Long-term Clinical Study of CN128 in Thalassemia Patients

1. Primary objectives:

   • To evaluate the safety and efficacy of long-term orally administration of CN128 in thalassaemia patients with blood transfusion dependent and aged 16 and above.
2. Design:

   * The study is designed as a single arm and opened phase IIa clinical trial, so as to investigate the safety and efficacy of CN128.
   * A total of 50 eligible subjects are planned to be enrolled, and orally administration of CN128 for 24 weeks or 48 weeks according to the administration plan. The treatment period is from day 0 to 24 weeks, and the extended treatment period was from 25 weeks to 96 weeks.
   * Subjects' medication status, uncomfortable symptoms, concomitant medication or non-drug therapy were recorded daily.
3. Subject inclusion criteria:

   * Thalassemia patients.
   * The number of blood transfusion per month ≥1. Or hemoglobin can not be maintained at 90g/L above, if blood transfusions is less than once per month.
   * Serum ferritin ≥ 500 µg/L
   * Patients aged 16 and above
   * Volunteer for the trial and sign the informed consent.
4. Subject exclusion criteria:

   * Active hepatitis B (HBsAg positive, HBsAb negative) or hepatitis C (HCV antibody positive, detectable HCV RNA, and alanine transaminase (ALT) beyond normal range)
   * Active gastrointestinal disease history (including: gastric ulcer, duodenal ulcer, stomach or esophageal varices, ulcerative colitis, Crohn's disease, gastrointestinal cancer, familial genetic multiple intestinal polyps), and History of gastrointestinal perforation, gastrointestinal surgery that influence drug absorption, and other potential intestinal complications considered by researchers;
   * ALT or Aspartate transaminase (AST) \> 2.5 × Upper limit of normal (ULN), or serum creatinine \> 1.5 × ULN;
   * Neutropenia patient (neutrophil count \< 1.5 × 109 / L);
   * Active infection uncontrolled;
   * The patients who are currently taking CYP3A strong inducer or strong inhibitor drugs, or the drug that may extend the QT interval, or the drug that may decrease neutrophil count, but can not temporarily interrupt the use of such drugs;
   * Congenital long QT syndrome or known family history of long QT syndrome; QTc \> 480 ms; clinically significant ventricular or atrial fast arrhythmia;
   * The patients who can not accept MRI as detection means, such as claustrophobic for MRI, pacemaker, and those using ferromagnetic metal implants.
   * Birth planner (including male subjects) within or within 3 months after the end of the trial;
   * Participated in other clinical trials in the three months before taking the test preparation, except for non-interventional studies;
   * Pregnant or lactating women;
   * Unsuitable to participate in the trial considered by the researchers.
5. Usage:

   * All subjects will be given the lower (10 mg/kg bw, bid) or higher dose (15 mg/kg bw, bid) for 24 or 48 weeks, according to the administration plan.
   * All subjects will be given the lower (15 mg/kg bw, bid) or higher dose (20 mg/kg bw, bid) for 49 or 96 weeks, according to the administration plan.
6. Safety assessments:

   Safety evaluations include adverse events, adverse reactions, severe adverse events, and severe adverse reactions; growth (weight, height); total and free testosterone in men, follicle-generating hormone and luteinizing hormone in women; vital signs and electrocardiogram; hearing, laboratory tests (blood routine analytes, blood biochemistry, coagulation function, thyroid and para-thyroid function, urine routine analytes.), urine pregnancy test (women of childbearing age),Levels of drug exposure during the study.
7. Efficacy assessments:

   Efficacy evaluations include serum ferritin, liver iron content (MRI R2) and cardiac iron content (MRI T2\*).
8. Statistics:

   * Subject characteristic distribution Demographic characteristics, general conditions, and baseline conditions (pre-treatment) of enrolled subjects were analyzed.The measurement data are described by means, standard deviation, minimum value and maximum value, while the qualitative data list frequency and percentage.
   * Safety analysis Descriptive statistical analysis was used for safety endpoints.
   * Effectiveness analysis Mean, standard deviation, median, minimum and maximum values were described and 95% confidence intervals were calculated. Paired T-test was used to compare each time point with the baseline if necessary. The 95% confidence interval was calculated by using Clopper-Pearson method for the proportion of patients.

Clinical Trial - IIa - Study Description - Detailed Description

1. Primary objectives:

   * To evaluate the adverse events, adverse reactions, severe adverse events and severe adverse reactions during the study period, so as to investigate the safety;
   * To evaluate the changes of serum ferritin over time after orally administration of CN128 in thalassaemia patients with blood transfusion dependent and aged 16 and above, so as to investigate the efficacy;
   * To evaluate the effect on iron excretion in liver after orally administration of CN128 for 12, 24 weeks in thalassaemia patients with blood transfusion dependent and aged 16 and above, so as to investigate the efficacy;
   * To evaluate the effect on iron excretion in heart after orally administration of CN128 for 12, 24 weeks in thalassaemia patients with blood transfusion dependent and aged 16 and above, so as to investigate the efficacy;
   * To evaluate the proportion of patients with decreased or unchanged liver iron content after orally administration of CN128 for 12, 24 weeks in thalassaemia patients with blood transfusion dependent and aged 16 and above, so as to investigate the efficacy;
   * To evaluate the safety and efficacy of long-term orally administration of CN128 in thalassaemia patients with blood transfusion dependent and aged 16 and above.
2. Design:

   * The study is designed as a single arm and opened phase IIa clinical trial, so as to investigate the safety and efficacy of CN128.
   * A total of 50 eligible subjects are planned to be enrolled, and orally administration of CN128 for 24 weeks or 48 weeks according to the administration plan. The treatment period is from day 0 to 24 weeks, and the extended treatment period was from 25 weeks to 96 weeks.
   * Administration plan:

   (1)0 day\~48 weeks： The trial will start with the lower dose of CN128 (10 mg/kg body weight \[bw\], bid) for two weeks, then the subjects will return to the study center. If no unacceptable toxicity associated with CN128 is found, the subjects will be given the higher dose (15 mg/kg body weight \[bw\], bid). If unacceptable toxicity associated with CN128 is found, the subjects will be suspended or stopped administration. If the adverse event turns to normal or abnormal but no clinical significance after suspension administration, the subjects will be given the lower dose of CN128 (10 mg/kg body weight \[bw\], bid).

   After taking CN128 at 15 mg/kg, if unacceptable toxicity associated with CN128 is found, the dosage will be reduce to 10 mg/kg. If no symptoms appear, the dose can be increased to 15 mg/kg. If the unacceptable toxicity related to CN128 still occurs, the subjects will be suspended or stopped administration. If the adverse event turns to normal or abnormal but no clinical significance after suspension administration, the subjects will be given the lower dose of CN128 (10 mg/kg body weight \[bw\], bid). The dose will be assessed once every two or four weeks.

   Subjects' medication status, uncomfortable symptoms, concomitant medication or non-drug therapy were recorded daily.

   (2)49 weeks\~96 weeks： Subjects who have completed 48 weeks of treatment may continue dosing at the original dose until the end of the study or withdraw early if they do not experience intolerable toxicity associated with CN128 tablets and have fair efficacy (≥20% elevation on MRI T2\*) and if, in the judgment of the investigator, the benefits outweigh the risks.

   Subjects who have completed 48 weeks of treatment, who have not experienced intolerable toxicity associated with CN128 tablets, but who have been assessed by the investigator as having poor efficacy (\<20% elevation of MRI T2\*) and in the judgment of the investigator the benefit outweighs the risk, may, with the subject's consent, have the dosage increased at the additional visit or the established most recent visit to 15 mg/kg in the morning and 20 mg/kg in the evening, with an assessment made at 2 weeks of dosing：

   If no relevant intolerable toxicity occurs, the dose may continue to be increased to 20 mg/kg bid and assessed after 2 weeks of dosing:
   1. If no relevant intolerable toxicity occurs, the 20 mg/kg bid dose may be administered until the end of the study or early withdrawal (daily dose 40 mg/kg/d);
   2. If relevant intolerable toxicity occurs, the dose may be reduced to 15 mg/kg in the morning and 20 mg/kg bid in the evening until the end of the study or early withdrawal (daily dose 35 mg/kg/d).

   If relevant intolerable toxicity occurs, the dose may be reduced to 15 mg/kg bid until the end of the study or early withdrawal (daily dose 30 mg/kg/d).
3. Subject inclusion criteria:

   * Thalassemia patients.
   * The number of blood transfusion per month ≥1. Or hemoglobin can not be maintained at 90g/L above, if blood transfusions is less than once per month.
   * Serum ferritin ≥ 500 µg/L
   * Patients aged 16 and above
   * Volunteer for the trial and sign the informed consent.
4. Subject exclusion criteria:

   * Active hepatitis B (HBsAg positive, HBsAb negative) or hepatitis C (HCV antibody positive, detectable HCV RNA, and ALT beyond normal range)
   * Active gastrointestinal disease history (including: gastric ulcer, duodenal ulcer, stomach or esophageal varices, ulcerative colitis, Crohn's disease, gastrointestinal cancer, familial genetic multiple intestinal polyps), and History of gastrointestinal perforation, gastrointestinal surgery that influence drug absorption, and other potential intestinal complications considered by researchers;
   * ALT or AST \> 2.5 × ULN, or serum creatinine \> 1.5 × ULN;
   * Neutropenia patient (neutrophil count \< 1.5 × 109 / L);
   * Active infection uncontrolled;
   * The patients who are currently taking CYP3A strong inducer or strong inhibitor drugs, or the drug that may extend the QT interval, or the drug that may decrease neutrophil count, but can not temporarily interrupt the use of such drugs;
   * The patients who are allergic or contraindicated to the main ingredients or excipients of CN128 tablets;
   * Congenital long QT syndrome or known family history of long QT syndrome; QTc \> 480 ms; clinically significant ventricular or atrial fast arrhythmia;
   * The patients who can not accept MRI as detection means, such as claustrophobic for MRI, pacemaker, and those using ferromagnetic metal implants;
   * Birth planner (including male subjects) within or within 3 months after the end of the trial;
   * Participated in other clinical trials in the three months before taking the test preparation, except for non-interventional studies;
   * Pregnant or lactating women;
   * Unsuitable to participate in the trial considered by the researchers.
5. Usage:

   All subjects will be given the lower (10 mg/kg bw, bid) or higher dose (15 mg/kg bw, bid) for 24 or 48 weeks, according to the administration plan.

   All subjects will be given the lower (15 mg/kg bw, bid) or higher dose (20 mg/kg bw, bid) for 49 or 96 weeks, according to the administration plan.
6. Safety assessments:

   Safety evaluations include adverse events, adverse reactions, severe adverse events, and severe adverse reactions; growth (weight, height); total and free testosterone in men, follicle-generating hormone and luteinizing hormone in women; vital signs and electrocardiogram; hearing, laboratory tests (blood routine analytes, blood biochemistry, coagulation function, thyroid and para-thyroid function, urine routine analytes.), urine pregnancy test (women of childbearing age),Levels of drug exposure during the study.
7. Efficacy assessments:

   Efficacy evaluations include serum ferritin, liver iron content (MRI R2) and cardiac iron content (MRI T2\*).
8. Statistics:

   * Subject characteristic distribution Demographic characteristics, general conditions, and baseline conditions (pre-treatment) of enrolled subjects were analyzed.The measurement data are described by means, standard deviation, minimum value and maximum value, while the qualitative data list frequency and percentage.
   * Safety analysis Descriptive statistical analysis was used for safety endpoints. Summarize the incidence of adverse events, adverse reactions, adverse events leading to withdrawal from the trial, adverse events leading to death, severe adverse events, and severe adverse reactions. The incidence is calculated by subsystem, symptom/sign. Severity of adverse events and adverse reactions: if multiple adverse events occur in the same subject, the most serious one is included in the analysis; if different adverse events occurred in the same subject, the most severe adverse events were counted in the analysis. Drug exposure during the study: describe medication compliance during the study, actual dose, administration adjustments during the study, whether the study was discontinued, and reasons for the suspension.
   * Effectiveness analysis Mean, standard deviation, median, minimum and maximum values were described and 95% confidence intervals were calculated. Paired T-test was used to compare each time point with the baseline if necessary. The 95% confidence interval was calculated by using Clopper-Pearson method for the proportion of patients.

Eligibility Criteria:
Inclusion Criteria:

* Thalassemia patients.
* The number of blood transfusion per month ≥1. Or hemoglobin can not be maintained at 90g/L above, if blood transfusions is less than once per month.
* Serum ferritin ≥ 500 µg/L
* Patients aged 16 and above
* Volunteer for the trial and sign the informed consent.

Exclusion Criteria:

* Active hepatitis B (HBsAg positive, HBsAb negative) or hepatitis C (HCV antibody positive, detectable HCV RNA, and ALT beyond normal range)
* Active gastrointestinal disease history (including: gastric ulcer, duodenal ulcer, stomach or esophageal varices, ulcerative colitis, Crohn's disease, gastrointestinal cancer, familial genetic multiple intestinal polyps), and History of gastrointestinal perforation, gastrointestinal surgery that influence drug absorption, and other potential intestinal complications considered by researchers;
* ALT or AST \> 2.5 × ULN, or serum creatinine \> 1.5 × ULN;
* Neutropenia patient (neutrophil count \< 1.5 × 109 / L);
* Active infection uncontrolled;
* The patients who are currently taking CYP3A strong inducer or strong inhibitor drugs, or the drug that may extend the QT interval, or the drug that may decrease neutrophil count, but can not temporarily interrupt the use of such drugs;
* The patients who are allergic or contraindicated to the main ingredients or excipients of CN128 tablets;
* Congenital long QT syndrome or known family history of long QT syndrome; QTc \> 480 ms; clinically significant ventricular or atrial fast arrhythmia;
* The patients who can not accept MRI as detection means, such as claustrophobic for MRI, pacemaker, and those using ferromagnetic metal implants;
* Birth planner (including male subjects) within or within 3 months after the end of the trial;
* Participated in other clinical trials in the three months before taking the test preparation, except for non-interventional studies;
* Pregnant or lactating women;
* Unsuitable to participate in the trial considered by the researchers.