Clinical trial NCT03748992
Conditions: Nontuberculous Mycobacterium Infection
Sponsor: Medical University of South Carolina
Start date: 2019-01-28; Completion date: 2020-03-26
Enrollment: 10 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
The purpose of this study is to evaluate the efficacy and safety of open-label exposure of gNO in patients with NTM lung disease. Subjects will receive the study drug by inhaling through a nasal mask. Subjects will be treated for 3 weeks (5 days per week) and followed monthly for 3 months.

Detailed description:

Arms: arm 1: Subjects will be receiving nitric oxide every week day for 3 weeks.
Interventions: intervention 1: gNO
Intervention descriptions: intervention 1: This is a proof-of-concept study in which all subjects will be treated with gNO (i.e. no control) to see if there can be a microbiological effect by conversion to negative sputum cultures and how long that effect can be sustained following treatment.

Participants will be treated for 3 weeks (5 days per week), Monday through Friday, and followed monthly for 3 months.

The treatment period includes a physical exam, vital signs, blood tests, echocardiogram, spirometry test, sputum sample, questionnaires, and the inhalation gas treatment. During the inhalation gas treatment, participants will wear a face mask (similar to an oxygen mask) and will be given nitric oxide gas through the participants nose for three treatments with fifty minutes each time. They will then be followed up monthly during the Follow-up period with tests that include a physical exam and questionnaires.

Protocol documents:
Prot_SAP_000.pdf: 
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1 
TITLE PAGE 
MEDICAL UNIVERSITY OF SOUTH CAROLINA 
Study Protocol 
A Proof of Concept Study of Inhaled Nitric Oxide for Adults 
with Pulmonary Non-Tuberculous Mycobacterial Infection 
IND Number: 140649  
Date and Version of Protocol: October 01, 2019 
(Version 3.0) 
NCT #:  03748992
IRB approved on 18SEP2018


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2 
PROTOCOL SYNOPSIS 
Title 
A Proof of Concept Study of Inhaled Gaseous Nitric Oxide (gNO) for 
Adults with Pulmonary Non-Tuberculous Mycobacterial (NTM) Infection 
Clinical Phase 
Phase 2 
Objective 
To evaluate the efficacy and safety of open-label exposure of gNO in 
patients with NTM lung disease 
Endpoints 
Primary 
•
Culture growth (positive or negative) at end of treatment (EOT)
compared to baseline
Secondary 
•
Safety and tolerability assessments based on adverse events (AEs),
clinical values (i.e., methemoglobin levels)
•
Semiquantitative mycobacterial culture results comparing EOT to
baseline
Exploratory 
•
Time to positive mycobacterial cultures comparing EOT to baseline
•
Measures of systemic inflammation comparing EOT to baseline
•
Absolute change in quality of life scores from baseline to EOT
Study Population 
Adult subjects with NTM lung disease and persistently positive 
mycobacterial sputum cultures 
Number of Subjects 
10 
Number of sites 
2 
Study Duration 
Subjects will be treated for 3 weeks (5 days per week) and followed 
monthly for 3 months 
Study Design 
This 2 study is designed to evaluate the efficacy and safety of open-label 
gNO treatment in subjects with NTM lung disease and persistently positive 
sputum cultures growing NTM.  This is a proof-of-concept study in which 
all subjects will be treated with gNO (i.e. no control) to see if there can be a 
microbiological effect by conversion to negative sputum cultures and how 
long that effect can be sustained following treatment. In addition, this study 
will assess the feasibility of such a treatment course in this patient 
population and measure relevant clinical outcomes (e.g. cough, quality of 
life).  Subjects will provide sputum for culture at baseline, weekly during 
treatment, and monthly for 3 months following treatment to assess if there 
is persistence of infection in cultures.  Safety measures will include 
monitoring of arterial oxygen saturation and methemoglobin levels. All 
serious and non-serious adverse events will be collected 
Assessments 
•
Feasibility: ability to recruit subjects, ability to complete the planned
treatment, and assessment of their experience and willingness to
undergo this therapy
•
Efficacy: sputum cultures (mycobacteria), symptom scores (cough,
quality of life)
•
Safety: AEs, clinical monitoring assessments (pulse oximetry), vital
signs, and physical examinations
Statistical Analyses 
Data will be summarized descriptively for each subject.  The overall 
response rates (culture conversion short and long term) will be calculated 
after each patient has completed the trial, and exact binomial confidence 
intervals will be constructed. 


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3 
SCHEDULE OF ASSESSMENTS 
Table 3-1: Schedule of Assessments 
Screening 
Treatment Period 
Follow up Period 
Visit 
S 
A1 
A2-4 
A5 
B1 
B2-4 
B5 
C1 
C1-4 
C5 
F1 
F2 
F3 
Day 
-28--14
1 
2-4
5 
8 
9-11
12 
15 
16-18
19 
W7 
W11 
W15 
Informed 
consent 
x 
Medical history 
x 
Demographicsa 
x 
Physical 
examination 
x 
x 
x 
x 
x 
x 
x 
Height and 
weight 
x 
x 
x 
x 
x 
x 
Vital signs 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Symptom scoreb 
x 
x 
x 
x 
x 
x 
x 
Safety labsc 
x 
x 
CRP 
x 
x 
Spirometryd 
x 
xd 
xd 
xd 
Sputum culturese 
x 
x 
x 
x 
x 
x 
x 
Echocardiogram 
x 
Pulse oximetry 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
MetHb 
measurement 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
gNO dosing 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Adverse events 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Concomitant 
medications 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
a
Demographics include sex, race, and age. Baseline characteristics include diagnosis, and if 
CF include CFTR genotype 
b
Symptom scores will include cough score (Leicester), quality of life (SGRQ, CFQ-R, QOL-
B), as appropriate for the underlying diagnosis (i.e. CF subjects will complete the CFQ-R 
and SGRQ; other subjects will complete the QOL-B and SGRQ) 
c
Safety labs include comprehensive metabolic panel (to include creatinine, AST, ALP, ALT 
and chemistry), complete blood cell count with differential, GGT, PT/INR, 6-GPD level, 
and urine pregnancy test (if applicable) 
d
Spirometry will be performed pre and post first treatment of the day 
e
Sputum will be tested for bacteria and mycobacteria (including AFB smear and culture).  
Susceptibility testing will not be performed 


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4 
TABLE OF CONTENTS 
1 Title Page 
1 
2 Protocol Synopsis  
2 
3 Schedule of Assessments 
3 
4 Table of Contents 
4 
List of Tables 
7 
5 List of Abbreviations  
8 
6 Introduction 
9 
Overview of NTM lung disease  
9 
Overview of gNO and Rationale for Study  
9 
7 Study Objective s 
11 
8 Study Endpoints 
11 
9 Study Design 
11 
9.1 
Overview of Study Design 
11 
9.1.1 Screening 
11 
9.1.2 Treatment Period 
12 
9.1.3 Follow up Months 1-3 
12 
9.2 
Rationale for Study Design 
12 
10 Selection of Study Population  
13 
10.1 
Inclusion Criteria  
13 
10.2 
Exclusion Criteria 
13 
11 Dosing of Study Drug 
14 
11.1 
General dosing information 
14 
11.2 
Dosing information 
14 
11.3 
Dosage administration 
14 
12 Assessments 
15 
12.1 
Timing of Assessments 
15 
12.2.1 Subject and Disease Characteristics  
15 
12.2.2 Physical examination 
15 
12.2.3 Vital signs 
16 
12.2.4 Oxygen saturation 
16 
12.2.5 Methemoglobin 
16 
12.2.6 Prior and Concomitant Medications 
16 
12.3 
Safety 
16 
12.3.1 Adverse Events  
16 
12.4.1 Sputum cultures 
16 
12.5.1 Quality of life measures 
16 
13 Discontinuation or withdrawal from treatment 
17 
13.1 
Discontinuation of an inhalation period 
17 
13.2 
Withdrawal from the study 
17 
14 Statistical and Analytical Plans  
18 
14.1 
Sample Size  
18 
14.2 
Statistical Analyses  
18 
14.3.1 
Background Characteristics 
18 
14.3.1.1 Subject Disposition  
18 
14.3.1.2 Demographics and Baseline Characteristics  
18 


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14.3.1.3 Prior and Concomitant Medications 
18 
14.3.2 
Efficacy Analysis 
19 
14.3.3 
Safety Analysis  
19 
14.3.3.1 Adverse Events 
19 
14.4 
Interim Analyses 
19 
15 Procedural, Ethical, Regulatory, and Administrative Considerations 
18 
15.1 
Adverse Event and Serious Adverse Event Documentation and Reporting 
19 
15.1.1 
Definition of an Adverse Event  
19 
15.1.2 
Definition of a Serious Adverse Event  
19 
15.1.3 
Documentation of Adverse Events  
19 
15.1.4 
Adverse Event Causality  
20 
15.1.5 
Adverse Event Outcome 
20 
15.1.6 
Reporting Procedure for Adverse Events and Pregnancy 
20 
15.2 
Administrative Requirements  
20 
15.2.1 
Ethical Considerations 
20 
15.2.2 
Subject Information and Informed Consent  
21 
15.2.3 
Investigator Compliance 
21 
15.2.4 
Access to Records 
21 
15.2.5 
Subject Privacy  
21 
15.2.6 
Record Retention  
21 
15.3 
Data Quality Assurance  
21 
15.4 
Data Capture  
22 
15.5 
Publications and Clinical Study Report 
22 
15.5.1 
Publication of Study Results 
22 
15.5.2 
Study Report  
22 
16 References 
23 


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List of Tables 
Table 3-1 
Schedule of Assessments  
3 
Table 15-1 
Classifications for Adverse Event Causality 
20 
Table 15-2 
Classifications for Outcome of an Adverse Event 
20 


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5 
LIST OF ABBREVIATIONS 
Abbreviation 
Definition 
AE 
Adverse events 
ALP 
Alkaline Phosphatase  
ALT 
Alanine transaminase 
AST 
Aspartate transaminase 
ATS 
American Thoracic Society 
BCG 
Bacillus Calmette-Guérin 
CF 
cystic fibrosis 
CFF 
Cystic Fibrosis Foundation 
CFFPR 
Cystic Fibrosis Foundation Patient Registry 
CFQ-R 
Cystic Fibrosis Questionnaire-Revised 
CFTR 
CF transmembrane conductance regulator gene 
CRF 
case report form 
DNA 
Deoxyribonucleoside acid 
ECFS 
European Cystic Fibrosis Society  
EDC 
electronic data capture 
FDA 
Food and Drug Association 
GCP 
Good Clinical Practice 
GGT 
Gamma-glutamyl transaminase 
gNO 
Gaseous Nitric Oxide 
HEENT 
Head, eyes, ears, nose and throat 
HIPAA 
Health Insurance Portability and Accountability Act 
IDSA 
Infectious Diseases Society of America  
IND 
Investigational new drug 
INODD 
Inhaled NO Delivery Device 
INR 
International normalized ratio 
IRB 
institutional review board 
LVEF 
Left ventricular ejection fraction 
Mabs 
Mycobacterium abscessus 
MAC 
Mycobacteria avium complex 
MedDRA 
Medical Dictionary for Regulatory Activities 
metHb 
Methemoglobin 
MUSC 
Medical University of South Carolina 
NO 
Nitric oxide 
NO2 
Nitrogen dioxide 
O2 
Oxygen 
NTM 
Non-tuberculous mycobacteria 
NTM-PD 
Non-tuberculous mycobacteria pulmonary disease 
PPM 
Parts per million 
SAE 
serious adverse event 
SaO2 
Arterial oxygen saturation 
SAP 
statistical analysis plan 
SGRQ 
St. Georges Respiratory Questionnaire 
WHO-DD 
World Health Organization Drug Dictionary 


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6 
INTRODUCTION 
Overview of NTM lung disease 
Non-tuberculous mycobacteria (NTM) have been identified as a pathogen of increasing 
importance in patients with cystic fibrosis (CF) [Floto 2016].  The Cystic Fibrosis Foundation 
Patient Registry (CFFPR) has shown prevalence rates for NTM-positive culture in the US of 
12% but with considerable variation among states ranging from 0-28% [Floto 2016; Adjemian 
2014]. The NTM most commonly identified in patients with CF are Mycobacterium avium 
complex (MAC) and M abscessus complex (Mabs) [Olivier 2003; Sermet-Gaudelus 2003].  
NTM are insidious opportunistic organisms that cause lung disease in certain patient 
populations especially those who have cystic fibrosis (CF) but also in other populations [Honda 
2015]. Although NTM could be an innocent resident in airway cultures [Martiniano 2017] there 
are patients in whom NTM may cause progressive lung damage leading to the diagnosis of 
NTM pulmonary disease (NTM-PD) [Tomashefski 1996]. There are consensus 
recommendations from the American Thoracic Society (ATS), infectious Diseases Society of 
America (IDSA), Cystic Fibrosis Foundation (CFF), and the European Cystic Fibrosis Society 
(ECFS) to guide clinicians in the diagnosis and management of NTM in patients including 
those with CF [Floto 2016; Griffith 2007].  
Treatment of NTM-PD currently involves a multidrug regimen (often 3 or more 
antibiotics) for prolonged durations; a frequently cited goal for treatment duration is for one 
year beyond conversion of cultures to negative [Griffith 2007]. These multidrug regimens have 
potential for intolerability and toxicity resulting in risk for suboptimal treatment and increased 
likelihood of antibiotic resistance.  In addition, many patients will not achieve culture 
conversion despite adhering to their treatment regimen.  There are few data available in CF 
patients, but overall culture conversion rates reported for other conditions are 55-65% for MAC 
[Wallace 1996; Tanaka 1998] and 48-58% for Mabs [Jarand 2011].  
It is clear from these observations that current options for NTM-PD treatment are 
limited in scope and in results. An additional problem for CF patients is that the presence of 
Mabs in sputum cultures may create an insurmountable hurdle for eventual lung 
transplantation.  Although the CFF/ECFS guidelines clearly state that NTM presence is not an 
absolute contraindication for lung transplantation [Floto 2016], there are some patients who 
have been declined for transplant listing because of NTM-PD. [Chalermskulrat 2006; personal 
communication].  Therefore, there is an urgent need for novel treatment of NTM-PD in patients 
with and without CF. 
Overview of gNO and Rationale for Study 
Recent observations of the antimicrobial effects of inhaled nitric oxide gas (gNO) 
suggest it may be a serious candidate for inclusion in the treatment regimen of NTM-PD.  
When NO molecules pass through the bacteria cell wall, they bind available thiols (e.g. 
glutathione) and cause cell death through a combination of asphyxiation of the electron 
transport complex, impairment of bacterial defense mechanisms, modification of oxygen and 
nitrogen radical species and metal ion deamination of its DNA [Schaefer 2006]. In vitro studies 
have demonstrated that NO possesses antimicrobial activity against a wide variety of bacteria, 
viruses, helminthes and parasites [Schaefer 2006].  
Safety data: Animal studies of acute exposure to high concentrations of NO (500-1500 ppm 
NO) for up to 30 minutes demonstrated no acute pulmonary injury (i.e. there were no 


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differences in histopathological evaluation between the NO-exposed animals and room air 
control animals). An FDA reviewer noted that, aside from the effects due to formation of 
methemoglobin (a known adverse effect of NO), oxidative insult to respiratory epithelia may be 
low/minimal at 200 ppm. 
Anti-mycobacterial effects: gNO has been demonstrated to be capable of eradicating M 
smegmatis, a fast-growing mycobacteria [Miller 2007]. In vitro testing of M smegmatis 
(mc2155), M bovis- Bacillus Calmette-Guérin (BCG) and M tuberculosis (H37Rv) exposed to 
160ppm gNO have recently been completed by Miller et al. (unpublished). The gNO was 
delivered both as a continuous exposure or as an interrupted exposure cycle (30 minutes 
repeated every 3.5 hours) until all bacteria were eradicated.  Initial bacterial concentrations 
were 6 log10 cfu/mL for all bacteria tested. M smegmatis and BCG were more susceptible to 
gNO and complete cidal effect occurred within 10 hrs of exposure or 1,600ppm-hrs. M 
tuberculosis required 18 hrs or 2,880ppm-hrs of exposure to achieve complete kill. The control 
arm of the study was exposed to air while the treatment arm was exposed to 160 ± 5ppm gNO. 
In each of the experiments the control samples remained viable for the duration of the study.  
The results of multiple 30 min, 160 ppm gNO exposures of M smegmatis, BCG and M 
tuberculosis showed a complete kill of each of the organisms tested was achieved by 96 hrs. 
These results demonstrate that gNO is capable of eradicating a variety of both fast- and slow-
growing mycobacteria. This study suggests that gNO could safely be delivered to humans with 
potential efficacy in patients with NTM.  
Preliminary human work: This approach to therapy has undergone typical phase I clinical 
investigation and there is a current Phase II study of CF subjects (clinicaltrials.gov 
NCT02498535) evaluating the effects of gNO on bacterial species (i.e. Pseudomonas 
aeruginosa, Staphylococcus aureus, and Stenotrophomonas maltophilia).  A prospective, single 
center, open labelled, clinical phase I study exposed eight adult CF patients (2 with Mabs in 
sputum cultures) to gNO by inhalation for 30 min, three times daily, at a concentration of 160 
ppm for two periods of 5 days each [Deppisch 2016]. The primary outcome was safety and no 
serious drug-related adverse events occurred. Methemoglobin increased in all patients to a 
maximum of 3.0% after 30 min of treatment, considered an acceptable level.  Oxygen 
saturation did not decrease below 95% in any patient.  Secondary endpoints were change of 
bacterial and or fungal load after completion of the treatment from baseline and change in 
FEV1 from baseline. The intent-to-treat (ITT) analysis revealed a significant mean reduction of 
the colony forming units (cfu) of all bacteria, but what was notable was the reduction of M 
abscessus by 5 orders of magnitude. 
More recently, two patients with CF with persistent Mabs infection and clinical decline despite 
antibiotic treatment were treated with compassionate use of gNO given in intermittent periods 
at 160ppm [Yaacoby-Bianu 2018]. One patient received 72 inhalations over 26 days, while the 
other received 90 inhalations over 21 days.  Both subjects showed significant reduction in 
estimated colony forming units (CFU/ml) for Mabs (decreased from 7000 to 550 and 3000 to 0, 
respectively). Clinically the subjects were reported to have improvement in well-being and ease 
of sputum production, while one patients experienced an increase in lung function. 
Finally, there are trials of gNO listed on clinicaltrials.gov.  One study is recruiting 
patients with Mabs for a Phase II study in Israel (NCT03208764) with a primary safety 
endpoint.   Another study is being performed in Canada, which is a safety study of gNO in 
adults with NTM-PD (HC6-24-c207204). 


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In sum, there is sufficient preclinical evidence of antimicrobial effect of gNO on NTM.  There 
are compelling reasons to use a gas for treatment as it may get to areas of the lung that will not 
be reached by antibiotics by either the systemic or inhalation route.  Even in poorly ventilated 
lung units, a 50 minute exposure should be sufficient time for NO to achieve therapeutic levels.  
There are also sufficient safety data that the proposed exposure should be well tolerated.  It is 
premature to predict how this therapy will be best used, but multiple options could be 
conceived such as eradication of first infection (especially for Mabs), improving outcomes 
when used in conjunction with standard antibacterial regimens, shorter durations of treatment 
regimens, among others.  This study proposes to demonstrate that there can, indeed, be a killing 
effect of NTM as well as assess for how quickly it may return in sputum cultures as these will 
be key factors in designing subsequent treatment trials. 
7 
STUDY OBJECTIVE 
The short term goal of this proposal is a proof-of-concept study in which we will expose 
patients with NTM lung disease and who have persistently positive sputum cultures to test the 
feasibility of this therapy in this population as well as the safety and efficacy of the therapy.   
8 
STUDY ENDPOINTS 
•
The primary measure of efficacy will be sputum culture for mycobacteria converted to
negative at completion of treatment.
•
Secondary measures of efficacy will include assessment of feasibility of this treatment (i.e.
recruitment, completion, and satisfaction), sputum culture results for mycobacteria at 3
months following completion of treatment, and safety and tolerability assessments based on
adverse events (AEs) and point of care testing for arterial oxygen saturation and
methemoglobin levels.
9 
STUDY DESIGN 
9.1 
Overview of Study Design 
This open-label treatment of NTM lung disease is a proof-of-concept study to assess the 
efficacy of gNO in reducing the burden of NTM in patients known to have persistently positive 
sputum cultures.  The patients will have documented NTM lung disease and meet inclusion 
criteria of persistently positive sputum cultures even if on antimicrobial therapy.  The study is 
designed to evaluate the feasibility, efficacy and safety of open-label gNO in this population.  
Feasibility will be assessed by ease of recruitment and completion of the study, as well as a 
survey of the subjects’ experience with the treatment and their willingness to use this as a 
therapy.  Efficacy will be assessed by the results of sputum cultures for mycobacteria, looking 
at the short term effect (i.e. conversion to negative while on treatment) as well as the long-term 
effect (i.e. looking at the duration of culture conversion after treatment).  Subjects will undergo 
sputum cultures at baseline and weekly during treatment, and monthly for 3 months following 
completion of therapy. Additional measures will include symptom scores of cough and quality 
of life.  Safety will be assessed by monitoring of SaO2 and metHb levels while on treatment.  
All serious and non-serious adverse events will be collected. 


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9.1.1 
Screening 
The investigator will review the protocol and obtain informed consent from the subjects prior 
to the conduct of any study procedures.  There will be a review of the medical history and 
demographic information including underlying diagnosis. For those patients with cystic 
fibrosis (CF) the results of previous genetic testing will be recorded.  Physical examination, 
including vital signs, height and weight, and pulse oximetry, will be performed.  Assessment of 
baseline measures for efficacy will be performed (i.e. sputum collection for mycobacterial 
culture, cough score (Leicester), quality of life (SGRQ, CFQ-R, QOL-B).   
9.1.2 
Treatment Period (Days 1-15) 
The treatment period is separated over 3 weeks (A, B, and C) each with 5 days of treatment, 
and 2 days off treatment in between.  On the first day of each treatment week (A1, B1, C1) 
subjects will be evaluated for any changes in health or medications.  They will undergo 
physical examination, including height and weight.  They will undergo measurement of 
efficacy outcomes (symptom scores) as per the Study Assessment Schedule (Table 3-1).  
During each day of treatment (A1-A5, B1-B5, and C1-C5), subjects will be exposed to gNO 
through a tight-fitting mask at 160 ppm for 50 minutes for each treatment.  There will be three 
treatments given on each day, with 3 hours between each treatment.  The subjects will be 
monitored with pulse oximetry throughout their exposure to gNO to assess SaO2 and metHb 
levels. On the last day of each treatment period (A5, B5, C5), the subjects will repeat their 
symptom scores as well as provide sputum for mycobacterial culture. 
9.1.3 
Follow Up Period (3 months) 
Patients will be evaluated monthly for 3 months for any changes in health or medications.  
They will undergo physical examination, including height and weight.  They will undergo 
measurement of efficacy outcomes (symptom scores, sputum cultures) as per the Study 
Assessment Schedule (Table 3-1).   
9.2 
Rationale for Study Design 
This is a proof-of-concept study based upon in vitro exposure of NTM to gNO.  The primary 
efficacy measure (conversion to negative mycobacterial cultures) are expected to change in 
the short term (i.e. during the 3 week treatment period), but assessment after completion of 
treatment is important to determine if there is a return to culture positivity in the immediate 
term post-treatment.  The overall culture response rate and the time to recurrence (if it recurs) 
will be important data to determine if this therapy has clinical potential for this patient 
population and the resulting data will be helpful for estimating the effect size to be used in 
designing a future randomized controlled trial 
The other key measures include reduction in the mycobacterial density (in the event that 
cultures do not convert to negative, this will provide information about some treatment effect), 
efficacy based on symptoms, safety, and the feasibility of conducting a larger trial or whether 
this therapeutic regimen would have viability. 
As this is a proof-of-concept study, there is no value to a blinded aspect for the study.  


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Treatment will be open-label and clinical outcomes will be assessed by the individuals. 
10 
SELECTION OF STUDY POPULATION 
10.1 
Inclusion Criteria 
Patients with NTM lung disease who persistently demonstrate infection with positive sputum 
cultures will be eligible for the study.  This will include patients with and without CF as this is 
typical of the NTM population and this therapy should be non-discriminatory.  Inclusion 
criteria are as follows: 
•
Subjects are >18 years of age and able to provide informed consent.
•
Subjects have NTM lung disease as defined by each of the following:
o
Sputum cultures positive for NTM (MAC or M abscessus)
o
Radiologic studies that demonstrate features consistent with disease such as 
nodular bronchiectasis and/or cavities
o
Symptoms consistent with disease including respiratory (e.g. cough, sputum 
production, hemoptysis, chest pain) and constitutional (e.g. fevers, night 
sweats, fatigue, myalgias, arthralgias, weight loss)
•
Subjects are able to produce sputum for culture (either spontaneous or induced).
•
Subjects have a history of persistently positive sputum cultures for NTM defined as
o
> 2 positive cultures over the preceding 6 months AND
o
Has not met the definition for culture clearance in the last 6 months
(three negatives in a row)
•
Clinically stable with no significant changes in health status within 14 days prior to 
Screening or Day 1
•
Subjects are willing and able to perform requirements of the study. 


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Appendix: Guidance for eligibility based on definition of persistent infection 
The definition of persistent infection in the inclusion criteria is:  
•
Subjects are able to produce sputum for culture (either spontaneous or induced).
•
Subjects have a history of persistently positive sputum cultures for NTM defined
as:
o
>2 positive cultures over the preceding 6 months AND
o
Has not met the definition for culture clearance in the last 6 months
(three negatives in a row.
Since there will be heterogeneity in culture frequency, this table will assist in defining 
eligibility: 
Samples 
taken 
Samples found to have NTM (positive samples) 
0 
1 
2 
3 
4 
5 
6 
2 
0/2 
1/2 
2/2 
-- 
-- 
-- 
-- 
3 
0/3 
1/3 
2/3 
3/3 
-- 
-- 
-- 
4 
0/4 
1/4 
2/4 
3/4 
4/4 
-- 
-- 
5 
0/5 
1/5 
2/5 
3/5 
4/5 
5/5 
-- 
6 
0/6 
1/6 
2/6 
3/6 
4/6 
5/6 
6/6 
Red = not eligible 
Green = eligible 
Yellow = potentially eligible (depending on whether culture conversion definition is met) 
The definition of culture conversion is at least 3 consecutive negative mycobacterial cultures 
from respiratory samples, collected at least 4 weeks apart (i.e. no intervening positives). The 
table below demonstrates the varying possibilities for the potentially eligible subjects from the 
table above. 
Number 
positives 
Months prior to screening 
Eligible 
6 
5 
4 
3 
2 
1 
0 
No 
2 
X 
O 
X 
O 
O 
O 
. 
No 
2 
O 
X 
X 
O 
O 
O 
. 
No 
2 
X 
X 
O 
O 
O 
O 
. 
No 
2 
O 
X 
O 
O 
O 
X 
. 
No 
2 
X 
O 
O 
O 
O 
X 
. 
No 


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2 
X 
O 
O 
O 
X 
O 
. 
No 
2 
O 
O 
O 
O 
X 
X 
. 
No 
2 
O 
O 
O 
X 
X 
O 
. 
No 
2 
O 
O 
O 
X 
O 
X 
. 
No 
 
3 
X 
X 
X 
O 
O 
O 
. 
No 
3 
X 
X 
O 
O 
O 
X 
. 
No 
3 
X 
O 
O 
O 
X 
X 
. 
No 
3 
O 
O 
O 
X 
X 
X 
. 
No 
 
2 
X 
O 
O 
X 
O 
O 
X 
Yes 
2 
O 
X 
O 
X 
O 
O 
X 
Yes 
2 
O 
X 
O 
O 
X 
O 
X 
Yes 
2 
O 
O 
X 
X 
O 
O 
X 
Yes 
2 
O 
O 
X 
O 
X 
O 
X 
Yes 
2 
O 
O 
X 
O 
O 
X 
X 
Yes 
 
 
 
 
 
 
 
 
 
 
 


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For those deemed ineligible, they may yet become eligible.  In the following table, are different 
scenarios in which could be rescreened or become eligible within a period of time.  S2, S3 and 
S4 indicate that the participant should be screened again after 2, 3, or 4 months.  For these 
participants, no more than one positive culture has occurred since meeting the definition for 
culture conversion, and more positive cultures will need to occur to meet eligibility 
requirements. E1 and E2 indicate that the participant will be eligible after 1 or 2 months. For 
these persons, two qualifying, positive cultures have occurred since evidence of culture 
conversion. 
Number 
positives 
Months prior to screening 
6 
5 
4 
3 
2 
1 
0 
2 
X 
O 
X 
O 
O 
O 
S4 
2 
O 
X 
X 
O 
O 
O 
S4 
2 
X 
X 
O 
O 
O 
O 
S4 
2 
O 
X 
O 
O 
O 
X 
S3 
2 
X 
O 
O 
O 
O 
X 
S3 
2 
X 
O 
O 
O 
X 
O 
S2 
2 
O 
O 
O 
O 
X 
X 
E2 
2 
O 
O 
O 
X 
X 
O 
E1 
2 
O 
O 
O 
X 
O 
X 
E1 
3 
X 
X 
X 
O 
O 
O 
S4 
3 
X 
X 
O 
O 
O 
X 
S3 
3 
X 
O 
O 
O 
X 
X 
E2 
3 
O 
O 
O 
X 
X 
X 
E1 
 
 
 


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10.2 
Exclusion Criteria 
 
Subjects will be excluded if they have any of the following: 
 
• Smoking history in the prior 6 months 
• Significant hemoptysis within 30 days prior to screening (>5 ml of blood in one 
coughing episode or >30 ml of blood in a 24 hour period) 
• Forced expiratory volume at one second (FEV1) <40% of predicted 
• On supplemental oxygen or SaO2 <90% at screening or Day 1, or within 30 days prior 
to enrollment. 
• Known cardiac (left heart) insufficiency (defined as LVEF <35%) prior to screening 
• Known pulmonary hypertension 
• Known or suspected hemoglobinopathy 
• Initiation of NTM treatment regimen or a change in the regimen was made in the prior 6 
months.  Subjects on active treatment can be enrolled if they have been on a stable anti-
NTM regimen for at least 6 months. 
• Initiation of new chronic therapy within 4 weeks prior to screening 
• Use of drugs known to increase methemoglobin (see 12.2.7) at screening 
• Any of the following abnormal lab values at screening: 
o 6-GPD deficiency 
o Hemoglobin <10g/dl 
o Platelet count <100,000/mm3 
o Prothrombin time international ratio (INR) >1.5 
o Abnormal liver function defined as any two of the following 
 ALT >3x ULN 
 AST >3x ULN 
 ALP >3x ULN 
 GGT >3x ULN 
o Abnormal renal function defined as:  
 Calculated Creatinine Clearance <50 ml (as calculated by 
Cockcroft/Gault) 
• For women of child bearing potential: 
o Positive pregnancy test at screening or 
o Lactating or 
o Unwilling to practice a medically acceptable form of contraception from 
screening to Day 15 (acceptable forms of contraception: abstinence, hormonal 
birth control, intrauterine device, or barrier method plus a spermicidal agent) 
• Use of an investigational drug within 30 days prior to screening 
• Intravenous or oral steroids (>10 mg/d prednisone equivalent) in the 14 days prior to 
screening 
• Any condition that the Investigator believes would interfere with the intent of this study 
or would make participation not in the best interest of the subject. 
 
 
 
 


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11 
DOSING OF STUDY DRUG 
 
11.1 
General Dosing Information 
 
Gaseous NO (5000 ppm), delivered with air as carrier to dilute it to 160 ppm, will be 
administered by inhalation for 50 minutes three times daily on Days 1-5, 8-12, and 15-19.  On 
each day, treatment will be given with a minimum of 3 hours between the end of one treatment 
and the start of the following treatment. Subjects will receive 160 ppm during each 50 minute 
inhalation period (daily exposure 400 ppm hours. This will result in a total of 6000 ppm hours 
of exposure. 
 
11.2 
Dosing Information 
 
The 5000 ppm nitric oxide source cylinder contains 5000 ppm (0.5% NO) with the balance of 
the gas being nitrogen. Only 3.2% of the gas the subject inhales will come from the NO 
cylinder. Therefore, the nitrogen in the NO cylinder will dilute the inspired oxygen in the 
carrier gas. This will lower the inspired oxygen from 20.9% to 20.3% or the equivalent of 
standing at approximately700 feet above sea level.  Inclusion criteria for subjects include 
oxygen saturation >90% on room air and the estimated 3.5 torr change in PaO2 is not 
anticipated to have a significant clinical effect on subject oxygenation. Subjects will be 
monitored continuously during treatment with a pulse oximeter. 
 
11.3 
Dosage Administration 
 
Gas cylinders with the study drug (5,000 ppm NO and 99.5% nitrogen) will be labeled with its 
contents.  These cylinders will be D-size cylinders with a CGA626 valve, containing 
approximately 350 liters of gas.  
 
Subjects will receive the study drug by inhaling through a nasal mask attached to an Inhaled 
NO Delivery Device (INODD) administration system. The INODD is comprised of three 
components including an inspiratory flow monitor with a ratio-metric matching NO injector 
module, an inhaled gas monitoring module, and a gas mixing subject interface and breathing 
valve. It is a variable inspiratory flow delivery system that instantaneously matches the 
subject’s inspiratory flow with the injected 5000 ppm NO to deliver 160 ppm of nitric oxide 
independent of inspiratory flow up to 120 LPM, while keeping nitrogen dioxide ≤ 3 ppm. It is 
a breath-initiated delivery system and the NO will be blended into the inspiratory gas stream 
only as long as the subject is inhaling and proportional to the inspiratory flow. The analyzer 
monitors the inhaled nitric oxide, nitrogen dioxide and oxygen concentrations. 
 
A sample pump in the INODD withdraws a low flow (~ 250 mL/min) from the inspiratory 
circuit to the subject for analysis of NO, NO2 and O2. These analyzers assure that the subject is 
receiving the correct gas concentration and assures that the oxygen concentration remains in a 
safe range and that the inspired concentration of NO2 is below the set alarm threshold limit. 
Should the NO concentration fall outside the targeted range, an operator set alarm will sound. 
The system will shut off the NO flow should the NO analyzer measure a value that is ≥ 200 
ppm In addition, should the NO2 rise above the alarm limit of 3 ppm, an alarm will sound. If 
the NO2 rises above 5 ppm, the system will alarm as well as shut off the flow of NO to the 


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circuit. 
 
12 
ASSESSMENTS 
 
12.1 
Timing of Assessments 
 
The timing of assessments is shown in Table 3-1. 
 
12.2 
Clinical Assessments 
 
12.2.1 
Subject and Disease Characteristics 
 
Demographic information (age, gender, race) will be captured at Screening.  Relevant 
medical history, including history of current disease, other pertinent respiratory history, 
and information regarding underlying diseases will be recorded at Screening. 
 
12.2.2 
Physical Examination 
 
A complete physical examination will be performed by a physician (either the principal 
investigator or a sub-investigator) at Screening. Body systems to be examined include General, 
Skin, Lymph Nodes, HEENT, Respiratory, Cardiovascular, Gastrointestinal, Neurologic and 
Muscoskeletal.  Qualified staff (e.g. MD, nurse practitioner, registered nurse, physician’s 
assistant) may complete the abbreviated physical exam (General, HEENT, Respiratory, 
Cardiovascular and Gastrointestinal) at all other visits. After screening, new clinically 
significant abnormal physical exam findings must be documented as adverse events (AEs) and 
will be followed by a physician or other qualified staff at the next scheduled visit or as 
medically indicated. 
 
12.2.3 
Vital Signs 
 
Heart rate, blood pressure, respiration rate and temperature will be performed and recorded 
after resting for 5 minutes at Screening and prior to the start of the first treatment on each day 
of treatment. Heart rate from the pulse oximeter will additionally be measured and recorded 
every 5 minutes during each treatment. 
 
12.2.4 
Oxygen Saturation 
 
Oxygen saturation will be measured by pulse oximetry on room air at multiple visits during the 
study after the subject has been at rest for 5 minutes. Additionally, during each 50 minute 
inhalation treatment period, measurements will be recorded at 0, 5, 10, 15, 20, 25, 30, 35, 40 
and 45 minutes. 
 
12.2.5 
Methemoglobin 
 
Will be non-invasively measured (and recorded every 5 minutes) using a pulse 
methemoglobinometer at Screening, Baseline, continuously during each treatment, recorded 
every 5 minutes during each treatment. For the first treatment, subjects will be monitored in 
clinic every 30 minutes post-treatment for adverse events related to study drug inhalation and to  


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ensure MetHb returns to baseline.  NOTE: Any Methemoglobin level >5% (absolute) above 
baseline requires a repeat level to be measured 5 minutes later and the final measurement 
should be recorded. If methemoglobin is 15% or higher, see section 13.1 for treatment 
procedures.  
 
Table 12.1 Monitoring before, during and after treatment 
Measurement 
Pre-treatment 
During treatment 
Post-treatment 
Vital signs 
HR, BP, RR, T prior 
to first treatment 
HR, BP, RR prior to 
each treatment 
HR every 5 minutes 
HR, BP, RR upon 
cessation of treatment 
Repeat at 30 minutes 
SaO2 
Prior to treatment 
Every 5 minutes 
Upon cessation of 
treatment 
Repeat at 30 minutes 
Methemoglobin 
Prior to treatment 
Every 5 minutes 
Upon cessation of 
treatment 
Repeat every 30 
minutes until return 
to baseline 
 
 
12.2.6 
Prior and Concomitant Medications 
 
Information regarding all medications administered before study enrollment and through 
the last study visit will be recorded. 
 
12.2.7 
Excluded concomitant medications 
 
Some medications are known to be capable of inducing methemoglobinemia and are 
excluded from use in this trial.  This list may include: 
 
 
 
 


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12.3 
Safety 
 
Study subjects will remain in the research clinic for at least one hour following each treatment, 
presuming all monitored parameters are acceptable as per Table 12.1 
 
12.3.1 
Adverse Events 
 
Information regarding occurrence of adverse events will be captured throughout the study. 
Duration (start and stop dates and times), severity, outcome, treatment and relation to study 
medication will be documented on the case report form. 
 
12.3.2 
Safety Monitoring 
 
A Medical Monitor for this study will consist of a single independent monitoring clinician 
with experience in the treatment and management of patients with pulmonary diseases. 
Safety data will be monitored on a continual basis throughout the trial.  SAEs and important 
protocol defined medical events will be reviewed in real time throughout the trial. The 
Medical Monitor will review all SAE reports and important protocol defined medical event 
reports, and may at any point temporarily stop the study for concerns of subject safety. IND 
safety reporting to the FDA and the IRB will be according to guidance procedures as 
delineated in CFR 312.32. 
12.4 
Research Laboratory Assessments 
 
12.4.1 
Sputum cultures 
 
Sputum will be collected for culture at Screening, and Days 5, 12, and 19 (treatment dates), and 
Weeks 7, 11 and 15 (follow up). Sputum samples will be processed at the MUSC clinical 
laboratory, using standard decontamination procedures, fluorochrome microscopy, solid 
medium culture on a biplate of Middlebrook 7H10 agar with and without antibiotics, and a 
broth culture (BACTEC 960 [Becton Dickinson, Sparks, MD] or ESP [TREK Diagnostic 
Systems, Cleveland, OH]). MAC isolates are identified with AccuProbe (Hologic-GenProbe, 
San Diego, CA). 
 
Semiquantitative AFB smear and culture results for each submitted clinical specimen will be 
recorded [Wallace 1996]. Briefly, a negative culture exhibits no mycobacterial growth. 
Cultures will be reported as positive if growth occurs in broth medium only; growth on broth 
medium plus solid medium cultures with countable colonies will be reported as 0–49 colonies, 
1+; solid medium growth with 50–99 colonies, 2+; solid medium growth with 100–199 
colonies; 3+, solid medium growth with 200–299 colonies; and 4+, solid medium growth with 
at least 300 colonies. For data analysis, each culture will be scored as follows: 0, no growth in 
broth or solid medium; 1, broth medium growth only; 2, countable colonies (<50 colonies) on 
solid medium; and 3–6, 1+ to 4+ growth on solid medium, respectively. 
 
12.5.1 
Quality of life measures 
 
Validated instruments will be used for measurement of symptoms and quality of life.  Since 
study subjects may have different underlying conditions, for which there are different quality of 
life measures, we will use a condition specific measure for each as follows: 


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• Cystic fibrosis: Cystic fibrosis Questionnaire-Revised (CFQ-R) 
• Bronchiectasis: Quality of Life – Bronchiectasis (QOL-B) 
• All: St. George’s Respiratory Questionnaire (SGR-Q) 
• All: Leicester Cough Score 
 
13 DISCONTINUATION OR WITHDRAWAL FROM TREATMENT 
13.1 Discontinuation of a 50 Minute Inhalation Period (note: treatment will not be 
initiated if threshold values are present beforehand) 
A 50 minute inhalation treatment period will be discontinued if the following occurs. 
• 
a change in the blood pressure systolic value ≥ 20 mmHg or an absolute value of ≤ 80 
mmHg repeated at 2 minutes 
• 
an oxygen saturation of < 85% and following recheck of sensor placement 
• 
a reduction in oxygen saturation >5% (e.g. 98% to 92%). 
• 
a persistent* increase in heart rate of ≥ 30 from start of a treatment or an absolute value 
of 150 
• 
a persistent* absolute increase in methemoglobin of more than 5% above the Day 1 
baseline value and follo0wing recheck of sensor placement 
• 
a recorded inspired NO2 > 5 ppm during any treatment 
• 
Subjects with methemoglobin of more than 15% should be treated with 100% oxygen. If 
20% or greater, subjects should be treated with Methylene Blue (1 to 2 mg/kg 
intravenously).  Repeat in one hour if necessary.  Note: Inject intravenously very slowly 
over a period of several minutes to prevent local high concentration of the compound 
from producing additional methemoglobin. Large intravenous doses of Methylene Blue 
may produce nausea, abdominal and precordial pain, dizziness, headache, profuse 
sweating, mental confusion and the formation of methemoglobin. Also note that 
methemoglobin cannot be measured by the oximeter after treatment with methylene blue 
and should be measured by blood values. See package insert for full contraindications 
and side-effects. Methylene blue is contraindicated in patients who have developed 
hypersensitivity reactions to it and in severe renal insufficiency. It is relatively 
contraindicated in G6PD deficient patients as it can cause severe hemolysis and also in 
patients with Heinz body anemia. In such cases it may be appropriate to treat with 
intravenous ascorbic acid. 
 
*Persistent means that the value was obtained on a repeated measurement taken 5 minutes 
following the original measurement. 
 
13.2 Withdrawal from study 
If a subject experiences any of the following events during the study period, they should be 
immediately be withdrawn from the study. 
Study drug related adverse events: 
• 
Two consecutive inhalation treatment periods with a persistent absolute increase in 
methemoglobin of more than 5% above the Day 1 baseline value 
• 
Study drug related significant hemoptysis: production of greater than 50 mL blood in a 
24 hour period. Note: Standard treatment for significant hemoptysis should include 
immediate chest x-ray, hematocrit measurement and if frothy sputum present, an 
evaluation for hemosiderin labeled macrophages. 
• 
Any study drug related adverse event that repeats upon treatment continuation. 
. 


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Other withdrawal criteria: 
• 
At the discretion of the subject 
• 
At the discretion of the Investigator, if deemed appropriate, for any reason 
• 
Subjects will also be withdrawn from the study if they have had to discontinue treatment 
during the 50-minute inhalation period more than twice due to criteria listed in 13.1. 
 
If a subject is withdrawn because of an adverse event, the subject will be followed and treated 
by the Investigator until the abnormal parameter or symptom has resolved or stabilized. 
 
The adverse events must be followed to resolution and the follow-up evaluations should be 
performed when the subject has stabilized. 
 
If for any reason a subject does not complete the study, the reason will be entered on the CRF. 
All subjects are free to withdraw from participation at any time, for any reason, specified or 
unspecified, and without prejudice. The Investigator must record the reason for the early 
termination. 
 
14 
STATISTICAL AND ANALYTICAL PLANS 
 
Data analysis will be performed by the investigator. 
 
14.1 
Sample Size and Power 
 
Planned enrollment is a minimum of 6 and a maximum of 10 subjects in this study. If a high 
enough proportion of subjects demonstrate a response (e.g. 5 of 6 or 6 of 8) early on in the trial, we 
may be able to limit the sample size, since the 95% confidence intervals would indicate a high 
certainty that this therapy is worth pursuing in a larger randomized controlled trial.  If, however, 
none of the 10 subjects exhibit a response, then we can be almost certain that this particular 
therapy is futile, since the resulting 95% confidence interval around the response rate would range 
from 0% to 31%.   
 
14.2 
Statistical Analyses 
 
Data will be summarized descriptively for each subject.  No formal comparative statistical 
analyses are planned 
 
14.3.1 
Background Characteristics 
 
14.3.1.1 
Subject Disposition 
 
The number of subjects in each disposition category (e.g., enrolled; prematurely discontinued 
from the study; and completed the study) will be summarized. 
 
14.3.1.2 
Demographics and Baseline Characteristics 
 
The following demographic and baseline characteristics will be captured (as appropriate): 
CFTR genotype, sex, race, age, weight, height, BMI, spirometry, SGRQ, CFQ-R, QOL-B, 
and sputum culture results. 


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14.3.1.3 
Prior and Concomitant Medications 
 
Medications taken during the collection period specified in Section 11 will be summarized by 
preferred term using the World Health Organization Drug Dictionary (WHO-DD) for the 
Safety Set as frequency tables in 2 parts: 
• Prior medication: medication that started before the first dose of inhaled nitric oxide 
regardless of when dosing of the medication ended. 
• Concomitant medication: medication received at or after the first dose of inhaled nitric 
oxide, medication that was received before initial dosing of and continued after initial 
dosing, or medication with missing stop date. 
 
Medications that started before the first dose of inhaled nitric oxide  and continued after the 
first dose of inhaled nitric oxide will be summarized separately as prior medications and 
concomitant medications, respectively.  Medications with a missing start date will be 
considered to have a start date before the first dose of inhaled nitric oxide. 
 
14.3.2 
Efficacy Analysis 
 
For the primary analysis, the proportion of subjects with culture conversion (negative) will be 
recorded.  For the secondary analysis the change (absolute change) in semi-quantitative cultures 
from baseline will be calculated as post-baseline value – baseline value.  Exploratory analysis 
will be the change in time-to-detection as reported in the broth culture system. 
 
14.3.3 
Safety Analysis 
 
All safety data will be presented in individual subject data listings. 
 
14.3.3.1 
Adverse Events 
 
All adverse events with start date on or after enrollment date through the last study visit will 
be summarized. Adverse events are defined in Section 15.1.1. Adverse event summary tables 
will include the following: 
• 
all adverse events; 
• 
related (identified as related to inhaled nitric oxide by the investigator) adverse events; 
• 
adverse events leading to treatment discontinuation; 
• 
serious adverse events (SAEs); and 
• 
adverse events by relationship. 
 
Summaries will be presented by MedDRA system organ class and preferred term using 
frequency counts and percentages. A subject with multiple occurrences of the same adverse 
event or a continuing adverse event will be counted only once, by relationship. 
 
14.4 
Interim Analyses 
 
No interim analyses will be performed but safety will be monitored throughout. 
 
15 
PROCEDURAL, ETHICAL, REGULATORY, AND 


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ADMINISTRATIVE CONSIDERATIONS 
 
15.1 
Adverse Event and Serious Adverse Event Documentation and 
Reporting 
 
15.1.1 
Definition of an Adverse Event 
 
For this study, an adverse event is defined as any untoward medical occurrence in a subject 
during the study, including any newly-occurring event or previous condition that has 
increased in severity or frequency after the informed consent form is signed. 
 
A subset of adverse events may meet serious criteria. The definition of an SAE and reporting 
procedures for SAEs are detailed in Section 15.1.2. The definitions below apply to both 
adverse events and SAEs. 
 
Planned hospital admissions or surgical procedures for an illness or disease that existed before 
the subject was enrolled in the study are not to be considered adverse events unless the 
condition deteriorated in an unanticipated manner during the study (e.g., surgery was performed 
earlier than planned). 
 
15.1.2 
Definition of a Serious Adverse Event 
 
An SAE is any adverse event that meets any of the following criteria: 
 
• Fatal (death, regardless of cause, that occurs during participation in the study, or 
occurs after participation in the study and is suspected of being possibly related 
toinhaled nitric oxide ). 
• Life-threatening, such that the subject was at immediate risk of death from the reaction as 
it occurred. 
• Inpatient hospitalization or prolongation of hospitalization, with the exception of 
planned or elective hospitalization. 
• Persistent or significant disability/incapacity (disability is defined as a 
substantial disruption of a person's ability to conduct normal life functions). 
• Congenital anomaly or birth defect. 
• Important medical event that, based upon appropriate medical judgment, may 
jeopardize the subject or may require medical or surgical intervention to prevent 1 of 
the outcomes listed above (e.g., an allergic bronchospasm requiring intensive treatment 
in an emergency room or at home). 
 
15.1.3 
Documentation of Adverse Events 
 
From the time informed consent is signed through the last study visit all adverse events will 
be collected.  The following data should be documented for each adverse event: 
• 
Description of the event 
• 
Classification of "serious" or "not serious" 
• 
Date of first occurrence and date of resolution (if applicable) 
• 
Causal relationship to inhaled nitric oxide exposure 
• 
Action taken 


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• 
Outcome 
• 
Concomitant medication or other treatment given 
 
15.1.4 
Adverse Event Causality 
 
Every effort should be made by the investigator to assess the relationship of the adverse 
event, if any, to inhaled nitric oxide exposure. Causality should be classified using the 
categories presented in Table 15-1. 
 
Table 15-1  Classification for Adverse Event Causality 
Classification 
Definition 
Related 
There is a suspected association between the event and the 
administration of inhaled nitric oxide , a plausible mechanism for the 
event to be related to inhaled nitric oxide and causes other than the 
inhaled nitric oxide have been ruled out, and/or the event re-
appeared on re-exposure to inhaled nitric oxide . 
Not related 
The event is believed related to an etiology other than theinhaled 
nitric oxide . (The alternative etiology should be documented in the 
study subject's medical record) 
 
15.1.5 
Adverse Event Outcome 
 
An adverse event should be followed until the investigator has determined and provided the 
final outcome. The outcome should be classified according to the categories shown in Table 
15-2. 
 
Table 15-2  Classifications for Outcome of an Adverse Event 
Classification 
Definition 
Recovered/Resolved 
Resolution of an adverse event with no residual signs 
or symptoms 
Recovered/Resolved with Sequelae Resolution of an adverse event with residual signs or 
symptoms 
Not Recovered/Not resolved 
(Continuing) 
Either incomplete improvement or no improvement of 
an adverse event, such that it remains ongoing 
Fatal 
Outcome of an adverse event is death. "Fatal" should 
be used when death is at least possibly related to the 
adverse event 
Unknown 
Outcome of an adverse event is not known (e.g., a 
subject lost to follow-up). 
 
15.1.6 
Reporting Procedure for Adverse Events and Pregnancy 
 
All serious events (as defined in Section 15.1.2) that occur after obtaining informed consent 
and assent (where applicable) through the last study visit, regardless of causality, will be 
reported to the MUSC IRB within 24 hours of their awareness. 
 
15.1.6 
Adverse events of special interest 
 


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Short-term NO2 exposures, ranging from 30 minutes to 24 hours, are associated with the 
following adverse respiratory effects: decreased pulmonary function, chronic bronchitis, 
dyspnea, chest pain, pulmonary edema, cyanosis, tachypnea, tachycardia, which can aggravate 
existing heart disease, leading to increased hospital admissions and premature death. We will 
monitor for and record the following adverse events of special interest: methemoglobinemia, 
acute hypoxia and hemoptysis, bronchospasm, nasal congestion, sinus congestion, sinusitis, 
cough, bronchitis, pneumonitis, and alveolitis, as well as nausea, vomiting and diarrhea. 
 
15.2 
Administrative Requirements 
 
15.2.1 
Ethical Considerations 
 
The study will be conducted in accordance with the ethical principles founded in the 
Declaration of Helsinki, and according to local applicable laws and regulations. The 
institutional review board (IRB) will review all appropriate study documentation to safeguard 
the rights, safety, and well-being of the subjects..  
 
15.2.2 
Subject Information and Informed Consent 
 
Subjects must also be informed that participation is voluntary and that they may withdraw 
from the study at any time, without prejudice to their current or future care. Documentation of 
the discussion and the date of informed consent must be recorded in the subject's medical 
record or a study/clinic chart. Once all of their questions have been answered and they have 
voluntarily agreed to participate in the study, each subject will be asked to sign and date the 
ICF.  Informed consent must be obtained from each subject before the performance of any 
study-related activity. 
 
15.2.3 
Investigator Compliance 
 
No modifications to the protocol should be made without the approval of the IRB, except 
where the modification is necessary to eliminate an apparent immediate hazard to human 
subjects.  Any departures from protocol must be fully documented in the source 
documentation and in a protocol deviation log. 
 
15.2.4 
Access to Records 
 
The records must also be available for direct inspection, verification, and copying, as required 
by applicable laws and regulations, by officials of the regulatory health authorities (FDA and 
others). The investigator must comply with applicable privacy and security laws for use and 
disclosure of information related to the research set forth in this protocol. 
 
15.2.5 
Subject Privacy 
 
To maintain subject confidentiality, all case report forms (CRFs), study reports, and 
communications relating to the study will identify subjects by assigned subject numbers. The 
FDA (or other regulatory authority) may also request access to all study records, including 
source documentation, for inspection. 
 


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As applicable, in accordance with the Health Insurance Portability and Accountability Act 
(HIPAA) and associated privacy regulations, a subject authorization to use personally 
identifiable health information may be required from each subject before research activities 
begin. This authorization document must clearly specify which parties will have access to a 
subject's personal health information, for what purpose, and for how long. 
 
15.2.6 
Record Retention 
 
The investigator will maintain all study records according to GCP guidelines for a minimum 
of 6 years per MUSC policy. 
 
15.3 
Data Quality Assurance 
 
The investigator will prepare and maintain adequate and accurate case histories designed to 
record all observations and other data pertinent to the study for each study participant. Study 
data for each enrolled subject will be entered into a CRF by site personnel using a secure, 
electronic data capture (EDC) application (REDCap).20  Any changes to study data will be 
made to the CRF and documented in an audit trail, which will be maintained within the study 
database. 
 
15.4 
Data Capture 
 
It is the investigator's responsibility to ensure the accuracy, completeness, clarity, and 
timeliness of the data reported in the subject's CRF. Source documentation supporting the 
CRF data should indicate the subject's participation in the study and should document the 
dates and details of study procedures, adverse events, other observations, and subject 
status. 
 
The investigator will retain the CRF data and corresponding audit trails that show all updates 
to data, with user identification, date, and time.  
 
15.5 
Publications and Clinical Study Report 
 
15.5.1 
Publication of Study Results 
 
Any and all scientific, commercial, and technical information in this protocol or elsewhere 
should be considered the confidential and proprietary property of the investigator.  The 
investigator will be responsible for publication and/or disclosure of study results. 
 
15.5.2 
Study Report 
A clinical study report will be written by the investigator and submitted to the FDA per IND 
requirements. 
 
 
 


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