Clinical trial NCT05277922
Conditions: Study Vasodilatory Effects of C21
Sponsor: Vicore Pharma AB
Start date: 2022-04-28; Completion date: 2022-05-18
Enrollment: 5 participants; Allocation: NON_RANDOMIZED; Intervention model: SINGLE_GROUP

Brief summary:
The purpose of this study is to assess the effect of C21 on forearm blood flow by use of strain-gauge venous occlusion plethysmography.

Detailed description:
Subject will be screened for eligibility. Eligible subjects will receive ascending doses of C21 (3, 10, 30, 100, and 200 µg/min through local intra-arterial infusions for 5 min/dose. Forearm blood flow measurements will be performed in both arms during the last 2 minutes of each dose.

Infusions of sodium nitroprusside will be performed as a positive control using the same methodology.

Arms: arm 1: 15 µg C21 (infusion rate 3 µg/min) 50 µg C21 (infusion rate 10 µg/min) 150 µg C21 (infusion rate 30 µg/min) 500 µg C21 (infusion rate 100 µg/min) 1000 µg C21 (infusion rate 200 µg/min) arm 2: 4 µg nitroprusside (infusion rate 0.8 µg/min) 8 µg nitroprusside (infusion rate 1.6 µg/min) 16 µg nitroprusside (infusion rate 3.2 µg/min)
Interventions: intervention 1: C21 intervention 2: Sodium Nitroprusside
Intervention descriptions: intervention 1: C21 in ascending doses of 15, 50, 150, 500 and 1000 µg intervention 2: Ascending doses of 4, 8 and 16 µg sodium nitroprusside Positive control

Protocol documents:
Prot_SAP_000.pdf: 
 
Clinical Trial Protocol and Statistical Analysis Plan 
 
Title: 
A phase 1, open-label, single-centre study investigating the effect of C21 on 
forearm blood flow in healthy male subjects by use of strain-gauge venous 
occlusion plethysmography  
 
Trial ID: 
 
VP-C21-009 
 
NCT No.: 
 
NCT05277922 
 
Version: 
 
2.0 
 
Date: 
 
09-Mar-2022 
 
 
 
 
 
 
 
 
 
 


 
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Clinical Study Protocol 
 
EudraCT No. 
2021-000288-62 
Test Product 
Compound 21 (C21) 
Sponsor study code 
VP-C21-009 
Protocol Version and Date 
Final v2.0; 09MAR2022 
 
A phase 1, open-label, single-centre study investigating 
the effect of C21 on forearm blood flow in healthy male 
subjects by use of strain-gauge venous occlusion 
plethysmography 
 
Test product 
C21  
Comparator product 
Nipruss® (sodium nitroprusside) 
Sponsor signatories 
 
 
 
Vicore Pharma AB 
Kronhusgatan 11 
SE-411 05 Gothenburg, Sweden 
Principal Investigator 
 
CTC Clinical Trial Consultants AB 
Clinical study conduct and management 
CTC Clinical Trial Consultants AB 
Dag Hammarskjölds väg 10B 
SE-752 37 Uppsala, Sweden 
and 
CTC Clinical Trial Consultants AB 
Uppsala University Hospital, 
Entrance 85, 2nd level  
SE-751 85 Uppsala, Sweden 
 


 
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1 
STUDY SYNOPSIS 
Study title 
A phase 1, open-label, single-centre study investigating the effect of C21 on forearm blood flow in 
healthy male subjects by use of strain-gauge venous occlusion plethysmography 
Study code 
VP-C21-009 
EudraCT No 
2021-000288-62 
Planned study period 
Q1 2022 
Phase of development 
Phase 1 
Principal Investigator 
 
CTC Clinical Trial Consultants AB, Uppsala University Hospital, Uppsala, Sweden  
Study design 
This is a phase 1, open-label, single-centre study investigating the effects of intra-arterial (i.a.) 
infusions of the angiotensin II type 2 receptor (AT2R) agonist Compound 21 (C21) on forearm blood 
flow (FBF) in healthy male subjects by use of strain-gauge venous occlusion plethysmography.  
Objectives  
Primary objective 
To investigate the effect of C21 on FBF measured by strain-gauge venous occlusion plethysmography 
in healthy male subjects.  
Secondary objectives 
− 
To establish the dose-response curve for C21. 
− 
To explore the method of measuring FBF by strain-gauge venous occlusion plethysmography by 
using sodium nitroprusside as a positive control. 
− 
To evaluate safety and tolerability of i.a. administrations of C21 to healthy male subjects. 
Endpoints 
Primary endpoint 
Percent change from baseline in FBF, in response to increasing i.a. doses of C21. 
Secondary endpoints 
− 
Dose-response curve of C21. 
− 
Percent change from baseline in FBF, in response to increasing i.a. doses of sodium nitroprusside. 
− 
Frequency, intensity, and seriousness of adverse events (AEs). 
− 
Clinically significant changes in vital signs, ECG and safety laboratory parameters. 
Number of subjects planned 
Approximately 10 subjects will be screened to achieve 5 completed subjects with evaluable FBF data. 
Diagnosis and main eligibility criteria 
Healthy male subjects between 18-45 years of age and a body mass index (BMI) of 18.5-30.0 kg/m2, 
good general health and fulfilling all the inclusion criteria and none of the exclusion criteria. 


 
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Methodology 
Consenting subjects will be screened for eligibility according to study-specific eligibility criteria 
within 30 days prior to investigational medicinal product (IMP) administration (Visit 1; screening).  
Eligible subjects will be scheduled for a treatment visit (Visit 2; Day 1) . Relevant inclusion/exclusion 
criteria will be confirmed and a standardised meal (breakfast or lunch depending on the time of the 
day) will be served 60 minutes (min) prior to the first FBF measurement.  
Measurements of FBF will be performed using a Conformité Européenne (CE)-marked automated 
strain-gauge venous occlusion plethysmography equipment providing on-line measurements, 
following a pre-specified procedure.  
The subject will be placed resting in a comfortable supine position in a quiet room with normal room 
temperature (+20 to +25º C) with the forearms positioned above the level of the heart. Cuffs will be 
placed on the widest part of both forearms and a smaller cuff will be placed around each wrist. The 
non-infused arm is used as a contemporaneous control to account for any minor changes in FBF 
affecting both arms, e.g. emotional stress or temperature changes. 
A catheter will be inserted into the brachial artery of the nondominant arm following standard 
hospital procedures and a resting period of approximately 25 min will follow. At the end of this 
resting period, baseline measurements of FBF will be performed.  
Ascending doses of C21 (3, 10, 30, 100 and 200 µg/min) will be administered through local i.a. 
infusions for 5 min/dose with an infusion rate of 1 mL/min or 2 mL/min for the 200 µg/min dose. 
Measurements of FBF will be performed in both arms simultaneously during the last 2 min of each 
infusion/dose. The C21 doses will be separated by a wash-out period of at least 15 min. At the end of 
each wash-out period, FBF will be measured and a baseline value for the next dose will be recorded. 
The Investigator will assess any emerging AEs by subject interview between each dose before 
deciding to proceed to the next dose level. 
A flow-chart of the C21 dosing and FBF measurement schedule is presented in Figure 1. 
Figure 1   Dosing and measurement flow-chart for C21 infusions 
 
When the last C21 dose has been administered there will be a resting period of 20 min. At the end of 
this resting period, FBF will be measured and a baseline value for the first sodium nitroprusside dose 
will be recorded. 
Infusions of sodium nitroprusside solution (Nipruss®) will be performed as a positive control, using 
the same methodology as described above. Ascending doses of 0.8, 1.6, and 3.2 µg/min will be 
administered. A flow-chart of the Nipruss® dosing and FBF measurement schedule is presented in 
Figure 2. 


 
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Figure 2   Dosing and measurement flow-chart for Nipruss® infusions 
 
Safety assessments (blood pressure, pulse, electrocardiogram [ECG], and safety laboratory 
parameters) will be performed prior to first dose of IMP and before the subject leaves the clinic. Any 
occurrence of AEs during the procedure will be recorded.  
After removal of the arterial catheter a compression bandage will be applied to prevent bleeding. 
Written instructions regarding how to handle the bandage, how to manage symptoms and when and 
how to contact the Investigator if necessary, will be provided to the subject before leaving the clinic.  
A follow-up phone call (end-of-study) will be performed 7 to 10 days after the treatment visit 
(Visit 2). 
Investigational med Investigational medicinal product, dosage and mode of administration 
Test product 
C21 is a novel first in class selective AT2R agonist. Activation of AT2R causes dilatation of blood 
vessels and inhibition of inflammation, apoptosis, and fibrosis, and is thus considered to play a 
beneficial counter-regulatory role to the effects of angiotensin II type 1 receptor (AT1R) activation.  
C21 solution for local i.a. infusion will be provided in concentrations of 30 µg/mL and 100 µg/mL. 
These concentrations will be diluted with 0.9% saline to achieve the two lower doses. The solution 
will be infused through a catheter placed in the brachial artery. Ascending doses of 3, 10, 30, and 
100 µg/min will be administered to each subject with an infusion rate of 1 mL/min. For the dose of 
200 µg/min, the infusion rate will be 2 mL/min. Each infusion will last for 5 min.  
Comparator product (positive control) 
Nipruss® powder for solution (active ingredient sodium nitroprusside dihydrate) will be used as a 
positive control due to the potent vasodilative properties of sodium nitroprusside. Each ampoule of 
Nipruss® contains 60 mg sodium nitroprusside dihydrate powder corresponding to 53 g water free 
sodium nitroprusside. The powder will be dissolved in water for injection solution or in a 5% glucose 
solution. This concentrated solution will be diluted with a 5% glucose solution to achieve the doses to 
be administered i.a. (0.8, 1.6, and 3.2 µg/min).  
Duration of treatment 
Each subject will receive up to 5 infusions with C21 and 3 infusions with the positive control. The 
duration of each infusion will be 5 min. The duration of treatment, including resting and wash-out 
periods, will be approximately 4 hours. 
Duration of each subject’s involvement in the study 
Each subject will be involved in the study for a maximum of 41 days, including screening and 
end-of-study follow-up call. 


 
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Efficacy assessments 
Strain-gauge venous occlusion plethysmography will be used for measurements of FBF. 
Safety assessments  
− 
Vital signs (blood pressure and pulse) 
− 
12-lead ECG 
− 
Safety laboratory parameters 
− 
Adverse events reporting 
Statistical methods 
No formal sample size calculation has been performed for this study. The proposed sample size is 
considered sufficient to provide adequate information for the study objectives. 
The full analysis set (FAS) will consist of all subjects who have been included and received at least 
one dose of IMP and have at least one post-baseline assessment.  
The safety analysis set will compromise all subject who received at least one dose of the IMP. 
Continuous data will be presented in terms of evaluable and missing observations, arithmetic mean, 
standard deviation (SD), median, minimum, and maximum value.  
Categorical data will be presented as counts and percentages. When applicable, summary data will be 
presented by treatment (test product/comparator), and by assessment time. Individual subject data will 
be listed by subject number, treatment, and, where applicable, by assessment time. 
All descriptive summaries and statistical analyses will be performed using SAS Version 9.4 or later 
(SAS Institute, Inc., Cary, NC). 
Baseline for safety assessments will be defined as the last data collection point prior to the first 
administration of IMP. For the FBF measurements, a baseline will be defined for each dose level. 
No imputation of missing data will be performed. 
The response to increasing i.a. doses of C21 will be summarised using descriptive statistics with 
percent change from baseline and presented by dose.  
The dose response curve of C21 will be presented using a mixed model. The natural logarithm of the 
maximum FBF value for each dose level and each subject will be used as the dependent variable in 
the model. Kenward-Roger’s approximation for degrees of freedom will be used. The least square 
means (LSMeans) estimates for the doses will be presented in a plot. In addition, the pairwise 
LSMeans differences between the doses will be tabulated. 
Study reporting 
After completion of the study, an International Council for Harmonisation (ICH) E3 compliant 
Clinical Study Report (CSR) will be prepared.  
 


 
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2 
TABLE OF CONTENTS 
1 
STUDY SYNOPSIS ........................................................................................................ 2 
2 
TABLE OF CONTENTS ............................................................................................... 6 
3 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS ........................... 11 
4 
IMPORTANT MEDICAL PROCEDURES TO BE FOLLOWED BY THE 
INVESTIGATOR ......................................................................................................... 14 
4.1 
Medical emergencies contacts ................................................................................... 14 
5 
INVESTIGATOR AND STUDY ADMINISTRATIVE STRUCTURE .................. 15 
6 
INTRODUCTION ........................................................................................................ 17 
6.1 
Background ................................................................................................................ 17 
6.2 
Non-clinical data ........................................................................................................ 17 
6.3 
Clinical experience ..................................................................................................... 18 
6.4 
Venous occlusion plethysmography ......................................................................... 20 
6.5 
Study rationale ........................................................................................................... 20 
6.6 
Risk/benefit assessment ............................................................................................. 20 
6.6.1 
Risks associated with arterial cannulation .............................................................. 21 
6.6.2 
Risks related to local tolerance ............................................................................... 21 
6.6.3 
Risk assessment with regards to the COVID-19 pandemic .................................... 22 
6.6.4 
Risk-benefit conclusion .......................................................................................... 24 
7 
STUDY OBJECTIVES AND ENDPOINTS .............................................................. 25 
7.1 
Primary objective ...................................................................................................... 25 
7.1.1 
Primary endpoint ..................................................................................................... 25 
7.2 
Secondary objectives ................................................................................................. 25 
7.2.1 
Secondary endpoints ............................................................................................... 25 
8 
STUDY DESIGN .......................................................................................................... 26 
8.1 
Overall study design and schedule of events ........................................................... 26 
8.2 
Rationale for study design ........................................................................................ 29 
8.2.1 
Selection of starting dose and rationale for planned dose escalation ...................... 29 
9 
STUDY POPULATION ............................................................................................... 30 
9.1 
Recruitment ................................................................................................................ 30 
9.2 
Screening and enrolment log .................................................................................... 30 
9.3 
Number of subjects .................................................................................................... 30 
9.4 
Inclusion criteria ........................................................................................................ 30 
9.5 
Exclusion criteria ....................................................................................................... 31 
9.6 
Restrictions during the study .................................................................................... 32 


 
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9.6.1 
General restrictions ................................................................................................. 32 
9.6.2 
Prior and concomitant therapy ................................................................................ 33 
9.7 
Screen failures ............................................................................................................ 33 
9.8 
Subject withdrawal .................................................................................................... 34 
9.8.1 
General withdrawal criteria ..................................................................................... 34 
9.8.2 
Withdrawal in case of extravascular cannulation ................................................... 34 
9.8.3 
Procedures for discontinuation of a subject from the study .................................... 34 
9.8.4 
Subject replacement ................................................................................................ 34 
9.9 
Randomisation and blinding..................................................................................... 34 
10 
TREATMENTS ............................................................................................................ 35 
10.1 
Identity of investigational medicinal products ........................................................ 35 
10.1.1 
Test product ............................................................................................................ 35 
10.1.2 
Comparator product ................................................................................................ 35 
10.2 
Manufacturing, packaging, and labelling and release ........................................... 35 
10.3 
Conditions for storage ............................................................................................... 35 
10.4 
Preparation and accountability ................................................................................ 36 
10.5 
Treatment administration ......................................................................................... 36 
10.6 
Continuation of treatment with investigational medicinal product ...................... 37 
10.7 
Treatment compliance ............................................................................................... 37 
10.8 
Return and destruction of investigational medicinal products ............................. 37 
11 
STUDY ASSESSMENTS ............................................................................................. 38 
11.1 
Recording of data ....................................................................................................... 38 
11.1.1 
Informed consent .................................................................................................... 38 
11.1.2 
Eligibility criteria .................................................................................................... 38 
11.1.3 
Demographic information ....................................................................................... 38 
11.1.4 
Weight and height ................................................................................................... 38 
11.1.5 
Medical/surgical history.......................................................................................... 38 
11.1.6 
HIV and Hepatitis B/C ............................................................................................ 38 
11.1.7 
Alcohol test ............................................................................................................. 38 
11.1.8 
Urine drug screen .................................................................................................... 38 
11.1.9 
Physical examination .............................................................................................. 39 
11.1.10 Prior and concomitant medications ......................................................................... 39 
11.1.11 Baseline symptoms ................................................................................................. 39 
11.2 
Efficacy assessments .................................................................................................. 39 
11.2.1 
Strain-gauge venous occlusion plethysmography ................................................... 39 


 
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11.3 
Safety assessments ..................................................................................................... 40 
11.3.1 
Adverse events ........................................................................................................ 40 
11.3.1.1 
Definition of adverse event ............................................................................. 41 
11.3.1.2 
Definition of serious adverse event ................................................................. 41 
11.3.1.3 
Definition of adverse reaction ......................................................................... 41 
11.3.1.4 
Definition of serious adverse reaction ............................................................. 41 
11.3.1.5 
Definition of suspected unexpected serious adverse reaction ......................... 41 
11.3.1.6 
Time period and frequency for collecting adverse events ............................... 42 
11.3.1.7 
Assessment of intensity ................................................................................... 42 
11.3.1.8 
Assessment of causal relationship ................................................................... 42 
11.3.1.9 
Assessment of outcome ................................................................................... 43 
11.3.1.10 Reporting of action taken with study treatment .............................................. 43 
11.3.1.11 Collecting adverse events ................................................................................ 43 
11.3.1.12 Recording adverse events ................................................................................ 43 
11.3.1.13 Reporting of serious adverse events ................................................................ 44 
11.3.1.14 Expedited reporting of suspected unexpected serious adverse reaction .......... 44 
11.3.1.15 Treatment and follow-up of adverse events .................................................... 44 
11.3.1.16 Procedures in case of pregnancy ..................................................................... 45 
11.3.1.17 Treatment of overdose ..................................................................................... 45 
11.3.2 
Vital signs ............................................................................................................... 46 
11.3.3 
Electrocardiogram ................................................................................................... 46 
11.3.4 
Laboratory safety assessments ................................................................................ 46 
11.4 
Appropriateness of measurements ........................................................................... 47 
12 
PROCEDURES FOR BIOLOGICAL SAMPLES .................................................... 48 
12.1 
Sample collection ....................................................................................................... 48 
12.2 
Volume of blood ......................................................................................................... 48 
12.3 
Handling, storage, and destruction of laboratory samples .................................... 48 
12.4 
Chain of custody of biological samples .................................................................... 48 
12.5 
Withdrawal of informed consent for donated biological samples ......................... 48 
13 
QUALITY MANAGEMENT, QUALITY ASSURANCE AND QUALITY 
CONTROL .................................................................................................................... 49 
13.1 
Quality management: critical process, system, and data identification ............... 49 
13.2 
Quality assurance and quality control ..................................................................... 49 
14 
ETHICAL AND REGULATORY REQUIREMENTS ............................................ 50 
14.1 
Ethical conduct of the study ..................................................................................... 50 


 
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14.2 
Ethics and regulatory review .................................................................................... 50 
14.3 
Subject information and consent .............................................................................. 50 
14.4 
Subject information card .......................................................................................... 50 
14.5 
Subject data protection ............................................................................................. 51 
14.6 
Changes to the approved clinical study protocol .................................................... 51 
14.7 
Audits and inspections ............................................................................................... 52 
14.8 
Insurance .................................................................................................................... 52 
15 
STUDY MANAGEMENT ........................................................................................... 53 
15.1 
Training of study site personnel ............................................................................... 53 
15.2 
Clinical monitoring .................................................................................................... 53 
15.3 
Source data documents ............................................................................................. 54 
15.4 
Study agreements ....................................................................................................... 54 
15.5 
Study timetable and end of study ............................................................................. 54 
15.6 
Termination of the study ........................................................................................... 54 
15.7 
Reporting and publication ........................................................................................ 55 
15.7.1 
Clinical Study Report .............................................................................................. 55 
15.7.2 
Annual safety report ................................................................................................ 55 
15.7.3 
Confidentiality and ownership of study data .......................................................... 55 
15.7.4 
Publication .............................................................................................................. 55 
15.8 
Archiving .................................................................................................................... 55 
16 
DATA MANAGEMENT.............................................................................................. 57 
16.1 
The web-based eCRF ................................................................................................. 57 
16.2 
The entering of data into the eCRF ......................................................................... 57 
16.3 
The query process ...................................................................................................... 58 
16.4 
Audit trail ................................................................................................................... 58 
16.5 
External data .............................................................................................................. 58 
16.6 
Medical coding ........................................................................................................... 58 
16.7 
Database lock ............................................................................................................. 58 
17 
STATISTICAL METHODS AND DETERMINATION OF SAMPLE SIZE ........ 59 
17.1 
General ....................................................................................................................... 59 
17.2 
Determination of sample size .................................................................................... 59 
17.3 
Analysis data sets ....................................................................................................... 59 
17.3.1 
Full analysis set ....................................................................................................... 59 
17.3.2 
Safety analysis set ................................................................................................... 59 
17.4 
Description of study population ............................................................................... 59 


 
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17.4.1 
Demographics and baseline characteristics ............................................................ 59 
17.4.2 
Medical/surgical history and prior/concomitant medication .................................. 60 
17.4.3 
Physical examination .............................................................................................. 60 
17.4.4 
Treatment compliance ............................................................................................. 60 
17.5 
Analysis of efficacy endpoints ................................................................................... 60 
17.5.1 
Effect of C21 on forearm blood flow ...................................................................... 60 
17.5.2 
Dose-response ......................................................................................................... 60 
17.5.3 
Effect of sodium nitroprusside on forearm blood flow ........................................... 60 
17.6 
Analysis of safety endpoints ...................................................................................... 60 
17.6.1 
Adverse events ........................................................................................................ 60 
17.6.2 
Vital signs ............................................................................................................... 61 
17.6.3 
12-lead ECG............................................................................................................ 61 
17.6.4 
Safety laboratory analyses ...................................................................................... 61 
18 
REFERENCES ............................................................................................................. 62 
19 
SIGNATURES .............................................................................................................. 64 
19.1 
Principal Investigator statement .............................................................................. 64 
19.2 
Signature page (approval of the clinical study protocol) ....................................... 65 
 
List of Tables 
Table 4.1-1 
Medical emergencies contact .......................................................................... 14 
Table 6.6-1 
COVID-19 related risks and mitigating actions .............................................. 23 
Table 8.1-1 
Schedule of events ........................................................................................... 28 
Table 10.5-1 
C21 doses ........................................................................................................ 36 
Table 10.5-2 
Sodium nitroprusside doses ............................................................................. 37 
Table 11.3-1 
Safety laboratory parameters ........................................................................... 47 
Table 12.2-1 
Estimated blood volumes ................................................................................ 48 
 
List of Figures 
Figure 8.1-1 
Dosing and measurement flow-chart for C21 infusions .................................. 26 
Figure 8.1-2 
Dosing and measurement flow-chart for Nipruss® infusions .......................... 27 
 


 
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3 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
Abbreviation or term  
Explanation 
AE 
Adverse event 
Ang II 
Angiotensin II 
ALP 
Alkaline phosphatase 
ALT 
Alanine aminotransferase 
APTT 
Activated partial thromboplastin time 
ASA 
Acetylsalicylic acid 
AST 
Aspartate aminotransferase 
ATC 
Anatomical therapeutic chemical  
AT1R 
Angiotensin II type 1 receptor 
AT2R 
Angiotensin II type 2 receptor  
AUC 
Area under the curve 
BCRP 
Breast cancer resistance protein 
Bpm 
Beats per minute (unit for pulse measurement) 
BMI 
Body mass index 
BUN 
Blood urea nitrogen 
C21 
Compound 21 
CA 
Competent authority 
CE 
European Conformity (“Conformité Européenne”) 
Cmax 
Maximum concentration 
COVID-19 
Coronavirus disease 2019 
CRO 
Contract research organisation 
CSP 
Clinical study protocol 
CSR 
Clinical study report 
CTC  
Clinical Trial Consultants AB 
CYP 
Cytochrome P450 enzymes 
DSUR 
Development safety update report 
ECG 
Electrocardiogram 
eCRF 
Electronic case report form 
EEA 
European Economic Area 
eGFR 
Estimated glomerular filtration rate 
eNOS 
Endothelial nitric oxide synthase 
EVF 
Erythrocyte volume fraction 


 
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Abbreviation or term  
Explanation 
FAS 
Full analysis set 
FBF 
Forearm blood flow 
GCP 
Good clinical practice 
GDPR 
General data protection regulation 
GMP 
Good manufacturing practice 
Hb 
Haemoglobin 
HIV 
Human immunodeficiency virus 
i.a. 
Intra-arterial 
IB 
Investigator’s brochure 
ICF 
Informed consent form 
ICH 
International Council for Harmonisation of technical 
requirements for pharmaceuticals for human use  
IEC 
Independent ethics committee 
IME 
Important medical event 
IMP 
Investigational medicinal product 
ISF 
Investigator site file 
IUD 
Intrauterine device 
IUS 
Intrauterine hormone-releasing system 
LSMeans 
Least square means 
MCH 
Mean corpuscular haemoglobin 
MCHC 
Mean corpuscular haemoglobin concentration 
MCV 
Mean corpuscular volume 
MDR1 
Multi-drug resistance 1 
MedDRA 
Medical dictionary for regulatory activities 
NO 
Nitric oxide 
NOAEL 
No-observed-adverse-effect-level 
NSAID 
Non-steroidal anti-inflammatory drug 
OAT3 
Organic anion transporter 
OATP1B1 
Organic anion transporting polypeptide 1B1 
PII 
Personally Identifiable Information 
PK(INR) 
Prothrombin complex international normalised ratio  
PT 
Preferred term 
QA 
Quality assurance 
QC 
Quality control 


 
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Abbreviation or term  
Explanation 
RAS 
Renin-angiotensin system 
RBC 
Red blood cell 
RBM 
Risk-based monitoring 
RSI 
Reference safety information 
SAR 
Serious adverse reaction 
SAE 
Serious adverse event 
SARS-CoV-2 
Severe acute respiratory syndrome coronavirus 2 
SD 
Standard deviation 
SDV 
Source data verification 
SLC 
Solute carrier 
SmPC 
Summary of product characteristics 
SoC 
Standard of care 
SOC 
System organ class 
SOP 
Standard operating procedures 
SuHx 
Sugen-hypoxia 
SUSAR 
Suspected unexpected serious adverse reaction 
TEAE 
Treatment emergent AE 
TMF 
Trial master file 
WBC 
White blood cell 
WHO 
World Health Organisation 
 
 
 




 
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5 
INVESTIGATOR AND STUDY ADMINISTRATIVE STRUCTURE  
Sponsor 
Vicore Pharma AB 
Kronhusgatan 11 
SE-411 05 Gothenburg, Sweden 
 
Sponsor Signatories 
  
  
 
 
 
  
  
  
 
 
 
Sponsor’s Project Manager 
 
 
 
 
 
 
Sponsor Study Physician 
 
 
 
 
 
Clinical conduct 
CTC Clinical Trial Consultants AB (CTC) 
Uppsala University Hospital, 
Entrance 85, 2nd level  
SE-751 85 Uppsala, Sweden 
Principal Investigator 
 
 
 
 
 
Study management 
CTC  
Dag Hammarskjölds väg 10B 
SE-752 37 Uppsala, Sweden 
Clinical Research Manager  
 
  
 
 
Biostatistician 
 
 
 
 
Medical Monitor 
 
 
 
 
Medical Writer 
 
 
 


 
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Evaluation of plethysmography data 
 
 
 
 
 
 
Laboratory (HIV and hepatitis) 
 
Clinical Microbiology 
Dag Hammarskjölds väg 38 
SE-752 37 Uppsala, Sweden 
 
 
Laboratory (safety parameters) 
 
Clinical Chemistry and Pharmacology 
Uppsala University Hospital 
Entrance 61, 2nd level 
SE-751 85 Uppsala, Sweden 
 
 
Manufacturing, packaging, labelling of test 
product (C21) 
Ardena 
Kleimor 4 
B-9030 Mariakerke, Belgium 
 
 
Release of test product (C21) and shipment 
to site 
 
ClinStorage AB 
Banvaktsvägen 22 
SE-171 48 Solna, Sweden 
 
 
Re-labelling and supply of comparator 
product (Nipruss®) 
Apoteket AB, Clinical Trial Unit 
Dag Hammarskjölds väg 18, Entrance C7 
SE-751 85 Uppsala, Sweden  
 
 
Electronic data capture system provider  
 
Viedoc Technologies AB 
Stationsgatan 23 
SE-753 40 Uppsala, Sweden 
Signatures are provided in Section 19. 


 
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6 
INTRODUCTION 
6.1 
Background  
Compound 21 (C21) is a potent and selective nonpeptide angiotensin II type 2 receptor 
(AT2R) agonist being developed for oral treatment of rare lung diseases where there is a 
substantial medical need for new therapeutic alternatives.  
Although the renin-angiotensin system (RAS) is best known as a major physiological 
regulator of blood pressure and fluid homeostasis, several other physiological functions 
including cell growth and differentiation, cell adhesion, inflammation and fibrosis are also 
regulated by the RAS. Angiotensin II (Ang II) is the major effector peptide of the RAS 
system.   
Ang II has potent vasoconstrictor effects mediated by the angiotensin II type 1 receptor 
(AT1R) [1]. The AT2R is described as a central component of the “protective arm” of the 
renin-angiotensin system [2]. In a study consisting of infusion of drugs into the brachial 
artery and measuring the response to forearm vasculature, Ang II infusion caused a dose 
dependent vasoconstriction; AT2R inhibition with PD-123319 (AT2 receptor blocker) 
increased the vasoconstriction response, indicating a vasodilatory role of the receptor [3]. 
Intra-arterial (i.a.) infusion of an AT2R agonist (not C21) has previously been tested in 
healthy volunteers and was shown to cause vasodilation in the forearm [4]. Further, the AT2R 
contributed to Ang II-mediated vasodilation in resistance arteries of hypertensive diabetic 
patients treated with AT1R blocker [5]. 
In a pre-clinical study on human heart micro-coronaries, it was demonstrated that endothelial 
cells expressed the AT2R, and that exposure to C21 caused relaxation of the vessels mediated 
through nitric oxide (NO) [6]. AT2R stimulation in human endothelial cells increases 
endothelial nitric oxide synthase (eNOS) activity through phosphorylation of 
activating eNOS residues and dephosphorylation of inactivating eNOS residues, thus 
increasing NO release [7].   
6.2 
Non-clinical data 
C21 exerts antifibrotic effects in several in vivo and in vitro models of fibrosis. In both the 
bleomycin -and monocrotaline-induced rat models of pulmonary fibrosis, C21 attenuated 
pulmonary fibrosis and within the monocrotaline model, C21 also reversed it. In addition, 
C21 restored cardiac function and reduced pulmonary vascular remodelling and pulmonary 
hypertension. The antifibrotic effects were in several studies accompanied by 
anti-inflammatory as well as antiproliferative effects. In the Sugen-Hypoxia (SuHx) model of 
pulmonary hypertension, C21 caused a robust reduction of the SuHx-induced increase in 
endothelial cell hyperplasia and pulmonary hypertension.  
 
 
 
 
 
 
 
 


 
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More detailed information is found in the current version of the C21 Investigator’s Brochure 
(IB) [8].  
6.3 
Clinical experience 
The efficacy of oral C21 in subjects with coronavirus disease 2019 (COVID-19) has been 
investigated in a multicentre, randomised, placebo-controlled, double-blind phase 2 clinical 
study (VP-C21-006). The subjects were randomised to receive oral treatment with C21 
(100 mg twice daily, n=51) or placebo (n=55) for 7 days on top of standard of care (SoC).  
The study results show that oral C21 on top of SoC, including glucocorticoids and 
Remdesivir, was beneficial in the treatment of COVID-19, where subjects receiving C21 had 
a significantly lower risk for extended need of supplementary oxygen therapy. 
The safety and tolerability of C21 have been evaluated in three completed phase 1 studies 
(C21-001-16, C21-002-16, and C21-003) and in the above mentioned completed phase 2 
study (VP-C21-006) with a total of 134 subjects exposed to at least one dose of C21.  
The phase 1 studies involved single ascending doses and multiple ascending doses of up to 
200 mg C21 twice daily administered for up to 8 days in healthy subjects and daily doses of 
100 mg C21 administered for 8 days in obese subjects. The phase 2 study involved 100 mg 
C21 twice daily (200 mg daily dose) administered for 7 consecutive days in subjects with 
COVID-19.  
 
Two phase 2 studies are currently ongoing; VP-C21-004 in subjects with Raynaud’s 
phenomenon secondary to systemic sclerosis to show proof of mechanism of C21 on 
vasodilation (12 subjects; dosing has been completed), and VP-C21-005 in subjects with 
idiopathic pulmonary fibrosis to evaluate safety, tolerability, pharmacokinetics, and efficacy 
of C21 in idiopathic pulmonary fibrosis.  
 
 
 
 
 
 


 
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In the phase 2 study in subjects with COVID-19 (VP-C21-006), the majority of TEAEs were 
of mild or moderate severity and no TEAE was considered related to treatment by the 
Investigator. The most frequently reported TEAE was a minor increase in blood glucose with 
a higher incidence in the C21 group compared to placebo. The vast majority of events were 
of mild severity and none of the events were related to treatment, considered by the 
Investigator. Four fatal SAEs were reported after treatment in the completed phase 2 study 
(VP-C21-006). Two subjects died following COVID-19 infection leading to cardio-
respiratory arrest, 1 in the C21 group and 1 in the placebo group. Two further subjects in the 
placebo group died as a result of COVID-19-related pneumonia. None of the events was 
judged related to treatment with C21 by the Investigator and all events were considered 
consistent with COVID-19. 
 
 
 
 
 
 
 
 
Sodium nitroprusside at low doses has been used frequently in a similar brachial artery model 
in previous experimental studies with no safety issues observed [9, 10, 11]. 


 
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6.4 
Venous occlusion plethysmography 
Venous occlusion plethysmography has been used extensively to study human vascular 
physiology in vivo, including i.a. drug administration. In fact, forearm venous occlusion 
plethysmography with local brachial artery infusion has become one of the golden standards 
in the assessment of vascular function in health and disease, and an accurate, reproducible 
and convenient method to assess the effect of new vasoactive drugs and hormones in humans 
in vivo. The advantage of the plethysmography technique is that drugs can be given at doses 
10 to 100 times below those causing systemic effects because forearm blood flow (FBF) 
(<50 mL/min) is around 100-fold lower than cardiac output. Therefore, the effects on 
resistance vessels can be studied without invoking systemic effects or neurohormonal 
reflexes, minimising the potential for side-effects and toxicity [11]. 
6.5 
Study rationale 
With the nonclinical and clinical observed efficacy and safety profile, C21 has the potential 
as a beneficial therapeutic agent for patients with fibrotic lung diseases.  
The rationale for conducting this phase 1 study is to provide further insight into the 
physiology/pharmacology of AT2R agonists and their relevance to disease, and to provide a 
method to assess the dose-dependent vasodilatory response of AT2R agonists. Hence, data 
from this study will serve to guide and support design of further clinical studies of new AT2R 
agonists. The rationale for the study design is presented in Section 8.2.  
6.6 
Risk/benefit assessment 
The healthy subjects participating in this study will have no medical benefit from 
participation and their safety and wellbeing are of outmost importance.  
The FBF (<50 mL/min) is around 100-fold lower than cardiac output and by using venous 
occlusion plethysmography, investigational medicinal product (IMP) can be infused locally at 
doses 10 to 100 times lower than those causing systemic effects. The low dose range will 
minimise the potential for side-effects and toxicity [11].  
There is extensive world-wide experience of using local brachial artery infusions of 
vasoactive agents, and it is considered a safe technique. Benjamin et al. have performed more 
than 1,000 such experiments, with no significant adverse effects [12]. 
Overdosing is not likely to occur since all IMP will be administered by site personnel under 
medical surveillance. In cases of accidental overdose, standard supportive measures should 
be adopted as required. For further information regarding overdosing, refer to 
Section 11.3.1.17. 
The Principal Investigator at the study site will ascertain that adequate facilities and 
procedures are available to handle emergency situations should they occur during the study. 
The medical staff at CTC have extensive experience from early phase 1 studies and there are 
adequate procedures in place to handle unexpected and expected adverse reactions in the 
study subjects.  


 
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A comprehensive non-clinical and early clinical data package is available for C21, as 
 
 With the total dose of C21 in the current study 
being 1.715 mg, safety margins for systemic exposure based on non-clinical data are 
extensive, 
 
The potential local toxicity risks related to the new administration route applied in the current 
study are discussed in Section 6.6.2. The excipients of the new formulation to be used are all 
well-known and accepted for use in injectable formulations. 
Since there are no data available on reproductive toxicology for C21, only male subjects will 
be recruited. Each subject will be provided with a subject information card with information 
about the subject’s participation in a study, see Section 14.4.  
Besides the risks related to the test product C21, as described in Sections 6.2 and 6.3, there 
may also be risks related to the medical devices used in the study. Venous blood sampling 
and arterial catheter placement may be associated with mild-to-moderate pain, haematoma, 
inflammation, bleeding, bruising, or infection at the puncture site. However, when these 
devices are used by trained staff, the risk associated with their use is considered low and 
ethically justifiable.  
6.6.1 
Risks associated with arterial cannulation 
Arterial cannulation will be performed by a trained physician according to standard hospital 
procedures (see Section 11.2.1). The risk of accidental extravascular infusion is assessed as 
minimal. Backflow of blood will be checked before infusion and saline will be infused to 
verify correct placement. 
The subjects will be lying still in bed during the treatment with the arm in the same position 
and the risk of dislocation during the treatment period is considered minimal. 
In case of accidental extravascular infusion, no local toxicity is anticipated due to the low 
concentrations infused (see Section 6.6.2). Also due to the continuous wash-out by the 
flowing blood in combination with the short half-life of C21, no accumulation of C21 to the 
tissue is expected. 
In very rare instances, insertion of arterial catheters may cause blocking of the artery, tearing 
of the artery, arterial leakage, poor healing, or infection at the insertion site [13]. To mitigate 
such risks, the cannula used will be small, the puncture will be done with a stylet rather than 
by using a guidewire and a Seldinger technique. Further, the duration of the FBF assessment 
procedure is short, which limits the risk of infection. 
After removal of the catheter a compression bandage will be applied to prevent bleeding. 
Written instructions regarding how to handle the bandage, how to manage symptoms and 
when to contact the Investigator will be provided to the subject before leaving the clinic. 
6.6.2 
Risks related to local tolerance 
The risk for local tissue irritability by C21 in this model has been thoroughly assessed and it 
has been concluded that a dedicated nonclinical local tolerance study is deemed not to be 
needed. This reasoning is based on:  
1. The general safety findings generated in nonclinical and clinical studies with C21 [8].  


 
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2. The daily doses to be used in this small exploratory study are between 100 to 300 times 
below the established safe oral human doses. Hence, the initial total dose given i.a. will 
be a microdose of 15 µg C21 and the maximal dose will be 1 mg (total daily dose 
1.715 mg). For comparison, the established safe single human therapeutic oral dose is 
200 mg.  
3. The highest concentration of C21 that will be infused into the arterial blood is 
100 µg/mL, and with an infusion rate of 2 mL/min, the temporary local intravascular 
concentration of C21 is estimated, including potential variance in the local blood flow, to 
be significantly below 10 µg/mL, which can be compared to the mean systemic Cmax of 
230 µg/mL achieved in monkeys without any safety concerns [8]. As a comparison, the 
systemic mean systemic Cmax after a single oral 200 mg dose is approximately 4.5 µg/mL. 
4. The study design is following a careful dose escalation strategy, which allows timely risk 
mitigation to take place. Thus, any potential reactions at the infusion site will be closely 
monitored by the Investigator and any signs of tissue irritability or pain will be promptly 
detected (the subjects are awake) and the infusion can be discontinued if deemed 
necessary. 
6.6.3 
Risk assessment with regards to the COVID-19 pandemic 
Current recommendations from the authorities will be considered on a day-to-day basis. 
Assessment sessions with Sponsors, Investigators, and contract research organisation 
(CRO)/vendor representative members to align on local restrictions, impact assessment, 
contingency plans and study-specific risk mitigation strategies will be made to safeguard the 
study conduct and the safety of the subjects included in the study. Risks regarding subject 
safety, study performance and data quality/integrity will hence be assessed on an ongoing 
basis during the study. The risks and mitigating actions will be documented in a risk log as 
part of the Sponsor’s trial master file (TMF).  
European Medicines Agency Guidance on the Management of Clinical Trials during the 
COVID-19 pandemic as well as local guidelines from the Swedish Medical Products Agency 
have been taken into consideration. Planned prevention and mitigating actions are outlined in 
Table 6.6-1. Risks and mitigating actions will be updated as applicable over the course of the 
study.  
This study has a short in-person time frame including a healthy population. Hence, study 
participation is not expected to confer increased risks to the subjects in terms of COVID-19 
exposure. 
 
 






 
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7 
STUDY OBJECTIVES AND ENDPOINTS 
7.1 
Primary objective 
The primary objective is to investigate the effect of C21 on FBF measured by strain-gauge 
venous occlusion plethysmography in healthy male subjects. 
7.1.1 
Primary endpoint 
The primary endpoint is percent change from baseline in FBF, in response to increasing i.a. 
doses of C21. 
7.2 
Secondary objectives  
The secondary objectives are: 
− To establish the dose-response curve for C21. 
− To explore the method of measuring FBF by strain-gauge venous occlusion 
plethysmography by using sodium nitroprusside as a positive control. 
− To evaluate safety and tolerability of i.a. administrations of C21 to healthy male 
subjects. 
7.2.1 
Secondary endpoints 
The secondary endpoints are: 
− Dose-response curve of C21. 
− Percent change from baseline in FBF, in response to increasing i.a. doses of sodium 
nitroprusside. 
− Frequency, intensity and seriousness of AEs. 
− Clinically significant changes in vital signs, ECG and safety laboratory parameters. 


 
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8 
STUDY DESIGN 
8.1 
Overall study design and schedule of events 
This is a phase 1, open-label, single-centre study investigating the effects of i.a. infusions of 
the AT2R agonist C21 on FBF in 5 healthy male subjects, by use of strain-gauge venous 
occlusion plethysmography. 
Consenting subjects will be screened for eligibility according to study-specific eligibility 
criteria (see Sections 9.4 and 9.5) within 30 days prior to IMP administration (Visit 1; 
screening). 
Eligible subjects will be scheduled for a treatment visit (Visit 2; Day 1). Relevant 
inclusion/exclusion criteria will be confirmed and a standardised meal (breakfast or lunch 
depending on the time of the day) will be served 60 minutes (min) prior to the first FBF 
measurement.  
Measurements of FBF will be performed using a Conformité Européenne (CE)-marked 
automated strain-gauge venous occlusion plethysmography equipment providing on-line 
measurements, following a pre-specified procedure (see Section 11.2.1).  
The subjects will be placed resting in a comfortable supine position in a quiet room with 
normal room temperature (+20 to +25º C) [14] with the forearms positioned above the level 
of the heart. Cuffs will be placed on the widest part of both forearms and a smaller cuff will 
be placed around each wrist. The non-infused arm is used as a contemporaneous control to 
account for any minor changes in FBF affecting both arms, e.g. emotional stress or 
temperature changes. 
A catheter will be inserted into the brachial artery of the nondominant arm following standard 
hospital procedures (see Section 11.2.1) and a resting period of approximately 25 min will 
follow. At the end of this resting period, baseline measurements of FBF will be performed.  
Ascending doses of C21 (3, 10, 30 100 and 200 µg/min) will be administered through local 
i.a. infusions for 5 min/dose with an infusion rate of 1 mL/min or 2 mL/min for the 
200 µg/min dose. Measurements of FBF will be performed in both arms simultaneously 
during the last 2 min of each infusion/dose. The C21 doses will be separated by a wash-out 
period of at least 15 min. At the end of each wash-out period FBF will be measured and a 
baseline value for the next dose will be recorded. The Investigator will assess any emerging 
AEs by subject interview between each dose before deciding to proceed to the next dose 
level. 
A flow-chart of the C21 dosing and FBF measurement schedule is presented in Figure 8.1-1. 
Figure 8.1-1 Dosing and measurement flow-chart for C21 infusions 
 
When the last C21 dose has been administered there will be a resting period of 20 min. At the 
end of this resting period, FBF will be measured and a baseline value for the first sodium 
nitroprusside dose will be recorded. 


 
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Infusions of sodium nitroprusside solution (Nipruss®) will be performed as a positive control, 
using the same methodology as described above. Ascending doses of 0.8, 1.6, and 3.2 µg/min 
will be administered. A flow-chart of the Nipruss® dosing and FBF measurement schedule is 
presented in Figure 8.1-2. 
Figure 8.1-2 Dosing and measurement flow-chart for Nipruss® infusions 
 
Safety assessments (blood pressure, pulse, ECG, and safety laboratory parameters) will be 
performed prior to first dose of IMP and before the subject leaves the clinic. Any occurrence 
of AEs during the procedure will be recorded.  
After removal of the arterial catheter a compression bandage will be applied to prevent 
bleeding. Written instructions regarding how to handle the bandage, how to manage 
symptoms and when and how to contact the Investigator if necessary, will be provided to the 
subject before leaving the clinic.  
A follow-up phone call (end-of-study) will be performed 7 to 10 days after the treatment visit 
(Visit 2).  
The schedule of events is shown in Table 8.1-1. Study assessments are described in 
Section 11. 




 
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8.2 
Rationale for study design 
This study evaluates for the first time the dose-response related vasodilative effects of C21.  
Suggested dose escalation design and i.a. infusion has been widely used in the FBF design for 
the past 80 years contributing to exploring human vascular physiology in vivo [11] and is 
considered as a golden standard in the assessment of vascular function. 
Strain-gauge venous occlusion plethysmography will be use as a method for assessment of 
the primary endpoint (see Section 6.4). 
The study design involves careful monitoring of the subject’s well-being. Furthermore, by 
infusing IMP locally, drug-induced changes in blood pressure and cardiovascular reflexes can 
be minimised.  
8.2.1 
Selection of starting dose and rationale for planned dose escalation  
The pre-defined doses of C21 (3, 10, 30, 100 and 200 µg/min) have been selected to achieve 
sufficient coverage of the receptor during the plethysmography measurements. The required 
dose of C21 to produce a local effect in the forearm is estimated based on prior similar 
studies [4]. The maximum dose of 200 µg/min has been chosen to ensure that a full 
dose-response curve is achieved. The total dose at the 200 µg/min dose level will not exceed 
1 mg (see Section 10.5, Table 10.5-1). Overall, C21 was well tolerated at doses up to 100 mg 
twice daily administered for up to 8 days [8]. 
Sodium nitroprusside is selected as a positive control due to its potent vasodilative properties. 
The doses of Nipruss® (sodium nitroprusside) (0.8, 1.6, and 3.2 µg/min) have been selected to 
achieve vasodilative effects demonstrated in previous experimental studies [9, 10]. The total 
dose at the highest dose level will not exceed 16.0 µg (see Section 10.5, Table 10.5-2). 


 
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9 
STUDY POPULATION  
Prospective approval of protocol deviations from eligibility criteria, also known as protocol 
waivers or exemptions, will not be permitted. 
9.1 
Recruitment 
The subjects will be recruited from CTC’s database of healthy volunteers and/or through 
advertisement in social media. 
9.2 
Screening and enrolment log 
Investigators must keep a record of all subjects screened even if they were not subsequently 
included in the study. This information is necessary to verify that subjects were selected 
without bias. The reason for screen failure should be stated for all subjects screened but not 
included. The reason for withdrawal should be stated for all subjects included but not 
completed.  
A screening number will be allocated to each subject in connection to the informed consent 
process at the screening visit (Visit 1). The screening number is generated automatically in 
the electronic case report form (eCRF). The screening number will allow identification of 
subjects irrespective of their possible eligibility for the study.  
Subjects included will be assigned a subject number (e.g. 101, 102 etc). 
If a subject cannot receive the planned doses of IMP within 30 days after screening (i.e. the 
time interval between signing informed consent until IMP administration), the subject should 
be re-screened before being included in the study. 
9.3 
Number of subjects 
Approximately 10 subjects will be screened to achieve 5 included and evaluable subjects. For 
replacements of subjects who discontinue from the study, see Section 9.8.4. 
9.4 
Inclusion criteria 
For inclusion in the study, subjects must fulfil the following criteria:  
1. Willing and able to give written informed consent for participation in the study and to 
comply with study requirements.  
2. Healthy male subject aged 18-45 years inclusive at the time of signing the informed 
consent.  
3. Body mass index (BMI) ≥ 18.5 and ≤ 30.0 kg/m2.  
4. Male subjects must be willing to use condom or be vasectomised or practice sexual 
abstinence to prevent pregnancy and drug exposure of a partner and refrain from donating 
sperm from the date of dosing until 4 weeks after dosing with the IMP. Their female 
partner of child-bearing potential must use contraceptive methods with a failure rate of < 
1% to prevent pregnancy (combined [oestrogen and progestogen containing] hormonal 
contraception associated with inhibition of ovulation [oral, intravaginal, transdermal], 
progestogen-only hormonal contraception associated with inhibition of ovulation [oral, 


 
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injectable, implantable], intrauterine device [IUD]or intrauterine hormone-releasing 
system [IUS]) from at least 4 weeks prior to dose to 4 weeks after last dose). 
5. Clinically normal medical history, physical findings, vital signs, ECG and laboratory 
values at the time of screening, as judged by the Investigator. 
9.5 
Exclusion criteria 
Subjects must not enter the study if any of the following exclusion criteria are fulfilled: 
1. History of any clinically significant disease or disorder which, in the opinion of the 
Investigator, may either put the subject at risk because of participation in the study, or 
influence the results or the subject’s ability to participate in the study. 
2. History of thrombotic disease, vascular disorder, or severe bleeding disease. 
3. Poor brachial artery access. 
4. Any clinically significant illness, medical/surgical procedure, or trauma within 4 weeks of 
Day 1 (Visit 2). 
5. Malignancy within the past 5 years with the exception of basal cell or squamous epithelial 
carcinomas of the skin that have been resected with no evidence of metastatic disease for 
3 years.  
6. Any planned major surgery within the duration of the study. 
7. Any positive result on screening for serum hepatitis B surface antigen, hepatitis C 
antibody and human immunodeficiency virus (HIV). 
8. After 10 min supine rest at the time of screening, any vital signs values outside the 
following ranges: 
− Systolic blood pressure <100 or >140 mmHg, or 
− Diastolic blood pressure <50 or >90 mmHg, or  
− Pulse <45 or >90 beats per minute (bpm) 
9. Prolonged QTcF (>450 ms), cardiac arrhythmias or any clinically significant 
abnormalities in the resting ECG at the time of screening, as judged by the Investigator. 
10. History of severe allergy/hypersensitivity or ongoing allergy/hypersensitivity, as judged 
by the Investigator, or history of hypersensitivity to drugs with a similar chemical 
structure or class to the IMPs, including any of the excipients of the IMPs.  
11. Regular use of any prescribed or non-prescribed medication including antacids, 
analgesics, herbal remedies, vitamins, and minerals within 2 weeks prior to Day 1 
(Visit 2), at the discretion of the Investigator. 
12. Regular use of non-steroidal anti-inflammatory drugs (NSAIDs) or acetylsalicylic acid 
(ASA) within 2 weeks prior to Day 1 (Visit 2). 
13. Vaccination within 1 week prior to dosing or plans to receive any vaccine during the 
study conduct.  
14. Planned treatment or treatment with another investigational drug within 3 months prior to 
Day 1 (Visit 2). Subjects consented and screened but not dosed in previous phase 1 
studies are not excluded. 


 
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15. Current regular smokers or users of nicotine products. Irregular use of nicotine (e.g. 
smoking, snuffing, chewing tobacco) less than 3 times per week is allowed before the 
screening visit. 
16. History of alcohol abuse or excessive intake of alcohol, as judged by the Investigator. 
17. Presence or history of drug abuse, as judged by the Investigator. 
18. Positive screen for drugs of abuse or alcohol at screening or Day 1 (Visit 2), prior to 
administration of the IMP.  
19. History of, or current use of, anabolic steroids.  
20. Inability to refrain from consuming caffeine-containing beverages during Day 1 (Visit 2), 
e.g. propensity to develop headaches when refraining from caffeine-containing beverages.  
21. Plasma donation within 1 month of screening or blood donation (or corresponding blood 
loss) during the 3 months prior to screening.  
22. Investigator considers the subject unlikely to comply with study procedures, restrictions 
and requirements. 
9.6 
Restrictions during the study 
The subjects must be willing to comply with the following restrictions during the entire study 
duration i.e. from screening to the end-of-study contact. 
9.6.1 
General restrictions 
− Contraception Requirements: The male subjects are expected to use condom to prevent 
pregnancy and drug exposure of a partner and refrain from donating sperm from the 
date of dosing until 4 weeks after last dose of the IMP. Fertile female partners are 
expected to use contraceptive methods with a failure rate of < 1% to prevent pregnancy 
(for details, refer to inclusion criterion no. 4). 
− Meals: A standardised breakfast or lunch, depending on the time of the day, will be 
served to all subjects 60 min prior to the first FBF measurement. 
− Alcohol: Consumption of alcohol is not allowed within 48 hours prior to screening 
(Visit 1) and Day 1 (Visit 2).  
− Drugs of abuse: Use of drugs of abuse is not allowed during the study (from the 
screening visit to the end-of-study contact).  
− Coffee: No coffee or caffeine-containing drinks are allowed on Day 1 (Visit 2), until 
leaving the clinic. Subjects may be served caffeine free coffee.  
− Xanthine or taurine containing products/beverages: Energy drinks (e.g. Red Bull) are 
not allowed on Day 1 (Visit 2), until leaving the clinic. 
− Nicotine: Smoking or use of nicotine-containing products is not allowed from screening 
until end of Day 1 (Visit 2). 
− Grapefruit and grapefruit containing products: Consumption of grapefruit and/or 
grapefruit containing products or Seville oranges is not allowed during the study.  
− Exercise: The subjects must refrain from strenuous exercise (defined as greater than 
70% of the maximal pulse rate for 1 hour or more) for 24 hours before Day 1 (Visit 2). 


 
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− Blood donation: The subjects must not donate blood or plasma during the study until 
3 months after the last dose of IMP. 
− Participation in other clinical studies: Study subjects are not allowed to participate in 
any other interventional clinical study during the study period. 
9.6.2 
Prior and concomitant therapy 
Prohibited medication 
Regular use of any prescribed or non-prescribed medication including antacids, analgesics, 
herbal remedies, vitamin supplements and minerals from 2 weeks prior to the first 
administration of IMP (Day 1) until the end-of-study contact, at the discretion of the 
Investigator.  
Any use of prescribed or non-prescribed medication including NSAIDS/ASA, antacids, 
analgesics, herbal remedies, vitamin supplements and minerals from the first administration 
of IMP (Day 1) until the end-of study contact is not allowed, except as detailed below. 
Allowed medication 
− Paracetamol in doses up to 2,000 mg/day for a maximum of 3 consecutive days. If 
this amount of paracetamol is not sufficient for treatment of the subjects, withdrawal 
should be considered. 
− Nasal decongestants without cortisone, antihistamine, or anticholinergics for a 
maximum of 10 days.  
Other medications considered necessary for the subject´s safety and wellbeing may be given 
at the discretion of the Investigator during the study period. Following consultation with the 
Sponsor, the Investigator will determine whether the subject should continue in the study.  
9.7 
Screen failures 
Screen failures are defined as subjects who consent to participate in the clinical study but do 
not fulfil all eligibility criteria and are not subsequently included in the study. A minimal set 
of screen failure information is required to ensure transparent reporting of screen failure 
subjects. Minimal information includes documentation of signed and dated informed consent 
form (ICF) and reason(s) for screening failure. 
Re-screening can be performed once/subject if any of the following were reasons for 
screening failure or non-inclusion (as judged by the Investigator): 
− Practical reasons  
− Non-significant medical conditions (e.g. influenza, nasopharyngitis)  
− Plasma or blood donation outside allowed time windows 
For subjects who are re-screened, a new screening number will be assigned and a new, signed 
ICF will be collected. 


 
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9.8 
Subject withdrawal 
9.8.1 
General withdrawal criteria  
Subjects are free to discontinue their participation in the study at any time and for whatever 
reason without affecting their right to an appropriate follow-up investigation or their future 
care. If possible, the reason for withdrawal of consent should be documented. 
Subjects may be discontinued from the study at any time at the discretion of the Investigator. 
Reasons for discontinuation include:  
− Subject decision 
− Severe non-compliance to clinical study protocol (CSP) procedures, as judged by the 
Investigator and/or Sponsor 
− Subject is lost to follow-up 
− Significant AEs posing a risk for the subject, as judged by the Investigator and/or Sponsor 
− Withdrawal of informed consent to the use of biological samples 
9.8.2 
Withdrawal in case of extravascular cannulation  
In case of accidental extravascular infusion of C21 or Nipruss® the subject will be withdrawn 
from further infusions.  
9.8.3 
Procedures for discontinuation of a subject from the study 
A subject who prematurely discontinues participation in the study will always be asked about 
the reason(s) for discontinuation and the presence of any AEs. If a subject withdraws consent, 
the Investigator must ask the subject if he is willing, as soon as possible, to be assessed 
according to the procedures scheduled for the end-of-study contact. Any ongoing AEs will be 
followed as described in Section 11.3.1.15.  
The primary reason for discontinuation/early withdrawal must be specified in the eCRF and 
final drug accountability must be performed. 
9.8.4 
Subject replacement 
Subjects who discontinue prior to IMP administration may be replaced. Subjects who 
discontinue after initiation of IMP administration, for other reason than occurrence of an AE 
assessed as related to the IMP, may be replaced. 
9.9 
Randomisation and blinding 
Randomisation will not be used. This is an open-label study and all subjects will receive the 
same IMP and undergo the same study procedures. 


 
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10 TREATMENTS  
10.1 Identity of investigational medicinal products  
10.1.1 
Test product 
C21 is a novel first in class selective AT2R agonist. Activation of AT2R causes dilatation of 
blood vessels and inhibition of inflammation, apoptosis, and fibrosis, and is thus considered 
to play a beneficial counter-regulatory role to the effects of AT1R activation.  
C21 solution for local i.a. infusion will be provided in concentrations of 30 µg/mL and 
100 µg/mL. These concentrations will be diluted with 0.9% saline to achieve the two lower 
doses (see Section 10.5). 
More detailed information about the IMP composition can be found in the Investigational 
Medical Product Dossier. 
10.1.2 
Comparator product 
A positive control solution will be prepared from Nipruss® powder for solution (active 
ingredient sodium nitroprusside dihydrate) due to the potent vasodilative properties of 
sodium nitroprusside.  
Nipruss® is provided as a pink hygroscopic powder in amber glass ampoules. Each ampoule 
contains 60 mg sodium nitroprusside dihydrate powder corresponding to 53 g water free 
sodium nitroprusside.  
The powder will be dissolved in water for injection solutions or in a 5% glucose solution. 
This concentrated solution will be diluted with a 5% glucose solution to achieve the doses 
given in Section 10.5.  
10.2 Manufacturing, packaging, and labelling and release 
The C21 solution will be manufactured, packed, and labelled by Ardena, Mariakerke, 
Belgium. The primary packaging for the bulk solution is 10 mL vials: 20 x 30 μg/mL and 
30 x100 μg/mL. The vials will be packaged in an outer cartoon (secondary package).  
The IMP will be released and shipped to site by ClinStorage AB, Solna, Sweden. 
Nipruss® powder for solution, 60 mg/ampoule, will be ordered from and labelled for the 
clinical study by Apoteket AB, Clinical Trial Unit, Uppsala, Sweden. 
Labels will comply with applicable Good Manufacturing Practice (GMP), with Annex 13 of 
the European Union Good Manufacturing Practice regulations and local regulatory 
requirements [15]. 
10.3 Conditions for storage 
The C21 solution should be stored refrigerated at +5º C (+2 ºC to +8 ºC).  
The Nipruss® powder should be stored at room temperature (+15 ºC to +25 ºC) protected 
from light. The prepared solution must be protected from light by using coloured or covered 
tubes and syringes. The prepared solution should be used immediately following preparation. 
Storage of the prepared solution for a maximum of 8 hours in +2 ºC to +8 ºC is allowed, if 
needed. 






 
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11 STUDY ASSESSMENTS 
The study assessments are described in the sections below and the timing of these 
assessments are detailed in the schedule of events (Section 8.1, Table 8.1-1). 
11.1 Recording of data 
The Principal Investigator will provide the Sponsor with all data produced from the 
scheduled study assessments during the study. He will ensure the accuracy, completeness, 
legibility, and timeliness of the data reported to Sponsor in the eCRF and in all required 
reports. 
11.1.1 
Informed consent 
Signed informed consent must be obtained before any screening procedures are initiated.  
The informed consent procedure is further described in Section 14.3. 
11.1.2 
Eligibility criteria 
Eligibility criteria should be checked during screening and relevant criteria confirmed before 
IMP administration on Day 1. The criteria are specified in Sections 9.4 and 9.5. 
11.1.3 
Demographic information 
The following demographic data will be recorded: gender, age, dominant/non-dominant arm, 
ethnicity, and race. 
11.1.4 
Weight and height 
Weight and height will be measured without shoes. BMI will be calculated, with one decimal, 
from the height and weight recorded. 
11.1.5 
Medical/surgical history  
Medical/surgical history will be obtained by subject interview to verify that the eligibility 
criteria are met. 
11.1.6 
HIV and Hepatitis B/C 
Subjects will be tested for HIV-1 and HIV-2 antibodies and HIV-1 p24 antigen, hepatitis B 
virus surface antigen and hepatitis C virus antibodies prior to inclusion into the study.  
Any positive result will exclude the subject from participating. 
11.1.7 
Alcohol test 
An alcohol test will be performed at time points outlined in the schedule of events (Table 
8.1-1).  
11.1.8 
Urine drug screen 
Urine will be screened for drugs of abuse at time points outlined in the schedule of events 
(Table 8.1-1) using the Drug Screen Multi-12/15 (Nal von minden). 


 
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11.1.9 
Physical examination 
A complete physical examination will be performed at screening and will include 
assessments of the head, eyes, ears, nose, throat, skin, thyroid, neurological, lungs, 
cardiovascular, abdomen (liver and spleen), lymph nodes, and extremities. 
Any abnormalities will be specified and documented as clinically significant or not clinically 
significant. 
11.1.10  Prior and concomitant medications 
Information on prior medications taken within 2 weeks prior to screening will be obtained by 
subject interview to verify that the eligibility criteria are met (see also Section 9.6.2). 
Medications will be classified as prior if treatment is discontinued before the first IMP 
administration and as concomitant if ongoing at the time of the first IMP administration, 
stopped after the first IMP administration or started after the first IMP administration.  
To distinguish between prior and concomitant medications on Day 1 (i.e. the dosing day), the 
start time of any newly introduced medication or the stop time of any previously ongoing 
medication must be recorded in the eCRF.  
Any use of prior/concomitant medications from screening (Visit 1) until the last end-of-study 
contact must be documented appropriately in the subject’s eCRF. Relevant information (i.e. 
name of medication, dose, dose form, unit, route, frequency, start and stop dates, reason for 
use) must be recorded. All changes in medication should be noted in the eCRF. 
11.1.11  Baseline symptoms 
A baseline symptom is defined as a medical event that occurs between the subject’s signing of 
the ICF until initiation of the study procedures on Day 1 (i.e. an event that occurs during the 
screening period). Such events are not AEs and will be recorded as baseline symptoms in the 
Medical History Log in the eCRF. 
11.2 Efficacy assessments 
11.2.1 
Strain-gauge venous occlusion plethysmography 
Measurements of FBF will be performed using a CE-marked automated strain-gauge venous 
occlusion plethysmography equipment providing on-line measurements; Bergenheim, 
Elektromedicin, Göteborg, Sweden. 
The underlying principle of this method is that when the venous return from the forearm is 
briefly interrupted by inflating a cuff placed around the upper arm to well above venous 
pressure but below diastolic pressure, and arterial inflow continues unimpeded, the forearm 
swells at a rate proportional to the rate of arterial inflow. Changes in forearm volume result in 
a corresponding change in arm circumference and thus strain-gauge length, which can be 
detected as an alteration in electrical resistance of the gauge, and thus potential difference 
[16]. 


 
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The subject will be placed resting in a comfortable supine position in a quiet room with 
normal room temperature (+20 ºC to +25 ºC) [14]. Both forearms must be positioned above 
the level of the heart to ensure adequate venous emptying during the period of deflation. This 
position will be achieved by resting the elbows on foam pads and supporting the hands with 
pillows. Cuffs will be placed on the widest part of both forearms and a smaller cuff will be 
placed around each wrist. The non-infused arm is used as a contemporaneous control to 
account for any minor changes in FBF affecting both arms, e.g. emotional stress or 
temperature changes. 
A catheter will be inserted into the brachial artery of the nondominant arm according to 
standard hospital procedures. A standard arterial cannula will be used. The artery will be 
palpated at the elbow of the non-dominant arm. The skin will be cleaned with alcohol after 
which the artery is cannulated transcutaneously. A small infusion of saline will be connected 
to maintain the line opened. 
After cannulation there will be a resting period of approximately 25 min. At the end of this 
resting period, baseline measurements of FBF will be performed. 
The subject will receive ascending doses of C21 (3, 10, 30, 100 and 200 µg/min) through 
local i.a. infusions for 5 min/dose with an infusion rate of 1 mL/min or 2 mL/min for the 
200 µg/min dose. The start -and stop times of the infusions will be recorded. Measurements 
of FBF will be performed in both arms simultaneously during the last 2 min of each infusion. 
The C21 doses will be separated by a wash-out period of at least 15 min. At the end of each 
wash-out period FBF will be measured and a baseline value for the next dose be recorded.  
For each FBF measurement, an inflation pressure of 60 mmHg will be used for intervals of 
approximately 7 sec followed by approximately 8 sec of deflation. This cycle will be repeated 
approximately 8 times during the last 2 min of each infusion. The wrist cuff will be inflated 
to supra-systolic pressures within 30 sec before each measurement to exclude the hand 
circulation. Changes in forearm volume will be measured using strain-gauges placed around 
the widest part of the forearms. A measure of blood flow to that part of the forearm enclosed 
by the two cuffs is provided, expressed as mL per 100 mL of forearm volume per minute. 
Actual forearm volume can be estimated by calculation, assuming the forearm is a simple 
truncated cone, or by simple water displacement. 
When the last C21 dose has been administered, the infusion will be discontinued and there 
will be a resting period of 20 min. At the end of this resting period, FBF will be measured 
and a baseline value for the first sodium nitroprusside dose will be recorded. 
Infusions of sodium nitroprusside solution (Nipruss®) will be performed as a positive control, 
using the same methodology as described above. Ascending doses of 0.8, 1.6, and 3.2 µg/min 
will be administered. 
After removal of the arterial catheter a compression bandage will be applied to prevent 
bleeding.  
11.3 Safety assessments 
11.3.1 
Adverse events  
The Principal Investigator is responsible for ensuring that all medical staff involved in the 
study is familiar with the content of this section and the content of the CTC SOPs regarding 
emergencies and phase 1 studies. 


 
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11.3.1.1 
Definition of adverse event  
An AE is defined as any untoward medical occurrence in a subject administered a medicinal 
product and which does not necessarily have a causal relationship with this product. An AE 
can therefore be any unfavourable and unintended sign (including an abnormal laboratory 
finding), symptom, or disease temporally associated with the use of a medicinal product, 
whether or not considered related to the medicinal product. 
11.3.1.2 
Definition of serious adverse event  
An SAE is any AE which: 
− results in death 
− is life-threatening (this refers to a reaction in which the subject was at risk of death 
at the time of the reaction; it does not refer to a reaction that hypothetically might 
had led to death if the reaction was more severe) 
− requires in-patient hospitalisation or prolongation of existing hospitalisation 
− results in persistent or significant disability/incapacity 
− is a congenital anomaly/birth defect 
− is an important medical event (IME) (this refers to a reaction that may not be 
immediately life-threatening or result in death or hospitalisation, but may jeopardise 
the subject or may require intervention to prevent any of the other outcomes defined 
above) 
Examples of IMEs are intensive treatment in an emergency room for allergic bronchospasm 
or blood dyscrasias, convulsions that do not result in hospitalisation, development of drug 
dependency, and drug abuse. 
Planned hospitalisations or surgical interventions for a condition that existed before the 
subject signed the ICF and that did not change in intensity are not SAEs. 
If there is any doubt as to whether an AE meets the definition of an SAE, a conservative 
viewpoint must be taken, and the AE must be reported as an SAE. 
11.3.1.3 
Definition of adverse reaction 
The term adverse reaction is to be used whenever either the Investigator or Sponsor or 
designee assessed the AE as related to the IMP. 
11.3.1.4 
Definition of serious adverse reaction  
The term serious adverse reaction (SAR) is to be used whenever either the Investigator or 
Sponsor or designee assessed the SAE as related to the IMP. 
11.3.1.5 
Definition of suspected unexpected serious adverse reaction  
A suspected unexpected serious adverse reaction (SUSAR) is any SAR whose nature or 
intensity is not consistent with the current reference safety information (RSI) in the IB or 
summary of product characteristics (SmPC) and therefore, is assessed as unexpected. 


 
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11.3.1.6 
Time period and frequency for collecting adverse events 
All AEs (including SAEs) will be collected from the start of the study procedure on Day 1 
until the end-of-study contact. Any AE with start date on Day 1 must be recorded with start 
time. 
During the end-of-study contact, information on new AEs or SAEs, if any, and stop dates for 
ongoing events must be recorded as applicable. 
Investigators are not obligated to actively seek AEs or SAEs after conclusion of the study 
participation. However, if the Investigator learns of any SAE, including a death, at any time 
after a participant has been discharged from the study, and he/she considers the event to be 
reasonably related to the study intervention or study participation, the Investigator must 
promptly notify the Sponsor. 
11.3.1.7 
Assessment of intensity 
The Investigator must assess the intensity of an AE using the following definitions, and 
record it on the AE Log in the eCRF:  
Mild 
Awareness of symptoms, sign, illness, or event that is easily tolerated. 
Moderate 
Discomfort sufficient to cause interference with usual activity. 
Severe 
Incapacitating with inability to work or undertake further normal activities.  
11.3.1.8 
Assessment of causal relationship 
The Investigator must assess the causal relationship between an AE and the IMPs (C21 and 
Nipruss® will be assessed separately) using the definitions below and record it on the AE Log 
of the eCRF: 
Related 
There is a reasonable possibility that the AE was caused by the IMP. 
There is a reasonable time relationship to IMP administration. The AE 
cannot be explained by disease or other drugs. There may or may not be 
information about de-challenge or re-challenge. Disappearance of the 
AE upon de-challenge supports this category. Reappearance upon re-
challenge is strongly supportive. 
Not related 
There is no reasonable possibility that the event was caused by the IMP. 
The temporal relationship to drug administration makes a causal 
relationship improbable or other drugs or underlying disease or 
conditions provide plausible explanations. 
Not applicable 
This assessment can be used, e.g. in cases where the subject did not 
receive any treatment with IMP. 
Causality to study procedures will also be assessed. 


 
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11.3.1.9 
Assessment of outcome 
The Investigator must assess the outcome of an AE using the rating and definitions below 
and record it on the AE Log of the eCRF: 
0 = Unknown 
 
1 = Recovered/resolved 
The subject has recovered completely, and no symptoms 
remain. 
2 = Recovering/resolving 
The subject’s condition is improving, but symptoms still 
remain. 
3 = Not recovered/not 
resolved/ongoing 
The subject’s condition has not improved, and the 
symptoms are unchanged (for example, an atrial 
fibrillation has become chronic). 
4 = Recovered/resolved 
with sequelae 
The subject has recovered, but some symptoms remain 
(for example, the subject had a stroke and is functioning 
normally but has some motor impairment). 
5 = Fatal 
 
11.3.1.10 
Reporting of action taken with study treatment 
The Investigator must report the action taken with study treatment using the definitions 
below and record it on the AE Log of the eCRF: 
Dose not changed 
Drug interrupted 
Drug withdrawn 
Not applicable 
Unknown 
11.3.1.11 
Collecting adverse events 
AEs identified using any of the following methods will be recorded: 
− AEs spontaneously reported by the subject. 
− AEs observed by the Investigator or medical personnel. 
− AEs elicited based on non-leading questions from the Investigator or medical 
personnel. 
11.3.1.12 
Recording adverse events 
Adverse events must be recorded in the AE Log of the eCRF. The Investigator must provide 
information on the AE, preferably with a diagnosis or at least with signs and symptoms; start 
and stop dates, start, and stop time; intensity; causal relationship to IMP; action taken, and 
outcome. 
If the AE is serious, this must be indicated in the eCRF. 


 
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Adverse events, including out-of-range clinically significant clinical safety laboratory values, 
must be recorded individually, except when considered manifestations of the same medical 
condition or disease state; in such cases, they must be recorded under a single diagnosis. 
11.3.1.13 
 Reporting of serious adverse events  
Serious adverse event reporting should be performed by the Investigator within 24 hours of 
awareness using the paper SAE form, provided in the investigator site file (ISF). All available 
information regarding the SAE should be entered using the SAE form (i.e. term, intensity, 
causality, outcome, SAE criteria, action taken, narrative including rational for causality 
assessment) for the specific subject. The completed, signed and dated paper SAE Form 
should, within 24 hours, be scanned and e-mailed to:  
Email: Vicore@primevigilance.com 
By saving the event as “serious” in the eCRF and once the Investigator has signed-off of the 
event, an e-mail alert is automatically sent to predefined recipients to highlight that an SAE 
has been registered. The same information is automatically sent to 
Vicore@primevigilance.com. However, all SAE management and follow-up takes place via 
the SAE paper forms. 
The SAE report is reviewed by a designated person at PrimeVigilance to ensure that the 
report is valid and correct. For fatal or life-threatening SAEs where important or relevant 
information is missing, immediate follow-up is undertaken and queries to the site are raised. 
Investigators or other site personnel should inform PrimeVigilance of any follow-up 
information (including rational for changes, e.g. changes in causality assessment and 
intensity, that should be described in the SAE narrative) on a previously reported SAE 
immediately but no later than within 24 hours of awareness. Such follow-up information 
should be documented on a new SAE report form, marked as a follow-up report and emailed 
to Vicore@primevigilance.com. 
If any additional documentation is required (e.g. autopsy report), PrimeVigilance will request 
this information from the study site.  
The Sponsor or delegate will assume responsibility for reporting SAEs to the competent 
authority (CA) and independent ethics committee (IEC) in accordance with local regulations. 
11.3.1.14 
Expedited reporting of suspected unexpected serious adverse reaction 
The term SAR is used whenever either the Investigator or Sponsor deems an SAE related to 
the IMP. If an SAR is assessed as unexpected it will be reported as a SUSAR to the CA and 
to the IEC in accordance with local regulations within the following timelines: 
− 7 calendar days if fatal or life-threatening (follow-up information within an additional 
8 days) 
− 15 calendar days if non-fatal and non-life-threatening (follow-up information as soon 
as possible) 
11.3.1.15 
Treatment and follow-up of adverse events 
Subjects with AEs occurring during the study must be treated according to daily clinical 
practice at the discretion of the Investigator. 


 
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Adverse events must be followed up until resolution or to the end-of-study contact, 
whichever comes first. At the end-of-study contact, information on new AEs, if any, and stop 
dates for previously reported AEs must be recorded (if known). AEs assessed as stable by the 
Investigator at the end-of-study contact will not have to be followed up until resolution. 
It is the responsibility of the Investigator to follow up on all SAEs until the subject has 
recovered, stabilised, or recovered with sequelae, and to report to the Sponsor all relevant 
new information using the same procedures and timelines as those for the initial report. 
Relevant information includes discharge summaries, autopsy reports, and medical 
consultation. 
11.3.1.16 
Procedures in case of pregnancy 
In case of pregnancy or suspicion of possible pregnancy of any female partners of male 
subjects, the outcome of the pregnancy (spontaneous miscarriage, elective termination, 
normal birth, or congenital abnormality) must be followed up and documented even after the 
end of the subject’s study participation. Pregnancy itself is not regarded as an AE unless there 
is a suspicion that the IMP may have interfered with the effectiveness of the contraceptive 
medication.  
All events of congenital abnormalities/birth defects are SAEs. Spontaneous miscarriages 
should also be reported and handled as AEs. All outcomes of pregnancy must be reported to 
the Sponsor and the Principal Investigator on the pregnancy outcomes report form. 
11.3.1.17 
Treatment of overdose 
An overdose is a dose in excess of the dose specified in this CSP. 
Over-dosing is not likely to occur in this study since the IMPs will be administered by site 
personnel under medical surveillance. The doses to be administered are substantially lower 
than the doses considered well tolerated in clinical practice (Nipruss®) and based on previous 
clinical studies (C21).  
In cases of accidental overdose of C21, standard supportive measures should be adopted as 
required. No known antidote is available. 
In cases of accidental overdose of sodium nitroprusside (Nipruss®), standard supportive 
measures should be adopted as required. Overdosage of sodium nitroprusside can be 
manifested as excessive hypotension or cyanide toxicity or as thiocyanate toxicity. 
Treatment of cyanide toxicity: Acidosis may not appear until more than an hour after the 
appearance of dangerous cyanide levels, and laboratory tests should not be awaited. 
Reasonable suspicion of cyanide toxicity is adequate grounds for initiation of treatment. 
Treatment of cyanide toxicity consists of: 
− discontinuing the administration of sodium nitroprusside; 
− providing a buffer for cyanide by using sodium nitrite to convert as much 
haemoglobin into methaemoglobin as the patient can safely tolerate; and then 
− infusing sodium thiosulfate in sufficient quantity to convert the cyanide into 
thiocyanate 
The necessary medications for this treatment are contained in commercially available 
Cyanide Antidote Kits.  


 
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Any overdose should be documented as follows:  
− An overdose with associated AE is recorded as the AE diagnosis/symptoms in the AE 
Log of the eCRF.  
− An overdose without associated symptoms is only reported in the subject’s medical 
records and on the protocol deviation log. 
11.3.2 
Vital signs 
Systolic and diastolic blood pressure and pulse will be measured in supine position after 
10 min of rest at time-points specified in Table 8.1-1.  
Any vital signs outside the normal ranges will be judged as not clinically significant or 
clinically significant by the Investigator. The assessment will be recorded in the eCRF. 
Abnormal post-dose values judged as clinically significant will be reported as AEs. 
11.3.3 
Electrocardiogram 
Single 12-lead ECG will be recorded in supine position after 10 min of rest using an ECG 
machine at time-points specified in Table 8.1-1. Heart rate and PR, QRS, QT and QTcF 
intervals will be recorded. ECGs will be reviewed and interpreted on-site by the Investigator. 
Any abnormalities will be specified and documented as clinically significant or not clinically 
significant by the Investigator. Abnormal post-dose findings assessed as clinically significant 
will be reported as AEs. 
11.3.4 
Laboratory safety assessments 
Blood samples for analysis of clinical chemistry, haematology and coagulation parameters 
will be collected through venepuncture or an indwelling venous catheter at time-points 
specified in Table 8.1-1 and sent to the certified Clinical Chemistry and Pharmacology 
laboratory at Uppsala University Hospital and analysed by routine analytical methods.  
The safety laboratory parameters are defined in Table 11.3-1.  
Any lab values outside the normal ranges will be judged as not clinically significant or 
clinically significant by the Investigator. The assessment will be recorded in the eCRF. 
Abnormal post-dose values assessed as clinically significant will be reported as AEs. If an 
abnormal value is associated with corresponding clinical signs or symptoms, the 
sign/symptom should be reported as the AE. 
 
 






 
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13 QUALITY MANAGEMENT, QUALITY ASSURANCE AND QUALITY 
CONTROL 
13.1 Quality management: critical process, system, and data identification 
During CSP development, the Sponsor have identified those processes, systems (facilities, 
computerised systems) and data that are critical to ensure human subject protection and the 
reliability of study results according to applicable SOPs and International Council for 
Harmonisation of technical requirements for pharmaceuticals for human use (ICH) E6 R2. 
Identified risks are categorised separately from the CSP. Risks associated with the 
COVID-19 pandemic and mitigation actions are described in Table 6.6-1. Sponsor oversight 
responsibilities, such as monitoring, AE reporting, safety monitoring, changes in 
Investigators and key study team staff and quality assurance activities may need to be 
reassessed in relation to the COVID-19 pandemic and temporary, alternative proportionate 
mechanisms of oversight may be required. An updated risk assessment will be performed 
prior to enrolment of the first subject. 
13.2 Quality assurance and quality control 
The Sponsor has implemented and is responsible for quality assurance (QA) and quality 
control (QC) systems with written SOPs with regards to management of identified risks, CSP 
compliance, good clinical practice (GCP) compliance and applicable regulatory requirements 
for all parties involved in the study.  
The Sponsor is responsible for securing agreements with involved vendors and to perform 
regular vendor oversight to ensure CSP compliance, GCP compliance and compliance with 
applicable regulatory requirements.  
Quality control is applied to each stage of data handling to ensure that all data are reliable and 
have been processed correctly. 
The Sponsor has delegated the responsibilities outlined above to CTC whilst maintaining 
overall study oversight of any study-related duties and functions carried out on its behalf.  
All references to Sponsor also apply to CTC with regards to the study related duties and 
functions carried out by CTC on Sponsor’s behalf. CTC must therefore implement both QA 
and QC. 


 
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14 ETHICAL AND REGULATORY REQUIREMENTS  
14.1 Ethical conduct of the study 
The study will be performed in accordance with ethical principles that have their origin in the 
Declaration of Helsinki [17] and are consistent with ICH/GCP E6 (R2), EU Clinical Trials 
Directive, and applicable local regulatory requirements. 
14.2 Ethics and regulatory review 
The Principal Investigator is responsible for submission of the CSP, the subject information 
and ICF, any other written information to be provided to the subjects and any advertisements 
used for recruitment of subjects to applicable IEC for approval.  
The Sponsor has delegated to CTC the responsibility to submit study documents to the 
applicable CA according to local regulatory requirements. 
Approval must be obtained in writing from both IEC and CA before the first subject can be 
recruited. 
The Sponsor will provide the CA, IEC and Principal Investigator with safety updates/reports 
according to local requirements. Progress reports and notifications of SUSARs will be 
provided to the IEC according to local regulations and guidelines. 
14.3 Subject information and consent 
It is the responsibility of the Investigator or an authorised associate to give each potential 
study subject adequate verbal and written information before any study specific assessments 
are performed. 
The information will include the objectives and the procedures of the study as well as any 
risks or inconveniences involved. It will be emphasised that participation in the study is 
voluntary and that the subject may withdraw from participation at any time and for any 
reason, without any prejudice. All subjects will be given the opportunity to ask questions 
about the study and will be given sufficient time to consider participation before signing the 
ICF. 
Before performing any study-related procedures the ICF must be signed and personally dated 
by the subject and by the Investigator. A copy of the subject information including the signed 
ICF will be provided to the subject. 
Documentation of the discussion and the date of informed consent must be recorded in the 
source documentation and in the eCRF. The subject information sheet and the signed ICF 
must be filed by the Investigator for possible future audits and/or inspections. 
The final approved version of the subject information and ICF must not be changed without 
approval from the Sponsor and the applicable IEC. 
14.4 Subject information card  
The subject will be provided with a subject information card including the following 
information:  
− That he is participating in a clinical study 


 
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− Subject study ID 
− That he will be/has been dosed with the IMP 
− The name and phone number of the Investigator  
− Name and address of the Sponsor 
14.5 Subject data protection 
The ICF includes information that data will be recorded, collected, and processed and may be 
transferred to European Economic Area (EEA) or non-EEA countries. In accordance with the 
General Data protection Regulation (GDPR EU 2016/679), the data will be pseudonymised 
and not directly identify any persons taking part in the study. 
The potential study subject should be informed that by signing the ICF he approves that 
authorised representatives from Sponsor and CTC, the concerned IEC and CA have direct 
access to his medical records for verification of clinical study procedures. For further details 
on the subject information and ICF process, refer to Section 14.3. 
The subject has the right to request access to his personal data and the right to request 
rectification of any data that is not correct and/or complete in accordance with the GDPR 
(EU 2016/679) and the request will be raised to the Principal Investigator.  
If the subject withdraw his consent to the collection, use and disclosure of information, no 
new information will be collected for the purposes of this study. However, data collected 
before withdrawal will be used as part of the study material. 
The Investigator must file a Subject Identification List which includes sufficient information 
to link records, i.e. the eCRF and clinical records. This list will be preserved for possible 
future inspections/audits but must not be made available to the Sponsor except for monitoring 
or auditing purposes. 
Personal data that are collected in the study such as health information and ethnicity are 
considered as sensitive personal data. This data will be pseudonymised, i.e. personally 
identifiable information (PII) will be removed and replaced by a unique subject ID and will 
be processed by the Sponsor and other involved parties during the study. After the study end, 
only pseudonymised data, i.e. aggregated data sets, can be used. 
For this study, the Sponsor is the data controller of all data processed during the study (e.g. 
TMF, clinical study report [CSR]) and CTC is the data processor. Any subcontractors used in 
the study, are also data processors.  
For data that are processed at the clinic (e.g. medical records and ISF), CTC is the data 
controller. 
14.6 Changes to the approved clinical study protocol  
Any proposed change to the approved final CSP will be documented in a written and 
numbered CSP amendment. All substantial amendments to the CSP must be approved by the 
appropriate IEC and/or CA before implementation according to applicable regulations. 


 
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14.7 Audits and inspections 
Authorised representatives of Sponsor, a CA, or the IEC may perform audits or inspections at 
the study site, with permission from the Investigator to have direct access to source 
data/documents. The purpose of an audit or inspection is to systematically and independently 
examine all study-related activities and documents, to determine whether these activities were 
conducted, and data were recorded, analysed, and accurately reported according to the CSP, 
ICH-GCP guidelines, GDPR and any applicable regulatory requirements. The Investigator 
will contact the Sponsor immediately if contacted by a CA about an inspection at the study 
site. 
14.8 Insurance 
Subjects will be covered under a liability insurance policy through the Swedish 
Pharmaceutical Insurance (Läkemedelsförsäkringen). The certificate of insurance and an 
information leaflet containing essential information about the insurance coverage can be 
provided upon request. The participating subjects are also protected in accordance with 
national regulations, as applicable. CTC has a company insurance covering services 
performed by CTC. 


 
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15 STUDY MANAGEMENT 
15.1 Training of study site personnel 
Before enrolment of the first subject, a Sponsor representative or delegate will perform a 
study initiation visit at the study site. The requirements of the CSP and related documents 
will be reviewed and discussed, and the investigational staff will be trained in any 
study-specific procedures and systems utilised. 
It is the responsibility of the Principal Investigator to ensure that all personnel involved in the 
study are fully informed of all relevant aspects of the study and have a detailed knowledge of 
and training in the procedures that are to be executed by them. Any new information of 
relevance to the performance of this study must be forwarded to the staff involved in a timely 
manner. 
The Investigator will keep a list of all personnel involved in the study together with their 
function and study-related duties delegated. A Curriculum Vitae will be available for all staff 
to whom study-specific duties are delegated.  
15.2 Clinical monitoring  
The Sponsor is responsible for securing agreement from all involved parties to ensure direct 
access to all study-related sites, source data/documents, and reports for the purpose of 
monitoring and auditing by the Sponsor, and inspection by domestic and foreign CAs.  
As defined in the risk-based monitoring (RBM) plan, approved by the Sponsor and provided 
separately, the responsible Monitor will periodically visit the study site at times agreed upon 
by the Investigator and the Monitor. Adaptations related to the on-site monitoring plan, when 
it is impossible or inappropriate to follow due to the COVID-19 pandemic, may be required 
such as supplementation with (additional/increased) centralised monitoring and central 
review of data if considered possible and meaningful (see Table 6.6-1). Results of adjusted 
monitoring/review measures should be reported to the Sponsor in monitoring reports and in 
the CSR. At the time of each monitoring visit, the role of the Monitor is (but not limited to) 
to: 
− provide information and support to the investigational team 
− confirm that facilities and resources remain acceptable 
− confirm that the investigational team is adhering to the CSP, applicable SOPs, guidelines, 
manuals, and regulatory requirements  
− verify that data are being accurately and timely recorded in the eCRFs and that IMP 
accountability checks are being performed 
− verify that data in the eCRF are consistent with the clinical records (SDV) in accordance 
with the RBM plan  
− verify that the correct informed consent procedure has been adhered to for participating 
subjects  
− ensure that withdrawal of informed consent to the use of the subject’s biological samples 
will be reported and biological samples are identified and disposed of/destructed 
accordingly, and that this action is documented and reported to the subject 


 
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− verify that AEs are recorded and reported in a timely manner and according to the CSP 
− raise and escalate any serious quality issues, serious GCP breach and any data privacy 
breach to the Sponsor  
Centralised monitoring will also be performed continuously by study team members at CTC 
in accordance with the RBM plan.  
When the study has been completed and all queries have been resolved and the database has 
been locked, the Monitor will perform a close-out visit. 
15.3 Source data documents 
A separate Origin of Source Data List will be generated for the study site before start of 
enrolment, specifying the location of the source of derived information appearing in the 
eCRF. This document must be signed by the Principal Investigator and the Monitor to 
confirm agreement before start of recruitment. 
Source documents are all documents used by the Investigator or hospital that relate to the 
subject’s medical history, that verifies the existence of the subject, the inclusion and 
exclusion criteria, and all records covering the subject’s participation in the study.  
They include laboratory notes, memoranda, material dispensing records, subject files, etc. 
The eCRF may constitute source data if clearly defined in the Origin of Source Data List. 
The Investigator should guarantee access to source documents to the Monitor, CAs and the 
IECs, if required. 
15.4 Study agreements 
The Principal Investigator must comply with all the terms, conditions, and obligations of the 
Clinical Study Agreement for this study. 
Agreements between Sponsor and CTC must be in place before any study-related procedures 
can take place, or subjects be enrolled. 
15.5 Study timetable and end of study 
The study is expected to be performed in Q1 2022. 
A subject is considered to have completed the study if he has completed all study visits and 
contacts including the end-of-study phone call. 
The end of the clinical part of the study is defined as the end-of-study phone call of the last 
subject participating in the study. 
15.6 Termination of the study 
The Investigator or the Sponsor may terminate this study prematurely for any reasonable 
cause. The IEC and CA should be informed promptly. Conditions that may warrant study 
termination include, but are not limited to: 
− The discovery of an unexpected, significant, or unacceptable risk to the subjects enrolled 
in the study or potential study subjects; or 
− A decision by the Sponsor to suspend or discontinue development of the IMP 


 
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If the CA obtains information that raises doubts about the safety or scientific validity of the 
clinical study, the CA can suspend or prohibit the study. Before the CA reaches its decision, 
it shall, except where there is imminent risk, ask the Sponsor and/or the Investigator for their 
opinion, to be delivered within 1 week (Directive 2001/20/EC, Article 12, Section 1).  
If the study is prematurely terminated or suspended for any reason, the 
Investigator/institution should promptly inform the subjects and should assure appropriate 
follow-up for the subjects. 
15.7 Reporting and publication 
15.7.1 
Clinical Study Report  
A summarising report must be submitted to the applicable CA and IEC within 12 months 
after completion of the study (in accordance with LVFS 2011:19, Chapter 9). 
A CSR, in compliance with ICH-E3, describing the conduct of the study, any statistical 
analyses performed, and the results obtained, will be prepared by CTC. The report will be 
reviewed and approved by, as a minimum, the Principal Investigator, the Statistician, and the 
Sponsor. The study results will be reported in the EudraCT database per applicable 
regulations within 12 months after completion of the study. 
15.7.2 
Annual safety report 
If the study duration exceeds 1 year, the Sponsor must submit a development safety update 
report (DSUR) to the CA and to the IEC. The report shall summarise all pertinent safety 
information collected during the reporting period and contain an update of the risk-benefit 
evaluation if there has been any change since the approval of the clinical study. 
15.7.3 
Confidentiality and ownership of study data 
Any confidential information relating to the IMP or the study, including any data and results 
from the study, will be the exclusive property of the Sponsor. The Investigator and any other 
persons involved in the study are responsible for protecting the confidentiality of this 
proprietary information belonging to the Sponsor. 
15.7.4 
Publication 
The results from this study may be submitted for publication at the discretion of the Sponsor. 
15.8 Archiving  
Records and documents pertaining to the conduct of this study should be retained by the 
investigator for 25 years after study completion unless local regulations or institutional 
policies require a longer retention period. This includes any original source documents 
related to the study, the Subject Identification List (providing the sole link between named 
subject source records and pseudonymous eCRF data), the original signed ICFs and detailed 
records of disposition of IMP. It is the responsibility of the Sponsor to inform the 
Investigator/institution as to when these documents no longer need to be retained. 
The Sponsor will archive the TMF in accordance with ICH E6 GCP, Section 8 and applicable 
regulatory requirements. 


 
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The data from the eCRFs (including metadata, audit trail and closed queries) will be sent to 
the Sponsor and a copy will be retained at the clinic and filed in the ISF for archiving for 
25 years after finalisation of the CSR. 
The completed eCRFs are the property of the Sponsor and should not be made available in 
any form to third parties, except for authorised representatives of appropriate 
Health/Regulatory Authorities, without written permission from the Sponsor. 


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16 DATA MANAGEMENT 
The data management routines include procedures for handling of the eCRF, database set-up 
and management, data entry and verification, data validation, QC of the database, and 
documentation of the performed activities including information of discrepancies in the 
process. The database, data entry screens, and program will be designed in accordance with 
the CSP. 
Data validation/data cleaning procedures are designed to assure validity and integrity of the 
clinical data. These procedures consist of computerised online edit checks identifying e.g. 
data values that are outside the allowed range and SAS-programmed batch checks and data 
listing for data quality reviews on data exports. All study-specific and standard data 
validation programming will be tested in a separate testing environment prior to use on 
production data. 
Detailed information on data management processes will be described in a study-specific 
Data Management Plan. 
16.1 The web-based eCRF 
Clinical data will be entered into a 21 CFR Part 11-compliant eCRF (Viedoc™) provided by 
Viedoc Technologies AB. The eCRF includes password protection and internal quality 
checks, such as automatic range checks, to identify data that appear inconsistent, incomplete, 
or inaccurate. Clinical data will be entered directly from the source documents or at bedside 
(if the eCRF data constitutes source data). Source data are to be defined at the study site 
before inclusion of the first subject (Section 15.3). 
Authorised site personnel designated by the Investigator will complete data collection. 
Appropriate eCRF training and security measures for access control will be completed with 
the Investigator and all authorised site personnel prior to the study being initiated and any 
data being entered into the system for any study subject. 
16.2 The entering of data into the eCRF 
All entries, corrections, and alterations are to be made by the Investigator or designee. 
Neither the Monitor nor any other study team member besides site staff can enter data in the 
eCRF. All data should be entered in English.  
The eCRFs should be completed as soon as possible during or after the subject’s visit.  
To avoid inter-observer variability, every effort should be made to ensure that preferably the 
same individual who made the initial baseline determinations completes all corresponding 
follow-up evaluations.  
The Investigator must verify that all data entries in the eCRFs are accurate and correct.  
If some assessments are not done, or if certain information is not available, not applicable, or 
unknown, the Investigator or assigned clinical staff should record such information in the 
eCRF. The Investigator will be required to electronically sign off the clinical data. This will 
be performed by means of the Investigator’s unique User ID and password; date and time 
stamps will be added automatically at time of electronic signature. 


 
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16.3 The query process 
The Monitor will review the eCRFs and evaluate them for completeness and consistency, 
according to the RBM plan. Data in the eCRF will be compared with the respective source 
documents to ensure that there are no discrepancies for critical data as described in the RBM 
plan. All entries, corrections, and alterations are to be made by the Investigator or designee. 
Neither the Monitor nor any other study team member besides site staff can enter data in the 
eCRF.  
If corrections are needed, queries will be raised within the eCRF, either because of built-in 
edit checks or manually raised by the Monitor. An appropriate member of the site staff will 
answer the queries in the eCRF either by correcting the data or by entering a response to the 
query. The Monitor will either approve the answer/correction or re-issue the query. 
16.4 Audit trail 
All entries in the eCRF will be fully recorded in a protected, readable, and not editable audit 
trail. Once clinical data have been saved, corrections to the data fields will be audit trailed, 
meaning that the reason for change, the name of the person who made the change, together 
with time and date will be logged. 
16.5 External data 
External data consists of data that are not recorded in the eCRF (i.e. safety laboratory data 
and FBF data). Data may be received in electronic format or as a paper printout.  
Key variables are defined to uniquely identify each sample record. File and data formats are 
agreed with the external data provider.  
Reconciliation of external data versus eCRF data will be performed ensuring data integrity. 
16.6 Medical coding 
Medical coding will be performed by trained personnel at CTC. Medical/surgical history 
verbatim terms and AEs will be coded using the Medical Dictionary of Regulatory Activities 
(MedDRA; latest version available at start of eCRF set up). Prior and concomitant 
medications will be coded according to the World Health Organisation (WHO) anatomic 
therapeutic chemical (ATC) classification system. All coding will be approved by Sponsor 
prior to database lock. 
16.7 Database lock 
When all data have been entered, discrepancies resolved, SDV has been performed according 
to the RBM plan, all external data and SAEs have been successfully reconciled, all medical 
terms have been coded, all protocol deviations have been categorised, and all Principal 
Investigator signatures have been collected, clean file will be declared after the classification 
of the subjects to the analysis populations, the database will be locked, and the data will be 
ready for analysis. 


 
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17 STATISTICAL METHODS AND DETERMINATION OF SAMPLE SIZE  
The principal features of the statistical analysis to be performed are described in this section. 
A more technical and detailed elaboration of the principal features will be presented in a 
separate Statistical Analysis Plan, which will be signed and approved prior to database lock. 
Analyses of the primary and secondary endpoints will be performed by CTC.  
17.1 General 
Continuous data will be presented in terms of evaluable and missing observations, arithmetic 
mean, standard deviation (SD), median, minimum, and maximum value. Categorical data will 
be presented as counts and percentages. When applicable, summary data will be presented by 
treatment (test product/comparator), and by assessment time. Individual subject data will be 
listed by subject number, treatment, and, where applicable, by assessment time. 
All descriptive summaries and statistical analyses will be performed using SAS Version 9.4 
or later (SAS Institute, Inc., Cary, NC). 
Baseline for the safety assessments will be defined as the last data collection point prior to the 
first administration of IMP. For the FBF measurements, a baseline will be defined for each 
dose level. 
No imputation of missing data will be performed. 
17.2 Determination of sample size 
No formal sample size calculation has been performed for this study. The proposed sample 
size is considered sufficient to provide adequate information for the study objectives. 
Approximately 10 subjects will be screened to achieve 5 included and evaluable subjects. 
17.3 Analysis data sets 
17.3.1 
Full analysis set 
The full analysis set (FAS) will consist of all subjects who have been included and received 
at least one dose of IMP and have at least one post-baseline assessment. 
17.3.2 
Safety analysis set 
The safety analysis set will compromise all subject who received at least one dose of the 
IMP. 
17.4 Description of study population 
17.4.1 
Demographics and baseline characteristics 
Descriptive statistics for demographics, weight, height, BMI, and dominant/non-dominant 
arm will be presented. 
Individual data will be listed by subject. 


 
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17.4.2 
Medical/surgical history and prior/concomitant medication 
Medical/surgical history will be summarised by system organ class (SOC) and preferred term 
(PT). Prior/concomitant medications will be presented by ATC level 4 and 5. 
Individual data will be listed by subject. 
17.4.3 
Physical examination 
Clinically significant and non-clinically significant abnormal findings will be specified and 
presented by subject. 
Individual data will be listed by subject. 
17.4.4 
Treatment compliance 
The number of subjects administered each IMP and start and stop times for each infusion will 
be listed. 
17.5 Analysis of efficacy endpoints 
17.5.1 
Effect of C21 on forearm blood flow 
The response to increasing i.a. doses of C21 will be summarised using descriptive statistics 
with percent change from baseline and presented by dose. 
17.5.2 
Dose-response 
The dose response curve of C21 will be presented using a mixed model. The natural 
logarithm of the maximum FBF value for each dose level and each subject will be used as the 
dependent variable in the model. Dose will be used as a class variable and subject as a 
random variable. Kenward-Roger’s approximation for degrees of freedom will be used. The 
least square means (LSMeans) estimates for the doses will be presented in a plot. In addition, 
the pairwise LSMeans differences between the doses will be tabulated. 
17.5.3 
Effect of sodium nitroprusside on forearm blood flow 
The response to increasing i.a. doses of sodium nitroprusside will be summarised using 
descriptive statistics with percent change from baseline and presented by dose. 
17.6 Analysis of safety endpoints 
17.6.1 
Adverse events  
An overview of all AEs, including SAEs, intensity, relationship to IMP/study procedures, and 
deaths will be presented by treatment group. Incidence of AEs and SAEs will be summarised 
by SOC and PT.  
All AE data will be listed by subject and include the verbatim term entered by the 
Investigator. 


 
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17.6.2 
Vital signs 
Vital signs (systolic/diastolic blood pressure and pulse) will be summarised using descriptive 
statistics. Data will be presented with absolute change from baseline. 
Individual data will be listed by subject. 
17.6.3 
12-lead ECG 
All ECGs will be categorised as normal, abnormal, not clinically significant, or abnormal, 
clinically significant (as judged by the Investigator) and summarised using descriptive 
statistics.  
Individual data will be listed by subject. 
17.6.4 
Safety laboratory analyses 
Safety laboratory data will be summarised using descriptive statistics with absolute change 
from baseline. Abnormal, clinically significant values will be summarised separately, if 
considered appropriate.  
Individual data will be listed by subject. 


 
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19.2 Signature page (approval of the clinical study protocol)