists of all patients having at least 80 % compliance with study drug and 
having participated in the transit evaluation. 
Safety data will be presented for all patients receiving investigational product. 
 
Reason for change: To add an analysis comprising patients having fully completed the transit 
evaluation without imputing any data as per the ITT paradigm. 
 
 
Section 24.6 Stool frequency and stool consistency 

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Previous text: 
Patients are asked to keep a daily bowel pattern diary documenting the number of stools and the 
consistency (Bristol Stool Scale) of each stool. These are averaged as number of bowel 
movements or consistency of bowel movements per day per patient. Number of bowel 
movements and consistency are subsequently averaged over the study periods (i.e. run-in and 
treatment) per patient. The ANCOVA will be used to assess treatment effects on each of these 
two measures separately, using the corresponding run-in values as covariates.  In addition, 
treatment effects on specific constipation symptoms , considered as discrete categorical 
responses, will be evaluated by a contingency table analysis of the post-treatment responses based 
on the final post-treatment bowel pattern diaries and questionnaires concerning constipation 
symptoms and treatment efficacy.  
 
Revised text: 
 
Patients are asked to keep a daily bowel pattern diary documenting the number of stools and the 
consistency (Bristol Stool Scale(28)) of each stool. These are averaged as number of bowel 
movements or consistency of bowel movements per day per patient. Number of bowel 
movements and consistency are subsequently averaged over the study periods (i.e. run-in and 
treatment) per patient. The ANCOVA will be used to assess treatment effects on each of these 
two measures separately, using the corresponding run-in values as covariates.  In addition, 
treatment effects on specific constipation symptoms , considered as discrete categorical 
responses, will be evaluated by a contingency table analysis of the post-treatment responses based 
on the final post-treatment bowel pattern diaries and questionnaires concerning constipation 
symptoms and treatment efficacy.  
 
Reason for change: Update of reference list 
 
 
Section 24.9 Assessment of sample size 
Previous text: 
† *  Based on data from previous studies(11,12,13,14,15,16)  using similar methods to those 
proposed here. Transit data† 
 
from C-IBS studies (e.g. Renzapride, prucalopride, Tegaserod).  
Revised text: 
† *  Based on data from previous studies(11,12,13,14,15,16 31,32,33)  using similar methods to 
those proposed here. Transit data† 
 
from C-IBS studies (e.g. Renzapride, prucalopride, Tegaserod).  
Reason for change: Update of reference list 
 
 
33 REFERENCES 
Previous text: 

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1 Angelin B, Eriksson M, Rudling M. Bile acids and lipoprotein metabolism: a renaissance for 
bile acids in the post-statin era? Curr Opin Lipidology 1999;10:269-74. 
2 Naoumova RP, O’Neill FH, Dunn S, Neuwirth CKY, Taylor GW, et al. Effect of inhibiting 
HM-CoA reductase on 7α-hydroxy-4-cholesten-3-one, a marker of bile acid synthesis: 
contrasting findings in patients with and without prior up-regulation of the latter pathway. 
Eur J Clin Investig 1999;29:404-12. 
3 Bertolotti M, Zambianchi L, Carulli L, Simonini MS, DelPuppo M, et al. Bile acid synthesis 
during chronic inhibition of bile acid absorption. Hepatology 2003;38:939-46. 
4  Winawer S, Fletcher R, Rex D, Bond J, Burt R, et al for the U.S. Multisociety Task Force on 
Colorectal Cancer. Colorectal cancer screening and surveillance: Clinical guidelines and 
rationale – Update based on new evidence. Am Gastroenterol Assn 2003 Feb;124:544-60. 
5 Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J 
Gastroenterol 1997;32(9):920-4. 
6 Burton DD, Camilleri M, Mullan BP, Forstrom LA, Hung JC.  Colonic transit scintigraphy 
labeled activated charcoal compared with ion exchange pellets.  J Nucl Med 1997;38:1807-1810. 
7 Camilleri M, Colemont LJ, Phillips SF, Brown ML, Thomforde GM, Chapman NJ, Zinsmeister 
AR. Human gastric emptying and colonic filling of solids characterized by a new method.  Am J 
Physiol 1989;257:G284-G290. 
8 Camilleri M, Zinsmeister AR. Towards a relatively inexpensive, noninvasive, accurate test for 
colonic motility disorders.  Gastroenterology 1992;103:36-42. 
9 Camilleri M, Zinsmeister AR, Greydanus MP, Brown ML, Proano M.  Towards a less costly but 
accurate test of gastric emptying and small bowel transit.  Dig Dis Sci 1991;36:609-615. 
10 Cremonini F, Mullan BP, Camilleri M, Burton DD, Rank MR.  Performance characteristics of 
scintigraphic transit measurements for studies of experimental therapies.  Aliment Pharmacol 
Ther 2002;16:1781-1790. 
11 Prather CM, Camilleri M, Zinsmeister AR, McKinzie S, Thomforde GM.  Tegaserod 
accelerates orocecal transit in patients with constipation-predominant irritable bowel syndrome. 
Gastroenterology 2000;118:463-468. 
12 Bouras EP, Camilleri M, Burton DD, Thomforde G, McKinzie S, Zinsmeister AR.  
Prucalopride accelerates gastrointestinal and colonic transit in patients with constipation without 
a rectal evacuation disorder.  Gastroenterology 2001;120:354-360. 
13 Camilleri M, McKinzie S, Fox J, Foxx-Orenstein A, Burton D, Thomforde G, Baxter K, 
Zinsmeister AR.  Effect of renzapride on transit in constipation-predominant irritable bowel 
syndrome.  Clin Gastroenterol Hepatol 2004;2:895-904. 
14 Andresen V, Camilleri M, Busciglio I, Grudell A, Burton D, McKinzie S, Foxx-Orenstein A, 
Kurtz CB, Sharma V, Johnston JM, Currie MG, Zinsmeister AR.  Effect of 5 days linaclotide on 
transit and bowel function in females with constipation-predominant irritable bowel syndrome.  
Gastroenterology 2007;133:761-768. 
15 Bouras EP, Delgado-Aros S, Camilleri M, et al. SPECT imaging of the stomach: comparison 
with barostat, and effects of sex, age, body mass index, and fundoplication. Gut 2002;51:781-786. 
16 Camilleri M, McKinzie S, Busciglio I, Low PA, Sweetser S, Burton D, Baxter K, Ryks M, 
Zinsmeister AR.  Prospective study of motor, sensory, psychologic, and autonomic functions in 
patients with irritable bowel syndrome.  Clin Gastroenterol Hepatol 2008;6:772-781. 

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Revised text: 
 
1 Angelin B, Eriksson M, Rudling M. Bile acids and lipoprotein metabolism: a renaissance for 
bile acids in the post-statin era? Curr Opin Lipidology 1999;10:269-74. 
2 Naoumova RP, O’Neill FH, Dunn S, Neuwirth CKY, Taylor GW, et al. Effect of inhibiting 
HM-CoA reductase on 7α-hydroxy-4-cholesten-3-one, a marker of bile acid synthesis: 
contrasting findings in patients with and without prior up-regulation of the latter pathway. 
Eur J Clin Investig 1999;29:404-12. 
3 Bertolotti M, Zambianchi L, Carulli L, Simonini MS, DelPuppo M, et al. Bile acid synthesis 
during chronic inhibition of bile acid absorption. Hepatology 2003;38:939-46. 
4  Winawer S, Fletcher R, Rex D, Bond J, Burt R, et al for the U.S. Multisociety Task Force on 
Colorectal Cancer. Colorectal cancer screening and surveillance: Clinical guidelines and 
rationale – Update based on new evidence. Am Gastroenterol Assn 2003 Feb;124:544-60. 
5 Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J 
Gastroenterol 1997;32(9):920-4. 
6 Burton DD, Camilleri M, Mullan BP, Forstrom LA, Hung JC.  Colonic transit scintigraphy 
labeled activated charcoal compared with ion exchange pellets.  J Nucl Med 1997;38:1807-1810. 
7 Camilleri M, Colemont LJ, Phillips SF, Brown ML, Thomforde GM, Chapman NJ, Zinsmeister 
AR. Human gastric emptying and colonic filling of solids characterized by a new method.  Am J 
Physiol 1989;257:G284-G290. 
8 Camilleri M, Zinsmeister AR. Towards a relatively inexpensive, noninvasive, accurate test for 
colonic motility disorders.  Gastroenterology 1992;103:36-42. 
9 Camilleri M, Zinsmeister AR, Greydanus MP, Brown ML, Proano M.  Towards a less costly but 
accurate test of gastric emptying and small bowel transit.  Dig Dis Sci 1991;36:609-615. 
10 Cremonini F, Mullan BP, Camilleri M, Burton DD, Rank MR.  Performance characteristics of 
scintigraphic transit measurements for studies of experimental therapies.  Aliment Pharmacol 
Ther 2002;16:1781-1790. 
11 Prather CM, Camilleri M, Zinsmeister AR, McKinzie S, Thomforde GM.  Tegaserod 
accelerates orocecal transit in patients with constipation-predominant irritable bowel syndrome. 
Gastroenterology 2000;118:463-468. 
12 Bouras EP, Camilleri M, Burton DD, Thomforde G, McKinzie S, Zinsmeister AR.  
Prucalopride accelerates gastrointestinal and colonic transit in patients with constipation without 
a rectal evacuation disorder.  Gastroenterology 2001;120:354-360. 
13 Camilleri M, McKinzie S, Fox J, Foxx-Orenstein A, Burton D, Thomforde G, Baxter K, 
Zinsmeister AR.  Effect of renzapride on transit in constipation-predominant irritable bowel 
syndrome.  Clin Gastroenterol Hepatol 2004;2:895-904. 
14 Andresen V, Camilleri M, Busciglio I, Grudell A, Burton D, McKinzie S, Foxx-Orenstein A, 
Kurtz CB, Sharma V, Johnston JM, Currie MG, Zinsmeister AR.  Effect of 5 days linaclotide on 
transit and bowel function in females with constipation-predominant irritable bowel syndrome.  
Gastroenterology 2007;133:761-768. 

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15 Bouras EP, Delgado-Aros S, Camilleri M, et al. SPECT imaging of the stomach: comparison 
with barostat, and effects of sex, age, body mass index, and fundoplication. Gut 2002;51:781-786. 
16
 
 Camilleri M, McKinzie S, Busciglio I, Low PA, Sweetser S, Burton D, Baxter K, Ryks M, 
Zinsmeister AR.  Prospective study of motor, sensory, psychologic, and autonomic functions in 
patients with irritable bowel syndrome.  Clin Gastroenterol Hepatol 2008;6:772-781. 
1. 
Talley NJ, Weaver AL, Zinsmeister AR, Melton LJ, 3rd
2. 
Surrenti E, Rath DM, Pemberton JH, Camilleri M. Audit of constipation in a tertiary 
referral gastroenterology practice.  Am J Gastroenterol. 1995:90(9):1471-5. 
. Functional constipation and outlet 
delay: a population-based study. Gastroenterology. 1993;105(3):781-90. 
3. 
Camilleri M, Thompson WG, Fleshman JW, Pemberton JH. Clinical management of 
intractable constipation. Ann Intern Med. 1994:121(7):520-8. 
4. 
Thompson WG, Longstreth GF, Drossman DA, Heaton KW, Irvine EJ, Muller-Lissner SA. 
Functional bowel disorders and functional abdominal pain. Gut. 1999:45 Suppl 2:II43-7. 
5. 
Hofmann AF. The continuing importance of bile acids in liver and intestinal disease. Arch 
Intern Med 1999:159:2647-2658. 
6. 
Wedlake L, A’hern R, Russell D, Thomas K, Walters J, Andreyev H. Systematic review: the 
prevalence of idiopathic bile acid malabsorption (I-BAM) as diagnosed by SeHCAT 
scanning in patients with diarrhea-predominant irritable bowel syndrome (IBS). Aliment 
Pharmacol Ther 2009 Jun 30. [Epub ahead of print]. 
7. 
Mekhjian HS, Phillips SF, Hofmann AF. Colonic secretion of water and electrolytes 
induced by bile acids: perfusion studies in man. J Clin Invest 1971;50:1569-1577. 
8. 
Wingate DL, Phillips SF, Hofmann AF. Effect of glycine-conjugated bile acids with and 
without lecithin on water and glucose absorption in perfused human jejunum. J Clin Invest 
1973;52:1230-1236. 
9. 
Conley DR, Coyne MJ, Bonorris GG, Chung A, Schoenfield LJ. Bile acid stimulation of 
colonic adenylate cyclase and secretion in the rabbit. Am J Dig Dis 1976;21:453-458. 
10. 
Camilleri M, Murphy R, Chadwick VS, Dose-related effects of chemodeoxycholic acid in 
the rabbit colon. Dig Dis Sci 1980;25:433-438. 
11. 
Chadwick VS, Gaginella TS, Carlson GL, Debongnie JC, Phillips SF, Hofmann AF. Effect 
of molecular structure on bile acid-induced alterations in absorptive function, 
permeability, and morphology in the perfused rabbit colon. J Lab Clin Med 1979;94:661-
674. 
12. 
Alrefai WA, Saksena S, Tyagi S, Gill RK, Ramaswamy K, Dudeja PK.  Taurodeoxycholate 
modulates apical Cl-/OH- exchange activity in Caco2 cells. Dig Dis Sci 2007;52:1270-
1278.   
13. 
Kruis W, Haddad A, Phillips SF. Chenodeoxycholic and ursodeoxycholic acids alter 
motility and fluid transit in the canine ileum. Digestion 1986;34:185-195. 
14. 
Bampton PA, Dinning PG, Kennedy ML, Lubowski DZ, Cook IJ. The proximal colonic 
motor response to rectal mechanical and chemical stimulation. Am J Physiol 
2002;282:G443-G449. 
15. 
Kirwan WO, Smith AN, Mitchell WD, Falconer JD, Eastwood MA. Bile acids and colonic 
motility in the rabbit and the human. Gut 1975;16:894-902. 

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16. 
Spiller RC, Brown ML, Phillips SF. Decreased fluid tolerance, accelerated transit, and 
abnormal motility of the human colon induced by oleic acid. Gastroenterology 
1986;91:100-107. 
17. 
Mitchell WD, Findlay JM, Prescott RJ, Eastwood MA, Horn DB. Bile acids in the 
diarrhoea of ileal resection. Gut 1973;14:348-353. 
18. 
van Tilburg AJ, de Rooij FW, van Blankenstein M, van den Berg JW, Bosman-Jacobs EP.  
Na+-dependent bile acid transport in the ileum: the balance between diarrhea and 
constipation. Gastroenterology 1990;98:25-32. 
19. 
Schoenfield LJ, Lachin JM. Chenodiol (chenodeoxycholic acid) for dissolution of 
gallstones: the National Cooperative Gallstone Study. A controlled trial of efficacy and 
safety. Ann Intern Med 1981;95:257-282. 
20. 
Mok HY, Bell GD, Dowling RH. Effect of different doses of chenodeoxycholic acid on bile-
lipid composition and on frequency of side-effects in patients with gallstones. Lancet 
1974;304:253-257. 
21. 
Iser JH, Dowling H, Mok HY, Bell GD. Chenodeoxycholic acid treatment of gallstones. A 
follow-up report and analysis of factors influencing response to therapy. N Engl J Med 
1975;293:378-383. 
22. 
Meredith TJ, Williams GV, Maton PN, Murphy GM, Saxton HM, Dowling RH. 
Retrospective comparison of 'Cheno' and 'Urso' in the medical treatment of gallstones. Gut 
1982;23:382-389. 
23. 
Bell GD, Mok HY, Thwe M, Murphy GM, Henry K, Dowling RH. Liver structure and 
function in cholelithiasis: effect of chenodeoxycholic acid. Gut 1974;15:165-172. 
24. 
Buchwald H, Varco RL, Bowen JR, Williams SE, Hansen BJ, Campos CT, Campbell GS, 
Pearce MB, Yellin AE, Edmiston WA, Smink RD Jr, Sawin HS Jr. Effective lipid 
modification by partial ileal bypass reduced long-term coronary heart disease mortality 
and morbidity: five-year post-trial follow-up report from the POSCH, Program on the 
Surgical Control of the Hyperlipidemias. Arch Intern Med 1998;158:1253-1261. 
25. 
Angelin B, Eriksson M, Rudling M. Bile acids and lipoprotein metabolism: a renaissance 
for bile acids in the post-statin era? Curr Opin Lipidology 1999;10:269-74. 
26. 
Naoumova RP, O’Neill FH, Dunn S, Neuwirth CKY, Taylor GW, et al. Effect of inhibiting 
HM-CoA reductase on 7α-hydroxy-4-cholesten-3-one, a marker of bile acid synthesis: 
contrasting findings in patients with and without prior up-regulation of the latter pathway. 
Eur J Clin Investig 1999;29:404-12. 
27. 
Bertolotti M, Zambianchi L, Carulli L, Simonini MS, DelPuppo M, et al. Bile acid synthesis 
during chronic inhibition of bile acid absorption. Hepatology 2003;38:939-46. 
28. 
Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J 
Gastroenterol 1997;32(9):920-4. 
29. 
Burton DD, Camilleri M, Mullan BP, Forstrom LA, Hung JC.  Colonic transit scintigraphy 
labeled activated charcoal compared with ion exchange pellets.  J Nucl Med 38: 1807-
1810, 1997. 
30. 
Cremonini F, Mullan BP, Camilleri M, Burton DD, Rank MR.  Performance 
characteristics of scintigraphic transit measurements for studies of experimental therapies.  
Aliment Pharmacol Ther 16: 1781-1790, 2002. 

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31. 
Bouras EP, Camilleri M, Burton DD, Thomforde G, McKinzie S, Zinsmeister AR:  
Prucalopride accelerates gastrointestinal and colonic transit in patients with constipation 
without a rectal evacuation disorder.  Gastroenterology 120:354-360, 2001. 
32. 
Camilleri M, McKinzie S, Fox J, Foxx-Orenstein A, Burton D, Thomforde G, Baxter K, 
Zinsmeister AR:  Effect of renzapride on transit in constipation-predominant irritable 
bowel syndrome.  Clin Gastroenterol Hepatol 2:895-904, 2004. 
33. 
Andresen V, Camilleri M, Busciglio I, Grudell A, Burton D, McKinzie S, Foxx-Orenstein A, 
Kurtz CB, Sharma V, Johnston JM, Currie MG, Zinsmeister AR:  Effect of 5 days 
linaclotide on transit and bowel function in females with constipation-predominant 
irritable bowel syndrome.  Gastroenterology 133:761-768, 2007 
 
Reason for change: Complete revision of reference list given errors in the list in the initial 
protocol 
 
 
Section 34.1 Study Flow Chart 
Previous text: 
1
 
 A rectal exam to be performed to exclude evacuation disorder if a normal exam not documented within 2 
years. 
Revised text: 
 
1
 
 A rectal exam to be performed at Visit 1 to exclude the possibility of an evacuation disorder if a normal 
exam not documented within 2 years by a qualified gastroenterologist. A patient may defer the rectal exam 
at Visits 6 and 7 if not clinically indicated. 
Reason for change:  To ensure appropriate staff and, as per clinical convention, rectal exam 
will only be performed based on clinical symptoms at visits 6 and 7. 
 
 
 
Section 34.4  Patient informed consent form, 2. What Will Happen To You While 
You Are In This Study?, Visit 4. 
Previous text: 
Visit 4 - You will be asked to return to Charlton 7 CRU fasting for the previous eight (8) hours, 
no food or drink allowed, to have your vital signs (pulse, blood pressure, respiration rate and 
temperature) measured. A 12-lead ECG will be performed. You will be given the study 
medication and a capsule containing a small amount of radioactivity. This allows the movement 
of food particles through the colon to be measured using an external camera. About one hour after 
taking the capsule, you will stand in front of a special camera and an anterior and posterior image 
will be obtained. You will be given a scrambled egg breakfast meal; the eggs also contain a small 
amount of radioactivity. Images will be obtained immediately after the egg breakfast; this image 
is considered the start of the imaging procedure or the ‘zero hour’ image. Images will be obtained 

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at 30, 60 and 90 minutes later and at 2, 3, 4, 5, 6, 7, and 8 hours after the ‘zero hour’ image. An 
intravenous line (a small sterile plastic catheter) will be placed in your forearm or hand to obtain 
small volume blood samples for pharmacokinetic (pk) analysis (the amount of study medication 
present in the blood sample). Small volume blood samples will be drawn immediately before the 
administration of the study medication and at 30, 60, 90, 120, 180, 240, 360 and 480 minutes 
after the administration of the study medication.  Blood and urine samples will also be obtained to 
perform standard laboratory safety tests including hematology, chemistry, coagulation studies, 
and a urinalysis. Blood samples will also be obtained for pharmacodynamics (C4, total 
cholesterol, LDL, HDL, and triglycerides) at this time. The total amount of blood taken will be 
about five (5) tablespoons.  Four (4) hours after the breakfast, you will eat a standard lunch meal 
consisting of chicken breast, baked potato, and vanilla pudding. You will have camera images 
taken at five (5),  six (6) and seven (7) hours and eat a standard dinner of a roast beef sandwich, 
sugar cookie and milk eight (8) hours after the breakfast followed by a final camera image. These 
standard meals are not radioactive, they are supplied only so all participants in this study eat the 
same type and same amount of food this day. You will be asked not to eat or drink anything while 
you are having the transit test performed today other than what you are given. After the eight (8) 
hour image is completed, you will be instructed to return to the Charlton 7 CRU at specific times 
on the following two (2) mornings for administration of study medication and to obtain one five 
(5) minute camera image. This visit will require about nine to ten (9 to 10) hours total. 
 
Revised text: 
Visit 4 - You will be asked to return to Charlton 7 CRU fasting for the previous eight (8) hours, 
no food or drink allowed, to have your vital signs (pulse, blood pressure, respiration rate and 
temperature) measured. A 12-lead ECG will be performed. You will be given the study 
medication and a capsule containing a small amount of radioactivity. This allows the movement 
of food particles through the colon to be measured using an external camera. About one hour after 
taking the capsule, you will stand in front of a special camera and an anterior and posterior image 
will be obtained. You will be given a scrambled egg breakfast meal; the eggs also contain a small 
amount of radioactivity. Images will be obtained immediately after the egg breakfast; this image 
is considered the start of the imaging procedure or the ‘zero hour’ image. Images will be obtained 
at 30, 60 and 90 minutes later and at 2, 3, 4, 5, 6, 7, and 8 hours after the ‘zero hour’ image. An 
intravenous line (a small sterile plastic catheter) will be placed in your forearm or hand to obtain 
small volume blood samples for pharmacokinetic (pk) analysis (the amount of study medication 
present in the blood sample). Small volume blood samples will be drawn immediately before the 
administration of the study medication and at 30, 60, 90, 120, 180, 240, 360 and 480 minutes 
after the administration of the study medication.  Blood and urine samples will also be obtained to 
perform standard laboratory safety tests including hematology, chemistry, coagulation studies, 
and a urinalysis. Blood samples will also be obtained for pharmacodynamics (C4, total 
cholesterol, LDL, HDL, and triglycerides) at this time. The total amount of blood taken will be 
about five (5) tablespoons.  About Ffour (4) hours after the breakfast, you will eat a standard 
lunch meal consisting of chicken breast, baked potato, and vanilla pudding lunch meal. You will 
have camera images taken at five (5),  six (6) and seven (7) hours. You will and eat a standard 
dinner of a roast beef sandwich, sugar cookie and milk snack about eight (8) hours after the 
breakfast followed by a final camera image. These standard meals are not radioactive, they are 
supplied only so all participants in this study eat the same type and same amount of food this day. 
You will be asked not to eat or drink anything while you are having the transit test performed 
today other than what you are given. After the eight (8) hour image is completed, you will be 
instructed to return to the Charlton 7 CRU at specific times on the following two (2) mornings for 
administration of study medication and to obtain one five (5) minute camera image. This visit will 
require about nine to ten (9 to 10) hours total. 

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Reason for change: To correct a fault in regard to description of food intake during the visit.