Clinical trial NCT04231318
Conditions: Osteoarthritis, Knee
Sponsor: Anika Therapeutics, Inc.
Start date: 2020-09-11; Completion date: 2022-05-16
Enrollment: 231 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
This is a multi-center, randomized, double-blind, parallel group, placebo controlled trial to compare the safety and effectiveness of a single injection of Cingal® to a single injection of Triamcinolone Hexacetonide (TH) to achieve pain relief and other symptoms of osteoarthritis of the knee.

Detailed description:
To determine the contribution of Triamcinolone Hexacetonide (TH) when combined with sodium hyaluronate for pain relief, both in terms of magnitude and duration, when used as single injection, as compared to a single injection of TH alone in subjects diagnosed with osteoarthritis of the knee.

A saline placebo is included within the trial to set the expectation of a return to Baseline pain for the subjects.

Arms: arm 1: Single injection of Cingal: 4 milliliter (mL) dose of 88 mg (22 mg/mL) of cross-linked sodium hyaluronate with 18 mg (4.5 mg/mL) of triamcinolone hexacetonide (TH). Manufactured by Anika Therapeutics. arm 2: Single injection of Triamcinolone Hexacetonide (TH): 1 milliliter (mL) dose of 20 mg/ml TH. Manufactured by IntraPharm. arm 3: Single injection of Placebo: 4 milliliter (mL) dose of 0.9% saline. Manufactured by Anika Therapeutics.
Interventions: intervention 1: Cingal intervention 2: Triamcinolone Hexacetonide (TH) intervention 3: Placebo
Intervention descriptions: intervention 1: Single intra-articular injection of Cingal into the knee. intervention 2: Single intra-articular injection of TH into the knee. intervention 3: Single intra-articular injection Placebo (0.9% Saline) into the knee.

Protocol documents:
Prot_000.pdf: 





























































































































































SAP_001.pdf: 
CINGAL 19-01- SAP v1.0 26Aug2020 
 
Page 1 of 14 
 
 
Statistical Analysis Plan 
 
 
A Randomized, Double-Blind, Placebo Controlled, 
Multi-Center Study of a Single Injection Cross-
Linked Sodium Hyaluronate Combined with 
Triamcinolone Hexacetonide (Cingal®) to Provide 
Symptomatic Relief of Osteoarthritis of the Knee 
 
Protocol Number:  CINGAL 19-01 Version 1.0 
Protocol Issue Date:  13 Dec2018 
SAP Date:26AUG2020 
SAP version number- V1.0 
Anika Therapeutics, Inc. 
 
 
 
 
 
Prepared by: Gary Stevens, Ph.D. 
 
 
DynaStat Consulting, Inc. 
 
 
 
Approved by: 
 
 
 
 
Gary Stevens, Ph.D. 
 
 
 
 
Anika Therapeutics, Inc. 
 
Dynastat Consulting, Inc. 
 
 
 
 
 
 
 
 
 
 
 


CINGAL 19-01- SAP v1.0 26Aug2020 
 
Page 2 of 14 
Table of Contents 
 
 
Contents 
Table of Contents ............................................................................................................................ 2 
1.0 
Introduction .......................................................................................................................... 3 
2.0 
Study Design ........................................................................................................................ 3 
3.0 
Objectives ............................................................................................................................ 4 
3.1 Primary Efficacy Endpoint ................................................................................................... 4 
3.2 Secondary Efficacy Endpoints .............................................................................................. 4 
3.3 Exploratory Endpoints .......................................................................................................... 5 
3.4 Safety Endpoint:.................................................................................................................... 5 
4.0 
Statistical Methods in Protocol ............................................................................................ 7 
4.1 Statistical Methods ................................................................................................................ 7 
4.1.1Sample Size ..................................................................................................................... 7 
4.1.2 Primary Efficacy Endpoint ............................................................................................ 7 
4.1.3 Secondary Efficacy Endpoints ....................................................................................... 9 
4.1.4 Exploratory Endpoints ................................................................................................. 12 
4.2 Statistical Methods .............................................................................................................. 13 
4.3 Demographic and Baseline Characteristics ........................................................................ 13 
4.4 Adverse Events ................................................................................................................... 13 
4.5 Subject Populations ............................................................................................................. 13 
4.6 Additional Analyses ............................................................................................................ 14 
 
 
 
 
 
 
 


CINGAL 19-01- SAP v1.0 26Aug2020 
 
Page 3 of 14 
1.0 Introduction 
 
 
This document presents the statistical analysis plan (SAP) for the Anika Therapeutics, Inc. 
protocol Cingal 19-01.  This incorporates the data listings, summary tables, and statistical 
analyses.  This document is based on the original final protocol and case report forms (CRFs). 
 
 
2.0 Study Design 
 
This is a multi-center, randomized, double-blind, parallel arm, placebo-controlled trial to 
determine the contribution of Triamcinolone Hexacetonide (TH) to pain relief, both in terms of 
magnitude and duration, when used within a single injection of Cingal® compared to a single 
injection of TH in subjects with Osteoarthritis (OA) of the knee. 
Subjects with OA defined as Kellgren-Lawrence (K-L) II or III in the index knee will be eligible 
for this study [9, 10].  Felson et al 2004, encouraged the use of both OA symptoms and 
radiographic changes in the assessment of OA [11].  This study will employ both methods to 
screen subjects.  Structural severity will be evaluated with the K-L classification score, a 
composite index of the presence and severity of joint space narrowing, osteophytes, sclerosis, 
deformity and cysts.  
For the evaluation of symptomatic severity, two main domains are important [12].  The first is 
pain and the second is functional impairment.  Other domains often used include subject’s 
overall assessment, ROM and performance.  Domains identified by OMERACT as core variables 
to be used in clinical trials involving OA are pain, function and the Patient Global Assessment 
which will be captured as part of this study [12]. 
Baseline and post-treatment pain, physical function and stiffness will be measured using the 
WOMAC questionnaire. VAS and NRS pain, ROM, Patient and Evaluator Global Assessment 
and the EuroQoL-5D-5L will be used to assess symptomatic severity throughout the study.  In 
addition, the number of acetaminophen pills taken will be captured as an indirect measure of pain 
and will be done at follow up visits.  
Subjects meeting the inclusion/exclusion criteria will be randomized to receive a single injection 
of Cingal®, Triamcinolone Hexacetonide (TH) or placebo in the index knee. Since there is a 
difference in volume between Cingal®, TH and placebo, the treating physician will not be 
considered blinded.  To maintain the double-blind design of the study, there will be a person 
assigned to the role of Treating Physician and one person assigned to the role of Blinded 
Evaluator. The Treating Physician, most often the PI, will administer the injection but will not 
participate in the evaluation of study treatment effectiveness. A second individual, designated as 
the Blinded Evaluator, is blinded to treatment and will complete the pre- and post-treatment 
Evaluator Global Assessment, knee exams and ROM measurements. To maintain the Subject 
blinding, the injection syringe will be prepared separate from the patient and the injection will be 
masked from the subject.   


CINGAL 19-01- SAP v1.0 26Aug2020 
 
Page 4 of 14 
The Subject will be trained on how to complete the WOMAC, VAS Pain, NRS Pain, Patient 
Global Assessment and EuroQoL.  
The Blinded Evaluator will collect and record AEs from the subjects and consult the Treating 
Physician only as needed in the management of AEs.  The Blinded Evaluator will be a physician, 
research nurse, registered physiotherapist or physician assistant trained to perform the 
assessments outlined in the protocol. 
Up to 40 sites in US may participate in the study to enroll and treat 231 subjects.  Subject 
participation will last approximately 7 months with follow-up visits scheduled at weeks 1, 3, 6, 
12, 18, and 26 after the treatment injection. 
 
 
3.0 Objectives 
 
To determine the contribution of Triamcinolone Hexacetonide (TH) to pain relief, both in terms 
of magnitude and duration, when used within a single injection of Cingal® compared to a single 
injection of TH in subjects with Osteoarthritis (OA) of the knee. A saline placebo is included 
within the trial to set the expectation of a return to pain in Subjects. 
3.1 PRIMARY EFFICACY ENDPOINT  
• The change from Baseline in knee pain as measured by the WOMAC Pain Score (100 
mm VAS) at 26 weeks post treatment comparing the Cingal® arm to the TH arm, the 
Cingal arm to the placebo arm, and the TH arm to the placebo arm. 
 
3.2 SECONDARY EFFICACY ENDPOINTS  
• The responder rate as identified by the Outcomes Measures for Rheumatic Arthritis 
Clinical Trials-Osteoarthritis Research Society International (OMERACT-OARSI) 
responder index at 26 weeks post treatment comparing the Cingal® arm to the TH arm 
and Placebo arm, the Cingal arm to the Placebo arm, and the TH arm to the Placebo 
arm. 
• The change from Baseline in knee pain as measured by daily VAS Pain Score and 
average weekly VAS Pain Score (100 mm VAS) through 26 weeks post treatment 
comparing the Cingal® arm to the TH arm and Placebo arm, the Cingal arm to the 
Placebo arm, and the TH arm to the Placebo arm. 
• The change from Baseline in knee pain as measured by daily NRS Pain Score and 
average weekly NRS Pain Score (0-10 NRS) through 26 weeks post treatment 
comparing the Cingal® arm to the TH arm and Placebo arm, the Cingal arm to the 
Placebo arm, and the TH arm to the Placebo arm. 
 
• The change from Baseline in WOMAC Physical Function score at 26 weeks post 
treatment comparing the Cingal® arm to the TH arm and Placebo arm, the Cingal arm 
to the Placebo arm, and the TH arm to the Placebo arm. 


CINGAL 19-01- SAP v1.0 26Aug2020 
 
Page 5 of 14 
 
• The change from Baseline in WOMAC Stiffness score at 26 weeks post treatment 
comparing the Cingal® arm to the TH arm and Placebo arm, the Cingal arm to the 
Placebo arm, and the TH arm to the Placebo arm, the Cingal arm to the Placebo arm, 
and the TH arm to the Placebo arm. 
• The change from Baseline in Total WOMAC score at 26 weeks post treatment 
comparing the Cingal® arm to the TH arm and Placebo arm, the Cingal arm to the 
Placebo arm, and the TH arm to the Placebo arm. 
• The change from Baseline in the Patient Global Assessment at 26 weeks post 
treatment in the Cingal® arm compared to the TH arm and Placebo arm, the Cingal 
arm to the Placebo arm, and the TH arm to the Placebo arm. 
 
• The change from Baseline in the Evaluator Global Assessment at 26 weeks post 
treatment in the Cingal® arm compared to the TH arm and Placebo arm, the Cingal 
arm to the Placebo arm, and the TH arm to the Placebo arm. 
 
• The usage of rescue medication through 26 weeks post treatment in the Cingal® arm 
compared to the TH arm and Placebo arm, the Cingal arm to the Placebo arm, and the 
TH arm to the Placebo arm. 
 
3.3 EXPLORATORY ENDPOINTS  
Any comparisons between arms (Cingal®, TH, Placebo), within arms and / or time points 
(from baseline through to 26 weeks) not described in the primary or secondary endpoints 
may be presented in the exploratory endpoints including: 
• EuroQoL (EQ-5D-5L) 
• WOMAC Pain Score (100mm VAS) 
• Daily VAS pain scores & weekly average VAS pain scores 
• Daily NRS pain scores & weekly average NRS pain scores 
• OMERACT-OARSI 
• Total WOMAC 
• WOMAC Stiffness Score 
• WOMAC Physical Function 
• Patient Global Assessment 
• Evaluator Global Assessment 
• Range of Motion  
• Rescue Medication Use 
• Number of Treatment Failures 
 
3.4 SAFETY ENDPOINT:  


CINGAL 19-01- SAP v1.0 26Aug2020 
 
Page 6 of 14 
The incidence, timing, severity, and relationship to treatment of all Adverse Events (AE) will be 
collected and coded using Medical Dictionary for Regulatory Activities (MedDRA).  Local 
injection site and non-local events will be recorded separately. 
 
 
 


CINGAL 19-01- SAP v1.0 26Aug2020 
 
Page 7 of 14 
4.0 Statistical Methods in Protocol 
 
4.1 STATISTICAL METHODS 
 
This Statistical Analysis Plan provides the details of the statistical analysis of the study data that 
is described in the protocol. 
4.1.1 Sample Size 
 
This is a pilot study designed to estimate as the primary assessment, the differences between Cingal 
and Triamcinolone Hexacetonide (TH) with respect to the difference in the change in WOMAC 
pain score from baseline to 26 weeks post treatment. For convenience the sample size will be 
assessed in a 3:3:1 ratio (Cingal: TH: Placebo) with the sample sizes being 99:99:33, for a total 
sample size of 231 patients treated.  It should be noted that if the standard deviation for the 
difference in change from baseline in the WOAMC Pain Score between Cingal and TH is 
approximately 20 points and a difference of 8 points would yield 80% power of detecting that 
difference.  If the difference is 10 points, this sample size yields over 90% power of detecting that 
difference. 
Since the primary analysis in this study is an intent to treat analysis and the missing data for a 
patient will be imputed using mixed effects models, no dropout rate will be assumed for this study.  
Thus, the total sample size will be 231 patients treated.    
 
4.1.2 Primary Efficacy Endpoint 
 
4.1.2.1 The primary efficacy endpoint is the change from baseline in knee pain as 
measured by the WOMAC Pain Score (1
00 mm VAS) at 26 weeks post treatment 
comparing the Cingal Arm  to the triamcinolone hexacetonide (TH)
 Arm, the Cingal 
Arm to the Placebo Arm, and the TH Arm to the Placebo Arm
. 
 
Data will be analyzed via an analysis of variance (ANOVA) with a term for treatment and baseline 
pain score as a covariate.  The primary hypothesis(es) will be tested by a predefined contrast for 
comparing the Cingal Arm to the triamcinolone hexacetonide (TH) Arm, the Cingal Arm to the 
Placebo Arm, and the TH Arm to the Placebo Arm.  Formally, the hypotheses to be tested is: 
 
H0: µDC = µDT versus HA: µDC ≠ µDT.  (Primary Cingal to TH) 
H0: µDC = µDP versus HA: µDC ≠ µDP.  (Primary Cingal to Placebo) 
H0: µDT = µDP versus HA: µDT ≠ µDP.  (Primary TH to Placebo) 
 
Where µDC is the mean change from baseline in the WOMAC Pain Score for the Cingal Arm at 26 
weeks, µDT is the mean change from baseline in the WOMAC Pain Score for the triamcinolone 
hexacetonide Arm at 26 weeks, and µDP is the mean change from baseline in the WOMAC Pain 
Score for the Placebo Arm at 26 weeks.  Since there are three treatment groups in this study, this 
hypothesis will be tested using a one way ANOVA and constructing a contrast for this hypothesis.  


CINGAL 19-01- SAP v1.0 26Aug2020 
 
Page 8 of 14 
This process is the same as using a baseline pain adjusted two-sample t-test with the common 
variance estimate from the ANOVA. 
 
The anticipated SAS code for this analysis is given as: 
The mean difference will be estimated and tested using the contrasts from PROC GLM on the 
responses at the 26 week time period. 
PROC GLM DATA=EFF; 
 WHERE VISITNO = 26; 
 CLASS TRT; 
 MODEL WOMDIFF = BASEWOM TRT / TYPE3 ALPHA=0.05; 
 ESTIMATE ‘CINGAL VS PLACEBO’  TRT 1 -1 0 ; 
 ESTIMATE ‘CINGAL VS TH’       TRT 1 0 -1 ; 
 ESTIMATE ‘PLACEBO VS TH’      TRT 0 1 -1 ; 
 LSMEANS TRT / DIFF CL ALPHA=0.05; 
FORMAT TRT TRTF. ; 
RUN; 
 
In this model, the WOMDIFF is the difference in WOMAC Pain Scores from baseline.  The 
variable TRT is a categorical variable where 1 = Cingal, 2=Placebo, and 3=TH.  The variable 
BASEWOM is the baseline WOAMC scores and the variable VISITNO is the visit number 
identifier.  ODS statements will be used to output the contrasts and the mean differences into  
data sets that can be easily displayed using PROC REPORT.  The primary analysis will be 
comparing Cingal to TH. 
 
The tables for this analysis will be displayed as: 
 
Summary of Least Squares Means at 26 weeks – WOMAC Pain Score 
Treatment 
Group 
Mean Percent 
Improvement 
LS Mean 
Standard 
Error 
Cingal 
 
 
Placebo 
 
 
TH 
 
 
 
Summary of Differences in Mean Responses at 26 Weeks – WOMAC Pain Score 
Treatment 
Group 
Mean Percent 
Improvement 
Standard 
Error 
Lower 
Confidence 
Limit 
Upper 
Confidence 
Limit 
p-value 
Cingal – Placebo 
 
 
 
 
 
Cingal – TH (Primary) 
 
 
 
 
 
Placebo - TH 
 
 
 
 
 
 
 


CINGAL 19-01- SAP v1.0 26Aug2020 
 
Page 9 of 14 
4.1.3 Secondary Efficacy Endpoints 
 
4.1.3.1 The responder rate as identified by the Outcomes Measures for 
Rheumatic Arthritis Clinical Trials-Osteoarthritis Research Society 
International (OMERACT-OARSI) responder index at 26 weeks post 
treatment comparing the Cingal® arm to the TH arm, the Cingal arm to the 
Placebo arm, and the TH arm to the Placebo Arm. 
 
The response rate for the Cingal group and Triamcinolone Hexacetonide (TH) group will be 
calculated and tested using Fisher’s exact test.  Formally, the hypothesis to be tested is: 
 
H0: πC = πT versus  H0: πC ≠ πT   
 
Where πC is the responder rate for the Cingal group and πT is the responder rate for the 
triamcinolone hexacetonide group.  
 
The response rate for the Cingal Arm, the Placebo Arm and Triamcinolone Hexacetonide (TH) 
Arm will be calculated and tested using Fisher’s exact test.  Formally, the hypotheses to be tested 
are: 
 
H0: πC = πP versus  H0: πC ≠ πP   
H0: πT = πP versus  H0: πT ≠ πP   
 
Where πC is the responder rate for the Cingal Arm, πT is the responder rate for the triamcinolone 
hexacetonide Arm, and πP is the responder rate for the Placebo Arm. 
 
This will be estimated and tested using PROC FREQ with the EXACT option.  The results will be 
displayed similar to: 
 
Summary of the OMERACT-OARSI Responder Rates at 26 Weeks 
Parameter 
Cingal 
Placebo 
TH 
Estimate n/N (%) 
 
 
 
Cingal vs TH (Primary) (p-value) 
 
 
 
Cingal vs Placebo  (p-value) 
 
 
 
Placebo vs TH (p-value) 
 
 
 
 
 
 


CINGAL 19-01- SAP v1.0 26Aug2020 
 
Page 10 of 14 
 
4.1.3.2  Other Secondary Endpoints . 
 
All of the following endpoints will be analyzed using the same methodology as the primary 
endpoint: 
 
 
• The change from Baseline in knee pain as measured by daily VAS Pain Score and 
average weekly VAS Pain Score (100 mm VAS) through 26 weeks post treatment 
comparing the Cingal® arm to the TH arm and Placebo arm, the Cingal arm to the 
Placebo arm, and the TH arm to the Placebo arm. 
• The change from Baseline in knee pain as measured by daily NRS Pain Score and 
average weekly NRS Pain Score (0-10 NRS) through 26 weeks post treatment 
comparing the Cingal® arm to the TH arm and Placebo arm, the Cingal arm to the 
Placebo arm, and the TH arm to the Placebo arm. 
 
• The change from Baseline in WOMAC Physical Function score at 26 weeks post 
treatment comparing the Cingal® arm to the TH arm and Placebo arm, the Cingal arm 
to the Placebo arm, and the TH arm to the Placebo arm. 
 
• The change from Baseline in WOMAC Stiffness score at 26 weeks post treatment 
comparing the Cingal® arm to the TH arm and Placebo arm, the Cingal arm to the 
Placebo arm, and the TH arm to the Placebo arm, the Cingal arm to the Placebo arm, 
and the TH arm to the Placebo arm. 
• The change from Baseline in Total WOMAC score at 26 weeks post treatment 
comparing the Cingal® arm to the TH arm and Placebo arm, the Cingal arm to the 
Placebo arm, and the TH arm to the Placebo arm. 
• The change from Baseline in the Patient Global Assessment at 26 weeks post 
treatment in the Cingal® arm compared to the TH arm and Placebo arm, the Cingal 
arm to the Placebo arm, and the TH arm to the Placebo arm. 
 
That is, Data will be analyzed via an analysis of variance (ANOVA) with a term for treatment and 
baseline pain score as a covariate.  The primary hypothesis(es) will be tested by a predefined 
contrast for comparing the Cingal Arm to the triamcinolone hexacetonide (TH) Arm, the Cingal 
Arm to the Placebo Arm, and the TH Arm to the Placebo Arm..  Formally, the hypotheses to be 
tested is: 
 
H0: µDC = µDT versus HA: µDC ≠ µDT.  (Primary Cingal to TH) 
H0: µDC = µDP versus HA: µDC ≠ µDP.  (Primary Cingal to Placebo) 
H0: µDT = µDP versus HA: µDT ≠ µDP.  (Primary TH to Placebo) 
 
Where µDC is the mean change from baseline in the Endpoint Score for the Cingal Arm at 26 
weeks, µDT is the mean change from baseline in the Endpoint Score for the triamcinolone 
hexacetonide Arm at 26 weeks, and µDP is the mean change from baseline in the Endpoint Score 


CINGAL 19-01- SAP v1.0 26Aug2020 
 
Page 11 of 14 
for the Placebo Arm at 26 weeks.  Since there are three treatment groups in this study, this 
hypothesis will be tested using a one way ANOVA and constructing a contrast for this hypothesis.  
This process is the same as using a baseline Endpoint Score adjusted two-sample t-test with the 
common variance estimate from the ANOVA. 
 
The anticipated SAS code for this analysis is given as: 
The mean difference will be estimated and tested using the contrasts from PROC GLM on the 
responses at the 26 week time period. 
PROC GLM DATA=EFF; 
 WHERE VISITNO = 26; 
 CLASS TRT; 
 MODEL PARMDIFF = BASEPARM TRT / TYPE3 ALPHA=0.05; 
 ESTIMATE ‘CINGAL VS PLACEBO’  TRT 1 -1 0 ; 
 ESTIMATE ‘CINGAL VS TH’       TRT 1 0 -1 ; 
 ESTIMATE ‘PLACEBO VS TH’      TRT 0 1 -1 ; 
 LSMEANS TRT / DIFF CL ALPHA=0.05; 
FORMAT TRT TRTF. ; 
RUN; 
In this model, the PARMDIFF is the difference in Endpoint Score from baseline.  The variable 
TRT is a categorical variable where 1 = Cingal, 2=Placebo, and 3=TH.  The variable 
BASEPARM is the baseline Endpoint Score and the variable VISITNO is the visit number 
identifier.  ODS statements will be used to output the contrasts and the mean differences into  
data sets that can be easily displayed using PROC REPORT.  The primary analysis will be 
comparing Cingal to TH. 
 
The tables for this analysis will be displayed as: 
 
Summary of Least Squares Means at 26 weeks – Endpoint Score 
Treatment 
Group 
Mean Percent 
Improvement 
LS Mean 
Standard 
Error 
Cingal 
 
 
Placebo 
 
 
TH 
 
 
 
Summary of Differences in Mean Responses at 26 Weeks – Endpoint Score 
Treatment 
Group 
Mean Percent 
Improvement 
Standard 
Error 
Lower 
Confidence 
Limit 
Upper 
Confidence 
Limit 
p-value 
Cingal – Placebo 
 
 
 
 
 
Cingal – TH (Primary) 
 
 
 
 
 
Placebo - TH 
 
 
 
 
 
 
 


CINGAL 19-01- SAP v1.0 26Aug2020 
 
Page 12 of 14 
4.1.3.9 The usage of rescue medication through 26 weeks post treatment 
comparing the Cingal group to the triamcinolone hexacetonide group. 
  
 
The percentage of  subjects using rescue medications will be calculated and tested using Fisher’s 
exact test.  Formally, the hypothesis to be tested is: 
 
H0: πC = πT versus  H0: πC ≠ πT   
H0: πC = πP versus  H0: πC ≠ πP   
H0: πT = πP versus  H0: πT ≠ πP   
 
Where πC is the usage rate for the Cingal Arm, πT is the usage rate for the triamcinolone 
hexacetonide Arm, and πP is the usage rate for the Placebo Arm. 
 
This will be estimated and tested using PROC FREQ with the EXACT option.  The results will be 
displayed similar to: 
 
Summary of the Usage Rates at 26 Weeks 
Parameter 
Cingal 
Placebo 
TH 
Estimate n/N (%) 
 
 
 
Cingal vs TH (Primary) (p-value) 
 
 
 
Cingal vs Placebo  (p-value) 
 
 
 
Placebo vs TH (p-value) 
 
 
 
 
 
 
4.1.4 Exploratory Endpoints 
Any comparisons between groups (Cingal, Placebo, TH), within groups and / or time points (from 
baseline through to 26 weeks) not described in the primary or secondary endpoints may be 
presented in the exploratory endpoints including: 
 
• EuroQoL (EQ-5D) 
• WOMAC Pain Score (100mm VAS) 
• OMERACT-OARSI 
• Total WOMAC 
• WOMAC Stiffness Score 
• WOMAC Physical Function Score 
• Patient Global Assessment 
• Evaluator Global Assessment 
• Range of Motion 
• Rescue Medication Usage: Difference in analgesic use measured by number of pills taken 
between visits will be compared between treatment groups descriptively. 
• Number of Subjects Considered Treatment Failures: Treatment Failure: A subject who 
undergoes a procedure or uses a medication (other than the rescue medication) for the 


CINGAL 19-01- SAP v1.0 26Aug2020 
 
Page 13 of 14 
treatment of OA in the index knee at any time after the study injection through the 12 week 
visit. 
 
For the exploratory analyses, the continuous variables will be analyzed via an analysis of variance 
and contrasts used to assess the prescribed comparisons.  For the discrete variables, a Fisher’s 
exact test will be used to assess the desired comparisons. 
 
4.2 STATISTICAL METHODS 
 
Tabulation of summary statistics, graphical presentations, and statistical analyses will be 
performed using SAS® software 9.4 or higher version. Where not otherwise specified, the last pre-
treatment observation will be used as baseline for calculating post-treatment changes from 
baseline. The primary presentations and analyses will be based on data pooled across study centers. 
Relevant summaries for individual centers, or combinations of centers, may be presented for 
primary data. All testing and confidence intervals will use a significance level of 5%. 
 
4.3 DEMOGRAPHIC AND BASELINE CHARACTERISTICS 
 
All demographic and baseline characteristics will be tabulated by treatment group and a test of 
homogeneity between the treatment groups will be conducted. For continuous variables (e.g. age, 
height, weight) a one way ANOVA will be used. For categorical variables (e.g. gender, race), a 
Fisher's exact test or chi-squared test will be used. Medical history findings, physical examinations 
and concomitant medications will be tabulated by treatment group. 
The baseline Chemistry, Hematology, Urinalysis, Vital Signs, and BMI data will be summarized 
via descriptive statistics and tested for homogeneity using a one way ANOVA. 
 
4.4 ADVERSE EVENTS 
 
All AEs will be coded according to MedDRA. Safety assessments will include Treatment-
Emergent Adverse Events (TEAEs) which are defined as AEs with an Investigator assessment of 
definitely, probably, or possibly related to CTM.  TEAEs will be summarized with frequencies 
and percentages by system organ class and preferred term, severity, and relationship to study CTM 
for each treatment group.  In summaries of TEAEs by severity and relationship to CTM for subjects 
reporting multiple episodes, all reported events will be included, not only the worst reported case.  
Serious Adverse Events will also be presented by relationship to the CTM.  
The number of subjects with at least one AE will be tabulated for each treatment group. Differences 
between the treatment groups will be tested using Fisher's exact test. Then the number of AEs for 
each treatment group will also be tabulated. 
 
The number of subjects and the number of AEs will be tabulated by severity, relationship, and 
local injection site specific events versus non local events. 
 
 
4.5 SUBJECT POPULATIONS   
 
All safety analyses will be conducted on all subjects who undergo treatment in any group.  


CINGAL 19-01- SAP v1.0 26Aug2020 
 
Page 14 of 14 
    
The primary analysis on the primary endpoint will be performed on the ITT populations using the 
Multiple Imputation Methodology.  The Multiple Imputation Methodology will use a mixed effects 
repeated measures model to predict the missing values.  All Primary and Secondary endpoints will 
be analyzed using the ITT population. 
 
It has been determined that any missing data in this study will follow the Missing at Random 
(MAR) assumption and is justified by the following section from the guide on missing data.  
 
Missing Data Because of Attrition in the Course of the Study The longer the planned length of 
a clinical trial, the greater the chance that participants will drop out of the trial due to their moving 
out of the area or otherwise experiencing changes in their lives that preclude or complicate further 
participation. If dropping out due to these situations is known to be unrelated to changes in health 
status, an MAR assumption for the missing values seems justified; 
 
Since none of these patients are likely to be in a life threatening disease situation and many have 
had knee pain for a period of time, the missing data will unlikely be due to any treatment effect or 
lack thereof.  Previous studies have demonstrated a missing data rate of less than 1%.  Thus, any 
missing data in this study follows that paradigm and thus should be considered MAR.  Under this 
MAR assumption, the mixed effects repeated measures analysis yields unbiased estimates of the 
treatment effects and thus will be utilized in the analysis. 
 
A secondary analysis will be conducted on the Per Protocol (PP) population.   Since the primary 
endpoint is at 26 weeks, this is all subjects who complete the 26 week visit and who are not major 
violators of the protocol.  For all other visits, this is defined as the subjects who complete those 
visits according to the protocol.   
 
4.6 ADDITIONAL ANALYSES 
 
All of the analyses are performed on the data with the specified covariates or other factors 
assumed in the model.  If it is determined that certain factors may influence the outcomes of the 
endpoints, then additional analyses will be performed.  For the continuous variables, the factors 
will be added to the ANOVA model and evaluated in a stepwise fashion for significance.  For the 
discrete variables, the data will be analyzed via a GEE model with the factors added to the 
model.