Clinical trial NCT01961921
Conditions: TTR-mediated Amyloidosis
Keywords: RNAi therapeutic
Sponsor: Alnylam Pharmaceuticals
Start date: 2013-10-01; Completion date: 2016-08-01
Enrollment: 27 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
The purpose of this study is to evaluate the safety and tolerability of long-term dosing with ALN-TTR02 (patisiran) in patients with transthyretin (TTR) mediated amyloidosis (ATTR).

Detailed description:

Arms: arm 1: None
Interventions: intervention 1: ALN-TTR02 (patisiran) administered by intravenous (IV) infusion
Intervention descriptions: intervention 1: None

Protocol documents:
Prot_000.pdf: 
 
 
Official Title: 
  
A Phase 2, Multicenter, Open‐Label, Extension Study to 
Evaluate the Long‐Term Safety, Clinical Activity, and 
Pharmacokinetics of ALN‐TTR02 in Patients With Familial 
Amyloidotic Polyneuropathy Who Have Previously Received 
ALN‐TTR02 
 
NCT Number:      
NCT01961921 
 
Document Date:     Protocol Version 2.0, 15 June 2015 




 
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Authorized Signatories 
 
INVESTIGATOR’S STATEMENT:  I agree to conduct this study as outlined in the 
protocol and in accordance with the guidelines and all applicable government regulations.  
I have read all parts of the protocol. 
 
Principal Investigator 
Signature    
Date   
Name (print)  
   
 
 
Version History: 
Version Number   
Date  
Comment 
1.0 (Original) 
26 April 2013 
Initial Release 
2.0 
15 June 2015 
Incorporating Global Amendment 1 
 


 
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Table of Contents 
Table of Contents 
................................
................................
...............................................3 
List of Tables 
................................
................................
......................................................7 
List of Appendices 
............................................................................................................7 
Protocol Synopsis 
................................
................................
...............................................8 
Abbreviations 
................................
................................
...................................................25 
1 
Introduction 
........................................................................................................28 
1.1 
Background and Rationale 
....................................................................... 28 
1.1.1 Transthyretin Biology and Impact of Transthyretin Lowering 
..... 28
 
1.1.2 Disease Overview 
................................
......................................... 28 
1.1.3 RNA interference 
................................
.......................................... 30 
1.1.4 ALN-TTR02 ................................................................................. 30 
1.2 
Summary of ALN-TTR02 Non-Clinical Data 
.......................................... 30
 
1.3 
Summary of Clinical Data with ALN-TTR02 
.......................................... 31
 
1.4 
Study Hypothesis and Rationale 
...............................................................
 32 
1.5 
Dose Selection and Rationale 
................................
................................... 32 
1.6 
Risk-Benefit Assessment 
................................
.......................................... 32 
1.6.1 Potential Benefit............................................................................ 33
 
1.6.2 Potential Risks .............................................................................. 33 
2 
Study Objectives...................................................................................................35
 
2.1 
Primary Objective 
................................
..................................................... 35 
2.2 
Secondary Objectives................................................................................ 35
 
2.3 
Tertiary Objectives.................................................................................... 35
 
3 
Study Plan 
...........................................................................................................36 
3.1 
Overall Design 
................................
.......................................................... 36 
3.2 
Safety Assessments 
.................................................................................. 36 
3.3 
Pharmacodynamic Assessments 
...............................................................
 36 
3.4 
Pharmacokinetic Assessments 
................................
.................................. 36 
3.5 
Clinical Activity Assessments 
................................
.................................. 37 
3.6 
Additional Assessments for the Pharmacokinetic/Pharmacodynamic 
Subgroup 
................................
................................
................................... 37 
3.7 
Additional Clinical Activity Assessments for the Cardiac Subgroup 
....... 38
 
3.8 
Other Assessments 
................................
.................................................... 38 
4 
Patient Population 
..............................................................................................39 
4.1 
Eligibility of Patients 
................................
................................................ 39 
4.2 
Inclusion Criteria ...................................................................................... 39 
4.3 
Exclusion Criteria 
................................
..................................................... 40 
4.4 
Blinding Procedure 
................................
................................................... 40 
4.5 
Early Patient Withdrawal 
......................................................................... 40 
4.5.1 Reasons for Withdrawal 
............................................................... 40 
4.5.2 Handling of Withdrawals 
.............................................................. 41 
5 
Study Medication 
................................
................................
.................................42 
5.1 
Presentation of Study Drug 
...................................................................... 42 
5.2 
Preparation of Study Drug 
................................
........................................ 42 


 
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5.3 
Storage of Study Drug .............................................................................. 42 
5.4 
Labeling and Packaging of Study Drug 
.................................................... 42 
5.5 
Premedication Plan 
................................
................................................... 43 
5.6 
Dose, Route, and Schedule of Study Drug Administration 
...................... 44 
5.7 
Criteria for Dose Modification or Discontinuation of Study Drug 
........... 44 
5.8 
Measurement of Patient Compliance 
........................................................ 45
 
5.9 
Study Drug Accountability 
................................
....................................... 45 
5.10 Concomitant Medication / Treatment 
....................................................... 45
 
5.11 Suggested Guidelines for Management of Infusion Reactions 
................. 46 
6 
Study Visits 
................................
................................
...........................................48 
6.1 
Screening/Baseline Visit (Day -28 to 0) 
................................................... 48 
6.2 
Treatment Visits 
....................................................................................... 50 
6.2.1 Routine Study Visits 
................................
..................................... 50 
6.2.2 Mid-Year and Annual Clinical Activity Study Visits 
................... 51
 
6.2.3 Additional Assessments for Pharmacokinetic/Pharmacodynamic 
Subgroup 
................................
....................................................... 52 
6.2.4 Additional Assessments for Cardiac Subgroup 
............................ 52 
6.2.5 Follow-Up Visits 
.......................................................................... 53 
6.3 
Early Termination 
................................
..................................................... 53 
6.4 
Unscheduled Visits 
................................
................................................... 55 
7 
Study Assessments ...............................................................................................56 
7.1 
Demographic Data and Medical History 
.................................................. 56
 
7.2 
Safety Assessments 
.................................................................................. 56 
7.2.1 Physical Examination.................................................................... 56
 
7.2.2 Vital Signs 
.................................................................................... 56 
7.2.3 Electrocardiogram 
........................................................................ 56 
7.2.4 Ophthalmology Examination 
........................................................ 57
 
7.2.5 Clinical Laboratory Tests 
.............................................................. 57
 
7.3 
Pharmacodynamic Assessments 
...............................................................
 59 
7.3.1 Transthyretin 
................................
................................................. 59 
7.3.2 Secondary Pharmacodynamic Biomarkers 
................................... 59
 
7.4 
Exploratory Biomarkers 
........................................................................... 60 
7.5 
Pharmacokinetic Evaluations 
................................................................... 60 
7.5.1 Plasma Pharmacokinetics.............................................................. 60
 
7.5.2 Urine Pharmacokinetics 
................................
................................ 62 
7.6 
Clinical Activity Assessments 
................................
.................................. 62 
7.6.1 Modified Neurological Impairment Score (mNIS) + 7................. 62
 
7.6.2 Vibration Detection Threshold ..................................................... 63 
7.6.3 Heart Rate Response to Deep Breathing 
....................................... 63
 
7.6.4 Hand Grip Strength 
................................
....................................... 63 
7.6.5 Ten-meter Walk Test 
................................
.................................... 63 
7.6.6 Neurological Impairment Score 
.................................................... 64
 
7.6.7 Composite Autonomic Symptom Score........................................ 64 
7.6.8 Quality of Life Questionnaire 
....................................................... 64
 
7.6.9 Rasch-built Overall Disability Scale 
............................................. 64
 


 
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7.6.10 Skin Punch Biopsies for Exploratory Intraepidermal Nerve Fiber 
Density and Sweat Gland Nerve Fiber Density 
............................ 64
 
7.6.11 FAP Stage and PND Score ........................................................... 64
 
7.6.12 Modified Body Mass Index .......................................................... 64 
7.6.13 Disease Burden and Healthcare Utilization 
.................................. 64
 
7.6.14 Echocardiogram 
................................
............................................ 65 
7.6.15 Biomarkers of Cardiac Function 
................................................... 65 
8 
Reporting Adverse Events 
..................................................................................66 
8.1 
Adverse Event Definition ......................................................................... 66 
8.2 
Serious Adverse Event Definition ............................................................ 66 
8.3 
Eliciting Adverse Event Information 
........................................................ 66
 
8.4 
Adverse Event Reporting 
......................................................................... 66 
8.5 
Adverse Event Reporting Period .............................................................. 67 
8.6 
Assessment of Causality 
................................
........................................... 67 
8.7 
Assessment of Severity 
................................
............................................. 68 
8.8 
Action Taken for Adverse Event 
.............................................................. 68 
8.9 
Outcome of Adverse Event 
...................................................................... 68 
8.10 Coding of Adverse Events 
................................
........................................ 68 
8.11 Serious Adverse Event Reporting 
............................................................. 68 
8.12 Pregnancy Reporting 
................................................................................ 70 
9 
Statistical Methods 
..............................................................................................71 
9.1 
Sample Size 
..............................................................................................
 71 
9.2 
Statistical Methodology 
................................
............................................ 71 
9.2.1 Populations to be Analyzed .......................................................... 71 
9.2.2 Baseline Evaluations 
.................................................................... 71 
9.2.3 Safety Analyses 
............................................................................ 71 
9.2.4 Pharmacodynamics 
................................
....................................... 72 
9.2.5 Pharmacokinetics 
................................
.......................................... 72 
9.2.6 Summary of Clinical Activity Assessments ................................. 73
 
9.2.7 Healthcare Utilization Assessments 
.............................................. 73
 
9.2.8 Pharmacokinetic/Pharmacodynamic and Cardiac Subgroup 
Analyses 
....................................................................................... 73 
9.2.9 Interim Analysis 
........................................................................... 74 
10 
Study Management 
................................
..............................................................75 
10.1 Data Handling and Quality Assurance 
...................................................... 75
 
10.1.1 Case Report Forms 
....................................................................... 75 
10.1.2 Monitoring 
................................
.................................................... 75 
10.1.3 Inspections 
................................
.................................................... 75 
10.2 Regulatory Guidelines .............................................................................. 75 
10.2.1 Independent Ethics Committee 
..................................................... 76 
10.2.2 Regulatory Authorities 
................................................................. 76 
10.2.3 Modification of the Protocol 
......................................................... 76 
10.2.4 Informed Consent Form 
............................................................... 76 
10.2.5 Study Reporting Requirements 
..................................................... 77 
10.2.6 Financial Disclosure Reporting Obligations 
................................. 77
 


 
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10.3 Ancillary Research 
................................................................................... 77 
10.4 Study Record Retention 
................................
............................................ 77 
10.5 Discontinuation of the Study by Alnylam ................................................ 77 
10.6 Study Documentation................................................................................ 78
 
10.7 Confidentiality 
................................
.......................................................... 78 
10.8 Publications/Reports 
................................
................................................. 79 
11 
References 
...........................................................................................................80 
12 
Appendices 
..........................................................................................................84 
 
 
 


 
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List of Tables 
Table 1-1:
 
Schedule of Assessments for Year 1 ― ALN-TTR02 Administered Once 
Every 3 Weeks 
................................
................................
.................................................. 17 
Table 1-2:
 
Schedule of Assessments for Year 2 ― ALN-TTR02 Administered Once 
Every 3 Weeks 
................................
................................
.................................................. 21 
Table 12-1:
 Schedule of Assessment for Patients Administered ALN-TTR02 Once 
Every Four Weeks – Year 1 
............................................................................................. 86 
Table 12-2:
 Schedule of Assessment for Patients Administered ALN-TTR02 Once 
Every Four Weeks – Year 2 
............................................................................................. 90 
 
List of Appendices 
Appendix 1: Karnofsky Scale 
................................
........................................................ 84 
Appendix 2: Schedule of Assessments for Patients Administered ALN-TTR02 Once 
Every Four Weeks............................................................................................................. 85
 
Appendix 3: New York Heart Association Classification of Heart Failure .................. 94
 
 


 
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PROTOCOL SYNOPSIS 
 
Protocol Title: 
A Phase 2, Multicenter, Open-Label, Extension Study to 
Evaluate the Long-Term Safety, Clinical Activity, and 
Pharmacokinetics of ALN-TTR02 in Patients With Familial 
Amyloidotic Polyneuropathy Who Have Previously Received 
ALN-TTR02 
Indication: 
Treatment of patients with familial amyloidotic 
polyneuropathy (FAP) 
Protocol Number: 
ALN-TTR02-003 
Phase of 
Development: 
2 
Design: 
This study is a multicenter, multinational, open-label, 
extension study that provides a mechanism for continued 
administration of ALN-TTR02 to FAP patients who 
participated in the ALN-TTR02-002 study. 
Consented eligible patients will be enrolled and receive 
0.3 mg/kg ALN-TTR02 once every 3 or 4 weeks for 
approximately 2 years, based on results from the ongoing 
ALN-TTR02-002 study where the safety and 
pharmacodynamics (PD) of these 2 dosing schedules are 
being explored.   
Safety will be assessed by collection of adverse events (AEs), 
including serious adverse events (SAEs); clinical laboratory 
tests, including hematology, clinical chemistry, thyroid 
function parameters, coagulation parameters, and urinalysis; 
electrocardiograms (ECGs); vital signs; physical examination 
findings; and ophthalmology examinations. 
Pharmacodynamic (PD) evaluation will include serial 
measurement of serum levels of transthyretin (TTR). 
Serum levels of secondary PD biomarkers, including retinol 
binding protein (RBP) and vitamin A, will also be evaluated. 
Clinical activity will be assessed through clinical 
examinations and electrophysiologic testing of neurologic 
impairment, patient reported outcomes for quality of life and 
disability, evaluation of motor functions with impact on 
activities of daily living, assessment of nutritional status, 
autonomic symptom assessment, and pathologic evaluation of 
sensory and autonomic innervation.  All evaluations of 


 
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clinical activity will be conducted at Screening/Baseline and 
approximately once every 6 months. 
Plasma and urine pharmacokinetic (PK) samples will be 
collected at specified time points up through 56 days post last 
dose.  
A subset of the FAP patients will undergo additional blood 
draws for assessment of PK/PD (PK/PD subgroup).  In 
addition, any patients with pre-existing cardiac amyloid 
involvement (Cardiac subgroup), will undergo additional 
testing including echocardiograms, troponin I, N-terminal 
prohormone of B-type natriuretic peptide (NT-proBNP) 
assessments to evaluate cardiac structure and function.   
Disease burden and healthcare utilization will be assessed 
using a patient reported pharmacoeconomics questionnaire. 
Blood will also be collected to evaluate exploratory 
biomarkers and anti-drug antibodies (ADA). 
Study Sites 
This study will be conducted at the same study sites that 
enrolled patients to Study ALN-TTR02-002. 
Investigational 
Drug: 
ALN-TTR02 is comprised of a small interfering ribonucleic 
acid (siRNA) targeting wild type TTR messenger RNA 
(mRNA), as well as all known TTR mutations, formulated in 
a lipid nanoparticle (LNP) containing the following lipid 
excipients: 1,2-dilinoleyloxy-N,N-dimethylpropylamine 
(DLin-MC3-DMA), 3-N-[(ω-methoxy poly(ethylene 
glycol)2000) carbamoyl]-1,2-dimyristyloxy-propylamine 
(PEG2000-C-DMG), 1,2-distearoyl-sn-glycero-3-
phosphocholine (DSPC), and cholesterol. 
Dosage, Route of 
Administration and 
Duration of 
Treatment of 
Investigational 
Drug: 
Patients will receive 0.3 mg/kg ALN-TTR02 once every 3 or 
4 weeks, based on results from the ongoing ALN-TTR02-002 
study where the safety and PD of 2 dosing schedules are being 
evaluated.  Doses of ALN-TTR02 will be administered as a 
70-minute intravenous (IV) infusion (or at a more prolonged 
infusion rate if required due to prior infusion related reaction 
[IRR]) by a controlled infusion device. 
Prior to ALN-TTR02, patients will receive the following 
premedications: 
• Intravenous dexamethasone (10 mg) or equivalent, 
administered at least 60 minutes prior to the start of the 
infusion of ALN-TTR02; 


 
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• Oral paracetamol (500 mg) or equivalent at least 
60 minutes prior to the start of the infusion of ALN-
TTR02; 
• Intravenous H2 blocker (e.g., ranitidine 50 mg, 
famotidine 20 mg, or equivalent other H2 blocker dose) 
at least 60 minutes prior to the start of the infusion of 
ALN-TTR02; and 
• Intravenous H1 blocker: diphenhydramine 50 mg (or 
equivalent other IV H1 blocker available at the study 
site) at least 60 minutes prior to the start of the infusion 
of ALN-TTR02.  Hydroxyzine or fexofenadine 25 mg 
per os (orally; PO) or cetirizine 10 mg PO may be 
substituted for any patient who does not tolerate IV 
diphenhydramine or other IV H1 blocker. 
 
Patients will remain at the study site for at least 1 hour 
following completion of dosing for safety assessments.  The 
PK/PD subgroup will remain at the site for 6 hours following 
the first dose and the doses given at 8 and 24 months. 
Time on Study 
The duration of patient participation in this study is 
approximately 2 years and 4 months (Screening/Baseline [up 
to 28 days prior to study drug administration] through the 56-
day Follow-up visit.) 
Primary Objective: 
To evaluate the safety and tolerability of long-term dosing 
with ALN-TTR02. 
Secondary 
Objectives: 
To assess the PD effect associated with long-term dosing of 
ALN-TTR02 on serum TTR. 
To assess changes from baseline in: 
• Neurologic impairment using the modified Neuropathy 
Impairment Score (mNIS) +7 composite score 
• Quality of life (EQ5D) and disability (Rasch-built 
Overall Disability Scale [R-ODS]) 
• Motor function impacting activities of daily living, 
including a 10-meter walk test and test of grip strength 
• Nutritional status (modified body mass index [mBMI]) 


 
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Tertiary Objectives: To further characterize the plasma and urine PK profile of 
ALN-TTR02. 
To assess changes in: 
• Secondary PD biomarkers (RBP and vitamin A) 
• Sensory and autonomic innervation (skin punch biopsies 
for intraepidermal nerve fiber density [IENFD] and 
sweat gland nerve fiber density [SGNFD]) 
• Neuropathy Impairment Score (NIS) and vibration 
detection threshold (VDT) 
• Heart rate response to deep breathing (HRdb) 
• Ambulation using FAP Stage and Polyneuropathy 
Disability (PND) Score 
• Patient reported autonomic neuropathy symptoms using 
Composite Autonomic Symptom Score (COMPASS 31) 
• Healthcare utilization using a pharmacoeconomics 
questionnaire 
• Cardiac structure/function through echocardiograms and 
serum levels of troponin I and NT-proBNP in patients 
with evidence of pre-existing cardiac amyloid 
involvement 
Sample Size: 
Up to 28 patients will be enrolled in this study.  Of these 
patients, up to 25 will be enrolled in the PK/PD subgroup, and 
additionally, any patients with pre-existing cardiac amyloid 
involvement will be enrolled in the Cardiac subgroup. 
Inclusion and 
Exclusion Criteria: 
To be enrolled in the study, each patient must meet the 
following criteria at Screening/Baseline: 
1. Previously received and tolerated ALN-TTR02 in Study 
ALN-TTR02-002. 
2. Karnofsky performance status of 60% or greater. 
3. Absolute neutrophil count (ANC) ≥1500 cells/mm³, 
platelet count ≥100,000 cells/mm³, and hemoglobin 
≥10 g/dL. 
4. Adequate liver function, demonstrated by an aspartate 
transaminase (AST) and alanine transaminase (ALT) 
level ≤2.5 × the upper limit of normal (ULN), total 
bilirubin within normal limits, albumin >3 g/dL, and 
international normalized ratio (INR) ≤1.2. 
5. Adequate renal function, demonstrated by serum 
creatinine ≤1.5 × ULN. 
6. Women of child-bearing potential must have a negative 
pregnancy test, cannot be breast feeding, and must be 
using 2 highly effective methods of contraception prior 


 
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to screening, throughout study participation, and for 75 
days after the last dose of study medication. 
7. Males agree to use appropriate contraception throughout 
study participation and for 75 days after the last dose of 
study medication. 
8. Patient is willing and able to comply with protocol-
required visit schedule and visit requirements and 
provide written informed consent. 
Additional inclusion criteria for patients participating in the 
PK/PD subgroup: 
9. At the time of enrollment, at least 6 months has elapsed 
since their last dose of ALN-TTR02. 
Additional inclusion criteria for patients participating in the 
Cardiac subgroup: 
10. Have a left ventricular wall thickness of ≥13 mm on 
transthoracic echocardiogram 
11. Be normotensive or have hypertension that is well-
controlled 
12. No aortic valve disease 
Patients will be excluded if they meet any of the following 
criteria at the time of Screening/Baseline: 
1. Pregnant or nursing. 
2. Has had a liver transplant. 
3. Has a known or suspected systemic bacterial, viral, 
parasitic, or fungal infection. 
4. Received an investigational agent, other than tafamidis 
or diflunisal, within 30 days prior to study drug 
administration. 
5. Has a New York Heart Association heart failure 
classification >2. 
6. Has unstable angina. 
7. Has uncontrolled clinically significant cardiac 
arrhythmia. 
8. Is considered unfit for the study by the Principal 
Investigator. 


 
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Safety Assessments 
Safety evaluations will include assessment of AEs, ECGs, 
vital signs (including blood pressure, pulse rate, oral body 
temperature, and respiration rate), clinical laboratory safety 
tests (including hematology, serum chemistry, thyroid 
function parameters, coagulation parameters, and urinalysis), 
and ophthalmology and physical examinations 
Pharmacodynamic 
Assessments 
The pharmacodynamic endpoint consists of serial 
measurement of serum levels of TTR.  Secondary PD 
biomarkers to be assessed include RBP and vitamin A. 
Clinical Activity 
Assessments 
Neurologic impairment will be assessed using the mNIS+ 7 
composite score.  The mNIS + 7 includes the modified NIS 
(weakness and reflexes only), nerve conduction studies (NCS) 
5 attributes (Σ5), quantitative sensory testing (QST) by body 
surface area including touch pressure (TP) and heat pain (HP), 
as well as autonomic assessment through postural blood 
pressure.  The NIS composite score will be assessed, as well 
as determining the vibration detection threshold (VDT) of 
patients. 
Patient reported quality of life will be evaluated using the 
EQ5D.  Disability will be reported by patients using the 
R-ODS.   
Autonomic neuropathy symptoms will be assessed using the 
COMPASS 31 questionnaire.   
Additional motor function assessments to be evaluated 
include a timed 10-meter walk test and test of grip strength, as 
well as evaluation of PND Score and FAP Stage.    
Autonomic function will be further assessed using HRdb. 
Nutritional status will be assessed using mBMI. 
Pathologic evaluation of sensory and autonomic innervation 
will be evaluated by IENFD analysis and quantitation of 
dermal SGNFD via 3 mm skin punch biopsies taken from the 
lower extremities at Baseline and approximately once every 
6 months.   
For any patient with pre-existing cardiac amyloid 
involvement, cardiac structure and function will be assessed 
through serial echocardiograms as well as measurement of 
serum levels of NT-proBNP and troponin I.  


 
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Pharmacokinetic 
Assessments 
The PK evaluation will include plasma-concentration time 
profiles for siRNA and the novel lipid components DLin-
MC3-DMA and polyethylene glycol (PEG)
2000-C-DMG.  The 
siRNA, DLin-MC3-DMA, and PEG
2000-C-DMG 
concentration will be determined at specific time points pre- 
and post-dose.  For the PK/PD subgroup, PK profiles will be 
evaluated for the first dose, and at Months 8 and 24.  In 
addition, population PK from all subjects will be evaluated 
whenever possible from sparse samples collected at pre-dose 
and post-dose at specified dosing period, and from various 
samples collected at specified time points at first dose, up 
through and including the 3 month dose, and once every 3 
months during the study period.  PK/PD relationship will be 
evaluated whenever possible for all samples collected  
Urine will be collected with void volume recorded at specified 
time points to determine the siRNA and 4-
dimethylaminodibutyric acid (the metabolite of DLin-MC3-
DMA) renal clearance (CL
R) after dosing with ALN-TTR02.   
Other Assessments 
Other effects of ALN-TTR02 will be evaluated by: 
• Measurement of other hepatocyte-derived proteins and 
ADA. 
• Determination of pharmacoeconomics outcomes through 
disease burden and healthcare utilization questionnaire. 
Statistical Methods: Statistical analyses will be primarily descriptive in nature.  
Adverse event summaries will include tabulations of all 
treatment-emergent AEs (TEAEs), treatment-related AEs, 
SAEs, discontinuations due to AEs, and AEs of various 
grading severity.  By-patient listings will be provided for 
deaths, SAEs, and AEs leading to discontinuation of 
treatment. 
Descriptive statistics will be provided for clinical laboratory 
data, vital signs data, and ECG interval data, presented as both 
actual values and changes from baseline relative to each on-
study evaluation.  Laboratory shift tables from baseline to 
worst values will be presented. 
Summary tables and graphical displays of observed values 
and changes from baseline in serum TTR, RBP, and vitamin 
A will be used to assess the durability of suppression over the 
course of the study.  As part of PK/PD analysis, additional PD 
baseline analysis on serum TTR, RBP, and vitamin A may be 
conducted to include the PD data obtained during the recovery 
period post last dose.   


 
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Pharmacokinetic analyses will be conducted using 
noncompartmental and/or compartmental evaluation.  The PK 
parameters of siRNA, DLin-MC3-DMA (lipid), and 
PEG2000-C-DMG (lipid) in plasma will be evaluated using a 
validated version of WinNonlin® Enterprise (Version 5.2 or 
higher) with NCA Model 200.  Summary tables and figures 
and inferential statistics will be provided.   
Population PK analyses will be performed on available 
siRNA and possibly DLin-MC3-DMA from sparse samples 
collected that may include sparse samples obtained from the 
PK/PD subgroups at various time points during the duration 
of the study.  Population PK modeling of siRNA and possibly 
DLin-MC3-DMA in plasma will be performed with Phoenix 
NLME (Version 1.1 or later).  Summary tables and figures 
and inferential statistics will be generated with Phoenix 
NLME (Version 1.1 or later) or similar software.  
The PK/PD analysis will be performed whenever possible 
using WinNonLin or Phoenix NLME (Version 1.1 or later) or 
similar software.  Summary tables and figures and inferential 
statistics of PD and PK/PD parameters, correlation between 
siRNA, DLin-MC3-DMA or PEG2000CDMG exposure versus 
TTR, RBP, or vitamin A, and between TTR versus RBP and 
vitamin A will be provided.  
Summary statistics of observed values and changes from 
baseline will be provided for the mNIS +7 composite score.  
Summaries will also be provided for the components of the 
composite score (i.e., the NIS weakness and reflex scores, the 
Σ5 NC, and QST values).  The full NIS (i.e., the sum of 
cranial nerve, muscle weakness, reflex and sensation scores) 
will be summarized also.  Values of the individual 
components of the mNIS weakness and reflex scores will be 
depicted graphically by presenting the mean (±SE) values 
over time for each location (hip, knee, etc.). 
Patient reported quality of life and disability will be assessed 
by summary statistics for the EQ5D and R-ODS.  Summary 
statistics will be provided for observed values and changes 
from baseline.  Patient reported autonomic neuropathy 
symptoms will be assessed by descriptive statistics for the 
COMPASS 31. 
Descriptive statistics will also be provided for observed 
values and changes from baseline in motor function (10-meter 
walk test and test of grip strength), nutritional status (mBMI), 


 
ALN-TTR02 
 
ALN-TTR02-003 
 
15 June 2015 
 
 
 
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Page 16  
sensory and autonomic innervation (IENFD and SGNFD), 
VDT, and ambulation (FAP stage and PND score). 
Descriptive statistics will be provided for actual values and 
changes from baseline in serum levels of troponin I and NT-
proBNP in the subset of patients with evidence of pre-existing 
cardiac amyloid involvement.  Results of echocardiograms 
will be summarized. 
 


 
ALN-TTR02 
 
ALN-TTR02-003 
 
15 June 2015 
 
 
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Table 1-1:   Schedule of Assessments for Year 1 ― ALN-TTR02 Administered Once Every 3 Weeks 
 
Visit Type 
Screening/ 
Baselinea 
Dosing 
Mid-
year/Annual 
Efficacy 
Assessment 
Procedure   Study Week 
NA   
1 & 28 4 & 31 7 & 34 10 & 37 13 & 40 16 & 43 19 & 46 22 & 49 25 & 52  27 & 54 
 
Study Day   
Day -28 to -0 D0 & 
D189 
D21 & 
D210 
D42 & 
D231 
D63 & 
D252 
D84 & 
D273 
D105 & 
D294 
D126 & 
D315 
D147 & 
D336 
D168 & 
D357 
D182 & 
D371 
 
Window 
NA   
±3Db 
±3D   ±3D   ±3D   ±3D   ±3D   ±3D   ±3D   ±3D   
±5D 
Informed Consent 
X   
   
   
   
   
   
   
   
   
   
 
Demographics 
X   
   
   
   
   
   
   
   
   
   
 
Medical Historyc 
X   
   
   
   
   
   
   
   
   
   
 
Inclusion/Exclusion Criteria 
X   
Xd   
   
   
   
   
   
   
   
   
 
Physical Examination 
X   
   
   
   
   
   
   
   
   
   
X 
Weight
e 
X   
X   
X   
X   
X   
X   
X   
X   
X   
X   
X 
Height 
X   
   
   
   
   
   
   
   
   
   
 
Vital Signsf 
X   
X   
X   
X   
X   
X   
X   
X   
X   
X   
X 
Echocardiogram 
X   
   
   
   
   
   
   
   
   
 
 
12-Lead ECGg 
X   
   
   
   
   
   
   
   
   
   
X 
Urine Pregnancy Test (females only)h   
X   
   
   
   
   
   
   
   
   
   
 
Hematologyi 
X   
Xd   
   
   
   
   
   
   
   
X   
 
Serum Chemistry and Urinalysisi   
X   
Xd   
   
   
   
X   
   
   
   
X   
 
Thyroid Function Tests and 
Coagulation Studiesi 
X   
Xd   
   
   
 
 
 
   
   
X   
 
Ophthalmology Exam 
X   
   
   
   
   
   
   
   
   
   
X 
PD Assessments: 
   
   
   
   
   
   
   
   
   
   
 
TTR protein (ELISA and 
turbidimetric) 
j 
X   
Xd   
   
   
   
X   
   
   
   
X   
X 
RBP and Vitamin Aj 
X   
Xd   
   
   
   
X   
   
   
   
X   
X 


 
ALN-TTR02 
 
ALN-TTR02-003 
 
15 June 2015 
 
 
Protocol Amendment 1 (Version 2.0) 
 
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Page 18  
 
Visit Type 
Screening/ 
Baselinea 
Dosing 
Mid-
year/Annual 
Efficacy 
Assessment 
Procedure   Study Week 
NA   
1 & 28 4 & 31 7 & 34 10 & 37 13 & 40 16 & 43 19 & 46 22 & 49 25 & 52  27 & 54 
 
Study Day   
Day -28 to -0 D0 & 
D189 
D21 & 
D210 
D42 & 
D231 
D63 & 
D252 
D84 & 
D273 
D105 & 
D294 
D126 & 
D315 
D147 & 
D336 
D168 & 
D357 
D182 & 
D371 
 
Window 
NA   
±3Db 
±3D   ±3D   ±3D   ±3D   ±3D   ±3D   ±3D   ±3D   
±5D 
Other Assessments: 
   
   
   
   
   
 
 
   
   
   
 
Exploratory Biomarkersk 
X   
Xd   
   
   
   
X 
 
   
   
X   
 
Anti-drug Antibodies
k 
X   
Xd   Xl   
   
   
Xl 
 
   
   
X   
 
Pharmacoeconomics Questionnaire   
X   
   
   
   
   
   
   
   
   
   
X 
Clinical Activity Assessments: 
   
   
   
   
 
 
 
   
   
   
 
mNIS + 7m n 
X 
   
   
   
 
 
 
   
   
   
X 
VDTn 
X   
   
   
   
 
 
 
   
   
   
X 
HRdbn 
X   
   
   
   
   
   
   
   
   
   
X 
Grip Strengthn,o 
X   
   
   
   
   
   
   
   
   
   
X 
10-Meter Walk Testn,p 
X   
   
   
   
   
   
   
   
   
   
X 
NISn 
X   
   
   
   
   
   
   
   
   
   
X 
Skin Punch Biopsy (IENFD & 
SGNFD)
q 
X   
   
   
   
   
   
   
   
   
   
X 
mBMI 
X   
   
   
   
   
   
   
   
   
   
X 
FAP Stage and PND Score 
X   
   
   
   
   
   
   
   
   
   
X 
COMPASS 31  
X   
   
   
   
   
   
   
   
   
   
X 
QOL and Disability Questionnaires
r   
X   
   
   
   
   
   
   
   
   
   
X 
Premedication Administrations 
   
X   
X   
X   
X   
X   
X   
X   
X   
X   
 
Study Drug Administrationt 
   
X   
X   
X   
X   
X   
X   
X   
X   
X   
 
Plasma PK Samplingu 
   
Xv 
Xv 
Xv 
Xv   
X   
   
   
   
X   
Xw 
Urine PK Samplingx 
   
Xv   Xv   Xv   Xv   
X   
   
   
   
X   
Xw 


 
ALN-TTR02 
 
ALN-TTR02-003 
 
15 June 2015 
 
 
Protocol Amendment 1 (Version 2.0) 
 
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Page 19  
 
Visit Type 
Screening/ 
Baselinea 
Dosing 
Mid-
year/Annual 
Efficacy 
Assessment 
Procedure   Study Week 
NA   
1 & 28 4 & 31 7 & 34 10 & 37 13 & 40 16 & 43 19 & 46 22 & 49 25 & 52  27 & 54 
 
Study Day   
Day -28 to -0 D0 & 
D189 
D21 & 
D210 
D42 & 
D231 
D63 & 
D252 
D84 & 
D273 
D105 & 
D294 
D126 & 
D315 
D147 & 
D336 
D168 & 
D357 
D182 & 
D371 
 
Window 
NA   
±3Db 
±3D   ±3D   ±3D   ±3D   ±3D   ±3D   ±3D   ±3D   
±5D 
PK/PD Subgroup Only 
   
   
   
   
   
   
   
   
   
   
 
TTR (ELISA and turbidimetric)y   
   
X   
   
X   
   
   
   
   
   
   
 
RBP and Vitamin Ay 
   
X   
   
X   
   
   
   
   
   
   
 
Plasma PK Sampling 
   
Xz   
   
Xz   
   
   
   
   
   
   
 
Urine PK Sampling 
   
Xaa   
   
Xaa   
   
   
   
   
   
   
 
Cardiac Subgroup Only: 
   
   
   
   
   
   
   
   
   
   
 
Echocardiogram 
   
   
   
   
   
   
   
   
   
   
X 
Troponin I and NT-proBNP  
   
Xd   
   
   
   
X   
   
   
   
X   
 
Concomitant Medications 
X 
X 
Adverse Events 
 
Xbb 
Note:  The schedule of assessments for patients administered ALN-TTR02 once every 4 weeks is provided in Appendix 2. 
a   Assessments performed during the ALN-TTR02-002 study that occur within the Screening/Baseline timeframe will not need to be repeated at the Screening/Baseline visit. 
b   Window does not apply to Day 0. 
c   Any AEs from the previous study (ALN-TTR02-002) that are ongoing on Day 0 are to be recorded on the Medical History case report form for the current study (ALN-
TTR02-003) and followed until resolution. 
d   To be performed only on Day 0, not on Day 189. 
e   On dosing days, weight will be measured predose. 
f   On dosing days, vital signs will be measured predose.  Vital signs to include: blood pressure, pulse rate, oral body temperature, and respiratory rate.  Parameters are to be 
measured in the supine position using an automated instrument after the patient has rested comfortably for 10 minutes. 
g   Triplicate recordings will be obtained. 
h   A pregnancy test will be performed on all females of child-bearing potential at Screening/Baseline and any time pregnancy is suspected. 
i   To be performed before administration of premedications and dosing with ALN-TTR02. 
j   Blood samples for TTR, RBP, and vitamin A will be collected on Day 0 at 2 separate time points: 1) prior (within 10 minutes) to administration of premedications and 2) 
after administration of premedications but immediately prior (within 10 minutes) to dosing of ALN-TTR02.  At all other dosing visits, a blood sample will be collected only 
once; prior to administration of premedications.  At the Mid-year and Annual visits, one sample should be collected on each day.  Additionally, aliquots of serum samples 
will be taken and frozen, to permit testing of additional proteins related to FAP. 
k    Blood samples for exploratory biomarkers and ADA will be collected prior to dosing with ALN-TTR02. 


 
ALN-TTR02 
 
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15 June 2015 
 
 
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l   To be collected only on Days 21 and 84, not on Days 210 and 273. 
m   The mNIS + 7 consists of the modified NIS tool (or aspects of the tool; weakness and reflexes only), nerve conduction studies (NCS), quantitative sensory testing (QST) by 
body surface area including touch pressure (TP) and heat pain (HP), and postural blood pressure.  Every effort will be made to use the same devices for a patient throughout 
the duration of the study. 
n   Two independent assessments will be performed on separate days at Screening/Baseline and then approximately every 6 months.  The Screening/Baseline assessments must 
be performed within 14 days prior to the first dose of study drug (Day 0).  The second (repeat) assessment must be conducted at least 24 hours (approximately) after the first 
assessment, but not more than 7 days apart.   
o   Hand grip strength will be measured using a dynamometer held in the dominant hand.  Every effort will be made to use the same device for a patient throughout the duration 
of the study.  At each time point, 2 independent assessments (each assessment performed in triplicate) will be performed. 
p   Patient will walk without assistance for 10 meters in order to complete the 10-meter walk test.  The time required for the patient to complete 2, 8, and 10 meters will be 
recorded. 
q   Two 3-mm skin punch biopsies are to be obtained.  One will be obtained from the distal lower leg, when a patient’s clinical status allows, and one from the distal thigh. 
r   Quality of life and disability assessments will include the EQ5D and R-ODS questionnaires. 
s    The following premedications will be administered at least 60 minutes prior to the start of the infusion of ALN-TTR02:  dexamethasone (10 mg IV, or equivalent), 
paracetamol (PO 500 mg; or equivalent), IV H2 blocker (e.g., ranitidine 50 mg, famotidine 20 mg, or equivalent other H2 blocker dose), and IV H1 blocker (e.g., 
diphenhydramine 50 mg or equivalent; hydroxyzine or fexofenadine 25 mg PO or cetirizine 10 mg PO may be substituted for any patient who does not tolerate IV 
diphenhydramine or other IV H1 blockers). 
t   The infusion site will be assessed for any localized reaction pre-dose, during the infusion, at the end of the infusion (EOI), and for 30 minutes after the infusion. 
u   Plasma PK samples will be collected pre-dose (within 1 hour of planned dosing start; -5 minutes), EOI (+5 minutes), and 1 hour post-dose (±5 min), except on Days 0 and 
231 for subjects in the PK/PD Subgroup.  The EOI will usually occur at 70 minutes after the start of the infusion, except in patients where the infusion has been prolonged.  
All post-infusion times are relative to the EOI, regardless of the duration of the infusion.  In addition, if the infusion is stopped and the site is considering restarting the 
infusion, a PK blood sample will be taken while the infusion is stopped.   
v   Samples to be collected on Day 0, 21, 42 and 63 only. 
w   Samples will be collected once on each day of the 2-day study visit. 
x   For each dose, urine PK samples will be collected pre-dose (within 1 hour of planned dosing start; -5 minutes) and 1 hour (±5 minutes) after dosing with ALN-TTR02.  
y   For patients in the PK/PD subgroup, blood samples for TTR, RBP, and vitamin A will be collected on Days 0 and 231 immediately prior (within 10 minutes) to 
administration of premedications.  In addition, a TTR, RBP, and vitamin A sample will also be collected 24 hours (±120 minutes) post-dose, and 3, 7, and 17 days (±1 day) 
after dosing with ALN-TTR02 for the study visits noted (blood samples for TTR will not be collected on Days 42 and 189). 
z   On Days 0 and 231, patients in the PK/PD subgroup will have PK samples taken pre-dose (within 1 hour of planned dosing start; -5 minutes), EOI (+5 minutes), and 1, 2, 4, 
6, and 24 hours postinfusion.  In addition, a plasma PK sample will also be collected 3, 7, and 17 days (±1 day) after dosing with ALN-TTR02 for the study visits noted.  The 
windows for sampling are ±5 minutes for the 1, 2, 4, and 6 hour sampling periods; and ±120 minutes for the 24 hour sampling period. 
aa  On Days 0 and 231, patients in the PK/PD subgroup will have a urine sample for PK analysis taken pre-dose (within 1 hour of planned dosing start; -5 minutes), EOI 
(+5 minutes), and 6 and 24 hours postinfusion.  In addition, a urine PK sample will also be collected 3, 7, and 17 days (±1 day) after dosing with ALN-TTR02 for the study 
visits noted.  The windows for sampling are ±5 minutes for the 1, 2, 4, and 6 hour sampling periods; and ±120 minutes for the 24-hour sampling period. 
bb  Adverse events are to be documented beginning with the initiation of the first infusion. 
 
 


 
ALN-TTR02 
 
ALN-TTR02-003 
 
15 June 2015 
 
 
Protocol Amendment 1 (Version 2.0) 
 
Confidential  
Page 21  
Table 1-2:   Schedule of Assessments for Year 2 ― ALN-TTR02 Administered Once Every 3 Weeks 
Procedure 
 
Visit Type 
Dosing 
Mid-
year/ 
Annual
Efficacy 
Assess-
ment 
21- and 56-day 
Follow-upa 
Early 
Termi-
nation 
Study Week   55 & 82 58 & 85 61 & 88 64 & 91 67 & 94 70 & 97  73 & 
100 
76 & 
103 
79 & 
106 
81 & 
108 
109   114   ET 
Study Day 
D378 & 
D567 
D399 & 
D588 
D420 & 
D609 
D441 & 
D630 
D462 & 
D651 
D483 & 
D672 
D504 & 
D693 
D525 & 
D714 
D546 & 
D735 
D560 & 
D749  D756  D791   N/A 
Window 
±3D 
±3D   ±3D   ±3D   ±3D   ±3D   ±3D   ±3D   ±3D   ±5D   ±5D   ±5D   2D to 
7D 
Physical Examination 
   
   
   
   
   
   
   
   
   
X   
X   
   
X 
Weightb 
X   
X   
X   
X   
X   
X   
X   
X   
X   
X   
X   
   
X 
Vital Signsc 
X   
X   
X   
X   
X   
X   
X   
X   
X   
X   
X   
   
X 
12-lead ECG
d 
   
   
   
   
   
   
   
   
   
X 
X   
 
X 
Hematologye 
   
   
   
   
   
   
   
   
X   
   
X   
   
X 
Serum Chemistry and Urinalysise      
   
   
   
X   
   
   
   
X   
   
X   
   
X 
Thyroid Function Tests and 
Coagulation Studiese 
   
   
   
 
   
 
   
   
X   
   
X   
   
X 
Ophthalmology Exam 
   
   
   
   
   
   
   
   
   
X   
   
   
X 
PD Assessments: 
   
   
   
   
   
   
   
   
   
   
   
   
 
TTR protein (ELISA and 
turbidimetric)
f 
X   
X   
X   
X   
X   
X   
X   
X   
X   
X   
X   
X   
X 
RBP and Vitamin Af 
   
   
   
   
X   
   
   
   
X   
X   
X   
X   
X 
Other Assessments: 
   
   
   
   
 
 
   
   
   
   
   
   
 
Exploratory Biomarkersg   
   
   
   
   
X 
 
   
   
X   
   
   
   
 
Anti-drug Antibodies 
   
   
   
   
 
 
   
   
Xh   
   
   
   
 
Pharmacoeconomics 
Questionnaire 
   
   
   
   
   
   
   
   
   
X   
   
   
Xi 


 
ALN-TTR02 
 
ALN-TTR02-003 
 
15 June 2015 
 
 
Protocol Amendment 1 (Version 2.0) 
 
Confidential  
Page 22  
Procedure 
 
Visit Type 
Dosing 
Mid-
year/ 
Annual
Efficacy 
Assess-
ment 
21- and 56-day 
Follow-upa 
Early 
Termi-
nation 
Study Week   55 & 82 58 & 85 61 & 88 64 & 91 67 & 94 70 & 97  73 & 
100 
76 & 
103 
79 & 
106 
81 & 
108 
109   114   ET 
Study Day 
D378 & 
D567 
D399 & 
D588 
D420 & 
D609 
D441 & 
D630 
D462 & 
D651 
D483 & 
D672 
D504 & 
D693 
D525 & 
D714 
D546 & 
D735 
D560 & 
D749  D756  D791   N/A 
Window 
±3D 
±3D   ±3D   ±3D   ±3D   ±3D   ±3D   ±3D   ±3D   ±5D   ±5D   ±5D   2D to 
7D 
Clinical Activity Assessments: 
   
   
   
 
   
 
   
   
   
   
   
   
 
mNIS + 7j,k 
   
   
   
 
   
 
   
   
   
X 
   
   
Xi 
VDTk 
   
   
   
 
   
 
   
   
   
X   
   
   
Xi 
HRdbk 
   
   
   
   
   
   
   
   
   
X   
   
   
Xi 
Grip Strengthk,l 
   
   
   
   
   
   
   
   
   
X   
   
   
Xi 
10-Meter Walk Testk,m   
   
   
   
   
   
   
   
   
   
X   
   
   
Xi 
NISk 
   
   
   
   
   
   
   
   
   
X   
   
   
Xi 
Skin Punch Biopsy (IENFD & 
SGFND)n 
   
   
   
   
   
   
   
   
   
X   
   
   
Xi 
mBMI 
   
   
   
   
   
   
   
   
   
X   
   
   
Xi 
FAP Stage and PND Score   
   
   
   
   
   
   
   
   
   
X   
   
   
Xi 
COMPASS 31 
   
   
   
   
   
   
   
   
   
X   
   
   
Xi 
QOL and Disability 
Questionnaireso 
   
   
   
   
   
   
   
   
   
X   
   
   
Xi 
Premedication Administrationp   
X   
X   
X   
X   
X   
X   
X   
X   
X   
   
   
   
 
Study Drug Administrationq   
X   
X   
X   
X   
X   
X   
X   
X   
X   
   
   
   
 
Plasma PK Samplingr 
   
   
   
   
X   
   
   
   
X   
X   
X   
X   
X 
Urine PK Samplings 
   
   
   
   
X   
   
   
   
X   
X   
   
   
X 


 
ALN-TTR02 
 
ALN-TTR02-003 
 
15 June 2015 
 
 
Protocol Amendment 1 (Version 2.0) 
 
Confidential  
Page 23  
Procedure 
 
Visit Type 
Dosing 
Mid-
year/ 
Annual
Efficacy 
Assess-
ment 
21- and 56-day 
Follow-upa 
Early 
Termi-
nation 
Study Week   55 & 82 58 & 85 61 & 88 64 & 91 67 & 94 70 & 97  73 & 
100 
76 & 
103 
79 & 
106 
81 & 
108 
109   114   ET 
Study Day 
D378 & 
D567 
D399 & 
D588 
D420 & 
D609 
D441 & 
D630 
D462 & 
D651 
D483 & 
D672 
D504 & 
D693 
D525 & 
D714 
D546 & 
D735 
D560 & 
D749  D756  D791   N/A 
Window 
±3D 
±3D   ±3D   ±3D   ±3D   ±3D   ±3D   ±3D   ±3D   ±5D   ±5D   ±5D   2D to 
7D 
PK/PD Subgroup Only: 
   
   
   
   
   
   
   
   
   
   
   
   
 
TTR (ELISA and 
turbidimetric) 
   
   
   
   
   
   
   
   
Xt   
   
   
   
 
RBP and Vitamin A 
   
   
   
   
   
   
   
   
Xt   
   
   
   
 
Plasma PK Sampling 
   
   
   
   
   
   
   
   
Xu   
   
   
   
 
Urine PK Sampling 
   
   
   
   
   
   
   
   
Xv   
   
   
   
 
Cardiac Subgroup Only: 
   
   
   
   
   
   
   
   
   
   
   
   
 
Echocardiogram 
   
   
   
   
   
   
   
   
   
X   
   
   
X 
Troponin I and NT-proBNP    
   
   
   
   
X   
   
   
   
X   
   
   
   
X 
Concomitant Medications 
Xw 
Adverse Events 
Xx 
Note:  The schedule of assessments for patients administered ALN-TTR02 once every 4 weeks is provided in Appendix 2. 
 
a   If a patient enrolls in the global extension study, the patient will only have to complete the 21-day follow-up assessments (Day 756) and not the 56-day follow-up 
assessments (Day 791).  Patients who do not enroll in the extension study will need to complete both Follow-up visits (Days 756 and 791). 
b   On dosing days, weight will be measured predose. 
c   On dosing days, vital signs will be measured predose.  Vital signs to include: blood pressure, pulse rate, oral body temperature, and respiratory rate.  Parameters are to be 
measured in the supine position using an automated instrument after the patient has rested comfortably for 10 minutes. 
d   Triplicate recordings will be obtained. 
e   On dosing days, to be performed before administration of premedications and dosing with ALN-TTR02. 
f   Blood samples for TTR, RBP, and vitamin A will be collected on Day 0 at 2 separate time points: 1) prior to administration of premedications and 2) after administration of 
premedications but before dosing with ALN-TTR02.  At all other dosing visits, a blood sample will be collected only once; prior to administration of premedications.  At the 


 
ALN-TTR02 
 
ALN-TTR02-003 
 
15 June 2015 
 
 
Protocol Amendment 1 (Version 2.0) 
 
Confidential  
Page 24  
Mid-year and Annual visits, one sample should be collected on each day.  Additionally, aliquots of serum samples will be taken and frozen, to permit testing of additional 
proteins related to FAP. 
g   Blood samples for exploratory biomarkers will be collected prior to dosing with ALN-TTR02. 
h   Blood samples for ADA will be collected only at the Day 735 visit (approximately 24 months), prior to dosing with ALN-TTR02. 
i   To be performed only in patients who have received at least 4 doses of study drug and who withdraw >3 months after the last clinical activity assessments were performed.  
These tests will not be repeated. 
j   The mNIS + 7 consists of the modified NIS tool (or aspects of the tool; weakness and reflexes only), NCS, QST by body surface area including TP and HP, and postural 
blood pressure.  Every effort will be made to use the same devices for a patient throughout the duration of the study. 
k   Two independent assessments will be performed at Screening/Baseline and at the Mid-year and Annual visits.  The second (repeat) assessment must be conducted at least 
24 hours (approximately) after the first assessment, but not more than 7 days apart.   
l   Hand grip strength will be measured using a dynamometer held in the dominant hand.  Every effort will be made to use the same device for a patient throughout the duration 
of the study.  At each time point, 2 independent assessments (each assessment performed in triplicate) will be performed. 
m   Patient will walk without assistance for 10 meters in order to complete the 10-meter walk test.  The time required for the patient to complete 2, 8, and 10 meters will be 
recorded.  
n   Two 3-mm skin punch biopsies are to be obtained.  One will be obtained from the distal lower leg, when a patient’s clinical status allows, and one from the distal thigh. 
o   Quality of life and disability assessments will include the EQ5D and R-ODS questionnaires. 
p    The following premedications will be administered at least 60 minutes prior to the start of the infusion of ALN-TTR02:  dexamethasone (10 mg IV, or equivalent), 
paracetamol (PO 500 mg; or equivalent), IV H2 blocker (e.g., ranitidine 50 mg, famotidine 20 mg, or equivalent other H2 blocker dose), and IV H1 blocker (e.g., 
diphenhydramine 50 mg or equivalent; hydroxyzine or fexofenadine 25 mg PO or cetirizine 10 mg PO may be substituted for any patient who does not tolerate IV 
diphenhydramine or other IV H1 blockers). 
q   The infusion site will be assessed for any localized reaction pre-dose, during the infusion, at the end of the infusion and for 30 minutes after the infusion. 
r   Plasma PK samples will be collected pre-dose (within 1 hour of planned dosing start; -5 minutes) and at EOI (+5 minutes).  In addition, if the infusion is stopped and the site 
is considering restarting the infusion, a PK blood sample will be taken while the infusion is stopped.  In addition, plasma samples will be collected once on each day of the 
Mid-year and Annual visits. 
s   For each dose, urine PK samples will be collected 1 hour postdose (±5 minutes).  
t   For patients in the PK/PD subgroup, blood samples for TTR, RBP, and vitamin A will be collected on Day 735 immediately prior (within 10 minutes) to administration of 
premedications.  In addition, a TTR, RBP, and vitamin A sample will also be collected 24 hours (±120 minutes) post-dose, and 3, 7, and 17 days (±1 day) after dosing with 
ALN-TTR02 for the study visit noted. 
u   On Day 735, patients in the PK/PD subgroup will have PK samples taken pre-dose (within 1 hour of planned dosing start; -5 minutes), EOI (+5 minutes), and 1, 2, 4, 6, and 
24 hours post-infusion.  In addition, a plasma PK sample will also be collected 3, 7, and 17 days (±1 day) after dosing with ALN-TTR02 for the study visit noted.  The 
windows for sampling are ±5 minutes for the 1, 2, 4, and 6 hour sampling periods; and ±120 minutes for the 24 hour sampling period. 
v   On Day 735, patients in the PK/PD subgroup will have a urine sample for PK analysis taken pre-dose (within 1 hour of planned dosing start; -5 minutes), EOI (+5 minutes), 
and 6 and 24 hours post-infusion.  In addition, a urine PK sample will also be collected 3, 7, and 17 days (±1 day) after dosing with ALN-TTR02 for the study visit noted.  
The windows for sampling are ±5 minutes for the 1, 2, 4, and 6 hour sampling periods; and ±120 minutes for the 24-hour sampling period. 
w   Use of all concomitant medications during Screening/Baseline, predose, and postdose will be recorded on the patient’s CRF up to the 21-day or 56-day Follow-up visit 
(depending on whether or not the patient plans to roll over to the open-label global extension study).  
x 
Adverse events are to be documented beginning with the initiation of the first infusion through the 21-day or 56-day Follow-up visit (depending on whether or not the patient 
plans to roll over to the open-label global extension study).  


 
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ABBREVIATIONS 
Abbreviation   
Definition 
Σ5 
5 attributes 
λz 
Elimination rate constant 
ADA 
Anti-drug antibodies 
AE 
Adverse event 
ALT 
Alanine transaminase 
ANC 
Absolute neutrophil count 
aPTT 
Activated partial thromboplastin time 
AST 
Aspartate transaminase 
ATTR 
Transthyretin-mediated amyloidosis 
AUC 
Area under the plasma concentration-time curve 
AUC0-∞ 
Area under the plasma concentration-time curve 
extrapolated to infinity 
AUC0-last 
Area under the plasma concentration-time curve from zero 
to the last measurable time point 
AUC0-t 
Area under the plasma concentration-time curve to the last 
measurable concentration 
AUCp 
Partial area under the plasma concentration-time curve 
BUN 
Blood urea nitrogen 
CDT 
Cooling detection threshold 
CEC 
Clinical Events Committee 
CFR 
Code of Federal Regulations 
CL 
Systemic clearance 
CLR 
Renal clearance 
Cmax 
Observed maximum plasma concentration  
COMPASS 31   
Composite Autonomic Symptom Score 
CRF 
Case Report Form 
CRO 
Contract research organization 
CV 
Curriculum vitae 
DEHP 
di(2-ethylhexyl)phthalate 
DLin-MC3-DMA   
1,2-Dilinoleyloxy-N,N-dimethylpropylamine 
DSPC 
1,2-Distearoyl-sn-glycero-3-phosphocholine 
ECG 
Electrocardiogram 
EDC 
Electronic data capture 
ELISA 
Enzyme linked immunosorbent assay 
EOI 
End of infusion 


 
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Abbreviation   
Definition 
ET 
Early termination 
EU 
European Union 
FAC 
Familial amyloidotic cardiomyopathy 
FAP 
Familial amyloidotic polyneuropathy 
GCP 
Good Clinical Practice 
GMP 
Good Manufacturing Practice 
H1/H2 blocker   
Histamine H1/H2 receptor antagonist 
HIPAA 
Health Insurance Portability and Accountability Act of 
1996 
HP 
Heat pain 
HPLC 
High performance liquid chromatography 
HRdb 
Heart rate response to deep breathing 
IB 
Investigator’s Brochure 
ICF 
Informed consent form 
ICH 
International Conference on Harmonization 
IEC 
Independent Ethics Committee 
IENFD 
Intraepidermal nerve fiber density 
INR 
International normalized ratio 
IRR 
Infusion-related reaction 
IV 
Intravenous(ly) 
LNP 
Lipid nanoparticles 
mBMI 
Modified body mass index 
MedDRA 
Medical Dictionary for Regulatory Activities 
mNIS 
Modified Neuropathy Impairment Score 
mRNA 
Messenger ribonucleic acid 
NCS 
Nerve conduction studies 
NHP 
Non-human primate (cynomolgus monkey) 
NOAEL 
No observed adverse effect limit 
NSAID 
Nonsteroidal anti-inflammatory 
NT-proBNP 
N-terminal prohormone of B-type natriuretic peptide 
OTC 
Over-the-counter 
PD 
Pharmacodynamic 
PEG2000-C-DMG   
3-N-[(ω-methoxy poly(ethylene glycol)2000) carbamoyl]-
1,2-dimyristyloxy-propylamine 
PI 
Principal Investigator 
PK 
Pharmacokinetic(s) 
PND 
Polyneuropathy disability  


 
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Abbreviation   
Definition 
PO 
Per os (orally) 
PVC 
Polyvinyl chloride 
PT 
Prothrombin time 
QST 
Quantitative sensory testing 
QTc 
QT interval corrected for heart rate 
RBC 
Red blood cell 
RBP 
Retinol binding protein 
RNAi 
RNA interference 
R-ODS 
Rasch-built Overall Disability Scale 
SAE 
Serious adverse event 
SGNFD 
Sweat gland nerve fiber density 
siRNA 
Small interfering ribonucleic acid 
SUSAR 
Suspected unexpected serious adverse reaction 
t
1/2 
Terminal elimination half-life 
t
1/2α 
Alpha half-life 
t
1/2β 
Beta half-life 
T3 
Triiodothyronine 
T4 
Thyroxine 
TBG 
Thyroxine-binding globulin 
TEAE 
Treatment-emergent adverse event 
t
max 
Time of observed maximum plasma concentration 
TP 
Touch pressure 
TSH 
Thyroid stimulating hormone 
TTR 
Transthyretin 
ULN 
Upper limit of normal 
US/USA 
United States 
USP/EP 
United States Pharmacopeia/European Pharmacopoeia 
Vss 
Volume of distribution at steady state 
Vz 
Volume of distribution based on the terminal phase 
VDT 
Vibration detection threshold 
WBC 
White blood cell 
WHO 
World Health Organization 
WT 
Wild type 
 


 
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1   
INTRODUCTION 
1.1   Background and Rationale 
1.1.1   Transthyretin Biology and Impact of Transthyretin Lowering 
Transthyretin (TTR), also known as prealbumin, is a tetramer protein produced 
predominantly by hepatocytes (>95% of TTR is liver-derived), with a small fraction 
produced in the choroid plexus and retina.1  The primary physiological role of TTR is to 
serve as a carrier of retinol (also known as vitamin A); it also plays a minor role as a 
carrier for thyroxine (T4).   
In humans, approximately 15% of T4 circulating in the plasma is bound to TTR; the 
remainder is predominantly bound to thyroxine-binding globulin (TBG).  In the mouse, 
where TTR plays a greater role as a carrier for T4, the absence of TTR reduces 
circulating levels of T4 but does not adversely affect the concentration of the hormone in 
peripheral tissues.2,3   
Vitamin A circulates through the plasma primarily bound to retinol binding protein 
(RBP).
1  The clearance of RBP from the circulation is greatly reduced through its binding 
to TTR.  Because vitamin A is lipid-soluble, it can diffuse across the membranes of cells 
and thus, most tissues receive adequate levels of vitamin A obtained normally from the 
diet without its being bound to RBP.  Studies performed in TTR-knockout mice have 
demonstrated that in the absence of TTR, circulating levels of both RBP and vitamin A 
are dramatically reduced (e.g., 5% of vitamin A seen in wild type [WT] mice); however, 
the concentration of vitamin A in the tissues is comparable with that seen in WT mice.
4,5  
In addition, the TTR-knockout mice did not demonstrate any signs of vitamin A 
deficiency.  In humans, individuals with mutations in the RBP gene leading to complete 
loss of circulating RBP and very low concentrations of circulating vitamin A have not 
shown any significant signs of vitamin A deficiency other than modest retinal dystrophy 
and decrease in night vision.6  This confirmed the finding in mice that vitamin A uptake 
by most tissues continues in the absence of RBP.  In women with breast cancer treated 
for an average of at least 30 months with the retinoid fenretinide, which causes a 75% 
reduction in circulating vitamin A levels, there were no reports of night blindness or any 
other signs of vitamin A deficiency, and only subtle changes in retinal function were seen 
on electroretinograms in women older than 50 years of age who were on fenretinide for 
30 months or longer.7,8  The safety of lowering vitamin A through TTR suppression has 
now been further confirmed by the absence of any vitamin A deficiency-related AEs in 
non-human primates treated with ALN-TTR02 at doses up to 2 mg/kg every 3 weeks for 
9 months, and in both healthy volunteers and familial amyloidotic polyneuropathy (FAP) 
patients treated with ALN-TTR02 who experienced substantial lowering of both TTR and 
vitamin A (see Section 1.3). 
1.1.2   Disease Overview 
Mutations in the TTR gene can lead to destabilization of the tetrameric protein and 
disassociation of the TTR subunits into dimers and individual monomers.  These 
misfolded TTR monomers (both mutant and WT) can then self-assemble into amyloid 
fibrils.
9  The amyloid fibrils are deposited into the extracellular space of various tissues 
where they form amyloid plaques, with the peripheral nervous system, gastrointestinal 
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There are over 100 reported TTR genetic mutations.  These mutations are phenotypically 
expressed as a spectrum of disease which is collectively referred to as TTR-mediated 
amyloidosis (ATTR).10  There is a range of clinical manifestations of ATTR; the most 
common manifestations include some form of cardiac and/or neurologic involvement 
(e.g., cardiomyopathy, autonomic neuropathy, and sensory and motor neuropathy) that 
depends, in part, upon the particular TTR mutation and the site of amyloid deposition.  
Transthyretin amyloidosis is associated with severe morbidity and mortality, with a life 
expectancy limited to approximately 5 to 15 years from symptom onset.11 
Two significant clinical syndromes of ATTR have been described: FAP and familial 
amyloidotic cardiomyopathy (FAC), both of which are characterized by amyloid deposits 
of both mutant and WT TTR.12   
Familial amyloidotic polyneuropathy, caused predominantly by the V30M mutation, 
occurs primarily in families with heritage from Portugal, Sweden, and Japan, has an 
earlier onset (age 30-50 years), and is characterized initially by peripheral neuropathy 
leading to sensory and motor deficits, as well as profound autonomic dysfunction that 
produces disabling gastrointestinal pathology, orthostatic hypotension, and bladder 
dysfunction.13,14  Amyloid infiltration of the sinus node and atrioventricular conduction 
system in the heart is also common in FAP.  Sudden death is not uncommon in FAP, and 
is believed to result from heart block or tachyarrhythmias.
15,16   
Familial amyloidotic cardiomyopathy, caused primarily by the TTR variant V122I, is a 
late-onset (age >60 years) syndrome in which amyloid deposition is largely restricted to 
the heart and manifests as conduction defects, arrhythmias, congestive heart failure, and 
death; neuropathy is uncommon.17  The V122I mutation is found in up to 4% of African 
Americans and in over 5% of West African populations, although rates of disease 
penetrance are low.18   
It is estimated that 45,000 – 50,000 individuals have FAP or FAC.  In both FAP and 
FAC, quality of life is severely impacted following the onset of symptoms, and the 
disease proceeds inexorably to death.19,20 
Because the liver is the primary source of mutant TTR, liver transplantation has been 
used over the past 20 years in an attempt to treat ATTR.1 However, the procedure is only 
effective in halting or slowing the progression of disease in patients with an early age of 
onset,21 especially for those with the V30M mutation and short disease duration prior to 
transplant; consequently almost two-thirds of ATTR patients are not transplant-eligible.  
When performed early in the course of the disease, liver transplantation can stabilize and 
slow progression of neuropathy in patients with FAP due to V30M.  However, in FAC 
patients and FAP patients with evidence of cardiac involvement, liver transplantation is 
contraindicated since it does not halt the progression of cardiac disease in these 
patients,22,23,24,25 and may actually accelerate the course of cardiomyopathy due to further 
deposition of WT TTR (originating from the transplanted liver) in the heart.26 
Tafamidis, a TTR tetramer stabilizer, was approved in November 2011 in the European 
Union (EU) for the treatment of ATTR in adult patients with stage 1 symptomatic 
polyneuropathy to delay peripheral neurologic impairment.27  Diflunisal, another TTR 
tetramer stabilizer, is currently being evaluated in a Phase 3 trial in FAP.  However, the 
large majority of ATTR patients do not qualify for either liver transplantation or 
tafamidis.  In these patients, the disease is primarily managed with palliative care.   


 
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1.1.3   RNA interference 
Ribonucleic acid interference (RNAi) is a naturally occurring cellular mechanism for 
regulating gene expression that is mediated by “small interfering ribonucleic acids” 
(siRNAs).
28  Typically, synthetic siRNAs are 19 to 23 base pair double-stranded 
oligonucleotides in a staggered duplex with a 2-nucleotide overhang at one or both of the 
3
' ends.  Such siRNAs can be designed to target an endogenous or virally-expressed gene.  
When introduced into cells, the net effect of an RNAi-based pharmacological approach is 
the binding of the siRNA to its complementary messenger ribonucleic acid (mRNA) 
sequence, cleavage of this target mRNA, and suppression of the target protein.
29  The 
ability to selectively and potently degrade the mRNA encoding the TTR protein using an 
siRNA offers a potent and specific approach for the treatment of ATTR. 
Unformulated siRNAs, and those without chemical modification, are rapidly degraded 
and eliminated upon systemic administration, and thus do not achieve significant tissue 
distribution.30  As a result, various formulations are used to target siRNA distribution to 
tissues, and to facilitate their uptake into the relevant cell type.  One approach that has 
been used successfully in vivo, including in rodents, non-human primates (NHPs), and 
humans, employs intravenous (IV) delivery of siRNAs in lipid nanoparticles 
(LNPs).
31,32,33,34  These LNPs, with their small size (<100 nm) and low surface charge, 
can pass through the fenestrated vascular endothelium of the liver.  Endocytosis of the 
intact LNPs, followed by fusion with the endosomal membrane and release of the siRNA 
into the cytoplasm, results in the siRNA engaging the endogenous RNAi machinery 
described above to cause targeted degradation of the mRNA, and a consequent reduction 
in target protein levels.
 35,36 
1.1.4   ALN-TTR02 
Alnylam Pharmaceuticals is developing ALN-TTR02 Solution for Injection (hereafter 
referred to as ALN-TTR02), a synthetic investigational RNAi therapeutic comprising an 
siRNA designed to suppress production of both mutant and WT TTR, formulated in a 
second generation LNP termed AF-011.  The LNP enables delivery of the siRNA 
primarily to the liver upon systemic administration, resulting in the down-regulation of 
hepatic TTR expression, and in turn, reducing serum mutant and WT TTR levels.  
ALN-TTR02 is intended for administration as an IV infusion over 70 minutes.   
1.2   Summary of ALN-TTR02 Non-Clinical Data  
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ed 
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Further information can be found in the ALN-TTR02 Investigator’s Brochure (IB). 
1.3   Summary of Clinical Data with ALN-TTR02 
A Phase 1 multicenter, randomized, placebo-controlled, single-blind, single-ascending 
dose clinical study of ALN-TTR02 in healthy volunteers was completed in the UK.  
ALN-TTR02 was administered as a single 60-minute IV infusion to healthy volunteers 
across doses of 10 to 500 µg/kg.  Patients were premedicated with dexamethasone, H1 
and H2 blockers, and paracetamol prior to dosing to minimize the risk of infusion-related 
reactions (IRRs).  Significant pharmacology in terms of TTR protein lowering (>80% 
reduction from pretreatment baseline) was observed at doses ≥0.15 mg/kg.  Transthyretin 
levels showed evidence of recovery beginning at around Day 21-28, with return to 
baseline by Day 70.   
An open-label Phase 2 multiple ascending dose study of ALN-TTR02 in ATTR patients 
with FAP (Study ALN-TTR02-002) is currently enrolling patients to determine the safety 
and tolerability, pharmacokinetic (PK), and pharmacodynamic (PD) of a 60-70 minute IV 
infusion of ALN-TTR02 administered once every 3 -4 weeks for 2 doses.  There have 
been no discontinuations or dose-limiting toxicities, and dosing is currently ongoing with 
the 0.3 mg/kg ALN-TTR02 dose.  The preliminary PD effects on TTR are consistent with 
the data observed in the Phase 1 ALN-TTR02-001 study.  It is anticipated that the 


 
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ALN-TTR02 dose and regimen for long-term dosing will be determined based on 
Study ALN-TTR02-002. 
Further details on these studies can be found in the ALN-TTR02 IB. 
1.4   Study Hypothesis and Rationale 
ALN-TTR02 is a novel drug to treat ATTR and consists of a single LNP-formulated TTR 
siRNA targeting both WT and all known mutant forms of TTR.  Since TTR amyloid 
deposits consist of both mutant and WT TTR, it is desirable to be able to lower the 
production of both WT and mutant TTR with a single drug in order to treat the different 
variants of ATTR.  While liver transplantation has shown both the advantages as well as 
the limitations of eliminating mutant TTR in ATTR, it also underscores the potential 
advantage of a drug that can lower both mutant and WT TTR for treating both the 
neuropathic and cardiac complications of ATTR.   
The ALN-TTR02 nonclinical pharmacology data described in the IB demonstrate that 
administration of ALN-TTR02 results in significant sustained suppression of TTR.  It is 
anticipated that lowering of mutant and WT TTR protein in humans will result in a 
decrease in the deposition of amyloid fibrils, thereby potentially slowing down or 
reversing the course of the disease. 
The primary objective of this study is to evaluate the safety and tolerability of long term 
ALN-TTR02 dosing administered to patients with FAP.  Secondary objectives include 
assessment of the PD effect of ALN-TTR02 on serum TTR, and preliminary evaluation 
of the clinical activity of ALN-TTR02 including neurologic impairment, motor 
functioning impacting activities of daily living, nutritional status, quality of life, and 
disability.  Tertiary objectives include the characterization of plasma and urine PK for 
ALN-TTR02, and other measures of clinical activity including pathologic changes in 
sensory and autonomic innervation, neurologic impairment, autonomic function, 
ambulation, autonomic neuropathy symptoms, and cardiac structure and function (in 
patients with pre-existing cardiac amyloid involvement).   
1.5   Dose Selection and Rationale 
The optimal dose and schedule for ALN-TTR02 is one that will obtain the greatest level 
of sustained TTR suppression with a favorable safety profile.  The experience from other 
systemic amyloidotic disorders,37,38,39,40 as well as the liver transplant data in FAP, 
suggest that lowering of the circulating amyloidogenic protein by at least 50% is required 
to impact the course of the disease, with increases in suppression beyond 50% providing 
further incremental improvements in outcomes.  Based on the data to date from the 
nonclinical and clinical studies with ALN-TTR02, >80% suppression of circulating TTR 
is achieved consistently at the 0.3 mg/kg dose, and is anticipated to be the dose for the 
Phase 3 trial.  Dosing once every 3 or 4 weeks is currently being explored in Study ALN-
TTR02-002; the schedule that is well tolerated and provides optimal PD effect will be 
employed in this study. 
1.6   Risk-Benefit Assessment 
Further details about potential benefits and risks can be found in the IB. 


 
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1.6.1   Potential Benefit 
Patisiran is a novel investigational agent intended for the treatment of FAP, a serious and 
life-threatening orphan disease. The therapeutic hypothesis that systemic amyloidoses can 
be managed by reduction in circulating levels of amyloidogenic protein has been 
validated in other acquired (e.g., immunoglobulin light chain systemic [AL], or amyloid 
A [AA]) and hereditary (e.g. Fibrinogen A α-chain, ApoA1) amyloidosis.  The 
experience from these systemic amyloidotic disorders,41,42,43,44 as well as the liver 
transplant data in FAP, suggest that lowering of the circulating amyloidogenic protein by 
at least 50% is required to impact the clinical course of the disease, with reductions in 
protein beyond 50% providing further incremental improvements in outcomes.  It is 
therefore postulated that the >80% suppression in both WT and mutant TTR observed 
upon administration of 0.3 mg/kg patisiran once every 21 days will result in clinical 
benefit in FAP patients with mild to moderate polyneuropathy.  This hypothesis is further 
supported by evidence from tafamidis suggesting that reduction in free TTR monomer 
can slow neuropathy progression in early-stage V30M patients with FAP.45  
Data as of March 13, 2015 demonstrate a sustained mean serum TTR knockdown of 
approximately 80%, with mean nadir up to 88% between doses, for approximately 16 
months. Neuropathy impairment scores were stable through 12 months with mean change in 
mNIS+7 and NIS of -2.5 and +0.4 points, respectively. 
1.6.2   Potential Risks 
1.6.2.1 Infusion-Related Reactions 
Infusion-related reactions can occur with systemic administration of certain biological 
agents such as liposomes or monoclonal antibodies.  These may include acute reactions 
and/or delayed febrile reactions.  Premedicating patients with corticosteroids and/or 
antihistamines, or slowing of the infusion rate, are approaches that have been taken to 
reduce the incidence and/or severity of infusion-related reactions (IRRs).
46,47,48  
Consistent with this, a premedication regimen (dexamethasone or equivalent, 
paracetamol or equivalent, histamine H1/H2 receptor antagonist [H1/H2 blocker]) similar 
to that proposed for this study was used in the prior ALN-PCS02, ALN-VSP02, 
ALN-TTR01, and ALN-TTR02 clinical studies that employed siRNAs in LNP 
formulations (Section 1.3).  In these studies, while IRRs have been observed, including 
with ALN-TTR02, they have been generally managed with temporarily stopping the 
infusion and resuming administration at a slower rate for the remainder of the dose; no 
subjects have discontinued dosing due to an IRR. 
In order to reduce the potential for an IRR with ALN-TTR02, all patients in this study 
will be premedicated prior to dosing with ALN-TTR02.  The premedication regimen is 
described in Section 5.5).  The infusion rate of approximately 70 minutes may further 
reduce the potential for an acute IRR.   
1.6.2.2 Vitamin A Lowering 
The suppression of serum levels of TTR and RBP are expected to result in the lowering 
of circulating vitamin A levels.  Preclinical and clinical data have shown that the 
lowering of circulating vitamin A associated with suppression of RBP does not result in 
severe vitamin A deficiency, as there are mechanisms independent of RBP by which 
vitamin A is transported to tissues and taken up by cells.  Provided there is adequate 


 
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vitamin A in the diet, tissue stores of vitamin A should not be affected by the lowering of 
TTR and RBP.  As the vitamin A content of the diet may vary between different 
countries and different individuals within a country, the recommended daily allowance of 
vitamin A will be provided to all patients on the study. 
1.6.2.3 Osteoporosis 
Patients with FAP may be at risk for osteoporosis.49 In addition, as part of the 
premedication regimen administered prior to patisiran dosing every three weeks, FAP 
patients participating in this study are given glucocorticoids, a drug known to have the 
potential to reduce bone mineralization.  If there are no medical contraindications, and 
per investigator judgment and local standard of care, study participants should, if 
appropriate, receive therapy for the prevention and early treatment of osteoporosis such 
as: calcium and vitamin D supplementation, bisphosphonates, calcitonin, parathyroid 
hormone, estrogen agonist/antagonist or combination therapies. 


 
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2   
STUDY OBJECTIVES 
2.1   Primary Objective 
The primary objective of this study is to evaluate the safety of long-term (approximately 
2 years) dosing with ALN-TTR02. 
2.2   Secondary Objectives 
Secondary objectives include: 
• Assessing the PD effect of long-term dosing of ALN-TTR02 on serum TTR. 
• Assessing changes from baseline in: 
• Neurologic impairment using the modified Neuropathy Impairment Score 
(mNIS) +7 composite score 
• Quality of life (EQ5D) and disability (Rasch-built Overall Disability Scale 
[R-ODS]) 
• Motor function impacting activities of daily living, including a 10-meter walk 
test and test of grip strength 
• Nutritional status (modified body mass index [mBMI]) 
2.3   Tertiary Objectives 
Tertiary objectives include: 
• Further characterization of the plasma and urine PK of ALN-TTR02. 
• Assessing changes in: 
• Secondary PD biomarkers (RBP and vitamin A) 
• Sensory and autonomic innervation (skin punch biopsies for intraepidermal 
nerve fiber density [IENFD] and sweat gland nerve fiber density [SGNFD]) 
• NIS and vibration detection threshold (VDT) 
• Heart rate variability with deep breathing (HRdb) 
• Ambulation, using FAP stage and Polyneuropathy Disability (PND) score 
• Patient reported autonomic neuropathy symptoms using the Composite 
Autonomic Symptom Score (COMPASS 31) questionnaire 
• Healthcare utilization using a pharmacoeconomics questionnaire 
• Cardiac structure/function through echocardiograms and serum levels of 
troponin I and N-terminal prohormone of B-type natriuretic peptide 
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STUDY PLAN 
3.1   Overall Design 
Protocol ALN-TTR02-003 is a multinational, multicenter, Phase 2, open-label, extension 
study designed to evaluate the safety and tolerability of long term ALN-TTR02 dosing 
administered to patients with FAP; additional information to be evaluated include PK, 
PD, and clinical activity.  
Patients eligible for inclusion in this study had to have previously received and tolerated 
ALN-TTR02 in Study ALN-TTR02-002.  In addition, they must have an adequate 
performance status (Karnofsky performance status of 60% or greater; see Appendix 1), 
and adequate hepatic and renal function.   
Patients will be eligible for inclusion in the PK/PD subgroup if their last dose of 
ALN-TTR02 was administered at least 6 months prior to the first dose in this study.  
Patients who have pre-existing cardiac amyloid involvement will be eligible for inclusion 
in the Cardiac subgroup. 
The duration of patient participation in this study is approximately 2 years and 4 months.  
Patients will be screened within 28 days prior to administration of study medication.  In 
order to reduce the potential of an IRR, patients will receive the following premedications 
at least 60 minutes prior to the start of infusion of ALN-TTR02: IV dexamethasone (or 
equivalent), oral paracetamol (or equivalent), and IV H1 and H2 blockers.  ALN-TTR02 
will be administered as a 70-minute IV infusion once every 3 or 4 weeks (based on 
results from the ongoing ALN-TTR02-002 study where the safety and PD of these 2 
dosing schedules is being evaluated).  The infusion time may be extended up to 3 hours 
in the event of a mild or moderate IRR (study drug administration will not be resumed for 
any patient following a severe IRR).  Details on the study drug administration are 
provided in Section 5.6.  Patients will remain at the clinic from 1-6 hours after the end of 
the study drug infusion.  In addition to returning to the site for dosing of study 
medication, patients will also return for out-patient visits approximately every 6 months 
for safety, PK, PD, and clinical activity monitoring (see Section 6 for details).   
3.2   Safety Assessments 
Safety monitoring will include assessment of AEs, 12-lead ECGs, vital signs (blood 
pressure, pulse rate, oral body temperature, and respiratory rate), clinical laboratory 
safety tests (hematology, serum chemistry, thyroid function parameters, coagulation 
parameters, and urinalysis), and ophthalmology and physical examinations.  Patients will 
be closely monitored for both acute and delayed IRRs (see Section 5.11 for clinical 
guidance).  All IRRs will be recorded as AEs. 
3.3   Pharmacodynamic Assessments 
The PD associated with long-term dosing of ALN-TTR02 in patients with FAP will be 
evaluated by serial measurement of serum TTR.  Secondary PD biomarkers to be 
assessed include RBP and vitamin A. 
3.4   Pharmacokinetic Assessments 
Pharmacokinetic analyses will be conducted using noncompartmental and/or 
compartmental evaluation.  The PK parameters of siRNA, 1,2-dilinoleyloxy-N,N-
dimethylpropylamine (DLin-MC3-DMA) and polyethylene glycol 3-N-[(ω-methoxy 


 
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poly(ethylene glycol)2000) carbamoyl]-1,2-dimyristyloxy-propylamine (PEG2000-C-
DMG) (lipid) in plasma obtained from the PK/PD subgroup will be evaluated with 
concentration-time profiles obtained at Day 0 and Months 8 and 24 with blood samples 
that will be collected pre- and postdose at specified time points up to receiving the next 
subsequent dose.  Pharmacokinetic parameters will be calculated using a validated 
version of WinNonlin® Enterprise (Version 5.2 or higher) with NCA Model 200.   
Population PK analyses will be performed on available siRNA and possibly DLin-MC3-
DMA on samples obtained from the PK/PD subgroup including the sparse samples 
collected during the study period.  Population PK modeling of siRNA and possibly 
DLin-MC3-DMA in plasma will be performed with Phoenix NLME (Version 1.1 or 
later).  Summary tables and figures and inferential statistics will be generated with 
Phoenix NLME (Version 1.1 or later) or similar software.   
Pharmacokinetic/PD analysis will be conducted of samples from the PK/PD subgroup, 
including sparse samples collected during the study period.  The analysis will include, but 
not limited to, the determination of the relationship between exposure to siRNA, 
DLin-MC3-DMA and PEG2000-C-DMG and the extent of suppression of TTR, RBP, and 
vitamin A and their correlation will be evaluated.  Correlation between TTR versus RBP 
and vitamin A will also be performed.  Whenever possible the strength of the relationship 
will be assessed using statistical estimators.  As part of the PK/PD analysis, additional PD 
baseline analysis on serum TTR, RBP, and vitamin A may be conducted to include the 
PD data obtained post-PD recovery period.  The PD and PK/PD analysis will be 
performed with WinNonLin or Phoenix NLME (Version 1.1 or later) or similar software.  
The PD and PK/PD parameters summary tables and figures and inferential statistics will 
be generated and will not be limited to descriptive statistics. 
Urine samples will be collected from the PK/PD subgroup subjects including sparse 
samples collected during the study period.  Renal clearance (CLR) will be determined for 
siRNA and 4-dimethylaminobutyric acid, metabolite of DLin-MC3-DMA, excreted in the 
urine.  Urine samples and urine volume void will be obtained at specified time points.  
3.5   Clinical Activity Assessments 
The clinical activity of ALN-TTR02 will be evaluated through changes in 
polyneuropathy measures.  Neurologic impairment will be assessed using the mNIS + 7 
composite score.  Quality of life and disability will be assessed through the EQ5D and R-
ODS, respectively.  The influence of changes in motor function impacting activities of 
daily living will be assessed using a 10-meter walk test and a grip strength test.  Patient 
reported autonomic neuropathy symptoms will be assessed using COMPASS 31.  The 
nutritional status of the patients will be monitored through mBMI. 
Other measures of the clinical activity of ALN-TTR02 will be evaluated through IENFD, 
SGNFD, NIS, VDT, HRdb, FAP stage, and PND score. 
3.6   Additional Assessments for the Pharmacokinetic/Pharmacodynamic 
Subgroup 
Patients enrolled in the PK/PD subgroup will have additional samples taken for 
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3.7   Additional Clinical Activity Assessments for the Cardiac Subgroup 
Patients enrolled in the Cardiac subgroup will complete additional clinical activity 
assessments to evaluate cardiac structure/function.  This will be achieved through 
echocardiograms and monitoring of NT-proBNP and troponin I. 
3.8   Other Assessments 
Disease burden and healthcare utilization will be assessed using a patient-reported 
pharmacoeconomics questionnaire.  Blood will also be collected to evaluate anti-drug 
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4   
PATIENT POPULATION 
4.1   Eligibility of Patients 
Up to 28 patients are expected to be enrolled.  All centers have been selected on the basis 
of their extensive experience with treatment of patients with FAP, their participation in 
Study ALN-TTR02-002, and have the equipment necessary to treat patients in case of an 
emergency. 
4.2   Inclusion Criteria 
Each patient must meet all of the following criteria within the Screening/Baseline period 
to be enrolled in the study: 
1. Patients have previously received and tolerated ALN-TTR02 in 
Study ALN-TTR02-002. 
2. Karnofsky performance status of 60% or greater. 
3. Absolute neutrophil count (ANC) ≥1500 cells/mm³, platelet count 
≥100,000 cells/mm³, and hemoglobin ≥10 g/dL. 
4. Adequate liver function, demonstrated by an aspartate transaminase (AST) and 
alanine transaminase (ALT) levels ≤2.5 × the upper limit of normal (ULN), total 
bilirubin level within normal limits, albumin >3 g/dL, international normalized 
ratio (INR) ≤1.2. 
5. Adequate renal function, demonstrated by serum creatinine level ≤1.5 × ULN. 
6. Women of child-bearing potential must have a negative pregnancy test, cannot be 
breast feeding, and must be using 2 highly effective methods of contraception 
prior to screening, throughout study participation, and for 75 days after the last 
dose of study medication.  Highly effective methods of birth control are defined 
as: hormonal - oral, implantable, injectable, or transdermal contraceptives in 
conjunction with spermicide, condom, or diaphragm; mechanical - spermicide in 
conjunction with a barrier such as a condom or diaphragm; intrauterine device in 
conjunction with spermicide or condom; or surgical sterilization of partner in 
conjunction with spermicide, condom, or diaphragm. 
7. Males agree to use appropriate contraception throughout study participation and 
for 75 days after the last dose of study medication. 
8. Patient is willing and able to comply with protocol-required visit schedule and 
visit requirements and provide written informed consent. 
Additional inclusion criteria for patients participating in the PK/PD subgroup include: 
9. At the time of enrollment, at least 6 months have elapsed since the patient’s last 
dose of ALN-TTR02. 
Additional inclusion criteria for patients participating in the Cardiac subgroup: 
10. Have a left ventricular wall thickness of ≥13 mm on transthoracic 
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11. Be normotensive or have hypertension that is well-controlled. 
12. Absence of aortic valve disease. 
4.3   Exclusion Criteria 
Patients meeting any of the following criteria within the Screening/Baseline period 
(Day -28 to Day 0) will be excluded from the study: 
1. Patient is pregnant or nursing. 
2. Patient has had a liver transplant. 
3. Has a known or suspected systemic bacterial, viral, parasitic, or fungal infection. 
4. Patient received an investigational agent, other than tafamidis or diflunisal, within 
30 days prior to first dose study drug administration. 
5. Patient has a New York Heart Association heart failure classification >2 (see 
Appendix 3). 
6. Patient has unstable angina. 
7. Patient has uncontrolled clinically significant cardiac arrhythmia. 
8. Patient is considered unfit for the study by the Principal Investigator (PI). 
4.4   Blinding Procedure 
This is an open-label, single-arm study; all patients will receive 0.3 mg/kg ALN-TTR02.  
No blinding procedures will be needed. 
4.5   Early Patient Withdrawal 
Patients are free to withdraw from the study at any time and for any reason, without 
penalty to their continuing medical care.  A patient will be considered to have completed 
the study if the patient completes protocol-specified procedures up through the 21-day 
Follow-up visit for patients continuing into the global extension study, and up through the 
56-day Follow-up visit for Year 2 for patients not continuing into the global extension 
study.  For patients who withdraw from the study early, every effort should be made to 
complete the Early Termination (ET) visit. 
4.5.1   Reasons for Withdrawal 
The Investigator may withdraw a patient from the study if the patient: 
• Is in violation of the protocol 
• Experiences a serious or intolerable adverse event (AE) 
• Develops conditions listed in the exclusion criteria during the course of the study 
• Becomes pregnant 
• Requires a prohibited medication (see Section 5.10) 
• Requests to be withdrawn from the study 
• Is found to be considerably non-compliant with the protocol required ALN-TTR02 
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A patient may be withdrawn from the study if, in the Investigator’s opinion, they are 
unable to continue.  The Investigator will also withdraw the patient from the study upon 
the request of Alnylam, including if Alnylam terminates the study.  Upon occurrence of a 
serious or intolerable AE, the Investigator will confer with Alnylam before discontinuing 
the patient.  A patient may withdraw consent to participate in the study at any time. 
Missing an occasional dose of study medication will not necessarily result in the patient 
being withdrawn from the study.  However, if a patient misses 3 consecutive doses of 
ALN-TTR02, the Investigator at the site and the Medical Monitor will determine whether 
the patient will be withdrawn from the study.  If the patient is withdrawn from the study, 
the reason will be noted on the case report form (CRF). 
4.5.2   Handling of Withdrawals 
In the event a patient is withdrawn from the study, the contract research organization 
(CRO) Medical Monitor must be informed immediately.  If there is a medical reason for 
withdrawal, the patient will remain under the supervision of the Investigator for protocol-
specified safety follow-up procedures.   
Patients who voluntarily withdraw are termed dropouts.  Dropouts will not be replaced.   
If a patient is withdrawn/withdraws every effort should be made to conduct the ET visit.  
Patients who fail to return for final evaluations will be contacted by the site in an attempt 
to have them comply with the protocol.  The site will follow-up by telephone at least 
twice and send a registered letter to any patient who fails to return for the final 
evaluation. 
When a patient withdraws from the study, the primary reason for discontinuation must be 
recorded in the appropriate section of the CRF and all efforts will be made to complete 
and report the observations as thoroughly as possible.   


 
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5   
STUDY MEDICATION 
5.1   Presentation of Study Drug 
ALN-TTR02 Solution for Injection is an RNAi therapeutic consisting of an siRNA 
targeting TTR mRNA formulated in LNPs.  The ALN-TTR02 drug product is a sterile 
formulation of TTR siRNA with lipid excipients (DLin-MC3-DMA, DSPC, cholesterol, 
and PEG
2000-C-DMG) in isotonic phosphate buffered saline.  ALN-TTR02 Solution for 
Injection contains 2 mg/mL of TTR siRNA drug substance. 
The ALN-TTR02 drug product is packaged in 10 mL glass vials with a fill volume of 
5.5 mL.  The container closure system consists of a United States 
Pharmacopeia/European Pharmacopoeia (USP/EP) Type I borosilicate glass vial, a 
Teflon-faced butyl rubber stopper, and an aluminium flip-off cap. 
5.2   Preparation of Study Drug 
Each investigational site will be responsible for IV preparation and labeling according to 
separate handling instructions and allocating treatments to the patients. 
The pharmacist will prepare the study drug under aseptic conditions.  The amount (in mg) 
of ALN-TTR02 to be administered will be determined based on the patient’s weight (kg).  
For each dose administered, the weight obtained during the previous dosing day should 
be used to calculate the dose of study drug.  In the event that the weight obtained on the 
previous dosing day is not available, the weight obtained pre-dose on the dosing day can 
be used for dose calculation.  Patients who weigh 105 kg or more will receive ALN-
TTR02 dosing based on an assumption of a body weight of 104 kg. 
A total of 200 mL will be infused into patients.  Sterile normal saline (0.9% NaCl) will be 
added to a sterile infusion bag, and the calculated volume of ALN-TTR02 will be 
withdrawn from the vials and injected into the infusion bag. 
Additional study drug preparation details are provided in the ALN-TTR02 Pharmacy 
Manual. 
5.3   Storage of Study Drug 
All study drug must be stored in a secure, temperature controlled location and may be 
dispensed only by a staff member specifically authorized by the Investigator or by a 
pharmacist, as appropriate.  All study medication will be stored upright and refrigerated 
at approximately 5 ± 3
oC.  Any deviation from the recommended storage conditions 
should be reported to the CRO and/or Alnylam and use of the study drug halted until 
authorization for its continued use has been given by Alnylam or designee. 
No special procedures for the safe handling of ALN-TTR02 are required.  Alnylam will 
be permitted, upon request, to audit the supplies, storage, dispensing procedures, and 
records. 
No trial product(s) may be administered to any person not enrolled in the trial. 
Additional storage details are provided in the ALN-TTR02 Pharmacy Manual. 
5.4   Labeling and Packaging of Study Drug 
All packaging and labeling as well as the preparation of ALN-TTR02 IV will be in 
compliance with Good Manufacturing Practice (GMP) specifications, as described in the 


 
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Manufacture of Investigational Medicinal Products Volume 4 Annex 13, and any other or 
local applicable regulations. 
Study drug labels will include all appropriate local labeling requirements on the vial and 
external label.  Sample labels will be submitted to health authorities, per local country 
submission requirements. 
5.5   Premedication Plan 
Prior to ALN-TTR02, patients will receive the following premedications: 
• Intravenous dexamethasone (10 mg) or equivalent, administered at least 60 minutes 
prior to the start of the infusion of ALN-TTR02; 
• Oral paracetamol (500 mg) or equivalent at least 60 minutes prior to the start of the 
infusion of ALN-TTR02; 
• Intravenous H2 blocker (e.g., ranitidine 50 mg, famotidine 20 mg, or equivalent other 
H2 blocker dose) at least 60 minutes prior to the start of the infusion of ALN-TTR02; 
and 
• Intravenous H1 blocker: diphenhydramine 50 mg (or equivalent other IV H1 blocker 
available at the study site) at least 60 minutes prior to the start of the infusion of 
ALN-TTR02.  Hydroxyzine or fexofenadine 25 mg PO or cetirizine 10 mg PO may 
be substituted for any patient who does not tolerate IV diphenhydramine or other IV 
H1 blocker. 
Patients will be started on the above premedication regimen.  However, modifications 
may be made to the premedication regimen after consultation with the medical monitor 
either due to a patient’s inability to tolerate one or more of the premedications or to the 
occurrence of IRRs unresponsive to slowing of the infusion rate. 
• If a patient is having difficulty tolerating the steroid premedication regimen (e.g., 
patient develops uncontrolled hyperglycemia, altered mental status, or other 
complication), then lowering of the steroid premedication may be allowed for that 
patient after consultation with the medical monitor.  
• If after consultation with the medical monitor, it is agreed that an individual patient’s  
steroid premedication will be lowered, then the following steps must be followed: 
1) If the current steroid dosage is 10 mg intravenous dexamethasone or equivalent, 
then the patient may be lowered in increments no greater than 2.5 mg 
intravenous dexamethasone or equivalent. 
2) After each incremental lowering below 10 mg intravenous dexamethasone or 
equivalent, the patient must receive three consecutive intravenous doses of 
patisiran without IRR and continued signs or symptoms of steroid intolerance 
before further reductions in steroid premedications.   
3) The premedication steroid dosage should not be reduced below 5 mg intravenous 
dexamethasone or equivalent. 
Alternatively, if a patient experiences an IRR when 10 mg or less of intravenous 
dexamethasone or equivalent is used as the steroid premedication, then proceed to 
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Further details can be found in the Study Reference Manual.   
5.6   Dose, Route, and Schedule of Study Drug Administration 
Patients meeting the eligibility criteria will receive 0.3 mg/kg ALN-TTR02 once every 3 
or 4 weeks, based on results from the ongoing ALN-TTR02-002 study where the safety 
and PD of 2 dosing schedules are being evaluated. 
Study drug will be administered under the supervision of the Investigator or designee, as 
a 70-minute IV infusion (or at a more prolonged infusion rate if required due to prior 
IRR).  ALN-TTR02 will be administered via a controlled infusion device with an 
extension set containing a 1.2 micron filter supplied by Alnylam or designee.  Infusion 
products containing polyvinyl chloride, di(2-ethylhexyl)phthalate (PVC, DEHP) must 
NOT be used.   
• If the patient experiences an IRR the infusion time may be extended up to 3 hours in 
the event of a mild or moderate IRR. 
1) If the patient experiences a mild or moderate IRR that resolves by slowing the 
infusion rate then no further premedication changes are recommended. 
2) If the patient experiences a severe IRR, then patisiran administration will not be 
resumed until the case is discussed with the Medical Monitor (see Section 5.11).   
• If the infusion time for a patient was already extended on the parent study due to an 
IRR, that modified infusion duration may be continued on this study for that 
particular patient.  Returning the patient’s infusion duration to 70 minutes will require 
a discussion with the Medical Monitor. 
• For the first 3 infusions of patisiran on this study, the patient’s infusion site should be 
assessed for signs of any localized reaction during the infusion and for 30 minutes 
after the end of the infusion, and the patient will remain at the clinical site for 1 hour 
following completion of dosing. 
Additional details can be found in the Pharmacy Manual. 
In addition, patients will receive an oral daily supplemental dose of the recommended 
daily allowance of vitamin A that should be taken after blood draws on study visit days.   
5.7   Criteria for Dose Modification or Discontinuation of Study Drug 
If a study drug related AE occurs in a patient that the Investigator judges as presenting a 
potential risk to the patient for further dosing, the Medical Monitors and Investigator will 
review all available safety data for that patient and for all other patients enrolled in the 
study.  Based on this review it may be decided to discontinue further administration of 
ALN-TTR02, or, if the Investigator concurs, the patient may resume ALN-TTR02 as 
before or any of the following modifications may be instituted for that patient: reduce the 
dose of ALN-TTR02 to 0.15 mg/kg, modify the premedication regimen, and/or increase 
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5.8   Measurement of Patient Compliance 
Patient compliance with study drug administration is dependent on the proper preparation 
and administration of IV infusions by study site personnel.  Treatment compliance will be 
verified by study staff observation. 
Patients will be permitted to miss an occasional dose of study medication.  However, if a 
patient misses 3 consecutive doses of ALN-TTR02, the PI, in consultation with the 
Medical Monitor, will determine whether the patient will be able to continue on the 
study. 
5.9   Study Drug Accountability 
The Investigator will maintain accurate records of receipt and the condition of all study 
drugs including dates of receipt.  In addition, accurate records will be kept of the weight 
used to calculate each dispensed ALN-TTR02 dose, and when and how much study drug 
is dispensed and used by each patient in the study.  Any reasons for departure from the 
protocol dispensing regimen must also be recorded. 
Drug accountability records and inventory will be available for verification by an 
Alnylam Monitor or designee.  Remaining study drug (all used, partially used and unused 
vials) will be returned to Alnylam or its specified designee/depot or destroyed at the site 
according to applicable regulations. 
Study drug must not be used for any purpose other than the present study.  Study drug 
which has been dispensed for a patient and returned unused must not be redispensed. 
Further instructions about study drug accountability are detailed in the Pharmacy Manual. 
5.10   Concomitant Medication / Treatment 
Use of the following medications/treatments is prohibited during study participation: 
• Any investigational agent other than ALN-TTR02. 
• Concurrent tafamidis or diflunisal (permitted only if started prior to study entry). 
• Corticosteroids, other than those administered as premedications prior to the dose of 
ALN-TTR02, those used to treat an infusion reaction, or topical or inhaled 
corticosteroids. 
Medications and treatments other than those specified above, including palliative and 
supportive care for disease-related symptoms, are permitted during the study. 
Use of all concomitant medications during Screening/Baseline, pre-dose, and post-dose 
up to end of participation in the study will be recorded on the patient’s CRF.  This will 
include all prescription drugs, herbal preparations, over-the-counter (OTC) medications, 
vitamins, and minerals.  Any changes in medications during the study will also be 
recorded on the CRF. 
Any concomitant medication that is required for the patient’s welfare may be given by 
the Investigator.  However, it is the responsibility of the Investigator to ensure that details 
regarding the medication are recorded on the CRF, and coded using an internationally 
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5.11   Suggested Guidelines for Management of Infusion Reactions 
In the event of an acute infusion reaction, the infusion of study drug will be stopped and 
the patient closely monitored until resolution of the reaction. 
• In the event of an IRR, the infusion of patisiran may be stopped and the patient 
closely monitored until resolution of the reaction.  Drugs that may be used to 
facilitate resolution and permit resumption of patisiran administration include, but are 
not limited to: paracetamol/acetaminophen (or equivalent), additional histamine 
H1/H2 receptor antagonists (eg, ranitidine), NSAIDs, adrenaline, supplemental 
oxygen, IV fluids, and/or corticosteroids. 
• Following resolution of a mild or moderate IRR that required interruption of the 
patisiran infusion, resumption of administration may occur at the Investigator’s 
discretion at a slower infusion rate (but not to exceed 3 hours) for that dose and for all 
subsequent doses of patisiran.  If the infusion is delayed, the administration of the 
infusion should be completed no more than 6 hours from the initial start of the 
infusion.   
• Patisiran administration will not be resumed for any patient following a severe IRR 
until the case is discussed with the Medical Monitor. 
• If after consultation with the medical monitor it is agreed that an individual patient’s  
steroid premedication will be increased then the following steps are recommended: 
1)  If the IRR occurred while the patient received 10 mg intravenous 
dexamethasone or equivalent at least 60 minutes before the infusion and did not 
resolve with slowing of the infusion rate, then the patient should be increased by 
multiples of 5 mg intravenous dexamethasone or equivalent at least 60 minutes 
before the infusion and/or 5 mg oral dexamethasone or equivalent the night 
before the intravenous infusion.  
2) Increased dose of premedication steroids should NOT exceed the combination of 
20 mg intravenous dexamethasone or equivalent on the day of infusion and 8 mg 
oral dexamethasone or equivalent taken the night before the infusion.  
3) If the IRR occurred while the patient received less than 10 mg intravenous 
dexamethasone or equivalent, then the patient should return to the prior dose of 
intravenous dexamethasone or equivalent that did not result in an IRR. 
 
After dosing, patients will remain at the study site for at least 1 hour for observation and 
PK assessments.  Subjects in the PK/PD subgroup will remain at the study site for 6 
hours for additional PK assessments following the first dose and the doses given at 8 and 
24 months.  Patients will be provided directions on self-administration of medications as 
needed to ameliorate reactions experienced outside of the study site to study drug 
infusion, such as fever, chills, and myalgia and to contact the Investigator if they 
experience any of these symptoms.  Medications may include, but are not limited to: 
antipyretics, antihistamines, and oral corticosteroids.  All concomitant medications, 
including self-administered medications, are to be listed on the CRF. 


 
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Patients will be instructed to contact the Investigator should they experience any 
reactions after leaving the study site. 


 
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6   
STUDY VISITS 
The duration of a patient’s participation in this study is approximately 2 years and 
4 months.   
Screening/Baseline evaluations are to be performed within 28 days before receiving the 
first dose of study drug, as indicated in Table 1-1 and (Appendix 2 provides the schedule 
of assessments for patients administered ALN-TTR02 once every 4 weeks).  Patients 
determined to be eligible based on Screening/Baseline assessments will receive treatment 
(IV infusion of study drug) once every 3 or 4 weeks; based on results from the ongoing 
ALN-TTR02-002 study where the safety and PD of 2 dosing schedules are being 
evaluated.  Patients will remain at the study site for at least 1 hour following completion 
of dosing for observation and for PK sampling.  Subjects in the PK/PD subgroup will 
remain at the study site for 6 hours following completion of dosing following the first 
dose and the doses given at 8 and 24 months for additional PK sampling.  Patients will 
return to the study site for clinical activity assessments approximately once every 
6 months. 
All patients who discontinue the study before the 56-day Follow-up visit (or before the 
21-day Follow-up visit for those patients continuing into the global extension study) will 
return to the study site for their Early Termination visit assessments.   
Visiting nurses may conduct interim PK/PD visits. 
6.1   Screening/Baseline Visit (Day -28 to 0) 
Screening/Baseline evaluations will be conducted up to 28 days prior to administration of 
the first dose of study drug (Day 0).  Table 1-1 provides an overview of the schedule of 
events required for Screening/Baseline. 
Prior to Screening/Baseline activities, the patient will sign and date an informed consent 
form (ICF) and receive a copy of the signed ICF.  No study procedures should be 
performed prior to informed consent being obtained.  The Investigator or another person 
authorized by the Investigator will also sign and date the informed consent prior to giving 
a copy to the patient.  The ICF will be filed in the patient’s medical record. 
The following activities should be performed during the Screening/Baseline visit as part 
of the initial screening: 
• Obtain demographic information 
• Obtain medical history information 
• Assess study eligibility using the inclusion and exclusion criteria 
• Obtain concomitant medications information 
• Perform a physical examination, including weight 
• Measure height 
• Measure vital signs 
• Perform an echocardiogram 
• Perform a 12-lead ECG 
• Collect blood samples for clinical laboratory tests, including: 


 
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• Hematology 
• Serum chemistries 
• Coagulation studies 
• Thyroid function tests 
• Collect blood sample for serum TTR protein, RBP, and vitamin A.  Additionally, 
aliquots of serum samples will be taken and frozen, to permit testing of additional 
proteins related to FAP. 
• Collect blood sample for exploratory biomarkers and ADA 
• Collect urine sample for urinalysis 
• Perform a urine pregnancy test (for females of child-bearing potential only) 
• Once the patient is deemed eligible to participate in the study, the following clinical 
activity assessments should be performed: 
• mNIS + 7* 
• VDT* 
• Grip strength* 
• Ten-meter walk test* 
• mBMI 
• NIS* 
• HRdb* 
• COMPASS 31  
• EQ5D 
• R-ODS 
• Pharmacoeconomics questionnaire 
• PND score 
• FAP stage 
• Collect paired 3-mm skin punch biopsies for IENFD and SGNFD analysis 
*Must be performed within 14 days prior to the first dose of study drug. 
• Perform an ophthalmology examination. 
Note:  Any of the above assessments that are performed during the ALN-TTR02-002 
study during the Screening/Baseline timeframe for ALN-TTR02-003 will not need to be 
repeated at the Screening/Baseline visit. 


 
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6.2   Treatment Visits 
6.2.1   Routine Study Visits  
The procedures described below are to be performed for all study visits, with the 
exception of the Mid-Year and Annual visits occurring approximately once every 
6 months during which patients undergo assessment of clinical activity parameters. 
Patients who are determined to be eligible for the study, based on Screening/Baseline 
evaluations, will be enrolled on Day 0. 
On all study visit days, patients should take their vitamin A supplement after blood 
draws. 
6.2.1.1 Pre-dosing 
Patients will undergo the following procedures before study drug administration: 
• Obtain measurements of: 
• Weight 
• Vital signs 
• Collect blood samples for serum chemistries at first dose, and during the 3, 6, 9, 12, 
15, 18, 21, and 24 month dosing days: 
• Collect blood samples for hematology, coagulation, and thyroid function tests at first 
dose and during the 6, 12, 18, and 24 month dosing days. 
• Collect urine sample for urinalysis at first dose and during the 3, 6, 9, 12, 15, 18, 21 
and 24 month dosing days. 
• Collect blood sample for PK pre-dose (within 1 hour of planned dosing 
start; -5 minutes) for the first dose and every dose up through, and including, the 3 
month dosing visit, and then on 6, 9, 12, 15, 18, 21, and 24 month dosing days. 
• Collect urine sample for PK pre-dose (within 1 hour of planned dosing 
start; -5 minutes) for the first dose and every dose up through, and including, the 3 
month dosing visit, and then on 6, 9, and 12 month dosing days. 
• Obtain concomitant medications information. 
• Collect blood samples for TTR and secondary PD biomarkers immediately 
(10 minutes) prior to and after administration of premedication, but before dosing of 
ALN-TTR02 at first dose on Day 0.  A single sample will be collected during the 3, 6, 
9, and 12 month dosing days prior to administration of premedication.  After the 12 
month dosing day, a single blood sample for TTR will be collected prior to 
administration of premedication for each dosing day, except for the mid-year and 
annual clinical visits (TTR collection for these visits is described in Section 6.2.2). 
• Collect blood samples for exploratory biomarkers pre-dose at first dose, and during 
the 3, 6, 9, 12, 15, 18, 21, and 24 month dosing days. 
• Collect blood samples for ADA at first dose, second dose, and at the 3, 6, 12, and 24 
month dosing days. 
• Administer premedications (see Section 5.5) 


 
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6.2.1.2 Administration of Study Drug 
After completion of all pre-dose evaluations and procedures, ALN-TTR02 will be 
administered as a 70-minute IV infusion (or at a more prolonged infusion rate if required 
due to prior IRR) by a controlled infusion device.  The infusion site will continue to be 
assessed for signs of any localized reaction through 30 minutes postdose. 
The infusion time may be extended up to 3 hours in the event of a mild or moderate 
infusion reaction (study drug administration will not be resumed for any patient following 
a severe infusion reaction).  Suggested guidelines for treatment of infusion reactions are 
provided in Section 5.11.  In addition, if the infusion is stopped and the site is considering 
restarting the infusion, a PK blood sample will be taken when the infusion was stopped.  
All remaining PK samples will be collected according to the schedule of assessments 
when the dose is completed. 
6.2.1.3 Post-dose 
Patients will remain at the study site for at least 1 hour following completion of dosing 
for the following assessments:  
• Collect blood samples for PK analyses at EOI and 1 hour post-dose for the first dose 
and every dose up through, and including, the 3 month dosing visit, and then on 6, 9, 
and 12 month dosing days.  Collect blood samples for PK analyses at EOI 
(+5 minutes) on 15, 18, 21, and 24 month dosing days.  If the infusion is stopped and 
the site is considering restarting the infusion, a PK blood sample will be taken while 
the infusion is stopped. 
• Collect urine for PK at 1 hour post-dose for the first dose and every dose up through, 
and including, the 3 month dosing visit, and then every 6, 9, 12, 15, 18, 21, and 24 
month dosing days. 
• Document any AEs, beginning with the initiation of the first infusion. 
• Obtain concomitant medications information. 
6.2.2   Mid-Year and Annual Clinical Activity Study Visits 
The clinical activity of the patients will be assessed approximately every 6 months.  
Patients will not receive any study medication on these days.  This visit will take place 
over 2 days. 
• Perform a physical examination, including weight. 
• Measure vital signs. 
• Perform a 12-lead ECG. 
• Collect blood samples for serum TTR protein and secondary PD biomarker analysis.  
Additionally, aliquots of serum samples will be taken and frozen, to permit testing of 
additional proteins related to FAP. 
• Collect blood samples for PK analyses 
• Collect urine samples for PK analyses 
• Perform clinical activity assessments 
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• VDT 
• Grip strength 
• Ten-meter walk test 
• mBMI 
• NIS 
• HRdb 
• COMPASS 31  
• EQ5D 
• R-ODS 
• Pharmacoeconomics questionnaire 
• PND score 
• FAP stage 
• Collect paired 3-mm skin punch biopsies for IENFD analysis 
At each time point, 2 independent assessments for the mNIS+7, VDT, HRdb, 
NIS, 10-meter walk test, and grip strength test will be performed.  Each site will 
make every effort to have these assessments performed by the same Investigator.  
The second (repeat) assessment must be performed at least 24 hours 
(approximately), but not more than 7 days after the first assessment.  During the 
repeat assessments (on each testing day), blood will be collected for PK, TTR, 
and secondary PD biomarkers (RBP and vitamin A) analyses.  A urine sample 
will also be collected for PK analyses.   
• Perform an ophthalmology examination. 
• Obtain concomitant medications information. 
• Document any AEs. 
6.2.3   Additional Assessments for Pharmacokinetic/Pharmacodynamic Subgroup 
• For patients who are eligible for inclusion in the PK/PD subgroup, additional blood 
samples will be collected for the quantification of TTR, secondary PD biomarkers 
(RBP and vitamin A), and PK assessments. 
• At the first dosing (Day 0) and then the 8, and 24-month dosing visits, in addition to 
the predose, EOI, and 1 hour post-infusion, collect blood samples for PK at 2, 4, and 
6 hours post-infusion.  Urine samples will also be collected for PK at EOI and 6 hours 
post-infusion. 
• In addition, at these study visits, blood and urine samples for PK analysis of TTR, 
RBP, and vitamin A will also be collected at 24 hours post-infusion and 3, 7, and 
17 days after dosing with ALN-TTR02.   
6.2.4   Additional Assessments for Cardiac Subgroup 
For patients who are eligible for inclusion in the Cardiac subgroup: 
• Perform an echocardiogram at the Mid-year and Annual study visits.   


 
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• Collect blood sample for assessment of NT-proBNP and troponin I at first dose and 
approximately once every 3 months.  
6.2.5   Follow-Up Visits 
Patients will return to the study site for 2 follow-up visits (approximately 21 and 56 days 
after receiving their last dose of ALN-TTR02).  If a patient enrolls in the global extension 
study, the patient will not have to complete the 56-day follow-up assessments.  Patients 
who do not enroll in the extension study will need to complete both follow-up visits. 
6.2.5.1 Twenty-One-Day Follow-Up 
The following procedures will be performed at the 21-day Follow-up visit.   
• Perform a physical examination, including weight. 
• Measure vital signs. 
• Perform a 12-lead ECG. 
• Collect blood samples for clinical laboratory tests, including: 
• Hematology 
• Serum chemistries 
• Coagulation studies 
• Thyroid function tests 
• Collect blood samples for serum TTR protein and secondary PD biomarker analysis.  
Additionally, aliquots of serum samples will be taken and frozen, to permit testing of 
additional proteins related to FAP. 
• Collect blood sample for PK analyses 
• Collect urine sample for urinalysis. 
• Obtain concomitant medications information. 
• Document any AEs. 
6.2.5.2 Fifty-Six-Day Follow-Up Visit 
The following procedures will be performed at the 56-day Follow-up visit.   
• Collect blood samples for serum TTR protein and secondary PD biomarker analysis.  
• Collect blood sample for PK analyses.  
A patient will continue to be followed every 4 weeks after their 56 day Follow Up visit if 
their TTR protein levels continue to recover but have not returned to within 50% of 
Screening/Baseline visit levels.  During these visits, blood samples will be collected for 
serum TTR protein and secondary PD biomarker analysis.  Additionally, aliquots of 
serum samples will be taken and frozen, to permit testing of additional proteins related to 
FAP.  Blood samples will also be collected for PK analysis.   
6.3   Early Termination 
For patients who withdraw early from the study, every effort will be made to have them 
return to the study site to have the following procedures performed.   


 
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• Perform a physical examination, including weight. 
• Measure vital signs. 
• Perform a 12-lead ECG. 
• Collect blood samples for clinical laboratory tests, including: 
• Hematology 
• Serum chemistries 
• Coagulation studies 
• Thyroid function tests 
• Collect blood samples for serum TTR protein and secondary PD biomarker analysis.  
Additionally, aliquots of serum samples will be taken and frozen, to permit testing of 
additional proteins related to FAP. 
• Collect blood sample for PK analyses 
• Collect urine sample for PK analyses 
• Collect urine sample for urinalysis. 
• Perform clinical activity assessments once, only in patients who withdraw >3 months 
after the last clinical activity assessments were performed and who received at least 
4 doses of study drug. 
• mNIS + 7 
• VDT 
• Grip strength 
• Ten-meter walk test 
• mBMI 
• NIS 
• HRdb 
• COMPASS 31 survey 
• Pharmacoeconomics questionnaire 
• EQ5D 
• R-ODS 
• PND score 
• FAP stage 
• Collect paired 3-mm skin punch biopsies for IENFD analysis 
• Perform an ophthalmology examination. 
• For patients enrolled in the Cardiac subgroup: 
• Perform an echocardiogram 


 
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• Collect blood sample for assessment of NT-proBNP and troponin I 
• Obtain concomitant medications information. 
• Document any AEs. 
6.4   Unscheduled Visits 
Unscheduled visits may occur if deemed clinically significant by the Investigator. 
A patient will continue to be followed every 4 weeks (±3 days) after their 56-day Follow-
up Visit if their TTR protein levels continue to recover but have not returned to within 
50% of Screening/Baseline visit levels.  The patient will have the blood samples collected 
for the following clinical laboratory tests at these visits: 
• Serum TTR protein and secondary PD biomarkers.  Additionally, aliquots of 
serum samples will be taken and frozen, to permit testing of additional 
proteins related to ATTR. 
• PK analysis 
These patients will be followed until their TTR level returns to within at least 50% of the 
Baseline value. 
 


 
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7   
STUDY ASSESSMENTS 
7.1   Demographic Data and Medical History 
Patient demographic data and a complete medical history will be obtained during 
Screening/Baseline.  The medical history will also look to include prior neuropathy 
assessments, including but not limited to, Neuropathy Impairment Scales and Nerve 
Conduction Studies. 
Any AEs from the previous study (ALN-TTR02-002) that are ongoing on Day 0 of 
Study ALN-TTR02-003 will be considered as part of the medical history and recorded on 
the Medical History case report form for the current study (ALN-TTR02-003). 
7.2   Safety Assessments 
All safety assessment measures will be recorded in the patient’s medical record and CRF. 
7.2.1   Physical Examination 
Physical examinations will be performed by a physician and will include the examination 
of the following: general appearance, head, eyes, ears, nose, throat, chest/respiratory, 
heart/cardiovascular, gastrointestinal/liver, musculoskeletal/extremities, 
dermatological/skin, thyroid/neck, lymph nodes, and neurological/psychiatric.    
Body weight will be measured at each study visit, with the exception of the 56-day 
Follow-up study visit, prior to dosing with ALN-TTR02.  The weight measured during 
the previous dosing day should be used to calculate the dose of study drug.  In the event 
that the weight obtained on the previous dosing day is not available, the weight obtained 
pre-dose on the dosing day can be used for dose calculation.  
Height will only be measured at Screening/Baseline. 
7.2.2   Vital Signs 
Vital signs will be measured at Screening/Baseline and pre-dose at each subsequent study 
visit with the exception of the 56-day Follow-up visit; including systolic/diastolic blood 
pressure, pulse rate, respiratory rate, and oral body temperature.  Vital signs will be 
measured in the supine position using an automated instrument after the patient has rested 
comfortably for 10 minutes.  Each patient’s blood pressure should be taken using the 
same arm.  Oral temperature will be recorded in Celsius.  Heart rate will be counted for a 
full minute and recorded in beats per minute.  Respirations will be counted for a full 
minute and recorded in breaths per minute. 
For the safety of the patient, additional vital signs may be added at the discretion of the 
Investigator. 
7.2.3   Electrocardiogram 
Computerized 12-lead ECG recordings will be obtained.  Each lead shall be recorded for 
at least 3 beats at a speed of 25 mm/s.  Triplicate recordings will be obtained during 
Screening/Baseline, approximately once every 6 months, at the 21-day Follow-up visit, 
and at the Early Termination visit.  
The following electrophysiologic parameters will be assessed: rhythm, ventricular rate, 
PR interval, QRS duration, and QT interval.  Either Bazett’s and/or Fridericia’s formula 
will be used to calculate the heart rate corrected QT interval (QTc). 


 
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For any clinically significant abnormal results, the Investigator must contact the CRO 
Medical Monitor to discuss continued participation of the patient in the study (e.g., 
ischemic ECG changes, wave/interval changes, or arrhythmia).  
7.2.4   Ophthalmology Examination 
Ophthalmology examinations will be performed at Screening/Baseline and approximately 
once every 6 months and at the Early Termination visit. 
Further details regarding the ophthalmology examinations will be provided in the Study 
Reference Manual. 
7.2.5   Clinical Laboratory Tests 
Laboratory tests of hematology, serum chemistries, pregnancy (urine), coagulation 
studies, thyroid function tests, and urinalysis will be collected prior to the administration 
of premedications and dosing with ALN-TTR02 and will be performed by each study 
site’s local laboratory. 
In the event of an unexplained clinically relevant abnormal laboratory test occurring after 
study drug administration, the test should be repeated and followed up at the discretion of 
the Investigator until it has returned to the normal range or stabilized, and/or a diagnosis 
is made to adequately explain the abnormality. 
The following clinical laboratory parameters are to be determined:  
Hematology 
• Hematocrit 
• Neutrophils, absolute and % 
• Hemoglobin 
• Lymphocytes, absolute and % 
• Red blood cell (RBC) count 
• Monocytes, absolute and % 
• White blood cell (WBC) count 
• Eosinophils, absolute and % 
• Mean corpuscular volume 
• Basophils, absolute and % 
• Mean corpuscular hemoglobin 
• Platelet count 
• Mean corpuscular hemoglobin concentration    
Serum Chemistries 
 
•  Aspartate transaminase (AST) 
•  Alkaline phosphatase 
•  Alanine transaminase (ALT) 
•  Bilirubin (total and direct) 
•  Sodium 
•  Glucose 
•  Potassium 
•  Phosphate 
•  Blood urea nitrogen (BUN) 
•  Albumin 
•  Creatinine 
•  Calcium 


 
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Coagulation Studies 
 
•  Prothrombin time (PT) 
•  International Normalized Ratio (INR) 
•  Activated partial thromboplastin time 
(aPTT) 
 
Thyroid Function Tests 
 
•  Thyroid stimulating hormone (TSH) 
•  Triiodothyronine (T3) 
•  Thyroxine (T4)  
 
Urinalysis 
 
•  Visual inspection for color and appearance  •  Leukocytes 
•  pH 
•  Bilirubin 
•  Specific gravity 
•  Nitrite 
•  Ketones 
•  Urobilinogen 
•  Protein 
•  Microscopic inspection of sediment 
•  Glucose 
 
Other 
•  β-human chorionic gonadotropin (women of child-bearing potential only) 
Additional and repeat testing may be performed at the discretion of the Investigator. 
7.2.5.1 Hematology, Coagulation Studies, and Thyroid Function Tests 
Blood samples for hematology, coagulation studies, and thyroid function tests will be 
collected Screening/Baseline, first dose, approximately every 6 months, at the 21-day 
Follow-up visit, and at the Early Termination visit.  These samples are to be processed at 
the site’s local laboratory. 
7.2.5.2 Serum Chemistries and Urinalysis 
Blood samples for serum chemistries and urine for urinalysis will be collected at 
Screening/Baseline, first dose, approximately every 3 months, at the 21-day Follow-up 
visit, and at the Early Termination visit.  These samples are to be processed at the site’s 
local laboratory. 
7.2.5.3 Pregnancy Test 
A urine pregnancy test will be performed for women of child-bearing potential at 
Screening/Baseline, and any time pregnancy is suspected, the results of which must be 
known prior to administration of study drug.  Patients who are pregnant are not eligible 
for study participation.  Patients determined to be pregnant while on study will be 
followed until pregnancy outcome is known (see Section 8.12). 


 
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7.3   Pharmacodynamic Assessments 
Details of how samples will be collected, processed, and stored will be in the Study 
Laboratory Manual. 
7.3.1   Transthyretin  
Blood for serum TTR levels is to be collected at Screening/Baseline, immediately prior 
(within 10 minutes) to the administration of premedication and immediately prior (within 
10 minutes) to first dose, and then approximately once every 3 months (prior to 
administration of premedications) through the 12 month dosing day, thereafter at every 
dosing day after the 12 month dosing day, as well as at the 21- and 56-day Follow-up 
visits, and at the Early Termination visit.  Select clinical assessments are to be performed 
on 2 separate days for each of the Mid-year and Annual study visits.  For those visits, 
blood will be collected on each day that an assessment is performed.   
In addition, for those patients enrolled in the PK/PD subgroup, blood for serum TTR 
assessment will be collected prior to the administration of premedications at Month 8, 
and 24 hours, 3, 7, and 17 days post first dose and 8 and 24 month dosing days. 
Additionally, aliquots of serum samples drawn for measurement of TTR levels will be 
taken and frozen, to permit future testing of TTR and other types of testing related to 
FAP. 
Serum TTR will be assessed using both ELISA and turbidimetric assays. 
7.3.2   Secondary Pharmacodynamic Biomarkers 
7.3.2.1 Retinol Binding Protein 
Blood for serum RBP levels is to be collected at Screening/Baseline, immediately prior 
(within 10 minutes) to the administration of premedication and immediately prior (within 
10 minutes) to first dose, and then approximately once every 3 months (prior to 
administration of premedications), at the 21- and 56-day Follow-up visits, and at the 
Early Termination visit.  Select clinical assessments are to be performed on 2 separate 
days for each of the Mid-year and Annual study visits.  For those visits, blood will be 
collected on each day that an assessment is performed.   
In addition, for those patients enrolled in the PK/PD subgroup, blood for RBP levels will 
be collected prior to the administration of premedications at Month 8, and 24 hours, 3, 7, 
and 17 days post first dose and 8 and 24 month dosing days. 
Serum RBP will be quantified using nephelometry. 
7.3.2.2 Vitamin A 
Blood for serum vitamin A levels is to be collected at Screening/Baseline, immediately 
prior (within 10 minutes) to the administration of premedication and immediately prior 
(within 10 minutes) to first dose, and then approximately once every 3 months (prior to 
administration of premedications), at the 21- and 56-day Follow-up visits, and at the 
Early Termination visit.  Select clinical assessments are to be performed on 2 separate 
days for each of the Mid-year and Annual study visits.  For those visits, blood will be 
collected on each day that an assessment is performed.   


 
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In addition, for those patients enrolled in the PK/PD subgroup, blood for vitamin A levels 
will be collected prior to the administration of premedications at Month 8, and 24 hours, 
3, 7, and 17 days post first dose and 8 and 24 month dosing days. 
7.4   Exploratory Biomarkers 
To explore the expression of hepatocyte derived proteins to further characterize the 
biological effects of siRNA and/ or to explore possible metabolite profiling of ALN-
TTR02, serum and plasma samples will be collected at selected time points (see 
Table 1-1). 
Details of how samples will be collected, processed, and stored will be in the Study 
Laboratory Manual. 
Biological samples for biomarker research and possible metabolic profiling can be 
retained on behalf of Alnylam for a maximum of 15 years following the last patient’s last 
visit in the study. 
7.5   Pharmacokinetic Evaluations 
Details of sample collection and processing for PK analyses will be included in a 
laboratory manual. 
7.5.1   Plasma Pharmacokinetics 
The PK evaluation will include plasma-concentration time profiles for siRNA and the 
novel lipid components DLin-MC3-DMA and polyethylene glycol (PEG)2000-C-DMG.  
Details of the PK evaluation and analysis will be described in the PK and PK/PD analysis 
plan. 
Plasma and urine samples will be evaluated using a validated ATTO-Probe-HPLC assay 
to determine siRNA concentration and by LC/MS/MS for DLin-MC3-DMA and PEG2000-
C-DMG concentrations.   
Blood sample collection times are included in the schedule of events (see Table 1-1 and 
Table 1-2 or Table 12-1 and Table 12-2).  For all patients, plasma PK samples will be 
collected pre-dose (within 1 hour of planned dosing start) EOI and 1 hour post-dose at 
first dose and every dose up through, and including, the 3 month dosing visit, and then at 
6, 9, and 12 month dosing days.  Plasma PK samples will be collected pre-dose (within 1 
hour of planned dosing start) and EOI at 15, 18, 21, and 24 month visits.  The EOI will 
usually occur at 70 minutes after the start of the infusion, except in patients where the 
infusion has been prolonged. In addition, if the infusion is stopped and the site is 
considering restarting the infusion, a PK blood sample will be taken while the infusion is 
stopped.  All PK samples will be collected according to the schedule of assessments 
when the dose is completed (i.e., all post-infusion times are relative to the EOI, regardless 
of the duration of the infusion).  Plasma PK samples will also be collected at the Mid-
year and Annual visits (1 sample collected on each of the 2 study visit days), the 21- and 
56-day Follow-up visits, and the Early Termination visit.   
For the PK/PD subgroup subjects, samples will be collected pre-dose, and at 1, 2, 4, 6, 
and 24 hours post-infusion; and at 3, 7 and 17 days post-dose for the first dose and the 8 
and 24 month dosing days.   
Pharmacokinetic analyses will consist of either a noncompartmental and/or 
compartmental analysis of plasma siRNA, DLin-MC3-DMA (lipid), and PEG
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DMG (lipid).  Details of the PK evaluation and analysis will be described in the PK and 
PK/PD analysis plan.  Pharmacokinetic parameter estimates to be calculated may include, 
but may not be limited to: 
•   Observed Cmax. 
•   Time of observed maximum concentration (tmax). 
•   Partial area under the plasma concentration-time curve (AUC
p). 
•   Area under the plasma concentration-time curve to the last measurable 
concentration (AUC
0-t). 
•   Area under the plasma concentration-time curve from zero to the last measurable 
time point (AUC
0-last). 
•   Area under the plasma concentration-time curve extrapolated to infinity 
(AUC
0-∞). 
•   Terminal elimination half-life (t
1/2β and t
1/2α). 
•   Elimination rate constant (λz). 
•   Systemic clearance (CL). 
•   Volume of distribution at steady state (Vss). 
•   Volume of distribution based on the terminal phase (Vz). 
Other parameters may be calculated if deemed necessary. 
A population PK analysis of the siRNA will be performed by integrating the PK/PD 
subgroup and sparse samples collected during the study.  Details of the Population PK 
evaluation and analysis will be described in the PK and PK/PD analysis plan.  A 
compartmental model will be developed to model the concentration-time data of plasma 
siRNA and possibly DLin-MC3-DMA.  Model evaluation and selection will be based on 
standard model diagnostics and goodness-of-fit criteria (e.g., log-likelihood difference) 
and by looking at pertinent graphical representations of goodness-of-fit (e.g., fitted and 
observed concentrations versus time, weighted residuals vs. time) to provide a robust 
evaluation of the population PK parameters of the siRNA and possibly DLin-MC3-DMA.  
Other parameters may be calculated if deemed necessary.  Post hoc PK parameters of 
siRNA and possibly DLin-MC3-DMA will be derived with the population PK models 
and summarized using descriptive statistics.   
As part of PK/PD analysis, additional PD baseline analysis on serum TTR, RBP, and 
vitamin A may be conducted to include the PD data obtained during PD recovery after 
receiving the last dose.  Details of the PD evaluation and analysis will be described in the 
PK and PK/PD analysis plan.  A PD analysis to determine PD parameters (e.g., 50% 
effective dose [ED
50], 50% effective concentration [EC50]) will be conducted.  The extent 
of suppression of TTR, RBP, and vitamin A (e.g., AUE, % E
max and E
max) will be 
evaluated using graphical display of data.  Correlation between TTR versus RBP and 
vitamin A will also be performed (e.g., TTR concentrations, AUE, % Emax and E
max vs. 
RBP and vitamin A concentrations, AUE, % Emax and E
max).  Whenever possible the 
strength of the relationship correlation will be evaluated using statistical estimators 


 
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(e.g. r
2, slope, and p-value for a slope of 0).  Other parameters may be calculated if 
deemed necessary.   
The PK/PD analysis will include, but not be limited to, the determination of the 
relationship between exposure to siRNA, DLin-MC3-DMA and PEG2000-C-DMG 
(e,g, C
max and AUC) and the extent of suppression of TTR, RBP, and vitamin A 
(e.g., AUE, % E
max and E
max) will be explored using graphical display of data.  Whenever 
possible the strength of the relationship correlation will be evaluated using statistical 
estimators (e.g. r
2, slope, and p-value for a slope of 0).  The PD and PK/PD parameters 
will include, but not limited to, descriptive statistics (e.g., mean, standard deviation, 
coefficient of variation, median, minimum, maximum, geometric mean, and geometric 
CV%) and also by statistical comparisons whenever possible.  Other parameters may be 
calculated if deemed necessary.  Details of the PK evaluation and analysis will be 
described in the PK and PK/PD analysis plan. 
7.5.2   Urine Pharmacokinetics 
The CLR of siRNA and 4-dimethylaminobutyric acid (metabolite of DLin-MC3-DMA) 
after dosing with ALN-TTR02 will be evaluated for the subjects in the PK/PD subgroups 
and whenever possible for other subjects in the study.  Other parameters may be 
calculated if deemed necessary.  Details of the urine PK evaluation and analysis will be 
described in the PK and PK/PD analysis plan.  Urine sample collection times are included 
in the schedule of assessments (see Table 1-1 and Table 1-2 or Table 12-1 and 
Table 12-2).   
Urine will be collected into suitable containers and kept refrigerated.    
7.6   Clinical Activity Assessments 
Assessment of clinical activity will occur approximately every 6 months.  Additional and 
repeat testing may be performed at the discretion of the Investigator and in conjunction 
with the Sponsor. 
Further details on performing these assessments will be provided in the Study Reference 
Manual. 
7.6.1   Modified Neurological Impairment Score (mNIS) + 7 
The mNIS + 7 assessment includes the modified NIS tool (weakness and reflexes only), 
nerve conduction studies (NCS), quantitative sensory testing (QST) by body surface area 
including touch pressure (TP) and heat pain (HP), and postural blood pressure.   
At each time point, 2 independent assessments will be performed.  Each site will make 
every effort to have these assessments performed by the same Investigator.  Assessments 
are to be performed at least 24 hours (approximately) apart from each other but not more 
than 7 days apart.  In order to limit potential intra-operator bias, results of the first 
assessment will not be available to the Investigator when performing the second 
assessment. 
Every effort will be made to use the same device for NCS and QST for a patient 
throughout the duration of the study.   


 
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7.6.2   Vibration Detection Threshold 
Large nerve fiber function will be further evaluated by VDT using the Computer Aided 
Sensory Evaluator, version IV.  Tests are automated and will last approximately 
3 minutes. 
At each time point, 2 independent assessments will be performed.  Each site will make 
every effort to have these assessments performed by the same Investigator.  Assessments 
are to be performed at least 24 hours (approximately) apart from each other but not more 
than 7 days apart.  In order to limit potential intra-operator bias, results of the first 
assessment will not be available to the Investigator when performing the second 
assessment. 
Every effort will be made to use the same device for a patient throughout the duration of 
the study.   
7.6.3   Heart Rate Response to Deep Breathing 
The HRdb test evaluates autonomic function by the cardio-vagal response.  The average 
heart rate difference while taking eight deep breaths is measured. 
At each time point, 2 independent assessments will be performed.  Each site will make 
every effort to have these assessments performed by the same Investigator.  Assessments 
are to be performed at least 24 hours (approximately) apart from each other but not more 
than 7 days apart.  In order to limit potential intra-operator bias, results of the first 
assessment will not be available to the Investigator when performing the second 
assessment. 
Every effort will be made to use the same device for a patient throughout the duration of 
the study.   
7.6.4   Hand Grip Strength 
Hand grip strength will be measured by dynamometer.  When performing the test, 
patients will stand, holding the dynamometer in their dominant hand, with their arm 
parallel to the body without squeezing the arm against the body.  Tests will be performed 
in triplicate on the same day at each time point.   
At each time point, 2 independent assessments (each assessment performed in triplicate) 
will be performed.  Assessments are to be performed at least 24 hours (approximately) 
apart from each other but not more than 7 days apart.   
Every effort will be made to use the same dynamometer for a patient throughout the 
duration of the study. 
7.6.5   Ten-meter Walk Test 
Patients will have to be able to walk without assistance for 10 meters in order to complete 
the 10-meter walk test.  The time required for the patient to complete 2, 8, and 10 meters 
will be recorded.  This will allow for any potential variation due to acceleration and 
deceleration.  The patient will complete 1 trial.   
At each time point, 2 independent assessments will be performed.  Assessments are to be 
performed at least 24 hours (approximately) apart from each other but not more than 7 
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7.6.6   Neurological Impairment Score 
Clinical activity will be assessed by a clinical assessment that tests weakness, reflexes, 
sensation and cranial nerves.   
At each time point, 2 independent assessments will be performed.  Each site will make 
every effort to have these assessments performed by the same Investigator.  Assessments 
are to be performed at least 24 hours (approximately) apart from each other but not more 
than 7 days apart.  In order to limit potential intra-operator bias, results of the first 
assessment will not be available to the Investigator when performing the second 
assessment. 
7.6.7   Composite Autonomic Symptom Score 
To evaluate changes in autonomic symptoms, patients will complete the COMPASS 31 
questionnaire approximately once every 6 months.  The COMPASS 31 questionnaire 
consists of 31 clinically selected questions.  The questions evaluate 6 autonomic domains 
(orthostatic intolerance, vasomotor, secretomotor, gastrointestinal, bladder, and 
pupillomotor).50 
7.6.8   Quality of Life Questionnaire 
Quality of life will be assessed through the use of the EQ5D-5L, a standardized 
5 question instrument for use as a measure of health outcomes.    
7.6.9   Rasch-built Overall Disability Scale 
An assessment of the disability each patient experiences will be assessed through the 
R-ODS51.  The R-ODS is comprised of a 24-item linearly weighted scale that specifically 
captures activity and social participation limitations in patients. 
7.6.10  Skin Punch Biopsies for Exploratory Intraepidermal Nerve Fiber Density 
and Sweat Gland Nerve Fiber Density 
Patients will have 2 tandem 3-mm skin punch biopsies for IENFD and SGNFD 
assessment obtained at Screening/Baseline and approximately once every 6 months 
throughout the study.   
One biopsy will be taken from the distal lower leg, when a patient’s clinical status allows, 
and one from the distal thigh at each time point. 
Details of how samples will be collected, processed, and stored will be in the Study 
Laboratory Manual. 
7.6.11  FAP Stage and PND Score 
Changes in disease stage will be evaluated through FAP Stage and PND Score.52,53 
7.6.12  Modified Body Mass Index 
The nutritional status of patients will be evaluated using the mBMI; calculated as BMI × 
albumin.   
7.6.13  Disease Burden and Healthcare Utilization 
The burden of disease and healthcare utilization will be assessed using a patient-reported 
16 question pharmacoeconomics questionnaire. 


 
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7.6.14  Echocardiogram 
An echocardiogram will be performed in all patients at Screening/Baseline, to assess any 
cardiac abnormalities.  In addition, for those patients enrolled in the Cardiac subgroup, an 
echocardiogram will be performed during approximately once every 6 months.   
7.6.15  Biomarkers of Cardiac Function 
For those patients in the Cardiac subgroup, blood samples will be collected for the 
quantification of biomarkers of cardiac function (troponin I and NT-proBNP) prior to 
their first dose of study drug and approximately once every 3 months.  Quantification of 
these biomarkers will be performed at a central laboratory.   
Details of how samples will be collected, processed, and stored will be in the Study 
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8   
REPORTING ADVERSE EVENTS 
8.1   Adverse Event Definition 
An AE is any untoward medical occurrence in a patient or clinical investigational patient 
administered a pharmaceutical product and which does not necessarily have a causal 
relationship with this treatment. 
An AE can therefore be any unfavorable and unintended sign (including an abnormal 
laboratory finding, for example), symptom, or disease temporally associated with the use 
of a medicinal product, whether or not considered related to the medicinal product. 
8.2   Serious Adverse Event Definition 
An SAE is any untoward medical occurrence that at any dose: 
• Results in death; 
• Is life-threatening (an event which places the patient at immediate risk of death from 
the event as it occurred.  It does not include an event that had it occurred in a more 
severe form might have caused death); 
• Requires inpatient hospitalization or prolongation of existing hospitalization; 
• Results in persistent or significant disability/incapacity; 
• Is a congenital anomaly or birth defect; 
• An important medical event that may not be immediately life-threatening or result in 
death or hospitalization but may jeopardize the patient or may require intervention to 
prevent one of the other outcomes listed in the definition above (e.g., such events 
include allergic bronchospasm, blood dyscrasias or convulsions, or the development 
of drug dependency or abuse). 
8.3   Eliciting Adverse Event Information 
The patient should be asked about medically relevant changes in his/her health since the 
last visit.  The patient should also be asked if he/she has been hospitalized, had any 
accidents, used any new medications, or changed concomitant medication routines (both 
prescription and OTC). 
In addition to patient observations, AEs will be documented from any clinically relevant 
laboratory findings, physical examination findings, ECG changes, or other findings. 
8.4   Adverse Event Reporting 
The Investigator is responsible for reporting all AEs that are observed or reported after 
the first dose of study drug regardless of their relationship to study drug through the 21 or 
56-day Follow-up visit (depending on whether or not the patient plans to enroll into the 
open-label global extension study).   
Any medical condition that is present when a patient is screened and does not deteriorate 
should not be reported as an AE.  However, if it does deteriorate at any time during the 
study, it should be reported as an AE. 
All AEs must be fully recorded in the site’s source records and in the patients’ CRF, 
whether or not they are considered to be drug-related.  Each AE should be described in 


 
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detail: onset time and date, description of event, severity, relationship to investigational 
product, action taken, and outcome (including time and date of resolution, if applicable). 
Adverse events should be followed for the reporting periods defined earlier or until 
recovery to the normal state has been achieved, whichever occurs first.  In the event of a 
patient not returning to the clinical unit, the outcome of this event will be recorded as lost 
at follow-up. 
For patients who withdraw from the study early, ongoing AEs will be followed until 
resolution or 28 days from last dose, whichever occurs first. 
8.5   Adverse Event Reporting Period 
As stated in Section 8.4, AEs will be assessed for 21 or 56 days following the last dose of 
study drug (depending on whether or not the patient plans to roll over to the open-label 
global extension study) or until recovery to the normal state has been achieved, 
whichever occurs first; all AEs that occur after the start of study drug administration on 
Day 0 (Baseline) must be reported in detail on the appropriate CRF page and followed to 
satisfactory resolution, or a period of 21 or 56 days after the last dose of study drug 
administration (depending on whether or not the patient plans to roll over to the open-
label global extension study), whichever is shorter.   
Serious AEs will be followed for 21 or 56 days following the last dose of study drug 
(depending on whether or not the patient plans to roll over to the open-label global 
extension study), or until satisfactory resolution, or until the SAE is considered by the 
Investigator to be chronic or the patient is stable, whichever occurs first. 
8.6   Assessment of Causality 
Causal relationship assessment to drug treatments is required for purposes of reporting 
AEs.  To promote consistency, the following guidelines should be taken into 
consideration along with good clinical and scientific judgment when determining the 
relationship of drug treatments to an AE: 
Definitely Related: A clinical event, including laboratory test abnormality, occurring 
in a plausible time relationship to the medication administration, 
and which cannot be explained by concurrent disease or other 
drugs or chemicals.  The response to withdrawal of the drug 
should be clinically plausible. 
Possibly Related:  A clinical event, including laboratory test abnormality, with a 
reasonable time sequence to the medication administration, but 
which could also be explained by concurrent disease or other 
drugs or chemicals.  Information on the drug withdrawal may be 
lacking or unclear. 
Unlikely Related:  A clinical event, including laboratory test abnormality, with little 
or no temporal relationship to medication administration, and 
which other drugs, chemicals, or underlying disease provide 
plausible explanations. 


 
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Not Related:   
A clinical event, including laboratory test abnormality, that has no 
temporal relationship to the medication or has more likely 
alternative etiology. 
8.7   Assessment of Severity 
Adverse events are to be graded according to the categories detailed below. 
Mild:   
Mild events are those which are easily tolerated with no 
disruption of normal daily activity. 
Moderate:   
Moderate events are those which cause sufficient discomfort to 
interfere with daily activity. 
Severe:   
Severe events are those which incapacitate and prevent usual 
activity. 
Changes in severity should be documented in the medical record to allow assessment of 
the duration of the event at each level of severity.  Adverse events characterized as 
intermittent require documentation of the start and stop of each incidence.  When changes 
in the severity of an AE occur more frequently than once a day, the maximum severity 
for the experience that day should be noted.  If the severity category changes over a 
number of days, then those changes should be recorded separately (with distinct onset 
dates). 
8.8   Action Taken for Adverse Event 
Action taken in regards to study medication will be defined as: 
• None; 
• Infusion interrupted and restarted at a later time; 
• Infusion stopped and was not restarted at a later time; 
• Infusion cycle delayed 
8.9   Outcome of Adverse Event 
Outcome will be defined as: 
• Resolved (with or without sequelae); 
• Ongoing; 
• Lost to follow-up. 
8.10   Coding of Adverse Events 
The Medical Dictionary for Regulatory Activities (MedDRA) will be used to code AEs. 
8.11   Serious Adverse Event Reporting 
An assessment of the seriousness of each AE will be made by the Investigator.  Any AE 
and laboratory abnormality that meets the above seriousness criteria (Section 8.2) must 
be reported immediately to Alnylam, always within 24 hours from the time that site 
personnel first learn of the event.  Every SAE must be documented by the Investigator on 


 
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the Serious Adverse Event Report form in addition to the AE form in the CRF.  All SAEs 
must be reported regardless of the relationship to study drug. 
The initial report should include at least the following information: 
• Patient’s study number, 
• Description and date of onset of the event, 
• Criterion for serious, and  
• Preliminary assignment of causality to study drug. 
SAE reporting will be via electronic data capture (EDC).   
To report the SAE, complete the SAE form electronically in the electronic data capture 
(EDC) system for the study.  When the form is completed,  
Safety personnel 
will be notified electronically and will retrieve the form.  If the event meets serious 
criteria and it is not possible to access the EDC system, send an email to 
 Safety 
at
m or call th
 hotline (phone 
number will be provided in the Study Manual), and fax the completed back-up paper 
SAE form to 
fax number will be provided in the Study Manual) within 
24 hours of awareness.  When the EDC system becomes available, the SAE information 
must be entered into the EDC system within 24 hours of the system becoming available.  
Safety personnel will be available for SAE reporting on a 24 hour basis.  
Incoming reports will be reviewed during normal business hours. 
Within 24 hours of receipt of follow-up information, the Investigator must update the 
SAE form electronically in the EDC system for the study and submit any supporting 
documentation (e.g., patient discharge summary or autopsy reports) to 
 Safety 
personnel via fax or e-mail.  If it is not possible to access the EDC system, refer to the 
procedures outlined above for initial reporting of SAEs. 
Appropriate remedial measures should be taken by the Investigator using his/her best 
medical judgment to treat the SAE.  These measures and the patient’s response to these 
measures should be recorded.  All SAEs, regardless of relationship to study drug, will be 
followed by the Investigator until satisfactory resolution or the Investigator deems the 
SAE to be chronic or stable.  Clinical, laboratory, and diagnostic measures should be 
employed by the Investigator as needed to adequately determine the etiology of the event.   
The Investigator will be responsible for reporting all SAEs to the local independent ethics 
committee (IEC) when required by national regulations. 
Alnylam or its representative will be responsible for the reporting of all relevant events to 
the concerned regulatory authorities according to all applicable regulations. 
In Europe, in accordance with the Directive 2001/20/EC, the Competent Authorities and 
the Ethics Committees in the concerned Member States will be notified of fatal and life-
threatening Suspected Unexpected Serious Adverse Reactions (SUSARs) as soon as 
possible but no later than 7 calendar days after Alnylam or its representative has first 
knowledge of the minimum criteria for expedited reporting.  Non-fatal and non-life-
threatening SUSARs should be reported no later than 15 calendar days after Alnylam or 
its representative has first knowledge of them. 


 
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The Investigator may be informed by Alnylam or its representative of SAEs from other 
Investigators or clinical studies which may have relevance to this clinical trial.  These 
SAEs should also be reported promptly to the IEC or Clinical Events Committee (CEC) 
that approved the study.  All SAE reports should be transmitted to the IEC/CEC with a 
cover letter or transmittal form, and a copy of that transmittal should be maintained in the 
Investigator’s files and forwarded to Alnylam as part of the Trial Master File on study 
completion. 
8.12   Pregnancy Reporting 
A female patient with a positive pregnancy test at Screening/Baseline is ineligible for this 
trial.  If a female patient is determined to be pregnant during the course of the study or 
during the 75 days after receiving the last dose of study medication, the Investigator 
should report the pregnancy to the CRO and Alnylam within 24 hours of being notified of 
the pregnancy.  Details of the pregnancy will be recorded on the pregnancy reporting 
form.  The patient should receive any necessary counseling regarding the risks of 
continuing the pregnancy and the possible effects on the fetus.   
The pregnancy should be followed by the Investigator until completion. At the 
completion of the pregnancy, the Investigator will document the outcome of the 
pregnancy. If the outcome of the pregnancy meets the criteria for an SAE 
(i.e., postpartum complication, spontaneous abortion, stillbirth, neonatal death, or 
congenital anomaly), then the Investigator should follow the procedures for reporting an 
SAE outlined above. 
Pregnancy occurring in the partner of a patient participating in the study should also be 
reported to the Investigator, who will then report this to the CRO and Alnylam.  The 
partner should be counseled and followed as described above. 


 
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9   
STATISTICAL METHODS 
9.1   Sample Size 
Based on the number of patients expected to be enrolled in Study ALN-TTR02-002, up to 
28 patients are expected to be enrolled in this extension study.  Of these patients, up to 25 
are expected to be included in the PK/PD subgroup.  Any patient with pre-existing 
cardiac amyloid involvement will be included in the Cardiac subgroup.   
9.2   Statistical Methodology 
Statistical analyses will be primarily descriptive in nature.  Adverse event summaries will 
include tabulations of all treatment-emergent AEs (TEAEs), treatment-related AEs, 
SAEs, discontinuations due to AEs, and AEs of various grading severity.  By-patient 
listings will be provided for deaths, SAEs, and AEs leading to discontinuation of 
treatment. 
Descriptive statistics will be provided for clinical laboratory data, vital signs data, and 
ECG interval data, presented as both actual values and changes from baseline relative to 
each on-study evaluation.  Laboratory shift tables from baseline to worst values will be 
presented. 
For categorical variables, summary tabulations of the number and percentage of patients 
within each category (with a category for missing data) will be presented.  For continuous 
variables, the number of patients, mean, median, standard deviation, minimum, and 
maximum values will be presented. 
All data will be provided in by-patient listings. 
9.2.1   Populations to be Analyzed 
The following patient populations (i.e., analysis sets) may be evaluated and used for 
presentation of the data: 
• Full Analysis Set:  All patients who were enrolled will be included in the full analysis 
set.  The full analysis set will be the primary set for the analysis of PD data and 
clinical activity assessments. 
• Safety Analysis Set:  All patients in the full analysis set who received study drug.  
The safety analysis set will be used for the analysis of safety assessments. 
• Pharmacokinetic (PK) Analysis Set:  All patients in the Safety Analysis Set who have 
adequate data to determine a full PK profile. 
9.2.2   Baseline Evaluations 
Demographic and baseline disease characteristic data will be summarized.  Data to be 
tabulated will include sex, age, and race, as well as disease-specific information. 
9.2.3   Safety Analyses 
A summary of study drug exposure, including the durations of the infusions and doses, 
and the proportions of patients with modifications in the durations of infusions will be 
produced. 
Adverse events will be summarized by MedDRA system organ class and preferred term.  
Separate tabulations will be produced for all TEAEs, treatment-related AEs (those 


 
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considered by the Investigator as at least possibly drug related), SAEs, and 
discontinuations due to AEs.  By-patient listings will be provided for deaths, SAEs, and 
AEs leading to discontinuation of treatment. 
Descriptive statistics will be provided for clinical laboratory data and vital signs data, 
presented as both actual values and changes from baseline relative to each on-study 
evaluation and to the last evaluation on study. 
Descriptive statistics will be provided for ECG interval data and presented as both actual 
values and changes from baseline relative to each on-study evaluation and to the last 
evaluation on study.  Details of any abnormalities will be included in patient listings. 
9.2.4   Pharmacodynamics 
Summary tables and graphical displays of observed values and changes from baseline in 
serum TTR will be used to assess the durability of suppression over the course of the 
study.  Similar analyses will be performed for the secondary PD biomarkers (RBP and 
vitamin A). 
9.2.5   Pharmacokinetics 
Plasma and urine samples will be evaluated using a validated ATTO-Probe-HPLC 
method to determine siRNA concentration and by LC/MS/MS method for DLin-MC3-
DMA and PEG2000-C-DMG concentrations.  The concentration of 4-dimethylbutyric acid 
(metabolite of DLinMC3DMA) in urine will be evaluated by a validated LC/MS/MS 
method.   
Pharmacokinetic analyses evaluation of siRNA, DLin-MC3-DMA, and PEG2000-C-DMG 
plasma concentration-time profiles.  Pharmacokinetic parameter estimates will be 
calculated for all subjects in the PK/PD subgroup receiving ALN-TTR02 will include, 
but may not be limited to: Cmax; t
max; t
½β; t
1/2α, AUC
p, AUC
0-t, AUC
0-last and AUC
0-∞; λz; 
CL, V
ss, and V
z.  The PK profile of each patient will be characterized by 
noncompartmental and or compartmental analysis of siRNA, DLin-MC3-DMA and 
PEG2000-C-DMG plasma concentration using validated computer software (WinNonlin
® 
or Phoenix®, Pharsight Corp., Mountain View, California, USA).  Parameters will 
include, but may not be limited to: C
max, t
max, AUC, CL, V
ss, and V
z.  The AUC will be 
calculated using the linear trapezoidal method (linear interpolation).  Other parameters 
may be calculated, if deemed necessary.  If possible, the terminal elimination phase of the 
PK profile will be identified and its slope calculated using log-linear regression.  The 
coefficient of determination of the line fitted to the terminal elimination phase will be 
calculated.  Pharmacokinetic parameters describing the systemic exposure of the test 
article in the test system will be estimated from observed plasma concentration values for 
each patient.   
Population PK analysis of siRNA and possibly DLin-MC3-DMA will be performed by 
integrating PK/PD and sparse samples collected during the study.  A compartmental 
model will be developed to model the concentration-time data of plasma siRNA and 
possibly DLin-MC3-DMA.  Pharmacokinetic parameters of siRNA and possibly DLin-
MC3-DMA will be derived with the population PK models and summarized with 
descriptive statistics.  Other parameters may be calculated if deemed necessary. 
 


 
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A PK/PD analysis will be performed whenever possible.  As part of PK/PD analysis, 
additional PD baseline analysis on serum TTR, RBP, and vitamin A may be conducted to 
include the PD data obtained during PD recovery after receiving the last dose.  A PD 
analysis to determine PD parameters will be conducted.  The extent of suppression of 
TTR, RBP, and vitamin A will be evaluated and their correlation between TTR versus 
RBP and vitamin A will also be performed.  The PK/PD analysis will include, but not be 
limited to, the determination of the relationship between exposure to siRNA, DLin-MC3-
DMA and PEG2000-C-DMG to the extent of suppression of TTR, RBP, and vitamin A 
will be evaluated, including their correlation relationship.  The PD and PK/PD parameters 
will include, but not be limited to, descriptive statistics.  Other parameters may be 
calculated if deemed necessary. 
The CLR of siRNA and 4-dimethylaminobutyric acid (metabolite of DLin-MC3-DMA) 
after dosing with ALN-TTR02 will be determined for the subjects in the PK/PD 
subgroups and whenever possible for the other subjects in the study.  Other parameters 
may be calculated if deemed necessary. 
9.2.6   Summary of Clinical Activity Assessments 
Summary statistics of observed values and changes from baseline will be provided for the 
mNIS +7 composite score.  Summaries will also be provided for the components of the 
composite score (i.e., the NIS weakness and reflex scores, the Σ5 NC, and QST values).  
The full NIS (i.e., the sum of cranial nerve, muscle weakness, reflex and sensation 
scores) will be summarized also.  Values of the individual components of the mNIS 
weakness and reflex scores will be depicted graphically by presenting the mean (±SE) 
values over time for each location (hip, knee, etc.). 
Patient reported quality of life and disease burden will be assessed by summary statistics 
for the EQ5D and R-ODS.  Summary statistics will be provided for observed values and 
changes from baseline.  Patient reported autonomic neuropathy symptoms will be 
assessed by descriptive statistics for the COMPASS 31. 
Descriptive statistics will also be provided for observed values and changes from baseline 
in motor function (10-meter walk test and test of grip strength), nutritional status 
(mBMI), sensory and autonomic innervation (IENFD and SGNFD), VDT, and 
ambulation (FAP stage and PND score). 
9.2.7   Healthcare Utilization Assessments 
The observed values and changes from baseline in healthcare utilization will be evaluated 
and summarized using descriptive statistics. 
9.2.8   Pharmacokinetic/Pharmacodynamic and Cardiac Subgroup Analyses 
Descriptive statistics will be provided for actual values and changes from baseline in 
serum levels of troponin I and NT-proBNP in the subset of patients with evidence of pre-
existing cardiac amyloid involvement.  Results of echocardiograms will be summarized. 
As part of PK/PD analysis, additional PD baseline analysis on serum TTR, RBP, and 
vitamin A may be conducted to include the PD data obtained during PD recovery after 
receiving the last dose.   


 
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9.2.9   Interim Analysis 
There is no formal interim analysis planned for this study.  Interim data examinations 
may be performed, but these will be of a descriptive nature and will not involve any 
formal hypothesis testing. 


 
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10   STUDY MANAGEMENT 
The Investigator is accountable for the conduct of the trial.  If any responsibilities are 
delegated, the Investigator should maintain a list of appropriately qualified staff to whom 
he/she has delegated specified significant trial related duties. 
10.1   Data Handling and Quality Assurance 
10.1.1  Case Report Forms 
The Investigator and designees agree to maintain accurate CRFs and source 
documentation as part of these case histories.  Source documents are the originals of any 
documents used by the Investigator or hospital/institution that allow verification of the 
existence of the patient and substantiate the integrity of the data collected during the trial. 
Alnylam will supply either paper or electronic CRFs for each patient.  Case report forms 
must be completed only by persons designated by the Investigator.  Corrections must be 
made so as not to obliterate original data and must be identified and dated by the person 
who made the correction.  All data entered into the CRF must also be available in the 
source documents.  The Investigator will allow designated Alnylam representatives and 
regulatory bodies to have direct access to the source documents to verify the data 
reported in the CRFs. 
Each completed CRF must be reviewed and signed by the Investigator or designee in a 
timely manner.  The completed CRF will be collected by Alnylam monitor as soon as 
practical after completion.  A copy of the CRF will remain in the Investigator’s files. 
10.1.2  Monitoring 
The clinical monitor, as a representative of Alnylam, has an obligation to follow the study 
closely.  In doing so, the monitor will visit the Investigator and site periodically as well as 
maintain frequent telephone and letter contact.  The monitor will maintain current 
personal knowledge of the study through observation, review of study records and source 
documentation and discussion of the conduct of the study with the Investigator and staff. 
All aspects of the study will be carefully monitored by Alnylam or its designee for 
compliance with applicable government regulations in respect to Good Clinical Practice 
(GCP) and current standard operating procedures. 
10.1.3  Inspections 
The Investigator will permit trial-related monitoring, audits and review by the IEC and/or 
Regulatory Authorities, providing direct access to source data/documents.  The study 
may be subject to audit by Alnylam or its representatives or by regulatory authorities.  If 
such an audit occurs, the Investigator must agree to allow access to the required patient 
records.  In the event of an audit, the Investigator agrees to allow Alnylam, 
representatives from Alnylam, or regulatory agencies access to all study records. 
10.2   Regulatory Guidelines 
This study will be performed in accordance with the clinical trial agreement, the protocol, 
all applicable government laws, regulations, and guidances where the study is being 
conducted including the World Health Organization (WHO) Declaration of Helsinki, the 
International Conference on Harmonization (ICH) of Technical Requirements for 
Registration of Pharmaceuticals for Human Use, the Health Insurance Portability and 


 
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Accountability Act of 1996 (“HIPAA”), and all other applicable medical privacy laws 
and regulations. 
10.2.1  Independent Ethics Committee 
National regulations and ICH require that approval be obtained from an IEC prior to 
participation of patients in research studies.  Prior to the study onset, the protocol, any 
protocol amendments, ICFs, advertisements to be used for patient recruitment, and any 
other written information regarding this study to be provided to a patient or patient’s legal 
guardian must be approved by the IEC. 
All IEC approvals must be dated and signed by the IEC Chairman or designee and must 
identify the IEC by name and address, the clinical protocol by title and/or protocol 
number, and the date of approval or favorable opinion was granted for the clinical 
research. 
No drug will be released to the site to dose a patient until written IEC authorization has 
been received by Alnylam or designee. 
The Investigator is responsible for obtaining continuing review of the clinical research at 
least annually or more often if specified by the IEC.  The Investigator must supply 
Alnylam with written documentation of the approval of the continued clinical research. 
The Investigator will make all attempts to ensure that the IEC is constituted and operates 
in accordance with Federal and ICH GCP and any local regulations. 
10.2.2  Regulatory Authorities 
Regulatory authorities will receive the protocol, amendments, reports on SAEs, and the 
Integrated Clinical Trial Report according to national regulations. 
10.2.3  Modification of the Protocol 
Major changes in this research activity, except those to remove an apparent immediate 
hazard to the patient, must be reviewed and approved by Alnylam and the IEC that 
approved the study.  Amendments to the protocol must be submitted in writing to the 
Investigator’s IEC and the Competent Authority for approval prior to patients being 
enrolled under the amended protocol. 
10.2.4  Informed Consent Form 
Written informed consent in compliance with 21 Code of Federal Regulations (CFR) § 50 
and ICH will be obtained from each patient prior to undergoing any protocol-specific 
tests or procedures that are not part of routine care.   
Alnylam will provide an ICF template to the Investigator for use in developing a site-
specific ICF.  Prior to submission of the site-specific ICF to the IEC, the site-specific ICF 
must be reviewed and approved by Alnylam or designee.  Any changes requested by the 
IEC must also be approved by Alnylam.  The final IEC approved ICF must be provided 
to Alnylam.  Revisions to the ICF required during the study must be approved by 
Alnylam, and a copy of the revised ICF provided to Alnylam. 
Before recruitment and enrollment, each prospective patient (or legal guardian) will be 
given a full explanation of the study and be allowed to read the ICF.  Once the 
Investigator is assured that the patient/legal guardian understands the commitments of 
participating in the study, the patient/legal guardian will be asked to sign and date the 


 
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ICF.  A copy of the fully signed and dated ICF will be given to the patient.  The original 
will be maintained in the patient’s medical record at the site.  All active patients will sign 
an updated ICF if revisions are made to the ICF during the course of the study. 
10.2.5  Study Reporting Requirements 
The Investigator will submit reports of SAEs as outlined in this protocol.  In addition, the 
Investigator agrees to submit progress reports to his/her IEC per their local reporting 
requirements, or at least annually and at the conclusion of the study.  The reports will be 
made available to Alnylam or designee. 
Deviations from the protocol necessary to protect patient safety should be reported to the 
CRO and Alnylam within 24 hours of knowledge of the event. 
Any communications from regulatory agencies in regard to inspections, other studies that 
impact this protocol or the qualifications of study personnel should be promptly reported 
to Alnylam. 
10.2.6  Financial Disclosure Reporting Obligations 
Each Investigator (including principal and/or any subinvestigators) directly involved in 
the treatment or evaluation of study patients is required to provide financial disclosure 
information according to all applicable legal requirements.  In addition, Investigators 
must commit to promptly updating this information if any relevant changes occur during 
the study and for a period of one year after the completion of the study. 
10.3   Ancillary Research 
Research ancillary to this main protocol may not be performed by individual study sites 
without prior discussion and approval by Alnylam. 
10.4   Study Record Retention 
Essential documents should be retained for the period of time required by applicable local 
law.  The essential documents include the signed and dated final protocol, signed and 
dated amendments(s), if applicable, signed and dated Curriculum Vitae (CVs) of the 
Investigators, copies of the completed CRFs, signed ICFs, IEC approval and all related 
correspondence, financial agreements, regulatory approval, drug accountability, study 
correspondence, and patient identification codes.  Records will not be destroyed without 
informing Alnylam in writing and giving Alnylam the opportunity to store the records for 
a longer period of time at Alnylam’s expense. 
The International Conference on Harmonization requires that patient identification codes 
be retained for at least 15 years after the completion or discontinuation of the study. 
10.5   Discontinuation of the Study by Alnylam 
Alnylam reserves the right to discontinue the study for clinical or administrative reasons 
at any time.  If the site does not recruit at a reasonable rate, the study may be 
discontinued.  Should the study be terminated and/or the site closed for whatever reason, 
all documentation and study medication pertaining to the study must be returned to 
Alnylam or its representative, and the Investigators, IEC and Regulatory Authorities will 
be promptly informed of the termination and the reason for the decision.  The 
Investigator should promptly inform the patients and assure appropriate therapy and 
follow-up. 


 
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10.6   Study Documentation 
Prior to beginning the study, the Investigator will be asked to comply with ICH E6 and 
21 CFR by providing at least the following essential documents: 
• An original signed Investigator agreement page of the protocol and any amendments; 
• An IEC and Alnylam approved ICF; 
• Independent Ethics Committee approval of the protocol, and any amendments; 
• Curriculum vitae for the Investigator signed and dated by the Investigator indicating 
that it is current; 
• Financial disclosure information (if applicable). 
• Other documents which the Investigator should provide before study start or shortly 
thereafter include: 
• Curriculum vitaes for all Sub-investigators; these should be signed and dated by the 
Sub-investigators indicating that they are current; 
• Financial disclosure information for all Sub-investigators (if applicable); 
• Advertisements for patient recruitment and any other written information to be given 
to patients or legal guardians and IEC approval of any advertisements and any other 
written information; 
• Independent Ethics Committee composition:  If the Investigator or any of the 
Sub-investigators is a member of the IEC, assurance that he/she refrained from voting 
should be provided; 
• Laboratory accreditation and reference ranges for any laboratory values for local 
laboratories. 
10.7   Confidentiality 
The Investigator must ensure that the patients’ anonymity will be maintained.  On the 
CRFs or other documents submitted to Alnylam, patients should not be identified by their 
names, but by the assigned patient number and initials.  If patient names are included on 
copies of documents submitted to Alnylam, the names (except for initials) will be 
obliterated and the assigned patient number added to the document.  Documents not for 
submission to Alnylam (e.g., signed ICFs) should be maintained by the Investigator in 
strict confidence. 
Following the principles of the Good Clinical Practice and the Portuguese Protection of 
Personal Data Directive 95/46/EC, only a patient’s number and initials will be used to 
identify the patient on their study records.  Laboratory samples will be labeled with an 
independent numbering code, and the label will not contain any other personal 
identification information.  The numbering code associated with these labels will be held 
by the study CRO and Alnylam, thereby allowing no unwarranted access to the 
information.  When reporting results for interim safety assessment and at the end of the 
study, the code will be shared per standard operating procedures with the responsible 
member of the Biostatistical and Data Management Departments of the CRO.  The 
numbering code will also be held for samples in storage until marketing approval of 
ALN-TTR02 in the countries where this study was conducted, or until clinical 


 
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development of ALN-TTR02 is halted.  Throughout sample collection, storage (limited, 
staff only access area containing locked sample storage, and limited access sample 
tracking) and processing, the samples will only be handled by appropriate personnel per 
the laboratory’s standard operating procedures. 
The Investigator must treat all of the information related to the study and the compiled 
data as confidential, whose use is for the purpose of conducting the study.  Alnylam must 
approve any transfer of information not directly involved in the study. 
10.8   Publications/Reports 
Following completion of the study, the data may be considered for publication in a 
scientific journal or for reporting at a scientific meeting.  A copy of the manuscript must 
be provided to Alnylam at least 30 days prior to its submission. 
No submission of a manuscript may be made until the results from all of the study sites 
have been received and analyzed by Alnylam, or the study has been terminated at all 
centers.  A separate, individual publication of the results of the study will be delayed until 
initial publication of the results of the multi-center study, or a decision not to publish is 
made.  If an initial draft is not produced within 18 months of completion of the study at 
all centers, or the timeframe for publication is not satisfactory, the Investigator may 
disclose the results after providing a copy of the manuscript to Alnylam 30 days prior to 
submission. 


 
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11   REFERENCES 
1     Liz MA, Mar FM, Franquinho F, Soursa MM. Aboard transthyretin: from transport to 
cleavage. IUBMB Life. 2010;62:429-435. 
2     Palha, JA, Episkopou V, Maeda S, et al. Thyroid hormone metabolism in a transthyretin-
null mouse strain. J Biol Chem. 1994;269:33135-33139. 
3    Palha JA, Hays MT, Morreale de Escobar G, et al. Transthyretin is not essential for 
thyroxine to reach the brain and other tissues in transthyretin-null mice. Am J Physiol. 
1997;272:E485-493. 
4     Episkopou V, Maeda S, Nishiguchi S, et al. Disruption of the transthyretin gene results in 
mice with depressed levels of plasma retinol and thyroid hormone. Proc Natl Acad Sci 
USA. 1993;90:2375-2379. 
5    Van Bennekum AM, Wei S, Gamble MV, et al. Biochemical basis for depressed serum 
retinol levels in transthyretin-deficient mice. J Biol Chem. 2001;276:1107-1113. 
6    Biesalski HK, Frank J, Beck SC, et al. Biochemical but not clinical vitamin A deficiency 
results from mutations in the gene for retinol binding protein. Am J Clin Nutr. 
1999;69:931-936. 
7     Decensi A, Fontana V, Fioretto M, et al. Long-term effects of fenretinide on retinal 
function. Eur J Cancer. 1997;33:80-84. 
8    Torrisi R, Parodi S, Fontana V, et al. Factors affecting plasma retinol decline during long-
term administration of the synthetic retinoid fenretinide in breast cancer patients. Cancer 
Epidemiol Biomarkers Prev. 1994;3:507-10. 
9     Hou X, Aguilar MI, Small DH. Transthyretin and familial amyloidotic polymeutopathy. 
Recent progress in understanding the molecular mechanism of neurodegeneration. FEBS 
J. 2007;274:1637-1650. 
10     Connors LH, Lim A, Prokaeva T, Roskens VA, Costello CE. Tabulation of human 
transthyretin (TTR) variants. Amyloid. 2003;10:160-184. 
11     Suhr OB, Herlenius G, Friman S, Ericzon BG. Liver transplantation for hereditary 
transthyretin amyloidosis. Liver Transpl. 2000;6:263-276. 
12     Yazaki M, Tokuda T, Nakamura A, et al. Cardiac amyloid in patients with familial 
amyloid polyneuropathy consists of abundant wild-type transthyretin. Biochem Biophys 
Res Commun. 2000;274:702-706. 
13    Carvalho M, Alves M, Luis ML. Octreotide--a new treatment for diarrhoea in familial 
amyloidotic polyneuropathy. J Neurol Neurosurg Psychiatry. 1992;55:860-861. 
14     Soares M., Coelho T, Sousa A, et al. Susceptibility and modifier genes in Portuguese 
transthyretin V30M amyloid polyneuropathy: complexity in a single-gene disease. Hum 
Mol Genet. 2005;14:543-553. 
15     Eriksson P, Olofsson BO. Pacemaker treatment in familial amyloidosis with 
polyneuropathy. Pacing Clin Electrophysiol. 1984;7:702-706. 
16    Delahaye N, Dinanian S, Slama MS, et al.Cardiac sympathetic denervation in familial 
amyloid polyneuropathy assessed by iodine-123 metaiodobenzylguanidine scintigraphy 
and heart rate variability. Eur J Nucl Med. 1999;26:416-424. 
 


 
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17     Buxbaum JN. Transthyretin and the transthyretin amyloidoses.  In: Uversky VN, ed. 
Protein Reviews: Protein Misfolding, Aggregation, and Conformational Diseases. New 
York, NY: Springer Publishing Co; 2007:259-283. 
18    Jacobson DR, Pastore RD, Yaghoubian R, et al. Variant-sequence transthyretin 
(isoleucine 122) in late-onset cardiac amyloidosis in black Americans. N Engl J Med. 
1997;336:466-473. 
19    Araki S. [Amyloidosis and amyloid protein]. Tanpakushitsu Kakusan Koso. 
1984;29:1770-1782. 
20    Benson MD. Familial amyloidotic polyneuropathy. Trends Neurosci. 1989;12:88-92. 
21    Okamoto S, Wixner J, Obayashi K, et al. Liver transplantation for familial amyloidotic 
polyneuropathy: impact on Swedish patients
' survival. Liver Transpl. 2009;15:1229-
1235. 
22     Adams D., Samuel D., Goulon-Goeau C, et al. The course and prognostic factors of 
familial amyloid polyneuropathy after liver transplantation. Brain. 2000;123:1495-1504. 
23     Sharma, P., Rakela, J., 2005a, Management of pre-liver transplantation patient--part 2. 
Liver Transpl 11, 249-260. 
24    Sharma P, Rakela J. Management of pre-liver transplantation patients--part 1. Liver 
Transpl. 2005;11:124-133. 
25     Suhr OB, Friman S, Ericzon BG. Early liver transplantation improves familial 
amyloidotic polyneuropathy patients
' survival. Amyloid. 2005:12:233-238 
26    Yazaki M, Mitsuhashi S, Tokuda T, et al. Progressive wild-type transthyretin deposition 
after liver transplantation preferentially occurs onto myocardium in FAP patients. Am J 
Transplant. 2007;7:235-242. 
27     European Medicines Agency. Vyndaqel: EPAR-Product Information. 2011. Available at: 
http://www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/medicines/00229
4/human_med_001498.jsp&mid=WC0b01ac058001d124. Last accessed on 8 December 
2011. 
28     Vaishnaw AK, Gollob J, Gamba-Vitalo C, et al. A status report on RNAi therapeutics. 
Silence. 2010;1(1):14. 
29    Elbashir SM, Lendeckel W, Tuschi T. RNA interference is mediated by 21- and 22-
nucleotide RNAs. Genes Dev. 2001;15:188-200. 
30     Soutschek J, Akinc A, Bramlage B, et al. Therapeutic silencing of an endogenous gene by 
systemic administration of modified siRNAs. Nature. 2004;432:173-178. 
31    Geisbert TW, Hensley LE, Kagan E, et al. Postexposure protection of guinea pigs against 
a lethal ebola virus challenge is conferred by RNA interference. J Infect Dis. 
2006;193:1650-1657. 
32    Judge AD, Bola G, Lee AC, MacLachlan I. Design of noninflammatory synthetic siRNA 
mediating potent gene silencing in vivo. Mol Ther. 2006;13:494-505. 
33     Morrissey DV, Lockridge JA, Shaw L, et al. Potent and persistent in vivo anti-HBV 
activity of chemically modified siRNAs. Nat Biotechnol. 2005;23:1002-1007. 
34     Zimmermann TS, Lee AC, Akinc A, et al. RNAi-mediated gene silencing in non-human 
primates. Nature. 2006;441(7089):111-4.  


 
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35     Maurer N, Mori A, Palmer L, et al. Lipid-based systems for the intracellular delivery of 
genetic drugs. Mol Membr Biol. 1999;16:129-140. 
36    Akinc A, Querbes W, De S, Qin J, et al. Targeted delivery of RNAi therapeutics with 
endogenous and exogenous ligand-based mechanisms. Mol Ther. 2010;18(7):1357-1364. 
37    Lachmann HJ, et al. Outcome in systemic AL amyloidosis in relation to changes in 
concentration of circulating free immunoglobulin light chains following chemotherapy. 
Br J Haematol, 2003;122:78-84. 
38    Lachmann HJ, et al. Natural history and outcome in systemic AA amyloidosis. N Engl J 
Med. 2007;356:2361-71. 
39    Gillmore JD, et al. Organ transplantation in hereditary apolipoprotein AI amyloidosis. 
Am J Transplant. 2006;6:2342-7. 
40     Stangou AJ, Banner NR, Hendry BM, et al. Hereditary fibrinogen A alpha-chain 
amyloidosis: phenotypic characterization of a systemic disease and the role of liver 
transplantation. Blood. 2010;115:2998-3007. 
41    Lachmann HJ, et al. Outcome in systemic AL amyloidosis in relation to changes in 
concentration of circulating free immunoglobulin light chains following chemotherapy. 
Br J Haematol, 2003;122:78-84. 
42    Lachmann HJ, et al. Natural history and outcome in systemic AA amyloidosis. N Engl J 
Med. 2007;356:2361-71. 
43    Gillmore JD, et al. Organ transplantation in hereditary apolipoprotein AI amyloidosis. 
Am J Transplant. 2006;6:2342-7. 
44     Stangou AJ, Banner NR, Hendry BM, et al. Hereditary fibrinogen A alpha-chain 
amyloidosis: phenotypic characterization of a systemic disease and the role of liver 
transplantation. Blood. 2010;115:2998-3007. 
45    Coelho T, Adams D, Silva A, et al. Safety and Efficacy of an RNAi Therapeutic 
Targeting Transthyretin (TTR) for TTR Amyloidosis. NEJM.  2013, accepted for 
publication. 
46     Gomes ER, Demoly P. Epidemiology of hypersensitivity drug reactions. Current Opin 
Allergy Clin Immunol. 2005;5:309-316. 
47     Solensky R. Drug hypersensitivity. Med Clin North Am. 2006;90:233-260. 
48     Tabernero J, Shapiro GI, Lorusso PM, , et al. First-in-humans trial of an RNA 
interference therapeutic targeting VEGF and KSP in cancer patients with liver 
involvement. Cancer Discov. 2013:406-417. 
49  
Conceiciao IM, Miranda LC, et al.  Bone mineral density in familial amyloid 
polyneuropathy and in other neuromuscular disorders. Eur J Neurol. 2005;12(6):480-2. 
50     Sletten DM, Suarez GA, Low PA, Mandrekar J, Singer W. COMPASS 31: a tefined and 
abbreviated composite autonomic symptom score. Mayo Clin Proc. 2012;87:1196-1201. 
51     van Nes SI, Vanhoutte EK, van Doorn PA, et al. Rasch-built Overall Disability Scale (R-
ODS) for immune-mediated peripheral neuropathies. Neurology. 2011;76:337-45.  
52     Yamamoto S, Wilczek HE, Nowak G, et al.  Liver transplantation for familial 
amyloidotic polyneuropathy (FAP): a single-center experience over 16 years. Am J 
Transplant. 2007;7:2597-604. 


 
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53     Coutinho P, DeSilva AM, Lima JL, Barbosa AR. Forty years of experience with type I 
amyloid neuropathy: review of 483 cases. In: Glenner GG, Pinho P, Costa E, Falcao de 
Freitas A, Eds. Amyloid and Amyloidosis.. Amsterdam: Excerpta Medica; 1980:88-98. 


 
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12   APPENDICES 
Appendix 1:  Karnofsky Scale 
 
Able to carry on normal activity 
and to work; no special care 
needed. 
100 Normal no complaints; no evidence of 
disease. 
90 Able to carry on normal activity; minor 
signs or symptoms of disease. 
80 Normal activity with effort; some signs or 
symptoms of disease.  
Unable to work; able to live at 
home and care for most personal 
needs; varying amount of 
assistance needed. 
70 Cares for self; unable to carry on normal 
activity or to do active work. 
60 Requires occasional assistance, but is able 
to care for most of his personal needs. 
50 Requires considerable assistance and 
frequent medical care.  
Unable to care for self; requires 
equivalent of institutional or 
hospital care; disease may be 
progressing rapidly. 
40 Disabled; requires special care and 
assistance. 
30 Severely disabled; hospital admission is 
indicated although death not imminent. 
20 Very sick; hospital admission necessary; 
active supportive treatment necessary. 
10 Moribund; fatal processes progressing 
rapidly. 
0   Dead 
 
 


 
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Appendix 2: Schedule of Assessments for Patients Administered ALN-TTR02 Once 
Every Four Weeks 
Patients may receive ALN-TTR02 once every 4 weeks, based on results from the ongoing 
ALN-TTR02-002 study where the safety and PD of 2 dosing schedules are being 
evaluated.  The schedule of assessments for patients receiving ALN-TTR02 once every 
3 weeks is provided in Table 12-1. 
 
 


 
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Table 12-1:  Schedule of Assessment for Patients Administered ALN-TTR02 Once Every Four Weeks – Year 1 
Procedure 
Weeks   
1 & 29   5 & 33   9 & 37   13 & 41   17 & 45   21 & 49   25 & 53   27 & 55 
Screening 
/Baseline
a 
Day -28 to -0 D0 & D196 
D28 & 
D224 
D56 & 
D252 
D84 & 
D280 
D112 & 
D308 
D140 & 
D336 
D168 & 
D364 
D182 & 
D378 
Window 
±2Db 
±2D   
±2D   
±2D   
±2D   
±2D   
±2D   
±5D 
Informed Consent 
X   
   
   
   
   
   
   
   
 
Demographics 
X   
   
   
   
   
   
   
   
 
Medical Historyc 
X   
   
   
   
   
   
   
   
 
Inclusion/Exclusion Criteria   
X   
Xd   
   
   
   
   
   
   
 
Physical Examination 
X   
   
   
   
   
   
   
   
X 
Weight 
X   
X   
X   
X   
X   
X   
X   
X   
X 
Height 
X   
   
   
   
   
   
   
   
 
Vital Signse 
X   
X   
X   
X   
X   
X   
X   
X   
X 
Echocardiogram 
X   
   
   
   
   
   
   
 
 
12-Lead ECG 
X   
   
   
   
   
   
   
   
X 
Urine Pregnancy Test (females 
only) 
X   
   
   
   
   
   
   
   
 
Hematology 
X   
Xd   
   
   
   
   
   
X   
 
Serum Chemistry and Urinalysisf   
X   
Xd   
   
   
X   
   
   
X   
 
Thyroid Function Tests and 
Coagulation Studies 
X   
Xd   
   
 
 
   
   
X   
 
Ophthalmology Exam 
X   
   
   
   
   
   
   
   
X 
PD Assessments: 
   
   
   
   
   
   
   
   
 
TTR protein (ELISA and 
turbidimetric)
g 
X   
Xd   
   
   
X   
   
   
X   
X 
RBP and Vitamin Ag 
X   
Xd   
   
   
X   
   
   
X   
X 


 
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Procedure 
Weeks   
1 & 29   5 & 33   9 & 37   13 & 41   17 & 45   21 & 49   25 & 53   27 & 55 
Screening 
/Baseline
a 
Day -28 to -0 D0 & D196 
D28 & 
D224 
D56 & 
D252 
D84 & 
D280 
D112 & 
D308 
D140 & 
D336 
D168 & 
D364 
D182 & 
D378 
Window 
±2Db 
±2D   
±2D   
±2D   
±2D   
±2D   
±2D   
±5D 
Other Assessments: 
   
   
   
   
   
   
   
   
 
Exploratory Biomarkers 
X   
Xd   
   
   
Xg   
   
   
X   
 
Anti-drug Antibodiesh 
X   
Xd   
Xi   
   
Xi   
   
   
X   
 
Pharmacoeconomics 
Questionnaire 
X 
   
   
   
   
   
   
   
X 
Clinical Activity Assessments: 
   
   
   
 
 
   
   
   
 
mNIS + 7j,k 
X 
   
   
 
 
   
   
   
X 
VDTk 
X   
   
   
 
 
   
   
   
X 
HRdbk 
X   
   
   
   
   
   
   
   
X 
Grip Strengthk,l 
X   
   
   
   
   
   
   
   
X 
10-Meter Walk Testk,m 
X   
   
   
   
   
   
   
   
X 
NISk 
X   
   
   
   
   
   
   
   
X 
Skin Punch Biopsy (IENFD & 
SGFND)n 
X   
   
   
   
   
   
   
   
X 
mBMI 
X   
   
   
   
   
   
   
   
X 
FAP Stage and PND Score   
X   
   
   
   
   
   
   
   
X 
COMPASS 31  
X   
   
   
   
   
   
   
   
X 
QOL and Disability 
Questionnaireso 
X 
   
   
   
   
   
   
   
X 
Premedication Administrationp   
   
X   
X   
X   
X   
X   
X   
X   
 
Study Drug Administrationq 
   
X   
X   
X   
X   
X   
X   
X   
 
Plasma PK Samplingr 
   
XX 
XX 
XX 
X   
   
   
X   
Xs 
Urine PK Samplingt 
   
XX 
XX 
XX 
X   
   
   
X   
Xs 


 
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Procedure 
Weeks   
1 & 29   5 & 33   9 & 37   13 & 41   17 & 45   21 & 49   25 & 53   27 & 55 
Screening 
/Baseline
a 
Day -28 to -0 D0 & D196 
D28 & 
D224 
D56 & 
D252 
D84 & 
D280 
D112 & 
D308 
D140 & 
D336 
D168 & 
D364 
D182 & 
D378 
Window 
±2Db 
±2D   
±2D   
±2D   
±2D   
±2D   
±2D   
±5D 
PK/PD Subgroup Only 
   
   
   
   
   
   
   
   
 
TTR (ELISA and 
turbidimetric) 
   
Xu   
Xu   
   
   
   
   
   
 
RBP and Vitamin A 
   
Xu   
Xu   
   
   
   
   
   
 
Plasma PK Sampling 
   
Xv   
Xv   
   
   
   
   
   
 
Urine PK Samplingw 
   
Xw   
Xw   
   
   
   
   
   
 
Cardiac Subgroup Only: 
   
   
   
   
   
   
   
   
 
Echocardiogram 
   
   
   
   
   
   
   
   
X 
Troponin I and NT-proBNP    
   
Xd   
   
   
X   
   
   
X   
 
Concomitant Medications 
X 
X 
Adverse Events 
 
X 
a   Assessments performed during the ALN-TTR02-002 study that occur within the Screening/Baseline timeframe will not need to be repeated at the Screening/Baseline visit. 
b   Window does not apply to Day 0. 
c   Any AEs from the previous study (ALN-TTR02-002) that are ongoing on Day 0 are to be recorded on the Medical History case report form for the current study (ALN-
TTR02-003) and followed until resolution. 
d   To be performed only on Day 0, not on Day 196 
e   Vital signs to include: blood pressure, pulse rate, oral body temperature, and respiratory rate.  Parameters are to be measured in the supine position using an automated 
instrument after the patient has rested comfortably for 10 minutes. 
f   To be performed before dosing with ALN-TTR02. 
g   Blood samples for TTR, RBP, and vitamin A will be collected on Day 0 at 2 separate time points: 1) prior to administration of premedications and 2) after administration of 
premedications but before dosing of ALN-TTR02.  On all other study visits, a blood sample will be collected only once; prior to administration of premedications. 
h   Blood samples for ADA will be collected prior to dosing with ALN-TTR02. 
i   To be collected only on Days 28 and 84, not on Days 224 and 280. 
j   The mNIS + 7 consists of the modified NIS tool (or aspects of the tool; weakness and reflexes only), nerve conduction studies (NCS), quantitative sensory testing (QST) by 
body surface area including touch pressure (TP) and heat pain (HP), and postural blood pressure.  Every effort will be made to use the same devices for a patient throughout 
the duration of the study. 
k   Two assessments will be performed on separate days at Screening/Baseline and then approximately every 6 months.  The Screening/Baseline assessments must be performed 
within 14 days prior to the first dose of study drug (Day 0).  The second (repeat) assessment must be conducted at least 24 hours after the first assessment.  In addition, every 
effort should be made to conduct the 2 assessments no greater than 7 days apart.   
l   Hand grip strength will be measured using a dynamometer held in the dominant hand.  Every effort will be made to use the same device for a patient throughout the duration 
of the study. 


 
ALN-TTR02 
 
ALN-TTR02-003 
 
15 June 2015 
 
 
Protocol Amendment 1 (Version 2.0) 
 
Confidential 
Page 89 
m   Patient will walk without assistance for 10 meters. 
n   Two 3-mm skin punch biopsies are to be obtained.  One will be obtained from the distal lower leg, when a patient’s clinical status allows, and one from the distal thigh. 
o   Quality of life and disability assessments will include the EQ5D and R-ODS questionnaires. 
p    The following premedications will be administered at least 60 minutes prior to the start of the infusion of ALN-TTR02:  dexamethasone (10 mg IV, or equivalent), 
paracetamol (PO 500 mg; or equivalent), IV H2 blocker (e.g., ranitidine 50 mg, famotidine 20 mg, or equivalent other H2 blocker dose), and IV H1 blocker (e.g., 
diphenhydramine 50 mg or equivalent; hydroxyzine or fexofenadine 25 mg PO or cetirizine 10 mg PO may be substituted for any patient who does not tolerate IV 
diphenhydramine or other IV H1 blockers).  Based on results from the ALN-TTR02-002 study, the following alternative premedication regimen can be used:  dexamethasone 
(8 mg, or equivalent), paracetamol (500 mg, or equivalent), H2 blocker (e.g., 150 mg ranitidine, or 20 mg famotidine, or equivalent other H2 blocker dose), and H1 blocker 
(10 mg cetirizine, 25 mg hydroxyzine, fexofenadine or equivalent may be substituted) self-administered per os (PO) the evening before study drug administration.  At least 
60 minutes prior to the start of study drug infusion, dexamethasone (20 mg PO, or equivalent), paracetamol (500 mg PO, or equivalent), an H2 blocker (PO), and an H1 
blocker (PO) will be administered by study site personnel.   
q   The infusion site will be assessed for any localized reaction pre-dose, during infusion, at the end of the infusion, for 30 minutes after the infusion. 
r   Plasma PK samples will be collected pre-dose (within 1 hour of planned dosing start), EOI, and 2 hrs post-dose (±5 min), except on Days 0 and 224 for subjects in the 
PK/PD Subgroup.   
s   Samples will be collected once during the study visit. 
t   For each dose, urine PK samples will be collected pre-dose and 2 hours after dosing with ALN-TTR02.  
u   For patients in the PK/PD subgroup, blood samples for TTR, RBP, and vitamin A will be collected on Days 0 and 224 prior to administration of premedications.  In addition, 
a TTR, RBP, and vitamin A sample will also be collected 24 hours (±120 minutes) post-dose, and 3, 7, and 17 days (±1 day) after dosing with ALN-TTR02 for the study 
visits noted. 
v   On Days 0 and 224, patients in the PK/PD subgroup will have samples taken pre-dose, EOI, and 1, 2, 4, 6, and 24 hours post-infusion.  In addition, a plasma PK sample will 
also be collected 3, 7, and 17 days (±1 day) after dosing with ALN-TTR02 for the study visits noted.   The windows for sampling are ±5 minutes for the 1, 2, 4, and 6 hour 
sampling periods; and ±120 minutes for the 24 hour sampling period. 
w   On Days 0 and 224, patients in the PK/PD subgroup will have a urine sample for PK analysis taken pre-dose,  and 6 and 24 hours post-infusion.  In addition, a urine PK 
sample will also be collected 3, 7, and 17 days (±1 day) after dosing with ALN-TTR02 for the study visits noted.  The windows for sampling are ±5 minutes for the 1, 2, 4, 
and 6 hour sampling periods; and ±120 minutes for the 24 hour sampling period. 
x   Samples to be collected on Day 0, Day 28, and Day 56 only 


 
ALN-TTR02 
 
ALN-TTR02-003 
 
15 June 2015 
 
 
Final Protocol 
 
Confidential 
Page 90 of 94 
Table 12-2:  Schedule of Assessment for Patients Administered ALN-TTR02 Once Every Four Weeks – Year 2 
Procedure 
Weeks  57 & 81 61 & 85 65 & 89 69 & 93 73 & 97  77 & 
101 
79 & 
103 
83 & 
107 
111   115   ET 
Days 
D392 & 
D588 
D420 & 
D616 
D448 & 
D644 
D476 & 
D672 
D504 & 
D700 
D532 & 
D728 
D560 & 
D756 
D574 & 
D784 
D812   D840   N/A 
Window ±2D 
±2D   ±2D   ±2D   ±2D   ±2D   ±2D   ±5D   ±5D   ±5D   ±5D 
Physical Examination 
   
   
   
   
X   
   
   
   
X   
X   
   
X 
Weight 
   
X   
X   
X   
X   
X   
X   
X   
X   
X   
   
X 
Vital Signsa 
   
X   
X   
X   
X   
X   
X   
X   
X   
X   
   
X 
12-Lead ECG 
   
   
   
   
   
   
   
   
X 
X 
 
X 
Hematologyb 
   
   
   
   
   
   
   
X   
   
X   
   
X 
Serum Chemistry and 
Urinalysisb 
   
   
   
   
X   
   
   
X   
   
X   
   
X 
Thyroid Function Tests and 
Coagulation Studiesb   
   
   
   
 
 
 
   
X   
   
X   
   
X 
Ophthalmology Exam 
   
   
   
   
   
   
   
   
X   
   
   
X 
PD Assessments: 
   
   
   
   
   
   
   
   
   
   
   
 
TTR protein (ELISA and 
turbidimetric) 
c 
   
   
   
   
X   
   
   
X   
X   
X   
X   
X 
RBP and Vitamin Ac   
   
   
   
   
X   
   
   
X   
X   
X   
X   
X 
Other Assessments: 
   
   
   
   
 
 
   
   
   
   
   
 
Exploratory Biomarkers   
   
   
   
   
X 
 
   
X   
X   
   
   
 
Anti-drug Antibodies   
   
   
   
   
 
 
   
Xd   
   
   
   
 
Pharmacoeconomics 
Questionnaire 
   
   
   
   
   
   
   
   
X   
   
   
Xf 
Clinical Activity 
Assessments: 
   
   
   
 
 
 
   
   
   
   
   
 
mNIS + 7e,g 
 
   
   
 
 
 
   
   
X 
   
   
Xf 
VDTg 
   
   
   
 
 
 
   
   
X   
   
   
Xf 


 
ALN-TTR02 
 
ALN-TTR02-003 
 
15 June 2015 
 
 
Final Protocol 
 
Confidential 
Page 91 of 94 
Procedure 
Weeks  57 & 81 61 & 85 65 & 89 69 & 93 73 & 97  77 & 
101 
79 & 
103 
83 & 
107 
111   115   ET 
Days 
D392 & 
D588 
D420 & 
D616 
D448 & 
D644 
D476 & 
D672 
D504 & 
D700 
D532 & 
D728 
D560 & 
D756 
D574 & 
D784   D812   D840   N/A 
Window ±2D 
±2D   ±2D   ±2D   ±2D   ±2D   ±2D   ±5D   ±5D   ±5D   ±5D 
HRdbg 
   
   
   
   
   
   
   
   
X   
   
   
Xf 
Grip Strengthg,h 
   
   
   
   
   
   
   
   
X   
   
   
Xf 
10-Meter Walk Testg,i   
   
   
   
   
   
   
   
   
X   
   
   
Xf 
NISg 
   
   
   
   
   
   
   
   
X   
   
   
Xf 
Skin Punch Biopsy (IENFD 
& SGFND)
j 
   
   
   
   
   
   
   
   
X   
   
   
Xf 
mBMI 
   
   
   
   
   
   
   
   
X   
   
   
Xf 
FAP Stage and PND Score   
   
   
   
   
   
   
   
   
X   
   
   
Xf 
COMPASS 31 
   
   
   
   
   
   
   
   
X   
   
   
Xf 
QOL and Disability 
Questionnairesk 
   
   
   
   
   
   
   
   
X   
   
   
Xf 
Premedication Administrationl      
X   
X   
X   
X   
X   
X   
X   
   
   
   
 
Study Drug Administrationm   
   
X   
X   
X   
X   
X   
X   
X   
   
   
   
 
Plasma PK Samplingn 
   
   
   
   
X   
   
   
X   
X   
X   
X   
X 
Urine PK Samplingo 
   
   
   
   
X   
   
   
X   
X   
   
   
X 
PK/PD Subgroup Only: 
   
   
   
   
   
   
   
   
   
   
   
 
TTR (ELISA and 
turbidimetric)
p 
   
    
   
   
   
   
Xp   
   
   
   
 
RBP and Vitamin Ap   
   
   
   
   
   
   
   
Xp   
   
   
   
 
Plasma PK Samplingq 
   
   
   
   
   
   
   
Xq   
   
   
   
 
Urine PK Samplingr 
   
   
   
   
   
   
   
Xr 
   
   
   
 
Cardiac Subgroup Only: 
   
   
   
   
   
   
   
   
   
   
   
 
Echocardiogram 
   
   
   
   
   
   
   
   
X   
   
   
 
Troponin I and NT-proBNP       
   
   
   
X   
   
   
X   
   
   
   
 


 
ALN-TTR02 
 
ALN-TTR02-003 
 
15 June 2015 
 
 
Final Protocol 
 
Confidential 
Page 92 of 94 
Procedure 
Weeks  57 & 81 61 & 85 65 & 89 69 & 93 73 & 97  77 & 
101 
79 & 
103 
83 & 
107 
111   115   ET 
Days 
D392 & 
D588 
D420 & 
D616 
D448 & 
D644 
D476 & 
D672 
D504 & 
D700 
D532 & 
D728 
D560 & 
D756 
D574 & 
D784   D812   D840   N/A 
Window ±2D 
±2D   ±2D   ±2D   ±2D   ±2D   ±2D   ±5D   ±5D   ±5D   ±5D 
Concomitant Medications   
 
X 
Adverse Events 
 
X 
a   Vital signs to include: blood pressure, pulse rate, oral body temperature, and respiratory rate.  Parameters are to be measured in the supine position using an automated 
instrument after the patient has rested comfortably for 10 minutes. 
b   To be performed before dosing with ALN-TTR02. 
c   Blood samples for TTR, RBP, and vitamin A will be collected on Day 0 at 2 separate time points: 1) prior to administration of premedications and 2) after administration of 
premedications but before dosing with ALN-TTR02.  At all other study visits, a blood sample will be collected only once; prior to administration of premedications. 
d   Blood samples for ADA will be collected only at the Day 756 visit (approximately 24 months), prior to dosing with ALN-TTR02. 
e   The mNIS + 7 consists of the modified NIS tool (or aspects of the tool; weakness and reflexes only), nerve conduction studies (NCS), and quantitative sensory testing (QST) 
by body surface area including touch pressure (TP) and heat pain (HP), and postural blood pressure.  These tests can be conducted over 2 study visits that occur no 
less than 24 hours from each other and no more than 7 days apart.  Every effort will be made to use the same devices for a patient throughout the duration of the 
study. 
f   To be performed only in patients who have received at least 4 doses of study drug and who withdraw >3 months after the last clinical activity assessments were performed.  
These tests will not be repeated. 
g   Two assessments will be performed at Screening/Baseline and then approximately every 6 months.  The Screening/Baseline assessments must be performed within 14 days 
prior to the first dose of study drug (Day 0).  The second (repeat) assessment must be conducted at least 24 hours after the first assessment.  In addition, every effort should 
be made to conduct the 2 assessments no greater than 7 days apart.   
h   Hand grip strength will be measured using a dynamometer held in the dominant hand.  Every effort will be made to use the same device for a patient throughout the duration 
of the study. 
i   Patient will walk without assistance for 10 meters.  
j   Two 3-mm skin punch biopsies are to be obtained.  One will be obtained from the distal lower leg, when a patient’s clinical status allows, and one from the distal thigh. 
k   Quality of life and disability assessments will include the EQ5D and R-ODS questionnaires. 
l    The following premedications will be administered at least 60 minutes prior to the start of the infusion of ALN-TTR02:  dexamethasone (10 mg IV, or equivalent), 
paracetamol (PO 500 mg; or equivalent), IV H2 blocker (e.g., ranitidine 50 mg, famotidine 20 mg, or equivalent other H2 blocker dose), and IV H1 blocker (e.g., 
diphenhydramine 50 mg or equivalent; hydroxyzine or fexofenadine 25 mg PO or cetirizine 10 mg PO may be substituted for any patient who does not tolerate IV 
diphenhydramine or other IV H1 blockers).  Based on results from the ALN-TTR02-002 study, the following alternative premedication regimen can be used:  dexamethasone 
(8 mg, or equivalent), paracetamol (500 mg, or equivalent), H2 blocker (e.g., 150 mg ranitidine, or 20 mg famotidine, or equivalent other H2 blocker dose), and H1 blocker 
(10 mg cetirizine, 25 mg hydroxyzine, fexofenadine or equivalent may be substituted) self-administered per os (PO) the evening before study drug administration.  At least 
60 minutes prior to the start of study drug infusion, dexamethasone (20 mg PO, or equivalent), paracetamol (500 mg PO, or equivalent), an H2 blocker (PO), and an H1 
blocker (PO) will be administered by study site personnel. 
m   The infusion site will be assessed for any localized reaction pre-dose, during infusion, at the end of the infusion, for 30 minutes after the infusion. 
n   Plasma PK samples will be collected pre-dose (within 1 hour of planned dosing start) ,  EOI and 2 hours post dose.   
o   For each dose, urine PK samples will be collected pre-dose and 2 hours after dosing with ALN-TTR02.  


 
ALN-TTR02 
 
ALN-TTR02-003 
 
15 June 2015 
 
 
Final Protocol 
 
Confidential 
Page 93 of 94 
p   For patients in the PK/PD subgroup, blood samples for TTR, RBP, and vitamin A will be collected on Day 756:  prior to administration of premedications and a blood 
sample will also be collected 24 hours, 3, 7 and 17 days after dosing with ALN-TTR02. 
q   On Day 756, patients in the PK/PD sub-group will have PK samples taken at predose, end of infusion, 1, 2, 4, 6, and 24 hours post-infusion.  In addition, a plasma PK sample 
will also be collected 3, 7, and 17 days (±1 day) after dosing with ALN-TTR02 for the study visits noted.   The windows for sampling are ±5 minutes for the 1, 2, 4, and 6 
hour sampling periods; and ±120 minutes for the 24 hour sampling period. 
r   On Day 756, patients in the PK/PD subgroup will have a urine sample for PK analysis taken pre-dose, EOI, and 6 and 24 hours post-infusion.  In addition, a urine PK          
sample will also be collected 3, 7, 10, and 14 days (±1 day) after dosing with ALN-TTR02 for the study visits noted.  The windows for sampling are ±5 minutes for the 1, 2, 
4, and 6 hour sampling periods; and ±120 minutes for the 24 hour sampling period. 
 


 
ALN-TTR02 
 
ALN-TTR02-003 
 
15 June 2015 
 
 
Protocol Amendment 1 (Version 2.0) 
 
Confidential 
Page 94 
Appendix 3: New York Heart Association Classification of Heart Failure 
 
Class   
Symptomatology 
I 
No symptoms.  Ordinary physical activity such as walking and 
climbing stairs does not cause fatigue or dyspnea. 
II 
Symptoms with ordinary physical activity.  Walking or climbing 
stairs rapidly, walking uphill, walking or stair climbing after meals, 
in cold weather, in wind or when under emotional stress causes 
undue fatigue or dyspnea. 
III 
Symptoms with less than ordinary physical activity.  Walking one 
to two blocks on the level and climbing more than one flight of 
stairs in normal conditions causes undue fatigue or dyspnea. 
IV 
Symptoms at rest.  Inability to carry on any physical activity 
without fatigue or dyspnea. 
 
 


ALN-TTR02 
ALN-TTR02-003 
26 November 2013 
 
 
 
Protocol ALN-TTR02-003 
Amendment 1.2 Summary of Changes 
A Phase 2, Multicenter, Open-Label, Extension Study to Evaluate the Long-Term 
Safety, Clinical Activity, and Pharmacokinetics of ALN-TTR02 in Patients With 
Familial Amyloidotic Polyneuropathy Who Have Previously Received ALN-TTR02 
 
 
Changes included in Amendment 1.2 to Protocol ALN-TTR02-003, dated 26 November 
2013, are detailed below. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Amendment 1.2 
Confidential 
Page 1 of 2 


ALN-TTR02 
ALN-TTR02-003 
26 November 2013 
 
 
 
 
 
 
 
 
Text added is indicated by bold font. 
 
Section 
Prior Text 
New Text 
Protocol Synopsis – 
Inclusion Criteria 
4.  Adequate liver function, demonstrated 
by an aspartate transaminase (AST) and 
alanine transaminase (ALT) level ≤2.5 × 
the upper limit of normal (ULN), total 
bilirubin within normal limits, albumin 
>3 g/dL, and international normalized 
ratio (INR) ≤1.2. 
4.  Adequate liver function, demonstrated by 
an aspartate transaminase (AST) and 
alanine transaminase (ALT) level ≤2.5 × 
the upper limit of normal (ULN), total 
bilirubin within normal limits, albumin 
>3 g/dL, and international normalized 
ratio (INR) ≤1.2 (patients on warfarin 
with an INR of ≤3 will be allowed). 
4.2 Inclusion 
Criteria 
4.  Adequate liver function, demonstrated 
by an aspartate transaminase (AST) and 
alanine transaminase (ALT) level ≤2.5 × 
the upper limit of normal (ULN), total 
bilirubin within normal limits, albumin 
>3 g/dL, and international normalized 
ratio (INR) ≤1.2. 
4.  Adequate liver function, demonstrated by 
an aspartate transaminase (AST) and 
alanine transaminase (ALT) level ≤2.5 × 
the upper limit of normal (ULN), total 
bilirubin within normal limits, albumin 
>3 g/dL, and international normalized 
ratio (INR) ≤1.2 (patients on warfarin 
with an INR of ≤3 will be allowed). 
 
 
 
 
 
 
 
 
 
 
 
 
Amendment 1.2 
Confidential 
Page 2 of 2
 

SAP_001.pdf: