Clinical trial NCT03626714
Conditions: Organ Transplant Rejection Psoriasis
Keywords: Tacrolimus Immunosuppressant Sustained-release Plexis
Sponsor: Auritec Pharmaceuticals
Start date: 2018-10-16; Completion date: 2019-01-05
Enrollment: 8 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
This first-in-human study is designed to assess the safety and pharmacokinetic (PK) profile of sustained-release (SR) depot tacrolimus, which will be administered as a single dose of 0.1 mg/kg by subcutaneous (SC) injection in healthy subjects.

Detailed description:
This is a first-in-human study to assess the safety and pharmacokinetic (PK) profile of sustained-release (SR) tacrolimus, which will be administered as a single dose of 0.1 mg/kg by subcutaneous (SC) injection in healthy subjects.

The short-term general investigational plan is to evaluate sustained release tacrolimus in healthy volunteers for up to 30 days in an exploratory trial to determine safety and drug concentrations in blood. The results from this study will inform the long-term goal of this program, which is to provide an improved treatment modality for prophylaxis of organ (kidney, liver and heart) transplant rejection with the additional benefit of enhancing medication compliance. These improvements have the potential to mitigate both the personal and economic burden of this disease.

Arms: arm 1: All subjects will be treated with a single dose injection of sustained-release Tacrolimus
Interventions: intervention 1: Sustained Release Injectable Tacrolimus
Intervention descriptions: intervention 1: Long-acting formulation of tacrolimus developed using Auritec's proprietary Plexis drug delivery technology.

Protocol documents:
Prot_SAP_000.pdf: 
1 
 
An Open-Label, First-in-human, Safety and Pharmacokinetic Study of 1-Month Sustained-Release 
Injectable Tacrolimus in Healthy Subjects (RTB-010) 
 
SR Tacrolimus Safety and PK Study in Healthy Subjects 
 
Version 2.0/July 2, 2018 
 
  Study Sponsor(s): 
  The National Institute of Allergy and Infectious Diseases (NIAID) 
NIAID Funding Mechanism: 
PAR 13-250 (U44 grant mechanism) 
IND Sponsor/Number 
Auritec Pharmaceuticals, Inc
 
Study Drug Manufacturer: 
Auritec Pharmaceuticals, Inc. 
 
PROTOCOL CHAIR 
THOMAS J. SMITH, MD 
Chief Executive Officer  
Auritec Pharmaceuticals, Inc.  
  
 
 
 
 
 
SITE PRINCIPAL 
INVESTIGATOR  
GEORGE J. ATIEE, MD 
Vice President/Medical Director/CLIA  
Lab Director 
Worldwide Clinical Trials 
  
  
 
BIOSTATISTICAN 
MARTIN LEE, PHD 
Director 
International Quantitative 
Consultants 
 
  
 
 
MEDICAL MONITOR 
JONAH ODIM, MD, PHD 
Division of Allergy, 
Immunology, and 
Transplantation 
National Institute of Allergy 
and Infectious Diseases 
 
 
 
 
 
REGULATORY OFFICER 
JULIA GOLDSTEIN, MD 
Office of Regulatory Affairs 
Division of Allergy, Immunology, and 
Transplantation 
National Institute of Allergy and 
Infectious Diseases 
 
 
 
 
PROJECT MANAGER 
NIKKI WILLIAMS 
Division of Allergy, Immunology, 
and Transplantation 
National Institute of Allergy and 
Infectious Diseases 
, 
 
 
 
 
 
Confidentiality Statement 
The information contained within this document is not to be disclosed in any way without the prior permission of the Protocol Chair, or 
the Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases of the National Institutes 
of Health. 
 
 
 
 
 
 
 
 
 
 
 
 
 




3 
 
Protocol Synopsis 
 
Title 
An Open-Label, First-in-human, Safety and Pharmacokinetic 
Study of 1-Month Sustained-Release (SR) Injectable 
Tacrolimus in Healthy Subjects 
Short Title 
SR Tacrolimus Safety and PK in Healthy Subjects 
Clinical Phase 
First-in-human 
Participating Site 
Worldwide Clinical Trials Early Phase Services, LLC 
IND Sponsor/Number 
Auritec Pharmaceuticals, Inc./
 
Study Objectives 
1) To evaluate the safety of a single dose of 1-month 
sustained-release subcutaneous injectable tacrolimus in 
healthy subjects. 
2) To evaluate the pharmacokinetic profile after a single 
dose of sustained-release injectable tacrolimus for up to 
60 days postdose. 
Study Design 
This is a single-center, nonrandomized, open-label, first-in-
human study to assess the safety and pharmacokinetic (PK) 
profile of sustained-release (SR) tacrolimus, which will be 
administered as a single dose of 0.1 mg/kg by subcutaneous 
(SC) injection in 8 healthy subjects. 
Following a screening period, eligible subjects will be 
admitted to the clinical research unit (CRU). On Day 1 
subjects will receive a single injection of SR tacrolimus. 
Subjects will remain at the CRU for at least 24-hours 
postdose for collection of serial blood samples for PK 
analysis and safety monitoring until discharge on Day 2. 
Subjects will return to the clinic for PK and safety evaluations 
for 60 days postdose. 
Primary Endpoint(s) 
1) Safety endpoints for this study include incidence, severity, 
and relatedness of adverse events (inclusive of injection 
site reactions), and changes from baseline (prior to 
dosing) in vital signs, clinical laboratory evaluations, 
physical examinations, and electrocardiograms. 
2) Pharmacokinetic (PK) endpoints include calculation of the 
following PK parameters: maximum observed tacrolimus 
whole blood concentration (Cmax), time to maximum 
observed tacrolimus whole blood concentration (tmax), 
area under the concentration-time curve (AUC) and 
absorption constant (kabs). 
Secondary Endpoint(s) 
Not Applicable. 


4 
 
Accrual Objective 
The number of subjects is not hypothesis driven; rather, a 
sample size of at least 6 pharmacokinetically evaluable 
subjects will provide sufficient PK and safety data. Additional 
subjects may be added as necessary to achieve this goal. 
Study Duration 
The study duration is approximately 88 days, inclusive of 
Screening (up to 28 days); Inpatient Period (Day -1 to 
discharge on Day 2), with follow-up visits for 60 days. 
Treatment Description 
SR Tacrolimus, single dose, 0.1 mg/kg, SC injectable 
Inclusion Criteria 
Subjects who meet the following criteria may be included in 
the study: 
1. Must be willing and able to provide signed informed 
consent. A signed informed consent form must be 
provided before any study assessments are done; 
2. Males or females, between 18 and 45 years of age, 
inclusive; 
3. Body mass index must be within the range 18.5 to 
32.0 kg/m2, inclusive; 
4. Must be in good health, as determined by no clinically 
significant findings from medical history, vital signs, and 
12-lead electrocardiogram (ECG), inclusive of 
documented absence of QT prolongation; 
5. Clinical laboratory evaluations (including clinical chemistry 
panel [fasted at least 10 hours], complete blood count 
[CBC], and urinalysis [UA]) must be within the reference 
range for the test laboratory, unless deemed not clinically 
significant by the Investigator; 
6. Must be negative for autoimmune disorders in the past 
3 months and at Screening - participant’s medical 
history will be used for this evaluation; 
7. Must not use any immunosuppressant calcineurin 
inhibitor product other than SR Injectable tacrolimus 
throughout the dosing period and until after the final 
visit; 
8. Must agree to blood draws throughout the course of the 
study and have venous access sufficient to allow for 
blood sampling as per the protocol; 
9. Must be negative for selected drugs of abuse at 
Screening and at Check-in (Day -1); 
10. Must have a negative hepatitis panel (including hepatitis 
B surface antigen and hepatitis C virus antibody) and 
negative human immunodeficiency virus antibody 
screens; 
11. Females will be nonpregnant, nonlactating, and either 
postmenopausal, defined as amenorrhea for at least 
1 year and follicle-stimulating hormone levels of 
40 mIU/mL or higher; surgically sterile (eg, tubal ligation, 
hysterectomy, oophorectomy) for at least 90 days prior to 
Screening; or agree to use, from the time of signing the 


5 
 
informed consent or 10 days prior to Check-in on Day -1 
of the Inpatient Period until 30 days after Study 
Discharge, one of the following forms of contraception: 
nonhormonal intrauterine device (IUD) with spermicide, 
female condom with spermicide, contraceptive sponge 
with spermicide, diaphragm with spermicide, cervical cap 
with spermicide, male sexual partner who agrees to use a 
male condom with spermicide, or sterile sexual partner. 
For all females of childbearing potential, the pregnancy 
test result must be negative at Screening; Check-in on 
Day -1 of the Inpatient period; alternatively, women must 
agree to maintain abstinence (must agree to use a 
double barrier method if they become sexually active 
during the study). Women must also agree not to douche 
throughout the dosing period and until after the final visit; 
12. Males will either be sterile or agree to use, from Check-in 
on Day -1 of the Inpatient Period until 90 days following 
Study Discharge, one of the following approved methods 
of contraception: male condom with spermicide; sterile 
sexual partner; or use by female sexual partner of an IUD 
with spermicide; a female condom with spermicide; a 
contraceptive sponge with spermicide; an intravaginal 
system (eg, NuvaRing®); a diaphragm with spermicide; a 
cervical cap with spermicide; or oral, implantable, 
transdermal, or injectable contraceptives. Subjects will 
refrain from sperm donation from Check-in on Day -1 of 
the Inpatient Period until 90 days following Study 
Discharge. 
Exclusion Criteria 
Subjects will be excluded from the study if they meet the 
following criteria: 
1. Inability or unwillingness of a participant to give written 
informed consent or comply with study protocol; 
2. Prisoners or patients who are compulsorily detained 
(involuntarily incarcerated) for treatment of either a 
psychiatric or physical (eg, infectious disease) illness 
must not be enrolled into this trial; 
3. Females of childbearing potential, or who are 
breast-feeding, or who have a positive urine or serum 
pregnancy test result prior to receiving study drug, or at 
any time during the study; 
4. Presence of an uncontrolled, unstable clinically significant 
medical condition that in the opinion of the Investigator 
may increase the risk to the subject or may interfere with 
the interpretation of safety and PK evaluations, or could 
impair the subject’s ability to complete the trial, or could 
impair the decisional capacity of the subject; 
5. Presence of clinically significant vital signs or a physical 
examination finding that, in the opinion of the Investigator, 
could increase the risk to the subject or may potentially 
 
 


6 
 
interfere with the ability to evaluate safety and tolerability 
in the trial; 
6. History of tacrolimus use, or hypersensitivity and/or 
adverse reaction to calcineurin inhibitor drugs; 
7. History of toxic shock syndrome; 
8. Currently receiving chemotherapy or immunosuppressive 
agents; 
9. Use of investigative drugs within 30 days or 5 half-lives 
prior to study participation; 
10. Currently using sirolimus; 
11. Currently using live vaccines; 
12. Currently on concomitant substrates and/or inhibitors of 
CYP3A4; 
13. Requires the use of any concomitant medication, except 
for treatment of an adverse event (AE) during the study; 
14. Any abnormality on clinical laboratory tests, or ECG 
finding that is considered to be clinically significant by 
the Investigator. 
15. Known or suspected (non-febrile) seizure disorder; 
16. Use of any other depot medications within the last three 
months. 
17.  Unwilling to commit to avoid eating grapefruit or 
drinking grapefruit juice during the first 30 days of this 
exploratory study 
18.  Grade ≥ 1 finding as described in the Toxicity Grading 
Scale for Healthy Adult and Adolescent Volunteers 
Enrolled in Preventive Vaccine Clinical Trials 
Study Stopping Rules 
The entire study may be discontinued at the discretion of the 
Investigator, Study Sponsor, IND Sponsor or Sponsor’s 
Medical Monitor based on the occurrence of the following: 
• 
AEs unknown to date with respect to their nature, 
severity, and duration; 
• 
increased frequency and/or severity and/or duration of 
known AEs; 
• 
medical or ethical reasons affecting the continued 
performance of the study; 
• 
difficulties in the recruitment of subjects; 
• 
cancellation of drug development. 


7 
 
Study Contact: Bioanalytical Laboratory  
 
 
BIOANALYTICAL LABORATORY 
 
Worldwide Clinical Trials Early Phase Services LLC  
  
 
 


8 
 
Table of Contents 
1. 
Background and Rationale ....................................................................................................................... 12 
1.1. 
Background and Scientific Rationale ................................................................................................. 12 
1.1. 
Rationale for Selection of Investigational Product or Intervention ...................................................... 12 
1.2. 
In vitro and Preclinical Experience ..................................................................................................... 14 
1.3. 
Clinical Studies .................................................................................................................................. 14 
2. 
Study Hypotheses/Objectives ................................................................................................................... 15 
2.1. 
Primary Objectives ............................................................................................................................ 15 
2.2. 
Secondary Objective(s) ..................................................................................................................... 15 
3. 
Study Design ............................................................................................................................................ 15 
3.1. 
Description of Study Design .............................................................................................................. 15 
3.2. 
Primary Endpoints/Outcomes ............................................................................................................ 17 
3.3. 
Secondary Endpoint(s)/Outcome(s) ................................................................................................... 18 
3.4. 
Exploratory Endpoint(s)/Outcome(s) .................................................................................................. 18 
3.5. 
Stratification, Randomization, and Blinding/Masking.......................................................................... 18 
3.5.1. 
Procedure for Unblinding/Unmasking ............................................................................................. 18 
4. 
Selection of Participants and Clinical Sites/Laboratories........................................................................... 19 
4.1. 
Rationale for Study Population .......................................................................................................... 19 
4.2. 
Inclusion Criteria ................................................................................................................................ 19 
4.4. 
Selection of Clinical Sites/Labs .......................................................................................................... 20 
5. 
Known and Potential Risks and Benefits to Participants ........................................................................... 20 
5.1. 
Risks of Investigational Product or Intervention as cited in Investigator Brochure or Package Insert .21 
5.2. 
Risks of Investigational Product or Intervention cited in Medical Literature ........................................ 21 
5.3. 
Risks of Other Protocol Specified Medications .................................................................................. 21 
5.4. 
Risks of Study Procedures ................................................................................................................ 21 
5.5. 
Potential Benefits .............................................................................................................................. 21 
6. 
Investigational Agent /Device/Intervention ................................................................................................ 22 
6.1. 
Investigational Agents/Devices/Interventions ..................................................................................... 22 
6.1.1. 
Investigational Agent .................................................................................................................. 22 
6.1.1.1. 
Formulation, Packaging, and Labeling .................................................................................... 22 
6.1.1.2. 
Dosage, Preparation, and Administration ................................................................................ 22 
6.2. 
Drug Accountability ........................................................................................................................... 23 
6.3. 
Assessment of Participant Compliance with Investigational Agent ..................................................... 23 
6.4. 
Toxicity Prevention and Management ................................................................................................ 23 
6.5. 
Premature Discontinuation of Investigational Agent ........................................................................... 23 
7. 
Other Medications .................................................................................................................................... 25 
7.1. 
Concomitant Medications .................................................................................................................. 25 
7.2. 
Prophylactic Medications ................................................................................................................... 25 
7.3. 
Prohibited Medications ...................................................................................................................... 25 
7.4. 
Rescue Medications .......................................................................................................................... 25 
8. 
Study Procedures ..................................................................................................................................... 26 
8.1. 
Enrollment ......................................................................................................................................... 26 
8.2. 
Screening Visit .................................................................................................................................. 26 
8.3. 
Study Visits or Study Assessments ................................................................................................... 26 
8.4. 
Unscheduled Visits ............................................................................................................................ 28 
8.5. 
Visit Windows .................................................................................................................................... 28 
9. 
Mechanistic Assays .................................................................................................................................. 29 
10. 
Biospecimen Storage ............................................................................................................................ 30 
11. 
Criteria for Participant and Study Completion and Premature Study Termination .................................. 31 
11.1. 
Participant Completion ................................................................................................................... 31 
11.2. 
Participant Stopping Rules and Withdrawal Criteria ....................................................................... 31 
11.3. 
Participant Replacement ................................................................................................................ 31 
11.4. 
Follow-up after Early Study Withdrawal .......................................................................................... 31 


9 
 
12. 
Safety Monitoring and Reporting ........................................................................................................... 33 
12.1 Overview .............................................................................................................................................. 33 
12.2 Definitions ............................................................................................................................................ 33 
12.2.1 Adverse Event (AE) ....................................................................................................................... 33 
12.2.2 Unexpected Adverse Event ........................................................................................................... 33 
12.2.3 Serious Adverse Event (SAE) ........................................................................................................ 34 
12.3 Grading and Attribution of Adverse Events ........................................................................................... 34 
12.3.1 Grading Criteria ............................................................................................................................. 34 
12.3.2 Attribution Definitions ..................................................................................................................... 34 
12.4 Collection and Recording of Adverse Events ........................................................................................ 35 
12.4.1 Collection Period ........................................................................................................................... 35 
12.4.2 Collecting Adverse Events ............................................................................................................. 35 
12.4.3 Recording Adverse Events ............................................................................................................ 35 
12.5 Reporting of Serious Adverse Events and Adverse Events .................................................................. 35 
12.5.1 Reporting of Serious Adverse Events to Auritec ............................................................................ 35 
12.5.2 
Reporting Serious Adverse Events to DAIT/NIAID ...................................................................... 36 
12.5.3 Reporting to Health Authority ......................................................................................................... 36 
12.5.4 Reporting of Adverse Events to IRBs/IECs .................................................................................... 37 
12.6 Pregnancy Reporting ........................................................................................................................... 37 
12.7 Reporting of Other Safety Information .................................................................................................. 38 
12.8 Review of Safety Information ............................................................................................................... 38 
12.8.1 DAIT/NIAID Medical Monitor Review ............................................................................................. 38 
12.9 DSMB Review ...................................................................................................................................... 38 
13. 
Statistical Considerations and Analytical Plan ....................................................................................... 39 
14. 
Identification and Access to Source Data .............................................................................................. 40 
14.1. 
Source Data ................................................................................................................................... 40 
14.2. 
Access to Source Data .................................................................................................................. 40 
15. 
Protocol Deviations ............................................................................................................................... 41 
15.1. 
Protocol Deviation Definitions ........................................................................................................ 41 
15.2. 
Reporting and Managing Protocol Deviations ................................................................................ 41 
16. 
Ethical Considerations and Compliance with Good Clinical Practice ..................................................... 42 
16.1. 
Statement of Compliance ............................................................................................................... 42 
16.2. 
Informed Consent Process ............................................................................................................. 42 
16.3. 
Privacy and Confidentiality ............................................................................................................. 42 
17. 
Publication Policy .................................................................................................................................. 42 
References ...................................................................................................................................................... 43 
 
APPENDICES 
Appendix 1: Schedule of Procedures and Evaluations ..................................................................................... 46 
Appendix 2: Statistical Analysis Plan ............................................................................................................... 48 
 


10 
 
Glossary of Abbreviations 
 
 
CFR 
Code of Federal Regulations 
CRF 
Case Report Form 
CRU 
Clinical Research Unit 
CYP450 
Cytochrome P450 
DAIT 
Division of Allergy, Immunology, and Transplantation 
DSMB 
Data Safety Monitoring Board 
EDTA 
Ethylenediaminetetraacetic acid 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
HDYF 
How Do You Feel 
ICH 
International Conference on Harmonization 
IND 
Investigational New Drug 
IRB 
Institutional Review Board 
MOP 
Manual of Procedures 
NF-AT 
Nuclear factor of activated T cells 
NIAID 
National Institute of Allergy and Infectious Diseases 
OPTN 
Organ Procurement and Transplantation Network 
PI 
[Site] Principal Investigator 
PK 
Pharmacokinetic 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SAR 
Suspected Adverse Reaction 
SC 
Subcutaneous 
SOP 
Standard Operating Procedure 
SR 
Sustained Release 
SUSAR 
Serious Unexpected Suspected Adverse Reaction 
US 
United States 
WCT 
Worldwide Clinical Trials Early Phase Services, LLC 


11 
 
1. Background and Rationale 
 
1.1. Background and Scientific Rationale 
Tacrolimus is a calcineurin inhibitor that is routinely used in the prophylaxis of kidney, liver and heart transplant 
rejection. 
 
Over 1 million people receive medical assistance from tissue transplant procedures each year. Of the five 
major solid organ transplants which include heart transplant, pancreas transplant, lung transplant, kidney 
transplant and liver transplant, tacrolimus is routinely used for prophylaxis of organ rejection in patients 
receiving allogeneic liver, kidney or heart transplants. In 2012, greater than 50,000 organ transplants were 
conducted in the seven major markets - US, Japan, the United Kingdom, France, Germany, Italy and Spain.1 In 
2013, organ transplant procedures saved more than 28,900 lives.2 According to a 2010 IMS Health report, the 
immunosuppression market for transplant patients in seven major markets added up to $5 billion.3 Per the 
Organ Procurement and Transplantation Network (OPTN), as of April 2015, 123,193 patients are currently 
waiting for lifesaving organ transplants in the U.S. Of these, 83% (101,662) are waiting for kidney transplants. 
On average, more than 3,000 new people are added to the kidney waiting list each month.4 Given these 
statistics, some analysts forecast the global transplantation market to grow at a CAGR of 9.36% over the 
period 2014-2019.5 
 
Tacrolimus is an FDA-approved immunosuppressive calcineurin inhibitor commonly used for prevention of 
transplant rejection. However, the calcineurin inhibitors have narrow therapeutic indices and poor 
bioavailability. This is partly due to inadequate uptake across the gastrointestinal epithelium and partly due to 
variable hepatic first pass metabolism.6, 7-9 Attempts to improve bioavailability by modifying oral formulations 
have met with modest success.10-15 For this reason, there are continued efforts to improve the formulations of 
these drugs.16-19 
 
Auritec Pharmaceuticals has developed a sustained-release (SR) formulation of tacrolimus as a subcutaneous 
(SC) injectable. The short-term general investigational plan is to evaluate SR tacrolimus in healthy subjects for 
up to 30 days in an open-label pilot study designed to assess safety and determine the pharmacokinetic (PK) 
profile of this new formulation following a single proposed 0.1 mg/kg dose. Sustained release (SR) injectables 
provide a unique and promising system capable of delivering safe, yet potent concentrations over long 
durations, and immunosuppressive calcineurin inhibitor injectables could potentially be useful in prevention of 
organ transplant rejection. Importantly, compliance has been poor with the current formulation of tacrolimus 
due to the frequency of dosing..20,21 Improved delivery characteristics of an injectable formulation could 
decrease the dosing frequency, thereby improving compliance and treatment outcomes in prophylaxis of organ 
(kidney, heart and liver) transplant rejection. 
 
The results from this study will inform the long-term goal of this program, which is to provide an improved 
treatment modality for prophylaxis of organ (kidney, liver and heart) transplant rejection with the additional 
benefit of enhancing medication compliance. These improvements have the potential to mitigate both the 
personal and economic burden of this disease. 
 
1.2. Rationale for Selection of Investigational Product or Intervention 
Auritec Pharmaceuticals has developed a membrane based, diffusion-driven release mechanism with drug 
particle sizing large enough to allow high drug loading, but small enough to be injected. This platform is used to 
develop SR formulations of the proposed 0.1 mg/kg injectable tacrolimus. Other investigators have proposed 
the SR formulation of calcineurin inhibitors through the use of polymer based delivery systems 22,23 Polymer 


12 
 
encapsulation has also been suggested in order to improve oral bioavailability15,18-22 but, with the exception of 
the once-a-day formulation Astagraf XL®, none of these proposals has led to clinical trials or approval to date. 
In contrast, Auritec’s Plexis® technology is well suited to the development of a SR formulation because the 
injectable depot is made up of thousands of biodegradable “mini-Norplants.” This technology combines the 
benefits of linearization of release with those of injectability. The polymers chosen for the membrane are stable 
over the projected time of drug delivery24 (in the proposed case, 1 month), which is essential for an optimal SR 
formulation, and yet ultimately biodegradable. Auritec has two broad patents pending for this technology, 
WIPO patents numbered 2004/058222 and 2004/058223, as well as Australian and Canadian applications 
which have been allowed (200329982 and 2,510,320 respectively), which is termed “Plexis™”. 
 
The Auritec SR injectable formulation has not been tested clinically. The short-term general investigational plan 
is to evaluate SR tacrolimus in a first-in-human study in healthy subjects as described above (Section 1.1). 
Additional exploratory studies will be considered and planned based in part on the results obtained in this 
study. The long-term investigational plan is to evaluate the safety and efficacy of SR tacrolimus injectable for 
its ability to provide an improved treatment modality for prophylaxis of organ (kidney, liver and heart) transplant 
rejection. 
 
The mechanism of action of tacrolimus is well documented. Tacrolimus is a macrolide calcineurin inhibitor with 
immunosuppressive properties initially developed and used to prevent organ transplant rejection reactions. It 
acts by binding to specific intracellular proteins after entering T cells. The formed complex inhibits calcinuerin 
phosphatase, which prevents the activation of the nuclear factor of activated T cells (NF-AT), a transcription 
factor needed for the production of cytokines such as interleukin 2 (IL-2) and γ interferon.25,26 Its mechanism of 
action is similar to that of cyclosporin A, but its immunosuppressive effect has been shown to be 30 to 
100 times greater in vitro and 10 to 20 times greater in vivo.27 
 
Current formulations of tacrolimus are effective, but, due to variable uptake and inter- and intra-individual 
variability in metabolism, require intense drug monitoring. Even elegant Bayesian approaches to modeling 
levels to guide dosing are unable to eliminate the problems of peaks that are too high and troughs that are too 
low.28-30 Poor bioavailability requires more frequent dosing, and this usually leads to problems with medication 
compliance. It has been well documented across many disease states that adherence to therapy is inversely 
proportional to dosing frequency and it has been specifically demonstrated that parenteral depot administration 
can significantly increase adherence to therapy.31-33 Improved delivery characteristics of an injectable 
formulation could decrease the dosing frequency, increase the bioavailability, reduce the first pass effects, and 
decrease the intra-patient variability in drug levels. It is well recognized that the peak-to trough ratio can be 
significantly reduced by sustained-release drug delivery.34,35 
There are no SR formulations of tacrolimus. Therefore, SR tacrolimus injectable offers an improved treatment 
option for prophylaxis of organ (kidney, liver and heart) transplant rejection due to the following potential 
advantages 
• 
Improved bioavailability with the opportunity to enhance efficacy; 
• 
Less frequent dosing to improve medication compliance; 
• 
Optimal treatment outcomes, which can decrease both disease and economic burden to the patient. 
 
 
1.2.1. Major advantages of the novel Plexis®- based sustained release injectable tacrolimus formulation 
Our formulation has demonstrated pseudo-zero order release in vitro and in vivo, suggesting that the formulation 
could be developed as weekly or monthly injectable, which could help improve treatment adherence and 
compliance in transplant patients, who are currently prescribed daily pills. Additionally, these pills are known to 
undergo first-pass metabolism, causing substantial inter-and intra-patient variability of tacrolimus due to 
genomic heterogeneity means that even frequent drug monitoring cannot eradicate rejection due to sub-
therapeutic troughs, or toxicity due to unavoidable peak levels. The potency and the long elimination half-life of 
tacrolimus makes it suitable for depot formulation, and pharmacokinetic modeling suggests that a formulation 
that could allow periodic subcutaneous dosing is feasible. We hypothesize that use of such a formulation could 
reduce or eliminate many of the problem of bioavailability, toxicity, and adherence.  


13 
 
1.3. In vitro and Preclinical Experience 
We have formulated sustained release injectable suspension of tacrolimus. We have measured the in vitro 
release and confirmed our ability to modify the release based on particle and coating parameters. We have 
developed an in vitro / in vivo correlation that will aid us in optimizing our formulation. We have demonstrated 
sustained release and preliminary safety in the rat. 
 
Pharmacokinetic Modeling shows the feasibility of the approach 
Pharmacokinetic modeling was carried out using USC*PACK version 11.8: a commercially available 
microcomputer software program (Figure 1).32 
 
 
 
 
Safety 
There was one unscheduled death of a tacrolimus injected rat in this study. All animals appeared normal: they 
showed no failure to eat or drink, failure to groom, or weight loss. There was no clinical evidence of 
inflammation at the injection sites. 
 
Microscopic pathology 
Microscopic findings were recorded manually on individual animal necropsy records. Microscopic findings were 
graded on a scale of 1-4 (minimal < mild < moderate < marked), according to the intensity and extent the 
change. Formalin-fixed injection site skin from three male SD rats (Group 1, #1, #3 and #6) was submitted for 
histopathologic evaluation following a study. No abnormalities were identified in individual animal necropsy 
records. No abnormalities were identified in any of the skin specimens. 
 
1.4. Clinical Studies 
Tacrolimus is an FDA-approved immunosuppressive calcineurin inhibitor indicated for the prophylaxis of organ 
rejection in patients receiving allogeneic liver, kidney, or heart transplants. Tacrolimus as an ointment has been 
approved for atopic dermatitis. Clinical data and postmarketing safety experience have demonstrated that 
systemic and topical tacrolimus is generally safe and effective. Additional information on clinical studies that 
support the safety and efficacy of tacrolimus are provided in the package inserts (PROGRAF® [tacrolimus] 
capsules, USP, PROGRAF® [tacrolimus] injection [for intravenous use])40 and PROTOPIC [tacrolimus] 
ointment41). 
 
 
 
 
Figure 1: Pharmacokinetic Modeling of 
Sustained-Release Tacrolimus 
The pharmacokinetics of tacrolimus can vary 
substantially depending on the population 
studied.36 Assumptions used in this model for 
tacrolimus in humans were taken from Moller 
et al in healthy human subjects37: Volume of 
distribution: 1.2 L/kg; Elimination half-life: 
44 hours; Delivery half-life: 10 days 
(Kabs 0.069).38 As may be seen, dosing at 
3 weekly intervals could maintain levels 
between 3 and 7ng/ml with a dose of 
0.5 mg/kg.39 


14 
 
2. Study Hypotheses/Objectives 
Hypotheses 
This is a pilot study designed to gather information regarding the safety and the pharmacokinetic profile of a 
new SR formulation of tacrolimus. This data will inform the clinical development program for SR tacrolimus, 
with the ultimate goal of offering an improved treatment option for prophylaxis of organ (kidney, liver or heart) 
transplant rejection. Our proposed sustained release dose levels of 0.1mg/kg tacrolimus chosen for this 30-day 
first-in-human study are approximately 30x less than the lowest marketed dose levels. As such, these doses 
are expected to be low enough to not cause adverse effects, yet high enough to provide data that will aid in 
future dose level adjustments for safety and efficacy determinations. Thus, we hypothesize that our SR 
tacrolimus formulation will be safe. 
 
2.1. Primary Objectives 
The primary objectives of this study are: 
1. To evaluate the safety of a single dose of 1-month SR subcutaneous injectable tacrolimus in healthy subjects. 
2. To evaluate the pharmacokinetic profile after a single dose of SR injectable tacrolimus for up to 60 days post-
dose. 
 
2.2. Secondary Objective(s) 
Not applicable. 
 
3. Study Design 
3.1. Description of Study Design 
This is a single-center, nonrandomized, open-label, first-in-human study designed to assess the safety and 
pharmacokinetic (PK) profile of sustained-release (SR) tacrolimus, which will be administered as a single dose 
of 0.1 mg/kg by subcutaneous (SC) injection in 6 healthy subjects. Following a screening period of up to 
30 days, eligible subjects will be admitted to the clinical research unit (CRU) on Day -1 (Check-in). On Day 1 
(Dose), subjects will receive a single injection of SR tacrolimus. Subjects will remain at the CRU for at least 
24 hours postdose for collection of serial blood samples for PK analysis and safety monitoring until discharge 
on Day 2. Subjects will return to the clinic for PK and safety evaluations (Outpatient Visits 3 through 7) for up to 
30 days postdose, with an additional 30 day Follow-up period. 
If a participant is unable or not willing to continue the study for 30 days, a new participant will be recruited to 
achieve a sample size of 6 pharmacokinetically evaluable subjects. 
Neither a control group nor randomization is required for this type of study. The study schematic is shown in 
Figure 2. The study flow diagram is shown in Figure 3. 
 
 
 


15 
 
Figure 2: Overview of Study Design 
 
 


16 
 
Figure 3: Study Flow Diagram 
 
 
 
 
 
 
3.2. Primary Endpoints/Outcomes 
1) Safety endpoints for this study include the incidence, severity, and relatedness of adverse events 
(inclusive of injection site reactions), and changes from baseline (prior to dosing) in the following: 
 
• 
Vital signs (blood pressure, pulse rate, respiratory rate and oral body temperature); 
• 
Clinical laboratory evaluations (chemistry panel, hematology panel, liver function); 
• 
Physical examinations (general appearance, eyes, ears, nose and throat, chest/respiratory, 
heart/cardiovascular, gastrointestinal/liver, musculoskeletal/extremities, dermatological skin, 
thyroid/neck, lymph nodes and neurological/psychiatric); 
• 
Electrocardiograms (RR, PR, QT using Fridericia’s formula, QT interval corrected using 
Fridericia’s formula, QRS duration and ventricular heart rate). 




18 
 
4. Selection of Participants and Clinical Sites/Laboratories 
 
4.1. Rationale for Study Population 
This is a first-in-human study. Only healthy subjects will be allowed to participate. Attempts will be made to 
enroll equal numbers of males and females. Since there is no data regarding any potential effect of SR 
injectable tacrolimus on pregnancy, women of childbearing potential may participate upon agreement to use 
appropriate contraception (see Section 4.2). 
 
4.2. Inclusion Criteria 
Subjects who meet the following criteria may be included in the study: 
1. Subjects must be able to understand and provide informed consent. A signed informed consent form 
must be provided before any study assessments are done; 
2. Males or females, between 18 and 45 years of age, inclusive; 
3. Body mass index must be within the range 18.5 to 32.0 kg/m2, inclusive; 
4. Must be in good health, as determined by no clinically significant findings from medical history, vital 
signs, and 12-lead electrocardiogram (ECG), inclusive of documented absence of QT prolongation; 
5. Clinical laboratory evaluations (including clinical chemistry panel [fasted at least 10 hours], complete 
blood count [CBC], and urinalysis [UA]) must be within the reference range for the test laboratory, 
unless deemed not clinically significant by the Investigator; 
6. Must be negative for autoimmune disorders in the past 3 months and at Screening - participant’s medical 
history will be used for this evaluation; 
7. Must not use any immunosuppressant calcineurin inhibitor product other than SR Injectable 
tacrolimus throughout the dosing period and until after the final visit; 
8. Must agree to blood draws throughout the course of the study and venous access sufficient to 
allow for blood sampling as per the protocol; 
9. Must be negative for selected drugs of abuse at Screening and at Check-in (Day -1); 
10. Must have a negative hepatitis panel (including hepatitis B surface antigen [HBsAg] and hepatitis C 
virus antibody [HCV]) and negative human immunodeficiency virus [HIV] antibody screens; 
11. Females will be nonpregnant, nonlactating, and either postmenopausal, defined as amenorrhea for at 
least 1 year and follicle-stimulating hormone levels of 40 mIU/mL or higher; surgically sterile (eg, tubal 
ligation, hysterectomy, oophorectomy) for at least 90 days prior to Screening; or agree to use, from the 
time of signing the informed consent or 10 days prior to Check-in on Day -1 of the Inpatient Period until 
30 days after Study Discharge, one of the following forms of contraception: nonhormonal intrauterine 
device (IUD) with spermicide; female condom with spermicide; contraceptive sponge with spermicide; 
diaphragm with spermicide; cervical cap with spermicide; male sexual partner who agrees to use a 
male condom with spermicide; or sterile sexual partner; alternatively, women must agree to maintain 
abstinence (must agree to use a double barrier method if they become sexually active during the 
study. For all females of childbearing potential, the pregnancy test result must be negative at 
Screening and Check-in on Day -1 of the Inpatient Period (see Appendix 1). Women must also agree 
not to douche throughout the dosing period and until after the final visit; 
12. Males will either be sterile or agree to use, from Check-in on Day -1 of the Inpatient Period until 90 
days following Study Discharge, one of the following approved methods of contraception: male 
condom with spermicide; sterile sexual partner; or use by female sexual partner of an IUD with 
spermicide; a female condom with spermicide; a contraceptive sponge with spermicide; an 
intravaginal system (eg, NuvaRing®); a diaphragm with spermicide; a cervical cap with spermicide; 
or oral, implantable, transdermal, or injectable contraceptives. Subjects will refrain from sperm 
donation from Check-in on Day -1 of the Inpatient Period until 90 days following Study Discharge. 
 
4.3. Exclusion Criteria 
Subjects will be excluded from the study if they meet the following criteria: 
1. Inability or unwillingness of a participant to give written informed consent or comply with study protocol; 
2. Prisoners or patients who are compulsorily detained (involuntarily incarcerated) for treatment of 
either a psychiatric or physical (eg, infectious disease) illness must not be enrolled into this trial; 


19 
 
3. Females of childbearing potential, or who are breast-feeding, or who have a positive urine or 
serum pregnancy test result prior to receiving study drug; 
4. Presence of an uncontrolled, unstable clinically significant medical condition that in the opinion of the 
Investigator may increase the risk to the subject or may interfere with the interpretation of safety and 
PK evaluations, or could impair the subject's ability to complete the trial, or could impair the decisional 
capacity of the subject; 
5. Presence of clinically significant vital signs or a physical examination finding that, in the opinion of 
the Investigator, could increase the risk to the subject or may potentially interfere with the ability to 
evaluate safety and tolerability in the trial; 
6. History of tacrolimus use, or hypersensitivity and/or adverse reaction to calcineurin inhibitor drugs; 
7. History of toxic shock syndrome; 
8. Currently receiving chemotherapy or immunosuppressive agents; 
9. Use of investigative drugs within 30 days or 5 half-lives of study participation; 
10. Currently using sirolimus; 
11. Currently using live vaccines; 
12. Currently on concomitant substrates and/or inhibitors of CYP3A4;  
13. Requires the use of any concomitant medication, except for treatment of an adverse event (AE) during the 
study; 
14. Any abnormality on clinical laboratory tests, or ECG finding that is considered to be clinically significant 
by the Investigator. 
15. Known or suspected (nonfebrile) seizure disorder; 
16. Use of any other depot medications within the last three months. 
17. Unwilling to commit to avoid eating grapefruit or drinking grapefruit juice during the first 30 days of this 
exploratory study.  
18. Grade ≥ 1 finding as described in the Toxicity Grading Scale for Healthy Adult and Adolescent Volunteers 
Enrolled in Preventive Vaccine Clinical Trials 
 
4.4. Selection of Clinical Sites/Labs 
This single site study will be conducted at Worldwide Clinical Trials Early Phase Services, LLC. The site is 
equipped with an onsite laboratory that will perform all clinical laboratory assessments. 
 
5. Known and Potential Risks and Benefits to Participants 
5.1. Risks of Investigational Product or Intervention as cited in Investigator Brochure or Package Insert 
This is a single dose study and the dose level selected is not expected to cause any adverse events (AEs). 
Effects such as inflammation at the site of delivery will be closely monitored.  
Some side effects associated with tacrolimus are lymphomas and other malignancies (particularly of the skin), 
bacterial, viral, fungal and protozoal infections, including opportunistic infections, polyoma virus infections, 
CMV viremia and CMV disease, acute or chronic nephrotoxicity, neurotoxicity, hyperkalemia, hypertension, 
anaphylactic reactions, QT prolongation, myocardial hypertrophy, pure red cell aplasia, gastrointestinal 
perforation and anaphylactic reactions. Side effects reported with the intake of much higher doses of 
tacrolimus include baldness, anemia, loss of appetite, diarrhea, high concentrations of potassium in the blood, 
high blood pressure, nausea, vomiting, tingling sensation in the extremities, itching, tremor, fever, headache, 
rash, high blood sugar concentrations, and abdominal pain. Subjects will be asked to not use other drugs 
during the course of this study. 
There is a theoretical concern of “drug dumping” i.e. complete delivery of the investigational product’s drug 
load (0.1 mg/kg) at the time of dose administration. Current dosage guidelines for marketed oral formulations 
of tacrolimus (Prograf®, Astagraf XL® and Envarsus®) are 0.075 mg/kg/day to 0.2 mg/kg/day, hence, the 
dosage resulting from possible dose dumping of the investigational drug is similar to the dosage delivered 
through commercial tacrolimus products. However, if the bioavailability of the investigational product is found 
to be higher than the currently marketed oral formulations because of its injectable nature, then the dose 
dumping will result in higher levels of whole blood tacrolimus concentrations. The bioavailability of the 
investigational product will be studied in this trial.  
 


20 
 
5.2. Risks of Investigational Product or Intervention cited in Medical Literature 
Tacrolimus has been marketed since 1994. No new risks have been identified in the literature with the use of 
tacrolimus. 
 
5.3. Risks of Other Protocol Specified Medications 
No concomitant medications are allowed during the study. 
 
5.4. Risks of Study Procedures 
There are minimal risks associated with blood draws for clinical laboratory analysis and PK analysis. There are 
also risks associated with the subcutaneous administration of a therapeutic agent. These risks are as follows: 
• 
Venipuncture: The risks of drawing blood include temporary discomfort from the needle stick, bruising, 
bleeding, and, rarely, fainting or infection. 
• 
Subcutaneous injections: Injections to the skin may be less convenient than some other forms of 
treatment, such as oral medications. In addition, injections may cause momentary discomfort and other 
local symptoms, such as bleeding, bruising, and, rarely, infection. 
At each post-dose clinic visit, subjects will be monitored for AEs, inclusive of injection site reactions. 
 
5.5. Potential Benefits 
There is a large database for conventional delivery of tacrolimus in animals. The safety of the injectable 
platform – Plexis® -has been studied in animals administered tacrolimus, as well as with other APIs. The risk- 
benefit ratio strongly favors the conduct of this study. While there are no direct benefits to the subject, clinical 
laboratory results will impart knowledge of kidney and liver function, ECGs will provide information regarding 
cardiac status, and physical examination may detect other diseases. The results of the research may 
contribute to scientific knowledge and may benefit patients in the future. There are theoretical risks 
associated with the investigational product, which have been described in Section 5.1. 
 
6. Investigational Agent /Device/Intervention 
6.1. Investigational Agents/Devices/Interventions 
Tacrolimus is an FDA-approved immunosuppressive calcineurin inhibitor. 
 
6.1.1. Investigational Agent 
Sustained-release tacrolimus, single dose, 0.1 mg/kg, SC injectable 
 
Drug Substance: 
tacrolimus, an immunosuppressive calcineurin inhibitor 
Pharmacological Class: 
Immunosuppressive calcineurin inhibitor agent. 
Drug Product: 
Sustained release injectable tacrolimus: particles of drug substance 
coated with layers of polyvinyl alcohol. 
 
Total Drug Dose Levels: 
Sustained-release injectable tacrolimus, releasing at 0.1 mg/kg 
Route of Administration: 
Injectable sustained release. 
Duration of Therapy 
30 days 
 
6.1.1.1. Formulation, Packaging, and Labeling 
Each injectable vial will be manufactured by Auritec Pharmaceuticals, Inc. (Pasadena, CA). 
Each vial to be used during the study will be enclosed in a pouch (3.5 x 5.25 inches; Crosstex 
International, Santa Fe Springs, CA). Each individually packaged SR injectable tacrolimus 
monohydrate vial will be labeled with the following information: 


21 
 
 
6.1.1.2. Dosage, Preparation, and Administration 
The dose of SR tacrolimus is 0.1 mg/kg. It will be administered as a single SC injection. This 
formulation has demonstrated pseudo-zero order release in vitro and in vivo (rats), suggesting 
that the formulation could be developed as weekly or monthly injectable, which could help 
improve treatment adherence and compliance in transplant patients, who are currently 
prescribed daily pills. 
The tacrolimus injectables will be stored at room temperature in the clinical research center, 
that employsfull-time state-licensed pharmacists familiar with first-in-human clinical studies.  
Although some responsibilities may be delegated, all activities related to study conduct are the 
responsibility of the Principal Investigator. The Pharmacy employees will adhere to site SOPs, 
GCP, USP 797, DEA and FDA Guidance. Pharmacy staff will ensure that the study drug is 
properly stored, prepared, and dispensed according to federal, state, and local laws, calculate 
appropriate study drug dosage, maintain study drug inventory records, and assist in the 
preparation of intravenous, intramuscular, and subcutaneous injections, when required. The 
Research Pharmacist will maintain an accurate inventory and accountability record of study 
products received and subsequently dispensed. After the study is completed, all unused study 
product will be returned to Auritec Pharmaceuticals or their designated recipient. 
The drug product will be subjected to gamma sterilization and then be put on an accelerated 
stability (40°C and 75% relative humidity) program and analyzed for appearance, purity, and 
dissolution at time 0, 1 and 6 months using HPLC and/or 1H-NMR spectroscopy to verify the 
drug product is stable throughout the period of use. 
 
6.2. Drug Accountability 
Under Title 21 of the Code of Federal Regulations (21CFR §312.62) the Investigator will maintain adequate 
records of the disposition of the investigational agent, including the date and quantity of the drug received, to 
whom the drug was dispensed (participant-by-participant accounting), and a detailed accounting of any drug 
accidentally or deliberately destroyed. The Investigator (or designee) will maintain an accurate record of the 
receipt of the test materials as shipped by the Auritec (IND Sponsor), including the date received. One copy of 
this receipt will be returned to Auritec when the contents of the test material shipment have been verified. In 
addition, an accurate drug disposition record will be kept, specifying the amount dispensed to each subject and 
the date of dispensation. This drug accountability record will be available for inspection at any time. At the 
completion of the study, the original drug accountability record will be available for review by Auritec upon 
request. 
Records for receipt, storage, use, and disposition will be maintained by the study site. All records regarding the 
disposition of the investigational product will be available for inspection. At the completion of the study, all 
unused drug supplies will be returned to Auritec (or designee) or disposed of by the study site, per Auritec’s (or 
designee’s) written instructions. 
 
 
 
 
 
Protocol Number: 
Lot Number: 
Drug: Sustained release (0.1 mg/kg) injectable tacrolimus 
IND Sponsor and Principal Investigator: 
Caution: New Drug- Limited by Federal Law to Investigational Use Only 


22 
 
6.3. Assessment of Participant Compliance with Investigational Agent 
This is a single dose study. The dose will be administered when the subject is confined to the site (inpatient 
period). The subject’s actual time of study drug administration will be recorded in the source documents and 
transcribed into the Case Report Form (CRF). 
 
6.4. Toxicity Prevention and Management 
This is a single dose study. The proposed dose for this exploratory study is 0.1mg/kg tacrolimus. In the event 
that there is an initial burst of tacrolimus (ie, 100% drug release on Day 1), subjects will be exposed to a 
maximum dose of 0.1 mg/kg/day, which is the prescribed dosage of the current marketed products, Prograf® 
and Astagraf XL®. As such, this dose is expected to be low enough to not cause adverse effects yet high 
enough to provide data that will aid in future dose level adjustments for safety and efficacy determinations. 
 
6.5. Premature Discontinuation of Investigational Agent 
The Investigator may remove a subject from the study if, in the Investigator’s opinion, it is not in the best 
interest of the subject to continue the study. Subjects may be discontinued due to the following: 
• 
Change in compliance with inclusion/exclusion criterion that is clinically relevant and affects subject 
safety; 
• 
Occurrence of AEs; 
• 
Intake of non-permitted concomitant medication that might affect subject safety or study 
assessments/objectives. 
• 
Reasons of noncompliance such as failure to comply with study guidelines, refusal to use the 
injectable, or missing follow-up visits. 
 
Notification of discontinuation will immediately be made to Auritec and the DAIT/NIAID Medical Monitor. In 
case of premature discontinuation of study participation, efforts will be made to perform all final study day 
assessments. The date the subject is withdrawn from the study and the reason for discontinuation will be 
recorded on the subject’s CRF. All dropouts will be followed until resolution of all their AEs or until the 
unresolved AEs are judged by the Investigator to have stabilized. 
 
7. Other Medications 
7.1. Concomitant Medications 
7.1.1. Protocol-mandated 
Only a single dose of SR tacrolimus at a dose of 0.1 mg/kg will be administered during this study. There 
are no protocol-mandated concomitant medications. 
7.1.2. 
Other permitted concomitant medications 
The administration of any other concomitant medications during the study is prohibited without prior 
approval of the Investigator unless its use is deemed necessary in a medical emergency. Any 
medication taken by a subject during the course of the study and the reason for its use will be 
documented in the source documents and the CRF. 
 
7.2. Prophylactic Medications 
No prophylactic medications are allowed in this study. 
 
7.3. Prohibited Medications 
No prescription or over-the counter medications are allowed during this study. No depot medications are 
allowed within 3 months prior to study participation. No other investigational study drug is allowed during this 
study or within 5 half-lives or 30 days, whichever is longer, prior to Check-in to the inpatient unit (Day -1). The 
use of immunosuppressive drugs or chemotherapeutic agents will not be permitted during the course of the 
study. Subjects will be queried on the use of medications prior to enrollment and during the course of the 
study. 
All concomitant prescription medications taken during study participation will be recorded on the subject’s CRF. 
For this protocol, a prescription medication is defined as a medication that can be prescribed only by a properly 
authorized/licensed clinician. Medications to be reported in the CRF are concomitant prescription medications, 


23 
 
over-the-counter medications, and medications taken at the time of adverse events (all grades). 
 
7.4. Rescue Medications 
In the event of an injection site reaction, symptomatic eruptions can be treated with cold compresses, topical 
corticosteroids, oral antihistamines, or acetaminophen. If a subject experiences a hypersensitivity reaction after 
administration of SR tacrolimus, basic equipment and medication will be readily available in the clinical 
research unit. 
 
8. Study Procedures 
The schedule of study procedures is shown in Appendix 1. 
 
8.1. Enrollment 
The research study will be explained in lay terms to each potential research participant. The potential 
participant will sign an informed consent form before undergoing any study procedures. Once the informed 
consent has been signed, screening procedures will be initiated to confirm eligibility. 
 
8.2. Screening Visit 
The purpose of the screening period is to confirm eligibility to participate in the study. The screening period is 
up to 28 (Day -28) days prior to Check-in (Day -1) to the inpatient unit. The following procedures, 
assessments, and laboratory measures will be conducted to determine participant eligibility: 
• 
Signed informed consent. 
• 
Medical history/demographics/height, weight, and body mass index. 
• 
An abbreviated physical examination, which includes assessment of general appearance, skin, 
thorax/lungs, cardiovascular status, and abdomen. 
• 
A 12-lead electrocardiogram (ECG). The ECG is to be recorded after the subject has been supine for at 
least 5 minutes. The ECG data will be obtained directly from the 12-lead ECG traces, including RR, PR, 
QT, and QT interval corrected using Fridericia's formula, QRS duration, and ventricular heart rate. 
• 
Vital signs (blood pressure, pulse rate, respiratory rate and oral body temperature). Vital signs will be 
measured in the supine position after the subject has rested comfortably for at least 5 minutes. 
• 
Clinical laboratory (chemistry, hematology, urinalysis) 
• 
Alcohol and drug screen, Serology (HIV, HBsAg, HCV), TB skin test 
• 
For females of childbearing potential, a serum qualitative pregnancy test (HCG). For postmenopausal 
women only, FSH. 
• 
Adverse events and concomitant medications will be recorded. 
 
8.3. Study Visits or Study Assessments  
 
Enrollment/Baseline 
Study participants must have signed study participation consent form to be considered enrolled into the 
trial and have all study screening complete to confirm eligibility requirements have been met before the 
study drug is administered. Evaluations prior to the first administration are the baseline for subsequent 
safety evaluations. Females of nonchildbearing potential must have negative serum pregnancy test 
results, if documentation of sterility has not been provided, and an FSH level greater than 40 IU/L 
verified prior to enrollment and dosing. 
 
 
 
 


24 
 
At Check in (Day -1) to the inpatient unit, the following procedures, assessments, and laboratory measures 
will be conducted: 
• 
Confirmation of eligibility 
• 
Interim medical history will be recorded 
• 
Complete physical examination. A complete medical examination includes general appearance, eyes, 
ears, nose and throat, chest/respiratory, heart/cardiovascular, gastrointestinal/liver, 
musculoskeletal/extremities, dermatological/skin, thyroid/neck, lymph nodes, and 
neurological/psychiatric assessments. 
• 
Vital signs (blood pressure, pulse rate, respiratory rate and oral body temperature) 
• 
Body weight 
• 
Clinical laboratory (chemistry, hematology, LFTs, urinalysis) after 10-hour fast 
• 
Serum qualitative pregnancy test (HCG) 
• 
Alcohol and Drug Screen 
• 
How Do You Feel Inquiry 
• 
Adverse events and concomitant medications will be recorded. 
• 
Blood collection for baseline measurement of drug levels. 
• 
Blood collection for possible post-study genetic evaluation of potential cytochrome P450 genetic 
variations 
  
Inpatient Period 
Day 1: Day 1 is defined as the day of enrollment and administration of the study drug. Following a, 
complete physical examination, recording of predose vital signs, and collection of a predose blood sample 
for PK analysis, subjects will receive a single SC injection of SR tacrolimus. Following injection, subjects 
will be monitored for anaphylactic reactions for the first 30 minutes. Vital signs, , clinical laboratory tests 
(chemistry, hematology, LFTs, urinalysis and blood samples for PK analysis will be obtained at 1, 3, 6, and 
12 hours postdose. Adverse events and concomitant medications will be recorded. 
 
Day 2: Subjects will be discharged from the inpatient unit with instructions to return to the clinic the next 
day following the procedures, assessments, and laboratory measures listed below. 
• 
Complete physical examination 
• 
Vital signs (blood pressure, pulse rate, respiratory rate and oral body temperature). 
• 
Clinical laboratory (chemistry, hematology, LFTs, urinalysis) after a 10-hour fast 
• 
How Do You Feel Inquiry 
• 
Blood samples for PK analysis 
• 
12-lead electrocardiogram (ECG). The ECG is to be recorded after the subject has been supine for at 
least 5 minutes 
• 
Adverse events and concomitant medications will be recorded. 
 
Outpatient Visits (Visit 3, 4, 5, 6, and 7 [End of Study (EOS)/Early Termination (ET)]) 
After discharge from the inpatient unit, subjects will return the next day (Visit 3, Day 3), again at 7 days 
postdose (Visit 4, Day 7), and weekly, thereafter (Visits 5, 6, and 7 [EOS/ET], Days 14, 21, and 30 
[EOS/ET]). The following procedures, assessments, and laboratory measures will be conducted: 
• 
Complete physical examination. (Visits 3, 4, 5, and 6). 
• 
Abbreviated physical examination (Visit 7 [EOS/ET]) 
• 
Vital signs (blood pressure, pulse rate, respiratory rate and oral body temperature). Vital signs should 
be assessed at approximately the same time of day at postdose visits on days 3, 7, 14, 21, 30 at end 
of the study ie, Day 60). The date and time of each vital sign assessment will be recorded in the 
CRF. 
• 
Clinical laboratory (chemistry, hematology, LFTs, urinalysis) at each visit after a 10-hour fast 
• 
How Do You Feel Inquiry 
 
 


25 
 
• 
Blood samples for PK analysis should be collected at approximately the same time of day at each 
postdose visit. The date and time of each PK blood sample will be recorded in the CRF). 
• 
Urine pregnancy test (visits 4, 5 and 6) 
• 
Serum qualitative pregnancy test (HCG) (visit 7) 
• 
12-lead electrocardiogram (ECG). The ECG is to be recorded after the subject has been supine for at 
least 5 minutes (visit 7) 
• 
Adverse events and concomitant medications will be recorded. 
 
     Follow-up Visits (8, 9, 10, and 11) 
Subjects will return within one week after the 30-day study period, and weekly thereafter (Visits 8, 9, 10, 
and 11 [Final Visit], Days 37, 44, 51 and 60, respectively]). The following procedures, assessments, and 
laboratory measures will be conducted: 
 
• 
Vital signs (blood pressure, pulse rate, respiratory rate and oral body temperature). Vital signs should 
be assessed at approximately the same time of day (ie, Day 60). The date and time of each vital sign 
assessment will be recorded in the CRF. 
• 
Clinical laboratory (chemistry, hematology, LFTs, urinalysis) at each visit after a 10-hour fast 
• 
How Do You Feel Inquiry 
• 
Blood samples for PK analysis should be collected at approximately the same time of day at each 
postdose visit. The date and time of each PK blood sample will be recorded in the CRF). 
• 
Urine Pregnancy Test (visits 8, 9, 10) 
• 
Serum qualitative pregnancy test (HCG) (visit 11) 
• 
Adverse events and concomitant medications will be recorded. 
 
The last follow-up visit will be held on Visit 11 (Day 60) after enrollment. At this time, if a subject has 
continued symptoms, they may be given a phone call to discuss resolution of symptoms and asked to 
return again in one week for an exam for resolution of findings. Subjects having an allergic reaction or a 
serious adverse event deemed related to a study drug will be asked to return for a clinical examination and 
follow-up until the event has resolved. 
 
Early Termination Visit 
Subjects who withdraw or discontinue the study will be asked to return for a final clinic visit. The 
procedures and assessments will be the same as those included in Visit 7 (Day 30). 
 
8.4. Unscheduled Visits 
If disease activity increases or other concerns arise between regularly scheduled visits, participants should be 
instructed to contact study personnel and may be asked to return to the study site for an “unscheduled” visit. 
The reason for the visit will determine the procedures and assessments included. 
 
8.5. Visit Windows 
Study visits should take place within ± 2 days for each scheduled visit. Visit and procedure windows are also 
indicated on the Schedule of Events (Appendix 1). 
 
8.6. Additional Visits 
If the subjects experience certain side effects or have a serious finding during an exam at a follow-up visit, 
they will be asked to return to the clinic. Subjects will be asked to come to the clinic until the symptoms go 
away. During these visits, subjects will be asked questions about their symptoms. Research blood will be 
collected to measure tacrolimus levels. Blood samples may be collected for safety analysis. 
 
 
 
 
9. Mechanistic Assays 


26 
 
Research blood will be collected for PK analysis and post-study CYP450 genetic evaluation as specified in the 
schedule of events. All samples will be stored at Worldwide Clinical Trials in San Antonio, TX for the duration of 
the study.  
 
 
 
10. Biospecimen Storage 
Blood samples collected during the study for clinical laboratory will be destroyed or discarded in compliance 
with state or local biological waste disposal requirements. If subject blood samples will be used for future 
research, this protocol (and other appropriate study documents, e.g., the informed consent and the statistical 
analysis plan) will be amended and submitted to the appropriate regulatory authorities, ethics committees, 
and IRBs for approval. Permission from the subject will be secured before additional evaluations are 
performed. 
 
11. Criteria for Participant and Study Completion and Premature Study Termination 
 
11.1. Participant Completion 
A subject who attends all visits and follows all procedures in accordance with the protocol, from Screening 
through the last study Follow-up visit (Visit 11), will have completed the study. 
 
11.2. Participant Stopping Rules and Withdrawal Criteria 
Participants may be prematurely terminated from the study for the following reasons: 
1. The participant elects to withdraw consent from all future study activities, including follow-up. 
2. The participant is “lost to follow-up” (ie, no further follow-up is possible because attempts to reestablish 
contact with the participant have failed). 
3. The participant dies. 
4. The Investigator no longer believes participation is in the best interest of the participant. 
5. Individual safety stopping rules 
 
11.3. Participant Replacement 
Data will be obtained from all enrolled subjects, including those that discontinue the study. Subjects will not be 
replaced. If needed, we will recruit up to 8 subjects to obtain six completers, while also reporting all data on all 
subjects who enter the study. The goal will be to have 6 fully evaluable subjects, who have completed all safety 
and PK assessments per protocol. 
 
11.4. Follow-up after Early Study Withdrawal 
If a participant is withdrawn from the study for any reason, the participant will be asked to complete a final visit 
and/or final assessments. At a minimum, the following information must be collected when a subject 
discontinues: 
• 
The reason the subject discontinued. 
• 
The date of the last dose of study drug 
• 
The date of the last assessment and/or contact. A follow-up contact (telephone or visit) will be arranged 
as appropriate. 
• 
Adverse events, including SAEs 
• 
Compliance with the study drug administration as specified in this protocol 
 
Final assessments: unless there is a withdrawal of consent or death, every effort should be made to ensure 
that all procedures and evaluations scheduled for the final visit are performed. 
 
11.5. Study Stopping Rules 
The study may be prematurely terminated for the following reasons: 
The entire study may be discontinued at the discretion of the Investigator, Auritec, or DAIT/NIAID based on the 
occurrence of the following: 


27 
 
• 
Adverse events unknown to date with respect to their nature, severity, and duration; 
• 
Increased frequency and/or severity and/or duration of known AEs; 
• 
Medical or ethical reasons affecting the continued performance of the study; 
• 
Difficulties in the recruitment of subjects; 
• 
Cancellation of drug development. 
 
In order to ensure six completers, up to 8 subjects may be enrolled.  
 
12. Safety Monitoring and Reporting 
12.1 Overview 
This section defines the types of safety data that will be collected under this protocol and outlines the 
procedures for appropriately collecting, grading, recording, and reporting those data. Adverse events that are 
classified as serious according to the definition of health authorities must be reported promptly (per Section 
12.5, Reporting of Serious Adverse Events and Adverse Events) to Auritec and DAIT/NIAID. Appropriate 
notifications will also be made to the site principal investigator, Institutional Review Board (IRB), and health 
authorities. 
Information in this section complies with ICH Guideline E2A: Clinical Safety Data Management: Definitions and 
Standards for Expedited Reporting, ICH Guideline E-6: Guideline for Good Clinical Practice, 21CFR Parts 312 
and 320, and applies the standards set forth in the Toxicity Grading Scale for Healthy Adult and Adolescent 
Volunteers Enrolled in Preventive Vaccine Clinical Trials:  
 
https://www.fda.gov/downloads/BiologicsBloodVaccines/ucm091977 . 
 
12.2 Definitions 
12.2.1 Adverse Event (AE) 
Any untoward or unfavorable medical occurrence associated with the subject’s participation in the 
research, whether or not considered related to the subject’s participation in the research (modified from 
the definition of adverse events in the 1996 International Conference on Harmonization E-6 Guidelines 
for Good Clinical Practice) (from OHRP "Guidance on Reviewing and Reporting Unanticipated 
Problems Involving Risks to Subjects or Others and Adverse Events (1/15/07)" 
http://www.hhs.gov/ohrp/policy/advevntguid.html#Q2 ) 
 
For this study, an adverse event will include any untoward or unfavorable medical occurrence 
associated with, but not limited to: 
 
• 
Study therapy regimen: Sustained release (0.1 mg/kg) injectable tacrolimus 
• 
Study mandated procedures: Research Blood Draw 
 
12.2.1.1 Suspected Adverse Reaction (SAR) 
Any AE for which there is a reasonable possibility that the investigational drug or study 
procedure caused the adverse event. For the purposes of safety reporting, ‘reasonable 
possibility’ means there is evidence to suggest a causal relationship between the drug and the 
AE. A suspected adverse reaction implies a lesser degree of certainty about causality than 
adverse reaction, which means any AE caused by a drug (21 CFR 312.32(a)). 
 
 


28 
 
12.2.2 Unexpected Adverse Event 
An AE or suspected adverse reaction is considered “unexpected” if it is not listed in the Investigator 
Brochure or package insert or is not listed at the specificity, severity or rate of occurrence that has been 
observed; or, is not consistent with the risk information described in the general investigational plan or 
elsewhere in the IND. 
 
“Unexpected” also refers to adverse events or suspected adverse reactions that are mentioned in the 
Investigator Brochure or package insert as occurring with a class of drugs or as anticipated from the 
pharmacological properties of the drug but are not specifically mentioned as occurring with the 
particular drug under investigation (21 CFR 312.32[a]). 
12.2.3 Serious Adverse Event (SAE) 
An adverse event or suspected adverse reaction is considered “serious” if, in the view of the 
investigator, Auritec or DAIT/NIAID, it results in any of the following outcomes (21 CFR 312.32(a)): 
1. Death. 
2. A life-threatening event: An AE or SAR is considered “life-threatening” if, in the view of either the 
investigator, Auritec or DAIT/NIAID, its occurrence places the subject at immediate risk of death. It 
does not include an AE or SAR that, had it occurred in a more severe form, might have caused 
death. 
3. Inpatient hospitalization or prolongation of existing hospitalization. 
4. Persistent or significant incapacity or substantial disruption of the ability to conduct normal life 
functions. 
5. Congenital anomaly or birth defect. 
6. Important medical events that may not result in death, be life threatening, or require 
hospitalization may be considered serious 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 above. 
 
Elective hospitalizations or hospital admissions for the purpose of conduct of protocol mandated 
procedures are not to be reported as an SAE unless hospitalization is prolonged due to complications. 
 
 Pregnancy will not be reported as an AE or SAE.  However, if at any time the pregnancy falls under the 
scope and definition of an SAE it will then be reported as such.  
 
12.3 Grading and Attribution of Adverse Events 
 
12.3.1 Grading Criteria 
The study site will grade the severity of adverse events experienced by the study subjects according to 
the criteria set forth in the Toxicity Grading Scale for Healthy Adult and Adolescent Volunteers Enrolled 
in Preventive Vaccine Clinical Trials. This document provides a common language to describe levels of 
severity, to analyze and interpret data, and to articulate the clinical significance of all adverse events. 
This Grading Scale has been reviewed by the Site Principal Investigator and has been deemed 
appropriate for the subject population to be studied in this protocol. 
 
Adverse events will be graded on a scale from 1 to 4 according to the following standards in the 
Toxicity Grading Scale for Healthy Adult and Adolescent Volunteers Enrolled in Preventive Vaccine 
Clinical Trials manual: 
 
Grade 1 = mild adverse event. 
Grade 2 = moderate adverse event. 
Grade 3 = severe adverse event.  
Grade 4 = potentially life-threatening adverse event.  
 
Events of all grades will be recorded on the appropriate AE/SAE CRF for this study. 


29 
 
 
12.3.2 Attribution Definitions 
The relationship, or attribution, of an AE to the study drug, regimen, or study procedure(s) will initially 
be determined by the site investigator and recorded on the appropriate AE/SAE CRF. Final 
determination of attribution for safety reporting will be determined by Auritec and DAIT/NIAID. The 
relationship of an AE to study drug or procedure will be determined using the descriptors and 
definitions provided in Table 12.3.2. 
 
Table 12.3.2 Attribution of Adverse Events 
 
Code 
Descriptor 
Relationship (to primary investigational 
product and/or other study procedure) 
UNRELATED CATEGORY 
1 
Unrelated 
The adverse event is clearly not related: there 
is insufficient evidence to suggest a causal 
relationship. 
RELATED CATEGORIES 
2 
Possible 
The adverse event has a reasonable possibility 
to be related; there is evidence to suggest a 
causal relationship. 
3 
Definite 
The adverse event is clearly related. 
 
 
12.4 Collection and Recording of Adverse Events 
 
12.4.1 Collection Period 
Adverse events will be collected from the time of enrollment until a subject completes study 
participation or until 30 days after he/she prematurely withdraws (without withdrawing consent) or is 
withdrawn from the study. 
 
12.4.2 Collecting Adverse Events 
Adverse events (including SAEs) may be discovered through any of these methods: 
• Observing the subject. 
• Interviewing the subject [e.g., using a checklist, structured questioning, etc.]. 
• Receiving an unsolicited complaint from the subject. 
• In addition, an abnormal value or result from a clinical or laboratory evaluation can also indicate an 
adverse event, as defined in Section 12.3, Grading and Attribution of Adverse Events. 
 
12.4.3 Recording Adverse Events 
Throughout the study, the investigator will record adverse events and serious adverse events as 
described previously (Section 12.2, Definitions) on the appropriate AE/SAE CRF regardless of the 
relationship to study therapy regimen or study procedure. 
Once recorded, an AE/SAE will be followed until it resolves with or without sequelae, or until the end of 
study participation, or until 30 days after the subject prematurely withdraws (without withdrawing 
consent)/or is withdrawn from the study, whichever occurs first. 
 
 


30 
 
12.5 Reporting of Serious Adverse Events and Adverse Events 
 
12.5.1 Reporting of Serious Adverse Events to Auritec 
Timely reporting of adverse events is required by 21 CFR and ICH E6 guidelines. 
The site investigator will report all serious adverse events (see Section 12.2.3, Serious Adverse Event), 
regardless of relationship or expectedness within 24 hours of discovering the event. 
 
For serious adverse events, all requested information on the AE/SAE CRF will be provided. However, 
unavailable details of the event will not delay submission of the known information. As additional details 
become available, the AE/SAE CRF will be updated and submitted.  The site will send a written 
confirmation or summary of the AE to Auritec within 3 working days of the original notification.  
 
12.5.2 Reporting Serious Adverse Events to DAIT/NIAID 
The DAIT/NIAID Medical Monitor will be notified within 24 hours of when a FDA-reportable SAE is first 
recognized or reported. 
 
1) All SAEs will be reported within 24 hours of awareness using the AE/SAE CRF. Notification of 
these events will be sent to Auritec and DAIT upon completion of the CRF.  
2) Any unanticipated study problem that does not fit the definition of an adverse event, but which may, 
in the opinion of the affiliate Site Principal Investigator, involve risk to the participant, affect others 
in the research study, or significantly impact the integrity of research data will be reported to 
Auritec and DAIT within 24 hours of awareness.  
3) SAEs will be entered into the NIAID/DAIT CRIS system. 
 
12.5.3 Reporting to Health Authority 
After an AE requiring 24-hour reporting (per Section 12.5.1, Reporting of Serious Adverse Events to 
Sponsor) is submitted by the site investigator and assessed by Auritec and DAIT/NIAID, there are two 
options for the Auritec to report the AE to the appropriate health authorities: 
 
 
12.5.3.1 Annual Reporting 
Auritec will include in the annual study report to health authorities all AEs classified as: 
o Serious, expected, suspected adverse reactions (see Section 12.2.1.1, Suspected Adverse 
Reaction, and Section 12.2.2, Unexpected Adverse Event). 
o Serious and not a suspected adverse reaction (see Section 12.2.2, Suspected Adverse 
Reaction). 
o Pregnancies. 
Note that all adverse events (not just those requiring 24-hour reporting) will be reported in the 
Annual Report. 
 
12.5.3.2 Expedited Safety Reporting 
This option, with 2 possible categories, applies if the AE is classified as one of the following: 
Category 1: Serious and unexpected suspected adverse reaction [SUSAR] (see Section 
12.2.1.1, Suspected Adverse Reaction and Section 12.2, Unexpected Adverse Event and 21 
CFR 312.32(c)(1)i). 
 
Auritec shall report any suspected adverse reaction that is both serious and unexpected. 
Auritec shall report an AE as a suspected adverse reaction only if there is evidence to 
suggest a causal relationship between the study drug and the adverse event, such as: 
 
 
 
 


31 
 
1. A single occurrence of an event that is uncommon and known to be strongly 
associated with drug exposure (e.g., angioedema, hepatic injury, or Stevens- 
Johnson Syndrome); 
2. One or more occurrences of an event that is not commonly associated with drug 
exposure, but is otherwise uncommon in the population exposed to the drug 
(e.g., tendon rupture); 
3. An aggregate analysis of specific events observed in a clinical trial (such as 
known consequences of the underlying disease or condition under investigation 
or other events that commonly occur in the study population independent of drug 
therapy) that indicates those events occur more frequently in the drug treatment 
group than in a concurrent or historical control group. 
 
Category 2: Any findings from studies that suggests a significant human risk 
Auritec shall report any findings from other epidemiological studies, analyses of adverse 
events within the current study or pooled analysis across clinical studies or animal or in 
vitro testing (eg, mutagenicity, teratogenicity, carcinogenicity) that suggest a significant 
risk in humans exposed to the drug that would result in a safety-related change in the 
protocol, informed consent, investigator brochure or package insert or other aspects of 
the overall conduct of the study. 
 
Auritec shall notify the FDA, DAIT/NIAID and all participating investigators of expedited Safety Reports within 
15 calendar days; unexpected fatal or immediately life-threatening suspected adverse reaction(s) shall be 
reported as soon as possible or within 7 calendar days. 
 
12.5.4 Reporting of Adverse Events to IRBs/IECs 
The investigator shall report AEs, including expedited reports, in a timely fashion to the IRB in 
accordance with applicable regulations and guidelines. The IRB will be notified in writing (eg, 
facsimile) within 24 hours (1 working day) of when an FDA-reportable SAE is first recognized or 
reported. In addition, a copy of the written confirmation or summary of the SAE, as submitted to 
Auritec, will also be submitted to the IRB within 3 working days of when the FDA-reportable SAE is 
first recognized or reported. The IRB Serious and Unexpected Adverse Experience Submission 
Form will be completed and submitted with the copy of the written confirmation or summary of the 
SAE. 
 
12.6 Pregnancy Reporting 
The investigator/Auritec shall be informed immediately of any pregnancy in a study subject or a partner 
of a study subject. The investigator shall counsel the subject and discuss the risks of continuing with 
the pregnancy and the possible effects on the fetus. Monitoring of the pregnant subject shall continue 
until the conclusion of the pregnancy. 
The investigator shall report all pregnancies to Auritec using the Pregnancy CRF. All pregnancies 
identified during the study shall be followed to conclusion and the outcome of each must be reported. 
The Pregnancy CRF shall be updated when details about the outcome are available. When possible, 
similar information shall be obtained for a pregnancy occurring in a partner of a study subject. 
 
Information requested about the delivery shall include: 
o 
Gestational age at delivery 
o 
Birth weight, length, and head circumference 
o 
Gender 
o 
Appearance, pulse, grimace, activity, and respiration (APGAR) score at 1 minute, 5 minutes, and 
24 hours after birth, if available 
o 
Any abnormalities. 
 
All pregnancy complications that result in a congenital abnormality, birth defect, miscarriage, and 


32 
 
medically indicated abortion will be considered SAE. Such pregnancy events shall be reported using 
the SAE reporting procedures described above. 
 
 
12.7 Reporting of Other Safety Information 
An investigator shall promptly notify the site IRB as well as Auritec when an “unanticipated problem 
involving risks to subjects or others” is identified, which is not otherwise reportable as an AE. 
 
12.8 Review of Safety Information 
12.8.1 DAIT/NIAID Medical Monitor Review 
• 
The DAIT/NIAID Medical Monitor shall receive a copy of the annual study report to health authorities 
from Auritec (See Sections 12.5.3.1, Annual Reporting). 
 
• 
The DAIT/NIAID Medical Monitor shall review and make decisions on the disposition of SAEs (See 
Sections 12.5.1, Reporting of Serious Adverse Events to Sponsor). 
 
• 
The DAIT/NIAID Medical Monitor shall be informed of any participant who experiences a large burst of 
tacrolimus release detected at any point during the study. 
 
• 
The DAIT/NIAID Medical Monitor shall be informed of any premature study drug discontinuation. 
 
12.9 DSMB Review 
The DAIT/NIAID Data and Safety Monitoring Board (DSMB) shall review safety data at least yearly during 
planned DSMB Data Review Meetings. Data for the planned safety reviews will include a listing of all reported 
SAEs. 
 
The DAIT/NIAID DSMB will be informed of any unanticipated problems involving risks to subjects or others in a 
timely manner 
 
13. Statistical Considerations and Analytical Plan 
The Statistical Analysis Plan (Appendix 2) provides details on Data Source, Analysis Objectives, Analysis 
sets/populations/subgroups, endpoints, covariates, handling of missing values, statistical procedures, 
measures to adjust for multiplicity/confounders/heterogeneity, sensitivity analysis, rationale for any deviation 
from pre-specified analysis plan and programming plans. 
 
14. Identification and Access to Source Data 
14.1. Source Data 
Source documents and source data are considered to be the original documentation where subject 
information, visits consultations, examinations and other information are recorded. Documentation of source 
data is necessary for the reconstruction, evaluation and validation of clinical findings, observations and other 
activities during a clinical trial. 
 
14.2. Access to Source Data 
The site investigator and site staff will make all source data available to the DAIT/NIAID and Auritec as well as 
to the FDA. Authorized representatives as noted above are bound to maintain the strict confidentiality of 
medical and research information that may be linked to identified individuals. 
 
 
 
 
 
 
 


33 
 
15. Protocol Deviations 
15.1. Protocol Deviation Definitions 
Protocol Deviation – The investigator and site staff will conduct the study in accordance to the protocol; no 
deviations from the protocol are permitted. Any change, divergence, or departure from the study design or 
procedures constitutes a protocol deviation. If necessary, corrective actions will be developed by the site 
and implemented promptly. 
 
Major Protocol Deviation (Protocol Violation) - A Protocol Violation is a deviation from the IRB-approved 
protocol that may affect the subject's rights, safety, or well-being and/or the completeness, accuracy and 
reliability of the study data. In addition, protocol violations include willful or knowing breaches of human subject 
protection regulations, or policies, any action that is inconsistent with the NIH Human Research Protection 
Program’s research, medical, and ethical principles, and a serious or continuing noncompliance with federal, 
state, local or institutional human subject protection regulations, policies, or procedures. 
 
Non-Major Protocol Deviation - A non-major protocol deviation is any change, divergence, or departure from 
the study design or procedures of a research protocol that does not have a major impact on the subject's 
rights, safety or well-being, or the completeness, accuracy and reliability of the study data. 
 
15.2. Reporting and Managing Protocol Deviations 
The study site principal investigator has the responsibility to identify, document and report protocol deviations 
as directed by Auritec. However, protocol deviations may also be identified during site monitoring visits or 
during other forms of study conduct review. 
 
16. Ethical Considerations and Compliance with Good Clinical Practice 
16.1. Statement of Compliance 
This clinical study will be conducted using good clinical practice (GCP), as delineated in Guidance for Industry: 
E6 Good Clinical Practice Consolidated Guidance, and according to the criteria specified in this study protocol. 
Before study initiation, the protocol and the informed consent documents will be reviewed and approved by the 
IRB. Any amendments to the protocol or to the consent materials will also be approved by the IRB before they 
are implemented. 
 
16.2. Informed Consent Process 
Written informed consent for the study will be obtained from all subjects before protocol specific procedures 
are carried out. The ICF will be approved (along with the protocol) by the IRB and will be acceptable to Auritec 
and DAIT/NIAID. 
 
The Investigator (or designee) will explain the nature of the study and the action of the test product. The 
subjects will be informed that participation is voluntary and that they can withdraw from the study at any time. 
In accordance with 21 CFR 50, the informed consent process shall be documented by the use of a written ICF 
approved by the IRB and signed by the subject prior to protocol-specific procedures being performed. 
 
A copy of the signed Informed Consent Document will be given to the subject; the original signed document will 
be maintained with the subject’s records. 
 
16.3. Privacy and Confidentiality 
A participant’s privacy and confidentiality will be respected throughout the study. Each participant will be 
assigned a unique identification number and these numbers rather than names will be used to collect, store, 
and report participant information. Site personnel will not transmit documents containing personal health 
identifiers (PHI) to Auritec or their representatives. 
 
 
 
 


34 
 
17. Publication Policy 
Any publication of the results, either in part or in total (eg, articles in journals or newspapers, oral 
presentations, abstracts) by the Investigator or his/her representative(s), shall require prior notification and 
review, within a reasonable time frame, by Auritec, and cannot be made in violation of the Auritec’s 
confidentiality restrictions or to the detriment of the Auritec’s intellectual property rights. 


35 
 
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38 
 
c An abbreviated physical examination will be performed at Screening and at the End of Study/Early Termination Visit: a full physical examination will be 
performed at all other visits. A full medical examination includes general appearance, eyes, ears, nose and throat, chest/respiratory, 
heart/cardiovascular, gastrointestinal/liver, musculoskeletal/extremities, dermatological/skin, thyroid/neck, lymph nodes, and 
neurological/psychiatricassessments. An abbreviated physical examination includes assessment of general appearance, skin, thorax/lungs, 
cardiovascular status, and abdomen. 
d A 12-lead ECG will be obtained at Screening, Discharge (Day 2), and at the End of Study/Early Termination Visit. The ECG is to be recorded after the 
subject has been supine for at least 5 minutes. The ECG data will be obtained directly from the 12-lead ECG traces, including RR, PR, QT, and QT 
interval corrected using Fridericia’s formula, QRS duration, and ventricular heart rate. 
e Vital signs include blood pressure, pulse rate, respiratory rate and oral body temperature. Vital signs will be measured in the supine position after 
the subject has rested comfortably for at least 5 minutes. Vital signs will be obtained at Screening,  predose at Day -1; and post-dose at 1, 3, 6, 12 
hours (Day 1), and 24 hours (Day 2) postdose during the inpatient period, and at each outpatient and at end of the study (ie, Day 60).  
f Subjects will be asked a nonleading HDYF question, such as “Have there been any changes in your health status since Screening/since you were last 
asked?” Subjects will also be encouraged to voluntarily report AEs occurring at any other time during the study. The “How Do You Feel” inquiry is to be 
asked during each day of the inpatient period and at all outpatient clinic visits. 
g Pharmacokinetic (PK) blood samples for the determination of SR tacrolimus concentrations are to be collected predose and at approximately 1, 3, 6, 12 
hours (Day 1), and 24 hours (Day 2) following dose administration. A single PK sample will be obtained at each postdose clinic visit.  
h Clinical laboratory assessments will be performed in the fasted state (10 hours). Basic safety labs (ie, standard chemistry panel [CMP], UA and 
hematology panel) will be done at baseline (Day -1) and at least 1 time on the day of dosing, at 24-hours postdose, and at each outpatient visit to the 
clinic. 
ii Women of childbearing potential will have a serum qualitative pregnancy test (human chorionic gonadotropin) on designated visits. A urine pregnancy 
test will be performed at other timepoints. 
j Follicle stimulating hormone levels will be measured at screening only to determine eligibility (postmenopausal women only). In the absence of 
documentation of sterility, a serum qualitative pregnancy test will also be performed (human chorionic gonadotropin) at screen and Day -1. 
 
 
Additional Visits - If the subjects experience certain side effects or have a serious finding during an exam at a follow-up visit, they will be asked to return to 
the clinic. Subjects will be asked to come to the clinic until the symptoms go away. During these visits, subjects will be asked questions about their 
symptoms. Research blood will be collected to measure tacrolimus levels. Blood samples may be collected for safety analysis.




40 
 
days. Eight healthy subjects are to be enrolled in this study. Each subject will be injected with the injectable 
sustained release tacrolimus formulation on the first day of enrollment. The anticipated sustained dose to be 
administered subcutaneously from an injection is approximately 0.1 mg/kg of tacrolimus over a 30-day study 
period. Safety examinations to include AE monitoring will be performed on Day 1 at 1, 3, 6, 12 and 24 hours 
after injection. 
Data will be obtained from the 8 subjects over a period of 30 days. Blood samples will be collected pre-dpse 
and at 1, 3, 6, 12 and 24 hours post-injection on Day 1 from each subject. After this, one blood sample will be 
collected from each subject on the following visits: Days 3, 7, 14, 21 and 30, 37, 44, 51 and 60. Cumulatively, 
15 samples (including blood collection prior to injection) will be taken from each of the six subjects for a total of 
90 samples. 
Other covariates, such as age, gender, race/ethnicity, etc., will be collected as a matter of course, but are 
ancillary to the primary objectives, and will likely not be employed in the analysis or model unless a major 
effect is observed. 
 
2.2. Primary Endpoints/Outcomes 
1) Safety endpoints for this study include the incidence, severity, and relatedness of adverse events 
(inclusive of injection site reactions), and changes from baseline (prior to dosing) in vital signs, clinical 
laboratory evaluations, physical examinations, and electrocardiograms. 
2) Pharmacokinetic (PK) endpoints include calculation of the following PK parameters: maximum 
observed tacrolimus whole blood concentration (Cmax), time to maximum observed tacrolimus 
whole blood concentration (tmax), area under the concentration-time curve (AUC) and elimination 
constant (kel). 
 
3. Analysis Objectives 
3.1. Overall scientific objectives of the analyses 
1) The first primary objective of this first-in-human study is to evaluate the safety of 1-month SR 
injectable containing the approved drug - tacrolimus in healthy volunteers. 
2) Another primary objective of this first-in-human study is to evaluate the pharmacokinetics of the drugs 
by measuring blood concentrations of the drug formulation in healthy volunteers. 
 
3.2. Key unanswered questions that these analyses are designed to address 
This research is designed to study a new formulation that is not approved by the FDA, to see how much 
tacrolimus is delivered to the body when released from a SR injectable formulation see if it is safe. The results 
of the research may contribute to scientific knowledge and may benefit patients in the future. 
The short-term general investigational plan is to evaluate sustained release tacrolimus in healthy volunteers for 
up to 30 days in an open-label, first-in-human study to determine safety and drug concentrations in blood. 
Additional exploratory studies will be considered and planned based in part on the results obtained in this 
study. The long-term investigational plan is to evaluate the safety and efficacy of sustained release tacrolimus 
for the prophylaxis of organ rejection in patients receiving allogeneic liver, kidney, or heart transplants. 
 
3.3. Additional detail to formulate the objectives in statistical terms. 
In making an initial determination of the safety of this formulation, it is necessary to observe both the incidence 
and time of onset for any adverse events to allow for appropriate planning and design of additional studies. 


41 
 
4. Analysis Sets/ Populations/Subgroups 
4.1. Brief definition of analysis sets/populations to be used 
Eight healthy participants in the age group 18-45 years of age. All subjects who receive any amount of the 
investigational product will be included in the safety population. A pharmacokinetic population will be defined 
as all subjects in the safety population who provide sufficient tacrolimus levels to enable a PK model to be 
fitted (in the opinion of the pharmacokineticist). 
 
4.2. Criteria for inclusion/exclusion for the population 
Please see protocol sections 4.2 and 4.3. 
 
4.3. Subgroups/subsets 
Not applicable 
 
5. Endpoints and Covariates 
The primary outcome variables will be the various pharmacokinetic parameters described in more detail in 
section 7.2. 
Safety as an outcome will be assessed through the recording of any adverse events, together with type of 
event and time of event as covariates. 
Various other common covariates, such as age, gender, race/ethnicity, etc., will be examined but will likely not 
be feasible to include in any modeling due to the small sample size. 
 
6. Handling of Missing Values and Other Data Conventions 
No missing data will be imputed. Missing blood tacrolimus data will be ignored in the calculation of PK 
parameters. This is the standard approach in the analysis of pharmacokinetic data. 
 
7. Statistical Methodology 
7.1 Statistical Procedures 
The sample size choice was based on the preliminary nature of the study and the goals of an initial analysis of 
pharmacokinetics of the sustained-release version of injectable tacrolimus as well as safety in a cohort study of 
healthy volunteers. 
Qualitative examination of the behavior of the blood concentration will be performed via a profile plot, which 
allows for the visual inspection of the data for all subjects simultaneously. Specific pharmacokinetic analyses 
are described below. 
 
7.2 Pharmacokinetic Analysis 
PK samples for the PK period are planned for all subjects (irrespective of their CYP-enzyme genotype since 
the injectable formulation of tacrolimus will not be metabolized by this enzyme). Blood samples will be 
collected before the injection (baseline) and 1, 3, 6, 12 and 24 hours post-injection on Day 1 from each subject. 
After this, one blood sample will be collected from each subject on days 3, 7, 14, 21 and 30, 37, 44, 51 and 60. 
Actual sampling times post start of the injection will be recorded and used for calculation. The following PK 
parameters will be calculated by a non-compartmental injection model, using WinNonlin® (Version 5.2 or 
higher) based on the blood levels of tacrolimus: 
 
The PK parameters will be calculated using the unadjusted and the baseline adjusted concentrations and 
actual sampling times post start of injection, for each subject and each PK period for which sufficient data 
are available to allow such calculations: 
• 
Cmax (ng/mL): Observed maximum tacrolimus whole blood concentration; 
• 
Cmin (ng/mL): Observed minimum tacrolimus whole blood concentration; 
• 
tmax (h): Time to reach Cmax; 
• 
λz: Elimination rate constant (kel); 
• 
AUC0-t (h*ng/mL): Area under the tacrolimus whole blood concentration time curve from time point 
zero to the last quantifiable time point; 
• 
AUC0-inf (h*ng/mL): Area under the tacrolimus whole blood concentration time curve from time point 


42 
 
zero to infinite time; 
• 
t1/2 (h): Terminal phase half life 
• 
MRT (h): Mean residence time; 
• 
CL (L/h*kg): Total clearance from the body, calculated as dose/AUC0-inf; where AUC0-inf can be 
reliably calculated; 
• 
Vss (L/kg): Volume of distribution at steady state, calculated as CL*MRT. 
 
Half-life will be calculated as ln (2) / λz, where ln (2) is the natural logarithm of 2. 
λz will be estimated by linear regression after log transformation of the concentrations: 
 
• 
Only those data points that are judged to describe the terminal log linear decline will be used in the 
regression. 
• 
λz will then be estimated using the highest adjusted R squared value, with R squared being the 
coefficient of determination from the regression (the PK scientist will review all profiles and PK 
parameters. The decision will be made based on his or her scientific judgment). 
• 
A minimum number of three data points in the terminal phase will be used in calculating λz with the line 
of regression starting at any post-Cmax data point and including Clast, tlast. 
• 
An appropriate number of decimal places will be used for λz to enable the reported value of t½ to be 
calculated. 
• 
For subjects who do not have a λz estimation, t1/2, Vss, AUC0-inf and MRT will not be estimated. 
 
The λz lower and λz upper times will be reported. 
Area under the curve (AUC0-t) to the last measured blood level will be calculated from the observed data using 
the linear trapezoidal method with linear/log interpolation. 
AUC0-inf will be calculated as AUC0-t + Ct/λz where Ct is the last quantifiable concentration in the profile; 
Peak concentration (Cmax) will be the observed maximum value during the collection period. The time to peak 
concentration (tmax) will be the time at which Cmax was observed (or first observed, if the peak value occurs 
more than once). 
Post injection concentrations will be baseline corrected as follows: 
Adjusted post injection value = measured post injection value-pre injection value. 
For calculation of clearance CL and incremental recovery, the dose of tacrolimus received as entered in the 
CRF will be used. These doses will be sumarized and listed. Unadjusted and baseline tacrolimus blood 
concentrations will be summarized by planned sampling time point by means of descriptive statistics, including 
the geometric mean and the coefficient of variation (CV%, calculated as 100 * SD / mean). For AUC0 t and 
Cmax, the 90% and 95% CI for the mean and the 90% and 95% CI for the geometric mean will also be 
computed. The CI for the geometric mean will be calculated assuming a log normal distribution. Four decimal 
places will be provided for all CIs. 
 
7.2 Safety Analyses 
7.2.1 Adverse events 
All AEs experienced will be recorded during the study. Details to be collected include AE diagnosis, date and 
time of onset and resolution, whether the event is ongoing, whether the event is serious, frequency, severity, 
outcome status, action taken and relationship to study drug. 
An overall summary table of AEs, including patients experiencing at least one AE, at least one SAE, related to 
study drug, discontinued due to AE, and death, will be presented. 
AEs will be summarized by system organ class and preferred term, showing the number and percentage of 
patients experiencing a given event. In addition, AEs will be summarized by system organ class, preferred term 
and worst severity, and also by system organ class, preferred term and relationship to study drug. A patient will 
be counted only once for each preferred term when multiple AEs are coded to the same preferred term. If a 
patient experiences multiple AEs coded to the same preferred term, the maximum toxicity grade will be used 
for the summary. 
 
 


43 
 
7.2.2 Serious adverse events 
Similar to AE reporting above, SAEs will be summarized by system organ class and preferred term, showing 
the number and percentage of patients experiencing a given event. In addition, SAEs will be summarized by 
system organ class, preferred term and relationship to study drug. 
 
7.2.3 Deaths 
Patients who die during study participation will be listed. Death will be determined from the AE CRF page 
(where outcome is death). 
 
7.2.4 Discontinuation due to AE 
Patients who discontinue the study because of an AE will be listed. Patient discontinuation will be determined 
from the evaluation (where reason for study termination is adverse event) and the specific adverse event will 
be determined from the AE CRF page (where action taken is discontinuation of study drug). 
 
7.2.5 Interruption in study drug injection 
Patients who have interruption in study drug injection will be listed. Listing will include start time of 
interruption, stop time of interruption and reason of interruption. Duration of interruption of study drug injection 
will be summarized. 
 
7.2.6 Safety laboratory tests 
Specimens for laboratory analysis at screen and predose baseline visit will be obtained to ascertain if the 
subject meets eligibility criteria and to provide a baseline to assess for possible AEs post drug administration. 
Complete blood count (CBC) panel, whole blood chemistry panel, urinalysis, and urine pregnancy test at 
baseline (as applicable) will be performed. 
Laboratory specimens will be obtained for testing to assess safety, including CBC panel, whole blood 
chemistry panel, and urinalysis panel at all study visits. 
Descriptive statistics will be provided for each test and for change-from-baseline values. Laboratory test results 
along with their normal ranges will be listed. Pregnancy test results will be listed. 
Clinically significant changes from baseline in laboratory test findings and abnormalities will be reported as 
AEs. 
 
7.2.7 Physical examination and vital signs 
Vital signs will be collected to include body temperature, blood pressure, respiratory rate, and heart rate. 
Descriptive statistics will be provided for vital signs and physical examination. Predose vital signs (Visit 2 
baseline predose) will be used as baseline to derive change from baseline of vital signs. Descriptive statistics 
will be provided for change from baseline vital signs at each available assessment time points. Shift tables on 
physical examination between normal and abnormal will be provided. Listings of vital signs and physical 
examination data will also be listed. 
 
7.3 Measures to Adjust for Multiplicity, Confounders, Heterogeneity, Etc. 
Not applicable for this study. 
 
8. Sensitivity Analyses 
Not applicable for this study. 
 
9. Rationale for any Deviation from Pre-Specified Analysis Plan Performed by Auritec 
Any change from the planned analysis as per final SAP will be documented in the study report along with the 
rationale. 
 
10. Programming Plans 
Data will be analyzed using WinNonlin® (Version 5.2 or higher) based on the blood levels of tacrolimus 
A profile plot will be constructed using the PROC SGPLOT procedure in SAS 9.4. A smoothing algorithm such 
as penalized B-splines or LOESS will be chosen as appropriate, depending on the behavior of the data. 


44 
 
A summary table delineating common demographic characteristics such as age, gender, etc. will be produced. 
 
11. Regulatory Compliance and Quality Assurance 
 
11.1 Record keeping 
The Investigator is responsible for maintaining all records pertaining to the clinical trial and for ensuring 
complete and accurate documentation. 
 
The Investigator is responsible for maintaining a subject identification log. This confidential subject 
identification code provides the link between named subject source records in the subject file and 
anonymous CRF data provided to the sponsor. 
The Sponsor requires that the Investigator retain records (all regulatory documents such as the protocol, study 
approval letters, all CRFs, drug dispensing and accountability logs, all original subject consent forms and all 
correspondence pertaining to the conduct of the study) for a period of no less than 5 years from the date of 
final regulatory approval or as per local regulations, whichever is longer. If the study is discontinued, or if no 
application/license is to be filed or if the application/license is not approved for such indication, records should 
be retained for 5 years after the investigation is discontinued or as per local regulations, whichever is longer. 
 
11.2 Quality control and quality assurance 
The Clinical Research Associates will monitor the data collected throughout the study thus providing Quality 
Control (QC) of the study. Independent monitoring of the clinical study for protocol and GCP compliance will be 
conducted periodically at the contract research organization (Worldwide Clinical Trials) by qualified Quality 
Assurance (QA) auditors. Clinical monitoring will be performed by ASKE CRA services.  
The investigator must make himself or herself available for CRAs during their visits and ensure that CRAs have 
direct access to all documents that they require, including direct access to the subjects’ files. The investigator 
agrees to cooperate with the CRAs to make certain that any problems detected in the course of monitoring 
visits are resolved. The investigator will permit direct access to the source data and documents to the 
appropriate regulatory authorities to verify the accuracy of this data. 
The present study will be conducted in accordance with ICH GCP. The clinical team will systematically control 
the essential documents generated during this trial. The trial will be monitored by the clinical team and will be 
subject to internal audits by Quality Assurance. All clinical study monitoring visits and audits by QA will be 
followed by internal reports and corrective actions, if needed. Follow-up letters will be forwarded to sites after 
all visits and any findings should be addressed by the investigator. The follow-up letters should be filed with the 
study correspondence and other essential documentation. 
 
11.3 Changes in the conduct of the study 
Any changes of the protocol (substantial amendments and non-substantial amendments) will be integrated into 
an updated study protocol, with a listing of all changes and reasoning for them. A protocol amendment must 
be submitted for DAIT/NIAD and IRB approval and consideration to the applicable regulatory agencies. 
Minor procedural changes will be implemented by Study Notes to File, with supporting documentation at each 
site, if appropriate. 
A non-substantial amendment of a study protocol includes minor correction or clarification that have no 
significant impact on the way the clinical study is to be conducted and no effect on subject safety (i.e., 
administrative changes like change of telephone number(s), logistical changes, etc.). 
 
11.4 Confidentiality 
The collection and processing of personal data from subjects enrolled in this study will be limited to those data 
that are necessary to investigate the efficacy, safety, quality, and utility of the investigational product(s) used in 
this study. 


The Investigator will ensure that the subjects’ anonymity will be maintained. The privacy rules of the US HIPAA 
will be followed to obtain authorization for most uses and disclosures of Protected Health Information. On 
CRFs or other documents submitted to the Sponsor or its designee, subjects will not be identified by their 
names, but by an identification code, consisting of the combination of subject’s initials and study number. 
Documents not for submission to Sponsor or its designee (e.g., the site confidential subject enrollment log and 
original subjects’ consent forms) will be maintained by the Investigator in strict confidence. Appropriate 
technical and organizational measures to protect the personal data against unauthorized disclosures or 
access, accidental or unlawful destruction, or accidental loss or alteration must be put in place. Sponsor 
personnel whose responsibilities require access to personal data agree to keep the identity of study subjects 
confidential. 
The informed consent obtained from the subject includes explicit consent for the processing of personal data 
and for the investigator to allow direct access to his or her original medical records for study-related monitoring, 
audit, IRB, and regulatory inspection. This consent also addresses the transfer of the data to other entities and 
to other countries. 
The subject has the right to request through the investigator access to his/her personal data and the right to 
request rectification of any data that are not correct or complete. Reasonable steps should be taken to respond 
to such a request, taking into consideration the nature of the request, the conditions of the study, and the 
applicable laws and regulations.