Clinical trial NCT02706483
Conditions: Irritable Bowel Syndrome
Sponsor: Bausch Health Americas, Inc.
Start date: 2016-01-01; Completion date: 2017-06-01
Enrollment: 2272 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
Multi-center, open-label, long-term safety study

Detailed description:
This is a phase 3, multicenter, open-label, long-term safety and tolerability study of 6 mg daily dose of plecanatide administered orally. Patients who are Study Completers or Eligible Screen Failures whose eligibility is confirmed at the end of their participation in the double-blind plecanatide studies SP304203-04 or SP304203-05 will be enrolled.

Beginning on Day 1, patients will take one (1) plecanatide 6.0 mg tablet in the clinic and thereafter every morning with approximately 240 mL (8 ounces) of liquid, with or without meals.

Safety and tolerability assessments and patients' self-assessment of disease severity will be performed according to the Schedule of Assessments.

Patients who discontinue early from the study will undergo an Early Withdrawal (EW) visit within 5 days after stopping study drug.

Arms: arm 1: Plecanatide 6.0 mg tablets
Interventions: intervention 1: Plecanatide
Intervention descriptions: intervention 1: None

Protocol documents:
Prot_SAP_000.pdf: 
Final Version 3.0 
1 of 54 
July 21, 2016  
An Open-Label, Long-Term Safety and Tolerability Study of Plecanatide in 
Patients with Irritable Bowel Syndrome with Constipation (IBS-C) 
Sponsor: 
Synergy Pharmaceuticals Inc. 
420 Lexington Avenue, Suite 2012 
New York, NY 10170 
Clinical Research 
Organizations: 
ICON Clinical Research Inc. 
2100 Pennbrook Parkway  
North Wales, PA 19454 
United States  
Chiltern International Inc. 
1241 Volunteer Parkway Suite 95 
Bristol, TN  37620 
United States 
Medical Monitor: 
Sponsor Protocol No.: 
SP304203-06 
IND No.: 
115,118 
Study Drug Name: 
Plecanatide 
Date/Version of Protocol: 
July 21, 2016 / Version 3.0  
October 28, 2015 / Version 2.0 
September 14, 2015 / Version 1.0 
The study will be conducted according to the protocol and in compliance with Good Clinical Practice 
(GCP) and with other applicable regulatory requirements. 
This document contains confidential information of Synergy Pharmaceuticals Inc. 
Do not copy or distribute without written permission from the Sponsor. 
CONFIDENTIAL 
NCT02706483 




Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
Final Version 3.0 
3 of 54 
July 21, 2016   
 
DECLARATION OF THE INVESTIGATOR 
Title: An Open-Label, Long-Term Safety and Tolerability Study of Plecanatide in Patients with 
Irritable Bowel Syndrome with Constipation (IBS-C). 
All documentation for this study that is supplied to me and that has not been previously published will be 
kept in the strictest confidence.  This documentation includes this study protocol, Investigator Brochure, 
electronic Case Report Forms (eCRFs), and other scientific data. 
The study will not be commenced without the prior written approval of a properly constituted Institutional 
Review Board (IRB) or Independent Ethics Committee (IEC).  No changes will be made to the study 
protocol without the prior written approval of the Sponsor and the IRB/IEC, except where necessary to 
eliminate an immediate hazard to the patients. 
I confirm that I have read and will follow the above-named protocol. I understand it, and I will work 
according to the principles of Good Clinical Practices (GCP) as described in the United States Code of 
Federal Regulations (CFR) parts 50, 54, 56, and 312, and the International Conference on Harmonization 
(ICH) document “Guidance for Industry—E6 Good Clinical Practice: Consolidated Guidance.” Further, I 
will conduct the study in keeping with local legal and regulatory requirements and principles of the 
Declaration of Helsinki as currently endorsed by regional regulatory health authorities. 
 
Responsible Investigator of the local study center 
 
_____________________________________       ______________________ 
Signature 
 
 
 
 
 
 
Date 
 
_____________________________________ 
Name (block letters) 
 
_____________________________________ 
Title (block letters) 
 
_____________________________________ 
Institution (block letters) 
 
_____________________________________ 
Phone number 
 
 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
Final Version 3.0 
4 of 54 
July 21, 2016   
PROTOCOL SYNOPSIS 
Study Title 
An Open-Label, Long-Term Safety and Tolerability Study of Plecanatide in 
Patients with Irritable Bowel Syndrome with Constipation (IBS-C) 
Sponsor  
Synergy Pharmaceuticals Inc.  
Study Number 
SP304203-06 
Study Centers 
Approximately 250 sites in the United States 
Objectives 
Primary objective: 
To evaluate long-term safety and tolerability of plecanatide administered once 
daily for the treatment of IBS-C. 
Additionally, patients’ assessments of their disease severity, adequacy of 
treatment and desire for treatment continuation will be collected. 
Methodology 
Multi-center, open-label, long-term safety study 
Number of Patients 
and Population 
Up to 1500 male and female patients with IBS-C who are either:                             
1) Study Completers - completed phase 3 double-blind plecanatide study 
SP304203-04 or SP304203-05 and did not experience a Serious Adverse Event 
deemed related to study drug, or  
2) Eligible Screen Failures - failed screening in study SP304203-04 or SP304203-
05 due to diary noncompliance (exclusion criterion 24 of the core study) or due to 
another reason, and in all cases, is allowed to enter this study by notification from 
Sponsor or delegate; confirmation of active IBS-C via ROME III modular 
questionnaire is required. 
3) Early withdrawal from SP304203-04 or SP304203-05 due to lack of efficacy 
and completed an early withdrawal visit (Visit EW).  
4) Patient completed plecanatide study SP304-20212, i.e, had an End-of-Study 
Visit and did not experience a Serious Adverse Event deemed related to study 
drug, or  
5) Patient was randomized and did not complete study SP304-20212, but  
(a) completed an early withdrawal visit, and  
(b) did not have an SAE and  
(c) the reason for early withdrawal was not a drug-related AE and  
(d) is allowed to enter this study with written approval from Sponsor or 
delegate 
6) Plecanatide study-naive Patients – patients that did  not previously participate 
in any plecanatide study  
 
 
Study Termination 
The study will end when its enrollment, regulatory and study drug exposure 
objectives have been met.  Consequently, not all enrolled patients will receive 53 
weeks of treatment. 
Study Drug 
Plecanatide 6 mg tablets 
Rescue Medication 
Bisacodyl (Dulcolax®) 5 mg tablets 
Treatment Duration 
Up to 53 weeks (1 year) 
Study Design 
This is a phase 3, multicenter, open-label, long-term safety and tolerability study 
of 6 mg daily dose of plecanatide administered orally. Patients who are Study 
Completers or Eligible Screen Failures whose eligibility is confirmed at the end of 
their participation in the double-blind plecanatide studies SP304203-04 or 
SP304203-05 will, ideally, start participation in this open-label trial on the day of or 
within 4 weeks of last dose of study drug in SP304203-04 or SP304203-05 or, for 
eligible screen failures, on the day of or within 4 weeks of the end of their 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
Final Version 3.0 
5 of 54 
July 21, 2016   
participation in SP304203-04 or SP304203-05 study (Short Interval Patients).  
If the patient is plecanatide study-naive, participated in the SP304-20212, or more 
than 4 weeks has elapsed since the patient’s last dose of study drug in the 
SP304203-04 or SP304203-05 study, or more than 4 weeks has elapsed since 
the end of an eligible screen failure’s participation in SP304203-04 or SP304203-
05, the patient will need to undergo additional screening assessments in order to 
be considered for enrollment into this trial (Long Interval Patients). 
Beginning on Day 1, patients will take an oral dose of study drug QD for up to 53 
weeks.  Dose adjustments of study drug are not permitted in this study.  Patients 
who interrupt study treatment for adverse events, intercurrent illness or other 
issues may continue in the study with the approval of the Principal Investigator 
and the Medical Monitor when the reason for interruption has been adequately 
reviewed and the patient is deemed appropriate to continue treatment. 
 
Bisacodyl (Dulcolax®) 5 mg tablets will be supplied as rescue medication (RM) for 
the study. 
 
Safety and tolerability assessments and patients’ self-assessment of disease 
severity will be performed according to the Schedule of Assessments. 
 
Patients who discontinue early from the study will undergo an Early Withdrawal 
(EW) visit within 5 days after stopping study drug.  Patients who prematurely 
withdraw from study treatment will not be eligible to participate in this or any other 
plecanatide study in the future.  Upon study termination by the Sponsor, patients 
will undergo an End of Treatment (EOT) visit.  
 
Criteria for Evaluation 
Safety and 
Tolerability  
Evaluation of the safety of once daily (QD) plecanatide over up to 53 weeks of 
dosing will be based on the occurrence of treatment-emergent adverse events 
(TEAEs) and assessment of: vital signs, clinical laboratory tests, physical 
examinations and electrocardiograms.  Tolerability will be assessed by treatment 
interruptions due to diarrhea or other AEs, AE-free days, and continued 
participation in the trial. 
 
Statistical Methods 
A formal Statistical Analysis Plan (SAP) will be written and include details of all 
statistical methods to be used to analyze the long-term safety and tolerability of 
plecanatide. 
 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
6 of 54 
July 21, 2016   
LIST OF STUDY PERSONNEL  
 
 
Sponsor 
 
Executive Vice President and Chief Medical Officer 
 
 
Synergy Pharmaceuticals Inc. 
420 Lexington Avenue, Suite 1609 
New York, NY 10170 
 
 
 
Medical Monitor 
 
 
 
 
  
 
  
 
 
SAE Reporting 
 
ICON Clinical Research 
Medical and Safety Services 
 
 
 
 
Central Laboratory 
 
ACM Medical Laboratory, Inc. 
160 Elmgrove Park 
Rochester, New York 14624 
 
 
Drug Manufacturer 
 
UPM Pharmaceuticals 
6200 Seaforth Street 
Baltimore, MD 21224 
 
 
Drug Packaging and Distribution 
Sharp Packaging Solutions 
7451 Keebler Way  
7339 Industrial Blvd 
Allentown, PA 18106 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
7 of 54 
July 21, 2016   
TABLE OF CONTENTS 
DECLARATION OF SPONSOR ................................................................................................................... 2 
DECLARATION OF THE INVESTIGATOR .................................................................................................. 3 
PROTOCOL SYNOPSIS ............................................................................................................................... 4 
LIST OF STUDY PERSONNEL .................................................................................................................... 6 
LIST OF FIGURES ...................................................................................................................................... 10 
LIST OF TABLES ........................................................................................................................................ 10 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERM ....................................................................... 11 
1 
OVERALL DESIGN AND PLAN OF THE STUDY .............................................................. 13 
2 
INTRODUCTION ................................................................................................................ 14 
2.1 
Background ......................................................................................................................... 14 
2.1.1 
Overview of Irritable Bowel Syndrome ................................................................................ 14 
2.1.2 
Plecanatide Mechanism of Action ....................................................................................... 15 
2.1.3 
Clinical Experience .............................................................................................................. 15 
2.2 
Rationale and Objectives .................................................................................................... 17 
2.2.1 
Rationale for the Dose Selection ......................................................................................... 18 
2.3 
Risk-Benefit Assessment .................................................................................................... 18 
2.4 
Criteria for Evaluation of the Study ..................................................................................... 18 
2.4.1 
Safety and Tolerability Endpoints ........................................................................................ 18 
2.4.2 
Exploratory Endpoints ......................................................................................................... 18 
2.5 
Study Design ...................................................................................................................... 18 
2.6 
Planned Sample Size and Number of Study Centers ........................................................ 18 
3 
STUDY POPULATION ....................................................................................................... 19 
3.1 
Inclusion Criteria ................................................................................................................. 19 
3.2 
Exclusion Criteria ................................................................................................................ 19 
3.3 
Concomitant Medications ................................................................................................... 21 
3.3.1 
Prohibited Concomitant Medications................................................................................... 21 
3.3.2 
Permitted Concomitant Medications ................................................................................... 22 
4 
VARIABLES AND METHODS OF ASSESSMENT ............................................................ 22 
4.1 
Demographics and Baseline Characteristics ...................................................................... 22 
4.1.1 
Disease and Medical History ............................................................................................... 22 
4.2 
Colonoscopy ....................................................................................................................... 22 
4.3 
Patient Reported Outcomes ............................................................................................... 23 
4.4 
Safety Variables .................................................................................................................. 23 
4.4.1 
Collection of Adverse Events .............................................................................................. 23 
4.4.2 
Clinical Laboratory Variables .............................................................................................. 23 
4.4.3 
Vital Signs ........................................................................................................................... 24 
4.4.4 
Electrocardiograms ............................................................................................................. 24 
4.4.5 
Physical Examinations ........................................................................................................ 24 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
8 of 54 
July 21, 2016   
4.4.6 
Concomitant Medications and Diet ..................................................................................... 24 
4.4.7 
Rescue Medication .............................................................................................................. 24 
5 
STUDY CONDUCT ............................................................................................................. 25 
5.1 
Schedule of Assessments .................................................................................................. 25 
5.2 
Procedures by Visit ............................................................................................................. 28 
5.2.1 
Screening Visit for plecanatide study-naive patients, SP304-20212 patients, and core  
study patients with enrollment delay of more than 4 weeks ............................................... 28 
5.2.2 
Baseline / Day 1 Visit .......................................................................................................... 29 
5.2.2.1 Baseline Visit for patients enrolling on the same day or within 4 weeks of core study completion or 
screen-failure .............................................................................................................................................. 29 
5.2.2.2 Baseline Visit for plecanatide study-naive patients, SP304-20212 patients, and patients enrolling 
after more than 4 weeks of core study participation ................................................................................... 30 
5.2.3 
Week 4, 12, 24 and 36 Visits (for all patients) .................................................................... 30 
5.2.4 
Week 53 Visit - End of Treatment ....................................................................................... 31 
5.2.5 
Early Withdrawal (EW) – visit performed ideally within 5 days of the last study drug intake
 ............................................................................................................................................ 31 
6 
STUDY DRUG .................................................................................................................... 32 
6.1 
Identity ................................................................................................................................ 32 
6.1.1 
Plecanatide .......................................................................................................................... 32 
6.2 
Rescue Medication ............................................................................................................. 32 
6.3 
Administration ..................................................................................................................... 33 
6.3.1 
Dose Adjustments ............................................................................................................... 33 
6.3.2 
Overdose ............................................................................................................................. 33 
6.4 
Packaging, Labeling and Storage ....................................................................................... 33 
6.4.1 
Packaging ............................................................................................................................ 33 
6.4.2 
Label .................................................................................................................................... 34 
6.4.3 
Storage ................................................................................................................................ 34 
6.5 
Drug Accountability ............................................................................................................. 34 
6.6 
Compliance ......................................................................................................................... 35 
7 
ASSESSMENT, REPORTING, RECORDING AND FOLLOW UP ADVERSE EVENTS ... 35 
7.1 
Definitions ........................................................................................................................... 35 
7.2 
Events of Special Interest - Diarrhea .................................................................................. 35 
7.3 
Assessment of Adverse Events .......................................................................................... 36 
7.3.1 
Seriousness ......................................................................................................................... 36 
7.3.2 
Intensity (Severity)............................................................................................................... 36 
7.3.3 
Causality .............................................................................................................................. 37 
7.4 
Recording Adverse Events ................................................................................................. 37 
7.5 
Reporting Serious Adverse Events ..................................................................................... 37 
7.6 
Follow-up of Adverse Events .............................................................................................. 39 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
9 of 54 
July 21, 2016   
7.7 
Pregnancy ........................................................................................................................... 39 
8 
STATISTICAL METHODS .................................................................................................. 40 
8.1 
Treatment Assignment........................................................................................................ 40 
8.2 
Sample Size and Power Considerations ............................................................................ 40 
8.3 
Analysis Populations........................................................................................................... 41 
8.4 
General Considerations ...................................................................................................... 41 
8.5 
Missing Data Conventions .................................................................................................. 41 
8.6 
Baseline Definition .............................................................................................................. 41 
8.6.1 
Baseline Characteristics ...................................................................................................... 41 
8.7 
Patient-Reported Outcomes ............................................................................................... 41 
8.7.1 
Patient Questionnaires ........................................................................................................ 41 
8.8 
Tolerability .......................................................................................................................... 42 
8.9 
Safety Analyses .................................................................................................................. 42 
8.10 
Interim Analyses ................................................................................................................. 42 
9 
ETHICAL, LEGAL, AND ADMINISTRATIVE ASPECTS .................................................... 42 
9.1 
Data Quality Assurance ...................................................................................................... 42 
9.1.1 
Database Management and Quality Control ....................................................................... 43 
9.2 
Electronic Case Report Forms and Source Documentation............................................... 43 
9.2.1 
Data Collection .................................................................................................................... 43 
9.3 
Access to Source Data ....................................................................................................... 44 
9.4 
Data Processing ................................................................................................................. 44 
9.5 
Archiving Study Records .................................................................................................... 45 
9.6 
Good Clinical Practice ........................................................................................................ 45 
9.7 
Informed Consent ............................................................................................................... 45 
9.8 
Protocol Approval and Amendment .................................................................................... 45 
9.9 
Duration of the Study .......................................................................................................... 45 
9.10 
Premature Termination of the Study ................................................................................... 46 
9.11 
Confidentiality ..................................................................................................................... 46 
9.12 
Other Ethical and Regulatory Issues .................................................................................. 46 
9.13 
Liability and Insurance ........................................................................................................ 46 
9.14 
Publication Policy ................................................................................................................ 47 
10 
REFERENCE LIST ............................................................................................................. 48 
11 
APPENDICES ..................................................................................................................... 49 
 
 
 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
10 of 54 
July 21, 2016   
LIST OF FIGURES 
Figure 1:   Study Design .............................................................................................................................. 13 
 
 
LIST OF TABLES 
 
Table 1:  Summary of completed, placebo-controlled, clinical trials with plecanatide ................................ 16 
Table 2:  Clinical Laboratory Assessments ................................................................................................. 24 
Table 3:  Schedule of Assessments for Short Interval Patients .................................................................. 26 
Table 4:  Schedule of Assessments for Long Interval Patients .................................................................. 27 
 
 
 
 
 
 
 
 
 
 
 
 
 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
11 of 54 
July 21, 2016   
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERM 
 
AE 
Adverse event 
AGA 
ALT / SGPT 
AST / SGOT 
American Gastroenterological Association 
Alanine transaminase / serum glutamic pyruvic transaminase 
Aspartate aminotransferase / serum glutamic oxaloacetic transaminase 
ANCOVA 
Analysis of covariance 
ANOVA 
Analysis of variance 
ATC 
Anatomical Therapeutic Chemical [Classification System] 
ß-HCG 
Beta-human chorionic gonadotropin 
BM 
Bowel movement 
BSFS 
Bristol Stool Form Scale 
CFR 
Code of Federal Regulations 
CFTR 
Cystic Fibrosis Transmembrane Conductance Regulator 
CI 
Confidence interval 
CIC 
Chronic Idiopathic Constipation 
cGMP 
Cyclic guanosine monophosphate 
CMH 
Cochran-Mantel-Haenszel (test) 
CRO 
Contract Research Organization 
CSBM 
Complete spontaneous bowel movement 
CTCAE 
Common Terminology Criteria for Adverse Events 
ECG 
Electrocardiogram 
eCRF 
Electronic Case Report Form 
EDC 
Electronic data capture 
EOS 
End of Study 
EOT 
ET 
EW 
End of treatment 
Early termination 
Early withdrawal 
FDA 
Food and Drug Administration 
FSH 
Follicle Stimulating Hormone 
GC-C 
Guanylate cyclase  
GCP 
Good Clinical Practice 
GI 
IB 
Gastrointestinal 
Investigator’s Brochure 
IBS 
Irritable Bowel Syndrome 
IBS-SSS 
Irritable Bowel Syndrome Severity Scoring System 
IBSQoL 
Irritable Bowel Syndrome Quality of Life 
IBS-C 
Irritable Bowel Syndrome with Constipation 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
12 of 54 
July 21, 2016   
ICF 
 Informed Consent Form 
ICH 
 International Conference on Harmonization 
IND 
IP 
 Investigational New Drug (application) 
 Investigational Product 
IRB 
 Institutional Review Board 
IWRS 
 Interactive Web-based Response System 
LLN 
 Lower limit of normal 
LOCF 
 Last observation carried forward 
MCG 
 Microgram 
MCH 
Mean corpuscular hemoglobin 
MCV 
Mean corpuscular volume 
Med DRA 
Medical Dictionary for Regulatory Activities 
MG 
MH 
Milligram 
Medical History 
PDUFA 
Prescription Drug User Fee Act 
PE 
Physical examination 
PGA 
Patient Global Assessment 
PI 
Principal Investigator 
PIN 
Personal Identification Number 
PP 
Per-Protocol (Population) 
QD 
 Once daily 
QoL 
RM 
 Quality of Life 
 Rescue Medication 
SAE 
Serious adverse event 
SAP 
Statistical analysis plan 
SBM 
Spontaneous bowel movement 
SD 
Standard deviation 
SOC 
System organ class 
SP-304 
Previous designation for Plecanatide 
TEAE 
Treatment-emergent adverse event 
ULN 
Upper limit of normal 
WHODD 
World Health Organization Drug Dictionary 
 
 
 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
13 of 54 
July 21, 2016   
1 
OVERALL DESIGN AND PLAN OF THE STUDY 
This is a multi-center, open-label study of plecanatide in patients with IBS-C.  Patients will receive up to 
53 weeks of study drug.  This clinical trial is designed to evaluate the long-term safety and tolerability of 
plecanatide in patients enrolling from the phase 2 safety and efficacy SP304-20212 study or phase 3 
safety and efficacy studies SP304203-04 and SP304203-05 as well as plecanatide study-naive patients 
that have not previously enrolled in any plecanatide study. The SP304203-04 and SP304203-05 are 
studies that will feed into SP304203-06 and will be referred to as the “core studies” in the remainder of 
this document. 
In addition to assessment of safety and tolerability of the once-daily 6 mg oral dose of plecanatide, 
patients’ self-assessment of disease severity and adequacy of treatment will be performed. The desire for 
treatment continuation will be assessed for each patient at their last visit in the study. 
This clinical trial will be conducted in approximately 250 centers in the US that have participated in the 
core studies. Patients will be evaluated for eligibility at the end of their participation in the double-blind 
plecanatide core studies and, ideally completers will enroll in this open-label trial SP304203-06 on the day 
or within 4 weeks of the last dose in the core studies (Short Interval Patients). 
For plecanatide study-naive patients, SP304-20212 patients, and any patient that needs a colonoscopy 
(as outlined in Appendix 3), or when more than 4 weeks have elapsed since the last study drug dose in 
the core studies, the patient will need to undergo additional screening assessments in order to be 
considered for enrollment into this trial (Long Interval Patients). 
The overall study plan is presented in Figure 1. 
Figure 1:   Study Design 
 
 
   
 
 
 
 
 
 
For Study Completers---after completing the requirements of the end-of-study visit (Visit 6) in the core 
studies, qualifying patients will be given the option to enter the SP304203-06 Study, ideally enrolling into 
SP304203-06 on the same day, where they will receive treatment with 6 mg plecanatide in an open-label 
fashion for up to 53 weeks. 
For Eligible Screen Failure patients and patients that withdrew early due to lack of efficacy from 
SP304203-04 or SP304203-05 (the core studies) - sites will be notified of eligible patients who meet 
eligibility criteria through IWRS or Medical Monitor or designee for possible enrollment into the study.  
Sites should also request notice of eligibility. 
Short Interval Patients: Patients enrolling from the core studies (a) less than or equal to 4 weeks from 
the last dose of study drug or (b) less than or equal to 4 weeks from Visit 2 for patients that are Eligible 
Screen Failure patients: The patient’s participation in this trial will start at the Baseline/Day 1 Visit, as per 
the schedule of assessments in Table 3.  After written informed consent is obtained, patients will receive 
Core Studies: 
SP304203-04 
SP304203-05 
Plecanatide study-
naive patients 
SP304-20212 
   SP304203-06: Open-Label Long-Term Safety Study   
Up to 53 Weeks 6 mg Plecanatide Daily 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
14 of 54 
July 21, 2016   
their assigned study drug and will take their first dose at the clinical site.  Patients will continue to take a 
single oral dose of study drug once daily for up to 53 weeks.   
Long Interval Patients: All patients enrolling that are (a) plecanatide study-naive, (b) SP304-20212 
(Phase 2) patients, (c) greater than 4 weeks from the last dose of study drug in the core study or (d) 
greater than 4 weeks from Visit 2 for patients that are Eligible Screen Failure patients in the core study: 
These patients will additionally require the Screening Visit, as per the schedule of assessments in     
Table 4.  Written informed consent will be obtained at the screening visit.  Consented patients will then 
undergo screening procedures to determine eligibility for further participation.  Patients eligible to continue 
on to Day 1 will then receive their assigned study drug and will take their first dose at the clinical site.  
Patients will continue to take a single oral dose of study drug once daily for up to 53 weeks.   
If there is doubt about whether a patient is a Short Interval Patient or a Long Interval Patient, they should 
be considered a Long Interval Patient and a Screening Visit performed.  The performance of a Screening 
Visit, even if not strictly required, will not be considered a protocol deviation. 
Safety and tolerability assessments and patients’ self-assessment of disease severity and adequacy of 
treatment will be performed  at Weeks 4, 12, 24, 36 and 53, as specified in the schedule of assessments 
(Table 3 or Table 4, as applicable). The desire for treatment continuation will be assessed for each 
patient at their last visit in the study. 
Dose adjustments are not permitted during this study.  Bisacodyl (Dulcolax®) 5 mg tablets will be 
supplied as rescue medication (RM). 
 
Patients who interrupt study treatment for adverse events, intercurrent illness or study drug supply issues 
may continue in the study with the approval of the Principal Investigator and the Medical Monitor when 
the reason for interruption has been adequately reviewed and the patient deemed appropriate to continue 
treatment. 
 
2 
INTRODUCTION 
 
2.1 
Background 
 
2.1.1 
Overview of Irritable Bowel Syndrome 
Irritable Bowel Syndrome (IBS) is characterized by recurrent episodes of abdominal pain and discomfort 
with associated alterations in bowel habits.  The altered bowel habits may include diarrhea, constipation 
or a mixed pattern of diarrhea and constipation.  Abdominal discomfort or pain is a universal feature 
required for the diagnosis of IBS, and the presence of the predominant abnormal bowel pattern leads to 
the subtyping of IBS: diarrhea-predominant (D-IBS), constipation-predominant (C-IBS), or mixed IBS (M-
IBS).  Of the approximately 30 million individuals in North America who meet the diagnostic criteria for 
IBS, approximately one-third experience constipation during episodes of disease activity [1].  The 
remaining patients are equally subdivided among the other two subtypes [2].  IBS is a chronic condition, 
and may start in adolescence with a 2-3:1 predominance in females as compared to males.  The most 
widely accepted definition for the diagnosis of IBS is the Rome III criteria and includes recurrent 
abdominal pain or discomfort at least 3 days/month in the last 3 months associated with 2 or more of the 
following: 1) improvement with defecation, 2) onset associated with a change in frequency of stool, and 3) 
onset associated with a change in form (appearance) of stool.  The IBS-C subtype is further characterized 
by stool pattern such that ≥ 25% of defecations are hard or lumpy stools and < 25% of defecations are 
loose or watery stools [3].  This study focuses on patients with IBS-C.   
Several underlying mechanisms have been implicated in the pathophysiology of IBS, although much 
remains poorly understood [3, 4].  The pain that patients with IBS experience is believed to be due to 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
15 of 54 
July 21, 2016   
visceral hypersensitivity.  In these patients visceral stimuli which are usually normal or not bothersome (in 
non-IBS patients) are perceived as painful.  Psychosocial stressors, genetic factors, altered intestinal 
microbiota, and altered brain-gut interaction have been theorized to exacerbate or lead to symptoms of 
IBS.  Infection and post-infectious inflammation have also been postulated to lead to the development of 
IBS or symptoms of IBS [5].  According to the Rome III criteria, a patient has to have continuous or 
intermittent symptoms of abdominal discomfort for at least 6 months before the diagnosis of IBS can be 
considered [6]. 
IBS-C is a multi-symptom disease and the goal of therapy is to provide treatment that alleviates its 
multiple symptoms.  Currently, in clinical practice, treatments are typically focused on the treatment of the 
individual symptoms of IBS-C.  If a patient has predominantly constipation symptoms, the patient is 
usually prescribed a fiber supplement or a laxative.  If bloating and distension occur, the patient may be 
prescribed an antispasmodic or dietary modification.  If a patient complains of abdominal pain, the patient 
may receive tricyclic anti-depressants although there is no FDA approved treatment for pain associated 
with IBS-C.  
2.1.2 
Plecanatide Mechanism of Action 
Plecanatide, a synthetic hexadecapeptide designed to mimic the actions of uroguanylin, is currently being 
developed by Synergy Pharmaceuticals Inc. (Synergy) for treatment of IBS-C and CIC. 
Uroguanylin (UG) and guanylin (GN) are endogenous peptide agonists of receptor guanylate cyclase-C 
(GC-C) that is expressed on the luminal surface of epithelial cells lining the gastrointestinal (GI) tract 
mucosa.  These receptor agonists, including plecanatide, bind and activate GC-C receptor to stimulate 
the intracellular production of cyclic guanosine monophosphate (cGMP), resulting in decreased Na+ 
reabsorption through Na+/H+ exchange and activation of the Cystic Fibrosis Transmembrane 
Conductance Regulator (CFTR). Activation of CFTR and the subsequent enhancement of transepithelial 
efflux of chloride and bicarbonate ions lead to influx of water into the intestinal lumen [7]. This fluid 
secretion is expected to facilitate bowel movements. 
In addition to being a secretagogue, plecanatide has demonstrated anti-inflammatory activity in the 
mouse DSS colitis model [8, 9]. This anti-inflammatory activity may be beneficial for treatment of IBS-C.    
2.1.3 
Clinical Experience 
In a recently completed double-blind trial, plecanatide has been shown to increase significantly the 
frequency of complete spontaneous bowel movements (CSBMs) and to improve symptoms in patients 
with IBS-C; it was safe and well-tolerated.  Plecanatide has also been shown to increase the frequency of 
bowel movements (BMs) in patients with Chronic Idiopathic Constipation (CIC) in a double-blind trial.  
Effects on stool consistency and reduction of the time to first bowel movement were also seen.   
Four clinical studies have been completed with plecanatide to date. They are summarized in Table 1. 
 
 
 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
16 of 54 
July 21, 2016   
Table 1:  Summary of completed, placebo-controlled, clinical trials with plecanatide 
Phase 
Population 
N 
Duration 
Doses (mg) 
1 
Healthy volunteers 
71 
Single-dose 
0.1- 48.6 
2a 
Patients with CIC 
78 
14 days 
0.3, 1.0, 3.0, 9.0 
2b 
Patients with CIC 
951 
12 weeks 
0.3, 1.0, 3.0 
2b 
Patients with IBS-C 
424 
12 weeks 
0.3, 1.0, 3.0, 9.0 
3 
Patients with CIC 
1,346 
12 weeks 
3.0, 6.0 
3 
Patients with CIC 
1,337 
12 weeks 
3.0, 6.0 
3 
Patients with CIC 
2,369 
Up to 72 weeks 
6.0 
 
The Phase I study (SP304101-08) was a single dose escalation study in 71 healthy subjects receiving 
doses of 0.1, 0.3, 0.9, 2.7, 5.4, 8.1, 16.2, 24.3, or 48.6 mg plecanatide (n=53) or placebo (n=18).  The 
study reported no systemic absorption at any dose and no serious adverse events (SAEs) or withdrawals 
due to adverse events (AEs).  Diarrhea was the most common AE in the study reported by 8 of 53 
(15.1%) plecanatide subjects and 3 of 18 (16.7%) placebo subjects.  The occurrence of diarrhea did not 
appear to be dose-related.  Other AEs occurring in 2 or more subjects included: abdominal discomfort, 
nausea, and vomiting [10]. 
The Phase 2a study in patients with CIC (SP304201-09) was a 14-day, repeat-dose, placebo-controlled, 
oral dose-escalation study to determine the safety of plecanatide.  Seventy-eight patients were enrolled in 
this study and randomized to receive one of four plecanatide doses: 0.3 mg, 1.0 mg, 3.0 mg, and 9.0 mg 
or placebo.  Each dose cohort consisted of 20 patients (15 active; 5 placebo).  After each cohort was 
completed, a safety review was conducted prior to initiating the next dose cohort.  There were no SAEs or 
withdrawals due to AEs for any of the patients who received plecanatide during this study.  Adverse 
events occurring in 2 or more subjects included: headache, flatulence, and elevated lipase.  None of the 
58 patients treated with plecanatide in this study had diarrhea.  The majority of AEs were mild or 
moderate in severity and transient in nature [11]. 
The Phase 2b study in patients with CIC (SP304-20210) was a large, 12-week, multicenter, dose-ranging 
study [12].  This randomized, double-blind, placebo-controlled study was initiated in October 2011 (first 
dose) and completed in December 2012 (last patient, last visit).  A total of 951 patients were randomized 
at 113 clinical site in the US.  Randomization was 1:1:1:1 to plecanatide (0.3, 1.0, or 3.0 mg) or placebo.  
In this study, 948 patients received study drug (712 plecanatide) and 946 patients had at least one study 
assessment and were included in the modified Intent-to-Treat (mITT) population.  In the high (3.0 mg) 
dose group (n=237), the proportion of patients who were Overall Responders (19%) was statistically 
significantly greater than in patients treated with placebo (10.7%) (p=0.009).   
Among secondary endpoints there were statistically significant changes from baseline (as compared to 
placebo) that were dose-related in the frequency of CSBMs, stool consistency (higher Bristol Stool Form 
Scale (BSFS) score), and straining with the greatest change and degree of statistical significance at the 
3.0 mg dose group. The median times to first SBM were statistically significantly shorter for all doses of 
plecanatide compared to placebo (27.3 hours) with the shortest median time to first SBM of 12.5 hours at 
the 3.0 mg dose. Statistically significantly different (from placebo) changes in patient global assessments 
and the PAC-SYM and PAC-QOL scales were also seen over the 12 weeks of treatment at the 1.0 and 
3.0 mg doses.  In general, plecanatide was safe and well tolerated.  


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
17 of 54 
July 21, 2016   
Diarrhea was the most common adverse event, which increased with increasing dose to an incidence of 
9.7% in the 3.0 mg dose group. Of the cases of diarrhea in patients treated with plecanatide, 0.7% overall 
were considered severe and in patients receiving 3.0 mg, only one case (0.4%) was considered severe. 
The other most common TEAEs occurring in at least 2% of patients were headache, abdominal pain, 
nausea, abdominal distension, urinary tract infection, flatulence, and upper respiratory infection.  SAEs 
were uncommon, occurring in only nine study patients, and none were considered related to study drug.  
Overall, approximately 5.5% of patients on 3.0 mg of plecanatide withdrew due to adverse events 
compared to 3.4% on placebo.  Three percent of patients at the 3.0 mg dose withdrew participation due to 
diarrhea compared to 0.4% on placebo.  There were no clinically significant changes in laboratory tests, 
ECGs, or vital signs. Further details can be found in the Investigator's Brochure that contains additional 
information on plecanatide.  
The most recently completed study was a 12-week, multicenter, dose-ranging study (SP304-20212) in 
patients with IBS-C [Data on file, Synergy Pharmaceuticals].  This randomized, double-blind, placebo-
controlled study was initiated in January 2013 (first dose) and completed in March 2014 (last patient, last 
visit) at 94 sites in the United States.   In this study, 428 patients received study drug (342 plecanatide) 
and 423 patients had at least one study assessment and were included in the modified Intent-to-Treat 
(mITT) population. The mITT population was the primary analysis population for all efficacy parameters.  
Randomization was 1:1:1:1:1 to plecanatide (0.3, 1.0, 3.0 or 9.0 mg daily) or placebo.  
The plecanatide 3.0 mg dose was selected as one of the doses for phase 3 based on achieving 
statistically significant improvement in the study’s primary endpoint and key secondary endpoints 
assessed in the topline analyses, which included change from baseline versus placebo over 12 weeks in: 
CSBM frequency (1.29 placebo vs. 2.74, p=<0.001), worst abdominal pain intensity (-1.4 [-24.5%] 
placebo vs.-2.0 [-33.9%], p=<0.05) and stool consistency (BSFS) (1.01 placebo vs. 2.49, p=<0.001). 
Importantly, plecanatide 3.0 mg dose also showed a statistically significant difference from placebo in the 
overall FDA responder endpoint (21% placebo vs. 41.9%, p=<0.05). An Overall Responder for the FDA 
endpoint fulfills both ≥30% reduction in worst abdominal pain and an increase of ≥1 complete 
spontaneous bowel movements (CSBMs) from baseline in the same week for at least 50% of the weeks 
(i.e. 6/12 weeks).The treatment effects of plecanatide occurred within the first week. Plecanatide was safe 
and well tolerated with no treatment-related serious adverse events. The most common event was 
diarrhea, which occurred in 9.3 percent of the 3.0 mg plecanatide-treated patients. 
Three large Phase 3 clinical trials with plecanatide in patients with Chronic Idiopathic Constipation (CIC) 
have been completed: (SP304203-00, SP304203-01, SP304203-03), and two Phase 3 studies in Irritable 
Bowel Syndrome with Constipation (IBS-C) are ongoing: (SP304203-04, SP304203-05). 
2.2 
Rationale and Objectives 
IBS-C is a chronic medical condition with few treatment options. Many patients either fail to achieve an 
adequate response or cannot tolerate the existing treatments. Therefore, new treatment options that offer 
similar or better levels of clinical benefit are needed.  Clinical studies of plecanatide in patients with IBS-C 
and CIC suggest that it is well-tolerated and may improve bowel frequency while decreasing abdominal 
pain. 
 
The primary objective of this study is to evaluate the long-term safety and tolerability of plecanatide 
administered once daily for the treatment of IBS-C.  In addition, patients’ assessments of disease severity 
and adequacy of treatment will be collected. Desire for treatment continuation will be assessed for each 
patient at their last visit in the study. 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
18 of 54 
July 21, 2016   
2.2.1 
Rationale for the Dose Selection  
The once a day 6 mg dose of plecanatide selected for this study is based upon observations from prior 
plecanatide studies. Doses of 3 and 9 mg/day given for 12 weeks were shown to be safe and effective in 
a Phase 2 trial of patients with IBS-C, with 3 mg dose demonstrating clinically significant efficacy.  The 6 
mg daily dose is being evaluated in the core studies and is anticipated to provide desired efficacy with 
minimal treatment-related side effects.  Administration of 6 mg plecanatide for longer-term treatment in 
this patient population is warranted and will support the highest intended dose in this indication.  
2.3 
Risk-Benefit Assessment 
Based on previously completed clinical studies in patients with IBS-C and CIC, the anticipated benefits of 
treatment with 6 mg/day of plecanatide for 53 weeks are expected to outweigh the potential risks.  
Plecanatide has demonstrated no detectable systemic absorption (with a 1 to 10 ng/ml limit of detection).  
Moreover, the safety profile for 9 mg plecanatide administered daily for 12 weeks was quite acceptable; a 
dose of 6 mg is expected to be at least as safe and well tolerated.  Study patients will be carefully 
monitored for TEAEs at scheduled study visits. 
2.4 
Criteria for Evaluation of the Study 
The safety, tolerability and exploratory endpoints are described below.  For information concerning the 
analyses of these endpoints, see Section 8.   
2.4.1 
Safety and Tolerability Endpoints 
Safety and tolerability will be measured by the number and nature of treatment-emergent adverse events 
(TEAEs), serious adverse events (SAEs), withdrawals due to adverse events (AEs), treatment 
interruptions due to diarrhea or other AEs, AE-free days, and the percentage of patients remaining in the 
study at each week.  Other clinically significant changes in vital signs, clinical laboratory assessments, 
physical examinations and ECGs will be assessed.   
2.4.2 
Exploratory Endpoints 
Patients’ assessments of disease severity and adequacy of treatment will be collected by self-
administered questionnaires completed by the patient at every study visit, ideally prior to any other study 
assessments (see Appendix 1 for details). 
2.5 
Study Design 
An open-label, single-arm design with up to 53 weeks of treatment with plecanatide 6 mg QD (the highest 
dose being evaluated in the core studies) was chosen in accordance with the ICH E1 exposure guideline 
for drugs intended for chronic use.  This study will provide additional data related to the chronic use of 
plecanatide at the dose intended for clinical use in patients with IBS-C. (See Figure 1)   
2.6 
Planned Sample Size and Number of Study Centers 
It is planned to recruit approximately 1500 patients at approximately 250 clinical sites in the US for this 
study.  See Section 8.2 for a discussion of sample size.  Patients will be enrolled in this multi-center, 
outpatient study by gastroenterologists, family practitioners, internists and general medicine practitioners 
who have been qualified as Investigators.  The study will end when its enrollment, regulatory and study 
drug exposure objectives have been met. Consequently, not all enrolled patients will receive 53 weeks of 
treatment. 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
19 of 54 
July 21, 2016   
3 
STUDY POPULATION 
The study population consists of male and female adult patients with Irritable Bowel Syndrome with 
Constipation (IBS-C).  Patients must meet all of the study entry criteria listed below to be enrolled. 
Every effort should be made to ensure that the patient’s participation in this trial begins as soon as 
participation in the plecanatide (“core”) study SP304203-04 or SP304203-05 has ended. Ideally, the first 
visit of this trial (SP304203-06) will occur on the same day as the core study’s end-of-study visit (Visit 6) 
for patients completing the study. For qualifying screen-failure patients, the first visit of this trial will also 
ideally occur on the same day as the core study’s Visit 2. For qualifying patients that withdrew early due 
to lack of efficacy, the first visit of this trial will also ideally occur on the same day as the core study’s EW 
Visit. In addition, plecanatide study-naive patients and patients that participated in the Phase 2 study 
SP304-20212 will be considered for enrollment after completing screening to determine eligibility.  
3.1 
Inclusion Criteria 
Patients with documented diagnosis of IBS-C must meet ONE of the following: 
1. Completed plecanatide study SP304203-04 or SP304203-05, were compliant with the previous 
study’s requirements, and did not experience any Serious Adverse Event (SAE) deemed related to 
study drug during the course of the previous study. 
2. Failed screening in study SP304203-04 or SP304203-05 due to diary noncompliance (exclusion 
criterion 24 of the core study) or due to another reason, and in all cases, is allowed to enter this study 
by notification from Sponsor or delegate; confirmation of active IBS-C via ROME III modular 
questionnaire is required. 
3. Withdrew early from SP304203-04 or SP304203-05 due to lack of efficacy and completed an early 
withdrawal visit (Visit EW) in the core study. 
4. Completed plecanatide study SP304-20212 
5. Completed an early withdrawal visit in SP304-20212 study and reason for withdrawal was not a drug 
related AE 
6. Never participated in a plecanatide study (plecanatide study-naive patient) 18 to 85 years of age 
(inclusive) with IBS-C as defined by Rome III criteria (See ROME III modular questionnaire for IBS in 
Appendix 2). 
 
Note: Details of how to use the Rome III questionnaire and the scoring system is provided in Appendix 2. 
At the clinical site patients will be given simple instructions on how to complete the form only; authorized 
personnel will review them for completeness only, to ensure that all questions have been answered. At no 
time will study staff correct or suggest changes of patient entries. The patient-reported responses to the 
questionnaire will be reviewed by the investigator or designee, who will use the scoring table provided in 
Appendix 2 for documentation of patients’ eligibility. The questionnaire and the scoring chart will be kept 
as part of the patient’s source documents. 
3.2 
Exclusion Criteria 
For patients entering from one of the core studies presence of any of the following will exclude the patient 
from enrollment: 
1. Patient is unwilling or unable to: participate in the study for the required duration, understand and 
sign the informed consent form (ICF) and undergo all protocol related tests and procedures 
throughout the study. 
2. Female patient of childbearing potential with a positive urine pregnancy test on Day 1.  


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
20 of 54 
July 21, 2016   
3. Male and female patients of childbearing potential who do not agree to continue to use the method 
of birth control used in the core double-blind plecanatide study or another acceptable form of birth 
control for the duration of this clinical trial. 
4. Patient has experienced a significant negative change in health status during the course of 
participation in the core double-blind plecanatide study or after completion of the study.  
Note: Any question or concern with regard to a patient’s general health status or a potentially 
significant change in the patient’s general health status during their participation in study 
SP304203-04 or SP304203-05 should be referred to the Medical Monitor for a medical opinion as 
to the suitability of the patient for participation in this clinical trial. 
5. In the opinion of the Investigator or Medical Monitor, it is not in the patient’s best interest to 
participate in the study.  The reason(s) for the patient’s exclusion must be specified. 
6. Use of Linzess® (linaclotide) or Amitiza® (lubiprostone) within 15 days of the Baseline Visit. 
7. Patient has not met the colonoscopy requirements outlined by the AGA Institute for his or her 
particular risk group as they relate to colon cancer screening and/or surveillance. (See       
Appendix 3) 
For plecanatide study-naive patients and patients that participated in SP304-20212 presence of any of 
the following will exclude the patient from enrollment: 
 
1. Patient is unwilling or unable to: participate in the study for the required duration, understand and 
sign the informed consent form (ICF), and undergo all protocol related tests and procedures 
throughout the study. 
2. Female patient is of childbearing potential with a positive urine pregnancy test on Day 1 
3. Female patient is lactating.  
4. Male and female patients of childbearing potential who do not agree to continue to use an 
acceptable method of birth control for the duration of this clinical trial. 
Acceptable methods of birth control include:  
a. Hormonal contraceptive (e.g., oral contraceptive, implanted or injected hormonal contraceptive) at 
least 2 months prior to enrollment. 
b. Use of double-barrier contraception (e.g., condom plus diaphragm, spermicide or intrauterine 
device). 
c. Surgical sterilization (men who have had a vasectomy or women with bilateral oophorectomy, 
hysterectomy or tubal ligation). 
d. Maintain a monogamous relationship with someone who is surgically sterile or is not of child-
bearing potential (e.g., post-menopausal). 
e. Note: Abstinence is not considered an acceptable form of contraception for the purposes of this 
study. 
Post-menopausal is defined as without menses for at least 12 consecutive months before screening 
and have an elevated Follicle-Stimulating Hormone (FSH) consistent with menopause. 
Women who are still menstruating must be able to differentiate their abdominal symptoms associated 
with IBS-C from those associated with their menses. 
5. In the opinion of the Investigator or Medical Monitor, it is not in the patient’s best interest to 
participate in the study.  The reason(s) for the patient’s exclusion must be specified. 
6. Use of Linzess® (linaclotide) or Amitiza® (lubiprostone) within 15 days of the Baseline Visit. 
7. Patient reports participation in a clinical study or use of an investigational drug treatment within 30 
days of Screening. Participation in an observational study (i.e., registry where no study drug is 
administered) will be allowed. 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
21 of 54 
July 21, 2016   
8. Patient has a BMI < 18 or > 40 kg/m2. 
9. Patient has not met the colonoscopy requirements outlined by the AGA Institute for his or her 
particular risk group as they relate to colon cancer screening and/or surveillance (See Appendix 3). 
10. Patient has unexplained and clinically significant “alarm symptoms” such as lower GI bleeding, iron-
deficiency anemia, weight loss or systemic signs of infection. 
11. Patient has any pre-existing medical condition (based on medical history or PE or laboratory 
evaluations) that is considered clinically significant enough to potentially interfere with study 
assessments or the patient’s participation in and completion of the study. The Investigator must get 
approval from the Sponsor’s Medical Monitor or designee before randomizing any patient who has 
what the Investigator considers clinically-significant medical history, signs, symptoms, or test results 
during the Screening Period of the study.  These include but are not limited to: 
a. History of or current clinically significant cardiovascular, nervous system, pulmonary, renal, 
hepatic, endocrine or gastrointestinal disease.  Gastrointestinal diseases and conditions include 
inflammatory disorders (e.g., ulcerative colitis or Crohn’s Diseases), familial adenomatous 
polyposis, structural abnormality of the GI tract that can affect GI motility or defecation, surgery to 
remove or bypass any portion of the GI tract 
b. History of or current cancer (other than basal cell or squamous cell carcinoma of the skin) unless 
the malignancy has been in a complete remission without maintenance chemotherapy for at least 
5 years prior to Visit 1. 
c. Any concomitant medical illness that is predominantly characterized by chronic abdominal pain 
d. Major surgery, i.e., requiring general anesthesia within 6 months of the Screening Visit, or 
abdominal laparoscopic procedure within 60 days of the Screening Visit. 
e. Determined at screening visit, patient has any abnormal laboratory value that is considered 
clinically significant by the Investigator.  Any laboratory value that is ≥ 3x the upper limit of normal 
(ULN) must be reviewed for potential clinical significance by the Sponsor’s Medical Monitor or 
designee and cleared for randomization (if otherwise eligible). 
12. Current clinically significant active viral hepatitis. 
13. History of or infection with HIV. 
14. Positive urine screen for opiates  
3.3 
Concomitant Medications 
Any medication the patient takes other than the study drug, including herbal and other non-traditional 
remedies, is considered a concomitant medication.  The following information must be recorded in the 
eCRF for each concomitant medication: generic name, route of administration, start date, stop date, 
dosage and indication.  Any change in the dose or regimen of a concomitant medication must be 
recorded in the eCRF.  
3.3.1 
Prohibited Concomitant Medications 
All prescription, non-prescription, or herbal therapies used to treat constipation or facilitate bowel 
movements are prohibited during the study, except the Sponsor-supplied rescue medication (see Section 
3.3.2).   
The following concomitant medications and supplements are prohibited during the study:  
• 
Resolor® (prucalopride) 
• 
Opioids intended for chronic use 
• 
Amitiza® (lubiprostone) 
• 
Linzess®/Constella® (linaclotide)  


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
22 of 54 
July 21, 2016   
• 
Lactulose 
• 
Laxatives, except the Sponsor-supplied rescue medication (RM) 
Note: There is no indication of any specific safety risk when these generally prohibited agents are used 
concomitantly with plecanatide; however, appropriate medical caution should be exercised when agents 
that may aggravate underlying constipation are taken or when agents with similar physiological outcomes 
(i.e., increased BM frequency) are used together.   
3.3.2 
Permitted Concomitant Medications 
Bisacodyl (Dulcolax®) 5 mg tablets will be supplied as rescue medication (RM) for the study.  Patients 
must only use the Dulcolax® supplied by the Investigator during the study.  See Sections 4.4.7 and 6.2 
for more information on RM.  Drugs given to treat AEs will be allowed.  
4 
VARIABLES AND METHODS OF ASSESSMENT 
 
4.1 
Demographics and Baseline Characteristics 
 
Demographic data, medical history (including ongoing AEs) and previous/concomitant medications 
recorded in the eCRF of the previous plecanatide core study will be replicated in the eCRF for this open-
label study when the patient signs the informed consent and is enrolled into this open-label study.  New 
information or clinically-significant changes since the core trial will be solicited from all patients for 
appropriate updates to the eCRF for this open-label study.  
 
4.1.1 
Disease and Medical History 
 
A complete medical history and GI disease history will be recorded for all plecanatide study-naive and 
SP304-20212 patients. Source documentation for previous treatment, diagnosis, and interventions, where 
available, should be included in the patient’s medical record to facilitate source documentation 
verification.  The outcome of the medical history assessment may be recorded as part of the worksheet 
for evaluation of eligibility and can be added to the patient’s medical records. 
 
4.2 
Colonoscopy 
A colonoscopy is not required to make a diagnosis of IBS or IBS-C.  However, there are two clinical 
settings where a colonoscopy is required during the screening period:  
 
1) If a patient has not completed a recommended colonoscopy based on the colon cancer screening 
and surveillance colonoscopy intervals outlined by the AGA, then a study-related eligibility 
colonoscopy can be authorized (see note) but must be completed within first 21 days following 
screening (Visit 0).   See Appendix 3 for a brief summary of the AGA guidelines for colonoscopy 
screening and surveillance for prevention of colorectal cancer. 
OR, 
2) If the patient satisfies all other Inclusion/Exclusion criteria at Screening Visit and has an 
unexplained and clinically significant “alarm” sign(s) or symptom(s) at Visit 1 and the Investigator 
determines that a colonoscopy is required to adequately assess the “alarm” sign or symptom, 
then a study related eligibility colonoscopy can be requested (see note) but must be completed 
within 21 days following screening (Visit 0).    
 
Note: If a colonoscopy is to be conducted as part of this study under either of the clinical scenarios outlined 
above, it will require sponsor or Medical Monitor approval, via the colonoscopy approval form.  Once 
sponsor/medical monitor approval has been received, the procedure must be completed within 21 days 
following screening (Visit 0) and results must be reviewed and all findings must be negative for the presence 
of cancer or any of the GI conditions detailed in the exclusion criteria before the patient can be enrolled into 
the study. 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
23 of 54 
July 21, 2016   
4.3 
Patient Reported Outcomes 
The following patient questionnaires will be administered at the scheduled study visits:   
• 
Patient Rating of Relief of IBS Symptoms 
• 
Treatment Satisfaction Assessment 
• 
Treatment Continuation Assessment 
The self-administered questionnaires will be conducted during the scheduled study visits (as specified in 
Section 5.2), preferably prior to any other study assessments.  Completion of the questionnaires takes 1 
to 5 minutes.  The items of the questionnaires are depicted in Appendix 1. 
4.4 
Safety Variables 
4.4.1 
Collection of Adverse Events 
Adverse event (AE) collection for the study will begin immediately after the ICF is signed. All AEs 
occurring prior to first dose of study drug are considered medical history (MH). It is the responsibility of 
the Investigator to ensure that all serious and non-serious AEs are collected.  For details on the 
assessment, reporting, recording and follow-up of adverse events, see Section 7. IBS-C is characterized 
primarily by abdominal pain and constipation; however, several additional symptoms are often associated 
with IBS-C including abdominal discomfort, abdominal bloating, incomplete evacuation and straining with 
bowel movements.  Because IBS-C is the condition under study in this clinical trial these IBS-C related 
symptoms are expected over the course of a patients participation in the trial; therefore, when reported as 
related to IBS-C, these symptoms should not be recorded as adverse events.      
4.4.2 
Clinical Laboratory Variables 
Clinical laboratory assessments will be performed by a central laboratory, as identified in the List of Study 
Personnel and Vendors.  The Laboratory Manual provided to investigative sites includes detailed 
instructions regarding the collection, processing, and handling of laboratory samples, including those for 
immunogenicity testing. 
6 to 12-hour fasting is recommended before laboratory assessments are performed.  The laboratory 
variables presented in  Table 2 will be assessed in accordance with the Schedule of Assessments (Table 
3 or Table 4, as applicable). 
Approximately 2.0 mL of blood will be drawn for each hematology sample, 5.0 mL for each serum 
chemistry sample, and 3.5 mL for each immunogenicity sample. The total blood volume collected from 
each patient for laboratory tests, not including possible repeat tests, over the course of 53 weeks will be 
approximately 60 mL.  
 
 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
24 of 54 
July 21, 2016   
Table 2:  Clinical Laboratory Assessments 
Hematology 
Erythrocytes, mean corpuscular volume (MCV), mean corpuscular 
hemoglobin (MCH), neutrophils, eosinophils, basophils, lymphocytes, 
monocytes, platelets, leukocytes, hemoglobin, and hematocrit 
Serum chemistry 
Alanine aminotransferase, aspartate aminotransferase, creatinine, alkaline 
phosphatase, total bilirubin, direct bilirubin, blood urea nitrogen, total protein, 
albumin, uric acid, glucose and cholesterol        
Electrolytes: Sodium, potassium, chloride, magnesium, phosphorus, calcium  
Urinalysis 
Specific gravity, pH, protein, glucose, ketones, blood, and microscopic 
examination of sediment 
Urine Pregnancy test 
Pregnancy test via dipstick (performed at study site for women of 
childbearing potential) 
Urine Drug Screen 
Urine tests for methadone, morphine and oxycodone (performed at study 
site) 
Immunogenicity 
Serum collection for anti-plecanatide antibodies testing (samples will be 
stored until an assay is developed) 
 
4.4.3 
Vital Signs 
Vital sign measurements will be performed after the patient has been seated for at least 5 minutes.  The 
following vital signs will be performed in accordance with the Schedule of Assessments (Table 3 or   
Table 4, as applicable):  
• 
Blood pressure (systolic and diastolic; mmHg) 
• 
Heart rate (beats per minute) 
• 
Body temperature (°C) 
• 
Respiration rate (breaths per minute)  
 
4.4.4 
Electrocardiograms 
Standard 12-lead ECGs will be performed in accordance with the Schedule of Assessments (Table 3 or 
Table 4, as applicable). 
All ECGs will be performed in either the supine or semi-recumbent position. 
4.4.5 
Physical Examinations 
Physical examinations will be performed in accordance with the Schedule of Assessments (Table 3 or 
Table 4, as applicable). The PE will be based on the following body systems: general appearance, head 
(ear, eyes, nose, and throat), cardiovascular, respiratory, abdomen, musculoskeletal, neurological, lymph 
nodes, and skin. 
4.4.6 
Concomitant Medications and Diet 
Any new or changes to concomitant medications and dietary supplements will be documented at each 
study visit.  Any clinically significant change in medications or dietary intake/supplements that could 
adversely affect the patient or study should be documented by the site and discussed with the Medical 
Monitor to determine whether the patient should continue in the study. 
4.4.7 
Rescue Medication 
Bisacodyl (Dulcolax®) 5 mg tablets will be supplied as rescue medication (RM) for the study.  Patients will 
be instructed to take the study-provided rescue medication ONLY if 72 hours have elapsed since their last 
bowel movement.  Therefore, patients should not take RM on more than two days per week.  See 
Sections 3.3.2 and 6.2 for instructions on RM use. 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
25 of 54 
July 21, 2016   
5 
STUDY CONDUCT 
 
5.1 
Schedule of Assessments 
 
Ideally, the roll-over patient’s participation in this trial begins as soon as participation in the core study 
SP304203-04 or SP304203-05 has ended.  
For Core Study Completers, Day 1 / Baseline Visit of this study will commence after completion of the 
core study (End-of-Study visit - Visit 6).   
For Eligible Screen Failure patients, the first visit of this trial will also ideally occur on the same day as the 
core study’s Visit 2.  
For patients that withdrew early from the core study due to lack of efficacy, the first visit of this trial will 
ideally occur on the same day as the core study’s EW Visit. 
The Schedule of Assessments for Core Study Completers or Eligible Screen Failure patients or patients 
that withdrew early who are enrolling on the same day or within 4 weeks of the last study drug dose or 
within 4 weeks of core study participation (Short Interval Patients) is presented in Table 3.  
For (a) plecanatide study-naive patients, (b) SP304-20212 patients, and (c) Core Study Completers or 
Eligible Screen Failure patients when (i) more than 4 weeks elapsed since the patient’s participation in 
the study or (ii) more than 4 weeks since the last study drug dose (Long Interval Patients), the patient will 
have to undergo additional assessments, specifically study participation begins with the Screening Visit 
(presented in Table 4). 
 
 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
26 of 54 
July 21, 2016   
 
Table 3:  Schedule of Assessments for Short Interval Patients 
Study Visit 
Baseline 
Visit 1 
Week 4 
Visit 2 
Week 12 
Visit 3 
Week 24 
Visit 4 
Week 36 
Visit 5 
Week 53 
(EOT)* 
Visit 6 
Early 
Withdrawal 
(EW) 
Visit Day ± Visit Window 
Day 1 (a)   
Day 28 
± 4 days 
Day 84    
± 7 days 
Day 168  
± 7 days 
Day 252   
± 7 days 
Day 371   
+ 7 days 
Within 5 days 
of last study 
drug treatment 
Informed Consent 
X 
 
 
 
 
 
 
Rome IBS Modular 
Questionnaire b (Appendix 2) 
X 
 
 
 
 
 
 
Inclusion/Exclusion Criteria 
X 
 
 
 
 
 
 
Medical History (additional 
new information not 
recorded in the core study) 
X 
 
 
 
 
 
 
Patient Questionnaires c 
 
X 
X 
X 
X 
X 
X 
Concomitant Medications 
X 
X 
X 
X 
X 
X 
X 
Adverse Events 
X 
X 
X 
X 
X 
X 
X 
Physical Examination d 
 
X 
X 
X 
X 
X 
X 
Vital Signs e 
 
X 
X 
X 
X 
X 
X 
Pregnancy Test (urine) f 
X 
X 
X 
X 
X 
X 
X 
Urine Drug Screen 
X 
 
 
 
 
 
 
Hematology, Serum 
Chemistry, Urinalysis g 
 
X 
X 
X 
X 
X 
X 
Immunogenicity Testing h 
 
 
X 
X 
X 
X 
X 
12-lead ECG i 
 
 
X 
 
 
X 
X 
Study Drug Dispensation j  
X 
X 
X 
X 
X 
 
 
Study Drug Collection k 
 
X 
X 
X 
X 
X 
X 
Rescue Medication (RM) 
Dispensation l 
X 
X 
X 
X 
X 
 
 
 
*  EOT visit is for patients that either complete week 53 or complete due to sponsor termination of the study 
a. Ideally, Day 1 Visit will overlap with the end-of-study visit (Visit 6) of the core trial. The following most recent data 
collected at the core study: physical exam, vital signs, pregnancy test, ECG, labs (hematology, serum chemistry, 
urinalysis), immunogenicity testing, concomitant medications and adverse events will be used as baseline 
assessments in this study. 
b. Required for Screen-Failures, who do not have confirmation of active IBS-C done by diary in the core study.  
c. Selected questionnaires self-administered by patient, preferably prior to any other study assessments. 
d. PE will be based on the following body systems: general appearance, head (ear, eyes, nose, and throat), 
cardiovascular, respiratory, abdomen, musculoskeletal, neurological, lymph nodes, and skin. 
e. Seated blood pressure, heart rate, respiration, and temperature using the same calibrated instrument for each 
measurement. 
f. Urine pregnancy test performed on-site for women of childbearing potential (site must confirm negative result prior 
to proceeding).  
g. 6 to12 -hour fast is recommended before clinical laboratory assessments. 
h. Serum samples for immunogenicity testing for antibodies to plecanatide will be collected and stored until analysis.  
See Laboratory Manual for processing and shipping instructions. 
i. ECG is to be performed on the same calibrated machine during the study. 
j.   The study drug will be dispensed at each visit as follows: one study drug kit on Day 1, two study drug kits at Week 
4, three study drug kits at Week 12 and Week 24, four study drug kits at Week 36. Patient will take the Day 1 
medication at the clinical site on Day 1; it is recommended that for dosing at home, patient will take study drug 
once daily at approximately the same time in the morning of each day.   
k.   Patients will be instructed to return all unused study drug at the subsequent study visit.  Site will perform study 
drug accountability at every visit. 
l. Rescue medication - Dulcolax tablets will be supplied (in commercial packaging) at the first study visit and re-
supplied as needed throughout the study 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
27 of 54 
July 21, 2016   
 
Table 4:  Schedule of Assessments for Long Interval Patients 
Study Visit 
Screening  
Visit 0 
Baseline 
Visit 1 
Week 4 
Visit 2 
Week 12 
Visit 3 
Week 24 
Visit 4 
Week 36 
Visit 5 
Week 
53 
(EOT)* 
Visit 6 
Early 
Withdrawal 
(EW) 
Visit Day ± Visit Window 
Day         
 -21 to -7**   
Day 1    
Day 28 
± 4 days 
Day 84     
± 7 days 
Day 168  
± 7 days 
Day 252   
± 7 days 
Day 371   
+ 7 days 
Within 5 days 
of last study 
drug treatment 
Informed Consent 
X 
 
 
 
 
 
 
 
Rome IBS Modular 
Questionnaire (Appendix2) a 
X 
 
 
 
 
 
 
 
Inclusion/Exclusion Criteria 
X 
X 
 
 
 
 
 
 
Medical History (additional 
new information not recorded 
in the core study) 
X 
 
 
 
 
 
 
 
Patient Questionnaires b 
 
 
X 
X 
X 
X 
X 
X 
Concomitant Medications 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse Events 
X 
X 
X 
X 
X 
X 
X 
X 
Physical Examination c 
X 
 
X 
X 
X 
X 
X 
X 
Vital Signs d 
X 
 
X 
X 
X 
X 
X 
X 
Pregnancy Test (urine) e 
X 
X 
X 
X 
X 
X 
X 
X 
Urine Drug Screen 
X 
X 
 
 
 
 
 
 
Hematology, Serum 
Chemistry, Urinalysis f 
X 
 
X 
X 
X 
X 
X 
X 
Immunogenicity Testing g 
 
X 
X 
X 
X 
X 
X 
 
12-lead ECG h 
X 
 
 
X 
 
 
X 
X 
Study Drug Dispensationi 
 
X 
X 
X 
X 
X 
 
 
Study Drug Collection j 
 
 
X 
X 
X 
X 
X 
X 
Rescue Medication (RM) 
Dispensation k 
X 
X 
X 
X 
X 
X 
 
 
* EOT visit is for patients that either complete week 53 or complete due to sponsor termination of the study 
** Minimum of 7 days should be allowed for plecanatide study-naive and SP304-20212 patients between screening 
and baseline visits 
a. 
Rome IBS Questionnaire is required for Screen-Failure Patients who do not have confirmation of active IBS-C 
done by diary in study SP304203-04 or SP304203-05.  
b. 
Selected questionnaires self-administered by patient, preferably prior to any other study assessments.  
c. 
PE will be based on the following body systems: general appearance, head (ear, eyes, nose and throat), 
cardiovascular, respiratory, abdomen, musculoskeletal, neurological, lymph nodes, and skin. 
d. 
Seated blood pressure, heart rate, respiration, and temperature using the same calibrated instrument for each 
measurement. 
e. 
Urine pregnancy test performed on-site for women of childbearing potential (site must confirm negative result 
prior to proceeding). 
f. 
6 to12 hours fast is recommended before clinical laboratory assessments. 
g. 
Serum samples for immunogenicity testing for antibodies to plecanatide will be collected and stored until 
analysis.  See Laboratory Manual for processing and shipping instructions. 
h. 
ECG is to be performed on the same calibrated machine during the study. 
i. 
The study drug will be dispensed at each visit as follows: one study drug kit on Day 1, two study drug kits at 
Week 4, three study drug kits at Week 12 and Week 24, four study drug kits at Week 36. . Patient will take the 
Day 1 medication at the clinical site on Day 1; it is recommended that for dosing at home, patient will take study 
drug once daily at approximately the same time in the morning of each day.   
j. 
Patients will be instructed to return all unused study drug at the subsequent study visit.  Site will perform study 
drug accountability at every visit. 
k. 
Rescue medication - Dulcolax tablets will be supplied (in commercial packaging) at the first study visit and re-
supplied as needed throughout the study. 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
28 of 54 
July 21, 2016   
 
5.2 
Procedures by Visit 
Prior to initiating any study-related procedures, written informed consent must be completed and 
documented.  When a patient is found to be eligible to enter the study, the investigator or designee will 
document enrollment of the patient in the site enrollment log. The Patient ID number will be the same as 
the 6-digit Patient ID used in the previous plecanatide study, except in rare circumstances when an 
administrative change to the Patient ID, pre-approved by the Sponsor, is required. The Patient ID number 
is also reflected as same in the eCRF. 
Plecanatide study-naive and SP304-20212 patient numbering: A unique 6-digit patient number will be 
assigned consecutively for each patient using the site enrollment log selection after he or she signs the 
ICF.  Unique patient numbers will begin with the clinical site number, e.g., 001 followed by a 3-digit 
number such as 601. The unique patient numbers will be assigned sequentially by clinical site personnel.  
For example, for clinical site number 002, the unique patient numbers might be as follows: 002-601, 002-
602, 002-603, etc.  The patient will keep this unique patient number for the duration of the study. 
Depending on the length of time elapsed since participation in the core study (SP304203-04 or 
SP304203-05) and whether patient is plecanatide study-naive or from SP304-20212 patients are divided 
into two subgroups which will follow distinct initial enrollment requirements: 
1) Patients who either completed the core study, withdrew early, or screen failed ≤4 weeks earlier  
(Study Completers, Early Withdrawals, and Eligible Screen Failures), will be enrolled into this 
study at the Baseline Visit, with study procedures described in section 5.2.2.1 (Short Interval 
Patients) 
2) Patients, for whom more than 4 weeks elapsed since the core study participation (Study 
Completers, Early Withdrawals, and Eligible Screen Failures and plecanatide study-naive patients 
and SP304-20212 patients), will be enrolled into this study at the Screening Visit, with study 
procedures described in section 5.2.1  (Long Interval Patients) 
 
Procedures at Weeks 4, 12, 24, 36, 53 and Early Withdrawal will be the same for all patients. 
     
5.2.1 
Screening Visit for plecanatide study-naive patients, SP304-20212 patients, and core  
study patients with enrollment delay of more than 4 weeks 
This visit is required for plecanatide study-naive Patients, SP304-20212 patients and core study 
completers, eligible early withdrawals and eligible screen failures whose participation in the core study 
ended more than 4 weeks prior to enrollment into this study and for any patient needing a colonoscopy as 
per the guidelines in Appendix 3. For plecanatide study-naive and SP304-20212 patients only – the 
interval between screening and baseline visit must be at least 7 days.  
The following procedures will be performed at this visit: 
• 
Informed consent 
• 
Rome IBS Modular Questionnaire (confirmation of IBS-C diagnosis via ROME III modular 
questionnaire (see Appendix 2) is required for patients not randomized in study SP304203-04 
or SP304203-05. 
• 
Review of inclusion/exclusion criteria   
• 
Review of recent medical history (for information not already recorded in the core study) 
• 
Review and recording of concomitant medications 
• 
Physical examination 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
29 of 54 
July 21, 2016   
 
• 
Vital signs measurement 
• 
12-lead ECG 
• 
Clinical laboratory assessments: hematology, serum chemistry, immunogenicity, urinalysis 
(see section 4.4.2 for details) 
• 
Urine pregnancy test, if applicable 
• 
Urine drug screen for selected opioids (see section 4.4.2 for details)  
• 
Dispensation of study-provided rescue medication (Dulcolax®) 
 
Patients who fail to qualify for enrollment into this study will be considered Screen Failures and the 
reason for failure will be documented. Once a patient screen fails in this study, they cannot be re-
screened. 
5.2.2 
Baseline / Day 1 Visit  
Patients who are Study Completers, Eligible Early Withdrawals, or Eligible Screen Failures and enrolling 
into this study within 4 weeks of the core study completion or within 4 weeks of the last study drug dose 
will begin with the Baseline / Day 1 Visit. The Baseline Visit assessments are described in section 5.2.2.1. 
Any adverse event that commenced during the core studies and are still ongoing/stable will be recorded 
on the Medical History CRF in SP304203-06, with the medical term and start date identical to those in the 
core study. 
Adverse events that occurred during the core studies and resolved or ongoing prior to enrollment in 
SP304203-06 will be reported in SP304203-06 in the patient’s medical history, according to their medical 
relevance. 
Results of laboratory tests performed in the core study and used as baseline at Visit 1 of this trial must be 
evaluated within 72 hours of the visit to confirm the patient’s continual eligibility for this open-label study. 
5.2.2.1 Baseline Visit for patients enrolling on the same day or within 4 weeks of core study 
completion or screen-failure   
Ideally, Day 1 / Baseline Visit of this study will commence immediately after completion of core study’s 
end-of-study visit (Visit 6) for patients completing the study. For eligible SP304203-04 or SP304203-05 
screen-failure patients, the first visit of this trial will also ideally occur on the same day as the core study’s 
Visit 2. For eligible SP304203-04 or SP304203-05 early withdrawal patients, the first visit of this trial will 
also ideally occur on the same day as the core study’s EW visit. 
The following procedures will be performed on Day 1: 
• 
Informed consent 
• 
Rome IBS Modular Questionnaire (confirmation of IBS-C diagnosis via ROME III modular 
questionnaire (see Appendix 2) is required for patients not randomized in study SP304203-04 or 
SP304203-05. 
• 
Review inclusion/exclusion criteria  
• 
Pregnancy Test (urine) 
• 
Urine Drug Screen 
• 
Review and recording of concomitant medications and procedures (only for new information that 
is not recorded in the core study) 
• 
Medical History (new information that is not recorded in the core study must be captured in the 
source documents and eCRF)  
• 
Dispensation of study drug 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
30 of 54 
July 21, 2016   
 
• 
Dispensation of study-provided rescue medication (RM) 
If the SP304203-06 baseline visit is within 4 weeks of the end-of-study visit (Visit 6) of the core study, 
certain data collected at Visit 6 or Visit 5 or Visit 2 of the core study will also be used as the data for the 
SP304203-06 baseline visit, i.e., these assessments do not have to be performed again for entry into 
SP304203-06, for practical reasons. This is indicated in the Schedule of Assessments in Table 3. 
The following last set of results collected at the core study (at Visit 5) will be used as baseline 
assessments in this study:  
• 
Physical exam  
• 
Vital signs 
• 
Laboratory tests (hematology, serum chemistry, urinalysis) 
• 
ECG  
• 
Immunogenicity testing 
• 
Medical History (new information that is not recorded in the core study must be captured in the 
source documents and eCRF)  
• 
Review and recording of concomitant medications and procedures (new information that is not 
recorded in the core study must be captured in the source documents and eCRF) 
• 
Review and recording of adverse events (new information that is not recorded in the core study 
must be captured in the source documents and eCRF) 
 
5.2.2.2 Baseline Visit for plecanatide study-naive patients, SP304-20212 patients, and patients 
enrolling after more than 4 weeks of core study participation 
For patients enrolling more than 4 weeks after the core study participation, plecanatide study-naive 
patients, and SP304-20212 patients and who completed the Screening Visit of this study, the following 
assessments will be performed at the Baseline Visit: 
• 
Review inclusion/exclusion criteria  
• 
Review and recording of concomitant medications 
• 
Review of adverse events   
• 
Pregnancy Test (urine) 
• 
Urine Drug Screen 
• 
Immunogenicity sample collection 
• 
Dispensation of study drug 
• 
Dispensation of study-provided rescue medication (RM) 
 
5.2.3 
Week 4, 12, 24 and 36 Visits (for all patients) 
The following procedures will be performed: 
• 
Patient self-administered questionnaires: Relief of Abdominal Symptoms and Treatment 
Satisfaction 
• 
Documentation of concomitant medications  
• 
Review of adverse events 
• 
Physical examination 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
31 of 54 
July 21, 2016   
 
• 
Vital signs measurement 
• 
Urine pregnancy test for women of childbearing potential 
• 
Clinical laboratory assessments 
• 
Immunogenicity sample collection 
• 
12-lead ECG (at Week 12 only) 
• 
Unused study drug collection and accountability 
• 
Dispensation of study drug as described in Section 6.4, and review dosing instructions with the 
patient 
• 
Re-supply RM as needed 
• 
Confirm the next visit and explain the importance of completing study visits within the allowable 
visit window.  Remind the patient to return all study drug kits/folders at the next visit. 
 
5.2.4 
Week 53 Visit - End of Treatment  
For patients that complete week 53 or complete due to sponsor termination of the study, the following 
procedures will be performed: 
• 
Patient self-administered questionnaires: Relief of Abdominal Symptoms, Treatment Satisfaction, 
Treatment Continuation 
• 
Documentation of concomitant medications 
• 
Review of adverse events 
• 
Physical examination 
• 
Vital signs measurement 
• 
Urine pregnancy test for women of childbearing potential 
• 
Clinical laboratory assessments 
• 
Immunogenicity sample collection 
• 
12-lead ECG 
• 
Study drug collection and accountability 
5.2.5 
Early Withdrawal (EW) – visit performed ideally within 5 days of the last study drug intake 
Patients are free to withdraw from participation in the study at any time.  Investigators may choose to 
discontinue a patient’s participation in the study if they believe it is in the patient’s best interest clinically. 
Patients unwilling or unable to maintain compliance with study drug administration or protocol procedures 
may be discontinued from the study at the discretion of the Investigator. 
The following qualify as adverse events (AEs) due to which study participation may be terminated: 
- 
Changes in laboratory values, PE findings or other assessments considered by the Investigator to 
be clinically significant  
- 
Clinically significant TEAEs including clinically significant laboratory test abnormalities or SAEs 
regardless of relatedness to study treatment that cause the patient, Investigator or Sponsor to 
feel it is not in the patient’s best interest to continue. 
A patient may also be withdrawn from study drug/study by the Sponsor, Regulatory Authorities, or the 
IRB/IEC. Since the study will end when its enrollment, regulatory and study drug exposure objectives 
have been met, patients may complete at the time of study termination even if they have not received 53 
weeks of therapy.  Patients will also be withdrawn if the entire study is terminated prematurely as 
described in Section 9.10. 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
32 of 54 
July 21, 2016   
 
For patients who discontinue early from the study, the following assessments for the Early Withdrawal 
(EW) visit should be performed, if possible, within 5 days of the last study drug dose:  
• 
Patient self-administered questionnaires: Relief of Abdominal Symptoms, Treatment 
Satisfaction and Treatment Continuation  
• 
Documentation of concomitant medications 
• 
Review of adverse events 
• 
Physical examination 
• 
Vital signs measurement 
• 
Urine pregnancy test for women of childbearing potential  
• 
Clinical laboratory assessments  
• 
Immunogenicity sample collection   
• 
12-lead ECG 
• 
Study drug collection and accountability 
In all cases, the reason(s) for withdrawal, and the primary reason, must be recorded on the eCRF and 
source records.  If the primary reason for withdrawal is an adverse event, a single adverse event must be 
recorded as the primary reason.  Patients who prematurely withdraw from study treatment will not be 
eligible to participate in this or any other plecanatide study in the future.  Patients withdrawn after 
enrollment into the study will not be replaced. 
For patients lost to follow-up, every attempt of contact (i.e. phone calls and registered letters) must be 
documented in the patient’s source records. 
 
6 
STUDY DRUG 
 
6.1 
Identity 
 
6.1.1 
Plecanatide 
 
The chemical name, molecular formula, molecular weight and amino acid sequence of plecanatide can be 
found in the Investigator Brochure.  Plecanatide is a synthetic hexadecapeptide that is an analog of 
uroguanylin, a natural peptide that occurs in the GI tract.  
The drug product is a tablet comprised of plecanatide, microcrystalline cellulose, and magnesium 
stearate.  Plecanatide tablets are manufactured by UPM Pharmaceuticals (Bristol, TN) and packaged and 
supplied to the clinical study centers by Sharp Packaging Solutions (Allentown, PA) for Synergy.   
6.2 
Rescue Medication 
The only RM allowed for use in this study is Dulcolax® 5 mg tablets supplied by the sponsor.  Patients 
are instructed to take one to three 5 mg tablets in a single dose, when they have not had a bowel 
movement for 72 hours or more. 
Rescue medication will be distributed to sites by Sharp Packaging Solutions (Allentown, PA). Sites may 
order additional bulk supplies of RM by submitting a Manual Shipment Request Form.  RM will be 
dispensed to patients at Day 1 and re-supplied at study visits as needed.  Supplies of Dulcolax® will not 
be reconciled at the completion of the study.  Sites must track inventory of RM supplies for the purpose of 
ensuring adequate quantities for re-supplying patients as needed.  The site’s supply of RM will not be 
managed nor automatically re-supplied by IWRS.  


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
33 of 54 
July 21, 2016   
 
6.3 
Administration 
If the patient is eligible and agrees to participate in this study, after signing the informed consent, the 
patient will be assigned to 6 mg plecanatide open-label treatment for the duration of their participation in 
the trial. 
Study drug will be administered for up to 53 consecutive weeks.  Except on Day 1, when patients will take 
the study drug at the clinical site, patients will be instructed to take the study drug once daily at home - 
one (1) tablet every morning (preferably at the same time each day) with approximately 240 mL (8 
ounces) of liquid, with or without meals.  
6.3.1 
Dose Adjustments 
Dose adjustments of study drug are not permitted in this study.  Patients who interrupt study treatment for 
adverse events, intercurrent illness or study drug supply issues may continue in the study with the 
approval of the Principal Investigator and the Medical Monitor when the reason for interruption has been 
adequately reviewed.   
6.3.2 
Overdose 
Standard symptomatic support measures should be used in the case of excessive pharmacological 
effects or overdose.  Careful attention to fluid balance should be made.  Standard treatment measures for 
the symptomatology being exhibited should be provided.   
Single doses up to 48.6 mg have been administered without medically important consequence.  
6.4 
Packaging, Labeling and Storage 
6.4.1 
Packaging 
The investigational drug kits will be supplied to the clinical sites by Sharp Packaging Solutions (Allentown, 
PA) for Synergy.  Sites will manually order additional kits with the Manual Shipment Request form 
The Investigator or qualified designee will dispense/administer the study drug only to patients eligible for 
participation and enrolled in this study, following the procedures described in this protocol.  
Each investigational drug kit will contain a 4-week supply (28 tablets) in blister packaging with four extra 
tablets (total of 32 tablets) to allow for window extension for a study visit.  Individually blister packaged 
tablets will be provided in four connected 1-week strips as a 4-panel key-pack that folds into a carton. The 
two bottom panels fold up into the two top panels, nesting blister cavities. Instructions for releasing a 
tablet from the blister dome are printed on the outside of the carton.  At each dispensing visit, each 
patient will be given a numbered drug kit(s). The patient’s unique number will be written in the designated 
area of the kit label; the tear-off portion of the label will be kept in the clinical site’s source records. 
Study drug will be dispensed to the patient as follows: 
• 
Visit 1 (Day 1, Week 1): one (1) study drug kit for dosing from Day 1 to end of Week 4, inclusive. 
• 
Visit 2 (End of Week 4): two (2) study drug kits for daily dosing from Week 5 to end of Week 12, 
inclusive. 
• 
Visit 3 (End of Week 12): (3) study drug kits for daily dosing from Week 13 to end of Week 24, 
inclusive. 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
34 of 54 
July 21, 2016   
 
• 
Visit 4 (End of Week 24): (3) study drug kits for daily dosing from Week 25 to end of Week 36, 
inclusive. 
• 
Visit 5 (End of Week 36): (4) study drug kits for daily dosing from Week 37 to end of Week 53, 
inclusive. 
Four (4) drug kits will be dispensed at Visit 5 (End of Week 36). This supply will include 128 tablets (28 
days plus 4 extra tablets per carton). 
At Visit 6 (End of Week 53) or Early Withdrawal, document the patient’s End of Treatment or Early 
Withdrawal visit date.  The patient’s reported last dose of study drug will be recorded in the eCRF. 
6.4.2 
Label 
Each of the investigational drug kits will have a unique yellow label containing the following information:  
protocol number, drug kit number, contents, directions for use, storage conditions, identification of 
Synergy Pharmaceuticals Inc. as the Sponsor and the statements: “Caution: New Drug - Limited by 
Federal Law to Investigational use.  Investigational Drug – To be used by Qualified Investigator Only.  For 
Clinical Trial Use Only.  Keep Out of Reach of Children.”   
The label will include the following fields to be completed by site personnel: Investigator name and phone 
number, subject identification number and treatment weeks.  There will be a smaller label on the carton 
spine that identifies the study number and kit number. When dispensing a kit to a patient, complete the 
required information and retain the tear-off portion of the label in the source documents. At each 
monitoring visit, the source document records will be verified against the drug accountability logs. 
6.4.3 
Storage 
The Investigator, or qualified designee, is responsible for the proper storage of the study medications 
according to the Sponsor’s recommendations and all applicable Federal/State regulatory guidelines. At 
the clinical site, plecanatide must be stored at controlled room temperature 20 to 25°C (68 to 77°F) in a 
secure area with restricted access and with Min-Max temperature monitoring. Deviations from Sponsor’s 
recommendations/guidelines should be reported, as directed in the Temperature Excursion Reporting 
Form.  
Patients will be instructed to store their blister-packs at room temperature defined for this study as 20 to 
25°C (68 to 77°F). 
 
The Investigator must agree not to dispense or store investigational drug at any location other than that 
listed on the Form FDA 1572.  
 
6.5 
Drug Accountability 
Distribution of all investigational drug kits and acknowledgement of receipt of drug shipments will be 
recorded in an IP shipment distribution tracker maintained by Sharp. 
In addition, accurate records of study drug dispensed to patients will be kept by the Investigator, or 
qualified designee, specifying the kit number on the drug kit, the patient number assigned, the amount 
dispensed to each patient and the date dispensed, using the appropriate eCRF page for the patient.   
At each visit after Baseline (Day 1), the patient is asked to return their previously dispensed drug kit and 
the number of remaining tablets is entered into the eCRF for drug accountability.   
A drug accountability log must be available for inspection at each monitoring visit and at the completion of 
the study.  At the completion of the study, the Investigator will provide copies of this accountability log to 
the Sponsor. 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
35 of 54 
July 21, 2016   
 
The Investigator is responsible for assuring the retrieval of all study supplies from patients. At the 
completion of the study, all unused investigational drug kits will be returned to a third party in accordance 
with the Sponsor’s (or designee’s) written instructions.   The Investigator must verify that all unused or 
partially used study drug supplies have been returned by the patient and that no remaining supplies are in 
the Investigator’s possession. 
 
6.6 
Compliance 
 
Patients will be advised as to how to take their daily medication and will return all unused study drug to 
the clinical site at each visit during the Treatment Period.  The number of remaining tablets will be 
counted and entered into the appropriate eCRF page for that patient.  Patients unwilling or unable to 
maintain compliance with study drug administration or procedures may be discontinued from the study at 
the discretion of the investigator in conjunction with the medical monitor. 
 
7 
ASSESSMENT, REPORTING, RECORDING AND FOLLOW UP ADVERSE EVENTS 
 
7.1 
Definitions 
 
An AE is any untoward medical occurrence associated with the use of a drug in humans, whether or not 
considered drug-related. An AE can therefore be any unfavorable and unintended sign (including 
abnormal laboratory finding), symptom, or disease temporally associated with the use of an 
investigational product or study procedure whether or not considered related to the product or procedure.  
All AEs, including intercurrent illnesses and regardless of the source of identification (e.g., PE, laboratory 
assessment, ECG, reported by patient), occurring during the study will be documented in the eCRF.  
Concomitant illnesses, which existed before entry into the study, will not be considered AEs unless they 
worsen (increase in intensity or frequency) during the treatment period. 
Adverse events occurring from the time of ICF signing up to the intake of the first dose of study drug will 
be classified as pre-existing conditions for this study.  Serious AEs (as defined below) occurring from the 
time of ICF signing up to the intake of the first dose of study medication will be collected and reported as 
such.  A TEAE is defined as an AE that begins or that worsens in frequency and/or severity after at least 
one dose of study drug has been administered. 
Minor fluctuations in laboratory values for standard monitoring (abnormal values) that the Investigator 
does not consider clinically significant or related to study drug will not be recorded as AEs.  However, if 
the laboratory abnormality is associated with a diagnosis, then the AE term for that diagnosis will be 
reported (see Section 7.4 for recording of AEs). 
7.2 
Events of Special Interest - Diarrhea 
An increase in the frequency of BMs and loosening of the stool consistency from baseline are expected 
pharmacodynamic effects of plecanatide.  These same attributes (increased stool frequency and looser 
stool consistency) are often used to define “diarrhea’; however, in light of significant inter-patient 
variability in bowel habit “phenotype” and wide differences in the perception of a “normal” bowel habit 
there is no standard definition of “diarrhea” for this patient population.  An increase in frequency or 
consistency for one person is a welcome event, while for another patient it might be bothersome 
“diarrhea”. 
One mechanism to introduce a level of consistency across patients, sites and the trial is to code an event 
as diarrhea only if it is characterized by a specific patient-reported and clinically relevant attribute such as 
“bothersomeness”.  Therefore, for this trial, for any event associated with a significant increase from 
baseline in BM frequency and/or loosening of BM consistency -  that would otherwise be coded as 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
36 of 54 
July 21, 2016   
 
diarrhea - the site is instructed to record it as an AE only if the patient reports that it was bothersome (as 
defined by each patient).   
7.3 
Assessment of Adverse Events 
The Investigator will assess each AE with regard to seriousness, intensity, and causality as described 
below. 
7.3.1 
Seriousness 
An SAE is defined as any untoward medical occurrence that, at any dose, is one of the following: 
• 
Results in death; 
• 
Is life-threatening; (an adverse event or suspected adverse reaction is considered “life 
threatening” if, in the view of either the Investigator or Sponsor, its occurrence places the 
patient or subject at immediate risk of death. It does not include an adverse event or 
suspected adverse reaction that, had it occurred in a more severe form, might have caused 
death); 
• 
Requires inpatient hospitalization or prolongation of existing hospitalization; 
• 
Results in a persistent or significant incapacity or substantial disruption of the ability to 
conduct normal life functions; 
• 
Is a congenital anomaly or birth defect; 
• 
Is a medically important event (Examples of such medical events include allergic 
bronchospasm requiring intensive treatment in an emergency room or at home, blood 
dyscrasias or convulsions that do not result in inpatient hospitalization or the development of 
drug dependency or drug abuse) 
The FDA has defined additional “Medically Important Events” that should also be reported as SAEs 
[13]. These include cases where: 
• 
Aminotransferases (ALT or AST) are ≥ 3 times the upper limit of normal (ULN) with an 
associated elevation of Total Bilirubin ≥ 2 times ULN without evidence of hemolysis or with 
alkaline phosphatase < 2 times ULN or not available OR 
• 
ALT or AST activity that is greater than 5 times the upper limit of normal.   
All patients with the above abnormalities should return as soon as possible or within 48 hours to the study 
center for further evaluation of the abnormalities including repeat ALT and AST, total and direct bilirubin, 
alkaline phosphatase, and related laboratory assessments of albumin, PT and PTT, creatinine kinase, 
and GGTP or 5’nucleotidase.   Hepatitis A, B, and C, hemolysis, and biliary obstruction should be ruled 
out. A detailed medical and drug use history should be taken to exclude all potential causes. 
The Medical Monitor should be consulted prior to withdrawing a patient early due to elevated ALT or AST.   
7.3.2 
Intensity (Severity) 
The Investigator will assess the intensity/severity of AEs according to the following general categorical 
descriptors: 
Mild:   
Asymptomatic or mild symptoms; clinical or diagnostic observations only; intervention not 
indicated 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
37 of 54 
July 21, 2016   
 
Moderate: Minimal, local or noninvasive intervention indicated; limiting age-appropriate instrumental 
activities of daily living e.g., preparing meals, shopping for groceries or clothes, using the 
telephone, managing money, etc. 
Severe:   
Medically significant but not immediately life-threatening; hospitalization or prolongation of 
hospitalization indicated; disabling; limiting self-care activities of daily living e.g., bathing, 
dressing and undressing, feeding self, using the toilet, taking medications, and not bedridden. 
It is important to distinguish between serious and severe AEs.  Severity is a measure of intensity whereas 
seriousness is a regulatory definition as per Section 7.3.1.  An AE of severe intensity may not necessarily 
be considered serious (by definition) or a mild AE (e.g., mild stroke) may be considered as an SAE. 
7.3.3 
Causality 
The Investigator will assess the causality/relationship between the study drug, or study procedure, and 
the AE and record that assessment in the eCRF.  
The causal relationship of the AE to study drug will be described in terms of: 
Reasonable Possibility:  
There is evidence to suggest a causal relationship between the drug and 
the AE (e.g., AE is uncommon and known to be strongly associated with 
drug exposure or is uncommon in the study population, but not commonly 
associated with drug exposure) 
No Reasonable Possibility: There is no evidence to suggest a causal relationship between the drug and 
the AE. 
The study conduct relatedness for AEs and SAEs will also be assessed and documented.  The most 
likely cause of an AE or SAE (e.g., disease under treatment, concomitant disease, concomitant 
medication, other) will be recorded in the eCRF with details of the concomitant disease or medication or 
other cause.  
7.4 
Recording Adverse Events 
Adverse event reporting will extend from signing of ICF up to 30 days after the administration of the last 
dose of the study medication. Adverse events occurring after the end of the study should be reported to 
the Sponsor by the Investigator only if the Investigator considers there to be a causal relationship to the 
study drug. 
All AE reports should contain a brief description of the event, date of onset, date of resolution, intensity, 
treatment required, relationship to study drug, action taken with the study drug, outcome of the adverse 
event, and whether the event is classified as serious. 
All AEs experienced by patients who are assigned to treatment, regardless of the relationship to study 
drug, will be recorded in the eCRF.   
7.5 
Reporting Serious Adverse Events 
All SAEs that occur during the study, as defined by the protocol, must be reported by the Investigator to 
the designated Safety Contact by faxing the SAE Form within 24 hours from the point in time when the 
Investigator becomes aware of the SAE. In addition, all SAEs including any deaths, which occur up to and 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
38 of 54 
July 21, 2016   
 
including 30 days after the administration of the last dose of the study medication, must be reported to the 
designated Safety Contact within 24 hours.   
All SAEs and deaths (as SAE or as outcome of SAE) must be reported whether or not considered 
causally related to the study medication.  Any SAE that occurs at any time after completion of the study 
(i.e., beyond 30 days after last study drug dose), which the Investigator considers to be related to study 
medication, must be reported to the designated safety contact. SAE forms will be provided to each clinical 
site.  The information collected will include a minimum of the following: protocol number, Investigator 
information, patient number, event term, a narrative description of the event including its start date, and 
an assessment by the Investigator as to the intensity and possible relatedness to study medication.  A 
sample of the SAE form can be found in the study manual. The Medical Monitor or Synergy may request 
follow up information regarding the SAE. 
The Investigator will prepare or directly oversee preparation of each SAE report and the Medical Monitor 
will evaluate and confirm the seriousness and the causal relationship of the event to study treatment. In 
addition, the Investigator and Medical Monitor will evaluate the expectedness according to the reference 
document (Investigator Brochure).  Based on the Medical Monitor’s and Sponsor’s assessment of the 
event, a decision will be made concerning the need for further action. 
All SAEs will be collected and reported from signing of ICF until the end of the study. Serious AEs 
occurring after the end of the study and coming to the attention of the Investigator must be reported only if 
they are considered (in the opinion of the Investigator) causally related to the study drug. 
SERIOUS ADVERSE EVENT REPORTING INSTRUCTIONS 
ICON Clinical Research 
Medical and Safety Services 
 
SAE Hotline: 
 
SAE Fax Number: 
 
SAE e-mail:
  
 
1.  Telephone the Safety Center to inform them that you are faxing a SAE form. If you are calling 
after business hours (8:30 am to 5:00 pm Eastern time, Monday to Friday), leave a message in the 
voice mailbox. 
2.  Provide the Investigator’s name, your name, the telephone number where you can be reached, 
and the protocol number and title. 
3.  Fax the SAE form and any supporting documentation to the Safety Center within 24 hours of 
becoming aware of the event. 
 
 
The CRO Safety Center telephone and fax numbers are available 24-hours a day.  In case the CRO 
Safety Center cannot be contacted (e.g., out of normal working hours or on weekends), an automated 
reporting service is available.  The required information should be faxed and a message should be left on 
the voicemail service.  If you leave a message, provide the protocol number (SP304203-06), the study 
drug name (plecanatide), and Synergy Pharmaceuticals as the sponsoring company. 
The minimum information required for an initial report is: 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
39 of 54 
July 21, 2016   
 
• 
Name of person sending the report (i.e., name and address of Investigator) 
• 
Patient identification (randomization number, initials, NOT patient name) 
• 
Protocol number 
• 
Description of SAE 
• 
Causality assessment, if possible 
However, as far as possible all points on the SAE form should be covered in the initial report, or the 
completed SAE form itself must be faxed to the designated Safety Contact.  In addition, the event must 
be documented in the eCRF. 
After receipt of the initial report, the Safety Contact and safety center will review the information and, if 
necessary, contact the Investigator, to obtain further information for assessment of the event.  
All SAEs must be reported by the Investigator to their IRB/IEC in writing, as well as appropriate regulatory 
authorities as required by law.  The CRO Safety Center will be responsible for all information processing 
and reporting according to local legal requirements.  
7.6 
Follow-up of Adverse Events 
All AEs experienced by a patient, irrespective of the suspected causality, will be monitored until:  
• 
the AE (including abnormal laboratory values) has resolved or have returned to baseline or 
stabilized at a level acceptable to the Investigator and Medical Monitor, 
• 
there is a satisfactory explanation for the changes observed, 
• 
the patient is lost to follow-up, or  
• 
the patient has died. 
7.7 
Pregnancy  
Every effort should be made to avoid pregnancy in this study. Female patients should be reminded at 
every visit to use appropriate birth control methods. However, if a female patient should become pregnant 
during the study (i.e., from the date the ICF was signed until the patient’s last visit), the Investigator (or 
authorized delegate) should notify the designated Safety Contact on the initial Pregnancy Report Form 
within 24 hours of the Investigator (or authorized delegate) first becoming aware of the pregnancy.   
The notification of pregnancy should be submitted using the initial Pregnancy Report Form.  The initial 
Pregnancy Report Form should be completed with study patient’s details (e.g., patient number, initials, 
date of birth, investigational product information, etc.).  Whenever possible, the initial notification of 
pregnancy should include detailed information on the pregnancy, including last menstrual period and/or 
expected date of delivery.  If pregnancy is to be terminated, the anticipated date of termination should be 
provided.  If a maternal AE is reported during the initial notification of pregnancy, the details of the AE 
should also be described in the narrative field of the initial Pregnancy Report Form. 
The Sponsor, Medical Monitor, or designated Safety Representative will request permission to follow the 
patient’s progress with the doctor medically responsible for the pregnancy.  If additional information on 
the progress of the pregnancy and/or any maternal AE is received by the clinical site, the Investigator (or 
designee) should also submit a pregnancy outcome report form to the designated Safety Contact within 
24 hours of becoming aware of the information.  If the outcome of the pregnancy is reported as premature 
birth, or as elective termination due to a medical reason or as spontaneous or accidental miscarriage, the 
details of the outcome should be described in the narrative section of the pregnancy outcome report form. 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
40 of 54 
July 21, 2016   
 
The pregnancy outcome will generally be reported as a follow-up report.  Details of birth/delivery, 
including date of birth, weight and sex of the fetus/new born should also be described in the narrative field 
of the Pregnancy Report Form. 
Pregnancy itself is not an AE, unless there is suspicion by the site that the investigational product may 
have interfered with the effectiveness of a contraceptive medication. Pregnancy reports, however, are 
tracked and reported in the safety (SAE) database.  Pregnancy occurring in the patient between start of 
study drug until 30 days after last dose will fall under the expedited reporting procedure for serious 
adverse events.  The pregnant patient will be immediately discontinued from the study but will be followed 
for the duration of the pregnancy.  Details of the outcome of the pregnancy (e.g., full-term normal delivery, 
stillbirth, congenital anomalies, and miscarriage) will be collected and reported by the site.  
All reports of congenital abnormalities/birth defects are SAEs.  Complete a new SAE Report Form if the 
delivery outcome meets the criteria for a SAE (e.g., congenital anomaly/birth defect, still birth, some other 
sickness, etc.). The SAE Report Form should be completed with study patient’s details (e.g., patient 
number, initials, date of birth, investigational product information, etc.) and the details of the fetal SAE 
should be described in the narrative field of the SAE Report Form.  The initial SAE Report Form must be 
faxed by the Investigator to the designated Safety Contact within 24 hours of becoming aware of the 
event.  Spontaneous miscarriages should also be reported and handled as SAEs.  However, elective 
abortions without complications should not be handled as SAEs. All neonatal deaths occurring within 30 
days of birth should be reported as SAEs, without regard to causality.   
All outcomes of pregnancy, if known, must be reported by the Investigator to the Medical Monitor or the 
designated Safety Contact on the pregnancy outcome report form within 30 days after he/she has gained 
knowledge of the normal delivery or elective abortion. 
8 
STATISTICAL METHODS 
Evaluation of the safety of once daily (QD) plecanatide over up to 53 weeks of dosing will be based on 
the occurrence of TEAEs (treatment-emergent adverse events) and assessment of: vital signs, clinical 
laboratory tests, physical examinations and ECGs.  Tolerability will be assessed by treatment 
interruptions due to diarrhea or other AEs, AE-free days, and continued participation in the trial.   
A formal Statistical Analysis Plan (SAP) will be written and include details of all statistical methods to be 
used to analyze the long-term safety and tolerability of plecanatide. The SAP will supersede the protocol 
with respect to the analyses specified, although the general approach described in this section will remain 
unchanged.  
8.1 
Treatment Assignment 
This is a long-term safety and tolerability study that will be conducted at approximately 250 clinical study 
centers.  Approximately 1500 patients will be assigned to receive plecanatide (6 mg QD).  
8.2 
Sample Size and Power Considerations 
Sample size and power calculations are not applicable.  The sample size for this study is to ensure at 
least 300 to 600 patients complete 6 months of treatment with plecanatide and that 100 patients complete 
12 months of treatment with plecanatide to satisfy ICH guidelines for drugs intended for chronic use.  A 
sample size of approximately 1500 patients will also allow numerous patients who have completed a 
previous plecanatide study to have the opportunity for continued treatment.  


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
41 of 54 
July 21, 2016   
 
8.3 
Analysis Populations 
The following populations will be assessed: 
• 
Safety: All enrolled patients who have received at least one dose of the study drug.  All safety 
analyses will be based upon the Safety Population. 
• 
Modified Intent-to-Treat (mITT): All enrolled patients who have had at least one dose of study 
drug and who have at least one post-baseline PGA assessment.  This will be the main population 
for assessment of patient-reported outcomes.   
If considered necessary, further populations may be defined in the SAP. 
8.4 
General Considerations   
Categorical variables will be summarized by the number and percent of patients in each level.  
Continuous variables will be summarized by number of observations, mean, standard deviation (SD), 
median, minimum, and maximum values.  Where data are collected over time, both the observed data 
and change from baseline will be summarized at each time point. For all analyses, data will be 
summarized by open-label treatment. 
8.5 
Missing Data Conventions 
In general, data will not be imputed.  Details of the missing data methodology will be provided in the SAP. 
8.6 
Baseline Definition 
Baseline values will be defined from the assessments collected at Visit 1 (Day 1; Baseline visit). 
8.6.1 
Baseline Characteristics 
Demographic data and other baseline characteristics, medical history (ongoing AEs from previous trial), 
and concomitant medication will be summarized by means of descriptive statistics.  
8.7 
Patient-Reported Outcomes 
8.7.1 
Patient Questionnaires  
Three patient self-reported questionnaires will be administered during study visits to assess the patient’s 
overall IBS symptoms, treatment satisfaction and desire for treatment continuation. These patient 
questionnaires (see Appendix 1) will be administered preferably prior to any other study assessments.  
• 
Patient’s Assessment of Relief of IBS symptoms, collected at all visits, will be rated on a 5-point 
scale where 2=Significantly Relieved, 1=Moderately Relieved,  0=Unchanged,  -1=Moderately worse, 
-2 =Significantly Worse. 
• 
Patient’s Treatment Satisfaction Assessment, collected at all visits except Visit 1, will be 
measured on a 5-point scale where 1=Not at all satisfied, 2=A little satisfied, 3=Moderately satisfied, 
4=Quite satisfied, 5=Very satisfied. 
• 
Patient’s Treatment Continuation Assessment, collected at the last study visit (Visit 6 or Early 
Withdrawal), will be measured on a 5-point scale where 1=Not at all likely, 2=A little likely, 
3=Moderately likely, 4=Quite likely, 5=Very likely 
The change from baseline will be summarized for each post-baseline assessment. 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
42 of 54 
July 21, 2016   
 
All assessments will be summarized using descriptive statistics on observed data.  Additional exploratory 
analyses such as linear mixed-effects models may be performed on the above assessments. Full details 
will be provided in the SAP. 
8.8 
Tolerability 
Tolerability will be assessed by treatment interruptions due to diarrhea or other AEs, AE-free days, and 
continued participation in the trial.  Full details will be provided in the SAP. 
8.9 
Safety Analyses 
Evaluation of the safety of once daily (QD) plecanatide over 53 weeks of dosing will be based on the 
occurrence of TEAEs, vital signs, clinical laboratory assessments, physical examinations and ECGs as 
recorded in the clinical database.  The safety analyses will use the Safety Population defined in Section 
8.3. 
Adverse events will be coded using Medical Dictionary for Regulatory Activities (MedDRA) classifications 
with reference to system organ class and preferred terms.  While all AEs will be listed, only TEAEs will be 
included in summary tables. Summaries of TEAEs will be presented by system organ class and preferred 
term.  Tabular summaries will include frequency of TEAEs overall and by intensity and by relationship to 
study drug.  Incidence rates by person-time will also be presented. TEAEs leading to treatment 
interruption, withdrawal from treatment, and SAEs will be presented separately.  
Out of range laboratory tests, ECGs and vital signs of potential clinical importance will also be 
summarized.  A listing of patients with at least 1 out of range value will be presented by visit for that test.  
Hematology, serum chemistry, and urinalysis absolute values and, where applicable, changes from 
baseline for each of the laboratory assessments will be presented over time.  An additional listing will be 
produced of clinically significant laboratory parameters. Shift tables will also be produced. 
Changes in vital signs and ECG evaluations will be presented. Absolute values and changes from 
baseline for each parameter will be presented, where applicable. 
Concomitant medications will be auto-encoded using the World Health Organization Drug Dictionary 
(WHODD) coding system with reference to Anatomical Therapeutic Chemical (ATC) Classification 
System text and preferred terms. Summaries of concomitant medication will be presented by ATC text 
and preferred terms.  Prior and concomitant medications will be presented separately. 
All physical examination findings will be presented in the data listing. 
8.10 Interim Analyses 
No interim analyses are planned. 
9 
ETHICAL, LEGAL, AND ADMINISTRATIVE ASPECTS 
 
9.1 
Data Quality Assurance 
 
The Sponsor or Sponsor’s designee will inform the Investigator of responsibilities and the procedures for 
ensuring adequate and correct documentation. 
 
The Investigator is required to prepare and maintain adequate and accurate case histories designed to 
record all observations and other data pertinent to the study for each study participant.  All information 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
43 of 54 
July 21, 2016   
 
recorded on the eCRF for this study must be consistent with the patients’ source documentation (i.e., 
medical records). 
9.1.1 
Database Management and Quality Control 
All data generated by the clinical site personnel will be captured electronically at each clinical site using 
eCRFs.  Data from external sources (such as laboratory data) will be imported into the database.  Once 
the eCRF clinical data have been submitted to the central server at the independent data center, 
corrections to the data fields will be captured in an audit trail.  The reason for change, the name of the 
person who performed the change, together with the time and date will be logged to provide an audit trail.  
Computerized data check programs and manual checks will identify any clinical data discrepancies for 
resolution.  If additional corrections are needed, the responsible monitor or data manager will raise a 
query in the electronic data capture (EDC) application.  The appropriate staff at the clinical site will 
answer queries sent to the site.  The name of the staff member responding to the query, and time and 
date stamp will be captured to provide an audit trail.  Once all source data verification is complete and all 
queries are closed, the data manager will freeze the eCRF page. 
The specific procedures to be used for data entry and query resolution using the EDC will be provided to 
investigative sites in a manual e.g., eCRF Completion Guidelines. In addition, clinical site personnel will 
receive training on the EDC system, including the eCRF.  
9.2 
Electronic Case Report Forms and Source Documentation 
All data obtained during this study should be entered into the EDC system promptly.  All source 
documents from which eCRF entries are derived should be placed in the patient’s medical records.  
Measurements for which source documents are usually available include laboratory assessments and 
ECG recordings.   
Data that are entered directly into the EDC system (i.e., for which there is no prior written or electronic 
record of data) are considered to be source data.   
All eCRF entries for each patient may be checked against source documents at the clinical site by the site 
monitor.  Instances of missing or uninterpretable data will be discussed with the Investigator or 
designated site staff for resolution. 
9.2.1 
Data Collection  
The Investigators (and appropriately authorized staff) will be given access to an online, web-based EDC 
system which is 21 CFR Part 11 compliant.  This system is specifically designed for the collection of the 
clinical data in electronic format.  Access and rights to the EDC system will be carefully controlled and 
configured according to each individual’s role throughout the study.  In general, only the Investigator and 
authorized staff will be able to enter data and make corrections in the eCRFs. 
The eCRF should be completed for each patient included in the study and should reflect the latest 
observations on the patients participating in the study.  It is recommended that a patient’s CRF is created 
in EDC as soon as the patient completes informed consent to reserve the patient’s assigned Subject ID in 
the system.  Then, all applicable eCRF pages are to be completed as soon as possible, i.e., during or 
immediately after the patient’s visit or assessment.  The expectation is that sites will complete data 
entry within 48 hours of a patient visit.   


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
44 of 54 
July 21, 2016   
 
For patients who do not qualify for the study, only the following eCRF pages need to be completed in 
EDC: Informed Consent/Demographics, Inclusion/Exclusion Criteria and disposition page.  All other forms 
are not required and should be marked as “Not Collected” in EDC, although sites are expected to have all 
source documentation supporting the patient’s status available on site for review by the monitor.  
The Investigator must attest that all data entries in the eCRF are accurate and correct.  If some 
assessments cannot be done, or if certain information is unavailable, not applicable, or unknown, the 
Investigator (or designee) should indicate this in the eCRF.  
Computerized data-check programs and manual checks will identify any clinical data discrepancies for 
resolution.  Corresponding queries will be loaded into the system and the clinical site will be informed 
about new issues to be resolved on-line.  All discrepancies will be solved online directly by the 
Investigator or by authorized staff.  Data managers and clinical site monitors will be available to assist 
sites in resolving queries.  Offline edit checks will be done to examine relationships over time and across 
panels to facilitate quality data. 
After completion of data entry and cleaning, the Investigator will be required to electronically sign off on 
the clinical data collected in the eCRF. 
9.3 
Access to Source Data 
During the study, a site monitor will visit clinical sites to review protocol compliance, compare eCRF 
entries and individual patient medical records, assess drug accountability, and ensure that the study is 
being conducted according to pertinent regulatory requirements.  eCRF entries will be verified with source 
documentation. The review of medical records will be carried out giving due consideration to data 
protection and patient confidentiality.   
Checking of the eCRF entries for completeness and clarity, and cross-checking with source documents, 
will be required to monitor the progress of the study.  Moreover, regulatory authorities, IRBs, and/or the 
Sponsor’s Quality Assurance Group (or designee) may wish to carry out such source data checks and/or 
on-site audit inspections.  Direct access to source data will be required for all monitoring visits, 
inspections and audits; they will be carried out giving due consideration to data protection and medical 
confidentiality.  The Investigator and authorized staff assure monitors, inspectors or auditors and the 
Sponsor of full access to study data and files and the necessary support of site personnel at all times.  
9.4 
Data Processing 
All data will be entered by clinical site personnel into the EDC system/eCRF as detailed in Section 9.2.1.  
The Data Management Plan for the study includes specifications for consistency and plausibility checks 
on data and also includes data-handling rules for obvious data errors.  Unresolved queries will be shared 
with the study monitors for resolution with the Investigator or designated site personnel.  The database 
will be updated on the basis of electronically-signed corrections.  
Previous and concomitant medications will be coded using the WHODD, which employs the ATC 
classification system.  Medical history/current medical conditions and AEs will be coded using the 
MedDRA terminology.   
The versions of the coding dictionaries will be provided in the Statistical Analysis Plan (SAP) and the 
Clinical Study Report (CSR). 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
45 of 54 
July 21, 2016   
 
9.5 
Archiving Study Records 
According to International Conference on Harmonisation (ICH) guidelines, essential documents should be 
retained for a minimum of 2 years after the last approval of a marketing application in an ICH region and 
until there are no pending or contemplated marketing applications in an ICH region or at least 2 years 
have elapsed since the formal discontinuation of clinical development of the investigational product.  Ten 
years is the recommended storage duration to ensure compliance with ICH requirements.  However, 
these documents should be retained for a longer period if required by the applicable legal requirements. 
9.6 
Good Clinical Practice 
The procedures set out in this study protocol are designed to ensure that the Sponsor and Investigator 
abide by the principles of GCP as described in the CFR and ICH guidelines. The study also will be carried 
out in keeping with local legal and regulatory requirements and principles of the Declaration of Helsinki as 
currently endorsed by regional regulatory health authorities. 
9.7 
Informed Consent 
Before each patient is admitted to the study, informed consent will be obtained from the patient (or his/her 
legally authorized representative) according to the regulatory and legal requirements of the participating 
country.  The informed consent form (ICF) must be dated and retained by the Investigator as part of the 
study records.  The Investigator will not undertake any investigation specifically required only for the 
clinical study until valid consent has been obtained.  The terms of the consent and when it was obtained 
must also be documented in the EDC system. 
If a protocol amendment is required, the ICF may need to be revised to reflect the changes to the 
protocol.  If the ICF is revised, it must be reviewed and approved by the appropriate IRB, and signed by 
all patients subsequently enrolled into the study as well as those currently participating in the study. 
9.8 
Protocol Approval and Amendment 
Before the start of the study, the study protocol and/or other relevant documents will be approved by the 
IRB, in accordance with local legal requirements.  The Sponsor must ensure that all ethical and legal 
requirements have been met before the first patient participates in the study. 
This protocol is to be followed exactly.  To alter the protocol, amendments must be written, receive 
approval from the appropriate personnel, and receive IRB approval prior to implementation (if 
appropriate).  Following approval, the protocol amendment(s) will be submitted to the Investigational New 
Drug (IND) application under which the study is being conducted.  
Administrative changes (not affecting the patient benefit/risk ratio) may be made without the need for a 
formal amendment but must be submitted to the applicable IRB/IEC.  All amendments will be distributed 
to all protocol recipients, with appropriate instructions. 
9.9 
Duration of the Study 
Once enrolled (on Day 1), the planned duration of the patient’s participation in the study is 53 weeks or 
371 days (378 including the permitted window).  


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
46 of 54 
July 21, 2016   
 
9.10 Premature Termination of the Study 
If the Investigator, the Sponsor, or the Medical Monitor becomes aware of conditions or events that 
suggest a possible hazard to patients if the study continues, the study may be terminated after 
appropriate consultation between the relevant parties.  The study may also be terminated early at the 
Sponsor’s discretion in the absence of such a finding. 
Conditions that may warrant termination include, but are not limited to: 
• 
The discovery of an unexpected, significant, or unacceptable risk to enrolled patients. 
• 
Failure to enroll patients at an acceptable rate. 
• 
A decision on the part of the Sponsor to suspend or discontinue development of the study 
drug. 
Sponsor reserves the right to discontinue, terminate or suspend the study upon submission of the New 
Drug Application to the FDA. If discontinued, terminated or suspended Sponsor will inform (1) the 
Principal Investigator at each study site, (2) the FDA and (3) the IRB of the discontinuation, termination or 
suspension and the reason(s) therefore.  
The Sponsor may also terminate the study when its enrollment, regulatory and study drug exposure 
objectives have been met.  Consequently, not all enrolled patients will receive 53 weeks of treatment. 
9.11 Confidentiality 
All study findings and documents will be regarded as confidential.  The Investigator and members of 
his/her research team must not disclose such information without prior written approval from the Sponsor. 
The anonymity of participating patients must be maintained. Patients will be identified on eCRFs and 
other documents submitted to the Sponsor (or designee) by their patient number, initials, and/or birth 
date, not by name.  Documents not to be submitted to Sponsor (or designee) that identify the patient 
(e.g., the signed informed consent) must be maintained in confidence by the Investigator.  
9.12 Other Ethical and Regulatory Issues  
If a significant safety issue is identified, either from an individual case report or review of aggregate data, 
then the Sponsor will issue prompt notification to all parties: Regulatory Authorities, Investigators and 
IRBs. 
A significant safety issue is one that has a significant impact on the course of the clinical study or program 
(including the potential for suspension of the development program or amendments to protocols) or 
warrants immediate update of informed consent and the Investigator Brochure. 
9.13 Liability and Insurance 
The Sponsor will take out reasonable third-party liability insurance coverage in accordance with all local 
legal requirements.  The civil liability of the Investigator, the persons instructed by him or her and the 
hospital, practice, or institute in which they are employed and the liability of the Sponsor with respect to 
medical costs for physical injury and other damage that may arise as a result of the carrying out of this 
study are governed by the applicable law. 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
47 of 54 
July 21, 2016   
 
The Sponsor will arrange for patients participating in this study to be insured against medical costs for 
physical injury caused by the pharmaceutical products being tested or by medical steps taken in the 
course of the study.  
9.14 Publication Policy 
By signing the study protocol, the Investigator agrees with the use of results of the study for the purposes 
of national and international registration, publication, and information for medical and pharmaceutical 
professionals.  If necessary, Regulatory Authorities will be notified of the Investigator's name, address, 
qualifications, and extent of involvement. 
An Investigator shall not publish any data (poster, abstract, paper, etc.) without having consulted with the 
Sponsor in advance.  Details are included in the Clinical Study Agreement completed for each 
investigational site. 
 
 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
48 of 54 
July 21, 2016   
 
10 REFERENCE LIST 
1. Drossman DA, Morris CB, Hu Y, et al. A prospective assessment of bowel habits in irritable bowel 
syndrome in women: defining an alternator. Gastroenterol 2005; 128: 580–9. 
2. Saito YA, Schoenfeld P, Locke GR III. The epidemiology of irritable bowel syndrome in North 
America: a systematic review. Am J Gastroenterol 2002; 97: 1910–5.  
3. Longstreth GF, Thompson WG, Chey WD, et al. Functional bowel disorders. Gastroenterol. 
2006;130:1480-1491.  
4. Drossman DA, Camilleri M, Mayer EA, Whitehead WE. AGA technical review on irritable bowel 
syndrome. Gastroenterol 2002; 123: 2108–31. 
5. Powell PH, Fleming VH. Chapter 43. Diarrhea, Constipation, and Irritable Bowel Syndrome. In: 
Talbert RL, DiPiro JT, Matzke GR, Posey LM, Wells BG, Yee GC, eds. Pharmacotherapy: A 
Pathophysiologic Approach. 8th ed. New York: McGraw-Hill; 
2011http://www.accesspharmacy.com/content.aspx?aID=7978775.  Accessed May 10, 2012. 
6. Drossman DA, Dumitrascu DL. Rome III: New Standard for Functional Gastrointestinal Disorders. 
Gastrointestin Liver Dis 2006; 15: 237-241. 
7. Sindic A and Schlatter E.  Cellular Effects of Guanylin and Uroguanylin. J Am Soc Nephrol 2006; 
17: 607–616. 
8. Assessment of SP-304 in DSS and TNBS Murine IBD Models (Study No. 06-119) 
9. Anti-Inflammatory Activity of SP-304 in an Animal Model of Experimental Colitis (Study No. SP-
PH-005) 
10. Shailubhai, K, Gerson W, Talluto, C, Jacob G.  SP 304 to Treat GI Disorders Effects of a single, 
oral dose of SP304 on safety, tolerability, pharmacokinetics and pharmacodynamics in healthy 
volunteers, Gastroenterology 2009; 136 (5 supplement 1): A 641. 
11. Shailubhai K, Talluto, C, Comiskey S, Foss J, Joslyn A, Jacob G.  A Ph IIa randomized. double-
blind, placebo-controlled, 14 day repeat,  oral, range finding study to assess the safety, 
pharmacokinetic  and pharmacodynamic effects of Plecanatide (SP-304) in patients with CIC, 
American College of Gastroenterology (ACG) Annual Scientific Meeting,  October 15-20, 2010 
Poster no 762. 
12. Synergy Pharmaceuticals Inc. A Randomized, 12-Week, Double-Blind, Placebo-Controlled, 
Repeat-Dose, Oral, Dose-Ranging Study to Assess the Safety and Efficacy of Plecanatide in 
Patients with Chronic Idiopathic Constipation. (Study SP304-20210) June 2013 
13. Guidance for Industry: Drug-Induced Liver Injury: Premarketing Clinical Evaluation, DHHS, FDA 
July 2009  
 
 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
49 of 54 
July 21, 2016   
 
11 APPENDICES 
Appendix 1: 
PATIENT QUESTIONNAIRES: Global Relief of IBS Symptoms, Treatment 
Satisfaction and Treatment Continuation Assessment 
The questionnaires will be used at the study site for collection of patients’ assessments of: Global Relief 
of IBS Symptoms, Treatment Satisfaction and Treatment Continuation. The self-administered 
questionnaires will be conducted preferably prior to any other study assessments.  The questionnaires 
take 1 to 5 minutes to be completed.  The site must ensure to use the current, IRB-approved version of 
the questionnaires and in the appropriate language/translation for the study subject.    
 
I. Patient Global Rating of Change – IBS Symptoms  
For the questions below, please choose the response that applies best to you  
 
RELIEF OF IBS SYMPTOMS 
How would you rate your Irritable Bowel Syndrome (IBS) signs and symptoms overall over the 
past 7 days? 
               2 = Significantly Relieved 
               1 = Moderately Relieved 
               0 = Unchanged  
              -1 = Moderately Worse 
              -2 = Significantly Worse  
 
 
 
 
 
 
 
 
 
 
 
II. Patient Treatment Satisfaction Assessment  


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
50 of 54 
July 21, 2016   
 
For the questions below, please choose the response that applies best to you  
 
TREATMENT SATISFACTION ASSESSMENT 
 
Overall, how satisfied are you with the study medication’s ability to relieve your constipation 
symptoms? 
              1 = Not at all satisfied 
              2 = A little satisfied 
              3 = Moderately satisfied 
              4 = Quite satisfied 
              5 = Very satisfied 
 
 
III. Patient Treatment Continuation Assessment  
For the questions below, please choose the response that applies best to you  
 
TREATMENT CONTINUATION ASSESSMENT 
 
If given the option, how likely is it that you would continue taking the study medication? 
             1 = Not at all likely 
             2 = A little likely 
             3 = Moderately likely 
             4 = Quite likely 
             5 = Very likely 
 
 
 
 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
51 of 54 
July 21, 2016   
 
Appendix 2: 
Rome III Diagnostic Criteria for Irritable Bowel Syndrome with Constipation;                                   
Rome III Diagnostic Questionnaire – IBS Module 
 
C1. Irritable Bowel Syndrome 
Diagnostic Criteria* 
 
Recurrent abdominal pain or discomfort** at least 3 days/month in last 3 months associated with two or 
more of criteria #1 - #3 below: 
Pain or discomfort at least 2-3 days/month (question 1>2) 
For women, does pain occur only during menstrual bleeding? (question 2=0 or 2) 
1. 
Improvement with defecation 
 
Pain or discomfort gets better after BM at least sometimes (question 4>0) 
2. 
Onset associated with a change in frequency of stool 
 
Onset of pain or discomfort associated with more stools at least sometimes (question 5>0), OR 
Onset of pain or discomfort associated with fewer stools at least sometimes (question 6>0) 
3. 
Onset associated with a change in form (appearance) of stool 
 
Onset of pain or discomfort associated with looser stools at least sometimes (question 7>0), OR 
Onset of pain or discomfort associated with harder stools at least sometimes (question 8>0) 
* Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis 
 
Yes. (question 3=1) 
**”Discomfort” means an uncomfortable sensation not described as pain. 
 
In pathophysiology research and clinical trials, a pain/discomfort frequency of at least two days a 
week is recommended for subject eligibility. 
 
Pain or discomfort more than one day per week (question 1>4) 
 
 
Criteria for IBS-C 
(question 9>0)  and (question 10=0) 
 
 
 
 
 
  


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
52 of 54 
July 21, 2016   
 
Rome III Diagnostic Questionnaire – IBS Module 
For each question below, please choose the response (place “X” over the circled number) that applies 
best to you.  
1. In the last 3 months, how often did 
you have discomfort or pain 
anywhere in your abdomen? 
0   Never             ( skip remaining questions)       
1   Less than one day a month 
2   One day a month 
3   Two to three days a month 
4   One day a week 
5   More than one day a week 
6   Every day 
2. For women: Did this discomfort or 
pain occur only during your 
menstrual bleeding and not at other 
times? 
0   No                       
1   Yes 
2   Does not apply because I have had the 
change in life (menopause) or I am a male 
3. Have you had this discomfort or 
pain 6 months or longer? 
0   No                        
1   Yes 
4. How often did this discomfort or 
pain get better or stop after you had 
a bowel movement? 
0   Never  or rarely                      
1   Sometimes 
2   Often 
3   Most of the time 
4   Always 
5. When this discomfort or pain 
started, did you have more frequent 
bowel movements? 
0   Never  or rarely                      
1   Sometimes 
2   Often 
3   Most of the time 
4   Always 
6. When this discomfort or pain 
started, did you have less frequent 
bowel movements? 
0   Never  or rarely                      
1   Sometimes 
2   Often 
3   Most of the time 
4   Always 
7. When this discomfort or pain 
started, were your stools (bowel 
movements) looser? 
0   Never  or rarely                      
1   Sometimes 
2   Often 
3   Most of the time 
4   Always 
8. When this discomfort or pain 
started, how often did you have 
harder stools? 
0   Never  or rarely                      
1   Sometimes 
2   Often 
3   Most of the time 
4   Always 
9. In the last 3 months, how often did 
you have hard or lumpy stools? 
0   Never  or rarely                      
1   Sometimes 
2   Often 
3   Most of the time 
4   Always 
10. In the last 3 months, how often did 
you have loose, mushy or watery 
stools? 
0   Never  or rarely                      
1   Sometimes 
2   Often 
3   Most of the time 
4   Always 
 
                                      Copyright Rome Foundation, Inc. All rights reserved 
 
 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
53 of 54 
July 21, 2016   
 
ROME III Modular Questionnaire Scoring for Study Eligibility 
The following table should be utilized to confirm the diagnosis of IBS-C. 
 
ROME Question 
Number 
Score 
Criterion Met         
Yes/No 
1 
3, 4, 5 or 6 
 
2 
0 or 2 
 
3 
1 
 
4* 
1, 2, 3 or 4 
 
5 or 6* 
1, 2, 3 or 4 
 
7 or 8* 
1, 2, 3 or 4 
 
9 
1, 2, 3 or 4 
 
10 
0 
 
 
The numbers listed in Column 1 reflect the specific questions of the Rome III Diagnostic Questionnaire 
– IBS Module.  
Column 2 lists the range of required answers for each question; the patient must supply individual 
answers to Questions 1, 2, 3, 4, 9 &10.   Questions 5 through 8 are treated differently as follows: 
- 
Questions 5 and 6, either but not both questions (5 or 6) would need to be answered as required  
- 
Questions 7 and 8, either but not both questions (7 or 8) would need to be answered as required  
 
*Note that for questions 4, 5/6 and 7/8, only two out of the three need to be met. 
Mark YES in Column 3 if the required answer was met or mark NO if a required answer is not met.  
The diagnosis of IBS-C is confirmed only if Column 3 contains a YES for Questions 1, 2, 3, 9 & 10 
AND at least two of Question 4, Questions 5/6 or Questions 7/8.   
 
 
 
 
*Only two of 
these 3 criteria 
need to be met 


Synergy Pharmaceuticals Inc. 
Clinical Study Protocol 
Protocol SP304203-06 
CONFIDENTIAL 
 
 
 
Final Version 3.0 
54 of 54 
July 21, 2016   
 
Appendix 3: 
Summary of American Gastroenterological Association (AGA) Guidelines for Colon 
Cancer Screening1 and Surveillance2  
 
The American Gastroenterological Association (AGA) colon cancer screening and surveillance guidelines 
recommendations as they apply to the study protocol:  
 
Patients of average risk aged 50 years and older must have had a colonoscopy with negative findings 
during the 10 years before the Screening Visit.  
 
Patients who have had polyps identified (and removed) on a previous screening colonoscopy should 
undergo surveillance at an accelerated interval (i.e., <10 years) depending on the number, size and 
histology of the identified polyps. For example, a patient who had >3 and <10 tubular adenomas identified 
should undergo a follow-up colonoscopy 3 years from the initial colonoscopy during which the polyps 
were identified (See AGA publication for further details). 
  
Patients who have a first-degree relative with colorectal cancer or adenomatous polyps diagnosed before 
age 60 or two first-degree relatives with colorectal cancer diagnosed at any age must have had a 
colonoscopy with negative findings during the 5 years before the Screening Visit. This applies to patients 
who are ≥ 40 years old and to patients < 40 years old who are ≤ 10 years from the age when their 
youngest relative was found to have one of the conditions described above. 
  
Patients who have a first-degree relative with colorectal cancer or adenomatous polyps diagnosed at age 
60 or older or two second-degree relatives with colorectal cancer diagnosed at any age must have had 
a colonoscopy with negative findings during the 10 years before the Screening Visit. This applies to 
patients who are ≥ 40 years old and to patients < 40 years old who are ≤ 10 years from the age when 
their youngest relative was found to have one of the conditions described above.  
 
Patients of any age who have alarm symptoms must have had a colonoscopy with negative findings after 
the onset of the alarm symptoms and during the five years before the Screening Visit. Alarm symptoms 
include lower GI bleeding (rectal bleeding or heme-positive stool), iron-deficiency anemia, unexplained 
clinically-significant weight loss, and systemic signs of infection or colitis. 
  
Appendix 3: References  
 
1. Levin B, Lieberman DA, McFarland B, Andrews K, et al Screening and Surveillance for the Early 
Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline From the 
American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the 
American College of Radiology. Gastroenterology 2008; 1434: 1570–1595 
  
2. Lieberman, DA, Rex, DK, Winawer, SJ, Giardiello, FM, Johnson, DA, Levin, TR (2012). 
Guidelines for Colonoscopy Surveillance After Screening and Polypectomy: A Consensus Update 
by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology; 143: 844–857