Clinical trial NCT04305184
Conditions: Chronic Tympanic Membrane Perforation
Keywords: ASP0598
Sponsor: Astellas Pharma Global Development, Inc.
Start date: 2020-09-10; Completion date: 2023-01-24
Enrollment: 36 participants; Allocation: RANDOMIZED; Intervention model: SEQUENTIAL

Brief summary:
The primary purpose of this study was to evaluate the safety and tolerability of ASP0598 Otic Solution. This study also evaluated the efficacy of ASP0598 otic solution.

Detailed description:
This study consisted of a dose escalation (single ascending dose - SAD and multiple ascending dose- MAD) and dose expansion (single dose expansion and/or multiple dose expansion). Dose escalation consisted of up to 4 cohorts for single ascending dose (SAD) and up to 2 cohorts for multiple ascending dose (MAD) with different dose levels. For SAD, after randomization on Day 1, participants received ASP0598 Otic Solution or placebo administration into the affected ear. Participants returned to the site on days 2, 3, 8, 15, 29, and 57 \[end of study (EOS)\]. Day 3 evaluations were only performed for cohorts 1, 2 and 3. For MAD, after randomization on Day 1, participants received ASP0598 Otic Solution or placebo administration into the affected ear and received additional treatments into the same ear on Days 15 and 29. Participants returned to the investigative site on Days 8, 15, 22, 29, 36, 57, and 85 (EOS). Dose expansion was based on the safety and efficacy results from an interim analysis. An interim analysis was conducted after completion of SAD and again after completion of MAD. The single and multiple dose expansion parts of the study were not opened following review of safety and efficacy results of SAD and MAD parts of the study by the DMC per the Interim Analysis Plan.

Arms: arm 1: Participants received single dose of 0.03 microgram (mcg) ASP0598 Otic Solution into the affected ear on day 1 and returned to the investigative site for assessments on days 2, 3, 8, 15, 29, and 57 \[End of Study (EOS)\]. arm 2: Participants received single dose of 0.15 mcg ASP0598 Otic Solution into the affected ear on Day 1 and returned to the investigative site for assessments on days 2, 3, 8, 15, 29, and 57 (EOS). arm 3: Participants received single dose of 0.75 mcg ASP0598 Otic Solution into the affected ear on day 1 and returned to the investigative site for assessments on days 2, 3, 8, 15, 29, and 57 (EOS). arm 4: Participants received single dose of 2.25 mcg ASP0598 Otic Solution into the affected ear on day 1 and returned to the investigative site for assessments on days 2, 3, 8, 15, 29, and 57 (EOS). arm 5: Participants received single dose of placebo matched to ASP0598 Otic Solution into the affected ear on day 1 and returned to the investigative site for assessments on days 2, 3, 8, 15, 29, and 57 (EOS). arm 6: Participants received multiple doses of 0.75 mcg ASP0598 Otic Solution into the affected ear on days 1, 15 and 29 and returned to the investigative site for assessments on days 8, 15, 22, 29, 36, 57, and 85 (EOS). arm 7: Participants received multiple doses of 2.25 mcg ASP0598 Otic Solution into the affected ear on days 1, 15 and 29 and returned to the investigative site for assessments on days 8, 15, 22, 29, 36, 57, and 85 (EOS). arm 8: Participants received multiple doses of placebo matched to ASP0598 Otic Solution into the affected ear on days 1, 15 and 29 and returned to the investigative site for assessments on days 8, 15, 22, 29, 36, 57, and 85 (EOS).
Interventions: intervention 1: ASP0598 intervention 2: Placebo
Intervention descriptions: intervention 1: ASP0598 Otic solution was administered onto the Tympanic Membrane (TM) through the external auditory canal via syringe. intervention 2: Placebo matched to ASP0598 Otic solution was administered onto the TM through the external auditory canal via syringe.

Protocol documents:
Prot_000.pdf: 
Sponsor: APGD 
ISN/Protocol 0598-CL-0101 
- CONFIDENTIAL - 
 
29 Aug 2022  
Astellas 
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Version 3.3 Incorporating Nonsubstantial Amendment 4 
A Phase 1/2, Randomized, Placebo-controlled Study to Assess the 
Safety, Tolerability, Efficacy, and Pharmacokinetics of ASP0598 
Otic Solution Following Topical Application into the Ear in 
Subjects with Chronic Tympanic Membrane Perforation (CTMP) 
ISN/Protocol 0598-CL-0101 
Version 3.3 
Incorporating Nonsubstantial Amendment 4 (see Section 13) 
29 Aug 2022 
 
 
IND 144579 CDER 
 
Sponsor: 
Astellas Pharma Global Development Inc. 
1 Astellas Way 
Northbrook, IL 60062, US 
 
 
Protocol History: 
Version 1.0 [21Oct2019] 
Version 1.1 [09 Dec 2019] Incorporating Nonsubstantial Amendment 1 
Version 2.0 [12Aug2020] Incorporating Substantial Amendment 1 
Version 3.0 [19Jul2021] Incorporating Substantial Amendment 2 
Version 3.1 [21Oct2021] Incorporating Nonsubstantial Amendment 2 
Version 3.2 [04May2022] Incorporating Nonsubstantial Amendment 3 
The information contained in this document is supplied as a background for clinical investigations. This document contains 
confidential information, which is the intellectual property of Astellas. By accepting or reviewing this document, you agree 
to hold this information in confidence and not copy or disclose it to others or use it for unauthorized purposes except (1) as 
otherwise agreed to in writing; (2) where required by applicable law; (3) where disclosure is directly related to the care and 
safety of the research subject; and (4) where disclosure of such information is made to a member of the investigator’s team 
who agrees to hold this information in confidence.   
 


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Table of Contents 
SIGNATURES ································
································
································
 8 
CONTACT DETAILS OF SPONSOR’S KEY PERSONNEL ································
·····  10 
1 
PROTOCOL SUMMARY ································
································
·······  11 
1.1 
Synopsis ································
································
························
 11 
1.2 
Study Schema ································
································
··················
 25 
1.3 
Schedule of Assessments ································
································
·····  34 
2 
INTRODUCTION ································
································
·················
 42 
2.1 
Background ································
································
····················
 42 
2.1.1 
Nonclinical and Clinical Data ································
··························
 43 
2.1.2 
Summary of Key Safety Information for Investigational Product(s) ··············
 44 
2.2 
Study Rationale ································
································
················
 44 
2.3 
Risk Benefit Assessment ································
································
·····  44 
3 
STUDY OBJECTIVE AND ENDPOINTS ································
···················
 45 
3.1 
Primary Objective and Endpoints ································
···························
 45 
3.2 
Secondary Objective and Endpoints ································
························
 45 
3.2.1 
Intercurrent Events ································
································
······  45 
3.2.2 
Treatment regimen under evaluation ································
··················
 46 
3.2.3 
Estimand ································
································
··················
 46 
3.3 
Exploratory Objectives and Endpoints ································
·····················
 47 
4 
STUDY DESIGN AND DOSE RATIONALE ································
················
 48 
4.1 
Study Design ································
································
···················
 48 
4.1.1 
Decision Process for Dose Escalation, Dose Escalation Stopping Rules and 
Definition of the Maximum Tolerated Dose ································
·········  51 
4.1.1.1 
Composition of Dose Escalation Committee ································
···  51 
4.1.1.2 
Decision Process for Dose Escalation and MAD Initiation ···················
 51 
4.1.1.3 
Dose Escalation Stopping Rules ································
·················
 51 
4.1.1.4 
Definition of the Maximum Tolerated Dose································
····  52 
4.2 
Decision Process for Dose Expansion ································
······················
 52 
4.3 
Dose Rationale ································
································
················
 52 
4.4 
End of Study Definition ································
································
······  53 
5 
STUDY POPULATION ································
································
··········
 54 


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5.1 
Inclusion Criteria ································
································
··············
 54 
5.2 
Exclusion Criteria ································
································
·············
 55 
5.3 
Restrictions During the Study ································
·······························
 56 
5.4 
Screen Failures ································
································
················
 57 
5.4.1 
Rescreening ································
································
··············
 57 
6 
INVESTIGATIONAL PRODUCT(S) ································
·························
 57 
6.1 
Investigational Product(s) Administered ································
···················
 57 
6.1.1 
Investigational Product Application ································
···················
 58 
6.2 
Preparation/Handling/Storage/Accountability ································
·············
 58 
6.2.1 
Packaging and Labeling ································
································
 58 
6.2.2 
Handling, Storage and Accountability ································
················
 59 
6.3 
Randomization and Blinding ································
································
 59 
6.3.1 
Blinding Method ································
································
·········  59 
6.3.2 
Confirmation of the Indistinguishability of the Investigational Product ··········
 60 
6.3.3 
Retention of the Assignment Schedule and Procedures for Treatment Code 
Breaking ································
································
··················
 60 
6.3.4 
Breaking the Treatment Code for Emergency ································
·······  60 
6.3.5 
Breaking the Treatment Code by the Sponsor ································
·······  60 
6.3.6 
Assignment and Allocation································
·····························
 61 
6.4 
Investigational Product Compliance ································
························
 61 
6.5 
Previous and Concomitant Treatment (Medication and Nonmedication Therapy) ····  62 
6.6 
Dose Modification ································
································
············
 62 
6.7 
Criteria for Continuation of Treatment ································
·····················
 62 
7 
STUDY PROCEDURES AND ASSESSMENTS ································
············
 63 
7.1 
Efficacy Assessments ································
································
·········  63 
7.1.1 
Imaging picture of tympanic membrane by endoscope ·····························
 63 
7.1.2 
Microscopic Ear Examination ································
·························
 63 
7.1.3 
Pure Tone Audiometry ································
································
··  63 
7.1.4 
Tympanometry ································
································
···········
 64 
7.2 
Safety Assessments ································
································
···········
 64 
7.2.1 
Adverse Events ································
································
··········
 65 
7.2.2 
Laboratory Assessments ································
································
 65 
7.2.3 
Vital Signs ································
································
················
 65 


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7.2.4 
Physical Examination ································
································
···  65 
7.2.5 
Microscopic Ear Examination ································
·························
 65 
7.2.6 
Pure Tone Audiometry for Ototoxicity Assessment································
· 65 
7.2.7 
Tinnitus Visual Analog Scale ································
··························
 66 
7.2.8 
Order of Assessments ································
································
···  66 
7.3 
Adverse Events and Other Safety Aspects ································
·················
 66 
7.3.1 
Time Period for Collecting Adverse Event and Serious Adverse Event 
Information ································
································
···············
 66 
7.3.2 
Method of Detecting Adverse Events and Serious Adverse Events ···············
 66 
7.3.3 
Follow-up of Adverse Events ································
··························
 66 
7.3.4 
Reporting of Serious Adverse Events ································
·················
 67 
7.3.5 
Disease-related Events and/or Disease-related Outcomes Not Qualifying as 
Adverse Events or Serious Adverse Events ································
··········
 67 
7.3.6 
Adverse Events of Special Interest ································
····················
 67 
7.3.7 
Special Situations ································
································
········  67 
7.3.8 
Supply of New Information Affecting the Conduct of the Study ··················
 68 
7.3.9 
Urgent Safety Measures ································
································
 68 
7.3.10 
Reporting Urgent Safety Measures ································
····················
 68 
7.4 
Pharmacokinetics ································
································
··············
 69 
7.5 
Immunogenicity ································
································
···············
 69 
7.6 
Total Amount of Blood ································
································
·······  69 
8 
DISCONTINUATION ································
································
············
 69 
8.1 
Discontinuation of Individual Subject(s) From Study Treatment ·······················
 69 
8.2 
Discontinuation of Individual Subject(s) From Study ································
····  70 
8.2.1 
Lost to Follow-up································
································
········  70 
8.3 
Discontinuation of the Study Site ································
···························
 70 
8.4 
Discontinuation of the Study································
································
· 70 
9 
STATISTICAL METHODOLOGY ································
···························
 70 
9.1 
Sample Size ································
································
····················
 71 
9.2 
Analysis Sets ································
································
···················
 72 
9.2.1 
Full Analysis Set ································
································
········  72 
9.2.2 
Safety Analysis Set ································
································
······  72 
9.3 
Demographics and Baseline Characteristics ································
···············
 72 
9.3.1 
Demographics ································
································
············
 72 


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9.3.2 
Subject Disposition ································
································
······  72 
9.3.3 
Previous and Concomitant Treatment (Medication and Nonmedication 
Therapy) ································
································
··················
 73 
9.3.4 
Medical History ································
································
··········
 73 
9.3.5 
Investigational Product Exposure ································
·····················
 73 
9.4 
Analysis of Efficacy ································
································
··········
 73 
9.4.1 
Analysis of Primary Endpoint ································
·························
 73 
9.4.2 
Analysis of Secondary Endpoints ································
·····················
 73 
9.4.2.1 
Analysis ································
································
·············
 74 
9.4.2.2 
Sensitivity Analysis ································
·······························
 76 
9.4.2.3 
Subgroup Analysis ································
································
· 76 
9.4.3 
Analysis of Exploratory Endpoints ································
····················
 76 
9.5 
Analysis of Safety ································
································
·············
 79 
9.5.1 
Adverse Events ································
································
··········
 79 
9.5.2 
Bone conduction hearing at 1, 2, 4 kHz by PTA and TVAS ·······················
 80 
9.5.3 
Concentration-response Relationship Analysis ································
······  80 
9.5.4 
Microscopic Ear Examination ································
·························
 80 
9.6 
Analysis of Pharmacokinetics ································
·······························
 80 
9.7 
Analysis of Immunogenicity ································
································
· 80 
9.8 
Other Analyses ································
································
················
 80 
9.8.1 
Analysis of Exploratory Biomarker(s) ································
················
 80 
9.9 
Major Protocol Deviations ································
································
···  81 
9.10 
Interim Analysis (and Early Discontinuation of the Study) ······························
 81 
9.11 
Additional Conventions ································
································
······  81 
10 
OPERATIONAL CONSIDERATIONS ································
·······················
 81 
10.1 
Data Collection ································
································
················
 81 
10.2 
Demographics and Baseline Characteristics ································
···············
 82 
10.2.1 
Demographics ································
································
············
 82 
10.2.2 
Medical History ································
································
··········
 82 
10.2.3 
Diagnosis of the Target Disease, Severity and Duration of Disease ··············
 82 
10.3 
Major Protocol Deviations ································
································
···  82 
10.4 
STUDY ORGANIZATION································
································
··  83 
10.4.1 
Dose Escalation Committee ································
····························
 83 
10.4.2 
Data Monitoring Committee ································
···························
 83 


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11 
REFERENCES ································
································
····················
 84 
12 
APPENDICES ································
································
·····················
 85 
12.1 
Ethical, Regulatory and Study Oversight Considerations ································
 85 
12.1.1 
Ethical Conduct of the Study ································
···························
 85 
12.1.2 
Institutional Review Board/Independent Ethics Committee/Competent 
Authorities ································
································
················
 85 
12.1.3 
Protocol Amendment and/or Revision ································
················
 85 
12.1.4 
Financial Disclosure ································
································
····  86 
12.1.5 
Informed Consent of Subjects ································
·························
 86 
12.1.5.1 
Subject Information and Consent ································
················
 86 
12.1.5.2 
Supply of New and Important Information Influencing the Subject’s 
Consent and Revision of the Written Information ·····························
 86 
12.1.6 
Source Documents ································
································
······  87 
12.1.7 
Record Retention ································
································
········  87 
12.1.8 
Subject Confidentiality and Privacy ································
···················
 87 
12.1.9 
Arrangement for Use of Information and Publication of the Study ···············
 88 
12.1.10 
Signatory Investigator for Clinical Study Report ································
····  88 
12.2 
Procedure for Study Quality Control ································
·······················
 89 
12.2.1 
Study Monitoring ································
································
········  89 
12.2.2 
Direct Access to Source Data/Documents ································
············
 89 
12.2.3 
Data Management ································
································
·······  89 
12.2.4 
Quality Assurance ································
································
·······  89 
12.3 
Contraception Requirements ································
································
· 91 
12.4 
Adverse Events: Definitions and Procedures for Recording, Evaluating, Follow-
up and Reporting ································
································
··············
 93 
12.4.1 
Definition of Adverse Events ································
··························
 93 
12.4.1.1 
Abnormal Laboratory Findings ································
··················
 93 
12.4.1.2 
Potential Cases of Drug-induced Liver Injury ································
··  93 
12.4.2 
Definition of Serious Adverse Events································
·················
 93 
12.4.3 
Criteria for Causal Relationship to Investigational Product ························
 94 
12.4.4 
Criteria for Defining the Severity of an Adverse Event ····························
 95 
12.4.5 
Reporting Procedures for Serious Adverse Events ································
··  96 
12.4.6 
Reporting Procedures for Special Situations ································
·········  97 
12.4.6.1 
Pregnancy ································
································
···········
 97 
12.4.6.2 
Medication Error, Overdose and “Off-label Use” ·····························
 98 


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12.4.6.3 
Misuse/Abuse ································
································
······  98 
12.4.6.4 
Occupational Exposure ································
···························
 98 
12.4.6.5 
(Suspicion of) Transmission of Infectious Agent ······························
 99 
12.4.6.6 
Suspected Drug-drug Interaction ································
················
 99 
12.5 
Liver Safety Monitoring and Assessment ································
················
 100 
12.6 
List of Excluded Concomitant Medications································
··············
 106 
12.7 
Laboratory Assessments ································
································
····  107 
12.8 
Ear Care and Water Precautions ································
···························
 108 
12.9 
Modified Brighton Grading Scheme ································
······················
 110 
12.10 
Tinnitus Visual Analog Scale (TVAS) ································
···················
 111 
12.11 
Clinical Study Continuity ································
································
··  112 
12.12 
List of Abbreviations and Definition of Key Study Terms ·····························
 125 
13 
PROTOCOL AMENDMENT SUMMARY OF CHANGES ····························
 129 
14 
SPONSOR SIGNATURES ································
································
····  130 
 


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SIGNATURES 
1.  SPONSOR’S SIGNATURES 
Required signatures (e.g., protocol authors and contributors, etc.) are located in [Section 14 
Sponsor’s Signatures].  
 


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3.  INVESTIGATOR’S SIGNATURE 
A Phase 1/2, Randomized, Placebo-controlled Study to Assess the Safety, 
Tolerability, Efficacy, and Pharmacokinetics of ASP0598 Otic Solution Following 
Topical Application into the Ear in Subjects with Chronic Tympanic Membrane 
Perforation (CTMP) 
ISN/Protocol 0598-CL-0101  
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Incorporating Nonsubstantial Amendment 4 
29 Aug 2022 
I have read all pages of this protocol for which Astellas is the sponsor. I agree to conduct the study 
as outlined in the protocol and to comply with all the terms and conditions set out therein. I 
confirm that I will conduct the study in accordance with International Council for Harmonisation 
of Technical Requirements for Pharmaceuticals for Human Use (ICH) Good Clinical Practice 
(GCP) guidelines and applicable local regulations. I will also ensure that sub-investigator(s) and 
other relevant members of my personnel have access to copies of this protocol and the ICH GCP 
guidelines to enable them to work in accordance with the provisions of these documents. 
Principal Investigator: 
Signature: 
 
 
 
 
Date (DD Mmm YYYY) 
Printed Name:  
  
Address: 
 
 
 
 
 
 
 
 
 


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CONTACT DETAILS OF SPONSOR’S KEY PERSONNEL 
24-hour Contact for 
Serious Adverse Events 
 
See [Section 12.4.5 
Reporting Procedures for 
Serious Adverse Events] 
Please fax or email the serious adverse events/special 
situations worksheet to: 
Astellas Pharma Global Development Inc.  
US Pharmacovigilance 
North America fax number: +1-888-396-3750 
North America alternate fax number: +1-847-317-1241 
Email: safety-us@astellas.com 
Medical Monitor/Study 
Physician 
 
 
 
 
 
Clinical Research 
Contact(s) 
Parexel 
 
 
 
 
 
PPD
PPD


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1 
PROTOCOL SUMMARY 
1.1 
Synopsis 
Date and Version of Protocol Synopsis: 
29 Aug 2022, Version 3.3 
Sponsor:   
Astellas Pharma Global Development Inc. (APGD) 
Protocol Number:  
0598-CL-0101 
Compound Name:  
ASP0598 
Phase of Development:   
Phase 1/2 
Title of Study:   
A Phase 1/2, Randomized, Placebo-controlled Study to Assess the Safety, Tolerability, Efficacy, 
and Pharmacokinetics of ASP0598 Otic Solution Following Topical application into the Ear in 
Subjects with Chronic Tympanic Membrane Perforation (CTMP) 
Planned Study Period:  
From approximately 3Q2020 to 3Q2024 
Study Objective(s) and Endpoint(s): 
Objective 
Endpoints 
Primary 
• To evaluate the safety and tolerability of 
ASP0598 Otic Solution  
● 
Treatment-emergent adverse events (TEAEs) 
● 
Incidence of adverse events of special interest as 
defined below:  
1. Cholesteatoma or ear neoplasm 
2. Ototoxic symptoms (tinnitus, sensorineural 
hearing loss, dizziness) 
3. Otitis media or otitis externa 
● 
Change from baseline in bone conduction hearing at 
1, 2, 4 kHz by Pure Tone Audiometry (PTA) 
● 
Change from baseline in Tinnitus Visual Analog 
Scale (TVAS) 
Table continued on next page 
 
 


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Objective 
Endpoints 
Secondary 
• To evaluate the efficacy of ASP0598 Otic 
Solution  
For secondary efficacy endpoints the 
hypothetical strategy will be applied. 
Efficacy 
Single Dose  
● 
Complete closure of Tympanic Membrane 
Perforation (TMP) at Week 8 for Single Ascending 
Dose (SAD) and at Week 12 for dose expansion  
● 
Change from baseline in the ratio of TMP size per 
total area of tympanic membrane at Week 8 for SAD 
and at Week 12 for dose expansion  
● 
Change from baseline in TMP size at Week 8 for 
SAD and at Week 12 for dose expansion  
Multiple Dose  
● 
Complete closure of TMP at Week 12 for Multiple 
Ascending Dose (MAD) and at Week 16 for dose 
expansion  
● 
Change from baseline in the ratio of TMP size per 
total area of tympanic membrane at Week 12 for 
MAD and at Week 16 for dose expansion  
● 
Change from baseline in TMP size at Week 12 for 
MAD and at Week 16 for dose expansion  
Exploratory 
• To evaluate otological parameters that may 
correlate with efficacy outcome and 
pharmacokinetics of ASP0598 Otic 
Solution 
Single Dose  
● 
Complete closure of TMP for post baseline visits at 
Day 2, Day 3*, Week 1, Week 2, and Week 4, for 
SAD and Week 2, Week 4, Week 8 for dose 
expansion  
● 
Change from baseline in the ratio of TMP size per 
total area of tympanic membrane for post baseline 
visits at Day 2, Day 3*, Week 1, Week 2, and Week 
4 for SAD and Week 2, Week 4, and Week 8 for 
dose expansion  
● 
Change from baseline in TMP size for post baseline 
visits at Day 2, Day 3*, Week 1, Week 2, and Week 
4 for SAD and Week 2, Week 4, and Week 8 for 
dose expansion  
* Day 3 evaluations will only be performed for 
cohorts 1, 2 and 3. 
Multiple Dose  
● 
Complete closure of TMP for post baseline visits at, 
Week 1, Week 2, Week 3, Week 4, Week 5 and 
Week 8 for MAD and Week 2, Week 4, Week 6, 
Week 8 and Week 12 for dose expansion  
● 
Change from baseline in the ratio of TMP size per 
total area of tympanic membrane for post baseline 
visits at Week 1, Week 2, Week 3, Week 4, Week 5 
and Week 8 for MAD and Week 2, Week 4, Week 
6, Week 8 and Week 12 for dose expansion  
● 
Change from baseline in TMP size for post baseline 
visits at Week 1, Week 2, Week 3, Week 4, Week 5 
and Week 8 for MAD and Week 2, Week 4, Week 
6, Week 8 and Week 12 for dose expansion  
Table continued on next page 


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Single and Multiple Dose  
● 
Time to closure of TMP  
● 
Size of TMP ≤ 5% of pars tensa surface area after 
treatment 
● 
Size of TMP ≤ 1% of pars tensa surface area (pin 
point perforation) after treatment 
● 
Change from baseline in air bone (A-B) gap by PTA 
● 
Change from baseline in air conduction hearing by 
PTA 
● 
Percentage improvement from baseline in A-B gap 
by PTA ≥ 50% (improvement of conductive 
hearing) 
● 
Improvement from baseline in air conduction 
hearing by PTA ≥ 15 dB 
● 
A-B gap after treatment was 15dB or less 
● 
Air conduction hearing threshold after treatment 
was 30 dB or less 
● 
Type of tympanogram (A, B or C) 
● 
Equivalent ear canal volume (ECV) by 
tympanometry   
Pharmacokinetics 
● 
Serum concentration of ASP0598 (dose escalation 
part only) 
To evaluate the safety of ASP0598 Otic 
Solution 
● 
Vital signs (body temperature, blood pressure and 
pulse rate) 


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Planned Total Number of Study Sites and Location(s):   
Approximately 20 study sites in the United States 
Study Population:   
Subjects between 18 and 75 years of age at the time of informed consent with a clinical diagnosis 
of CTMP. 
Number of Subjects to be Enrolled/Randomized:   
Single Dose  
Approximately 20 subjects in SAD (5 subjects per cohort) and up to 39 subjects in single dose 
expansion. 
Multiple Dose  
Approximately 16 subjects in MAD (8 subjects per cohort) and up to 39 subjects in multiple dose 
expansion. 
Study Design Overview:   
This is a randomized, placebo-controlled and investigator and subject blinded study to evaluate the 
safety, tolerability, efficacy and pharmacokinetics in subjects with CTMP.  
The main part of this study is dose escalation. Dose escalation will start with single ascending dose 
(SAD) followed by multiple ascending dose (MAD, Q2W×3).   
Dose escalation will primarily assess safety and tolerability of single dose and multiple doses of 
ASP0598 Otic Solution. Dose escalation will consist of up to 4 cohorts for SAD and up to 2 
cohorts for MAD, with different dose levels (Table 1).  Each cohort will consist of 5 subjects 
(ASP0598 Otic Solution n = 4 and placebo n = 1) for SAD and 8 subjects (ASP0598 Otic Solution 
n = 6 and placebo n = 2) for MAD.  
Single and/or multiple dose expansion will be opened based on the safety and efficacy results 
following an interim analysis. Single dose expansion will be opened based on the results of the first 
interim analysis, which will occur after the completion of SAD. Multiple dose expansion will be 
opened based on the results of the second interim analysis, which will occur after the completion of 
MAD.  
 


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Table 1 
Planned Dose Levels for Dose Escalation 
Cohort 
Dose 
regimen 
Dose (µg) 
Drug 
concentration 
(µg/mL) 
Administration 
volume (mL) 
ASP0598 
Otic Solution (n) 
Placebo 
(n) 
1 
Single 
0.03 
0.2 
0.15 
4 
1 
2 
Single 
0.15a 
1.0a 
0.15 
4 
1 
3 
Single 
0.75a 
5.0a 
0.15 
4 
1 
4 
Single 
2.25a 
15a 
0.15 
4 
1 
5 
Q2W×3 
0.75a 
5.0a 
0.15 
6 
2 
6 
Q2W×3 
2.25a 
15a 
0.15 
6 
2 
a Planned dose levels. Doses may be adapted depending on emergent safety and tolerability data. 
The study will consist of the following:  
Single Dose  
• Screening (Day -28 to -1) 
• Randomization (Day 1) 
• Observation [through Day 57 (SAD) or through Day 85 (single dose expansion)] 
Multiple Dose  
• Screening (Day -28 to -1) 
• Randomization (Day 1) 
• Observation [through Day 85 (MAD) or through Day 113 (multiple dose expansion)] 
• Additional Treatment on Days 15 and 29 
 
Prior to any study-related assessments, the Informed Consent Authorization Form will be signed by 
the subject at Screening (Visit 1). All subjects will enter into a screening period (Days -28 to -1) 
and will be evaluated for randomization eligibility after completing all the screening procedures.  
Eligible subjects will be randomized on Day 1 (Visit 2). 
For a subject with bilateral TMP, once both ears have been identified as meeting all 
inclusion/exclusion criteria at Randomization on Day 1 (Visit 2), the ear with the worse hearing 
will be selected as the treated ear, unless a rationale exists to treat the other ear. In the case of 
equivalent hearing level in both ears, the investigator will decide the treatment side with subject 
and will document the reason in the source document and the electronic case report form (eCRF).  
In the case that the investigator is unable to decide the appropriate ear to treat, consultation with the 
sponsor may be required. 


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To Dose Escalation  
Approximately 20 subjects for SAD and 16 subjects for MAD will be enrolled in the dose 
escalation part of the study. The initiation and selection of dose concentrations for MAD will be 
based on at least 3 cohorts from SAD. For SAD, after randomization on Day 1, subjects will 
receive ASP0598 Otic Solution or placebo administration into the affected ear. Subjects will return 
to the investigative site for assessments on Days 2, 3, 8, 15, 29, and 57 [end of study (EOS)]. Day 3 
evaluations will only be performed for cohorts 1, 2 and 3.   
For MAD, after randomization on Day 1, subjects will receive ASP0598 Otic Solution or placebo 
administration into the affected ear and will receive additional treatments into the same ear on Days 
15 and 29. Subjects will return to the investigative site for assessments on Days 8, 15, 22, 29, 36, 
57, and 85 (EOS).   
For SAD and MAD, subjects who terminate early from the study will complete EOS assessments.  
For MAD only, subjects who discontinue treatment will be encouraged to complete all protocol 
defined study visits through the Day 85 (EOS). 
The decision to escalate or stop escalation during SAD will be made by the Dose Escalation 
Committee (DEC). The DEC will operate as per the approved DEC Charter. 
The DEC will decide dose escalation and the initiation and selection of doses for MAD cohorts 
based on the emerging safety and tolerability data from SAD.  The tentative starting dose 
concentration of MAD will be 5.0 μg/mL, and another dose concentration up to a maximum 
feasible dose concentration of 15 μg/mL will be considered. 
The first interim analysis will be conducted after completion of the last SAD cohort. The second 
interim analysis will be conducted after completion of the last MAD cohort. 
The Data Monitoring Committee (DMC) will review the data and make the final decision to open 
single and/or multiple dose expansion. DMC operation, roles, and responsibilities will be described 
in the DMC Charter. 
Subjects may be replaced at the discretion of the sponsor. If replaced, the replacement subject will 
be given the same treatment group as the original subject’s randomized treatment group. 
Dose Expansion 
The decision to open single and/or multiple dose expansion will be made based on the safety and 
efficacy results of the interim analyses after completion of SAD and after completion of MAD by 
the DMC charter. Once the decision to open single and/or multiple dose expansion is made, the 
number of treatment groups (2 or 3 treatment groups, including 1 or 2 active treatment groups and 
1 placebo group) and the dose for ASP0598 Otic Solution will be selected based on the safety and 
efficacy results of the interim analyses. All analyses will be described in the Interim Analysis Plan 
(IAP). 
Up to 39 subjects will be randomized to single dose and/or multiple dose expansion. Based on the 
interim analysis results: 
• 
If 3 treatment groups are selected, approximately 39 subjects will be randomized in a 1:1:1 
ratio of high dose ASP0598 Otic Solution, low dose ASP0598 Otic Solution, or placebo 
(13 subjects in each treatment group). 
• 
If 2 treatment groups are selected, approximately 26 subjects will be randomized in a 1:1 ratio 
of high dose ASP0598 Otic Solution or placebo (13 subjects in each treatment group). 
Stratification at the time of randomization will be based on the % size of the TMP at the screening 
visit and subjects will be balanced equally between the treatment groups. 
Dose expansion will assess safety and efficacy of ASP0598 Otic Solution.   


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Single Dose Expansion 
After randomization on Day 1, subjects will receive ASP0598 Otic Solution or placebo 
administration into the affected ear at the investigative site.  Subjects will return to the investigative 
site for assessments on Days 15, 29, 57, and 85 (EOS). 
Subjects who terminate early from the study will complete EOS assessments at the time of 
discontinuation.   
Multiple Dose Expansion 
After randomization on Day 1, subjects will receive ASP0598 Otic Solution or placebo 
administration into the affected ear.  Subjects may receive additional treatment in the same ear on 
Days 15 and 29.  Subjects will return to the investigative site for assessments on Days 15, 29, 43, 
57, 85, and 113 (EOS).   
In cases where complete closure is confirmed on Day 15 or Day 29, the subject will not receive the 
next scheduled dose(s) but will complete all visit assessments as defined in the Schedule of 
Assessments through Day 113.   
Subjects who terminate early from the study will complete EOS assessments at the time of 
discontinuation 
Subjects who discontinue treatment will be encouraged to complete all protocol defined study visits 
through Day 113. 
In single and/or multiple dose expansion, subjects may be replaced at the discretion of the sponsor. 
If replaced, the replacement subject will be given the same treatment group the original subject’s 
randomized treatment group.  
Inclusion/Exclusion Criteria:   
Inclusion Criteria: 
A subject is eligible for the study if all the following apply: 
1. Institutional Review Board (IRB)/Independent Ethics Committee (IEC) approved written 
Informed Consent and privacy language as per national regulation (e.g., Health Insurance 
Portability and Accountability Authorization for US sites) must be obtained from the subject or 
legally authorized representative prior to any study-related procedures (including withdrawal of 
prohibited medication, if applicable). 
2. Subject must be 18 to 75 years of age at the time of informed consent.   
3. Subject has chronic tympanic membrane perforation (CTMP) documented as persisting longer 
than 3 months. 
4. A female subject is eligible to participate if she is not pregnant (see Appendix 12.3: 
Contraception Requirements) and at least one of the following conditions applies: 
a. Not a woman of childbearing potential (WOCBP) as defined in Appendix 12.3: 
Contraception Requirements OR 
b. WOCBP who agrees to follow the contraceptive guidance as defined in Appendix 12.3: 
Contraception Requirements starting at screening and for at least 28 days after 
investigational product (IP) application. 
5. Female subject must agree not to breastfeed starting at drug application on Day 1 and for at 
least 28 days after IP application. 
6. Female subject must not donate ova starting on Day 1 and for at least 28 days after IP 
application.  
7. A male subject with female partner(s) of child-bearing potential must agree to use 
contraception starting on Day 1 and for at least 28 days after IP application as detailed in 
Appendix 12.3. 


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8. A male subject must not donate sperm starting on Day 1 and for at least 28 days after IP 
application. 
9. Male subject with a pregnant or breastfeeding partner(s) must agree to remain abstinent or use a 
condom from Day 1 and for at least 28 days after IP application. 
10. Subject must be willing and able to comply with the study requirements including refraining 
from using prohibited concomitant medication. 
11. Subject agrees not to participate in another interventional study during the study period.  
12. Subject has the ability to understand and the willingness to sign a written informed consent 
document. 
13. Waivers to the inclusion criteria will NOT be allowed. 
Exclusion Criteria: 
A subject will be excluded from participation if any of the following apply: 
1. Subject has one of following conditions, that is confirmed by the investigator, that may affect 
the ipsilateral side of the ear with CTMP: 
a. Perforation involving 3 or more quadrants. 
b. Pin hole perforation (only for the expansion cohort) 
c. Presence of tympanosclerosis adjacent to the perforation. 
d. Perforation involves malleus erosion. 
e. Absent malleus. 
f. Marginal perforation (i.e., involving the annulus or exposing the handle of malleus). 
g. TMP caused by electric/slag/blast/burn injury. 
h. Post radiated TMP. 
i. History of tympanic membrane repair by any type of live tissue. 
j. Active otorrhea or active treatment for otorrhea within the last 3 months prior to 
Screening. 
k. Bellucci otorrhea grade 3 or above. 
l. Active external ear canal inflammation (otitis externa, dermatitis) or within the last 3 
months prior to Screening. 
m. Active diagnosis of Eustachian Tube dysfunction or diagnosis within 6 months prior to 
Screening. 
n. Craniofacial abnormalities, history of head and neck surgery within the last 3 months 
prior to Screening, history of radiation to head and neck. 
o. Recent (within 2 weeks) diagnosis of upper respiratory tract infection. 
p. Presence or history of cholesteatoma. 
q. Presence of pars-flaccida or pars tensa retraction or adhesion. 
r. Presence or history of tumors of the middle or external ear.  
s. Contraindications to tympanic membrane closure 
t. An audiometric finding indicates a characteristic of Carhart's notch which is an increase 
in bone conduction threshold with a peak at 2,000 Hz. 
u. Only hearing ear or better hearing ear and the contralateral ear ≥ 40 dB by average 
four-frequency (500, 1000, 2000 and 4000 Hz). 
v. Whole circumference of the tympanic membrane perforation is not visible by endoscope. 
w. Presence/history of eosinophilic otitis media in either ear. 
2. Subject has a presence of adhesive otitis media in the contralateral ear. 
3. Subject has a presence of any wound healing systemic condition. 


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4. Subject has Obstructive Sleep Apnea where the subject is required to use Continuous Positive 
Airway Pressure (CPAP) during the study period. 
5. Subject is exposed in their daily life to high volume of water into the ear canal (e.g., swimmer 
or surfer). 
6. Subject has health conditions that would prevent him/her from fulfilling the study requirements 
as judged by the clinical investigator on the basis of medical history and laboratory test (Serum 
Chemistries, CBC with Differential, Urinalysis) results at the screening visit. 
7. Subject is receiving any other investigational agents during study participation. 
8. Subject has any form of substance abuse, or psychiatric illness/social situations that would limit 
compliance with study requirements, or a condition that in the opinion of the investigator could 
invalidate communication with the investigator.   
9. Subject has a known or suspected hypersensitivity to ASP0598, or any components of the 
formulation used. 
10. Subject has had previous exposure with ASP0598. 
11. Subject is unlikely to comply with the visits scheduled in the protocol, in the opinion of the 
investigator. 
Waivers to the exclusion criteria will NOT be allowed. 
Investigational Product(s):  
Name:  
ASP0598 is a recombinant human heparin-binding EGF-like (epidermal growth factor-like) growth 
factor (rhHB-EGF).  ASP0598 Otic Solution contains rhHB-EGF that is diluted with a buffered 
aqueous solution to adjust the dose strength and mixed with a polymer solution to enable forming 
hydrogel and retention after administration. 
Use:  
Test product 
Dose(s):   
0.2, 1.0, 5.0, and 15.0 µg/mL 
Administration Volume:  
Up to a maximum volume of 0.15 mL/administration 
Mode(s) of Administration: 
Single Dose: Topical application on Day 1 onto the tympanic membrane through the external 
auditory canal via syringe.  
Multiple Dose: Topical application on Days 1, 15, and 29 onto the tympanic membrane through the 
external auditory canal via syringe. 
Comparator: 
Name:  
The matching placebo is a sterile solution of buffered aqueous solvent combined with a copolymer 
prior to otic administration. 
Use :  
Placebo 
Dose(s): 
Matching placebo for ASP0598 Otic Solution 
Administration Volume:  
Up to a maximum volume of 0.15 mL/administration 


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Mode(s) of Administration: 
Single Dose: Topical application on Day 1 onto the tympanic membrane through the external 
auditory canal via syringe.  
Multiple Dose: Topical application on Days 1, 15, and 29 onto the tympanic membrane through the 
external auditory canal via syringe. 
Dose Modifications: 
SAD and single dose expansion  
Not Applicable. 
MAD 
On Day 15 or Day 29, treatment can be skipped at the investigator’s discretion based on safety 
reasons that interrupt IP administration (e.g., ear canal skin irritation, mild otorrhea).  Subjects 
should be encouraged to return to the office for evaluation and additional IP administration within 
the Day 15 or Day 29 visit windows. In cases where the investigator is unable to conduct IP 
administration for anything other than safety reasons, consultation with the sponsor may be 
required. 
Multiple dose expansion 
The statement above for MAD is also applicable to the multiple dose expansion. Additionally, the 
treatment on Day 15 or Day 29 will be skipped in cases where complete closure is confirmed. If the 
perforation is detected on Day 29 after treatment was skipped on Day 15, IP administration can be 
conducted. 
Concomitant Treatment (Medication and Nonmedication Therapy) Restrictions or 
Requirements:  
These restrictions are required after ASP0598 Otic Solution or placebo administration on 
Randomization (Day 1), until completion of study procedures at Day 57 (SAD)/Day 85 (single 
dose expansion or MAD) / Day 113 (multiple dose expansion) or End of Study (EOS) visit.  
• 
Ear drop agents will be used only for the treatment of otitis media with suppurative ear 
discharge. Only Ciprofloxacin or Ofloxacin ear drops (does not include steroids) are 
allowed to be used in the ASP0598 Otic Solution or placebo treated ear.  Investigators 
should minimize treatment with ear drops up to a maximum of 10 days and consider 
alternative treatment (e.g., oral antibiotics). 
• 
Any other topical agents in the ear canal are prohibited to use in the ASP0598 Otic Solution 
or placebo treated ear. 
• 
Any otologic procedures (e.g. paper patch or surgeries) to the ASP0598 Otic Solution or 
placebo treated ear are prohibited. 
All concomitant medication usage will be noted and recorded during each study visit.  
Other restrictions: 
These restrictions are required after ASP0598 Otic Solution or placebo administration on Day 1 
until completion of the study procedures at Day 57 (SAD)/Day 85 (single dose expansion) or Day 
85 (MAD) / Day 113 (multiple dose expansion) or End of Study (EOS) visit. 
• 
Subjects must refrain from showering or bathing for at least 24 hours after IP 
administration.  
o Showering or bathing are allowed 24 hours after IP administration. Water 
precautions are to be taken as per the guidelines in Appendix 12.8. 


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• 
Any water activities that risk submersion of the ear (e.g., swimming or surfing) are 
prohibited throughout the entire study period. 
• 
Subjects are not allowed to use any materials (e.g., Q-tips) placed into the ear canal of the 
treated ear (ear buds or headphones placed at the entrance to the ear canal are considered 
acceptable). If ear cleaning is desired, then subjects can use a soft tissue placed gently at 
the entrance to the ear canal. 
• 
Investigators will not clean the ASP0598 Otic Solution/placebo treated ear by suctioning 
throughout Observation period, unless subjects experience uncomfortable ear discharge. 
General ear cleaning will be allowed to visualize the whole tympanic membrane at Day 57 
(SAD), Day 85 (single dose expansion and MAD), Day 113 (multiple dose expansion), or 
EOS visit, before imaging picture. 
• 
Investigators may gently remove an obstacle that is blocking the ear canal if it prevents IP 
application or causes subjects to experience an uncomfortable sensation. If the obstacle is 
adherent to the tympanic membrane, it should not be removed; it is recommended to wait 
until the obstacle comes off. 
• 
Subjects should refrain from activities that can increase the middle ear pressure including 
plane travel (at least 28 days after IP application), positive pressure ventilation (e.g., CPAP 
or BiPAP) devices, Valsalva maneuvers, excessive high-pressure nose blowing, or diving 
underwater.  
• 
Subject must refrain from activities that can excessively increase body temperature (e.g. 
Sauna) for at least 3 days after IP application. 
• 
Subject must refrain from activities that stimulate sweating excessively for at least 3 days 
after IP application. 
Duration of Treatment:   
SAD and single dose expansion: Topical application into the affected ear on Day 1. 
MAD: Topical application into the affected ear on Days 1, 15, and 29.   
Multiple Dose Expansion: Topical application into the affected ear on Day 1 and if the subject has 
not achieved complete closure of the TMP at Day 15 and Day 29, additional treatment will occur.  
If the subject achieves complete closure on either Day 15 or Day 29, no additional treatment is 
required at those visit(s).   
Treatment Discontinuation Criteria:  
SAD and single dose expansion  
Not applicable because there is a single treatment of ASP0598 Otic Solution or placebo. 
MAD and multiple dose expansion  
Treatment Discontinuation 
During the course of IP administration, if the subject experiences a drug-related adverse event 
(AE), the IP administration may be discontinued at the investigator’s discretion.    
In addition, IP administration will be discontinued if severe intensity occurs in any of the following 
situations: 


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• Subject develops cholesteatoma or suspicion of neoplasm in the treated ear as determined by 
the investigator. 
• Subject develops suspected ototoxicity symptoms (e.g., sudden hearing loss at high frequencies 
(1, 2, 4 kHz), new high frequency tinnitus or new balance disorder) which are considered by the 
investigator to be related to the study drug. 
• Subjects with persistent otitis media or otitis externa unresponsive to oral and topical antibiotics 
(as described in Previous and Concomitant Treatment [Medication and Nonmedication Therapy 
of the synopsis and protocol Section 6.5]) 
Dose Escalation: 
Decision Process for Dose Escalation and Initiation of MAD 
The DEC will decide dose escalation and the initiation and selection of doses for MAD cohorts 
based on the emerging safety and tolerability data from SAD. After all subjects in a cohort have 
been dosed and completed study procedures through Day 15, the overall safety and tolerability of 
the dose will be determined after evaluation of the blinded safety data [treatment emergent adverse 
events (TEAEs), adverse events (AEs) of special interest, otology examinations (imaging pictures 
of tympanic membrane, bone conduction hearing at 1, 2, 4 kHz by PTA, TVAS, Modified Brighton 
Grading Scale), and vital signs] for the current cohort. Cumulative AE data from the preceding 
cohort(s) will also be included in the assessment for dose escalation. Details will be defined in the 
DEC Charter.  
Dose Escalation Stopping Rules  
Depending on the nature, frequency and severity of the safety profile observed in the study, the 
DEC will decide whether to:  
• Proceed with dose escalation and determine the next higher dose or, 
• Stop dose escalation (i.e., no further dosing with IP). 
Dose escalation will be stopped if 1 (or more) of the following apply: 
• If 1 or more subjects in 1 cohort develop cholesteatoma or suspicion of ear neoplasm which is 
considered to be related to ASP0598.  
• If 2 or more subjects in 1 cohort develop Ototoxicity (clinically significant report of vestibular 
symptoms, tinnitus, or acute hearing loss) which are considered to be related to the IP.  
• If 2 or more subjects in 1 cohort develop persistent otitis media or otitis externa unresponsive to 
oral and topical antibiotics which is described in concomitant treatment requirements section of 
the synopsis which are considered to be related to the IP. 
• If 1 or more subjects in 1 cohort experience AEs of severe intensity or 2 or more subjects in 1 
cohort experience AEs of the same character of moderate intensity, which are considered to be 
related to the IP, and of clinical concern.  
In the event that it is deemed relevant to unblind a subject for the purposes of a dose escalation 
decision, the DEC chair or delegate can request the treatment assigned to one or more from the 
study statistician.  The DEC charter will include information on unblinding of study team 
members and other details.  
Definition of the Maximum Tolerated Dose: 
If the DEC decides to stop dose escalation based on available safety data, the current dose level 
will be considered as the minimum intolerable dose (MID). The dose just below the MID will be 
regarded as the maximum tolerated dose (MTD). If the dose escalation is stopped due to reaching 
exposure limit without dosing limiting safety findings, MTD cannot be determined. 


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Statistical Methods: 
Sample Size Justification:  
SAD 
Formal sample size calculations were not performed. SAD is not intended to show statistical 
difference between ASP0598 Otic Solution and placebo subjects.  
A sample size of 5 per cohort (n = 4 ASP0598 Otic Solution, n = 1 placebo) is based on precedent 
set by other clinical studies of similar nature. The number of subjects and study procedures planned 
for this clinical study are considered reasonable to achieve the clinical study objectives.   
MAD 
Formal sample size calculations were not performed. MAD is not intended to show statistical 
difference between ASP0598 Otic Solution and placebo subjects.  
A sample size of 8 per cohort (n = 6 ASP0598 Otic Solution, n = 2 placebo) is based on precedent 
set by other clinical studies of similar nature. The number of subjects and study procedures planned 
for this clinical study are considered reasonable to achieve the clinical study objectives.   
Dose Expansion 
Assuming the complete closure rate in placebo and ASP0598 higher concentration group are 10% 
and 80%, respectively, 11 subjects per treatment group will provide more than 90% power to detect 
a statistically significant difference at a 2-sided significance level of 0.05. Considering the drop-out 
rate of 10%, 13 subjects per treatment group will be enrolled (nQuery Advisor 7.0). 
Efficacy:   
Dose Escalation  
Continuous data will be summarized by using descriptive statistics (mean, SD, median, min, max) 
by treatment group, including placebo pooled across cohort. For categorical data, the number and 
percentage of subjects in each category will be presented by treatment group, including placebo 
pooled across cohort. 
The following parameters will be summarized: 
• 
Complete closure of TMP 
• 
Change from baseline in the ratio of TMP size per total area of tympanic membrane 
• 
Change from baseline in TMP size 
• 
Time to closure of TMP  
• 
Size of TMP ≤ 5% of pars tensa surface area after treatment 
• 
Size of TMP ≤ 1% of pars tensa surface area (pin point perforation) after treatment 
• 
Change from baseline in air bone (A-B) gap by PTA 
• 
Change from baseline in air conduction hearing by PTA 
• 
Percentage improvement from baseline in A-B gap by PTA ≥ 50% (improvement of 
conductive hearing) 
• 
Improvement from baseline in air conduction hearing by PTA ≥ 15 dB 
• 
A-B gap after treatment was 15 dB or less 
• 
Air conduction hearing threshold after treatment was 30 dB or less 
• 
Type of tympanogram (A, B or C) 
• 
Equivalent Ear Canal Volume (ECV) by tympanometry   
• 
Vital signs (body temperature, blood pressure and pulse rate) 
No statistical hypothesis testing will be performed. 


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Dose Expansion  
The efficacy parameters shown above will be summarized by using descriptive statistics by 
treatment group.  
For the proportion of subjects with complete closure of TMP at week 12 for single dose expansion 
and at week 16 for multiple dose expansion, stratified MH test by categorized baseline perforation 
size will be applied. For the subjects with intercurrent events (ICEs), the complete closure status 
just before the ICEs will be used as complete closure status at week 12 for single dose expansion 
and week 16 for multiple dose expansion.  Based on the interim analysis results, if 3 treatment 
groups are selected for dose expansion, hierarchical testing method will be used to 
control familywise error rate where the highest dose group vs placebo will be tested first at 2-sided 
significance level of 0.05. 
For the change from baseline in TMP size and change from baseline in the ratio of TMP size per 
total area of tympanic membrane at Week 12 for single dose expansion and week 16 for multiple 
dose expansion, a mixed models repeated measures (MMRM) will be used with treatment group 
and week as factors, baseline TMP size as a covariate, as well as an interaction of treatment by 
week and an interaction of baseline TMP size by week. For subjects with ICEs, only data obtained 
before the ICE will be used in the MMRM.  No multiplicity will be made from change from 
baseline secondary endpoints. 
Safety:   
Dose Escalation  
To characterize the safety profile, descriptive statistics will be presented for TEAEs, vital signs 
(body temperature, blood pressure and pulse rate), bone conduction hearing at 1, 2, 4 kHz by PTA 
and TVAS by treatment group, including placebo pooled across cohorts. 
Dose Expansion  
To characterize the safety profile, descriptive statistics will be presented for TEAEs, vital signs (body 
temperature, blood pressure and pulse rate), bone conduction hearing at 1, 2, 4 kHz by PTA and 
TVAS by treatment group. 
Pharmacokinetics (dose escalation only):   
Descriptive statistics will be presented for serum concentrations of ASP0598 by scheduled sample 
time. These summaries will be provided by treatment group, including placebo, pooled across 
cohorts.  
Immunogenicity:   
Not applicable  
Interim Analyses:  
The decision to open single and/or multiple dose expansion will be made based on the safety and 
efficacy results of the interim analysis after all SAD cohorts have completed and after all the MAD 
cohorts have completed, respectively. Two interim analyses are planned. The first interim analysis 
will be conducted after completion of the last cohort of SAD. The second interim analysis will be 
conducted after completion of MAD. The DMC will review the data and make the final decision to 
open single and/or multiple dose expansion. Two or three treatment groups including one placebo 
group will be selected to open single and/or multiple dose expansion. All analyses will be 
described in the Interim Analysis Plan (IAP). 
 


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1.2 
Study Schema 
Figure 1 
Study Design Schema 
 
A: active; P: placebo; L: low-dose ASP0598; H: high-dose ASP0598 
 


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Figure 2 
Study Flow Chart – SAD  
 
 
CBC: complete blood count; PK: pharmacokinetic; SAD: Single Ascending Dose 
 


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Figure 3 
Study Flow Chart – Single Dose Expansion 
 
CBC: complete blood count 
 
 
 


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Figure 4 
Study Flow Chart – MAD 
 
CBC: complete blood count; MAD: Multiple Ascending Dose; PK: pharmacokinetic 
 


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Figure 5 
Study Flow Chart – Multiple Dose Expansion 
 
CBC: complete blood count  
 


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Figure 6 
Otology Examination and PK Blood Draw Flow Chart – Single Dose 
 
Footnotes appeared on next page 


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EOS: end of study; PK: pharmacokinetic; PTA: Pure Tone Audiometry; SAD: single ascending dose; TM: tympanic membrane; VAS: Tinnitus Visual Analog Scale  
a. After ASP0598 Otic Solution or placebo administration, subjects will be required to remain on their side with the treated ear facing up for at least 15 minutes.  Please see the 
Pharmacy Manual, Section 9.4: Dose Administration for detailed instructions. 
b. Day 1, imaging picture will be taken pre-dose, immediately after, 30 (±5) minutes and 60 (±5) minutes after ASP0598 Otic Solution or placebo administration into the affected ear. 
c. PK blood samples will be collected on Day 1 at pre-dose (-15) minutes and at the following post-dose time points: 30 (±5) minutes and 60 (±5) minutes. PK blood sampling will be 
performed only in SAD after ASP0598 Otic Solution or placebo administration into the affected ear.   
d. Skin local reaction at the ASP0598 Otic Solution/placebo application site will be evaluated by Modified Brighton Grading Scheme (Appendix 12.9) at all visits. 
e. Ear cleaning will not be conducted between Days 2 – 29 (SAD) or Days 2 – 57 for (single dose expansion), unless it is absolutely necessary. Investigators will not clean the treated 
ear by suctioning unless subjects experience uncomfortable ear discharge).   
f. At Day 57 (SAD) or Day 85 (single dose expansion) and/or EOS, the whole TM should be visible before taking imaging picture.  If the whole TM is not visible, the investigator 
should clean the ear canal. 
 
 
 


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Figure 7 
Otology Examination and PK Blood Draw Flow Chart – Multiple Dose  
 
Footnotes appear on next page 


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EOS: end of study; MAD: multiple ascending dose; PK: pharmacokinetic; PTA: Pure Tone Audiometry; TM: tympanic membrane; TVAS: Tinnitus Visual Analog Scale.  
a. 
Days 15 and 29, PTA will be conducted only for bone conduction hearing at 1, 2, 4 kHz and Tympanometry will not be conducted. 
b. After ASP0598 Otic Solution or placebo administration, subjects will be required to remain on their side with the treated ear facing up for at least 15 minutes. Please see the 
Pharmacy Manual, Section 9.4: Dose Administration for detailed instructions. 
c. 
Days 1, 15, and 29, imaging picture will be taken pre-dose, immediately after, 30 (±5) minutes and 60 (±5) minutes after ASP0598 Otic Solution or placebo administration into the 
affected ear. 
d. Day 1 and Day 29, PK blood draw will be performed pre-dose (-15) minutes, 30 (±5) minutes and 60 (±5) minutes after ASP0598 Otic Solution or placebo administration into the 
affected ear. PK sampling will be performed only during MAD. 
e. 
Skin local reaction at the ASP0598 Otic Solution/placebo application site will be evaluated by Modified Brighton Grading Scheme (Appendix 12.9) at all visits. 
f. 
Ear cleaning will not be conducted between Days 2 – 57 (MAD) or Days 2 – 85 for (multiple dose expansion), unless it is absolutely necessary. Investigators will not clean the 
treated ear by suctioning unless subjects experience uncomfortable ear discharge). 
g. At Day 85 (MAD) or Day 113 (multiple dose expansion) and/or EOS, the whole TM should be visible before taking imaging picture.  If the whole TM is not visible, the 
investigator should clean the ear canal. 
h. For multiple dose expansion, ASP0598 Otic Solution or placebo administration on Day 15 and Day 29 will be conducted in the case that the TMP closure is not confirmed. If the 
treatment is not conducted on these visits, imaging pictures and Microscopic ear examination for skin local reaction after the drug administration will be skipped. 
 


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1.3 
Schedule of Assessments 
Table 2 
Schedule of Assessments – SAD 
 
Screening 
Randomization 
Observation  
Day 
Day -28 to Day -1 
Day 1 
Day 2 
Day 8 
Day 15 
Day 29 
Day 57 
Last Visit/ 
EOS 
Week 
 
 
 
Week 1 
Week 2 
Week 4 
Week 8 
Visit Windows 
 
 
+ 1 day 
+/- 3 days 
+/- 3 days 
+/- 3 days 
+/- 3 days 
Visit number 
1 
2 
3 
4 
5 
6 
7 
Study Procedures 
Informed Consent 
X 
 
 
 
 
 
 
Verify Inclusion/Exclusion 
X 
X 
 
 
 
 
 
Medical History/Disease History/Demographics 
X 
X 
 
 
 
 
 
Physical Exam including Height and Weight 
X 
 
 
 
 
 
 
Vital Signs a 
X 
X 
X 
X 
X 
X 
X 
Prior/Concomitant Medications b  
X 
X 
X 
X 
X 
X 
X 
Adverse Events Assessment c 
X 
X 
X 
X 
X 
X 
X 
Study Treatment Administration 
ASP0598 or placebo  
 
X d 
 
 
 
 
 
Otology Examinations 
Microscopic Ear Examination 
X e 
X f 
X g 
X g 
X g 
X g 
X i 
Modified Brighton Grading Scheme Evaluation 
 
X f 
X 
X 
X 
X 
X 
Imaging picture of tympanic membrane by endoscope 
X e 
X h 
X  
X 
X 
X 
X  
Bone conduction by Pure Tone Audiometry (PTA) 
X e 
X 
X j 
X j 
X j 
X j 
X 
Air conduction by PTA  
X e 
X 
 
 
 
 
X 
Tympanometry  
X e 
X 
 
 
 
 
X 
Tinnitus Visual Analog Scale (TVAS) 
X 
X 
X 
X 
X 
X 
X 
Table continued on next page 


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Screening 
Randomization 
Observation  
Day 
Day -28 to Day -1 
Day 1 
Day 2 
Day 8 
Day 15 
Day 29 
Day 57 
Last Visit/ 
EOS 
Week 
 
 
 
Week 1 
Week 2 
Week 4 
Week 8 
Visit Windows 
 
 
+ 1 day 
+/- 3 days 
+/- 3 days 
+/- 3 days 
+/- 3 days 
Visit number 
1 
2 
3 
4 
5 
6 
7 
Blood Collection 
Serum Chemistries 
X 
 
 
 
 
 
 
CBC with Differential 
X 
 
 
 
 
 
 
Pregnancy Test k 
X 
X 
 
 
 
 
X 
Pharmacokinetic Sample 
 
X l 
X 
 
 
 
 
Blood Sample for Future Analysis 
 
X 
 
 
 
X 
 
Urine Collection 
Urinalysis 
X 
 
 
 
 
 
 
AE: adverse event; CBC: complete blood count; EOS: end of study; SAD: single ascending dose; TM: tympanic membrane  
a. 
Vital Signs include blood pressure, body temperature, and heart rate. 
b. Includes all medications taken within 28 days prior to ASP0598 Otic Solution or placebo administration at Day 1. 
c. 
AEs will be collected from the time of informed consent through Day 57 or EOS.  Any AEs ongoing at Day 57 or EOS Visit must be followed until resolution or investigator 
determines the event to be stable. AEs should be assessed at least monthly. 
d. ASP0598 Otic Solution or placebo will be applied onto the remaining tympanic membrane under a microscope with a 22-gauge blunt needle. After ASP0598 Otic Solution or 
placebo administration, subjects will be required to remain on their side with the treated ear facing up for at least 15 minutes. Please see the Pharmacy Manual, Section 9.4: Dose 
Administration for detailed instructions. 
e. 
Otology examinations will be performed for both ears at the screening visit. 
f. 
Microscopic Ear examination will be performed prior to and 60 (±5) minutes after ASP0598 Otic Solution/placebo administration. Skin local reaction at the application site will be 
evaluated by Modified Brighton Grading Scheme (Appendix 12.9) at 60 (±5) minutes after ASP0598 Otic Solution/placebo administration. 
g. Ear cleaning will not be conducted between Days 2 – 29, unless it is absolutely necessary. Investigators will not clean the treated ear by suctioning unless subject’s experience 
uncomfortable ear discharge.   
h. At Day 1, imaging pictures will be taken at the following time points: pre-dose, immediately after, 30 (±5) minutes, and 60 (±5) minutes after the ASP0598 Otic Solution or 
placebo administration. 
i. 
At Day 57 or EOS, the whole TM should be visible before taking imaging picture.  If the whole TM is not visible, the investigator should clean the ear canal. 
j. 
Bone conduction testing at Day 2, 8, 15, 29 will be tested only at 1, 2 and 4 kHz (ototoxicity assessment). 
k. Urine or serum pregnancy test will be performed in women of childbearing potential.  
l. 
Day 1, PK blood draw will be performed at the following time points: pre-dose (-15) minutes, 30 (±5) minutes and 60 (±5) minutes after ASP0598 Otic Solution or placebo 
administration into the affected ear.   


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Table 3 
Schedule of Assessments – Single Dose Expansion 
 
Screening 
Randomization 
Observation  
Day 
Day -28 to Day -1 
Day 1 
Day 15 
Day 29 
Day 57 
Day 85 
Last Visit/ 
EOS 
Week 
 
 
Week 2 
Week 4 
Week 8 
Week 12 
Visit Windows 
 
 
+/- 3 days 
+/- 3 days 
+/- 3 days 
+/- 3 days 
Visit number 
1 
2 
3 
4 
5 
6 
Study Procedures 
Informed Consent 
X 
 
 
 
 
 
Verify Inclusion/Exclusion 
X 
X 
 
 
 
 
Medical History/Disease History/Demographics 
X 
X 
 
 
 
 
Physical Exam including Height and Weight 
X 
 
 
 
 
 
Vital Signs a 
X 
X 
X 
X 
X 
X 
Prior/Concomitant Medications b 
X 
X 
X 
X 
X 
X 
Adverse Events Assessment c 
X 
X 
X 
X 
X 
X 
Study Treatment Administration 
ASP0598 or placebo  
 
X d 
 
 
 
 
Otology Examinations 
Microscopic Ear Examination  
X e 
X f 
Xg 
Xg 
Xg, 
X i 
Modified Brighton Grading Scheme Evaluation 
 
X f 
X 
X 
X 
X 
Imaging picture of tympanic membrane by endoscope  
X e 
Xh  
X 
X  
X 
X  
Bone conduction by Pure Tone Audiometry (PTA)  
X e 
X 
X j 
X j 
X j 
X 
Air conduction by PTA  
X e 
X 
 
 
 
X 
Tympanometry  
X e 
X 
 
 
 
X 
Tinnitus Visual Analog Scale (TVAS) 
X 
X 
X 
X 
X 
X 
Table continued on next page 


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Screening 
Randomization 
Observation  
Day 
Day -28 to Day -1 
Day 1 
Day 15 
Day 29 
Day 57 
Day 85 
Last Visit/ 
EOS 
Week 
 
 
Week 2 
Week 4 
Week 8 
Week 12 
Visit Windows 
 
 
+/- 3 days 
+/- 3 days 
+/- 3 days 
+/- 3 days 
Visit number 
1 
2 
3 
4 
5 
6 
Blood Collection 
Serum Chemistries 
X 
 
 
 
 
 
CBC with Differential 
X 
 
 
 
 
 
Pregnancy Test k 
X 
X 
 
 
X 
X 
Blood Sample for Future Analysis 
 
X 
 
X 
 
 
Urine Collection 
Urinalysis 
X 
 
 
 
 
 
AE: adverse event; CBC: complete blood count; EOS: end of study; TM: tympanic membrane 
a. Vital Signs include blood pressure, body temperature, and heart rate. 
b. Includes all medications taken within 28 days prior to ASP0598 Otic Solution or placebo administration at Day 1. 
c. AEs will be collected from the time of informed consent through Day 57 or EOS. Any AEs ongoing at Day 85 or EOS Visit must be followed until resolution or investigator 
determines the event to be stable. AEs should be assessed at least monthly. 
d. ASP0598 Otic Solution or placebo will be applied onto the remaining tympanic membrane under a microscope with a 22-gauge blunt needle. After ASP0598 Otic Solution or 
placebo administration, subjects will be required to remain on their side with the treated ear facing up for at least 15 minutes. Please see the Pharmacy Manual, Section 9.4: Dose 
Administration for detailed instructions. 
e. Otology examinations will be performed for both ears at the screening visit. 
f. Microscopic Ear examination will be performed prior to and 60 (±5) minutes after ASP0598 Otic Solution/placebo administration. Skin local reaction at the application site will be 
evaluated by Modified Brighton Grading Scheme (Appendix 12.9) at 60 (±5) minutes after ASP0598 Otic Solution/placebo administration. 
g. Ear cleaning will not be conducted between Days 2 – 57, unless it is absolutely necessary. Investigators will not clean the treated ear by suctioning unless subjects experience 
uncomfortable ear discharge. 
h. At Day 1, imaging pictures will be taken at the following time points: pre-dose, immediately after, 30 (±5) minutes, and 60 (±5) minutes after the ASP0598 Otic Solution or 
placebo administration. 
i. At Day 85 or EOS, the whole TM should be visible before taking imaging picture.  If the whole TM is not visible, the investigator should clean the ear canal. 
j. Bone conduction testing at Day 15, 29, and 57 will be tested only at 1, 2 and 4 kHz (ototoxicity assessment). 
k. Urine or serum pregnancy test will be performed in women of childbearing potential.  
 


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Table 4 
Schedule of Assessments – MAD  
 
Screening 
Randomization 
Observation  
Day 
Day – 28 to 
Day -1 
Day 1 
Day 8 
Day 15  
Day 22  
Day 29   
Day 36   
Day 57 
  
Day 85  
Last Visit/ 
EOS 
Week 
 
 
Week 1 
Week 2 
Week 3 
Week 4 
Week 5 
Week 8 
Week 12 
Visit Windows 
 
 
+/- 3 days 
+/- 3 days 
+/- 3 days 
+/- 3 days 
+/- 3 days 
+/- 3 days 
+/- 3 days 
Visit number 
1 
2 
3 
4 
5 
6 
7 
8 
9 
Study Procedures 
Informed Consent 
X 
 
 
 
 
 
 
 
 
Verify Inclusion/Exclusion 
X 
X 
 
 
 
 
 
 
 
Medical History/Disease History/Demographics 
X 
X 
 
 
 
 
 
 
 
Physical Exam including Height and Weight  
X 
 
 
 
 
 
 
 
 
Vital Signs a 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Prior/Concomitant Medications 
b 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse Events Assessment 
c 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Treatment Administration 
ASP0598 or placebo d 
 
X 
 
X 
 
X 
 
 
 
Otology Examinations 
Microscopic Ear Examination 
X e 
X f 
X g 
X f, g 
X g 
X f, g 
X g 
X g 
X i 
Modified Brighton Grading Scheme Evaluation 
 
X f 
X 
X f 
X 
X f 
X 
X 
X 
Imaging picture of tympanic membrane by endoscope 
X e 
X h 
X 
X h 
X 
X h 
X 
X 
X  
Bone conduction by Pure Tone Audiometry (PTA) 
X e 
X 
X j 
X j 
X j 
X j 
X j 
X j 
X 
Air conduction by PTA 
X e 
X 
 
 
 
 
 
 
X 
Tympanometry 
X e 
X 
 
 
 
 
 
 
X 
Tinnitus Visual Analog Scale (TVAS) 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Table continued on next page 


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Screening 
Randomization 
Observation  
Day 
Day – 28 to 
Day -1 
Day 1 
Day 8 
Day 15  
Day 22  
Day 29   
Day 36   
Day 57 
  
Day 85  
Last Visit/ 
EOS 
Week 
 
 
Week 1 
Week 2 
Week 3 
Week 4 
Week 5 
Week 8 
Week 12 
Visit Windows 
 
 
+/- 3 days 
+/- 3 days 
+/- 3 days 
+/- 3 days 
+/- 3 days 
+/- 3 days 
+/- 3 days 
Visit number 
1 
2 
3 
4 
5 
6 
7 
8 
9 
Blood Collection 
Serum Chemistries 
X 
 
 
 
 
 
 
 
 
CBC with Differential 
X 
 
 
 
 
 
 
 
 
Pregnancy Test k 
X 
X 
 
 
 
 
 
X 
X 
Pharmacokinetic Sample 
 
X l 
 
 
 
X  
 
 
 
Sample for Future Analysis  
 
X 
 
 
 
 
 
X 
 
Urine Collection 
Urinalysis 
X 
 
 
 
 
 
 
 
 
AE: adverse event; CBC: complete blood count; EOS: end of study; TM: tympanic membrane 
a. 
Vital Signs include blood pressure, body temperature, and heart rate. 
b. Includes all medications taken within 28 days prior to ASP0598 Otic Solution or placebo administration at Day 1. 
c. 
AEs will be collected from the time of informed consent through Day 85 or EOS.  Any AEs ongoing at Day 85 or EOS Visit must be followed until resolution or investigator 
determines the event to be stable. AEs should be assessed at least monthly. 
d. ASP0598 Otic Solution or placebo will be applied onto the remaining tympanic membrane under a microscope with a 22-gauge blunt needle. After ASP0598 Otic Solution or 
placebo administration, subjects will be required to remain on their side with the treated ear facing up for at least 15 minutes. Please see the Pharmacy Manual, Section 9.4: Dose 
Administration for detailed instructions. 
e. 
Otology examinations will be performed for both ears at the screening visit. 
f. 
Days 1, 15 and 29, microscopic ear examination will be performed prior to and 60 (±5) minutes after ASP0598 Otic Solution/placebo administration. Skin local reaction at the 
application site will be evaluated by Modified Brighton Grading Scheme (Appendix 12.9) at 60 (±5) minutes after ASP0598 Otic Solution/placebo administration. 
g. Ear cleaning will not be conducted between Days 2 – 57, unless it is absolutely necessary. Investigators will not clean the treated ear by suctioning unless subjects experience 
uncomfortable ear discharge). 
h. At Days 1, 15, and 29, imaging pictures will be taken at the following time points: pre-dose, immediately after, 30 (±5) minutes, and 60 (±5) minutes after the ASP0598 Otic 
Solution or placebo administration. 
i. 
At Day 85 and/or EOS, the whole TM should be visible before taking imaging picture.  If the whole TM is not visible, the investigator should clean the ear canal. 
j. 
Bone conduction testing at Day 8, 15, 22, 29, 36 and 57 will be tested only at 1, 2 and 4 kHz (ototoxicity assessment). 
k. Urine or serum pregnancy test will be performed in women of childbearing potential.  
l. 
Day 1 and Day 29, PK blood draw will be performed at the following time points: pre-dose (-15) minutes, 30 (±5) minutes and 60 (±5) minutes after ASP0598 Otic Solution or 
placebo administration into the affected ear.   


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Table 5 
Schedule of Assessments – Multiple Dose Expansion  
 
Screening 
Randomization 
Observation  
Day 
Day – 28 to Day -1 
Day 1 
Day 15  
Day 29   
Day 43 
Day 57 
  
Day 85  
 
Day 113  
Last Visit/ 
EOS 
Week 
 
 
Week 2 
Week 4 
Week 6 
Week 8 
Week 12 
Week 16 
Visit Windows 
 
 
+/- 5 days 
+/- 5 days 
+/- 3 days 
+/- 3 days 
+/- 3 days 
+/- 3 days 
Visit number 
1 
2 
3 
4 
5 
6 
7 
8 
Study Procedures 
Informed Consent 
X 
 
 
 
 
 
 
 
Verify Inclusion/Exclusion 
X 
X 
 
 
 
 
 
 
Medical History/Disease History/Demographics 
X 
X 
 
 
 
 
 
 
 Physical Exam including Height and Weight 
X 
 
 
 
 
 
 
 
Vital Signs a 
X 
X 
X 
X 
X 
X 
X 
X 
Prior/Concomitant Medications b  
X 
X 
X 
X 
X 
X 
X 
X 
Adverse Events Assessment c 
X 
X 
X 
X 
X 
X 
X 
X 
Study Treatment Administration 
ASP0598 or placebo d 
 
X 
X l 
X l 
 
 
 
 
Otology Examination 
Microscopic Ear Examination 
X e 
X f 
X f, g 
X f, g 
X g 
X g 
X g 
X i 
Modified Brighton Grading Scheme Evaluation 
 
X f 
X f 
X f 
X 
X 
X 
X 
Imaging picture of tympanic membrane by endoscope 
X e 
X h 
X h 
X h 
X 
X 
X 
X  
Bone conduction by Pure Tone Audiometry (PTA)  
X e 
X 
X j 
X j  
X j 
X j 
X j 
X 
Air conduction by PTA  
X e 
X 
 
 
 
 
X 
X 
Tympanometry  
X e 
X 
 
 
 
 
X 
X 
Tinnitus Visual Analog Scale (TVAS) 
X 
X 
X 
X 
X 
X 
X 
X 
Blood Collection 
Serum Chemistries 
X 
 
 
 
 
 
 
 
CBC with Differential 
X 
 
 
 
 
 
 
 
Pregnancy Test k 
X 
X 
 
 
 
X 
 
X 
Sample for Future Analysis  
 
X 
 
 
 
X  
 
 
Urine Collection 
Urinalysis 
X 
 
 
 
 
 
 
 
Footnotes appear on next page 


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AE: adverse event; CBC: complete blood count; EOS: end of study; TM: tympanic membrane; TMP: tympanic membrane perforation 
a. 
Vital Signs include blood pressure, body temperature, and heart rate. 
b. Includes all medications taken within 28 days prior to ASP0598 Otic Solution or placebo administration at Day 1. 
c. 
AEs will be collected from the time of informed consent through Day 113 or EOS.  Any AEs ongoing at Day 113 or EOS Visit must be followed until resolution or investigator 
determines the event to be stable. AEs should be assessed at least monthly. 
d. ASP0598 Otic Solution or placebo will be applied onto the remaining tympanic membrane under a microscope with a 22-gauge blunt needle. After ASP0598 Otic Solution or 
placebo administration, subjects will be required to remain on their side with the treated ear facing up for at least 15 minutes. Please see the Pharmacy Manual, Section 9.4: Dose 
Administration for detailed instructions. 
e. 
Otology examinations will be performed for both ears at the screening visit. 
f. 
Microscopic Ear examination will be performed prior to and 60 (±5) minutes after ASP0598 Otic Solution/placebo administration. Skin local reaction at the application site will be 
evaluated by Modified Brighton Grading Scheme (Appendix 12.9) at 60 (±5) minutes after ASP0598 Otic Solution/placebo administration. 
g. Ear cleaning will not be conducted between Days 2 – 85, unless it is absolutely necessary. Investigators will not clean the treated ear by suctioning unless subjects experience 
uncomfortable ear discharge). 
h. At Days 1, 15, and 29, imaging pictures will be taken at the following time points: pre-dose, immediately after, 30 (±5) minutes, and 60 (±5) minutes after the ASP0598 Otic 
Solution or placebo administration. 
i. 
At Day 85 (SAD) or Day 113 (single dose expansion) and/or EOS, the whole TM should be visible before taking imaging picture.  If the whole TM is not visible, the investigator 
should clean the ear canal. 
j. 
Bone conduction testing at Day 15, 29, 43, 57, and 85 will be tested only at 1, 2 and 4 kHz (ototoxicity assessment). 
k. Urine or serum pregnancy test will be performed in women of childbearing potential.  
l. 
ASP0598 Otic Solution or placebo administration on Day 15 and Day 29 will be conducted in the case that the TMP closure is not confirmed. 
 


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2 
INTRODUCTION 
2.1 
Background 
Target Disease 
Chronic Tympanic Membrane Perforation (CTMP) is defined as stable maintenance of 
tympanic membrane perforation over 3 months, in contrast to acute tympanic membrane 
perforations, which heal within 7 to 10 days [Seonwoo et al, 2013].  CTMP affects both 
pediatric and adult patients and can result from disease, trauma, or medical procedures.  Due to 
the continuous opening in the tympanic membrane, chronic perforation is usually attributed to 
chronic inflammation in the middle ear, resulting in suppurative otitis media [Seonwoo et al, 
2013; Aggarwal et al, 2006].  Surgical repairs such as myringoplasty or tympanoplasty are 
employed and are currently the main treatments for patients with CTMP.  Successful tympanic 
membrane closure rates vary between studies, ranging from 35% to 99% [Aggarwal et al, 
2006].  Disadvantages associated with these surgical procedures include anesthesia-associated 
risks and the inconvenience of surgery.  Therefore, a non-invasive treatment is desired in order 
to address the unmet need. 
ASP0598 and Its Pharmacological Concept 
Preclinical studies revealed that proliferation and migration of keratinocytes across layers of 
the tympanic membrane facilitate closure of the perforation site during the healing process 
[Santa Maria et al, 2010a].  Keratinocyte proliferation and migration are essential to 
cutaneous wound healing, and wound stimuli induce keratinocyte shedding of epidermal 
growth factor (EGF) receptor ligands in vitro, particularly the ligand HB-EGF [Tokumaru et 
al, 2000].  HB-EGF (an 87 amino acid glycoprotein) is a member of the EGF family of 
proteins that is encoded by the HB-EGF gene.  Preclinical studies showed that HB-EGF was 
upregulated by over 8-fold by 12 hours following perforation of the tympanic membrane and 
remained upregulated for a prolonged time compared to constantly expressed EGF in rats 
[Santa Maria et al, 2010b].  Thus, HB-EGF appears to play a crucial role in tympanic 
membrane wound healing after acute tympanic membrane perforation.  In a study [Santa 
Maria et al, 2015a], KB-R7785, which inhibits HB-EGF expression, was administered for 
1 week to mice with tympanic membrane perforation (CTMP animal model); persistent 
tympanic membrane perforation longer than 3 months was observed in these mice.  In 
addition, single topical administration of recombinant mouse pro-heparin-binding EGF-like 
growth factor with a sustained-release dose via a bioabsorbable chitosan-based polymer to 
the CTMP animal model showed complete closure of tympanic membrane perforation in 
83.3% of animals, while application of other growth factors, such as EGF and fibroblast 
growth factor 2, healed only 15.8% and 31.6%, respectively, of the tympanic membrane 
perforations in the animal model [Santa Maria et al, 2015a].  These data from the literature 
suggest that topical, non-invasive administration of HB-EGF is a potentially effective 
treatment for patients with CTMP. 
ASP0598 Otic Solution contains recombinant human heparin-binding EGF-like growth factor 
that is diluted with a buffered aqueous solution to adjust the dose strength and mixed with a 


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polymeric solution to enable the formation and retention of hydrogel after administration into 
the ear.   
2.1.1 
Nonclinical and Clinical Data 
Detailed information can be found in the Investigational Brochure (IB). 
Pharmacology 
ASP0598 enhanced the proliferation of primary human and mouse epidermal keratinocytes 
with half-maximal effective concentrations (EC50) of 11.72 and 52.92 ng/mL, respectively. 
A single dose of topical application of ASP0598 Otic Solution (0.04 μg/mL to 5 μg/mL as 
final concentrations of ASP0598) onto a perforated tympanic membrane increased the 
healing rate, meaning that ASP0598 Otic Solution increased the number of animal ears with 
complete perforation closure in a mouse model of CTMP.  The minimum efficacious 
concentration in this model was 0.2 μg/mL. 
Pharmacokinetics 
The toxicokinetics of ASP0598 were assessed in mice and cynomolgus monkeys.  After a 
single administration into the external auditory canal or transtympanic administration of 
ASP0598 Otic Solution at concentrations of 15 μg/mL and 150 μg/mL, there was no 
discernible absorption of ASP0598.  Administration of [89Zr]ASP0598 Otic Solution toward 
tympanic membranes in cynomolgus monkeys followed by positron emission tomography 
(PET) scans showed the presence of residual [89Zr]ASP0598 Otic Solution around the 
tympanic membranes from 0 to 14 days after administration.  Radioactivity in all plasma 
samples collected from these same animals was at background levels. 
Toxicology 
The safety of ASP0598 Otic Solution has been evaluated in 8 good laboratory practice (GLP) 
toxicity studies in CBA/CaJ mice and cynomolgus monkeys:  2 pivotal, extended single-dose 
toxicity studies following administration into the external auditory canal and 2 pivotal, 
single-dose ototoxicity studies following transtympanic administration, 2 pivotal, repeat-dose 
toxicity studies following administration into the external auditory canal and 2 pivotal, 
repeat-dose ototoxicity studies following transtympanic administration. 
Single dose administration of ASP0598 Otic Solution into the external auditory canal of 
either mice or cynomolgus monkeys resulted in no adverse findings or observations at 
concentrations up to 150 μg/mL.  These results were confirmed following transtympanic 
administration of ASP0598 Otic Solution in both species.  However, non-adverse, minimal to 
moderate procedure and/or vehicle related, histopathological changes were observed in 
cynomolgus monkeys following a single dose administration of ASP0598 Otic Solution into 
the external auditory canal or transtympanically. 
Administration of ASP0598 Otic Solution to mice by the external auditory canal or 
transtympanically resulted in serum concentrations of HB-EGF near or below the limit of 
quantification, while in cynomolgus monkeys, ASP0598 Otic Solution administration 


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resulted in serum concentrations of HB-EGF that remained at baseline values.  These data 
indicate that the external auditory canal or transtympanic route of administration of ASP0598 
Otic Solution was not associated with discernible systemic exposure to HB-EGF. 
Based on these results, no observed adverse effect level (NOAEL) was set at the highest 
concentration of 150 μg/mL in both the mouse and cynomolgus monkey studies following 
single external auditory canal or transtympanic administration.  
Finally, results from 4 GLP repeat dose toxicity studies in mice and cynomolgus monkeys 
were comparable with the results from the single dose administration assessments.  In these 
studies, ASP0598 Otic Solution was administered either into the external auditory canal or 
transtympanically 3 times at 2-week intervals.  No test article-related adverse effects were 
noted in either species when ASP0598 Otic Solution was applied either into the external 
auditory canal or transtympanically to the middle ear.  For both mice and cynomolgus 
monkeys the repeat dose results indicated that the NOAEL was also 150 µg/mL. 
Clinical Studies 
As of the date of the preparation of this protocol, no clinical studies of ASP0598 have been 
conducted. Therefore, the safety profile of ASP0598 Otic Solution has not been established. 
2.1.2 
Summary of Key Safety Information for Investigational Product(s)  
Given the limited safety information with ASP0598, there are currently no expected serious 
adverse reactions for ASP0598.  Detailed reference safety information (RSI) can be found in 
the IB.  
2.2 
Study Rationale 
This is the first clinical trial for ASP0598 Otic Solution. Surgical procedure is the only 
available treatment for CTMP and includes anesthesia-associated risks and the inconvenience 
of surgery. ASP0598 Otic Solution will be developed as a non-invasive treatment in order to 
address the unmet need. This study will be a randomized, placebo-controlled and investigator 
and subject blinded study to evaluate the safety, tolerability, efficacy and pharmacokinetics in 
subjects with CTMP.  
2.3 
Risk Benefit Assessment 
The non-clinical profile of ASP0598 Otic Solution demonstrates its potential efficacy on 
tympanic membrane perforation, localized distribution at the administration site with no 
systemic exposure to HB-EGF, and a favorable safety profile, supporting its clinical 
investigation. In this study, skin local reaction in the external ear canal will be assessed after 
topical application of ASP0598 Otic Solution. An appropriate administration to the tympanic 
membrane and observation of administration site are required to minimize exposure to the 
middle ear. In addition, monitoring of auditory functions (otology examinations) is 
recommended. 
Overall, the risk associated with the participation of subjects with CTMP in this study is 
considered acceptable. 


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3 
STUDY OBJECTIVE AND ENDPOINTS 
3.1 
Primary Objective and Endpoints  
Objective 
Endpoints 
● 
To evaluate the safety and tolerability of 
ASP0598 Otic Solution  
● 
Treatment-emergent adverse events (TEAEs) 
● 
Incidence of adverse events of special interest as 
defined below:  
1. Cholesteatoma or ear neoplasm 
2. Ototoxic symptoms (tinnitus, sensorineural hearing 
loss, dizziness) 
3. Otitis media or otitis externa 
● 
Change from baseline in bone conduction hearing at 1, 
2, 4 kHz by Pure Tone Audiometry (PTA) 
● 
Change from baseline in Tinnitus Visual Analog Scale 
(TVAS) 
 
3.2 
Secondary Objective and Endpoints  
Objective 
Endpoints 
• To evaluate the efficacy of ASP0598 Otic 
Solution  
For secondary efficacy endpoints the 
hypothetical strategy will be applied. 
Efficacy 
Single Dose  
● 
Complete closure of Tympanic Membrane Perforation 
(TMP) at Week 8 for Single Ascending Dose (SAD) 
and at Week 12 for dose expansion  
● 
Change from baseline in the ratio of TMP size per total 
area of tympanic membrane at Week 8 for SAD and at 
Week 12 for dose expansion  
● 
Change from baseline in TMP size at Week 8 for SAD 
and at Week 12 for dose expansion  
Multiple Dose: 
● 
Complete closure of TMP at Week 12 for Multiple 
Ascending Dose (MAD) and at Week 16 for dose 
expansion  
● 
Change from baseline in the ratio of TMP size per total 
area of tympanic membrane at Week 12 for MAD and 
at Week 16 for dose expansion  
● 
Change from baseline in TMP size at Week 12 for 
MAD and at Week 16 for dose expansion  
For the dose expansion, hypothetical strategy will be applied to analyze the secondary 
endpoints.  Details of intercurrent events (ICEs) and estimand are shown below. 
3.2.1 
Intercurrent Events 
The following ICEs may happen:  
● 
Treatment discontinuation due to any reason 
● 
Study discontinuation due to any reason 


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3.2.2 
Treatment regimen under evaluation  
Randomized treatment administered as directed per Schedule of Assessments. 
3.2.3 
Estimand 
Population: defined by the appropriate inclusion/exclusion criteria in the protocol.  
Efficacy endpoints:  
1. Complete closure of TMP at Week 12 for single dose expansion and Week 16 for 
multiple dose expansion. 
2. Change from baseline in the ratio of TMP size per total area of tympanic membrane at 
Week 12 for single dose expansion and Week 16 for multiple dose expansion. 
3. Change from baseline in TMP size at Week 12 for single dose expansion and Week 16 
for multiple dose expansion. 
Strategy for addressing ICEs: hypothetical strategy will be used to estimate the outcome at 
Week 12 for single dose expansion and Week 16 for multiple dose expansion. 
Population-level summary:  
• Endpoint #1: difference in proportion of subjects with complete closure of TMP at 
Week 12 for single dose expansion and Week 16 for multiple dose expansion between 
ASP0598 Otic Solution and placebo. 
• Endpoint #2: difference in mean change from baseline in the ratio of TMP size per total 
area of tympanic membrane at Week 12 for single dose expansion and Week 16 for 
multiple dose expansion between ASP0598 Otic Solution and placebo. 
• Endpoint #3: difference in mean change from baseline in TMP size at Week 12 for 
single dose expansion and Week 16 for multiple dose expansion between ASP0598 Otic 
Solution and placebo. 
Data that will be used for the analysis:  
• Endpoint #1: data necessary for this analysis is complete closure status at Week 12 for 
single dose expansion and Week 16 for multiple dose expansion. For the subjects who 
have discontinued treatment or the study before these data are collected due to ICEs, the 
complete closure status just before the ICE will be used as the status at Week 12 for 
single dose expansion and Week 16 for multiple dose expansion.  
• Endpoints #2 and #3: data necessary for these analyses are TMP size per total area of 
tympanic membrane and TMP size at each visit, respectively. For the subjects who have 
discontinued treatment or the study before these data are collected due to ICEs, only data 
obtained before the ICE will be used in the mixed model repeated measures (MMRM) to 
handle discontinued subjects in some sense if the subjects remained in the study under 
missing at random (MAR) assumption. 


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3.3 
Exploratory Objectives and Endpoints  
Objective 
Endpoints 
To evaluate otological parameters that 
may correlate with efficacy outcome and 
pharmacokinetics of ASP0598 Otic 
Solution 
Single Dose:  
● 
Complete closure of TMP for post baseline visits at Day 2, 
Day 3* Week 1, Week 2, Week 4 for SAD and Week 2, 
Week 4, and Week 8 for dose expansion  
● 
Change from baseline in the ratio of TMP size per total area 
of tympanic membrane for post baseline visits at Day 2, 
Day 3*, Week 1, Week 2, and Week 4 for SAD and Week 
2, Week 4, and Week 8 for dose expansion  
● 
Change from baseline in TMP size for post baseline visits at 
Day 2, Day 3*, Week 1, Week 2, and Week 4 for SAD and 
Week 2, Week 4, and Week 8 for dose expansion  
* Day 3 evaluations will only be performed for cohorts 1, 2 
and 3. 
Multiple Dose:  
● 
Complete closure of TMP for post baseline visits at Week 1, 
Week 2, Week 3, Week 4, Week 5, and Week 8 for MAD 
and Week 2, Week 4, Week 6, Week 8, and Week 12 for 
dose expansion  
● 
Change from baseline in the ratio of TMP size per total area 
of tympanic membrane for post baseline visits at Week 1, 
Week 2, Week 3, Week 4, Week 5, and Week 8 for MAD 
and Week 2, Week 4, Week 6, Week 8, and Week 12 for 
dose expansion  
● 
Change from baseline in TMP size for post baseline visits at 
Week 1, Week 2, Week 3, Week 4, Week 5, and Week 8 for 
MAD and Week 2, Week 4, Week 6, Week 8, and Week 12 
for dose expansion  
Single and Multiple Dose:  
● 
Time to closure of TMP  
● 
Size of TMP ≤ 5% of pars tensa surface area after treatment 
● 
Size of TMP ≤ 1% of pars tensa surface area (pin point 
perforation) after treatment 
● 
Change from baseline in air bone (A-B) gap by PTA 
● 
Change from baseline in air conduction hearing by PTA 
● 
Percentage improvement from baseline in A-B gap by PTA 
≥ 50% (improvement of conductive hearing) 
● 
Improvement from baseline in air conduction hearing by 
PTA ≥ 15 dB 
● 
A-B gap after treatment was 15 dB or less 
● 
Air conduction hearing threshold after treatment was 30 dB 
or less 
● 
Type of tympanogram (A, B or C) 
● 
Equivalent ear canal volume (ECV) by tympanometry   
Pharmacokinetics 
● 
Serum concentration of ASP0598 (dose escalation part 
only) 
Table continued on next page 


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Objective 
Endpoints 
To evaluate the safety of ASP0598 Otic 
Solution 
● 
Vital signs (body temperature, blood pressure and pulse 
rate) 
4 
STUDY DESIGN AND DOSE RATIONALE 
4.1 
Study Design 
This is a randomized, placebo-controlled and investigator and subject blinded study to 
evaluate the safety, tolerability, efficacy and pharmacokinetics in subjects with CTMP.  
The main part of this study is dose escalation.  Dose escalation will start with single 
ascending dose (SAD) followed by multiple ascending dose (MAD, Q2W x3).   
Dose escalation will primarily assess safety and tolerability of single dose and multiple doses 
of ASP0598 Otic Solution. Dose escalation will consist of up to 4 cohorts for SAD and up to 
2 cohorts for MAD, with different dose levels (Table 6).  Each cohort will consist of 
5 subjects (ASP0598 Otic Solution n = 4 and placebo n = 1) for SAD and 8 subjects 
(ASP0598 Otic Solution n = 6 and placebo n = 2) for MAD.    
Single and/or multiple dose expansion will be opened based on the safety and efficacy results 
following an interim analysis. Single dose expansion will be opened based on the results of 
the first interim analysis, which will occur after the completion of SAD. Data will be 
summarized for all time points available. Multiple dose expansion will be opened based on 
the results of the second interim analysis, which will occur after the completion of MAD. 
Table 6 
Planned Dose Levels for Dose Escalation 
Cohort 
Dose 
regimen 
Dose (µg) 
Drug 
concentration 
(µg/mL) 
Administration 
volume (mL) 
ASP0598 
Otic Solution (n) 
Placebo 
(n) 
1 
Single 
0.03 
0.2 
0.15 
4 
1 
2 
Single 
0.15a 
1.0a 
0.15 
4 
1 
3 
Single 
0.75a 
5.0a 
0.15 
4 
1 
4 
Single 
2.25a 
15a 
0.15 
4 
1 
5 
Q2W×3 
0.75a 
5.0a 
0.15 
6 
2 
6 
Q2W×3 
2.25a 
15a 
0.15 
6 
2 
a 
Planned dose levels, doses may be adapted depending on emergent safety and tolerability data. 
This study will consist of the following:  
Single Dose:  
● 
Screening (Days -28 to -1) 
● 
Randomization (Day 1) 
● 
Observation [through Day 57 (SAD) or through Day 85 (single dose expansion)] 
 


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Multiple Dose:  
● 
Screening (Day -28 to -1) 
● 
Randomization (Day 1) 
● 
Observation [through Day 85 (for MAD) or through Day 113 (for multiple dose 
expansion)] 
● 
Additional Treatment on Days 15 and 29 
Prior to any study-related assessments, the Informed Consent Authorization Form will be 
signed by the subject at Screening (Visit 1).  All subjects will enter into a screening period 
(Days -28 to -1) and will be evaluated for randomization eligibility after completing 
screening procedures.  Eligible subjects will be randomized on Day 1 (Visit 2).  
For a subject with bilateral TMP, once both ears have been identified as meeting all 
inclusion/exclusion criteria at Randomization on Day 1 (Visit 2), the ear with the worse 
hearing will be selected as the treated ear, unless a rationale exists to treat the other ear.  In 
the case of equivalent hearing level in both ears, the investigator will decide the treatment 
side with subject and will document the reason in the source document and the eCRF. In the 
case that the investigator is unable to decide the appropriate ear to treat, consultation with the 
sponsor may be required.  
Dose Escalation  
Approximately 20 subjects for SAD and 16 subjects for MAD will be enrolled in dose 
escalation part of the study.  The initiation and selection of dose concentrations for MAD will 
be based on at least 3 cohorts of SAD.  
For SAD, after randomization on Day 1, subjects will receive ASP0598 Otic Solution or 
placebo administration into the affected ear.  Subjects will return to the investigative site for 
assessments on Days 2, 3, 8, 15, 29, and 57 [End of Study (EOS)]. Day 3 evaluations will 
only be performed for cohorts 1, 2 and 3. 
For MAD, after randomization on Day 1, subjects will receive ASP0598 Otic Solution or 
placebo administration into the affected ear and will receive additional treatments into the 
same ear on Days 15 and 29.  Subjects will return to the investigative site for assessments on 
Days 8, 15, 22, 29, 36, 57, and 85 (EOS). 
For SAD and MAD, subjects who terminate early from the study will complete EOS 
assessments.  
For MAD only, Subjects who discontinue treatment will be encouraged to complete all 
protocol defined study visits through the Day 85 (EOS). 
The decision to escalate or stop escalation during SAD will be made by the Dose Escalation 
Committee (DEC). The DEC will operate as per the approved DEC Charter. 
The DEC will decide dose escalation and the initiation and selection of doses for MAD 
cohorts based on the emerging safety and tolerability data from SAD.  The tentative starting 


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dose concentration of MAD will be 5.0 μg/mL, and another dose concentration up to a 
maximum feasible dose concentration of 15 μg/mL will be considered. 
The first interim analysis will be conducted after completion of the last SAD cohort. Data 
will be summarized for all time points available. The second interim analysis will be 
conducted after completion of the last MAD cohort.   
The Data Monitoring Committee (DMC) will review the data and make the final decision to 
open single and/or multiple dose expansion.  The DMC operation, roles and responsibilities 
will be described in the DMC Charter. 
Subjects may be replaced at the discretion of the sponsor. If replaced, the replacement subject 
will be given the same treatment group the original subject’s randomized treatment group.  
Dose Expansion 
The decision to open single and/or multiple dose expansion will be made based on the safety 
and efficacy results of the interim analyses after completion of SAD and after completion of 
MAD by the DMC per the charter. Once the decision to open single and/or multiple dose 
expansion is made, the number of treatment groups (2 or 3 treatment groups including 1 or 2 
active treatment groups and 1 placebo group) and the dose for ASP0598 Otic Solution will be 
selected based on the safety and efficacy result of the interim analyses.  All analyses will be 
described in the Interim Analysis Plan (IAP). 
Up to 39 subjects will be randomized to single dose and/or multiple dose expansion. Based 
on the interim analysis results: 
● 
If 3 treatment groups are selected, approximately 39 subjects will be randomized in a 
1:1:1 ratio of high dose ASP0598 Otic Solution, low dose ASP0598 Otic Solution, or 
placebo (13 subjects in each treatment group). 
● 
If 2 treatment groups are selected, approximately 26 subjects will be randomized in a 1:1 
ratio of high dose ASP0598 Otic Solution or placebo (13 subjects in each treatment 
group). 
Stratification at the time of randomization will be based on the % size of the TMP at the 
screening visit and subjects will be balanced equally between the treatment groups. Dose 
expansion will assess safety and efficacy of ASP0598 Otic Solution.   
Single Dose Expansion 
After randomization on Day 1, subjects will receive ASP0598 Otic Solution or placebo 
administration into the affected ear at the investigative site.  Subjects will return to the 
investigative site for assessments on Days 15, 29, 57, and 85 (EOS).   
Subjects who terminate early from the study will complete EOS assessments at the time of 
discontinuation. 
Multiple Dose Expansion 
After randomization on Day 1, subjects will receive ASP0598 Otic Solution or placebo 
administration into the affected ear.  Subjects may receive additional treatment in the same 


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ear on Days 15 and 29.  Subjects will return to the investigative site for assessments on 
Days 15, 29, 43, 57, 85 and 113 (EOS).   
In cases where complete closure is confirmed on Day 15 or Day 29, the subject will not 
receive the next scheduled dose(s), but will complete all visit assessments as defined in the 
Schedule of Assessments through Day 113.  
Subjects who terminate early from the study will complete EOS assessments at the time of 
discontinuation.   
Subjects who discontinue treatment will be encouraged to complete all protocol defined study 
visits through the Day 113. 
In single dose expansion and/or multiple dose expansion, subjects may be replaced at the 
discretion of the sponsor. If replaced, the replacement subject will be given the same 
treatment group the original subject’s randomized treatment group.  
4.1.1 
Decision Process for Dose Escalation, Dose Escalation Stopping Rules and 
Definition of the Maximum Tolerated Dose  
4.1.1.1 Composition of Dose Escalation Committee 
Proceeding to the next higher dose requires an agreement of the DEC, which is comprised of 
Sponsor representatives.  The DEC Charter will provide detailed additional information. 
4.1.1.2 Decision Process for Dose Escalation and MAD Initiation 
The DEC will decide dose escalation and the initiation and selection of doses for MAD 
cohorts based on emerging safety and tolerability data from SAD.  After all subjects in a 
cohort have been dosed and completed study procedures through Day 15, the overall safety 
and tolerability of the dose will be determined after evaluation of the blinded safety data 
[treatment emergent adverse events (TEAEs), adverse events (AEs) of special interest, 
otology examinations (imaging pictures of tympanic membrane, bone conduction hearing at 
1, 2, 4 kHz by PTA, TVAS, Modified Brighton Grading Scale, and vital signs] for the current 
cohort. Cumulative AE data from the preceding cohort(s) will also be included in the 
assessment for dose escalation.  Details will be defined in the DEC Charter. 
4.1.1.3 Dose Escalation Stopping Rules 
Depending on the nature, frequency and severity of the safety profile observed in the study, 
the DEC will decide whether to:  
● 
Proceed with dose escalation and determine the next higher dose or, 
● 
Stop dose escalation (i.e., no further dosing with IP). 
Dose escalation will be stopped if 1 (or more) of the following apply: 
● 
If 1 or more subjects in 1 cohort develop cholesteatoma or suspicion of ear neoplasm 
which is considered to be related to the ASP0598.  
● 
If 2 or more subjects in 1 cohort develop Ototoxicity (clinically significant report of vestibular 
symptoms, tinnitus, or acute hearing loss) which are considered to be related to the IP.  


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● 
If 2 or more subjects in 1 cohort develop persistent otitis media or otitis externa 
unresponsive to oral and topical antibiotics which is described in concomitant treatment 
requirements section of the synopsis which are considered to be related to the IP. 
● 
If 1 or more subjects in 1 cohort experience AEs of severe intensity or 2 or more subjects 
in 1 cohort experience AEs of the same character of moderate intensity, which are 
considered to be related to the IP, and of clinical concern.  
In the event that it is deemed relevant to unblind a subject for the purposes of a dose 
escalation decision, the DEC chair or designee can request the treatment assigned to one or 
more subjects from the study statistician.  The DEC charter will include information on 
unblinding of study team members and other details.   
4.1.1.4 Definition of the Maximum Tolerated Dose 
If the DEC decides to stop dose escalation based on available safety data, the current dose 
level will be considered as the minimum intolerable dose (MID). The dose just below the 
MID will be regarded as the maximum tolerated dose (MTD).  If the dose escalation is 
stopped due to reaching exposure limit without dosing limiting safety findings, MTD cannot 
be determined. 
4.2 
Decision Process for Dose Expansion  
A Data Monitoring Committee (DMC) will be implemented and is responsible for the interim 
evaluation of safety and efficacy data and decision to open single and/or multiple dose 
expansion.  The DMC membership will be described in a separate DMC Charter.  
Two interim analyses will be conducted. The analyses will be performed after completion of 
last cohorts from of SAD and MAD, respectively.  
The analysis will be conducted by the Astellas study statistician, with results reviewed by the 
DMC as per IAP.  Details of the interim analysis procedure and the criteria to open single 
and/or multiple dose expansion will be described in the DMC charter. 
4.3 
Dose Rationale 
SAD 
The starting dose for SAD is 0.2 μg/mL administered in a single 0.15 mL dose volume. This 
starting concentration is equivalent to the minimum efficacious concentration in a nonclinical 
pharmacology study in a mouse CTMP model (minimum efficacious dose = 0.2 μg/mL, 5-μL 
single-dose volume). The dose volume has been scaled for clinical application based on 
tympanic membrane surface area between mice (3 mm2) and humans  
(68.3 – 90 mm2).  
The nonclinical pharmacology study showed concentration-dependent efficacy of ASP0598 
[Section 2.1.1].  In addition, given the nature of ASP0598 Otic Solution as a topical agent 
with local exposure and toxicity, the concentration (μg/mL) of ASP0598 Otic Solution was 
used as the basis for selecting the doses for the first-in-human study. 


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GLP studies were conducted to evaluate the toxicity after single-dose administration of 
ASP0598 Otic Solution in 2 different species: mice and cynomolgus monkeys 
[Section 2.1.1].  The no adverse effect levels (NOAEL) were determined in the GLP toxicity 
studies as follows: 
● 
NOAEL after a single administration into external auditory canal: 
150 μg/mL administered in a 10-μL volume in mice. 
150 μg/mL administered in a 100-μL volume in cynomolgus monkeys. 
In both species, the NOAEL was the highest concentration tested in the study. 
● 
NOAEL after a single transtympanic dose administration: 
150 μg/mL administered in a 2-μL volume in mice. 
150 μg/mL administered in a 100-μL volume in cynomolgus monkeys. 
In both species, the NOAEL was the highest concentration tested in the study. 
The first-in-human starting concentration of 0.2 μg/mL has a 750-fold safety margin over the 
NOAEL concentration from the GLP toxicity studies.  
The first-in-human maximum concentration is tentatively set at a concentration 15 μg/mL in 
a 0.15 mL volume dose, which is the maximum feasible concentration in the clinic. This 
maximum concentration has a 10-fold safety margin over the NOAEL concentration from the 
GLP toxicity studies. Dose adjustments will be based on altering the concentration of 
ASP0598 in the solution to 1.0, 5.0, and 15 μg/mL while the administration volume will be 
held constant at 0.15 mL. More than a 3-fold dose-increment, especially at lower 
concentration levels, is considered acceptable, considering the large safety margin as well as 
the non-steep concentration-response relationship observed in the CTMP mouse model. 
MAD 
The initiation and selection of dose concentrations for MAD will be based on emerging 
safety and tolerability data, and at least 3 dose cohorts of SAD should be available for the 
decision to initiate MAD.  The starting dose of MAD will be 5.0 μg/mL or lower, and another 
dose concentration up to the maximum feasible dose (15 μg/mL) or the NOAEL, whichever 
is lower, will be selected. The toxicology profile associated with repeat doses of ASP0598 
given 3 times at 2-week intervals has been tested in CBA/CaJ mice and cynomolgus monkeys 
and did not produce any significant toxicological findings. A bi-weekly dose schedule is 
selected that is considered convenient for patients and otolaryngology clinics, and it is 
predicted to resemble single treatments with minimal chance of drug accumulation. 
Therefore, Q2W × 3 is selected for the dose frequency of the multiple dose.  
4.4 
End of Study Definition  
End of the study is defined as the last visit or scheduled procedure shown in schedule of 
assessments for the last subject in the study. 


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5 
STUDY POPULATION 
All screening assessments must be completed and reviewed to confirm the potential subject 
meets all eligibility criteria. Prospective approval of protocol deviations (PDs) to eligibility 
criteria (also known as protocol waivers or exemptions) is not permitted. 
5.1 
Inclusion Criteria 
A subject is eligible for the study if all the following apply: 
1. Institutional Review Board (IRB)/Independent Ethics Committee (IEC) approved written 
Informed Consent and privacy language as per national regulation (e.g., Health Insurance 
Portability and Accountability Authorization for US sites) must be obtained from the 
subject or legally authorized representative prior to any study-related procedures 
(including withdrawal of prohibited medication, if applicable). 
2. Subject must be 18 to 75 years of age at the time of informed consent.   
3. Subject has chronic tympanic membrane perforation (CTMP) documented as persisting 
longer than 3 months. 
4. A female subject is eligible to participate if she is not pregnant see Appendix 12.3: 
Contraception Requirements and at least one of the following conditions applies: 
a. 
Not a woman of childbearing potential (WOCBP) as defined in Appendix 12.3: 
Contraception Requirements OR 
b. WOCBP who agrees to follow the contraceptive guidance as defined in 
Appendix 12.3: Contraception Requirements starting at screening and for at least 
28 days after investigational product (IP) application. 
5. Female subject must agree not to breastfeed starting at drug application on Day 1 and for 
at least 28 days after IP application. 
6. Female subject must not donate ova starting on Day 1 and for at least 28 days after IP 
application. 
7. A male subject with female partner(s) of child-bearing potential must agree to use 
contraception starting on Day 1 and for at least 28 days after IP application as detailed in 
Appendix 12.3. 
8. A male subject must not donate sperm starting on Day 1 and for at least 28 days after IP 
application. 
9. Male subject with a pregnant or breastfeeding partner(s) must agree to remain abstinent 
or use a condom from Day 1 and for at least 28 days after IP application. 
10. Subject must be willing and able to comply with the study requirements including 
refraining from using prohibited concomitant medications. 
11. Subject agrees not to participate in another interventional study during the study period.  


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12. Subject has the ability to understand and the willingness to sign a written informed 
consent document. 
Waivers to the inclusion criteria will NOT be allowed. 
5.2 
Exclusion Criteria 
A subject will be excluded from participation if any of the following apply: 
1. Subject has one of following conditions, that is confirmed by the investigator, that may 
affect the ipsilateral side of the ear with CTMP: 
a. 
Perforation involving 3 or more quadrants. 
b. Pin hole perforation (only for the expansion cohort). 
c. 
Presence of tympanosclerosis adjacent to the perforation. 
d. Perforation involves malleus erosion. 
e. 
Absent malleus. 
f. 
Marginal perforation (i.e., involving the annulus or exposing the handle of 
malleus). 
g. TMP caused by electric/slag/blast/burn injury. 
h. Post radiated TMP. 
i. 
History of tympanic membrane repair by any type of live tissue. 
j. 
Active otorrhea or active treatment for otorrhea within the last 3 months prior to 
Screening. 
k. Bellucci otorrhea grade 3 or above. 
l. 
Active external ear canal inflammation (otitis externa, dermatitis) or within the 
last 3 months prior to Screening. 
m. Active diagnosis of Eustachian Tube dysfunction or diagnosis within 6 months 
prior to Screening. 
n. Craniofacial abnormalities, history of head and neck surgery within the last 
3 months prior to Screening, history of radiation to head and neck. 
o. Recent (within 2 weeks) diagnosis of upper respiratory tract infection. 
p. Presence or history of cholesteatoma. 
q. Presence of pars-flaccida or pars tensa retraction or adhesion. 
r. 
Presence or history of tumors of the middle or external ear.  
s. 
Contraindications to tympanic membrane closure. 
t. 
An audiometric finding indicates a characteristic of Carhart's notch which is an 
increase in bone conduction threshold with a peak at 2,000 Hz. 
u. Only hearing ear or better hearing ear and the contralateral ear ≥ 40 dB by average 
four-frequency (500, 1000, 2000 and 4000 Hz). 
v. Whole circumference of the tympanic membrane perforation is not visible by 
endoscope. 
w. Presence/history of eosinophilic otitis media in either ear. 
2. Subject has a presence of adhesive otitis media in the contralateral ear. 
3. Subject has a presence of any wound healing systemic condition. 


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4. Subject has Obstructive Sleep Apnea where the subject is required to use Continuous 
Positive Airway Pressure (CPAP) during the study period. 
5. Subject is exposed in their daily life to high volume of water into the ear canal (e.g., 
swimmer or surfer). 
6. Subject has health conditions that would prevent him/her from fulfilling the study 
requirements as judged by the clinical investigator on the basis of medical history and 
laboratory test (Serum Chemistries, CBC with Differential, Urinalysis) results at the 
screening visit. 
7. Subject is receiving any other investigational agents during study participation. 
8. Subject has any form of substance abuse, or psychiatric illness/social situations that 
would limit compliance with study requirements, or a condition that in the opinion of the 
investigator could invalidate communication with the investigator.   
9. Subject has a known or suspected hypersensitivity to ASP0598, or any components of 
the formulation used. 
10. Subject has had previous exposure with ASP0598. 
11. Subject is unlikely to comply with the visits scheduled in the protocol, in the opinion of 
the Investigator. 
Waivers to the exclusion criteria will NOT be allowed.  
5.3 
Restrictions During the Study 
These restrictions are required after ASP0598 Otic Solution/placebo administration at Day 1 
until completion of the study procedures at Day 57 (SAD), Day 85 (single dose expansion), or 
Day 85 (MAD), Day 113 (multiple dose expansion), or EOS visit. 
● Subjects must refrain from showering or bathing for at least 24 hours after IP 
administration.  
○ Showering or bathing are allowed 24 hours after IP administration. Water 
precautions are to be taken as per the guidelines in Appendix 12.8. 
● Any water activities that risk submersion of the ear (e.g., swimming or surfing) are 
prohibited throughout the entire study period. 
● Subjects are not allowed to use any materials (e.g., Q-tips) placed into the ear canal of the 
treated ear (ear buds or headphones placed at the entrance to the ear canal are considered 
acceptable).  If ear cleaning is desired, then subjects can use a soft tissue placed gently at 
the entrance to the ear canal. 
● Investigators will not clean the ASP0598 Otic Solution/placebo treated ear by suctioning 
throughout Observation period, unless subjects experience uncomfortable ear discharge. 
General ear cleaning will be allowed to visualize the whole tympanic membrane at Day 57 
(SAD), Day 85 (single dose expansion or MAD), Day 113 (multiple dose expansion) or 
End of Study (EOS) visit, before imaging picture. 


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● Investigators may gently remove an obstacle that is blocking the ear canal if it prevents IP 
application or causes subjects to experience an uncomfortable sensation. If the obstacle is 
adherent to the tympanic membrane, it should not be removed; it is recommended to wait 
until the obstacle comes off. 
● Subjects should refrain from activities that can increase the middle ear pressure including 
plane travel (at least 28 days after IP application), positive pressure ventilation (e.g., 
CPAP or BiPAP) devices, Valsalva maneuvers, excessive high-pressure nose blowing or 
diving underwater.   
● Subject must refrain from activities that can excessively increase body temperature (e.g., 
Sauna) for 3 days after IP application. 
● Subject must refrain from activities that stimulate sweating excessively for 3 days after IP 
application. 
5.4 
Screen Failures 
A screen failure is defined as a potential subject who signed the Informed Consent Form 
(ICF), but did not meet 1 or more criteria required for participation in the study and was not 
randomized.  
For screen failures, the demographic data, date of signing the ICF, inclusion and exclusion 
criteria, AEs up to the time of screen failure and reason for screen failure will be collected in 
the eCRF.  
5.4.1 Rescreening 
Results of screening assessments that do not meet the parameters required by eligibility 
criteria (e.g., clinical laboratory tests, vital signs, physical examination, ear examination, etc.) 
may be repeated once within the 28-day screening period without the need to register the 
subject as a screen failure. If more than 28 days elapses from the date of signing the ICF, the 
subject must be documented as a screen failure. In order to re-screen, a new ICF must be 
signed and the subject entered into screening with a new subject identification number. 
Rescreening is only allowed once for an individual subject. 
6 
INVESTIGATIONAL PRODUCT(S)  
6.1 
Investigational Product(s) Administered 
Table 7 
Investigational Product(s)  
Name 
ASP0598 Otic Solution 
Buffered Aqueous Solvent with Copolymer 
Use 
Test Product 
Placebo 
Dosage 
Formulation 
Liquid for reconstitution and 
administration  
Solution for administration 
Physical 
Description 
Colorless to pale yellow, clear to 
slightly opalescent liquid solution 
Colorless to pale yellow, clear to slightly 
opalescent liquid solution 
Unit Dose 
Strength 
0.2, 1.0, 5.0, and 15.0 μg/mL  
N/A 
Table continued on next page 


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Packaging and 
Labeling 
Clear glass, single-use vial with a 
rubber stopper and an aluminum 
crimping cap. 
Clear glass, single-use vial with a robber 
stopper with an aluminum crimping cap. 
Route of 
Administration 
Single administration onto the 
tympanic membrane through the 
external auditory canal via syringe. 
Single administration onto the tympanic 
membrane through the external auditory 
canal via syringe. 
Administration 
Instruction 
See Section 6.4 and Pharmacy Manual 
and other supporting materials 
See Section 6.4 and Pharmacy Manual and 
other supporting materials 
IMP or Non-
IMP 
IMP 
IMP 
Sourcing 
Provided centrally by the sponsor  
Provided centrally by the sponsor  
Refer to the pharmacy manual and product label for detailed information regarding 
preparation, handling and storage of the IP and other study treatment(s).  
6.1.1 
Investigational Product Application  
IP (ASP0598 Otic Solution or placebo) will be prepared by the pharmacist or designee 
according the IRT treatment allocation using the pharmacy manual.  The final IP Otic 
Solution will be brought to the Study Physician or designee in the 1 mL Luer Lock™ syringe.  
Ensure the final IP Otic Solution is administered within the appropriate window of time, 
depending on the assigned treatment.  Refer to the Pharmacy Manual, Section 9.3, for 
detailed information.  The final IP Otic Solution should be stored at room temperature 
(20-25°C) and protected from light prior to administration.  The following information 
should be provided by the pharmacist / designee with the final IP Otic Solution as per 
institutional standards: subject’s initials, randomization number, end time of IP preparation, 
and administer by (time).  
The Study Physician or designee will put the 22G sheathed blunt-end needle onto the 1 mL 
Luer Lock™ syringe prior to administration.  The Study Physician or designee should prime 
the syringe prior to otic administration so that up to a maximum volume of 0.15 mL is 
applied onto the tympanic membrane.  
After ASP0598 Otic Solution or placebo administration, subjects will be required to remain 
on their side with the treated ear facing up for at least 15 minutes.  Please see the Pharmacy 
Manual, Section 9.4: Dose Administration for detailed instructions. 
6.2 
Preparation/Handling/Storage/Accountability 
6.2.1 
Packaging and Labeling 
All IP used in this study will be prepared, packaged and labeled under the responsibility of 
qualified personnel at APGD or sponsor’s designee in accordance with APGD or sponsor’s 
designee standard operating procedures (SOPs), Good Manufacturing Practice (GMP) 
guidelines, International Council for Harmonisation of Technical Requirements for 
Pharmaceuticals for Human Use (ICH) Good Clinical Practice (GCP) guidelines and 
applicable local laws/regulations. 


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Each carton and vial will bear a label conforming to regulatory guidelines, GMP and local 
laws and regulations that identifies the contents as investigational drug. 
Refer to the pharmacy manual and product label for detailed information regarding 
packaging, labeling, and preparation of the IP. 
6.2.2 
Handling, Storage and Accountability 
1. The pharmacist or designee must confirm appropriate temperature conditions have been 
maintained during transit for all IP received and any discrepancies are reported and 
resolved before use of the IP. 
2. Only subjects enrolled in the study may receive IP and only authorized study site 
personnel may supply or administer IP. Only IP with appropriate expiry/retest dating 
may be dispensed. 
3. All IP must be stored in a secure, environmentally controlled and monitored (manual or 
automated) area in accordance with the labeled storage conditions and access must be 
limited to the investigator and authorized study site personnel. 
4. The pharmacist, investigator, institution or the head of the medical institution (where 
applicable) is responsible for accountability, reconciliation and record maintenance (i.e., 
receipt, reconciliation and final disposition records).  
5. Further guidance and instruction on final disposition of used and unused IP is provided 
in the pharmacy manual.  
Refer to the pharmacy manual for detailed information regarding handling, storage and 
accountability of the IP. 
6.3 
Randomization and Blinding 
This is an investigator and subject blinded study.  Subjects will be randomized by IRT to 
receive ASP0598 Otic Solution or placebo in a blinded manner such that neither the 
investigator nor the subject will know which IP is being administered.   
Only the pharmacist and designated staff will be unblinded to treatment. All other study site 
staff will remain blinded to subjects’ treatment assignment.  
6.3.1 
Blinding Method  
In order to maintain the blind, the ASP0598 Otic Solution and placebo will be received in the 
same volume and route from the pharmacist or designee.  The pharmacist or designee will 
receive the unblinded treatment assignment from IRT in order to prepare the correct 
concentration of ASP0598 Otic Solution or placebo.  The subject and investigator will be 
blinded to the treatment assignment. 
Dose Escalation 
Only one cohort will be enrolled at a time.  The randomization number will be assigned 
based on information obtained from the IRT system.  


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Dose Expansion 
Subjects will be randomized through the IRT system in a 1:1:1 ratio, if 3 treatment groups are 
selected or 1:1 ratio, if 2 treatment groups are selected based on the interim analysis.  
6.3.2 
Confirmation of the Indistinguishability of the Investigational Product 
The appearance of both the dosage form and packaging of ASP0598 Otic Solution are 
identical to those of their matching placebo.  
6.3.3 
Retention of the Assignment Schedule and Procedures for Treatment Code 
Breaking  
The randomization list and treatment assignment blind will be maintained by the IRT system. 
6.3.4 
Breaking the Treatment Code for Emergency  
The treatment code for each randomized subject will be obtained from the IRT system in the 
event of a medical emergency requiring knowledge of the treatment assigned to the subject. 
The IRT system will be programmed with blind-breaking instructions that can only be 
requested by the investigator or sub-investigators designated to have access to perform blind-
breaking. In case of a medical emergency, the investigator has the sole responsibility for 
determining if unblinding of the subject’s treatment assignment is warranted. Subject safety 
must always be the first consideration in making such determination. If the investigator 
decides that unblinding is warranted, the investigator should make every effort to contact the 
sponsor prior to unblinding a subject’s treatment assignment unless this could delay 
emergency treatment for the subject.  
Prior to the initial IP shipment, the investigator must have confirmed ability to access 
code-break through the IRT system and must have a designated backup (e.g., redundant 
processes) to support emergency unblinding requirements.  
Prior to randomization, subjects should be provided with information that includes the study 
site emergency contact number and back-up contact number in case of a medical emergency. 
Any unblinding by the investigational personnel must be reported immediately to the sponsor 
and include an explanation of why the IP was unblinded. If unblinding is associated with a 
serious adverse event (SAE), the investigator is to follow the instructions in [Section 12.4.5 
Reporting Procedures for Serious Adverse Events].  
Care still be taken to limit knowledge of the treatment assignment, in case this can affect the 
blinding of other subjects or future study assessment for the subject.  
6.3.5 
Breaking the Treatment Code by the Sponsor  
The sponsor may break the treatment code for subjects who experience a suspected 
unexpected serious adverse reaction (SUSAR), in order to determine if the individual case or 
a group of cases requires expedited regulatory reporting. Individual emergency codes will be 
provided to the limited personnel who are responsible to break the codes for all SUSAR cases 
for reporting purposes.   


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6.3.6 
Assignment and Allocation 
SAD 
In each cohort, a total of 5 subjects will be randomized in a 4:1 ratio of ASP0598 Otic 
Solution (4 subjects) and placebo (1 subject).  
MAD 
In each cohort, a total of 8 subjects will be randomized in a 6:2 ratio of ASP0598 Otic 
Solution (6 subjects) and placebo (2 subjects).  
Dose Expansion 
● 
Based on the interim analysis results, if 3 treatment groups are selected, approximately 
39 subjects will be randomized in a 1:1:1 ratio of high dose ASP0598 Otic Solution, low 
dose ASP0598 Otic Solution, or placebo (13 subjects in each treatment group).  
● 
If 2 treatment groups are selected, approximately 26 subjects will be randomized in a 1:1 
ratio of high dose ASP0598 Otic Solution or placebo (13 subjects in each treatment 
group).  
Subjects will be stratified at the time of randomization by % size of the TMP (< 15%, > 15%) 
at the Screening Visit.  Subjects will be balanced equally between the treatment groups.  
TMP size group will be determined by the Screening images sent from the investigative site 
to the central imaging vendor.  
For SAD, MAD, and dose expansion, randomization will be performed via IRT using central 
allocation. If a subject is assigned a randomization number, but does not receive study drug, 
the randomization number will not be used again. The randomization schedule that 
determines subject treatment will be computer-generated by IRT before the beginning of the 
study. The unblinded study site personnel will dispense the treatment according to the IRT 
system’s assignment. Specific procedures for randomization through the IRT are contained in 
the study-specific IRT manual. 
6.4 
Investigational Product Compliance 
Single Dose  
IP will be administered by the PI or designee on Day 1.  Ensure the final IP Otic Solution is 
administered within the appropriate window of time, depending on the assigned treatment.  
Refer to the Pharmacy Manual, Section 9.3, for detailed information.  Subjects will be 
provided Ear Care Recommendations (Appendix 12.8) that must be reviewed and 
acknowledged on Day 1 in the source document. The subject should follow this guidance for 
the duration of their participation. The investigator will examine the treated ear at every visit.   
Multiple Dose 
IP will be administered by the PI or designee on Days 1, 15, and 29.  Ensure the final IP Otic 
Solution is administered within the appropriate window of time, depending on the assigned 
treatment.  Refer to the Pharmacy Manual, Section 9.3, for detailed information.  Subjects 


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will be provided Ear Care Recommendations (Appendix 12.8) that must be reviewed and 
acknowledged at each IP administration visit in the source document. The subject should 
follow this guidance for the duration of their participation. The investigator will examine the 
treated ear at every visit.   
6.5 
Previous and Concomitant Treatment (Medication and 
Nonmedication Therapy) 
These restrictions are required after ASP0598 Otic Solution or placebo administration on 
Randomization (Day 1), until completion of study procedures at Day 57 (SAD) / Day 85 
(single dose expansion or MAD) / Day 113 (multiple dose expansion) or EOS visit. 
● 
Ear drop agents will be used only for the treatment of otitis media with suppurative ear 
discharge. Only Ciprofloxacin or Ofloxacin ear drops (does not include steroids) are 
allowed to be used in the ASP0598 Otic Solution or placebo treated ear.  Investigators 
should minimize treatment with ear drops up to a maximum of 10 days and consider 
alternative treatment (e.g., oral antibiotics). 
● 
Any other topical agents in the ear canal are prohibited to use in the ASP0598 Otic 
Solution or placebo treated ear. 
● 
Any otologic procedures (e.g., paper patch or surgeries) to the ASP0598 Otic Solution or 
placebo treated ear are prohibited. 
All concomitant medication usage will be noted and recorded during each study visit.  
6.6 
Dose Modification 
SAD and single dose expansion  
Not Applicable. 
MAD 
On Day 15 or Day 29, treatment can be skipped at the Investigator’s discretion based on 
safety reasons that interrupt IP administration (e.g., ear canal skin irritation, mild otorrhea).  
Subjects should be encouraged to return to the office for evaluation and additional IP 
administration within the Day 15 or Day 29 visit windows. In the case that the investigator is 
unable to conduct IP administration for anything other than safety reasons, consultation with 
the sponsor may be required. 
Multiple dose expansion 
The statement above for MAD is also applicable to the multiple dose expansion. 
Additionally, the treatment on Day 15 or Day 29, treatment will be skipped in cases where 
complete closure is confirmed. If the perforation is detected on Day 29 after treatment was 
skipped on Day 15, IP administration can be conducted. 
6.7 
Criteria for Continuation of Treatment  
SAD and single dose expansion  
Not applicable because there is a single treatment of ASP0598 Otic Solution or placebo. 


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MAD and multiple dose expansion  
Treatment Discontinuation 
During the course of IP administration, if the subject experiences a drug-related AE, the IP 
administration may be discontinued at the investigator’s discretion.    
In addition, IP administration will be discontinued if severe intensity occurs in any of the 
following: 
● 
Subject develops cholesteatoma or suspicion of neoplasm in the treated ear as 
determined by investigator. 
● 
Subjects develops suspected ototoxicity symptoms (e.g., sudden hearing loss at high 
frequencies (1, 2, 4 kHz), new high frequency tinnitus or new balance disorder) which 
are considered by the investigator to be related to the study drug. 
● 
Subjects with persistent otitis media or otitis externa unresponsive to oral and topical 
antibiotics (as described in Previous Concomitant Treatment [Medication and 
Nonmedication Therapy of the synopsis and protocol Section 6.5]) 
7 
STUDY PROCEDURES AND ASSESSMENTS 
Refer to the Alternate Schedule of Assessments in [Section 12.11 Clinical Study Continuity] 
for acceptable alternate methods to assess safety and efficacy parameters in the event the 
study is interrupted due to a crisis (e.g., natural disaster, pandemic). 
7.1 
Efficacy Assessments 
7.1.1 
Imaging picture of tympanic membrane by endoscope 
At Screening, an imaging picture of the tympanic membrane for both ears will be captured by 
endoscope. After the treated ear is determined at Day 1, an imaging picture will be taken only 
of the treated ear throughout the study.  
An imaging picture of the tympanic membrane will be recorded to support evaluation of 
efficacy endpoints at all visits.  TMP closure is defined as TMP closure without presence of 
pin hole. All images from each visit will be sent to a central imaging vendor for measurement 
and interpretation. TMP size calculation and evaluation of complete closure will be 
performed by central imaging vendor and detailed instruction will be described in 
Independent Review Charter.  See the SAD and Single Dose Expansion Schedule of 
Assessments (Table 2 and Table 3) and MAD and Multiple Dose Expansion Schedule of 
Assessments (Table 4 and Table 5) for timing of procedures. 
7.1.2 
Microscopic Ear Examination 
The site investigator will examine the tympanic membrane by microscope. TMP closure will 
be evaluated at all visits except for Screening and Day 1, and will be recorded in the eCRF.  
7.1.3 
Pure Tone Audiometry 
Pure Tone Audiometry (PTA) is a behavioral test and generally the first quantitative hearing 
test done to assess the nature and degree of hearing loss in adults and in children. This 


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measure involves the peripheral and central auditory systems. Pure tone air conduction and 
bone conduction tests determine whether or not there is any hearing loss; what type of 
hearing loss it is (conductive, sensorineural or mixed hearing loss); the frequencies that are 
affected (configuration); magnitude of hearing loss (intensity) and whether hearing loss is 
unilateral or bilateral. The result is plotted on an audiogram, which is a graph displaying 
intensity as a function of frequency.  
PTA will be performed on the bilateral ears at Screening and will be tested only for the 
treated ear after the treatment side is determined by investigator at Day 1. This will be 
performed on a calibrated audiometer by a licensed audiologist. 
For the efficacy evaluation, PTA will be measured following different frequencies:  
Air: 250 Hz, 500 Hz, 1 kHz, 2 kHz, 4 kHz, and 8 kHz 
Bone: 500 Hz, 1 kHz, 2 kHz, and 4 kHz 
Follow the Schedule of Assessments (Table 2, Table 3, Table 4 and Table 5) for timing of 
procedures. 
PTA result(s) (decibel at each frequency) will be recorded in the eCRF at each visit. 
7.1.4 
Tympanometry  
Tympanometry (an objective test of middle-ear function) is an examination used to test the 
condition of the middle ear and mobility of the tympanic membrane (TM) by creating 
variations of air pressure in the ear canal.  Tympanometry will be performed on the bilateral 
ear at Screening and only for the treated ear for the remaining study visits. 
Tympanogram type (A, Ad, As, B or C) and ear canal volume (ECV) will be recorded in the 
eCRF.  Tympanometry will be performed at Screening, Day 1 and Day 57 (SAD) or Day 85 
(single dose expansion and MAD) or Day 113 (multiple dose expansion) or EOS Visits. The 
assessment will be performed by a licensed audiologist on a calibrated tympanometer.  A 
print-out containing the tympanogram will be collected from the machine or, if no print out is 
available, the tympanogram should be drawn and stored in the source documents. 
7.2 
Safety Assessments 
Single Dose study procedures and their timing are summarized in the Schedule of 
Assessments (Table 2 and Table 3). Multiple Dose study procedures and their timing are 
summarized in the Schedule of Assessments (Table 4 and Table 5).  Protocol waivers or 
exemptions are not allowed. 
Procedures conducted as part of a subject’s routine clinical management (i.e., standard of 
care) obtained before signing the ICF may be utilized for screening or baseline purposes, 
provided the procedures met the protocol-specified criteria and were performed within the 
time frame, as defined in the Single Dose Schedule of Assessments (Table 2 and Table 3) and 
the Multiple Dose Schedule of Assessments (Table 4 and Table 5).  


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7.2.1 
Adverse Events 
See [Section 7.3 Adverse Events and Other Safety Aspects] for information regarding AE 
collection and data handling. 
7.2.2 
Laboratory Assessments 
● 
Will be performed at Screening for eligibility purposes. 
● 
The investigator or sub-investigator must review the laboratory report and document this 
review. 
● 
Clinical significance of out-of-range laboratory findings is to be determined and 
documented by the investigator or sub-investigator who is a qualified physician. 
● 
Unscheduled laboratory assessments may be performed for Adverse Events. 
7.2.3 
Vital Signs 
Vital signs will include systolic and diastolic blood pressure (mmHg), heart rate (bpm), and 
body temperature (°F / °C). Vital signs will be performed according to the Schedule of 
Assessments (Table 2, Table 3, Table 4, Table 5).  Additional vital sign assessments may be 
taken as indicated or according to institutional standard procedure. 
7.2.4 
Physical Examination  
A physical examination of the subject will be conducted by a medically qualified person at 
the Screening Visit.  This will consist of an examination of general appearance, nose, throat, 
neck, and lymph nodes, as well as measurements of height and weight.  A symptom-directed 
physical may be performed at any of the other visits, if necessary. 
The screening physical examination also includes any significant, ongoing medical 
conditions.   
7.2.5 
Microscopic Ear Examination 
At Screening, both ears will be examined microscopically to identify the TMP and evaluate 
the eligibility of the subject for the study. Only the ASP0598 Otic Solution or placebo treated 
ear will be examined at Day 1 and at subsequent visits. 
Local skin reaction around the application site will be examined at 60 minutes after the 
treatment at Day 1 for single dose and Days 1, 15, and 29 for multiple dose and throughout 
the observation period. Skin toxicity will be evaluated by the Modified Brighton Grading 
Scheme (Appendix 12.9) and recorded in the eCRF. 
7.2.6 
Pure Tone Audiometry for Ototoxicity Assessment 
For the ototoxicity evaluation, bone conduction hearing level at 1, 2 and 4 kHz will be 
measured by PTA. PTA for ototoxicity assessment will be performed for the treated ear on a 
calibrated audiometer by a licensed audiologist.  
Bone Conduction hearing level measured by PTA will be performed according to the 
Schedule of Assessments (Table 2, Table 3, Table 4, Table 5).   
PTA result (decibel at each frequency) will be recorded in the eCRF at each visit. 


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7.2.7 
Tinnitus Visual Analog Scale 
Subjects will be given the Tinnitus Visual Analog Scale (Appendix 12.10) to rate their 
tinnitus at all visits.  The Scale is a numeric scale and ranges from 0 (not at all strong or loud) 
to 10 (extremely strong or loud). The subject’s response will be recorded in the eCRF at each 
visit.  The scale is designed to assess the loudness of the subject’s tinnitus, its annoyance, the 
degree of stress it was causing to the subject, and how well the subject was coping with the 
tinnitus.   
7.2.8 
Order of Assessments  
Refer to and Figures 4 and 5 (Single Dose) and Figures 6 and 7 (Multiple Dose): Otology 
Examination Flow Chart for the order of assessments. 
7.3 
Adverse Events and Other Safety Aspects 
The definitions of an AE or SAE can be found in [Appendix 12.4 Adverse Events: 
Definitions and Procedures for Recording, Evaluating, Follow-up or Reporting].  
The investigator and medically qualified designee(s) are responsible for detecting, 
documenting and recording events that met the definition of an AE or SAE.  
7.3.1 
Time Period for Collecting Adverse Event and Serious Adverse Event 
Information 
In order to identify any events that may be associated with study procedures and could lead to 
a change in the conduct of the study, Astellas collects AEs even if the subject has not 
received IP. AE collection begins after the signing of the ICF and will be collected until 
14 days after the last study visit or when the subject is determined to be a screen failure.  
7.3.2 
Method of Detecting Adverse Events and Serious Adverse Events 
The methods of recording, evaluating and assessing seriousness, causality and severity of 
AEs and SAEs are described in [Appendix 12.4 Adverse Events: Definitions and Procedures 
for Recording, Evaluating, Follow-up or Reporting]. Care will be taken not to introduce bias 
when detecting AEs and/or SAEs. Open-ended and nonleading verbal questioning of the 
subject is the preferred method to inquire about AE occurrences. 
An AE with a change in severity is recorded as a new AE. 
7.3.3 
Follow-up of Adverse Events 
All AEs occurring during or after the subject has discontinued the study are to be followed up 
on until resolved or judged to be no longer clinically significant, or until they become chronic 
to the extent that they can be fully characterized by the investigator.  
If after the protocol-defined AE collection period (see [Section 7.3.1 Time Period for 
Collecting Adverse Event and Serious Adverse Event Information]), an AE progresses to an 
SAE, or the investigator learns of any (S)AE (serious adverse event or adverse event) 
including death, where he/she considers there is reasonable possibility it is related to the IP or 
study participation, the investigator must promptly notify the sponsor. 


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7.3.4 
Reporting of Serious Adverse Events 
Prompt notification by the investigator to the sponsor of an SAE is essential, so that legal 
obligations and ethical responsibilities towards the safety of subjects and the safety of a study 
intervention under clinical investigation are met. 
In the case of an SAE, the investigator must contact the sponsor by fax or email immediately 
(within 24 hours of awareness). 
Procedures for reporting SAEs to the sponsor are described in [Section 12.4.5 Reporting 
Procedures for Serious Adverse Events]. 
7.3.5 
Disease-related Events and/or Disease-related Outcomes Not Qualifying as 
Adverse Events or Serious Adverse Events 
Under this protocol, the following event(s) will not be considered as an(S)AE: 
● 
Disease progression: events including defined study endpoints that are clearly consistent 
with the expected pattern of progression of the underlying disease are not to be recorded 
as AEs. These data will be captured as efficacy assessment data as outlined in 
[Section 7.1 Efficacy Assessments]. If there is any uncertainty as to whether an event is 
due to anticipated disease progression and/or if there is evidence suggesting a causal 
relationship between the IP and the event, it should be reported as an (S)AE. All deaths 
up to 30 days after the final administration of IP must be reported as an SAE, even if 
attributed to disease progression.   
● 
Pre-planned and elective hospital/clinical procedures/interventions or procedures for 
diagnostic, therapeutic, or surgical procedures for a pre-existing condition that did not 
worsen during the course of the study. These procedures are collected per the eCRF’s 
completion guidelines. 
7.3.6 
Adverse Events of Special Interest   
Incidence of adverse events of special interest as defined below:  
1. Cholesteatoma or ear neoplasm 
2. Ototoxic symptoms (tinnitus, sensorineural hearing loss, dizziness) 
3. Otitis media or otitis externa 
Additional data may be collected for AEs of special interest (i.e., unscheduled microscopic 
pictures, histopathology, surgical procedures, or other treatments). 
7.3.7 
Special Situations  
Certain special situations observed in association with the IP, such as incorrect administration 
(e.g., wrong dose of IP or background therapy) are collected in the eCRF, as PDs per 
[Section 10.3 Major Protocol Deviations] or may require special reporting, as described 
below. These special situations are not considered AEs, but do require to be communicated to 
Astellas as per the timelines defined below.  
If a special situation is associated with, or results in, an AE, the AE is to be assessed 
separately from the special situation and captured as an AE in the eCRF.  If the AE meets the 


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definition of an SAE, the SAE is to be reported as described in [Section 12.4.5 Reporting 
Procedures for Serious Adverse Events] and the details of the associated special situation are 
to be included in the clinical description on the SAE worksheet. 
The special situations are: 
● 
Pregnancy  
● 
Medication error, overdose and use outside protocol 
● 
Misuse/abuse 
● 
Occupational exposure 
● 
Suspected drug-drug interaction 
Instructions and procedures for reporting special situations are provided in [Appendix 12.4.6 
Reporting Procedures for Special Situations].  
7.3.8 
Supply of New Information Affecting the Conduct of the Study 
When new information becomes available that is necessary for conducting the study properly, the 
sponsor will inform all investigators involved in the study as well as the appropriate regulatory 
authorities. Investigators should inform the IRB/IEC of such information when needed.  
The investigator will also inform the subjects, who will be required to sign an updated ICF in 
order to continue in the study. 
7.3.9 
Urgent Safety Measures  
An urgent safety measure (USM) is an intervention that is not defined by the protocol and 
can be put in place with immediate effect without needing to gain prior approval by the 
sponsor, relevant competent authorities (CA), IRB/IEC, where applicable, in order to protect 
subjects from any immediate hazard to their health and/or safety. Either the investigator or 
the sponsor can initiate a USM. The cause of a USM can be safety-, product- or 
procedure-related.  
7.3.10 Reporting Urgent Safety Measures 
In the event of a potential USM, the investigator must contact the study physician (within 
24 hours of awareness). Full details of the potential USM are to be recorded in the subject’s 
medical records. The sponsor may request additional information related to the event to 
support their evaluation.  
If the event is confirmed to be a USM, the sponsor will take appropriate action to ensure the 
safety and welfare of the subjects. These actions may include but are not limited to a change 
in study procedures or study treatment, halting further enrollment in the study, or stopping 
the study in its entirety. The sponsor or sponsor's designee will notify the relevant competent 
authorities and concerned ethics committee within the timelines required per current local 
regulations, and will inform the investigators, as required. When required, investigators must 
notify their IRB/IEC within timelines set by regional regulations. 


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7.4 
Pharmacokinetics 
Serum will be collected to assess the pharmacokinetic profile of ASP0598 Otic Solution as 
indicated in the Schedule of Assessments (Table 2 and Table 4).   
The actual date and time of each blood sample collection will be collected in the source 
documents.  Serum will be prepared according to procedures further specified in the 
laboratory manual.  Samples will be shipped on dry ice to designated contract research 
organization (CRO) and analyzed using a validated method.  
7.5 
Immunogenicity 
Banking blood samples for future analysis will be collected for all subjects at timepoints as 
detailed in the Schedules of Assessments (Table 2, Table 3, Table 4, and Table 5). The actual 
date and time of each blood sample collection will be recorded in the source documents. 
Serum will be prepared according to procedures further specified in the laboratory manual. 
Samples will be shipped to designated CRO. When deemed appropriate at a later date, 
banked serum sample may be used for potential future immune testing. The results of these 
tests will be described in a separate report and will not be incorporated in the integrated 
clinical study report.  
7.6 
Total Amount of Blood 
The total amount of whole blood including clinical laboratory, pharmacokinetic sampling, 
and blood banking sample that will be collected during the entire study is approximately 
20.0 mL per subject. For MAD cohorts only, the total amount of whole blood collected will 
be approximately 30.0 mL per subject. 
8 
DISCONTINUATION 
8.1 
Discontinuation of Individual Subject(s) From Study Treatment  
SAD and single dose expansion  
Not applicable because there is a single treatment of ASP0598 Otic Solution or placebo. 
MAD and multiple dose expansion 
Treatment Discontinuation 
During the course of IP administration, if the subject experiences a drug-related adverse 
event (AE) the IP administration may be discontinued at the investigator’s discretion.    
In addition, study drug administration will be discontinued if any of the following occur: 
● 
Subject develops cholesteatoma or suspicion of neoplasm in the treated ear as 
determined by investigator. 
● 
Subjects develops suspected ototoxicity symptoms (e.g., sudden hearing loss at high 
frequencies (1, 2, 4 kHz), new high frequency tinnitus or new balance disorder) which 
are considered by the investigator to be related to the study drug. 


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● 
Subjects with persistent otitis media or otitis externa unresponsive to oral and topical 
antibiotics (as described in other area of synopsis) 
A discontinuation from treatment is defined as a subject who enrolled in the study and for 
whom study treatment is permanently discontinued for any reason.   
The subject is free to withdraw from the study treatment and/or study for any reason and at 
any time without giving reason for doing so and without penalty or prejudice. The 
investigator is also free to discontinue the subject from study treatment or to terminate a 
subject’s involvement in the study at any time if the subject’s clinical condition warrants it. 
The reason for discontinuation from study treatment must be documented in the subject’s 
medical records. 
A subject must discontinue study treatment for any of the following reasons: 
● 
Subject requests to stop treatment.  
● 
Any clinical AE, laboratory abnormality or intercurrent illness, in the opinion of the 
investigator, indicates continued treatment is not in the best interest of the subject. 
8.2 
Discontinuation of Individual Subject(s) From Study 
All subjects who discontinue study treatment will remain in the study and must continue to 
be followed for protocol-specific follow-up procedures as outlined in the Schedule of 
Assessments (Table 2, Table 3, Table 4, and Table 5). The only exception to this is when the 
subject specifically withdraws consent for any further contact with him/her or persons 
previously authorized by the subject to provide this information. 
8.2.1 
Lost to Follow-up 
Every reasonable effort is to be made to contact any subject lost to follow-up during the 
course of the study to complete study-related assessments and record outstanding data.  
8.3 
Discontinuation of the Study Site 
If an investigator intends to discontinue participation in the study, the investigator must 
immediately inform the sponsor.  
8.4 
Discontinuation of the Study 
The sponsor may terminate this study prematurely, either in its entirety or at any study site, 
for reasonable cause provided that written notice is submitted in advance of the intended 
termination. Advance notice is not required if the study is stopped due to safety concerns. If 
the sponsor terminates the study for safety reasons, the sponsor will immediately notify the 
investigator and subsequently provide written instructions for study termination.  
9 
STATISTICAL METHODOLOGY 
A statistical analysis plan (SAP) will be written to provide details of the analysis, along with 
specifications for tables, listings and figures to be produced. The SAP will be finalized before 
the database lock. Any changes to the dose escalation of the SAP will be approved prior to 


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unblinding the dose escalation data for the prescribed interim analysis. Changes from the 
planned analyses in the final SAP that impact the statistical analyses will be justified in the 
clinical study report (CSR). 
In general, continuous data will be summarized using descriptive statistics (number of 
subjects, mean, standard deviation and/or standard error, minimum, median and maximum), 
and categorical data will be summarized using number and percentage of subjects. Baseline 
will be defined as the last non-missing observation on or prior to the administration of study 
drug, unless otherwise specified. 
For SAD and MAD, results will be presented by ASP0598 treatment group in each cohort 
and placebo group where placebo subjects will be pooled across cohorts. 
For single dose expansion and multiple dose expansion, results will be presented by 
ASP0598 treatment group and placebo group. 
All statistical comparisons between ASP0598 and placebo will be made using a 2-sided test 
at α = 0.05 significance level and 2-sided 95% confidence intervals (CIs) will be reported for 
each treatment group and difference from placebo. 
9.1 
Sample Size 
SAD 
Formal sample size calculations were not performed. SAD is not intended to show statistical 
difference between ASP0598 Otic Solution and placebo subjects.  
A sample size of 5 per cohort (n = 4 ASP0598 Otic Solution, n = 1 placebo) is based on 
precedent set by other clinical studies of similar nature. The number of subjects and study 
procedures planned for this clinical study are considered reasonable to achieve the clinical 
study objectives.  
MAD 
Formal sample size calculations were not performed. MAD is not intended to show statistical 
difference between ASP0598 Otic Solution and placebo subjects.  
A sample size of 8 per cohort (n = 6 ASP0598 Otic Solution, n = 2 placebo) is based on 
precedent set by other clinical studies of similar nature. The number of subjects and study 
procedures planned for this clinical study are considered reasonable to achieve the clinical 
study objectives.   
Dose expansion 
Assuming the complete closure rate in placebo and ASP0598 higher concentration group are 
10% and 80% respectively, 11 subjects per treatment group will provide more than 90% 
power to detect a statistically significant difference at a 2-sided significance level of 0.05. 
Considering the drop-out rate of 10%, 13 subjects per treatment group will be enrolled 
(nQuery Advisor 7.0).   


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9.2 
Analysis Sets 
9.2.1 
Full Analysis Set 
The full analysis set (FAS) will consist of all randomized subjects who receive a dose of 
study drug and have baseline value and at least 1 post baseline complete closure assessment 
during study period. This will be the primary analysis set for efficacy analyses. 
In the analyses of FAS, subjects will be presented by randomized (planned) treatment group 
even if the treatment they received was different. 
9.2.2 
Safety Analysis Set 
SAD and single dose expansion 
The safety analysis set (SAF) consists of all randomized subjects who receive a dose of study 
drug. The SAF will be the primary analysis set for the safety data and pharmacokinetic data. 
In the analyses of SAF and pharmacokinetic data, subjects will be presented by actual 
treatment received. 
MAD and multiple dose expansion 
The SAF consists of all randomized subjects who receive a dose of study drug. The SAF will 
be the primary analysis set for the safety data and pharmacokinetic data. 
In the analyses of SAF, subjects will be presented by actual treatment received.  Actual 
treatment will be the same as planned treatment if the subject receives randomized treatment 
for the entire treatment duration.  Otherwise, actual treatment will be the treatment 
corresponding to the first treatment actually received. 
9.3 
Demographics and Baseline Characteristics  
9.3.1 
Demographics 
Demographics and baseline characteristics will be summarized for all randomized subjects, 
SAF and FAS by treatment group and ‘total’ over all treatment groups.  
9.3.2 
Subject Disposition  
The following subject data will be presented: 
● 
Number of subjects with informed consent, discontinued during the screening period and 
randomized for all subjects with informed consent (overall only), 
● 
Screening disposition for all subjects with informed consent (overall only), 
● 
Number and percentage of subjects who were randomized, were administered study 
drug, did not receive study drug administration, in the analysis sets by treatment group 
and ‘total’ over all treatment groups for all randomized subjects, 
● 
Treatment disposition for all randomized subjects, SAF and FAS by each treatment 
group and ‘total’ over all treatment groups, 
● 
Investigational period disposition for all randomized subjects, SAF and FAS by each 
treatment group and ‘total’ over all treatment groups, and 


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● 
Protocol version disposition for all subjects with informed consent by each treatment 
group and ‘total’ over all treatment groups for all randomized subjects, screen failures 
only and overall including screen failures. 
9.3.3 
Previous and Concomitant Treatment (Medication and Nonmedication 
Therapy)  
All previous and concomitant treatment will be listed. 
9.3.4 
Medical History  
Medical history is coded in Medical Dictionary for Regulatory Activities (MedDRA) and will 
be summarized for the SAF by system organ class (SOC) and preferred term (PT), by 
treatment group and ‘total’ over all treatment groups. 
9.3.5 
Investigational Product Exposure 
SAD and single dose expansion 
Actual dose of study drug will be summarized using descriptive statistics and entire planned 
volume of study drug administered (Yes, No), needle stick injury during study drug 
administration (Yes, No) and area of needle stick injury will be summarized using number 
and percentage of subjects for the SAF by treatment group. 
MAD and multiple dose expansion 
Actual total dose of study drug will be summarized using descriptive statistics, entire planned 
volume of study drug administered (Yes, No) and total number of doses administered (1, 2 
and 3), needle stick injury during study drug administration (Yes, No) and area of needle 
stick injury will be summarized using number and percentage of subjects for the SAF by 
treatment group. 
9.4 
Analysis of Efficacy  
Efficacy analysis will be conducted on the FAS.  
For continuous endpoints, descriptive statistics will be used to summarize baseline value, 
post baseline value and change from baseline at each specified post baseline analysis visit by 
treatment group. For categorical endpoints, number and percentage of subjects will be used to 
summarize baseline value and post baseline value at each specified post baseline analysis 
visit by treatment group. 
9.4.1 
Analysis of Primary Endpoint  
Not Applicable. 
9.4.2 
Analysis of Secondary Endpoints  
SAD and single dose expansion 
Categorical endpoint: 
● 
Complete closure of TMP at Week 8 for SAD and at Week 12 for dose expansion. 


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Observed response is defined as follows using the non-missing result: 
Yes: if a subject with complete closure of TMP, 
No: if the above condition is false. 
Continuous endpoints: 
● 
Change from baseline in the ratio of TMP size per total area of tympanic membrane at 
Week 8 for SAD and at Week 12 for dose expansion. 
● 
Change from baseline in TMP size at Week 8 for SAD and at Week 12 for dose 
expansion. 
MAD and multiple dose expansion 
Categorical endpoint: 
● 
Complete closure of TMP at Week 12 for MAD and at Week 16 for dose expansion. 
Observed response is defined as follows using the non-missing result: 
Yes: if a subject with complete closure of TMP, 
No: if the above condition is false. 
Continuous endpoints: 
● 
Change from baseline in the ratio of TMP size per total area of tympanic membrane at 
Week 12 for MAD and at Week 16 for dose expansion. 
● 
Change from baseline in TMP size at Week 12 for MAD and at Week 16 for dose 
expansion. 
9.4.2.1 Analysis 
SAD 
No statistical hypothesis testing will be performed. 
Single dose expansion 
● 
Subjects with complete closure of TMP at Week 12 
At week 12, to understand the relationship between complete closure of TMP and 
treatment group, Mantel–Haenszel (MH) test adjusting for baseline perforation size 
group will be used. Analysis will be performed using the data for the estimand (refer to 
Section 3.2 for details) and done separately for each ASP0598 treatment group vs 
placebo. 
From this analysis, the following results will be presented: 
○ Proportion of subjects with complete closure of TMP in each treatment group (each 
of ASP0598 treatment group and placebo)  
○ For the comparisons between each of the ASP0598 treatment group vs placebo, risk 
difference (ASP0598 – placebo), 2-sided p-value for overall general association 
between treatment group and response and 2-sided 95% stratified Newcombe CI 
computed using MH weights for the risk difference. If the CI cannot be obtained 
using Newcombe method then they will be presented using Sato method. 


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If the Mantel and Fleiss criterion (across-strata sum of expected values for a particular cell 
has a difference of at least 5 from both the minimum possible sum and the maximum possible 
sum of the observed values) is not satisfied, the above analysis will be performed with no 
stratification factor and exact p-value using Fisher exact method and CI using Clopper-
Pearson method will be presented. 
Based on the interim analysis results, if 3 treatment groups are selected for the dose 
expansion, hierarchical testing method will be used to control familywise error rate where the 
highest dose group vs placebo will be tested first at a 2-sided significance level of 0.05 and if 
the null hypothesis is rejected, low dose group vs placebo will be tested at a 2-sided 
significance level of 0.05. 
● 
Change from baseline in the ratio of TMP size per total area of tympanic membrane at 
Week 12. 
● 
Change from baseline in TMP size at Week 12. 
For the change from baseline in TMP size at Week 12, a mixed models repeated measures 
(MMRM) will be used with treatment group and week (Week 2, 4, 8 and 12) as factors, 
baseline TMP measurement as a covariate, as well as an interaction of treatment by week and 
an interaction of baseline TMP measurement by week. For the change from baseline in the 
ratio of TMP size per total area of tympanic membrane at Week 12, the MMRM model will 
contain treatment group and week as factors, baseline ratio of TMP size per total area of 
tympanic membrane as a covariate, as well as an interaction of treatment by week and an 
interaction of baseline ratio of TMP size per total area of tympanic membrane by week. The 
model will assume unstructured covariance among the within subject repeated measurements. 
If this is not feasible, an additional covariance structure will be considered.  Analysis will be 
performed using the data for the estimand (refer to Section 3.2 for details).  From this 
analysis, the following results will be presented: 
○ Least square (LS) mean estimate, standard error (SE), and 2-sided 95% CI for 
change from baseline to each treatment week within a treatment group (placebo and 
each ASP0598 treatment group) 
○ For comparisons between each of the ASP0598 treatment group vs placebo: 
▪ Difference in LS mean estimates (ASP0598 – placebo), SE and 
corresponding 2-sided 95% CI for the change from baseline at each week.  
▪ The differences in the LS mean estimates will be used to obtain 2-sided p-
value for the difference. 
No multiplicity adjustment will be applied for the above change from baseline secondary 
endpoints.  
MAD 
No statistical hypothesis testing will be performed. 
Multiple dose expansion 
● 
Subjects with complete closure of TMP at Week 16 


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At week 16, to understand the relationship between complete closure of TMP and 
treatment group, MH test adjusting for baseline perforation size group will be used. 
Refer to Single dose expansion endpoint Patients with complete closure of TMP at Week 
12 for details. 
● 
Change from baseline in the ratio of TMP size per total area of tympanic membrane at 
Week 16. 
● 
Change from baseline in TMP size at Week 16. 
For the change from baseline in TMP size at Week 16, a MMRM will be used with 
treatment group and week (Week 2, 4, 6, 8, 12, and 16) as factors, baseline TMP 
measurement as a covariate, as well as an interaction of treatment by week and an 
interaction of baseline TMP measurement by week. For the change from baseline in the 
ratio of TMP size per total area of tympanic membrane at Week 16, the MMRM model 
will contain treatment group and week as factors, baseline ratio of TMP size per total area 
of tympanic membrane as a covariate, as well as an interaction of treatment by week and 
an interaction of baseline ratio of TMP size per total area of tympanic membrane by 
week. Refer to Single dose expansion endpoint change from baseline in TMP size at 
Week 12 for details.  
No multiplicity adjustment will be applied for the above change from baseline secondary 
endpoints. 
9.4.2.2 Sensitivity Analysis 
Sensitivity Analysis will be described in the SAP. 
9.4.2.3 Subgroup Analysis 
SAD 
No subgroup analysis is planned. 
MAD 
No subgroup analysis is planned. 
Dose expansion 
Subgroup summary of proportion of subjects with complete closure of TMP at week 12 for 
single dose expansion and week 16 for multiple dose expansion will be performed on the 
following subgroups: sex, race, age group (≤ 60 years and > 60 years), BMI group 
(≤ 30 kg/m2 and >30 kg/m2), baseline disease duration (≤ 1 year, > 1 year to ≤ 10 years and 
>10 years), smoking status, causation of TMP and stratification factor TMP size group.  The 
SAP will provide more details on subgroup analyses.  
9.4.3 
Analysis of Exploratory Endpoints  
SAD and single dose expansion 
Categorical endpoints: 


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● 
Complete closure of TMP for post baseline visits at Day 2, Day 3 (evaluations at this 
visit will only be performed for cohorts 1, 2 and 3), Week 1, Week 2, and Week 4 for 
SAD and Week 2, Week 4, and Week 8, for dose expansion.  
For observed response definition, refer to Section 9.4.2. 
● 
Size of TMP ≤ 5% of pars tensa surface area after treatment. 
Observed response is defined as follows using the non-missing result: 
Yes: if the post-baseline size of the TMP per pars tensa surface area ≤ 5% and the size of 
the TMP per pars tensa surface area is smaller than baseline 
No: if the above condition is false 
● 
Size of TMP ≤ 1% of pars tensa surface area (pin point perforation) after treatment. 
Observed response is defined as follows using the non-missing result: 
Yes: if the post-baseline size of the TMP per pars tensa surface area ≤ 1% and the size of 
the TMP per pars tensa surface area is smaller than baseline 
No: if the above condition is false 
● 
Percentage improvement from baseline in A-B gap by PTA ≥ 50% (improvement of 
conductive hearing). 
For A-B gap, decrease (reduction) from baseline indicates an improvement.  
Observed response is defined as follows using the non-missing result: 
Yes: if the percentage change from baseline in mean A-B gap (derived using mean of the 
A-B gap results at 500 Hz, 1, 2 and 4 kHz) ≤ -50% 
No: if the above condition is false 
● 
Improvement from baseline in air conduction hearing by PTA ≥ 15 dB. 
For air conduction hearing, decrease (reduction) from baseline indicates an 
improvement.  
Observed response is defined as follows using the non-missing result: 
Yes: if the change from baseline in mean air conduction hearing by PTA (derived using 
mean of the results at 500 Hz, 1, 2 and 4 kHz) ≤ -15 dB 
No: if the above condition is false 
● 
A-B gap after treatment was 15 dB or less. 
Observed response is defined as follows using the non-missing result:  
Yes: if the post baseline result in the mean A-B gap (derived using mean of A-B gap 
results at 500 Hz, 1, 2 and 4 kHz) ≤ 15 dB 
No: if the above condition is false 
● 
Air conduction hearing threshold after treatment was 30 dB or less. 
Observed response is defined as follows using the non-missing result:  
Yes: if the post baseline result in mean air conduction hearing threshold by PTA 
(derived using mean of results at 500 Hz, 1, 2 and 4 kHz) ≤ 30 dB 


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No: if the above condition is false 
● 
Type of tympanogram (A, B or C). 
For Type A, there are 2 additional subcategories: Ad and As. 
Continuous endpoints: 
● 
Change from baseline in the ratio of TMP size per total area of tympanic membrane for 
post baseline visits at Day 2, Day 3 (evaluations at this visit will only be performed for 
cohorts 1, 2 and 3), Week 1, Week 2, and Week 4 for SAD and Week 2, Week 4, and 
Week 8 for dose expansion  
● 
Change from baseline in TMP size for post baseline visits at Day 2, Day 3 (evaluations 
at this visit will only be performed for cohorts 1, 2 and 3), Week 1, Week 2, and Week 4 
for SAD and Week 2, Week 4, and Week 8 for dose expansion  
The above change from baseline in dose expansion endpoints will be analyzed using the 
MMRM model as described in Section 9.4.2. 
● 
Time to closure of TMP 
● 
Change from baseline in A-B gap by PTA 
● 
Change from baseline in air conduction hearing by PTA 
● 
ECV by tympanometry  
For the exploratory endpoints excluding the above change from baseline in dose expansion 
endpoints, no statistical analysis will be performed. 
MAD and multiple dose expansion 
Categorical endpoints: 
● 
Complete closure of TMP for post baseline visits at Week 1, Week 2, Week 3, Week 4, 
Week 5, and Week 8 for MAD and Week 2, Week 4, Week 6, Week 8, and Week 12 for 
dose expansion  
For observed response definition, refer to Section 9.4.2 
● 
Reduction from baseline in size of TMP to less than or equal to 5% of pars tensa surface 
area  
● 
Reduction from baseline in size of TMP to less than or equal to 1% of pars tensa surface 
area (pin point perforation) 
● 
Percentage improvement from baseline in A-B gap by PTA ≥ 50% (improvement of 
conductive hearing) 
● 
Improvement from baseline in air conduction hearing by PTA ≥ 15 dB 
● 
A-B gap after treatment was 15 dB or less 
● 
Air conduction hearing threshold after treatment was 30 dB or less 
● 
Type of tympanogram (A, B or C) 
For Type A, there are 2 additional subcategories: Ad and As. 


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Continuous endpoints: 
● 
Change from baseline in the ratio of TMP size per total area of tympanic membrane for 
post baseline visits at Week 1, Week 2, Week 3, Week 4, Week 5 and Week 8 for MAD 
and Week 2, Week 4, Week 6, Week 8, and Week 12 for dose expansion  
● 
Change from baseline in TMP size for post baseline visits at Week 1, Week 2, Week 3, 
Week 4, Week 5 and Week 8 for MAD and Week 2, Week 4, Week 6, Week 8, and 
Week 12 for dose expansion  
The above change from baseline dose expansion endpoints will be analyzed using the 
MMRM model as described in Section 9.4.2. 
● 
Time to closure of TMP 
● 
Change from baseline in A-B gap by PTA 
● 
Change from baseline in air conduction hearing by PTA 
● 
ECV by tympanometry  
For the exploratory endpoints excluding the above change from baseline dose expansion 
endpoints, no statistical analysis will be performed. 
9.5 
Analysis of Safety 
Safety analysis will be conducted using the SAF, unless otherwise specified.  
The primary endpoints to evaluate the safety and tolerability of ASP0598 Otic Solution are 
shown below: 
● 
TEAEs 
● 
Incidence of AEs of special interest:  
1. Cholesteatoma or ear neoplasm  
2. Ototoxic symptoms (tinnitus, sensorineural hearing loss, dizziness) 
3. Otitis media or otitis externa 
● 
Change from baseline in bone conduction hearing at 1, 2, 4 kHz by PTA 
● 
Change from baseline in TVAS 
No statistical hypothesis testing will be performed.  
Continuous data will be summarized using descriptive statistics and categorical data will be 
summarized using number and percentage of subjects. 
9.5.1 
Adverse Events  
AEs will be coded using MedDRA.   
A TEAE is defined as an AE observed after starting administration of the study drug through 
EOS visit.  A drug-related TEAE is defined as any TEAE with a causal relationship assessed 
as “yes” by the investigator. 
An overview of TEAEs and Death by treatment group will be presented. In addition, the 
following summaries will be presented by SOC and PT: 


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● 
TEAEs by treatment group 
● 
Drug-related TEAEs by treatment group 
● 
Serious TEAEs by treatment group 
● 
Drug-related serious TEAEs by treatment group 
An overview of TEAEs of special interest by treatment group will be presented. The 
following summaries will be presented by SOC and PT:  
● 
TEAEs of special interest by treatment group 
● 
Serious TEAEs of special interest by treatment group 
Details about selection of AEs of special interest will be provided in the SAP.  
9.5.2 
Bone conduction hearing at 1, 2, 4 kHz by PTA and TVAS  
For the mean bone conduction hearing and TVAS, descriptive statistics will be used to 
summarize baseline value, post baseline value and change from baseline at each specified 
post baseline analysis visit by treatment group. For the mean bone conduction hearing by 
PTA, the summaries will also present the number and percentage of subjects with an increase 
of ≥ 10 to 20, ≥ 20 to 30, ≥ 30 to 40, and ≥ 40 dB from baseline at each post baseline analysis 
visit.  
9.5.3 
Concentration-response Relationship Analysis  
Not Applicable 
9.5.4 
Microscopic Ear Examination  
Parameters and categories will be described in the SAP. 
For categorical endpoints, number and percentage of subjects will be used to summarize 
baseline value and post baseline value at each specified post baseline analysis visit by 
treatment group.  
9.6 
Analysis of Pharmacokinetics 
Descriptive statistics will include n, mean, SD, minimum, median, maximum, coefficient of 
variation (CV), geometric mean, and geometric CV. 
Descriptive statistics will be used to summarize baseline value, post baseline value, and 
change from baseline at each post-baseline timepoint for serum concentrations of ASP0598 
by treatment group including placebo using the SAF. 
9.7 
Analysis of Immunogenicity 
Not Applicable. 
9.8 
Other Analyses 
Not Applicable. 
9.8.1 
Analysis of Exploratory Biomarker(s)  
Not Applicable. 


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9.9 
Major Protocol Deviations  
Major PDs as defined in [Section 10.3 Major Protocol Deviations] will be summarized for all 
randomized subjects by treatment group and overall, as well as by study site. 
Major PD data will be listed by study site and subject. 
The major PD criteria will be uniquely identified in the summary table and listing. 
9.10 
Interim Analysis (and Early Discontinuation of the Study) 
SAD Interim Analysis  
The decision to open single dose expansion will be made based on the safety and efficacy 
results of the interim analysis. One interim analysis is planned during SAD and will be 
conducted after completion of last cohort of the SAD. The DMC will review the data and 
make the final decision to open single dose expansion. Two different ASP0598 treatment 
groups and placebo or one ASP0598 treatment group and placebo will be selected to open 
single dose expansion. All analyses will be described in the IAP. 
MAD Interim Analysis 
The decision to open multiple dose expansion will be made based on the safety and efficacy 
results of the interim analysis. One interim analysis is planned during MAD and will be 
conducted after completion of last cohort of MAD. The DMC will review the data and make 
the final decision to open multiple dose expansion. Two different ASP0598 treatment groups 
and placebo or one ASP0598 treatment group and placebo will be selected to open multiple 
dose expansion. All analyses will be described in an IAP.  
9.11 
Additional Conventions 
If the start and stop dates of AEs and concomitant medications are incomplete or onset date of 
TMP is incomplete, imputed dates will be used to determine whether an AE is/is not treatment 
emergent or to allocate a concomitant medication to the study period it was taken or to 
calculate time since TMP onset.  
See the SAP for details of the definition for analysis windows to be used for analyses by visit. 
Relevant listings will present the actual partial dates; imputed dates will not be shown. 
10 
OPERATIONAL CONSIDERATIONS 
10.1 
Data Collection 
The investigator or site designee will enter data collected using an electronic data capture 
system. In the interest of collecting data in the most efficient manner, the investigator or 
designee should record data (including clinical laboratory values, if applicable) in the eCRF 
within 5 days after the subject’s visit. For SAD and MAD, the investigator or site designee 
must enter data collected into the RAVE data management system within 24 hours after the 
completion of the Screening, Day 1, Day 8 and Day 15 visits. 


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The investigator or site designee is responsible to ensure that all data in the eCRFs and 
queries are accurate and complete and that all entries are verifiable with the source. These 
documents should be appropriately maintained by the study site. 
The monitor should verify the data in the eCRFs with the source and confirm that there are 
no inconsistencies among them. 
Clinical laboratory tests are performed at the local laboratory. Clinical laboratory results will 
be documented in the subject’s source records.  All PK samples and additional samples 
collected for future analysis will be shipped to the central laboratory for storage and shipping 
to the laboratory responsible for analyzing the samples.  PK data will be transferred 
electronically to the sponsor or designee at predefined intervals during the study.  
All procedures conducted under the protocol must be documented.  
The investigator or designee is responsible for eCRF and source data completion and will 
ensure that all data and queries are accurate, complete and are verifiable with the source. The 
source should be appropriately maintained by the study site. 
Electronic data sources and any supporting documents should be available for 
review/retrieval by the sponsor/designee at any time. 
10.2 
Demographics and Baseline Characteristics 
10.2.1 Demographics 
Demographic information will be collected for all subjects at Screening and will include age 
or date of birth, sex, race, and ethnicity (as allowed by local regulation). 
10.2.2 Medical History 
Medical history will include all significant medical conditions that have occurred or are 
ongoing at the time of consent.  Details that will be collected include the onset date and 
recovery date for condition that are ongoing at the time of consent. 
10.2.3 Diagnosis of the Target Disease, Severity and Duration of Disease  
A complete medical history of the target disease will be recorded during the screening period 
and entered into the eCRF.  
10.3 
Major Protocol Deviations 
A PD is generally an unplanned excursion from the protocol that is not implemented or 
intended as a systematic change. All deviations from the protocol are to be recorded. A 
protocol waiver is a documented prospective approval of a request from an investigator to 
deviate from the protocol. Protocol waivers are strictly prohibited. 
The investigator is responsible for ensuring the study is conducted in accordance with the 
procedures and evaluations described in this protocol and must protect the rights, safety and 
well-being of subjects. The investigator should not implement any deviation from, or changes 
of, the protocol, unless it is necessary to eliminate an immediate hazard to subjects.  


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A major PD is 1 that may potentially impact the completeness, accuracy or reliability of data 
contributing to the primary endpoint or affect the rights, safety or well-being of a subject. 
Major PDs will have additional reporting requirements. 
When a major deviation from the protocol is identified for an individual subject, the 
investigator or designee must ensure the sponsor is notified. The sponsor will follow up with 
the investigator, as applicable, to assess the deviation and the possible impact to the safety 
and/or efficacy of the subject to determine subject continuation in the study.  
The major PD criteria that will be summarized at the end of the study are as follows: 
PD1 - Entered into the study even though the subject did not satisfy entry criteria  
PD2 - Developed withdrawal criteria during the study and was not withdrawn 
PD3 - Received wrong treatment or incorrect dose 
PD4 - Received excluded concomitant treatment 
The investigator will also assure that deviations meeting IRB/IEC and appropriate regulatory 
authorities’ criteria are documented and communicated appropriately. All documentation and 
communications to the IRB/IEC and appropriate regulatory authorities will be provided to the 
sponsor and maintained within the Trial Master File (TMF).   
10.4 
STUDY ORGANIZATION 
10.4.1 Dose Escalation Committee 
For SAD and MAD, the Dose Escalation Committee (DEC) is responsible for dose escalation 
decisions.  The DEC will consist of Astellas team members and an advisor.  For detailed 
information on the dose escalation decision process, refer to Section 4.1.1 Decision Process 
for Dose Escalation, Dose Escalation Stopping Rules and Definition of the Maximum 
Tolerated Dose.  A separate DEC Charter will be maintained detailing the membership, roles, 
and responsibilities of the DEC. 
10.4.2 Data Monitoring Committee  
The Data Monitoring Committee is an Astellas internal committee consisting of Astellas 
team members and an advisor.  It is not independent and is responsible for the interim 
evaluation of the safety and efficacy data to open the single and multiple dose expansion 
cohorts.  For detailed information on the dose expansion process, refer to Section 4.2 
Decision Process for Dose Expansion.  A separate DMC Charter will be maintained detailing 
the operation, roles, and responsibilities of the DMC.  


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11 
REFERENCES  
Aggarwal R, Saeed SR, Green KJ. Myringoplasty. J Laryngol Otol. 2006;120:429-32. 
Lindisfarne ME, Berwick J, Das P. Clinical Review: Acute Otitis Externa. Available from: 
https://www.gponline.com.   
Santa Maria PL, Redmond SL, Atlas MD, Ghassemifar R. Histology of the healing tympanic 
membrane following perforation in rats. Laryngoscope. 2010a;120:2061-70. 
Santa Maria PL, Redmond SL, Atlas MD, Ghassemifar R. The role of epidermal growth factor in the 
healing tympanic membrane following perforation in rats. J Mol Hist. 2010b;41:309-14. 
Santa Maria PL, Kim S, Varsak YK, Yang YP. Heparin binding - epidermal growth factor - like 
growth factor for regeneration of chronic tympanic membrane perforations in mice. Tissue Eng 
Part A. 2015a;21:1483-94. 
Seonwoo H, Kim SW, Kim J, Chunjie T, et al. Regeneration of chronic tympanic membrane 
perforation using an EGF-releasing chitosan patch. Tissue Eng Part A. 2013;19:2097-107. 
Tokumaru S, Higashiyama S, Endo T, Nakagawa T, Miyagawa JI, Yamamori K et al. Ectodomain 
shedding of epidermal growth factor receptor ligands is required for keratinocyte migration in 
cutaneous wound healing. J Cell Biol. 2000;151:209-20. 


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12 
APPENDICES 
12.1 
Ethical, Regulatory and Study Oversight Considerations 
12.1.1 Ethical Conduct of the Study 
The study will be conducted in accordance with the protocol, ICH guidelines, applicable 
regulations and guidelines governing study conduct and the ethical principles that have their 
origin in the Declaration of Helsinki.  
12.1.2 Institutional Review Board/Independent Ethics Committee/Competent 
Authorities 
GCP requires that the protocol, any protocol amendments, investigator’s brochure, ICF and 
all other forms of subject information related to the study (e.g., advertisements used to recruit 
subjects) and any other necessary documents be reviewed by an IRB/IEC. The IRB/IEC will 
review the ethical, scientific and medical appropriateness of the study before it is conducted. 
IRB/IEC approval of the protocol, ICF and subject information and/or advertising, as 
relevant, will be obtained prior to initiation of any study-specific procedures. 
Any substantial amendments to the protocol will require competent authority and IRB/IEC 
approval before implementation, except for changes necessary to eliminate an immediate 
hazard to subjects. 
The investigator will be responsible for the following: 
● 
Providing written summaries of the status of the study to the IRB/IEC annually or more 
frequently in accordance with the requirements, policies and procedures established by 
the IRB/IEC. 
● 
Notifying the IRB/IEC of SAEs or other significant safety findings as required by 
IRB/IEC procedures. 
● 
Providing oversight of the conduct of the study at the study site and adherence to 
requirements of 21 CFR, ICH guidelines, the IRB/IEC, EU Regulation No. 536/2014 for 
studies (if applicable), and all other applicable local regulations. 
12.1.3 Protocol Amendment and/or Revision 
Any changes to the study that arise after approval of the protocol must be documented as 
protocol amendments: substantial amendments and/or nonsubstantial amendments. 
Depending on the nature of the amendment, either IRB/IEC or competent authority approval 
or notification may be required. The changes will become effective only after the approval of 
the sponsor, investigator, IRB/IEC and appropriate regulatory authorities. 
Amendments to this protocol must be signed by the sponsor and investigator. Written 
verification of IRB/IEC approval will be obtained before any amendment is implemented. 
Modifications to the protocol that are administrative in nature do not require IRB/IEC 
approval, but will be submitted to the IRB/IEC for their information, if required by local 
regulations. 


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If there are changes to the ICF, written verification of IRB/IEC approval must be forwarded 
to the sponsor. An approved copy of the new ICF must also be forwarded to the sponsor. 
12.1.4 Financial Disclosure   
Investigators and sub-investigators will provide the sponsor with sufficient, accurate financial 
information as requested to allow the sponsor to submit complete and accurate financial 
certification or disclosure statements to the appropriate regulatory authorities. Investigators 
are responsible for providing information on financial interests during the course of the study 
and for 1 year after completion of the study. 
12.1.5 Informed Consent of Subjects 
12.1.5.1 Subject Information and Consent 
The investigator or his/her representative will explain the nature of the study to the subject 
and answer all questions regarding this study. Prior to any study-related screening procedures 
being performed on the subject, the ICF will be reviewed, signed and dated by the subject, 
the person who administered the ICF and any other signatories according to local 
requirements. A copy of the signed ICF will be given to the subject and the original will be 
placed in the subject’s medical record. An entry must also be made in the subject’s dated 
source documents to confirm that the ICF was signed prior to any study-related procedures 
and that the subject received a signed copy of the ICF. 
The signed ICFs will be retained by the investigator and made available (for review only) to 
the study monitor, auditor and appropriate regulatory authorities and other applicable 
individuals upon request.  
12.1.5.2 Supply of New and Important Information Influencing the Subject’s Consent 
and Revision of the Written Information 
1. The investigator or his/her representative will immediately inform the subject verbally 
whenever new information becomes available that may be relevant to the subject’s 
consent or may influence the subject’s willingness to continue participating in the study 
(e.g., report of serious adverse drug reaction). The communication must be documented 
in the subject’s medical records and whether the subject is willing to remain in the study 
or not must be confirmed and documented.  
2. The investigator must update the subject’s ICF and submit it for approval to the 
IRB/IEC. The investigator or his/her representative must obtain written informed consent 
from the subject on all updated ICFs throughout their participation in the study. The 
investigator or his/her designee must reconsent subjects with the updated ICF even if 
relevant information was provided verbally. The investigator or his/her representative 
who obtained the written informed consent and the subject should sign and date the ICF.  
A copy of the signed ICF will be given to the subject and the original will be placed in 
the subject’s medical record. An entry must be made in the subject’s records 
documenting the reconsent process.  


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12.1.6 Source Documents 
Source data must be available at the study site to document the existence of the subjects and 
to substantiate the integrity of study data collected. Source data must include the original 
documents relating to the study, as well as the medical treatment and medical history of the 
subject.   
The investigator is responsible for ensuring the source data are attributable, legible, 
contemporaneous, original, accurate and complete whether the data are handwritten on paper 
or entered electronically. If source data are created (first entered), modified, maintained, 
achieved, retrieved or transmitted electronically via computerized systems (and/or other kind 
of electronic devices) as part of regulated study activities, such systems must be compliant 
with all applicable laws and regulations governing use of electronic records and/or electronic 
signatures. Such systems may include, but are not limited to, electronic medical/health 
records, protocol-related assessments, AE tracking, electronic clinical outcome assessments 
and/or drug accountability.  
Paper records from electronic systems used in place of electronic format must be certified 
copies. A certified copy must be an exact copy and must have all the same attributes and 
information as the original. Certified copies must include signature and date of the individual 
completing the certification. Certified copies must be a complete and chronological set of 
study records (including notes, attachments, and audit trail information, if applicable). All 
printed records must be kept in the subject file and be available for archiving.  
12.1.7 Record Retention 
The investigator will archive all study data (e.g., subject identification code list, source data 
eCRFs and investigator's file) and relevant correspondence. These documents are to be kept 
on file for the appropriate term determined by local regulation (for US study sites, 2 years 
after approval of the NDA or discontinuation of the IND).  The investigator agrees to obtain 
the sponsor's agreement prior to disposal, moving or transferring of any study-related records. 
The sponsor will archive and retain all documents pertaining to the study according to local 
regulations. 
Data generated by the methods described in the protocol will be recorded in the subject’s 
medical records and/or study progress notes. 
12.1.8 Subject Confidentiality and Privacy 
Individual subject medical information obtained as a result of this study is considered 
confidential and disclosure to third parties is prohibited unless the subject provides written 
consent or approval. Additional medical information may be given only after approval of the 
subject to the investigator or to other appropriate medical personnel responsible for the 
subject's well-being. 
The sponsor shall not disclose any confidential information on subjects obtained during the 
performance of their duties in the study without justifiable reasons. 


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Even though any individuals involved in the study, including the study monitors and auditors, 
may get to know matters related to a subject’s privacy due to direct access to source 
documents, or from other sources, they may not disclose the content to third parties.  
The sponsor affirms the subject's right to protection against invasion of privacy. Only a 
subject identification number will identify subject data retrieved by the sponsor. However, 
the sponsor requires the investigator to permit the sponsor, sponsor's representative(s), the 
IRB/IEC and when necessary, representatives of the regulatory health authorities to review 
and/or to copy any medical records relevant to the study. 
The sponsor agrees to comply and process personal data in accordance with all applicable 
privacy laws and regulations, including, without limitation, the Personal Information 
Protection Law in Japan and privacy laws in the US. If the services will involve the 
collection or processing of personal data (as defined by applicable data protection legislation) 
within the European Economic Area (EEA), then the sponsor shall serve as the controller of 
such data, as defined by the EU Data Protection Directive (DPD), and investigator and/or 
third party shall act only under the instructions of the sponsor in regard to personal data. If 
the sponsor is not based in the EEA, the sponsor must appoint a third party to act as its local 
data protection representative or arrange for a co-controller established in the EU for data 
protection purposes in order to comply with the DPD. 
12.1.9 Arrangement for Use of Information and Publication of the Study 
Information concerning the test product, patent applications, processes, unpublished scientific 
data, the investigator’s brochure and other pertinent information is confidential and remains 
the property of the sponsor. Details should be disclosed only to the persons involved in the 
approval or conduct of the study. The investigator may use this information for the purpose 
of the study only. It is understood by the investigator that the sponsor will use the 
information obtained during the study in connection with the development of the drug and 
therefore may disclose it as required to other clinical investigators or to regulatory agencies. 
In order to allow for the use of the information derived from this study, the investigator 
understands that he/she has an obligation to provide the sponsor with all data obtained during 
the study. 
Publication of the study results is discussed in the study agreement. 
12.1.10 Signatory Investigator for Clinical Study Report 
ICH E3 guidelines recommend and EU Directive 2001/83/EC requires that a final CSR that 
forms part of a marketing authorization application, be signed by the representative for the 
coordinating investigator(s) or the principal investigator(s). The representative for the 
coordinating investigator(s) or the principal investigator(s) will have the responsibility to 
review the final study results to confirm to the best of his/her knowledge it accurately 
describes the conduct and results of the study. The representative for the coordinating 
investigator(s) or the principal investigator(s) will be selected from the participating 
investigators by the sponsor prior to database hard-lock. 


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12.2 
Procedure for Study Quality Control 
12.2.1 Study Monitoring 
The sponsor or delegated CRO is responsible for monitoring the study to ensure that the 
rights, safety and well-being of subjects are protected, the study is properly conducted in 
adherence to the current protocol and GCP and the study data reported by the 
investigator/sub-investigator are accurate, complete and verifiable with the source. The 
sponsor is responsible for assigning the study monitor(s) to this study for proper monitoring. 
They will monitor the study in accordance with planned monitoring procedures.   
12.2.2 Direct Access to Source Data/Documents 
The investigator and the study site must accept monitoring and auditing by the sponsor or 
delegated CRO, as well as inspections from the IRB/IEC and appropriate regulatory 
authorities. In these instances, they must provide all study-related records including source 
documents when they are requested by the sponsor monitors and auditors, the CRO, the 
IRB/IEC or appropriate regulatory authorities. The confidentiality of the subject’s identity 
shall be well protected consistent with local and national regulations when the source 
documents are subject to direct access. 
12.2.3 Data Management 
Data management will be coordinated by the Data Science department or designee of the 
sponsor in accordance with the SOPs for data management. All study-specific processes and 
definitions will be documented by data management. eCRF completion will be described in 
the eCRF instructions. Coding of medical terms and medications will be performed using 
MedDRA and the WHO Drug Dictionary, respectively.  
12.2.4 Quality Assurance 
The sponsor is implementing and maintaining quality assurance (QA) and quality control 
(QC) systems with written SOPs to ensure that studies are conducted and data are generated, 
documented, recorded, and reported in compliance with the protocol, GCP and applicable 
regulatory requirement(s). Where applicable, the QA and QC systems and written SOPs of 
the CRO will be applied. 
The sponsor or sponsor’s designee may arrange to audit the study at any or all study sites and 
facilities. The audit may include on-site review of regulatory documents, CRFs and source 
documents. Direct access to these documents will be required by the auditors. 
To support quality around subject safety and reliability of study results, quality tolerance 
limits (QTLs) are defined and monitored. QTLs represent the acceptable variation of study 
data, taking into consideration the current state of medical and statistical knowledge about the 
variables to be analyzed as well as the statistical design of the study. It is a level, point, or 
value associated with a parameter that should trigger an evaluation if a deviation is detected 
to determine if there is a possible systematic issue (i.e., a trend has occurred). The QTLs 
defined for this study are provided below. 


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Table 8 
Quality Tolerance Limit 
QTL #: Name and Parameter 
Definition 
Parameter Justification 
TMP Imaging Compliance 
Number of randomized subjects that have 
received study drug who do not have an 
acceptable TMP image at specific study visits. 
Missing images can have 
a negative impact on key 
secondary endpoints 
QLT: quality tolerance limit; TMP: tympanic membrane perforation 
 
QTL Management Activities: 
Not Applicable.  


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12.3 
Contraception Requirements 
WOCBP who are eligible for participation in the study, including those who choose complete 
abstinence, must have pregnancy tests as specified in the schedule of assessments. Pregnancy 
test results must confirm that the subject is not pregnant. 
WOMEN OF CHILDBEARING POTENTIAL DEFINITIONS AND METHODS OF 
CONTRACEPTION DEFINITIONS 
A female is considered fertile (i.e., WOCBP) following menarche and until becoming 
postmenopausal unless permanently sterile.  
Females in the following categories are not considered WOCBP 
● 
Premenarchal 
● 
Premenopausal with 1 of the following (i.e., permanently sterile): 
○ Documented hysterectomy 
○ Documented bilateral salpingectomy 
○ Documented bilateral oophorectomy 
● 
Postmenopausal 
A postmenopausal state is defined as at least 12 months after last menstrual bleeding without 
an alternative medical cause.  
In case the last menstrual bleeding cannot be clearly determined, confirmation with more 
than 1 follicle-stimulating hormone (FSH) measurement of at least > 40 IU/L (or higher per 
local institutional guidelines) is required.  
Females on hormone replacement therapy (HRT) and whose menopausal status is in doubt 
will be required to use 1 of the nonestrogen hormonal highly effective contraception methods 
if they wish to continue their HRT during the study. Otherwise, they must discontinue HRT 
to allow confirmation of postmenopausal status by repeated FSH measurements before study 
enrollment. 
Documentation of any of these categories can come from the study site personnel’s review of 
the female subject’s medical records, medical examination or medical history interview. 
CONTRACEPTION GUIDANCE FOR FEMALE SUBJECTS OF CHILDBEARING 
POTENTIAL 
Female subjects of childbearing potential are eligible for participation in the study if they 
agree to use 1 of the highly effective methods of contraception listed below from the time of 
signing the ICF and until the end of relevant systemic exposure, defined as 28 days after the 
IP application.a 
Highly effective methods of contraception (failure rate of < 1% per year when used 
consistently and correctly)b: 
● 
Combined (estrogen- and progestogen-containing) hormonal contraception associated 
with inhibition of ovulation 


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○ Oral 
○ Intravaginal 
○ Transdermal 
● 
Progestogen-only hormonal contraception associated with inhibition of ovulation 
○ Oral 
○ Injectable 
○ Implantable 
● 
Other combined (estrogen- and progesterone-containing) methods 
○ Vaginal ring 
○ Injectable 
○ Implantable 
○ Intrauterine hormone-releasing system or intrauterine device 
● 
Other combined methods 
● 
Vasectomized partner 
A vasectomized partner is a highly effective contraception method provided that the 
partner is the sole male sexual partner of the WOCBP and the absence of sperm has been 
confirmed. If not, an additional highly effective method of contraception should be used. 
● 
Sexual abstinence 
Sexual abstinence is considered a highly effective method only if defined as refraining 
from heterosexual intercourse during the entire period of risk associated with the test 
product. The reliability of sexual abstinence needs to be evaluated in relation to the 
duration of the study and the preferred and usual lifestyle of the subject. It is not 
necessary to use any other method of contraception when complete abstinence is elected. 
a Local laws and regulations may require use of alternative and/or additional contraception methods. 
b Typical use failure rates may differ from those when used consistently and correctly. Use should be consistent 
with local regulations regarding the use of contraceptive methods for subjects participating in clinical studies. 
CONTRACEPTION GUIDANCE FOR MALE SUBJECTS WITH PARTNER(S) OF 
CHILDBEARING POTENTIAL. 
Male subjects with female partners of childbearing potential are eligible for participation in 
the study if they agree to the following during treatment and until the end of relevant 
systemic exposure defined as 28 days after IP application.a 
● 
Inform any and all partner(s) of their participation in a clinical drug study and the need to 
comply with contraception instructions as directed by the investigator 
● 
Use a condom 
● 
Female partners of male subjects who have not undergone a vasectomy with the absence 
of sperm confirmed or a bilateral orchiectomy should consider use of effective methods 
of contraception 
a Local laws and regulations may require use of alternative and/or additional contraception methods. 


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12.4 
Adverse Events: Definitions and Procedures for Recording, 
Evaluating, Follow-up and Reporting 
12.4.1 Definition of Adverse Events 
An AE is any untoward medical occurrence in a subject administered an IP, and which does 
not necessarily have to have a causal relationship with this treatment. An AE can therefore be 
any unfavorable and unintended sign (including an abnormal laboratory finding), symptom, 
or disease (new or exacerbated) temporally associated with the use of IP whether or not 
considered related to the IP. 
12.4.1.1 Abnormal Laboratory Findings 
Any abnormal laboratory test result (e.g., hematology, biochemistry or urinalysis) or other 
safety assessment (e.g., vital signs, physical examination, ECGs or radiographic scans), 
including those that worsen from baseline, that is considered to be clinically significant in the 
medical and scientific judgment of the investigator and not related to underlying disease, is to 
be reported as an (S)AE. 
Any clinically significant abnormal laboratory finding or other abnormal safety assessment, 
which is associated with the underlying disease, does not require reporting as an (S)AE, 
unless judged by the investigator to be more severe than expected for the subject’s condition. 
Repeating an abnormal laboratory test or other safety assessment, in the absence of any of the 
above criteria, does not constitute an AE. Any abnormal test result that is determined to be an 
error does not require reporting as an AE.  
12.4.1.2 Potential Cases of Drug-induced Liver Injury 
This is a single and multiple dose administration and liver safety monitoring will be applied 
if any AEs occur that prompt safety consideration.  
Refer to [Appendix 12.5 Liver Safety Monitoring and Assessment] for detailed instructions 
on drug induced liver injury. Abnormal values in AST and/or ALT concurrent or with 
abnormal elevations in TBL that meet the criteria outlined in [Appendix 12.5 Liver Safety 
Monitoring and Assessment], in the absence of other causes of liver injury, are considered 
potential cases of drug-induced liver injury (potential Hy’s Law cases) and are always to be 
considered important medical events and reported per [Section 12.4.5 Reporting Procedures 
for Serious Adverse Events]. 
12.4.2 Definition of Serious Adverse Events 
For this phase 1/2 study, there are no anticipated SAEs for which a single occurrence will be 
excluded from IND safety reporting.  
An AE is considered “serious” if, in the view of either the investigator or sponsor, the event:  
● 
Results in death 
● 
Is life-threatening (An AE is considered “life-threatening” if, in the view of either the 
investigator or sponsor, its occurrence places the subject at immediate risk of death; it 


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does not include an AE that, had it occurred in a more severe form, might have caused 
death.) 
● 
Results in persistent or significant disability/incapacity or substantial disruption of the 
ability to conduct normal life functions  
● 
Results in congenital anomaly, or birth defect 
● 
Requires inpatient hospitalization (except for planned procedures as allowed per study) 
or leads to prolongation of hospitalization (except if prolongation of planned 
hospitalization is not caused by an AE)  
● 
Other medically important events (defined in paragraph below) 
Medical and scientific judgment should be exercised in deciding whether expedited reporting 
is appropriate in other situations, such as important medical events that may not be 
immediately life-threatening or result in death or hospitalization, but may jeopardize the 
subject or may require intervention to prevent one of the other outcomes listed in the 
definition above. These events, including those that may result in disability/incapacity, 
usually are considered serious. Examples of such events are intensive treatment in an 
emergency room or at home for allergic bronchospasm, blood dyscrasias or convulsions that 
do not result in hospitalization, or development of drug dependency or drug abuse.  
12.4.3 Criteria for Causal Relationship to Investigational Product 
A medically qualified investigator is obligated to assess the relationship between IP and each 
occurrence of each (S)AE. This investigator will use medical judgment as well as the 
reference safety information Section 2.1.2 Summary of Key Safety Information to determine 
the relationship. The causality assessment is 1 of the criteria used when determining 
regulatory reporting requirements. 
The investigator is requested to provide an explanation for the causality assessment for each 
(S)AE and must document in the medical notes that he/she has reviewed the (S)AE and has 
provided an assessment of causality. 
Following a review of the relevant data, the causal relationship between the IP and each 
(S)AE will be assessed by answering “yes” or “no” to the question “Do you consider that 
there is a reasonable possibility that the event may have been caused by the IP?” 
When making an assessment of causality, the following factors are to be considered when 
deciding if there is evidence and/or arguments to suggest there is a “reasonable possibility” 
that an (S)AE may have been caused by the IP (rather than a relationship cannot be ruled out) 
or if there is evidence to reasonably deny a causal relationship: 
● 
Has the subject been administered IP?  
● 
Plausibility (i.e., could the event been caused by the suspect drug? Consider biologic 
and/or pharmacologic mechanism, half-life, literature evidence, drug class, preclinical 
and study data, etc.) 
● 
Dechallenge/dose reduction/rechallenge:  
○ Dechallenge: Did the (S)AE resolve or improve after only stopping the dose of the 
suspect drug without any treatment? 


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○ Dose reduction: Did the (S)AE resolve or improve after reducing the dose of the 
suspect drug? 
○ Rechallenge: Did the (S)AE reoccur if the suspected drug was reintroduced after 
having been stopped?  
● 
Laboratory or other test results: a specific lab investigation supports the assessment of 
the relationship between the (S)AE and the IP (e.g., based on values pre-, during and 
post-treatment) 
● 
Available alternative explanations independent of IP exposure; such as other 
concomitant drugs, past medical history, concurrent or underlying disease, risk factors 
including medical and family history, season, location, etc., and strength of the 
alternative explanation  
● 
Finally, judging which are more likely based on all the above contents, factors of 
reasonable possibility or confounding factors, comprehensive judgment of plausible 
temporal relationship between exposure to the IP and (S)AE onset and/or resolution will 
be provided. Did the (S)AE occur in a reasonable temporal relationship to the 
administration of the IP? 
There may be situations in which an SAE has occurred and the investigator has minimal 
information to include in the initial report to the sponsor. However, it is very important that 
the investigator always assesses causality for every event before the initial transmission of 
the SAE data to the sponsor. With limited or insufficient information about the event to make 
an informed medical judgment and in absence of any indication or evidence to establish a 
causal relationship, a causality assessment of “no” is to be considered. In such instance, the 
investigator is expected to obtain additional information regarding the event as soon as 
possible and to re-evaluate the causality upon receipt of additional information. The 
medically qualified investigator may revise his/her assessment of causality in light of new 
information regarding the SAE and shall send an SAE follow-up report and update the eCRF 
with the new information and updated causality assessment.  
12.4.4 Criteria for Defining the Severity of an Adverse Event 
AEs will be classified for severity using the Clinical Data Interchange Standards Consortium 
Study Data Tabulation Model Controlled (CDISC) Terminology as described in the table 
below. 
Table 9 
Criteria for the Severity of an Adverse Event  
Classification 
CDISC Definition 
Mild 
A type of AE that is usually transient and may require only minimal treatment or 
therapeutic intervention. The event does not generally interfere with usual activities of 
daily living.  
Moderate 
A type of AE that is usually alleviated with additional specific therapeutic intervention. 
The event interferes with usual activities of daily living, causing discomfort but poses no 
significant or permanent risk of harm to the research participant.  
Severe 
A type of AE that interrupts usual activities of daily living, or significantly affects clinical 
status, or may require intensive therapeutic intervention.  
AE: adverse event; CDISC: Clinical Data Interchange Standards Consortium. 


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Modified Brighton Grading Scheme will assess local skin reaction at the application site. 
12.4.5 Reporting Procedures for Serious Adverse Events 
The investigator must complete and submit an SAE worksheet containing all information that 
is required by local and/or regional regulations to the sponsor by fax or email immediately 
(within 24 hours of awareness).   
The SAE worksheet must be signed by a medically qualified investigator (as identified on 
delegation of authority log). Signature confirms accuracy and completeness of the SAE data 
as well as the investigator causality assessment including the explanation for the causality 
assessment. 
If the SAE is associated with emergency unblinding by the investigator as outlined in 
[Section 6.3.4 Breaking the Treatment Code for Emergency], this is to be recorded on the 
SAE worksheet. On the SAE worksheet, the investigator is to include when unblinding took 
place in association with the SAE.  
For contact details, see Contact Details of Sponsor's Key Personnel. Fax or email the 
SAE/special situations worksheet to: 
Astellas Pharma Global Development Inc. 
Pharmacovigilance  
North America fax number: +1-888-396-3750 
North America alternate fax number: +1-847-317-1241 
Email: safety-us@astellas.com 
If there are any questions, or if clarification is needed regarding the SAE, please contact the 
sponsor’s medical monitor/study physician or their designee [CONTACT DETAILS OF 
SPONSOR’S KEY PERSONNEL].  
Follow-up information for the event should be sent promptly (as soon as available but no 
longer than within 7 days of the initial notification. 
Full details of the SAE should be recorded on the medical records, SAE/special situation 
worksheet and on the eCRF.  
The following minimum information is required: 
● 
International study number/study number  
● 
Subject number, sex and age 
● 
Date of report 
● 
Description of the SAE (event and seriousness criteria)  
● 
Causal relationship to the IP (including reason) 
● 
IP provided (if any) 
The sponsor or sponsor’s designee will medically evaluate the SAE and determine if the 
report meets the requirements for expedited reporting based on seriousness, causality, and 
expectedness of the events (e.g., SUSAR reporting) according to current local/regional 
regulatory requirements. The sponsor or sponsor's designee will submit expedited safety 


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reports to competent authorities and concerned ethics committee per current local regulations, 
and will inform the investigators of such regulatory reports as required. Investigators must 
submit safety reports as required by their IRB/IEC within timelines set by regional 
regulations (e.g., EMA, FDA) where required. Documentation of the submission to and 
receipt by the IRB/ IEC of expedited safety reports should be retained by the study site. In the 
US, FDA expedited IND reporting guidelines will be followed. 
The sponsor will notify all investigators responsible for ongoing clinical studies with the test 
product of all SUSARs, which require submission per local requirements IRB/IEC. 
The investigators should provide written documentation of IRB/IEC notification for each 
report to the sponsor. 
The investigator may contact the sponsor’s medical monitor/study physician for any other 
problem related to the rights, safety or well-being of the subject. 
12.4.6 Reporting Procedures for Special Situations 
12.4.6.1 Pregnancy 
If a female subject becomes pregnant during the study dosing period or within 28 days after 
IP application on Day 1 , the investigator is to report the information to the sponsor according 
to the timelines in [Section 12.4.5 Reporting Procedures for Serious Adverse Events] using 
the SAE worksheet or a pregnancy form and in the eCRF.  
The investigator will attempt to collect pregnancy information on any female partner of a 
male subject who becomes pregnant during the study dosing period or within 28 days after IP 
application on Day 1 from the discontinuation of dosing and report the information to 
sponsor according to the timelines in [Section 12.4.5 Reporting Procedures for Serious 
Adverse Events] using the SAE worksheet or pregnancy form.  
The expected date of delivery or expected date of the end of the pregnancy, last menstruation, 
estimated conception date, pregnancy result and neonatal data, etc., should be included in this 
information. 
While pregnancy itself is not considered to be an AE or SAE, any pregnancy complication or 
termination (including elective termination) of a pregnancy is to be reported for a female 
subject as an AE in the eCRF or SAE per [Section 12.4.5 Reporting Procedures for Serious 
Adverse Events]. For (S)AEs experienced by a female partner of a male subject, (S)AEs are 
to be reported via the SAE worksheet.  
Additional information regarding the outcome of a pregnancy when also categorized as an 
SAE is mentioned below:  


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● 
"Spontaneous abortion" includes miscarriage, abortion and missed abortion. 
● 
Death of a newborn or infant within 1 month after birth is to be reported as an SAE 
regardless of its relationship with the IP. 
● 
If an infant dies more than 1 month after the birth, it is to be reported if a relationship 
between the death and intrauterine exposure to the IP is judged as “possible” by the 
investigator. 
● 
Congenital anomaly (including anomaly in miscarried fetus) 
Unless a congenital anomaly is identified prior to spontaneous abortion or miscarriage, the 
embryo or fetus should be assessed for congenital defects by visual examination or other 
means as appropriate. (S)AEs experienced by the newborn/infant should be reported via the 
pregnancy reporting form. Generally, follow up will be no longer than 6 to 8 weeks following 
the estimated delivery date. 
12.4.6.2 Medication Error, Overdose and “Off-label Use” 
If a medication error (defined as an unintended failure in the treatment process that leads to, 
or has the potential to lead to, harm to the subject), overdose or “off-label use” (i.e., use 
outside of what is stated in the protocol) is suspected, refer to [Section 10.3 Major Protocol 
Deviations]. Any associated (S)AEs are to be reported in the eCRF. If the AE meets the 
definition of an SAE, the SAE is also to be reported as described in [Section 12.4.5 Reporting 
Procedures for Serious Adverse Events] together with the details of the medication error, 
overdose and/or “off-label use.” 
12.4.6.3 Misuse/Abuse 
Definition of misuse: Situations where the IP is/are intentionally and inappropriately used not 
in accordance with the intended use as defined in the protocol. 
Definition of abuse: Persistent or sporadic, intentional excessive use of medicinal products 
which is accompanied by harmful physical or psychological effects. 
If misuse or abuse of the IP is suspected, the investigator must forward the special situation 
worksheet to the sponsor by fax or email immediately (within 24 hours of awareness). Any 
associated (S)AEs are to be reported in the eCRF. If the AE meets the definition of an SAE, 
the SAE is also to be reported as described in [Section 12.4.5 Reporting Procedures for 
Serious Adverse Events] together with details of the misuse or abuse of the IP. 
12.4.6.4 Occupational Exposure 
If occupational exposure (e.g., inadvertent exposure to the IP of study site personnel while 
preparing it for administration to the subject) to the IP occurs, the investigator must forward 
the special situation worksheet to the sponsor by fax or email immediately (within 24 hours 
of awareness). Any associated (S)AEs occurring to the individual associated with or resulting 
from the special situation are to be reported on the special situations worksheet. 


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12.4.6.5 (Suspicion of) Transmission of Infectious Agent  
If transmission of an infectious agent associated with the IP is suspected, the investigator 
must forward the special situation worksheet to the sponsor by fax or email immediately 
(within 24 hours of awareness) and any associated (S)AEs are to be reported in the eCRF. If 
the AE meets the definition of an SAE, the SAE is also to be reported as described in 
[Section 12.4.5 Reporting Procedures for Serious Adverse Events] together with the details of 
the suspected transmission of infectious agent.  
12.4.6.6 Suspected Drug-drug Interaction 
If a drug-drug interaction associated with the IP is suspected, the investigator must forward 
the special situation worksheet to the sponsor by fax or email immediately (within 24 hours 
of awareness). Any associated (S)AEs are to be reported in the eCRF. If the AE meets the 
definition of an SAE, the SAE is also to be reported as described in [Section 12.4.5 Reporting 
Procedures for Serious Adverse Events] together with details of the suspected drug-drug 
interaction. 


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12.5 
Liver Safety Monitoring and Assessment  
This is a single dose administration and liver safety monitoring will be applied if any AEs 
occur that prompt safety consideration.  
The purpose of this appendix is to provide guidance for the monitoring of drug-induced liver 
injury during the course of the study. It should be noted that this section does not specify the 
EOS analyses of liver enzymes. The EOS liver enzymes analyses will be described in the 
SAP. Any subject enrolled in a study with active drug therapy and reveals an increase of 
serum aminotransferases (AT) to > 3 × ULN or bilirubin > 2 × ULN should undergo detailed 
testing for liver enzymes (including at least ALP, ALT, AST and TBL). Testing should be 
repeated within 72 hours of notification of the test results. For studies for which a central 
laboratory is used, alerts will be generated by the central laboratory regarding moderate and 
severe liver abnormality to inform the investigator and study team. Subjects should be asked 
if they have any symptoms suggestive of hepatobiliary dysfunction. 
Definition of Liver Abnormalities 
Confirmed abnormalities will be characterized as moderate and severe where ULN is as 
shown below. 
Table 10 
Moderate and Severe Liver Abnormalities 
 
ALT or AST 
 
TBL 
Moderate 
> 3 × ULN 
or 
> 2 × ULN 
Severe 
> 3 × ULN 
and† 
> 2 × ULN 
ALT: alanine aminotransferase; AST: aspartate aminotransferase; TBL: total bilirubin; ULN: upper limit of 
normal 
†Samples taken simultaneously or within maximum 24 hours. 
In addition, the subject should be considered to have severe hepatic abnormalities for any of 
the following: 
● 
ALT or AST > 8 × ULN 
● 
ALT or AST > 5 × ULN for more than 2 weeks. 
● 
ALT or AST > 3 × ULN and† and* TBL > 2 × ULN or international normalized ratio 
(INR) > 1.5 (if INR testing is applicable/evaluated) 
● 
ALT or AST > 3 × ULN with the appearance of fatigue, nausea, vomiting, right upper 
quadrant pain or tenderness, fever, rash and/or eosinophilia (> 5%)  
† Samples taken simultaneously or within a maximum of 24 hours. 
The investigator may determine that abnormal liver function results, other than as described 
above, may qualify as moderate or severe abnormalities and require additional monitoring 
and follow-up.  
Follow-up Procedures 
Confirmed moderate and severe abnormalities in hepatic functions should be thoroughly 
characterized by obtaining appropriate expert consultations, detailed pertinent history, 


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physical examination and clinical laboratory tests. The study site personnel are to complete 
the liver abnormality case report form (LA-CRF). Subjects with confirmed abnormal liver 
function testing should be followed as described below. 
Confirmed moderately abnormal liver function tests should be repeated 2 to 3 times weekly, 
and then weekly or less if abnormalities stabilize or the IP has been discontinued and the 
subject is asymptomatic.   
Severe hepatic liver function abnormalities as defined above, in the absence of another 
etiology, may be considered an important medical event and may be reported as a SAE. The 
sponsor should be contacted and informed of all subjects for whom severe hepatic liver 
function abnormalities possibly attributable to IP are observed.  
To further assess abnormal hepatic laboratory findings, the investigator is expected to: 
● 
Obtain a more detailed history of symptoms and prior or concurrent diseases. Symptoms 
and new-onset diseases are to be recorded as “AEs” within the eCRF. Illnesses and 
conditions such as hypotensive events, and decompensated cardiac disease that may lead 
to secondary liver abnormalities should be noted. Nonalcoholic steatohepatitis is seen in 
obese hyperlipoproteinemic and/or diabetic subjects, and may be associated with 
fluctuating AT levels. The investigator should ensure that the medical history form 
captures any illness that predates study enrollment that may be relevant in assessing 
hepatic function.  
● 
Obtain a history of concomitant drug use (including nonprescription medication, 
complementary and alternative medications), alcohol use, recreational drug use and 
special diets. Medications are to be entered in the eCRF. Information on alcohol, other 
substance use and diet should be entered on the LA-CRF or an appropriate document. 
● 
Obtain a history of exposure to environmental chemical agents. 
● 
Based on the subject’s history, other testing may be appropriate including:  
○ Acute viral hepatitis (A, B, C, D, E or other infectious agents) 
○ Ultrasound or other imaging to assess biliary tract disease 
○ Other clinical laboratory tests, including INR and direct bilirubin 
● 
Consider gastroenterology or hepatology consultations. 
● 
Submit results for any additional testing and possible etiology on the LA-CRF or an 
appropriate document. 
Study Treatment Discontinuation 
In the absence of an explanation for increased liver function tests, such as viral hepatitis, 
preexisting or acute liver disease, or exposure to other agents associated with liver injury, the 
subject may be discontinued from study treatment. The investigator may determine that it is 
not in the subject’s best interest to continue study treatment. Discontinuation of study 
treatment should be considered if: 
● 
ALT or AST > 8 × ULN 
● 
ALT or AST > 5 × ULN for more than 2 weeks 


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● 
ALT or AST > 3 × ULN and† TBL > 2 × ULN or INR > 1.5) (if INR testing is 
applicable/evaluated) 
● 
ALT or AST > 3 × ULN with the appearance of fatigue, nausea, vomiting, right upper 
quadrant pain or tenderness, fever, rash and/or eosinophilia (> 5%)  
† Samples taken simultaneously or within a maximum of 24 hours. 
In addition, if close monitoring for a subject with moderate or severe hepatic laboratory tests 
is not possible, study treatment should be discontinued. 
Hy’s Law definition: Drug-induced jaundice caused by hepatocellular injury, without a 
significant obstructive component, has a high rate of bad outcomes, from 10% to 50% 
mortality (or transplant).  
The 2 “requirements” for Hy’s Law are:  
1. Evidence that a drug can cause hepatocellular-type injury, generally shown by an increase 
in AT elevations > 3 × ULN (“2 × ULN elevations are too common in treated and 
untreated subjects to be discriminating”).  
2. Cases of increased total bilirubin (at least 2 × ULN) with concurrent AT elevations at 
least 3 × ULN and no evidence of intra- or extra-hepatic bilirubin obstruction (elevated 
ALP) or Gilbert’s syndrome [Temple, 2006]. 
FDA Guidance for Industry titled, “Drug-induced Liver Injury: Premarketing Clinical 
Evaluation” issued by the FDA on July 2009: 
1. The drug causes hepatocellular injury, generally shown by a higher incidence of 3-fold or 
greater elevations above the ULN of ALT or AST than the (nonhepatotoxic) control drug 
or placebo. 
2. Among subjects showing such AT elevations, often with ATs much greater than 3 × 
ULN, 1 or more also show elevation of serum TBL to > 2 × ULN, without initial findings 
of cholestasis (elevated serum ALP). 
3. No other reason can be found to explain the combination of increased AT and TBL, such 
as viral hepatitis A, B, or C; preexisting or acute liver disease; or another drug capable of 
causing the observed injury. 
References 
Temple R. Hy’s Law: Predicting Serious Hepatotoxicity. Pharmacoepidemiol Drug Saf. 
2006;15(4):241-3. 
The purpose of this appendix is to provide guidance for the monitoring of drug-induced liver 
injury during the course of the study. It should be noted that this section does not specify the 
EOS analyses of liver enzymes. The EOS liver enzymes analyses will be described in the SAP. 
Any subject enrolled in a study with active drug therapy and who reveals an increase of serum 
aminotransferases (AT) to > 3 × ULN (to > 5 × ULN in subjects with liver metastases) or total 
bilirubin > 2 × ULN should undergo detailed testing for liver enzymes (including at least ALP, 


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ALT, AST and TBL). Testing should be repeated within 72 hours of notification of the test 
results. For studies for which a central laboratory is used, alerts will be generated by the central 
laboratory regarding moderate and severe liver abnormality to inform the investigator and study 
team. Subjects should be asked if they have any symptoms suggestive of hepatobiliary 
dysfunction. 
Definition of Liver Abnormalities 
Confirmed abnormalities will be characterized as moderate and severe where ULN is as 
shown below. 
Table 11 
Moderate and Severe Liver Abnormalities  
 
ALT or AST 
 
TBL 
Moderate 
> 3 × ULN (in subjects without liver metastases),  
> 5 × ULN (in subjects with liver metastases) 
or 
> 2 × ULN 
Severe 
> 3 × ULN 
and† 
> 2 × ULN 
ALT: alanine aminotransferase; AST: aspartate aminotransferase; TBL: total bilirubin; ULN: upper limit of 
normal 
†Samples taken simultaneously or within maximum 24 hours. 
In addition, the subject should be considered to have severe hepatic abnormalities for any of 
the following: 
● 
ALT or AST > 8 × ULN 
● 
ALT or AST > 5 × ULN for more than 2 weeks (in the absence of liver metastases) 
● 
ALT or AST > 3 × ULN and† TBL > 2 × ULN or international normalized ratio (INR) 
> 1.5 (If INR testing is applicable/evaluated) 
● 
ALT or AST > 3 × ULN with the appearance of fatigue, nausea, vomiting, right upper 
quadrant pain or tenderness, fever, rash and/or eosinophilia (> 5%)  
† Samples taken simultaneously or within a maximum of 24 hours.  
The investigator may determine that abnormal liver function results, other than those described 
above, may qualify as moderate or severe abnormalities and require additional monitoring and 
follow-up. 
Follow-up Procedures 
Confirmed moderate and severe abnormalities in hepatic functions should be thoroughly 
characterized by obtaining appropriate expert consultations, detailed pertinent history, physical 
examination and clinical laboratory tests. The study site personnel are to complete the liver 
abnormality case report form (LA-CRF). Subjects with confirmed abnormal liver function 
testing should be followed as described below.  
Confirmed moderately abnormal liver function tests should be repeated 2 to 3 times weekly 
then weekly or less if abnormalities stabilize or the IP has been discontinued and the subject is 
asymptomatic.   
Severe hepatic liver function abnormalities as defined above, in the absence of another etiology 
may be considered an important medical event and may be reported as an SAE. The sponsor 


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should be contacted and informed of all subjects for whom severe hepatic liver function 
abnormalities possibly attributable to IP are observed.   
To further assess abnormal hepatic laboratory findings, the investigator is expected to: 
● Obtain a more detailed history of symptoms and prior or concurrent diseases. Symptoms 
and new-onset diseases are to be recorded as AEs in the eCRF. Illnesses and conditions 
such as hypotensive events and decompensated cardiac disease that may lead to 
secondary liver abnormalities should be noted. Nonalcoholic steatohepatitis is seen in 
obese hyperlipoproteinemic and/or diabetic subjects and may be associated with 
fluctuating AT levels. The investigator should ensure that the medical history form 
captures any illness that predates study enrollment that may be relevant in assessing 
hepatic function.  
● 
Obtain a history of concomitant drug use (including nonprescription medication, 
complementary and alternative medications), alcohol use, recreational drug use and 
special diets. Medications, including dose, are to be entered in the eCRF. Information on 
alcohol, other substance use and diet should be entered on the LA-CRF or an appropriate 
document. 
● 
Obtain a history of exposure to environmental chemical agents. 
● 
Based on the subject’s history, other testing may be appropriate including:  
○ Acute viral hepatitis (A, B, C, D, E or other infectious agents)  
○ Ultrasound or other imaging to assess biliary tract disease 
○ Other clinical laboratory tests including INR, direct bilirubin 
● 
Consider gastroenterology or hepatology consultations. 
● 
Submit results for any additional testing and possible etiology on the LA-CRF or an 
appropriate document. 
Study Treatment Discontinuation 
In the absence of an explanation for increased liver function tests, such as viral hepatitis, 
preexisting or acute liver disease, presence of liver metastases, or exposure to other agents 
associated with liver injury, the subject may be discontinued from study treatment. The 
investigator may determine that it is not in the subject’s best interest to continue study 
treatment. Discontinuation of study treatment should be considered if:  
● 
ALT or AST > 8 × ULN 
● 
ALT or AST > 5 × ULN for more than 2 weeks (in subjects without liver metastases 
● 
ALT or AST > 3 × ULN and† TBL > 2 × ULN or INR > 1.5 (If INR testing is 
applicable/evaluated) 
● 
ALT or AST > 5 × ULN and† (TBL > 2 × ULN in subjects with liver metastases) 
● 
ALT or AST > 3 × ULN with the appearance of fatigue, nausea, vomiting, right upper 
quadrant pain or tenderness, fever, rash and/or eosinophilia (> 5%) 
† Samples taken simultaneously or within a maximum of 24 hours. 
In addition, if close monitoring for a subject with moderate or severe hepatic laboratory tests 
is not possible, study treatment should be discontinued. 


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Hy’s Law Definition:  
1. Evidence that a drug can cause hepatocellular-type injury, generally shown by a higher 
rate than control of people with 3 × AT elevations over the ULN (2 × elevations are too 
common in treated and untreated subjects to be discriminating). 
2. Cases of increased bilirubin (to at least 2 × ULN) in people with concomitant AT 
elevation to at least 3 × ULN (but it is almost invariably higher) and no evidence of 
intra-or extra-hepatic bilirubin obstruction (elevated ALP) or Gilbert’s syndrome 
[Temple, 2006]. 
FDA Guidance for Industry titled “Drug-induced Liver Injury: Premarketing Clinical 
Evaluation” issued by the FDA on July 2009: 
FDA Guidance for Industry: 
1. The drug causes hepatocellular injury, generally shown by a higher incidence of 3-fold or 
greater elevations above the ULN of ALT or AST than the (nonhepatotoxic) control drug 
or placebo.  
2. Among subjects showing such AT elevations, often with AT levels much greater than 
3 × ULN, 1 or more also show elevation of serum TBL to > 2 × ULN, without initial 
findings of cholestasis (elevated serum ALP). 
3. No other reason can be found to explain the combination of increased AT and TBL, such 
as viral hepatitis A, B or C; preexisting or acute liver disease; or another drug capable of 
causing the observed injury. 
 
References 
Temple R. Hy’s Law: Predicting Serious Hepatotoxicity. Pharmacoepidemiol Drug Saf. 
2006;15(4):241-3. 


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12.6 
List of Excluded Concomitant Medications 
These restrictions are required after ASP0598 Otic Solution or placebo administration on 
Randomization (Day 1), until completion of study procedures at Day 57 (SAD) / Day 85 
(single dose expansion or MAD) / Day 113 (multiple dose expansion) or EOS visit. 
● 
Ear drop agents will be used only for the treatment of otitis media with suppurative ear 
discharge. Only Ciprofloxacin or Ofloxacin ear drops (does not includes steroids) are 
allowed to be used in the ASP0598 Otic Solution or placebo treated ear.  Investigators 
should minimize treatment with ear drops up to a maximum of 10 days and consider 
alternative treatment (e.g., oral antibiotics). 
● 
Any other topical agents in the ear canal are prohibited to use in the ASP0598 Otic 
Solution or placebo treated ear. 
● 
Any otologic procedures (e.g., paper patch or surgeries) to the ASP0598 Otic Solution or 
placebo treated ear are prohibited. 


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12.7 
Laboratory Assessments  
Laboratory tests will be performed at screening for eligibility assessment and sent to the local 
laboratory for analysis. 
Table 12 
Clinical Laboratory Tests 
Panel/Assessments 
Parameters to be Analyzed 
Hematology 
Hematocrit 
Hemoglobin 
Platelets 
Red blood cell count 
White blood cell count 
White blood cell count differential 
Biochemistry 
Albumin  
Alanine aminotransferase 
Alkaline phosphatase 
Aspartate aminotransferase 
Blood urea nitrogen 
Chloride 
Creatinine 
Creatinine kinase 
Glucose 
Lactate dehydrogenase 
Phosphate 
Potassium 
Serum HCG for female subjects  
Sodium  
Total bilirubin (total and direct) 
Total protein 
Urinalysis 
Bilirubin 
Glucose 
Ketones 
pH 
Protein 
Red blood cells 
 


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12.8 
Ear Care and Water Precautions 
These restrictions are required after IP administration at Day 1 until completion of the study 
procedures at Day 57 (SAD), Day 85 (single dose expansion or MAD), Day 113 (multiple 
dose expansion) or EOS visit. 
● 
Subjects must refrain from showering or bathing for at least 24 hours after IP 
administration. 
○  Showering or bathing are allowed 24 hours after IP administration. When 
showering or bathing, follow “How to Keep Your Ear Dry” guidelines. 
● 
Any water activities that risk submersion of the ear (e.g., swimming or surfing) are 
prohibited throughout the entire study period. 
● 
Are not allowed to use any materials (e.g., Q-tips) placed into the ear canal of the treated 
ear (ear buds or headphones placed at the entrance to the ear canal are considered 
acceptable). If ear cleaning is desired, then a soft tissue can be used and placed gently at 
the entrance to the ear canal. 
● 
Should refrain from activities that can increase the middle ear pressure including plane 
travel (at least 28 days after IP application), positive pressure ventilation (e.g., CPAP or 
BiPAP) devices, Valsalva maneuvers, excessive high-pressure nose blowing, diving 
underwater.   
● 
Must refrain from activities that can excessively increase body temperature (e.g., Sauna) 
for 3 days after IP application. 
● 
Must refrain from activities that stimulate sweating excessively for 3 days after IP 
application. 
 
 


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How to Keep Your Ear Dry 
To keep water out of your ear when showering and bathing, place half of a cotton ball rolled 
in 1 tablespoon of petroleum jelly to the ear. 
1. The cotton ball should be completely saturated with petroleum jelly.  
2. Place this in the bowl part of the outer ear, covering your ear canal. Do not shove the 
cotton ball into the ear canal. Smooth the edges of the cotton ball down to ensure a 
good seal.  
3. Please use a new cotton ball each time and do not submerge your head underwater with 
this technique.  
 
Other options for keeping your ear dry: 
Over the counter options include plastic or soft, moldable silicone earplugs. 
 
It is not recommended to use foam earplugs to keep water out of the ear. 
 
 


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12.9 
Modified Brighton Grading Scheme 
Grade 
 
0 
no abnormalities 
1 
canal erythema 
1b 
canal erythema with otorrhea (ear canal fluid discharge) 
2 
canal erythema + swelling, TM still visible 
2b 
canal erythema + swelling, TM still visible with otorrhea 
3 
canal erythema + swelling, TM not visible 
3b 
canal erythema + swelling, TM not visible with otorrhea 
4 
canal erythema + swelling, TM not visible + erythema and swelling of the pinna 
4b 
canal erythema + swelling, TM not visible + erythema and swelling of the pinna 
with otorrhea 
 
Lindisfarne ME, Berwick J, Das P. Clinical Review: Acute Otitis Externa. Available from: 
https://www.gponline.com.   
 
 


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12.10 Tinnitus Visual Analog Scale (TVAS) 
 
 
 
 


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12.11 Clinical Study Continuity 
INTRODUCTION 
The purpose of this appendix is to provide acceptable alternate methods to assess safety and 
efficacy parameters, as appropriate, in the event the clinical study is interrupted at the 
country, state, site or participant level during any crisis (e.g., natural disaster, pandemic). 
BENEFIT-RISK RATIONALE 
Maintaining the safety of clinical study subjects and delivering continuity of care in the 
clinical study setting is paramount during any crisis. The site is expected to follow the 
protocol and associated Schedule of Assessments/ Table 2, Table 3, Table 4, and Table 5 
unless the site PI discusses the need with the Astellas Medical Monitor to implement the 
alternate measures.  
The approach outlined within this appendix defines which assessments are required to 
maintain a favorable benefit/risk to the participant, to maintain overall study integrity and to 
provide acceptable alternate methods to complete the study required assessments and 
procedures if study activities are unable to be performed as described in Section 7: Study 
Procedures and Assessments due to a crisis.  
INFORMED CONSENT 
Subjects who need to follow any or all of the alternate measures outlined in this Appendix 
will be required to provide informed consent which explicitly informs them of the nature of, 
and rationale for these changes, and gain their agreement to continue participation in the 
study prior to the implementation of any of these changes. In the event the urgency of 
implementing the alternate measures does not allow for the participant to provide written 
consent prior to implementation, the PI or designee will obtain oral agreement from the 
subject followed by written documentation as soon as is feasible. A separate addendum to the 
study informed consent will be provided to document the participant’s consent of the 
changes. 
PARTICIPANT PROCEDURES ASSESSMENT 
Sites with subjects who are currently enrolled into this clinical study may consider 
implementing the alternate methods outlined below if one or more of the following 
conditions are met due to the crisis: 
● 
Regional or local travel has been restricted, inclusive of mandatory shelter in place 
measures, which makes participant travel to/from the study site nearly impossible 
● 
Site facilities have been closed for clinical study conduct  
● 
Site has been restricted to treating patients with conditions outside of the scope of the 
study 
● 
Site personnel have temporarily relocated the conduct of the study to a location that 
place a burden on the participant with respect to time and travel 
● 
Participant(s) have temporarily relocated from the current study site to an alternate study 
site to avoid placing a burden on the participant with respect to travel 


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● 
Participant(s) have temporarily relocated from their home location and the new distances 
from the site would cause undue burden with respect to time and travel 
● 
Participant has risk factors for which traveling to the site poses an additional risk to the 
participant’s health and safety 
Adherence to the protocol as reflected in the Schedule of Assessment (Table 2, Table 3, 
Table 4, and Table 5) is expected, where plausible. The alternate measures as noted in 
Table 13, Table 14, Table 15 and Table 16 below are only permissible in the event of a crisis, 
and after discussing the need to implement the alternate measure with the Astellas Medical 
Monitor.  Patients with CTMP are generally healthy and not at higher risk of COVID-19 
infection.   IP must be administered in a medical facility by a trained and qualified physician.  
All otology examinations and procedures, including imaging of the tympanic membrane, 
must be conducted at the study site by a trained and qualified physician or audiologist.  This 
is to allow for continuity of receiving IP (applicable to MAD). The following assessments 
can occur outside the medical facility for subjects participating in the study in a time of crisis: 
blood draws, vital signs, concomitant medications, TVAS, and AE assessments. 
If alternate measures are implemented for a participant, the site should record the justification 
for implementing the alternate measure(s) and which alternate measure(s) that was 
implemented at a particular visit in the participant’s source document. 
 


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Table 13 
Schedule of Assessments – SAD 
 
Alternative Approach  
Screening 
Randomization 
Observation  
Day 
 
Day -28 to Day 
-1 
Day 1 
Day 2 
Day 8 
Day 15 
Day 29 
Day 57 
Last Visit/ 
EOS 
Week 
 
 
 
 
Week 1 
Week 2 
Week 4 
Week 8 
Visit Windows 
 
 
 
+1 day 
+/- 3 days 
+/- 3 days 
+/- 3 days 
+/- 3 days 
Visit number 
 
1 
2 
3 
4 
5 
6 
7 
Informed Consent 
 
X 
 
 
 
 
 
 
Verify Inclusion/Exclusion 
 
X 
X 
 
 
 
 
 
Medical History/Disease 
History/Demographics 
 
X 
X 
 
 
 
 
 
Physical Exam including Height and Weight 
 
X 
 
 
 
 
 
 
Vital Signs a 
Remote/Virtual/Telemedicine Visits 
allowed. 
 
X 
X 
X 
X 
X 
X 
X 
Prior/Concomitant Medications b  
X 
X 
X 
X 
X 
X 
X 
Adverse Events Assessment c 
X 
X 
X 
X 
X 
X 
X 
ASP0598 or placebo  
 
 
X d 
 
 
 
 
 
Microscopic Ear Examination 
 
 
 
If delayed, should be completed as 
soon as possible 
X e 
X f 
X g 
X g 
X g 
X g 
X i 
Modified Brighton Grading Scheme 
Evaluation 
 
X f 
X 
X 
X 
X 
X 
Imaging picture of tympanic membrane by 
endoscope 
X e 
X h 
X  
X 
X 
X 
X  
Bone conduction by Pure Tone Audiometry 
(PTA) 
X e 
X 
X j 
X j 
X j 
X j 
X 
Air conduction by PTA  
X e 
X 
 
 
 
 
X 
Tympanometry  
X e 
X 
 
 
 
 
X 
Tinnitus Visual Analog Scale (TVAS) 
Remote/Virtual/Telemedicine Visits 
allowed for non-dosing visits. 
X 
X 
X 
X 
X 
X 
X 
Table continued on next page 


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Alternative Approach  
Screening 
Randomization 
Observation  
Day 
 
Day -28 to Day 
-1 
Day 1 
Day 2 
Day 8 
Day 15 
Day 29 
Day 57 
Last Visit/ 
EOS 
Week 
 
 
 
 
Week 1 
Week 2 
Week 4 
Week 8 
Visit Windows 
 
 
 
+1 day 
+/- 3 days 
+/- 3 days 
+/- 3 days 
+/- 3 days 
Visit number 
 
1 
2 
3 
4 
5 
6 
7 
Serum Chemistries 
 
Visit collection of samples at local 
facility is acceptable if results can be 
made available to investigative site 
X 
 
 
 
 
 
 
CBC with Differential 
X 
 
 
 
 
 
 
Pregnancy Test k 
X 
X 
 
 
 
 
X 
Pharmacokinetic Sample 
 
X l 
X 
 
 
 
 
Blood Sample for Future Analysis 
 
X 
 
 
 
X 
 
Urinalysis 
Visit collection of samples at local 
facility is acceptable if results can be 
made available to investigative site 
X 
 
 
 
 
 
 
AE: adverse event; CBC: complete blood count; EOS: end of study; PK: pharmacokinetic; SAD: Single Ascending Dose; TM: tympanic membrane 
a. 
Vital Signs include blood pressure, body temperature, and heart rate. 
b. Includes all medications taken within 28 days prior to ASP0598 Otic Solution or placebo administration at Day 1. 
c. 
AEs will be collected from the time of informed consent through Day 57 or EOS.  Any AEs ongoing at Day 57 or EOS Visit must be followed until resolution or Investigator 
determines the event to be stable. AEs should be assessed at least monthly. 
d. ASP0598 Otic Solution or placebo will be applied onto the remaining tympanic membrane under a microscope with a 22-gauge blunt needle. After ASP0598 Otic Solution or 
placebo administration, subjects will be required to remain on their side with the treated ear facing up for at least 15 minutes. Please see the Pharmacy Manual, Section 9.4: Dose 
Administration for detailed instructions. 
e. 
Otology examinations will be performed for both ears at the screening visit. 
f. 
Microscopic Ear examination will be performed prior to and 60 (±5) minutes after ASP0598 Otic Solution/placebo administration. Skin local reaction at the application site will be 
evaluated by Modified Brighton Grading Scheme (Appendix 12.9) at 60 (±5) minutes after ASP0598 Otic Solution/placebo administration. 
g. Ear cleaning will not be conducted between Days 2 – 29, unless it is absolutely necessary. Investigators will not clean the treated ear by suctioning unless subject’s experience 
uncomfortable ear discharge.   
h. At Day 1, imaging pictures will be taken at the following time points: pre-dose, immediately after, 30 (±5) minutes, and 60 (±5) minutes after the ASP0598 Otic Solution or 
placebo administration. 
i. 
At Day 57 or EOS, the whole TM should be visible before taking imaging picture.  If the whole TM is not visible, the investigator should clean the ear canal. 
j. 
Bone conduction testing at Day 2, 3, 8, 15, 29 will be tested only at 1, 2 and 4 kHz (ototoxicity assessment). 
k. Urine or serum pregnancy test will be performed in women of childbearing potential.  
l. 
Day 1, PK blood draw will be performed at the following time points: pre-dose (-15) minutes, 30 (±5) minutes and 60 (±5) minutes after ASP0598 Otic Solution or placebo 
administration into the affected ear.   
 


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Table 14 
Schedule of Assessments – Single Dose Expansion 
 
Alternative Approach  
Screening 
Randomization 
Observation  
Day 
 
Day -28 to 
Day -1 
Day 1 
Day 15 
Day 29 
Day 57 
Day 85 
Last Visit/ 
EOS 
Week 
 
 
 
Week 2 
Week 4 
Week 8 
Week 12 
Visit Windows 
 
 
 
+/- 3 days 
+/- 3 days 
+/- 3 days 
+/- 3 days 
Visit number 
 
1 
2 
3 
4 
5 
6 
Study Procedures 
Informed Consent 
 
X 
 
 
 
 
 
Verify Inclusion/Exclusion 
 
X 
X 
 
 
 
 
Medical History/Disease History/Demographics 
 
X 
X 
 
 
 
 
Physical Exam including Height and Weight 
 
X 
 
 
 
 
 
Vital Signs a 
Remote/Virtual/Telemedicine Visits 
allowed. 
X 
X 
X 
X 
X 
X 
Prior/Concomitant Medications b 
X 
X 
X 
X 
X 
X 
Adverse Events Assessment c 
X 
X 
X 
X 
X 
X 
Study Treatment Administration 
ASP0598 or placebo  
 
 
X d 
 
 
 
 
Otology Examinations 
Microscopic Ear Examination  
 
 
 
If delayed, should be completed as soon 
as possible 
X e 
X f 
Xg 
Xg 
Xg, 
X i 
Modified Brighton Grading Scheme Evaluation 
 
X f 
X 
X 
X 
X 
Imaging picture of tympanic membrane by endoscope  
X e 
Xh  
X 
X  
X 
X  
Bone conduction by Pure Tone Audiometry (PTA)  
X e 
X 
X j 
X j 
X j 
X 
Air conduction by PTA  
X e 
X 
 
 
 
X 
Tympanometry  
X e 
X 
 
 
 
X 
Tinnitus Visual Analog Scale (TVAS) 
Remote/Virtual/Telemedicine Visits 
allowed. 
X 
X 
X 
X 
X 
X 
Table continued on next page 


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Alternative Approach  
Screening 
Randomization 
Observation  
Day 
 
Day -28 to 
Day -1 
Day 1 
Day 15 
Day 29 
Day 57 
Day 85 
Last Visit/ 
EOS 
Week 
 
 
 
Week 2 
Week 4 
Week 8 
Week 12 
Visit Windows 
 
 
 
+/- 3 days 
+/- 3 days 
+/- 3 days 
+/- 3 days 
Visit number 
 
1 
2 
3 
4 
5 
6 
Blood Collection 
Serum Chemistries 
 
X 
 
 
 
 
 
CBC with Differential 
 
X 
 
 
 
 
 
Pregnancy Test k 
Visit collection of samples at local 
facility is acceptable if results can be 
made available to investigative site 
X 
X 
 
 
X 
X 
Blood Sample for Future Analysis 
 
X 
 
X 
 
 
Urine Collection 
Urinalysis 
Visit collection of samples at local 
facility is acceptable if results can be 
made available to investigative site 
X 
 
 
 
 
 
AE: adverse event; CBC: complete blood count; EOS: end of study; TM: tympanic membrane 
a. Vital Signs include blood pressure, body temperature, and heart rate. 
b. Includes all medications taken within 28 days prior to ASP0598 Otic Solution or placebo administration at Day 1. 
c. AEs will be collected from the time of informed consent through Day 57 or EOS.  Any AEs ongoing at Day 85 or EOS Visit must be followed until resolution or Investigator 
determines the event to be stable. AEs should be assessed at least monthly. 
d. ASP0598 Otic Solution or placebo will be applied onto the remaining tympanic membrane under a microscope with a 22-gauge blunt needle. After ASP0598 Otic Solution or 
placebo administration, subjects will be required to remain on their side with the treated ear facing up for at least 15 minutes.  Please see the Pharmacy Manual, Section 9.4: Dose 
Administration for detailed instructions. 
e. Otology examinations will be performed for both ears at the screening visit. 
f. Microscopic Ear examination will be performed prior to and 60 (±5) minutes after ASP0598 Otic Solution/placebo administration. Skin local reaction at the application site will be 
evaluated by Modified Brighton Grading Scheme (Appendix 12.9) at 60 (±5) minutes after ASP0598 Otic Solution/placebo administration. 
g. Ear cleaning will not be conducted between Days 2 – 57, unless it is absolutely necessary. Investigators will not clean the treated ear by suctioning unless subjects experience 
uncomfortable ear discharge. 
h. At Day 1, imaging pictures will be taken at the following time points: pre-dose, immediately after, 30 (±5) minutes, and 60 (±5) minutes after the ASP0598 Otic Solution or placebo 
administration. 
i. At Day 85 or EOS, the whole TM should be visible before taking imaging picture.  If the whole TM is not visible, the investigator should clean the ear canal. 
j. Bone conduction testing at Day 15, 29, and 57 will be tested only at 1, 2 and 4 kHz (ototoxicity assessment). 
k. Urine or serum pregnancy test will be performed in women of childbearing potential.  


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Table 15 
Schedule of Assessments – MAD  
 
Alternative Approach  
Screening 
Randomization 
Observation  
Day 
 
Day – 28 to 
Day -1 
Day 1 
Day 
8 
Day 
15  
Day 
22  
Day 
29   
Day 
36   
Day 
57 
  
Day 
85  
Last 
Visit/ 
EOS 
Week 
 
 
 
Week 
1 
Week 
2 
Week 
3 
Week 
4 
Week 
5 
Week 
8 
Week 
12 
Visit Windows 
 
 
 
+/- 3 
days 
+/- 3 
days 
+/- 3 
days 
+/- 3 
days 
+/- 3 
days 
+/- 3 
days 
+/- 3 
days 
Visit number 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
Study Procedures 
Informed Consent 
 
X 
 
 
 
 
 
 
 
 
Verify Inclusion/Exclusion 
 
X 
X 
 
 
 
 
 
 
 
Medical History/Disease History/Demographics 
 
X 
X 
 
 
 
 
 
 
 
Physical Exam including Height and Weight  
 
X 
 
 
 
 
 
 
 
 
Vital Signs a 
 
Remote/Virtual/Telemedicine Visits 
allowed. 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Prior/Concomitant Medications 
b 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse Events Assessment 
c 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study Treatment Administration 
ASP0598 or placebo d 
 
 
X 
 
X 
 
X 
 
 
 
Otology Examinations 
Microscopic Ear Examination 
 
 
 
Remote/Virtual/Telemedicine Visits 
allowed. 
X e 
X f 
X g 
X f, g 
X g 
X f, g 
X g 
X g 
X i 
Modified Brighton Grading Scheme Evaluation 
 
X f 
X 
X f 
X 
X f 
X 
X 
X 
Imaging picture of tympanic membrane by 
endoscope 
X e 
X h 
X 
X h 
X 
X h 
X 
X 
X  
Bone conduction by Pure Tone Audiometry (PTA) 
X e 
X 
X j 
X j 
X j 
X j 
X j 
X j 
X 
Air conduction by PTA 
X e 
X 
 
 
 
 
 
 
X 
Tympanometry 
X e 
X 
 
 
 
 
 
 
X 
Tinnitus Visual Analog Scale (TVAS) 
Remote/Virtual/Telemedicine Visits 
allowed. 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Table continued on next page 


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Alternative Approach  
Screening 
Randomization 
Observation  
Day 
 
Day – 28 to 
Day -1 
Day 1 
Day 
8 
Day 
15  
Day 
22  
Day 
29   
Day 
36   
Day 
57 
  
Day 
85  
Last 
Visit/ 
EOS 
Week 
 
 
 
Week 
1 
Week 
2 
Week 
3 
Week 
4 
Week 
5 
Week 
8 
Week 
12 
Visit Windows 
 
 
 
+/- 3 
days 
+/- 3 
days 
+/- 3 
days 
+/- 3 
days 
+/- 3 
days 
+/- 3 
days 
+/- 3 
days 
Visit number 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
Blood Collection 
Serum Chemistries 
 
Visit collection of samples at local 
facility is acceptable if results can be 
made available to investigative site 
X 
 
 
 
 
 
 
 
 
CBC with Differential 
X 
 
 
 
 
 
 
 
 
Pregnancy Test k 
X 
X 
 
 
 
 
 
X 
X 
Pharmacokinetic Sample 
 
X l 
 
 
 
X  
 
 
 
Sample for Future Analysis  
 
X 
 
 
 
 
 
X 
 
Urine Collection 
Urinalysis 
Visit collection of samples at local 
facility is acceptable if results can be 
made available to investigative site 
X 
 
 
 
 
 
 
 
 
AE: adverse event; CBC: complete blood count; EOS: end of study; MAD: Multiple Ascending Dose; PK: pharmacokinetic; TM: tympanic membrane 
a. 
Vital Signs include blood pressure, body temperature, and heart rate. 
b. Includes all medications taken within 28 days prior to ASP0598 Otic Solution or placebo administration at Day 1. 
c. 
AEs will be collected from the time of informed consent through Day 85 or EOS.  Any AEs ongoing at Day 85 or EOS Visit must be followed until resolution or Investigator 
determines the event to be stable. AEs should be assessed at least monthly. 
d. ASP0598 Otic Solution or placebo will be applied onto the remaining tympanic membrane under a microscope with a 22-gauge blunt needle. After ASP0598 Otic Solution or 
placebo administration, subjects will be required to remain on their side with the treated ear facing up for at least 15 minutes.  Please see the Pharmacy Manual, Section 9.4: Dose 
Administration for detailed instructions. 
e. 
Otology examinations will be performed for both ears at the screening visit. 
f. 
Days 1, 15 and 29, microscopic ear examination will be performed prior to and 60 (±5) minutes after ASP0598 Otic Solution/placebo administration. Skin local reaction at the 
application site will be evaluated by Modified Brighton Grading Scheme (Appendix 12.9) at 60 (±5) minutes after ASP0598 Otic Solution/placebo administration. 
g. Ear cleaning will not be conducted between Days 2 – 57, unless it is absolutely necessary. Investigators will not clean the treated ear by suctioning unless subjects experience 
uncomfortable ear discharge). 
h. At Days 1, 15, and 29, imaging pictures will be taken at the following time points: pre-dose, immediately after, 30 (±5) minutes, and 60 (±5) minutes after the ASP0598 Otic 
Solution or placebo administration. 
Footnotes continued on next page 


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i. 
At Day 85 and/or EOS, the whole TM should be visible before taking imaging picture.  If the whole TM is not visible, the investigator should clean the ear canal. 
j. 
Bone conduction testing at Day 8, 15, 22, 29, 36 and 57 will be tested only at 1, 2 and 4 kHz (ototoxicity assessment). 
k. Urine or serum pregnancy test will be performed in women of childbearing potential.  
l. 
Day 1 and Day 29, PK blood draw will be performed at the following time points: pre-dose (-15) minutes, 30 (±5) minutes and 60 (±5) minutes after ASP0598 Otic Solution or 
placebo administration into the affected ear.   
 
 
 


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Table 16 
Schedule of Assessments – Multiple Dose Expansion  
 
Alternative Approach  
Screening 
Randomization 
Observation  
Day 
 
Day – 28 to 
Day -1 
Day 1 
Day 
15  
Day 
29   
Day 
43 
Day 
57 
  
Day 85  
 
Day 
113  
Last 
Visit/ 
EOS 
Week 
 
 
 
Week 
2 
Week 
4 
Week 
6 
Week 
8 
Week 
12 
Week 
16 
Visit Windows 
 
 
 
+/- 5 
days 
+/- 5 
days 
+/- 3 
days 
+/- 3 
days 
+/- 3 
days 
+/- 3 
days 
Visit number 
 
1 
2 
3 
4 
5 
6 
7 
8 
Study Procedures 
Informed Consent 
 
X 
 
 
 
 
 
 
 
Verify Inclusion/Exclusion 
 
X 
X 
 
 
 
 
 
 
Medical History/Disease History/Demographics 
 
X 
X 
 
 
 
 
 
 
 Physical Exam including Height and Weight 
 
X 
 
 
 
 
 
 
 
Vital Signs a 
 
Remote/Virtual/Telemedicine Visits 
allowed. 
X 
X 
X 
X 
X 
X 
X 
X 
Prior/Concomitant Medications b  
X 
X 
X 
X 
X 
X 
X 
X 
Adverse Events Assessment c 
X 
X 
X 
X 
X 
X 
X 
X 
Study Treatment Administration 
ASP0598 or placebo d 
 
 
X 
X l 
X l 
 
 
 
 
Table continued on next page 


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Version 3.3 Incorporating Nonsubstantial Amendment 4 
 
Alternative Approach  
Screening 
Randomization 
Observation  
Day 
 
Day – 28 to 
Day -1 
Day 1 
Day 
15  
Day 
29   
Day 
43 
Day 
57 
  
Day 85  
 
Day 
113  
Last 
Visit/ 
EOS 
Week 
 
 
 
Week 
2 
Week 
4 
Week 
6 
Week 
8 
Week 
12 
Week 
16 
Visit Windows 
 
 
 
+/- 5 
days 
+/- 5 
days 
+/- 3 
days 
+/- 3 
days 
+/- 3 
days 
+/- 3 
days 
Visit number 
 
1 
2 
3 
4 
5 
6 
7 
8 
Otology Examination 
Microscopic Ear Examination 
 
 
If delayed, should be completed as soon 
as possible 
X e 
X f 
X f, g 
X f, g 
X g 
X g 
X g 
X i 
Modified Brighton Grading Scheme Evaluation 
 
X f 
X f 
X f 
X 
X 
X 
X 
Imaging picture of tympanic membrane by 
endoscope 
X e 
X h 
X h 
X h 
X 
X 
X 
X  
Bone conduction by Pure Tone Audiometry 
(PTA)  
X e 
X 
X j 
X j  
X j 
X j 
X j 
X 
Air conduction by PTA  
X e 
X 
 
 
 
 
X 
X 
Tympanometry  
X e 
X 
 
 
 
 
X 
X 
Tinnitus Visual Analog Scale (TVAS) 
Remote/Virtual/Telemedicine Visits 
allowed. 
X 
X 
X 
X 
X 
X 
X 
X 
Blood Collection 
Serum Chemistries 
Visit collection of samples at local 
facility is acceptable if results can be 
made available to investigative site 
X 
 
 
 
 
 
 
 
CBC with Differential 
X 
 
 
 
 
 
 
 
Pregnancy Test k 
X 
X 
 
 
 
X 
 
X 
Sample for Future Analysis  
 
X 
 
 
 
X  
 
 
Urine Collection 
Urinalysis 
Visit collection of samples at local 
facility is acceptable if results can be 
made available to investigative site 
X 
 
 
 
 
 
 
 
AE: adverse event; CBC: complete blood count; EOS: end of study; SAD: Single Ascending Dose; TM: tympanic membrane; TMP: tympanic membrane perforation  
a. 
Vital Signs include blood pressure, body temperature, and heart rate. 
b. Includes all medications taken within 28 days prior to ASP0598 Otic Solution or placebo administration at Day 1. 
Footnotes continued on next page 


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c. 
AEs will be collected from the time of informed consent through Day 113 or EOS.  Any AEs ongoing at Day 113 or EOS Visit must be followed until resolution or Investigator 
determines the event to be stable. AEs should be assessed at least monthly. 
d. ASP0598 Otic Solution or placebo will be applied onto the remaining tympanic membrane under a microscope with a 22-gauge blunt needle. After ASP0598 Otic Solution or 
placebo administration, subjects will be required to remain on their side with the treated ear facing up for at least 15 minutes.  Please see the Pharmacy Manual, Section 9.4: Dose 
Administration for detailed instructions. 
e. 
Otology examinations will be performed for both ears at the screening visit. 
f. 
Microscopic Ear examination will be performed prior to and 60 (±5) minutes after ASP0598 Otic Solution/placebo administration. Skin local reaction at the application site will be 
evaluated by Modified Brighton Grading Scheme (Appendix 12.9) at 60 (±5) minutes after ASP0598 Otic Solution/placebo administration. 
g. Ear cleaning will not be conducted between Days 2 – 85, unless it is absolutely necessary. Investigators will not clean the treated ear by suctioning unless subjects experience 
uncomfortable ear discharge). 
h. At Days 1, 15, and 29, imaging pictures will be taken at the following time points: pre-dose, immediately after, 30 (±5) minutes, and 60 (±5) minutes after the ASP0598 Otic 
Solution or placebo administration. 
i. 
At Day 85 (SAD) or Day 113 (single dose expansion) and/or EOS, the whole TM should be visible before taking imaging picture.  If the whole TM is not visible, the investigator 
should clean the ear canal. 
j. 
Bone conduction testing at Day 15, 29, 43, 57, and 85 will be tested only at 1, 2 and 4 kHz (ototoxicity assessment). 
k. Urine or serum pregnancy test will be performed in women of childbearing potential.  
l. 
ASP0598 Otic Solution or placebo administration on Day 15 and Day 29 will be conducted in the case that the TMP closure is not confirmed. 
 


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INVESTIGATIONAL MEDICINAL PRODUCT SUPPLY 
If any of the conditions outlined above in the Subjects Procedures Assessment are met, one or 
all of the following mitigating strategies will be employed, as needed, to ensure continuity of 
IMP supply to the subjects:   
● 
Increase stock of IMP on site to reduce number of shipments required, if site space will 
allow.  
DATA COLLECTION REQUIREMENTS 
Additional data may be collected in order to indicate how participation in the study may have 
been affected by a crisis and to accommodate data collection resulting from alternate 
measures implemented to manage the conduct of the study and participant safety.  
Critical assessments for safety and efficacy based on study endpoints to be identified as 
missing or altered (performed virtually, at alternative locations, out of window, or other 
modifications) due to the crisis.  
 
 


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12.12 List of Abbreviations and Definition of Key Study Terms 
List of Abbreviations 
Abbreviations 
Description of abbreviations 
AE 
adverse event 
ALP 
alkaline phosphatase 
ALT 
alanine aminotransferase 
AST 
aspartate aminotransferase 
bpm 
Beats per minute 
BUN 
blood urea nitrogen 
CA 
Competent authority 
CBC 
complete blood count 
CCSI 
company core safety information 
CI 
Confidence interval 
Cmax 
maximum concentration 
CPAP 
Continuous Positive Airway Pressure 
CRF 
case report form 
CRO 
contract research organization 
CSR 
Clinical study report 
CTCAE 
common terminology criteria for adverse events 
CTMP 
Chronic Tympanic Membrane Perforation 
CV 
Coefficient of variation 
dB 
Decibels 
DEC 
Dose Escalation Committee 
DILI 
drug-induced liver injury 
DMC 
Data Monitoring Committee 
DPD 
Data Protection Directive 
eCRF 
electronic case report form 
EC50 
Effective Concentration 
ECV 
Equivalent Ear Canal Volume 
EEA 
European Economic Area 
EGF 
Epidermal growth-like factor 
EMA 
European Medicines Agency 
EOS 
End of Study 
FAS 
full analysis set 
GCP 
Good Clinical Practice 
GCPL 
Global Pharmacology Lead 
GML 
Global Medical Lead 


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Version 3.3 Incorporating Nonsubstantial Amendment 4 
Abbreviations 
Description of abbreviations 
GMP 
Good Manufacturing Practices 
GGT 
gamma-glutamyltransferase  
Hz 
hertz 
IAP 
Interim Analysis Plan 
IB 
Investigational Brochure 
ICE 
Intercurrent event 
ICF 
informed consent form 
ICH  
International Council for Harmonisation of Technical Requirements for 
Pharmaceuticals for Human Use 
IEC 
Independent Ethics Committee 
IP 
investigational product 
IMP 
investigational medicinal product 
IRB 
Institutional Review Board 
IRT 
interactive response technology 
ISN 
international study number 
kHz 
kilohertz 
LA-CRF 
liver abnormality case report form 
LS 
Least square 
MAD 
Multiple Ascending Dose 
MAR 
Missing at random 
MEDRA 
Medical Dictionary for Regulatory Activities 
MH 
Mantel-Haenszel 
MID 
Minimum Intolerable Dose 
mL 
milliliter 
mm 
Millimeters 
mmHg 
Millimeters of mercury 
MMRM 
mixed models repeated measures 
MTD 
Maximum tolerated dose 
NOAEL 
No observed adverse event level 
PD 
protocol deviation 
PET 
Positron emission tomography 
PK 
Pharmacokinetic 
PTA 
Pure Tone Audiometry 
PT 
Preferred Term 
QA 
quality assurance 
QC 
quality control 
RBC 
red blood cell 


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Version 3.3 Incorporating Nonsubstantial Amendment 4 
Abbreviations 
Description of abbreviations 
RNA 
Ribonucleic acid 
RSI 
reference safety information 
(S)AE 
serious adverse event or adverse event 
SAD 
Single Ascending Dose 
SAE 
serious adverse event 
SAF 
Safety analysis set 
SAP 
Statistical analysis plan 
SDV 
source document verification 
SE 
Standard error 
SFL 
screen failure log 
SOC 
System organ class 
SOP 
standard operating procedure 
SPC 
summary of product characteristics 
SUSAR 
suspected unexpected serious adverse reactions 
TEAE 
treatment-emergent adverse event 
TBL 
total bilirubin 
TM 
Tympanic membrane 
TMF 
Trial Master File 
TMP 
Tympanic membrane perforation 
TVAS 
Tinnitus visual analog scale 
ULN 
upper limit of normal 
USM 
Urgent safety matter 
WBC 
white blood cell 
WOCBP 
Women of child bearing potential 
µg 
microgram 
 


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Version 3.3 Incorporating Nonsubstantial Amendment 4 
Definition of Key Study Terms 
Terms 
Definition of Terms 
Baseline  
Assessments of subjects as they enter a study before they receive any 
treatment.  
Endpoint  
Variable that pertains to the efficacy or safety evaluations of a study. 
Note: Not all endpoints are themselves assessments since certain endpoints 
might apply to populations or emerge from analysis of results. That is, 
endpoints might be facts about assessments (e.g., prolongation of survival). 
Enroll 
To register or enter a subject into a study. Note: Once a subject has received 
the IP or placebo, the protocol applies to the subject.  
Intervention 
The drug, device, therapy or process under investigation in a study that is 
believed to have an effect on outcomes of interest in a study (e.g., health-
related quality of life, efficacy, safety and pharmacoeconomics).  
Investigational 
period 
Period of time where major interests of protocol objectives are observed, and 
where the test product or comparative drug (sometimes without 
randomization) is given to a subject and continues until the last assessment 
after completing administration of the test product or comparative drug. 
Randomization 
The process of assigning subjects to treatment or control groups using an 
element of chance to determine assignments in order to reduce bias. 
NOTE: Unequal randomization is used to allocate subjects into groups at a 
differential rate; for example, three subjects may be assigned to a treatment 
group for every one assigned to the control group. 
Screening 
A process of active consideration of potential subjects for randomization in a 
study. 
Screen failure 
Potential subject who signed the ICF, but did not meet 1 or more criteria 
required for participation in the study and was not randomized. 
Screening period 
Period of time before entering the investigational period, usually from the 
time when a subject signs the consent form until just before the test product 
or comparative drug (sometimes without randomization) is given to a 
subject.  
Study period 
Period of time from the first study site initiation date to the last study site 
completing the study. 
Variable 
Any quantity that varies; any attribute, phenomenon or event that can have 
different qualitative or quantitative values. 
 
 


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13 
PROTOCOL AMENDMENT SUMMARY OF CHANGES 
ISN/Protocol 0598-CL-0101 A Phase 1/2, Randomized, Placebo-controlled Study to Assess the Safety, Tolerability, Efficacy, and 
Pharmacokinetics of ASP0598 Otic Solution Following Topical Application into the Ear in Subjects with Chronic Tympanic Membrane 
Perforation (CTMP) 
Amendment 4 [Nonsubstantial] 29 Aug 2022 
This amendment is considered to be nonsubstantial based on the criteria set forth in Article 10(a) of Directive 2001/20/EC of the European Parliament 
and the Council of the European Union because it neither significantly impacts the safety or physical/mental integrity of participants nor the scientific 
value of the study. 
Overall Rationale for the Amendment: 
Language was revised in the protocol to offer the elderly population more opportunity to participate in this First In Human study.   
 
Summary of Changes 
Table 1 
Nonsubstantial Changes 
Section Number 
Description of Change 
Brief Rationale 
Synopsis 
The planned study period is updated to end 3Q2024. 
To update the study period according to the latest timeline. 
Synopsis, 5.1 
Inclusion criterion #2 is updated to allow for enrollment of 
subjects 18 to 75 years of age. 
To allow a more elderly population to participate in the study after the 
study team identified a significant unmet need based on study site 
feedback. Considering this is the First In Human study, an upper age 
limit was included based on the predicted mechanisms of action. There 
is no safety concern for increasing the upper age limit given the nature 
of the CTMP patient population and the observed safety data to date. 
7.6 
Add that for MAD cohorts only, the total amount of whole 
blood collected will be approximately 30.0 mL per subject. 
To reflect the correct amount of blood sample taken for MAD cohorts. 
Throughout 
Minor administrative-type changes, e.g., typos, format, 
numbering, consistency throughout the protocol. 
To provide clarifications to the protocol and to ensure complete 
understanding of study procedures. 
 


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Version 3.3 Incorporating Nonsubstantial Amendment 4 
14 
SPONSOR SIGNATURES 
 

SAP_001.pdf: 
Sponsor: Astellas Pharma Global Development, Inc. 
SAP Final Version 3.0 
ISN/Protocol 0598-CL-0101 
06-July-2022 
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Page 1 of 48 
 
 
 
 
STATISTICAL ANALYSIS PLAN 
 
Final Version 3.0 dated 06-July-2022 
 
A Phase 1/2, Randomized, Placebo-controlled Study to Assess the Safety, Tolerability, 
Efficacy, and Pharmacokinetics of ASP0598 Otic Solution Following Topical application 
into the Ear in Subjects with Chronic Tympanic Membrane Perforation (CTMP) 
 
 
 
ISN: 0598-CL-0101 
 
IND number: 144579 CDER 
 
 
 
 
Astellas Pharma Global Development, Inc. (APGD) 
 
 
 
 
This document contains confidential information which is the intellectual property of Astellas. By accepting or reviewing 
this document, you agree to hold this information in confidence and not copy or disclose it to others or use it for 
unauthorized purposes except (1) as otherwise agreed to in writing; (2) where required by applicable law; (3) where 
disclosure is directly related to the care and safety of the research participant; and (4) where disclosure of such information 
is made to a member of the investigator’s team who agrees to hold this information in confidence. 


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Table of Contents 
I. 
LIST OF ABBREVIATIONS AND KEY TERMS ································
···········
 4 
1 
INTRODUCTION ································
································
··················
 6 
2 
STUDY OBJECTIVE(S) AND DESIGN ································
·······················
 6 
2.1 
Study Objective(s) ································
································
·············
 6 
2.2 
Study Design ································
································
····················
 6 
2.3 
Randomization ································
································
··················
 6 
3 
SAMPLE SIZE································
································
······················
 7 
4 
ANALYSIS SETS ································
································
··················
 7 
4.1 
Full Analysis Set ································
································
···············
 7 
4.2 
Safety Analysis Set ································
································
············
 8 
5 
EFFICACY AND SAFETY ENDPOINTS ································
····················
 8 
5.1 
Primary Safety Endpoint(s) ································
································
···  8 
5.2 
Primary Efficacy Endpoints ································
································
···  9 
5.3 
Secondary Efficacy Endpoints ································
································
 9 
5.3.1 
Intercurrent Events ································
································
······  12 
5.3.2 
Estimand ································
································
··················
 12 
5.4 
Exploratory Endpoints ································
································
········  13 
6 
STATISTICAL METHODOLOGY ································
···························
 17 
6.1 
General Considerations ································
································
·······  17 
6.2 
Study Population ································
································
··············
 18 
6.2.1 
Disposition of Subjects ································
································
· 18 
6.2.2 
Protocol Deviations ································
································
·····  19 
6.2.3 
Demographic and Other Baseline Characteristics ································
···  19 
6.2.4 
Previous and Concomitant Medications ································
··············
 22 
6.3 
Study Drugs Exposure and Compliance ································
····················
 22 
6.4 
Analysis of Efficacy ································
································
··········
 23 
6.4.1 
Analysis of Primary Efficacy Endpoint(s) ································
············
 26 
6.4.2 
Analysis of Secondary Efficacy Endpoints ································
···········
 26 
6.4.3 
Analysis of Exploratory Endpoints ································
····················
 29 
6.5 
Analysis of Safety ································
································
·············
 30 
6.5.1 
Adverse Events ································
································
··········
 30 


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6.5.2 
Bone Conduction Hearing at 1, 2, 4 kHz by PTA ································
···  31 
6.5.3 
Tinnitus Visual Analog Scale (TVAS)································
················
 32 
6.5.4 
Microscopic Ear Examination ································
·························
 32 
6.5.5 
Clinical Laboratory Evaluation ································
························
 34 
6.5.6 
Vital Signs ································
································
················
 34 
6.5.7 
Electrocardiograms ································
································
······  34 
6.6 
Pharmacokinetic ································
································
···············
 34 
6.7 
Other Analyses ································
································
················
 35 
6.8 
Interim Analysis (and Early Discontinuation of the Clinical Study) ····················
 35 
6.9 
Additional Conventions ································
································
······  35 
6.9.1 
Analysis Windows for Safety Variables ································
··············
 35 
6.9.2 
Analysis Windows for Efficacy Variables ································
···········
 37 
6.9.3 
Imputation Rules ································
································
········  39 
7 
REVISION AND RATIONALE ································
································
 42 
7.1 
List of Changes in SAP Version 3.0 from Version 2.0 ································
···  42 
7.2 
List of Changes in SAP Version 2.0 from Version 1.0 ································
···  43 
8 
REFERENCES ································
································
····················
 44 
9 
APPENDICES ································
································
·····················
 45 
9.1 
Appendix 1: Pre-Specified Criteria for Adverse Events of Interest: 
Cholesteatoma or Neoplasm ································
································
· 45 
9.2 
Appendix 2: Pre-Specified Criteria for Adverse Events of Interest: Ototoxic 
symptoms (Tinnitus, Sensorineural hearing loss, Dizziness) ····························
 46 
9.3 
Appendix 3: Pre-Specified Criteria for Adverse Events of Interest: Otitis media 
or Otitis externa ································
································
···············
 47 
9.4 
Appendix 4: Author and Approver Signatures ································
············
 48 
 


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I. 
LIST OF ABBREVIATIONS AND KEY TERMS 
List of Abbreviations 
Abbreviations 
Description of abbreviations 
A-B 
Air bone 
AE 
Adverse Event 
BLQ 
Below the Limit of Quantification 
BMI 
Body Mass Index 
CMQ 
Custom MedDRA Query 
COVID-19 
Coronavirus Disease 2019 
CSR 
Clinical Study Report 
CTMP 
Chronic Tympanic Membrane Perforation 
CV 
Coefficient of Variation 
dB  
Decibels 
DMC 
Data Monitoring Committee 
EOS 
End of Study 
FAS 
Full Analysis Set 
IAP 
Interim Analysis Plan 
ICE 
Intercurrent Event 
ICH 
International Conference on Harmonization 
IRT 
Interactive Response Technology 
LS 
Least Square 
MAD 
Multiple Ascending Dose 
MDE 
Multiple Dose Expansion 
MedDRA 
Medical Dictionary for Regulatory Activities 
MH 
Mantel–Haenszel 
MI 
Multiple imputation 
mL 
Milliliter 
mmHg 
Millimeters of mercury 
MMRM 
Mixed Model Repeated Measures 
MNAR 
Missing Not At Random 
PD1-x 
Protocol Deviation 1-x 
PT 
Preferred Term 
PTA 
Pure Tone Audiometry 
ROI 
Region of Interest 
SAD 
Single Ascending Dose 
SAF 
Safety Analysis Set 
SAP 
Statistical Analysis Plan 
SD 
Standard Deviation 


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Abbreviations 
Description of abbreviations 
SE 
Standard Error 
SOC 
System Organ Class 
TEAE 
Treatment-Emergent Adverse Event 
TLF 
Tables, Listings, and Figures 
TMP 
Tympanic Membrane Perforation 
TVAS 
Tinnitus Visual Analog Scale 
 
List of Key Terms 
Terms 
Definition of Terms 
TEAE 
An adverse event (AE) observed after starting administration of the study 
drug through end of study visit. If an AE occurs on Day 1 and the onset check 
box is marked “Onset after the dose of study drug” or the onset check box is 
left blank, then the AE will be considered Treatment-Emergent AE.  
Drug-related 
TEAE 
Any TEAE with a causal relationship assessed as “yes” by the investigator. 
Study Period 
Period of time from the first study site initiation date to the last study site 
completing the study. 
 
 
 


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1 
INTRODUCTION 
This Statistical Analysis Plan (SAP) contains technical and detailed elaboration of the 
principal features of the analysis described in the protocol, and includes procedures for 
executing the statistical analysis to fulfil the objectives of the study. 
The final SAP will be approved prior to database lock. Any changes to the dose escalation 
phase of the SAP will be approved prior to unblinding the dose escalation phase data for the 
prescribed interim analysis. Interim analysis plan (IAP) for the dose escalation phase will be 
prepared separately, and approved prior to unblinding the dose escalation phase.  
Changes from the planned analyses in the final SAP that impact the statistical analyses will 
be documented in the Clinical Study Report (CSR).  
2 
STUDY OBJECTIVE(S) AND DESIGN 
2.1 
Study Objective(s) 
Primary objective: To evaluate the safety and tolerability of ASP0598 Otic Solution. 
Secondary objective: To evaluate the efficacy of ASP0598 Otic Solution.  
Exploratory objective:  
To evaluate otological parameters that may correlate with efficacy outcome and 
pharmacokinetics of ASP0598 Otic Solution. 
To evaluate the safety of ASP0598 Otic Solution.  
2.2 
Study Design 
Details of the schedule of clinical assessments are available in the protocol. 
2.3 
Randomization 
Dose escalation 
Dose escalation will consist of up to 4 cohorts for single ascending dose (SAD) and up to 
2 cohorts for multiple ascending dose (MAD). In each cohort of the SAD, a total of 
5 subjects will be randomized in a 4:1 ratio of ASP0598 Otic Solution and placebo. In each 
cohort of the MAD, a total of 8 subjects will be randomized in a 3:1 ratio of ASP0598 Otic 
Solution and placebo.  
For each cohort in SAD and MAD, a simple block randomization schedule will be generated.  
Dose expansion 
The decision to open the single and multiple dose expansion phases will be based on the 
safety and efficacy results of the interim analyses after completion of SAD and after 
completion of MAD, respectively.  
Up to 39 subjects will be randomized to each of the single dose and/or multiple dose 
expansion phases of the study. Based on the interim analysis results, 


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● If 3 treatment groups are selected, approximately 39 subjects will be randomized in a 
1:1:1 ratio of high dose ASP0598 otic solution, low dose ASP0598 otic solution and 
placebo (13 subjects in each treatment group).  
● If 2 treatment groups are selected, approximately 26 subjects will be randomized in a 
1:1 ratio of high dose ASP0598 otic solution (13 subjects) or placebo (13 subjects).  
Stratification at the time of randomization will be based on the % size of the TMP (≤ 15%, 
> 15%) and subjects will be balanced equally between the treatment groups.  
For all phases subjects may be replaced at the discretion of the sponsor. If replaced, the 
replacement subject will be given the same treatment group the original subject’s randomized 
treatment group. Randomization will be performed via interactive response technology (IRT) 
using central allocation. If a subject is assigned a randomization number, but does not receive 
study drug, the randomization number will not be used again. Specific procedures for 
randomization through the IRT are contained in the study-specific IRT manual.  
3 
SAMPLE SIZE 
SAD and MAD 
Formal sample size calculations were not performed. The dose escalation phase is not 
intended to show statistical difference between ASP0598 Otic Solution and placebo subjects.  
A sample size of 5 per cohort (n = 4 ASP0598 Otic Solution, n = 1 placebo) for SAD and 
8 per cohort (n = 6 ASP0598 Otic Solution, n = 2 placebo) for MAD is based on precedent 
set by other clinical studies of similar nature. The number of subjects and study procedures 
planned for this clinical study are considered reasonable to achieve the clinical study 
objectives.   
Dose expansion 
Assuming the complete closure rate in placebo and ASP0598 higher concentration group are 
10% and 80% respectively, eleven (11) subjects per treatment group will provide more than 
90% power to detect a statistically significant difference at a 2-sided significance level of 
0.05. Considering the drop-out rate of 10%, 13 subjects per treatment group will be enrolled 
(nQuery Advisor 7.0).  
4 
ANALYSIS SETS 
In accordance with International Conference on Harmonization (ICH) recommendations in 
guidelines E3 and E9, the following analysis sets will be used for the analyses. 
The determination of whether subjects are included or excluded from the safety and efficacy 
analysis sets will be made prior to database lock. For the dose escalation phase, the 
determination will be made prior to finalization of relevant programming activities for the 
prescribed interim analysis. 
4.1 
Full Analysis Set 
The full analysis set (FAS) will consist of all randomized subjects who receive a dose of 


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study drug and have baseline value and at least 1 post baseline complete closure assessment 
during study period. This will be the primary analysis set for efficacy analyses. 
In the analyses of FAS, subjects will be presented by randomized (planned) treatment group 
even if the treatment they received was different. 
For study period, post baseline values will not contribute to the FAS as shown below:  
● SAD: if the study day of the value is > minimum(study day of end of study visit, 57)  + 
7 days.  
● Single dose expansion and MAD: if the study day of the value is > minimum(study day of 
end of study visit, 85)  + 7 days. 
● Multiple dose expansion: if the study day of the value is > minimum(study day of end of 
study visit, 113)  + 7 days. 
4.2 
Safety Analysis Set 
The safety analysis set (SAF) consists of all randomized subjects who receive a dose of study 
drug. The SAF will be the primary analysis set for the safety data and pharmacokinetic data. 
In the analyses of SAF, subjects will be presented by actual treatment received.  
For MAD and multiple dose expansion, actual treatment will be the same as planned 
treatment if the subject receives randomized treatment for the entire treatment duration. 
Otherwise, actual treatment will be the treatment corresponding to the first treatment actually 
received.  
5 
EFFICACY AND SAFETY ENDPOINTS  
5.1 
Primary Safety Endpoint(s) 
● Treatment-emergent adverse events (TEAEs) 
o TEAE: an AE observed after starting administration of the study drug through end of 
study visit. If an AE occurs on Day 1 and the onset check box is marked “Onset after 
the dose of study drug” or the onset check box is left blank, then the AE will be 
considered TEAE. Refer to Section 6.9.1 for end day of end of study visit definition. 
o Drug-related TEAE: any TEAE with a causal relationship assessed as “yes” by the 
investigator. If the relationship is missing then it is considered as drug-related. 
Imputed date for AE onset date may be used to determine TEAE (Section 6.9.3.1).  
The investigator will use the following definitions to rate the severity of each AE: 
o Mild 
o Moderate 
o Severe 


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● Incidence of AEs of special interest will be defined as shown below.  
1. Cholesteatoma or neoplasm 
2. Ototoxic symptoms (tinnitus, sensorineural hearing loss, dizziness) 
3. Otitis media or otitis externa 
AEs of special interest will be identified using custom MedDRA queries (CMQs). 
Detailed information about AEs of special interest is provided in Appendices 1, 2 and 3. 
● Change from baseline in bone conduction hearing at 1, 2, 4 kHz by Pure Tone 
Audiometry (PTA) 
A lower value indicates better level of hearing. 
For the change from baseline, a negative value (decrease from baseline) indicates 
improvement (i.e., better level of hearing). 
Mean bone conduction hearing (dB): 
Arithmetic mean of the values at 1, 2 and 4 kHz. If the value is missing for any of the 
3 frequencies, then the mean value will be set to missing. 
● Change from baseline in Tinnitus Visual Analog Scale (TVAS) 
The TVAS is a numeric scale and ranges from 0 (not at all strong or loud) to 
10 (extremely strong or loud). A lower value indicates less level of discomfort. 
For the change from baseline, a negative value (decrease from baseline) indicates 
improvement (i.e., less level of discomfort). 
TVAS may be reported for one of the following areas: ear (left, right or bilateral) or 
other.  
At a time point, if a subject did not experience tinnitus, TVAS will be reported as 0. In 
this case, the TVAS will be considered as 0 for all two areas. 
At a time point, if a subject experiences tinnitus, the result will be reported with a value 
ranging from 1 to 10 for one of the areas. In this situation, the TVAS result will be 
imputed as 0 for the other areas [e.g., if TVAS = 3 for the ear (left) then TVAS will be 
imputed as 0 for ear (right) and other. if TVAS = 3 for the ear (bilateral) then TVAS will 
be imputed as 3 for ear (left) and ear (right) and 0 for other].  
5.2 
Primary Efficacy Endpoints  
Not applicable.  
5.3 
Secondary Efficacy Endpoints 
SAD and Single dose expansion  
Categorical endpoint: 
● Complete closure of Tympanic Membrane Perforation (TMP) at Week 8 for SAD and at 
Week 12 for single dose expansion 


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TMP complete closure observed response: 
Using the non-missing result of complete closure of TMP, an observed response is 
Yes: if a subject with complete closure of TMP, 
No: if the above condition is false. 
TMP complete closure imputed response at Week 8 for SAD: 
Using the non-missing result at Week 8, an imputed response is same as observed 
response at Week 8.  
If a response is missing at Week 8, assign the latest post baseline observed response 
available prior to Week 8. 
TMP complete closure imputed response at Week 12 for single dose expansion 
(Primary analysis imputation): 
For endpoint #1 defined in Section 5.3.2, using the non-missing result at Week 12, an 
imputed response is 
No intercurrent events (ICE) occurs: same as observed response at Week 12, 
ICE occurs: assign the latest post baseline observed response available just before the 
ICE.  
TMP complete closure imputed response at Week 12 for single dose expansion 
(Sensitivity analysis imputation): 
For endpoint #1 defined in Section 5.3.2, using the non-missing result at Week 12, an 
imputed response is 
No ICE occurs: same as observed response at Week 12, 
ICE occurs: No. 
Continuous endpoints: 
● Change from baseline in the ratio of TMP size per total area of tympanic membrane at 
Week 8 for SAD and at Week 12 for single dose expansion 
Ratio of TMP size per total area of tympanic membrane (%): 
[TMP Size ÷ Periphery of the Tympanic Membrane Region of Interest (ROI)] × 100 
● Change from baseline in TMP size at Week 8 for SAD and at Week 12 for single dose 
expansion 
Here TMP size = TMP ROI from imaging data. 
MAD and Multiple dose expansion  
Categorical endpoint: 
● Complete closure of TMP at Week 12 for MAD and at Week 16 for multiple dose 


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expansion 
TMP complete closure observed response: 
Using the non-missing result of complete closure of TMP, an observed response is 
Yes: if a subject with complete closure of TMP, 
No: if the above condition is false. 
TMP complete closure imputed response at Week 12 for MAD: 
Using the non-missing result at Week 12, an imputed response is same as observed 
response at Week 12.  
If a response is missing at Week 12, assign the latest post baseline observed response 
available prior to Week 12. 
TMP complete closure imputed response at Week 16 for multiple dose expansion 
(Primary analysis imputation): 
For endpoint #1 defined in Section 5.3.2, using the non-missing result at Week 16, an 
imputed response is 
No ICE occurs: same as observed response at Week 16, 
ICE occurs: assign the latest post baseline observed response available just before the 
ICE.  
TMP complete closure imputed response at Week 16 for multiple dose expansion 
(Sensitivity analysis imputation): 
For endpoint #1 defined in Section 5.3.2, using the non-missing result at Week 16, an 
imputed response is 
No ICE occurs: same as observed response at Week 16, 
ICE occurs: No. 
TMP complete closure imputed response at Week 12 for multiple dose expansion: 
Using the non-missing result at Week 12, an imputed response is same as observed 
response at Week 12.  
If a response is missing at Week 12, assign the latest post baseline observed response 
available prior to Week 12. 
Continuous endpoints: 
● Change from baseline in the ratio of TMP size per total area of tympanic membrane at 
Week 12 for MAD and at Week 16 for multiple dose expansion 
● Change from baseline in TMP size at Week 12 for MAD and at Week 16 for multiple 
dose expansion 
For the change from baseline in the ratio of TMP size per total area of tympanic membrane 


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and the change from baseline in TMP size, a negative value (decrease from baseline) 
indicates improvement. 
For dose expansion, hypothetical strategy will be applied to analyze the secondary endpoints. 
Details of ICEs and estimand are shown in Section 5.3.1.  
5.3.1 
Intercurrent Events 
Single dose expansion and Multiple dose expansion 
1. Intercurrent events (ICEs): For the subjects discontinued during the study 
investigational period, the following ICEs may happen: 
● Randomized but never received study drug 
● Study investigational period discontinuation due to  
o 
AE 
o 
Lack of efficacy 
o 
Lost to follow up 
o 
Protocol deviation 
o 
Withdrawal by subject 
o 
Other 
● Death 
2. Treatment regimen under evaluation: randomized treatment administered as directed 
per schedule of assessments. 
5.3.2 
Estimand 
Population: defined by the appropriate inclusion/exclusion criteria in the protocol.  
Efficacy endpoints:  
3. Complete closure of TMP at Week 12 for single dose expansion and Week 16 for 
multiple dose expansion. 
4. Change from baseline in the ratio of TMP size per total area of tympanic membrane at 
Week 12 for single dose expansion and Week 16 for multiple dose expansion. 
5. Change from baseline in TMP size at Week 12 for single dose expansion and Week 16 
for multiple dose expansion. 
Strategy for addressing ICEs: hypothetical strategy will be used to estimate the outcome at 
Week 12 for single dose expansion and Week 16 for multiple dose expansion. 
Population-level summary:  
● Endpoint #1 (Categorical): difference in proportion of subjects with complete closure of 
TMP at Week 12 for single dose expansion and Week 16 for multiple dose expansion 
between ASP0598 and placebo. 
● Endpoint #2 (Continuous): difference in mean change from baseline in the ratio of TMP 
size per total area of tympanic membrane at Week 12 for single dose expansion and 
Week 16 for multiple dose expansion between ASP0598 and placebo. 


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● Endpoint #3 (Continuous): difference in mean change from baseline in TMP size at 
Week 12 for single dose expansion and Week 16 for multiple dose expansion between 
ASP0598 and placebo. 
Data that will be used for the estimand:  
● Endpoint #1: data necessary for this estimand is complete closure status at Week 12 for 
single dose expansion and Week 16 for multiple dose expansion. For the subjects 
discontinued during the study investigational period with ICEs, the complete closure 
status just before the ICE will be used as the status at Week 12 for single dose expansion 
and Week 16 for multiple dose expansion. 
● Endpoints #2 and #3: data necessary for these estimands are TMP size per total area of 
tympanic membrane and TMP size at each visit, respectively. For the subjects 
discontinued during the study investigational period with ICEs, only data obtained before 
the ICE will be used in the Mixed model repeated measures (MMRM) to handle 
discontinued subjects in some sense if the subjects remained in the study under missing at 
random (MAR) assumption. 
5.4 
Exploratory Endpoints 
Single dose phase:  
● 
Complete closure of TMP for post baseline visits at Day 2, Day 3 (evaluations at this 
visit will only be performed for cohorts 1, 2 and 3), Week 1, Week 2 and Week 4 for 
SAD and Week 2, Week 4 and Week 8 for single dose expansion  
For the observed response definition, refer to Section 5.3.  
● 
Change from baseline in the ratio of TMP size per total area of tympanic membrane for 
post baseline visits at Day 2, Day 3 (evaluations at this visit will only be performed for 
cohorts 1, 2 and 3), Week 1, Week 2 and Week 4 for SAD and Week 2, Week 4 and 
Week 8 for single dose expansion 
● 
Change from baseline in TMP size for post baseline visits at Day 2, Day 3 (evaluations 
at this visit will only be performed for cohorts 1, 2 and 3), Week 1, Week 2 and Week 4 
for SAD and Week 2, Week 4 and Week 8 for single dose expansion 
Multiple dose phase: 
● 
Complete closure of TMP for post baseline visits at Week 1, Week 2, Week 3, Week 4, 
Week 5 and Week 8 for MAD and Week 2, Week 4, Week 6, Week 8 and Week 12 for 
multiple dose expansion 
For the observed response definition, refer to Section 5.3. 
● 
Change from baseline in the ratio of TMP size per total area of tympanic membrane for 
post baseline visits at Week 1, Week 2, Week 3, Week 4, Week 5 and Week 8 for MAD 
and Week 2, Week 4, Week 6, Week 8 and Week 12 for multiple dose expansion 


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● 
Change from baseline in TMP size for post baseline visits at Week 1, Week 2, Week 3, 
Week 4, Week 5 and Week 8 for MAD and Week 2, Week 4, Week 6, Week 8 and 
Week 12 for multiple dose expansion 
Single and multiple dose phases: 
● 
Time to closure of TMP 
Time to closure of TMP (days):  
TMP closure date - first dose date + 1. If the TMP is not closed, then time to closure will 
be set to missing. 
● 
Size of TMP ≤ 5% of pars tensa surface area after treatment 
Observed response: 
Using the non-missing size of TMP per pars tensa surface area, an observed response is 
Yes: if the post baseline size of the TMP per pars tensa surface area ≤ 5% and the size 
of the TMP per pars tensa surface area is smaller than baseline, 
No: if the above condition is false. 
Ratio of TMP size per total area of tympanic membrane will be used in the above 
calculation as an approximation for TMP per pars tensa surface area. 
● 
Size of TMP ≤ 1% of pars tensa surface area (pin point perforation) after treatment 
Observed response: 
Using the non-missing size of TMP per pars tensa surface area, an observed response is 
Yes: if the post baseline size of the TMP per pars tensa surface area ≤ 1% and the size 
of the TMP per pars tensa surface area is smaller than baseline, 
No: if the above condition is false. 
Ratio of TMP size per total area of tympanic membrane will be used in the above 
calculation as an approximation for TMP per pars tensa surface area. 
● 
Change from baseline in Air bone (A-B) gap by PTA 
For the change from baseline in A-B gap, a negative value (decrease from baseline) 
indicates an improvement.  
PTA is a behavioral test and generally the 1st quantitative hearing test done to assess the 
nature and degree of hearing loss in adults and in children. 
PTA air conduction and bone conduction tests analyzed together determines any hearing 
loss: type and magnitude of hearing loss; frequencies that are affected; and whether 
hearing loss is unilateral or bilateral. For both air and bone conduction, a lower value 
indicates better hearing threshold. 


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Type of hearing loss can be as follows: 
o Conductive hearing loss: when air conduction thresholds are elevated relative to bone 
conduction thresholds, an “A-B gap” exists, indicates a conductive hearing loss.  
o Sensorineural hearing loss: when air conduction and bone conduction thresholds 
showing the same amount of hearing loss, indicates sensorineural hearing loss. 
o Mixed hearing loss: when both air and bone conduction thresholds are elevated, but 
air conduction thresholds are more elevated than bone conduction thresholds, 
indicates mixed hearing loss. 
Definitions for mean bone conduction hearing, mean air conduction hearing, mean A-B 
gap and A-B gap (dB) for each frequency are provided below: 
Mean bone conduction hearing (dB): 
Arithmetic mean of the bone conduction hearing values at 500 Hz, 1, 2 and 4 kHz. If the 
value is missing for any of the 4 frequencies, then the mean value will be set to missing. 
Mean air conduction hearing (dB): 
Arithmetic mean of the air conduction hearing values at 500 Hz, 1, 2 and 4 kHz. If the 
value is missing for any of the 4 frequencies, then the mean value will be set to missing. 
Mean A-B gap (dB):  
Mean air conduction hearing  - mean bone conduction hearing. If either one is missing or 
both are missing then the mean A-B gap is set to missing. 
A-B gap (dB) for each frequency: 
Air conduction hearing at the frequency level - bone conduction hearing at the frequency 
level. If either one is missing or both are missing then the A-B gap is set to missing. This 
will be derived for frequencies 500 Hz, 1 kHz, 2 kHz, and 4 kHz. 
● 
Change from baseline in air conduction hearing by PTA 
Mean air conduction hearing will be derived as explained in the endpoint Percentage 
improvement from baseline in A-B gap by PTA ≥ 50% (improvement of conductive 
hearing) 
● 
Percentage improvement from baseline in A-B gap by PTA ≥ 50% (improvement of 
conductive hearing) 
Observed response: 
Using the non-missing percentage change from baseline in mean A-B gap, an observed 
response is 
Yes: if the percentage change from baseline in mean A-B gap (derived using mean of 
the A-B gap results at 500 Hz, 1, 2 and 4 kHz)  ≤ -50%, 
No: if the above condition is false. 


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● 
Improvement from baseline in air conduction hearing by PTA ≥ 15 dB 
For the change from baseline in air conduction hearing, a negative value (decrease from 
baseline) indicates an improvement.  
Observed response: 
Using the non-missing change from baseline mean air conduction hearing, an observed 
response is 
Yes: if the change from baseline in mean air conduction hearing by PTA ≤ -15 dB, 
No: if the above condition is false. 
● 
A-B gap after treatment was 15 dB or less 
Observed response: 
Using the non-missing mean A-B gap, an observed response is 
Yes: if the post baseline mean A-B gap  ≤ 15 dB, 
No: if the above condition is false. 
● 
Air conduction hearing threshold after treatment was 30 dB or less 
For the air conduction hearing, a lower value indicates better hearing threshold. 
Observed response: 
Using the non-missing mean air conduction hearing, an observed response is 
Yes: if the post baseline mean air conduction hearing  ≤ 30 dB, 
No: if the above condition is false. 
● 
Type of tympanogram (A, B or C) 
For Type A, there are 2 additional subcategories: Ad and As. 
● 
Equivalent ear canal volume (ECV) by tympanometry 
Safety endpoint: 
● 
Vital signs (body temperature, blood pressure and pulse rate) 
● 
Microscopic ear examination 
At screening, both ears will be examined microscopically to identify the TMP and 
evaluate the eligibility of the subject for the study. Only treated ear will be examined at 
Day 1 and the following visits.  
On Day 1, Week 2 (multiple dose only), and Week 4 (multiple dose only), 1 h after the 
treatment, the following ear canal reactions of treated ear will be collected. 
Did the ear experience an abnormal ear sensation 
o No 


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o Yes 
▪ Burning 
▪ Stinging 
▪ Itching 
▪ Pain 
▪ Other 
After Day 1, data for the following parameters will be collected: 
o Gel visible in the treated ear (Yes, No) 
o Gel visible in the middle ear (Yes, No) 
o TMP of treated ear completely closed (Yes, No, Unknown) 
o Ear pain (otalgia) in the treated ear (Yes, No) 
o Status of the treated tympanic membrane (Normal, Abnormal, Abnormal: Myringitis, 
Abnormal: Hematoma, Abnormal: Other, Not visible) 
o Status of the middle ear in the treated ear (Normal, Abnormal, Abnormal: Mucosal 
inflammation with effusion, Abnormal: Mucosal inflammation without effusion, 
Abnormal: Other, Not visible) 
Local skin reaction around the application site will be examined at 60 minutes after the 
treatment at Day 1 and throughout the observation period. Skin toxicity will be evaluated by 
Modified Brighton Grading Scheme as shown below.  
Grade 
Description 
0 
no abnormalities 
1 
canal erythema 
1b 
canal erythema with otorrhea (ear canal fluid discharge) 
2 
canal erythema + swelling, TM still visible 
2b 
canal erythema + swelling, TM still visible with otorrhea 
3 
canal erythema + swelling, TM not visible 
3b 
canal erythema + swelling, TM not visible with otorrhea 
4 
canal erythema + swelling, TM not visible + erythema and swelling of the pinna 
4b 
canal erythema + swelling, TM not visible + erythema and swelling of the pinna with 
otorrhea 
Pharmacokinetics: 
● 
Serum concentration of ASP0598 (dose escalation part only) 
6 
STATISTICAL METHODOLOGY 
6.1 
General Considerations 
Continuous data will be summarized descriptively including the number of subjects (n), 
mean, standard deviation (SD) and/or standard error, median, minimum and maximum.  


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Categorical data will be summarized by frequencies and percentages. Percentages by 
categories will be based on the number of subjects with no missing data, i.e. the percentages 
for the non-missing categories will add up to 100%. 
For SAD and MAD, results will be presented by ASP0598 treatment group in each cohort 
and placebo group where placebo subjects will be pooled across cohorts. 
For single dose expansion and multiple dose expansion, results will be presented by each 
ASP0598 treatment group and placebo group. 
All statistical comparisons between ASP0598 and placebo will be conducted using 2-sided 
tests at α = 0.05 significance level, unless stated otherwise. For dose expansion phase, a 
hierarchical testing method will be used to control familywise error rate where the highest 
dose group vs placebo will be tested first. Refer to Section 6.4.2 for details.  
All data summarization and analyses will be performed using SAS® Version 9.4 or higher on 
Redhat Enterprise Linux. Specifications for tables, listings, and figures (TLF) formats can be 
found in the TLF specifications.  
6.2 
Study Population 
6.2.1 
Disposition of Subjects 
The following subject data will be presented. Unique subjects are defined as rescreened 
subjects for whom the data from the last enrollment are used. 
● Number of subjects with informed consent, unique subjects with informed consent,  
subjects with rescreening, subjects discontinued before randomization, unique subjects 
who discontinued before randomization and randomized for all subjects with informed 
consent (overall only), 
● Screening disposition for all unique subjects with informed consent (overall only), 
● Number and percentage of subjects who were randomized, were administered study drug, 
were not administered study drug, in the analysis sets by treatment group, ASP0598 total 
and ‘total’ over all treatment groups for all randomized subjects, 
● Treatment disposition for all randomized subjects, SAF and FAS by each treatment 
group, ASP0598 total and ‘total’ over all treatment groups, 
● Investigational period disposition for all randomized subjects, SAF and FAS by each 
treatment group, ASP0598 total and ‘total’ over all treatment groups, and 
● Protocol version disposition for all unique subjects with informed consent by each 
treatment group and ‘total’ over all treatment groups for all randomized subjects, screen 
failures only and overall including screen failures, 
● Number and percentage of subjects by site and country by treatment group and ‘total’ 
over all treatment groups for all randomized subjects. 
● Number and percentage of subjects discontinued (cumulative by analysis visit) the study 
investigational period by analysis visit (Weeks 2, 4 and 8 for SAD, Weeks 2, 4, 8 and 12 
for single dose expansion, Weeks 1, 2, 3, 4, 5, 8 and 12 for MAD, Weeks 2, 4, 6, 8, 12 
and 16 for multiple dose expansion) and completed the study investigational period by 


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each treatment group for the FAS. For analysis visit windows, refer to Table 6. For 
Week 2 SAD visit window will be same as Week 2 single dose expansion window.  
6.2.2 
Protocol Deviations 
The number and percentage of subjects with the following protocol deviation criteria will be 
summarized for each criterion and overall, by treatment group, ASP0598 total and ‘total’ 
over all treatment groups as well as by investigative site. Subjects deviating from a criterion 
more than once will be counted once for the corresponding criterion. 
The unique identifiers will be as follows: 
PD1 - Entered into the study even though they did not satisfy entry criteria,  
PD2 - Developed withdrawal criteria during the study and was not withdrawn, 
PD3 - Received wrong treatment or incorrect dose, 
PD4 - Received excluded concomitant treatment. 
6.2.3 
Demographic and Other Baseline Characteristics 
Demographics and baseline characteristics will be summarized using descriptive statistics for 
all randomized subjects, SAF and FAS by treatment group, ASP0598 total (if applicable) and 
‘total’ over all treatment groups. 
Demographics variables: 
Variable 
Variable Type Categories 
Sex 
Categorical 
• Male 
• Female 
• Unknown 
Race 
Categorical 
• White 
• Black or African American 
• Asian 
• American Indian or Alaska Native 
• Native Hawaiian or Other Pacific 
Islander 
• Other 
Ethnicity  
Categorical 
• Not Hispanic or Latino 
• Hispanic or Latino 
Table continued on next page 


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Variable 
Variable Type Categories 
Age 
Continuous 
NA 
Age Group 
Categorical 
• ≤ 60 years 
• > 60 years 
EudraCT Age Category 
Categorical 
• ≥ 18 to ≤ 64 years  
• ≥ 65 years to ≤ 84 years 
Baseline weight 
Continuous 
NA 
Height 
Continuous 
NA 
Baseline body mass index (BMI) Continuous 
NA 
Baseline BMI group 
Categorical 
• ≤ 30 kg/m2 
• > 30 kg/m2 
Primary Diagnosis: 
Onset of chronic tympanic 
membrane perforation (CTMP) 
(years) 
derived as (Informed consent 
date  - onset date of 
CTMP)/365.25.  
Imputed date for onset date of 
CTMP may be used to calculate 
the onset of CTMP  
(Section 6.9.3.4). 
Continuous 
NA 
CTMP duration group 
Categorical 
• ≤ 1 year 
• > 1 year 
o > 1 to ≤ 10 years 
o > 10 years 
TMP present 
Categorical 
• Left ear 
• Right ear 
• Both ears 
Treated ear 
Categorical 
• Left ear 
• Right ear 
Primary Cause of TMP 
Categorical 
• Infection (CSOM) 
• Trauma 
• Placement of tube 
• Iatrogenic complication 
• Other 
Table continued on next page 


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Variable 
Variable Type Categories 
Areas of tympanic membrane 
involved in TMP 
Categorical 
• Anterior superior 
• Anterior inferior 
• Posterior superior 
• Posterior inferior 
• Anterior Superior/ 
Anterior Inferior 
• Anterior Inferior/ 
Posterior Inferior 
• Posterior Superior/ 
Posterior Inferior 
Areas of tympanic membrane 
involved in TMP group 
Categorical 
• 1 
• 2 
• ≥ 3 
Derived as number of areas of 
tympanic membrane involved in TMP. 
Paper patch to treat the treated 
ear 
Categorical 
• Yes 
• No 
Stratification factor TMP size 
group (expansion only) 
Categorical 
• ≤ 15% 
• > 15% 
Targeted Medical History 
Tobacco history 
Categorical 
• Yes (Current) 
• No (Former or Never) 
o Former 
o Never 
Diabetes history 
Categorical 
• Yes 
• No 
Latex allergy history 
Categorical 
• Yes 
• No 
Latex sensitivity history 
Categorical 
• Yes 
• No 
Cannabis History 
History of Cannabis Use 
Categorical 
• Current 
• Former 
• Never 
 


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Baseline variables: 
Variable 
Variable Type 
Categories 
Secondary Variables: 
Baseline ratio of TMP size 
group per total area of tympanic 
membrane from central imaging 
Categorical 
• ≤ 15% 
• > 15% 
Baseline TMP size from central 
imaging 
Continuous 
NA 
Baseline ratio of TMP size per 
total area of tympanic 
membrane from central imaging 
Continuous 
NA 
Other Efficacy Variables: 
Baseline mean air conduction 
hearing loss by PTA 
Continuous 
NA 
Baseline mean air conduction 
hearing loss group by PTA  
Categorical 
• Normal (≤ 25 dB) 
• Mild hearing loss (> 25 to ≤ 40 dB) 
• Moderate hearing loss  
(> 40 to ≤ 55 dB) 
• Moderately severe hearing loss  
(> 55 to ≤ 70 dB) 
• Severe hearing loss  
(> 70 to ≤ 90 dB) 
• Profound loss (> 90 dB) 
Medical history is coded in Medical Dictionary for Regulatory Activities (MedDRA) and will 
be summarized by System Organ Class (SOC) and Preferred Term (PT) for the SAF by 
treatment group, ASP0598 total (if applicable) and ‘Total’ over all treatment groups. 
6.2.4 
Previous and Concomitant Medications 
A previous medication is defined as any medication taken before the dose of study drug. 
A concomitant medication is defined as any medication taken on or after the dose of study 
drug through end of study visit. Refer to Section 6.9.1 for end day of end of study visit 
definition. 
Medications that started prior to the dose of study drug and continued on or after the dose of 
study drug will be counted in both previous and concomitant medications. 
Imputed dates for medication start and stop dates may be used to determine the medication is 
a previous or concomitant medication or both (Section 6.9.3.2). 
Previous and concomitant medications will be listed only.  
6.3 
Study Drugs Exposure and Compliance 
Actual dose of study drug will be summarized using descriptive statistics, entire planned 
volume of study drug administered (Yes, No), was there needle stick of injury during study 


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drug administration (Yes, No), area of injury (Ear Canal Skin, Tympanic membrane, Other)  
and multiple dose phase only: total number of doses administered (1, 2 and 3) will be 
summarized using number and percentage of subjects for the SAF by treatment group. 
Actual dose of study drug (µg) = Administration concentration (µg/mL) x Actual volume of 
study drug (mL). 
Administration concentration values for each dose are provided in Table 1 of the protocol. 
Imputed date for study drug dose date may be used (Section 6.9.3.3). 
6.4 
Analysis of Efficacy  
Efficacy analyses will be presented by treatment group for FAS, unless specified otherwise. 
For the endpoint complete closure of TMP at Week 12/Week 16 in dose expansion, based on 
the interim analysis results, if 3 treatment groups are selected, hierarchical testing method 
will be used to control familywise error rate where the highest dose group vs placebo will be 
tested first. Refer to Section 6.4.2 for details. If 2 treatment groups are selected, no 
multiplicity adjustment is needed. 
For continuous endpoints, descriptive statistics will be used to summarize baseline value, 
post baseline value and change from baseline at each specified post baseline analysis visit by 
treatment group.  
For categorical endpoints, number and percentage of subjects will be used to summarize 
baseline value and post baseline value at each specified post baseline analysis visit by 
treatment group. Difference from placebo will be presented, where applicable.  
Table 1 and Table 2 provides list of variables that will be summarized for categorical 
endpoints using number and percentage of subjects and for continuous endpoints using 
descriptive statistics respectively.   
Table 3 provides an overview of efficacy analyses of secondary and exploratory variables for 
dose expansion phase.   
Table 1 
Categorical Efficacy Variables for Number and Percentage of Subjects 
Variable 
Analysis Visits 
Observed response for complete closure 
of TMP as assessed by site investigator 
SAD: Baseline, Day 2, Day 3*, Week 1, Week 2, Week 4, 
Week 8 and End of Study (EOS) 
Single dose expansion: Baseline, Week 2, Week 4, Week 8, 
Week 12 and EOS 
MAD: Baseline, Week 1, Week 2, Week 3, Week 4, Week 5, 
Week 8, Week 12 and EOS 
Multiple dose expansion: Baseline, Week 2, Week 4, Week 6, 
Week 8, Week 12, Week 16 and EOS 
Table continued on next page 


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Variable 
Analysis Visits 
Observed response for complete closure 
of TMP as assessed by central reader 
SAD: Baseline, Day 2, Day 3*, Week 1, Week 2, Week 4, 
Week 8 and End of Study (EOS) 
Single dose expansion: Baseline, Week 2, Week 4, Week 8, 
Week 12 and EOS 
MAD: Baseline, Week 1, Week 2, Week 3, Week 4, Week 5, 
Week 8, Week 12 and EOS 
Multiple dose expansion: Baseline, Week 2, Week 4, Week 6, 
Week 8, Week 12, Week 16 and EOS 
Imputed response for complete closure 
of TMP as assessed by site investigator 
SAD: Week 8 
Single dose expansion: Week 12 primary analysis and Week 12 
sensitivity analysis 
MAD: Week 12  
Multiple dose expansion: Week 12 and Week 16 primary 
analysis and Week 16 sensitivity analysis 
Imputed response for complete closure 
of TMP as assessed by central reader 
SAD: Week 8 
Single dose expansion: Week 12 primary analysis and Week 12 
sensitivity analysis 
MAD: Week 12  
Multiple dose expansion: Week 12 and Week 16 primary 
analysis and Week 16 sensitivity analysis 
Reduction from baseline in size of TMP 
to less than or equal to 5% of pars tensa 
surface area 
● 
Observed response 
● 
Observed response where subjects 
with ≤ 5% at baseline are excluded 
SAD: Week 8 and EOS 
Single dose expansion: Week 8, Week 12 and EOS 
MAD: Week 12 and EOS 
Multiple dose expansion: Week 12, Week 16 and EOS 
Reduction from baseline in size of TMP 
to less than or equal to 1% of pars tensa 
surface area 
● 
Observed response 
● 
Observed response where subjects 
with ≤ 1% at baseline are excluded 
Observed response for percentage 
improvement from baseline in A-B gap 
by PTA ≥ 50% (improvement of 
conductive hearing) 
SAD: Week 8 and EOS 
Single dose expansion and MAD:  
Week 12 and EOS 
Multiple dose expansion: Week 16 and EOS 
Observed response for improvement 
from baseline in air conduction hearing 
by PTA ≥ 15 dB 
Observed response for A-B gap after 
treatment was 15 dB or less 
Observed response for air conduction 
hearing threshold after treatment was 
30 dB or less 
Type of tympanogram 
SAD: Baseline, Week 8 and EOS 
Single dose expansion and MAD: Baseline, Week 12 and EOS 
Multiple dose expansion: Baseline, Week 12, Week 16 and EOS 
*Day 3 evaluations will only be performed for cohorts 1, 2 and 3 


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Table 2 
Continuous Efficacy Variables for Descriptive Statistics 
Variable 
Plots 
Analysis Visits 
Ratio of TMP size per total 
area of tympanic membrane 
SAD and MAD: 
Mean +/- SE for the change 
from baseline vs Analysis Visit 
by treatment group (overlay) 
Dose expansion: 
Least squares mean +/- SE for 
the change from baseline vs 
Analysis Visit by treatment 
group (overlay)a 
SAD: Baseline, Day 2, Day 3b, Week 1, 
Week 2, Week 4, Week 8 and EOS 
Single dose expansion: Baseline, Week 2, 
Week 4, Week 8, Week 12 and EOS 
MAD: Baseline, Week 1, Week 2, Week 3, 
Week 4, Week 5, Week 8, Week 12 and 
EOS 
Multiple dose expansion: Baseline, Week 
2, Week 4, Week 6, Week 8, Week 12, 
Week 16 and EOS 
EOS visit will not be included in the plot. 
TMP size 
Time to closure of TMPc 
Not Applicable 
Not Applicable 
Air conduction hearing at 
250 Hz, 500 Hz, 1 kHz, 2 kHz, 
4 kHz and 8 kHz 
SAD, MAD and Dose 
expansion: 
Individual subject plot of air 
conduction hearing and bone 
conduction hearing for each 
frequency and mean by 
Analysis Visit (Overlay) 
SAD: Baseline, Week 8 and EOS 
Single dose expansion and MAD: Baseline, 
Week 12 and EOS 
Multiple dose expansion: Baseline, 
Week 12, Week 16 and EOS 
Mean air conduction hearing 
Bone conduction hearing at 
500 Hz, 1 kHz, 2 kHz and 
4 kHz 
Mean bone conduction hearing 
A-B gap at 500 Hz, 1 kHz, 
2 kHz, and 4 kHz 
Mean A-B gap 
ECV by tympanometry 
Not Applicable 
a 
from the MMRM model as described in Section 6.4.2 and Section 6.4.3. 
b 
Day 3 evaluations will only be performed for cohorts 1, 2, and 3 
c 
change from baseline is not applicable. 
For the secondary endpoint complete closure of TMP at Week 12 (single dose expansion) and 
Week 16 (multiple dose expansion), number and percentage of subjects will be provided by 
treatment group for the following subgroups: 
● Sex,  
● Race,  
● Age group, 
● BMI group,  
● CTMP duration group (≤ 1 year, > 1 to ≤ 10 years, > 10 years),  
● Tobacco history (Yes, No),  
● Causation of TMP, 
● Diabetes history 
● Stratification factor TMP size group, 
● Baseline TMP size group per total area of tympanic membrane from central imaging. 
For the dose expansion secondary endpoints (change from baseline in ratio of TMP size per 
total area of tympanic membrane and change from baseline in TMP size), descriptive 
statistics will be used to summarize the Week 12 (single dose expansion) and Week 16 
(multiple dose expansion) analysis visit results by treatment group for the subgroup baseline 
TMP size group per total area of tympanic membrane from central imaging.  


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For the categories of the subgroup variables, refer to Section 6.2.3.  
Table 3 
Overview of Efficacy Analysis for Dose Expansion 
Endpoint Type 
Analysis Variable 
Analysis Method 
Secondary 
Efficacy 
Imputed response for complete closure of TMP 
at Week 12 for single dose expansion and 
Week 16 for multiple dose expansion 
● 
Primary analysis imputation  
● 
Sensitivity analysis imputation 
Mantel–Haenszel (MH) test: 
adjusted for baseline perforation size 
group by each ASP0598 treatment 
group 
Fisher-exact test and Clopper-
Perason method (no stratification 
factor) if Mantel and Fleiss criterion 
not satisfied 
Change from baseline in the ratio of TMP size 
per total area of tympanic membrane at 
Week 12 for single dose expansion and 
Week 16 for multiple dose expansion 
● 
Primary analysis: No imputation  
● 
Sensitivity analysis: discontinuation 
reason based multiple imputation (MI)a 
MMRM model: 
Treatment group and week as factors, 
baseline TMP size as a covariate, as 
well as an interaction of treatment by 
week and an interaction of baseline 
TMP size by week 
Change from baseline in TMP size at Week 12 
for single dose expansion and Week 16 for 
multiple dose expansion 
● 
Primary analysis: No imputation 
● 
Sensitivity analysis: discontinuation 
reason based MIa 
MMRM model: 
Treatment group and week as factors, 
baseline TMP size as a covariate, as 
well as an interaction of treatment by 
week and an interaction of baseline 
TMP size by week 
Exploratory 
Efficacy 
Relationship between change from baseline in 
the ratio of TMP size per total area of tympanic 
membrane and mean A-B gap at Week 12 for 
single dose expansion and Week 16 for 
multiple dose expansion 
Linear regression:  
Change from baseline in the ratio of 
TMP size per total area of tympanic 
membrane as predictor variable and 
change from baseline in mean A-B 
gap as response  
a 
Discontinuation-reason based MI will use a “Jump to Reference” algorithm (where placebo is the 
reference group) for subjects who discontinue the study investigational period due to lack of efficacy or 
AEs and standard regression-based MI for subjects with missing data for other reasons. 
6.4.1 
Analysis of Primary Efficacy Endpoint(s) 
Not applicable. 
6.4.2 
Analysis of Secondary Efficacy Endpoints  
SAD and MAD 
No statistical hypothesis testing will be performed. 
Single dose expansion 
● 
Subjects with complete closure of TMP at Week 12 
Primary Analysis: 
At week 12, to understand the relationship between complete closure of TMP and 
treatment group, MH test adjusting for baseline perforation size group (≤ 15%, > 15%) 
will be used. Analysis will be performed using the data for the estimand (refer to 


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Section 5.3 for details) and done separately for each ASP0598 treatment group vs 
placebo. Here baseline perforation size group is the same as baseline TMP size group per 
total area of tympanic membrane from central imaging.  
From this analysis, the following results will be presented: 
o Proportion of subjects with complete closure of TMP in each treatment group (each of 
ASP0598 treatment group and placebo),  
o For the comparisons between each of the ASP0598 treatment group vs placebo, risk 
difference (ASP0598 – placebo), 2-sided p-value for overall general association 
between treatment group and response and 2-sided 95% stratified Newcombe 
Confidence Interval (CI) computed using MH weights for the risk difference. If the CI 
cannot be obtained using Newcombe method then they will be presented using Sato 
method. 
If the Mantel and Fleiss criterion (across-strata sum of expected vales for a particular 
cell has a difference of at least 5 from both the minimum possible sum and the 
maximum possible sum of the observed values) is not satisfied, the above analysis 
will be performed with no stratification factor and exact p-value using Fisher-exact 
method and CI using Clopper-Pearson method will be presented. 
Based on the interim analysis results, if 3 treatment groups are selected for the dose 
expansion phase, hierarchical testing method will be used to control familywise error 
rate where the highest dose group vs placebo will be tested first at a 2-sided 
significance level of 0.05 and if the null hypothesis is rejected for this comparison, 
low dose group vs placebo will be tested at a 2-sided significance level of 0.05.  
Sensitivity analysis: 
The above analysis will be repeated using sensitivity analysis imputation definition. 
● 
Change from baseline in the ratio of TMP size per total area of tympanic membrane at 
Week 12 
● 
Change from baseline in TMP size at Week 12 
Primary analysis: 
For the change from baseline in TMP size at Week 12, a MMRM will be used with 
treatment group and week (Week 2, 4, 8 and 12) as factors, baseline TMP size as a 
covariate, as well as an interaction of treatment by week and an interaction of baseline 
TMP size by week.  
For the change from baseline in the ratio of TMP size per total area of tympanic 
membrane at Week 12, a MMRM will be used with treatment group and week (Week 2, 
4, 8 and 12) as factors, baseline ratio of TMP size per total area of tympanic membrane as 
a covariate, as well as an interaction of treatment by week and an interaction of baseline 
ratio of TMP size per total area of tympanic membrane by week.  
The repeated measures are not equally spaced. The model will assume unstructured 


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covariance among the within subject repeated measurements. Fitting a model can be 
computationally intensive and if the algorithm does not converge, spatial power 
covariance structure and then compound symmetry as a covariance structure will be tried 
to achieve convergence. Denominator degrees of freedom will be estimated using the 
Kenward-Roger approximation. Analysis will be performed using the data for the 
estimand (refer to Section 5.3 for details).  From this analysis, the following results will 
be presented: 
o Least square (LS) mean estimate, standard error (SE), and 2-sided 95% CI for change 
from baseline to each treatment week within a treatment group (placebo and each 
ASP0598 treatment group), 
o For comparisons between each of the ASP0598 treatment group vs placebo: 
➢ Difference in LS mean estimates (ASP0598 – placebo), SE and corresponding 
2-sided 95% CI for the change from baseline at each week.  
➢ The differences in the LS mean estimates will be used to obtain 2-sided p-value 
for the difference. 
Sensitivity analysis: 
The above analysis will be repeated under the assumption that data is MNAR using 
discontinuation-reason based MI. For the discontinuation-reason based MI, refer to 
Section 6.9.3.5 for details. From this analysis, the following results will be presented 
using the pooled results per step 3 of Section 6.9.3.5.  
o LS mean estimate, SE, and 2-sided 95% CI for change from baseline to each 
treatment week within a treatment group (placebo and each ASP0598 treatment 
group), 
o For comparisons between each of the ASP0598 treatment group vs placebo: 
➢ Difference in LS mean estimates (ASP0598 – placebo), SE and corresponding 
2-sided 95% CI for the change from baseline at each week.  
➢ The differences in the LS mean estimates will be used to obtain 2-sided p-value 
for the difference. 
o Descriptive statistics at each visit will be derived using the mean of the M=100 
imputed datasets. 
Checks of model assumptions will be carried using residual plots of scaled residuals 
against the predicted values and scaled residuals normal plot. 
If the lack of model assumptions are detected, additional model using generalized linear 
mixed model may be fitted as appropriate.  
Multiple dose expansion 
● 
Subjects with complete closure of TMP at Week 16 


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Primary Analysis: 
At week 16, to understand the relationship between complete closure of TMP and 
treatment group, MH test adjusting for baseline perforation size group will be used. 
Refer to single dose expansion endpoint subjects with complete closure of TMP at 
Week 12 primary analysis for details. 
Sensitivity analysis: 
The above analysis will be repeated using sensitivity analysis imputation definition. 
● 
Change from baseline in the ratio of TMP size per total area of tympanic membrane at 
Week 16  
● 
Change from baseline in TMP size at Week 16 
Primary Analysis: 
For the change from baseline in TMP size at Week 16, a MMRM will be used with 
treatment group and week (Week 2, 4, 6, 8, 12 and 16) as factors, baseline TMP 
measurement as a covariate, as well as an interaction of treatment by week and an 
interaction of baseline TMP measurement by week. For the change from baseline in the 
ratio of TMP size per total area of tympanic membrane at Week 16, the MMRM model 
will contain treatment group and week as factors, baseline ratio of TMP size per total 
area of tympanic membrane as a covariate, as well as an interaction of treatment by week 
and an interaction of baseline ratio of TMP size per total area of tympanic membrane by 
week. Refer to single dose expansion endpoint change from baseline in TMP size at 
Week 12 primary analysis for details. 
Sensitivity analysis: 
The above analysis will be repeated under the assumption that data is MNAR using 
discontinuation-reason based MI. Refer to single dose expansion endpoint change from 
baseline in TMP size at Week 12 sensitivity analysis for details.  
6.4.3 
Analysis of Exploratory Endpoints 
Continuous endpoints: 
SAD and MAD 
No statistical analysis will be performed. 
For the mean air conduction hearing loss group, a shift table of category changes from 
baseline value to post baseline value at each analysis visit (Week 8 and EOS for SAD, 
Week 12 and EOS for MAD) will be presented.  
Dose expansion 
● 
Change from baseline in the ratio of TMP size per total area of tympanic membrane for 
post baseline visits at Week 2, Week 4, and Week 8 for single dose expansion 


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● 
Change from baseline in TMP size for post baseline visits at Week 2, Week 4, and 
Week 8 for single dose expansion 
● 
Change from baseline in the ratio of TMP size per total area of tympanic membrane for 
post baseline visits at Week 2, Week 4, Week 6, Week 8, and Week 12 for multiple dose 
expansion 
● 
Change from baseline in TMP size for post baseline visits at Week 2, Week 4, Week 6, 
Week 8, and Week 12 for multiple dose expansion 
The above change from baseline dose expansion phase endpoints will be analyzed using 
the MMRM model as described in Section 6.4.2 Single Dose Expansion. 
To understand the relationship between change from baseline in the ratio of TMP size per 
total area of tympanic membrane and mean A-B gap at Week 12 for single dose expansion 
and Week 16 for multiple dose expansion, linear regression will be used with change from 
baseline in mean A-B gap as response and change from baseline in the ratio of TMP size per 
total area of tympanic membrane as predictor variable. A scatter plot with linear regression 
line, regression equation and 95% CI for the slope will be provided. 
For the mean air conduction hearing loss group, a shift table of category changes from 
baseline value to post baseline value at each analysis visit (Week 12 and EOS for single dose 
expansion, Week 12, Week 16 and EOS for multiple dose expansion) will be presented. 
Categorical endpoints: 
Refer to Section 5.4 for the list of categorical endpoints. No statistical analysis will be 
performed.  
6.5 
Analysis of Safety 
Safety analyses will be presented by treatment group and ASP0598 total for SAF, unless 
specified otherwise. 
6.5.1 
Adverse Events 
AEs will be coded using MedDRA.   
For the AEs, the following summaries will be presented: 
● An overview of TEAEs and deaths 
o Number of TEAEs 
o Number and percentage of subjects with TEAEs 
o Number of drug-related TEAEs 
o Number and percentage of subjects with drug-related TEAEs 
o Number of serious TEAEs 
o Number and percentage of subjects with serious TEAEs 
o Number of serious drug-related TEAEs 
o Number and percentage of subjects with serious drug-related TEAEs 
o Number of TEAEs leading to treatment discontinuation (MAD and MDE only) 


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o Number of deaths 
● Number and percentage of subjects with TEAEs by SOC and PT for the following: 
1) TEAEs  
2) Drug-related TEAEs 
3) TEAEs Leading to Treatment Discontinuation (MAD and MDE) 
4) Serious TEAEs and including number of events 
5) Drug-related serious TEAEs and including number of events 
6) Common (≥15% in any treatment group) TEAEs for expansion only 
7) TEAEs excluding serious AEs and including number of events and number of 
threshold events. Here threshold equals 5%.This summary will be created only if at 
least one serious TEAE is present. 
● An overview of TEAEs of interest  
o Number of TEAEs of interest 
o Number and percentage of subjects with TEAEs of interest 
o Number of drug-related TEAEs of interest 
o Number and percentage of subjects with drug-related TEAEs of interest 
o Number of serious TEAEs of interest 
o Number and percentage of subjects with serious TEAEs of interest 
o Number of serious drug-related TEAEs of interest 
o Number and percentage of subjects with serious drug-related TEAEs of interest 
The above summary will present results for any TEAEs of interest and each of the 
TEAEs of interest: Cholesteatoma or neoplasm, Ototoxic symptoms (tinnitus, 
sensorineural hearing loss, dizziness) and Otitis media or otitis externa. 
● Number and percentage of subjects with TEAEs of special interest by SOC and PT for 
the following: 
1) TEAEs of special interest for Cholesteatoma or neoplasm  
2) TEAEs of special interest for Ototoxic symptoms (tinnitus, sensorineural hearing loss, 
dizziness) 
3) TEAEs of special interest for Otitis media or otitis externa 
4) Serious TEAEs of special interest for Cholesteatoma or neoplasm and including 
number of events 
5) Serious TEAEs of special interest for Ototoxic symptoms (tinnitus, sensorineural 
hearing loss, dizziness) and including number of events 
6) Serious TEAEs of special interest for Otitis media or otitis externa and including 
number of events 
6.5.2 
Bone Conduction Hearing at 1, 2, 4 kHz by PTA 
Descriptive statistics will be used to summarize the bone conduction hearing at each 
frequency (1, 2 and 4 kHz) and the mean baseline value, post baseline value and change from 


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baseline at each specified post baseline analysis visit by treatment group.  
A summary will also present the number and percentage of subjects with an increase of 
≥ 20 dB from baseline for each frequency and the mean bone conduction hearing at each post 
baseline analysis visit. This summary will also present results for an increase of ≥ 10 dB from 
baseline at 2 consecutive frequencies (≥ 10 dB at 1 and 2 kHz or ≥ 10 dB at 2 and 4 kHz) for 
each post baseline analysis visit.  
Analysis visits: 
SAD 
Baseline, Day 2, Day 3a, Week 1, Week 2, Week 4, Week 8, 
EOS and Maximumb 
Single dose expansion 
Baseline, Week 2, Week 4, Week 8, Week 12, EOS and 
Maximumb 
MAD 
Baseline, Week 1, Week 2, Week 3, Week 4, Week 5, 
Week 8, Week 12, EOS and Maximumb 
Multiple dose expansion 
Baseline, Week 2, Week 4, Week 6, Week 8, Week 12, 
Week 16, EOS and Maximumb 
a Day 3 evaluations will only be performed for cohorts 1, 2 and 3. 
b Maximum during study period. 
6.5.3 
Tinnitus Visual Analog Scale (TVAS) 
Descriptive statistics will be used to summarize the treated ear TVAS baseline value, post 
baseline value and change from baseline at each specified post baseline analysis visit by 
treatment group. Refer to Section 6.5.2 for the list of analysis visits. Number and percentage 
of subjects will be used to summarize an increase from baseline for the TVAS at each 
specified post baseline analysis visit by treatment group.  
● An increase in tinnitus in any ear. 
● An increase in tinnitus in treated ear.  
Analysis visits: 
SAD 
Day 2 to Week 2, Day 2, Day 3a, Week 1, Week 2, Week 4, Week 8 and 
Maximum* 
Single dose expansion 
Day 2 to Week 2, Week 2, Week 4, Week 8, Week 12 and Maximumb 
MAD 
Day 2 to Week 2, Week 1, Week 2, Week 3, Week 4, Week 5, Week 8, 
Week 12, EOS and Maximumb 
Multiple dose 
expansion 
Day 2 to Week 2, Week 2, Week 4, Week 6, Week 8, Week 12, Week 16, 
EOS and Maximumb 
For Day 2 to Week 2, maximum post baseline value during the analysis window will be used. 
a Day 3 evaluations will only be performed for cohorts 1, 2 and 3. 
b Maximum post baseline value during study period. 
6.5.4 
Microscopic Ear Examination 
On Day 1, Week 2 (multiple dose only) and Week 4 (multiple dose only), 1 hour after the 
treatment, number and percentage of subjects will be used to summarize the following canal 
reactions of treated ear by treatment group: 


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● Did the Ear experience an abnormal ear sensation 
o No 
o Yes 
▪ Burning 
▪ Stinging 
▪ Itching 
▪ Pain 
▪ Other 
Percentages for the subcategories of ‘Yes’ will be based on number of subjects with 
abnormal ear sensation=Yes. 
● After Day 1, for categorical endpoints status of the middle ear and status of the treated 
tympanic membrane, number and percentage of subjects will be used to summarize 
baseline value and post-baseline value at each specified post-baseline analysis visit by 
treatment group. Other parameters will be listed only.  
Status of the treated tympanic membrane (Normal, Abnormal, Abnormal: Myringitis, 
Abnormal: Hematoma, Abnormal: Other, Not visible) 
Status of the middle ear in the treated ear (Normal, Abnormal, Abnormal: Mucosal 
inflammation with effusion, Abnormal: Mucosal inflammation without effusion, 
Abnormal: Other, Not visible) 
Percentages for the subcategories of ‘Abnormal’ will be based on number of subjects 
with abnormal. 
Analysis visits: 
SAD 
Day 2, Day 3*, Week 1, Week 2, Week 4, Week 8 and  EOS 
Single dose expansion 
Week 2, Week 4, Week 8, Week 12 and EOS 
MAD 
Week 1, Week 2, Week 3, Week 4, Week 5, Week 8, Week 12 and EOS 
Multiple dose 
expansion 
Week 2, Week 4, Week 6, Week 8, Week 12, Week 16 and EOS 
*Day 3 evaluations will only be performed for cohorts 1, 2 and 3. 
Number and percentage of subjects will be used to summarize the local skin reaction at the 
application site by grade as assessed by Modified Brighton Grading Scheme.  
● Day 1 post dose through end of study visit by grade, grade 1 or above, grade 3 or above  
● Day 1 post dose by grade, grade 1 or above, grade 3 or above 
● Day 2 by grade, grade 1 or above, grade 3 or above (SAD only) 
● Day 3 by grade, grade 1 or above, grade 3 or above (SAD cohorts 1, 2 and 3 only) 
● 2nd dose: post dose through end of study by grade, grade 1 or above, grade 3 or above 
(MAD and multiple dose expansion) 
● 2nd dose: post dose on the dosing day by grade, grade 1 or above, grade 3 or above 
(MAD and multiple dose expansion) 


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● 3rd dose: post dose through end of study by grade, grade 1 or above, grade 3 or above 
(MAD and multiple dose expansion) 
● 3rd dose: post dose on the dosing day by grade, grade 1 or above, grade 3 or above (MAD 
and multiple dose expansion) 
● Days 2 to 18 by grade, grade 1 or above, grade 3 or above 
● ≥ Days 19 by grade, grade 1 or above, grade 3 or above 
When assessing severity, if the event changes in severity (0, 1, 1b, 2, 2b, 3, 3b, 4 and 4b 
where Grade 4b is the worst grade) during a time interval for a subject, the event with the 
worst grade will be chosen. If the event is reported multiple times with missing grade(s) and 
with non-missing grade(s) during an analysis period for a subject, then the subject will be 
counted for the non-missing worst grade. If the event is reported multiple times with all 
missing grade(s) for a subject, then the subject will be counted as a missing grade. 
Refer to Section 6.9.1 for end day of end of study visit definition. 
6.5.5 
Clinical Laboratory Evaluation 
Not applicable. 
6.5.5.1 Liver Safety Assessment  
Not applicable. 
6.5.6 
Vital Signs 
For vital signs parameters: systolic blood pressure, diastolic blood pressure, pulse rate and 
body temperature, descriptive statistics will be used to summarize baseline value, 
post-baseline value and change from baseline at each specified post-baseline analysis visit by 
treatment group. Refer to Section 6.5.2 for the list of analysis visits excluding maximum. 
6.5.7 
Electrocardiograms  
Not applicable. 
6.6 
Pharmacokinetic 
Descriptive statistics (n, mean, SD, minimum, median, maximum, coefficient of variation 
(CV), geometric mean, and geometric CV) will be used to summarize baseline value, 
post-baseline value, and change from baseline at each post-baseline time point for serum 
concentrations of ASP0598 by treatment group including placebo using the SAF. 
Analysis time points: 
SAD: Baseline, Day 1 0.5 hour post dose, Day 1 1 hour post dose and Day 3 (Cohorts 1, 2, 
and 3.) or Day 2 (Cohorts 4, 5, and 6). 
MAD: Baseline, Day 1 0.5 hour post dose, Day 1 1 hour post dose, Week 4 predose, Week 4 
0.5 hour post dose, Week 4 1 hour post dose. 
Dose expansion: Not Applicable. 


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6.7 
Other Analyses 
No other analyses are planned. 
6.8 
Interim Analysis (and Early Discontinuation of the Clinical Study) 
Two interim analyses are planned and will be conducted after completion of the last cohort of 
the SAD and MAD, respectively. The decision to open the single dose expansion and 
multiple dose expansion will be made based on the safety and efficacy results of the above 
interim analyses. During each interim analysis, the Data Monitoring Committee (DMC) team 
will review the data and make the final decision to open the dose expansion. Three different 
treatment groups including placebo or two different treatment groups including placebo will 
be selected to open the expansion phase. Additional details and analyses will be described in 
a DMC charter/an IAP. 
6.9 
Additional Conventions 
6.9.1 
Analysis Windows for Safety Variables 
For the assessments where the summaries and/or analyses are presented by analysis visit 
during study period, post baseline values will not contribute to the safety analyses: 
● SAD: if the study day of the value is > minimum(study day of end of study visit, 57)  + 
7 days.  
● Single dose expansion and MAD: if the study day of the value is > minimum(study day of 
end of study visit, 85)  + 7 days. 
● Multiple dose expansion: if the study day of the value is > minimum (study day of end of 
study visit, 113)  + 7 days. 
For the assessments where the summaries and/or analyses are not presented by analysis visit 
during study period (AEs, previous and concomitant medications and modified brighton 
grading scheme), end day of end of study visit is defined as follows: 
● SAD: minimum(study day of end of study visit, 57)  + 7 days.  
● Single dose expansion and MAD: minimum(study day of end of study visit, 85)  + 7 days. 
● Multiple dose expansion: minimum (study day of end of study visit, 113)  + 7 days. 
6.9.1.1 Duplicate Values on the Same Day 
If more than one value is reported on the same day, then the value based on the following 
convention will be used for analysis visit window programming. This needs to be done before 
creating the analysis visits or time points. 


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Variable Type 
Assessment 
Convention 
Continuous 
variable 
Bone Conduction by PTA 
Last value on that day based on non-missing 
time. If time is missing for all values on the 
same day, then the value corresponding to 
the scheduled visit will be used. 
 
TVAS 
 
Vital Signs 
Categorical 
variable 
Microscopic ear examination Last value on that day based on non-missing 
time. If time is missing for all values on the 
same day, then the value corresponding to 
the scheduled visit will be used. 
 
6.9.1.2 Analysis Visit Windows 
Table 4 
Analysis Visit Windows: Bone Conduction by PTA, TVAS, Microscopic 
Ear Examination and Vital Signs 
 
 
Analysis Visit Window (Study Day) 
Analysis Visit 
Target Study 
Day 
SAD 
Single dose 
expansion 
MAD 
Multiple dose 
expansion 
Baseline a 
1 
≤ 1 
≤ 1 
≤ 1 
≤ 1 
Day 2b 
2 
2 
NA 
NA 
NA 
Day 2c 
2 
2 to 3 
NA 
NA 
NA 
Day 3d 
3 
3 to 4 
NA 
NA 
NA 
Week 1 
8 
5 to 11 
NA 
2 to 11 
NA 
Week 2 
15 
12 to 18 
2 to 18 
12 to 18 
2 to 22 
Week 3 
22 
NA 
NA 
19 to 25 
NA 
Week 4 
29 
19 to 39 
19 to 39 
26 to 32 
23 to 36 
Week 5 
36 
NA 
NA 
33 to 39 
NA 
Week 6 
43 
NA 
NA 
NA 
37 to 50 
Week 8 
57 
≥ 40 
40 to 74 
40 to 74 
51 to 71 
Week 12 
85 
NA 
≥ 75 
≥ 75 
72 to 99 
Week 16 
113 
NA 
NA 
NA 
≥ 100 
Minimum e 
 
≥ 2 
≥ 2 
≥ 2 
≥ 2 
Maximum f 
 
≥ 2 
≥ 2 
≥ 2 
≥ 2 
EOS g 
 
≥ 2 
≥ 2 
≥ 2 
≥ 2 
a  
Baseline value for the above data is based on the last available non-missing value on or prior to the first 
dose day (Day 1) of study drug within the visit window. 
b  
For cohorts 1, 2 and 3. 
c  
For cohorts 4, 5 and 6. 
d  
Day 3 evaluations will only be performed for cohorts 1, 2 and 3. 
e  
Minimum value for the above data is based on the minimum of non-missing post-baseline value within the 
visit window. 
f  
Maximum value for the above data is based on the maximum of non-missing post-baseline value within the 
visit window. 
g  
EOS value for the above data is based on the last available non-missing post-baseline value within the visit 
window. 
 


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For microscopic ear examination, 1 hour post dose analysis timepoint on dosing days will be 
assigned same as the nominal timepoint.  
To identify the value for the analysis, the following rules will apply excluding baseline, 
minimum, maximum and EOS: 
1. For an analysis visit, if a subject has more than one result with a value included within a 
window, the value closest to the target study day will be used. In case of ties between values 
located on different sides of the target study day, the later assessment will be used.  
2. For the categorical parameter, if a subject has more than one result included within a 
window, the assessment closest to the target study day will be used. In case of ties between 
results located on different sides of the target study day, the later assessment will be used. 
Planned time points will be used as analysis time points. Concentrations will be excluded 
from analysis if the actual time from dosing (actual sample date/time – dose date/time) is 
outside the time window as specified below.  
Table 5 
Analysis Visit Windows: Serum ASP0598 or Placebo Concentrations 
Analysis Time Point 
Analysis Time Window 
Baseline (Pre-dose) 
Actual time from dosing ≤ 0  
0.5 hour post dose 
Actual time from dosing = 30 ± 5 minutes 
1 hour post dose 
Actual time from dosing = 60 ± 5 minutes 
 
6.9.1.3 Value Below Limit of Quantification 
1) Serum concentration values (ASP0598 or Placebo) below limit of quantification (BLQ) will 
be set to 0 for the calculation of summary statistics. Geometric mean and Geometric CV will 
not be calculated if at least 1 concentration value is equal to 0. 
2) If more than 50% of the concentrations are BLQ at a given time point, SD and CV will not 
be calculated in the summary statistics. 
6.9.2 
Analysis Windows for Efficacy Variables 
For the assessments where the summaries and/or analyses are presented by analysis visit 
during study period, post baseline values will not contribute to the efficacy analyses: 
● SAD: if the study day of the value is > minimum(study day of end of study visit, 57)  + 
7 days.  
● Single dose expansion and MAD: if the study day of the value is > minimum(study day of 
end of study visit, 85)  + 7 days. 
● Multiple dose expansion: if the study day of the value is > minimum(study day of end of 
study visit, 113)  + 7 days. 
6.9.2.1 Duplicate Values on the Same Day 
If more than one value is reported on the same day, then the result based on the following 
convention will be used for analysis visit window programming. This needs to be done before 
creating any analysis visits or time points including baseline or screening. 


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Variable Type 
Assessment 
Convention 
Continuous 
variable 
Imaging 
Last value on that day based on non-missing time. 
If time is missing for all values on the same day, 
then the value corresponding to the scheduled 
visit will be used. 
 
PTA 
Assessments 
 
Tympanometry 
Categorical 
variable 
Imaging 
For complete closure of TMP, Last value on that 
day based on non-missing time. If time is missing 
for all values on the same day, then the value 
corresponding to the scheduled visit will be used. 
 
6.9.2.2 Analysis Visit Windows 
Table 6 
Analysis Visit Windows: Imaging 
 
 
Analysis Visit Window (Study Day) 
Analysis 
Visit 
Target Study Day 
SAD 
Single dose 
expansion 
MAD 
Multiple dose 
expansion 
Baseline a 
1 
≤ 1 
≤ 1 
≤ 1 
≤ 1 
Day 2b 
2 
2 
NA 
NA 
NA 
Day 2c 
2 
2 to 3 
NA 
NA 
NA 
Day 3d 
3 
3 to 4 
NA 
NA 
NA 
Week 1 
8 
5 to 11 
NA 
2 to 11 
NA 
Week 2 
15 
12 to 18 
2 to 18 
12 to 18 
2 to 22 
Week 3 
22 
NA 
NA 
19 to 25 
NA 
Week 4 
29 
19 to 39 
19 to 39 
26 to 32 
23 to 36 
Week 5 
36 
NA 
NA 
33 to 39 
NA 
Week 6 
43 
NA 
NA 
NA 
37 to 50 
Week 8 
57 
≥ 40 
40 to 74 
40 to 74 
51 to 71 
Week 12 
85 
NA 
≥ 75 
≥ 75 
72 to 99 
Week 16 
113 
NA 
NA 
NA 
≥ 100 
EOS e 
 
≥ 2 
≥ 2 
≥ 2 
≥ 2 
For the results corresponding to post-dose timepoints immediately after, 0.5 hour and 1 hour post-dose on the 
dosing days, analysis timepoint will be assigned same as the nominal timepoint and these results will not be 
used to identify the value for analysis.  
a  
Baseline value for the above data is based on the last available non-missing value on or prior to the first 
dose day (Day 1) of study drug within the visit window. 
b  
For cohorts 1, 2 and 3. 
c  
For cohorts 4, 5 and 6. 
d  
Day 3 evaluations will only be performed for cohorts 1, 2 and 3. 
e  
EOS value for the above data is based on the last available non-missing post-baseline value within the visit 
window. 
 


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Table 7 
Analysis Visit Windows: PTA Assessments, Tympanometry and 
Tympanogram 
 
 
Analysis Visit Window (Study Day) 
Analysis Visit 
Target 
Study Day 
SAD 
Single dose 
expansion 
MAD 
Multiple dose 
expansion 
Baseline a 
1 
≤ 1 
≤ 1 
≤ 1 
≤ 1 
Week 8 
57 
≥ 40 
NA 
NA 
NA 
Week 12 
85 
NA 
≥ 75 
≥ 75 
72 to 99 
Week 16 
113 
NA 
NA 
NA 
≥ 100 
EOS b 
 
≥ 2 
≥ 2 
≥ 2 
≥ 2 
a  
Baseline value for the above data is based on the last available non-missing value on or prior to the first 
dose day (Day 1) of study drug within the visit window. 
b  
EOS value for the above data is based on the last available non-missing post-baseline value within the visit 
window. 
To identify the value for the analysis, the following rules will apply excluding baseline and 
EOS: 
1. For an analysis visit, if a subject has more than one result included within a window, the 
value closest to the target study day will be used. In case of ties between values located on 
different sides of the target study day, the later assessment will be used.  
2. For the categorical parameter, if a subject has more than one result included within a 
window, the assessment closest to the target study day will be used. In case of ties between 
results located on different sides of the target study day, the later assessment will be used. 
6.9.3 
Imputation Rules 
6.9.3.1 Imputation of AE Onset Date 
For AEs, a missing or incomplete onset date will be imputed according to the following 
conventions: 
AE Onset Date 
Scenario 
Convention 
Completely missing or 
only the year is known 
Non-missing first dose date of study drug 
Only the month and year 
is known 
Set surrogate onset date = AE onset date where day is set to the 
first day of that month and then apply the following rules: 
1. If the month and year of the onset date is prior to the month 
and year of the first dose of study drug, then the surrogate onset 
date will be the imputed onset date. 
2. If the month and year of the onset date is on or after the 
month and year of the first dose of study drug, then the imputed 
onset date will be the latest of the following non-missing dates: 
• First dose date of study drug 
• Surrogate onset date 
If the above imputed onset date is after a complete AE end date, the imputed onset date will 
be the same as the complete AE end date. 


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6.9.3.2 Imputation of Previous and Concomitant Medication Dates 
For previous and concomitant medications, a missing or incomplete start and stop dates will 
be imputed according to the following conventions: 
Start Date Scenario 
Convention 
Missing day 
first day of the month under consideration 
Missing month 
January 
Missing year  
year of the informed consent date 
Completely missing 
Informed consent date 
 
Stop Date Scenario 
Convention 
Missing day and not ongoing 
last day of the month under consideration 
Missing month and not ongoing 
December 
(Missing year or completely 
missing) and not ongoing 
December 31st, 2099 
Ongoing 
Remains missing 
 
If the above imputed start date is after the stop date, then the imputed start date will be one 
day prior to the stop date. 
6.9.3.3 Imputation of Study Drug Start Date 
For the randomized subjects that received study drug, a missing or partial first dose date of 
study drug will be imputed  as the non-missing dispense date at randomization. 
6.9.3.4 Onset Date of CTMP 
Onset Date Scenario 
Convention 
Missing day, but month and year are 
present 
the day will be imputed as the 15th day of the 
month 
Missing day and month, but year is 
present 
the day and month will be imputed as 30 June of 
the year 
Missing year, but day and month are 
present 
No imputations will occur, and the subject will be 
excluded from all summaries related to CTMP 
duration 
Completely missing 
Informed consent date 
 
If the above imputed date falls after the informed consent date, then the onset date will be 
taken as equal to the informed consent date. 
6.9.3.5 Discontinuation-Reason based MI 
The MMRM analysis that will be used to perform the primary analysis of the secondary 
endpoints assumes that missingness is at random. That is, the model assumes that the 
trajectory of TMP size (or ratio of TMP size per total area of tympanic membrane) over time 
for subjects who withdrew the study is similar to the trajectory for those observed in their 
own treatment group which is valid so long as that assumption is reasonable. 


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Discontinuation-reason based MI will be used to examine the sensitivity of the primary 
analysis results to departures from that underlying assumption and will assess a situation 
where data for subjects who discontinue early follow a pattern which is missing not at 
random.  
First Markov chain Monte Carlo (MCMC) method will be used to partially impute 
non-monotone missing data for completed and discontinued subjects from the study 
investigational period for each treatment group separately. After this is done, MI will be used 
to impute the monotone missing data for the subjects discontinue the study investigational 
period as follows: 
MI will be used for imputation of any missing data, using “Jump to Reference” algorithm 
(where placebo is the reference group) [Carpenter et al. 2013] under the assumption of 
MNAR for subjects who discontinue due to lack of efficacy or AEs and standard regression 
based MI under the assumption of MAR for subjects with missing data for other reasons. The 
analysis will be implemented using the general three-step process (imputation phase, analysis 
phase and pooling phase) described in O’Kelly and Ratitch, 2014. 
1. The imputation phase will implement MI via sequential modelling for both the “Jump to 
Reference” algorithm and standard regression-based MI. In particular, when 
implementing the “Jump to Reference” algorithm via sequential modelling, only baseline 
values are used in the imputation of missing values for subjects in the ASP0598 active 
groups who discontinue study investigational period due to lack of efficacy or AEs (this 
variation of the “Jump to Reference” algorithm is also referred to as the “Unconditional 
Reference” approach). The imputation phase will generate M imputed datasets, where 
M =100.  
2. The analysis phase will perform the primary MMRM analysis model of the change from 
baseline secondary efficacy endpoints as described in Section 6.4.2 for each of the 
M = 100 imputed datasets (which now contain complete data, where missing data have 
been filled in).  
3. Rubin’s rules will be used to generate an overall set of pooled results which combines the 
analysis results from the M = 100 imputed datasets.  


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7 
REVISION AND RATIONALE 
7.1 
List of Changes in SAP Version 3.0 from Version 2.0 
The changes from the approved SAP from Version 2.0 (Dated 22-Nov-2020) to Version 3.0 
(Dated 06-Jul 2022) that impact analyses are listed with the rationale in the table below. 
SAP Sections 
Description 
Rationale 
4.1 
Changed definition of FAS 
to match protocol 
The protocol changed the definition of the FAS to 
account for  
5.4, Table 1, 
Table 2, 6.5.2, 
6.5.3, 6.5.4, 
6.6, Table 4, 
Table 6 
Changed references to Day 
3 to note that Day 3 
assessments were 
completed for cohorts 1, 2, 
and 3 only. 
The protocol was revised to remove Day 3 for 
SAD to consolidate visits and procedures for 
the subjects. The revision to add a + 1 day 
visit window to Day 2 is made so that 
assessments (including the pharmacokinetic 
[PK] sample) can take place on Day 1 or 
Day 3 depending on the site or subject’s 
schedule. 
Table 1 
Added line Observed 
response for complete 
closure of TMP as assessed 
by site investigator 
 and Imputed Response for 
complete closure of TMP 
as assessed by site 
investigator 
The tables for complete TMP closure and 
imputation of TMP closure were changed to 
include both the site investigator assessment and 
central reader assessment. 
6.5.1 
Added TEAEs causing 
treatment discontinuation 
(only for MAD and MDE) 
These TEAEs are collected for MAD and MDE. 
 


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7.2 
List of Changes in SAP Version 2.0 from Version 1.0 
The changes from the approved SAP Version 1.0 (Dated 23-Mar-2020) to Version 2.0 
(Dated 22-Nov-2020) that impact analyses are listed with the rationale in the table below. 
SAP Sections 
Description  
Rationale 
6.4, 
6.4.3 
For the regression analysis of 
change from baseline in TMP 
size and mean air conduction 
hearing at Week 12 treatment 
group as a classification 
variable is removed. Also 
predictor variable is updated 
as change from baseline in 
ratio of TMP size per total 
area of tympanic membrane 
and response is updated as 
change from baseline in 
mean A-B gap. 
An improvement in TMP size should 
improve the air conduction hearing hence 
the response and predictor variables are 
reversed. 
The analysis is to understand the 
relationship between the response variable 
and predictor hence the classification 
variable is removed. Change from baseline 
in ratio of TMP size per total area of 
tympanic membrane is used because it is 
normalized per the total area of tympanic 
membrane. 
Change from baseline in mean A-B gap is 
used because air conduction and bone 
conduction tests analyzed together 
determines any hearing loss.  
6.5.4  
For Modified Brighton 
Grading Scheme, time 
intervals Days 2 to 11 is 
updated as Days 2 to 18, 
Day 19 to 39 is updated as 
≥ Days 19. ≥ Days 40 time 
interval is removed. 
Provides comparisions across SAD, MAD, 
single dose expansion and multiple dose 
expansion in a consistent manner. 
6.9.1.1  
Details to address duplicate 
values on the same day for 
Microscopic ear examination 
is added. 
Missing hence added. 
9.1, 
9.2, 
9.3 
For the categorical variable 
coming from imaging data, 
updated about addressing 
duplicates values on the same 
day as the continuous 
variables. 
For consistency across variables coming 
from imaging data. 
6.9.1.2, 
6.9.2.2 
Visit Window for Week 2 
single dose expansion is 
updated. 
Due to Protocol Version 2.0 (Week 1 is 
removed). 
 
Adverse Events of Interest 
list is revised using MedDRA 
version 23.0. 
Due to MedDRA version update which is 
updated to capture COVID-19 related terms. 
The terms in Sections 9.2 and 9.3 remained 
the same compared to MedDRA version 
22.0. 
 


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8 
REFERENCES 
ICH Harmonized Tripartite Guideline E 3. Structure and Content of Clinical Study Reports, 
November 1995. (www.ich.org; Guidelines; "Efficacy" Topics) 
ICH Harmonized Tripartite Guideline E 9. Statistical Principles for Clinical Trials, February 1998. 
(www.ich.org; Guidelines; "Efficacy" Topics) 
Carpenter JR, Roger JH & Kenward MG. Analysis of longitudinal trials with protocol deviation: a 
framework for relevant, accessible, assumptions, and inference via multiple imputation. Journal 
of Biopharmaceutical Statistics. 2013; 23(6): 1352-1371. 
O’Kelly M. & Ratitch B. Clinical Trials with Missing Data A Guide for Practitioners, Statistics in 
Practice (2014): 189 - 190. 


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9 
APPENDICES 
9.1 
Appendix 1: Pre-Specified Criteria for Adverse Events of Interest: 
Cholesteatoma or Neoplasm 
All selected terms are based on MedDRA Version 23.0 
Neoplasm 
1. Aural neoplasms benign (PTs) 
Preferred Term Code 
Preferred Term 
10052241 
Aural cystadenoma 
10003794 
Aural polyp 
10069051 
Benign ear neoplasm 
10004292 
Benign middle ear neoplasm 
10008649 
Cholesterin granuloma of middle ear 
10008660 
Cholesterol granuloma 
10061332 
Paraganglion neoplasm 
 
2.Aural neoplasms malignant (PTs) 
Preferred Term Code 
Preferred Term 
10055016 
Ear neoplasm 
10055017 
Ear neoplasm malignant 
10082277 
External ear neoplasm malignant 
10061267 
Malignant middle ear neoplasm 
 
Cholesteatoma (PTs) 
Preferred Term Code 
Preferred Term 
10008642 
Cholesteatoma 
 


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9.2 
Appendix 2: Pre-Specified Criteria for Adverse Events of Interest: 
Ototoxic symptoms (Tinnitus, Sensorineural hearing loss, Dizziness) 
All selected terms are based on MedDRA Version 23.0 
Ototoxicity symptoms (PTs) 
Preferred Term Code 
Preferred Term 
10043882 
Tinnitus 
10047340 
Vertigo 
10013573 
Dizziness 
10011878 
Deafness 
10061373 
Sudden hearing loss 
 
Ototoxicity (PTs) 
Preferred Term Code 
Preferred Term 
10033109 
Ototoxicity 
 


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9.3 
Appendix 3: Pre-Specified Criteria for Adverse Events of Interest: 
Otitis media or Otitis externa 
All selected terms are based on MedDRA Version 23.0 
Middle ear infections (PTs) 
Preferred Term Code 
Preferred Term 
10061557 
Allergic otitis media 
10078160 
Bezold abscess 
10081430 
Eosinophilic otitis media 
10063095 
Gradenigo's syndrome 
10065838 
Middle ear inflammation 
10061302 
Myringitis 
10078830 
Noninfective myringitis 
10033078 
Otitis media 
10033079 
Otitis media acute 
10065176 
Otitis media bacterial 
10033081 
Otitis media chronic 
10065175 
Otitis media fungal 
10067322 
Otitis media haemophilus 
10033083 
Otitis media moraxella 
10080507 
Otitis media pneumococcal 
10033085 
Otitis media post measles 
10080508 
Otitis media staphylococcal 
10065177 
Otitis media viral 
10033102 
Otosalpingitis 
10034762 
Petrositis 
External ear infections (PTs) 
Preferred Term Code 
Preferred Term 
10000295 
Abscess of external auditory meatus 
10075072 
Allergic otitis externa 
10014014 
Ear lobe infection 
10015729 
External ear cellulitis 
10065837 
External ear inflammation 
10019959 
Herpes simplex otitis externa 
10063491 
Herpes zoster oticus 
10033072 
Otitis externa 
10065179 
Otitis externa bacterial 
10033076 
Otitis externa candida 
10052557 
Otitis externa fungal 
10065178 
Otitis externa viral 
10062067 
Perichondritis 
 


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9.4 
Appendix 4: Author and Approver Signatures 
(E-signatures are attached at the end of document.)