Clinical trial NCT03656926
Conditions: Bronchiolitis Obliterans Chronic Rejection of Lung Transplant Lung Transplant Rejection Lung Transplant; Complications Lung Transplant Failure and Rejection Chronic Lung Allograft Dysfunction
Sponsor: Zambon SpA
Start date: 2019-03-26; Completion date: 2024-03-12
Enrollment: 169 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
The objective of this trial was to assess the efficacy and safety of aerosolized liposomal cyclosporine A (L-CsA) as add-on therapy to standard of care (SoC) as compared to SoC alone in double lung transplant (DLT) recipients with chronic lung allograft dysfunction (CLAD)-bronchiolitis obliterans syndrome (BOS).

Detailed description:
This was a Phase III, open-label, prospective, multicenter, randomized, controlled clinical trial of L-CsA for the treatment of BOS in adults following DLT. The patient population was recipients of a double pulmonary allograft, \> or = 18 years old, with clinically defined CLAD--BOS with screening FEV1 \>or = 51% of personal best FEV1 value post-transplant during the Screening period.

The rationale for an open-label study was driven by concerns that a sucrose-containing placebo formulation could increase a potential risk of pulmonary infection without the benefit of L-CsA. Sucrose is a lyoprotectant in the manufacturing process. After carefully considering alternative options for lyoprotection, no sugar-free alternatives that would qualify as a real placebo (i.e., undistinguishable by means of appearance, taste, or smell) could be identified.

Therefore, an open-label, randomized controlled trial versus SoC was the only suitable alternative.

An open-label clinical trial generally bears the potential for bias in patient treatment and care, and thus trial outcome. However, for this trial the risk of bias is considered low because of the following reasons:

* During the trial, the general treatment of BOS was use of immunosuppressive therapy to the highest tolerable level unless limited by systemic toxicity. As inhaled L-CsA has not been associated with additional systemic drug burden, dose reductions or adaptations of other components of the immunosuppressive cocktail would not be required and were not desired.
* The selected primary endpoint FEV1 is an objective parameter and its measurement was performed according to recommended guidelines of American Thoracic Society (ATS)/European Respiratory Society (ERS) which had to be respected by each participating center. Following this methodology, a subjective and intentional manipulation of outcome was highly unlikely even if healthcare professional and patient were aware of the treatment allocation.
* Pulmonary function technicians, respiratory therapists, or physiotherapists who performed spirometry at each site were blinded to each patient's study treatment assignment.
* Finally, the correctness and validity of individual FEV1 curves and their resulting value had to be approved in a central and blinded reading by a pulmonary expert who was independent and not involved in patient care or treatment. The implementation of these measures should have ensured that the reported data of the primary outcome was as free as possible of bias induced by the open-label trial design.

Stratification prior to randomization was performed to limit imbalances between treatment arms with respect to key variables and potential confounders.

There were major recruitment issues in both the BOSTON-1 trial (SLT recipients) and the present BOSTON-2 trial, in part due to Coronavirus disease-2019 (COVID-19) and specifically in BOSTON-1 due to a marked decline over time in the use of SLT. Following FDA recommendation to obtain an adequately sized safety database for inhaled L-CsA and reach the originally planned sample size for BOSTON-1 and BOSTON-2 trials combined, it was planned to stop randomization into the two Phase III clinical trials upon achievement of a combined total of approximately 220 patients, of which approximately 160 to 170 patients were planned for enrollment in BOSTON-2. To assure balance between treatment arms with regard to key variables and potential confounders, stratification prior to randomization was performed. Within each of the 8 strata, using a permuted blocks randomization, patients were randomly assigned with equal probability (1:1) to receive either L-CsA (10 mg) via the PARI eFlow Nebulizer System twice daily (BID) plus SoC treatment or SoC alone, for a period of 48 weeks. Patients were monitored every 4 to 8 weeks over 48 weeks for efficacy parameters and for all safety evaluations. All patients were eligible to continue in an open-label extension trial of L-CsA, BOSTON-3 (Study BT-L-CsA-303-FU) following completion of either BOSTON-1 or BOSTON-2.

Up to 11 visits (Screening, V1 through V10) were planned during the clinical trial. After informed consent had been obtained, a Screening Visit was carried out to check general eligibility for participation. At the Baseline Visit (V1, Randomization Visit), inclusion and exclusion criteria were re-checked, and Baseline serial spirometry was performed. During the 48-week treatment period, visits were scheduled every 4 to 8 weeks (V2 to V9). Visit 9 (End of Treatment \[EoT) was scheduled to occur 48 weeks after Visit 1. If a patient had an event that met the first criterion for progression of BOS, progression of BOS must have been confirmed by measurements that were taken with COMPACT spirometer at least 2 weeks apart. Visit 10 (EoS) was a safety follow-up visit performed 4 weeks after Visit 9/EoT only in patients not rolling over to the extension study (BOSTON-3). For patients who rolled over to BOSTON-3, the EoT Visit was the EoS Visit. Every effort was made to have all planned and unscheduled visits at the study site. However, if one of the visits from Visit 2 to Visit 8 and discontinuation visits could not be performed at the site due to COVID-19, remote visits (e.g., by telephone) were possible. Mandatory on-site visits were Screening Visit, Visit 1, and Visit 9.

Arms: arm 1: Liposomal Cyclosporine A (L-CsA) 10 mg twice daily for 48 weeks, plus Standard of Care Therapy arm 2: This is a maintenance regimen of immunosuppressive agents
Interventions: intervention 1: Liposomal Cyclosporine A intervention 2: Standard of Care
Intervention descriptions: intervention 1: This formulation is developed for inhalation use and delivered via the PARI eFlow® Device, which is a new technology of nebulizing liquid drugs with a perforated vibrating membrane resulting in an aerosol with a low ballistic momentum and a high percentage of droplets in a respirable size range of 3-5 μm.

The L-CsA was administered as 10 mg/2.4 mL inhalation via the PARI eFlow device BID (morning/evening, approximately 12 hours apart) for 48 weeks. Nebulization time per inhalation dose was approximately 6 to 17 minutes.

Patients received training on the use of the device and the first dose of L-CsA was self-administered by each patient under the supervision of trained personnel. In addition, during all subsequent scheduled visits the L-CsA inhalation was self-administered by the patient and under the supervision of trained study personnel. intervention 2: Standard of Care Therapy (SoC). The SoC included maintenance immunosuppressive medication including tacrolimus, a second agent such as but not limited to MMF or azathioprine, and a systemic corticosteroid such as prednisone as third agent; but also a prophylaxis against common opportunistic infections, and all other necessary medications and therapies for the optimal care of the patient.

This also included vaccination against COVID-19 All changes in concurrent treatment or medication were administered according to site's SoC.

The regimen must be stable within 4 weeks prior to randomization with respect to the therapeutic agents. Patients receiving azithromycin for prophylaxis or treatment of BOS, should be on a stable regimen for a least 4-weeks prior to randomization and continued to receive azithromycin during the trial as deemed appropriate by the investigator.

Protocol documents:
Prot_000.pdf: 
CCI 
CCI 
 
 
 
 
 
 
 
CLINICAL TRIAL PROTOCOL 
 
 
A Phase III, Prospective, Multicenter, Randomized, Controlled Clinical Trial to 
Demonstrate the Efficacy and Safety of Liposomal Cyclosporine A (L-CsA) Inhalation 
Solution Delivered via the 
plus Standard of Care 
versus Standard of Care Alone in the Treatment of Chronic Lung Allograft Dysfunction / 
Bronchiolitis Obliterans Syndrome in Patients post Double Lung Transplantation 
 
Protocol No: BT – L-CsA – 302 – DLT 
(BOSTON-2) 
Version: 6.0 
Date: 7-Apr-2023 
Protocol Amendment Number 5 
IND Number: 78,854 
EUDRACT Number: 2018-003205-25 
 
 
SPONSOR 
Zambon SpA 
Via Lillo del Duca, 10 
Bresso (MI) 20091 
Italy 
 
INVESTIGATIONAL MEDICINAL PRODUCT 
Liposomal Cyclosporine A (L-CsA) 
 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
Page 2 of 109 
Clinical Trial Protocol BT–L-CsA–302–DLT 
Version 6.0_7-Apr-2023 
 
 
 
 
1 SIGNATORIES 
 
SPONSOR 
Zambon SpA 
Via Lillo del Duca, 10 
Bresso (MI) 20091 
Italy 
 
 
 
PPD 
        
PPD 
 
 
Phone: PPD 
 
Email: PPD 
 
 
 
Date 
Signature 
 
 
 
 
PPD 
             
PPD 
 
 
Phone: PPD 
 
Email: PPD 
 
 
 
Date 
Signature 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
Page 3 of 109 
Clinical Trial Protocol BT–L-CsA–302–DLT 
Version 6.0_7-Apr-2023 
 
 
CCI 
 
 
 
 
Protocol Acknowledgment / Confidentiality 
 
 
A Phase III, Prospective, Multicenter, Randomized, Controlled Clinical Trial to 
Demonstrate the Efficacy and Safety of Liposomal Cyclosporine A (L-CsA) Inhalation 
Solution Delivered via the 
plus Standard of Care 
versus Standard of Care Alone in the Treatment of Chronic Lung Allograft Dysfunction / 
Bronchiolitis Obliterans Syndrome in Patients post Double Lung Transplantation 
(Protocol No.: BT – L-CsA – 302 – DLT) 
 
 
By signing this Protocol, the Principal Investigator acknowledges and agrees: 
The Protocol contains all necessary details for conducting the clinical trial. The Principal 
Investigator will conduct this clinical trial as detailed herein, in compliance with Good Clinical 
Practice (GCP) and the applicable regulatory requirements, and will make every reasonable effort 
to complete the clinical trial within the time designated. 
The Protocol and all relevant information on the drug and device relating to nonclinical and clinical 
experience, which was furnished by the Sponsor, Zambon SpA, will be made available to all 
physicians, nurses and other personnel who participate in the conduct of this clinical trial. The 
Investigator will discuss this material with them to assure that they are fully informed regarding 
the Investigational Medicinal Product and the conduct of the clinical trial. 
This document contains information that is privileged or confidential. As such, it may not be 
disclosed unless specific prior permission is granted in writing by the Sponsor or such disclosure 
is required by federal or other laws or regulations. Persons to whom any of this information is to 
be disclosed must first be informed that the information is confidential. These restrictions on 
disclosure will apply equally to all future information supplied, which is indicated as privileged or 
confidential. 
Zambon SpA or its designee will have access to any source documents from which Case Report 
Form information may have been generated. The Case Report Forms and other data pertinent to 
this clinical trial are the sole property of Zambon SpA which may utilize the data in various ways, 
such as for submission to government regulatory authorities, or in publication of the results of the 
clinical trial. 
The conduct and results of this clinical trial will be kept confidential. The results of this clinical 
trial may be published. Upon completion of the clinical trial it is the intention of the parties to 
prepare a joint publication regarding or describing the clinical trial and all the results there from 
and both parties shall cooperate in this regard. 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
Page 4 of 109 
Clinical Trial Protocol BT–L-CsA–302–DLT 
Version 6.0_7-Apr-2023 
 
 
 
 
I have read and agree to the protocol numbered BT – L-CsA – 302 – DLT. I am aware of my 
responsibilities as a Principal Investigator and agree to conduct this clinical trial according to US 
and international standards of Good Clinical Practice (FDA Title 21 part 312 and International 
Conference on Harmonisation guidelines), applicable government regulations, and Institutional 
research policies and procedures under the guidelines of International Conference on 
Harmonisation (ICH) Good Clinical Practice (GCP), national regulations, and the protocol. I agree 
to appropriately direct and assist the staff under my control, who will be involved in the clinical 
trial. 
 
 
Principal Investigator’s Signature 
 
 
 
Name & Title  
 
 
 
 
 
 
(Print) 
 
 
Date 
Signature 
 
 
 
Center Name  
 
(Print) 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
Page 5 of 109 
Clinical Trial Protocol BT–L-CsA–302–DLT 
Version 6.0_7-Apr-2023 
 
 
 
 
2 TABLE OF CONTENTS 
1 SIGNATORIES 
2 
2 
TABLE OF CONTENTS 
5 
3 ABBREVIATIONS 
9 
4 
PROTOCOL-SPECIFIC DEFINITIONS 
13 
5 
PROTOCOL SYNOPSIS 
15 
6 INTRODUCTION 
29 
6.1 
BRONCHIOLITIS OBLITERANS AND BRONCHIOLITIS OBLITERANS SYNDROME 
29 
7 
BACKGROUND INFORMATION 
35 
7.1 
INVESTIGATIONAL MEDICINAL PRODUCT 
35 
7.1.1 
DRUG COMPONENT 
35 
7.1.2 
DEVICE COMPONENT 
35 
7.1.3 
NONCLINICAL DATA 
35 
7.1.4 
CLINICAL EXPERIENCE 
36 
7.1.5 
SUMMARY OF KNOWN AND POTENTIAL RISKS AND BENEFITS 
37 
7.1.6 
JUSTIFICATION OF DOSE REGIMEN 
38 
7.1.7 
STATEMENT OF COMPLIANCE 
39 
7.1.8 
POPULATION 
39 
8 
TRIAL OBJECTIVES AND PURPOSE 
40 
8.1 
TRIAL OBJECTIVES 
40 
8.2 
PURPOSE OF THE TRIAL 
40 
9 
TRIAL DESIGN 
41 
9.1 ENDPOINTS 
41 
9.1.1 
PRIMARY ENDPOINT 
41 
CCI  
9.2 
TRIAL DESIGN 
42 
9.3 
STRATIFICATION AND RANDOMIZATION 
43 
9.3.1 
BLINDING 
43 
9.4 
INVESTIGATIONAL MEDICINAL PRODUCT: TREATMENT, DOSAGE AND ADMINISTRATION 
43 
9.4.1 
FORMULATION OF L-CSA 
43 
9.4.2 
TREATMENT AND DOSAGE 
44 
9.4.3 
ADMINISTRATION OF L-CSA 
45 
9.5 
INVESTIGATIONAL MEDICINAL PRODUCT PACKAGING, LABELING AND STORAGE 
47 
9.5.1 
PACKAGING AND LABELING OF IMP 
47 
9.5.2 
STORAGE 
48 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
Page 6 of 109 
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Version 6.0_7-Apr-2023 
 
 
9.5.3 
CCI 
 
48 
9.6 
STOPPING RULES AND DISCONTINUATION CRITERIA 
48 
9.6.1 
PATIENT LEVEL 
48 
9.6.2 
CENTER LEVEL 
49 
9.6.3 
STUDY LEVEL 
50 
9.7 
INVESTIGATIONAL MEDICINAL PRODUCT: SUPPLY AND ACCOUNTABILITY 
50 
10 
SELECTION AND WITHDRAWAL OF PATIENTS 
51 
10.1 
PATIENT INCLUSION CRITERIA 
51 
10.2 
PATIENT EXCLUSION CRITERIA 
52 
10.3 
PATIENT WITHDRAWAL CRITERIA 
53 
10.3.1 PROCEDURES FOR PATIENTS WITHDRAWAL AND TYPE AND TIMING OF DATA COLLECTION 
53 
10.3.2 REPLACEMENT OF WITHDRAWN PATIENTS 
54 
10.3.3 FOLLOW-UP OF WITHDRAWN PATIENTS 
54 
10.3.4 COMPLETION OF CLINICAL TRIAL AND LOSS TO FOLLOW-UP 
54 
11 
TREATMENT OF PATIENTS 
55 
11.1 
STANDARD OF CARE ALONE 
55 
11.2 
L-CSA PLUS STANDARD OF CARE 
55 
11.3 
CONCURRENT TREATMENT OR MEDICATION 
55 
11.3.1 IMMUNOSUPPRESSIVE MEDICATION 
55 
11.3.2 PROPHYLAXIS AND THERAPY OF INFECTIONS 
56 
11.3.3 AZITHROMYCIN 
56 
11.3.4 OTHER MEDICATION 
56 
11.3.5 CCI 
 
57 
12 
ASSESSMENT OF EFFICACY 
58 
12.1 
METHODS AND TIMING OF EFFICACY ASSESSMENTS AND ANALYSES 
58 
12.1.1 SPIROMETRY 
58 
12.1.2 PROGRESSION OF BOS 
60 
12.1.3 AUGMENTATION OR CHANGE OF IMMUNOSUPPRESSION 
61 
12.1.4 RE-TRANSPLANTATION 
61 
12.1.5 DEATH 
61 
12.1.6 ACUTE REJECTION AND ITS SEVERITY 
61 
12.1.7 ANTIBODY-MEDIATED REJECTION 
62 
12.1.8 QUALITY OF LIFE QUESTIONNAIRE (EQ-5D-5L) 
62 
12.1.9 HOSPITALIZATIONS 
62 
13 
ASSESSMENT OF SAFETY 
63 
13.1 
SAFETY PARAMETERS 
63 
13.1.1 ADVERSE EVENTS (AES) 
63 
13.1.2 ACUTE TOLERABILITY OF L-CSA 
67 
13.1.3 INFECTIONS 
67 
13.1.4 MALIGNANCIES 
68 
13.1.5 CLINICAL LABORATORY 
68 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
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Version 6.0_7-Apr-2023 
 
 
13.1.6 VITAL SIGNS 
71 
13.1.7 PHYSICAL EXAMINATIONS 
71 
13.2 
DATA MONITORING COMMITTEE (DMC) 
71 
13.3 
ADJUDICATION COMMITTEE (AC) 
72 
14 
VISIT SCHEDULE 
72 
14.1 
CLINICAL TRIAL FLOW CHART 
77 
14.2 
STUDY VISITS 
78 
14.2.1 SCREENING 
78 
14.2.2 VISIT 1 / BASELINE VISIT 
79 
14.2.3 VISIT 2 THROUGH VISIT 9 / EOT 
80 
14.2.4 VISITS 1, 4, 6, AND 9 / EOT 
81 
14.2.5 VISIT 10 / END OF STUDY (EOS) 
81 
14.2.6 PERMANENTLY THROUGHOUT THE COMPLETE CLINICAL TRIAL PERIOD 
81 
14.2.7 UNSCHEDULED VISITS 
81 
14.2.8 REMOTE VISITS (V2 - V8) 
81 
15 STATISTICS 
83 
15.1 
ANALYSIS DATA SETS 
83 
15.2 
STATISTICAL AND ANALYTICAL METHODS 
84 
15.2.1 DESCRIPTIVE STATISTICS 
84 
15.2.2 CHARACTERIZATION AND BASELINE COMPARABILITY OF TREATMENT GROUPS 
85 
15.2.3 ANALYSIS OF EFFICACY 
85 
15.2.4 CUMULATIVE MAINTENANCE IMMUNOSUPPRESSION 
87 
15.2.5 ANALYSIS OF SAFETY 
87 
15.3 
INTERIM ANALYSIS 
88 
15.4 
MISSING DATA 
89 
15.5 
SAMPLE SIZE CONSIDERATIONS 
89 
16 
DIRECT ACCESS TO SOURCE DATA/DOCUMENTS 
90 
17 
QUALITY CONTROL AND QUALITY ASSURANCE 
91 
18 
INSTITUTIONAL REVIEW BOARD (IRB)/ETHICS COMMITTEE (EC) 
92 
19 
PATIENT INFORMED CONSENT 
93 
20 
NOTIFICATION TO AUTHORITIES 
94 
21 
DATA HANDLING AND RECORD KEEPING 
95 
21.1 CONFIDENTIALITY 
95 
21.2 
COMPLETION OF ELECTRONIC CASE REPORT FORMS 
95 
21.3 
SOURCE DATA AND PATIENT FILES 
96 
21.4 
INVESTIGATOR FILE AND ARCHIVING 
97 
21.5 
MONITORING, QUALITY ASSURANCE, AND INSPECTION BY AUTHORITIES 
97 
21.6 
DATA MANAGEMENT AND DATA CONTROL 
98 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
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Version 6.0_7-Apr-2023 
 
 
22 
FINANCING AND INSURANCE 
99 
23 PUBLICATIONS 
100 
24 REFERENCES 
101 
25 
APPENDIX I – CORE INFORMED CONSENT FORM 
103 
26 
APPENDIX II – ACCEPTABLE METHODS OF CONTRACEPTION 
105 
27 
APPENDIX III – ANTIBODY-MEDIATED REJECTION 
106 
28 
APPENDIX IV – STUDY PROTOCOL VERSIONS HISTORY OF CHANGES 
108 
 
 
 
LIST OF TABLES 
TABLE 1. CLAD STAGING OF LUNG ALLOGRAFT DISEASE FOLLOWING LUNG TRANSPLANTATION 
14 
TABLE 2. BASIC PHENOTYPES OF CHRONIC LUNG ALLOGRAFT DYSFUNCTION 
14 
TABLE 3. BRONCHIOLITIS OBLITERANS SYNDROME (BOS) CLASSIFICATION 
32 
TABLE 4. BASIC PHENOTYPES OF CHRONIC LUNG ALLOGRAFT DYSFUNCTION 
32 
TABLE 5. QUALITATIVE COMPOSITION OF THE IMP 
44 
TABLE 6. REVISED WORKING FORMULATION FOR CLASSIFICATION AND GRADING OF PULMONARY ALLOGRAFT 
REJECTION 
62 
TABLE 7. TERMINOLOGY OF RENAL DISORDERS 
70 
TABLE 8. DEFINITION AND DIAGNOSTIC CERTAINTY OF CLINICAL PULMONARY AMR 
106 
TABLE 9. DEFINITION AND DIAGNOSTIC CERTAINTY OF SUB-CLINICAL PULMONARY AMR 
107 
 
 
 
LIST OF FIGURES 
FIGURE 1: FREEDOM FROM BRONCHIOLITIS OBLITERANS SYNDROME BY DIAGNOSIS (ISHLT REGISTRY 2017) 
29 
FIGURE 2: RELATIVE INCIDENCE OF LEADING CAUSES OF DEATH (ISHLT REGISTRY 2017) 
332 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
Page 9 of 109 
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Version 6.0_7-Apr-2023 
 
 
 
 
3 ABBREVIATIONS 
 
AC 
Adjudication Commitee 
ADR 
Adverse Drug Reaction 
AE 
Adverse Event 
ALT 
Alanine Aminotransferase 
AMR 
Antibody-Mediated Rejection 
AST 
Aspartate Aminotransferase 
ATG 
Anti-Tymocyte Globulin 
ATS 
American Thoracic Society 
AZA 
Azathioprine 
BAL 
Bronchoalveolar Lavage 
BID, b.i.d. 
Bis in die, twice daily 
BO 
Bronchiolitis Obliterans 
BOS 
Bronchiolitis Obliterans Syndrome 
BDRM 
Blind Data Review Meeting 
BUN 
Blood Urea Nitrogen 
CFR 
Code of Federal Regulation 
CLAD 
Chronic Lung Allograft Dysfunction 
CMV 
Cytomegalovirus 
CNI 
Calcineurin Inhibitor 
COPD 
Chronic Obstructive Pulmonary Disease 
CRF 
Case Report Form 
CRO 
Contract Research Organization 
CsA 
Cyclosporine A 
CsA-PG 
Cyclosporine A Propylene Glycol Inhalation Solution 
CRS 
Clinical Study Report 
CT 
Computed Tomography 
CTC 
Common Toxicity Criteria 
dL 
Deciliter 
DLT 
Double Lung Transplant 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
Page 10 of 109 
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Version 6.0_7-Apr-2023 
 
 
 
DMC 
Data Monitoring Committee 
DSA 
Donor specific Antibodies 
EBV 
Epstein Barr Virus 
EC 
Ethics Committee 
ECP 
Extracorporeal Photopheresis 
eCRF 
Electronic Case Report Form 
EoS 
End of Study 
EoT 
End of Treatment 
EQ-5D-5L 
Euro QOL Health Questionnaire 
ERS 
European Respiratory Society 
FAS 
Full Analysis Set 
FDA 
Food and Drug Administration 
CCI 
 
FEV1 
Forced Expiratory Volume in One Second 
FVC 
Forced Vital Capacity 
GDPR 
General Data Protection Regulation 
GERD 
Gastro-Esophageal Reflux Disease 
GCP 
Good Clinical Practice 
HIPAA 
Health Insurance Portability and Accountability Act 
HLA 
Human Leukocyte Antigen 
IB 
Investigator Brochure 
ICH 
International Conference on Harmonisation 
ICU 
Intensive Care Unit 
IgM 
Immunoglobulin M 
IMP 
Investigational Medicinal Product (study drug: L-CsA) 
IND 
Investigational New Drug 
IRB 
Institutional Review Board 
ISHLT 
International Society of Heart and Lung Transplantation 
IUD 
Intrauterine Device 
Kg 
Kilogram 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
Page 11 of 109 
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Version 6.0_7-Apr-2023 
 
 
 
L 
Liter 
LABA 
Long-Acting Beta Agonist 
LAMA 
Long-Acting Muscarinic Antagonist 
L-CsA 
Liposomal Cyclosporine A 
 
CCI 
LMM 
Linear Mixed Model 
MAR 
Missing At Random 
MedDRA 
Medical Dictionary for Regulatory Activities 
Mg 
Milligram 
µm 
Micrometer 
Min 
Minute 
mL 
Milliliter 
MMF 
Mycophenolate Mofetil 
mTOR 
Mammalian Target of Rapamycin 
N (n) 
Number 
Ng 
Nanogram 
NOAEL 
No Observable Adverse Effect Level 
OB 
Obliterative Bronchiolitis 
PG 
Propylene Glycol 
PI 
Principal Investigator 
Ph Eur 
European Pharmacopeia 
PK 
Pharmacokinetics 
PPS 
Per Protocol Set 
Q 
Quartile 
RAS 
Restrictive Allograft Syndrome 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SAS 
Statistical Analysis Software 
CCI  
SLT 
Single Lung Transplant 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
Page 12 of 109 
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Version 6.0_7-Apr-2023 
 
 
 
SmPC 
Summary of Product Characteristics 
SOC 
Standard of Care 
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
TAC 
Tacrolimus 
TDT 
Triple Drug Therapy 
TEAE 
Treatment-Emergent Adverse Event 
USA 
United States of America 
USP 
United States Pharmacopeia 
WHO-DD 
World Health Organization Drug Dictionary 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
Page 13 of 109 
Clinical Trial Protocol BT–L-CsA–302–DLT 
Version 6.0_7-Apr-2023 
 
 
 
 
4 PROTOCOL-SPECIFIC DEFINITIONS 
Acute Rejection: Acute rejections are classified according to the revised working formulation for 
classification and grading of pulmonary allograft rejection and will be assessed at any time of 
occurrence throughout the clinical trial period. 
 
Antibody Mediated Rejection: Diagnosis of antibody mediated rejection is performed 
according to the International Society of Heart and Lung Transplantation (ISHLT) consensus 
guidelines and assessed at any time of occurrence throughout the clinical trial period. In this 
context, clinically stable patients displaying low and stable levels of Donor Specific Antibodies 
at Screening (as judged by the Investigator) are eligible for the study. 
 
BOS diagnosis: The Investigator will have used the site’s clinical spirometer to determine that 
the patient has clinically defined BOS (CLAD – BOS phenotype) (for definitions, please see 
below) before referring patients to the study. In this context, FEV1 values are defined as follows: 
Personal Best FEV1: The highest FEV1 value following transplant surgery - this can be 
derived from one single spirometry session or the mean of two best FEV1 values derived 
from two spirometry sessions (as per the usual practice by the site; see also Meyer 2014). 
 
FEV1 confirming diagnosis of BOS: The FEV1 value used by the clinician to confirm 
the diagnosis of BOS - this can be derived from one single spirometry session or the 
mean of two best FEV1 values derived from two spirometry sessions (as per the usual 
practice by the site; see also Meyer 2014). 
 
Baseline FEV1: For the purpose of this study, the FEV1 value that is the mean of the best FEV1 
obtained with the study spirometer at the Screening Visit and the best FEV1 obtained at the 
Baseline Visit is referred to as “baseline FEV1”. 
CLAD (BOS and RAS phenotypes): Following the ISHLT 2019 recommendations [Verleden 
2019] for the definition of lung allograft disease following lung transplantation, sufficient 
diagnostic proof using – amongst others – spirometry, body plethysmography, and/or CT scans 
should be available to confirm the diagnosis of CLAD and differentiate subtypes (see also Table 
1 and Table 2). 
 
For the purpose of this protocol, patients with RAS phenotypes are to be excluded applying the 
definitions in the consensus report issued by the ISHLT 2019 [Glanville 2019]. In particular, 
persisting parenchymal opacities on historical High Resolution CT scan or Chest X-Ray should be 
considered as an important diagnostic feature of CLAD - RAS phenotype. 


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Table 1. CLAD Staging of Lung Allograft Disease Following Lung Transplantation 
 
CLAD Stage (2019) 
Spirometric criteria 
BOS Grade (2002) 
CLAD 0 
FEV1 > 90% of personal best 
0 
CLAD 0 
FEV1 81-90% of personal best 
0-p 
CLAD 1 
FEV1 66-80% of personal best 
1 
CLAD 2 
FEV1 51-65% of personal best 
2 
CLAD 3 
FEV1 35-50% of personal best 
3 
CLAD 4 
FEV1 < 35% of personal best 
3 
 
 
Table 2. Basic Phenotypes of Chronic Lung Allograft Dysfunction 
 
Obstruction 
(CCI 
< 0.7) 
Restriction 
(TLC decline ≥ 10% 
from baseline) 
CT opacities 
BOS 
YES 
NO 
NO 
RAS 
NO 
YES 
YES 
Mixed 
YES 
YES 
YES 
Undefined 
YES 
YES 
NO 
YES 
YES 
NO 
 
For example, the diagnosis and staging according to these recent recommendations would read 
“CLAD Stage 2, BOS phenotype” for a diagnosis which would have been entitled “BOS Grade 2” 
following previous recommendations [Glanville 2019]. 


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5 PROTOCOL SYNOPSIS 
 
Protocol Title: 
A Phase III, Prospective, Multicenter, Randomized, Controlled 
Clinical Trial to Demonstrate the Efficacy and Safety of 
Liposomal Cyclosporine A (L-CsA) Inhalation Solution 
Delivered via the 
CCI Device plus 
Standard of Care versus Standard of Care Alone in the Treatment 
of Chronic Lung Allograft Dysfunction / Bronchiolitis Obliterans 
Syndrome in Patients post Double Lung Transplantation 
Sponsor: 
Zambon SpA 
Via Lillo del Duca, 10 
Bresso (MI) 20091 
Italy 
Protocol Number: 
BT – L-CsA – 302 – DLT (BOSTON-2) 
IND Number: 
78,854 
EUDRACT Number: 
2018-003205-25 
NCT Number: 
NCT03656926 
Investigational 
Medicinal Product: 
Liposomal Cyclosporine A (L-CsA) Inhalation Solution 
Protocol Phase: 
Phase III 
Protocol Date: 
Version 6.0; 7-Apr-2023 
Protocol Amendment: 
5 
Clinical Trial 
Centers/Countries: 
Approximately 43 centers Worldwide. 
Planned Clinical Trial 
Period: 
Duration of therapy: 
 48 weeks 
Total clinical trial duration per patient: 
up to 56 weeks 
Planned Number of 
Patients: 
The clinical trial plans to stop randomization upon achievement 
of a total of approximately 220 patients with clinically defined 
bronchiolitis obliterans syndrome (BOS) in both the present BT 
– L-CsA – 302 – DLT (BOSTON-2) and the BT – L-CsA – 301 
– SLT (BOSTON-1) studies combined. 
Patients will be randomized 1:1 as follows: 
Treatment Arm A (investigational treatment arm): 
L-CsA inhalation therapy (10 mg bid) plus Standard of Care 
(SoC). 
Treatment Arm B (control treatment arm): 
SoC alone. 


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Objective: 
The objective of the trial is to assess the efficacy and safety of L- 
CsA plus SoC in the treatment of BOS in double lung transplant 
(DLT) recipients. 
Clinical Trial Design: 
This is a Phase III, prospective, multicenter, randomized, 
controlled clinical trial of L-CsA for the treatment of 
bronchiolitis obliterans syndrome in adults diagnosed with BOS 
following double lung transplant. 
Patients will receive either L-CsA (10 mg) via the CCI   
twice daily plus 
SoC treatment or SoC alone, for a period of 48 weeks. 
All patients will be eligible to continue in an open-label extension 
trial of L-CsA following completion of BOSTON-2. 
Stratification 
To assure balance between study treatment arms with regard to 
some key variables and potential confounders, stratification prior 
to randomization will be performed for the following variables: 
• Screening FEV1 ≥ 81% of personal best FEV1 value post- 
transplant versus Screening FEV1 between 80-51% of 
personal best FEV1 value post-transplant 
• Age at the time of randomization: < 55 years versus ≥ 55 
years 
• Region: North America versus all other countries together 


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Eligibility Criteria: 
Inclusion Criteria: 
1. Adult patients ≥ 18 years who received a double lung transplant 
at least 12 months prior to Screening. 
2. Patients with BOS diagnosis defined as CLAD-BOS phenotype 
with: 
a) Screening FEV1 between 85-51% of personal best FEV1 
value post-transplant. 
OR 
b) Screening FEV1 >85% of personal best FEV1 
associated with EITHER a ≥ 200 mL decrease in FEV1 
in the previous 12 months OR according to medical 
history showing BOS progression. 
3. Diagnosis of CLAD-BOS must be made at least 12 months after 
lung transplantation and 
a) within 12 months prior to the screening visit 
OR 
b) more than 12 months from screening and patient must 
have shown a decline in FEV1 ≥ 200ml in the previous 
12 months before screening, which is not due to acute 
infection or acute organ rejection 
4. Patients in whom the diagnosis of BOS has been confirmed by 
the elimination of other possible causes of obstructive or 
restrictive lung disease (CLAD – RAS phenotype, see Protocol 
Specific Definitions). 
5. Patients 
should 
be 
on 
a 
maintenance 
regimen 
of 
immunosuppressive agents including tacrolimus, a second agent 
such as but not limited to MMF or azathioprine, and a systemic 
corticosteroid such as prednisone as third agent. The regimen 
must be stable within 4 weeks prior to randomization with 
respect to the therapeutic agents. In case a patient is also 
receiving concomitant azithromycin for prophylaxis or 
treatment of BOS, in addition to the previously described 
immunosuppressive regimen, azithromycin must be on a stable 
regimen for at least 4-weeks prior to randomization. 
6. Patients capable of understanding the purposes and risks of the 
clinical trial, who have given written informed consent and 
agree to comply with the clinical trial requirements/visit 
schedules, and who are capable of aerosol inhalation. Patients 
must consent to retrieve prespecified data from the historic 


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medical record (e.g., information related to the transplant 
surgery; spirometry data; medication use). 
7. Women of childbearing potential must have a negative serum or 
urine pregnancy test within 7 days prior to randomization and 
must agree to use one of the methods of contraception listed in 
Appendix II through their End of Study Visit. 
8. Patients have no concomitant diagnoses that are considered fatal 
within one year (12 months) of Screening. 


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Exclusion Criteria: 
1. 
Patients with confirmed other causes for loss of lung function, 
such as acute infection, acute rejection, restrictive allograft 
syndrome (RAS) (CLAD – RAS phenotype, see Protocol 
Specific Definition), etc. 
2. 
Cystic Fibrosis patients with multi-drug resistant infections not 
responding to available anti-microbial therapies. 
3. 
Patients with acute antibody-mediated rejection at Screening. 
In this context, clinically stable patients (as judged by the 
Investigator) with detectable levels of donor specific antibodies 
(DSA) at the Screening Visit are eligible for the study. 
4. 
Active acute bacterial, viral, or fungal infection not 
successfully resolved at least 4 weeks prior to the Screening 
Visit. Patients with chronic infection or colonization who are 
clinically stable as per judgement of the Investigator are 
eligible for the study. 
5. 
Mechanical ventilation (including CPAP) within 12 weeks 
prior to Randomization. 
6. 
Patients with uncontrolled hypertension. 
7. 
Patient has baseline resting oxygen saturation of < 89% on 
room air or use of supplemental oxygen at rest. 
8. 
Evidence 
of 
functional 
airway 
stenosis 
(e.g., 
bronchomalacia/tracheomalacia, airway stents, or airways 
requiring balloon dilatations to maintain patency)with onset 
after the initial diagnosis of BOS and ongoing at Screening 
and/or Randomization Visit. 
9. 
Known hypersensitivity to L-CsA or to cyclosporine A. 
10. Patients with chronic renal failure, defined as serum creatinine 
> 2.5 mg/dL at screening, or requiring chronic dialysis. 
11. Patients with liver disease and serum bilirubin > 3-fold upper 
limit of normal range or transaminases > 2.5 upper limit of 
normal range. 
12. Patients with active malignancy within the previous 2 years, 
including post-transplant lymphoproliferative disorder, with 
the exception of treated, localized basal and squamous cell 
carcinomas. 
13. Pregnant women or women who are unwilling to use 
appropriate birth control to avoid pregnancy through their End 
of Study Visit. 
14. Women who are currently breastfeeding. 
15. Receipt of an investigational drug as part of a clinical trial 
within 4 weeks prior to the Screening Visit. This is defined as 
any treatment that is implemented under an Investigational 
New Drug (IND) or compassionate use. 


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16. Patients who have received extracorporeal photophoresis 
(ECP) for treatment of BOS within 1 month prior to 
Randomization. 
17. Patients who are currently participating in an interventional 
clinical trial. 
18. Psychiatric disorders or altered mental status precluding 
understanding of the informed consent process and/or 
completion of the necessary procedures. 
19. Any co-existing medical condition that in the Investigator’s 
judgment will substantially increase the risk associated with the 
patient’s participation in the clinical trial. 
Investigational 
Medical Product: 
Mode of 
Administration/ 
Dosing Schedule: 
The L-CsA lyophilizate is supplied in CCI 
 containing 10 mg 
of product. The lyophilizate is reconstituted with 2.4 mL 0.25% 
NaCl to obtain a ready to use dispersion for inhalation using the CCI 
. 
The investigational medicinal product (IMP) will be administered 
by CCI 
. At every visit, CCI 
. The patient must remain in the clinic for at 
least 2 hours for observation after the first inhalation. 
CCI 
 
provides the investigators with 
further information on the inhalations performed by the patient. 
Nebulization time per inhalation dose is approximately CCI 
. Inhalation will be performed twice daily, approximately CCI 
through a mouthpiece by slow and deep respiration 
using the CCI 
 


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Treatment Regimen: 
Basic Immunosuppression: 
Regardless of treatment allocation, all participants will continue to 
receive their Standard of Care (SoC) regimen for maintenance of 
the lung allograft. See Section 11.3 for additional information 
regarding use of concurrent medications or treatments prior to and 
during clinical trial participation. 
Patients 
should 
be 
on 
a 
maintenance 
regimen 
of 
immunosuppressive agents including tacrolimus, a second agent 
such as but not limited to MMF or azathioprine, and a systemic 
corticosteroid such as prednisone as third agent. The regimen must 
be stable within 4 weeks prior to randomization with respect to the 
therapeutic agents. Patients will be randomized to one of the 
following treatment Groups: 
Group A (L-CsA treatment plus SoC Therapy): 
• 
L-CsA 10 mg/2.5 mL twice daily for 48 weeks 
Plus 
• 
Standard of Care Therapy 
Group B (Standard of Care alone): 
• 
Standard of Care Therapy 


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C 
C 
 
Endpoints: 
Primary Endpoint: 
Mean change in FEV1 (mL) from baseline to Week 48. 
CI 
 
 
 
 
 
 
 
 
 
 
 
CI 
 
 
 
 
 
 
 
 
 
 
Safety: 
• Adverse events (including infections and malignancies) 
• Acute tolerability of IMP 
• Clinical laboratory parameters 
• Renal Function 
• Vital signs 
• Physical examinations 


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Assessment of 
Efficacy: 
Clinical Trial Plan: 
A total of 11 study visits (Screening, V1 through V10) will be 
performed during the clinical trial. 
After informed consent has been obtained, a Screening Visit will be 
carried out in order to check general eligibility for participation. 
At the Baseline Visit (V1, randomization visit), inclusion and 
exclusion criteria from screening visit will be verified and 
procedures as per Schedule of Activities will be performed. 
During the 48-week treatment period, visits are scheduled every 4- 
8 weeks (V2 – 9). . 
Visit 10 will be a follow-up visit unless the patient is enrolled into 
the extension study, in which case visit 10 will not be completed. 
Every effort will be made to have all planned and unscheduled visits 
at the study site. Mandatory on site visits are Screening Visit, Visit 
1 and Visit 9. 
However, if one of the visits from Visit 2 to Visit 8 and 
discontinuation visits cannot be performed at site due to COVID- 
19, remote visits (e.g. by telephone) are possible. 
Assessments: 
Spirometry (FEV1, CCI 
, and FVC) will be measured at all visits 
using the provided study on-site spirometer 
CCI 
) according to ATS/ERS 2005 guidelines. 
Spirometry measurements on site will be performed by a registered 
respiratory therapist or certified pulmonary function technician who 
is blind to the patient’s treatment assignment. Spirometry data will 
be reviewed by a blinded central reader, as described in the 
Vitalograh site manual. 
Portable spirometers ( 
CCI   ) will also be introduced 
at the screening visit for all patients newly enrolled under protocol 
version 3.0 or later. In addition to the Spirometry performed on the 
CCI 
 patients will perform spirometry using the CCI 
device at every on-site study visit CCI 
 
. If patients cannot attend visits on site due to COVID- 
19, remote visits with guided home spirometry will be performed 
(FEV1, CCI  , and FVC) using the CCI 
. 
For the determination of eligibility at Screening, only spirometry 
data obtained with the study CCI 
 spirometer will be used. 
For the evaluation of of BOS progression during the clinical trial 
period the further decline of FEV1 of ≥ 10% or ≥ 200 mL from 
baseline, absolute decrease in CCI 
 of > 5% must be 


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confirmed by measurements taken with CCI 
 
least 2 weeks apart. 
spirometer at 
Changes to standard of care are allowed at the investigator’s 
discretion (e.g., changes in doses of immunosuppression, 
azithromycin, 
ATG, 
Photopheresis, 
leukotriene 
receptor 
antagonists, cytostatics, irradiation therapy). All changes to SoC 
must be recorded in the eCRFs (Electronic Case Report Forms). 
All medically indicated procedures performed during the course of 
the clinical trial will be documented in the eCRFs. 
For assessment of patient survival, overall mortality, BOS-related 
mortality and non-BOS-related mortality will be taken into account 
at any time throughout the clinical trial period. 
Cumulative dose of immunosuppressants will be assessed 
throughout the Study for tacrolimus, MMF/equivalent, and 
corticosteroids. 
Quality of Life will be assessed at Visits 1, 4, 6, and 9/End of 
Treatment (EoT) when patients have to complete the EQ-5D-5L 
Questionnaire. Absolute and relative change from baseline will be 
calculated. 
Hospitalization will be assessed for overall number of days, days on 
regular ward, days in ICU, and days in ICU on ventilation. 


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Assessment of Safety: 
Safety Assessments at every study visit include physical 
examination, vital signs, adverse event reporting, and clinical 
laboratory tests performed in the local labs at each clinical trial site. 
Acute tolerability of IMP will be assessed measuring spirometry 
before and CCI 
 after inhalation of L-CsA at initial 
dosing. 
Data Monitoring 
Committee: 
Adjudication 
Committee: 
An independent Data Monitoring Committee (DMC) will be 
established to monitor the safety of Investigational Medicinal 
Product (IMP) throughout the clinical trial. The DMC will monitor 
safety by evaluating the safety analyses generated by the unblinded 
independent statistician during the course of the clinical trial. 
Details of the safety analyses will be included in the DMC’s Charter. 
The DMC will evaluate treatment groups for possible trends in 
adverse events, determine whether the basic protocol assumptions 
remain valid, evaluate whether the overall integrity, scientific merit 
and conduct of the clinical trial remain acceptable, and make 
recommendations to the Sponsor. 
The DMC will also perform comparisons between the rate of 
observed COVID-19 cases, rate of patients withdrawal, and rate of 
missing data among trial participants in both treatment arms. 
The AC – consisting of three independent physicians, with 
documented expertise in the clinical management of lung 
transplantation and diagnosis and treatment of BOS - will maintain 
the role of reviewing the BOS progression data in blind condition 
once each participating subject completes the study period, with 
the aim to ensure consistent and complete recording of data. If 
necessary, the AC may query the sites to ask for clarifications. 
In case there are discrepancies between the assessment of the AC 
and that of the investigator re: BOS progression events, the CRO 
will notify the Investigator. In all cases the final decision as to 
whether or not specific event qualifies as BOS progression stands 
with the investigator. 
Details of the AC activities will be included in the AC’s Charter 


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Statistical 
Considerations: 
FEV1 data collected from the CCI 
 spirometer will be 
considered primary, while the data collected with the CCI   home 
spirometer will be used for supportive analyses. 
The primary estimand to be assessed will be the between-treatment- 
group difference in mean absolute change in FEV1 between baseline 
and the end of Week 48, assessed in the patient population defined 
by the inclusion and exclusion criteria, regardless of whether or not 
starting additional immunosuppressive medication or stopping of 
the investigational treatment had occurred (Treatment Policy 
Strategy, effectiveness). Testing will be performed on the full 
analysis set (FAS) which will include all randomized patients 
All available FEV1 measurements will be entered into a linear mixed 
model (LMM), with change in FEV1 between baseline and 
subsequent visits as the dependent variable, randomized treatment, 
time, region (North America vs all other countries together), and age 
(< 55 versus ≥ 55 years), as the independent factors and with 
baseline FEV1 and azithromycin use at randomization as covariates. 
Moreover, the treatment by time interaction and the baseline FEV1 
by time interaction will be included into the model. In case few data 
are collected at intermediate timepoints between baseline and Week 
48 (see section 15.3 on interim analysis), the LMM model will be 
replaced by an ANCOVA model on the changes in FEV1 from 
baseline to Week 48, using the same stratification factors and the 
same covariates described for the LMM. 
Sensitivity analyses will be performed in the per-protocol analysis 
set as well as using an alternative estimand according to which 
outcome measurements will only be used for the period during 
which patients were on randomized treatment (i. e., prior to the 
initiation of additional immunosuppressive therapy or L-CsA 
discontinuation; While-on-Treatment strategy, efficacy). Moreover, 
sensitivity analyses will also be performed to assess the validity of 
the Missing-at-Random assumption for the LMM. In addition to use 
of LMM to analyze the primary endpoint, simple t-test comparing 
the difference in mean FEV1 change from baseline to Week 48 
between the treatment group in the FAS population including a 95% 
confidence interval for the treatment difference of the mean FEV1 
change between the two treatment groups will be performed. 
Further sensitivity analyses will be described in the SAP. 
The overall type I error rate of the clinical trial will be α = 0.025 
one-sided, corresponding to α = 0.05 two-sided. Strong control of 
the clinical trial-wise type I error rate will be achieved by a-priori 


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ordering of hypotheses in the indicated order of primary CCI 
endpoints (see section 15.2.3.3 on type I error level 
control). 
The previous version of the protocol anticipated the following: 
CCI 
 
 
 
 
 
 
 
The protocol also anticipated a blinded interim analysis for: 
• Re-estimation of the standard deviation, with the purpose of 
increasing the sample size (bigger SD then assumed) but not of 
decreasing it Evaluation of the actual amount of FEV1 data 
collected at all timepoints using the site spirometer 
• Evaluation of the number of drop-outs and the number and 
pattern of the missing data 
• Appropriateness of the analysis based on the anticipated 
longitudinal model (LMM) vs. the analysis based on the 
ANCOVA model in the light of the collected data. 
CCI 
 
 
 
Furthermore, the sample size was judged roughly appropriate for 
this model but considered small for ANCOVA. 
CCI 
 
 
 
 
 
 
Since the BOSTON-1 study is experiencing serious enrolment 
delay, it is anticipated that approximately 160-170 patients will be 
randomized in the present study and 50-60 patients in BOSTON-1. 
The sample size for BOSTON-2 will provide a more reasonable 
power for the planned sensitivity analyses, including ANCOVA. 
Details of all evaluations will be provided in the Statistical Analysis 
Plan. 


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6 INTRODUCTION 
6.1 Bronchiolitis Obliterans and Bronchiolitis Obliterans Syndrome 
Lung transplantation is the ultimate treatment option for patients with advanced lung disease or 
irreversible pulmonary failure. Although refinements and advancements in surgical techniques, 
lung preservation, immunosuppressive regimen, management of ischemia/reperfusion injury and 
infections, as well as post-transplant patient care have resulted in improved outcomes, acute and 
chronic pulmonary allograft rejection continues to be the major obstacle for satisfactory long-term 
results. Acute rejection after lung transplantation exceeds the incidence and severity compared 
with other solid organ transplantations. Chronic rejection, commonly denoted bronchiolitis 
obliterans (BO), obliterative bronchiolitis (OB), or bronchiolitis obliterans syndrome (BOS), is the 
leading cause of death beyond the first-year after lung transplantation. Whereas the development 
of BOS is rare within the first year after lung transplantation, annual increments of approximately 
10% are recorded in subsequent years, resulting in a cumulative incidence range of 40-50% within 
the first five years and 70-80% within 10 years of transplantation (Figure 1; ISHLT Registry 2017). 


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2017 
JHLT. 2017 Oct; 36(10): 1037-1079 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 1: Freedom from bronchiolitis obliterans syndrome by diagnosis (ISHLT Registry 
2017) 
The main histologic hallmark of BO is scarring with fibrosis of the airway. However, this process 
is patchy, making the sensitivity of transbronchial biopsy for detection of BO highly dependent on 
adequacy of sampling and skill of histologic interpretation. Therefore, the clinical manifestation 
of BO, the bronchiolitis obliterans syndrome (BOS), is defined as irreversible airway obstruction, 
diagnosed by pulmonary function, in the absence of other causes. This diagnosis does not require 
histologic confirmation but is considered a reliable surrogate physiologic marker of the presence 
of BO. 
In its most common presentation, BO is characterized by the pathophysiological features of 
respiratory obstruction. The major findings on spirometry are a reduced forced expiratory volume 
in 1 second (FEV1), a normal, or slightly decreased forced vital capacity (FVC), and a reduced 
ratio of FEV1 to FVC, with poor response to inhaled bronchodilators. Lung volumes indicate air 
trapping, with a normal total lung capacity and high residual volume. However, a subset of patients 
present with a restrictive pattern characterized by a low FVC and a normal CCI 
 ratio, or a 
mixed pattern of obstruction and restriction [Barker 2014]. BOS is often a diagnosis of exclusion 
A1ATD (N=1,051) 
COPD (N=7,131) 
ILD-not IIP (N=1,079) 
CF (N=3,027) 
IIP (N=6,684) 
Retransplant (N=778) 
No pair-wise comparisons were significant 
at p < 0.05 except all comparisons with 
Retransplant and CF vs. COPD 


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and other causes of allograft dysfunction, including restrictive allograft syndrome (RAS), acute 
rejection, and acute infection, need to be excluded before the diagnosis of BOS is made [Glanville 
2019]. 
The 2002 BOS grading system for Grades 0 through 3 (Table 3), which is based solely on FEV1 
and/or CCI 
 is a useful surrogate marker for BO: it is easy to 
measure by standardized spirometry and is reproducible; it becomes abnormal prior to histologic 
confirmation [Chacon 2000]; and it displays high sensitivity and specificity when assessed against 
biopsy- and autopsy-confirmed BO [Heng 1998]. In the following Tables, “baseline” is defined as 
the patient’s personal best FEV1 following transplant. 


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Table 3. Bronchiolitis obliterans syndrome (BOS) classification 
 
Original classification 
(1993) 
2002 Classification 
2019 ISHLT Classification 
- 
- 
BOS 0 
FEV1 > 90% of baseline and 
CCI 
> 75% of baseline 
- 
- 
BOS 0 
FEV1 80% or more 
of baseline 
BOS 0-p 
FEV1 81% to 90% of baseline 
and/or 
CCI 
≤ 75% of baseline 
CLAD 0 
FEV1 > 80% of baseline 
BOS 1 
FEV1 66% to 80% 
of baseline 
BOS 1 
FEV1 66% to 80% of baseline 
CLAD 1 
FEV1 66-80% of baseline 
BOS 2 
FEV1 51% to 65% 
of baseline 
BOS 2 
FEV1 51% to 65% of baseline 
CLAD 2 
FEV1 51-65% of baseline 
BOS 3 
FEV1 50% or less of 
baseline 
BOS 3 
FEV1 50% or less of baseline 
CLAD 3 
FEV1 35-50% of baseline 
- 
- 
- 
- 
CLAD 4 
FEV1 < 35% of baseline 
BOS: bronchiolitis obliterans syndrome; CCI 
; FEV1: forced expiratory volume in 1 
second [Estenne 2002]. CLAD: chronic lung allograft dysfunction. 
 
 
 
Table 4. Basic Phenotypes of Chronic Lung Allograft Dysfunction 
 
Obstruction 
CCI 
 < 0.7) 
Restriction 
(TLC decline ≥ 10% 
from baseline) 
CT opacities 
BOS 
Yes 
No 
No 
RAS 
No 
Yes 
Yes 
Mixed 
Yes 
Yes 
Yes 
Undefined 
Yes 
Yes 
No 
Yes 
Yes 
No 
 
BOS represents the major determinant of long-term graft and patient survival. To reduce the rate 
of rejection (acute as well as chronic forms), immunosuppressive regimens are employed. 
Although the immunosuppressive protocols vary from center to center, conventional maintenance 
therapy consists principally of triple drug therapy comprising a calcineurin inhibitor (cyclosporine 
A [CsA] or tacrolimus [TAC]), an antiproliferative agent (mycophenolate mofetil [MMF], 
azathioprine [AZA], sirolimus, or everolimus), and corticosteroids. Historically, CsA and AZA 
were used along with prednisone, but additional agents have become available, including 


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Infection (non-CMV) 
2017 
 
 
 
tacrolimus, mycophenolate, and Mammalian Target of Rapamycin (mTOR) inhibitors like 
sirolimus and everolimus. Often when BOS is diagnosed in a lung transplant recipient, 
immunosuppression is augmented but no augmentation therapy has been demonstrated to impact 
BO reliably. Additional systemic immunosuppression comes with the added burden of additional 
end-organ toxicity and tolerability issues. Development of BOS is the major confounding factor 
of long-term successful outcome. BOS is reported as the main cause of death beyond the first post- 
transplant year over the last three decades (Figure 2; ISHLT Registry 2017). 
 
 
 
 
 
 
 
 
 
 
Figure 2: Relative incidence of leading causes of death (ISHLT Registry 2017) 
Bronchiolitis obliterans as a disease has been recognized for many decades. However, the need 
for better treatment options for BOS increased dramatically in the 1990s when lung transplantation 
became a more acceptable treatment for lung failure, but was also limited by BO as a late-term 
sequelae. A better understanding of the pathology of the disease as well as the limitations of high- 
dose systemic immunosuppression, due to their toxic effects, has led to the idea of administering 
higher doses of drug via alternative routes. BO is uniquely suited to this potential approach as a T- 
cell mediated disease of the airways of the lungs. 


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The first studies of an inhaled immunosuppressive for BOS associated with lung transplantation 
were done using cyclosporine in a formulation that contained propylene glycol, CsA-propylene 
glycol (CsA-PG). In these studies, CsA-PG showed poor tolerability due to the hyperosmolality 
of the PG formulation and its propensity to cause airway inflammation. However, efficacy results 
from clinical trials evaluating prevention of BOS were promising [Iacono 1996; Iacono 2006]. 
With the goal of increasing tolerability as well as improving airway deposition, a liposomal 
formulation of CsA (L-CsA) was developed. L-CsA also was formulated specifically for use with 
theCCI 
for optimal aerosol dynamics. 


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7 BACKGROUND INFORMATION 
7.1 Investigational Medicinal Product 
The Investigational Medicinal Product is a drug/device combination consisting of liposomal 
cyclosporine A (L-CsA) and theCCI 
. 
7.1.1 
Drug component 
 
L-CsA consists of the active substance CsA and excipients as described in the Investigator 
Brochure (IB). L-CsA is a lyophilisate for reconstitution with 0.25% saline. The formulation is 
developed for inhalation use and is therefore adjusted to a physiological tolerable value of CCI   
. 
The liposome size in the reconstituted formulation is in the range of 40-100 nm with a 
polydispersity index of not more than 0.50, which indicates the width of the size distribution. PI 
values above 0.5 indicate a broad distribution. 
The dose of 10 mg L-CsA is reconstituted in a total volume of 2.5 mL. The entire volume of the 
reconstituted solution is used per aerosol administration. 
Additional information can be found in the IB. 
7.1.2 
Device component 
CCI 
 
 
 
The CCI 
 to be used in this clinical trial is a modified version of the 
for an optimized delivery of the investigational drug for the designated patient group. The 
configuration of the optimized CCI 
 has a high delivered dose, short nebulization time 
and inhibits contamination of the environment by using an exhalation filter. The device is CE- 
marked in Europe. Comparable devices are also available on the US market. The CCI 
 
was used in the nonclinical and clinical trials of L-CsA. The CCI 
 
 
. The usual 
nebulization time is CCI 
 for the 10 mg dose. 
Additional information can be found in the IB. 
7.1.3 
Nonclinical Data 
 
For systemic administration of CsA, the nonclinical pharmacologic, pharmacokinetic, and toxicity 
profiles of systemic CsA are well established [UK SmPC Ciclosporin A CCI 
 ]. 
CCI 


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For aerosolized administration of L-CsA, additional nonclinical studies have been conducted with 
L-CsA. Importantly, L-CsA inhibited T-cell proliferation in stimulated human peripheral blood 
mononuclear cells. Across 3 nonclinical toxicology studies in rats, aerosolized L-CsA given as 
4-day, 6-week, and 26-week repeated applications of up to 2.6 mg/kg/day, no dose-limiting 
toxicity  occurred.  The  no-observed-adverse-effect-level  (NOAEL)  is  considered  to  be 
2.0 mg/kg/day via inhalation for chronic application based on the maximum dosage achieved in 
the 26-week inhalation study in rats. 
Nonclinical and clinical data to date with L-CsA show negligible increase in serum levels of 
calcineurin inhibitors and do not show an increased risk of nephrotoxicity, respiratory infections, 
or malignancies. 
Additional information can be found in the IB. 
7.1.4 
Clinical Experience 
 
L-CsA has been evaluated in 3 clinical trials in adult patients who received a single-lung or double- 
lung transplantation: (1) a Phase 1b study of the deposition and pharmacokinetics (PK) of 
aerosolized L-CsA in patients with lung transplantation (G035.011); (2) a Phase 3 study of the 
efficacy, safety, and PK of the addition of aerosolized L-CsA to SOC systemic immunosuppression 
therapy vs aerosolized placebo plus SOC therapy in the prevention of BOS following lung 
transplantation (12011.201; study was terminated early for business reasons); and (3) an 
investigator-initiated study of the efficacy, safety, and PK of the addition of aerosolized L-CsA to 
SOC systemic immunosuppression therapy vs SOC therapy alone in the treatment of BOS 
following lung transplantation (AI001). Collectively, these studies provided safety, efficacy, and 
PK data to support further evaluation in 2 Phase III studies of the efficacy and safety of the addition 
of aerosolized L-CsA to SOC systemic immunosuppression therapy vs SOC therapy alone for the 
treatment of BOS following single-lung transplantation (BT – L-CsA – 301 – SLT) or double lung 
transplantation (BT – L-CsA – 302 – DLT). In particular: 
• The Phase 1b lung deposition study (G035.011) showed that inhalation of 10 mg and 20 mg 
L-CsA via the CCI 
 would result in sufficient peripheral lung deposition of L-CsA 
(≥15 mg L-CsA/week). Aerosol application of 10 mg L-CsA was associated with an acceptable 
inhalation time of approximately 9 minutes. 
• In the Phase 3 study investigating prevention of BOS (12011.201), the primary endpoint for 
prevention of BOS (BOS-free survival) was not met, although efficacy results may have been 
confounded by early termination of the trial due to business reasons. 
• In the investigator-initiated study investigating treatment of BOS (AI001), the responder 
analysis of BOS progression-free survival based on Kaplan-Meier estimates revealed a 
treatment success rate of 81.8% in the L-CsA + SOC group (9 of 11 patients) and 50% in the 
control group (5 of 10 patients). FEV1 slope analyses over time resulted in monthly decrements 


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of -0.008 L in the L-CsA + SOC group and -0.045 L in the control group. This difference 
translated into an annual preservation of FEV1 of more than 400 mL in the L-CsA + SOC 
group, consistent with a meaningful slowing of the progression of the disease. The beneficial 
effect of L-CsA was also reflected in consistently positive trends favoring the L-CsA + SOC 
group in other lung function parameters, including CCI  , FVC, and FEV1 % predicted. Five 
years after the start of Study AI001 (as of September 2017), 5 of 11 patients treated with 
L-CsA + SOC were alive, compared with 0 of 10 control patients who received SOC alone. 
With respect to safety, inhaled L-CsA was generally well tolerated across all clinical trials. The 
overall analysis of Adverse Events (AEs), Serious Advere Events (SAEs), and deaths showed that 
these were mostly associated with pulmonary and immunological events, which are expected in a 
population of lung transplant and immunosuppressed patients and did not differ from the control 
arms. Neither laboratory values nor vital signs assessments showed any clinically relevant changes 
over time. 
Nonclinical and clinical data to date with L-CsA do not show an increased risk of nephrotoxicity, 
respiratory infections, or malignancies. 
Additional information can be found in the IB. 
7.1.5 
Summary of Known and Potential Risks and Benefits 
 
Details about specific risks for patients participating in this clinical trial may be found in the IB, 
including a tabular summary of all adverse reactions reported to date for L-CsA. 
Patients in clinical trials generally cannot expect to receive direct benefit from treatment during 
participation, as clinical trials are designed to provide information about the safety and efficacy 
of an investigational medicine. 
BOS is a known life-limiting complication of lung transplantation without any meaningful 
therapy. This trial is the first to evaluate the safety and efficacy of L-CsA for the treatment of 
BOS in patients with BOS following double lung transplantation. 
COVID-19 specific considerations: according to the Guidance from the International Society of 
Heart and Lung Transplantation regarding the SARS CoV-2 pandemic (ISHLT, 2020) “at this 
time, it is unknown if specific patient populations are at higher risk of SARS-CoV-2 infection. 
Published case series and personal reports thus far do not suggest that transplant recipients in 
particular have a higher risk of acquiring the virus”. 
 
The medical value of this trial remains unchanged. 
 
Furthermore, the medical surveillance of transplanted patients is already based on specific 
precautions typical to all patients taking immunosuppressive agents. 


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7.1.6 
Justification of Dose Regimen 
 
Although multifactorial in etiology, most evidence suggests that BO is a host-dependent, immune 
mediated airway injury to bronchiolar cells. It has been postulated that the most important cause 
of chronic rejection of the lung allograft and BOS is T-lymphocyte activation by major 
histocompatibility alloantigens- or alloimmune-dependent mechanisms [Halloran 1997; Soubani 
& Uberti 2007]. Cyclosporine A was selected as the active substance for the development of a 
liposomal formulation because of its well characterized mode of action and proven 
immunosuppressive potency. 
The liposomal formulation of cyclosporine A (L-CsA) was developed with the intent of improving 
local tolerability, as shown in studies 12011.201 and AI001. Because lung function is significantly 
compromised in patients with BOS, an inhalation formulation that is tolerable and facilitates 
patient use is important for treatment compliance and assessment of safety and efficacy parameters 
of the IMP. The rationale for the selection of twice-daily 5 mg and 10 mg doses of aerosolized L- 
CsA, in SLT and DLT patients, respectively, is based on: 
• Correlation of drug amount deposition and stabilization of lung function [Corcoran 
2004] with CsA-PG 
• Clinical trial deposition data from Corcoran [2006] in SLT and DLT patients (CsA- 
PG) 
• Clinical trial deposition data from Behr [2009] in SLT and DLT patients (L-CsA) 
During the clinical development of cyclosporine in its propylene glycol formulation, [Corcoran 
2004] recorded lung function in correlation with different amounts of CsA-PG deposited in the 
transplanted lung. A threshold of ≥ 5 mg CsA-PG peripheral dose per inhalation was determined 
to be required to result in a stabilization of lung function on the basis of FEV1 measurements. 
Patients in this clinical trial inhaled CsA-PG three times per week. Hence, the minimal effective 
peripheral drug dose was calculated to be 15 mg/week. 
The same group [Corcoran 2006] investigated the pattern of drug deposition in SLT and DLT 
patients and discovered that substantial amounts of drug were found only in the transplanted parts 
of the lung. The native lung of SLT patients was almost free of drug due to its limited ventilation 
capacity. The same result was achieved when Behr [2009] repeated the investigation of drug 
deposition in SLT and DLT patients with the L-CsA formulation. Again, it was shown that major 
deposition of the drug took place only in the ventilated parts of the lung allograft, i.e., almost no 
drug arrived in the native lung via inhalation. 
The combination of the clinical data cited above on drug deposition behavior and the 
pharmacokinetic data from Behr [2009] showing that approximately 20% of the inhaled drug 
reaches the periphery of the lung led to the calculation for a dosing regimen of L-CsA.  It is 


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Sponsor: 
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estimated that a dose of L-CsA 10 mg BID will result in 4 mg deposited in the peripheral airways 
per day, and 28 mg per week. 
7.1.7 
Statement of Compliance 
This study will be conducted in compliance with the protocol approved by the appropriate 
Institutional Review Boards (IRB) and Ethics Committees (EC), according to International 
Council for Harmonisation (ICH) and Good Clinical Practice (GCP) standards, and in accordance 
with the ethical principles that have their origin in the Declaration of Helsinki. 
7.1.8 
Population 
 
Recipients of a double pulmonary allograft, ≥ 18 years of age, with clinically defined BOS with 
screening FEV1 above 51% of personal best FEV1 value post-transplant during the screening 
period. The study investigator should confirm the diagnosis of BOS prior to referring the subject 
for the study. 


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8 TRIAL OBJECTIVES AND PURPOSE 
8.1 Trial Objectives 
The objective of this trial is to assess the efficacy and safety of add-on aerosolized L-CsA to 
Standard of Care therapy as compared to SoC therapy alone in the treatment of BOS in double 
lung transplant recipients. 
8.2 Purpose of the Trial 
Currently, there is no approved medicinal product for the prevention or treatment of BOS after 
lung transplantation. All attempts for therapeutic intervention to alter the incidence or the 
progression of BOS are empirical and investigational and are usually based on center-specific 
evidence. This circumstance explains the diversity and disharmony of therapeutic concepts in the 
lung transplant community. There are SoC practices established to manage BOS that develops 
after lung transplantation, but no therapeutic regimens have conclusively demonstrated evidence 
of significant benefit in the prevention or treatment of BOS. Adequately designed and executed, 
randomized, controlled trials to assess efficacy and safety are needed to identify optimal therapies 
for established BOS. 
The hypothesis that local delivery of CsA by aerosol inhalation will achieve higher intrapulmonary 
concentration than by systemic administration alone, and will result in decreased allograft rejection 
with limited toxicity compared to similar systemic doses due to minimal absorption of drug into 
the blood circulation, has been substantiated by the studies described in Section 7.1.4. 
In particular, the investigator-initiated trial AI001 provided evidence of L-CsA’s potential to delay 
progression of BOS when administered as add-on inhalation therapy as compared to SoC for 
systemic BOS therapy. In combination with the acceptable safety profile of L-CsA, observed in 
clinical trial 12011.201 when patients were treated for up to two years, L-CsA has the potential to 
provide superior efficacy over current best practice BOS therapy. The purpose of this trial is to 
confirm the efficacy and safety of L-CsA in a distinct lung transplant population, i.e., in double 
lung transplant recipients. 


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CCI 
CCI 
 
 
9 TRIAL DESIGN 
9.1 Endpoints 
9.1.1 
Primary Endpoint 
Mean change in FEV1 (mL) from baseline to Week 48. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Safety: 
• 
Adverse events (including infections and malignancies) 
• 
Acute tolerability of IMP 
• 
Clinical laboratory parameters 
• 
Renal Function 
• 
Vital signs 
• 
Physical examinations 


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9.2 Trial Design 
This is a Phase III, prospective, multi-center, randomized, controlled clinical trial in the treatment 
of BOS in adult recipients of a bilateral pulmonary allograft. Approximately 160-170 patients are 
planned for enrollment. The clinical trial will be conducted in approximately 43 centers worldwide. 
Patients will be randomly allocated to receive either L-CsA plus SoC or SoC alone for the 
treatment of BOS. Patients will be monitored every 4-8 weeks over 48 weeks for efficacy 
parameters and for all safety evaluations. 
The rationale for not using a placebo control is driven by concerns that a sucrose-containing 
formulation could increase a potential risk of pulmonary infection without the benefit of L-CsA. 
Sucrose is a lyoprotectant in the manufacturing process. After carefully weighing alternative 
options for lyoprotection, no sugar-free alternatives that qualify as real placebo (i.e., 
undistinguishable by means of appearance, taste or smell) could be identified. Therefore, a 
randomized controlled trial versus SoC is the only suitable alternative. 
An open-label clinical trial generally bears the potential regarding biased patient treatment and 
care, and thus trial outcome. However, for this trial the risk of bias is considered low because of 
the following reasons: 
• 
Currently, the general strategy to treat BOS is augmentation of immunosuppressive therapy 
to the highest tolerable level unless limited by systemic toxicity. Since application of L-CsA 
via inhalation has not shown to lead to an additional systemic drug burden, dose reductions or 
adaptations of other components of the immunosuppressive cocktail will not be required and 
are not desired. 
• 
Furthermore, the selected primary endpoint FEV1 is an objective parameter and its 
measurement will be performed according to recommended guidelines of ATS/ERS which 
have to be respected by each participating center. Following this methodology, a subjective 
and intentional manipulation of outcome is highly unlikely even if health care professional 
and patient are aware of the treatment allocation. 
• 
The pulmonary function technicians, respiratory therapists, or physiotherapists who perform 
spirometry at each site will be blinded to each study patient’s study treatment assignment. 
• 
Finally, the correctness and validity of individual FEV1 curves and their resulting value has to 
be approved in a central and blinded reading by a pulmonary expert who is independent and 
not involved in patients’ care or treatment. 
The implementation of these measures shall guarantee that the reported data of the primary 
outcome will be free of bias induced by the open-label character of the clinical trial. 
A similar Phase III clinical trial, BT – L-CsA – 301 – SLT (BOSTON-1) will be conducted in 
patients who have undergone single-lung transplantations. Patients who complete either 
BOSTON-1 or BOSTON-2, will be eligible to participate in a follow-on study, BT – L-CsA – 303 
– FU (BOSTON-3). 


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9.3 Stratification and Randomization 
At the baseline visit (see Section 14.2.2), after all inclusion and exclusion criteria have been fully 
evaluated, eligible patients will be assigned to the two treatment groups at a ratio of 1:1 by means 
of block randomization. Randomization will be performed by a statistician otherwise not involved 
with the trial, using validated random number generator software. The randomization code of each 
patient will be provided to the Investigator after compliance with all eligibility criteria has been 
confirmed, through the electronic Case Report Form (eCRF) into which the generated random 
code list will be uploaded. Each patient will be assigned a number as part of the randomization 
process. The number assigned to a patient will become that patient’s unique treatment number 
throughout the clinical trial and cannot be re-assigned to another patient. 
The randomization will be stratified by Screening FEV1 of ≥ 81% of personal best FEV1 value 
post-transplant versus Screening FEV1 between 80-51% of personal best FEV1 value post- 
transplant, by age (< 55 versus ≥ 55 years), and by region (North America versus all other countries 
together). The block size will be withheld from the investigators in order to reduce the 
predictability of the treatment assignment and is therefore not mentioned in this study protocol. 
9.3.1 
Blinding 
The pulmonary function technicians, respiratory therapists, or physiotherapists who conduct 
spirometry on site will be blinded to treatment assignment. Patients and other unblinded personnel 
will be asked to not share treatment assignment information with the pulmonary function 
technicians, respiratory therapists, and physiotherapists. The statistician who performed the 
interim sample size re-assessment was blinded to study treatment assignment. For details of the 
blinding of the Data Monitoring Committee members, see Section 13.2. For details of the blinding 
of the Adjudication Committee members, see Section 13.3. Clinical trial monitors, treating 
physicians, study nurses, study coordinators, and enrolled patients will not be blinded to study 
treatment assignment. 
 
 
9.4 Investigational Medicinal Product: Treatment, Dosage and 
Administration 
9.4.1 
Formulation of L-CsA 
The composition of the L-CsA formulation is shown in Table 5. It is a lyophilisate intended for 
reconstitution with 0.25% saline. The formulation is developed for inhalation use and adjusted to 
physiological tolerable values of 


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Sponsor: 
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Table 5. Qualitative Composition of the IMP 
 
Ingredient 
Function 
Quality 
Cyclosporine A 
Active ingredient 
Ph Eur1 
CCI 
1: European Pharmacopeia 
2: United States Pharmacopeia 
The particle size of the liposomes is in the range of 40-100 nm with a polydispersity index of not 
more than 0.50, which indicates the width of the size distribution. Values of polydispersity index 
above 0.5 indicate a broad distribution. For colloidal disperse systems a PI of 0.20 to 0.50 is 
appropriate. 
The IMP L-CsA and 0.25% saline for reconstitution will be supplied by: 
Zambon SpA 
Via Lillo del Duca, 10 
Bresso (MI) 20091 
Italy 
 
9.4.2 
Treatment and Dosage 
Basic Immunosuppression: 
Regardless of treatment allocation, all participants will receive Standard of Care (SoC). Eligible 
patients should be on a maintenance regimen of immunosuppressive agents including tacrolimus, 
a second agent such as but not limited to MMF or azathioprine, and a systemic corticosteroid such 
as prednisone as third agent. The regimen must be stable for within 4 weeks prior to randomization 
with respect to the therapeutic agents. Patients receiving azithromycin for prophylaxis or treatment 
of BOS, must be on a stable regimen for at least 4-weeks prior to randomization and will continue 
to receive azithromycin during the trial as deemed appropriate by the study investigator. 
After screening, patients complying with all inclusion and exclusion criteria (see Sections 10.1 and 
10.2) will be randomized to one of the following treatments: 


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Group A (aerosolized L-CsA treatment plus Standard of Care BOS Therapy): 
• 
L-CsA 10 mg/2.5 mL twice daily for 48 weeks 
Plus 
• 
Standard of Care (as directed by treating physician) 
 
Group B (Standard of Care alone): 
• 
Standard of Care (as directed by treating physician) 
 
 
9.4.3 
Administration of L-CsA 
Patients randomized to L-CsA treatment will receive L-CsA inhalation therapy in addition to SoC 
as outlined below. 
Prior use in clinical trial 12011.201 and clinical trial AI001 created no evidence suggesting L-CsA 
was intolerable to patients. However, patients with BOS typically have inflamed airways which 
could increase the likelihood of bronchospasm. Thus, to minimize risk to patients randomized to 
L-CsA, patients will receive training on the use of the device CCI 
 
. In addition, during 
all subsequent scheduled visits the CCI 
 
. 
Each patient will ideally receive two L-CsA administrations per day, CCI 
 
. The inhalations are scheduled to be taken approximately CCI 
 
. Instructions for administration should be followed as described 
in the Instructions For Use. 
If patients develop dyspnea or signs of drug intolerance at any point during the course of the trial, 
the site investigator should take appropriate actions, immediately. If clinically indicated, L-CsA 
will be held and re-challenged and/or discontinued. Patients will be encouraged to complete all 
remaining study visits through the end of the trial. 
Patients who demonstrate signs of acute infection or acute rejection should be evaluated by the 
treating physician and treated appropriately. L-CsA should be continued if tolerated during this 
period. If L-CsA is held, it should be tracked in the eCRFs. The reasons for discontinuation or 
dosage adjustments have to be documented accordingly with specification of the date and reason 
on the respective case report form. 
For those patients on inhalation therapy, reasons for temporary interruption may include the 
following: 
o 
Significant acute respiratory infection requiring antimicrobial therapy until a clinical 
response is documented 


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o 
Respiratory failure from any cause until the event has resolved 
o 
Mechanical ventilation 
o 
If a significant decline in FEV1 CCI 
 should occur associated with breathlessness or 
other respiratory symptoms. 
Patients temporarily interrupting L-CsA inhalation will be asked to return for clinical trial visits 
according to the visit schedule defined in the protocol but shall not receive IMP. If there is full 
clinical resolution of the reasons for temporary interruption, the Investigator may attempt to re- 
introduce the IMP at a later time. If the patient agrees, she/he will resume all mandatory evaluations 
according to the study protocol until end of treatment (Week 48). 
CCI 
 
CCI 
 
 
 
 
 
 
 


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9.5 Investigational Medicinal Product Packaging, Labeling and Storage 
9.5.1 
Packaging and Labeling of IMP 
Packaging 
The investigational medicinal product will be provided as 10 mg L-CsA lyophilisate 
 
 
 
 
Labeling: CCI 
(U.S. Version. Labelling will meet applicable 
regulatory requirements.) 
• Protocol No.: BT – L-CsA – 302 – DLT 
• 10 mg L-CsA, powder for nebulization solution. 
• For inhalation use. 
• Batch No.: 
• Expiry Date: mm/yyyy 
• Zambon SpA. 
Labeling: Saline 0.25% Solution (U.S. Version. Labelling will meet applicable regulatory 
requirements.) 
• 
Protocol No.: BT – L-CsA – 302 – DLT 
• 
NaCl 0.25%, solvent for L-CsA 
• 
LOT No.: 
• 
EXP: mm/yyyy 
Zambon SpA 
Labeling: CCI 
(U.S. Version. Labelling will meet applicable regulatory requirements.) 
• 
Protocol No.: BT – L-CsA – 302 – DLT 
• 
FOR DOUBLE LUNG TRANSPLANT PATIENTS ONLY 
• 
CCI 
 
 
• 
For inhalation use. 
• 
LOT No.: 
• 
Box No.: 
• 
Expiry Date: mm/yyyy 
• 
Inhale CCI 
, according to the instructions from 
your research team. 
• 
Do not store above 77 °F (25 °C), do not freeze. Protect from light. 
CCI 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
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• 
Keep out of reach of children. 
• 
FOR CLINICAL TRIAL USE ONLY 
• 
Return all unused medication to the investigator. 
• 
Sponsor: Zambon S.p.A., Via Lillo del Duca 10, 20091 Bresso (MI), Italy, 
• 
Phone: +39 02 665241 
• 
Investigator name: 
• 
Site No.: 
• 
Patient No.: 
• 
Visit No.: 
9.5.2 
Storage 
The unopened IMP must be kept in a secure location carefully stored not above 77 °F (25 °C) 
protected from light. 
CCI  
 
 
 
 
 
 
 
 
 
 
 
 
9.6 Stopping Rules and Discontinuation Criteria 
9.6.1 
Patient Level 
Regular termination of clinical trial participation: 
The investigational treatment will be terminated after 48 weeks (End of Treatment [EoT]). The 
treatment period will be followed by a follow-up of 4 week duration (End of Study [EOS]). Patients 
who enroll in Clinical Trial BT – L-CsA – 303 – FU (BOSTON-3) will forego the 4-week follow- 
up period of BOSTON-2 and will enroll directly into BOSTON-3 at the Week 48 Visit. For these 
patients, the End of Treatment (EoT) visit will be the EOS visit. 


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Any patients with ongoing SAEs will be followed-up until recovery or stabilization of the SAE. 
If a patient has enrolled in BOSTON-3, pharmacovigilance will be continuously assessed in the 
scope of the follow-up clinical trial. 
Premature termination of clinical trial participation: 
• 
Patients may discontinue participation in the clinical trial at any time by revoking their 
informed consent. 
• 
The Investigator may withdraw a patient at any time if it is in the best interest of the patient 
based upon clinical assessments. 
• 
Patient is lost to follow-up. 
• 
Re-transplantation. Patients who are eligible for and/or listed for re-transplantation will 
continue to participate in the trial until they receive re-transplantation surgery. 
• 
Pregnancy (the patient will be followed via a pregnancy registry). 
• 
Zambon SpA may choose to terminate the study at a site or as a whole for reasons such as, 
but not limited to, medical futility, safety concerns, or poor study site performance. 
Patients stopping to take study treatment but not revoking their consent will be encouraged to 
continue the visits planned until the scheduled end and perform all the important safety and 
efficacy assessment for the full duration of the study. 
If the patient fails to return for clinical follow-up, the patient will be contacted by telephone or a 
letter will be sent requesting a mandatory clinic visit and the reason for non-compliance will be 
documented. 
9.6.2 
Center Level 
Regular termination of clinical trial centers: 
All centers will be closed after the pre-defined number of patients have been randomized (i.e., 
approximately 220) in the BOSTON 1 and the present BOSTON 2 study combined and the patients 
enrolled have completed clinical trial participation. 
Premature termination of a clinical trial center: 
The sponsor may close a center for the following reasons: 
• 
In case of repeated and continuous violations of GCP regulations 
• 
Inaccurate or incomplete data collection 
• 
Falsification of records 
• 
Failure to adhere to the protocol 
• 
Organizational or structural changes in the center which challenge the requirements or 
qualification for clinical trial participation (e.g., change of investigator, shift of center 
activities etc.). 


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In case a center is closed for any of the reasons above, efforts will be made to ensure the safety 
and data reliability of ongoing patients until clinical trial completion. 
9.6.3 
Study Level 
Regular termination of the clinical trial: 
The clinical trial will be considered complete after the pre-defined number of patients (i.e., 
approximately 220) have been randomized in the BOSTON 1 and the present study combined, and 
the patients have completed clinical trial participation (last patient last visit). 
Premature termination of the clinical trial: 
• 
Serious Safety concerns that indicate a potential health hazard caused by treatment with the 
IMP or SoC (termination due to safety issues). 
Zambon SpA may choose to terminate the study as a whole for reasons such as, but not limited to, 
medical futility or safety concerns. In this case, adverse event data will be reported to 
FDA/Competent Authorities according to applicable regulatory requirements. The Investigator 
must notify his IRB/EC of clinical trial closure. 
 
9.7 Investigational Medicinal Product: Supply and Accountability 
Each Investigator is responsible for ensuring that deliveries of IMPCCI 
and other clinical trial materials from Zambon SpA are correctly received and recorded, that these 
are handled and stored safely and properly, and that they are used in accordance with this protocol. 
CCI 
 
Unused and used L-CsA CCI 
 
must be returned to Zambon SpA or destroyed on-site after drug accountability is performed or at 
least at termination of the clinical trial when overall drug accountability has been completed.A list 
of L-CsA, CCI 
, and other materials received, used, returned, or destroyed must be 
prepared, completed and signed by the Investigator; any discrepancies must be accounted for. 
COVID-19 specific consideration: in case the planned on-site visit can not be performed, the 
Principal Investigator (PI) or the Sub-Investigator and/or an appropriately qualified site study team 
member can arrange for the delivery of the IMP directly to patient home, if allowed by local 
regulation and the site IRBs/ECs. 


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10 SELECTION AND WITHDRAWAL OF PATIENTS 
10.1 Patient Inclusion Criteria 
1. Adult patients of ≥ 18 years who received a double lung transplant at least 12 months prior 
to Screening. 
2. Patients with BOS diagnosis defined as CLAD-BOS phenotype with: 
a) Screening FEV1 between 85-51% of personal best FEV1 value post-transplant. 
OR 
b) Screening FEV1 >85% of personal best FEV1 associated with EITHER a ≥ 200 
mL decrease in FEV1 in the previous 12 months OR according to medical history 
showing BOS progression. 
3. Diagnosis of CLAD-BOS must be made at least 12 months after lung transplantation and 
a) within 12 months prior to the screening visit. 
OR 
b) more than 12 months from screening and patient must have shown a decline in 
FEV1 ≥ 200ml in the previous 12 months before screening, which is not due to 
acute infection or acute organ rejection. 
4. Patients in whom the diagnosis of BOS has been confirmed by the elimination of other 
possible causes of obstructive or restrictive lung disease (CLAD – RAS phenotype, see 
Protocol Specific Definitions). 
5. Patients should be on a drug maintenance regimen of immunosuppressive agents including 
tacrolimus, a second agent such as but not limited to MMF or azathioprine, and a systemic 
corticosteroid such as prednisone as third agent. The regimen must be stable within 4 
weeks prior to randomization with respect to the therapeutic agents. In case a patient is also 
receiving concomitant azithromycin for prophylaxis or treatment of BOS, in addition to the 
previously described immunosuppressive regimen, azithromycin must be on a stable 
regimen for at least 4-weeks prior to randomization. 
6. Patients capable of understanding the purposes and risks of the clinical trial, who have 
given written informed consent and agree to comply with the clinical trial 
requirements/visit schedules, and who are capable of aerosol inhalation. Patients must 
consent to retrieve prespecified data from the historic medical record (e.g., information 
related to the transplant surgery; spirometry data; medication use). 
7. Women of childbearing potential must have a negative serum or urine pregnancy test 
within 7 days prior to randomization and must agree to use one of the methods of 
contraception listed in Appendix II through their End of Study Visit. 
8. Patients have no concomitant diagnoses that are considered fatal within one year (12 
months) of Screening. 


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10.2 Patient Exclusion Criteria 
1. Patients with confirmed other causes for loss of lung function, such as acute infection, acute 
rejection, restrictive allograft syndrome (CLAD – RAS phenotype, see Protocol Specific 
Definitions), etc. 
2. Cystic Fibrosis patients with multi-drug resistant infections not responding to available 
anti-microbial therapies. 
3. Patients with acute antibody-mediated rejection at Screening. In this context, clinically 
stable patients (as judged by the Investigator) with detectable levels of donor specific 
antibodies (DSA) at the Screening Visit are eligible for the study. 
4. Active bacterial, viral, or fungal infection not successfully resolved at least 4 weeks prior 
to the Screening Visit. Patients with chronic infection or colonization who are clinically 
stable as per judgement of the Investigator are eligible for the study 
5. Mechanical ventilation (including CPAP) within 12 weeks prior to Randomization. 
6. Patients with uncontrolled hypertension. 
7. Patient has baseline resting oxygen saturation of < 89% on room air or use of supplemental 
oxygen at rest. 
8. Evidence of functional airway stenosis (e.g., bronchomalacia/tracheomalacia, airway 
stents, or airways requiring balloon dilatations to maintain patency) with onset after the 
initial diagnosis of BOS and ongoing at Screening and/or Randomization Visit. 
9. Known hypersensitivity to L-CsA or cyclosporine A. 
10. Patients with chronic renal failure defined as serum creatinine > 2.5 mg/dL at screening or 
requiring chronic dialysis. 
11. Patients with liver disease and serum bilirubin > 3-fold upper limit of normal range or 
transaminases > 2.5 upper limit of normal range. 
12. Patients with active malignancy within the previous 2 years, including post-transplant 
lymphoproliferative disorder, with the exception of treated, localized basal and squamous 
cell carcinomas. 
13. Pregnant women or women who are unwilling to use appropriate birth control to avoid 
pregnancy through their End of Study Visit. 
14. Women who are currently breastfeeding. 
15. Receipt of an investigational drug as part of a clinical trial within 4 weeks prior to the 
Screening Visit. This is defined as any treatment that is implemented under an 
Investigational New Drug (IND) or compassionate use. 
16. Patients who have received extracorporeal photophoresis (ECP) for treatment of BOS 
within 1 month prior to Randomization. 
17. Patients who are currently participating in an interventional clinical trial. 
18. Psychiatric disorders or altered mental status precluding understanding of the informed 
consent process and/or completion of the necessary procedures. 


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19. Any co-existing medical condition that in the Investigator’s judgment will substantially 
increase the risk associated with the patient’s participation in the clinical trial. 
 
10.3 Patient Withdrawal Criteria 
In the event of patient withdrawal, the Investigator must complete the appropriate end of study 
form in the eCRF as soon as possible after withdrawal, stating the reason and date of withdrawal. 
An automated e-mail alert will be generated by the eCRF system and will be sent to the Clinical 
Research Organization (CRO). 
 
 
10.3.1 
Procedures for patients Withdrawal and Type and Timing of Data Collection 
The patient is free to withdraw from the clinical trial for any reason and at any time without giving 
a reason for doing so and without penalty or prejudice. The Investigator is also free to terminate a 
patient’s involvement in the clinical trial at any time if the patient’s clinical condition warrants it 
and if it is in the best interest of the patient based upon clinical assessments. 
If the subject decides to withdraw the consent or the Investigator decide to withdrawn a patient 
from the study, he/she should perform: 
• End of Treatment Visit (Visit 9) PRIOR to discontinuation, whenever possible (the reason 
for premature withdrawal should always be documented) 
• A final clinical trial visit (Visit 10) at least 1 month after Visit 9, if possible 
If subjects permanently discontinue study treatment and maintain consent, or the Investigator 
decide to withdrawn a patient from study treatment, patients should be followed for additional 
outcome information. Subjects should be encouraged to continue the participation in the clinical 
trial until the scheduled end, regardless of the treatment arm. Subjects should perform all study 
visits required by Study Protocol performing all important safety and efficacy assessments for the 
full duration of the Study. 
It is also possible that the Competent Authority(ies), IRBs/ECs or the sponsor request termination 
of the clinical trial, if there are concerns about conduct or safety. 
Reasons for withdrawal are outlined in detail in Section 9.6.1 
The reasons for withdrawal must be recorded in the eCRF. 
 
10.3.1.1 Additional information for the Investigator in case of decision to withdraw a patient 
from IMP: 
To support the Investigator in his/her decision to withdraw a patient from IMP, it is recommended 
to use the maximum intensity of any IMP-related adverse events (see Section 13.1.1.3) as the basis 


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for evaluation. If the patient reports any severe adverse events that are determined to be related to 
L-CsA, the Investigator should consider withdrawing the patient from IMP. 
Spirometry using the CCI 
 spirometer will be performed CCI 
 
after inhalation of L-CsA during the supervised treatments on Day 1. 
Patients may be evaluated in the clinic on Day 2 for further observation with administration of L- 
CsA if warranted in the Investigator’s opinion based upon Day-1 L-CsA administration. A 
reduction in the FEV1 of CCI 
 associated with clinical symptoms of breathlessness or other 
respiratory symptoms will be considered intolerability of the IMP and grounds for discontinuation 
of inhalation. 
 
 
10.3.2 
Replacement of Withdrawn Patients 
Patients withdrawn before randomization (e. g., screening failures) will be replaced until the pre- 
defined number of randomized patients has been reached. If a subject fails the screening process 
due to not meeting inclusion/exclusion criteria, a re-screening is allowed. Randomized patients 
will not be replaced. The eligibility of prematurely withdrawn patients for the different analysis 
populations will be determined in a blind data review meeting with consideration of the definition 
of these analysis populations provided in Section 15.1. 
10.3.3 
Follow-up of Withdrawn Patients 
Patients stopping to take study treatment but not revoking their consent will be encouraged to 
continue the visits planned until the scheduled end and perform all the important safety and 
efficacy assessment for the full duration of the study. 
All patients withdrawn from the clinical trial prematurely will be followed for AEs and SAEs for 
further 4 weeks. Any patient with ongoing SAEs will be followed until recovery or stabilization 
of the SAE. 
The 4-week safety follow-up will be obsolete if a patient completes participation in the clinical 
trial and consents to participate in Study BT – L-CsA – 303 – FU (BOSTON-3). In this case, safety 
will be continuously assessed in the scope of the follow-up clinical trial. 
10.3.4 
Completion of Clinical Trial and Loss to Follow-up 
Patients will be considered to have completed the clinical trial if they were followed-up through 
Study Visit 9 (Study Week 48). 
A patient will be considered lost-to-follow-up only if no contact has been established by the time 
the clinical trial is completed such that there is insufficient information to determine the patient’s 
status at Visit 9 (Week 48). The Investigator should document attempts to re-establish contact with 
any missing patient throughout the clinical trial period. If contact with a missing patient is re- 
established, IMP inhalation and follow-up should resume according to the protocol. 


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11 TREATMENT OF PATIENTS 
11.1 Standard of Care Alone 
Patients randomized to the control arm will receive only the Standard of Care regimen as 
prescribed by the treating physician and as described in Section 9.4.2. 
Any changes in Standard of Care treatment will be documented in the eCRF. 
 
11.2 L-CsA plus Standard of Care 
Patients randomized to the L-CsA arm will receive L-CsA 10 mg twice daily in addition to SoC 
as prescribed by the treating physician and as described in Section 9.4.2. L-CsA will be 
administered as 10 mg/2.5 mL inhalation via the CCI 
 for 48 weeks. 
Any changes in Standard of Care treatment will be documented in the eCRF. 
11.3 Concurrent Treatment or Medication 
All participants randomized, whether enrolled in the L-CsA plus SoC arm or the Standard of Care 
arm of this protocol, will receive standard of care therapies for the maintenance of their allograft. 
SoC includes maintenance immunosuppressive medication, prophylaxis against common 
opportunistic infections, and all other necessary medications and therapies for the optimal care of 
the patient. This also include vaccination against CoV-SARS 2. Changes to immunosuppression 
and use of azithromycin are also considered SoC. All changes in the concurrent treatment or 
medication will be administered according to site’s standard of care. 
11.3.1 
Immunosuppressive Medication 
Maintenance Immunosuppressive Therapy 
Maintenance immunosuppressive therapy including tacrolimus, a second agent such as but not 
limited to MMF or azathioprine, and a systemic corticosteroid such as prednisone as third agent 
will be administered according to institutional standards. Dosages, dates of start and stop or change 
in dosage will be recorded on the respective eCRF. 
Systemic tacrolimus doses should not need to be adjusted based on prior experience using 
aerosolized cyclosporine A. However, systemic tacrolimus doses should be adjusted based upon 
renal function. Should elevations of creatinine occur during the course of the trial by 30% from 
baseline at randomization, tacrolimus levels given systemically should be reduced by 
approximately 30% from baseline and levels should be followed and creatinine monitored 
according to standard protocols at the discretion of the Investigator. 
In the event of renal insufficiency (creatinine > 2.5 mg/dL), the dose of oral tacrolimus may be 
reduced by 30% and the creatinine should be followed by subsequent monthly blood analyses. 
Alternatively, a switch from Calcineurin Inhibitor (CNI) to mTOR inhibitors should be considered 
according to investigators judgement. 


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Augmentation or Change of Immunosuppression 
Augmentation or change of immunosuppression/immunomodulation following randomization of 
the patient into the clinical trial must be recorded on the concomitant medication in the eCRFs. 
All efforts should be made to maintain the type of immunosuppressive drugs at inclusion 
throughout the study. Changes in doses should be driven by medical considerations. Should a 
fourth immunosuppressive drug be needed, an mTOR inhibitor can be considered during the 
study if regarded only as strictly necessary, based on the Investigator’s judgement. 
11.3.2 
Prophylaxis and Therapy of Infections 
All patients will receive standard infectious disease prophylaxis and therapy consisting of 
appropriately targeted antibiotics, antivirals and/or antifungals according to institutional standards. 
Dates of start and stop or change in dosage will be recorded on the respective eCRF. 
11.3.3 
Azithromycin 
Patients receiving azithromycin prior to randomization (for prophylaxis or treatment of BOS), 
must be on a stable regimen for at least 4 weeks prior to randomization. These patients can continue 
to receive azithromycin during the clinical trial as deemed appropriate by the investigator. 
11.3.4 
Other Medication 
All concurrent treatment or medications given within 30 days prior to Randomization and until 
Visit 10/EoS, will be recorded in the CRF. 
The use of any inhaled formulation of Cyclosporine A other than the IMP is strictly prohibited 
during the complete clinical trial period. Topical formulations (e.g., eye drops) containing CsA 
are allowed. Patients should not receive systemic Cyclosporine A at any time during Screening 
and Randomization. If medically indicated after Randomization, the treating physician can 
exchange Tacrolimus for systemic Cyclosporine A. 
All inhaled medications, except investigational inhaled medications, are permissible during the 
trial and should be administered in the following order: inhaled bronchodilators, inhaled 
corticosteroids, inhaled antifungals/antibiotics, and then inhaled L-CsA. Spirometry must be 
performed without the use of bronchodilators (see Section 12.1.1.1) and preferably before but at 
least 2 hours after the last administration of inhaled antifungals/antibiotics. 
To standardize spirometry across the two treatment arms, patients should not use short-acting 
bronchodilators (e.g., albuterol) 2 hours prior to spirometry. Patients on scheduled Long-Acting 
Beta Agonists (LABAs) or Long-Acting Muscarinic Antagonists (LAMAs) should ideally have 
spirometry done at the same time of day following their scheduled dose. Patients have to note 
their use and timing of bronchodilators carefully. 


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11.3.5 CCI 
 
CCI 
 
 
 
 
 
CCI 
 
 
. 
The reason for non-compliance shall be documented accordingly on the respective CRF. 


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12 ASSESSMENT OF EFFICACY 
12.1 Methods and Timing of Efficacy Assessments and Analyses 
12.1.1 
Spirometry 
12.1.1.1 
CCI 
 
For on-site spirometry each clinical trial site will be provided with a CCI 
 
), which will stay on site. 
Clinical trial personnel at each site will be trained and certified on the use of protocol specific 
software installed on the CCI 
 Spirometry will be measured according to American 
Thoracic Society (ATS)/European Respiratory Society (ERS) spirometry guidelines at each visit 
[Miller 2005a; Miller 2005b; Wanger 2005; Pellegrino 2005]. Three acceptable maneuvers will be 
obtained and the largest value for FVC and FEV1 will be recorded. The CCI 
 
from the 
maneuver with the largest sum of FEV1 + FVC will be recorded. FEV1, FVC, and CCI 
 
will 
be recorded in absolute terms. Centralized overread will be applied to all maneuvers obtained. 
 
It is well known that spirometry relies on the cooperation between the patient and examiner and 
that the results obtained will depend on technical as well as personal factors. Therefore, all efforts 
will be undertaken to have a particular patient assessed by the same examiner. To reduce the 
variability of the results, the method should be standardized as far as possible. 
Within-maneuver acceptability criteria: 
Individual spirograms are acceptable if: 
• 
They are free from artefacts 
o 
Cough during the first second of exhalation 
o 
Glottis closure that influences the measurement 
o 
Early termination or cut-off 
o 
Effort that is not maximal throughout 
o 
Leak 
o 
Obstructed mouthpiece 
• 
They have good starts 
o 
Extrapolated volume < 5% of FVC or 0.15 L whichever is greater 
• 
They show satisfactory exhalation 
o 
Duration of ≥ 6 seconds or a plateau in the volume-time curve or if the patient cannot or 
should not continue to exhale. 
Between-maneuver repeatability criteria: 
After three acceptable spirograms have been obtained, apply the following test: 
• 
The two largest values of FVC must be within 0.150 L of each other 


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• 
The two largest values of FEV1 must be within 0.150 L of each other. 
If both of these criteria are met, the test session may be concluded. 
If both of these criteria are not met, continue testing until: 
• 
Both of the criteria are met with analysis of additional acceptable spirograms 
or 
• 
A total of eight tests have been performed (optional) 
or 
• 
The patient cannot or should not continue. 
Save, as a minimum, three acceptable and repeatable maneuvers. 
12.1.1.2 
CCI 
 
Each site will receive portable spirometers ( 
CCI 
 
) for newly enrolled patients to be used at all on-site and remote visits. Clinical 
trial personnel will be trained in the use of theCCI 
, patients will be trained by the 
clinical trial personnel in the use of the device at screening. Refresher training for patients will be 
provided at all subsequent clinic visits (and during remote visits, if required). The patient will 
receive written instructions on how to use the CCI    to perform spirometry correctly. 
Spirometry on the CCI 
 should be performed using the same within and between maneuver 
criteria that would be applied during on-site spirometry testing as described above. The largest 
value for FVC and FEV1 will be recorded. The CCI 
 from the maneuver with the largest sum 
of FEV1 + FVC will be recorded. FEV1, FVC, and CCI 
 will be recorded in absolute terms. As 
a minimum, three acceptable and repeatable manoeuvres will be recorded. 
To assist the clinical trial personnel and patient to achieve the spirometry within (acceptability) 
and between (repeatability) manoeuvre criteria described above [Miller 2005a; Miller 2005b; 
Wanger 2005; Pellegrino 2005], theCCI 
will be programmed to give feedback. For 
example, if an individual spirogram did not meet the start of test criteria, the device will indicate 
to the patient there was a slow start of test. 
Spirometry data stored on the CCI 
 device will be transmitted to a central database, via a GSM 
cradle from the patients home and be subject to centralized overread. 
12.1.1.3 
General Considerations 
 
For the determination of eligibility at Screening, only spirometry data obtained with the 
CCI 
 spirometer will be used. 


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To standardize spirometry across the two treatment arms, patients should not use a short-acting 
bronchodilator (e.g., albuterol) 2 hours prior to spirometry. If patients are on scheduled LABAs 
or LAMAs then the time from last dose to spirometry should be consistent throughout the study. 
Spirometry should ideally be performed before, or a minimum of 2 hours following the last 
inhalation of inhaled antifungals/antibiotics. 
 
All inhaled medications, except investigational inhaled medications, are permissible during the 
trial and should be administered in the following order: inhaled bronchodilators, inhaled 
corticosteroids, inhaled antifungals/antibiotics, and then inhaled L-CsA. 
 
Spirometry must always be performed before L-CsA inhalation. 
12.1.1.4 
Onsite Visits 
 
On-site spirometry should be performed by blinded personnel. 
At every visit, spirometry will be measured using the CCI 
 spirometers. 
Instructions for Use (including additional information on accuracy checks, cleaning of the device 
and further support) for both devices are available in the Study Manual. At least three acceptable 
and repeatable maneuvers on each device should be obtained at each visit. 
At Visit 1, the spirometry at CCI 
 
CCI 
 
post IMP will only be performed using the 
Sufficient rest between both spirometry sessions should be granted to the subject at the 
Investigator’s discretion. For the CCI 
 spirometry session, procedures identical to those to be 
used at home will be followed. 
12.1.1.5 
Remote Visits 
 
If patients cannot attend clinic visits due to COVID-19, remote visits using guided home 
spirometry may be performed (FEV1, CCI   5, and FVC) on the CCI   device. For remote visits, 
the clinical trial personnel will telephone the patient and guide them through performing 
spirometry on the CCI    device (for further assessments during remote visits, see Section 14.2.8). 
Home spirometry should be scheduled around the same time as the usual clinic visits, whenever 
possible, to minimize the effects of circadian variation of lung function measurements. 
In case measurements are not satisfactory after central overread, home spirometry may be repeated 
as close to the initially scheduled remote visit as possible. 
12.1.2 
Progression of BOS 
Due to the patchy distribution of affected areas in the pulmonary allograft, chronic rejection and 
BOS are not uniformly detectable by biopsy. This method has turned out to be too unspecific and 
harmful for routine diagnostic use. Therefore, non-invasive spirometry has been routinely 


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established using standardized airflow measurements which nowadays is used to determine FEV1 
as a surrogate marker for the diagnosis of BOS, its classification and its control of progression. 
Progression of BOS during the treatment period is defined as a further decline of FEV1 of ≥ 10% 
or ≥ 200 mL from Baseline FEV1 and absolute decrease in CCI 
 of > 5% that is confirmed 
by measurements that are taken with CCI 
 spirometer at least 2 weeks apart, OR 
worsening in BOS grade OR Re-transplantation, OR Death from respiratory failure. 
If a patient has an event which meets one of the criteria for progression of BOS, the Investigator 
should report the event via the eCRF. 
12.1.3 
Augmentation or Change of Immunosuppression 
Augmentation or change of immunosuppression/immunomodulation must be recorded in the 
eCRFs. 
 
12.1.4 
Re-transplantation 
Re-transplantation is defined as the date that a patient undergoes lung re-transplantation surgery. 
The reason for re-transplantation will be recorded. At the time of re-transplantation, the patient 
will be withdrawn from the study. 
 
12.1.5 
Death 
If a patient dies during the clinical trial, the medical monitor should be contacted as soon as is 
feasible. The cause of death and a clinical summary will be requested. 
12.1.6 
Acute Rejection and its Severity 
A patient with symptoms of a concomitant medical condition should be evaluated as clinically 
indicated. If a patient is diagnosed with acute rejection, the diagnosis should be recorded according 
to the following classification scheme. Any medications used to treat acute rejection should be 
recorded on the concomitant medication eCRF. The grade of acute rejection, airway inflammation, 
chronic airway rejection and chronic vascular rejection will be evaluated by the Investigator 
according to the revised working formulation for classification and grading of pulmonary allograft 
rejection [Stewart 2007] (Table 6): 


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Table 6. Revised Working Formulation for Classification and Grading of Pulmonary 
Allograft Rejection 
 
A: Acute rejection 
Grade 0 
None 
Grade 1 
Minimal 
Grade 2 
Mild 
Grade 3 
Moderate 
Grade 4 
Severe 
B: Airway inflammation 
Grade 0 
None 
Grade 1R 
Low grade 
Grade 2R 
High grade 
Grade X 
Ungradable 
C: Chronic airway rejection – obliterative bronchiolitis 
0 
Absent 
1 
Present 
D: Chronic vascular rejection – accelerated graft vascular sclerosis 
 
“R” denotes revised grade to avoid confusion with 1996 scheme. 
12.1.7 
Antibody-Mediated Rejection 
While less common in patients more than one-year post-transplant, if the treating physician makes 
the diagnosis of antibody-mediated rejection (AMR), this should be recorded in the eCRF. The 
diagnostic criteria and a working consensus definition established by the ISHLT with the aim of 
determining criteria for pulmonary AMR and establishing a definition should be used to support 
the diagnosis [Levine 2016]. See Appendix III for further information on Antibody-Mediated 
Rejection. 
12.1.8 
Quality of Life Questionnaire (EQ-5D-5L) 
The EQ-5D-5L is a standardized measure of health status developed by the EuroQol Group in 
order to provide a simple, generic measure of health for clinical appraisal. Patients will be asked 
to manually complete the EQ-5D-5L at Visits 1, 4, 6, and 9/EoT and results will be entered into 
the eCRFs by site staff. 
12.1.9 Hospitalizations 
Hospitalizations for any reason other than a scheduled procedure should be considered as serious 
adverse event and should be recorded in the eCRFs with admission date, discharge date, reason 
for admission, and additional diagnoses. If a patient requires mechanical ventilation for any 
reason other than a planned surgical procedure, dates of mechanical ventilation, and reason for 
mechanical ventilation should be recorded separately. A Hospitalization Discharge Summary 
may be requested by the Medical Monitor and shared with the DMC and/or AC. 


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13 ASSESSMENT OF SAFETY 
13.1 Safety Parameters 
Safety Assessments at every visit include physical examination, vital signs, adverse event 
reporting, and clinical laboratory parameters (performed at the local labs in each study site). 
Acute tolerability of IMP during initial dosing will be assessed by spirometry before and after 
inhalation. 
COVID-19 specific consideration: In case the planned on-site visit cannot be performed, the PI or 
the Sub-Investigator and/or an appropriately qualified site study team member must call the patient 
to assess any potential adverse events (AEs) and to confirm the patient’s status and wellbeing (see 
also Section 14.2.8). 
13.1.1 
Adverse Events (AEs) 
13.1.1.1 
Definitions 
Adverse Event (AE) 
An AE is any untoward medical occurrence in a patient after administration of a pharmaceutical 
product and which 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 (ICH Guidelines for Good Clinical 
Practice, E6(R2), 9 November 2016). 
This includes worsening of a pre-existing condition or increase in frequency of a pre-existing 
condition. An adverse event is considered serious if it meets any of the serious criteria listed below. 
To ensure no confusion or misunderstanding of the difference between the terms “serious” and 
“severe”, which are not synonymous, the following clarification is provided: 
The term “severe” is often used to describe the intensity (severity) of a specific event (as in mild, 
moderate, or severe myocardial infarction); the event itself, however, may be of relatively minor 
medical significance (such as severe headache). This is not the same as “serious”, which is based 
on patient/event outcome or action criteria usually associated with events that pose a threat to a 
patient’s life or functioning. Seriousness (not severity) serves a guide for defining regulatory 
reporting obligations. 
The official definition also extends to AEs occurring during the off-treatment follow-up period. 
Each patient will be closely observed and questioned for AEs during the clinical trial period with 
non-leading questions (e.g., how do you feel?). The patients will be instructed to report to the 
clinical trial staff immediately any symptoms and/or signs which occur between the scheduled 
observation times. 


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All AEs reported by the patient or observed by the Investigator or hospital personnel will be 
documented in the respective eCRF. The following information regarding each adverse event will 
be obtained: date and time of onset and resolution (duration), serious or non-serious (as defined 
below), severity, treatment required, outcome, relationship to certain medication, and if the AE 
caused withdrawal from the clinical trial. 
In addition to the Investigator's own description of the AE, each AE event will be coded by data 
management according to the Medical Dictionary for Regulatory Activities (MedDRA) code list. 
The verbatim term will be recorded in the eCRF. 
Abnormal laboratory test results will be reported as AEs if they are indicative of a clinical 
condition that meets the criteria for an AE. 
Adverse Drug Reaction (ADR) 
Adverse drug reactions (ADRs) are all noxious and unintended responses to a medicinal product 
related to any dose that a causal relationship between the medicinal product and an adverse event 
is at least a reasonable possibility, i.e., the relationship cannot be ruled out. An unexpected ADR 
is any adverse reaction not identified in nature, frequency, or intensity in the current Investigator’s 
Brochure. 
Serious Adverse Event (SAE) 
Each adverse event is to be classified by the Investigator as SERIOUS or NON-SERIOUS. 
The International Conference on Harmonisation (ICH) of Technical Requirements for Registration 
of Pharmaceuticals for Human Use defines a serious adverse event as any adverse event occurring 
at any dose that results in any of the following outcomes: 
• 
Death 
• 
A life-threatening event (immediate risk of death at the time of the event) 
• 
Inpatient hospitalization or prolongation of existing hospitalization 
• 
A persistent or significant disability/incapacity 
• 
A congenital anomaly/birth defect 
• 
Other important medical event (Medical and scientific judgment should be exercised in 
deciding whether expedited reporting is appropriate in other situations, such as important 
medical events that may not be immediately life-threatening or result in death or 
hospitalization but may jeopardize the patient or may require intervention to prevent one of 
the other outcomes listed in the definition above. These should also usually be considered 
serious.) 
13.1.1.2 
Relationship to Clinical Trial Treatment Assignment 
All adverse events will be evaluated by the Investigator for potential relationship to the clinical 
trial treatment assignment (L-CsA plus SoC or SoC alone) in the following categories: 


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• 
Unrelated: An AE for which there is no evidence of any causal relationship with the clinical 
trial treatment assignment 
• 
Possible: An AE that might be due to the use of the clinical trial treatment assignment. An 
alternative explanation, e.g., concomitant drug(s), concomitant disease(s), is inconclusive. 
The relationship in time is reasonable; therefore, the causal relationship cannot be excluded. 
• 
Definite: An adverse event that follows a reasonable temporal sequence from administration 
of the clinical trial treatment assignment; that follows a known or expected response pattern 
to the suspected clinical trial treatment assignment. 
13.1.1.3 
Maximum Intensity 
All adverse events will be graded according to the following: 
• 
Mild: Event requiring no special treatment and generally does not interfere with usual 
activities. 
• 
Moderate: Event that impairs usual activities but may be ameliorated by simple therapeutic 
maneuvers. 
• 
Severe*: Event which impairs usual activities and requires intervention. 
* There is a distinction between a severe adverse event and a serious adverse event; a severe 
reaction is not a serious adverse event unless it meets one of the criteria for serious events (see 
Section 13.1.1.1). 
13.1.1.4 
Serious Adverse Event (SAE) Reporting 
Any serious adverse events occurring 
• 
between the first clinical trial procedure after obtaining informed consent and within 4 weeks 
after the completion of the EoT visit, whether or not considered related to the clinical trial 
treatment assignment 
or 
• 
at any time after completion of the last follow-up and coming to the attention of the 
Investigator, if it is judged as related to the patient’s participation in the clinical trial 
must be reported to CCI  IMMEDIATELY, but within 24 hours upon knowledge, as follows: 
• 
Document the event in the eCRF within 24 hours of discovery 
• 
Submit the SAE report by FAX or e-mail it to a list of predefined recipients. 
• 
Follow-up the SAE until the outcome is determined, providing periodic updates in the eCRF 
• 
Provide any additional information if requested 
Contacts of CCI  are as follows: 


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CCI 
 
13.1.1.4.1 
Timelines for Suspected Unexpected Serious Adverse Reaction (SUSAR) reporting to 
Competent Authorities and IRBs/ECs 
All suspected unexpected serious adverse reactions (SUSARs) will be reported by the Sponsor to 
the Competent Authorities and to the IRBs/ECs concerned as soon as possible, but within a 
maximum of 15 days (fatal or life-threatening SUSARs within a maximum of 7 days) of first 
knowledge. 
Relevant follow-up information of fatal or life-threatening SUSARs will be communicated 
subsequently within an additional eight days. 
13.1.1.4.2 
Other Events to be Treated as Serious Adverse Events 
Exposure to drug during pregnancy/lactation: 
In principle, pregnancy and the lactation period are exclusion criteria. In the event of a pregnancy 
occurring during the course of the clinical trial, the patient must be withdrawn from all IMP 
treatment immediately and permanently. The Sponsor must be notified without delay and the 
patient followed during the entire course of the pregnancy and postpartum period. Prenatal and 
neonatal outcomes must be recorded even if they are completely normal and without AEs. The 
SAE reporting procedure should be followed, even though pregnancy is not considered an SAE. 
No “serious criterion” should be checked. The SAE report form is solely used to ensure expedited 
reporting. 
If any clinical trial patient becomes pregnant during the study period, the Investigator must contact 
Zambon SpA as the Sponsor of the clinical trial or its designee to discuss the management of the 
patient. 
13.1.1.4.3 
Investigational Medicinal Product (IMP) Overdosing 
An overdose is a deliberate or inadvertent administration of a treatment at a dose higher than 
specified in the protocol. For the purposes of this clinical trial, any dose of aerosolized IMP 
administered to a patient that exceeds the dose foreseen in the protocol by more than 50% over 4 
weeks should be reported as an overdose. 
The Investigator/Sponsor responsibilities in regard to reporting SAEs are in accordance with the 
US Food and Drug Administration and other Competent Authorities concerned. 


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13.1.1.4.4 
Events not Regarded as Adverse Events/Serious Adverse Events 
The following events will be not regarded as AEs/SAEs: 
• 
Pre-scheduled (before any trial-related activities commenced) hospitalizations/surgeries/ 
interventions 
• 
Trial endpoint-related worsening; this will be assessed in the endpoint analysis. 
13.1.1.4.5 
Duration of Follow-up after Adverse Events 
All adverse events should be followed until they are resolved or until a stable clinical endpoint is 
reached. The occurrence of AEs and SAEs will be monitored until 4 weeks after the EoT visit. 
Any patient with ongoing SAEs will be followed until recovery or stabilization of the SAE. 
COVID-19 specific considerations: All confirmed cases of COVID-19, occurring after the patient 
has provided informed consent and until 4 weeks after the EoT visit, must be reported as SAE, and 
reported to CCI  within 24 hours upon knowledge. 
The seriousness criterion for COVID-19 hospitalized patients should be “hospitalization”; if the 
patient was not admitted to a hospital or the event is not resulting in prolonged hospitalization, the 
seriousness citerion “medically significant” should be used. 
In all cases, details of the patient's symptoms, treatment and any clinically relevant information, 
should be entered in the SAE forms, as appropriate. 
13.1.2 
Acute Tolerability of L-CsA 
Acute tolerability of L-CsA during initial dosing will be determined by measuring spirometry 
CCI 
. FEV1 will be measured at prior to dosing with L-CsA. A decline 
of CCI 
 associated with symptoms could warrant IMP discontinuation. 
13.1.3 Infections 
Acute infections will be evaluated according to the following criteria: 
• Bacterial infection: bacterial infections will be diagnosed by conventional laboratory culture 
methods in combination with clinical symptoms [Bonvillain 2007]. Pneumonia requires 
presence of new worsening infiltrates by chest radiography and growth of organisms in 
Bronchoalveolar Lavage (BAL) or sputum samples with anti-microbial treatment. 
• Fungal infection: the revised consensus definitions of the European Organization for Research 
and Treatment of Cancer / Mycosis Study Group will be used for the diagnosis of fungal 
infections [De Pauw 2008]. Fungal infections will be classified as proven, probable or possible 
according to host, clinical and microbiological criteria. 
• Viral infection: the diagnosis of viral infection requires a 4-fold increase in serial serum 
samples and/or one of the following: a newly positive IgM antibody titer associated with 
clinical signs/symptoms requiring antiviral therapy; sero-conversion; virus isolation; or 


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histopathologic evidence of viral infection [Bonvillain 2007]. The diagnosis of viral 
pneumonia requires impairment of either pulmonary mechanisms or gas exchange, or 
reduction in gas transfer in the appropriate clinical context. 
Occurrence of acute infections will be monitored permanently throughout the complete clinical 
trial period. Sputum and BAL samples will be collected, if indicated, and monitored for the 
presence of bacterial, viral and fungal pathogens. 
An infection is defined as any acute infection requiring antimicrobial therapy. All acute infections 
will be reported as AEs. Information captured on the AE CRF will include: date of onset, pathogen 
identified, resolution, and action taken. 
In the case of an acute infection episode fulfilling the criteria of a serious adverse event, the 
reporting timelines as laid down in Section 13.1.1.4 have to be adhered to. 
The cumulative incidence of acute infections as well as the number of acute infections per patient 
will be summarized by treatment group. 
The samples should be evaluated by the local certified laboratory of each center. When needed 
due to unexpected circumstances and upon clinical judgment (e.g. patient travelling, acute event 
happening in a location distant to clinical center etc.), samples could also be analyzed by a 
different laboratory as per patient convenience and the related results will be provided to the 
Investigator. 
13.1.4 
Malignancies 
All malignancies must be confirmed by histopathology. Malignancies will be documented on the 
AE CRF. 
13.1.5 
Clinical Laboratory 
Laboratory assessments will be performed following the routine protocols at each study visit by 
the local laboratory at each site. 
The following clinical laboratory parameters have to be documented: 
• White Blood Cell (WBC) count with differential 
• Red Blood Cell (RBC) count 
• Platelet count 
• Alkaline phosphatase (AP) 
• Alanine Aminotransferase (ALT) 
• Aspartate Aminotransferase (AST) 
• Gamma Glutamyl Transferase (γ-GT) 
• Blood Urea Nitrogen (BUN) 
• Serum bilirubin 
• Serum creatinine 


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Laboratory assessments listed above will be performed at a certified local facility. 
13.1.5.1 
Pregnancy Test 
Serum samples from women of childbearing potential will be collected for pregnancy tests at 
screening and with all scheduled blood draws. Positive results will be recorded in the eCRF and 
appropriate actions will be taken. At Visit 1, a serum or urine pregnancy test must be obtained 
within 7 days prior to randomization. A urine pregnancy test is allowed at this visit so that the 
result can be obtained rapidly in order to not delay randomization. 
13.1.5.2 
Cyclosporine A and Tacrolimus Whole Blood Trough Levels 
A whole blood sample for the determination of cyclosporine A and/or tacrolimus trough level will 
be collected at each visit. In patients allocated to L-CsA inhalation, the sample should be collected 
within 60 minutes before inhalation. The mean cyclosporine A and/or tacrolimus trough level will 
be compared across treatment groups. Blood samples will be evaluated by the local laboratories. 
13.1.5.3 
Donor Specific Antibody Test 
Serum samples for donor specific antibody testing will be collected at Screening, and at Visits 4, 
6, and 9. If a DSA test performed within 4 weeks before screening is available, a further DSA 
test at screening visit will not be mandatory and the previous result will be reported in eCRF. 
13.1.5.4 
Renal Function 
As lung transplant patients frequently present with symptoms of renal impairment special 
emphasis is paid for the key parameter of renal function, i.e., serum creatinine. The classification 
of renal dysfunction shall follow a unique terminology to describe the disorder (Table 7): 


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Table 7. Terminology of renal disorders 
 
 
Proposed Term 
Medical Condition 
Preferred Term 
Blood creatinine abnormal 
or 
Enhanced creatinine level 
or 
Increase of creatinine level 
Temporarily increased creatinine 
values due to medical or nutrition 
condition 
Blood creatinine increased 
Renal impairment 
Continuously increased creatinine 
values due to medical condition 
No treatment required 
Renal impairment 
Continuously increased creatinine 
values due to medical condition 
Treatment required and laboratory 
values clinically significant 
Acute renal dysfunction 
Creatinine value temporarily over 
2.5 mg/dL 
Possible actions: Fluid 
administration; adjustment of 
TAC/CsA or co-medication 
Renal impairment 
Severe renal dysfunction 
Creatinine value stable over 2.5 
mg/dL 
Treatment required, but adjustment 
of TAC/CsA or co-medication not 
effective anymore; CNI toxicity 
Renal impairment 
Chronic severe renal 
dysfunction 
or 
Renal failure 
Creatinine value stable over 2.5 
mg/dL 
Dialysis or renal transplantation 
required 
Renal impairment 
Renal Failure 
Terminology of renal disorders table is prepared in accordance with Dictionary MedDRA - 23.1 


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13.1.6 
Vital Signs 
Vital signs will be assessed at each visit. 
The following vital signs will be recorded: 
Systolic and diastolic blood pressure (sitting, after 5 minutes of rest), pulse rate (sitting, after 5 
minutes of rest), body temperature (the same method should be used for each patient and 
throughout the clinical trial), and respiratory rate. 
Abnormal values will be summarized by Common Toxicity Criteria (CTC) AE grade (version 5.0) 
for each patient. 
13.1.7 
Physical Examinations 
A physical examination will be carried out at the Screening Visit and at every subsequent visit. 
The following body systems will be examined: body weight, cardiovascular, respiratory, nervous, 
gastrointestinal, hepatic, renal, dermatological, musculoskeletal, extremities, eyes, ears, nose, 
throat, and lymphatic. Patient height will be measured at Screening Visit only. 
Abnormal findings will be summarized for each patient. 
13.2 Data Monitoring Committee (DMC) 
An independent Data Monitoring Committee will be established to monitor the safety of IMP 
throughout the studies BT – L-CsA – 301 – SLT and BT – L-CsA – 302 – DLT. The DMC will 
monitor safety by evaluating the safety analysis generated by the unblinded independent 
statistician during the course of the clinical trial. Details of the safety analyses will be included in 
the DMC’s Charter. The DMC will evaluate treatment groups for possible trends in adverse events, 
determine whether the basic clinical trial assumptions remain valid, evaluate whether the overall 
integrity, scientific merit and conduct of the clinical trial remain acceptable, and make 
recommendations to the Sponsor. 
The DMC will peform a comparison between the rate of observed COVID-19 cases, rate of 
patient's withdrawal, and rate of missing data among trial participants in both treatment arms. 
Members of the DMC will be unblinded to the treatment group label, i.e., the DMC will know 
which group is L-CsA + Standard of Care and which group is Standard of Care alone. The DMC 
will evaluate all safety and acute tolerability parameters, to be detailed in the DMC charter. 
Safety and acute tolerability parameters include adverse events, acute tolerability of L-CsA, 
infections, malignancies, clinical laboratory data (white blood cell count with differential, red 
blood cell count, platelet count, alkaline phosphatase, alanine aminotransferase, aspartate 
aminotransferase, gamma glutamyl transferase, blood urea nitrogen, serum bilirubin, serum 
creatinine), vital signs, physical examinations and FEV1. The statistics provided will be merely 
descriptive. 


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13.3 Adjudication Committee (AC) 
 
The AC – consisting of three independent physicians, with documented expertise in the clinical 
management of lung transplantation and diagnosis and treatment of BOS - will maintain the role 
of reviewing the BOS progression data in blind condition once each participating subject 
completes the study period, with the aim to ensure consistent and complete recording of data. 
If necessary, the AC may query the sites to ask for clarifications. 
In case there are discrepancies between the assessment of the AC and that of the investigator re: 
BOS progression events, the CRO will notify the investigator. In all cases, the final decision as to 
whether or not specific event qualifies as BOS progression stands with the Investigator. 
Details of the AC activities will be included in the AC’s Charter. 
 
14 VISIT SCHEDULE 
All clinical trial visits, investigations and activities are listed in the Clinical Trial Schedule of 
Activities below. Further details on the methodology of these investigations and activities are 
described in detail in Section 12 and 13. The investigator will adhere to the visit and procedure 
schedule as closely as possible. 
All patients assigned to a randomization number will be followed according to the protocol unless 
consent for follow-up is withdrawn. The Sponsor must be notified of all deviations from the 
protocol visit schedule or evaluations, and these visits/evaluations, if applicable, must be 
rescheduled or performed at the closest possible time to the original schedule. 
For all patients randomized to L-CsA, proper patient understanding and competency of the CCI   
use will be ensured in an individual training by the responsible clinic personnel. The patient 
will be administering the drug independently under supervision to verify patient competency with 
the equipment and drug tolerability. 
After randomization, patients will visit the clinic every 4-8 weeks throughout the 48-week duration 
of the treatment period. 
It is recommended that the Investigators contact the patient approximately 1 to 2 weeks prior to 
the next visit to remind the patient about the next scheduled visit. Patients will be instructed to call 
clinical trial personnel to report any abnormalities, including any hospitalizations or doctor visits 
during the interval between visits and to come to the clinical trial site if medical evaluation is 
needed and urgency of the situation permits. For emergency and other unscheduled visits to a 
medical facility other than the clinical trial site, medical records of the visit should be obtained by 
the Investigator. 
If a patient prematurely discontinues clinical trial participation for any reason apart death, re- 
transplantation or withdrawal of consent, he/she will be encouraged to complete the follow-up 


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visits planned in the protocol. All patients who prematurely discontinue the study, including the 
ones who undergo re-transplantation or withdraw their consent for further participation in the 
clinical trial, should complete at least the evaluation listed under “End of Treatment Visit” (Visit 
9) prior to discontinuation whenever possible (the reason for premature withdrawal should always 
be documented). 


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Schedule of Activities 
 
Clinical Trial Period 
Screening 
Baseline 
Treatment 
Visit Number 
- 
V 1 
V 2 
V 3 
V 4 
V 5 
V 6 
Week & Window 
W -4 to W 0 
W 0 Day 
1 
W 4 
± 7 Days 
W 8 
± 7 Days 
W 12 
± 7 Days 
W 16 
± 7 Days 
W 24 
± 14 Days 
Historical Spirometry (from patient’s 
medical file) 
X 
Informed Consent1 
X 
Demographics/Medical History 
X 
X 
Donor-specific Antibody Test 
X9 
X8 
X8 
Inclusion/Exclusion 
X 
X 
(confirmation 
of screening) 
Serum/Urine Pregnancy Test2 
X 
X2 
X8 
X8 
X8 
X8 
X8 
Physical Examination3 
X 
X 
X 
X 
X 
X 
X 
Vital signs4 
X 
X 
X 
X 
X 
X 
X 
Clinical Laboratory Tests 
X 
X10 
X8 
X8 
X8 
X8 
X8 
Spirometry5 
X 
X 
X 
X 
X 
X 
X 
Randomization 
X 
L-CsA Administration6 
Twice daily administration of 10 mg L-CsA 
Adherence via CCI 
Permanently throughout the complete clinical trial period (for Israel: after EoT) 
Blood Sampling 
(CNI, mTor inhibitors)7 
X 
X 
X8 
X8 
X8 
X8 
X8 
Concomitant Medication 
X 
X 
X 
X 
X 
X 
X 
Adverse Events 
Permanent assessment throughout the complete clinical trial period 
Acute L-CsA Tolerability6 
X 
Drug Accountability6 
X 
X 
X 
X 
X 
EQ-5D-5L 
X 
X 
X 


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Clinical Trial Period 
Treatment 
Follow-Up 
Visit Number 
V7 
V8 
V9 / EoT 
Remote Visit 
V 2 – V8 
V10 / EoS 
Week/Month & Window 
W 32 
± 14 Days 
W 40 
± 14 Days 
W 48 
± 14 Days 
W 52 
CCI
Donor-specific Antibody Test 
X8 
Serum/Urine Pregnancy Test2 
X8 
X8 
X8 
X8 
Physical Examination3 
X 
X 
X 
X 
Vital Signs4 
X 
X 
X 
X 
Clinical Laboratory Tests 
X8 
X8 
X8 
X8 
Spirometry5 
X 
X 
X 
X 
X 
L-CsA Administration6 
Twice daily administration of 10 mg L-CsA 
Adherence via CCI 
Permanently throughout the complete clinical trial period (for Israel: after EoT) 
Blood Sampling (CNI, mTor inhibitors)7 
X8 
X8 
X8 
X8 
Concomitant Medication 
X 
X 
X 
X 
X 
Adverse Events 
Permanent assessment throughout the complete clinical trial period 
Acute L-CsA Tolerability6 
Drug Accountability6 
X 
X 
X 
EQ-5D-5L 
X 
NOTE: The Screening phase (time between screening and randomization visit) last from one day to up to 4 weeks. 
1 
Conduct prior to any screening activities. 
2 
Not more than 7 days prior to Randomization. Urine pregnancy test is allowed at Visit 1 only. Austria only: Urine pregnancy tests will be performed every 
month according to local law (Visits 5 through 9). 
3 
Including body weight, height (Screening Visit only), cardiovascular, respiratory, nervous, gastrointestinal, hepatic, renal, dermatological, musculoskeletal, 
extremities, eyes, ears, nose, throat, and lymphatic. 
4 
Including systolic and diastolic blood pressure (sitting, after 5 minutes of rest), pulse rate (sitting, after 5 minutes of rest), body temperature (the same method 
should be used for each patient and throughout the clinical trial), and respiratory rate. 
5 
At all visits, spirometry will be performed on the CCI 
 and on the CCI 
 as per Section 12.1.1.1. At the Baseline Visit (V1), serial spirometry is to 
be performed prior to Randomization (CCI 
and CCI 
 CCI 
 after 
completion of L-CsA dose (or after Randomization to SoC). Remote visits will be performedCCI 
performed in those patients not rolling over to Boston 3 on the CCI 
 only. 
6 
Only in patients randomized to receive L-CsA treatment. 
. Visit 10 spirometry will be 


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7 
within 60 min. prior to next CNI (cyclosporine A and/or tacrolimus) administration. Blood levels of mTor inhibitors will be taken only if applicable, i.e., if 
patient is treated with mTor inhibitors. 
8 
±3 days of the Visit date. 
9 
If a DSA test performed within 4 weeks before screening is available, a further DSA test at screening visit will not be mandatory. 
10 Laboratory tests at V1 are not mandatory in case laboratory tests at screening visit have been performed within 2 weeks from V1. 


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DLT patient 
with confirmed 
BOS diagnosis 
 
14.1 Clinical Trial Flow Chart 
 
 


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14.2 Study Visits 
14.2.1 Screening 
Eligible patients who express interest in participating in the trial must sign an IRB/EC approved 
informed consent form (ICF) prior to initiation of any clinical trial activities. Patients who fulfill 
all of the inclusion criteria and none of the exclusion criteria may be enrolled into the clinical trial. 
Documentation of the patient’s consent and eligibility must be completed by the Investigator or 
his/her designee. All patients who fail the screening activities will be documented in the screening 
failure log. 
The following screening activities will be performed during the screening period (up to 4 weeks 
prior to Visit 1): 
• 
Informed Consent: Obtain informed consent prior to performing any clinical trial activities. 
• 
Demographics: Year of birth, gender, ethnic group, date of body measurements, height and 
weight. 
• 
Medical History: Details related to each patient’s lung transplant will be recorded and will 
include: underlying condition (cause of lung failure), date, type of transplantation, donor 
demographics, donor cause of death, donor/recipient Human Leukocyte Antigen (HLA)- 
status, induction therapy, antiviral/antifungal/antibacterial therapy, cold ischemia time, 
donor/recipient CMV-status, donor/recipient Epstein Barr Virus (EBV)-status, acute lung 
injury. All other significant medical conditions (including GERD) and procedures (including 
past surgeries) occurring before the ICF is signed will be recorded as medical history. Females 
will be queried regarding their reproductive histories. 
• Confirmation of screening FEV1 above 51% of personal best FEV1 value post- 
transplant. 
• Proof of diagnosis will be recorded. 
 
• 
Donor-specific antibody assay: Collect a blood sample for this assay at the Screening Visit. 
If DSA test performed within 4 weeks before screening is available, a further DSA test at 
screening visit will not be mandatory 
• 
Inclusion/Exclusion Criteria: Evaluate eligibility for the clinical per the inclusion/exclusion 
criteria. 
• 
Serum Pregnancy Test: Will be obtained in women of childbearing potential (see Appendix 
II). A serum or urine pregnancy test must be obtained within 7 days prior to randomization. 
• 
Physical Examination: Body weight and height, cardiovascular, respiratory, nervous, 
gastrointestinal, hepatic, renal, dermatological, musculoskeletal, extremities, eyes, ears, nose, 
and throat, and lymphatic. 
• 
Vital Signs: Blood pressure, heart rate, body temperature, respiratory rate. 


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CCI 
 
• 
Clinical Laboratory Tests: All parameters listed in Section 13.1.5 of the protocol, to be 
performed in the local laboratory at the study site. 
• 
(CCI 
portable spirometer. 
Patients will be trained by site personnel on the use of this 
 
• 
CCI 
 (on CCI 
 ): FEV1, CCI 
, FVC, CCI 
 ratio 
A spirometry assessment will be performed on CCI 
 
Section 12.1.1. 
 
as per 
 
• 
Document historical spirometry data from personal best post-transplant prior to Screening, 
plus 
▪ Date of personal best FEV1 post-transplant and all lung function values 
available (FVC [absolute], FEV1 [absolute], CCI 
 [absolute]) 
▪ Dates of meeting BOS 0-p or BOS 1 criteria and all lung function values 
available (FVC, FEV1, CCI 
) 
• 
Blood Sampling: For determination of serum levels of calcineurin inhibitors and mTor 
inhibitors 
• 
Dosages of maintenance immunosuppression: record on the Concomitant Medication eCRF 
• 
Concomitant Medications/Therapies: Name of drug, dosage, duration 
• 
Adverse Events 
 
 
14.2.2 Visit 1 / Baseline Visit 
Baseline Prior to Start of Treatment 
• 
Verify Informed Consent was obtained 
• 
Verify Demographics/Medical History 
• 
Verify Inclusion/Exclusion Criteria were met at the Screening Visit 
• 
Repeat Serum (or Urine) Pregnancy Test, if result was obtained more than 7 days prior to the 
visit 
• 
Physical examination 
• 
Vital signs 
• 
Clinical laboratory tests. Not mandatory in case laboratory tests at screening visit have been 
performed within 2 weeks from Visit 1 
• 
CCI 
 CCI 
); if needed, refresher training for CCI   Patients will 
be provided with the portable spirometer at the Visit 1 / Baseline Visit only if the patient will 
be randomized in the study 
• 
Randomization 
• 
Blood sampling for serum levels of calcineurin inhibitors and mTor inhibitors 


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• 
Concomitant medications/therapies 
• 
Adverse events 
• 
EQ-5D-5L Questionnaire 
Start of Treatment 
Following activities will be performed (in patients randomized to L-CsA): 
• 
Train patient on CCI 
 use, drug storage and inhalation technique 
• 
L-CsA Administration: only in patients randomized to receive L-CsA treatment. Supervise 
first inhalation. 
• 
Activate CCI 
 function in the clinical trial center 
• 
Emphasize importance of adherence to IMP 
• 
Emphasize importance of adherence to usual medications as taken prior to participating in the 
trial 
• 
CCI 
 (CCI 
) at CCI 
 after 
completion of IMP inhalation 
• 
Queries about general health status 
• 
Verify patient is familiar with drug administration and use of nebulizer device 
Prior to release from clinic, adequate drug and the nebulizer system for home use will be dispensed 
to each patient. 
Following activities will be performed (in patients randomized to Standard of Care alone): 
• 
Queries about general health status 
• 
Emphasize importance of adherence to usual medications as taken prior to participating in the 
trial 
• 
CCI 
 (CCI 
only) at CCI 
 after 
randomization 
14.2.3 Visit 2 through Visit 9 / EoT 
• 
Physical examination 
• 
Vital signs 
• 
Clinical laboratory tests 
• 
Serum pregnancy test (for Austria only: additional monthly urine pregnancy tests between the 
trial Visits 5 through 9) 
• 
CCI 
 (CCI 
); if needed, refresher training for CCI 
 
• 
L-CsA Administration 
• 
Blood sampling serum levels of calcineurin inhibitors and mTor inhibitors 
• 
Concomitant medications/therapies 
• 
Adverse events 
• 
Hospitalization 


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• 
Adherence via CCI 
 
• 
Drug Accountability 
14.2.4 Visits 1, 4, 6, and 9 / EoT 
• 
Euro Quality of Life Questionnaire (EQ-5D- 5L) 
14.2.5 
Visit 10 / End of Study (EoS) 
Only performed: 
In patients not rolling over to Boston 3. 
In patients who decided to withdraw the consent during the study (if possible) [see 
section 10.3.1] 
• 
Physical examination 
• 
Vital signs 
• 
Clinical laboratory tests 
• 
Serum pregnancy test 
• 
CCI 
 
• 
Blood sampling for serum levels of calcineurin inhibitors and mTor inhibitors 
• 
Concomitant medications/therapies 
• 
Adverse events 
• 
Hospitalization 
14.2.6 
Permanently throughout the complete clinical trial period 
• 
Adverse events 
14.2.7 
Unscheduled Visits 
Whenever medically warranted, the Investigator may ask the patient to appear or the patient may 
elect to appear at the clinic for an unscheduled visit. All medical measures performed as 
appropriate shall be documented in the Case Report Form for unscheduled visits. 
14.2.8 
Remote Visits (V2 - V8) 
Mandatory on site visits are Screening Visit, Visit 1 and Visit 9. Every effort will be made to have 
also all planned V2 to V8 and unscheduled visits at the study site. However, if one of these visits 
cannot be performed at site due to COVID-19, the site will schedule a remote visit with the patient 
according to the visit windows as defined in the Schedule of Activities. The scheduled time and 
the sequence of procedures (i.e. spirometry, IMP inhalation) should be the same as during on-site 
visits. The PI or Sub-Investigator and/or an appropriately qualified site study team member must 
call the patient to 
• capture any potential adverse events (AEs) and to confirm the patient’s status and 
wellbeing. 
• capture any changes in concomitant medication 
• check IMP supply with patient (if required re-supply needs to be arranged, see Section 9.7) 


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• provide refresher training for CCI 
 
version 3.0 or later) 
if needed (for patients enrolled under protocol 
• guide the patient through a spirometry session using the CCI 
 device (see Section 
12.1.1.). Home spirometry should be scheduled around the same time as the usual clinic 
visits, whenever possible, to minimize the effects of circadian variation of lung function 
measurements (for patients enrolled under protocol version 3.0 or later). 
• remind the patient to bring their CCI 
 with them to their next clinic visit so that it can 
be checked and returned to them for continued use. 
• remind the patient of IMP inhalation (to be performed after home spirometry assessment 
has been completed, for further details see also Section 12.1.1.4) 
The PI or Sub-Investigator must confirm if, in their opinion, the patient is stable and suitable for 
prolonged home-treatment, and that patient is in agreement to continuing home-treatment until 
their next on-site study visit can occur. 
All medical measures performed as appropriate shall be documented in the eCRF. 


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15 STATISTICS 
This section presents an overview of the planned analyses. Final analyses are not limited to the 
summaries described herein. The Statistical Analysis Plan (SAP) will provide a detailed 
description of the planned statistical analyses and data summaries. If circumstances arise during 
the clinical trial that make these analyses inappropriate or if improved methods become available, 
the SAP may be revised. If discrepancies exist between the text of the statistical analysis as 
planned in the protocol and the final SAP, the final SAP will define the planned analysis of record. 
Reasons for such discrepancies will be described in the final Clinical Study Report (CSR). 
This is a Phase III, prospective, multicenter, randomized, controlled trial with one blinded, 
adaptive interim analysis for sample size re-estimation and final identification of the model to be 
used for the primary analysis. 
The primary outcome measure of the trial is the difference in mean FEV1 (mL) change from 
baseline to Week 48 between the L-CsA plus SoC and SoC alone groups. 
 
 
 
For the purpose of this study, “baseline FEV1” is the mean of the best FEV1 obtained at the 
Screening Visit and the best FEV1 obtained at the Baseline (randomization) Visit. 
For all spirometer-based measurements see Section 12.1.1. 
Data will be listed by patient and treatment group. 
15.1 Analysis Data Sets 
The following analysis data sets will be analyzed: 
Safety analysis set (SAFSet) 
The SAF is defined as all randomized patients in the SoC group and all randomized patients 
receiving at least one dose of IMP in the L-CsA plus SoC group. All data collected after baseline 
to the end of clinical trial participation will be included in the safety summaries. Patients will be 
analysed according to the treatment they actually received. 
Full analysis set (FAS) 
The FAS is defined as all randomized patients. Patients who receive augmentation of SoC therapy, 
are re-transplanted, or die before the first post-baseline assessment of the primary outcome 
measure will be retained in the FAS. Patients will be analysed according to the treatment group to 
which they were randomized. 
CCI 


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A Data Review Meeting (DRM) will be used to determine if patients should be excluded from the 
FAS in cases of significant, major protocol deviations that would interfere with the assessment of 
treatment efficacy (e.g., patients not suffering from the condition under investigation). 
Per protocol Set (PPS) 
The PPS is defined as all patients included in the FAS: 
• who complete randomized treatment as scheduled or who are withdrawn prematurely due to 
lack of efficacy or lack of tolerability of the clinical trial treatment, and 
• for whom no major protocol deviations interfering with the assessment of treatment efficacy 
are observed. 
Eligibility for the analysis data sets will be determined in DRMs held after closing the database 
before the interim analysis and before the final analysis. Protocol deviations will be classified as 
‘major’ when a significant influence on the assessment of the primary outcome measure for 
treatment efficacy cannot be excluded. Comprehensive justification for the classification of a 
protocol deviation as ‘major’ will be given in the DRM minutes as well as in the integrated CSR. 
Any exclusion of patients from the FAS will require individual justification. 
The primary analysis of treatment efficacy will be performed in the FAS. An additional efficacy 
analysis in the PPS will be provided as a sensitivity analysis. Any data pertaining to safety and 
tolerability will be analyzed in the SAF. 
15.2 Statistical and Analytical Methods 
15.2.1 
Descriptive Statistics 
The data recorded in the case report forms will be summarized as appropriate, per treatment group 
and for the total group, using the following descriptive measures: 
• All continuous study assessments will be summarized using descriptive statistics (i.e., n, mean, 
standard deviation, median, Q1, Q3, minimum, and maximum). 
• All categorical study assessments will be summarized by time point, as applicable, using 
frequency counts and percentages. 
• Discrete ordinal or higher-level data will be summarized as continuous data, but a tabulation 
of categories may be included additionally depending on the number of categories. 
For all measures analyzed descriptively (i.e., measures to characterize the treatment groups and 
their baseline status, efficacy, and safety outcomes), tabulations comparing the treatment groups 
will be prepared. For outcomes measured more than once, the analyses will include tabulations of 
the measured values by visit as well as an analysis of change from baseline. Where provided, all 
confidence intervals will be two-sided 95% confidence intervals. 


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15.2.2 
Characterization and Baseline Comparability of Treatment Groups 
The number and percentage of patients who complete and discontinue the study treatment and the 
number and percentage of patients who complete and discontinue the clinical trial as well as 
reasons for early discontinuation (of both study treatments ) will be presented. 
Descriptive statistics will be presented for demographic, anthropometric, medical history, and 
antibody-response data. 
15.2.3 
Analysis of Efficacy 
15.2.3.1 
Primary 
endpoint 
Analysis population and estimand 
FEV1 data collected from the on site CCI 
 spirometer will be considered primary, while the 
data collected with the CCI    home spirometer will be used for supportive analyses. 
The primary efficacy parameter is the difference in mean FEV1 change from baseline to Week 48 
between L-CsA plus SoC and SoC alone in the FAS population. Intercurrent events will be 
ignored, in line with the “treatment policy strategy” (ICH E9 addendum on estimands and 
sensitivity analysis in clinical trials to the guideline on statistical principles for clinical trials). After 
intercurrent events such as stopping treatment with L-CsA, augmentation of SoC therapy etc., 
FEV1 measurements will still be collected and used in the analysis. Intercurrent events preventing 
the use of FEV1 measurements after the event are death, re-transplantation, and withdrawal of the 
patient’s consent. It is anticipated that these events will be rare in this patient population. The 
estimand will be estimated as if these events had not happened, i.e., the unobserved FEV1 data of 
such patients will be modeled until the scheduled end of treatment at Week 48. 
Working hypothesis 
The alterative hypothesis (H1) for this trial is that L-CsA plus SoC is superior to SoC alone in 
preserving FEV1, i. e., under H1 it is expected that patients treated with L-CsA plus SoC will 
exhibit a smaller mean FEV1 decline between baseline and the end of Week 48 than those who 
receive SoC alone. 
The analysis model 
The primary efficacy analysis will be carried out with a linear mixed model (LMM) for repeated 
measurements, using all available FEV1 measurements. The dependent variables are the absolute 
change from baseline of FEV1 measurements at visits 2 (i. e., the first post-baseline visit) to 9 
(Week 48). 
 
A flexible and robust model will be chosen for the random part of the LMM according to a pre- 
specified stepwise procedure as described in detail in the SAP. The fixed part of the LMM is 
specified as follows. Time will be represented in a flexible and robust way using cubic splines, as 
described in detail in the SAP. The model will contain the following covariates (apart from the 


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intercept): time splines, treatment, the interactions of time splines by treatment, baseline FEV1, 
the interactions of time splines with the baseline FEV1, region (North America versus all other 
countries together), age (< 55 versus ≥ 55 years), and use of azithromycin at randomization. The 
primary efficacy estimand will be estimated from the model as the adjusted difference between 
groups in mean FEV1 change from baseline after 48 weeks. The one-sided p-value and the two 
sided 95% confidence interval will be provided. Superiority of L-CsA will be demonstrated by a 
statistically significant result (defined as p<0.025, one-sided) in favor of the L-CsA plus SoC 
treatment. 
In case few data are collected at intermediate timepoints between baseline and Week 48 (see 
section 15.3 on interim analysis), the LMM model will be replaced by an ANCOVA model on the 
changes in FEV1 from baseline to Week 48, using the same stratification factors and the same 
covariates described for the LMM 
Sensitivity analyses 
Intercurrent missing values and values missing due to death, re-transplantation and withdrawal of 
consent are assumed to be Missing At Random (MAR). Sensitivity analyses to the MAR 
assumption will be performed using different approaches, including selection modelling, 
simultaneous modelling of repeated FEV1 outcome and time to drop out, and controlled missing 
values imputation, and an analysis where re-transplantation and death are included in the definition 
of outcome variable and estimand as worst outcomes. 
In addition to use of LMM to analyze the primary endpoint, simple t-test comparing the difference 
in mean FEV1 change from baseline to Week 48 between the treatment group in the FAS 
population including a 95% confidence interval for the treatment difference of the mean FEV1 
change between the two treatment groups will be performed. 
Further sensitivity analyses will be described in the SAP. 
CCI 
 
CCI 
 
 
 
 
 
 
 
 
 
 


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15.2.3.3 Type I error level control 
The over-all type I error rate of the clinical trial will be α = 0.025 one-sided, corresponding to 
α = 0.05 two-sided. 
Strong control of the clinical trial-wise type I error level will be achieved by a-priori ordering of 
hypotheses: 
1. The primary endpoint (mean change in FEV1 from baseline to Week 48) will be tested first. 
2. CCI 
 
 
 
 
 
 
All tests will be performed using a local type I error level of α = 0.025 (one-sided). 
If testing stops due to failure to reject a null hypothesis on a particular level of the hierarchy, all 
lower level tests will still be performed but will be considered descriptive. 
 
CCI 
 
 
 
 
 
 
15.2.4 
Cumulative Maintenance Immunosuppression 
The total immunosuppression administered from the day of randomization will be evaluated. At 
each trial visit, the doses of calcineurin inhibitors (e.g., tacrolimus), antimetabolic agents (e.g., 
mycophenolate mofetil), and corticosteroids will be recorded by the Investigator on the 
concomitant medications eCRF. The cumulative dose of maintenance immunosuppressive 
treatment will be summarized for each group and compared descriptively. 
15.2.5 
Analysis of Safety 
Safety outcomes are listed in Section 13.1. All safety measures will be compared descriptively 
between the treatment groups in accordance with the concept of descriptive data analysis in the 
SAS population. Treatment group comparisons of safety outcomes will be based on statistical tests 
and confidence intervals (if applicable). 


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15.2.5.1 
Extent of Exposure 
Exposure to IMP will be confirmed based on the report of IMP vials returned and dosing 
recorded in the clinical database. 
15.2.5.2 
Adverse Events 
Adverse events (AEs) will be coded using the Medical Dictionary for Regulatory Activities 
(MedDRA). Events will be identified as treatment-emergent (TEAE) and non-treatment-emergent 
(Non-TEAE) on the basis of the date of onset relative to the date of randomization. 
Summaries (number and percentage of events as well as of patients with any events of a particular 
type) of treatment-emergent AEs (by system organ class and preferred term) will be provided. 
Number (%) of patients experiencing TEAEs by severity, relationship to IMP, seriousness, and 
action taken with regard to IMP will be summarized. Number (%) of patients with TEAEs leading 
to discontinuation of clinical trial participation will also be summarized. 
15.2.5.3 
Laboratory and Other Safety Evaluations 
For clinical safety laboratory test results and vital signs, the numeric values and corresponding 
changes from baseline will be summarized using descriptive statistics by parameter and time point. 
In addition to the tables showing the distribution parameters, laboratory measures will be presented 
in ‘shift tables’ that show the position of all patients relative to the applicable reference range at 
clinical trial entry, broken down by the position at clinical trial exit. Common Toxicity Criteria 
(CTC version 5.0) will be applied to abnormal laboratory test results and abnormal vital signs. 
Parameters reflecting acute tolerability of IMP (spirometry, cough, or dyspnea) will be 
summarized. 
15.3 Interim Analysis 
Approximately one-two months before the last patient of the initial sample size is projected to be 
randomized in the clinical trial, an interim analysis was to be performed with the following 
objectives: 
• Re-estimation of the standard deviation of the primary endpoint. 
• Evaluation of the actual amount of FEV1 data collected at all timepoints using the CCI 
 
spirometer. 
• Evaluation of the number of drop-outs and the number and pattern of the missing data. 
• Appropriateness of the analysis based on the anticipated longitudinal model (LMM) vs. the 
analysis based on the ANCOVA model in the light of the collected data. 
All analyses were to be performed on blinded data available at that time. 
For the re-estimation of the standard deviation, using the methodology described in Kieser and 
Friede (2003), no unblinding is required and no adjustment of the significance level α is necessary. 


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If the sample size calculated on the basis of the new value for the standard deviation is higher 
than the initial estimate, the sample size of the trial might be increased accordingly in order to 
preserve the pre-specified power. If the re-calculated sample size is lower than the initial estimate, 
the clinical trial was to be continued with the initial sample size (110 patients). 
Full details of the procedure for sample size re-estimation and for performing the other analyses 
were to be provided in the SAP. 
The interim analysis has been performed by an independent, blinded statistician on 01/Dec/2021. 
The conclusions were as follows: 
• The LMM is applicable and therefore this model will be used for the primary analysis, while 
ANCOVA will be used as an additional sensitivity analysis 
• The sample size is approximately adequate for this model but considered small for ANCOVA. 
The statistician communicated these conclusions to the Sponsor. Confidentiality of results was 
ensured and no interim analysis results were provided to the Sponsor or the Investigators. 
 
15.4 Missing Data 
See Sections 15.2.3.1 and 15.2.3.2. 
15.5 Sample Size Considerations 
The initial sample size was based on the following consideration. Assuming a treatment group 
difference for mean FEV1 change from baseline of 200 mL and a standard deviation of 350 mL at 
the end of treatment Week 48, an independent samples t-test with a one-sided type I error level of 
α=0.025 will have at least 80% power to reject the null hypothesis when the sample size in each 
treatment group is at least 50 patients. To compensate for a loss of power due to premature 
withdrawals, a total of 110 patients will initially be randomized. 
Results of the interim analysis have been presented in Section 15.3. 
Following FDA recommendation to obtain an adequately sized safety database for L-CsA 
inhalation and reach the originally planned sample size for BOSTON 1 and 2 studies combined, 
randomization will be stopped upon achievement of a total of approximately 220 patients in the 
present BOSTON-2 and BOSTON-1 studies. 
Since the BOSTON-1 study is experiencing serious enrolment delay, it is anticipated that 
approximately 160-170 patients will be randomized in the present study and 50- 60 patients in 
BOSTON 1. This sample size will provide a more reasonable power for the planned sensitivity 
analyses, including ANCOVA, for the present study (BOSTON-2). 


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16 DIRECT ACCESS TO SOURCE DATA/DOCUMENTS 
Source data is all information, original records of clinical findings, observations, or other activities 
in a clinical trial necessary for the reconstruction and evaluation of the trial. Source data are 
contained in source documents. Examples of these original documents and data records include 
but are not limited to: hospital records, clinical and office charts, laboratory notes, memoranda, 
patients’ diaries or questionnaires or evaluation checklists, pharmacy dispensing records, recorded 
data from automated instruments, copies or transcriptions certified after verification as being 
accurate and complete, microfiches, photographic negatives, microfilms or magnetic media, X- 
rays, patient files, and records kept at the pharmacy, at the laboratories, and at medico-technical 
departments involved in the clinical trial. 
Case report forms, all copies of test results, and clinical trial-related regulatory documents [e.g., 
Informed 
Consents, 
Institutional 
Review 
Board 
(IRB)/Ethics 
Committee 
(EC) 
approvals/correspondence, etc.] must be available always for regulatory agency inspection and 
review by the Sponsor or its designee. During the periodic site monitoring visits, the source 
documents will be verified against data entered onto the eCRF to assure that all data is accurately 
and completely reflected on the patient’s eCRF. 


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17 QUALITY CONTROL AND QUALITY ASSURANCE 
This clinical trial will be monitored by the Sponsor or its designee according to ICH GCP (E6R2) 
guidelines. A site visit will be held prior to initiation of patient enrollment. The protocol, CRFs, 
IMP supplies, and relevant procedures will be explained in detail at the Site Initiation Visit. 
Subsequent to patient enrollment, a study site monitor from the Sponsor or its designee will review 
the eCRFs and source documents to ensure that the study is conducted according to the protocol 
and ICH GCP guidelines. 
To ensure compliance with ICH GCP guidelines and all applicable regulatory requirements, the 
Sponsor or its designee may conduct a quality assurance audit. Regulatory agencies may also 
conduct a regulatory inspection of this clinical trial. Such audits or inspections can occur at any 
time during or after completion of the clinical trial. If audits or inspections occur, the Investigator 
and the institution agree to allow the auditor/inspector direct access to all relevant documents and 
to allocate his/her time and the time of his/her staff to the auditor/inspector to discuss findings and 
any relevant issues. 


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18 INSTITUTIONAL REVIEW BOARD (IRB)/ETHICS COMMITTEE (EC) 
The protocol and informed consent form(s) for this clinical trial must be approved by an 
appropriately constituted Institutional Review Board (IRB)/Ethics committee (EC) as defined by 
local requirements. A list of the IRB/EC voting members, their titles or occupation, and their 
institutional affiliations (if available and allowable under EU law) and/or the IRB/EC general 
assurance number, if applicable, must be submitted to the Sponsor or its designee to be archived 
in the Trial Master File. 
Any documents that the IRB/EC may need to fulfill its responsibilities, such as protocol 
amendments, and information concerning patient recruitment, payment or compensation 
procedures, or information from the Sponsor or its designee will be submitted to the IRB/EC. The 
IRB’s/EC’s written approval/favorable opinion of the protocol and the informed consent 
form/patient information leaflet will be in the possession of the Investigator before the clinical trial 
is initiated. The IRB’s/EC’s unconditional approval statement/favorable opinion will be 
transmitted by the Investigator to the Zambon SpAor its designee prior to shipment of IMP supplies 
to the site. This approval/favorable opinion must refer to the clinical trial by exact protocol title 
and number, and should identify the documents reviewed and the date of review. 
Protocol modifications or changes may not be initiated without prior written IRB/EC 
approval/favorable opinion except when necessary to eliminate immediate hazards to the patients 
or when the change(s) involves only logistical or administrative aspects of the clinical trial. Such 
modifications will be submitted to the IRB/EC and written verification that the modification was 
submitted should be obtained. 
The IRB/EC must be informed by the Investigator of informed consent changes or revisions of 
other documents originally submitted for review; serious and/or unexpected adverse events 
occurring during the clinical trial; new information that may affect adversely affect the safety of 
the patients or the conduct of the clinical trial; an annual update and/or request for re-approval; 
and when the clinical trial has been completed. 
The Investigator will ensure that the conduct of the clinical trial conforms to the Declaration of 
Helsinki (current revision) and with applicable national laws and regulations for clinical research. 
Before starting this clinical trial, the protocol will be submitted to each center’s Institutional 
Review Board/Ethics Committee for evaluation at each site. As required, the clinical trial will not 
start before the IRB/EC has given approval/favorable opinion. 
Periodic status reports and adverse events must be submitted to the IRB/EC according to the 
IRB/EC reporting requirements. The IRB/EC must also be notified of completion of the clinical 
trial and a final report must be submitted to the IRB/EC in accordance with the IRB/EC reporting 
requirements. The Investigator must maintain an accurate and complete record of all 
communication, reports and submissions to the IRB/EC. 


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19 PATIENT INFORMED CONSENT 
Patients will be required to sign a statement of informed consent that meets the requirements of 
the Code of Federal Regulation (US FDA Title 21 CFR 50), local regulations, ICH GCP 
guidelines, and the IRB/EC of the center. The medical record will include a statement that written 
informed consent was obtained before the patient was enrolled in the clinical trial and the date 
written consent was obtained. 
Members of the treating team will review the nature of the clinical trial, its purpose, the procedures 
involved, the expected duration, the potential risks and benefits and alternative therapies including 
best supportive care. Patients must be informed that participation in the clinical trial is voluntary, 
he/she may withdraw from the clinical trial at any time and withdrawal from the trial will not affect 
his/her subsequent medical treatment or relationship with the treating physician. Financial costs 
that will or may be incurred as a result of participation in the trial, as well as the efforts to maintain 
patient confidentiality will also be discussed. 
This consent must be dated and retained by the Investigator/Designee as part of the clinical trial 
records. A copy of the informed consent form must be given to the patient. If the patient signed 
the informed consent more than 30 days prior to the date of randomization, it should be 
documented that consent has not been rescinded. Alternatively, the site should follow the 
IRB/EC’s requirement for re-consenting a patient. 
If an Experimental Patient’s Bill of Rights is applicable at the Investigator’s site, that form must 
also be prepared and signed by each patient and retained as a part of the required clinical trial 
records. A copy of the Bill of Rights must be given to the patient or the patient’s legally authorized 
representative. 
A copy of the IRB/EC approved consent form must be submitted to Zambon SpA or its designee 
prior to shipment of IMP supplies to the Investigator. Each patient’s signed informed consent must 
be kept on file by the Investigator for regulatory authority and Sponsor inspection at any time. 
The HIPAA Privacy rule authorization or GDRP language must be included in the Informed 
Consent/authorization form (or a separate authorization document) and approved by the IRB/EC 
(or Privacy board) as applicable. 
The Declaration of Helsinki, as amended (version of Fortaleza, 2013), recommendations guiding 
doctors in clinical research must be signed by the Investigator and returned to the Sponsor or its 
designee. A copy must also be kept on file by the Investigator. 


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20 NOTIFICATION TO AUTHORITIES 
The protocol and any applicable documentation (e.g., patient information, informed consent form) 
will be notified to the regulatory authorities in compliance with applicable US, Israeli and 
European regulations. 


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21 DATA HANDLING AND RECORD KEEPING 
21.1 Confidentiality 
To maintain confidentiality, all laboratory specimens, evaluation forms, reports and other records 
will be identified by a coded number and initials only. All clinical trial records will be kept at each 
center in a secure location. Clinical information will not be released without written permission of 
the patient, except as necessary for monitoring or inspections by the authorities or a designee of 
the Sponsor. The Investigator must also comply with all applicable privacy regulations (e.g., 
Health Insurance Portability and Accountability Act of 1996). 
The Investigator must assure that the privacy of the patients, including their personal identity and 
all personal medical information, will be maintained at all times. In CRFs and other documents 
patients will not be identified by their names, but by an identification code (e.g., by an arbitrary, 
unique patient number). 
The Investigator agrees that all information received from Zambon SpA including but not limited 
to this protocol, eCRF, and any other clinical trial information, remain the sole and exclusive 
property of Zambon SpA during the conduct of the clinical trial and thereafter. This information 
is not to be disclosed to any third party (except employees or agents directly involved in the 
conduct of the trial or as required by law) without prior written consent from Zambon SpA. The 
Investigator further agrees to take all reasonable precautions to prevent the disclosure by any 
employee or agent of the investigative site to any third party or otherwise into the public domain. 
21.2 Completion of Electronic Case Report Forms 
An electronic case report form (eCRF) will be used in this clinical trial. Staff authorized to enter 
or modify data on the eCRF will be assigned an appropriate user role: 
• study coordinators or nurses may enter, modify, or delete data and may enter, modify, or delete 
responses to queries; 
• investigators may perform the same activities as study coordinators. Moreover, they may 
authorize data by entering an electronic signature. 
Any data entries, modifications, and deletions will be recorded in an automated audit trail together 
with a time stamp and the identification code of the person performing the entry / modification / 
deletion. 
To access the eCRF authorized users will receive a unique user name and password that will also 
be required for data authorization (investigators only). These credentials are strictly personal and 
confidential and must not be shared with anyone. 
Investigators will be provided with detailed eCRF Completion Guidelines that will identify the 
required data points to be collected, how to document them and when these data should be 
documented. Appropriate training in electronic data capture and support will be provided. 


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It is the responsibility of the Investigator to maintain adequate and accurate eCRFs to record 
(according to the eCRF Completion Guidelines) all observations and other data pertinent to the 
clinical trial obtained during scheduled, remote or unscheduled visits. All eCRFs should be fully 
completed to ensure accurate data interpretation. 
All eCRF entries should be made within a maximum of 5 business days of a study visit by a 
designated and trained member of the site staff. The Investigator must ensure the accuracy, 
completeness legibility and timeliness of data reported in the eCRF and all required reports. Any 
change or correction to an eCRF must be documented as instructed and explained (if necessary) in 
the clinic notes, this applies to both written and electronic changes. The patient’s medical source 
documents must support any changes made. 
Data reported in the eCRF that are derived from source documents should be consistent with the 
source documents or the discrepancies should be explained. 
The investigator must review and electronically sign the completed eCRF casebook to verify its 
accuracy. 
The main objective is to obtain those data required by the protocol in a complete, accurate, legible, 
and timely fashion. These data in the eCRF should be consistent with the relevant source 
documents. 
The eCRFs and the corresponding electronic database shall be processed, evaluated, and stored in 
anonymous form in accordance with the Personal data-protection regulations. 
These data recorded in the course of this clinical trial may periodically be remotely reviewed and 
compared to the electronic database. The computerized handling of these data after receipt of the 
eCRFs may generate additional requests via electronic queries to which the Investigator is obliged 
to respond by confirming or modifying these data questioned. These requests with their responses 
will be available in the eCRFs held by the Investigator and Sponsor. 
The eCRFs are regulatory documents and must be suitable for electronic submission to authorities. 
The Investigator must keep a separate patient identification list showing code numbers, names, 
and dates of birth to allow unambiguous identification of each patient included in the clinical trial. 
A note will be made in the hospital medical records that the patient is participating in a clinical 
trial. The eCRF will be completed appropriately. 
21.3 Source Data and Patient Files 
The Investigator has to keep a paper or electronic patient file for every patient participating in the 
clinical trial. In this patient file, the available demographic and medical information of a patient 
has to be documented, in particular the following: name, date of birth, sex, height, weight, patient 
history, concomitant diseases and concomitant medication (including changes during the clinical 
trial), statement of entry into the clinical trial, trial identification, patient number, the date of 


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informed consent, all study visit dates, pre-defined performed examinations and clinical findings, 
observed AEs (if applicable) and reason for withdrawal from clinical trial treatment or from the 
trial (if applicable). It should be possible to verify the inclusion and exclusion criteria for the 
clinical trial from the available data in this file. It must be possible to identify each patient by using 
this patient file. 
Additionally, any other documents with source data, especially original printouts of data that were 
generated by technical equipment have to be filed. This may include laboratory value listings, ECG 
recordings, X-rays, CT scans, etc. (if applicable). All these documents have to bear at least the 
patient identification and the printing date printed by the recording device to indicate to which 
patient and to which procedure the document belongs. The medical evaluation of such records 
should be documented as necessary and signed/dated by the Investigator. 
Printouts of computerized patient files must be signed and dated by the Investigator, and kept as a 
source document. 
21.4 Investigator File and Archiving 
The Sponsor will provide, and the investigator will maintain an Investigator Site File (ISF) 
containing all essential documents for the clinical trial. The ISF will contain each patient’s eCRF 
pdf after the database has been locked. The investigator should maintain a record of the 
location(s) of their respective essential documents including source documents. The storage 
system used during the trial and for archiving (irrespective of the type of media used) should 
provide for document identification, version history, search and retrieval. 
 
Essential documents are subject to audit and inspection at all times and will be archived 
according to applicable regulatory requirements. 
 
21.5 Monitoring, Quality Assurance, and Inspection by Authorities 
This clinical trial is to be conducted in accordance with ICH GCP E6 (R2) and applicable US, 
Israeli and European regulations. Monitoring and auditing of the trial will be the responsibility of 
the Sponsor or a designee authorized by the Sponsor. 
To ensure compliance with ICH GCP guidelines and all applicable regulatory requirements, the 
Sponsor or its designee may conduct quality assurance audits. Regulatory agencies may also 
conduct a regulatory inspection of this clinical trial. Such audits or inspections can occur at any 
time during or after completion of the clinical trial. If audits or inspections occur, the Investigator 
and the institution agree to allow the auditor/inspector direct access to all relevant documents and 
to allocate his/her time and the time of his/her staff to the auditor/inspector to discuss findings and 
any relevant issues and to implement corrective and preventive actions for such findings. 


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21.6 Data Management and Data Control 
The Sponsor will be responsible for the processing and quality control of the data. Data 
management and filing will be carried out as described in the contracted CRO's SOPs for clinical 
trials. 
Prior and concurrent medications within 30 days of randomization will be listed. Prior/concurrent 
medications will be coded using the World Health Organization (WHO-DD) classification system 
and grouped by drug class and preferred term. AEs and medical history terms will be coded using 
MedDRA. 
The eCRF data and patient data listings will be archived by the Sponsor for the lifetime of the 
product. No clinical trial document or image should be destroyed without prior written agreement 
between the Sponsor and the Investigator. Should the Investigator wish to assign the clinical trial 
records to another party or move them to another location, advance written notice should be given 
to the Sponsor. 


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22 FINANCING AND INSURANCE 
A separate financial agreement (Clinical Investigators' Agreement) will be made between each 
Investigator and the Sponsor before the IMP is delivered. The Sponsor will ensure financing of 
the complete clinical trial. 
The clinical trial is covered under a Sponsor group combined liability insurance policy. The 
certificate of insurance and an information leaflet containing essential information about the 
insurance coverage will be provided upon request. 


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23 PUBLICATIONS 
After conclusion of the clinical trial, an integrated clinical and statistical study report will be 
prepared by the Sponsor or designee. The first publication of the clinical trial will comprise of data 
from the entire clinical trial population enrolled at all sites. Any publications of the results, either 
in part or in total (abstracts in journals or newspapers, oral presentations, etc.) by Investigators or 
their representatives will require pre-submission review by the Sponsor. The Sponsor is entitled to 
delay publication in order to obtain patent protection. For more details regarding publications, refer 
to the clinical trial agreement/Investigator trial agreement. 
The results of the clinical trial will be published and/or presented in scientific meetings in a timely 
manner. Any formal publication of clinical trial results will be a collaborative effort between the 
Sponsor and the Investigator(s). All manuscripts and abstracts will be reviewed and approved in 
writing by the Sponsor prior to submission. 
Policies regarding the publication of the clinical trial results are defined in the Clinical 
Investigator's Agreement. 


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24 REFERENCES 
Barker AF, Bergeron, A Rom WN et al. Obliterative Bronchiolitis. N Engl J Med 2014;370:1820- 
1828. 
Behr J, Zimmermann G, Baumgartner R et al. Lung deposition of a liposomal cyclosporine A 
inhalation solution in patients after lung transplantation. J Aerosol Med Pulm Drug Deliv 
2009;22(2):121-130. 
Bonvillain RW, Valentine VG, Lombard G et al. Post-operative infections in cystic fibrosis and 
non-cystic fibrosis patients after lung transplantation. J Heart Lung Transplant 2007; 26:890-897. 
Chacon RA, Corris PA, Dark JH et al. Tests of Airway Function in Detecting and Monitoring 
Treatment of Obliterative Bronchiolitis After Lung Transplantation. J Heart Lung Transplant 
2000;19:263-269. 
Corcoran TE, Smaldone GC, Dauber JH et al. Preservation of post-transplant lung function with 
aerosol cyclosporin. Eur Respir J 2004;23(3):378-383. 
Corcoran TE. Inhaled delivery of aerosolized cyclosporine. Advances Drug Delivery Reviews 
2006;58:1119-1127. 
De Pauw B, Walsh TJ, Donnelly JP et al. Revised definitions of invasive fungal disease from the 
European Organization for Research and Treatment of Cancer/Invasive Fungal Infections 
Cooperative Group and the National institute of Allergy and Infectious Disease Mycoses Study 
Group. Clin Infect Dis 2008;46:1813-1821. 
Estenne M, Maurer JR, Boehler A et al. Bronchiolitis obliterans syndrome 2001: an update of the 
diagnostic criteria. J Heart Lung Transplant 2002;21(3):297-310. 
Glanville AR, Verleden GM, Todd JL et al. Chronic lung allograft dysfunction: Definition and 
update of restricitive allograft syndrome. A consensus report from the Pulmonary Council of the 
ISHLT, J Heart Lung Transplant 2019;5:483-493. 
Halloran PF. Immunosuppressive agents in clinical trials in transplantation. Am J Med Sci 
1997;313(5):283-288. 
Heng D, Sharples LD, McNeil K et al. Bronchiolitis Obliterans Syndrome: Incidence, Natural 
History, Prognosis, and Risk Factors. J Heart Lung Transplant 1998;17:1255-1263. 
Iacono AT, Keenan RJ, Duncan SR et al. Aerosolized cyclosporine in lung recipients with 
refractory chronic rejection. Am J Respir Crit Care Med 1996;153(4 Pt 1):1451-1455. 
Iacono AT, Johnson BA, Grgurich WF et al. A randomized trial of inhaled cyclosporine in lung- 
transplant recipients. N Engl J Med 2006;354(2):141-150. 
ICH E9 addendum on estimands and sensitivity analysis in clinical trials to the guideline on 
statistical principles for clinical trials 


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ISHLT. (2017). Registry data. Retrieved from https://www.ishlt.org/registries/slides.asp?slides= 
heart Lung Registry 
ISHLT. Guidance from the International Society of Heart and Lung Transplantation regarding 
the SARS CoV-2 pandemic - REVISED: April 4, 2020 Received from 
https://ishlt.org/ishlt/media/documents/SARS-CoV-2_-Guidance-for-Cardiothoracic-Transplant- 
and-VAD-centers.pdf 
Kieser M, Friede T. Simple procedures for blinded sample size adjustment that do not affect the 
type I error rate. Stat Med 2003;22(23):3571-3581. 
Levine D, Glanville A, Aboyoun C et al. Antibody-mediated rejection of the lung: A consensus 
report of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 
2016;35:397-406. 
Meyer KD, Raghu G, Verleden GM, et al. An international ISHLT/ATS/ERS clinicalpractice 
guideline: diagnosis and management of bronchiolitis obliterans syndrome. Eur Respir J 2014; 44: 
1479–1503. 
Miller MR, Hankinson J, Brusasco V et al. Standardisation of spirometry. Eur Respir J 
2005a;26:319-338. 
Miller MR, Crapo R, Hankinson J et al. General considerations for lung function testing. Eur 
Respir J 2005b;26:153-161. 
Pellegrino R, Viegi G, Brusasco V et al. Interpretative strategies for lung function tests. Eur Respir 
J 2005;26(5):948-968. 
Soubani AO, Uberti JP. Bronchiolitis obliterans following haematopoietic stem cell 
transplantation. Eur Respir J 2007;29(5):1007-1019. 
Stewart S, Fishbein M, Snell G. Revision of the 1996 Working formulation for the Standardization 
of Nomenclature in the Diagnosis of Lung Rejection. J Heart Lung Transplant 2007;26:1229-1242. 
UK SmPC Ciclosporin A (Neoral®). 
Verleden GM, Glanville AR, Lease ED, et al. Chronic lung allograft dysfunction: Definition, 
diagnostic criteria and approaches to treatment. A consensus report from the Pulmonary Council 
of the ISHLT, J Heart Lung Transplant 2019;5:493-503. 
Wanger J, Clausen JL, Coates A et al. Standardisation of the measurement of lung volumes. Eur 
Respir J 2005;26(3):511-522. 


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25 APPENDIX I – CORE INFORMED CONSENT FORM 
The informed consent form must be adapted to local requirements but must contain at least the 
following points: 
• 
That the trial involves research. 
• 
The purpose of the trial. 
• 
The trial treatment(s) and the probability for random assignment to each treatment. 
• 
The trial procedures to be followed, including all invasive procedures. 
• 
The patient’s responsibilities. 
• 
Those aspects of the trial that are experimental. 
• 
The reasonably foreseeable risks or inconveniences to the patient and, when applicable, to an 
embryo, foetus, or nursing infant. 
• 
The reasonably expected benefits. When there is no intended clinical benefit to the patient, 
the patient should be made aware of this. 
• 
The alternative procedure(s) or course(s) of treatment that may be available to the patient, and 
their important potential benefits and risks. 
• 
The compensation and/or treatment available to the patient in the event of trial related patient 
injury. 
• 
The anticipated prorated payment, if any, to the patient for participating in the trial. 
• 
The anticipated expenses, if any, to the patient for participating in the trial. 
• 
That the patient‘s participation in the trial is voluntary and that the patient may refuse to 
participate or withdraw from the trial, at any time, without penalty or loss of benefits to which 
the patient is otherwise entitled. 
• 
That the monitor(s), the auditor(s), the IRB/IEC, and the regulatory authority(ies) will be 
granted direct access to the patient‘s original medical records for verification of clinical trial 
procedures and/or data, without violating the confidentiality of the patient, to the extent 
permitted by the applicable laws and regulations and that, by signing a written informed 
consent form, the patient is authorizing such access. 
• 
That records identifying the patient will be kept confidential and, to the extent permitted by 
the applicable laws and/or regulations, will not be made publicly available. If the results of 
the trial are published, the patient’s identity will remain confidential. 
• 
That the patient will be informed in a timely manner if information becomes available that 
may be relevant to the patient‘s willingness to continue participation in the trial. 


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• 
The person(s) to contact for further information regarding the trial and the rights of trial 
patients, and whom to contact in the event of trial-related injury. 
• 
The foreseeable circumstances and/or reasons under which the patient‘s participation in the 
trial may be terminated. 
• 
The expected duration of the patient‘s participation in the trial. 
• 
The approximate number of patients involved in the trial. 
• 
Information regarding the trial can be found on clinicaltrials.gov. 


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26 APPENDIX II – ACCEPTABLE METHODS OF CONTRACEPTION 
 
A woman is considered of childbearing potential, i.e. fertile, following menarche and until 
becoming post-menopausal unless permanently sterile. The status of post-menopausal is defined 
as no menses for 12 months without an alternative medical cause and/or the age of 60 years. 
 
According to the Clinical Trial Facilitation Group (CTFG) dated 15/04/2014, the following 
methods are allowed for contraception during the clinical trial with a failure rate of less than 1%: 
 
• 
combined (estrogen and progestogen containing) hormonal contraception associated with 
1 
inhibition of ovulation : 
 
o oral 
o intravaginal o transdermal 
 
• 
progestogen-only hormonal contraception associated with inhibition of ovulation 1: 
 
o oral 
o injectable 
2 
o implantable 
 
2 
• 
intrauterine device (IUD) 
2 
• 
intrauterine hormone-releasing system (IUS) 
2 
• 
bilateral tubal occlusion 
2,3 
• 
vasectomised partner 
4 
• 
sexual abstinence 
 
From results of previous clinical trials with aerosolized L-CsA potential interactions 
between the IMP and hormonal contraceptives have not been investigated. It is 
recognized that hormonal contraceptives can increase serum levels of systemically dosed 
cyclosporine, but cyclosporine does not alter the efficacy of hormonal contraceptives. 
Subjects in the trial will be monitored for systemic cyclosporine levels. 
 
1 Hormonal contraception may be susceptible to interaction with the IMP, which may reduce the efficacy of the contraception method 
 
2 Contraception methods that in the context of this guidance are considered to have low user dependency. 
 
3Vasectomised partner is a highly effective birth control method provided that partner is the sole sexual partner of the WOCBP trial participant 
and that the vasectomised partner has received medical assessment of the surgical success. 
 
4 In the context of this guidance sexual abstinence is considered a highly effective method only if defined as refraining from heterosexual intercourse 
during the entire period of risk associated with the study treatments. The reliability of sexual abstinence needs to be evaluated in relation to the 
duration of the clinical trial and the preferred and usual lifestyle of the subject. 


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27 APPENDIX III – ANTIBODY-MEDIATED REJECTION 
 
Key diagnostic criteria include the presence of antibodies directed toward donor human leukocyte 
antigens and characteristic lung histology with or without evidence of complement 4d within the 
graft. Exclusion of other causes of allograft dysfunction increases confidence in the diagnosis but 
is not essential. Pulmonary AMR may be clinical (allograft dysfunction which can be 
asymptomatic) or sub-clinical (normal allograft function). Both clinical and sub-clinical AMR 
were further sub-categorized into 3 mutually exclusive possibilities (definite, probable and 
possible). These categories were based on the degree of certainty related to the presence or absence 
of a number of pathologic, serologic, clinical and immunologic criteria (Table 8 and Table 9). 
Table 8. Definition and diagnostic certainty of clinical pulmonary AMR 
 
Allograft 
dysfunction 
Other causes 
excluded 
Lung 
histology 
Lung biopsy 
C4d 
DSA 
Definite 
+ 
+ 
+ 
+ 
+ 
Probable 
+ 
+ 
+ 
- 
+ 
Probable 
+ 
+ 
+ 
+ 
- 
Probable 
+ 
+ 
- 
+ 
+ 
Probable 
+ 
- 
+ 
+ 
+ 
Possible 
+ 
+ 
+ 
- 
- 
Possible 
+ 
+ 
- 
- 
+ 
Possible 
+ 
+ 
- 
+ 
- 
Possible 
+ 
- 
+ 
+ 
- 
Possible 
+ 
- 
+ 
- 
+ 
Possible 
+ 
- 
- 
+ 
+ 
DSA, donor-specific antibodies; +, item present; - item absent or missing 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
Page 107 of 109 
Clinical Trial Protocol BT–L-CsA–302–DLT 
Version 6.0_7-Apr-2023 
 
 
 
Table 9. Definition and diagnostic certainty of sub-clinical pulmonary AMR 
 
Lung histology 
Lung biopsy C4d 
DSA 
Definite 
+ 
+ 
+ 
Probable 
+ 
- 
+ 
Probable 
- 
+ 
+ 
Probable 
+ 
+ 
- 
Possible 
+ 
- 
- 
Possible 
- 
+ 
- 
Possible 
- 
- 
+ 
DSA, donor-specific antibodies; +, item present; - item absent or missing 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
Page 108 of 109 
Clinical Trial Protocol BT–L-CsA–302–DLT 
Version 6.0_7-Apr-2023 
 
 
 
28 APPENDIX IV – STUDY PROTOCOL VERSIONS HISTORY OF CHANGES 
 
Study Protocol Version 6.0 dated 7-April-2023 
The Study Protocol version 6.0 (dated 7-April-2023) has been issued CCI 
 
for amendment to Study Protocol BOSTON-2 
version 5.0 submitted on December 8, 2022, IND 078854 L-Cyclosporine A. 
This amendment is considered to be substantial according to the guidance on the request to the 
competent authorities for authorisation of substantial amendments (2010/C 82/01). 
CCI 
 
 
Full descriptions of substantial and other minor changes or clarifications are provided in the 
Summary of Changes Document. 
 
 
Study Protocol Version 5.0 dated 28-October-2022 
The Study Protocol version 5.0 (Amendment 4) has been issued to CCI 
 
ensure the adequacy of the safety database and to implement the 
efforts to minimize missing data in both studies. 
This amendment is considered to be substantial based on the criteria set forth in Article 10(a) 
of Directive 2001/20/EC of the European Parliament and the Council of the European Union. 
CCI 
 
 
Full description of substantial and other minor changes/clarifications are provided in the 
Summary of Changes Document. 
 
Study Protocol Version 4.0 dated 19-January-2021 
CCI 
 
CCI 
Only discussions (type C meeting) and the EMA guidelines on 
clinical trial conducted during the COVID-19 contingency was added. This amendment had 
considered to be substantial based on the criteria set forth in Article 10(a) of Directive 
2001/20/EC of the European Parliament and the Council of the European Union. 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
Page 109 of 109 
Clinical Trial Protocol BT–L-CsA–302–DLT 
Version 6.0_7-Apr-2023 
 
 
Full description of substantial and other minor changes are provided in the Summary of 
Changes Document. 
 
 
 
Study Protocol Version 3.0 dated_9-June-2020 
The Study Protocol version 3.0 (Amendment 2) has been issued to add the COVID-19 related 
measures in order to ensure patient safety and efficacy data collection in case a given on-site 
visits cannot take place due to COVID-19 outbreak, including the possibility to perform remote 
visits, to carry out spirometry examination at patient home and the IMP re-supply at patient 
home. Furthermore the Eligibility Criteria have been reviewed. 
The amendment had considered to be substantial based on the criteria set forth in Article 10(a) 
of Directive 2001/20/EC of the European Parliament and the Council of the European Union. 
Full description of substantial and other minor changes/clarifications are provided in the 
Summary of Changes Document. 
 
Study Protocol Version 2.0 dated 30-April-2019 
The Study Protocol version 2.0 (Amendment 1) has been issued to review the Eligibility 
Criteria, Treatment of Patients, Assessment of Efficacy and Safety, Visits Schedule and 
Statistical considerations. This amendment had considered to be substantial based on the 
criteria set forth in Article 10(a) of Directive 2001/20/EC of the European Parliament and the 
Council of the European Union. 
Full description of substantial and other minor changes/clarifications are provided in the 
Summary of Changes Document. 
 

SAP_001.pdf: 
 
 
 
 
 
 
 
 
 
 
 
S T A TI S TI C A L A N A L Y SI S P L A N  
 
A P h ase III, Pr os pecti v e, M ultice nter, R a n d o mize d, C o ntr olle d Cli nic al Tri al t o 
De m o nstr ate t he Effi c a c y a n d S afet y of Li p os o m al C ycl os p ori ne A ( L -Cs A ) I n h al ati o n 
S ol uti o n Deli vere d vi a t he 
 De vice pl us St a n d ar d of C are 
vers us St a n d ar d of C are Al o ne i n t he Tre at me nt of C hr o nic L u n g All o gr aft D ysf u ncti o n / 
Br o nc hi olitis O bliter a ns S y n dr o me i n P atie nts p ost D o u ble L u n g Tr a ns pl a n t ati o n 
 
Pr ot oc ol N o: B T –  L -Cs A –  3 0 2 –  D L T( B O S T O N -2)  
Statistical A nal ysis Pla n Stat us: Fi nal   
Statistical A nal ysis Pla n Versi o n: 5 .0  
Statistical A nal ysis Pla n Date: 2 7 M A R C H 2 0 2 4  
 
S P O N S O R  
Za m b o n S p A  
Via Lill o del D uca, 1 0  
Bress o ( MI) 2 0 0 9 1, It al y  
 
I N V E S TI G A TI O N A L M E DI CI N A L P R O D U C T 
Li p os o mal C ycl os p ori ne A ( L -Cs A)  
 
 
De vel o pe d b y 
 
 
P P D
C CI
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 2  of 7 6  
 
 
1  
SI G N A T O RI E S  
S P O N S O R  
Za m b o n S p A  
Via Lill o del D uca, 1 0  
Bress o ( MI) 2 0 0 9 1  
Ital y 
 
 
 
 
 
 
   _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
  
 
 
 
     Date  
 
Si g nat ure  
P h o ne: 
 
E mail: 
  
 
  
 
 
 
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     Date  
 
Si g nat ure  
P h o ne: 
 
E mail:  
 
 
 
 
 
                            _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
 
 
 
 
     Date  
 
Si g nat ure  
P h o ne: 
 
E mail: 
 
 
 
P P D
P P D
P P D
P P D
P P D
P P D
P P D
P P D
P P D
P P D
P P D
P P D


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 3  of 7 6  
 
 
2  
T A B L E O F C O N T E N T S  
1  SI G N A T O RI E S  .................................................................................................................2  
2  T A BL E O F C O N T E N T S  ......................................................................................................3  
3  A B B R E VI A TI O N S  .............................................................................................................9  
4  V E R SI O N HI S T O R Y  ........................................................................................................ 1 1  
5  I N T R O D U C TI O N ............................................................................................................ 1 4  
6  T RI AL O BJ E C TI V E S  ........................................................................................................ 1 4  
7  I N V E S TI G A TI O N AL PL A N ............................................................................................... 1 4  
7. 1  
T RI AL D E SI G N  ........................................................................................................ 1 4  
7. 2  
R A N D O MI Z A TI O N A N D S T R A TI FI C A TI O N  ........................................................................ 1 5  
7. 3  
P RI M A R Y E F FI C A C Y E N D P OI N T  ................................................................................... 1 5  
 
 
 
 
7. 6  
S A F E T Y E N D P OI N T S  ................................................................................................. 1 6  
8  S T A TI S TI C AL C O N SI D E R A TI O N S ..................................................................................... 1 7  
8. 1  
G E N E R AL C O N SI D E R A TI O N S A N D D E S C RI P TI V E S T A TI S TI C S  ................................................. 1 7  
8. 1. 1  
B A S ELI N E D E FI NI TI O N  ......................................................................................................... 1 7  
8. 1. 2  
T R E A T M E N T D E FI NI TI O N ..................................................................................................... 1 8  
8. 2  
S A M PL E S I Z E C O N SI D E R A TI O N S  .................................................................................. 1 8  
8. 3  
IN T E RI M A N AL Y SI S  .................................................................................................. 1 8  
8. 3. 1  
IN T E RI M A N AL Y SI S F O R S A M PL E S I Z E R E -E S TI M A TI O N  ............................................................... 1 9  
8. 3. 1. 1  D A T A H A N DLI N G  ............................................................................................................... 2 0  
C CI


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
 
Final Version 5.0 
Page 4 of 76 
 
 
8.3.1.2 HANDLING OF MISSING DATA .............................................................................................. 21 
8.3.1.3 LINEAR MIXED MODEL ....................................................................................................... 21 
8.3.1.4 ANALYSIS OF COVARIANCE .................................................................................................. 23 
8.3.2 
INTERIM ANALYSIS FOR MISSING VALUES EVALUATION ............................................................... 23 
8.3.3 
COMMUNICATION OF IA RESULTS TO SPONSOR AND INVESTIGATORS ........................................... 24 
8.3.4 
FINAL DECISION ON APPROPRIATENESS OF PRIMARY ANALYSIS: LMM VS. ANCOVA. ..................... 25 
8.4 
TYPE I ERROR CONSIDERATIONS ................................................................................. 26 
8.5 
DATA MONITORING COMMITTEE AND CONFIDENTIALITY OF RESULTS ................................... 26 
8.6 
ADJUDICATION COMMITTEE ...................................................................................... 27 
9 DEFINITIONS ................................................................................................................ 27 
9.1 
PROTOCOL DEVIATIONS ........................................................................................... 27 
9.2 
ANALYSIS DATA SETS ............................................................................................... 27 
9.2.1 
SAFETY ANALYSIS SET (SAF) ................................................................................................ 28 
9.2.2 
FULL ANALYSIS SET (FAS) ................................................................................................... 28 
9.2.3 
INTERIM ANALYSIS FULL ANALYSIS SET (IA-FAS) ..................................................................... 28 
9.2.4 
PER PROTOCOL SET (PPS) .................................................................................................. 28 
9.3 
STUDY DAY AND TIME FROM RANDOMIZATION .............................................................. 29 
9.4 
VISIT WINDOWS .................................................................................................... 29 
9.5 
HANDLING OF MISSING DATA .................................................................................... 30 
9.5.1 
HANDLING OF MISSING EFFICACY DATA ................................................................................. 30 
9.5.2 
HANDLING OF MISSING SAFETY DATA ................................................................................... 30 
9.5.3 
HANDLING OF PARTIAL AND MISSING DATES .......................................................................... 30 
9.5.3.1 PARTIAL AND MISSING DATES OF BIRTH ................................................................................. 30 
9.5.3.2 MISSING OR PARTIAL AE AND PRIOR / CONCOMITANT MEDICATION START AND END DATES ........... 31 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
 
Final Version 5.0 
Page 5 of 76 
 
 
10 DISPOSITION ................................................................................................................ 32 
11 DEMOGRAPHICS AND BASELINE CHARACTERISTICS, AND DISEASE AND MEDICAL HISTORY
 
32 
11.1 
DEMOGRAPHIC AND BASELINE CHARACTERISTICS ............................................................ 32 
11.2 
DISEASE AND MEDICAL HISTORY ................................................................................ 33 
11.3 
BASELINE LUNG ALLOGRAFT DYSFUNCTION ................................................................... 34 
12 IMMUNOSUPPRESSANTS ............................................................................................. 35 
12.1 
BASIC IMMUNOSUPPRESSANTS ................................................................................... 36 
12.2 
OTHER IMMUNOSUPPRESSANTS ................................................................................. 37 
13 PRIOR AND CONCOMITANT MEDICATIONS ................................................................... 37 
14 EFFICACY ...................................................................................................................... 38 
14.1 
PRIMARY EFFICACY ANALYSIS............................................................................. 38 
14.1.1 ANALYSIS POPULATION AND ESTIMAND ................................................................................. 38 
14.1.2 WORKING HYPOTHESIS ....................................................................................................... 41 
14.1.3 ANALYSIS MODEL .............................................................................................................. 41 
14.1.4 SPECIFICATION OF THE MODEL ............................................................................................. 41 
14.1.5 SPECIFICATION OF THE COVARIANCE MODEL ........................................................................... 42 
14.2 
SENSITIVITY ANALYSES FOR THE PRIMARY ENDPOINT ....................................................... 43 
14.2.1 MISSING DATA NOT AT RANDOM (MNAR) ............................................................................. 43 
14.2.2 DELTA-BASED CONTROLLED IMPUTATION (TIPPING POINT)........................................................ 44 
14.2.3 MIXED MODEL REPEATED MEASURES (MMRM) ..................................................................... 44 
14.2.4 MMRM UNDER MNAR .................................................................................................... 45 
14.2.5 ANCOVA ....................................................................................................................... 45 
14.2.6 SELECTION MODELING ....................................................................................................... 45 


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 6  of 7 6  
 
 
1 4. 2. 7  JOI N T M O D EL  ................................................................................................................... 4 6  
1 4. 3  
S U P PL E M E N T A R Y A N AL Y S E S F O R T H E P RI M A R Y E N D P OI N T  ................................................. 4 6  
1 4. 3. 1  P P S  ................................................................................................................................ 4 7  
1 4. 3. 2  
 D A T A .................................................................................................................. 4 7  
1 4. 3. 3  T H E I M P A C T O F C O VI D -1 9  ................................................................................................. 4 7  
1 4. 3. 3. 1  P A TI E N T S I M P A C T E D B Y C O VI D -1 9  P A N D E MI C  ....................................................................... 4 7  
1 4. 3. 3. 2  P I E C E WI S E R E G R E S SI O N ...................................................................................................... 4 8  
1 4. 3. 3. 3  " WHIL E O N T R E A T M E N T “  S T R A T E G Y (F O R C O VI D -1 9)  ............................................................. 4 9  
1 4. 3. 4  T -T E S T ............................................................................................................................ 4 9  
1 4. 3. 5  " WHIL E O N T R E A T M E N T “  S T R A T E G Y“ .................................................................................... 4 9  
1 4. 3. 6  T RI M M E D M E A N S ............................................................................................................. 5 0  
 
 
 
 
 
 
 
  
 
 
 
  
 
  
 
 
 
 
 
  
 
 
 
 
 
 
  
 
  
 
  
 
 
 
  
 
 
 
 
 
 
 
  
 
 
 
  
 
 
 
  
 
  
 
 
 
 
 
 
 
  
 
 
 
  
 
 
 
 
 
C CI
C CI
P P D
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 7  of 7 6  
 
 
1 4. 6  
S U B G R O U P  A N AL Y S E S  ........................................................................................ 5 9  
1 5  S A F E T Y D A T A  ............................................................................................................... 6 0  
1 5. 1  
G E N E R AL C O N SI D E R A TI O N S  ....................................................................................... 6 0  
1 5. 2  
E X T E N T O F E X P O S U R E  .............................................................................................. 6 0  
1 5. 2. 1  E X P O S U R E T O L-C SA  .......................................................................................................... 6 0  
1 5. 2. 2  E X P O S U R E T O S T U D Y T R E A T M E N T ( SO C  O R S O C +L -C SA)  .......................................................... 6 1  
1 5. 3  
A D V E R S E E V E N T S  ................................................................................................... 6 1  
1 5. 3. 1  IN F E C TI O N S  ...................................................................................................................... 6 3  
1 5. 3. 2  M ALI G N A N CI E S  ................................................................................................................. 6 3  
1 5. 4  
A C U T E T OL E R A BILI T Y O F I M P .................................................................................... 6 3  
1 5. 5  
C LI NI C AL L A B O R A T O R Y D A T A  ..................................................................................... 6 4  
1 5. 5. 1  H E M A T OL O G Y A N D B I O C H E MI S T R Y ....................................................................................... 6 4  
1 5. 5. 2  B L O O D S A M PLI N G C NI/ M T O R  IN HI BI T O R S  ............................................................................ 6 5  
1 5. 5. 3  D O N O R S P E CI FI C A N TI B O D Y T E S T S ........................................................................................ 6 5  
1 5. 5. 4  P R E G N A N C Y T E S T S ............................................................................................................. 6 5  
1 5. 6  
R E N AL F U N C TI O N  ................................................................................................... 6 5  
1 5. 7  
V I T AL S I G N S .......................................................................................................... 6 6  
1 5. 8  
P H Y SI C AL E X A MI N A TI O N  .......................................................................................... 6 6  
1 6  C H A N G E S F R O M PL A N N E D A N AL Y S E S ........................................................................... 6 6  
1 7  
 C O D E S ................................................................................................................... 6 8  
1 7. 1  
P RI M A R Y A N AL Y SI S  ................................................................................................. 6 9  
1 7. 2  
S E N SI TI VI T Y A N AL Y SI S - M N A R  .................................................................................. 7 0  
1 7. 3  
S E N SI TI VI T Y A N AL Y SI S –  T I P PI N G P OI N T ........................................................................ 7 1  
C CI


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
 
Final Version 5.0 
Page 8 of 76 
 
 
17.4 
SENSITIVITY ANALYSIS - MMRM ................................................................................ 72 
17.5 
SUPPLEMENTARY ANALYSIS - PIECEWISE REGRESSION ....................................................... 72 
18 REFERENCES ................................................................................................................. 74 
19 APPENDICES ................................................................................................................. 75 
19.1 
INTERIM ANALYSIS REPORT ........................................................................................ 75 
19.2 
INTERIM ANALYSIS COMMUNICATION PLAN .................................................................... 76 
 
 
 


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 9  of 7 6  
 
 
3  
A B B R E VI A TI O N S   
A C  
A dj u dicati o n C o m mit tee 
A E  
A d verse E v e nt  
AI C  
A kai ke I nf or mati o n Criteri o n  
A L T  
Ala ni ne A mi n otra nsferas e  
A N C O V A  
A nal ysis of C o varia nce  
A P  
Al kali ne P h os p hatase  
A S T  
As partate A mi n otra nsferase  
A T C  
A nat o mical T hera pe utic C o de  
A T G  
A ntit h y m oc yte Gl o b uli n  
B L A D  
Baseli ne L u n g All o graft D ysf u ncti o n  
B O S  
Br o nc hi olitis O blitera ns S y n dr o me  
B U N  
Bl o o d Urea Nitr o ge n  
C L A D  
C hr o nic L u n g All o graft D ysf u ncti o n  
C M V  
C yt o me gal o vir us  
C NI  
Calci ne uri n I n hi bit or  
C O P D  
C hr o nic O bstr ucti ve P ul m o nar y Diseas e  
C O VI D -1 9  
C or o na vir us Disease of 2 0 1 9  
C S R  
Cli nical St u d y Re p ort  
C T C  
C o m m o n T o xicit y Criteria  
D L T  
D o u ble L u n g Tra ns pla nt  
D M C  
Data M o nit ori n g C o m mittee  
D R M  
Data Re vie w M eeti n g  
E B V  
E pstei n Barr Vir us  
eC R F  
Electr o nic Case Re p ort F or m  
E o S  
E n d of St u d y  
E o T  
E n d of Treat me nt  
E Q -5 D -5 L  
E ur o Q O L Healt h Q uesti o n naire  
F A S  
F ull A nal ysis Set  
F D A  
F o o d a n d Dr u g A d mi nistrati o n  
 
 
F E V 1 
F orce d E x pirat or y V ol u me i n O ne Sec o n d  
F V C  
F orce d Vital Ca pacit y  
γ-G T  
Ga m ma Gl uta m yl Tra nsferase  
I A  
I nteri m A nal ysis 
I A C P 
I nteri m A nal ysis C o m m u nicati o n Pla n 
I A-F A S  
I nteri m A nal ysis F ull A nal ysis Set 
I C H 
I nter nati o nal C o nfere nce o n Har m o nizati o n  
I E 
I nterc urre nt E ve nt 
C CI
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 1 0  of 7 6  
 
 
I M P 
I n v esti gati o nal Me dici nal Pr o d uct (st u d y dr u g: L-Cs A)  
L  
Liter  
L -Cs A  
Li p os o mal C ycl os p ori ne A I n halati o n S ol uti o n  
L M M  
Li near Mi xe d M o del  
L S M  
Least S q uare M ea ns  
M A R  
Missi n g at Ra n d o m 
Me d D R A  
Me dical Dicti o nar y f or R e g ulat or y Acti vities  
MI  
M ulti ple I m p utati o n  
MI -R D  
MI fr o m Retrie ve d Disc o nti n ue d patie nts  
m L  
Milliliter  
M M F  
M yc o p he n olate M ofetil  
M M R M  
Mi xe d M o del of Re peat e d Meas ures  
M N A R  
Missi n g N ot at Ra n d o m 
m T O R  
Ma m malia n Tar get of  Ra pa m yci n  
P D  
Pr ot oc ol De viati o n  
P E F  
Pea k E x pirat or y Fl o w  
P P S  
Per Pr ot oc ol Set  
P T  
Preferre d Ter m  
R E M L  
Restricte d Ma xi m u m Li keli h o o d  
S A E  
Seri o us A d verse E v e nt  
S A P  
Statistical A nal ysis Pla n  
S A F  
Safet y A nal ysis Set  
 
 
S D  
Sta n dar d De viati o n  
S D T M  
St u d y Data Ta b ulati o n M o del  
S L T  
Si n gle L u n g Tra ns pla nt  
S o C  
Sta n dar d of Care  
S O C  
S yste m Or ga n Class  
T E A E  
Treat me nt -E mer ge nt A d verse E ve nt  
T F L  
Ta ble, fi g ure a n d listi n g  
U S A  
U nite d States of A merica  
V A S  
Vis ual A nal o g ue Scale  
W H O -D D  
W orl d Healt h Or ga nizati o n -Dr u g Dicti o nar y  
W R O  
Writte n Res p o nse O nl y  
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 1 1  of 7 6  
 
 
4  
V E R SI O N HI S T O R Y  
D ate  
Versi o n  
Brief Descri pti o n of C h a n ges  
2 8 J ul y  2 0 1 8  
1 . 0 
I nitial draft versi o n  
1 5  Oct o ber  2 0 2 1  
2. 0  
U p dates o n t he i nteri m a nal ysis, i ntr o d uci n g t he I A -F A S 
p o p ulati o n, a n d u p dates fr o m t he pr ot oc ol a me n d me nt 3, 
date d 1 9 J a n uar y 2 0 2 1. T he ai m was t o all o w f or t h e i nteri m 
a nal ysis pr ocess t o pr ocee d, wit h a vie w t o u p date t he rest 
of t he secti o ns i n t he n e xt versi o n of t he S A P. A d de d 
se parat e d secti o ns t o des cri be I A o bj ecti ves a n d a nal ysis. 
3 1 J ul y 2 0 2 3  
3. 0  
U p dates reflecti n g t he pr ot oc ol a me n d me nt 5, dat e d 7 A pril 
2 0 2 3 ( V 6). T he ai m 
was t o s pecif y t he re -scree ni n g 
pr oce d ures as per c urre nt pr oce d ure si nc e t he be gi n ni n g of 
t he st u d y, 
 
 
, 
 
, t o clarif y t he 
nee d t o i d e ntif y o nl y c ha n ge i n ter ms of a d eteri orati o n of 
B O S gra de (f or t he ti me t o B O S pr o gressi o n e n d p oi nt),  
 
  
  
  
  
  
  
 
 
 
.  
A d diti o nal e x pla nati o ns ha ve bee n pr o vi de d re g ar di n g t he 
res ults of t he i nteri m a nal ysis a n d t he fi nal decisi o n o n t he 
a p pr o priate ness of t he pri mar y a nal ysis t hr o u g h L M M.  
F u rt her details o n: 
- 
Ha n dli n g of missi n g data;  
- 
A nal ysis of i m m u n os u p pressa nts;  
- 
A nal ysis of  
 
  
 s afet y 
e n d p oi nts.  
T he met h o ds use d f or t he pri mar y a n al ysis ha ve bee n 
f urt her e x pl ai ne d a n d  
 c o de e xcer pts ha ve b ee n a d de d. 
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L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
 
Final Version 5.0 
Page 12 of 76 
 
 
Date 
Version 
Brief Description of Changes 
Additional sensitivity and supportive analyses have been 
included to evaluate the reliability of the assumptions made 
in the primary analysis. The previous sensitivity and 
supportive analyses have also been verified and expanded 
upon. 
Supportive analyses to assess the impact of COVID-19 
pandemic on study results have been developed. It is 
anticipated that if any evidence emerges that the pandemic 
has affected the study endpoints, then it is necessary to 
consider how the initial study assumptions have changed 
and apply changes in the statistical criteria for final 
judgment of the study results. 
The present amendment also includes minor updates on 
section referencing and sentencing restructuring. 
31 October 2023 
4.0 
Section 9.2.1 has been modified to clarify the definition of 
actual treatment in the SAF population. 
Additional explanations have been added in Section 12.1 to 
clarify the calculation of intervals between visits and in 
Section 14.1.1 (Table 5) to summarize the different 
approaches for handling intercurrent events. 
In Section 14.2.5 a ranked ANCOVA has been planned in 
case of violation of normality assumption even after log-
transformation of data. 
Sections 14.3.3.1, 14.3.5, and 14.3.6 have been further 
elaborated to provide additional details. 
Sensitivity analyses have added in sections 14.4.1, 14.4.2, 
14.5.2, and 14.5.3. 
Additional subgroup analyses (by use of azithromycin at 
baseline and by BLAD disease at baseline) have been added 
in Section 14.6. The BLAD definition has been added in 
section 11.3. 
In section 15.2 more instructions for the analysis of Extent 
of Exposure have been added, while in Section 15.3.1 it has 


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 1 3  of 7 6  
 
 
D ate  
Versi o n  
Brief Descri pti o n of C h a n ges  
bee n a d d e d a n a n al ysis of i nfecti o n rates b y year a n d 
o verall.  
2 7  Marc h 2 0 2 4  
5. 0  
, t he f oll o wi n g c h a n ges ha v e 
bee n a p plie d:  
•  S ecti o n 1 4. 1. 1  has bee n a me n de d t o  c o nsi der a 
treat me nt c o m p osite strat e g y i nstea d of a tr eat me nt 
p olic y o ne . T heref ore, d eat h a n d re-tra ns pla ntati o n 
I E are i ncl u d e d i n t he e n d p oi nt t hr o u g h a n 
i m p utati o n of  F E V 1 as a treat me nt fail ure ( F E V 1 
e q ual t o zer o).  T his a p plies als o t o 1 4. 1. 3 , 1 4. 2. 1 , 
1 4. 2. 2 , 1 4. 2. 3 , 1 4. 2. 5 , 1 4. 3. 3. 3 , 1 4. 3. 4 , 1 4. 3. 5 , 
1 4. 3. 6 , 1 4. 4. 1 , a n d Ta ble 5 . 
•  S A P te xt has bee n  re vise d t o better se parate t he 
c o nce pt of missi n g data a n d i nterc urre nt e ve nts.  
•  Ta ble 5  h as bee n u p date d f or clarif yi n g h o w st u d y 
disc o nti n uati o n f or lac k of efficac y are treate d i n t he 
trial. 
Clarificati o ns i n secti o n 1 4. 3. 3. 1 , 1 4. 3. 3. 2 , a n d 1 4. 4. 2  ha ve 
bee n a d d e d t o s pecif y a n al ysis , c o m paris o ns, an d fi g ures.  
It is clarifie d i n secti o n 1 4. 4. 2  t hat B O S pr o gressi o ns will 
be c o nsi dere d u p t o st u d y  e n d, e ve n after treat me nt 
c o m pleti o n/ disc o nti n uati o n.  
It is s pecifie d i n secti o n 1 4. 5. 1  t hat i n case of n ot e n o u g h 
res p o nses f or usi n g l o gistic re gressi o n, t he n e xact met h o ds 
will be use d f or CI a n d test.  
Secti o n 1 5. 5. 1  has bee n u p date d wit h t he f ull list of 
He mat ol o g y a n d Bi oc he mistr y  e xa ms.  
Mi n or err ors i n t he 
 ha ve bee n fi xe d i n secti o n 
1 7 . 
 
 
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L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 1 4  of 7 6  
 
 
5  
I N T R O D U C TI O N 
T his Statistical A nal ysis Pla n ( S A P) pr o vi des details of s pecific pla n ne d a nal yses t o be perf or me d 
o n t he data t o be c ollecte d fr o m cli nical trial B T –  L -Cs A –  3 0 2 –  D L T ( B O S T O N -2) . T his S A P  
is base d o n t he Cli nical trial p r ot oc ol versi o n 6 .0  (a me n d me nt 5 .0) , date d 0 7 A pril 2 0 2 3 . 
M o dificati o ns t o t his S A P will be s u bject t o detaile d d oc u me ntati o n relati n g t o ti mi n g a n d 
rati o nale, wit h a f oc us o n i de ntif yi n g a n d pr o vi di n g a rati o nale f or c h a n ges. A n y de viati o ns fr o m 
t he S A P will be f ull y descri be d i n t he i nte grate d cli nical st u d y re p ort ( C S R). 
T he mai n p ur p os e of t his S A P is t o pre -s pecif y statistical a nal yses t hat relat e t o i de ntifie d cli nical 
trial o bjecti ves. A n y s u p p orti ve or e x pl orat or y a nal ys es prese nte d i n t he i nte grate d C S R w hic h are 
n ot descri be d i n t he S A P will be n ote d as s uc h.  
6  
T RI A L O BJ E C TI V E S  
T he o bjecti ve of t his tri al is t o assess t he efficac y a n d s afet y of a d d -o n aer os olize d Li p os o mal 
C ycl os p ori ne A I n h alati o n S ol uti o n ( L -Cs A ) t o Stan dar d of Care ( S o C) t hera p y as c o m pare d t o 
S o C t hera p y al o ne i n t he treat me nt of br o nc hi olitis o blitera ns s y n dr o me ( B O S) i n d o u ble l u n g 
tra ns pla nt ( D L T) reci pie nts. 
7  
I N V E S TI G A TI O N A L P L A N 
7. 1  T ri al D e si g n  
T his is a P hase III, pr os p ecti ve, m ultice nter, ra n d o mize d , c o ntr olle d cli nical trial of L-Cs A f or t he 
treat me nt of B O S i n a d ults wit h cli nicall y defi ne d B O S  ( C L A D –  B O S p he n ot y pe)  f oll o wi n g D L T. 
Patie nts will recei ve eit her L -Cs A ( 1 0 m g) via t h e 
 
t wice dail y pl us S o C treat me nt or S o C al o ne, f or a peri o d of 4 8 wee ks. All patie nts will be eli gi ble 
t o c o nti n ue i n a n o pe n-l a bel e xte nsi o n trial of L-Cs A , B T –  L -Cs A –  3 0 3 –  F U ( B O S T O N -3)  
f oll o wi n g c o m pleti o n of B O S T O N-2.  
A t otal of 1 1 visits ( Scree ni n g, V 1 t hr o u g h V 1 0) will b e perf or m e d d uri n g t he cli nical trial. Aft er 
i nf or me d c o nse nt has bee n o btai ne d, a Scree ni n g Visit will be carrie d o ut i n or der t o c hec k ge neral 
eli gi bilit y f or partici pati o n.  If a patie nt  fails t he scree ni n g pr ocess d ue t o n ot 
meeti n g 
i ncl usi o n/e xcl usi o n criteria, a re-scree ni n g is all o we d. At t he Baseli ne Visit ( V 1, ra n d o mizati o n 
visit), i ncl usi o n a n d e xcl usi o n criteria will be re -c hec k e d , a n d baseli ne  serial s pir o metr y will be  
perf or me d.  D uri n g t h e 4 8 -wee k treat me nt peri o d, visits are sc h e d ule d e ver y 4 -8 wee ks ( V 2 , …, 
V 9). Visit 9 ( E n d of Treat me nt, E o T) is sc he d ule d t o occ ur 4 8 wee ks aft er Visit 1. If a patie nt has 
a n e ve nt t hat meets o ne of t he criteria f or pr o gressi o n of B O S, pr o gressi o n of B O S m ust be 
c o nfir me d b y meas ur e m e nts t hat are ta ke n wit h  
 s pir o meter at least 2 wee ks a p art. 
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L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 1 5  of 7 6  
 
 
Visit 1 0 ( E n d of St u d y, E o S) is a safet y f oll o w -u p visit  perf or me d 4 wee ks after Visit 9/ E o T  o nl y 
i n patie nts n ot r olli n g o ver t o t he e xte nsi o n st u d y (B O S T O N -3) or  if p ossi ble, i n patie nts w h o 
deci de d t o wit h dra w t he c o nse nt d uri n g t he st u d y . F or p atie nts w h o will e nr oll t o B O S T O N -3, t he 
E o T visit will be t he E o S visit.  
H o we ver, if o ne of t he visits fr o m Visit 2 t o Visit 8 a n d disc o nti n uati o n visits ca n n ot be perf or me d 
at site d ue t o C O VI D -1 9, re m ote visits (e. g. , b y tel e p h o ne) are p ossi ble.  
7. 2  R a n d o mi z ati o n a n d St r atifi c ati o n  
At t he B aseli ne visit ( V 1), after all i ncl usi o n a n d e xcl usi o n criteria ha ve bee n f ull y e val uate d, 
eli gi ble patie nts will be ra n d o mi ze d wit h e q ual pr o ba bilit y t o o ne of t w o treat me nt ar ms, a c o ntr ol 
ar m ( S o C  al o ne) a n d a n i n vesti gati o nal ar m ( L-Cs A pl us  S o C). T he i n vesti gati o nal me dici nal 
pr o d uct (I M P) is L -Cs A. T o ass ure b ala nce b et wee n treat me nt ar ms wit h re gar d t o ke y vari a bles 
a n d p ote ntial c o nf o u n ders, stratificati o n pri or t o ra n d o mizati o n will be perf or me d f or t he f oll o wi n g 
varia bles:  
•  Scree ni n g F E V 1 ≥8 1 % of pers o nal b est F E V 1 val u e p ost -tra ns pla nt v ers us S cree ni n g F E V 1 
bet wee n 8 0 -5 1 % of pers o nal best F E V 1 val ue p ost -tra ns pla nt;  
•  A ge at t he ti me of ra n d o mizati o n:  < 5 5 years vers us ≥5 5 years ; 
•  Re gi o n: N ort h A merica  v ers us all ot her c o u ntri es t o get her . 
Wit hi n eac h of t h e 8  strat a, patie nts will be ra n d o ml y assi g ne d wit h e q ual pr o ba bilit y ( 1: 1) t o eit her 
t he i n vesti gati o nal or c o ntr ol ar m usi n g a p er m ute d bl oc ks ra n d o mizati o n. T he ra n d o mizati o n 
c o de, i ncl u di n g s pecifi cati o n of t he bl oc k size, will be ge nerate d b y a statistici a n n ot ot her wise 
i n v ol ve d wit h t he trial, usi n g vali date d s oft ware. T he u ni q ue ra n d o mizati o n n u m ber a n d tr eat me nt 
assi g n me nt of eac h p atie nt will be pr o vi de d t o t he I n v esti gat or t hr o u g h t he electr o nic Cas e Re p ort 
F or m (e C R F) after eli gi bilit y has bee n veri fie d. T he n u m ber assi g ne d t o a patie nt will be t hat 
patie nt’s u ni q ue i d e ntifier t hr o u g h o ut t he cli nical trial a n d ca n n ot b e re-assi g ne d t o a n ot h er p atie nt.  
T his is a n o pe n -la bel cli nical trial . Cli nical trial m o nit ors, treati n g p h ysicia ns, st u d y n urses, st u d y 
c o or di nat ors, a n d e nr olle d patie nts will n ot be bli n de d t o treat me nt assi g n m e nt . 
7. 3  P ri m a r y Effi c a c y E n d p oi nt  
•  Mea n c ha n g e i n F E V
1 ( L) fr o m baseli ne t o Wee k 4 8 
F E V 1 data c ollecte d fr o m t he o n site  
 s pir o meter will b e c o nsi dere d pri mar y, w h ile t he 
data c ollecte d wit h t he  
 h o me s pir o meter will be use d f or s u p p orti ve a nal yses.  
7. 4  
 
•  
 
 
 
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L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 1 6  of 7 6  
 
 
o  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
7. 6  S af et y E n d p oi nt s  
•  A d verse e ve nts ( A Es) (i n cl u di n g i nfecti o ns a n d m ali g na ncies); 
•  Ac ute t olera bilit y of I M P (L -Cs A ); 
•  Cli nical la b orat or y varia bles ; 
•  Re nal f u ncti o n ; 
•  Vitals si g ns ; 
•  P h ysical e xa mi nati o ns . 
 
 
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L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 1 7  of 7 6  
 
 
8  
S T A TI S TI C A L C O N SI D E R A TI O N S  
8. 1  G e n e r al C o n si d e r ati o n s  a n d D es c ri pti v e St ati sti c s  
All re p ort o ut p uts will be pr o d uce d usi n g 
 
 versi o n 
9 . 2 or later , i n a sec ure a n d vali date d e n vir o n me nt. All ta bles, fi g ures a n d data listi n gs ( T F Ls) t o 
be i ncl u de d i n t he re p ort will be i n de pe n de ntl y c h ec ke d f or c o nsiste nc y a n d i nte grit y . 
T he data r ec or de d i n t h e e C R F will be s u m marize d as a p pr o priate, p er tr eat me nt gr o u p a n d f or t he 
t otal gr o u p, usi n g t he f oll o wi n g descri pti ve meas ures: 
•  All c o nti n u o us varia bles will be s u m marize d usi n g descri pti ve statistics (i.e., n, mea n, 
sta n dar d de viati o n ( S D), me dia n, Q 1, Q 3, mi ni m u m, a n d ma xi m u m).  
•  All cate g oric al varia bles will b e s u m marize d b y usi n g fre q ue nc y c o u nts a n d perce nt a ges .  
•  Discrete or di nal or hi g her -le vel data will be s u m marize d as c o nti n u o us data, b ut a 
ta b ulati o n of cate g ories ma y als o be i ncl u de d, de pe n di n g o n t he n u m ber of cate g ories. 
•  F or ti me -t o-e v e nt varia bl es, c u m ulati ve e ve nt -free s ur vi val ti mes will be e val uate d usi n g 
t he Ka pla n-Meier met h o d. A fre q ue nc y ta bl e s h o wi n g t he n u m ber of e ve nts a n d ce ns ore d 
patie nts  b y treat me nt gr o u p, will be prese nte d  al o n g wit h t he e ve nt -free rates (a n d t w o-
si de d 9 5 % c o nfi d e nce). Ka pla n -Mei er gra p hs will be prese nt e d al o n g wit h t he n u m ber of 
patie nt -at-ris k at e x act ti me p oi nts. If differe nt r ules are n ot s pecifie d, patie nts w h o are free 
fr o m e ve nt will be ce ns or e d at t he st u d y ter mi nati o n. 
F or all meas ur es a n al yze d descri pti vel y (i. e., meas ures t o c h aracterize t he treat me nt gr o u ps a n d 
t heir baseli ne stat us, efficac y, a n d safet y o utc o mes), ta b ulati o ns c o m pari n g t he treat me nt gr o u ps 
will be pre pare d. F or o utc o mes meas ure d m or e t ha n o nce, t he a nal yses will i ncl u de ta b ul ati o ns of 
t he meas ure d val u es b y visit, as well as c ha n ge fr o m baseli ne. W here pr o vi de d, all c o nfi de nce 
i nter vals will be t w o-si de d 9 5 % i nter vals. 
8. 1. 1  B a s eli n e D efi niti o n  
 b aseli ne F E V 1: t he F E V1 val ue t hat is t he mea n of t he best F E V 1 o btai ne d wit h t he  
 st u d y s pir o meter at t he Scree ni n g Visit a n d t he pre -ra n d o mizati o n best F E V 1 o btai ne d 
at t he Bas eli ne Visit  ( V 1) is referre d t o as “ b as eli ne F E V1”. If t he val u e at Scree ni n g visit is 
missi n g, t he n t he baseli ne F E V 1 will be t he pre -ra n d o mizati o n val ue fr o m t he Baseli ne Visit  ( V 1). 
If t he pre -ra n d o mizati o n val ue at Baseli ne V isit ( V 1) is missi n g, t he n t he baseli ne F E V1 will be 
t he val ue fr o m t he Scree ni n g Visit.  
Ot her  
 baseli ne s pir o metr y val ues : will be defi ne d si milarl y as f or Baseli ne F E V 1.  
 b as eli ne F E V 1: will be defi ne d si milarl y as f or 
 b aseli ne F E V 1 b ut usi n g t he 
 h o me s pir o met er . 
 
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L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 1 8  of 7 6  
 
 
Baseli ne la b orat or y v al ues:  t he last meas ure me nt o btai ne d pri or t o or at t he Baseli ne Visit (V 1 ).  
Ot her b aseli ne me as ure m e nts : u nle ss ot her wise s p ecifie d, bas eli ne refers t o  meas ure me nt o btai ne d 
at t he B aseli ne V isit (V 1 ).  
8. 1. 2  T r e at m e nt D efi niti o n  
Treat me nt refers t o a d d-o n L -Cs A t o S o C t hera p y, as well as S o C t hera p y al o ne.  Treat me nts 
peri o ds are d efi ne d i n secti o n  1 5. 2. 2 . 
8. 2  S a m pl e Si z e C o n si d e r ati o n s  
T he i ni tial sa m ple size was base d o n t he f oll o wi n g c o nsi derati o n s. Ass u mi n g a treat me nt gr o u p 
differe n ce f or me a n F E V 1 c ha n ge fr o m b aseli ne of 2 0 0 m L  ( 0. 2 L) a n d a sta n dar d de viati o n of 3 5 0 
m L  ( 0. 3 5 L) at t he e n d of treat me nt Wee k 4 8, a n i n de pe n de nt s a m ples t -test wit h a o ne-si d e d t y pe 
I err or le v el of α = 0. 0 2 5 will ha ve at le ast 8 0 % p o wer t o reject t he n ull h y p ot hesis w he n t he sa m ple 
size i n eac h treat me nt gr o u p is at least 5 0 patie nts. T o c o m pe nsate f or a l oss of p o wer d ue t o 
pre mat ure wit h dra wals, a t otal of 1 1 0 patie nts will i nitiall y be ra n d o mize d.  
A n i nteri m a nal ysis  (I A) was perf or me d t o re -assess sa m ple size  a n d d eli vere d t o t he S p o ns or o n 
Dece m b er 1 st, 2 0 2 1. Res ults of t he I A are pres e nte d i n a se parate I A re p ort (secti o n 1 9. 1 ). 
I n acc or da nce wit h t he a me n de d versi o n of t he pr ot oc ol ( versi o n 6. 1 ) 
 
 
,
 
 
 
 
It was a ntici pate d t hat a p pr o xi matel y 1 6 0-1 7 0 patie nts ha ve bee n ra n d o mize d i n B O S T O N -2 a n d 
a p pr o xi matel y 6 0 pat ie nts i n B O S T O N-1. 1 6 9 patie nts were act uall y ra n d o mize d i n B O S T O N -2 
a n d 6 2 patie nts i n B O S T O N -1 . 
8. 3  I nt e ri m A n al ysi s 
A n I A w as  t o be c o n d u cte d at t he ti me w he n a p pr o xi matel y 5 4  patie nt s ( 5 0 %) h a d at least 
c o m plete d Wee k 2 4 (f or t he rati o nale pleas e refer t o secti o n 8. 3. 1 ), w hic h is referre d as I A F ull 
A nal ysis Set (I A -F A S) p o p ulati o n (refer t o secti o n 9. 2. 3  f or t he I A-F A S p o p ulati o n defi niti o n), 
b ut o nl y i ncl u di n g patie nts w h o eit her ha d at least c o m plete d 
Wee k 2 4 assess me nts or ha d 
disc o nti n ue d  (at a n y ti me p oi nt) at t he c ut off dat e, 3 0 -Se p -2 0 2 1 .  
Rejecte d s pir o metries were n ot t o be a nal y ze d a n d were  e xcl u de d fr o m t he i nteri m a nal ysis.  
T he i nteri m a nal ysis was t o be  perf or m e d wit h t he f oll o wi n g o bjecti ves:  
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L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 1 9  of 7 6  
 
 
•  Re -esti mati o n of t he S D  of t he pri mar y e n d p oi nt , wit h t he p ur p os e of re-esti mati n g t he 
sa m ple size. 
•  E val uati o n of t he act ual a m o u nt of F E V 1 data c ollecte d at all ti me p oi nts usi n g t he 
 s pir o meter. 
•  E val uati o n of t he n u m ber of dr o p -o uts a n d t he n u m ber a n d patter n of t he missi n g data . 
•  A p pr o pr iate n ess of t he a nal ysis base d o n t he a ntici pate d l o n git u di nal m o del vers us t he 
a nal ysis base d o n t he a nal ysis of c o varia n ce ( A N C O V A) m o del i n t he li g ht of t he c ollect e d 
data .  
All a nal yses were perf or me d o n t he bli n de d data a vaila ble at t hat ti me b y a n i n de pe n d e nt, bli n de d 
statisticia n.  
F or t he st u d y, a Bli n di n g C harter des cri bi n g t he c o m m u nicati o n pr ocess a n d c o n d uct of 
pr ofessi o nal a cti vities i n or der t o  e ns ure t he pr o p er bli n di n g of t he st u d y pers o n nel wa s i n place.  
I n a d diti o n t o t he Bli n di n g C harter, a n I nteri m A nal ysis C o m m u nicati o n Pla n (I A C P) had  bee n 
pr o d uce d s pecificall y f or t he I A ( pleas e refer t o  Secti o n  1 9. 2 ). T he I A C P i n partic ular ai me d at 
descri bi n g t he pr ocesses a n d pr oce d ures t hat were t o be e m pl o ye d at t h e ti me of t he i nteri m 
a nal ysis a n d t he res ulti n g c o ntr olle d disse mi nati o n of i nteri m a nal ysis d ata. I n or der t o c o ntr ol 
bli n di n g, I A C P clearl y d efi ne d data access, r oles, c o m m u nicati o n fl o ws a n d pr oce d ures.   
8. 3. 1  I nt e ri m A n al ysi s f o r S a m pl e Si z e R e-esti m ati o n  
Gi ve n t he u ncertai nt y i n t he esti mate of t he S D  of F E V 1 c ha n ge fr o m baseli ne at Wee k 4 8 d ue t o 
d iffere n ces i n p atie nt p o p ulati o ns bet wee n t his trial a n d t hat u p o n w hic h t h e esti mate was o btai ne d, 
a bli n de d  I A w as  t o be c o n d ucte d b y a n i n de pe n de nt , bli n de d statisticia n t o re-esti mate t he S D .  
Kieser a n d Frie de  [1 ] ha ve de m o nstrate d t hat t he t y pe I err or rate of t he t -test is n ot affecte d if 
si m ple bli n d varia nce esti mat ors are us e d f or sa m ple size recal c ulati o n . He nce, n o a dj ust me nt t o 
t he t y pe I err or rate was  t o be ma de.  If t he sa m ple size calc ulat e d o n t he basis of t he ne w val ue f or 
t he S D  is hi g her t ha n t he i nitial esti mate, t he sa m ple size of t he trial mi g ht be i ncrease d acc or di n gl y 
i n or der t o preser ve t he pre-s pecifie d p o wer ( 8 0 %). If t he re-calc ulat e d sa m ple size is l o wer t ha n 
t he i nitial esti mate, t he cli nical trial  was t o be c o nti n ue d wit h t he i nitial l y pla n ne d sa m ple size ( 1 1 0 
patie nts).  
Acc or di n g t o t he  pre vi o us versi o ns of  t he pr ot oc ol s, t his I A was t o be c o n d ucte d a p pr o xi matel y 
o ne or t w o m o nt hs bef ore t he last patie nt wa s pr ojecte d t o be ra n d o mize d i n t he cli nical trial. 
H o we ver, a t t he ti me of S A P ame n d me nt v ersi o n 2. 0 , e nr ol me nt of last patie nt was pr ojecte d b y 
Marc h 2 0 2 2. It was deci de d t o pre pare t he I A a fe w  m o nt hs  earlier 
 
 f or t he f oll o wi n g reas o ns: 
C CI
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 2 0  of 7 6  
 
 
•  T he n u m ber of patie nts t o be c o nsi dere d i n  t he I A was 
 
a p pr o xi matel y 5 0 % of t h e ori gi nall y pla n ne d sa m ple size, w hic h is a c o m m o n c h oice f or 
c o n d ucti n g I A f or sa m ple size re-assess me nt  
•  St u d y  e nr ol me nt was halte d starti n g fr o m 
 f or all partici pati n g sites a n d it 
was re -acti vat e d site b y site after t h e  a p pr o val of t he pr ot oc ol ve rsi on 3 . 0 (a me n d me nt 2. 0) 
i ncl u di n g t he C O VI D-1 9 s pecific meas ures a n d c o nti n ge nc y pla n starti n g fr o m 
 as a date of first site re-acti vate d. T heref ore,  waiti n g a fe w m ore m o nt hs w o ul d o nl y 
mar gi nall y i ncreas e t h e n u m ber of p atie nts wit h a l o n g f oll o w -u p d urati o n (f or e xa m ple, 
patie nts wit h 4 8 wee ks of o bser vati o n)  
•  If a sa m ple siz e i ncrease was nee d e d, ha vi n g t his i nf or mati o n earlier w o ul d re n der feasi ble 
t o a me n d t he st u d y pr ot oc ol, wit h o ut pa usi n g  patie nt e nr ol me nt a g ai n.  
F or o n g oi n g patie nts w h o were still at t h eir earl y p hases of t he trial, it was n ot c o nsi dere d t o be 
cli nicall y mea ni n gf ul t o re p ort a v al ue t h at was  h ea vil y base d o n e xtra p ol ati o n. T heref ore, t he I A 
was  c o n d uct e d o n t he p atie nts w h o ha d at least c o m plete d Wee k 2 4  ( Visit 6), w hic h was a h alf wa y 
of t hei r treat me nt. 
 
A n i n de pe n de nt statisticia n ha d bee n  pr o vi d e d wit h t he T F L  o ut p uts bli n de d t o treat me nt 
assi g n me nt w hic h i ncl u de d  F E V 1 o u tc o mes a n d t he c o variat e data  t o re-esti mate t he S D  a n d t he 
res ults ca n be f o u n d i n t he i nteri m a nal ysis re p ort (see secti o n 1 9. 1 ).  
8. 3. 1. 1  
D at a h a n dli n g  
F or p atie nts w h o were o n g oi n g at or after Wee k 2 4  of t he st u d y  ( Visit 6) b ut still n ot reac hi n g 
Wee k 4 8 at t he ti me of t he I A , t heir st u d y stat us was t o be ra n d o ml y assi g ne d t o eit her t he 
c o m pleter p o p ulati o n or dr o p -o uts p o p ulati o n, i n s uc h a wa y t hat t he dr o p -o ut patter n was as m uc h 
as p ossi ble e q ual t o t he dr o p -o u t patter n o bs er ve d at t he ti me of t he I A  (see des cri pti o n bel o w).  
T he f oll o wi n g pr o p orti o ns were t o be calc ul ate d:  
•  N u m ber of patie nts disc o nti n ue d after Wee k 2 4 ( Visit 6) at t he ti me of I A; 
•  N u m ber of patie nts w h o c o m plete d t he st u d y at t he ti me of I A. 
T he pr o p orti o n s were t he n t o be a p plie d t o all o n g oi n g patie nts i n t he st u d y a n d t o assi g n  a patie nt 
t o eit her t he c o m pleter p o p ulati o n or dr o p-o uts p o p ulati o n , tw o ra n d o m pr ocesses  were t o be 
i m ple me nte d: 
1.  Patie nts c o m pleti n g Wee k 2 4 ( Visit 6) b ut still n ot re ac hi n g Wee k 4 8 at t he ti me of t he I A 
or disc o nti n ue d w ere t o be ra n d o ml y assi g ne d eit her t o t h e c o m pleter p o p ulati o n or dr o p-
o uts p o p ulati o n base d o n t he pr o p orti o n of t h e o bser ve d d ata at t he ti me of t he I A.  T his 
selecti o n was p erf or me d usi n g 
. T he datas et wit h c o m plete 
st u d y stat us is referre d t o as t he c o m plete data w hic h was t o be re peate dl y ge nerate d f or 
1 0 0 ti mes.  
 
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C CI
C CI
C CI
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L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
 
Final Version 5.0 
Page 21 of 76 
 
 
2. For patients who were to be assigned to the drop-outs population in each of the complete 
dataset, their last visit was to be randomly chosen from options of later visits among 
patients discontinued after Week 24 (Visit 6). If there were no later visits observed at the 
time of the IA, the patients were assumed to be discontinued at their last known visit. 
8.3.1.2 
Handling of Missing data 
Following the random process, the additional visits were presented as missing rows which were 
handled based on the below rules: 
• The same set of baseline covariates (e.g., age, region, baseline FEV1) for the same patients 
were carried over to the missing rows;  
• Missing data on temporal variables were placed by nominal time (see section 9.4). 
Missing data on dependent variable, change in FEV1 at Week 48 from baseline, were imputed 
based on multiple imputation model assuming missing at random (MAR) mechanism. The set of 
variables included in the multiple imputation model were region, age group, baseline FEV1 and 
temporal (time) variables. The number of imputed datasets generated was 100. The number of 
datasets generated were 10000 with 100 imputations within each of the 100 complete datasets. 
8.3.1.3 
Linear Mixed Model 
A linear mixed model (LMM) for repeated measurements, similar to the analysis of the primary 
endpoint (section 14.1) was performed to model FEV1 measurements for each complete dataset. 
Since the IA was blinded, the treatment group, and the interactions of time splines by treatment 
were excluded from the model.  
The model included change in FEV1 between baseline and subsequent visits as the dependent 
variable, and contain the following covariates (except from the intercept): 
• Time splines:  S1=t, S2=t2 , S3=t3 and S4=max(t-182,0)3 where t is the study day of the 
measurement and S4 = (t-182)3 if t>182 and 0 otherwise; 
• base_FEV1:  Baseline FEV1; 
• base_FEV1*S1,…, base_FEV1*S4: The interactions of time splines with the baseline 
FEV1; 
• region: North America versus all other countries together; 
• age group: age (< 55 versus  55 years). 
In case the model did not converge, or the covariance matrix was not positive definite, 
consideration was taken to drop from the model the highest order random effect. 
The adjusted mean change from baseline at Week 48 derived from the LMM was adjusted at the 
mean baseline FEV1 for all patients who were observed to complete the study or discontinued, not 
the mean of the covariates over all observations. 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
 
Final Version 5.0 
Page 22 of 76 
 
 
Results from each complete dataset was combined using Rubin’s rule to provide the least square 
means (LSMs) for change at Week 48 from baseline as well as the standard error of the LSM. Let 
seall denote the estimated standard error of the mean change from baseline of FEV1 at Week 48.  
The median of squared standard error over all complete datasets can be written as:  
𝑠𝑒𝑎𝑙𝑙,𝑚𝑒𝑑𝑖𝑎𝑛
2
= 𝑣2/(𝑛𝑐𝑜𝑚𝑝𝑙𝑒𝑡𝑒+ 𝑤 𝑛𝑑𝑟𝑜𝑝−𝑜𝑢𝑡 ) , 
where ncomplete and ndrop-out denote the number of completer patients (i.e., having a 48 weeks 
measurement) and the number of patients who dropped-out, respectively, and w is the average 
weight of the drop-outs. The weight of the completer patients is by definition 1, and w (<1) 
quantifies the average contribution of the drop-outs to the estimation of the mean change from 
baseline of FEV1 at Week 48. The variance v2 is the residual variance of the change from baseline 
of FEV1 at Week 48 after adjustment for the covariates.  
Then we remove the rows of the drop-outs and calculate the standard error again. The median of 
squared standard error is now written as 
𝑠𝑒𝑐𝑜𝑚𝑝𝑙𝑒𝑡𝑒,𝑚𝑒𝑑𝑖𝑎𝑛
2
= 𝑣2/𝑛𝑐𝑜𝑚𝑝𝑙𝑒𝑡𝑒. 
From the two equations, one can solve for v and w. The resulting v disregards the treatment group, 
so it is larger than the pooled within treatment group variance if the treatment effect is unequal to 
zero. Under the alternative hypothesis used in the original sample size calculation, H1:  = 200 mL 
(0.2 L), the pooled within groups residual variance estimate can be estimated as v2 - δ2/4 (see 
Kieser and Friede [1]). This value can be used in the sample size formula for the independent 
samples t-test to calculate the effective sample size neffective needed for a certain power, or for 
calculating the power for a given neffective. The corresponding number of randomized patients is 
nrandomized = neffective / (1-π+ πw), where π is the probability of dropping out, estimated by a Kaplan-
Meier analysis based on the observed data at the time of the IA.  
The independent statistician had provided the Sponsor with the recommended sample size, defined 
as: 
𝑛𝑟𝑒𝑐𝑜𝑚𝑚𝑒𝑛𝑑𝑒𝑑=  𝑚𝑎𝑥𝑖𝑚𝑢𝑚 [ 110, 𝑛𝑢𝑝𝑑𝑎𝑡𝑒𝑑]. 
Here nupdated is the total number of patients that has to be randomized in order to have 80% power 
against a treatment effect of 200 mL (0.2 L). 
A sensitivity analysis was conducted for the sample size re-estimation by considering patients who 
have completed Week 48 or have discontinued when calculating the standard error of the change 
from baseline to Week 48 for FEV1 measurements. The data were fitted using the same LMM for 
primary analysis for sample size re-estimation without any imputation. The LSM as well as its 
associated standard error overall were reported with all data under sensitivity analyses and data 
excluding drop-outs, respectively.  


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
 
Final Version 5.0 
Page 23 of 76 
 
 
8.3.1.4 
Analysis of Covariance  
Since one of the objectives of the IA was to verify appropriateness of the analysis based on the 
anticipated longitudinal model vs the analysis based on the ANCOVA model, the sample size 
calculation was performed also assuming that the final model will be ANCOVA, so that if the 
decision were to conduct ANCOVA, the power information on this analysis was not missing. 
The imputation method described for LMM was repeated and each of the complete datasets after 
imputation was then analyzed in an ANCOVA model adjusting for region, age group, and baseline 
FEV1 as a continuous covariate. Time variables were not included as only Week 48 was analyzed 
for ANCOVA. 
Results from each complete dataset were combined using Rubin’s rule to provide the LSMs for 
change in FEV1 at Week 48 from baseline as well as standard error of the LSM. 
The adjusted mean change from baseline at Week 48 derived from the ANCOVA was adjusted at 
the mean of the other covariates at baseline for all patients who had completed the study at the 
time of the IA, not the mean of the covariates over all observations. 
The median of squared standard error over all complete datasets is now written as: 
𝑠𝑒𝑐𝑜𝑚𝑝𝑙𝑒𝑡𝑒,𝑚𝑒𝑑𝑖𝑎𝑛
2
= 𝑣2/𝑛𝑐𝑜𝑚𝑝𝑙𝑒𝑡𝑒. 
One could solve for v. The resulting v disregards the treatment group, and is larger than the pooled 
within treatment group variance if the treatment effect is unequal to zero. Under the alternative 
hypothesis used in the original sample size calculation, H1:  = 200 mL (0.2 L), the pooled within 
groups residual variance estimate could be estimated as v2 - δ2/4 (see Kieser and Friede [1]). This 
value could be used in the sample size formula for the independent samples t-test to calculate the 
effective sample size neffective needed for a certain power, or for calculating the power for a given 
neffective. The corresponding number of randomized patients is nrandomized = neffective / (1-π), where π 
is the probability of dropping out, estimated by a Kaplan-Meier analysis based on the observed 
data at the time of the IA.  
The independent statistician was to provide to the Sponsor with the recommended sample size, 
defined as: 
𝑛𝑟𝑒𝑐𝑜𝑚𝑚𝑒𝑛𝑑𝑒𝑑=  𝑚𝑎𝑥𝑖𝑚𝑢𝑚 [ 110, 𝑛𝑢𝑝𝑑𝑎𝑡𝑒𝑑]. 
Here nupdated is the total number of patients that has to be randomized in order to have 80% power 
against a treatment effect of 200 mL (0.2 L). 
8.3.2 Interim Analysis for missing values evaluation 
In accordance with the previous versions of the protocol (version 4.0 and below), the other 
objectives of the IA were: 


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 2 4  of 7 6  
 
 
•  E val uati o n of t he act ual a m o u nt of F E V 1 data c ollecte d at all ti me p oi nts usi n g t he 
 s pir o meter; 
•  E val uati o n of t he n u m ber of dr o p -o uts a n d t he n u m ber a n d patter n of t he mi ssi n g data; 
•  E val uati o n of t he a p pr o priate ness of t he a n al ysis base d o n t he a ntici pat e d l o n git u di nal 
m o del vs t he a nal ysis bas e d o n t he A N C O V A m o d el i n t he li g ht of t he c ollecte d data . 
T hese o bjecti ve s w ere e v al uate d b y mea ns of des cri pti ve statistics o n t he act ual a m o u nt of F E V 1 
data, n u m ber of disc o nti n ue d patie nt s a n d n u m ber of missi n g data at eac h st u d y visit.  
Patter n of t he missi n g data w ere e v al uate d b y n u m ber of missi n g val ues eit her d ue t o dr o p -o ut s or 
data n ot c ollecte d at eac h ti me p oi nts  (i nterc urre nt missi n g val ues).  
8. 3. 3  C o m m u ni c ati o n of I A r e s ult s t o S p o n s o r a n d I n v e sti g at o r s  
Rec o m me n dati o ns were c o m m u nicate d as descri b e d i n  the I A C P. T he I A was  perf or m e d b y t he 
i n de pe n de nt, bli n de d st atisticia n a n d deli vere d  o n  0 1 Dece m ber  2 0 2 1 . T he rec o m me n dati o ns were 
as re p orte d i n T a ble 1 . 
T a ble 1 : I A rec o m me n d ati o ns. 
 
Secti o n  
Rec o m me n d ati o n  
1  
Sa m ple Size Re -esti mati o n usi n g L M M 
wit h 
m ulti ple i m p utati o n  - Pri mar y 
A nal ysis  
T he rec o m me n dati o n is t o c o nti n ue wit h t he 
i nitial sa m ple size ( 1 1 0 patie nts) as t he re-
esti mati n g  sa m ple size is l o wer t ha n t he i nitial 
esti mate. 
2  
Sa m ple Size Re -esti mati o n usi n g L M M  
- Se nsiti vit y A nal ysis  
L M M Se nsiti vit y a nal ysis s u p p orts t he fi n di n gs i n 
t he pri mar y a nal ysis. T he a nal ysis is o nl y f or 
i nf or mati o n p ur p ose d ue t o l o w sa m p le sizes. 
3  
Sa m ple 
Size 
Re -esti mati o n 
usi n g 
A N C O V A wit h m ulti ple i m p utati o n  
T he rec o m me n dati o n is t o i ncrease t he sa m ple 
size t o a t otal n u m ber of 1 5 2 i n or der t o preser ve 
t he pre-s pecifie d p o wer. 
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 2 5  of 7 6  
 
 
 
Secti o n  
Rec o m me n d ati o n  
4  
O T H E R 
O BJ E C TI V E S. It 
ma y be 
c o ncer ni n g 
w he n usi n g a ntici pate d 
l o n git u di nal m o del as t h ere m a y be a 
fe w data c ollect e d at i nter me diate 
ti me p oi nts bet wee n Wee k 4 a n d Wee k 
4 8  
T he c o m pleti o n rates are preser ve d at a b o ve 6 7 % 
le vel a n d are fl uct uat e d acr oss t he visits. 
T here is n o cl ear 
missi n g tre n d t hat ca n b e 
o bser ve d fr o m t he data.  
I n li g ht of t he c ollecte d data, t he rec o m me n dati o n 
is t o c o nti n ue t o t he a nal ysis base d o n t he L M M 
as t here is n o earl y i n dicati o n f or tr e n di n g of 
missi n g data . 
T he bli n de d statisticia n c o m m u nicate d t hese c o ncl usi o ns t o t he S p o ns or. C o nfi de ntialit y of res ults 
was e ns ur e d,  a n d n o I A res ults were pr o vi d e d t o t he S p o ns or or t he I n vesti gat ors. 
8. 3. 4  Fi n al d e ci si o n o n a p p r o p ri at e n e s s of p ri m a r y a n al y si s:  L M M 
v s. A N C O V A.  
T he rec o m me n dati o ns fr o m t he bli n de d statisticia n (Dece m b er 1st, 2 0 2 1 ) ha ve bee n e val u ate d 
 
 
•  t o c o nti n ue t o stri ve t o ac hie ve t he ori gi nall y plan ne d t otal patie nt  n u m ber of 2 2 0 f or b ot h 
cli nical trials c o m bi ne d ( B O S T O N -1 a n d B O S T O N -2) a n d re vise  t he B O S T O N-2 pr ot o c ol 
a n d t he ne w s a m ple size acc or di n gl y.  
•  t o i m ple me nt eff orts t o mi ni mize missi n g data i n b ot h st u dies. I n ge neral, all patie nts w h o 
mai ntai n c o nse nt t o be f oll o we d f or a d diti o nal o utc o me  i nf or mati o n, i ncl u di n g patie nts 
w h o disc o nti n ue st u d y treat me nt, s h o ul d re mai n i n t he  st u d y f or all i m p orta nt safet y a n d 
effic ac y ass ess me nts f or t he f ull d urati o n of t he tri al. 
•  t o clearl y pre-s pecif y a pri mar y a nal ysis (the meeti n g pac ka ge i n dicates t hat t he pri mar y 
a nal ysis ma y be base d o n A N C O V A, if t he L M M m o del is n ot via ble at t he e n d of t he 
st u d y, i n li g ht of t he o n g oi n g C O VI D-1 9 pa n d e mic ). M o dificati o ns t o t he a nal ysis  of t he 
pri mar y 
 e n d p oi nts s h o ul d be reflecte d i n a n u p date d statistical a nal ysis 
pla n bef ore l oc ki n g t he d ata base a n d pri or t o  vie wi n g a n y c o m parati ve a nal ysis res ults . 
Base d o n t he a b o v e c o nsi derati o ns , the L M M is dee me d a p plica ble, a n d it will be use d f or t h e 
pri mar y a nal ysis, w hile A N C O V A will be use d as se nsiti vit y a nal ysis , i n a d diti o n t o se nsiti vit y 
a nal yses assess i n g r o b ust ness o n missi n g ness mec ha nis m a n d L M M.  
C CI
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L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 2 6  of 7 6  
 
 
8. 4  T y p e I E r r o r C o n si d e r ati o n s  
T he o verall t y pe I err or rate of t he cli nical trial will be  =  0. 0 2 5 o ne -si de d. Str o n g c o ntr ol of t he 
cli nical trial -wise t y pe I err or le vel will be ac hie ve d b y a -pri ori or d eri n g of h y p ot heses:  
1.  T he pri mar y e n d p oi nt ( mea n c ha n g e i n F E V 1 fr o m baseli ne t o Wee k 4 8) will be teste d first.  
2.  If, a n d o nl y if, t he n ull h y p ot hesis ass ociate d wit h t he pri mar y e n d p oi nt ca n be rejecte d, a 
test 
 
will be perf or me d.  
3.  If, a n d o nl y if, t he n ull h y p ot hesis 
 
 ca n be rej ecte d, a test 
 
 will be perf or me d. 
All tests will be perf or me d usi n g a l ocal t y pe I err or le vel of  =  0. 0 2 5 ( o ne-si de d). If testi n g st o ps 
d ue t o fail ure t o reje ct a n ull h y p ot hesis o n a partic ular le vel of t he hierarc h y, all l o wer -le vel tests 
will still be perf or me d b ut will be c o nsi dere d des cri pti ve.  
T he bli n de d I A perf or me d t o re -assess t he S D a n d t o m o nit or t he missi n g data d oes n ot ha ve a n y 
i m pact o n t he o verall t y p e I err or rate. 
8. 5  D at a M o nit o ri n g C o m mitt e e a n d C o nfi d e nti alit y of R e s ult s  
A n i n de pe n de nt  Data M o nit ori n g C o m mittee ( D M C) will be esta blis he d t o m o nit or t he safet y of 
t he I M P t hr o u g h o ut t he c o n d uct of B O S T O N -1 a n d B O S T O N -2 st u dies. T he D M C will m o nit or 
safet y b y e val uati n g t he s afet y a nal ysis ge nerate d b y t he u n bli n de d i n de pe n de nt statisticia n  d uri n g 
t he c o urse of t he cli nical trial. Details of t he safet y a nal yses will be i ncl u de d i n t he D M C’s C harter 
(fr o m 
). T h e D M C will e val uate t he treat me nt gr o u ps f or p ossi ble tre n ds 
i n A E s, deter mi ne w het her t he basic cli nical trial ass u m pti o ns re mai n vali d, e val uate w het her t he 
o verall i nte grit y, s cie ntific merit a n d c o n d u ct of t he cli nical trials re mai n acce pta ble, a n d ma ke 
rec o m me n dati o ns t o t he S p o ns or.  
T he D M C will pe rf or m a c o m paris o n bet w ee n t he rate of o bser ve d C O VI D-1 9 ca ses, rate of 
patie nts ’ wit h dra wal, a n d rate of missi n g data a m o n g trial partici pa nts i n b ot h treat me nt ar ms.  
Me m bers of t he D M C will be u n bli n de d t o t he tr eat me nt gr o u p la bel, i. e., t he D M C will k n o w 
w hic h gr o u p is L -Cs A + Sta n dar d of Care a n d w hic h gr o u p is Sta n dar d of Care al o ne. T h e D M C 
will e val uate all safet y a n d ac ute t olera bilit y para meters  as detaile d i n t he D M C c harter.  
Safet y a n d ac ute t olera bilit y para meters i ncl u de A E s, ac ute t olera bilit y of L-Cs A, i nfecti o ns, 
mali g na ncies, cli nical la b orat or y d ata ( w hite bl o o d cell c o u nt wit h differe ntial, re d bl o o d cell 
c o u nt, platelet c o u nt, al kali ne p h os p hatase, ala ni n e a mi n otra nsferase, as partate  a mi n otra nsferase, 
ga m ma gl uta m yl tra nsferase, bl o o d urea nitr o ge n, ser u m bilir u bi n, ser u m creati ni ne), vital si g n s, 
p h ysical e xa mi nati o ns a n d F E V 1. T he statistics pr o vi de d will be merel y descri pti ve.  
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Criteria for membership, responsibilities, meeting frequency, and identification of data listings, 
summaries and analyses to be provided to the DMC are detailed in the DMC charter. 
Statistical analyses to be provided to DMC are planned in a specific DMC SAP. 
8.6 Adjudication Committee 
The AC – consisting of three independent physicians, with documented expertise in the clinical 
management of lung transplantation and diagnosis and treatment of BOS - will maintain the role 
of reviewing the BOS progression data in blind condition once each participating patient completes 
the study period, with the aim to ensure consistent and complete recording of data. If necessary, 
the AC may query the sites to ask for clarifications. In case there are discrepancies between the 
assessment of the AC and that of the Investigator regarding BOS progression events, the CRO will 
notify the Investigator. In all cases, the final decision as to whether or not specific event qualifies 
as BOS progression stands with the Investigator.  
9 
DEFINITIONS 
9.1 Protocol Deviations 
Major protocol deviations (PDs) are defined as those deviations from the clinical trial protocol for 
which there could be a significant influence on the assessment of the treatment efficacy. The 
impact of major protocol deviations on the efficacy results will be investigated by assessing the 
robustness of the clinical trial results and conclusions to the choice of analysis population, both 
including and excluding data potentially affected by major protocol deviations. Please note that 
other study documents may refer to the major PDs as important PDs, and minor PDs as non-
important PDs. The SAP and TFL shells will be using the terminology major and minor PDs. For 
the study, a PD List has been pre-specified. The PD list contains the list of all study PDs, the 
categorization, the criticality [Major (important) or Minor (non-important)], the potential impact 
on analysis populations. All the processes around the collection and the review of PDs are 
described in detail in the study PD Management Plan. 
9.2 Analysis Data Sets 
The term analysis data set is used to define the set of patients to be included in a class of analyses. 
The analysis data set is described in terms of the specific criteria for patient inclusion. 
Eligibility for the analysis data sets will be determined in a blinded Data Review Meeting (DRM) 
held after closing, but before locking the database and then producing the final analysis.  The 
blinded DRM will be used to determine if patients should be excluded from the Per-Protocol Set 
(PPS) in cases of significant and major protocol deviations that would interfere with the assessment 


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 2 8  of 7 6  
 
 
of treat me nt efficac y. T h e pr ot oc ol de viati o ns a n d  t heir i m pact are r o uti nel y c ollecte d a n d assesse d 
d uri n g t he c o n d uct  of t he st u d y . 
9. 2. 1  S af et y A n al y si s S et ( S A F ) 
T he S A F  is defi n e d as all ra n d o mize d patie nts recei vi n g S o C a n d/ or at least o ne d ose of L-Cs A, 
i n de pe n de ntl y of t he tr eat me nt all ocati o n at ra n d o mizati o n. A s per IE criteria , ra n d o mize d patie nts 
s h o ul d be alrea d y i n S o C  at e nr oll me nt , t heref ore it is e x pecte d t hat all ra n d o mize d patie nts will 
e nter t he S A F p o p ulati o n .  
I n d e pe n de ntl y of t he treat me nt all ocati o n at ra n d o mizati o n, patie nts will be a nal yze d acc or di n g t o 
t he treat me nt t he y act uall y recei v e d: 
•  L -Cs A pl us S o C gr o u p : f or all ra n d o mize d patie nts recei vi n g at least o n e d ose o n I M P  (L -
Cs A ); 
•  S o C gr o u p : f or all ra n d o mize d patie nts n ot recei vi n g a n y d ose o n I M P ( L-Cs A)  b ut treat e d 
wit h S o C .  
All data c ollecte d aft er baseli ne t o t h e e n d of cli nical trial p artici pati o n will be i ncl u de d i n t he 
safet y s u m maries.  
All safet y a n d t olera bilit y data will be s u m marize d a n d a nal yze d usi n g t he S A F . 
9. 2. 2  F ull A n al y si s S et ( F A S)  
T he F A S is defi ne d  as all ra n d o mize d patie nts . Patie nts will be a nal yze d acc or di n g t o t he treat me nt 
gr o u p t o w hic h t he y were ra n d o mize d.  A ll pri mar y, 
 e n d p oi nts will be 
perf or me d usi n g t he F A S , u nless ot her wise s pecifie d. 
9. 2. 3  I nt e ri m A n al ysi s F ull A n al y si s S et (I A -F A S)  
T he I A -F A S is a s u bset of t he F A S p o p ulati o n , use d f or r u n ni n g t he bli n de d I A  f oresee n b y t he 
st u d y pr ot oc ol; it i ncl u de d patie nts w h o ha d  a bas eli ne a n d had  c o m plete d Wee k 2 4, 
or 
disc o nti n ue d at t he c ut off date, 3 0-Se p -2 0 2 1 .  
N o si g n ifica nt, maj or pr ot oc ol de viati o ns were  i d e ntifie d f or t he I A-F A S.  
Patie nts were  a n al yze d acc or di n g t o t he treat me nt gr o u p t o w hic h t he y were ra n d o mize d.  
T he I A -F A S was o nl y us e d f or t he I A c o m plete d o n Dece m ber 2 0 2 1 , a n d no f urt her a n al yses or 
s u m maries were or will be pr o d uce d f or t he I A -F A S.  
9. 2. 4  P e r P r ot o c ol S et ( P P S)  
T he P P S is defi ne d as all patie nts i ncl u de d i n t he F A S   
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• who complete randomized treatment as scheduled or who are withdrawn prematurely due 
to lack of efficacy or lack of tolerability of the clinical trial treatment, and  
• for whom no major protocol deviations interfering with the assessment of treatment 
efficacy are observed. 
For selected efficacy endpoints, including the primary endpoint, the PPS may be used as a 
supplementary analysis to assess the impact of drop-outs and major protocol deviations on the 
results. 
Lack of efficacy is defined by the withdrawn reason “Lack of efficacy” as collected in the End Of 
Study CRF form. Lack of tolerability is defined by the withdrawn reason “Adverse Event 
(Including SAE/Death)” as collected in the End Of Study CRF form. 
9.3 Study Day and Time from Randomization 
Study Day 1 is defined to be the day of the randomization visit (visit 1, week 0). Time from 
randomization (in days) for subsequent visits is defined to be visit date – date of randomization 
visit +1. 
9.4 Visit Windows 
Following randomization, the visits are scheduled every 4-8 weeks, but the actual times of the 
visits may deviate from the scheduled times. With spirometry data, consideration needs to be taken 
to remove the rejected spirometry assessments for analysis before applying the visit windowing.  
To allow for any presentation that summarizes values by visit, visit windows will be defined 
according to the table below. Measurements (both scheduled and unscheduled) will be allocated 
to visits (and analyzed) as reported in Table 2. 
Table 2: Visit windows. 
Nominal Visit 
V1 
V2 
V3 
V4 
V5 
V6 
V7 
V8 
V9/EoT 
V10/EoS 
Nominal Week 
W0 
W4 
W8 
W12 
W16 
W24 
W32 
W40 
W48 
W52 
Nominal Day 
1 
29 
57 
85 
113 
169 
225 
281 
337 
365 
Time (days) from 
Randomization*** 
0 
1-42 
43-70 
71-98 
99-140 
141-196 
197-252 
253-308 
*309-364 
**309-385 
*365-385 
*Patients who do not consent or participate in BT – L-CsA – 303 – FU (BOSTON-3). 
**Patients who consented and participated in BT – L-CsA – 303 – FU (BOSTON-3) and will not have a V10 / EoS 
*** Visit windows are based on [visit date – date of randomization visit] formula for time (days) from randomization.  
 
Data collected after 385 days or 364 days (as applicable, as per the table above) will not be used 
for analyses but will be included in the listings. If there are two or more measurements assigned 
to a nominal visit, only the one closest to the scheduled time of the visit will be used in the analysis, 
unless an additional measurement will be the last measurement during a patient’s trial participation 


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 3 0  of 7 6  
 
 
(e. g., i n case of a n u nsc h e d ule d visit bef ore pre mat ure wit h dr a wal), w hic h will al wa ys be i n cl u de d 
i nt o t he a nal ysis.  
I n t he case a sc he d ul e d visit is perf or me d i n t he sa me date of a n u nsc he d ule d visit, t he sc he d ule d 
visit assess me nts will be use d; i n t he s p ecific case of s pir o metries, if t he s pir o metr y data is 
acce pte d i n t he sc h e d ule d visit, t he sc he d ule d visit data will be use d, ot her wise (if t h e s pir o metr y 
i n t he sc he d ule d visit is rejecte d) if t he s pir o metr y data is acce pte d i n t he u nsc he d ule d visit, t h e 
u nsc he d ule d visit data will be use d.  
Fi nall y, if a n o mi nal visit has m ore t ha n o n e acce pte d s pir o metr y d ata assi g ne d, a n d s o m e of t he m 
are perf or me d after I M P i n halati o n, t he n o nl y t he s pir o metries d o ne bef ore i n hali n g t he I M P will 
be use d f or t he visit wi n d o w ma p pi n g r ules descri be d a b o ve. I nste a d, if all t he acce pte d 
s pir o metries of t he n o mi nal visit are d o ne after i n hali n g t he I M P, t h e n all of t he m will be 
c o nsi dere d f or t he a b o ve ma p pi n g r ules.  S pir o metries  c ollecte d at 1 h a n d 4 h p ost d ose will be use d 
o nl y f or safet y e val uati o ns  a n d will o nl y be prese nte d i n data listi n gs . 
Wi n d o wi n g will be a p plie d t o t he data pri or t o a n y missi n g data i m p utati o n.  
9. 5  H a n dli n g of Mi s si n g D at a  
9. 5. 1  H a n dli n g of Mi s si n g Effi c a c y D at a  
If a patie nt pre mat urel y disc o nti n ues cli nical trial partici pati o n f or a n y reas o n a p art d eat h, re-
tra ns pla ntati o n or wit h dr a wal of c o ns e nt, he/s he will be e nc o ura g e d t o c o m plete t he f oll o w-u p . All 
o bser ve d a vaila bl e data will be use d f or t he pri mar y 
 a nal ys es. T he ass u m pti o n of 
t he L M M (secti o n 1 4. 1 ) f or missi n g data will be M A R . Si nce t he defi niti o n of p r o gressi o n of B O S 
i ncl u des all rele va nt i nterc urre nt e v e nts (I Es) as fail ures, dr o p -o uts  d ue t o ot her reas o ns  will be 
treate d as n o n-i nf or mati v e ce ns ori n g (secti o n 1 4. 4. 2 ). 
Se veral  se nsiti vit y a nal yses ha ve bee n pla n n e d t o assess r o b ust ness of pri mar y res ults i n case of 
de viati o n fr o m M A R  me c ha nis m  (secti o ns 1 4. 2 ). 
9. 5. 2  H a n dli n g of Mi s si n g S af et y D at a  
I n g e neral, missi n g cli nical la b orat or y d ata, vital si g ns, a n d p h ysical e x a mi nati o n data will n ot be 
i m p ute d. U n k n o w n or partial me dicati o n a n d A E date i m p utati o ns are gi v e n i n t he ne xt s ecti o n 
a n d t o b e use d o nl y  f or t he assess me nt of pri or/c o nc o mita nt stat us f or me di cati o ns a n d treat me nt -
e mer ge nt stat us f or A Es.  
9. 5. 3  H a n dli n g of P a rti al a n d Mi s si n g D at e s  
9. 5. 3. 1  
P a rti al a n d Mi s si n g D at e s of Bi rt h  
W here t h e Date of Birt h is missi n g t he f oll o wi n g c o n ve nti o n will be use d:  
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Protocol Number: 
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Sponsor: 
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• Where the day is missing and month and year are available, the day will be completed as 
the 15th. For example, Date of Birth specified as --JAN1980 will be completed as 
15JAN1980. 
• If the day and month are missing and the year is available, the day and month will be 
completed as 02JUL (the 183rd day of the year). For example, Date of Birth specified as -
----1980 will be completed as 02JUL1980. 
9.5.3.2 
Missing or Partial AE and Prior / Concomitant 
Medication Start and End Dates 
Missing and/or incomplete dates for medications and AEs are imputed in a manner resulting in the 
earliest onset or the longest duration during the Treatment Period, whilst ensuring that the start 
date does not occur after the stop date.  
For the derivation of the duration and cumulative of concomitant medication, if the medication is 
“Ongoing” then the medication end date will be imputed with the last visit date. 
The stop date will not be imputed if the AE is “Ongoing”. Technically, this will be done as follows: 
• For a missing/incomplete start date/time, the earliest date/time of the following will be 
imputed: 
o The later date / time of: the earliest possible start date/time and the date/time of first 
dose of treatment (date/time of randomization). 
o The latest possible start date/time. 
• For a missing/incomplete stop date/time, the later date/time of the following will be 
imputed: 
o The earlier date/time of: the latest possible stop date/time and the date/time of last 
dose of treatment (date/time of study completion or early termination). 
o The earliest possible stop date/time. 
• Here, the earliest possible date/time is defined as: 
o The date/time itself if available. 
o The date/time of the first day of the month at 00:00hrs, if month and year are 
available but the day/time is missing. 
o The date/time of the first day of the year at 00:00hrs, if year is available but 
day/time and month are missing. 
o 00:00hrs on the day of informed consent, if the date/time is completely missing. 
• The latest possible date/time is defined as: 
o The date / time itself if available. 
o The date / time of the last day of the month at 23:59hrs, if month and year are 
available but the day / time is missing.  


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
 
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o The date / time of the last day of the year at 23:59hrs, if year is available but day / 
time and month are missing. 
o 23:59hrs on the date of last known date on the study for the patient plus one year, 
if the date / time is completely missing. 
10 
DISPOSITION  
The number of patients screened, failed screening (patients who did not meet all eligibility criteria 
and was not randomized), enrolled (patients with informed consent and all eligibility criteria met 
or randomized), treated but not randomized, randomized (treated, and not treated with clinical trial 
treatment), completing clinical trial treatment (and reasons for not completing), and completing 
the clinical trial (and reason for not completing) will be presented in frequency tables by treatment 
group.  
The number of patients in each analysis population (SAF, FAS, and PPS) will be summarized by 
treatment group. A by-patient listing of disposition will be provided. 
All major protocol deviations will be presented as a frequency table by treatment group and in a 
by-patient listing for all randomized patients, which will include the category of the deviation, the 
deviation text, and whether the patient was excluded from PPS. 
In addition, the counts on COVID-19 related major PDs will be provided, together with a 
by-patient listing for all COVID-19 related PDs. 
In addition, a listing of the patients affected by Coronavirus Disease of 2019 (COVID-19) and 
their COVID-19 AE details will be provided for the FAS. 
A table for the summary of stratification factors by treatment group for FAS and a separate listing 
of patients with mis-stratifications will be displayed.  
11 
DEMOGRAPHICS AND BASELINE CHARACTERISTICS, AND DISEASE 
AND MEDICAL HISTORY 
11.1 Demographic and Baseline Characteristics 
All demographic, baseline characteristics, including azithromycin at randomization, and antibody-
response data will be summarized by treatment group for SAF, FAS and PPS. For summary 
purposes, the most recent, non-missing result obtained on or prior to the baseline visit will be used.  
Azithromycin at randomization will be derived by identifying azithromycin among medications 
collected in the study (generic name: azithromycin) using any of the following rules: 
• azithromycin is ongoing at the date of randomization (regardless of start date); 


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 3 3  of 7 6  
 
 
•  azit hr o m yci n  start date is o n  t he ra n d o mizati o n dat e (re g ar dless of e n d date). 
B y -patie nt listi n gs will be pr o vi de d f or all de m o gr a p hic a n d bas eli ne c haracteristics.  
1 1. 2  Di s e a s e a n d M e di c al Hi st o r y  
Details of Hist or y of B O S dia g n osis e C R F pa ge [F V C (a bs ol ute), F V C - % of pers o nal best p ost -
tra ns pla nt, F E V 1 (a bs ol ute), F E V 1 - % of pers o nal best p ost -tra ns pla nt, 
(a bs ol ute), 
 - % of pers o nal best p ost -tra ns pla nt a n d F E V 1/ F V C (rati o)], d etails of Hist or ical S pir o metr y 
e C R F pa ge [F V C (a bs ol ute), F E V 1 (a bs ol ute), 
-  (a bs ol ute) a n d F E V 1/ F V C (rati o)] as well 
as details relate d t o eac h patie nt’s l u n g tra ns pla nt as rec or de d i n t he L u n g Tra ns pla ntati o n Hist or y 
e C R F pa ge [ty p e of u n d erl yi n g in dicati o n f or lu n g tra ns pla nt, ti me bet wee n lu n g tra ns pla ntati o n 
a n d o nset of B O S,  d o n or ge n der,  c yt o me gal o vir us ( C M V ) stat us d o n or, C M V stat us reci pie nt, 
E pstei n Barr Vir us ( E B V )-stat us d o n or, E B V-stat us reci pie nt, recei ve in d u cti o n t hera p y, recei ve 
anti viral/a ntif u n gal/a nti bacterial t hera p y, col d isc he mia d urati o n d o u ble l u n g ] will be s u m marize d 
b y treat me nt gr o u p f or S A F, F A S a n d P P S.  
Disease hist or y , i ncl u di n g t he details fr o m t he Ris k Fact ors e C R F will be li ste d b y F A S .  
Ti me  ( da ys) bet w ee n l u n g tra ns pla ntati o n a n d o nset of B O S is defi ne d as t he d urati o n bet wee n 
date of l u n g tra ns pla ntati o n a n d o nset of i nitial B O S +  1.  
All ot her si g nifica nt 
me dical c o n diti o ns (i ncl u di n g 
gastr o -es o p ha geal refl u x disease) a n d 
pr oce d ures (i n cl u di n g past s ur geries) occ urri n g b ef ore t he i nf or me d c o nse nt f or m is si g ne d will be 
rec or de d as me dical hist or y. 
Me dical hist or y will be c o de d usi n g t he Me dical Dicti o nar y f or R e g ulat or y Acti vities ( Me d D R A) 
[Versi o n 2 3 . 1] a n d will be prese nte d b y I nter nati o nall y A gree d or der S yste m Or ga n Cl ass ( S O C) 
a n d Preferre d Ter m ( P T ) a n d t otal. T he S O Cs a n d P Ts are t o be s orte d b y S O C a n d desce n di n g 
P Ts.  
M e dical hist or y will be s u m marize d b y treat me nt gr o u p a n d o verall f or t he S A F, F A S a n d P P S as 
f oll o ws:  
•  T he n u m ber a n d p erce nt a ge of p atie nt s wit h at least o ne me dical hist or y rec or d will be 
prese nte d.  
•  T he n u m ber a n d perce nt a ge of patie nt s wit h at least o ne me dical hist or y rec or d wit hi n eac h 
pri mar y S O C a n d P T will be prese nt e d. T he s u m mar y will be s ort e d usi n g t he 
i nter nati o nall y a gree d or der f or S O C a n d usi n g desce n di n g or der of o verall n u merical 
c o u nts f or P T. W here ter ms tie, t hese will be s orte d al p ha b eticall y.  
Me dical hist or y rec or ds will be liste d b y -patie nt  a n d wit hi n -patie nt  b y me dical hist or y start date 
f or t he F A S. 
C CI
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L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
 
Final Version 5.0 
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11.3 Baseline Lung Allograft Dysfunction 
Baseline Lung Allograft Dysfunction (BLAD) at baseline (Yes, No) will be reported in the 
demographic table. BLAD patients are defined as patients with baseline FEV1/predicted 
FEV1*100 <80% [10]. The following formula for the calculation of predicted FEV1 will be used: 
Predicted FEV1 = b0 + b1 * age + b2 * age2 + b3 * height2 
where the coefficients of the regression are reported in Table 3. 
Table 3: Coefficients for FEV1 Prediction  
Sex 
Ethnicity 
Intercept 
(b0) 
Age 
(b1) 
Age2 
(b2) 
Ht (cm)2 
(b3) 
Male 
Caucasian < 20 yr of age 
−0.7453 
−0.04106 
  0.004477 
0.00014098 
Male 
Caucasian ⩾ 20 yr of age 
  0.5536 
−0.01303 
−0.000172 
0.00014098 
Male 
African-American < 20 yr of age 
−0.7048 
−0.05711 
  0.004316 
0.00013194 
Male 
African-American ⩾ 20 yr of age 
  0.3411 
−0.02309 
0  
0.00013194 
Male 
Mexican-American < 20 yr of age 
−0.8218 
−0.04248 
  0.004291 
0.00015104 
Male 
Mexican-American ⩾ 20 yr of age 
  0.6306 
−0.02928 
 0 
0.00015104 
Female 
Caucasian < 18 yr of age 
−0.8710 
  0.06537 
 0 
0.00011496 
Female 
Caucasian ⩾ 18 yr of age 
  0.4333 
−0.00361 
−0.000194 
0.00011496 
Female 
African-American < 18 yr of age 
−0.9630 
  0.05799 
 0 
0.00010846 
Female 
African-American ⩾ 18 yr of age 
  0.3433 
−0.01283 
−0.000097 
0.00010846 
Female 
Mexican-American < 18 yr of age 
−0.9641 
  0.06490 
0  
0.00012154 
Female 
Mexican-American ⩾ 18 yr of age 
  0.4529 
−0.01178 
−0.000113 
0.00012154 
Due to eCRF study design, ethnicity has not been recorded as required for Table 3, and as a result, 
the race field as recorded in the eCRF will be used for mapping as detailed below in Table 4.  
Table 4: eCRF Race Classification  
eCRF Term 
Remapping 
White 
Caucasian 
Black or African American 
African-American 
Asian 
 
0.88% reduction will be used versus the Caucasian  
Other 
check "other, specify" to see additional race info.  
- 
If patients are defined as “white” or “black/African”, please 
use the corresponding classification. 
- 
If patients are defined as "latinos" , then use “Mexican-
American”.  
- 
If patient is defined as “Arabian” then treat as the Asian 
category with the 0.88% reduction used versus the Caucasian. 
Otherwise consider them as "unknown" 
 


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For Asian or Other field with Arabian ethnicity, the calculation will be performed using the 
Caucasian coefficients of Table 3 (considering the corresponding sex, age, and height values) and 
then applying a correction factor of 0.88 [12]. For example, in case of an Asian male patient older 
than 20 years, the calculation will be:  
Predicted FEV1 = 0.88 * (0.5536 − 0.01303 * age − 0.000172 * age2 + 0.00014098 * height2). 
In case of other races (American Indian or Alaskan, Native, Native Hawaiian or Other, Pacific 
Islander), unknown, or unspecified ethnicities (including “multiracial”, “multicultural”, “mixed”, 
etc.), parameters calculated as average of the Caucasian, African-American, and Mexican-
American parameters will be used, according to Table 4:  
Table 4: Coefficients for FEV1 Prediction for other/unspecified ethnicities. 
Sex 
Age class 
Intercept 
(b0) 
Age 
(b1) 
Age2 
(b2) 
Ht (cm)2 
(b3) 
Male 
< 20 yr of age 
-0,7573 
-0,04688 
0,004361333 
0,000141 
Male 
⩾ 20 yr of age 
0,508433 
-0,0218 
-0,0000573 
0,000141 
Female 
< 18 yr of age 
-0,9327 
0,062753 
0 
0,000115 
Female 
⩾ 18 yr of age 
0,409833 
-0,00941 
-0,000134667 
0,000115 
12 
Immunosuppressants 
Immunosuppressants are collected in the Concomitant Medications CRF form. 
As per CRF completion guidelines, immunosuppressants are to be collected using the same 
measurement unit i.e., mg. In those cases where it is not done, considerations will be taken on 
ongoing basis (at DRM at the latest) to convert units for each immunosuppressive agent to allow 
cumulative dose to be calculated. Immunosuppressant medications will be coded using the World 
Health Organization (WHO-DD) classification system and grouped by drug class and PT. 
In order to identify immunosuppressants among concomitant medications, any of the following 
two rules will be applied.   
1. Only the following routes are to be considered: oral, intramuscular, intravenous, and 
subcutaneous; 
the following codes are to be considered: 
o L04A Immunosuppressants:  
1. 
L04AA Selective immunosuppressants,   
2. 
L04AB Tumor necrosis factor alpha (TNF-α) inhibitors,  
3. 
L04AC Interleukin inhibitors,  
4. 
L04AD Calcineurin inhibitors, 
5. 
L04AX Other immunosuppressants;  
o H02AB Glucocorticoids (all); 


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 3 6  of 7 6  
 
 
2.  L 0 4 A D 0 2  T acr oli m us , a n d ro ute =  s u bli n g ual. 
 
 
  
 
 
  
  
 
  
  
  
 
 
 
1 2. 1  B a si c I m m u n o s u p p r e s s a nt s  
As per pr ot oc ol, r e g ar dl ess of treat me nt assi g n m e nt, all cli nical trial p artici pa nts m ust be o n a 
mai nte na nce re gi me n of i m m u n os u p pressi ve a ge nts i ncl u di n g tacr oli m us, a sec o n d a g e nt s uc h as 
b ut n ot li mite d t o m yc o p he n olate m otfetil ( M M F) or azat hi o pri ne, a n d a s yste mic c ortic oster oi d 
s uc h as pre d nis o ne as t hir d a ge nt. 
At eac h visit, t he a vera ge 
m ai nte na nce d oses of 
i m m u n os u p pressi ve a ge nts will be rec or de d b y t h e I n vesti gat or o n t he C o nc o mita nt Me dicati o n  
e C R F.  
B asic i m m u n os u p pressa nts refer t o mai nte na nce re gi me n of i m m u n os u p pressi ve a ge nts  a n d 
i ncl u de t he f oll o wi n g: 
•  Calci ne uri n i n hi bit ors ( T acr oli m us, C ycl os p ori ne A) ;     
•  A nti meta b olicte  ( A nti meta b olite) a ge nts ( M M F, A zat hi o pri ne);  
•  m T O R i n hi bit or ( E ver oli m us, S ir oli m us);  
•  Selecti ve c osti m ulati o n bl oc ker ( Belat ace pt) ;  
•  C ortic oster oi ds . 
T he t otal basic i m m u n os u p pressi o n a d mi nistere d fr o m t he da y of ra n d o mizati o n will be e val uate d.  
Basic  im m u n os u p pressi ve s will be c o de d b y  A nat o mical T hera p e utic C o de ( A T C) c o des , a n d will 
be s u m marize d b y tr eat m e nt gr o u p f or S A F, F A S a n d P P S.  
A p -val ue will be o btai ne d fr o m t he Fis her’s E xact test f or t he c o m paris o n of patie nts wit h a n y 
basic 
i m m u n os u p pressa nts fr o m 
L-Cs A 
pl us 
S o C 
vers us 
patie nts 
wit h 
a n y 
basic 
i m m u n os u p pressa nts fr o m S o C al o ne, f or eac h cl ass of basic i m m u n os u p pressa nts liste d a b o ve.   
Descri pti ve statistics o n c u m ulati ve d oses f or b asic i m m u n os u p pressa nts will be pr o vi de d : 
•  f or t he w h ole tr eat me nt p eri o d (fr o m d a y of ra n d o mizati o n t o e n d of st u d y) ,  
•  f or eac h peri o d bet wee n st u d y visits ( V 1 t o V 2, V 2  t o V 3, etc.),  
•  c u m ulati vel y f or eac h peri o d bet wee n st u d y visits ( V 1 t o V 2, V 1 t o V 3, V 1 t o V 4, etc.), 
w here peri o ds bet wee n st u d y visits V i t o Vi + 1 ( wit h i = 2, 3, 4, et c) is d efi ne d as t he i nter val starti n g 
fr o m t he first d a y p ost visit Vi a n d e n di n g t he l ast da y of visit V i + 1 (i ncl u de d). F or V 1 t o V 2 t h e 
date of V 1 m ust be c o nsi dere d  t o o. 
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Sponsor: 
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Final Version 5.0 
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Descriptive statistics will be calculated for each class of basic immunosuppressants listed above 
and overall. If a patient took more than one basic immunosuppressant related to the same class, 
then the total dose will be taken into consideration in the calculation. 
P-values will be obtained from the Fisher’s Exact test for the comparison of patients with any basic 
immunosuppressants, including each of basic immunosuppressant listed above from L-CsA plus 
SoC versus patients with any basic immunosuppressants from SoC alone at each time interval (V1 
to V2, V1 to V3, …. ,V1 to V9). 
Exposure to immunosuppressant medication details will be summarized similarly for each 
category of basic immunosuppressant, and overall for all.  
This includes the calculation of the duration of intake (date of last basic immunosuppressant intake 
– date of first basic immunosuppressant intake + 1). The duration will be calculated by summing 
the duration of the associated treatments. The overlapping days will be counted only once.  
The ratio between the cumulative dose and intake duration will be used to produce the dose per 
day. The overall dose per day per patient will then be displayed for each treatment group for each 
time interval along with the 95% confidence interval.  
By-patient listings will be provided for all basic immunosuppressants for FAS. 
12.2 Other Immunosuppressants 
Other immunosuppressants refer to all the immunosuppressive therapies that are not classified as 
maintenance regimen as described in section 12.1 (but meet the conditions reported in section 12). 
Other immunosuppressive therapies will be coded by Anatomical Therapeutic Code (ATC) codes, 
and will be summarized by treatment group for SAF, FAS and PPS. 
All other immunosuppressants administered from the day of randomization will be evaluated. The 
number (%) of patients taking any other immunosuppressants will be provided overall and for each 
ATC code. 
The same summary statistics for cumulative dose and for exposure as described in section 12.1 
will be provided. 
13 
Prior and concomitant medications 
Prior medications are those medications taken prior to randomization with a stop date and time 
prior to the randomization date/time (standard definition of prior/concomitant medications 
considers the first dose of study treatment but, as in this study SOC group won’t have any first 
dose date, randomization date will be considered instead).  
Concomitant medications are those medications with a start date and time on or after the 
randomization date/time, or those with a start date and time before the randomization date/time 


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 3 8  of 7 6  
 
 
a n d eit her a st o p date a n d ti me o n or aft er t he st u d y ra n d o mizati o n or are o n g oi n g at t he e n d of t he 
st u d y. 
Pri or a n d c o n c o mita nt me dicati o ns  will be s u m marize d b y A T C c o d es a n d liste d f or F A S . 
Pri or/ c o nc o mita nt me dica ti o ns will be c o de d usi n g t he 
W H O-D D classificati o n s yste m a n d 
gr o u pe d b y dr u g cl ass a n d P T . 
1 4  
E F FI C A C Y  
F or t he efficac y a n al ysis, t he a de q uac y of t he m o del ass u m pti o ns will be c hec ke d, a n d if it is f o u n d 
t hat t hese are i na de q uat e t he n alter nati ve a p pr oac h es ma y  be perf or me d.  
F or all varia bles ass u me d t o be n or mall y distri b ute d, t he c o n diti o nal st u de ntize d resi d uals fr o m 
t his m o del will be teste d usi n g t he S ha pir o-Wil k test. If t he ass u m pti o n of n or malit y of t hese 
resi d uals is vi olate d, t he n a l o g-tra nsf or me d m o del will be fitte d. T h e n ee d f or a p ossi ble l o g 
tra nsf or mati o n of t hes e v aria bles will be i n vesti gate d pri or t o u n bli n di n g b y assessi n g t he m o del 
resi d uals wit h o ut a treat me nt ter m. W here dat a are tr a nsf or me d f or a n al ysis, bac k tr a nsf or m ati o n 
will be a p plie d f or t he prese ntati o n of res ults. Prese ntati o n of t he ta bles will be a me n de d as nee de d 
f or t his, wit h t he a d diti on of a n e x pla n at or y f o ot n ote.  
Classificati o n a n d i m p utati o n of missi n g data will be c o m plete d pri or t o a n y tra nsf or mati o n of t he 
data f or a nal ysis.  
As a ge n eral re mar k f or all efficac y e n d p oi nts bas e d o n s pir o metr y data, v al ues c ollecte d at 1 h a n d 
4 h p ost d ose will n ot be use d f or a n y effi cac y a nal yses as t he y are c ollecte d o nl y f or safet y 
e val uati o ns.  
1 4. 1  P RI M A R Y E F FI C A C Y A N A L Y SI S  
1 4. 1. 1  
A n al ysi s P o p ul ati o n a n d E sti m a n d  
T he pri mar y e n d p oi nts will be a nal yze d usi n g  a  “c o m p osite strate g y” (I nter nati o nal C o nfere nce 
o n H ar m o nizati o n (I C H) g ui deli ne E 9 a d de n d u m o n esti ma n ds a n d se nsiti vit y a nal ysis i n cli nical 
trials t o t he g ui deli ne o n statistical pri nci ples f or cli nical trials). T he esti ma n d is defi ne d b y t h e 
f oll o wi n g: 
•  P o p ulati o n: a d ult reci pie nts of a d o u ble p ul m o nar y all o graft wit h cli nicall y defi ne d B O S, 
matc hi n g t he i ncl usi o n a n d e xcl usi o n pr ot oc ol criteria.  
•  Varia ble: F E V 1 d ata at Wee k 4 8 ( visit 9) c ollecte d fr o m t he o nsite  
 s pir o meter 
( data c ollecte d wit h t he 
 h o me s pir o meter will be use d f or s u p ple me ntar y a n al yses). 
O nl y acce pte d o v er -rea d er best F E V 1 data f or t he sessi o n fr o m  
 will be use d 
f or a nal ysis; data will n ot be re -d eri ve d.  
C CI
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L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
 
Final Version 5.0 
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Intercurrent events: After IEs such as stopping treatment with L-CsA, augmentation of SoC 
therapy, etc., FEV1 measurements will still be collected and used in the analysis. In case of IEs 
preventing the use of FEV1 measurements, i.e. death and re-transplantation, the FEV1 will be 
imputed as treatment failure: FEV1 equal to zero for all visits subsequent the event. 
Rejected spirometries are those that did not meet the American Thoracic Society criteria; 
if rejected, then they would be re-done but there may be cases where they are rejected twice 
and resulting in missing data. Rejected spirometry is not an indicator of a better/worse 
outcome and can be assumed to be MAR. 
• Population-level summary: difference in mean change from baseline in the FEV1 at week 
48 between treatment groups.  
Table 5 summarizes the statistical approaches for handling IEs and missing data. 
 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
 
Final Version 5.0 
Page 40 of 76 
 
 
Table 5: Summary of strategies for Intercurrent Events and Missing data. 
Type of IEs 
Statistical analysis 
Primary analysis 
(section 14.1.3) 
Missing data not at 
random (MNAR) 
(section 14.2.1) 
"While on treatment“ 
strategy (for COVID-19) 
(section 14.3.3.3) 
"While on treatment“ 
strategy 
(section 14.3.5) 
Trimmed Means 
(section 14.3.6) 
Death 
The FEV1 value will be 
imputed equal to zero. 
The FEV1 value will be 
imputed equal to zero. 
Not applicable. 
Not applicable. 
The FEV1 value will be 
imputed equal to zero at 
W48. 
Re-transplantation 
The FEV1 value will be 
imputed equal to zero. 
The FEV1 value will be 
imputed equal to zero. 
Treatment discontinuation 
Study discontinuation for lack of efficacy* 
FEV1 measurements after 
IE will still be collected 
and included in the 
analysis.  
FEV1 measurements after 
IE will still be collected 
and included in the 
analysis.  
FEV1 measurements after 
IE will still be collected 
and included in the 
analysis.  
Data after IE will not be 
considered**. 
FEV1 measurements after 
IE will still be collected 
and included in the 
analysis. Last observation 
will be used for 
determining the ordering of 
patients to be trimmed. 
Initiation of additional 
immunosuppressive 
COVID-19 infection 
Data after IE will not be 
considered. 
FEV1 measurements after 
IE will still be collected 
and included in the 
analysis.  
 
In case of: 
- 
residual missing data, or 
- 
study discontinuation for consent 
withdrawal or lost to follow-up: 
Missing data handled under 
MAR 
Missing data imputed using 
fully conditional 
specification based on data 
from retrieved discontinued 
patients ***. 
Missing data handled under 
MAR 
Missing data handled under 
MAR 
Last observation will be 
used for determining the 
ordering of patients to be 
trimmed. Missing data 
handled under MAR. 
* If a patient discontinues the study for lack of efficacy, he/she will be encouraged to complete the follow-up visits planned in the protocol. All patients who prematurely discontinue the study should 
complete at least the evaluation at EoT prior to discontinuation whenever possible. 
** Two analyses will be performed: first considering only treatment discontinuation as IEs, then considering the initiation of additional immunosuppressive too. 
*** If there are not enough retrieved patients for the convergence of MI-RD regression model, a reference-based MI will be adopted. 
 


 
 
 
 
14.1.2 
Working Hypothesis 
The alternative hypothesis (H1) for this trial is that L-CsA plus SoC is superior to SoC alone in 
preserving FEV1, i.e., under H1 it is expected that patients treated with L-CsA plus SoC will exhibit 
a smaller mean FEV1 decline between baseline and the end of Week 48 than those who receive 
SoC alone. 
14.1.3 
Analysis Model 
The primary efficacy analysis will be carried out using a LMM for repeated measurements, using 
all observed available FEV1 measurements. In case of death or re-transplantation events, FEV1 
will be imputed as zero at each nominal day post event. 
The dependent variables are the absolute change from baseline of FEV1 measurements at visit 2 
(i.e., the first post-baseline visit) through visit 9 (Week 48). For the definition of baseline FEV1 
please refer to section 8.1.1.   
A flexible and robust model will be chosen for the random part of the LMM according to a pre-
specified stepwise procedure (see next section). The fixed part of the LMM is specified as follows: 
the model will contain (except from the intercept) time cubic splines, treatment, the interactions of 
time splines by treatment, baseline FEV1, the interactions of time splines with the baseline FEV1, 
region (North America versus all other countries together), age (< 55 versus  55 years), and use 
of azithromycin at randomization (i.e. Baseline, Visit 1).  
The primary efficacy parameter will be estimated from the model by the adjusted difference 
between treatment groups in mean FEV1 change from baseline after 48 weeks. The p-value for the 
null hypothesis of no difference and a two-sided 95% confidence interval for the difference will 
be provided.  
Superiority of L-CsA will be demonstrated by a statistically significant result (defined as p<0.025, 
one-sided) in favor of the L-CsA plus SoC treatment compared to SoC alone. 
The above comparison between treatment groups at all the other visits (2-8) will also be presented.  
A figure of observed mean change from baseline and standard errors at each visit, by treatment 
group will be presented. A figure with adjusted mean changes from baseline at each visit by 
treatment group derived from the LMM will be provided. 
14.1.4 
Specification of the Model 
For valid inference on the primary efficacy parameter, the evolution of FEV1 in both treatment 
groups should be modeled as a flexible function in time, without unnecessarily strong assumptions.  
Therefore, time will be modeled assuming that the time evolution of FEV1 is a smooth function of 
time. Cubic splines will be used with a large enough number of parameters to minimize the risk of 
misspecification. We will choose one knot at 182 days, i.e., halfway between the first (day 28) and 


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 4 2  of 7 6  
 
 
t he last sc he d ule d meas ure me nt ( 3 37  da ys).  S o , it is ass u me d t hat t he mea n of F E V1 is a t hir d-
de gree p ol y n o mial at eac h of t he t w o i nter vals, s m o ot hl y c o n necte d, e q ual at da y 1 8 2 wit h e q ual 
first a n d sec o n d deri vati ve. T h us, 4 para m eters per gr o u p are us e d t o m o del ti me. I n t otal, as ma n y 
as 1 2 para meters i n t he m o del will i n v ol ve ti me, e ns uri n g r o b ust esti mati o n of t he ti me e v ol uti o n 
of F E V 1.  De n oti n g t he c o variates ass o ciate d wit h t he s pli nes b y S 1=t, S 2=t 2, S3=t 3 a n d S 4= ma x(t -
1 8 2, 0 )3, t he treat me nt gr o u p b y T ( 0 = S o C; 1 = L-Cs A  pl us S o C), t he da y of t he meas ure me nt b y t 
a n d t he baseli ne F E V 1 b y X, t he fi xe d part of t he m o del will c o ntai n t he f oll o wi n g c o variates:  
I nterce pt, S1, …, S4, T, T * S1, …, T * S4, X, X * S1, …, X * S4, ot her c o variates  
T he Ke n w ar d -R o ger a dj ust me nt will be use d f or t he de n o mi nat or de grees of free d o m nee de d f or 
h y p ot hesis tests a n d c o nfi de nce i nter vals.  
T he ot her c o v ariates are:  
o  A ge ( < 5 5 v ers us  5 5 years) ; 
o  Re gi o n ( N ort h A meric a vers us all ot her c o u ntri es t o get her) ; 
o  Use of azit hr o m yci n at ra n d o mizati o n. 
I n t he u nli kel y case of c olli nearit y, c o vari ates will be dr o p pe d i n t he a b o ve or der, starti n g wit h t he 
last. 
T he ra n d o m part of t he L M M will be selected b y c o m pari n g t he A kai k e I nf or mati o n Criteri o n 
(AI C ) of t hree m o dels:  
•  m o del wit h ra n d o m i nterce pt a n d ra n d o m ti me ; 
•  m o del wit h ra n d o m i nterce pt, ra n d o m ti me a n d ra n d o m s q uare d ti me ; 
•  m o del wit h ra n d o m i nterce pt, ra n d o m ti me, ra n d o m s q uare d ti me , a n d ra n d o m c u bic ti me . 
T he m o del wit h t he l o west AI C will be a d o pte d f or t he pri mar y a n al ysis. 
T he c ore e xcer pt of 
 c o de f or t h e pri mar y a nal ysis is re p orte d i n secti o n 1 7. 1 . 
1 4. 1. 5  
 S p e cifi c ati o n of t h e C o v a ri a n c e M o d el  
T he m o del f or t he mea n uses t he act ual ti mes of t he visits as a c o nti n u o us varia ble i nstea d of t he 
sc he d ule d visit ti mes. T heref ore, t he c o vari a nce m o del will als o use t he act ual visit ti mes, usi n g 
ra n d o m effects. F or vali d i nfere nce, t he m o del f or t he c o vari a nce s h o ul d be c orrectl y s pecifie d. 
T h us, t he prefere n ce will be f or m o d els wit h relati vel y ma n y para m eters i n or der t o e ns ure r o b ust 
esti mati o n of t he c o varia nce, t h o u g h t his ma y lea d t o a l oss of efficie n c y.  
T heref ore  a m o del will be s pecifie d wit h f o ur per patie nt ra n d o m effects: i nterce pt , t, t2, t3, wit h a n 
u nstr uct ure d c o v aria n ce matri x. T his c o varia n ce m o del c o ntai ns 1 1 para m eters, e ns uri n g s ufficie nt 
r o b ust ness. I n cas e t he m o del d oes n ot c o n ver ge, or t he c o vari a nce matri x is n ot p ositi ve defi nite, 
we will dr o p ter ms fr o m t he hi g hest or der ra n d o m effect. 
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L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 4 3  of 7 6  
 
 
1 4. 2  S e n siti vit y A n al y s e s f o r t h e P ri m a r y E n d p oi nt  
1 4. 2. 1  
Mi s si n g d at a n ot at r a n d o m ( M N A R)  
T o i n vesti gate t he i m pact of de part ures fr o m M A R ass u m pti o n , a M N A R  a p pr oac h will be 
e val uate d usi n g t he L M M  descri be d f or t he pri m ar y a nal ysis. After re ma p pi n g of t he visits as per 
secti o n 9. 4 , F E V 1 at s pecific visit  will be i m p ute d de pe n di n g o n t he I E e x perie nce d b y t he patie nt.  
I n case of I Es as deat h or re -tra ns pl a ntati o n, F E V 1  will be i m p ute d as zer o at eac h p ost -e v e nt 
n o mi nal da y  as per secti o n 9. 4 . Ot her I Es (see T a ble 5 ) will be a d dresse d per treat me nt p olic y 
strate g y, a n d F E V 1 meas ure me nts c ollecte d after I E will be use d  i n t he a nal ysis. 
Resi d ual m issi n g data ( or missi n g data d ue t o disc o nti n uati o n f or c o ns e nt wit h dra wal or patie nt 
l ost t o f oll o w-u p) will be i m p ute d usi n g f ull y c o n diti o nal s pecificati o n, a t y pe of m ulti ple  
i m p utati o n usi n g c hai ne d e q uati o ns, i m ple me nte d wit h 
 u n der t he F C S o pti o n. 
T he i m p utati o n m o del will i ncl u de  baseli ne F E V 1, a ge (as a c o nti n u o us varia ble), re gi o n, use of 
azit hr o m yci n at ra n d o mi zati o n , a n d i nter me diate F E V 1 u p t o wee k 4 8 as c o variates. T w o h u n dre d 
data sets will be ge nerate d, a n d t he ra n d o m see d n u m ber will be 5 2 0 8 2. I n case of i m p utati o n, t he 
ass ociate d n o mi nal da y of  assess me nt will be c o nsi dere d as p er secti o n 9. 4 . 
O nl y o bser ve d  val ues fr o m retrie ve d  disc o nti n ue d patie nts will be use d t o i nf or m t he MI re gressi o n 
m o del (t his m o del will be defi ne d as MI -R D). Retrie ve d disc o nti n ue d patie nts are d efi ne d as 
patie nts w h o disc o nti n ue st u d y treat me nt a n d d eci de t o re mai n i n t he st u d y b y f oll o wi n g t he 
sc he d ule of assess me nts a n d c o nti n ui n g t o a d h ere t o pr ot oc ol re q uir e me nts. If t here are n ot e n o u g h 
retrie ve d p atie nts f or t he c o n ver ge n ce of MI-R D re gressi o n m o del, a refere nce -bas e d MI will be 
a d o pte d: i m p utati o n of val ues i n t he i n vesti gati o nal ar m will be d o ne usi n g t he n o n -missi n g val ues 
fr o m t he c o ntr ol gr o u p (t his a p pr oac h will be referre d as “ C o p y Refere nce”). T his a p pr oac h d oes 
n ot ass u me be nefits f or t he i n vesti gati o nal ar m i n case of disc o nti n uati o n a n d li mits a p ost -
disc o nti n uati o n cli nical effect t o t hat of S o C. T he fi nal decisi o n o n t he use of t he MI -R D vs C o p y -
Refere n ce will be d o n e at t he ti me of t he a nal ysis a n d re p orte d i n t he C S R.  
Eac h of t he 2 0 0 i m p ute d datasets  will be a n al yze d usi n g t he L M M  (see pri mar y a nal ysis ) i ncl u di n g 
all o bser ve d a n d i m p ute d data. R u bi n’s r ule [2 ] will be use d f or c o m bi ni n g res ults t o dra w 
i nfere n ce.  
T he r o b ust ness of pri mar y res ults will be e val uate d b y mea ns of t he a dj uste d differe n ce b et wee n 
treat me nt gr o u ps i n mea n F E V 1 c ha n ge fr o m bas eli ne after 4 8 wee ks. T he p -val ue f or t he n ull 
h y p ot hesis of  n o differe nce a n d a t w o -si de d 9 5 % c o nfi de n ce i nter val f or t he differe n ce will be 
pr o vi de d. T he s a me c o m paris o n bet wee n treat me nt gr o u ps at all t he ot her visits ( 2 -8) will b e 
prese nte d.  
T he c ore e xcer pt of  
 c o de f or t his se nsiti vit y a nal ysis is re p orted i n secti o n  1 7. 2  
T he 2 0 0 i m p ute d datasets will be use d als o f or se nsiti vit y a nal ysis re p orte d i n secti o n 1 4. 2. 4 . 
C CI
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 4 4  of 7 6  
 
 
1 4. 2. 2  
D elt a -B a s e d C o nt r oll e d I m p ut ati o n ( Ti p pi n g p oi nt)  
A  delta -b ase d c o ntr olle d i m p utati o n a p pr oac h usi n g t he ti p pi n g p oi nt a nal ysis  will be perf or me d  
as a se nsiti vit y a nal ysis of treat me nt s u peri orit y, if s h o w n. Ti p pi n g p oi nt a n al ysis will assess h o w 
de part ures fr o m M A R ass u m pti o n m ust be t o o vert ur n c o ncl usi o ns fr o m t he pri mar y s u p eri orit y 
a nal ysis. Ti p pi n g p oi nt will be base d o n iterati ve a p plicati o n  of MI.  
I n case of d eat h or re-tra ns pla ntati o n e ve nts, F E V 1 will be i m p ute d as zer o at eac h n o mi nal da y 
p ost e ve nt.  
I n t he first iterati o n, t he missi n g F E V1 o utc o mes will be i m p ute d se paratel y f or eac h treat me nt 
gr o u p, usi n g t he f ull y c o n diti o nal s pecificati o n. T h e i m p utati o n m o del will i ncl u de baseli ne F E V 1, 
a ge, re gi o n, use of azit hr o m yci n at ra n d o mizati o n, a n d i nter me diate F E V 1 u p t o wee k 4 8 as 
c o variates. T w o h u n dre d data sets will be ge nerate d, a n d t he ra n d o m see d n u m ber will be 9 9 8 2 3.  
N o n -missi n g val u es fr o m all patie nts will be use d.  
I n s uccessi ve iterati o ns, t o re prese nt de part ures fr o m M A R, val ues Δ 1 a n d Δ 2 will be a d de d a n d 
s u btracte d t o t he i m p ute d val ues f or L-Cs A pl us S o C treat me nt a n d S O C treat me nt gr o u ps 
res pecti vel y. Δ 1 a n d Δ 2 will ra n ge fr o m  0  t o 1 0 0 m L  ( 0. 1 L) b y 1 0 m L  ( 0. 0 1 L).  
F or eac h sce n ari o  (i.e., eac h c o m bi nati o n of Δ 1 a n d Δ 2) , t he 2 0 0 delta -a dj uste d i m p ute d datasets 
will be a n al yze d usi n g t h e pri mar y L M M i ncl u di n g all o bser ve d a n d i m p ute d data. R u bi n’s r ule 
will be use d f or c o m bi ni n g res ults t o dra w i nf ere nce. T h e a dj uste d differe nce b et wee n treat me nt 
gr o u ps i n mea n F E V 1 c ha n ge fr o m b aseli ne after 4 8 wee ks  will be pr o vi de d al o n g wit h its  p -val ue 
f or t he n ull h y p ot hesis of n o differe n ce .  
T hese res ults will s h o w h o w e xtre m e t he de part ures fr o m M A R m ust b e t o o vert ur n t he res ults of 
t he pri mar y a n al ysis. C o ntr olle d i m p utati o n is al wa ys feasi ble, i n de pe n d e nt fr o m t he i nci de nce of 
dr o p o uts . 
T he c ore e xcer pt  of  
 c o de f or t his se nsiti vit y a nal ysis is re p orte d i n secti o n  1 7. 3 . 
1 4. 2. 3  
Mi x e d m o d el r e p e at e d m e a s u r es ( M M R M)  
T o i n vesti gate r o b ust ness a gai nst de viati o ns fr o m t he m o del, a M M R M m o del will be carrie d o ut 
usi n g all o bser ve d a vaila ble F E V 1 meas ure me nts  ( u n der 
M A R ass u m pti o n). T he de pe n de nt 
varia bles are t he a bs ol ute c ha n ge fr o m baseli ne of F E V 1 meas ure me nts at visit 2 (i.e., t he first 
p ost -baseli ne visit) t hr o u g h visit 9 ( Wee k 4 8) . I n case of d eat h or re-tra ns pla ntati o n e ve nts, F E V1 
will be i m p ute d as zer o at eac h n o mi nal da y p ost e ve nt.  
As fi xe d effects, t he m o del will c o ntai n t he f oll o wi n g c o variates (e xce pt fr o m t he i nterce pt): 
cate g oric al (sc he d ule d) visit, treat me nt, t he i nteracti o ns of treat me nt b y cate g orical visit, baseli ne 
F E V 1, t he i nteracti o ns of cate g orical visit wit h t he baseli ne F E V 1, re gi o n ( N ort h A merica vers us 
all ot her c o u ntri es t o get her), a g e ( < 5 5 v ers us  5 5 years), a n d us e of azit hr o m yci n at 
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 4 5  of 7 6  
 
 
ra n d o mizati o n (i.e. Baseli ne, Visit 1). Ra n d o m effects per patie nt f or t his m o del will i ncl u de 
cate g oric al  visit.  
A n u nstr uct ure d c o v aria n ce patter n will be use d t o esti mate t he varia n ce – c o varia nce of t he wit hi n -
patie nt re peate d meas ures. If t he m o del fails t o c o n ver ge, a heter o g e ne o us T oe plitz str uct ure will 
be use d. Para met ers will be esti mate d usi n g R E M L wit h t he Ne wt o n – Ra p hs o n al g orit h m a n d usi n g 
t he Ke n war d– R o ger met h o d f or cal c ulati n g t he de n o mi nat or de grees of free d o m.  
Treat me nt gr o u p c o m paris o ns at eac h visit will be esti mate d b y differe n ces bet wee n least s q uares 
( L S) mea ns fr o m t he visit b y treat me nt i nteracti o n, wit h acc o m pa n yi n g p-v al ues a n d 9 5 % CIs. T h e 
r o b ust ness of pri mar y res ults will be e val uate d b y mea ns of t he differe n ce of L S mea ns at wee k  
4 8.  
T he c ore e xcer pt of  
 c o de f or t h e se nsiti vit y a nal ysis is re p orte d i n secti o n 1 7. 4 . 
1 4. 2. 4  
 M M R M u n d e r M N A R  
Eac h of t he 2 0 0 i m p ute d datasets create d u n der M N A R c o n diti o n as descri be d i n s ecti o n  1 4. 2 . 1, 
will be a n al yze d usi n g t h e M M R M  des cri be d i n pre vi o us secti o n 1 4. 2. 3  i ncl u di n g all o bser ve d a n d 
i m p ute d data. R u bi n’s r ule will be use d f or c o m bi ni n g res ults t o dra w i nfere nce.  
Treat me nt gr o u p c o m paris o ns at eac h visit will be esti mate d b y differe n ces bet wee n  least s q uares 
( L S) mea ns fr o m t he visit b y treat me nt i nteracti o n, wit h acc o m pa n yi n g p-v al ues a n d 9 5 % CIs. T h e 
r o b ust ness of pri mar y res ults will be e val uate d b y mea ns of t he differe n ce of L S mea ns at wee k 
4 8.  
1 4. 2. 5  
A N C O V A  
T he p o p ulati o n -le vel s u m mar y f or t he varia ble will be altere d. A n A N C O V A m o del will be 
perf or me d o n t h e c ha n g es fr o m baseli ne i n F E V 1 t o Wee k 4 8, usi n g t he sa me stratificati o n fact ors 
a n d t he sa me c o v ariates descri be d f or t he L M M f or t he pri mar y efficac y a nal ysis  (e xce pt f or  ti me 
fact ors). I n case of deat h or r e-tra ns pla ntati o n e v e nts, F E V 1 will be i m p ute d as zer o at eac h n o mi nal 
da y p ost e ve nt.  
I n case of vi olati o n of t he n or malit y ass u m pti o n  e ve n after l o g tra nsf or mati o n (secti o n 1 4 ), t he n 
ra n k tr a nsf or mati o n will be a p plie d t o n or m alize t he dat a . T he sa me A N C O V A  m o del will be  
a p plie d t o t he ra n k -tr a nsf or me d data.  
1 4. 2. 6  
S el e cti o n M o d eli n g  
A sele cti o n m o del fits si m ulta ne o usl y a m o del f or t he re peate d F E V 1 meas ure me nts a n d a m o del 
f or t he pr o ba bilities of dr o p pi n g o ut at t he differe nt visits. T hese m o dels are referre d t o as t he 
meas ure me nt m o del a n d t he dr o p -o ut  m o del.  
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L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
 
Final Version 5.0 
Page 46 of 76 
 
 
Applying Diggle and Kenward's Selection Model on incomplete longitudinal data, the response is 
modeled through a repeated measures model, while a logistic regression model is used to describe 
the dependency of the missing data indicators on the longitudinal responses.  
Under this approach, the probability of dropout is considered a function of the observed 
longitudinal response measured prior to dropout at time j and the unobserved response at the time 
of dropout. For individuals with complete data, dropout depends on the response prior to the last 
measurement (yi,j-1) and the final observed response (yij). In either case, dropout cannot depend on 
future responses. Specifically, the logit of the probability of dropout depends on the observation 
prior to dropout (yi,j-1) (assuming the individual was observed prior to dropout) and the unobserved 
response at dropout (yij): 
Logit[P(Di=j|Di>=j] = Intercept + α1 yi,j-1 + α2 yij 
where the coefficients α1 and α2 are the effects of yi,j-1 and yij on the logit, respectively. Under this 
model, if both α1 and α2 are equal to zero, then the missingness is independent of the previous and 
missing responses. In such cases, the missing data are Missing Completely at Random, and 
consequently, the missing data process is ignorable. If α2 but not α1 is equal to zero, then the 
missingness is related to the response prior to dropout. In this case, the missing data are MAR, and 
again, the missing data process is ignorable. If α2 is not equal to zero, then the missingness depends 
on the missing data at dropout. Consequently, the missing data process cannot be ignored. 
These scenarios will describe how large the departure from the MAR assumption should be in 
order to substantially affect the results of the primary analysis. If the number of drop-outs turns 
out to be small, this sensitivity analysis may not be feasible because of insufficient information to 
fit the logistic drop-out model, and the CSR will mention this as a caution. This model can be fitted 
using the selection modelling macros from the Drug Information Association Scientific Working 
Group on Estimands and Missing Data [8].  
14.2.7 
Joint Model 
This analysis jointly models the repeated FEV1 measurements and the time to dropout. The 
longitudinal measurement process model follows a standard random-coefficient mixed effect 
model, while the dropout mechanism model uses a complementary log-log link. 
This model will be fitted using the shared parameters macros from the Drug Information 
Association Scientific Working Group on Estimands and Missing Data [8]. 
14.3 Supplementary Analyses for the Primary Endpoint 
Supplementary analyses can provide additional insights into the understanding of a treatment 
effect.  


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 4 7  of 7 6  
 
 
1 4. 3. 1  
P P S  
T he p o p ulati o n f or t he pri mar y esti ma n d will be altere d fr o m t he F A S t o t he P P S. T he a nal ysis 
will be c o n d ucte d as d escri be d f or t he pri mar y e n d p oi nt.  
1 4. 3. 2  
 d at a  
T he e n d p oi nt f or t he esti ma n d will be s pir o metr y data st ore d o n t he
. T h e a nal ysis 
will be c o n d ucte d as d escri be d f or t he pri mar y e n d p oi nt.  
1 4. 3. 3  
T h e i m p a ct of  C O VI D -1 9  
T he C O VI D -1 9 p a n de mic ha s i m pacte d t he c o n d uct of t he st u d y a n d mi g ht  ha ve i m pacte d its 
res ults for  differe nt as p ects i ncl u di n g i nfecti o ns, q uara nti nes, s ocial dista nces [5 ], a n d ot her 
c o nsi derati o ns li n ke d t o t he differe nt wa ys t hat eac h site has face d t he p a n de mic . D ate of C O VI D -
1 9 o ut brea k  was  set at Marc h 1 1, 2 0 2 0 a n d differe nt a nal yses will be perf or me d t o assess t he 
i m pact of t he C O VI D-1 9 pa n de mic t o t he st u d y  pre a n d p ost pa n de mic . I n case e vi de nce of a n 
i m pact of pa n de mic  o n st u d y e n d p oi nts  s h o ul d e mer ge, c o nsi derati o ns o n h o w t he  i nitial st u d y 
ass u m pti o ns ha ve bee n altere d m ust b e d o ne, a n d c ha n g es i n t h e st atistical criteri a f or fi nal 
j u d g me nt s h o ul d be a p plie d.  
1 4. 3. 3. 1  P ati e nt s i m p a ct e d b y C O VI D -1 9  p a n d e mi c  
T he a nal ysis of pri mar y e n d p oi nt will be perf or me d usi n g t he L M M  descri be d i n t he pri mar y 
a nal ysis wit h t he i ncl usi o n of a d diti o nal cate g orical c o variate s: 
•  A bi nar y c o variate  re prese nti n g if patie nts ha ve bee n affect e d b y C O VI D-1 9 d uri n g t he 
treat me nt peri o d: 
o  Affecte d , if a n A E  of C O VI D -1 9 is re p orte d i n t he e C R F A E pa g e b et wee n 
ra n d o mizati o n a n d e n d of treat me nt date; 
o  N ot affecte d , if n o A E s of C O VI D-1 9 are re p orte d i n t he e C R F A E pa g e bet wee n 
ra n d o mizati o n a n d e n d of treat me nt date. 
•  A bi nar y c o variate re prese nti n g if patie nts ha ve bee n ra n d o mize d bef ore  or after t he 
C O VI D -1 9 pa n d e mic o ut brea k:  
o  Bef ore, if d ate of ra n d o mizati o n i s bef ore 1 1 M arc h 2 0 2 0;  
o  After, if dat e of ra n d o mizati o n i s e q ual or after 1 1 Marc h 2 0 2 0.  
F E V 1 data  will be descri pti vel y s u m marize d b y i m pact of C O VI D -1 9 ( C O VI D -1 9 affecte d vs N ot 
C O VI D -1 9 affecte d, a n d ra n d o mize d b ef ore C O VI D -1 9 Pa n de mic O ut brea k vs ra n d o mize d after 
C O VI D -1 9 o ut brea k) at eac h visit, b y treat me nt a n d o verall. T he  treat me nt c o m paris o n for 
differe n ce i n m ea n c ha n g e fr o m b aseli ne i n t he F E V 1 at wee k 4 8 will be carrie d o ut usi n g t -tests 
as descri be d i n secti o n  1 4. 3. 4 . T his will als o b e p erf or me d f or eac h of t h e s u b p o p ulati o ns defi ne d 
C CI
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L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
 
Final Version 5.0 
Page 48 of 76 
 
 
by the binary covariates above i.e. patients affected/not affected by COVID-19 during the 
treatment period and patients randomized before/after the COVID-19 pandemic outbreak.  
Furthermore, it is of interest to categorize each visit for each patient to assign these before or after 
the COVID-19 pandemic outbreak. A summary table will be produced to descriptively display the 
effects of FEV1 over time by taking each visit with respect to the COVID-19 outbreak pandemic 
date into consideration. The treatment comparison for difference in mean change from baseline in 
the FEV1 at week 48 will be analyzed similarly using the t-test as described in section 14.3 for 
both groups, visits before COVID-19 pandemic outbreak, visits after COVID-19 pandemic 
outbreak.  
The observed mean change from baseline and standard errors of FEV1 at each timepoint will be 
graphically reported by treatment and by impact of COVID-19 categorization. This will also be 
displayed by COVID-19 pandemic outbreak at each visit. Furthermore, a figure with adjusted 
mean changes from baseline at each visit by treatment group derived from the LMM with impact 
of COVID-19 will be provided. 
14.3.3.2 Piecewise regression 
The analysis of primary endpoint will be carried out using a modified LMM for repeated 
measurements that will allow to assess if FEV1 trajectory slopes are different before and after the 
COVID pandemic outbreak. All observed available FEV1 measurements will be used and the 
model will contain (except from the intercept) time (from randomization), time after COVID 
pandemic outbreak (defined as days after March 11, 2020, with March 11, 2020 considered as 
equal to zero; for assessments of FEV1 done before 11 March 2020 this time is set at zero), 
treatment, the interactions of time (from randomization) by treatment, the interactions of time after 
COVID pandemic outbreak by treatment, baseline FEV1, the interactions of time (from 
randomization) with the baseline FEV1, the interactions of time after COVID pandemic outbreak 
with the baseline FEV1, region (North America versus all other countries together), age (< 55 
versus 
 55 years), and use of azithromycin at randomization (i.e. Baseline, Visit 1). The model 
will include random intercept, time and time after COVID pandemic outbreak. 
Denoting the time from randomization and the time after COVID pandemic outbreak by S1 and S2 
respectively, treatment group by T (0=SoC; 1=L-CsA plus SoC), the day of the measurement by t 
and the baseline FEV1 by X, the fixed part of the model will contain the following covariates: 
Intercept, S1, S2, T, T*S1, T*S2, X, X*S1, X*S2, other covariates. 
The Kenward-Roger adjustment will be used for the denominator degrees of freedom needed for 
hypothesis tests and confidence intervals. 
The primary efficacy parameter will be estimated from the model by the adjusted difference 
between treatment groups in mean FEV1 change from baseline after 48 weeks. The p-value for the 
null hypothesis of no difference and a two-sided 95% confidence interval for the difference will 


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 4 9  of 7 6  
 
 
be pr o vi de d. S u peri orit y of L -Cs A will be c o nfir me d b y a statisticall y si g nifica nt  res ult i n fa v or of 
t he L-Cs A pl us S o C treat me nt c o m pare d t o S o C al o ne.  
T he sl o pes of F E V 1 bef ore a n d aft er Marc h 1 1, 2 0 2 0 will be assesse d a n d c o m pare d.  
T he c ore e xcer pt of  
 c o de f or t h e pri mar y a nal ysis is re p orte d i n secti o n  1 7. 5 . 
1 4. 3. 3. 3  " Whil e o n t r e at m e nt “ st r at e g y  (f o r C O VI D-1 9)  
A  f urt her s u p ple me ntar y a nal ysis o n t he i m pact of C O VI D-1 9 will be perf or me d. T he  I E of  
C O VI D -1 9  i nfecti o n ( per e C R F pa ge, see defi niti o n i n secti o n 1 4. 3. 3. 1 ) will be c o nsi d ere d a n d 
will be ha n dle d b y t he “w hile o n treat me nt ” strate g y: the a nal ysis will be c o n d ucte d as t he pri mar y 
a nal ysis  wit h t he e xce pti o n t hat, i n case of a C O VI D -1 9 I Es, o nl y t he F E V1 meas ure me nts u p t o 
t he date t he C O VI D-1 9 A E starte d will be use d.  
I n case re-tra ns pla ntati o n e ve nts, F E V1 will be i m p ute d as zer o at eac h n o mi nal da y p ost e ve nt  u p 
t o t he C O VI D -1 9 i nfecti o n date . Acc or di n g Ta ble 5, i n case of deat h, n o i m p utati o n will be d o ne.  
1 4. 3. 4  
T -t e st 
T he p o p ulati o n -le vel s u m mar y f or t he varia ble will be altere d. T he m ea n treat me nt differe nce i n 
c ha n ge fr o m baseli ne t o Wee k 4 8 i n F E V 1, sta n d ar d de viati o n a n d 9 5 % c o nfi de nce i nter val  will 
be pres e nte d. A t w o -sa m ple t-test will be perf or me d b y treat me nt gr o u p usi n g c ha n ge fr o m 
baseli ne i n F E V 1 t o Wee k 4 8. 
I n case of d eat h or re-tra ns pla ntati o n e ve nts, F E V 1 will be i m p ute d as zer o at eac h n o mi nal da y 
p ost e ve nt.  
1 4. 3. 5  
" W hil e o n t r e at m e nt“ st r at e g y“  
T he I E disc o nti n uati o n of ra n d o mize d treat me nt will be c o nsi dere d a n d treate d f oll o wi n g a w hile 
o n treat me nt str ate g y. I n case of s uc h I E, all F E V 1 meas ure me nts u p t o t he date of t he I E will be 
i ncl u de d, w hile t he o bser vati o n p ost I E will n ot be c o nsi dere d. T he a n al ysis will be c o n d ucte d as 
descri be d f or t he pri mar y e n d p oi nt  (secti o n 1 4. 1 ). 
As  a n a d diti o nal a nal ysis , t he i nitiati o n of a d diti o nal i m m u n os u p pressi ve t hera p y (see secti o n 
1 4. 5. 1  f or details o n a d diti o nal i m m u n os u p pressi ve t hera pies) will be i ncl u d e d i n t he a n al ysis: I Es 
of eit her disc o nti n uati o n of ra n d o mize d treat me nt or i nitiati o n of a d diti o nal i m m u n os u p pressi ve 
t hera p y will be a n aly ze d acc or di n g t o  t he a b o ve w hile o n treat me nt strate g y.  
I n b ot h a nal yses, t he s u m mar y statistics of ti me t o treat me nt disc o nti n uati o n ( wee ks) a n d ti me t o 
i nitiati o n of a d diti o nal i m m u n os u ppressi ve t hera p y  ( wee ks) (f or t he sec o n d a nal ysis o nl y) will be 
pr o vi de d f or a better i nter pretati o n of res ults.  
I n case of r e-tra ns pla nt ati o n e ve nts, F E V1 will be i m p ute d as zer o at eac h n o mi nal da y p ost e ve nt.  
Acc or di n g T a ble 5, i n case of deat h, n o i m p u tati o n will be d o ne. 
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 5 0  of 7 6  
 
 
 
1 4. 3. 6  
T ri m m e d M e a n s  
T he tri m me d mea ns a nal ysis uses a differe nt esti ma n d a n d f oll o ws t he a p pr oac h of Per m utt a n d Li 
( 2 0 1 7) [3 ]. T his met h o d pr o vi des a n e x act test usi n g all ra n d o mize d patie nts t hat is ver y r o b ust 
a n d d oes n ot re q uire a n y m o deli n g ass u m pti o ns. T he esti ma n d of t he pri mar y a nal ysis is t he 
differe n ce be t wee n tr eat me nt gr o u ps i n mea n F E V1 c ha n ge fr o m b aseli ne at wee k 4 8 i n t he 
p o p ulati o n of all ra n d o mize d patie nts, i ncl u di n g t he patie nts w h o die or are re -tra ns pla nte d a n d 
ha ve n o F E V 1 meas ure m e nt at wee k 4 8. T h e pri m ar y a n al ysis i m plicitl y m o dels t he F E V
1 at wee k 
4 8 f or p atie nts w h o die d or were re -tra ns pla nte d, w hic h is s o me w h at u n nat ural. I n t he a p pr oac h of 
Per m utt a n d Li, all dr o p o uts are c o nsi d ere d t o b e fail ures a n d t hes e patie nts are gi ve n a F E V 1 val ue 
of zer o at wee k 4 8. T he e xact i m p ute d val ue d oes  n ot matter, as l o n g as it is w orse t ha n all val ues 
o bser ve d i n p atie nts wit h F E V 1 meas ure me nts at wee k 4 8. T h e i m p ute d v al ue will be zer o. T h e 
esti ma n d is t he bet wee n gr o u p differe nce i n mea n c ha n ge fr o m baseli n e i n t he perce nta ge p 
s u b p o p ulati o n wit h t he best F E V 1 val ues at wee k 4 8. T y pical c h oices f or p are i n t he ra n ge of 5 0 
t o 9 0 %, de pe n di n g o n t he a ntici pate d perce nt a ge of patie nts wit h a n i m p ute d l o w val ue. F or t his 
se nsiti vit y a nal ysis p = 7 0 % will be use d. T he met h o d is base d o n a per m utati o n test f or t he n ull 
h y p ot hesis t hat t he o utc o me distri b uti o ns at wee k 4 8 are e q ual. T h e vari a nt of t he met h o d des cri be d 
i n Secti o n 4. 3 of Per m utt a n d Li ( 2 0 1 7) t hat e x pl oits t he i nter me diate F E V1 val ues a n d c o variat es 
i n t he sa me wa y as t he pri mar y a nal ysis will be use d. T he o nl y re q uir e me nt f or t his met h o d is t hat 
it m ust be reas o na ble t o c o nsi der t he o utc o me of dr o p o uts as w orse t ha n t he l o west o utc o me of t he 
c o m pleters. T his is reas o na ble f or dr o p o ut d ue t o deat h or re -tra ns pla ntati o n b ut ma y n ot al wa ys 
be reas o n a ble f or dr o p o ut d ue t o ot her reas o ns. T h eref ore, i m p utati o n will be a p plie d  o n l y i n case 
of deat h , r e-tra ns pla nt ati o n, or lac k of efficac y I Es.  
 
 
 
 
 
 
 
 
 
 
 
C CI
C CI
C CI
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 5 1  of 7 6  
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
C CI
C CI
C CI
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 5 2  of 7 6  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
  
  
  
  
 
 
  
  
  
  
 
 
 
 
 
 
 
 
 
C CI
C CI
C CI
C CI
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 5 3  of 7 6  
 
 
 
 
  
  
  
  
 
 
 
  
 
  
  
 
 
 
 
 
 
 
 
 
 
  
  
  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
  
 
 
 
C CI
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 5 4  of 7 6  
 
 
 
 
  
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
C CI
C CI
C CI
C CI
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 5 5  of 7 6  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
C CI
C CI
C CI
C CI
C CI
C CI
C CI
C CI
C CI
C CI
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 5 6  of 7 6  
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
  
 
  
 
  
 
  
C CI
C CI
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 5 7  of 7 6  
 
 
 
 
 
 
  
 
 
  
 
 
 
 
 
 
  
  
 
 
 
 
 
 
  
C CI
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
Fi n al  Versi o n  5 . 0 
Pa ge 5 8  of 7 6  
 
 
 
 
 
 
  
 
 
 
C CI
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 5 9  of 7 6  
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
1 4. 6  S U B G R O U P A N A L Y S E S  
A nal yses of pri mar y 
 e n d p oi nts will be perf or me d o n t he f oll o wi n g s u b gr o u ps of 
patie nts : 
•  A ge class ( < 5 5 years , ≥5 5 years ), 
•  Ge n der  (fe mal e, male, u n differe ntiat e d ), 
•  Re gi o n ( N ort h A meric a , all ot her c o u ntries t o get h er ), 
•  Se verit y of disease , d efi n e d  b y : 
o  % of baseli ne F E V 1 o ver pers o nal best  F E V 1 p ost -tra ns pla nt (bas eli ne F E V 1 > 8 0 % , 
> 6 5 ‒ 8 0 %, > 5 0 ‒ 6 5 %, a n d ≤5 0 % of pers o nal best F E V 1 p ost -tra ns pla nt),  
o  baseli ne  F E V 1 % of pre di cte d ( < 7 0 %, ≥ 7 0 % ), 
o  baseli ne  F E V 1/ F V C rati o ( < 0. 7, ≥ 0. 7) , 
o  B L A D  at baseli ne ( Yes , N o ); 
•  Race  (A merica n I n dia n or Alas ka n Nati ve , Asia n , Blac k or Africa n A m erica n , N ati ve 
Ha waiia n or Ot her  Pacific Isla n der , W hite , Ot her),  
•  Use of azit hr o m yci n at ra n d o mizati o n ( Yes/ N o). 
C CI
C CI
C CI


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
 
Final Version 5.0 
Page 60 of 76 
 
 
Subgroup levels may be pooled to have an adequate number (≥ 10) of patients per strata to perform 
the analysis. Decision on pooling will be taken during the blinded DRM, before data base lock.  
Within each subgroup level, descriptive analyses (section 8.1) will be performed on: 
• FEV1, 
• FEV1/FVC, 
• Time to Progression of BOS. 
FEV1 and FEV1/FVC change from baseline will be compared using a two-sample t-test (assuming 
unequal variances) or, if the required assumptions are not met, a two-sample Mann–Whitney U 
test.  
Comparison of time to progression of BOS curves among treatments will be performed with the log-
rank test. 
15 
SAFETY DATA 
15.1 General Considerations 
Summaries of safety data (e.g., AEs, laboratory data, vital signs) will be provided for the SAF. No 
inferential analyses are planned for safety endpoints. 
15.2 Extent of Exposure 
15.2.1 
Exposure to L-CsA 
Exposure to the investigational medicinal product (IMP), L-CsA will be confirmed based on the 
report of IMP vials returned and dosing recorded in the eCRF. IMP vials that were missing will 
not be included in the counts of returned (i.e. used) vials; this will also apply where vials are 
missing but the patients were considered to have taken the vials. A summary table will be prepared 
including the following details about administration of L-CsA: 
• Descriptive statistics for the total vials planned. This is calculated as ([date of last dose – 
date of randomization + 1] x 2 vials); 
• Descriptive statistics for the total actual dose (mg). This is calculated as total empty (used) 
vials multiplied by dose; 
• Descriptive statistics for the duration of treatment in days and weeks. For each patient, the 
treatment duration will be calculated as the difference between the dates of last and first 
administration of L-CsA plus 1; 
• Descriptive statistics for the duration of treatment in days and weeks, excluding the 
inhalation temporarily discontinued. For each patient, the treatment duration will be 
calculated as the difference between the dates of last and first administration of L-CsA plus 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
 
Final Version 5.0 
Page 61 of 76 
 
 
1, excluding the days of any inhalation temporarily discontinued. Derivation: (date of last 
dose – date of first dose + 1) - (stop date of inhalation temporarily discontinued– start date 
of inhalation temporarily discontinued +1). 
Compliance of L-CsA using the drug accountability data is calculated as the total empty (used) 
vials returned divided by the total vials planned and will be summarized on the FAS population. 
For the evaluation of compliance, all the planned vials up to the actual end of treatment for each 
patient will be considered in the calculation. 
By-patient listings will present all IMP administration data. 
15.2.2 
Exposure to Study treatment (SoC or SoC+L-CsA) 
SoC therapy period starts at randomization date and stops at date of study completion or early 
termination. L-CsA treatment period starts at date of first dose of L-CsA and stops at the date of 
last dose administered. 
Descriptive statistics for the duration of any study treatment (SoC or SoC+L-CsA) in days and 
weeks will be provided. Since the SoC will cover the entire study period post-randomization, the 
study treatment duration (SoC or SoC+L-CsA) will be calculated as the difference between the 
date of study completion/early termination and randomization plus 1. 
15.3 Adverse Events 
All AEs occurring during the clinical trial, whether or not attributable to study treatment, will be 
documented in the eCRF. All AEs will be coded to SOCs and PTs using the MedDRA dictionary 
(version 23.1).  
Treatment-emergent adverse events (TEAEs) are defined as AEs with onset on or after the date of 
randomization. 
The Investigator will assess the relationship (unrelated, possible, definite) of each AE to the 
clinical trial treatment assignment (L-CsA plus SoC or SoC alone). Treatment-related AEs are 
defined as events the Investigator considers to be possibly or definitely related to clinical trial 
treatment assignment.  
All AEs reported in the eCRF will be presented in by-patient listings for the SAF.  
The following summaries will be presented for AEs by treatment group and overall:  
• Overview table including the number and percent of patients with: 
o AEs,  
o TEAEs,  
o TEAEs leading to discontinuation of study treatment, 
o TEAEs leading study discontinuation, 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
 
Final Version 5.0 
Page 62 of 76 
 
 
o TEAEs leading to death. 
o TEAEs by severity (Mild, Moderate, Severe), 
o Study treatment related TEAEs, 
o Serious TEAEs, 
o Serious study treatment related TEAEs; 
• TEAEs, grouped within SOC by decreasing frequency of PT; 
• TEAEs by decreasing frequency of PT; 
• TEAEs leading to discontinuation of study treatment, grouped within SOC by decreasing 
frequency of PT; 
• TEAEs leading to study discontinuation, grouped within SOC by decreasing frequency of 
PT; 
• TEAEs leading to death, grouped within SOC by decreasing frequency of PT; 
• TEAEs by maximum severity, grouped within SOC by decreasing frequency of PT; 
• TEAEs by relationship, grouped within SOC by decreasing frequency of PT; 
• Serious TEAEs, grouped within SOC by decreasing frequency of PT; 
• Related serious TEAEs, grouped within SOC by decreasing frequency of PT. 
Patients who have multiple events coded to the same PT or within the same SOC will be counted 
only once in the patient counts for the corresponding summaries, but all events will be considered 
and listed. Table presentations will contain counts of patients, percentages of patients, and the 
number of events.  
Any AE with missing relationship will be assumed related and summarized in the possible related 
category to clinical trial treatment assignment. Patients who experience the same event multiple 
times will be included in the most related category for summarization. 
In summaries including severity, the following severity categories will be summarized: ‘Mild’, 
‘Moderate’, ‘Severe’. Any AEs with missing severity will be assumed as ‘Severe’. Patients who 
experience the same event multiple times will be included in the most severe category.  
AE summaries will be ordered in terms of decreasing frequency for SOC, and PT within SOC, in 
the L-CsA plus SoC column. 
The following by-patient listings will be provided:  
• AEs; 
• TEAEs;  
• TEAEs leading to discontinuation of study treatment; 
• TEAEs leading to study discontinuation; 
• TEAEs leading to death; 
• Study treatment related TEAEs; 
• Serious TEAEs. 


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 6 3  of 7 6  
 
 
T he se listi n gs will i ncl u de at least: ce nter, patie nt i de ntifier, treat me nt gr o u p, A Es ( S O C, P T, a n d 
ver bati m ter m), A E start date/ti me, A E e n d date/ti me, d urati o n of A E, se verit y, seri o us ness, acti o n 
ta ke n, o utc o me a n d relati o ns hi p.  
1 5. 3. 1  
I nf e cti o n s 
All i nfecti o ns will be re p orte d as A Es o n t he A E e C R F . T he s u m maries d escri be d i n t his secti o n 
will be pr o vi de d f or treat me nt -e mer g e nt i nfecti o ns ( defi ne d as f or T E A Es) . Treat me nt -e m er ge nt 
i nfecti o ns will be s u m marize d o n t he basis of i nf or mati o n re p orte d o n t he A E e C R F.  
F or a n y i nf ecti o n , the f oll o wi n g s u m maries will be prese nt e d b y treat me nt gr o u p:  
•  N u m ber ( perce nt) of pati e nts wit h at least o ne i nfecti o n , 
•  N u m ber  a n d % of i nfecti o ns  per patie nt  ( 0, 1, 2, …), 
•  Descri pti ve statistics f or n u m ber of i nfecti o ns per patie nt . 
T he n u m ber of i nf ecti o ns per p atie nt  a n d per patie nt -years (c u m ulati ve f oll o w -u p  of eac h patie nt ) 
will be pr o vi de d b y year (e. g., 2 0 1 9, 2 0 2 0, 2 0 2 1, etc.) a n d o verall.  
A b y -patie nt listi n g s u m marizi n g i nf or mati o n o n i nfecti o ns  will be pr o vi de d  o n S A F set . 
1 5. 3. 2  
M ali g n a n ci e s  
All mali g na ncies m ust be c o nfir me d b y hist o pat h ol o g y . Mali g na ncies are d o c u me nte d  as A Es, a n d 
will be c o d e d b y S O C a n d P T . T he s u m maries descri b e d i n t his s ecti o n will be pr o vi de d f or 
treat me nt-e mer ge nt mali g na ncies ( defi ne d as f or T E A Es). Mali g na nci es will be i de ntifie d t hr o u g h 
a bli n de d me dical re vie w of c ollecte d A Es.  T he res ult of t he me dical re vie w  will be a fla g  f or t he 
i de ntificati o n of mali g na ncies ad de d i n a n e xcel s heet , t hat will be i m p orte d f or a nal ysis. 
A s u m mar y ta ble  b y S O C a n d P T  a n d b y -patie nt listi n g s u m marizi n g i nf or mati o n c ollecti o n will 
be pr o vi de d  o n S A F . 
1 5. 4  A c ut e T ol e r a bilit y of I M P 
At Visit 1, a c ute t olera bilit y of I M P (L -Cs A ) d uri n g i nitial d osi n g will be deter mi ne d b y 
meas uri n g : 
•  S pir o metr y ( F E V 1, 
, F V C) meas ure d b ef ore a n d 
 
  
•  S p o nta ne o us re p ort of c o u g h or d ys p nea, rec or de d as A E  i n t he a p pr o priate e C R F. 
Descri pti ve statistics of pre -d ose  ( V 1), p ost -d ose 
 a n d c h a n ge fr o m 
pre -d ose will be prese nte d f or eac h s pir o metr y para meter  o n t he S A F p o p ulati o n .  
I n a d diti o n, t he n u m b er a n d perce nt of patie nts e x perie nci n g a d ecli ne of  
 i n F E V 1 will be 
prese nte d.  
C CI
C CI
C CI
C CI


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
 
Final Version 5.0 
Page 64 of 76 
 
 
The number and percent of patients experiencing new onset or worsening of TEAEs having the 
following PTs on the date of the first visit at which L-CsA is administered will be summarized: 
• Cough; 
• Dyspnea. 
15.5 Clinical Laboratory Data 
15.5.1 
Hematology and Biochemistry 
Clinical laboratory assessments will be performed at each visit by a certified local facility 
following the routine protocols at each site. As described in the clinical trial protocol (Section 
13.1.5), the following clinical laboratory parameters will be reported in the eCRF: 
Hematology  
• White Blood Cell (WBC) count with differential, 
• Red Blood Cell (RBC) count, 
• Platelet count, 
• Neutrophils, 
• Lymphocytes, 
• Monocytes, 
• Eosinophils, 
• Basophils, 
• Neutrophils Absolute Count, 
• Lymphocytes absolute counts, 
• Eosinophils absolute count, 
• Basophils absolute count, 
• Monocyte absolute count. 
Biochemistry 
• Alkaline phosphatase (AP), 
• Alanine aminotransferase (ALT), 
• Aspartate aminotransferase (AST), 
• Gamma Glutamyl Transferase (-GT), 
• Blood urea nitrogen (BUN), 
• Serum bilirubin, 
• Serum creatinine, 
• Sodium, 
• Potassium, 
• Chloride, 


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
 
Final Version 5.0 
Page 65 of 76 
 
 
• Bicarbonate, 
• Calcium, 
• Magnesium. 
Descriptive statistics of observed values and changes from baseline will be presented by visit and 
treatment group. The summaries described in this section will be presented relative to baseline, 
defined as the most recent, non-missing result on or before the date of randomization. No 
imputation for missing data will be performed. 
All clinical laboratory data reported in the eCRF will be presented in by-patient listings.  
15.5.2 
Blood Sampling CNI/mTOR Inhibitors 
A whole blood sample for the determination of blood sampling CNI/mTOR inhibitors will be 
collected at each visit; this includes cyclosporine A and/or tacrolimus trough level. In patients 
allocated to L-CsA plus SoC, the sample should be collected 60 min before L-CsA inhalation. 
Blood samples will be evaluated by the local laboratories associated with each site. The summaries 
described in this section will be presented relative to baseline, defined as the most recent, non-
missing result on or before the date of randomization. No imputation for missing data will be 
performed. 
All CNI/mTOR data reported in the eCRF will be presented in by-patient listings. Descriptive 
statistics of observed values and changes from baseline will be presented by visit and treatment 
group.  
15.5.3 
Donor Specific Antibody Tests 
Serum samples for donor specific antibody testing will be collected at Screening, and at Visits 4, 
6, and 9. A by-patient listing of all results will be provided. 
15.5.4 
Pregnancy Tests 
Serum samples from women of childbearing potential will be collected for pregnancy. A by-patient 
listing of all results will be provided. 
15.6 Renal Function 
In addition to the summarization of serum creatinine as described in previous section, renal 
dysfunction will be further listed and summarized by treatment group based upon the classification 
of AEs with the following PTs (see protocol section 13.1.5.4, Table 7): 
• Blood Creatinine Increased; 
• Renal Impairment; 
• Renal Failure. 


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 6 6  of 7 6  
 
 
1 5. 7  Vit al Si g n s  
Vital si g ns will be assesse d at eac h visit.  T he f oll o wi n g vital si g ns will be rec or de d:  
•  S yst olic a n d diast olic bl o o d press ure (sitt i n g, after 5 mi n utes of rest); 
•  Heart  rate (sitti n g, after 5 mi n utes of rest); 
•  B o d y te m perat ure (t he sa me met h o d s h o ul d be use d f or eac h patie nt a n d t hr o u g h o ut t he 
trial); 
•  R es pirat or y rate ; 
•  W ei g ht. 
T he s u m maries descri be d i n t his secti o n will be prese nte d relati ve t o baseli ne, defi ne d as t he m ost 
rece nt, n o n-missi n g res ult o n or bef ore t he dat e of ra n d o mizati o n . N o i m p utati o n f or missi n g data 
will be perf or me d.  
Descri pti ve st atistics of o bser ve d v al ues a n d f or c ha n ges fr o m bas eli ne will be prese nte d b y visit 
a n d treat me nt gr o u p o n S A F. Vital si g ns data re p orte d i n t he e C R F will be prese nte d i n b y-patie nt  
listi n gs. 
1 5. 8  P h y si c al E x a mi n ati o n  
A p h ysical e xa mi nati o n will be carri e d o ut at Scree ni n g a n d e v er y s u bse q ue nt visit .  
T he f oll o wi n g b o d y s yste ms will be e xa mi ne d: b o d y wei g ht, car di o vasc ul ar, res pir at or y, n er v o us, 
gastr oi ntesti nal, he patic, re nal, der mat ol o gical, m usc ul os keletal, e xtre mities, e yes, ears, n ose, 
t hr oat, a n d l y m p hatic. Patie nt hei g ht will be meas ure d at Scree ni n g Visit o nl y.  
All  p h ysical e xa mi nati o n dat a, i ncl u di n g  a b n or mal fi n di n gs re p orte d i n t he e C R F will o nl y be 
prese nte d i n b y -p atie nt  listi n g. 
1 6  
C h a n g e s f r o m Pl a n n e d A n al y s e s  
T he c ha n g es i n dicate d b el o w are b ei n g ma de, n o ne of t hese c h a n ges are d oc u me nte d as f or m al 
pr ot oc ol a me n d me nts.  
•  T he S A F p o p ulati o n has bee n f urt her detaile d t o b etter defi ne t he act u al treat me nt recei ve d 
b y patie nts.  
•  
 
 
•  T he pr ot oc ol a me n d m e nt versi o n 6. 0 Ta ble 1 dis pl a yi n g t he 2 0 1 9 C L A D st a gi n g  has bee n 
a me n de d i n t his S A P . Ta ble 7  s h o ws t he c orrect d escri pti o ns f or t h e 2 0 1 9 C L A D Sta gi n g 
as re p orte d i n Verle d e n et al., 2 0 1 9 [ 4 ]. 
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 6 7  of 7 6  
 
 
•  
 
 
   
•  I n secti o n 9. 4  f urt her details c o m pare d t o pr ot oc ol ha ve bee n a d de d f or h a n dli n g visits t hat 
ha ve m ore t h a n o ne acce pte d s pir o metr y assi g ne d, wit h s o me of t he m perf or me d after I M P 
i n halati o n. 
•  
 
 
 
 
•  B O S Pr o gressi o ns 
will be e val uate d u p t o l ast assess me nt, e ve n after treat me nt  
disc o nti n u ati o n or c o m pleti o n.  
•  
 
 
 
 
C CI
C CI
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L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 6 8  of 7 6  
 
 
1 7  
 
Please refer t o Ta bl e 8  f or details o n na mes a n d c o nte nt of t he varia bl e s use d i n t he  
 of t his secti o n . 
T a ble 8 : V ari a ble n a mes a n d descri pti o n s. 
V ari a bl e N a m e  
D escri pti o n  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
C CI
C CI
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L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 6 9  of 7 6  
 
 
1 7. 1  P ri m a r y a n al y si s  
  
  
 
 
 
  
  
  
 
 
 
  
  
  
 
 
 
 
 
 
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
 
 
  
  
  
  
  
 
  
 
 
 
 
 
  
 
 
  
  
 
 
 
 
 
  
 
 
 
 
 
 
 
  
 
 
  
  
  
 
 
 
 
 
  
  
  
  
 
 
  
  
 
 
 
  
  
  
  
 
  
 
  
 
 
  
  
  
 
 
 
  
 
 
 
 
   
 
 
 
 
 
  
  
  
  
  
  
  
 
   
 
 
 
 
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L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 7 0  of 7 6  
 
 
1 7. 2  S e n siti vit y a n al ysi s - M N A R  
  
  
 
 
 
  
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
 
  
  
  
  
  
  
  
  
 
 
  
  
  
  
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
  
 
 
  
  
 
 
 
  
  
  
  
 
 
 
  
  
  
 
 
 
 
 
 
  
  
  
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
  
  
  
 
 
  
  
  
  
  
 
  
 
 
 
 
  
 
  
  
 
  
 
 
  
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
  
 
 
 
  
 
 
  
 
 
  
 
 
 
 
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L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 7 1  of 7 6  
 
 
1 7. 3  S e n siti vit y a n al ysi s –  Ti p pi n g p oi nt  
 
 
 
 
 
 
  
 
 
 
 
 
 
  
 
 
 
 
 
 
  
 
 
 
  
  
 
 
 
 
  
  
 
 
 
 
  
  
 
 
 
 
  
  
 
 
 
 
 
  
  
 
 
 
 
  
  
 
 
 
 
  
  
  
  
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
  
  
 
 
 
  
  
  
 
 
 
 
  
  
  
 
 
 
 
 
 
  
  
  
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
  
 
 
 
 
  
  
  
  
  
 
  
 
 
 
 
  
 
  
  
 
  
 
 
  
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
  
 
 
 
  
 
 
  
 
  
  
 
 
 
 
 
 
C CI
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 7 2  of 7 6  
 
 
1 7. 4  S e n siti vit y a n al ysi s - M M R M  
  
  
 
 
 
  
  
  
  
 
 
 
 
  
 
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
  
 
 
 
 
 
 
  
  
  
 
 
1 7. 5  S u p pl e m e nt a r y a n al y si s - Pi e c e wi s e r e g r e s si o n  
  
  
 
 
 
  
  
  
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
  
 
 
 
 
 
 
  
  
 
 
 
  
  
 
  
 
  
 
 
 
 
 
 
 
        
 
  
 
 
 
 
 
 
 
 
      
 
  
 
 
 
 
 
 
 
 
  
 
  
 
 
 
  
  
 
  
 
 
 
 
      
 
 
 
  
 
 
 
 
 
  
 
 
  
  
 
  
 
 
 
 
     
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
  
  
 
  
 
 
 
 
     
 
 
 
  
 
 
 
 
 
 
 
 
  
  
 
  
 
 
 
 
    
 
 
 
  
 
 
 
 
 
 
 
 
  
  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
  
 
 
 
  
 
 
 
 
     
 
C CI
C CI
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 7 3  of 7 6  
 
 
 
 
 
  
 
 
 
 
 
 
 
 
  
 
 
  
 
 
 
  
 
 
 
 
    
 
 
 
  
 
 
 
 
 
 
 
 
  
  
 
  
 
 
 
  
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
C CI


L-CsA: 
Treatment of BOS after DLT 
Protocol Number: 
BT – L-CsA – 302 – DLT 
Sponsor: 
Zambon SpA 
 
Final Version 5.0 
Page 74 of 76 
 
 
18 
REFERENCES 
 
1. Kieser M, Friede T (2003). Simple procedures for blinded sample size adjustment that do 
not affect the type I error rate. Stat Med, 22(23):3571-3581. 
2. Rubin DB. Multiple imputation for nonresponse in surveys. John Wiley and Sons, Inc.: 
New York, 1987. 
3. Permutt T, Li F (2017). Trimmed means for symptom trials with dropouts. Pharm Stat, 
16(1):20-28. 
4. Verleden GM, Glanville AR, Lease ED, et al. Chronic lung allograft dysfunction: 
Definition, diagnostic criteria and approaches to treatment. A consensus report from the 
Pulmonary Council of the ISHLT, J Heart Lung Transplant 2019;5:493-503. 
5. de Zwart AES, Riezebos-Brilman A, Lunter GA, Neerken ECU, van Leer-Buter CC, 
Alffenaar JC, van Gemert AP, Erasmus ME, Gan CT, Kerstjens HAM, Vonk JM, 
Verschuuren EAM. Impact of COVID-19 social distancing measures on lung transplant 
recipients: decline in overall respiratory virus infections is associated with stabilisation of 
lung function. Eur Respir J. 2022 Nov 24;60(5):2200085. doi: 10.1183/13993003.00085-
2022. PMID: 35896214; PMCID: PMC9301935. 
6. Fine JP and Gray RJ. A Proportional Hazards Model for the Subdistribution of a Competing 
Risk. J Am Stat Assoc 1999; 94:496–509. 
7. https://euroqol.org/eq-5d-instruments/eq-5d-5l-about/valuation-standard-value-sets/. 
8. https://www.lshtm.ac.uk/research/centres-projects-groups/missing-data#dia-missing-data. 
9. Interim Analysis documents: Interim Analysis Summary Dated 01Dec2021, and Interim 
Analysis Communication Plan, Final Version 1.0 dated 23 August 2021. 
10. Liu J, Jackson K, Weinkauf J, Kapasi A, Hirji A, Meyer S, Mullen J, Nagendran J, Lien D, 
Halloran K. Baseline lung allograft dysfunction is associated with impaired survival after 
double-lung transplantation. J Heart Lung Transplant. 2018 Jul;37(7):895-902. doi: 
10.1016/j.healun.2018.02.014. Epub 2018 Feb 27. PMID: 29602706. 
11. Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of 
the general U.S. population. Am J Respir Crit Care Med. 1999 Jan;159(1):179-87. doi: 
10.1164/ajrccm.159.1.9712108. PMID: 9872837. 
12. Hankinson, J. L., Kawut, S. M., Shahar, E., Smith, L. J., Stukovsky, K. H., & Graham 
Barr, R. (2010). Performance of american thoracic society-recommended spirometry 
reference values in a multiethnic sample of adults the multi-ethnic study of 
atherosclerosis (MESA) lung study. Chest, 137(1), 138–145. 
https://doi.org/10.1378/chest.09-0919 
 
 
 


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 7 5  of 7 6  
 
 
1 9  
A P P E N DI C E S  
1 9. 1  I nt e ri m a n al y si s r e p o rt 
 
C CI
C CI


L -Cs A:  
Treat me nt of B O S after D L T  
Pr ot o c ol N u m ber:  
B T –  L -Cs A –  3 0 2 –  D L T  
S p o ns or : 
Za m b o n S p A  
 
Fi n al  Versi o n  5 . 0 
Pa ge 7 6  of 7 6  
 
 
1 9. 2  I nt e ri m a n al y si s c o m m u ni c ati o n pl a n 
 
C CI
C CI
P P D