Clinical trial NCT02094417
Conditions: Aplastic Anemia
Keywords: Anemia, Aplastic Thrombopoietin Thrombocytopenia
Sponsor: Kyowa Kirin Korea Co., Ltd.
Start date: 2014-04-14; Completion date: 2017-11-07
Enrollment: 35 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
The present study will be conducted to evaluate the efficacy and safety of AMG531 and to determine the recommended initial dose of AMG531 on the basis of its efficacy and safety when it is administered subcutaneously (SC) to the Aplastic Anemia (AA) patients with immunosuppressive-therapy refractory thrombocytopenia and also to assess the pharmacokinetics of this product. Its efficacy and safety during the extension period beyond one year will also be evaluated.

Detailed description:

Arms: arm 1: None arm 2: None arm 3: None arm 4: None
Interventions: intervention 1: AMG531
Intervention descriptions: intervention 1: Subcutaneous, weekly injection

Protocol documents:
Prot_SAP_000.pdf: 
 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
1 
  
A Phase 2, Randomized, Open-Label, 
Parallel, Comparative, Dose-Finding Study 
to Evaluate the Efficacy and Safety of 
AMG531 in Aplastic Anemia Subjects with 
Thrombocytopenia Refractory to 
Immunosuppressive Therapy  
 
Protocol 
 
 
KYOWA HAKKO KIRIN KOREA CO., LTD. 
 
11F ASIA TOWER B/D, 430 NONHYEON-RO, 
GANGNAM-GU, SEOUL, KOREA 06223  
 
 
 
Protocol No.: 531-KR001 
Master Ver 3.1 
 Date: Dec, 20, 2016 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
2 
Confidentiality Statement 
The information contained in this document is the proprietary to Kyowa Hakko Kirin 
Korea Co., Ltd. The information is provided to you in confidence which is requested 
under an agreed upon and signed Confidentiality and Disclosure Agreement. Do not give 
this document or any copy of it or reveal any proprietary information contained in it to 
any third party (other than those in your organization who are assisting you in this work 
and are bound by the Confidentiality and Disclosure Agreement) without the prior written 
permission of an authorized representative of Kyowa Hakko Kirin Korea Co., Ltd. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
3 
TABLE OF CONTENTS 
 
V-3 Long-term treatment period (Week 53 to Week 156) 
...................................................... 16 
1 
BACKGROUND AND STUDY RATIONALE 
........................................................ 21 
 
 
 
 
 
 
 
 
 
 
2 
STUDY OBJECTIVES 
............................................................................................... 27 
3 
STUDY DESIGN 
......................................................................................................... 27 
3.1 
Study design .............................................................................................................. 27 
3.2 
Study phase 
............................................................................................................... 27 
3.3 
Study endpoints 
......................................................................................................... 28 
3.3.1 
Efficacy 
................................
.................................................................................. 28 
3.3.2 
Pharmacokinetics 
................................................................................................... 28
 
3.3.3 
Safety 
..................................................................................................................... 28
 
3.3.4 
Exploratory ............................................................................................................ 29
 
3.4 
Randomization 
.......................................................................................................... 29 
3.5 
Target sample size 
..................................................................................................... 29 
3.5.1 
Efficacy and Safety 
................................................................................................ 29 
3.5.2 
Pharmacokinetics 
................................................................................................... 29 
 
 
 
 
 
 
 
 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
4 
4 
INVESTIGATIONAL PRODUCT ........................................................................... 33
 
4.1 
Investigational product 
.............................................................................................. 33
 
4.2 
Labeling and packaging 
............................................................................................. 33 
4.2.1 
Packaging 
.............................................................................................................. 33 
4.2.2 
Labeling 
................................
................................................................................. 33 
4.3 
Storage 
....................................................................................................................... 34 
4.4 
Dispensing, storage, control and collection of investigational product 
..................... 34 
5 
SELECTION OF SUBJECTS ................................................................................... 34 
5.1 
Study subjects 
................................
............................................................................ 34 
5.2 
Inclusion criteria 
........................................................................................................ 35
 
5.3 
Exclusion criteria 
....................................................................................................... 35
 
5.4 
Criteria for entering long-term treatment period 
....................................................... 36 
6 
DOSING SCHEDULE AND CONCOMITANT THERAPY 
................................. 36 
6.1 
Dose, dosing schedule, and treatment duration 
......................................................... 36 
6.1.1 
Initial-dose evaluation period (Week 1 to Week 8) 
............................................... 36
 
6.1.2 
Extension period (Week 9 to Week 52) 
................................................................. 37
 
6.1.3 
Long-term treatment period (Week 53 to Week156) 
............................................. 37 
6.1.4 
Criteria for discontinuing and resuming study treatment ...................................... 39 
6.2 
Concomitant medications and therapies 
.................................................................... 39
 
6.2.1 
Concomitant medications and therapies ................................................................ 39 
6.2.2 
Prohibited medications and therapies .................................................................... 39 
6.2.3 
Recording concomitant medication and therapy in electronic Case 
Report Form (eCRF) 
.............................................................................................. 40 
7 
ENROLLMENT OF SUBJECTS 
.............................................................................. 40
 
8 
OBSERVATIONS/ASSESSMENTS/EXAMINATIONS   
AND 
SCHEDULE ................................................................................................................ 42
 
8.1 
Schedule .................................................................................................................... 42 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
5 
8.2 
Observations/assessments/examinations and schedule ............................................. 45 
8.2.1 
Screening examinations 
......................................................................................... 45 
8.2.2 
Treatment Period: Week 1 (day of initial administration of 
AMG531) to Week 8 ............................................................................................. 46 
8.2.3 
Treatment Period: Week 9 to Week 52 
.................................................................. 47 
8.2.4 
Treatment Period: Week 53 to Week 156 
.................................................... 48 
8.2.5 
End of treatment: one week after last administration of AMG531 
........................ 50 
8.2.6 
End of study: four weeks after last administration of AMG531 
............................ 50 
8.2.7 
Outcome surveillance for Survival, AML/MDS transformation, and 
cytogenetic abnormality 
......................................................................................... 51 
9 
ADVERSE EVENTS .................................................................................................. 51 
9.1 
Definition of adverse events 
...................................................................................... 51 
9.1.1 
Definition of serious adverse events 
................................
...................................... 52 
9.1.2 
Definition of other significant adverse events 
....................................................... 52 
9.2 
Safety assessment parameters 
.................................................................................... 52 
9.3 
Actions to be taken on occurrence of an adverse event and follow-up 
..................... 54 
9.3.1 
Actions for Subjects 
............................................................................................... 54 
9.3.2 
Notification to the concerned parties (reporting to relevant 
personnel) 
.............................................................................................................. 54 
9.3.3 
Follow-up of adverse events 
.................................................................................. 55 
10 
MANAGEMENT OF SUBJECTS; MEASURE FOR PATIENTS’ 
SAFETY PROTECTION 
........................................................................................... 55 
10.1 
Notification to other departments/hospitals 
............................................................... 55 
10.2 
Contraception ............................................................................................................ 55 
10.3 
Others ........................................................................................................................ 56 
11 
STOPPING RULES AND PROCEDURES ............................................................. 56 
11.1 
Subject withdrawal 
.................................................................................................... 56
 
11.1.1 
Criteria for subject withdrawal .............................................................................. 56 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
6 
11.1.2 
Procedure for subject withdrawal .......................................................................... 56 
11.2 
Premature termination or suspension of the study at a specific 
investigative site 
........................................................................................................ 57
 
11.3 
Premature termination or suspension of the entire study .......................................... 57 
12 
STATISTICAL ANALYSIS ...................................................................................... 57 
12.1 
Statistical methods 
..................................................................................................... 57
 
12.1.1 
Efficacy 
................................
.................................................................................. 58 
12.1.2 
Pharmacokinetics 
................................................................................................... 59 
12.1.3 
Safety 
..................................................................................................................... 60 
12.1.4 
Additional analyses 
................................................................................................ 60 
12.2 
Level of significance ................................................................................................. 60 
12.3 
Stopping rules for the study 
....................................................................................... 60 
12.4 
Handling of missing, unused, and abnormal data 
...................................................... 61 
12.5 
Development of the statistical analysis plan and procedure for 
reporting deviations from the original statistical analysis plan 
................................. 61
 
12.6 
Analysis Subsets 
........................................................................................................ 61
 
12.6.1 
Full Analysis Set (FAS) 
......................................................................................... 61 
12.6.2 
Per Protocol Set (PPS) 
........................................................................................... 61 
12.6.3 
Pharmacokinetic analysis set ................................................................................. 62 
12.6.4 
Safety analysis set 
.................................................................................................. 62 
13 
ETHICS ....................................................................................................................... 62 
13.1 
Regulatory considerations 
......................................................................................... 62 
13.2 
Institutional Review Board 
........................................................................................ 63
 
13.3 
Informed Consent 
...................................................................................................... 63
 
14 
FINANCING AND INSURANCE 
............................................................................. 64
 
15 
PROTOCOL DEVIATIONS 
..................................................................................... 64 
16 
DATA MANAGEMENT 
............................................................................................ 65 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
7 
17 
DIRECT ACCESS TO SOURCE DOCUMENTS 
................................................... 65 
18 
QUALITY CONTROL AND QUALITY ASSURANCE 
........................................ 65 
18.1 
Data collection 
.......................................................................................................... 65 
18.2 
Study monitoring 
....................................................................................................... 66 
18.3 
Audit and inspection of the study 
.............................................................................. 67 
19 
PLANNED STUDY PERIOD 
.................................................................................... 67 
20 
END OF THE STUDY ............................................................................................... 67
 
21 
RECORD KEEPING 
.................................................................................................. 67 
22 
PUBLICATION POLICY 
.......................................................................................... 68 
 
 
 
 
 
 
 
  
   
 
 
  
   
   
 
 
 
 
 
 
APPENDICES/ATTACHMENTS 
....................................................................................... 72
 
 
 
 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
8 
LIST OF ABBREVIATIONS 
ABBREVIATION 
DEFINITION 
AA 
Aplastic Anemia 
ADR 
Adverse Drug Reaction 
AE 
Adverse Event 
ALB 
Albumin 
ALP 
Alkaline phosphatase 
ALT 
Alanine aminotransferase 
AML 
Acute myelogenous leukemia 
APTT 
Activated partial thromboplastin time 
 
 
AST 
Aspartate aminotransferase 
ATG 
Anti-thymocyte globulin 
AUC0-t 
Area under the serum concentration-time curve from time 0 to the last 
detectable time 
BUN 
Blood urea nitrogen 
CI 
Confidence Interval 
 
 
Cmax 
Maximum serum concentration 
CMML 
Chronic myelomonocytic leukemia 
Cr 
Creatinine 
CTCAE 
Common Terminology Criteria for Adverse Events 
D-Bil 
Direct bilirubin 
ECG 
Electrocardiogram 
ECOG 
Eastern Cooperative Oncology Group 
eCRF 
Electronic case report form 
EDC 
Electronic data capture 
 
 
FAS 
Full Analysis Set 
γ-GTP 
γ-glutamyl transpeptidase 
GCP 
Good Clinical Practice, international standards for conducting clinical studies. 
G-CSF 
Granulocyte-colony stimulating factor 
GPI-cell 
Glycosyl phosphatidyl inositol-cell 
Hb 
Hemoglobin 
 
 
Ht 
Hematocrit 
ICF 
Informed Consent Form 
IFN- γ 
Interferon- γ 
IST 
Immunosuppressive therapy 
ITP 
Idiopathic (Immune) Thrombocytopenic Purpura 
IRB 
Institutional review board 
IWRS 
Interactive Web Response System 
LIN 
Lineage 
LDH 
Lactate dehydrogenase 
NYHA 
New York Heart Association 
MCH 
Mean corpuscular hemoglobin 
MCHC 
Mean corpuscular hemoglobin concentration 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
9 
ABBREVIATION 
DEFINITION 
MCV 
Mean corpuscular volume 
MDS 
Myelodysplastic syndromes 
MedDRA 
Medical Dictionary for Regulatory Activities 
 
 
 
 
 
 
 
 
PNH 
Paroxysmal nocturnal hemoglobinuria 
PPS 
Per Protocol Set 
PS 
Performance status 
PT-INR 
Prothrombin time - International Normalized Ratio 
PTs 
Preferred Terms 
RBC 
Red blood cell 
Ret 
Reticulocyte 
SDP 
Single Donor Platelet 
SID 
Subject identification 
SOC 
System Organ Class 
T-Bil 
Total bilirubin 
T-Cho 
Total cholesterol 
TIBC 
Total iron-binding capacity 
TMP 
Thrombopoietin mimetic peptide 
TNF- α 
Tumor necrosis factor- α 
Tmax 
Time to reach maximum serum drug concentration 
TP 
Total protein 
TPO 
Thrombopoietin 
TSAT 
Transferrin saturation : TSAT=Fe×100/TIBC 
UA 
Uric acid 
UIBC 
Unsaturated iron-binding capacity 
WBC 
White blood cell 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
10 
DEFINITION OF TERMS 
 
Platelet Response 
Platelet response is defined as (1) Absolute increase of ≥ 20x109/L above baseline or, (2) 
Increase to ≥10x109/L and by at least 100% from baseline. 
Erythroid Response 
Erythroid response is defined in those who with a pretreatment hemoglobin of < 9.0 g/dL 
as an increase in hemoglobin concentration of ≥ 1.5 g/dL above baseline without 
transfusion, or reduction in the transfusion unit by at least 4 units for 8 consecutive weeks 
compared with the pretreatment transfusion requirement in the previous 8 weeks prior to 
the first administration of AMG531 (Day -55 to Day 1).  
Neutrophil Response 
Neutrophil response is defined in those with a pretreatment absolute neutrophil count 
(ANC) of < 0.5x10
9/L as a 100% increase over the baseline, or an increase in ANC of > 
0.5x109/L in subjects with a pretreatment ANC of < 1.0x10
9/L.   
Baseline   
Baseline values are defined as the values obtained before dosing AMG531 on Study Day 
1. Data obtained during the screening period will serve as baseline values for those not 
measured or reported on Study Day 1. If multiple evaluations are performed during the 
screening period for a particular test, with the exception of platelet count, the values 
measured closest to the first administration of AMG531 will be considered as the baseline 
values (if hemoglobin concentration at Study Day 1 is within 28 days after RBC 
transfusion, hemoglobin concentration determined during the screening period will be 
used as baseline hemoglobin).  
Baseline Platelet Count 
Baseline platelet count is defined as the mean of two lowest platelet counts measured in 8 
weeks prior to enrollment. Platelet count that is obtained within 7 days after platelet 
transfusion will not be used. The baseline platelet according to the definition of protocol 
Master Ver1.1 (The mean of two lowest platelet counts measured in 8 weeks prior to 
enrollment. Platelet count that is obtained within 3 days after platelet transfusion will not 
be used.) will be also collected  . 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
11 
Platelet Transfusion 
Platelet transfusion given due to platelet count of < 10x109/L (prophylactic transfusion) or 
due to bleeding (therapeutic transfusion). 
RBC Transfusion 
RBC transfusion given due to the hemoglobin concentration of ≤ 9.0 g/dL or due to 
symptomatic anemia 
Adverse Drug Reaction 
Adverse events of which causal relationship to the investigational product cannot be ruled 
out (any events assessed to be other than “unlikely” or “not related”). 
Study Duration 
Study duration of each subject in this study is specified as the period from the day of 
obtaining written informed consent through the end of examinations on completion of 
treatment (or withdrawal). 
Observation and Examination Period 
In this study, Week 1 (Day 1) is defined to be the day of initial administration of 
AMG531. Initial dose evaluation period is defined to be the period from Week 1 to Week 
8, Extension period is the period from Week 9 to Week 52, and Long-term treatment 
period is the period from Week 53 to Week 156. 
Aplastic Anemia with Refractory Thrombocytopenia 
Aplastic anemia with thrombocytopenia defined as platelet count of ≤ 30x109/L that does 
not respond to the immunosuppressive therapy (ATG + cyclosporine), or relapsed after 
having showed response. 
Transfusion Independence 
Achieving platelet or RBC transfusion free period of at least 8 consecutive weeks. 
Tri-lineage response 
Tri-lineage response is defined in those achieving platelet response, erythroid response, 
and neutrophil response all together.  


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
12 
Normal level 
Normal level is defined as platelet counts >50x109/L, hemoglobin concentration 
>10.0 g/dL, and neutrophil counts >1.0x109/L  
Stable response 
Stable response is defined as platelet counts ≥30x109/L, hemoglobin concentration 
≥9.0 g/dL, and neutrophil counts ≥0.5x109/L maintained during dose tapering or 
discontinuation without transfusion 
Cytogenetic abnormality 
Any cytogenetic abnormalities newly emerged during or after the initiation of AMG531 
treatment  


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
13 
PROTOCOL SYNOPSIS 
I  TITLE 
A phase 2, Randomized, Open-Label, Parallel, Comparative, Dose-Finding Study to 
Evaluate the Efficacy and Safety of AMG531 in Aplastic Anemia (AA) Subjects with 
Thrombocytopenia Refractory to Immunosuppressive Therapy 
II  STUDY OBJECTIVES 
The present study will be conducted to evaluate the efficacy and safety of AMG531 and to 
determine the recommended initial dose of AMG531 on the basis of its efficacy and 
safety when it is administered SC, QW at a dose of 1, 3, 6 or 10 μg/kg to the aplastic 
anemia patients with immunosuppressive-therapy refractory thrombocytopenia and also to 
assess the pharmacokinetics of this product during the initial dose evaluation period. Its 
efficacy and safety during the extension period will also be evaluated. Efficacy and safety 
of AMG531 in the long term treatment beyond 1-year will be further evaluated for those 
showing continuous responses after 1 year treatment. 
III  STUDY DESIGN 
This is a multi-center, randomized, open-label, parallel, comparative, dose-finding study. 
The overall study design is presented below. 
 




 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
15 
within 6 months or is post angioplasty or stenting within 6 months; uncontrolled 
hypertension; clinically significant cardiac arrhythmia) 
6) Arterial or venous thrombosis within the last 1 year before enrollment 
7) Other cause of thrombocytopenia (for instance MDS, ITP, liver cirrhosis) 
8) Subjects with AML or CMML 
9) AA with hemolytic predominant PNH (hemolytic predominant is defined as LDH > 
1.5 times the upper limit of the laboratory normal range) 
10) 
Uncontrolled diabetes 
11) 
Receiving other investigational agents within 16 weeks before starting the study 
treatment 
12) 
Receiving any agent used to treat AA, including ATG or ATG + cyclosporine within 6 
months before starting study treatment and/or cyclosporine or anabolic hormone 
within 6 weeks before starting the study treatment  
13) 
History of PEG-rHuMGDF, recombinant human thrombopoietin, AMG531, and other 
TPO-receptor agonist   
14) 
Who plans to conduct hematopoietic stem cell transplantation within 1 year  
15) 
Known hypersensitivity to any recombinant E. Coli derived product   
16) 
Female subjects who are nursing or pregnant or are unwilling to take oral 
contraceptives or refrain from pregnancy if of childbearing potential 
17) 
Subjects who are considered to be ineligible for the study by the investigator for 
reasons other than the above   
V  DOSE, DOSING SCHEDULE, AND TREATMENT DURATION 
There must be at least 3 days between the doses of AMG531 in each subject. 
V-1  Initial dose evaluation period (Week 1 to Week 8) 
AMG531 will be administered at a dose of 1, 3, 6 or 10 μg/kg SC QW for 8 weeks. Dose 
adjustment (either escalation or reduction) will not be allowed during the initial dose 
evaluation period except for the cases defined in the V-4 Criteria for discontinuing and 
resuming study treatment. 
V-2  Extension period (Week 9 to Week 52) 
Initial dose of AMG531 for the extension period will be decided based on the efficacy and 
safety data observed during the initial dose evaluation period. If a subject does not show a 
platelet response at Week 9, the dose will be increased by one level according to Table V-
1. AMG531 dose adjustment (extension period) table. If no platelet measurement is 
available due to the platelet transfusion, then that week’s platelet response is considered 
as having no response. 
1) Dose escalation 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
16 
Dose escalation will be allowed during the extension period. If a subject does not show a 
platelet response after 4-week treatment with AMG531 at the previously escalated dose, 
the dose may be further increased by one level according to Table V-1 at the discretion of 
the investigator, with the highest dose being 20 μg/kg. The necessity and timing of dose 
escalation after 4 week administration at a previously escalated dose will be decided by 
investigator after thorough consideration of the relevant safety and efficacy data for each 
subject. 
2) Dose adjustment 
If a subject shows a platelet response, the dose may be adjusted as appropriate to maintain 
the platelet response at the discretion of the investigator referring to the relevant efficacy 
and safety data of the each subject. For each dose adjustment, dose may be increased or 
decreased only by one level at a time according to the Table V-1, with the highest dose 
being 20 μg/kg.  
Table V-1  AMG531 Dose adjustment table (extension period) 
AMG531 Dose 
1 μg/kg 
3 μg/kg 
6 μg/kg 
10 μg/kg 
13 μg/kg 
16 μg/kg 
20 μg/kg 
V-3 Long-term treatment period (Week 53 to Week 156) 
1) Initial Dose 
AMG531 will be administered SC QW at the same dose received as the last dose in the 
extension period. If dose adjustment is deemed to be necessary at Week 53 by investigator, 
the dose may be adjusted according to the Table V-2 Dose adjustment (long-term 
treatment period) table. 
2) Dose adjustment 
The dose may be adjusted as appropriate to maintain the platelet response at the discretion 
of the investigator. For each dose adjustment, dose may be increased or decreased only by 
one level at a time according to the Table V-2, with the highest dose being 20 μg/kg and 
the lowest dose being 3 μg/kg. 
 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
17 
Table V-2  AMG531 Dose adjustment  (long-term treatment period) 
AMG531 Dose 
3 μg/kg 
6 μg/kg 
10 μg/kg 
 13 μg/kg 
16 μg/kg 
20 μg/kg 
 
3) Tapering and Discontinuation 
If tri-lineage is maintained within normal level for 8-consecutive weeks with the same 
dose without transfusion, the dose will be decreased by one level at every 4 weeks. If tri-
lineage is maintained within normal level for 4 consecutive weeks with 3 µg/kg without 
transfusion, AMG531 will be discontinued. 
Normal level is defined as platelet counts >50×109/L and hemoglobin concentration >10.0 
g/dL and neutrophil counts >1.0×109/L. 
While tapering, if platelet counts drop to less than 30×109/L, hemoglobin to less than 9.0 
g/dL, or neutrophil counts to less than 0.5×109/L, the tapering has to be stopped and dose 
will be adjusted following section V-3 2). If the study drug were discontinued, it will be 
resumed at a dose of 3 µg/kg and further adjusted in accordance with section V-3 2). 
Tapering may be tried again at the discretion of investigator. 
While tapering, if patient does not meet the criteria of further tapering but maintains 
steady stable response, the dose will be kept stable. During tapering, dose reduction 
should follow section V-3 3), not V-3 2). While discontinuation, if patient maintains the 
steady stable response, dosing will not be resumed. 
V-4  Criteria for discontinuing and resuming study treatment 
If the platelet has exceeded 400x10
9/L during the treatment period, study treatment will be 
temporarily discontinued. Once the platelet count falls to < 200x109/L, administration of 
AMG531 will resume at a reduced dose by one level according to the protocol. Once the 
platelet count falls to ≤ 50x109/L during the treatment with reduced dose by one level, 
dosing will be resumed at the temporarily discontinued dose.  
If the platelet has exceeded 200x10
9/L during the treatment period, the dose of AMG531 
will be reduced to the next lower dose tested. If the temporarily discontinued dose is 1 
μg/kg, treatment will be resumed at the dose of 1 μg/kg.  


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
18 
Other than the reasons above, investigator can reduce the dose at any time during the 
study if safety concerns arise.   
VI  STUDY ENDPOINTS 
VI-1  Efficacy 
1) Primary endpoint 
The proportion of subjects achieving a platelet response at Week 9.  
2) Secondary endpoints 
• The proportion of subjects achieving a platelet response any time during the initial 
dose evaluation period, Week1 through Week 12, Week 1 through Week 16, Week 
1 through Week 24, and Week 1 through Week 52 
• The proportion of subjects who become platelet transfusion independent during the 
initial dose evaluation period, Week1 through Week 12, Week 1 through Week 16, 
Week 1 through Week 24, Week 1 through Week 52, Week 1 through Week 104, 
and Week1 through Week 156 
• The proportion of subjects achieving erythroid response and/or neutrophil response 
during the initial dose evaluation period, Week1 through Week 12, Week 1 through 
Week 16, Week 1 through Week 24, Week 1 through Week 52, Week 1 through 
Week 104, and Week1 through Week 156 
• Duration of platelet response 
• Time to platelet response 
• Changes in platelet count, hemoglobin concentration, and neutrophil count as 
continuous variables 
• Changes in bone marrow cellularity and reticulin grade 
• Changes in GIMEMA bleeding scale 
• The proportion of subjects achieving tri-lineage responses 
• The proportion of subjects able to discontinue study drugs after achieving normal 
level for 8 consecutive weeks without transfusion. 
• Duration of study drug discontinuation while maintaining stable response 
VI-2  Pharmacokinetics 
• Serum AMG531 concentration 
• Pharmacokinetic parameters 
VI-3  Safety 
• Adverse events 
• Antibody formation against AMG531 and TPO  


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
19 
 
VI-4  Exploratory  
• The changes of primitive hematopoietic stem and progenitor cells  
• The changes of progenitor cell pool (colony forming cell assay) 
• The changes of stromal cell (colony forming unit fibroblast assay) 
• Cytokine assay (IL-2, IL-6, IL-10, IL-12, IL-17, IFN-γ, TNF-α) 
VII  CRITERIA FOR SUBJECT WITHDRAWAL 
Any of the following circumstances will result in the subject being withdrawn from the 
study: 
1) The subject is found to be ineligible for participation in this study due to violations in 
the inclusion or exclusion criteria specified in the study protocol; 
2) The subject decides to discontinue his/her participation in the study; 
3) The subject becomes unable to undergo necessary observations or examinations; 
4) The subject who does not achieve a platelet response after 8-week treatment with 
AMG531 20 μg/kg QW; 
5) The investigator considers that the subject should be withdrawn from the study due to 
an adverse event (including progression of the primary disease); 
6) The subject received any of the prohibited concomitant medications or treatments; 
7) The subject becomes pregnant or wants to have children during the study; 
8) The investigator assesses that the subject needs to be withdrawn from the study for 
any reason not specified above; 
9) The subject who does not meet the entry criteria for long-term treatment period 
 
VIII  TARGET SAMPLE SIZE 
1) Efficacy and Safety 
Eight in each cohort, a total of 32 subjects receiving AMG531 at a dose of 1, 3, 6 or 
10 μg/kg during the initial dose evaluation period will be assessed for the primary 
endpoint. 
2) Pharmacokinetics 
Serum concentrations of AMG531 will be determined in 3 subjects in each cohort, a total 
of 12 subjects (in chronological order of enrollment) receiving AMG531 at a dose of 1, 3, 
6 or 10 μg/kg. 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
20 
IX  PLANNED STUDY PERIOD 
January 2014 to March 2018 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
21 
1  BACKGROUND AND STUDY RATIONALE 












 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
27 
2  STUDY OBJECTIVES 
The present study will be conducted to evaluate the efficacy and safety of AMG531 and to 
determine the recommended dose of AMG531 on the basis of its efficacy and safety when 
it is administered SC, QW at a dose of 1, 3, 6 or 10 μg/kg to the AA patients with 
immunosuppressive-therapy refractory thrombocytopenia and also to assess the 
pharmacokinetics of this product during the initial dose evaluation period. Its efficacy and 
safety during the extended period will also be evaluated. 
 
. Efficacy and 
safety of AMG531 in the long term treatment beyond 1-year will be further evaluated for 
those showing continuous responses after 1 year treatment. 
3  STUDY DESIGN 
3.1  Study design 
This is a multi-center, randomized, open-label, parallel, comparative, dose-finding study. 
The overall study design is presented below. 
 
3.2  Study phase 
Phase 2 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
28 
3.3 Study endpoints 
3.3.1  
Efficacy 
3.3.1.1  Primary endpoint 
The proportion of subjects achieving a platelet response at Week 9 
3.3.1.2  Secondary endpoints 
• The proportion of subjects achieving a platelet response any time during the initial 
dose evaluation period, Week1 through Week 12, Week 1 through Week 16, 
Week 1 through Week 24, and Week 1 through Week 52. 
• The proportion of subjects who become platelet transfusion independent during the 
initial dose evaluation period, Week1 through Week 12, Week 1 through Week 16, 
Week 1 through Week 24, Week 1 through Week 52, Week 1 through Week 104, 
and Week1 through Week 156 
• The proportion of subjects achieving erythroid response and/or neutrophil response 
during the initial dose evaluation period, Week1 through Week 12, Week 1 through 
Week 16, Week 1 through Week 24, Week 1 through Week 52, Week 1 through 
Week 104, and Week1 through Week 156 
• Duration of platelet response 
• Time to platelet response 
• Changes in platelet count, hemoglobin concentration, and neutrophil count as 
continuous variables 
• Changes in bone marrow cellularity and reticulin grade 
• Changes in GIMEMA bleeding scale 
• The proportion of subjects achieving tri-lineage responses 
• The proportion of subjects able to discontinue study drugs after achieving normal 
level for 8 consecutive weeks without transfusion. 
• Duration of study drug discontinuation while maintaining stable response 
3.3.2  
Pharmacokinetics 
• Serum AMG531 concentration 
• Pharmacokinetic parameters 
3.3.3  
Safety 
• Adverse events 
• Antibody formation against AMG531 and TPO  


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
29 
 
3.3.4  
Exploratory 
• The changes of primitive hematopoietic stem and progenitor cells 
• The changes of progenitor cell pool (colony forming cell assay) 
• The changes of stromal cell (colony forming unit fibroblast assay) 
• Cytokine assay (IL-2, IL-6, IL-10, IL-12, IL-17, IFN-γ, TNF-α)  
3.4 Randomization 
Subjects assessed to be eligible for the study will be randomized to either of the four dose 
groups (1, 3, 6, or 10 μg/kg) according to a static allocation procedure using the baseline 
platelet count (platelet ≤ 10x109/L or 10x10
9/L < platelet ≤ 30x109/L). A written 
procedure for randomization will be created and the details will be specified in it. 
3.5 Target sample size 
3.5.1  
Efficacy and Safety 
Eight in each cohort, a total of 32 subjects receiving AMG531 at a doses of 1, 3, 6 or 
10 μg/kg during the initial dose evaluation period will be assessed for the primary 
endpoint. 
3.5.2  
Pharmacokinetics 
Serum concentrations of AMG531 will be determined in 3 in each cohort, a total of 
12 subjects (in chronological order of enrollment) receiving AMG531 at a doses of 1, 3, 6 
or 10 μg/kg. 








Master Ver 3.1_20Dec2016 
 
Confidential 
33 
4  INVESTIGATIONAL PRODUCT 
4.1 Investigational product 
1) Investigational Product: AMG531 
2) Generic Name: Romiplostim 
3) Content and Dosage Form: AMG531 is supplied in a single use glass vial as a sterile, 
white, preservative free, lyophilized powder. After reconstitution with 0.72 mL of 
sterile water for injection, AMG531 is available at a concentration of 0.5 mg/mL. 
4.2 Labeling and packaging 
4.2.1  
Packaging 
Each box contains 10 vials. 
4.2.2  
Labeling 
Each label displays the following information. Color of outer carton and vial labels are 
designated to be white. 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
34 
4.2.2.1  Label for outer cartons 
Statements of “For clinical trial use only” and “Cannot be used for any other purposes 
except for clinical trial”, name and address of the IND holder, name of investigational 
product, batch number, expiration date and storage directions.  
4.2.2.2  Label for vials 
Statements of “For clinical trial use only”, name of investigational product and batch 
number, expiration date, and IND holder name. 
4.3 Storage 
To be stored at 2 to 8°C and protected from light. 
4.4 Dispensing, storage, control and collection of investigational product 
The sponsor will provide each investigative site with the investigational product after 
execution of the clinical study agreement. The sponsor will develop a written procedure 
for controlling the investigational product and deliver it to each investigative site. 
The investigational product manager at each investigative site will properly store and 
control the investigational product according to the procedure, and will maintain records 
of the inventory, dispensing and return. He/she will properly check the quantity of the 
investigational product against the investigational product management record. In 
principle, the investigational product manager will return unused vials to the sponsor after 
study completion or at the delivery of a new batch. Partially used and empty vials will be 
destroyed at the site per site’s standard procedures. 
The investigational product manager will submit a copy of the investigational product 
management record to the sponsor after study completion. 
5  SELECTION OF SUBJECTS 
5.1 Study subjects 
Aplastic anemia (AA) subjects with thrombocytopenia refractory to immunosuppressive 
agents. 




 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
36 
7) Other cause of thrombocytopenia (for instance MDS, ITP, liver cirrhosis) 
8) Subjects with AML or CMML 
9) AA with hemolytic predominant PNH (hemolytic predominant is defined as LDH > 
1.5 times the upper limit of the laboratory normal range) 
10) 
Uncontrolled diabetes 
11) 
Receiving other investigational agents within 16 weeks before starting the study 
treatment 
12) 
Receiving any agent used to treat AA, including ATG or ATG+cyclosporine within 6 
months before starting study treatment and/or cyclosporine or anabolic hormone 
within 6 weeks before starting the study treatment 
13) 
History of PEG-rHuMGDF, recombinant human thrombopoietin, AMG531, and other 
TPO-receptor agonist   
14) 
Who plans to conduct hematopoietic stem cell transplantation within 1 year  
15) 
Known hypersensitivity to any recombinant E. coli derived product   
16) 
Female subjects who are nursing or pregnant or are unwilling to take oral 
contraceptives or refrain from pregnancy if of childbearing potential 
17) 
Subjects who are considered to be ineligible for the study by the investigator for 
reasons other than the above   
5.4 Criteria for entering long-term treatment period  
1) Subjects with platelet responses confirmed during 8 weeks prior to Week 53 (Week 
46-Week 53)  
2) Subjects who do not have any significant changes in medical condition during the 
initial evaluation period and extension period (Week 1-Week 52) including bone 
marrow stem cell disorders or new active malignancies 
 
6  DOSING SCHEDULE AND CONCOMITANT THERAPY 
6.1 Dose, dosing schedule, and treatment duration 
There must be at least 3 days between the doses of AMG531 in each subject. 
6.1.1  Initial-dose evaluation period (Week 1 to Week 8) 
AMG531 will be administered at a dose of 1, 3, 6, or 10 μg/kg SC QW for 8 weeks. Dose 
adjustment (either escalation or reduction) will not be allowed during the initial dose 
evaluation period except for the cases defined in the 6.1.4 Criteria for discontinuing and 
resuming study treatment. 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
37 
6.1.2  
Extension period (Week 9 to Week 52) 
Initial dose of AMG531 for the extension period will be decided based on the efficacy and 
safety data observed during the initial dose evaluation period. If a subject does not show a 
platelet response at Week 9, the dose will be increased by one level according to Table 
6.1.2-1 AMG531 dose adjustment (extension period) table. If no platelet measurement is 
available due to the platelet transfusion, then that week’s platelet response is considered 
as having no response. 
6.1.2.1  Dose escalation 
Dose escalation will be allowed during the extension period. If a subject does not show a 
platelet response after 4-week treatment with AMG531 at the previously escalated dose, 
the dose may be further increased by one level according to Table 6.1.2-1 at the discretion 
of the investigator, with the highest dose being 20 μg/kg. The necessity and timing of dose 
escalation after 4 week administration at a previously escalated dose will be decided by 
investigator after thorough consideration of the relevant safety and efficacy data for each 
subject. 
6.1.2.2  Dose adjustment 
If a subject shows a platelet response, the dose may be adjusted as appropriate to maintain 
the platelet response at the discretion of the investigator referring to the relevant efficacy 
and safety data of the each subject.  For each dose adjustment, dose may be increased or 
decreased only by one level at a time according to the Table 6.1.2-1, with the highest dose 
being 20 μg/kg. 
Table 6.1.2-1 AMG531 Dose adjustment table (extension period) 
AMG531 Dose 
1 μg/kg 
3 μg/kg 
6 μg/kg 
10 μg/kg 
13 μg/kg 
16 μg/kg 
20 μg/kg 
6.1.3 
Long-term treatment period (Week 53 to Week156) 
6.1.3.1  Initial Dose 
AMG531 will be administered SC QW at the same dose received as the last dose in the 
extension period. If dose adjustment is deemed to be necessary at Week 53 by investigator, 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
38 
the dose may be adjusted according to the Table 6.1.3-1 Dose adjustment (long-term 
treatment period) table. 
6.1.3.2  Dose adjustment 
The dose may be adjusted as appropriate to maintain the platelet response at the discretion 
of the investigator. For each dose adjustment, dose may be increased or decreased only by 
one level at a time according to the Table 6.1.3-1, with the highest dose being 20 μg/kg 
and the lowest dose being 3 μg/kg. 
Table 6.1.3-1 AMG531 Dose adjustment  (long-term treatment period) 
AMG531 Dose 
3 μg/kg 
6 μg/kg 
10 μg/kg 
 13 μg/kg 
16 μg/kg 
20 μg/kg 
6.1.3.3  Tapering and Discontinuation 
If tri-lineage is maintained within normal level for 8-consecutive weeks with the same 
dose without transfusion, the dose will be decreased by one level at every 4 weeks. If tri-
lineage is maintained within normal level for 4 consecutive weeks with 3 µg/kg without 
transfusion, AMG531 will be discontinued. 
Normal level is defined as platelet counts >50×109/L and hemoglobin concentration >10.0 
g/dL and neutrophil counts >1.0×109/L. 
While tapering, if platelet counts drop to less than 30×109/L, hemoglobin to less than 
9.0 g/dL, or neutrophil counts to less than 0.5×10
9/L, the tapering has to be stopped and 
dose will be adjusted following section 6.1.3.2. If the study drug were discontinued, it will 
be resumed at a dose of 3 µg/kg and further adjusted in accordance with section 6.1.3.2. 
Tapering may be tried again at the discretion of investigator. 
While tapering, if patient does not meet the criteria of further tapering but maintains 
steady stable response, the dose will be kept stable. During tapering, dose reduction 
should follow section 6.1.3.3, not 6.1.3.2. While discontinuation, if patient maintains the 
steady stable response, dosing will not be resumed 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
39 
6.1.4  
Criteria for discontinuing and resuming study treatment 
If the platelet has exceeded 400x109/L during the treatment period, study treatment will be 
temporarily discontinued. Once the platelet count falls to < 200x109/L, administration of 
AMG531 will resume at a reduced dose by one level according to the protocol. Once the 
platelet count falls to ≤ 50x109/L during the treatment with reduced dose by one level, 
dosing will be resumed at the temporarily discontinued dose.  
If the platelet has exceeded 200x10
9/L during the treatment period, the dose of AMG531 
will be reduced to the next lower dose tested. If the temporarily discontinued dose is 1 
μg/kg, treatment will be resumed at the dose of 1 μg/kg.  
Other than the reasons above, investigator can reduce the dose at any time during the 
study if safety concerns arise. 
6.2 Concomitant medications and therapies 
6.2.1  
Concomitant medications and therapies 
Throughout the study period, investigator may prescribe any concomitant medications or 
therapies deemed necessary to provide adequate supportive care except for those listed in 
section 6.2.2. Rescue medication is defined as any medication that is administered to raise 
platelet counts, hemoglobin concentration or neutrophil counts. Rescue medication should 
only be administered when subjects is at immediate risk except for the case of transfusion. 
Platelet and RBC transfusions will be allowed during the study period as clinically 
indicated. Platelet counts, hemoglobin concentration and neutrophil counts determined 
after administration of rescue medication suspected to affect its level will not be used for 
the efficacy assessment. For the platelet transfusion, only single donor platelet (SDP) 
transfusion will be allowed during the study period. 
Iron chelator will be allowed during the study period as clinically indicated. 
6.2.2  
Prohibited medications and therapies 
While on study treatment, subjects are not permitted to receive any additional 
experimental medication or any therapy known or suspected to affect platelet production 
and AA from the time of enrollment throughout the study period. Examples of prohibited 
medications or therapies are follows;  
1) Any investigational agents other than AMG531 
2) TPO agonist other than AMG531 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
40 
3) Other drugs to treat AA or symptoms associated with AA (e.g., immunosuppressive 
agents, cyclosporine, growth factors [For the case of G-CSF, its administration is only 
permitted as a rescue medication to treat infection, and will be prohibited for the 
purpose of treating AA]) 
4) Any medication known or suspected to affect platelet production 
5) Hematopoietic stem cell transplantation 
6.2.3  
Recording concomitant medication and therapy in electronic Case 
Report Form (eCRF) 
All concomitant medication and therapy that a subject received during the period after 
enrollment through to the end of the study will be recorded on electronic case report form 
(eCRF) by the investigator with the following information for each concomitant 
medication and therapy: name of drug, route of administration, duration of treatment and 
justification for the administration. Agents not intended for medical treatment such as 
rehydration including saline solution, dissolving solution, or contrast medium for imaging 
diagnostics are not required to be recorded.  
Platelet transfusions given between the period within 56 days (Day -55) prior to the first 
administration of AMG531 (Day 1) and RBC transfusion given between the period of 
within 26 weeks (Day -181) prior to the first administration of AMG531 (Day 1) through 
to the end of study will be recorded in eCRF, including date of each transfusion, volume 
of transfusion (unit and mL), platelet count or hemoglobin concentration before each 
transfusion, and reason for each transfusion.  
7  ENROLLMENT OF SUBJECTS 
Before obtaining written informed consent from a subject, the investigator will examine 
the characteristics of each subject, as well as results of evaluations performed so far to 
select subjects who are expected to fulfill all of the inclusion criteria and not to meet any 
of the exclusion criteria. 
The details of the study will be sufficiently explained by the investigator to the selected 
subjects, and those who agree to participate in the study will provide an informed consent. 
All subjects who have submitted an informed consent will be identified by subject 
identification code (SID) assigned by the investigative site and registered to interactive 
web response system (IWRS). The numbering conventions of SID are as shown below. 
SID assigned to each subject after obtaining the informed consent will be consistently 
used till the end of the study. 
SID: 531-XX-YY 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
41 
XX: Investigative site number (refer to the Study Protocol Supplement) 
YY: Serial number of subjects given in chronological order of providing informed consent 
in each investigative site. 
Example: SID of the first subject who provided informed consent in ## Hospital 
(Investigative site number, 01) will be 531-01-01. 
The investigator will start treatment of each subject within 7 days after enrollment at an 
assigned dose. 
 
 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
42 
8  OBSERVATIONS/ASSESSMENTS/EXAMINATIONS AND 
SCHEDULE 
8.1 Schedule 
The study schedule is shown in Table 8.1-1. 
Table 8.1-1 Study schedule 
〔Written informed consent to Week 8〕 
Week 
Screening 
Examination 
1  2  3  4  5  6  7  8 
Informed Consent 
X  
  
  
  
  
  
  
  
 
Subject Background 
X  
  
  
  
  
  
  
  
 
AMG531 Administration 
  
X  X  X  X  X  X  X  X 
Bone Marrow Examination 
X  
  
  
  
  
  
  
  
 
Pregnancy Test 
X  
  
  
  
  
  
  
  
 
ECOG PS 
X  
  
  
  
  
  
  
  
 
Vital Signs 
X  
X  X  X  X  X  X  X  X 
Hematology 
X  
X  X  X  X  X  X  X  X 
Serum Chemistry 
X  
X  X  X  X  X  X  X  X 
Blood Iron-Related Parameters1) 
X  
X  
  
  
  
X  
  
  
 
Blood Coagulation and Fibrinolysis2)  
X  
X  
  
  
  
X  
  
  
 
Folic Acid, Vitamin B12 
X  
  
  
  
  
  
  
  
 
Viral serologies for HIV, hepatitis B and C  
X  
  
  
  
  
  
  
  
 
12-Lead ECG 
X  
  
  
  
  
  
  
  
 
Flow cytometry for GPI-cells 
X  
  
  
  
  
  
  
  
 
Serum AMG531 Concentration3) 
  
X  
  
  
X  
  
  
  
X 
Serum TPO Concentration 
  
X  
  
  
  
  
  
  
 
Antibodies for AMG531 and TPO 
  
X  
  
  
  
  
  
  
 
Cytokine assay 
  
X  
  
  
  
  
  
  
 
GIMEMA bleeding scale 
  
X  
  
  
  
  
  
  
 
Adverse Events 
  
  
  
  
  
  
  
  
 
Concomitant Medications4) 
  
  
  
  
  
  
  
  
 
PLT or RBC Transfusion 
  
  
  
  
  
  
  
  
 
 
 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
43 
 
〔Week 9 to Week 52 (or withdrawal)〕 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Week 
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 
AMG531 Administration  
X X X X X X X X X X X X X X X X 
Vital Signs 
X X X X X X X X X X X X X X X X 
Hematology  
X X X X X X X X X X X X X X X X 
Serum Chemistry  
X        X        X        X       
Blood Iron-Related Parameters1) 
X        X        X        X       
Blood Coagulation and Fibrinolysis2) X        X        X        X       
Serum TPO Concentration  
X                               
Antibodies for AMG531 and TPO X                               
Cytokine assay  
X                               
GIMEMA bleeding scale  
X                               
Adverse Events  
                                
Concomitant Medications  
                               
PLT or RBC Transfusion  
                               
Week 
25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 
AMG531 Administration  
X X X X X X X X X X X X X X X X 
Bone Marrow Examination  
X5)                              
Vital Signs 
X X X X X X X X X X X X X X X X 
Hematology  
X X X X X X X X X X X X X X X X 
Serum Chemistry  
X        X        X        X       
Blood Iron-Related Parameters1) 
X        X        X        X       
Blood Coagulation and Fibrinolysis2) X        X        X        X       
Antibodies for AMG531 and TPO X                               
Cytokine assay  
X                               
GIMEMA bleeding scale  
X                               
Adverse Events  
                                
Concomitant Medications  
                               
PLT or RBC Transfusion  
                               
Week 
41 42 43 44 45 46 47 48 49 50 51 52 
AMG531 Administration  
X X X X X X X X X X X X 
Vital Signs 
X X X X X X X X X X X X 
Hematology  
X X X X X X X X X X X X 
Serum Chemistry  
X        X        X       
Blood Iron-Related Parameters1) 
X        X        X       
Blood Coagulation and Fibrinolysis2) X        X        X       
Antibodies for AMG531 and TPO X                       
Adverse Events  
                        
Concomitant Medications  
                       
PLT or RBC Transfusion  
                       


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
44 
 
〔Week 53 to End of Study (or withdrawal)〕 
 
1) Fe, TIBC, UIBC, TSAT and ferritin will be measured for the screening lab but starting from W1 to End of study, 
only ferritin level will be measured.  
2) PT-INR, APTT and D-dimer will be measured for the screening lab but starting from W1 to End of study, only D-
dimer will be measured. 
3) Restricted to the patients assigned to AMG531 concentration test group. Refer to the Table 8.2.2-1 for detailed 
schedule and time windows for PK sample collections.  
4) Information for the concomitant medication will be colleted after enrollment.  
5) For the bone marrow examination, ± 2 weeks will be allowed 
6) This bone marrow examination will be exempt for the patients withdrawn from the study within 11 weeks from the 
last bone marrow examination. Test time window of ± 2 weeks will be allowed. 
7) Required only for premature termination at W8 or earlier. 
Week 
53 
54 
55 
56 
57 
58 
59 
60 
61 
62 
63 
64 
65 
66 
67 
68 
End of 
Treatment8) 
End of Study 9) 
69 
70 
71 
72 
73 
74 
75 
76 
77 
78 
79 
80 
81 
82 
83 
84 
85 
86 
87 
88 
89 
90 
91 
92 
93 
94 
95 
96 
97 
98 
99 100 
101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 
117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 
133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 
149 150 151 152 153 154 155 156    
  
  
  
  
  
  
  
AMG531 
Administration 
12) 
X 
X  X  X  X  X  X  X  X  X  X  X  X  X  X  X 
  
 
Bone Marrow 
Examination 
Before dosing of AMG531 at W53, W77, W105, W129 
5) 
X6) 
 
Vital Signs 
X X11) X X11) X X11) X X11) X X11) X X11) X X11) X X11) X  X 
Hematology 
X X11) X X11) X X11) X X11) X X11) X X11) X X11) X X11) X  X 
Serum 
Chemistry 
X 
  
  
 
X 
  
  
 
X 
  
  
 
X 
  
  
 
X  X 
Blood Iron-
Related 
Parameters1) 
X 
  
  
 
X 
  
  
 
X 
  
  
 
X 
  
  
 
X  X 
Blood 
Coagulation and 
Fibrinolysis2) 
X 
  
  
 
X 
  
  
 
X 
  
  
 
X 
  
  
 
X  X 
12-Lead ECG 
X13) 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
X 
 
Serum AMG531 
concentration  
  
 
  
  
  
  
  
  
  
  
  
  
  
  
  
 
X7) 
 
Serum TPO 
Concentration Before dosing AMG531 at W53, W105 
X 
 
Antibodies for 
AMG531 and 
TPO 
Before dosing AMG531 at W57, W77, W105, W129 
 
X 
Cytokine assay Before dosing AMG531 at W53 only 
X10) 
 
GIMEMA 
bleeding scale Before dosing AMG531 at W53, W77, W105, W129 
X 
 
Adverse Events 
 
 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
Concomitant 
Medications 
 
 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
PLT or RBC 
Transfusion 
 
 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
45 
8) One week after last administration of AMG531, or refer to the section 11.1.2 if subject is withdrawn from the study 
due to safety issues and cannot conduct the scheduled end of treatment visit. 
9) Four weeks after last administration of AMG531, or refer to the section 11.1.2 if subject is withdrawn from the 
study due to safety issues and cannot conduct the scheduled end of study visit. 
10) This cytokine assay will be required only for the patients withdrawn from the study before Week 53. 
11) Subjects on discontinuation of AMG531 after achieving normal level for 8 consecutive weeks without transfusion 
(refer to the section 6.1.3.3) can skip even-numbered visit (i.emake bi-weekly visits).  
12) For those who discontinued the AMG531 after achieving normal level for 8 consecutive weeks without transfusion 
(refer to the section 6.1.3.3), dosing will be skipped. 
13) Required only at Week53 before dosing of AMG531 
8.2 Observations/assessments/examinations and schedule 
8.2.1  
Screening examinations 
A signed and dated IRB approved informed consent must be obtained before any study 
specific procedures are performed. Procedures that are part of routine care are not 
considered as study specific procedures.  
The screening period begins on the date of subject signed the IRB approved informed 
consent and continues until the date of first administration of AMG531. The following 
screening examination will be conducted within 4 weeks prior to the first administration 
of AMG531 (Week -4 to Day 1). Retesting during this period may be performed as 
needed. 
Subjects who fail screening will be allowed to be re-screened if a remediable cause for the 
original screen failure is found.  
 
1) Baseline characteristics: date on which the subject is diagnosed with AA, severity of 
AA (Appendix 2), previous treatments for AA (duration and sort of treatment), 
baseline platelet count, platelet transfusion in the previous 8 weeks prior to the first 
administration of AMG531 (Day -55 to Day 1), RBC transfusion in the previous 26 
weeks prior to the first administration of AMG531 (Day -181 to Day1), concomitant 
medications, medical history, current complications, date of birth, gender, weight, and 
height, baseline platelet count according to the protocol Master Ver1.1 (The mean of 
two lowest platelet counts measured in 8 weeks prior to enrollment. Platelet count that 
is obtained within 3 days after platelet transfusion will not be used)  
2) Bone marrow biopsy and aspiration with cytogenetics (M/E ratio, celluarity of bone 
marrow, reticulin grade (reticulin stain/trichrome stain (Appendix 1)), iron stain, 
narrative pathology report, cytogenetic report and exploratory test described in section 
3.3.4) 
3) Pregnancy test (excluding male subjects and female subjects underwent oophorectomy 
or hysterectomy or those who are non-childbearing potential i.e., menstrual periods 
have been absent for at least 12 months) 
4) ECOG PS 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
46 
5) Vital signs (systolic blood pressure, diastolic blood pressure and pulse rate) 
6) Hematology (WBC, RBC, Hb, Ht, MCV, MCH, MCHC, PLT, Ret and WBC with 
differential count) 
7) Serum chemistry (TP, ALB, T-Bil, D-Bil, AST, ALT, ALP, LDH, γ-GTP, T-Cho, UA, 
BUN, Cr, Na, K, Ca, P and Cl) 
8) Blood iron-related parameters (Fe, TIBC, UIBC, TSAT and ferritin) 
9) Blood coagulation and fibrinolysis (PT-INR, APTT and D-dimer) 
10) 
Folic acid and vitamin B12 
11) 
Viral serologies for HIV, hepatitis B and C 
12) 
12-lead ECG 
13) 
Flow cytometry of the peripheral blood for GPI-cells 
8.2.2  
Treatment Period: Week 1 (day of initial administration of AMG531) 
to Week 8 
The following observations and examinations during the period of Week 1 (day of initial 
treatment with AMG531) through to Week 8 will be conducted on the day of study 
treatment, as a general rule. In consideration of convenience for subjects and 
investigational sites, ± 3 days will be allowed except for the subjects assigned to the 
AMG531 concentration test group. Subjects on dose interruption will also undergo the 
same observations and examinations. Serum for the determination of AMG531 
concentration can be collected at Week 1, Week 4 and Week 8 as described in Table 
8.2.2-1 Schedule for PK sampling. 
1) Vital signs (systolic blood pressure, diastolic blood pressure and pulse rate) 
Timing of measurement: Every week before dosing AMG531 in Week 1 to Week 8 
2) Hematology (WBC, RBC, Hb, Ht, MCV, MCH, MCHC, PLT, Ret and WBC with 
differential count) 
Timing of measurement: Every week before dosing AMG531 in Week 1 to Week 8 
3) Serum chemistry (TP, ALB, T-Bil, D-Bil, AST, ALT, ALP, LDH, γ-GTP, T-Cho, UA, 
BUN, Cr, Na, K, Ca, P and Cl) 
Timing of measurement: Every week before dosing AMG531 in Week 1 to Week 8  
4) Blood iron-related parameter (ferritin) 
Timing of measurement: Before dosing AMG531 at Week 1 and Week 5 
5) Blood coagulation (D-dimer) 
Timing of measurement: Before dosing AMG531 at Week 1 and Week 5 
6) Serum AMG531 concentration 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
47 
Timing of measurement: Before dosing and 4, 12, 24, 48, 72, 96, and 168 hours after 
dosing AMG531 at Week 1 and Week 8, and before dosing AMG531 at Week 4. 
Detailed time point with sampling time window is described in Table 8.2.2-1. 
7) Serum TPO concentration 
Timing of measurement: Before dosing AMG531 at Week 1 
8) Antibodies against AMG531 and TPO  
Timing of measurement: Before dosing AMG531 at Week 1 (Additional antibody test 
can be performed on subjects who show clinical findings suggested of possible 
antibody formation) 
9) Cytokine assay 
Timing of measurement: Before dosing AMG531 at Week 1 
10) 
GIMEMA bleeding scale (Appendix 3) 
Timing of measurement: Before dosing AMG531 at Week 1 
 
Table 8.2.2-1  
Schedule for PK sampling 
Study Week  
Study date 
Time of Collection 
Week 1 
Day 1 
Before dosing of 
AMG531 
within 2 hours 
After dosing of 
AMG531 
4 hours ± 30 minutes 
12 hours ± 90 minutes
 
Day 2 
24 hours ± 3 hours 
Day 3 
48 hours ± 3 hours 
Day 4 
72 hours ± 3 hours 
Day 5 
96 hours ± 3 hours 
Day 81) 
168 hours ± 3 hours 
Week 4 
Day 22 
Before dosing of 
AMG531 
within 2 hours 
Week 8 
Day 50 
Before dosing of 
AMG531  
within 2 hours 
After dosing of 
AMG531 
4 hours ± 30 minutes
 
12 hours ± 90 minutes 
Day 51 
24 hours ± 3 hours 
Day 52 
48 hours ± 3 hours 
Day 53 
72 hours ± 3 hours 
Day 54 
96 hours ± 3 hours 
Day 572) 
168 hours ± 3 hours 
1) The examination at 168 hours after dosing AMG531 at Week 1 will be conducted before dosing AMG531 at Week 2 
2) The examination at 168 hours after dosing AMG531 at Week 8 will be conducted before dosing AMG531 at Week 9 
8.2.3  
Treatment Period: Week 9 to Week 52  
The following observations and examinations during Week 9 through to Week 52 will be 
conducted on the day of study treatment, as a general rule. In consideration of 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
48 
convenience for subjects and investigational sites, ± 3 days will be allowed. Subjects on 
dose interruption will also undergo the same observations and examinations. 
1) Vital signs (systolic blood pressure, diastolic blood pressure, and pulse rate) 
Timing of measurement: Every week before dosing AMG531 at Week 9 through to 
Week 52 
2) Hematology (WBC, RBC, Hb, Ht, MCV, MCH, MCHC, PLT, Ret and WBC with 
differential count) 
Timing of measurement: Every week before dosing AMG531 at Week 9 through to 
Week 52  
3) Serum chemistry (TP, ALB, T-Bil, D-Bil, AST, ALT, ALP, LDH, γ-GTP, T-Cho, UA, 
BUN, Cr, Na, K, Ca, P and Cl) 
Timing of measurement: Before dosing AMG531 at Week 9, 13, 17, 21, 25, 29, 33, 
37, 41, 45 and 49 
4) Blood iron-related parameter (ferritin) 
Timing of measurement: Before dosing AMG531 at Week 9, 13, 17, 21, 25, 29, 33, 
37, 41, 45 and 49 
5) Blood coagulation (D-dimer) 
Timing of measurement: Before dosing AMG531 at Week 9, 13, 17, 21, 25, 29, 33, 
37, 41, 45 and 49 
6) Bone marrow biopsy and aspiration with cytogenetics (M/E ratio, celluarity of bone 
marrow, reticulin grade (reticulin stain/trichrome stain (Appendix 1)), iron stain, 
narrative pathology report, cytogenetic report and exploratory test described in section 
3.3.4). 
Timing of measurement: Before dosing AMG531 at Week 25 ± 2 weeks 
7) Serum TPO concentration 
Timing of measurement: Before dosing AMG531 at Week 9 
8) Antibodies against AMG531 and TPO  
Timing of measurement: Before dosing AMG531 at Week 9, Week 25 and Week 41 
(Additional antibody test can be performed on subjects who show clinical findings 
suggested of possible antibody formation) 
9) Cytokine assay  
Timing of measurement: Before dosing AMG531 at Week 9 and Week 25 
10) 
GIMEMA bleeding scale (Appendix 3) 
Timing of measurement: Before dosing AMG531 at Week 9 and Week 25 
8.2.4  
Treatment Period: Week 53 to Week 156  
The following observations and examinations during Week 53 through to Week 156 will 
be conducted on the day of study treatment, as a general rule. In consideration of 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
49 
convenience for subjects and investigational sites, ± 3 days will be allowed. Subjects on 
dose interruption or tapering will also undergo the same observations and examinations. 
For those on dose discontinuation after achieving tri-lineage normal level for 8 
consecutive weeks without transfusion according to section 6.1.3.3 will be visiting site in 
every 2 weeks. 
1) Vital signs (systolic blood pressure, diastolic blood pressure, and pulse rate) 
Timing of measurement: Every week before dosing AMG531 at Week 53 through to 
Week 156 [For subjects on drug discontinuation: every 2 weeks before dosing 
AMG531 at Week 53 through to Week 156] 
2) Hematology (WBC, RBC, Hb, Ht, MCV, MCH, MCHC, PLT, Ret and WBC with 
differential count) 
Timing of measurement: Every week before dosing AMG531 at Week 53 through to 
Week 156 [For subjects on drug discontinuation: every 2 weeks before dosing 
AMG531 at Week 53 through to Week 156] 
3) Serum chemistry (TP, ALB, T-Bil, D-Bil, AST, ALT, ALP, LDH, γ-GTP, T-Cho, UA, 
BUN, Cr, Na, K, Ca, P and Cl) 
Timing of measurement: Every 4 weeks before dosing AMG531 at Week 53 through 
to Week 156 
4) Blood iron-related parameter (ferritin) 
Timing of measurement: Every 4 weeks before dosing AMG531 at Week 53 through 
to Week 156 
5) Blood coagulation (D-dimer) 
Timing of measurement: Every 4 weeks before dosing AMG531 at Week 53 through 
to Week 156 
6) 12-lead ECG 
Timing of measurement: Required only at Week53 before doing of AMG531 
7) Bone marrow biopsy and aspiration with cytogenetics (M/E ratio, celluarity of bone 
marrow, reticulin grade (reticulin stain/trichrome stain (Appendix 1)), iron stain, 
narrative pathology report, cytogenetic report and exploratory test described in section 
3.3.4). 
Timing of measurement: Before dosing AMG531 at Week 53, Week 77, Week 105, 
Week 129.  ± 2 weeks will be allowed. 
8) Serum TPO concentration 
Timing of measurement: Before dosing AMG531 at Week 53, Week105 
9) Antibodies against AMG531 and TPO  
Timing of measurement: Before dosing AMG531 at Week 57, Week 77, Week 105, 
Week 129 (Additional antibody test can be performed on subjects who show clinical 
findings suggested of possible antibody formation) 
10) 
GIMEMA bleeding scale (Appendix 3) 
Timing of measurement: Before dosing AMG531 at Week 53, Week 77, Week 105, 
Week 129 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
50 
8.2.5  
End of treatment: one week after last administration of AMG531 
All subjects who completed the study treatment will undergo the following observations, 
assessments and examinations one week after the last administration of AMG531. In 
consideration of convenience for subjects and investigational sites, ± 3 days will be 
allowed. 
Subjects exposed to AMG531 but terminated the study treatment earlier than scheduled 
will undergo the same observations, assessments and examinations one week after their 
last administration of AMG531. In consideration of convenience for subjects and 
investigational sites, ± 3 days will be allowed. 
1) Vital signs (systolic blood pressure, diastolic blood pressure, and pulse rate) 
2) Hematology (WBC, RBC, Hb, Ht, MCV, MCH, MCHC, PLT, Ret and WBC with 
differential count) 
3) Serum chemistry (TP, ALB, T-Bil, D-Bil, AST, ALT, ALP, LDH, γ-GTP, T-Cho, UA, 
BUN, Cr, Na, K, Ca, P and Cl) 
4) Blood iron-related parameter (ferritin) 
5) Blood coagulation (D-dimer) 
6) Bone marrow biopsy and aspiration with cytogenetics (M/E ratio, celluarity of bone 
marrow, reticulin grade (reticulin stain/trichrome stain (Appendix 1)), iron stain, 
narrative pathology report, cytogenetic report and exploratory test described in section 
3.3.4) (to be exempt for the patient withdrawn from the study within 11 weeks from 
the last bone marrow examination). Time window ± 2 weeks will be allowed. 
7) Serum AMG531 concentration (only at withdrawal in Week 8 or earlier) 
8) Serum TPO concentration 
9) Cytokine assay (To be required only for the patients withdrawn from the study before 
Week 53) 
10) 
GIMEMA bleeding scale (Appendix 3) 
11) 
12-Lead ECG 
8.2.6  
End of study: four weeks after last administration of AMG531 
All subjects should complete an end of study visit four weeks after their last 
administration of AMG531. In consideration of convenience for subjects and 
investigational sites, ± 3 days will be allowed. 
Subjects exposed to AMG531 but terminated the study treatment earlier than scheduled 
will undergo the same observations, assessments and examinations four weeks after their 
last administration of AMG531. In consideration of convenience for subjects and 
investigational sites, ± 3 days will be allowed. 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
51 
1) Vital signs (systolic blood pressure, diastolic blood pressure, and pulse rate) 
2) Hematology (WBC, RBC, Hb, Ht, MCV, MCH, MCHC, PLT, Ret and WBC with 
differential count) 
3) Serum chemistry (TP, ALB, T-Bil, D-Bil, AST, ALT, ALP, LDH, γ-GTP, T-Cho, UA, 
BUN, Cr, Na, K, Ca, P and Cl) 
4) Blood iron-related parameter (ferritin) 
5) Blood coagulation (D-dimer) 
6) Antibodies against AMG531 and TPO  
8.2.7  
Outcome surveillance for Survival, AML/MDS transformation, and 
cytogenetic abnormality 
All subjects received at least one dose of AMG531 will be assessed for the following 
parameters. The results of the survey will be reported using the outcome surveillance form 
(refer to Attachment 1 of the Study Protocol Supplement. 
1) Parameters 
– Survival (date of confirmation) or death (date and cause of death). 
– Presence or absence of cytogenetic abnormality (date of confirmation, 
cellularity of bone marrow, karyotype by cytogenetic report) 
– Presence or absence of fibrosis according to reticulin grade (reticulin 
stain/trichrome stain (Appendix 1)) 
– Presence or absence of AML or MDS transformation (date of initial diagnosis 
in case of presence, or date of last confirmation in case of absence) 
– Presence or absence of Hematopoietic Stem Cell Transplantation (date of 
transplantation, or the last date of confirmation in case of absence) 
2) Timing of assessment 
– Approximately 3 years after the initial administration of AMG531 and 
whenever required by the regulatory authority or investigators. 
9  ADVERSE EVENTS 
9.1 Definition of adverse events 
An adverse event (AE) is herein defined as any untoward medical occurrence in subjects 
received AMG531. An AE can therefore be any unfavorable or unintended sign (including 
an abnormal laboratory finding), symptom or disease, regardless of causal relationship to 
AMG531. An adverse drug reaction (ADR) is defined as any AE of which causal 
relationship to AMG531 cannot be ruled out (any events assessed to be other than 
“unlikely” or “not related”).  


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
52 
Laboratory results (hematology, serum chemistry, blood iron-related parameters, blood 
coagulation and fibrinolysis) will be evaluated for deviations (abnormalities) from normal 
range of each investigative site. In the event of an abnormal value (abnormal change), 
clinically significance of the abnormal change in comparison with baseline will be 
assessed. In consideration of pharmacological effects of AMG531, an increase in platelet, 
hemoglobin, reticulocyte, and/or neutrophil will be treated as abnormal only in the cases 
where the investigator considers it to be medically important.  
For signs, symptoms, and abnormal laboratory findings associated with a disease 
(diagnosed disease), the disease will be treated as an AE. If any atypical sign is observed 
in that disease, the sign will be treated as an individual AE.  
Observation period of both non-serious and serious adverse events will be the period 
between the start of study treatment through to the end of study visit or 4 weeks after the 
last administration of AMG531, whichever is longer.  However, any event reported as 
delayed toxicity or the like attributed the investigational product will be treated as an 
adverse event as well.  
9.1.1  
Definition of serious adverse events 
A serious adverse event (SAE) is any adverse event that: 
1) Results in death; 
2) Is life-threatening; 
3) Requires inpatient hospitalization or prolongation of existing hospitalization 
(excluding a hospitalization needed for medical examinations and a hospitalization 
planned before the start of the study); 
4) Results in disability/incapacity; 
5) Results in potential disability; 
6) Results in other conditions as important as 1) to 5); or 
7) Is a congenital anomaly/birth defect. 
9.1.2  
Definition of other significant adverse events 
Other significant AEs are defined as any events other than those reported as SAEs that 
lead a subject to treatment interruption, dose reduction or withdrawal. 
9.2 Safety assessment parameters 
For safety assessment, the following parameters will be investigated. 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
53 
The investigator will follow subjects with AEs until the event has recovered to the 
pretreatment level or archived the condition which is not clinically important, excluding 
the cases where the investigator considers that the safety of the relevant subject is 
sufficiently assured and further follow-up is not necessary. Any action taken for the AE 
during the follow-up will be recorded on the eCRF.  
1) Name of AE 
2) Date of onset 
3) Severity 
Severity will be graded using the 5-point scale, Common Terminology Criteria for 
Adverse Events (CTCAE) version 4.0. AEs to which the CTCAE severity scale is not 
applicable will be graded as described below:  
• Grade 1: Mild; asymptomatic or mild symptoms; clinical or diagnostic observations 
only; intervention not indicated. 
• Grade 2: Moderate; minimal local or noninvasive intervention indicated; limiting 
age-appropriate instrumental active daily living (preparing meals, shopping for 
groceries or clothes, using the telephone, managing money, etc). 
• Grade 3: Severe or medically significant but not immediately life-threatening; 
hospitalization or prolongation of hospitalization indicated; disabling; limiting self 
care active daily living (bathing, dressing and undressing, self feeding, using the 
toilet, taking medications, and not bedridden). 
• Grade 4: Life-threatening consequences; urgent intervention indicated. 
• Grade 5: Death related to AE 
4) Seriousness 
• Serious: Events defined in Section 9.1.1. 
• Non-serious: Events other than those defined in Section 9.1.1. 
5) Actions taken for the study treatment 
• None/not applicable 
• Dose reduced 
• Dose interrupted 
• Discontinued 
6) Other actions taken 
• None 
• Other medication prescribed or concomitant medication changed, etc. 
7) Outcome 
• Resolved/recovered 
• Resolving/recovering 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
54 
• Not resolved/not recovered 
• Resolved/recovered with squeal 
• Death 
• Unknown 
8) Date of outcome assessment 
9) Causal relationship to investigational product 
Causal relationship to investigational product will be determined using the 
following 5-point scale.  
• Certain 
• Probable 
• Possible 
• Unlikely 
• Not related 
9.3 Actions to be taken on occurrence of an adverse event and follow-up 
9.3.1  
Actions for Subjects 
If an AE occurs, the investigator will take appropriate actions as needed, including 
providing proper medical care and discontinuing study treatment in order to ensure the 
subject’s safety. 
9.3.2  
Notification to the concerned parties (reporting to relevant 
personnel) 
9.3.2.1  Serious adverse event 
1) If a SAE occurs, regardless of the causal relationship with AMG531, the investigator 
will immediately (within 24 hours of the investigator becoming aware of the event) 
notify the sponsor or the designee in person or by phone, e-mail, or fax (using the 
SAE Report or a form prescribed by the investigative site) and will promptly (within 7 
days of the investigator becoming aware of the event) submit a detailed written report 
to the sponsor or the designee and the IRB. When reporting to the IRB, unexpected 
serious adverse reactions should be identified. 
2) The investigator is obligated to pursue and provide additional information upon 
request from the sponsor or the designee, the directors of investigative sites and the 
IRB. 
3) The director of the investigative site will discuss with the IRB whether to continue the 
study at their site, if applicable. 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
55 
4) In the case of serious and unexpected ADRs that are fatal or life-threatening, the 
sponsor or the designee should expedite the report to all concerned investigators, to 
the IRBs where required, and to the regulatory authorities within 7 days after first 
knowledge by the sponsor. Serious, unexpected reactions (ADRs) that are not fatal or 
life-threatening must be filed within 15 days after first knowledge by the sponsor. 
9.3.2.2  Non-serious adverse events 
If a noteworthy but non-serious AE occurs, the investigator will promptly provide the 
sponsor with a description of the event and the action taken. Other adverse events will be 
recorded in the eCRF. 
9.3.3  
Follow-up of adverse events 
The investigator will follow subjects with AEs until the event has recovered to the 
pretreatment level or archived the condition which is not clinically important, excluding 
the cases where the investigator considers that the safety of the relevant subject is 
sufficiently assured and further follow-up is not necessary. Any action taken for the AEs 
during the follow-up will be recorded in the eCRF. 
10 MANAGEMENT OF SUBJECTS; MEASURE FOR PATIENTS’ 
SAFETY PROTECTION 
10.1 Notification to other departments/hospitals 
The investigator will check with the subject if he/she is scheduled to receive medical care 
or medications at any other department/hospital. If this is the case, the investigator will 
notify the relevant physician that the subject will participate in the clinical study. The 
investigator will identify the name of any medication that the subject has received other 
than those prescribed by the investigator as well as how it has been used. If the subject 
received platelet and/or RBC transfusion at any other department/hospital, investigations 
should be made in the same manner. 
If the subject is newly receives medical care or medication at any other 
department/hospital during the study, the investigator will take actions same as above. 
10.2 Contraception 
Women of childbearing potential will be instructed to use one or more reliable methods of 
contraception (including condoms) throughout the study.  


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
56 
If the subject becomes pregnant or wants to have children during the study, the subject 
will be immediately withdrawn from the study. 
10.3 Others  
The eligibility of the subject to participate in the study will be strictly assessed through 
the screening test.  
In addition, the study will be conducted in compliance with the study protocol, and the 
occurrence and severity of AEs and ADRs will be monitored throughout the study period 
and the appropriate actions will be taken when needed for the protection of subjects.    
11 STOPPING RULES AND PROCEDURES 
11.1 Subject withdrawal 
11.1.1 
Criteria for subject withdrawal 
Any of the following circumstances will result in the subject being withdrawn from the 
study: 
1) The subject is found to be ineligible for participation in this study due to violations in 
the inclusion or exclusion criteria specified in the study protocol; 
2) The subject decides to discontinue his/her participation in the study; 
3) The subject becomes unable to undergo necessary observations or examinations; 
4) The subject who does not achieve a platelet response after 8-week treatment with 
AMG531 20 μg/kg QW; 
5) The investigator considers that the subject should be withdrawn from the study due to 
an adverse event (including progression of the primary disease); 
6) The subject received any of the prohibited concomitant medications or treatments; 
7) The subject becomes pregnant or wants to have children during the study;  
8) The investigator assesses that the subject needs to be withdrawn from the study for 
any reason not specified above. 
9) The subject who does not meet the entry criteria for long-term treatment period 
11.1.2 Procedure for subject withdrawal 
If a subject is withdrawn from the study because of safety issues including occurrence of 
an adverse event, the investigator will provide appropriate treatment for the subject. For 
each subject withdrawn from the study, the investigator will check up the safety and 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
57 
conduct  the end of treatment and end of study procedures described in section 8.2.5 and 
8.2.6 at withdrawal and follow him/her up as necessary until further monitoring is 
considered to be not required. If subject is withdrawn from the study due to safety issues 
and cannot conduct the scheduled end of treatment and end of study procedures, the end 
of treatment and end of study procedures described in section 8.2.5 and 8.2.6 will be 
conducted as soon as the study termination is decided. It is recommended that subjects 
withdrawn consent also return to the physician’s office for the end of treatment and end of 
study examination for follow up. 
Date and the reasons of study withdrawal, any medications given for the treatment during 
the follow up period, etc. will be recorded in the eCRF. 
11.2 Premature termination or suspension of the study at a specific 
investigative site 
If the investigator prematurely terminates or suspends the study at his/her site due to 
concerns over the safety of investigational product or for any other reason, the 
investigator will promptly notify the sponsor and IRB in writing, with a written detailed 
explanation. Also, if the investigative site’s IRB says that the study should not be 
continued, the investigator will promptly notify the sponsor in writing, with a written 
detailed explanation on the study termination or suspension. The investigative site has 
major or continuous violations of GCP, the protocol or the clinical study agreements, the 
study will be prematurely terminated at the site. In such event, appropriate actions will be 
taken in the same manner to the above. 
11.3 Premature termination or suspension of the entire study 
When the entire study needs to be prematurely terminated or suspended, the sponsor will 
promptly inform all investigators, IRB, and the regulatory agency with a detailed 
explanation of the reason. When the study is prematurely terminated or suspended, the 
investigator will promptly brief subjects and take necessary measures including providing 
appropriate medical care. 
12 STATISTICAL ANALYSIS 
12.1 Statistical methods 
Generally, categorical variables will be summarized by the number of subjects and the 
percentage of subjects in each category to the total number of subjects, and continuous 
variables will be summarized by descriptive statistics (number of subjects, mean, standard 
deviation, median, minimum, and maximum). Coefficient of variation and geometric 
mean will be also presented to summarize pharmacokinetic parameters. 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
58 
Data will be cut off, collected and analyzed when all subjects complete the observations at 
week 17.  
12.1.1 Efficacy 
Platelet count measured within 7 days after platelet transfusion will not be subjected to the 
efficacy assessment. Likewise, hemoglobin concentrations determined within 28 days 
after RBC transfusion will not be subjected to the efficacy assessment. Neutrophil counts 
determined within 7 days of G-CSF as a rescue medication will not be used for the 
efficacy assessment.  
Platelet count, hemoglobin concentrations and neutrophil counts determined in occasions 
other than in the scheduled visit in this study, including ordinary medical examinations 
and follow-up, will not be used for efficacy assessment.   
12.1.1.1 Primary endpoint 
The primary endpoints will be evaluated based on the Per Protocol Set (PPS). The 
proportion of subjects achieving a platelet response at Week 9, and two-sided 95% 
confidence interval will be calculated. Platelet response is defined as 1) achieving 
absolute platelet increase of ≥ 20x109/L above baseline or 2) increase to ≥ 10x10
9/L and 
by at least 100% from baseline.  
Robustness of the results will be evaluated by the analysis calculated in the same manner 
based on the full analysis set (FAS).  
12.1.1.2 Secondary endpoint 
The secondary endpoint will be evaluated based on the PPS. The proportion of subjects 
with a platelet response in any time during the initial dose evaluation period, Week1 
through Week 12, Week 1 through Week 16, Week 1 through Week 24, and Week 1 
through Week 52 or the proportion of subjects achieving platelet transfusion 
independency during the initial dose evaluation period, Week1 through Week 12, Week 1 
through Week 16, Week 1 through Week 24, Week 1 through Week 52, Week 1 through 
Week 104, and Week1 through Week 156 will be calculated in the same manner as the 
primary variables. Platelet transfusion independence is defined as achieving transfusion 
free period of at least 8 consecutive weeks.  
The proportion of subjects with erythroid and/or neutrophil response during the initial 
dose evaluation period as well as in Week1 through Week 12, Week 1 through Week 16, 
Week1 through Week 24, Week 1 through Week 52, Week 1 through Week 104, and in 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
59 
Week1 through Week 156 will be calculated in the same manner as the primary variables. 
An erythroid response is defined as achieving an increase in hemoglobin concentration of 
≥ 1.5 g/dL above baseline without transfusion or reduction in the transfusion unit by at 
least 4 units for 8 consecutive weeks compared with the pretreatment transfusion 
requirement in the previous 8 weeks prior to the first administration of AMG531 (Day -55 
to Day 1). A neutrophil response is defined in those with ANC of < 0.5x109/L as a 100% 
increase over the baseline, or an increase in ANC of > 0.5x10
9/L in subjects with a 
pretreatment ANC of < 1.0x109/L. 
Time to platelet response and duration of platelet response will be summarized.  
The change in platelet counts, hemoglobin concentrations, and neutrophil counts from 
baseline will be summarized at each scheduled visit. For the transfusion, only the platelet 
transfusion given due to platelet count of < 10x10
9/L (prophylactic transfusion) or due to  
bleeding (therapeutic transfusion) and RBC transfusions of which hemoglobin 
concentration is ≤ 9.0 g/dL or due to symptomatic anemia will be included in the response 
assessment.  
The changes in bone marrow celluarity and reticulin grade will be summarized by each 
subject based on the test reports. The changes in the GIMEMA bleeding scale will be 
summarized.  
Tri-lineage response is defined in those achieving platelet response, erythroid response, 
and neutrophil response all together. The proportion of subjects with tri-lineage response 
will be calculated in the same manner as the primary variables. Time to tri-lineage 
response will be summarized. 
The proportion of subjects who achieved normal level for 8 consecutive weeks, who 
started tapering, and who discontinued study drug will be calculated. Time to achieving 
normal level for 8 consecutive weeks (the initial day of the period), to starting tapering, to 
discontinuing study drug as a result of tapering will be summarized. 
Longest duration of drug discontinuation in subjects while maintaining stable response 
will be summarized. 
Robustness of the results will be evaluated by the analysis calculated in the same manner 
based on the FAS. 
12.1.2 Pharmacokinetics 
1) Serum AMG531 concentration 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
60 
Serum AMG531 concentration will be summarized by descriptive statistics for each dose 
group at each sampling point. Time course of the serum concentrations of AMG531 will 
be presented in a chart. 
2) Pharmacokinetic parameters 
Pharmacokinetic parameters (including Tmax, C
max, AUC
0-t) will be calculated for each 
subject and summarized by descriptive statistics for each dose group. Dose proportionality 
will be also assessed. 
12.1.3 Safety 
All AEs will be tabulated by MedDRA Preferred Terms (PTs) and System Organ Classes 
(SOCs) and number as well as percentage of subjects with each AE will be calculated by 
dose group. ADRs will be summarized in the same manner. All AEs will be graded with 
CTCAE ver.4.0 and number and percentage of subjects for each AE will be calculated.  
All AEs occurred during the initial dose evaluation period will be separately summarized 
and analyzed as above. 
Laboratory tests and vital signs will be summarized by descriptive statistics for all 
examination points of each dose group.  
A listing of subjects with positive antibody against AMG531, TPO and TMPwill be 
summarized by antibody expression. 
12.1.4 
Additional analyses 
Additional exploratory analyses of the data will be performed as deemed to be appropriate. 
12.2 Level of significance 
Level of significance is not specified, since no statistical assumptions are provided in this 
study.  
12.3 Stopping rules for the study 
No stopping rules based on statistical evidence are specified. 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
61 
12.4 Handling of missing, unused, and abnormal data 
Any missing data on platelet, hemoglobin, and neutrophil for evaluating efficacy response 
will be handled as a missing value and will not be imputed with an alternative value using 
a statistical approach.  
If data from a particular subject needs to be examined how to handle them because of an 
event unexpected at the start of the study, how to treat such data will be decided before 
database lock. 
12.5 Development of the statistical analysis plan and procedure for 
reporting deviations from the original statistical analysis plan 
The detailed statistical analysis plan including the analyses described in this section will 
be finalized before database lock. Any major change to the statistical analysis plan will be 
described in the clinical study report. 
12.6 Analysis Subsets 
The analysis sets are defined below. For efficacy analysis, PPS and FAS will be used, 
with PPS as the primary analysis set.  
Whether or not to include each subject in a particular set will be determined before 
database lock. 
12.6.1 Full Analysis Set (FAS) 
Efficacy will be assessed in the subjects of FAS who meet all of the following criteria:  
• Subjects received at least one dose of AMG531; and 
• Subjects whose platelet count is measured before and at least one point after dosing 
AMG531. 
12.6.2 Per Protocol Set (PPS) 
Efficacy will be assessed in the population of PPS comprised of subjects of FAS who 
meet all the following criteria. PPS is the primary efficacy analysis set. 
• Subjects who meet all of the inclusion criteria and none of the exclusion criteria;  
• Subjects who have received ≥ 6 times of the specified dose (dose interruption 
according to the dose discontinuation criteria (section 6.1.3) will be considered as 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
62 
being dosed but dose interruption due to SAE will not be considered as being dosed) 
in the initial dose evaluation period; and  
• Subjects with no major violations of the study protocol in the initial dose evaluation 
period. 
12.6.3 Pharmacokinetic analysis set 
Pharmacokinetics will be evaluated in the subjects whose serum AMG531 concentrations 
are measured and who meet all of the following criteria: 
• Subjects received at least one dose of AMG531; and 
• Subjects whose at least one pharmacokinetic parameter is calculable. 
12.6.4 Safety analysis set 
Safety will be assessed in the subjects of safety analysis set who meet the following 
criterion: 
• Subjects received at least one dose of AMG531. 
13 ETHICS  
13.1 Regulatory considerations 
The study will be conducted in accordance with ethical principles that have their origin in 
the Declaration of Helsinki and are consistent with the ICH guidelines on GCP, any 
applicable laws and requirements, and any conditions required by a regulatory authority 
and/or IRB that approves this study to be conducted in its territory. Good clinical practice 
is defined as a standard for the design, conduct, performance, monitoring, auditing, 
recording, analysis, and reporting of clinical studies in a way that provides assurance that 
the data and reported results are credible and accurate, and that the rights, safety, and 
well-being of study subjects are protected. 
Per GCP, the protocol will be reviewed and approved by the IRB of each participating 
center prior to study initiation. Serious adverse events regardless of causality will be 
reported to the sponsor, and the investigator will keep the IRB informed as to the progress 
of the study. 
The investigator will explain the nature of the study and will inform the subject that 
participation is voluntary and that the subject can withdraw or be withdrawn from the 
study at any time. Written informed consent will be obtained from each subject prior to 
the screening procedures to determine if study eligibility criteria are met. A copy of the 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
63 
signed consent form will be given to every subject, and the original will be maintained 
with the subject’s records. 
13.2 Institutional Review Board 
A list of IRB members or a Statement of GCP Compliance should be obtained by the 
investigator and provided to the sponsor. 
Any documents that the IRB may need to fulfill its responsibilities, such as protocol 
amendments, and information concerning subject recruitment, payment, or compensation 
procedures, or information from the sponsor will be submitted to the IRB. The IRB’s 
written unconditional approval of the study protocol, the informed consent form(s), and 
any other written materials to be provided to subjects will be in the possession of the 
investigator and the sponsor before the study is initiated. The IRB’s unconditional 
approval statement will be transmitted by the investigator to the sponsor prior to shipment 
of investigational product supplies to the investigative site. This approval must refer to the 
study by exact protocol title and number, and should identify the documents reviewed and 
the date of review. 
Protocol modifications or changes may not be initiated without prior written IRB approval 
except when necessary to eliminate immediate hazards to the subjects or when the 
change(s) involves only logistical or administrative aspects of the study. Such 
modifications will be submitted to the IRB and written verification that the modification 
was submitted should be obtained. 
The IRB must be informed by the investigator of informed consent form changes or 
revisions of other documents originally submitted for review; serious and/or unexpected 
adverse experiences occurring during the study; new information that may affect 
adversely the safety of the subjects or the conduct of the study; an annual update and/or 
request for reapproval; and when the study has been completed. 
13.3 Informed Consent 
Freely given informed consent will be obtained and documented for all subjects under this 
protocol in accordance with ethical principles that have their origin in the Declaration of 
Helsinki and are consistent with the ICH guidelines on GCP, any applicable laws and 
requirements, and any conditions required by a Regulatory Authority and/or IRB. 
Information should be given in both oral and written form, and subjects must be given 
ample opportunity to inquire about details of the study. 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
64 
The consent form(s) generated by the investigator must be approved by the IRB and be 
acceptable to the sponsor. Consent forms must be written so as to be understood by the 
prospective subject. Informed consent will be documented by the use of a written consent 
form(s) approved by the IRB and signed and dated by the subject, and by the person who 
conducted the informed consent discussion. The signature confirms the consent is based 
on information that has been understood. Each subject’s signed informed consent form(s) 
must be kept on file by the investigator for possible inspection by the sponsor or its 
designated monitors, auditors, or regulatory agency representatives. The subject should 
receive a copy of the signed and dated written informed consent form(s) and any other 
written information provided to the subject, and should receive copies of any signed and 
dated consent form updates and any amendments to the written information provided to 
subjects. 
14 FINANCING AND INSURANCE 
Financing and insurance are detailed in the individual site contracts. 
15 PROTOCOL DEVIATIONS 
The investigator should notify the IRB and the sponsor of deviations from the protocol in 
accordance with local regulation/procedures. 
The investigator should conduct the study in compliance with the protocol agreed to by 
the sponsor and, if required, by the regulatory authority, and which was given 
approval/favorable opinion by the IRB. 
A deviation to any protocol procedure or waiver to any stated criteria will not be allowed 
in this study except where necessary to eliminate immediate hazard(s) to the subject. The 
sponsor must be notified of all intended or unintended deviations to the protocol (e.g., 
inclusion/exclusion criteria, missed study visits) on an expedited basis. 
The investigator, or person designated by the investigator, should document and explain 
any deviation from the approved protocol. 
Any data recorded in eCRF will be collected and included in the database. If a subject was 
ineligible or received the incorrect dose or investigational treatment, and had at least one 
administration of investigational product, data should be collected for safety purposes. 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
65 
16 DATA MANAGEMENT 
Appropriately validated standard computer systems will be used by the sponsor involved 
in this study. 
The Electronic Data Capture (EDC) system is to provide investigative sites with the 
functions for entering data directly in eCRFs, for querying inconsistent data, for 
answering queries on entered information from the sponsor, and for electronic signature. 
The entered information will be coded and sent to the EDC server via the Internet.  
The investigator will sign the eCRF via the EDC system’s electronic signature. These 
signatures will indicate that the investigator inspected or reviewed the data on the eCRF, 
the data queries, and the site notifications, and agrees with the content. 
Instructions will be provided for the completion of the eCRF and any corrections made 
will be automatically documented via the EDC software’s “audit trail”. 
17 DIRECT ACCESS TO SOURCE DOCUMENTS 
The study will be monitored by the sponsor on a regular basis throughout the study period. 
During monitoring visits, the investigator will provide direct access to all source 
documentation relevant to the subject’s participation in the study. Source documentation 
includes, but is not limited to, the subject’s clinic and/or office chart, hospital chart, 
informed consent forms, treatment notes, laboratory reports, pharmacy records, 
radiographs, recorded data from automated instruments, and any other records maintained 
to conduct and evaluate the clinical study. The investigator must also ensure that direct 
access to study documents be made available for study-related audits, IRB review, or 
regulatory inspection. 
18 QUALITY CONTROL AND QUALITY ASSURANCE 
18.1 Data collection 
As part of the responsibilities assumed by participating in the study, the investigator 
agrees to maintain adequate and accurate case histories for the subjects treated under this 
protocol. 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
66 
Case histories include CRFs and supporting data including, but not limited to, signed and 
dated informed consent forms, progress notes, hospital charts, nurse’s notes, diary cards, 
laboratory reports, ECG strips, etc. 
Subject demographics and key/essential disease baseline characteristics thought to affect 
outcome, i.e., stratification variables and other prognostic factors, will be collected, as 
available, for all subjects who provide written informed consent. For subjects who provide 
informed consent and were not entered/randomized into the study, the reason the subject 
was not entered/randomized, i.e., did not meet one or more inclusion criteria, met one or 
more exclusion criteria, or other (e.g., lost to follow-up, consent withdrawn), will also be 
collected. 
18.2 Study monitoring 
The primary source document for this study will be the subject’s medical record. If 
separate research records are maintained by the investigator, both the medical records and 
the research records will be monitored/audited for the purposes of the study. 
The investigator and institutions involved in the study will permit study-related 
monitoring and provide direct access to all study records and facilities. Adequate time and 
space for monitoring visits should be made by the investigator or other investigative site 
staff. 
The monitor will visit study facilities at periodic intervals, in addition to maintaining 
necessary contact through telephone, e-mail, and letter. The monitor will assess subject 
enrollment and informed consent procedures; investigational product storage, dispensing, 
administration and accountability; compliance with protocol procedures; completeness 
and accuracy of data entered onto validated data collection instruments (paper CRF of 
electronic data screen) against original source documents; and the occurrence of 
AEs/SAEs. All aspects of the study will be carefully monitored for compliance with the 
protocol, applicable regulatory requirements, GCP, and the site’s standard operating 
procedures. 
The monitor will discuss the conduct and progress of the study with the investigator and 
other site staff. The investigator must cooperate with the monitor to ensure that corrective 
action is taken to resolve any problems noted in the course of the monitoring, and that the 
preventative measures are put into place to prevent recurrence of issues. In cases where 
compliance is not achieved, shipment(s) of investigational product to the investigator will 
be discontinued and study participation by that investigator will be terminated. 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
67 
18.3 Audit and inspection of the study 
During the conduct of the study, the sponsor or its representative may conduct audits of 
any data and any facility participating in the study. The investigator and institutions 
involved in the study will permit such study-related audits and provide direct access to all 
study records and facilities. The investigator must maintain a comprehensive and 
centralized filing system of all study-related documentation that is suitable for inspection 
by the sponsor or its designated monitors, auditors, IRB/IEC, or regulatory agency 
representatives. The investigator agrees to participate in audits conducted at a convenient 
time in a reasonable manner. 
Government regulatory authorities from any of the country where the study is conducted 
may also perform inspections either during or after the study. In the event of an inspection 
by any regulatory authority, the investigator should promptly notify the sponsor. The 
investigator agrees to cooperate fully with inspections conducted by regulatory authorities 
and to allow representatives of the regulatory authority access to all study records. The 
investigator will forward to the sponsor a copy of any inspection records received. 
19 PLANNED STUDY PERIOD 
January 2014 to March 2018 
20 END OF THE STUDY 
The end of the study (“study completion”) is defined as the date of the last protocol-
specified visit/assessment for all subjects in the study. All materials or supplies provided 
by the sponsor will be returned to the sponsor upon study completion. The investigator 
will notify the IRB when the study has been completed. 
21 RECORD KEEPING 
Study documents (including subject records, copies of data submitted to the sponsor, 
study notebook, and pharmacy records) must be kept secured until the date when relevant 
regulations stipulate in Japan or South Korea, whichever comes later. If the documents 
should be retained for a longer period than the regulation of the country where the 
organization exists, the sponsor will discuss the duration and method of archiving with the 
organization in responsible for archiving. The sponsor will inform the organization as to 
when these documents no longer need to be retained. 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
68 
22 PUBLICATION POLICY 
Publication by investigative site of any data from this study must be carried out with prior 
agreement of the sponsor. 








 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
72 
APPENDICES/ATTACHMENTS 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
73 
Appendix 1 
 
 
MODIFIED BAUERMEISTER GRADING SCALE FOR RETICULIN* 
 
 
Grade 
Quantification of bone marrow reticulin and collagen 
0 
No reticulin fibers demonstrable 
1 
Occasional fine individual fibers and foci of a fine fiber network 
2 
Fine fiber network throughout most of the section; no coarse fibers 
3 
Diffuse fiber network with scattered thick coarse fibers but no mature collagen 
(negative to trichrome staining) 
4 
Diffuse, often coarse fiber network with areas of collagenization (positive 
trichrome staining) 
*  Adopted from Bauermeister, 1971; Bain et al, 2001  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
74 
Appendix 2 
 
 
APLASTIC ANEMIA WITH SEVERITY CRITERIA* 
 
 
 
Classification 
Criteria 
Severe 
BM cellularity < 25% (or < 50% if < 30% of BM is hematopoietic cells) 
AND ≥ 2 of the following: 
• Peripheral blood neutrophil count < 0.5x109/L 
• Peripheral blood platelet count < 20x109/L 
• Peripheral blood reticulocyte count < 20x109/L 
Very severe 
As above, but peripheral blood neutrophil count 
must be < 0.2x109/L 
Nonsevere 
Hypocellullar BM with peripheral blood values not 
meeting criteria for severe aplastic anemia 
*  Adopted from Guinan, 2011. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
Master Ver 3.1_20Dec2016 
 
Confidential 
75 
Appendix 3 
 
 
GIMEMA BLEEDING SCALE* 
 
 
 
Grade 
Definition 
0 
No bleeding 
1 
Petechiae or mucosal bleeding, not requiring 
intervention 
2  
Melena, hematemesis, hematuria, hemoptysis 
3  
Bleeding requiring red blood cell transfusion 
4 
Retinal bleeding with visual impairment 
5 
Non-fatal cerebral bleeding 
6 
Fatal cerebral bleeding 
7 
Fatal non-cerebral bleeding 
    * Adopted and modified from Rubella et al., 1997