Clinical trial NCT03217591
Conditions: Type 2 Diabetes Mellitus With Diabetic Nephropathy
Sponsor: Akebia Therapeutics
Start date: 2017-08-01; Completion date: 2019-08-20
Enrollment: 156 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
To evaluate the safety and efficacy of IW-1973 in patients with type 2 diabetes mellitus with albuminuria who are on a stable regimen of renin-angiotensin system inhibitors.

Detailed description:

Arms: arm 1: Administered daily for 12 weeks arm 2: Administered daily for 12 weeks arm 3: Placebo to match experimental drug administered daily for 12 weeks
Interventions: intervention 1: IW-1973 intervention 2: IW-1973 intervention 3: Placebo
Intervention descriptions: intervention 1: Oral Tablet intervention 2: Oral Tablet intervention 3: Oral Tablet

Protocol documents:
Prot_000.pdf: 




IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 3 of 106 
SYNOPSIS 
Sponsor: Ironwood Pharmaceuticals, Inc. 
Name of Finished Product: IW-1973 Tablets 
Name of Active Ingredient: IW-1973 
Study Title: 
A Randomized, Double-blind, Placebo-controlled, Phase 2 Study to Evaluate the Safety and 
Efficacy of IW-1973 in Patients with Type 2 Diabetes with Albuminuria Treated with Renin-
Angiotensin System Inhibitors  
Study Number: C1973-203 
Study Phase: 2 
Study Objectives 
Primary 
• To assess the safety and tolerability of oral IW-1973 when administered daily for 
approximately 12 weeks to adult patients with type 2 diabetes mellitus with albuminuria 
who are on a stable regimen of renin-angiotensin system inhibitors 
• To evaluate the effect of oral IW-1973 on renal function when administered daily for 
approximately 12 weeks to adult patients with type 2 diabetes mellitus with albuminuria 
who are on a stable regimen of renin-angiotensin system inhibitors 
Study Design 
This multicenter, randomized, double-blind, placebo-controlled, parallel-group study will 
evaluate 2 dose levels of IW-1973 compared with placebo.  
Study Population and Planned Number of Patients  
The study population will consist of adult patients with type 2 diabetes mellitus, albuminuria, 
and impaired renal function. Patients must have been taking antihyperglycemic medications for 
at least 12 weeks and with their regimen stable (ie, drug and dose) for at least 28 days before 
the Randomization Visit. Additionally, patients must have been on a stable regimen of an 
angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB), for 
at least 28 days before the Randomization Visit. For details, see Eligibility Criteria. 
Approximately 150 patients (50 per arm) will be stratified by baseline estimated glomerular 
filtration rate (eGFR) (ie, eGFR 30 to 45, >45 to 60, and >60 to 75 mL/min/1.73 m2) and 
randomized 1:1:1 to daily 20 mg IW-1973, 40 mg IW-1973, or placebo. Patients who withdraw 
from the study after Randomization will not be replaced. 
Test Product, Dose, and Mode of Administration  
• 20 mg dose: Two IW-1973 Tablets, 10 mg administered orally 
• 40 mg dose: Two IW-1973 Tablets, 20 mg administered orally 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 4 of 106 
Reference Therapy, Dosage, and Mode of Administration 
Placebo to match IW-1973 Tablets: Two tablets administered orally 
Study Periods  
The study will consist of 3 periods (see Study Schematic). 
Screening Period: The Screening Period will begin with the signature of the informed consent 
form (ICF) at the Screening Visit and may last up to 45 days. At the Screening Visit (which can 
occur from Day -45 to Day -15), patients will undergo preliminary screening procedures to 
determine their eligibility. Eligible patients will return to the clinic for the Baseline Visit (Day 7 
±3) for baseline and eligibility assessments including 24-hour ambulatory blood pressure 
monitoring (ABPM). The end of the Screening Period will coincide with the beginning of the 
Treatment Period. 
Treatment Period: The Treatment Period will begin on Day 1 at Randomization (there is no 
Day 0) and will end after the End of Treatment Visit on Day 87 (±3). Patients will be stratified 
by baseline eGFR (ie, eGFR 30 to 45, >45 to 60, and >60 to 75 mL/min/1.73 m2) and 
randomized in a 1:1:1 ratio to receive 20 mg IW-1973, 40 mg IW-1973, or placebo for 
approximately 12 weeks. 
Dosing on Days 1 to 7 (±1) will be BID (twice daily), morning and evening; dosing on Day 8 
(±1) onward will be QD (once daily), 2 tablets in the morning.  
At the Randomization Visit on Day 1, patients will receive their morning dose of study drug in 
the clinic and will undergo safety, efficacy, and pharmacokinetic (PK) assessments, including 
blood and urine collections at prespecified times (Schedule of Events). Patients must stay in the 
clinic at least 6 hours postdose and may leave the clinic at the Investigator’s discretion 
following all study procedures.  
At the Week 1 Visit on Day 8 (±1), patients will return to the clinic and receive their first QD 
dose of study drug in the clinic. Patients will undergo safety, efficacy, and PK assessments, 
including blood and urine collections at prespecified times (see Schedule of Events). Patients 
must stay in the clinic at least 6 hours postdose and may leave the clinic at the Investigator’s 
discretion following all study procedures.  
At the Week 4 (Day 29 ±3), Week 8 (Day 57 ±3), and End of Treatment (Day 87 ±3) Visits, 
patients will return to the clinic for study drug administration; safety, efficacy, and PK 
assessments; and study drug supply, if applicable (see Schedule of Events). 
Follow-up Period: The Follow-up Period will begin immediately after the End of Treatment 
Visit and will last for 28 (±3) days. At the Follow-up Visit on Day 115 (±3), patients will return 
to the clinic for final study assessments (see Schedule of Events). 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 5 of 106 
Study Schematic  
 
Study Drug Administration 
During Week 1, patients will take study drug BID (2×/day), 1 tablet in the morning and 1 tablet 
approximately 12 hours later in the evening, preferably at approximately the same times each 
day. From the Week 1 Visit (Day 8 ±1) on, patients will take study drug QD (1×/day), 2 tablets 
in the morning, preferably at approximately the same time each day. Patients should take study 
drug with water, may take study drug with or without food, and, for QD dosing, may swallow 
tablets together, if desired. On study visit days, patients will receive their study drug dose in the 
clinic (on Randomization Day, patients will receive only their morning dose in the clinic). 
Study visits should be scheduled in the morning to accommodate regular dosing schedule. 
Duration of Treatment 
Patients will receive daily study drug for up to 90 days. Total patient participation will be 131 
to 163 days, including the Screening, Treatment, and Follow-up Periods. 
Dose Reduction 
Per Investigator discretion, on a per-patient basis, dose may be reduced by half, ie, from 
2 tablets daily to 1 tablet daily (in the morning). Each patient’s dose may only be reduced once 
and may not be increased after reduction. Investigators should notify the Medical Monitor of all 
decisions to dose reduce on a per-patient basis.
Follow-up
Visit
(Day 115 ±3)
Screening
Visit
(Day -45 to -15)
Randomization
Visit
(Day 1)
End of Treatment
Visit
(Day 87 ±3)
Screening 
Period 
Treatment
Period
Follow-up 
Period
15 to 45 days
87 (±3) days
28 (±3) days
Week 1 
Visit
(Day 8 ±1)
Baseline
Visit
(Day -7 ±3)
Week 4
Visit
(Day 29 ±3)
Week 8
Visit
(Day 57 ±3)
40 mg IW-1973
20 mg IW-1973
Placebo
BID
QD
1
2 to 12
Dosing
Week
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 6 of 106 
Individual Stopping Criteria and Data Monitoring Committee Reviews 
If any events included in the table below are reported during the study and are judged to be both 
study drug related and a serious adverse event (SAE; per causality and SAE definitions in the 
protocol), individual stopping criteria or Data Monitoring Committee (DMC) review will be 
triggered as described below. The inclusion of these AEs is based on the clinical experience 
with IW-1973, the prescribing information for riociguat, and the patient population for this 
study. 
 
Treatment-emergent,  
Study Drug-related SAE Category 
# of patients to 
trigger DMC review 
Renal failure  
(eGFR <15 mL/min/1.73 m2; dialysis or renal transplant indicated) 
2 
Spontaneous bleeding events  
(eg, hemoptysis, subarachnoid or subdural hemorrhage, hematemesis, 
hematochezia) 
2 
Symptomatic hypotension-related events 
(eg, syncope) 
2 
DMC=Data Monitoring Committee; eGFR=estimated glomerular filtration rate; SAE=serious adverse event 
 
Individual  
On an individual basis, a patient will be discontinued from study drug dosing if 1 or more SAEs 
from the table is reported. At the Investigator’s or Sponsor’s discretion, any AE(s) of concern 
can likewise be the basis for patient discontinuation from the trial. 
Study 
An independent DMC will review trial safety data. The DMC will comprise experts in 
cardiovascular and/or renal disease and/or diabetes and a biostatistician who have experience in 
clinical trials and are not involved in the conduct of this trial.  
Periodic safety review meetings will be scheduled after 30 subjects have been randomized or 
5 months after the first subject is randomized (whichever is earlier) and when approximately 
1/3 and 2/3 of patients have completed or discontinued treatment. The committee will review 
accumulated AE data and recommend trial continuation, continuation with modification, or 
termination. For these periodic reviews, the DMC will be provided with summaries of AE and 
blood pressure data. If a safety/tolerability signal or concerning AE imbalance is identified at a 
review, the committee can request unblinding of the masked treatment groups and may request 
additional safety data (eg, vital signs, concomitant medications).  
The DMC will also be required to perform an ad hoc review if SAEs from the same category in 
the above table are reported at the incidence indicated in the table shown above (eg, 2 patients 
with spontaneous bleeding SAEs). In this circumstance, the DMC will be provided with 
narrative descriptions and all relevant clinical supporting documentation related to the SAEs. 
Upon request, the unblinded treatment codes and dose the subjects with the SAEs received will 
be made available to the committee.  
In addition to the periodic and ad hoc reviews, during the trial, committee members will be 
provided with blinded reports on all SAEs. The DMC or the Sponsor may request ad hoc 
meetings at any time. 
Document Date: 22-Dec-2017 10:15




IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 8 of 106 
Study Endpoints 
Primary Endpoints 
• Primary Safety:  Incidence of TEAEs and study drug-related TEAEs  
• Primary Efficacy: Change from baseline in UACR over Weeks 8 and 12 
Statistical Methods  
Sample Size Determination 
Using an estimate of standard deviation of 0.67, a sample size of 40 patients per treatment 
group would provide approximately 80% power to detect a mean between-group difference 
of -0.376 units in change from baseline in log-transformed UACR over 12 weeks, with a one-
sided significance level of 0.05 for at least 1 dose versus placebo comparison. This difference 
corresponds to a 31% between-group reduction of geometric mean change from baseline in 
UACR. Assuming a drop-out rate of 20%, approximately 150 patients will be randomly 
assigned in a 1:1:1 ratio (approximately 50 patients per treatment group) to 20 mg IW-1973, 
40 mg IW-1973, or placebo. 
Analysis Populations 
Safety Population: The Safety Population will consist of all randomized patients who receive at 
least 1 dose of study drug. Patients in this population will be evaluated according to the 
treatment they actually received. 
Intent-to-Treat (ITT) Population: The ITT Population will consist of all randomized patients 
who receive at least 1 dose of study drug. Patients in this population will be evaluated 
according to the treatment group they were assigned at Randomization. 
PK Population: The PK Population will consist of all randomized patients who receive at least 
1 dose of study drug and have at least 1 postdose PK parameter assessment. 
Per-Protocol (PP) Population: The PP Population will consist of all ITT patients who did not 
have any major protocol deviations or dose reduction.  
Efficacy Analyses 
Corresponding with the primary efficacy objective of the trial, the primary inference for 
hypothesis testing is the treatment difference between the placebo group and the IW-1973 
groups on the change from baseline in log UACR over Weeks 8 and 12. The primary efficacy 
analysis will be conducted using the ITT population using a mixed-effects model repeated 
measures (MMRM) analysis with change from baseline in log-transformed UACR as the 
response variable, treatment, site, visit, treatment-by-visit interaction, and baseline eGFR 
stratum as fixed effects, and baseline log UACR and baseline mean arterial pressure as 
covariates with unstructured as the variance-covariance structure. Treatment differences 
between the pooled IW-1973 dose groups and the placebo group will be estimated overall. The 
null hypothesis of the test will be interpreted as equality between the placebo and pooled 
treatment groups, and rejection of the null hypothesis as evidence that the pooled IW-1973 
groups have a greater effect on lowering UACR than the placebo group. If the null hypothesis 
is rejected, the nature of these differences will be explored further by estimating the treatment 
differences between each IW-1973 dose group and the placebo group overall and at each 
assessment timepoint. Least square (LS) means, and LS mean differences between each 
Document Date: 22-Dec-2017 10:15




IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 10 of 106 
TABLE OF CONTENTS 
STUDY IDENTIFICATION ...........................................................................................................2
SYNOPSIS .......................................................................................................................................3
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS ................................................17
ELIGIBILITY CRITERIA .............................................................................................................21
INCLUSION CRITERIA .........................................................................................................21
EXCLUSION CRITERIA .......................................................................................................22
SCHEDULE OF EVENTS ............................................................................................................25
1.
INTRODUCTION .................................................................................................................28
1.1
DIABETIC NEPHROPATHY .....................................................................................28
1.2
THE NO-SGC-CGMP PATHWAY ............................................................................29
1.3
RATIONALE FOR USE OF AN SGC STIMULATOR IN DIABETIC 
NEPHROPATHY ........................................................................................................30
1.4
IW-1973 BACKGROUND ..........................................................................................30
1.4.1
Nonclinical Studies in Support of DN ...............................................................30
2.
STUDY OBJECTIVES ..........................................................................................................32
3.
INVESTIGATIONAL PLAN ................................................................................................33
3.1
OVERALL STUDY DESIGN AND PLAN ................................................................33
3.2
DISCUSSION OF STUDY DESIGN AND CONTROL GROUP ..............................35
3.3
STUDY DURATION ..................................................................................................35
3.4
STUDY POPULATION ..............................................................................................35
3.4.1
Study Population Description ............................................................................35
3.4.2
Removal of Patients from Therapy or Assessment ............................................36
3.4.3
Early Termination Procedures ...........................................................................37
3.4.4
Replacement Procedures ....................................................................................37
3.5
STUDY TREATMENT(S) ..........................................................................................37
3.5.1
Description of Treatment(s) ...............................................................................37
3.5.1.1
Investigational Product ............................................................................37
3.5.1.2
Placebo .....................................................................................................37
3.5.1.3
Packaging and Labeling ...........................................................................37
3.5.1.4
Dosage......................................................................................................38
3.5.1.5
Storage and Accountability ......................................................................38
3.5.2
Method of Assigning Patients to Treatment Groups ..........................................39
3.5.3
Selection of Dosage in the Study .......................................................................39
3.5.4
Selection and Timing of Dose for Each Patient and Dose Reduction ...............40
3.5.4.1
Study Drug Administration ......................................................................40
3.5.4.2
Dose Reduction ........................................................................................40
3.5.5
Treatment Compliance .......................................................................................40
Document Date: 22-Dec-2017 10:15




IW-1973 Tablets 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
20 December 2017 
Confidential 
Page 12 of 106 
3.8.12
Pharmacokinetic Assessments ...........................................................................57
3.8.13

3.9
STUDY ACTIVITIES .................................................................................................58
3.9.1
Screening Period (Day -45 to Day -1) ...............................................................58
3.9.1.1
Screening Visit (Days -45 to -15) ............................................................58
3.9.1.2
Baseline Visit (Days –7 ±3) .....................................................................59
3.9.2
Treatment Period (Day 1 to Day 87 ±3) ............................................................59
3.9.2.1
Randomization Visit (Day 1) ...................................................................59
3.9.2.2
Week 1 Visit (Day 8 ±1) ..........................................................................60
3.9.2.3
Week 4 Visit (Day 29 ±3) ........................................................................61
3.9.2.4
Week 8 Visit (Day 57 ±3) ........................................................................62
3.9.2.5
End of Treatment Visit (Day 87 ±3) ........................................................63
3.9.3
Follow-up Period (Day 87 ±3 to Day 115 ±3) ...................................................64
3.9.3.1
Follow-up Visit (Day 115 ±3) ..................................................................64
4.
STUDY ENDPOINTS ...........................................................................................................65
4.1
PRIMARY ENDPOINTS ............................................................................................65
4.1.1
Primary Safety ...................................................................................................65
4.1.2
Primary Efficacy ................................................................................................65
4.2
EXPLORATORY ENDPOINTS .................................................................................65






5.
STATISTICAL METHODS ..................................................................................................67
5.1
GENERAL CONSIDERATIONS ...............................................................................67
5.2
DETERMINATION OF SAMPLE SIZE ....................................................................67
5.3
ANALYSIS POPULATIONS .....................................................................................67
5.4
PATIENT DISPOSITION ...........................................................................................68
5.5
DEMOGRAPHICS AND BASELINE CHARACTERISTICS...................................68
5.6
DRUG EXPOSURE AND COMPLIANCE ................................................................68
5.7
PRIOR AND CONCOMITANT MEDICATIONS .....................................................68
5.8
MAJOR PROTOCOL DEVIATIONS .........................................................................69
5.9
EFFICACY ANALYSES ............................................................................................69
5.9.1
Controlling for Multiplicity ...............................................................................70
5.10
SAFETY ANALYSES.................................................................................................70
5.10.1
Adverse Events ..................................................................................................70
5.10.2
Clinical Laboratory Parameters .........................................................................71
5.10.3
Vital Signs ..........................................................................................................71
5.10.4
ECGs ..................................................................................................................71
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
20 December 2017 
Confidential 
Page 13 of 106 
5.10.5

5.11
PK 
 .....................................................................................72
5.12











5.13
DATA MONITORING COMMITTEE .......................................................................73
5.14
INTERIM ANALYSIS (OPTIONAL) ........................................................................74
5.15
CHANGES IN THE CONDUCT OF THE STUDY OR PLANNED ANALYSES ...74
6.
ETHICAL CONSIDERATIONS ...........................................................................................76
6.1
INSTITUTIONAL REVIEW BOARD ........................................................................76
6.2
PATIENT INFORMATION AND INFORMED CONSENT .....................................76
7.
INVESTIGATORS AND STUDY ADMINISTRATIVE STRUCTURE ............................78
7.1
GENERATION OF STUDY RECORDS ....................................................................78
7.2
DATA QUALITY ASSURANCE ...............................................................................79
7.3
ELECTRONIC CASE REPORT FORMS AND DATA MANAGEMENT ...............79
7.4
STUDY MONITORING .............................................................................................79
8.
STUDY SPONSORSHIP.......................................................................................................81
8.1
INVESTIGATOR AND STUDY TERMINATION ...................................................81
8.2
REPORTING AND PUBLICATION ..........................................................................81
9.
INVESTIGATOR OBLIGATIONS ......................................................................................82
9.1
DOCUMENTATION ..................................................................................................82
9.2
PERFORMANCE ........................................................................................................84
9.3
USE OF INVESTIGATIONAL MATERIALS ...........................................................84
9.4
RETENTION AND REVIEW OF RECORDS ...........................................................84
9.5
PATIENT CONFIDENTIALITY ................................................................................85
10. REFERENCE LIST ...............................................................................................................86
11. SPONSOR SIGNATURES ....................................................................................................89
12. INVESTIGATOR’S SIGNATURE .......................................................................................90
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 14 of 106 
LIST OF IN-TEXT TABLES 
Table 1.
Key Study Participants .........................................................................................2
Table 2.
Dosage by Week ................................................................................................38
Table 3.
Categories of SAEs Triggering Individual Stopping Criteria and Safety 
Committee Review ............................................................................................44
Table 4.
Clinical Laboratory Tests ...................................................................................50
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 15 of 106 
LIST OF IN-TEXT FIGURES 
Figure 1.
Study Schematic ................................................................................................33
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 16 of 106 
LIST OF APPENDICES 
Appendix 1
Prohibited Medicines and Supplements .............................................................91
Appendix 2

Appendix 3

Appendix 4

 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 17 of 106 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
Abbreviation 
Term 
ABPM 
ambulatory blood pressure monitoring 
ACEi 
angiotensin-converting enzyme inhibitor 
AE 
adverse event 
ALT 
alanine aminotransferase 
AOBP 
automated office blood pressure 
ARB 
angiotensin receptor blocker 
AST 
aspartate aminotransferase 
 
 
BID 
twice daily 
BMI 
body mass index (kg/m2) 
BP 
blood pressure 
BUN 
blood urea nitrogen 
CBC 
complete blood count 
cGMP 
cyclic guanosine 3’, 5’-monophosphate 
CKD-EPI 
Chronic Kidney Disease Epidemiology Collaboration  
 
 
CMH 
Cochran-Mantel-Haenszel 
CYP3A 
cytochrome P450 3A 
DBP 
diastolic blood pressure 
DMC 
Data Monitoring Committee 
DN 
diabetic nephropathy 
DNA 
deoxyribonucleic acid 
ECG 
electrocardiogram 
eCRF 
electronic case report form 
EDC 
electronic data capture 
eGFR 
estimated glomerular filtration rate (mg/mL/1.73 m2) 
eNOS 
endothelial nitric oxide synthase 
 
 
ESRD 
end-stage renal disease 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 18 of 106 
Abbreviation 
Term 
FDA 
Food and Drug Administration 
FPG 
fasting plasma glucose 
FPI 
fasting plasma insulin  
GCP 
good clinical practice 
GGT 
gamma glutamyl transferase  
GI 
gastrointestinal 
GLP 
good laboratory practice 
h 
hour(s)  
HbA1c 
hemoglobin A1c (glycated hemoglobin) 
HBsAG 
hepatitis B surface antigen 
HCV 
hepatitis C virus 
HDPE 
high-density polyethylene 
hERG 
ether-à-go-go related gene 
HIV 
human immunodeficiency virus 
HOMA-IR 
homeostatic model assessment to quantify insulin resistance 
HPF 
high power field 
HR 
heart rate 
IC50 
half maximal inhibitory concentration 
ICF  
informed consent form 
ICH 
International Conference on Harmonisation 
IRB 
Institutional Review Board 
ITT 
intent to treat 
IUD 
intrauterine device 
IWRS 
interactive web response system 
KDIGO 
Kidney Disease: Improving Global Outcomes 
 
 
kg 
kilogram 
kg/m2 
kilograms/meters squared (body mass index) 
LDH 
lactate dehydrogenase  
L-NAME 
L-nitroarginine methyl ester 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 19 of 106 
Abbreviation 
Term 
LS 
least square 
m 
minute  
MAD 
multiple ascending dose 
MAP 
mean arterial pressure 
MCH 
mean corpuscular hemoglobin 
MCHC 
mean corpuscular hemoglobin concentration 
MCV 
mean corpuscular volume 
MedDRA 
Medical Dictionary for Regulatory Activities 
MEMS 
Medication Event Monitoring System 
mg 
milligram 
MI 
myocardial infarction 
mL 
milliliter 
mm Hg 
millimeters of mercury 
MMRM 
mixed-effects model repeated measures 
MPV 
mean platelet volume 
msec 
millisecond 
NO 
nitric oxide 
NT-proBNP 
N-terminal pro B-type natriuretic peptide  
NYHA 
New York Heart Association  
PEG 
polyethylene glycol 
pd 
postdose 
 
 
PDE 
phosphodiesterase 
 
 
 
 
PID 
patient identification 
PK 
pharmacokinetic(s) 
PKG 
protein kinase G 
PP 
per protocol 
PRN 
pro re nata [ie, as needed]  
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 20 of 106 
Abbreviation 
Term 
PT 
preferred term 
QD 
once daily  
QTcF 
QT interval corrected using Fridericia’s formula 
RAAS 
renin-angiotensin-aldosterone system 
SAE 
serious adverse event 
SBP 
systolic blood pressure 
Scr 
serum creatinine 
sGC 
soluble guanylate cyclase 
SOC 
system organ class 
tau 
dosing interval 
TEAE 
treatment-emergent adverse event 
UACR 
urine albumin creatinine ratio 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 21 of 106 
ELIGIBILITY CRITERIA 
INCLUSION CRITERIA 
Patients must meet all of the following criteria to be eligible for enrollment in this study: 
1. Patient has signed an informed consent form (ICF) before any study-specific procedures are 
performed. 
2. Patient is an ambulatory male or female from 25 to 75 years old at the Screening Visit. 
3. Patient has type 2 diabetes diagnosed by a physician or nurse practitioner 6 months before 
the Screening Visit, has been on 1 antihyperglycemic medication for 12 weeks preceding 
the Randomization Visit, and has been on a stable regimen (ie, same drug and same dose) of 
1 antihyperglycemic medication for 28 days preceding the Randomization Visit. 
(Modification of short-acting insulin throughout the Screening Period will not affect 
eligibility.) 
4. Patient has been on a stable regimen (ie, same drug and dose) of an angiotensin-converting 
enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB), for 28 days preceding 
the Randomization Visit and is expected to remain on their regimen through the Follow-up 
Visit. (Note: These medications may be modified during the study if medically necessary.) 
5. If patient is on medications for hypertension, regimen (drug[s] and dose[s]) must be stable 
for 28 days preceding the Randomization Visit and is expected to remain stable through the 
Follow-up Visit. (Note: Medications for antihypertension may be modified during the study 
if medically necessary.) 
6. Patient has the following:   
a. Estimated glomerular filtration rate (eGFR) 30 to 75 mL/min/1.73 m2 by the Chronic 
Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation (1) at the 
Screening and Baseline Visits 
b. Urine albumin creatinine ratio (UACR) >200 mg/g and <5000 mg/g at the Screening and 
Baseline Visits (at the Baseline Visit, the mean of the 2 first morning void tests will be 
used to determine eligibility) 
c. Serum albumin >3.0 g/dL at the Screening and Baseline Visits 
d. Hemoglobin A1c (HbA1c) 12% at the Screening and Baseline Visits 
e. Systolic blood pressure (BP) of 110 to 160 mm Hg based on the average of 3 seated 
automated office blood pressure (AOBP) measurements at the Screening and Baseline 
Visits 
7. Female patient must be postmenopausal (no menses for 12 consecutive months); surgically 
sterile (ie, bilateral oophorectomy, hysterectomy, or tubal sterilization [tie, clip, band, or 
burn]); must agree to completely abstain from heterosexual intercourse; or, if heterosexually 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 22 of 106 
active, must agree to use 1 of the following methods of birth control from the date she signs 
the ICF until 60 days after the final dose of study drug: 
a. Progesterone implant or an intrauterine device (IUD) 
b. Combination of 2 highly effective birth control methods (eg, diaphragm with spermicide 
plus a condom, condom with spermicide plus a diaphragm or cervical cap, hormonal 
contraceptive [eg, oral and transdermal patch] plus a barrier method, partner with 
vasectomy [conducted 60 days before the Screening Visit or confirmed via sperm 
analysis] plus a hormone/barrier method).  
8. Male patients must be surgically sterile by vasectomy (conducted 60 days before the 
Screening Visit or confirmed via sperm analysis), must agree to completely abstain from 
heterosexual intercourse, or, if heterosexually active, must agree to use a combination of 
2 highly effective birth control methods (eg, condom with spermicide plus partner IUD, 
condom with spermicide plus a partner diaphragm or cervical cap, partner hormonal 
contraceptive [including progesterone implant] plus a barrier method, or postmenopausal 
partner [no menses for 1 year or 12 consecutive months] plus barrier method) from the 
Screening Visit through 60 days after the final dose of study drug. 
9. Patient must agree not to make any major lifestyle (eg, diet, exercise) changes from the 
Screening Visit through the Follow-up Visit. 
 
EXCLUSION CRITERIA 
Patients who meet any of the following criteria will not be eligible to participate in the study: 
1. Patient has a history of secondary hypertension (ie, renal artery stenosis, primary 
aldosteronism, or pheochromocytoma). 
2. Patient has a body mass index (BMI) <20 or >45 kg/m2 at the Screening Visit. 
3. Patient has elevated (>1.5× the upper limit of normal as defined by laboratory) levels of 
alanine aminotransferase (ALT) or aspartate aminotransferase (AST) at the Screening or 
Baseline Visits. 
4. Patient has hemoglobin level <9 g/dL at the Screening or Baseline Visit. 
5. Patient has a 12-lead electrocardiogram (ECG) demonstrating severe bradycardia (heart rate 
<50 beats per minute) or QTcF is 450 msec for male patients or is 470 msec for female 
patients at the Screening or Baseline Visit. (NOTE: If on initial ECG, QTcF exceeds the 
limit, the ECG will be repeated 2 more times, and the average of the 3 QTcF values will be 
used to determine the patient's eligibility at the Screening and Baseline Visits.) 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 23 of 106 
6. Patient has any history of platelet dysfunction, hemophilia, von Willebrand disease, 
coagulation disorder, other bleeding diathesis, or significant, nontraumatic bleeding episodes, 
such as from a gastrointestinal (GI) source. 
7. Patient has hepatic impairment defined as Child-Pugh A, B, C. 
8. Patient has significant comorbidities (eg, malignancy, advanced liver disease, pulmonary 
hypertension, pulmonary fibrosis, lung disease requiring supplemental oxygen) or other 
significant conditions, including clinically significant abnormality(ies) in laboratory values, 
that, in the Investigator’s opinion, would limit the patient’s ability to complete or participate 
in this clinical study; has been hospitalized for cardiovascular, renal, or metabolic cause in 
the 3 months before the Screening Visit; or has a life expectancy of less than 1 year. 
9. Patient has a history of a chronic GI disease, which in the Investigator's opinion could cause 
significant GI malabsorption. 
10. Patient with known nondiabetic renal disease (eg, known polycystic kidney disease, focal 
segmental glomerulosclerosis) or nondiabetic etiology of renal function compromise. 
Concomitant hypertension-associated nephrosclerosis superimposed on diabetic nephropathy 
is acceptable. 
11. Patient has had prior dialysis, renal transplant, or planned renal transplant. (Prior dialysis 
does not include transient, short-term dialysis indicated for an illness or during acute 
hospitalization. This “transient” dialysis must have occurred >3 months prior to 
Randomization, must have been <7 days in duration, and the current eGFR must be stable 
and within the eligible range [>30 mL/min/1.73 m2].) 
12. Patient has clinically active, symptomatic, or unstable coronary artery or heart disease within 
the 3 months before the Screening Visit, defined as 1 of the following: 
a. Hospitalization for myocardial infarction (MI), unstable angina, or heart failure 
b. New-onset angina with positive functional study or coronary angiogram revealing 
stenosis 
c. Coronary revascularization procedure 
13. Patient has a documented history of New York Heart Association (NYHA) Class III or IV 
heart failure.(2)  A prior brief/transient NYHA Class III or IV designation is not exclusionary 
provided that, at Randomization, the status is Class II or better and has been stable without 
deterioration into a more severe class for 3 months.  
14. Patient has a positive hepatitis panel (hepatitis B surface antigen [HBsAg] and antihepatitis C 
virus [HCV]) or human immunodeficiency virus (HIV) antibody at the Screening Visit. 
15. Patient has a history of viral or bacterial infection within 4 weeks of the Screening Visit. 
16. Patient has had surgery with general anesthesia in the 12 weeks before the Screening Visit or 
has scheduled or planned surgery with general anesthesia during the study. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 24 of 106 
17. Patient has a history of active alcoholism or drug addiction during the year before the 
Screening Visit or, at the Screening Visit, has a positive drug screen for drugs not legally 
prescribed. 
18. Patient is taking specific inhibitors of phosphodiesterase 5 (PDE5), nonspecific inhibitors of 
PDE5 (including dipyridamole and theophylline), any supplements for the treatment of 
erectile dysfunction, riociguat, or nitrates or nitric oxide (NO) donors in any form. These 
medications and supplements are prohibited from 7 days before Randomization through the 
duration of the study.  
Patient is taking strong cytochrome P450 3A (CYP3A) inhibitors, examples of which include 
azole antifungals, macrolide antibiotics, protease inhibitors, and diltiazem. These 
medications and excessive grapefruit intake are prohibited 14 days before Randomization 
through the duration of the trial. 
See Appendix 1 for a more detailed list of prohibited medications and supplements. 
19. Female patient who may wish to become pregnant and/or plan to undergo egg donation or 
egg harvesting for current or future in vitro fertilization during the study and for at least 
60 days after the final dose of study drug. 
20. Male patient unwilling to refrain from sperm donation during the study and for at least 
60 days after the final dose of study drug. 
21. Patient has a history of clinically significant hypersensitivity or allergies to any of the 
inactive ingredients contained in the active or placebo drug products. 
22. Patient has previously received IW-1973 in a study, or received an investigational drug 
during the 30 days or 5 half-lives of that investigational drug (whichever is longer) before the 
Screening Visit, or is planning to receive another investigational drug at any time during the 
study. 
23. Female patient is pregnant or nursing at the Screening Visit. Nursing is not allowed from the 
Screening Visit through the Follow-up Visit. 
24. Patient will not be able to adhere to the trial assessment schedule, or, in the clinical judgment 
of the Investigator, the patient is otherwise not suitable for the trial. 
 
Note: Screening Visit assessments may take place over more than 1 day. Patients may be 
rescreened should they discontinue in the Screening Period due to visit window deviations or 
other administrative reasons. In addition, laboratory values or BPs that are outside the range 
specified in the protocol may be repeated to confirm eligibility during the Screening Period at the 
Investigator’s discretion after consultation with the Medical Monitor.
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 25 of 106 
SCHEDULE OF EVENTS 
 
Visit Days ĺ 
Study Procedure Ļ 
Screening Period 
Treatment Period 
Follow-up 
Period 
Screening 
Visit 
(Day -45 
to -15) 
Baseline 
Visit 
(Day -7 
±3) 
Randomization 
Visit 
(Day 1) 
Week 1 Visit 
(Day 8 ±1) 
Week 4 Visit 
(Day 29 ±3) 
Week 8 Visit 
(Day 57 ±3) 
End of 
Treatment 
Visit 
(Day 87 ±3) 
Follow-up 
Visit 
(Day 115 ±3) 
ICF signed 
X 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
Prior & concomitant meds 
X 
X 
X 
X 
X 
X 
X 
X 
Inclusion/exclusion 
evaluation/review 
X 
X 
X 
 
 
 
 
 
Physical exam 
X 
 
 
 
 
 
X 
 
Hepatitis (HBsAg, HCV) & 
HIV screen 
X 
 
 
 
 
 
 
 
Drug screen (a) 
X 
 
 
 
 
 
 
 
Urine pregnancy test (b) 
X 
X 
predose 
predose 
predose 
predose 
predose 
X 
Weight (W) & height (H) 
W, H 
W 
W 
W 
W 
W 
W 
W 
12-lead ECG (c) 
X 
X 
 
 
 
 
predose 
 
Respiratory rate and oral 
temperature  
X 
 
pre: 0 (30m) 
pd: 1h (±15m) 
pre: 0 (30m) 
pd: 1h (±15m)
 
 
X 
X 
Seated pulse and BP (d) 
X 
X 
 
 
 
 
 
 
First-void urine for UACR (e) 
X 
preVisit 
preVisit 
preVisit 
 preVisit 
 preVisit 
 preVisit 
preVisit 
Issue UACR sample supplies 
X 
X 
X 
X 
X 
X 
X 
 
Urinalysis sample (f) 
X 
X 
 
 
 
 
predose 
X 
Serum chemistry, coagulation, 
hematology (f) 
X 
X 
serum creatinine 
& glucose only 
pre: 0 (30m) 
serum creatinine 
& glucose only 
pre: 0 (30m) 
pre: 0 (30m) 
serum creatinine 
& glucose only 
pre: 0 (30m) 
pre: 0 (30m)
X 
Hemoglobin A1c (f) 
X 
X 
 
pre: 0 (30m) 
pre: 0 (30m) 
pre: 0 (30m) 
pre: 0 (30m)
X 
Adverse event evaluations 
X 
X 
X 
X 
X 
X 
X 
X 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
20 December 2017 
Confidential 
Page 26 of 106 
Visit Days ĺ 
Study Procedure Ļ 
Screening Period 
Treatment Period 
Follow-up 
Period 
Screening 
Visit 
(Day -45 
to -15) 
Baseline 
Visit 
(Day -7 
±3) 
Randomization 
Visit 
(Day 1) 
Week 1 Visit 
(Day 8 ±1) 
Week 4 Visit 
(Day 29 ±3) 
Week 8 Visit 
(Day 57 ±3) 
End of 
Treatment 
Visit 
(Day 87 ±3) 
Follow-up 
Visit 
(Day 115 ±3) 
Fasting plasma glucose & 
insulin (f) 
X 
pre: 0 (30m) 
pre: 0 (30m) 
pre: 0 (30m) 
pre: 0 
(30m) 
Urine cotinine 
predose 
24- or 12-h ABPM (h)
X (24h)
X (12h) 
X (12h) 
X (24h) 
Return of ABPM monitor 
X 
X 
X 
X 
Orthostatic (seated to 
standing) pulse and BP (i) 
pre: 0 (30m) 
pd: 1,2,4,6h 
(±15m) 
pre: 0 (30m) 
pd: 1,2,4,6h 
(±15m) 
pre: 0 (30m) 
pre: 0 (30m) 
pre: 0 
(30m) 
X 
Randomization
 
X
MEMS instruction/review 
X 
X
X
X
Study drug dispensed 
X 
X 
X 
In-clinic study drug 
administration (j) 
X
X
X
X
X
Study drug return (k)
X
X
X
X
Pharmacokinetic blood 
samples  
pre: 0 (30m) 
pd: 1,3,6h 
(±15m) 
pre: 0 (30m) 
pd: 1,3,6h 
(±15m) 
pre: 0 (30m) 
pre: 0 (30m) pre: 0 (30m) 
pd: 3h (±15m)
X 
Study completion 
X
Document Date: 22-Dec-2017 10:15




IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 28 of 106 
1. 
INTRODUCTION 
1.1 
DIABETIC NEPHROPATHY 
Diabetic nephropathy (DN), also known as diabetic kidney disease, is a common and serious 
complication of Type 1 and Type 2 diabetes mellitus and is characterized by pathological urinary 
albumin excretion, glomerular lesions, hypertension, and progressive loss of renal function.(3-5) 
Diagnosis is based on the presence of albuminuria (urine albumin creatinine ratio [UACR] 
>30 mg/g) and/or reduced estimated glomerular filtration rate (eGFR <90 mL/min/1.73 m2) in 
patients with diabetes.(6) The Kidney Disease: Improving Global Outcomes (KDIGO) Clinical 
Practice Guideline (7) provides a kidney disease classification system and risk-stratifies patients 
based on levels of albuminuria and eGFR.  
Diabetic nephropathy is the leading cause of end-stage renal disease (ESRD) in the United States 
and other industrialized countries.(8,9) Diabetic nephropathy is also a major risk factor for 
cardiovascular disease as well as the single strongest predictor of mortality in patients with 
diabetes. An estimated 20% to 40% of patients with diabetes develop DN, with higher rates seen 
in middle-aged African Americans, Hispanics, and American Indians.(3,9) The prevalence of 
DN is increasing in the United States and globally with the increasing prevalence of 
diabetes.(9,10) The estimated number of persons in the United States with DN has increased 
from 3.9 million in 1988-1994 to 6.9 million in 2005-2008.(9) 
Current first-line therapy for DN includes glycemic and blood pressure (BP) control and 
treatment with renin-angiotensin-aldosterone system (RAAS) inhibitors: angiotensin-converting-
enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs).(3,4,6) RAAS inhibitors 
have been shown in clinical trials to reduce albuminuria and delay progression to ESRD and 
renal replacement therapy. However, the current standard of care does not prevent progression to 
ESRD, and the prevalence of DN has not declined with increased use of RAAS inhibitors and 
glucose-lowering medications.(9) The burden of caring for DN patients is extremely high due to 
the cost of treating ESRD as well as the strong association of DN with cardiovascular disease.(3) 
New therapies for DN are urgently needed. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 29 of 106 
1.2 
THE NO-SGC-CGMP PATHWAY 
Although the pathogenesis of DN is not completely understood, nitric oxide (NO) deficiency 
resulting from endothelial dysfunction is believed to play an important role.(11,12) In the healthy 
endothelium, the enzyme endothelial nitric oxide synthase (eNOS) catalyzes the conversion of 
L-arginine to NO. Locally generated NO stimulates soluble guanylate cyclase (sGC) to produce 
cyclic guanosine 3’, 5’-monophosphate (cGMP), which acts on downstream targets including 
cGMP-dependent protein kinases (PKG), phosphodiesterases, and ion channels. NO-sGC-cGMP 
signaling promotes the relaxation of vascular smooth muscles cells and blocks endothelial cell 
activation and cytokine-induced injury in the kidney and elsewhere.(13) Intracellular cGMP also 
plays a role in processes that affect vascular proliferation (14), fibrosis (15,16), and 
inflammation.(17)  
Diabetes patients show evidence of vascular endothelial dysfunction (18,19), and endothelial 
dysfunction promotes the progression of DN.(18) In patients with diabetes, endothelial NO 
bioavailability may be reduced by several mechanisms, including the generation of advanced 
glycation end-products, increased uric acid levels, increased levels of the eNOS inhibitor 
asymmetric dimethyl arginine, and increased oxidative stress.(11,12) High levels of glucose also 
induce the uncoupling of endothelial eNOS, resulting in decreased production of NO and 
increased production of superoxide. Superoxide can react with NO to produce peroxynitrite, 
further reducing NO bioavailability. 
Animal model data suggest that NO deficiency plays a role in the pathogenesis of DN. Animal 
models of diabetes generally produce only early signs of kidney disease, but models of diabetes 
in the context of NO deficiency, such as the diabetic eNOS-knockout mouse model, show 
features more consistent with human DN, including nephrotic albuminuria, systemic 
hypertension, glomerular hypertension, tubulointerstitial damage, and glomerular ischemia and 
fibrosis.(11,20) In a rat model of obstructive nephropathy, treatment with the eNOS inhibitor 
L-nitroarginine methyl ester (L-NAME) resulted in increased renal fibrosis and apoptosis, 
reduced blood flow, and reduced filtration rates.(21) In another study using a sub-total 
nephrectomized rat model, eNOS inhibition by L-NAME resulted in impaired autoregulation of 
glomerular blood flow and increased renal injury.(22) Recently, Ueda et al (23) showed that 
endothelial NO is required for mitochondrial integrity in cultured podocytes. They also showed 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 30 of 106 
that eNOS-knockout mice exhibit morphologic evidence of podocyte damage and develop 
oxidative stress associated with podocyte mitochondrial abnormalities. Overall, these data 
indicate that NO deficiency may be involved in producing renal damage by multiple 
mechanisms. 
1.3 
RATIONALE FOR USE OF AN SGC STIMULATOR IN DIABETIC 
NEPHROPATHY 
Pharmacologic stimulation of sGC could offer a new approach for treating DN.(24,25) By 
increasing intracellular cGMP levels, sGC stimulators could potentially compensate for deficient 
NO bioavailability and thereby improve renal endothelial function and attenuate or prevent renal 
inflammation and fibrosis. Both sGC stimulators (which act synergistically with NO on the 
native, heme-containing form of the enzyme) and sGC activators (which act independently of 
NO on the heme-free form of the enzyme) have shown activity in multiple animal models of DN 
and other kidney diseases.(24) For example, in the diabetic eNOS-knockout mouse model of DN, 
treatment with the sGC stimulator riociguat in combination with the ARB telmisartan reduced 
systemic BP, albuminuria, and renal interstitial fibrosis.(26) In another set of studies,(27) 
riociguat was found to reduce mortality, normalize systemic BP, and reduce renal damage in 
low- and high-renin models of hypertension in the rat. Furthermore, the sGC activator cinaciguat 
reversed impaired autoregulation of renal blood flow induced by L-NAME in rats.(28) In a 
recent study using the obese ZSF1 rat model of Type 2 DN, treatment with the sGC activator BI 
703704 resulted in significant reductions in albuminuria, glomerulosclerosis, and interstitial 
fibrosis, despite only modest reductions in systemic BP. Together, these nonclinical data provide 
the rationale for the investigation of sGC stimulators in patients with DN.  
1.4 
IW-1973 BACKGROUND 
For a detailed description of the properties of IW-1973 and the results of the nonclinical and 
clinical studies conducted thus far, please refer to the most recent Investigator’s Brochure.  
1.4.1 
Nonclinical Studies in Support of DN 
IW-1973 is a potent and selective stimulator of sGC. In vitro, IW-1973 was shown to sensitize 
sGC to endogenous NO, and to directly stimulate sGC independently of NO. IW-1973 also 
potently relaxed precontracted human subcutaneous resistance arteries ex vivo. Oral 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 31 of 106 
administration of IW-1973 to normotensive and spontaneously hypertensive rats and to 
normotensive dogs was shown to elicit a dose-dependent decrease in systolic, diastolic, and 
mean arterial BP, as well as a concomitant rise in heart rate. 
IW-1973 stimulated purified human recombinant sGC to produce cGMP in a concentration-
responsive manner, both in the absence and in the presence of an NO donor. The EC50 value was 
267 nM in the presence of NO; the production of cGMP was lower in the absence of NO than in 
the presence of NO. In vitro, IW-1973 showed anti-fibrotic and anti-inflammatory effects in 
human renal proximal tubular cells. In the Dahl salt-sensitive rat model of hypertension and end-
organ damage, orally administered IW-1973 demonstrated a dose-dependent (1-10 mg/kg/day) 
reduction in BP that was sustained over a 6-week treatment period. Treatment with IW-1973 also 
decreased albuminuria and attenuated levels of serum biomarkers known to be involved in 
inflammatory and fibrotic processes. Histopathological analysis of the kidneys showed a clear 
reduction at all doses in glomerulosclerosis, interstitial fibrosis, vascular alterations and 
interstitial inflammation. Additionally, in this model, IW-1973 demonstrated significant 
reductions in heart hypertrophy and reduced levels of plasma N-terminal pro B-type natriuretic 
peptide (NT-proBNP), a marker of cardiac injury. In the ZSF1 rat model of DN, IW-1973 
(10 mg/kg/day) reduced mean arterial pressure (MAP), kidney and liver weight gain, urine 
volume, proteinuria, and fasting glucose in comparison with untreated controls. Similar effects 
were observed with IW-1973 in combination with enalapril. These results support investigation 
of IW-1973 as a potential treatment for DN. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 32 of 106 
2. 
STUDY OBJECTIVES 
Primary 
• To assess the safety and tolerability of oral IW-1973 when administered daily for 
approximately 12 weeks to adult patients with type 2 diabetes mellitus with albuminuria who 
are on a stable regimen of renin-angiotensin system inhibitors  
• To evaluate the effect of oral IW-1973 on renal function when administered daily for 
approximately 12 weeks to adult patients with type 2 diabetes mellitus with albuminuria who 
are on a stable regimen of renin-angiotensin system inhibitors 
 
Exploratory 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 33 of 106 
3. 
INVESTIGATIONAL PLAN 
3.1 
OVERALL STUDY DESIGN AND PLAN 
This Phase 2, multicenter, randomized, double-blind, placebo-controlled, parallel-group study 
will evaluate 2 dose levels of IW-1973 compared with placebo. The study will enroll 
approximately 150 patients with type 2 diabetes mellitus and albuminuria who are on a steady 
regimen of a RAAS inhibitor, such as an ACEi or an ARB (see Eligibility Criteria). Patients will 
be stratified by baseline eGFR (ie, eGFR 30 to 45, >45 to 60, and >60 to 75 mL/min/1.73 m2) 
and randomized in a 1:1:1 ratio to receive daily 20 mg IW-1973 Tablets, 40 mg IW-1973 
Tablets, or placebo tablets for daily for approximately 12 weeks.  
Each patient will progress through 3 distinct study periods (Figure 1).  
Figure 1. 
Study Schematic 
 
 
Screening Period: The Screening Period will begin with the signature of the informed consent 
form (ICF) at the Screening Visit and may last up to 45 days. At the Screening Visit (which can 
occur from Day -45 to Day -15), patients will undergo preliminary screening procedures to 
determine their eligibility. Eligible patients will return to the clinic for the Baseline Visit 
(Day -7 ±3) for baseline and eligibility assessments including 24-hour ambulatory blood pressure 
Follow-up
Visit
(Day 115 ±3)
Screening
Visit
(Day -45 to -15)
Randomization
Visit
(Day 1)
End of Treatment
Visit
(Day 87 ±3)
Screening 
Period 
Treatment
Period
Follow-up 
Period
15 to 45 days
87 (±3) days
28 (±3) days
Week 1 
Visit
(Day 8 ±1)
Baseline
Visit
(Day -7 ±3)
Week 4
Visit
(Day 29 ±3)
Week 8
Visit
(Day 57 ±3)
40 mg IW-1973
20 mg IW-1973
Placebo
BID
QD
1
2 to 12
Dosing
Week
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 34 of 106 
monitoring (ABPM). The end of the Screening Period will coincide with the beginning of the 
Treatment Period. 
Treatment Period: The Treatment Period will begin on Day 1 at Randomization and will end 
after the End of Treatment Visit on Day 87 (±3). Patients will be stratified by baseline eGFR 
(ie, eGFR 30 to 45, >45 to 60, and >60 to 75 mL/min/1.73 m2) and randomized in a 1:1:1 ratio to 
receive daily 20 mg IW-1973, 40 mg IW-1973, or placebo daily for approximately 12 weeks; 
each daily dose will comprise 2 tablets. Dosing on Days 1 to 7 (±1) will be BID (twice daily), 
1 tablet in the morning and 1 tablet approximately 12 hours later in the evening; dosing on Day 8 
(±1) onward will be QD (once daily), 2 tablets in the morning.  
At the Randomization Visit on Day 1, patients will receive their morning dose of study drug in 
the clinic and will undergo safety, efficacy, and PK assessments, including blood and urine 
collections at prespecified times (see Schedule of Events). Patients must stay in the clinic at least 
6 hours postdose and may leave the clinic at the Investigator’s discretion following all study 
procedures.  
At the Week 1 Visit on Day 8 (±1), patients will return to the clinic and receive their first QD 
dose of study drug in the clinic. Patients will undergo safety, efficacy, and PK assessments, 
including blood and urine collections at prespecified times (see Schedule of Events). Patients 
must stay in the clinic at least 6 hours postdose and may leave the clinic at the Investigator’s 
discretion following all study procedures.  
At the Week 4 (Day 29 ±3), Week 8 (Day 57 ±3), and End of Treatment (Day 87 ±3) Visits, 
patients will return to the clinic for study drug administration; safety, efficacy, and PK 
assessments; and study drug, if applicable (see Schedule of Events). 
Follow-up Period: The Follow-up Period will begin immediately after the End of Treatment 
Visit and will last for 28 (±3) days. At the Follow-up Visit on Day 115 (±3), patients will return 
to the clinic for final study assessments (see Schedule of Events). 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 35 of 106 
3.2 
DISCUSSION OF STUDY DESIGN AND CONTROL GROUP 
A double-blind, placebo-controlled, randomized study design was chosen to provide comparable 
treatment groups and minimal chance of selection or investigator bias in accordance with the 
concepts in ICH E10, Choice of Control Groups and Related Issues in Clinical Trials 
(International Conference on Harmonisation of Technical Requirements for Registration of 
Pharmaceuticals for Human Use, 2001). Placebo was chosen as the control so that the rate of 
spontaneously occurring AEs can be determined and to reduce the potential for bias in the 
reporting of AEs.  
This study has a 12-week Treatment Period to compare the effects of IW-1973 to a placebo 
control. The treatment duration of 12 weeks is sufficient in length to observe changes in UACR 
and hemodynamic measures, and in addition to establish a difference in treatment effect between 
IW-1973 and placebo in these measures.(29)  
Patients will be stratified by baseline eGFR to minimize the potential impact of baseline disease 
severity imbalance between treatment groups. Individual stopping criteria and Data Monitoring 
Committee safety reviews (Section 3.7) have been established to ensure that dosing will stop 
should a safety signal be detected. Patients will have a Follow-up Visit 28 (±3) days after the 
final dose of study drug to determine if any AEs have developed and if any AEs that were 
ongoing at the time of Discharge have resolved. In addition, at the Follow-up Visit as well at 
each study visit, female patients of reproductive potential will have a pregnancy test. 
3.3 
STUDY DURATION  
Patients will receive daily oral study drug for up to 90 days. Total patient participation will be 
131 to 163 days, including the Screening, Treatment, and Follow-up Periods.  
3.4 
STUDY POPULATION  
3.4.1 
Study Population Description 
This study will enroll approximately 150 adult patients with type 2 diabetes mellitus and 
albuminuria at multiple sites in the US. Patients must have type 2 diabetes diagnosed by a 
physician or nurse practitioner no fewer than 6 months before the Screening Visit and must have 
been taking at least 1 medication specifically for control of glycemia, either oral or injectable, for 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 36 of 106 
at least 12 weeks before the Randomization Visit and have been on a stable regimen (ie, same 
drug and same dose) for at least 28 days preceding the Randomization Visit. To be eligible, 
patients must have a hemoglobin A1c (HbA1c) level of 12%. At Screening, patients must also 
have an eGFR of 30 to 75 mL/min/1.73 m2 (Chronic Kidney Disease Epidemiology 
Collaboration [CKD-EPI] creatinine equation), UACR >200 and <5000 mg/g, and serum 
albumin >3.0 g/dL. In addition, patients must have been on a stable regimen (ie, same drug and 
dose) of an ACEi or an ARB, for at least 28 days before the Randomization Visit. Patients must 
have systolic BP of 110 to 160 mm Hg, and if taking medications for hypertension, regimen must 
be stable for at least 28 days preceding the Randomization Visit. Patients with known 
nondiabetic renal disease are not eligible. 
Refer to Eligibility Criteria for full inclusion and exclusion criteria. 
3.4.2 
Removal of Patients from Therapy or Assessment 
A premature discontinuation will occur when a patient who has signed the ICF and has been 
randomized ceases participation in the study. 
A patient will be considered to have completed the study after completing the Follow-up Visit. 
Patients will be informed that they are free to withdraw from the study at any time and for any 
reason. The Investigator may remove a patient from the study if, in the Investigator’s opinion, it 
is not in the best interest of the patient to continue the study. Patients may also be discontinued 
from the study by the Investigator or the Sponsor at any time for any reason, including the 
following: 
• Adverse event(s) 
• Protocol violation, including lack of compliance 
• Lost to follow-up (every effort should be made to contact the patient; a certified letter should 
be sent) 
• Withdrawal of consent (attempts should be made to determine the reason for the patient 
withdrawing consent if possible) 
• Study termination by the Sponsor 
• Other reasons (eg, administrative reasons or pregnancy) 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 37 of 106 
The Sponsor will be notified of any patient discontinuation after Randomization. The date the 
patient is withdrawn from the study and the reason for discontinuation will be recorded on the 
study termination form of the electronic case report form (eCRF). Patients who discontinue from 
the study will be followed until resolution of all their AEs or until the unresolved AEs are judged 
by the Investigator to have stabilized. 
If a patient does not return for a scheduled visit, the study center should contact the patient. An 
effort should be made to contact the patient, including sending a certified letter. In every case, 
the patient outcome, including lost to follow-up information, will be documented. 
3.4.3 
Early Termination Procedures 
Patients who prematurely discontinue study drug for any reason should complete the assessments 
required at the End of Treatment Visit at the time of their discontinuation and should complete 
the Follow-up Visit 28 ±3 days after their final dose of study drug.  
3.4.4 
Replacement Procedures 
Patients withdrawing from the study after Randomization will not be replaced. 
3.5 
STUDY TREATMENT(S) 
3.5.1 
Description of Treatment(s) 
3.5.1.1 
Investigational Product 
IW-1973 Tablets are 10 mg or 20 mg oral tablets and are white and round in appearance. 
3.5.1.2 
Placebo 
Placebo will match IW-1973 Tablets in appearance. The number of placebo tablets administered 
will match the number of tablets used for the IW-1973 treatment arm. 
3.5.1.3 
Packaging and Labeling 
IW-1973 and placebo tablets will be provided by PCI Pharma Services (Rockford, IL) on behalf 
of Ironwood in 100cc high-density polyethylene (HDPE) induction-sealed bottles, 35 tablets per 
bottle, containing two 1-gram mole desiccant sieves and 4-6 inches of purified polyester coil. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 38 of 106 
The bottles will be compatible with a Medication Event Monitor System cap (MEMSCap™, 
WestRock®; Sion, Switzerland) that will be interchanged at the clinical site.  
3.5.1.4 
Dosage 
Table 2 summarizes the dosage and dosing regimen for each treatment arm by Treatment Period 
week. 
Table 2. 
Dosage by Week 
Dose 
Week 1, BID Dosing  
Weeks 2 through 12, QD Dosing 
20 mg 
one 10-mg IW-1973 Tablet, orally twice daily 
two 10-mg IW-1973 Tablets, orally once daily 
40 mg 
one 20-mg IW-1973 Tablet, orally twice daily 
two 20-mg IW-1973 Tablets, orally once daily 
Placebo 
one matching placebo tablet, orally twice daily 
two matching placebo tablets, orally once daily 
BID=twice daily; QD=once daily 
 
3.5.1.5 
Storage and Accountability 
IW-1973 Tablet and placebo to match must be stored under refrigerated conditions, 2° to 8°C 
(36° to 46°F) at the clinical sites. Any deviation from these storage conditions must be reported 
to Ironwood, and use of the study drug suspended until re-authorization has been provided by 
Ironwood. If a temperature excursion occurs above 8°C (46°F) up to a maximum temperature of 
30°C (86°F) for not longer than 24 hours, the clinical site is authorized by Ironwood 
Pharmaceuticals to continue using the study drug after documentation of the excursion has been 
completed. If a temperature excursion occurs below 2°C or above 30°C (<36°F or >86°F) for any 
amount of time, or from 8°C to 30°C for periods longer than 24 hours, the use of the study drug 
is suspended until authorization for its continued use has been provided by Ironwood. 
Once distributed to patients, patients will be instructed to keep the bottles at room temperature 
(15°C to 30°C/59°F to 86°F). 
The Investigator must ensure that the receipt and use of all study drug supplied is recorded. All 
study drug supplies must be retained in a locked room that may only be accessed by the 
pharmacist, Investigator, or other duly designated persons. Study drug must not be used outside 
the context of this protocol, and under no circumstances should the Investigator or study center 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 39 of 106 
personnel allow the supplies to be used other than as directed by this protocol without prior 
authorization from Ironwood. 
Study drug accountability should be performed at the medication level. Patients will be 
instructed to return all unused study drug to the study center. All returned and unused study drug 
must be retained at the site. At the end of the study, a complete reconciliation of the study drug 
supplies will be performed. A copy of the final Drug Accountability Log will be provided to 
Ironwood, or accountability will be completed electronically within the product returns module 
of an interactive response technology system when available. All unused and reconciled drug 
supplies will be returned to PCI Pharma Services or destroyed according to standard institutional 
policy or per written instruction from Ironwood should an alternate disposition be requested. No 
study drug is to be destroyed without prior written permission of Ironwood. A copy of the 
Certificate of Destruction or equivalent shall be provided to Ironwood once available.  
In addition, study drug will be dispensed to patients in bottles equipped with a MEMSCap, 
which will record the dates and times the bottle is opened and closed. 
3.5.2 
Method of Assigning Patients to Treatment Groups 
Approximately 150 patients who meet all of the inclusion criteria and none of the exclusion 
criteria will be stratified by Baseline eGFR (ie, eGFR 30 to 45, >45 to 60, and >60 to 
75 mL/min/1.73 m2) and randomized 1:1:1 to 20 mg IW-1973, 40 mg IW-1973, or placebo at the 
Randomization Visit on Day 1. 
Patients will be randomized through central randomization. The computer-generated 
randomization schedule will be prepared by an independent statistician not otherwise associated 
with the study. 
Patients and Investigators will be blinded to treatment assignments in this study (see 
Section 3.5.6 for more details on blinding in this study). 
3.5.3 
Selection of Dosage in the Study 
This Phase 2 study will evaluate 2 dose levels of oral IW-1973 administered daily for 12 weeks: 
20 mg and 40 mg. In the Phase 1b MAD study (ICP-1973-102), 40 mg IW-1973 was considered 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 40 of 106 
adequately tolerated and produced pharmacodynamic (PD) effects (including reduced BP and 
increased plasma cGMP levels). It was therefore chosen as the high dose for evaluation in this 
patient population. For comparison to 40 mg, 20 mg IW-1973 was chosen for evaluation because 
it demonstrated pharmacodynamic effects following 2 weeks of dosing in the MAD study and 
was associated with a lower incidence of AEs. The plasma concentrations achieved in humans at 
the 20- and 40-mg dose levels were within the range associated with renal efficacy in the Dahl 
salt-sensitive rat model (reduced albuminuria, attenuated kidney weight gain, and improved renal 
histology). 
3.5.4 
Selection and Timing of Dose for Each Patient and Dose Reduction 
3.5.4.1 
Study Drug Administration 
During Week 1, all patients will take study drug BID (2×/day), 1 tablet in the morning and 
1 tablet approximately 12 hours later in the evening, preferably at approximately the same times 
each day. From Day 8 (±1) on, patients will take study drug QD (1×/day), 2 tablets in the 
morning, preferably at approximately the same time each day. Patients should take study drug 
with water, may take study drug with or without food, and, for QD dosing, may swallow tablets 
together, if desired. On study visit days, study drug will be administered in the clinic after 
predose BP/pulse measurements and blood/urine sampling (on Randomization Day, patients will 
receive only their morning dose in the clinic); therefore, study visits should be scheduled in the 
morning to accommodate patients’ regular dosing schedules. 
3.5.4.2 
Dose Reduction 
Per Investigator discretion, on a per-patient basis, dose may be reduced by half, ie, from 2 tablets 
daily to 1 tablet daily (in the morning). Each patient’s dose may only be reduced once and may 
not be increased after reduction. Investigators should notify the Medical Monitor of all decisions 
to dose reduce on a per-patient basis.  
3.5.5 
Treatment Compliance 
The appropriate amount of study drug will be dispensed to patients in prelabeled bottles at the 
Randomization, Week 1, Week 4, and Week 8 Visits. Patients will be asked to return all bottles 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 41 of 106 
(including unused tablets) at the Week 1, Week 4, Week 8, and End of Treatment Visits for 
assessment of compliance with the dosing regimen.  
Treatment compliance will be based on count of pills. 
3.5.6 
Blinding 
This study is double blind and placebo controlled. The investigational product and placebo will 
be identical oral tablets.  
Unblinding of a patient’s treatment assignment is restricted to emergency situations and should 
only be used under circumstances where knowledge of the treatment is necessary for the proper 
handling of the patient. Except in a medical emergency, the Investigator and study center staff 
will remain blinded during the conduct of the study and until, at a minimum, all discrepancies in 
the clinical database are resolved (ie, at the time of the database lock). Individual patient 
treatment assignment unblinding is available to the Investigator through the interactive web 
response system (IWRS) in the event of an emergency. The Investigator should make all 
reasonable efforts to notify and discuss the circumstances requiring unblinding with the Medical 
Monitor or designee in advance of breaking the blind. If the treatment blind is broken, the reason 
and the date should be recorded and signed by the Investigator and information regarding the 
unblinding should be submitted as soon as possible to the Sponsor. If the Investigator is 
unblinded to the treatment assignment of a patient, the patient will be immediately withdrawn 
from study drug dosing and should follow early termination procedures (Section 3.4.3). 
The Sponsor may also break the blind in circumstances where unblinding is necessary for the 
safety of the patients. 
To allow ongoing safety monitoring during the conduct of the study, members of an external 
DMC will review summaries of AE data by treatment groups randomly masked as A, B, and C 
and may request unblinded safety data. Please refer to Section 5.13 for more details. 
 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 42 of 106 
3.5.7 
Prior and Concomitant Therapy 
At the Screening Visit, the following information will be recorded for each patient: 
• All medications the patient is taking (ongoing) 
• All prior medications taken during the 30 days before the Screening Visit 
 
Beginning at the Screening Visit, any medication or change in medication taken by a patient 
during the study will be documented in the source documents and the eCRF along with the start 
and stop date and the reason for use.  
Patients will be on a stable regimen of at least 1 antihyperglycemic medication and an ACEi or 
an ARB (see Inclusion Criteria for details), which may be modified during the study if medically 
necessary. Patients may be on a stable regimen of medication(s) for hypertension, which may be 
modified during the study if medically necessary. Permitted concomitant medications should be 
taken at the same time each day and may be taken at the same time as study drug.  
Pharmacological stimulation of sGC by IW-1973 produces an increase in cGMP production. 
Concomitant administration of IW-1973 with an angiotensin receptor neprilysin inhibitor (ie, 
sacubitril/valsartan) should be allowed with caution as neprilysin inhibition results in increased 
cGMP concentrations via protection of natriuretic peptides. 
Prohibited medications and supplements are listed in Sections 3.6 and Appendix 1. 
3.6 
RESTRICTIONS 
3.6.1 
Prohibited Medicines and Supplements 
Specific inhibitors of phosphodiesterase 5 (PDE5) (including sildenafil and tadalafil), 
nonspecific inhibitors of PDE5 (including dipyridamole and theophylline), any supplements for 
the treatment of erectile dysfunction, riociguat, and nitrates or NO donors in any form are 
prohibited from 7 days before the Randomization Visit on Day 1 through the duration of the trial.  
Strong inhibitors of CYP3A are prohibited from 14 days before Randomization through the 
duration of the trial. Examples include azole antifungals, macrolide antibiotics, protease 
inhibitors, diltiazem, and concentrated grapefruit supplements. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 43 of 106 
See Appendix 1 for a more detailed list of prohibited medicines and supplements.  
3.6.2 
Fluid and Food Restrictions 
Patients should fast overnight (at least 8 hours) before predose blood and urine sample 
collections at all study visits, except for the Screening Visit.  
Excessive grapefruit intake is prohibited from 14 days before Randomization through the 
duration of the trial. 
Patient must agree not to make any major changes to their diet from the Screening Period 
through the Follow-up Visit. 
3.6.3 
Patient Activity  
Patient must agree not to make any major changes to their exercise routine from the Screening 
Period through the Follow-up Visit. 
3.6.3.1 
Sexual Activity and Birth Control 
Female patients who are not postmenopausal for at least 1 year (ie, 12 months of spontaneous 
amenorrhea [not induced by a medical condition or medical therapy]) or are not surgically sterile 
(ie, bilateral oophorectomy, hysterectomy, or tubal sterilization [tie, clip, band, or burn]) must 
agree to completely abstain from heterosexual intercourse or, if heterosexually active, must agree 
to use 1 of the following methods of birth control from the date she signs the ICF until 60 days 
after the final dose of study drug: 
• Progesterone implant or an intrauterine device (IUD) 
• Combination of 2 highly effective birth control methods (eg, diaphragm with spermicide plus 
a condom, condom with spermicide plus a diaphragm or cervical cap, hormonal 
contraceptive [eg, oral and transdermal patch] plus a barrier method, partner with vasectomy 
[conducted 60 days before the Screening Visit or confirmed via sperm analysis] plus a 
hormone/barrier method). 
 
Female patients must wait at least 60 days after the final dose of study drug to try to become 
pregnant and/or to undergo egg donation or egg harvesting for current or future in vitro 
fertilization. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 44 of 106 
Male patients who are not surgically sterile by vasectomy (conducted 60 days before the 
Screening Visit or confirmed via sperm analysis) must agree to completely abstain from 
heterosexual intercourse or, if heterosexually active, must agree to use a combination of 2 highly 
effective birth control methods (eg, condom with spermicide plus partner IUD, condom with 
spermicide plus a partner diaphragm/cervical cap, partner use of hormonal contraceptive 
[including progesterone implant] plus a barrier method, or postmenopausal partner [for 1 year] 
plus barrier method) from the Screening Visit through 60 days after the final dose of study drug. 
Male patients must refrain from sperm donation during the study through at least 60 days after 
the final dose of study drug. 
3.7 
 INDIVIDUAL STOPPING CRITERIA AND DMC REVIEWS 
If any events included in Table 3 are reported during the study and are judged to be both study 
drug related and an SAE (per causality and SAE definitions in Section 3.8.9.3), individual 
stopping criteria or DMC review will be triggered per the criteria in Sections 3.7.1 and Table 3, 
respectively. The inclusion of these AEs is based on the clinical experience with IW-1973, the 
prescribing information for riociguat, and the patient population for this study. 
Table 3. 
Categories of SAEs Triggering Individual Stopping Criteria and Safety 
Committee Review 
Treatment-emergent Study Drug-related SAE Category 
# of patients to trigger 
DMC review 
Renal failure 
(eGFR <15 mL/min/1.73 m2; dialysis or renal transplant indicated) 
2 
Spontaneous bleeding events  
(eg, hemoptysis, subarachnoid or subdural hemorrhage, hematemesis, 
hematochezia) 
2 
Symptomatic hypotension-related events  
(eg, syncope) 
2 
DMC=Data Monitoring Committee; eGFR=estimated glomerular filtration rate; SAE=serious adverse event 
 
3.7.1 
Individual Stopping Criteria 
On an individual basis, a patient will be discontinued from study drug dosing if 1 SAE from 
Table 3 is reported. At the Investigator’s or Sponsor’s discretion, any AE(s) of concern can 
likewise be the basis for patient discontinuation from the trial. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 45 of 106 
3.7.2 
Data Monitoring Committee Reviews  
An independent DMC comprising experts in cardiovascular and/or renal disease and/or diabetes 
and a biostatistician will review trial safety data both periodically and if SAEs from the same 
category in Table 3 are reported at the incidence indicated in the table (eg, 2 patients with 
spontaneous bleeding SAEs). After review of safety data, the DMC will recommend trial 
continuation, continuation with modification, or termination. Refer to Section 5.13 for details 
regarding the DMC, the scheduled and ad hoc reviews, the data that will be provided for review, 
and Sponsor decision-making. 
3.8 
STUDY PROCEDURES AND ASSESSMENTS 
3.8.1 
Informed Consent 
Informed consent procedures will comply with the Code of Federal Regulations (CFR) 21, 
Parts 50 and 312. 
The written ICF must be approved by the Institutional Review Board (IRB) for the purposes of 
obtaining and documenting consent. 
Before entry into the study, each patient will be provided with a written explanation of the study. 
It is the responsibility of the Investigator or appropriately trained health professional to give each 
patient full and adequate information regarding the objectives and procedures of the study and 
the possible risks involved. Patients will then be given the opportunity to ask questions and the 
Investigator will be available to answer questions as needed. Patients will be informed of their 
right to withdraw from the study at any time without prejudice. After this explanation and before 
entering the study, the patient will voluntarily sign the study-specific ICF. The patient will 
receive a copy of the signed and dated ICF. The Investigator must retain each patient’s original 
signed ICF. 
If new information becomes available that may be relevant to the patient’s consent and 
willingness to participate in the study, the ICF will be revised. The revised ICF must be 
submitted to the IRB for review and approval before its use. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 46 of 106 
3.8.2 
Medical History 
A complete medical history, including history of smoking, will be recorded at the Screening 
Visit. 
3.8.3 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 47 of 106 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 48 of 106 
3.8.4 
Physical Examination 
A complete physical examination will be performed according to the Schedule of Events. The 
physical examination of each patient should include examination and assessment of the 
following: 
General appearance 
Head, eyes, ears, nose, and throat 
Cardiovascular system 
Neck 
Respiratory system 
Musculoskeletal system 
Abdomen/liver/spleen 
Nervous system 
Lymph nodes 
Skin 
Neurologic status 
Mental status 
 
Breast, genitourinary, and rectal examinations are optional and may be performed at the 
discretion of the Investigator. Any new, clinically significant abnormal findings from the 
physical examination will be reported as an AE. 
Each patient’s weight will be recorded at each study visit; height will only be recorded at the 
Screening Visit. 
3.8.5 
Respiratory Rate and Temperature  
Respiratory rate and oral temperature (°C) will be measured according to the Schedule of Events 
and documented on the eCRF. Respiratory rate should be measured after the patient has been 
seated for at least 5 minutes. 
3.8.6 
Hemodynamics 
Hemodynamic assessments will include seated BP and pulse, orthostatic (seated-to-standing) BP 
and pulse, and ABPM. Outside of the ABPM assessments, all other BP and pulse measurements 
will be taken by automated office blood pressure (AOBP); manual measurements are allowed in 
cases in which an AOBP machine malfunctions or is not available. 
Blood pressure and pulse measurements at the Screening and Baseline Visits will be performed 
with patients in the seated position. Seated BPs for study eligibility will be the average of 
3 measurements obtained at 2-minute intervals after the patient has been sitting quietly for at 
least 5 minutes.  
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 49 of 106 
Blood pressure and pulse measurements at the Randomization, Week 4, Week 8, End of 
Treatment, and Follow-up Visits will be seated-to-standing for calculation of orthostatic BP and 
pulse. Patients should sit quietly for at least 5 minutes before seated measurements are taken, and 
then assume a standing position for 30 to 60 seconds before standing measurements are taken. At 
the End of Treatment visit, seated predose BP will be the average of 3 measurements. 
When applicable, BP and pulse measurements should be taken before blood draws. All predose 
BP and pulse measurements should be taken before all oral and any antihypertensive 
concomitant medications. 
Patients will begin 24-hour ABPM at the study site during the Baseline and End of Treatment 
Visits and will begin 12-hour ABPM at the study site during the Week 4 and Week 8 Visits. 
Patients will return the ABPM equipment to the study site at the following study visit.  
Baseline Visit ABPM assessment: At least 65% compliance is preferred, with no more than 
10 missed readings during the day (7 am – 10 pm) and/or 3 missed readings at night (10:30 pm – 
6:30 am), and no more than 6 missed readings in succession. (If a patient’s ABPM assessment 
does not meet these criteria, the medical monitor must be contacted PRIOR to randomizing the 
patient.) 
At the Week 4, Week 8, and End of Treatment Visits, ABPM should begin before study drug 
administration. 
3.8.7 
Electrocardiograms 
A 12-lead electrocardiogram (ECG) will be performed according to the Schedule of Events and 
documented on the eCRF. Electrocardiograms should be obtained after the patient has been 
supine for at least 5 minutes. At the Screening and Baseline Visits, if on initial ECG, QTcF is 
450 msec for male patients or is 470 msec for female patients, the ECG will be repeated 
2 more times, and the average of the 3 QTcF values will be used to determine eligibility. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 50 of 106 
3.8.8 
Clinical Laboratory Tests 
Blood and urine samples for clinical laboratory tests will be collected according to the Schedule 
of Events. Except for the Screening Visit, patients should fast for at least 8 hours before sample 
collections. 
The clinical laboratory evaluations will include the serum chemistry, hematology (complete 
blood count [CBC]), coagulation, UA, and additional tests as presented in Table 4. 
Table 4. 
Clinical Laboratory Tests 
Serum Chemistry 
Hematology (CBC) 
Urinalysis 
Albumin 
Hematocrit 
Color and appearance 
Alkaline Phosphatase 
Hemoglobin 
pH and Specific Gravity 
ALT 
Platelet count 
Bilirubin 
AST 
MPV 
Glucose 
Bicarbonate 
RBC count 
Ketones 
BUN 
WBC count 
Leukocytes 
Calcium 
WBC differential 
Nitrites 
Chloride 
  (% & absolute): 
Occult blood 
Cholesterol 
Basophils 
Protein 
Creatinine 
Eosinophils 
Urobilinogen 
GGT 
Lymphocytes 
Microscopic  
Glucose 
Monocytes 
Including bacteria, RBCs, WBCs 
HDL-c 
Neutrophils 
per HPF if dipstick is abnormal 
LDH 
RBC indices 
 
LDL-c (calculated) 
MCH 
Additional blood tests 
Magnesium 
MCHC 
Hemoglobin A1c 
Phosphorus 
MCV 
Fasting plasma glucose 
Potassium 
RDW 
Fasting plasma insulin 
Sodium 
 
 
Total Bilirubin 
Coagulation 
Additional urine tests  
Total Protein 
aPTT 
Urine albumin & creatinine for UACR* 
Triglycerides 
Prothrombin time 
Urine cotinine  
Uric acid 
INR 
 
ALT=alanine aminotransferase; aPTT=activated partial thromboplastin time; AST=aspartate aminotransferase; 
BUN=blood urea nitrogen; CBC=complete blood count; GGT=gamma glutamyl transferase; HPF=high power 
field; INR=International Normalized Ratio; LDH=lactate dehydrogenase; MCH=mean corpuscular hemoglobin; 
MCHC=mean corpuscular hemoglobin concentration; MCV=mean corpuscular volume; MPV=mean platelet 
volume; RBC=red blood cell; RDW=red blood cell distribution width; UACR=urine albumin-creatinine ratio; 
WBC=white blood cell.  
 
* At the Screening Visit, a single urine sample, which may not be first void, may be collected. Thereafter, 
samples should be 2 first-void urine samples collected on the 2 consecutive mornings before each scheduled 
study visit. Patients will be supplied with specimen collection supplies at the preceding study visit. 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 51 of 106 
3.8.8.1 
Pregnancy Tests 
For female patients, a negative pregnancy test (by urine dipstick) must be documented at all 
study visits with results available before dosing, where applicable. In the event of a positive 
pregnancy test, the test will be repeated. If pregnancy is confirmed, see Section 3.8.9.5. Female 
patients who are postmenopausal (no menses for 12 consecutive months) or surgically sterile 
(ie, bilateral oophorectomy, hysterectomy, or tubal sterilization [tie, clip, band, or burn]) do not 
have to have a urine pregnancy test. 
3.8.8.2 
Hepatitis, HIV, and Drug Screens 
Screens for a hepatitis panel (including HBsAg and anti-HCV) and human immunodeficiency 
virus (HIV) antibody will be performed at the Screening Visit. 
A urine drug screen for the following drugs of abuse will be performed at the Screening Visit: 
Amphetamines 
Cocaine 
Phencyclidine (PCP) 
Barbiturates 
Marijuana 
Propoxyphene 
Benzodiazepines 
Opiates 
 
 
3.8.8.3 
Urine Albumin Creatinine Ratio (UACR) 
UACR will be calculated as urine albumin (mg/dL) / urine creatinine (g/dL).  
Urine albumin and urine creatinine levels will be determined as part of the clinical laboratory 
tests (Table 4). At the Screening Visit, a single urine sample, which may not be first void, will be 
collected for determination of albumin and creatinine levels. For subsequent study visits, patients 
will be given urine collection supplies and will collect 2 first-void urine samples on the 
2 consecutive mornings before each scheduled visit.  
3.8.8.4 
Estimated Glomerular Filtration Rate (eGFR) 
Estimated glomerular filtration rate will be based on the serum creatinine level determined as 
part of the clinical laboratory tests (Table 4) and will be calculated according to the Chronic 
Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation.(1)  
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 52 of 106 
The CKD-EPI equation, expressed as a single equation, is  
GFR= 141 × min(Scr/ț, 1)Į × max(Scr/ț, 1) -1 209 × 0.993Age × 1.018 [if female] _ 1.159 [if black], 
 
where Scr is serum creatinine, ț is 0.7 for females and 0.9 for males, Į is -0.329 for females and 
-0.411 for males, min indicates the minimum of Scr/țor 1, and max indicates the maximum of 
Scr/ț or 1. 
3.8.8.5 
HOMA-IR 
Blood samples for determination of fasting plasma glucose and insulin levels will be collected 
according to the Schedule of Events. Values will be used in the Homeostatic Model Assessment 
to estimate insulin resistance (HOMA-IR).(34,35)  
The HOMA-IR equation is:  
HOMA-IR = (FPI × FPG)/22.5, 
where FPI is fasting plasma insulin concentration (mU/L) and FPG is fasting plasma glucose 
(mmol/L). 
3.8.9 
Adverse Events  
All patients will be monitored for AEs throughout the study. All AEs will be recorded in 
accordance with the procedures outlined in this section. 
An AE is any untoward medical occurrence in a patient or clinical investigation subject 
administered a pharmaceutical product and which does not necessarily have to have a causal 
relationship with this treatment.  
An AE, therefore, can be any unfavorable and unintended sign (including an abnormal laboratory 
finding, for example), symptom, or disease temporally associated with the use of a medicinal 
product, whether or not considered related to the medicinal product. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 53 of 106 
An AE includes, but is not limited to, the following: 
• Any unfavorable changes in general condition 
• Any clinically significant worsening of a preexisting condition 
• Any intercurrent diseases and accidents 
 
Note: A procedure is not an AE, but the reason for a procedure may be an AE. 
3.8.9.1 
Causality Assessment 
For all AEs, the Investigator must provide an assessment of causal relationship to study drug. 
The causality assessment must be recorded in the patient’s source documentation and on the AE 
page of the subject’s eCRF. Causal relationship must be assessed according to the following: 
Related:  
An event where there is a reasonable possibility of a causal relationship between 
the event and the study drug 
Unrelated:  
Any other event 
3.8.9.2 
Severity Assessment 
The Investigator will provide an assessment of the severity of each AE by recording a severity 
rating in the patient’s source documentation and on the AE page of the patient’s eCRF. Severity, 
which is a description of the intensity of manifestation of the AE, is distinct from seriousness, 
which implies a patient outcome or AE-required treatment measure associated with a threat to 
life or functionality. Severity will be assessed according to the following scale: 
Mild: 
A type of AE that is usually transient and may require only minimal treatment or 
therapeutic intervention. The event does not generally interfere with usual 
activities of daily living. 
Moderate: 
A type of AE that is usually alleviated with additional specific therapeutic 
intervention. The event interferes with usual activities of daily living, causing 
discomfort but poses no significant or permanent risk of harm to the research 
participant. 
Severe: 
A type of AE that interrupts usual activities of daily living, or significantly affects 
clinical status, or may require intensive therapeutic intervention. 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 54 of 106 
3.8.9.3 
Serious Adverse Events 
An SAE is defined as any AE occurring at any dose that results in any of the following 
outcomes: 
• Death 
• Life-threatening: the patient was at immediate risk of death from the reaction as it occurred 
(ie, it does not include a reaction that hypothetically might have caused death if it had 
occurred in a more severe form) 
• Hospitalization or prolongation of existing hospitalization 
• Persistent or significant disability/incapacity: a substantial disruption of a person’s ability to 
conduct normal daily functions 
• Congenital anomaly/birth defect 
• Important medical events: events that may not result in death, be life threatening, or require 
hospitalization. Such an event may be considered serious when, based on appropriate medical 
judgment, it may jeopardize the subject and may require medical or surgical intervention to 
prevent 1 of the outcomes listed in this definition. Examples of such medical events include 
allergic bronchospasm requiring intensive treatment in an emergency department or at home, 
blood dyscrasias or convulsions that do not result in inpatient hospitalization, or the 
development of drug dependency or drug abuse. 
 
Emergency room visits that do not result in admission to the hospital should be evaluated for 1 of 
the other serious outcomes (eg, life-threatening, other serious [medically important] event). 
3.8.9.4 
Recording Adverse Events 
Adverse events will be collected and recorded from the time the patient signs the ICF at the 
Screening Visit through the Follow-up Visit. All AEs, regardless of the assumption of a causal 
relationship with study procedures or study medication, must be recorded in the patient’s source 
documentation and subsequently on the appropriate AE page of the patient’s eCRF. This record 
includes AEs the patient reports spontaneously, those observed by the Investigator, and those 
elicited by the Investigator in response to open-ended questions during the study, such as “Have 
you had any health problems since your last visit?” 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 55 of 106 
For every AE, the Investigator must: 
• Provide an assessment of the severity, causal relationship to the study medication, and 
seriousness of the event 
• Document all actions taken with regard to the study medication (ie, no action taken, 
treatment temporarily interrupted, or treatment discontinued)  
• Detail any other treatment measures taken for the AE, including concomitant medications 
and/or procedures 
 
Pretreatment AEs will be collected from the time the patient signs the ICF until the patient 
receives study drug. Pretreatment AEs will be captured in the patient’s source documentation but 
will only be entered for randomized patients on the AE page of the patient’s eCRF. 
Laboratory abnormalities and changes in vital signs, physical examination findings, and 12-lead 
ECG parameters should be considered AEs and reported on the AE page of the patient’s eCRF if 
the Investigator considers them clinically significant and/or they necessitate intervention. 
Any medical condition that is present when a patient is screened and does not worsen in severity 
and/or frequency should be reported as Medical History and not as an AE. However, if the 
condition does deteriorate in severity and/or frequency at any time during the study, it should be 
reported as an AE. 
3.8.9.5 
Reporting Serious Adverse Events and Pregnancy 
An AE that meets any of the serious criteria must be reported to Covance within 24 hours from 
the time that site personnel first learn of the event, using the SAE Report form provided for the 
study. All SAEs must be recorded in the subject’s source documentation and, subsequently, on 
the appropriate AE reporting page of the subject’s eCRF, whether or not they are considered 
causally related to study medication.  
Regardless of causality, all SAEs must be recorded and reported from the time the patient signs 
the ICF at the Screening Visit until the final Follow-up Visit. Any SAE that occurs at any time 
after the specified follow-up period and which the Investigator considers study drug related 
should be reported immediately. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 56 of 106 
The initial SAE report should include the following information at minimum: 
• Patient identification number 
• Description and onset of the event 
• Serious criteria 
• Causality assessment to study drug 
 
All SAE and pregnancy information should be emailed to Covance as shown below. 
All SAE and Pregnancy Report Forms should be emailed or faxed to: 
 
or 
Fax#: 
 
If follow-up is obtained, or is requested by Covance, the additional information should be 
emailed on an SAE or Pregnancy Report Form to Covance, in a timely manner according to the 
procedures outlined above. Copies of discharge summaries, consultant reports, autopsy reports, 
and any other relevant documents may also be requested. 
Appropriate remedial measures should be taken by the Investigator using his/her best medical 
judgment to treat the SAE. These measures and the subject’s response to these measures should 
be recorded. All SAEs regardless of relationship to study drug will be followed by the 
Investigator until satisfactory resolution, until the Investigator deems the SAE to be chronic or 
stable, or until the subject is lost to follow-up. Clinical, laboratory, and diagnostic measures 
 
In the event that a pregnancy occurs in a patient, study drug must be stopped at once and study 
personnel must report the pregnancy within 24 hours from the time that site personnel first learn 
of the pregnancy using the pregnancy notification form provided for this study. Study personnel 
must also make every reasonable effort to follow the pregnancy until resolution and report the 
outcome using the pregnancy outcome form provided for this study. If the pregnancy is 
associated with an SAE (eg, if the mother is hospitalized), a separate SAE form must be 
submitted. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
20 December 2017 
Confidential 
Page 57 of 106 
should be employed by the Investigator as needed to adequately determine the etiology of the 
event. 
The Investigator will be responsible for reporting all SAEs to the IRB. Ironwood will be 
responsible for reporting to the regulatory authorities. 
3.8.10 
  
 
 
  
3.8.11 
 
 
 
 
 
 
 
 
 
 
3.8.12 
Pharmacokinetic Assessments 
Blood samples for PK assessments will be collected according to the Schedule of Events.  
3.8.13 
  
 
 
 
  
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 58 of 106 
3.9 
STUDY ACTIVITIES 
3.9.1 
Screening Period (Day -45 to Day -1) 
3.9.1.1 
Screening Visit (Days -45 to -15) 
• Obtain informed consent  
• Record demographics and medical history 
• Review inclusion and exclusion criteria 
• Review prior and concomitant medications (all medicines taken during the 30 days before the 
Screening Visit) 
• 
 
• Record weight and height 
• Perform physical examination 
• Perform 12-lead ECG (if QTcF exceeds eligibility criterion, conduct 2 more ECGs and use 
average of 3 values for determination of eligibility) 
• Record respiratory rate and oral temperature 
• Record seated BP (average of 3 measurements) and pulse  
• Collect blood and urine samples for: 
- 
Serum chemistry, hematology (CBC), coagulation 
- 
Urinalysis (may be collected at any time during study visit) 
- 
Urine albumin and creatinine (may be collected at any time during study visit) 
- 
Urine pregnancy test, as applicable (must be confirmed negative) (may be collected at 
any time during study visit) 
- 
Hemoglobin A1c 
- 
Urine drug screen (may be collected at any time during study visit) 
- 
HBsAg, HCV, and HIV screen 
• Conduct AE evaluation 
• Issue supplies and instructions for first-void urine sampling 
 
Note: Screening Visit assessments may take place over more than 1 day. Patients may be 
rescreened should they discontinue in the Screening Period due to visit window deviations or 
other administrative reasons. In addition, laboratory values, ECG values, or BPs that are outside 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 59 of 106 
the range specified in the protocol may be repeated to confirm eligibility during the Screening 
Period at the Investigator’s discretion after consultation with the Medical Monitor. 
3.9.1.2 
Baseline Visit (Days –7 ±3) 
• Return by patient:  
- 
2 first-void urine samples  
• Review inclusion and exclusion criteria 
• Review prior and current medications  
• Record weight 
• Perform 12-lead ECG (if QTcF exceeds eligibility criterion, conduct 2 more ECGs and use 
average of 3 values for determination of eligibility) 
• Record seated BP (average of 3 measurements) and pulse  
• Begin ABPM; patient will wear 24 hours and should return monitor to clinic at next study 
visit 
• Collect blood and urine samples for: 
- 
Serum chemistry, hematology (CBC), coagulation 
- 
Urinalysis (may be collected at any time during study visit) 
- 
Urine pregnancy test, as applicable (must be confirmed negative; may be collected at any 
time during study visit) 
- 
Hemoglobin A1c 
- 
Fasting plasma glucose and insulin 
• Conduct AE evaluation 
• Issue supplies and instructions for first-void urine sampling 
 
3.9.2 
Treatment Period (Day 1 to Day 87 ±3) 
3.9.2.1 
Randomization Visit (Day 1) 
• Return by patient:  
- 
2 first-void urine samples  
- 
ABPM cuff and monitor (may be returned outside of study visit) 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
20 December 2017 
Confidential 
Page 60 of 106 
•
Collect predose urine samples for:
-
Pregnancy test, as applicable (must be confirmed negative before randomization)
-
Urine cotinine
-
•
Confirm inclusion and exclusion criteria
•
Review prior and concomitant medications
•
Record weight
•
•
Record respiratory rate and oral temperature predose (30 minutes)
•
Record seated-to-standing (orthostatic) pulse and BP predose (30 minutes)
•
Collect predose (30 minutes) blood samples for:
-
Serum creatinine and glucose
-
-
PK
-
-
•
Randomize patient
•
Dispense study drug
•
MEMS introduction
•
Administer study drug (morning dose)
•
Record respiratory rate and oral temperature at 1 hour (±15 minutes) postdose
•
Record seated-to-standing (orthostatic) pulse and BP at 1, 2, 4, and 6 hours (±15 m) postdose
•
Collect blood samples for PK at 1, 3, and 6 hours (±15 minutes) postdose
•
Conduct AE evaluation
•
Issue supplies and instructions for first-void urine sampling
3.9.2.2 
Week 1 Visit (Day 8 ±1) 
•
Return by patient:
-
2 first-void urine samples
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 61 of 106 
- 
Study drug (Patients will bring in study drug dispensed on Day 1. MEMS Caps will be 
read, and the subject will be administered the Day 8 [±1] study drug dose in the clinic 
from the Day 1 bottles. The subject will continue to dose from the Day 1 bottles until 
returning for the Week 4 Visit.) 
• Collect predose urine samples for pregnancy test, as applicable  
• Record concomitant medications 
• Record weight 
• Record respiratory rate and oral temperature predose (30 minutes)  
• Record seated-to-standing (orthostatic) pulse and BP predose (30 minutes)  
• Collect predose (30 minutes) blood samples for: 
- 
Serum creatinine and glucose  
- 
Hemoglobin A1c 
- 
Fasting plasma glucose and insulin 
- 
 
- 
PK  
• Review MEMS cap data 
• Administer study drug 
• Record respiratory rate and oral temperature at 1 hour (±15 minutes) postdose 
• Record seated-to-standing (orthostatic) pulse and BP at 1, 2, 4 and 6 hours (±15 minutes) 
postdose 
• Collect blood samples for PK at 1, 3, and 6 hours (±15 minutes) postdose 
• 
 
• Conduct AE evaluation 
• Issue supplies and instructions for first-void urine sampling 
 
3.9.2.3 
Week 4 Visit (Day 29 ±3) 
• Return by patient:  
- 
2 first-void urine samples 
- 
Study drug  
• Collect predose urine sample for pregnancy test, as applicable  
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 62 of 106 
• Record concomitant medications 
• Record weight 
• 
 
• Record seated-to-standing (orthostatic) pulse and BP predose (30 minutes)  
• Begin ABPM; patient will wear 12 hours and should return monitor at next study visit 
• Collect predose (30 minutes) blood samples for: 
- 
Serum chemistry, hematology (CBC), coagulation  
- 
Hemoglobin A1c 
- 
Fasting plasma glucose and insulin 
- 
PK  
• Review MEMS cap data 
• Dispense study drug  
• Administer study drug 
• Conduct AE evaluation 
• Issue supplies and instructions for first-void urine sampling 
 
3.9.2.4 
Week 8 Visit (Day 57 ±3) 
• Return by patient:  
- 
2 first-void urine samples  
- 
ABPM cuff and monitor (may be returned outside of study visit) 
- 
Study drug 
• Collect predose urine samples for pregnancy test, as applicable  
• Record concomitant medications 
• Record weight 
• 
 
• Record seated-to-standing (orthostatic) pulse and BP predose (30 minutes)  
• Begin ABPM; patient will wear 12 hours and should return monitor to clinic at next study 
visit 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
20 December 2017 
Confidential 
Page 63 of 106 
•
Collect predose (30 minutes) blood samples for:
-
Serum creatinine and glucose
-
Hemoglobin A1c
-
Fasting plasma glucose and insulin
-
PK
•
Review MEMS cap data
•
Dispense study drug
•
Administer study drug
•
Conduct AE evaluation
•
Issue supplies and instructions for first-void urine sampling
3.9.2.5 
End of Treatment Visit (Day 87 ±3) 
•
Return by patient:
-
2 first-void urine samples
-
ABPM cuff and monitor (may be returned outside of study visit)
-
Study drug
•
Collect predose urine samples for:
-
Pregnancy test, as applicable
-
Urinalysis
-
•
Record concomitant medications
•
Record weight
•
Perform physical examination
•
•
Record respiratory rate and oral temperature
•
Perform 12-lead ECG
•
Record seated-to-standing (orthostatic) pulse and BP predose (30 minutes) (seated
measurement will be the average of 3 measurements)
•
Begin ABPM; patient will wear 24 hours and should return monitor to clinic at next study
visit
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
20 December 2017 
Confidential 
Page 64 of 106 
•
Collect predose (30 minutes) blood samples for:
-
Serum chemistry, hematology (CBC), coagulation
-
Hemoglobin A1c
-
Fasting plasma glucose and insulin
-
-
PK
-
•
Administer study drug
•
Collect blood sample for PK at 3 hours (±15 minutes) postdose
•
Conduct AE evaluation
•
Issue supplies and instructions for first-void urine sampling
3.9.3 
Follow-up Period (Day 87 ±3 to Day 115 ±3) 
3.9.3.1 
Follow-up Visit (Day 115 ±3)  
•
Return by patient:
-
2 first-void urine samples
-
ABPM cuff and monitor (may be returned outside of study visit)
•
Record concomitant medications
•
Record weight
•
•
Record respiratory rate and oral temperature
•
Record seated-to-standing (orthostatic) pulse and BP
•
Collect blood and urine samples for:
-
Urine pregnancy test, as applicable
-
Serum chemistry, hematology (CBC), coagulation
-
Hemoglobin A1c
-
Urinalysis
-
PK
-
•
Conduct AE evaluation
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
20 December 2017 
Confidential 
Page 65 of 106 
4.
STUDY ENDPOINTS
4.1 
PRIMARY ENDPOINTS
4.1.1 
Primary Safety
•
Incidence of TEAEs and study drug-related TEAEs
4.1.2 
Primary Efficacy 
•
Change from baseline in UACR over Weeks 8 and 12
4.2 
EXPLORATORY ENDPOINTS 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 66 of 106 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 67 of 106 
5. 
STATISTICAL METHODS 
5.1 
GENERAL CONSIDERATIONS 
Descriptive statistics (n, mean or geometric mean, standard deviation, coefficient of variation, 
minimum, median, maximum, 25th and 75th percentiles) will be calculated to summarize 
continuous variables. Frequency and percentage of patients in each category will be calculated to 
summarize categorical variables. Additional details regarding the statistical methods will be 
provided in the Statistical Analysis Plan (SAP), to be finalized before unblinding of the study. 
5.2 
DETERMINATION OF SAMPLE SIZE 
Using an estimate of standard deviation of 0.67, (29) a sample size of 40 patients per treatment 
group would provide approximately 80% power to detect a mean between-group difference 
of -0.376 units in change from baseline in log-transformed UACR over 12 weeks, with a one-
sided significance level of 0.05 for at least 1 dose versus placebo comparison. This difference 
corresponds to a 31% between-group reduction of geometric mean change from baseline in 
UACR. Assuming a drop-out rate of 20%, approximately 150 patients will be randomly assigned 
in a 1:1:1 ratio (approximately 50 patients per treatment group) to 20 mg IW-1973, 40 mg 
IW-1973, or placebo. 
5.3 
ANALYSIS POPULATIONS 
The following populations will be defined for this study: 
• Safety Population: The Safety Population will consist of all randomized patients who 
receive at least 1 dose of study drug. Patients in this population will be summarized 
according to the treatment they actually received. 
• Intent-to-Treat (ITT) Population: The ITT Population will consist of all randomized 
patients who receive at least 1 dose of study drug. Patients in this population will be 
evaluated according to the treatment group they were assigned to at Randomization. 
• PK Population: The PK Population will consist of all randomized patients who receive at 
least 1 dose of study drug and have at least 1 postdose PK parameter assessment. 
• Per-Protocol (PP) Population: The PP Population will consist of all ITT patients who did 
not have any major protocol deviations or dose reduction. 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 68 of 106 
5.4 
PATIENT DISPOSITION 
The total number of screened patients and the number of patients who are screen failures will be 
tabulated. The number of patients who were randomized and the number and percentage of 
patients included in each population will be presented by treatment group. The number and 
percentage of patients who completed the study or discontinued early, as well as the reasons for 
discontinuation, will be presented by treatment group.  
5.5 
DEMOGRAPHICS AND BASELINE CHARACTERISTICS 
Demographic parameters (eg, age, sex, race, ethnicity, weight, height, body mass index [BMI]) 
and other baseline characteristics will be summarized by treatment group for the Safety and 
ITT Populations.  
The number and percentage of patients with abnormalities in medical and surgical histories in 
each system organ class (SOC) and preferred term (PT) will be summarized by treatment group 
for the Safety Population. 
5.6 
DRUG EXPOSURE AND COMPLIANCE 
Exposure to study drug, calculated as the number of days from the first dose taken to the date of 
the last dose taken, inclusive, will be summarized by treatment group for the ITT Population. 
The total number of doses taken between each scheduled visit and overall for the entire study 
will be calculated for each subject. Compliance will be based on the number of doses expected to 
be taken. Percent compliance for study medication will be summarized by treatment group and 
overall for the ITT Population. Compliance rates will also be categorized as missing, <80%, 
80% and 120%, and >120% and summarized by treatment group.  
5.7 
PRIOR AND CONCOMITANT MEDICATIONS 
Prior medicines are defined as any medicines taken before the date of first dose of study drug. 
Concomitant medicines are defined as any medicines taken on or after the date of first dose of 
study drug. Any medicines taken after the date of last dose of study drug will not be considered 
concomitant medicines. Both prior and concomitant medicine use will be summarized by the 
number and percentage of patients in each treatment group receiving each medicine within each 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 69 of 106 
therapeutic class for the ITT Population. Multiple medicines used by a patient in the same 
category (based on Anatomical-Therapeutic-Chemical classification) will only be counted once. 
5.8 
MAJOR PROTOCOL DEVIATIONS 
Major protocol deviations will be identified and documented based on a review of protocol 
deviations before database lock and treatment unblinding, and will be used to define the 
PP population. The categories of major protocol deviations to be reviewed include, but are not 
limited to, patients who: 
• Did not meet key inclusion/exclusion criteria 
• Received disallowed concomitant medication that could meaningfully impact results 
• Had overall treatment compliance rate <80% or >120% 
 
The number and percentage of subjects with major protocol deviations will be summarized by 
type of deviation and by treatment group for the ITT Population. All major protocol deviations 
will be presented in a data listing. 
5.9 
EFFICACY ANALYSES 
All efficacy analyses will be based on the ITT and PP Populations. 
Corresponding with the primary efficacy objective of the trial, the primary inference for 
hypothesis testing is the treatment difference between the placebo group and the IW-1973 groups 
on the change from baseline in log UACR over Weeks 8 and 12. The primary efficacy analysis 
will be conducted using the ITT population using a mixed-effects model repeated measures 
(MMRM) analysis with change from baseline in log-transformed UACR as the response 
variable, treatment, site, visit, treatment-by-visit interaction, and baseline eGFR stratum as fixed 
effects, and baseline log UACR and baseline MAP as covariates with unstructured as the 
variance-covariance structure. Treatment differences between the pooled IW-1973 dose groups 
and the placebo group will be estimated overall. The null hypothesis of the test will be 
interpreted as equality between the placebo and pooled treatment groups, and rejection of the 
null hypothesis as evidence that the pooled IW-1973 groups have a greater effect on lowering 
UACR than the placebo group. If the null hypothesis is rejected, the nature of these differences 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 70 of 106 
will be explored further by estimating the treatment differences between each IW-1973 dose 
group and the placebo group overall and at each assessment timepoint. Least square (LS) means, 
and LS mean differences between each IW-1973 group and placebo, and their associated one-
sided 95% confidence intervals will be calculated overall and for each assessment timepoint. The 
contrasts between each IW-1973 dose group and the placebo group at each assessment timepoint 
will be compared using a one-sided significance level of 0.05. If the treatment-by-visit 
interaction is significant at the 0.1 significance level, LS mean treatment differences relative to 
the previous visit will also be presented.  
All change-from-baseline efficacy parameters will use the same MMRM model.  
Treatment group differences in the proportion of patients who achieved a 30% or 40% reduction 
in UACR from baseline to Week 12 will be analyzed using Cochran-Mantel-Haenszel (CMH) 
test stratified by baseline eGFR stratum. 
Summary statistics will be presented by treatment group for the biomarker parameters. Change 
from baseline in these variables will also be presented, where applicable. 
5.9.1 
Controlling for Multiplicity 
No adjustments will be made for multiple comparisons. 
5.10 
SAFETY ANALYSES 
All safety parameters will be analyzed descriptively for the Safety Population. 
5.10.1 
Adverse Events 
Adverse events will be coded using the latest version of Medical Dictionary for Regulatory 
Activities (MedDRA) available at the start of the study. Treatment-emergent adverse events 
(TEAEs) are those AEs that started or worsened in severity after the administration of study 
drug. TEAEs will be summarized for each treatment group by SOC and PT; PT and severity, by 
SOC; PT and relationship to study drug; and by SOC, PT, and baseline eGFR. If a patient has 
more than 1 TEAE coded to the same preferred term, the patient will be counted only once for 
that preferred term by identifying those TEAEs with the highest severity and the closest 
relationship to study drug.  
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 71 of 106 
In addition, the incidence of AEs leading to premature discontinuation of study drug will be 
summarized by treatment group. Listings of pretreatment AEs, TEAEs, severe TEAEs, study 
drug-related AEs, SAEs, AEs leading to study discontinuation, and AEs leading to death (if any) 
will be provided. 
5.10.2 
Clinical Laboratory Parameters 
Descriptive statistics for clinical laboratory values (in standard units) and changes from the 
baseline values at each assessment time point will be presented by treatment group for each 
clinical laboratory parameter. 
5.10.3 
Vital Signs 
Descriptive statistics for vital signs (ie, pulse rate, systolic and diastolic BP, respiratory rate, 
temperature, and body weight) and changes from baseline values at each visit will be presented 
by treatment group for the Safety Population. 
5.10.4 
ECGs 
Descriptive statistics for ECG parameters and changes from the baseline values at the end of 
treatment visit will be presented by treatment group for the Safety Population. 
The number and percentage of patients with ECG abnormalities will be tabulated by treatment 
group. A listing of all AEs for patients with ECG abnormalities will also be provided. 
5.10.5 
  
 
 
 
 
 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 72 of 106 
5.11 
PK 
 
All PK analyses will be based on the PK Population. Descriptive statistics will be presented for 
IW-1973 plasma concentrations at each assessed timepoint.  
 
 
 
 
 
5.12 
 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
Confidential 
Page 73 of 106 
5.13 
DATA MONITORING COMMITTEE  
An independent DMC will be given the responsibility to review trial safety and provide guidance 
consistent with the objectives of the study and appropriate ethical requirements.  
The DMC will comprise experts in cardiovascular and/or renal disease, diabetes, and 
biostatistics, who have experience in clinical trials and are not involved in the conduct of this 
trial. Their only role in this study will be as a member of the DMC, thus ensuring their 
independent review of safety data.  
Three safety review meetings will be scheduled: the first after 30 patients have been randomized, 
or 5 months after the first subject is randomized (whichever is earlier); the second after 
approximately 1/3 of patients have completed or discontinued treatment; and the third after 
approximately 2/3 of patients have completed or discontinued treatment. 
For these periodic reviews, the DMC will be provided with summaries of all available AE and 
blood pressure data by treatment groups randomly masked as A, B, and C. An independent 
statistician will be responsible for summarizing and submitting these safety data to members of 
the DMC. All data presentations for the DMC will be performed using the Safety Population. If a 
safety/tolerability signal or concerning AE imbalance is identified at a review, the committee can 
request unblinding of the masked treatment groups as well as additional safety data. At each 
meeting, the DMC will review accumulated AE data and recommend trial continuation, 
modification, or termination. The DMC will also be required to perform an ad hoc review if 2 or 
more study drug-related SAEs from 1 category in Table 3 are reported. In this circumstance, the 
committee will be provided with narrative descriptions and all relevant clinical supporting 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 74 of 106 
documentation related to the SAEs. Upon request, the unblinded treatment and dose the subjects 
received will be provided to the committee.  
In addition to the periodic and ad hoc reviews, during the trial, committee members will be 
provided with blinded reports on all SAEs.  
The DMC or the Sponsor may request ad hoc meetings at any time and at their discretion. 
There are no predefined stopping rules for the trial (for individual stopping rules, see 
Section 3.7.1). However, the DMC will be reviewing safety data as described above. The 
Sponsor, upon the recommendation of the DMC, may stop the study at any time for significant 
safety concerns. If the DMC recommends stopping or modifying the trial, a senior review team 
from the Sponsor will have the opportunity to review the blinded data and discuss study findings 
with the DMC. The senior review team will be separate from the study project teams. The 
Sponsor may also seek input from relevant regulatory authorities. The Sponsor will make the 
final decision on the recommendation and will relay its decision to the DMC and relevant 
regulatory authorities. Additional details will be provided in the DMC charter, which will be 
developed in collaboration with the DMC members and will be finalized before trial initiation. 
5.14 
INTERIM ANALYSIS (OPTIONAL) 
After at least one half of the subjects (N75) have completed the last visit, an interim analysis to 
review unblinded efficacy data may be performed to assist with the planning of future studies. If 
performed, details regarding the interim analysis will be included in the SAP, along with updates 
to the data management plan as necessary. The independent statistician (who will not be 
involved in study data collection or interpretation) performing the interim analysis and Ironwood 
staff members, as identified in the SAP, may be unblinded. DMC reviews of safety data will be 
independent of this possible interim analysis of efficacy.  
5.15 
CHANGES IN THE CONDUCT OF THE STUDY OR PLANNED 
ANALYSES 
Any amendment to this protocol will be provided to the Investigator in writing by Ironwood or 
its designee. Before implementation, any protocol amendment regarding reportable deviations 
(as defined by the IRB) must be approved by the IRB and the signature page must be signed by 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 75 of 106 
the Investigator and received by Ironwood or its designee, with the following exception: If the 
protocol is amended to eliminate or reduce the risk to patients, the amendment may be 
implemented before IRB review and approval. However, the IRB must be informed in writing of 
such an amendment, and approval must be obtained within reasonable time limits. 
Deviating from the protocol is permitted only if absolutely necessary for the safety of the 
patients and must immediately be reported to Ironwood or its designee. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 76 of 106 
6. 
ETHICAL CONSIDERATIONS 
6.1 
INSTITUTIONAL REVIEW BOARD 
Before study onset, the protocol, any protocol amendments, ICFs, advertisements to be used for 
patient recruitment, and any other written information regarding this study to be provided to a 
patient or patient’s legal guardian must be approved by the IRB. 
All IRB approvals must be dated and signed by the IRB Chair or his or her designee and must 
identify the IRB by name and address, the clinical protocol by title and/or protocol number, and 
the date upon which approval or favorable opinion was granted for the clinical research. Copies 
of IRB approvals should be forwarded to Ironwood. All correspondence with the IRB should be 
maintained in the Investigator File. 
No drug will be released to the site to dose a patient until written IRB approval has been received 
by Ironwood. 
The Investigator is responsible for obtaining continuing review of the clinical research at least 
annually or more often if specified by the IRB. The Investigator must supply Ironwood with 
written documentation of the approval of the continued clinical research. 
The IRB must be constituted in accordance with Federal and International Conference on 
Harmonization (ICH) Good Clinical Practice (GCP) guidelines and any relevant and applicable 
local regulations. 
Major changes in this research activity, except those to remove an apparent immediate hazard to 
the patient, must be reviewed and approved by Ironwood and by the IRB that approved the study. 
Amendments to the protocol must be submitted in writing to the Investigator’s IRB for approval 
before patients being enrolled into the amended protocol. 
6.2 
PATIENT INFORMATION AND INFORMED CONSENT 
Informed consent procedures will comply with the Code of Federal Regulations (CFR) 21, 
Parts 50 and 312. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 77 of 106 
The written ICF must be approved by the IRB for the purposes of obtaining and documenting 
consent. 
Before entry into the study, each patient will be provided with a written explanation of the study. 
It is the responsibility of the Investigator or appropriately trained health professional to give each 
patient full and adequate information regarding the objectives and procedures of the study and 
the possible risks involved. Patients will then be given the opportunity to ask questions and the 
Investigator will be available to answer questions as needed. Patients will be informed of their 
right to withdraw from the study at any time without prejudice. After this explanation and before 
entering the study, the patient will voluntarily sign an ICF. The patient will receive a copy of the 
signed and dated ICF. The Investigator must retain each patient’s original signed ICF. 
If new information becomes available that may be relevant to the patient’s consent and 
willingness to participate in the study, the ICF will be revised. The revised ICF must be 
submitted to the IRB for review and approval before its use. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 78 of 106 
7. 
INVESTIGATORS AND STUDY ADMINISTRATIVE 
STRUCTURE 
This study will be performed at multiple study sites in the US. The Investigator at the study site 
will be responsible for ensuring that the study is conducted according to the signed Clinical Trial 
Agreement, the protocol, IRB requirements, and ICH GCP guidelines. 
The Investigator will be responsible for the oversight of the site’s conduct of the study, which 
will consist of completing all protocol assessments, maintaining the study file and the patient 
records, drug accountability, corresponding with the IRB, and completing the eCRF. 
7.1 
GENERATION OF STUDY RECORDS 
Ironwood or its designated representative will conduct a study site visit to verify the 
qualifications of each Investigator, inspect study site facilities, and inform the Investigator of 
responsibilities and procedures for ensuring adequate and correct study documentation. 
The Investigator is required to prepare and maintain adequate and accurate case histories 
designed to record all observations and other data pertinent to the study for each study patient. 
All information recorded in the eCRFs for this study must be consistent with the patient’s source 
documentation. 
During the course of the study, the Clinical Site Monitor will make study site visits to review 
protocol compliance, compare eCRFs and individual patient’s medical records, assess drug 
accountability (in a blinded manner), and ensure that the study is being conducted according to 
pertinent regulatory requirements. All eCRFs will be verified with source documentation. The 
review of medical records will be performed in a manner that ensures patient confidentiality is 
maintained. 
The Clinical Site Monitor will discuss instances of missing or uninterpretable data with the 
Investigator for resolution. Any changes to the study data will be made to the eCRF and 
documented via an electronic audit trail associated with the affected eCRF. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 79 of 106 
7.2 
DATA QUALITY ASSURANCE 
Ironwood performs quality control and assurance checks on all of its clinical studies. Section 7.4 
provides details regarding study monitoring procedures. 
The study may be subject to audit by Ironwood, its representatives, or regulatory authorities. In 
the event of an audit, the Investigator must agree to allow Ironwood, representatives of 
Ironwood, or the Food and Drug Administration (FDA) or other regulatory agencies access to all 
study records. 
7.3 
ELECTRONIC CASE REPORT FORMS AND DATA MANAGEMENT 
All data relating to the study will be recorded in the patient’s source documentation and eCRF to 
be provided by Ironwood or designee via the electronic data capture (EDC) system. Source 
documentation supporting the eCRF data should indicate the patient’s participation in the study 
and should document the dates and details of study procedures, AEs, all observations, and patient 
status. The Investigator is responsible for verifying that all data entries on the eCRFs are accurate 
and correct and ensuring that all data are entered in a timely manner, as soon as possible after the 
information is collected. An explanation should be provided for any missing data. The 
Investigator must provide through the EDC system his or her formal approval of all the 
information in the eCRFs and changes to the eCRFs to endorse the final submitted data for each 
patient. 
Ironwood will retain the final eCRF data and corresponding audit trails. A copy of the final 
archival eCRF in the form of a compact disc or other electronic media will be placed in the 
Investigator’s study file. 
A record of screen failures and pretreatment failures will be maintained for patients who do not 
qualify for enrollment, including the reason for the failure. 
7.4 
STUDY MONITORING 
Ironwood performs quality control and assurance checks on all of its clinical studies. Before any 
patients are enrolled in the study, a representative of Ironwood or its authorized designee will 
meet with the Investigator and his/her staff to review relevant and important study-related 
information including, but not limited to, the protocol, the Investigator’s Brochure, the eCRFs 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 80 of 106 
and instructions for their completion using the EDC system, the procedure for obtaining 
informed consent, and the procedure for reporting AEs and SAEs. 
An Ironwood representative, the Clinical Site Monitor, will monitor the progress and conduct of 
the study by periodically conducting monitoring visits and by frequent communications 
(telephone, e-mail, letter, and fax) with the study sites. The site monitor will ensure that the study 
is conducted according to the protocol and regulatory requirements. During monitoring visits, the 
information recorded on the eCRFs will be verified against source documents. Upon request of 
the monitor, auditor, IRB, or regulatory authority, the Investigator should make all requested 
study-related records available for direct access. 
All aspects of the study will be carefully monitored by Ironwood or its designee for compliance 
with applicable government regulations with respect to GCP and current standard operating 
procedures. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 81 of 106 
8. 
STUDY SPONSORSHIP 
8.1 
INVESTIGATOR AND STUDY TERMINATION 
Ironwood may terminate Investigator participation at any institution for any reason. If 
participation is ended at the site by either Ironwood or the Investigator, the Investigator must: 
• Return all study medications and any study materials to Ironwood 
• In cases where the Investigator opts to self-terminate, provide a written statement describing 
why the study was terminated prematurely 
 
Ironwood may terminate the study in its entirety or at a specific center at any time for any 
reason, including but not limited to the following: 
• Failure to enroll patients 
• Protocol violations 
• Inaccurate or incomplete data 
• Unsafe or unethical practice 
• Questionable safety of the study medication 
• Suspected lack of efficacy of the study medication  
• Administrative decision 
 
8.2 
REPORTING AND PUBLICATION 
 All data generated in this study will be the property of Ironwood. An integrated clinical and 
statistical report will be prepared at the completion of the study. 
Publication of the results by the Investigator will be subject to agreement between the 
Investigator and Ironwood. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 82 of 106 
9. 
INVESTIGATOR OBLIGATIONS 
9.1 
DOCUMENTATION 
The Investigator must provide the Sponsor with the following documents BEFORE the 
enrollment of any subjects, in accordance with ICH E6 (Note: Ironwood must be notified if there 
are any changes to these documents): 
1. Completed and signed Form FDA 1572 (Statement of Investigator) including all sub-
investigators involved in the study 
2. Financial disclosure form(s) for the Investigator and all sub-investigators listed on Form 
FDA 1572 
3. Current, signed curricula vitae of the Investigator and all sub-investigators 
4. Copy of current medical license of the Investigator and all sub-investigators (as applicable) 
5. Copy of the IRB approval letter for the protocol and ICF 
6. Copy of the IRB-approved ICF to be used 
7. Copy of the IRB approval of recruitment advertising (if applicable) 
8. A list of IRB members and their qualifications, and a description of the committee’s working 
procedures 
9. Protocol Approval Page signed by the Investigator 
10. Fully executed Clinical Trial Agreement 
11. Written document containing the name, location, certification number, and date of 
certification of the local laboratory to be used for laboratory assays and those of other 
facilities conducting tests 
12. List of normal laboratory values and units of measurements for all laboratory tests required 
by the protocol. This list is required for each local laboratory to be used during the study. 
 
During the study, the Investigator must maintain the following essential/administrative 
documents related to the study: 
1. Copy of the signed Protocol Signature Page 
2. Copy of financial disclosure form(s) for the Investigator and all sub-investigators (as 
applicable) if updated 
3. Curricula vitae of any new Investigator(s) and/or sub-investigators involved in the study 
4. Copy of current medical license of the Investigator and all sub-investigators (as applicable) if 
updated 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 83 of 106 
5. Copy of the signed Form FDA 1572 
6. IRB Approval Notification for the following: 
a. Protocol 
b. Informed consent document 
c. Recruitment advertising (if applicable) 
d. Amendment(s) (if applicable) 
e. Annual review of the protocol and the informed consent document 
f. SAEs 
g. Study closure 
7. SAE Reports 
8. Drug Inventory Forms (drug receipts, drug dispensing, and inventory forms) 
9. Name and address of local or central laboratory, list of normal laboratory values and units of 
measurement, as well as laboratory certification or hospital accreditation 
10. Updates of medical/laboratory/technical procedures/tests: 
a. Normal value(s)/ranges(s) 
b. Certification 
c. Accreditation 
d. Established quality control and/or external quality assessment 
e. Other validation (where required) 
11. Record of retained body fluids/tissue samples (if any) 
12. Correspondence with Sponsor 
13. Written assurance of continuing approval (at least annually) as well as a copy of the annual 
progress report submitted to the IRB must also be provided to the Sponsor. Any changes in 
this study or unanticipated problems involving risks to the patients must be reported 
promptly to the IRB. An Investigator must not make any changes in a study without IRB and 
Sponsor approval, except when necessary to eliminate apparent immediate hazards to the 
subjects. All protocol amendments must be submitted to the IRB and approved. 
14. Responsibility Log 
15. Other logs (eg, screening, enrollment) 
16. Signed ICFs 
17. Patient source documentation 
18. eCRFs 
19. Audit certificate(s), if applicable 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 84 of 106 
9.2 
PERFORMANCE 
The Investigator must demonstrate reasonable efforts to obtain qualified patients for the study. 
The Sponsor may terminate the study with any Investigator for any reason, including, but not 
limited to, Investigator nonperformance or Investigator noncompliance. 
9.3 
USE OF INVESTIGATIONAL MATERIALS 
The Investigator will acknowledge that the drug supplies are investigational and as such must be 
used strictly in accordance with the protocol and only under the supervision of the Investigator or 
sub-investigators. Study medication must be stored in a safe and secure temperature-monitored 
location. The Investigator must maintain adequate records documenting the receipt and 
disposition of all study supplies. The study site must record the date the study medication was 
received and maintain a dispensing record in which to record each patient’s use. A complete 
reconciliation of study medication will be performed at the site close-out visit with a final 
accountability report provided to Ironwood as part of the site close-out report. Written 
instructions for return of all unused and reconciled study medication to an appropriate waste 
handler will be provided before the end of the study. No study medication may be destroyed by 
study site without prior written permission of Ironwood. 
9.4 
RETENTION AND REVIEW OF RECORDS 
Records and documents pertaining to the conduct of this study, including eCRFs, source 
documents, ICFs, laboratory test results, and medication inventory records, must be retained by 
the Investigator in accordance with locally applicable regulatory requirements; and, in any event, 
for a minimum period of 5 years.  
No study records shall be destroyed without notifying Sponsor and giving Sponsor the 
opportunity to take such study records or authorizing in writing the destruction of records after 
the required retention period. 
If the Investigator retires, relocates, or otherwise withdraws from the responsibility of keeping 
the study records, custody must be transferred to another person (Ironwood, IRB, or other 
Investigator) who will accept the responsibility. Ironwood must be notified of and agree to the 
change. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 85 of 106 
9.5 
PATIENT CONFIDENTIALITY 
All data collected in the context of this study will be stored and evaluated in such a way as to 
guarantee patient confidentiality in accordance with the legal stipulations applying to 
confidentiality of data. All patient records will be identified only by initials and patient 
identification (PID) number. Patient names are not to be transmitted to Ironwood or its 
authorized designee. The Investigator will keep a Master Patient List on which the PID number 
and the full name, address, and telephone number of each patient is listed. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 86 of 106 
10. 
REFERENCE LIST 
1. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF, Feldman HI, et al. A new 
equation to estimate glomerular filtration rate. Annals of Internal Medicine 2009;150(9):604-
12. 
2. The Criteria Committee of the New York Heart Association. Nomenclature and Criteria for 
Diagnosis of Diseases of the Heart and Great Vessels.  253-256. 1994. Boston, Mass., Little, 
Brown & Co.  
3. Tuttle KR, Bakris GL, Bilous RW, Chiang JL, de Boer IH, Goldstein-Fuchs J, et al. Diabetic 
kidney disease: a report from an ADA Consensus Conference. Diabetes Care 2014 
Oct;37(10):2864-83. 
4. Lim AK. Diabetic nephropathy - complications and treatment. Int J Nephrol Renovasc Dis 
2014;7:361-81. 
5. Reidy K, Kang HM, Hostetter T, Susztak K. Molecular mechanisms of diabetic kidney 
disease. J Clin Invest 2014 Jun;124(6):2333-40. 
6. Fineberg D, Jandeleit-Dahm KA, Cooper ME. Diabetic nephropathy: diagnosis and 
treatment. Nat Rev Endocrinol 2013 Dec;9(12):713-23. 
7. National Kidney Foundation. KDIGO 2012 Clinical Practice Guideline for the Evaluation 
and Management of Chronic Kidney Disease. Kidney International Supplements 
2013;3(1):1-150. 
8. Narres M, Claessen H, Droste S, Kvitkina T, Koch M, Kuss O, et al. The Incidence of End-
Stage Renal Disease in the Diabetic (Compared to the Non-Diabetic) Population: A 
Systematic Review. PLoS One 2016;11(1):e0147329. 
9. de Boer IH, Rue TC, Hall YN, Heagerty PJ, Weiss NS, Himmelfarb J. Temporal trends in the 
prevalence of diabetic kidney disease in the United States. JAMA 2011 Jun 22;305(24):2532-
9.  
10. Toth-Manikowski S, Atta MG. Diabetic Kidney Disease: Pathophysiology and Therapeutic 
Targets. J Diabetes Res 2015;2015:697010 
11. Nakagawa T, Tanabe K, Croker BP, Johnson RJ, Grant MB, Kosugi T, et al. Endothelial 
dysfunction as a potential contributor in diabetic nephropathy. Nat Rev Nephrol 2011 
Jan;7(1):36-44. 
12. Cheng H, Harris RC. Renal endothelial dysfunction in diabetic nephropathy. Cardiovasc 
Hematol Disord Drug Targets 2014;14(1):22-33. 
13. Liao JK. Linking endothelial dysfunction with endothelial cell activation. J Clin Invest 2013 
Feb;123(2):540-1. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 87 of 106 
14. Wharton J, Strange JW, Møller GM, Growcott EJ, Ren X, Franklyn AP, et al. 
Antiproliferative effects of phosphodiesterase type 5 inhibition in human pulmonary artery 
cells. Am J Respir Crit Care Med 2005;172:105-13. 
15. Beyer C, Zenzmaier C, Palumbo-Zerr K, Mancuso R, Distler A, Dees C, et al. Stimulation of 
the soluble guanylate cyclase (sGC) inhibits fibrosis by blocking non-canonical TGF? 
signalling. Ann Rheum Dis 2014. 
16. Masuyama H, Tsuruda T, Sekita Y, Hatakeyama K, Imamura T, Kato J, et al. Pressure-
independent effects of pharmacological stimulation of soluble guanylate cyclase on fibrosis 
in pressure-overloaded rat heart. Hypertens Res 2009. 
17. Ahluwalia A, Foster P, Scotland RS, McLean PG, Mathur A, Perretti M, et al. 
Antiinflammatory activity of soluble guanylate cyclase: cGMP-dependent down-regulation 
of P-selectin expression and leukocyte recruitment. Proc Natl Acad Sci U S A 
2004;101:1386-91. 
18. Calles-Escandon J, Cipolla M. Diabetes and endothelial dysfunction: a clinical perspective. 
Endocr Rev 2001 Feb;22(1):36-52. 
19. Gargiulo P, Marciano C, Savarese G, D'Amore C, Paolillo S, Esposito G, et al. Endothelial 
dysfunction in type 2 diabetic patients with normal coronary arteries: a digital reactive 
hyperemia study. Int J Cardiol 2013 Apr 30;165(1):67-71. 
20. Baylis C. Nitric oxide synthase derangements and hypertension in kidney disease. Curr Opin 
Nephrol Hypertens 2012 Jan;21(1):1-6. 
21. Ito K, Chen J, Seshan SV, Khodadadian JJ, Gallagher R, El CM, et al. Dietary arginine 
supplementation attenuates renal damage after relief of unilateral ureteral obstruction in rats. 
Kidney Int 2005 Aug;68(2):515-28. 
22. Griffin K, Polichnowski A, Licea-Vargas H, Picken M, Long J, Williamson G, et al. Large 
BP-dependent and -independent differences in susceptibility to nephropathy after nitric oxide 
inhibition in Sprague-Dawley rats from two major suppliers. Am J Physiol Renal Physiol 
2012 Jan 1;302(1):F173-F182. 
23. Ueda S, Ozawa S, Mori K, Asanuma K, Yanagita M, Uchida S, et al. ENOS deficiency 
causes podocyte injury with mitochondrial abnormality. Free Radic Biol Med 2015 
Oct;87:181-92. 
24. Stasch JP, Schlossmann J, Hocher B. Renal effects of soluble guanylate cyclase stimulators 
and activators: a review of the preclinical evidence. Curr Opin Pharmacol 2015 Apr;21:95-
104. 
25. Wang-Rosenke Y, Neumayer HH, Peters H. NO signaling through cGMP in renal tissue 
fibrosis and beyond: key pathway and novel therapeutic target. Curr Med Chem 
2008;15(14):1396-406. 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 88 of 106 
26. Ott IM, Alter ML, von WK, Kretschmer A, Tsuprykov O, Sharkovska Y, et al. Effects of 
Stimulation of Soluble Guanylate Cyclase on Diabetic Nephropathy in Diabetic eNOS 
Knockout Mice on Top of Angiotensin II Receptor Blockade. PLoS ONE 2012;7:e42623. 
27. Sharkovska Y, Kalk P, Lawrenz B, Godes M, Hoffmann LS, Wellkisch K, et al. Nitric oxide-
independent stimulation of soluble guanylate cyclase reduces organ damage in experimental 
low-renin and high-renin models. J Hypertens 2010 Aug;28(8):1666-75. 
28. Dautzenberg M, Kahnert A, Stasch JP, Just A. Role of soluble guanylate cyclase in renal 
hemodynamics and autoregulation in the rat. Am J Physiol Renal Physiol 2014 Nov 
1;307(9):F1003-F1012. 
29. de Zeeuw D., Coll B, Andress D, Brennan JJ, Tang H, Houser M, et al. The endothelin 
antagonist atrasentan lowers residual albuminuria in patients with type 2 diabetic 
nephropathy. Journal of the American Society of Nephrology : JASN 2014;25(5):1083-93. 
30. EuroQol Group. EuroQol--a new facility for the measurement of health-related quality of 
life. The EuroQol Group. Health Policy 1990;16(3):199-208. 
31. Shaw JW, Johnson JA, Coons SJ. US valuation of the EQ-5D health states: development and 
testing of the D1 valuation model. Med Care 2005;43(3):203-20. 
32. Ware J, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales 
and preliminary tests of reliability and validity. Med Care 1996;34(3):220-33. 
33. Hays RD, Kallich JD, Mapes DL, Coons SJ, Carter WB. Development of the kidney disease 
quality of life (KDQOL) instrument. Qual Life Res 1994 Oct;3(5):329-38. 
34. Wallace TM, Levy JC, Matthews DR. Use and abuse of HOMA modeling. Diabetes care 
2004;27(6):1487-95. 
35. Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner RC. Homeostasis 
model assessment: insulin resistance and beta-cell function from fasting plasma glucose and 
insulin concentrations in man. Diabetologia 1985;28(7):412-9. 
 
Document Date: 22-Dec-2017 10:15




IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 90 of 106 
12. 
INVESTIGATOR’S SIGNATURE 
Study Title: 
A Randomized, Double-blind, Placebo-controlled, Phase 2 Study to 
Evaluate the Safety and Efficacy of IW-1973 in Patients with Type 2 
Diabetes with Albuminuria Treated with Renin-Angiotensin System 
Inhibitors 
Study Number: 
C1973-203 
Final Date: 
20 December 2017 
I have read the protocol described above. I agree to comply with all applicable regulations and to 
conduct the study as described in the protocol.  
 
 
Signed: 
 
 
Date:  
 
 
Print Name: 
 
 
 
 
 
 
 
 
 
 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 91 of 106 
APPENDIX 1 
PROHIBITED MEDICINES AND SUPPLEMENTS  
 
Prohibited from 7 days before Randomization (Day 1) through the duration of the study 
• Specific inhibitors of PDE5, including sildenafil, tadalafil, vardenafil 
• All supplements for the treatment of erectile dysfunction 
• Nonspecific inhibitors of PDE5, including dipyridamole, theophylline 
• Other sGC stimulators, including riociguat 
• Nitrates including nitroglycerin, isosorbide mononitrate, isosorbide dinitrate, sodium 
nitroprusside, amyl nitrate  
• Other NO donors in any form, including beetroot 
Prohibited from 14 days before Randomization (Day 1) through the duration of the study
• Strong inhibitors of CYP3A, including azole antifungals (eg, itraconazole, posaconazole), 
conivaptan, diltiazem, idelalisib, macrolide antibiotics (eg, clarithromycin, telithromycin), 
nefazodone, protease inhibitors (eg, ritonavir, boceprivir), and excessive grapefruit intake 
or concentrated grapefruit supplements 
CYP=cytochrome P450; NO=nitric oxide; PDE=phosphodiesterase 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 92 of 106 
APPENDIX 2 
 
APPENDIX 2 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 93 of 106 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 94 of 106 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 95 of 106 
APPENDIX 3 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 96 of 106 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 97 of 106 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 98 of 106 
APPENDIX 4 
 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 99 of 106 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 100 of 106 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 101 of 106 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 102 of 106 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 103 of 106 
 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 104 of 106 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 105 of 106 
 
Document Date: 22-Dec-2017 10:15


IW-1973 Tablets 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Trial Protocol: C1973-203 Amendment 4 
 
20 December 2017 
 
Confidential 
Page 106 of 106 
 
 
Document Date: 22-Dec-2017 10:15

SAP_001.pdf: 
Final V2: 24 September 2019
Page 1 of 97
STATISTICAL ANALYSIS PLAN
A Randomized, Double-blind, Placebo-controlled, Phase 2 Study to 
Evaluate the Safety and Efficacy of IW-1973 in Patients with Type 2 
Diabetes with Albuminuria Treated with Renin-Angiotensin System 
Inhibitors
Statistical Analysis Plan Status: Final V2
Statistical Analysis Plan Date: 24 September 2019
Study Drug: Praliciguat (IW-1973) Tablet
Cyclerion Study Number: C1973-203
Covance Study Number: 8362330
Clinical Phase: 2
Sponsor:
Cyclerion Therapeutics, Inc.
(formerly part of Ironwood 
Pharmaceuticals, Inc.)
301 Binney Street
Cambridge, MA 02142
Study Site:
Multiple Sites
Sponsor Signatory:
Telephone:
Telephone: 


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 2 of 97
1 STATISTICAL ANALYSIS PLAN APPROVAL SIGNATURES
By signing this page when the Statistical Analysis Plan (SAP) is considered final, the signatories 
agree to the statistical efficacy and pharmacokinetic (PK) analyses to be performed for this 
study, and to the basic format of the tables, figures, and listings (TFLs). Once the SAP has been 
signed, programming of the TFLs based upon this document can proceed. Any modifications to 
the SAP and TFLs made after signing may result in a work-scope change.


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 3 of 97
2 TABLE OF CONTENTS
1 
STATISTICAL ANALYSIS PLAN APPROVAL SIGNATURES................................. 2 
2 
TABLE OF CONTENTS ............................................................................................... 3 
3 
ABBREVIATIONS........................................................................................................ 5 
4 
INTRODUCTION ......................................................................................................... 7 
5 
STUDY OBJECTIVES.................................................................................................. 7 
6 
STUDY DESIGN........................................................................................................... 8 
7 
TREATMENTS ............................................................................................................. 9 
8 
RANDOMIZATION AND BLINDING....................................................................... 10 
9 
STUDY SCHEMATIC AND SCHEDULE OF ASSESSMENTS................................. 11 
10 SAMPLE SIZE JUSTIFICATION ............................................................................... 15 
11 DEFINITION OF ANALYSIS POPULATIONS.......................................................... 15 
12 STATISTICAL METHODOLOGY ............................................................................. 15 
12.1 General.................................................................................................................. 15 
12.1.1 Study Periods ............................................................................................... 16 
12.1.2 Definition of Baseline and Change from Baseline......................................... 16 
12.1.3 Handling of Dropouts or Missing Data ......................................................... 16 
12.1.4 Multiple Comparisons/Multiplicity............................................................... 17 
12.1.5 Repeat and Unscheduled Readings ............................................................... 17 
12.1.6 Protocol Deviations ...................................................................................... 17 
12.2 Demographics and Patient Disposition................................................................... 17 
12.3 Medical History..................................................................................................... 18 
12.4 Prior and Concomitant Medication ........................................................................ 18 
12.5 Exposure and Drug Compliance ............................................................................ 18 
12.6 Efficacy Analyses.................................................................................................. 19 
12.6.1 Baseline Summaries for Efficacy Endpoints ................................................. 19 
12.6.2 Primary Efficacy Endpoint ........................................................................... 19 
12.6.3 Exploratory Efficacy Endpoints.................................................................... 21 
12.6.4 Subgroup Analyses....................................................................................... 24 
12.7 Pharmacokinetic Assessment................................................................................. 25 
12.7.1 Pharmacokinetic Analysis............................................................................. 25 
 
 
12.8 Safety and Tolerability Assessments...................................................................... 25 
12.8.1 Primary Safety Endpoints ............................................................................. 25 
12.8.2 Adverse Events............................................................................................. 26 
12.8.3 Subgroup Analyses....................................................................................... 26 
12.8.4 TEAEs of Clinical Interest (AECI) ............................................................... 26 


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 4 of 97
12.8.5 Clinical Laboratory Endpoints...................................................................... 26 
12.8.6 Vital Signs.................................................................................................... 28 
12.8.7 Electrocardiogram ........................................................................................ 29 
12.8.8 
 
12.9 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
13 INTERIM ANALYSES ............................................................................................... 31 
14 CHANGES FROM THE PROTOCOL SPECIFIED STATISTICAL ANALYSES ...... 31 
15 DATA PRESENTATION ............................................................................................ 32 
13.1 Insufficient Data for Presentation............................................................................ 32 
16 DATA HANDLING CONVENTIONS ........................................................................ 32 
16.1 End of Treatment Assessment................................................................................ 32 
16.2 Repeated or unscheduled assessments of safety endpoints ..................................... 32 
16.3 Conventions for Summarizing Adverse Events...................................................... 32 
16.4 Missing Date Information for Adverse Events ....................................................... 33 
16.5 Missing Severity Assessment for Adverse Events.................................................. 33 
16.6 Missing Relationship to Study Drug for Adverse Events........................................ 33 
16.7 Missing Date Information for Prior or Concomitant Medications........................... 33 
17 REFERENCES ............................................................................................................ 33 
18 APPENDIX 1 – ADVERSE EVENTS OF CLINICAL INTEREST ............................. 34 
19 APPENDIX 2 
 
20 APPENDIX 3 – POOLING OF TRIAL CENTERS...................................................... 37 
21 APPENDIX 4 
 
22 APPENDIX 5 
 


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 5 of 97
3 ABBREVIATIONS
Abbreviations pertain to the SAP only (not the TFLs).
ABPM
ambulatory blood pressure monitoring
ADaM
analysis data model
ADMA
asymmetric dimethylarginine
ALQ
above the limit of quantitation
ANCOVA
Analysis of covariance
AOBP
automated office blood pressure
AE
adverse event
AECI
Adverse event of clinical interest
ARU
aspirin reaction units
ATC
Anatomical Therapeutic Chemical
BID
Twice daily
BP
Blood pressure
BLQ
Below the limit of quantification
BMI
Body mass index
CDISC
Clinical Data Interchange Standards Consortium
CKD-EPI
Chronic Kidney Disease Epidemiology Collaboration
CMH
Cochran-Mantel-Haenszel
CSR
Clinical Study Report
CV%
coefficient of variation
DBP
diastolic blood pressure
DMC
Data Monitoring Committee
EC
Early Clinical
ECG
Electrocardiogram
eGFR
estimated glomerular filtration rate
FGF-23
fibroblast growth factor
FPG
fasting plasma glucose
FPI
fasting plasma insulin
HOMA-IR
Homeostatic model assessment of insulin resistance
ICAM-1
intercellular adhesion molecule 1 
ICF
Informed consent form
ICH
International Conference on Harmonisation
IL-6
interleukin-6
ITT
Intent-to-Treat
KIM-1
kidney injury molecule 1
L-Arg
L- arginine
LLN
Lower limit of normal
LLOQ
Lower limit of quantification


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 6 of 97
LOCF
last-observation-carried-forward
LS
Least square
MAP
mean arterial pressure
MCP-1
monocyte chemoattractant protein 1
MCS
Mental component score
MedDRA
Medical Dictionary for Regulatory Activities
MEMS
Medication Event Monitoring System
MMRM
mixed-effect model repeated measures
NGAL
neutrophil gelatinase-associated lipocalin
PCS
potentially clinically significant
PK
Pharmacokinetic
PP
per protocol
PRU
P2Y12 reaction units
PT
Preferred term
QD
Once daily
QTc
QT correction; QT interval corrected for heart rate
QTcF
QTc calculated using the Fridericia correction 
SAA
serum amyloid A
SAE
Serious Adverse Event
SAP
Statistical Analysis Plan
SBP
systolic blood pressure
sCr
serum creatinine
SD
standard deviation
SDMA
symmetric dimethylarginine
SI
International System of Units
SOC
System organ class
TEAE
treatment-emergent adverse event
TFLs
tables, figures, and listings
TGF-β
transforming growth factor beta
TNF-α
tumor necrosis factor alpha
TNFR-1
tumor necrosis factor receptor 1
UACR
urine albumin creatinine ratio
ULN
Upper limit of normal
ULOQ
upper limit of quantitation
VCAM-1
vascular cell adhesion molecule 1
WHO
World Health Organization


Statistical Analysis Plan  
 
CONFIDENTIAL 
Covance Study: 8362330 
 
Cyclerion Study: C1973-203 
 
Final V2: 24 September 2019 
 
Page 7 of 97 
 
 
4  INTRODUCTION 
Note: This study was initiated by/on behalf of Ironwood Pharmaceuticals, Inc. As of 01 April 
2019, Cyclerion Therapeutics was established as an independent spin-off of Ironwood and has 
assumed the sponsorship of praliciguat (IW-1973). 
This SAP has been developed after review of the clinical study protocol (protocol amendment 
No. 4 [dated 20 December 2017]). 
This SAP describes the planned analysis of the safety, tolerability, efficacy and PK data from 
this study. A detailed description of the planned TFLs to be presented in the Clinical Study 
Report (CSR) is provided in the accompanying TFL shell document. 
The intent of this document is to provide guidance for the statistical analyses of efficacy and PK 
concentration data. In general, the analyses are based on information from the protocol, unless 
they have been modified by agreement between Cyclerion and Covance Early Clinical (EC) 
Biometrics. A limited amount of information concerning this study (eg, objectives, study design) 
is given to help the reader’s interpretation. This SAP must be finalized prior to the lock of the 
clinical database for this study. When the SAP and TFL shells are agreed upon and finalized, 
they will serve as the template for this study’s CSR, along with the final version of the protocol, 
as applicable. 
This SAP supersedes the statistical considerations identified in the protocol; where 
considerations are substantially different, they will be so identified. If additional analyses are 
required to supplement the planned analyses described in this SAP, they may be performed and 
will be identified in the CSR. Any substantial deviations from this SAP will be agreed upon 
between Cyclerion and Covance EC Biometrics and identified in the CSR. 
This SAP is written with consideration of the recommendations outlined in the International 
Conference on Harmonisation (ICH) E9 guideline entitled, “Guidance for Industry: Statistical 
Principles for Clinical Trials” and the ICH E3 guideline entitled, “Guidance for Industry: 
Structure and Content of Clinical Study Reports.”1,2 
5  STUDY OBJECTIVES 
Primary Objectives 
1. To assess the safety and tolerability of oral praliciguat when administered daily for 
approximately 12 weeks to adult patients with type 2 diabetes mellitus with albuminuria 
who are on a stable regimen of renin-angiotensin system inhibitors 
2. To evaluate the effect of oral praliciguat on renal function when administered daily for 
approximately 12 weeks to adult patients with type 2 diabetes mellitus with albuminuria 
who are on a stable regimen of renin-angiotensin system inhibitors 


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 8 of 97
Exploratory Objectives
6 STUDY DESIGN
Study C1973-203 is a multicenter, randomized, double-blind, placebo-controlled, parallel-group 
12-week study to evaluate 2 dose levels of praliciguat compared with placebo. The study will 
enroll approximately 150 adult patients with type 2 diabetes mellitus, albuminuria, and impaired 
renal function. Patients will be stratified by baseline estimated glomerular filtration rate (eGFR) 
(ie, eGFR 30 to 45, >45 to 60, and >60 to 75 mL/min/1.73 m2) and randomized in a 1:1:1 ratio to 
receive 20 mg praliciguat, 40 mg praliciguat, or placebo daily for approximately 12 weeks. 
Patients will receive daily oral study drug for up to 90 days. Total patient participation will be 
131 to 163 days.
PPD


Statistical Analysis Plan  
 
CONFIDENTIAL 
Covance Study: 8362330 
 
Cyclerion Study: C1973-203 
 
Final V2: 24 September 2019 
 
Page 9 of 97 
 
 
Figure 1: Overview of Study Design 
 
7  TREATMENTS 
The following is a list of the study treatment abbreviations and ordering that will be used in the 
TFLs. 
Study Treatment Name 
Treatment Order on 
TFLs 
Placebo 
1 
20 mg Praliciguat  
2 
40 mg Praliciguat  
3 
Overall Praliciguat  
4 
Table 2 summarizes the dosage and dosing regimen that will be administered during the 12-week 
double-blind treatment period.  


Statistical Analysis Plan  
 
CONFIDENTIAL 
Covance Study: 8362330 
 
Cyclerion Study: C1973-203 
 
Final V2: 24 September 2019 
 
Page 10 of 97 
 
Table 2. 
Dosage by Week 
Dose 
Week 1, BID Dosing  
Weeks 2 through 12, QD Dosing 
20 mg 
one 10-mg praliciguat tablet, orally twice daily 
two 10-mg praliciguat tablets, orally once daily 
40 mg 
one 20-mg praliciguat tablet, orally twice daily 
two 20-mg praliciguat tablets, orally once daily 
Placebo 
one matching placebo tablet, orally twice daily 
two matching placebo tablets, orally once daily 
BID=twice daily; QD=once daily 
Per Investigator discretion, on a per-patient basis, patients will be allowed to reduce his or her 
daily dose by half, ie, from 2 tablets daily to 1 tablet daily. Each patient’s dose may only be 
reduced once and will not be increased after reduction. 
8  RANDOMIZATION AND BLINDING 
Patients who meet all the inclusion criteria and none of the exclusion criteria will be stratified by 
baseline eGFR and randomized 1:1:1 to 20 mg praliciguat, 40 mg praliciguat or placebo at the 
Randomization Visit on Day 1 through central randomization. The randomization schedule was 
prepared by an independent statistician using SAS® PLAN procedure (PC SAS® Version 9.3) 
using a block size of 3. The lowest randomization number within a stratum will be assigned to 
the first patient that qualifies for randomization, and subsequent assignments will proceed in 
increasing sequential order within a block as patients qualify for the study. The randomization 
schedule also includes separate blocks for patients at sites that have the capability to perform 
VerifyNow assessments to facilitate approximately equal proportions of patients with VerifyNow 
assessments in each treatment group. 
This is a double-blind, placebo-controlled study in which the patients, investigators, study staff 
and the sponsor study team will remain blinded to the randomization scheme until the blind is 
formally broken for all subjects after all subjects have completed the study and the study 
database is locked. 
Please refer to Section 13 for details on the external Data Monitoring Committee’s (DMC) 
review of masked and potentially unblinded safety data to monitor trial safety. 
Prior to database lock, a treatment assignment may be unblinded by the site only in emergency 
situations and/or by the Sponsor’s Global Patient Safety group if the knowledge of the treatment 
received is essential for managing a serious adverse event (SAE).


Statistical Analysis Plan  
 
CONFIDENTIAL 
Covance Study: 8362330 
 
Cyclerion Study: C1973-203 
 
Final V2: 24 September 2019 
 
 
 
 
 
 
 
 
Page 11 of 97 
 
9  STUDY SCHEMATIC AND SCHEDULE OF ASSESSMENTS 
The schedule of evaluations for Study C1973-203 is presented in Table 3. 
Table 3. Schedule of Events 
 
Visit Days → 
Study Procedure ↓ 
Screening Period 
Treatment Period 
Follow-up 
Period 
Screening 
Visit (Day 
-45 to 
-15) 
Baseline 
Visit 
(Day -7 
±3) 
Randomization 
Visit 
(Day 1) 
Week 1 Visit 
(Day 8 ±1) 
Week 4 Visit 
(Day 29 ±3) 
Week 8 Visit 
(Day 57 ±3) 
End of 
Treatment 
Visit 
(Day 87 ±3) 
Follow-up 
Visit 
(Day 115 ±3) 
ICF signed 
X 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
Prior & concomitant meds 
X 
X 
X 
X 
X 
X 
X 
X 
Inclusion/exclusion 
evaluation/review 
X 
X 
X 
 
 
 
 
 
Physical exam 
X 
 
 
 
 
 
X 
 
Hepatitis (HBsAg, HCV) & 
HIV screen 
X 
 
 
 
 
 
 
 
Drug screen (a) 
X 
 
 
 
 
 
 
 
Urine pregnancy test (b) 
X 
X 
predose 
predose 
predose 
predose 
predose 
X 
Weight (W) & height (H) 
W, H 
W 
W 
W 
W 
W 
W 
W 
12-lead ECG (c) 
X 
X 
 
 
 
 
predose 
 
Respiratory rate and oral 
temperature  
X 
 
pre: 0 (≤30m) 
pd: 1h (±15m) 
pre: 0 
(≤30m) 
pd: 1h (±15m) 
 
 
X 
X 
Seated pulse and BP (d) 
X 
X 
 
 
 
 
 
 
First-void urine for UACR (e) 
X 
preVisit 
preVisit 
preVisit 
 preVisit 
 preVisit 
 preVisit 
preVisit 


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 12 of 97
Visit Days →
Study Procedure ↓
Screening Period
Treatment Period
Follow-up
Period
Screening 
Visit (Day 
-45 to 
-15)
Baseline 
Visit
(Day -7
±3)
Randomization 
Visit
(Day 1)
Week 1 Visit
(Day 8 ±1)
Week 4 Visit
(Day 29 ±3)
Week 8 Visit
(Day 57 ±3)
End of 
Treatment 
Visit
(Day 87 ±3)
Follow-up
Visit
(Day 115 ±3)
Issue UACR sample supplies
X
X
X
X
X
X
X
Urinalysis sample (f)
X
X
predose
X
Serum chemistry, coagulation, 
hematology (f)
X
X
serum creatinine 
& glucose only 
pre: 0 (≤30m)
serum creatinine 
& glucose only
pre: 0 (≤30m)
pre: 0 (≤30m)
serum creatinine 
& glucose only 
pre: 0 (≤30m)
pre: 0 (≤30m)
X
Hemoglobin A1c (f)
X
X
pre: 0 (≤30m)
pre: 0 (≤30m)
pre: 0 (≤30m)
pre: 0 (≤30m)
X
Adverse event evaluations
X
X
X
X
X
X
X
X
Fasting plasma glucose & 
insulin (f)
X
pre: 0
(≤30m)
pre: 0
(≤30m)
pre: 0
(≤30m)
pre: 0
(≤30m)
Urine cotinine
predose
24- or 12-h ABPM (h)
X (24h)
X (12h)
X (12h)
X (24h)
Return of ABPM monitor
X
X
X
X
Orthostatic (seated to 
standing) pulse and BP (i)
pre: 0 (≤30m)
pd: 1,2,4,6h 
(±15m)
pre: 0 (≤30m)
pd: 1,2,4,6h 
(±15m)
pre: 0
(≤30m)
pre: 0
(≤30m)
pre: 0
(≤30m)
X
Randomization
X


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 13 of 97
Visit Days →
Study Procedure ↓
Screening Period
Treatment Period
Follow-up
Period
Screening 
Visit (Day 
-45 to 
-15)
Baseline 
Visit
(Day -7
±3)
Randomization 
Visit
(Day 1)
Week 1 Visit
(Day 8 ±1)
Week 4 Visit
(Day 29 ±3)
Week 8 Visit
(Day 57 ±3)
End of 
Treatment 
Visit
(Day 87 ±3)
Follow-up
Visit
(Day 115 ±3)
MEMS instruction/review
X
X
X
X
Study drug dispensed
X
X
X
In-clinic study drug 
administration (j)
X
X
X
X
X
Study drug return (k)
X
X
X
X
Pharmacokinetic blood 
samples 
pre: 0 (≤30m)
pd: 1,3,6h 
(±15m)
pre: 0 (≤30m)
pd: 1,3,6h 
(±15m)
pre: 0 
(≤30m)
pre: 0 
(≤30m)
pre: 0 (≤30m)
pd: 3h (±15m)
X
Study completion 
X
ABPM=ambulatory blood pressure monitoring; automated office blood pressure (AOBP); BP=blood pressure; cGMP=cyclic guanosine monophosphate; 
ECG=electrocardiogram; 
 h=hour(s); H=height; HBsAg=hepatitis B surface antigen; HCV=hepatitis C virus; HIV=human 
immunodeficiency virus; ICF=informed consent form; KDQOL-SF=Kidney Disease Quality of Life–Short Form; m=minute(s); MEMS=Medication Event Monitoring 
System; pd=postdose; 
 pre=predose; 
UACR=urine albumin creatinine ratio; W=weight
a.
Urine drug screen for selected drugs of abuse 
b.
For female patients, a negative pregnancy test (by urine dipstick) must be documented at all study visits and confirmed negative before dosing, when 
applicable. Female patients who are postmenopausal (no menses for ≥12 consecutive months) or surgically sterile (ie, bilateral oophorectomy, 
hysterectomy, or tubal sterilization [tie, clip, band, or burn]) do not have to have a urine pregnancy test. Patients should be reminded of birth control 
requirements.
c.
Patients must be supine for ≥5 m before the ECG recording (Note: If on initial ECG, QTcF is ≥450 msec for male patients or is ≥470 msec for female 
patients, the ECG will be repeated 2 more times, and the average of the 3 QTcF values will be used to determine the patient's eligibility).


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 14 of 97
d.
Seated BP will be the average of 3 measurements obtained by AOBP at 2-m intervals after the patient has been sitting quietly for ≥5 m.
e.
At the Screening Visit, single urine sample, which may not be first void; thereafter, 2 first-void urine samples collected on the 2 consecutive mornings 
before each scheduled visit. Patients will be supplied with specimen collection supplies at the preceding study visit.
f.
Except for the Screening Visit, patients must fast for ≥8 h before predose sample collection. Excess
g.
h.
Patients will begin using the ABPM monitor at the clinic visit before dosing, where applicable, will wear it for ≥12 or 24 h, and return the monitor to 
the clinic. 
i.
Patient must sit quietly for ≥5 m before seated BP and pulse measurements are taken by AOBP, and then assume standing position for 30 to 60 seconds 
before standing BP and pulse measurements are taken. At End of Treatment visit, seated predose BP will be the average of 3 measurements. When 
applicable, BP and pulse measurements will be obtained before blood draws and before study drug administration.
j.
Study drug will be administered in the clinic on study visit days after predose assessments (Day 1, morning dose only). Patients should take study drug 
with water, may take with or without food, and for QD dosing (Week 1 Visit onward), may swallow 2 tablets together. 
k.
At the Week 1 Visit, patients will bring the study drug bottles dispensed on Day 1 to the clinic. MEMS Caps will be read, and the subject will be 
administered their Day 8 (±1) study drug dose in the clinic from the Day 1 bottles. The subject will continue to dose from the Day 1 bottles until they 
return for the Week 4 Visit.


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 15 of 97
10 
SAMPLE SIZE JUSTIFICATION
Using an estimate of standard deviation of 0.673, a sample size of 40 patients per treatment group 
would provide approximately 80% power to detect a mean between-group difference of -0.376 
units in change from baseline in log-transformed UACR over 12 weeks, with a one-sided 
significance level of 0.05 for at least 1 dose versus placebo comparison. This difference 
corresponds to a 31% between-group reduction of geometric mean change from baseline in 
UACR. Assuming a drop-out rate of 20%, approximately 150 patients will be randomly assigned 
in a 1:1:1 ratio (approximately 50 patients per treatment group) to 20 mg praliciguat, 40 mg 
praliciguat, or placebo.
11 
DEFINITION OF ANALYSIS POPULATIONS
The following populations will be defined for this study:
xScreened: All screened patients who have signed the informed consent form for the 
study and received a patient identification number.
xSafety:  All randomized patients who receive at least 1 dose of study drug. Data from 
patients in this population will be summarized according to the treatment they actually 
received. If a patient received more than 1 treatment, then the patient’s data will be 
summarized according to the treatment they received for the longest duration.
xIntent-to-Treat (ITT): All randomized patients who receive at least 1 dose of study 
drug. Patients in this population will be evaluated according to the treatment group they 
were assigned to at Randomization.
xPer Protocol (PP) Population:  Subset of ITT patients who did not have any major 
protocol deviations that might have a potential impact on efficacy evaluations and did 
not have a dose reduction.  
xPK Population: All randomized patients who receive at least 1 dose of study drug and 
have at least 1 postdose assessment with measurable PK concentration levels.
12 
STATISTICAL METHODOLOGY
12.1 General
For descriptive summaries, the number of patients with non-missing values (n) for the 
summarized endpoint, mean, standard deviation, median, 25th and 75th percentiles, minimum and 
maximum will be calculated for continuous variables. For clinical laboratory data, vital signs and 
ECG data the 95% CI for the mean will also be presented. For summaries of continuous PK data, 
the geometric mean and the coefficient of variation (CV) will also be presented. For categorical 
variables, number and percentage of patients in each category will be presented. Percentages will 
be based on the total number of patients with non-missing values. If there are missing values, the 
number missing will be presented, but without a percentage. 
All summary statistics will be presented by treatment group (Placebo, 20 mg Praliciguat, 40 mg 
Praliciguat, and Overall Praliciguat), unless otherwise specified. 
Data from screen-failure subjects will be presented in by-patient listings.


Statistical Analysis Plan  
 
CONFIDENTIAL 
Covance Study: 8362330 
 
Cyclerion Study: C1973-203 
 
Final V2: 24 September 2019 
 
Page 16 of 97 
 
All hypothesis tests will be one-sided with a 5% significance level (two-sided significance level 
of 10%), and two-sided 90% confidence intervals (one-sided 95% confidence intervals) will be 
used, unless otherwise specified.   
All statistical analyses will be performed using SAS® Version 9.4 or later.  SF-12 scoring for the 
component scores will be performed using QualityMetric Health Outcomes™ Scoring Software 
5.0 
Analysis Data Model (ADaM) datasets will be prepared using Clinical Data Interchange 
Standards Consortium (CDISC) ADaM Version 2.1, and CDISC ADaM Implementation Guide 
Version 1.1. Pinnacle 21 Community Validator Version 2.2.0 will be utilized to ensure 
compliance with CDISC standards. 
12.1.1 Study Periods 
Table 4. 
Study Periods 
Period 
Start Date 
End Date 
Screening/Baseline 
Date of Signed ICF 
Up to Date/Time of First Dose 
Treatment 
Date/Time of First Dose 
Date of Last Dose 
Follow-up 
Date of Last Dose +1 
Follow-up Visit Date 
 
12.1.2 Definition of Baseline and Change from Baseline 
The following definitions of baseline will be used to calculate change from baseline endpoints, 
unless specified otherwise: 
Baseline for UACR will be defined as the average of the assessments from the samples collected 
on the 2 consecutive mornings before the scheduled Randomization Visit (Day 1). Log Baseline 
will be calculated as the average of the log-transformed values from the individual assessments. 
If only one sample was collected, then the single assessment will be used.  
For endpoints evaluated from ABPM monitoring, baseline will be calculated using the predose 
assessments at the Baseline Visit that correspond to the respective postdose assessments. 
For all other endpoints, study baseline will be defined as the last non-missing assessment before 
first administration of study drug, usually the predose assessment on Day 1 
12.1.3 Handling of Dropouts or Missing Data 
All available data will be included.  
For mixed-effect model repeated measures (MMRM) analyses, patients with missing baseline 
and all treatment period values will be excluded. The missing at random assumption of MMRM 
will be utilized, and no imputation will be performed for missing observations.   
For responder analyses, all patients will be included. Patients with missing postdose data will be 
treated as non-responders. 


Statistical Analysis Plan  
 
CONFIDENTIAL 
Covance Study: 8362330 
 
Cyclerion Study: C1973-203 
 
Final V2: 24 September 2019 
 
Page 17 of 97 
 
All safety and tolerability data will be summarized and analyzed when data values are available 
for a patient. Data handling for missing dates and other key safety data are described in Section 
16.   
12.1.4 Multiple Comparisons/Multiplicity 
No multiple comparison adjustments are planned for this study, as the focus is more on 
estimation rather than inferential testing. All reported p-values will be considered nominal. 
12.1.5 Repeat and Unscheduled Readings 
If a patient has repeated safety assessments (eg, for a lab endpoint) prior to initial dosing of study 
drug, then the results from the final non-missing assessment made prior to the start of study drug 
will be used as baseline. If there is more than 1 safety measurement (eg, for a lab endpoint) at a 
postbaseline timepoint, only the last measurement will be used. All postbaseline assessments, 
including unscheduled assessments, if any, will be used for PCS value determination, and all 
assessments will be presented in by-patient listings.  
12.1.6 Protocol Deviations 
Major protocol deviations will be identified and documented for all randomized patients prior to 
unblinding through data reviews and programmatic checks of the study data and used to define 
the PP population, unless specified otherwise.  Major protocol deviations will be determined 
based on review of all protocol deviations performed by members of the study team, including 
but not limited to the Sponsor Medical Monitor and study Biostatistician. The categories of 
major protocol deviations to be reviewed will include, but are not limited to, patients who: 
Did not meet any of the following key inclusion/exclusion criteria (Inclusion criteria # 3, 4, 6a, 
6b or Exclusion criteria # 1, 8, 10, 11, 12, 18 - use of PDE 5 inhibitors, nitrates, or nitric oxide 
donors) 
Had overall study drug compliance rate ≤60% in the last 8 weeks of the treatment period or did 
not have measurable (non-BLQ) plasma concentration levels at predose assessments at Week 8 
and Week 12, despite being randomized to one of the Praliciguat arms. The unblinded review of 
plasma concentration levels to identify such cases will be performed after database lock and 
study unblinding. 
Received the wrong treatment or incorrect dose.  
Received disallowed concomitant medication that could meaningfully impact results, such as 
PDE5 inhibitors (sildenafil, tadalafil, vardenafil, etc.) or nitrates (nitroglycerin, isosorbide 
mononitrate, isosorbide dinitrate, sodium nitroprusside, amyl nitrate, etc.), if used > 2× a week 
for all 12 weeks of the Treatment Period or for the last 6 weeks, or other sGC stimulators, 
including riociguat.  
The number and percentage of subjects with major protocol deviations will be summarized by 
type of deviation and by treatment group for the ITT Population. All protocol deviations will be 
presented in a by-patient listing.  
12.2 Demographics and Patient Disposition 
The number of patients screened and screen-failed, along with the reason for screen failure will 
be presented for the Screened Population. Categorical summaries of patients who are included in 


Statistical Analysis Plan  
 
CONFIDENTIAL 
Covance Study: 8362330 
 
Cyclerion Study: C1973-203 
 
Final V2: 24 September 2019 
 
Page 18 of 97 
 
each of the analysis populations, who completed the study, or who discontinued early (along 
with the reasons for discontinuation) will be presented. Patient disposition will also be 
summarized by investigational site. In addition, by-patient listings of patient disposition, 
including all patients who failed screening or terminated early, will be presented.  
Patient demographics (age, age category, sex, race, ethnicity, weight, height, and body mass 
index [BMI, defined as weight in kg divided by height in meters squared]) and baseline eGFR 
strata will be summarized by treatment group for the ITT and if different, for the Safety and Per 
Protocol Populations.  
12.3 Medical History 
Medical history, abnormalities and surgeries, reported and occurring prior to screening will be 
coded using MedDRA version 20.0 or newer.  Categorical summaries will be presented by 
MedDRA system organ class (SOC) and preferred term by treatment arm and overall for the 
Safety Population.  Patients will be counted once per SOC and PT. 
12.4 Prior and Concomitant Medication 
Prior medications will be defined as medicines taken or procedures performed on the patient 
prior to the date of first dose of study drug. Concomitant medications and procedures will be 
defined as medications taken or procedures performed on or after the date of first dose of study 
drug. Any medication taken or procedure performed after the date of last dose of study drug will 
not be considered concomitant for the purposes of analysis. 
Reported medication will be coded using the World Health Organization (WHO) Drug 
Dictionary, Version March 2017 Enhanced Dictionary Version B2 or newer to their Anatomical 
Therapeutic Chemical (ATC) class and PT.  Categorical summaries for both prior and 
concomitant medications will be presented by ATC and PT for the ITT Population.  Patients will 
be counted once per ATC and PT.   
12.5 Exposure and Drug Compliance 
Exposure to study drug, calculated as the number of days from the first dose taken to the date of 
the last dose taken, inclusive, will be summarized by treatment group for the ITT Population. 
The total number of doses taken between each scheduled visit and overall for the entire study 
will be calculated for each patient. Patient-years, defined as exposure to the study drug in years, 
will be summarized by treatment for the ITT Population. 
Dosing compliance for the treatment period will be defined as the number of doses actually taken 
by a patient divided by the number of doses that were expected to be taken, multiplied by 100. 
The total number of doses actually taken will be calculated by subtracting the total number of 
tablets returned from the total number of tablets dispensed, divided by 2. For patients who had a 
dose reduction, the total number of actual doses taken from the date of dose reduction will be the 
difference between the total number of tablets dispensed and returned. The total number of doses 
expected to be taken is the number of days between the date of first dose taken and the date of 
the end of treatment visit, inclusive. In addition, drug compliance for the intervals 
Randomization Visit up to Week 4 Visit, Week 4 Visit up to Week 8 Visit, Week 8 Visit to 
Week 12 Visit, and Randomization Visit to Week 12 Visit will be presented.  Patients will only 
be included in the intervals that they were on study (that is, the intervals that are prior to or 


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 19 of 97
contain the last dose date). Summaries will be presented by treatment arm and overall for the ITT 
Population.
Compliance rates will also be categorized as missing, <60%, ≥60% and < 80%, ≥80% and 
<120%, and ≥120% and summarized by treatment group.
Study drug is dispensed to patients in bottles equipped with a Medication Event Monitor System 
(MEMS) cap, which records the dates and times the bottle is opened and closed. Data obtained 
from MEMS caps will be presented in by-patient listings.
12.6 Efficacy Analyses
12.6.1
Baseline Summaries for Efficacy Endpoints
Baseline efficacy parameters including UACR, eGFR, eGFR strata (30 - 45, >45 - 60, >60 - 75), 
24-hour MAP, SBP, DBP, and pulse rate, hemoglobin A1c, HOMA-IR, fasting plasma glucose, 
fasting plasma insulin, total cholesterol, LDL cholesterol, and triglycerides will be summarized 
descriptively by treatment group for the ITT population. 
12.6.2
Primary Efficacy Endpoint
The primary efficacy endpoint is the change from baseline in UACR over Weeks 8 and 12.
12.6.2.1  Definition of Endpoint
UACR will be calculated using the following equation:
UACR value for a visit will be defined as the average of UACR values obtained from the 
individual samples collected on the mornings prior to the visit. These individual values will be 
log-transformed prior to calculating averages or change from baseline. If only one sample was 
collected, then the single assessment will be used. If UACR values of 0 are present, a small 
constant (0.1) will be added to all data prior to performing the log transformation.
12.6.2.2  Main Analytical Approach
Corresponding with the primary efficacy objective of the trial, the primary inference for 
hypothesis testing is the treatment difference between the placebo group and the pooled 
praliciguat groups on the change from baseline in log UACR over Weeks 8 and 12. The primary 
efficacy analysis will be conducted using the ITT population using a mixed-effects model 
repeated measures (MMRM) analysis with change from baseline in log-transformed UACR as 
the response variable, treatment, visit, treatment-by-visit interaction, and baseline eGFR stratum 
(using the actual stratum based on the eGFR lab values rather than the information from 
IRT) as fixed effects; and baseline log UACR and baseline MAP as covariates with unstructured 
as the variance-covariance structure. All available data will be included in the analyses and 
appropriate contrasts will be specified to obtain parameter estimates for the specified timepoints. 
Treatment differences between the pooled praliciguat dose groups and the placebo group will be 
estimated overall. The null hypothesis of the test will be interpreted as equality between the 


Statistical Analysis Plan  
 
CONFIDENTIAL 
Covance Study: 8362330 
 
Cyclerion Study: C1973-203 
 
Final V2: 24 September 2019 
 
Page 20 of 97 
 
placebo and pooled treatment groups, and rejection of the null hypothesis as evidence that the 
pooled praliciguat groups have a greater effect on lowering UACR than the placebo group.  
The nature of these differences will be explored further by estimating the treatment differences 
between each praliciguat dose group and the placebo group, overall and at each assessment 
timepoint. Least square (LS) means, and LS mean differences between each praliciguat group 
and placebo, and their associated two-sided 90% confidence intervals (CIs) will be calculated 
overall and for each assessment timepoint. The contrasts between each praliciguat dose group 
and the placebo group at each assessment timepoint will be compared using a one-sided 
significance level of 0.05.  
If the treatment-by-visit interaction is significant at the 0.1 significance level, LS mean treatment 
differences relative to the previous visit will also be presented. Please see example SAS code in 
Appendix 5.  
Continuous summaries for baseline, each week, and change from baseline on the original scale 
will be presented by treatment group. LS means, LS mean differences and 90% CIs will be 
exponentiated back to original scale, and the geometric mean change (%) and the associated 
confidence intervals will be derived as 100 * [exp (LS mean change)-1]. 
12.6.2.3  Sensitivity/Supportive Analyses 
Table 5. 
Sensitivity Analyses of Primary Efficacy Endpoint 
Endpoint/Method 
Description 
Summary Method 
Weeks 8 and 12 
Per Protocol Population 
Primary efficacy analysis will be repeated using the 
Per Protocol Population 
Continuous Summary 
MMRM overall 
MMRM by visit  
Weeks 8 and 12 
Subset of  ITT Population 
Primary efficacy analysis will be repeated on subset 
of patients who completed the 12-week treatment 
period 
Continuous Summary 
MMRM 
MMRM by visit 
Week 12 – LOCF 
ITT Population 
A last-observation-carried-forward (LOCF) approach 
will be used to impute missing postbaseline for 
change from baseline in UACR. Under the LOCF 
approach, the patient’s previous value during the 
Treatment Period will be used in case of missing 
postdose assessments. In the case of premature 
discontinuation from the trial, the patient’s last 
available value during the Treatment Period will be 
used.  If no previous postdose value exists, a log 
change-from-baseline value of “0” will be imputed. 
Analysis of change from baseline in UACR at Week 
12 will be performed using an ANCOVA model with 
change from baseline in log-transformed UACR as 
response variable; treatment, baseline eGFR stratum 
as fixed effects, and log baseline UACR and baseline 
MAP as covariates. 
Continuous Summary 
ANCOVA 


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 21 of 97
Table 5.
Sensitivity Analyses of Primary Efficacy Endpoint
Endpoint/Method
Description
Summary Method
Weeks 8 and 12
By eGFR strata
ITT Population
Primary efficacy analysis (with the exception of 
including the eGFR stratum as a fixed effect) will be 
repeated for the eGFR strata using the ITT population
Continuous Summary
MMRM overall
MMRM by visit 
Weeks 8 and 12
By eGFR strata
PP Population
Primary efficacy analysis (with the exception of 
including the eGFR stratum as a fixed effect) will be 
repeated for the eGFR strata using the PP population
Continuous Summary
MMRM overall
MMRM by visit 
Weeks 8 and 12 – include 
additional covariates
ITT Population
If baseline imbalances are apparent across treatment 
groups, then the primary efficacy analysis will be 
repeated including these baseline parameters as 
covariates in the MMRM model.
Continuous Summary
MMRM
MMRM by visit
Weeks 8 and 12 – by
geographic region
ITT Population
Primary efficacy analysis will be repeated by 
geographic region subgroup, as defined in Appendix 
3- Table 11.
Continuous Summary
MMRM overall
MMRM by visit
Weeks 8 and 12
Rank Transform
ITT Population
Change from baseline and baseline values will be 
ranked based on the normalization method of Blom 
with ties set to the mean.  If the results of the 
sensitivity analysis show consistency with those 
obtained from the original analysis, only results from 
the original analysis will be reported.
12.6.2.4 Graphical Presentation of Primary Efficacy Data
Geometric Change (%) to baseline in UACR assessments over time, along with the 
corresponding 90% confidence intervals will be presented by treatment group.  
Boxplots of observed values of UACR will be presented by treatment group for all assessment 
weeks.
In addition, cumulative distribution function plots of the percent change from baseline values at 
Week 12 will be plotted by treatment group.
12.6.3
Exploratory Efficacy Endpoints
PPD


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 22 of 97
PPD


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 23 of 97
PPD


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 24 of 97
12.6.4
Subgroup Analyses
Analysis for change from baseline in UACR will be performed for each of the following 
subgroups:
Sex (male/female)
Age categories (18 - 45, >45 - 65, >65)
Race (white/black)
PPD


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 25 of 97
Ethnicity (Hispanic/not Hispanic)
Actual Baseline eGFR strata (30 - 45, >45 - 60, >60)
Baseline UACR (≤ median, > median)
Baseline MAP (≤ median, > median)
Baseline BMI (≤30, >30)
Insulin use at baseline (yes/no)
Baseline hemoglobin A1c (≤ median, > median)
Subgroup analyses will be performed only if the total number of subjects in each treatment group 
within a subgroup category is ≥10. MMRM models will be used with change from baseline as 
the response variable, treatment, visit, treatment-by-visit interaction and eGFR stratum as fixed 
effects, and the respective baseline value as covariate with unstructured as the variance-
covariance structure. Separate models will be used for each subgroup and appropriate contrasts 
will be specified to obtain parameter estimates for each subgroup.
12.7 Pharmacokinetic Assessment
12.7.1
Pharmacokinetic Analysis
Plasma concentration of Praliciguat will be summarized using the PK Population for each 
assessment timepoint by active treatment groups. Concentrations that are BLQ will be treated as 
zero on Day 1 and as missing on all other study days for the computation of descriptive statistics. 
Results where the actual sampling time deviated by greater than 25% from the nominal time will 
be excluded from the descriptive statistics. A by-subject listing of all concentration-time data for 
each treatment and scheduled sample collection time will be presented.  A listing of PK blood 
sample collection times, and elapsed time relative to dose will be provided.
12.8 Safety and Tolerability Assessments
The following endpoints will be evaluated to explore the safety and tolerability of praliciguat.
12.8.1
Primary Safety Endpoints
The primary safety endpoints are the incidence of patients with treatment-emergent adverse 
events (TEAEs) and study drug-related TEAEs.


Statistical Analysis Plan  
 
CONFIDENTIAL 
Covance Study: 8362330 
 
Cyclerion Study: C1973-203 
 
Final V2: 24 September 2019 
 
Page 26 of 97 
 
12.8.2 Adverse Events 
A TEAE is defined as an adverse event (AE) that started or worsened in severity after the 
administration of study drug. 
TEAEs will be summarized for each treatment group by SOC and PT; by relationship to study 
drug, and by severity for the Safety population. If a patient has more than 1 TEAE coded to the 
same preferred term, the patient will be counted only once for that preferred term by identifying 
those TEAEs with the highest severity and the strongest causality relationship to study drug per 
investigator. 
TEAEs will also be summarized by study period, where AEs that started during the Screening 
Period, Treatment Period, or Follow-up Period will be presented by treatment group for the 
respective period of onset. In addition, the incidence of AEs leading to premature discontinuation 
of study drug will be summarized by treatment group.  
For presentation of AE incidence, AEs will be sorted alphabetically by SOC, and within each 
SOC, by decreasing incidence of PT in the overall praliciguat group. An additional presentation 
will include a summary of TEAEs for each treatment group by PTs only, sorted by decreasing 
incidence of PT in the overall praliciguat group. 
Listings of AEs in screen-failure patients, pretreatment AEs in randomized patients, TEAEs, 
severe TEAEs, study drug-related TEAEs, SAEs, TEAEs leading to study discontinuation, and 
AEs leading to death (if any) will be provided. 
12.8.3 Subgroup Analyses 
Subgroup analyses of TEAEs will be performed by sex, race, ethnicity, baseline eGFR strata, 
baseline UACR, baseline hemoglobin A1c levels and insulin use at baseline. See Section 12.6.4 
for definitions of the subgroups. Subgroup analyses will be performed only if the total number of 
subjects in each treatment group within a subgroup category is ≥10 
12.8.4 TEAEs of Clinical Interest (AECI) 
Although not collected as such in the protocol, based on a possible class effect with sGC 
stimulators, TEAEs related to bleeding, hypotension, and elevated heart rate will be categorized 
as AECI. These will be summarized by treatment group, by severity and by PT and presented in 
a by-patient listing. See Appendix 1 for details on the determination of the events for each 
category of interest.  
12.8.5 Clinical Laboratory Endpoints 
For each quantitative clinical laboratory endpoint, descriptive statistics of the observed values (in 
standard units) as well as change from study baseline will be presented overall for each 
assessment timepoint for the Safety population. 
Laboratory test values will also be categorized as low, normal, or high based on reference ranges 
provided by the lab. Shifts from study baseline to each later timepoint will be tabulated. If there 
is more than 1 measurement for a lab endpoint at a postbaseline timepoint, only the last 
measurement will be used. Listings of laboratory endpoints with reference ranges and the above 
categorizations will be provided.  


Statistical Analysis Plan  
 
CONFIDENTIAL 
Covance Study: 8362330 
 
Cyclerion Study: C1973-203 
 
Final V2: 24 September 2019 
 
Page 27 of 97 
 
Clinical laboratory test values will also be considered potentially clinically significant (PCS) if 
they meet either the lower-limit or higher-limit PCS criteria listed in Table 6. The number and 
percentage of patients who have PCS postbaseline clinical laboratory values will be tabulated by 
treatment group. The percentages will be calculated relative to the number of patients with 
available non-PCS baseline values and at least 1 assessment in the corresponding postbaseline 
period. The numerator will be the total number of patients with available non-PCS baseline 
values and at least 1 PCS value in the corresponding postbaseline period. A supportive listing of 
patients with PCS postbaseline values will be provided, including the baseline and all 
postbaseline (including non-PCS) values. A listing of all TEAEs for patients with postbaseline 
PCS laboratory values will also be provided. 
Table 6. 
Criteria for Potentially Clinically Significant Laboratory Results 
Parameter 
SI Unit 
Lower Limit 
Higher Limit 
CHEMISTRY 
Albumin 
g/L 
< 0.75 × LLN 
> 1.1 × ULN 
Alanine aminotransferase 
U/L 
— 
≥ 3 × ULN 
Alkaline phosphatase 
U/L 
— 
≥ 3 × ULN 
Aspartate aminotransferase U/L 
— 
≥ 3 × ULN 
Bicarbonate 
mmol/L 
< 0.9 × LLN 
> 1.1 × ULN 
Bilirubin, total 
μmol/L 
— 
> 1.5 × ULN 
Calcium 
mmol/L 
< 0.9 × LLN 
> 1.1 × ULN 
Chloride 
mmol/L 
< 0.9 × LLN 
> 1.1 × ULN 
Cholesterol, total 
mmol/L 
— 
> 1.6 × ULN 
Creatinine 
μmol/L 
— 
> 1.3 × ULN 
Glucose 
mmol/L 
< 0.5 × LLN 
> 2 × ULN 
Phosphate 
mmol/L 
< 0.9 × LLN 
> 1.1 × ULN 
Potassium 
mmol/L 
< 0.9 × LLN 
> 1.1 × ULN 
Protein, total  
g/L 
< 0.8 × LLN 
> 1.1 × ULN 
Sodium 
mmol/L 
< 0.9 × LLN 
> 1.1 × ULN 
Uric acid  
μmol/L 
< 0.9 × LLN 
> 1.1 × ULN 
HEMATOLOGY 
Hematocrit 
Ratio 
< 0.8 × LLN 
> 1.1 × ULN 
Hemoglobin 
g/L 
< 0.8 × LLN 
> 1.1 × ULN 


Statistical Analysis Plan  
 
CONFIDENTIAL 
Covance Study: 8362330 
 
Cyclerion Study: C1973-203 
 
Final V2: 24 September 2019 
 
Page 28 of 97 
 
Table 6. 
Criteria for Potentially Clinically Significant Laboratory Results 
Parameter 
SI Unit 
Lower Limit 
Higher Limit 
Neutrophils, absolute cell 
count 
109/L 
< 0.8 × LLN 
> 1.5 × ULN 
Platelet count 
109/L 
< 0.5 × LLN 
> 1.5 × ULN 
Red blood cell count 
1012/L 
< 0.8 × LLN 
> 1.1 × ULN 
White blood cell count 
109/L 
< 0.7 × LLN 
> 1.5 × ULN 
LLN = lower limit of normal value provided by the laboratory; SI = Le Système International d’Unités (International System of 
Units); ULN = upper limit of normal value provided by the laboratory. 
12.8.6 Vital Signs 
Descriptive statistics of the observed values as well as change from study baseline will be 
presented for seated BP and pulse at each assessment timepoint for the Safety population. All 
vital signs evaluations at each assessment timepoint will be presented in a by-patient listing. The 
number and percentage of patients who had a potentially clinically significant change from study 
baseline in BP and pulse (based on the criteria in Table 7), will be presented by treatment group 
for the Safety population. Percentages will be calculated relative to the number of patients who 
did not meet the observed value criteria in Table 7) and had at least 1 assessment in the 
corresponding postbaseline period. The numerator will be the total number of patients with 
available non-PCS baseline values and at least 1 PCS value in the corresponding postbaseline 
period. Percentage of patients with a PCS change in weight will be calculated relative to the 
number of patients with non-missing baseline values. 
Table 7. 
Criteria for Potentially Clinically Significant Vital Signs Results  
Vital Sign Parameter 
Flag 
Criteria* 
Observed Value 
Change from Study Baseline 
Seated Systolic Blood 
Pressure (mmHg) 
High 
≥180 
Increase of ≥30 
Low 
≤90 
Decrease of ≥30 
Seated Diastolic Blood 
Pressure (mmHg) 
High 
≥105 
Increase of ≥20 
Low 
≤50 
Decrease of ≥20 
Seated Pulse Rate 
(bpm) 
High 
≥110 
Increase of ≥20 
Low 
≤50 
Decrease of ≥20 
Weight, kg 
High 
— 
Increase of >5 kg and ≥5% 
Low 
— 
Decrease of >5 kg and ≥5% 
*A postbaseline value is considered potentially clinically significant if it meets both the criteria for observed value and change 
from baseline. 


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 29 of 97
Orthostatic changes in systolic BP, diastolic BP, and pulse will be summarized for each 
treatment group. An orthostatic measurement is obtained by subtracting the seated measurement 
from the standing measurement. 
The number and percentage of patients who meet the following notable orthostatic criteria at any 
postdose timepoint during a visit, as well as over the overall treatment period will also be 
summarized by treatment group:
xOrthostatic decrease in systolic BP of >20 mmHg from seated to standing
xOrthostatic decrease in diastolic BP of >15 mmHg from seated to standing
xOrthostatic increase in pulse of >30 bpm from seated to standing
A supportive listing of patients with PCS postbaseline values or notable orthostatic values will be 
provided, including the baseline and all postbaseline (including non-PCS) values. A listing of all 
TEAEs for patients with postbaseline PCS vital signs values will also be provided.
12.8.7
Electrocardiogram
For each ECG endpoint, descriptive statistics of the observed values as well as change from 
study baseline will be presented overall for each assessment timepoint for the Safety population. 
Shift tables from study baseline to the end of treatment visit for the overall ECG interpretation 
(normal, abnormal not clinically significant, or abnormal clinically significant) will be 
summarized for all subjects in the Safety population. The number and percentage of patients who 
had a potentially clinically significant change from study baseline in ECG values (based on the 
criteria in Table 8), will be presented by treatment group. Percentages will be calculated relative 
to the number of patients with available non-PCS baseline values and at least 1 assessment in the 
corresponding postbaseline period. The numerator will be the total number of patients with 
available non-PCS baseline values and at least 1 PCS value in the corresponding postbaseline 
period.
Table 8.
Criteria for Potentially Clinically Significant ECG Results   
ECG Parameter (unit)
Higher Limit
QRS duration (msec)
≥150
PR interval (msec)
≥250
QTc interval (msec)
>480
ECG endpoints will also be presented in a by-patient listing.
12.8.8


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 30 of 97
12.9


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 31 of 97
13 
INTERIM ANALYSES
Please refer to the study protocol and DMC charter for information on the DMC activities.
No interim analyses of efficacy (specified as optional in Section 5.14 of the Protocol) will be 
performed.  
14 
CHANGES FROM THE PROTOCOL SPECIFIED STATISTICAL ANALYSES
The following analyses will be performed in addition to those described in the study protocol. 
x Assessment of TEAEs of clinical interest
The following changes will be made to the analyses as described in the study protocol. 


Statistical Analysis Plan  
 
CONFIDENTIAL 
Covance Study: 8362330 
 
Cyclerion Study: C1973-203 
 
Final V2: 24 September 2019 
 
Page 32 of 97 
 
x Due to the potential of many trial sites having a small number of patients, site will not be 
included as a fixed effect in the primary model, as noted in the protocol. The trial sites will 
instead be pooled into 5 geographical regions (defined in Appendix 3), and a sensitivity 
analysis of the primary analysis will be performed by geographical region. 
x The conditionality requirement for exploring the nature of differences between each 
praliciguat dose group and the placebo group will be dropped. Contrasts will be specified 
to estimate these treatment differences, regardless of whether the primary null hypothesis is 
rejected. No multiplicity adjustments will be performed. 
15  
DATA PRESENTATION 
13.1 Insufficient Data for Presentation 
Some of the TFLs may not have sufficient numbers of subjects or data for presentation. If this 
occurs, the blank TFL shell will be presented with a message printed in the center of the table, 
such as, “No serious adverse events occurred for this study.” 
16  
DATA HANDLING CONVENTIONS 
16.1 End of Treatment Assessment 
Assessments performed at the end of treatment visit will be included in Week 8 and Week 12 
evaluations as follows: 
If a patient has a missing Week 8 visit, but has a non-missing EOT assessment, then the EOT 
assessment will be used as the Week 8 assessment if the EOT assessment was conducted on or 
after study day 50 but before study day 77. 
If a patient has a non-missing Week 8 visit and has a non-missing EOT assessment, then the 
EOT assessment will be used at the Week 12 assessment if the EOT assessment was performed 
on or after study day 77. 
16.2 Repeated or unscheduled assessments of safety endpoints 
If a patient has repeated safety assessments (eg, for a lab endpoint) prior to initial dosing of study 
drug, then the results from the final non-missing assessment made prior to the start of study drug 
will be used as baseline. If there is more than 1 safety measurement (eg, for a lab endpoint) at a 
postbaseline timepoint, only the last measurement will be used. All postbaseline assessments, 
including unscheduled assessments, if any, will be used for PCS value determination, and all 
assessments will be presented in by-patient listings.  
16.3 Conventions for Summarizing Adverse Events 
The following conventions will be followed in summarizing TEAEs within a treatment group: 
x For patient incidence summaries, each patient will be counted only once per category 
within each SOC, PT, or the overall AE summary 
x If a patient reported more than 1 AE within an SOC or PT, then the TEAE with the highest 
severity or strongest causality relationship to study drug per investigator within each SOC 


Statistical Analysis Plan  
 
CONFIDENTIAL 
Covance Study: 8362330 
 
Cyclerion Study: C1973-203 
 
Final V2: 24 September 2019 
 
Page 33 of 97 
 
and each PT will be included in the respective summaries by severity or relationship, 
respectively.   
16.4 Missing Date Information for Adverse Events 
If it is not possible to determine when an AE started due to incomplete start dates/times, it will 
be assumed to be treatment emergent. 
16.5 Missing Severity Assessment for Adverse Events 
If severity is missing for an AE that started prior to the initiation of study drug dosing, all efforts 
should be made to obtain the severity from the Investigator. If it is still missing after all efforts, 
then a severity of “Mild” will be assigned. If the severity is missing for a TEAE, then a severity 
of “Severe” will be assigned. The imputed values for the missing severity assessment will be 
used for the incidence summary, while the actual missing values will be presented in by-patient 
listings. 
16.6 Missing Relationship to Study Drug for Adverse Events 
If the relationship to study drug is missing for a TEAE, all efforts should be made to obtain the 
relationship from the Investigator. If it is still missing after all efforts, a study drug causality of 
“Related” will be assigned in the corresponding analysis-derived data set for non-serious adverse 
events. The imputed values for the missing relationship to study drug will be used only for 
incidence summary, while the actual missing values will be presented in by-patient listings. For 
SAEs and AECIs, if causality from investigators is missing after all efforts to obtain it, then the 
causality determination from the sponsor will apply. 
16.7 Missing Date Information for Prior or Concomitant Medications 
If the start date of a medication is missing or incomplete (ie, partially missing), then the 
medication will be assumed to be concomitant. 
 
17  
REFERENCES 
1. International Conference on Harmonisation of Technical Requirements for Registration of 
Pharmaceuticals for Human Use, ICH Harmonised Tripartite Guideline, Statistical Principles 
for Clinical Trials (E9), 5 February 1998. 
2. International Conference on Harmonisation of Technical Requirements for Registration of 
Pharmaceuticals for Human Use, ICH Harmonised Tripartite Guideline, Structure and 
Content of Clinical Study Reports (E3), 30 November 1995. 
3. de Zeeuw D., Coll B, Andress D, Brennan JJ, Tang H, Houser M, et al. The endothelin 
antagonist atrasentan lowers residual albuminuria in patients with type 2 diabetic 
nephropathy. Journal of the American Society of Nephrology : JASN 2014;25(5):1083-93. 


Statistical Analysis Plan  
 
CONFIDENTIAL 
Covance Study: 8362330 
 
Cyclerion Study: C1973-203 
 
Final V2: 24 September 2019 
 
Page 34 of 97 
 
 
18  
APPENDIX 1 – ADVERSE EVENTS OF CLINICAL INTEREST 
The table below provides the criteria for identifying adverse events within each category. 
Medical review of AEs prior to database lock will identify any additional adverse events.  
 
Event Category 
AE Criteria 
Bleeding Events 
Identify using MedDRA SMQ of ‘haemorrhage terms (excluding laboratory 
terms)’ 
Hypotensive Events 
Identify using the following MedDRA preferred terms: 
Blood pressure ambulatory decreased 
Blood pressure decreased 
Blood pressure diastolic decreased 
Blood pressure systolic decreased 
Blood pressure orthostatic decreased 
Orthostatic hypotension 
Presyncope 
Syncope 
Dizziness 
Dizziness postural   
Elevated Heart Rate 
Identify using the following MedDRA preferred terms: 
Heart rate increased 
Orthostatic heart rate increased 
Tachycardia 
Palpitations 
Headache 
Identify using MedDRA HLGT Headache that include the word *headache* 
with the exception of ‘Typical aura without headache’ 
SMQ=standardized MedDRA query. 


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 35 of 97
19 
APPENDIX 2 


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 36 of 97


Statistical Analysis Plan  
 
CONFIDENTIAL 
Covance Study: 8362330 
 
Cyclerion Study: C1973-203 
 
Final V2: 24 September 2019 
 
Page 37 of 97 
 
20  
APPENDIX 3 – POOLING OF TRIAL CENTERS 
Because of the potential of many trial centers to have a small number of patients, the centers will 
be pooled by the following 5 geographic regions (as listed in Table 11): Northeast, Southeast, 
Midwest, Southwest, and West. Analyses using geographic region will use this 5-category 
geographic region variable. 
Table 11. Definition of Geographic Regions 
Northeast 
Southeast 
Midwest 
Southwest 
West 
CT 
AL 
IA 
AZ 
CA 
DC 
AR 
IL 
NM 
CO 
DE 
FL 
IN 
OK 
ID 
MA 
GA 
KS 
TX 
MT 
MD 
KY 
MI 
 
NV 
ME 
LA 
MN 
 
OR 
NH 
MS 
MO 
 
UT 
NJ 
NC 
ND 
 
WA 
NY 
SC 
NE 
 
WY 
PA 
TN 
OH 
 
 
RI 
VA 
SD 
 
 
VT 
WV 
WI 
 
 
 


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 38 of 97
21 
APPENDIX 4 


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 39 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 40 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 41 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 42 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 43 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 44 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 45 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 46 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 47 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 48 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 49 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 50 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 51 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 52 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 53 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 54 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 55 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 56 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 57 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 58 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 59 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 60 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 61 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 62 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 63 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 64 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 65 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 66 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 67 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 68 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 69 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 70 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 71 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 72 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 73 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 74 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 75 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 76 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 77 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 78 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 79 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 80 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 81 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 82 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 83 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 84 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 85 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 86 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 87 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 88 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 89 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 90 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 91 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 92 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 93 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 94 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 95 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 96 of 97


Statistical Analysis Plan 
CONFIDENTIAL
Covance Study: 8362330
Cyclerion Study: C1973-203
Final V2: 24 September 2019
Page 97 of 97
22 
APPENDIX 5