Clinical trial NCT02912468
Conditions: Chronic Rhinosinusitis Phenotype With Nasal Polyps (CRSwNP)
Keywords: Nasal polyposis, Chronic rhinosinusitis, Intranasal corticosteroids, Dupilumab, Human monoclonal antibody
Sponsor: Sanofi
Start date: 2016-12-05; Completion date: 2018-07-05
Enrollment: 276 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
Primary Objective:

To evaluate the efficacy of dupilumab 300 milligram (mg) every 2 weeks (q2w) compared to placebo on a background of mometasone furoate nasal spray (MFNS) in reducing nasal congestion/obstruction (NC) severity and endoscopic nasal polyp score (NPS) in participants with bilateral nasal polyposis (NP). In addition for Japan participants, reduction in computed tomography (CT) scan opacification of the sinuses was a coprimary objective.

Secondary Objectives:

* To evaluate the efficacy of dupilumab in improving total symptoms score (TSS).
* To evaluate the efficacy of dupilumab in improving sense of smell.
* To evaluate the efficacy of dupilumab in reducing CT scan opacification of the sinuses (primary objective for Japan).
* To evaluate ability of dupilumab in reducing proportion of participants requiring treatment with systemic corticosteroids or NP surgery.
* To evaluate the effect of dupilumab on participant reported outcomes and health related quality of life outcome by sinonasal outcome test-22 (SNOT-22).
* To evaluate the effect of dupilumab in the subgroups of participants with prior surgery and co-morbid asthma (including non-steroid antiinflammatory drug \[NSAID\] exacerbated respiratory disease \[ERD\]).
* To evaluate residual effect in follow up.
* To evaluate the safety of dupilumab in participants with bilateral NP.
* To evaluate functional dupilumab concentrations (systemic exposure) and incidence of treatment-emergent anti-drug antibodies.

Detailed description:
The total study duration per participant was expected to be up to 52 weeks that consisted of a 4-weeks run-in period, 24-weeks treatment period, and a 24-weeks post treatment period.

Arms: arm 1: Placebo (for dupilumab), 1 subcutaneous (SC) injection every 2 weeks (q2w) from Day 1 of Week 0 up to Week 24 added to background therapy of intranasal mometasone furoate nasal spray (MFNS) at stable dose. arm 2: Dupilumab 300 mg SC injection q2w from Day 1 of Week 0 up to Week 24 added to background therapy of intranasal MFNS at stable dose.
Interventions: intervention 1: Dupilumab SAR231893 (REGN668) intervention 2: Placebo intervention 3: Mometasone furoate 50 micrograms
Intervention descriptions: intervention 1: Pharmaceutical form: Solution

Route of administration: Subcutaneous intervention 2: Pharmaceutical form: Solution

Route of administration: Subcutaneous intervention 3: Pharmaceutical form: Suspension (Nasal spray)

Route of administration: Intranasal

Protocol documents:
Prot_000.pdf: 
Any and all information presented in this document shall be treated as confidential and shall remain the exclusive property of Sanofi (or any of its 
affiliated companies). The use of such confidential information must be restricted to the recipient for the agreed purpose and must not be 
disclosed, published or otherwise communicated to any unauthorized persons, for any reason, in any form whatsoever without the prior written 
consent of Sanofi (or the concerned affiliated company); ‘affiliated company’ means any corporation, partnership or other entity which at the date 
of communication or afterwards (i) controls directly or indirectly Sanofi, (ii) is directly or indirectly controlled by Sanofi, with ‘control’ meaning 
direct or indirect ownership of more than 50% of the capital stock or the voting rights in such corporation, partnership or other entity 
According to template: QSD-002579 VERSION N°14.0 (04-FEB-2016) 
Page 1 
AMENDED CLINICAL TRIAL PROTOCOL 01  
COMPOUND: SAR231893 (dupilumab)   
A randomized, 24-week treatment, double-blind, placebo-controlled efficacy and safety 
study of dupilumab 300 mg every other week, in patients with bilateral nasal polyposis on 
a background therapy with intranasal corticosteroids 
STUDY NUMBER: EFC14146 
STUDY NAME: SINUS-24 
VERSION DATE / STATUS: Approval date (17-May-2017) / Approved 
Protocol Amendment 01 
Version number: 1 (electronic 1.0) 
Date : 17-May-2017 
Clinical Trial Protocol 
Version number: 1 (electronic 2.0) 
Date : 04-Aug-2016 
 
EudraCT
2015-003101-42
IND Number(s) 
105379 
Version Number: 
1 
Date: 
17-May-2017 
Total number of pages: 
143 
(electronic 1.0)
NCT Number: NCT02912468


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NAMES AND ADDRESSES OF 
COORDINATING 
INVESTIGATOR 
 
Name: 
Address: 
 
 
Tel: 
Fax: 
E-mail: 
 
 
MONITORING TEAM’S 
REPRESENTATIVE 
 
Name: 
Address: 
 
 
 
Tel: 
Fax: 
E-mail: 
 
 
SPONSOR 
 
Company: 
Address: 
 
 
 
 
 
 
OTHER EMERGENCY 
TELEPHONE NUMBERS 
 
 
 
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CLINICAL TRIAL SUMMARY 
 
COMPOUND: SAR231893 
(dupilumab) 
STUDY No.: EFC14146  
 
TITLE 
A randomized, 24-week treatment double-blind, placebo-controlled efficacy and safety study 
of dupilumab 300 mg every other week, in patients with bilateral nasal polyposis on a 
background therapy with intranasal corticosteroids 
INVESTIGATOR/TRIAL 
LOCATION 
Worldwide 
PHASE OF 
DEVELOPMENT 
3 
STUDY OBJECTIVES 
 
Primary objective: 
• 
To evaluate the efficacy of dupilumab 300 mg every 2 weeks (q2w) compared to 
placebo on a background of mometasone furoate nasal spray (MFNS) in reducing 
nasal congestion/obstruction (NC) severity and endoscopic nasal polyp score 
(NPS) in patients with bilateral nasal polyposis (NP). In addition for Japan, 
reduction in computed tomography (CT) scan opacification of the sinuses will be 
also a coprimary objective. 
Secondary objectives: 
• 
To evaluate the efficacy of dupilumab in improving total symptom score (TSS). 
• 
To evaluate the efficacy of dupilumab in improving sense of smell. 
• 
To evaluate the efficacy of dupilumab in reducing CT scan opacification of the 
sinuses (for Japan, this is part of the primary objective) 
• 
To evaluate the ability of dupilumab to reduce the proportion of patients who 
require treatment with systemic corticosteroids (SCS) or surgery for NP. 
• 
To evaluate the effect of dupilumab on patient reported outcomes (PROs) and 
health-related quality of life (HRQoL). 
• 
To evaluate the effect of dupilumab in the subgroups of patients with prior surgery 
and comorbid asthma (including nonsteroidal anti-inflammatory drug [NSAID] 
Exacerbated Respiratory Disease [NERD]). 
• 
To evaluate the residual effect of dupilumab through the 24-week follow-up period. 
• 
To evaluate the safety of dupilumab in patients with bilateral NP.  
• 
To evaluate functional dupilumab concentrations (systemic exposure) and 
incidence of treatment-emergent antidrug antibodies (ADA). 
Exploratory objectives: 
• 
To explore the effects of dupilumab on nasal microbiome, total and allergen-
specific immunoglobulin Es (IgEs) in blood, and urinary leukotriene E4 and a 
metabolite of prostaglandin D2 (PGDM). 
• 
To evaluate the effect of dupilumab on healthcare resource utilization. 
• 
To evaluate the effect of dupilumab on SNOT-22 items: ‘decreased sense of 
smell/taste’, 'difficulty falling asleep,' 'wake up at night,' 'lack of a good night's 
sleep,' 'wake up tired,' 'fatigue,' and 'reduced productivity’. 
• 
To assess the effect of dupilumab in improving sense of taste. 
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STUDY DESIGN 
General design 
Multinational, multicenter, randomized, double-blind, Phase 3, placebo-controlled, parallel 
group study comparing the efficacy of dupilumab to placebo, in patients with bilateral NP on 
a background treatment with intranasal corticosteroids (INCS). 
Study periods 
The clinical trial consists of 3 periods: 
Run-in period (4 weeks +/-3 days): 
All patients will enter a run-in period of 4 weeks receiving MFNS of 2 actuations 
(50 µg/actuation) in each nostril twice daily (BID), total daily dose of 400 µg, starting at 
Visit 1 (V1), unless the patients are unable to tolerate or there is a specific regulatory 
requirement preventing use of this dose, in which case they can stay on a lower dose 
regimen (200 µg once daily) of MFNS. 
Randomized treatment period (up to 24 weeks +/-3 days): 
Patients will be randomized to one of the following treatments: 
• 
Arm A: dupilumab 300 mg subcutaneous (SC) q2w.  
• 
Arm B: placebo matching dupilumab SC q2w. 
All patients will continue on the stable dose of MFNS used during the run-in period except if 
dose is changed due to adverse event (AE). 
Rescue:  
During the study treatment period and off-treatment follow-up, based on clinical evaluation, 
in case of worsening of signs and/or symptoms requiring medical intervention, the 
Investigator may consider rescue treatment with:  
• 
Nasal lavage with saline and/or systemic antibiotics (up to 2 weeks in case of 
acute infection). 
• 
Short course OCS (prednisone or prednisolone). 
• 
Sino-nasal surgery for nasal polyps (based on previous observations, 8 weeks of 
IMP treatment it is recommended prior to surgery to allow onset of treatment 
effect) 
Patients receiving rescue treatment other than surgery during the study should continue on 
study drug unless the Investigator decides to withdraw the study treatment (see 
Section 8.2.2). Before starting treatment with SCS, patients should come to the study site for 
clinical assessments including endoscopy and PROs.  
For patients undergoing surgery for NP the Investigator may decide to continue IMP up to 
the time of surgery or end of treatment (EOT), whichever date comes first (see 
Section 9.2.1.5 for details). At the time of surgery patients will be permanently discontinued 
from study treatment and assessed as soon as possible using the procedures normally 
planned for the EOT Visit and will be instructed to return to the study site as described in 
Section 10.3.1.  
Post treatment period (24 weeks +/-3 days): 
After completing 24 weeks of treatment with the investigational medicinal product (IMP) (or 
following early discontinuation of IMP or discontinuation from the study), patients will be 
instructed to: 
• 
Return to the study site for all the last scheduled study visits for evaluations of 
pharmacokinetics (PK) and ADA, physical examination, nasal peak inspiratory 
flow (NPIF), University of Pennsylvania smell identification test (UPSIT), NPS, CT 
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scan (unless not approved by local ethics committee), PROs (SNOT-22, visual 
analog scale [VAS]), asthma control questionnaire-6 [ACQ-6] and forced 
expiratory volume in 1 second [FEV1] for patients with asthma and safety. 
• 
Continue to complete daily the e-diary for symptom evaluation. 
• 
Continue on MFNS stable dose during the post treatment period except if dose is 
changed due to AE. 
• 
Contact the Investigator during the post treatment period up to the EOS visit if the 
symptoms worsen requiring medical attention. 
• 
Report any adverse event (AE). 
For procedure to be followed for early discontinuation of IMP refer to Section 10.3.1. 
STUDY POPULATION  
Main selection criteria 
Inclusion criteria: 
Patients with bilateral sino-nasal polyposis that despite prior treatment with SCS anytime 
within the past 2 years; and/or have a medical contraindication / intolerance to SCS; and/or 
had prior surgery for NP at the screening visit, have: 
• 
An endoscopic bilateral NPS at V1 of at least 5 out of a maximum score of 8 (with 
a minimum score of 2 in each nasal cavity).  
• 
Ongoing symptoms (for at least 8 weeks prior to V1) of: 
- 
Nasal congestion/blockage/obstruction with moderate or severe symptom 
severity (score 2 or 3) at V1 and a weekly average severity of greater than 1 
at the time of randomization (V2), and 
- 
Another symptom such as loss of smell, rhinorrhea (anterior/posterior). 
• 
Signed written informed consent. 
Exclusion criteria: 
See Section 7.2 for the complete list of exclusion criteria 
• 
Patients <18 years of age. 
• 
Patient who has previously been treated in dupilumab studies. 
• 
Patient who has taken: 
- 
Biologic therapy/systemic immunosuppressant to treat inflammatory disease 
or autoimmune disease (eg, rheumatoid arthritis, inflammatory bowel 
disease, primary biliary cirrhosis, systemic lupus erythematosus, multiple 
sclerosis, etc.) within 2 months before V1 or 5 half-lives, whichever is longer. 
- 
Any experimental monoclonal antibody (mAB) within 5 half-lives or within 
6 months before V1 if the half-life is unknown. 
- 
Anti-immunoglobulin E (IgE) therapy (omalizumab) within 130 days prior to 
V1. 
- 
Patients who are receiving Leukotriene antagonists/modifiers at V1 unless 
they are on a continuous treatment for at least 30 days prior to V1. 
• 
Initiation of allergen immunotherapy within 3 months prior to V1 or a plan to begin 
therapy or change its dose during the run-in period or the randomized treatment 
period. 
• 
Patients who have undergone any intranasal and/or sinus surgery (including 
polypectomy) within 6 months prior to V1. 
• 
Patients who have had a sino-nasal or sinus surgery changing the lateral wall 
structure of the nose making impossible the evaluation of NPS. 
• 
Patients with conditions/concomitant diseases making them nonevaluable at V1 or 
for the primary efficacy endpoint such as: 
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- 
Antrochoanal polyps. 
- 
Nasal septal deviation that would occlude at least one nostril. 
- 
Acute sinusitis, nasal infection or upper respiratory infection. 
- 
Ongoing rhinitis medicamentosa. 
- 
Allergic granulomatous angiitis (Churg-Strauss syndrome), granulomatosis 
with polyangiitis (Wegener’s granulomatosis), Young’s syndrome, 
Kartagener’s syndrome or other dyskinetic ciliary syndromes, concomitant 
cystic fibrosis. 
- 
Radiologic suspicion, or confirmed invasive or expansive fungal 
rhinosinusitis. 
• 
Patients with nasal cavity malignant tumor and benign tumors (eg, papilloma, 
blood boil etc). 
• 
Patients with forced expiratory volume in 1 second (FEV1) 50% or less (of 
predicted normal). 
Total expected number of 
patients 
A total of approximately 240 patients with bilateral NP will be randomized to 2 treatment 
arms (120 patients/arm). 
The randomization will be stratified based on asthma status, prior NP surgery, and country. 
In order to have adequate number of patients for the subgroup analysis of patients with 
asthma/NERD and patients with prior surgery, respectively, enrollment of the following 
categories of patients will be limited as follows (see rationale Section 4.2):  
• 
Patients without asthma and/or NERD history will be limited to 120 patients (out of 
the total 240 randomized patients). 
• 
Patients without prior surgery will be limited to 120 patients (out of the total 
240 randomized patients). 
Patients may fall in more than one category without limitation in numbers. 
Expected number of sites Approximately 80 sites. 
STUDY TREATMENTS 
Dupilumab (SAR231893/REGN668) or matching placebo. 
Investigational medicinal 
product Formulation 
Dupilumab: 150 mg/mL in prefilled syringe to deliver 300 mg in 2 mL. 
Placebo: Prefilled syringe to deliver 2 mL. 
Route of administration: 
Subcutaneous (SC) injection. 
Dose regimen 
Randomized 1:1 to the following regimens until Week 24: 
• 
Arm A: dupilumab 300 mg SC q2w. 
• 
Arm B: placebo matching dupilumab SC q2w. 
Noninvestigational 
medicinal product  
Formulation 
• 
Mometasone furoate (NASONEX®) 50 µg/actuation nasal spray, suspension. 
Nasal spray is provided in a bottle that contains 18 g (140 actuations) of product formulation.
Route of administration 
Mometasone furoate (NASONEX): Nasal spray. 
Dose regimen 
Mometasone furoate nasal spray 2 actuations (50 µg/actuation) in each nostril BID (total 
daily dose of 400 µg), or once daily (total daily dose of 200 µg) if the patients are unable to 
tolerate BID or there is a specific regulatory requirement preventing use of this dose, in 
which case they can stay on a lower dose regimen (200 µg) of MFNS. 
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ENDPOINTS 
 
Coprimary endpoints: 
Change from baseline at Week 24: 
• 
Nasal congestion/obstruction (NC) symptom severity score based on the patient 
daily morning (AM) assessment. 
• 
Nasal polyp score, as assessed by central video recordings of nasal endoscopy. 
For Japan, in addition to the coprimary endpoints above, the following will also be a 
coprimary endpoint. 
• 
Change from baseline in opacification of sinuses assessed by CT scans using the 
Lund Mackay score (LMK) at Week 24. 
Secondary endpoints: 
Efficacy key secondary 
• 
Change from baseline in TSS at Week 24: composite severity score consisting of 
the patient daily AM assessed NC, decreased/loss of sense of smell, 
anterior/posterior rhinorrhea. 
• 
Change from baseline in the UPSIT smell test at Week 24. 
• 
Change from baseline in the severity of decreased/loss of smell daily assessed by 
the patient at Week 24. 
• 
Change from baseline in opacification of sinuses assessed by CT scans using the 
LMK score at Week 24. (This endpoint will not be assessed as a secondary 
endpoint for Japan as it is already a coprimary endpoint.) 
• 
Change from baseline in SNOT-22 at Week 24.  
• 
Proportion of patients during study treatment receiving SCS and/or planned to 
undergo surgery for nasal polyps. 
Other secondary 
• 
Change from baseline at Week 24 in: 
- 
VAS for overall rhinosinusitis. 
- 
Nasal peak inspiratory flow (NPIF). 
- 
Rhinorrhea (anterior/posterior nasal discharge) daily symptom score 
assessed by the patient. 
• 
Efficacy endpoints for the subgroups of patients with prior surgery and patients 
with comorbid asthma (including NERD history). 
• 
Efficacy endpoints through the 24-week follow up period. 
• 
Safety (incidence of treatment-emergent AEs (TEAE), of treatment-emergent 
serious AEs (TESAEs), and TEAEs leading to treatment discontinuation), 
laboratory values, vital signs.  
• 
Dupilumab concentration in serum and ADA. 
• 
Total SCS rescue dose prescribed (in mg) during the treatment period. 
• 
Total SCS rescue intake in days during the treatment period. 
• 
Patient reported outcomes including HRQoL scales (EQ-5D-5L VAS score, self-
rated health). 
Details in the statistical analysis for other secondary endpoints in the intent-to-treat (ITT) 
and predefined subgroups will be provided with the final statistical analysis plan (SAP). 
Additional ITT and subgroup exploratory analyses are discussed in Section 9 and Section 
11.4.2. 
Exploratory endpoints: 
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• 
Healthcare resource utilization.  
• 
Proportion and time-to-event of patients with SCS rescue for nasal polyps. 
• 
Proportion and time-to-event of patients planned for surgery of nasal polyps. 
• 
Change from baseline in decreased/loss of sense of taste symptom severity. 
• 
SNOT-22 items: ‘decreased sense of smell/taste’, 'difficulty falling asleep,' 'wake 
up at night,' 'lack of a good night's sleep,' 'wake up tired,' 'fatigue,' and 'reduced 
productivity’. 
• 
Pharmacodynamic biomarkers in blood and urine. 
• 
Microbiome in nasal mucus swab. 
• 
 
• 
FEV1, forced vital capacity (FVC), and forced expiratory flow 25% to 75% 
(FEF 25-75) in patients with asthma. 
• 
Efficacy endpoints for the subgroup of patients with systemic corticosteroid use 
prior to study V1. 
• 
Patient reported outcomes including HRQoL scale (Index Score of EQ5D-5L) 
ASSESSMENT 
SCHEDULE 
Run-in period: 4 weeks +/-3 days. 
Randomized treatment period: 24 weeks +/-3 days. 
Post treatment period: 24 weeks +/-3 days. 
For detailed assessment schedule across the study randomized treatment period, refer to 
the study flow chart (see Section 1.2). 
STATISTICAL 
CONSIDERATIONS 
 
Sample size determination: 
The sample size is chosen to enable an adequate characterization of the efficacy between 
dupilumab 300 mg q2w and placebo with regard to the 2 coprimary endpoints, changes from 
baseline in NC and NPS at Week 24.  
The observed mean NC reduction of the dupilumab group with weekly dosing (qw) in 
ACT12340 is 0.95 and the observed mean NC reduction of the placebo group is 0.26. To 
calculate the power, a conservative estimate is used that assumes the placebo-adjusted NC 
reduction of the dupilumab 300 mg q2w group is 80% of the placebo-adjusted effect 
observed with dupilumab 300 mg qw. Thus, the mean NC reduction of the dupilumab 
300 mg q2w is then assumed to be 0.81 = 0.8 * (0.95 – 0.26) + 0.26 at Week 24. Assuming 
normal distribution of the change in NC, a common standard deviation (SD) of 1.03, which 
has incorporated a 20% inflation from the observed SD in ACT12340, and a 25% dropout 
rate, with 120 patients per group, the study will have 95% power to detect an effect size of 
0.534 using a two-sided test with alpha = 0.05 for the change in NC at Week 24 in the 
dupilumab 300 mg q2w group versus placebo.  
The observed mean NPS reduction of the dupilumab group with qw dosing in ACT12340 is 
1.85 and the observed mean NPS reduction of the placebo group is 0.30. Using the same 
conservative approach that assumes the placebo-adjusted NPS reduction with the 
dupilumab 300 mg q2w is 80% of the placebo-adjusted effect observed with dupilumab 
300 mg qw, the mean NPS reduction of the dupilumab 300 mg q2w group is then assumed 
to be 1.54 = 0.8 * (1.85 – 0.30) + 0.30. Assuming normal distribution of the change in NPS, 
a common SD of 2.11, which has incorporated a 20% inflation from the observed SD in 
ACT12340, and a 25% dropout rate, with 120 patients per group, the study will have 98% 
power to detect an effect size of 0.588 using a two-sided test with alpha = 0.05 for the 
change in NPS at Week 24 in the dupilumab 300 mg q2w group versus placebo. 
Therefore, with a sample size of 120 patients per group, the combined power of the two 
coprimary efficacy endpoints is at least 93% for dupilumab 300 mg q2w group with 
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alpha = 0.05 assuming no negative correlation between the two endpoints. 
The observed mean LMK reduction of the dupilumab group with qw dosing in ACT12340 is 
9.07 and the observed mean LMK reduction of the placebo group is 0.23. Using same 
conservative approach that assumes the placebo-adjusted LMK reduction of the dupilumab 
300 mg q2w group is 80% of the dupilumab 300 mg qw, the mean LMK reduction of the 
dupilumab 300 mg q2w group is then assumed to be 7.30 = 0.8*(9.07-0.23)+0.23. Assuming 
normal distribution of the change in LMK, a common standard deviation (SD) of 5.50, which 
has incorporated a 20% inflation from the observed SD in ACT12340, and a 25% dropout 
rate, with 120 patients per group, the study will have 99% power to detect an effect size of 
1.285 using a two-sided test with alpha = 0.05 for the change in LMK at Week 24 in the 
dupilumab 300 mg q2w group. 
With the same sample size of 120 patients per group, the combined power of the 
3 coprimary efficacy endpoints for Japan is at least 92% for dupilumab 300 mg q2w group 
with alpha = 0.05 assuming no negative correlation between the 3 endpoints. 
The sample size calculations were performed using nQuery Advisor 7.0. 
Randomization: 
Patients will be randomized using a 1:1 randomization ratio to dupilumab 300 mg q2w or 
placebo. The randomization will be stratified based on asthma status, prior surgery, and 
country. 
Analysis population: 
The primary analysis population for the efficacy endpoints will be the randomized ITT 
population which includes all patients who have been allocated to a randomized treatment 
regardless of whether the treatment kit was used or not. The efficacy analyses will be 
conducted according to the treatment to which they were randomized. 
The analysis population for safety endpoints is defined as all patients exposed to study 
medication, regardless of the amount of treatment administered. The safety analyses will be 
conducted according to the treatment patients actually received. 
The treatment emergent period is defined as the time from the first administration of study 
medication to Week 12 of the post treatment period. 
Coprimary efficacy variables: 
For all countries except Japan, the coprimary efficacy variables are: change from baseline in 
NC and in NPS at Week 24 assessed for dupilumab 300 mg q2w versus placebo. 
For Japan only, in addition to the 2 coprimary endpoints above, the following will also be a 
coprimary endpoint: 
• 
Change from baseline in sinus opacifications assessed by CT scans using the 
LMK score at Week 24. 
The following null hypothesis and alternative will be tested for dupilumab versus placebo:  
• 
H0: No treatment difference between the dupilumab dose regimen and placebo. 
• 
H1: There is a treatment difference between the dupilumab dose regimen and 
placebo. 
Analysis of the coprimary efficacy variables: 
Each of the 2 coprimary efficacy endpoints (3 coprimary endpoints for Japan) will be 
analyzed using a hybrid method of the worst-observation carried forward (WOCF) and the 
multiple imputation (MI). With this approach, for patients who undergo surgery for NP or 
receive SCS for any reason, data collected postsurgery or post-SCS will be set to missing, 
and the worst postbaseline value on or before the time of surgery or SCS will be used to 
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impute missing Week 24 value (for patients whose postbaseline values are all missing, the 
baseline will be used to impute). For patients who discontinue the treatment without being 
rescued by surgery or receiving SCS, an MI approach will be used to impute missing 
Week 24 value, and this MI will use all patients who have not been rescued by surgery or 
receiving SCS at Week 24 and data collected after treatment discontinuation will be included 
in the analysis. Each of the imputed complete data will be analyzed by fitting an analysis of 
covariance model with the baseline covariate and factors for treatment, asthma status, prior 
surgery history, and regions. Statistical inference obtained from all imputed data will be 
combined using Rubin’s rule. Descriptive statistics including number of subjects mean, 
standard error, and least squares (LS) means will be provided. In addition, difference in LS 
means and the corresponding 95% confidence intervals (CI) will be provided along with the 
p-values. 
Analyses of key secondary efficacy endpoints 
Analysis of the change from baseline in TSS, UPSIT score, daily loss of smell assessment, 
LMK, and SNOT-22 scores at Week 24 for dupilumab 300 mg q2w versus placebo  
The change from baseline in TSS, SNOT-22, UPSIT, daily loss of smell and LMK at Week 
24 will be analyzed using the hybrid method of the WOCF and the MI in the same fashion as 
for the coprimary endpoints. 
Analysis of proportion of patients receiving SCS and/or planned to undergo surgery for NP 
during the 24-week treatment period for dupilumab 300 mg q2w versus placebo  
Proportion of patients with first SCS rescue or surgery (actual or planned) for NP during the 
24-week treatment period will be derived and analyzed using the Cox proportional hazards 
model and log rank test stratified by asthma status, prior surgery history, and regions, by 
considering the first SCS rescue use or surgery for NP (actual or planned) as the event. 
Descriptive statistics including number of patients with rescue or surgery and number of 
patients without rescue or surgery (censored) and the corresponding rates will be provided 
by treatment group. The estimates of the hazard ratio and corresponding 95% CI will be 
provided for the dupilumab group versus the placebo group. 
Analysis of other secondary endpoints: 
Changes from baseline in continuous endpoints at Week 24 will be analyzed using the 
hybrid method of the WOCF and the MI in the same fashion as for the coprimary endpoints.  
For each subgroup factor, interaction tests will be carried out to investigate consistency of 
the dupilumab effect across different subgroups identified by that factor. In addition to the 
analysis in the current study, statistical analysis for these subgroups with comorbid 
asthma/NERD and prior surgery will be further conducted using the pooled data of 
EFC14146 and EFC14280, and the details will be provided in the SAP for the Integrated 
Summary of Efficacy. 
For any responder type endpoints, the Cochran-Mantel-Haenszel test stratified by asthma 
status, prior surgery history, and region will be used. Comparisons of the proportions of 
responders between dupilumab 300 mg q2w and placebo will be derived. Patients who 
undergo surgery for NP or receive SCS for any reason will be considered as nonresponders 
for time points after using SCS or surgery. For patients who discontinue treatment without 
using SCS or surgery, data collected during the off-treatment period will be used to 
determine the responder/nonresponder status. Missing data will be considered as 
nonresponders.  
Proportion and time-to-event of patients with SCS rescue for any airway exacerbated 
disease will be analyzed using a similar approach as the key secondary endpoint of the 
proportion of patients with SCS rescue or surgery (actual or planned) for NP. 
For the change from baseline in continuous endpoints through the 24-week follow up period, 
descriptive statistics including number of subjects, mean, standard error of the mean (SEM), 
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and the corresponding 95% confidence interval (CI) will be provided by treatment. 
The safety variables, including AEs, laboratory parameters, vital signs, electrocardiogram 
(ECG) and physical examinations will be summarized using descriptive statistics. 
Missing data handling: 
For all continuous efficacy endpoints, in the primary approach for missing data handling, for 
patients who undergo surgery for NP or receive SCS for any reason, data collected 
postsurgery or post-SCS will be set to missing, and the worst postbaseline value on or 
before the time of surgery or SCS will be used to impute missing value at the certain 
analyzed visit (for patients whose postbaseline values are all missing, the baseline will be 
used to impute), and for patients who discontinue the treatment without being rescued by 
surgery or receiving SCS on or before the analyzed visit, a MI approach will be used to 
impute missing value at the certain analyzed visit, and this MI will use all patients who have 
not been rescued by surgery or receiving SCS at that analyzed visit and data collected after 
treatment discontinuation will be included in the analysis. 
For responder type endpoints, patients who undergo surgery for NP or receive SCS for any 
reason will be considered as nonresponders for time points after using SCS or surgery; for 
patients who discontinue treatment without using SCS or surgery, data collected during the 
offtreatment period will be used to determine the responder/nonresponder status, and 
missing data will be considered as nonresponders. 
In addition, the reason and pattern of missing data will be carefully examined and tipping 
point analyses and other sensitivity analyses will also be performed. 
Multiplicity considerations:  
The multiplicity procedure is proposed to control the overall type-I error rate for testing the 
coprimary and selected secondary endpoints. The overall alpha is 0.05. The comparisons 
with placebo will be tested based on the hierarchical order below at 2-sided α = 0.05 for 
300 mg q2w dose regimen versus placebo: 
1. 
Coprimary efficacy endpoints: 
In countries other than Japan: 
• 
Change from baseline in NC and in NPS at Week 24. 
In Japan: 
• 
Change from baseline in NC, in NPS and in CT LMK at Week 24. 
 
2. 
Secondary efficacy endpoints: 
• 
Change from baseline to TSS at Week 24. 
• 
Change from baseline in UPSIT at Week 24. 
• 
Change from baseline in loss of smell daily symptoms at Week 24. 
• 
Change from baseline in SNOT-22 at Week 24. 
• 
Change from baseline in CT LMK score at Week 24 (this will not be a secondary 
endpoint for Japan as it is already a coprimary endpoint). 
• 
Proportion of patients with SCS rescue or surgery for NP during the treatment 
period. 
In countries other than Japan, the study is considered positive when both coprimary 
endpoints, the change from baseline in NC and NPS at Week 24, achieve statistical 
significance. 
In Japan, the study is considered positive when all coprimary endpoints, the change from 
baseline in NC, in NPS, and in CT LMK at Week 24, achieve statistical significance. 
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First step analysis: 
A first step analysis may be performed when all patients complete the Week 24 visit, 
including early dropouts. Since this analysis is the final analysis of the coprimary endpoints 
and other 24-week endpoints, and no decision on the conduct of the study will be made 
based on the first step analysis (in particular, no decision to prematurely stop the study), 
there will be no alpha adjustment due to the EOT analysis. Specific steps will be taken to 
maintain the blind of the study to all individuals involved in the conduct of the study and/or 
analysis. 
Individuals involved in the first step analysis of the study will not be involved in the conduct 
of the study afterwards; individual patient identification will not be released to anyone who is 
directly involved in the conduct of the study. 
DURATION OF STUDY 
PERIOD (per patient)  
The total duration of the study (per patient) is expected to be approximately 52 weeks: 
• 
Run-in period (4 weeks +/- 3 days). 
• 
Randomized treatment period (24 weeks +/- 3 days). 
• 
Post treatment period (24 weeks +/- 3 days). 
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1 
FLOW CHARTS 
1.1 
GRAPHICAL STUDY DESIGN 
 
BID twice daily; D day; EOS end of study; EOT end of treatment; IMP investigational medicinal product; q2w every 2 weeks; MFNS mometasone furoate nasal spray; R* randomization; QD once daily; SC 
subcutaneous; V visit; W week 
IMP: Regardless of the treatment group, all randomized patients will receive q2w SC administrations of dupilumab or placebo. Every other week IMP administrations must be separated by at least 11 days. At V2 the 
Investigator or delegate will perform the injection. After V2, every other week administration of IMP will be performed at the investigational site up to at least Week 8 (Visit 6). Patients will be monitored at the study site 
for at least 30 minutes or the minimum time required by your local regulator after injections. From Week 10, every other week home administration of IMP (patient, caregiver, or health care professional) is possible if 
the patient (or the caregiver) has been trained. If the patient (or caregiver) is unable or unwilling to administer IMP, arrangements must be made for qualified site personnel and/or healthcare professionals to 
administer IMP for the doses not scheduled to be given at the study site. 
Non-investigational medicinal product: MFNS will be self-administered by the patient BID or QD (if they cannot tolerate BID). At each visit the Investigator must ensure that the patient has the necessary doses up 
to the next visit, knowing that one MFNS device (1 bottle) contains sufficient doses for: either 2 weeks of BID treatment/regimen or 4 weeks of QD treatment/regimen. 
Week 48 
+/- 3 days 
EOS 
V2 (D1/W0) 
Randomization 
Run-in 
Week 24 
+/- 3 days 
EOT 
R* 
N=120                  Arm B: Placebo q2w up to Week 24
N=120              Arm A: Dupilumab 300 mg q2w up to Week 24 
Background therapy: mometasone furoate nasal spray (MFNS) 
V1 
Week-4 
+/- 3 days 
Post-treatment period
24 weeks 
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1.2 
STUDY FLOW CHART 
 
 
Run-ina 
Randomized treatment period 
EOTc 
FU1 
FU2 
(EOS) 
VISIT 
1 
2 
3 
4 
5 
6 
 
7 
 
8 
9 
10 
Week 
W-4 
W0 
2 
4 
6 
8 
10,12,14b 
16 
18, 20, 22b 
24 
36 
48 
Day +/- 3 days 
D-28 
D1 
D15 
D29 
D43 
D57 
 
D113 
 
D169 
D253 
D337 
Informed Consents 
X 
 
 
 
 
 
 
 
 
 
 
 
Inclusion and Exclusion Criteriad 
X 
X 
 
 
 
 
 
 
 
 
 
 
Patient Demography 
X 
 
 
 
 
 
 
 
 
 
 
 
Medical/Surgical/Medication Historyd 
X 
 
 
 
 
 
 
 
 
 
 
 
Physical Examination 
X 
 
 
 
 
 
 
 
 
X 
X 
X 
Spirometrye 
X 
 
 
 
 
X 
 
X 
 
X 
 
X 
Chest X-rayf 
X 
 
 
 
 
 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
 
 
 
Treatment: 
 
 
 
 
 
 
 
 
 
 
 
 
IMP: Dupilumab/placebo injectiong 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
Call IVRS (IWRS)  
at scheduled and unscheduled visits as needed 
X 
|---------------------------------------------------------------------X------------------------------------------------------------| 
X 
X 
X 
Review IMP and/or NIMP compliance 
 
|---------------------------------------------------------------------X------------------------------------------------------------| 
X 
 
 
Dispense or download electronic diary for 
symptomsh 
|--------------------------------------------------------------------------------------------------X----------------------------------------------------------------------------------------------------------| 
NIMP 
|--------------------------------------------------------------------------------------------------X----------------------------------------------------------------------------------------------------------| 
Record concomitant medication 
|--------------------------------------------------------------------------------------------------X----------------------------------------------------------------------------------------------------------| 
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Run-ina 
Randomized treatment period 
EOTc 
FU1 
FU2 
(EOS) 
VISIT 
1 
2 
3 
4 
5 
6 
 
7 
 
8 
9 
10 
Week 
W-4 
W0 
2 
4 
6 
8 
10,12,14b 
16 
18, 20, 22b 
24 
36 
48 
Day +/- 3 days 
D-28 
D1 
D15 
D29 
D43 
D57 
 
D113 
 
D169 
D253 
D337 
Record planned surgery for NP, SCS use, and 
other rescue medication usei 
|--------------------------------------------------------------------------------------------------X----------------------------------------------------------------------------------------------------------| 
Efficacy 
 
Nasal endoscopyj 
X 
X 
 
 
 
X 
 
X 
 
X 
X 
X 
CT scank 
Xk 
 
 
 
 
 
 
 
 
X 
 
X 
Smell test (UPSIT) 
 
X 
X 
 
 
X 
 
X 
 
X 
 
X 
NPIF 
X 
|----------------------------------------------------------------Daily AM --------------------------------------------------------------| 
X 
X 
Patient reported outcomes/HRQoLl 
 
SNOT-22 
 
X 
 
 
 
X 
 
X 
 
X 
X 
X 
Visual analog scale (VAS) for rhinosinusitis 
 
X 
X 
X 
 
X 
 
X 
 
X 
X 
X 
Severity score (0-3) for reduced sense of taste 
 
X 
X 
X 
 
X 
 
X 
 
 X 
 
 
EQ-5D 
 
X 
 
 
 
 
 
 
 
X 
 
 
SF-36 
 
X 
 
 
 
 
 
 
 
 
 
 
ACQ-6 in patients with asthma 
 
X 
 
 
 
X 
 
X 
 
X 
 
X 
Healthcare resource utilization 
 
X 
 
 
 
X 
 
X 
 
X 
 
 
Safety 
AE/SAE recording (if any) 
|--------------------------------------------------------------------------------------------------X----------------------------------------------------------------------------------------------------------| 
Vital Signsm 
X 
X 
 
 
 
X 
 
X 
 
X 
X 
X 
ECG (local reading) 
 
X 
 
 
 
 
 
 
 
X 
 
 
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Run-ina 
Randomized treatment period 
EOTc 
FU1 
FU2 
(EOS) 
VISIT 
1 
2 
3 
4 
5 
6 
 
7 
 
8 
9 
10 
Week 
W-4 
W0 
2 
4 
6 
8 
10,12,14b 
16 
18, 20, 22b 
24 
36 
48 
Day +/- 3 days 
D-28 
D1 
D15 
D29 
D43 
D57 
 
D113 
 
D169 
D253 
D337 
Laboratory Testing 
 
 
 
 
 
 
 
 
 
 
 
 
Clinical laboratory testingn 
X 
X 
 
 
 
 
 
X 
 
X 
 
 
Hepatitis B viral loado 
 
X 
 
 
 
 
 
 
 
X 
 
 
Pregnancy test (for WOCBP) p 
X 
X 
 
X 
 
X 
X (W12) 
X 
X (W20) 
X 
X 
X 
Sampling for serum dupilumab concentrationq 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
Antidrug antibody samplingq 
 
X 
 
 
 
X 
 
X 
 
X 
X 
X 
Blood biomarkers (TARC, eotaxin-3, periostin) 
 
X 
 
 
 
 
 
 
 
 
 
 
Serum Total IgE, allergen-specific IgE panel 
sampling including Staph enterotoxins IgE  
 
X 
 
 
 
 
 
 
 
X 
 
 
Spot urine for biomarker sampling (LTE4, PGDM, 
creatinine)  
 
X 
 
 
 
 
 
 
 
X 
 
 
Nasal swabs for microbiome 
 
X 
 
 
 
 
 
 
 
X 
 
 
  
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
a The run-in period is 28 days in duration to run in any patient on MFNS, and to collect baseline data. Patients receiving rescue medication with systemic corticosteroid (SCS) or and surgery during this period will not be 
randomized. V2 will take place 28 days +/-3 day window after V1. Windows for subsequent visits are also +/- 3 days. Assessments/procedures at a site visit are performed in the following order if applicable: 
patient-reported outcomes and other questionnaires; procedures; safety and laboratory assessments; IMP administration, 
b Optional interim visit may be scheduled at site for IMP/NIMP supply or IMP administration. 
c Patients who discontinue treatment early will be assessed as soon as possible using the procedures normally planned for the EOT Visit and will be instructed to return to the study site as described in Section 
10.3.1. 
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d Past medical history including allergic comorbidities (asthma, aspirin sensitivity, allergic rhinitis etc.). Surgeries for NP will be assessed including number, type and dates of sino-nasal surgeries, polypectomies in 
the past. Systemic corticosteroids (SCS) use (number of courses, doses, way of administration and duration) in the past 2 years before V1 and/or contraindication/intolerance to SCS, as well as long term 
antibiotics use (>2 weeks) in the previous year will be entered in the e-CRF. NERD: NSAID (nonsteroidal anti-inflammatory drug) Exacerbated Respiratory Disease will be assessed through a specific 
questionnaire (Appendix F). 
e Spirometry (FEV1, FVC and FEF25-75): should be performed anytime during the run-in period (between V1 and V2) before a first administration of IMP for all patients, locally after withholding the last dose of 
salbutamol/albuterol or levosalbutamol/levalbuterol for at least 6 hours. FEV1, FVC and FEF25-75 will be determined at the designated treatment visits. All patients should have the result of FEV1 (% of predicted 
normal) recorded in e-CRF: anytime during the run-in period (before V2). Patients with FEV1 50% or less (of predicted normal) will not be randomized. For the other scheduled visits during the randomized 
treatment period, spirometry will be performed only in patients with asthma at V6, V7, V8 and V10 and the result of FEV1, FVC and FEF25-75 will be recorded in e-CRF at the study scheduled visits. 
f 
Chest X-ray if no chest imaging (X-ray, CT, MRI) is available within the previous year of V1. In countries for which a specific approval procedure for the x-ray or CT scan is required by a different committee than 
the local EC/IRB, a chest MRI between V1 and V2 can be performed. 
g Refer to Section 1 and Section 6 Study Design for details on treatment arms. IMP will be administered after completion of all scheduled clinical assessments and sample collections at the visit or at home. 
h Electronic diary/NPIF meter is used for daily recording of MFNS use, AM NPIF (daily up to Week 24 and afterwards at Week 36 and Week 48 during the follow up) and daily symptoms severity from V1 to end of 
study: 1) nasal congestion/obstruction, 2) anterior rhinorrhea (runny nose), 3) posterior rhinorrhea (post nasal drip), and 4) loss of sense of smell, scored using a 0-3 categorical scale where 0 = no symptoms, 1 = 
mild symptoms, 2 = moderate symptoms and 3 = severe symptoms). This device is dispensed at V1 and information is downloaded from this device on the other indicated days. For nasal congestion, a severity ≥2 
on V1 and a weekly average severity >1 at the time of randomization (V2) is required and will be made available to the site to determine patient eligibility. If there are 4 or more measurements collected within 
7  days prior to randomization, the baseline will be the average of these measurements; if less than 4 measurements are collected, the baseline will be the average of the most recent 4 prior to randomization.  
i 
At baseline (V1 and V2) eligibility to surgery based on Investigator opinion will be assessed. During the study treatment and follow-up, if rescue medication with systemic corticosteroids is required, oral prednisone 
or prednisolone will be dispensed by the site to the patient through a scheduled or unscheduled in-clinic visit. Use of oral steroids for rescue treatment of worsening nasal polyps or for another reason will be 
captured by the Investigator (or designee) on the appropriate page(s) of the e-CRF and the date and dosing information (daily dose, duration, INN) will be informed. Details on actual or planned date for surgery for 
NP, type and outcome (wherever possible) will be recorded in a specific e-CRF page. If surgery is performed during the study treatment period or follow-up, an AE or SAE page will be completed. They will be 
discontinued from study treatment and assessed as soon as possible using the procedures normally planned for the EOT visit and will be instructed to return to the study site as described in Section 10.1.11. If 
surgery is scheduled after the planned end of study, EOS visit will not be delayed. A follow up contact(s) should be performed around the time of planned surgery to document the surgery date and outcome. 
Surgery data will be collected until e-CRF closure of the trial. 
j 
Nasal endoscopy: endoscopy (including use of decongestants before the procedure) will be performed after all other efficacy assessments have been completed for each visit. Standard video sequences will be 
downloaded by the Investigator to the central reader’s secured internet site. For eligibility, central reading of V1 will be used. At V2, Investigator will review V1 results from central reader to confirm entry criteria and 
reconfirm eligibility based on review of Inclusion/Exclusion Criteria and the V2 endoscopy local reading. To confirm eligibility at V2, only the V1 central reading will be made available to the site. In addition at V2 the 
Investigator will perform the NE to confirm eligibility score and enter the result in the e-CRF. Thus the patient is considered eligible based on a V1 central reading followed by a V2 local reading NPS score of 5 or 
more and at least 2 each side. The final results of central reading from V2 onward will be made available to the site after the study. 
k A CT scan should be performed anytime during the run-in period before the first administration of IMP and at Visit 8 (Week 24). Central reading will be used for comparison baseline (BL) to Week 24 for the primary 
analysis and at EOT. A Week 48 CT scan may be performed if approved by local ethics committees. Whenever possible, a cone beam CT scan should be utilized. In countries where local EC do not approve a CT 
scan or for which a specific approval procedure for the CT scan is required by a different committee than the local EC/IRB, patients may be enrolled using a CT available in the previous year or perform an MRI of 
the sinuses between V1 and V2. These countries will be exempted from all the planned study CT scans until approval from these committees is received. The MRI will be used only for confirmation of exclusion 
criteria. 
l 
During the study the PROs should be completed by the patient in the e-diary, in the following order: daily symptoms of NC, loss of smell and rhinorrhea; SNOT-22; VAS rhinosinusitis; loss of taste severity, EQ-5D; 
ACQ-6 (in patients with asthma). 
m Vital signs, including blood pressure (mmHg), heart rate (beats per minute), respiratory rate (breaths per minute), body temperature (degrees Celsius) and body weight (kg) will be measured at the screening and 
randomization visits (V1 and V2) and subsequent visit pre-specified in the flow-chart. Height (cm) will be measured at screening (V1) only. Vital signs will be measured prior to receiving investigational product at 
the clinic visits in the sitting position using preferably the same arm at each visit. 
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n Hematology: hemoglobin, hematocrit, platelet count, total white blood cell (WBC) count with five-part differential count, and total red blood cell count. Serum chemistry: creatinine, blood urea nitrogen, glucose, uric 
acid, total cholesterol, total protein, albumin, total bilirubin (in case of values above the normal range, differentiation in conjugated and nonconjugated bilirubin), alanine aminotransferase, aspartate 
aminotransferase, alkaline phosphatase, lactate dehydrogenase, electrolytes (sodium, potassium, chloride), bicarbonate, and creatine phosphokinase. Clinical laboratory testing at V1 includes hepatitis screen 
covering hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb), hepatitis B core antibody (HBcAb) including HBcAb IgM and total, hepatitis C virus antibodies (HCVAb), Human 
Immunodeficiency Virus (HIV) screen (anti-HIV-1 and HIV-2 antibodies) and antinuclear antibody (ANA). In case of results showing HBsAg (negative), and HBcAb total or HBcAb IgM (positive), an HBV DNA 
testing must be performed prior to randomization to rule out a false positivity if the Investigator believes the patient is a false positive, or to clarify the serological status if the Investigator finds it unclear to interpret 
in absence of known HBV infection. In case of results showing HCV Ab (positive), an HCV RNA testing may be performed to rule out a false positivity, if the Investigator believes the patient is a false positive. Note: 
Anti-ds DNA antibody will be tested if ANA is positive (≥1:160 titer). Tuberculosis local testing at baseline would be performed on a country by country basis according to local guidelines if required by regulatory 
authorities or ethic committees. 
o This is only applicable for patients in countries/regions where there is local regulatory requirement who are HBsAg negative and HBsAb positive at the run-in period visit.  
p Serum pregnancy test at V1 and urine pregnancy tests every 4 weeks thereafter. A negative result must be obtained between V1 and V2 prior to randomization visits. Urinary test could be performed at home as 
part of visit with or without the assistance of a home care provider. In case of positive urinary test the study treatment will be withheld and a serum pregnancy test to confirm the pregnancy should be performed as 
soon as possible. Pregnancy will lead to definitive treatment discontinuation in all cases. 
q Serum dupilumab concentration, immune response assessment (ADA) samples will be collected and archived prior to administration of IMP and during the randomized treatment period. Blood samples for PK and 
ADA assessment will be collected at any time in case an SAE occurs. In response to AEs of special interest like anaphylaxis or hypersensitivity additional ADA samples closer to the event may be analyzed, 
based on the judgement of the medical Investigator and/or medical monitor. Patients who are ADA positive at their last study visit (early termination or EOS) will be considered for follow-up based on the overall 
clinical presentation at that time. Patients who are considered for follow-up may be asked to return to the clinic to have additional samples collected for analysis.  
 
 
 
Abbreviations: ACQ-6 asthma control questionnaire-6; ADA antidrug antibodies; AE adverse event; AM ante meridiem; CT computed tomography; D day; ECG electrocardiogram; e-CRF electronic case report form; 
EOS end of study; EOT end of treatment; EQ-5D European quality of life -5D questionnaire; FEF 25-75 forced expiratory flow to 25% to 75% of forced vital capacity; FEV1 forced expiratory volume in one second; FU 
follow-up; FVC forced vital capacity; HRQoL health-related quality of life; IgE immunoglobulin E; IMP investigational medicinal product; IVRS interactive voice response system; IWRS interactive web response system; 
LTE4 leukotriene E4; MFNS mometasone furoate nasal spray; MRI magnetic resonance imaging; NC nasal congestion; NERD NSAID exacerbated respiratory disease; NIMP noninvestigational medicinal product; NP 
nasal polyposis; NPIF nasal peak inspiratory flow; PGDM prostaglandin D2 metabolite; PK pharmacokinetic; RDN randomization; SAE serious adverse event; SCS systemic corticosteroids; SF-36 short form 36; 
SNOT-22 sino-nasal outcome test; UPSIT University of Pennsylvania smell identification test; VAS visual analog scale; W week; WBC white blood cell; WOCBP women of child bearing potential.  
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2 
TABLE OF CONTENTS 
 
AMENDED CLINICAL TRIAL PROTOCOL 01 ..............................................................................................1 
1 
FLOW CHARTS.............................................................................................................................13 
1.1 
GRAPHICAL STUDY DESIGN ......................................................................................................13 
1.2 
STUDY FLOW CHART ..................................................................................................................14 
2 
TABLE OF CONTENTS ................................................................................................................19 
2.1 
LIST OF TABLES...........................................................................................................................26 
3 
LIST OF ABBREVIATIONS ..........................................................................................................27 
4 
INTRODUCTION AND RATIONALE.............................................................................................30 
4.1 
INTRODUCTION............................................................................................................................30 
4.2 
STUDY RATIONALE......................................................................................................................32 
4.3 
POPULATION................................................................................................................................32 
4.4 
STUDY DESIGN ............................................................................................................................33 
4.4.1 
Endpoints rationale and description...............................................................................................33 
4.4.2 
Dupilumab dose and regimen rationale .........................................................................................35 
4.5 
OVERALL BENEFITS AND RISKS ASSESSMENT......................................................................36 
5 
STUDY OBJECTIVES ...................................................................................................................38 
5.1 
PRIMARY.......................................................................................................................................38 
5.2 
SECONDARY ................................................................................................................................38 
5.3 
EXPLORATORY ............................................................................................................................38 
6 
STUDY DESIGN ............................................................................................................................39 
6.1 
DESCRIPTION OF THE STUDY...................................................................................................39 
6.2 
DURATION OF STUDY PARTICIPATION ....................................................................................40 
6.2.1 
Duration of study participation for each patient .............................................................................40 
6.2.2 
Determination of end of clinical trial (all patients) ..........................................................................40 
6.3 
FIRST STEP ANALYSIS................................................................................................................40 
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6.4 
STUDY COMMITTEES..................................................................................................................41 
6.4.1 
Data monitoring committee ............................................................................................................41 
6.4.2 
Clinical advisory committee ...........................................................................................................41 
7 
SELECTION OF PATIENTS..........................................................................................................41 
7.1 
INCLUSION CRITERIA..................................................................................................................41 
7.2 
EXCLUSION CRITERIA ................................................................................................................42 
7.2.1 
Exclusion criteria related to study methodology ............................................................................42 
7.2.2 
Exclusion criteria related to the active comparator and/or mandatory background therapies.......43 
7.2.3 
Exclusion criteria related to the current knowledge of sanofi compound.......................................43 
7.2.4 
Additional exclusion criteria during or at the end of the run-in period............................................45 
8 
STUDY TREATMENTS .................................................................................................................46 
8.1 
INVESTIGATIONAL MEDICINAL PRODUCT(S) ..........................................................................46 
8.1.1 
Dupilumab......................................................................................................................................46 
8.1.2 
Placebo for dupilumab ...................................................................................................................46 
8.1.3 
Preparation of investigational medicinal product ...........................................................................46 
8.1.4 
Dosing schedule.............................................................................................................................46 
8.2 
NONINVESTIGATIONAL MEDICINAL PRODUCT(S) ..................................................................47 
8.2.1 
Intranasal corticosteroid background therapy................................................................................47 
8.2.1.1 
Run-In Period.................................................................................................................................47 
8.2.1.2 
Randomized treatment period........................................................................................................48 
8.2.1.3 
Post treatment period.....................................................................................................................48 
8.2.2 
Rescue treatment...........................................................................................................................48 
8.3 
BLINDING PROCEDURES............................................................................................................49 
8.3.1 
Methods of blinding........................................................................................................................49 
8.3.2 
Randomization code breaking during the study.............................................................................49 
8.4 
METHOD OF ASSIGNING PATIENTS TO TREATMENT GROUP ..............................................50 
8.5 
PACKAGING AND LABELING ......................................................................................................50 
8.6 
STORAGE CONDITIONS AND SHELF LIFE................................................................................51 
8.7 
RESPONSIBILITIES ......................................................................................................................51 
8.7.1 
Treatment accountability and compliance......................................................................................52 
8.7.2 
Return and/or destruction of treatments ........................................................................................52 
8.8 
CONCOMITANT MEDICATION.....................................................................................................52 
8.8.1 
Prohibited concomitant medication................................................................................................53 
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8.8.2 
Permitted concomitant medication.................................................................................................53 
9 
ASSESSMENT OF INVESTIGATIONAL MEDICINAL PRODUCT ..............................................55 
9.1 
COPRIMARY ENDPOINTS ...........................................................................................................55 
9.2 
SECONDARY ENDPOINTS ..........................................................................................................57 
9.2.1 
Key secondary efficacy endpoints .................................................................................................57 
9.2.1.1 
Disease specific daily symptom assessment and total symptom score (TSS)..............................57 
9.2.1.2 
Smell test: University of Pennsylvania Smell Identification Test (UPSIT) .....................................57 
9.2.1.3 
Decreased/loss of sense of smell ..................................................................................................58 
9.2.1.4 
Lund-Mackay score........................................................................................................................58 
9.2.1.5 
Proportion of patients during the treatment period who receive SCS rescue or are planned 
to undergo surgery for NP..............................................................................................................58 
9.2.1.6 
22-Item Sino-nasal Outcome Test (SNOT-22) ..............................................................................59 
9.2.2 
Other secondary endpoints............................................................................................................59 
9.2.2.1 
SCS dose and number of courses.................................................................................................59 
9.2.2.2 
Visual analog scales (VAS)............................................................................................................60 
9.2.2.3 
Nasal peak inspiratory flow............................................................................................................60 
9.2.2.4 
Asthma Control Questionnaire, 6-question version (ACQ-6) in those patients comorbid with 
asthma ...........................................................................................................................................61 
9.2.2.5 
Health related quality of life (HRQoL) ............................................................................................61 
9.3 
EXPLORATORY ENDPOINTS......................................................................................................62 
9.3.1 
Spirometry......................................................................................................................................62 
9.4 
SAFETY ENDPOINTS ...................................................................................................................63 
9.4.1 
Adverse events ..............................................................................................................................63 
9.4.2 
Laboratory safety variables............................................................................................................63 
9.4.3 
Hepatitis screening.........................................................................................................................63 
9.4.4 
Pregnancy test ...............................................................................................................................64 
9.4.5 
Vital signs.......................................................................................................................................64 
9.4.6 
Physical examination .....................................................................................................................64 
9.4.7 
Electrocardiogram variables ..........................................................................................................64 
9.5 
OTHER ENDPOINTS.....................................................................................................................64 
9.5.1 
Functional dupilumab concentration and antidrug antibodies in serum.........................................64 
9.5.1.1 
Sampling time ................................................................................................................................64 
9.5.1.2 
Handling procedure........................................................................................................................65 
9.5.1.3 
Bioanalytical methods ....................................................................................................................65 
9.5.1.4 
Functional dupilumab concentration and antidrug antibody measurement and samples..............66 
9.5.2 
Pharmacodynamics........................................................................................................................66 
9.5.2.1 
Serum biomarkers..........................................................................................................................66 
9.5.2.2 
Plasma biomarkers ........................................................................................................................67 
9.5.2.3 
Urine biomarkers............................................................................................................................67 
9.5.2.4 
Microbiome in nasal mucus ...........................................................................................................67 
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9.5.3 
........................................................................................................................67 
9.5.3.1 
......................................................................67 
9.6 
FUTURE USE OF SAMPLES ........................................................................................................68 
9.7 
APPROPRIATENESS OF MEASUREMENTS ..............................................................................68 
10 
STUDY PROCEDURES ................................................................................................................69 
10.1 
VISIT SCHEDULE..........................................................................................................................69 
10.1.1 
Visit 1 (Week -4/Day -28 +/- 3 days): Run-in period ......................................................................71 
10.1.2 
Visit 2 (Week 0): Randomization....................................................................................................72 
10.1.3 
Visit 3 (Week 2 +/- 3 days).............................................................................................................74 
10.1.4 
Visit 4 (Week 4 +/- 3 days).............................................................................................................75 
10.1.5 
Visit 5 (Week 6 +/- 3 days).............................................................................................................76 
10.1.6 
Visit 6 (Week 8 +/- 3 days).............................................................................................................77 
10.1.7 
Optional visits (Weeks 10, 12, 14) .................................................................................................78 
10.1.8 
Visit 7 (Week 16 +/- 3 days)...........................................................................................................79 
10.1.9 
Optional visits (Weeks 18, 20, 22) .................................................................................................80 
10.1.10 Visit 8 (Week 24 +/- 3 days): End of treatment..............................................................................81 
10.1.11 Visit 9 (Week 36)............................................................................................................................82 
10.1.12 Visit 10 (Week 48): End of study....................................................................................................83 
10.2 
DEFINITION OF SOURCE DATA..................................................................................................84 
10.3 
HANDLING OF PATIENT TEMPORARY OR PERMANENT TREATMENT 
DISCONTINUATION AND OF PATIENT STUDY DISCONTINUATION.......................................84 
10.3.1 
Permanent treatment discontinuation with investigational medicinal product(s) ...........................84 
10.3.2 
Temporary treatment discontinuation with investigational medicinal product(s) ...........................85 
10.3.3 
List of criteria for permanent treatment discontinuation.................................................................86 
10.3.4 
Handling of patients after permanent treatment discontinuation ...................................................87 
10.3.5 
Procedure and consequence for patient withdrawal from study....................................................87 
10.4 
OBLIGATION OF THE INVESTIGATOR REGARDING SAFETY REPORTING ..........................88 
10.4.1 
Definitions of adverse events.........................................................................................................88 
10.4.1.1 Adverse event ................................................................................................................................88 
10.4.1.2 Serious adverse event ...................................................................................................................88 
10.4.1.3 Adverse event of special interest...................................................................................................89 
10.4.2 
Serious adverse events waived from expedited regulatory reporting to regulatory 
authorities.......................................................................................................................................90 
10.4.3 
General guidelines for reporting adverse events ...........................................................................90 
10.4.4 
Instructions for reporting serious adverse events ..........................................................................91 
10.4.5 
Guidelines for reporting adverse events of special interest...........................................................91 
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10.4.6 
Guidelines for management of specific laboratory abnormalities ..................................................91 
10.5 
OBLIGATIONS OF THE SPONSOR .............................................................................................92 
10.6 
SAFETY INSTRUCTIONS .............................................................................................................93 
10.6.1 
Hypersensitivity..............................................................................................................................93 
10.6.2 
Severe injection site reactions .......................................................................................................93 
10.6.3 
Infections, including opportunistic and parasitic infections ............................................................93 
10.6.4 
Elevated liver function tests ...........................................................................................................95 
10.7 
ADVERSE EVENTS MONITORING..............................................................................................95 
11 
STATISTICAL CONSIDERATIONS..............................................................................................95 
11.1 
DETERMINATION OF SAMPLE SIZE...........................................................................................95 
11.2 
DISPOSITION OF PATIENTS .......................................................................................................96 
11.3 
ANALYSIS POPULATIONS...........................................................................................................97 
11.3.1 
Efficacy populations .......................................................................................................................97 
11.3.2 
Safety population ...........................................................................................................................97 
11.3.3 
Systemic drug concentration population........................................................................................97 
11.3.4 
Anti-drug antibody population ........................................................................................................97 
11.4 
STATISTICAL METHODS .............................................................................................................97 
11.4.1 
Extent of study treatment exposure and compliance.....................................................................97 
11.4.1.1 Extent of investigational medicinal product exposure....................................................................98 
11.4.2 
Analyses of efficacy endpoints.......................................................................................................98 
11.4.2.1 Analysis of coprimary efficacy endpoint(s).....................................................................................98 
11.4.2.2 Analyses of key secondary efficacy endpoints ..............................................................................99 
11.4.2.3 Multiplicity considerations ............................................................................................................100 
11.4.2.4 Analyses of other secondary efficacy endpoints and subgroup analysis ....................................100 
11.4.2.5 Analyses of exploratory efficacy endpoints..................................................................................102 
11.4.2.6 Missing data handling ..................................................................................................................103 
11.4.3 
Analyses of safety data................................................................................................................103 
11.4.3.1 Adverse events ............................................................................................................................103 
11.4.4 
Analyses of pharmacokinetic and pharmacodynamic variables and antidrug metabolites .........105 
11.4.4.1 Functional dupilumab concentration analysis ..............................................................................105 
11.4.4.2 Anti-drug antibodies analysis .......................................................................................................105 
11.4.4.3 Pharmacodynamics......................................................................................................................106 
11.4.5 
Analyses of Patient Reported Outcomes (Health-related Quality of Life/health economics 
variables)......................................................................................................................................106 
11.5 
FIRST STEP ANALYSIS..............................................................................................................106 
12 
ETHICAL AND REGULATORY CONSIDERATIONS.................................................................107 
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12.1 
ETHICAL AND REGULATORY STANDARDS ............................................................................107 
12.2 
INFORMED CONSENT ...............................................................................................................107 
12.3 
HEALTH AUTHORITIES AND INSTITUTIONAL REVIEW BOARD/INDEPENDENT 
ETHICS COMMITTEE (IRB/IEC).................................................................................................108 
13 
STUDY MONITORING.................................................................................................................109 
13.1 
RESPONSIBILITIES OF THE INVESTIGATOR(S).....................................................................109 
13.2 
RESPONSIBILITIES OF THE SPONSOR...................................................................................109 
13.3 
USE AND COMPLETION OF CASE REPORT FORMS (CRFS) AND ADDITIONAL 
REQUEST....................................................................................................................................110 
13.4 
USE OF COMPUTERIZED SYSTEMS........................................................................................110 
14 
ADDITIONAL REQUIREMENTS.................................................................................................111 
14.1 
CURRICULUM VITAE..................................................................................................................111 
14.2 
RECORD RETENTION IN STUDY SITES ..................................................................................111 
14.3 
CONFIDENTIALITY .....................................................................................................................111 
14.4 
PROPERTY RIGHTS...................................................................................................................112 
14.5 
DATA PROTECTION...................................................................................................................112 
14.6 
INSURANCE COMPENSATION..................................................................................................113 
14.7 
SPONSOR AUDITS AND INSPECTIONS BY REGULATORY AGENCIES ...............................113 
14.8 
PREMATURE DISCONTINUATION OF THE STUDY OR PREMATURE CLOSE-OUT OF 
A SITE..........................................................................................................................................113 
14.8.1 
By the Sponsor.............................................................................................................................113 
14.8.2 
By the Investigator .......................................................................................................................114 
14.9 
CLINICAL TRIAL RESULTS ........................................................................................................114 
14.10 
PUBLICATIONS AND COMMUNICATIONS ...............................................................................114 
15 
CLINICAL TRIAL PROTOCOL AMENDMENTS ........................................................................116 
16 
BIBLIOGRAPHIC REFERENCES...............................................................................................117 
17 
APPENDICES..............................................................................................................................120 
APPENDIX A 
LIST OF PROHIBITED LIVE ATTENUATED VACCINES.................................................120 
APPENDIX B 
SNOT-22............................................................................................................................121 
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APPENDIX C EQ-5D-5L...........................................................................................................................122 
APPENDIX D VAS....................................................................................................................................125 
APPENDIX E 
ACQ-6................................................................................................................................126 
APPENDIX F QUESTIONS FOR PATIENTS WITH CRSWNP TO ASSIST DETERMINATION OF 
NERD DIAGNOSIS......................................................................................................................129 
APPENDIX G 
SF-36V2® HEALTH SURVEY © 1992, 1996, 2000 .........................................................130 
APPENDIX H GENERAL GUIDANCE FOR THE FOLLOW-UP OF LABORATORY 
ABNORMALITIES BY SANOFI....................................................................................................136 
APPENDIX I 
DEFINITION OF ANAPHYLAXIS........................................................................................142 
APPENDIX J 
LIST OF OPPORTUNISTIC INFECTIONS ........................................................................143 
 
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2.1 
LIST OF TABLES 
Table 1 – Symptom severity score................................................................................................................55 
Table 2 - Endoscopic nasal polyp score........................................................................................................56 
Table 3 - Summary of handling procedures for SAR231893 (dupilumab) ....................................................65 
Table 4 - Summary of bioanalytical methods for dupilumab and anti-dupilumab antibody...........................66 
Table 5 - Summary of adverse event reporting instructions..........................................................................92 
 
 
 
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3 
LIST OF ABBREVIATIONS 
 
ACQ-6: 
asthma control questionnaire-6 
AD: 
atopic dermatitis 
ADA: 
antidrug antibodies 
AE: 
adverse event 
AESI: 
adverse event of special interest 
ALT: 
alanine aminotransferase 
AM: 
ante meridiem 
ANA: 
antinuclear antibody 
BID: 
twice daily administration 
CI: 
confidence interval 
CPK: 
creatine phosphokinase 
CRF: 
case report form 
CRSwNP: 
chronic rhinosinusitis with nasal polyposis 
CSR: 
clinical study report 
CT: 
computed tomography 
CYP: 
cytochrome P450 
DMC: 
data monitoring committee 
DNA: 
deoxyribonucleic acid 
DRF: 
discrepancy resolution form 
ECG: 
electrocardiogram 
e-CRF: 
electronic case report form 
e-diary: 
electronic diary 
EOT: 
end of treatment 
EQ-5D: 
European quality of life 5D scale 
FDA: 
Food and Drug Administration 
FEF25-75: 
forced expiratory flow at 25% to 75% of forced vital capacity 
FEV1: 
forced expiratory volume in 1 second 
FVC: 
forced vital capacity 
GCP: 
good clinical practice 
GSO: 
Global Safety Officer 
HBcAb: 
hepatitis B core antibody  
HBsAb: 
hepatitis B surface antibody 
HBsAg: 
hepatitis B surface antigen  
HBV: 
hepatitis B virus 
HCAb: 
hepatitis C antibody 
HCVAb: 
hepatitis C virus antibody 
HIV: 
human immunodeficiency virus 
HLGT: 
high level group term 
HLT: 
high level term 
HRQoL: 
health-related quality of life 
ICH: 
International Conference for Harmonization 
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ID: 
Identification 
IDMC: 
independent data monitoring committee 
IEC: 
independent ethics committee 
IgE: 
immunoglobulin E 
IL: 
interleukin 
IL-4Rα: 
interleukin-4 receptor alpha 
IM: 
intramuscular 
IMP: 
investigational medicinal product 
INCS: 
intranasal corticosteroid 
INN: 
international nonproprietary name 
IRB: 
institutional review board 
ITT: 
intent-to-treat 
IV: 
intravenous 
IVRS: 
interactive voice response system 
IWRS: 
interactive web response system 
K-M: 
Kaplan-Meier 
LFT: 
liver function test 
LMK: 
Lund Mackay 
LS: 
least squares 
mAB: 
monoclonal antibody 
MCID: 
minimal clinically important difference 
MFNS: 
mometasone furoate nasal spray 
MI: 
multiple imputation 
MID: 
minimal important difference 
MRI: 
Magnetic Resonance Imaging 
NC: 
nasal congestion 
NERD: 
nonsteroidal anti-inflammatory drug exacerbated respiratory disease 
NIMP: 
noninvestigational medicinal product 
NP: 
nasal polyposis 
NPIF: 
nasal peak inspiratory flow 
NPS: 
nasal polyp score 
NSAID: 
nonsteroidal anti-inflammatory drug 
OC: 
osteomeatal complex 
OCS: 
oral corticosteroid 
PCSA: 
potentially clinically significant abnormality 
PD: 
pharmacodynamic 
PGDM: 
prostaglandin D2 metabolite 
PK: 
pharmacokinetic 
POC: 
proof of concept 
PRO: 
patient reported outcome 
PT: 
preferred term 
q2w: 
every 2 weeks 
q4w: 
every 4 weeks 
QD: 
once daily administration 
QoL: 
quality of life 
qw: 
once weekly 
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RNA: 
ribonucleic acid 
SAE: 
serious adverse event 
SAP: 
statistical analysis plan 
SC: 
subcutaneous 
SCS: 
systemic corticosteroids 
SD: 
standard deviation 
SEM: 
standard error of the mean 
SF-36: 
Short Form 36 
SNOT-22: 
sino-nasal outcome test 
SOC: 
system organ class 
SUSAR: 
suspected unexpected adverse drug reaction 
TARC: 
thymus and activation regulated chemokine 
TEAE: 
treatment emergent adverse event 
Th2: 
T-helper cell-2 
TSS: 
total symptom score 
ULN: 
upper limit of normal 
UPSIT: 
University of Pennsylvania smell identification test 
US: 
United States 
V: 
Visit 
VAS: 
visual analog scale 
WOCBP: 
women of childbearing potential 
WOCF: 
worst observation carried forward 
β-hCG: 
beta human chorionic gonadotrophin 
 
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4 
INTRODUCTION AND RATIONALE 
4.1 
INTRODUCTION 
Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a clinical condition characterized by the 
presence of multiple polyps in the upper nasal cavity, originating from the osteomeatal complex 
(OC) and the spheno-ethmoid recess and characterized by mucosal inflammation of the nasal 
cavity and paranasal sinuses with symptoms lasting more than 12 weeks. Clinically, CRSwNP is 
defined by long-term symptoms of nasal obstruction and congestion, reduction in or loss of sense 
of smell, and anterior and posterior rhinorrhea. These symptoms can impact greatly upon a 
patient’s quality of life (QoL). The presence or absence of polyps is confirmed by performing 
endoscopy. Coronal computed tomography (CT) scans can confirm the presence and extent of 
sinus and polyp involvement. With an estimated prevalence of 2% to 4% (in Europe and United 
States [US]), nasal polyps (NP) has a high burden of symptoms and a high relapse rate after 
treatment. Despite the high prevalence and significant morbidity associated with CRSwNP, 
treatment options range from local or systemic corticosteroids (SCS) to functional endoscopic 
sinus surgery. Patients with CRSwNP and comorbid asthma (~30% of patients with NP) have a 
characteristically poor therapeutic response and a high recurrence rate, and their disease tends to 
be more resistant (1, 2). 
The pathogenesis of nasal polyps is unknown. Nasal polyps are most commonly thought to be 
caused by allergy, although a significant number are associated with nonallergic adult asthma or 
no respiratory or allergic trigger that can be demonstrated. Risk factors include genetic 
susceptibility, anatomic abnormalities, infection, local immunologic imbalance and eicosanoid 
dysmetabolism (manifested as aspirin intolerance), some or most of which may play a role in its 
pathogenesis (3, 4, 5). 
Pathophysiologically, CRSwNP is an inflammatory and remodeling process affecting the mucosa 
of the nose and paranasal sinuses often associated with mucocilliary impairment, bacterial 
infection, allergic disease, and/or anatomical abnormalities (6, 7, 8). CRSwNP is a T-helper cell-2 
(Th2) driven inflammatory process in which eosinophils are the predominant inflammatory cell 
found in the sinuses and nasal polyps, and is frequently associated with asthma and aspirin 
sensitivity (9). In European and US populations, more than 80% of patients with CRSwNP have 
eosinophilic upper airway inflammation. The extent of sinomucosal involvement, the size of the 
polyps, and the severity of nasal disease correlate with the extent of eosinophilic inflammation 
(10). The chronic inflammation associated with eosinophilic polyps exhibits elevated levels of 
interleukin-5 (IL)-5 (promoter of eosinophil survival, differentiation and taxis), eosinophil 
cationic protein (eosinophil activation product), eotaxins (eosinophil chemoattractants), and 
immunoglobulin E (IgE) in the nasal polyps and local secretions (11).  
The therapeutic armamentarium of clinically proven medical interventions for CRSwNP is 
limited. First-line treatment is topical corticosteroids. Intranasal corticosteroid (INCS) sprays 
improve the symptoms of nasal obstruction (12), secretion, and sneezing to some extent. 
However, their effect in reducing polyp size and on improving the sense of smell (13), a cardinal 
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symptom of NP (14) is limited. Overall, due to the relatively modest effects on the symptoms of 
NP, in many instances, INCSs do not address the main QoL issues for patients. Short courses of 
oral steroids are also prescribed as adjunctive therapy to INCS or in cases of severe disease (15); 
however, the long-term use of systemic steroids for the treatment of nasal polyps is not 
recommended as the risk of prolonged systemic steroids use is not outweighed by the benefit (12). 
The current US practice guidelines indicate that the duration of clinical benefit of oral 
corticosteroids (OCS) is variable and may decrease with repeated courses of treatment (16). 
The only alternative for most patients that respond inadequately to medical treatment is surgery of 
the sinuses. However, even after surgical treatment, continued use of at least INCS is needed and 
disease recurrence requiring repeated surgeries is high. 
Recent therapeutic approaches have been focused on trying to control the Th2 response and 
clinical improvement in CRSwNP and associated symptoms have been observed in other studies 
of biological therapies, including the anti-IgE monoclonal antibody (mAB) omalizumab (17), or 
the anti-IL-5 mAB mepolizumab (18). 
Dupilumab is a systemic targeted immunomodulatory agent, inhibiting the Th2 pathway. It is a 
fully human mAB directed against the interleukin-4 receptor alpha (IL-4Rα) subunit, a component 
of IL-4 receptors Type I and Type II, which mediate signaling by IL-4 (both receptors) and by 
IL-13 (Type II receptor). Dupilumab binds to IL-4Rα, preventing IL-4 and IL-13 activation of 
their respective receptors. 
For further complete information regarding the preclinical and clinical evaluation of dupilumab to 
date, refer to the current version of the Investigator Brochure. 
Dupilumab is in clinical development for the treatment of CRSwNP worldwide. However in the 
US, based on Food and Drug Administration (FDA) feedback, this clinical development program 
will support the indication of nasal polyposis (NP).  
Preliminary clinical evidence, based on the proof of concept (POC) data and the mechanism of 
action, suggests that dupilumab provides an effective treatment and substantial improvement over 
INCS for patients suffering from CRSwNP. In a POC study (ACT12340), 60 patients with 
bilateral NP and chronic symptoms of sinusitis refractory to INCS were randomized to dupilumab 
300 mg once weekly (qw) SC administration for 16 weeks or placebo, with background intranasal 
mometasone furoate nasal spray (MFNS; NASONEX). In this study, dupilumab demonstrated a 
significant improvement in endoscopic, radiographic and clinical measures of NP and sinusitis, as 
well as improvements in lung function and disease control in patients with comorbid asthma (19).  
Dupilumab, therefore, offers promise of significant benefit above and beyond current standard of 
care in this patient population and may provide an alternative for those patients who respond 
inadequately to INCS and may obviate the need for repeated surgeries. 
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4.2 
STUDY RATIONALE 
This is a phase 3, randomized, placebo-controlled efficacy and safety study of dupilumab in 
patients with moderate-to-severe signs and symptoms of NP who are not controlled on standard of 
care.  
This study will primarily investigate the efficacy and safety of dupilumab 300 mg every 2 weeks 
(q2w) compared to placebo on top of the current standard of care background therapy of (daily 
use of intranasal MFNS [NASONEX]), utilizing multiple objective and subjective outcome 
measures in patients with NP. By allowing Investigators, at their discretion, to use SCS or surgery 
as a rescue therapy for worsening of NP, the study will also assess the effect of dupilumab on the 
need for surgery and SCS use over the randomized treatment period. 
4.3 
POPULATION 
The population of the EFC14146 study is composed of patients with bilateral NP (endoscopic 
bilateral nasal polyp score [NPS] has to be ≥5 out of a maximum score of 8) that present with 
chronic symptoms of nasal congestion (NC) (moderate/severe) and another symptom such as loss 
of smell and/or rhinorrhea despite background treatment with INCS and maximum therapy with 
standard of care including systemic corticosteroids (in the previous 2 years) and/or surgery in the 
past (see Section 7.1). 
The proposed patient selection criteria will reflect standard of care in this severe uncontrolled 
patient setting by allowing enrollment of patients that received INCS, SCS prior to the run-in 
period, and/or patients with previous surgeries. 
Approximately 26% to 50% of NP patients suffer from comorbid asthma and it is estimated that 
asthma is underdiagnosed in up to 25% of these patients (20, 21). NP has also been observed to be 
associated with chronic bronchitis and, in those with asthma, lower airway obstruction (6, 20). 
NP patients also more frequently present with nonsteroidal anti-inflammatory drug (NSAID) 
intolerance (22) and if they also suffer from asthma they are diagnosed with NSAID-exacerbated 
respiratory disease (NERD). 
These patients have the highest rates of exacerbation and hospital admissions and tend to have a 
poorer perception of control of disease, due to the persistence and severity of the associated 
sinonasal symptoms (23). Additionally, asthma symptoms tend to be more severe in these 
patients. 
Taking into account the high prevalence, the high disease burden and unmet need of NP patients 
that have comorbid asthma and aspirin or NERD, these patients will be allowed to enter the study 
(unless they present with any of the exclusion criteria described in Section 7.2). In addition, 
stratification at randomization for asthma and specific subgroup analysis will be performed to 
specifically assess efficacy in these subgroups. 
NP patients who have persistent signs and symptoms or disease relapse after short course treatment 
with SCS or after a surgery for NP, represent a subgroup of patients with higher burden and unmet 
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need, and therefore will be also analyzed. In addition, stratification at randomization for patients 
with prior surgery will be performed. 
4.4 
STUDY DESIGN 
This phase 3 multinational, multicenter, randomized, double-blind, placebo-controlled, parallel 
group study will evaluate the efficacy of dupilumab 300 mg administered subcutaneously (SC) 
q2w for 24 weeks followed by 24 weeks off-treatment period on a background of INCS. 
The proposed study, allowing daily use of INCS and SCS courses and/or surgery as needed or 
other treatments considered standard of care, will aim at evaluating a potential role for dupilumab 
in the existing treatment paradigm, for the treatment of nasal polyps.  
The clinical study consists of 3 periods: 
• 
Run-in period where the patients will receive MFNS for 4 weeks +/-3 days. 
• 
Randomized dupilumab/placebo treatment period (24 weeks) where approximately 
240 patients will be randomized, 120 p/arm, to one of the following treatments: 
- 
Arm A: dupilumab 300 mg SC q2w  
- 
Arm B: placebo matching dupilumab SC q2w. 
• 
Post treatment period - where patients will be followed for 24 weeks to evaluate potential 
disease recurrence (through objective and subjective efficacy assessments), systemic 
concentrations of functional dupilumab (PK), immunogenicity, and safety after they are 
off the investigational medicinal product (IMP). 
During the whole study duration, patients will continue MFNS stable dose started at Visit 1 (V1) 
except if dose is changed due to AE.  
In addition, patients may receive rescue medications (including SCS) and/or undergo surgery for 
NP as deemed necessary by the Investigator and patient. Short courses of oral steroids are often 
used as adjunctive therapy to INCS or in cases NP patients who fail standard of care with INCS 
(15). Refer to Section 8.2.2 for additional details. 
Overall, this study will evaluate the potential real life benefit that dupilumab may provide for 
patients that failed currently available treatment options. 
4.4.1 Endpoints rationale and description 
Clinically, NP is defined by long-term symptoms of nasal obstruction and congestion, reduction in 
or loss of sense of smell, and anterior and posterior rhinorrhea. The presence or absence of polyps 
is confirmed by performing endoscopy. These symptoms can greatly impact patient’s QoL.  
Medical and surgical intervention decisions are mainly driven by the nasal polyp symptom burden 
and response to standard therapy with topical and SCS. Therefore, in this study severity of 
symptoms will be scored daily by the patient (0-3). For NC which is a major clinical symptom, 
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the monthly average of the daily recorded symptom score will be assessed as coprimary endpoint 
along with the objective endoscopic assessment of NP score.  
Thus, the coprimary endpoints of this study are the change from baseline at Week 24 in: 
• 
Nasal congestion/obstruction severity score consisting of the monthly average of the daily 
morning ante meridiem (AM) patient-assessed daily symptom severity (using a 0 to 3 
categorical scale). The NC is assessed by the patient on a daily basis from V1 and 
throughout the study, using an electronic diary (e-diary) using a 0 to 3 categorical scale 
(where 0 = no symptoms, 1 = mild symptoms, 2 = moderate symptoms and 3 = severe 
symptoms).  
• 
The bilateral endoscopic NPS ranges from 0 to 8 points and is the sum of the right and left 
scores (from 0 = no polyps; 1 = small polyps in the middle meatus not reaching below the 
inferior border of the middle turbinate; 2 = polyps reaching below the lower border of the 
middle turbinate; 3 = large polyps reaching the lower border of the inferior turbinate or 
polyps medial to the middle turbinate; 4 = large polyps causing complete obstruction of the 
inferior nasal cavity) (17, 18, 24). For further detail, see Section 9.1. 
• 
In addition, for Japan: Lund-Mackay score. The Lund-Mackay (LMK) system is based 
on localization with points given for degree of opacification on CT scan: 0 = normal, 
1 = partial opacification, 2 = total opacification. These points are then applied to the 
maxillary, anterior ethmoid, posterior ethmoid, sphenoid, frontal sinus on each side. The 
OC is graded as 0 = not occluded, or 2 = occluded deriving a maximum score of 12 per 
side. For further detail, see Section 9.1. 
Key secondary endpoints of the study include: 
• 
Change from baseline in the severity of total symptoms score (TSS) at Week 24.  
• 
Change from baseline in University of Pennsylvania smell identification test (UPSIT) at 
Week 24. 
• 
Change from baseline in the severity of decreased/loss of smell daily assessed by the 
patient at Week 24.  
• 
Change from baseline in sinus opacifications assessed by CT scans using the LMK score 
at Week 24. (Note for Japan: this is considered as primary endpoint) 
• 
Change from baseline in 22-item sino-nasal outcome test (SNOT-22) at Week 24. 
• 
Proportion of patients receiving SCS and/or undergoing surgery (actual or planned) for 
nasal polyps during the study treatment. 
The proposed study design and endpoints will answer important clinical questions about the 
efficacy on symptoms and objective signs of the disease and the effect of dupilumab on reduction 
of SCS rescue therapy and surgery, which are the most relevant clinical practice assessments and 
reflect current standard of care. 
Other efficacy, safety and exploratory assessments in patient reported outcomes (PROs), 
health-related quality of life (HRQoL) and condition-specific and general medical questionnaires 
to evaluate the potential real life benefit will be evaluated too. 
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These treatment approaches and endpoints reflect real-life clinical assessment and are in line with 
increasing focus in the medical field on the effects of medical conditions and treatments on the 
QoL of, and functioning of, patients (1). 
4.4.2 Dupilumab dose and regimen rationale  
The dose regimens are selected based on the totality of clinical evidence in the dupilumab 
program including data from Phase 2 efficacy and safety study (ACT12340) in patients with nasal 
polyps and symptoms of chronic sinusitis, the result of Phase 2b dose ranging study in patients 
with moderate to severe asthma (DRI12544), the Phase 2b dose ranging study (R668-AD-1021) 
and Phase 3 studies (R668-AD-1334 and R668-AD-1416) in patients with moderate to severe 
atopic dermatitis (AD), as well as the supportive pharmacokinetic (PK)/pharmacodynamic (PD) 
analysis.  
While the clinical manifestations may be distinct across NP, asthma and AD indications, Th2 
mediated inflammation is implicated in the disease etiology and pathophysiology of all 
3 conditions. Dupilumab has demonstrated marked concentration dependent inhibition of the 
upstream and downstream Th2 inflammatory biomarkers including thymus and 
activation-regulated chemokine (TARC) and IgE with a very similar PD profile and 
exposure-response relationship in AD, asthma and NP patients. In asthma dose ranging study 
(DRI12544), 300 mg q2w regimen demonstrated a robust treatment effect across all relevant 
indices of drug action, while less frequent dose regimens 200 mg q2w and 300 mg once every 
4 weeks (q4w) showed less effect in some endpoints including SNOT-22. Both dose-response and 
exposure-response analyses indicated that therapeutic responses (eg, improvement in forced 
expiratory volume in 1 second [FEV1] at Week 12) and biomarker responses (including fractional 
exhaled nitric oxide and TARC) plateaued by 300 mg q2w. Thus, a further increase in dose above 
300 mg q2w is unlikely to achieve additional clinical benefit. The 300 mg q2w regimen is being 
currently evaluated as the higher dose regimen in the asthma phase 3 pivotal study.  
In the AD dose ranging study (R668-AD-1021), a similar treatment effect between 300 mg qw 
and 300 mg q2w was also observed for most efficacy endpoints (eg, IGA [Immunoglobulin A] 
and EASI [Eczema Area and Severity Index]). Consistently, results from the Phase 3 efficacy and 
safety studies in AD patients (R668-AD-1334 and R668-AD-1416) confirmed the highly similar 
clinical efficacy for the 300 mg qw and 300 mg q2w regimens across all endpoints. 
In the phase 2 POC study in NP patients with chronic symptoms of sinusitis (ACT12340), the 
300 mg qw regimen demonstrated a robust, clinically and statistically significant treatment 
response on the primary and secondary efficacy endpoints for NP and chronic sinusitis at the end 
of the 16-week treatment period. Pharmacokinetic/PD analysis of ACT12340 efficacy endpoints 
predicted a superior therapeutic benefit at both 300 mg q2w and 300 mg qw regimens, including 
clinical significant reduction in bilateral NPS (>1 point from baseline) and significant 
improvement in symptoms of NC and decrease/loss of smell. The exposure-response analysis of 
SNOT-22 by leveraging both ACT12340 and the dose ranging data from DRI12544 NP patients 
consistently supports significant clinical benefits of 300 mg q2w regimen in improving SNOT-22 
outcome (total score and selected nasal components of loss of smell and nasal blockage) and 
limited additional benefit with further increase in dose beyond 300 mg q2w. Thus, the available 
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efficacy data from asthma, AD and NP trials collectively indicate a high potential for achieving an 
optimal treatment effect at 300 mg q2w in NP patients. 
Nasal polyposis is an inflammatory disorder of upper airways of chronic and recurring nature 
requiring the use of long-term anti-inflammatory treatment to achieve a maintenance state (25). 
In the ACT12340 study, a gradual development of treatment response was observed for bilateral 
NPS and NP symptoms of NC and sense of smell. The PD steady-state for the above endpoints 
was not reached at the end of treatment (EOT) at Week 16, suggesting additional therapeutic 
benefit with longer treatment duration. The time-course PK/PD analysis predicts 24 weeks to be 
the optimal treatment duration to assess the maximal symptomatic effect for NPS, NC and other 
key secondary efficacy endpoints. 
In ACT12340 study, a single loading dose of 600 mg was used on Day 1 to rapidly achieve an 
efficacious concentration range for a potentially earlier onset of significant response. Consistent 
with the observed PK and PD profile of NP response (gradual development of response as well as 
slow offset of response during off-treatment), PK/PD simulation of coprimary endpoints of NPS 
and NC showed minimal difference in the development of treatment effect and steady-state 
response of NPS and NC in the presence and absence of the loading dose of 600 mg on Day 1. 
Therefore, no loading dose is included in the present study. 
In summary, the present clinical evidence from the 3 related Th2 disease populations of NP, AD, 
and asthma supports selection of 300 mg q2w as the potential efficacious dose regimen to be 
evaluated for benefit risk in the Phase 3 study. 
4.5 
OVERALL BENEFITS AND RISKS ASSESSMENT 
Polyps are generally comprised of eosinophilic infiltrate and associated with a Th2 orchestrated 
inflammatory state characterized by high IgE, increased Th2 cytokines such as IL-5 and IL-13, 
and decreased T-regulatory function. 
Dupilumab prevents IL-4 and IL-13 binding and activation of their respective receptors involved 
in signaling pathways that play key roles in the pathophysiology of NP. A Phase 2a study in 
patients with NP and symptoms of sinusitis, demonstrated efficacy of dupilumab with 
improvements in endoscopic, radiographic and clinical measures of disease as well as 
improvements in lung function and disease control in patients with comorbid asthma. Based on 
the POC data and the mechanism of action, dupilumab may provide an effective treatment for 
patients suffering from NP despite maximal treatment with available therapy.  
Overall, 7408 subjects have been enrolled into the dupilumab development program (completed 
and ongoing studies) as of 30 September 2016. 
Based upon the currently available data for dupilumab and the review of the data by an 
independent data monitoring committee (IDMC), systemic hypersensitivity has been identified as 
an important potential risk. Use in patients with helminthic infections is considered missing 
information based on mechanism of action and evidence of the role of IL-4 in helminth repulsion 
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in animal studies published in literature. Other theoretical risks based on immune-modulating 
properties of IL-4 are being managed conservatively through: 
• 
Exclusion of patients with immunosuppressed status or receiving systemic 
immunosuppressants, and/or having active bacterial, viral or parasitic infection, or at high 
risk for developing or reactivating infections. 
• 
Monitoring of safety data, including periodic blinded safety monitoring team review and 
unblinded IDMC review. 
The total number of patients exposed to dupilumab is over 5,000.  Data from these patients 
showed that dupilumab is well tolerated and has a favorable safety profile. This, together with the 
efficacy demonstrated in ACT12340 study in patients with NP, show a favorable benefit risk 
balance, and support continued development of dupilumab in NP. 
 
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5 
STUDY OBJECTIVES 
5.1 
PRIMARY  
The primary objective of the study is to evaluate the efficacy of dupilumab 300 mg q2w compared 
to placebo on a background of MFNS in reducing NC/obstruction severity and endoscopic NPS in 
patients with bilateral NP.  
5.2 
SECONDARY  
• 
To evaluate the efficacy of dupilumab in improving total symptoms score (TSS). 
• 
To evaluate the efficacy of dupilumab in improving sense of smell. 
• 
To evaluate the efficacy of dupilumab in reducing CT scan opacification of the sinuses 
(for Japan, this is part of the primary objective) 
• 
To evaluate the ability of dupilumab to reduce the proportion of patients who require 
treatment with SCS or surgery for NP. 
• 
To evaluate the effect of dupilumab on PROs and HRQoL. 
• 
To evaluate the effect of dupilumab in the subgroups of patients with prior surgery and 
comorbid asthma (including NERD). 
• 
To evaluate the residual effect of dupilumab through the 24-week follow-up period. 
• 
To evaluate the safety of dupilumab in patients with bilateral NP.  
• 
To evaluate functional dupilumab concentrations (systemic exposure) and incidence of 
treatment-emergent antidrug antibodies (ADA). 
5.3 
EXPLORATORY 
• 
To explore the effects of dupilumab on nasal microbiome, total and allergen-specific IgEs 
in blood, and urinary leukotriene E4 and a metabolite of prostaglandin D2 (PGDM). 
• 
To evaluate the effect of dupilumab on healthcare resource utilization. 
• 
To evaluate the effect of dupilumab on SNOT-22 items: ‘decreased sense of smell/taste’, 
'difficulty falling asleep,' 'wake up at night,' 'lack of a good night's sleep,' 'wake up tired,' 
'fatigue,' and 'reduced productivity’. 
• 
To assess the effect of dupilumab in improving sense of taste. 
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6 
STUDY DESIGN 
6.1 
DESCRIPTION OF THE STUDY 
EFC14146 is a multinational, multicenter, randomized, double-blind, Phase 3, placebo-controlled, 
parallel group study to evaluate dupilumab in patients with bilateral NP. All patients will enter a 
run-in period of 4 weeks +/-3 days receiving MFNS of 2 actuations (50 µg/actuation) in each 
nostril twice daily (BID), total daily dose of 400 µg, starting at V1, unless they are unable to 
tolerate or there is a specific regulatory requirement preventing use of this dose, in which case 
they can stay on a lower dose regimen (200 µg) of MFNS.  
Approximately 240 patients with bilateral NP will be randomized 1:1 (120 patients/arm) into 
2 treatment groups as follows:  
• 
Arm A: dupilumab 300 mg SC q2w until Week 24. 
• 
Arm B: placebo matching dupilumab SC q2w until Week 24. 
The 240 patients will be included in approximately 80 sites. Patients will be randomized 
according to asthma status (history of asthma or not), prior NP surgery (yes or no), and country. 
In order to have adequate number of patients for the subgroup analysis of patients with 
asthma/NERD and prior surgery enrollment of the following categories of patients will be limited 
as follows (see rationale Section 4.2):  
• 
Patients without asthma and/or NERD history will be limited to 120 patients (out of the 
total 240 randomized patients). 
• 
Patients without prior surgery will be limited to 120 patients (out of the total 
240 randomized patients). 
Patients may fall into more than one category without limitation in numbers. 
During the randomized treatment period, patients will continue the stable dose of intranasal 
MFNS stabilized during the run-in period except if dose is changed due to AE. For a schematic 
study design refer to Section 1.1. 
During the study, patients who report deterioration requiring medical/surgical intervention may 
come to the site for an endoscopy and clinical evaluation. An unscheduled visit may be used for 
this purpose and if necessary the Investigator may consider one of the treatment alternatives 
described in Section 8.2.2. 
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6.2 
DURATION OF STUDY PARTICIPATION 
6.2.1 Duration of study participation for each patient 
The clinical trial will consist of 3 periods: 
• 
Run-in period (4 weeks, +/-3 days): to determine a patient’s eligibility and for 
run-in/standardization of background INCS (MFNS) prior to randomization. 
• 
Randomized dupilumab/placebo treatment period (24 weeks +/-3 days): to randomize the 
patient into a treatment arm and treat with dupilumab or placebo dose regimen. 
• 
Post treatment period (24 weeks +/-3 days): to continue to collect data for PK, 
immunogenicity, safety, and efficacy after the patient has completed the study drug 
treatment period. 
If surgery is scheduled after the planned end of study, EOS visit will not be delayed. A follow up 
contact(s) should be performed around the time of planned surgery to document the surgery date 
and outcome (see Section 9.2.1.5). Surgery data will be collected until e-CRF closure of the trial. 
The total duration of study participation for patients that complete the randomized treatment 
period and post treatment follow up is approximately 52 weeks. The schedule of the visits is 
described in the study flow chart in Section 1.2. 
6.2.2 Determination of end of clinical trial (all patients) 
The last patient last visit will occur when the last randomized patient has completed the end of his 
or her 24-week follow-up period or prematurely discontinues from the study. The end of the 
clinical trial is defined as the last patient’s last visit. 
6.3 
FIRST STEP ANALYSIS 
A first step analysis may be performed when all patients complete the Week 24 visit, including 
early dropouts. Since this analysis is the final analysis of the coprimary endpoints and other 
24-week endpoints, and no decision on the conduct of the study will be made based on the first 
step analysis (in particular, no decision to prematurely stop the study), there will be no alpha 
adjustment due to the interim analysis. Specific steps will be taken to maintain the blind of the 
study to all individuals involved in the conduct of the study and/or analysis, if we perform this 
first step analysis, and to protect the overall blinding of, and integrity of, the study data given the 
first step analysis as further described in Section 11.5. 
Individuals involved in the first step analysis of the study will not be involved in the conduct of 
the study afterwards; individual patient identification (ID) will not be released to anyone who is 
directly involved in the conduct of the study. 
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6.4 
STUDY COMMITTEES 
6.4.1 Data monitoring committee 
A data monitoring committee (DMC) with members independent from Sponsor and Investigators 
is commissioned for the dupilumab clinical development program. This committee is comprised 
of externally-based individuals with expertise in the diseases under study, biostatistics, or clinical 
research. The DMC will monitor the safety data of patients (serious adverse events [SAE], 
treatment emergent adverse events [TEAE] and/or adverse events of special interest [AESI]) at 
regular intervals and is responsible for providing recommendations for protecting the safety and 
ensuring the welfare of these patients and provide sanofi with appropriate recommendations in a 
timely manner to ensure the welfare and safety of the study patients. The DMC review is blinded 
with the ability to be unblinded at DMC request. 
The detailed DMC procedures and safety data to be reviewed are described in the DMC charter. 
In the above capacities, the DMC is advisory to the Sponsor. The Sponsor is responsible for 
promptly reviewing and for taking into account in a timely manner the recommendations of the 
DMC in terms of trial continuation with or without alterations or of potential trial termination.  
6.4.2 Clinical advisory committee 
Not applicable. 
7 
SELECTION OF PATIENTS 
7.1 
INCLUSION CRITERIA 
Patients with bilateral sino-nasal polyposis that despite prior treatment with SCS anytime within 
the past 2 years; and/or have a medical contraindication/intolerance to SCS; and/or had prior 
surgery for NP at the screening visit, have: 
I 01. An endoscopic bilateral NPS at V1 of at least 5 out of a maximum score of 8 (with a 
minimum score of 2 in each nasal cavity). 
I 02. Ongoing symptoms (for at least 8 weeks before V1) of: 
• 
Nasal congestion/blockade/obstruction with moderate or severe symptom severity (score 
2 or 3) at V1 and a weekly average severity of greater than 1 at time of randomization 
(V2).  
and 
• 
Another symptom such as loss of smell, rhinorrhea (anterior/posterior). 
I 03. Signed written informed consent. 
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7.2 
EXCLUSION CRITERIA 
Patients who have met all the above inclusion criteria listed in Section 7.1 will be screened for the 
following exclusion criteria which are sorted and numbered in the following 4 subsections:  
7.2.1 Exclusion criteria related to study methodology 
E 01. Patients <18 years of age. 
E 02. Patient who has previously been treated in dupilumab studies. 
E 03. Patient who has taken: 
• 
Biologic therapy/systemic immunosuppressant to treat inflammatory disease or 
autoimmune disease (eg, rheumatoid arthritis, inflammatory bowel disease, primary biliary 
cirrhosis, systemic lupus erythematosus, multiple sclerosis, etc) within 2 months before V1 
or 5 half-lives, whichever is longer. 
• 
Any experimental mAB within 5 half-lives or within 6 months before V1 if the half-life is 
unknown. 
• 
Anti-IgE therapy (omalizumab) within 130 days prior to V1. 
• 
Patients who are receiving leukotriene antagonists/modifiers at V1 unless they are on a 
continuous treatment for at least 30 days prior to V1. 
E 04. Initiation of allergen immunotherapy within 3 months prior to V1 or a plan to begin therapy 
or change its dose during the run-in period or the randomized treatment period. 
E 05. Patients who have undergone any intranasal and/or sinus surgery (including polypectomy) 
within 6 months prior to V1. 
E 06. Patients who have had a sino-nasal or sinus surgery changing the lateral wall structure of 
the nose making impossible the evaluation of NPS. 
E 07. Patients with conditions/concomitant diseases making them nonevaluable at V1 or for the 
primary efficacy endpoint such as: 
• 
Antrochoanal polyps. 
• 
Nasal septal deviation that would occlude at least one nostril. 
• 
Acute sinusitis, nasal infection or upper respiratory infection. 
• 
Ongoing rhinitis medicamentosa. 
• 
Allergic granulomatous angiitis (Churg-Strauss syndrome), granulomatosis with 
polyangiitis (Wegener’s granulomatosis), Young’s syndrome, Kartagener’s syndrome or 
other dyskinetic ciliary syndromes, concomitant cystic fibrosis. 
• 
Radiologic suspicion, or confirmed invasive or expansive fungal rhinosinusitis. 
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E 08. Patients with nasal cavity malignant tumor and benign tumors (eg, papilloma, blood boil 
etc). 
E 09. Patients with forced expiratory volume (FEV1) 50% or less of predicted normal. 
E 10. Patients receiving concomitant treatment prohibited in the study (see Section 8.8.1). 
E 11. Patient is the Investigator or any Subinvestigator, research assistant, pharmacist, study 
coordinator, other staff or relative thereof directly involved in the conduct of the protocol. 
E 12. NIMP noncompliance at V2 (<80%) or any condition that could make the patient 
noncompliant with the study procedures and daily assessment in the e-diary. 
7.2.2 Exclusion criteria related to the active comparator and/or mandatory background 
therapies  
E 13. Patients meet any contraindications or warning on National Product labeling for MFNS. 
7.2.3 Exclusion criteria related to the current knowledge of sanofi compound  
E 14. Pregnant or intent to become pregnant during the study, or breast-feeding women. 
E 15. Women of childbearing potential (WOCBP) (premenopausal female biologically capable 
of becoming pregnant) who do not fulfill: 
• 
 A confirmed negative serum beta-human chorionic gonadotrophin (β-hCG) test at V1. 
AND either: 
• 
An established use of an acceptable contraceptive method: 
- 
Oral, injected, inserted or implanted hormonal contraceptive 
- 
Intrauterine device with or intrauterine system with progestogen 
- 
Barrier contraceptive (condom, diaphragm or cervical/vault caps) used with spermicide 
(foam, gel, film, cream or suppository), if allowed by local regulation. 
OR 
• 
Female sterilization (eg, tubal occlusion, hysterectomy or bilateral salpingectomy). 
• 
True abstinence in keeping with the preferred and usual lifestyle and if allowed by local 
regulation; periodic abstinence (eg, calendar, ovulation, symptothermal, postovulation 
methods) is not an acceptable method of contraception. 
• 
Postmenopausal women (defined as at least 12 consecutive months with no menses 
without an alternative medical cause) are not required to use additional contraception. 
E 16. Diagnosed active parasitic infection (helminths); suspected or high risk of parasitic 
infection, unless clinical and (if necessary) laboratory assessments have ruled out active 
infection before randomization. 
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E 17. History of human immunodeficiency virus (HIV) infection or positive HIV screen  
(anti HIV-1 and HIV-2 antibodies) at V1. 
E 18. A subject with a history of clinically significant renal, hepatic, cardiovascular, metabolic, 
neurologic, hematologic, ophthalmologic, respiratory, gastrointestinal, cerebrovascular or 
other significant medical illness or disorder which, in the judgment of the Investigator, 
could interfere with the study or require treatment that might interfere with the study. 
Specific examples include but are not limited to uncontrolled diabetes, uncontrolled 
hypertension, and active hepatitis. 
E 19. Known or suspected history of immunosuppression, including history of invasive 
opportunistic infections (eg, histoplasmosis, listeriosis, coccidioidomycosis, 
pneumocystosis, aspergillosis), despite infection resolution; or unusually frequent, 
recurrent or prolonged infections, per Investigator’s judgment. 
E 20. Active tuberculosis, latent untreated tuberculosis or a history of incompletely treated 
tuberculosis or non-tuberculous mycobacterial infection will be excluded from the study 
unless it is well documented by a specialist that the patient has been adequately treated and 
can now start treatment with a biologic agent, in the medical judgment of the Investigator 
and/or infectious disease specialist. Tuberculosis testing would be performed on a country 
by country basis according to local guidelines if required by regulatory authorities or ethics 
committees. 
E 21. Evidence of acute or chronic infection requiring treatment with systemic antibacterials, 
antivirals, antifungals, antiparasitics, or antiprotozoals within 4 weeks before V1 or during 
the run-in period, or significant viral infections within 4 weeks prior to V1 that may not 
have received antiviral treatment. 
E 22. Live, attenuated vaccinations within 4 weeks prior to V1 or planned live attenuated 
vaccinations and during the study (refer to Appendix A). 
E 23. Patients with active autoimmune disease and/or patients using immunosuppressive therapy 
for autoimmune disease (eg, Hashimoto’s thyroiditis, Graves’ disease, inflammatory bowel 
disease, primary biliary cirrhosis, systemic lupus erythematous, multiple sclerosis, and 
other neuro-inflammatory disease, psoriasis vulgaris, rheumatoid arthritis), or patients with 
high titer autoantibodies at V1 who are suspected of having high risk for developing 
autoimmune disease at the discretion of the Investigator or the Sponsor. 
E 24. History of malignancy within 5 years before V1, except completely treated in situ 
carcinoma of the cervix, completely treated and resolved nonmetastatic squamous or basal 
cell carcinoma of the skin. 
E 25. Known or suspected alcohol and/or drug abuse. 
E 26. Patients with a history of a systemic hypersensitivity reaction, other than localized 
injection site reaction, to any biologic drug. 
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E 27. Active hepatitis or patients with positive or indeterminate hepatitis B surface antigen 
(HBsAg), hepatitis B core antibody (HBcAb) [confirmed with presence of hepatitis B virus 
(HBV) deoxyribonucleic acid (DNA)], or positive hepatitis C virus antibody (HCVAb) 
[confirmed with presence of HCV ribonucleic acid (RNA)] at V1. 
E 28. Patient with the following liver injury related criteria at V1:  
• 
Clinically significant/active underlying hepatobiliary disease  
OR, 
• 
Alanine aminotransferase (ALT) >3 upper limit of normal (ULN). 
E 29. Abnormal laboratory values at V1: 
• 
Creatine phosphokinase (CPK) >10 ULN  
OR, 
• 
Platelets <100 000 cells/mm3  
OR, 
• 
Eosinophils >1500 cells/mm3. 
E 30. Conditions/situations such as: Patients considered by the Investigator or any 
Subinvestigator as inappropriate for this study for any reason, eg,: 
• 
Those deemed unable to meet specific protocol requirements, such as scheduled visits. 
• 
Those deemed unable to administer or tolerate long-term injections as per the patient or 
the Investigator. 
• 
Presence of any other conditions (eg, geographic, social…) actual or anticipated, that the 
Investigator feels would restrict or limit the patient’s participation for the duration of the 
study. 
7.2.4 Additional exclusion criteria during or at the end of the run-in period 
E 31. Patient who has withdrawn consent before enrollment/randomization. 
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8 
STUDY TREATMENTS 
8.1 
INVESTIGATIONAL MEDICINAL PRODUCT(S) 
8.1.1 Dupilumab 
Sterile dupilumab 150 mg/mL will be provided in prefilled syringes (2.25 mL total volume) to 
deliver 300 mg in 2 mL.  
8.1.2 Placebo for dupilumab 
Sterile placebo for dupilumab will be provided in identically matching prefilled syringes to 
deliver 2 mL. 
8.1.3 Preparation of investigational medicinal product 
Dupilumab in prefilled syringes will be dispensed to the patients, if required for home 
administration. 
8.1.4 Dosing schedule 
Regardless of the treatment arm, all randomized patients will receive q2w SC administrations of 
either dupilumab or placebo on Day 1 (V2). Every other week IMP administrations must be 
separated by at least 11 days (See Section 1.2).  
At V2, the Investigator (or delegate) will perform the injection. After V2, q2w administration of 
IMP will be performed at the investigational site up to at least Week 8 (V6). The IMP will be 
administered following clinic procedures and blood collection. Patients will be monitored at the 
study site for at least 30 minutes (or minimum time approved by the local regulator) after 
injections for signs of a hypersensitivity reaction. 
From Week 10, q2w home administration of IMP (by patient, caregiver, or health care 
professional) is possible if the patient (or caregiver) has been trained for 4 injections. Training 
must be documented when completed successfully and training injections must be recorded in the 
source documents. When IMP is administered at home, the patients must be advised by the site 
staff to self-monitor for potential signs and symptoms that may suggest a hypersensitivity reaction 
for at least 30 minutes after administration (or minimum time approved by the local regulator). If 
the patient (or caregiver) is unable or unwilling to administer IMP, arrangements must be made 
for qualified site personnel and/or healthcare professionals to administer IMP for the doses not 
scheduled to be given at the study site. If the patient, or caregiver(s) do not develop the comfort to 
inject the IMP at home, or the Investigator determines that the patient (or caregiver) injection at 
home is not appropriate, injections can be performed at the site by way of unscheduled visits. 
Subcutaneous injection sites should be alternated among the 4 quadrants of the abdomen 
(avoiding navel and waist areas), the upper thighs or the upper arms, so that the same site is not 
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injected twice consecutively. Injection in the upper arms could be done only by a trained person 
(caregiver trained by Investigator or Delegate) or healthcare professional but not the patient 
themselves. 
Detailed instructions for transport, storage, preparation, and administration of IMP are provided to 
the patient. For doses not given at the study site patients will complete a paper dosing diary to 
document compliance with self-injection (or caregiver) of IMP, location of injection, and any 
symptoms. The diary will be kept as source data in the patient’s study file. 
8.2 
NONINVESTIGATIONAL MEDICINAL PRODUCT(S) 
8.2.1 Intranasal corticosteroid background therapy 
On a daily basis throughout the study, the patient will use an e-diary to record daily use of 
mometasone furoate nasal spray (MFNS) (NASONEX) 50 µg/actuation nasal spray suspension, 
(refer to the package insert & SmPC for a description, administration details and precautions for 
use). MFNS is provided in a bottle that contains 18 g (140 actuations) of product formulation. The 
Sponsor will provide the MFNS to the Investigator sites for dispensing to the patients. If patient is 
unable to tolerate 200 micrograms twice a day (total dose 400 micrograms) due to experiencing 
AE, patient may reduce dose to 200 micrograms once per day. 
Detailed instructions for transport, storage, preparation, and administration of noninvestigational 
medicinal product (NIMP) are provided to the patient. Patients will complete the e-diary to 
document compliance. The e-diary will be considered as source data. 
8.2.1.1 Run-In Period 
After V1, once patient eligibility for study entry has been confirmed, all patients will enter a 
run-in period of 4 weeks during which they will receive starting at V1 MFNS:  
• 
Two actuations (50 µg/actuation) in each nostril BID (total daily dose of 400 µg), unless 
they are unable to tolerate the BID regimen or this dose is not approved in specific 
countries, in which case, they will follow a once daily (QD) regimen.  
MFNS will be self-administered by the patient, and at each visit the Investigator must ensure that 
the patient has the necessary doses up to the next visit, knowing that one MFNS device (1 bottle) 
contains sufficient doses for either 2 weeks of BID treatment/regimen or 4 weeks of QD 
treatment/regimen. 
Patients who receive rescue medication including INCS drops or systemic (oral, intravenous [IV], 
intramuscular [IM]) steroids between V1 and V2 will not be randomized. They can be rescreened 
as described in Section 10.1. 
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8.2.1.2 Randomized treatment period 
During the randomized treatment period, all patients will continue on the MFNS stable dose 
initiated at V1. If they experience an AE during the treatment period, patients can reduce the 
frequency of MFNS administration. 
8.2.1.3 Post treatment period 
Upon completing the randomized treatment period (or following early discontinuation of IMP or 
discontinuation from the study), patients can continue treatment with the stable dose of MFNS 
that was maintained throughout the randomized treatment period until the EOS visit, or modify 
treatment based on medical judgment. 
If surgery is scheduled after the planned end of study, EOS visit will not be delayed. A follow up 
contact(s) should be performed around the time of planned surgery to document the surgery date 
and outcome (see Section 9.2.1.5). Surgery data will be collected until e-CRF closure of the trial.  
8.2.2 Rescue treatment  
During the study treatment period and off-treatment follow-up, based on clinical evaluation, in 
case of worsening of endoscopic/radiological signs and/or clinical symptoms requiring medical 
intervention, the Investigator may consider rescue treatment with: 
• Nasal lavage with saline and/or systemic antibiotics (up to 2 weeks in case of acute 
infection). 
• Short course OCS (prednisone or prednisolone up to 2 weeks). 
• Sino-nasal surgery for nasal polyps. Based on previous observations from the POC study, 
8 weeks of IMP treatment is recommended prior to surgery to allow onset of treatment 
effect.  
Patients receiving rescue medication during the study should continue on study drug unless the 
Investigator decides to withdraw the study treatment. Before starting treatment with SCS, patients 
should come to the study site for clinical assessments including endoscopy and PROs. 
Patients scheduled for sino-nasal surgery may continue IMP up to the time of surgery or EOT 
whichever date comes first and at time of surgery will be permanently discontinued from study 
treatment and perform the efficacy and safety assessments planned at the EOT visit and return to 
the site for additional visits as described in Section 10.3.1. 
In any case, patients who prematurely discontinue the treatment will be encouraged to return to 
the study site for the efficacy and safety assessments planned at EOT visit and for additional visits 
as described in Section 10.3.1. 
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8.3 
BLINDING PROCEDURES 
8.3.1 Methods of blinding 
Dupilumab and placebo will be provided in identically matching 2 mL prefilled syringes. To 
protect the blind, each treatment kit of 2 mL (dupilumab/placebo) glass prefilled syringes will be 
prepared such that the treatments (dupilumab and its matching placebo according to its dose) are 
identical and indistinguishable and will be labeled with a treatment kit number. The randomized 
treatment kit number list will be generated by sanofi. Both the patient and Investigator will be 
blinded to assigned active drug or placebo for the whole study period. For further details, see 
Section 8.5, Packaging and Labeling. 
Study patients, Investigators, and study site personnel will not have access to the randomization 
code list except under circumstances described in Section 8.3.2. 
Refer to Section 10.5 for suspected unexpected adverse drug reaction (SUSAR) unblinding by the 
Sponsor. 
8.3.2 Randomization code breaking during the study 
In case of an adverse event (AE), the code should only be broken in circumstances when 
knowledge of the IMP is required for treating the patient.  
If possible, a contact should be initiated with the Monitoring Team before breaking the code. 
Code breaking can be performed at any time by using the proper module of the interactive voice 
response system (IVRS)/interactive web response system (IWRS) and/or by calling any other 
phone number provided by the Sponsor for that purpose. If the blind is broken, the Investigator 
should document the date, time of day, and reason for code breaking. 
Patient withdrawal will only occur when the code break call is made at the site level, not the study 
level. This means that if the Emergency Unblinding transaction is performed by the Investigator 
(ie, at the site level), then the patient will be withdrawn from treatment. However, if the 
Emergency Unblinding transaction is performed by the Global Safety Officer (GSO) (ie, at the 
study level, as the GSO is not site based), it is not required to withdraw the patient from treatment. 
At the facilities where the PK measurements, ADA and selected biomarkers are determined, the 
samples will be analyzed prior to database lock leading to unblinding of responsible bioanalysts. 
Bioanalysts are excluded from the clinical trial team. 
The DMC will receive blinded by treatment group or unblinded (if necessary) confidential reports 
from an independent statistician for review, which have to be handled strictly confidentially. None 
of these reports can be delivered to unauthorized persons. 
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8.4 
METHOD OF ASSIGNING PATIENTS TO TREATMENT GROUP 
A randomized treatment kit number list will be generated centrally by sanofi. The IMP 
(dupilumab or placebo) will be packaged in accordance with this list. 
The sanofi Clinical Supplies team will provide the randomized treatment kit number list and the 
Study Biostatistician will provide the randomization scheme to the centralized treatment 
allocation system. This centralized treatment allocation system will generate the patient 
randomization list according to which it will allocate the treatments to the patients. 
Patients who meet the entry criteria will be randomized to one of the following treatment arms 
using a 1:1 randomization ratio: 
• 
Arm A: dupilumab 300 mg SC q2w until Week 24. 
• 
Arm B: placebo matching dupilumab SC q2w until Week 24. 
Approximately 240 (120 patients/arm) patients shall be randomized. Randomization will be 
stratified based on asthma status (history of asthma or not), prior NP surgery (yes or no) and 
country.  
In order to have adequate number of patients for the subgroup analysis of patients with 
asthma/NERD and prior surgery enrollment of the following categories of patients will be limited 
as follows (see rationale Section 4.2):  
• 
Patients without asthma and/or NERD history will be limited to 120 patients (out of the 
total 240 randomized patients). 
• 
Patients without prior surgery will be limited to 120 patients (out of the total 
240 randomized patients). 
At randomization, IVRS will allocate to a patient a treatment number for dupilumab or placebo. A 
patient cannot be randomized more than once in the study. 
Patients who meet exclusion criteria may be rescreened and a different patient identification will 
be issued. There is no requirement for a waiting period between the screen-failure date and the 
rescreening date. The IVRS/IWRS report will flag rescreened patients. Patients who are 
rescreened must sign a new consent form and all V1 procedures must be repeated. The 
Investigator obtains treatment kit numbers at randomization and subsequent scheduled visits via 
the IVRS/IWRS which will be available 24 hours a day. 
8.5 
PACKAGING AND LABELING 
From randomization (V2) up to Week 22, dupilumab 300 mg or placebo will be supplied as one 
glass prefilled syringe packed in one patient kit box. The kit boxes for Arm A (300 mg q2w 
administration) will contain only dupilumab 300 mg syringes and the kit boxes for Arm B 
(placebo q2w administration) will contain only placebo syringes. 
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Mometasone furoate nasal spray will be supplied as commercial product of a box containing a 
bottle. Both bottle and box will be relabeled. 
Packaging is in accordance with the administration schedule. The content of the labeling is in 
accordance with the local regulatory specifications and requirements. 
8.6 
STORAGE CONDITIONS AND SHELF LIFE 
Dupilumab and placebo IMPs should be stored at a temperature between 2°C and 8°C. 
Mometasone furoate nasal spray storage conditions are specified on the bottle and its box.  
All IMP and NIMP should be stored in an appropriate, locked room under the responsibility of the 
Investigator or other authorized persons (eg, pharmacists) in accordance with local regulations, 
policies and procedures. NASONEX should be stored at room temperature. 
Control of storage conditions, especially control of temperature (eg, refrigerated storage) and 
information on in-use stability and instructions for handling the sanofi compound should be 
managed according to the rules provided by the Sponsor. It is the responsibility of the 
Investigators to inform the patients regarding the mandatory storage requirements for the IMP. No 
temperature monitoring will be performed at the patients’ homes. 
8.7 
RESPONSIBILITIES 
The Investigator, the hospital pharmacist, or other personnel allowed to store and dispense the 
IMP will be responsible for ensuring that the IMP used in the clinical trial is securely maintained 
as specified by the Sponsor and in accordance with applicable regulatory requirements. 
All IMP will be dispensed in accordance with the Investigator's prescription and it is the 
Investigator's responsibility to ensure that an accurate record of IMP issued and returned is 
maintained. 
Any quality issue noticed with the receipt or use of an IMP (deficiency in condition, appearance, 
pertaining documentation, labeling, expiration date, etc.) should be promptly notified to the 
Sponsor. Some deficiencies may be recorded through a complaint procedure. 
A potential defect in the quality of IMP may be subject to initiation of a recall procedure by the 
Sponsor. In this case, the Investigator will be responsible for promptly addressing any request 
made by the Sponsor, in order to recall IMP and eliminate potential hazards. 
Under no circumstances will the Investigator supply IMP to a third party (except for direct-to-
patient shipment, for which a courier company has been approved by the Sponsor), allow the IMP 
to be used other than as directed by this clinical trial protocol, or dispose of IMP in any other 
manner. 
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8.7.1 Treatment accountability and compliance 
The Investigator or delegate will keep accurate records of the quantities of the IMP 
dispensed and returned, used and unused and NIMP dispensed and returned, used and unused by 
each patient.  
• 
Proper recording of treatment kit numbers as required on appropriate electronic case report 
form (e-CRF) page for accounting purposes. 
• 
All medication treatment kits (whether empty or unused) will be returned by the patient at 
each visit when a treatment dispensing is planned, and at the EOT visit. 
• 
The completed patient diary (returned to the site at each visit), returned IMP treatment and 
NIMP kit boxes (used and unused) along with any unused prefilled syringes will be used 
for drug accountability purposes. Patients will also return used prefilled syringes to the site 
in a sharps container. 
• 
The Investigator (or designee) will track treatment accountability/compliance, by diary, 
and by counting the number of used and unused treatment kits and syringes and will 
complete the appropriate page of the patient treatment log. 
• 
The monitor in charge of the study will check the data entered on the IMP and NIMP 
administration page by comparing them with the IMP and NIMP that have been retrieved 
and the patient treatment log forms. Reconciliation will occur with paper and electronic 
diary as appropriate depending on study visit/period. 
8.7.2 Return and/or destruction of treatments 
Whenever possible all partially used, used or unused IMP and NIMP provided by the Sponsor will 
be destroyed on site according to the standard practices of the site. A detailed treatment log of the 
destroyed IMP and NIMP supplied by the Sponsor will be established with the Investigator (or the 
pharmacist) and countersigned by the Investigator and the monitoring team. The Investigator will 
not destroy any IMP and NIMP supplied by the Sponsor unless the Sponsor provides written 
authorization. When destruction at site cannot be performed, all IMP and NIMP supplied by the 
Sponsor will be retrieved by the Sponsor. A detailed treatment log of the returned IMP and NIMP 
supplied by the Sponsor will be established with the Investigator (or the pharmacist) and 
countersigned by the Investigator and the monitoring team. 
8.8 
CONCOMITANT MEDICATION 
A concomitant medication is any treatment received by the patient concomitantly to any IMP(s) or 
NIMP. 
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8.8.1 Prohibited concomitant medication  
The following concomitant treatments are not permitted during the run-in period and/or the 
randomized treatment period: 
• 
Any systemic immunosuppressive treatment including but not limited to methotrexate, 
cyclosporine, mycophenolate, tacrilomus, gold, penicillamine, sulfasalazine, 
hydroxychloroquine, azathioprine, and cyclophosphamide. 
• 
Anti-IgE therapy (omalizumab) 
• 
Mepolizumab or Reslizumab 
• 
Allergen immunotherapy (except if initiated more than 3 months prior to V1 and dose 
stable 1 month prior to V1). 
• 
Intranasal corticosteroid drops. 
• 
Long term use of intranasal decongestants 
• 
Long term courses (>2 weeks) of systemic steroids. 
• 
Short term courses (≤2 weeks) of IV, IM, SCS except as indicated treatment of NP or to 
treat other serious coexisting disease (such as asthma). 
• 
Short course use (≤2 weeks) of SCS between V1 and V2. 
• 
Live, attenuated vaccines (Appendix A). 
• 
Monoclonal antibodies. 
Patients who between V1 and V2, receive any of the prohibited treatments, or treatment with 
INCS drops or systemic (oral, IV, IM) steroids, or undergo surgery will not be randomized. They 
may, however, be rescreened following the procedures described in Section 10.1. 
8.8.2 Permitted concomitant medication 
The following treatments are allowed:  
• 
MFNS during the run-in period and throughout the whole study. 
• 
Nasal normal saline lavage (only considered rescue if initiated after V2). 
• 
Single topical decongestants administration for example oxymetazoline hydrochloride (to 
reduce the swelling and widen the path for the endoscope), as well as a topical anesthetic 
for example lidocaine are allowed before endoscopy. 
• 
Short term use of antibiotics (<2 weeks) are allowed during the study. 
• 
Short-acting β2-adrenoceptor agonist, long-acting β2-adrenoceptor agonist and long-acting 
muscarinic antagonist. 
• 
Methylxanthines (for example theophylline, aminophyllines). 
• 
Inhaled corticosteroids. 
• 
Systemic antihistamines. 
• 
Leukotriene antagonists/modifiers are permitted during the study, only for patients who 
were on a continuous treatment for ≥30 days prior to V1. 
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• 
Allergen immunotherapy in place for ≥3 months prior to V1 is permitted. 
• 
Rescue medication including short courses of SCS for treatment of NP as described in 
Section 8.2.2 or short courses of SCS to treat other serious coexisting diseases (such as 
asthma exacerbation) are allowed. 
Cytochrome P450 (CYP) substrates 
The impact of dupilumab on cytochrome P450 (CYP450) enzymes activity has not been studied 
and the effect on dupilumab on the levels of IL-4 and IL-13 cytokines has not been fully 
characterized. 
However, literature data of studies in human hepatocytes indicate that the IL-4 was able to 
upregulate CYP450 2E1, 2B6, 3A4 mRNA expression or down regulate CYP1A2 mRNA 
(26, 27). Another study in human peripheral blood mononuclear cells incubated with various Th2 
cytokines, reports that Th2 cytokines IL-4 and IL-13 generally increased the protein expression of 
CYP2B6 and CYP3A4 (28). 
A drug-drug interaction study (R668-AD-1433) designed to examine the effects of dupilumab on 
the PK of selected CYP450 substrates in adult patients with moderate to severe AD was 
completed recently.  The data indicated no clinically meaningful effect of dupilumab on CYP1A2, 
CYP3A4, CYP2C19 or CYP2C9 activity. 
During the study medication and at least up to the end of follow-up, caution should be used for 
drugs with narrow therapeutic index that are metabolized via these CYP450 isoforms. 
This means that unless the drug is prohibited in the study Section 8.8.1, close clinical observation 
and/or laboratory monitoring as applicable are required in order to enable early detection of toxic 
manifestations or lack of activity/efficacy of these drugs, followed by dose adjustment or their 
withdrawal if needed. 
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9 
ASSESSMENT OF INVESTIGATIONAL MEDICINAL PRODUCT 
Investigators must make their best efforts educating their patients on the importance of sticking to 
visit schedules, study required procedures and assessments up to the end of the study. 
Investigators must make best efforts to prevent missing data, in order that a high level of quality 
can be achieved for the study. 
9.1 
COPRIMARY ENDPOINTS 
There are 2 coprimary endpoints for this study for countries other than Japan:  
1. Change from baseline in nasal congestion/obstruction (NC) at Week 24: NC is 
assessed by the patient on a daily basis from V1 and throughout the study, using an e-diary 
using a 0 to 3 categorical scale (where 0 = no symptoms, 1 = mild symptoms, 
2 = moderate symptoms and 3 = severe symptoms) (2).  
Nasal congestion/obstruction will be scored as a reflective score (evaluation of symptom severity 
over the past 24 hours) by the patient (see Table 1). 
Table 1 – Symptom severity score 
Scale 
Symptoms 
0 
No symptoms 
1 
Mild symptoms (symptoms clearly present, but minimal awareness and easily tolerated) 
2 
Moderate symptoms (definite awareness of symptoms that is bothersome but tolerable) 
3 
Severe symptoms (symptoms that are hard to tolerate, cause interference with activities or daily living) 
 
The e-diary is dispensed at V1 and information is downloaded from this device on the other 
indicated days.  
A severity ≥2 on the day of V1 and a weekly average severity greater than 1 at time of 
randomization (V2) is required and will be provided to the site to determine patient eligibility. If 
there are 4 or more measurements collected within 7 days prior to randomization, the baseline will 
be the average of these measurements; if less than 4 measurements are collected, the baseline will 
be the average of the most recent 4 prior to randomization. 
For the baseline to EOT analysis, 4 weeks average of the symptom scores will be used. 
2. Change from baseline in NPS at Week 24: NPS (17, 18, 24) is assessed by central video 
recordings of nasal endoscopy. The score (NPS) is the sum of the right and left 
nostril scores, as evaluated by means of nasal endoscopy. NPS is graded based on polyp 
size described in Table 2. 
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Table 2 - Endoscopic nasal polyp score 
Polyp Score 
Polyp Size 
0 
No polyps 
1 
Small polyps in the middle meatus not reaching below the inferior border of the middle turbinate 
2 
Polyps reaching below the lower border of the middle turbinate  
3 
Large polyps reaching the lower border of the inferior turbinate or polyps medial to the middle turbinate 
4 
Large polyps causing complete obstruction of the inferior nasal cavity 
 
Nasal endoscopy should be performed at the end of the scheduled visits before the administration 
of IMP and preceded by local administration of anesthetic drugs in combination with a 
decongestant. 
Standard video sequences will be downloaded or sent to centralized reader. Centralized imaging 
data assessments and scoring by independent physician reviewer(s) for the imaging data will be 
performed for all endoscopies. To confirm eligibility at V2, only the V1 central reading will be 
made available to the site. In addition at V2 the Investigator will perform the nasal endoscopy to 
confirm eligibility score and enter the result in the e-CRF. Thus the patient is considered eligible 
based on a V1 central reading followed by a V2 local reading NPS score of 5 or more and at least 
2 each side. The final results of central reading from V2 onward will be made available after the 
study. 
For the analysis of primary endpoint, central reading of V2 will be used for comparison with the 
Week 24 reading. The sites will remove patient-identifying information from the imaging data 
header prior to sending the imaging data to the central reader. 
Further details on nasal endoscopy will be available in a separate operational manual provided to 
the sites. 
3. Lund-Mackay score 
For Japan, in addition to the two coprimary endpoints above, the following will also be a 
coprimary endpoint: 
The LMK system is based on localization with points given for degree of opacification: 
0 = normal, 1 = partial opacification, 2 = total opacification. These points are then applied to the 
maxillary, anterior ethmoid, posterior ethmoid, sphenoid, frontal sinus on each side. The OC is 
graded as 0 = not occluded, or 2 = occluded deriving a maximum score of 12 per side. This 
scoring system has been validated in several studies (29, 30, 31). 
For patients in whom the OC is missing (because of a previous surgery) the reader should 
consider the location of the former OC and provide a scoring (as if the OC was there). 
CT scan should be performed anytime during the run-in period before first administration of IMP, 
and at V8 (Week 24). Whenever possible a cone beam CT scan should be utilized. In countries for 
which a specific approval procedure for the CT scan is required by a different committee than the 
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local independent ethics committee (IEC)/institutional review board (IRB), patients may be 
enrolled using a CT available in the previous year or perform an MRI of the sinuses between V1 
and V2. These countries will be exempted from all the planned study CT scans until approval 
from these committees is received. The MRI will be used only for confirmation of exclusion 
criteria. 
Details for CT will be available in a separate operational manual provided to the sites. 
CT scans central reading for LMK scoring will be used for the analysis. 
9.2 
SECONDARY ENDPOINTS 
9.2.1 Key secondary efficacy endpoints 
For the analysis of key secondary endpoints see Section 11.4.2.2. 
9.2.1.1 Disease specific daily symptom assessment and total symptom score (TSS)  
On a daily basis from V1 and throughout the study, the patient will use an e-diary to: 
• 
Respond to the morning individual rhinosinusitis symptom questions using a 0 to 
3 categorical scale (where 0 = no symptoms, 1 = mild symptoms, 2 = moderate symptoms 
and 3 = severe symptoms) (2):  
- 
Congestion and/or obstruction. 
- 
Loss of sense of smell. 
- 
Anterior rhinorrhea (runny nose). 
- 
Posterior rhinorrhea (postnasal drip). 
The total symptom score is a composite score (ranging between 0 and 9) consisting of the sum of 
the following symptoms assessed daily in the morning: NC, decreased/loss of sense of smell, 
rhinorrhea (average of anterior/posterior nasal discharge). 
9.2.1.2 Smell test: University of Pennsylvania Smell Identification Test (UPSIT) 
The UPSIT (UPSIT 40-odorant test) is a rapid and easy-to-administer method to quantitatively 
assess human olfactory function. The UPSIT shows a high test-retest reliability (r: 0.981) and 
scores on this test are strongly correlated with the detection threshold for phenyl ethyl alcohol in 
the same individuals. When the UPSIT is administered in the standardized manner, clinical 
subjects show a high degree of uniformity in UPSIT performance when tested in different 
laboratories. 
The test will be dispensed to the patient by the study site personnel and consists of 4 booklets, 
each containing 10 odorants with one odorant per page. The test-time is about 15 minutes. The 
stimuli are embedded in 10 to 50 (mu) diameter plastic microcapsules on brown strips at the 
bottom of each page. Above each odorant strip is a multiple choice question with 4 alternative 
words to describe the odor. The subject is asked to release the odorant by rubbing the brown-strip 
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with the tip of a pencil and to indicate which of 4 words best describes the odor. Thus each subject 
receives a score out of 40 possible correct answers. The final score will be recorded in the e-CRF.  
The odorants of the UPSIT test utilized in this study will take into account cultural differences. 
The 40-odorant UPSIT is used in over 1500 clinics and laboratories throughout the US, Canada, 
South America, and Europe, and has been administered to nearly 200 000 people since its 
development in the early 1980s. A particular strength of this test is that it provides an olfactory 
diagnosis based on comparing the patient's test score with normative data, providing a percentile 
score of an individual relative to his or her age-matched normal group. Furthermore, a clinician 
can distinguish patients with a normal sense of smell ("normosmia") from those with different 
levels of reduction ("mild, moderate and severe microsmia") or loss ("anosmia") (32). 
9.2.1.3 Decreased/loss of sense of smell 
The decreased/loss of sense of smell severity is assessed by the patient on a daily basis from V1 
and throughout the study, using an e-diary to using a 0 to 3 categorical scale (where 0 = no 
symptoms, 1 = mild symptoms, 2 = moderate symptoms and 3 = severe symptoms). 
9.2.1.4 Lund-Mackay score 
Lund-Mackay score is a secondary efficacy endpoint in countries other than Japan. Details of this 
endpoint are presented in Section 9.1. 
9.2.1.5 Proportion of patients during the treatment period who receive SCS rescue or are 
planned to undergo surgery for NP 
SCS rescue 
Oral steroids for rescue treatment of nasal polyps or for another reason will be prescribed to the 
patient by the site depending on local legislation/regulation. PROs and a nasal endoscopy should 
be performed before starting treatment with SCS. The Investigator (or designee) records the date 
and dosing information (daily dose, duration, INN) on the appropriate page(s) of the e-CRF. 
Indication for SCS use will also be captured by selecting one or more of the following categories:  
1. Nasal polyposis 
2. Asthma 
3. Other respiratory disease (specify) 
4. Other ear, nose or throat disease (specify) 
5. Other reason (specify). 
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Surgery (actual or planned) for NP 
For patients who have a surgery or have a scheduled date for sino-nasal surgery for NP, the reason 
(worsening signs and/or symptoms during the study), the expected or actual surgery date, the type 
and outcome of surgery will be recorded in a specific CRF page. If surgery: 
• 
Is performed during the study treatment period, patient and Investigator may decide to 
continue IMP up to the time of surgery or EOT whichever date comes first. At the time of 
surgery patients will be permanently discontinued from study treatment and assessed as 
soon as possible using the procedures normally planned for the EOT Visit and will be 
instructed to return to the study site as described in Section 10.3.1. An AE or SAE page 
will be completed. 
• 
Is performed during the follow-up the patients will be assessed according to the 
procedures normally planned for the EOS Visit and will be instructed to return to the study 
site as described in Section 10.3.1 An AE or SAE page will be completed. 
• 
If surgery is scheduled after the planned end of study, EOS visit will not be delayed. A 
follow up contact(s) should be performed around the time of planned surgery to document 
the surgery date and outcome. Surgery data will be collected until e-CRF closure of the 
trial. 
9.2.1.6 22-Item Sino-nasal Outcome Test (SNOT-22) 
The SNOT-22 is a validated questionnaire to assess the impact of chronic rhinosinusitis on 
HRQoL (Appendix B). The SNOT-22 has 22 items on a 5-category scale applicable to sino-nasal 
conditions and surgical treatments. The range of the global score is 0 to 110 and a minimal 
important difference (MID), the smallest difference between clinical trial arms mean change from 
baseline (point estimates) that will be interpreted as important, of 8.9 (33). Lower scores indicate 
less impact and the recall period is the past 2 weeks. There are 5 domains that can be described 
within SNOT-22, including nasal, ear, sleep, general and practical, and emotional. 
9.2.2 Other secondary endpoints  
For the assessment of other secondary endpoints, see analyses of efficacy endpoints, 
Section 11.4.2.4. 
9.2.2.1 SCS dose and number of courses 
Total SCS rescue dose prescribed (in mg/year) during the study period and total SCS rescue 
intake in days and courses during the study period could be derived based on SCS dose  
prescribed and intake days of SCS during the study, recorded in e-CRF pages. 
A course of SCS is considered continuous if treatment is separated by less than 7 days. Various 
doses of systemic corticosteroids will be converted to prednisone-equivalent OCS. 
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9.2.2.2 Visual analog scales (VAS)  
The visual analog scale (VAS) for rhinosinusitis is used to evaluate total severity (2). 
Rhinosinusitis disease can be divided into MILD, MODERATE and SEVERE based on total 
severity VAS score (0 to 10 cm): 
• 
MILD = VAS 0 to 3 
• 
MODERATE = VAS >3 to 7 
• 
SEVERE = VAS >7 to 10. 
The patient is asked to indicate on a VAS the answer to the question: “How troublesome are your 
symptoms of rhinosinusitis?” 
The VAS ranks from 0 (Not troublesome) to 10 (Worst thinkable troublesome) (Appendix D). 
9.2.2.3 Nasal peak inspiratory flow 
Nasal peak inspiratory flow (NPIF) evaluation represents a physiologic measure of the air flow 
through both nasal cavities during forced inspiration expressed in liters per minute. The NPIF is 
the best validated technique for the evaluation of nasal flow through the nose. Nasal inspiration 
correlates most with the subjective feeling of obstruction and is the best validated technique for 
monitoring nasal flow in clinical trials. 
On V1, patients will be issued an NPIF meter for recording morning NPIF. Patients will be 
instructed on the use of the device, and written instructions on the use of the NPIF meter will be 
provided to the patients. In addition, the Investigator will instruct the patients on how to record the 
following variables in the e-diary on a daily basis. 
• 
AM NPIF performed within 15 minutes after arising (before 12 noon) prior to taking 
MFNS.  
Three NPIF efforts will be performed by the patient; all 3 values will be recorded by the patient in 
the e-diary, and the highest value will be used for evaluation. The procedure takes about 
5 minutes. 
Baseline AM NPIF will be the mean AM measurement recorded for the 7 days prior to the first 
dose of IMP. If fewer than 4 measurements are collected during the 7 days, the average of the 
most recent 4 prior to randomization during the run-in period will serve as the baseline.  
The NPIF will be performed daily from V1 to Week 24 (V8). After V8 the NPIF will be 
performed every 4 weeks. 
The nasal flow is expressed in liters per minute, and consecutive measurements are performed. 
Taking the best of 3 outcomes with less than 10% variation is considered to be the best means of 
expression of the result (32). 
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9.2.2.4 Asthma Control Questionnaire, 6-question version (ACQ-6) in those patients 
comorbid with asthma 
The asthma control questionnaire-6 (ACQ-6) was designed to measure both the adequacy of 
asthma control and change in asthma control which occurs either spontaneously or as a result of 
treatment. Only patients with comorbid asthma will be asked to complete the questionnaire in the 
e-diary during clinic visits. Patients should complete the questionnaire before the spirometry test. 
The ACQ-6 has 6 questions which assess the most common asthma symptoms: 
• 
Frequency in past week awoken by asthma during the night. 
• 
Severity of asthma symptoms in the morning. 
• 
Limitation of daily activities due to asthma. 
• 
Shortness of breath due to asthma. 
• 
Frequency of wheezing. 
• 
Short-acting bronchodilator use. 
Patients are asked to recall how their asthma has been during the previous week and to respond to 
the symptom questions on a 7-point scale (0 = no impairment, 6 = maximum impairment) (see 
Appendix E). 
A global score is calculated: the questions are equally weighted and the ACQ-6 score is the mean 
of the 6 questions and, therefore, between 0 (totally controlled) and 6 (severely uncontrolled). 
Higher score indicates lower asthma control. Patients with a score below 1.0 reflect adequately 
controlled asthma and patients with scores above 1.0 reflect inadequately controlled asthma. On 
the 7-point scale of the ACQ-6, a change or difference in score of 0.5 is the smallest change that 
can be considered clinically important, corresponding to the minimal clinically important 
difference (MCID) defined by the developer. 
Measurement properties such as reliability, ability to detect change have been documented in the 
literature (34). 
9.2.2.5 Health related quality of life (HRQoL) 
9.2.2.5.1 Euro-QOL-5D 
The European quality of life-5D scale (EQ-5D) (Appendix C) is a standardized HRQoL 
questionnaire developed by the EuroQoL Group in order to provide a simple, generic measure of 
health for clinical and economic appraisal (35). EQ-5D is designed for self-completion by 
patients. 
The EQ-5D essentially consists of 2 pages: the EQ-5D descriptive system and the EQ VAS. The 
EQ-5D descriptive system comprises 5 dimensions: mobility, self-care, usual activities, 
pain/discomfort and anxiety/depression. Each dimension has 5 levels: no problems, slight 
problems, moderate problems, severe problems, and extreme problems. The EQ VAS records the 
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respondent’s self-rated health on a vertical VAS. The EQ VAS ‘thermometer’ has endpoints of 
100 (Best imaginable health state) at the top and 0 (Worst imaginable health state) at the bottom. 
9.2.2.5.2 Short Form 36 (SF-36) Version 2 
The SF-36 (Short-Form-36 (SF-36)-Version 2.0) (Appendix G) is a generic questionnaire 
measuring general health status (QoL) in the last 4 weeks before completing the questionnaire. 
The SF-36 is a 36-item questionnaire that measures eight multi-item dimensions of health: 
physical functioning (10 items) social functioning (2 items) role limitations due to physical 
problems (4 items), role limitations due to emotional problems (3 items), mental health (5 items), 
energy/vitality (4 items), pain (2 items), and general health perception (5 items). 
For each dimension, item scores are coded, summed, and transformed on to a scale from 0 (worst 
possible health state measured by the questionnaire) to 100 (best possible health state). Two 
standardized summary scores can also be calculated from the SF-36; the physical component 
summary (PCS) and the mental health component summary (MCS). 
In this study SF-36 will be assessed only at V2 to evaluate the baseline QoL impact in the defined 
phase 3 population. 
9.3 
EXPLORATORY ENDPOINTS 
• 
Healthcare resource utilization. 
• 
Proportion and time-to-event of patients with SCS rescue for nasal polyps. 
• 
Proportion and time-to-event of patients who have or are planned for surgery for nasal 
polyps. 
• 
Change from baseline in decreased/loss of sense of taste symptom severity. 
• 
SNOT-22 items: ‘decreased sense of smell/taste’, 'difficulty falling asleep,' 'wake up at 
night,' 'lack of a good night's sleep,' 'wake up tired,' 'fatigue,' and 'reduced productivity’. 
• 
Patient reported outcomes including HRQoL scale (Index Score of EQ5D-5L) 
• 
Pharmacodynamic biomarkers in blood and urine. 
• 
Microbiome in nasal mucus swab. 
• 
 
• 
FEV1, FVC and FEF 25-75 in patients with asthma. 
• 
Efficacy endpoints for the subgroup of patients with systemic corticosteroid use in the year 
prior to study (V1). 
9.3.1 Spirometry 
Spirometry will be performed at local level (study site or another facility) in the morning after 
withholding the last dose of salbutamol/albuterol or levosalbutamol/levalbuterol for at least 
6 hours. FEV1, forced vital capacity (FVC), and forced expiratory flow at 25% to 75% of forced 
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vital capacity (FEF 25-75) will be determined at the designated treatment visits. The result of 
FEV1 (% of predicted normal), FVC, and FEF 25-75 should be recorded in the e-CRF anytime 
during run-in period (before V2) for all patients, and in patients with asthma for the other 
scheduled visits during the randomized treatment period and follow-up. 
Whenever possible the same spirometer and standard spirometric techniques, including 
calibration, must be used to perform spirometry at all visits and the same person should perform 
the measurements. 
9.4 
SAFETY ENDPOINTS 
9.4.1 Adverse events 
Refer to Section 10.4 to Section 10.6 for details. 
9.4.2 Laboratory safety variables 
The clinical laboratory data consist of blood and urine analysis (including serum hematology and 
clinical chemistry). Clinical laboratory values will be analyzed after conversion into standard 
international units. International units will be used in all listings and tables. 
• 
Hematology includes: hemoglobin, hematocrit, platelet count, total white blood cell count 
with five-part differential count, and total red blood cell count.  
• 
Serum chemistry includes: creatinine, blood urea nitrogen, glucose, uric acid, total 
cholesterol, total protein, albumin, total bilirubin (in case of values above the normal 
range, differentiation in conjugated and non-conjugated bilirubin), ALT, aspartate 
aminotransferase, alkaline phosphatase, lactate dehydrogenase, electrolytes (sodium, 
potassium, chloride), bicarbonate, and CPK. 
• 
HIV screening (anti-HIV-1 and HIV-2 antibodies)  
• 
Anti-nuclear antibody (ANA). Note: Anti-ds DNA antibody will be tested if ANA is 
positive (≥1:160 titer). 
9.4.3 Hepatitis screening 
Clinical laboratory testing at V1 includes hepatitis screen covering HBsAg, hepatitis B surface 
antibody (HBsAb), HBcAb including HBcAb IgM and total, and HCVAb. In case of results 
showing HBsAg (negative), and HBcAb total or HBcAb IgM (positive), an HBV DNA testing 
must be performed prior to randomization to rule out a false positivity if the Investigator believes 
the patient is a false positive, or to clarify the serological status if the Investigator finds it unclear 
to interpret in absence of known HBV infection. In case of results showing HCV Ab (positive), an 
HCV RNA testing may be performed to rule out a false positivity, if the Investigator believes the 
patient is a false positive. 
In countries where there is local regulatory requirement, for patients who are HBsAg negative and 
HBsAb positive at V1, hepatitis B viral load will be tested at V2 and V8. 
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9.4.4 Pregnancy test 
A serum pregnancy test (β-hCG) will be performed at run-in (V1) in WOCBP, and a urine 
dipstick pregnancy test will be performed at V2 prior to randomization and every 4 weeks during 
the study. A negative result must be obtained at V1 and V2 prior to randomization.   
In case of positive urinary test the study treatment will be withheld and a serum pregnancy test to 
confirm the pregnancy should be performed as soon as possible. Pregnancy will lead to definitive 
treatment discontinuation in all cases. 
9.4.5 Vital signs 
Vital signs include: blood pressure (mmHg), heart rate (beats per minute), respiration rate (breaths 
per minute), body temperature (degrees Celsius) and body weight (kg). Height (cm) will be 
measured at V1 only. Vital signs will be measured in the sitting position using the same arm 
(preferably) at each visit, and will be measured prior to receiving IMP at the clinic visits. 
9.4.6 Physical examination 
Physical examinations will include an assessment of general appearance, skin, eyes, 
ear/nose/throat, heart, chest, abdomen, reflexes, lymph nodes, spine, and extremities. All 
deviations from normal will be recorded, including those attributable to the patient’s disease. 
9.4.7 Electrocardiogram variables 
A standard 12-lead electrocardiogram (ECG) will be performed at the sites at the time points 
noted in the study flow chart (see Section 1.2) to monitor any potential abnormality. In case of an 
abnormal ECG finding, the Investigator should enter details into the e-CRF. At V2, the 
Investigator should use their medical judgment to consider whether the patient is eligible for the 
study. 
9.5 
OTHER ENDPOINTS 
9.5.1 Functional dupilumab concentration and antidrug antibodies in serum 
9.5.1.1 Sampling time 
Predose blood samples will be collected for determination of functional dupilumab (PK) in serum 
and antidupilumab antibodies at timepoints designated in the study flow chart (see Section 1.2). 
The date of collection should be recorded in the patient e-CRF. The date and time will also be 
collected on the central laboratory requisition form and entered into the database through data 
transfers from the central laboratory. 
In the event of any serious adverse event (SAE) or any AESI of anaphylactic reactions or systemic 
allergic reactions that are related to IMP and require treatment, or severe injection site reaction 
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lasting longer than 24 hours, samples will be collected near the onset and resolution of the event 
for any additional analysis if required or for archival purposes. An unscheduled systemic drug 
concentration page in the e-CRF must be completed as well. 
Patients who are ADA positive at their last study visit (early termination or planned EOS), may be 
asked to return to the clinic to have additional ADA samples collected for analysis based on the 
overall clinical presentation at the time of discontinuation.  
9.5.1.2 Handling procedure 
Special procedures for collection, storage, and shipping of serum are described in separate 
operational manuals. An overview of handling procedures for samples used in the determination 
of functional dupilumab serum concentration and ADAs is provided in Table 3.  
Table 3 - Summary of handling procedures for SAR231893 (dupilumab) 
Sample type 
Functional dupilumab serum 
concentration 
Antidupilumab antibody 
Matrix 
Serum 
Serum 
Blood sample 
volume 
5 mL 
5 mL 
Anticoagulant 
None 
None 
Blood handling 
procedures 
 See Operational Manual 
See Operational Manual 
Serum aliquot split 
Storage conditions 
Serum shipment 
condition 
Two aliquots 
<6 months: below -20°C 
≥6 months: below -80°C (preferred) 
In dry ice 
Two aliquots 
<6 months: below -20°C 
≥6 months: below -80°C (preferred) 
In dry ice 
9.5.1.3 Bioanalytical methods 
Serum samples will be assayed using validated methods as described in Table 4.  
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Table 4 - Summary of bioanalytical methods for dupilumab and anti-dupilumab antibody 
Analyte 
Functional dupilumab 
concentration 
Anti-dupilumab antibody 
Matrix 
Serum 
Serum 
Analytical technique 
ELISA 
ECL bridging 
ECL electrochemiluminescence; ELISA enzyme-linked immunosorbent assay 
 
9.5.1.4 Functional dupilumab concentration and antidrug antibody measurement and 
samples 
Predose functional dupilumab concentrations in serum at V2 (Day 1), dupilumab trough 
concentrations at Week 4, Week 8, Week 16, Week 24 (EOT), and post treatment at Week 36 and 
Week 48 (EOS) will be provided.  
Antidupilumab antibody status (negative or titer value) will be provided for samples collected at 
timepoints as specified in the study flow chart. 
Patients who are ADA positive at their last study visit (early termination or planned EOS), will be 
considered for follow-up based on the overall clinical presentation at that time. 
Unused samples collected for drug concentration or ADA analyses may be used for exploratory 
analyses if the specific Future Use of Samples Informed Consent is signed (see Section 9.6). 
9.5.2 Pharmacodynamics 
Several biomarkers related to CRSwNP and Th2 polarization will be assessed for their value in 
predicting therapeutic response and/or in documenting the time course of drug response. 
Patients, Investigators and site personnel will not have access to assay results for total IgE, 
allergen-specific IgE (including aeroallergen and Staphylococcal aureus enterotoxin-specific 
IgEs), while the study is ongoing, as the related data are not essential for patient care and have the 
potential for unblinding the study treatments.  
Sample collection will be performed as per the study flow chart (Section 1.2) and assay 
methodologies are briefly summarized below. In general, duplicate aliquots of each sample for PD 
biomarkers should be stored to assure generation of a complete set of assay results. More detailed 
information on the collection, handling, transport and preservation of samples (eg, minimum 
volumes required for blood collection and for aliquots for each biomarker assay) will be provided 
in a separate laboratory manual. 
9.5.2.1 Serum biomarkers 
Total IgE, allergen-specific IgE for aeroallergens (regional panels) and Staphylococcus aureus 
enterotoxins A and B IgE will be measured using quantitative methods (eg, ImmunoCAP® 
FEIA), approved for diagnostic testing.  
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Thymus and activation-regulated chemokine will be assayed with a validated enzyme 
immunoassay (eg, Human TARC Quantikine ELISA kit; R&D Systems). 
Concentrations of periostin will be assayed with a validated immunoassay. 
9.5.2.2 Plasma biomarkers 
Eotaxin-3 will be measured in heparinized plasma with a validated enzyme immunoassay. 
9.5.2.3 Urine biomarkers  
Leukotriene E4 and a metabolite of prostaglandin D2 (PGDM) will be measured in morning spot 
urine samples using validated quantitative assays. Assay results will be reported per mg of 
creatinine.  
9.5.2.4 Microbiome in nasal mucus 
Using a nasal swab, mucus will be collected from the middle meatus of each nostril and assessed 
for relative abundance of microbes, in all patients prior to MFNS administration. A minimum of 2 
hours should be allowed following MFNS administration in all patients prior to collection. 
9.5.3 
 
 
 
 
 
 
  
 
 
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9.6 
FUTURE USE OF SAMPLES 
Not all of the samples collected during this study may be required for the tests planned in this 
clinical trial. For patients who have consented to it, the samples that are archived, unused or left 
over after planned testing may be used for additional research purposes 
 
 For patients who have consented to it, archival 
blood samples will be collected at the visit specified in the study flow chart, 10 mL each, will be 
collected into a dry, red topped tube with clotting activator (or into smaller tubes of equivalent 
total volume) kept at room temperature for 30 minutes and then centrifuged at approximately 
1500 g for 10 minutes at room temperature. The serum will then be transferred, in equal portions, 
into 3 storage tubes, which will be immediately capped and frozen in an upright position at -20°C 
or colder. 
These archived serum samples, and any residual or leftover serum, plasma or blood remaining 
from planned laboratory work, may be used for research purposes related to airway disease, 
response to dupilumab treatment, additional drug safety assessments or development and 
validation of bioassay methods beyond those defined in the present protocol. 
These samples will remain labelled with the same identifiers as the ones used during the study 
(ie, Subject ID, Sample ID). They will be transferred to a Sanofi site (or a subcontractor site) 
which can be located outside of the country where the study is conducted. The Sponsor has 
included safeguards for protecting patient confidentiality and personal data (see Section 14.3 
and Section 14.5). 
9.7 
APPROPRIATENESS OF MEASUREMENTS  
Refer to Section 4.4.1 for rationale on the coprimary and secondary endpoints. The proposed 
study design and endpoints will answer important clinical questions about the efficacy on 
symptoms and objective signs of the disease and the effect of dupilumab on reduction of SCS 
rescue therapy and surgery, which are the most relevant clinical practice assessments and reflect 
current standard of care. 
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10 
STUDY PROCEDURES 
Medical history should be recorded consistent with Good Clinical and local practice.  This would 
typically include atopic medical history (including asthma history, hypersensitivity to aspirin or 
NSAIDs, NERD, allergy/atopy history), history of surgeries, concomitant medications, etc. 
10.1 
VISIT SCHEDULE 
This section describes how the visits are carried out, in chronological order (according to the flow 
chart Section 1.2 and identical to the order shown in the e-CRF): 
The clinical trial consists of 3 periods, using an add-on therapy approach to INCS: 
• 
Run-in period (28 days +/-3 days; V1). 
• 
Randomized treatment period (up to 24 weeks +/-3 days; V2 to V8). 
• 
Post treatment period (24 weeks +/-3 days; V9 and V10). 
The study visits occur on the planned dates (relative to the first injection), as scheduled. The visit 
schedule should be adhered to within the +/-3 day visit window. 
If a patient is prematurely discontinued from treatment, every attempt should be made for the 
patients to return to the study site as soon as possible after last IMP administration to perform all 
assessments planned at the EOT visit, and patients will be asked and encouraged to return to the 
study site for the visit scheduled as described in Section 10.3.1 (early treatment discontinuation) 
for a 24-week follow-up. 
Prior to all screening assessments, after discussion of participation in the study, the written 
consent form including HIV as required by local regulations,
 
must be signed and dated (see Section 12.2). 
Although the screening assessments for this study are grouped under the heading of a single visit 
in this protocol, it is possible for them to be performed over more than 1 site visit if necessary, as 
long as the visit window prior to Day 1 (V2) is respected. These patients do not need to sign a 
new consent form and be allocated a new patient number within this same window. 
Rescreening 
Patients that fail screening between V1 and V2 may be rescreened for study eligibility only once 
for the following criteria: 
• 
They do not meet the inclusion criteria for a weekly average NC >1 at V2. 
• 
They had an acute illness such as acute sinusitis, nasal infection or upper respiratory 
infection (E 07). These patients can be rescreened only after complete resolution of 
symptoms. 
• 
They took one of the prohibited treatments listed in Section 8.8.1 below between V1 and 
V2.  
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Patients that are rescreened must sign a new consent form and all of the V1 procedures must be 
repeated (refer to Section 8.4 for further instructions related to rescreening) unless a prior 
assessment is performed within the time frame permitted prior to study entry or the V1 baseline 
CT scan of sinuses and spot urine for biomarker sampling were performed. 
Note, no waivers will be approved for randomization; all patients must fulfil all eligibility criteria 
before randomization into the study. 
If certain dynamic laboratory tests do not meet the eligibility criteria, these laboratory assessments 
may be repeated, at the discretion of the investigator, if it is judged to be likely to return to 
acceptable range for study inclusion within the screening visit window. 
For patients who do not fulfil other exclusion criteria, rescreening should be discussed with the 
Sponsor. In all cases, a given patient can only be re-screened once. 
Order of assessments 
During the treatment and post treatment period if necessary, it is possible to perform the study 
procedures within a 3 day period as long as these days are within the scheduled visit window and 
the order of procedures is maintained. 
It is recommended that assessments/procedures at a site visit are performed in the following order 
if applicable: 
1. Patient-reported outcomes and other questionnaires: 
- 
Daily symptoms of NC, loss of smell and anterior and posterior rhinorrhoea 
- 
SNOT-22 
- 
VAS rhinosinusitis 
- 
Reduced sense of taste severity 
- 
EQ-5D 
- 
ACQ-6 (in patients with asthma) 
- 
Other questionnaires. 
2. Procedures. 
3. Safety and laboratory assessments. 
4. IMP administration. 
5. NIMP boxes should be collected at all visits following provision during all study periods. 
6. IMP boxes should be collected at all visits following provision for home dosing during 
treatment period. 
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10.1.1 Visit 1 (Week -4/Day -28 +/- 3 days): Run-in period 
Following a discussion of participation in the clinical trial, signed informed consent must be 
obtained and documented. 
The following procedures will then be performed: 
• 
Call IVRS/IWRS to assign patient number, register V1, and obtain first NIMP 
(NASONEX) box(es). 
• 
Interview to collect patient demographic information, NP information, other medical 
history (including asthma history, hypersensitivity to aspirin or NSAIDs, NERD, 
allergy/atopy history), surgical history (including number, type and dates of previous 
surgery for nasal polyps in the past), and prior and concomitant medications (including 
background therapy for NP and asthma), courses of SCS in the previous 2 years (number of 
SCS courses, doses, route of administration and duration in the previous year will be 
entered in the e-CRF. Long term antibiotics use [> 2 weeks] in the previous year will be 
also entered in the e-CRF). 
• 
Review entry criteria to assess eligibility, with special attention to verify and document the 
following: 
- 
Use of SCS for NP within 2 years prior to V1; and/or contraindication/intolerance to 
SCS; and or prior surgery for NP (whenever in the past)  
- 
Nasal polyp score of 5 or greater (and at least 2 in each side). 
- 
Presence of NC (blockade/obstruction) severity ≥2 on the day of V1 and loss of smell, 
rhinorrhea (anterior/posterior).  
- 
Patients have not received any of the prohibited medications described in E 03 and/or 
Section 8.8.1.  
• 
Measure vital signs: blood pressure, heart rate, respiration rate, body temperature, weight, 
height. 
• 
Perform physical examination. 
• 
Perform CT scan (within the time period between V1 and V2, prior to first administration 
of IMP). In countries for which a specific approval procedure for the CT scan is required 
by a different committee than the local IEC/IRB, patients may be enrolled using a CT 
available in the previous year or perform an MRI of the sinuses between V1 and V2. 
• 
Perform spirometry within the time period between V1 and V2, for all patients and ensure 
that patients with co-morbid asthma have FEV1>50%. Spirometry will be performed after 
the last dose of salbutamol/albuterol or levosalbutamol/levalbuterol has been withheld for 
at least 6 hours. 
• 
Obtain blood samples for screening clinical laboratory determinations: Hematology and 
serum chemistry (see Section 9.4.2 for details) 
• 
Obtain blood samples for hepatitis screen (HBsAg, HBsAb, HBcAb, HCVAb, HIV screen 
(anti-HIV-1 and HIV-2 antibodies) and antinuclear antibody (ANA). In case of results 
showing HBsAg (negative), and HBcAb total or HBcAb IgM (positive), an HBV DNA 
testing may be performed prior to randomization to rule out a false positivity if the 
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Investigator believes the patient is a false positive, or to clarify the serological status if the 
Investigator finds it unclear to interpret in absence of known HBV infection. In case of 
results showing HCVAb (positive), an HCV RNA testing may be performed to rule out a 
false positivity, if the Investigator believes the patient is a false positive. 
- 
Note: Anti-ds DNA antibody will be tested if ANA is positive (≥1:160 titer). 
• 
Obtain serum β-hCG pregnancy test if WOCBP. 
• 
Perform chest X-ray if no chest imaging (X-ray, CT, magnetic resonance imaging) 
available within the previous year as per local standard of care, or if there is local 
requirement. In countries for which specific approval procedure for the X-ray or CT scan 
is required by a different committee than the IEC/IRB, a chest MRI between V1 and V2 
can be performed). 
• 
Perform nasal endoscopy and send to central reader. 
• 
Dispense e-diary/NPIF meter, provide instructions for daily use, and remind patient to 
bring the device to the next visit. 
• 
NIMP: Dispense MFNS for use as mandatory background therapy throughout the study. 
Ensure that the patient has sufficient quantity for dosing up until the next visit, knowing 
that one MFNS bottle contains sufficient doses for either 2 weeks of BID treatment or 
4 weeks of QD treatment. Instruct patient to record usage in the e-diary. 
• 
Start AE reporting. 
• 
Review and record all medication use with start date and dose in e-CRF.  
- 
Check for use of prohibited medications. 
• 
Advise patients with comorbid atopic conditions (such as asthma) not to adjust their 
treatment without consultation with their physicians. 
• 
Schedule appointment for the next visit. 
10.1.2 Visit 2 (Week 0): Randomization  
• 
PRO patient administration in the e-diary before seeing the physician: 
- 
Daily symptoms of NC, loss of smell and anterior and posterior rhinorrhoea 
• 
Inquire about AEs/SAEs and background therapy tolerability.  
• 
Review and record all medication use with start date and dose in e-CRF.  
- 
Check for use of prohibited medications. 
• 
Download data from e-diary/NPIF meter and check compliance with use of the mandatory 
background therapy (MFNS), as defined as:  
- 
≥80% of total number of prescribed “stable dose” sprays taken during the run-in 
period. Compliance is verified based on MFNS use recorded in the patient e-diary. 
- 
Remind patient to bring the device to the next visit. 
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• 
Confirm patient eligibility: 
- 
Review V1 nasal endoscopy results from central reader to confirm that patient has a 
score of 5 or more and at least 2 each side. 
- 
Perform and review local nasal endoscopy to confirm that patient still has a score of 
5 or more and at least 2 on each side and record result in e-CRF. If the patient does not 
have the required scores at the V2 nasal endoscopy, the inclusion criteria are not 
fulfilled and the patient should not be randomized. 
- 
Record symptoms of sinusitis, and check the severity average of the last week before 
V2 is >1 for NC.  
- 
Record spirometry result from V1 and FEV1(liters and predicted), FVC and FEF 25-
75 result in the e-CRF. Confirm eligibility for patients with FEV1 >50%. 
- 
Check patient compliance with daily diary. 
• 
Investigator to assess eligibility for nasal polyp surgery. 
• 
Perform ECG. 
• 
Obtain urine β-hCG pregnancy test if WOCBP. In case of a positive urinary test, a serum 
pregnancy test to confirm the pregnancy should be performed as soon as possible. 
Pregnancy will lead to a definitive screen failure in all cases. 
• 
Measure vital signs (blood pressure, heart rate, respiration rate, body temperature, weight). 
• 
Review all inclusion/exclusion criteria to reconfirm eligibility. 
- 
Reminder that patients receiving prohibited medications described in Section 8.8.1, 
including rescue with INCS drops, SCS, or surgery for NP during the run-in period, 
are NOT eligible for randomization. 
If entry criteria are not met, call IVRS/IWRS to register the visit and screen-fail the patient. 
Refer to Section 8.4 for details regarding rescreening. 
If the patient meets all eligibility criteria: 
• 
Call IVRS/IWRS to register visit to randomize the patient and receive the first IMP kit 
number assignment and NIMP (NASONEX) boxes, if needed.  
• 
Administer SNOT-22, VAS (for rhinosinusitis), reduced sense of taste severity, QoL 
(EQ-5D), ACQ-6 (for patients with asthma), and SF-36.  
• 
Healthcare resource utilization via e-CRF. 
• 
Administer smell test (UPSIT).  
• 
Obtain blood samples (prior to IMP) for:  
- 
Hematology and serum chemistry laboratories (see Section 9.4.2 for details),  
- 
Note: Anti-ds DNA antibody will be tested if ANA is positive (≥1:160 titer). 
- 
Serum dupilumab concentration and ADA. 
- 
Hepatitis B viral load for patients in countries/regions if there is local regulatory 
requirement who are HBsAg negative and HBsAb positive at V1. 
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- 
Tuberculosis test if required by local regulation. 
- 
Serum and plasma biomarkers (TARC, eotaxin, and periostin). 
- 
Serum for total IgE, allergen-specific IgE including Staphylococcal enterotoxins IgE. 
- 
Stored DNA sampling, stored serum, and stored whole blood RNA, for those patients 
who have signed a specific informed consent form. 
• 
Perform urine sampling for biomarkers and creatinine. 
• 
Obtain nasal swabs for microbiome prior to MFNS administration. 
• 
Remind patient to bring the e-diary/NPIF meter to the next visit. 
• 
Reminder: sexually active female patients of reproductive potential are required to practice 
an acceptable contraception (as defined in E 15 or local protocol amendment in case of 
specific local requirement) during the entire study duration, while taking dupilumab and 
for 12 weeks after the last IMP dose. Sexually active male patients should be reminded 
that if their partner is a woman of childbearing potential, their partner should consider 
protection by acceptable method(s) of birth control.  
• 
Administer IMP:  
- 
Patients will be monitored for at least 30 minutes (or minimum time required by your 
local regulator) after the end of administration of IMP for any signs or symptoms of a 
hypersensitivity reaction. 
- 
Throughout the study, SC injection sites will be alternated between the 4 quadrants of 
the abdomen (avoiding navel and waist areas) or upper thighs or upper arms, so that the 
same site is not injected twice consecutively. Injection in the upper arms can only be 
performed by a person trained for 4 injections (caregiver trained by Investigator or 
delegate) or health care professional, but not the patient themselves. This instruction 
pertains to the day the first dose is injected as well as the administration of q2w 
injections. Detailed instructions for transport, storage, preparation, and administration 
of IMP are provided to the patient. 
• 
NIMP:  
- 
Ensure that the patient has sufficient quantity for dosing up until the next visit, 
knowing that one MFNS bottle contains sufficient doses for either 2 weeks of BID 
treatment or 4 weeks of QD treatment. Dispense MFNS if needed. Instruct patient to 
record usage in the e-diary. 
• 
Advise patients with comorbid atopic conditions (such as asthma) not to adjust their 
treatment without consultation with their physicians. 
• 
Schedule appointment for next visit. 
10.1.3 Visit 3 (Week 2 +/- 3 days) 
• 
PRO patient administration in the e-diary: 
- 
Daily symptoms of NC, loss of smell and anterior and posterior rhinorrhoea 
- 
VAS for rhinosinusitis and  
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- 
Reduced sense of taste severity score. 
• 
Administer smell test (UPSIT) 
• 
Inquire about AEs/SAEs and background therapy tolerability. 
• 
Collect NIMP boxes 
• 
Record all medication use with start date and dose in the e-CRF. 
- 
Check for use of prohibited medications. 
- 
Complete rescue medication/surgery page(s) of e-CRF. Use of oral steroids for rescue 
treatment of worsening nasal polyps or for another reason will be captured by the 
Investigator (or designee) on the appropriate page(s) of the e-CRF page and the date 
and dosing information (daily dose, duration, INN) will be informed. Details on 
planned date for surgery, type and outcome (whenever possible) of surgery will be 
recorded in a specific e-CRF page. If surgery is performed during the study treatment 
period or follow-up an AE or SAE page will be completed. 
• 
Call IVRS/IWRS to register visit, and obtain next IMP kit number assignment and NIMP 
(NASONEX) box(es), if needed, or report potential definitive IMP stop. 
• 
Download e-diary/NPIF meter and review the data; remind patient to bring the device to the 
next visit. 
• 
Administer IMP (one SC injection). 
- 
Patients will be monitored at the study site for at least 30 minutes (or minimum time 
required by your local regulator) after the injection. 
• 
NIMP:  
- 
Ensure that the patient has sufficient quantity for dosing up until the next visit, 
knowing that one MFNS bottle contains sufficient doses for either 2 weeks of BID 
treatment or 4 weeks of QD treatment. Dispense MFNS if needed. Instruct patient to 
record usage in the e-diary.  
• 
Schedule appointment for next visit. 
10.1.4 Visit 4 (Week 4 +/- 3 days) 
• 
PRO patient administration in the e-diary: 
- 
Daily symptoms of NC, loss of smell, and anterior and posterior rhinorrhea. 
- 
VAS for rhinosinusitis.  
- 
Reduced sense of taste severity score. 
• 
Inquire about AEs/SAEs and background therapy tolerability. 
• 
Collect NIMP boxes 
• 
Record all medication use with start date and dose in the e-CRF. 
- 
Check for use of prohibited medications. 
- 
Complete rescue medication/surgery page(s) of e-CRF. Use of oral steroids for rescue 
treatment of worsening nasal polyps or for another reason will be captured by the 
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Investigator (or designee) on the appropriate page(s) of the e-CRF page and the date 
and dosing information (daily dose, duration, INN) will be informed. Details on 
planned date for surgery, type and outcome (whenever possible) of surgery will be 
recorded in a specific e-CRF page. If surgery is performed during the study treatment 
period or follow-up an AE or SAE page will be completed. 
• 
Call IVRS/IWRS to register visit and obtain next IMP kit number assignment and NIMP 
(NASONEX) box(es), if needed or report potential definitive IMP stop. 
• 
Download e-diary/NPIF meter and review the data; remind patient to bring the device to the 
next visit. 
• 
Perform blood sampling for serum dupilumab concentration. 
• 
Obtain urine β-hCG pregnancy test if WOCBP. In case of a positive urinary test, the study 
treatment will be withheld and a serum pregnancy test to confirm the pregnancy should be 
performed as soon as possible. Pregnancy will lead to a definitive treatment 
discontinuation in all cases. 
• 
Administer IMP (one SC injection). 
- 
IMP can be administered by the patient or caregiver under supervision of the 
Investigator or the designee. 
- 
Patients will be monitored at the study site for a minimum of 30 minutes (or minimum 
time required by your local regulator) after the injection. 
• 
NIMP:  
- 
Ensure that the patient has sufficient quantity for dosing up until the next visit, 
knowing that one MFNS bottle contains sufficient doses for either 2 weeks of BID 
treatment or 4 weeks of QD treatment. Dispense MFNS if needed. Instruct patient to 
record usage in the e-diary.  
• 
Schedule appointment for next visit. 
10.1.5 Visit 5 (Week 6 +/- 3 days) 
• 
Inquire about AEs/SAEs and background therapy tolerability. 
• 
Collect NIMP boxes 
• 
Record all medication use with start date and dose in the e-CRF. 
- 
Check for use of prohibited medications. 
- 
Complete rescue medication/surgery page(s) of e-CRF. Use of oral steroids for rescue 
treatment of worsening nasal polyps or for another reason will be captured by the 
Investigator (or designee) on the appropriate page(s) of the e-CRF page and the date 
and dosing information (daily dose, duration, INN) will be informed. Details on 
planned date for surgery, type and outcome (whenever possible) of surgery will be 
recorded in a specific e-CRF page. If surgery is performed during the study treatment 
period or follow-up an AE or SAE page will be completed. 
• 
Call IVRS/IWRS to register visit and obtain next IMP kit number assignment and NIMP 
(NASONEX) box(es), if needed or report potential definitive IMP stop. 
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• 
Download e-diary/NPIF meter and review the data; remind patient to bring the device to the 
next visit. 
• 
Administer IMP (one SC injection). 
- 
IMP can be administered by the patient or caregiver under supervision of the 
Investigator or the designee. 
- 
Patients will be are monitored for a minimum of 30 minutes (or minimum time required 
by your local regulator) after the injection. 
• 
NIMP:  
- 
Ensure that the patient has sufficient quantity for dosing up until the next visit, 
knowing that one MFNS bottle contains sufficient doses for either 2 weeks of BID 
treatment or 4 weeks of QD treatment. Dispense MFNS if needed. Instruct patient to 
record usage in the e-diary.  
• 
Schedule appointment for next visit. 
• 
Remind patients with asthma to withhold the last dose of salbutamol/albuterol or 
levosalbutamol/levalbuterol for at least 6 hours prior to arriving at V6. 
10.1.6 Visit 6 (Week 8 +/- 3 days) 
• 
PRO patient administration in the e-diary: 
- 
Daily symptoms of NC, loss of smell, and anterior and posterior rhinorrhea. 
- 
SNOT-22. 
- 
VAS for rhinosinusitis.  
- 
Reduced sense of taste severity score. 
- 
ACQ-6 (for patients with asthma)  
• 
Health care resource utilization via e-CRF. 
• 
Inquire about AEs/SAEs and background therapy tolerability.  
• 
Collect NIMP boxes 
• 
Review and record all medication use with start date and dose in e-CRF.  
- 
Check for use of prohibited medications. 
- 
Complete rescue medication/surgery page(s) of e-CRF. Use of oral steroids for rescue 
treatment of worsening nasal polyps or for another reason will be captured by the 
Investigator (or designee) on the appropriate page(s) of the e-CRF page and the date 
and dosing information (daily dose, duration, INN) will be informed. Details on 
planned date for surgery, type and outcome (whenever possible) of surgery will be 
recorded in a specific e-CRF page. If surgery is performed during the study treatment 
period or follow-up an AE or SAE page will be completed. 
• 
Call IVRS/IWRS to register visit and obtain next IMP kit number assignment and NIMP 
(NASONEX) box(es), if needed or report potential definitive IMP stop. 
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• 
Download e-diary/NPIF meter and review the data; remind patient to bring the device to the 
next visit. 
• 
Perform spirometry (for patients with asthma) and record FEV1, FVC and FEF 25-75 
result in the e-CRF. 
• 
Administer smell test (UPSIT).  
• 
Perform nasal endoscopy and send to central reader. 
• 
Measure vital signs (blood pressure, heart rate, respiration rate, body temperature, weight).  
• 
Perform blood sampling for serum dupilumab concentration and ADA. 
• 
Obtain urine β-hCG pregnancy test if WOCBP. In case of a positive urinary test, the study 
treatment will be withheld and a serum pregnancy test to confirm the pregnancy should be 
performed as soon as possible. Pregnancy will lead to a definitive treatment 
discontinuation in all cases. 
• 
Administer IMP:  
- 
IMP can be administered by the patient or caregiver under supervision of the 
Investigator or the designee. 
- 
Patients will be monitored for a minimum of 30 minutes (or minimum time required by 
your local regulator) after injection. 
• 
NIMP:  
- 
Ensure that the patient has sufficient quantity for dosing up until the next visit, 
knowing that one MFNS bottle contains sufficient doses for either 2 weeks of BID 
treatment or 4 weeks of QD treatment. Dispense MFNS if needed. Instruct patient to 
record usage in the e-diary. 
• 
In case of home administration for next IMP injection remind the patient to return IMP 
treatment and NIMP kit boxes along with any unused prefilled syringes that will be used 
for drug accountability purposes. Patients will also return used prefilled syringes to the site 
in a sharps container. 
• 
WOCBP are reminded to perform at Week 12 a urinary pregnancy test and bring the test 
back for the next visit. In case of a positive urinary test, the study treatment will be 
withheld and a serum pregnancy test to confirm the pregnancy should be performed as 
soon as possible.  Pregnancy will lead to a definitive treatment discontinuation in all cases. 
In case of positive test at home, patient should contact the site immediately. 
• 
Remind the patient to withhold the last dose of salbutamol/albuterol or 
levosalbutamol/levalbuterol for at least 6 hours prior to arriving at V7. 
• 
Supply IMP for patients who will have off-site visits on Weeks 10, 12 and 14.  
• 
Schedule appointment for next visit. 
10.1.7 Optional visits (Weeks 10, 12, 14) 
Optional visits can be scheduled at Weeks 10, 12 and 14 for IMP/NIMP supply or IMP 
administration. 
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From Week 10, q2w home administration of IMP (by patient, caregiver, or health care 
professional) is possible if the patient (or caregiver) has been trained. When IMP is administered 
at home, the patients must be advised by the site staff to self-monitor for potential signs and 
symptoms that may suggest a hypersensitivity reaction for at least 30 minutes (or minimum time 
required by your local regulator) after administration. Patients will complete a dosing diary to 
document compliance with self-injection of IMP (or injection by a caregiver), including anatomic 
site of administration and any adverse reactions). 
If the patient (or caregiver) is unable or unwilling to administer IMP, arrangements must be made 
for qualified site personnel and/or healthcare professionals to administer IMP for the doses not 
scheduled to be given at the study site. 
• 
Urinary pregnancy test for WOCBP performed at home at Week 12.  In case of positive 
test at home, patient should contact the site immediately. 
• 
Patient should be informed to record home administration of the IMP in the diary. 
10.1.8 Visit 7 (Week 16 +/- 3 days) 
• 
PRO patient administration in the e-diary: 
- 
Daily symptoms of NC, loss of smell, and anterior and posterior rhinorrhea. 
- 
SNOT-22. 
- 
VAS for rhinosinusitis.  
- 
Reduced sense of taste severity score. 
- 
ACQ-6 (for patients with asthma)  
• 
Health care resource utilization via e-CRF.  
• 
Inquire about AEs/SAEs and background therapy tolerability. 
• 
Collect IMP and NIMP boxes 
• 
Record all medication use with start date and dose in the e-CRF. 
- 
Check for use of prohibited medications. 
- 
Complete rescue medication/surgery page(s) of e-CRF. Use of oral steroids for rescue 
treatment of worsening nasal polyps or for another reason will be captured by the 
Investigator (or designee) on the appropriate page(s) of the e-CRF page and the date 
and dosing information (daily dose, duration, INN) will be informed. Details on 
planned date for surgery, type and outcome (whenever possible) of surgery will be 
recorded in a specific e-CRF page. If surgery is performed during the study treatment 
period or follow-up an AE or SAE page will be completed. 
• 
Call IVRS/IWRS to register visit and obtain next IMP kit number assignment and NIMP 
(NASONEX) box(es), if needed or report potential definitive IMP stop. 
• 
Download e-diary/NPIF meter and review the data; remind patient to bring the device to the 
next visit. 
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• 
Perform spirometry (for patients with asthma) and record FEV1, FVC and FEF 25-75 
results in the e-CRF. 
• 
Perform nasal endoscopy and send to central reader. 
• 
Administer smell test (UPSIT). 
• 
Measure vital signs (blood pressure, heart rate, respiration rate, body temperature, weight) 
• 
Obtain blood samples (prior to IMP) for:  
- 
Hematology and serum chemistry (see Section 9.4.2 for details)  
- 
Serum dupilumab concentration and ADA. 
• 
Obtain urine β-hCG pregnancy test if WOCBP and record the Week 12 result. In case of a 
positive urinary test, the study treatment will be withheld and a serum pregnancy test to 
confirm the pregnancy should be performed as soon as possible. Pregnancy will lead to a 
definitive treatment discontinuation in all cases. 
• 
Administer IMP (one SC injection). 
- 
IMP can be administered by the patient or caregiver under the supervision of the 
Investigator or the designee  
- 
Patients will be monitored for a minimum of 30 minutes (or minimum time required by 
your local regulator) after the injection. 
• 
NIMP:  
- 
Ensure that the patient has sufficient quantity for dosing up until the next visit, 
knowing that one MFNS bottle contains sufficient doses for either 2 weeks of BID 
treatment or 4 weeks of QD treatment. Dispense MFNS if needed. Instruct patient to 
record usage in the e-diary.  
• 
Schedule appointment for next visit. 
• 
Remind the patient to withhold the last dose of salbutamol/albuterol or 
levosalbutamol/levalbuterol for at least 6 hours prior to arriving at V8. 
• 
Remind the patient to return IMP treatment and NIMP kit boxes along with any unused 
prefilled syringes that will be used for drug accountability purposes. Patients will also 
return used prefilled syringes to the site in a sharps container. 
• 
WOCBP are reminded to perform the urinary pregnancy test at Week 20 and bring the test 
back for the next visit. In case of a positive urinary test, the study treatment will be 
withheld and a serum pregnancy test to confirm the pregnancy should be performed as 
soon as possible. Pregnancy will lead to a definitive treatment discontinuation in all cases. 
In case of positive test at home, patient should contact the site immediately. 
• 
Supply IMP for optional visits can be scheduled at Weeks 18, 20, and 22.  
10.1.9 Optional visits (Weeks 18, 20, 22) 
Optional visits can be scheduled at Weeks 18, 20, and 22 for IP/NIMP supply or IMP 
administration. 
• 
Urinary pregnancy test for WOCBP performed at home at Week 20. In case of positive 
test at home, patient should contact the site immediately. 
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• 
Patient should be informed to record home administration of the IMP in the diary. 
10.1.10 
Visit 8 (Week 24 +/- 3 days): End of treatment 
• 
PRO patient administration in the e-diary: 
- 
Daily symptoms of NC, loss of smell, and anterior and posterior rhinorrhea. 
- 
SNOT-22. 
- 
VAS for rhinosinusitis.  
- 
Reduced sense of taste severity score. 
- 
EQ-5D 
- 
ACQ-6 (for patients with asthma)  
• 
Health care resource utilization via e-CRF.  
• 
Inquire about AEs/SAEs and background therapy tolerability. 
• 
Collect IMP and NIMP boxes 
• 
Record all medication use with start date and dose in the e-CRF. 
- 
Check for use of prohibited medications. 
- 
Complete rescue medication/surgery page(s) of e-CRF. Use of oral steroids for rescue 
treatment of worsening nasal polyps or for another reason will be captured by the 
Investigator (or designee) on the appropriate page(s) of the e-CRF page and the date 
and dosing information (daily dose, duration, INN) will be informed. Details on 
planned date for surgery, type and outcome (whenever possible) of surgery will be 
recorded in a specific e-CRF page. If surgery is performed during the study treatment 
period or follow-up an AE or SAE page will be completed. 
• 
Call IVRS/IWRS to register visit and obtain next NIMP (NASONEX) box(es), if needed. 
• 
Download e-diary/NPIF meter and review the data; remind patient to bring the device to the 
next visit. 
• 
Perform spirometry (for patients with asthma) and record FEV1, FVC and FEF 25-75 
results in the e-CRF. 
• 
Perform nasal endoscopy and send to central reader. 
• 
Administer smell test (UPSIT). 
• 
Perform ECG. 
• 
Measure vital signs (blood pressure, heart rate, respiration rate, body temperature, weight). 
• 
Perform physical examination. 
• 
Perform CT scan. 
• 
Obtain blood samples for:  
- 
Hematology and serum chemistry (see Section 9.4.2 for details). 
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- 
Hepatitis B viral load (for patients in countries/regions if there is local regulatory 
requirement) who are HBsAg negative and HBsAb positive at V1. 
- 
Serum dupilumab concentration and ADA. 
- 
Serum for total IgE, allergen-specific IgE including Staphylococcal enterotoxins IgE  
- 
Stored serum for those patients who have signed a specific informed consent form. 
• 
Obtain urine for: 
- 
β-hCG pregnancy test if WOCBP and record the Week 20 result. In case of a positive 
urinary test, the study treatment will be withheld and a serum pregnancy test to 
confirm the pregnancy should be performed as soon as possible. Pregnancy will lead to 
a definitive treatment discontinuation in all cases 
- 
Urine biomarkers and creatinine. 
• 
Obtain nasal swabs for microbiome prior to MFNS administration. 
• 
NIMP:  
- 
Ensure that the patient has sufficient quantity for dosing up until the next visit, 
knowing that one MFNS bottle contains sufficient doses for either 2 weeks of BID 
treatment or 4 weeks of QD treatment. Dispense MFNS if needed. Instruct patient to 
record usage in the e-diary.  
• 
Advise patients with comorbid atopic conditions (such as asthma) not to adjust their 
treatment without consultation with their physicians. 
• 
Schedule appointment for next visit. 
10.1.11 
Visit 9 (Week 36) 
• 
PRO patient administration in the e-diary: 
- 
Daily symptoms of NC, loss of smell, and anterior and posterior rhinorrhea. 
- 
SNOT-22. 
- 
VAS for rhinosinusitis.  
• 
Inquire about AEs/SAEs and background therapy tolerability. 
• 
Collect IMP and NIMP boxes 
• 
Record all medication use with start date and dose in the e-CRF. 
- 
Complete rescue medication/surgery page(s) of e-CRF. Use of oral steroids for rescue 
treatment of worsening nasal polyps or for another reason will be captured by the 
Investigator (or designee) on the appropriate page(s) of the e-CRF page and the date 
and dosing information (daily dose, duration, INN) will be informed. Details on 
planned date for surgery, type and outcome (whenever possible) of surgery will be 
recorded in a specific e-CRF page. If surgery is performed during the study treatment 
period or follow-up an AE or SAE page will be completed. 
• 
Call IVRS/IWRS to register visit and obtain next NIMP (NASONEX) box(es), if needed. 
• 
Download e-diary/NPIF and review the data. 
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• 
Measure vital signs (blood pressure, heart rate, respiration rate, body temperature, weight). 
• 
Perform physical examination  
• 
Perform nasal endoscopy and send to central reader. 
• 
Perform blood sampling for serum dupilumab concentration and ADA.  
• 
Obtain urine β-hCG pregnancy test if WOCBP. 
• 
Schedule appointment for next visit. 
10.1.12 
Visit 10 (Week 48): End of study 
• 
PRO patient administration in the e-diary: 
- 
Daily symptoms of NC, loss of smell, and anterior and posterior rhinorrhea. 
- 
SNOT-22. 
- 
VAS for rhinosinusitis.  
- 
ACQ-6 (for patients with asthma). 
• 
Inquire about aes/saes and background therapy tolerability. 
• 
Collect IMP and NIMP boxes 
• 
Record all medication use with start date and dose in the e-CRF. 
- 
Complete rescue medication/surgery page(s) of e-CRF. Use of oral steroids for rescue 
treatment of worsening nasal polyps or for another reason will be captured by the 
Investigator (or designee) on the appropriate page(s) of the e-CRF page and the date 
and dosing information (daily dose, duration, INN) will be informed. Details on 
planned date for surgery, type and outcome (whenever possible) of surgery will be 
recorded in a specific e-CRF page. If surgery is performed during the study treatment 
period or follow-up an AE or SAE page will be completed. 
• 
Call IVRS/IWRS to register visit. 
• 
Download e-diary/NPIF and review the data. 
• 
Perform spirometry (for patients with asthma) and record FEV1, FVC and FEF 25-75 
results in the e-CRF. 
• 
Perform nasal endoscopy and send to central reader. 
• 
Administer smell test (UPSIT). 
• 
Measure vital signs (blood pressure, heart rate, respiration rate, body temperature, weight). 
• 
Perform physical examination. 
• 
Perform CT scan (unless not approved by local ethics committee). 
• 
Perform blood sampling for serum dupilumab concentration and ADA.  
• 
Obtain urine β-hcg pregnancy test if WOCBP. 
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10.2 
DEFINITION OF SOURCE DATA 
Source data is all information in original records and certified copies of original records of clinical 
findings, observations, or other activities in a clinical trial necessary for the reconstruction and 
evaluation of the trial. Source data are contained in source documents. Source documents are 
original documents, data and records such as hospital records, clinic and office charts, laboratory 
notes, memoranda, pharmacy dispensing records, recorded data from automated instruments, etc. 
All the data collected in the e-CRF should be transcribed directly from source documents. Data 
downloaded from the study-associated central laboratories, endoscopy, CT scan, NPIF 
measurement, and patient diary meter will be considered source data. HCRU will be collected 
directly in the e-CRF. 
10.3 
HANDLING OF PATIENT TEMPORARY OR PERMANENT TREATMENT 
DISCONTINUATION AND OF PATIENT STUDY DISCONTINUATION  
The IMP should be continued whenever possible. In case the IMP is stopped, it should be 
determined whether the stop can be made temporarily; permanent IMP discontinuation should be 
a last resort. Any IMP discontinuation should be fully documented in the CRF. In any case, the 
patient should remain in the study as long as possible. 
10.3.1 Permanent treatment discontinuation with investigational medicinal product(s) 
Patients who permanently discontinue treatment earlier than planned during the randomization 
period, will be assessed as soon as possible using the procedures normally planned for the EOT 
visit (Refer to Section 10.1.10 Visit 8 (Week 24 +/- 3 days): End of treatment)  
Those patients who permanently discontinue during the post-treatment period will be assessed 
using the procedures normally planned for the EOS visit.   
Furthermore, all patients will be instructed as follows: 
• 
Return to the study site for evaluation of NPS, SNOT-22 for all remaining visits 
corresponding to study flowchart.  . 
- 
CT Scan will be performed at time of early treatment discontinuation.   
- 
For those patients where discontinuation occurs during the treatment period, CT scan 
will  be performed at W24 and not at ETD. An optional CT may be performed at Week 
48. 
- 
For those patients where early treatment discontinuation occurs during the post-
treatment period, the week 48 CT scan will not be performed. 
• 
Perform PK, ADA sampling at the initially scheduled visits for ADA. 
• 
Continue to complete the e-diary for NC, anterior and posterior rhinorrhea and loss of 
smell daily symptom evaluation up to Week 48. 
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• 
Continue on MFNS stable dose but patients are not required to complete the INCS use 
daily in the e-diary after ETD. 
• 
Advise patients with comorbid atopic conditions (such as asthma) not to adjust their 
treatment without consultation with their physicians. 
• 
Report any AE up to the last scheduled visit (Week 48). 
• 
Contact the Investigator during the post treatment period up to the EOS visit if the 
symptoms worsen requiring medical attention 
- 
The Investigator will record in the corresponding e-CRF pages rescue medication 
prescribed or surgical interventions during the planned study treatment period. Use of 
oral steroids for rescue treatment of worsening nasal polyps or for another reason will 
be captured by the Investigator (or designee) on the appropriate page(s) of the e-CRF 
page and the date and dosing information (daily dose, duration, INN) will be informed. 
Details on planned date for surgery, type and outcome (whenever possible) of surgery 
will be recorded in a specific e-CRF page. If surgery is performed during the study 
treatment period or follow-up an AE or SAE page will be completed. 
If surgery is scheduled after the planned end of study, EOS visit will not be delayed. A follow up 
contact(s) should be performed around the time of planned surgery to document the surgery date 
and outcome. Surgery data will be collected until e-CRF closure of the trial. 
For patients undergoing surgery for NP please refer to Section 9.2.1.5. 
Procedures to perform and/or report at Week 36 and 48 are as follows: 
• 
Blood draw and laboratory studies as detailed in study flowchart for these visits 
• 
NPIF 
• 
Vital Signs 
10.3.2 Temporary treatment discontinuation with investigational medicinal product(s) 
Temporary treatment discontinuation may be considered by the Investigator because of AEs. 
Reinitiation of treatment with the IMP will be made under close and appropriate clinical and/or 
laboratory monitoring once the Investigator will have considered according to his/her best medical 
judgment that the AE is sufficiently resolved and unlikely to recur after resuming therapy with 
IMP. 
In addition, any of the following conditions will be a cause for temporary treatment 
discontinuation: 
• 
Infections or infestations that do not respond to medical treatment should have study drug 
discontinued until the infection is resolved 
• 
Any laboratory abnormality that meets temporary treatment discontinuation criteria as per 
Appendix H. 
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For all temporary treatment discontinuations, duration should be recorded by the Investigator in 
the appropriate pages of the e-CRF. If the IMP is interrupted for more than 2 doses, then the 
patient should permanently discontinue the study treatment. 
10.3.3 List of criteria for permanent treatment discontinuation 
The patients may withdraw from treatment with the IMP if they decide to do so, at any time and 
irrespective of the reason, or this may be the Investigator’s decision. All efforts should be made to 
document the reasons for treatment discontinuation and this should be documented in the e-CRF. 
Patients must be withdrawn from the study (ie, from any further IMP or study procedure) for the 
following reasons: 
• At their own request or at the request of their legally authorized representative (legally 
authorized representative means an individual or judicial or other body authorized under 
applicable law to consent on behalf of a prospective patient to the patient’s participation in 
the procedure(s) involved in the research). 
• If, in the Investigator’s opinion, continuation in the study would be detrimental to the 
patient’s wellbeing. 
• In case of surgery for NP, refer to Section 9.2.1.5 for details. 
• At the specific request of the Sponsor. 
• In the event of a critical protocol deviation, at the request of the Investigator or the 
Sponsor. 
• Any code broken requested by the Investigator will lead to permanent treatment 
discontinuation. 
• In the event of an anaphylactic systemic allergic reaction that is related to IMP and that 
requires treatment. 
• In the event that the patient is diagnosed with a malignancy during the study, excluding 
carcinoma in situ of the cervix or squamous or basal cell. 
• Pregnancy  
• Any opportunistic infection, such as tuberculosis or other infections whose nature or 
course may suggest an immunocompromised status (refer to Appendix J). 
• Serum ALT >3 ULN and total bilirubin > 2ULN. 
• Serum ALT >5 ULN if baseline ALT <2 ULN or ALT >8 ULN if baseline ALT >2 ULN.  
Stopping rules described in Appendix H should be applied. 
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10.3.4 Handling of patients after permanent treatment discontinuation 
Patients will be followed-up according to the study procedures as specified in this protocol up to 
the scheduled date of study completion, or up to recovery or stabilization of any AE to be 
followed-up as specified in this protocol, whichever comes last.  
Patients who permanently discontinue the study medication will be asked and encouraged to 
return to the clinic and participate in follow-up assessments described in Section 10.3.1. 
Patients who discontinue early from treatment may be asked to return to the clinic to have 
additional ADA samples collected for analysis based on the overall clinical presentation at the 
time of discontinuation. 
10.3.5 Procedure and consequence for patient withdrawal from study 
The patients may withdraw from the study before study completion if they decide to do so, at any 
time and irrespective of the reason. Withdrawal of consent for treatment should be distinguished 
from withdrawal of consent for follow-up visits and from withdrawal of consent for non-patient 
contact follow-up, eg, medical records check. If possible, the patients should be assessed using the 
procedures normally planned for the end-of-study visit including a systemic drug concentration 
sample with the exception of CT scan. 
Patients who withdraw should be explicitly asked about the contribution of possible AEs to their 
decision to withdraw consent, and any AE information elicited should be documented. Preferably 
the patient should withdraw consent in writing and, if the patient or the patient’s representative 
refuses or is physically unavailable, the site should document and sign the reason for the patient’s 
failure to withdraw consent in writing. 
All study withdrawals should be recorded by the Investigator in the appropriate screens of the e-
CRF and in the patient’s medical records when considered as confirmed. In the medical record, at 
least the date of the withdrawal and the reason should be documented. 
For patients who fail to return to the site, the Investigator should make the best effort to re-contact 
the patient (eg, contacting patient’s family or private physician, reviewing available registries or 
health care databases), and to determine his/her health status, including at least his/her vital status. 
Attempts to contact such patients must be documented in the patient’s records (eg, times and dates 
of attempted telephone contact, receipt for sending a registered letter). A patient should only be 
designated as lost to follow-up if the site is unable to establish contact with the patient after 3 
documented attempts via 2 different methods (phone, text, e-mail, certified letter, etc.).  
The statistical analysis plan (SAP) will specify how these patients lost to follow-up for their 
primary endpoints will be considered.  
Patients who have withdrawn from the study cannot be re-randomized (treated) in the study. Their 
inclusion and treatment numbers must not be reused.  
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10.4 
OBLIGATION OF THE INVESTIGATOR REGARDING SAFETY REPORTING 
10.4.1 Definitions of adverse events  
10.4.1.1 Adverse event 
An AE is any untoward medical occurrence in a patient or clinical investigation patient 
administered a pharmaceutical product and which does not necessarily have to have a causal 
relationship with this treatment. 
10.4.1.2 Serious adverse event 
An SAE is any untoward medical occurrence that at any dose: 
• 
Results in death, or 
• 
Is life-threatening, or 
Note: The term “life-threatening” in the definition of “serious” refers to an event in which 
 the patient was at risk of death at the time of the event; it does not refer to an event which 
hypothetically might have caused death if it were more severe. 
• 
Requires inpatient hospitalization or prolongation of existing hospitalization, or 
• 
Results in persistent or significant disability/incapacity, or 
• 
Is a congenital anomaly/birth defect, or 
• 
Is a medically important event. 
Medical and scientific judgment should be exercised in deciding whether expedited reporting is 
appropriate in other situations, such as important medical events that may not be immediately 
life-threatening or result in death or hospitalization but may jeopardize the patient or may require 
medical or surgical intervention (ie, specific measures or corrective treatment) to prevent one of 
the other outcomes listed in the definition above. 
Note: The following list of medically important events is intended to serve as a guideline for 
determining which condition has to be considered as a medically important event. The list is not 
intended to be exhaustive: 
• 
Intensive treatment in an emergency room or at home for: 
- 
Allergic bronchospasm  
- 
Anaphylaxis (refer to Appendix I for definition of anaphylaxis) 
- 
Blood dyscrasias (ie, agranulocytosis, aplastic anemia, bone marrow aplasia, 
myelodysplasia, pancytopenia, etc),  
- 
Convulsions (seizures, epilepsy, epileptic fit, absence, etc). 
• 
Development of drug dependence or drug abuse. 
• 
ALT >3 x ULN + total bilirubin >2 x ULN. 
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• 
Suicide attempt or any event suggestive of suicidality. 
• 
Syncope, loss of consciousness (except if documented as a consequence of blood 
sampling). 
• 
Bullous cutaneous eruptions. 
• 
Cancers diagnosed during the study or aggravated during the study. 
• 
Chronic neurodegenerative diseases (newly diagnosed) or aggravated during the study. 
10.4.1.3 Adverse event of special interest 
An adverse event of special interest (AESI) is an AE (serious or nonserious) of scientific and 
medical concern specific to the Sponsor’s product or program, for which ongoing monitoring and 
immediate notification by the Investigator to the Sponsor is required. Such events may require 
further investigation in order to characterize and understand them. Adverse events of special 
interest may be added or removed during a study by protocol amendment. 
For these AESIs, the Sponsor will be informed immediately (ie, within 24 hours), per SAE 
notification described Section 10.4.4, even if not fulfilling a seriousness criterion.  
AESIs for this study include: 
• 
Anaphylactic or systemic allergic reactions that are related to IMP and that require 
treatment (refer to Appendix I for the definition of anaphylaxis). 
• 
Severe injection site reactions that last longer than 24 hours. 
• 
Any infection meeting at least 1 of the following criteria: 
- 
Any serious infection (SAE) 
- 
Requires parenteral (IV, IM, SC) antimicrobial therapy  
- 
Requires oral antimicrobial therapy for longer than 2 weeks 
- 
Is a parasitic infection  
- 
Is an opportunistic infection (see Appendix J) 
Note:  Antimicrobial therapy refers to antibiotic, antiviral, and antifungal agents. For 
safety instructions, please see Section 10.6.3. 
• 
Significant elevation of ALT (see Appendix H) 
- 
ALT >5 × ULN in patients with baseline ALT <2 × ULN; or 
- 
ALT >8 × ULN if baseline ALT >2 × ULN. 
• 
Pregnancy occurring in a female patient entered in the clinical trial or in a female partner 
of a male patient entered in the clinical trial.  It will be qualified as an SAE only if it 
fulfills 1 of the seriousness criteria (see Section 10.4.1.2). 
- 
In the event of pregnancy in a female participant, IMP should be discontinued.  
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- 
Follow-up of the pregnancy in a female participant or in a female partner of a male 
participant is mandatory until the outcome has been determined. 
• Symptomatic overdose (serious or non-serious) with IMP/NIMP 
- 
An overdose (accidental or intentional) with the IMP/NIMP is an event suspected by 
the Investigator or spontaneously notified by the patient (not based on systematic 
syringes or pills count) and defined as at least twice the intended dose during an 
interval of less than 11 days.  The circumstances (ie, accidental or intentional) should 
be clearly specified in the verbatim and symptoms, if any, entered on separate AE 
forms. 
Of note, asymptomatic overdose has to be reported as a standard AE. 
10.4.2 Serious adverse events waived from expedited regulatory reporting to regulatory 
authorities 
Not applicable for this study. 
10.4.3 General guidelines for reporting adverse events 
All AEs, regardless of seriousness or relationship to IMP/NIMP, spanning from the signature of 
the informed consent form until the end of the study as defined by the protocol for that patient, are 
to be recorded on the corresponding page(s) or screen(s) of the e-CRF. 
Whenever possible, diagnosis or single syndrome should be reported instead of symptoms. The 
Investigator should specify the date of onset, intensity, action taken with respect to IMP, 
corrective treatment/therapy given, additional investigations performed, outcome, and his/her 
opinion as to whether there is a reasonable possibility that the AE was caused by the IMP or by 
the study procedure(s). 
The Investigator should take appropriate measures to follow all AEs until clinical recovery is 
complete and laboratory results have returned to normal, or until progression has been stabilized, 
or until death, in order to ensure the safety of the patients. This may imply that observations will 
continue beyond the last planned visit per protocol, and that additional investigations may be 
requested by the monitoring team up to as noticed by the Sponsor. 
When treatment is prematurely discontinued, the patient’s observations will continue until the end 
of the study as defined in Section 10.3.1. 
Laboratory, vital signs or ECG abnormalities are to be recorded as AEs only if:  
• 
Symptomatic and/or  
• 
Requiring either corrective treatment or consultation, and/or  
• 
Leading to IMP discontinuation or modification of dosing, and/or  
• 
Fulfilling a seriousness criterion, and/or  
• 
Defined as an AESI. 
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. 
10.4.4 Instructions for reporting serious adverse events 
In the case of occurrence of an SAE, the Investigator or any designee must immediately: 
• 
ENTER (within 24 hours) the information related to the SAE in the appropriate screens of 
the e-CRF; the system will automatically send a notification to the monitoring team after 
approval of the Investigator within the e-CRF or after a standard delay. 
• 
SEND (preferably by fax or e-mail) a photocopy of all examinations carried out and the 
dates on which these examinations were performed, to the representative of the monitoring 
team whose name, fax number, and email address appear on the clinical trial protocol. 
Care should be taken to ensure that the patient's identity is protected and the patient's 
identifiers in the clinical trial are properly mentioned on any copy of a source document 
provided to the Sponsor. For laboratory results, include the laboratory normal ranges. 
• 
All further data updates should be recorded in the e-CRF as appropriate, and further 
documentation as well as additional information (for laboratory data, concomitant 
medications, patient status, etc) should be sent (by fax or e-mail) to the monitoring team 
within 24 hours of knowledge of the SAE. In addition, every effort should be made to 
further document any SAE that is fatal or life threatening within a week (7 days) of the 
initial notification. 
• 
A back-up plan (using a paper CRF process) is available and should be used when the 
e-CRF system does not work. 
Any SAE brought to the attention of the Investigator at any time after the end of the study for the 
patient and considered by him/her to be caused by the IMP with a reasonable possibility, should 
be reported to the monitoring team. 
10.4.5 Guidelines for reporting adverse events of special interest  
For AESIs, the Sponsor must be informed immediately (ie, within 24 hours), as per SAE 
notification guidelines described in Section 10.4.4, even if not fulfilling a seriousness criterion, 
using the corresponding pages of the CRF (to be sent) or screens in the e-CRF. Instructions for 
AE reporting are summarized in Table 5. 
10.4.6 Guidelines for management of specific laboratory abnormalities 
Decision trees for the management of certain laboratory abnormalities by Sanofi are provided in 
Appendix H.  
The following laboratory abnormalities should be monitored, documented, and managed 
according to the related flow chart in protocol appendices.  
• 
Neutropenia. 
• 
Thrombocytopenia. 
• 
Increase in ALT. 
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• 
Acute renal insufficiency. 
• 
Suspicion of rhabdomyolysis. 
In addition, on treatment eosinophil counts >3000 cells/µL (3.0 G/L) are to be reported as AEs. 
NOTE: In some clinical trials these laboratory abnormalities can be considered as AESIs (see 
Section 10.4.1.3). 
Table 5 - Summary of adverse event reporting instructions 
Adverse event/laboratory abnormality 
Reporting timeframe 
Serious adverse event 
 
Within 24 hours 
Adverse Event (non-SAE, 
non-AESI)a  
 
Routine 
Pregnancyb 
 
Within 24 hours 
Overdose 
Symptomatic 
Within 24 hours 
 
Asymptomatic 
Routine 
ALT elevation 
ALT >5 ULN if baseline ALT is ≤2 ULN 
Within 24 hours 
 
ALT >8 ULN if baseline ALT is >2 ULN 
Within 24 hours 
Anaphylactic or systemic allergic reactions that are related to IMP and that require treatment 
Within 24 hours 
Severe injection site reactions that last longer than 24 hours 
Within 24 hours 
Infections as defined in Section 10.4.1.3 
 
ALT=alanine aminotransaminase; ULN=upper limit of normal. 
a For reporting of epistaxis as an AE, use both AE form and Safety complementary form to provide date, features and outcome of the event. 
b The Drug Exposure Via Parent (DEVP) form is not part of the Case Report Form, but needs to be completed for pregnancy 
10.5 
OBLIGATIONS OF THE SPONSOR 
During the course of the study, the Sponsor will report in an expedited manner: 
• 
All SAEs that are both unexpected and at least reasonably related to the IMP (suspected 
unexpected adverse drug reaction [SUSAR]), to the regulatory authorities, IECs/IRBs as 
appropriate and to the Investigators. 
• 
All SAEs that are expected and at least reasonably related to the IMPs to the regulatory 
authorities, according to local regulations. 
Any other AE not listed as an expected event in the Investigator’s Brochure or in this protocol 
will be considered unexpected. 
For safety, the treatment code will be unblinded by the Sponsor for reporting to the Health 
Authorities. 
Authority of any SUSAR according to either the judgment of the Investigator and/or the Sponsor. 
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In case of a SUSAR, sanofi Global Pharmacovigilance and Epidemiology will utilize XGRID to 
reveal medication assignment for regulatory reporting requirements for the particular case. 
The Sponsor will report all safety observations made during the conduct of the trial in the CSR. 
10.6 
SAFETY INSTRUCTIONS 
10.6.1 Hypersensitivity  
An allergic reaction is a potential risk associated with the administration of most therapeutic mAB 
treatments. 
Allergic reactions may be defined as allergic reaction-mediated signs and symptoms experienced 
by patients during or shortly after the pharmacologic or biologic agent is given. These reactions 
may present in a variety of ways, including dizziness, headache, anxiety, dyspnea, hypotension, 
tachycardia, pruritus, rash, urticaria/angioedema, flushing, nausea or vomiting, and joint pain with 
fever. Allergic reactions may begin within a few hours and persist up to 24 hours post dosing. 
Refer to Appendix I “Definition of Anaphylaxis”, which describes the clinical criteria for the 
diagnosis of anaphylaxis. 
Patients should be monitored for at least 30 minutes (or minimum time required by your local 
regulator) after each study-site administered IMP administration for any signs or symptoms of a 
hypersensitivity reaction. Any instance of allergic reaction should be reported as an AESI. Any 
anaphylactic reactions or acute allergic reactions that require immediate treatment will be AESI 
with immediate reporting (within 24 hours) and study medication must be permanently 
discontinued. Trained personnel and medications should be available to treat anaphylaxis or any 
severe allergic reaction if it occurs. Furthermore, the study patients will be advised, when the IMP 
is administered at home, to self-monitor for potential signs and symptoms that may suggest a 
hypersensitivity reaction for at least 30 minutes (or minimum time required by your local 
regulator) after administration. 
10.6.2 Severe injection site reactions 
Based on the SC mode of administration of high doses of protein and on a higher incidence of 
local injection site reactions observed at the highest dose level (300 mg weekly) in dupilumab 
studies, severe injection site reactions, are considered as a potential risk. Patients who experience 
an injection site reaction must be closely monitored for the possibility of a more intense injection 
site reaction with a future injection. Any severe injection reaction that lasts over 24 hours will be 
reported as an AESI with immediate notification. ADA and PK samples will be collected near the 
onset and completion resolution of the AESI for any additional analysis. 
 Prophylactic treatment/premedication for an injection site reaction is not permitted.   
10.6.3 Infections, including opportunistic and parasitic infections 
Some immuno-modulating biologics have been associated with an increased risk of infection, 
including opportunistic infection. Though dupilumab has not been shown to increase the 
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frequency of severe or serious infections in general, as a precautionary measure, the Investigator 
is required to carefully monitor for any signs or symptoms of infection such as, but not limited to, 
increased body temperature, malaise, weight loss, sweats, cough, dyspnea, pulmonary infiltrates, 
or serious febrile systemic illness. 
Since dupilumab binds to IL-4Rα, preventing IL-4 and IL-13 binding and activation of their 
respective receptors, it inhibits the Th2 cytokines productions. Infections with a diversity of 
helminthic parasites elicit eosinophilia via stimulation of Th2-like lymphocyte responses. The Th2 
response is characterized by production of IL-4 and IL-5, subsequently generating IgG1 
[Immunoglobulin Gamma 1] and IgE-secreting cells, and eliciting eosinophilia. Eosinophilia is 
prominent in a number of helminthic parasitic diseases. The eosinophilic response to helminths is 
determined both by the host's immune response and by the parasite, including its distribution, 
migration, and development within the infected host. Therefore, patients with treatment of 
dupilumab may potentially have an increased risk of parasitic infection. 
Infections defined in Section 10.4.1.3 should be reported as AESIs within 24 hours. 
A complete diagnostic work-up should be performed (ie, cultures, histopathological or cytological 
evaluation, antigen detection and serum antibody titers).  Patients should be referred to an 
infectious disease specialist if deemed necessary for diagnostic work up and appropriate 
treatment. 
Infections or infestations that do not respond to medical treatment should have study drug 
discontinued until the infection is resolved. 
For any opportunistic infection, such as tuberculosis or other infections whose nature or course 
may suggest an immunocompromised status (see Appendix J), patients must be permanently 
discontinued from study medication. 
In order to minimize this risk, any patient with an active parasitic infection is excluded from the 
study. Similarly, patients with suspected parasitic infection, or those at high risk of parasitic 
infection are also excluded, unless clinical and (if necessary) laboratory assessments have ruled 
out active infection before randomization. During the study, appearance of signs or symptoms 
(such as abdominal pain, cough, diarrhea, fever, fatigue hepatosplenomegaly) that could be 
associated with a parasitic infection should be carefully evaluated, especially if there is a history 
of parasitic exposure through recent travel to/ or residence in endemic areas, especially when 
conditions are conducive to infection (eg, extended stay, rural or slum areas, lack of running 
water, consumption of uncooked, undercooked, or otherwise potentially contaminated food, close 
contact with carriers and vectors, etc.). Subsequent medical assessments (eg, stool exam, blood 
tests, etc.) must be performed in order to rule out parasitic infection/infestation. Confirmed 
parasitic infections during the study should be reported as AESI with immediate notification. 
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10.6.4 Elevated liver function tests 
No preclinical or clinical data have suggested any hepatic toxicity of dupilumab; however, as a 
general consideration of clinical development, the administration of immunosuppressant or 
immunomodulating agents may represent an additional risk factor for hepatotoxicity. 
In order to closely follow liver function tests (LFT), assessment of total protein, albumin, total 
bilirubin, ALT, aspartate aminotransferase, and alkaline phosphatase are measured as part of the 
clinical laboratory testing. Clinical laboratory testing at V1 adds hepatitis screen (HBsAg, 
HBsAb, HBcAb, hepatitis C antibodies [HCAb]). Active hepatitis or patients with positive or 
indeterminate HBsAg, HBcAb or positive HCAb at V1 are excluded from the study. 
Guidance for the investigation of elevated LFTs is provided in Appendix H. 
10.7 
ADVERSE EVENTS MONITORING 
All events will be managed and reported in compliance with all applicable regulations, and 
included in the final CSR. 
11 
STATISTICAL CONSIDERATIONS 
11.1 
DETERMINATION OF SAMPLE SIZE 
The sample size is chosen to enable an adequate characterization of the efficacy between 
dupilumab 300 mg q2w and placebo with regard to the 2 coprimary endpoints, changes from 
baseline in NC and NPS at Week 24.  
The observed mean NC reduction of the dupilumab group with qw dosing in ACT12340 is 0.95 
and the observed mean NC reduction of the placebo group is 0.26. To calculate the power, a 
conservative estimate is used that assumes the placebo adjusted NC reduction of the dupilumab 
300 mg q2w group is 80% of the effect observed with dupilumab 300 mg qw. Thus, the mean NC 
reduction of the dupilumab 300 mg q2w is then assumed to be 0.81 = 0.8 * (0.95 – 0.26) + 0.26 at 
Week 24. Assuming normal distribution of the change in NC, a common standard deviation (SD) 
of 1.03, which has incorporated a 20% inflation from the observed SD in ACT12340, and a 25% 
dropout rate, with 120 patients per group, the study will have 95% power to detect an effect size 
of 0.534 using a two-sided test with alpha = 0.05 for the change in NC at Week 24 in the 
dupilumab 300 mg q2w group versus placebo.  
The observed mean NPS reduction of the dupilumab group with qw dosing in ACT12340 is 1.85 
and the observed mean NPS reduction of the placebo group is 0.30. Using the same conservative 
approach that assumes the placebo adjusted NPS reduction with the dupilumab 300 mg q2w is 
80% of the effect observed with dupilumab 300 mg qw, the mean NPS reduction of the dupilumab 
300 mg q2w group is then assumed to be 1.54 = 0.8 * (1.85 – 0.30) + 0.30. Assuming normal 
distribution of the change in NPS, a common SD of 2.11, which has incorporated a 20% inflation 
from the observed SD in ACT12340, and a 25% dropout rate, with 120 patients per group, the 
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study will have 98% power to detect an effect size of 0.588 using a two-sided test with 
alpha = 0.05 for the change in NPS at Week 24 in the dupilumab 300 mg q2w group versus 
placebo.  
Therefore, with a sample size of 120 patients per group, the combined power of the 2 coprimary 
efficacy endpoints is at least 93% for dupilumab 300 mg q2w group with alpha = 0.05 assuming 
no negative correlation between the 2 endpoints. 
The observed mean LMK reduction of the dupilumab group with qw dosing in ACT12340 is 9.07 
and the observed mean LMK reduction of the placebo group is 0.23. Using same conservative 
approach that assumes the placebo-adjusted LMK reduction of the dupilumab 300 mg q2w group 
is 80% of the dupilumab 300 mg qw, the mean LMK reduction of the dupilumab 300 mg q2w 
group is then assumed to be 7.30 = 0.8*(9.07-0.23)+0.23. Assuming normal distribution of the 
change in LMK, a common standard deviation (SD) of 5.50, which has incorporated a 20% 
inflation from the observed SD in ACT12340, and a 25% dropout rate, with 120 patients per 
group, the study will have 99% power to detect an effect size of 1.285 using a two-sided test with 
alpha = 0.05 for the change in LMK at Week 24 in the dupilumab 300 mg q2w group. 
Therefore, with the same sample size of 120 patients per group, the combined power of the 3 
coprimary efficacy endpoints for Japan is at least 92% for dupilumab 300 mg q2w group with 
alpha = 0.05 assuming no negative correlation between the 3 endpoints. 
With the same sample size of 120 patients per group, the study will have greater than 99% power 
to detect difference between the treatment groups for key secondary endpoints change from 
baseline in TSS, UPSIT and loss of smell at Week 24, and will have 98% power to detect 
difference between the treatment groups for the key secondary endpoint change from baseline in 
SNOT-22 at Week 24, using a similar assumption procedure as the change from baseline in NC 
and NPS at Week 24. 
The sample size calculations were performed using nQuery Advisor 7.0. 
11.2 
DISPOSITION OF PATIENTS 
Screened patients are defined as any patient who signed the informed consent. 
Randomized patients consist of all patients who have been allocated a treatment kit based on a 
randomization process. It will consist of all patients with a treatment kit number allocated and 
recorded in IVRS/IWRS database, and regardless of whether the treatment kit was used or not. 
Patients treated without being randomized will not be considered as randomized and will not be 
included in any efficacy population.  
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11.3 
ANALYSIS POPULATIONS 
11.3.1 Efficacy populations 
The population considered for the efficacy analysis will be the intent-to-treat (ITT) population.  
ITT population: all randomized patients analyzed according to the treatment group allocated by 
randomization regardless of whether the treatment kit is used or not. 
11.3.2 Safety population 
The population considered for safety analysis will be the safety population. 
Safety population: all patients exposed to study medication, regardless of the amount of treatment 
administered. The safety analyses will be conducted according to the treatment patients actually 
received. 
Treatment emergent period for the safety population is defined as the time between the first 
administration of study medication to Week 12 of the post treatment period. 
In addition:  
• 
Nonrandomized but treated patients will be part of the safety population.  
• 
Randomized patients for whom it is unclear whether they took the study medication will 
be included in the safety population as randomized. 
11.3.3 Systemic drug concentration population 
The systemic drug concentration population will consist of all patients in the safety population 
with at least one evaluable functional dupilumab concentration result. Patients will be analyzed 
according to the treatment actually received. 
11.3.4 Anti-drug antibody population  
The ADA population will consist of all patients in the safety population with at least one 
evaluable ADA serum sample that was assayed successfully in the ADA assay following the first 
dose of the study medication. Patients will be analyzed according to the treatment actually 
received. 
11.4 
STATISTICAL METHODS 
11.4.1 Extent of study treatment exposure and compliance 
The extent of study treatment exposure and compliance will be assessed and summarized 
according to actual treatment received within the safety population. 
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11.4.1.1 Extent of investigational medicinal product exposure 
Duration of IMP exposure is defined as: last dose date – first dose date + 14 days, regardless of 
unplanned intermittent discontinuations. Compliance 
A given administration will be considered noncompliant if the patient did not take the planned 
dose of treatment as required by the protocol. No imputation will be made for patients with 
missing or incomplete data. 
Percentage of compliance for a patient will be defined as the number of administrations the 
patient was compliant divided by the total number of administrations the patient was planned to 
take during the treatment period (ie, from the first to the last administration). 
Treatment compliance, above-planned and underplanned dosing percentages will be summarized 
descriptively (N, Mean, SD, Median, Min, and Max). The percentage of patients with compliance 
is <80% will be summarized. In addition, number and percentage of patients with at least 1 above 
planned dosing administration will be given, as well as the number and percentage of patients 
with 0, (0, 20%), and >20% underplanned dosing administrations. 
11.4.2 Analyses of efficacy endpoints 
11.4.2.1 Analysis of coprimary efficacy endpoint(s) 
11.4.2.1.1 Coprimary efficacy variables 
The coprimary efficacy variables are: change from baseline in NC and in NPS at Week 24 
assessed for dupilumab 300 mg q2w (Arm A) versus placebo (Arm B). 
For Japan only, in addition to the 2 coprimary endpoints above, the following will also be a 
coprimary endpoint: 
• 
Change from baseline in sinus opacifications assessed by CT scans using the LMK score 
at Week 24. 
The following null hypothesis and alternative hypothesis will be tested for dupilumab 300 mg 
q2w group against placebo:  
• 
H0: No treatment difference between the dupilumab dose regimen and placebo. 
• 
H1: There is a treatment difference between the dupilumab dose regimen and placebo. 
11.4.2.1.2 Analysis of the coprimary efficacy variables 
Each of the 2 coprimary efficacy endpoints (3 coprimary endpoints for Japan) will be analyzed 
using a hybrid method of the worst-observation carried forward (WOCF) and the multiple 
imputation (MI). With this approach, for patients who undergo surgery for NP or receive SCS for 
any reason, data collected postsurgery or post SCS will be set to missing, and the worst 
postbaseline value on or before the time of surgery or SCS intake will be used to impute missing 
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Week 24 value (for patients whose postbaseline values are all missing, the baseline will be used to 
impute). For patients who discontinue the treatment without being rescued by surgery or receiving 
SCS, an MI approach will be used to impute missing Week 24 value, and this MI will use all 
patients who have not been rescued by surgery or receiving SCS at Week 24 and data collected 
after treatment discontinuation will be included in the analysis. Each of the imputed complete data 
will be analyzed by fitting an analysis of covariance model with the baseline covariate and factors 
for treatment, asthma status, prior surgery history, and regions. Statistical inference obtained from 
all imputed data will be combined using Rubin’s rule. Descriptive statistics including number of 
subjects mean, standard error of the mean (SEM), and least squares (LS) means will be provided. 
In addition, difference in LS means and the corresponding 95% confidence intervals (CI) will be 
provided along with the p-values. 
11.4.2.1.3 Sensitivity analyses 
The reason and pattern of missing data will be carefully examined and tipping point analyses and 
other sensitivity analyses will be performed. Details of the sensitivity analyses will be provided in 
the SAP. 
11.4.2.1.4 Subgroup analysis 
To assess the consistency in treatment effects across different subgroup levels, subgroup analyses 
will be conducted for the coprimary efficacy endpoints with respect to age group, gender, region, 
prior surgery history, race, INCS dose level, baseline NPS, baseline NC, baseline TSS, baseline 
LMK, prior SCS use, and asthma/NERD comorbidity. The details will be provided in the SAP. 
11.4.2.2 Analyses of key secondary efficacy endpoints 
11.4.2.2.1 Analysis of the change from baseline in TSS, UPSIT, daily loss of smell, LMK, and 
SNOT-22 at Week 24 for dupilumab 300 mg q2w versus placebo  
The change from baseline in TSS, SNOT-22, UPSIT score, daily loss of smell, and LMK score at 
Week 24 will be analyzed using the hybrid method of the WOCF and the MI in the same fashion 
as for the coprimary endpoints.  
Note:  LMK will not be a secondary endpoint for Japan as it is already a coprimary endpoint. 
11.4.2.2.2 Analysis of proportion of patients with SCS rescue or surgery (actual or planned) for 
NP during the 24-week treatment period for dupilumab 300 mg q2w versus placebo  
Proportion of patients with first SCS rescue and/or surgery (actual or planned) for NP during the 
24 weeks of treatment period will be derived and analyzed using the Cox proportional hazards 
model and log rank test stratified by asthma status, prior surgery history, and regions, by 
considering the first SCS rescue use or surgery (actual or planned) for NP as the event. 
Descriptive statistics including number of patients with rescue and/or surgery and number of 
patients without rescue or surgery (censored) and the corresponding rates will be provided by 
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treatment group. The estimates of the hazard ratio and corresponding 95% CI will be provided for 
dupilumab group versus placebo group. 
11.4.2.3 Multiplicity considerations 
The multiplicity procedure is proposed to control the overall type-I error rate for testing the 
coprimary and selected secondary endpoints dupilumab 300 mg q2w versus placebo. The overall 
alpha is 0.05. The comparisons with placebo will be tested based on the hierarchical order below 
at 2-sided α = 0.05 for 300 mg q2w dose regimen versus placebo: 
1. Co-primary efficacy endpoints: 
In countries other than Japan: 
• 
Change from baseline in NC and in NPS at Week 24. 
In Japan: 
• 
Change from baseline in NC, in NPS, and in CT LMK at Week 24. 
2. Secondary efficacy endpoints: 
• 
Change from baseline in TSS at Week 24. 
• 
Change from baseline in UPSIT at Week 24. 
• 
Change from baseline in loss of smell daily symptoms at Week 24. 
• 
Change from baseline in SNOT-22 at Week 24. 
• 
Change from baseline in LMK score at Week 24. (This will not be a secondary endpoint 
for Japan as it is already a coprimary endpoint). 
• 
Proportion of patients with SCS rescue or surgery for NP during the treatment period. 
In countries other than Japan, the study is considered positive when both coprimary endpoints, the 
change from baseline in NC and NPS at Week 24, achieve statistical significance. 
In Japan, the study is considered positive when all coprimary endpoints, the change from baseline 
in NC, in NPS, and in CT LMK at Week 24, achieve statistical significance. 
11.4.2.4 Analyses of other secondary efficacy endpoints and subgroup analysis  
11.4.2.4.1 Comparisons for other secondary efficacy endpoints 
Comparisons will be made between dupilumab and placebo in the following endpoints: 
• 
Change from baseline at Week 24 in: 
- 
VAS for overall rhinosinusitis. 
- 
NPIF. 
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- 
Rhinorrhea (anterior/posterior nasal discharge) daily symptom score assessed by the 
patient. 
- 
Patient reported outcomes including HRQoL scales (EQ-5D-5L VAS score). 
• 
Proportion of responders at Week 24 (defined as patients with improvement by at least 
1 point in NPS).  
• 
Proportion of patients with improvement by at least 1 point in NPS and 0.5 reduction in 
NC by Week 24. 
• 
Proportion and time-to-event of patients with SCS rescue for any airway exacerbated 
disease (included but not limited to NP, CRS, allergic rhinitis, and asthma). 
• 
Proportion of patients with MCID ≥8.9 in SNOT-22 at Week 24. 
• 
Proportion of patients with overall rhinosinusitis severity VAS ≤7 at Week 24. 
• 
Safety (incidence of treatment-emergent AEs (TEAE), of treatment-emergent SAEs 
(TESAEs), and TEAEs leading to treatment discontinuation), laboratory values, vital 
signs.  
• 
Dupilumab concentration in serum and ADA. 
In the subgroups of patients with prior surgery, or comorbid asthma (including NERD history): 
• 
Change from baseline and time course profiles in in NC, NPS, TSS, UPSIT, loss of smell 
daily symptoms, LMK score, and SNOT-22 at Week 24. 
• 
Proportion and time-to-event of patients with SCS rescue and/or surgery (actual or 
planned) for nasal polyps during the treatment period. 
• 
Proportion and time-to-event of patients with SCS use for any airway exacerbated disease. 
• 
Proportion of patients with VAS ≤7 at Week 24. 
• 
Change from baseline in ACQ-6 (in patients with asthma/NERD only) at Week 24. 
• 
Proportion of responders at Week 24 (defined as patients with improvement by at least 
1 point in NPS). 
• 
Proportion of patients with improvement by at least 1 point in NPS and 0.5 reduction in 
NC by Week 24. 
Through the 24-week follow-up period, the following endpoints will be analyzed: 
• 
Change from baseline at Week 36 (12-week follow-up after the EOT) and Week 48 
(24-week follow-up after the EOT) in: 
- 
NC and NPS. 
- 
TSS, UPSIT, LMK, SNOT-22, and VAS for overall rhinosinusitis. 
• 
Change from Week 24 (the EOT visit) to Week 36 (12-week follow-up after the EOT) and 
change from Week 24 (the EOT visit) to Week 48 (24-week follow-up after the EOT) in: 
- 
NC and NPS. 
- 
TSS, UPSIT, LMK, SNOT-22, and VAS for overall rhinosinusitis. 
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11.4.2.4.2 Analysis of continuous secondary efficacy endpoints 
Changes from baseline in continuous endpoints at week 24 will be analyzed using the hybrid 
method of the WOCF and the MI in the same fashion as for the coprimary endpoints. 
11.4.2.4.3 Analysis of subgroups with comorbid asthma/NERD and prior surgery 
For each subgroup factor, interaction tests will be carried out to investigate consistency of the 
dupilumab effect across different subgroups identified by that factor. 
In addition to the analysis in the current study, statistical analysis for subgroups with comorbid 
asthma/NERD, and prior surgery will be further conducted using the pooled data of EFC14280 
and EFC14146, and the details will be provided in the SAP for the Integrated Summary of 
Efficacy. 
11.4.2.4.4 Analysis of the responder endpoints  
For any responder type endpoint, including the proportion of responders at Week 24, the 
proportion of patients with MCID ≥8.9 in SNOT-22 at Week 24, and the proportion of patients 
with VAS ≤7 at Week 24, the Cochran-Mantel-Haenszel test stratified by asthma status, prior 
surgery history, and region will be used. Comparisons of the proportions of responders between 
dupilumab 300 mg q2w and placebo will be derived. Patients who are indicated for surgery for 
NP or receive SCS for any reason will be considered as nonresponders for time points after using 
SCS or surgery. For patients who discontinue treatment without using SCS or surgery, data 
collected during the off-treatment period will be used to determine the responder/nonresponder 
status. Missing data will be considered as nonresponders. 
11.4.2.4.5 Analysis of the proportion and time-to-event of patients with SCS rescue for any airway 
exacerbated disease 
Proportion and time-to-event of patients with SCS rescue for any airway exacerbated disease will 
be analyzed using a similar approach as the key secondary endpoint of the proportion of patients 
with SCS rescue or surgery (actual or planned) for NP. 
11.4.2.4.6 Analysis of continuous efficacy endpoints through the 24-week follow-up period 
For the change from baseline in continuous endpoints through the 24-week follow-up period, 
descriptive statistics including number of subjects, mean, SEM, and the corresponding 95% 
confidence interval (CI) will be provided by treatment. 
11.4.2.5 Analyses of exploratory efficacy endpoints 
Statistical analysis for exploratory efficacy endpoints will be provided in the final SAP. 
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11.4.2.6 Missing data handling 
For all continuous efficacy endpoints, in the primary approach for missing data handling, for 
patients who are indicated to undergo surgery for NP or receive SCS for any reason, data 
collected postsurgery or post SCS will be set to missing, and the worst postbaseline value on or 
before the time of surgery or SCS will be used to impute missing value at the certain analyzed 
visit (for patients whose postbaseline values are all missing, the baseline will be used to impute), 
and for patients who discontinue the treatment without being rescued by surgery or receiving SCS 
on or before the analyzed visit, a MI approach will be used to impute missing value at the certain 
analyzed visit, and this MI will use all patients who have not been rescued by surgery or receiving 
SCS at that analyzed visit and data collected after treatment discontinuation will be included in 
the analysis. 
For responder type endpoints, patients who are indicated for surgery for NP or receive SCS for 
any reason will be considered as nonresponders for time points after using SCS or surgery; for 
patients who discontinue treatment without using SCS or surgery, data collected during the 
off-treatment period will be used to determine the responder/non- responder status, and missing 
data will be considered as non-responders. 
In addition, the reason and pattern of missing data will be carefully examined and tipping point 
analyses and other sensitivity analyses will also be performed. 
11.4.3 Analyses of safety data 
The summary of safety results will be presented by treatment groups. All safety analyses will be 
performed on the safety population using the following common rules: 
The baseline value is defined generally as the last available value before randomization. 
The following definitions will be applied to laboratory parameters, vital signs and ECG. 
• 
The potentially clinically significant abnormality (PCSA) values are defined as abnormal 
values considered medically important by the Sponsor according to predefined 
criteria/thresholds based on literature review and defined by the Sponsor for clinical 
laboratory tests, vital signs, and ECG. 
• 
PCSA criteria will determine which patients had at least 1 PCSA during the treatment 
emergent period, taking into account all evaluations performed during the on-treatment 
period, including unscheduled or repeated evaluations. The number of all such patients 
will be the numerator for the on-treatment PCSA percentage. 
11.4.3.1 Adverse events 
Adverse event incidence tables will present by system organ class (SOC) (sorted by 
internationally agreed order), high level group term (HLGT), high level term (HLT) and preferred 
term (PT) sorted in alphabetical order for each treatment group, the number (n) and percentage 
(%) of patients experiencing an AE. Multiple occurrences of the same event in the same patient 
will be counted only once in the tables within a treatment phase. The denominator for 
computation of percentages is the safety population within each treatment group. 
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Proportion of patients with at least one TEAE, serious TEAE and TEAE leading to permanent 
treatment discontinuation will be tabulated by treatment groups. In addition, TEAEs will be 
described according to maximum intensity and relation to the study drug. Serious AEs and AEs 
leading to study discontinuation that occur outside the treatment emergent period will be 
summarized separately. 
11.4.3.1.1 Adverse event of special interest (AESI) 
The following summaries will be generated:  
• 
Incidence of each AESI will be tabulated by treatment groups. 
• 
The time-to-first event analyzed using Kaplan-Meier (K-M) methods and displayed as 
K-M plots (cumulative incidence [%] versus time based on K-M estimates) will be 
provided to depict the course of onset over time. When TEAE start date or worsening date 
is partially available, the maximum of the earliest possible TEAE start date and the 
treatment start date will be used. When TEAE start date or worsening date is completely 
missing, the treatment start date will be used. 
AESI definitions and the method to identify AESIs will be specified in the SAP. 
11.4.3.1.2 Death 
The following deaths summaries will be generated: 
• 
Number (%) of patients who died by study period (TEAE, on-study) and reasons for death 
summarized on the safety population by treatment received. 
• 
Death in nonrandomized patients or randomized and not treated patients. 
• 
TEAE leading to death (death as an outcome on the AE e-CRF page as reported by the 
Investigator) by primary SOC, HLGT, HLT and PT showing number (%) of patients 
sorted by internationally agreed order of SOC and alphabetic order of HLGT, HLT, and 
PT. 
Patient data listings will be provided for all AEs, TEAEs, SAE, AEs leading to permanent 
treatment discontinuation, AESIs and deaths. 
11.4.3.1.3 Clinical laboratory evaluation, vital signs and electrocardiogram (ECG) data  
Results and change from baseline for clinical laboratory evaluation and vital signs parameters will 
be summarized by treatment groups for baseline and each post baseline time point, endpoint, 
minimum and maximum value. Summary statistics will include number of patients, mean, SD, 
median, Q1, Q3, minimum and maximum. 
The proportion of patients who had at least one incidence of PCSA at any time during the 
treatment emergent period will be summarized by treatment groups within each treatment phase. 
Shift tables showing changes with respect to the baseline status will be provided. 
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Listings will be provided with flags indicating clinically out-of-range values, as well as PCSA 
values. 
11.4.4 Analyses of pharmacokinetic and pharmacodynamic variables and antidrug 
metabolites 
11.4.4.1 Functional dupilumab concentration analysis 
Concentrations of functional dupilumab in serum will be summarized using arithmetic and 
geometric means, SD, SEM, coefficient of variation (CV%), minimum, median, and maximum by 
treatment arms per visit. 
Concentrations of functional dupilumab in serum will be used for population PK analysis by 
nonlinear mixed effects modeling if warranted. Additional details of the analysis plan and the 
results will be provided in a separate document. 
11.4.4.2 Anti-drug antibodies analysis 
Incidence of positivity in the ADA assay will be assessed on samples collected, as absolute 
occurrence (n) and percent of patients (%), presented by treatment groups. Listing of all ADA titer 
levels will be provided for patients positive in the ADA assay. Samples positive in the ADA assay 
will be further characterized for the presence of antidupilumab neutralizing antibodies. 
Plots of concentrations of functional dupilumab will be examined and the potential influence of 
ADA on individual concentration-time profiles will be evaluated. Assessment of the potential 
impact of ADA on safety and efficacy may be provided. 
ADA at baseline will be summarized by: 
• 
Number (%) of patients with a baseline sample negative in the ADA assay. 
• 
Number (%) of patients with a baseline sample positive in the ADA assay (pre-existing 
immunoreactivity). 
Total subject number (%) will be provided for the following: 
• 
Number (%) of patients with treatment-emergent positive response in the ADA assay. 
(ADA incidence). 
• 
Number (%) of transient treatment-emergent positive patients. 
• 
Number (%) of persistent treatment-emergent positive patients. 
• 
Number (%) of treatment-boosted positive patients. 
• 
Number (%) of undetermined treatment-emergent positive patients. 
Titer values (Titer value category). 
The minimum titer for positive samples in the ADA assay is based on the minimum required 
dilution of the assay. 
• 
Low (Titer <1000). 
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• 
Moderate (1000 ≤Titer ≤10 000). 
• 
High (Titer >10 000). 
Definitions of pre-existing immunoreactivity, treatment emergent, persistent response, transient 
response, treatment-boosted, and undetermined response will be specified in the SAP. 
11.4.4.3 Pharmacodynamics 
The values to be used as baselines will be those collected on Day 1 (predose assessments). If any 
of the scheduled assessments on Day 1 are technically disqualified (eg, insufficient sample) and 
the parameters are measured at any of the run-in period visits, then values determined at the run-in 
period visits can be used as baseline. 
For all parameters, raw data, changes from baseline and percent changes from baseline will be 
summarized in descriptive statistics by treatment arms and time points. 
Summary plots (mean +/- SEM) on raw data, changes from baseline and percent changes from 
baseline will be provided by treatment arms. 
11.4.5 Analyses of Patient Reported Outcomes (Health-related Quality of Life/health 
economics variables) 
Change from baseline in the quantitative variables of EQ-5D-5L (index score) and EQ-5D VAS 
(self-rated health) will be analyzed using the hybrid method of the WOCF and the MI in the same 
fashion as for the coprimary endpoints. Descriptive statistics including number of patients, mean, 
SEM, and LS means will be provided. In addition, difference in LS means and the corresponding 
95% CI will be provided along with the p-values.  
11.5 
FIRST STEP ANALYSIS 
A first step analysis may be performed when all patients complete the Week 24 visit, including 
early dropouts. Since this analysis is the final analysis of the coprimary endpoints and other 
24-week endpoints and no decision on the conduct of the study will be made based on the first 
step analysis (in particular, no decision to prematurely stop the study), there will be no alpha 
adjustment due to the interim analysis. Specific steps will be taken to maintain the blind of the 
study to all individuals involved in the conduct of the study and/or analysis. 
Individuals involved in the first step analysis of the study will not be involved in the conduct of 
the study afterwards; individual patient identification will not be released to anyone who is 
directly involved in the conduct of the study. 
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12 
ETHICAL AND REGULATORY CONSIDERATIONS 
12.1 
ETHICAL AND REGULATORY STANDARDS 
This clinical trial will be conducted by the Sponsor, the Investigator, delegated Investigator staff 
and Subinvestigator, in accordance with the principles laid down by the 18th World Medical 
Assembly (Helsinki, 1964) and all applicable amendments laid down by the World Medical 
Assemblies, and the International Conference for Harmonization (ICH) guidelines for good 
clinical practice (GCP), all applicable laws, rules and regulations. 
This clinical trial will be recorded in a free, publicly accessible, internet-based registry, no later 
than 21 days after the first patient enrollment, in compliance with applicable regulatory 
requirements and with sanofi public disclosure commitments. 
12.2 
INFORMED CONSENT 
The Investigator (according to applicable regulatory requirements), or a person designated by the 
Investigator, and under the Investigator's responsibility, should fully inform the patient of all 
pertinent aspects of the clinical trial including the written information giving approval/favorable 
opinion by the ethics committee (IRB/IEC). All participants should be informed to the fullest 
extent possible about the study, in language and terms they are able to understand. 
Prior to a patient’s participation in the clinical trial, the written informed consent form should be 
signed, name filled in and personally dated by the patient or by the patient’s legally acceptable 
representative, and by the person who conducted the informed consent discussion. A copy of the 
signed and dated written informed consent form will be provided to the patient.  
 
 
 
Depending on local regulations, prior to collection of blood for HIV testing, an optional respective 
informed consent form(s) (written) must be signed, name completed, and personally dated by the 
patient or by the patient’s legally acceptable representative, and by the person who conducted the 
informed consent discussion. A copy of the signed and dated written optional informed consent 
form(s) will be provided to the patient. 
The informed consent form and the optional informed consent forms used by the Investigator for 
obtaining the patient's informed consent must be reviewed and approved by the Sponsor prior to 
submission to the appropriate IRB/IEC for approval/favorable opinion. 
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12.3 
HEALTH AUTHORITIES AND INSTITUTIONAL REVIEW BOARD/INDEPENDENT 
ETHICS COMMITTEE (IRB/IEC)  
As required by local regulation, the Investigator or the Sponsor must submit this clinical trial 
protocol to the health authorities (competent regulatory authority) and the appropriate IRB/IEC, 
and is required to forward to the respective other party a copy of the written and dated 
approval/favorable opinion signed by the chairman with IRB/IEC composition. 
The clinical trial (study number, clinical trial protocol title and version number), the documents 
reviewed (clinical trial protocol, informed consent form, Investigator’s Brochure with any 
addenda or labeling documents (summary of product characteristics, package insert, Investigator’s 
curriculum vitae [CV], etc) and the date of the review should be clearly stated on the written 
(IRB/IEC) approval/favorable opinion. 
The IMP will not be released at the study site and the Investigator will not start the study before 
the written and dated approval/favorable opinion is received by the Investigator and the Sponsor. 
During the clinical trial, any amendment or modification to the clinical trial protocol should be 
submitted to the health authorities (competent regulatory authority), as required by local 
regulation, in addition to the IRB/IEC before implementation, unless the change is necessary to 
eliminate an immediate hazard to the patients, in which case the health authorities (competent 
regulatory authority) and the IRB/IEC should be informed as soon as possible. They should also 
be informed of any event likely to affect the safety of patients or the continued conduct of the 
clinical trial, in particular any change in safety. All updates to the Investigator’s Brochure will be 
sent to the IRB/IEC and to health authorities (competent regulatory authority), as required by 
local regulation. 
 
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13 
STUDY MONITORING 
13.1 
RESPONSIBILITIES OF THE INVESTIGATOR(S) 
The Investigator is required to ensure compliance with all procedures required by the clinical trial 
protocol and with all study procedures provided by the Sponsor (including security rules). The 
Investigator agrees to provide reliable data and all information requested by the clinical trial 
protocol (with the help of the CRF, Discrepancy Resolution Form [DRF] or other appropriate 
instrument) in an accurate and legible manner according to the instructions provided and to ensure 
direct access to source documents by Sponsor representatives. 
If any circuit includes transfer of data particular attention should be paid to the confidentiality of 
the patient's data to be transferred. 
The Investigator may appoint such other individuals as he/she may deem appropriate as 
Subinvestigators to assist in the conduct of the clinical trial in accordance with the clinical trial 
protocol. All Subinvestigators shall be appointed and listed in a timely manner. The 
Subinvestigators will be supervised by, and work under the responsibility of, the Investigator. The 
Investigator will provide them with a copy of the clinical trial protocol and all necessary 
information. 
13.2 
RESPONSIBILITIES OF THE SPONSOR 
The Sponsor of this clinical trial is responsible to regulatory authorities for taking all reasonable 
steps to ensure the proper conduct of the clinical trial as regards ethics, clinical trial protocol 
compliance, and integrity and validity of the data recorded on the e-CRFs. Thus, the main duty of 
the monitoring team is to help the Investigator and the Sponsor maintain a high level of ethical, 
scientific, technical and regulatory quality in all aspects of the clinical trial. 
At regular intervals during the clinical trial, the site will be contacted, through monitoring visits, 
letters or telephone calls, by a representative of the monitoring team to review study progress, 
Investigator and patient compliance with clinical trial protocol requirements and any emergent 
problems. These monitoring visits will include but not be limited to review of the following 
aspects: patient informed consent, patient recruitment and follow-up, SAE documentation and 
reporting, AESI documentation and reporting, AE documentation, IMP allocation, patient 
compliance with the IMP regimen, IMP accountability, concomitant therapy use and quality of 
data. Source document requirements 
According to the ICH GCP, the monitoring team must check the e-CRF entries against the source 
documents, except for the preidentified source data directly recorded in the CRF. The informed 
consent form will include a statement by which the patient allows the Sponsor’s duly authorized 
personnel, IRB/IEC, and the regulatory authorities to have direct access to original medical 
records which support the data on the e-CRFs (eg, patient's medical file, appointment books, 
original laboratory records, etc). These personnel, bound by professional secrecy, must maintain 
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the confidentiality of all personal identity or personal medical information (according to 
confidentiality and personal data protection rules). 
13.3 
USE AND COMPLETION OF CASE REPORT FORMS (CRFS) AND ADDITIONAL 
REQUEST 
It is the responsibility of the Investigator to maintain adequate and accurate CRFs (according to 
the technology used) designed by the Sponsor to record (according to Sponsor instructions) all 
observations and other data pertinent to the clinical investigation in a timely manner. All CRFs 
should be completed in their entirety in a neat, legible manner to ensure accurate interpretation of 
data. 
Should a correction be made, the corrected information will be entered in the e-CRF overwriting 
the initial information. An audit trail allows identifying the modification. 
Data are available within the system to the Sponsor as soon as they are entered in the e-CRF. 
The computerized handling of the data by the Sponsor may generate additional requests (DRFs) to 
which the Investigator is obliged to respond by confirming or modifying the data questioned. The 
requests with their responses will be managed through the e-CRF. 
13.4 
USE OF COMPUTERIZED SYSTEMS 
The complete list of computerized systems used for the study is provided in a separate document 
which is maintained in the Sponsor and Investigator study files. 
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14 
ADDITIONAL REQUIREMENTS 
14.1 
CURRICULUM VITAE 
A current copy of the curriculum vitae describing the experience, qualification and training of 
each Investigator and Subinvestigator will be signed, dated and provided to the Sponsor prior to 
the beginning of the clinical trial. 
14.2 
RECORD RETENTION IN STUDY SITES 
The Investigator must maintain confidential all study documentation, and take measures to 
prevent accidental or premature destruction of these documents. 
The Investigator should retain the study documents at least 15 years after the completion or 
discontinuation of the clinical trial. 
However, applicable regulatory requirements should be taken into account in the event that a 
longer period is required. 
The Investigator must notify the Sponsor prior to destroying any study essential documents 
following the clinical trial completion or discontinuation. 
If the Investigator's personal situation is such that archiving can no longer be ensured by him/her, 
the Investigator shall inform the Sponsor and the relevant records shall be transferred to a 
mutually agreed upon designee. 
14.3 
CONFIDENTIALITY 
All information disclosed or provided by the Sponsor (or any company/institution acting on their 
behalf), or produced during the clinical trial, including, but not limited to, the clinical trial 
protocol, personal data in relation to the patients, the CRFs, the Investigator's Brochure, and the 
results obtained during the course of the clinical trial, is confidential, prior to the publication of 
results. The Investigator and any person under his/her authority agree to undertake to keep 
confidential and not to disclose the information to any third party without the prior written 
approval of the Sponsor. 
However, the submission of this clinical trial protocol and other necessary documentation to the 
IRB/IEC is expressly permitted, the IRB/IEC members having the same obligation of 
confidentiality. 
The Subinvestigators shall be bound by the same obligation as the Investigator. The Investigator 
shall inform the Subinvestigators of the confidential nature of the clinical trial. 
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The Investigator and the Subinvestigators shall use the information solely for the purposes of the 
clinical trial, to the exclusion of any use for their own or for a third party's account. 
14.4 
PROPERTY RIGHTS 
All information, documents and IMP provided by the Sponsor or its designee are and remain the 
sole property of the Sponsor. 
The Investigator shall not and shall cause the delegated Investigator staff/Subinvestigator not to 
mention any information or the Product in any application for a patent or for any other intellectual 
property rights. 
All the results, data, documents and inventions, which arise directly or indirectly from the clinical 
trial in any form, shall be the immediate and exclusive property of the Sponsor. 
The Sponsor may use or exploit all the results at its own discretion, without any limitation to its 
property right (territory, field, continuance). The Sponsor shall be under no obligation to patent, 
develop, market or otherwise use the results of the clinical trial. 
As the case may be, the Investigator and/or the Subinvestigators shall provide all assistance 
required by the Sponsor, at the Sponsor's expense, for obtaining and defending any patent, 
including signature of legal documents. 
14.5 
DATA PROTECTION 
• 
The patient's personal data, which are included in the Sponsor database shall be treated in 
compliance with all applicable laws and regulations. 
• 
When archiving or processing personal data pertaining to the Investigator and/or to the 
patients, the Sponsor shall take all appropriate measures to safeguard and prevent access to 
this data by any unauthorized third party. 
• 
The Sponsor also collects specific data regarding Investigator as well as personal data 
from any person involved in the study which may be included in the Sponsor’s databases, 
shall be treated by both the Sponsor and the Investigator in compliance with all applicable 
laws and regulations. 
Patient race and ethnicity (Caucasian/White, Black, Asian/Oriental, Others) will be collected in 
this study because these data are required by several regulatory authorities (eg, on Afro-American 
population for Food and Drug Administration [FDA], on Japanese population for the 
Pharmaceuticals and Medical Devices Agency [PMDA] in Japan). 
 
The data collected in this study will only be used for the purpose(s) of the study and to document 
the evaluation of the benefit/ risk ratio, efficacy and safety of the product(s). They may be further 
processed if they have been anonymized. 
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14.6 
INSURANCE COMPENSATION 
The Sponsor certifies that it has taken out a liability insurance policy covering all clinical trials 
under its sponsorship. This insurance policy is in accordance with local laws and requirements. 
The insurance of the Sponsor does not relieve the Investigator and the collaborators from any 
obligation to maintain their own liability insurance policy. An insurance certificate will be 
provided to the IECs/IRBs or regulatory authorities in countries requiring this document.  
14.7 
SPONSOR AUDITS AND INSPECTIONS BY REGULATORY AGENCIES 
For the purpose of ensuring compliance with the clinical trial protocol, GCP, and applicable 
regulatory requirements, the Investigator should permit auditing by or on the behalf of the 
Sponsor and inspection by regulatory authorities. 
The Investigator agrees to allow the auditors/inspectors to have direct access to his/her study 
records for review, being understood that these personnel are bound by professional secrecy, and 
as such will not disclose any personal identity or personal medical information. 
The Investigator will make every effort to help with the performance of the audits and inspections, 
giving access to all necessary facilities, data, and documents. 
As soon as the Investigator is notified of a planned inspection by the authorities, he will inform 
the Sponsor and authorize the Sponsor to participate in this inspection. 
The confidentiality of the data verified and the protection of the patients should be respected 
during these inspections. 
Any result and information arising from the inspections by the regulatory authorities will be 
immediately communicated by the Investigator to the Sponsor. 
The Investigator shall take appropriate measures required by the Sponsor to take corrective 
actions for all problems found during the audit or inspections. 
14.8 
PREMATURE DISCONTINUATION OF THE STUDY OR PREMATURE CLOSE-OUT OF 
A SITE 
14.8.1 By the Sponsor 
The Sponsor has the right to terminate the participation of either an individual site or the study at 
any time, for any reason, including but not limited to the following: 
• The information on the product leads to doubt as to the benefit/risk ratio. 
• Patient enrollment is unsatisfactory. 
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• The Investigator has received from the Sponsor all IMP, means, and information necessary 
to perform the clinical trial and has not included any patient after a reasonable period of 
time mutually agreed upon. 
• Noncompliance of the Investigator or Subinvestigator, delegated staff with any provision 
of the clinical trial protocol, and breach of the applicable laws and regulations or breach of 
the ICH GCP. 
• The total number of patients are included earlier than expected. 
In any case the Sponsor will notify the Investigator of its decision by written notice. 
14.8.2 By the Investigator 
The Investigator may terminate his/her participation upon thirty (30) days' prior written notice if 
the study site or the Investigator for any reason becomes unable to perform or complete the 
clinical trial.  
In the event of premature discontinuation of the study or premature close-out of a site, for any 
reason whatsoever, the appropriate IRB/IEC and regulatory authorities should be informed 
according to applicable regulatory requirements. 
14.9 
CLINICAL TRIAL RESULTS 
The Sponsor will be responsible for preparing a CSR and to provide a summary of study results to 
the Investigator. 
14.10 PUBLICATIONS AND COMMUNICATIONS 
The Investigator undertakes not to make any publication or release pertaining to the study and/or 
results of the study prior to the Sponsor’s written consent, being understood that the Sponsor will 
not unreasonably withhold its approval. 
As the study is being conducted at multiple sites, the Sponsor agrees that, consistent with 
scientific standards, a primary presentation or publication of the study results based on global 
study outcomes shall be sought. However, if no multicenter publication is submitted, underway, 
or planned within 12 months of the completion of this study at all sites, the Investigator shall have 
the right to publish or present independently the results of this study in agreement with other 
Investigators and stakeholders. The Investigator shall provide the Sponsor with a copy of any such 
presentation or publication for review and comment at least 30 days in advance of any 
presentation or submission for publication. In addition, if requested by the Sponsor, any 
presentation or submission for publication shall be delayed for a limited time, not to exceed 
90 days, to allow for filing of a patent application or such other justified measures as the Sponsor 
deems appropriate to establish and preserve its proprietary rights. 
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The Investigator shall not use the name(s) of the Sponsor and/or its employees in advertising or 
promotional material or publication without the prior written consent of the Sponsor. The Sponsor 
shall not use the name(s) of the Investigator and/or the collaborators in advertising or promotional 
material or publication without having received his/her and/or their prior written consent(s). 
The Sponsor has the right at any time to publish the results of the study. 
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15 
CLINICAL TRIAL PROTOCOL AMENDMENTS 
All appendices attached hereto and referred to herein are made part of this clinical trial protocol. 
In case of substantial amendment to the clinical trial protocol, approval from the health authorities 
(competent regulatory authority) will be sought before implementation. 
The Investigator should not implement any deviation from, or changes of the clinical trial protocol 
without agreement by the Sponsor and prior review and documented approval/favorable opinion 
from the IRB/IEC of an amendment, except where necessary to eliminate an immediate hazard(s) 
to clinical trial patients, or when the change(s) involves only logistical or administrative aspects of 
the trial. Any change agreed upon will be recorded in writing, the written amendment will be 
signed by the Investigator and by the Sponsor and the signed amendment will be filed with this 
clinical trial protocol. 
Any amendment to the clinical trial protocol requires written approval/favorable opinion by the 
IRB/IEC prior to its implementation, unless there are overriding safety reasons. 
In some instances, an amendment may require a change to the informed consent form. The 
Investigator must receive an IRB/IEC approval/favorable opinion concerning the revised informed 
consent form prior to implementation of the change and patient signature should be recollected if 
necessary. 
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16 
BIBLIOGRAPHIC REFERENCES 
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European position paper on rhinosinusitis and nasal polyps 2012. Rhinology. 2012;50:1-12. 
3. Bryson JM, Tasca RA, Rowe-Jones JM. Local and systemic eosinophilia in patients 
undergoing endoscopic sinus surgery for chronic rhinosinusitis with and without polyposis. 
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7. Ferguson BJ. Categorization of eosinophilic chronic rhinosinusitis. Curr Opin Otolaryngology 
and Head and Neck Surg. 2004;12:237-42. 
8. Sakuma Y, Ishitoya J, Komatsu M, Shiono O, Hirama M, Yamashita Y, et al. New clinical 
diagnostic criteria for eosinophilic chronic rhinosinusitis. Auris Nasus Larynx. 2011;38:583-8. 
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deposition of toxic eosinophil major basic protein in mucus: implications for chronic 
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10. Zacharek MA, Krouse JH. The role of allergy in chronic rhinosinusitis. Curr Opin Otolaryngol 
Head Neck Surg. 2003;11:196-200. 
11. Bhattacharyya N, Vyas DK, Fechner FP, Gliklich RE, Metson R. Tissue eosinophilia in 
chronic sinusitis: quantification techniques. Arch Otolaryngol Head Neck Surg. 
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12. Kalish L, Snidvongs K, Sivasubramaniam R, Cope D, Harvey RJ. Topical steroids for nasal 
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13. Lund VJ. Where Are We in the Medical Treatment of Nasal Polyps? In Önerci TM and 
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14. Hox V, Bobic S, Callebaut I, Jorissen M, Hellings PW. Nasal obstruction and smell 
impairment in nasal polyp disease: correlation between objective and subjective parameters. 
Rhinology 2010;48:426-32. 
15. Alobid I, Mullol J. Role of Medical Therapy in the Management of Nasal Polyps. Curr 
Allergy Asthma Rep. 2012;12:144-53. 
16. Peters AT, Spector S, Hsu J, Hamilos DJ, Baroody FM, Chandra RK et al. Diagnosis and 
management of rhinosinusitis: a practice parameter update. Ann Allergy Asthma Immunol. 
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17. Gevaert P, Calus L, Van Zele T, Blomme K, De Ruyck N, Bauters W, et al. Omalizumab is 
effective in allergic and nonallergic patients with nasal polyps and asthma. J Allergy 
Clin.Immunol; 2013;131:110-6. 
18. Gevaert P, Van Bruaene N, Cattaert T, Van Steen K., Van Zele T, Acke F et al. Mepolizumab, 
a humanized anti-IL-5 mAb, as a treatment option for severe nasal polyposis. J Allergy Clin 
Immunol. 2011;128:989-95. 
19. Bachert C, Mannent L, Naclerio RM, Mullol J, Ferguson BJ, Gavaert P, et al. Effect of 
subcutaneous dupilumab on nasal polyp burden in patients with chronic sinusitis and nasal 
polyposis. JAMA. 2016 Feb 2;315(5):469-79. 
20. Håkansson K, Thomsen SF, Konge L, Mortensen J, Backer V, von Buchwald C. A 
comparative and descriptive study of asthma in chronic rhinosinusitis with nasal polyps. Am J 
Rhinol Allergy. 2014 Oct;28(5):383–7. 
21. Caimmi D, Marseglia A, Pieri G, Benzo S, Bosa L and Caimmi S. Nose and lungs: one way, 
one disease.  Ital J Pediatr. , p. 38:60, 2012. 
22. Graefe H,  Roebke C, Schäfer D, Meyer JE  Aspirin Sensitivity and Chronic Rhinosinusitis 
with Polyps: A Fatal Combination. Journal of Allergy Volume 2012, Article ID 817910, 10 
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23. SEAIC-SEORL. Consensus Document on Nasal Polyposis. POLINA Project. Journal of 
Investigational Allergology and Clinical Immunology 2011 Supplement 1, Vol 21 
24. Van Zele T, Gevaert P, Holtappels G, Beule A, Wormald PJ, Mayr S, et al. Oral steroids and 
doxycycline: two different approaches to treat nasal polyps. J Allergy Clin Immunol. 
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25. Chin D, Harvey RJ. Nasal polyposis: An inflammatory condition requiring effective anti-
inflammatory treatment. Curr Opin Otolaryngol Head Neck Surg. 2013;21:23-30. 
26. Christensen H and Hermann M. Immunological response as a source to variability in drug 
metabolism and transport. Front Pharmacol. 2012:10;3:8. 
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27. Abdel-Razzak Z, Loyer P, Fautrel A, Gautier JC, Corcos L, Turlin B, et al. Cytokines down-
regulate expression of major cytochrome P-450 enzymes in adult human hepatocytes in 
primary culture. Mol Pharmacol. 1993;44:707-15. 
28. Liptrott NJ, Penny M, Bray PG, Sathish J, Khoo SH, Back DJ and Owen A. The impact of 
cytokines on the expression of drug transporters, cytochrome P 450 enzymes and chemokine 
receptors in human PBMC. Br J Pharmacol. 2009;156:497-508. 
29. Lund VJ, Mackay, IS. Staging in rhinosinusitus. Rhinology. 1993;31:183-4. 
30. Metson R, Gliklich RE, Stankiewicz JA, Kennedy DW, Duncavage JA, Hoffman SR, et al. 
Comparison of sinus computed tomography staging systems. Otolaryngol Head Neck Surg. 
1997;117:372-9. 
31. Oluwole M, Russell N, Tan L, Gardiner Q, White P. A comparison of computerized 
tomographic staging systems in chronic sinusitis. Clin Otolaryngol Allied Sci. 1996; 21: 91-
95. 
32. Scadding G, Hellings P, Alobid I, Bachert C, Fokkens W, Van Wijk RG, et al. Diagnostic 
tools in Rhinology EAACI position paper. Clin Transl Allergy. 2011;1:1-39. 
33. Hopkins C, Gillett S, Slack R, Lund VJ and Browne JP. Psychometric validity of the 22- item 
sinonasal outcome test. Clin Otolaryngol. 2009;34:447-54. 
34. Juniper EF, Svensson K, Mork AC, Stahl E. Measurement properties and interpretation of 
three shortened versions of the asthma control questionnaire. Respir Med. 2005;99:553-8. 
35. Van Agthoven M, Fokkens WJ, Van de Merwe JP, Marijke Van Bolhuis E, Uyl-de Groot CA, 
Busschbach JJ. Am J Rhinol. 2001;15:231-7. 
 
 
 
 
 
 
 
 
 
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SAP_001.pdf: 
Any and all information presented in this document shall be treated as confidential and shall remain the exclusive property of Sanofi (or any of its 
affiliated companies). The use of such confidential information must be restricted to the recipient for the agreed purpose and must not be 
disclosed, published or otherwise communicated to any unauthorized persons, for any reason, in any form whatsoever without the prior written 
consent of Sanofi (or the concerned affiliated company); ‘affiliated company’ means any corporation, partnership or other entity which at the date 
of communication or afterwards (i) controls directly or indirectly Sanofi, (ii) is directly or indirectly controlled by Sanofi, with ‘control’ meaning direct 
or indirect ownership of more than 50% of the capital stock or the voting rights in such corporation, partnership or other entity 
According to template: QSD-002643 VERSION 6.0 (06-JUL-2016) 
Page 1
STATISTICAL ANALYSIS PLAN 
A randomized, 24-week treatment, double-blind, placebo-controlled efficacy and 
safety study of dupilumab 300 mg every other week, in patients with bilateral nasal 
polyposis on a background therapy with intranasal corticosteroids 
SAR231893(REGN668)-EFC14146 
STATISTICIAN:
DATE OF ISSUE: 14-Aug-2017 
Total number of pages: 
95 
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NCT Number: NCT02912468


Statistical Analysis Plan  
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Page 2 
TABLE OF CONTENTS 
STATISTICAL ANALYSIS PLAN....................................................................................................................1 
TABLE OF CONTENTS..................................................................................................................................2 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS ..........................................................................5 
1 
OVERVIEW AND INVESTIGATIONAL PLAN.................................................................................8 
1.1 
STUDY DESIGN AND RANDOMIZATION ......................................................................................8 
1.2 
OBJECTIVES...................................................................................................................................8 
1.2.1 
Primary objectives............................................................................................................................8 
1.2.2 
Secondary objectives .......................................................................................................................8 
1.2.3 
Exploratory objectives ......................................................................................................................9 
1.3 
DETERMINATION OF SAMPLE SIZE.............................................................................................9 
1.4 
STUDY PLAN.................................................................................................................................11 
1.4.1 
Graphic study design......................................................................................................................11 
1.5 
MODIFICATIONS TO THE STATISTICAL SECTION OF THE PROTOCOL................................12 
1.6 
STATISTICAL MODIFICATIONS MADE IN THE STATISTICAL ANALYSIS PLAN......................12 
2 
STATISTICAL AND ANALYTICAL PROCEDURES .....................................................................13 
2.1 
ANALYSIS ENDPOINTS................................................................................................................13 
2.1.1 
Demographic and baseline characteristics ....................................................................................13 
2.1.2 
Prior or concomitant medications...................................................................................................16 
2.1.2.1 
MFNS controller medication...........................................................................................................17 
2.1.3 
Efficacy endpoints ..........................................................................................................................17 
2.1.3.1 
Primary efficacy endpoint(s)...........................................................................................................17 
2.1.3.2 
Secondary efficacy endpoint(s)......................................................................................................20 
2.1.4 
Safety endpoints.............................................................................................................................24 
2.1.4.1 
Adverse events variables ...............................................................................................................25 
2.1.4.2 
Deaths............................................................................................................................................27 
2.1.4.3 
Laboratory safety variables ............................................................................................................27 
2.1.4.4 
Vital signs variables........................................................................................................................28 
2.1.4.5 
Electrocardiogram variables...........................................................................................................28 
2.1.4.6 
Physical Examination .....................................................................................................................28 
2.1.5 
Pharmacokinetic variables .............................................................................................................29 
2.1.6 
Pharmacodynamic
endpoints ........................................................................................30 
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2.1.7 
Health Related Quality-of-life endpoints.........................................................................................30 
2.1.7.1 
Euro-QOL-5D.................................................................................................................................30 
2.1.7.2 
Short Form 36 (SF-36) Version 2...................................................................................................30 
2.1.8 
Health economic endpoints............................................................................................................31 
2.2 
DISPOSITION OF PATIENTS .......................................................................................................31 
2.2.1 
Randomization and drug dispensing irregularities .........................................................................32 
2.3 
ANALYSIS POPULATIONS ...........................................................................................................33 
2.3.1 
Efficacy populations .......................................................................................................................33 
2.3.1.1 
Intent–to-treat population ...............................................................................................................33 
2.3.2 
Safety population............................................................................................................................34 
2.3.3 
Pharmacokinetics (PK) population.................................................................................................34 
2.3.4 
Anti-drug antibody population.........................................................................................................34 
2.4 
STATISTICAL METHODS .............................................................................................................34 
2.4.1 
Demographics and baseline characteristics ..................................................................................34 
2.4.2 
Prior or concomitant medications...................................................................................................35 
2.4.2.1 
INCS/MFNS controller medication .................................................................................................35 
2.4.3 
Extent of investigational medicinal product exposure and compliance..........................................36 
2.4.3.1 
Extent of investigational medicinal product exposure ....................................................................36 
2.4.3.2 
Compliance ....................................................................................................................................37 
2.4.4 
Analyses of efficacy endpoints.......................................................................................................37 
2.4.4.1 
Analysis of primary efficacy endpoint(s).........................................................................................37 
2.4.4.2 
Analyses of key secondary efficacy endpoints...............................................................................44 
2.4.4.3 
Multiplicity issues............................................................................................................................45 
2.4.4.4 
Additional efficacy analyses ...........................................................................................................47 
2.4.4.5 
Analyses of exploratory efficacy endpoints ....................................................................................50 
2.4.4.6 
Missing data handling.....................................................................................................................51 
2.4.5 
Analyses of safety data ..................................................................................................................51 
2.4.5.1 
Analyses of adverse events ...........................................................................................................52 
2.4.5.2 
Deaths............................................................................................................................................55 
2.4.5.3 
Analyses of laboratory variables ....................................................................................................55 
2.4.5.4 
Analyses of vital sign variables ......................................................................................................57 
2.4.5.5 
Analyses of electrocardiogram variables .......................................................................................57 
2.4.6 
Analyses of pharmacokinetic and pharmacodynamic variables ....................................................58 
2.4.6.1 
Pharmacokinetic analyses .............................................................................................................58 
2.4.6.2 
Pharmacodynamics
analyses........................................................................................59 
2.4.7 
Analyses of health economics variables ........................................................................................60 
2.5 
DATA HANDLING CONVENTIONS...............................................................................................60 
2.5.1 
General conventions ......................................................................................................................60 
2.5.2 
Data handling conventions for secondary efficacy variables..........................................................61 
2.5.3 
Missing data ...................................................................................................................................61 
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2.5.4 
Windows for time points.................................................................................................................63 
2.5.5 
Unscheduled visits .........................................................................................................................66 
2.5.6 
Pooling of centers for statistical analyses ......................................................................................66 
2.5.7 
Statistical technical issues .............................................................................................................66 
3 
INTERIM ANALYSIS .....................................................................................................................67 
4 
DATABASE LOCK ........................................................................................................................68 
5 
SOFTWARE DOCUMENTATION..................................................................................................69 
6 
REFERENCES...............................................................................................................................70 
7 
LIST OF APPENDICES .................................................................................................................71 
APPENDIX A 
POTENTIALLY CLINICALLY SIGNIFICANT ABNORMALITIES CRITERIA.......................72 
APPENDIX B 
DOUBLE CENTRAL READING WITH ADJUDICATION PROCEDURE.............................77 
APPENDIX C 
ACQ-6..................................................................................................................................79 
APPENDIX D 
22-ITEM SINONASAL OUTCOME TEST (SNOT-22).........................................................82 
APPENDIX E 
EUROQUAL QUESTIONNAIRE (EQ-5D-5L) ......................................................................84 
APPENDIX F 
SF-36V2® HEALTH SURVEY © 1992, 1996, 2000.............................................................87 
APPENDIX G 
DEFINITION OF ANAPHYLAXIS ........................................................................................94 
APPENDIX H 
LIST OF OPPORTUNISTIC INFECTIONS .........................................................................95 
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LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
 
ACQ-6 
Asthma Control Questionnaire 6-question version 
AD 
Atopic Dermatitis 
ADA 
Anti-drug Antibodies  
AE 
Adverse Event 
AESI 
Adverse Event of Special Interest  
ALT 
Alanine Aminotransferase 
AM 
Ante Meridiem 
ANA 
Antinuclear Antibodies 
BID 
 
Twice Daily 
CI 
Confidence Interval 
CPK 
Creatine Phosphokinase 
CRFs 
Case Report Forms 
CT 
Computed Tomography  
CV% 
Coefficient of Variation 
DMC 
Data Monitoring Committee  
DNA 
Deoxyribonucleic Acid 
ECG 
Electrocardiography  
ECP 
Eosinophil Cationic Protein  
e-CRF 
Electronic Case Report Form 
e-diary 
Electronic Diary 
EQ-5D 
European Quality of Life-5D Scale 
EOS 
End-of-Study 
EOT 
End-of-Treatment 
FEF 25-75 
Forced Expiratory Flow at 25% to 75% of forced vital capacity 
FEV1 
Forced Expiratory Volume in one second 
FVC 
Forced Vital Capacity  
HBc Ab 
Hepatitis B Core Antibody 
HBs Ab 
Hepatitis B Surface antibody 
HBs Ag 
Hepatitis B Surface Antigen 
HBV 
Hepatitis B Virus 
HCV Ab 
Hepatitis C Virus Antibody 
HLGT 
High-Level Group Term  
HLT 
High Level Term 
HIV 
Human Immunodeficiency Virus  
HRQoL 
Health related quality of life  
ICH 
International Council for Harmonisation 
IDMC 
Independent Data Monitoring Committee 
IEC 
Institutional Ethics Committee 
IgE 
Immunoglobulin E 
IMP 
Investigational Medicinal Product 
INCS 
Intranasal Corticosteroid Spray  
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INN 
International Nonproprietary Name 
IRB 
Institutional Review Board 
ITT 
Intent-to-treat 
IV 
Intravenous 
IRT 
Interactive Response Technologies 
IVRS/IWRS 
Interactive Voice Response System/Interactive Web Response System  
K-M 
Kaplan-Meier 
LFT 
Liver Function Test 
LLOQ 
Lower Limit of Quantitation 
LMK 
Lund Mackay 
LS 
Least Squares 
MCID 
Minimal Clinically Important Difference 
MFNS 
Mometasone Furoate Spray 
MI 
Multiple Imputation 
MID 
Minimal Important Difference 
MMRM 
Mixed-effect Model with Repeated Measures  
MRI 
Magnetic Resonance Imaging 
NC 
Nasal Congestion 
NERD 
Nonsteroidal Anti-inflammatory Drug Exacerbated Respiratory Disease 
NIMP 
Noninvestigational Medicinal Product 
NP 
Nasal Polyposis 
NPIF 
Nasal Peak Inspiratory Flow 
NPS 
Nasal Polyp Score 
NSAID 
Nonsteroidal Anti-inflammatory Drug 
OC 
Osteomeatal Complex  
PCSA 
Potentially Clinically Significant Abnormalities   
PD 
Pharmacodynamics 
PGDM 
Metabolite of Prostaglandin D2 
PK 
Pharmacokinetics  
PROs 
Patient-Reported Outcomes  
PT 
Preferred Term 
q2w 
Every 2 weeks 
q4w 
Every 4 weeks 
QD 
Once daily administration 
QoL 
Quality of Life 
qw 
Once weekly 
RNA 
Ribonucleic Acid 
SAE 
Serious Adverse Event  
SC 
Subcutaneously 
SCS 
Systemic Corticosteroid 
SD 
Standard Deviation 
SEM 
Standard Error of the Mean  
SNOT-22 
Sinonasal Outcomes Test 22-item scale 
SOC 
System Organ Class  
TARC 
Thymus and Activation-Regulated Chemokine  
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TE 
Treatment-Emergent 
TEAE 
Treatment-Emergent Adverse Event 
Th2 
Type 2 T-helper cell 
TSS 
Total Symptoms Score 
ULN 
Upper Limit of Normal  
UPSIT 
University of Pennsylvania Smell Identification Test 
US 
United States 
V 
Visit 
VAS 
Visual Analogue Scale  
WBC 
White Blood Cell 
WOCF 
Worst Observation Carried Forward 
 
 
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1 
OVERVIEW AND INVESTIGATIONAL PLAN   
1.1 
STUDY DESIGN AND RANDOMIZATION 
EFC14146 is phase 3 multinational, multicenter, randomized, double-blind, placebo-controlled, 
parallel group study that will evaluate the efficacy of dupilumab 300 mg administered 
subcutaneously (SC) q2w for 24 weeks followed by 24 weeks off-treatment period on a 
background of INCS. Both the patient and investigator will be blinded to the assigned drug, active 
or matching placebo in identical pre-filled syringes. 
After a run-in period of 4 weeks ±3 days, patients will be centrally randomized using a permuted 
block randomization schedule via Interactive Voice Response System/Interactive Web Response 
System (IVRS/IWRS) in a 1:1 randomization ratio for dupilumab 300 mg q2w until Week 24 
(Arm A) and placebo matching dupilumab q2w administration (Arm B). Randomization will be 
stratified by asthma/ non-steroid anti-inflammatory drug exacerbated respiratory disease (NERD) 
status (with co-morbid asthma and/or NERD history, without co-morbid asthma nor NERD 
history) at screening (V1), prior surgery (with prior surgery for NP, without any prior surgery for 
NP) at screening (V1) and country. 
A total of approximately 240 patients with bilateral NP will be randomized to two treatment arms 
(120 patients/arm). Recruitment for patients without asthma/ NERD will be limited to 120 patients 
(out of the total of 240 randomized patients). Recruitment for patients without any prior surgery 
for nasal polyposis will be limited to 120 patients (out of the total 240 randomized patients). 
Patients may fall in more than one category without limitation in numbers. 
1.2 
OBJECTIVES 
1.2.1 Primary objectives 
The primary objective of this study is to evaluate the efficacy of dupilumab 300 mg every 2 weeks 
(q2w) compared to placebo on a background of Mometasone Furoate Nasal Spray (MFNS) in 
reducing nasal congestion/obstruction (NC) severity and endoscopic nasal polyp score (NPS) in 
patients with bilateral nasal polyposis (NP) at Week 24. In addition for regulatory purpose in 
Japan only, reduction in computed tomography (CT) scan opacification of the sinuses will be also 
a co-primary objective.  
1.2.2 Secondary objectives 
• 
To evaluate the efficacy of dupilumab in reducing CT scan opacification of the sinuses as 
assessed by the Lund Mackay (LMK) score (for regulatory purposes ex-Japan; in Japan, 
this is part of the primary objective).  
• 
To evaluate the efficacy of dupilumab in improving total symptoms score (TSS). 
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• 
To evaluate the efficacy of dupilumab in improving sense of smell through daily loss of 
smell assessment and UPSIT functional smell test.   
• 
To evaluate the effect of dupilumab on patient reported outcome (PRO) sino-nasal 
outcome test (SNOT-22). 
 
• 
To evaluate the efficacy of dupilumab in reducing the proportion of patients requiring 
rescue treatment defined as: use systemic corticosteroids (SCS) or NP surgery (actual or 
planned) during the treatment period. 
• 
To evaluate the efficacy of dupilumab on lung function (forced expiratory volume in one 
second, FEV1) in the sub-group of patients with asthma at Week 24. 
• 
To evaluate the residual effect of dupilumab through the 24-week follow-up period. 
• 
To evaluate the safety of dupilumab in patients with bilateral NP.  
• 
To evaluate functional dupilumab concentrations (systemic exposure) and incidence of 
treatment-emergent anti-drug antibodies (ADA). 
1.2.3  Exploratory objectives 
• 
To explore the effects of dupilumab on nasal microbiome, total and allergen-specific IgEs 
in blood, and urinary leukotriene E4 and a metabolite of prostaglandin D2 (PGDM). 
• 
To evaluate the effect of dupilumab on healthcare resource utilization. 
• 
To evaluate the effect of dupilumab on SNOT-22 items: “decreased sense of smell/taste”, 
“difficulty falling asleep”, “'wake up at night”, “lack of a good night's sleep”, “wake up 
tired”, “fatigue”, and “reduced productivity”.  
• 
To evaluate the effect of dupilumab on health related quality of life (HRQoL) scale (Index 
Score of EQ5D-5L) and EQ-5D-5L VAS score (self-rated health). 
• 
To assess the effect of dupilumab in improving sense of taste. 
1.3 
DETERMINATION OF SAMPLE SIZE 
The sample size was chosen to enable an adequate characterization of the efficacy between 
dupilumab 300 mg q2w and placebo with regard to the 2 co-primary endpoints, changes from 
baseline in NC and NPS at Week 24.  
• 
The observed mean difference in NC reduction between the dupilumab group with 300 mg 
weekly dosing (qw)  and placebo in  the proof of concept study of dupilumab in patients 
with bilateral nasal polyposis (ACT12340) was 0.95-0.26=0.69, and discounting 20% for 
300 q2w, the mean difference was assumed to be 0.69*0.8=0.55. (NC scores range from 0 
to 3) 
• 
The observed common standard deviation (SD) was 0.86, and inflated by 20%, the 
assumed SD was 0.86*1.2=1.03. 
• 
 Then the assumed effect size was 0.55/1.03=0.534. 
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Assuming normal distribution of the change in NC, a common standard deviation (SD) of 1.03, 
and a 25% dropout rate, with 120 patients per group, the study will have 95% power to detect an 
effect size of 0.534 using a two-sided test with alpha = 0.05 for the change in NC at Week 24 in 
the dupilumab 300 mg q2w group.  
• 
The observed mean NPS reduction of the dupilumab group with 300 mg qw dosing in the 
proof of concept study (ACT12340) was 1.85 and the observed mean NPS reduction of the 
placebo group was 0.30. So the observed mean difference is 1.85-0.30=1.55. Discounting 
20% for 300 q2w, the mean difference was assumed to be 1.55*0.8= 1.24 (NPS values 
range from 0 to 8.) 
• 
The observed common SD is 1.76, and inflated by 20%, the assumed SD is 1.76*1.2=2.11. 
• 
Then the assumed effect size was 1.24/2.11=0.588. 
Assuming normal distribution of the change in NPS, a common SD of 2.11,  and a 25% dropout 
rate, with 120 patients per group, the study will have 98% power to detect the effect size of 0.588 
using a two-sided test with alpha = 0.05 for the change in NPS at Week 24 in the dupilumab 
300 mg q2w group. 
Therefore, with a sample size of 120 patients per group, the combined power of the two coprimary 
efficacy endpoints is at least 93% for dupilumab 300 mg q2w group with alpha = 0.05 assuming 
no negative correlation between the two endpoints. 
• 
The observed mean Lund-Mackay score (LMK) reduction of the dupilumab group with qw 
dosing in ACT12340 was 9.07 and the observed mean LMK reduction of the placebo 
group was 0.23. So the observed mean difference was 9.07-0.23=8.84. Discounting 20% 
for 300 q2w, the mean difference was assumed to be 8.84*0.8= 7.07 (LMK values range 
from 0 to 24.) 
• 
The observed common SD is 4.58, and inflated by 20%, the assumed SD is 4.58*1.2=5.50. 
• 
Then the assumed effect size was 7.07/5.50=1.285. 
• 
Assuming normal distribution of the change in LMK, a common SD of 5.50, and a 25% 
dropout rate, with 120 patients per group, the study will have 99% power to detect the 
effect size of 1.285 using a two-sided test with alpha = 0.05 for the change in LMK at 
Week 24 in the dupilumab 300 mg q2w group. 
With the same sample size of 120 patients per group, the combined power of the 3 co-primary 
efficacy endpoints for Japan is at least 92% for dupilumab 300 mg q2w group with alpha = 0.05 
assuming no negative correlation between the 3 endpoints. 
The sample size calculations were performed using nQuery Advisor 7.0. 
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1.4 
STUDY PLAN 
The clinical trial will consist of 3 periods: 
• 
Run-in period (4 weeks, +/-3 days): to determine a patient’s eligibility and for 
run-in/standardization of background INCS (MFNS) prior to randomization. 
• 
Randomized dupilumab/placebo treatment period (24 weeks +/-3 days): to randomize 
the patient into a treatment arm and treat with dupilumab or placebo dose regimen. 
• 
Post-treatment period (24 weeks +/-3 days): to continue to collect data for PK, 
immunogenicity, safety, and efficacy after the patient has completed the study drug 
treatment period. 
If surgery is scheduled after the planned end of study, EOS visit will not be delayed. A follow up 
contact(s) should be performed around the time of planned surgery to document the surgery date 
and outcome. Surgery data will be collected until e-CRF closure of the trial. 
1.4.1 Graphic study design 
Please refer of Section 1.2 of the study protocol for the detailed study flow chart.
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BID twice daily; D day; EOS end of study; EOT end of treatment; IMP investigational medicinal product; q2w every 2 weeks; MFNS mometasone 
furoate nasal spray; R* randomization; QD once daily; SC subcutaneous; V visit; W week 
IMP: Regardless of the treatment group, all randomized patients will receive q2w SC administrations of dupilumab or placebo. Every other week 
IMP administrations must be separated by at least 11 days. At V2 the Investigator or delegate will perform the injection. After V2, every other 
week administration of IMP will be performed at the investigational site up to at least Week 8 (Visit 6). Patients will be monitored at the study site 
for at least 30 minutes or the minimum time required by your local regulator after injections. From Week 10, every other week home 
administration of IMP (patient, caregiver, or health care professional) is possible if the patient (or the caregiver) has been trained. If the patient (or 
caregiver) is unable or unwilling to administer IMP, arrangements must be made for qualified site personnel and/or healthcare professionals to 
administer IMP for the doses not scheduled to be given at the study site. 
Non-investigational medicinal product: MFNS will be self-administered by the patient BID or QD (if they cannot tolerate BID). At each visit the 
Investigator must ensure that the patient has the necessary doses up to the next visit, knowing that one MFNS device (1 bottle) contains 
sufficient doses for: either 2 weeks of BID treatment/regimen or 4 weeks of QD treatment/regimen. 
1.5 
MODIFICATIONS TO THE STATISTICAL SECTION OF THE PROTOCOL  
There is no change from the statistical section of the protocol.  
1.6 
STATISTICAL MODIFICATIONS MADE IN THE STATISTICAL ANALYSIS PLAN 
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2 
STATISTICAL AND ANALYTICAL PROCEDURES 
2.1 
ANALYSIS ENDPOINTS 
2.1.1 Demographic and baseline characteristics 
The baseline value of efficacy parameters is defined as the last available value up to 
randomization but prior to the first dose of study medication unless otherwise specified. The 
baseline value of safety parameters is defined as the last available value prior to the first dose of 
investigational medicinal product (IMP). The baseline value of the other parameters is defined as 
the last available value prior to the first dose of IMP if the patient is treated, or the last available 
value up to randomization if the patient is not exposed to IMP.  
The calculation of the baseline for the daily symptom scores and the nasal peak inspiratory flow 
(NPIF) will be based on measurements obtained during the 7 days prior to randomization. For 
daily assessed electronic diary/NPIF parameters,  
• 
If there are 4 or more measurements collected within 7 days prior to randomization, the 
baseline will be the average of these measurements. 
• 
If less than 4 measurements are collected within 7 days prior to randomization, the 
baseline will be the average of the most recent 4 measurements prior to randomization 
(between V1 and V2). 
All baseline safety and efficacy parameters (apart from those listed below) will be presented along 
with the on-treatment summary statistics in the safety and efficacy sections (Section 2.4.5 and 
Section 2.4.4). 
Demographic characteristics 
Demographic variables are  
- 
Gender (Male, Female) 
- 
Race (Caucasian/white, Black/of American descent, Asian/Oriental, American Indian 
or Alaska Native, Native Hawaiian or other Pacific Island, Multiple, Unknown) 
- 
Ethnicity (Hispanic or Latino, Not Hispanic or Latino) 
- 
Age in years (quantitative and qualitative variable: 18-64, 65–74, 75-84, and ≥85 
years) 
- 
Region (East Europe: Russia, Ukraine, Cz. Republic, Hungary, Poland, Romania, 
Bulgaria; Western Countries: France, Germany, Italy, United Kingdom, Netherlands, 
USA)  
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- 
Territory (North America: USA; European Union: Cz. Republic, Hungary, Poland, 
Romania, Bulgaria, France, Germany, Italy, United Kingdom and Netherlands; Rest of 
World: Russia and Ukraine) 
- 
Weight in kg (quantitative and qualitative variable : <50, 50-<100 and ≥100 kg) 
- 
BMI in kg/m2 (quantitative and qualitative variable: <30, ≥30 kg/m2) 
Medical or surgical history 
Medical (or surgical) history includes all the relevant medical (or surgical) history during the 
lifetime of the patient. 
This information will be coded using the version of Medical Dictionary for Regulatory Activities 
(MedDRA) currently in effect at Sanofi at the time of database lock. 
Comorbidity will be summarized separately. The following comorbid diseases will be summarized 
from eCRF pages which were filled in by investigators based on patient reporting. Asthma will be 
captured under disease characteristics at baseline. 
Atopic dermatitis history (Yes, Ongoing condition) 
Allergic conjunctivitis history (Yes, Ongoing condition) 
Allergic rhinitis seasonal history (Yes, Ongoing condition) 
Allergic rhinitis perennial history (Yes, Ongoing condition) 
Eosinophilic esophagitis history (Yes, Ongoing condition) 
Hives history (Yes, Ongoing condition) 
Food allergy history (Yes, Ongoing condition) 
Epsitaxis history (Yes, Ongoing condition) 
NSAID exacerbated respiratory disease history (Yes, Ongoing condition) 
Disease characteristics at baseline   
The following baseline disease characteristics will be summarized by treatment group: 
• 
NPS  
• 
Lund-Mackay score 
• 
AM symptom scores for nasal congestion/obstruction, decreased/loss of sense of smell, 
rhinorrhea (anterior/posterior nasal discharge) and total symptom score (TSS) respectively: 
For the daily symptoms the presence and the severity at 4 weeks and 8 weeks prior to 
screening will be provided. 
• 
UPSIT smell test score 
• 
SNOT-22 
• 
Time since first diagnosis of nasal polyposis (years)  to be derived as 
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- 
(Year of randomization – Year of first diagnosis of nasal polyposis) + (month of 
randomization – month of first diagnosis of nasal polyposis)/12 
• 
Age of onset of nasal polyposis (years) 
• 
Number of previous surgeries for nasal polyposis (0, 1, 2, ≥3) 
• 
Number of previous surgery for nasal polyposis by type: 
- 
Nasal/sinus endoscopy, surgical, with ethmoidectomy, total (anterior and posterior) 
- 
Nasal/sinus endoscopy, surgical, with maxillary and antrostomy with removal of tissue 
from maxillary sinus 
- 
Nasal/sinus endoscopy, surgical, with frontal sinus exploration, with or without 
removal of tissue from frontal sinus 
- 
Nasal/sinus endoscopy, surgical, with maxillary antrostomy 
- 
Nasal/sinus endoscopy, surgical, with sphenoidotomy with removal of tissue from the 
sphenoid sinus 
- 
Nasal/sinus endoscopy, surgical, with sphenoidotomy 
- 
Nasal/sinus endoscopy, surgical, with ethmoidectomy, partial (anterior) 
- 
Excision, nasal polyp(s), extensive 
- 
Excision, nasal polyp(s), simple 
- 
Excision or destruction (eg,laser), intranasal lesion; internal approach 
- 
Other 
• 
Time since most recent nasal polyposis surgery (years) to be derived as 
- 
(Year of randomization – Year of most recent nasal surgery) + (month of 
randomization – month of most recent nasal surgery)/12 
• 
Smoking history (former, current, never) 
• 
Cessation prior to screening (months) for former smokers to be derived as 
- 
(Year of randomization – Year of cessation)×12 + (month of randomization – month of 
cessation) 
- 
Smoking quantity (cigarettes per day) 
• 
Frequency of alcohol drinking in the past 12 months (never, occasional, at least monthly, at 
least weekly, at least daily) 
- 
For daily drinkers, provide the following 
 Number of standard alcohol drinks on a typical day (1 or 2, >2) 
• 
Asthma comorbidity status (Yes, No) 
- 
For asthma patients, provide the following: 
 Time since first diagnosis of asthma (years) to be derived as 
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(Year of randomization – Year of first diagnosis of asthma) + (month of 
randomization – month of first diagnosis of asthma)/12 
 Time since last asthma exacerbation (days) to be derived as  
      Date of randomization – Date of last asthma exacerbation  
 Number of asthma exacerbations experienced 1 year before visit 1 
(comorbid asthma patients only, quantitative variable and qualitative 
variable: 0,1,2,3, ≥4) 
 Age of onset of asthma 
• 
Number of courses of systemic corticosteroid (SCS) use during the past 2 years (0, 1, 2, 3, 
4, ≥ 5) 
- 
A course of SCS is considered continuous if treatment is separated by less than 7 days.  
• 
Number of days of systemic corticosteroid (SCS) use during the past 2 years (0, >0 - ≤7, 
>7 - ≤14, >14 - ≤ 21, >21 - ≤28, >28) 
Any technical details related to computation, dates, and imputations for missing dates are 
described in Section 2.5.   
2.1.2 Prior or concomitant medications  
All medications taken within 30 days prior to screening and until end of the study, including nasal 
polyposis medications (except for MFNS), chronic rhinosinusitis medications (except for MFNS), 
asthma medications, and all other medications are to be reported in the case report form (CRF) 
pages. 
All medications will be coded using the World Health Organization-Drug Dictionary (WHO-DD) 
version currently in effect at Sanofi at the time of database lock. 
Prior medications are those the patient used prior to first IMP injection.  Prior medications can be 
discontinued before first administration or can be ongoing during treatment phase.   
Concomitant medications are any treatments received by the patient concomitantly to the IMP, 
anytime from the first administration of IMP to the last administration of IMP + 98 days. A given 
medication can be classified as a prior medication, concomitant medication and post-treatment 
medication at the same time. 
Post-treatment medications are those the patient took in the period from the last administration of 
IMP + 99 days to the end of the study. 
Any technical details related to computation, dates, imputation for missing dates are described in 
Section 2.5. 
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2.1.2.1 MFNS controller medication 
On a daily basis throughout the study, mometasone furoate nasal spray (MFNS) will be self-
administered (and recorded using an e-diary) by the patients. Starting from V1, they will 
administer two actuations (50 µg/actuation) in each nostril BID (total daily dose of 400 µg), unless 
they are unable to tolerate the BID regimen or this dose is not approved in specific countries, in 
which case, they will follow a once daily (QD) regimen (total daily dose of 200 µg). 
2.1.3 Efficacy endpoints 
Baseline for efficacy endpoints is defined as the last non-missing value up to randomization but 
prior to the administration of the first IMP unless otherwise specified. 
2.1.3.1 Primary efficacy endpoint(s) 
There are 2 co-primary endpoints for this study for all countries except for Japan:  
1. Change from baseline in the nasal congestion/obstruction (NC) score at Week 24: The 
NC score is assessed by the patient on a daily basis from V1 and throughout the study, 
using an e-diary, on a 0-3 categorical scale (1):  
Nasal congestion/obstruction will be scored as a reflective score (evaluation of symptom severity 
over the past 24 hours) by the patient: 
 
Scale 
Symptoms 
0 
No symptoms 
1 
Mild symptoms (symptoms clearly present, but minimal awareness and easily tolerated) 
2 
Moderate symptoms (definite awareness of symptoms that is bothersome but tolerable) 
3 
Severe symptoms (symptoms that are hard to tolerate, cause interference with activities 
or daily living) 
 
The e-diary is dispensed at V1 and information is downloaded from this device on the other 
protocol specified visit days.  
A severity ≥2 on V1 and a weekly average severity greater than 1 at time of randomization (V2) is 
required for patient eligibility.  
For baseline calculation (used to determine eligibility and to assess efficacy),  
• 
If there are 4 or more measurements collected within 7 days prior to randomization 
available, the baseline will be the average of these measurements. 
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• 
If less than 4 measurements are collected within 7 days prior to randomization, the 
baseline will be the average of the most recent 4 measurements prior to randomization 
(between V1 and V2). 
For the baseline to EOT analysis, the average of all scores from the preceding 4 weeks to the 
corresponding visit will be used as the analysis score for that visit. 
2. Change from baseline in the NPS at Week 24: The NPS (2)(3)(4) is assessed by 
centralized scoring of nasal endoscopy video recordings. The score (NPS) is the sum of 
the right and left nostril scores, as evaluated by means of nasal endoscopy. NP is graded 
based on polyp size described below. 
 
Polyp Score 
Polyp Size 
0 
No polyps 
1 
Small polyps in the middle meatus not reaching below the inferior border of the middle turbinate 
2 
Polyps reaching below the lower border of the middle turbinate  
3 
Large polyps reaching the lower border of the inferior turbinate or polyps medial to the middle turbinate 
4 
Large polyps causing complete obstruction of the inferior nasal cavity 
Nasal endoscopy should be performed before the administration of IMP and preceded by local 
administration of anesthetic drugs in combination with a decongestant. 
Standard video sequences of the nasal endoscopy will be sent to centralized reader for blinded 
review. The sites will remove patient-identifying information from the imaging data prior to 
sending the imaging data to the central reader. Centralized imaging data assessments and scoring 
by independent physician reviewer(s) for the imaging data will be performed for all endoscopies. 
Specifically, a double central reading with adjudication process will be performed to improve 
scoring quality.  
To confirm eligibility at V2, only the V1 central reading will be made available to the site. In 
addition, at V2 the investigator will perform the nasal endoscopy to confirm eligibility score and 
enter the result in the e-CRF. Thus the patient is considered eligible based on a V1 central reading 
followed by a V2 local reading NPS total score of 5 or more and a score of at least 2 in each side. 
The final results of central reading from Visit 2 onward will be made available after the study. 
The adjudication for V1 will not be required if both readers score ineligible (total NPS score less 
than 5 or at least one side less than 2, in which case the patient will be considered as ineligible) or 
both readers score eligible (total NPS score of 5 or more and at least 2 in each side, in which case 
the patient will be considered as eligible). Unreadable scores (bad quality videos) at V1 even from 
one reader should have endoscopy redone as soon as possible (requiring patient to come back at 
site). In the case the two readers differ on eligibility for the study, an adjudicator will read the 
endoscopy again independently. The total NPS score and each side score to determine eligibility 
will be based on the average of the adjudicator and one of the two readers whose total NPS score 
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is closer to the adjudicator’s reading (in the case that the two readers’ scores are different but 
equidistant from the adjudicator’s score, the reader with the higher score will be used in the 
calculation). In the special case that the two readers give different eligibility opinions but the total 
NPS scores are the same (the only possibility of the total NPS score for such a case is 5), 
eligibility will follow the adjudicator’s opinion. 
 For V2 and onward (excluding V1), if the total NPS scores assigned by two independent readers 
differ less than or equal to 1, the total NPS score for analysis for this endoscopy will be the 
average of the two readings; if they differ more than 1, an adjudicator will read the endoscopy 
again independently, and the total NPS score for analysis will be the average of the total NPS 
scores by the adjudicator and one of the two readers whose total NPS score is closer to the 
adjudicator’s reading (in the case that the two readers’ total NPS scores are equidistant from the 
adjudicator’s total NPS score, the higher score will be used in the calculation). If the endoscopy is 
scored unreadable by both readers, the analysis score will be set to missing. If one and only one of 
the two readers score unreadable, the endoscopy will be read again independently by the 
adjudicator. Then the average of the two available readings (if the adjudicator gives a readable 
score) or missing value (if the adjudicator scores it as unreadable) will be set as the total NPS 
score for analysis. 
More details regarding the study eligibility determination based on the double central reading with 
adjudication are listed in Appendix B. 
For the analysis of primary endpoint, central reading of V2 will be used as the baseline. In the 
scenario that V2 central reading scores are missing, V1 central reading will be used instead and 
adjudication will be required if the total NPS scores by the two readers  at V1 differ more than 1 
and the adjudication has not been performed. Calculations of the analysis score for such V1 
readings will follow the aforementioned approach for V2 and onward.       
3. Change from baseline in Lund-Mackay score (LMK) at Week 24 
For Japan, in addition to the two co-primary endpoints above, Lund-Mackay score (LMK) will 
also be a co-primary endpoint (for countries other than Japan, change from baseline in LMK at 
Week 24 will be a key secondary endpoint) which is defined as follows: 
The LMK system is based on localization with points given for degree of opacification:  
0 = normal, 1 = partial opacification, 2 = total opacification. These points are then applied to the 
maxillary, anterior ethmoid, posterior ethmoid, sphenoid and frontal sinuses on each side. The 
Osteomeatal complex (OC) is graded as 0 = not occluded, or 2 = occluded. Adding the scores of 
these 6 parameters will derive a maximum score of 12 per side (left and right). The total score of 
the two sides will be used for analysis. This scoring system has been validated in several studies 
(5)(6)(7). 
For patients in whom the OC is missing (because of a previous surgery) the reader should consider 
the location of the former OC and provide a scoring (as if the OC was there).  
One reviewer will review CT images for all subjects enrolled in the clinical trial. The reviewer 
will perform the independent review under guidance of the study protocol and GCP. 
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A CT scan should be performed anytime during the run-in period before first administration of 
IMP, and at V8 (Week 24). CT scan is optional at V10 (Week 48). Whenever possible a cone 
beam CT scan should be utilized. In countries for which a specific approval procedure for the CT 
scan is required by a different committee than the local independent ethics committee 
(IEC)/institutional review board (IRB), patients may be enrolled using a CT available in the 
previous year or perform an MRI of the sinuses between V1 and V2. These countries are 
exempted from all the planned study CT scans until approval from these committees is received. 
2.1.3.2 Secondary efficacy endpoint(s) 
2.1.3.2.1 Key secondary endpoint 
2.1.3.2.1.1 Lund-Mackay score 
Lund-Mackay score is a secondary efficacy endpoint in countries other than Japan. Details of this 
endpoint are presented in Section 2.1.3.1.  
2.1.3.2.1.2 Disease specific daily symptom assessment and total symptom score (TSS) 
On a daily basis from V1 and throughout the study, the patient will use an e-diary to: 
• 
Respond to the morning individual rhinosinusitis symptom questions using a 0 to 
3 categorical scale (where 0 = no symptoms, 1 = mild symptoms, 2 = moderate symptoms 
and 3 = severe symptoms) :  
- 
Congestion and/or obstruction. 
- 
Loss of sense of smell. 
- 
Anterior rhinorrhea (runny nose). 
- 
Posterior rhinorrhea (postnasal drip). 
The TSS is a composite score (ranging between 0 and 9) consisting of the sum of the following 
symptoms assessed daily in the morning: nasal congestion/obstruction, decreased/loss of sense of 
smell, rhinorrhea (average of anterior/posterior nasal discharge).  
The symptom scores at baseline and from baseline to EOT analysis will be calculated using the 
same approach as for NC as described in Section 2.1.1 and Section 2.1.3.1. If there are 4 or more 
measurements collected within 7 days prior to randomization, the baseline will be the average of 
these measurements; if less than 4 measurements are collected, the baseline will be the average of 
the most recent 4 prior to randomization. For the baseline to EOT analysis, 4 weeks average of the 
symptom scores prior to the corresponding visit will be used as the analysis score for that visit. 
2.1.3.2.1.3 Smell test: University of Pennsylvania Smell Identification Test (UPSIT)  
The UPSIT (UPSIT 40 odorant test) is a rapid and easy-to-administer method to quantitatively 
assess human olfactory function. The UPSIT shows a high test-retest reliability (r: 0.981) and 
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scores on this test are strongly correlated with the detection threshold for phenyl ethyl alcohol in 
the same individuals. When the UPSIT is administered in the standardized manner, clinical 
subjects show a high degree of uniformity in UPSIT performance when tested in different 
laboratories. 
The test consists of 4 booklets, each containing 10 odorants with one odorant per page. Above 
each odorant strip is a multiple-choice question with four alternative words to describe the odor. 
The subject is asked to release the odorant by rubbing the brown-strip with the tip of a pencil and 
to indicate which of four words best describes the odor. Thus each subject receives a score out of 
40 possible correct answers. The final score is recorded in the e-CRF. The odorants of the UPSIT 
test utilized in this study take into account cultural differences. 
2.1.3.2.1.4 Decreased/loss of sense of smell 
The decreased/loss of sense of smell severity is assessed by the patient on a daily basis from V1 
and throughout the study, using an e-diary to using a 0-3 categorical scale (where 0 = no 
symptoms, 1 = mild symptoms, 2 = moderate symptoms and 3 = severe symptoms). The symptom 
scores at baseline and from baseline to EOT analysis will be calculated using the same approach 
as for NC. 
2.1.3.2.1.5 22-Item sino-nasal outcome test (SNOT-22) 
The SNOT-22 is a validated questionnaire to assess the impact of chronic rhinosinusitis on 
HRQoL (Appendix D). The SNOT-22 has 22 items on a 5-category scale applicable to sino-nasal 
conditions and surgical treatments. The range of the global score is 0-110 with a minimal 
important difference (MID) of 8.9 (8). The MID is the smallest mean change from baseline (point 
estimates) that will be interpreted as important; lower scores indicate less impact. The recall 
period is the prior 2 weeks. At baseline, the patient is also asked to rank the 5 most important 
items affecting their health. 
The global score is the sum of response to each of the 22 questions. For responses with some item 
scores are missing, the global score will be imputed as mean of the completed scores× 22, 
providing at least 50% of items have been completed. If more than 50% of items are missing, the 
global score is set to missing.  
2.1.3.2.1.6 Proportion of patients requiring rescue treatment defined as: use systemic 
corticosteroids or NP surgery (actual or planned) during the treatment period 
SCS for any reason 
Systemic corticosteroids for rescue treatment of nasal polyps or for another reason administered 
during study treatment are recorded by the Investigator (or designee) who records the date and 
dosing information (daily dose, duration, INN) on the appropriate page(s) of the e-CRF. Indication 
for SCS use will be also captured by selecting one or more of the following categories:  
1. Nasal polyposis. 
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2. Asthma. 
3. Other respiratory disease (specify).  
4. Other ear, nose or throat disease (specify). 
5. Other reason (specify).  
Surgery (actual or planned) for NP  
For patients who undergo or are planned for sino-nasal surgery for NP, the reason (worsening 
signs and/or symptoms during the study), the date of decision for surgery, the planned date and the 
effective surgery date, the type and outcome of surgery will be recorded in a specific e-CRF page. 
 If surgery is performed during the study treatment period, patient and investigator may decide to 
continue IMP up to the time of surgery or EOT whichever date comes first. At the time of surgery 
patients will be permanently discontinued from study treatment and assessed as soon as possible 
using the procedures normally planned for the EOT Visit and will be instructed to return to the 
study site as described in the protocol. An AE or serious adverse event (SAE) page will be 
completed.  
If surgery is performed during the follow-up, the patients will be assessed according to the 
procedures normally planned for the EOS Visit and will be instructed to return to the study site as 
described in protocol. An AE or SAE page will be completed.  
If surgery date is scheduled after the planned end of study, EOS visit will not be delayed. A follow 
up contact(s) should be performed around the time of planned surgery to document the surgery 
date and outcome. Surgery data will be collected until e-CRF closure of the trial. 
2.1.3.2.1.7 Spirometry 
Spirometry was performed at local level (study site or another facility) in the morning after 
withholding the last dose of salbutamol/albuterol or levosalbutamol/levalbuterol for at least 
6 hours. Forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and forced 
expiratory flow at 25% to 75% of forced vital capacity (FEF 25-75) were determined at the 
designated treatment visits (9). The results of FEV1 (score in L, % of predicted normal,), FVC and 
FEF 25-75 were recorded in the e-CRF anytime during run-in period (before V2) for all patients 
and in patients with asthma for the other scheduled visits during the randomized treatment period.  
Whenever possible, the same spirometer and standard spirometric techniques, including 
calibration, should be used to perform spirometry at all visits and, the same person should perform 
the measurements. 
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2.1.3.2.2 Other secondary efficacy endpoints 
2.1.3.2.2.1 Visual analogue scale  
The visual analogue scale (VAS) for rhinosinusitis is used to evaluate the total severity (1). 
Rhinosinusitis disease can be divided into MILD, MODERATE and SEVERE based on total 
severity VAS score (0 to 10 cm): 
• 
MILD = VAS 0 to 3.  
• 
MODERATE = VAS >3 to 7.  
• 
SEVERE = VAS >7 to 10.  
The patient is asked to indicate on a VAS the answer to the question below:  
“How troublesome are your symptoms of your rhinosinusitis” 
The VAS ranks from 0 (Not troublesome) to 10 (Worst thinkable troublesome). 
2.1.3.2.2.2 Nasal peak inspiratory flow 
Nasal peak inspiratory flow (NPIF) evaluation represents a physiologic measure of the air flow 
through both nasal cavities during forced inspiration expressed in liters per minute. The NPIF is 
the best validated technique for the evaluation of nasal flow through the nose. Nasal inspiration 
correlates most with the subjective feeling of obstruction and is the best validated technique for 
monitoring nasal flow in clinical trials. 
On V1 patients will be issued an NPIF meter for recording morning (AM) NPIF. Patients will be 
instructed on the use of the device, and written instructions on the use of the NPIF meter will be 
provided to the patients. In addition, the Investigator will instruct the patients on how to record the 
following variables in the e-diary on a daily basis. 
• 
AM NPIF performed within 15 minutes after arising (before 12 noon) prior to taking 
MFNS.  
Three NPIF efforts will be performed by the patient; all 3 values will be recorded by the patient in 
the e-diary, and the highest value will be used for evaluation. The procedure takes about 
5 minutes. 
Baseline AM NPIF will be the mean AM measurement recorded for the 7 days prior to the first 
dose of IMP. If less than 4 measurements are collected within 7 days prior to randomization, the 
average of the most recent 4 prior to randomization during the run-in period will serve as the 
baseline as described in Section 2.1.1.  
The NPIF will be performed daily from V1 to V8 (Week 24). After V8 the NPIF will be 
performed every 4 weeks. 
The nasal flow is expressed in liter per minute, and consecutive measurements are performed.  
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2.1.3.2.2.3 Asthma Control Questionnaire, 6-question version (ACQ-6) in those patients 
comorbid with asthma 
The asthma control questionnaire-6 (ACQ-6) was designed to measure both the adequacy of 
asthma control and change in asthma control which occurs either spontaneously or as a result of 
treatment. Only patients with co-morbid asthma will be asked to complete the questionnaire in the 
e-diary during clinic visits. Patients should complete the questionnaire before the spirometry test. 
The asthma control questionnaire-6 (ACQ-6) has 6 questions which assess the most common 
asthma symptoms: 
• 
Frequency in past week awoken by asthma during the night. 
• 
Severity of asthma symptoms in the morning.  
• 
Limitation of daily activities due to asthma.  
• 
Shortness of breath due to asthma. 
• 
Frequency of wheezing, and 
• 
Short-acting bronchodilator use.  
Patients are asked to recall how their asthma has been during the previous week and to respond to 
the symptom questions on a 7-point scale (0 = no impairment, 6 = maximum impairment)  
(see Appendix C). 
A global score is calculated: the questions are equally weighted and the ACQ-6 score is the mean 
of the 6 questions and, therefore, between 0 (totally controlled) and 6 (severely uncontrolled). 
Higher score indicates lower asthma control. Patients with a score below 1.0 reflect adequately 
controlled asthma and patients with scores above 1.0 reflect inadequately controlled asthma. On 
the 7-point scale of the ACQ-6, a change or difference in score of 0.5 is the smallest change that 
can be considered clinically important, corresponding to the Minimal Clinically Important 
Difference (MCID) defined by the developer. 
Measurement properties such as reliability and ability to detect change have been documented in 
the literature (10). 
2.1.4 Safety endpoints 
The safety analysis will be based on the reported adverse events and other safety information, such 
as clinical laboratory data, vital signs, ECG and physical examination. 
Observation period  
The observation period will be divided into 4 epochs: 
• 
The screening epoch is defined as the time from the signed informed consent date up to 
the time prior to first administration of the IMP. 
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• 
The treatment epoch is defined as the time from the first administration of the IMP to the 
last administration of the IMP + 14 days.  
• 
The residual treatment epoch is defined as the time from the last administration of the 
IMP +15 days to the last administration of the IMP + 98 days. 
The treatment-emergent adverse event period will include both treatment and residual treatment 
epochs. 
• 
The post-treatment epoch is defined as the period of time starting the day after the end of 
the treatment-emergent adverse event period up to the end of the study (defined as last 
protocol planned visit or the resolution/stabilization of all serious adverse events and 
adverse events with pre-specified monitoring). 
The on-study observation period is defined as the time from start of treatment until the end of the 
study (defined as last protocol planned visit or lost to follow-up or the resolution/stabilization of 
all serious adverse events and adverse events with pre-specified monitoring).  
2.1.4.1 Adverse events variables 
Adverse event observation period  
• 
Pretreatment adverse events are adverse events that developed or worsened or became 
serious during the screening epoch. 
• 
Treatment-emergent adverse events are adverse events that developed or worsened or 
became serious during the treatment-emergent adverse event period 
• 
Post-treatment adverse events are adverse events that developed or worsened or became 
serious during the post-treatment epoch. 
All adverse events (including serious adverse events and adverse events with pre-specified 
monitoring/of special interests) will be coded to a lower-level term (LLT), preferred term (PT), 
high-level term (HLT), high-level group term (HLGT), and associated primary system organ class 
(SOC) using the version of Medical Dictionary for Regulatory Activities (MedDRA) currently in 
effect at Sanofi at the time of database lock. 
The occurrence of adverse events (including serious adverse events and adverse events with pre-
specified monitoring) will be recorded from the time of signed informed consent until the end of 
the study.  
Adverse events of special interests (AESI) and other selected AE groupings will be searched 
based on the criteria in Table 1. 
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Table 1 Criteria for adverse events of special interest and other selected AE groupings 
AE Grouping 
Criteria 
AESI 
 
Anaphylactic reaction 
Anaphylactic reaction algorithmic approach (Introductory Guide for 
Standardised MedDRA Queries (SMQs) Version 18.1): includes 
anaphylactic reaction narrow SMQ (20000021) terms; for selection 
based on occurrence of multiple symptoms, the symptoms must have 
occurred within 24 hours of each other 
Hypersensitivity  
(medically reviewed) 
SMQ hypersensitivity (20000214) narrow search) and [AE corrective 
treatment/therapy=’Y’ or Action taken with IMP=’Drug withdrawn’ or 
Action taken with IMP=’Drug interrupted’] followed by blinded medical 
review (documented process) for selection of relevant systemic 
hypersensitivity events  
Serious injection site reactions or 
severe injection site reactions that 
last longer than 24 hours 
HLT = ‘Injection site reaction’ and either with serious status, or with 
severe status and (AE end date/time - AE start date/time) ≥ 24 hours or 
ongoing 
Severe or serious infection 
Primary SOC = ‘Infections and infestations’ and (Intensity=’Severe’ or 
Serious=’Y’) 
Parasitic infection 
The Infection Type ‘Parasitic’ was checked on eCRF page “Infection 
Defined as AESI Complementary Form” 
Opportunistic infection 
The Infection Type ‘Opportunistic’ was checked on eCRF page 
“Infection Defined as AESI Complementary Form” 
Drug-related hepatic disorder 
Drug-related hepatic disorders-Comprehensive search narrow SMQ 
(20000006) 
Pregnancy 
Primary SOC ‘Pregnancy, puerperium and perinatal conditions’ or PT in 
(Aborted pregnancy, False negative pregnancy test, Pregnancy test 
positive, Pregnancy test urine positive, Ectopic pregnancy termination) 
Symptomatic overdose with IMP 
The question “Is the event a Symptomatic Overdose with IMP?” is 
answered “Yes” on the eCRF page “Adverse Event”. 
Symptomatic overdose with NIMP The question “Is the event a Symptomatic Overdose with NIMP?” is 
answered “Yes” on the eCRF page “Adverse Event”. 
Other selected AE grouping 
 
Injection site reaction  
HLT = ‘Injection site reaction’  
Malignancy 
Sub-SMQ (20000091)– Malignant or unspecified tumors 
 
Suicidal behavior 
PT in (Completed suicide, Suicidal ideation, Depression suicidal, 
Suicidal behavior, Suicide attempt) 
Partner pregnancy 
PT in (Pregnancy of partner, Miscarriage of partner) 
 
Epistaxis/nose bleeding 
PT in (Epistaxis, Nasal septum haematoma) 
Conjunctivitis (narrow company 
medical query) 
PT in (Conjunctivitis, Conjunctivitis allergic, Conjunctivitis bacterial, 
Conjunctivitis viral, Atopic keratoconjunctivitis) 
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AE Grouping 
Criteria 
Conjunctivitis (broad company 
medical query) 
PT in (Conjunctivitis, Conjunctivitis allergic, Conjunctivitis bacterial, 
Conjunctivitis viral, Atopic keratoconjunctivitis, Blepharitis, Dry eye, Eye 
irritation, Eye pruritus, Lacrimation increased, Eye discharge, Foreign 
body sensation in eyes, Photophobia, Xerophthalmia, Ocular 
hyperaemia, Conjunctival hyperaemia) 
Hypereosinophilia 
HLT = ‘Eosinophilic disorders’ or PT = ‘Eosinophil count increased’ 
2.1.4.2 Deaths 
The deaths observation period are per the observation periods defined above.  
• 
Death on-study:  deaths occurring during the on-study observation period 
• 
Death on-treatment:  deaths occurring during the treatment-emergent adverse event period  
• 
Death post-study:  deaths occurring after the end of the study  
2.1.4.3 Laboratory safety variables 
Clinical laboratory data consists of blood analysis, including hematology, clinical chemistry, and 
urinalysis.  Clinical laboratory values after conversion will be analyzed into standard international 
units and international units will be used in all listings and tables. 
Blood samples for clinical laboratories will be taken at Visit 1(Week -4±1), Visit 2 (Week 0), 
Visit 7 (Week 16), Visit 8 (Week 24), and early termination unless otherwise specified.  The 
laboratory parameters will be classified as follows:   
• 
Hematology  
- 
Red blood cells and platelets and coagulation:  hemoglobin, hematocrit, red blood 
cell count, platelet count 
- 
White blood cells:  white blood cell count, neutrophils, lymphocytes, monocytes, 
basophils, eosinophils 
• 
Clinical chemistry  
- 
Metabolism:  glucose, total cholesterol, total protein, creatine phosphokinase. 
- 
Electrolytes:  sodium, potassium, chloride, bicarbonate. 
- 
Renal function:  creatinine, blood urea nitrogen, uric acid. 
- 
Liver function:  alanine aminotransferase, aspartate aminotransferase, alkaline 
phosphatase, lactate dehydrogenase, total bilirubin (in case of values above the normal 
range, differentiation in conjugated and non-conjugated bilirubin), albumin. 
- 
Pregnancy test:  Serum β-human chorionic gonadotropin (all female patients) will be 
performed at screening (V1) in women of childbearing potential, and a urine dipstick 
pregnancy test will be performed at V2 prior to randomization and every 4 weeks 
thereafter. A negative result must be obtained at V1 and V2 prior to randomization. In 
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case of positive urinary test the study treatment will be withheld and a serum 
pregnancy test to confirm the pregnancy should be performed as soon as possible. 
Pregnancy will lead to definitive treatment discontinuation in all cases. 
- 
Hepatitis screen: hepatitis B surface antigen (HBs Ag), hepatitis B Surface antibody 
(HBs Ab), hepatitis B core antibody (HBc Ab), hepatitis C virus antibodies (HCV Ab), 
In case of results showing HBs Ag (negative), HBs Ab (negative) and HBc Ab 
(positive), an HBV DNA testing may be performed prior to randomization to rule out a 
false positivity if the investigator believes the patient is a false positive, or to clarify the 
serological status if the investigator finds it unclear to interpret in absence of known 
HBV infection. In case of results showing HCV Ab (positive), an HCV RNA testing 
may be performed to rule out a false positivity, if the investigator believes the patient is 
a false positive. 
- 
Hepatitis B viral load will be tested at V2, and V8 for patients in Japan or other 
countries/regions if there is local regulatory requirement who are HBs Ag negative and 
HBs Ab positive at screening. 
- 
HIV screen: Anti-HIV-1 and HIV-2 antibodies will be tested at Visit 1.  
- 
Anti-nuclear antibody (ANA) will be tested at Visit 1.  
- 
Note: Anti-ds DNA antibody will be tested if ANA is positive (≥1:160 titer).  
Technical formulas are described in Section 2.5.1. 
2.1.4.4 Vital signs variables 
Vital signs, including blood pressure (mmHg), heart rate (beats per minute), respiratory rate 
(breaths per minute), body temperature (degrees Celsius) and body weight (kg) will be measured 
at the screening and randomization visits (Visits 1 and 2) and subsequent visits pre-specified in 
the flowchart. Height (cm) will be measured at screening (Visit 1) only. Vital signs will be 
measured in the sitting position using the same arm (preferably) at each visit, and will be 
measured prior to receiving IMP at the clinic visits. 
2.1.4.5 Electrocardiogram variables 
A standard 12-lead electrocardiogram (ECG) will be performed at the sites at the time points 
noted in the Study Flowchart (Section 1.4.1) to monitor any potential abnormality. In case of an 
abnormal ECG finding, the Investigator should enter details into the e-CRF. At V2, the 
investigator should use their medical judgment to consider whether the patient is eligible for the 
study. 
2.1.4.6 Physical Examination 
Physical examinations will be performed at Visit 1(Week -4±1), Visit 8 (Week 24), Visit 9 (Week 
36), and Visit 10 (Week 48) including an assessment of general appearance, skin, eyes, 
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ear/nose/throat, heart, chest, abdomen, reflexes, lymph nodes, spine, and extremities. All 
deviations from normal will be recorded, including those attributable to the patient’s disease. 
2.1.5 Pharmacokinetic variables  
Predose functional dupilumab concentrations in serum at V2 (Day 1), dupilumab trough 
concentrations at Week 4, Week 8, Week 16, Week 24 (EOT), and post-treatment at Week 36 and 
Week 48 (EOS) will be provided.  
Anti-dupilumab antibody (ADA) status (negative or titer value, if positive in the ADA assay) at 
Visit 2 (Day 1), Week 8, Week 16, Week 24, Week 36 and Week 48 will be provided. Patients 
who discontinue early from treatment may be asked to return to the clinic to have additional ADA 
samples collected for analysis based on the overall clinical presentation at that time.  
ADA incidence will be classified as the following: 
Pre-existing immunoreactivity are defined as:  
An ADA positive response in the assay at baseline with all post-treatment ADA results negative, 
OR an ADA positive response at baseline with all post-treatment ADA responses less than 4-fold 
over baseline titer levels. 
Treatment-emergent anti-drug antibodies are defined as:  
A positive response in the ADA assay post first dose, when baseline results are negative or 
missing. 
Treatment-emergent ADA responses are further classified as Persistent, Indeterminate or Transient 
A) Persistent Response- defined as a treatment-emergent ADA response with two or more 
consecutive ADA positive sampling time points, separated by greater than (>) 12-week  
period (84 days) ,with no ADA negative samples in between. 
B) Indeterminate Response- defined as a treatment-emergent response with only the last 
collected sample positive in the ADA assay  
C) Transient Response - defined as a treatment-emergent response that is not considered 
persistent OR indeterminate 
Treatment-boosted response is defined as:   
An ADA positive response in the assay post first dose that is greater-than or equal to 4-fold over 
baseline titer levels, when baseline results are positive. 
Titer values (Titer value category) 
• 
Low (Titer < 1000) 
• 
Moderate (1,000 ≤ Titer ≤ 10,000) 
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• 
High (Titer > 10,000) 
2.1.6 Pharmacodynamic
 endpoints  
Blood biomarkers (Eotaxin-3, Thymus and Activation-Regulated Chemokine [TARC] and 
periostin) will all be assayed at Visit 2(Week 0). 
Serum Total IgE, allergen-specific IgE panel sampling including Staph enterotoxins IgE will be 
assayed at Visit 2(Week 0) and Visit 8(Week 24). 
Urine biomarkers (Leukotriene E4 and a metabolite of prostaglandin D2 (PGDM) and creatinine) 
will be measured in morning spot urine samples using validated quantitative assays. 
 
 
 
Using a nasal swab, mucus will be collected from the middle meatus of each nostril and assessed 
for relative abundance of microbes, in all patients prior to MFNS administration. Mucus will be 
assayed at Visit 2(Week 0) and Visit 8(Week 24). 
2.1.7 Health Related Quality-of-life endpoints  
2.1.7.1 Euro-QOL-5D 
The European quality of life-5D scale (EQ-5D) (Appendix E) is a standardized HRQoL 
questionnaire developed by the EuroQol Group in order to provide a simple, generic measure of 
health for clinical and economic appraisal (11). EQ-5D is designed for self-completion by 
patients. 
The EQ-5D essentially consists of 2 pages: the EQ-5D descriptive system and the EQ VAS. The 
EQ-5D comprises 5 dimensions: mobility, self-care, usual activities, pain/discomfort and 
anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate 
problems, severe problems, and extreme problems. The EQ VAS records the respondent’s self-
rated health on a vertical VAS. The EQ VAS ‘thermometer’ has endpoints of 100 (best imaginable 
health state) at the top and 0 (worst imaginable health state) at the bottom. EQ-5D self-reported 
VAS data generates information on the self-perceived overall health-related quality of life.  
EQ-5D will be assessed at Visit 2 (Week 0) and Visit 8 (Week 24). 
2.1.7.2 Short Form 36 (SF-36) Version 2 
The SF-36 (Short-Form-36 (SF-36)-Version 2.0) (Appendix F) is a generic questionnaire 
measuring general health status (QoL) in the last 4 weeks before completing the questionnaire. 
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The SF-36 is a 36-item questionnaire that measures eight multi-item dimensions of health: 
physical functioning (10 items) social functioning (2 items) role limitations due to physical 
problems (4 items), role limitations due to emotional problems (3 items), mental health (5 items), 
energy/vitality (4 items), pain (2 items), and general health perception (5 items). 
For each dimension, item scores are coded, summed, and transformed on to a scale from 0 (worst 
possible health state measured by the questionnaire) to 100 (best possible health state). Two 
standardized summary scores can also be calculated from the SF-36; the physical component 
summary (PCS) and the mental health component summary (MCS). 
In this study SF-36 will be assessed only at V2 to evaluate the baseline QoL impact in the defined 
phase 3 population. 
2.1.8 Health economic endpoints  
Health care resource utilization (reliever medication, specialist visit, hospitalization, emergency or 
urgent medical care facility visit), and productivity (sick leaves, school days loss, usual activity 
loss etc.) will be collected at Visit 2 (Week 0), Visit 6 (Week 8), Visit 7 (Week 16), and Visit 8 
(Week 24) through eCRF. 
2.2 
DISPOSITION OF PATIENTS 
This section describes patient disposition for both patient study status and the patient analysis 
populations. 
Screened patients are defined as any patients who signed the informed consent.  
Randomized patients consist of all patients with a signed informed consent form who have had a 
treatment kit number allocated and recorded in the IRT database, regardless of whether the 
treatment kit was used. 
For patient study status, the total number of patients in each of the following categories will be 
presented in the clinical study report using a flowchart diagram or summary table: 
• 
Screened patients 
• 
Screen failure patients and reasons for screen failure 
• 
Nonrandomized but treated patients 
• 
Randomized patients 
• 
Randomized but not treated patients 
• 
Randomized and treated patients 
• 
Patients who did not complete the 24-week treatment as per protocol  
• 
Patients who did not complete the 48-week follow-up as per protocol 
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• 
Patients who withdraw from study 
• 
Patients who withdraw from study by main reason for study discontinuation 
• 
Patients who withdraw from study prior to Week 24  
• 
Patients who withdraw from study prior to Week 24 by main reason for study 
discontinuation.  
• 
Vital status at last study contact 
For all categories of patients (except for the screened and nonrandomized categories) percentages 
will be calculated using the number of randomized patients as the denominator. Whether patients 
received rescue treatment (SCS or NP surgery) by Week 24 and Week 48 will be provided in 
tables. The tables will list patient numbers and percentages by treatment group and type of rescue 
treatment (SCS or NP surgery).  
All critical or major deviations potentially impacting efficacy analyses, randomization, and 
drug-dispensing irregularities, and other major or critical deviations will be summarized in tables 
giving numbers and percentages of deviations by treatment group. 
Additionally, efficacy populations will be summarized by number of patients on the randomized 
population. 
• 
Efficacy population: intent-to-treat (ITT) population 
The analysis populations for safety, pharmacokinetics/pharmacodynamics will be summarized by 
number of patents on the safety population. 
• 
Safety population 
• 
Systemic drug concentration population 
• 
PK population 
• 
ADA population 
2.2.1 Randomization and drug dispensing irregularities 
Randomization and drug-dispensing irregularities occur whenever: 
1. A randomization is not in accordance with the protocol-defined randomization method, 
such as a) an ineligible patient is randomized, b) a patient is randomized based on an 
incorrect stratum, c) a patient is randomized twice, or d) in a dynamic randomization 
scheme the treatment assignment is, in fact, not random, due to a computer program error.  
 
OR 
2. A patient is dispensed an IMP kit not allocated by the protocol-defined randomization, 
such as a) a patient at any time in the study is dispensed a different treatment kit than as 
randomized (which may or may not contain the correct-as-randomized IMP), or b) a 
nonrandomized patient is treated with IMP reserved for randomized patients. 
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Randomization and drug-dispensing irregularities will be monitored throughout the study and 
reviewed on an ongoing basis.  
All randomization and drug-dispensing irregularities will be documented in the clinical study 
report.  If the number of irregularities is large enough to make a tabular summary useful, the 
irregularities will be categorized and summarized among randomized patients (number and 
percentages).  Nonrandomized, treated patients will be described separately.  
Randomization and drug-dispensing irregularities to be prospectively identified include but are not 
limited to:  
Randomization and drug allocation irregularities 
Kit dispensation without IRT transaction 
Erroneous kit dispensation 
Kit not available 
Randomization by error 
Patient randomized twice 
Forced randomization 
Stratification error 
Patient switched to another site 
2.3 
ANALYSIS POPULATIONS 
Patients treated without being randomized will not be considered randomized and will not be 
included in any efficacy population.   
The randomized population includes any patient who has been allocated to a randomized 
treatment regardless of whether the treatment kit was used. 
For any patient randomized more than once, only the data associated with the first randomization 
will be used in any analysis population.  The safety experience associated with any later 
randomization will be assessed separately. 
2.3.1 Efficacy populations 
The primary efficacy analysis population will be the ITT population as defined in Section 2.3.1.1. 
2.3.1.1 Intent–to-treat population  
The intent-to-treat population is the randomized population analyzed according to the treatment 
group allocated by randomization.  
Patients will be analyzed in the treatment group to which they are randomized. 
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2.3.2 Safety population 
The safety population is defined as: All patients who actually received at least 1 dose or part of a 
dose of the IMP, analyzed according to the treatment patients actually received. 
In addition:  
• 
Nonrandomized but treated patients will be part of the safety population 
• 
Randomized patients for whom it is unclear whether they took the IMP will be included in 
the safety population as randomized 
• 
For patients on placebo but accidentally exposed to dupilumab, the treatment group 
allocation for as-treated analysis will be 300 q2w dose group  
2.3.3 Pharmacokinetics (PK) population 
The PK population will consist of all patients in the safety population with at least one evaluable 
functional dupilumab concentration result. Patients will be analyzed according to the treatment 
actually received. 
2.3.4 Anti-drug antibody population  
The anti-drug antibody (ADA) population will consist of all patients in the safety population with 
at least one reportable ADA results (either ‘ADA negative’ or ‘ADA positive’) after first dose of 
the study treatment. Patients will be analyzed according to the treatment actually received. 
2.4 
STATISTICAL METHODS 
2.4.1 Demographics and baseline characteristics 
Continuous data will be summarized using the number of available data, mean, standard 
deviation (SD), median, minimum, and maximum for each treatment group.  Categorical and 
ordinal data will be summarized using the number and percentage of patients in each treatment 
group.  
Parameters will be summarized on the randomized population analyzed in the treatment group to 
which they were randomized.  Analyses for the safety population will be included in the 
appendices if the size of the safety population is different (>10%) from the size of that in the 
primary analysis population for any treatment group. 
Parameters described in Section 2.1.1 will be summarized by treatment group and overall 
treatment groups using descriptive statistics.  
Medical and surgical history will be summarized by treatment group and by system organ class 
(SOC) and preferred term (PT) sorted by internationally agreed order of SOC and by the 
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decreasing frequency of PT within SOC based on the overall incidence across treatment groups. 
Atopic medical history will be summarized separately.  
No statistical testing on demographic and baseline characteristic data will be performed.  
No specific description of the safety parameters will be provided at baseline.  If relevant, the 
baseline values will be described along with each safety analysis. 
2.4.2 Prior or concomitant medications  
The prior and concomitant medications will be presented for the randomized population.  
Medications will be summarized by treatment group according to the WHO-DD dictionary, 
considering the first digit of the anatomic category (ATC) class (anatomic category) and the first 3 
digits of the ATC class (therapeutic category).  All ATC codes corresponding to a medication will 
be summarized, and patients will be counted once in each ATC category (anatomic or therapeutic) 
linked to the medication. Therefore patients may be counted several times for the same 
medication.  
The table for prior medications will be sorted by decreasing frequency of ATC followed by all 
other therapeutic classes based on the overall incidence across treatment groups.  In case of equal 
frequency regarding ATCs (anatomic or therapeutic categories), alphabetical order will be used. 
Concomitant medication received during first IMP to last IMP +14 days and concomitant 
medication received during first IMP to last IMP +98 days will be summarized separately. The 
tables for concomitant medications will be sorted by decreasing frequency of ATC followed by all 
other therapeutic classes based on the incidence in the dupilumab 300 q2w group. In case of equal 
frequency regarding ATCs (anatomic or therapeutic categories), alphabetical order will be used.  
Medications will also be summarized by generic name sorted by decreasing frequency based on 
the overall incidence across treatment groups. 
In addition, MFNS controller medication will be summarized separately. Asthma controller 
medication(s) will also be summarized for asthma patients at baseline, Week 24 and Week 48 
visits. 
2.4.2.1 INCS/MFNS controller medication 
INCS/MFNS controller medication taken within 1 year prior to screening will be summarized by 
treatment group sorted by decreasing frequency of generic name followed by total daily dosage 
based on the incidence in the overall group.  
The prescription of INCS/MFNS controller medication at randomization will be summarized 
regarding QD and BID by treatment group.  
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2.4.2.1.1 Compliance 
During the study, the daily intake of the INCS/MFNS controller medication will be recorded on 
the electronic diary every morning by patients as number of actuations. Compliance for INCS will 
be calculated for each patient. For each day, a patient is considered as compliant to the prescribed 
controller medication if the actual dose is the same as or greater than the prescribed dose (ie, two 
actuations) for each nostril during each administration throughout the day: for one follows a QD 
(or BID) regimen, the patient is only considered as compliant to the prescribed INCS medication if 
the actual dose for each nostril administered during the day (or both in the morning and evening) 
is the same as or greater than the prescribed dose. 
Percentage of Compliance is defined as the number of days when the patient is compliant to the 
prescribed controller medication divided by the number of days the patient stays in the treatment 
period (from first IMP to last IMP + 14 days).  
2.4.3 Extent of investigational medicinal product exposure and compliance  
The extent of IMP exposure and compliance will be assessed and summarized by actual treatment 
within the safety population (Section 2.3.2).  
2.4.3.1 Extent of investigational medicinal product exposure 
The extent of IMP exposure will be assessed by the duration of IMP exposure. 
Duration of IMP exposure is defined as last dose date – first dose date + 14 days, regardless of 
unplanned intermittent discontinuations (see Section 2.5.3 for calculation in case of missing or 
incomplete data). Duration of IMP exposure will be summarized descriptively as a quantitative 
variable (number, mean, SD, median, minimum, and maximum).  In addition, duration of 
treatment exposure will also be summarized categorically by numbers and percentages for each of 
the following categories and cumulatively according to these categories:  
• 
>0 and ≤2 weeks 
• 
>2 and ≤4 weeks 
• 
>4 and ≤8 weeks 
• 
>8 and ≤12 weeks 
• 
>12 and ≤16 weeks 
• 
>16 and ≤20 weeks 
• 
>20 and ≤24 weeks 
• 
>24 weeks 
Additionally, the cumulative duration of treatment exposure will be provided, defined as the sum 
of the duration of treatment exposure for all patients, and will be expressed in patient years. 
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2.4.3.2 Compliance  
A given administration will be considered noncompliant if the patient did not take the planned 
dose of treatment as required by the protocol.  No imputation will be made for patients with 
missing or incomplete data. 
Percentage of compliance for a patient will be defined as the number of administrations that the 
patient was compliant divided by the total number of administrations that the patient was planned 
to take during the treatment epoch defined in Section 2.1.4. 
Treatment compliance percentages will be summarized descriptively as quantitative variables 
(number, mean, SD, median, minimum, and maximum). The percentage of patients whose 
compliance is <80% will be summarized in Section 2.4.4.5.  
Cases of overdose (defined as at least twice the intended dose during an interval of less than 11 
days) will constitute serious adverse events and will be listed as such. More generally, dosing 
irregularities will be listed in Section 2.2.1. 
2.4.4 Analyses of efficacy endpoints 
The primary analysis population for the efficacy endpoints will be the randomized ITT population 
which includes all patients who have been allocated to a randomized treatment regardless of 
whether the treatment kit was used or not. The efficacy analyses will be conducted according to 
the treatment to which they were randomized. 
2.4.4.1 Analysis of primary efficacy endpoint(s) 
Co-primary efficacy variables 
The co-primary efficacy variables are: change from baseline in NC and in NPS (change from 
baseline in NC, NPSand LMK for Japan) at Week 24 assessed for dupilumab 300 mg q2w (Arm 
A) versus placebo (Arm B), respectively. 
The following null hypothesis and alternative will be tested for dupilumab arm against placebo:  
• 
H0: No treatment difference between the dupilumab dose regimen and placebo. 
• 
H1: There is a treatment difference between the dupilumab dose regimen and placebo. 
Primary statistical model (ITT analysis)  
Each of the 2 co-primary efficacy endpoints (3 co-primary efficacy endpoints for Japan) will be 
analyzed using a hybrid method of the worst-observation carried forward (WOCF) and multiple 
imputation. Data collected after treatment discontinuation will be included in the analysis. With 
this approach, for patients who undergo surgery for NP or receive SCS for any reason, data 
collected post-surgery (actual date) or post SCS will be set to missing, and the worst post-baseline 
value on or before the time of surgery or SCS will be used to impute missing Week 24 value (for 
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patients whose post-baseline values are all missing, the baseline will be used to impute). For 
patients who discontinue the treatment without being rescued by surgery or receiving SCS, a 
multiple imputation approach will be used to impute missing Week 24 value, and this multiple 
imputation will use all patients who have not been rescued by surgery or receiving SCS at 
Week 24. Each of the imputed complete data will be analyzed by fitting an ANCOVA model with 
the baseline value of the corresponding co-primary endpoint, treatment group, asthma/NERD 
status, prior surgery history, and regions as covariates. Statistical inference obtained from all 
imputed data will be combined using Rubin’s rule. Descriptive statistics including number of 
patients, mean, standard error, and least squares (LS) means will be provided. In addition, 
difference in LS means and the corresponding 95% confidence intervals (CI) will be provided 
along with the p-values. 
Imputation and analysis model will be built with the following sample SAS code:  
1.  40 datasets with a monotone missing pattern will be obtained, induced by Markov Chain 
Monte Carlo (MCMC) method on patients who have not been rescued by surgery or 
receiving SCS at Week 24. 
proc mi data=dat_etd seed=14280 nimpute=40 out=dat_mc; 
    mcmc impute=monotone; 
    var asthma surgery region treatment basenps chg4nps chg8nps  
chg16nps   chg24nps; 
run; 
 
2. For each of the imputed dataset with monotone missing pattern in step 1, the remaining 
missing data will be imputed using the regression method for the monotone pattern with 
adjustment for covariates including treatment groups, region, asthma/NERD strata, surgery 
strata and baseline value of the response variable. 
 
proc mi data=dat_mc nimpute=1 seed=14280 out=dat_mi;   
    by _imputation_; 
class asthma surgery region treatment; 
monotone method=reg; 
var asthma surgery region treatment basenps chg4nps chg8nps chg16 
nps chg24nps; 
run; 
 
 
3. Each of the 40 imputed datasets will be merged with the one dataset imputed by WOCF 
approach, and then be analyzed using the main statistical model. These 40 imputed 
datasets will be saved. 
 
%macro w1; 
%do i=1%to 40; 
data wocf&i.; 
set wocf; 
_imputation_=&i.; 
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run; 
%end; 
data wocf_all; 
set %do j=1 %to 40; wocf&j. %end;; 
run; 
    
%mend w1; 
 
%w1 
 
data dat_imp; 
    
 
set dat_mi  wocf_all; 
Run;  
 
proc sort data=dat_imp; 
       
by _imputation_; 
run; 
 
proc glm data= dat_imp; 
       
by _imputation_; 
       
class region asthma surgery treatment;  
       
model  = chg24nps = basenps asthma surgery region treatment; 
 
 
lsmeans treatment / stderr; 
       
estimate 'Diff Dupilumab vs Placebo' treatment -1 1; 
       
ods output LSMeans=implsmeans Estimates=implsmeandiff; 
  
run; 
 
4. Applying Rubin’s rule to combine analysis results (point estimates and standard errors) 
from 40 imputations using PROC MIANALYZE for the LS means and difference in LS 
means between dupilumab and placebo. Sample code: 
 
   
proc sort data=implsMeans; by trt01pn _imputation_;run; 
 
   
proc mianalyze data= implsmeans; 
       
by trt01pn; 
       
modeleffects lsmean; 
       
stderr stderr; 
       
ods output ParameterEstimates=lsmeans; 
     run; 
 
    
proc mianalyze data=implsmeandiff; 
       
modeleffects estimate; 
       
stderr stderr; 
       
ods output ParameterEstimates=lsmeandiff; 
     run;   
 
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Sensitivity analysis 
For all sensitivity approaches, for patients who undergo surgery for NP or receive SCS for any 
reason, data collected post-surgery or post SCS will be set to missing. 
Mixed-effect model with repeated measures (MMRM) approach  
The model will include change from baseline values up to week 24 as response variables, and 
factors (fixed effects) for treatment, stratification factor (co-morbid asthma/NERD, prior surgery, 
region), visit, treatment-by-visit interaction, NPS/NC baseline value and baseline-by-visit 
interaction. An unstructured correlation matrix will be used to model the within-patient errors. 
Parameters will be estimated using restricted maximum likelihood method with the Newton-
Raphson algorithm. The DDFM=KR will be used to compute the denominator degrees of freedom 
in the F-test. Data collected after treatment discontinuation will be included in the analysis. 
Descriptive statistics including number of patients, mean, standard error and LS means will be 
provided. In addition, difference in LS means, the corresponding 95% CI and the p-value will be 
provided for comparison of dupilumab against placebo. No imputation will be performed for the 
MMRM model.  
If MMRM model fails to achieve convergence due to complexity of model specification, we will 
add some procedures to handle this issue including:  1) using maximum likelihood estimation 
instead of restricted maximum likelihood method; 2) covariance structure selection to reduce the 
number of unknown parameters to be estimated, the path is UN→TOEPH→TOEP→AR(1).   
Pattern mixture model with copy increment from placebo 
Each of the 2 co-primary efficacy endpoints (3 co-primary efficacy endpoints for Japan) will be 
analyzed with imputed missing value at 24 weeks using pattern mixture model with copy 
increment from placebo (12). This copy increment from placebo implies that when subjects 
discontinue treatment early, they continue to take advantage of their previous therapy, but they 
progress in the same way as subjects in the placebo group.  
The imputed dataset will be analyzed by fitting an ANCOVA model same as the one in primary 
analysis. Descriptive statistics including number of patients, mean, standard error, and least 
squares (LS) means will be provided. In addition, difference in LS means and the corresponding 
95% confidence intervals (CI) will be provided along with the p-values. 
Tipping point analysis 
Each of the 2 co-primary efficacy endpoints (3 co-primary efficacy endpoints for Japan) will be 
analyzed with imputed missing value at 24 weeks as follows. 
- 
Step 1. Monotone missing pattern was induced by Markov Chain Monte Carlo 
(MCMC) method using PROC MI: for patients who have intermediate missing values, 
the intermediate missing values will be imputed assuming a multivariate normal 
distribution over observations from all visits. 40 datasets with a monotone missing 
pattern will be obtained using this method. 
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- 
Step 2. For each of the imputed dataset with monotone missing pattern obtained in 
Step 1, the remaining missing data will be imputed using the regression method for the 
monotone pattern with adjustment for covariates including response variable, treatment 
groups, asthma/NERD strata, prior surgery strata, region, and baseline value of the 
corresponding endpoint. All available data in the monotone missing pattern data will 
be used. One imputed dataset will be obtained for each of the imputed dataset at Step 
1. So, 40 fully imputed datasets will be obtained altogether. 
- 
Step 3. The imputed values in Dupilumab group are added by a positive amount d for 
each imputed data sets. 
- 
Step 4. The imputed values in placebo group are subtracted by a positive amount p for 
each imputed data sets. 
- 
Step 5. Change from baseline in endpoint will be analyzed using ANCOVA model 
same as the one in primary analysis. Then the SAS MIANALYZE procedure will be 
used to generate statistical inferences by combining results from the 40 analyses using 
Rubin’s formula. 
Step 3 to Step 5 will be repeated iteratively until the p-value for treatment effect of dupilumab 
compared to placebo estimated in Step 5 is >0.05.  
LS mean difference between dupilumab and placebo in change from baseline in co-primary 
endpoints at Week 24 and the corresponding p-values will be provided for each combination of 
shift parameters. 
Additional analysis 
An additional analysis will be conducted on the 2 co-primary efficacy endpoints (3 co-primary 
efficacy endpoints for Japan) which includes all data including data collected after SCS for any 
reason and treatment discontinuation but excludes post NP surgery data. For patients who undergo 
surgery for NP, data collected post-surgery will be set to missing (as a comparison, data collected 
post-surgery and post SCS for any reason are both set to missing in the primary approach), and the 
worst post-baseline value on or before the time of surgery will be used to impute missing Week 24 
value (for patients whose post-baseline values are all missing, the baseline will be used to impute). 
For patients who discontinue the treatment without being rescued by surgery, all data collected 
after treatment discontinuation or after SCS for any reason will be included in the analysis and a 
multiple imputation approach will be used to impute missing Week 24 value, and this multiple 
imputation will use all patients who have not been rescued by NP surgery at Week 24. The data 
will be analyzed in the same ANCOVA model for the primary approach. Descriptive statistics 
including number of patients, mean, standard error, and least squares (LS) means will be provided. 
In addition, difference in LS means and the corresponding 95% confidence intervals (CI) will be 
provided along with the p-values. 
Mixed-effect model with repeated measures (MMRM) approach for NC as binary response 
data 
In the primary analysis, NC will be analyzed as the average of 28-day nasal congestion data. To 
assess the robustness of this approach with respect to the ordinal categorical data nature of nasal 
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congestion score, a MMRM approach on NC as longitudinal binary response data which gives 
statistical inference in terms of rate difference will be performed based on methods proposed and 
evaluated by Fan (13). First, the data will be processed to a repeated measures binary data format 
to facilitate the use of methods for longitudinal binary response data as follows. 
A) Baseline: the baseline of the NC will be the median of the daily score in the 7 days prior to 
randomization if there are at least 4 observations during these 7 days; if there are less than 
4 observations, the baseline of the NC will be the median of the last 4 daily scores prior to 
randomization. In both cases, if the median ends in a .5 score, round it up. 
B) Justification: The primary analysis uses the mean. Assuming the NC symptoms are 
reasonably stable during these 7 days (observed in ACT12340), it deemed to be 
appropriate to use median here. Using median instead of mean is also in accordance with 
the ordinal categorical data nature of nasal congestion score. 
C) Week 24: for each day during study day 142 to study day 169, the change from baseline in 
scores will be re-coded as 
a) =1 if a subject improves at least 1 category at that day.  
b) =0 if a subject does not improve at least 1 category at that day.  
For a patient with observations during days 142 to 169 (28 days), he would have daily symptom 
improvement score as a 28-dimensional vector. Each element of the vector represents whether the 
subject shows improved symptom in nasal congestion on that day compared with baseline. 
Missing data in any day during study day 142 to study day 169 will be imputed as not improved 
for that day (=0). 
By such an approach, daily data are used in the model, and such data also preserve the categorical 
data nature of nasal congestion score. This approach gives statistical inference in terms of rate 
difference and has been theoretically and quantitatively validated (13). 
In this model, factors (fixed effects) for treatment, stratification factors (region, co-morbid 
asthma/NERD and prior surgery), day, treatment-by-day interaction, baseline value as a 
categorical variable will be included. Generalized estimating equations (GEE) will be used to 
obtain statistical inference. A variance component working covariance matrix which is merely a 
weight matrix will be used in the model to obtain unweighted proportions. Descriptive statistics 
including number of patients, LS average proportion of patients with improvement across the 28 
days, and corresponding standard error will be provided. In addition, difference in LS average 
proportion of patients with improvement, the corresponding 95% CI and the p-value will be 
provided for comparison of dupilumab against placebo. 
Subgroup analyses 
To assess the consistency in treatment effects across different subgroup levels, subgroup analyses 
will be conducted for the co-primary efficacy endpoints with respect to  
• 
Age group (18-64, ≥65 years) 
• 
Gender  (Male, Female) 
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• 
Baseline weight (<70, ≥70- < 90, ≥ 90 kg; <60, ≥60 kg) 
• 
Baseline BMI (<25, ≥25-<30, ≥30 kg/m2) 
• 
Region (East Europe: Russia, Ukraine, Cz. Republic, Hungary, Poland, Romania, 
Bulgaria; Western Countries: France, Germany, Italy, United Kingdom, Netherlands, 
USA)  
• 
Territory (North America: USA; European Union: Cz. Republic, Hungary, Poland, 
Romania, Bulgaria, France, Germany, Italy, United Kingdom and Netherlands; Rest of 
World: Russia and Ukraine) 
• 
Prior NP surgery history (Yes, No) 
• 
Race (Caucasian/White, Black/of African descent, Asian/Oriental, all the Others) 
• 
Ethnicity (Hispanic, non-Hispanic) 
• 
Asthma comorbidity (Yes, No) 
• 
Asthma and/or NERD (Yes, No) 
• 
NERD (Yes, No) 
• 
Allergic rhinitis at baseline (Yes, No) 
• 
SCS use during the past 2 years prior to V1 (Yes, No) 
To assess the consistency of the treatment effects across the subgroup levels, subgroup analyses 
will be conducted for co-primary endpoints at Week 24. The analysis will be performed based on 
imputed datasets from the primary analysis.   
To test the interaction between treatment and subgroup factor, an ANCOVA model incorporating 
subgroup-by-treatment interaction will be built for each subgroup factor. The model will include 
all the covariates in the main statistical model plus the subgroup variable (if not one of the 
covariates adjusted in the main model already) and the subgroup-by-treatment interaction. 
Statistical inference obtained from all imputed data will be combined using Rubin’s rule. A 
p-value for the test of interaction will be provided based on the combined inference.  
In each subgroup, the co-primary endpoints will be analyzed using the primary approach for co-
primary endpoints, but on the specific subgroup of the imputed primary analysis population. 
Descriptive statistics including number of patients, mean, standard error, and least squares (LS) 
means for each subgroup will be provided. In addition, difference in LS means and the 
corresponding 95% confidence intervals (CI) will be provided for each subgroup. 
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2.4.4.2 Analyses of key secondary efficacy endpoints 
2.4.4.2.1 Analysis of the change from baseline in LMK, TSS, UPSIT score, the daily loss of 
smell assessment, and SNOT-22 scores at Week 24 for dupilumab 300 mg q2w 
versus placebo 
The change from baseline in LMK score, TSS, UPSIT score, daily loss of smell, and SNOT-22 at 
Week 24 will be assessed for dupilumab 300 mg q2w (Arm A) versus placebo (Arm B) and will 
be analyzed using the hybrid method of the WOCF and the MI the same as the primary approach 
of the co-primary endpoints. Descriptive statistics including number of patients, mean, standard 
error, and least squares (LS) means will be provided. In addition, difference in LS means and the 
corresponding 95% confidence intervals (CI) will be provided along with the p-values. 
Note: LMK will not be a secondary endpoint for Japan as it is already a co-primary endpoint. 
2.4.4.2.2 Analysis of proportion and time-to-event of patients requiring rescue treatment defined 
as: use systemic corticosteroids or NP surgery (actual or planned) during the 
treatment period for dupilumab 300 mg q2w versus placebo 
Proportion of patients requiring rescue treatment defined as: use systemic corticosteroids or NP 
surgery (actual or planned) during the treatment period will be derived and analyzed using the Cox 
proportional hazards model. The event of interest is the first SCS use for any reason or NP surgery 
(actual or planned), whichever is earlier if both occur. The decision date of surgery for nasal 
polyps or the first SCS intake date will be used as the event date, whichever is earlier if both 
occur. In case the decision date of NP surgery is missing, the planned surgery date will be used in 
place. In case the planned surgery date is also missing, the actual surgery date will be used in 
place.  
Due to potential low number of events in each single study, proportion of patients requiring rescue 
treatment defined as: use systemic corticosteroids or NP surgery (actual or planned) during the 
treatment period for dupilumab 300 mg q2w versus placebo will be analyzed by pooling the two 
NP studies SINUS-52 (EFC14280) and SINUS-24 (EFC14146, the study this SAP is for). In the 
pooled analysis, the treatment period by dupilumab 300 mg q2w will be the total of the entire 
treatment period in Arm A of EFC14280, the treatment period of 300 mg q2w in Arm B (that is, 
the first 24 weeks) of EFC14280, and the entire treatment period in Arm A of EFC14146; and the 
treatment period by placebo will be the total of the entire treatment period in Arm C of EFC14280 
and the entire treatment period in Arm B of EFC14146.  
The pooled data will be analyzed by the Cox model. The Cox model will include the event as the 
dependent variable, and a study indicator (0 for EFC14280 and 1 for EFC14146), treatment group, 
asthma/NERD strata, prior surgery strata, and region (pooled countries) as covariates. Hazard ratio 
and corresponding 95% CI and p values will be estimated for dupilumab 300 mg q2w versus 
placebo. The Kaplan-Meier method will be used to derive the probabilities that a patient would 
experience events up to Week 52 for 300 mg q2w and placebo. Kaplan-Meier curves will be 
generated; quartiles and point probabilities will be calculated. Interval estimates will be calculated 
using 95% point wise confidence intervals. 
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2.4.4.2.3 Analysis of the change from baseline in FEV1 at Week 24 for asthma patients 
The change from baseline in FEV1(L) at Week 24 will be assessed by pooling the two NP studies 
SINUS-52 (EFC14280) and SINUS-24 (EFC14146, the study this SAP is for). The missing data in 
FEV1 at Week 24 will be imputed using the hybrid method of the WOCF and the MI the same as 
the primary approach of the co-primary endpoints. Each of the imputed complete data will be 
analyzed by fitting an ANCOVA model with  the change from baseline in FEV1 at Week 24 as the 
response variable, and a study indicator (0 for EFC14280 and 1 for EFC14146), the baseline value 
of FEV1, treatment group, prior surgery strata, and region (pooled countries) as covariates. 
Statistical inference obtained from all imputed data will be combined using Rubin’s rule.  
Descriptive statistics including number of patients, mean, standard error, and least squares (LS) 
means will be provided. In addition, difference in LS means and the corresponding 95% 
confidence intervals (CI) will be provided along with the p-values. 
2.4.4.3 Multiplicity issues  
The multiplicity procedure is proposed to control the overall type-I error rate for testing the co-
primary and selected secondary endpoints. The overall alpha is 0.05. The comparisons with 
placebo will be tested based on the hierarchical order below at 2-sided α = 0.05: 
 
1. Co-primary efficacy endpoints: 
In countries other than Japan: 
• 
Change from baseline in NC and in NPS at Week 24 for 300mg q2w versus placebo. 
In Japan: 
• 
Change from baseline in NC, in NPS, and in CT LMK at Week 24 for 300mg q2w versus 
placebo. 
2. Secondary efficacy endpoints:  
• 
Change from baseline in CT LMK score at Week 24 for 300mg q2w versus placebo (this 
will not be a secondary endpoint for Japan as it is already a co-primary endpoint). 
• 
Change from baseline in TSS at Week 24 for 300mg q2w versus placebo. 
• 
Change from baseline in UPSIT at Week 24 for 300mg q2w versus placebo. 
• 
Change from baseline in loss of smell daily symptoms at Week 24 for 300mg q2w versus 
placebo. 
• 
Change from baseline in SNOT-22 at Week 24 for 300mg q2w versus placebo. 
• 
Proportion of patients requiring rescue treatment defined as: use SCS or NP surgery (actual 
or planned) during the treatment period for 300mg q2w versus placebo using the pooled 
data from the EFC14280 and EFC14146.┼ 
• 
Change from baseline in FEV1(L) at Week 24 for 300mg q2w versus placebo for patients 
with co-morbid asthma using the pooled data from the EFC14280 and EFC14146. * 
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The figure below shows individual studies hierarchy for EFC14280 and EFC14146 as well as 
the pre-specified pooled analysis for proportion of patients requiring rescue treatment with 
SCS or NP surgery and change from baseline in FEV1(L) at Week 24. 
 
 
┼: The pooled analysis for this endpoint (Proportion of patients requiring rescue treatment of SCS 
or NP surgery) will be tested in the hierarchy only when in both EFC14280 and EFC14146 
hierarchies, all endpoints before this one reach statistical significance with p-value ≤ 0.05. 
*: The pooled analysis for this endpoint (Change from baseline in FEV1 at Week 24) will be 
tested in the hierarchy only when the previous endpoint (the pooled analysis for the proportion of 
patients requiring rescue treatment of SCS or NP surgery) achieves statistical significance in this 
hierarchical testing procedure as described in the previous paragraph. 
In countries other than Japan, the study is considered positive when both co-primary endpoints, 
the change from baseline in NC and in NPS at Week 24, achieve statistical significance. 
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In Japan, the study is considered positive when all co-primary endpoints, the change from baseline 
in NC, in NPS, and in CT LMK at Week 24, achieve statistical significance. 
2.4.4.4 Additional efficacy analyses 
2.4.4.4.1 Comparisons for other secondary efficacy endpoints 
• 
Comparisons at Week 24 will be made between dupilumab 300 mg q2w (Arm A) versus 
placebo (Arm B). 
• 
Comparisons at Week 48 will be made between dupilumab 300 mg q2w (Arm A) versus 
placebo (Arm B). 
• 
Comparisons will be made for the following secondary endpoints: 
- 
Change from baseline and time course profiles in NPS, NC, LMK, TSS, UPSIT, daily 
assessed loss of smell, and SNOT-22 at Week 48, 
- 
Change from baseline at Week 24 in: 
- 
VAS for overall rhinosinusitis, 
- 
NPIF, 
- 
VAS for EQ-5D 
- 
In the severity of rhinorrhea (anterior/posterior nasal discharge) daily symptom score 
assessed by the patient, 
- 
Percentage change from baseline at Week 24 and time course profiles in: 
- 
NC 
- 
Daily assessed loss of smell 
- 
TSS 
- 
Percentage change from baseline at Week 24 in VAS for overall rhinosinusitis 
- 
Proportion of responders at Week 24 (defined as patients with improvement by at least 
1 point in NPS), 
- 
Proportion of responders at Week 24 (defined as patients with improvement by at least 
2 points in NPS), 
- 
Proportion of patients with improvement by at least 1 point in NPS and 0.5 reductions 
in NC at Week 24 and Week 48, 
- 
Proportion of patients with greater than or equal to the minimal clinically important 
difference (MCID)(≥8.9) in SNOT-22 at Week 24, 
- 
Proportion of patients with overall rhinosinusitis severity VAS ≤7 at Week 24. 
- 
The cumulative distribution function (CDF) of change from baseline in NC, NPS, 
SNOT-22 and VAS for rhinosinusitis severity at Week 24, 
- 
Proportion of patients with anosmia by UPSIT scores at Week 24. 
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2.4.4.4.2 Analyses of other efficacy endpoints for 300 mg q2w versus placebo at Week 24 
The change from baseline in VAS for overall rhinosinusitis, NPIF, EQ-5D utility and daily 
assessed severity of rhinorrhea at Week 24 and percent change from baseline in NC, TSS, daily 
assessed loss of smell and VAS for overall rhinosinusitis at Week 24 will be assessed for 
dupilumab 300 mg q2w (Arm A) versus placebo (Arm B) and will be analyzed using the hybrid 
method of the WOCF and the MI the same as the primary approach of the co-primary endpoints. 
Descriptive statistics including number of patients, mean, standard error, and least squares (LS) 
means will be provided. In addition, difference in LS means and the corresponding 95% 
confidence intervals (CI) will be provided along with the p-values. 
For responder type endpoints including  
• 
The proportion of responders at Week 24 (defined as patients with improvement by at least 
1 point in NPS) 
• 
The proportion of responders at Week 24 (defined as patients with improvement by at least 
2 points in NPS) 
• 
The proportion of patients with improvement by at least 1 point in NPS and 0.5 reductions 
in NC at Week 24  
• 
The proportion of patients with MCID ≥8.9 in SNOT-22 at Week 24  
• 
The proportion of patients with VAS ≤7 at Week 24  
The Cochran-Mantel-Haenszel test will be performed on the association between the responder 
status and treatment group, stratified by asthma/NERD status, prior surgery history, and region. 
Comparisons of the proportions of responders between dupilumab 300mg q2w and placebo will 
be derived. And corresponding odds ratios and 95% CI will be reported. Patients who are 
indicated for surgery for NP or receive SCS for any reason will be considered as non-responders 
for time points after using SCS or surgery. For patients who discontinue treatment without using 
SCS or surgery, data collected during the off- treatment period will be used to determine the 
responder/non- responder status. Missing data at Week 24 will be considered as non-responders. 
In addition, the cumulative distribution function (CDF) of change from baseline in NC, NPS, 
SNOT-22 and VAS for rhinosinusitis severity at Week 24 will also be presented by treatment. 
2.4.4.4.3 Analyses of efficacy endpoints for Arm A versus Arm B at Week 48 
The change from baseline in NPS, NC, LMK, TSS, UPSIT, daily assessed loss of smell, SNOT-
22, VAS for overall rhinosinusitis, and daily assessed severity of rhinorrhea at Week 48 and 
percent change from baseline in NC, TSS, daily assessed loss of smell and VAS for overall 
rhinosinusitis at Week 48 will be assessed for Arm A versus Arm B and only descriptive statistics 
will be provided by treatment. For analyses at week 48, dupilumab 300 mg q2w (Arm A) versus 
placebo (Arm B) will be analyzed using the hybrid method of the WOCF and the MI in the same 
fashion as for the primary analysis for co-primary endpoints at Week 24. Descriptive statistics 
including number of patients, mean, standard error, and least squares (LS) means will be provided. 
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In addition, difference in LS means and the corresponding 95% confidence intervals (CI) will be 
provided. 
For responder type endpoints including  
• 
The proportion of patients with improvement by at least 1 point in NPS and 0.5 reductions 
in NC at Week 48 
The Mantel-Haenszel estimator will be provided on the association between the responder status 
and treatment group, stratified by asthma/NERD status, prior surgery history, and region. 
Comparisons of the proportions of responders between dupilumab 300mg q2w (Arm A) and 
placebo (Arm B) will be derived. And corresponding odds ratios and 95% CI will be reported. 
Patients who are indicated for surgery for NP or receive SCS for any reason will be considered as 
non-responders for time points after using SCS or surgery. For patients who discontinue treatment 
without using OCS or surgery, data collected during the off- treatment period will be used to 
determine the responder/non- responder status. Missing data at Week 48 will be considered as 
non-responders. 
2.4.4.4.4 Time course profile of the efficacy endpoints over 24 and 48 weeks 
For the continuous efficacy endpoints, descriptive statistics including number of patients, mean, 
standard error, and least squares (LS) means will be provided and plotted separately by treatment 
group for 300mg q2w (Arm A) versus placebo (Arm B) at each visit up to Week 48. In addition, 
using the hybrid method of the worst-observation carried forward (WOCF) and the multiple 
imputation separately at each visit, difference in LS means and the corresponding 95% confidence 
intervals (CI) will be provided along with the p-values (p-values will be provided up to Week 24). 
Such analyses will be conducted on the following variables: 
• 
Change from baseline in NPS 
• 
Change and percent change from baseline in NC 
• 
Change from baseline in CT LMK scores 
• 
Change and percent change from baseline in TSS 
• 
Change from baseline in UPSIT 
• 
Change and percent change from baseline in loss of smell 
• 
Change from baseline in SNOT-22 
For proportion type efficacy endpoints, the response rate at each visit up to Week 48 will be 
summarized and plotted by treatment groups.  The odds ratio and the corresponding 95% CI will 
be derived between dupilumab 300mg q2w and placebo at each visit with p-values provided up to 
Week 24. Patients who are indicated for surgery for NP or receive SCS for any reason will be 
considered as non-responders for time points after using SCS or surgery. For patients who 
discontinue treatment without using SCS or surgery, data collected during the off- treatment 
period will be used to determine the responder/non- responder status. Missing data will be 
considered as non-responders. Such analyses will be conducted on the following variables:  
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• 
Proportion of responders (defined as patients with improvement by at least 1 point in 
NPS), 
• 
Proportion of responders (defined as patients with improvement by at least 2 point in 
NPS), 
• 
Proportion of patients with improvement by at least 1 point in NPS and 0.5 reductions in 
NC  
• 
Proportion of patients with MCID≥8.9 in SNOT-22 
• 
Proportion of patients with VAS ≤7  
2.4.4.4.5 Analysis of anosmia category 
For UPSIT, number (%) of patients with anosmia will be summarized for dupilumab 300mg q2w 
and placebo, respectively, at baseline and Week 24.  
The anosmia category is defined as: 
• 
0-18 anosmia 
• 
19-25 severe microsmia 
• 
26-30 moderate microsmia 
• 
31-34 mild microsmia 
• 
35-40 normal 
2.4.4.5 Analyses of exploratory efficacy endpoints 
Total SCS dose prescribed (in mg) during the study period and total SCS intake in days and 
courses during the study period will be summarized by treatment groups. A course of SCS is 
considered continuous if treatment is separated by less than 7 days. Various doses of systemic 
corticosteroids will be converted to prednisone-equivalent oral corticosteroid.  For patients who 
discontinue treatment, data collected during the off- treatment period will also be used. 
Descriptive statistics including number of subjects, mean, standard error, min, and max will be 
provided, and no statistical testing will be conducted.  
Proportion and time-to-event of patients requiring rescue treatment with SCS for any season, SCS 
for nasal polyps, SCS for respiratory disease, and surgery (actual or planned) for NP will also be 
performed using the same method as those for the secondary endpoint of the proportion of 
patients requiring rescue with SCS or NP surgery (actual or planned) during the treatment 
period for dupilumab 300 mg q2w versus placebo using the pooed data of the two NP studies 
SINUS-52 (EFC14280) and SINUS-24 (EFC14146).  
Change from baseline in decreased/loss of sense of taste symptom severity and SNOT-22 items: 
“decreased sense of smell/taste”, “difficulty falling asleep”, ”wake up at night”, “lack of a good 
night's sleep”, “wake up tried”, ”fatigue”, and “reduced productivity”, (FEV1, FVC and FEF25-75 
in patients with asthma) at Week 24 and Week 48 will be assessed separately. For analyses at 
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Week 24, Dupilumab 300 mg q2w (Arm A) versus placebo (Arm B) will be analyzed using the 
hybrid method of the WOCF and the MI in the same fashion as for the primary analysis for co-
primary endpoints at Week 24. For analyses at Week 48, Arm A versus Arm B will be analyzed 
using descriptive statistics. Descriptive statistics including number of patients, mean, standard 
error, and least squares (LS) means will be provided. In addition, difference in LS means and the 
corresponding 95% confidence intervals (CI) will be provided. 
2.4.4.6 Missing data handling 
For all continuous efficacy endpoints, the details of missing data handling are described in Section 
2.4.4.1. 
For responder type endpoints, the details of missing data handling are described in Section 
2.4.4.4.2. 
In addition, the reason and pattern of missing data will be carefully examined and pattern mixture 
modeling approach and other sensitivity analyses will also be performed as specified in Section 
2.4.4.1. 
2.4.5 Analyses of safety data 
The summary of safety results will be presented by treatment group.  
General common rules 
All safety analyses will be performed on the safety population as defined in Section 2.3.2, unless 
otherwise specified, using the following common rules: 
• 
The baseline value is defined as the last available value before the first dose of IMP 
• 
The potentially clinically significant abnormality (PCSA) values are defined as abnormal 
values considered medically important by the Sponsor according to predefined 
criteria/thresholds based on literature review and defined by the Sponsor for clinical 
laboratory tests, vital signs, and ECG [Appendix A]) 
• 
PCSA criteria will determine which patients had at least 1 PCSA during the treatment-
emergent adverse event period, taking into account all evaluations performed during the 
treatment-emergent adverse event period, including nonscheduled or repeated evaluations.  
The number of all such patients will be the numerator for the on-treatment PCSA 
percentage 
• 
The treatment-emergent PCSA denominator by group for a given parameter will be based 
on the number of patients assessed for that given parameter in the treatment-emergent 
adverse event period by treatment group on the safety population 
• 
For quantitative safety parameters based on central laboratory/reading measurements, 
descriptive statistics will be used to summarize results and change from baseline values by 
visit and treatment group.  Summaries will include the endpoint value and/or the worst on-
treatment value.  The endpoint value is commonly defined as the value collected at the end 
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of treatment.  If this value is missing, this endpoint value will be the closest value prior to 
the end of treatment epoch.  The worst value is defined as the nadir and /or the peak post-
baseline (up to the end of treatment epoch or EOT) according to the direction (minimum or 
maximum) of the abnormality as defined in the PCSA list 
• 
The analysis of the safety variables will be essentially descriptive and no systematic testing 
is planned.  Relative risks versus placebo and their 95% confidence intervals may be 
provided, if relevant 
• 
All safety values including unscheduled measurements will be assigned to the appropriate 
safety analysis visit window defined in Section 2.5.3. 
2.4.5.1 Analyses of adverse events 
Generalities 
The primary focus of adverse event reporting will be on treatment-emergent adverse events.  
Pretreatment and post-treatment adverse events will be described separately.  
If an adverse event date/time of onset (occurrence, worsening, or becoming serious) is incomplete, 
an imputation algorithm will be used to classify the adverse event as pretreatment, treatment-
emergent, or post-treatment.  The algorithm for imputing date/time of onset will be conservative 
and will classify an adverse event as treatment emergent unless there is definitive information to 
determine it is pretreatment or post-treatment.  Details on classification of adverse events with 
missing or partial onset dates are provided in Section 2.5.2. 
Adverse event incidence tables will present by SOC, HLGT, HLT, and PT, sorted in alphabetical 
order for each treatment group, the number (n) and percentage (%) of patients experiencing an 
adverse event.  Multiple occurrences of the same event in the same patient will be counted only 
once in the tables within a treatment phase.  The denominator for computation of percentages is 
the safety population within each treatment group. 
Sorting within tables ensures the same presentation for the set of all adverse events within the 
observation period (pretreatment, treatment-emergent, and post-treatment).  For that purpose, the 
table of all treatment-emergent adverse events presented by SOC and PT sorted by the 
internationally agreed SOC order and decreasing frequency of PTs within SOCs will define the 
presentation order for all other tables unless otherwise specified. Sorting will be based on results 
for the dupilumab 300 mg q2w group. 
Analysis of all treatment-emergent adverse events 
The following treatment-emergent adverse event summaries will be generated for the safety 
population. 
• 
Overview of treatment-emergent adverse events, summarizing number (%) of patients with 
any 
- 
Treatment-emergent adverse event 
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- 
Serious treatment-emergent adverse event 
- 
Treatment-emergent adverse event leading to death 
- 
Treatment-emergent adverse event leading to permanent treatment discontinuation 
• 
All treatment-emergent adverse event by primary SOC, HLGT, HLT, and PT, showing 
number (%) of patients with at least 1 treatment-emergent adverse event sorted by the SOC 
internationally agreed order.  The other levels (HLGT, HLT, PT) will be presented in 
alphabetical order 
• 
Number (%) of patients experiencing TEAE(s) presented by PT, sorted by decreasing 
incidence of PT  
• 
All treatment-emergent adverse events by primary SOC and PT, showing the number (%) 
of patients with at least 1 treatment-emergent adverse event, sorted by the internationally 
agreed SOC order and by decreasing incidence of PTs within each SOC in the 300 q2w 
treatment group  
• 
All treatment-emergent adverse events regardless of relationship and related by primary 
SOC, HLGT, HLT and PT, showing the number (%) of patients with at least 1 treatment-
emergent adverse event, sorted by the internationally agreed SOC order.  The other levels 
(HLGT, HLT, PT) will be presented in alphabetical order 
• 
All treatment-emergent adverse events by maximal severity, presented by primary SOC 
and PT, showing the number (%) of patients with at least 1 treatment-emergent adverse 
event by severity (ie, mild, moderate, or severe), sorted by the internationally agreed SOC 
order and by decreasing incidence of PTs within each SOC in the 300 q2w treatment group  
• 
Number (%) of patients experiencing treatment-emergent adverse event(s) presented by 
primary and secondary SOC, HLGT, HLT, and PT sorted by the internationally agreed 
SOC order.  The other levels (HLGT, HLT, PT) will be presented in alphabetical order. 
A listing of all treatment-emergent adverse events will be presented. 
Analysis of all treatment emergent serious adverse event(s) 
• 
All treatment-emergent serious adverse events by primary SOC, HLGT, HLT, and PT, 
showing the number (%) of patients with at least 1 serious treatment-emergent adverse 
event, sorted by the internationally agreed SOC order.  The other levels (HLGT, HLT, PT) 
will be presented in alphabetical order 
• 
All treatment-emergent serious adverse events regardless of relationship and related to 
IMP, by primary SOC, HLGT, HLT, and PT, showing the number (%) of patients with at 
least 1 treatment-emergent serious adverse event, sorted by the internationally agreed SOC 
order.  The other levels (HLGT, HLT, PT) will be presented in alphabetical order 
• 
All treatment-emergent serious adverse events by primary SOC and PT, showing the 
number (%) of patients with at least 1 treatment-emergent serious adverse event, sorted by 
the internationally agreed SOC order and by decreasing incidence of PTs within each SOC 
in the 300 q2w treatment group.   
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A listing of all treatment-emergent serious adverse events will be presented. 
Analysis of all treatment-emergent adverse event(s) leading to treatment discontinuation 
• 
All treatment-emergent adverse events leading to treatment discontinuation, by primary 
SOC, HLGT, HLT, and PT, showing the number (%) of patients sorted by the 
internationally agreed SOC order.  The other levels (HLGT, HLT, PT) will be presented in 
alphabetical order 
• 
All treatment-emergent adverse events leading to permanent treatment discontinuation or 
drug interruption, by primary SOC and PT, showing number (%) of patients with at least 
one TEAE, will be presented by SOC internationally agreed order and by decreasing 
incidence of PTs within each SOC in the 300 q2w treatment group. 
Analysis of adverse events of special interests (AESI) and other selected AE groupings 
• 
All treatment-emergent adverse events, by selected standardized MedDRA query (SMQ) 
and PT or by laboratory values (as in ALT elevation), showing the number (%) of patients 
with at least 1 PT, sorted by decreasing incidence of PTs within each SMQ in the 300 q2w 
treatment group. 
• 
For each AESI and other selected AE groupings,  
- 
Number (%) of patients with any specific TEAE  
- 
Number (%) of patients with any specific serious AE (regardless of treatment emergent 
status) 
- 
Number (%) of patients with any specific treatment emergent serious AE 
- 
Number (%) of patients with any specific AE leading to death 
- 
Number (%) of patients with any specific TEAE leading to permanent study drug 
discontinuation 
- 
Number (%) of patients with any specific TEAE by maximum intensity, corrective 
treatment, and final outcome 
- 
Number of any specific TEAE adjusted by the exposure duration 
- 
Number of patients with any specific TEAE adjusted by the exposure duration at risk. 
For each specific TEAE, Kaplan-Meier estimates of cumulative incidence at Week 12, 
24, 36 and 48 and K-M plot may be provided to depict the course of onset over time if 
the number of events is large enough. 
- 
Number (%) of patients with injection site reactions by the related injection. 
- 
Number (%) of patients with different number of injection site reactions. 
• 
In addition, AESIs reported by the investigator in CRF will be summarized separately. 
Analysis of treatment-emergent adverse events up to Week 24 (On treatment adverse event) 
• 
Selective safety analyses will be performed on safety data from baseline to Week 24 with 
respect to TEAE, SAE, TEAE leading to permanent treatment discontinuation or drug 
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interruption, AE adverse events of special interests (AESI) and other selected AE 
groupings. 
Analysis of pretreatment adverse events  
• 
All pretreatment adverse events by primary SOC and PT, showing the number (%) of 
patients with at least 1 pretreatment adverse event, sorted by the internationally agreed 
SOC order and decreasing incidence of PTs within each SOC in the 300 q2w treatment 
group. 
• 
All serious pretreatment adverse events by primary SOC and PT, showing the number (%) 
of patients with at least 1 pretreatment adverse event, sorted by the internationally agreed 
SOC order and decreasing incidence of PTs within each SOC 
• 
All pretreatment adverse events leading to permanent treatment discontinuation by primary 
SOC and PT, showing the number (%) of patients, sorted by the internationally agreed 
SOC order and decreasing incidence of PTs within each SOC 
• 
All pretreatment adverse events leading to death by primary SOC and PT, showing the 
number (%) of patients, sorted by the internationally agreed SOC order and decreasing 
incidence of PTs within each SOC 
• 
If only a few patients have pretreatment adverse events leading to permanent treatment 
discontinuation, a listing will be presented instead of the summary table above. 
2.4.5.2 Deaths 
The following summaries of deaths will be generated for the safety population. 
• 
Number (%) of patients who died by study period (on-study, on-treatment, post-study)  
• 
Deaths in nonrandomized patients or randomized but not treated patients 
• 
Treatment-emergent adverse events leading to death (death as an outcome on the adverse 
event case report form page as reported by the Investigator) by primary SOC , HLGT, 
HLT, and PT showing number (%) of patients sorted by internationally agreed SOC order, 
with HLGT, HLT, and PT presented in alphabetical order within each SOC  
• 
All pretreatment adverse events leading to death by primary SOC and PT, showing the 
number (%) of patients, sorted by the internationally agreed SOC order and decreasing 
incidence of PTs within each SOC. 
A listing of deaths will be provided. 
2.4.5.3 Analyses of laboratory variables  
The summary statistics (including number, mean, median, Q1, Q3, standard deviation, minimum 
and maximum) of all laboratory variables (central laboratory values and changes from baseline) 
will be calculated for each visit or study assessment (baseline, each post-baseline time point, last 
on-treatment and/or worst on-treatment value) by treatment group.  For each continuous 
parameters listed in Section 2.1.4.3, mean changes from baseline with the corresponding standard 
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error will be plotted over time in each treatment group. This section will be organized by 
biological function as specified in Section 2.1.4.3. 
The incidence of PCSAs (list provided in Appendix A) at any time during the treatment-emergent 
adverse event period will be summarized by biological function and treatment group whatever the 
baseline level and/or according to the following baseline status categories:  
• 
Normal/missing 
• 
Abnormal according to PCSA criterion or criteria 
The incidence of PCSAs from baseline to Week 24 during the treatment-emergent adverse event 
period will be summarized by biological function and treatment group whatever the baseline level 
and/or according to the following baseline status categories:  
• 
Normal/missing 
• 
Abnormal according to PCSA criterion or criteria 
For parameters for which no PCSA criteria are defined, similar table(s) using the normal range 
will be provided. 
For PCSA analyses, the laboratory measurements obtained at either scheduled or unscheduled 
visits should be used; and, both the centralized and local test results should be used, as long as 
their available dates/time is different from each other’s. Centralized data will be used 
preferentially to the local measures in the PCSA analyses when measurements are performed on 
the same date and at the same time for a given laboratory test. 
Possible Drug-induced liver injury 
If there is any imbalance in the incidence of liver-related adverse events across the treatment 
groups, analysis of liver-related adverse events will be performed. 
The liver function tests, namely AST, ALT, alkaline phosphatase, and total bilirubin, are used to 
assess possible drug-induced liver toxicity.  The proportion of patients with PCSA values at any 
post-baseline visit by baseline status will be displayed by treatment group for each parameter.  The 
proportion of patients with PCSA values at any post-baseline visit will also be displayed by 
duration of exposure for each treatment group.  
Time to onset of the initial ALT and AST elevation (>3 x ULN) and total bilirubin elevation 
(>2 x ULN) (time to first observation of ALT > 3 x ULN or total bilirubin > 2 x ULN, whichever 
comes first) will be analyzed using Kaplan-Meier estimates, presented by treatment group.  
Consideration should be given to the impact of the spacing of scheduled tests.  A graph of 
distribution of peak values of ALT versus peak values of total bilirubin will also be presented.  
Note that the ALT and total bilirubin values are presented on a logarithmic scale. The graph will 
be divided into 4 quadrants with a vertical line corresponding to 3 x ULN for ALT and a 
horizontal line corresponding to 2 x ULN for total bilirubin. 
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Listing of possible Hy’s law cases identified by treatment group (eg, patients with any elevated 
ALT>3 x ULN, and associated with an increase in bilirubin ≥2 x ULN) with ALT, AST, alkaline 
phosphatase, total bilirubin, and the following complementary parameters:  conjugated bilirubin 
and creatine phosphokinase, serum creatinine, complete blood count, HCV RNA. 
Summarize the normalization by parameter (to ≤1 x ULN or return to baseline) of elevated liver 
function tests by categories of elevation (3 x, 5 x, 10 x, 20 x ULN for ALT and AST, 1.5 x ULN 
for alkaline phosphatase, and 1.5 x and 2 x ULN for total bilirubin), with the following categories 
of normalization:  never normalized, normalized despite treatment continuation of IMP, or 
normalized after IMP discontinuation.  Note that a patient will be counted only under the 
maximum elevation category. 
2.4.5.4 Analyses of vital sign variables 
The summary statistics (including number, mean, median, Q1, Q3, standard deviation, minimum 
and maximum) of all vital signs variables (values and changes from baseline) will be calculated 
for each visit or study assessment (baseline, each post-baseline time point, last on-treatment and/or 
worst on-treatment value) by treatment group.  For all parameters, mean changes from 
baseline with the corresponding standard error will be plotted over time (at same time points) in 
each treatment group.  
The incidence of PCSAs at any time during the treatment-emergent adverse event period will be 
summarized by treatment group irrespective of the baseline level and/or according to the following 
baseline status categories:  
• 
Normal/missing 
• 
Abnormal according to PCSA criterion or criteria 
The incidence of PCSAs from baseline to Week 24 during the treatment-emergent adverse event 
period will be summarized by biological function and treatment group whatever the baseline level 
and/or according to the following baseline status categories:  
• 
Normal/missing 
• 
Abnormal according to PCSA criterion or criteria 
2.4.5.5 Analyses of electrocardiogram variables 
The incidence of PCSAs at any time during the treatment-emergent adverse event period will be 
summarized by treatment group irrespective of the baseline level and/or according to the following 
baseline status categories:  
• 
Normal/missing 
• 
Abnormal according to PCSA criterion or criteria 
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The incidence of PCSAs from baseline to Week 24 during the treatment-emergent adverse event 
period will be summarized by biological function and treatment group whatever the baseline level 
and/or according to the following baseline status categories:  
• 
Normal/missing 
• 
Abnormal according to PCSA criterion or criteria 
2.4.6 Analyses of pharmacokinetic and pharmacodynamic variables 
2.4.6.1 Pharmacokinetic analyses 
2.4.6.1.1 Analyses of serum concentrations of SAR231893 (REGN668) 
Serum concentrations of SAR231893 (REGN668) will be summarized in the PK population using 
arithmetic and geometric means, SD, standard error of the mean (SEM), coefficient of variation 
(CV), minimum, median and maximum per sampling time. If date and/or time of the drug 
injection and/or sampling is missing then the concentration will not be taken into account. For 
drug-treated patients, where concentration values are below the lower limit of quantification 
(LLOQ), one-half of the LLOQ will be used. Values will be expressed in the tables with no more 
than three significant figures. For patients in the placebo group, concentration values are below the 
LLOQ will be taken into account with a plasma concentration considered equal to 0. 
2.4.6.1.2 Analyses of ADA variables  
The following summary will be provided based on ADA population: 
• 
Number (%) of patients with pre-existing immunoreactivity 
• 
Number (%) of patients with treatment-emergent ADA  
• 
The summary statistics (including number, median, Q1, Q3, minimum and maximum) of 
the peak post-baseline titer for patients with treatment-emergent ADA, and patients with 
persistent, indeterminate and transient ADA response 
• 
Number (%) of patient with transient treatment-emergent ADA  
• 
Number (%) of patients with persistent treatment-emergent ADA  
• 
Number (%) of patients with indeterminate treatment-emergent ADA  
• 
Number (%) of patients with treatment-boosted ADA  
• 
The summary statistics (including number, median, Q1, Q3, minimum and maximum) of 
the peak post-baseline titer for patients with treatment-boosted ADA  
• 
The summary statistics (including number, mean, SD, median, Q1, Q3, minimum and 
maximum) of the ratio of peak post-baseline titer to baseline titer for patients with 
treatment-boosted ADA  
• 
Listing of ADA peak titer levels and neutralizing antibody status 
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• 
Number(%) of patients with neutralizing antibody status  
Kinetics of treatment-emergent ADA response 
Number (%) of patients with treatment-emergent ADA positive response at each visit will be 
summarized by each treatment group. 
Plot of percentage of patients with treatment-emergent ADA positive response at each visit will be 
provided by each treatment group. 
Impact of ADA on PK  
Associations between ADA variables (eg, ADA peak titers, neutralizing antibody status, 
treatment-emergent, persistent, indeterminate and transient response, treatment-boosted) and 
serum concentration of dupilumab may be explored for dupilumab dose group. Plot of serum 
concentration of functional SAR231893 (REGN668) versus visit will be provided by ADA 
classifications for dupilumab dose group. Individual patient plots of PK according to ADA status 
will be provided to determine which individuals may have had PK impacted by ADAs. 
Association of ADA with clinical efficacy endpoints 
Associations between the ADA variables (eg, ADA peak titers, neutralizing antibody status, 
treatment-emergent, persistent, indeterminate and transient response, treatment-boosted) and the 
co-primary efficacy endpoints may be explored for the dupilumab dosed group. 
Association of ADA with clinical safety endpoints 
Association of safety versus ADA status may be analyzed in the ADA population. The safety 
assessment may focus on the following events:  
• 
Severe injection site reactions last longer than 24 hours or serious injection site reactions. 
• 
Hypersensitivity reactions (SMQ hypersensitivity narrow search confirmed by medical 
review) 
• 
Anaphylactic reactions (SMQ anaphylactic reaction narrow search) 
• 
In response to AESI like anaphylaxis or hypersensitivity additional ADA samples closer to 
the event may be analyzed, based on the judgment of the medical investigator and/or 
medical monitor. 
• 
Associations between ADA variables (eg, ADA peak titers, neutralizing antibody status, 
treatment-emergent and treatment-boosted) and safety may be explored. 
2.4.6.2 Pharmacodynamic
analyses 
All biomarkers listed in Section 2.1.6 will be summarized in the Safety population defined as 
patients who actually received at least 1 dose or part of a dose of the IMP.  Baseline values will be 
the last value collected prior to the first IMP. For randomized but not treated patients, baseline 
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value will be the last value collected prior to the randomization. Descriptive statistics (including 
number, mean, SD, median, Q1, Q3, min, max) of biomarkers at baseline will be summarized. 
Summary plots (mean +/- standard error of the mean) on values at each visit, absolute changes 
from baseline and percent changes from baseline will be provided for each biomarker by treatment 
group. 
2.4.7 Analyses of health economics variables 
Analyses of healthcare resource utilization will be performed under the responsibility of the 
Health Economics Outcomes Research (HEOR) department of Sanofi. Methods and results will be 
made available in a separate report. 
2.5 
DATA HANDLING CONVENTIONS 
2.5.1 General conventions 
The following formulas will be used for computation of parameters. 
Demographic formulas 
Age is calculated as: 
Integer part of (informed consent date -birth date)/365.25 
 
Age of onset of nasal polyposis is calculated as: 
Integer part of (nasal polyposis diagnosis date - birth date)/365.25 
 
Age of onset of asthma is calculated as: 
Integer part of (first diagnosis of asthma date - birth date)/365.25 
 
BMI is calculated as: 
Weight in kg / (height2 in meters) 
 
Renal function formulas  
For patients  ≥18 years old, creatinine clearance (CLcr) value will be derived using the equation of 
Cockroft and Gault: 
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CLcr (ml/min) = (140 - age) ×  weight (kg) ×   (1 - 0.15 ×  sex (0-M, 1-F))/ (0.814 ×  creatinine 
(µmol/l)) 
CLcr will be calculated using the last weight measurement on or before the visit of the creatinine 
measurement and age at the lab sampling date. Here age is calculated as following: 
Age = integer part of (lab sampling date - birth date)/365.25 
2.5.2 Data handling conventions for secondary efficacy variables 
 
Periodical average of daily efficacy endpoints at designated study days 
For the daily efficacy endpoints, the time period used to calculate the periodical average at each 
designated study day is summarized in Table 2. Randomization day is used as the reference day 
(Day 1). 
Table 2 - Periodical average of daily efficacy assessment 
Time point 
Morning TSS and its 
components (nasal 
congestion, loss of 
smell, anterior 
rhinorrhea, posterior 
rhinorrhea)  
Morning NPIF 
Day 29 
2-29 
2-29 
Day 57 
30-57 
30-57 
Day 113 
86-113 
86-113 
Day 169 
142-169 
142-169 
Day 253 
226-253 
- 
Day 337 
310-337 
- 
2.5.3 Missing data 
For categorical variables, patients with missing data are not included in calculations of 
percentages unless otherwise specified.  When relevant, the number of patients with missing data 
is presented. 
Handling of computation of treatment duration if investigational medicinal product end of 
treatment date is missing  
For the calculation of the treatment duration, the date of the last dose of IMP is equal to the date of 
last administration reported on the end-of-treatment case report form page.  If this date is missing, 
the exposure duration should be left as missing.  
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The last dose intake should be clearly identified in the case report form and should not be 
approximated by the last returned package date. 
Handling of medication missing/partial dates 
No imputation of medication start/end dates or times will be performed.  If a medication date or 
time is missing or partially missing and it cannot be determined whether it was taken prior or 
concomitantly, it will be considered a prior, concomitant, and post-treatment medication. 
Handling of adverse events with missing or partial date/time of onset 
Missing or partial adverse event onset dates and times will be imputed so that if the partial adverse 
event onset date/time information does not indicate that the adverse event started prior to 
treatment or after the treatment-emergent adverse event period, the adverse event will be classified 
as treatment-emergent.  No imputation of adverse event end dates/times will be performed.  These 
data imputations are for categorization purpose only and will not be used in listings.  No 
imputation is planned for date/time of adverse event resolution. 
Handling of adverse events when date and time of first investigational medicinal product 
administration is missing 
When the date and time of the first IMP administration is missing, all adverse events that occurred 
on or after the day of randomization should be considered as treatment-emergent adverse events.  
The exposure duration should be kept as missing. 
The last dose intake should be clearly identified in the case report form and should not be 
approximated by the last returned package date. 
Handling of missing assessment of relationship of adverse events to investigational medicinal 
product  
If the assessment of the relationship to IMP is missing, then the relationship to IMP has to be 
assumed and the adverse event considered as such in the frequency tables of possibly related 
adverse events, but no imputation should be done at the data level. 
Handling of missing severity of adverse events 
If the severity is missing for 1 of the treatment-emergent occurrences of an adverse event, the 
maximal severity on the remaining occurrences will be considered.  If the severity is missing for 
all the occurrences, a “missing” category will be added in the summary table. 
Handling of potentially clinically significant abnormalities  
If a patient has a missing baseline he will be grouped in the category “normal/missing at baseline.” 
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For PCSAs with 2 conditions, one based on a change from baseline value or a normal range and 
the other on a threshold value, with the first condition being missing, the PCSA will be based only 
on the second condition. 
For a PCSA defined on a threshold and/or a normal range, this PCSA will be derived using this 
threshold if the normal range is missing; eg, for eosinophils the PCSA is > 0.5 GIGA/L or >ULN 
if ULN ≥0.5 GIGA/L.  When ULN is missing, the value 0.5 should be used. 
Measurements flagged as invalid by the laboratory will not be summarized or taken into account 
in the computation of PCSA values.   
2.5.4 Windows for time points 
For the safety assessment, the reference date for the derivation of relative days of events or 
findings will be the date of first IMP administration. Selected safety variables will be summarized 
by the analysis window define in Table 3 for the by visit descriptive analysis. All available values 
from central lab will be assigned to the appropriate visit window. In the event of multiple 
measurements of the same test in the same window, the one closest to the targeted visit date will 
be used for the by-visit summary. If they are at the same distance to the target day, the latest one 
will be used. For procedures planned on Visit 2, if it is done on the same date as the first IMP 
injection but the performance time is missing, it will belong to Visit 2 time window. 
Table 3 – Time window for safety endpoints 
 
 
Time windows for 
 
Visit 
Target 
Day 
Vital 
signs 
Clinical 
lab 
testing 
Serum Pregnancy 
test ,Hepatitis 
screen, HIV 
screen, ANA and 
Anti-ds DNA 
antibody 
Urine 
Pregnancy 
test 
Hepatitis B 
viral load 
ECG 
Visit 1 
(Week -
4±1) 
-28±7 
<-14 
<-14 
1- 
 
 
 
Visit 2 
(Week 0) 
1 
-14-1- 
-14-1- 
 
1- 
1- 
1- 
Visit 3 
(Week 2) 
15 
 
 
 
 
 
 
Visit 4 
(Week 4) 
29 
 
 
 
1+-42 
 
 
Visit 5 
(Week 6) 
43 
 
 
 
 
 
 
Visit 6 
(Week 8) 
57 
1+-84 
 
 
43-70 
 
 
(Week 12) 
85 
 
 
 
71-98 
 
 
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Time windows for 
 
Visit 
Target 
Day 
Vital 
signs 
Clinical 
lab 
testing 
Serum Pregnancy 
test ,Hepatitis 
screen, HIV 
screen, ANA and 
Anti-ds DNA 
antibody 
Urine 
Pregnancy 
test 
Hepatitis B 
viral load 
ECG 
Visit 7 
(Week 16) 
113 
85-140 
1+-140 
 
99-126 
 
 
(Week 20) 
141 
 
 
 
127-154 
 
 
Visit 8 
(Week 24) 
169 
141-210 
>140 
 
155-182 
1+ 
1+ 
(Week 28) 
197 
 
 
 
183-210 
 
 
(Week 32) 
225 
 
 
 
211-238 
 
 
Visit 9 
(Week 36) 
253 
211-294 
 
 
239-266 
 
 
(Week 40) 
281 
 
 
 
267-294 
 
 
(Week 44) 
309 
 
 
 
295-322 
 
 
Visit 10 
(Week 48) 
337 
>294 
 
 
>322 
 
 
 
1-: up to 1st dose date/time; 1+: after 1st dose date/time; 
 
For the efficacy assessment, the reference date for the derivation of relative days of events or 
findings will be the randomization day. If a patient receives IMP prior to the randomization by 
mistake, the reference date of efficacy assessment will be the date of the first IMP administration 
for that patient. For the primary analyses, all available values of scheduled measurements will be 
assigned to the appropriate visit window according to Table 4. In the event of multiple 
measurements of the same test in the same window, the one closest to the targeted visit date will 
be used for the by-visit summary. If they are at the same distance to the target day, the latest one 
will be used. For the on-treatment sensitivity analyses, only scheduled measurements collected 
during the treatment epoch will be assigned to a time window.  
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Table 4 – Time window for efficacy variables 
Visit 
Target 
Day 
 
Time windows for 
 
 
Nasal 
endo-
scopy 
CT 
scan 
UPSIT 
VAS for 
rhino-
sinusitis 
sense 
of 
taste 
Spirometry, 
ACQ-6 
EQ-
5D 
SNOT-
22 
SF-
36 
Visit 1 (Week -
4±1) 
-28±7 
<-14 
 
 
 
 
 
 
 
 
Visit 2 (Week 0) 
1 
-14-1- 
1- 
1- 
1- 
1- 
1- 
1- 
1- 
1- 
Visit 3 (Week 2) 
15 
 
 
1+-35 
1+-21 
1+-21 
 
 
 
 
Visit 4 (Week 4) 
29 
 
 
36-84 
22-42 
22-42 
 
 
 
 
Visit 5 (Week 6) 
43 
 
 
 
 
 
 
 
 
 
Visit 6 (Week 8) 
57 
1+-84 
 
 
43-84 
43-84 
1+-84 
 
1+-84 
 
Visit 7 (Week 16) 
113 
85-140 
 
85-140 
85-140 
85-140 
85-140 
 
85-140 
 
Visit 8 (Week 24) 
169 
141-210 
1+-252 
141-252 
141-210 
>141 
141-252 
1+ 
141-210 
 
Visit 9 (Week 36) 
253 
211-294 
 
 
211-294 
 
 
 
211-294 
 
Visit 10 (Week 
48) 
337 
>294 
>252 
>252 
>294 
 
>252 
 
>294 
 
1-: up to randomization and before 1st dose date/time; 1+: after randomization or 1st dose date/time   
For the pharmacokinetics/pharmacodynamics variables summary, the reference date for the 
derivation of relative days of measurements will be the date of first IMP administration if the 
patient is treated with study treatment, or the randomization date if the patient is not treated. 
Pharmacokinetics /pharmacodynamics variables will be summarized by the analysis window 
defined in Table 5 for the by visit descriptive analyses. All available values of measurements will 
be assigned to the appropriate visit window. In the event of multiple measurements of the same 
test in the same window, the one closest to the targeted visit date will be used for the by-visit 
summary. If they are at the same distance to the target day, the latest one will be used. For 
procedures planned on Visit 2, if it is done on the same date as the first IMP injection but the 
performance time is missing, it will belong to Visit 2 time window. 
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Table 5 – Time window for pharmacokinetics/pharmacodynamics variables 
 
 
Time windows for 
Visit 
Target 
day 
TARC, 
Eotaxin-3, 
periostin,  
total IgE, 
antigen-
specific IgE 
Serum 
dupilumab 
concentration 
Anti-drug 
antibodies 
Visit 1 (Week -4±1) 
-28±7 
 
 
 
 
Visit 2 (Week 0) 
1 
1- 
1- 
1- 
1- 
Visit 3 (Week 2) 
15 
 
 
 
 
Visit 4 (Week 4) 
29 
 
 
1+-42 
 
Visit 5 (Week 6) 
43 
 
 
 
 
Visit 6 (Week 8) 
57 
 
 
43-84 
1+-84 
Visit 7 (Week 16) 
113 
 
 
85-140 
85-140 
Visit 8 (Week 24) 
169 
 
1+ 
141-210 
141-210 
Visit 9 (Week 36) 
253 
 
 
211-294 
211-294 
Visit 10 (Week 48) 
337 
 
 
>294 
>294 
1-: up to 1st dose date/time or randomization if patient is not treated; 1+: after 1st dose date/time or randomization date if 
patient is not treated; 
2.5.5 Unscheduled visits 
Unscheduled visit measurements of laboratory data, vital signs, and ECG will be included in the 
by-visit summaries, computation of baseline, worst values, and PCSAs. 
2.5.6 Pooling of centers for statistical analyses 
Due to the large number of centers, the randomization is stratified by country. Due to small 
sample size in some countries, the countries will be pooled into regions as defined below for the 
analyses: 
• 
East Europe: Russia, Ukraine, Cz. Republic, Hungary, Poland, Romania, Bulgaria 
• 
Western Countries: France, Germany, Italy, United Kingdom, Netherlands, USA. 
2.5.7 Statistical technical issues 
NA 
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3 
INTERIM ANALYSIS 
No interim analysis will be performed before the final database lock described in Section 4. 
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4 
DATABASE LOCK 
The database lock is planned based on when all patients complete Week 48 visit (last patient last 
visit) or discontinue from the study before Week 48. Analyses will be based on all data collected 
up to this database lock and will be considered as the final analyses in the CSR.  
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Statistical Analysis Plan  
14-Aug-2017 
SAR231893-EFC14146 - dupilumab 
Version number: 1 
 
Property of the Sanofi Group - strictly confidential 
Page 69 
5 
SOFTWARE DOCUMENTATION 
All summaries and statistical analyses will be generated using SAS version 9.4 or higher. 
(electronic 
 
 
 
1.0)


Statistical Analysis Plan  
14-Aug-2017 
SAR231893-EFC14146 - dupilumab 
Version number: 1 
 
Property of the Sanofi Group - strictly confidential 
Page 70 
6 
REFERENCES 
 
1. 
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is effective in allergic and nonallergic patients with nasal polyps and asthma. J Allergy 
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Lund VJ, Mackay, IS. Staging in rhinosinusitus. Rhinology. 1993;31:183-4. 
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Carpenter JR, Roger JH, Kenward MG. Analysis of Longitudinal Trials with Protocol 
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