Clinical trial NCT01614964
Conditions: Malaria
Keywords: Plasmodium falciparum pharmacokinetics antimalarials (antimalarial drugs) chloroquine (chloroquine-resistant) QT (QTc) interval
Sponsor: Tulane University
Start date: 2013-08-01; Completion date: 2017-02-01
Enrollment: 66 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
This is an initial efficacy study of a candidate antimalarial in human subjects with uncomplicated malaria caused by the most common and most important parasite in Africa (Plasmodium falciparum). This study will enroll 66 adult Malian males with uncomplicated P. falciparum malaria and randomize them to treatment with 1750 mg of the investigational drug (AQ-13) by mouth over 3 days or the current standard treatment, which is 2 doses of Coartem twice daily for 3 days. The hypothesis underlying this study is that AQ-13 will be similarly effective to Coartem for the treatment of uncomplicated P. falciparum malaria due to both chloroquine-susceptible and chloroquine-resistant parasites. Funding Source - FDA Office of Orphan Product Development (OOPD).

Detailed description:
This is an initial efficacy study (Phase 2 Proof of Concept Study) of a candidate antimalarial in human subjects with uncomplicated malaria caused by the most common and most important parasite in Africa (Plasmodium falciparum). This study will enroll 66 adult Malian males with uncomplicated P. falciparum malaria and randomize them to treatment with 1750 mg of the investigational drug (AQ-13) by mouth over 3 days or the current standard treatment, which is 80 mg of artemether and 480 mg of lumefantrine twice daily for 3 days. The hypothesis underlying this study is that AQ-13 will be similarly effective to Coartem for the treatment of uncomplicated P. falciparum malaria due to both chloroquine-susceptible and chloroquine-resistant parasites.

Arms: arm 1: Adult Malian males 18 years of age or older with uncomplicated P. falciparum malaria who agree to participate and provide their informed consent will be randomized to receive treatment with either AQ-13 or Coartem. Intervention 'AQ-13 Treatment' Participants randomized to the AQ-13 arm will be treated with two (350 mg) capsules on days 1 and 2 and one (350 mg) AQ-13 capsule on day 3 for a total oral dose of 1750 mg of AQ-13 (5 capsules containing 350 mg apiece) over 3 days. arm 2: Adult Malian males 18 years of age or older with uncomplicated P. falciparum malaria who agree to participate and provide their informed consent will be randomized to receive treatment with either AQ-13 or Coartem. Intervention: Active Comparator: Coartem. Participants randomized to the Coartem arm will be treated with 80 mg artemether and 480 mg lumefantrine at the time of diagnosis and 8 hours later on day 1, the same doses (80 mg artemether and 480 mg lumefantrine) twice on day 2 (24 and 36 hours after diagnosis) and twice more on day 3 (48 and 60 hours after diagnosis) for total oral doses of 480 mg artemether and 2880 mg lumefantrine over 3 days.
Interventions: intervention 1: AQ-13 Treatment intervention 2: Coartem Treatment
Intervention descriptions: intervention 1: Adult Malian males 18 years of age or older with uncomplicated P. falciparum malaria who agree to participate and provide their informed consent will be randomized to receive treatment with either AQ-13 or Coartem. Intervention 'AQ-13 Treatment' Participants randomized to the AQ-13 arm will be treated with two (350 mg) capsules on days 1 and 2 and one (350 mg) AQ-13 capsule on day 3 for a total oral dose of 1750 mg of AQ-13 (5 capsules containing 350 mg apiece) over 3 days. intervention 2: Adult Malian males 18 years of age or older with uncomplicated P. falciparum malaria who agree to participate and provide their informed consent will be randomized to receive treatment with either AQ-13 or Coartem. Intervention 'Coartem Treatment' Participants randomized to the Coartem arm will receive six doses of Coartem tablets over 3 days (each dose containing 80 mg artemether and 480 mg lumefantrine). Those six doses will be given at the time of diagnosis and 8 hours later on day 1, at 24 and 36 hours on day 2 and at 48 and 60 hours on day 3 for total doses of 480 mg artemether and 2880 mg lumefantrine over 3 days.

Protocol documents:
Prot_SAP_000.pdf: 
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TITLE:  AQ-13 for Uncomplicated Plasmodium falciparum 
Malaria: Proof of Concept Study 
 
FDA Protocol Number: 
FD-R-01-003373 
 
Support Provided by: 
Food and Drug Administration (FDA) 
 
Funding Mechanism: 
FDA Office of Orphan Product Development (OOPD) Grants Program 
 
Industrial Support Provided by:   
Not Applicable 
 
Principal Investigator: 
Donald J. Krogstad, MD 
 
Mali Principal Investigator: 
Ousmane A. Koita, PharmD, PhD 
 
Study Sponsor: 
Donald J. Krogstad, MD 
 
Person authorized to sign the Protocol and Protocol Amendments: 
Donald J. Krogstad, MD 
 
Medical Monitor 
Aliou Sissako, MD  
 
DMID Protocol Champion, Clinical/Regulatory Affairs Specialists:  
 
  
Draft or Version Number:  
2017-001 
 
Day Month Year 
13th February 2017 
 
 


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Statement of Compliance 
 
The study will be performed in accordance with Good Clinical Practice (GCP) as required by the 
following: 
• 
U.S. Code of Federal Regulations applicable to clinical studies (45 CFR 46) 
• 
ICH GCP E6 
• 
Completion of Human Subjects Protection Training 
• 
Terms of the FDA Office of Orphan Product Development Notice of Grant Award 
Refer to:  http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.htm#46. 
http://www.fda.gov/cder/guidance/959fnl.pdf 
http://grants.nih.gov/grants/guide/notice-files/NOT-OD-01-061.html 
 


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SIGNATURE PAGE 
The signature below constitutes the approval of this protocol and the attachments, and provides the 
necessary assurances that this trial will be conducted according to all stipulations of the protocol, 
including all statements regarding confidentiality, and according to local legal and regulatory 
requirements and applicable US federal regulations and ICH guidelines.  
 
Site Investigator (Principal Investigator):* 
 
Signed: 
 
Date: 
 
 
Name     Donald J. Krogstad, MD  
Title        Henderson Professor of Tropical Medicine 
               Tulane University of Louisiana  
 
 
* The protocol should be signed by the local investigator who is responsible for the study 
implementation at his/her specific site; i.e., if Investigational New Drug study, the individual who 
signs the Form FDA 1572. 
 
 
 
Site Investigator (Mali PI):* 
 
Signed: 
 
Date: 
 
 
Name     Ousmane A. Koita, PharmD, PhD  
Title        Faculties of Medicine and Biology 
               University of Bamako, Bamako, Mali  
 
 


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Statement of Compliance ................................................................................................................. i 
Signature Page ................................................................................................................................ ii 
List of Abbreviations......................................................................................................................... v 
Protocol Summary ......................................................................................................................... vii 
 
Flow Chart 1…………………………………………………………………………………….viii 
 
1 
Key Roles ....................................................................................................................... …   10 
2 
Background Information and Scientific Rationale ............................................................... 11 
2.1 
Background Information ........................................................................................... 11 
2.2 
Rationale .................................................................... Error! Bookmark not defined. 
2.3 
Potential Risks and Benefits .................................................................................... 12 
2.3.1 Potential Risks ............................................................................................. 12 
2.3.2   Known Potential Risks.………………………………………………………......4 
3 
Objectives ............................................................................................................................ 14 
4 
Study Design ........................................................................................................................ 15 
5 
Study Population………………………………………………………………………………….12 
5.1 
Selection of the Study Population……………………………………………………...12 
5.2 
Inclusion/Exclusion Criteria..……………………………………………………………13 
6 
Study Procedures/Evaluations…………………………………………………………………..14 
6.1 
Study Procedures………………………………………………………………………..14 
6.2 
Laboratory Evaluations………………………………………………………………….14 
6.2.1 Laboratory Evaluations/Assays………………………………………………..14 
6.2.2 Special Assays or Procedures…………………………………………………15 
6.2.3 Specimen Collection, Preparation, Handling, Shipping……………………..15 
7 
Study Schedule…………………………………………………………………………………...16 
7.1 
Screening…………………………………………………………………………………16 
7.2 
Enrollment/Baseline, if applicable……………………………………………………...16 
7.3 
Follow-up and Final Visits, if applicable……………………………………………….16 
7.4 
Early Termination Visit, if applicable…………………………………………………...16 
7.5 
Criteria for Discontinuation or Withdrawal of Subject, if applicable………………...17 
8       Assessment of Outcome Measures .................................................................................... 30 
8.1 
Specification of the Appropriate Outcome Measures.............................................. 30 
8.1.1 Primary Outcome Measures ........................................................................ 30 
8.1.2 Secondary Outcome Measures ................................................................... 30 
9 
Safety assessment and reporting ........................................................................................ 32 
9.1 
Definition of Adverse Event (AE) ............................................................................. 32 
9.2 
Definition of Serious Adverse Event (SAE) ............................................................. 32 
9.3 
Reporting Procedures .............................................................................................. 32 
9.3.1 Serious Adverse Event Detection and Reporting ........................................ 33 


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9.3.2 Reporting of Pregnancy ............................................................................... 33 
9.3.3 Procedures to be Followed in the Event of Abnormal Laboratory Test 
Values or Abnormal Clinical Findings .......................................................... 34 
9.3.4 Type and Duration of the Follow-up of Subjects After Adverse Events ...... 34 
9.4 
Halting Rules ............................................................................................................ 33 
10 
Clinical Monitoring Structure ................................................................................................ 37 
10.1 
Site Monitoring Plan ................................................................................................. 37 
11 
Statistical Considerations .................................................................................................... 40 
11.1 
Study Outcome Measures ....................................................................................... 40 
11.2 
Sample Size Considerations ................................................................................... 40 
11.3 
Participant Enrollment and Follow-Up ..................................................................... 20 
11.4 
Analysis Plan............................................................................................................ 41 
12 
Access to Source Data/Documents ..................................................................................... 44 
13 
Quality Control and Quality Assurance ............................................................................... 46 
14 
Ethics/Protection of Human Subjects .................................................................................. 47 
14.1 
Declaration of Helsinki ............................................................................................. 47 
14.2 
Institutional Review Board ....................................................................................... 47 
14.3 
Informed Consent Process ...................................................................................... 47 
14.3.1 Informed Consent/Assent Process (in Case of a Minor or others unable to 
consent for themselves) ............................................................................... 47 
14.4 
Exclusion of Women, Minorities, and Children (Special Populations) .................... 47 
14.5 
Subject Confidentiality ............................................................................................. 48 
14.6 
Future Use of Stored Specimens ............................................................................ 48 
15 
Data Handling and Record Keeping .................................................................................... 49 
15.1 
Data Management Responsibilities ......................................................................... 49 
15.2 
Data Capture Methods ............................................................................................. 49 
15.3 
Types of Data ........................................................................................................... 50 
15.4 
Timing/Reports ......................................................................................................... 50 
15.5 
Study Records Retention………………………………………………………………..35 
15.6 
Protocol Deviations………………………………………………………………………35 
16 
Publication Policy…………………………………………………………………………………36 
17 
Literature References .......................................................................................................... 51 
 
SUPPLEMENTS/APPENDICES 
A: Study Schedule 
 


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AE 
Adverse Event 
AQ 
aminoquinoline  
AQ-13 
Investigational aminoquinoline active against CQ- and multi-
resistant Plasmodium falciparum parasites (n-propyl side chain)  
AQ-72 
mono–N-dealkylated metabolite of AQ-13  
AQ-73 
di-N-dealkylated metabolite of AQ-13  
AUC 
Integrated area under the curve of drug blood levels over time, 
which is used as a measure of oral bioavailability  
-hCG 
Beta Human Chorionic Gonadotropin  
BP  
Blood Pressure (mm Hg)  
C 
Comparator (Coartem in these studies)  
CBC  
Complete Blood Count  
CDC  
Centers for Disease Control (and Prevention)  
CFA  
West African Franc ($1.00 US=500 CFA)  
CFR 
Code of Federal Regulations 
CK  
Creatine Kinase  
Cl 
Clearance of drug from the blood (by excretion or conversion to 
metabolites inactive against CQ-resistant parasites)  
CPD  
Citrate Phosphate Dextrose (anticoagulant)  
CQ 
chloroquine  
CRF 
Case Report Form 
CYP450 
Cytochrome P-450  
DMID 
Division of Microbiology and Infectious Diseases, NIAID, NIH 
DSMB 
Data and Safety Monitoring Board 
ECG 
ElectroCardioGram  
EDTA 
Ethylene Diamine Tetra-acetic Acid (anticoagulant)  
F 
Constant to adjust pharmacokinetic data for oral dosing  
FDA 
Food and Drug Administration 
FWA 
Federal-Wide Assurance (number) 
GCP 
Good Clinical Practice 
G6PD 
Glucose-6-Phosphate Dehydrogenase  
H0 
Null hypothesis 
H1 
Alternative hypothesis 
Hb 
Hemoglobin  
Hct 
Hematocrit  
HPLC  
High Performance Liquid Chromatography  
ICH 
International Conference on Harmonisation 
ID 
Identification (study) number for study participants 
ICMJE 
International Committee of Medical Journal Editors  
IEC 
Independent or Institutional Ethics Committee 


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IND 
IRB 
Investigational New Drug (Application) 
Institutional Review Board 
ITT 
Intent-to treat (analysis)  
K76T 
Lysine to Threonine point mutation at position (amino acid) 76 
M 
Margin of non-inferiority  
MOP 
Manual of Procedures 
MRT 
Mean Residence Time  
N 
Number (typically refers to subjects) 
NIAID 
National Institute of Allergy and Infectious Diseases, NIH, DHHS 
NIH 
National Institutes of Health 
OHRP 
Office for Human Research Protections 
OOPD 
Office of Orphan Product Development (FDA)  
ORA 
Office of Regulatory Affairs, DMID, NIAID, NIH, DHHS 
P 
Placebo  
PCR 
Polymerase Chain Reaction  
PE 
Physical Examination  
pfcrt 
Plasmodium falciparum Chloroquine Resistance Transporter  
PI 
Principal Investigator 
QT  
Interval from the beginning of ventricular depolarization (start of 
QRS) to the conclusion of repolarization (end of T wave) 
QTc 
QT interval adjusted (corrected) for heart rate  
SAE 
Serious Adverse Event 
SOP 
Standard Operating Procedure 
t ½  
Half-Time (for concentration to decrease by 50%)  
Vd 
Volume of distribution (Liters)  
WBC 
White Blood Cell  
WHO 
World Health Organization 
X 
the percentage of the efficacy of the active control vs. placebo  
(C – P) that one desires to retain in the investigational drug (I) 
(see the Statistical Section on pages 37-40) 


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Title: 
AQ-13 for Uncomplicated P. falciparum Malaria: Proof of Concept Study 
 
Population: 
Adult Malian males with uncomplicated Plasmodium falciparum Malaria   
 
This study will include adult Malian males ≥18 years of age in good general health 
(who have no known medical conditions other than malaria). Subjects who agree 
to participate and provide their informed consent will be randomized to one of two 
study arms (33 per arm x 2 arms = 66 subjects) to receive either AQ-13 (1596 mg 
orally over 3 days) or Coartem (4 tabs twice daily x 3 days).  
 
Number of Sites: 
There are several initial screening sites at: 1] the Missira/Sirakoroba Community 
Health Center in the Kolokani District and 2] referral outpatient clinics in and near 
Bamako. Although there is only one inpatient study site at the Clinical Research 
Center in Bamako, there will be two study follow-up sites for the 5 weeks of 
outpatient follow-up: the Community Health Center for Missira and Sirakoroba and 
the Clinical Research Center in Bamako.  
 
Study Duration:   
The duration of this study will be up to 15 months (including follow-up), beginning 
on June 15th, 2013 and concluding on or before January 15, 2016.  
 
Subject Duration: 
The duration of each subject’s participation will be 6 weeks, based on a 1 week 
inpatient stay for treatment/observation, plus 5 weeks of twice-weekly follow-up.  
 
Primary Objective and Primary Endpoints: 
 
 
  1] 
The primary objective is to determine and compare the cure rates for AQ-13 and Coartem.  
Cure is a lack of recrudescence within 42 days (PCR-corrected) – no evidence of  recrudescence with the 
same parasite genotype(s) after reduction of the asexual parasitemia to less than 25% of the admission 
value by day 3 and clearance of asexual parasites and fever by day 7. Failure is defined as lack of cure.  
 
Secondary Objectives and associated Endpoints for comparisons of AQ-13 with Coartem:     
  1] 
Adverse Events (AEs) – within 4 weeks of treatment as judged by blinded physician reviewers to 
be possibly related to the study drug(s).  
  2] 
Parasite clearance time – time from the initiation of treatment to the first of 2 successive negative 
thick smears.  
  3] 
Time to recrudescence or reinfection – time from the initiation of treatment to the reappearance of 
asexual P. falciparum parasites on the thick smear.  
  4] 
Effects on the QT (QTc) interval – mean changes from the baseline (pre-treatment) QTc interval to 
the post-treatment QTc interval after treatment with AQ-13 or Coartem.  
  5] 
Pharmacokinetic parameters for AQ-13 – will include measurements of AQ-13 blood levels over 
time (peak levels, AUC, MRT), drug distribution (Vd/F) and drug elimination (t½, Cl/F).  
  6]  
Fever clearance time: time in hours from the initiation of therapy until the disappearance of fever 
for at least 24 hours.  
 
Tertiary Objectives and associated Endpoints for comparisons of AQ-13 with Coartem:  
  1] 
Pharmacokinetics of AQ-13 metabolites – estimates of pharmacokinetic parameters for the mono- 
and di-N-dealkylated metabolites of AQ-13 (AQ-72, AQ-73).   
  2] 
Aminoquinoline (CQ) pruritus – pruritus in persons receiving AQ-13 or Coartem, especially in 
persons with a history of pruritus after treatment with CQ.     


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Schematic of Study Design (Flow Chart 1, below): 
 
This is a randomized study in which subjects who have provided their informed consent to participate 
will be randomized to one of two study arms: 1] oral administration of AQ-13 (1596 mg AQ-13 base 
over 3 days) or 2] the control arm, in which subjects will receive the standard treatment dose of Coartem 
(artemether + lumefantrine; 4 tablets twice daily x 3 days) which is currently recommended as the first-line 
treatment for uncomplicated P. falciparum malaria in Mali, including infections likely to be resistant to 
chloroquine (CQ) or pyrimethamine + sulfadoxine (Fansidar®). This is a single-blind study because the 
subjects (but not the investigators) will know which subjects are receiving AQ-13 vs. Coartem (by the 
number and types of capsules [AQ-13] or tablets [Coartem]).  
 


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1 
KEY ROLES 
Individuals: FDA Representative:  
Soumya Patel, PharmD  
Principal Investigator:   
Donald J. Krogstad, MD 
Mali PI:  
 
 
Ousmane A. Koita, PharmD, PhD  
Medical Monitor: 
 
Aliou Sissako, MD   
Institutions:  
Tulane University School of Public Health and Tropical Medicine, Department of Tropical Medicine, 1430 
Tulane Avenue, SL-17, J. Bennett Johnston Building, Room 510, New Orleans, LA 70112.  
 
Contact Person: Donald J. Krogstad, MD, PH: 504-988-6618; Cell: 504-296-4763; Cell 
phone in Mali: 223-6960-2474; FAX: 504-988-4667; E-Mails: krogstad@tulane.edu and 
donkrogstad@gmail.com   
 
University of Bamako, Faculties of Medicine and Science, BP 1805, Point G and BP E 3260, 
Badalabougou, Bamako, MALI.  
 
Contact Person: Ousmane A. Koita, PharmD, PhD, PH: 223-2022-6501 and 223-2023-
7925; Cell phones: 223-6363-8888 and 223-6674-9312; FAX: 223-2023-8168; E-Mail: 
okoita@icermali.org.   
 


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2 
BACKGROUND, RATIONALE, RISKS/BENEFITS 
2.1 
Background 
Antimalarial resistance was the single most important factor in the recent global resurgence of malaria [1] 
and is now the greatest obstacle to the control and potential elimination of malaria [2]. Specifically, the 
increasing prevalence of chloroquine (CQ) resistance [3] and the recent appearance of artemisinin 
resistance [4-5] have had a profoundly negative impact on malaria morbidity and mortality [6-7]. 
Therefore, the development of new antimalarials active against otherwise drug-resistant parasites that are 
also safe and orally bioavailable is an urgent global health priority. In particular, it would be desirable to 
have alternative antimalarials that were as safe and orally bioavailable as CQ, and were also active 
against CQ-, mefloquine- and multi-resistant strains of Plasmodium falciparum.  
 
Our recent studies have shown that aminoquinolines (AQs) with side chains shorter or longer (≤ 3 or ≥ 10 
carbons) than the 5 carbon isopentyl side chain of chloroquine (CQ) are active in vitro against CQ-, 
mefloquine- and multi-resistant P. falciparum [8-10]. They have also shown that short chain AQs 
administered orally are effective in vivo in two monkey models of human malaria (the P. 
cynomologi/rhesus monkey model of human P. vivax infection, and the P. falciparum/squirrel monkey 
model of human infection with the CQ-resistant Indochina I strain after adaptation to the squirrel monkey).  
 
In addition, recent Phase 1 (safety and pharmacokinetic) studies have shown that the side effects  
(adverse events [AEs] associated with) of the lead compound AQ-13 (which has a linear n-propyl side 
chain) in human subjects are similar to those of CQ and that the pharmacokinetics of AQ-13 and CQ are 
similar [11]. In terms of potential cost, the current estimate of the cost of goods for AQ-13 is $0.03 per 
dose (for an AQ-13 oral dose equivalent to 700 mg CQ base in terms of bioavailability), which is 
approximately $0.08 per treatment course if the treatment dose chosen is 1596 mg over 3 days. In 
addition, the close structural similarity between AQ-13 and CQ and the similar Adverse Events (AEs) 
observed with AQ-13 and CQ in the Phase 1 studies [11] suggest that AQ-13 may be as safe as CQ for 
the treatment of human subjects with malaria, and raise the possibility that AQ-13 may share the safety of 
CQ during pregnancy. Although these arguments are part of the rationale for studying AQ-13, please note 
that adult women (including women who are pregnant or breast-feeding) are excluded from 
participation in these studies. Finally, please note that AQ-13 is only one of 66 AQs which we have 
synthesized and shown to be active against CQ- and multi-resistant P. falciparum [9-10]. Therefore, if 
these studies are successful, they have the potential to create a new class of AQ antimalarials effective 
against otherwise drug-resistant P. falciparum malaria parasites.  
 
2.2  
Rationale  
Therefore, the next logical step in the evaluation of AQ-13 is to determine whether it is active against CQ-
resistant P. falciparum infection in human subjects. The hypotheses underlying this protocol are that: 1]  
an AQ-13 dose of 1596 mg administered orally will be efficacious for the treatment of uncomplicated P. 
falciparum malaria in human subjects, and 2] the bioavailability, pharmacokinetics and adverse events 
(AEs) of AQ-13 in human subjects with uncomplicated malaria will be similar to those observed previously 
in healthy uninfected subjects during the Phase 1 studies [11].   


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The rationales for the selection of adult men for this Proof of Efficacy Study with AQ-13 are that: 1] the 
involvement of only males will obviate potential concerns about inadvertent pregnancies in female 
volunteers who have agreed to contraception and 2] that persons who have survived to adulthood in Mali 
are protected against life-threatening complications and death from malaria because they have acquired 
the semi-immune state [12]. Therefore, if for reasons we have not foreseen, AQ-13 does not work (if AQ-
13 is not effective for treatment of uncomplicated malaria in human subjects), the risk of severe disease or 
death in these subjects will still be extremely low – because they are protected by their previous 
acquisition of the semi-immune state.  
 
2.3 
Potential Risks and Benefits  
2.3.1 Potential Risks 
Immediate (Short-Term) Risks. The first potential risk of participation in this study is that the 
investigational drug AQ-13 may not work; it may not cure uncomplicated P. falciparum malaria in Malian 
adults. If AQ-13 does not clear malaria parasites from subjects’ blood by day 7 in the AQ-13 arm, those 
subjects will be treated with Quinine. In addition, if Coartem does not clear malaria parasites from 
subjects’ blood in the Coartem control arm by day 7, these subjects will also be treated with Quinine, 
which is recommended in Mali for rescue in persons who fail treatment for uncomplicated malaria.   
 
The most frequent side effects of AQ-13 in the volunteers who received it during the Phase 1 studies (and 
therefore the most likely adverse events (AEs) in these Proof of Concept studies) are similar to those of 
CQ: they include headache, dizziness, and digestive tract symptoms (nausea, loss of appetite, diarrhea, 
vomiting and abdominal pain). One of 126 subjects developed a mild, transient rash on her lower body, 
and 1 had muscle damage for several days, which is thought not to have been caused by the study drug, 
and is often caused by vigorous exercise. Other potential risks include bleeding, bruising, discomfort, 
black and blue spots and infection from venipunctures to obtain blood specimens. Abnormal beating of the 
heart is a potential risk, and has been observed in two subjects during the previous studies. Although it is 
thought not to have been caused by the study drug, the study drug will be stopped and subjects will be 
treated with quinine if they have abnormal beating of the heart and were randomized to AQ-13.  
 
Potential Long-Term Risks. There are no long-term risks which are likely, in part because the subjects 
participating in this study will receive AQ-13 for only 3 days in daily doses that are 6 to 10-fold lower than 
the doses of CQ used previously to treat rheumatoid arthritis and other non-infectious diseases [13-14]. 
However, there have been reports of ocular complications when other 4-AQs (CQ or hydroxy-CQ; 
retinopathy) or an 8-AQ (tafenoquine keratopathy) [15] have been given for periods as short as 3 months  
(tafenoquine) or as long as 4-10 years (CQ or hydroxy-CQ doses of >3 or >6.5 mg base/kg/day) [16]. 
Therefore, although the likelihood of such complications is extremely low, we will perform eye 
examinations before and after treatment with AQ-13 to ensure that there is no evidence for ocular AEs 
with AQ-13. Note that the eye examinations performed before and after AQ-13 dosing during the Phase 1 
studies revealed no evidence of ocular AEs.  
 


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Potential for Unknown Risks. Because AQ-13 is an investigational drug, there may be other risks that 
we do not know about. Those risks have been substantially reduced – although not eliminated – by the 
absence of such AEs during the Phase 1 studies in healthy human volunteers.  
Potential Loss of Confidentiality. Although there is a risk that information about subjects’ participation in 
this study could become known, that risk is low. That risk will be minimized by keeping study information 
in password-protected computers and locked cabinets. When the results of the study are published or 
made available on the Internet, participants will be identified by study ID (identification) number and not by 
name. Officials of the US and Mali Governments, Tulane University and the University of Bamako will 
have access to the study records. Referrals to Malian physicians will be provided for problems related to 
this study and subjects will receive new information about AQ-13 that may affect their willingness to 
participate as that information becomes available.  
 
Rationale (Justification) for Risks. Although these risks (including the similar AEs observed with AQ-13 
and CQ) [10] are real, they are small in relation to the risks of untreated malaria for individual patients [1-
2]. For the community, drug-resistant parasites are the most important obstacle to the control and 
potential elimination of malaria. In addition, after a candidate antimalarial has been found active in vitro 
and in vivo in monkey models of human malaria [8-9] and safe in healthy human subjects [11], the only 
way to determine whether that candidate compound has the potential to be used as an antimalarial to 
treat humans with CQ-resistant malaria is to perform a Phase 2 Proof of Concept Study and ultimately 
Phase 3 studies. Thus, at this point in the evaluation of AQ-13 as the lead compound, it is appropriate to 
perform a Proof of Concept Efficacy Study of AQ-13 in human subjects.  
 
2.3.2 Known Potential Benefits.   
The potential benefit to the subjects from participating in this study is the information obtained from the 
initial blood testing and heart and eye examinations. If there are abnormal results on those tests, they will 
be explained to the subjects in detail, and the subjects will be referred for initial evaluation and treatment 
by medical specialists in Mali. Alternatively, for subjects whose only abnormal test result is a positive 
malaria smear, treatment with either AQ-13 or Coartem may benefit them by clearing those malaria 
parasites from their blood. In addition, knowledge gained from this study may benefit both these subjects 
and others in the future. However, there are no expected benefits to the subjects (participants) from 
measuring the levels of AQ-13 and its metabolites in their blood or urine or from studying the genes that 
metabolize these drugs or control the host immune response to malaria infection.  
 
 
 


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3 
OBJECTIVES (ENDPOINTS):  
Statement of Purpose. To summarize the information in the Background and Significance section above, 
the next logical step in the evaluation of AQ-13 as the lead compound is to determine whether it is active 
against (efficacious for the treatment of) uncomplicated P. falciparum malaria in human subjects. That is 
the purpose of (rationale for) this Proof of Concept Study. The hypotheses underlying this protocol are 
that: 1] an AQ-13 dose of 1596 mg administered orally will be efficacious for the treatment of 
uncomplicated P. falciparum malaria in human subjects, and 2] the bioavailability, pharmacokinetics and 
adverse events (AEs) of AQ-13 in human subjects with uncomplicated malaria will be similar to those 
observed previously in healthy uninfected subjects (during the Phase 1 studies) [11].The rationale for 
beginning with studies of adults before proceeding to studies of children is based on safety. Our rationale 
is that it is safer to begin with studies of adults (who have acquired the semi-immune state) before 
performing studies of children (who may not yet acquired the semi-immune state and are therefore at 
greater risk of severe or complicated malaria if AQ-13 is not efficacious for the treatment of uncomplicated 
malaria). The rationale for performing the Proof of Efficacy Study with only males is to ensure there is no 
chance that an adult female volunteer who has agreed to practice contraception before and after 
exposure to AQ-13 will inadvertently become pregnant during or shortly after these studies.  
 
Primary Objective and associated Endpoints: 
 
  1] 
The primary objective is to determine and compare the cure rates for AQ-13 and Coartem.  
Cure is a lack of recrudescence within 42 days (PCR-corrected - no evidence of recrudescence with the 
same parasite genotype(s)) after reduction of the asexual parasitemia to < 25% of the admission value by 
day 3 and clearance of asexual parasites and fever by day 7. Failure is defined as “lack of cure.”  
 
Secondary Objectives and associated Endpoints for comparisons of AQ-13 with Coartem:     
  1] 
Adverse Events (AEs) – within 4 weeks of treatment as judged by blinded physician reviewers to 
be possibly related to the study drug(s) using the same criteria as in the Phase 1 study.  
  2] 
Parasite clearance time – from the initiation of treatment to the first of 2 successive negative thick 
smears.  
  3] 
Time to recrudescence or reinfection – time from the initiation of treatment to the reappearance of 
asexual P. falciparum parasites on the thick smear.   
  4] 
Effects on the QT (QTc) interval – mean changes from the baseline (pre-treatment) QT interval to 
the post-treatment QT interval after treatment with AQ-13 or Coartem.  
  5] 
Pharmacokinetic parameters for AQ-13 – these will include measurements of blood levels over 
time (peak levels, AUC, MRT), drug distribution (Vd/F) and drug elimination (t½, Cl/F).  
6]  
Fever clearance time: Time in hours from the initiation of therapy until disappearance of fever for 
at least 24 hours.  
 
Tertiary Objectives and associated Endpoints for comparisons of AQ-13 with Coartem:    
  1] 
Pharmacokinetics of AQ-13 metabolites – estimates of pharmacokinetic parameters for the mono- 
and di-N-dealkylated metabolites of AQ-13 (AQ-72, AQ-73).   
  2] 
Aminoquinoline (CQ) pruritus – pruritus in persons receiving AQ-13 or Coartem, especially in 
persons who have a history of pruritus after treatment with CQ.     
 


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4 
STUDY DESIGN 
 
Description of Study Design. This is a randomized single-blind study of uncomplicated P. falciparum 
malaria in adult Malian males (≥ 18 years of age) in which subjects who provide their informed consent to 
participate will be randomized to either the study arm (1596 mg oral dose of AQ-13 over 3 days) or the 
control Coartem arm (4 tablets twice daily x 3 days). The rationale for the Coartem controls is to relate the 
AQ-13 results to Coartem – which is the recommended first-line treatment (current state-of-the-art) for the 
treatment of uncomplicated P. falciparum malaria in sub-Saharan Africa [19-22]. This is a single-blind 
study because the subjects will potentially know whether they are receiving AQ-13 (capsules) or 
Coartem (tablets). However, the investigators evaluating AEs, the relatedness of AEs to the study 
drugs and other data will not know which subjects were randomized to which arm of the study.  
 
Patient population (Flow Chart 2, page 16, below). The patient population and flow of potential subjects 
from screening to study accrual are summarized in Flow Chart 2. Recruitment of adult Malian subjects 
with uncomplicated P. falciparum malaria will be performed at the Missira Community Health Center for 
persons from Missira and the adjacent village of Sirakoroba (total population 6,000) and at the outpatient 
referral centers in Bamako. Please note that the inpatient studies for all subjects will be performed at the 
Clinical Research Center and that the subsequent outpatient follow-up visits (twice weekly for 5 weeks) 
will be at both the Community Health Center in Missira (for subjects from Missira or Sirakoroba) and the 
Clinical Research Center (for subjects from urban and per-urban regions of Bamako).  
 
Times to obtain Blood Specimens and other Samples and Studies (Flow Charts 3-4, Gantt Chart, 
pages 17, 26 and 27, below). After providing their informed consent to participate, subjects will be asked 
to provide 2 tubes of blood for chemistry and hematology testing. Beginning at the time of dosing, 
participants will also be asked to provide serial blood samples for AQ-13 drug and metabolite blood levels 
8, 7 and 7 times on days 1-3, once on days 4 and 5, twice in week 2 (at each of the twice-weekly 
outpatient visits) and once per week in weeks 3-6 (days 15-42). This information is provided in tabular 
form and graphically in a Gantt Chart below in Section 7 (page 27). To facilitate the drawing of multiple 
blood specimens, a heparin lock plastic catheter with a scalp vein needle will be placed in the arm of 
participants for use during inpatient days 1-4 or 1-5.  
 
Methods for Collecting Blood Specimens. Blood specimens will be obtained by finger stick or through 
the heparin lock plastic catheter for the screening blood smear, filter paper blot, and Hb, AQ-13 and AQ-
13 metabolite levels. Subsequently, they will be obtained by venipuncture for the AQ-13 drug and 
metabolite levels and for the repeat chemistry and hematology panels beginning on day 4 of the inpatient 
stay or at the start of outpatient studies in Week 2. A heparin lock (scalp vein attached to a plastic 
catheter containing heparin to keep the line open) will be placed on inpatient day 1 to permit drawing 24-
26 blood samples on inpatient days 1-4 or 1-5 without separate venipunctures for each sample.  
 
Collection of Urine Specimens. To monitor the urinary excretion of AQ-13 and its two major metabolites, 
subjects will be asked to save their 24 hour urines during inpatient days 1-4.  
 


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Expected Duration of Subject Participation from the time of screening and enrollment to the conclusion 
of their participation in the study is 42 days (6 weeks).  
 
Description of Subject Participation. As noted above, these subjects will be asked to provide or have:  
• 
32 Tubes of blood for a total volume of 160 ml (5 ml per tube),  
• 
4 (24 hour) urine collections on inpatient days 1-4,  
• 
7 Holter recordings at the times of screening (1 hour), during inpatient days 1-4 (24 hours each) 
and at the 1 and 2 week outpatient follow-up visit (2 hours),  
• 
2 Eye examinations at the times of screening and the 1 week outpatient follow-up visit.  
 
Safety Oversight will be assisted by a Data Safety and Monitoring Board (see section 8.7 on page 
33, below).   
 
 
 
 


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 5 
STUDY POPULATION 
5.1 
Selection of the Study Population 
The population to be studied is the subset of adult Malian males with uncomplicated P. falciparum 
malaria. There are two rationales for this choice. The first is that uncomplicated malaria with asexual 
parasite counts ≥ 2,000 per l is extremely common in Mali (affecting ≥ 40-90% of the population in the 
transmission season). The second is that adults in Mali have acquired the semi-immune state and will 
therefore have an extremely low risk of severe or complicated malaria if AQ-13 is not effective for the 
treatment of uncomplicated malaria (which we do not expect to be the case).  
 
Target Sample Size, including the actual numbers to be enrolled. The target sample size for the 
number of evaluable subjects is 28 evaluable subjects in each of 2 study arms for a total of 56 evaluable 
subjects. However, the numbers of potential subjects that will be recruited are greater than 28 per arm 
because of expected losses from: 1] persons who have a negative blood smear for malaria parasites, 2] 
the need to spend one week (5-7 days) at the Clinical Research Center during the inpatient phase of the 
study, 3] the subsequent 5 weeks of twice-weekly outpatient follow-up visits and 4] the multiple blood 
samples, monitoring and urine collections required for participation.  
 
Numbers of subjects (adult males) that will be recruited. For the reasons outlined above and in Flow 
Charts 2-3 (pages 16-17), we expect to recruit 132 men (adult Malian males ≥ 18 years of age) thought to 
have uncomplicated malaria to identify 118 eligible men (who have positive smears with ≥ 2,000 asexual 
parasites per l and no other medical conditions that require diagnosis or treatment) in order to obtain 70 
men willing to provide their informed consent to enroll and participate in the inpatient studies (33 per arm 
for the 2 study arms). Based on an additional 20% attrition during inpatient and outpatient follow-up, this 
should yield approximately 28 evaluable subjects per study arm (based on approximately 56 evaluable 
subjects from the initial 132 who were recruited and the 70 who provided their informed consent to 
participate in the study).  
 
Indicate the source/site from which the study population will be drawn. The study population of 
Malian adult males with uncomplicated malaria will be drawn from several outpatient sites: 1] the Missira 
Community Health Center which serves the adjacent communities of Missira and Sirakoroba 160-170 km 
northwest of Bamako that have an estimated population of 6,000, and 2] referral clinics in urban and peri-
urban Bamako, where >100 outpatients from the urban and peri-urban areas in and around Bamako seek 
treatment for uncomplicated malaria every day between August and November.  
 
Identify strategies for subject recruitment and retention. Subjects will be recruited from persons who 
come to the Missira Community Health Center or to clinics that refer to the University of Bamako for the 
diagnosis and treatment of presumed uncomplicated P. falciparum malaria (fever, chills, headache, 
without signs or symptoms of severe or complicated malaria) [23]. We expect that close personal care and 
attention during the inpatient week of the study will minimize attrition during that time. To maximize cohort 
retention for the twice-weekly outpatient follow-up visits during the subsequent 5 weeks, we will provide 
financial compensation (CFA 5,000=$10 US) for each outpatient visit and transportation home at the 
conclusion of each follow-up outpatient visit.  


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Ability to accomplish participant enrollment and Follow-Up 
As noted above and in Flow Charts 2-3, this study is based on the analysis of approximately 28 evaluable 
subjects in each of the 2 study arms (28 x 2 = 56), and therefore on ≥ 56 evaluable subjects completing 
the study protocol. To achieve that goal, we expect to screen and enroll substantially greater numbers of 
subjects. Based on the number of subjects seeking diagnosis and treatment for uncomplicated malaria at 
the two recruitment sites (≥ 200 per month) and on the inpatient capacity of the Clinical Research Center 
at the Hôpital Point G (8-10 inpatients), it should be possible to accomplish this study and determine 
whether the 1596 mg dose of AQ-13 is as effective as Coartem for treatment of uncomplicated malaria. 
 
As described above (on page 18) in the section on subject recruitment and retention), the majority of the 
subjects for this study will be recruited because they came to the Missira Community Health Center or a 
referral outpatient clinic in Bamako, requesting studies to diagnose and medicines to treat uncomplicated 
malaria. For those subjects, the initial screening malaria smear and rapid Hb determination are part of 
their routine clinical care. However, if it is necessary to recruit additional subjects from the community, a 
protocol amendment will be prepared in order to obtain a separate informed consent before performing a 
malaria smear, Hb determination or other studies potentially related to this Phase 2 Proof of Concept 
Efficacy Study of AQ-13. As noted below, and in the enclosed Gantt Chart (page 27), informed consent 
will be obtained before subjects are considered for the initial referral and transportation from Missira or 
other sites to the Clinical Research Center in Bamako.  
  
5.2 
Eligibility (Inclusion/Exclusion) Criteria 
Inclusion criteria for this study include:  
  1]  
Adult Malian males ≥ 18 years of age,  
  2]  
Uncomplicated malaria with ≥ 2,000 asexual P. falciparum parasites per l, and  
  3]  
Informed consent obtained and signed.  
 
After obtaining the initial consent to treat, a physical examination and medical history will be obtained and 
recorded on a standard form. Thick smears will be obtained to diagnose P. falciparum infection. Patients 
who fulfill the first two criteria above will be invited to participate in the study, and informed consent will be 
obtained from those who choose to participate.  
 
Exclusion criteria for this study include:  
  1] 
Severe or complicated malaria (including temperatures ≥ 40o C),  
  2] 
≥ 100,000 asexual parasites per l of blood,  
  3] 
Anemia or other laboratory results (other than malaria) that require treatment (e.g., Hb ≤ 7 gm/dL, 
K+ ≤ 3.5 mM, BP ≥ 140/90),  
  4] 
Seizures or impaired consciousness, 
  5] 
Recent antimalarial treatment by history (within ≤ 2 weeks),   
  6] 
Chronic medications (including CYP3A4 inducers such as rifampin and nevirapine),  
  7] 
Ventricular or atrial arrhythmias including frequent ventricular premature beats or extrasystoles (> 
20 per hour) or second or third degree heart block on the screening Holter recording,  
  8] 
Infection with other plasmodial species on the blood smear (P. ovale, P. ovale, P. vivax). 
 
Enrollment and randomization will occur only after a final review to ensure that all of the inclusion criteria 


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have been met and that none of the exclusionary criteria are present.  


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6 
STUDY PROCEDURES/EVALUATIONS 
Table 1.  
 
Study Schedule: PROOF OF CONCEPT EFFICACY STUDY OF AQ-13  
   Activity, Day(s)  
Tests Performed and Potential Findings  
DIAGNOSIS, Day 1: 
Malian males ≥ 18 years 
with Fever and Chills  
Blood smear to diagnose malaria in an adult Malian male is positive  
(and the subject fulfills none of the exclusion criteria)  
INVITATION, Day 1: 
Invite to Participate in 
Study of AQ-13  
Decide whether to participate in the Phase 2 Proof of Concept Study of 
AQ-13 by providing informed consent  
SCREENING, Day 1:  
Subjects with malaria 
who provide consent  
Screening 1 hour Holter recording, 2 tubes of blood for chemistry and 
hematology testing, eye examination 
ENROLLMENT, Day 1: 
Randomize eligible, 
consented subjects  
Randomization of subjects to AQ-13 (1596 mg orally over 3 days) or to 
the control arm, Coartem (4 tabs x 2/day x 3 days)  
INPATIENT STUDIES: 
Days 1-7  
Blood samples for drug and metabolite levels on days 1-5;  
Two tubes of blood for hematology and chemistry panels on day 4; 
24 Holter recordings on dosing days 1-4; Urine collections on days 1-4; 
Eye exam plus an additional Holter recording at the end of week 1.  
OUTPATIENT 
FOLLOW-UP,  
Days 8-42:  
(Weeks 2-6) 
Five weeks of outpatient follow-up with 2 visits each week, to obtain 1 
tube of blood for drug and metabolite levels on both visits in week 2, and 
1 tube per week (at 1 of the 2 outpatient visits) in weeks 3 to 6;  
During week 2, there is a repeat 1 hour Holter recording and a review 
(discussion) of potential side effects (AEs).  
6.1 
Study Procedures 
As noted above and in Flow Chart 4 below, the initial study procedures for subjects with uncomplicated P. 
falciparum malaria are a history and physical examination. The history and physical examination will be 
performed as outlined in the enclosed Case Report Form. Other study procedures that will be performed 
at the times of screening and enrollment include:  
• 
Specimen Collection – performed by medical and nursing staff at designated times for collection of 
blood samples and 24 hour urines during inpatient days 1-4 (Flow Chart 4, page 26),  
• 
Medical History – emphasizing fever, chills, other symptoms and signs of malaria, as well as 
weight loss and other signs of long-term and potentially confounding illnesses,  
• 
History of concomitant Medications – emphasizing: a] medications for malaria in the past 2 weeks, 
and b] medications other than contraceptives, especially medications such as rifampin and 
nevirapine which induce 3A4 CYP450 activity and are therefore grounds for exclusion,  
• 
Physical Examination – emphasizing conjunctival pallor (anemia), signs of increased cardiac 
output consistent with fever or anemia, splenomegaly (Hackett Classes I-V) [24],   


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• 
Counseling – other issues of concern to the patient.  
 
6.2 
Initial Laboratory Evaluation 
Subjects thought to have uncomplicated P. falciparum malaria will be evaluated by obtaining a finger stick 
blood sample for a thick smear, filter paper blot and a rapid Hb determination in order to screen for P. 
falciparum malaria and anemia.  
 
6.2.1 Laboratory Evaluations/Assays 
Subjects who satisfy the first two inclusion criteria (adult Malian males ≥ 18 years of age with 
uncomplicated P. falciparum malaria, and 2,000 to 99,999 asexual parasites per l of blood) will be invited 
to participate in this study if they fulfill none of the exclusion criteria. Those who accept by providing their 
informed consent will have 2 additional tubes of blood drawn in Bamako for chemistry and hematology 
panels (1 each), including glucose-6-phosphate dehydrogenase (G6PD) assays and a separate sample 
for drug and metabolite blood levels that will also be used to freeze (cryopreserve) malaria parasites for 
future reference (Flow Chart 4, below on page 26). Laboratory evaluations or assays that will be 
performed in these studies include:  
• 
Thick smear for asexual P. falciparum parasites with quantitative parasite counts (Mali; SOP) 
• 
Filter paper blot for parasite and host genomic DNA (Mali; SOP) 
• 
Rapid (Hemocue) Hb determination for anemia (Mali; SOP)  
• 
Chemistry panel (Piccolo-Abaxis) (Mali; SOP) 
• 
Hematology panel (Coulter ACT 10) for Hb, Hct, WBC, platelets (Mali; SOP)       
• 
Glucose-6-phosphate dehydrogenase (G6PD) determination (Mali; SOP)  
 
6.2.2 Special Assays or Procedures 
Prior to treatment with AQ-13 or Coartem, subjects will have a 1 hour baseline Holter recording to exclude 
pre-existing arrhythmias and other cardiac abnormalities and a baseline eye examination to ensure that 
there are no pre-existing ocular abnormalities before treatment or any new ocular abnormalities (potential 
AEs) after treatment. Randomization will be performed after the chemistry, hematology, eye and Holter 
recording results have been checked to ensure there are no criteria for exclusion and that informed 
consent to participate has been obtained and signed. Special assays or procedures that will be used in 
these studies include:  
• 
PCR testing for parasite genotypes and for the K76T point mutation in pfcrt (Mali; SOP), 
• 
Fluorescence HPLC assay for AQ-13 and its metabolites (New Orleans; SOP),  
• 
Holter recordings for evidence of arrhythmias (Mali and New Orleans; SOP),  
• 
Eye examinations pre- and post-treatment to test for evidence of keratopathy, retinopathy, other 
pre-existing abnormalities or treatment-related ocular side effects (adverse events) (Mali; SOP),  
• 
Pharmacokinetic analysis of AQ-13 drug and metabolite blood and urine levels (Mali and New 
Orleans; SOPs for AQ-13 HPLC, CRFs for Out-Patient Follow-Up).   
  
6.2.3 Specimen Collection, Preparation, Handling and Shipping 
 
Blood Drawing for AQ-13 Drug and Metabolite Levels (Flow Chart, page 26, Section 7).  


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Because of the need to define the pharmacokinetics of AQ-13 and its metabolites, this blood sampling is 
more intense at the times of dosing (during days 1-3) when AQ-13 is being administered to the 
participants. (That is also the reason this table is below on a different page, because the substantial 
number of samples in Week One [n=25, Table 3, page 26] required that this table be presented in 
landscape orientation.)  
 
  
After day 5, blood samples for the pharmacokinetic studies (drug and metabolite levels) will be 
drawn twice-weekly in the first week of outpatient follow-up (week 2 from day 8 to day 14) and once 
weekly during the subsequent 4 weeks (weeks 2 to 6 from days 15 to 42). The 25 samples obtained on 
days 1-5 plus the 10 samples obtained during outpatient follow-up are a total of 35 samples for the 
pharmacokinetic studies of AQ-13 and its metabolites at 5 ml apiece = 175 ml per subject.  
 
6.2.3.1 
Instructions for Specimen Preparation, Handling, and Storage 
Specimens for chemistry, hematology and drug blood level testing are anticoagulated with lithium heparin, 
EDTA and CPD, respectively. Filter paper blots are kept in individually-labeled and dated envelopes in a 
dessicator at room or refrigerator temperature.  
 
6.2.3.2 
Specimen Shipments 
Blood and urine specimens for the measurement of AQ-13 drug and metabolite levels will be shipped from 
Mali to Tulane University in New Orleans at 0-4o C because there have been no changes in those results 
when specimens have been stored at 0-4o C for ≥ 6 months. Specimens containing live frozen parasites 
shipped to New Orleans will be transported by commercial carrier using a CDC Permit for the Importation 
of Potentially Infectious Agents issued to the PI. Holter recordings will be sent from Bamako to New 
Orleans via the WEB using encryption to protect subject confidentiality, so they can be reviewed 
independently by cardiologists in both the U.S. and Mali using the Box.com WEB Site.  
 
 
Permissible Concomitant Medications (Table 2, page 23, below) 
As noted above, persons taking chronic medications and persons with chronic or acute diseases other 
than malaria will be excluded from participation in this study. However, in the course of uncomplicated 
malaria, supportive treatment is normally provided for: 1] fever and other discomforts, 2] nausea and 
vomiting, and 3] treatment of seizures (which would require withdrawal of the subject from this study for 
cerebral malaria). Therefore, those treatments (medications) will be allowed for participants in this study. 
Because the list provided below is based on discussions with Malian physician investigators, it focuses on 
drugs available in Mali, rather than drugs used for these indications in the U.S. For example, based on 
current practice in Mali, it lists: 1] paracetamol and aspirin including aspegic, rather than acetaminophen 
(Tylenol) for fever, headache, arthralgias and myalgias, and 2] metopimazine rather than prochlorperazine 
(Compazine) for nausea and vomiting.  
 
Please note that: 1] these drugs and doses are not investigational (they are provided as examples of 
current practice for the supportive treatment of malaria in Mali) and 2] doses are provided only for adults 
because this study is restricted to adult Malian males ≥ 18 years of age with uncomplicated P. falciparum 
malaria. 


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Table 2.  
 
 
 
Medications used for the supportive Care of Persons with Malaria in Mali  
 
INDICATION 
MEDICATION 
DOSING 
FEVER, DISCOMFORT  
 
Antipyretic Analgesics 
Paracétamol Tablets  
   500 mg tablets 
0.5-1.0 gm every 4-6 hours, not to exceed 4  
   doses per 24 hours,  
 
Paracétamol Injectable  
   (Perfalgan), 10 mg/ml  
Intravenous infusion of 1.0 gm (100 ml) not to   
   exceed 4 doses per 24 hours,  
 
Aspirin Tablets 
0.5-1.0 gm every 4-6 hrs, not to exceed 4  
   doses per 24 hours,  
 
Aspégic Injectable  
1.0 gm every 6-8 hours, not to exceed 4 doses  
   per 24 hours,  
NAUSEA, VOMITING  
 
 
Antiemetics  
Metopimazine (Volgalène) 
   5 and 10 mg oral, rectal 
10 mg orally up to 3 doses per day, or  
   5-10 mg rectally not to exceed 3 doses/day 
 
Metopimazine Injectable  
5-10 mg per injection, not to exceed 4 doses  
   per day, 
SEIZURES  
 
 
Anticonvulsants  
Diazepam (Valium)  
   10  mg tablets  
10-20 mg as needed, not to exceed 5 doses 
   per 24 hours,  
 
Diazepam Injectable  
10-20 mg as needed, not exceed 5 doses per  
   24 hours.  
 
 
6.3 
Screening 
As noted above (section 6.2) and in Table 1, subjects thought to have uncomplicated P. falciparum 
malaria will be evaluated (diagnosed) by obtaining a finger stick blood sample for a thick smear, filter 
paper blot and a rapid Hb determination to screen for P. falciparum malaria and anemia. The time 
between screening and enrollment must be ≤ 48 hours, although ≤ 24 hours is preferable (intervals 
> 24 hours are acceptable if they result from consultation or deliberation related to informed consent). If a 
subject is eligible for the study and agrees to participate by providing their signed informed consent, other 
screening tests then performed will include a 1 hour Holter recording, 2 tubes of blood for chemistry and 
hematology testing and an eye examination (Table 1, Flow Chart 4). 
  
6.4 
Enrollment/Baseline, if applicable 
Baseline data should be obtained within 24 hours of enrollment. This should allow for (permit) delays 
related to venipunctures for blood samples and the insertion of a heparin-lock to facilitate drawing multiple 
timed blood samples during the first 3 inpatient days, a 1 hour baseline Holter recording to exclude 
arrhythmias and a baseline eye examination.  
 


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6.5 
Inpatient Period 
Blood samples will be taken for drug and metabolite levels on days 1-5 and hematology and chemistry 
panels on day 4. After screening Holter recordings have been obtained and reviewed for pre-existing 
arrhythmias, continuous 24 hour Holter recordings will be performed on each of days 1- 4 (focusing on the 
time between 2 and 6 hours after dosing for maximal effects on the QT interval). Urine collections will be 
performed on each of days 1-4. An eye exam plus an additional 1 hour Holter recording will be performed 
at the end of week 1.  
 
6.6 
Follow-up and Final Visits, if applicable  
After completion of the 5-7 day inpatient stay (Flow Chart 4 below, and Table 1, above), there are 2 
follow-up outpatient visits each week for the next 5 weeks (total of 6 weeks active involvement in the 
study). At each of the follow-up visits during Weeks 3-6, a blood sample is obtained for AQ-13 drug and 
metabolite blood levels to define the pharmacokinetics of AQ-13 and its metabolites. In addition, there is a 
final 1 hour Holter recording at the 2 week follow-up visit plus an in-depth interview about potential AEs.  
                                        
Sequence of Events during the Follow-Up Outpatient Visits. The twice-weekly follow-up outpatient 
visits will include (in sequence): an interval history with discussion of potential AEs related to study drugs, 
review of current medications and a physical examination with recorded results for vital signs (blood 
pressure, heart rate, respiratory rate, temperature), conjunctival pallor, pulmonary, cardiac and abdominal 
examinations (including splenomegaly) (see the Out-Patient Follow-Up CRFs).    
 
Allowable Windows (Times) for Follow-Up Outpatient Visits. The major purposes of the follow-up 
outpatient visits are to: 1] follow the pharmacokinetics of AQ-13 and its metabolites over time to estimate 
the terminal elimination t½ and other pharmacokinetic parameters for AQ-13 and its metabolites in 
subjects with uncomplicated malaria and 2] to test for recurrent infection by distinguishing new infections 
(which do not represent recurrences or treatment failures) from recrudescences of infection with the same 
parasite genotypes (which do potentially represent treatment failures). Although the best data (in terms of 
points on the time-concentration curve to estimate the pharamacokinetic parameters) are provided by 
twice-weekly follow-up blood samples during the first two weeks (Weeks 1 and 2), the software that will be 
used for this purpose (PharSight) can adjust and still provide reasonable estimates of the relevant 
pharmacokinetic parameters no matter what the time points are. For this reason and because recurrent 
infection should be detected as soon as possible, late return visits will be permitted up to the final 6 week 
(42 day) time point.  
 
6.7 
Early Termination Visit, if applicable 
Evidence for the recurrence of P. falciparum infection (positive smear for asexual parasites) at a follow-up 
outpatient visit within the 42 day period of post-treatment observation is reason for re-treatment and for 
the termination of a subject’s participation in the study. At that time, blood will be drawn for AQ-13 drug 
and metabolite levels and to freeze asexual parasites for study in the future, 2 filter paper blots will be 
obtained, and repeat chemistry and hematology testing will be performed. The rationale for performing 
these studies at that time is to determine whether:  


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  a] 
the recurring parasite was present at the time of the initial diagnosis and treatment (in 
which case the recurrent infection would represent a treatment failure) and 
  b] 
the blood levels of AQ-13 and its metabolites are within the expected range (in order to exclude 
treatment failure due to ultrarapid metabolism of AQ-13 to its N-dealkylated metabolites by the 
CYP450 system.   
 
6.8 
Discontinuation or Withdrawal of a Subject  
Treatment with AQ-13 or Coartem in this study may be discontinued for any of the reasons below. 
However, whenever possible (i.e., except when informed consent to participate has been withdrawn) 
subjects will be followed through to the conclusion of the treatment of their illness and outcomes will be 
examined using both intent to treat and per protocol analyses.  
  1] 
Recurrence of uncomplicated malaria,  
  2] 
Progression to severe or complicated malaria,  
  3] 
Development of ventricular tachyarrhythmias or conduction defects (new 2nd or 3rd degree heart 
block),  
  4] 
Other Serious Adverse Events (SAEs) possibly related to AQ-13, or  
  5] 
The subject’s decision to withdraw his/her informed consent to participate.  
 
If lack of cure (recurrence of uncomplicated malaria) occurs with either AQ-13 or Coartem, the subject will 
be treated with Quinine. Likewise, if a subject develops severe or complicated malaria, he will be treated 
with Quinine as recommended by the Mali Ministry of Health and the National Malaria Control 
Programme. Treatment with either AQ-13 or Coartem will be stopped in subjects who develop ventricular 
tachyarrhythmias, conduction defects or other serious adverse events (SAEs) possibly related to AQ-13 or 
Coartem. In those instances, further antimalarial treatment (if necessary) will be provided using Quinine 
based on the recommendations of the Mali Ministry of Health and the Mali National Malaria Control 
Programme.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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7 
ASSESSMENT OF OUTCOME MEASURES 
 
7.1 
Specification of the Appropriate Outcome Measures 
The major question being asked in these studies is whether AQ-13 is efficacious for the treatment of 
uncomplicated malaria due to P. falciparum. Therefore, the major outcome is whether treatment with AQ-
13 clears P. falciparum parasites from the bloodstream and fever within 7 days without recrudescence 
within 42 days (3 times the 14-15 day terminal t½ of AQ-13 in human subjects) [11]. Because the 
transmission of malaria is often intense in Mali (100-300 bites per person per night during the rainy 
season), the data for recrudescence will be PCR-corrected [16-17]. Based on the amplification of selected 
polymorphic loci, recrudescences with parasites different from those in the initial infection will be 
categorized as new infections, which do not represent treatment failure. Conversely, recrudescences with 
parasites indistinguishable from those in the initial infection will be categorized as recurrent infections and 
do potentially represent treatment failures.  
 
7.1.1         Primary Outcome Measures 
Cure is a lack of recrudescence within 42 days (PCR-corrected) – no evidence of recrudescence with the 
same parasite genotype(s) after reduction of the asexual parasitemia to less than 25% of the admission 
value by day 3 and clearance of asexual parasites and fever by day 7. Failure is defined as “lack of cure”.  
 
7.1.2        Secondary Outcome Measures 
  1] 
Adverse Events (AEs) – within 4 weeks of treatment as judged by blinded physician reviewers to 
be possibly related to the study drug(s) using the same criteria as in the Phase 1 study.   
  2] 
Parasite clearance time – from the initiation of treatment to the first of 2 successive negative 
smears.   
  3] 
Time to recrudescence or reinfection – time from the initiation of treatment to the reappearance of 
asexual P. falciparum parasites on the thick smear.   
  4] 
Effects on the QT (QTc) interval – mean changes from the baseline pre-treatment QT (QTc) 
interval to the post-treatment QT (QTc) interval after treatment with AQ-13 or Coartem.  
  5] 
Pharmacokinetic parameters for AQ-13 – these will include measurements of AQ-13 blood levels 
over time (peak levels, AUC, MRT), drug distribution (Vd/F) and drug elimination (t½, Cl/F).  
6]  
Fever clearance time: Time in hours from the initiation of therapy until disappearance of fever for 
at least 24 hours.  
 
7.1.3 
Tertiary Outcome Measures 
  1] 
Pharmacokinetics of AQ-13 metabolites – estimates of pharmacokinetic parameters for the mono- 
and di-N-dealkylated metabolites of AQ-13 (AQ-72, AQ-73).   
  2] 
Aminoquinoline (CQ) pruritus – pruritus in persons receiving AQ-13 or Coartem, especially in 
persons with a history of pruritus after treatment with CQ.     
 
 
 
 
 


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7.2 
Assessment of Treatment Outcomes  
7.2.1 
Parasitologic Data  
Asexual parasite counts (parasite densities per l of blood) will be based on the average of two 
independent readings for each time point – performed by two independent microscopists (both blinded to 
the treatment the patient received). Blood smears will be obtained beginning at the time of enrollment and 
continuing twice daily (every 12 hours) until two successive smears are negative during the week-long (6-
7 day) inpatient stay. After the patient has been discharged, two thick smears will be obtained at each of 
the twice weekly follow-up appointments during weeks 2 to 6 (Gantt Chart on page 27).  
 
Laboratory Procedures: Parasite counts will be obtained by examining Giemsa-stained thick blood smears 
containing a minimum of 300 white blood cells and multiplying the number of asexual parasites observed 
by 25 to estimate the parasite count based on a white blood cell count of 7,500 white cells per l of blood.  
 
Quality Control: Slides for which the parasite densities estimated by the two microscopists vary by more 
than 20% or differ qualitatively (negative vs. positive, presence vs. absence of species other than P. 
falciparum) will be examined by a third senior microscopist to resolve those questions.  
 
Parasitologic Outcomes that will be assessed and compared between the two study arms will include:  
• 
Reduction of asexual parasitemia to < 25% of the admission parasite count by day 3,  
• 
Clearance of asexual parasites from the blood on or before day 7 after treatment, and   
• 
Recurrent asexual stage parasitemia on or before day 42.  
 
 
Assessment and Reporting of Parasitologic Outcomes  
Based on the parasitologic data, the PI and one physician colleague (both blinded to the treatment the 
patients received) will assess the parasitologic outcomes for each of the participants. Those data will then 
be summarized by the subject’s study numbers and returned to the study statistician who will place the 
data in groups by study arm (retaining blindedness by using Arm 1 and Arm 2 to identify the study arm 
rather than AQ-13 and Coartem) before the data are tested for differences and presented to the DSMB.  
 
7.2.2  
Clinical Data  
Clinical assessments of study participants at the times of screening, inpatient studies and outpatient 
follow-up will be performed by Malian physicians (likewise blinded to the treatments the participants have 
received) using the Case Report Forms prepared for this study.  
 
Assessment of Clinical Outcomes  
Judgments about progression to severe or complicated malaria and the recurrence of uncomplicated 
malaria will be made by the Mali PI and a physician colleague (both blinded to the treatment the patient 
received) based on the CRFs and parasitologic data. As for the parasitologic data, those results will then 
be summarized by the subject’s study numbers and returned to the study statistician who will place the 
data in groups by study arm (retaining blindedness by using Arm 1 and Arm 2 to identify the study arm 
rather than AQ-13 and Coartem) before the data are tested for differences and presented to the DSMB. 
 
 
 


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8 
SAFETY ASSESSMENT AND REPORTING 
 
8.1 
Definition of an Adverse Event (AE) 
An adverse event (AE) is any adverse change in health or side-effect that occurs in a person participating 
in a clinical trial while the patient is receiving the treatment (study medication) or within a pre-specified 
period of time after their treatment has been completed (in this case, within 6 weeks or 42 days).  
 
8.2 
Definition of a Serious Adverse Event (SAE) 
An adverse event (AE) is serious and should be reported when the patient outcome is one or more of the 
following:  
• 
Death,  
• 
Life-threatening illness,  
• 
Requires an inpatient hospitalization or the prolongation of an existing hospitalization,   
• 
Results in persistent or permanent disability,   
• 
Is associated with a congenital anomaly or birth defect,   
• 
Requires intervention to prevent permanent impairment or damage. Serious AEs do not include 
treatment failure with recurrent parasitemia and uncomplicated malaria (i.e., failure to clear 
asexual parasites from the bloodstream within 7 days or recurrence within 42 days).  
 
8.3 
Definition of the Relatedness of AEs to DRUG TREATMENT  
Definitions to be used in assessing the relationship of the investigational product to the AE/SAE are: 
• 
Unknown: 
Use this category only if the cause of the AE/SAE is not possible to determine.  
 
• 
Not Related:   
The subject did not receive the investigational product, the temporal sequence of the AE/SAE onset 
relative to administration of the investigational product is not reasonable, or there is another obvious 
cause of the AE/SAE. 
 
• 
Unlikely (to be Related):   
There is no evidence of exposure to the investigational product or there is another more likely cause 
of the AE/SAE.  
 
• 
Possibly Related:  
There is evidence of exposure to the investigational product, the temporal sequence of the AE/SAE 
onset relative to administration of the investigational product is reasonable, but the AE/SAE could 
have been due to another equally likely cause.  
 
• 
Probably Related:  
There is evidence of exposure to the investigational product, the temporal sequence of the AE/SAE 
onset relative to administration of the investigational product is reasonable, and the AE/SAE is more 
likely explained by the investigational product than by any other cause.  
 
• 
Definitely Related:  
There is evidence of exposure to the investigational product, the temporal sequence of the AE/SAE 
onset relative to administration of the investigational product is reasonable, the AE/SAE is more likely 


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explained by the investigational product than by any other cause, and the AE/SAE shows a pattern 
consistent with previous knowledge of the investigational product or investigational product class.  
8.4 
Assessment of Adverse Events  
8.4.1 Detection of Adverse Events  
Detection of adverse events (AEs) will be based on twice daily interviews during the inpatient stay and on 
interviews during each of the outpatient visits. At these times, the physician will ask about common 
symptoms such as headache, dizziness, nausea and any other symptoms or signs patients may have. 
Please note that patient diaries (which were used during the Phase 1 studies in New Orleans) are unlikely 
to be useful (although they will be offered) because we expect that > 90% of the study participants will be 
illiterate.  
 
8.4.2 Assessment (Grading) of Adverse Events (AEs)   
Based on the information in the patient’s record and the Case Report Forms, the Mali PI and a physician 
colleague (blinded to the treatments that the patients have received) will grade the AEs observed and 
report those results by study number to the Study Statistician, who will provide those data to the DSMB 
grouped by study arm, but not identified in terms of which treatments the different study arms received.  
 
8.5 
Reporting Procedures 
Researchers participating in clinical trials must report all adverse events to the Food and Drug 
Administration (FDA) or the relevant regulatory authority in the country where the drug is to be registered. 
Serious AEs must be reported immediately; minor AEs are 'bundled' by the sponsor and submitted later. 
Specific reporting procedures are summarized below for:  
• 
Deaths – will be reported to the Medical Monitor, the Chair and other members of the DSMB, the 
Mali and Tulane IRBs and the FDA by phone within 24 hours of becoming aware of their 
occurrence and confirmed by E-Mail also within 24 hours of awareness of their occurrence.  
• 
Non-fatal serious AEs (regardless of their relationship to the study protocol) - will be reported to 
the Medical Monitor and the Chair of the DSMB via E-Mail within 72 hours after becoming aware 
of their occurrence.  
• 
Other Adverse Events (AEs) – AEs that do not result in death or life-threatening events, and are 
judged not to be serious will be accumulated (collated) as they occur and reported with annual and 
other regular reports to the Medical Monitor, Data Safety and Monitoring Board (DSMB), the Mali 
and Tulane IRBs and the FDA at regular intervals.  
 
8.5.1 Serious Adverse Event Detection and Reporting 
For events meeting the previously described definition of Serious Adverse Events, the completion of a 
Serious Adverse Event Form is required. Information on where to send this form is included in the Manual 
of Procedures for this study. All serious AEs will be followed through resolution by a study physician and 
reviewed by a Senior Investigator. Any AE considered serious by the PI or the Senior Investigator must be 
reported according to the guidelines on the Serious Adverse Event Form.  
 
8.5.2 Reporting of Pregnancy 
Please note that this section does not apply to this Proof of Concept Study for AQ-13 because enrollment 
in this study is restricted to males.  
 


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8.5.3 Procedures to be Followed in the Event of Abnormal Laboratory Test 
Values or Abnormal Clinical Findings 
New abnormalities in chemistry or hematology test results during or after treatment with AQ-13 or 
Coartem will be graded based on the recent FDA Guidance for Healthy Adult and Adolescent Volunteers 
in Preventive Vaccine Trials [25]. Because a number of subjects will have abnormal chemistry and 
hematology laboratory values at admission because of malaria, the presence of abnormal laboratory 
values at the time of admission) is not an exclusion from participation (unless those values require 
treatment), and the presence of abnormal laboratory values during treatment is an indication of an AE 
ONLY IF the initial laboratory values for that parameter were normal.  
 
8.5.4 Type and Duration of the Follow-up of Subjects after Adverse Events 
Mild AEs known to occur with both AQ-13 and malaria (e.g., headache, nausea, vomiting, myalgias, 
arthralgias) and other AEs will be followed daily until they have resolved and treated symptomatically as 
described in Table 2 on page 23 (acetaminophen for headache and for muscle and joint pains; 
antiemetics for nausea or vomiting).  
 
8.6 
Study Halting Rules  
Because of the limited numbers of subjects in this study (33 per study arm), halting rules based on 
statistical significance are likely to be of limited value. Therefore, the guidelines proposed below are 
based on the limited numbers of subjects likely to be evaluable and on the number, severity and 
relatedness of adverse events (AEs). If those guidelines are met for subjects in the arm receiving AQ-13, 
the enrollment of new subjects into the trial will be halted until the DSMB has had time to review the 
information available and thus to recommend whether the enrollment and treatment of adult Malian males 
who have uncomplicated malaria should continue with AQ-13 and Coartem in this study.  
 
Table 4.  
 
Temporary Halting Rules based on Adverse Events  
Number 
Severity of Adverse Event  
Relatedness to Drug 
Action(s) Taken 
1 or more 
Serious Adverse Event (SAE) 
Probably or Definitely  Temporary Halt for DSMB Review 
1 or more 
Grade 4 Adverse Event  
Probably or Definitely  Temporary Halt for DSMB Review 
2 or more 
Grade 3 Adverse Event 
Probably or Definitely 
Temporary Halt for DSMB Review 
 
Table 5.  
 
Temporary Halting Rules based on Efficacy (based on 15 subjects per study arm)  
Control Coartem Result 
(number of failures) 
AQ-13 Study Arm Result 
(number of failures) 
Action(s) Taken  
0 or 1 of 15 
0 or 1 of 15  
No action   
0 or 1 of 15 
2 or 3 of 15 
No action   
0 or 1 of 15 
4 or 5 (or more) of 15 
Temporary Halt for DSMB Review 


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In addition, summary data on efficacy (both blinded and separated by treatment group) will be presented 
to the DSMB at one pre-specified Interim Analysis for futility (after 15 patients have been enrolled in each 
treatment group/arm and have completed their follow-ups).   
8.7 
Data Safety and Monitoring Board  
Oversight of safety, accrual and – if necessary – efficacy will be provided by a Data Safety and Monitoring 
Board. We propose a data safety and monitoring plan similar to the one utilized for the Phase 1 Studies in 
New Orleans. This was initially a challenge because FDA, NIH and CDC decided that the DMSB should 
not include any Tulane investigators (because of potential conflicts of interest) and because all the 
investigators in New Orleans with malaria experience of whom we were aware were involved in this 
project. However, we were able to identify 5 individuals with relevant experience, who were willing to 
serve on the Phase 1 DSMB, and are willing to serve on the Phase 2 DSMB. Although we had planned to 
bring a number of investigators from overseas for this purpose, we were told on a previous review that 
FDA support would not be provided to cover travel expenses for a more international DSMB which had 
more experience with malaria and antimalarial drugs. For this reason, we have suggested that four 
members of the Phase 1 DSMB continue to serve on the Phase 2 DSMB. Please note that each member 
of the Phase 1 DSMB has gained substantial experience during their 6-8 years of service on the Phase I 
DSMB. Thus, they are today more knowledgeable about malaria and studies of antimalarials than they 
were more than 6-8 years ago when the Phase 1 Studies began. To accomplish the goal of effective 
monitoring while adding expertise, we have identified two investigators with extensive relevant experience 
(each indicated by an asterisk), who have agreed to serve with the members of the Phase 1 DSMB to 
monitor the Phase 2 Studies of AQ-13 in MALI. In addition, Professor Kéita (also marked with an asterisk) 
and Dr. Obinna Nnedu (who has worked on-site in Kenya) have been added because the DSMB was 
criticized because it had no investigators from malaria-endemic areas or with experience in malaria-
endemic areas.  
 
Table 6.  
 
 MEMBERS OF THE DSMB FOR THE PROOF OF CONCEPT STUDY FOR AQ-13  
 
George A. PANKEY, MD,  
Director of Research, Ochsner Clinic Foundation  
   Chair of DSMB 
 
   extensive background in infectious disease research  
John R. DAVID, MD *  
Millennium Project, Immunologic Studies of Tropical Disease,  
 
 
 
 
   Professor and Chair Emeritus, Tropical Public Health, Harvard SPH 
Mamadou M. KÉITA, MD * 
Professor and Chair Emeritus, Department of Pediatrics, Hôpital Gabriel 
   Touré and the Faculty of Medicine, University of Bamako, MALI  
Donald MERCANTE, PhD    Professor and Director of Biostatistics, LSU School of Public Health  
Adrienne MITCHELL   
Director, Clinical Research Unit, Xavier College of Pharmacy   
Obinna NNEDU, MD, MPH * Infectious Disease Physician, Ochsner Clinic Foundation   
Eve E. SLATER, MD * 
Former Senior Investigator and Vice President, Merck, Sharp and Dohme,  
 
 
 
 
   Assistant Secretary of Health in Health and Human Services (2002-03) 
 
 
 
 
   Associate Professor of Medicine, Columbia University  


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Emel SONGU-MIZE, PhD  
Professor of Pharmacology Emerita, LSU School of Medicine  


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9 
CLINICAL MONITORING STRUCTURE 
Monitoring will be performed before, during and after these studies and according to the guidelines 
provided by the E6 Good Clinical Practice document [24] to ensure that the:  
• 
Rights and welfare of the subjects are respected,  
• 
Data reported from the trial are accurate, complete and verifiable from source documents,  
• 
Conduct of the trial is consistent with the currently approved protocol amendments, with GCP and 
with applicable regulatory requirements.  
 
9.1 
Site Monitoring Plan 
Selection and Qualifications of Monitors.  
• 
Monitors will be appointed by the Sponsor,  
• 
Monitors will be appropriately trained so they have the scientific and clinical knowledge necessary 
to monitor the trial adequately,  
• 
Monitor’s qualifications will be documented.  
 
Extent and Nature of Monitoring.  
• 
Sponsor will determine the appropriate extent and nature of monitoring based on the objectives, 
purpose, design, complexity, blinding, size and endpoints of the trial,  
• 
Sponsor will then ensure that the trial is adequately monitored,  
• 
Monitoring will be performed before, during and after the trial,  
• 
Written documentation can support GCP training, meetings and investigators’ qualifications,  
• 
Statistically designed sampling will be used to select the data (specimens) to be verified.  
 
Monitor’s Responsibilities.  
The monitor should ensure that the trial is conducted and documented properly by:  
• 
Providing the main line of communication between the Sponsor and the Investigator,  
• 
Ensuring that the Investigators have adequate resources and that those resources remain 
adequate throughout the trial,  
• 
Ensure that the staff and facilities (laboratories and equipment) are adequate to conduct the trial 
and remain adequate throughout the trial,  
• 
Verify for the investigational product that:  
o 
Storage times and conditions are acceptable, and supplies are sufficient throughout the 
trial,  
o 
Investigational product is supplied only to subjects eligible to receive it and at protocol-
specified doses,  
o 
Subjects are provided with the necessary instructions on properly using, handling, storing 
and returning the investigational product,  
o 
Receipt, use and return of the investigational product at the trial sites is controlled and 
adequately documented,  


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o 
Disposition of unused investigational product at the trial sites complies with applicable 
regulatory requirements and the Sponsor’s authorized procedures,  
• 
Verify that the Investigators follow the currently approved protocol and amendments,  
• 
Verify that written informed consent was obtained before each subject’s participation in the trial,  
• 
Ensure that the Investigator receives the current Investigator’s Brochure and all documents and 
supplies to conduct the trial properly, and comply with applicable regulatory requirements,  
• 
Ensure that the Investigators and the Investigators’ trial staff are adequately informed about the 
trial,  
• 
Verify that the Investigators and the Investigators’ trial staff are performing the specified trial 
functions in accord with the protocol and other written agreements between the Sponsor and 
Investigator or Institution, and have not delegated those responsibilities to unauthorized 
individuals,  
• 
Verify that the Investigators are enrolling only eligible subjects,  
• 
Verify that the Investigators are reporting the recruitment rate,  
• 
Verify that source data and documents are accurate, complete, up-to-date and maintained,  
• 
Verify that the Investigators provide all required reports, notifications, applications and 
submissions, and that those documents are accurate, complete, timely, legible, dated and identify 
the trial,  
• 
Check the accuracy and completeness of CRF entries, source data and documents, and other 
trial-related documents against each other. The monitor should specifically verify that:  
o Data required by the protocol are reported accurately on the CRFs and are consistent with 
the source data and documents,  
o Any dose or treatment modifications are well-documented for each of the trial subjects,  
o AEs, concomitant medications and intercurrent illnesses are reported on the CRFs in 
accordance with the protocol,  
o Visits that subjects do not make, and tests and examinations that are not performed are 
clearly marked (so indicated) on the CRFs,  
o All withdrawals and dropouts from the trial are reported and explained on the CRFs.  
• 
Inform the Investigator about CRF entry errors, omissions or illegibility, The monitor should ensure 
that appropriate corrections (additions, deletions) are made, dated, explained (if necessary) and 
signed by the Investigator or an authorized [documented] member of their trial staff,  
• 
Determine whether all AEs are reported within the time periods required by GCP, ICH Guidance 
for Clinical Safety Data Management: Definitions and Standards for Expedited Reporting, the 
protocol, the IRB/IEC, Sponsor and applicable regulatory requirement,  
• 
Determine whether the Investigator is maintaining the appropriate documents (see Section 8. 
Essential Documents for the Conduct of a Clinical Trial),  
• 
Communicate deviations from the protocol, GCP, SOPs and applicable regulatory requirements to 
the Investigator and take appropriate actions to prevent recurrence of the detected deviations,  
 
Monitoring Procedures.  
The monitor(s) should follow the sponsor’s established written SOPs as well as the procedures specified 
by the sponsor for monitoring a specific trial.  
 


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Monitoring Report.  
• 
The monitor should submit a written report to the sponsor after each trial-site visit or trial-related 
communication. 
• 
Reports should include the date, site, name of the monitor, and names of the Investigators or 
other individuals contacted. 
• 
Reports should include a summary of what the monitor reviewed and the monitor's statements 
concerning the significant findings/facts, deviations and deficiencies, conclusions, actions taken or 
to be taken, and/or actions recommended to secure compliance. 
• 
The review and follow-up of the monitoring report by the sponsor should be documented by the 
sponsor’s designated representative. 
 
 
 
 
 


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10 
STATISTICAL CONSIDERATIONS 
 
10.1 
Study Outcome Measures 
The primary, secondary and tertiary objectives (Section 3, above) and outcome measures (Section 8, 
above) in this study will be assessed statistically as outlined below (Table 7).  
 
Table 7.   
 
Statistical Assessment of Study Endpoints   
COMPONENTS OF THE PRIMARY ENDPOINT 
STATISTICAL TESTS 
Lack of recrudescence at 42 days 
Pearson  2, Fisher Exact test 
< 25% of baseline asexual parasitemia on day 3 
Pearson  2, Fisher Exact test 
Clearance of asexual parasitemia and fever by day 7 
Pearson  2, Fisher Exact test 
 
  
SECONDARY ENDPOINTS 
 
Adverse Events (AEs)  
Pearson 2, Fisher Exact test 
Effects on the QT (QTc) Interval (within individuals) 
Wilcoxon, Friedman test 
Effects on the QT (QTc) Interval (between groups) 
ANOVA, Kruskal-Wallis test 
Pharmacokinetic Parameters for Parent Compounds (AUCt, t1/2, 
   Vd/F, Cl/F, MRT ) 
Mann-Whitney, Kruskal-Wallis 
 
Time to parasite Clearance, Recrudescence or Reinfection 
   (between groups) 
Kaplan-Meier, Cox Hazard 
 
Time to fever clearance (between groups)  
Kaplan-Meier, Cox Hazard 
 
TERTIARY ENDPOINTS 
 
Pharmacokinetics of metabolites  
as above 
Aminoquinoline (chloroquine) pruritus 
Fisher Exact test 
AUCt = total area under the curve; t1/2 = elimination half-life; Cl/F = oral clearance; Vd/F = oral apparent  
volume of distribution; MRT = mean residence time.  
 
10.2 Sample Size Considerations  
The proposed sample sizes are 33 per group for a total of 66 subjects in 2 treatment groups (one AQ-13 
group receiving 1596 mg orally + one Coartem control group) for this Proof of Concept Study of AQ-13 in 
adult Malian males ≥ 18 years of age with uncomplicated malaria (Flow Charts 2-3 on pages 16-17 and 
Flow Chart 4 on page 26).  
 
Because sample sizes vary markedly with the efficacy of the comparator, accurate estimation of the 
Coartem cure rate is a key issue. The sample sizes estimated were based on an expected efficacy (cure 
rate) of 95% for Coartem [20-22, 25-27] and a conservative 20% estimate of attrition after treatment . An 
expected cure rate of 95% has been used for Coartem because this estimate is at the lower end of the 
range of cure rates reported in the recent literature (93.9%, 95.5%, 97.1%, and 97.5%) [20-22, 36], and 
because it simultaneously recognizes recent concerns about in vivo selection by Coartem for the 86N 
allele of pfmdr1 in P. falciparum, which has the potential to further reduce the cure rate [37-38].  


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Another major factor is the width of the non-inferiority margin (M), the range within which the 
investigational drug is considered non-inferior to the comparator (control). We have used a value of M = 
15%. In the recent Guidance Document “Non Inferiority Clinical Trials” [Mar 2010], M equal to 40% of the 
efficacy of the positive control is stated to be a statistically persuasive result for phase III trials of drugs in 
general and elsewhere in this document it is stated that a non-inferiority margin of 50% for cardiovascular 
drugs is equivalent to a non-inferiority margin of 10-15% for antibiotics. From these statements, we infer 
that for a candidate antimalarial such as AQ-13, a non-inferiority margin of 10-15% would be statistically 
persuasive for a phase 3 trial, in which case this margin should also be sufficient for the present Phase 2 
Proof of Concept Efficacy Trial of AQ-13.  
 
With M=15%, a Coartem efficacy assumed to be 95% and a dropout rate up to 20%, a table from Machin 
and Campbell [Statistical tables for the design of clinical trials. Blackwell, Oxford: 1987, pp. 35-53] gives 
33 patients per group as a sample size [80% power] (an excerpt from that table is provided as Table 8). 
 
Table 8. 
Effects of the Margin and the Dropout Rate on Sample Sizes 
  necessary to test for Non-Inferiority of AQ-13 to Coartem 
 
 
Dropout Rate (percent) 
Non-Inferiority Margin 
 0% 
 10% 
 20% 
5% 
235 
261 
294 
7.5% 
104 
116 
130 
9% 
73 
81 
91 
10% 
59 
66 
74 
15% 
26 
29 
33 
20% 
15 
17 
19 
 
Although the sample size calculation was based on the primary endpoint of cure for all patients, based on 
studies we have performed in Mali previously, we expect that approximately 65% of the 26 evaluable 
subjects in each group will have CQ-resistant P. falciparum [35]. Therefore, subgroup analysis according 
to chloroquine susceptibility should make it possible to generate hypotheses about the efficacy of AQ-13, 
compared to Coartem, for subjects with either CQ-resistant or –susceptible parasites.  
 
10.3 Analysis Plan 
This is a Proof of Concept Efficacy Study of AQ-13 in comparison to the gold standard (Coartem). Thus, 
this study in adult Malian males can be viewed as a non-inferiority study, comparing one dose of AQ-13 
(1596 mg orally over 3 days) to Coartem [39].  
 
The null and alternative hypotheses to be tested are:   
 
 
H0 = (C – E)  ≥ M 
(control is superior to experimental) 
 
H1 = (C – E)  < M 
(experimental is not inferior to control)  


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C is the efficacy of the comparator (Coartem), E the efficacy of the investigational drug (AQ-13) and M  
the non-inferiority margin. M = 15% will be used (see above). AQ-13 will be considered equivalent to (not 
inferior to) the comparator (Coartem) if the null hypothesis is rejected with a one-sided alpha of 0.025 [29, 
40]. Cure rates, adjusted for reinfection, will be calculated for AQ-13 and Coartem and differences 
between cure rates with AQ-13 and Coartem will be calculated with 95% confidence intervals. Non-
inferiority of AQ-13 will be established if the upper limit of the 95% CI for the difference between AQ-13 
and Coartem is less than the non-inferiority margin of 15% [28-29].  
 
Analyses will be performed based on both the original randomization (intent-to-treat, ITT) and the subset 
of patients who complete the study protocol, for whom complete information is available (per-protocol 
analysis). Paradoxically, intent-to-treat (ITT) analysis poses a special problem in non-inferiority trials. ITT 
is in fact a non-conservative approach in non-inferiority trials because the inclusion of non-compliant 
subjects and dropouts dilutes the differences between treatments and therefore, favors the conclusion 
that the drugs are equivalent [39]. However, we expect the differences between ITT and per-protocol 
analyses will be small because drug administration under direct observation should reduce 
noncompliance to very low levels. Nevertheless, every effort will be made to obtain follow-up data on non-
compliant subjects and subjects who drop out because of adverse events (AEs). In contrast, excluding 
subjects with protocol “violations” (per-protocol analysis) can bias the analysis toward concluding 
equivalence of the two drugs. This would be the case if drop outs from the investigational treatment were 
related to non-response (treatment failure). Thus, excluding those dropouts from the per-protocol analysis 
could inflate the efficacy estimate for the investigational drug and lead to an inappropriate conclusion of 
non-inferiority. Careful examination of the data from subjects who are excluded from the analysis helps to 
detect such bias and facilitates the correct interpretation of trial results.  
 
Times to recrudescence and reinfection will be analyzed using life tables, and compared using the log 
rank test. Cox regression will be used to compare multiple (multivariate) predictors of times to 
recrudescence and reinfection. Pharmacokinetic parameters will be examined for AQ-13 doses and 
compared to data from the Phase 1 studies, as appropriate. Using the same protocol as in the Phase 1 
study [11], the relatedness of adverse events (AEs) to study drugs will be classified independently 
by two blinded physicians according to the definitions in section 8.3 on page 30 as unknown, not 
related, unlikely to be related, or possibly, probably or definitely related to the study drugs, based 
on temporal relationships and biological plausibility. The frequencies of AEs will be compared 
between AQ-13 and Coartem using Pearson Chi-square. Because more than one AE may occur in an 
individual patient, the proportion of patients receiving AQ-13 with AEs will be compared with Coartem 
using Chi-square or the Fisher Exact test. The severity of AEs will be classified using the recent FDA 
Guidance for Healthy Adult and Adolescent Volunteers in Preventive Vaccine Trials [23], and the severity 
of AEs across the study arms will be compared using Chi-square. QT interval corrections for heart rate 
(QTc) will be made using both Bazett’s and Fridericia’s formulas [41-42]. Within-patient maximum 
changes from baseline will be assessed using the Wilcoxon test for paired observations. Between-group 
QT interval changes will be compared using ANOVA or Kruskal-Wallis.  
 
HYPOTHESES BEING TESTED.     
The primary hypothesis is that the efficacy of AQ-13 for uncomplicated P. falciparum malaria is similar to 


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that of Coartem - based on a non-inferiority margin of 15%. That is, that AQ-13 will produce a cure rate     
       within 15% of the Coartem control (standard). The secondary hypothesis is that AQ-13 will have 
safety profiles in subjects with uncomplicated malaria comparable to those for AQ-13 in healthy volunteers 
[11].  
 
 
EXPECTED OUTCOMES.   
Our preliminary (previous) studies have shown that AQ-13 is:  
• 
active in vitro against CQ-resistant and multi-resistant P. falciparum [8-9],  
• 
active in vivo against CQ-resistant P. falciparum in the squirrel monkey model of human infection 
with CQ-resistant P. falciparum (enclosed Figures 1 and 2 in the Appendix), and  
• 
safe in human subjects based on Phase 1 studies recently performed in New Orleans [11].  
 
Therefore, we expect this Proof of Concept Study of AQ-13 in adults will demonstrate that AQ-13 is:   
• 
efficacious for the treatment of human subjects with uncomplicated P. falciparum malaria – i.e., 
that the efficacy of AQ-13 will be similar to that of Coartem, and  
• 
safe – i.e., that the adverse events (AEs) observed with AQ-13 will be similar to those of Coartem 
in these studies, as  they were to CQ in the Phase 1 studies of AQ-13 and CQ [11].  
 
10.4 RANDOMIZATION  
Randomization of individual subjects will be performed after screening is complete, signed informed 
consent has been obtained, and the inclusion and exclusion criteria have been satisfied and reviewed. 
Randomization to the 2 treatments (study arms) will involve permuting blocks of 4 and 6 with a random 
number generator [11]. Only the pharmacist will have access to the computer generated form.  
 
 


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11 
 ACCESS TO SOURCE DATA/DOCUMENTS 
 
Access to Source Data and Documents for Study Forms and other Record-Keeping will be provided 
both electronically and in hard copy. Electronic access will be provided via a password-protected WEB 
Site portal (Box.com) which will be used to post and retain both original and amended versions of study 
protocols such as Case Report Forms, Standard Operating Procedures, Equipment Maintenance and 
Performance Records and Investigator Training and Job Description records. Please note that the WEB 
Site Portal with the source data and documents for this study will be hosted in a cloud which has full back-
up and is therefore protected against power failures, hurricanes, fire and other potential local catastrophes 
that could occur at either site.  
 
Access to Source Data/Documents for Participant-based Information (patient records). In contrast, 
patient records (for screening, informed consent, the inpatient stay and outpatient follow-up) will not be 
posted on the WEB Portal. However, they will be available in electronic format after scanning for review 
by authorized individuals under controlled conditions (on designated password-protected 
microcomputers).  
 
Data and Document Storage. Electronic records will be stored on a dedicated server at the University of 
Bamako with duplicate electronic files maintained on a separate server at Tulane in New Orleans. Hard 
copies of forms and patient records will be maintained and available for review at one site in Bamako: in 
the Clinical Research Center at the Faculty of Medicine (Hôpital Point G). Hard copies of patient records 
will be kept under lock and key (in locked cabinets within rooms that have doors with locks); electronic 
copies of patient records will be protected (in both Mali and New Orleans) by storage in password-
protected files within password-protected computers. Patient files will be organized by the subject’s study 
number; the document linking study ID numbers to patient names will be stored under lock and key with 
the PI, the Mali PI and the Study Monitor (3 hard copies).  
 
Case Report Forms will be maintained in individual folders (one folder for each type [category] of Case 
Report Form) on the Box.com WEB Site and will therefore be accessible to all investigators participating 
in this study. Each revision of a Case Report Form will be identified by the date on which it was approved, 
and each folder will have a chronologic record of revisions, which will be entered as they are posted and 
implemented and beginning with the date of implementation.  
  
Standard Operating Procedures will likewise be maintained in individual folders (one folder for each 
Standard Operating Procedure [SOP], e.g., for Hb determinations and PCR). As with the Case Report 
Forms, both the original and revised versions of each SOP will be available via the SharePoint WEB Site. 
Likewise, each SOP folder will have a chronologically-organized record of the revisions of that SOP, 
including the dates on which they were posted and implemented.  
 
Equipment Inventory, Maintenance and Performance will likewise be recorded for each of the 
instruments that will be used for these studies. During these studies, those forms (records) will be updated 
at least once every 3 months (quarterly), and modified on Box.com WEB Site as new information 
becomes available. Hard copies of these forms will be available at two sites in Mali: the Faculty of 


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Medicine (Clinical Research Center at the Hôpital Point G) and the Faculty of Science of the University of 
Bamako.  
Investigator Training, Job Descriptions and Responsibilities will be documented in hard copy and in 
electronic format for each of the investigators participating in these studies. Electronic copies of these 
records will be available on the Google Apps WEB Portal; the hard copies will be available at two sites in 
Mali: the Faculty of Medicine (Clinical Research Center at the Hôpital Point G) and at the Faculty of 
Science of the University of Bamako.  
 
The Manual of Procedures for these studies will also be available in electronic form on the Box.com 
WEB Site and in hard copy at two sites in Mali: the Faculty of Medicine (Clinical Research Center at the 
Hôpital Point G) and at the Faculty of Science of the University of Bamako.  
 
Individual Participant Records and Files will be available in hard copy under lock and key in a locked 
room at the Faculty of Medicine (Clinical Research Center at the Hôpital Point G) which is part of the 
University of Bamako. Electronic versions of these records (Adobe Acrobat pdf versions of participant 
records and files) will be available, but will not be posted on the Box.com WEB Site because of concerns 
about patient confidentiality. Identifying information in the hard copies and electronic copies of these files 
will be limited to participants’ study ID numbers and initials because of concerns about patient 
confidentiality.  
 
 


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12 
QUALITY CONTROL AND QUALITY ASSURANCE 
 
• 
The sponsor is responsible for implementing and maintaining quality assurance and quality control 
systems with written SOPs to ensure that trials are conducted and data are generated, 
documented (recorded) and reported in compliance with the protocol, GCP, and the applicable 
regulatory requirement(s). 
• 
The sponsor is responsible for securing agreement from all involved parties to ensure direct 
access (see section 1.21) to all trial-related sites, source data/documents, and reports for the 
purpose of monitoring and auditing by the sponsor, and inspection by domestic and foreign 
regulatory authorities.  
• 
Quality control should be applied to each stage of data handling to ensure that all data are reliable 
and have been processed correctly.  
• 
Agreements, made by the sponsor with the investigator/institution and/or with any other parties 
involved with the clinical trial, should be in writing, as part of the protocol or in a separate 
agreement.  
 
These goals will be accomplished using two complementary methods:  
  1] 
by the random selection of a fraction of specimens for blind retesting (without their original 
identification) for all procedures, and is described in the relevant SOPs. The fraction of specimens 
selected for blind retesting will initially be 10% and will then decrease to 5% as reproducibility 
increases and coefficients of variation decrease (reproducibility).   
  2] 
by participating in quality control testing programs that distribute unknown specimens for testing 
by participating laboratories at overseas sites (accuracy).  
 


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13 
ETHICS/PROTECTION OF HUMAN SUBJECTS 
 
13.1 Declaration of Helsinki 
The investigator will ensure that this study is conducted in full conformity with the current revision of the 
Declaration of Helsinki, or with the International Conference for Harmonisation Good Clinical Practice 
(ICH-GCP) regulations and guidelines, whichever affords the greater protection to the subject.  
 
13.2 Institutional Review Board 
Each participating institution must provide for the review and approval of this protocol and the associated 
informed consent documents and recruitment material by an appropriate independent ethics review 
committee (IEC) or Institutional Review Board (IRB) registered with OHRP.  Any amendments to the 
protocol or consent materials must also be approved before they are placed into use. In both the United 
States and in other countries, only institutions holding a current U. S. Federal-Wide Assurance issued by 
OHRP may participate. Refer to: http://ohrp.osophs.dhhs.gov. 
 
13.3 Informed Consent Process 
Informed consent is a process that is initiated prior to the individual’s agreeing to participate in the study 
and continues throughout the individual’s study participation. Extensive discussion of risks and possible 
benefits of participation in this study will be provided to the subjects and their families. Consent forms 
describing in detail the study procedures and risks are given to the subject and written documentation of 
informed consent is required prior to enrolling in the study. Consent forms will be IRB-approved. Literate 
subjects will be asked to read and review the document. Illiterate subjects will receive oral presentations 
of the content of consent document by study staff in their native Bambara language. Upon reviewing the 
document, the investigator or their staff will explain the research study to the subject and answer any 
questions that may arise. The subjects will sign the informed consent document prior to being enrolled in 
the study. The subjects should have the opportunity to discuss the study with their surrogates and think 
about it prior to agreeing to participate. The subjects may withdraw consent at any time throughout the 
course of the study. A copy of the informed consent document will be given to the subjects for their 
records. The rights and welfare of the subjects will be protected by emphasizing to them that the quality of 
their medical care will not be adversely affected if they choose not to participate in this study.  
  
13.3.1 Informed Consent/Assent Process (in Case of a Minor or others 
unable to consent for themselves) 
Not Applicable. This study will enroll only adult Malian males ≥ 18 years of age.  
 
13.4 Exclusion of Women, Minorities, and Children (Special 
Populations) 
Minorities will not be excluded from these studies. Because Mali is in sub-Saharan Africa, all the 
subjects recruited will be minorities by U.S. criteria (African).  
 


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In contrast, both adult women and children will be excluded from these studies. The rationale for 
excluding children from these initial Phase 2 dose-finding efficacy studies of AQ-13 is to ensure that the 
doses of AQ-13 proposed for use in children (10 or 15 mg base per kg daily x 3 days, based on scaling 
down the mg base per kg doses from the doses used in adults) do not have untoward or unexpected 
effects in adults before they are tested in children for the treatment of uncomplicated malaria. The 
rationale for excluding women from this Proof of Concept Study for AQ-13 is to ensure that adult women 
volunteers who volunteer to participate and commit to contraception do not inadvertently become 
pregnant while receiving AQ-13 or shortly thereafter.  
 
13.5 Subject Confidentiality 
Subject confidentiality is held strictly in trust by the participating investigators, their staff, and the 
sponsor(s) and their agents. This confidentiality is extended to cover testing of biological samples and 
genetic tests, in addition to the clinical information relating to participating subjects. As noted above and 
in the consent form, participants will be identified in hard copies and electronic copies of case 
report forms and other patient records by their initials and study ID numbers, but not by name.  
 
The study protocol, documentation, data and all other information generated will be held in strict 
confidence.  No information concerning the study or the data will be released to any unauthorized third 
party without prior written approval of the sponsor.  
 
The study monitor or other authorized representatives of the sponsor may inspect all documents and 
records required to be maintained by the Investigator, including but not limited to, medical records (office, 
clinic or hospital) and pharmacy records for the subjects in this study.  The clinical study site will permit 
access to such records. 
 
13.6 Future Use of Stored Specimens 
As noted above and in the consent form, residual specimens will be held for a minimum of three 
years after the study is complete to permit repeat testing as necessary. As also noted in the 
consent, participants have the option to withdraw their consent at any time, which includes the 
withdrawal and removal of their specimens if they so choose. Specimens will be maintained at the 
University of Bamako in Mali and at Tulane University in New Orleans. As also noted in the consent, 
participants are asked to consent to genetic studies of the parasites in their blood and of the genes 
responsible for the metabolism of drugs such as AQ-13 and the host immune response to uncomplicated 
malaria. As with other data, that testing will be performed with specimens identified only by the 
participant’s study ID number.  
 
 


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14 
DATA HANDLING AND RECORD KEEPING 
The steps noted below will be taken to assure that the data collected are accurate, consistent, complete,  
reliable and in accordance with ICH GCP guidelines and 21 CFR Part 11. Included below are references 
to source documentation, case report forms, data handling procedures and procedures for data 
monitoring. Details may be provided in a Manual of Procedures, User’s Guide or other citable reference 
document. Refer to: http://www.fda.gov/ora/compliance_ref/part11/ 
 
14.1 Data Management Responsibilities  
The responsibilities for data handling and record keeping as they relate to the sponsor, clinical site, 
laboratory and data coordinating center are outlined in Table 9, below. This information includes the roles 
of groups and individuals in data collection, review of data, study materials and reports and the retention 
of source documents, files and records. At the conclusion of the study, a copy of all data sets will be 
provided to DMID, FDA, the Mali Ministry of Health and other participating federal and international 
agencies. These data sets will be sent by the Information Technology director for this project, Ayouba 
Diarra, at the Faculty of Science of the University of Bamako.  
 
All source documents and laboratory reports will be reviewed by the clinical team and data entry staff in 
order to ensure they are accurate and complete. Adverse Events will be graded, assessed for severity 
and causality, and reviewed by the Principal Investigator and co-investigators (who will be blinded to the 
treatment arms to which the subjects were assigned).  
 
Table 9.  
 
Overview of Data Management Responsibilities  
 
Data Management 
Clinical Information 
Clinical Lab Data 
Holters  
Molecular Results 
Data Collection 
(Source Documents) 
Screening, Enrollment 
CRFs and scans  
Clin- Laboratory  
Data Printouts  
Screen, Enroll,   
Holter reports 
Initial & Follow-Up 
Lab reports  
Data Review  
as CRFs (StudyTRAX) Printouts & CRFs Holter reports 
Lab rep’s & CRFs 
Data Entry, Cleaning Bamako, StudyTRAX   
Bamako, Tulane  
Bamako  
Bamako 
Data Storage (source 
docs, electronic)  
Bamako, Tulane  
Bamako, Tulane 
Bamako, Tulane  Bamako, Tulane 
Initial Summary 
Epidemiol, Mali PI 
Epidemio, Mali PI Cardiol Point G 
Faculty of Science 
Initial Data Review 
Biostat, Clin Monitor 
Clinical Monitor 
Cardiol Mali 
Mali PI 
Additional Review 
Tulane 
Tulane 
Cardiol Tulane 
Sequence data 
Evaluation, Grading  
of Adverse Events 
PI, colleagues blind  
to treatment arm  
PI, others blind to 
treatment arm 
PI and Tulane 
Cardiology 
Interpretation 
of 
recurrent infections 
Reports  
PI, Sponsor 
PI, Sponsor 
PI, Sponsor 
PI, Sponsor  
Long-term Storage 
Hard copy, electronic 
Mali and U.S.  
Mali and U.S.  
Mali and U.S.  
 
14.2 Data Capture Methods 
Data capture methods will begin with hard copy source documents such as Case Report Forms (CRFs) 
which will be entered into the data base (StudyTRAX forms for the AQ-13 Proof of Concept Study) after 


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they have been reviewed for accuracy by the Data Manager and Clinical Monitor. This approach will also 
be used for the clinical forms (Screening, Enrollment and Follow-Up) and for the clinical laboratory forms 
(Screening, Enrollment and Follow-Up). For other types of data (Holter recordings, molecular results - see 
section 14.3, below), the original records will be retained and used as source documents at the time of 
data entry, rather than case report forms (CRFs). The expectation is that data from CRFs and other 
source documents will be entered within 2 weeks after they have been obtained and reviewed.  
 
14.3 Types of Data 
The types of data that will be collected in this Phase 2 Proof of Concept Efficacy Study include:  
Clinical and Historical Data during the processes of screening, enrollment and follow-up (CRFs; 
StudyTRAX),  
Physical Examination information from the times of screening, enrollment and follow-up (CRFs, 
StudyTRAX),  
Clinical Laboratory information from the times of screening, enrollment and follow-up (CRFs; StudyTRAX),  
Electrocardiograms and Holter recordings from the times of screening, enrollment, dosing and follow-up 
(CRFs, Rozinn Holter Monitoring System),  
Molecular results in terms of ApoI endonuclease cleavage and sequence data for the chloroquine 
resistance locus (positions 72-76 of pfcrt – CRFs and reports of sequence data).  
 
14.4 Timing of Reports 
For this abbreviated Phase 2 Proof of Concept Efficacy Study, there will be two reports. The first report 
will be provided after 15 subjects have been enrolled in each of the two arms of the protocol (AQ-13 and 
Coartem) and have completed their follow-ups (Interim Analysis for Futility – section 8.6 of this protocol on 
page 32). The second report (Final Analysis for Efficacy, Adverse Events and Pharmacology) will be 
provided after 18 additional subjects have been enrolled in each arm (total of 66 subjects) and have 
completed their follow-ups.  
 
14.5 Study Records Retention 
Records and specimens will be maintained (stored under protected conditions) for the duration of the 
study and a minimum of three years thereafter to permit repeat testing and re-examination as necessary. 
At that time, both records and specimens will be destroyed if there is no further need for them.  
 
14.6 Protocol Deviations 
Information about potential deviations from the study protocol will be sought by the Clinical Monitor (who 
will visit the sites of inpatient and outpatient follow-up weekly during the course of this study), the director 
for Information Technology, the Clinical Coordinator, the Mali PI and his colleagues (again based on 
weekly follow-up visits) and the PI. Information about protocol deviations will be summarized monthly 
during the course of these studies and reported each month (within 5 days) to the Mali PI and the study PI 
and sponsor.  
 
 


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15 
PUBLICATION POLICY 
 
Following completion of the study, the investigator may publish the results of this research in a scientific 
journal.  The International Committee of Medical Journal Editors (ICMJE) member journals have adopted 
a trials-registration policy as a condition for publication. This policy requires that all clinical trials be 
registered in a public trials registry such as ClinicalTrials.gov, which is sponsored by the National Library 
of Medicine. Other biomedical journals are considering adopting similar policies. It is the responsibility of 
DMID to register this trial in an acceptable registry. Any clinical trial starting enrollment after 01 July 2005 
must be registered either on or before the onset of patient enrollment. For trials that began enrollment 
prior to this date, the ICMJE member journals will require registration by 13 September 2005 before 
considering the results of the trial for publication.  
 
The ICMJE defines a clinical trial as any research project that prospectively assigns human subjects to 
intervention or comparison groups to study the cause-and-effect relationship between a medical 
intervention and a health outcome. Studies designed for other purposes, such as to study 
pharmacokinetics or major toxicity (e.g., Phase 1 trials), would be exempt from this policy. 
 


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16 
LITERATURE REFERENCES 
 
1. 
Sibley CH, Barnes KI, Plowe CV: The rationale and plan for creating a World Antimalarial 
Resistance Network (WARN). Malaria J 2007; 6: 118.  
2. 
Breman JG: Eradicating malaria. Science Progress 2009; 92(Part 1): 1-38.  
3. 
Farooq U, Mahajan RC: Drug resistance in malaria. J Vector-Borne Dis 2004; 41(3-4): 45-53.  
4. 
Dondorp AM, Nosten F, Yi P, Das D, Phyo AP, Tarning J, Lwin KM, Ariey F, Hanpithakpong W, 
Lee SJ, Ringwald P, Silamut K, Imwong M, Chotivanich K, Lim P, Herdman T, An SS, Yeung S, 
Singhasivanon P, Day NF, Lindegardh N, Socheat D, White NJ: Artemisinin resistance in 
Plasmodium falciparum malaria. N Engl J Med 2009; 361(5): 455-467.  
5. 
Noedl H, Socheat D, Satimai W: Artemisinin-resistant malaria in Asia. N Engl J Med 2009; 361(5): 
540-541.  
6. 
Trape J-F: The public health impact of chloroquine resistance in Africa. Am J trop Med Hyg 2001; 
64(1-2Suppl): 12-17.  
7. 
Trape JF, Pison G, Preziosi MP, Enel C, Desgrees du Lou A, Delaunay V, Samb B, Lagarde 
E, Molez JF, Simondon F: Impact of chloroquine resistance on malaria mortality. CR Acad Sci 
1998; 321(8): 689-697.  
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De D, Krogstad FM, Cogswell FB, Krogstad DJ:  Aminoquinolines that circumvent resistance in P. 
falciparum in vitro. Am J Trop Med Hyg 1996; 55(6): 579-583.  
9. 
De D, Krogstad FM, Byers LD, Krogstad DJ: Structure-activity relationships (SARs) for 
antiplasmodial activity among 7-substituted-4-aminoquinolines. J Med Chem 1998; 41(25): 4918-
4926.    
10. 
Hocart SJ, Liu H, Deng H, De D, Krogstad FM, Krogstad DJ: 4-Aminoquinolines active against 
chloroquine-resistant Plasmodium falciparum: Basis of antiparasite activity and quantitative 
structure-activity relationship analyses. Antimicrob Agents Chemother 2011; 55(5): 2233-2244.  
11. 
Mzayek F, Deng H, Mather FJ, Wasilevich EC, Liu H, Hadi C, Chansolme DH, Murphy HA, Melek 
BH, Tenaglia AN, Mushatt DM, Dreisbach AW, Lertora JJL, Krogstad DJ: Randomized controlled 
trial of AQ-13, a candidate antimalarial, and chloroquine. PLoS Clin Trials 2007; 2(1): e6.    
12. 
Bojang K, Milligan P, Pinder M, Doherty T, Leach A, Ofori-Anyinam O, Lievens M, Kester K, 
Schaecher K, Ballou WR, Cohen J: Five-year safety and immunogenicity of GlaxoSmithKline's 
candidate malaria vaccine RTS,S/AS02 following administration to semi-immune adult men living 
in a malaria-endemic region of The Gambia. Human Vaccines 2009; 5(4): 242-247.  
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Tsega E:  Long-term effect of high-dose, short-course chloroquine therapy on porphyria cutanea 
tarda.  Quart J Med 1987; 65: 953-957.  
14. 
Sanders AM:  A review of controlled clinical trials examining the effects of antimalarial compounds 
and gold compounds on radiographic progression in rheumatoid arthritis.  J Rheumatol 2000; 27: 
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Cissé M, Suzanne M, Krogstad DJ: Susceptibility of Plasmodium falciparum to chloroquine in the 
malaria-endemic village of Missira in Mali using the WHO in vivo test and sequencing. Abstract 
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SUPPLEMENTS/APPENDICES 
PREVIOUSLY CITED MANUSCRIPTS THAT ARE PROVIDED:  
De D, Krogstad FM, Cogswell FB, Krogstad DJ: Aminoquinolines that circumvent resistance in 
Plasmodium falciparum in vitro. Am J Trop Med Hyg 1996; 55(6): 479-583.  
 
De D, Krogstad FM, Byers LD, Krogstad DJ: Structure-activity relationships for antiplasmodial 
activity among 7-substituted 4-aminoquinolines. J Med Chem 1998; 41(25): 4918-4926. 
 
Lakshmanan V, Bray PG, Verdier-Pinard D, Johnson DJ, Horrocks P, Muhle RA, Alakpa GE, 
Hughese RH, Ward SA, Krogstad DJ, Sidhu ABS, Fidock DA: A critical role for PfCRT K76T 
in Plasmodium falciparum verapamil-reversible chloroquine resistance. EMBO J 2005; 
24(13): 2294-2305.  
 
Deng H, Liu H, Krogstad FM, Krogstad DJ: Sensitive fluorescence HPLC assay for AQ-13, a 
candidate antimalarial that also detects chloroquine and N-dealkylated metabolites. J 
Chromatogr B 2006; 833(2): 122-128.  
 
Colborn JM, Koita OA, Cissé O, Bagayoko MW, Guthrie E, Krogstad DJ: Identifying and quantifying 
genotypes in polyclonal infections due to single species.  Emerg Infect Dis 2006; 12(3): 475-
482.  
 
Mzayek F, Deng H, Mather FJ, Wasilevich EC, Liu H, Hadi C, Chansolme DH, Murphy HA, Melek 
BH, Tenaglia AN, Mushatt DM, Dreisbach AW, Lertora JJL, Krogstad DJ: Randomized 
controlled trial of AQ-13, a candidate antimalarial, and chloroquine. PLoS Clin Trials 2007; 
2(1): e6.    
 
Londono BL, Eisele TP, Keating J, Bennett A, Chattopadhyay C, Heyliger G, Mack B, Rawson I, 
Vely J-F, Désinor O, Krogstad DJ: Chloroquine-resistant haplotype Plasmodium falciparum 
parasites, Haiti. Emerg Infect Dis 2009; 15(5): 735-740.  
 
Krogstad DJ, Diop S, Diallo A, Mzayek F, Keating J, Koita OA, Touré YT: Informed consent in 
international research: the rationale for different approaches. Am J Trop Med Hyg 2010; 
83(4): 743-747.  
 
Hocart SJ, Liu H, Deng H, De D, Krogstad FM, Krogstad DJ: 4-Aminoquinolines active against 
chloroquine-resistant Plasmodium falciparum: basis of antiparasite activity and quantitative 
structure-activity relationship analyses. Antimicrob Agents Chemother 2011; 55(5): 2233-
2244.  
 
FIGURES PROVIDED FROM THE INITIAL IND SUBMISSION:  
Figures 1 and 2 illustrating the effect of AQ-13 on P. cynomolgi in the rhesus monkey model of 
human P. vivax infection and on the CQ-resistant Indochina I strain of P. falciparum from 
page 15 of the Initial IND Submission in April 1998.  


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STANDARD OPERATING PROCEDURES (submitted January 2010): 
AQ-13 HPLC ASSAY: CALCULATING AQ-13 AND METABOLITE CONCENTRATIONS. Deng H, 
Krogstad DJ: Drafted Dec 8, 2009; Last revision Jan 23, 2010.  
AQ-13 HPLC ASSAY: EXTRACTING (PREPARING) WHOLE BLOOD AND URINE SAMPLES. 
Deng H, Krogstad DJ: Drafted Dec 5, 2009; Last revision Jan 23, 2010.   
AQ-13 HPLC ASSAY: FLUORESCENCE HPLC ASSAY FOR AQ-13 AND ITS METABOLITES. 
Deng H, Krogstad DJ: Drafted Dec 4, 2009; Last revision Jan 5, 2010.  
CENTRIFUGATION OF BLOOD AND RED CELL SUSPENSIONS. Sangaré L, Koita OA: Drafted 
Oct 30, 2009; Last revision Jan 23, 2010.  
CLEANING (PREPARING) SLIDES FOR MALARIA BLOOD SMEARS. Sangaré L, Koita OA: 
Drafted Oct 30, 2009; Last revision Jan 23, 2010.  
COULTER ACT 10 HEMATOLOGY ANALYZER. Sangaré L, Koita OA: Drafted Oct 30, 2009; Last 
revision Jan 23, 2010.   
CRYOPRESERVATION (FREEZING) OF MALARIA PARASITES. Sangaré L, Koita OA: Drafted 
Oct 30, 2009; Last revision Nov 5, 2009.  
DATA ACQUISITION, TRANSFER AND STORAGE. Diarra A, Koita OA: Drafted Dec 29, 2009; 
Last revision Jan 23, 2010.  
DNA ELECTROPHORESIS IN AGAROSE. Sangaré L, Koita OA: Drafted Oct 30, 2009; Last 
revision Jan 23, 2010.  
DNA EXTRACTION FROM FILTER PAPER BLOTS. Sangaré L, Koita OA: Drafted Oct 30, 2009; 
Last revision Jan 23, 2010.  
DNA QUANTITATION BY SPECTROPHOTOMETRY. Sangaré L, Koita OA: Drafted Nov 2, 2009; 
Last revision Jan 23, 2010.  
G6PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE) TESTING. Sangaré L, Koita OA: Drafted 
Jan 6, 2010; Last revision Jan 7, 2010.  
HEMOCUE RAPID HB DETERMINATION. Sangaré L, Koita OA: Drafted Oct 30, 2009; Last 
revision Jan 5, 2010.  
PCR (POLYMERASE CHAIN REACTION) AMPLIFICATION OF DNA. Sangaré L, Koita OA: 
Drafted Nov 2, 2009; Last revision Jan 23, 2010.  
PICCOLO CHEMISTRY ANALYZER. Sangaré L, Koita OA: Drafted Nov 2, 2009; Last revision Jan 
23, 2010.  
PREGNANCY TESTING. Sangaré L, Koita OA: Drafted Nov 2, 2009; Last revision Jan 5, 2010.  
RNA EXTRACTION. Sangaré L, Koita OA: Drafted Oct 30, 2006; Last revision Jan 23, 2010.  
STORAGE OF BIOLOGICAL SPECIMENS. Sangaré L, Koita OA: Drafted Oct 30, 2009; Last 
revision Jan 23, 2010.  
THICK SMEARS, THIN SMEARS AND FILTER PAPER BLOTS. Sangaré L, Koita OA: Drafted Oct 
30, 2009; Last revision Jan 5, 2010.  
 
 
 
 


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Appendix A: Study Schedule  
 
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This information is provided in the Study Proposal, particularly in Section 6 (Screening and Study 
Procedures), which has a flow chart on screening and first week of inpatient studies (Flow Chart 4, 
page 20) and a color-coded Gantt Chart on page 21, which provides an overview of the entire 42 
day study period. In addition, an initial overview is provided in Flow Chart 1 (page viii), and flow 
charts describing the screening (Flow Chart 2) and inpatient drug administration and outpatient 
follow-up (Flow Chart 3) are provided on pages 11 and 12.  
 
Material provided in tabular form includes information about the estimation of sample size (Table 1 
on page 6), the persons on the Data Safety and Monitoring Board (Table 2, page 9), medications 
used in Mali for supportive care of persons with malaria in Mali – Permissible Concomitant 
Medications (Table 2, page 16), an overview of the Study Schedule (Table 3, page 17), a list of 
blood samples to be drawn during week one for the pharmacokinetic studies of AQ-13 and its 
metabolites – Week One Blood Sampling Schedule for AQ-13 Drug and Metabolite Levels (Table 5, 
page 20) and a table on the Statistical Assessment of Study Endpoints (Table 6, page 28).