Clinical trial NCT02450552
Conditions: Amyotrophic Lateral Sclerosis
Keywords: Amyotrophic Lateral Sclerosis ALS Lou Gehrig
Sponsor: Brian Wainger
Start date: 2015-06-01; Completion date: 2018-02-01
Enrollment: 65 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
This study evaluates the effect of retigabine (600 mg/day, 900 mg/day, or placebo) on motor neuron activity in people with Amyotrophic Lateral Sclerosis (ALS). The total study duration is approximately 14 weeks. ALS subjects will take study drug for approximately 10 weeks.

Detailed description:
One of the major disease features of ALS is the progressive death of motor neurons. Human, rodent and stem cell-based model studies support the hypothesis that neuronal hyperexcitability may contribute to neurodegeneration in both sporadic and familial ALS. The investigators are doing this research study to find out whether retigabine will reduce motor neuron excitability in people with ALS. the investigators will also determine whether the drug is tolerable and safe for patients with ALS.

The proposed study will determine how the potassium channel opener ezogabine (retigabine) affects neurophysiological measures of upper and lower motor neuron excitability in ALS patients as assessed by transcranial magnetic stimulation (TMS) and threshold tracking nerve conduction studies (TTNCS), respectively. The study will include the recruitment of approximately 60 unmatched healthy control subjects for analysis of variability of the neurophysiological tests prior to recruitment of ALS subjects. There will also be 12 matched healthy control subjects, recruited at the same time as ALS subjects.

Arms: arm 1: None arm 2: None arm 3: None
Interventions: intervention 1: Ezogabine intervention 2: Placebo
Intervention descriptions: intervention 1: Potiga is FDA-approved for adjunctive treatment of partial-onset seizures in patients aged 18 years and older who have responded inadequately to several alternative treatments. intervention 2: Matched placebo

Protocol documents:
Prot_001.pdf: 
Cover Page – Protocol 
 
 
 
 
 
Study Official Title: A Phase 2 Pharmacodynamic Trial 
of Ezogabine on Neuronal Excitability in Amyotrophic 
Lateral Sclerosis 
 
NCT #: NCT02450552 
 
Version Date of the Document: October 31, 2016 
 
 
 
 
 


 
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A Phase 2 Pharmacodynamic Trial of Ezogabine  
on Neuronal Excitability in Amyotrophic Lateral Sclerosis 
 
 
 
 
Regulatory Sponsor: 
Brian J. Wainger, MD, PhD 
Funding Sponsor: 
 
 
ALS Association (ALSA) 
GlaxoSmithKline (GSK) 
Harvard Stem Cell Institute (HSCI) 
Neurological Clinical Research Institute (NCRI) 
 
Study Product: 
Ezogabine (Potiga®)/Retigabine 
Version Number: 
5.0  
Original Date: 
09 March  2015 
 
 
 
ALS Consortium: 
Northeast ALS Consortium (NEALS) 
 
 
 
The information contained herein is confidential and proprietary in nature and will not be 
disclosed to any third party without written approval of authorized designee. 
This document may be disclosed to the appropriate institutional review boards  
under the condition that they maintain confidentiality.  
 
 
 
 
 


 
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STATEMENT OF COMPLIANCE 
 
This study will be conducted in compliance with the protocol, International Conference on 
Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use 
(ICH), Good Clinical Practice (GCP), and the applicable regulatory requirements, United States 
Code of Federal Regulations (CFR) Title 45 CFR Part 46 and Title 21 CFR Parts 50, 56, and 
312. 
 


 
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SIGNATURE PAGE 
I have read the attached protocol entitled, “A Phase 2 Pharmacodynamic Study of Ezogabine on 
Neuronal Excitability in Amyotrophic Lateral Sclerosis” dated 09 March 2015 (Version Number 
5.0) and agree to abide by all described protocol procedures.  I agree to comply with the 
International Conference on Harmonisation Tripartite Guideline on Good Clinical Practice, 
applicable guidelines identified in 21 CFR Parts 11, 50, 54, and 312, local Institutional Review 
Board (IRB) guidelines and policies, and the Health Insurance Portability and Accountability Act 
(HIPAA). 
 
 
Site Investigator: _______________________________________________________________ 
 
 
 
Signed: 
 
Date: 
 
 
 
 
 
 


 
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TABLE OF CONTENTS 
STATEMENT OF COMPLIANCE ····························································································· 3 
SIGNATURE PAGE ·············································································································· 4 
LIST OF ABBREVIATIONS ···································································································· 9 
PROTOCOL SUMMARY ······································································································ 11 
SCHEDULE OF ACTIVITIES (ALS SUBJECTS)1 ······································································ 15 
SCHEDULE OF ACTIVITIES (UNMATCHED CONTROLS)1 ························································ 16 
SCHEDULE OF ACTIVITIES (MATCHED CONTROLS)1,4 ··························································· 17 
EZOGABINE WORKFLOW FOR ALS SUBJECTS AND MATCHED HEALTHY CONTROLS ············ 18 
1 
ETHICS/PROTECTION OF HUMAN SUBJECTS ······························································· 19 
1.1 
INSTITUTIONAL REVIEW BOARD (IRB) ·································································· 19 
1.2 
ETHICAL CONDUCT OF STUDY ··········································································· 19 
1.3 
SUBJECT INFORMATION AND CONSENT ································································ 19 
2 
INTRODUCTION: BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE ················· 20 
2.1 
BACKGROUND INFORMATION ············································································ 20 
2.2 
RATIONALE ·································································································· 21 
2.3 
POTENTIAL RISKS AND BENEFITS ······································································· 22 
2.3.1 
Potential Risks ······························································································································ 22 
2.3.2 
Known Potential Benefits ············································································································ 25 
3 
OBJECTIVES ············································································································· 26 
3.1 
STUDY OBJECTIVES························································································ 26 
3.2 
STUDY OUTCOME MEASURES ············································································ 27 
3.2.1 
Primary Outcome Measure ········································································································· 27 
3.2.2 
Secondary Outcome Measures ·································································································· 27 
4 
STUDY DESIGN ·········································································································· 28 
4.1 
OVERALL STUDY DESIGN AND PLAN ··································································· 28 
4.2 
STUDY CENTERS ··························································································· 28 
4.3 
STUDY DURATION ·························································································· 28 
4.4 
PROTOCOL ADHERENCE ·················································································· 28 
5 
STUDY ENROLLMENT AND WITHDRAWAL ··································································· 29 
5.1 
NUMBER OF STUDY SUBJECTS ·········································································· 29 
5.2 
INCLUSION AND EXCLUSION CRITERIA FOR ALS SUBJECTS ······································· 29 
5.2.1 
Inclusion Criteria ··························································································································· 29 
5.2.2 
Exclusion Criteria·························································································································· 30 
5.3 
INCLUSION AND EXCLUSION CRITERIA FOR HEALTHY CONTROLS (UNMATCHED AND 
MATCHED) ············································································································· 31 
5.3.1 
Inclusion Criteria ··························································································································· 31 
5.3.2 
Exclusion Criteria·························································································································· 31 
5.4. 
TREATMENT ASSIGNMENT PROCEDURES ······························································ 32 
5.5. 
RANDOMIZATION PROCEDURES ········································································· 32 


 
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5.6. 
REASONS FOR WITHDRAWAL ············································································ 32 
5.7. 
HANDLING OF WITHDRAWALS ············································································ 32 
5.8. 
TERMINATION OF STUDY ·················································································· 33 
6 
TREATMENTS ADMINISTERED ···················································································· 34 
6.1 
TREATMENTS ································································································ 34 
6.1.1 
Study Product Description··········································································································· 34 
6.1.2 
Placebo ·········································································································································· 34 
6.2 
ACQUISITION ································································································ 34 
6.2.1 
Formulation, Packaging, and Labeling ······················································································ 35 
6.2.2 
Product Storage and Stability ····································································································· 35 
6.3 
DOSAGE, PREPARATION AND ADMINISTRATION OF STUDY INTERVENTION/INVESTIGATIONAL 
PRODUCT ·············································································································· 35 
6.3.1  
Missed Doses ······························································································································· 36 
6.3.2 
Crushing Pills ································································································································ 36 
6.3.3  
Feeding Tube ································································································································ 36 
6.4 
MODIFICATION OF STUDY INTERVENTION/INVESTIGATIONAL PRODUCT FOR A SUBJECT ······ 37 
6.4.1. 
Dosage Discontinuation ·············································································································· 37 
6.5 
ACCOUNTABILITY PROCEDURES FOR EZOGABINE ··················································· 38 
6.6 
ASSESSMENT OF SUBJECT COMPLIANCE WITH EZOGABINE ······································· 38 
6.7 
PRIOR AND CONCOMITANT THERAPY ··································································· 38 
6.7.1 
Prohibited Medications and Contraindications ········································································· 38 
7  
STUDY SCHEDULE (UNMATCHED HEALTHY CONTROLS) ·············································· 40 
7.1 
VISIT 1 (SCREENING) ······················································································ 40 
7.1.1 
Screen Failures ····························································································································· 40 
7.2 
VISIT 2 ········································································································ 40 
7.3 
VISIT 3 (4 & 5 IF NEEDED) ················································································· 41 
8 
STUDY SCHEDULE (ALS SUBJECTS) ··········································································· 42 
8.1 
SCREENING VISIT ··························································································· 42 
8.1.1 
Screen Failures ····························································································································· 43 
8.3 
WEEK 2 AND WEEK 10 TELEPHONE CALLS ··························································· 44 
8.4 
WEEK 4 VISIT ······························································································· 44 
8.5 
WEEK 6 VISIT ······························································································· 45 
8.6 
WEEK 8 VISIT ······························································································· 45 
8.7 
WEEK 12 VISIT ······························································································ 46 
8.8 
WEEK 14 TELEPHONE CALL ············································································· 46 
8.9 
FINAL SAFETY VISIT & TELEPHONE CALL ····························································· 46 
8.10 
PROTOCOL DEVIATIONS ··················································································· 47 
8.11 
MISSED VISITS AND PROCEDURES ······································································ 47 
8.12 SURVIVAL DATA ······························································································· 48 
9 
STUDY SCHEDULE (MATCHED HEALTHY CONTROLS) ··················································· 49 
9.1 
SCREENING VISIT ··························································································· 49 
9.1.1 
Screen Failures ····························································································································· 49 
9.2 
WEEK 6 VISIT ······························································································· 49 
9.3 
WEEK 12 VISIT ······························································································ 50 


 
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10 
CLINICAL ASSESSMENTS AND OUTCOME MEASURES ·················································· 51 
10.1 
CLINICAL ASSESSMENTS ················································································· 51 
10.1.1 
Vital Signs, Height & Weight ······································································································· 51 
10.1.2 
Clinical Laboratory Assessments ······························································································· 51 
10.1.3 
Blood Sample for iPSCs ·············································································································· 52 
10.1.4  
12-Lead Electrocardiogram (ECG) ···························································································· 52 
10.1.5 
 Physical Examination ·················································································································· 52 
10.1.6 
Neurological Examination ··········································································································· 52 
10.1.7 
Columbia Suicide Severity Rating Scale (C-SSRS) ································································ 52 
10.1.8 
Ophthalmological Examination ··································································································· 53 
10.1.9 
Lumbar Puncture ·························································································································· 53 
10.1.10   Adverse Events ······························································································································· 54 
10.1.11  Blood Biobanking ····························································································································· 54 
10.1.12  Neurophysiological Testing ············································································································ 54 
10.1.13  American Urological Association (AUA) Symptom Score ··································································· 55 
10.1.14  Blindedness Questionnaire and Exit Survey ························································································· 55 
10.2  CLINICAL OUTCOME MEASURES ··········································································· 55 
10.2.1 ALSFRS-R ·································································································· 55 
10.2.2 Slow Vital Capacity (SVC) ················································································································· 55 
10.2.3 Edinburgh Handedness Inventory Short Form ······················································································· 56 
10.2.4 Hand-held Dynamometry (HHD) ··········································································································· 56 
10.2.6 Training and Validation ······················································································································· 56 
10.2.7 Assessment of Muscle Symptoms ···································································································· 56 
10.2.7.1 Muscle Cramps ································································································································ 56 
10.2.7.2  Fasciculations ····································································································································· 57 
11 
SAFETY AND ADVERSE EVENTS ················································································· 58 
11.1 
DEFINITIONS OF AES, SUSPECTED ADVERSE DRUG REACTIONS & SAES ······················ 58 
11.1.1 
Adverse Event and Suspected Adverse Drug Reactions ······················································· 58 
11.1.1.1  Adverse Events of Special Interest ················································································· 59 
11.1.2 
Serious Adverse Events ·············································································································· 59 
11.2 
ASSESSMENT AND RECORDING OF ADVERSE EVENTS ·············································· 60 
11.2.1 
Assessment of Adverse Events ································································································· 61 
11.2.2 
Relatedness of Adverse Event to Investigational Product ····················································· 61 
11.2.3 
Recording of Adverse Events ····································································································· 62 
11.3 
ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS - REPORTABLE EVENTS ·················· 62 
12 
DATA SAFETY MONITORING ······················································································· 64 
12.1 
DATA AND SAFETY MONITORING BOARD ······························································ 64 
12.2 
SAFETY MONITORING ······················································································ 64 
12.2.1 
Safety Management Resource Team························································································ 64 
12.2.2 
Medical Monitoring ······················································································································· 65 
13 
STATISTICAL CONSIDERATIONS ················································································· 66 
13.1 
ANALYSIS POPULATIONS ················································································· 66 
13.2 
ANALYSIS OF UNMATCHED HEALTHY CONTROL SUBJECTS ········································ 66 
13.3 
PRIMARY ANALYSIS ························································································ 67 
13.4 
SECONDARY ANALYSES ·················································································· 67 
13.5 
MISSING DATA ······························································································ 68 


 
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13.6 
MULTIPLICITY ADJUSTMENT FOR PRIMARY AND KEY SECONDARY ENDPOINTS ················ 68 
13.7 
INTERIM ANALYSIS ························································································· 68 
13.8 
POWER CALCULATIONS ··················································································· 69 
14 
DATA COLLECTION, MANAGEMENT AND MONITORING ················································· 70 
14.1 
ROLE OF DATA MANAGEMENT ··········································································· 70 
14.1.1 
Data Entry and Checks ················································································································ 70 
14.1.2 
Data Lock Process ······················································································································· 70 
14.1.3 
Quality Assurance ························································································································ 70 
14.2 
CLINICAL MONITORING ···················································································· 71 
14.3 
DATA HANDLING AND RECORD KEEPING ······························································ 71 
14.3.1 
 Confidentiality ······························································································································ 71 
14.3.2 GLOBAL UNIQUE IDENTIFIER (GUID) ··································································· 72 
14.3.3 
 Study Discontinuation ················································································································· 72 
14.3.4 
 Retention of Records ·················································································································· 72 
14.3.5 
 Publications ·································································································································· 72 
14.3.6 
 Use of Samples ··························································································································· 72 
15 
LITERATURE REFERENCES ························································································ 74 
16 
APPENDICES ············································································································· 77 
16.1 APPENDIX I: EL ESCORIAL WORLD FEDERATION OF NEUROLOGY CRITERIA FOR THE DIAGNOSIS 
OF ALS ················································································································ 77 
16.2 APPENDIX II: ALS FUNCTIONAL RATING SCALE – REVISED (ALSFRS-R) ························· 78 
16.3 APPENDIX III: COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS) BASELINE VERSION ·· 82 
16.4 APPENDIX IV: COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS) SINCE LAST VISIT ···· 85 
16.5 APPENDIX V: RETIGABINE MUSCLE CRAMP DIARY – VISUAL ANALOG SCALE (PAIN SCALE) ·· 89 


 
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LIST OF ABBREVIATIONS 
ADR 
Adverse Drug Reaction  
AE 
Adverse Event 
ANOVA 
Analysis of Variance  
ALS 
Amyotrophic Lateral Sclerosis 
ALSFRS-R 
Amyotrophic Lateral Sclerosis Functional Rating Scale - Revised 
APB 
Abductor Pollicis Brevis 
AUA 
American Urological Association  
BID 
Twice a Day 
CBC 
Complete blood count 
CFR 
Code of Federal Regulations 
CMAP 
Compound motor action potential 
CSF 
Cerebrospinal Fluid  
DSMB 
Data and Safety Monitoring Board 
eCRF 
Electronic Case Report Form 
EDC 
Electronic Data Capture  
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
HHD 
Hand Held Dynamometry 
HIPAA 
Health Insurance Portability and Accountability Act 
IB 
Investigator’s Brochure  
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
iPSC 
Induced Pluripotent Stem Cell 
IRB 
Institutional Review Board 
ITT 
Intent to Treat  
LMN 
Lower Motor Neuron 
LP 
Lumbar Puncture 
MEP                      
NEALS 
Motor Evoked Potential 
Northeast ALS Consortium 
MOP 
Manual of Procedures 
NCRI CC 
Neurological Clinical Research Institute Coordination Center  
NCS 
Nerve Conduction Studies 
PHI 
Protected Health Information 
PI 
Principal Investigator 
PK 
Pharmacokinetic 
QA 
Quality Assurance 
QC 
Quality Control 
QD 
Once a Day  


 
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SAE 
SI 
SICI 
Serious Adverse Event 
Site Investigator 
Short-Interval Intracortical Inhibition 
SMaRT 
Safety Management Resource Team 
SOP 
Standard Operating Procedure 
SVC 
Slow Vital Capacity 
TID 
Three Times a Day  
TMS  
Transcranial Magnetic Stimulation 
UMN 
Upper Motor Neuron 
US 
WOCBP 
United States 
Women of Child Bearing Potential 


 
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PROTOCOL SUMMARY 
Study Title 
A Phase 2 Pharmacodynamic Study of Ezogabine on Neuronal Excitability in Amyotrophic 
Lateral Sclerosis 
 
Version Number 
5.0 
 
Study Indication 
Amyotrophic Lateral Sclerosis (ALS) 
 
Phase of Development 
2 
 
Rationale for the Study 
A significant body of literature from human neurophysiology studies of upper and lower motor 
neurons supports the hypothesis that neuronal hyperexcitability may contribute to 
neurodegeneration in both sporadic and familial ALS, and lower motor neuron excitability 
indices have been found prospectively to predict survival duration in recently diagnosed sporadic 
ALS patients. Data from the SOD1 mouse model also support this hypothesis, and now we have 
found that induced pluripotent stem cell-derived (iPSC) motor neurons from ALS patients are 
hyperexcitable compared to control-derived motor neurons. Based on the identified mechanism 
of reduced delayed-rectifier potassium channel currents (discussed below), we determined that 
the Kv7 agonist ezogabine (retigabine/Potiga) could reduce the in vitro motor neuron 
hyperexcitability. Consistent with the importance of hyperexcitability in the ALS disease 
process, we also found that ezogabine improved the in vitro survival of ALS-derived motor 
neurons, returning the survival to that of control-derived motor neurons. We now propose to 
determine how ezogabine affects neurophysiological measures of upper and lower motor neuron 
excitability in ALS patients as assessed by transcranial magnetic stimulation and threshold 
tracking nerve conduction studies, respectively, as such studies could be used as 
pharmacodynamic markers of a drug’s effect on blocking motor neuron hyperexcitability. We 
will also draw subject blood samples to obtain and characterize iPSC-derived motor neurons 
from select trial subjects. Thus, a phase two trial investigating ezogabine in ALS patients could 
both 
evaluate 
a 
promising 
drug 
using 
neurophysiological 
excitability 
indices 
as 
pharmacodynamic monitors and serve as a proof of concept study for determining how iPSC-
derived motor neurons might provide clinically relevant information with minimal time delay. 
Despite failed trials of multiple other anti-epileptics, ezogabine’s unique mechanism combined 
with the strong preliminary data makes it an attractive candidate for the proposed translational 
study. Documentation of an effect on reducing hyperexcitability in ALS subjects, as well as 


 
Phase 2 Trial of Ezogabine in ALS 
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Page 12 of 90 
validating safety and determining dose, could pave the way for a larger trial to investigate effect 
on ALS using a combined measure of function/survival. 
 
Study Design 
This is a multicenter, randomized, double-blind, placebo-controlled 14-week study evaluating 
the effect of ezogabine treatment on neuronal excitability in ALS subjects. 
 
Study Objectives and Endpoints  
The primary efficacy outcome is change in paired pulse short-interval intracortical inhibition 
(SICI) assessed by transcranial magnetic stimulation (TMS) after treatment with 600 mg/day or 
900 mg/day of ezogabine vs. matched oral placebo. Change in motor evoked potential (MEP) 
threshold is the key secondary efficacy outcome. Additional upper motor neuron secondary 
outcomes include MEP amplitude, MEP latency, cortical silent period, and paired pulse 
facilitation, assessed by TMS. Lower motor neuron excitability outcomes include change in 
electrotonus, recovery cycle and strength duration time constant as determined by threshold 
tracking axonal nerve conduction studies (NCS) and CMAP amplitude.   The effect of retigabine 
on strength will be assessed using hand held dynamometry, and muscle symptoms will also be 
assessed utilizing a subject muscle symptom diary, in which the subjects will record the 
frequency, location and severity of their muscle cramps and fasciculations over the course of 
study treatment. Additional secondary outcomes include dosing, tolerability and safety of 
ezogabine in ALS patients. Serum and optional cerebrospinal fluid (CSF) sampling will be 
collected (at Week 6) for limited pharmacokinetic (PK) analysis and banking.  
 
Exploratory outcomes include in vitro analysis of subject iPSC-derived motor neurons and in 
vitro response of motor neuron firing to ezogabine treatment. We will also recruit approximately 
72 healthy control subjects to perform quality control analysis for the neurophysiology testing 
(approximately 60 healthy controls) and to correlate differences between ALS subjects and 
healthy controls as assessed using in vitro measurements of hyperexcitability compared to using 
the in vivo neurophysiological ones (approximately 12 healthy controls). Healthy control subjects 
will undergo neurophysiological testing but not be treated with drug or placebo. Approximately 
sixty (60) healthy control subjects will be evaluated prior to ALS subjects, to assess test-retest 
and inter-investigator variability for the neurophysiology measurements.  Approximately twelve 
(12) healthy control subjects will be recruited in parallel with the ALS subjects, to allow an age 
and site-matched comparison between ALS and healthy control subjects. These 12 healthy 
control subjects will also undergo blood sampling for iPSC generation.  
 
Study Locations 
Approximately 12 Northeast ALS Consortium (NEALS) centers in the US will participate in the 
study.  
 
Number of Planned Subjects 


 
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Approximately 192 subjects will be enrolled in this study. Approximately sixty (60) healthy 
controls will be enrolled for assessment of short-term reliability of TMS and NCS measurements 
(approximately five (5) from each site) prior to recruiting ALS subjects. Approximately twelve 
(12) additional healthy controls will be age and site-matched and enrolled in parallel with the 
ALS subjects. An initial sample of 45 ALS subjects will be recruited and randomized prior to an 
interim futility analysis. If the trial of one of the two active treatment groups is not stopped early 
for futility or safety, then approximately 120 ALS subjects will be recruited in total. 
 
Study Population 
This study will be conducted in ALS subjects who meet the El Escorial criteria of possible, 
laboratory-supported probable, probable, or definite criteria for a diagnosis of ALS.  At 
screening, eligible subjects must be at least 18 years old, must have a slow vital capacity (SVC) 
≥ 50% of expected, and must provide written informed consent prior to screening.  Subjects on a 
stable dose of riluzole and those not taking riluzole, and women of child-bearing age at screening 
are eligible for inclusion as long as they meet specific protocol requirements.  This study will 
also be conducted in healthy controls that do not have a history or family history of possible 
motor neuron disease. Detailed criteria are described in the body of the protocol. 
 
Treatment Groups 
ALS subjects will be randomly assigned in a 1:1:1 ratio to oral ezogabine (Potiga® or 
Retigabine) 600 mg/day, 900 mg/day or matching placebo. 
 
Healthy controls will not be randomized nor receive study drug. 
 
Duration of Treatment and Follow-up 
ALS subjects will remain on randomized, placebo-controlled, double-blind treatment for 10 
weeks as detailed in the Schedule of Activities.  Each randomized subject will also have a Week 
14 Telephone Call to assess for adverse events (AEs), changes in concomitant medications and 
to administer the ALSFRS-R. 
 
Healthy controls will have neurophysiological testing but will otherwise only undergo limited 
components (see separate Schedule of Activities). The number of healthy controls recruited and 
the number of their study visits may vary based on the ongoing recommendation of the study 
Steering Committee, which will review the incoming data dynamically. Approximately five (5) 
unmatched healthy control subjects at each site will undergo three (3) study visits each for 
neurophysiological testing and test-retest reliability estimates over up to a six week period. 
Based on review of the incoming data by the Steering Committee, changes in the number of 
unmatched healthy controls and number of visits required may occur, with a maximum potential 
number of five (5) visits per subject. The Steering Committee will determine when individual 
sites will be activated to begin recruitment of ALS subjects based on test-retest and inter-
investigator reliability.    
 


 
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Study Workflow  
 
 
 
 
 
 
 
 
 
 
 
 


 
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SCHEDULE OF ACTIVITIES (ALS SUBJECTS)1 
Activity 
Screening 
Visit 
Baseline 
Visit2 
Week 2 
Call 
Week 4 
Visit3 
Week 6 
Visit3 
Week 8 
Visit3 
Week 10 
Call 
Week 12 
Visit 
Week 14 
Call 
CLINIC 
CLINIC 
CALL 
CLINIC 
CLINIC 
CLINIC 
CALL 
CLINIC 
CALL 
-21 days 
Day 0 
Day 14  
± 3 
Day 28  
± 3 
Day 42  
± 3 
Day 56  
± 3 
Day 70  
± 3 
Day 84  
± 3 
Day 98  
+5 
Written Informed Consent  
X 
 
 
 
 
 
 
 
 
Inclusion/Exclusion Review  
X 
 
 
 
 
 
 
 
 
Medical History  
X 
 
 
 
 
 
 
 
 
Demographics  
X 
 
 
 
 
 
 
 
 
ALS Diagnosis History 
X 
 
 
 
 
 
 
 
 
Concomitant Medication Review 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse Event Review4 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Physical Examination  
X 
 
 
 
 
 
 
X 
 
Neurological Exam 
X 
 
 
 
 
 
 
X 
 
Manual Muscle Testing (MMT) 
X 
 
 
 
 
 
 
X 
 
Vital Signs5  
X 
X 
 
X 
X 
X 
 
X 
 
12-Lead Electrocardiogram (ECG) 
X 
X15 
 
 
X 
 
 
X 
 
Height & Weight6 
X 
X 
 
X 
X 
X 
 
X 
 
Safety Labs7  
X 
 
 
X 
X 
X 
 
X 
 
Urological Symptom Score 
X 
 
 
X 
 
X 
 
X 
 
ALSFRS-R 
X 
X 
 
X 
X 
X 
 
X 
 
Slow Vital Capacity (SVC) 
X 
X 
 
X 
X 
X 
 
X 
 
Hand Held Dynamometry (APB only) 
X 
X 
 
X 
X 
X 
 
X 
 
Assign Global Unique Identifier (GUID) 
X 
 
 
 
 
 
 
 
 
Blindedness Questionnaire and Exit Survey  
 
 
 
 
 
 
 
X 
 
Suicide Assessment (C-SSRS) 
 
X 
 
X 
X 
X 
 
X 
 
Edinburgh Handedness Inventory – short form 
X 
 
 
 
 
 
 
 
 
Blood collection for iPSC Lines 
 
 
 
X8  
(X8 ) 
(X8 ) 
 
 
 
Neurophysiological Testing (TMS/NCS)  
X 
X 
 
 
X 
X 
 
 
 
Ophthalmologic Examination9 
 
X 
 
 
 
 
X 
 
Lumbar Puncture (Optional)  
 
 
 
 
X16 
 
 
 
 
Pharmacokinetics (PK)/Biobanking 
 
 
 
 
X 
 
 
 
 
Telephone Call10 
 
 
X 
 
 
 
X 
 
X 
Randomization11 
 
X 
 
 
 
 
 
 
 
Administer/Dispense Study Drug 
 
X12 
 
X 
 
 
 
 
 
Drug Accountability/ Compliance 
 
X 
 
X13 
X13 
X13 
 
X13 
 
Review of Muscle Symptoms Diary14 
 
X 
 
X 
X 
X 
 
X 
 
Fasciculation Assessment Form 
 
X 
 
X 
X 
X 
 
X 
 
 
1 All clinic visits after the Baseline Visit will have a +/- 3 day window. 
2 Screening procedures must be completed prior to the Baseline Visit, which will be scheduled up to 21 days after the Screening Visit. 
3 Study staff should document the time the last dose of ezogabine was administered. 
4Adverse events that occur AFTER signing the informed consent form will be recorded. 
5 Vital signs include systolic and diastolic pressure in mm Hg, respiratory rate/minute, heart rate/minute and temperature.   
6 Height measured at Screening Visit only. 
7 Labs include Hematology (CBC with differential), Complete Chemistry Panel, Liver Function Tests, Urinalysis and serum pregnancy test (WOCBP, screening visit only).  
8 Blood for iPSC lines can be collected at either week 4, 6 or 8. 
9 Ophthalmologic Examinations may be scheduled separately, but within 14 days prior to Baseline Visit and within 14 days of Week 12 Visit. 
10 Subjects will be called at the designated time points, as a reminder to escalate up or taper off study drug, when appropriate. 
11 Randomization should occur at or prior to the Baseline Visit. 
12 Administer first dose of study drug AFTER all Baseline Visit procedures are completed (with the exception of ECG testing).  Subjects to take study drug until the Week 10 call. 
13 Review dosing diary 
14 Muscle symptoms will be completed every day, starting at the Baseline visit, with a Muscle Symptom Diary and should be reviewed by study staff at every visit after Baseline.    
15 ECG testing should be performed 3 hours post initial study drug administration. 
16 Lumbar puncture is optional 


 
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SCHEDULE OF ACTIVITIES (UNMATCHED CONTROLS)1 
Activity 
Visit 1 (Screening) 
Visit 25 
Visit 34,5 
CLINIC 
CLINIC 
CLINIC 
Written Informed Consent 
X 
 
 
Inclusion/Exclusion Review 
X 
 
 
Medical History 
X 
 
 
Demographics 
X 
 
 
Vital Signs2 
X 
 
 
Height and Weight 
X 
 
 
Edinburgh Handedness Inventory – 
short form 
X 
 
 
Neurophysiological Testing  
(TMS/NCS) 
X 
X 
X 
Concomitant Medication Review 
X 
X 
X 
Adverse Event Review3 
X 
X 
X 
 
1Visits are defined by the required components, which do not need to take place on the same day. Specifically, TMS and NCS sessions can be on separate days. Please note that a 
screening TMS and NCS test must be complete and meet eligibility criteria prior to additional TMS and NCS testing performed. All three NCS sessions can occur in a single day if 
preferred. Up to two TMS sessions can occur in a single day, but the three TMS sessions must be spread out over at least two days. 
2 Vital signs include systolic and diastolic pressure in mmHg, respiratory rate/minute, heart rate/minute and temperature.   
3 Adverse events that occur AFTER signing the informed consent form will be recorded. 
4 As determined by Steering Committee review of neurophysiology data, unmatched controls could be asked to return for up to 5 study visits. 
5 All visits must be completed < 6 weeks from the screening visit. 


 
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Page 17 of 90 
SCHEDULE OF ACTIVITIES (MATCHED CONTROLS)1,4 
Activity 
Screening 
Visit 
Week 6 Visit 
Week 12 Visit 
CLINIC 
CLINIC 
CLINIC 
 
42 days 
+10 
84 days  
+10 
Written Informed Consent 
X 
 
 
Inclusion/Exclusion Review 
X 
 
 
Demographics 
X 
 
 
Medical History 
X 
 
 
Neurological Examination 
X 
 
 
Vital Signs2 
X 
X 
X 
Height and Weight 
X 
 
 
Blood collection for iPSC Lines 
X 
(X5) 
(X5) 
Edinburgh Handedness Inventory – short form 
X 
 
 
Neurophysiological Testing  
(TMS/ NCS)  
X 
X 
X 
Concomitant Medication Review 
X 
X 
X 
Adverse Event Review3 
X 
X 
X 
 
1 All clinic visits after the Screening/Baseline Visit will have a +/- 10 day window. 
2 Vital signs include systolic and diastolic pressure in mmHg, respiratory rate/minute, heart rate/minute and temperature.   
3 Adverse events that occur AFTER signing the informed consent form will be recorded. 
4Visits are defined by the required components, which do not need to take place on the same day. Specifically, TMS and NCS sessions can be on separate days. 
5 Blood for iPSC lines can be collected at Screening, Week 6 or Week 12 
 
 
 
 
 
 
 


 
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EZOGABINE WORKFLOW FOR ALS SUBJECTS AND MATCHED 
HEALTHY CONTROLS 
Study Schematic: Randomized, double-blind, placebo-controlled parallel Phase 2 study of ezogabine at 2 
active doses for 10 weeks treatment 
 
 


 
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1 
ETHICS/PROTECTION OF HUMAN SUBJECTS 
1.1 
Institutional Review Board (IRB) 
This study will be conducted in compliance with current Good Clinical Practices (GCP) and 
Title 21 Part 56 of the US Code of Federal Regulations (CFR) relating to IRBs.  
1.2 
Ethical Conduct of Study 
The study will be conducted in accordance with GCP defined by the International Conference on 
Harmonization (ICH) and the ethical principles of the Declaration of Helsinki. 
1.3 
Subject Information and Consent 
This study will be conducted in compliance with Title 21 Part 50 of the US CFR Federal 
Regulations and ICH Guidance Documents pertaining to informed consent.  At the first visit, 
prior to initiation of any study-related procedures, subjects will be informed about the nature and 
purpose of the study, participation/termination conditions, and risks and benefits. Subjects will 
be given adequate time to ask questions and become familiar with the study prior to providing 
consent to participate. Subjects who wish to give their written consent to participate in the study 
will be provided with a copy of the fully executed consent form for their records. 


 
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2 
INTRODUCTION: BACKGROUND INFORMATION AND 
SCIENTIFIC RATIONALE 
2.1 
Background Information 
This is a phase 2, multi-center, randomized, double-blind, placebo-controlled 14 week study (10 
weeks of drug treatment) evaluating the safety and tolerability, dosing, and effect on 
neurophysiological excitability measures of ezogabine in ALS subjects. 
 
Multiple lines of evidence demonstrate the importance of motor neuron hyperexcitability as a 
disease mechanism in ALS. Human neurophysiological studies using nerve conduction threshold 
testing demonstrate axonal hyperexcitability of motor neurons in both sporadic and familial ALS 
patients (Bostock et al., 1995; Vucic & Kiernan, 2010) and parallel studies using TMS have 
shown cortical motor neuron hyperexcitability (reviewed in Vucic et al., 2012). Recently, an 
initial prospective stratification by axonal excitability was found to predict survival in sporadic 
ALS patients, in that subjects with higher excitability indices survived for shorter periods than 
subjects with lower initial excitability indices (Kanai et al., 2012). 
 
Several independent groups have documented hyperexcitability in primary mouse SOD1G93A 
spinal motor neurons (Pieri et al., 2003; Kuo et al., 2004; van Zundert et al., 2008). Riluzole, the 
only FDA-approved ALS medication, blocks the persistent sodium current – a likely contributor 
to motor neuron hyperexcitability in ALS (Kuo et al., 2005). Furthermore, the toxic effects of 
SOD1G93A astrocyte-conditioned media may be mediated through increasing motor neuron 
excitability (Fritz et al., 2013). Thus, motor neuron hyperexcitability may represent a 
convergence of both cell-autonomous and non cell-autonomous disease mechanisms, making it 
an ideal therapeutic target. 
 
In our study (Wainger et al., 2014), we identified primary motor neuron hyperexcitability 
markers in motor neurons derived using induced pluripotent stem cells (iPSCs) from ALS 
patients compared to healthy controls. We recorded decreased delayed-rectifier potassium 
currents in the ALS compared to control-derived motor neurons. As ezogabine’s primary 
mechanism of action is to increase such currents, we hypothesized that the drug could 
compensate for the observed current reduction we found in ALS motor neurons. Indeed, we 
observed that ezogabine blocks hyperexcitability and improves motor neuron survival in vitro, 
thus showing that the increased excitability is likely linked to motor neuron death. We observed 
phenotypic motor neuron hyperexcitability and its reduction by ezogabine treatment in vitro in 
motor neurons derived from a range of familial ALS patients, including those due to SOD1 
mutation, C9orf72 expansion, and fused-in-sarcoma mutation. 
 
Despite the broad range of studies suggesting the importance of upper and lower motor neuron 
hyperexcitability in ALS, few studies have tried to employ the specific neurophysiological tests 


 
Phase 2 Trial of Ezogabine in ALS 
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Page 21 of 90 
used to identify clinical hyperexcitability in ALS subjects as pharmacodynamic markers. 
Caramia and colleagues showed that gabapentin and diazepam, but not riluzole, reduced cortical 
hyperexcitability in ALS subjects (Caramia et al., 2000). Using similar outcomes, Stefan and 
colleagues did find that riluzole reduced cortical hyperexcitability (Stefan et al., 2001). One may 
argue that most anti-epileptics reduce cortical excitability and that there is no reason to suspect 
otherwise in ALS subjects. However, the magnitude of such effects in ALS subjects will be 
important for determining dosing of a potential larger study.  
 
A relatively small number of studies have shown the proposed neurophysiological outcome 
measures of neurophysiological excitability are stable enough in ALS subjects over the proposed 
study time course to reliably compare to baseline (Floyd et al., 2009; Cheah et al., 2012). For this 
reason, it is critical that we include a placebo-treated control group and a matched and untreated 
healthy control group as comparisons. 
2.2 
Rationale 
The overarching rationale for the proposal is that motor neuron hyperexcitability contributes to 
neurodegeneration in ALS and that reduction of neuronal hyperactivity may slow the disease 
course. The clinical neurophysiological techniques used to demonstrate hyperexcitability may be 
useful as biomarkers to indicate reduction in excitability with treatment. Studies involving 
clinical neurophysiology, mouse motor neuron models and human iPSC-derived motor neurons 
from ALS patients all suggest that motor neuron hyperexcitability may contribute to motor 
neuron death in ALS. In particular, in vitro treatment of ALS patient-derived motor neurons with 
ezogabine can reverse the hyperexcitability and improve motor neuron survival. On account of 
these data, the primary goal of this study is to determine whether ezogabine treatment safely 
reduces neurophysiological indices of motor neuron hyperexcitability in ALS subjects.  
 
The upper dose limit for this study was chosen based on tolerability in previous epilepsy studies 
(Porter et al, 2007; Brodie et al, 2010; French et al, 2011). Oral doses of 600 mg/day (all doses 
divided TID), 900 mg/day, and 1200 mg/day were used in two of the three studies. At 1200 
mg/day, subject drop out due to AEs was nearly 30% (vs. 20% in the 900 mg/day dose) in Porter 
et al. (2007). On the opposite end, there was no statistically significant benefit in the 600 mg/day 
dose compared to placebo, while a clear reduction in seizure frequency was observed with 900 
and 1200 mg/day treatments. There is no indication, given the stable linear PK properties over 
multiple doses and lack of drug-drug interactions in repeated studies, that pharmacokinetics or 
tolerability would differ markedly in ALS subjects (no CYP metabolism; predominantly renal 
clearance). We thus chose a fixed dosing strategy with 600 mg/day and 900 mg/day arms to 
include two doses that were both likely to be tolerated and likely to reduce excitability. 
Importantly, we will determine whether the CSF concentration approaches the known EC50 of ~ 
2 µM from both our in vitro studies and heterologous expression of Kv7 channels (Wickenden et 
al., 2000). CSF levels were not measured in the epilepsy studies. With regard to study duration, 
the observed effects on hyperexcitability in the most relevant clinical studies (Caramia et al., 


 
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2000; Stefan et al., 2001) were observed within the time frame (4 weeks of maintenance dose 
treatment) proposed in the study. 
2.3 
Potential Risks and Benefits 
Overall, it is believed that the risks of the study are small compared to the devastating impact of 
the clinical disease and that the potential for improved clinical understanding, treatment and 
future benefit outweigh the risk to the study subjects of this FDA-approved medication and the 
associated other risks described here.  
2.3.1 Potential Risks 
Potential risks include those associated with ezogabine treatment, lumbar puncture (LP), blood 
draws, neurophysiological studies, risk due to compromise of medical information and 
psychological risk. 
2.3.1.1. Warnings and Precautions 
In pivotal controlled trials, urinary retention, urinary hesitation, and dysuria were reported in 
0.9%, 2.2%, and 2.3% of patients on ezogabine, respectively, and in 0.5%, 0.9%, and 0.7% of 
patients on placebo, respectively. The rate of urinary retention in combined Phase II/Phase III 
studies was 2%.  Of the 29 patients of 1,365 treated who had urinary retention, 5 (17%) required 
catheterization. Four of 5 of these patients discontinued ezogabine and were able to void 
spontaneously following discontinuation, but 1 of these 4 continued intermittent catheterization. 
The fifth patient continued treatment with ezogabine and was able to void spontaneously after 
catheter removal. Hydronephrosis occurred in 2 patients, one of whom had associated renal 
impairment that resolved upon treatment discontinuation. The risk of urinary retention is larger 
in patients who take anticholinergic medications. 
 
In 813 subjects treated with ezogabine in placebo-controlled epilepsy trials, major neuro-
psychiatric symptoms included confusional state (75, 9% compared to 11, 3% in placebo), 
psychosis (9, 1% compared to 0 in placebo) and hallucinations (14, 2% compared to 2, <1% in 
placebo).  Dizziness and somnolence were reported in 23% of patients treated with ezogabine 
compared to 9% of patients treated with placebo.  Ezogabine produced a mean 7.7 ms QT 
prolongation in healthy volunteers titrated to 400 mg 3 times daily.  Pooled analyses of anti-
epileptic drugs showed treatment increased the risk of suicide by about two-fold. Ezogabine has 
been associated with elevations in liver function tests (1-2%) of treated subjects across multiple 
dose ranges. Withdrawal seizures are a risk of rapid medication discontinuation and for this 
reason a taper is recommended. A recent FDA safety alert has been posted for the risk of blue 
skin and retinal epithelium discoloration.  Discoloration of the skin, nails, lips and/or mucosa has 
been described as blue grey color and has been observed generally at higher doses and after 
several years of treatment. 
 


 
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All known cases of retinal pigment abnormalities were reported after an exposure to ezogabine 
of at least three years. It is not known if the abnormalities can begin earlier, and it is also not 
known whether such changes affect visual acuity. Such changes were present in approximately 
one-third of patients who had eye examinations. Approximately one-third of the patients with 
retinal pigment abnormalities had no skin discoloration. Relevant information from the FDA is 
described in the following websites: <http://www.fda.gov/Safety/MedWatch/SafetyInformation/ 
SafetyAlertsforHumanMedicalProducts/ucm349847.htm> 
and 
<http://www.fda.gov/Drugs/ 
DrugSafety/DrugSafetyPodcasts/ucm350120.htm>. 
 
The most common adverse reactions leading to withdrawal in patients receiving ezogabine 
treatment were dizziness (6%), confusional state (4%), fatigue (3%), and somnolence (3%). 
Overall, the most frequently reported adverse reactions in patients receiving ezogabine (≥4% and 
occurring approximately twice the placebo rate) were dizziness (23%), somnolence (22%), 
fatigue (15%), confusional state (9%), vertigo (8%), tremor (8%), abnormal coordination (7%), 
diplopia (7%), disturbance in attention (6%), memory impairment (6%), asthenia (5%), blurred 
vision (5%), gait disturbance (4%), aphasia (4%), dysarthria (4%), and balance disorder (4%). In 
most cases the reactions were of mild or moderate intensity. Ezogabine was associated with 
dose-related weight gain, with mean weight increasing by 0.2 kg, 1.2 kg, 1.6 kg, and 2.7 kg in 
the placebo, 600 mg/day, 900 mg/day, and 1,200 mg/day groups, respectively. Following is a list 
of adverse reactions reported by patients treated with ezogabine during all clinical trials: rash, 
nystagmus, dyspnea, leukopenia, muscle spasms, alopecia, nephrolithiasis, syncope, neutropenia, 
thrombocytopenia, euphoric mood, renal colic, coma, and encephalopathy. Although abrupt 
withdrawal of antiepileptic drugs can be associated with a risk of withdrawal seizures, there is 
not a known risk of withdrawal seizures after abrupt cessation of ezogabine in non-epileptic 
patients. 
 
Ezogabine has been associated with the following adverse reactions, labeled as very common 
(≥1/10), common (≥1/100 to 1/10), uncommon (≥1/1,000 to 1/100), and rare (≥1/10,000 to 
1/1,000): 
• Metabolism and nutrition:  
o Common: weight increased, increased appetite 
• Psychiatric disorders: 
o Common: Confusional state, psychotic disorders, hallucinations, disorientation, 
anxiety 
• Nervous system disorders 
o Very Common: Dizziness, somnolence 
o Common: Amnesia, aphasia, coordination abnormal, vertigo, paraesthesia, 
tremor, balance disorder, memory impairment, dysphasia, dysarthria, disturbance 
in attention, gait disturbance, myoclonus. 
o Uncommon: Hypokinesia. 
• Eye disorders: 
o Common: Pigment changes (discoloration) of ocular tissues, including the retina 
(particularly after prolonged use). 


 
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o Common: Diplopia, blurred vision 
• Gastrointestinal Disorders 
o Common: Nausea, constipation, dyspepsia, dry mouth. 
o Uncommon: Dysphagia. 
• Hepatobiliary disorders 
o Common: Increased liver function tests. 
• Skin and subcutaneous tissue disorders 
o Common: Blue-grey discoloration of the nails, lips and/or skin have been 
observed, generally at higher doses and after several years of treatment. 
o Uncommon: Hyperhidrosis. 
• Renal and urinary disorders 
o Common: Dysuria, urinary hesitation, hematuria, chromaturia. 
o Uncommon: Urinary retention. 
• General disorders and administration site conditions. 
o Very common: Fatigue. 
o Common: Asthenia, malaise, peripheral edema. 
 
Both ALS subjects and matched healthy control volunteers will have a blood draw to collect a 
blood sample (approximately 45mL) that will be used for isolating human somatic cells, which 
then can be cultured and reprogrammed into subject-derived iPSCs. Motor neurons and other 
relevant cell types can be differentiated in vitro from the iPSCs.  
 
Blood and cerebrospinal fluid (CSF) will be collected for biobanking. Approximately 40 mL of 
blood will be collected from ALS subjects. Risks of blood collection include the possibility of 
fainting, pain, bruising, infection, and blood clot at the site of intravenous (IV) catheter insertion. 
Approximately 30 mL of CSF will be collected using standard clinical procedures. Risks include 
discomfort, bleeding, infection, headache, and pain at the site. Approximately 1 out of 3 people 
who have a LP develop a post-LP headache, which can range in severity from mild to severe. If 
the headache lasts more than 3 days, a blood patch may be performed, in which blood taken 
sterilely from the research subject is removed and inserted into the epidural space. The clotting 
of the blood should stop further CSF leaking and resolve the headache. 
 
There are small risks associated with neurophysiological tests. TMS is associated with risk of 
headache (common), neck pain (uncommon), tinnitus and transient decreased hearing (made 
minimal by wearing ear plugs), seizure (rare), skin irritation (common), changes in memory 
(theoretical), attention (theoretical) or other cognitive function (theoretical) or other unknown 
risk. The threshold tracking NCS tests can be associated with mild to moderate discomfort and 
transient skin irritation due to either electrodes or stimulation. 
 
Sample distribution (blood & CSF) will occur only of encoded samples. Non-study investigators 
who are provided access to study data for subsequent analyses of these samples will not seek or 
have access to subject identifying information. All subject identifying information will be kept 
on password-protected computers and will only be accessible to the study investigators. Despite 
study investigators taking all appropriate precautions, there is still a small chance of compromise 


 
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of identifying information. Standards for subject confidentiality, particularly with regard to 
genetic analysis, will be tightly followed according to the IRBs at all participating sites. 
 
There is potential emotional and psychological discomfort when participating in this study, 
including during the blood draw and LP.  
2.3.2 Known Potential Benefits 
There are no specific anticipated potential benefits to subjects for participating in this study, 
although subjects may benefit from the close follow-up and detailed medical care associated with 
study participation. It is not known whether treatment with ezogabine will be helpful or harmful 
for ALS subjects. It is possible that results from the study may yield benefits to future ALS 
patients. 


 
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3 
OBJECTIVES 
3.1 
Study Objectives 
The primary purpose of the proposed study is to determine whether ezogabine reduces 
neurophysiological excitability indices in ALS subjects as assessed by axonal threshold NCS and 
TMS. The study also will evaluate in ALS subjects dosing, safety and tolerability, and limited 
serum and CSF PK prior to a larger study designed to evaluate effect on a combined score of 
function and survival, should reduction in neurophysiological excitability indices be achieved.  
 
Although motor neuron hyperexcitability has been repeatedly demonstrated in ALS subjects, two 
central questions relate to the use of such measures in clinical trials. First, it is not known if 
reducing excitability will influence the disease course. That is, the hyperexcitability may be a 
downstream property that results as a consequence of the neurodegenerative disease process, and 
blocking it might not affect clinical progression. While in vitro evidence from our work and that 
of other groups (Fritz et al., 2013) suggests that reducing activity may improve motor neuron 
survival in vitro, accurate mouse models exist only for SOD1 familial ALS (2% of total ALS 
cases) and thus the question can only be properly addressed in clinical studies of human subjects. 
Second, should a reduction in motor neuron excitability be capable of influencing the disease 
progression, it is not known what magnitude of reduction – particularly in the neurophysiological 
markers described in this proposal – would be clinically significant. Still, given the well-
established differences between healthy control and ALS patients in both the TMS and axonal 
hyperexcitability assessments, a reasonable assumption is that reduction of excitability to the 
levels of controls may constitute a clinically relevant difference, and this study is sufficiently 
powered to detect that.  
 
Because the dose of ezogabine is well-defined by prior studies in epilepsy and on account of the 
favorable metabolic profile of the drug and the lack of reason to believe that dosing and 
tolerability would be substantially different in ALS patients, we believe that the proposed 
approach and outcomes in this study are reasonable. Two oral doses of ezogabine (600 mg/day 
and 900 mg/day, both with generally TID dosing) will be compared to matched placebo. The PK 
analysis will provide data on the relationship between dose of ezogabine and CSF 
concentrations. We will attempt to estimate the dose-dependent maximum CSF concentration to 
determine if zero, one, or both doses reach physiologically relevant levels, approximately 2 µM 
as determined by our dose response studies in iPSC-derived motor neurons and those evaluating 
ezogabine on heterologously expressed Kv7 channels (Wickenden et al., 2000). 


 
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3.2 
Study Outcome Measures 
3.2.1 Primary Outcome Measure 
The primary efficacy outcome is the change in paired pulse short-interval intracortical inhibition 
(SICI) assessed by transcranial magnetic stimulation (TMS). 
3.2.2 Secondary Outcome Measures 
Secondary outcomes include additional measures of efficacy and measures of safety, tolerability, 
pharmacokinetics, and in vitro response. Secondary efficacy outcomes include measures of upper 
and lower motor neuron excitability and measures of clinical progression. Motor evoked 
potential (MEP) threshold is the key secondary efficacy outcome, pre-specified for secondary 
efficacy analysis ahead of all other secondary efficacy outcomes. Additional upper motor neuron 
secondary outcomes include MEP amplitude, MEP latency, cortical silent period, and paired 
pulse facilitation, assessed by TMS. Lower motor neuron excitability outcomes include change 
in electrotonus, recovery cycle and strength duration time constant as determined by threshold 
tracking axonal nerve conduction studies (NCS) and compound motor action potential (CMAP) 
amplitude.   The effect of retigabine on strength will be assessed using hand held dynamometry, 
and muscle symptoms (muscle cramps and fasciculations) will also be assessed utilizing a 
subject daily diary, in which the subjects will record the frequency, location and severity of their 
cramps over the course of study treatment. 
 
Clinical progression outcomes include change in ALS Functional Rating Scale-Revised 
(ALSFRS-R) and slow vital capacity (SVC). Safety outcomes include adverse and serious 
adverse events, laboratory tests (including hematology, white cell differentials, blood chemistry, 
liver function tests, and urinalysis), weight loss, changes in electrocardiographic (ECG) 
parameters, changes in ophthalmologic parameters, and suicidality. Tolerability is defined as the 
proportion of participants able to reach their target dose and remain on study drug until planned 
discontinuation. Pharmacokinetic outcomes include peak concentration and time to peak 
concentration in serum and cerebrospinal fluid (CSF) after 2 weeks at target dose. In vitro 
exploratory outcomes include the following assessments of iPS-derived motor neurons: 
assessment of correlation between the primary clinical outcome (SICI using TMS) prior to 
treatment with ezogabine and the spontaneous firing rate of the in vitro-derived motor neurons; 
and correlation of the magnitude of the in vivo response to ezogabine detected by TMS and the in 
vitro EC50 for blocking motor neuron spontaneous action potential firing by ezogabine.  


 
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4 
STUDY DESIGN 
4.1 
Overall Study Design and Plan 
During the enrollment period, approximately 150 ALS patients will be screened from 
approximately 12 Northeast ALS Consortium (NEALS) centers in the US. Approximately 120 
eligible ALS subjects will be randomly assigned in a 1:1:1 ratio to oral ezogabine 600 mg/day, 
900 mg/day or matching placebo. After randomization, subjects will undergo the Baseline Visit 
and take their first dose of study drug in clinic at that visit. All visit windows are consecutive 
calendar days and are calculated from the day the participant has their Baseline Visit (Day 0). An 
interim futility analysis will be performed after the first 45 ALS subjects have completed Week 
12 of the study. One or the other active treatment groups or the full trial may be terminated based 
on results of the futility analysis and/or periodic review of safety data by the DSMB.  
4.2 
Study Centers 
The study will be conducted at approximately 12 NEALS Centers in the US.  Sites will be 
selected based on recruitment records from prior trials, compliance with prior study protocols 
and regulations, clinical research expertise, availability of necessary resources, and test-retest 
reliability of TMS and NCS assessments of unmatched healthy control subjects. 
4.3 
Study Duration 
Subjects will remain on randomized, placebo-controlled, double-blind treatment from Baseline 
until Week 10 (10 weeks).  Each randomized subject will also have a Week 14 Follow-up 
Telephone Interview, in addition to the Week 12 Clinic Visit, to assess for AEs, changes in 
concomitant medications and to administer the ALSFRS-R. 
4.4 
Protocol Adherence 
Each Site Investigator (SI) must adhere to the protocol detailed in this document and agree that 
any changes to the protocol must be approved by the NCRI Coordination Center (CC) or their 
representative prior to seeking approval from the site IRB. Each SI will be responsible for 
enrolling only those study subjects who have met protocol eligibility criteria. 
 


 
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5 
STUDY ENROLLMENT AND WITHDRAWAL 
5.1 
Number of Study Subjects 
Approximately 72 healthy control volunteers will be enrolled in the study. In addition, 
approximately 120 ALS subjects will be enrolled and randomized in a 1:1:1 ratio to oral 
ezogabine 600 mg/day, 900 mg/day or matching placebo.  Additional ALS subjects may be 
randomized if any randomized subjects withdraw from the study prior to initiating study drug. 
5.2 
Inclusion and Exclusion Criteria for ALS Subjects 
5.2.1 Inclusion Criteria 
Study subjects meeting all of the following criteria will be allowed to enroll in the study:  
1. Male or female, aged 18 to 80. 
2. Sporadic or familial ALS diagnosed as possible, laboratory-supported probable, probable, 
or definite as defined by revised El Escorial criteria.  
3. Slow vital capacity (SVC) measure ≥ 50% of predicted for gender, height and age at the 
Screening Visit, OR in the opinion of the SI, ability to perform and safely complete all 
study visit procedures.  
4. Subjects must not have taken riluzole for at least 30 days, or be on a stable dose of 
riluzole for at least 30 days prior to the Screening Visit and continue on the stable dose 
throughout the course of the study (riluzole-naïve subjects are permitted in the study). 
5. Subjects must be able to swallow oral medication at the Screening Visit and expected to 
be able to swallow tablets throughout the course of the study. 
6. Capable of providing informed consent and following trial procedures. 
7. Geographically accessible to the site. 
8. Women must not be able to become pregnant (e.g., post menopausal, surgically sterile, or 
using adequate birth control methods) for the duration of the study and three months after 
study completion. Adequate contraception includes: abstinence, hormonal contraception 
(oral contraception, implanted contraception, injected contraception or other hormonal 
contraception, for example patch or contraceptive ring), intrauterine device (IUD) in 
place for ≥ 3 months, barrier method in conjunction with spermicide, or another adequate 
method.  
9. Use of medications known to affect the neurophysiology measures in the study must be 
scheduled, not as needed (pro re nata, PRN). A subject must have been on a fixed dose 
for 30 days prior to the Screening Visit, and there must be no reason to believe that a 
subsequent change would be necessary during the course of the study. These medications 
include: benzodiazepines, muscle relaxants, tricyclic antidepressants, selective serotonin 
reuptake inhibitors, non-selective serotonin reuptake inhibitors, hypnotics (including anti-
histamines) and anti-cholinergics. 
10. TMS shows sufficient MEP amplitude and/or NCS studies show sufficient CMAP 
amplitude (amplitudes defined in MOP). 
 


 
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5.2.2 Exclusion Criteria  
Study subjects meeting any of the following criteria during screening evaluations will be 
excluded from entry into the study: 
1. Medical condition, laboratory finding, or physical exam finding that precludes 
participation. 
2. Serum AST or ALT value >2.0 times the upper normal limit 
3. Clinically significant conduction abnormalities on electrocardiogram or a known 
history of cardiac arrhythmia, myocardial infarction within the past 24 months, or 
congestive heart failure. 
4. Estimated glomerular filtration rate < 50 mL/min at Screening Visit. 
5. Concomitant digoxin treatment. 
6. Known allergic reactions to components of the study product(s). 
7. Exposure to any other agent currently under investigation for the treatment of patients 
with ALS (off-label use or investigational) within 30 days of the Screening Visit 
including ezogabine, exposure to cell replacement therapy within six months of the 
Screening Visit or any prior intraparenchymal cell replacement injection within the 
spinal cord or brain at anytime in the past. 
8. Presence of tracheostomy at the Screening Visit. 
9. History of clinically significant urinary retention, or current use of medications to treat 
urinary retention. 
10. History of drug and or alcohol abuse within 12 months of the Screening Visit. 
11. The presence of unstable psychiatric disease, cognitive impairment, or dementia that 
would impair ability of the subject to provide informed consent, according to SI 
judgment. 
12. Clinically significant history of unstable or severe cardiac, oncologic, hepatic, or renal 
disease, or other uncontrolled medical condition. 
13. Presence of feeding tube. 
14. Current use of antipsychotic, antiepileptic (except benzodiazepines, gabapentin, 
pregabalin) or class 1 (e.g. flecainide) or class 3 (e.g. amiodarone) antiarrhythmic 
medications. Quinidine or a quinidine-containing drug is allowed if the quinidine dose 
is not greater than 20 mg/day (for a full list of medications, please reference the study 
MOP). 
15. Pregnant women or women currently breastfeeding. 
16. Contraindication to TMS studies including ferromagnetic metal in the head or neck 
(potentially found in aneurysm clips, implanted medication pumps, implanted brain 
stimulators, pacemakers, cochlear implants), or history of epilepsy. Dental fillings are 
permitted. 
17. Anything else that, in the opinion of the SI, would place the subject at increased risk or 
preclude the subject’s full compliance with or completion of the study. 
 
Riluzole. Subjects taking concomitant riluzole at study entry must be taking riluzole for 30 days 
prior to the Screening Visit and must continue taking the same dosage throughout the study, 
unless the SI determines that riluzole should be discontinued for medical reasons.     
 


 
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Lumbar Puncture. The lumbar puncture procedure is optional at the Week 6 visit. Subjects 
undergoing the lumbar procedure must not be currently taking anticoagulation medications such 
as warfarin that would be a contraindication to LP; aspirin and non-steroidal anti-inflammatories 
are allowed. 
5.3 
Inclusion and Exclusion Criteria for Healthy Controls (Unmatched and Matched) 
5.3.1 Inclusion Criteria 
Healthy control volunteers meeting all of the following criteria will be allowed to enroll in the 
study:  
1. Male or female, aged 18 to 80. 
2. Capable of providing informed consent and following trial procedures. 
3. Geographically accessible to the site. 
4. Use of medications known to affect the neurophysiology measures in the study must be 
scheduled, not as needed (pro re nata, PRN). A subject must have been on a fixed dose 
for 30 days prior to the Screening Visit, and there must be no reason to believe that a 
subsequent change would be necessary during the course of the study. These medications 
include: benzodiazepines, muscle relaxants, tricyclic antidepressants, selective serotonin 
reuptake inhibitors, non-selective serotonin reuptake inhibitors, hypnotics (including anti-
histamines) and anti-cholinergics. 
5. Age (+/- 10 years and site-matched to a ALS participant within 6 months of their 
Baseline visit).[Matched controls only] 
6. TMS shows sufficient MEP amplitude and/or NCS studies show sufficient CMAP 
amplitude (amplitudes defined in MOP). 
 
5.3.2 Exclusion Criteria  
Healthy control volunteers meeting any of the following criteria during screening evaluations 
will be excluded from entry into the study: 
1. History of ALS or other neurodegenerative disease. 
2. Presence of positive family history of ALS. 
3. Presence of a neurological disorder. 
4. Current use of an antipsychotic or antiarrhythmic medication 
5. Definitely or possibly pregnant. 
6. Contraindication to TMS studies including ferromagnetic metal in the head or neck ( 
potentially found in aneurysm clips, implanted medication pumps, implanted brain 
stimulators, pacemakers, cochlear implants), or history of epilepsy. Dental fillings are 
permitted. 
7. Anything that, in the opinion of the SI, would place the subject at increased risk or 
preclude the subject’s full compliance with or completion of the study. 


 
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5.4. 
Treatment Assignment Procedures 
Each ALS subject who meets all eligibility criteria, is accepted for the study, signs an informed 
consent form (ICF) and undergoes successful lead-in neurophysiological testing, will be 
randomized to receive either 600 mg/day or 900 mg/day oral ezogabine or matching placebo for 
10 weeks of treatment.   
5.5. 
Randomization Procedures 
A permuted-block randomization schedule, stratified by site, will be developed by the study 
statistician with assignments in a 1:1:1 ratio among 600 mg/day oral ezogabine, 900 mg/day oral 
ezogabine, and placebo. If a randomized subject withdraws from the study prior to initiating 
study drug, their assignment will be released and re-used.  
5.6. 
Reasons for Withdrawal 
A subject will be withdrawn from the study if: 
• Any clinical AE, laboratory abnormality, concurrent illness, or other medical condition or 
situation occurs such that continued participation in the study would not be in the best 
interest of the subject. Note, however, that any subject who has initiated treatment should 
only discontinue study drug and remain on study if the safety concern relates to study 
drug and not to study procedures. 
• The subject no longer meets eligibility criteria at any time prior to initiating study drug or 
is discovered at anytime to have been enrolled in error. 
 
Subjects are free to withdraw from participation in the study at any time upon request. 
5.7. 
Handling of Withdrawals 
The medical monitor should be notified in all instances if a subject chooses to discontinue their 
participation, start a prohibited medication, or wishes to withdraw consent. 
 
A subject may choose to discontinue participation in the study at any time.  However, the SI or 
designee will encourage subjects to continue with follow-up, regardless of their compliance with 
study drug. If a subject who initiated study drug permanently discontinues study drug, the SI or 
designee should still encourage subjects to follow the study protocol under the modified intent-
to-treat principle (ITT). These subjects will be encouraged to follow the study visits, off drug, up 
to the final visit. Loss to follow-up should be prevented whenever possible. 
 
Any subject who is on study drug and needs to begin the use of any prohibited medication, must 
immediately discontinue use of study drug and should not begin use of the prohibited medication 
before an appropriate wash-out period occurs.  Subjects who permanently discontinue study drug 
should return any unused study drug and complete early study drug discontinuation procedures 


 
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without any study drug unblinding, if possible.  Subjects who must permanently discontinue 
study drug may continue in the ITT portion of the study, per protocol. 
 
If a subject wishes to withdraw consent, i.e., withdraw his or her participation in future study 
procedures, the subject will be asked to delay consent withdrawal to allow for a final safety visit 
and final safety telephone call. The subject will be asked to return to the study site for a final 
safety visit within 14 days of asking to withdraw consent. The subject will also be asked to have 
a final telephone call no sooner than 28 days after taking their last dose of study drug to monitor 
their safety and to permit review of their medical records at the end of the study to document 
their vital status.  
 
Subjects who discontinue study drug due to an AE will be followed for outcome measures under 
the ITT protocol as noted above.  
5.8. 
Termination of Study  
This study may be prematurely terminated if, in the opinion of the PI or sponsor, there is 
sufficient reasonable cause.  Written notification, documenting the reason for study termination, 
will be provided to the PI or sponsor by the terminating party. 
 
Circumstances that may warrant termination include, but are not limited to: 
• Determination of unexpected, significant, or unacceptable risk to subjects. 
• Enrollment is unsatisfactory. 
• Insufficient adherence to protocol requirements. 
• Data that is not sufficiently complete and/or evaluable.  
• Plans to modify, suspend or discontinue the development of the study drug. 
 
If the study is prematurely terminated or suspended, the sponsor will promptly inform the 
investigators/institutions, of the termination or suspension and the reason(s) for the termination 
or suspension.  The site IRBs will also be informed promptly and provided the reason(s) for the 
termination or suspension by the sponsor or by the investigator/institution. Study subjects will be 
called to explain the decision to terminate the trial and asked to return study drug at a final safety 
visit scheduled to occur within 14 days after last known dose of study drug. If the study was 
prematurely terminated due to safety concerns, they will be provided with relevant safety 
information to share with their primary care provider. 


 
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6 
TREATMENTS ADMINISTERED 
6.1 
Treatments 
Ezogabine (retigabine or trade name Potiga) is indicated as adjunctive treatment of partial-onset 
seizures in patients aged 18 years and older. An investigator’s brochure (IB) will be available to 
all Study Investigators (SIs).  
6.1.1 Study Product Description 
The chemical name of ezogabine is N-[2-amino-4-(4-fluorobenzylamino)-phenyl] carbamic acid 
ethyl ester, and it has the following structure: 
 
 
The empirical formula is C16H18FN3O2, with a molecular weight of 303.3 AMU. Ezogabine is a 
white to slightly colored, odorless, tasteless, crystalline powder. At room temperature, ezogabine 
is practically insoluble in aqueous media at pH values above 4, while the solubility is higher in 
polar organic solvents. At gastric pH, ezogabine is sparingly soluble in water (about 16 g/L). The 
pKa is approximately 3.7 (basic). 
POTIGA® (ezogabine) is supplied for oral administration as 50-mg, 200-mg, 300-mg, and 400-
mg film-coated immediate-release tablets. The 50, 200 and 300 mg tablets will be utilized for 
this study.  Each tablet contains the labeled amount of ezogabine and the following inactive 
ingredients: cochineal (50 mg), croscarmellose sodium, FD&C Blue No. 2 (50 mg, 300 mg), 
hypromellose, iron oxide yellow (200 mg, 300 mg), lecithin, magnesium stearate, 
microcrystalline cellulose, polyvinyl alcohol, talc, titanium dioxide, and xanthan gum.   
6.1.2 Placebo 
A matched placebo will be used to maintain the dosage-blind.  The placebo tablets for this study 
will match the corresponding ezogabine tablets in size, color, and presentation. 
 
Administration of matching placebo will be the same as for subjects in the treatment group. 
6.2 
Acquisition 
Upon receipt of the study treatment supplies, an inventory must be performed and a drug receipt 
log filled out and signed by the person accepting the shipment.  It is important that the designated 


 
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study staff counts and verifies that the shipment contains all the items noted in the shipment 
inventory.  Any damaged or unusable study drug in a given shipment will be documented in the 
study files.  The SI must notify the study sponsor of any damaged or unusable study treatments 
that were supplied to the SI’s site. 
6.2.1 Formulation, Packaging, and Labeling 
The study drug is prepackaged in bottles and ready for oral administration. The site pharmacy 
and SI have the responsibility to ensure that the integrity of packaged study drug is not 
jeopardized prior to dispensing.  Each individual subject bottle must be dispensed as provided 
with no further repackaging or labeling done at the investigational site, unless required by the 
institution per institutional polices. 
6.2.2 Product Storage and Stability 
The SI must ensure that all investigational drug supplies are kept in a locked, safe area at 
controlled room temperature 59°-86°F (15°-30°C) with access limited to those directly involved 
in the study. Investigational drug supplies should not be repackaged in any way.  It is 
recommended that each site utilize their Research Pharmacy for this study. 
6.3 
Dosage, Preparation and Administration of Study Intervention/Investigational 
Product 
The sole investigational agent is ezogabine via oral administration. Generally, the study will 
include a combination of 50 mg ezogabine, 200 mg ezogabine and 300 mg ezogabine tablets or 
matching placebos for each of the groups as described in the table below. The study drug kits are 
comprised of two sub-kits (Weeks 1 through 4 and Weeks 5 through 10). 
 
Subjects from all 3 ALS randomization groups will receive their first dose of study medication 
and drug sub-kit to take home at the Baseline Visit.  At the Week 4 Visit, subjects will bring all 
study drug bottles for compliance, accountability and witnessed destruction from the first sub-kit 
and receive the second sub-kit (Weeks 5 through 10). In order to maintain the blind and escalate 
each group up to the appropriate dosage, the following bottles have been configured: 
 
Week 1 – Week 4 (4 weeks) 
• The placebo group will receive and take: 50 mg placebo; 50 mg placebo; 200 mg 
placebo.   
• The 600 mg/day group will receive and take: 50 mg ezogabine; 50 mg placebo; 200 mg 
ezogabine.   
• The 900 mg/day group will receive and take: 50 mg ezogabine; 50 mg ezogabine; 200 mg 
ezogabine. 
 
Week 5 through 10 (6 weeks) 


 
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• The placebo group will receive and take: 200 mg placebo; 300 mg placebo.   
• The 600 mg/day group will receive and take: 200 mg ezogabine; 300 mg placebo.   
• The 900 mg/day group will receive and take: 200 mg placebo;300 mg ezogabine. 
 
As described in the drug dosing schedule table below, equal number of tablets will be taken by 
all subjects during each week. Subjects will be instructed to take the specified number of tablets 
one, two, or three times a day at each week of the study according to the schedule found in Table 
1. 
Table 1. Study Drug Titration Schedule 
Number of tablets per day  
 
Week 1  
Week 2 
Week 3 
Week 4 
50 mg 
2  TID 
3  TID 
- 
1 TID 
200mg 
- 
- 
1 TID 
1 TID  
 
Number of tablets per day  
 
Week 5 
Week 6 
Week 7 
Week 8 
Week 9 
Week 10 
200 mg 
1 TID 
1 TID 
1 TID 
1 TID 
1 BID 
1 QD 
300 mg 
1 TID 
1 TID 
1 TID 
1 TID 
1 BID 
1 QD 
 
6.3.1  Missed Doses 
Subjects who miss one or more doses should immediately take the most recently missed dose 
and then resume the current treatment, making sure to wait at least three hours in between doses. 
Missed doses should be documented at the subsequent clinic visit and in the subject’s study drug 
diary. 
6.3.2 Crushing Pills  
Should a subject be unable to swallow the tablets over the course of the study, the tablets can be 
crushed and dispersed in water to form a suspension. The suspension should only be taken orally 
or delivered by a silicone-based gastrostomy tube.  
6.3.3  Feeding Tube 
Should a subject no longer be able to swallow and require a gastrostomy tube over the course of 
the study, the tablets can be crushed and dispersed in water to form a suspension to be delivered 
via the tube. The study drug cannot be given accurately via a non-silicone-based nasogastric or 


 
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non-silicone-based gastrostomy tube, thus the preference is for subjects to use only a silicone 
based tube.  In the event that a subject becomes unable to swallow the study drug and receives a 
non-silicone-based nasogastric or non-silicone based gastrostomy tube over the course of the 
study, subjects should continue to take study drug regardless of the tube material.  A notation on 
the eCRF will indicate the type and material of the feeding tube placed. 
6.4 
Modification of Study Intervention/Investigational Product for a Subject 
Any dosage adjustment, including the reason for and dates of adjustment, will be documented in 
the CRF for each subject requiring this manipulation. The SI or licensed physician Sub-
Investigator may reduce the dosage of study drug or discontinue study drug in its entirety for 
AEs thought to be related to study drug or for other reasons during the trial (the reason for and 
dates of suspension or dose reduction must be documented).  If the AE is mild or moderate, the 
dosage may be reduced until the event improves.  The SI may then choose to resume the higher 
dosage or maintain the subject at a reduced dosage. Reference the study Manual of Procedures 
for additional information.  
 
If the event is serious or life threatening and deemed to be definitely drug related, study drug will 
be discontinued immediately. Study subjects must remain off study drug permanently. Subjects 
may not resume study drug. The medical monitor should be notified immediately, preferably 
prior to any dosage adjustments, if possible. 
6.4.1. Dosage Discontinuation 
Reasons for discontinuation of study drug may include an AE, Medical Monitor or SI 
recommendation, Sponsor termination, protocol deviation, loss to follow-up, patient request, or 
death.  
 
Study subjects who discontinue study drug prematurely and decide not to continue study visits 
(wish to withdraw consent) will be encouraged to delay consent withdrawal in order to return for 
a Final Safety Visit within 14 days of expressing wish to withdraw consent and to permit a 
Follow-Up Telephone Call no sooner than 28 days after taking last known dose of study drug to 
monitor their safety and permit review of their medical records at the end of the study to 
document their vital status. 
 
All subjects who discontinue study drug early and choose to continue study visits will be 
encouraged to follow the normal study visits, off drug, up to the time of the last visit (Follow-Up 
Telephone Call).   
 
SAEs will be followed for resolution for 28 days (+5 days) after a subject’s last known dose of 
study drug, regardless of whether they prematurely discontinued study drug or completed the 
treatment.  


 
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6.5 
Accountability Procedures for Ezogabine 
There will be a final reconciliation of drug shipped, drug consumed, and drug remaining.  This 
reconciliation will be logged, signed and dated.  Any discrepancies noted will be investigated, 
resolved, and documented prior to destruction of unused study drug.  Drug destroyed on site will 
be documented in the study files. 
6.6 
Assessment of Subject Compliance with Ezogabine 
Subjects will be instructed to return empty and unused study medication containers at the Week 
4 and Week 12 Visits or the Final Safety Visit (whichever occurs first).  Site personnel will 
review returned and unused study medication to determine compliance.  
 
Non-compliance will be otherwise defined as taking less than 80% or more than 125% of study 
medication as determined by tablet counts.  If a study subject is non-compliant with study 
medication, the SI and staff should re-educate and train the subject in administration of study 
drug.  Data indicating compliance will be used in secondary analyses.   
6.7 
Prior and Concomitant Therapy 
Throughout the study, SIs may prescribe concomitant medications or treatments deemed 
necessary to provide adequate supportive care provided that the medications are licensed in the 
United States. Study subjects should not receive other experimental agents during the study.  
This includes marketed agents at experimental dosages that are being tested for the treatment of 
ALS.  All concomitant medications and/or treatments and significant non-drug therapies, 
including supplements and assistive devices, received by a subject should be recorded on the 
appropriate source document and eCRF. 
6.7.1 Prohibited Medications and Contraindications 
Prohibited Medications 
Throughout the course of the trial, study subjects should not be treated with the following 
medications.  If an investigator learns that a patient has begun therapy with any of these 
medications, this should be reported to the NCRI Coordination Center (CC) immediately and 
action should be taken to discontinue the prohibited medication.  If, for safety or health reasons, 
or by subject choice, the prohibited medication cannot be stopped, then the study drug should be 
stopped. For a complete and updated listing of prohibited medications and contraindications 
refer to the study Manual of Procedures.  
 
Prohibited medications include: 
• Digoxin 
 


 
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The following medications are prohibited when given on an as needed (PRN) basis (full list is 
provided in Site Manual of Operations). A subject must therefore be on a stable dose for 30 days 
prior to the Screening Visit, and the dose must not change during the course of the study, unless 
there is a safety risk to the subject, in which case the change must be documented at the 
subsequent clinical encounter. 
• Benzodiazepines 
• Muscle relaxants  
• Tricyclic antidepressants 
• Selective serotonin reuptake inhibitors 
• Non-selective serotonin reuptake inhibitors 
• Hypnotics (including anti-histamines) 
• Anti-cholinergics. 
 
Any investigational therapy being used or evaluated for the treatment of ALS is prohibited 
beginning 30 days prior to Screening Visit and throughout the study.  This includes, but is not 
limited to, the following: 
• Pioglitazone 
• Arimoclomol 
• Olanzapine 
• Tamoxifen 
• Antisense oligonucleotide treatment targeting SOD1 or C9orf72 
• Mexiletine 
• Ozanezumab (GSK 1223249) 
• Rasagiline 
• Fingolimod 
• CK-2017357 
• Tocilizumab 
 
The medical monitor should be notified immediately, preferably prior to the start of any of these 
medications, if possible. 
 
Pregnancy & Nursing Mothers 
There are no adequate and well-controlled studies in pregnant women. Subjects or partners of 
male subjects should not become pregnant during the study or 1 month after stopping study drug.  
If a female subject becomes pregnant, study treatment must be discontinued immediately.  
 
As it is not known whether ezogabine is excreted in human milk, caution should be exercised. 
No subject should nurse their infant while participating in this study.  


 
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7  
STUDY SCHEDULE (UNMATCHED HEALTHY CONTROLS) 
No study procedures should be performed prior to the signing of the ICF. All subjects will sign 
an ICF prior to undergoing any study tests or procedures. Components of each visit can be 
distributed on different days. TMS neurophysiology for all three visits can be scheduled on two 
or more days. NCS neurophysiology for all three visits can be scheduled on one or more days. 
One (1) TMS and one (1) NCS test must meet inclusion/exclusion criteria prior to performing 
additional neurophysiology tests. All visits must be completed < 6 weeks from the screening 
visit. Please reference the study Manual of Procedures (MOP) Outcome Measures for additional 
information. 
7.1 
Visit 1 (Screening) 
The following procedures will be performed at an office visit to determine the subject’s 
eligibility for the study: 
• Obtain written informed consent 
• Assess inclusion and exclusion criteria. If ineligible, record reason for screen failure.  
• Collect demographic data 
• Obtain medical history 
• Review and document concomitant medications and therapies 
• Assess and document AEs that occur after subject signs ICF 
• Measure vital signs including height and weight 
• Complete Edinburgh Handedness Inventory- Short Form 
• Perform neurophysiological testing (TMS and NCS). At sites that have two TMS or two 
NCS physiologists, both should independently perform neurophysiological testing of 
unmatched healthy controls. 
• Schedule next visit. 
7.1.1 Screen Failures 
Any subject who signs consent will be considered enrolled in the study.  If a subject fails 
screening, at a minimum, the following information should be captured and entered in the 
Electronic Data Capture (EDC) System: 
• Demographics 
• Inclusion/Exclusion criteria 
• Reason for screen failure 
7.2 
Visit 2  
• Review and document concomitant medications and therapies 
• Assess and document AEs 


 
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• Perform neurophysiological testing (TMS and NCS). At sites that have two TMS or two 
NCS physiologists, both should independently perform neurophysiological testing of 
unmatched healthy controls. 
• Schedule next visit 
7.3 
Visit 3 (4 & 5 if needed) 
• Review and document concomitant medications and therapies 
• Assess and document AEs 
• Perform neurophysiological testing (TMS and NCS). At sites that have two TMS or two 
NCS physiologists, both should independently perform neurophysiological testing of 
unmatched healthy controls. 
• Schedule next visit, if applicable. 


 
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8 
STUDY SCHEDULE (ALS SUBJECTS) 
No study procedures should be performed prior to the signing of the ICF. All subjects will sign 
an ICF prior to undergoing any study tests or procedures. The slow vital capacity (SVC) should 
be performed first at the visits so as not to fatigue the subject with other testing; however, the 
order of testing will be at the discretion of each site investigator (SI).  
 
Visit windows are consecutive calendar days and the target visit dates are calculated from the 
Baseline Visit, which should occur within 21 days of the Screening Visit. All clinic visits and 
calls after the Baseline visit will have a +/- 3 day window, except the Week 14 phone call which 
has a +5 day window only. 
 
Subjects who withdraw consent or terminate from the study early will be asked to come in for a 
Final Safety Visit within 14 days of withdrawing consent, and will have a Final Telephone Call 
no sooner than 28 days after last known dose of study drug.    
8.1 
Screening Visit 
The following procedures will be performed at an office visit to determine the subject’s 
eligibility for the study: 
• Obtain written informed consent 
• Assess inclusion and exclusion criteria. If ineligible, record reason for screen failure.  
• Collect demographic data 
• Obtain medical history 
• Obtain ALS diagnosis history 
• Assign a Global Unique Identifier (GUID) 
• Review and document concomitant medications and therapies 
• Assess and document AEs that occur after subject signs ICF 
• Perform physical examination 
• Perform neurological examination, including MMT 
• Measure vital signs including height and weight 
• Administer ALSFRS-R questionnaire 
• Administer the American Urological Association (AUA) Symptom Score survey  
• Perform SVC 
• Perform hand held dynamometry (HHD) APB bilaterally 
• Complete Edinburgh Handedness Inventory- Short Form 
• Perform neurophysiological testing (TMS and NCS) 
• Collect blood samples and urinalysis for safety clinical laboratory assessments, 
pregnancy test (WOCBP)  
• Perform 12-lead ECG 
• Schedule Ophthalmologic visit (visit must be completed within 14 days prior to baseline 
visit)  


 
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• Schedule the Baseline Visit 
8.1.1 Screen Failures 
Any subject who signs consent will be considered enrolled in the study.  If a subject fails 
screening but later becomes eligible, the subject may be re-screened once eligible. If the subject 
becomes eligible before the window between screening and baseline is up (<21 days), the subject 
will not need to be re-consented and study procedures will be repeated on a case by case basis 
only. If the subject is eligible outside the screening and baseline window (>21 days), then the 
subject must be re-consented and all study procedures will be repeated.  
 
If a subject fails screening and is not eligible for rescreen, at a minimum, the following 
information should be captured and entered in the Electronic Data Capture (EDC) System: 
• Demographics 
• Inclusion/Exclusion criteria 
• Reason for screen failure 
 
Subjects who screen fail during the Screening Visit on account of TMS and NCS should be given 
the option of completing remaining components of the Screening Visit and the additional data 
should be captured and entered in the Electronic Data Capture (EDC) System: 
• Concomitant medications and therapies 
• Medical history including ALS diagnosis history 
• ALSFRS-R  
• Adverse Events (if applicable) 
• Neurophysiology testing (if performed) 
• Neurological Exam, MMT testing and HHD (APB) 
• SVC (if performed) 
  
8.2 
Baseline Visit 
The Baseline Visit (from which all other study time points will be determined) will occur not 
more than 21 days after the Screening Visit.  The Baseline Visit for an individual subject can be 
spread over two consecutive days (both within +/- 3 day window) at the discretion of the SI.  If 
the visit is spread over consecutive days it is recommended that the drug administration and 
associated activities be performed on the second day. The following procedures will be 
performed: 
• Randomize subject (after the subject’s successful Screening Visit and confirmation of 
inclusion criteria) 0 to 48 hours before the Baseline clinic visit as necessary to obtain 
study drug from the research pharmacy 
• Review and document concomitant medications and therapies 
• Assess and document AEs 
• Measure vital signs including weight 
• Administer ALSFRS-R questionnaire  
• Perform SVC [Note: Baseline SVC is not exclusionary, even if below 50% of expected] 
• Perform hand held dynamometry (HHD) 


 
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• Administer the suicide prevention (C-SSRS) questionnaire 
• Perform neurophysiological testing (TMS and NCS) 
• Perform ophthalmologic examination (may be scheduled separately, but within 14 days 
prior to the Baseline Visit and results signed by Ophthalmologist and SI prior to drug 
administration) 
• Complete Baseline Muscle Cramp and Fasciculation Assessments 
• Administer first dose of study drug.  The subject will be observed at the site for 60 
minutes by an appropriate healthcare staff member according to the site’s 
institutional/state regulations to assess medical status and any immediate reaction to the 
study drug.  
• Perform 12-Lead ECG three (3) hours after the first dose administration 
• Provide subject with study drug for next four weeks and dispense Study Drug Diary to 
subject 
• Distribute Muscle Symptom Diary 
• Schedule next visit 
8.3 
Week 2 and Week 10 Telephone Calls 
These phone calls will take place at Weeks 2 (14 ±3 days from Baseline) and Week 10 (70 ±3 
days from Baseline).  The following procedures will be performed: 
• Review and document concomitant medications and therapies 
• Assess and document AEs 
• Confirm next visit  
8.4 
Week 4 Visit 
This visit will take place 28 ± 3 days after the Baseline Visit (end of drug escalation phase).  The 
following procedures will be performed: 
• Review and document concomitant medications and therapies 
• Assess and document AEs 
• Measure vital signs including weight 
• Collect blood samples and urinalysis for safety clinical laboratory assessments and iPSC 
generation  
• Administer ALSFRS-R questionnaire 
• Administer the American Urological Association (AUA) Symptom Score survey  
• Perform SVC 
• Perform hand held dynamometry (HHD - APB bilaterally) 
• Administer the suicide prevention (C-SSRS) questionnaire 
• Check study drug compliance and dosing diary  
• Perform study drug accountability and collect all unused study drug and empty containers 
• Provide study drug for the next six (6) weeks and dispense new dosing diary to subject 
• Review returned Muscle Symptom Diary and dispense new Muscle Symptom Diary to 
subject 
• Complete Fasciculation Assessment  
• Schedule next visit 


 
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8.5 
Week 6 Visit 
This visit will take place 42 ± 3 days after the Baseline Visit (after two weeks of maintenance 
drug dose). The Week 6 Visit for an individual subject can be spread over two consecutive days 
(both within +/- 3 day window) at discretion of SI. 
 
The following procedures will be performed: 
• Review and document concomitant medications and therapies 
• Assess and document AEs 
• Perform 12-lead ECG 
• Measure vital signs including weight 
• Collect blood samples and urinalysis for safety clinical laboratory assessments 
• Collect blood for biobanking at time of CSF collection 
• Perform LP for CSF analysis (optional) 
• Administer ALSFRS-R questionnaire 
• Perform SVC 
• Perform hand held dynamometry (HHD - APB bilaterally) 
• Administer the suicide prevention (C-SSRS) questionnaire 
• Perform neurophysiological testing (TMS and NCS) (may be performed on separate day 
if necessary) 
• Check study drug compliance and dosing diary  
• Review Muscle Symptom Diary with subject 
• Complete Fasciculation Assessment 
• Schedule next visit  
8.6 
Week 8 Visit 
This visit will take place 56 ± 3 days after the Baseline Visit (after four weeks of maintenance 
drug dose).  The following procedures will be performed: 
• Review and document concomitant medications and therapies 
• Assess and document AEs 
• Measure vital signs including weight 
• Collect blood samples and urinalysis for safety clinical laboratory assessments 
• Administer ALSFRS-R questionnaire 
• Administer the American Urological Association (AUA) Symptom Score survey 
• Perform SVC 
• Perform hand held dynamometry (HHD - APB bilaterally) 
• Administer the suicide prevention (C-SSRS) questionnaire 
• Perform neurophysiological testing (TMS and NCS) 
• Check study drug compliance and dosing diary 
• Review Muscle Symptom Diary with subject 
• Complete Fasciculation Assessment 
• Schedule next visit  


 
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8.7 
Week 12 Visit  
This visit will take place 84 ± 3 days after the Baseline Visit (two weeks after drug cessation). 
The following procedures will be performed: 
• Review and document concomitant medications and therapies  
• Assess and document AEs  
• Perform physical examination 
• Perform neurological examination, including MMT 
• Perform ophthalmologic examination (may be scheduled separately, but within 14 days 
of Week 12 Visit) 
• Measure vital signs including weight 
• Perform 12-lead ECG 
• Collect blood samples and urinalysis for safety clinical laboratory assessments  
• Administer ALSFRS-R questionnaire 
• Administer the American Urological Association (AUA) Symptom Score survey 
• Perform hand held dynamometry (HHD - APB bilaterally) 
• Perform SVC 
• Administer the suicide prevention (C-SSRS) questionnaire 
• Check study drug compliance and collect dosing diary 
• Review returned Muscle Symptom Diary 
• Complete Fasciculation Assessment  
• Perform study drug accountability and collect all unused study drug and empty containers 
• Schedule telephone call 
• Complete Blindedness Questionnaire and Exit Survey 
8.8 
Week 14 Telephone Call 
This phone call will take place 98 +5 days after the Baseline Visit.  The following procedures 
will be performed: 
• Review and document concomitant medications and therapies 
• Assess and document AEs 
8.9 
Final Safety Visit & Telephone Call 
ALS subjects who withdraw consent will be asked to come in for a Final Safety Visit and will be 
asked to have a final Follow-Up Telephone Call no sooner than 28 days after subject’s last 
known dose of study drug. 
 
The Final Safety Visit should be scheduled as soon as possible, but within 14 days of subject 
withdrawing consent. The following will be performed: 
• Review and document concomitant medications and therapies 
• Assess and document AEs 
• Perform physical examination 
• Perform neurological examination, including MMT 


 
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• Perform ophthalmologic examination (may be scheduled separately, but within 14 days 
of the Final Safety Visit) 
• Measure vital signs and weight 
• Perform 12-lead ECG 
• Collect blood samples and urinalysis for safety clinical laboratory assessments 
• Administer ALSFRS-R questionnaire 
• Administer the American Urological Association (AUA) Symptom Score survey 
• Perform SVC 
• Perform hand held dynamometry (HHD - APB bilaterally) 
• Administer the suicide prevention (C-SSRS) questionnaire 
• Perform neurophysiological testing (TMS and NCS) unless the decision to withdraw 
consent was due to intolerance of neurophysiological testing. 
• Check study drug compliance and collect dosing diary 
• Review returned Muscle Symptom Diary  
• Complete Fasciculation Assessment 
• Perform study drug accountability and collect all unused study drug and empty containers 
• Complete Blindedness Questionnaire and Exit Survey 
The final Follow-Up Telephone Call phone call will take place no sooner than 28 days after the 
last known dose of study drug. The following procedures will be performed: 
• Review and document concomitant medications and therapies 
• Assess and document AEs 
8.10 
Protocol Deviations 
A protocol deviation is any noncompliance with the clinical trial protocol.  The noncompliance 
may be either on the part of the subject, the SI, or the study site staff.  As a result of deviations, 
corrective actions are to be developed by the site and implemented promptly. 
 
All deviations from the protocol must be addressed in the subject’s source documents.  Protocol 
deviations must be sent to the local IRB per their guidelines and entered in the Protocol 
Deviations Log in the EDC System.  
8.11 
Missed Visits and Procedures  
Missed visits and any procedures not performed (not attempted) for reasons other than illness, 
injury or progressive disability (i.e., subject is physically unable to perform test) will be reported 
as protocol deviations.   
 
Procedures or visits not performed due to illness, injury or disability, including procedures that 
were attempted but failed (i.e., blood samples unable to be drawn after multiple attempts, or 
weight unable to be obtained due to subject immobility) will not be reported as protocol 
deviations.   
 


 
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Study drug compliance that is outside the limits set in the study Manual of Procedures will be 
reported as a protocol deviation.   
 
Details and specific instructions regarding protocol deviations, including any exceptions to this 
standard procedure, are found in the Site Manual of Operations. 
8.12 Survival Data 
For all subjects, including those who have discontinued participation or are lost to follow-up, 
attempts may be made every 6 months to document vital status and collect future clinical data 
related to ALS progression (e.g. ALSFRS). 


 
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9 
STUDY SCHEDULE (MATCHED HEALTHY CONTROLS) 
No study procedures should be performed prior to the signing of the ICF. All subjects will sign 
an ICF prior to undergoing any study tests or procedures.  
 
Visit windows are consecutive calendar days and the target visit dates are calculated from the 
Baseline Visit. All clinic visits after the Baseline visit will have a +/- 10 day window. 
9.1 
Screening Visit 
The following procedures will be performed at an office visit to determine the subject’s 
eligibility for the study and to collect baseline data if eligible: 
• Obtain written informed consent 
• Assess inclusion and exclusion criteria. If ineligible, record reason for screen failure.  
• Review and document concomitant medications and therapies 
• Assess and document AEs that occur after subject signs ICF 
• Collect demographic data 
• Obtain medical history 
• Complete Edinburgh Handedness Inventory-Short Form 
• Perform neurological examination 
• Measure vital signs including height and weight 
• Perform neurophysiological testing (TMS and NCS) 
• Collect blood for iPS cell line generation 
• Schedule the Week 6 Visit 
9.1.1 Screen Failures 
Any subject who signs consent will be considered enrolled in the study.  If a subject fails 
screening, at a minimum, the following information should be captured and entered in the 
Electronic Data Capture (EDC) System: 
• Inclusion/Exclusion criteria 
• Demographics 
• Reason for screen failure 
9.2 
Week 6 Visit 
This visit will take place 42 ± 10 days after the Baseline Visit. 
• Review and document concomitant medications and therapies 
• Assess and document AEs 
• Measure vital signs 
• Perform neurophysiological testing (TMS and NCS) 
• Collect blood for iPS cell line generation (if not done at Screening) 
• Schedule next visit  


 
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9.3 
Week 12 Visit 
This visit will take place 84 ± 10 days after the Baseline Visit. The following procedures will be 
performed: 
• Review and document concomitant medications and therapies 
• Assess and document AEs 
• Perform neurophysiological testing (TMS and NCS) 
• Collect blood for iPS cell line generation (if not done previously) 
 
 


 
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10 
CLINICAL ASSESSMENTS AND OUTCOME MEASURES 
10.1 
Clinical Assessments 
Assessments will be performed at designated time-points throughout the study for clinical 
evaluation.  In addition to the assessments evaluated below, subjects will provide information on 
their demographics, current medical conditions, medical history, as well as concomitant 
medication usage. 
10.1.1 Vital Signs, Height & Weight 
Vital signs will be obtained after the subject has been in a seated position for several minutes.  
Vital signs, including systolic and diastolic blood pressure, pulse rate (radial artery)/minute, 
respiratory rate/minute, temperature and weight will be assessed at specified visits.  Height will 
be measured and recorded at the Screening Visit only.   
10.1.2 Clinical Laboratory Assessments 
The following laboratory tests will be performed to evaluate eligibility and for safety: 
 
o Hematology with differential panel: complete blood count with differential (hematocrit, 
hemoglobin, platelet count, RBC indices, Total RBC, Total WBC, and WBC & 
differential)  
 
o Blood chemistry panel/Liver function tests (LFTs): alanine aminotransferase (ALT 
(SGPT)), aspartate aminotransferase  (AST (SGOT)), albumin, alkaline phosphatase, 
bicarbonate, blood urea nitrogen, calcium, chloride, creatinine, glucose, magnesium, 
phosphate, potassium, sodium, total bilirubin and total protein 
 
o Urinalysis: blood, clarity, color, glucose, ketones, nitrate, pH, protein, specific gravity, 
and WBC screen  
 
o Serum human chorionic gonadotrophin (hCG) for WOCBP (collected only at Screening 
Visit, and as necessary throughout course of study) 
 
All subjects will have safety laboratory tests at the designated visits outlined in the protocol. 
These samples will be analyzed at a central laboratory.  The SI may order additional testing, if 
needed, to further assess an AE, or if there is any suspicion that a subject may be pregnant, 
throughout the course of the study.  


 
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10.1.3 Blood Sample for iPSCs  
ALS subjects will provide a one-time research blood sample following standard clinical 
protocols at the Week 4 visit. If subjects are unable to provide a sample at Week 4, the sample 
could also be collected at the Week 6 or 8 visit.  Matched healthy control subjects will provide a 
one-time research blood sample at the Screening, Week 6 or Week 12 Visit following standard 
clinical protocols. These samples will be used to derive iPSCs for the exploratory aims of this 
study and for other future research both within and outside of motor neuron diseases.  All 
samples will be labeled with a code.  The code will not include any identifiable information.  
Coded blood samples will be stored at a central laboratory prior to iPSC generation and other 
research use. Third party safety protocols for iPSC generation require blood testing for infectious 
agents including HIV, Hepatitis B and Hepatitis C. Results will not be conveyed to study staff or 
to subjects. 
10.1.4  12-Lead Electrocardiogram (ECG) 
A standard 12-lead ECG will be performed.  Tracings will be reviewed by a local on-site 
cardiologist, and a copy of the tracings will be kept on site as part of the source documents. QTc 
interval > 450ms in males or > 470ms in females should be brought to the attention of the 
medical monitor. 
10.1.5  Physical Examination 
A physical examination will be performed and recorded.  The following systems will be 
examined: head/neck, eyes, ears, nose/throat, cardiovascular, lungs, abdomen, musculoskeletal, 
central nervous system, extremities, and skin.  The skin assessment will include evaluation for 
discoloration of the nails, lips, skin and oral mucosa. 
10.1.6 Neurological Examination 
A neurological examination will be performed and recorded.  Examination will include 
assessment of mental status, cranial nerves, motor and sensory function, reflexes, coordination, 
and stance/gait. 
10.1.7 Columbia Suicide Severity Rating Scale (C-SSRS) 
The US FDA recommends the use of a suicidality assessment instrument that maps to the 
Columbia Classification Algorithm for Suicide Assessment (C-CASA) (Posner et al., 2007). The 
C-CASA was developed to assist the FDA in coding suicidality data accumulated during the 
conduct of clinical trials of antidepressant drugs. One such assessment instrument is the 
Columbia Suicide Severity Rating Scale (C-SSRS) (US FDA Draft Guidance, 2010). The C-
SSRS involves a series of probing questions to inquire about possible suicidal thinking and 
behavior. 


 
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At the Baseline Visit, the C-SSRS Baseline version will be administered.  This version is used to 
assess suicidality over the subject’s lifetime and specifically for the previous 6 month time 
period.  Suicidality will also be assessed at follow-up visits over the course of the study.   
10.1.8 Ophthalmological Examination 
Ophthalmological examinations will be performed and recorded at the Baseline and Week 12 
Visits (within 14 days prior of each). Exams will include visual acuity testing, dilated fundus 
photography, and a slit-lamp examination. If deemed warranted by the examining 
ophthalmologist, fluorescein angiogram, ocular coherence tomography, perimetry, and electro-
retinogram may also be obtained. 
10.1.9 Lumbar Puncture 
The lumber puncture is optional.  
 
For subjects consenting to a LP, it will be performed to collect CSF at the Week 6 Visit.  Study 
staff should document the time of last ezogabine dose administered. The SI will discuss all 
potential LP risks to the subjects including: 
o Local pain at injection site 
o Reaction to anesthetic agents 
o Bleeding at needle entrance site  
o Infection at needle entrance site 
o Post-LP low-pressure headache   
 
Extensive experience with research LP in Alzheimer’s disease reveals a very low incidence of 
complication, including the incidence of post-LP headache (Zetterberg et al., 2010).  Fewer than 
2.6% of patients in a memory disorder clinic developed post-LP headache, and only a single 
patient in a cohort of over 1,000 had a headache lasting more than 5 days (Zetterberg et al., 
2010).  No other local or generalized complications occurred.   
 
The procedure must be performed by the SI or another licensed practitioner with experience and 
training in performing LPs, and must be listed on the site delegation log.  When possible, LPs 
will be performed with an atraumatic Sprotte needle to reduce the risk of post-LP headache.   
 
Coded CSF samples (with no subject identifying information) will be stored in the NEALS 
Biorepository located at Massachusetts General Hospital. They will be used for broad research 
purposes including retigabine drug levels.   


 
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10.1.10   Adverse Events 
AEs will be documented at all study visits, including the Screening Visit once the ICF has been 
signed by the subject, and at all scheduled telephone calls, including the final telephone call. Any 
unresolved AEs at the time of study completion will be followed for up to 28 days after the final 
telephone call. Information on AEs will be determined at each visit by direct questioning of the 
subjects, review of concomitant medications, and vital sign results.  
10.1.11  Blood Biobanking  
Up to 40mL will be collected at the same time as the lumbar puncture (LP). The time of the most 
recent ezogabine dose will be recorded for this blood draw. Encoded blood samples (with no 
subject identifying information) will be stored in the NEALS Biorepository located at 
Massachusetts General Hospital. They will be used for broad research purposes.   
10.1.12  Neurophysiological Testing 
TMS measurements will be performed by a board-certified physician or experienced technician. 
NCS measurements will be performed by a neuromuscular physician. Each site will have up to 
two TMS physiologists and up to two NCS physiologists (overlap allowed). Experienced 
neuromuscular physicians will obtain TMS and threshold NCS training at the investigator 
meeting, as it is critical to minimize test-retest and inter-site variation.  
 
For ALS subjects, neurophysiological testing will be performed on the side (right or left) as 
determined during the neurological examination. For unmatched and matched healthy control 
subjects, neurophysiological testing will be performed on the right side. Sites will have the 
option of including one additional recording on the left side for unmatched healthy control 
subjects at the third visit. 
 
Cortical motor neuron excitability will be measured by TMS. Measurements will include SICI, 
paired pulse facilitation, MEP amplitude and threshold, and cortical silent period. These 
measurements typically take 60 minutes but can take up to 120 minutes to complete at each 
session. 
 
Lower motor neuron excitability will be measured using NCS. For studies of lower motor 
neurons, median compound nerve action potentials will be recorded using surface electrodes in a 
standard belly/tendon montage using disposable self-adhesive ground and disk electrodes with 
constant temperature monitoring. For axonal threshold testing, data acquisition and stimulation 
for threshold tracking measurements will be performed using a computerized program, QTRACS 
with multiple excitability protocols (Institute of Neurology). We will obtain the following 
measurements: stimulus-response curve, strength-duration time constant, threshold electrotonus, 
and recovery cycle analysis (as described in detail in Kiernan et al., 2000; Nakata et al., 2006; 
Kanai et al., 2006; Vucic & Kiernan, 2006). When necessary, a clinical NCS machine may be 


 
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used for optimization of electrode placement and validation of inclusion criteria. Lower motor 
neuron excitability measurements typically take approximately 20 minutes to complete at each 
session but can take up to 40 minutes. 
10.1.13  American Urological Association (AUA) Symptom Score 
The AUA Symptom Score will be administered to subjects at baseline, and the Week 4, 8, and 12 
Visits. This instrument is widely used to track symptoms of urinary dysfunction. Because 
ezogabine has a risk of urinary dysfunction including urinary retention, we will include this 
survey to help SIs and medical monitor assess symptoms. 
10.1.14  Blindedness Questionnaire and Exit Survey 
The Blindedness Questionnaire will be used to determine whether there is effective unblinding 
due to treatment effects, as assessed by the subject and a member of the study team. The Exit 
Survey will assess subject tolerance of components of the study, including TMS, threshold 
tracking NCS and lumbar puncture. 
10.2  Clinical Outcome Measures 
10.2.1 ALSFRS-R 
The ALSFRS-R is a quickly administered (5 minutes) ordinal rating scale (ratings 0-4) used to 
determine subjects' assessment of their capability and independence in 12 functional activities.  
All 12 activities are relevant in ALS. Initial validity was established by documenting that in ALS 
patients, change in ALSFRS-R scores correlated with change in strength over time, was closely 
associated with quality of life measures, and predicted survival. The test-retest reliability is 
greater than 0.88 for all test items. The advantages of the ALSFRS-R are that the categories are 
relevant to ALS, it is a sensitive and reliable tool for assessing activities of daily living function 
in those with ALS, and it is quickly administered.  With appropriate training the ALSFRS-R can 
be administered with high inter-rater reliability and test-retest reliability.   
10.2.2 Slow Vital Capacity (SVC) 
The SVC (percent of predicted normal) will be determined, using the upright SVC method. The 
SVC can be measured using conventional spirometers that have had a calibration check prior to 
subject testing.  A printout from the spirometer of all SVC trials will be retained. All SVC 
evaluators must be NEALS certified. Three SVC trials are required for each testing session, 
however up to 5 trials may be performed if the difference between the highest and second highest 
relative to the highest SVC is 10% or greater for the first 3 trials. All values will be recorded. 
The highest SVC recorded is utilized for eligibility.  


 
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10.2.3 Edinburgh Handedness Inventory Short Form 
The Edinburgh Handedness Inventory Short Form is a common instrument used to assess 
handedness and is important in interpreting the neurophysiological data. This will be completed 
at the screening visit.  
 
10.2.4 Hand-held Dynamometry (HHD)   
Hand held dynamometry (HHD) will be used as a quantitative measure of muscle strength of the 
abductor pollicis brevis (APB) muscle.  
10.2.5 Manual Muscle Testing (MMT) is a procedure for the evaluation of the function and 
strength of individual muscles and muscle groups based on the effective performance of a 
movement in relation to the forces of gravity and manual resistance. MMT testing will be 
performed on the bilateral APB muscles only.  
 
10.2.6 Training and Validation 
All evaluators must be NEALS certified to perform the ALSFRS-R, SVC and HHD; specific 
certification requirements are outlined in the study operations manual. Repeat NEALS 
certification will follow NEALS standard practices for all outcome measures. It is strongly 
preferred that a single evaluator performs all measures throughout the study, if possible. NEALS 
certification is required for all evaluators prior to performing any study tests. 
10.2.7 Assessment of Muscle Symptoms 
Subjects will be provided with a Muscle Symptom Diary to record muscle cramp frequency and 
intensity and severity of fasciculations at home daily. At each subsequent visit, the site staff will 
review the diary and record the daily frequency and maximal intensity of muscle cramps and 
fasciculations before providing the subject with a new diary. 
10.2.7.1 Muscle Cramps 
The effects of retigabine on muscle cramps will also be assessed as a secondary endpoint.  
Cramps in ALS patients are common and are often debilitating.  Various medications including 
quinine sulfate, magnesium, lioresal, dantrolene, clonazepam, diphenylhydantoin and 
gabapentin, have been used in the treatment of cramps in ALS, though few have been studied in 
the ALS population and none have clearly shown efficacy.  
 
The visual analog scale (VAS) is a scale that measures pain associated with muscle cramping.  It 
will be used to measure muscle cramp intensity in this study.  The scale rating is from 0-10; 0 
equals no symptoms, 10 equals most severe symptoms.   
 


 
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For the purposes of this study, a muscle cramp is defined as a sustained painful muscle 
contraction lasting seconds to minutes. At the Baseline Visit, subjects will be asked to recount 
the number of muscle cramps experienced in the previous 24 hours and the total number of 
cramps experienced in the previous 30 days. Subjects will also be asked to recount the maximum 
pain experienced with a muscle cramp in the previous 24 hours and the maximum pain 
experienced with a muscle cramp in the previous 30 days. The coordinator will record this on the 
source document at this visit. The VAS will also be explained at the Baseline Visit to all 
subjects.  The coordinator will provide the subject with a muscle cramp diary to record muscle 
cramp frequency and intensity at home, daily.  At each future visit (beginning at the Week 4 
Visit), the coordinator will review the Muscle Cramp Diary.   
10.2.7.2  Fasciculations 
Fasciculations will also be recorded in the daily diary. At Baseline, Weeks 4, 6, 8 and 12, 
subjects will be asked several questions related to their fasciculations experienced in the previous 
14 days. Reference the study Manual of Procedures for additional information.  
 
For the purpose of this study, a fasciculation is a brief, spontaneous contraction affecting a small 
number of muscle fibers, often causing a flicker of movement under the skin. Defining 
interference with daily activities may be different for each subject and defining daily activities 
will be different for each subject.  


 
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11 
SAFETY AND ADVERSE EVENTS 
The AE definitions and reporting procedures provided in this protocol comply with all applicable 
International Conference on Harmonization (ICH) guidelines.  The SI will carefully monitor 
each subject throughout the study for possible AEs.  All AEs will be documented on CRFs 
designed specifically for this purpose.  It is also important to report all AEs, especially those that 
result in permanent discontinuation of the investigational product being studied, whether serious 
or non-serious. 
11.1 
Definitions of AEs, Suspected Adverse Drug Reactions & SAEs 
11.1.1 Adverse Event and Suspected Adverse Drug Reactions 
An AE is any unfavorable and unintended sign (including a clinically significant abnormal 
laboratory finding, for example), symptom, or disease temporally associated with a study, use of 
a drug product or device whether or not considered related to the drug product or device.  
 
Adverse drug reactions (ADR) are all noxious and unintended responses to a medicinal product 
related to any dose.  The phrase “responses to a medicinal product” means that a causal 
relationship between a medicinal product and an AE is at least a reasonable possibility, i.e., the 
relationship cannot be ruled out.  Therefore, a subset of AEs can be classified as suspected 
ADRs, if there is a causal relationship to the medicinal product. 
 
Examples of AEs include: new conditions, worsening of pre-existing conditions, clinically 
significant abnormal physical examination signs (e.g., skin rash, peripheral edema), or clinically 
significant abnormal test results (e.g., lab values or vital signs), with the exception of outcome 
measure results, which are not being recorded as AEs in this trial (they are being collected, but 
analyzed separately). Stable chronic conditions (e.g., diabetes, arthritis) that are present prior to 
the start of the study and do not worsen during the trial are NOT considered AEs.  Chronic 
conditions that occur more frequently (for intermittent conditions) or with greater severity, 
would be considered as worsened and therefore would be recorded as AEs. 
 
AEs are generally detected in two ways: 
 
 
Clinical → symptoms reported by the subject or signs detected on examination. 
 
Ancillary Tests → abnormalities of vital signs, laboratory tests, and other diagnostic 
procedures (other than the outcome measures, the results of which are not being captured 
as AEs). 
 


 
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For the purposes of this study, symptoms of progression/worsening of ALS, including ‘normal’ 
progression, will be recorded as AEs.     
 
The following measures of disease progression will not be recorded as AEs even if they worsen 
(they are being recorded and analyzed separately): vital capacity results and ALSFRS-R results.  
 
If discernible at the time of completing the AE log, a specific disease or syndrome rather than 
individual associated signs and symptoms should be identified by the SI and recorded on the AE 
log.  However, if an observed or reported sign, symptom, or clinically significant laboratory 
anomaly is not considered by the SI to be a component of a specific disease or syndrome, then it 
should be recorded as a separate AE on the AE log.  Clinically significant laboratory 
abnormalities, such as those that require intervention, are those that are identified as such by the 
SI. 
 
Subjects will be monitored for AEs from the time they sign consent until completion of their 
participation in the study (defined as death, consent withdrawal, loss to follow up, early study 
termination for other reasons or following completion of the entire study).   
 
An unexpected AE is any AE, the specificity or severity of which is not consistent with the 
current IB.  An unexpected, suspected ADR is any unexpected AE that, in the opinion of the SI 
or Sponsor, there is a reasonable possibility that the investigational product caused the event. 
11.1.1.1  Adverse Events of Special Interest 
All subjects participating in this trial will be informed that they could be at risk for: 
o new or worsened urinary retention (in the clinical judgment of the site investigator)     
o retinal hyperpigmentation abnormalities and/or vision loss,  
o pigmentation of non-retinal ocular tissues (e.g., conjunctiva, sclera, iris)  
o discoloration of nails, lips, skin (including skin around the eyes) or mucosa. 
 
Subjects must inform the SI of any of these symptoms immediately.  The SI must contact the 
Medical Monitor to discuss the subject’s continued use of study drug. Per the discretion of the 
SI, subjects may be referred to a dermatologist for skin discoloration at any point in the study.   
 
Special attention must also be made for AEs of possible drug-induced liver injury with 
hyperbilirubinemia defined as ALT 3x ULN and bilirubin 2x ULN (with >35% direct). 
 
11.1.2 Serious Adverse Events 
An SAE is defined as an AE that meets any of the following criteria: 
1. Results in death. 
2. Is life threatening: that is, poses an immediate risk of death as the event occurred. 


 
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a. This serious criterion applies if the study subject, in the view of the SI or Sponsor, 
is at immediate risk of death from the AE as it occurs.  It does not apply if an AE 
hypothetically might have caused death if it were more severe. 
3. Requires inpatient hospitalization for 24 hours or more or prolongation of existing 
hospitalization. 
a. Hospitalization for an elective procedure (including elective PEG tube/g-
tube/feeding tube placement) or a routinely scheduled treatment is not an SAE by 
this criterion because an elective or scheduled “procedure” or a “treatment” is not 
an untoward medical occurrence. 
4. Results in persistent or significant disability or incapacity. 
a. This serious criterion applies if the “disability” caused by the reported AE results 
in a substantial disruption of the subject’s ability to carry out normal life 
functions. 
5. Results in congenital anomaly or birth defect in the offspring of the subject (whether the 
subject is male or female).   
6. Necessitates medical or surgical intervention to preclude permanent impairment of a 
body function or permanent damage to a body structure. 
7. Important medical events that may not result in death, are not life-threatening, or do not 
require hospitalization may also be considered SAEs when, based upon appropriate 
medical judgment, they may jeopardize the subject and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition.  Examples of such 
medical events include blood dyscrasias or convulsions that do not result in inpatient 
hospitalization, or the development of drug dependency or drug abuse. 
 
An inpatient hospital admission in the absence of a precipitating, treatment-emergent, clinical 
AE may meet criteria for "seriousness" but is not an adverse experience, and will therefore, not 
be considered an SAE.  An example of this would include a social admission (subject admitted 
for other reasons than medical, e.g., lives far from the hospital, has no place to sleep). 
 
A serious, suspected ADR is an SAE for which, in the opinion of the SI or Sponsor, there is a 
reasonable possibility that the investigational product caused the event. 
 
The SI is responsible for classifying AEs as serious or non-serious. 
11.2 
Assessment and Recording of Adverse Events 
The SI will carefully monitor each subject throughout the study for possible AEs.  All AEs will 
be documented on CRFs designed specifically for this purpose.  All AEs will be collected and 
reported in the EDC system and compiled into reports for monthly reviewing by the Medical 
Monitor. The Medical Monitor shall promptly review all information relevant to the safety of the 
investigational product, including all SAEs.  Special attention will be paid to those that result in 


 
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permanent discontinuation of the investigational product being studied, whether serious or non-
serious. 
11.2.1 Assessment of Adverse Events 
At each visit (including telephone interviews), the subject will be asked if they have had any 
problems or symptoms since their last visit in order to determine the occurrence of AEs.  If the 
subject reports an AE, the SI will probe further to determine: 
1. Type of event 
2. Date of onset and resolution (duration) 
3. Severity (mild, moderate, severe) 
4. Seriousness (does the event meet the above definition for an SAE) 
5. Causality, relation to investigational product and disease 
6. Action taken regarding investigational product 
7. Outcome 
11.2.2 Relatedness of Adverse Event to Investigational Product 
The relationship of the AE to the investigational product should be specified by the SI using the 
following definitions: 
 
1.  Not Related:          
Concomitant illness, accident or event with no reasonable 
association with treatment. 
 
2.  Unlikely: 
The reaction has little or no temporal sequence from administration 
of the investigational product, or a more likely alternative etiology 
exists. 
 
3.  Possibly Related: 
The reaction follows a reasonably temporal sequence from 
administration of the investigational product and follows a known 
response pattern to the suspected investigational product; the 
reaction could have been produced by the investigational product 
or could have been produced by the subject’s clinical state or by 
other modes of therapy administered to the subject. (Suspected 
ADR) 
 
4.  Probably Related: 
The reaction follows a reasonably temporal sequence from 
administration of investigational product; is confirmed by 
discontinuation of the investigational product or by re-challenge; 
and cannot be reasonably explained by the known characteristics 
of the subject’s clinical state. (Suspected ADR) 
 


 
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5.  Definitely Related: 
The reaction follows a reasonable temporal sequence from 
administration of investigational product; that follows a known or 
expected response pattern to the investigational product; and that is 
confirmed by improvement on stopping or reducing the dosage of 
the investigational product, and reappearance of the reaction on 
repeated exposure (Suspected ADR). 
11.2.3 Recording of Adverse Events 
All clinical AEs are recorded in the AE Log in the subject’s study binder. The site should fill out 
the AE Log and enter the AE information into the EDC system within 48 hours of the site 
learning of a new AE or receiving an update on an existing AE.   
 
Please Note: SAEs must be reported to the NCRI CC within 24 hours of the site learning of the 
SAE.  This applies regardless of whether the subject is taking study drug or not.  Any events of 
drug-induced liver injury, retinal pigmentation and/or vision loss, skin pigmentation changes or 
urinary retention, whether classified as SAEs or not, must also be reported within 24 hours.  
 
Entries on the AE Log (and into the EDC) will include the following: name and severity of the 
event, the date of onset, the date of resolution, relationship to investigational product, action 
taken, and primary outcome of event.   
11.3 
Adverse Events and Serious Adverse Events - Reportable Events 
The following are considered reportable events and must be reported to the NCRI CC within 24 
hours of the site being notified of the event.  
 
o All events that meet the above criteria for Serious Adverse Events (SAEs) 
 
o Events of special interest as described in Section 11.1.1.1. 
 
o Dosage Changes (Dose Management) 
o Investigational Product Suspension, Reduction or Re-challenge 
o Investigational Product Discontinuation 
 
o Key Study Events: 
o Subject Final Disposition 
o Feeding Tube Placement 
o Permanent Assisted Ventilation (PAV)* 
o Tracheostomy 
o Mortality 
o Pregnancy 


 
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o Diaphragm Pacing System (DPS) device implantation 
 
* Permanent Assisted Ventilation (PAV) is defined as more than 22 hours daily of non-invasive 
mechanical ventilation for more than one week.  The date of onset of PAV is the first day of the 
seven days. 
 


 
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12 
DATA SAFETY MONITORING 
12.1 
Data and Safety Monitoring Board 
An independent DSMB will be assembled for the trial. The DSMB receives the blinded and 
unblinded summary reports of the frequency of all clinical AEs and safety laboratory tests for 
planned periodic meetings approximately every 3-6 months throughout the study. Meetings will 
be held via teleconference. In addition, the DSMB Chair may call ad hoc meetings.  
 
Summaries of SAEs and enrollment will be provided approximately monthly to the DSMB by 
the Study Biostatistician. AEs occurring within 24 hours of dosing, AE(s) related to visual 
acuity, skin pigmentation, hyperbilirubinemia, and urinary retention, and any severe unexpected 
SAEs are considered events of interest and will be reported in the monthly summaries to the 
DSMB by the NCRI CC.  The DSMB can ask to receive the SAE reports more frequently.  As 
necessary, the DSMB can review the frequencies of clinical and laboratory abnormalities.  
Recommendations for modification or termination of the trial based on safety data will be made 
by the DSMB to the PI and Steering Committee.  The DSMB will review safety data throughout 
the trial and may stop the trial for safety if it determines that there is a significant difference in 
the rate of a particular AE that would indicate a risk that is greater than the possible benefit of 
the study drug. A notable increase in the frequency of any AE should be examined by the DSMB 
although it may not lead to a recommendation by the DSMB. There will not be early stopping for 
efficacy in this trial.  
 
Prior to each DSMB meeting, the NCRI CC will provide an update to the DSMB on enrollment, 
data quality (missing data) and protocol adherence.  The NCRI CC will be responsible for 
communication with the DSMB.   
 
Complete information can be found in the Data and Safety Monitoring Plan. 
12.2 
Safety Monitoring 
12.2.1 Safety Management Resource Team  
The NCRI CC Safety Management Resource Team (SMaRT) is comprised of physicians, project 
managers, data managers, and systems personnel. On a periodic basis, the SMaRT will review 
AEs, SAEs, abnormal laboratory measurements, ECGs and protocol deviations as detailed in the 
study’s Safety Management Plan.  


 
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12.2.2 Medical Monitoring 
The designated Medical Monitor for the study is identified in the Site Manual of Procedures.  
Site personnel should contact the Medical Monitor for assistance with the following: 
• Medically-related protocol questions 
• Safety concerns, including AEs and SAEs 
• Protocol deviations 
• Protocol eligibility questions 
 
The Medical Monitor can decide whether a specific subject must discontinue study drug due to 
concerns about recurrent or persistent serious side effects such as cardiac events. 


 
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13 
STATISTICAL CONSIDERATIONS 
13.1 
Analysis Populations 
The unmatched healthy controls, matched healthy controls, and ALS subjects represent three 
distinct populations of individuals for the purposes of analysis. Some unmatched or matched 
healthy controls may be excluded from analysis if there is good reason to question their status as 
neurologically normal. All ALS subjects who are randomized and receive at least one dose of 
study drug will compose the modified intention to treat (mITT) population and will be included 
in primary analyses of safety, tolerability, and efficacy. For mITT analyses, subjects will be 
grouped according to their randomized treatment assignment regardless of treatment actually 
received or compliance with assigned treatment.  
13.2 
Analysis of Unmatched Healthy Control Subjects 
Neurophysiological testing (TMS and NCS) will be performed on unmatched healthy control 
subjects at each site to evaluate test-retest variation of the primary outcome prior to activating a 
site for enrollment of ALS subjects. Approximately five unmatched healthy control subjects per 
site will each undergo three repeat neurophysiological testing sessions. The Steering Committee 
will review estimates of test-retest reliability and other measures of site performance 
dynamically and will determine when individual sites may begin enrolling ALS subjects. The 
Steering Committee may adjust the number of healthy controls and the number of testing 
sessions per subject at individual sites based on the existing data at the time of review. The 
decision to activate a site to enroll ALS subjects will take into consideration the test-retest 
variation relative to performance at other participating sites. The goal will be to activate eight (8) 
to twelve (12) sites to recruit ALS subjects. The Steering Committee may recommend additional 
healthy control testing and delayed activation of sites to recruit ALS subjects.  
 
Estimates of test-retest variability will be obtained by analysis of the unmatched healthy control 
subjects using random effects models with random intercepts for site and subject and site-
specific within-person heteroscedasticity, 
 
 
 
where i indexes site, j indexes subject, and k indexes repeated testing sessions, ai ~ N(0,Var[a]), 
bij ~ N(0,Var[b]), and εijk ~ N(0,Var[ε]i). Test-retest reliability will be calculated as the person-
level intraclass correlation, the ratio of among-person variance over the sum of among-person 
and within-person variance for a given site. By assuming that among-person variance is not site-
specific, a site can achieve high intraclass correlation only by ensuring low within-person 
variance, not by enrolling highly variable subjects. TMS and NCS parameters will be analyzed 
on their original scale or after log transformation depending on which scale yields residuals that 


 
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are more nearly normally distributed by the Anderson-Darling goodness of fit statistic. The 
Steering Committee may also consider the absolute magnitudes of TMS and NCS parameter 
estimates for each site in evaluating site performance. 
13.3 
Primary Analysis 
We will test the effect of ezogabine on SICI using the mITT sample of ALS subjects in a shared-
baseline mixed model with fixed effects for visit (6 levels: Screening, Baseline, and Weeks 4, 6, 
8, and 12), treatment group (3 levels: placebo and 600 and 900 mg/day ezogabine) x post-
baseline visit (4 levels) and random site-specific intercepts and random participant-specific 
intercepts and slopes with unstructured covariance. The use of a shared-baseline reflects the 
homogeneity of the trial cohort prior to randomization and the combination with participant-
specific random effects induces an adjustment for any chance baseline differences similar to 
ANCOVA (Liu et al, 2009). We will use linear contrasts to test for dose-dependent differences in 
change from baseline to the average SICI over the stable dose period from weeks 6 through 8. A 
significant reduction of SICI (i.e., higher MEP amplitude) of either dose relative to placebo 
would be accepted as evidence of benefit from ezogabine treatment. 
13.4 
Secondary Analyses 
We will use the same shared-baseline mixed model analysis to test other continuous secondary 
efficacy outcomes (additional TMS parameters, NCS parameters, ALSFRS-R, and SVC). MEP 
threshold, the key secondary outcome, will be tested prior to and separate from all other 
secondary efficacy outcomes. We will compare trajectories in TMS and NCS parameters 
between ALS and matched healthy control subjects in an augmented model with the addition of 
fixed effects for patient group (2 levels: ALS and healthy controls) and patient group x visit 
interactions (9 levels: 6 visits for ALS patients and 3 for matched healthy controls) and separate 
patient-level variance-covariance and residual variance estimates by patient group. Comparisons 
between matched healthy controls and ALS patients will be estimated using linear contrasts. 
 
Safety and tolerability will be compared across treatments by log-rank test of time to first SAE, 
time to death, and time to dose discontinuation and by negative binomial regression of overall 
SAE and AE rates. The proportion of participants experiencing each MedDRA-classified AE 
will be compared across treatment groups by Fisher’s exact test. Treatment-dependent 
differences in suicidality will be estimated from C-SSRS total scores analyzed using the same 
shared-baseline mixed model used for the primary analysis. 
 
Serum PK estimates will be obtained for Cmax and time to peak concentration. 
 
Associations between firing rate of iPSC-derived motor neurons and baseline in vivo 
neurophysiological excitability indices will be compared within and between ALS and healthy 
control subjects by linear regression with in vivo paired pulse SICI as the dependent variable and 


 
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in vitro-firing rate, disease status and their interaction as predictors. A change-point model will 
be explored with a break at each participant’s in vitro-estimated EC50 for blocking motor neuron 
spontaneous action potential firing by ezogabine. Spontaneous firing rate of the in vitro-derived 
motor neurons and in vitro-estimated EC50 for blocking motor neuron spontaneous action 
potential firing by ezogabine will be considered as moderators of treatment efficacy in tests of 
neurophysiological and clinical response by augmenting the shared-baseline mixed models with 
fixed effects for iPSC parameters, the two-way interaction with visit, and the three-way 
interaction with treatment group and post-baseline visit. 
13.5 
Missing Data 
Following the ITT principle, all subjects in the mITT sample will be included in the primary 
efficacy analysis. Missing data will be handled by using models that are unbiased when data are 
missing at random. Alternative models that might achieve the missing at random assumption and 
alternative handling of missing values, e.g., by multiple imputation or explicit modeling of the 
missingness process, may be pursued as a sensitivity analysis, particularly if the active treatment 
arms have higher rates of missingness. 
13.6 
Multiplicity Adjustment for Primary and Key Secondary Endpoints 
The effect of each dose of ezogabine on the primary efficacy outcome in the mITT sample will 
be tested at two-tailed p < 0.027 following Dunnett's correction for comparing two active 
treatments to placebo. If this primary analysis identifies a significant benefit from ezogabine 
treatment, then testing the key secondary efficacy outcome at p < 0.027 maintains an overall type 
I error rate at 5% under a closed testing sequential analysis. If significance of the key secondary 
outcome alone is accepted as evidence of a therapeutic benefit from ezogabine when the primary 
analysis is not significant, then the overall type I error rate will be limited to 10% or less 
(depending on the correlation between the primary and key secondary outcomes). 
13.7 
Interim Analysis 
An interim futility analysis will take place after data are available from the forty-fifth (45th) ALS 
subject. Futility analysis will be performed independently for each study arm based on 
probability of “success”, which we define as being at least 95% certain that ezogabine treatment 
is beneficial relative to placebo with regard to the primary outcome or the key secondary 
outcome given a sample size of 30 subjects in each group. Futility for a specific study arm will 
be met if the probability of “success” conditioned on the data from the initial forty-five subjects 
is less than 20%. If a single arm meets the futility requirement, that arm will be discontinued. If 
both arms meet the futility requirement, the study will stop pending completion of already 
enrolled subjects. Recruiting will continue during the interim analysis period. 
 
In addition to early stopping for futility, the DSMB, SMaRT, and the medical monitor will 
review safety data throughout the trial. While no formal early stopping rules for safety have been 


 
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predefined given the diversity of possible safety signals that might arise, the DSMB may stop the 
trial for safety, for example, if they determine that there is a significant difference in the rate of a 
particular adverse event that would indicate a greater risk than the possible benefit of the study 
drug. The DSMB can also decide whether a specific subject must discontinue study drug due to 
concerns about recurrent or persistent serious side effects such as cardiac events. A significant 
increase in the frequency of any adverse event should be examined by the DSMB although it 
may not lead to a recommendation by the DSMB.  
13.8 
Power Calculations 
Caramia et al. (2000) report mean (SD) paired pulse SICI at 3 ms among 16 ALS patients of 
125.7 (25.7) percent of MEP control size. Stefan et al. (2001) report paired pulse SICI at 3 ms 
among 13 ALS patients of 96.9 (35.9) percent of MEP control size. Assuming a mean (SD) equal 
to 100 (30) percent of MEP and using a two-sided alpha of 0.027 based on Dunnett's correction 
for comparing two treatments to placebo, 40 patients in each group and up to 25% loss to follow-
up would give 80% power to detect a 25% difference between placebo and each active treatment 
based on a simple two-sample t-test. This accommodates the loss of power due to early stopping 
for futility and is conservative relative to our proposed shared-baseline mixed model analysis. 
For reference, Caramia et al. (2000) report an effect of three-week exposure to gabapentin equal 
to an 80% reduction of the paired pulse amplitude in untreated patients, and Stefan et al. (2001) 
report an effect of 5 or more day exposure to riluzole equal to a 35% reduction of the conditioned 
stimulus amplitude. 
 


 
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14 
DATA COLLECTION, MANAGEMENT AND MONITORING 
14.1 
Role of Data Management 
Data Management is the development, execution and supervision of plans, policies, programs, 
and practices that control, protect, deliver, and enhance the value of data and information assets. 
 
All data will be managed in compliance with NEALS policies, and applicable Sponsor and 
regulatory requirements. Site personnel will collect, transcribe, correct, and transmit the data 
onto source documents, Case Report Forms (CRFs), and other forms used to report, track and 
record clinical research data.  Clinical sites will be monitored to ensure compliance with data 
management requirements and Good Clinical Practices.  NCRI Data Management is responsible 
for developing, testing, and managing clinical data management activities. 
14.1.1 Data Entry and Checks 
The site personnel are instructed to enter information into the EDC System within 5 days of a 
visit.  Data collection is the responsibility of the staff at the site under the supervision of the SI.  
During the study, the SI must maintain complete and accurate documentation for the study. 
 
The EDC includes password protection.  An edit checking and data clarification process will be 
put in place to ensure accuracy and completeness of the database.  Logic and range checks as 
well as more sophisticated rules will be built into the EDC to provide immediate error checking 
of the data entered.  The system has the capability to automatically create electronic queries for 
forms that contain data that are out of range, out of window, missing or not calculated correctly.  
The sites will only have access to the queries concerning their subjects.   
14.1.2 Data Lock Process 
The application will have the ability to lock the database to prevent any modification of data 
once the study is closed.  Once this option is activated, every user will have Read-Only access to 
the data. The database can only be locked after each SI has signed off on their subjects and all 
queries have been resolved.   
14.1.3 Quality Assurance 
Protocol procedures are reviewed with the SI and associated personnel prior to the study to 
ensure the accuracy and reliability of data. Each SI must adhere to the protocol detailed in this 
document and agree that any changes to the protocol must be approved by the NCRI CC prior to 
seeking approval from the site IRB.  Each SI will be responsible for enrolling only those study 
subjects who have met protocol eligibility criteria. 


 
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14.2 
Clinical Monitoring 
Study Monitors will visit each study site to review source documentation materials, ICFs, and 
confirm entered data and that data queries have been accurately completed, and again at a study 
close-out visit.  Study Monitors will also verify that SAEs and protocol deviations have been 
reported appropriately, as required.  The Study Monitors will also review clinical facilities, 
resources and procedures for evaluating study subjects and study drug dispensing.  Subsequently, 
the Study Monitors will provide monitoring reports to the Project Manager and, if requested, will 
provide reports of protocol compliance to the Study PI and the Steering Committee.  Completed 
ICFs from each subject must be available in the subject’s file and verified for proper 
documentation.  A document outlining the monitoring plan is provided to each Study Monitor. 
More information regarding monitoring guidelines, timelines, and processes can be found in the 
study Manual of Procedures.  
14.3 
Data Handling and Record Keeping 
The SI is responsible to ensure the accuracy, completeness, legibility, and timeliness of the data 
reported.  All source documents should be completed in a neat, legible manner to ensure accurate 
interpretation of data.  Dark ink is required to ensure clarity of reproduced copies.  When making 
changes or corrections, cross out the original entry with a single line, and initial and date the 
change.  Do not erase, overwrite, or use correction fluid or tape on the original.  
 
Source document templates (SDTs) will be provided for use and maintained for recording data 
for each subject enrolled in the study.  Data reported in the eCRF derived from source documents 
should be consistent with the source documents and discrepancies should be explained.  The 
NCRI CC will provide guidance to SIs on making corrections to the source documents and 
eCRFs. 
14.3.1  Confidentiality 
Study subject medical information obtained by this study is confidential, and disclosure to third 
parties other than those noted below is prohibited. Upon the subject’s permission, medical 
information may be given to his or her personal physician or other appropriate medical personnel 
responsible for his or her welfare. All local and federal guidelines and regulations regarding 
maintaining study subject confidentiality of data will be adhered to. 
 
Data generated by this study must be available for inspection by representatives of the Office for 
Human Research Protections (OHRP), the sponsor, all pertinent local health and regulatory 
authorities, the NCRI CC or their representative, Study Monitoring personnel, and the IRBs. 


 
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14.3.2 Global Unique Identifier (GUID) 
A patient Global Unique Identifier (GUID) will be used as an identifier for individuals 
participating in this study. The GUID is an 11-character string that is generated using encryption 
technology and algorithms licensed by the NCRI from the National Institutes of Health (NIH). 
 
The GUID is generated on a secure website that utilizes 128-bit Secure Socket Layer (SSL). This 
website is not linked to the study database. The GUID is generated using an irreversible 
encryption algorithm – it accepts twelve identifying data elements, (e.g. last name at birth, first 
name at birth, gender at birth, day, month and year of birth, city and country of birth, etc.), and 
produces a unique random-generated character string, or GUID.  No identifying information is 
stored in the system; it is simply used to generate the GUID.  If the same information is entered 
again, the same GUID will be returned.  
 
The GUID is entered into the study database when the patient is being created in the system. As 
the same patient may participate in multiple studies, the study database will also allow capturing 
a study-specific ID for the patient. 
14.3.3  Study Discontinuation  
The study can be terminated at any time.  Reasons for terminating the study may include the 
following: 
• The incidence or severity of AEs in this or other studies indicates a potential health 
hazard to study subjects. 
• Study subject enrollment is unsatisfactory. 
• Data recording is inaccurate or incomplete. 
• Sponsor withdraws funding. 
14.3.4  Retention of Records 
The SIs should retain all study documents and records in accordance with their site IRB policies.  
14.3.5  Publications 
The PI, Brian Wainger, MD, PhD, along with the Steering Committee will be responsible for 
publications of results from this trial. This responsibility will include the following: 
• Analyze and interpret data gathered in this study, and write publications from these data. 
• Submit manuscripts to selected journals and address peer reviewers’ comments. 
• Submit abstracts to selected meetings and present data at the meetings. 
• Determine authorship on the basis of the Uniform Requirements for Manuscripts. 
14.3.6  Use of Samples 
Blood and CSF samples as well as iPSCs generated from subject blood samples will be used for 
broad research purposes both related to and potentially unrelated to motor neuron disease. 
Encoded samples that do not contain subject identifying information will be stored in research 


 
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repositories from which researchers will be able to obtain them for research purposes only. 
Research using the samples may take place within both academic and non-academic settings.  
Although genetic information may be analyzed, no genetic information will be given to the 
subject nor will the information that may be obtained be placed in a subject’s medical records.   
 
There is no scheduled date on which the samples will be destroyed.  Samples may be stored for 
research until they are used, damaged, decay or otherwise become unfit for analysis. Subjects 
have the option of declining participation in this portion of the study at any time by withdrawing 
their consent to have their sample used.  However, it will not be possible to destroy samples that 
have already been submitted to a repository.   
 


 
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15 
LITERATURE REFERENCES 
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and Group, R.S. (2010). Efficacy and safety of adjunctive ezogabine (retigabine) in refractory 
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Madrid, R., and van Zundert, B. (2013). Mutant SOD1-expressing astrocytes release toxic factors 
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Kanai, K., Kuwabara, S., Misawa, S., Tamura, N., Ogawara, K., Nakata, M., Sawai, S., Hattori, 
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Fujimaki, Y., Ohmori, S., Koga, S., and Kuwabara, S. (2012). Motor axonal excitability 
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Kuo, J.J., Schonewille, M., Siddique, T., Schults, A.N., Fu, R., Bar, P.R., Anelli, R., Heckman, 
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16 
APPENDICES 
16.1 Appendix I: El Escorial World Federation of Neurology Criteria for the Diagnosis of 
ALS 
 
Information obtained from the web site: www.wfnals.org. 
 
The diagnosis of Amyotrophic Lateral Sclerosis [ALS] requires:  
A - The presence of: 
 
(A:1) evidence of lower motor neuron (LMN) degeneration by clinical, electrophysiology
 
cal or  neuropathologic examination,  
 
(A:2)  evidence of upper motor neuron (UMN) degeneration by clinical examination, and  
 
(A:3) progressive spread of symptoms or signs within a region or to other regions, as 
determined  
by history or examination, together with 
B - The absence of: 
 
(B:1) electrophysiological and pathological evidence of other disease processes that 
might  
 
explain the signs of LMN and/or UMN degeneration, and  
 
(B:2) neuroimaging evidence of other disease processes that might explain the observed 
 
clinical and electrophysiological signs.  
 
CLINICAL STUDIES IN THE DIAGNOSIS OF ALS 
A careful history, physical and neurological examination must search for clinical evidence of 
UMN and LMN signs in four regions [brainstem, cervical, thoracic, or lumbosacral spinal cord] 
(see Table 1) of the central nervous system [CNS]. Ancillary tests should be reasonably applied, 
as clinically indicated, to exclude other disease processes. These should include 
electrodiagnostic, neurophysiological, neuroimaging and clinical laboratory studies.  Clinical 
evidence of LMN and UMN degeneration is required for the diagnosis of ALS.  The clinical 
diagnosis of ALS, without pathological confirmation, may be categorized into various levels of 
certainty by clinical assessment alone depending on the presence of UMN and LMN signs 
together in the same topographical anatomic region in either the brainstem [bulbar cranial motor 
neurons], cervical, thoracic, or lumbosacral spinal cord [anterior horn motor neurons]. The terms 
Clinical Definite ALS and Clinically Probable ALS are used to describe these categories of 
clinical diagnostic certainty on clinical criteria alone: 
 
A. Clinically Definite ALS is defined on clinical evidence alone by the presence of UMN, as 
well as LMN signs, in three regions.  
 
B. Clinically Probable ALS is defined on clinical evidence alone by UMN and LMN signs in at 
least two regions with some UMN signs necessarily rostral to (above) the LMN signs. 


 
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C. Clinically Probable ALS - Laboratory-supported is defined when clinical signs of UMN and 
LMN dysfunction are in only one region, or when UMN signs alone are present in one region, 
and LMN signs defined by EMG criteria are present in at least two limbs, with proper 
application of neuroimaging and clinical laboratory protocols to exclude other causes. 
 
D. Clinically Possible ALS is defined when clinical signs of UMN and LMN dysfunction are 
found together in only one region or UMN signs are found alone in two or more regions; or 
LMN signs are found rostral to UMN signs and the diagnosis of Clinically Probable - 
Laboratory-supported ALS cannot be proven by evidence on clinical grounds in conjunction with 
electrodiagnostic, neurophysiologic, neuroimaging or clinical laboratory studies. Other diagnoses 
must have been excluded to accept a diagnosis of Clinically Possible ALS. 
 
 
Table 1 
 
Brainstem  
Cervical  
Thoracic  
Lumbosacral  
Lower motor 
neuron signs 
weakness, 
atrophy, 
fasciculations  
jaw, face, 
palate, 
tongue, larynx  
neck, arm, hand, 
diaphragm  
back, 
abdomen  
back, abdomen, 
leg, foot  
Upper motor 
neuron signs 
pathologic spread 
of reflexes, clonus, 
etc.  
clonic jaw 
gag reflex 
exaggerated 
snout reflex 
pseudobulbar 
features 
forced yawning 
pathologic 
DTRs 
spastic tone  
clonic DTRs  
Hoffman reflex 
pathologic 
DTRs 
spastic tone 
 
preserved reflex 
in weak wasted 
limb  
loss of 
superficial 
abdominal 
reflexes 
pathologic 
DTRs 
spastic tone  
clonic DTRs - 
extensor plantar 
response 
pathologic DTRs 
spastic tone 
 
preserved reflex in 
weak wasted limb  
 
16.2 Appendix II: ALS Functional Rating Scale – Revised (ALSFRS-R) 
ALSFRS-R 
 
QUESTIONS: 
 
 
 
 
 
 
 
SCORE: 
    
1. Speech 
4 = Normal speech processes 


 
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3 = Detectable speech disturbances 
2 = Intelligible with repeating 
1 = Speech combined with nonvocal communication 
0 = Loss of useful speech 
 
2. Salivation 
4 = Normal 
3 = Slight but definite excess of saliva in mouth; may have nighttime drooling 
2 = Moderately excessive saliva; may have minimal drooling 
1 = Marked excess of saliva with some drooling 
0 = Marked drooling; requires constant tissue or handkerchief 
 
3. Swallowing 
4 = Normal eating habits 
3 = Early eating problems – occasional choking 
2 = Dietary consistency changes 
1 = Needs supplemental tube feeding 
0 = NPO (exclusively parenteral or enteral feeding) 
 
4. Handwriting 
4 = Normal 
3 = Slow or sloppy; all words are legible 
2 = Not all words are legible 
1 = No words are legible but can still grip a pen  
0 = Unable to grip pen 
 
 
 
 
 
 


 
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5a. Cutting Food and Handling Utensils (patients without gastrostomy) 
 
 
 
4 = Normal 
3 = Somewhat slow and clumsy, but no help needed 
2 = Can cut most foods, although clumsy and slow; some help needed 
1 = Food must be cut by someone, but can still feed slowly 
0 = Needs to be fed 
 
5b. Cutting Food and Handling Utensils (alternate scale for patients with gastrostomy) 
4 = Normal 
3 = Clumsy, but able to perform all manipulations independently 
2 = Some help needed with closures and fasteners 
1 = Provides minimal assistance to caregivers 
0 = Unable to perform any aspect of task 
 
6. Dressing and Hygiene 
4 = Normal function 
3 = Independent, can complete self-care with effort or decreased efficiency 
2 = Intermittent assistance or substitute methods 
1 = Needs attendant for self-care 
0 = Total dependence 
 
7. Turning in Bed and Adjusting Bed Clothes 
4 = Normal function 
3 = Somewhat slow and clumsy, but no help needed 
2 = Can turn alone, or adjust sheets, but with great difficulty 
1 = Can initiate, but not turn or adjust sheets alone 
0 = Helpless 
 
8. Walking 
4 = Normal 
3 = Early ambulation difficulties 
2 = Walks with assistance 
1 = Nonambulatory functional movement only 
0 = No purposeful leg movement 
 
 
 
 
 
9. Climbing Stairs 
4 = Normal 
3 = Slow 


 
Phase 2 Trial of Ezogabine in ALS 
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Page 81 of 90 
2 = Mild unsteadiness or fatigue 
1 = Needs assistance 
0 = Cannot do 
 
R-1. Dyspnea  
 
 
 
4 = None 
3 = Occurs when walking 
2 = Occurs with one or more of the following: eating, bathing, dressing 
1 = Occurs at rest, difficulty breathing when either sitting or lying 
0 = Significant difficulty, considering using mechanical respiratory support 
 
R-2 Orthopnea 
 
 
 
4 = None 
3 = Some difficulty sleeping at night due to shortness of breath, does not routinely use more than 
two pillows 
2 = Needs extra pillow in order to sleep (more than two) 
1 = Can only sleep sitting up 
0 = Unable to sleep without mechanical assistance 
 
R-3 Respiratory Insufficiency 
 
4 = None 
3 = Intermittent use of BiPAP 
2 = Continuous use of BiPAP during the night 
1 = Continuous use of BiPAP during the night and day 
0 = Invasive mechanical ventilation by intubation or tracheostomy 
  
Evaluator’s Initials: _____ _____ ______ 
 


 
Phase 2 Trial of Ezogabine in ALS 
V5.0 – 10/31/2016  
Page 82 of 90 
16.3 Appendix III: Columbia-Suicide Severity Rating Scale (C-SSRS) Baseline Version  
Information obtained from: http://www.cssrs.columbia.edu/ 
 
SUICIDAL IDEATION  
Ask questions 1 and 2. If both are negative, proceed to “Suicidal Behavior” section. If the 
answer to question 2 is “yes”, ask questions 3, 4 and 5. If the answer to question 1 
and/or 2 is “yes”, complete “Intensity of Ideation” section below.  
Lifetime:  
Time 
He/She 
Felt Most 
Suicidal  
1. Wish to be Dead  
Subject endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake 
up.  
Have you wished you were dead or wished you could go to sleep and not wake up?  
If yes, describe:  
Yes No  
□ □  
2. Non-Specific Active Suicidal Thoughts  
General, non-specific thoughts of wanting to end one’s life/commit suicide (e.g., “I’ve thought about killing 
myself”) without thoughts of ways to kill oneself/associated methods, intent, or plan.  
Have you actually had any thoughts of killing yourself?  
If yes, describe:  
Yes No  
  □ □  
3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act  
Subject endorses thoughts of suicide and has thought of at least one method during the assessment period. 
This is different than a specific plan with time, place or method details worked out (e.g., thought of method to 
kill self but not a specific plan). Includes person who would say, “I thought about taking an overdose but I 
never made a specific plan as to when, where or how I would actually do it…and I would never go through with 
it.”  
Have you been thinking about how you might do this?  
If yes, describe:  
Yes No  
  □ □  
4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan  
Active suicidal thoughts of killing oneself and subject reports having some intent to act on such thoughts, as 
opposed to “I have the thoughts but I definitely will not do anything about them.”  
Have you had these thoughts and had some intention of acting on them?  
If yes, describe:  
Yes No  
  □ □  
5. Active Suicidal Ideation with Specific Plan and Intent  
Thoughts of killing oneself with details of plan fully or partially worked out and subject has some intent to carry 
it out.  
Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this 
plan?  
If yes, describe:  
Yes No  
  □ □  
INTENSITY OF IDEATION  
The following features should be rated with respect to the most severe type of ideation (i.e., 1-5 
from above, with 1 being the least severe and 5 being the most severe). Ask about time he/she 
was feeling the most suicidal.  
_____ _________________________________________________  
Most Severe Ideation:  
Type # (1-5) Description of Ideation  
Most 
Severe  
Frequency  
How many times have you had these thoughts?  
(1) Less than once a week (2) Once a week (3) 2-5 times in week (4) Daily or almost daily (5) Many times each 
day  
____  


 
Phase 2 Trial of Ezogabine in ALS 
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Duration  
When you have the thoughts, how long do they last?  
(1) Fleeting - few seconds or minutes (4) 4-8 hours/most of day  
(2) Less than 1 hour/some of the time (5) More than 8 hours/persistent or continuous  
(3) 1-4 hours/a lot of time  
____  
Controllability  
Could/can you stop thinking about killing yourself or wanting to die if you want to?  
(1) Easily able to control thoughts (4) Can control thoughts with a lot of difficulty  
(2) Can control thoughts with little difficulty (5) Unable to control thoughts  
(3) Can control thoughts with some difficulty (0) Does not attempt to control thoughts  
____  
Deterrents  
Are there things - anyone or anything (e.g., family, religion, pain of death) - that stopped you 
from wanting to die or acting on thoughts of committing suicide?  
(1) Deterrents definitely stopped you from attempting suicide (4) Deterrents most likely did not stop you  
(2) Deterrents probably stopped you (5) Deterrents definitely did not stop you  
(3) Uncertain that deterrents stopped you (0) Does not apply  
____  
Reasons for Ideation  
What sort of reasons did you have for thinking about wanting to die or killing yourself? Was it 
to end the pain or stop the way you were feeling (in other words you couldn’t go on living with 
this pain or how you were feeling) or was it to get attention, revenge or a reaction from 
others? Or both?  
(1) Completely to get attention, revenge or a reaction from others (4) Mostly to end or stop the pain (you 
couldn’t go on  
(2) Mostly to get attention, revenge or a reaction from others living with the pain or how you were feeling)  
(3) Equally to get attention, revenge or a reaction from others (5) Completely to end or stop the pain (you 
couldn’t go on  
and to end/stop the pain. living with the pain or how you were feeling)  
(0) Does not apply  
____  
 
SUICIDAL BEHAVIOR  
(Check all that apply, so long as these are separate events; must ask about all types)  
Lifetime  
Actual Attempt:  
A potentially self-injurious act committed with at least some wish to die, as a result of act. Behavior was in 
part thought of as method to kill oneself. Intent does not have to be 100%. If there is any intent/desire to die 
associated with the act, then it can be considered an actual suicide attempt. There does not have to be 
any injury or harm, just the potential for injury or harm. If person pulls trigger while gun is in mouth but 
gun is broken so no injury results, this is considered an attempt.  
Inferring Intent: Even if an individual denies intent/wish to die, it may be inferred clinically from the behavior or 
circumstances. For example, a highly lethal act that is clearly not an accident so no other intent but suicide 
can be inferred (e.g., gunshot to head, jumping from window of a high floor/story). Also, if someone denies 
intent to die, but they thought that what they did could be lethal, intent may be inferred.  
Have you made a suicide attempt?  
Have you done anything to harm yourself?  
Have you done anything dangerous where you could have died?  
What did you do?  
Did you______ as a way to end your life?  
Did you want to die (even a little) when you_____?  
Were you trying to end your life when you _____?  
Or did you think it was possible you could have died from_____?  
Or did you do it purely for other reasons / without ANY intention of killing yourself 
(like to relieve stress, feel better, get sympathy, or get something else to happen)? 
(Self-Injurious Behavior without suicidal intent)  
If yes, describe:  
Has subject engaged in Non-Suicidal Self-Injurious Behavior?  
Yes No  
□ □  
 
Total # of  
Attempts  
______  
 
Yes No  
□ □  


 
Phase 2 Trial of Ezogabine in ALS 
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Page 84 of 90 
Interrupted Attempt:  
When the person is interrupted (by an outside circumstance) from starting the potentially self-injurious act (if 
not for that, actual attempt would have occurred).  
Overdose: Person has pills in hand but is stopped from ingesting. Once they ingest any pills, this becomes an 
attempt rather than an interrupted attempt. Shooting: Person has gun pointed toward self, gun is taken away 
by someone else, or is somehow prevented from pulling trigger. Once they pull the trigger, even if the gun 
fails to fire, it is an attempt. Jumping: Person is poised to jump, is grabbed and taken down from ledge. 
Hanging: Person has noose around neck but has not yet started to hang - is stopped from doing so.  
Has there been a time when you started to do something to end your life but someone 
or something stopped you before you actually did anything?  
If yes, describe:  
Yes No  
□ □  
 
Total # of 
interrupted  
______  
Aborted Attempt:  
When person begins to take steps toward making a suicide attempt, but stops themselves before they 
actually have engaged in any self-destructive behavior. Examples are similar to interrupted attempts, except 
that the individual stops him/herself, instead of being stopped by something else.  
Has there been a time when you started to do something to try to end your life but 
you stopped yourself before you actually did anything?  
If yes, describe:  
Yes No  
□ □  
 
Total # of  
aborted  
______  
Preparatory Acts or Behavior:  
Acts or preparation towards imminently making a suicide attempt. This can include anything beyond a 
verbalization or thought, such as assembling a specific method (e.g., buying pills, purchasing a gun) or 
preparing for one’s death by suicide (e.g., giving things away, writing a suicide note).  
Have you taken any steps towards making a suicide attempt or preparing to kill 
yourself (such as collecting pills, getting a gun, giving valuables away or writing a 
suicide note)?  
If yes, describe:  
Yes No  
□ □  
Suicidal Behavior:  
Suicidal behavior was present during the assessment period?  
Yes No  
□ □  
Answer for Actual Attempts Only  
Most 
Recent  
Attempt  
Date:  
Most 
Lethal  
Attempt  
Date:  
Initial/First  
Attempt  
Date:  
Actual Lethality/Medical Damage:  
0. No physical damage or very minor physical damage (e.g., surface scratches).  
1. Minor physical damage (e.g., lethargic speech; first-degree burns; mild bleeding; 
sprains).  
2. Moderate physical damage; medical attention needed (e.g., conscious but 
sleepy, somewhat responsive; second-degree burns; bleeding of major vessel).  
3. Moderately severe physical damage; medical hospitalization and likely intensive 
care required (e.g., comatose with reflexes intact; third-degree burns less than 
20% of body; extensive blood loss but can recover; major fractures).  
4. Severe physical damage; medical hospitalization with intensive care required 
(e.g., comatose without reflexes; third-degree burns over 20% of body; extensive 
blood loss with unstable vital signs; major damage to a vital area).  
5. Death  
Enter 
Code  
______  
Enter 
Code  
______  
Enter Code  
______  
Potential Lethality: Only Answer if Actual Lethality=0  
Likely lethality of actual attempt if no medical damage (the following examples, 
while having no actual medical damage, had potential for very serious lethality: put 
gun in mouth and pulled the trigger but gun fails to fire so no medical damage; 
laying on train tracks with oncoming train but pulled away before run over).  
0 = Behavior not likely to result in injury  
1 = Behavior likely to result in injury but not likely to cause death  
2 = Behavior likely to result in death despite available medical care  
Enter 
Code  
______  
Enter 
Code  
______  
Enter Code  
______  
 
 


 
Phase 2 Trial of Ezogabine in ALS 
V5.0 – 10/31/2016  
Page 85 of 90 
16.4 Appendix IV: Columbia-Suicide Severity Rating Scale (C-SSRS) Since Last Visit  
SUICIDAL IDEATION  
Ask questions 1 and 2. If both are negative, proceed to “Suicidal Behavior” section. If the 
answer to question 2 is “yes”, ask questions 3, 4 and 5. If the answer to question 1 and/or 2 is 
“yes”, complete “Intensity of Ideation” section below.  
Since 
Last 
Visit  
1. Wish to be Dead  
Subject endorses thoughts about a wish to be dead or not alive anymore, or 
wish to fall asleep and not wake up.  
Have you wished you were dead or wished you could go to sleep and not wake 
up?  
If yes, describe:  
Yes 
No  
□     □  
2. Non-Specific Active Suicidal Thoughts  
General, non-specific thoughts of wanting to end one’s life/commit suicide 
(e.g., “I’ve thought about killing myself”) without thoughts of ways to kill 
oneself/associated methods, intent, or plan during the assessment period.  
Have you actually had any thoughts of killing yourself?  
If yes, describe:  
Yes 
No  
□     □ 
3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act  
Subject endorses thoughts of suicide and has thought of at least one method 
during the assessment period. This is different than a specific plan with time, 
place or method details worked out (e.g., thought of method to kill self but not a 
specific plan). Includes person who would say, “I thought about taking an 
overdose but I never made a specific plan as to when, where or how I would 
actually do it…and I would never go through with it.”  
Have you been thinking about how you might do this?  
If yes, describe:  
Yes 
No  
□     □ 
4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan  
Active suicidal thoughts of killing oneself and subject reports having some 
intent to act on such thoughts, as opposed to “I have the thoughts but I 
definitely will not do anything about them.”  
Have you had these thoughts and had some intention of acting on them?  
If yes, describe:  
Yes 
No  
□     □  
5. Active Suicidal Ideation with Specific Plan and Intent  
Thoughts of killing oneself with details of plan fully or partially worked out and 
subject has some intent to carry it out.  
Have you started to work out or worked out the details of how to kill yourself? 
Do you intend to carry out this plan?  
If yes, describe:  
Yes 
No  
□     □   


 
Phase 2 Trial of Ezogabine in ALS 
V5.0 – 10/31/2016  
Page 86 of 90 
Information obtained from: http://www.cssrs.columbia.edu/ 
 
SUICIDAL BEHAVIOR  
(Check all that apply, so long as these are separate events; must ask about all types)  
Since 
Last Visit  
INTENSITY OF IDEATION  
The following features should be rated with respect to the most severe type of ideation (i.e., 1-5 from 
above, with 1 being the least severe and 5 being the most severe).  
Most Severe Ideation: _____ _________________________________________________  
Type # (1-5) Description of Ideation  
Most 
Severe  
Frequency  
How many times have you had these thoughts?  
(1) Less than once a week (2) Once a week (3) 2-5 times in week (4) Daily or 
almost daily (5) Many times each day  
____  
Duration  
When you have the thoughts, how long do they last?  
(1) Fleeting - few seconds or minutes (4) 4-8 hours/most of day  
(2) Less than 1 hour/some of the time (5) More than 8 hours/persistent or 
continuous  
(3) 1-4 hours/a lot of time  
____  
Controllability  
Could/can you stop thinking about killing yourself or wanting to die if you want to?  
(1) Easily able to control thoughts (4) Can control thoughts with a lot of difficulty  
(2) Can control thoughts with little difficulty (5) Unable to control thoughts  
(3) Can control thoughts with some difficulty (0) Does not attempt to control 
thoughts  
____  
Deterrents  
Are there things - anyone or anything (e.g., family, religion, pain of death) - that stopped you from 
wanting to die or acting on thoughts of committing suicide?  
(1) Deterrents definitely stopped you from attempting suicide (4) Deterrents 
most likely did not stop you  
(2) Deterrents probably stopped you (5) Deterrents definitely did not stop you  
(3) Uncertain that deterrents stopped you (0) Does not apply  
____  
Reasons for Ideation  
What sort of reasons did you have for thinking about wanting to die or killing yourself? Was it to end 
the pain or stop the way you were feeling (in other words you couldn’t go on living with this pain or 
how you were feeling) or was it to get attention, revenge or a reaction from others? Or both?  
(1) Completely to get attention, revenge or a reaction from others (4) Mostly to 
end or stop the pain (you couldn’t go on  
(2) Mostly to get attention, revenge or a reaction from others living with the pain 
or how you were feeling)  
(3) Equally to get attention, revenge or a reaction from others (5) Completely to 
end or stop the pain (you couldn’t go on  
and to end/stop the pain living with the pain or how you were feeling)  
(0) Does not apply  
____  


 
Phase 2 Trial of Ezogabine in ALS 
V5.0 – 10/31/2016  
Page 87 of 90 
Actual Attempt:  
A potentially self-injurious act committed with at least some wish to die, as a result of act. Behavior was in part 
thought of as method to kill oneself. Intent does not have to be 100%. If there is any intent/desire to die associated 
with the act, then it can be considered an actual suicide attempt. There does not have to be any injury or harm, just 
the potential for injury or harm. If person pulls trigger while gun is in mouth but gun is broken so no injury results, 
this is considered an attempt.  
Inferring Intent: Even if an individual denies intent/wish to die, it may be inferred clinically from the behavior or 
circumstances. For example, a highly lethal act that is clearly not an accident so no other intent but suicide can be 
inferred (e.g., gunshot to head, jumping from window of a high floor/story). Also, if someone denies intent to die, but 
they thought that what they did could be lethal, intent may be inferred.  
Have you made a suicide attempt?  
Have you done anything to harm yourself?  
Have you done anything dangerous where you could have died?  
What did you do?  
Did you______ as a way to end your life?  
Did you want to die (even a little) when you_____?  
Were you trying to end your life when you _____?  
Or did you think it was possible you could have died from_____?  
Or did you do it purely for other reasons / without ANY intention of killing yourself (like to relieve 
stress, feel better, get sympathy, or get something else to happen)? (Self-Injurious Behavior 
without suicidal intent)  
If yes, describe:  
 
Has subject engaged in Non-Suicidal Self-Injurious Behavior?  
Yes No  
□  □  
 
Total # of  
Attempts  
______  
 
Yes No  
□  □  
Interrupted Attempt:  
When the person is interrupted (by an outside circumstance) from starting the potentially self-injurious act (if not for 
that, actual attempt would have occurred).  
Overdose: Person has pills in hand but is stopped from ingesting. Once they ingest any pills, this becomes an 
attempt rather than an interrupted attempt. Shooting: Person has gun pointed toward self, gun is taken away by 
someone else, or is somehow prevented from pulling trigger. Once they pull the trigger, even if the gun fails to fire, it 
is an attempt. Jumping: Person is poised to jump, is grabbed and taken down from ledge. Hanging: Person has 
noose around neck but has not yet started to hang - is stopped from doing so.  
Has there been a time when you started to do something to end your life but someone or 
something stopped you before you actually did anything?  
If yes, describe:  
Yes No  
□  □  
 
Total # of 
interrupted  
______  
Aborted Attempt:  
When person begins to take steps toward making a suicide attempt, but stops themselves before they actually have 
engaged in any self-destructive behavior. Examples are similar to interrupted attempts, except that the individual 
stops him/herself, instead of being stopped by something else.  
Has there been a time when you started to do something to try to end your life but you 
stopped yourself before you actually did anything?  
If yes, describe:  
Yes No  
□  □  
 
Total # of  
aborted  
______  
Preparatory Acts or Behavior:  
Acts or preparation towards imminently making a suicide attempt. This can include anything beyond a verbalization 
or thought, such as assembling a specific method (e.g., buying pills, purchasing a gun) or preparing for one’s death 
by suicide (e.g., giving things away, writing a suicide note).  
Have you taken any steps towards making a suicide attempt or preparing to kill yourself (such as 
collecting pills, getting a gun, giving valuables away or writing a suicide note)?  
If yes, describe:  
Yes No  
□  □  
Suicidal Behavior:  
Suicidal behavior was present during the assessment period?  
Yes No  
□  □  
Suicide:  
Yes No  
□  □ 
Answer for Actual Attempts Only  
Most Lethal 
Attempt  
Date:  


 
Phase 2 Trial of Ezogabine in ALS 
V5.0 – 10/31/2016  
Page 88 of 90 
Actual Lethality/Medical Damage:  
0. No physical damage or very minor physical damage (e.g., surface scratches).  
1. Minor physical damage (e.g., lethargic speech; first-degree burns; mild bleeding; sprains).  
2. Moderate physical damage; medical attention needed (e.g., conscious but sleepy, somewhat responsive; second-
degree burns; bleeding of major vessel).  
3. Moderately severe physical damage; medical hospitalization and likely intensive care required (e.g., comatose 
with reflexes intact; third-degree burns less than 20% of body; extensive blood loss but can recover; major 
fractures).  
4. Severe physical damage; medical hospitalization with intensive care required (e.g., comatose without reflexes; 
third-degree burns over 20% of body; extensive blood loss with unstable vital signs; major damage to a vital area).  
5. Death  
 
Enter Code  
______  
Potential Lethality: Only Answer if Actual Lethality=0  
Likely lethality of actual attempt if no medical damage (the following examples, while having no actual medical 
damage, had potential for very serious lethality: put gun in mouth and pulled the trigger but gun fails to fire so no 
medical damage; laying on train tracks with oncoming train but pulled away before run over).  
0 = Behavior not likely to result in injury  
1 = Behavior likely to result in injury but not likely to cause death  
2 = Behavior likely to result in death despite available medical care  
 
Enter Code  
______  
 
 
 


 
Phase 2 Trial of Ezogabine in ALS 
V5.0 – 10/31/2016  
Page 89 of 90 
16.5 Appendix V: Retigabine Muscle Cramp Diary – Visual Analog Scale (Pain Scale) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
Phase 2 Trial of Ezogabine in ALS 
V5.0 – 10/31/2016  
Page 90 of 90 
16.6 Appendix VI: Edinburgh Handedness Inventory- Short Form  
 

SAP_000.pdf: 
 
 
Cover Page – Statistical Analysis Plan 
 
 
 
 
 
Study Official Title: A Phase 2 Pharmacodynamic Trial 
of Ezogabine on Neuronal Excitability in Amyotrophic 
Lateral Sclerosis 
 
NCT #: NCT02450552 
 
Version Date of the Document: September 27, 2018 
 
 
 


Wainger (PI) Ezogabine Trial: Statistical Analysis Plan 
Version 1.0, 27 Sep 2018 
 
Page 2 of 19 
 
 
STATISTICAL ANALYSIS PLAN (SAP) 
Title 
A Phase 2 Pharmacodynamic Trial of Ezogabine on Neuronal 
Excitability in Amyotrophic Lateral Sclerosis 
Regulatory Sponsor 
Brian J. Wainger, MD, PhD 
Current Protocol Version 
5.0 
Current Protocol Date 
09 Mar 2015 
Statistical Analysis Plan 
Version 
1.0 
Statistical Analysis Plan 
Date 
27 Sep 2018 
 
SAP APPROVAL SIGNATURES 
 
 
Brian J. Wainger, MD, PhD 
Principal Investigator and Sponsor 
Date 
 
 
Eric A. Macklin, PhD 
Study Biostatistician 
Date 
 


Wainger (PI) Ezogabine Trial: Statistical Analysis Plan 
Version 1.0, 27 Sep 2018 
 
Page 3 of 19 
 
SAP REVISION HISTORY 
Version 
Date 
Description of Changes 
1.0 
27 Sep 2018 Initial version 
 


Wainger (PI) Ezogabine Trial: Statistical Analysis Plan 
Version 1.0, 27 Sep 2018 
 
Page 4 of 19 
 
Table of Contents 
1. 
Introduction ........................................................................................................................... 5 
2. 
Study Design .......................................................................................................................... 5 
2.1 
Overview ......................................................................................................................................................... 5 
2.2 
Study Objectives ............................................................................................................................................. 5 
2.3 
Study Populations ............................................................................................................................................ 5 
2.4 
Participant Flow and Site Approval ................................................................................................................ 6 
2.5 
Treatment Allocation ....................................................................................................................................... 6 
2.6 
Treatment Administration ............................................................................................................................... 6 
2.7 
Allocation Concealment .................................................................................................................................. 7 
2.8 
Schedule of Assessments for ALS Participants ............................................................................................... 7 
3. 
Statistical Methodology ........................................................................................................ 8 
3.1 
General Considerations ................................................................................................................................... 8 
3.1.1 
Statistical Software ................................................................................................................................ 8 
3.1.2 
Summary Statistics ................................................................................................................................ 8 
3.1.3 
Precision ................................................................................................................................................ 9 
3.2 
Study Endpoints .............................................................................................................................................. 9 
3.2.1 
Efficacy Endpoints ................................................................................................................................. 9 
3.2.2 
Safety Endpoints .................................................................................................................................. 10 
3.2.3 
Tolerability Endpoint ........................................................................................................................... 10 
3.3 
Measurement Definitions .............................................................................................................................. 10 
3.3.1 
TMS Measures ..................................................................................................................................... 10 
3.3.2 
TTNCS Measures ................................................................................................................................ 11 
3.3.3 
ALSFRS-R ........................................................................................................................................... 12 
3.3.4 
SVC ..................................................................................................................................................... 12 
3.3.5 
APB Strength ....................................................................................................................................... 12 
3.3.6 
Cramping ............................................................................................................................................. 12 
3.3.7 
Fasciculations ...................................................................................................................................... 12 
3.3.8 
AUA Symptom Score .......................................................................................................................... 13 
3.4 
Determination of Sample Size ....................................................................................................................... 13 
3.5 
Analysis Samples .......................................................................................................................................... 13 
3.6 
Baseline Characterization .............................................................................................................................. 14 
3.7 
Interim Analysis ............................................................................................................................................ 14 
3.8 
Efficacy Analysis .......................................................................................................................................... 14 
3.8.1 
Primary Analysis of the Primary Efficacy Endpoint ............................................................................ 14 
3.8.2 
Secondary Analyses of the Primary Efficacy Endpoint ....................................................................... 15 
3.8.3 
Secondary Efficacy Endpoints ............................................................................................................. 16 
3.8.4 
Subgroup Analyses .............................................................................................................................. 16 
3.8.5 
Multiplicity Adjustments ..................................................................................................................... 16 
3.8.6 
Missing Data ........................................................................................................................................ 17 
3.9 
Safety Analysis .............................................................................................................................................. 17 
3.9.1 
Treatment-emergent Adverse Events ................................................................................................... 17 
3.9.2 
Suicidality ............................................................................................................................................ 17 
3.9.3 
Safety Labs .......................................................................................................................................... 17 
3.9.4 
Vital Signs ........................................................................................................................................... 17 
3.9.5 
Additional Continuous Safety Outcomes ............................................................................................. 18 
3.9.6 
Post-study Mortality ............................................................................................................................ 18 
3.10 
Other Analyses ......................................................................................................................................... 18 
3.10.1 
Participant Disposition ......................................................................................................................... 18 
3.10.2 
Study Drug Compliance and Tolerance ............................................................................................... 18 
3.10.3 
Prior and Concomitant Medication Use ............................................................................................... 18 
4. 
References ............................................................................................................................ 18 


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1. Introduction 
This Statistical Analysis Plan (SAP) defines the outcome measures and analysis samples and 
specifies the planned analyses of data from Dr. Brian Wainger's Ezogabine trial. This SAP is 
specific to analysis of data related to the ALS participants in the randomized intervention trial. 
The SAP supplements the clinical protocol. Please refer to the clinical protocol for details on the 
rationale for the intervention, eligibility criteria, conduct of the trial, clinical assessments and the 
timing of their use in the trial, definitions and reporting of adverse events, data management 
conventions, and regulatory oversight and compliance procedures. In case of discrepancies 
between the SAP and the clinical protocol concerning matters of analysis, the SAP is 
authoritative. On all other matters, the clinical protocol is authoritative. 
2. Study Design 
2.1 
Overview 
This is a multicenter, double-blind, placebo-controlled, three-arm, parallel-group, phase 2 
randomized controlled trial to examine the effect of two dosages of ezogabine on neuronal 
excitability in ALS patients. The trial also enrolls unmatched and age-matched healthy control 
subjects to evaluate disease-dependent differences in baseline measures and longitudinal changes 
in neuronal excitability. Trial participation for ALS participants includes a screening visit, 
randomization to 600 mg/day or 900 mg/day ezogabine or placebo, 10 weeks of follow-up on 
study drug, and 4 weeks of follow-up after last dose of study drug. Trial participation for 
unmatched healthy control (UHC) participants includes a screening visit and up to 4 additional 
neurophysiological testing visits with one or two neurophysiologists over a span of up to 6 
weeks. Trial participation for age-matched healthy control (MHC) participants includes a 
screening visit and two follow-up visits over 12 weeks. The trial is registered at Clinicaltrials.gov 
as study NCT02450552 (see https://clinicaltrials.gov/ct2/show/NCT02450552). 
2.2 
Study Objectives 
The primary efficacy objective of the trial is to determine whether ezogabine reduces 
neurophysiological excitability indices in ALS participants as assessed by transcranial magnetic 
stimulation (TMS) and threshold tracking axonal nerve conduction studies (TTNCS). Secondary 
efficacy objectives include evaluating the effect of ezogabine on measures of clinical 
progression, including functional scores, vital capacity, and muscle strength, and on measures of 
muscle cramping and fasciculations. 
The safety objectives of the trial are to assess the safety and tolerability of ezogabine by 
assessing treatment-emergent adverse events (TEAEs), vital signs, laboratory assessments, 
electrocardiography (ECG), urologic symptoms, ophthalmologic symptoms, and suicidality. 
2.3 
Study Populations 
Individuals eligible for trial participation as an ALS participant are men or women at least 18 
years old who meet the El Escorial criteria of possible, laboratory-supported probable, probable, 
or definite criteria for a diagnosis of ALS and have a slow vital capacity (SVC) at least 50% of 
that expected based on age, sex, and height. Individuals eligible for study participation as an 
UHC participant are men or women at least 18 years old who do not have a history or family 


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history of possible motor neuron disease. Individuals eligible for study participation as a MHC 
participant are men or women who do not have a history or family history of possible motor 
neuron disease and are within 10 years of age of an enrolled ALS participant. Detailed inclusion 
and exclusion criteria are specified in the clinical protocol. 
Participants will be recruited from a total of 12 clinical sites located through the US. 
2.4 
Participant Flow and Site Approval 
After providing informed consent, approximately 5 UHC participants will be screened for 
eligibility at each site, including assessment of neurophysiology by TMS and TTNCS by one or 
two neurophysiologists. Each UHC participant will have up to 4 additional neurophysiological 
testing visits over a span of up to 6 weeks. 
After completing TMS and TTNCS assessments of the first UHC participant, sites must receive 
approval from the Coordination Center before continuing enrollment of UHC participants. 
Approval will be based on review of TMS and TTNCS data by the respective central reading 
centers. After completing enrollment of approximately 5 UHC participants, sites must receive 
approval from the Coordination Center before initiating recruitment of ALS participants. 
After a site is activated for recruitment of ALS participants and after each ALS patient provides 
informed consent and is determined eligible, approximately 120 ALS participants will be 
randomized to receive ezogabine 600 mg/day, ezogabine 900 mg/day, or placebo in a 1:1:1 ratio, 
stratified by clinical site. The first dose of stdy drug is administered at the baseline visit. ALS 
participants are exposed to study drug for 10 weeks, from baseline to a week 10 telephone call. 
ALS participants complete in-clinic evaluations at weeks 4, 6, 8, and 12 and complete follow-up 
by telephone at weeks 2, 10, and 14 to assess for TEAEs and update concomitant medication 
logs. Participants who discontinue study drug should remain on study following the normal 
schedule of assessments. Patients withdrawing consent are asked to delay withdrawing consent 
until after they return for a Final Safety Visit approximately 2 weeks after their last dose of study 
drug and after they complete a final telephone call 4 weeks after their last dose of study drug. 
Detailed descriptions of study procedures and timing are specified in the clinical protocol. 
2.5 
Treatment Allocation 
Prior to the baseline visit, eligible ALS participants are randomly allocated in equal proportions 
to one of three treatment groups, ezogabine 600 mg/day, ezogabine 900 mg/day, or placebo, 
according to a permuted-block randomization schedule, stratified by site. The randomization 
schedule was prepared by computer program by the unblinded study statistician. 
2.6 
Treatment Administration 
Study drug will be orally self-administered in film-coated immediate-release tablets of a variety 
of strengths of ezogabine or matching placebo. In the 600 mg/day arm, ezogabine is titrated as 
follows: 100 mg TID for week 1, 150 mg TID for week 2, 200 mg TID for weeks 3 through 8, 
200 mg BID for week 9, and 200 mg QD for week 10. In the 900 mg/day arm, ezogabine is 
titrated as follows: 100 mg TID for week 1, 150 mg TID for week 2, 200 mg TID for week 3, 
250 mg TID for week 4, 300 mg TID for weeks 5 through 8, 200 mg BID for week 9, and 200 
mg QD for week 10. In the placebo arm, participants receive a matching pseudo-titration of 
placebo tablets matched for size, color, and presentation. 


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2.7 
Allocation Concealment 
The randomization schedule is known only by the unblinded study statistician who generated the 
schedule and by the study drug distributor. Concealment of the true treatment allocation of 
specific participants is achieved by use of anonymous subject identifiers to link participants with 
specific study drug kits and by use of matching active and placebo tablets and titration schedules. 
Clinical members of the Steering Committee, site investigators and other site staff, clinical 
coordination and data management staff, the medical monitor, and all participants are blinded to 
participant treatment allocations. The Data and Safety Monitoring Board (DSMB) members are 
provided treatment-specific information in order to monitor the trial but such information is 
masked by use of coded values to identify the treatment groups. The DSMB may request the true 
treatment identities. 
2.8 
Schedule of Assessments for ALS Participants 
Activity 
Screening 
Baseline2 
Week 2 
Week 4 3 
Week 63 
Week 83 
Week 10 
Week 12 
Week 14 
CLINIC 
CLINIC 
CALL 
CLINIC 
CLINIC 
CLINIC 
CALL 
CLINIC 
CALL 
Day  
-21 to -1 
Day 0 
 
Day 14  
± 3 
Day 28  
± 3 
Day 42  
± 3 
Day 56  
± 3 
Day 70  
± 3 
Day 84  
± 3 
Day 98  
+5 
Written Informed Consent 
X 
 
 
 
 
 
 
 
 
Inclusion/Exclusion Review 
X 
 
 
 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
ALS Diagnosis History 
X 
 
 
 
 
 
 
 
 
Concomitant Medication Review 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse Event Review4 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Physical Examination 
X 
 
 
 
 
 
 
X 
 
Neurological Exam 
X 
 
 
 
 
 
 
X 
 
Manual Muscle Testing (MMT) 
X 
 
 
 
 
 
 
X 
 
Vital Signs5 
X 
X 
 
X 
X 
X 
 
X 
 
12-Lead Electrocardiogram (ECG) 
X 
X15 
 
 
X 
 
 
X 
 
Height & Weight6 
X 
X 
 
X 
X 
X 
 
X 
 
Safety Labs7  
X 
 
 
X 
X 
X 
 
X 
 
Urological Symptom Score 
X 
 
 
X 
 
X 
 
X 
 
ALSFRS-R 
X 
X 
 
X 
X 
X 
 
X 
 
Slow Vital Capacity (SVC) 
X 
X 
 
X 
X 
X 
 
X 
 
Hand Held Dynamometry (APB only) 
X 
X 
 
X 
X 
X 
 
X 
 
Assign Global Unique Identifier (GUID) 
X 
 
 
 
 
 
 
 
 
Blindedness Questionnaire and Exit Survey 
 
 
 
 
 
 
 
X 
 
Suicide Assessment (C-SSRS) 
 
X 
 
X 
X 
X 
 
X 
 
Edinburgh Handedness Inventory – short form 
X 
 
 
 
 
 
 
 
 
Blood collection for iPSC Lines 
 
 
 
X8  
(X8) 
(X8) 
 
 
 
Neurophysiological Testing (TMS/NCS) 
X 
X 
 
(X17) 
X 
X 
 
(X17) 
 
Ophthalmologic Examination9 
 
X 
 
 
 
 
 
X 
 
Lumbar Puncture (Optional) 
 
 
 
 
X16 
 
 
 
 
Pharmacokinetics (PK)/Biobanking 
 
 
 
 
X 
 
 
 
 


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Activity 
Screening 
Baseline2 
Week 2 
Week 4 3 
Week 63 
Week 83 
Week 10 
Week 12 
Week 14 
CLINIC 
CLINIC 
CALL 
CLINIC 
CLINIC 
CLINIC 
CALL 
CLINIC 
CALL 
Day  
-21 to -1 
Day 0 
 
Day 14  
± 3 
Day 28  
± 3 
Day 42  
± 3 
Day 56  
± 3 
Day 70  
± 3 
Day 84  
± 3 
Day 98  
+5 
Telephone Call10 
 
 
X 
 
 
 
X 
 
X 
Randomization11 
 
X 
 
 
 
 
 
 
 
Administer/Dispense Study Drug 
 
X12 
 
X 
 
 
 
 
 
Drug Accountability/ Compliance 
 
X 
 
X13 
X13 
X13 
 
X13 
 
Review of Muscle Symptoms Diary14 
 
X 
 
X 
X 
X 
 
X 
 
Fasciculation Assessment Form 
 
X 
 
X 
X 
X 
 
X 
 
1 All clinic visits after the Baseline Visit and before Week 14 will have a ± 3 day window. 
2 Screening procedures must be completed prior to the Baseline Visit, which will be scheduled up to 21 days after the Screening 
Visit. 
3 Study staff should document the time the last dose of ezogabine was administered. 
4Adverse events that occur AFTER signing the informed consent form will be recorded. 
5 Vital signs include systolic and diastolic pressure in mm Hg, respiratory rate/minute, heart rate/minute and temperature. 
6 Height measured at Screening Visit only. 
7 Labs include Hematology (CBC with differential), Complete Chemistry Panel, Liver Function Tests, Urinalysis and serum 
pregnancy test (WOCBP, screening visit only).  
8 Blood for iPSC lines can be collected at either week 4, 6 or 8. 
9 Ophthalmologic Examinations may be scheduled separately, but within 14 days prior to Baseline Visit and within 14 days of 
Week 12 Visit. 
10 Subjects will be called at the designated time points, as a reminder to escalate up or taper off study drug, when appropriate. 
11 Randomization should occur at or prior to the Baseline Visit. 
12 Administer first dose of study drug AFTER all Baseline Visit procedures are completed (with the exception of ECG testing).  
Subjects to take study drug until the Week 10 call. 
13 Review dosing diary 
14 Muscle symptoms will be completed every day, starting at the Baseline visit, with a Muscle Symptom Diary and should be 
reviewed by study staff at every visit after Baseline. 
15 ECG testing should be performed 3 hours post initial study drug administration. 
16 Lumbar puncture is optional 
17 Only participant enrolled prior to protocol version 4 were scheduled to complete TMS and TTNCS testing at the week 4 and 12 
visits. 
3. Statistical Methodology 
3.1 
General Considerations 
3.1.1 Statistical Software 
All statistical analyses will be performed using SAS (SAS Institute, NC, USA) or R (R 
Foundation for Statistical Computing, Vienna, Austria).  
3.1.2 Summary Statistics 
Data will be summarized with respect to disposition, demographics, pre-treatment 
characteristics, safety outcomes, tolerability, and efficacy outcomes. Summary statistics for 
continuous variables will include the number of subjects, the mean, median, standard deviation, 
and range. For categorical data, summaries will include counts and percentages. 


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3.1.3 Precision 
Results will generally be reported to 3 significant figures. Percentages will generally be reported 
to 0.1 percentage points. P-values will be reported to two digits when greater than or equal to 
0.095, to three digits when greater than or equal to 0.00095 and less than 0.095, and as <0.001 
for all smaller values. 
3.2 
Study Endpoints 
3.2.1 Efficacy Endpoints 
The primary efficacy endpoint is the change from pre-treatment to the average of the week 6 and 
week 8 visits in paired-pulse short-interval intracortical inhibition (SICI) assessed by TMS. 
The key secondary efficacy endpoint is the change from pre-treatment to the average of the week 
6 and week 8 visits in resting motor evoked potential (MEP) threshold (RMT) assessed by TMS. 
The other secondary efficacy endpoints are the change from pre-treatment to the average of the 
week 6 and week 8 visits in the following measures. 
TMS measures: 
• MEP amplitude at 120% of RMT,  
• Intracortical facilitation (ICF), and 
• Cortical silent period (CSP). 
TTNCS measures: 
• Strength duration time-constant (SDTC),  
• Depolarizing and hyperpolarizing electrotonus at 90 to 100 ms (TEd(90-100 ms) and 
TEh(90-100 ms)),  
• Recovery cycle measures of relative refractory period (RRP), superexcitability, and 
subexcitability, and  
• Compound motor action potential (CMAP). 
Clinical measures: 
• ALS Functional Rating Scale-Revised (ALSFRS-R) total score,  
• Slow vital capacity (SVC),  
• Abductor pollicis brevis (APB) muscle strength by hand-held dynamometry (HHD),  
• Muscle cramping frequency and pain, and  
• Fasciculation occurrence and interference with daily life. 
Exploratory efficacy measures include: maximum amplitude, minimum amplitude, midpoint of 
activation, and slope at the midpoint of activation from input/output curves; rheobase, TEd(40-60 
ms), TEh(10-20 ms), TEd(peak), subexcitability after second pre-pulse, and stimulus for 50% 
maximum response assessed by TTNCS; MEP amplitude at 120% of RMT divided by CMAP. 


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3.2.2 Safety Endpoints 
The following safety endpoints will be evaluated: 
• Proportion of participants experiencing and number of unique events of each type of TEAE 
and serious TEAE classified by MedDRA system organ class and preferred term,  
• Proportion of participants experiencing and number of unique events of TEAEs classified by 
seriousness, severity, relatedness to study drug, relatedness to TMS and TTNCS procedures, 
action taken with study drug, action taken with TMS/TTNCS, and outcome, summarized 
across all MedDRA terms,  
• Instances of treatment-emergent laboratory abnormalities classified by assay, whether the 
abnormality is below or above the normal range, and extend of deviation from normal,  
• Mean change from baseline in weight 
• Proportion of participants experiencing treatment-emergent clinically significant ECG 
abnormalities 
• Proportion of participants experiencing treatment-emergent ophthalmologic complication,  
• Mean change in AUA Symptom Score and proportion of participants with mild, moderate, or 
severe symptoms by visit,  
• Proportion of participants reporting any treatment-emergent suicidal ideation 
• Maximum post-baseline suicidal ideation planning, frequency, duration, controllability, 
deterrents, and reasons 
• Proportion of participants reporting any post-baseline suicidal behavior, actual attempts, non-
suicidal self-injurious behavior, interrupted attempts, aborted attempts, preparatory acts or 
behaviors, or completed suicide 
• Maximum post-baseline suicidal behavior lethality and potential lethality 
Reported proportions will use as their denominator all participants in the Safety and Tolerability 
sample (see Section 3.5 below). 
3.2.3 Tolerability Endpoint 
Participants will be judged tolerant of study drug if they reached their target dose and remain on 
study drug until planned discontinuation. Tolerability will be summarized as the proportion of 
participants in a treatment group who are tolerant of study drug. 
3.3 
Measurement Definitions 
3.3.1 TMS Measures 
Transcranial magnetic stimulation (TMS) is a neurophysiologic test for assessing upper motor 
neuron function. A magnetic coil is positioned on the head above the motor cortex at a location 
that causes excitation of the abductor pollicis brevis (APB) muscle in a participant's dominant 
hand. High-frequency sampling of motor evoked potentials (MEP) in the APB is used to record 
neurophysiologic response to specific magnetic field strengths and sequences. The MEP traces 
are used to calculate a range of derived measures. MEPs that were below the limit of detect and 
recorded as zero mV were replaced by 0.005 mV. 


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• Resting motor threshold (RMT): RMT is the magnetic field strength, measured as a 
percentage of the maximum stimulator output, that produces at least a 0.05 mV response in at 
least 5 of 10 consecutive trials. 
• MEP amplitude: MEP amplitude is defined as the response when a stimulus equal to 120% of 
RMT is administered. MEP amplitude is calculated as the geometric mean of replicate 
estimates. 
• Short-interval intracortical inhibition (SICI): Paired-pulse SICI is defined as the ratio of the 
response after a conditioning pulse equal to 80% of RMT is administered 3 ms prior to the 
signaling pulse divided by MEP amplitude. SICI is calculated as the geometric mean of 
replicate estimates. 
• Intracortical facilitation (ICF): Paired-pulse ICF is defined as the ratio of the response after a 
conditioning pulse equal to 80% of RMT is administered 15 ms prior to the signaling pulse 
divided by MEP amplitude. ICF is calculated as the geometric mean of replicate estimates. 
• Cortical silent period (CSP): CSP is the suppression of voluntary muscle contraction elicited 
by stimulation equal to 120% of RMT. CSP duration is measured from the time of the muscle 
activity suppression to return of muscle activity. 
• Input/Output curve parameters: MEPs elicited by stimuli ranging in strength from 60% of 
RMT to 150% of RMT follow a sigmoidal curve with upper and lower thresholds and a 
smooth, symmetric transition between the thresholds. A four-parameter logistic function fit 
to the input/output curve after log-transformation of output potentials yields estimates of 
maximum amplitude, minimum amplitude, midpoint of activation, and slope at the midpoint 
of activation. 
• TMS quality: Good vs. poor quality TMS assessments will be evaluated as a measure of 
electrophysiologic response. Good quality will be defined as a central reader's evaluation that 
the TMS records were of good quality overall and that individual measurements of RMT, 
input/output curves, and CSP were of good quality. 
TMS tracings were centrally reviewed and processed. Central readers indicated the reliability of 
the overall TMS assessment and of individual measures using a set of quality flags. Only TMS 
assessments that were evaluated as good quality overall and for measurement of RMT, 
input/output curves, and CSP are used for primary analysis. CSP times equal to zero were 
considered low quality whether flagged as such or not. 
3.3.2 TTNCS Measures 
Threshold-tracking nerve conduction studies (TTNCS) is a neurophysiologic test for assessing 
lower motor neuron function. The following measures were obtained using standard procedures 
(Kiernan et al. 2000): strength-duration measures of strength duration time-constant (SDTC) and 
rheobase; threshold electrotonus measures of depolarizing threshold electrotonus at 40 to 60 ms 
[TEd (40-60 ms)], 90 to 100 ms [TEd (90-100 ms)], and at peak [TEd (peak)] and 
hyperpolarizing threshold electrotonus at 10 to 20 ms [TEh (10-20 ms)] and 90 to 100 ms [TEh 
(90-100 ms)]; recovery cycle measures of RRP, superexcitability, subexcitability after first pre-
pulse, and subexcitability after second pre-pulse; peak amplitude measures of compound motor 
evoked potential (CMAP) and stimulus for 50% maximum response. 


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TTNCS tracings were centrally reviewed and processed. A central reader indicated the reliability 
of the overall TTNCS assessment and of individual measures using a set of quality flags. For 
primary analysis, all measures were excluded if the overall quality flag indicated that the full 
assessment was unusable. Otherwise, acceptable quality for primary analysis was separately 
indicated for peak amplitude (CMAP, stimulus for 50% maximum response), strength-duration 
measures (SDTC, rheobase), threshold electrotonus (TEd (40-60 ms), TEd (90-100 ms), TEd 
(peak), TEh (10-20 ms), TEh (90-100 ms)), RRP, superexcitability, and subexcitability (after 
first and second pre-pulse). 
3.3.3 ALSFRS-R 
The ALSFRS-R (Cedarbaum et al. 1999) is a 12-item clinician-completed interview scale for 
assessing participants’ function in four domains: bulbar, fine motor, gross motor, and respiratory. 
Each item is scored from 0 to 4 with higher scores indicating greater function. The ALSFRS-R 
total score is the sum of all items (range 0 to 48). 
3.3.4 SVC 
Slow vital capacity (SVC) is the maximum volume of air that can be slowly exhaled after slow, 
maximal inhalation. Trained technicians coach participants through 3 to 5 maneuvers using a 
spirometer. The maximum volume expired is converted to percent of predicted normal. Normal 
values are calculated based on sex, age, and height using equations published by Knudsen et al. 
(1983). 
3.3.5 APB Strength 
Bilateral abductor pollicis brevis (APB) muscle strength will be measured quantitatively by 
hand-held dynamometry (HHD) and assessed subjectively by manual muscle testing (MMT). 
MMT is a single 8-level item with scores ranging from 0 if no contraction can be achieved and 5 
if the muscle exerts normal strength. Scores of 4 are subdivided into three levels ranging from 4- 
if active movement is achieved against the force of gravity and slight resistance to 4+ if active 
movement is achieved against the force of gravity and strong resistance. 
3.3.6 Cramping 
Frequency of muscle cramping and maximum pain from muscle cramping is collected at baseline 
by retrospective report of the prior 7 and 30-day intervals. Prospective muscle cramping and pain 
from muscle cramping is recorded starting at baseline by participants in daily diaries and then 
summarized as weekly summaries of total number of cramps experienced and maximum and 
average daily maximum pain from muscle cramping. 
3.3.7 Fasciculations 
Data on muscle fasciculations are captured at baseline and each post-baseline clinic visit by 
retrospective report of the prior 14-day interval. Data are captured on the experience of any 
fasciculations, the average duration of fasciculations, the association of fasciculations with 
exertion or times of rest, the degree to which fasciculations interfere with daily activities, and 
interference of fasciculations with sleep. Prospective data on fasciculations are recorded starting 
at baseline by participants in daily diaries and then summarized as weekly summaries indicating 
the number of days with no fasciculations, with fasciculations after exertion that did not 
substantially interfere with daily activities, with fasciculations at rest or after exertion that did 


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not substantially interfere with daily activities, and fasciculations that substantially interfered 
with daily activities. 
3.3.8 AUA Symptom Score 
The American Urological Association (AUA) Symptom Index (Barry et al. 2017) is a 7-item 
instrument addressing urinary frequency, nocturia, weak urinary stream, hesitancy, intermittence, 
incomplete emptying, and urgency. Each item is scored from 0 to 5 with higher scores indicating 
greater symptom severity. The AUA Symptom Score is the sum of all items (range 0 to 35). 
AUA Symptom Scores from 0 through 7 are classified as mild symptoms, scores from 8 through 
19 are classified as moderate symptoms, and scores of 20 through 35 are classified as severe 
symptoms. 
3.4 
Determination of Sample Size 
Caramia et al. (2000) report mean (SD) paired pulse SICI at 3 ms among 16 ALS patients of 
125.7 (25.7) percent of MEP control size. Stefan et al. (2001) report paired pulse SICI at 3 ms 
among 13 ALS patients of 96.9 (35.9) percent of MEP control size. Assuming a mean (SD) equal 
to 100 (30) percent of MEP and using a two-sided alpha of 0.027 based on Dunnett's correction 
for comparing two treatments to placebo, 40 patients in each group and up to 25% loss to follow-
up would give 80% power to detect a 25% difference between placebo and each active treatment 
based on a simple two-sample t-test. This accommodates the loss of power due to early stopping 
for futility and is conservative relative to our proposed shared-baseline mixed model analysis. 
For reference, Caramia et al. (2000) report an effect of three-week exposure to gabapentin equal 
to an 80% reduction of the paired pulse amplitude in untreated patients, and Stefan et al. (2001) 
report an effect of 5 or more day exposure to riluzole equal to a 35% reduction of the conditioned 
stimulus amplitude. 
3.5 
Analysis Samples 
The following analysis samples will be used for testing safety, tolerability, and efficacy 
endpoints: 
• 
Safety and Tolerability (ST) Sample: ALS participants who are eligible, randomized, and 
take at least one dose of study drug, classified according to the actual treatment received. 
Observations made after premature permanent discontinuation of study drug are included in 
this sample, should such participants remain on study. 
• 
Efficacy Modified Intent-to-treat (mITT) Sample: ALS participants who are eligible, 
randomized, and take at least one dose of study drug, classified according to their 
randomized treatment assignment. Observations made after premature permanent 
discontinuation of study drug are included in this sample, should such participants remain on 
study. 
• 
Efficacy Per-protocol (PP) Sample: ALS participants who are eligible, randomized, and take 
at least one dose of study drug, classified according to the actual treatment received. 
Observations made after premature permanent discontinuation of study drug (whether due to 
intolerance, early termination, loss to follow-up, or death) are excluded from this sample. 


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• 
Efficacy Low RMT (loRMT) Sample: ALS participants and observations in the PP sample 
with RMT less than 67% of maximum stimulator output. This criterion ensures that the full 
TMS input/output curve could be conducted. 
• 
Efficacy All Quality (AllQual) Sample: ALS participants and observations in the PP sample 
with no restriction that TMS quality is good. 
3.6 
Baseline Characterization 
Each analysis sample will be summarized overall and by treatment group for the following 
characteristics: randomization site; age, sex, race, ethnicity, El Escorial diagnosis, years since 
ALS symptom onset, delay between symptom onset and ALS diagnosis, site of ALS symptom 
onset, use of riluzole at baseline, ALSFRS-R total score, SVC, APB muscle strength by HHD on 
the dominant hand, TMS parameters, TTNCS parameters, cramping frequency, cramping pain, 
fasciculation intensity, fasciculation interference with daily living, fasciculation interference with 
sleep, and AUA Symptom Score. The magnitude of differences between treatment groups will be 
summarized using Fisher's exact tests for nominal variables and two-sample t-tests for 
approximately continuous variables. 
3.7 
Interim Analysis 
An interim analysis for futility was planned after complete follow-up data were available from 
the 45th ALS participant; however, because the final randomization was scheduled less than 
three months after this timepoint due to slower than anticipated enrollment, the interim analysis 
was not conducted, with DSMB approval. The independent DSMB reviewed safety data 
quarterly and could request specific analyses at any time. 
3.8 
Efficacy Analysis 
3.8.1 Primary Analysis of the Primary Efficacy Endpoint 
The primary efficacy analysis will be performed on SICI of the APB after log-transformation in 
the mITT sample of ALS participants and will use a shared-baseline mixed model with fixed 
effects for visit (6 levels: Screening, Baseline, and Weeks 4, 6, 8, and 12), treatment group (3 
levels: placebo and 600 and 900 mg/day ezogabine) x post-baseline visit (4 levels) and random 
site-specific intercepts and random participant-specific intercepts and slopes with unstructured 
covariance. The interaction between fixed effects for treatment group and visit will be restricted 
to post-baseline visits by including a numeric indicator variable (0 pre-treatment, 1 post-
treatment) in the interaction. Use of a shared baseline reflects the true state of the population 
sampled prior to randomization and has the advantage of adjusting for any chance differences at 
baseline in a manner similar to analysis of covariance (Liang and Zeger, 2000) with potentially 
greater efficiency with more than one follow-up visit and drop-out. Random participant-specific 
slopes will be estimated per month from treatment initiation with all pre-treatment observations 
assigned a value of 0 months from treatment initiation. Data from Final Safety or Early 
Termination visits will be assigned to the next scheduled post-baseline visit. The following SAS 
code specifies the model: 
proc mixed data=xxx method=reml; 
  class site id trtrnd visit; 
  model Value = visit post*trtrnd*visit; 
  random intercept / subject=site type=vc; 
  random intercept month / subject=id(site) type=un; 


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Treatment-dependent differences in the change from pre-treatment to the average of the week 6 
and 8 visits on SICI will be estimated by a linear contrast and tested using a two-tailed Wald-test 
at alpha = 0.027. The following SAS code specifies the linear contrasts used to obtain the two 
co-primary estimands (with the sort order for treatment group being placebo, 600 mg/day 
ezogabine, and 900 mg/day ezogabine, and the sort order for visit being chronological): 
  estimate "2|600vsPlb|dAvg 6&8"  
            post*trtrnd*visit 1 1 0 -1 -1 0  -1 -1 0 1 1 0  0 0 0 0 0 0 / cl divisor=2; 
  estimate "2|900vsPlb|dAvg 6&8"  
            post*trtrnd*visit 1 1 0 -1 -1 0  0 0 0 0 0 0  -1 -1 0 1 1 0 / cl divisor=2; 
Estimates and their 95% confidence bounds will be back-transformed for reporting as 
proportional changes. A significant mean reduction in SICI from pre-treatment to the average of 
weeks 6 and 8 among participants randomized to either 600 or 900 mg/day ezogabine relative to 
mean changes among participants randomized to placebo would be considered evidence that 
ezogabine is effective in reducing cortical hyperexcitability. 
3.8.2 Secondary Analyses of the Primary Efficacy Endpoint 
Several secondary analyses will be investigated to assess sensitivity of our estimates of treatment 
effect to alternative modeling assumptions. 
• Active vs. placebo: A secondary estimand of the efficacy of ezogabine will compare both 
600 mg/day and 900 mg/day treatment arms vs. placebo, tested at alpha = 0.05. The 
following SAS code specifies the linear contrast for this comparison: 
  estimate "2|ActvsPlb|dAvg 6&8"  
            post*trtrnd*visit 2 2 0 -2 -2 0  -1 -1 0 1 1 0  -1 -1 0 1 1 0 / cl divisor=4; 
• Random-slopes model: The visit-specific fixed effects will be replaced with a continuous 
predictor of month since treatment initiation. Data from Final Safety and Early Termination 
visits will be placed at their observed follow-up time. Only assessments completed through 
Week 10, the end of planned study drug exposure, will be included. The following SAS code 
specifies the model and the linear contrasts used to estimate treatment-dependent differences 
in rate of change per month: 
proc mixed data=xxx method=reml; 
  where visit in ("Screening","Baseline","Week 04","Week 06","Week 08","Week 10"); 
  class site id trtrnd; 
  model Value = month trtrnd*month; 
  random intercept / subject=site type=vc; 
  random intercept month / subject=id(site) type=un; 
  estimate "2|600vsPbl|Slope/mn" intercept 0 month 0 trtrnd*month -1 1 0 / cl; 
  estimate "2|900vsPbl|Slope/mn" intercept 0 month 0 trtrnd*month -1 0 1 / cl; 
  estimate "2|ActvsPbl|Slope/mn" intercept 0 month 0 trtrnd*month -2 1 1 / cl divisor=2; 
• Shared-baseline mixed model with pMI for missing data: The shared-baseline mixed model 
with fixed effects for visits described above for the primary analysis will be applied to 
datasets generated by placebo multiple imputation (Ayele et al. 2014). Fifty imputed datasets 
will be generated for a given endpoint. 
• PP sample: The primary efficacy model and the secondary random-slopes model and active 
vs. placebo estimand will be applied to the PP sample. 
• loRMT sample: The primary efficacy model and the secondary random-slopes model and 
active vs. placebo estimand will be applied to the loRMT sample. 


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• AllQual sample: The primary efficacy model and the secondary random-slopes model and 
active vs. placebo estimand will be applied to the AllQual sample. 
3.8.3 Secondary Efficacy Endpoints 
The key secondary efficacy endpoint of RMT will be analyzed using the same analysis samples 
and models as specified for the primary efficacy endpoint in Sections 3.8.1 and 3.8.2. 
Continuous non-key secondary efficacy endpoints and exploratory efficacy endpoints measuring 
electrophysiology and clinical progression will all be analyzed using the mITT sample and the 
primary efficacy analysis described in Section 3.8.1. Variables that are strongly right-skewed 
(e.g., MEP amplitude, ICF) will be log-transformed prior to analysis, and estimates will be back-
transformed for reporting. 
The binary indicator of good quality TMS recordings will be analyzed in an equivalent 
generalized mixed model treating the indicator variable as a Bernoulli random variable with logit 
link. 
Weekly cramping frequency data will be analyzed in similar generalized mixed models treating 
the number of cramps experienced in a week as a negative binomial random variable with log 
link and with the log of the number of days at risk for cramps as an offset. Similarly, weekly 
number of days with fasciculations will be analyzed in similar generalized mixed models treating 
the number of days with fasciculations in a week as a binomial random variable with logit link. 
Because diary data are only collected after baseline, fixed effects in the model will include 
treatment group, post-baseline week, and baseline retrospective report of number of cramps 
experienced in the prior 30-day interval or the experience of fasciculations in the prior 14-day 
interval. 
3.8.4 Subgroup Analyses 
Differences in treatment efficacy will be explored in several pre-defined subgroups: baseline 
SICI (median split), baseline MEP amplitude (median split), and baseline riluzole use (yes vs. 
no). Subgroup specific estimates will be obtained by including subgroup, subgroup × visit, and 
subgroup × treatment × post-baseline visit terms to models for primary and key secondary 
efficacy outcomes based on the mITT sample. 
3.8.5 Multiplicity Adjustments 
The effect of each dose of ezogabine on the primary efficacy outcome in the mITT sample will 
be tested at two-tailed p < 0.027 following Dunnett's correction for comparing two active 
treatments to placebo. If this primary analysis identifies a significant benefit from ezogabine 
treatment, then testing the key secondary efficacy outcome at p < 0.027 maintains an overall type 
I error rate at 5% under a closed testing sequential analysis. If significance of the key secondary 
outcome alone is accepted as evidence of a therapeutic benefit from ezogabine when the primary 
analysis is not significant, then the overall type I error rate will be limited to 10% or less 
(depending on the correlation between the primary and key secondary outcomes). Results from 
analysis of non-key secondary efficacy endpoints, exploratory efficacy endpoints, and subgroup 
analyses will report nominal, comparison-wise p-values, recognizing that the totality of results 
will be evaluated in judging the potential efficacy of ezogabine. 


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3.8.6 Missing Data 
Baseline values for efficacy endpoints will be determined from the last non-missing data 
collected prior to the first dose of study medication. The planned mixed model yields estimates 
that are unbiased conditional on the observed scores under a missing at random assumption. In 
addition, a secondary analysis of the primary endpoint will use placebo-based multiple 
imputation of missing data. Additional sensitivity analyses may be pursued to impute missing 
values or otherwise construct models for unobserved outcomes if more than 20% of participants 
are missing follow-up data for any reason. 
3.9 
Safety Analysis 
3.9.1 Treatment-emergent Adverse Events 
The incidence of TEAEs will be summarized by the number of events of a given classification 
experienced by participants in each treatment group and by the number and proportion of 
participants experiencing such an event in each treatment group in the ST sample. TEAEs will be 
summarized in aggregate across all MedDRA terms and separately by MedDRA system organ 
class and preferred term. 
Aggregate summaries of TEAE grade will include characteristics of: (a) seriousness, (b) severity, 
(c) relatedness to study drug, (d) relatedness to TMS, (e) relatedness to TTNCS, (f) action taken 
with study drug, (g) action taken with study procedure, and (h) outcome. For each level of a 
given TEAE characteristic, summaries will include the number of events of a given classification 
and by the number and proportion of participants for which that level of a characteristic was the 
worst they experienced (treating any unknown characteristic as not worst).  
3.9.2 Suicidality 
The proportion of participants who report any post-baseline suicidal ideation or any post-baseline 
suicidal behavior will be summarized by treatment group. Suicidal behaviors will include: actual 
attempts, non-suicidal self-injurious behavior, interrupted attempts, aborted attempts, preparatory 
acts or behaviors, and completed suicide. The most severe ideation, maximal frequency, maximal 
duration, minimal controllability, minimal deterrents, maximal reasons for ideation, maximal 
actual lethality or medical damage, and maximal potential lethality will be summarized as 
means, standard deviations, medians, and ranges by treatment group. 
3.9.3 Safety Labs 
The absolute level and the absolute change from baseline for each safety laboratory assay will be 
summarized as means, standard deviations, medians, and ranges at each visit by treatment group. 
The proportion of participants with safety lab levels below the lower limit of normal or above the 
upper limit of normal will be summarized by treatment group by visit and at any post-baseline 
visit. 
3.9.4 Vital Signs 
The absolute level and the absolute change from baseline for vital signs will be summarized as 
means, standard deviations, medians, and ranges at each visit by treatment group. 


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3.9.5 Additional Continuous Safety Outcomes 
The additional continuous safety outcomes of weight, ECG parameters, AUA Symptom Score 
and their absolute change from baseline will be summarized as means, standard deviations, 
medians, and ranges at each visit by treatment group. 
3.9.6 Post-study Mortality 
Long-term survival will be summarized for each treatment group by Kaplan-Meier product-limit 
estimates and compared between treatments by log-rank test. 
3.10 Other Analyses 
3.10.1 Participant Disposition 
The number of patients who were screened, randomized, completed scheduled follow up, and 
prematurely withdrew study participation will be summarized overall and by treatment group. 
Reasons for screen failure and for withdrawal from study will be presented. 
3.10.2 Study Drug Compliance and Tolerance 
The number of days of exposure to study drug will be summarized by treatment group. 
Compliance with study drug will be calculated as the number of doses taken divided by the 
scheduled number of doses taken prior to permanent discontinuation, expressed as a percentage. 
Time to discontinuation of study drug will be estimated using Kaplan-Meier product-limit 
estimates. Treatment-dependent differences will be tested by log-rank test. 
3.10.3 Prior and Concomitant Medication Use 
Concomitant medications taken during the study period will be listed for each patient, coded 
using the World Health Organization Drug Dictionary Enhanced. The percentage of patients 
taking each class of medications will be summarized overall and by treatment group. 
4. References 
Ayele BT, Lipkovich I, Molenberghs G, Mallinckrodt CH. A multiple-imputation-based 
approach to sensitivity analyses and effectiveness assessments in longitudinal clinical 
trials. J Biopharm Stat. 2014;24(2):211-28. 
 Barry MJ, Fowler FJ Jr, O'leary MP, Bruskewitz RC, Holtgrewe HL, Mebust WK, Cockett AT; 
Measurement Committee of the American Urological Association. The American Urological 
Association Symptom Index for Benign Prostatic Hyperplasia. J Urol. 2017 
Feb;197(2S):S189-S197. 
Cedarbaum JM, Stambler N, Malta E, Fuller C, Hilt D, Thurmond B, Nakanishi A. The 
ALSFRS-R: a revised ALS functional rating scale that incorporates assessments of 
respiratory function. BDNF ALS Study Group (Phase III). J Neurol Sci. 1999 Oct 31;169(1-
2):13-21. 
Kiernan MC1, Burke D, Andersen KV, Bostock H. Multiple measures of axonal excitability: a 
new approach in clinical testing. Muscle Nerve. 2000 Mar;23(3):399-409. 


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Knudson RJ, Lebowitz MD, Holberg CJ, Burrows B. Changes in the normal maximal expiratory 
flow-volume curve with growth and aging. Am Rev Respir Dis. 1983 Jun;127(6):725-34. 
Liang KY, Zeger S. Longitudinal data analysis of continuous and discrete responses for pre–post 
designs. Sankhyā Ser B. 2000 Apr;62(1):134–148.