Clinical trial NCT03689972
Conditions: Multiple Sclerosis, Relapsing-Remitting
Sponsor: Biogen
Start date: 2018-11-27; Completion date: 2023-07-24
Enrollment: 585 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
Part 1: The primary objective is to evaluate the efficacy of natalizumab extended interval dosing (EID) (every 6 weeks \[Q6W\]) in participants who have previously been treated with natalizumab standard interval dosing (SID) (every 4 weeks \[Q4W\]) for at least 12 months, in relation to continued Q4W treatment. The secondary objectives is to evaluate relapse-based clinical efficacy measures, disability worsening, additional Magnetic resonance imaging (MRI)-lesion efficacy measures and safety of Q6W in participants who have previously been treated with natalizumab Q4W for at least 12 months, in relation to continued Q4W treatment.

Part 2: The primary objective is to evaluate participant preference for subcutaneous (SC) versus intravenous (IV) route of natalizumab administration. The secondary objectives is to evaluate treatment satisfaction, drug preparation and administration time, safety and immunogenicity, efficacy and characterize pharmacokinetic (PK) and pharmacodynamic (PD) drug preparation and administration time of SC versus IV routes of natalizumab administration.

Detailed description:
This study will be conducted in 2 parts. At the end of part 1, participants who provide consent and are eligible, and newly enrolled participants, will enter part 2, an Open Label Extension comprising a crossover analysis.

Those participants who completed part 1 and cannot participate, or elect not to participate, in Part 2 (Open label extension) will enter a 12-week follow-up.

Arms: arm 1: Participants received natalizumab 300 mg intravenous (IV) infusion once Q4W up to Week 72. arm 2: Participants received natalizumab 300 mg IV infusion once Q6W up to Week 72. arm 3: Participants who completed Part 1 or were newly enrolled in Part 2 received natalizumab 300 mg IV infusion Q6W from Week 72 through Week 102. arm 4: Participants who completed run-in period of Part 2 were randomized to receive natalizumab 300 mg IV infusion Q6W from Week 108 through Week 126 followed by natalizumab 300 mg subcutaneous (SC) injection Q6W from Week 132 through Week 150 along with a single dose of natalizumab 300 mg SC injection or IV infusion as per participant's choice at Week 156. arm 5: Participants who completed run-in period of Part 2 were randomized to receive natalizumab 300 mg SC injection Q6W from Week 108 through Week 126 followed by natalizumab 300 mg IV infusion Q6W from Week 132 through Week 150 along with a single dose of natalizumab 300 mg SC injection or IV infusion as per participant's choice at Week 156.
Interventions: intervention 1: Natalizumab intervention 2: Natalizumab
Intervention descriptions: intervention 1: Natalizumab 300 mg IV infusion. intervention 2: Natalizumab 300 mg SC injection or IV infusion.

Protocol documents:
Prot_000.pdf: 
COVER PAGE 
Official Title: A Randomized, Controlled, Open-Label, Rater-Blinded, Phase 3b 
Study of the Efficacy, Safety, and Tolerability of 6-Week Extended 
Interval Dosing (EID) of Natalizumab (BG00002) in Subjects With 
Relapsing-Remitting Multiple Sclerosis Switching From Treatment 
With 4-Week Natalizumab Standard Interval Dosing (SID) in Relation 
to Continued SID Treatment - Followed by an Open-Label Crossover 
Extension Study Comprising Subcutaneous and Intravenous 
Natalizumab Administration 
NCT Number: 
NCT03689972 
Document Date: 
Protocol version 4.0: 20 Aug 2020 


CONFIDENTIAL
The information contained herein may not be used, disclosed, or published without the written consent of 
Biogen MA Inc.
1
Biogen MA Inc.
225 Binney Street
Cambridge, MA  02142
United States
PROTOCOL NUMBER:
101MS329
Biogen Idec Research Limited
Innovation House
70 Norden Road
Maidenhead Berkshire
SL6 4AY
United Kingdom
PHASE OF DEVELOPMENT:
3b
PROTOCOL TITLE: A Randomized, Controlled, Open-Label, Rater-Blinded, Phase 3b 
Study of the Efficacy, Safety, and Tolerability of 6-Week Extended Interval Dosing (EID) 
of Natalizumab (BG00002) in Subjects With Relapsing-Remitting Multiple Sclerosis 
Switching From Treatment With 4-Week Natalizumab Standard Interval Dosing (SID) in 
Relation to Continued SID Treatment - Followed by an Open-Label Crossover Extension
Study Comprising Subcutaneous and Intravenous Natalizumab Administration
EUDRA CT NUMBER:
2018-002145-11
DATE:
20 August 2020
Version 4.0
FINAL
Supersedes previous Version 3.0 dated 08 July 2020




Protocol 101MS329
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Phase 3b Efficacy Study of Natalizumab EID After Switch From Natalizumab SID in Subjects With RRMS
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TABLE OF CONTENTSTABLE OF CONTENTS
SPONSOR SIGNATURE PAGE ....................................................................................................2
1.
SYNOPSIS ...................................................................................................................9
2.
LIST OF ABBREVIATIONS.....................................................................................15
3.
SPONSOR INFORMATION .....................................................................................17
4.
INTRODUCTION......................................................................................................18
4.1.
Overview of Multiple Sclerosis..................................................................................18
4.2.
Current Therapies for Multiple Sclerosis ...................................................................19
4.3.
Profile of Previous Experience With Natalizumab.....................................................19
4.3.1.
Nonclinical Experience...............................................................................................19
4.3.2.
Clinical Experience.....................................................................................................19
4.4.
Benefit-Risk Assessment............................................................................................20
4.5.
Study Rationale...........................................................................................................21
5.
SCHEDULE OF ACTIVITIES ..................................................................................22
5.1.
Part 1 – Schedule of Activities ...................................................................................22
5.2.
Part 2 – Schedule of Activities ...................................................................................32
6.
STUDY OBJECTIVES AND ENDPOINTS..............................................................42
6.1.
Part 1 Objectives and Endpoints.................................................................................42
6.2.
Part 2 Objectives and Endpoints.................................................................................44
7.
STUDY DESIGN .......................................................................................................47
7.1.
Study Duration for Subjects........................................................................................49
7.1.1.
Study Duration for Subjects Enrolled Only in Part 1 .................................................49
7.1.2.
Study Duration for Subjects Enrolled in Part 1 and Part 2.........................................49
7.2.
Responsibilities of Study Site Staff............................................................................49
7.2.1.
General Staff Responsibilities During Part 1 and Part 2 ............................................49
7.2.2.
Changes in Responsibilities During Part 2.................................................................52
7.3.
Unscheduled Visits and Treatment for MS Relapses .................................................52
7.3.1.
Unscheduled Visits in Part 1.......................................................................................53
7.3.2.
Unscheduled Visits in Part 2.......................................................................................53
7.4.
Study Stopping Rules .................................................................................................53
7.5.
End of Study ...............................................................................................................53
8.
SELECTION OF SUBJECTS ....................................................................................54


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8.1.
Part 1 Inclusion Criteria..............................................................................................54
8.2.
Part 1 Exclusion Criteria.............................................................................................54
8.3.
Part 2 Inclusion Criteria..............................................................................................56
8.4.
Part 2 Exclusion Criteria.............................................................................................56
8.5.
Part 2 Inclusion Criteria for New Subjects.................................................................56
8.6.
Part 2 Exclusion Criteria for New Subjects................................................................57
9.
SCREENING AND RANDOMIZATION .................................................................58
9.1.
Screening ....................................................................................................................58
9.1.1.
Part 1 Screening..........................................................................................................58
9.1.2.
Part 2 Screening..........................................................................................................58
9.2.
Randomization............................................................................................................59
9.2.1.
Part 1 Randomization .................................................................................................59
9.2.2.
Part 2 Randomization .................................................................................................59
9.3.
Blinding Procedures....................................................................................................59
9.3.1.
Part 1 Blinding............................................................................................................59
9.3.2.
Part 2 Blinding............................................................................................................59
10.
DISCONTINUATION OF STUDY TREATMENT AND WITHDRAWAL 
OF SUBJECTS FROM THE STUDY........................................................................60
10.1.
Discontinuation of Study Treatment...........................................................................60
10.2.
Lost to Follow-Up.......................................................................................................61
10.3.
Withdrawal of Subjects From Study...........................................................................61
11.
STUDY TREATMENT USE .....................................................................................62
11.1.
Regimen......................................................................................................................62
11.1.1.
Part 1 Regimen ...........................................................................................................62
11.1.2.
Part 2 Regimen ...........................................................................................................62
11.2.
Modification of Dose and Treatment Schedule..........................................................62
11.2.1.
Modification of Dose..................................................................................................62
11.2.2.
Modification of Treatment Schedule..........................................................................62
11.2.2.1.
Part 1 Modification of Treatment ...............................................................................62
11.2.2.2.
Part 2 Modification of Treatment ...............................................................................63
11.3.
Precautions..................................................................................................................63
11.4.
Compliance.................................................................................................................63


Protocol 101MS329
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Phase 3b Efficacy Study of Natalizumab EID After Switch From Natalizumab SID in Subjects With RRMS
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11.5.
Concomitant Therapy and Procedures........................................................................63
11.5.1.
Concomitant Therapy .................................................................................................63
11.5.1.1.
Allowed Concomitant Therapy...................................................................................63
11.5.1.2.
Disallowed Concomitant Therapy..............................................................................64
11.5.2.
Concomitant Procedures.............................................................................................64
11.5.2.1.
Disallowed Concomitant Procedures..........................................................................64
11.6.
Continuation of Treatment..........................................................................................65
12.
STUDY TREATMENT MANAGEMENT................................................................66
12.1.
Natalizumab................................................................................................................66
12.1.1.
Natalizumab Preparation ............................................................................................66
12.1.2.
Natalizumab Storage...................................................................................................66
12.1.3.
Natalizumab Handling and Disposal ..........................................................................67
12.1.4.
Natalizumab Accountability.......................................................................................67
13.
EFFICACY, PHARMACOKINETIC, AND PHARMACODYNAMIC 
ASSESSMENTS.........................................................................................................68
13.1.
Clinical Efficacy Assessments....................................................................................68
13.1.1.
Part 1 Efficacy Assessments.......................................................................................68
13.1.2.
Part 2 Efficacy Assessments.......................................................................................69
13.2.
Pharmacokinetic Assessments....................................................................................69
13.3.
Pharmacodynamic Assessments.................................................................................69
13.3.2.
Part 2 Pharmacodynamic Assessments.......................................................................70
14.
SAFETY ASSESSMENTS ........................................................................................71
14.1.
Clinical Safety Assessments.......................................................................................71
14.2.
Laboratory Safety Assessments..................................................................................71
14.3.
Natalizumab Safety Assessments ...............................................................................71
15.
SAFETY DEFINITIONS, RECORDING, REPORTING, AND 
RESPONSIBILITIES .................................................................................................72
15.1.
Definitions ..................................................................................................................72
15.1.1.
Adverse Event.............................................................................................................72
15.1.2.
Serious Adverse Event................................................................................................72
15.1.3.
Prescheduled or Elective Procedures or Routinely Scheduled Treatments................73


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15.2.
Safety Classifications..................................................................................................73
15.2.1.
Investigator Assessment of Events.............................................................................73
15.2.2.
Relationship of Events to Study Treatment................................................................73
15.2.3.
Severity of Events.......................................................................................................74
15.2.4.
Expectedness of Events ..............................................................................................74
15.3.
Monitoring and Recording Events..............................................................................74
15.3.1.
Adverse Events ...........................................................................................................74
15.3.2.
Serious Adverse Events..............................................................................................75
15.3.3.
Immediate Reporting of Serious Adverse Events.......................................................75
15.3.3.1.
Deaths .........................................................................................................................75
15.3.4.
Suspected Unexpected Serious Adverse Reactions....................................................76
15.4.
Procedures for Handling Special Situations ...............................................................76
15.4.1.
Progressive Multifocal Leukoencephalopathy ...........................................................76
15.4.2.
Pregnancy ...................................................................................................................76
15.4.3.
Overdose.....................................................................................................................76
15.4.4.
Medical Emergency....................................................................................................77
15.5.
Contraception Requirements ......................................................................................77
15.6.
Safety Responsibilities................................................................................................78
15.6.1.
The Investigator..........................................................................................................78
15.6.2.
Biogen.........................................................................................................................78
16.
STATISTICAL METHODS AND DETERMINATION OF SAMPLE SIZE...........79
16.1.
Efficacy.......................................................................................................................79
16.1.1.
Analysis Population....................................................................................................79
16.1.2.
General Methods of Analysis .....................................................................................79
16.1.3.
Part 1 Statistical Analysis...........................................................................................79
16.1.3.1.
Analysis of the Primary Endpoint in Part 1................................................................79
16.1.3.2.
Primary and Secondary Estimands and Handling of Intercurrent Events in 
Part 1...........................................................................................................................80
16.1.3.3.
Analysis of the Secondary Endpoints in Part 1 ..........................................................81
16.1.3.5.
Subgroup Analyses in Part 1.......................................................................................82
16.1.4.
Part 2 Statistical Analysis...........................................................................................83


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16.1.4.1.
Analysis of the Primary Endpoint in Part 2................................................................83
16.1.4.2.
Analysis of the Secondary Endpoint in Part 2............................................................83
16.2.
Pharmacokinetics........................................................................................................86
16.2.1.
Analysis Population....................................................................................................86
16.2.2.
Methods of Analysis...................................................................................................86
16.3.
Pharmacodynamics.....................................................................................................86
16.3.1.
Analysis Population....................................................................................................86
16.3.2.
Methods of Analysis...................................................................................................86
16.5.
Safety..........................................................................................................................87
16.5.1.
Analysis Population....................................................................................................87
16.5.2.
Methods of Analysis...................................................................................................87
16.5.2.1.
Adverse Events ...........................................................................................................87
16.5.2.2.
Clinical Laboratory Results........................................................................................88
16.5.2.3.
Vital Signs ..................................................................................................................88
16.5.2.4.
C-SSRS.......................................................................................................................88
16.6.
Antigenicity/Immunogenicity Data ............................................................................88
16.6.1.
Analysis Population....................................................................................................88
16.6.2.
Methods of Analysis...................................................................................................88
16.7.
Interim Analyses.........................................................................................................88
16.8.
Sample Size Considerations .......................................................................................89
17.
ETHICAL REQUIREMENTS ...................................................................................90
17.1.
Declaration of Helsinki...............................................................................................90
17.2.
Ethics Committee........................................................................................................90
17.3.
Subject Information and Consent ...............................................................................90
17.4.
Subject Data Protection ..............................................................................................91
17.5.
Compensation for Injury.............................................................................................91
17.6.
Conflict of Interest......................................................................................................92
17.7.
Registration of Study and Disclosure of Study Results..............................................92


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18.
ADMINISTRATIVE PROCEDURES.......................................................................93
18.1.
Study Site Initiation....................................................................................................93
18.2.
Quality Control and Quality Assurance......................................................................93
18.3.
Monitoring of the Study..............................................................................................93
18.4.
Study Funding.............................................................................................................93
18.5.
Publications.................................................................................................................94
19.
FURTHER REQUIREMENTS AND GENERAL INFORMATION........................95
19.1.
External Contract Organizations.................................................................................95
19.1.1.
Contract Research Organization.................................................................................95
19.1.2.
Interactive Response Technology...............................................................................95
19.1.3.
Electronic Data Capture..............................................................................................95
19.1.4.
Central Facility for MRI Scans...................................................................................95
19.2.
Study Committees.......................................................................................................95
19.2.1.
Advisory Committee...................................................................................................95
19.2.2.
Independent Neurology Evaluation Committee .........................................................96
19.3.
Changes to Final Study Protocol ................................................................................96
19.4.
Ethics Committee Notification of Study Completion or Termination........................96
19.5.
Retention of Study Data..............................................................................................96
19.6.
Study Report Signatory...............................................................................................96
20.
REFERENCES ...........................................................................................................97
21.
SIGNED AGREEMENT OF THE STUDY PROTOCOL.........................................98
LIST OF TABLES
Table 1:
Part 1 Schedule of Activities – SID............................................................................23
Table 2:
Part 1 Schedule of Activities – EID............................................................................28
Table 3:
Part 2 Schedule of Activities – EID SC vs. IV OLE for Subjects Who 
Participated in Part 1...................................................................................................33
Table 4:
Part 2 Schedule of Activities – EID SC vs. IV OLE for New Subjects .....................37
LIST OF FIGURES
Figure 1:
Design for Study 101MS329 with Open-Label Extension.........................................48


Protocol 101MS329
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1.
SYNOPSIS
Protocol Title:
A Randomized, Controlled, Open-Label, Rater-Blinded, Phase 3b 
Study of the Efficacy, Safety, and Tolerability of 6-Week Extended 
Interval Dosing (EID) of Natalizumab (BG00002) in Subjects With 
Relapsing-Remitting Multiple Sclerosis Switching From Treatment 
With 4-Week Natalizumab Standard Interval Dosing (SID) in Relation 
to Continued SID Treatment - Followed by an Open-Label Crossover 
Extension Study Comprising Subcutaneous and Intravenous
Natalizumab Administration
Protocol Number:
101MS329
Version Number:
4.0
Name of Study 
Treatment:
BG00002 (natalizumab; Tysabri®)
Study Phase:
3b
Study Indication:
Relapsing-remitting multiple sclerosis (RRMS)
Study Rationale:
Extending the dosing interval of natalizumab (e.g., to 6 weeks) has 
been practiced by some physicians in anti-John Cunningham virus
antibody-positive patients with the intention of improving the 
benefit/risk of the treatment by reducing the exposure-dependent risk of 
progressive multifocal leukoencephalopathy while maintaining 
efficacy. Whether extending the dosing interval of natalizumab can 
potentially improve benefit/risk for some patients remains to be 
established as there are no prospective, randomized, controlled studies 
assessing the efficacy of extended interval dosing (EID). This study 
aims to assess the following: the initial efficacy, safety, and tolerability 
of switching to EID (dosing interval every 6 weeks [Q6W]) after at 
least 12 months of disease stability on standard interval dosing (SID) 
[dosing interval every 4 weeks (Q4W)] compared to the continuation of 
SID; and the long-term efficacy, safety, and tolerability of EID when 
natalizumab is delivered by subcutaneous (SC) or intravenous (IV) 
administration. This study has 2 parts.

Part 1 is a randomized, controlled, rater-blinded analysis
designed to compare the efficacy, safety, and tolerability of 
natalizumab EID and SID outcomes.

Part 2 is a randomized open-label extension (OLE) designed to 
assess subject preference for SC natalizumab EID treatment 


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and explore long-term efficacy, safety, and tolerability of EID.
Study Objectives 
and Endpoints:
Part 1
The primary objective of Part 1 of the study is to evaluate the efficacy 
of natalizumab EID in subjects who have previously been treated with 
natalizumab SID for at least 12 months, in relation to continued SID 
treatment, with the goal of estimating the difference between SID and 
EID, with high precision and a narrow 95% confidence interval, to 
support the treatment decision based on individualized benefit/risk 
assessments.

The primary endpoint that relates to this objective is the 
number of new or newly enlarging T2 hyperintense lesions at 
Week 72.
Secondary objectives and endpoints for Part 1 of the study are as 
follows:

To evaluate additional relapse-based clinical efficacy measures 
of natalizumab EID in subjects who have previously been 
treated with natalizumab SID for at least 12 months, in relation 
to continued SID treatment.
o
Time to first relapse (relapses will be adjudicated by an 
Independent Neurology Evaluation Committee)
o
Annualized relapse rate at Week 72

To evaluate disability worsening of natalizumab EID in 
subjects who have previously been treated with natalizumab 
SID for at least 12 months, in relation to continued SID 
treatment.
o
Time to Expanded Disability Status Scale (EDSS) 
worsening (confirmed after at least 24 weeks)

To evaluate additional magnetic resonance imaging 
(MRI)-lesion efficacy measures of natalizumab EID in subjects 
who have previously been treated with natalizumab SID for at 
least 12 months, in relation to continued SID treatment.
o
Number of new or newly enlarging T2 hyperintense lesions 
at Week 24 and Week 48
o
Number of new gadolinium (Gd)-enhancing and new 
T1 hypointense lesions at Weeks 24, 48, and 72

To evaluate the safety of natalizumab EID in subjects who have 
previously been treated with natalizumab SID for at least 
12 months in relation to continued SID treatment.








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up visit or follow-up safety phone call 24 weeks after the last dose of 
study treatment in Part 1.
Part 2 
Study duration for subjects enrolled in Part 2 after completing Part 1 
and for new subjects will be approximately 108 weeks, comprising the 
following: 

36-week period of IV Q6W treatment

48-week randomized crossover treatment period comprising 
24 weeks SC Q6W and 24 weeks IV Q6W

12-week follow-up period

Follow-up safety phone call 12 weeks after the follow-up 
period (24 weeks after the last dose of study treatment)
The total duration of study participation for subjects who participate in 
both Part 1 and Part 2 will be approximately 186 weeks.
The Part 2 Screening, informed consent, and eligibility assessment 
should be performed during Week 72 of Part 1. In the event that the 
Part 2 Screening cannot be performed at that time, a separate Part 2 
Screening may occur within 6 weeks prior to Week 78 or Week 84, 
whichever visit and infusion is the first Part 2 administration of study 
treatment to the subject. Subject randomization to crossover sequence 
in Part 2 will occur at the Week 108 visit to confirm crossover 
treatment allocation.
After Week 84, subjects are not eligible for enrollment in Part 2 of the 
study.


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2.
LIST OF ABBREVIATIONS
AE
adverse event
CI
confidence interval
CNS
central nervous system
CRF
case report form
CRO
contract research organization
C-SSRS
Columbia Suicide Severity Rating Scale
Ctrough
trough serum concentration of natalizumab
DHA
Directions for Handling and Administration
DNA
deoxyribonucleic acid
EDSS
Expanded Disability Status Scale
EID
extended interval dosing
EOS
end of study
ET
early termination
FSH
follicle stimulating hormone
GCP
Good Clinical Practice
Gd
gadolinium
Hep
hepatitis
HIV
human immunodeficiency virus
IB
Investigator’s Brochure
ICF
informed consent form
ICH
International Council for Harmonisation
INEC
Independent Neurology Evaluation Committee
IRT
interactive response technology
IV
intravenous(ly)
JCV
John Cunningham virus
KM
Kaplan-Meier
mAb
monoclonal antibody
mITT
modified intent to treat
MMRM
mixed model of repeated measures
MRI
magnetic resonance imaging
MS
multiple sclerosis
D


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OLE
open-label extension
PBMC
peripheral blood mononuclear cell
PBVC
percentage of brain volume change
PD
pharmacodynamic(s)
PK
pharmacokinetic(s)
PML
progressive multifocal leukoencephalopathy
PPQ
Patient Preference Questionnaire
PRO
patient-reported outcome
Q4W
every 4 weeks
Q6W
every 6 weeks
RNA
ribonucleic acid
RRMS
relapsing-remitting multiple sclerosis
SAE
serious adverse event
SC
subcutaneous
SID
standard interval dosing
SUSAR
suspected unexpected serious adverse reaction
TSQM
Treatment Satisfaction Questionnaire for Medication
USA
United States
VCAM-1
vascular cell adhesion molecule 1


Protocol 101MS329
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3.
SPONSOR INFORMATION
Biogen MA Inc.
225 Binney Street
Cambridge, MA  02142
United States
Biogen Idec Research Limited
Innovation House
70 Norden Road
Maidenhead, Berkshire 
SL6 4AY
United Kingdom
Biogen Australia PTY Ltd.
Suite 1, Level 3 
123 Epping Road
North Ryde, NSW 2113
Australia
For urgent medical issues in which the study Medical Director should be contacted, please refer 
to the Study Reference Guide’s Official Study Contact List for complete contact information.
Biogen may transfer any or all of its study-related responsibilities to a contract research 
organization (CRO) and other third parties; however, Biogen retains overall accountability for 
these activities.


Protocol 101MS329
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4.
INTRODUCTION 
Natalizumab is a recombinant humanized anti-α4 integrin antibody, derived from a monoclonal 
antibody (mAb) [AN100226m] raised against human α4 integrin. The murine mAb 
(AN100226m) was humanized by complementarity-determining region grafting of the 
hypervariable region of the gene encoding AN100226m onto a human immunoglobulin G4 
framework, producing the humanized immunoglobulin G4/kappa antibody, natalizumab.
Natalizumab has been approved under the propriety name Tysabri® and was licensed for use in 
relapsing forms of multiple sclerosis (MS) by the United States (US) Food and Drug 
Administration on 23 November 2004. Natalizumab was authorized in the US on 05 June 2006, 
in the European Union on 27 June 2006 (Austria, Belgium, Bulgaria, Croatia 
[15 December 2008], Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, 
Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Poland, 
Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, and the United Kingdom), and in 
multiple other countries in the rest of the world (Algeria, Argentina, Australia, Azerbaijan, 
Bahrain, Bosnia and Herzegovina, Brazil, Canada, Chile, Colombia, Costa Rica, Dominican 
Republic, El Salvador, Georgia, Guatemala, Honduras, Hong Kong, Iceland, India, Israel, Japan, 
Jordan, Kazakhstan, Kuwait, Lebanon, Libya, Malaysia, Mexico, Morocco, New Zealand, 
Norway, Oman, Panama, Peru, Qatar, Russia, Serbia, Singapore, South Africa, South Korea, 
Switzerland, Syria, Taiwan, Tunisia, Ukraine, the United Arab Emirates, Uruguay, and 
Venezuela).
4.1.
Overview of Multiple Sclerosis
MS is a progressive, degenerative disease of the central nervous system (CNS) characterized by 
a variety of clinical courses. Approximately 90% of patients present with episodic neurological 
symptoms and will have bouts of disease activity (exacerbations) separated by periods of total or 
partial remission (relapsing-remitting phase). A typical patient will have 1 or 2 exacerbations per 
year with variable duration, lasting from several weeks to more than a month. This 
relapsing-remitting phase may last many years but, in most patients, is eventually followed by a 
period of chronic progressive decline (secondary progression), with increasing disability and 
with or without exacerbations. Approximately 10% of patients will have progression from the 
onset of the disease (primary progression), without acute exacerbations.
MS is an inflammatory disease of the CNS characterized by areas of demyelination (lesions), 
which give rise to the clinical symptoms of the disease. Although lesions can occur throughout 
the CNS, certain sites seem particularly vulnerable, such as the optic nerve, brainstem, spinal 
cord, and periventricular regions. Lesions are believed to occur when activated T lymphocytes 
cross the blood-brain barrier and, once in the parenchyma, initiate a series of events leading to 
activation of endothelial cells, recruitment of additional lymphocytes and monocytes, release of 
proinflammatory cytokines, and subsequent demyelination [Ffrench-Constant 1994].  
Trafficking of leukocytes across the blood-brain barrier involves interaction of the cell adhesion 
molecule α4 integrin, expressed on lymphocytes and monocytes, with its counter receptors 
vascular cell adhesion molecule 1 (VCAM-1) and fibronectin on brain endothelial cells. In 


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19
particular, VCAM-1 is expressed on inflamed brain endothelial cells and on activated microglial 
cells, while fibronectin is expressed around inflamed brain microvessels [Hartung 1995].
Blockade of these cell adhesion interactions is assumed to either prevent trafficking of 
leukocytes across the vascular endothelium, into parenchyma tissue, and subsequently into 
inflamed tissue; or prevent their activation by ligands in the parenchyma. It is believed that the 
clinical progression of MS is related to the demyelination caused by leukocyte injury to the 
myelin sheaths. Thus, inhibiting or preventing leukocyte entry into the CNS and subsequent 
leukocyte activation is expected to be of therapeutic benefit in MS.
4.2.
Current Therapies for Multiple Sclerosis
Approved therapies for MS include the following: 

interferon 

glatiramer acetate

dimethyl fumarate

teriflunomide

alemtuzumab

fingolimod

ocrelizumab

cladribine

mitoxantrone

natalizumab

diroximel fumarate

siponimod

ozanimod
4.3.
Profile of Previous Experience With Natalizumab
See the Investigator’s Brochure (IB) for detailed information on relevant nonclinical and clinical
studies.
4.3.1.
Nonclinical Experience
The pharmacology, pharmacokinetics (PK), and toxicology of natalizumab have been 
characterized in nonclinical in vitro and in vivo experimental systems. Nonclinical studies are 
outlined in the accompanying natalizumab IB.
4.3.2.
Clinical Experience
Natalizumab has been used extensively in relapsing-remitting multiple sclerosis (RRMS) and 
Crohn’s disease, both in clinical studies as well as in the postmarketing setting.


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As of 07 August 2017, natalizumab has been administered for MS to approximately 
5064 subjects in clinical studies and approximately 171,630 patients in the postmarketing setting. 
Approximately 1639 and 1688 subjects have received natalizumab for Crohn’s disease in clinical 
studies and in the postmarketing setting, respectively. Additionally, subjects have received 
natalizumab in clinical studies for rheumatoid arthritis (231 subjects), acute ischemic stroke 
(210 subjects), and multiple myeloma (6 subjects).
The efficacy of natalizumab in subjects with relapsing forms of MS has been established in 
3 controlled studies: a Phase 2 dose-comparison study as well as 2 Phase 3 efficacy and safety 
studies. These studies show that treatment with natalizumab has a profound impact on disability 
worsening and relapse rate and markedly attenuates brain magnetic resonance imaging (MRI) 
measures of inflammation and tissue destruction in subjects with relapsing forms of MS. 
Moreover, the data indicate that efficacy is realized early and persists throughout the treatment 
period.
4.4.
Benefit-Risk Assessment
After more than 10 years of postmarketing experience, natalizumab continues to demonstrate a 
high level of efficacy with a well-characterized safety profile and a significant beneficial impact 
on the quality of life in patients with RRMS. In pivotal clinical studies, natalizumab 
demonstrated a 67% reduction in annualized relapse rate and a 42% reduction in the risk of 
disability progression over 2 years. Since the marketing of natalizumab, publications from 
multiple independent groups, as well as publications from the Sponsor, have further 
demonstrated the clinical effectiveness of natalizumab when used in patients with MS with high 
disease activity despite treatment with first-line therapies [Belachew 2011; Morrow 2010; Oturai 
2009; Sangalli 2011].
Extensive safety data from clinical studies and the postmarketing setting have resulted in a 
well-characterized safety profile for natalizumab. Infusion and hypersensitivity reactions and 
anti-natalizumab antibody production are important safety concerns; however, they are 
manageable in routine clinical practice. Serious herpes infections and hepatic events are 
additional safety concerns that are also included in product labeling; however, the incidence of 
these adverse events (AEs) is low.
The most important AE affecting natalizumab benefit-risk assessment is the occurrence of 
progressive multifocal leukoencephalopathy (PML). Three established risk factors for the 
development of PML have been identified and are currently included in the product labeling: that 
PML risk is increased with the presence of anti-John Cunningham virus (JCV) antibodies, 
treatment duration (especially beyond 2 years of therapy), and prior use of an 
immunosuppressant therapy. These 3 risk factors, as well as information about anti-JCV 
antibody index in anti-JCV antibody-positive patients without any prior immunosuppressant use, 
can be utilized to further stratify the risk of PML and therefore provide an important tool for 
physicians and patients when making individual benefit-risk decisions regarding initiation or 
continuation of natalizumab therapy. 
Overall, the benefit-risk ratio for natalizumab in treating RRMS remains positive.


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4.5.
Study Rationale
The safety and efficacy of the currently recommended dose (300 mg natalizumab administered 
intravenously [IV] every 4 weeks [Q4W]) has been well established through clinical trials and in 
real-world clinical practice.  
Extending the dosing interval of natalizumab (e.g., to every 6 weeks [Q6W]) has been practiced 
by some physicians in anti-JCV antibody-positive patients with the intention of improving the 
benefit/risk of the treatment by reducing the exposure-dependent risk of PML while maintaining 
efficacy. In a prespecified, retrospective analysis of anti-JCV antibody-positive patients treated 
with natalizumab in the US TOUCH (Tysabri® Outreach: United Commitment to Health) 
program (n = 18,755), the risk of PML was compared between patients treated with standard 
interval dosing (SID) and patients treated with extended interval dosing (EID) for at least 
6 months (300 mg with an average dosing interval of 5 to 6 weeks). The majority of patients 
were treated with SID for at least 1 year before switching to EID (median of 25 SID infusions 
prior to switch). The analysis demonstrated a clinically and statistically significant reduction in 
the risk of PML in patients treated with EID. Whether extending the dosing interval of 
natalizumab can potentially improve benefit/risk for some patients remains to be established as 
there are no prospective, randomized, controlled studies assessing efficacy of EID.
This study will be conducted in 2 parts: Part 1 is a randomized, controlled, rater-blinded, 
analysis designed to assess the efficacy, safety, and tolerability of switching to EID (Q6W 
dosing) after at least 12 months of disease stability on SID (Q4W dosing);Part 2 is a randomized
open-label extension (OLE) designed to assess preference for SC natalizumab EID treatment and 
explore long-term efficacy, safety, and tolerability of EID.




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Table 1:
Part 1 Schedule of Activities – SID
Tests and assessments are listed in the recommended order. At each visit, assessments should be performed as follows:
, 2) clinical and neurological assessments, 
, and 4) dose administration. 
It is not required that all screening tests and assessments be completed during 1 visit.
Study Week
Screening
Visit1
-6 to -1
Baseline 
Visit
0
4
8
12
16
20
24
28
32
36
40
44
48
52
56
60
64
68 722 Follow 
Up 
EOS 
Visit
84
Follow 
Up 
Safety 
Phone 
Call
963
ET 
Visit4 Unscheduled 
Visit 
(Neurological 
Worsening 
and Relapse 
Assessment)5
Study Day
-42 to -1
0
28
(-2/
+5)
56
(-2/
+5)
84
(-2/
+5)
112
(-2/
+5)
140
(-2/
+5)
168
(-2/
+5)
196
(-2/
+5)
224
(-2/
+5)
252
(-2/
+5)
280
(-2/
+5)
308
(-2/
+5)
336
(-2/
+5)
364
(-2/
+5)
392
(-2/
+5)
420
(-2/
+5)
448
(-2/
+5)
476
(-2/
+5)
504
(-2/
+5)
588
(±10)
672
(±10)
Informed Consent 
Form 
X
Eligibility Criteria 
Check
X
X
Randomization
X
Medical History
X
Physical 
Examination
X
X6
X
X
X
X
X
X
Body Weight
X
X6
X
X
X
X
X
X
Vital Signs7
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
HIV, Hep B, and 
Hep C Testing
X


Protocol 101MS329
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Study Week
Screening
Visit1
-6 to -1
Baseline 
Visit
0
4
8
12
16
20
24
28
32
36
40
44
48
52
56
60
64
68 722 Follow 
Up 
EOS 
Visit
84
Follow 
Up 
Safety 
Phone 
Call
963
ET 
Visit4 Unscheduled 
Visit 
(Neurological 
Worsening 
and Relapse 
Assessment)5
Study Day
-42 to -1
0
28
(-2/
+5)
56
(-2/
+5)
84
(-2/
+5)
112
(-2/
+5)
140
(-2/
+5)
168
(-2/
+5)
196
(-2/
+5)
224
(-2/
+5)
252
(-2/
+5)
280
(-2/
+5)
308
(-2/
+5)
336
(-2/
+5)
364
(-2/
+5)
392
(-2/
+5)
420
(-2/
+5)
448
(-2/
+5)
476
(-2/
+5)
504
(-2/
+5)
588
(±10)
672
(±10)
C-SSRS8
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
EDSS
X
X
X
X
X
X
X
Neurological 
Examination (MS 
Signs & Symptoms)
X
X
X
X
X
X
X
Blood Hematology9
X
X
X
X
X
X
Blood Chemistry10
X
X
X
Serum Pregnancy 
Test11
X
Serum FSH12
X
Urine Pregnancy 
Test13
X






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9
Sample to be collected prior to dosing.
10 If a subject experiences signs and symptoms suggestive of liver injury (such as jaundice, vomiting, anorexia, nausea, fatigue, and right upper abdominal 
discomfort), liver function tests (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, gamma-glutamyl transferase, bilirubin, and 
albumin) must be performed at the local laboratory on an expedited basis.
11 Required for women of childbearing potential. Results must be known prior to Day 0/Baseline.
12 For postmenopausal subjects only.
13 Required for women of childbearing potential. Follow-up testing throughout the study will be done at the discretion of the Investigator or as required by local 
law. In each case of delayed menstruation (over 1 month between menstrual periods), a urine pregnancy test should be performed.
15 The screening MRI must be performed at least 2 weeks prior to the Baseline Visit to confirm eligibility. All postbaseline MRIs, with the exception of the one 
conducted at the Neurological Worsening and Relapse Assessment, are to be completed within a 7-day window of the dosing visit. MRIs conducted at the 
Neurological Worsening and Relapse Assessment must be completed prior to dosing with rescue therapy, but can be completed on the same day. If a subject's 
MRI is scheduled to occur <4 weeks after the last dose of steroid treatment for relapse, the MRI should be rescheduled so that it is performed either before the 
steroid treatment of between 4 and 8 weeks after the last dose of steroid treatment. MRI does not need to be performed at the ET Visit if the last MRI was 
performed within the previous 4 weeks. In the event of an early study termination for a pregnancy, a Gd-enhancing MRI should not be conducted.
16
Please refer to the Directions for Handling and Administration (DHA) located in the Study Reference Guide for details of postdose observation requirements.
17 Subjects should be contacted by phone 24 weeks after the last dose of study treatment to discuss if there has been any new development of any new 
neurological symptoms. PML or new neurological symptoms indicative of PML (e.g., new or sudden change in thinking, vision, balance, or strength 
persisting over several days) must be immediately reported as an SAE.
P


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Table 2:
Part 1 Schedule of Activities – EID
Tests and assessments are listed in the recommended order. At each visit, assessments should be performed as follows:
, 
2) clinical and neurological assessments, 
, and 4) dose administration. It is not required that all 
screening tests and assessments be completed during 1 visit.
Study Week
Screening 
Visit1
-6 to -1
Baseline 
Visit
0
6
12
18
24
30
36
42
48
54
60
66
722
Follow
Up EOS 
Visit
84
Follow Up 
Safety 
Phone 
Call3
96
ET 
Visit4
Unscheduled 
Visit 
(Neurological 
Worsening 
and Relapse 
Assessment)5
Study Day
-42 to -1
0
42
(-2/
+5)
84
(-2/
+5)
126
(-2/
+5)
168
(-2/
+5)
210
(-2/
+5)
252
(-2/
+5)
294
(-2/
+5)
336
(-2/
+5)
378
(-2/
+5)
420
(-2/
+5)
462
(-2/
+5)
504
(-2/
+5)
588
(±10)
672
(±10)
Informed Consent Form
X
Eligibility Criteria Check
X
X
Randomization
X
Medical History
X
Physical Examination
X
X6
X
X
X
X
X
X
Body Weight
X
X6
X
X
X
X
X
X
Vital Signs7
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
HIV, Hep B, and Hep C 
Testing
X
C-SSRS8
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X


Protocol 101MS329
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29
Study Week
Screening 
Visit1
-6 to -1
Baseline 
Visit
0
6
12
18
24
30
36
42
48
54
60
66
722
Follow
Up EOS 
Visit
84
Follow Up 
Safety 
Phone 
Call3
96
ET 
Visit4
Unscheduled 
Visit 
(Neurological 
Worsening 
and Relapse 
Assessment)5
Study Day
-42 to -1
0
42
(-2/
+5)
84
(-2/
+5)
126
(-2/
+5)
168
(-2/
+5)
210
(-2/
+5)
252
(-2/
+5)
294
(-2/
+5)
336
(-2/
+5)
378
(-2/
+5)
420
(-2/
+5)
462
(-2/
+5)
504
(-2/
+5)
588
(±10)
672
(±10)
EDSS
X
X
X
X
X
X
X
Neurological Examination 
(MS Signs & Symptoms)
X
X
X
X
X
X
X
Blood Hematology9
X
X
X
X
X
X
Blood Chemistry10
X
X
X
Serum Pregnancy Test11
X
Serum FSH12
X
Urine Pregnancy Test13
X




Protocol 101MS329
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3
Subjects should have a follow-up safety phone call 24 weeks after their last dose of study treatment.
4
If a subject chooses to withdraw from the study, an ET Visit should occur as soon as possible but no later than 4 weeks after the last dose of study treatment, 
to be followed by a final EOS Visit at 12 weeks (± 10 days) and the follow-up safety phone call at 24 weeks after the final dose of study treatment.
5
Subjects who suspect that they are experiencing new or worsening neurological symptoms, including possible relapse, need to phone the Investigator within 
72 hours of the onset of the symptoms. The subject is to be evaluated by the neurologist within 5 days of the onset of symptoms. Relapses should be 
documented in the relapse assessment form. The maximum number of samples eligible for collection and analysis are 2 (1 for each unscheduled visit). The 
samples will be named NW1 and NW2.
6
If a screening test is performed within 7 days of the Baseline Visit, the assessment does not need to be repeated at Baseline.
7
Vital signs collected at each of the specified timepoints include temperature, systolic and diastolic blood pressures, pulse rate, and respiratory rate. Vital signs 
collected as part of the subject’s standard of care on the same day as a study visit do not need to be repeated for the study if Biogen has access to the 
information and data are recorded in the subject’s CRF. Vital signs taken on a study treatment day must be performed prior to study treatment administration.
8
The “baseline/screening” C-SSRS must be completed at the Screening Visit; at all other visits, the “since last visit” C-SSRS must be used.
9
Sample to be collected prior to dosing.
10 If a subject experiences signs and symptoms suggestive of liver injury (such as jaundice, vomiting, anorexia, nausea, fatigue, and right upper abdominal 
discomfort), liver function tests (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, gamma-glutamyl transferase, bilirubin, and 
albumin) must be performed at the local laboratory on an expedited basis.
11 Required for women of childbearing potential. Results must be known prior to Day 0/Baseline.
12 For postmenopausal subjects only.
13 Required for women of childbearing potential. Follow-up testing throughout the study will be done at the discretion of the Investigator or as required by local 
law. In each case of delayed menstruation (over 1 month between menstrual periods), a urine pregnancy test should be performed.
15 The screening MRI must be performed at least 2 weeks prior to the Baseline Visit to confirm eligibility. All postbaseline MRIs, with the exception of the one 
conducted at the Neurological Worsening and Relapse Assessment, are to be completed within a 7-day window of the dosing visit. MRIs conducted at the 
Neurological Worsening and Relapse Assessment must be completed prior to dosing with rescue therapy, but can be completed on the same day. If a subject’s 
MRI is scheduled to occur < 4 weeks after the last dose of steroid treatment for relapse, the MRI should be rescheduled so it is performed either before the 
steroid treatment or between 4 and 8 weeks after the last dose of steroid treatment. MRI does not need to be performed at the ET Visit if the previous MRI 
was performed within the previous 4 weeks. In the event of an early study termination for a pregnancy, a Gd-enhancing MRI should not be conducted.
16 Subjects are to continue with their natalizumab SID until they have received their baseline dose. Please refer to the DHA located in the Study Reference 
Guide for details of postdose observation requirements.
17 Subjects should be contacted by phone 24 weeks after the last dose of study treatment to discuss if there has been any new development of any new 
neurological symptoms. PML or new neurological symptoms indicative of PML (e.g., new or sudden change in thinking, vision, balance, or strength 
persisting over several days) must be immediately reported as an SAE.
P


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5.2.
Part 2 – Schedule of Activities
For subjects who completed Part 1 treatment and enrolled in Part 2, the schedule of activities for 
Part 2 (Table 3) does not differ for subjects randomized to SC/IV or IV/SC with the exception of 
the order of treatment administration during the crossover period.
For new subjects enrolled in Part 2, the initial screening, inclusive of select assessments, differs 
from those subjects who participated in Part 1 but is otherwise the same beginning at Week 78 
through the end of Part 2 (Table 4).


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Table 3:
Part 2 Schedule of Activities – EID SC vs. IV OLE for Subjects Who Participated in Part 1
Tests and assessments are listed in the recommended order. At each visit, assessments should be performed as follows:
, 
2) clinical and neurological assessments, 3) PK/PD 
 collection, and 4) dose administration. It is not required that all 
screening tests and assessments be completed during 1 visit.
Study Week
78
841
90
96
102
108
114
120
126
132
138
144
150
156
Follow-
Up EOS 
Visit
168
ET 
Visit2
Unscheduled 
Visit 
(Neurological 
Worsening and 
Relapse 
Assessment)3
Follow-Up 
Safety 
Phone Call
1804
Study Day
546
(-2/
+5)
588
(-2/
+5)
630
(-2/
+5)
672
(-2/
+5)
714
(-2/
+5)
756
(-2/
+5)
798
(-2/
+5)
840
(-2/
+5)
882
(-2/
+5)
924
(-2/
+5)
966
(-2/
+5)
1008
(-2/
+5)
1050
(-2/
+5)
1092
(-2/
+5)
1176
(±10)
-
-
1260
(±10)
Informed 
Consent Form 
for Part 25
---- X ----
Eligibility 
Criteria Check 
for Part 25
---- X ----
Randomization
X
Vital signs6
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Physical 
Examination1
X
X
X
X
X
X
X
Body Weight1
X
X
X
X
C-SSRS1,7
X
TSQM
X
X
X


Protocol 101MS329
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34
Study Week
78
841
90
96
102
108
114
120
126
132
138
144
150
156
Follow-
Up EOS 
Visit
168
ET 
Visit2
Unscheduled 
Visit 
(Neurological 
Worsening and 
Relapse 
Assessment)3
Follow-Up 
Safety 
Phone Call
1804
Study Day
546
(-2/
+5)
588
(-2/
+5)
630
(-2/
+5)
672
(-2/
+5)
714
(-2/
+5)
756
(-2/
+5)
798
(-2/
+5)
840
(-2/
+5)
882
(-2/
+5)
924
(-2/
+5)
966
(-2/
+5)
1008
(-2/
+5)
1050
(-2/
+5)
1092
(-2/
+5)
1176
(±10)
-
-
1260
(±10)
EDSS
X
X
X
X
X
X
Neurological 
Examination 
(MS Signs &
Symptoms)
X
X
X
X
X
X
Blood 
Hematology8
X
X
X
X
X
X
X
Blood 
Chemistry9
X
X
X
X
Urine Pregnancy 
Test10
PD Assessments 
(whole blood)8
X
X
X
X
X
X
X
X
X
X
PK Natalizumab 
Concentration 
(serum)8
X
X
X
X
X
X
X
X
X
X
Anti-
natalizumab 
Antibodies8
X
X
X
X
X
X
Brain MRI11
X
X
X
X




Protocol 101MS329
Version 4.0
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to crossover study treatment should be done at the Week 108 visit to confirm crossover treatment allocation. After Week 84, subjects are not eligible for 
enrollment in Part 2 of the study.
6
Vital signs collected at each of the specified timepoints include temperature, systolic and diastolic blood pressure, pulse rate, and respiratory rate. Vital signs 
collected as part of the subject's standard of care on the same day as a study visit do not need to be repeated for the study if Biogen has access to the 
information and data recorded in the subject's CRF. Vital signs on a study treatment day must be performed prior to the administration of study treatment.
7
The Part 1 "baseline/screening" C-SSRS must be completed at the Part 1 screening Visit; at all other visits, the "since last visit" C-SSRS must be used.
8
Sample to be collected prior to dosing.
9
If a subject experiences signs and symptoms suggestive of liver failure (such as jaundice, vomiting, anorexia, nausea, fatigue, and right upper abdominal 
discomfort), liver function tests (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, gamma-glutamyl transferase, bilirubin, and 
albumin) must be performed at the local laboratory on an expedited basis.
10 Follow-up testing for women of childbearing potential throughout the study will be done at the discretion of the Investigator or as required by local law. In 
each case of delayed menstruation (more than 1 month between menstrual periods), a urine pregnancy test should be performed.
11 All postbaseline MRIs are to be completed within a 7-day window of the dosing visit. If a subject's MRI is scheduled to occur < 4 weeks after the last dose of 
steroid treatment for relapse, the MRI should be rescheduled so it is performed either before the steroid treatment or between 4 and 8 weeks after the last dose 
of steroid treatment. MRI does not need to be performed at the ET Visit if the last MRI was performed within the previous 4 weeks. In the event of an early 
termination for a pregnancy, a Gd-enhancing MRI should not be conducted.
12 The time required for drug preparation and drug administration should be recorded in detail for each occasion of treatment administration during the crossover 
period. Please refer to the DHA located in the Study Reference Guide for details of postdose observation requirements.
13 Subjects in Part 2 will receive a final dose of natalizumab 300 mg by SC injection or IV infusion at the Week 156 visit with the route of administration being 
the subject’s choice.
14 PPQ assessments at Week 138 and Week 150 must be collected after study treatment administration.


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Table 4:
Part 2 Schedule of Activities – EID SC vs. IV OLE for New Subjects
Tests and assessments are listed in the recommended order. At each visit, assessments should be performed as follows:
, 
2) clinical and neurological assessments, 3) PK/PD 
 collection, and 4) dose administration. It is not required that all 
screening tests and assessments be completed during 1 visit. This Schedule of Activities is identical to the Schedule in Table 3 after 
the Week 84 visit.
Nominal
Study Week
Screen1
Baseline 
Visit
72
78
842
90
96
102
108
114
120
126
132
138
144
150
156
Follow-
Up EOS 
Visit
168
ET 
Visit3
Unscheduled 
Visit 
(Neurological 
Worsening 
and Relapse 
Assessment)4
Follow-
Up Safety 
Phone 
Call5
180
Nominal
Study Day
-42 to
-1
504
(-2/
+5)
546
(-2/
+5)
588
(-2/
+5)
630
(-2/
+5)
672
(-2/
+5)
714
(-2/
+5)
756
(-2/
+5)
798
(-2/
+5)
840
(-2/
+5)
882
(-2/
+5)
924
(-2/
+5)
966
(-2/
+5)
1008
(-2/
+5)
1050
(-2/
+5)
1092
(-2/
+5)
1176
(±10)
-
-
1260
(±10)
Informed 
Consent Form 
for Part 21
X
Eligibility 
Criteria Check 
for Part 21
X
X
Randomization
X
Medical 
History1
X
Physical 
Examination1
X
X
X
X
X
X
X
X
X
Body Weight1
X
X
X
X
X
X
Vital signs6
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
HIV, Hep B, 
and Hep C 
Testing
X
TSQM
X
X
X
X


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Nominal
Study Week
Screen1
Baseline 
Visit
72
78
842
90
96
102
108
114
120
126
132
138
144
150
156
Follow-
Up EOS 
Visit
168
ET 
Visit3
Unscheduled 
Visit 
(Neurological 
Worsening 
and Relapse 
Assessment)4
Follow-
Up Safety 
Phone 
Call5
180
Nominal
Study Day
-42 to
-1
504
(-2/
+5)
546
(-2/
+5)
588
(-2/
+5)
630
(-2/
+5)
672
(-2/
+5)
714
(-2/
+5)
756
(-2/
+5)
798
(-2/
+5)
840
(-2/
+5)
882
(-2/
+5)
924
(-2/
+5)
966
(-2/
+5)
1008
(-2/
+5)
1050
(-2/
+5)
1092
(-2/
+5)
1176
(±10)
-
-
1260
(±10)
EDSS
X
X
X
X
X
X
X
Neurological 
Examination 
(MS Signs &
Symptoms)
X
X
X
X
X
X
X
Blood 
Hematology7
X
X
X
X
X
X
X
X
Blood 
Chemistry8,7
X
X
X
X
X
Serum 
Pregnancy Test9
X
Serum FSH10
X
Urine Pregnancy 
Test11
X
PD Assessments 
(whole blood)7
X
X
X
X
X
X
X
X
X
X
X
PK Natalizumab 
Concentration 
(serum)7
X
X
X
X
X
X
X
X
X
X
X


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Nominal
Study Week
Screen1
Baseline 
Visit
72
78
842
90
96
102
108
114
120
126
132
138
144
150
156
Follow-
Up EOS 
Visit
168
ET 
Visit3
Unscheduled 
Visit 
(Neurological 
Worsening 
and Relapse 
Assessment)4
Follow-
Up Safety 
Phone 
Call5
180
Nominal
Study Day
-42 to
-1
504
(-2/
+5)
546
(-2/
+5)
588
(-2/
+5)
630
(-2/
+5)
672
(-2/
+5)
714
(-2/
+5)
756
(-2/
+5)
798
(-2/
+5)
840
(-2/
+5)
882
(-2/
+5)
924
(-2/
+5)
966
(-2/
+5)
1008
(-2/
+5)
1050
(-2/
+5)
1092
(-2/
+5)
1176
(±10)
-
-
1260
(±10)
Anti-
natalizumab 
Antibodies7
X
X
X
X
X
X
X
Brain MRI12
X
X
X
X
X
Natalizumab 
EID IV infusion
X
X
X
X
X
X
X
Natalizumab 
EID SC-IV 
Crossover13
X
X
X
X
X
X
X
X
X14
PPQ15
X
X
X
Safety (AEs, 
SAEs)
Record as per Section 15.3 of the protocol
Concomitant 
Therapy and 
Procedures
Record as per Section 11.5 of the protocol
X
Assessment of 
New 
Neurological 
Symptoms16
X
AE = adverse event; CRF = case report form; EDSS = Expanded Disability Status Scale; EID = extended interval dosing; EOS = end of study; 
 
; ET = early termination; FSH = follicle stimulating hormone; Gd = gadolinium; Hep = hepatitis; HIV = human immunodeficiency virus; 




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15 PPQ assessments at Week 138 and Week 150 must be collected after study treatment administration.
16 Subjects should be contacted by phone 24 weeks after the last dose of study treatment to discuss if there has been any new development of neurological 
symptoms. PML or new neurological symptoms indicative of PML (new or sudden change in thinking, vision, balance, or strength persisting over several 
days) must be immediately reported as a SAE.




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To evaluate drug preparation and 
administration time between SC and IV 
routes of natalizumab administration.
Mean time for drug preparation and 
administration.
To evaluate the safety and immunogenicity of 
SC versus IV routes of natalizumab 
administration.
All endpoints will be assessed between
6 months of SC and 6 months IV in the 
randomized, crossover period.

The proportion of subjects with 
treatment emergent AEs

The proportion of subjects who develop 
anti-natalizumab antibodies 
To evaluate the efficacy of SC versus IV 
routes of natalizumab administration.
All endpoints will be assessed between
6 months of SC and 6 months IV in the 
randomized, crossover period.

Number of new or newly enlarging 
T2 hyperintense lesions

Time to first relapse

Annualized relapse rate

Change in EDSS score

Number of new Gd-enhancing lesions

Number of new T1 hypointense lesions

PBVC and change in cortical and 
thalamic brain region volume
To characterize PK and PD of SC versus IV 
routes of natalizumab administration.
All endpoints will be assessed between
6 months of SC and 6 months IV in the 
randomized, crossover period.

Ctrough

Trough α4 integrin saturation


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7.
STUDY DESIGN
This study will be conducted in 2 parts. Part 1 is a prospective, randomized, interventional, 
controlled, open-label, rater-blinded, Phase 3b study in subjects with RRMS who have been 
receiving natalizumab SID for at least 12 months without relapses in the last 12 months. All MRI 
scans will be read at a central facility with raters blinded to subject assignment. Approximately 
480 subjects are expected to be enrolled at approximately 100 sites in North America, Europe, 
and Australia. Subjects will be randomly assigned to continue to receive natalizumab in 1 of the 
following 2 groups:

SID:  approximately 240 subjects will receive natalizumab as a 300 mg IV infusion 
every 4 weeks (28 [-2/+5 days]).

EID:  approximately 240 subjects will receive natalizumab as a 300 mg IV infusion 
every 6 weeks (42 [-2/+5 days]). 
Randomization will be stratified by country/region (North America [includes USA and Canada], 
United Kingdom, Europe and Israel [includes Belgium, France, Germany, Israel, Italy, 
Netherlands, and Spain], and Australia), body weight (≤80 kg versus > 80 kg), and duration of 
natalizumab exposure (≤3 years versus > 3 years). Subjects will receive open-label natalizumab 
at their assigned frequency throughout the 72 weeks of the study.
At the completion of their 72-week treatment period, subjects in Part 1 who cannot participate, or 
elect not to participate, in Part 2 will enter a 12-week follow-up period, and will receive a 
follow-up safety phone call 12 weeks later (i.e., 24 weeks after the last dose of study treatment) 
before completing the study.
Part 2 is a 108-week OLE for approximately 200 subjects at approximately 45 sites in Canada, 
the United Kingdom, Europe, Israel, and Australia who complete their randomized treatment in 
Part 1, provide consent, and are eligible to participate immediately following completion of the 
72-week treatment period.
Subjects who did not participate in Part 1 but provide consent and satisfy the inclusion-exclusion 
and eligibility requirements of Part 1, including treatment with natalizumab SID for at least 
12 months without relapses in the last 12 months, may also be enrolled in Part 2 as new subjects
to ensure adequate sample size for the Part 2 analysis.
Subjects enrolled in Part 2 will receive natalizumab 300 mg by IV infusion once every 6 weeks 
(42 ± 7 days) for a period of 36 weeks and be randomized to an additional 48 weeks of crossover
treatment comprising 24 weeks EID SC Q6W and 24 weeks EID IV Q6W. All MRI scans will be 
read at a central facility by blinded raters.
At the completion of their 48-week crossover treatment period, subjects in Part 2 will receive a 
final dose of natalizumab 300 mg by SC injection or IV infusion at Week 156 with the route of 
administration being the subject’s choice, proceed to the 12-week follow-up period, and receive 
a follow-up safety phone call 12 weeks later (i.e., 24 weeks after the last dose of study treatment) 
before completing the study.
The design of this study, inclusive of Parts 1 and 2, is presented in Figure 1.




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7.1.
Study Duration for Subjects
7.1.1.
Study Duration for Subjects Enrolled Only in Part 1
The total duration of study participation in Part 1 for subjects who do not participate in Part 2 
will be up to 102 weeks. This comprises a screening period of up to 6 weeks; a treatment period 
of 72 weeks; a follow-up period of 12 weeks; and a follow-up safety phone call 12 weeks after 
the follow-up period (i.e., 24 weeks after the last dose of study treatment).
The end of study (EOS) date for a subject in Part 1 may be the last study visit, the follow-up 
safety phone call, or last protocol-specified assessment; if the subject has ongoing AEs that are 
being followed, then the date may be the date of AE resolution.
7.1.2.
Study Duration for Subjects Enrolled in Part 1 and Part 2
The total duration of study participation in Part 1 for subjects who also participate in Part 2 will 
be up to 78 weeks, comprising a screening period of up to 6 weeks and the randomized SID or 
EID treatment period of 72 weeks.
The total duration of study participation in Part 2 for these subjects will be approximately 
108 weeks. This comprises EID IV treatment for 36 weeks; a randomized EID SC vs. EID IV
crossover treatment period of 48 weeks; a follow-up period of 12 weeks; and a follow-up safety 
phone call 12 weeks after the follow-up period (i.e., 24 weeks after the last dose of study 
treatment).  The total duration of study participation for subjects who participate in both Part 1 
and Part 2 will be approximately 186 weeks.
The EOS date for subjects participating in Part 1 and Part 2 may be the last study visit, the 
follow-up safety phone call, or last protocol-specified assessment; if the subject has ongoing AEs 
that are being followed, then the date may be the date of AE resolution.
7.2.
Responsibilities of Study Site Staff
7.2.1.
General Staff Responsibilities During Part 1 and Part 2
For each subject in Part 1 and Part 2, the Investigator of the study site will designate the 
following study site staff:

A primary and backup unblinded treating neurologist

An unblinded treating nurse (or study coordinator; may be performed by treating 
neurologist)

A primary and backup blinded examining neurologist

A blinded examining technician (may be performed by blinded examining 
neurologist) (see Section 7.2.2 for changes in Part 2)

An unblinded MRI technician

An unblinded pharmacist (or unblinded authorized designee)


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Both the examining neurologist and the treating neurologist must have a minimum of 2 years of 
neurology specialty training and, at study initiation, do not anticipate leaving the study within at 
least 1 year. Where specified, evaluations described in this section must be performed only by 
the personnel indicated. Treating neurologists may review neurological examination results 
obtained by examining neurologists. The examining neurologist and examining technician
should not administer study treatment.
The primary treating neurologist will be responsible for the following:

Management of the routine neurological care of the subject, including the physical 
examination, management of treatment, and associated safety monitoring.

Assessment (including assignment of causality) and treatment of AEs, SAEs, and MS 
relapses.

Assessing whether the subject’s study treatment should be discontinued as per the 
criteria detailed in Section 10.

The treating neurologist may designate the backup treating neurologist or the treating 
nurse at the study site to perform some of the tests and evaluations listed under 
“treating neurologist.” If there is more than 1 treating neurologist available at a given 
study site such that each one is assigned to particular subjects, then these treating 
neurologists may act as backup for each other.

Review of hematology and blood chemistry data from the central laboratory to aid in 
the management of the subject. As with other laboratory and clinical information, 
these data should NOT be reviewed by the examining neurologist, the backup 
examining neurologist, or the examining technician.
The primary treating nurse (or study coordinator; may be performed by treating neurologist) will 
be responsible for the following:

Assisting the treating neurologist in subject management, including the treatment of 
AEs, the treatment and assessment of disease relapses, and the recording of 
AEs/SAEs and concomitant medications.

Administering the PROs (TSQM, 
 

Collecting blood samples.

Obtaining vital signs.
The examining neurologist will be responsible for the following:

Obtaining an EDSS score and MS signs and symptoms based on a detailed
neurological examination at the scheduled timepoints required in the protocol.

Obtaining an EDSS score at every unscheduled Neurological Worsening and Relapse 
Assessment Visit, if referred by the treating neurologist when there is the possibility 
of a relapse.

The following guidelines must be strictly followed:




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
If an examining technician has to be replaced, the new examining technician must 
undergo a training session prior to performing any study assessment. 
The MRI technician will be responsible for the following:

Performing a brain MRI scan with and without contrast, in accordance with the 
study-specific MRI manual, at all protocol-required timepoints.
The unblinded pharmacist (or unblinded authorized designee) will be responsible for the 
following:

Receipt, storage, distribution, and accountability of study treatment.

Storage and security of documentation related to study treatment, dose preparation, 
and study treatment assignment. All treatment assignment or study treatment 
preparation information must be maintained strictly confidential from the examining 
neurologist and examining technician at all times. Measures to prevent inadvertent 
unblinding must be followed.

Preparation of study treatments for IV infusion.
7.2.2.
Changes in Responsibilities During Part 2
The role of examining technician is no longer required in Part 2. The blinded examining 
technician will need to remain blinded until the Week 84 visit has been completed for all subjects 
who enrolled in Part 1, all queries have been addressed, and protection of the associated database 
secured. The Sponsor will confirm when the blinded examining technician can be unblinded. The 
primary and backup blinded examining neurologist along with the central MRI rater will remain 
blinded throughout the study. All other roles as presented in Section 7.2.1 will remain unchanged 
in Part 2.
7.3.
Unscheduled Visits and Treatment for MS Relapses
If an MS relapse is suspected during the study, the subject should return to the study site for an 
unscheduled visit and be evaluated as soon as possible (within 5 days after onset of the event) for 
confirmation and to determine the severity of the relapse. Relapses will be documented in the 
relapse assessment form.
An MS relapse will be defined as the onset of new or recurrent neurological symptoms lasting at 
least 24 hours, accompanied by new objective abnormalities on a neurological examination, and 
not explained solely by non-MS processes such as fever, infection, severe stress, or drug toxicity 
(adapted from [Schumacher 1965]).
The Unscheduled Visit for Neurological Worsening and Relapse Assessment should not modify 
or replace the subjects’ visit schedule. If a subject’s study MRI is scheduled to occur < 4 weeks 
after the last dose of steroid treatment for relapse, the MRI should be rescheduled so that it is 
performed either before the steroid treatment or between 4 and 8 weeks after the last dose of 
steroid treatment. MRI does not need to be performed at the ET Visit if the previous MRI was 
performed within the previous 4 weeks.


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New or recurrent neurological symptoms that occur < 30 days following the onset of a protocol-
defined relapse should be considered as part of the same relapse. New or recurrent neurologic 
symptoms that evolve gradually over months should be considered disability progression, not an 
acute relapse, and should not be treated with high-dose corticosteroids. Laboratory tests to 
investigate possible causes of pseudorelapse can be done at the discretion of the Investigator.
7.3.1.
Unscheduled Visits in Part 1
In Part 1, an unscheduled visit for a suspected relapse should be recorded at a Neurological 
Worsening and Relapse Assessment Visit, with the relapse reported on the relapse assessment 
form and not reported as an AE. A brain MRI should be performed before treatment of a 
protocol-defined relapse. The potential abnormalities must then be reviewed and confirmed by 
the INEC for the purposes of confirming the secondary endpoint (see Section 19.2.2). Treatment 
of a protocol-defined relapse may proceed at the discretion of the Investigator prior to INEC 
confirmation according to local standard of care and will not affect the subject’s eligibility to 
continue in the study. At the discretion of the Investigator, treatment may include 
methylprednisolone 1000 mg IV administered daily for 3 to 5 days with or without an oral
prednisone taper (up to 15 days).
7.3.2.
Unscheduled Visits in Part 2
In Part 2, an unscheduled visit for a suspected relapse should be recorded at a Neurological 
Worsening and Relapse Assessment Visit with the relapse reported on the relapse assessment 
form and not reported as an AE. The Investigator is responsible for determining whether a 
protocol-defined relapse has occurred. After all Part 2 unscheduled visit assessments have been 
performed, relapse treatment can proceed per local standard of care without INEC review.
7.4.
Study Stopping Rules
The study will be stopped if the interim futility analysis shows a statistically significant 
worsening of efficacy in Part 1 as gauged by new or newly enlarging T2 hyperintense lesions in
the EID group relative to the SID group.
Biogen will notify Investigators when the study is to be placed on hold, completed, or 
terminated.
7.5.
End of Study
The EOS is defined as the last subject, last visit for final collection of data during the study.


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8.
SELECTION OF SUBJECTS
8.1.
Part 1 Inclusion Criteria
To be eligible to participate in this study, candidates must meet the following eligibility criteria 
at the time of randomization, or at the timepoint specified in the individual eligibility criterion 
listed:
1. Ability of the subject to understand the purpose and risks of the study and provide signed 
and dated informed consent and authorization to use confidential health information in 
accordance with national and local subject privacy regulations.
2. Aged 18 to 60 years old, inclusive, at the time of informed consent.
3. Diagnosis of RRMS according to the McDonald criteria [Thompson 2018].
4. Treatment with natalizumab as disease-modifying monotherapy for RRMS that is 
consistent with the approved dosing for a minimum of 12 months prior to randomization. 
The subject must have received at least 11 doses of natalizumab in the 12 months prior to 
randomization with no missed doses in the 3 months prior to randomization.
5. EDSS score ≤5.5 at Screening.
6. No relapses in the last 12 months prior to randomization, as determined by the enrolling 
Investigator.
7. All women of childbearing potential must practice highly effective contraception during 
the study and for 3 months after their last dose of study treatment. For further details of 
contraceptive requirements for this study, see Section 15.5.
8.2.
Part 1 Exclusion Criteria
Candidates will be excluded from study entry if any of the following exclusion criteria exist at 
the time of randomization, or at the timepoint specified in the individual criterion listed:
1. Primary- and secondary-progressive MS.
2. MRI positive for Gd-enhancing lesions at Screening.
3. Subjects for whom MRI is contraindicated (e.g., have a contraindicated pacemaker or 
other contraindicated implanted metal device, have suffered, or are at risk for, side effects 
from Gd, or have claustrophobia that cannot be medically managed).
4. History of any clinically significant (as determined by the Investigator) cardiac, 
endocrinologic, hematologic, hepatic, immunologic, metabolic (including diabetes), 
urologic, pulmonary, neurologic (except for RRMS), dermatologic, psychiatric, renal, or 
other major disease that would preclude participation in a clinical study, in the opinion of 
the Investigator.
5. History of human immunodeficiency virus or positive test result at Screening, or history 
of other immunodeficient conditions. The requirement for testing at Screening may be 
omitted if it is not permitted by local regulations.


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6. Known history of hepatitis C (test for hepatitis C virus antibody) or hepatitis B virus (test 
for hepatitis B surface antigen and/or hepatitis B core antibody).
7. History of malignant disease, including solid tumors and hematologic malignancies (with 
the exception of basal cell and squamous cell carcinomas of the skin that have been 
completely excised and are considered cured).
8. History of transplantation or any antirejection therapy.
9. History of severe allergic or anaphylactic reactions or known hypersensitivity to any 
antibody drug therapy.
10. A clinically significant infectious illness (e.g., cellulitis, abscess, pneumonia, septicemia) 
within 30 days prior to Screening, or PML or other opportunistic infections at any time.
11. Presence of anti-natalizumab antibodies at Screening.
12. Signs or symptoms suggestive of any serious infection, based on medical history, 
physical examination, or laboratory testing, as determined by the Investigator.
Treatment History
13. Prior treatment with cladribine, mitoxantrone, T-cell or T-cell receptor vaccination, 
cyclophosphamide, cyclosporine, azathioprine, methotrexate, or mycophenolate mofetil.
14. Prior treatment with any therapeutic mAb other than natalizumab within 24 months prior 
to randomization.
15. Prior treatment with total lymphoid irradiation.
16. Prior treatment with IV immunoglobulin, plasmapheresis, or cytapheresis within 
12 months prior to randomization.
17. Treatment with IV or oral corticosteroids (topical or inhaled corticosteroids are 
acceptable) or related products (e.g., Acthar®) within 3 months prior to randomization.
Miscellaneous
18. History of drug or alcohol abuse within 2 years prior to entry, per Investigator judgment.
19. Current enrollment or a plan to enroll in any interventional clinical study in which an 
investigational treatment or approved therapy for investigational use is administered 
within 30 days (or 5 half-lives of the agent, whichever is longer) prior to the Baseline 
Visit or at any time during this study.
20. Inability to comply with study requirements.
21. Other unspecified reasons that, in the opinion of the Investigator or Biogen, make the 
subject unsuitable for enrollment.
22. Women who are pregnant or breastfeeding, and women intending to become pregnant 
during the study.


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8.3.
Part 2 Inclusion Criteria
To be eligible to participate in Part 2, candidates previously enrolled in Part 1 must meet the 
following eligibility criteria at the timepoint specified in the individual eligibility criterion listed:
1. Ability of the subject to understand the purpose and risks of the study and provide signed 
and dated informed consent for Part 2 and authorization to use confidential health 
information in accordance with national and local subject privacy regulations.
2. Completed Part 1 Week 72 visit while remaining on their randomized treatment 
assignment of SID or EID.
8.4.
Part 2 Exclusion Criteria
Candidates who completed Part 1 will be excluded from Part 2 entry if any of the following 
exclusion criteria exist at the timepoint specified in the individual criterion listed:
1. Subject treated with natalizumab EID was reverted to natalizumab SID by choice or as 
rescue treatment in Part 1.
2. Subject received treatment with any MS disease-modifying therapy other than 
natalizumab in Part 1 or in the period between Part 1 and Part 2.
3. History of any clinically significant (as determined by the Investigator) cardiac, 
endocrinologic, hematologic, hepatic, immunologic, metabolic (including diabetes), 
urologic, pulmonary, neurologic (except for RRMS), dermatologic, psychiatric, renal, or 
other major disease that would preclude participation in a clinical study, in the opinion of 
the Investigator.
4. History of human immunodeficiency virus or history of other immunodeficient 
conditions. 
5. History of malignant disease, including solid tumors and hematologic malignancies (with 
the exception of basal cell and squamous cell carcinomas of the skin that have been 
completely excised and are considered cured).
6. Current enrollment or a plan to enroll in any interventional clinical study in which an 
investigational treatment or approved therapy for investigational use is administered 
within 30 days (or 5 half-lives of the agent, whichever is longer) prior to the Baseline 
Visit or at any time during this study.
7. Inability to comply with study requirements.
8. Other unspecified reasons that, in the opinion of the Investigator or Biogen, make the 
subject unsuitable for enrollment.
9. Women who are pregnant or breastfeeding, and women intending to become pregnant 
during the study.
8.5.
Part 2 Inclusion Criteria for New Subjects
The inclusion criteria for new subjects who did not participate in Part 1 of the study are the same 
as those for subjects who did participate in Part 1, as presented in Section 8.1.


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8.6.
Part 2 Exclusion Criteria for New Subjects
The exclusion criteria for new subjects who did not participate in Part 1 of the study are the same 
as those for subjects who did participate in Part 1, as presented in Section 8.2.


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9.
SCREENING AND RANDOMIZATION
9.1.
Screening 
9.1.1.
Part 1 Screening
Subjects must provide informed consent before any screening tests are performed (see 
Section 17.3). Participating study sites are required to document all screened candidates initially 
considered for inclusion in the study.
Screen failures are defined as subjects who sign the informed consent form (ICF) but are not 
subsequently randomized. If a subject is considered a screen failure, the reasons for exclusion 
must be documented in the subject’s source documents and on the screening log. A minimal set 
of screen failure information is required to ensure transparent reporting of screen failure 
participants to meet the Consolidated Standards of Reporting Trials publishing requirements and 
to respond to queries from regulatory authorities. Minimal information includes demography, 
screen failure details, eligibility criteria, and any SAEs. Subjects who fail screening due to 
clinically nonsignificant laboratory result(s) or transient infection can be rescreened once, at the 
discretion of the Investigator.
It is not required that all screening tests and assessments be completed during 1 pretreatment 
visit; however, some tests and assessments must be completed immediately prior to subjects 
receiving their last prestudy dose of natalizumab. Other assessments can occur anytime between 
the subjects receiving their last prestudy dose of natalizumab and baseline (see Section 5).
Participating study sites are required to document all screened candidates initially considered for 
inclusion in the study. If a subject is excluded from the study, the reasons for exclusion will be 
documented in the subject’s source documents and on the screening log. A minimal set of 
screening failure information is required to ensure transparent reporting of screening failure to 
meet the Consolidated Standards of Reporting Trials publishing requirements and to respond to 
queries from regulatory authorities. Minimal information includes demography, screening failure 
details, eligibility criteria, and any SAEs.
9.1.2.
Part 2 Screening
Subjects must provide informed consent before any Part 2 assessments are performed (see 
Section 17.3). Participating study sites are required to document all screened candidates initially 
considered for inclusion in the study. New subjects enrolling in Part 2 of the study should follow 
all guidance with respect to screening as described in Section 9.1.1. New subjects who fail 
screening due to a clinically nonsignificant laboratory result(s) or transient infection can be 
rescreened once at the discretion of the Investigator.
Part 2 Screening Visit will be performed during the Week 72 visit if possible or within 6 weeks 
prior to Week 78 or Week 84, whichever visit/infusion is the first Part 2 study treatment 
administration to the subject.
Subjects who meet Part 2 inclusion/exclusion criteria and provide informed consent will be 
enrolled and will receive their first Part 2 study treatment at Week 78. In the event that a subject 


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cannot be enrolled at Week 78 for any reason, the subject can enroll up to a maximum of 
12 weeks after their Week 72 visit, provided that the subject has continued to receive treatment 
with natalizumab between the end of Part 1 and the beginning of Part 2.
9.2.
Randomization 
9.2.1.
Part 1 Randomization
Subjects will be randomized after all screening assessments have been completed and after the 
Investigator has verified that the subjects are eligible per criteria in Sections 8.1 and 8.2. Subjects 
will be assigned a unique identification number that will be used on study-related documents 
pertaining to the subject. Any subject identification numbers that are assigned will not be reused 
even if the subject does not continue in the study.
Randomization will be performed using interactive response technology (IRT). Subjects will be 
randomized to receive natalizumab SID or natalizumab EID in a 1:1 ratio. The randomization 
will be stratified by country/region (North America [includes USA and Canada], United 
Kingdom, Europe and Israel [includes Belgium, France, Germany, Israel, Italy, Netherlands, and 
Spain], and Australia), body weight (≤80 kg versus > 80 kg), and duration of natalizumab 
exposure (≤3 years versus > 3 years).
Refer to the Study Reference Guide for details on randomization.
9.2.2.
Part 2 Randomization
Subjects will be randomized in a 1:1 ratio, stratified by their treatment assignment in Part 1 (SID, 
EID, new subjects) to receive SC/IV or IV/SC before the first dose of crossover treatment in 
Part 2 of the study.
9.3.
Blinding Procedures
9.3.1.
Part 1 Blinding
The designated examining neurologist, backup examining neurologist, and examining technician 
will be blinded to treatment assignments; however, the subjects, Investigator, Biogen, and 
IQVIA will know the subject’s treatment assignment. The central MRI rater will remain blinded 
throughout the study. To maintain the rater blinding, it is imperative that subject treatment 
assignments, infusion dates, and laboratory data are not shared with the examining neurologist, 
backup examining neurologist, or examining technician.
9.3.2.
Part 2 Blinding
All blinding procedures will be maintained in Part 2 until all Part 1 Week 84 data have been 
entered, checked, and secured. The Sponsor will notify the sites when the Part 1 examining 
technician can be unblinded. The examining neurologist, backup examining neurologist, and 
central MRI rater will remain blinded throughout the study.


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10.
DISCONTINUATION OF STUDY TREATMENT AND 
WITHDRAWAL OF SUBJECTS FROM THE STUDY
10.1.
Discontinuation of Study Treatment
A subject must permanently discontinue study treatment for any of the following reasons:

The subject becomes pregnant. Study treatment must be discontinued immediately. 
Report the pregnancy according to the instructions in Section 15.4.2.

The subject develops persistent anti-natalizumab antibodies (2 consecutive readings).

The subject develops PML or another serious opportunistic infection.

The subject withdraws consent to continue study treatment.

The subject experiences an AE or SAE that necessitates permanent discontinuation of 
study treatment.

The subject experiences hypersensitivity or suspected allergic reaction to study 
treatment.

The subject experiences a medical emergency that necessitates permanent 
discontinuation of study treatment.

The subject is unwilling or unable to comply with the protocol.

At the discretion of the Investigator for medical reasons.

At the discretion of the Investigator or Sponsor for noncompliance.
The primary reason for discontinuation of study treatment must be recorded in the subject’s case 
report form (CRF).
In Part 1, subjects who discontinue treatment may remain in the study and continue 
protocol-required tests and assessments. Of note, subjects who discontinue natalizumab do not 
need to return for visits at which only vital signs and Columbia Suicide Severity Rating Scale 
(C-SSRS) assessments are performed. Subjects who discontinue natalizumab should continue 
visits at 12-week intervals (e.g., Weeks 12, 24, 36, 48, 60, and 72).
If a subject chooses to withdraw from the study, an Early Termination (ET) Visit should occur as 
soon as possible but no later than 4 weeks after the last dose of study treatment; in addition, all 
EOS assessments should be conducted at a separate EOS visit 12 weeks (± 10 days) after the 
final dose of study treatment is received. A follow-up safety phone call will be performed 
24 weeks after the last dose of study treatment.
In Part 2, subjects who discontinue study treatment will be required to withdraw from the study. 
If a subject chooses to withdraw from the study, an ET Visit should occur as soon as possible but 
no later than 4 weeks after the last dose of study treatment. In addition, all EOS assessments 
should be conducted at a separate EOS Visit 12 weeks (± 10 days) after the final dose of study 
treatment. A follow-up safety phone call will be performed 24 weeks after the last dose of study 
treatment.


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10.2.
Lost to Follow-Up
Subjects will be considered lost to follow-up if they repeatedly fail to return for scheduled visits 
and are unable to be contacted by the study site. 
The following actions must be taken if a subject fails to return to the study site for a required 
study visit:
1. The study site must attempt to contact the subject and reschedule the missed visit as soon 
as possible and counsel the subject on the importance of maintaining the assigned visit 
schedule and ascertain whether the subject wishes to and/or should continue in the study.
2. In cases in which the subject is deemed lost to follow-up, the Investigator or designee 
must make every effort to regain contact with the subject. These contact attempts should 
be documented in the subject’s medical records.
3. Should the subject continue to be unreachable, that subject will be considered to have 
withdrawn from the study with a primary reason of lost to follow-up.
10.3.
Withdrawal of Subjects From Study
Subjects must be withdrawn from the study for any one of the following reasons:

The subject withdraws consent.  

The subject enrolls into another interventional clinical study in which an 
investigational treatment or approved therapy for investigational use is administered.

The subject is unwilling or unable to comply with the protocol.

The subject discontinues study treatment in Part 2.
The primary reason for the subject’s withdrawal from the study must be recorded in the subject’s 
CRF.
Subjects must undergo an ET Visit unless withdrawal is due to death or withdrawal of consent.
Subjects who withdraw from the study may not be replaced.


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11.
STUDY TREATMENT USE
11.1.
Regimen
Refer to and follow the DHA for natalizumab IV infusion in both Parts 1 and 2 of the study; refer 
to the DHA for natalizumab SC injection in Part 2 of the study.
11.1.1.
Part 1 Regimen
Subjects will continue to receive natalizumab either SID (300 mg IV infusion Q4W) or EID 
(300 mg IV infusion Q6W) for a period of 72 weeks.
11.1.2.
Part 2 Regimen
Subjects will initially receive natalizumab 300 mg IV Q6W beginning on Week 78. During the 
treatment period beginning on Week 108, subjects will receive natalizumab 300 mg Q6W for 
24 weeks by SC injection and natalizumab 300 mg by IV infusion for 24 weeks in a randomized 
crossover
11.2.
Modification of Dose and Treatment Schedule
11.2.1.
Modification of Dose
The dosage of natalizumab cannot be modified.
11.2.2.
Modification of Treatment Schedule
11.2.2.1.
Part 1 Modification of Treatment
If a subject treated with natalizumab EID experiences any of the following conditions, the 
Investigator will have the option of reverting to natalizumab SID as a rescue treatment. If a 
subject treated with SID experiences any of the following conditions, the Investigator will have 
the option of selecting another disease-modifying therapy that is available to the subject per local 
standard of care. Rescue treatment decisions are to occur within 4 weeks of either the date of 
MRI that showed the disease activity or confirmation of EDSS score worsening for at least 
24 weeks, at the Investigator’s discretion:

Two or more new or enlarging T2 hyperintense lesions of any size, compared with a 
previous scan performed as part of this study.

An EDSS worsening compared with previous assessment and confirmed at least 
24 weeks after the initial increase meeting any of the following criteria:  1) an 
increase of ≥1.0 in EDSS as compared with previous assessment if previous EDSS 
was ≤5.5 and > 0; or 2) an increase of ≥1.5 in EDSS if previous EDSS was 0; or 3) 
an increase of ≥0.5 in EDSS if previous EDSS was ≥6.0.

A clinical relapse with new or recurrent neurological symptoms, not associated with 
fever or infection, having a minimum duration of 24 hours and any of the following:  
1) an increase of ≥1 grade in ≥2 functional scales of the EDSS; or 2) an increase of 


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≥2 grades in 1 functional scale of the EDSS; or 3) an increase of ≥1 in the EDSS if 
the previous EDSS was ≤5.5, or ≥0.5 if the previous EDSS was ≥6 (an increase of 
≥1.5 in EDSS if previous EDSS was equal to 0).
Subjects who receive rescue treatment with natalizumab SID should remain in the study and 
follow the schedule of activities for SID. Subjects who receive rescue treatment different from 
natalizumab SID may remain in the study and follow the schedule of activities with exception of 
natalizumab administration. Note, for subjects who experience acute clinical relapse, high dose 
corticosteroid treatment as per local standard of care (up to 5 days) for relapse treatment may be 
administered (see Section 7.3).
11.2.2.2.
Part 2 Modification of Treatment
In Part 2, there will be no protocol-defined rescue treatment; subjects who discontinue study 
treatment in Part 2 for any reason will be withdrawn from the study and will be treated as per 
local standard of care.
11.3.
Precautions
Please refer to the DHA located in the Study Reference Guide for details on postdose observation 
requirements.
11.4.
Compliance
All doses of study treatment will be administered by the study site staff.
11.5.
Concomitant Therapy and Procedures
11.5.1.
Concomitant Therapy
A concomitant therapy is any drug or substance administered between the time of the subject’s 
written consent and the subject’s last study visit.
11.5.1.1.
Allowed Concomitant Therapy
Concomitant treatment with any of the following is allowed so long as the exclusionary criteria 
described in Section 8.2 are observed:

Medications necessary for the treatment of AEs.

4-aminopyridine if used per label and maintained on a stable regimen for at least 
30 days prior to randomization and throughout the study.

Medications used to treat MS symptoms such as spasticity, bladder impairment, pain, 
fatigue, or depression.

Short courses of high-dose corticosteroids per local standard of care in the treatment 
of protocol-defined relapse of MS disease (see Section 7.3).

Corticosteroids that are administered by nonsystemic routes (e.g., topical, inhaled).


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
In Part 2 only, corticosteroids administered via systemic routes (e.g., oral, injected, 
and intravenous) are also allowed.
11.5.1.2.
Disallowed Concomitant Therapy
Subjects should be instructed to contact their Investigators before taking any new medications, 
including nonprescription drugs and herbal preparations.
Concomitant treatment with any of the following is not allowed while receiving study treatment, 
unless as otherwise described in this protocol:

Any nonstudy treatments directed toward the treatment of MS such as chronic 
immunosuppressant therapy or other immunomodulatory treatments. This includes, 
but is not limited to interferon, glatiramer acetate, dimethyl fumarate, diroximel 
fumarate, cyclophosphamide, methotrexate, azathioprine, cladribine, mitoxantrone, 
IV immunoglobulin, mycophenolate mofetil, fingolimod, siponimod, ozanimod, 
daclizumab, rituximab, ocrelizumab, or any therapeutic mAb. 

Any investigational product, including investigational symptomatic therapies for MS 
and investigational therapies for non-MS indications.

In Part 1 only, systemic steroid therapy including, but not limited to, oral 
corticosteroids (e.g., prednisone) or periodic (e.g., monthly) treatment with IV 
methylprednisolone, except for protocol-defined treatment of relapses as described in 
Section 7.3. These therapies are allowed in Part 2 only.
Subjects who receive any of these restricted treatments may be required to discontinue study 
treatment permanently and may be withdrawn from the study as outlined in Section 10.1.
11.5.2.
Concomitant Procedures
A concomitant procedure is any therapeutic intervention (e.g., surgery/biopsy, physical therapy) 
or diagnostic assessment (e.g., blood gas measurement, bacterial culture) performed between the 
time of the subject’s written consent and the subject’s last study visit, unless the subject is being 
followed up for study-related toxicity.
11.5.2.1.
Disallowed Concomitant Procedures
Treatment with any of the following concomitant procedures is not allowed while receiving 
study treatment, unless as otherwise described in this protocol:

total lymphoid irradiation

T-cell or T-cell receptor vaccination

plasmapheresis

cytapheresis
Subjects who receive treatment with any of these restricted procedures may be required to 
permanently discontinue study treatment and may be withdrawn from the study as outlined in 
Section 10.1.


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The use of concomitant therapies or procedures defined above must be recorded in the subject’s 
CRF, according to the instructions for CRF completion. AEs related to the administration of 
these therapies or procedures must be documented in the appropriate CRF.
11.6.
Continuation of Treatment
There is no provision to provide study treatment after the study. Natalizumab is available 
commercially and subjects/Investigators can continue Tysabri treatment via a commercial 
source. Once subjects have completed the Part 1 or Part 2 treatment period in the study, it is up 
to the treating physician and subject as to what the most appropriate treatment plan is for that 
subject per local practice.


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12.
STUDY TREATMENT MANAGEMENT
Study treatment will be manufactured, handled, and stored in accordance with applicable Good 
Manufacturing Practice.
Study site staff should follow the DHA for specific instructions on the handling, preparation, 
administration, and disposal of the study treatment. The DHA supersedes all other references 
(e.g., protocol).
Study treatment must be dispensed only by a pharmacist or appropriately qualified staff. Study 
treatment is to be dispensed only to subjects enrolled in this study. Once study treatment is 
prepared for a subject, it can be administered only to that subject. Study treatments are for 
one-time use only; do not use any study treatment remaining in the vial for another subject.
12.1.
Natalizumab
Natalizumab is a recombinant, humanized anti-α4 integrin antibody manufactured by Biogen.
Natalizumab for IV infusion is supplied as a liquid in 15 mL vials containing 300 mg of 
natalizumab per vial and excipient materials (sodium phosphate monobasic monohydrate, 
sodium phosphate dibasic heptahydrate, sodium chloride, and polysorbate 80).
Natalizumab for SC injection is provided in a 1 mL prefilled syringe containing 150 mg 
natalizumab and excipient materials (sodium phosphate, sodium chloride, polysorbate 80, 
pH 6.0); 2 injections in succession are required to administer 300 mg.
The contents of the natalizumab label will be in accordance with all applicable regulatory 
requirements. At a minimum, the label will include a study reference code, study treatment 
identifier, quantity of dosage units, lot number, and other pertinent information in accordance 
with local law. The expiry or use-by date will be stored in the IRT system, and printable 
assignment reports will be available to study site staff. Study treatment should not be used after 
the expiration, expiry, or use-by date.
12.1.1.
Natalizumab Preparation
The individual preparing natalizumab should carefully review the instructions provided in the 
DHA.
If the packaging is damaged, or if there is anything unusual about the appearance or attributes of 
the container closure system or study treatment, do not use the study treatment. The drug product
in question should be saved at the study site and the problem immediately reported to Biogen. 
Information on reporting product issues can be found in the Study Reference Guide, Pharmacy 
Manual, and DHA.
12.1.2.
Natalizumab Storage
Study treatment must be stored in a secure location.


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Natalizumab is to be stored at 2C to 8C (36F to 46F), protected from light, in a monitored 
and locked refrigerator with limited access. Study treatment is not to be frozen. For the most 
up-to-date storage requirements, follow the instructions provided in the DHA.
12.1.3.
Natalizumab Handling and Disposal
The Investigator must return all used and unused natalizumab study treatment as instructed by 
Biogen unless approved for onsite destruction.
If any natalizumab supplies are to be destroyed at the study site, the institution or appropriate 
study site staff must obtain prior approval from Biogen, by providing, in writing, the destruction 
policy or details of the method of destruction. After such destruction, Biogen must be notified, in 
writing, of the details of the study treatment destroyed (e.g., lot or kit numbers, quantities), the 
date of destruction, and proof of destruction.
12.1.4.
Natalizumab Accountability
Accountability for study treatment is the responsibility of the Investigator. The study site must 
maintain accurate records demonstrating the dates and amount of study treatment received, to 
whom study treatment was dispensed (subject-by-subject accounting), and accounts of any study 
treatment accidentally or deliberately destroyed or lost.
Unless otherwise notified, all study treatment both used and unused must be saved for 
accountability. By the end of the study, reconciliation must be made between the amount of 
natalizumab supplied, dispensed, and subsequently destroyed, lost, or returned to Biogen. A 
written explanation must be provided for any discrepancies.








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14.
SAFETY ASSESSMENTS
See Section 5 for the timing of all safety assessments.
14.1.
Clinical Safety Assessments
The following clinical assessments will be performed to evaluate the safety profile of 
natalizumab:
In Part 1 only:

C-SSRS
In Part 1 and for new subjects in Part 2 only,

Medical history
In Part 1 and Part 2:

Physical examination

Body weight

Vital sign measurements: temperature, systolic and diastolic blood pressures, pulse 
rate, and respiratory rate

Concomitant therapy and procedure recording

AE and SAE recording
14.2.
Laboratory Safety Assessments
Samples will be analyzed using Good Laboratory Practice-validated assays in Part 1 and Part 2.
The following laboratory assessments will be performed to evaluate the safety profile of 
natalizumab:

Hematology: complete blood count with differential and platelet count and absolute 
neutrophil count

Blood chemistry: total protein, albumin, creatinine, blood urea nitrogen, uric acid, 
bilirubin (total and direct), alkaline phosphatase, alanine aminotransferase, aspartate 
aminotransferase, gamma-glutamyl transferase, glucose, calcium, phosphorus, 
bicarbonate, chloride, sodium, and potassium 
14.3.
Natalizumab Safety Assessments
The following assessments will be performed to determine the safety of natalizumab in 
 Part 2:

Anti-natalizumab antibodies



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15.
SAFETY DEFINITIONS, RECORDING, REPORTING, AND 
RESPONSIBILITIES
Throughout the course of the study, every effort must be made to remain alert to possible AEs. If 
an AE occurs, the first concern should be for the safety of the subject. If necessary, appropriate 
medical intervention should be provided.
At the signing of the ICF, each subject must be given the names and telephone numbers of study 
site staff for reporting AEs and medical emergencies.
15.1.
Definitions
15.1.1.
Adverse Event
An AE is any untoward medical occurrence in a patient or clinical investigation subject 
administered a pharmaceutical product and that does not necessarily have a causal relationship 
with this treatment. An AE can therefore be any unfavorable and unintended sign (including an 
abnormal laboratory finding), symptom, or disease temporally associated with the use of a 
medicinal (investigational) product, whether or not related to the medicinal (investigational) 
product.
Determination of whether an abnormal laboratory value and/or vital sign result meets the 
definition of an AE will be made by the Investigator. Abnormal results are not considered AEs 
unless one or more of the following criteria are met:

The result meets the criteria for an SAE.

The result requires the subject to receive specific corrective therapy.

The result is considered by the Investigator to be clinically significant.
15.1.2.
Serious Adverse Event
An SAE is any untoward medical occurrence that at any dose:

Results in death

In the view of the Investigator, places the subject at immediate risk of death (a 
life-threatening event); however, this does not include an event that, had it occurred 
in a more severe form, might have caused death

Requires inpatient hospitalization or prolongation of existing hospitalization

Results in persistent or significant disability/incapacity

Results in a congenital anomaly/birth defect

Is a medically important event
A medically important event is an AE that, in the opinion of the Investigator, may jeopardize the 
subject or may require intervention to prevent one of the other outcomes listed in the definition 
above. (Examples of such medical events include allergic bronchospasm requiring intensive 


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treatment in an emergency room or convulsions occurring at home that do not require an 
inpatient hospitalization.)
15.1.3.
Prescheduled or Elective Procedures or Routinely Scheduled Treatments
A prescheduled or elective procedure or a routinely scheduled treatment will not be considered 
an SAE, even if the subject is hospitalized. The study site must document all of the following:

The prescheduled or elective procedure or routinely scheduled treatment was 
scheduled (or was on a waiting list to be scheduled) prior to obtaining the subject’s 
consent to participate in the study.

The condition requiring the prescheduled or elective procedure or routinely scheduled 
treatment was present before and did not worsen or progress in the opinion of the 
Investigator between the subject’s consent to participate in the study and the time of 
the procedure or treatment.

The prescheduled or elective procedure or routinely scheduled treatment is the sole 
reason for the intervention or hospital admission.
o
If a subject is hospitalized due to local requirements for administration of the 
study treatment, the hospitalization should not be considered an SAE unless 
one of the requirements in Section 15.1.2 is met.
15.2.
Safety Classifications
15.2.1.
Investigator Assessment of Events
All events must be assessed to determine the following:

If the event meets the criteria for an SAE as defined in Section 15.1.2.

The relationship of the event to study treatment as defined in Section 15.2.2

The severity of the event as defined in Section 15.2.3.
15.2.2.
Relationship of Events to Study Treatment
The following definitions should be considered when evaluating the relationship of AEs and 
SAEs to the study treatment.






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15.3.4.
Suspected Unexpected Serious Adverse Reactions
Suspected unexpected serious adverse reactions (SUSARs) are SAEs that are unexpected and 
judged by the Investigator or Biogen to be related to the study treatment administered.
Biogen will report SUSARs to the appropriate regulatory authorities and Investigators as 
required, according to local law.
15.4.
Procedures for Handling Special Situations
15.4.1.
Progressive Multifocal Leukoencephalopathy
Due to the risk of PML in natalizumab-treated subjects, if neurological symptoms or MRIs 
indicate a possible pathology other than MS, the following diagnostic procedures are 
recommended:

Careful evaluation of MRI, including comparison with previous MRI scans.

.

Timely discontinuation of treatment.  If the Investigator is unable exclude PML or 
other opportunistic infections (viral, bacterial, or fungal), natalizumab must be 
discontinued.
If, in the opinion of the Investigator, a subject’s individualized risk for PML requires more 
frequent MRI monitoring than is performed as part of this study, additional MRIs to monitor for 
PML may be performed at the Investigator’s discretion.
15.4.2.
Pregnancy
Subjects should not become pregnant after the first dose in this study and for at least 
3 months after their last dose of study treatment. If a female subject becomes pregnant, study 
treatment must be discontinued immediately. In the event of early study termination for a 
pregnancy, an EOS Gd-enhancing MRI should not be conducted.
The Investigator must report a pregnancy occurring in a female subject between the first dose of 
study treatment and 3 months after the last dose of study treatment by faxing the appropriate 
form to Biogen within 24 hours of the study site staff becoming aware of the pregnancy. Refer to 
the Study Reference Guide’s Official Study Contact List for complete contact information. The 
Investigator or study site staff must report the outcome of the pregnancy to Biogen. A pregnancy 
is not considered an AE and should not be recorded in the AE CRF.
Congenital abnormalities and birth defects in the offspring of male or female subjects should be 
reported as an SAE if conception occurred during the study treatment period.
15.4.3.
Overdose
An overdose is any dose of study treatment administered to a subject or taken by a subject that 
exceeds the dose assigned to the subject according to the protocol. Overdoses are not considered 
AEs and should not be recorded as an AE in the CRF; however, all overdoses must be recorded 
on an Overdose form and faxed to Biogen within 24 hours of the study site becoming aware of 
the overdose. An overdose must be reported to Biogen even if the overdose does not result in an 


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AE. If an overdose results in an AE, the AE must be recorded. If an overdose results in an SAE, 
both the SAE and Overdose forms must be completed and faxed to Biogen. All study 
treatment-related dosing information must be recorded in the dosing CRF.
15.4.4.
Medical Emergency
In a medical emergency requiring immediate attention, study site staff will apply appropriate 
medical intervention, according to current standard of care. The Investigator (or designee) should 
contact the study’s Medical Director. Refer to the Study Reference Guide’s Official Study 
Contact List for complete contact information.
15.5.
Contraception Requirements
All women of childbearing potential must ensure that highly effective contraception is used 
during the study and for at least 3 months after their last dose of study treatment.
For the purposes of this study, women who do not meet one of the following criteria are 
considered to be physiologically capable of becoming pregnant and are, therefore, defined as 
women of childbearing potential:

Postmenopausal
o
12 continuous months of natural (spontaneous) amenorrhea without an alternative 
medical cause 
o
6 weeks after surgical bilateral oophorectomy with or without hysterectomy

Posthysterectomy

Female surgical sterilization (e.g., bilateral tubal ligation)
For the purposes of the study, highly effective contraception is defined as contraception that 
achieves a failure rate of < 1% when used consistently and correctly, and includes the following:
For females:

Established use of oral, intravaginal, or transdermal combined (estrogen and progestogen 
containing) hormonal methods of contraception associated with the inhibition of 
ovulation.

Established use of oral, injected, or implanted progestogen-only hormonal methods of 
contraception associated with the inhibition of ovulation.

Placement of an intrauterine device or intrauterine hormone-releasing system.

Bilateral tubal occlusion.
True abstinence, when this is consistent with the preferred and usual lifestyle of the subject, can 
be considered an acceptable method of contraception based on the evaluation of the Investigator 
who should also take into consideration the duration of the clinical study. Periodic abstinence 
(e.g., calendar, ovulation, symptothermal, postovulation methods) and withdrawal are not 
considered acceptable methods of contraception.
Pregnancy reporting is described in Section 15.4.2.


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15.6.
Safety Responsibilities
15.6.1.
The Investigator
The Investigator’s responsibilities include the following:

Monitor and record all AEs, including SAEs, in the CRF regardless of the severity or 
relationship to study treatment.

Determine the seriousness, relationship, and severity of each event.

Determine the onset and resolution dates of each event.

Monitor and record all pregnancies in female subjects and follow up on the outcome 
of all pregnancies.

Complete an SAE form for each SAE and fax it to Biogen within 24 hours of the 
study site staff becoming aware of the event.

Pursue SAE follow-up information actively and persistently. Follow-up information 
must be reported to Biogen within 24 hours of the study site staff becoming aware of 
new information.

Ensure that all AE and SAE reports are supported by documentation in the subjects’ 
medical records.

Pursue AE follow-up information, if possible, until the event has resolved or become 
stable. Record AE follow-up information, including resolution, in the CRF, as 
applicable.

Report SAEs to local ethics committees, as required by local law.
15.6.2.
Biogen 
Biogen’s responsibilities include the following:

Before a study site can enroll any subjects, the Clinical Monitor is responsible for 
reviewing with study site staff the definitions of AE and SAE, as well as the 
instructions for monitoring, recording, and reporting AEs and SAEs.

Biogen is to notify all appropriate regulatory authorities, central ethics committees, 
and Investigators of SAEs, as required by local law, within the required time frames.


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16.
STATISTICAL METHODS AND DETERMINATION OF 
SAMPLE SIZE
The objectives of the study and the endpoints to be analyzed are listed in Section 6.
In this more detailed description of the associated statistical methods, the endpoints are presented 
in relationship to categorical assessment. The associated endpoints of primary, secondary, 
 importance are specifically identified under each of these categories.
16.1.
Efficacy
16.1.1.
Analysis Population
The modified intent-to-treat (mITT) population, defined as all randomized subjects who receive 
at least 1 dose of study treatment and have at least 1 postbaseline efficacy assessment, will be 
used for all efficacy analyses. Subjects will be analyzed in the groups to which they are 
randomized.
16.1.2.
General Methods of Analysis
Data will be collected and analyzed in 2 parts:
1. After the completion of the randomized phase in Part 1, the primary efficacy and safety 
analyses will be performed. All data will be summarized by randomized treatment group 
(SID and EID).
2. After the completion of the randomized phase in Part 2, analyses of all Part 2 endpoints 
will be performed. Data from Part 1 will be combined with data from Part 2 to evaluate 
the long-term efficacy and safety data of natalizumab EID.
For the continuous endpoints, the summary statistics will generally include the number of 
subjects with data, mean, standard deviation, median, interquartile range, and overall range. For 
categorical endpoints, the summary statistics will generally include the number of subjects with 
available data and the percentage of subjects with data in each category. 
In the analysis of Part 1 efficacy variables, comparisons will be made between the EID group 
and the SID group.
16.1.3.
Part 1 Statistical Analysis
16.1.3.1.
Analysis of the Primary Endpoint in Part 1
The primary endpoint, the number of new or newly enlarging T2 hyperintense lesions at 
Week 72, will be analyzed using negative binomial regression models with treatment as the 
classification variable and baseline body weight (≤80 kg versus > 80 kg), duration of 
natalizumab exposure at baseline (≤3 years versus > 3 years), and region (North America 
[includes USA and Canada], United Kingdom, Europe, and Israel [includes Belgium, France, 
Germany, Israel, Italy, Netherlands, and Spain], and Australia) as covariates. The ratio of mean 
lesion numbers of EID versus SID (EID/SID) will be derived from the model with a 95% CI and 


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associated p-value. The treatment will be considered different if the lower limit of the 95% CI is 
above 1. As a secondary inference, the possibility of a 2-fold increase in the mean lesion number 
in the EID group as compared with the SID group will be considered ruled out if the upper limit 
of 95% CI is no greater than 2. The proportion of subjects with no new or newly enlarging 
T2 hyperintense lesions will be analyzed using logistic regression models with the same 
covariates as those described above.
16.1.3.2.
Primary and Secondary Estimands and Handling of Intercurrent Events in 
Part 1
The study plans to make every effort to retain subjects in the study and to continue the follow-up 
in the cases with the initiation of rescue medication, switch to different dosing frequency, 
treatment discontinuation due to AEs, lack of efficacy, or for other reasons. This will allow 
continuing assessments of subjects’ MS disease activity. Efforts will also be made to obtain 
details of withdrawals in the generic categories of “lost to follow-up” or “other” whenever 
possible. Classification of the withdrawals in these nonspecific categories into “possibly efficacy 
related,” “possibly safety-related,” or “no information” will be made based on all available 
information by independent Sponsor personnel who are blinded to the treatment regimen and 
will be documented prior to database lock.
The proposed primary estimand will be based on a treatment policy strategy, in which the study 
is intended to estimate the difference of a potential treatment decision of switching subjects from 
SID to EID compared with keeping subjects on SID over the next 72 weeks in a realistic clinical 
setting, where switching to a different dosing regimen or different medication may occur 
depending on disease activity. Therefore, the primary analysis will utilize all measurements 
regardless of whether subjects remain on randomized treatment. For subjects who withdraw from 
the study for reasons related to the efficacy or an AE or who have a “possibly related” 
withdrawal, as described above, the missing values will be imputed by the worst observed value 
of the subjects on study treatment at the given timepoint. For withdrawals classified as “no 
information,” the missing values will be treated as missing at random and will be addressed 
using multiple imputations. The number and proportion of subjects with intercurrent events and 
the time to intercurrent event will also be tabulated and compared between randomized groups. 
Sensitivity analysis may be conducted using tipping point analysis. Supplementary analyses by 
imputing all missing values by treating all as missing at random using multiple imputations will 
also be conducted.
The secondary estimand will be based on a hypothetical strategy, in which the difference in the 
efficacy of EID versus SID over the 72 weeks following randomization if no intercurrent events 
occurred will be the target of estimation. The primary analysis for this estimand will treat the 
data obtained post-intercurrent event as missing values. For treatment discontinuation or 
switching due to efficacy as well as a withdrawal that is due to efficacy or is “possibly efficacy 
related,” the missing values will be imputed by the worst observed values of the subjects on 
study treatment at the given timepoint. For intercurrent events due to other reasons, the resulting 
missing values will be addressed using multiple imputations. Sensitivity analysis may be 
conducted using tipping point analysis.






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
Country/region (North America [includes USA and Canada], United Kingdom, 
Europe and Israel [includes Belgium, France, Germany, Israel, Italy, Netherlands, and 
Spain], and Australia)

Baseline weight (40 to 59 kg, 60 to 79 kg, 80 to 89 kg, and ≥90 kg)
In addition, subgroup analysis of the primary and key secondary endpoints will be evaluated in 
subgroups defined by prior disease activity, the number and type of therapies prior to 
natalizumab, quartiles of the Ctrough values, and α-integrin saturation levels at Weeks 24, 48 and 
72.
16.1.4.
Part 2 Statistical Analysis
In Part 2, the mITT population is defined as all randomized subjects in Part 2 who received at 
least 1 dose of SC natalizumab and completed at least the first question in the PPQ on 1 
occasion.
During Part 2, the baseline of each period is defined as the last assessment before the first dose 
administration during that period.
16.1.4.1.
Analysis of the Primary Endpoint in Part 2
Proportion of subjects indicating preference for SC versus IV administration at the end of Part 2.
For each subject, the last answer in the PPQ will be used to derive the primary endpoint of 
Part 2. The proportion of subjects preferring SC natalizumab at the end of Part 2 will be 
estimated, and the 95% CI will be calculated using the exact Binomial method. Additionally, the 
proportion of subjects preferring SC will be summarized by randomized arms during Part 2, 
i.e., the group receiving SC followed by IV and that receiving IV followed by SC.
16.1.4.2.
Analysis of the Secondary Endpoint in Part 2
Mean score on TSQM.
Total TSQM value will be summarized by route of administration during Part 2. No formal 
comparison is planned.
Mean time for drug preparation and administration between SC and IV routes of administration.
Mean time for drug preparation and administration will be summarized by route of 
administration during Part 2. No formal comparison is planned.
For the remaining secondary endpoints, analysis will be performed by using data, respectively, 
during the first period, the second period, and both periods.
Number of new or newly enlarging T2 hyperintense lesions.
In Part 2, the number of new or newly enlarging T2 hyperintense lesions will be summarized by 
route of administration.
Time to first relapse
In Part 2, if a subject withdraws from the study prior to the end of either period in the crossover 
design and did not experience a relapse reported prior to withdrawal, the subject will be censored 


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on the last day in the period. The start date for time to first relapse or censoring is defined as the 
start date of each period.
The proportion of relapsed subjects will be estimated using the KM product limit method and be 
presented as KM curves over time by route of administration.
The comparisons of route will be based on Cox regression models with route of administration as 
the classification variable and treatment arm during Part 1 and period during Part 2 as covariates. 
The hazard ratio of relapse of SC versus IV (SC/IV) will be derived from the Cox model with a 
95% CI and associated p-value.
Annualized relapse rate
During each period of the crossover design in Part 2, all relapses reported prior to the end of each 
period will be included in the analysis for this endpoint.
The relapse rate for each route will be calculated as the total number of relapses experienced for
the administration route divided by the total number of subject-years on study at the end of each 
period for the route of administration. This is the unadjusted relapse rate.
In addition, the relapse rate for an individual subject will be calculated as the number of relapses
for that subject in each period divided by the duration of the subject on study in years at the end 
of each period. Based on these individual relapse rates, the mean and median for each route will 
be presented. This is called the subject relapse rate.
The annualized relapse rate at the end of each period will be analyzed using a negative binomial 
regression model, with route of administration as the classification variable and the treatment 
arm during Part 1 and period during Part 2 as covariates. The logarithmic transformation of the 
number of years in the study at the end of each period will be included in the model as the 
“offset” parameter. The ratio of mean annualized relapse rate of SC/IV will be derived from the 
model with a 95% CI and associated p-value. If negative binomial regression model does not 
converge, a Poisson regression model with the same classification variable and covariates will be 
used instead.
Change in EDSS score
During each period of the crossover design in Part 2, the change in EDSS score from the start 
date of a period to the end date of the same period will be calculated and summarized by route of 
administration.
Number of new Gd-enhancing lesions
The same method for the analysis of new or newly enlarging T2 hyperintense lesions will be 
applied.
Number of new T1 hypointense lesions
The same method for the analysis of new or newly enlarging T2 hyperintense lesions will be 
applied.
PBVC and change in cortical and thalamic brain region volume
The same method for the analysis of new or newly enlarging T2 hyperintense lesions will be 
applied.










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covariates. The ratio of mean lesion numbers of EID versus SID (EID/SID) will be derived from 
the model with a 95% CI. The study may be stopped for futility if the lower limit of the 95% CI 
is > 2 and a 2-fold increase in mean lesion numbers in the EID group can be concluded with 
97.5% confidence.
In Part 2, no formal interim analysis will be performed; however, there may be intermittent 
analyses of the data as needed.
16.8.
Sample Size Considerations
Historical data on MS treatments, including a meta-analysis on the relationship between new or 
newly enlarging T2 lesions and relapses, suggest little or no clinical relevance of a difference of 
0.2 to 0.3 in mean lesion numbers over 72 weeks [Sormani and Bruzzi 2013].  With the planned 
sample size of N = 200/group, the precision of the estimated mean lesion numbers is sufficient to 
allow > 80% probability to observe the lower limit of the 95% CI for the ratio of EID to SID in 
the estimated mean lesion number above 1 if the true mean is 0.5 and 0.3 in the EID and SID 
group, respectively. If the true mean is 0.6 and 0.3 in the EID and SID group, respectively, the 
probability will be approximately 90%. In the other direction, the sample size provides a 
precision that allows approximately 90% probability to observe the upper limit of the 95% CI to 
be ≤2 if the true mean lesion numbers in both groups are 0.3. Approximately 480 subjects will 
be enrolled to account for a drop-out rate of approximately 17%.
For Part 2, in the absence of EID SC natalizumab data, it is assumed that the proportion of 
subjects who would prefer SC natalizumab is 75%, with a 7.5% margin of error; therefore, a 
sample size of 130 subjects for the 95% CIs to be within 67.5% and 82.5%. Approximately 
160 subjects are needed to allow for 20% of subjects who do not provide an evaluable preference 
assessment (calculated by nQuery Advisor Version 7).


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17.
ETHICAL REQUIREMENTS
Biogen, IQVIA, and the Investigator must comply with all instructions, regulations, and 
agreements in this protocol and applicable International Council for Harmonisation (ICH) and 
Good Clinical Practice (GCP) guidelines and conduct the study according to local regulations.
The Investigator is responsible for endorsing all data on completed CRFs electronically, prior to 
any interim lock or database lock.
The Investigator may delegate responsibilities for study-related tasks where appropriate to 
individuals sufficiently qualified by education, training, and experience, in accordance with 
applicable ICH and GCP guidelines. The Investigator should maintain a list of the appropriately 
qualified persons to whom significant study-related duties have been delegated. The Investigator 
is responsible for supervising those individuals and for implementing procedures to ensure the 
integrity of the tasks performed and any data generated.
17.1.
Declaration of Helsinki
This study will be performed in alignment with the ethical principles outlined in the Declaration 
of Helsinki.
17.2.
Ethics Committee
The Investigator must obtain ethics committee approval of the protocol, ICF, and other required 
study documents prior to starting the study. Biogen or designee will submit documents on behalf 
of the study sites in countries other than the US.
If the Investigator makes any changes to the ICF, Biogen must approve the changes before the 
ICF is submitted to the ethics committee. A copy of the approved ICF must be provided to 
Biogen. After approval, the ICF must not be altered without the agreement of the relevant ethics 
committee and Biogen.
It is the responsibility of the Investigators to ensure that all aspects of institutional review are 
conducted in accordance with current applicable regulations.
Biogen must receive a letter documenting ethics committee approval, which specifically 
identifies the protocol, protocol number, and ICF, prior to the initiation of the study. Protocol 
amendments will be subject to the same requirements as those in the original protocol.
A progress report must be submitted to the ethics committee at required intervals and not less 
than annually.
At the completion or termination of the study, the study site must submit a close-out letter to the 
ethics committee and Biogen.
17.3.
Subject Information and Consent
Prior to performing any study-related activities under this protocol, including screening tests and 
assessments, written informed consent with the approved ICF must be obtained from the subject 




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17.6.
Conflict of Interest
The Investigators should address any potential conflicts of interest (e.g., financial interest in 
Biogen) with the subject before the subject makes a decision to participate in the study.
17.7.
Registration of Study and Disclosure of Study Results
Biogen will register the study and post-study results regardless of the outcome on a publicly
accessible website in accordance with the applicable laws and regulations.


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18.
ADMINISTRATIVE PROCEDURES
18.1.
Study Site Initiation
The Investigator must not screen any subjects prior to completion of a study initiation visit, 
conducted by Biogen. This initiation visit will include a detailed review of the protocol and study 
procedures.
18.2.
Quality Control and Quality Assurance
Quality control procedures will be implemented at each stage of data handling to ensure that all 
data are reliable and have been processed correctly. Data anomalies will be communicated to the 
study sites for clarification and resolution, as appropriate. The Investigator is responsible for 
endorsing all CRF data prior to any interim or final database lock.
During and/or after completion of the study, quality assurance officers named by Biogen or the 
regulatory authorities may wish to perform onsite audits or inspections. The Investigator will be 
expected to cooperate with any audit or inspection and to provide assistance and documentation 
(including source data) as requested.
18.3.
Monitoring of the Study
The Investigator must permit study-related monitoring by providing direct access to source data 
and to the subjects’ medical histories. Source data must be attributable, legible, 
contemporaneous, original, accurate, and complete. Changes to source data must be traceable, 
not obscure the original entry, and be explained if necessary (e.g., with an audit trail). The 
Investigator should maintain a record of the location(s) of essential documents.
The Clinical Monitor will visit the study site at regular intervals during the study and after the 
study has completed, as appropriate. A clinical site monitoring plan will detail who performs the 
monitoring, how often, and the extent of review. It also will provide the monitoring strategy, 
with emphasis on subject safety, data integrity, and critical data and processes.
During these visits, CRFs, supporting documentation, and essential documentation related to the 
study will be reviewed, and any discrepancies or omissions will be resolved. Documentation of 
results will be provided to Biogen in a timely fashion to allow follow-up and verification of 
compliance with the monitoring plan. Remote evaluation of data (centralized monitoring) may 
also be conducted and reported as defined in the monitoring plan.
Monitoring visits must be conducted according to the applicable ICH and GCP guidelines to 
ensure the protection of subject rights and well-being, protocol adherence, quality of data 
(accurate, complete, and verifiable), study treatment accountability, compliance with regulatory 
requirements, and continued adequacy of the study site and its facilities.
18.4.
Study Funding
Biogen is the Sponsor of the study and is funding the study. All financial details are provided in 
the separate contracts between the institution, Investigator, and Biogen.


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18.5.
Publications
Details are included in the clinical trial agreement for this study.


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19.
FURTHER REQUIREMENTS AND GENERAL INFORMATION
19.1.
External Contract Organizations
Biogen will ensure oversight of any study-related duties and functions carried out on its behalf 
and will specify in writing all duties and functions that are transferred.
19.1.1.
Contract Research Organization 
A CRO will be responsible for administrative aspects of the study including but not limited to 
study initiation, monitoring, management of SAE reports, and data management. Before subjects 
are screened at each study site, the CRO will review study responsibilities with the Investigators 
and other study site staff, as appropriate.
19.1.2.
Interactive Response Technology
IRT will be used in this study. Before subjects are screened or enrolled, the IRT vendor will 
provide each study site with the necessary training, a user manual, and access rights to the 
system.
19.1.3.
Electronic Data Capture
Subject information will be captured and managed by study sites in electronic CRFs by a 
web-based electronic data capture tool configured by the CRO and hosted by the electronic data 
capture vendor. PROs will be completed by the subject on paper forms and subsequently entered 
into the electronic CRF by study site staff.
19.1.4.
Central Facility for MRI Scans
A central MRI reader has been selected by Biogen to read and interpret all MRI scans for this 
study. All study sites will need to perform a dummy scan for the qualification of the study site’s
MRI machine; a separate ICF will be used for this scan. If there is a change in the MRI machine 
during the study, this process will need to be repeated. The MRI central reader will be blinded to 
treatment allocation.
19.2.
Study Committees
An Independent Data Monitoring Committee will not be used for this study because the 
Investigators and treating staff are not blinded to the subjects’ treatment assignment, natalizumab 
has a well-established safety profile, and the study has built-in rescue criteria and a futility 
analysis to check efficacy failure.
19.2.1.
Advisory Committee
An advisory committee will be formed to provide scientific and medical direction for the study 
and to oversee the administrative progress of the study. The advisory committee will meet at 
least annually to monitor subject accrual and to monitor compliance with the protocol at 
individual study sites. The advisory committee will be blinded to subject treatment assignments.


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Members of the advisory committee will include the Medical Director, Clinical Operations Lead, 
and Project Statistician from Biogen, and participating Investigators. Biogen will designate one 
of the participating Investigators to be the chairperson of the advisory committee.
19.2.2.
Independent Neurology Evaluation Committee
An INEC will be formed to review and confirm potential abnormalities related to suspected 
relapses for the purposes of confirming the Part 1 secondary endpoint.
19.3.
Changes to Final Study Protocol
All protocol amendments must be submitted to the ethics committee and regulatory authorities if 
required by local law. Protocol modifications that affect subject safety, the scope of the 
investigation, or the scientific quality of the study must be approved by the ethics committee 
before the implementation of such modifications to the conduct of the study. If required by local 
law, such modifications must also be approved by the appropriate regulatory agency prior to 
implementation.
However, Biogen may, at any time, amend this protocol to eliminate an apparent immediate 
hazard to a subject. In this case, the appropriate regulatory authorities will be notified subsequent 
to the modification.
In the event of a protocol modification, the ICF may require similar modifications (see 
Section 17).
19.4.
Ethics Committee Notification of Study Completion or Termination
Where required, the regulatory authorities and ethics committees must be notified of the 
completion or termination of this study and sent a copy of the study synopsis in accordance with 
the necessary timelines.
19.5.
Retention of Study Data
The minimum retention time for study records will meet the strictest standard applicable to that 
study site, as dictated by any institutional requirements or local, national, or regional laws or 
regulations. Prior to proceeding with the destruction of records, the Investigator must notify
Biogen in writing and receive written authorization from Biogen to destroy study records. In 
addition, the Investigator must notify Biogen of any changes in the archival arrangements 
including but not limited to archival at an offsite facility or transfer of ownership if the 
Investigator leaves the study site.
19.6.
Study Report Signatory
Biogen will designate one of the participating Investigators as a signatory for the study report. 
This determination will be made by several factors, including but not limited to, the 
Investigator's experience and reputation in the studied indication; the Investigator’s contribution 
to the study in terms of design, management, and/or subject enrollment; or by other factors 
determined to be relevant by Biogen.


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97
20.
REFERENCES
Belachew S, Phan-Ba R, Bartholomé E, et al. Natalizumab induces a rapid improvement of 
disability status and ambulation after failure of previous therapy in relapsing-remitting multiple 
sclerosis. Eur J Neurol. 2011;18(2):240-245.
Calabresi PA, Mellion M, Edwards KR, et al. Efficacy Results From the Phase 2b SYNERGY 
Study: Treatment of Disabling Multiple Sclerosis with the Anti-LING0-1 Monoclonal Antibody 
Opicinumab. Presented at the 2017 American Academy of Neurology Annual Meeting.
Ffrench-Constant C. Pathogenesis of multiple sclerosis. Lancet. 1994;343(8892):271-5.
Hartung HP, Archelos JJ, Zielasek J, et al. Circulating adhesion molecules and inflammatory 
mediators in demyelination: a review. Neurology. 1995;45(6 Suppl 6):S22-S32.
Morrow SA, O'Connor PW, Polman CH, et al. Evaluation of the symbol digit modalities test 
(SDMT) and MS neuropsychological screening questionnaire (MSNQ) in natalizumab-treated 
MS patients over 48 weeks. Mult Scler. 2010;16(11):1385-92.
Oturai AB, Koch-Henriksen N, Petersen T, et al. Efficacy of natalizumab in multiple sclerosis 
patients with high disease activity: a Danish nationwide study. Eur J Neurol. 2009;16(3):420-3.
Sangalli F, Moiola L, Bucello S, et al. Efficacy and tolerability of natalizumab in relapsing–
remitting multiple sclerosis patients: a post-marketing observational study. Neurol Sci. 
2011;31(0):299-302.
Schumacher G, Beebe G, Kibler R, et al. Problems of experimental trials of therapy in multiple 
sclerosis: Report by the Panel on the Evaluation of Experimental Trials of Therapy in Multiple 
Sclerosis. Ann NY Acad Sci. 1965;122(1):552-568.
Sormani MP, Bruzzi P. MRI lesions as a surrogate for relapses in multiple sclerosis: a meta-
analysis of randomised trials. Lancet Neurol. 2013;12(7):669-76.
Thompson AJ, Banwell BL, Barkhof F, et al. Diagnosis of multiple sclerosis: 2017 revisions of 
the McDonald criteria. Lancet Neurol. 2018;17(2):162-173. Epub 2017/12/21.


Protocol 101MS329
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21.
SIGNED AGREEMENT OF THE STUDY PROTOCOL
I have read the foregoing protocol, “A Randomized, Controlled, Open-Label, Rater-Blinded, 
Phase 3b Study of the Efficacy, Safety, and Tolerability of 6-Week Extended Interval Dosing of 
Natalizumab (BG00002) in Subjects With Relapsing-Remitting Multiple Sclerosis Switching 
From Treatment With 4-Week Natalizumab Standard Interval Dosing (SID) in Relation to 
Continued SID Treatment - Followed by an Open-Label Crossover Extension Study Comprising 
Subcutaneous and Intravenous Natalizumab Administration” and agree to conduct the study 
according to the protocol and the applicable ICH guidelines and GCP regulations, and to inform 
all who assist me in the conduct of this study of their responsibilities and obligations.
____________________________________________________
Investigator’s Signature
        Date (dd - MONTH - yyyy)
____________________________________________________
Investigator’s Name (Print)
____________________________________________________
Study Site (Print)


CONFIDENTIAL
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Biogen MA Inc.
1
Biogen MA Inc.
225 Binney Street
Cambridge, MA  02142
United States
Biogen Idec Research Limited
Innovation House
70 Norden Road
Maidenhead, Berkshire
SL6 4AY
United Kingdom
______________________________________________________________________
AMENDMENT SUMMARY
Biogen Protocol 101MS329
A Randomized, Controlled, Open-Label, Rater-Blinded, Phase 3b Study of the Efficacy, 
Safety, and Tolerability of 6-Week Extended Interval Dosing (EID) of Natalizumab (BG00002) 
in Subjects With Relapsing-Remitting Multiple Sclerosis Switching From Treatment With 
4-Week Natalizumab Standard Interval Dosing (SID) in Relation to Continued SID Treatment -
Followed by an Open-Label EID Crossover Extension Study Comprising Subcutaneous and 
Intravenous Natalizumab Administration
Version 4.0
Date: 20 August 2020
EUDRA CT Number: 2018-002145-11
Version 4.0 of the protocol has been prepared for this amendment, which supersedes Version 3.0.


Amendment Summary for Protocol 101MS329, Version 4.0
CONFIDENTIAL
The information contained herein may not be used, disclosed, or published without the written consent of 
Biogen MA Inc.
2
PRIMARY REASON FOR AMENDMENT
The primary reason for this amendment to Protocol 101MS329 is the addition of details
regarding the Screening visit for new participants who did not participate in Part 1 of the study 
and are being enrolled in Part 2.
New text is shown in bold type; deleted text is shown with a strikethrough.
Section 5.2, Part 2 - Schedule of Activities, Table 4, footnote 1
Now reads:
1
The Part 2 Screening, informed consent, and eligibility assessment for a new subject should 
be performed within 6 weeks of the Baseline Visit.Informed consent can be obtained any 
time between Day -42 and the day of the last prestudy dose of natalizumab. The last 
prestudy dose of natalizumab must occur between Days -33 and -26 from the baseline 
visit. Some screening assessments must be performed immediately prior to the last 
prestudy dose of natalizumab (see footnote 7). All other screening assessments can 
occur any time between the day of the last prestudy natalizumab dose and baseline.
Randomization to crossover study treatment should be done at the Week 108 visit to confirm 
crossover treatment allocation.
Rationale: The change was made to clarify the timing of the last prestudy dose of natalizumab
and screening requirements for new participants being enrolled in the open-label extension, as 
well as the assessments that must be completed prior to the last prestudy dose of natalizumab.


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3
SUMMARY OF MAJOR CHANGES TO THE PROTOCOL
Changes to the protocol are presented chronologically. New text is shown in bold type; deleted 
text is shown with a strikethrough.
Section 5.1, Part 1 - Schedule of Activities, Table 1
Change: In footnote 16, instructions for postdosing observation requirements were revised
Now reads:
16
Subjects must be observed for 1 hour after completion of infusion. Please refer to the 
Directions for Handling and Administration (DHA) located in the Study Reference 
Guide for details of postdose observation requirements.
Rationale: Biogen has elected to specify requirements for postdosing observation in the DHA of 
natalizumab rather than the study protocol.
This change also affects Section 5.1, Part 1 - Schedule of Activities (Table 2, footnote 16); 
Section 5.2, Part 2 - Schedule of Activities (Table 3, footnote 12); Section 5.2, Part 2 - Schedule 
of Activities (Table 4, footnote 13); and Section 11.3, Precautions.
Section 5.2, Part 2 - Schedule of Activities, Table 4
Change: The Nominal Study Day for the Screening visit was revised.
Now reads:
-4142 to -1
Rationale: This revision was required to align with the change in footnote 1 of this table.
Section 5.2, Part 2 - Schedule of Activities, Table 4
Change: Reference to footnote 7 was added to the Blood Chemistry assessment schedule.
Now reads:  
Blood Chemistry8,7
Rationale: The need for reference to footnote 7 was overlooked in the previous version.


Amendment Summary for Protocol 101MS329, Version 4.0
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4
SUMMARY OF MINOR CHANGES TO THE PROTOCOL
The following minor changes were made to the protocol, as appropriate:

The version number and date were updated throughout the protocol.

The Sponsor Signature Page was revised.


Amendment Summary for Protocol 101MS329, Version 4.0
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5
LIST OF ABBREVIATIONS
DHA
Directions for Handling and Administration


CONFIDENTIAL
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Biogen MA Inc.
1
Biogen MA Inc.
225 Binney Street
Cambridge, MA  02142
United States
Biogen Idec Research Limited
Innovation House
70 Norden Road
Maidenhead, Berkshire
SL6 4AY
United Kingdom
______________________________________________________________________
AMENDMENT SUMMARY
Biogen Protocol 101MS329
A Randomized, Controlled, Open-Label, Rater-Blinded, Phase 3b Study of the Efficacy, 
Safety, and Tolerability of 6-Week Extended Interval Dosing (EID) of Natalizumab (BG00002) 
in Subjects With Relapsing-Remitting Multiple Sclerosis Switching From Treatment With 
4-Week Natalizumab Standard Interval Dosing (SID) in Relation to Continued SID Treatment -
Followed by an Open-Label EID Crossover Extension Study Comprising Subcutaneous and 
Intravenous Natalizumab Administration
Version 3
Date: 08 July 2020
EUDRA CT Number: 2018-002145-11
Version 3 of the protocol has been prepared for this amendment, which supersedes Version 2.


Amendment Summary for Protocol 101MS329, Version 3
CONFIDENTIAL
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Biogen MA Inc.
2
PRIMARY REASON FOR AMENDMENT
The primary reason for this amendment to Protocol 101MS329 is the addition of an OLE 
comprising a crossover analysis of natalizumab administered by IV infusion and SC injection
under EID.
New text is shown in bold type; deleted text is shown with a strikethrough.
Section 7, Study Design
Now reads:
This study will be conducted in 2 parts. Part 1 is a prospective, randomized, interventional, 
controlled, open-label, rater-blinded, Phase 3b study in subjects with RRMS who have been 
receiving natalizumab SID for at least 12 months without relapses in the last 12 months. All MRI 
scans will be read at a central facility with raters blinded to subject assignment. Approximately 
480 subjects are expected to be enrolled at approximately 100 sites in North America, Europe, 
and Australia. Subjects will be randomly assigned to continue to receive natalizumab in 1 of the 
following 2 armsgroups:

SID: approximately 240 subjects will receive natalizumab as a 300 mg IV infusion 
every 4 weeks (28 [-2/+5 days]).

EID:  approximately 240 subjects will receive natalizumab as a 300 mg IV infusion 
every 6 weeks (42 [-2/+5 days]). 
Randomization will be stratified by country/region (North America [includes USA and Canada], 
United Kingdom, Europe and Israel [includes Belgium, France, Germany, Israel, Italy, 
Netherlands, and Spain], and Australia), body weight (≤80 kg versus > 80 kg), and duration of 
natalizumab exposure (≤3 years versus > 3 years). Subjects will receive open-label natalizumab 
at their assigned frequency throughout the 72 weeks of the study.
At the completion of their 72-week treatment period, subjects in Part 1 who cannot 
participate, or elect not to participate, in Part 2 will enter a 12-week follow-up, and will 
receive a follow-up safety phone call 12 weeks later (i.e., 24 weeks after the last dose of 
study treatment) before completing the study.
See Figure 1 for a schematic of the study design.


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3
Figure 1:
Study Design
Part 2 is a 108-week OLE for approximately 200 subjects at approximately 45 sites in 
Canada, the United Kingdom, Europe, Israel, and Australia who complete their 
randomized treatment in Part 1, provide consent, and are eligible to participate 
immediately following completion of the 72-week treatment period.
Subjects who did not participate in Part 1 but provide consent and satisfy the inclusion-
exclusion and eligibility requirements of Part 1, including treatment with natalizumab SID 
for at least 12 months without relapses in the last 12 months, may also be enrolled in Part 2 
as new subjects to ensure adequate sample size for the Part 2 analysis.
Subjects enrolled in Part 2 will receive natalizumab 300 mg by IV infusion once every 
6 weeks (42 ± 7 days) for a period of 36 weeks and be randomized to an additional 48 weeks 
of crossover treatment comprising 24 weeks EID SC Q6W and 24 weeks EID IV Q6W. All 
MRI scans will be read at a central facility by blinded raters.
At the completion of their 48-week crossover treatment period, subjects in Part 2 will 
receive a final dose of natalizumab 300 mg by IV infusion at Week 156, proceed to the 12-
week follow-up, and receive a further safety follow-up by telephone 12 weeks later (i.e., 
24 weeks after the last dose of study treatment) before completing the study.
The design of this study, inclusive of Parts 1 and 2, is presented in Figure 1.






Amendment Summary for Protocol 101MS329, Version 3
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6
…
15
The screening MRI must be performed at least 2 weeks prior to the Baseline Visit to confirm eligibility. All 
postbaseline MRIs, with the exception of the one conducted at the Neurological Worsening and Relapse 
Assessment, are to be completed within a 7-day window of the dosing visit. MRIs conducted at the 
Neurological Worsening and Relapse Assessment must be completed prior to dosing with rescue therapy, but 
can be completed on the same day. If a subject's MRI is scheduled to occur <4 weeks after the last dose of 
steroid treatment for relapse, the MRI should be rescheduled so that it is performed either before the steroid 
treatment of between 4 and 8 weeks after the last dose of steroid treatment. MRI does not need to be 
performed at the ET Visit if the last MRI was performed within the previous 4 weeks. In the event of an 
early study termination for a pregnancy, a Gd-enhancing MRI should not be conducted.
In Section 5.2:

Introductory text was added to Section 5.2, Part 2 – Schedule of Activities.

Table 3: Part 2 Schedule of Activities – EID SC vs. IV OLE for Subjects Who 
Participated in Part 1 was added, with supporting footnotes.

Table 4: Part 2 Schedule of Activities – EID SC vs. IV OLE for New Subjects was 
added, with supporting footnotes.
Now reads:
5.2.
Part 2 – Schedule of Activities
For subjects who completed Part 1 treatment and enrolled in Part 2, the schedule of 
activities for Part 2 (Table 3) does not differ for subjects randomized to SC/IV or IV/SC 
with the exception of the order of treatment administration during the crossover period.
For new subjects enrolled in Part 2, the initial screening, inclusive of select assessments, 
differs from those subjects who participated in Part 1 but is otherwise the same beginning 
at Week 78 through the end of Part 2 (Table 4).


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7
Table 1:
Part 2 Schedule of Activities – EID SC vs. IV OLE for Subjects Who Participated in Part 1
Tests and assessments are listed in the recommended order. At each visit, assessments should be performed as follows:
 
 2) clinical and neurological assessments, 3) PK/PD 
 collection, and 4) dose administration. It is not 
required that all screening tests and assessments be completed during 1 visit.
Study Week
78
841
90
96
102
108
114
120
126
132
138
144
150
156
Follow-
Up EOS 
Visit
168
ET 
Visit2
Unscheduled Visit
(Neurological 
Worsening and 
Relapse 
Assessment)3
Follow-Up 
Safety 
Phone Call
1804
Study Day
546
(-2/
+5)
588
(-2/
+5)
630
(-2/
+5)
672
(-2/
+5)
714
(-2/
+5)
756
(-2/
+5)
798
(-2/
+5)
840
(-2/
+5)
882
(-2/
+5)
924
(-2/
+5)
966
(-2/
+5)
1008
(-2/
+5)
1050
(-2/
+5)
1092
(-2/
+5)
1176
(±10)
-
-
1260
(±10)
Informed 
Consent Form 
for Part 25
---- X ----
Eligibility 
Criteria Check 
for Part 25
---- X ----
Randomization
X
Vital signs6
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Physical 
Examination1
X
X
X
X
X
X
X
Body Weight1
X
X
X
X
C-SSRS1,7
X
TSQM
X
X
X
EDSS
X
X
X
X
X
X


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8
Study Week
78
841
90
96
102
108
114
120
126
132
138
144
150
156
Follow-
Up EOS 
Visit
168
ET 
Visit2
Unscheduled Visit
(Neurological 
Worsening and 
Relapse 
Assessment)3
Follow-Up 
Safety 
Phone Call
1804
Study Day
546
(-2/
+5)
588
(-2/
+5)
630
(-2/
+5)
672
(-2/
+5)
714
(-2/
+5)
756
(-2/
+5)
798
(-2/
+5)
840
(-2/
+5)
882
(-2/
+5)
924
(-2/
+5)
966
(-2/
+5)
1008
(-2/
+5)
1050
(-2/
+5)
1092
(-2/
+5)
1176
(±10)
-
-
1260
(±10)
Neurological 
Examination 
(MS Signs & 
Symptoms)
X
X
X
X
X
X
Blood 
Hematology8
X
X
X
X
X
X
X
Blood 
Chemistry9
X
X
X
X
Urine Pregnancy 
Test10
PD Assessments 
(whole blood)8
X
X
X
X
X
X
X
X
X
X
PK Natalizumab 
Concentration 
(serum)8
X
X
X
X
X
X
X
X
X
X
Anti-
natalizumab 
Antibodies8
X
X
X
X
X
X
Brain MRI11
X
X
X
X
Natalizumab 
EID IV infusion
X
X
X
X
X
X




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10
6
Vital signs collected at each of the specified timepoints include temperature, systolic and diastolic blood pressure, pulse rate, and respiratory rate. 
Vital signs collected as part of the subject's standard of care on the same day as a study visit do not need to be repeated for the study if Biogen has 
access to the information and data recorded in the subject's CRF. Vital signs on a study treatment day must be performed prior to the 
administration of study treatment.
7
The Part 1 "baseline/screening" C-SSRS must be completed at the Part 1 screening Visit; at all other visits, the "since last visit" C-SSRS must be 
used.
8
Sample to be collected prior to dosing.
9
If a subject experiences signs and symptoms suggestive of liver failure (such as jaundice, vomiting, anorexia, nausea, fatigue, and right upper 
abdominal discomfort), liver function tests (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, gamma-glutamyl 
transferase, bilirubin, and albumin) must be performed at the local laboratory on an expedited basis.
10 Follow-up testing for women of childbearing potential throughout the study will be done at the discretion of the Investigator or as required by local 
law. In each case of delayed menstruation (more than 1 month between menstrual periods), a urine pregnancy test should be performed.
11 All postbaseline MRIs are to be completed within a 7-day window of the dosing visit. If a subject's MRI is scheduled to occur < 4 weeks after the last 
dose of steroid treatment for relapse, the MRI should be rescheduled so it is performed either before the steroid treatment or between 4 and 8 weeks 
after the last dose of steroid treatment. MRI does not need to be performed at the ET Visit if the last MRI was performed within the previous 
4 weeks. In the event of an early termination for a pregnancy, a Gd-enhancing MRI should not be conducted.
12 The time required for drug preparation and drug administration should be recorded in detail for each occasion of treatment administration during 
the crossover period. Subjects must be observed for 1 hour after completion of the SC injection or IV infusion.
13 Subjects in Part 2 will receive a final dose of natalizumab 300 mg by SC injection or IV infusion at the Week 156 visit with the route of 
administration being the subject’s choice.
14 PPQ assessments at Week 138 and Week 150 must be collected after study treatment administration.


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11
Table 2:
Part 2 Schedule of Activities – EID SC vs. IV OLE for New Subjects
Tests and assessments are listed in the recommended order. At each visit, assessments should be performed as follows:
 
, 2) clinical and neurological assessments, 3) PK/PD 
 collection, and 4) dose administration. It is not 
required that all screening tests and assessments be completed during 1 visit. This Schedule of Activities is identical to the 
Schedule in Table 3 after the Week 84 visit.
Nominal
Study Week
Screen1
Baseline 
Visit
72
78
842
90
96
102
108
114
120
126
132
138
144
150
156
Follow-
Up EOS 
Visit
168
ET 
Visit3
Unscheduled 
Visit 
(Neurological 
Worsening 
and Relapse 
Assessment)4
Follow-
Up Safety 
Phone 
Call5
180
Nominal
Study Day
-41 to -
1
504
(-2/
+5)
546
(-2/
+5)
588
(-2/
+5)
630
(-2/
+5)
672
(-2/
+5)
714
(-2/
+5)
756
(-2/
+5)
798
(-2/
+5)
840
(-2/
+5)
882
(-2/
+5)
924
(-2/
+5)
966
(-2/
+5)
1008
(-2/
+5)
1050
(-2/
+5)
1092
(-2/
+5)
1176
(±10)
-
-
1260
(±10)
Informed
Consent Form 
for Part 21
X
Eligibility 
Criteria Check 
for Part 21
X
X
Randomization
X
Medical 
History1
X
Physical 
Examination1
X
X
X
X
X
X
X
X
X
Body Weight1
X
X
X
X
X
X
Vital signs6
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
HIV, Hep B, and 
Hep C Testing
X
TSQM
X
X
X
X
P
D


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12
Nominal
Study Week
Screen1
Baseline 
Visit
72
78
842
90
96
102
108
114
120
126
132
138
144
150
156
Follow-
Up EOS 
Visit
168
ET 
Visit3
Unscheduled 
Visit 
(Neurological 
Worsening 
and Relapse 
Assessment)4
Follow-
Up Safety 
Phone 
Call5
180
Nominal
Study Day
-41 to -
1
504
(-2/
+5)
546
(-2/
+5)
588
(-2/
+5)
630
(-2/
+5)
672
(-2/
+5)
714
(-2/
+5)
756
(-2/
+5)
798
(-2/
+5)
840
(-2/
+5)
882
(-2/
+5)
924
(-2/
+5)
966
(-2/
+5)
1008
(-2/
+5)
1050
(-2/
+5)
1092
(-2/
+5)
1176
(±10)
-
-
1260
(±10)
EDSS
X
X
X
X
X
X
X
Neurological 
Examination 
(MS Signs & 
Symptoms)
X
X
X
X
X
X
X
Blood 
Hematology7
X
X
X
X
X
X
X
X
Blood 
Chemistry8
X
X
X
X
X
Serum 
Pregnancy Test9
X
Serum FSH10
X
Urine Pregnancy 
Test11
X
PD Assessments 
(whole blood)7
X
X
X
X
X
X
X
X
X
X
X
PK Natalizumab 
Concentration 
(serum)7
X
X
X
X
X
X
X
X
X
X
X
Anti-
natalizumab 
Antibodies7
X
X
X
X
X
X
X


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13
Nominal
Study Week
Screen1
Baseline 
Visit
72
78
842
90
96
102
108
114
120
126
132
138
144
150
156
Follow-
Up EOS 
Visit
168
ET 
Visit3
Unscheduled 
Visit 
(Neurological 
Worsening 
and Relapse 
Assessment)4
Follow-
Up Safety 
Phone 
Call5
180
Nominal
Study Day
-41 to -
1
504
(-2/
+5)
546
(-2/
+5)
588
(-2/
+5)
630
(-2/
+5)
672
(-2/
+5)
714
(-2/
+5)
756
(-2/
+5)
798
(-2/
+5)
840
(-2/
+5)
882
(-2/
+5)
924
(-2/
+5)
966
(-2/
+5)
1008
(-2/
+5)
1050
(-2/
+5)
1092
(-2/
+5)
1176
(±10)
-
-
1260
(±10)
Brain MRI12
X
X
X
X
X
Natalizumab 
EID IV infusion
X
X
X
X
X
X
X
Natalizumab 
EID SC-IV 
Crossover13
X
X
X
X
X
X
X
X
X14
PPQ14
X
X
X
Safety (AEs, 
SAEs)
Record as per Section 15.3 of the protocol
Concomitant 
Therapy and 
Procedures
Record as per Section 11.5 of the protocol
X
Assessment of 
New 
Neurological 
Symptoms15
X
AE = adverse event; CRF = case report form; EDSS = Expanded Disability Status Scale; EID = extended interval dosing; EOS = end of study; 
 ET = early termination; FSH = follicle stimulating hormone; Gd = gadolinium; Hep = hepatitis; HIV = 
human immunodeficiency virus; IV=intravenous; MRI = magnetic resonance imaging; MS = multiple sclerosis; 
 
; OLE = open-label extension; PD = pharmacodynamic; PK = pharmacokinetic; PPQ = Patient Preference 
Questionnaire; SAE = serious adverse event; SC = subcutaneous; Sg = Screening; TSQM = Treatment Satisfaction Questionnaire for Medication.


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1
The Part 2 Screening, informed consent, and eligibility assessment for new subjects should be performed within 6 weeks of the Baseline Visit. 
Randomization to crossover study treatment should be done at the Week 108 visit to confirm crossover treatment allocation.
2
The Part 1 and Part 2 assessments at Week 84 are the same and should be performed only once.
3
If a subject chooses to withdraw from the study, an ET Visit should occur as soon as possible but no later than 4 weeks after the last dose of study 
treatment, to be followed by a final EOS Visit at 12 weeks (± 10 days) and the safety follow-up phone call at 24 weeks after the last dose of study 
treatment.
4
Subjects who suspect that they are experiencing new or worsening neurological symptoms, including possible relapse, need to phone the Investigator 
within 72 hours of the onset of symptoms. The subject is to be evaluated by the neurologist within 5 days of the onset of symptoms. Relapses should 
be documented in the relapse assessment form. The maximum number of samples eligible for collection and analysis are 2 (1 for each unscheduled 
visit).
5
Subjects should have a follow-up safety phone call 24 weeks after their last dose of study treatment.
6
Vital signs collected at each of the specified timepoints include temperature, systolic and diastolic blood pressure, pulse rate, and respiratory rate. 
Vital signs collected as part of the subject's standard of care on the same day as a study visit do not need to be repeated for the study if Biogen has 
access to the information and data recorded in the subject's CRF. Vital signs taken on a study treatment day must be performed prior to the 
administration of study treatment.
7
Sample to be collected prior to dosing.
8
If a subject experiences signs and symptoms suggestive of liver failure (such as jaundice, vomiting, anorexia, nausea, fatigue, and right upper 
abdominal discomfort), liver function tests (alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, bilirubin, and 
albumin) must be performed at the local laboratory on an expedited basis.
9
Required for women of childbearing potential. Results must be known prior to Baseline.
10 For postmenopausal subjects only.
11 Follow-up testing for women of childbearing potential throughout the study will be done at the discretion of the Investigator or as required by local 
law. In each case of delayed menstruation (more than 1 month between menstrual periods), a urine pregnancy test should be performed.
12 The screening MRI must be performed at least 2 weeks prior to the Baseline Visit to confirm eligibility. All postbaseline MRIs are to be completed 
within a 7-day window of the dosing visit. If a subject's MRI is scheduled to occur < 4 weeks after the last dose of steroid treatment for relapse, the 
MRI should be rescheduled so it is performed either before the steroid treatment or between 4 and 8 weeks after the last dose of steroid treatment. 
MRI does not need to be performed at the ET Visit if the last MRI was performed within the previous 4 weeks. In the event of an early termination 
for a pregnancy, a Gd-enhancing MRI should not be conducted.
13 The time required for drug preparation and drug administration should be recorded in detail for each occasion of treatment administration during 
the crossover period. Subjects must be observed for 1 hour after completion of the IV infusion or the SC injection.
14 Subjects in Part 2 will receive a final dose of natalizumab 300 mg by SC injection or IV infusion at the Week 156 visit with the route of 
administration being the subject’s choice.
15 PPQ assessments at Week 138 and Week 150 must be collected after study treatment administration.


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15
15 Subjects should be contacted by phone 24 weeks after the last dose of study treatment to discuss if there has been any new development of 
neurological symptoms. PML or new neurological symptoms indicative of PML (new or sudden change in thinking, vision, balance, or strength 
persisting over several days) must be immediately reported as a SAE.




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17
To evaluate the efficacy of SC versus IV 
routes of natalizumab administration.
All endpoints will be assessed between 
6 months of SC and 6 months IV in the 
randomized, crossover period.

Number of new or newly enlarging 
T2 hyperintense lesions

Time to first relapse

Annualized relapse rate

Change in EDSS score

Number of new Gd-enhancing lesions

Number of new T1 hypointense lesions

PBVC and change in cortical and 
thalamic brain region volume
To characterize PK and PD of SC versus 
IV routes of natalizumab administration.
All endpoints will be assessed between 
6 months of SC and 6 months IV in the 
randomized, crossover period.

Ctrough

Trough α4 integrin saturation


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Rationale: The objective of the OLE is to evaluate subject preference for, and satisfaction, with 
SC injection and IV infusion of natalizumab under EID, and to develop long-term efficacy and 
safety data with regard to natalizumab administration in general under the EID regimen.
This change also substantially affects Section 13, Efficacy, Pharmacokinetic, and 
Pharmacodynamic Assessments; and Section 16, Statistical Methods and Determination of 
Sample Size.
Section 7.1, Study Duration for Subjects
Change: Section 7 was revised to comprise Section 7.1.1, Study Duration for Subjects Enrolled 
Only in Part 1, and Section 7.1.2, Study Duration for Subjects Enrolled in Part 1 and Part 2. 
Now reads:
7.1.1. Study Duration for Subjects Enrolled Only in Part 1
The total duration of study participation in Part 1 for each subjects who do not participate in 
Part 2 will be up to 102 weeks;. tThis consists of comprises a screening period of up to 
6 weeks,; a treatment period of 72 weeks,; and a follow-up period of 12 weeks; and .  Aa
follow-up safety phone call will be performed 2412 weeks after the follow-up period 
(i.e., 24 weeks after the last dose of study treatment).
The end of study (EOS) date for a subject in Part 1 may be the last study visit, last the follow-up 
safety phone conversationcall, or last protocol-specified assessment,; or if the subject has 
ongoing AEs that are being followed up, then the date may be the date of AE resolution.
7.1.2
Study Duration for Subjects Enrolled in Part 1 and Part 2
The total duration of study participation in Part 1 for subjects who also participate in Part 
2 will be up to 78 weeks, comprising a screening period of up to 6 weeks and the 
randomized SID or EID treatment period of 72 weeks.


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The total duration of study participation in Part 2 for these subjects will be approximately 
108 weeks. This comprises EID IV treatment for 36 weeks; a randomized EID SC vs. IV 
crossover-treatment period of 48 weeks; a follow-up period of 12 weeks; and a follow-up 
safety phone call 12 weeks after the follow-up period (i.e., 24 weeks after the last dose of 
study treatment).  The total duration of study participation for subjects who participate in 
both Part 1 and Part 2 will be approximately 186 weeks.
The EOS date for subjects participating in Part 1 and Part 2 may be the last study visit, the 
follow-up safety phone call, or last protocol-specified assessment; if the subject has ongoing 
AEs that are being followed, then the date may be the date of AE resolution.
Rationale: Revision of this section was required to differentiate the duration of study for 
subjects who participate in Part 1 only, in both Part 1 and Part 2, as well as for new subjects who 
participate in Part 2 of the study without having participated in Part 1.
This change also substantially affects Section 7.3, Unscheduled Visits and Treatment for MS 
Relapses; Section 7.5, End of Study; Section 9, Screening and Randomization; Section 10, 
Discontinuation of Study Treatment and Withdrawal of Subjects from the Study; and Section 11, 
Study Treatment Use.


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SUMMARY OF MINOR CHANGES TO THE PROTOCOL
The following minor changes were made to the protocol, as appropriate:

The title, version number, and date were updated throughout the protocol.

Section 2, List of Abbreviations, was updated.

In Section 4.2, current therapies for multiple sclerosis were updated.

Typographical errors and formatting were corrected.


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21
LIST OF ABBREVIATIONS
AE
adverse event
CRF
case report form
C-SSRS
Columbia Suicide Severity Rating Scale
Ctrough
trough serum concentration of natalizumab
DNA
deoxyribonucleic acid
EDSS
Expanded Disability Status Scale
EID
extended interval dosing
EOS
end of study
ET
early termination
FSH
follicle stimulating hormone
Gd
gadolinium
Hep
hepatitis
HIV
human immunodeficiency virus
IV
intravenous(ly)
JCV
John Cunningham virus
MRI
magnetic resonance imaging
MS
multiple sclerosis
OLE
open-label extension
PBMC
peripheral blood mononuclear cell
PBVC
percentage of brain volume change
PD
pharmacodynamic(s)
PK
pharmacokinetic(s)
PML
progressive multifocal leukoencephalopathy
PPQ
Patient Preference Questionnaire
PRO
patient-reported outcome
Q4W
every 4 weeks
Q6W
every 6 weeks
RNA
ribonucleic acid
RRMS
relapsing-remitting multiple sclerosis
SAE
serious adverse event
D


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SC
subcutaneous
SID
standard interval dosing
TSQM
Treatment Satisfaction Questionnaire for Medication
USA
United States
VCAM-1
vascular cell adhesion molecule 1


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1
Biogen MA Inc.
225 Binney Street
Cambridge, MA  02142
United States
Biogen Idec Research Limited
Innovation House
70 Norden Road
Maidenhead Berkshire
SL6 4AY
United Kingdom
______________________________________________________________________
AMENDMENT SUMMARY
Biogen Protocol 101MS329
A Randomized, Controlled, Open-Label, Rater-Blinded, Phase 3b Study of the Efficacy, Safety, 
and Tolerability of 6-Week Extended Interval Dosing of Natalizumab (BG00002) in Subjects 
With Relapsing-Remitting Multiple Sclerosis Switching From Treatment With 4-Week 
Natalizumab Standard Interval Dosing (SID) in Relation to Continued SID Treatment
Version 2.0
Date: 28 February 2019
EUDRA CT Number: 2018-002145-11
Version 2.0 of the protocol has been prepared for this amendment, which supersedes Version 1.0.




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who have previously been treated with 
natalizumab SID for at least 12 months, in 
relation to continued SID treatment.
and Week 7248

Number of new gadolinium 
(Gd)-enhancing and new 
T1 hypointense lesions at Weeks 24, 
48, and 72
…
…
Rationale: The timing of the primary efficacy endpoint was changed to Week 72 to allow the 
collection of efficacy data over a 48-week period after stable trough concentrations have been 




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5
withdrawal will be summarized by treatment group.  Clinically relevant abnormalities for 
laboratory parameters will be identified by treatment group.
16.1.1.
Analysis Population
The modified intent-to-treat population, defined as all randomized subjects who receive at least 
1 dose of study treatment and have at least 1 postbaseline efficacy assessment, will be used for 
all efficacy analyses.  Subjects will be analyzed in the groups to which they are randomized.
16.1.2.
Methods of Analysis
16.1.2.1.
Analysis of the Primary Endpoint
The primary endpoint, the number of new or newly enlarging T2 hyperintense lesions at 
Week 4872, will be analyzed using negative binomial regression models with treatment as the 
classification variable and baseline body weight (≤90 80 kg versus >90 80 kg), EDSS,duration 
of natalizumab exposure at baseline (≤3 years versus > 3 years), and region (North America 
[includes USA and Canada], United Kingdom, Europe and Israel [includes Belgium, 
France, Germany, Israel, Italy, Netherlands, and Spain], and Australia) as covariates.  The 
ratio of mean lesion numbers of EID versus SID (EID/SID) will be derived from the model with 
a 95% CI and associated p-value.  The treatment will be considered different if the p value 
(2 sided) is less than 0.05.  Thelower limit of the 95% CI is above 1.  As a secondary 
inference, the possibility of a 2-fold increase in the mean lesion number in the EID group as 
compared with the SID group will be considered ruled out if the upper limit of 95% CI is lessno 
greater than 2.  The proportion of subjects with no new or newly enlarging T2 hyperintense 
lesions will be analyzed using logistic regression models with the same covariates as those 
described above.
For subjects who withdraw or receive rescue SID natalizumab prior to Week 48, the Week 48 
number of lesions may be imputed using the MMRM.
16.1.2.2.
Primary and Secondary Estimands and Handling of Intercurrent Events
The study plans to make every effort to retain subjects in the study and to continue 
follow-up in the cases of the initiation of rescue medication, switching to different dosing 
frequency, and treatment discontinuation due to AEs, lack of efficacy, or for other reasons.  
This will allow continuing assessments of subjects’ MS disease activity.  Efforts will also be 
made to obtain details of withdrawals in the generic categories of “lost to follow-up” or 
“other” whenever possible.  Classification of the withdrawals in these nonspecific 
categories into “possibly efficacy related”, “possibly safety related”, or “no information” 
will be made based on all available information by independent Sponsor personnel who are 
blinded to treatment regimen and will be documented prior to database lock. 
The proposed primary estimand will be based on a treatment policy strategy, in which the 
study is intended to estimate the difference of a potential treatment decision of switching 
subjects from SID to EID compared with keeping subjects on SID over the next 72 weeks in 


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a realistic clinical setting, where switching to a different dosing regimen or different 
medication may occur depending on disease activity.  Therefore, the primary analysis will 
utilize all measurements regardless of whether subjects remain on randomized treatment.  
For subjects who withdraw from the study for reasons related to efficacy or an AE or who 
have a “possibly related” withdrawal, as described above, the missing values will be 
imputed by the worst observed value of the subjects on study treatment at the given 
timepoint.  For withdrawals classified as “no information”, the missing values will be 
treated as missing at random and will be addressed using multiple imputation.  The 
number and proportion of subjects with intercurrent events and the time to intercurrent 
event will also be tabulated and compared between randomized groups.  Sensitivity 
analysis may be conducted using tipping point analysis.  Supplementary analyses by 
imputing all missing values by treating all as missing at random using multiple imputation 
will also be conducted. 
The secondary estimand will be based on a hypothetical strategy, in which the difference in 
the efficacy of EID versus SID over the 72 weeks following randomization if no 
intercurrent events occurred will be the target of estimation.  The primary analysis for this 
estimand will treat the data obtained post-intercurrent event as missing values.  For 
treatment discontinuation or switching due to efficacy as well as withdrawal that is due to 
efficacy or is “possibly efficacy related”, the missing values will be imputed by the worst 
observed values of the subjects on study treatment at the given timepoint.  For intercurrent 
events due to other reasons, the resulting missing values will be addressed using multiple 
imputation.  Sensitivity analysis may be conducted using tipping point analysis.
16.1.2.216.1.2.3.
Analysis of the Secondary Endpoints
…
Annualized Relapse Rate
The annualized relapse rate at Week 48 and Week 72 will be analyzed at each timepoint using 
negative binomial regression models with treatment as the classification variable and baseline 
body weight (≤90 80 kg versus >90 80 kg), EDSS,duration of natalizumab exposure at 
baseline (≤3 years versus > 3 years), and region (North America [includes USA and 
Canada], United Kingdom, Europe and Israel [includes Belgium, France, Germany, Israel, 
Italy, Netherlands, and Spain], and Australia) as covariates.  The ratio of mean lesion 
numbers of EID versus SID (EID/SID) will be derived from the model with a 95% CI and 
associated p-value.
EDSS Worsening
Confirmed EDSS worsening is defined as an increase of at least 1.0 point from a baseline 
EDSS score ≥ 1.0 or an increase of at least 1.5 points from a baseline EDSS score of 0 that is 
confirmed after at least 24 weeks.  Time to EDSS worsening will be analyzed using KM 
estimates and Cox regression models similar to the method described above for time to first 
relapse.




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…
16.7.
Interim Analyses
An interim futility analysis, based on the number of new or newly enlarging T2 hyperintense 
lesions at 24 weeks, will be conducted when 50% of subjects have at least 6 months of 
randomized treatment.  The interim futility analysis is designed to ensure that if clinically 
meaningful loss of efficacy is occurring in the EID group, the study can be stopped early to 
prevent unnecessary risk to the study participants of uncontrolled MS disease activity as a result 
of potential efficacy failure on EIDThe interim data will be analyzed using negative binomial 
regression models with treatment as the classification variable and baseline body weight 
(≤80 kg versus > 80 kg), duration of natalizumab exposure at baseline (≤3 years versus 
> 3 years), and region (North America [includes USA and Canada], United Kingdom, 
Europe and Israel [includes Belgium, France, Germany, Israel, Italy, Netherlands, and 
Spain], and Australia) as covariates.  The ratio of mean lesion numbers of EID versus SID 
(EID/SID) will be derived from the model with a 95% CI.  The study may be stopped for 
futility if the lower limit of the 95% CI is > 2 and a 2-fold increase in mean lesion numbers 
in the EID group can be concluded with 97.5% confidence.
16.8.
Sample Size Considerations
To detect an increase in the mean number of new or newly enlarging T2 hyperintense lesions 
over 48 weeks at the alpha level of 0.05 (2 sided), a sample size of 400 subjects (200 subjects per 
arm) will provide the following:

>80% power to detect an increase from a mean of 0.3 (expected efficacy of 
SID dosing arm in this population) to 0.5.

≥90% power to detect an increase from a mean of 0.3 to 0.6.
Historical data on MS treatments, including meta analyses on the relationship between new or 
newly enlarging T2 hyperintense lesions and relapses, suggest little or no clinical relevance of a 
difference smaller than 0.2 in mean new or newly enlarging T2 hyperintense lesions over 
48 weeks.Historical data on MS treatments, including a meta-analysis on the relationship 
between new or newly enlarging T2 lesions and relapses, suggest little or no clinical 
relevance of a difference of 0.2 to 0.3 in mean lesion numbers over 72 weeks [Sormani and 
Bruzzi 2013].  With the planned sample size of N = 200/group, the precision of the 
estimated mean lesion numbers is sufficient to allow > 80% probability to observe the 
lower limit of the 95% CI for the ratio of EID to SID in the estimated mean lesion number 
above 1 if the true mean is 0.5 and 0.3 in the EID and SID group, respectively.  If the true 
mean is 0.6 and 0.3 in the EID and SID group, respectively, the probability will be 
approximately 90%.  In the other direction, the sample size provides a precision that allows 
approximately 90% probability to observe the upper limit of the 95% CI to be ≤2 if the 
true mean lesion numbers in both groups are 0.3.  Approximately 480 subjects will be 
enrolled to account for a drop-out rate of approximately 17%.


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Rationale: The text describing the overview of statistical analysis for efficacy in Section 16.1 
was revised per regulatory advice, and detailed rationales for each section are provided below. 
The timing of the primary efficacy endpoint was changed to Week 72 to allow the collection of 
efficacy data over a 48-week period after stable trough concentrations have been reached. 
Stratification on the factor “country/region” was clarified per EMA request because it was not 
clear whether stratification would be based on regions, countries, or a mixture of the two. A 
lower cutoff for body weight (i.e., 80 kg) was used because at weight > 80 kg, a decrease in 
efficacy was suggested based on the PK/PD modelling data and per EMA request. Duration of 
natalizumab exposure was added as a covariate in place of EDSS per EMA request and guidance 
that any factor utilized in randomization stratification should also be utilized as a model 
covariate.  Detailed inference criteria for the primary analysis were edited to avoid the potential 
misinterpretation that the study was designed to test the superiority of EID over SID and to better 
reflect the study goal of estimating the difference between SID and EID, with high precision and 
a narrow 95% confidence interval (CI), to support the treatment decision based on individualized 
benefit/risk assessments, as discussed and agreed upon with the EMA.
The analysis plan was revised to include primary and secondary estimands based on International 
Council for Harmonisation E9 (R1) Draft Addendum on estimands 
EMA/CHMP/ICH/436221/2017 and per request from the EMA that these statistical details be 
included in the protocol rather than only in the study statistical analysis plan.
With the primary endpoint changed to Week 72, the corresponding secondary endpoint timing 
was changed to Week 48 and there will no longer be an efficacy analysis performed at Week 48;
.  EDSS 
worsening was further defined, consistent with the reprioritization of EDSS worsening as a 
secondary endpoint. 
Time to EDSS worsening was prioritized as a secondary endpoint;
 
Subgroup analyses are useful for assessing heterogeneity and might further stress or refute the 
need for individualized benefit/risk assessments. The EMA requested that information on 
prespecified subgroup analyses be included in the protocol rather than only in the statistical 
analysis plan.
Interim analysis text was updated to clarify that the study may be stopped for a degree of inferior 
efficacy that would discourage the use of EID in all settings. Consultation with leading 
neurologists treating MS led to an empirical consensus view that a change from 0.3 with SID to 
0.6 (a 2-fold increase) with EID at a population level would represent an unacceptable disease 
activity for considering EID as a reasonable PML risk mitigation strategy. The EMA requested 
that details of the analysis planned for assessment of futility be included in the protocol rather 
than only in the statistical analysis plan.
Sample size considerations were revised to avoid the potential misinterpretation that the study 
was designed to test superiority of EID over SID and to better reflect the study goal of estimating 


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the difference between SID and EID, with high precision and a narrow 95% CI, to support the 
treatment decision based on individualized benefit/risk assessments, as discussed and agreed 
upon with the EMA. Text was added to address the sample size appropriateness for both the 
primary and secondary analyses discussed with the EMA, i.e., to check if there is a difference 
between EID and SID and to exclude the worsening of efficacy with EID at a level that would 
discourage the use of EID in most clinical settings.


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SUMMARY OF MAJOR CHANGES TO THE PROTOCOL
Changes to the protocol are presented chronologically. New text is shown in bold type; deleted 
text is shown with a strikethrough.
Section 1, Synopsis
The Synopsis was revised to reflect changes made throughout the protocol.
Section 5, Schedule of Activities
Change: The screening period was extended to Days -42 to -1, and a new footnote (Footnote 1) 
was added to clarify the screening timing. 
Week 84 EDSS and neurological examination assessments as well as Week 60 assessments for 
anti-natalizumab antibodies were added.
Footnote 9 of Table 1 was added to include language on liver function testing in the event of a 
subject experiencing signs and symptoms suggestive of liver injury.
Footnote 12 of Table 1 was updated to include language on delayed menstrual period and 
pregnancy testing. 


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Now reads:
Table 1:
Schedule of Activities – SID
Study Week
Screening 
Visit
41
-6 to -1
Baseline 
Visit
0
4
8
12
16
20
24
28
32
36
40
44
48
52
56
60
64
68
72 Follow 
Up 
EOS 
Visit
84
Follow 
Up 
Safety 
Phone 
Call12
96 
ET 
Visit23 Unscheduled 
Visit 
(Neurological 
Worsening 
and Relapse 
Assessment)34
Study Day
-2842 to -1
1
28
(-2/
+5)
56
(-2/
+5)
84
(-2/
+5)
112
(-2/
+5)
140
(-2/
+5)
168
(-2/
+5)
196
(-2/
+5)
224
(-2/
+5)
252
(-2/
+5)
280
(-2/
+5)
308
(-2/
+5)
336
(-2/
+5)
364
(-2/
+5)
392
(-2/
+5)
420
(-2/
+5)
448
(-2/
+5)
476
(-2/
+5)
504
(-2/
+5)
588
(±10)
672
(±10)
Informed Consent 
Form
X
Eligibility Criteria 
Check
X
X
Randomization
X
Medical History
X
Physical 
Examination
X
X45
X
X
X
X
X
X
Body Weight
X
X45
X
X
X
X
X
X
Vital Signs56
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
HIV, Hep B, and 
Hep C Testing
X


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Study Week
Screening 
Visit
41
-6 to -1
Baseline 
Visit
0
4
8
12
16
20
24
28
32
36
40
44
48
52
56
60
64
68
72 Follow 
Up 
EOS 
Visit
84
Follow 
Up 
Safety 
Phone 
Call12
96 
ET 
Visit23 Unscheduled 
Visit 
(Neurological 
Worsening 
and Relapse 
Assessment)34
Study Day
-2842 to -1
1
28
(-2/
+5)
56
(-2/
+5)
84
(-2/
+5)
112
(-2/
+5)
140
(-2/
+5)
168
(-2/
+5)
196
(-2/
+5)
224
(-2/
+5)
252
(-2/
+5)
280
(-2/
+5)
308
(-2/
+5)
336
(-2/
+5)
364
(-2/
+5)
392
(-2/
+5)
420
(-2/
+5)
448
(-2/
+5)
476
(-2/
+5)
504
(-2/
+5)
588
(±10)
672
(±10)
C-SSRS67
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
EDSS
X
X
X
X
X
X
X
Neurological 
Examination
X
X
X
X
X
X
X
Blood 
Hematology78
X
X
X
X
X
X
Blood Chemistry9
X
X
X
Serum Pregnancy 
Test810
X
Serum FSH911
X
Urine Pregnancy 
Test1012
X






Protocol 101MS329, Version 2.0
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16
89If a subject experiences signs and symptoms suggestive of liver injury (such as jaundice, vomiting, anorexia, nausea, fatigue, and right upper 
abdominal discomfort), liver function tests (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, gamma-glutamyl 
transferase, bilirubin, and albumin) must be performed at the local laboratory on an expedited basis.
10Required for women of childbearing potential.  Results must be known prior to Day 1/Baseline.
911
For postmenopausal subjects only.
1012
Required for women of childbearing potential.  Follow-up testing throughout the study will be done at the discretion of the Investigator or as required by 
local law. In each case of delayed menstrual period (over 1 month between menstruations), a urine pregnancy test should be performed.
1214
The screening MRI must be performed at least 2 weeks prior to the Baseline Visit to confirm eligibility.  All postbaseline MRIs, with the exception of 
the one conducted at the Neurological Worsening and Relapse Assessment, are to be completed within a 7-day window of the dosing visit.  MRIs conducted at 
the Neurological Worsening and Relapse Assessment must be completed prior to dosing with rescue therapy, but can be completed on the same day.  If a 
subject’s MRI is scheduled to occur less than< 4 weeks after the last dose of steroid treatment for relapse, the MRI should be rescheduled so it is performed 
either before the steroid treatment or between 4 and 8 weeks after the last dose of steroid treatment.
1315
Subjects must be observed for 1 hour after completion of infusion.
1416
Subjects should be contacted by phone 24 weeks after the last dose of study treatment to discuss if there has been any new development of any new 
neurological symptoms.  PML or new neurological symptoms indicative of PML (e.g., new or sudden change in thinking, vision, balance, or strength persisting 
over several days) must be immediately reported as an SAE.
P


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17
Rationale: The screening period was extended to Days -42 to -1 to improve logistics for sites in 
the collection of informed consents. 
EDSS and neurological examination assessments were added at Week 84 to confirm the 
Week 72 secondary endpoint. Anti-natalizumab antibodies assessment at Week 60 was added to 
make the schedule consistent with the existing text in the protocol and the ICF. 
Footnote 9 of Table 1 was added to include information on the monitoring of liver function to 
make the global protocol consistent with the local protocol amendment required in France.
Footnote 12 of Table 1 was updated to include pregnancy testing consistent with Heads of 
Medicines Agencies Clinical Trial Facilitation Group guidance and to make the global protocol 
consistent with the local protocol amendment required in the UK. 
This change also affects Table 2, Schedule of Activities – EID, Figure 1, Study Design, and 
Section 7.1, Study Duration for Subjects.
Section 7, Study Design
Change: Text was updated to clarify stratification on the factor “country/region” and to use a 
lower cut-off for body weight. 
Now reads: Randomization will be stratified by country/region (North America [includes 
USA and Canada], United Kingdom, Europe and Israel [includes Belgium, France, 
Germany, Israel, Italy, Netherlands, and Spain], and Australia), body weight (≤90 80 kg 
versus >90 80 kg), and duration of natalizumab exposure (≤3 years versus > 3 years).  Subjects 
will receive open-label natalizumab at their assigned frequency throughout the 72 weeks of the 
study.
Rationale: Clarified stratification on the factor “country/region” because it was not clear 
whether stratification would be based on regions, countries, or a mixture of the two. A lower 
cut-off for body weight (i.e., 80 kg) was used because at weight > 80 kg, a decrease in efficacy 
was suggested based on the PK/PD modelling data and per the request of the EMA. 
This change also affects Section 9.2, Randomization, Section 16.1.2.1, Analysis of the Primary 
Endpoint, and Section 16.1.2.3, Analysis of the Secondary Endpoints.
Section 11.6, Continuation of Treatment
Change: Text related to continuation of treatment after 72-week randomized treatment period 
was clarified. 
Now reads: There is no provision to provide study treatment after the study.  Natalizumab is 
available commercially and subjects/Investigators can continue Tysabri treatment via a 
commercial source.  Once subjects have completed the randomized 72-week treatment 




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19
Now reads: Expectedness of all AEs will be determined by Biogen according to the local label
natalizumab Investigator’s Brochure.
Rationale: This change was made for consistency in using the reference safety information 
contained in the Investigator’s Brochure to determine the expectedness of all adverse events.
Section 15.4.2, Pregnancy
Change: Text related to reporting of pregnancy events was updated. 
Now reads: The Investigator must report a pregnancy occurring in a female subject between 
the first dose of study treatment and 3 months after the last dose of study treatment by 
faxing the appropriate form to Biogen within 24 hours of the study site staff becoming aware of 
the pregnancy.  Refer to the Study Reference Guide’s Official Study Contact List for complete 
contact information.  The Investigator or study site staff must report the outcome of the 
pregnancy to Biogen.  A pregnancy is not considered an AE and should not be recorded in the 
AE CRF.
Rationale: Text was revised to specify the pregnancy events collection period. 
Section 15.5, Contraception Requirements
Change: Text related to contraception for males and the donation of eggs/sperm for all subjects 
was removed.
Now reads: All women of childbearing potential and all men must ensure that highly effective 
contraception is used during the study and for at least 3 months after their last dose of study 
treatment.  In addition, subjects should not donate sperm or eggs for the duration of the study and 
for at least 3 months after their last dose of study treatment.
For the purposes of this study, women who do not meet one of the following criteria are 
considered to be physiologically capable of becoming pregnant and are, therefore, defined as 
women of childbearing potential:

Postmenopausal
o
12 continuous months of natural (spontaneous) amenorrhea without an alternative 
medical cause 
o
6 weeks after surgical bilateral oophorectomy with or without hysterectomy

Posthysterectomy

Female surgical sterilization (e.g., bilateral tubal ligation)
For the purposes of the study, highly effective contraception is defined as contraception that 
achieves a failure rate of less than< 1% when used consistently and correctly, and includes the 
following:


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For females:

Established use of oral, intravaginal, or transdermal combined (estrogen and progestogen 
containing) hormonal methods of contraception associated with the inhibition of 
ovulation.

Established use of oral, injected, or implanted progestogen-only hormonal methods of 
contraception associated with the inhibition of ovulation.

Placement of an intrauterine device or intrauterine hormone-releasing system.

Bilateral tubal occlusion.
For males:

Vasectomy with negative semen analysis at follow up.

Sex with a woman who uses the methods described for females if she is of childbearing 
potential.
True abstinence, when this is consistent with the preferred and usual lifestyle of the subject, can 
be considered an acceptable method of contraception based on the evaluation of the Investigator 
who should also take into consideration the duration of the clinical study.  Periodic abstinence 
(e.g., calendar, ovulation, symptothermal, postovulation methods) and withdrawal are not 
considered acceptable methods of contraception.
Pregnancy reporting is described in Section 15.4.2.
Rationale:  The deletions make this section consistent with the inclusion/exclusion criteria.


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21
SUMMARY OF MINOR CHANGES TO THE PROTOCOL
The following minor changes were made to the protocol, as appropriate:

The version number and date were updated throughout the protocol.

Typographical errors and formatting were corrected. 

SAP_001.pdf: 
COVER PAGE 
Official Title: 
A Randomized, Controlled, Open-Label, Rater-Blinded, Phase 3b 
Study of the Efficacy, Safety, and Tolerability of 6-Week Extended 
Interval Dosing (EID) of Natalizumab (BG00002) in Subjects With 
Relapsing-Remitting Multiple Sclerosis Switching From Treatment 
With 4-Week Natalizumab Standard Interval Dosing (SID) in Relation 
to Continued SID Treatment - Followed by an Open-Label Crossover 
Extension Study Comprising Subcutaneous and Intravenous 
Natalizumab Administration 
NCT Number: 
NCT03689972 
Document Date: 
SAP Part 1 version 2.0: 05 May 2021 
 SAP Part 2 version 2.0: 30 Aug 2023 
 
 


 
 
 
Page 1 of 47 
Statistical Analysis Plan
Version No.:  Final Version 2 
 Study Title: A Randomized, Controlled, Open-Label, Rater-Blinded, Phase 3b Study of the Efficacy, 
Safety, and Tolerability of 6-Week Extended Interval Dosing of Natalizumab (BG00002) in Subjects 
With Relapsing-Remitting Multiple Sclerosis Switching From Treatment With 4-Week Natalizumab 
Standard Interval Dosing (SID) in Relation to Continued SID Treatment 
Name of Study Treatment: Natalizumab (BG00002) 
Protocol No.: 101MS329 
Study Phase: Phase 3b 
Confidential Information 
The information contained in this Statistical Analysis Plan (SAP) is confidential and may not be 
reproduced or otherwise disseminated without the approval of Biogen, Inc.  
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1 
VERSION HISTORY 
 
SAP Version 
Date 
Primary Reasons for 
Amendment 
Final version 1.0 
06-Jun-2019 
Finalized version 1 
Final version 2.0 
04-May-2021 
Finalized version 2. To add 
amendment to include 
additional analyses to 
evaluate impact of COVID-
19, and to clarify/amend 
some planned analyses, such 
as the definition of per-
protocol (PP) population.  
 
 
 
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Table of Contents 
1 
VERSION HISTORY ..........................................................................................................3 
LIST OF ABBREVIATIONS ..........................................................................................................6 
2 
DESCRIPTION OF OBJECTIVES AND ENDPOINTS ....................................................7 
2.1 
Primary Objective and Endpoint ..............................................................................7 
2.2 
Secondary Objectives and Endpoints .......................................................................7 
 
 
 
 
 
 
3 
STUDY DESIGN.................................................................................................................9 
3.1 
Study Overview ...........................................................................................................9 
3.2 
Schedule of Events ....................................................................................................10 
4 
SAMPLE SIZE JUSTIFICATION ....................................................................................10 
5 
STATISTICAL ANALYSIS METHODS .........................................................................11 
5.1 
General Considerations ............................................................................................11 
5.2 
Treatment Period Definitions ..................................................................................11 
5.3 
Analysis Population ..................................................................................................12 
5.4 
Background Characteristics ....................................................................................13 
5.4.1 Accounting of Subject ......................................................................................................13 
5.4.2 Demographics and Baseline Characteristics .................................................................13 
5.4.3 Concomitant Medications and Non-Drug Therapies....................................................14 
5.4.4 Protocol Deviations ..........................................................................................................15 
5.4.5 Study Drug Exposure and Study Drug Compliance .....................................................15 
5.5 
Efficacy Analysis .......................................................................................................16 
5.5.1 Primary Efficacy Endpoint .............................................................................................16 
5.5.2 Secondary Efficacy Endpoint..........................................................................................20 
5.5.3 Subgroup Analysis ...........................................................................................................22 
 
 
5.6 
Safety Analysis ..........................................................................................................29 
5.6.1 Clinical Adverse Events ...................................................................................................29 
5.6.2 Clinical Laboratory Data ................................................................................................31 
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5.6.3 Quantitative laboratory analysis ....................................................................................31 
5.6.4 Qualitative laboratory analysis .......................................................................................31 
5.6.5 Vital Sign Measurements ................................................................................................34 
5.6.6 Physical and Neurological Examination ........................................................................35 
5.6.7 Columbia Suicide Severity Rating Scale (C-SSRS) ......................................................35 
 
 
 
 
 
 
 
 
 
 
 
 
6 
INTERIM ANALYSIS ......................................................................................................38 
7 
CHANGES FROM PROTOCOL-SPECIFIED ANALYSES ...........................................38 
7.1 
COVID-19 Related Analyses ...................................................................................38 
8 
SUMMARY OF CHANGES FROM THE PREVIOUS VERSION OF THE SAP ..........39 
8.1 
Changes in Planned Analysis Methods ...................................................................39 
8.2 
COVID-19 Related Analyses ...................................................................................39 
9 
APPENDIX I: PSEUDO SAS CODE FOR MULTIPLE IMPUATION ..........................40 
10 
APPENDIX II: VISIT WINDOW MAPPING ..................................................................40 
 
 
 
 
 
 
12 
APPENDIX IV: COLUMBIA SUICIDE SEVERITY RATING SCALE (C-SSRS) .......46 
13 
REFERENCE .....................................................................................................................47 
 
 
 
 
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LIST OF ABBREVIATIONS 
 
 
AE 
adverse event 
 
 
CI 
confidence interval 
CNS 
central nervous system 
CRF 
case report form 
C-SSRS 
Columbia Suicide Severity Rating Scale 
EDSS 
Expanded Disability Status Scale 
EID 
extended interval dosing 
EOS 
end of study 
 
 
Gd 
gadolinium 
ICF 
informed consent form 
INEC 
Independent Neurology Evaluation Committee 
IRT 
interactive response technology 
IV 
intravenous(ly) 
 
 
KM 
Kaplan-Meier 
MMRM 
mixed model of repeated measures 
MRI 
magnetic resonance imaging 
MS 
multiple sclerosis 
 
 
 
 
PBMC 
peripheral blood mononuclear cell 
 
 
 
 
 
 
PML 
progressive multifocal leukoencephalopathy 
 
 
RNA 
ribonucleic acid 
RRMS 
relapsing-remitting multiple sclerosis 
SAE 
serious adverse event 
 
 
SID 
standard interval dosing 
 
 
 
 
US 
United States 
SDV 
Source data verification 
 
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2 
DESCRIPTION OF OBJECTIVES AND ENDPOINTS 
2.1 
Primary Objective and Endpoint 
The primary objective of this study is to evaluate the efficacy of natalizumab EID in subjects who have 
previously been treated with natalizumab SID for at least 12 months, in relation to continued SID 
treatment, with the goal of estimating the difference between SID and EID, with high precision and a 
narrow 95% confidence interval (CI), to support the treatment decision based on individualized 
benefit/risk assessments. 
The primary endpoint that relates to this objective is the number of new or newly enlarging 
T2 hyperintense lesions at Week 72. 
2.2 
Secondary Objectives and Endpoints 
The secondary objectives of this study are: 
• 
To evaluate additional relapse-based clinical efficacy measures of natalizumab EID in subjects 
who have previously been treated with natalizumab SID for at least 12 months, in relation to 
continued SID treatment. 
• 
To evaluate disability worsening of natalizumab EID in subjects who have previously been 
treated with natalizumab SID for at least 12 months, in relation to continued SID treatment. 
• 
To evaluate additional MRI-lesion efficacy measures of natalizumab EID in subjects who have 
previously been treated with natalizumab SID for at least 12 months, in relation to continued 
SID treatment. 
• 
To evaluate the safety of natalizumab EID in subjects who have previously been treated with 
natalizumab SID for at least 12 months in relation to continued SID treatment. 
The secondary endpoints are: 
• 
Time to first relapse (relapses will be adjudicated by an Independent Neurology Evaluation 
Committee [INEC])  
• 
Annualized relapse rate at Week 72 
• 
Time to Expanded Disability Status Scale (EDSS) worsening (confirmed after at least 24 weeks) 
• 
Number of new or newly enlarging T2 hyperintense lesions at Week 24 and Week 48 
• 
Number of new gadolinium (Gd)-enhancing and new T1 hypointense lesions at Weeks 24, 48, 
and 72 
• 
Safety assessments of AEs and serious adverse events (SAEs) 
 
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3 
STUDY DESIGN 
3.1 
Study Overview 
This is a prospective, randomized, interventional, controlled, open-label, rater-blinded, Phase 3b study 
in subjects with RRMS who have been receiving natalizumab SID for at least 12 months without relapses 
in the last 12 months. All MRI scans will be read at a central facility with raters blinded to subject 
assignment. Approximately 480 subjects are expected to be enrolled at approximately 100 sites in North 
America, Europe, and Australia. Subjects will be randomly assigned to continue to receive natalizumab in 
1 of the following 2 arms: 
• 
SID:  approximately 240 subjects will receive natalizumab as a 300 mg IV infusion every 
4 weeks (28 -2/+5 days). 
• 
EID:  approximately 240 subjects will receive natalizumab as a 300 mg IV infusion every 
6 weeks (42 -2/+5 days).  
Randomization will be stratified by country/region (North America [includes USA and Canada], United 
Kingdom, Europe and Israel [includes Belgium, France, Germany, Israel, Italy, Netherlands, and Spain], 
and Australia), body weight (≤ 80 kg versus > 80 kg), and duration of natalizumab exposure (≤ 3 years 
versus > 3 years). Subjects will receive open-label natalizumab at their assigned frequency throughout 
the 72 weeks of the study. 
See Figure 1 for a schematic of the study design. 
The total duration of study participation for each subject will be up to 102 weeks; this consists of a 
screening period of up to 6 weeks, a treatment period of 72 weeks, and follow-up period of 12 weeks. A 
follow-up safety phone call will be performed 24 weeks after the last dose of study treatment. 
The end of study (EOS) date for a subject may be the last study visit, last follow-up phone conversation, 
or last protocol-specified assessment, or if the subject has ongoing AEs that are being followed up, then 
the date may be the date of AE resolution. 
 
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Figure 1: 
Study Design 
 
 
3.2 
Schedule of Events  
• 
See Protocol Section 5. 
• 
Start date of COVID-19 phase 
COVID-19 phase refers to the time period during which conduct of this study is impacted by COVID-
19 infection or COVID-19 pandemic measures. The start date of the COVID-19 phase for this study is 
02 March, 2020. 
• 
COVID-19 pandemic measures  
Refer to any action or challenges arising due to COVID-19 that may impact study conduct, including 
quarantines, site closures, travel limitation, interruptions to the supply chain for the investigational 
product, or other considerations if site personnel become infected with COVID-19. 
4 
SAMPLE SIZE JUSTIFICATION 
Historical data on MS treatments, including a meta-analysis on the relationship between new or newly 
enlarging T2 lesions and relapses, suggest little or no clinical relevance of a difference of 0.2 to 0.3 in 
mean lesion numbers over 72 weeks [Sormani and Bruzzi 2013]. With the planned sample size of 
N = 200/group, the precision of the estimated mean lesion numbers is sufficient to allow > 80% 
probability to observe the lower limit of the 95% CI for the ratio of EID to SID in the estimated mean 
lesion number above 1 if the true mean is 0.5 and 0.3 in the EID and SID group, respectively. If the true 
mean is 0.6 and 0.3 in the EID and SID group, respectively, the probability will be approximately 90%. In 
the other direction, the sample size provides a precision that allows approximately 90% probability to 
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observe the upper limit of the 95% CI to be ≤ 2 if the true mean lesion numbers in both groups are 0.3. 
Approximately 480 subjects will be enrolled to account for a drop-out rate of approximately 17%. 
5 
STATISTICAL ANALYSIS METHODS 
5.1 
General Considerations 
Summary tables will be presented using descriptive summary statistics. For continuous variables, 
summary statistics will generally include: number of subjects with data, mean, standard deviation, 
median, 25% percentile, 75% percentile, minimum and maximum. For categorical variables, this will 
generally include: number of subjects randomized or dosed, number with data, and the percent of those 
with data in each category. 
Country/region will be categorized as following in the analysis, including the demographics, the 
covariate in statistical models and subgroup analysis: 
• 
North America (includes USA and Canada) 
• 
United Kingdom  
• 
Europe and Israel (includes Belgium, France, Germany, Israel, Italy, Netherlands, and Spain) 
• 
Australia 
Unless otherwise specified, baseline value is defined as the most recent non-missing measurement 
collected prior to the first randomized treatment infusion. Change from baseline will be defined as post-
baseline value minus baseline value.  
In the analysis using negative binomial regression model, if the data are underdispersed, or if the 
negative binomial regression model does not converge, a Poisson regression model with the same 
covariates will be used instead of the negative binomial regression model.  Dispersion will be evaluated 
from the Pearson Chi-Square statistic.  If the ratio of the Pearson Chi-Square statistic to the degrees of 
freedom is ≤ 1 which indicates no overdispersion, then a Poisson regression model with adjustment for 
underdispersion will be used. 
Unless stated otherwise, all statistical tests will be 2-sided with statistical significance level of 0.05.  
The statistical software, SAS® will be used for all summaries and analyses. 
5.2 
Treatment Period Definitions 
Treatment period: treatment period is defined as from the date of the first study infusion to the 
date of the last study infusion (Week 72) or the date of ET visit.  
Study period: Study period is defined as from the date of the first study infusion to a subject’s last 
study visit, last follow-up phone conversation, or last protocol-specified assessment, or if the 
subject has ongoing AEs that are being followed up, to the date of AE resolution. 
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5.3 
Analysis Population 
• 
Modified Intent-to-treat (mITT) population:  
The modified intent-to-treat population is defined as all randomized subjects who receive 
at least 1 dose of study treatment and have at least 1 postbaseline result from below clinical 
efficacy assessments: 
▪ MRI Efficacy Assessments (not include locally read MRIs) 
▪ Relapses (clinical relapses are assessed as defined by new or recurrent neurologic 
symptoms not associated with fever or infection having a minimum duration of 24 
hours; see protocol section 7.3 for further details) 
▪ Neurological examination and EDSS 
▪ 
 
▪ 
 
▪ 
 
Subjects will be analyzed in the groups to which they are randomized for mITT population. 
• 
Per-protocol (PP) population:  
The per-protocol (PP) population is defined as the subset of the mITT population and also  
▪ Have no significant of following protocol deviations that would be expected to 
affect efficacy assessments: 
o Subject was enrolled without meeting one or more inclusion or met any 
exclusion criteria 
o Subject receives rescue medication without meeting protocol-defined 
rescue criteria 
▪ 
Subjects with <=3 total number of missed doses or doses received outside of the 
protocol defined dosing visit windows. 
The primary and secondary endpoints will be evaluated on the per protocol population. Subjects 
will be analyzed in the groups to which they are randomized. 
• 
Safety population:  
The safety population is defined as all randomized subjects who receive at least 1 dose of 
study treatment. Subjects will be analyzed based on the treatment they receive. 
 
 
 
 
 
• 
 
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. 
Subjects will be analyzed based on randomized treatment for mITT population and per-protocol 
population, while subject will be analyzed based on actual treatment received for safety population, 
. If a subject 
is randomized to EID arm but half or more number of doses the subject receives are actually given every 
four weeks, then the actual treatment for this subject is SID, and vice versa.   
5.4 
Background Characteristics 
The summaries in this section will be based on the mITT population. 
5.4.1 Accounting of Subject 
Disposition of subjects will be summarized and the summary data will include number  of subjects 
randomized and dosed, number of subjects who completed the treatment (week 72 visit), number of 
subjects who completed week 84 visit, number of subjects who completed the study including week 96 
safety phone call follow-up, and number of subjects who discontinued treatment and/or withdrew from 
study. For subjects who discontinued treatment and/or withdrew from study, the reasons for 
discontinuation and/or withdrawal, and days on treatment and days on study will be summarized and 
listed.  
Number of subjects in each analysis population will be summarized. Number of subjects dosed will be 
summarized by country/region. In addition, number of subjects who completed the treatment/study will 
be summarized by country/region.  
The number of subjects whose visits are impacted by the pandemic, including missing or out-of-window 
study treatment will be summarized, according to information recorded in the study protocol deviation 
listing. Due to COVID-19 pandemic measures, there may be challenges to conduct on-site monitoring 
visits and thereof result in some study data pending source data verification (SDV). The number of 
subjects who have any pending SDV data and the number of study visits without SDV performed will be 
presented. 
5.4.2 Demographics and Baseline Characteristics 
The demographic data including age (years), age category (<40 and ≥ 40), sex, ethnicity, race, 
Country/region, height, weight, and body mass index (BMI) will be summarized by treatment groups. 
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Body weight at baseline will also be categorized and presented using the following two groupings: <40 
kg, 40 to 59 kg, 60 to 79 kg, 80 to 89 kg, and ≥ 90 kg, and ≤ 80 kg, > 80 kg. 
Baseline disease characteristics will also be summarized by treatment groups, using descriptive 
statistics. These include years since disease (MS) onset, years since diagnosis, number of relapses during 
the one year prior to first dose of Tysabri, score of last EDSS assessment prior to first dose of Tysabri and 
baseline EDSS scores.  In addition, summary statistics for following baseline MRI assessments will also be 
presented.  
• T2 hyperintense lesion volume 
• Gd-enhancing lesion number and volume 
• T1 hypointense volume 
• Normalized brain volume 
Medical history will be coded using the Medical Dictionary for Regulatory Activities (MedDRA). The 
number (%) of subjects with history (including both ongoing and not ongoing medical conditions) will be 
summarized by system organ class and preferred term. A listing of medical history will be generated. 
Number and percentage of subjects with previous MS treatments other than Tysabri will be summarized 
by medications and treatment groups. Prior MS treatments other than Tysabri will also be listed. 
In addition, Tysabri treatment history will also be summarized. These include total number of doses of 
Tysabri the subjects have ever received prior to enrollment, total duration of Tysabri the subjects have 
received prior to enrollment, number of doses of Tysabri the subjects have received in the last 12 
months prior to enrollment, and number and percentage of subjects missed any doses of Tysabri in the 
last 3 months of treatment prior to the screening visit. Details of Tysabri treatment history will be listed 
for each subject. 
5.4.3 Concomitant Medications and Non-Drug Therapies 
All concomitant medications will be coded using the World Health Organization (WHO) medication 
dictionary. All concomitant non-drug therapies will be coded using the MedDRA dictionary. A 
concomitant medication/therapy will be defined as any therapy that was taken on or after the day of 
the first infusion of study drug. This includes therapies that start prior to the initiation of the first 
infusion if their use continues on or after the date of first infusion. To define concomitant use for 
therapies with missing start or stop dates, the following additional criteria will be used:  
• if both the start and stop dates of a therapy are missing, that therapy will be considered 
concomitant.  
• if the start date of a therapy is missing and the stop date of that therapy fall on or after the 
date of the first infusion, that therapy will be considered concomitant.  
• if the start date of a therapy is prior to the date of the first infusion and the stop date of 
that therapy is missing and the therapy is listed as continuing, that therapy will be 
considered concomitant, or  
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• if the start date of a therapy is prior to the date of the first infusion and the stop date of 
that therapy is missing and the therapy is not listed as continuing, that therapy will be 
considered non-concomitant.  
For a therapy with a partial start date, the year/month of the therapy date will be compared to that of 
the first dosing date to determine whether the therapy is concomitant. If the date of the therapy is 
missing and the year/month of the therapy date is same as the first infusion, that therapy will be 
considered as concomitant. 
The number and percentage of subjects taking concomitant medication and non-drug therapies will be 
summarized by treatment groups. Non-drug therapies will be presented by treatment groups. 
Concomitant medications and non-drug therapies will be listed.  
The most frequent concomitant medications, defined as those taken by at least 10% of subjects in any 
group, will also be summarized by treatment groups. In addition, number and percentage of subjects 
taking (switching to) rescue treatment will also be summarized. 
5.4.4 Protocol Deviations 
Protocol deviations identified during site monitoring will be captured in a protocol deviation log and 
categorized as major or minor deviations. The major protocol deviations will be summarized (presented 
by treatment groups). Listings will be generated for the major and minor protocol deviations, 
respectively. All protocol deviations related to COVID-19 pandemic measures will be provided in a listing 
with all available details. 
5.4.5 Study Drug Exposure and Study Drug Compliance 
Study drug compliance will be summarized for each treatment group. Overall compliance, which is the 
percentage of drug infusion actually received over total planned infusions for 72 weeks, will be 
summarized regardless of treatment completion for all subjects. Study drug compliance percentage up 
to the last dose of randomized treatment received will be defined as the number of infusions actually 
received divided by the number of infusions that the subject is expected to receive during the study 
period.  
The total number of infusions actually received and the number of infusions missed at the protocol 
defined dosing visit window will be summarized by treatment groups. Time on study, time on 
randomized treatment and time exposed to study treatment will separately be summarized. Time on 
study is defined to start on the date of the first study infusion and will continue until the last date on 
study. The last date on study will be taken as the last visit / evaluation from all available data for the 
subject. Time on randomized treatment is based on number of days from the date of the first study 
infusion to the date of the last study infusion before the rescue treatment and will be summarized using 
descriptive statistics and will be categorized into 24 week intervals and summarized by treatment 
groups. Time exposed to study treatment is based on number of days from the date of the first study 
infusion to the 28 days after the date of the last study infusion before the rescue treatment. Time on 
study excluding time on rescue treatment and time on study after the last dose will also be presented. In 
addition, average duration between two study infusions before rescue treatment will be presented by 
treatment groups. 
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In this study, some subjects with study treatment administration are impacted by COVID-19 infection or 
COVID-19 pandemic measures. Therefore, drug non-compliance due to COVID-19 will be presented by 
treatment arm, including the missed and out-of-window doses.  
5.5 
Efficacy Analysis 
All efficacy analyses will be performed on the mITT population. In addition, the primary and secondary 
endpoints will also be performed on the per-protocol population. The efficacy analysis will be presented 
by treatment groups (per randomization). 
For efficacy data that are summarized or analyzed by visit, data collected on all scheduled visits and all 
unscheduled visits will be mapped to an appropriate analysis visit using the windowing scheme shown in 
Table 1. If there are 2 or more assessments available in the same analysis window for a subject, the 
assessment that is closest to the target visit day will be used for analysis. If there are 2 or more 
assessments in the same analysis window with the same distance from the target visit day, the later 
assessment will be used.  
MRI assessments collected within 4 weeks after the last dose of steroid treatment for relapse will not be 
included in the efficacy analysis. MRI data collected at unscheduled visit for safety monitoring won’t be 
included in the efficacy analysis.   
Table 1 Visit Windows for Efficacy Endpoints 
Analysis visit 
Target visit day 
Analysis visit window 
Baseline 
1 
Most recent non-missing pre-dose value<=1 
Week 12 
85 
[2,127] 
Week 24 
169 
[128,211] 
Week 36 
253 
[212,295] 
Week 48 
337 
[296,379] 
Week 60 
421 
[380,463] 
Week 72 
505 
[464,547] 
Week 84 
589 
>=548 
 
5.5.1 Primary Efficacy Endpoint  
5.5.1.1 Primary Analysis 
The primary endpoint, the number of new or newly enlarging T2 hyperintense lesions at Week 72, will 
be analyzed using negative binomial regression models with treatment as the classification variable and 
baseline body weight (≤ 80 kg versus > 80 kg), duration of natalizumab exposure at baseline (≤ 3 years 
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versus > 3 years), and region (North America [includes USA and Canada], United Kingdom, Europe and 
Israel [includes Belgium, France, Germany, Israel, Italy, Netherlands, and Spain], and Australia) as 
covariates. The ratio of mean lesion numbers of EID versus SID (EID/SID) will be derived from the model 
with a 95% CI and associated p-value. The treatment will be considered different if the lower limit of the 
95% CI is above 1. As a secondary inference, the possibility of a 2-fold increase in the mean lesion 
number in the EID group as compared with the SID group will be considered ruled out if the upper limit 
of 95% CI is no greater than 2. However, if the total number of observed new/newly enlarging T2 lesion 
at Week 72 is less than 15, then the negative binomial regression model won’t be conducted, and only 
descriptive summary statistics at Week 72 will be presented. Otherwise, if negative binomial regression 
model doesn’t work, poisson regression model will be conducted instead, and if poisson regression 
model doesn’t work, either, then only descriptive summary statistics at Week 72 will be presented. This 
rule will be applicable to the analysis of new/newly enlarging T2 lesion number at Week 24 and Week 48 
as well as the analysis of other MRI parameters.   
The study plans to make every effort to retain subjects in the study and to continue follow-up in the 
cases of the initiation of rescue treatment, switching to different dosing frequency, and treatment 
discontinuation due to AEs, lack of efficacy, or for other reasons. This will allow continuing assessments 
of subjects’ MS disease activity. Efforts will also be made to obtain details of withdrawals in the generic 
categories of “lost to follow-up” or “other” whenever possible. Classification of the withdrawals in these 
nonspecific categories into “possibly efficacy related”, “possibly safety related”, or “no information” will 
be made based on all available information by independent Sponsor personnel who are blinded to 
treatment regimen and will be documented prior to database lock.  
The proposed primary estimand will be based on a treatment policy strategy, in which the study is 
intended to estimate the difference of a potential treatment decision of switching subjects from SID to 
EID compared with keeping subjects on SID over the next 72 weeks in a realistic clinical setting, where 
switching to a different dosing regimen or different medication may occur depending on disease activity. 
Therefore, the primary analysis will utilize all measurements regardless of whether subjects remain on 
randomized treatment. For subjects who withdraw from the study for reasons related to efficacy or an 
AE or who have a “possibly related” withdrawal, as described above, the missing values will be imputed 
by the worst observed value of the subjects on study treatment at the given timepoint. For withdrawals 
classified as “no information”, the missing values will be treated as missing at random and will be 
addressed using multiple imputation. The number and proportion of subjects with intercurrent events 
and the time to intercurrent event will also be tabulated by randomized groups.  
The secondary estimand will be based on a hypothetical strategy, in which the difference in the efficacy 
of EID versus SID at the 72 weeks following randomization if no intercurrent events occurred will be the 
target of estimation. The analysis for this estimand will treat the data obtained post-intercurrent event 
as missing values. For treatment discontinuation or switching due to efficacy as well as withdrawal that 
is due to efficacy or is “possibly efficacy related”, the missing values will be imputed by the worst 
observed values of the subjects on study treatment at the given timepoint. For intercurrent events due 
to other reasons, the resulting missing values will be addressed using multiple imputation.  
Multiple Imputation 
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Multiple imputation using fully conditional specification logistic regression method will be performed to 
impute intercurrent events due to other reasons. The treatment group variable will be coded so that the 
EID group is the first in the sort order. When the multiple imputation (MI) procedure is performed by 
treatment, the imputation will be done on the EID subjects first.  
Prior to the Proc MI step the dataset will be sorted by treatment code and ascending unique subject 
identifier (USUBJID). The imputation will include the treatment, baseline volume of T2 hyperintense 
lesions, and stratification factors (country/region, body weight (≤ 80 kg versus > 80 kg) and duration of 
natalizumab exposure (≤ 3 years versus > 3 years)) as well as the number of new or newly enlarging 
T2 hyperintense lesions at each time point up to week 72 and the study visit in the model. A set of 100 
complete imputed data sets will be generated with 100 burn-in iterations and the relative efficiency (RE) 
parameter will be checked.  
The pseudo SAS code can be found in Appendix I and seed 87922 will be used to perform the multiple 
imputation.  
To handle the missing MRI data, the reason for the occurrence of the first intercurrent event should be 
determined first. If the first intercurrent event is receiving rescue treatment, including switching from 
EID to SID or taking non-natalizumab rescue treatment, then the reason will be ‘possibly efficacy 
related’. If the first intercurrent event is early termination from randomized treatment (EOT) or early 
withdrawal from study (EOS), then medical team will review the data of each EOT/EOS subject, including 
EOT/EOS, adverse event, lab, MRI, EDSS, concomitant medication and relapse, and adjudicate the 
reason, which takes a value from ‘possibly efficacy related’, ‘possibly safety related’, ‘no information’ or 
‘no information/not related’. Therefore, missing MRI data due to COVID-19 can be still handled with the 
procedure as prespecified above. Additionally, the MRI data (except the collection date) won’t need SDV 
because they are collected from a central vendor, and the chance that the pending SDV collection date 
will affect the primary analysis is minimal. Therefore, as a supportive analysis, we will only present the 
pending SDV MRI collection date by treatment arm.  
5.5.1.2 Sensitivity analysis 
All the sensitivity analyses will be conducted for the mITT population and will be performed for both 
estimands, respectively. 
5.5.1.2.1. Tipping point analysis 
Tipping point analysis will be performed to assess the robustness of the primary analysis to deviation 
from the missing-at-random assumption.  
The tipping-point analysis is a progressive stress-testing to assess how severe departures from missing-
at-random must be in order to overturn the conclusion of the primary analysis [Yan et al. 2009]. For this 
study, subjects are assumed to have more N/NE T2 lesions after early withdrawal from study due to 
other reasons compared to subjects who remain on study.  
The missing data are first imputed by the standard multiple imputation (assuming missing at random). 
To reflect the worse performance after early withdrawal, pre-specified shift parameters, the imputed 
values for subjects on SID and EID will be multiplied by a factor delta, 𝛿𝑐 and 𝛿𝑡, respectively. The 
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adjusted multiple imputed datasets will then be analyzed by a negative binomial model and the results 
will be combined using the Rubin’s rule for inference. A range of 𝛿𝑐 and 𝛿𝑡 will be applied by including -
log(𝛿𝑐) and -log(𝛿t) as offset in the negative binomial regression model for the missing data imputed by 
the multiple imputation. 
The ratio of mean lesion numbers of EID versus SID (EID/SID) with a 95% CI and associated p-value will 
be calculated for each combination of 𝛿𝑐 and 𝛿𝑡. The tipping region is defined as the combinations of 𝛿𝑐 
and 𝛿𝑡 such that if the upper limit of the 95% CI is above 2. 𝛿𝑐 and 𝛿𝑡 will range between 1 and 5 in 
increments of 0.5 for the number of new or newly enlarging T2 hyperintense lesions at 72 weeks. For a 
given comparison, if a tipping point was observed with analysis at 0.5 increments, the δ values will be 
further refined down to 0.25 increments for the relevant interval. For example, if a tipping point is 
identified when increasing δt from 1 to 1.5, the matrix will be expanded to include also the value δt = 
1.25. 
The tipping region of yielding the lower limit of the 95% CI below 1 will also be presented, respectively.  
The scientific plausibility of the tipping region will be evaluated. If implausible departures from the 
missing-at-random assumption (large δ) are needed in order to change the results from statistically 
significant to insignificant, the results of the primary analysis are considered to be robust to departure 
from the missing-at-random assumption. 
5.5.1.2.2. Adjusting for baseline volume of T2 hyperintense lesions 
Baseline volume of T2 hyperintense lesions will be added to the negative binomial regression model of 
primary analysis specified in section 4.5.1.1 as a sensitivity analysis for the primary endpoint. 
 
5.5.1.3 Supplementary analysis 
5.5.1.3.1. Assuming all missing values as missing at random 
The primary analysis will be repeated by imputing all missing values by treating all as missing at random 
using multiple imputation. Both primary estimand and secondary estimand will be estimated in this 
supplementary analysis. The multiple imputation model specified in the primary analysis will be 
employed. 
5.5.1.3.2. Per-protocol analysis  
The per-protocol analysis will repeat the primary analysis as specified in Section 4.5.1.1 based on the 
per-protocol population. 
5.5.1.3.3. Proportion of subjects with no new or newly enlarging T2 hyperintense lesions over week 
72 
The proportion of subjects with no new or newly enlarging T2 hyperintense lesions over week 72 will be 
analyzed using logistic regression models with the same covariates as those described above.  Data will 
be censored at the time the subject starts rescue treatment or withdraw from study treatment. 
Responder for this analysis is defined as subjects who complete study treatment until week 72 and have 
no new or newly enlarging T2 hyperintense lesions prior to week 72. Non responder includes subjects 
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with new or newly enlarging T2 hyperintense lesions reported prior to week 72 and subjects who 
discontinue randomized treatment and switch due to efficacy as well as withdraw due to efficacy or is 
“possibly efficacy related” prior to week 72. Subjects who discontinue treatment or switch due to non-
efficacy reasons prior to week 72 and have no new or newly enlarging T2 hyperintense lesions reported 
prior to the intercurrent event will be excluded from this analysis. 
As a sensitivity analysis, subjects who discontinue treatment or switch due to non-efficacy related 
reasons prior to week 72 and have no new or newly enlarging T2 hyperintense lesions reported prior to 
the intercurrent event will be included as responders. 
5.5.2 Secondary Efficacy Endpoint  
5.5.2.1 Time to First Relapse 
Only INEC-confirmed protocol-defined relapses prior to Week 72 will be included in the analysis 
for this endpoint. Relapses that occur after subjects have received rescue treatment including 
reverting to natalizumab SID as a rescue treatment or switching to another disease-modifying 
therapy prior to Week 72 will be excluded from the analyses of time to first relapse, and the 
subject’s time in the study will be censored at the time the subject starts rescue treatment. If a 
subject withdraws from the study prior to Week 72 and the subject did not experience relapse as 
adjudicated by INEC prior to withdrawal, he or she will be censored on the last day they were in 
the study if the reason for withdrawal is not related to lack of efficacy. For withdrawals due to lack 
of efficacy, the withdrawal time will be considered as event time. The start date for time to first 
relapse or censoring is defined as the date of first randomized infusion. 
The proportion of relapsed subjects will be estimated using the Kaplan-Meier (KM) product limit 
method and be presented as KM curves over time. The comparison of treatment groups will be 
based on Cox regression models with treatment as the classification variable and baseline body 
weight (≤ 80 kg versus > 80 kg), duration of natalizumab exposure at baseline (≤ 3 years versus 
> 3 years)  and region (North America [includes USA and Canada], United Kingdom, Europe and 
Israel [includes Belgium, France, Germany, Israel, Italy, Netherlands, and Spain]) as covariates. 
The hazard ratio of relapse of EID versus SID (EID/SID) will be derived from the model with a 
95% CI and associated p-value. 
5.5.2.2 Annualized Relapse Rate 
Only INEC-confirmed protocol-defined relapses prior to Week 72 will be included in the analysis for this 
endpoint. Relapses that occur after subjects receive rescue treatments will be excluded from the 
analyses of relapse rate, and the subject’s time on study will be censored at the time the rescue 
treatment is started.    
The relapse rate for each treatment group will be calculated as the total number of relapses experienced 
in the group divided by the total number of patient-years on study at the time of the last randomized 
treatment infusion (week 72) or at the time of censoring for the group.  This is the unadjusted relapse 
rate. 
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In addition, the relapse rate for an individual subject will be calculated as the number of relapses for 
that subject divided by the duration of the subject on study in years at the time of the last randomized 
treatment infusion (week 72) or at the time of censoring.  Based on these individual relapse rates, the 
mean and median for each treatment group will be presented.  This is called the subject relapse rate.  
The annualized relapse rate at Week 72 will be analyzed using negative binomial regression models with 
treatment as the classification variable and baseline body weight (≤ 80 kg versus > 80 kg), duration of 
natalizumab exposure at baseline (≤ 3 years versus > 3 years), and region as covariates. The logarithmic 
transformation of the number of years in the study at the time of the last randomized treatment 
infusion (week 72) or at the time of censoring will be included in the model as the “offset” parameter. 
The ratio of mean annualized relapse rate of EID versus SID (EID/SID) will be derived from the model 
with a 95% CI and associated p-value.  
5.5.2.3 EDSS Worsening 
Confirmed EDSS worsening is defined as an increase of at least 1.0 point from a baseline EDSS score 
≥ 1.0 or an increase of at least 1.5 points from a baseline EDSS score of 0 that is confirmed after at least 
24 weeks. The EDSS worsening is defined as confirmed when this minimum EDSS change is present on 
the next study visit.   
EDSS worsening will not be confirmed at a visit where a relapse is also occurring.  A subject is considered 
to be having a relapse for at least 29 days after the start date of an INEC-confirmed objective relapse.  If 
a subject meets the defined criteria of EDSS worsening and is also having a relapse, the subject will be 
required to meet the defined minimum criteria at the subsequent visit.   If subjects had a tentative EDSS 
worsening prior to the start of rescue MS medication, the EDSS evaluation after rescue MS medication 
will be used to confirm EDSS worsening.  If subjects had a tentative EDSS worsening at Week 72, the 
EDSS evaluation at Week 84 will be used to confirm the tentative worsening. 
Death due to MS will be counted as confirmed EDSS worsening.  If the subject was in the midst of a 
tentative EDSS worsening at the time of death (e.g. the EDSS evaluation prior to death is a tentative 
worsening), the EDSS worsening date will be the date of the start of the worsening.  If the subject had a 
confirmed EDSS worsening prior to death, the EDSS worsening date is the start date of the tentative 
worsening.  Otherwise, the EDSS worsening date will be the date of death. 
EDSS worsening can be confirmed at the early (premature) study withdrawal visit, according to the rules 
above, as long as the early withdrawal visit is not also a relapse assessment visit.   
Subjects who do not have a confirmed EDSS worsening based on the above rules will be censored.  The 
censor date will be the date of the last EDSS assessment in the study, or the last EDSS assessment prior 
to the rescue treatment, unless the subject has a tentative EDSS worsening at this assessment.  For 
subjects with a tentative EDSS worsening at the last study visit, (or the last EDSS prior to rescue 
treatment that was not confirmed) the censor date will be the date of the EDSS assessment prior to the 
last EDSS.  The start date for calculation of day to confirm EDSS worsening or censor will be date of first 
infusion, and if date of first infusion is incomplete, date of randomization will be used.  
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Subjects who withdraw from the study after the baseline visit but prior to the first clinical evaluation 
scheduled visit will be censored at baseline.  The start date is defined as the date of dose of natalizumab 
during the study. 
Time to first confirmed EDSS worsening will be analyzed using KM estimates and Cox regression models 
similar to the method described above for time to first relapse. 
5.5.2.4 Secondary MRI Endpoints 
The number of new or newly enlarging T2 hyperintense lesions at Week 24 and Week 48 and the 
number of new Gd-enhancing and new T1 hypointense lesions at Weeks 24, 48, and 72 will be analyzed 
using the same approach as that for the primary endpoint. 
Missing values of secondary MRI endpoints will be imputed following the same approach for the primary 
analysis based on hypothetical strategy. 
5.5.2.5 Sensitivity/Supplementary analysis 
Per-protocol analyses will be performed as supplementary analyses for secondary efficacy endpoints. 
5.5.3 Subgroup Analysis 
Subgroup analyses of the primary and key secondary endpoints will be conducted, as defined below, to 
evaluate the consistency of findings across populations.  
• Baseline EDSS (EDSS score ≤ 2.0 versus EDSS score > 2.0) 
• Age at baseline (age < 40 years versus age ≥ 40 years) 
• Duration of natalizumab exposure (≤ 3 years versus > 3 years) at baseline 
• Sex 
• Country/region (North America [includes USA and Canada], United Kingdom, 
Europe and Israel [includes Belgium, France, Germany, Israel, Italy, Netherlands, and 
Spain], and Australia) 
• Baseline weight (40 to 59 kg, 60 to 79 kg, 80 to 89 kg, and ≥ 90 kg) 
• 
 
In addition, subgroup analysis of the primary and key secondary endpoints will be evaluated in 
subgroups defined by prior disease activity, and the number and type of therapies prior to natalizumab 
 at baseline 
and  Weeks 24. 
 
  
  
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5.6 
Safety Analysis 
All Safety analyses will be performed on the Safety population.  
All adverse events (AEs) and serious adverse events (SAEs), clinical laboratory abnormalities, vital sign 
measurements, physical examination findings, body weight and Columbia Suicide Severity Rating Scale 
(C-SSRS), will be evaluated for safety. Safety data collected by follow-up safety phone call visit (week 96 
or earlier for early termination subjects) will be summarized using descriptive statistics by treatment 
groups. Unless otherwise specified, no formal statistical testing will be performed on the safety data. 
For safety data that are summarized by visit, assessment from all scheduled visits, ET visit, EOS visit, 
follow-up safety phone call visit and unscheduled visit will be mapped to an appropriate analysis visit 
using a windowing scheme (Tables 4-9 in APPENDIX II). 
5.6.1 Clinical Adverse Events              
Any AE experienced by the subject after the first infusion in this study (Day 1/Baseline visit) until the 
follow-up safety phone call is to be recorded in the eCRF, regardless of the severity of the event or its 
relationship to study treatment. Any SAE experienced by the subject between the time of the signing of 
the ICF and the follow-up safety phone call visit is to be recorded on an SAE form, regardless of the 
severity of the event or its relationship to study treatment.   
Unless otherwise specified, only treatment-emergent adverse events will be presented in the summary 
tables. Treatment-emergent is defined as having onset date on or after the first randomized infusion 
date and prior to the 84 days after the last randomized infusion date.  
In order to define treatment emergence for AE with missing start or stop dates, the following additional 
criteria will be used: 
• 
If both the start and stop dates for a particular event are missing, then that event is considered 
treatment emergent; 
• 
If the start date for a particular event is missing and the stop date/time falls after the first 
infusion date/time, then that event is considered treatment emergent; 
• 
If the start date was the same as the first infusion date, and the start time was missing, then 
that event is considered treatment emergent. 
For events with a partial start date, the year/month of the event date will be compared to that of the 
first dosing date to determine whether the event is treatment emergent. If it cannot be determined 
whether an event is treatment emergent due to a missing or partial date, then the event will be 
tabulated as treatment emergent.  
The overall summary table of AEs will present the number of subjects with the following events for each 
treatment group. A subject is counted only once in each category. 
• 
Any AE; 
• 
AE with severity as “moderate” or “severe”; 
• 
AE with severity as “severe”; 
• 
Natalizumab related AE; 
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• 
Any SAE; 
• 
Natalizumab related SAE; 
• 
AE leading to discontinuation of study treatment; and  
• 
AE leading to withdrawal from study. 
• 
AE of special interest 
The incidence of AEs will be also presented for each treatment group. They will be summarized by the 
following,  
• 
preferred term (PT); 
• 
primary system organ class (SOC); 
• 
primary system organ class (SOC) and preferred term (PT);  
• 
severity, primary SOC and PT; and 
• 
relationship to study treatment, primary SOC and PT.  
Corresponding to the five scenarios above, the data will be processed as follows,  
• 
a subject will be counted only once within each PT, and PTs will be ordered by decreasing 
incidence in the column of overall group, which combines all subjects in the study; 
• 
a subject will be counted only once within each primary SOC, and primary SOCs will be ordered 
by decreasing incidence in the column of overall group; 
• 
 a subject will be counted only once within each primary SOC/PT, and PTs will be ordered by 
decreasing incidence within each primary SOC in the column of overall group.  
• 
a subject will be counted only once within each primary SOC/PT, and the AE with the greatest 
severity will be used. PTs will be ordered by decreasing incidence within each primary SOC in the 
column of overall group. 
• 
a subject will be counted only once within each primary SOC/PT, and the AE with the strongest 
relationship to study treatment will be used. PTs will be ordered by decreasing incidence within 
each primary SOC in the column of overall group. 
The incidence of SAEs, incidence of AEs that led to withdrawal from study, and incidence of AEs that led 
to discontinuation of study drug will be also summarized by treatment groups with the use of primary 
SOCs/PTs. The data will be processed as what is done for incidence of AEs. Listing of AEs, SAEs, AEs that 
led to study treatment discontinuation and AEs that led to study withdrawal, regardless of treatment 
emergent or not, will be presented. Listing of death will be provided if applicable.  
The incidence of adverse events of special interest will also be presented. These adverse event of special 
interest categories are defined mainly based on Standardized MedDRA Queries (SMQs), SOCs, and/or 
PTs. The AEs of special interest categories may include but are not limited to the following:  
• 
PML progressive multifocal leukoencephalopathy (all events occur before the end of the study) 
• 
Infusion reaction  
• 
Opportunistic infections 
• 
Drug induced liver injury 
• 
Hypersensitivity reactions 
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In some AE/SAE listings, complete AE start and end dates are needed to calculate the relative 
study days of AE start and end. Therefore, any partial date will be imputed for these listings. 
Specifically, the partial AE start date will be imputed as the earliest possible date on or after the 
first infusion based on the partial information, and the partial AE end date will be imputed as 
the latest possible date on or before the follow-up safety phone call visit. 
5.6.2 Clinical Laboratory Data 
The following clinical laboratory parameters are assessed as stated in the protocol Section 5 and Section 
14.2:  
• 
Blood hematology:  complete blood count with differential and platelet count, and absolute 
neutrophil count.  
• 
Blood chemistry:  total protein, albumin, creatinine, blood urea nitrogen, uric acid, bilirubin 
(total and direct), alkaline phosphatase, alanine aminotransferase (ALT or SGPT), aspartate 
aminotransferase (AST or SGOT), gamma-glutamyl-transferase (GGT), glucose, calcium, 
phosphorus, bicarbonate, chloride, sodium and potassium. 
All the laboratory tables and listings, unless otherwise specified, will be presented by treatment groups.  
5.6.3 Quantitative laboratory analysis 
Actual laboratory values, changes from baseline and percent changes from baseline in the selected 
quantitative laboratory values will be summarized using descriptive statistics by treatment groups and 
visit. Number of evaluable subjects, mean, standard deviation, median, min and max values will be 
presented at each visit. 
Plots of mean values (with standard deviation) for the key numeric laboratory parameters by visit will be 
provided.  
Visit windows for by visit summaries 
For laboratory by visit summaries, the analysis visit should be defined using visit windows (Tables 4-5 in 
APPENDIX II).  If there is more than 1 value in the same analysis visit window (>1 value for the same 
analysis visit) for a certain parameter for a subject, then the closest record to the target visit day will be 
used for the by visit analysis.  If there are 2 values in the same analysis visit window with the same 
distance from the target visit day for a certain parameter for a subject, then the record with the later 
date will be used for the by visit analysis.  If there are 2 values on the same day for a certain parameter 
for a subject, then the record with the later time will be used for the by visit analysis. 
5.6.4 Qualitative laboratory analysis 
For all qualitative analyses, all values will be included (not just the “analyzed record” within each visit 
window in the quantitative analyses). 
 
 
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Shift analyses 
Laboratory data will be summarized using shift tables where appropriate.  Each subject’s hematology 
and blood chemistry values will be flagged as “low”, “normal”, or “high” based on the normal ranges of 
the central laboratory or as “unknown” if no result is available. Shifts from baseline to high or low status 
for hematology and blood chemistry parameters will be presented.    
In the hematology and blood chemistry shift summary tables, entries are numbers of subjects shift to 
low (or high) divide by number of subjects at risk followed by corresponding percentages. Number at 
risk for shifting to low (or high) is the number of subjects whose baseline value was not low (or high) and 
who had at least one post-baseline evaluation. Shift to low includes normal to low, high to low, and 
unknown to low. Shift to high includes normal to high, low to high, and unknown to high.  
Potentially clinically significant (PCS) abnormalities 
For hematology and blood chemistry, the number and percentage of subjects with any post-baseline 
PCS laboratory abnormalities will be summarized by treatment groups for the parameters provided in 
Table 2. 
Subject listings will also be presented for all subjects with any PCS laboratory abnormalities. In these 
listings, each subject’s complete history from screening to last study visit for that specific laboratory test 
meeting the PCS criteria will be listed; any abnormal values based on the normal ranges of the central 
laboratory and abnormal values based PCS criteria will be separately flagged in the same listing. 
Table 2 Criteria to Determine Clinically Relevant Abnormalities in blood hematology and 
blood chemistry 
Parameter Name 
Unit 
PCS Low 
PCS High 
Blood hematology 
White Blood Cells 
x109 cells/L 
< 3.0  
>16  
Neutrophils 
x109 cells/L 
< 1.5  
>13.5  
Lymphocytes 
x109 cells/L 
< 0.8   
>12  
Monocytes 
x109 cells/L 
N/A 
>2.5 
Eosinophils 
x109 cells/L 
N/A 
>1.6  
Basophils 
x109 cells/L 
N/A 
>1.6  
Hemoglobin for females 
                     for males 
g/L 
<= 95  
<= 115  
>=175  
>=190  
Hematocrit for females 
                   for males 
% 
<= 32 
<= 37 
>=54 
>=60 
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Red Blood Cells (RBC) 
x1012 cells/L 
<= 3.5  
>=6.4  
Platelet count 
x109 cells/L 
<= 75  
>=700  
Blood chemistry 
Sodium 
mmol/L 
<= 126  
>= 156  
Potassium 
mmol/L 
<= 3  
>= 6  
Chloride 
mmol/L 
<= 90  
>= 118  
Bicarbonate 
mmol/L 
<= 16  
>= 35  
Calcium 
mmol/L 
<= 2 
>= 3 
Phosphorus 
mmol/L 
<= 0.5491 
>= 1.7119  
Aspartate aminotransferase (AST) 
IU/L 
N/A 
>= 3x ULN 
Alanine Aminotransferase (ALT) 
IU/L 
N/A 
>= 3x ULN 
Alkaline phosphatase 
IU/L 
N/A 
>= 3x ULN 
Creatinine 
umol/L 
N/A 
>= 1.5x ULN 
Total Bilirubin 
umol/L 
N/A 
>= 1.5x ULN 
Total Protein 
g/L 
<= 45 
>= 100 
Albumin 
g/L 
<= 25 
N/A 
Uric Acid for females 
                 for males 
umol/L 
N/A 
N/A 
>= 501.5 
>= 619.5 
Glucose (non-fasting) 
mmol/L 
<= 2.2 
>= 13.75 
Blood urea nitrogen 
Mg/dl 
<6 
>20 
Gamma-glutamyl transferase 
Units/litre 
<9 
>48 
 
Liver function laboratory tests 
For liver function laboratory tests (ALT, AST and total bilirubin), counts and percentages of maximal 
post-baseline values by following categories will be provided: 
For ALT or AST,  
• 
<= Upper Limit of Normal (ULN),  
• 
> ULN,  
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• 
>= 3x ULN,  
• 
> 5x ULN,  
• 
> 10x ULN,  
• 
> 20x ULN. 
For total bilirubin,  
• 
<= ULN,  
• 
> ULN,  
• 
>= 1.5x ULN,  
• 
> 2x ULN,  
• 
> 3x ULN,  
• 
> 10x ULN.  
Listing of the liver function test parameters by treatment groups will be provided.  
5.6.5 Vital Sign Measurements 
Vital signs collected in this study include temperature, systolic and diastolic blood pressure, pulse rate, 
respiratory rate and body weight. All measurements are collected at all study visits until the EOS visit 
except body weight, which is only collected at screening visit and then every 24 weeks from baseline 
visit to EOS visit. All measurements are collected at unscheduled visits if applicable. The analysis of vital 
signs will focus on the incidence of clinically relevant abnormalities from Day 1/Baseline to the EOS visit, 
based on the following criteria in Table 3. 
Table 3 Criteria to Determine Clinically Relevant Abnormalities in Vital Signs 
Vital Sign 
Criteria for Abnormalities 
Temperature 
> 38°C and an increase from pre-dose of at least 1°C 
Heart rate 
> 120 beat per minute and an increase from pre-dose of more than 
20 beats per minute. 
< 50 beats per minute and a decrease from pre-dose of more than 
20 beats per minute. 
Systolic Blood Pressure > 180 mmHg and an increase from pre-dose of more than 40mmHg. 
< 90 mmHg and a decrease from pre-dose of more than 30 mmHg. 
Diastolic Blood 
Pressure 
> 105 mmHg and an increase from pre-dose of more than 
30 mmHg. 
< 50 mmHg and a decrease from pre-dose of more than 20 mmHg. 
Respiratory rate 
>=20 breaths per minute with a pre-dose rate of < 20 breaths per 
minute 
<= 10 breaths per minute with a pre-dose rate of > 10 breaths per 
minute 
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A summary table for subjects with any clinically relevant post-baseline abnormalities will be provided. In 
the summary table, entries are numbers of subjects with an abnormality divided by number of subjects 
evaluated followed by corresponding percentages. Number evaluated is the number of subjects who 
had a baseline assessment and at least one post-baseline assessment for that vital sign.  
For each vital sign parameter, actual values and changes from baseline will be summarized using 
descriptive statistics by treatment groups and visit. The line of mean vital sign over time by treatment 
groups may be graphed. 
A subject listing will be presented for subjects with any post-baseline clinically relevant abnormalities in 
vital signs. In this listing, each subject’s complete vital sign values from screening visit to EOS visit will be 
listed with abnormalities labeled. 
For vital sign visit summaries, the analysis visit will be defined by visit window (Tables 6-7 in APPENDIX 
II). For the same parameter for a subject, if there is more than 1 record in the same analysis visit 
window, then select the record closest to the target visit day.  If there are 2 records in the same analysis 
visit window with the same distance from the target visit day, then select the record with the later date. 
If there are 2 records on the same date, then use the average value for quantitative parameters and the 
worse value for qualitative parameters. 
5.6.6 Physical and Neurological Examination 
New abnormalities in physical and neurological assessments will be reported as AEs and presented in 
the AE summaries. 
5.6.7 Columbia Suicide Severity Rating Scale (C-SSRS) 
Please refer to appendix IV for the structure of this scale, and how to use it to assess suicidal ideation 
and behavior.  
The following analyses on C-SSRS measurements will be conducted: 
• 
Descriptive summary of subjects who answered “Yes” to any question 1-12 as well as subjects 
who had suicidal ideation or suicidal behavior at screening visit and at any post-screening visits. 
The denominator for baseline summary is the number of subjects who were dosed and had 
assessment at screening visit; the denominator for post-baseline summary is the number of 
subjects who were dosed and had at least one assessment at the post-screening visits for each 
question.  
• 
Descriptive summary of subjects who had treatment-emergent suicidal ideation, subjects who 
had new suicidal ideation as well as subjects who had worsening suicidal ideation. The 
denominator is the number of dosed subjects with suicidal ideation assessment at both 
screening visit and at least one post-screening visit.  
• 
Descriptive summary of subjects who had treatment-emergent suicidal behavior. The 
denominator is the number of subjects who answered “No” to all suicidal behavior questions at 
screening visit and had suicidal behavior assessment at least one post-screening visit.  
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Listing of subjects having treatment-emergent suicidal ideation will be provided. Subjects who had new 
suicidal ideation and subjects who had worsening suicidal ideation will be flagged. The listing will display 
both baseline (collected at screening visit) and post-baseline (collected at all post-screening visits) 
Suicidal Ideation Scores for each subject. Listing of subjects having treatment-emergent suicidal 
behavior will also be provided.  
 
 
 
 
 
 
 
 
 
 
  
 
 
  
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
  
 
  
 
 
 
  
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6 INTERIM ANALYSIS 
An interim futility analysis, based on the number of new or newly enlarging T2 hyperintense lesions at 
24 weeks, will be conducted when 50% of subjects have at least 6 months of randomized treatment.   
The interim data will be analyzed using negative binomial regression models with treatment as the 
classification variable and baseline body weight (≤ 80 kg versus > 80 kg), duration of natalizumab 
exposure at baseline (≤ 3 years versus > 3 years), and region as covariates.  The ratio of mean lesion 
numbers of EID versus SID (EID/SID) will be derived from the model with a 95% CI.  The study may be 
stopped for futility if the lower limit of the 95% CI is > 2 and a 2-fold increase in mean lesion numbers in 
the EID group can be concluded with 97.5% confidence.   
 
7 CHANGES FROM PROTOCOL-SPECIFIED ANALYSES 
7.1 
COVID-19 Related Analyses 
In 2020 there is a worldwide outbreak of respiratory disease named as “Coronavirus Disease 2019” 
(COVID-19). It has been recognized that this COVID-19 public health emergency may impact the conduct 
of clinical trials of medical products and the challenges caused by the COVID-19 pandemic may lead to 
difficulties in meeting protocol-specified procedures including administering the investigational 
product or adhering to protocol-mandated visits and laboratory/diagnostic testing (FDA 2020 and 
EMA 2020).  
For this study 101MS329, most subjects have visits impacted by COVID-19 pandemic. The missing MRI 
data can be imputed and handled with the procedure prespecified, and therefore, no extra inferential 
analysis of the primary endpoint will be added. But some summary analyses due to COVID-19 are 
considered, including summary of study subjects with early termination from randomized treatment, 
early withdrawal from study, protocol deviation, missed or out-of-window dose due to COVID-19 as well 
as AE and non-drug concomitant treatment related to COVID-19. 
 
 
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There were also challenges to conduct on-site monitoring visits and thereof result in some study data 
pending source data verification (SDV) because of COVID-19. The incomplete SDV on dosing information, 
EOT/EOS data, as well as key efficacy assessments and AE/SAE due to the pandemic will  be summarized 
by visit.  
8 SUMMARY OF CHANGES FROM THE PREVIOUS VERSION OF 
THE SAP 
8.1 
Changes in Planned Analysis Methods 
A few changes are made to the planned analysis methods to best suit the characteristics of the data to 
be analyzed, as well as to focus on the most relevant analyses addressing the trial objectives and 
scientific questions of interest. These changes include the following.  
• 
The definition of actual treatment arm is added for the analysis of 
safety/
  
• 
The definition of the per-protocol population is updated by changing the total number of missed 
dose/out-of-window dose that are allowed from 1 to 3.  
 
 
  
 
 
 
  
• 
The definition of AE of special interest (AESI) is also updated by replacing ‘Injection site 
reactions’ with ‘Infusion reaction’.  
 
 
 
8.2 
COVID-19 Related Analyses 
As discussed in Section 7, additional analyses are added in the SAP to assess impact of the COVID-19 
pandemic.   
 
 
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9 APPENDIX I: PSEUDO SAS CODE FOR MULTIPLE IMPUATION 
Following pseudo SAS code will be used for multiple imputation: 
 
proc mi data= in_data seed=x nimpute=100  out=imp_data; 
class   treatment region wtgrp expogrp visit NNET2cnt; 
var  treatment region wtgrp expogrp visit NNET2cnt T2volbl; 
fcs NBITER=100 logistic(NNET2cnt = treatment region wtgrp expogrp T2volbl visit); 
run; 
 
where, treatment: Planned treatment for the trial; region : Country/region; wtgrp: Baseline body weight 
(≤ 80 kg versus > 80 kg);  expogrp: Duration of natalizumab exposure at baseline (≤ 3 years versus > 3 
years); visit: Study visit; NNET2cnt: Number of new or newly enlarging T2 hyperintense lesions from 
previous visit. 
 
Note that variable or parameter names may change prior to database lock. 
10 APPENDIX II: VISIT WINDOW MAPPING 
For data that are summarized by visit and longitudinal analysis, assessment from all scheduled visits 
including ET visit and EOS visit, and all unscheduled visits will be mapped to an appropriate analysis visit 
using a windowing scheme. Analysis visit windows are defined in Table 4- table 9 for different endpoints. 
To define analysis visit window, the target visit day is calculated as (week number*7+1). The lower 
bound of visit window is calculated as target day−(target day−target day of previous visit)/2+1, except 
for the first post-baseline visit window whose lower bound is set as Day 2; the upper bound of visit 
window is calculated as target day+(target day of next visit−target day)/2. 
If there are 2 or more assessments from visits other than ET or EOS visits mapped to the same analysis 
visit for a subject, the assessment that is closest to the target visit day will be used for analysis.  If there 
are 2 or more assessments from visits other than ET or EOS visits mapped to the same analysis visit with 
the same distance from the target visit day, then select the later one(s) for the analysis.  If there are 2 or 
more assessments from visits other than ET or EOS visits mapped to the same analysis visit and on the 
same day, use the average value for quantitative parameters and the worst value for qualitative 
parameters for analysis.  
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If ET visit is mapped to an analysis visit and a prior visit (either scheduled or unscheduled visit) is 
mapped to the same analysis visit, then ET visit will be remapped to the next analysis visit. If EOS visit is 
mapped to an analysis visit and a prior visit, e.g., ET visit, is mapped to the same analysis visit, then EOS 
visit will be remapped to the next analysis visit. The latest analysis visit for ET visit can be up to Week 72 
and for EOS visit can be up to Week 84. 
 
Table 4: Visit Windows for Blood Hematology  
Analysis visit  
Target visit 
day  
Analysis visit window for 
SID Group 
Analysis visit window for 
EID group 
Baseline/Day 1 
1 
≤ 1 
≤ 1 
Week 24 
169 
[2,253] 
[2,253] 
Week 48 
337 
[254, 421] 
[254, 421] 
Week 72 
505 
[422,547] 
[422,547] 
Week 84 
589 
≥ 548 
≥ 548 
 
Table 5: Visit Windows for Blood Chemistry  
Analysis visit  
Target visit 
day  
Analysis visit window for 
SID Group 
Analysis visit window for 
EID group 
Baseline/Day 1 
1 
≤ 1 
≤ 1 
Week 84 
589 
≥2 
≥2 
 
Table 6: Visit Windows for Vital Signs Measurements 
Analysis visit 
Target visit 
day  
Analysis visit window 
visit for SID Group 
Analysis visit window 
for EID group 
Baseline/Day 1 
1 
≤ 1 
≤ 1 
Week 4 
29 
[2,43] 
NA 
Week 6 
43 
NA 
[2,64] 
Week 8 
57 
[44,71] 
NA 
Week 12 
85 
[72,99] 
[65,106] 
Week 18 
127 
NA 
[107,148] 
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Analysis visit 
Target visit 
day  
Analysis visit window 
visit for SID Group 
Analysis visit window 
for EID group 
Week 16 
113 
[100,127] 
NA 
Week 20 
141 
[128,155] 
NA 
Week 24 
169 
[156,183] 
[149,190] 
Week 28 
197 
[184,211] 
NA 
Week 30 
211 
NA 
[191,232] 
Week 32 
225 
[212,239] 
NA 
Week 36 
253 
[240,267] 
[233,274] 
Week 40 
281 
[268,295] 
NA 
Week 42 
295 
NA 
[275,316] 
Week 44 
309 
[296,323] 
NA 
Week 48 
337 
[324,351] 
[317,358] 
Week 52 
365 
[352,379] 
NA 
Week 54 
379 
NA 
[359,400] 
Week 56 
393 
[380,407] 
NA 
Week 60 
421 
[408,435] 
[401,442] 
Week 64 
449 
[436,463] 
NA 
Week 66 
463 
NA 
[443,484] 
Week 68 
477 
[464,491] 
NA 
Week 72 
505 
[492,547] 
[485,547] 
Week 84 
589 
≥ 548 
≥ 548 
 
Table 7: Visit Windows for Body Weight 
Analysis visit 
Target visit 
day  
Analysis visit window 
for SID Group 
Analysis visit window 
for EID Group 
Baseline/Day 1 
1 
≤ 1 
≤ 1 
Week 24 
169 
[2,253] 
[2,253] 
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Analysis visit 
Target visit 
day  
Analysis visit window 
for SID Group 
Analysis visit window 
for EID Group 
Week 48 
337 
[254,421] 
[254,421] 
Week 72 
505 
[422,547] 
[422,547] 
Week 84 
589 
≥ 548 
≥ 548 
 
 
 
 
 
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12 
APPENDIX IV: COLUMBIA SUICIDE SEVERITY RATING SCALE 
(C-SSRS) 
The Columbia Suicide Severity Rating Scale (C-SSRS) is an assessment that evaluates suicidal ideation and 
behavior. Measurements are collected with the C-SSRS Baseline version at screening visit, and the C-
SSRS Since last visit version is used instead at all other study visits until the EOS visit, including the 
unscheduled visits if applicable.   
There are 11 common “Yes/No” questions at screening and post-screening visits. Five questions on 
suicidal ideation and five questions on suicidal behavior are re-ordered and follow increasing severity 
order respectively as shown in Table 4; another question on self-injurious behavior without suicidal 
intent is listed separately. In particular, only subjects who answered “Yes” to question 2 will proceed to 
question 3, 4 and 5. Thus, for any subjects who answered “No” to question 2, an answer “No” will also 
be assumed to question 3, 4, and 5. An additional “Yes/No” question is used to record if subject had 
committed suicide in post-screening visits.  
Table 11 C-SSRS re-ordered questions 
Suicidal Ideation 
Question 1 
Wish to be dead 
Question 2 
Non-specific active suicidal thoughts 
Question 3 
Active suicidal ideation with any methods (not plan) without 
intent to act 
Question 4 
Active suicidal ideation with some intent to act, without 
specific plan 
Question 5 
Active suicidal ideation with specific plan and intent 
Suicidal Behavior 
Question 6 
 Preparatory acts or behavior 
Question 7 
Aborted attempt 
Question 8 
Interrupted attempt 
Question 9 
 Actual attempt  
Question 10 
Suicidal behavior 
Question 11 (post-screening visits 
only) 
Suicide 
Self-Injurious Behavior without Suicidal Intent 
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Question 12 
Self-injurious behavior without suicidal intent 
 
A subject is considered to have suicidal ideation at the period of interest if a “Yes” is answered to any of 
the five suicidal ideation questions (Question 1-5). A subject is considered to have suicidal behavior at 
the period of interest if a “Yes” is answered to any of the five suicidal behavior questions (Question 6-
10) at screening visit or a “Yes” is answered to any of the six suicidal behavior questions (Question 6-11) 
at post-screening visits.  
A subject’s Suicidal Ideation Score is defined as the maximal suicidal ideation question number (maximal 
of 1-5) with an answer “Yes” per visit. The score is defined as 0 if the subject answered “No” to all 5 
Suicidal Ideation questions at that visit.  
A subject is considered to have treatment-emergent suicidal ideation if the subject had either new or 
worsening suicidal ideation.  A subject is considered to have new suicidal ideation if the subject’s 
Suicidal Ideation Score increased at any post-screening visit compared to a score 0 at screening visit. A 
subject is considered to have worsening suicidal ideation if the subject’s Suicidal Ideation Score 
increased at any post-screening visit compared to a positive score at screening visit. 
A subject is considered to have treatment-emergent suicidal behavior if the subject answered “Yes” to 
any suicidal behavior questions at any post-screening visit while answered “No” to all suicidal behavior 
questions at the screening visit. 
 
13 
REFERENCE 
Calabresi PA, Mellion M, Edwards KR, et al. Efficacy Results From the Phase 2b SYNERGY Study: 
Treatment of Disabling Multiple Sclerosis with the Anti-LING0-1 Monoclonal Antibody Opicinumab. 
Presented at the 2017 American Academy of Neurology Annual Meeting. 
EMA Points to consider on implications of the Coronavirus Disease (COVID-19) on methodological 
aspects of ongoing clinical trials (2020)  
FDA Guidance for Industry: Statistical considerations for clinical trials during the COVID-19 public health 
emergency (2020) 
Sormani MP, Bruzzi P. MRI lesions as a surrogate for relapses in multiple sclerosis: a meta-analysis of 
randomised trials. Lancet Neurol. 2013;12(7):669-76. 
Yan, X., Lee, S., and Li, N. (2009), “Missing data handling methods in medical device clinical trials,” 
Journal of Biopharmaceutical Statistics, 19(6), 1085-1098. 
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Product: natalizumab (Tysabri®; BG00002) 
Study: 101MS329OLE (NOVA Part 2) 
Statistical Analysis Plan 
Version: 2.0 
 
 
Page 1 
 
 
 
 
 
 
STATISTICAL ANALYSIS PLAN 
NOVA PART 2 
 
 
Version No.: 2.0 
Date: 30 Aug 2023 
 Author: 
  
 
Study Title: A Randomized, Controlled, Open-Label, Rater-Blinded, Phase 3b Study of the 
Efficacy, Safety, and Tolerability of 6 Week Extended Interval Dosing (EID) of Natalizumab 
(BG00002) in Subjects with Relapsing Remitting Multiple Sclerosis Switching From Treatment 
With 4 Week Natalizumab Standard Interval Dosing (SID) in Relation to Continued SID 
Treatment - Followed by an Open-Label Crossover Extension Study Comprising Subcutaneous 
and Intravenous Natalizumab Administration 
Name of Study Treatment: natalizumab (Tysabri®; BG00002) 
Protocol No.: 101MS329 
Study Phase: 3b 
 
 
 
 
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Product: natalizumab (Tysabri®; BG00002) 
Study: 101MS329OLE (NOVA Part 2) 
Statistical Analysis Plan 
Version: 2.0 
 
 
Page 3 
 
 
 
VERSION HISTORY 
 
SAP Version 
Date 
Primary Reasons for 
Amendment 
1.0 
23 March 2023 
Not Applicable 
2.0 
30 August 2023 
Updated to clarify details of 
the analysis performed.  
 
 
 
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Product: natalizumab (Tysabri®; BG00002) 
Study: 101MS329OLE (NOVA Part 2) 
Statistical Analysis Plan 
Version: 2.0 
 
 
Page 4 
 
 
 
TABLE OF CONTENTS 
 
STATISTICAL ANALYSIS PLAN ........................................................................................... 1 
APPROVAL ................................................................................................................................. 2 
VERSION HISTORY ................................................................................................................. 3 
TABLE OF CONTENTS ............................................................................................................ 4 
LIST OF ABBREVIATIONS ..................................................................................................... 7 
1. 
Introduction ........................................................................................................................ 8 
2. 
Study Overview ................................................................................................................... 8 
2.1. 
Part 2 Study Objectives and Endpoints ........................................................................ 8 
2.2. 
Part 2 Study Design .................................................................................................... 10 
2.3. 
Part 2 Study Duration for Subjects ............................................................................. 11 
2.4. 
Sample Size Considerations ....................................................................................... 11 
3. 
Definitions ......................................................................................................................... 12 
3.1. 
Dates and Points of Reference .................................................................................... 12 
3.1.1. 
Definition of Baseline ............................................................................................. 12 
3.1.2. 
Visit Mapping in Part 2 ........................................................................................... 13 
3.2. 
Study Treatment in Part 2 ........................................................................................... 14 
3.3. 
Study Treatment Periods in Part 2 .............................................................................. 14 
3.4. 
Key Derived Variables ............................................................................................... 14 
3.4.1. 
Baseline Weight of Crossover Study ...................................................................... 14 
3.4.2. 
Baseline Duration of Exposure to Tysabri of Crossover Study .............................. 14 
3.5. 
Stratification Factors and Subgroup Variables ........................................................... 14 
3.5.1. 
Stratification Factors ............................................................................................... 14 
3.5.2. 
Subgroup Variables ................................................................................................. 15 
3.6. 
Analysis Populations .................................................................................................. 15 
3.6.1. 
Safety population .................................................................................................... 15 
3.6.2. 
Modified intent to treat population ......................................................................... 15 
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Study: 101MS329OLE (NOVA Part 2) 
Statistical Analysis Plan 
Version: 2.0 
 
 
Page 5 
 
 
3.6.3. 
Full analysis set ....................................................................................................... 16 
3.6.4. 
Per-protocol population .......................................................................................... 16 
3.6.5. 
Immunogenicity population .................................................................................... 16 
 
 
3.6.7. 
PK population ......................................................................................................... 17 
3.6.8. 
PD population ......................................................................................................... 17 
4. 
List of Planned Study Analyses ....................................................................................... 17 
5. 
Statistical Methods for Planned Analyses ...................................................................... 17 
5.1. 
General Principles ....................................................................................................... 17 
5.2. 
Subject Accountability ............................................................................................... 18 
5.3. 
Demographic and Baseline Characteristics ................................................................ 19 
5.4. 
Protocol Deviations .................................................................................................... 20 
5.5. 
Concomitant Medications and Non-Drug Therapies .................................................. 20 
5.6. 
Study Treatment Exposure ......................................................................................... 21 
5.7. 
Study Treatment Compliance ..................................................................................... 21 
5.8. 
Efficacy Endpoints ..................................................................................................... 22 
5.8.1. 
General Consideration for Efficacy Endpoints ....................................................... 22 
5.8.2. 
Handling of Missing Data ....................................................................................... 22 
5.8.3. 
Lesion Count Data .................................................................................................. 22 
5.8.4. 
Primary Efficacy Endpoint ..................................................................................... 23 
5.8.5. 
Secondary Efficacy Endpoints ................................................................................ 23 
 
 
 
 
 
 
 
 
 
 
5.10. 
Immunogenicity Endpoints......................................................................................... 30 
5.10.1. 
Anti-Natalizumab Antibodies Analysis .............................................................. 30 
5.11. 
Anti-JCV Antibodies Analysis ................................................................................... 31 
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Statistical Analysis Plan 
Version: 2.0 
 
 
Page 6 
 
 
5.12. 
Pharmacokinetic Endpoints ........................................................................................ 31 
5.13. 
Pharmacodynamic Endpoints ..................................................................................... 32 
5.14. 
Safety Endpoints ......................................................................................................... 33 
5.14.1. 
Clinical Adverse Events ...................................................................................... 33 
5.14.2. 
Clinical Laboratory Data ..................................................................................... 37 
5.14.3. 
Vital Sign Measurements .................................................................................... 40 
5.14.1. 
Body Weight ....................................................................................................... 42 
5.14.2. 
Physical and Neurological Examination ............................................................. 42 
5.14.3. 
Columbia Suicide Severity Rating Scale (C-SSRS) ........................................... 42 
6. 
Changes from Protocol-Specified Analyses ................................................................... 42 
7. 
Summary of Changes from the Previous Version of the SAP ...................................... 43 
8. 
References ......................................................................................................................... 45 
APPENDIX I - VISIT WINDOW MAPPING ........................................................................ 46 
 
 
 
 
 
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Product: natalizumab (Tysabri®; BG00002) 
Study: 101MS329OLE (NOVA Part 2) 
Statistical Analysis Plan 
Version: 2.0 
 
 
Page 7 
 
 
 
LIST OF ABBREVIATIONS 
 
Abbreviation 
Definition 
AE 
adverse event 
CI 
confidence interval 
CRF 
case report form 
C-SSRS 
Columbia Suicide Severity Rating Scale 
EDSS 
Expanded Disability Status Scale 
EID 
extended interval dosing 
EOS 
end of study 
 
 
Gd 
gadolinium 
ICF 
informed consent form 
INEC 
Independent Neurology Evaluation Committee 
IV 
intravenous(ly) 
JCV 
John Cunningham virus 
KM 
Kaplan-Meier 
mITT 
modified intent to treatment 
MCMC 
Markov chain Monte Carlo 
MMRM 
mixed model of repeated measures 
MRI 
magnetic resonance imaging 
MS 
multiple sclerosis 
 
 
 
 
OLE 
open-label extension 
PBMC 
peripheral blood mononuclear cell 
PBVC 
percentage of brain volume change 
PD 
pharmacodynamic(s) 
PK 
pharmacokinetic(s) 
PML 
progressive multifocal leukoencephalopathy 
PPQ 
patient preference questionnaire 
 
 
RRMS 
relapsing-remitting multiple sclerosis 
SAE 
serious adverse event 
SAP 
statistical analysis plan 
SID 
standard interval dosing 
TSQM 
Treatment Satisfaction Questionnaire for Medication 
US 
United States 
 
 
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Product: natalizumab (Tysabri®; BG00002) 
Study: 101MS329OLE (NOVA Part 2) 
Statistical Analysis Plan 
Version: 2.0 
 
 
Page 10 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2.2. 
Part 2 Study Design 
Part 2 is a 108-week OLE for approximately 158 subjects at approximately 45 sites in Canada, 
the United Kingdom, Europe, Israel, and Australia who complete their randomized treatment in 
Part 1, provide consent, and are eligible to participate immediately following completion of the 
72-week treatment period. 
Subjects who did not participate in Part 1 but provide consent and satisfy the inclusion-exclusion 
and eligibility requirements of Part 1, including treatment with natalizumab SID for at least 12 
months without relapses in the last 12 months, may also be enrolled in Part 2 as new subjects to 
ensure adequate sample size for the Part 2 analysis.  
Subjects enrolled in Part 2 will receive natalizumab 300 mg by IV infusion once every 6 weeks 
(42 ± 7 days) for a period of 36 weeks (run-in phase) and be randomized to an additional 48 
weeks of crossover treatment comprising 24 weeks EID SC Q6W and 24 weeks EID IV Q6W 
(crossover phase). All MRI scans will be read at a central facility by blinded raters. 
Subjects will be randomized in a 1:1 ratio, stratified by their treatment assignment in Part 1 (SID, 
EID, new subjects) to receive SC/IV or IV/SC before the first dose of crossover treatment in Part 
2 of the study. 
At the completion of their 48-week crossover treatment phase, subjects in Part 2 will receive a 
final dose of natalizumab 300 mg by SC injection or IV infusion with the route of administration 
being the subject’s choice, proceed to the 12-week follow-up period, and receive a follow-up 
safety phone call 12 weeks later (i.e., 24 weeks after the last dose of study treatment) before 
completing the study. 
The design of the study is presented in Figure 1. The week numbers below correspond to the 
NOVA Part 1 baseline. Randomization into the crossover period of the study takes place at Week 
108 for continuing Part 1 subjects and after the 36-week run-in period for new subjects in Part 2. 
The mapping of analysis visits in Part 2 is presented in Section 3.1.2. 
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Product: natalizumab (Tysabri®; BG00002) 
Study: 101MS329OLE (NOVA Part 2) 
Statistical Analysis Plan 
Version: 2.0 
 
 
Page 11 
 
 
Figure 1: 
Study Design 
 
Figure 2: 
Nominal Visit Mapping 
Phase 
IV run-in 
Period 1 
 
Period 2 
 
Last 
dosea 
EOS 
Safety 
follow-up 
Part 1 
Week 72 102 
108 114 120 126 
132 
138 
144 
150 
156 
168 
180 
Part 2 
Week 1 
30 
36 
42 
48 
54 
60 
66 
72 
78 
84 
96 
108 
Part 2 
crossover 
 
 
Week 1b 
6 
12 
18 
24 
30 
36 
42 
48 
60 
72 
a Last dose is subject’s choice. b Randomization visit.  
2.3. 
Part 2 Study Duration for Subjects 
The total duration of study participation in Part 2 for these subjects will be approximately 
108 weeks. This comprises EID IV treatment for 36 weeks; a randomized EID SC vs. EID IV 
crossover treatment phase of 48 weeks; a follow-up period of 12 weeks; and a follow-up safety 
phone call 12 weeks after the follow-up period (i.e., 24 weeks after the last dose of study 
treatment).  The EOS date for subjects participating in Part 2 may be the last study visit, the 
follow-up safety phone call, or last protocol-specified assessment; if the subject has ongoing AEs 
that are being followed, then the date may be the date of AE resolution. 
2.4. 
Sample Size Considerations   
Historical data on MS treatments, including a meta-analysis on the relationship between new or 
newly enlarging T2 lesions and relapses, suggest little or no clinical relevance of a difference of 
0.2 to 0.3 in mean lesion numbers over 72 weeks [Sormani and Bruzzi 2013].  With the planned 
sample size of N = 200/group in Part 1, the precision of the estimated mean lesion numbers is 
sufficient to allow > 80% probability to observe the lower limit of the 95% CI for the ratio of 
EID to SID in the estimated mean lesion number above 1 if the true mean is 0.5 and 0.3 in the 
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Product: natalizumab (Tysabri®; BG00002) 
Study: 101MS329OLE (NOVA Part 2) 
Statistical Analysis Plan 
Version: 2.0 
 
 
Page 12 
 
 
EID and SID group, respectively. If the true mean is 0.6 and 0.3 in the EID and SID group, 
respectively, the probability will be approximately 90%. In the other direction, the sample size 
provides a precision that allows approximately 90% probability to observe the upper limit of the 
95% CI to be ≤ 2 if the true mean lesion numbers in both groups are 0.3. Approximately 
480 subjects will be enrolled in Part 1 to account for a drop-out rate of approximately 17%. 
For Part 2, in the absence of EID SC natalizumab data, it is assumed that the proportion of 
subjects who would prefer SC natalizumab is 75%, with a 7.5% margin of error; therefore, a 
sample size of 130 subjects for the 95% CIs to be within 67.5% and 82.5%. Approximately 
160 subjects are needed to allow for 20% of subjects who do not provide an evaluable preference 
assessment (calculated by nQuery Advisor Version 7). 
3. 
Definitions 
3.1. 
Dates and Points of Reference 
3.1.1. Definition of Baseline 
The randomization visit for the crossover phase of the study takes place after the 36-week run-in 
period at Week 108 for Part 1 subjects and Week 36 for new subjects in Part 2. Unless stated 
otherwise, baseline data is defined as the data collected prior to the time and/or on the date of the 
first randomized dose which is usually the same day as baseline visit for the crossover phase.  If 
there is more than one value on/before the date of first randomized dose, the non-missing value 
closest to and prior to first dose will be used as the baseline value.  
 
 
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Product: natalizumab (Tysabri®; BG00002) 
Study: 101MS329OLE (NOVA Part 2) 
Statistical Analysis Plan 
Version: 2.0 
 
 
Page 13 
 
 
3.1.2. Visit Mapping in Part 2 
As the NOVA Part 2 OLE will be treated as independent study, the analysis visits will be 
remapped based on the Part 2 randomization date as follows (Table 1).  
Table 1 Visit Mapping in Part 2  
Raw Visit Label 
SDTM Visit Label 
Analysis Visit Label 
Screening OLE 
Screening – Part 2 
Screening 
Baseline-week 72 
Week 1 – Part 2 
Run-in period – visit 1 
Week 78 
Week 6 – Part 2 
Run-in period – visit 2 
Week 84 
Week 12 – Part 2 
Run-in period – visit 3 
Week 90 
Week 18 – Part 2 
Run-in period – visit 4 
Week 96 
Week 24 – Part 2 
Run-in period – visit 5 
Week 102 
Week 30 – Part 2 
Run-in period – visit 6 
Week 108 
Week 36 – Part 2 
Baseline * 
Week 114 
Week 42 – Part 2 
Week 6 
Week 120 
Week 48 – Part 2 
Week 12 
Week 126 
Week 54 – Part 2 
Week 18 
Week 132 
Week 60 – Part 2 
Week 24 
Week 138 
Week 66 – Part 2 
Week 30 
Week 144 
Week 72 – Part 2 
Week 36 
Week 150 
Week 78 – Part 2 
Week 42 
Week 156 
Week 84 – Part 2 
Week 48 
Week 168 
Week 96 – Part 2 
Week 60 – End of Study 
Week 180 
Week 108 – Part 2 
Week 72 – Safety Follow-up 
* Randomization visit.   
 
 
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Statistical Analysis Plan 
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Page 14 
 
 
3.2. 
Study Treatment in Part 2 
All subjects enrolled in Part 2 will receive natalizumab as a 300 mg IV infusion Q6W (42 [ 2/+5] 
days) for a period of 36 weeks. Subjects will then be randomized in a 1:1 ratio, stratified by 
Part 1 treatment group (SID, EID, new subjects) to receive natalizumab 300 mg SC Q6W for 
24 weeks followed by 300 mg IV Q6W for 24 weeks or the 48-week crossover in reverse 
treatment sequence order.  
3.3. 
Study Treatment Periods in Part 2 
Period 1 is defined as the first 24 weeks of the crossover phase.   
Period 2 is defined as the second 24 weeks of the crossover phase.  
3.4. 
Key Derived Variables 
3.4.1. Baseline Weight of Crossover Study 
Weight for all subjects at baseline of the crossover phase will be taken as the last value closest to 
and prior to (including on) the date of first dose in Period 1.  
3.4.2. Baseline Duration of Exposure to Tysabri of Crossover Study 
Data of first dose of Tysabri will be taken from the CRF for newly enrolled subjects and drawn 
from Part 1 data for continuing subjects.   
Duration of exposure to Tysabri at baseline of the crossover phase will be calculated as follows: 
 (Date of Randomization in Period 1 – Tysabri Start Date +1) / 365.25 
Subjects will be grouped by duration of exposure (≤ 3 years versus > 3 years).  
3.5. 
Stratification Factors and Subgroup Variables 
3.5.1. Stratification Factors 
The study randomization stratification factor and corresponding categories is listed as follows. 
 Treatment assignment in Part 1 (SID, EID, new subjects) 
 
 
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3.5.2. Subgroup Variables 
Subgroup analyses may be performed for selected endpoints to evaluate the consistency of 
findings across populations. Subgroups may be defined by prior disease activity, and the number 
and type of therapies prior to natalizumab as well as quartiles of the trough PK concentrations, α-
integrin saturation levels and sVCAM-1 at baseline and after 24 weeks of treatment.  
Other subgroups may include, but are not limited to: 
 Baseline weight (≤ 80 kg, and > 80 kg) 
 Baseline weight (40 to 59 kg, 60 to 79 kg, 80 to 89 kg, and ≥ 90 kg) 
 Duration of natalizumab exposure (≤ 3 years versus > 3 years) at baseline 
 
 
 Anti-drug antibody status (positive versus negative) 
 Baseline EDSS (EDSS score ≤ 2.0 versus EDSS score > 2.0) 
 Country/region (Canada, United Kingdom, Europe, and Israel [includes Belgium, 
France, Germany, Israel, Italy, Netherlands, and Spain], and Australia) 
 Age at baseline (age < 40 years versus age ≥ 40 years) 
 Sex 
3.6. 
Analysis Populations 
3.6.1. Safety population 
The safety population is defined as all randomized subjects who receive at least one dose of 
study treatment during the crossover phase of Part 2. Subjects in the safety population will be 
analyzed according to the actual treatment received. 
Any safety analyses performed on data collected during the run-in phase (prior to randomization 
into the crossover phase) will be presented separately for all enrolled subjects in Part 2 of 
NOVA.  
3.6.2. Modified intent to treat population 
The protocol-defined mITT population is defined as all randomized subjects who receive at least 
one dose of SC natalizumab after randomization in Part 2 and who completed at least the first 
question in the PPQ on one occasion.  
The primary endpoint will be evaluated on the mITT population. Subjects will be analyzed by 
randomized treatment sequence and overall.  
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Statistical Analysis Plan 
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3.6.3. Full analysis set 
The full analysis set is defined as all randomized subjects who receive at least one dose of study 
treatment during at least one study period and have at least one baseline assessment from the 
below clinical efficacy assessments:  
 MRI Efficacy Assessments (not including locally read MRIs) 
 Relapses (clinical relapses are assessed as defined by new or recurrent neurologic 
symptoms not associated with fever or infection having a minimum duration of 24 hours; 
see protocol section 7.3 for further details) 
 Neurological examination and EDSS 
 PPQ, TSQM, 
 
The secondary and 
 efficacy endpoints will be evaluated on the full analysis set.  
3.6.4. Per-protocol population 
The per-protocol population is defined as the subset of the full analysis set who  
 Did not have a significant protocol deviation that would be expected to affect efficacy 
assessments, which may include but is not limited to,  
o Subject was enrolled without meeting one or more inclusion or met any exclusion 
criteria 
 Subjects with ≤ 3 total number of missed doses or doses received out of the protocol-
defined dosing visit windows.  
3.6.5. Immunogenicity population 
In Part 2, the analysis population will include all subjects who receive at least one dose of SC or 
IV natalizumab and have at least one assessment for anti-drug antibody during the crossover 
phase of Part 2.  
Subjects will be analyzed according to actual treatment received. 
 
 
 
 
 
 
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3.6.7. PK population 
In Part 2, the PK population is defined as all subjects who receive at least one dose of SC or IV 
natalizumab and have at least one assessment for the concentration of natalizumab in serum 
during the crossover phase of Part 2.  
Subjects will be analyzed according to actual treatment received.   
3.6.8. PD population 
In Part 2, the PD population is defined as all subjects who receive at least one dose of SC or IV 
natalizumab and have at least one assessment of the PD parameter during the crossover phase of 
Part 2. PD parameters may include trough α4 integrin saturation on MNC, monocytes, 
lymphocytes, B cell (CD19), T cells (CD4, CD8), and dendritic cells.  
In addition, 
 biomarkers may include soluble VCAM‑ 1.  
Subjects will be analyzed according to actual treatment received.  
4. 
List of Planned Study Analyses 
No formal interim analysis is planned. After the last subject has completed the last dosing visit, 
data will be cleaned, and pages signed up to and including the last dosing visit and data will be 
reviewed.   
5. 
Statistical Methods for Planned Analyses 
5.1. 
 General Principles  
Summary tables will be presented using descriptive summary statistics. For continuous variables, 
summary statistics will generally include number of subjects with data, mean, standard deviation, 
median, 25% percentile, 75% percentile, minimum and maximum. For categorical variables, this 
will generally include number of subjects randomized or dosed, number with data, and the 
percent of those with data in each category.  
Country/region will be categorized as follows:  
 Canada 
 United Kingdom 
 Europe and Israel (includes Belgium, France, Germany, Israel, Italy, Netherlands, and 
Spain) 
 Australia 
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Unless otherwise specified, baseline value is defined as the most recent non-missing 
measurement collected prior to the first randomized dose. Change from baseline will be defined 
as post-baseline value minus baseline value.  
If a sample result is received as an inexact value, e.g., >2.35, then the numerical value excluding 
the non-numerical character will be taken for analysis purposes.   
In the analysis using negative binomial regression model, if the data are underdispersed, or if the 
negative binomial regression model does not converge, a Poisson regression model with the 
same covariates will be used instead of the negative binomial regression model. Dispersion will 
be evaluated from the Pearson Chi-Square statistic. If the ratio of the Pearson Chi-Square 
statistic to the degrees of freedom is ≤ 1 which indicates no overdispersion, then a Poisson 
regression model with adjustment for underdispersion will be used. 
Unless stated otherwise, all statistical tests will be 2-sided with statistical significance level of 
0.05.  
The statistical software, SAS® 9.4 or higher will be used for all summaries and analyses. 
5.2. 
 Subject Accountability 
Subject disposition will be summarized by randomized treatment sequence and overall. 
Summary data will include the number of subjects enrolled into Part 2, dosed during the run-in 
phase, randomized into the crossover phase of the study, dosed during Period 1, dosed during 
Period 2, and dosed during Periods 1 and 2. The number of subjects who discontinued treatment 
and/or withdrew from study, and the reasons for discontinuation and/or withdrawal will be 
summarized and listed.  
Number of subjects dosed will be summarized by country/region and time on study after 
randomization will also be summarized and listed by randomized treatment sequence and 
overall.  
Time on randomized treatment and time exposed to study treatment will be summarized by route 
of administration and listed.  
Subjects impacted by the COVID-19 pandemic will be summarized. The number of subjects who 
discontinued treatment and/or withdrew from the study due to COVID-19 will be summarized 
and listed. COVID-19 adverse events and concomitant non-drug treatments related to COVID-19 
will be summarized. Protocol deviations, including the impact of and reasons for protocol 
deviations due to COVID-19 will be summarized.  
 
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5.3. 
 Demographic and Baseline Characteristics 
Demographic data and baseline characteristics collected at the Part 1 screening visit will be 
imported for the continuing subjects rolling over from the Part 1 and summarized alongside data 
collected at the Part 2 screening visit for newly enrolled subjects. A footnote will be provided on 
relevant tables to ensure clarity. 
Demographic data collected at screening including age (years), age category (<40 and ≥ 40), sex, 
ethnicity, race, country/region, height, and childbearing potential will be summarized by 
randomized treatment sequence (SC/IV or IV/SC).  
MS disease characteristics collected at screening including number of relapses during the one 
year prior to first dose of Tysabri, and score of last EDSS assessment prior to first dose of 
Tysabri will also be summarized by treatment sequence, using descriptive statistics.  
In Part 2, baseline refers to the randomization visit for the crossover phase of the study 
(Week 108 for continuing Part 1 subjects and Week 36 for newly enrolled subjects) unless 
specified.  
MS baseline characteristics will be derived relative to the date of randomization and will be 
summarized by treatment sequence, using descriptive statistics, including years since disease 
(MS) onset, and years since diagnosis. 
Weight, body mass index (BMI), and EDSS score at baseline will also be summarized, where 
baseline is the last assessment prior to randomization. Body weight at baseline will also be 
categorized and presented using the following two groupings: <40 kg, 40 to 59 kg, 60 to 79 kg, 
80 to 89 kg, and ≥ 90 kg, and ≤ 80 kg, > 80 kg. 
In addition, summary statistics for following baseline MRI assessments (where baseline is the 
last assessment prior to randomization) will also be presented.  
 T2 hyperintense lesion volume 
 Gd-enhancing lesion number and volume 
 T1 hypointense volume 
 Normalized brain volume 
Medical history will be coded using the Medical Dictionary for Regulatory Activities (MedDRA 
v25.1 or higher). The number (%) of subjects with history (including both ongoing and not 
ongoing medical conditions) will be summarized by system organ class and preferred term. A 
listing of medical history will be generated.  
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Number and percentage of subjects with previous MS treatments other than Tysabri will be 
summarized by medications and treatment sequence. Prior MS treatments other than Tysabri will 
also be listed.  
In addition, Tysabri treatment history will also be summarized. These include total number of 
doses of Tysabri the subjects have ever received prior to enrollment, total duration of Tysabri the 
subjects have received prior to enrollment, number of doses of Tysabri the subjects have 
received in the last 12 months prior to enrollment, and number and percentage of subjects missed 
any doses of Tysabri in the last 3 months of treatment prior to the screening visit. Details of 
Tysabri treatment history will be listed for each subject.  
Medical history, prior MS treatment and Tysabri treatment history were only collected at the 
screening visit of Part 1 for the continuing subjects who rolled over into Part 2 of the NOVA 
study. Therefore, medical history, prior MS treatments, and Tysabri treatment history collected at 
the Part 1 screening visit will be imported for continuing subjects and summarized alongside data 
collected at the Part 2 screening visit for newly enrolled subjects. A footnote will be provided on 
relevant tables to ensure clarity.  
5.4. 
Protocol Deviations 
Protocol deviations identified during site monitoring will be captured in a protocol deviation log 
and categorized as major or minor deviations. The major protocol deviations will be summarized 
by treatment sequence and route of administration. Protocol deviation will be assigned to the 
most recent route of administration received before the deviation date. All protocol deviations 
will be listed.  
All protocol deviations related to COVID-19 pandemic measures will be provided in a listing 
with all available details.  
5.5. 
Concomitant Medications and Non-Drug Therapies 
All concomitant medications will be coded using the World Health Organization (WHO) 
medication dictionary September 2022 version or higher. All concomitant non-drug therapies 
will be coded using the MedDRA dictionary v25.1 or higher. A concomitant medication/therapy 
will be defined as any therapy that was taken on or after the day of the first dose of study drug 
after randomization in Period 1 of the crossover phase. This includes therapies that start prior to 
the initiation of the first dose if their use continues on or after the date of first dose. To define 
concomitant use for therapies with missing start or stop dates, the following additional criteria 
will be used: 
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 if both the start and stop dates of a therapy are missing, that therapy will be considered 
concomitant.  
 if the start date of a therapy is missing and the stop date of that therapy fall on or after the 
date of the first dose, that therapy will be considered concomitant.  
 if the start date of a therapy is prior to the date of the first dose and the stop date of that 
therapy is missing and the therapy is listed as continuing, that therapy will be considered 
concomitant, or 
 if the start date of a therapy is prior to the date of the first dose and the stop date of that 
therapy is missing and the therapy is not listed as continuing, that therapy will be 
considered non-concomitant. 
For a therapy with a partial start date, the year/month of the therapy date will be compared to that 
of the first dosing date to determine whether the therapy is concomitant. If the date of the therapy 
is missing and the year/month of the therapy date is same as the first dose, that therapy will be 
considered as concomitant.  
Concomitant medications and non-drug therapies will be assigned to the most recent route of 
administration received before the start date of the medication or non-drug therapy. Missing or 
partial start dates will be handled in the same manner as for determining concomitance.  
The number and percentage of subjects taking concomitant medication and non-drug therapies 
will be summarized by treatment sequence and route of administration. Non-drug therapies will 
be presented by treatment sequence and route of administration. Medications taken prior to first 
dose in Period 1, concomitant medications and non-drug therapies will be listed.  
The most frequent concomitant medications, defined as those taken by at least 10% of subjects in 
any group, will also be summarized by treatment sequence and route of administration.  
5.6. 
Study Treatment Exposure 
Study treatment exposure will be summarized by route of administration.  
Time on randomized treatment in weeks is calculated as (the date of last dose of the period - the 
date of first dose of the specific treatment period + 1)/7. 
Time exposed to each route of administration during the crossover phase in weeks is calculated 
as (the date of last dose of the period + 42 - the date of first dose of the specific period + 1)/7. 
5.7. 
Study Treatment Compliance 
A summary of doses received over time by visit and treatment sequence will be provided.  
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Study treatment compliance will be summarized for each route of administration (IV or SC). The 
number of doses received by IV or SC, and percentage compliance will be presented.   
Compliance (%) is calculated as number of actual doses / number of planned doses * 100 per 
route of administration. Planned doses are calculated based on the number of doses a subject is 
scheduled to receive, based on their time on study.  
5.8. 
Efficacy Endpoints 
5.8.1. 
General Consideration for Efficacy Endpoints 
The primary endpoint will be evaluated on the mITT population. The mITT population may also 
be used for selected secondary 
 efficacy endpoints.  
All secondary 
 efficacy endpoints will be evaluated on the full analysis set 
(FAS). The number of subjects included in statistical analyses will be those with baseline data 
and data from at least one treatment period.  
Subjects will be analyzed according to randomized route of administration.  
5.8.2. 
Handling of Missing Data 
Missing data will be not imputed for the primary endpoint. Multiple imputation may be 
conducted for selected secondary 
 endpoints as part of ad hoc sensitivity analyses 
if appropriate.  
For continuous or count endpoints, multiple imputation will be performed on the actual values 
using the Markov chain Monte Carlo (MCMC) method. The imputation model will include 
treatment sequence (IV/SC, SC/IV), the endpoint values at each visit (baseline, week 24, week 
48), stratification factor (new subject, SID, EID), baseline body weight, baseline Tysabri 
exposure (≤ 3 years versus > 3 years). The imputed complete datasets can then be used to 
calculate the change from/relative to baseline for each period.   
Prior to imputation, the dataset will be sorted by ascending unique subject identifier (USUBJID). 
All categorical variables be coded in numerical form in the imputation model.  A set of 100 
complete imputed datasets will be generated with 100 burn-in iterations and the relative 
efficiency (RE) will be checked.  The seed used for imputation is 87922.    
5.8.3. 
Lesion Count Data 
If the total number of lesions across the two arms are less than 15 for each visit, then the negative 
binomial regression model will not be conducted for that parameter, and only descriptive 
summary statistics will be presented.  
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Otherwise, if negative binomial regression model does not work, Poisson regression model will 
be conducted, and if Poisson regression model does not work, then only descriptive summary 
statistics will be presented. This rule will be applicable to the analysis of all lesion parameters.  
5.8.4. 
Primary Efficacy Endpoint 
5.8.4.1. Proportion of subjects indicating a preference for natalizumab SC administration 
at the end of Part 2 
The primary endpoint in Part 2 of the study is the proportion of subjects indicating a preference 
for natalizumab SC administration at the end of Part 2. The mITT population will be used for 
analyses of the primary endpoint.  
For each subject, the first answer in the PPQ will be used to derive the primary endpoint of Part 2 
‘All things considered which method of administration did you prefer? (IV, SC, No preference)’.  
The proportion of subjects preferring SC natalizumab at the end of Part 2 will be estimated, and 
the 95% CI will be calculated using the exact Binomial method.  
Summary statistics will be provided for the preferred route of administration, strength of 
preference and two main reasons for preference at each visit (Week 30, Week 42 relative to the 
randomization visit). Summary statistics will be presented by treatment sequence and overall.  
Subjects’ choice of last dose on the study (IV or SC) will be summarized by treatment sequence 
and overall.  
5.8.5. Secondary Efficacy Endpoints 
5.8.5.1. Treatment Satisfaction Questionnaire for Medication (TSQM) 
Summary statistics for total TSQM score, each sub score, and the change in each from baseline 
to Week 24 and Week 48 will be presented by treatment sequence and visit.   
Change from baseline in total TSQM score for each route of administration after 24 weeks will 
also be calculated relative to the beginning of the treatment period and analyzed using a linear 
mixed effect model including route of administration (IV, SC), treatment period, and treatment 
sequence as fixed effects and subject as random effect, adjusting for baseline body weight 
(continuous variable), baseline duration of natalizumab exposure (≤ 3 years versus > 3 years), 
stratification factor (SID, EID, new subjects), and baseline total TSQM score.  
Estimates for each route of administration, as well as the difference between IV and SC routes 
after 24 weeks of treatment will be presented, along with 95% CI and p-value.  
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5.8.5.2. Mean time for drug preparation and administration between SC and IV routes of 
administration 
Mean time for preparation of IV treatment will be summarized. Mean drug administration time 
will be summarized for both IV and SC treatments. Data is collected for the preparation and 
administration of each route of administration at each visit and will be pooled before 
summarizing.  Preparation time, administration time, and total administration time (preparation 
time + administration time) will be calculated and presented by route of administration.   
Number of new or newly enlarging T2 hyperintense lesions 
The number of new or newly enlarging T2 hyperintense lesions will be summarized over time by 
treatment sequence and visit. The number of new or newly enlarging T2 hyperintense lesions 
from Baseline to Week 24, Week 24 to Week 48, and Baseline to Week 48 (calculated 
cumulatively over time) will be presented.   
The number of new or newly enlarging T2 hyperintense lesions after 24 weeks of treatment 
relative to the beginning of the period will also be summarized and analyzed using a negative 
binomial generalized linear model. The model will include route of administration (IV or SC), 
treatment period, and treatment sequence, as fixed effects, and subject as random effect, 
adjusting for baseline body weight (continuous variable), baseline duration of natalizumab 
exposure (≤ 3 years versus > 3 years), stratification factor (SID, EID, new subjects), and baseline 
number of lesions.  
The ratio of mean lesion numbers of SC versus IV will be derived from the model with a 95% CI 
and associated p-value.  
However, if the total number of observed new/newly enlarging T2 lesion is less than 15 across 
both arms for each visit, then the negative binomial regression model will not be conducted, and 
only descriptive summary statistics will be presented.  
Otherwise, if negative binomial regression model does not work, Poisson regression model will 
be conducted, and if Poisson regression model does not work, then only descriptive summary 
statistics will be presented. This rule will also be applicable to the analysis of other MRI 
parameters.  
5.8.5.3. Proportion of subjects with no new or newly enlarging T2 hyperintense lesions 
over 48 weeks 
The proportion of subjects with no new or newly enlarging T2 hyperintense lesions over 48 
weeks will be summarized by treatment sequence and overall.  Data will be censored at the time 
of withdrawal from study treatment.  
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Responders for this analysis are defined as subjects who complete study treatment until Week 48 
and have no new or newly enlarging T2 hyperintense lesions prior to Week 48. Non responders 
include subjects with new or newly enlarging T2 hyperintense lesions reported prior to Week 48 
and subjects who discontinue randomized treatment due to lack of efficacy prior to Week 48. 
Subjects who discontinue treatment due to non-efficacy reasons prior to Week 48 and have no 
new or newly enlarging T2 hyperintense lesions reported prior to the intercurrent event will be 
excluded from this summary. 
5.8.5.4. Time to first relapse 
Given the nature of crossover study design, the proposed protocol-specified analytical approach 
does not account for the correlation of within subject effect.  In Part 2, the start date for time to 
first relapse or censoring will be defined as the start date of the first randomized dose. If a 
subject withdraws from the study prior to the end the crossover phase and did not experience a 
relapse reported prior to withdrawal, the subject will be censored on the last day in the crossover 
phase.  
The proportion of relapsed subjects will be estimated using the KM product limit method and be 
presented as KM curves over time by treatment sequence. The hazard ratio of SC/IV versus 
IV/SC will be estimated from the Cox model with terms for treatment sequence, baseline body 
weight (continuous), baseline duration of Tysabri exposure (≤ 3 years versus > 3 years), and 
stratification factor (SID, EID, new subjects). 
Analysis will only be performed if a number of events sufficient to obtain a reliable estimate are 
observed.  
5.8.5.5. Annualized relapse rate 
During each period of the crossover design in Part 2, all relapses reported prior to the end of each 
period will be included in the analysis for this endpoint. 
The relapse rate for each route will be calculated as the total number of relapses experienced for 
the administration route divided by the total number of subject-years on study at the end of each 
period for the route of administration. This is the unadjusted relapse rate. 
In addition, the relapse rate for an individual subject will be calculated as the number of relapses 
for that subject in each period divided by the duration of the subject on study in years at the end 
of each period. Based on these individual relapse rates, the mean and median for each route will 
be presented. This is called the subject relapse rate. 
The annualized relapse rate at the end of each period will be analyzed using a negative binomial 
regression model, with route of administration, treatment sequence, treatment period, and 
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stratification factor (SID, EID, new subjects) as the classification variables and with baseline 
body weight (continuous), and duration of natalizumab exposure (≤ 3 years versus > 3 years) as 
covariates. The logarithmic transformation of the number of years in the study at the time end of 
each period will be included in the model as the “offset” parameter. The ratio of mean 
annualized relapse rate of SC versus IV will be derived from the model with a 95% CI and 
associated p-value. If negative binomial regression model does not converge, a Poisson 
regression model with the same classification variable and covariates will be used instead. If 
Poisson regression model doesn’t work, then only descriptive summary statistics will be 
presented. 
Annualized relapse rate will only be calculated if a number of events sufficient to obtain a 
reliable estimate are observed.  
5.8.5.6. Change in EDSS score 
EDSS score and change from baseline will be summarized over time by treatment sequence and 
visit. Change from baseline will also be calculated after 24 weeks relative to the beginning of the 
period and analyzed by route of administration in the same manner as described in section 
5.8.5.1 for the TSQM total score.  
Confirmed EDSS worsening is defined as an increase of at least 1.0 point from a baseline EDSS 
score >=1.0 or an increase of at least 1.5 points from a baseline EDSS score of 0 (observed at the 
Week 24 visit), that is confirmed after at least 24 weeks (at the Week 48 visit). 
The number of subjects with confirmed EDSS worsening will be presented by treatment 
sequence. The proportion of subjects free of confirmed EDSS worsening at Week 48 will be 
estimated based on the Kaplan-Meier product limit method.  
Confirmed EDSS improvement is defined as a decrease of at least 1.0 point from a baseline 
EDSS score of >=2.0 (observed at the Week 24 visit) that is confirmed after at least 24 weeks (at 
the Week 48 visit). The number of subjects with confirmed EDSS improvement will be 
presented in the same manner as described for confirmed EDSS worsening.  
Worsening or improvement observed at Week 48 only could not be confirmed without follow-up 
data.  
5.8.5.7. Number of new Gd-enhancing lesions 
The number of new Gd-enhancing lesions over time will be summarized by treatment sequence 
and visit. The number of new or newly enlarging T2 hyperintense lesions from Baseline to Week 
24, Week 24 to Week 48, and Baseline to Week 48 (calculated cumulatively over time) will be 
presented.  
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The number of lesions observed after 24 weeks of treatment relative to the beginning of the 
treatment period will be summarized and analyzed by route of administration in the same manner 
as described in section 0 for new or newly enlarging T2 hyperintense lesions.  
5.8.5.8. Number of new T1 hypointense lesions 
The number of new T1 hypointense lesions over time will be summarized by treatment sequence 
and visit. The number of new T1 hypointense lesions from Baseline to Week 24, Week 24 to 
Week 48, and Baseline to Week 48 (calculated cumulatively over time) will be presented. The 
number of lesions observed after 24 weeks of treatment relative to the beginning of the treatment 
period will be summarized and analyzed by route of administration in the same manner as 
described in section 0 for new or newly enlarging T2 hyperintense lesions.  
5.8.5.9. PBVC  
Summary statistics for normalized brain volume will be presented by treatment sequence and 
visit. Change from baseline and percentage change from baseline in brain volume over time will 
be presented by treatment sequence and visit.  
Percentage change from baseline in normalized brain volume will also be calculated after 24 
weeks of treatment relative to the beginning of the treatment period and analyzed using a linear 
mixed effect model. The model will include route of administration, treatment period, and 
treatment sequence as fixed effects and subject as random effect, adjusting for baseline body 
weight (continuous variable), baseline duration of natalizumab exposure (≤ 3 years versus > 3 
years), stratification factor (SID, EID, new subjects), and baseline normalized brain volume.  
Estimates for each route of administration, as well as the mean difference between IV and SC 
groups after 24 weeks of treatment, will be presented, along with 95% CI and p-value. 
5.8.5.10. Cortical brain region grey matter volume 
Summary statistics for normalized cortical grey matter volume and change from baseline in 
cortical grey matter volume over time will be presented by treatment sequence and visit.  
Change from baseline in cortical grey matter volume will also be calculated after 24 weeks of 
treatment relative to the beginning of the treatment period and analyzed using a linear mixed 
effect model. The model will include route of administration, treatment period, and treatment 
sequence as fixed effects and subject as random effect, adjusting for crossover baseline body 
weight (continuous variable), duration of natalizumab exposure at baseline (≤ 3 years versus > 3 
years), baseline stratification factor (SID, EID, new subjects), and baseline normalized cortical 
grey matter volume.    
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Estimates for each route of administration, as well as the mean difference between IV and SC 
groups after 24 weeks of treatment, will be presented, along with 95% CI and p-value. 
5.8.5.11. Thalamic brain region volume 
Summary statistics for normalized thalamic volume and change from baseline in thalamic 
volume over time will be presented by treatment sequence and visit.  
Change from baseline in thalamic volume after 24 weeks relative to the beginning of the period 
will be analyzed for each route of administration in the same manner as described in section 
5.8.5.10 for the cortical grey matter volume.  
 
 
 
 
 
 
 
  
 
 
 
  
 
 
  
 
 
 
  
 
 
  
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5.10. 
Immunogenicity Endpoints 
The immunogenicity population will be used for immunogenicity analysis. Immunogenicity data 
will be mapped to an appropriate analysis visit using the windowing scheme described in 
Appendix I.  
5.10.1. Anti-Natalizumab Antibodies Analysis 
Serum samples to test for anti-natalizumab antibodies will be collected immediately prior to 
dosing, at baseline of the crossover phase, and at weeks 12, 24, 36, and 48 relative to 
randomization.  
The percentage of subjects who develop antibodies will be determined and summarized over 
time by treatment sequence (at baseline, Week 12, Week 24, Week 36, and Week 48 relative to 
randomization) and by route of administration (at beginning of period, and after 6, 12, 18, and 24 
weeks relative to the beginning of the period). 
 The baseline value is defined as the latest immunogenicity data collected at any time 
prior to the first dose of the crossover phase.  If no immunogenicity data are collected 
prior to the first dose, the baseline value will be designated ‘Missing’ in summary tables.  
A summary of negative and positive will also be presented using the following definitions: 
 Subjects with no positive post-treatment samples for anti-natalizumab antibodies will be 
considered negative regardless of their baseline result. 
 Subjects with at least one confirmed post-treatment positive result will be considered 
positive for anti-natalizumab antibodies if their baseline result is negative. 
 In addition, for subjects that are considered anti-natalizumab antibody positive, the 
following may be evaluated: 
 Persistent anti-natalizumab antibody response:  
 More than one positive time point that are ≥112 days apart 
or 
One or more positive time point, but < 112 days of evaluable data post first positive 
time point.  
 Transient anti-natalizumab antibody response:  
A single positive time point, followed by ≥112 days results which are all negative. 
or 
Two positive data points with <112 days apart, with later negative samples that are 
≥112 days apart from the first positive result.  
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An impact on efficacy and safety may be conducted by considering antibody status [positive 
(transient and persistent) or negative].  
A listing will be generated for subjects determined to be persistent positive including confirmed 
progression status, on study relapse status (both INEC confirmed and any reported) and the 
following by visit data, anti-natalizumab antibody result, and EDSS. 
A separate listing will be generated for subjects determined to be persistent positive and who had 
a hypersensitivity event.  
 
 
 
 
  
 
 
 
  
5.12. 
Pharmacokinetic Endpoints 
The PK population will be used for pharmacokinetics analysis. Concentration data taken from 
early termination visits will be assigned to the next scheduled visit within the same route of 
administration. 
Serum trough natalizumab concentration (Ctrough) will be summarized using descriptive summary 
statistics (number of subjects with data, mean, standard deviation, median, 25% percentile, 75% 
percentile, minimum, maximum, geometric mean, and CV%)). Summary statistics will be 
presented at 6-weekly intervals for each scheduled visit from baseline of the crossover period up 
to pre-dose at Week 48 for each treatment sequence. Summary statistics will also be presented at 
6-weekly intervals (at beginning of period, and after 6, 12, 18, and 24 weeks relative to the 
beginning of the period), for each route of administration. Concentrations below the limit of 
quantification (BLQ) will be treated as zero for summary statistics and shown as BLQ in data 
listings.  
Plots of arithmetic mean concentration by visit will be provided for all time points. All above 
analyses will be summarized by treatment sequence and by route of administration.   
Population PK and PK/PD analysis may be performed when data supports and deemed 
necessary. 
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5.13. 
Pharmacodynamic Endpoints 
The PD population will be used for pharmacodynamic analysis. Post-baseline measurements will 
be mapped to an appropriate analysis visit using the windowing scheme described in Appendix I.  
The PD properties of natalizumab will be evaluated using the following assessments that include, 
but may be not limited to, the following: 
 trough α4 integrin saturation on MNC, monocytes, lymphocytes, B cell (CD19), T cells 
(CD4, CD8), and dendritic cells.  
In addition, 
 biomarkers may include soluble VCAM‑ 1.  
Measurements taken at Baseline/Day1, Week 6, Week 12, Week 18, Week 24, Week 36 and 
Week 48, and the changes from baseline over time will be summarized by treatment sequence 
and visit. Mean values will also be plotted over time for each parameter. Parameters with non-
normal distributions may be analyzed in logarithmic scale. 
For statistical analyses, change from baseline will be obtained within each period separately, 
where the baseline of each period is defined as the last assessment before the first dose 
administration during that period.  
Change from baseline relative to the first dose of the period will be analyzed over the 24-week 
treatment period by route of administration. Data from both treatment periods will be used. 
Change from baseline will be analyzed using a linear mixed model to estimate the mean 
difference between routes of administration (IV vs SC) at each time point.  Visit, route, treatment 
period, and sequence will be treated as class variables. Visit, route, treatment period, sequence, 
and the interaction term for route and visit will be included in the model as fixed effect and 
subject as random effect. The model will also be adjusted for crossover baseline body weight 
(continuous), duration of natalizumab exposure (≤ 3 years or < 3 years), and stratification factor 
(SID, EID, new subjects).  
The LS means of each route as well as the estimated differences between each route of 
administration (IV vs SC) will be presented, along with 95% CI and p-value at each visit. 
Where a MMRM model is used, an unstructured covariance (UN) matrix will be used to model 
the within-subject variability. Model convergence will be checked. If the unstructured covariance 
model fails to converge with the default Newton-Raphson algorithm, the Fisher scoring 
algorithm will be used to provide initial values of the covariance parameters. In the event that 
none of the above methods yield convergence, a structured covariance such as heterogeneous 
Toeplitz (TOEPH) structure will be used. 
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5.14. 
Safety Endpoints 
All safety analyses will be performed on the safety population. 
Clinical laboratory data (including any abnormalities), vital sign measurements, physical 
examination findings, neurological examination findings, and body weight, will be evaluated for 
safety up to the end of study visit (Week 60 or earlier for early termination subjects).  
Adverse events (AEs), and serious adverse events (SAEs) will continue to be evaluated up to the 
follow up safety phone call at Week 72 relative to the randomization visit (Week 180 relative to 
the start of Part 1).   
Unless otherwise specified, no formal statistical testing will be performed on the safety data.  
Safety data collected at ET visits and unscheduled visits will be mapped to an appropriate 
analysis visit using a windowing scheme described in Appendix I.  
Additional safety analyses may be performed as needed after reviewing data from all subjects .  
Data from subjects who experienced an SAE, an AESI, withdrew from the study or discontinued 
from study treatment due to a TEAE, life-threatening event, hepatic injury events, malignancies, 
or pregnancy related outcomes will be provided as required for the purposes of reporting subject 
narratives. Additional subject narratives may be provided as needed after reviewing the safety 
data. 
Listings will be presented by randomized sequence and will indicate the most recent route of 
administration received before the assessment where appropriate.  
5.14.1. Clinical Adverse Events 
Any AE experienced by the subject from the time of signing of the ICF through the follow-up 
safety phone call is to be recorded on the eCRF, regardless of the severity of the event or its 
relationship to study treatment. Any SAE experienced by the subject between the time of the 
signing of the ICF and the follow-up safety phone call visit is to be recorded on an SAE form, 
regardless of the severity of the event or its relationship to study treatment.  
5.14.1.1. Treatment-emergent adverse events 
Treatment-emergent is defined as having an onset date on or after the first randomized dose, up 
to and including 84 days after the last dose date (or up to and including 168 days after the last 
dose date for PML events). 
Adverse events with onset date 85 days or later after last dose, will be presented separately.  
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In order to define treatment emergence for AE with missing start or stop dates, the following 
additional criteria will be used: 
 If both the start and stop dates for a particular event are missing, then that event is 
considered treatment emergent; 
 If the start date for a particular event is missing and the stop date/time falls after the first 
dose date/time, then that event is considered treatment emergent; 
 If the start date was the same as the first dose date, and the start time was missing, then 
that event is considered treatment emergent. 
For events with a partial start date, the year/month of the event date will be compared to that of 
the first dosing date to determine whether the event is treatment emergent. If it cannot be 
determined whether an event is treatment emergent due to a missing or partial date, then the 
event will be tabulated as treatment emergent. 
Adverse events will be assigned to the most recent route of administration received before the 
start date of the adverse event. Missing or partial start dates will be handled in the same manner 
as for determining treatment emergence. 
The overall summary table of AEs will present the number of subjects with the following events 
for each treatment sequence and route of administration. A subject is counted only once in each 
category. 
 Any AE; 
 AE with severity as “moderate” or “severe”; 
 AE with severity as “severe”; 
 Natalizumab related AE; 
 Any SAE;  
 Natalizumab related SAE;  
 AE leading to discontinuation of study treatment; and  
 AE leading to withdrawal from study.  
 AE of special interest 
 Other events of interest 
 Deaths 
The incidence of AEs will be also presented for each treatment sequence and route of 
administration. They will be summarized by the following, 
 preferred term (PT); 
 primary system organ class (SOC); 
 primary system organ class (SOC) and preferred term (PT);  
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 severity, primary SOC and PT; and 
 relationship to study treatment, primary SOC and PT. 
Corresponding to the five scenarios above, the data will be processed as follows, 
 a subject will be counted only once within each PT, and PTs will be ordered by 
decreasing incidence in the column of overall group, which combines all subjects in the 
study; 
 a subject will be counted only once within each primary SOC, and primary SOCs will be 
ordered by decreasing incidence in the column of overall group; 
 a subject will be counted only once within each primary SOC/PT, and PTs will be 
ordered by decreasing incidence within each primary SOC in the column of overall 
group.  
 a subject will be counted only once within each primary SOC/PT, and the AE with the 
greatest severity will be used. PTs will be ordered by decreasing incidence within each 
primary SOC in the column of overall group. 
 a subject will be counted only once within each primary SOC/PT, and the AE with the 
strongest relationship to study treatment will be used. PTs will be ordered by decreasing 
incidence within each primary SOC in the column of overall group. 
The incidence of SAEs, incidence of AEs that led to withdrawal from study, and incidence of 
AEs that led to discontinuation of study drug will be also summarized by treatment groups and 
by route of administration with the use of primary SOCs/PTs. The data will be processed as what 
is done for incidence of AEs. Listing of AEs, SAEs, AEs that led to study treatment 
discontinuation and AEs that led to study withdrawal, regardless of treatment emergent or not, 
will be presented. Listing of death will be provided if applicable.  
The incidence of adverse events of special interest and other events of interest will also be 
presented. These adverse event of special interest categories are defined mainly based on 
Standardized MedDRA Queries (SMQs), SOCs, and/or PTs.  
The AEs of special interest categories include but are not limited to the following: 
 PML progressive multifocal leukoencephalopathy (all events occur before the end of the 
study) 
 Serious herpes infections 
 Malignancies 
 Immunogenicity of Tysabri SC 
Other events of interest include but are not limited to the following: 
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 Infusion and injection reactions (defined as any event occurring within 2 hours of the 
start of infusion or injection) 
 Infusion and injection site reactions (defined as any PT occurring under the higher-level 
terms (HLT) of ‘Injection site reactions’ or ‘Infusion site reactions’) 
 Injection site reactions upon switching to SC (defined as any PT under the HLT of 
‘Injection site reactions’ occurring on or after the first dose of SC but prior to the second 
dose of SC.  
 Injection site pain 
 Opportunistic infections (excluding PML) 
 Hepatic injury  
 Drug induced liver injury 
 Hypersensitivity reactions 
In some AE/SAE listings, complete AE start and end dates are needed to calculate the relative 
study days of AE start and end. Therefore, any partial date will be imputed for these listings. 
Specifically, the partial AE start date will be imputed as the earliest possible date on or after the 
first dose based on the partial information, and the partial AE end date will be imputed as the 
latest possible date on or before the follow-up safety phone call visit. 
5.14.1.1. Events occurring during the run-in period 
AEs occurring during the run-in period are defined as any event occurring on or after the time of 
informed consent and prior to time of first dose after randomization (at Week 108 for continuing 
Part 1 subjects and Week 36 for newly enrolled subjects). AEs occurring during the run-in period 
will be presented for the following groups, 'discontinued during run-in period/or who were 
randomized but who did not receive a dose after randomization’, ‘IV/SC after randomization’, 
and ‘SC/IV after randomization’, for all enrolled subjects. Tabulations for AEs and SAEs as well 
as listings for each will be provided.  
5.14.1.2. Events ongoing at the end of Part 1 
Of 497 participants who entered Part 1, 68 participants rolled over into Part 2 before or at 
Week 84 and were not included in the safety population for the 101MS329 Part 1 CSR 
Addendum dated 07JUL2022 as their safety data (for completed AEs before rollover) were 
already included in the 101MS329 Final (Part 1) CSR dated 12APR2021. Ongoing AEs at the 
time of rollover will be summarized as part of the Part 2 safety analysis and will be identified as 
events beginning prior to the date of informed consent in Part 2. AEs will be presented by the 
treatment received during Part 1 (SID or EID). Tabulations for AEs and SAEs as well as listings 
for each will be provided. 
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5.14.2. Clinical Laboratory Data 
The following clinical laboratory parameters are assessed as stated in the protocol Section 5 and 
Section 14.2:  
 Blood hematology: complete blood count with differential and platelet count, and 
absolute neutrophil count  
 Blood chemistry: total protein, albumin, creatinine, blood urea nitrogen, uric acid, 
bilirubin (total and direct), alkaline phosphatase, alanine aminotransferase (ALT or 
SGPT), aspartate aminotransferase (AST or SGOT), gamma-glutamyl-transferase (GGT), 
glucose, calcium, phosphorus, bicarbonate, chloride, sodium, and potassium 
Laboratory tables and listings, unless otherwise specified, will be presented over time by 
treatment sequence and will indicate the most recent route of administration received before the 
assessment where appropriate.  
Quantitative Laboratory Analysis 
Actual laboratory values, changes from baseline and percent changes from baseline in the 
selected quantitative laboratory values will be summarized using descriptive statistics by 
treatment sequence and visit. Number of evaluable subjects, mean, standard deviation, median, 
min and max values will be presented at each visit. 
Plots of mean values (with standard deviation) for the key numeric laboratory parameters by visit 
will be provided. 
Visit windows for by visit summaries 
For laboratory by visit summaries, the analysis visit should be defined using visit windows 
(Appendix I). If there is more than 1 value in the same analysis visit window (>1 value for the 
same analysis visit) for a certain parameter for a subject, then the closest record to the target visit 
day will be used for the by visit analysis. If there are 2 values in the same analysis visit window 
with the same distance from the target visit day for a certain parameter for a subject, then the 
record with the later date will be used for the by visit analysis. If there are 2 values on the same 
day for a certain parameter for a subject, then the record with the later time will be used for the 
by visit analysis. 
Qualitative Laboratory Analysis 
For all qualitative analyses, all values will be included (not just the “analyzed record” within 
each visit window in the quantitative analyses). 
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Shift analyses 
Laboratory data will be summarized using shift tables where appropriate. Each subject’s 
hematology and blood chemistry values will be flagged as “low”, “normal”, or “high” based on 
the normal ranges of the central laboratory or as “unknown” if no result is available. Shifts from 
baseline to high or low status for hematology and blood chemistry parameters will be presented.   
In the hematology and blood chemistry shift summary tables, entries are numbers of subjects 
shift to low (or high) divide by number of subjects at risk followed by corresponding 
percentages. Number at risk for shifting to low (or high) is the number of subjects whose 
baseline value was not low (or high) and who had at least one post-baseline evaluation. Shift to 
low includes normal to low, high to low, and unknown to low. Shift to high includes normal to 
high, low to high, and unknown to high.  
Potentially clinically significant (PCS) abnormalities 
For hematology and blood chemistry, the number and percentage of subjects with any post-
baseline PCS laboratory abnormalities will be summarized by treatment sequence and route of 
administration for the parameters provided in Table 2. Post-baseline PCS laboratory 
abnormalities will be assigned to the most recent route of administration received before the 
sample date.   
Subject listings will also be presented for all subjects with any PCS laboratory abnormalities. In 
these listings, each subject’s complete history from screening to last study visit for that specific 
laboratory test meeting the PCS criteria will be listed; any abnormal values based on the normal 
ranges of the central laboratory and abnormal values based PCS criteria will be separately 
flagged in the same listing. 
Table 2 Criteria to Determine Clinically Relevant Abnormalities in blood hematology and 
blood chemistry 
Parameter Name 
Unit 
PCS Low 
PCS High 
Blood hematology 
White Blood Cells 
x109 cells/L 
< 3.0  
>16  
Neutrophils 
x109 cells/L 
< 1.5  
>13.5  
Lymphocytes 
x109 cells/L 
< 0.8   
>12  
Monocytes 
x109 cells/L 
N/A 
>2.5 
Eosinophils 
x109 cells/L 
N/A 
>1.6  
Basophils 
x109 cells/L 
N/A 
>1.6  
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Hemoglobin for females 
                     for males 
g/L 
<= 95  
<= 115  
>=175  
>=190  
Hematocrit for females 
                   for males 
% 
<= 32 
<= 37 
>=54 
>=60 
Red Blood Cells (RBC) 
x1012 cells/L 
<= 3.5  
>=6.4  
Platelet count 
x109 cells/L 
<= 75  
>=700  
Blood chemistry 
Sodium 
mmol/L 
<= 126  
>= 156  
Potassium 
mmol/L 
<= 3  
>= 6  
Chloride 
mmol/L 
<= 90  
>= 118  
Bicarbonate 
mmol/L 
<= 16  
>= 35  
Calcium 
mmol/L 
<= 2 
>= 3 
Phosphorus 
mmol/L 
<= 0.5491 
>= 1.7119  
Aspartate aminotransferase (AST) 
IU/L 
N/A 
>= 3x ULN 
Alanine Aminotransferase (ALT) 
IU/L 
N/A 
>= 3x ULN 
Alkaline phosphatase 
IU/L 
N/A 
>= 3x ULN 
Creatinine 
umol/L 
N/A 
>= 1.5x ULN 
Total Bilirubin 
umol/L 
N/A 
>= 1.5x ULN 
Total Protein 
g/L 
<= 45 
>= 100 
Albumin 
g/L 
<= 25 
N/A 
Uric Acid for females 
                 for males 
umol/L 
N/A 
N/A 
>= 501.5 
>= 619.5 
Glucose (non-fasting) 
mmol/L 
<= 2.2 
>= 13.75 
Blood urea nitrogen 
mg/dl 
<6 
>20 
Gamma-glutamyl transferase 
Units/litre 
<9 
>48 
 
 
 
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Liver function laboratory tests 
For liver function laboratory tests (ALT, AST, and total bilirubin), counts and percentages of 
maximal post-baseline values by following categories will be provided: 
For ALT or AST,  
 <= Upper Limit of Normal (ULN),  
 > ULN,  
 >= 3x ULN,  
 > 5x ULN,  
 > 10x ULN,  
 > 20x ULN. 
For total bilirubin,  
 <= ULN,  
 > ULN,  
 >= 1.5x ULN,  
 > 2x ULN,  
 > 3x ULN,  
 > 10x ULN. 
Listing of the liver function test parameters will be provided. 
5.14.3. Vital Sign Measurements 
Vital signs collected in this study include temperature, systolic and diastolic blood pressure, 
pulse rate, and respiratory rate. All measurements are collected at 6-weekly study visits until the 
EOS visit. All measurements are collected at unscheduled visits if applicable. The analysis of 
vital signs will focus on the incidence of clinically relevant abnormalities from Day 1/baseline of 
the crossover phase up to the EOS visit, based on the following criteria in Table 3. 
 
 
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Table 3 Criteria to Determine Clinically Relevant Abnormalities in Vital Sign 
Vital Sign 
Criteria for Abnormalities 
Temperature 
> 38°C and an increase from pre-dose of at least 1°C 
Heart rate 
> 120 beat per minute and an increase from pre-dose of more than 
20 beats per minute. 
< 50 beats per minute and a decrease from pre-dose of more than 20 beats 
per minute. 
Systolic Blood Pressure 
> 180 mmHg and an increase from pre-dose of more than 40mmHg. 
< 90 mmHg and a decrease from pre-dose of more than 30 mmHg. 
Diastolic Blood Pressure 
> 105 mmHg and an increase from pre-dose of more than 30 mmHg. 
< 50 mmHg and a decrease from pre-dose of more than 20 mmHg. 
Respiratory rate 
>=20 breaths per minute with a pre-dose rate of < 20 breaths per minute 
<= 10 breaths per minute with a pre-dose rate of > 10 breaths per minute 
 
A summary table for subjects with any clinically relevant post-baseline abnormalities will be 
provided. In the summary table, entries are numbers of subjects with an abnormality divided by 
number of subjects evaluated followed by corresponding percentages. Number evaluated is the 
number of subjects who had a baseline assessment and at least one post-baseline assessment for 
that vital sign.  
For each vital sign parameter, actual values and changes from baseline will be summarized using 
descriptive statistics by treatment sequence and visit. The line of mean vital sign over time by 
treatment sequence may be graphed.  
Subjects with any post-baseline clinically relevant abnormalities in vital signs will be tabulated 
by treatment sequence and route of administration and listed. Clinically relevant abnormalities in 
vital signs will be assigned to the most recent route of administration received before the date of 
assessment.  
In the listing, each subject’s complete vital sign values from screening visit to EOS visit will be 
listed with abnormalities labeled. A separate listing of adverse events will also be provided for 
subjects with any post-baseline clinically relevant abnormalities in vital signs.  
For vital sign visit summaries, the analysis visit will be defined by visit window (Tables 4-10 in 
APPENDIX II). For the same parameter for a subject, if there is more than 1 record in the same 
analysis visit window, then select the record closest to the target visit day. If there are 2 records 
in the same analysis visit window with the same distance from the target visit day, then select the 
record with the later date. If there are 2 records on the same date, then use the average value for 
quantitative parameters and the worse value for qualitative parameters.  
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5.14.1. Body Weight 
Body weight, collected at the screening visit, baseline of the crossover phase, Week 24, and 
Week 48 will be summarized by treatment sequence over time. 
5.14.2. Physical and Neurological Examination 
New abnormalities in physical and neurological assessments will be reported as AEs and 
presented in the AE summaries.  
5.14.3. Columbia Suicide Severity Rating Scale (C-SSRS) 
C-SSRS was not assessed during the crossover phase of Part 2 of the study.  
C-SSRS was collected at Week 84 relative to the start of Part 1 for rollover subjects only and 
recorded in the Part 2 database. Analysis of Week 84 data will be performed alongside C-SSRS 
data from all other visits in Part 1 as a separate analysis.  
6. 
Changes from Protocol-Specified Analyses 
This SAP supersedes the statistical considerations identified in the protocol; analyses specified in 
the SAP reflect an approach that accounts for the Part 2 crossover study design. The full analysis 
set was defined to address secondary 
 endpoints.  
1. The per-protocol set was defined to provide supportive analyses of selected efficacy 
endpoints as needed.  
2. Considerations have been made for data pertaining to subjects rolling over into Part 2 
from Part 1.   
3. Considerations have been made for data related to the 36-week run-in period prior to 
randomization into the crossover phase.  
4. Time to event analyses will be presented over time by treatment sequence rather than 
route of administration as the protocol-specified analysis does not account for the 
correlation of the within subject effect.  
 
 
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7. 
Summary of Changes from the Previous Version of the SAP 
Section 
Change and rationale 
3.1.1. Definition 
of Baseline 
The definition of baseline of the crossover phase was clarified.  
5.1. 
 General 
Principles 
Text added to reflect data handling performed:  
‘If a sample result is received as an inexact value, e.g., >2.35, then the 
numerical value excluding the non-numerical character will be taken for 
analysis purposes.’ 
5.2. 
 Subject 
Accountability 
Text edited for clarity as last dose is subject’s choice (rather than randomized): 
time exposed to randomized study treatment 
5.8.5.4. Time to first 
relapse 
Text added to reflect the actual data observed:  
‘Analysis will only be performed if a number of events sufficient to obtain a 
reliable estimate are observed.’ 
5.8.5.5. Annualized 
relapse rate 
Text added to reflect the actual data observed:  
‘Annualized relapse rate will only be calculated if a number of events sufficient 
to obtain a reliable estimate are observed.’ 
5.8.5.6. Change in 
EDSS score 
Definitions and description of analyses performed were added as follows:  
‘Confirmed EDSS worsening is defined as an increase of at least 1.0 point from 
a baseline EDSS score >=1.0 or an increase of at least 1.5 points from a 
baseline EDSS score of 0 (observed at the Week 24 visit), that is confirmed 
after at least 24 weeks (at the Week 48 visit). 
The number of subjects with confirmed EDSS worsening will be presented by 
treatment sequence. The proportion of subjects free of confirmed EDSS 
worsening at Week 48 will be estimated based on the Kaplan-Meier product 
limit method.  
Confirmed EDSS improvement is defined as a decrease of at least 1.0 point 
from a baseline EDSS score of >=2.0 (observed at the Week 24 visit) that is 
confirmed after at least 24 weeks (at the Week 48 visit). The number of subjects 
with confirmed EDSS improvement will be presented in the same manner as 
described for confirmed EDSS worsening.  
Worsening or improvement observed at Week 48 only could not be confirmed 
without follow-up data.’ 
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5.10. 
Immunogenicity 
Endpoints 
Text edited to reflect data handling performed:  
Immunogenicity data taken from the early termination visit will be assigned 
mapped to the next scheduled visit an appropriate analysis visit using the 
windowing scheme described in Appendix I. 
 
 
 
  
 
 
5.13. 
Pharmacodynamic 
Endpoints 
Text edited to reflect data handling performed:  
Measurements taken from early termination visits Post-baseline measurements 
will be assigned mapped to the next scheduled an appropriate analysis visit 
within the same treatment period using the windowing scheme described in 
Appendix I. 
5.14.1.1. Treatment-
emergent adverse 
events 
Text edited for clarity: 
Treatment-emergent is defined as having an onset date on or after the first 
randomized dose in Period 1, up to and including 84 days after the last 
randomized dose date. (or up to and including 168 days after the last dose 
date for PML events). 
5.14.1.1. Treatment-
emergent adverse 
events 
Text added to reflect data presented: 
‘Adverse events with onset date 85 days or later after last dose, will be 
presented separately.’ 
5.14.1.1. Treatment-
emergent adverse 
events 
Adverse event of special interest was clarified:  
• Immunogenicity of Tysabri SC 
APPENDIX I - 
VISIT WINDOW 
MAPPING 
Table 5: Visit Windows for Brain MRI 
Text added for clarity: 
‘MRI data collected at scheduled visits will not be mapped. ET data will be 
mapped to the next scheduled visit.’ 
APPENDIX I - 
VISIT WINDOW 
MAPPING 
Subtitle edited for clarity: 
Table 6: Visit Windows for TSQM, PROs, EDSS and Neurological 
Examination 
APPENDIX I - 
VISIT WINDOW 
MAPPING 
Visit window mapping included to reflect data handling performed:  
Table 11: Visit Windows for Pharmacodynamic Measurements 
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8. 
References 
Kenward MG, Roger JH. The use of baseline covariates in crossover studies. Biostatistics. 2010 
Jan;11(1):1-17. 
Senn, S, Cross-over Trials in Clinical Trial Research, Second Edition, 2002, John Wiley & Sons, 
Ltd. 
Sormani MP, Bruzzi P. MRI lesions as a surrogate for relapses in multiple sclerosis: a meta-
analysis of randomised trials. Lancet Neurol. 2013;12(7):669-76. 
 
 
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APPENDIX I - VISIT WINDOW MAPPING 
For data that are summarized by visit and longitudinal analysis, assessment from all scheduled 
visits including ET visit and EOS visit, and all unscheduled visits will be mapped to an 
appropriate analysis visit using a windowing scheme. Analysis visit windows are defined in 
Table 4 - Table 10 for different endpoints. To define analysis visit window, the target visit day is 
calculated as (week number*7+1). The lower bound of visit window is calculated as target 
day−(target day−target day of previous visit)/2+1, except for the first post-baseline visit window 
whose lower bound is set as Day 2; the upper bound of visit window is calculated as target 
day+(target day of next visit−target day)/2. 
If there are 2 or more assessments from visits other than ET or EOS visits mapped to the same 
analysis visit for a subject, the assessment that is closest to the target visit day will be used for 
analysis.  If there are 2 or more assessments from visits other than ET or EOS visits mapped to 
the same analysis visit with the same distance from the target visit day, then select the later 
one(s) for the analysis.  If there are 2 or more assessments from visits other than ET or EOS 
visits mapped to the same analysis visit and on the same day, use the average value for 
quantitative parameters and the worst value for qualitative parameters for analysis.  
If ET visit is mapped to an analysis visit and a prior visit (either scheduled or unscheduled visit) 
is mapped to the same analysis visit, then ET visit will be remapped to the next analysis visit. If 
EOS visit is mapped to an analysis visit and a prior visit, e.g., ET visit, is mapped to the same 
analysis visit, then EOS visit will be remapped to the next analysis visit. The latest analysis visit 
for ET visit can be up to Week 48 and for EOS visit can be up to Week 60. 
Table 4: Visit Windows for Patient Preference Questionnaire 
Analysis visit  
Target visit day  
Analysis visit window 
Week 30 
211 
[1,253] 
Week 42 
295 
≥ 254 
Table 5: Visit Windows for Brain MRI 
MRI assessments collected within 4 weeks after the last dose of steroid treatment for relapse will 
not be included in the efficacy analysis. MRI data collected at scheduled visits will not be 
mapped. ET data will be mapped to the next scheduled visit. MRI data collected at unscheduled 
visit for safety monitoring won’t be included in the efficacy analysis. 
Table 6: Visit Windows for TSQM, PROs, EDSS and Neurological Examination 
DocuSign Envelope ID: AE60A536-228E-4409-956E-474271CF0F53


Product: natalizumab (Tysabri®; BG00002) 
Study: 101MS329OLE (NOVA Part 2) 
Statistical Analysis Plan 
Version: 2.0 
 
 
Page 47 
 
 
Analysis visit  
Target visit day  
Analysis visit window 
Baseline/Day 1 
1 
≤ 1 
Week 24 
169 
[2,253] 
Week 48 
337 
≥ 254 
Table 7: Visit Windows for Blood Hematology 
Analysis visit  
Target visit day  
Analysis visit window 
Baseline/Day 1 
1 
≤ 1 
Week 24 
169 
[2,253] 
Week 48 
337 
[254, 379] 
Week 60/End of Study 
421 
≥ 380 
Table 8: Visit Windows for Blood Chemistry 
Analysis visit  
Target visit day  
Analysis visit window 
Run-in visit 3 
-168 
≤ 1 
Week 60/End of Study 
421 
≥ 2 
Table 9: Visit Windows for Vital Signs Measurements 
Analysis visit  
Target visit day  
Analysis visit window 
Baseline/Day 1 
1 
≤ 1 
Week 6 
43 
[2, 64] 
Week 12 
85 
[65, 106] 
Week 18 
127 
[107, 148] 
Week 24 
169 
[149, 190] 
Week 30 
211 
[191, 232] 
Week 36 
253 
[233, 274] 
Week 42 
295 
[275, 316] 
Week 48 
337 
[317, 379] 
DocuSign Envelope ID: AE60A536-228E-4409-956E-474271CF0F53


Product: natalizumab (Tysabri®; BG00002) 
Study: 101MS329OLE (NOVA Part 2) 
Statistical Analysis Plan 
Version: 2.0 
 
 
Page 48 
 
 
Analysis visit  
Target visit day  
Analysis visit window 
Week 60/End of Study 
421 
≥ 380 
Table 10: Visit Windows for Anti-natalizumab Antibodies 
Analysis visit  
Target visit day  
Analysis visit window 
Baseline/Day 1 
1 
≤ 1 
Week 12 
85 
[2, 127] 
Week 24 
169 
[128, 211] 
Week 36 
253 
[212, 295] 
Week 48 
337 
≥ 296 
Table 11: Visit Windows for Pharmacodynamic Measurements 
Analysis visit  
Target visit day  
Analysis visit window 
Baseline/Day 1 
1 
≤ 1 
Week 6 
43 
[2, 64] 
Week 12 
85 
[65, 106] 
Week 18 
127 
[107, 148] 
Week 24 
169 
[149, 190] 
Week 30 
211 
[191, 232] 
Week 36 
253 
[233, 274] 
Week 42 
295 
[275, 316] 
Week 48 
337 
≥ 317 
 
 
DocuSign Envelope ID: AE60A536-228E-4409-956E-474271CF0F53


Product: natalizumab (Tysabri®; BG00002) 
Study: 101MS329OLE (NOVA Part 2) 
Statistical Analysis Plan 
Version: 2.0 
 
 
Page 49 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
DocuSign Envelope ID: AE60A536-228E-4409-956E-474271CF0F53


Product: natalizumab (Tysabri®; BG00002) 
Study: 101MS329OLE (NOVA Part 2) 
Statistical Analysis Plan 
Version: 2.0 
 
 
Page 50 
 
 
 
DocuSign Envelope ID: AE60A536-228E-4409-956E-474271CF0F53




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