Clinical trial NCT02790034
Conditions: Rett Syndrome
Sponsor: Newron Pharmaceuticals SPA
Start date: 2016-10-26; Completion date: 2020-05-04
Enrollment: 129 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
This study evaluates the safety, tolerability and efficacy of Sarizotan in reducing respiratory abnormalities in Rett Syndrome in an initial double blind 24 week period followed by an open label treatment phase of up to 168 weeks (the latter for patients with no safety and tolerability issues).

Detailed description:
This is a randomized, double-blind, placebo-controlled study designed to evaluate the safety, tolerability, and efficacy of multiple doses of sarizotan in patients with Rett syndrome with respiratory abnormalities. The study participants will be randomized to either sarizotan between 2 and 10 mg bid or placebo bid, based on age and weight criteria.

All patients who have completed the final evaluations at Week 24 (Day 168) and have no safety or tolerability issues that would preclude continuing on the study medication and have been compliant with the trial requirements will have the option of continuing open-label treatment with Sarizotan for up to 168 weeks.

Arms: arm 1: 2 mg or 5 mg bid based on age and weight criteria for 24 wks DB 2 mg bid (4 to \<13 years; ≥13 years of age and weighing \<25 kg 5 mg bid (≥13 years of age and weighing ≥25 kg) arm 2: 5 mg or 10 mg bid based on age and weight criteria for 24 wks DB 5 mg bid (4 to \<13 years; ≥13 years of age and weighing \<25 kg 10 mg bid (≥13 years of age and weighing ≥25 kg) arm 3: Placebo bid for 24 wks DB age 4 and above
Interventions: intervention 1: Sarizotan low dose intervention 2: Sarizotan high dose intervention 3: Placebo
Intervention descriptions: intervention 1: 2 mg or 5 mg bid based on age and weight criteria for 24 wks DB 2 mg bid (4 to \<13 years; ≥13 years of age and weighing \<25 kg; 5 mg bid (≥13 years of age and weighing ≥25 kg). Assessment of safety, tolerability and efficacy on reducing the respiratory symptoms in patients. intervention 2: 5 mg or 10 mg bid based on age and weight criteria for 24 wks DB 5 mg bid (4 to \<13 years; ≥13 years of age and weighing \<25 kg; 10 mg bid (≥13 years of age and weighing ≥25 kg) Assessment of safety, tolerability and efficacy on reducing the respiratory symptoms in patients intervention 3: Placebo BID followed by assessment of safety, tolerability and efficacy on reducing the respiratory symptoms in patients.

Protocol documents:
Prot_000.pdf: 
A RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED, SIX-MONTH 
STUDY TO EVALUATE THE EFFICACY, SAFETY AND TOLERABILITY OF 
SARIZOTAN IN PATIENTS WITH RETT SYNDROME WITH RESPIRATORY 
SYMPTOMS  
SARIZOTAN 
 
Protocol No:  Sarizotan/001/II/2015  
IND No: 125,510 
EudraCT Number: 2015-004448-20 
Final  
27 October 2015  
Annotated Protocol Incorporates: 
 Amendment 1: 19 January 2016  
 Amendment 2: 18 May 2016 
 Amendment 3: 21 October 2016 
 Amendment 4: 03 March 2017 
 Amendment 5: 29 March 2017 
 Amendment 6: 13 April 2017 
 Amendment 7: 02 October 2017 
 Amendment 8: 02 November 2017 
 Amendment 9: 11 February 2018 
 Amendment 10: 29 November 2018 
 Amendment 13: 10 December 2019 
 Amendment 14: 17 March 2020 
Author:  Richard D. Hartman, PhD 
Sponsor: 
Newron Pharmaceuticals S.p.A. 
Via Antonio Meucci, 3 
20091 Bresso (Milano) 
Italy 
Tel. +39-02-6103461 
Protocol Version:  
Version 15.0 
 
This document is a confidential communication of NEWRON Pharmaceuticals to be used by the study 
personnel at the Investigator’s site.  Submission to the Ethics Committee is expressly permitted. Acceptance of 
this document constitutes the agreement by the recipient that no unpublished information contained herein 
will be published or disclosed without NEWRON’s prior written approval, except as necessary to obtain the 
Subject Informed Consent.  


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1 
SYNOPSIS 
 
 
Title of Study: A Randomized, Double-Blind, Placebo-Controlled, Six-Month Study to Evaluate the Efficacy, 
Safety and Tolerability of Sarizotan in Patients with Rett Syndrome with Respiratory Symptoms 
 
 
Protocol No.:  Sarizotan/001/II/2015 
 
 
Phase of Development:  II/III 
 
 
Objectives: 
The objectives of the study are as follows: 
Primary Efficacy Objective:  
• 
To evaluate the effect of sarizotan (high dose), compared to placebo, on reducing the number of apnea 
episodes, during awake time, in patients with RTT with respiratory abnormalities.  
 
Key Secondary Efficacy Objective:  
• 
To evaluate the effect of sarizotan (high dose), compared to placebo, on the Caregiver-rated Impression of 
Change (CIC) from baseline;  
 
Secondary Objectives:  
• 
Safety: To evaluate the safety and tolerability of sarizotan in patients with Rett syndrome (RTT) with 
respiratory abnormalities.  
• 
Efficacy: To evaluate the efficacy of sarizotan, compared to placebo, on the following: 
o 
Severity of patient symptoms, based on evaluation of Caregiver Top 3 Concerns (Visual Analogue 
Scale [VAS]); 
o 
Global change from baseline, assessed by the Clinical Global Impression of Change (CGI-C); 
o 
Motor behavior, assessed by the Motor-Behavioral Assessment Scale; 
o 
Other respiratory symptoms of Rett syndrome, assessed during awake time, including:  
▪ 
Percent time spent with breathing dysrhythmia (% time apnea + % time hyperventilation) per 
hour; 
▪ 
Number of hyperventilation episodes (≥10 seconds each) per hour;  
▪ 
Oxygen saturation (number of episodes of oxygen desaturation below 90% per hour).  
▪ 
Respiratory Distress Index - The sum of the following parameters calculated per hour of 
wakefulness: 1) number of breath-holding episodes, 2) number of episodes of 
hyperventilation [1 and 2 are as defined in inclusion criteria; each would have to be ≥10 
seconds in duration], and 3) number of drops in oxygen values to < 90%. 
o 
Overall assessment of symptoms of RTT using the Rett syndrome Clinical Severity Scale (RCSS). 
o 
To determine the efficacy of sarizotan in patients who attain a minimum plasma exposure of 
400 ng/ml on Day 15 (expected efficacious concentration based on the knockout mouse model);  
• 
To determine the pharmacokinetic (PK) profile of sarizotan at the doses tested and compare with the PK profile 
in adults.  
 
 
Study Design and Methods:  
Initial 24-Week Double-blind Treatment Period 
This is a prospective, 24-week, randomized, double-blind, placebo-controlled study designed to evaluate the safety, 
tolerability, and efficacy of multiple oral doses of sarizotan in patients with RTT with respiratory abnormalities.  At 
least 129 patients will be randomized (approximately 43/group) to receive either low dose sarizotan (2 mg or 5 mg 
bid), high dose sarizotan (5 mg bid or 10 mg bid) or placebo bid.  Patients 4 to <13 years of age will be randomized 


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equally (1:1:1) to sarizotan 2 mg bid (low dose group), sarizotan 5 mg bid (high dose group), or placebo.  Patients 
≥13 years of age and weighing ≥25 kg will be randomized equally (1:1:1) to sarizotan 5 mg bid (low dose group), 
sarizotan 10 mg bid (high dose group), or placebo [Note: patients ≥13 years of age and weighing <25 kg will be 
eligible for the study, but will be included with the younger patients and randomized equally (1:1:1) to sarizotan 2 mg 
bid (low dose), sarizotan 5 mg bid (high dose) or placebo]. 
 
All patients 4 to <13 years of age, as well as those ≥13 years of age and weighing <25 kg, randomized to sarizotan 2 
or 5 mg bid will start at a single dose of 2 mg on the morning of Day 1. Patients assigned to the 2 mg bid dose will 
remain on 2 mg once daily on Days 2-7, and will have their dose increased to 2 mg bid on Days 8-14.  Patients 
assigned to the 5 mg bid dose will have their daily dose of sarizotan increased to 4 mg (2 mg bid) on Days 2-7, 7 mg 
(5 mg AM, 2 mg PM) on Day 8, and 10 mg (5 mg bid) on Days 9-14.  Patients ≥13 years of age and weighing ≥25 
kg randomized to sarizotan 5 or 10 mg bid will start at a single dose of 5 mg on the morning of Day 1, with an increase 
to 5 mg bid on Day 2. Patients randomized to 5 mg bid will continue on this dose for the rest of the study, while 
patients randomized to 10 mg bid will receive a single dose of 10 mg on Day 8 and have their dose increased to 10 
mg bid on Day 9, and continue on this dose.  If patients do not tolerate the proposed titration and target dose, the 
investigator will provide only one of the two daily doses (e.g. 5 mg/day) for a few days prior to reinitiating the 
intended bid dose (e.g. 5 mg bid).  If the dose is still not tolerated, a reduction to a lower rescue dose will be permitted.  
Dose titration should be completed by Day 14, after which patients will continue on their maximum tolerated dose 
(MTD) through the final dose, unless intolerance develops and a dose reduction is warranted.  
 
Each patient’s parent, legal guardian, or representative, must provide written informed consent prior to the patient’s 
participation in the trial.  The patient should provide assent, if capable of doing so.  Each patient will enter a 4-week 
period during which the screening evaluations will be performed. Patients who meet the respiratory criteria for 
enrolment in the study in one of the first 3 weeks may have their screening period shortened.  The screening 
assessments, which must be completed and results available prior to baseline, will consist of the following: a 
confirmation of the diagnosis of Rett syndrome, based on clinical criteria (a proven mutation of the methyl CpG-
binding protein 2 (MECP2) gene is not required), a review of the patient’s medical history and current use of 
medications, vital signs, 12-lead electrocardiogram (ECG), laboratory tests (hematology, blood chemistry, urinalysis, 
virology, serum pregnancy test for post-pubertal females, and thyroid function tests), physical and neurological 
examination.  The patient’s respiratory abnormalities will be documented, based on parental feedback for the presence 
of one of the following: periodic apnea during wakefulness; intermittent hyperventilation; breath holding spells; air 
swallowing; forced expulsion of air or saliva.  
 
Cardio-respiratory monitoring using a specialized ambulatory data acquisition system, the BioRadio™ system, will 
be performed at home during the first week of the screening period to ensure proficiency of the caregiver/patient in 
using the system, and to evaluate the quality of the data and resolve any problems the caregiver may be experiencing 
in using the device (this will be determined by the remote data monitoring service provider, Vivonoetics). Data from 
the BioRadio system will be used to confirm that the patient has at least 10 episodes of breathing dysrhythmia per 
hour over a 24-hour period. Home monitoring should be attempted for 6 hours each day, during the time the patient 
is awake, on at least 3 days during the first, second and third week of screening.  The patient must meet all criteria 
related to breathing abnormalities in at least one of the three screening period assessments, as specified in the Inclusion 
Criteria, to be eligible for enrollment. If the patient meets the criteria, as determined by Vivonoetics, in any week of 
the Screening period, home monitoring in the subsequent week(s) of Screening will not be required. Adverse events 
and use of concomitant medication will be recorded from the time of signing of the consent form.   
 
At the Baseline visit (Day 0), the inclusion/exclusion criteria (respiratory inclusion criteria will be assessed based on 
home respiratory monitoring performed during screening) will be reviewed to ensure that the patient is suitable for 
enrolment. Patients meeting all entry criteria at baseline will undergo a series of evaluations on the day prior to dosing 
(Day 0).  Baseline assessments of respiratory function will be performed in the clinic using a stretch-sensitive 
resistance plethysmograph (SOMNOtouch™ device), Tanner Staging will be performed, and a blood sample will be 
taken for measurement of serum prolactin, and plasma ACTH and cortisol. The routine laboratory tests and physical 
and neurological examinations do not need to be repeated if performed less than 28 days before baseline, unless 
abnormalities are noted that require follow-up; however, a serum pregnancy test must be performed for post-pubertal 
females. An ophthalmologist would be required to perform a routine ophthalmological examination at Baseline, 


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including Optical Coherence Tomography (OCT; only if feasible, for the patient).  In addition, baseline assessments 
for all of the efficacy variables [respiratory measures, heart rate, Motor-Behavioral Assessment Scale, Caregiver Top 
3 Concerns, and Rett syndrome Clinical Severity Scale (RCSS)], as well as the suicidality assessment, will be 
performed on Day 0. Baseline vital signs and ECG evaluations will be performed in triplicate (10 min apart) on Day 
0 or at least one hour prior to dosing on Day 1. 
 
On Day 1 the patient will be randomized to treatment, with the dose assigned based on age, and for patients ≥13 years 
of age, body weight categories, as described above, and will receive the initial oral dose of study medication (Dose 
Level 1: 2 or 5 mg sarizotan or matching placebo) in the morning.  In the initial 12-hour period after the first dose, 
safety evaluations (vital signs, 12-lead ECG) will be performed at 1 and 4 hr post-dose. Blood samples for the 
pharmacokinetic (PK) analysis will be collected prior to dosing (blank sample) and at approximately 1 and 4 hr post-
dose, following completion of the vital signs and ECG assessments.  The patient will receive the evening dose (Dose 
Level 1: placebo for all patients) in the hospital (minimally 6 hours after the morning dose) and will be housed 
overnight, either in the hospital or with their parent/caregiver in a separate facility. The morning dose of Dose Level 
2 (2 or 5 mg sarizotan or placebo) will be administered on Day 2 in the clinic. Safety evaluations [vital signs, 12-lead 
ECG, laboratory tests (hematology, blood chemistry, urinalysis, and measurement of plasma ACTH and cortisol), 
physical/neurological examination, assessment of adverse events] will be repeated, and if no significant side effects 
are noted within the 4-hr period following this dose, the patient will be released from the hospital and given a supply 
of study medication for the remainder of the first week of dosing at Dose Level 2 (Days 2 [PM] to 7) and for the 
second week of dosing at Dose Level 3 [2 mg sarizotan bid, 5 mg sarizotan bid, 7 mg sarizotan/day (5 mg in AM + 2 
mg in PM), 10 mg sarizotan once daily (in AM, with placebo in PM) or placebo bid; on Day 8] and Dose Level 4 [2 
mg sarizotan bid, 5 mg sarizotan bid, 10 mg sarizotan bid, or placebo bid; on Days 9 to 14].  
 
The caregiver will be contacted by telephone by the Investigator/site staff on Day 7 to inquire about the tolerability 
of Dose Level 2 of the study medication and any adverse events the patient might have experienced. If there are no 
tolerability issues, the patient/caregiver will be instructed to increase the dose to Dose Level 3 on Day 8 and Dose 
Level 4 on Day 9.  During the time the patient is at home, monitoring of their cardio-respiratory function will be 
attempted for 6 hours each day, during the time the patient is awake, on any 3 days in the week preceding the next 
scheduled office visit on Day 14, using the BioRadio. Data recorded using this system will be downloaded from the 
device at home using the Internet/WiFi or a dedicated laptop provided by the Sponsor, if Internet access is not 
available.  
 
The patient will be required to return for a scheduled visit on Day 14 and safety [vital signs, 12-lead ECG, laboratory 
tests (hematology, blood chemistry, urinalysis), physical/neurological examination] and selected efficacy (respiratory 
measures, CGI-C, CIC) evaluations, will be performed.  The tolerability of the current dose of study medication will 
be evaluated, and the patient will be housed overnight, if necessary. On Day 15, if there are no safety or tolerability 
issues that would require a dose reduction, the patient will be given the morning dose of Dose Level 4 (2 mg sarizotan, 
5 mg sarizotan, 10 mg sarizotan or placebo, bid). Prior to administering the dose, a PK blood sample for assessing 
steady state trough levels of sarizotan at Dose Level 4 will be taken, and PK blood samples will be collected at 1 and 
4 hr post-dose following the dose. Post-dose safety assessments (vital signs, ECG) will be performed, and if there are 
no tolerability issues, the patient will be released from the hospital after the last PK sample, and will be provided with 
a supply of Dose Level 4 (or a lower dose if Dose Level 4 was not tolerated) for dosing on Days 15 [PM] to 56 (Week 
8). Home respiratory monitoring will be attempted for 6 hours each day on any 3 days in the week prior to each of 
the scheduled office visits at Weeks 8, 16 and 24.  
 
The patient will be required to return for scheduled visits on Weeks 8 and 16 and safety (vital signs, routine laboratory 
tests, ECG, physical and neurological examinations) and efficacy evaluations will be performed. The suicidality 
assessment will be performed at Week 8. In addition, serum prolactin, and plasma ACTH and cortisol measurements, 
and an ophthalmological examination will be done at Week 16.  At each of these visits, the patient will be dispensed 
an 8-week supply of their current dose level of study medication for dosing during the period until the next scheduled 
visit, provided there are no safety or tolerability issues that would require a dose reduction.   
 
The patient will return for the final scheduled visit at Week 24, or if they discontinue from the study prematurely. 
The caregiver should be instructed not to administer the morning dose of the study medication on the day of the Week 


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24 visit to the clinic, as patients who continue in the open-label extension treatment period will receive their first dose 
of study medication on this day.  All final safety [vital signs, 12-lead ECG, laboratory tests (hematology, blood 
chemistry, urinalysis, serum pregnancy test for post-pubertal females, and measurement of serum prolactin, and 
plasma ACTH and cortisol), Tanner Staging, and physical, neurological and ophthalmological examinations 
(including OCT, if feasible for the patient), and the suicidality assessment] and efficacy assessments [respiratory 
measures, heart rate, CGI-C, CIC, Motor-Behavioral Assessment Scale, Caregiver Top 3 Concerns, and RCSS] will 
be performed at this visit.  The results from the Week 24 assessment of the primary efficacy measure of respiratory 
function (data from home respiratory monitoring on 3 days in the week preceding the visit), as well as all other 
secondary efficacy measures assessed during the visit, will be considered the endpoint value for statistical analysis 
purposes.  
 
At Week 24, all patients who have completed the final evaluations at Week 24 (Day 168), have no safety or tolerability 
issues that would preclude continuing on the study medication, have been compliant with the trial requirements, and 
have not worsened to the extent that they are considered at an increased risk for morbidity or mortality, as judged by 
the Investigator, will be eligible to enter the initial 24-week, open-label, extension treatment period of the study.  
Patients who do not wish to continue treatment will have their study medication discontinued and will be asked to 
return for a safety follow-up visit 2 weeks after their final dose, during which vital signs and an assessment of adverse 
events will be performed.  Any Serious Adverse Events (SAEs) occurring within 30 days after the final dose will be 
reported. 
 
168-Week Open-label Extension Treatment Period 
All patients who have completed the final evaluations at Week 24 (Day 168), have no safety or tolerability issues that 
would preclude continuing on the study medication, have been compliant with the trial requirements, and have not 
worsened to the extent that they are considered at an increased risk for morbidity or mortality, as judged by the 
Investigator, will have the option of continuing open-label treatment with sarizotan for 24 weeks. Each patient’s 
parent, legal guardian, or representative, must provide written informed consent prior to the patient’s participation in 
this initial extension period. The patient should provide assent, if capable of doing so.  At the end of the initial 24 
weeks of open-label treatment, the Investigator will make a global assessment of the patient.  If in the Investigator’s 
opinion, the patient is benefitting from treatment with sarizotan and is not experiencing any significant adverse events, 
they will be eligible to continue open-label treatment.  Informed consent must be obtained at Week 48, for the patient 
to continue open-label treatment for an additional 48 weeks (through Week 96), again at Week 96 for the patient to 
continue open-label treatment for another 48 weeks (through Week 144), and again at Week 144 for the patient to 
continue open-label treatment for another 48 weeks (through Week 192).   
 
At Week 24 (Day 168), all patients ≥13 years of age and weighing ≥25 kg, including those originally randomized to 
placebo and those receiving 5 mg once daily, will receive treatment with sarizotan, and will start at a dose of 5 mg 
bid.  Patients 4 to <13 years of age and patients ≥13 years of age but weighing <25 kg, including those who were 
randomized to placebo, will receive sarizotan at a starting dose of 2 mg bid.  If patients do not tolerate this starting 
dose, the Investigator will instruct the caregiver to administer only the morning dose (i.e. 2 or 5 mg once daily) for a 
few days prior to reinitiating the intended bid dose (i.e. 2 or 5 mg bid).  If the 2 or 5 mg bid dose is still not tolerated, 
a reduction to 2 or 5 mg once daily will be permitted.   
 
At Week 28 (Day 196), patients ≥13 years of age and weighing ≥25 kg will have their dose increased to 10 mg bid, 
if the starting dose was well tolerated, or may remain on a lower dose.  Patients 4 to <13 years of age and weighing 
10 to <18 kg will remain on a dose of 2 mg bid, while those weighing ≥18 kg, as well as patients ≥13 years of age but 
weighing <25 kg, will have their dose increased to 5 mg bid, provided there are no tolerability issues.   
 
If the patient does not tolerate the target dose (2, 5 or 10 mg bid, based on age and weight criteria), the Investigator 
will instruct the caregiver to administer only the morning dose (i.e. 2, 5 or 10 mg/day) for a few days prior to 
reinitiating the intended bid dose (i.e. 2, 5 or 10 mg bid).  If the target dose of 2, 5 or 10 mg bid dose is still not 
tolerated, a reduction to 2 mg once daily, 2 mg bid or 5 mg bid, respectively will be permitted.  Patients will continue 
on their maximum tolerated dose (MTD) through the final dose, unless intolerance develops, and a dose reduction is 
warranted.  
 


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The final evaluations performed at Week 24 in the double-blind period, including assessments of respiratory function 
performed in the clinic using a stretch-sensitive resistance plethysmograph (SOMNOtouch), vital signs (body weight, 
height, temperature, respiratory rate, pulse, and systolic and diastolic blood pressure), laboratory tests (hematology, 
biochemistry, urinalysis, serum prolactin, plasma ACTH and cortisol, serum pregnancy test for post-pubertal 
females), ECG, physical and neurological examinations, Tanner Staging, routine ophthalmological examination 
[including Optical Coherence Tomography (OCT), if feasible] and final assessments for other efficacy variables 
[Motor-Behavioral Assessment Scale, Caregiver Top 3 Concerns, and Rett syndrome Clinical Severity Scale (RCSS)] 
will serve as the baseline assessments for the open-label extension period.  Once all of these Week 24 assessments 
have been completed, and the consent form for the extension period has been signed, patients meeting all entry criteria 
will start on the low dose (5 mg bid) of sarizotan.   
 
The first dose of the extension period (2 or 5 mg sarizotan) should be administered in the clinic (if the morning dose 
was given, wait at least 6 hours after the prior dose before administration) on the same day (Day 168); however, if 
necessary, it can be postponed until the following morning.  Patients will be observed for the occurrence of any 
adverse events in the initial 4hour period after the first dose.  Safety evaluations (vital signs, 12-lead ECG, physical 
and neurological examinations) will be performed at 1 and 4 hr- post-dose.  If no significant side effects are noted 
within the 4-hr period following the first dose, the patient will be released from the hospital and given a supply of 
study medication for the remainder of the first four weeks of dosing at 2 or 5 mg bid. 
 
The patient/caregiver will receive a telephone contact from the Investigator/site staff on Days 175 (Week 25) to 
inquire about the tolerability of the current dose of the study medication. If there are no tolerability issues, the 
patient/caregiver will be instructed to continue on the current dose.  If intolerance develops, a reduction to 2 or 5 mg 
once daily can be instituted, or if necessary, the patient can be asked to return to the clinic for an unscheduled visit 
for a full assessment.  
 
The patient will be required to return for a scheduled visit on Day 196 (Week 28). The caregiver should be instructed 
not to administer the morning dose of the study medication on the day of the Week 28 visit to the clinic, as the first 
dose of the next dose level will be administered in the clinic. At this visit, safety [vital signs, 12-lead ECG, 
physical/neurological examination] and selected efficacy (in-clinic respiratory measures, CIC, CGI-C) evaluations, 
will be performed.  The tolerability of the current dose of study medication will be evaluated.  If there are no safety 
or tolerability issues that would require the dose to be maintained or reduced, the patient will have their dose 
maintained at 2 mg bid, or increased to 5 or 10 mg bid, and will be given their first dose in the clinic (if the morning 
dose was given, wait at least 6 hours after the prior dose before administration). Safety evaluations (vital signs, 12-
lead ECG, physical and neurological examinations) will be performed prior to dosing and at 1 and 4 hr post-dose.  If 
no significant side effects are noted within the 4-hr period following the dose, the patient will be released from the 
hospital and given a supply of study medication for the next 4 weeks of dosing at 2 mg bid, 5 mg bid or 10 mg bid.   
 
The caregiver will be contacted by telephone by the Investigator/site staff on Day 203 (Week 29) to inquire about the 
tolerability of the study medication and any adverse events the patient might have experienced. If there are no 
tolerability issues, the patient/caregiver will be instructed to continue on the current dose.  If intolerance develops, a 
reduction in dose can be instituted, or if necessary, the patient can be asked to return to the clinic for an unscheduled 
visit for a full assessment.  Similar telephone contacts will be made at Weeks 54, 66, 78, 90, 102, 114, 126, 138, 150, 
162, 174 and 186 during the additional open-label extension treatment period, during which adverse events, 
concomitant medication usage and overall compliance with the study medication will be assessed.  
 
Patients will be required to return for scheduled visits at Weeks 32, 40, and 48 in the initial 24-week open-label 
treatment period, and Weeks 60, 72, 84, 96, 108, 120, 132, 144, 156, 168, 180 and 192 if they continue open-label 
treatment. At each of these visits, safety assessments, comprising vital signs, laboratory tests (hematology, blood 
chemistry, urinalysis), ECG, and physical and neurological examinations, as well as selected efficacy assessments 
(in-clinic respiratory measures, CIC, CGI-C), will be performed. In addition, at Weeks 48, 72, 96, 120, 144, 168 and 
192 the following assessments will be performed: serum prolactin, plasma ACTH and cortisol, a serum pregnancy 
test (for post-pubertal females), Tanner Staging, an ophthalmological examination (including OCT, if feasible for the 
patient), and the suicidality assessment, as well as additional efficacy assessments (Motor-Behavioral Assessment 
Scale, Caregiver Top 3 Concerns, and RCSS). At each of these visits, the patient will be dispensed an 8-week or 


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12-week supply of their current dose of study medication, provided there are no safety or tolerability issues that would 
require a dose reduction, for dosing during the period until the next scheduled visit.  The Week 48 assessments will 
be considered the final evaluation for patients discontinuing after 24 weeks of open-label treatment.  
 
All patients continuing open-label treatment after Week 48 will return for the final evaluations at Week 96, if they 
complete 72 weeks of open-label treatment and do not continue further treatment, or at the time of discontinuation, if 
they discontinue from the study prematurely prior to Week 96.  Patients continuing open-label treatment after Week 
96, will return for the final evaluations at Week 144, or at the time of discontinuation, if they discontinue from the 
study prematurely prior to Week 144. Patients continuing open-label treatment after Week 144, will return for the 
final evaluations at Week 192, or at the time of discontinuation, if they discontinue from the study prematurely prior 
to Week 192. All final safety [vital signs, 12-lead ECG, laboratory tests (hematology, blood chemistry, urinalysis, 
serum prolactin, plasma ACTH and cortisol, and serum pregnancy test for post-pubertal females), Tanner Staging, 
and physical, neurological and ophthalmological (including OCT, if feasible for the patient) examinations, and the 
suicidality assessment] and efficacy [in-clinic respiratory measures, CIC, CGI-C, Motor-Behavioral Assessment 
Scale, Caregiver Top 3 Concerns, and RCSS] assessments will be performed at this visit.  The results from the final 
(Week 48, 96, 144, or 192, or at early discontinuation) assessment of the respiratory function (data from in-clinic 
respiratory monitoring using the SOMNOtouch), as well as all other efficacy measures assessed during the visit, will 
be considered the endpoint values for the open-label extension period for statistical analysis purposes.  
 
Patients who discontinue treatment prematurely or at the end of the initial open-label extension treatment period 
(Week 48), as well as those who discontinue treatment after completing Part 1 (through Week 96), Part 2 (through 
Week 144) or Part 3 (through Week 192) of the additional extension treatment period, will be asked to return for a 
safety follow-up visit 2 weeks after their final dose. Vital signs and an assessment of adverse events will be performed 
at this visit.  Any SAEs occurring within 30 days after the final dose will be reported.  
 
 
Planned Study Duration:  
The study will last up to 196 weeks, including a 4-week screening period, followed by a 24-week randomized, 
double-blind treatment period, and a 168-week open-label extension period. A safety follow-up visit will be 
performed 2 weeks after the final dose of study medication. 
 
 
Study Population: 
A minimum of 129 patients with RTT will be randomized to either sarizotan 2 mg bid, sarizotan 5 mg bid, sarizotan 
10 mg bid or placebo bid, based on age and weight criteria. 
 
 
Inclusion Criteria: 
The patient must meet all of the following inclusion criteria to be eligible for enrolment into the study: 
Demographics 
1. Female or male ≥ 4 years of age.  
2. Body weight ≥ 10 kg, and within the expected range for an RTT patient, based on age and height.  
Diagnostic 
3. Diagnosis of Rett syndrome based on consensus clinical criteria (Neul et al, 2010; Appendix 4).  A test for 
MECP2 mutations (Xq28) will be performed at screening if results from an accredited laboratory are not 
available; selection for the trial is not contingent on the results of the MECP2 test. Patients with known 
MECP2 duplications will not be eligible.  
4. One or more of the following breathing dysfunctions: periodic apnea during wakefulness; intermittent 
hyperventilation; breath holding spells; air swallowing; forced expulsion of air or saliva. 
5. Patient meets all of the following criteria related to breathing abnormalities: 
a. 
Parent report of 10 episodes or more of breathing abnormality per day during wakefulness in the 
week prior to the screening visit; 


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b. Time per hour spent on normal breathing is less than 90% of the total time per hour of wakefulness 
(i.e., ≥10% of the time should be abnormal breathing);  
c. 
Has at least 10 episodes of breathing dysrhythmia, defined by episodes ≥10 seconds of breath 
holding (apnea), per hour, during cardiorespiratory monitoring (performed with home/ambulatory 
monitoring system during screening period).  
6. Stable medication regimen for 4 weeks prior to beginning the study (if receiving services - physical, 
occupational, or speech therapy - subjects must be on a stable regimen of these services for 3 months prior 
to beginning the study). Female patients of childbearing potential are to use adequate contraception as 
recommended by their Health Care Provider (see Section 13.1.8). 
Procedural 
7. Parent/legal guardian/representative has provided written consent prior to the patient participating in the 
study. Where feasible, consent or assent for patients less than 18 years of age, has also been provided by the 
patient. 
8. Ability to take study medication provided either as capsules or combined with food/drink. 
9. Patient is cooperative, willing to complete all aspects of the study, and capable of doing so with assistance 
of a caregiver.  
10. Caregiver is able to understand the instructions and fully participate.   
 
 
Exclusion Criteria: 
The presence of any of the following will exclude a patient from study enrollment: 
1. Meets any of the diagnostic exclusion criteria for Rett syndrome, Typical (Neul et al, 2010; Appendix 4); 
2. Patient is participating in a clinical trial with another investigational drug or has taken an investigational drug 
within one month or 5 half-lives (whichever is longer) prior to screening; 
3. Hypersensitivity to sarizotan or other 5-HT1a agonists, [UK only: or to the capsule material gelatin or 
microcrystalline cellulose used in the placebo capsules]; 
4. Current clinically significant (as determined by Investigator) 
a. 
cardiovascular, respiratory (e.g. severe asthma), gastrointestinal, renal, hepatic, hematologic or 
other medical disorders, in addition to those directly related to the patient’s Rett syndrome [for US, 
Italy, India and Australia]; 
b. cardiovascular, respiratory (e.g. severe asthma), or gastrointestinal disease, renal impairment (as 
indicated by creatinine >2X ULN), hepatic impairment (as indicated by total bilirubin >2X ULN), 
history of moderate or severe hepatic insufficiency or moderate or severe liver cirrhosis, or 
hematologic or other medical disorders, in addition to those directly related to the patient’s Rett 
syndrome [for UK only]; 
5. QTcF interval on the ECG is greater than 450 msec.  
6. Surgery planned during the study (except for insertion of gastrostomy tube); 
7. Severe diabetes mellitus or fatty acid oxidation disorder.  
8. Ophthalmologic history including any of the following conditions: albino patients, family history of 
hereditary retinal disease, retinitis pigmentosa, any active retinopathy or severe diabetic retinopathy. 
9. Females who are pregnant, breastfeeding, or of childbearing potential and not using adequate contraception 
(see Section 13.1.8), as recommended by their Health Care Provider.  
10. [UK only: Subjects who have an inborn error of metabolism.] 
11. Evidence of clinically significant malnutrition. 
 
 
Study Medication Description: 
Sarizotan is formulated as capsules of 2-mg, 5-mg and 10-mg dosage strength. 
 
 


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Study Medication – Dose and Mode of Administration:  
 
The study medication will be administered as capsules of 2-mg, 5-mg or 10-mg dosage strength of sarizotan or 
matching placebo capsules. The capsules should be given orally; however, if necessary, they can be dissolved in an 
appropriate liquid and administered as a solution either orally or through an enteral feeding tube, e.g. gastrostomy 
tube (G-tube). Patients will receive 1 capsule bid, with combinations of active and placebo (double-blind period 
only) capsules being used to achieve the desired daily dose of sarizotan. Study medication with each different 
dosage (2-mg, 5-mg or 10-mg sarizotan, or placebo) will be provided in kits for dispensing to the patient for twice 
daily dosing over the period between scheduled visits. In the double-blind period, the study medication (sarizotan 
2 mg, 5 mg or 10 mg, or placebo) administered to each patient will be determined according to a computer-
generated randomization scheme.  Drug supplies, randomization of patients to treatment (double-blind period only), 
and dispensing of appropriate medication kits (double-blind and open-label periods) will be managed by an 
Interactive Voice or Web Response System (IWRS).  
 
 
Comparator – Dose and Mode of Administration:  
In the initial 24-week double-blind period, patients randomized to the placebo group will be administered an equal 
number of matching placebo capsules (1 capsule bid) at each dose level.  
 
 
Methodology: 
Safety Outcomes – Secondary Objective 
Safety will be assessed by the following: 
• 
Adverse events (AEs) 
• 
Vital signs (systolic/diastolic blood pressure, pulse, body weight, body temperature, respiratory rate) 
• 
Laboratory evaluations (blood chemistry, hematology, urinalysis, serum prolactin, and plasma ACTH and 
cortisol) 
• 
Electrocardiogram (ECG) – 12-lead standard  
• 
Physical examination 
• 
Neurological examination 
• 
Routine ophthalmology examination (including OCT, if feasible for the patient) 
• 
Tanner Staging 
• 
Suicidality assessment. 
 
Primary Efficacy Outcome 
The primary efficacy outcome in the double-blind period will be the percent reduction (change) from baseline in the 
number of apnea episodes (each ≥10 seconds in duration) per hour, during awake time. This will be calculated from 
the data obtained during home respiratory monitoring by means of an ambulatory data acquisition system 
(BioRadioTM) designed to record specific respiratory and cardiac parameters. Assessment of the respiratory 
outcomes will be performed at home on any 3 days in each of the first 3 weeks of the screening period, and in the 
week prior to each of the visits at Weeks 2, 8, 16, and 24. In parallel, cardio-respiratory monitoring will be 
performed at the hospital/clinic at Baseline and at Weeks 16 and 24, using a stretch-sensitive resistance 
plethysmograph (SOMNOtouch).  
 
Home respiratory monitoring will be performed during the screening period (three 3-day periods during the first 3 
weeks) and for 3 days in the week prior to each scheduled clinic visit at Weeks 2, 8, 16, and 24. Monitoring will be 
performed when the patient is awake and should be attempted for 6 hours on each of the 3 days. Data from all of the 
quality recording time (minimally 3 hours) in the Screening period, and from the week prior to each of the visits at 
Weeks 2, 8, 16, and 24, will be averaged and used in calculating the value for the primary efficacy measure. If the 
patient meets the criterion for number of apnea episodes, as determined by Vivonoetics, in any week of the 
Screening period, home monitoring in the subsequent week(s) would not be required, and the screening data would 
be used to calculate the baseline value for the analyses.  
 


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During the open-label extension phase of the study patients will return for visits every 4, 8 or 12 weeks, and 
respiratory assessments will be performed in the clinic at Weeks 28, 32, 40, 48, 60, 72, 84, 96, 108, 120, 132, 144, 
156, 168, 180 and 192 using the SOMNOtouch.  Respiratory measures derived from the SOMNOtouch data will be 
similar to those from the BioRadioTM, including apnea episodes.  Efficacy data from the extension period from 
patients randomized to sarizotan at Baseline will be analyzed to determine if there is any attenuation of the benefit 
noted during the first six months.  In addition, a comparison will be made between patients who received sarizotan 
throughout both periods of the study and those who were randomized to placebo in the double-blind period and 
switched to sarizotan in the open-label extension period. 
 
The following system will be used for home monitoring of cardio-respiratory function: 
• 
BioRadioTM wireless physiological monitor (http://glneurotech.com/bioradio/physiological-signal-
monitoring/wireless-respiration/).   
 
Key Secondary Efficacy Outcome 
The following global assessment performed by the caregiver will be the key secondary efficacy outcome: 
• 
Caregiver-rated Impression of Change (CIC): 7-point scale requiring the caregiver to rate how much the 
patient’s illness has improved or worsened relative to the baseline state.  
 
Other Secondary Efficacy Outcomes 
The Secondary efficacy outcomes will include the following: 
• 
Caregiver Top 3 Concerns: Visual Analogue Scale-based evaluation of three priority concerns identified by 
caregivers related to the patient’s RTT syndrome which they would like to see change as a result of treatment. 
The severity of these concerns is rated by the caregiver at baseline and is evaluated again at subsequent follow-
up visits. 
• 
Clinical Global Impression of Change (CGI-C): 7-point scale requiring the clinician to rate how much the 
patient’s illness has improved or worsened relative to the baseline state. 
• 
Motor-Behavioral Assessment Scale: comprised of three sub-scales: 
I. 
Behavioral/Social Assessment – 16 items 
II. Orofacial/Respiratory Assessment – 7 items 
III. Motor Assessment/Physical Signs – 14 items.  
• 
Respiratory Measures: 
o 
Percent time spent with breathing dysrhythmia (% time apnea + % time hyperventilation) per hour; 
o 
Number of hyperventilation episodes (≥10 seconds each);  
o 
Oxygen saturation (# of episodes of oxygen desaturation below 90% per hour).  
o 
Respiratory Distress Index - The sum of the following parameters calculated per hour of wakefulness: 
1) number of breath-holding episodes, 2) number of episodes of hyperventilation [1 and 2 are as 
defined in inclusion criteria; each would have to be ≥10 seconds in duration], and 3) number of drops 
in oxygen values to < 90%. 
• 
Rett Syndrome Clinical Severity Scale (RCSS): frequency and manageability of seizures, respiratory 
irregularities, scoliosis, ability to walk (gait apraxia), hand use, speech and sleep; yielding total and feature-
specific scores.  
• 
Efficacy in patients with a sarizotan plasma concentration of >400 ng/mL on Day 15.  
 
Pharmacokinetics – Secondary Objective 
Blood samples for measurement of plasma levels of sarizotan and its major metabolites and determination of PK 
parameters will be collected just prior to the first dose of Dose Level 1 (blank sample) and at approximately 1 and 
4 hr post-dose (±15 min) on Day 1.  On Day 15, a blood sample will be taken prior to dosing on Day 15 (trough level 
for Dose Level 4) and at 1 and 4 hr post-dose (Dose Level 4).  
 
Details of the population PK analysis and determination of dose-proportionality for sarizotan will be provided in a 
separate document. 
 


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Safety Monitoring Board 
Safety data from all patients will be examined periodically by an Independent Safety Monitoring Board (ISMB). The 
ISMB may request modifications to the study design or request that the study be terminated, should any significant 
safety concerns become evident.  
 
Statistical Methods:   
 
Sample Size:  
A minimum of 129 patients with RTT will be included in this study, with approximately equal numbers of patients 
randomly assigned to each of the three treatment groups:  
• 
low dose sarizotan [sarizotan 2 mg bid (age 4 to <13 years; or age ≥13 years, weight <25 kg) or 5 mg bid 
(age ≥13 years, weight ≥25 kg)],  
• 
high dose sarizotan [sarizotan 5 mg bid (age 4 to <13 years; or age ≥13 years, weight <25 kg), or 10 mg bid 
(age ≥13 years, weight ≥25 kg)],  
• 
or placebo bid.   
The sample size estimate was based on the following assumptions: 
• 
3 treatment groups (2 active + placebo)  
• 
Primary endpoint: Percent reduction in the number of apnea episodes (≥10 sec each) per hour 
• 
H0: Percent reduction in apnea episodes in placebo and active groups is the same 
• 
HA: There is a difference in the % reduction in apnea episodes between high dose sarizotan and placebo.  
 
The assumptions for the estimated standard deviation (SD) are based on limited data from a study by Khwaja et al. 
(2014), in RTT patients. There were only 5 patients with data reported for apnea index (for apnea episodes > 10 
seconds).  Pilot observational data collected using the BioRadio device in 26 patients with RTT indicated that the 
number of episodes of apnea may approach 60 per hour. Based on the range of 10-60 episodes per hour, ranges of 10-
30, 10-45 and 10-60 apnea episodes per hour indicate SDs of 5.0, 8.75 and 12.5, respectively.  
 
Sample sizes were computed to determine the number of patients required to detect a minimum difference in mean 
percent reduction of 20% (high dose sarizotan 30%, placebo 10%) and 10% (high dose sarizotan 20%, placebo 10%), 
based on differences between high dose sarizotan and placebo.  
 
Sample sizes of 23 or 34 in each treatment group will have 90% power to detect a difference in mean percent reduction 
of -20% or -10%, respectively, assuming a common SD of 20 (for the 20% reduction) and 12.5 (for the 10% 
reduction), using a two-group t-test with a 0.050 two-sided significance level. Assuming an attrition rate of 25% (7 
or 9 patients) per group, a total of 30 or 43 patients would need to be enrolled in each group to get 23 or 34 patients 
completing the study. As this is the first large-scale study evaluating the effect of sarizotan on respiratory symptoms 
in patients with RTT, a conservative estimate of 10% reduction in apnea episodes was used to estimate the sample 
size required, i.e. approximately 43 patients per group.  
 
The sample size may be revised based on a prospective assessment of variability in the frequency of apnea episodes, 
of 10 seconds or greater duration, from data collected from the first 20 patients who complete screening. 
 
Subject Characteristics:   
The background and demographic characteristics (age, race, ethnicity, weight, height, education, past and current 
medical conditions, etc.), disease characteristics, and prior/concomitant medication use for randomized patients will 
be summarized by treatment group. Continuous variables will be summarized by minimum, maximum, mean, median, 
and standard deviation, and discrete variables will be summarized using frequencies and percentages. 
 
Safety Analysis: 
The safety population will consist of all subjects who took at least one dose of study medication.  All AEs will be 
summarized by body system and preferred term.  The incidence (%) of SAEs, AEs that are newly occurring or 
worsened after administration of study medication (i.e. treatment-emergent AEs [TEAEs]), and AEs leading to 
discontinuation (ADOs) will also be summarized; severity of each AE and relatedness to study medication will be 


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assessed and presented.  Changes from baseline in vital signs, ECG and laboratory values, and findings on physical, 
neurological and routine ophthalmology examinations will be summarized, with abnormal and clinically notable 
values/findings being identified.  In the initial 24-week, double-blind, placebo-controlled period, a comparison will 
be made between the sarizotan and placebo groups in the proportion of patients experiencing SAEs, ADOs, TEAEs 
and any clinically significant abnormalities in other safety parameters.  Where feasible, mean changes from baseline 
will be examined using a paired t-test.  Safety data for the open-label extension period will be analyzed separately 
and will use the Week 24 evaluations from the double-blind period as the baseline assessments.   
 
Efficacy Analysis: 
Primary Efficacy Outcome. The primary efficacy analysis for the initial, 24-week, double-blind, treatment period will 
be performed on the Intent-to-Treat (ITT) population, consisting of all patients who were randomized to treatment. 
The percent reduction (change) from baseline in the number of apnea episodes (each ≥10 seconds in duration) per 
hour, during awake time, will be compared between treatment groups using a Mixed Model Repeated Measures 
(MMRM) analysis. The MMRM model will include percent change from baseline as response, the fixed, categorical 
effects of treatment group, visit, treatment group-by-visit interaction, and the continuous terms age and baseline value 
as covariate. A statistically significant difference between high dose sarizotan (5 or 10 mg bid) and placebo will be 
considered evidence of efficacy in reducing apnea.  
 
Key Secondary Efficacy Outcome. The mean rating of the caregiver-rated CIC at Week 24/endpoint will be compared 
between treatment groups using the Van Elteren test (a stratified Cochran Mantel Haenszel test with modified ridit 
scores).  The following age strata will be considered in the analysis: <13 years and ≥ 13 years. In addition to the above 
analysis, comparisons between treatments for the proportion of patients rated improved at Week 24 will be done using 
logistic regression. 
 
Other Secondary Efficacy Outcomes.  
The analysis of the Caregiver Top 3 Concerns will be performed first, comparing the change from baseline in the total 
score on the VAS for each of the 3 symptoms identified as most concerning at baseline using an ANCOVA-LOCF 
analysis. The model will include treatment group and the baseline value along with age as covariates. Change will be 
estimated using the least-squares mean derived from the ANCOVA. Comparisons between treatment groups at Week 
24 will be made using the difference in least-squares mean, 95% confidence interval (CI) and p-values from the 
ANCOVA model. 
 
Descriptive statistics will be presented for the other secondary efficacy outcomes. The proportion of patients rated 
improved, as well as the mean score, on the Investigator-rated CGI-C at each of the scheduled visits will be presented.  
Actual values and the change from baseline in other secondary efficacy variables (Motor Behavioral Assessment 
Scale and subscales, other respiratory parameters, and RCSS) at all scheduled visits will be presented. An additional 
analysis of efficacy will be performed for patients with a sarizotan plasma concentration of >400 ng/mL.  
 
Multiple comparisons/ multiplicity.  
The study level error rate will be controlled by following a sequential multiple testing procedure, where testing will 
begin with the primary efficacy endpoint. The effects of the high dose sarizotan versus placebo will be analyzed first 
for all parameters in a pre-specified sequence.  
 
The sequence of testing will be as presented below:  
• 
Percentage change from baseline in the number of apnea episodes, 
• 
Mean rating of CIC, 
• 
Mean change from baseline in the Top Three Concerns Total Score. 
 
Initial 24-week Double-Blind Treatment Period. The primary efficacy assessment for the study will be performed 
using data from the initial 24-week double-blind, placebo-controlled treatment period.  A statistical “Win” will be 
claimed if the following results are obtained in the primary and key secondary efficacy analyses: 


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• 
Statistically significant difference between high dose sarizotan (5 or 10 mg bid) and placebo in the percent 
reduction (change) from baseline in the number of apnea episodes (each ≥10 seconds in duration) per hour, 
during awake time; 
• 
Directional change on the CIC in favor of high dose sarizotan (5 or 10 mg bid) compared to placebo. 
 
168-week Open-label Extension. Efficacy data from the extension period obtained from patients randomized to 
sarizotan at Baseline will be analyzed to determine if there is any attenuation of the benefit noted during the first six 
months. The response in placebo patients switched to sarizotan in the extension period will be compared with that in 
patients who were treated with sarizotan throughout the study.  
 
 


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2 
SIGNATURE PAGE 
 
Study Title:  
A Randomized, Double-Blind, Placebo-Controlled, Six-Month Study to Evaluate the Efficacy, Safety and 
Tolerability of Sarizotan in Patients with Rett Syndrome with Respiratory Symptoms. 
 
Study Code:  
Sarizotan/001/II/2015 
 
Principal Investigator 
 
 
 
Name  
 
 
 
 
 
Title 
 
 
 
Signature 
 
 
 
 
 
Date 
 
 
Sponsor Representative 
Ravi Anand, M.D. 
Chief Medical Officer 
Newron Pharmaceuticals 
Via Antonio Meucci, 3 
20091 Bresso (MI), Italy 
 
 
 
Signature 
 
 
 
 
 
Date 
 
 
Clinical Research Organization 
IQVIA Limited, formerly Quintiles Limited 
500 Brook Drive 
Green Park 
Reading 
Berkshire RG2 6UU 
United Kingdom 
 
 
The Sponsor has transferred all responsibilities for the conduct of the trial to the CRO.  
 
 


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3 
TABLE OF CONTENTS  
1 
SYNOPSIS ........................................................................................................................................................... 2 
2 
SIGNATURE PAGE ......................................................................................................................................... 14 
3 
TABLE OF CONTENTS .................................................................................................................................. 15 
4 
ABBREVIATIONS AND DEFINITIONS OF TERMS ................................................................................. 19 
5 
TITLE OF STUDY ........................................................................................................................................... 21 
6 
PROTOCOL NUMBER ................................................................................................................................... 21 
7 
INTRODUCTION ............................................................................................................................................. 21 
7.1 Background Information ..................................................................................................... 21 
7.1.1 
Pharmacology ........................................................................................................ 21 
7.1.2 
Toxicology ............................................................................................................. 24 
7.1.3 
Pharmacokinetics and Metabolism ........................................................................ 27 
7.1.4 
Clinical Studies ...................................................................................................... 28 
7.2 Chemistry and Pharmaceutical Properties of Sarizotan ....................................................... 29 
7.3 Study Rationale ................................................................................................................... 31 
8 
STUDY OBJECTIVES ..................................................................................................................................... 37 
9 
INVESTIGATIONAL PLAN ........................................................................................................................... 38 
9.1 Study Design ....................................................................................................................... 38 
9.2 Study Population ................................................................................................................. 42 
9.2.1 
Inclusion Criteria.................................................................................................... 42 
9.2.2 
Exclusion Criteria .................................................................................................. 43 
9.2.3 
Documentation of Randomization ......................................................................... 44 
9.2.4 
Premature Discontinuation ..................................................................................... 44 
9.2.5 
Record of Screening Failures ................................................................................. 44 
9.2.6 
Record of Study Participants .................................................................................. 44 
9.2.7 
Enrolment in Extension Treatment Period ............................................................. 44 
10 
STUDY MEDICATION ................................................................................................................................... 46 
10.1 
Description, Labeling and Packaging ............................................................................ 46 
10.1.1 
Description of the Supplies .................................................................................... 46 
10.1.2 
Labelling ................................................................................................................ 46 
10.1.3 
Packaging ............................................................................................................... 46 
10.2 
Administration ............................................................................................................... 50 
10.3 
Storage ........................................................................................................................... 52 
10.4 
Blinding and Randomization ......................................................................................... 52 
10.5 
Accountability ................................................................................................................ 53 
10.6 
Overdosage .................................................................................................................... 53 
10.7 
Occupational safety ........................................................................................................ 53 
11 
EVALUATIONS AND PROCEDURES ......................................................................................................... 54 
11.1 
Written Informed Consent ............................................................................................. 54 
11.2 
Study Conduct ................................................................................................................ 54 
11.3 
Study Flow Chart ........................................................................................................... 60 
11.4 
Visit Schedule and Assessments .................................................................................... 68 
11.4.1 
Screening (Days -28 to -1) ..................................................................................... 68 
11.4.2 
Baseline (Day 0 through Day 1 pre-dose) .............................................................. 68 
11.4.3 
Day 1 (Dose Level 1) ............................................................................................. 69 
11.4.4 
Day 2 (Dose Level 2) ............................................................................................. 70 


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11.4.5 
Day 7 - Telephone Contact ..................................................................................... 70 
11.4.6 
Day 14 .................................................................................................................... 70 
11.4.7 
Day 15 .................................................................................................................... 70 
11.4.8 
Week 8 (Day 56) .................................................................................................... 71 
11.4.9 
Week 16 (Day 112) ................................................................................................ 71 
11.4.10 
Week 24 (Day 168 or at early discontinuation) – Final Evaluation ....................... 72 
11.4.11 
Safety Follow-up (Day 182 or 14 days after last dose of study medication) ......... 73 
11.4.12 
Week 24 (Day 168) – Baseline for open-label extension period ............................ 73 
11.4.13 
Week 25 (Day 175) - Telephone Contact ............................................................... 73 
11.4.14 
Week 28 (Day 196) ................................................................................................ 73 
11.4.15 
Week 29 (Day 203) - Telephone Contact ............................................................... 74 
11.4.16 
Week 32 (Day 224) ................................................................................................ 74 
11.4.17 
Week 40 (Day 280) ................................................................................................ 74 
11.4.18 
Week 48 (Day 336 or early discontinuation) ......................................................... 75 
11.4.19 
Week 54 (Day 378) - Telephone Contact ............................................................... 76 
11.4.20 
Week 60 (Day 420) ................................................................................................ 76 
11.4.21 
Week 66 (Day 462) - Telephone Contact ............................................................... 76 
11.4.22 
Week 72 (Day 504) ................................................................................................ 76 
11.4.23 
Week 78 (Day 546) - Telephone Contact ............................................................... 77 
11.4.24 
Week 84 (Day 588) ................................................................................................ 77 
11.4.25 
Week 90 (Day 630) - Telephone Contact ............................................................... 77 
11.4.26 
Week 96 (Day 672 or early discontinuation) ......................................................... 78 
11.4.27 
Week 102 (Day 714) - Telephone Contact ............................................................. 78 
11.4.28 
Week 108 (Day 756) .............................................................................................. 79 
11.4.29 
Week 114 (Day 798) - Telephone Contact ............................................................. 79 
11.4.30 
Week 120 (Day 840) .............................................................................................. 79 
11.4.31 
Week 126 (Day 882) - Telephone Contact ............................................................. 80 
11.4.32 
Week 132 (Day 924) .............................................................................................. 80 
11.4.33 
Week 138 (Day 966) - Telephone Contact ............................................................. 80 
11.4.34 
Week 144 (Day 1008 or early discontinuation) ..................................................... 81 
11.4.35 
Week 150 (Day 1050) - Telephone Contact ........................................................... 81 
11.4.36 
Week 156 (Day 1092) ............................................................................................ 82 
11.4.37 
Week 162 (Day 1134) - Telephone Contact ........................................................... 82 
11.4.38 
Week 168 (Day 1176) ............................................................................................ 82 
11.4.39 
Week 174 (Day 1218) - Telephone Contact ........................................................... 83 
11.4.40 
Week 180 (Day 1260) ............................................................................................ 83 
11.4.41 
Week 186 (Day 1302) - Telephone Contact ........................................................... 83 
11.4.42 
Week 192 (Day 1344 or early discontinuation) – Final Evaluation ....................... 83 
11.4.43 
Safety Follow-up (14 days after last dose of study medication) ............................ 84 
11.5 
Concomitant Medications .............................................................................................. 85 
12 
SAFETY AND EFFICACY EVALUATIONS ................................................................................................ 86 
12.1 
Safety Assessments ........................................................................................................ 86 
12.1.1 
Physical and Neurological Examinations ............................................................... 86 
12.1.2 
Vital Signs .............................................................................................................. 86 
12.1.3 
Electrocardiogram (ECG) ...................................................................................... 87 
12.1.4 
Drug levels and pharmacokinetic assessments ...................................................... 87 
12.1.5 
Laboratory Evaluations .......................................................................................... 87 
12.1.6 
Routine Ophthalmological Examination ................................................................ 89 
12.1.7 
Adverse Events ...................................................................................................... 89 


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12.1.8 
Tanner Staging ....................................................................................................... 90 
12.1.9 
Suicidality Assessment ........................................................................................... 90 
12.2 
Efficacy Assessments ..................................................................................................... 91 
12.2.1 
Number of Apnea Episodes (Primary Efficacy Outcome) ..................................... 91 
12.2.2 
Caregiver-rated Impression of Change (CIC) ........................................................ 92 
12.2.3 
Clinical Global Impression of Change (CGI-C) .................................................... 92 
12.2.4 
Other Respiratory Symptoms of RTT .................................................................... 92 
12.2.5 
Motor-Behavioral Assessment Scale ...................................................................... 93 
12.2.6 
Caregiver Top 3 Concerns ...................................................................................... 93 
12.2.7 
Rett Syndrome Clinical Severity Scale (RCSS) ..................................................... 94 
12.2.8 
Rater Training ........................................................................................................ 94 
13 
REPORTING SAFETY INFORMATION ..................................................................................................... 95 
13.1 
Adverse Events .............................................................................................................. 95 
13.1.1 
Glossary ................................................................................................................. 95 
13.1.2 
Data Collection ...................................................................................................... 96 
13.1.3 
Subject Follow-up .................................................................................................. 98 
13.1.4 
Reporting Serious Adverse Events ......................................................................... 99 
13.1.5 
Safety Reporting to Investigators, IRBs, IECs and Regulatory Authorities .......... 99 
13.1.6 
Reporting of Overdose ........................................................................................... 99 
13.1.7 
Breaking of the Study Blind by the Investigator .................................................... 99 
13.1.8 
Pregnancy ............................................................................................................. 100 
13.2 
Safety Monitoring Board ............................................................................................. 100 
14 
SUBJECT COMPLETION AND DISCONTINUATION ........................................................................... 102 
14.1 
Procedures for handling withdrawals ........................................................................... 102 
15 
PHARMACOKINETIC AND STATISTICAL METHODS ....................................................................... 104 
15.1 
Pharmacokinetics and Determinants of Pharmacokinetic Variability .......................... 104 
15.2 
Statistical methods ....................................................................................................... 104 
15.2.1 
Populations ........................................................................................................... 104 
15.2.2 
Background and demographic characteristics ...................................................... 104 
15.2.3 
Study medication.................................................................................................. 104 
15.2.4 
Concomitant therapy ............................................................................................ 105 
15.2.5 
Safety evaluations ................................................................................................ 105 
15.2.6 
Efficacy evaluations ............................................................................................. 105 
15.2.7 
Interim analysis .................................................................................................... 107 
15.2.8 
Sample size and power considerations ................................................................. 107 
16 
ETHICS ........................................................................................................................................................... 108 
16.1 
Ethical Considerations ................................................................................................. 108 
16.2 
Institutional Review Board / Independent Ethics Committee Approval ...................... 109 
17 
ADMINISTRATIVE CONSIDERATIONS ................................................................................................. 109 
17.1 
Regulatory Requirements–Sponsor/Investigator Obligations ...................................... 109 
17.2 
Curriculum Vitae ......................................................................................................... 109 
17.3 
Investigators and Study Administrative Structure ........................................................ 109 
17.4 
Investigator’s Statement ............................................................................................... 110 
17.5 
Monitoring Procedures ................................................................................................. 110 
17.5.1 
Study Monitoring ................................................................................................. 110 
17.5.2 
Case Report Form ................................................................................................ 110 
17.5.3 
Auditing/Inspecting .............................................................................................. 111 


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17.6 
Archiving of Records ................................................................................................... 111 
17.7 
Final Report ................................................................................................................. 111 
17.8 
Study Documentation and Publication of Study Results ............................................. 111 
17.9 
Financial Agreement .................................................................................................... 112 
17.10 
Termination of the Study ......................................................................................... 112 
17.10.1 
Study discontinuation by the Sponsor .................................................................. 112 
17.10.2 
Study discontinuation by the Clinical Investigator .............................................. 113 
17.11 
Insurance Policy ....................................................................................................... 113 
17.12 
Financial Disclosure ................................................................................................. 113 
18 
REFERENCES ................................................................................................................................................ 114 
19 
APPENDICES ................................................................................................................................................. 116 
19.1 
APPENDIX 1: Declaration of Helsinki ....................................................................... 116 
19.2 
APPENDIX 2: Clinically Notable Values ................................................................... 124 
19.3 
APPENDIX 3: Investigator Statement ......................................................................... 126 
19.4 
APPENDIX 4: RTT Diagnostic Criteria ...................................................................... 128 
19.5 
APPENDIX 5: Cardiorespiratory Measurements using the BioRadio ......................... 130 
19.6 
APPENDIX 6: Procedure for Preparing and Administering Sarizotan as a Solution .. 133 
19.7 
APPENDIX 7: Tanner Staging .................................................................................... 135 
 
 


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4 
ABBREVIATIONS AND DEFINITIONS OF TERMS 
 
ACTH 
= 
adrenocorticotrophic hormone 
ADO 
= 
adverse dropout 
ADR 
= 
adverse drug reaction 
AE 
= 
adverse event 
AED(s) 
= 
antiepileptic drug(s) 
AIC 
= 
Active-In-Capsule  
ALT 
= 
alanine-aminotransferase 
ANCOVA 
= 
analysis of covariance 
ANOVA 
= 
analysis of variance 
AST 
= 
aspartic-aminotransferase 
AUC 
= 
area under the plasma drug concentration vs. time curve 
bid 
= 
twice daily 
BUN 
= 
blood urea nitrogen 
CGI-C 
= 
Clinical Global Impression – Change from baseline 
CIC 
= 
Caregiver-rated Impression of Change from baseline  
CI 
= 
confidence intervals 
Cmax 
= 
maximum post-dose plasma drug concentration 
CNS 
= 
Central Nervous System 
CRF 
= 
case report form 
CTCAE 
= 
Common Terminology Criteria for Adverse Events 
CYP 
= 
Cytochrome P450 
DBP 
= 
diastolic blood pressure 
EC 
= 
Ethics Committee 
ECG 
= 
Electrocardiogram 
ESR 
= 
Erythrocyte sedimentation rate 
GCP 
= 
Good Clinical Practice 
GMP 
= 
Good Manufacturing Practice 
GT 
= 
gamma-glutamyl transpeptidase 
GLP 
= 
Good Laboratory Practice 
HDL 
= 
high density lipoprotein 
HBV 
= 
Hepatitis-B Virus 
HCV 
= 
Hepatitis-C Virus 
hERG 
= 
human Ether-a-go-go Related Gene 
HIV 
= 
human immunodeficiency virus 
HR 
= 
heart rate 
HPA 
= 
hypothalamic – pituitary – adrenal  


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ICH 
= 
International Conference on Harmonisation 
IMP 
= 
Investigational Medicinal Product 
i.p. 
= 
Intraperitoneal 
IRB 
= 
Institutional Review Board 
ITT 
= 
Intent to Treat 
IWRS 
= 
Interactive Web Response System 
LDH 
= 
lactate dehydrogenase 
LC-MS/MS 
= 
Liquid Chromatography/Mass Spectrometry/Mass Spectrometry 
LDL 
= 
low density lipoprotein 
LOCF 
= 
Last Observation Carried Forward 
MECP2 
= 
methyl-CpG-binding protein 2 (human gene) 
MeCP2 
= 
methyl-CpG-binding protein 2 (human protein) 
Mecp2 
= 
methyl-CpG-binding protein 2 (mouse gene) 
Mecp2 
= 
methyl-CpG-binding protein 2 (mouse protein) 
MTD 
= 
Maximum tolerated dose 
NOAEL 
= 
No observed adverse effect level 
OCT 
= 
Optical Coherence Tomography 
OTC 
= 
Over-The-Counter 
PK 
= 
Pharmacokinetics 
PRL 
= 
Prolactin 
RBC 
= 
red blood cells 
RCSS 
= 
Rett syndrome Clinical Severity Scale 
RTT 
= 
Rett syndrome 
RDO 
= 
Retrieved dropout 
SAE 
= 
Serious Adverse Event 
SBP 
= 
systolic blood pressure 
SD 
= 
standard deviation 
SMB 
= 
Safety Monitoring Board 
SOP 
= 
standard operating procedure 
T3 
= 
Triiodothyronine 
T4 
= 
Thyroxine 
TEAE 
= 
Treatment-emergent adverse event 
TSH 
= 
Thyroid Stimulating Hormone 
VLDL 
= 
very low density lipoprotein 
WBC 
= 
white blood cells 


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5 
TITLE OF STUDY 
 
A Randomized, Double-Blind, Placebo-Controlled, Six-Month Study to Evaluate the Efficacy, Safety and 
Tolerability of Sarizotan in Patients with Rett Syndrome with Respiratory Symptoms. 
 
6 
PROTOCOL NUMBER 
This study is being conducted under protocol no.: Sarizotan/001/II/2015. 
 
7 
INTRODUCTION  
 
7.1 
Background Information  
7.1.1 
Pharmacology 
Sarizotan hydrochloride (also referred to as Sarizotan and EMD 128130), binds with high affinity to 
h5-HT1A and 5-HT7 serotonin receptors, and to D2-like dopamine receptors, including hD2S, hD2L, hD3, 
hD4.2, hD4.4 and hD4.7 subtypes. 
In functional in vitro tests, sarizotan hydrochloride exhibited the profile of a full agonist at serotonin 
5-HT1A and dopamine D4.4 receptors and of an antagonist at dopamine D2 receptors (with weak intrinsic 
D2 agonistic activity at high doses). Although the role of its D4.4 agonistic properties, as well as its high 
affinity for D3 receptors, remains unclear, sarizotan hydrochloride displays a highly favorable profile, since 
theoretically possible dopamine D2 receptor mediated motor impairments are counteracted by its 5-HT1A 
agonism.  The role of the high affinity of sarizotan hydrochloride for 5-HT7 receptors is unclear.  EMD 
148 107 and EMD 329 989, two minor metabolites of sarizotan hydrochloride, show pharmacological 
activity at the D2 and D4 receptors, respectively; however, there is no relevant contribution of these 
metabolites to the activity of sarizotan. EMD 329 989 also binds to the 5-HT1A receptors. 
Functional in vivo studies on the turnover of biogenic amines in rats indicate both serotoninergic agonistic 
activity and dopaminergic antagonistic activity of sarizotan in the brain; the dopaminergic agonist activity 
is more than 10 times weaker.  
Antidyskinetic and neuroleptic activity 
In vivo behavioral studies indicate that sarizotan acts as a 5-HT1A agonist. Sarizotan hydrochloride 
inhibited, and at higher doses totally suppressed, ultrasonic vocalization induced by foot shock, with 
an ID50 of 1.4 mg/kg po, suggestive of a serotoninergic activity at the 5-HT1A receptor.  Anti-
dyskinetic effects, seen both in L-dopa treated parkinsonian rats and monkeys have also been attributed 
to its 5-HT1A agonistic component, as anti-dyskinetic effects were abolished by the selective 5-HT1A 
antagonist WAY 100635. In 6-OHDA lesioned rats, sarizotan decreased L-dopa induced dyskinesia 
/dystonia at a dose of 3 mg/kg sc, inhibited the L-dopa induced abnormal involuntary movements at 
doses of 1-5 mg/kg ip, and at the single oral dose of 2.5 mg/kg normalized the shortening of turning 
behavior duration induced by chronic (22 days) treatment with L-dopa. In parkinsonian MPTP –treated 
monkeys, sarizotan dose-dependently (0.2 – 2 mg/kg po) reduced the L-dopa- induced dyskinesia 
(Figure 1). 
 
 


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Figure 1: effects of sarizotan in L-dopa treated MPTP-lesioned monkeys. Dose-dependent reduction of total 
dyskinesia (expressed as Dyskinesia Severity Index) by sarizotan 0.2 - 2 mg/kg po. ’0’ refers to the placebo-treated 
control of sarizotan. M and H refer to the medium and high dose of L-dopa. * p<0.05 compared to placebo. 
 
Sarizotan showed lower potency in models that are suggestive of dopamine D2 antagonistic properties: 
doses of 16-20 mg/kg were needed to inhibit apomorphine-induced stereotyped behaviors, and avoidance 
reaction in rodents.  
Sarizotan does not induce catalepsy even at high doses (single doses of 100 and 1000 mg/kg p.o in mice 
and rats; sub-chronic 100 mg/kg po in rats); at lower doses it counteracts haloperidol-induced catalepsy 
(ID50 = 10 mg/kg/po, Figure 2) and chronic haloperidol-induced repetitive jaw movements (model of 
tardive dyskinesia; ID50 between 1.5 and 9 mg/kg po, Figure 3). The lack of catalepsy and the suppression 
of the D2 antagonist induced EPS is due to 5-HT1A agonistic effects of sarizotan, as these effects were 
reversed by the 5-HT1A antagonist WAY 100635. 
 
 
Figure 2: Sarizotan does not induce catalepsy in rats up to 1000 mg/kg (black bars); sarizotan reverses haloperidol-
induced catalepsy with ID50 of 10 mg/kg po (gray bars) * p < 0.05 versus haloperidol alone. In the title is reported 
the oral ID50 (16 mg/kg) for the inhibition of apomorphine-induced stereotyped behavior indicating D2 antagonism.  
 
 
 


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Figure 3: sarizotan reduces repetitive jaw movements (RJM) produced by chronic treatment with haloperidol. 
Haloperidol (1 mg/kg/day) was administered for 6 months. After 3 weeks of haloperidol washout, sarizotan 
hydrochloride was administered at the given doses (mg/kg/day) for 2 months. (n=12 rats per group). 
 
Respiratory dysfunction 
The new proposed indication for sarizotan is “breathing dysfunction in Rett syndrome (RTT) patients”.  
Dysregulation of breathing is very common in RTT, and is particularly severe.  It is characterized by 
alternating periods of hyperventilation and apneas, breath holds terminated by Valsalva’s maneuvers, forced 
and deep breathing, as well as apneustic breathing, and it commonly reveals abnormal cardiorespiratory 
coupling.  It has been reported that complications of cardiorespiratory dysfunctions may result in sudden 
and unexpected deaths that account for 26% of all deaths in RTT (Julu et al, 1997; Kerr et al 1997; Julu et 
al, 2008; Byard et al, 2006). Neurophysiological studies have shown that breathing defects and abnormal 
cardiac responses reflect the immaturity of the brainstem (Julu et al 2001).  Deficits in various 
neurotransmitter systems in the brainstem have been observed in patients and animal models of RTT (Katz 
et al., 2009; Weng et al., 2011). Activation of 5-HT1A receptors in specific areas of the brainstem involved 
in the neuronal control of respiration plays a key role in modulation of the respiratory rhythm, including 
the response to CO2 concentration (Abdala, May 2014). Studies in in Mecp2 mutant mice (validated 
preclinical model of RTT) have indicated that breathing irregularities are mostly characterized by overactive 
brainstem expiratory neurons, possibly due to a lack of synaptic inhibitory control (Abdala 2010). Agonism 
at the 5-HT1A receptor using the reference standard 8-OH-DPAT has been shown to provide inhibitory 
control of expiratory neurons within the lower brainstem, resulting in potential benefit in reducing the 
breathing irregularities and apneas (Lalley et al, 1994, Abdala et al, 2010; Abdala et al May 2014).  
There are no treatments available that ameliorate breathing irregularities in RTT patients. Effective 
treatment of respiratory abnormalities contributing to the RTT morbidity and mortality would address a 
significant unmet medical need. The potential benefits of sarizotan on respiratory symptoms in patients 
with RTT were evaluated by examining its effects in Mecp2 deficient RTT mice models (Abdala et al, June 
2014).  


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The effect of acute administration of sarizotan was evaluated in heterozygous female mice strains with 
different Mecp2 deletions (Mecp2 Jae/ + and Mecp2 Bird/+, respectively) and in homozygous null male 
mice (Mecp2 Jae/y). These transgenic mice models present a significantly higher basal incidence of apnea 
(number of apneas per hour) and breathing irregularities compared to their corresponding wild-type (WT) 
strains.  
A sarizotan dose of 5.0 mg/kg significantly reduced the incidence of apnea in Mecp2 deficient heterozygous 
females (n=10) from 143 ± 31 to 20 ± 8/hr (~ 86% reduction, p=0.001). Sarizotan also resulted in a 
significant decrease in the irregularity variance from 0.34 ± 0.07 to 0.06 ± 0.01 (p < 0.0001), approximating 
the irregularity variance measured in the WT. Frequency was also significantly increased, although not to 
the WT level. 
Sarizotan (10.0 mg/kg) was equally effective in improving respiration in Mecp2 null male mice. The 
incidence of apnea fell from 200 ± 42 to 30 ± 16/hr (~ 85% reduction, p=0.003).  Irregularity significantly 
declined from 0.55 ± 0.21 to 0.11 ± 0.05 (p = 0.048). 
The effect of sarizotan was also evaluated in two separate long-term studies (7 and 14 days administration) 
in two heterozygous female mice strains (Mecp2 Bird/+ and Mecp2R168X/+; the latter represents a 
common nonsense mutation seen in RTT patients).  Sarizotan was administered by dissolving it in drinking 
water (0.0625 mg/ml, vehicle 1.25% DMSO + 0.1% saccharin). The dose of sarizotan ingested by drinking 
averaged ~ 14 mg/kg per day.  
The results in Mecp2 Bird/+ mice, indicated a significant reduction of 63.3% (p = 0.009) and 66.1% (p= 
< 0.001) in the incidence of apnea on days 5 and 7 respectively, and a significant reduction of the irregularity 
score towards the WT level. The second study performed in Mecp2R168X/+ mice indicated a significant 
reduction of apnea of approximately 75% that was maintained between days 7-14 compared to the control 
(p = 0.008–0.022). Irregularity score was significantly improved as compared to that of animals receiving 
vehicle (on day 7: p = 0.006; on day 10: p = 0.049; on day 14: p = 0.05).  
7.1.2 
Toxicology  
Completed toxicology studies 
Sarizotan was initially developed for other indications (Parkinson’s disease and schizophrenia), and the 
preclinical safety program is considered to be almost complete and includes numerous studies, i.e. 
pharmacology studies including evaluating the effects of sarizotan in RTT mice, studies relevant to the 
earlier indications and a full safety pharmacology package. There is a comprehensive DMPK package with 
toxicokinetic studies. Toxicology studies consist of single and repeat dose oral toxicity studies, including 
chronic studies in rats and dogs; a battery of in vitro and in vivo mutagenicity tests, and carcinogenicity 
bioassays in rats and mice; a full range of reproductive toxicity studies in rats and rabbits; juvenile toxicity 
studies in rats; local tolerance (eye, skin) in rabbits, sensitization in guinea pigs, and an in vitro phototoxicity 
study; in vitro (adrenal steroid biosynthesis) and in vivo (monkey, dog) mechanistic studies; and 
combination repeated-dose studies with L-dopa/carbidopa in rats and dogs.  
During the course of the large preclinical safety program the key findings identified include:  
CNS signs (mainly reduced spontaneous activity & unsteady gait) were the predominant feature in 
pharmacology and toxicity studies. In the toxicity studies, rats showed prone position, salivation and 
burrowing in the litter, dogs showed reduced activity, unsteady gait and salivation and monkeys showed 
reduced activity, tremor, salivation and hunched position. In the proposed clinical trial, RTT patients will 
be monitored for clinical signs. 


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CV effects: Sarizotan and its active metabolites EMD 148 107 and EMD 329 989 inhibited in vitro hERG 
channel activity at low concentrations (IC50s of 1.95, 0.2 and 0.35 µM, respectively).  Sarizotan was not 
associated with any increase in cardiac action potential duration (APD) or prolongation of the QT interval 
in functional studies, but was associated with APD shortening at high concentrations in cardiac in vitro 
preparations (10µM in rabbit isolated Purkinje fibers, 30 µM in Guinea pig heart papillary muscles, and at 
6 µM in sheep isolated cardiac Purkinje fibers). No APD shortening is expected in humans at the free plasma 
concentration of 0.35 µM that would be reached at a 10 mg single sarizotan dose in a subject with a 25-kg 
body weight. The two active metabolites EMD 148 107 and EMD 329 989 increased the APD duration in 
isolated rabbit Purkinje fibers at concentrations of 1µM. However, no APD prolongation is expected in 
humans, as the plasma concentrations of these two metabolites are < 10% of those of the parent compound 
sarizotan. No relevant cardiovascular adverse effects were noted in telemetric studies in conscious 
normotensive rats (oral administration) and in anaesthetized open-chest dogs (intra-duodenal 
administration).  There were no adverse ECG findings on the repeated-dose dog studies (oral 4-, 26-, 52-
weeks duration, i.v. 2-weeks duration). In clinical trials, no meaningful increase in QTc was observed at 
doses of 20 - 40 mg bid. Based on these data, no relevant (> 10 msec) increase in QTc is expected in RTT 
patients weighing 25 kg or more, who will be receiving a maximum dose of 10 mg bid in the current study. 
Patients with a QTcF at baseline which exceeds 450 msec will be excluded from the study.  In addition, 
ECGs will be performed at regular intervals in all patients throughout the trial. 
Adrenal cortical changes consisting principally of hypertrophy/hyperplasia in the rat (≥ 125 mg/kg/day) 
and dog (≥ 25 mg/kg/day) and atrophy in the monkey (≥ 10 mg/kg/day) and mammary changes of  
hyperplasia and atrophy in rats at ≥5 mg/kg/day and hyperplasia/neoplasia in the mouse carcinogenicity 
study.  
The mammary hyperplasia/neoplasia in rodents, as well as the adrenal hypertrophy/hyperplasia/atrophy in 
various animal species, were a consequence of the pharmacological action of sarizotan i.e. 5-HT1A receptor 
activation which induces secretion of ACTH and PRL. In addition, in vitro data indicate that sarizotan can 
cause a relatively selective inhibition of the 11ß-hydroxylase isoenzyme in the biogenesis pathway of 
corticosterone/cortisol and aldosterone. This conclusion is supported by the results of a 4-week explanatory 
study in dogs. It is therefore possible that this mechanism contributed to the elevated ACTH concentrations 
via the adrenal-pituitary axis feedback system. The induction of PRL-related mammary proliferative lesions 
is rodent specific. PRL is luteotrophic in rodents, but not in humans; the synergistic effect of PRL, 
progesterone (from corpora lutea) and estrogen leads to mammary proliferation in rodents.  
Clinical data showed no clear dose- or time-dependent effect on ACTH concentrations in Phase I clinical 
studies. In Phase II studies, high sarizotan doses (≥40 mg/day) elicited abnormal responses in cortisol 
following an ACTH test. However, at lower doses (≤20 mg/day), no abnormal tests were observed. 
Sarizotan did not impair the cortisol response to ACTH stimulation as assessed in the Phase III Open-Label 
PADDY-O study. No dose-dependent effects on PRL secretion or the mammary gland were observed in 
Phase I and II clinical studies.  
Testicular atrophy was present in monkeys at ≥ 10 mg/kg/day. As the RTT syndrome almost exclusively 
affects females, testicular atrophy in monkeys is of low concern. Testicular effects were not recorded in 
clinical trials. 
An increased incidence of retinal atrophy was recorded in the albino rat carcinogenicity study at ≥25 
mg/kg/day. Retinal atrophy was seen in all groups including the controls. However, when compared with 
the controls, the incidence and severity of this change was higher in both sexes at ≥25 mg/kg/day. Retinal 
atrophy was not found in the mouse carcinogenicity (105/107-weeks), dog (52-weeks), monkey (4-weeks) 
or rat (26-weeks) studies. 


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The histopathological description of the atrophy is similar to light -induced atrophy in albino rats, i.e. 
bilaterally increased incidence of atrophy of the outer nuclear layer of the retina. As sarizotan reduced the 
spontaneous activity at ≥5 mg/kg and frequently prevented the rats from seeking the provided means to 
hide from light, it is possible that the atrophy is not a direct compound-related effect. This form of retinal 
atrophy is not unique to sarizotan. In a literature review of marketed compounds, retinal degeneration was 
found in toxicity studies primarily with CNS-active drugs and in rodents but not in non-rodent species 
(dogs, monkeys). The published data from these compounds show that the features of the atrophy are similar 
to that of sarizotan, particularly the rat specificity, dose and light dependency. The vast majority of these 
compounds have not been associated with retinal changes in humans, suggesting a general lack of 
predictability for this type of toxicological finding.  
In the clinic, sarizotan in the dose range of 1 to 200 mg/day was administered as single and/or repeated 
doses to more than 1500 subjects in Phase II-III studies. More than 1000 patients received treatment with 
sarizotan in Phase III trials, with over 300 patients completing 2 years of treatment without any evidence 
of an increase in the incidence of ocular adverse events compared with placebo. 
In the current RTT study, ophthalmological monitoring has been included at baseline and at Weeks 16, 24, 
48, 72, 96, 120, 144, 168 and 192, or at early discontinuation.  
Completed juvenile toxicology studies 
The preclinical data discussed in Section 7.1.1, and in the section above, together with adequate clinical 
data in the adult population without adverse events of concern, are considered sufficient for the conduct of 
the proposed 6-month initial trial that will include adolescent RTT patients (≥13 years of age). Juvenile 
toxicology studies in rats 7-21 days of ages are described in detail in Section 5.3.7 of the Sarizotan 
Investigator’s Brochure, v.3, 14 September 2018, and summarized below. The main juvenile toxicity study 
(YG47PW) commenced in 21-day old rat pups, which correspond to a 2-year old child (Buelke-Sam, 2003). 
The results of this study, therefore, support the treatment of RTT patients as young as 4 years of age and up 
to 13 years of age.   
Two sarizotan dose-range-finding studies conducted in juvenile rats, an initial study (ONP0106) in which 
treatment started in 21-day old pups (corresponding to a 2-year old child), and a 2nd study (ONP0113) in 
7-day old pups (corresponding to a newly born child), indicated the presence of effects on body weight, and 
relatively severe CNS signs in the 7-day old pups, thus limiting the main study (YG47PW) to be performed 
in 21-day old pups, at doses of 0, 12.5, 25 and 50 mg/kg/day. In this study, at the 50 mg/kg dose, a treatment-
related death was observed, as well as CNS signs (underactive behavior, flat posture, piloerection, and 
splayed limbs); similar signs, but of a lower severity, were encountered in all dose groups (including 12.5 
and 25 mg/kg), which resolved during the day. In addition, reduced ulnar growth (50 mg/kg), abnormalities 
in weight gain (50 mg/kg males, all groups females), oestrus irregularity (all groups), delay in reproductive 
maturity (50 mg/kg), abnormalities in motor activity (50 mg/kg) and during the functional operational 
battery (FOB) (all groups), and impairments in learning and memory (all groups) were noted. All of the 
above changes showed recovery, apart from the increase in motor activity.  Despite treatment-related 
histopathological changes (large corpora lutea, vaginal dioestrus, mammary gland hypertrophy/ 
hyperplasia, and adrenal gland zona glomerulosa hypertrophy) during treatment, there was no difference 
between sarizotan and placebo-treated animals during recovery.  There was no evidence of an effect of any 
of the doses on mating behavior, pregnancy, conception and fertility indices, or the number of live embryos 
or litter size.  


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The Functional Observational Battery (FOB) revealed an increase in vocalisation, particularly in females, 
in all treated groups during the in-hand observations, and an increase in the incidence of flattened posture, 
abnormal gait, tremors, urination and defecation, and a decrease in the levels of arousal and rearing during 
the 2-minute arena observation.  All arena counts, except high urination and fecal counts, showed full 
recovery.   
The Morris water maze assessment revealed a clear and generally dose-dependent effect on cognition 
(learning and memory) in all treated groups.  In Weeks 3-4 of the recovery period, there was clear evidence 
of long-term memory retention and no deterioration of long-term memory over time. The overall percentage 
improvement in mean trial times over the four days of testing during recovery was unaffected by previous 
treatment with sarizotan.  
The occurrence of the treatment-related death and the lack of recovery for motor activity at the 50 
mg/kg/day dose indicate that the next lower dose of 25 mg/kg/day should be considered as the No-
Observed-Adverse-Effect-Level (NOAEL).  Safety margins based on the NOAEL and compared to the 
predicted exposures in RTT patients are in the range of x1 to x5 (Section 5.3.8 of the Sarizotan Investigator’s 
Brochure, v.3, 14 September 2018). 
Many of the sarizotan-related changes in the juvenile toxicity study had been noted in earlier toxicity studies 
in rats, and were attributable to activation of 5-HT1A receptors, with subsequent perturbation of the 
pituitary-adrenal-gonadal hormone axis. Data from previous trials in human subjects did not detect any 
effects on growth, motor activity or memory.  There was no effect of sarizotan at doses of 20 mg or lower 
on prolactin, growth hormone, progesterone and testosterone concentrations, or on the cortisol response to 
ACTH.  In this study, RTT patients will undergo regular neurological and clinical examinations, as well as 
measurements of serum prolactin, and plasma ACTH and cortisol. 
Evidence of good tolerability, without any signal of safety risk, in over 1800 human subjects treated at doses 
of 0.2-200 mg/day, including >200 subjects treated for 2 years or longer, together with the safety precautions 
in the trial, including oversight by an Independent Safety Monitoring Board, support dosing with sarizotan 
in children from 4 years of age in the ongoing clinical trial.  
7.1.3 
Pharmacokinetics and Metabolism 
Twenty-three Phase I studies were performed to investigate the safety, tolerability, pharmacodynamic and 
pharmacokinetic effects of sarizotan after single and multiple administrations. A total of 549 subjects were 
treated with sarizotan in these studies.  
Single doses of 20 mg sarizotan hydrochloride and multiple doses up to 50 mg BID have been given in 
studies in healthy volunteers, including 12 elderly subjects; these doses were generally well tolerated. The 
most frequent adverse events following administration of sarizotan, affected the nervous system (central 
(CNS) or peripheral nervous system). The most frequent events within this class were dizziness, headache, 
and somnolence. Other adverse events were predominantly categorized as either general disorders (fatigue), 
or those affecting the gastro-intestinal tract.  
Pharmacokinetics (PK) of sarizotan are linear in the dose range investigated (0.5-25 mg). Cmax occurred 
within 1 hour after administration, indicating a rapid absorption. Absorption is almost complete, with an 
absolute bioavailability of ~90%. Sarizotan hydrochloride concentrations declined poly-exponentially with 
a terminal elimination half-life of 5-7 hours.  
Sarizotan is extensively metabolized, less than 5 % of unchanged drug was found in excreta (urine, feces). 
Major routes of metabolism are hydroxylation at various positions in the chromane ring system and N-
dealkylation. Plasma metabolite concentrations are considerably lower than those of the parent drug.  


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Age does not affect the pharmacokinetics of sarizotan in a clinically relevant manner. Sarizotan does not 
change the PK profile of L-dopa or digoxin. The plasma levels of sarizotan (Cmax) are decreased by 
approximately 40% when taken with food, compared to when taken fasted; however, the AUC is unaffected.  
Sarizotan had no impact on the PK profiles and the metabolic ratios of five probe drugs for the CYP P450 
enzymes 2D6, 1A2, 2C19, 2C9 and 3A4. Therefore, no clinically relevant drug-drug interactions between 
sarizotan and potential co-medications being cleared by these P450s are expected. Erythromycin, a 
CYP3A4 inhibitor, did not influence the PK properties of sarizotan to a clinically relevant extent. 
Fluvoxamine, a CYP1A2 inhibitor, had a moderate effect on the PK of sarizotan and its metabolites. The 
effect of St. John’s Wort, a CYP3A4 inducer, on the PK of sarizotan and its metabolites was moderate.  
Total exposure of sarizotan was reduced in subjects with severe renal impairment, as compared to normal 
subjects, in accordance with a shorter terminal half-life. In subjects with hepatic impairment, exposure to 
sarizotan was increased to 140% and 190% in moderately and severely impaired subjects, respectively, as 
compared to normal subjects.  
In summary, the PK profile of the drug indicates that dosing in clinical studies should be based on a twice 
-daily dosing regimen.  
All pre-clinical studies performed to date, including general and specific pharmacology studies on the 
mechanism of action, pharmacokinetics and toxicology, are described in the Investigator's Brochure 
[Sarizotan Investigator’s Brochure (IB), version 3 for Rett Syndrome, dated 14 September 2018]. 
7.1.4 
Clinical Studies 
Exposure 
The safety and tolerability of sarizotan in the dose range of 0.2 to 200 mg/day has been adequately 
established in other programs with over 1800 subjects having been exposed to at least a single dose of 
sarizotan, with over 1000 patients having received treatment for 6 months, and over 400 for 1 year, >200 
for 2 years, >150 for 3 years, and >50 for 4 years, during long-term, open-label treatment, without evidence 
of any significant treatment-related adverse outcomes.  
Sarizotan was administered to 433 subjects in the dose range of 0.2 to 200 mg/day in phase I studies. The 
Phase II and III Clinical program explored the safety and efficacy of sarizotan in patients with schizophrenia 
(N=112) at doses ranging from 40 to 180 mg/day (Study EMD 128130-008). Four other studies in 
Parkinson’s disease (PD) patients (three double-blind, placebo-controlled studies, and one open-label 
study) recruited 1447 patients, of which 862 received sarizotan (dose range 1 to 20 mg/day).  In addition, 
456 patients who received placebo in the randomized phase of the studies received sarizotan in the long-
term open label extension.  Over 300 patients were treated with doses of 1 to 5 mg BID, with approximately 
100 patients receiving doses of 10 mg/day for over 1 year.   
Therapeutic Studies 
The phase II and III Clinical program completed with sarizotan explored the safety and efficacy of sarizotan 
in two indications: schizophrenia (one study at doses ranging from 40 to 180 mg/day) and L-dopa induced 
dyskinesias at doses ranging from 1 to 20 mg/day in PD (4 double-blind, placebo-controlled studies and 3 
long-term open-label studies).  No clinical studies have been performed to date with sarizotan in patients 
with Rett syndrome, and no clinical studies are currently ongoing for any indication. Details of all clinical 
studies performed to date with sarizotan are described in the Investigator's Brochure [Sarizotan 
Investigator’s Brochure (IB), version 3 for Rett Syndrome, dated 14 September 2018]. 


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Studies in schizophrenia 
A 6-week, double-blind, Phase II study was performed in 231 patients with chronic or sub-chronic 
schizophrenia to test the antipsychotic efficacy of different dose ranges of sarizotan (i.e. 40-80 mg/day and 
100-180 mg/day, overall 112 patients) compared to haloperidol (4-16 mg/day, 57 patients) and placebo (62 
patients). Patient enrolment was terminated prematurely as approximately 70% of the 231 enrolled patients 
(83 out of 112 on sarizotan - 74.1%; 44 out of 62 on placebo -70.9%; 40 out of 57 on haloperidol - 70.2%) 
discontinued from the study prematurely.  
Abnormal (blunted) cortisol responses to ACTH challenge were observed in both sarizotan treatment 
groups (17.8% of patients in the sarizotan groups), compared with the placebo and haloperidol groups (1.6% 
in the placebo group and 5.3% in the haloperidol group). 
Studies in Parkinson’s disease (L-dopa induced dyskinesia) 
An open-label study in 64 PD patients with treatment-related dyskinesia (SPLENDID) with a dose range 
of sarizotan of 2 -10 mg bid indicated significant improvement of dyskinesia compared to baseline. 
Subsequently, three double-blind, placebo-controlled studies were performed in PD patients with L-dopa 
induced dyskinesia.  
Neither the two 12-week studies (SPIRID, 100 patients/group [4 treatment arms, sarizotan 1 mg bid, 2 mg 
bid, 5 mg bid, and placebo] and PADDY-1, 253 patients/group [2 treatment arms, sarizotan 1 mg bid and 
placebo]), nor the 24-week study (PADDY-2, 235 patients on sarizotan 1 mg bid and 246 patients on 
placebo) demonstrated any significant difference compared to placebo on the variables ‘ON time without 
dyskinesia’, OFF time, and the proportion of “Responders”, based on change from baseline to endpoint of 
at least 25% on the UPDRS Section IV, Items 32 + 33.  
Overview of Tolerability and Efficacy 
Sarizotan was well tolerated in the schizophrenia study in the dose range up to 180 mg/day; however, it was 
associated with a blunted cortisol response after ACTH stimulation in some patients, at doses of 80 mg/day 
and higher. No such effect was noted at doses of 2-20 mg/day that were evaluated in patients with PD.  In 
patients with PD, there was no difference in the incidence of these findings between sarizotan and placebo. 
No tolerability or safety findings were identified in these studies at doses up to and including 10 mg BID. 
Neither the two 12-week studies, nor the 24-week study, in PD patients demonstrated any significant 
difference compared to placebo for any efficacy variable related to PD or dyskinesia. 
No tolerability or safety findings were identified in any of these studies that would preclude further 
evaluation of sarizotan.   
 
7.2 
Chemistry and Pharmaceutical Properties of Sarizotan  
The nomenclature, structure and chemical properties of sarizotan and the composition of the available 
dosage forms (5.0 and 10.0 mg capsules) are provided below.   
International Nonproprietary Name (INN) 
Sarizotan hydrochloride 
United States Adopted Name (USAN) (RR-123) 
Sarizotan hydrochloride 
Chemical Name 
(-)-3-[[[(R)-2-Chromanylmethyl]amino]methyl]-5-(p-fluorophenyl)pyridine hydrochloride 


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(R)-2-[5-(4-Fluorophenyl)-3-pyridylmethylaminomethyl]-chroman hydrochloride, or 
3-[(2R)-3,4-Dihydro-2H-1-benzopyran-2- pyridylmethylamino-methyl]-5-(4-fluorophenyl)-
pyridine hydrochloride, or  
(R)-1-(chroman-2-yl)-N-((5-(4-fluorophenyl)pyridin-3-yl)methyl)methanamine hydrochloride 
Company Name or Laboratory Code 
EMD 128130 
Chemical Abstract Service (CAS) Registry Number (RN) 
195068-07-6 
Structure  
 
Molecular formula: 
C22H21FN2O.HCl 
Molecular weight: 
384.88 g/mol 
Description: 
Sarizotan hydrochloride is an off-white, fine crystalline powder with a melting point at 242 °C 
(combined with decomposition) 
Hygroscopicity 
The substance is not hygroscopic. 
General Description of Sarizotan Drug Product 
The dosage form used in this study is an orally administered immediate release capsule containing only 
drug substance; commonly referred to as Active-In-Capsule (AIC). Sarizotan AIC for the clinical study will 
be provided in dose strengths of 2 mg, 5 mg and 10 mg.  The capsule shells are made of animal gelatin, just 
under a standard size 4, opaque, Swedish Orange color and purchased from Capsugel ™. There are no other 
excipients in the capsule.  Placebo capsules, manufactured to contain a small amount of microcrystalline 
cellulose, match the sarizotan AIC investigational product. 
Route of Administration and Dosing Regimen 
Sarizotan is manufactured using an AIC formulation for oral administration. The maximum daily dose is 
20 mg (10 mg bid). The intended dosing regimen is twice daily.  
Sarizotan hydrochloride AIC may be administered as an oral solid dosage that can be swallowed or as a 
drinkable oral liquid dosage. The oral capsule is administered in the standard manner with sips of water or 
juice before and after swallowing to help the pill go down. The administration of sarizotan as an oral liquid, 
for patients unable to swallow a capsule, requires dissolving the sarizotan hydrochloride AIC in apple juice, 
cranberry juice, orange juice, tea (with or without milk) or water. Sarizotan may also be administered via 
an enteral feeding tube by dissolving the capsules in water.  The procedures for the preparation and 
administration of these solutions are described in Section 10.2 and Appendix 6.  


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7.3 
Study Rationale  
Rationale for use of Sarizotan in treating respiratory abnormalities in RTT patients 
Sarizotan is a full agonist at 5-HT1A receptors and an antagonist/partial agonist at the dopamine-D2 and 
related dopamine receptors. It is effective in animal models predictive of anti-dyskinetic activity. Sarizotan 
was initially evaluated for the treatment of schizophrenia and L-dopa induced dyskinesia in patients with 
Parkinson’s disease (PD); efficacy could not be demonstrated in either indication. Sarizotan at doses of 1 – 
20 mg was well tolerated, even when administered for extended periods of time.  
Serotonin is an important neuromodulator in the central control of the respiratory processes. Dysregulation 
of the serotonin pathways in the brainstem respiratory network has been described in RTT. There is 
currently no approved treatment for managing the breathing irregularities observed in RTT.  Therefore, 
effective treatment of respiratory abnormalities contributing to the RTT morbidity and mortality would 
address a significant unmet medical need. Mecp2-deficient mice (a preclinical model of RTT), show 
respiratory alterations that could benefit from increasing serotonergic activity at the nuclei involved in 
control of respiratory activity. It is postulated that sarizotan, a full 5-HT1A receptor agonist, would 
modulate respiratory neurons and provide beneficial effects in reducing breathing irregularities in RTT. 
Sarizotan is effective in reducing apnea incidence and to regularize the abnormal respiratory pattern in 
Mecp2-deficient mice of different strains. Benefits are observed after single and repeated dosing. These 
findings suggest that sarizotan could represent a new pharmacotherapeutic approach to treat respiratory 
dysregulation in RTT patients. 
Rationale for study design 
The primary objectives of the current study are to evaluate the safety and tolerability of sarizotan given as 
an oral dose (2 to 10 mg bid) in patients with Rett syndrome (RTT) with respiratory abnormalities and to 
evaluate the effect of sarizotan, compared to placebo, on reducing the number of apnea episodes in these 
patients.  
A randomized, double-blind study design will be used for the initial 24-week treatment period of this study 
to reduce potential bias in the assignment of patients to treatment and in the assessment of efficacy and 
safety parameters. A total of 129 patients will be included in this study, with approximately equal numbers 
of patients randomly assigned (1:1:1) to treatment with low dose sarizotan [2 mg bid (age 4 to <13 years; 
or age ≥13 years, weight <25 kg) or 5 mg bid (age ≥13 years, weight ≥25 kg)], high dose sarizotan [5 mg 
bid (age 4 to <13 years; or age ≥13 years, weight <25 kg), or 10 mg bid (age ≥13 years, weight ≥25 kg)], 
or placebo bid.  The approximately equal randomization to each group allows for a drug-placebo 
comparison for safety and efficacy for each dose. Samples sizes were computed based on percent reductions 
of 20% and 10% between the sarizotan high dose and placebo groups, assuming an attrition rate of 25%, 
and a SD of 20 or 12.5, respectively.  The sample sizes of 30 or 43 per group provides 90% power to detect 
a difference of -20% (-30% for sarizotan high dose vs. -10% for placebo) or -10% (-20% for sarizotan high 
dose vs. -10% for placebo) in the percent reduction in apnea episodes per hour (apnea index).  
There are currently no approved treatments for respiratory abnormalities in RTT patients; therefore, a 
placebo control, rather than an active control, will be used in this study. The use of a device to record 
respiration as well as the structured method of observation may lead to learning effects. The placebo control 
has been included so that a background rate of spontaneous occurrence of adverse events, as well as changes 
in other safety and efficacy parameters, can be established in placebo-treated patients, against which the 
active treatment will be compared, without introducing a bias from knowledge of the treatment by the 
caregivers or investigators.  


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The initial treatment period of the study will be 6 months, which is a standard period of observation for 
chronic neurological diseases.  All patients who have completed the final evaluations at Week 24 (Day 
168), have no safety or tolerability issues that would preclude continuing on the study medication, have 
been compliant with the trial requirements, and have not worsened to the extent that they are considered at 
an increased risk for morbidity or mortality, as judged by the Investigator, will be eligible for continuing 
open-label treatment with sarizotan for up to 24 weeks, to allow for collection of long-term safety and 
efficacy data.  
Each patient will return to the hospital on the day prior to the administration of the first dose to allow for 
performance of safety and efficacy evaluations, and will remain in the facility until 4 hours after the morning 
dose on Day 2 to facilitate safety monitoring and collection of samples for PK analysis, and to ensure 
standardized conditions for all patients. Subsequent dose increases will be performed during outpatient 
treatment, with monitoring of tolerability through scheduled telephone contacts.   
The study incorporates a dose titration design in which the target dose and dose titration will be dependent 
on the age and, in the case of patients ≥13 years of age, weight of the patient. All patients will start on the 
lowest dose (Dose Level 1: 2 or 5 mg sarizotan or placebo), and will have their doses increased to Dose 
Level 2 (2 mg sarizotan once daily, 2 mg sarizotan bid, 5 mg sarizotan bid, or placebo bid) on Day 2, then 
to Dose Level 3 (2 mg sarizotan bid, 5 mg AM + 2 mg PM sarizotan, 5 mg sarizotan bid, 10 mg sarizotan 
once daily, or placebo bid) on Day 8; and finally to Dose Level 4 (2 mg sarizotan bid, 5 mg sarizotan bid, 
10 mg sarizotan bid, or placebo bid) on Day 9, dependent on tolerability.  The dose may be maintained at 
the current level or reduced if needed if tolerability issues develop.  Patients will be titrated to their 
maximum tolerated dose (MTD) and would be expected to complete the study on this dose; however, dose 
reductions are permitted at any time if intolerance develops.   
Patients will return to the hospital for a visit on Day 14 to assess their tolerability of their current dose, and 
will be housed overnight with their parent/caregiver in a separate facility (hotel/hostel/etc.) and return to 
the hospital on the following morning, so that blood samples for PK analysis at the highest dose (Dose 
Level 4) can be collected prior to and 1 and 4 hours after the morning dose on Day 15. If the dose is well 
tolerated, the patient will be dispensed medication for the next 6-week period at the current dose level.  The 
data collected from the device (BioRadio™) for monitoring cardio-respiratory function at home will be 
reviewed on an ongoing basis throughout the study, and if this review of the cardiorespiratory data indicates 
a problem with the use of the device, additional training will be provided to the caregiver at the next visit. 
[See discussion below regarding rationale for selection of the primary efficacy variable and the procedure 
for its measurement].   
Subsequent visits will take place at Weeks 8 and 16, at which time safety and efficacy assessments will be 
performed and medication will be dispensed to the patient of the next dosing period.  Final evaluations will 
be performed at Week 24 (or at early discontinuation) and will be used for assessing the safety and efficacy 
of sarizotan, compared to placebo.  For patients who discontinue prematurely or complete 24 weeks of 
treatment, but do not continue in the open-label extension period, safety follow-up assessments (vital signs 
and adverse events) will be performed 14 days after the final dose of study medication.  
The 168-week extension treatment period of the study uses an open-label design, such that the Investigator, 
site staff, caregiver/patient and Sponsor will know what treatment the patient is receiving. To ease the 
burden on the patient/caregiver, the number of assessments has been reduced in this open-label extension 
period; in particular in-home cardio-respiratory monitoring using the BioRadio will not be performed.  All 
patients treated in the initial double-blind period, including those randomized to placebo, will have an 
opportunity to receive open-label treatment with sarizotan for up to 24 weeks in the initial open-label period. 
Only those patients who are judged by the Investigator to be benefitting from sarizotan treatment, and not 
experiencing significant adverse events, will be eligible to continue open-label treatment for an additional 
144 weeks. The open-label design allows simplification of the packaging, dispensing and dosing of the 


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study medication. All patients enrolled in the extension period, including those originally randomized to 
placebo, will receive treatment with sarizotan, and will start at a dose of 2 mg bid (patients 4 to <13 years 
of age and weighing 10 to <18 kg, and patients ≥13 years of age but weighing <25 kg) or 5 mg bid (patients 
≥13 years of age and weighing ≥25 kg). At Week 28, patients will return to the clinic for safety and efficacy 
assessments, and will have their dose maintained at 2 mg bid (patients 4 to <13 years of age and weighing 
10 to <18 kg), increased to 5 mg bid (patients 4 to <13 years of age and weighing ≥18 kg, and patients 
≥13 years of age and weighing <25 kg) or increased to 10 mg bid (patients ≥13 years of age and weighing 
≥25 kg), if the starting dose was well tolerated. Since patients may be receiving sarizotan for the first time 
or receiving a different dose than in the initial double-blind period, the Week 24 evaluations will be used 
as the baseline assessments for evaluating changes in the safety and efficacy parameters measured in the 
extension period.  
Sarizotan has not been administered previously to pediatric patients, or patients with RTT; therefore, safety 
data from all patients will be evaluated periodically by a Safety Monitoring Board (SMB) throughout the 
study.   
Rationale for pharmacokinetic sampling times 
No PK data has been collected previously for sarizotan in pediatric patients or patients with RTT; therefore, 
blood samples will be collected in this study for measurement of sarizotan. However, due to the small size 
and fragile nature of RTT patients, PK sampling in this study will be limited to samples taken pre-dose and 
1 and 4 hours post-dose for the initial dose (Dose Level 1) on Day 1, and the morning dose at Dose Level 
4 on Day 15.  In adults, sarizotan had a rapid Tmax of ~1 hr and a relatively short terminal elimination half-
life of 5-7 hr (see Section 7.1.3). Therefore, if metabolism in these RTT patients is similar to adults, these 
sampling times should capture the post-dose peak concentration and the initial tail of the curve.  
Rationale for choice of patient population  
To be eligible for the study patients must have a diagnosis of RTT based on consensus clinical criteria (Neul 
et al, 2010; Appendix 4); a test for MECP2 mutations (Xq28) will be performed, but is not required for the 
diagnosis. The selected population for this first study will include patients 4 years of age or older, and 
weighing at least 10 kg (Tarquinio et al, 2102). As shown in a recent study (Mackay et al, 2017), autonomic 
breathing abnormalities, including breath-holding and hyperventilation, have been observed in a substantial 
proportion of RTT patients below the age of 6 years. Dosing of patients as young as 4 years of age is 
supported by the results of a recently completed juvenile toxicity study performed in 21-day old rats (see 
Section 7.1.2). 
Both male and female patients will be eligible; however, male patients rarely survive past 2 years of age, 
and most male patients with loss of functional mutations in MECP2 do not meet clinical criteria for RTT. 
Since sarizotan is being developed for the treatment of respiratory abnormalities, patients must have a 
significant level of breathing dysfunctions, e.g. periodic apnea during wakefulness, and must meet the 
following criteria: at least 10 episodes of breathing abnormality per hour, time spent in normal breathing is 
<90% of total time per hour of wakefulness, and at least 10 episodes of breath holding (apnea) ≥10 seconds 
in duration per hour during home cardiorespiratory monitoring.  Ensuring that the patients have a substantial 
level of respiratory symptoms, in particular apnea, at baseline will facilitate measurement of a potential 
treatment effect for the primary efficacy endpoint, i.e. percent reduction in number of apnea episodes per 
hour, during awake time.   
Excluding patients with significant or severe concomitant medical illnesses and ensuring that patients are 
on stable doses of any concomitant medication prior to baseline will prevent bias in determining the 
tolerability and safety of sarizotan.  Since adverse ocular effects of sarizotan have been observed in studies 
in albino rats, patients will be excluded if they have an ophthalmologic history including any of the 


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following conditions: albino patients, family history of hereditary retinal disease, retinitis pigmentosa, any 
active retinopathy or severe diabetic retinopathy, will be excluded.  
Rationale for dose selection 
Currently, there are no PK or efficacy data in RTT patients.  Sarizotan has been studied in 23 Phase 1 study 
in healthy adult volunteers that evaluated PK and safety of sarizotan in a wide range of deses from 0.5.  A 
population PK analysis was performed on PK data collected from 230 healthy adult volunteers (with 5528 
PK samples) who received doses of sarizotan ranging between 0.5-100 mg bid. The final population PK 
model was validated and shown to adequately represent the PK of sarizotan (Appendix 3 of the Sarizotan 
Investigator’s Brochure, v.3, 14 September 2018).  The final population model was used to allometrically 
(based on weight) extrapolate the adult healthy volunteer PK data to RTT patients who are known to be 
mostly below the age of 18 and have lower weight for a given age compared to healthy subjects. The 
predictions from the final population PK model shows:  
• 
pediatric and adolescent RTT patients following, 10 mg bid of sarizotan are expected to have a 
median AUCss ranging between 6352 and 9907 ng*hr/mL and a median Cmax,SS ranging between 
516 and 817 ng/mL for body weights in the ranges 45-55 kg and 15-20 kg, respectively. 
• 
pediatric and adolescent RTT patients following 5 mg bid of sarizotan are expected to have a 
median AUCSS ranging between 3176 and 4953 ng*hr/mL, and a median Cmax,SS ranging between 
258 and 409 ng/mL for body weights in the ranges 45-55 kg and 15-20 kg, respectively. 
• 
pediatric and adolescent RTT patients following 2 mg bid of sarizotan are expected to have a 
median AUCSS ranging between 1270 and 1981 ng*hr/mL, and a median Cmax,SS ranging between 
103 and 164 ng/mL for body weights in the ranges 45-55 kg and 15-20 kg, respectively. 
Selection of the doses for the current study was based on targeting the predicted AUC for RTT patients 
(presented above) being above the efficacious AUC values associated with efficacy in improving 
respiratory abnormalities observed in a mice RTT model (i.e., an AUC of 2033 ng.h/ml), while staying 
below the AUC values associated with NOAEL in rats (i.e., 10020 ng.h/ml). These target exposures are 
approximately met at doses between 2-10 mg bid dose in RTT patients, with patients with a body weight 
of 10 kg or higher.  The exposure in patients weighing 10 to <18 kg who are randomized to a dose of 5 mg 
bid would be expected to be lower than the NOAEL in rats. 
Rationale for efficacy measures and method of measurement for respiratory parameters 
Primary efficacy outcome 
The primary efficacy endpoint in this study is the percent reduction in the number of apnea episodes (≥ 10 
seconds in duration) observed per hour, during awake time. Apnea episodes of at least 10 seconds in 
duration are considered clinically meaningful (Khwaja et al, 2014).  The selection of apnea as a primary 
endpoint was based on its prevalence at all stages of RTT, its impact on the patient and caregiver, its 
contribution to long-term adverse outcomes, the ability to measure it objectively over a long period of time 
under conditions that are not stressful for the patient, and the benefit that may accrue from its attenuation.  
The apnea endpoint is considered clinically relevant and can be measured objectively over a longer 
continuous period of time than a point estimate.  The use of an automated home monitoring device 
(BioRadio™) to measure cardiorespiratory parameters (episodes of apnea, hyperventilation, disordered 
breathing, respiratory volumes, oxygen saturation) provides the additional advantage of lack of 
measurement bias, higher sensitivity, lower variability, and more robust data. The BioRadio will be used 
only in the initial 24-week double-blind period of the study.   
For the primary efficacy outcome, apnea episodes will be defined as those with duration considered to be 
of clinical significance (i.e., ≥ 10 seconds).  The Sponsor will also determine the effect on apnea episodes 


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that are associated with a biological change that would make it clinically meaningful, e.g. oxygen saturation 
lower than 90%.  
Secondary efficacy outcomes 
Key secondary efficacy outcome.  The Sponsor, based on a request from regulatory authorities to include a 
measure that assesses the clinical meaningfulness of any drug effect, proposed that a caregiver-rated global 
assessment of change in the patient’s condition should be used as a key secondary measure. This caregiver-
rated measure will take into account activities, behavior, mood and functioning.  Therefore, the Caregiver-
rated Impression of Change (CIC), a 7-point Likert-type scale requiring the caregiver to rate how much the 
patient’s illness has improved or worsened relative to the baseline state, has been included as the key 
secondary efficacy outcome. This rating will be performed in consultation with the study Investigator, but 
should be based largely on the caregiver’s evaluation of the patient during the reporting period.  
Other standard measurements of respiratory function, evaluated during awake time, will also be assessed 
as secondary efficacy outcomes: percent time spent with breathing dysrhythmia (% time apnea + % time 
hyperventilation) per hour; number of hyperventilation episodes (≥10 seconds each) per hour; oxygen 
saturation (# of episodes of oxygen desaturation below 90% per hour); Respiratory Distress Index [sum of 
the number of breath-holding episodes (>10 sec), number of episodes of hyperventilation (>10 sec), and 
number of drops in oxygen values to < 90%]; and incidence of breathing dysrhythmia episodes, including 
apneustic breathing style and forceful breathing style.  
In addition, several scales, specifically assessing the symptoms of Rett syndrome have been included as 
secondary efficacy measures.  These include the Rett syndrome Clinical Severity Scale (RCSS), which 
assesses multiples symptoms of the disease, a global assessment performed by the Investigator (CGI-C), an 
assessment of motor and behavioral symptoms (Motor-Behavioral Assessment Scale), and the Caregiver 
Top 3 Concerns, a visual analogue scale evaluating change in the symptoms the caregiver finds most 
troubling.  
Rationale for safety measures 
Adverse events (AEs) will be assessed throughout the study, and other standard safety assessments will be 
performed in the hospital following the first 3 doses, and at all scheduled visit, including vital signs, 
laboratory tests (hematology, biochemistry, urinalysis), ECGs (12-lead standard), and physical and 
neurological examinations. In addition, the cardiorespiratory function will be assessed during the screening 
period, at baseline and at Weeks 8, 16 and 24 in the initial double-blind treatment period, and at Weeks 28, 
32, 40, 48, 60, 72, 84, 96, 108, 120, 132, 144, 156, 168, 180 and 192 (or at early discontinuation) in the 
open-label extension treatment period. As requested by the FDA, an assessment of treatment-emergent 
suicidal ideation and behavior will be performed at baseline and periodically throughout the study (Weeks 
8, 24, 48, 72, 96, 120, 144, 168 and 192) using a structured suicidality assessment query.  This simple 
questionnaire was compiled by the Sponsor, based on other instruments commonly used to assess 
suicidality, to help the caregiver answer questions on potential symptoms of suicidality in the patient.  A 
follow-up safety assessment (vital signs and AEs) will be performed 14 days after the last dose of study 
medication for all patients to evaluate any adverse events emerging after withdrawal of the study drug. 
Testing for hepatitis B and C and HIV will be performed at Screening, and any patients testing positive will 
be excluded from the trial. 
In a prior study evaluating two dose ranges of sarizotan (40-80 mg/day and 100-180 mg/day) in patients 
with schizophrenia, abnormal (blunted) cortisol responses to ACTH challenge were observed in both 
sarizotan treatment groups (17.8% of patients), compared with the placebo and haloperidol groups (1.6% 
and 5.3%, respectively).  These effects are not anticipated at the lower doses (2, 5 and 10 mg, bid) to be 
administered in the current study; however, plasma ACTH and cortisol levels will be measured at Baseline 
and at Day 2 and Weeks 16, 24, 48, 72, 96, 120, 144, 168 and 192 during the treatment period of the trial.  


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In addition, serum prolactin will be measured at Baseline and at Weeks 16, 24, 48, 72, 96, 120, 144, 168 
and 192 to monitor the effect of sarizotan on this hormone.   
Adverse ocular effects (e.g. retinal atrophy) have been observed with sarizotan in carcinogenicity studies 
in albino rats at doses of ≥25 mg/kg/day. However, retinal atrophy was not found in mouse carcinogenicity 
(105/107-weeks), dog (52-weeks), monkey (4-weeks) or rat (26-weeks) studies. No adverse ocular effects 
have been observed or reported in any of the clinical studies performed with sarizotan to date at doses up 
to 180 mg/day.  However, as a precaution, routine ophthalmological examinations (including OCT, if 
feasible for the patient) will be performed by an ophthalmologist at Baseline and at Weeks 16 and 24 in the 
initial treatment period and at Weeks 48, 72, 96, 120, 144, 168 and 192 (or at early discontinuation) in the 
extension treatment period.   
Finally, since pediatric patients will be enrolled in this study, the potential effects of sarizotan on their 
sexual maturity will be evaluated at Baseline and at Weeks 24, 48, 72, 96, 120, 144, 168 and 192 using the 
Tanner scale (Marshall and Tanner, 1969; Marshall and Tanner, 1970; see Appendix 7).  


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8 
STUDY OBJECTIVES 
 
The objectives of the study are as follows: 
Primary Efficacy Objective:  
• 
To evaluate the effect of sarizotan (high dose), compared to placebo, on reducing the number of 
apnea episodes, during awake time, in patients with RTT with respiratory abnormalities.  
Key Secondary Efficacy Objective:  
• 
To evaluate the effect of sarizotan (high dose), compared to placebo, on the Caregiver-rated 
Impression of Change (CIC) from baseline;  
Secondary Objectives: 
• 
Safety: To evaluate the safety and tolerability of sarizotan in patients with Rett syndrome (RTT) with 
respiratory abnormalities. 
• 
Efficacy: To evaluate the efficacy of the dose range of sarizotan, compared to placebo, on the 
following: 
o Severity of patient symptoms, based on evaluation of Caregiver Top 3 Concerns (Visual 
Analogue Scale [VAS]);  
o Global change from baseline, assessed by the Clinical Global Impression of Change (CGI-C);  
o Motor behavior, assessed by the Motor-Behavioral Assessment Scale;  
o Other respiratory symptoms of Rett syndrome, assessed during awake time, including:  
▪ 
Percent time spent with breathing dysrhythmia (% time apnea + % time 
hyperventilation) per hour; 
▪ 
Number of hyperventilation episodes (≥10 seconds each) per hour;  
▪ 
Oxygen saturation (number of episodes of oxygen desaturation below 90% per hour).  
▪ 
Respiratory Distress Index - The sum of the following parameters calculated per hour 
of wakefulness: 1) number of breath-holding episodes, 2) number of episodes of 
hyperventilation [1 and 2 are as defined in inclusion criteria; each would have to be 
≥10 seconds in duration], and 3) number of drops in oxygen values to < 90%. 
o Overall assessment of symptoms of RTT using the Rett syndrome Clinical Severity Scale 
(RCSS). 
o To determine the efficacy of sarizotan in patients who attain a minimum plasma exposure of 
400 ng/ml on Day 15 (expected efficacious concentration based on the knockout mouse 
model);  
• 
To determine the pharmacokinetic profile of sarizotan at the doses tested and compare with the 
pharmacokinetic profile in adults.  


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9 
INVESTIGATIONAL PLAN 
9.1 
Study Design 
This is a prospective, 24-week, randomized, double-blind, placebo-controlled study designed to evaluate 
the safety, tolerability, and efficacy of multiple oral doses of sarizotan in patients with RTT with respiratory 
abnormalities.  At least 129 patients will be randomized (approximately 43/group) to receive either low 
dose sarizotan (2 mg bid or 5 mg bid), high dose sarizotan (5 mg bid or 10 mg bid) or placebo bid. Patients 
4 to <13 years of age will be randomized equally (1:1:1) to sarizotan 2 mg bid (low dose group), sarizotan 
5 mg bid (high dose group), or placebo. Patients ≥13 years of age and weighing ≥25 kg will be randomized 
equally (1:1:1) to sarizotan 5 mg bid (low dose group), sarizotan 10 mg bid (high dose group), or placebo 
[Note: patients ≥13 years of age and weighing <25 kg will be eligible for the study, but will be included 
with the younger patients and randomized equally (1:1:1) to sarizotan 2 mg bid (low dose), sarizotan 5 mg 
bid (high dose) or placebo]. The paradigm for randomizing patients based on age and weight criteria is 
summarized schematically in Figure 4.   
Figure 4. Randomization of patients to treatment according to age and body weight criteria 
 
 
All patients 4 to <13 years of age, as well as those ≥13 years of age and weighing <25 kg, randomized to 
sarizotan 2 or 5 mg bid will start at a single dose of 2 mg on the morning of Day 1. Patients assigned to the 
2 mg bid dose will remain on 2 mg once daily on Days 2-7, and will have their dose increased to 2 mg bid 
on Days 8-14.  Patients assigned to the 5 mg bid dose will have their daily dose of sarizotan increased to 
4 mg (2 mg bid) on Days 2-7, 7 mg (5 mg AM, 2 mg PM) on Day 8, and 10 mg (5 mg bid) on Days 9-14.  
Patients ≥13 years of age and weighing ≥25 kg randomized to sarizotan 5 or 10 mg bid will start at a single 
dose of 5 mg on the morning of Day 1, with an increase to 5 mg bid on Day 2.  Patients randomized to 5 
mg bid will continue on this dose for the rest of the study, while patients randomized to 10 mg bid will 
receive a single dose of 10 mg on Day 8 and have their dose increased to 10 mg bid on Day 9, and continue 


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on this dose.  If patients do not tolerate the proposed titration and target dose, the investigator will provide 
only one of the two daily doses (e.g. 5 mg/day) for a few days prior to reinitiating the intended bid dose 
(e.g. 5 mg bid).  If the dose is still not tolerated, a reduction to a lower rescue dose will be permitted.  Dose 
titration should be completed by Day 14, after which patients will continue on their maximum tolerated 
dose (MTD) through the final dose, unless intolerance develops, and a dose reduction is warranted. Patients 
will return for scheduled visits at Weeks 8, 16 and 24, at which time efficacy and safety assessments will 
be performed. 
All patients, including those randomized to placebo, who have completed the final evaluations at Week 24 
(Day 168), have no safety or tolerability issues that would preclude continuing on the study medication, 
have been compliant with the trial requirements, and have not worsened to the extent that they are 
considered at an increased risk for morbidity or mortality, as judged by the Investigator, will have the option 
of continuing open-label treatment with sarizotan for an additional 24 weeks.  Patients who are judged to 
be benefitting from treatment with sarizotan, and are not experiencing significant adverse events, will be 
eligible for an additional 144 weeks of open-label treatment.  
The final safety and efficacy evaluations performed at Week 24 will serve as the baseline assessments for 
this open-label extension period.  All patients meeting the inclusion/exclusion criteria, including those 
previously randomized to placebo, will receive treatment with sarizotan, and will start at a dose of 2 mg bid 
(patients <13 year of age and patients ≥13 years of age weighing <25 kg) or 5 mg bid (patients ≥13 years 
of age weighing ≥25 kg). Patients will have their dose maintained at 2 mg bid (patients <13 year of age 
weighing 10 to <18 kg), increased to 5 mg bid (patients <13 year of age weighing ≥18 kg and patients ≥13 
years of age weighing <25 kg), or increased to 10 mg bid (patients ≥13 years of age weighing ≥25 kg) at 
Week 28, if there are no tolerability issues, and will continue on this dose.  Patients will return for scheduled 
visits at Weeks 32, 40 and 48, in the initial open-label period, and Weeks 60, 72, 84, 96, 108, 120, 132, 
144, 156, 168, 180 and 192, if they continue open-label treatment, at which time efficacy and safety 
assessments will be performed.  A Safety Follow-up visit will be performed two weeks after the last dose 
of study medication.  
An overview of the study design for the initial 24-week double-blind treatment period, the initial 24-week 
open-label extension treatment period, and Parts 1, 2 and 3 of the additional 144-week extension treatment 
period is provided in Table 1, and Tables 2A, 2B, 2C, and 2D, respectively.  


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Table 1.  Summary of Study Design: Initial 24-Week, Double-blind, Treatment Period 
Period 
Screening 
Baseline 
Randomized Treatment Period 
Final 
Evaluation 
Safety 
follow-up 
Study 
Day(s)/ 
Week 
-28 to -1 
Days 0 and  
1 (pre-dose) 
Days 1  
and 2 
Days 14  
and 15 
Week 8 
Week 16 
Week 24  
(or early d/c) 
2 weeks 
after last 
dose 
Duration 
28 days 
1 day 
2 days 
2 days 
1 day 
1 day 
1 day 
1 day 
Treatment/ 
Procedures 
Informed 
consent; 
Screening 
evaluations; 
home 
respiratory 
monitoring 
(on 3 days in 
each of the 
first 3 weeks); 
I/E criteria 
assessed 
Hospital visit; 
Baseline safety 
and efficacy 
assessments; 
confirm patient 
still meets I/E 
criteria; 
randomization 
First 3 doses 
in hospital 
setting; dose 
titration, PK 
sampling and 
safety 
assessments; 
return home 
on Day 2 
Hospital visit; 
dose titration 
complete 
(telephone 
contact on  
Day 7); home 
respiratory 
monitoring on  
3 days in the 
week prior to 
visit; PK 
sampling, and 
safety and 
efficacy 
assessments  
Home 
respiratory 
monitoring on 
3 days in the 
week prior to 
visit; all safety 
and efficacy 
assessments 
Home 
respiratory 
monitoring on 
3 days in the 
week prior to 
visit; all safety 
and efficacy 
assessments 
Home 
respiratory 
monitoring on  
3 days in the 
week prior to 
visit; all safety 
and efficacy 
assessments 
Vital signs and 
adverse events 
for patients not 
continuing 
treatment in the 
open-label 
extension 
period 
 
Table 2A.  Summary of Study Design: Open-Label Extension Treatment Period (Weeks 24 – 48) 
Period 
Baseline 
(extension) 
Initial Open-Label Treatment Period 
Safety  
follow-up 
Study  
Week 
Week 24 
Week 25 Week 28 Week 29 Week 32 
Week 40 
Week 48  
(or early d/c) 
2 weeks 
after last 
dose* 
Duration 
1 day 
1 day 
1 day 
1 day 
1 day 
1 day 
1 day 
1 day 
Treatment/Pr
ocedures 
Informed consent; 
Week 24 safety  
and efficacy 
assessments from 
initial period will 
serve as baseline for 
extension; confirm 
patient is eligible to 
continue treatment; 
all patients start  
re-titration with 
sarizotan 5 mg bid  
on same day # 
Telephone 
contact on 
Day 175 to 
confirm 
tolerability 
of dose; 
assess AEs 
and conc. 
medication  
Selected 
safety and 
efficacy 
assessments; 
dose increase 
to 10 mg bid, 
if no 
tolerability 
issues 
Telephone 
contact on 
Day 203 to 
confirm 
tolerability 
of dose; 
assess AEs 
and conc. 
medication  
Selected 
safety and 
efficacy 
assessments  
Selected 
safety and 
efficacy 
assessments 
All safety and 
efficacy 
assessments; 
this will be the 
final evaluation 
for patients not 
continuing 
open-label 
treatment 
Vital signs and 
adverse events 
for all patients 
# Additional procedures and administration of the first dose of study medication in the open-label extension period 
should be performed on the same day as the Week 24 final assessments from the double-blind period, if possible. 
*To be performed for patients who discontinue prematurely and those not continuing open-label treatment.  
 


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Table 2B.  Summary of Study Design: Open-Label Extension Treatment Period (Weeks 49 - 96) 
Period 
Additional Open-Label Treatment Period (Part 1)* 
Final (#) 
Evaluation 
Safety  
follow-up 
Study  
Week 
Week 54 Week 60 Week 66 Week 72 Week 78 Week 84 Week 90 
Week 96  
(or early d/c) 
2 weeks after 
last dose 
Duration 
1 day 
1 day 
1 day 
1 day 
1 day 
1 day 
1 day 
1 day 
1 day 
Treatment/ 
Procedures 
Telephone 
contact to 
assess AEs, 
conc. 
medication 
and 
compliance 
with study 
medication 
Selected 
safety and 
efficacy 
assessments 
Telephone 
contact to 
assess AEs, 
conc. 
medication 
and 
compliance 
with study 
medication 
All safety 
and efficacy 
assessments  
Telephone 
contact to 
assess AEs, 
conc. 
medication 
and 
compliance 
with study 
medication 
Selected 
safety and 
efficacy 
assessments 
Telephone 
contact to 
assess AEs, 
conc. 
medication 
and 
compliance 
with study 
medication 
All safety and 
efficacy 
assessments 
Vital signs and 
adverse events 
for all patients 
*Only those patients who have completed 24 weeks of open-label treatment, and at the Week 48 visit are judged by 
the Investigator to be benefitting from treatment, are not experiencing significant adverse events, and for whom 
informed consent has been provided, will be eligible to continue open-label treatment in this period of the study.  
# The Week 96 evaluation will be the final assessment for patients in Part 1 who are not continuing in Part 2 of the 
additional open-label extension treatment period (Weeks 97-144).  
 
Table 2C.  Summary of Study Design: Open-Label Extension Treatment Period (Weeks 97 - 144)  
Period 
Additional Open-Label Treatment Period (Part 2)* 
Final (#) 
Evaluation 
Safety  
follow-up 
Study  
Week 
Week 102 Week 108 Week 114 Week 120 Week 126 Week 132 Week 138 Week 144  
(or early d/c) 
2 weeks after 
last dose 
Duration 
1 day 
1 day 
1 day 
1 day 
1 day 
1 day 
1 day 
1 day 
1 day 
Treatment/ 
Procedures 
Telephone 
contact to 
assess AEs, 
conc. 
medication 
and 
compliance 
with study 
medication 
Selected 
safety and 
efficacy 
assessments 
Telephone 
contact to 
assess AEs, 
conc. 
medication 
and 
compliance 
with study 
medication 
All safety 
and efficacy 
assessments  
Telephone 
contact to 
assess AEs, 
conc. 
medication 
and 
compliance 
with study 
medication 
Selected 
safety and 
efficacy 
assessments 
Telephone 
contact to 
assess AEs, 
conc. 
medication 
and 
compliance 
with study 
medication 
All safety and 
efficacy 
assessments 
Vital signs and 
adverse events 
for all patients 
*Only those patients who have completed 72 weeks of open-label treatment, and at the Week 96 visit are judged by 
the Investigator to be benefitting from treatment, are not experiencing significant adverse events, and for whom 
informed consent has been provided, will be eligible to continue open-label treatment in this period of the study.  
# The Week 144 evaluation will be the final assessment for patients in Part 2 who are not continuing in Part 3 of the 
additional open-label extension treatment period (Weeks 145-192). 
 
 


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Amend. 6, 13Apr2017; Amend. 7, 02Oct2017; Amend. 8, 02Nov2017; Amend. 9, 11Feb2018; Amend. 10, 29Nov2018; 
Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
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Table 2D.  Summary of Study Design: Open-Label Extension Treatment Period (Weeks 145 - 192) 
Period 
Additional Open-Label Treatment Period (Part 3)* 
Final 
Evaluation 
Safety  
follow-up 
Study  
Week 
Week 150 Week 156 Week 162 Week 168 Week 174 Week 180 Week 186 Week 192  
(or early d/c) 
2 weeks after 
last dose 
Duration 
1 day 
1 day 
1 day 
1 day 
1 day 
1 day 
1 day 
1 day 
1 day 
Treatment/ 
Procedures 
Telephone 
contact to 
assess AEs, 
conc. 
medication 
and 
compliance 
with study 
medication 
Selected 
safety and 
efficacy 
assessments 
Telephone 
contact to 
assess AEs, 
conc. 
medication 
and 
compliance 
with study 
medication 
All safety 
and efficacy 
assessments  
Telephone 
contact to 
assess AEs, 
conc. 
medication 
and 
compliance 
with study 
medication 
Selected 
safety and 
efficacy 
assessments 
Telephone 
contact to 
assess AEs, 
conc. 
medication 
and 
compliance 
with study 
medication 
All safety and 
efficacy 
assessments 
Vital signs and 
adverse events 
for all patients 
*Only those patients who have completed 120 weeks of open-label treatment, and at the Week 144 visit are judged by 
the Investigator to be benefitting from treatment, are not experiencing significant adverse events, and for whom 
informed consent has been provided, will be eligible to continue open-label treatment in this period of the study.  
 
 
9.2 
Study Population  
9.2.1 
Inclusion Criteria 
The patient must meet all of the following inclusion criteria to be eligible for enrolment into the study: 
Demographics 
 
1. Female or male ≥ 4 years of age.  
2. Body weight ≥ 10 kg, and within the expected range for an RTT patient, based on age and height. 
Diagnostic 
3. Diagnosis of Rett syndrome based on consensus clinical criteria (Neul et al, 2010; Appendix 4).  A 
test for MECP2 mutations (Xq28) will be performed if results from an accredited laboratory are 
not available; selection for the trial is not contingent on the results of the MECP2 test. Patients 
with known MECP2 duplications will not be eligible.  
4. One or more of the following breathing dysfunctions: periodic apnea during wakefulness; 
intermittent hyperventilation; breath holding spells; air swallowing; forced expulsion of air or 
saliva. 
5. Patient meets all of the following criteria related to breathing abnormalities: 
a. Parent report of 10 episodes or more of breathing abnormality per day during wakefulness 
in the week prior to the screening visit; 
b. Time per hour spent on normal breathing is less than 90% of the total time per hour of 
wakefulness (i.e., ≥10% of the time should be abnormal breathing);  


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c. Has at least 10 episodes of breathing dysrhythmia, defined by episodes ≥10 seconds of 
breath holding (apnea), per hour, during cardiorespiratory monitoring (performed with 
home/ambulatory monitoring system during screening period).  
6. Stable medication regimen for 4 weeks prior to beginning the study (if receiving services - physical, 
occupational, or speech therapy - subjects must be on a stable regimen of these services for 3 
months prior to beginning the study). Female patients of childbearing potential are to use adequate 
contraception as recommended by their Health Care Provider (see Section 13.1.8). 
Procedural 
7. Parent/legal guardian/representative has provided written consent prior to the patient participating 
in the study. Where feasible, consent or assent for patients less than 18 years of age, has also been 
provided by the patient. 
8. Ability to take study medication provided either as capsules or combined with food/drink. 
9. Patient is cooperative, willing to complete all aspects of the study, and capable of doing so with 
assistance of a caregiver.  
10. Caregiver is able to understand the instructions and fully participate.  
9.2.2 
Exclusion Criteria  
The presence of any of the following will exclude a patient from study enrollment: 
1. Meets any of the diagnostic exclusion criteria for Rett syndrome, Typical (Neul et al, 2010); 
2. Patient is participating in a clinical trial with another investigational drug or has taken an 
investigational drug within one month or 5 half-lives (whichever is longer) prior to screening; 
3. Hypersensitivity to sarizotan or other 5-HT1a agonists, [UK only: or to the capsule material gelatin 
or microcrystalline cellulose used in the placebo capsules]; 
4. Current clinically significant (as determined by Investigator)  
a. cardiovascular, respiratory (e.g. severe asthma), gastrointestinal, renal, hepatic, hematologic 
or other medical disorders, in addition to those directly related to the patient’s Rett syndrome 
[for US, Italy, India and Australia];  
b. cardiovascular, respiratory (e.g. severe asthma), or gastrointestinal disease, renal 
impairment (as indicated by creatinine >2X ULN), hepatic impairment (as indicated by total 
bilirubin >2X ULN), history of moderate or severe hepatic insufficiency or moderate or 
severe liver cirrhosis, or hematologic or other medical disorders, in addition to those directly 
related to the patient’s Rett syndrome [for UK only]; 
5. QTcF interval on the ECG is greater than 450 msec. 
6. Surgery planned during the study (except for insertion of gastrostomy tube); 
7. Severe diabetes mellitus or fatty acid oxidation disorder.  
8. Ophthalmologic history including any of the following conditions: albino patients, family history 
of hereditary retinal disease, retinitis pigmentosa, any active retinopathy or severe diabetic 
retinopathy.  
9. Females who are pregnant, breastfeeding, or of childbearing potential and not using adequate 
contraception (see Section 13.1.8), as recommended by their Health Care Provider.  
10. [UK only: Subjects who have an inborn error of metabolism.]  


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11. Evidence of clinically significant malnutrition. 
9.2.3 
Documentation of Randomization 
Only subjects who meet all of the inclusion criteria and none of the exclusion criteria for randomization are 
eligible for randomization into the treatment phase. In addition to violations of inclusion and exclusion 
criteria, reasons for randomization failure include a major protocol deviation, lost to follow-up, voluntary 
withdrawal, and study termination; the primary reason must be noted on the applicable CRF. Randomization 
will be on Day 1 at the start of dosing. 
9.2.4 
Premature Discontinuation 
Subjects who discontinue from the study prematurely must have their reason for discontinuation entered in 
the CRF.  Subjects who discontinue from the study after having received at least one dose of study 
medication will not be replaced.  All subjects who discontinue prematurely from the initial 24-week double-
blind treatment period will be asked to return for a final assessment at which time all Week 24 assessments 
are to be performed.  Similarly, all subjects who discontinue prematurely from the open-label extension 
treatment period will be asked to return for a final assessment at which time all Week 48 (initial 24-week 
open-label period), Week 96 (Part 1 of the additional open-label period), Week 144 (Part 2 of the additional 
open-label period), or Week 192 (Part 3 of the additional open-label period) assessments are to be 
performed.   
9.2.5 
Record of Screening Failures 
Investigators must account for all subjects who failed screening and have signed informed consent forms.  
The primary reason for screen failure will be recorded on the screen failure CRF using the following 
categories: 
• 
Did not meet entry criteria 
• 
Major protocol deviation 
• 
Pretreatment Event/Adverse Event 
• 
Lost to follow-up 
• 
Voluntary withdrawal (specify reason) 
• 
Study termination 
• 
Other (specify reason) 
Subject numbers assigned to subjects who fail screening will not be reused.  
9.2.6 
Record of Study Participants 
The investigator will be required to maintain a confidential record of all study participants, including all 
subjects who were screened for the study, but were not actually randomized to treatment. The confidential 
record must include sufficient information so that it would be possible to contact the study subject.  
9.2.7 
Enrolment in Extension Treatment Period 
All patients who have completed the final evaluations at Week 24 (Day 168) will be eligible for continuing 
open-label treatment with sarizotan in the initial 24-week open-label extension treatment period, if they 
meet the following criteria: 
• have no safety or tolerability issues that would preclude continuing on the study medication, 
• have been compliant with the trial requirements, and 


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Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
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• have not worsened to the extent that they are considered at an increased risk for morbidity or 
mortality, as judged by the Investigator.  
At the end of the initial 24 weeks of open-label treatment, the Investigator will make a global assessment 
of the patient.  If in the Investigator’s opinion, the patient is benefitting from treatment with sarizotan and 
is not experiencing any significant adverse events, they will be eligible to continue open-label treatment.  
Informed consent must be obtained at Week 48, for the patient to continue open-label treatment for an 
additional 48 weeks in Part 1 of the additional open-label treatment period (through Week 96).  A similar 
assessment of the patient will be performed at Week 96 for patients being considered for continuing 
treatment in Part 2 of the additional open-label treatment period. Informed consent must be obtained for the 
patient to continue open-label treatment for another 48 weeks (through Week 144).  For patients completing 
Part 2, a similar assessment of the patient will be performed at Week 144 for patients being considered for 
continuing treatment in Part 3 of the additional open-label treatment period. Informed consent must be 
obtained for the patient to continue open-label treatment for another 48 weeks (through Week192).  
 


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Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
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10 STUDY MEDICATION 
10.1 Description, Labeling and Packaging  
10.1.1 
Description of the Supplies  
The supplies for the study will consist of sarizotan capsules (2-mg, 5-mg and 10-mg dosage strengths) 
provided to each site in separate bottles with a child-proof screw cap.  Bottles with matching placebo will 
also be provided for the initial double-blind treatment period.  Bottles will be packaged as separate 2-bottle 
kits that will be blinded for use during the double-blind dosing period, and will have the dose of sarizotan 
indicated on the labels of the box and bottles for the open-label dosing period. Medication kits will be 
packaged for 1-day, 6-day and 2-week periods. Four kits will be provided for the initial 2-week double-
blind titration period: Dose Level 1 (1-day kit); Dose Level 2 (6-day kit), Dose Level 3 (1-day kit) and Dose 
Level 4 (6-day kit). Multiple 2-week kits will be provided to cover the 4-week (2 kits), 6-week (3 kits) and 
8-week (4 kits) intervals between scheduled clinic visits.   
10.1.2 
Labelling 
The following information will appear on the study medication bottles: 
• 
Protocol No. Sarizotan-001-II-2015 
• 
Space for entering the Subject No.  
• 
Bottle A (for morning dose) or Bottle B (for evening dose) 
• 
Unique medication kit number 
• 
Dose strength (5 mg or 10 mg sarizotan) – open-label period only  
• 
Project Code and Batch Number 
• 
Quantity of capsules 
• 
Date of manufacture  
• 
Stored at 15 - 25°C 
• 
Caution: New Drug – Limited by Federal (United States) Law to Investigational Use Only 
• 
Newron Pharmaceuticals  
• 
Space for entering name of Investigator 
• 
Any other country-specific requirements. 
In addition, labels for designating the Study Days for which a kit is to be used will be provided to the site 
pharmacist for attaching to the kits designated for the initial titration period. For the initial dose titration 
period these labels would be as follows: Day 1, Days 2-7, Day 8, and Days 9-14.   
10.1.3 
Packaging  
The Investigational Medicinal Product (IMP) will be packaged and labeled in accordance with all applicable 
regulatory requirements and GMP Guidelines.  Combinations of capsules containing the active drug (2 mg, 
5 mg or 10 mg sarizotan) or matching placebo capsules will be used for the initial double-blind period to 
achieve the planned target doses of 2, 5 or 10 mg, or placebo, which will be given twice daily. The 
packaging of the medication for each treatment group by study day and dose level is presented in Table 3 
for the initial treatment period.  Extra capsules will be provided in each bottle for each period of dosing in 
case of lost or damaged medication, or a delay in the patient returning for a scheduled visit. The medication 
for each dosing interval (1-day, 6-day or 2-week) will be packaged as 2-bottle kits, with expiry date on the 
carton label. Separate bottles will be provided for morning (AM) and evening (PM) dosing. Two-bottle kits 


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Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
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for dosing after the titration period will contain enough medication for 2 weeks of dosing plus 2 extra 
capsules (16 capsules total).  Multiple kits will be supplied to cover the period of dosing prior to the next 
scheduled visit.  
Table 3. Drug Packaging According to the Planned Dose Titration – Initial Double-Blind 
Treatment Period  
Group 
Target 
Dose 
Suggested 
Dosing 
Time 
Study Days 
1 # 
2-7 # 
8 # 
9-14 # 
15-168* 
Dose Level 1 
Dose Level 2 
Dose Level 3 
Dose Level 4 
Dose Level 4 
or MTD 
1  
[Low 
Dose] 
 
2 mg bid 
Sarizotan 
8:00 AM 
1 x 2 mg Sar 
6 x 2 mg Sar 
1 x 2 mg Sar 
6 x 2 mg Sar 
7 x 2 mg Sar 
8:00 PM 
1 x Pbo 
6 x Pbo 
1 x 2 mg Sar 
6 x 2 mg Sar 
7 x 2 mg Sar 
5 mg bid 
Sarizotan 
8:00 AM 
1 x 5 mg Sar 
6 x 5 mg Sar 
1 x 5 mg Sar 
6 x 5 mg Sar 
7 x 5 mg Sar 
8:00 PM 
1 x Pbo 
6 x 5 mg Sar 
1 x 5 mg Sar 
6 x 5 mg Sar 
7 x 5 mg Sar 
2 
[High 
Dose] 
 
5 mg bid 
Sarizotan 
8:00 AM 
1 x 2 mg Sar 
6 x 2 mg Sar 
1 x 5 mg Sar 
6 x 5 mg Sar 
7 x 5 mg Sar 
8:00 PM 
1 x Pbo 
6 x 2 mg Sar 
1 x 2 mg Sar 
6 x 5 mg Sar 
7 x 5 mg Sar 
10 mg bid 
Sarizotan 
8:00 AM 
1 x 5 mg Sar 
6 x 5 mg Sar 
1 x 10 mg Sar 
6 x 10 mg Sar 
7 x 10 mg Sar 
8:00 PM 
1 x Pbo 
6 x 5 mg Sar 
1 x Pbo 
6 x 10 mg Sar 
7 x 10 mg Sar 
3 
 
Placebo 
8:00 AM 
1 x Pbo 
6 x Pbo 
1 x Pbo 
6 x Pbo 
7 x Pbo 
8:00 PM 
1 x Pbo 
6 x Pbo 
1 x Pbo 
6 x Pbo 
7 x Pbo 
# Each bottle for the 14-day titration period will contain one extra capsule in case of loss or damage. 
*Number of capsules supplied for each week of dosing; patient will continue at maximum tolerated dose (MTD). 
Each of the 2-week kits dispensed during this maintenance period will have 2 extra capsules in each bottle in case 
of loss or damage.   
Abbreviations: Pbo = Placebo; Sar = Sarizotan 
 
Packaging for the 168-week open-label extension treatment period will consist of 2-bottle kits containing 
enough medication (2-mg, 5-mg or 10-mg sarizotan capsules) for 2 weeks of dosing plus 2 extra capsules 
(16 capsules total). The dose strength will be pre-printed on the labels on the boxes for the 2-bottle kits, as 
well as on the individual bottles. Multiple kits will be supplied to cover the period of dosing prior to the 
next scheduled visit. Study medication dispensing for the open-label period by visit is presented in 
Tables 4A and 4B.   
 
 


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Table 4A. Study Medication Dispensing by Visit and Age/Body Weight Category: Initial Open-Label Extension Period (Weeks 24 - 40) 
Study Week (Day) 
Age / Body Wt. 
Category 
Dose Type 
Sarizotan  
Daily Dose 
Dosing 
Period  
No. of Two-Bottle Kits 
(Bottles) Dispensed $ 
Total No. of 
Capsules Dispensed 
Week 24  
(Day 168) 
<13 yr / ≥10 kg, or  
≥13 yr / <25 kg 
Starting  
2 mg bid 
4 weeks 
2 (4) 
64 
≥13 yr / ≥25 kg 
Starting  
5 mg bid 
4 weeks 
2 (4) 
64 
Week 28 
(Day 196) 
<13 yr / ≥10 to <18 kg 
Target  
2 mg bid 
4 weeks 
2 (4) 
64 
Drop-back (od dosing) # 
2 mg od 
4 weeks 
1 (2) 
32 
<13 yr / ≥18 kg, or  
≥13 yr / <25 kg 
Target  
5 mg bid 
4 weeks 
2 (4) 
64 
Drop-back * 
2 mg bid 
4 weeks 
2 (4) 
64 
Drop-back (od dosing) # 
2 mg od 
4 weeks 
1 (2) 
32 
≥13 yr / ≥25 kg 
Target  
10 mg bid 
4 weeks 
2 (4) 
64 
Drop-back * 
5 mg bid 
4 weeks 
2 (4) 
64 
Drop-back (od dosing) # 
5 mg od 
4 weeks 
1 (2) 
32 
Weeks 32 & 40 
(Days 224 & 280) 
<13 yr / ≥10 to <18 kg 
Target  
2 mg bid 
8 weeks 
4 (8) 
128 
Drop-back (od dosing) # 
2 mg od 
8 weeks 
2 (4) 
64 
<13 yr / ≥18 kg, or  
≥13 yr / <25 kg 
Target  
5 mg bid 
8 weeks 
4 (8) 
128 
Drop-back * 
2 mg bid 
8 weeks 
4 (8) 
128 
Drop-back (od dosing) # 
2 mg od 
8 weeks 
2 (4) 
64 
≥13 yr / ≥25 kg 
Target  
10 mg bid 
8 weeks 
4 (8) 
128 
Drop-back * 
5 mg bid 
8 weeks 
4 (8) 
128 
Drop-back (od dosing) # 
5 mg od 
8 weeks 
2 (4) 
64 
# Patients unable to tolerate the starting dose (2 or 5 mg bid), may drop back to a once daily dose (2 or 5 mg od), and later reattempt the starting dose; or they may 
continue on this lower dose throughout the study.  
* Patients having minor tolerability issues at the starting dose (2 or 5 mg bid), as well as patients who are unable to tolerate the target dose (5 or 10 mg bid), may 
remain on, or drop back to, the starting dose of 2 or 5 mg bid, respectively, and continue on this dose throughout the study.  
$ Each bottle will contain 16 capsules, enough for 2 capsules/day for 7 days + 2 extra capsules in case of loss or damage, or a delay in returning for a scheduled 
visit.  
 
 


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Table 4B. Study Medication Dispensing by Visit and Age/Body Weight Category: Additional Open-Label Extension Period (Weeks 48 – 
180) 
Study Week (Day) 
Age / Body Wt. 
Category 
Dose Type 
Sarizotan  
Daily Dose 
Dosing 
Period  
No. of Two-Bottle Kits 
(Bottles) Dispensed $ 
Total No. of 
Capsules Dispensed 
Weeks 48, 60, 72, 
84, 96, 108, 120, 
132, 144, 156, 168, 
and 180 
(Days 336, 420, 
504, 588, 672, 756, 
840, 924, 1008, 
1092, 1176 and 
1260) 
<13 yr / ≥10 to <18 kg 
Target  
2 mg bid 
12 weeks 
6 (12) 
192 
Drop-back (od dosing) # 
2 mg od 
12 weeks 
3 (6) 
96 
<13 yr / ≥18 kg, or  
≥13 yr / <25 kg 
Target  
5 mg bid 
12 weeks 
6 (12) 
192 
Drop-back * 
2 mg bid 
12 weeks 
6 (12) 
192 
Drop-back (od dosing) # 
2 mg od 
12 weeks 
3 (6) 
96 
≥13 yr / ≥25 kg 
Target  
10 mg bid 
12 weeks 
6 (12) 
192 
Drop-back * 
5 mg bid 
12 weeks 
6 (12) 
192 
Drop-back (od dosing) # 
5 mg od 
12 weeks 
3 (6) 
96 
# Patients unable to tolerate the starting dose (2 or 5 mg bid), may drop back to a once daily dose (2 or 5 mg od), and later reattempt the starting dose; or they may 
continue on this lower dose throughout the study.  
* Patients having minor tolerability issues at the starting dose (2 or 5 mg bid), as well as patients who are unable to tolerate the target dose (5 or 10 mg bid), may 
remain on, or drop back to, the starting dose of 2 or 5 mg bid, respectively, and continue on this dose throughout the study.  
$ Each bottle will contain 16 capsules, enough for 2 capsules/day for 7 days + 2 extra capsules in case of loss or damage, or a delay in returning for a scheduled 
visit.  
 
 


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Drug supplies and randomization of patients to treatment will be managed by an Interactive Voice or Web 
Response System (IWRS).  At the start of each dosing interval, the Investigator will enter the patient number 
in the IWRS and indicate whether it is the first dose, or if the patient’s dose will be increased, decreased or 
maintained at the current level.  The IWRS will provide the Investigator with the appropriate unique 
number(s) corresponding to the blinded/unblinded medication kit(s) that is (are) to be dispensed to the 
patient for that dosing period.   
10.2 Administration 
The test drug (sarizotan) will be provided by the Sponsor in the form of capsules at dosage strengths of 2, 
5 and 10 mg. The placebo for use in the double-blind period will be provided in matching capsules.  All 
study drugs, together with relevant documentation, will be supplied to the investigational site.   
The first 2 doses of study medication (Dose Level 1) will be administered to the patient in the clinic on Day 
1 in the presence of a licensed physician. On Day 2, if there are no tolerability issues, the patient will receive 
Dose Level 2 in the clinic and will be observed for at least 4 hours post-dose. If there are no tolerability 
issues, the patient will then receive a supply of study medication for the next 12 days and return home. 
Dose increases to Dose Levels 3 and 4 will be performed on Days 8 and 9 when the patient is residing at 
home.  The patient/caregiver will be contacted by telephone on Day 7 to assess the tolerability of the current 
dose before the dose titration is continued.  The date, time, and number of capsules administered in the 
hospital setting will be recorded on the CRFs.  The doses of sarizotan or matching placebo to be 
administered to the patient for each dose level are summarized by treatment group in Table 5.  
 
Table 5. Dose Titration by Treatment Group in Initial Double-Blind Treatment Period 
 
 
Sarizotan Doses 
Matching  
Placebo  
 
 
Low Dose 
High Dose 
Dose 
Level 
Study 
Day(s) 
2 mg bid a,c 
5 mg bid b 
5 mg bid a,c 
10 mg bid b 
AM 
Dose 
PM 
Dose 
AM 
Dose 
PM 
Dose 
AM 
Dose 
PM 
Dose 
AM 
Dose 
PM 
Dose 
 
1 
1 
2 mg 
Placebo 
5 mg 
Placebo 
2 mg 
Placebo 
5 mg 
Placebo 
1 capsule bid 
2 
2-7 
2 mg 
Placebo 
5 mg 
5 mg 
2 mg 
2 mg 
5 mg 
5 mg 
1 capsule bid 
3 
8 
2 mg 
2 mg 
5 mg 
5 mg 
5 mg 
2 mg 
10 mg 
Placebo 
1 capsule bid 
4 
9-14 
2 mg 
2 mg 
5 mg 
5 mg 
5 mg 
5 mg 
10 mg 
10 mg 
1 capsule bid 
4 
15-168 
2 mg 
2 mg 
5 mg 
5 mg 
5 mg 
5 mg 
10 mg 
10 mg 
1 capsule bid 
a Patients 4 to <13 years of age, (randomized 1:1:1 to sarizotan 2 mg bid, sarizotan 5 mg bid or placebo bid) 
b Patients ≥13 years of age, weighing ≥25 kg (randomized 1:1:1 to sarizotan 5 mg bid, sarizotan 10 mg bid, or 
placebo bid) 
c Patients ≥13 years of age, weighing <25 kg (randomized 1:1:1 to sarizotan 2 mg bid, sarizotan 5 mg bid or 
placebo bid) 
 


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In the initial double-blind period, the study medication will be administered as capsules of 2, 5 and 10 mg 
dosage strengths of sarizotan, or an equal number of matching placebo capsules. Doses will be 
administered as 1 capsule bid given at approximately 8:00 AM and 8:00 PM, with an interval of 
approximately 12 hours (minimally 6 hours) between doses.   
If intolerance develops, the Investigator may reduce a patient’s dose to the next lower level at any time. If 
patients do not tolerate the proposed titration and target dose, the investigator will instruct the caregiver to 
administer only one of the two daily doses (e.g. 2 or 5 mg once daily) for a few days prior to reinitiating 
the intended bid dose (e.g. 2 or 5 mg bid).  If the dose is still not tolerated, a reduction to a lower rescue 
dose will be permitted. Patients unable to tolerate Dose Level 1, even after a dose interruption, should be 
discontinued from the study.  Dose titration should be completed by Day 14, after which patients will 
continue on their maximum tolerated dose (MTD) through the final dose in the double-blind period, unless 
intolerance develops and a dose reduction is warranted.  
In the open-label extension treatment period, all patients, including those originally randomized to placebo, 
will receive treatment with sarizotan, and will start at a dose of 2 mg bid (patients 4 to <13 years of age and 
weighing 10 to <18 kg, and patients ≥13 years of age but weighing <25 kg) or 5 mg bid (patients ≥13 years 
of age and weighing ≥25 kg).  The first dose (2 or 5 mg) will be administered in the clinic (if the morning 
dose was given, wait at least 6 hours after the prior dose before administration), in the presence of a licensed 
physician, on the same day as the Week 24 evaluations from the initial period, if possible.  The date, time, 
and number of capsules administered in the hospital setting on the first day of open-label dosing will be 
recorded on the CRF.  If no tolerability issues are noted in the 4-hr post-dose follow-up period, the patient 
will then receive a supply of study medication (sarizotan 2-mg or 5-mg capsules) for the 4-week period 
until the next scheduled visit and return home.   
The caregiver will be contacted by telephone by the Investigator/site staff on Day 175 (Week 25) to inquire 
about the tolerability of the study medication and any adverse events the patient might have experienced. 
If patients do not tolerate this starting dose, the Investigator will instruct the caregiver to administer only 
the morning dose (i.e. 2 or 5 mg/day) for a few days prior to reinitiating the intended bid dose (i.e. 2 or 5 
mg bid).  If the 2 or 5 mg bid dose is still not tolerated, a reduction to 2 or 5 mg once daily will be permitted. 
At Week 28, patients will return to the clinic for safety and efficacy assessments, and will have their dose 
maintained at 2 mg bid (patients 4 to <13 years of age and weighing 10 to <18 kg), increased to 5 mg bid 
(patients 4 to <13 years of age and weighing ≥18 kg, and patients ≥13 years of age and weighing <25 kg) 
or increased to 10 mg bid (patients ≥13 years of age and weighing ≥25 kg), if the starting dose was well 
tolerated. The first 2-mg, 5-mg or 10-mg dose will be administered in the clinic (if the morning dose was 
given, wait at least 6 hours after the prior dose before administration). The date, time, and number of 
capsules administered in the hospital setting will be recorded on the CRF. If no tolerability issues are noted 
in the 4-hr post-dose follow-up period, the patient will then receive a supply of study medication (sarizotan 
2-mg, 5-mg or 10-mg capsules) for the 4-week period until the next scheduled visit and return home.  
The caregiver will be contacted by telephone by the Investigator/site staff on Day 203 (Week 29) to inquire 
about the tolerability of the study medication. If the patient does not tolerate this dose, the Investigator will 
instruct the caregiver to administer only the morning dose (i.e. 2, 5 or 10 mg/day) for a few days prior to 
reinitiating the intended bid dose (i.e. 2, 5 or 10 mg bid).  If the target dose of 2, 5 or 10 mg bid is still not 
tolerated, a reduction to 2 mg once daily, 2 mg bid, or 5 mg bid, respectively, will be permitted.  Patients 
will continue on their maximum tolerated dose (MTD) through the final dose, unless intolerance develops 
and a dose reduction is warranted.  Patients completing the initial 24 weeks of open-label treatment and 
entering the additional open-label treatment period will continue on the same dose of sarizotan.  
If intolerance develops at any time during the extension treatment period, the Investigator may reduce a 
patient’s dose to the next lower level. Alternatively, the Investigator may instruct the caregiver to administer 


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only one of the two daily doses (e.g. 2 mg, 5 mg or 10 mg, once daily) for a few days prior to reinitiating 
the intended bid dose (e.g. 2 mg bid, 5 mg bid or 10 mg bid).  If the dose is still not tolerated, a reduction 
to a lower dose will be permitted.  Patients unable to tolerate a dose of 2 mg or 5 mg once daily (dependent 
on age and weight) must be discontinued from the study.  
Flexibility will be allowed in dosing during the open-label extension period to accommodate the needs of 
individual patients. Investigators will use medical judgement to improve tolerability by adjusting dosing in 
cases of intolerance. If deemed necessary by the Investigator for minimizing intolerance and maintaining 
efficacy, different doses may be administered in the morning and evening, e.g., 10 mg in the morning and 
5 mg in the evening for a patient not tolerating the assigned 10 mg bid dose. In all of these cases, the 
Investigator must contact the Medical Monitor to discuss the planned dosing. Appropriate medication kits 
will be dispensed and instructions provided to the caregiver by the Investigator to implement the revised 
dosing paradigm.  
For patients unable to swallow a capsule, sarizotan may be administered as a drinkable solution.  This 
requires dissolving the sarizotan hydrochloride AIC in apple juice, cranberry juice, orange juice, tea (with 
or without milk), or water.  The details of these procedures are provided in Appendix 6.  In the case of 
patients who have severe difficulty with swallowing and are currently receiving alimentation through a 
gastrostomy tube (G-tube), sarizotan- may be administered through the G-tube as capsules dissolved in 
water (see Appendix 6 for details).   
10.3 Storage 
In the clinic, supplies of the study medication must be stored at 15 - 25°C, in a secure locked area.  During 
out-patient treatment, patients will be requested to store the medication at room (ambient) temperature.  All 
unused study medication and medication bottles must be returned to Newron or its designee at the end of 
the trial or destroyed by the study site per their local SOP following completion of accountability by the 
CRO’s monitor and authorization from Newron. The destruction of unused medication will be documented 
in accordance with ICH GCP.  
10.4 Blinding and Randomization  
Subject identifier 
Each screened subject will receive a five-digit subject number, with the first two digits specifying the center 
number and the last 3 digits the subject at the center. The “ID” field will appear in the header at the top-
center of each CRF page, with a space for entering the “Subject No.”  
The Investigator will assign the five-digit subject number to each patient at screening. The subject number 
should be assigned sequentially, beginning with ##-001, in the order of the patients (or their parent/legal 
guardian/representative) signing the informed consent. This five-digit number should be entered in the 
“Subject No.” space on every CRF for a given patient.  
Should a patient discontinue from the study for any reason after having been assigned a subject number, 
the number will not be reassigned to another patient. Information regarding the demographics of the patient 
and reason for discontinuation will be recorded in an End of Screening Log.  
In cases where the Investigator is uncertain of a patient’s eligibility for the study (e.g., selection criteria, 
coexistent medical conditions or concomitant therapy) the Medical Monitor should be contacted to confirm 
the appropriateness of the inclusion of the patient.  
Patient Randomization 
A minimum of 129 patients will be randomized approximately equally to treatment with low dose or high 
dose sarizotan or placebo bid as follows:  


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• 
Age 4 to <13 years randomized 1:1:1 to sarizotan 2 mg bid [low dose sarizotan group], sarizotan 5 
mg bid [high dose sarizotan group] or placebo bid; 
• 
Age ≥13 years and weight <25 kg - randomized 1:1:1 to sarizotan 2 mg bid [low dose sarizotan 
group], sarizotan 5 mg bid [high dose sarizotan group] or placebo bid; 
• 
Age ≥13 years, weight ≥25 kg – randomized 1:1:1 to sarizotan 5 mg bid [low dose sarizotan group], 
sarizotan 10 mg bid [high dose sarizotan group] or placebo bid.  
A randomization number corresponding to the treatment assignment will be assigned to each randomized 
subject using the IVRS/IWRS, and must be registered in the subject’s files for identification.  Each patient 
randomized at the site should receive the next sequential randomization and treatment assignment.  
Breaking the Blind 
Should it be necessary to break the blind during the double-blind period for reasons of safety, the 
Investigator will be able to break the blind using the IWRS. The Investigator will be asked to inform the 
Sponsor and their representative of this as soon as possible and to provide a reason for the unblinding.  
10.5 Accountability 
In accordance with ICH and FDA requirements, the Investigator or Drug Dispensing Person (e.g., 
pharmacist) must at all times be able to account for all study drugs furnished to the institution.  The 
pharmacist or the Investigator must sign the Drug Receipt Form, confirming that he/she has received the 
clinical supplies for the study and provide assurance that the investigational products will be handled and 
stored properly. 
The investigational treatments must only be dispensed to subjects in accordance with the protocol. At the 
end of the study, it must be possible to reconcile delivery records with those of usage and returned stocks. 
Account must be given of any discrepancy.  Any unused products must be returned to the Drug Broker. 
Certificates of returns must be signed with assurance from the pharmacist/investigator that all unused 
investigational drugs and all medication containers provided for the stated study have been returned. 
Under no circumstances is the Investigator allowed to use the study medications other than as directed by 
the protocol.  
10.6 Overdosage 
To date more than 1800 subjects have been exposed to at least one dose of sarizotan in clinical studies in 
healthy volunteers and patients with schizophrenia or Parkinson’s disease. The maximum single dose 
given in these studies was 200 mg.  This dose, which is 20 times higher than the maximum individual 
dose to be administered in the current trial, was not associated with any significant adverse effects.  
Therefore, in case of an accidental overdosage, conservative management of symptoms and signs is 
advised.  The procedure for reporting a symptomatic overdose is described in Section 13.1.6.  
10.7 Occupational safety 
Sarizotan is not expected to pose any significant occupational safety risks to investigational staff under 
normal conditions of use and administration. Caregivers and site staff should take appropriate precautions 
when heating juice or other liquids to 80°C for dissolving capsules for administration to patients who are 
unable to swallow the medication in a capsule form.  
 


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11 EVALUATIONS AND PROCEDURES 
11.1 Written Informed Consent 
Written informed consent must be obtained from the patient or his/her parent (if the patient is below the 
age of consent or unable to consent), or legal guardian/representative (if necessary), at screening prior to 
initiating any study procedures required by the protocol, according to the procedure described in Section 
16.1. The patient, if able, may provide assent.  The details of the study should be discussed with the patient 
and parent/caregiver or legal representative (if necessary) prior to obtaining informed consent, and the 
Informed Consent Form (ICF) must be signed and dated by the patient, parent/caregiver, or legal 
representative (if necessary), and by the Investigator or his/her designee. A copy of the signed ICF will be 
provided to the patient/ parent/ legal guardian/representative, and the original will be retained with the 
source documents. The initial consent will cover one year (48 weeks) of treatment; however, the patient/ 
parent/ legal guardian/representative will be asked to provide an additional consent/assent after completing 
the 6-month initial treatment period, before continuing in the initial 24-week, open-label extension 
treatment period.  At the end of the initial 24 weeks of open-label treatment, the Investigator will make a 
global assessment of the patient.  If in the Investigator’s opinion, the patient is benefitting from treatment 
with sarizotan and is not experiencing any significant adverse events, they will be eligible to continue open-
label treatment.  The patient/ parent/ legal guardian/representative must provide informed consent/assent at 
Week 48 for the patient to continue open-label treatment for an additional 48 weeks in Part 1 of the 
additional open-label extension period (through Week 96), again at Week 96 for the patient to continue 
open-label treatment for another 48 weeks in Part 2 of the additional open-label extension period (through 
Week 144), and again at Week 144 for the patient to continue open-label treatment for another 48 weeks in 
Part 3 of the additional open-label extension period (through Week 192).   
 
11.2 Study Conduct 
Initial 24-Week Double-blind Treatment Period 
Each patient’s parent, legal guardian, or representative, must provide written informed consent prior to the 
patient’s participation in the trial. The patient should provide assent, if capable of doing so. Each patient 
will enter a 4-week period during which the screening evaluations will be performed. Patients who meet 
the respiratory criteria for enrolment in the study in one of the first 3 weeks may have their screening period 
shortened. The screening assessments, which must be completed and results available prior to baseline, will 
consist of the following: a confirmation of the diagnosis of Rett syndrome, based on clinical criteria (a 
proven mutation of the methyl CpG-binding protein 2 (MECP2) gene is not required), a review of the 
patient’s medical history and current use of medications, vital signs, 12-lead electrocardiogram (ECG), 
laboratory tests (hematology, blood chemistry, urinalysis, virology, serum pregnancy test for post-pubertal 
females, and thyroid function tests), and physical and neurological examinations.  The patient’s respiratory 
abnormalities will be, documented, based on parental feedback for the presence of one of the following: 
periodic apnea during wakefulness; intermittent hyperventilation; breath holding spells; air swallowing; 
forced expulsion of air or saliva.  
Cardio-respiratory monitoring using a specialized ambulatory data acquisition system, the BioRadio™ 
system, will be performed at home during the first week of the screening period to ensure proficiency of 
the caregiver/patient in using the system, and to evaluate the quality of the data and resolve any problems 
(this will be determined by the remote data monitoring service provider, Vivonoetics). Data from the 
BioRadio system will be used to confirm that the patient has at least 10 episodes of breathing dysrhythmia 
per hour over a 24-hour period. Home monitoring should be attempted for 6 hours each day, during the 
time the patient is awake, on at least 3 days during the first, second and third week of screening.  The patient 


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must meet all criteria related to breathing abnormalities in at least one of the three screening period 
assessments, as specified in the Inclusion Criteria, to be eligible for enrollment. If the patient meets the 
criteria, as determined by Vivonoetics, in any week of the Screening period, home monitoring in the 
subsequent week(s) of Screening would not be required.  Adverse events and use of concomitant medication 
will be recorded from the time of signing of the consent form.   
At the Baseline visit (Day 0), the inclusion/exclusion criteria, (respiratory inclusion criteria will be assessed 
based on home respiratory monitoring performed during screening) will be reviewed to ensure that the 
patient is suitable for enrolment. Patients meeting all entry criteria at baseline will undergo a series of 
evaluations on the day prior to dosing (Day 0).  Baseline assessments of respiratory function will be 
performed in the clinic using a stretch-sensitive resistance plethysmograph (SOMNOtouch™ device), 
Tanner Staging will be performed, and a blood sample will be taken for measurement of serum prolactin, 
and plasma ACTH and cortisol. The routine laboratory tests and physical and neurological examinations 
do not need to be repeated if performed less than 28 days before baseline, unless abnormalities are noted 
that require follow-up.  A routine ophthalmological examination (including visual acuity, lens, intraocular 
pressure and dilated examination of the fundus, and OCT, if feasible for the patient) will be performed. A 
serum pregnancy test must be performed for post-pubertal females.  In addition, baseline assessments for 
all of the efficacy variables [respiratory measures, heart rate, Motor-Behavioral Assessment Scale, 
Caregiver Top 3 Concerns, and RCSS], as well as the suicidality assessment, will be performed on Day 0. 
Baseline vital signs and ECG evaluations will be performed in triplicate (10 min apart) on Day 0 or at least 
one hour prior to dosing on Day 1.  
On Day 1 the patient will be randomized to treatment, with the dose assigned based on age and body weight 
categories, as described in Section 10.4, and will receive the initial oral dose of study medication (Dose 
Level 1: 2 or 5 mg sarizotan or matching placebo) in the morning.  In the initial 12-hour period after the 
first dose, safety evaluations (vital signs, 12-lead ECG) will be performed at 1 and 4 hr post-dose. Blood 
samples for the pharmacokinetic (PK) analysis will be collected prior to dosing (blank sample) and at 
approximately 1 and 4 hr post-dose, following completion of the vital signs and ECG assessments.  The 
patient will receive the evening dose (Dose Level 1: placebo for all patients) in the hospital (minimally 6 
hours after the morning dose) and will be housed overnight, either in the hospital or with their 
parent/caregiver in a separate facility. The morning dose of Dose Level 2 (2 or 5 mg sarizotan or placebo, 
bid) will be administered on Day 2 in the clinic. Safety evaluations [vital signs, 12-lead ECG, laboratory 
tests (hematology, blood chemistry, urinalysis, and measurement of plasma ACTH and cortisol), 
physical/neurological examination, assessment of adverse events] will be repeated, and if no significant 
side effects are noted within the 4-hr period following this dose, the patient will be released from the 
hospital given a supply of study medication for the remainder of the first week of dosing at Dose Level 2 
(Days 2 [PM] to 7) and for the second week of dosing at Dose Level 3 [2 mg sarizotan bid, 5 mg sarizotan 
bid, 7 mg sarizotan/day (5 mg in AM + 2 mg in PM), 10 mg sarizotan once daily (in AM, with placebo in 
PM) or placebo bid; on Day 8] and Dose Level 4 [2 mg sarizotan bid, 5 mg sarizotan bid, 10 mg sarizotan 
bid, or placebo bid; on Days 9 to 14].  
The caregiver will receive a telephone contact from the Investigator/site staff on Day 7 to inquire about the 
tolerability of Dose Level 2 of the study medication and any adverse events the patient might have 
experienced. If, in the Investigator’s judgement, there are no tolerability issues that would preclude a dose 
increase, the patient/caregiver will be instructed to increase the dose to Dose Level 3 on Day 8 and Dose 
Level 4 on Day 9.  During the time the patient is at home, monitoring of their cardio-respiratory function 
will be attempted for 6 hours each day, during the time the patient is awake, on any 3 days in the week 
preceding the next scheduled office visit on Day 14, using the BioRadio. Data recorded using this system 
will be downloaded from the device at home using the Internet/WiFi or a dedicated laptop provided by the 
Sponsor, if Internet access is not available.  


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The patient will be required to return for a scheduled visit on Day 14 and safety [vital signs, 12-lead ECG, 
laboratory tests (hematology, blood chemistry, urinalysis), physical/neurological examination] and selected 
efficacy (respiratory measures, CGI-C, CIC) evaluations, will be performed.  The tolerability of the current 
dose of study medication will be evaluated, and the patient will be housed overnight, if necessary. On Day 
15, if there are no safety or tolerability issues that would require a dose reduction, the patient will be given 
the morning dose of Dose Level 4 (2 mg sarizotan, 5 mg sarizotan, 10 mg sarizotan or placebo, bid). Prior 
to administering the dose, a PK blood sample for assessing steady state trough levels of sarizotan at Dose 
Level 4 will be taken, and PK blood samples will be collected at 1 and 4 hr post-dose. Post-dose safety 
assessments (vital signs, ECG) will be performed, and if there are no tolerability issues, the patient will be 
released from the hospital after the last PK sample, and will be provided with a supply of Dose Level 4 (or 
a lower dose if Dose Level 4 was not tolerated) for dosing on Days 15 [PM] to 56 (Week 8). Home 
respiratory monitoring will be attempted for 6 hours each day on any 3 days in the week prior to each of 
the scheduled office visits at Weeks 8, 16 and 24.  
The patient will be required to return for scheduled visits on Weeks 8 and 16, and safety (vital signs, routine 
laboratory tests, ECG, physical and neurological examinations) and efficacy evaluations will be performed. 
The suicidality assessment will be performed at Week 8. In addition, serum prolactin and plasma ACTH 
and cortisol measurements, and an ophthalmological examination will be done at Week 16.  At each of 
these visits, the patient will be dispensed an 8-week supply of their current dose level of study medication 
for dosing during the period until the next scheduled visit, provided there are no safety or tolerability issues 
that would require a dose reduction.   
The patient will return for the final scheduled visit at Week 24, or if they discontinue from the study 
prematurely. The caregiver should be instructed not to administer the morning dose of the study medication 
on the day of the Week 24 visit to the clinic, as patients who continue in the open-label extension treatment 
period will receive their first dose of study medication on this day. All final safety [vital signs, 12-lead 
ECG, laboratory tests (hematology, blood chemistry, urinalysis, and measurement of serum prolactin, and 
plasma ACTH and cortisol), Tanner Staging, and physical, neurological and ophthalmological 
examinations (including OCT, if feasible for the patient), and the suicidality assessment] and efficacy 
assessments [respiratory measures, heart rate, CGI-C, CIC, Motor-Behavioral Assessment Scale, Caregiver 
Top 3 Concerns, and RCSS] will be performed at this visit.  The results from the Week 24 assessment of 
the primary efficacy measure of respiratory function (data from home respiratory monitoring on 3 days in 
the week preceding the visit), as well as all other secondary efficacy measures assessed during the visit, 
will be considered the endpoint value for statistical analysis purposes. 
All patients who have completed the final evaluations at Week 24 (Day 168), have no safety or tolerability 
issues that would preclude continuing on the study medication, have been compliant with the trial 
requirements, and have not worsened to the extent that they are considered at an increased risk for morbidity 
or mortality, as judged by the Investigator, will be eligible to enter the initial 24-week, open-label, extension 
treatment period of the study. Patients who do not wish to continue treatment will have their study 
medication discontinued and will be asked to return for a safety follow-up visit 2 weeks after their final 
dose, during which vital signs and an assessment of adverse events will be performed. Any Serious Adverse 
Events (SAEs) occurring within 30 days after the final dose will be reported.  
168-Week Open-label Extension Treatment Period  
All patients, including those randomized to placebo, who have completed the final evaluations at Week 24 
(Day 168), have no safety or tolerability issues that would preclude continuing on the study medication, 
have been compliant with the trial requirements, and have not worsened to the extent that they are 
considered at an increased risk for morbidity or mortality, as judged by the Investigator, will have the option 
of continuing open-label treatment with sarizotan for 24 weeks. Each patient’s parent, legal guardian, or 
representative, must provide written informed consent prior to the patient’s participation in this initial 


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extension period. The patient should provide assent, if capable of doing so. At the end of the initial 24 
weeks of open-label treatment, the Investigator will make a global assessment of the patient.  If in the 
Investigator’s opinion, the patient is benefitting from treatment with sarizotan and is not experiencing any 
significant adverse events, they will be eligible to continue open-label treatment.  Informed consent must 
be obtained at Week 48, for the patient to continue open-label treatment for an additional 48 weeks (through 
Week 96), again at Week 96 for the patient to continue open-label treatment for another 48 weeks (through 
Week 144), and again at Week 144 for the patient to continue open-label treatment for another 48 weeks 
(through Week 192). 
At Week 24 (Day 168), all patients ≥13 years of age and weighing ≥25 kg, including those originally 
randomized to placebo and those receiving 5 mg once daily, will receive treatment with sarizotan, and will 
start at a dose of 5 mg bid.  Patients 4 to <13 years of age and patients ≥13 years of age but weighing <25 
kg, including those who were randomized to placebo, will receive sarizotan at a starting dose of 2 mg bid.  
If patients do not tolerate this starting dose, the Investigator will instruct the caregiver to administer only 
the morning dose (i.e. 2 or 5 mg once daily) for a few days prior to reinitiating the intended bid dose (i.e. 
2 or 5 mg bid).  If the 2 or 5 mg bid dose is still not tolerated, a reduction to 2 or 5 mg once daily will be 
permitted.   
At Week 28 (Day 196), patients ≥13 years of age and weighing ≥25 kg will have their dose increased to 10 
mg bid, if the starting dose was well tolerated, or may remain on a lower dose.  Patients 4 to <13 years of 
age and weighing 10 to <18 kg will remain on a dose of 2 mg bid, while those weighing ≥18 kg, as well as 
patients ≥13 years of age but weighing <25 kg, will have their dose increased to 5 mg bid, provided there 
are no tolerability issues. If the patient does not tolerate the target dose (2, 5 or 10 mg bid, based on age and 
weight criteria, the Investigator will instruct the caregiver to administer only the morning dose (i.e. 2, 5 or 
10 mg/day) for a few days prior to reinitiating the intended bid dose (i.e. 2, 5 or 10 mg bid).  If the target 
dose of 2, 5 or 10 mg bid is still not tolerated, a reduction to 2 mg once daily, 2 mg bid or 5 mg bid, 
respectively, will be permitted.  Patients will continue on their maximum tolerated dose (MTD) through the 
final dose, unless intolerance develops, and a dose reduction is warranted.  
The final evaluations performed at Week 24 in the double-blind period, including assessments of respiratory 
function performed in the clinic using a stretch-sensitive resistance plethysmograph (SOMNOtouch), vital 
signs (body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic blood pressure), 
laboratory tests (hematology, biochemistry, urinalysis, serum prolactin, plasma ACTH and cortisol, serum 
pregnancy test for post-pubertal females), ECG, physical and neurological examinations, Tanner Staging, 
routine ophthalmological examination [including Optical Coherence Tomography (OCT), if feasible] and 
final assessments for other efficacy variables [Motor-Behavioral Assessment Scale, Caregiver Top 3 
Concerns, and Rett syndrome Clinical Severity Scale (RCSS)] will serve as the baseline assessments for 
the open-label extension period.  Once all of these Week 24 assessments have been completed, and the 
consent form for the extension period has been signed, patients meeting all entry criteria will start on the 
low dose (5 mg bid) of sarizotan.   
The first dose of the extension period (2 or 5 mg sarizotan) should be administered in the clinic (if the 
morning dose was given, wait at least 6 hours after the prior dose before administration) on the same day 
(Day 168); however, if necessary, it can be postponed until the following morning.  Patients will be 
observed for the occurrence of any adverse events in the initial 4hour period after the first dose.  Safety 
evaluations (vital signs, 12-lead ECG, physical and neurological examinations) will be performed at 1 and 
4 hr- post-dose.  If no significant side effects are noted within the 4-hr period following the first dose, the 
patient will be released from the hospital and given a supply of study medication for the remainder of the 
first four weeks of dosing at 2 or 5 mg bid.  
The patient/caregiver will receive a telephone contact from the Investigator/site staff on Day 175 (Week 
25) to inquire about the tolerability of the current dose of the study medication.  If there are no tolerability 


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issues, the patient/caregiver will be instructed to continue on the current dose.  If intolerance develops, a 
reduction to 2 or 5 mg once daily can be instituted, or if necessary, the patient can be asked to return to the 
clinic for an unscheduled visit for a full assessment.  
The patient will be required to return for a scheduled visit on Day 196 (Week 28). The caregiver should be 
instructed not to administer the morning dose of the study medication on the day of the Week 28 visit to 
the clinic, as the first dose of the next dose level will be administered in the clinic. At this visit, safety [vital 
signs, 12-lead ECG, physical/neurological examinations] and selected efficacy (in-clinic respiratory 
measures, CIC, CGI-C) evaluations, will be performed.  The tolerability of the current dose of study 
medication will be evaluated.  If there are no safety or tolerability issues that would require the dose to be 
maintained or reduced, the patient will have their dose maintained at 2 mg bid, or increased to 5 or 10 mg 
bid, and will be given their first dose in the clinic (if the morning dose was given, wait at least 6 hours after 
the prior dose before administration). Safety evaluations (vital signs, 12-lead ECG, physical and 
neurological examinations) will be performed prior to dosing and at 1 and 4 hr post-dose.  If no significant 
side effects are noted within the 4-hr period following the dose, the patient will be released from the hospital 
and given a supply of study medication for the next 4 weeks of dosing at 2 mg bid, 5 mg bid or 10 mg bid. 
The caregiver will be contacted by telephone by the Investigator/site staff on Day 203 (Week 29) to inquire 
about the tolerability of the study medication and any adverse events the patient might have experienced. 
If there are no tolerability issues, the patient/caregiver will be instructed to continue on the current dose.  If 
intolerance develops, a reduction in dose can be instituted, or if necessary, the patient can be asked to return 
to the clinic for an unscheduled visit for a full assessment.  Similar telephone contacts will be made at 
Weeks 54, 66, 78, 90, 102, 114, 126, 138, 150, 162, 174, and 186 in the additional open-label extension 
treatment period, during which adverse events, concomitant medication usage and overall compliance with 
the study medication will be assessed. 
Patients will be required to return for scheduled visits at Weeks 32, 40, and 48 in the initial 24-week open-
label treatment period, and Weeks 60, 72, 84, 96, 108, 120, 132, 144, 156, 168, 180 and 192 if they continue 
open-label treatment. At each of these visits, safety assessments comprising vital signs, laboratory tests 
(hematology, blood chemistry, urinalysis), ECG, and physical and neurological examinations, as well as 
selected efficacy assessments (in-clinic respiratory measures, CIC, CGI-C), will be performed. In addition, 
at Weeks 48, 72, 96, 120, 144 168 and 192, the following assessments will be performed: serum prolactin, 
plasma ACTH and cortisol, a serum pregnancy test (for post-pubertal females), Tanner Staging, an 
ophthalmological examination (including OCT, if feasible for the patient), and the suicidality assessment, 
as well as additional efficacy assessments (Motor-Behavioral Assessment Scale, Caregiver Top 3 Concerns, 
and RCSS). At each of these visits, the patient will be dispensed an 8-week or 12-week supply of their 
current dose of study medication, provided there are no safety or tolerability issues that would require a 
dose reduction, for dosing during the period until the next scheduled visit.  The Week 48 assessments will 
be considered the final evaluation for patients discontinuing after 24 weeks of open-label treatment. 
All patients continuing open-label treatment after Week 48 will return for the final evaluations at Week 96, 
if they complete 72 weeks of open-label treatment and do not continue further treatment, or at the time of 
discontinuation, if they discontinue from the study prematurely prior to Week 96.  Patients continuing open-
label treatment after Week 96, will return for the final evaluations at Week 144, or at the time of 
discontinuation, if they discontinue from the study prematurely prior to Week 144. Patients continuing 
open-label treatment after Week 144, will return for the final evaluations at Week 192, or at the time of 
discontinuation, if they discontinue from the study prematurely prior to Week 192. All final safety [vital 
signs, 12-lead ECG, laboratory tests (hematology, blood chemistry, urinalysis, serum prolactin, plasma 
ACTH and cortisol, and serum pregnancy test for post-pubertal females), Tanner Staging, and physical, 
neurological and ophthalmological (including OCT, if feasible for the patient) examinations, and the 
suicidality assessment] and efficacy [in-clinic respiratory measures, CIC, CGI-C, Motor-Behavioral 


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Assessment Scale, Caregiver Top 3 Concerns, and RCSS] assessments will be performed at this visit.  The 
results from the final (Week 48, 96, 144 or 192, or at early discontinuation) assessment of the respiratory 
function (data from in-clinic respiratory monitoring using the SOMNOtouch), as well as all other secondary 
efficacy measures assessed during the visit, will be considered the endpoint values for the open-label 
extension period for statistical analysis purposes. 
Patients who discontinue treatment prematurely or at the end of the initial open-label extension treatment 
period (Week 48), as well as those who discontinue treatment after completing Part 1 (through Week 96), 
Part 2 (through Week 144), or Part 3 (through Week 192) of the additional extension treatment period will 
be asked to return for a safety follow-up visit 2 weeks after their final dose.  Vital signs and an assessment 
of adverse events will be performed at this visit.  Any SAEs occurring within 30 days after the final dose 
will be reported. 
 
Laboratory and PK Sample Collection and Processing 
Blood sampling 
Venous blood samples will be drawn for safety evaluations, comprising hematology, blood chemistry, 
virology (hepatitis B/C and HIV), thyroid function tests, serum prolactin and plasma ACTH and cortisol 
levels.  
The maximum blood volume collected on any day for these tests will be 25 mL: 
• 
2 mL will be collected for hematology tests, 
• 
2.5 mL will be collected for blood chemistry tests, 
• 
4 mL will be collected for virology tests (Screening only), 
• 
2.5 mL will be collected for the thyroid tests (Screening only), 
• 
6.25 mL will be collected for plasma ACTH (3.75 mL) and cortisol (2.5 mL) levels (Baseline, Day 2, 
Weeks 16, 24, 48, 72, 96, 120, 144, 168 and 192),  
• 
1.25 mL will be collected for plasma prolactin levels (Baseline, Weeks 16, 24, 48, 72, 96, 120, 144, 
168 and 192), 
• 
1.25 mL will be collected for a serum pregnancy test (post-pubertal females at Screening, Baseline, 
Weeks 24, 48, 72, 96, 120, 144, 168 and 192), 
• 
6 mL for MECP2 genetic mutation testing (optional; Screening only). This test will be performed only 
if the patient has not had the test performed previously, or does not have adequate documentation of 
the test results from an accredited laboratory. The results from this test do not need to be available prior 
to randomizing the patient to treatment.   
Urine collection 
The minimal quantity of urine needed for the urinalysis is 30 ml.   
Pharmacokinetic sampling 
In addition to the blood samples taken for laboratory tests, 7.5-ml blood samples will be collected into 10-
ml Li-heparinized test tubes for measurement of plasma concentrations of sarizotan and its main 
metabolites and determination of PK parameters.  Samples will be collected just prior to the first dose of 
Dose Level 1 (blank sample) and at approximately 1 and 4 hr post-dose (±15 min) on Day 1.  On Day 15, 


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a blood sample will be taken prior to dosing on Day 15 (trough level for Dose Level 4) and at 1 and 4 hr 
post-dose (Dose Level 4).  The exact time of sampling, relative to dosing must be noted in the eCRF.  
For each sample time point, 7.5 mL of whole blood will be collected in standard Li-heparinized vacuum 
tubes, gently inverted several times and centrifuged within 15 minutes at 4°C. After centrifugation (15 
minutes at approx. 1500g), the supernatant plasma (at least 2 x 1.5 mL) will be immediately pipetted off, 
transferred into two pre-labeled polypropylene cryo-vials and deep frozen at < -70°C as soon as possible. 
The tubes will be kept frozen at < -70°C pending shipment for analysis.   
Processing of samples  
All blood and urine samples for screening (virology/thyroid tests) and routine safety parameters 
(hematological/ biochemical/urinalysis), serum prolactin, plasma ACTH and cortisol evaluations, and 
MECP2 genetic testing (optional), will be sent to a Central Laboratory, following the instructions provided 
by the Central Laboratory.   
All plasma samples for each cohort for the assay of systemic concentrations of sarizotan will be transferred 
to the central laboratory (Q2 Solutions) on dry ice in batches, where they will be stored at  
-70°C (urine and plasma PK) until analysis.  Samples will only be destroyed or sent where indicated, upon 
approval/request by the Sponsor. 
Determination of sarizotan in human plasma  
The concentration of sarizotan in human plasma will be determined using a bioanalytical method based 
upon liquid chromatography – tandem mass spectrometry (LC-MS/MS), which has been validated in 
mouse and human plasma.  Quantification of the parent drug and the three major metabolites EMD 
148107, EMD 329989 and EMD 50929 will be performed. The LLOQ for sarizotan and the three 
metabolites was 0.5 – 1 ng/mL in mouse plasma and 0.1 ng/mL in human plasma.  
 
11.3 Study Flow Chart 
The schedules of evaluations to be performed during the initial 24-week double-blind treatment period, and 
the 24-week initial, and three 48-week additional (Part 1, Part 2 and Part 3), open-label extension treatment 
periods, are presented in Tables 6A, 6B, 6C, 6D, and 6E, respectively.  
 


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Table 6A.  Schedule of Evaluations: Initial 24-Week Double-blind Treatment Period  
Visit 
Assessment 
Screening 
BaselineA 
Day 1 
Day 2 
Day 7 
Day 14 
Day 15 
Week 8 
Week 16 
Final  
(Week 24)H 
Safety 
follow-upJ 
Study day(s) 
-28 to -1 
0 
1 
2 
3-7 
8-14 
15 
16-56 
57-112 
113-168 
169-182 
Informed consent (before any study procedure) 
X 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
Demography/Background Information 
X 
 
 
 
 
 
 
 
 
 
 
MECP2 gene mutation confirmation  
XP 
 
 
 
 
 
 
 
 
 
 
Medical History and Current Medical 
Conditions 
X 
 
 
 
 
 
 
 
 
 
 
Vital Signs 
X 
XC 
XC 
X 
 
X 
X 
X 
X 
X 
X 
ECG (12-lead) 
X 
XD 
XD 
X 
 
X 
X 
X 
X 
X 
 
Physical Examination 
X 
XB 
 
X 
 
X 
 
X 
X 
X 
 
Neurological Examination 
X 
XB 
 
X 
 
X 
 
X 
X 
X 
 
Ophthalmological Examination 
 
X 
 
 
 
 
 
 
X 
X 
 
Laboratory Evaluation (Hematology, 
Biochemistry, Urinalysis) 
X 
XB 
 
 
 
X 
 
X 
X 
X 
 
Thyroid Function Tests (TSH, T3, T4) 
X 
 
 
 
 
 
 
 
 
 
 
Virology (Hepatitis B/C, HIV) 
X 
 
 
 
 
 
 
 
 
 
 
Plasma ACTH and cortisol 
 
X 
 
X 
 
 
 
 
X 
X 
 
Serum prolactin 
 
X 
 
 
 
 
 
 
X 
X 
 
Serum pregnancy test O 
X 
X 
 
 
 
 
 
 
 
X 
 
Tanner Staging 
 
X 
 
 
 
 
 
 
 
X 
 
Suicidality assessment 
 
X 
 
 
 
 
 
X 
 
X 
 
Dosage administration and drug label record  
 
 
X 
X 
X 
X 
X 
X 
X 
XK 
 
Prior/Concomitant Medications and Significant 
Non-Drug Therapies 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Adverse Events 
X 
X 
X 
X 
X 
X 
X 
X 
X 
XE 
X 
Respiratory monitoring (in clinic) M 
 
X 
 
 
 
 
 
 
X 
X 
 
Respiratory monitoring (at home) N 
X 
 
 
 
 
X 
 
X 
X 
X 
 
CGI-C 
 
 
 
 
 
X 
 
X 
X 
X 
 
CIC 
 
 
 
 
 
X 
 
X 
X 
X 
 
RCSS 
 
X 
 
 
 
 
 
 
 
X 
 
Motor-Behavioral Assessment Scale 
 
X 
 
 
 
 
 
X 
X 
X 
 
Caregiver Top 3 Concerns 
 
X 
 
 
 
 
 
X 
X 
X 
 
Telephone contact G 
 
 
 
 
X 
 
 
 
 
 
 
Pharmacokinetic blood sample 
 
 
XF 
 
 
 
XF 
 
 
 
 
Overnight stay (hotel/housing) required  
 
X 
X 
XL 
 
X 
XL 
 
 
 
 
Study Completion 
 
 
 
 
 
 
 
 
 
XI 
X 


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A Patients meeting all entry criteria will report to the hospital/clinic on Day 0.  Baseline evaluations may be started on Day 0 and continued on Day 1 pre-dose. 
Following completion of baseline evaluations, subjects will be randomized and dosed on Day 1.  
B This evaluation does not need to be performed at baseline unless the screening assessment was done more than 28 days beforehand or there were abnormalities 
noted that require follow-up. 
C Vital signs to be performed at baseline must be repeated 3 times, with an interval of at least 10 minutes between readings, on Day 0 or at least 1 hr prior to dosing 
on Day 1, and at 1 and 4 hr post-dose, just prior to taking blood samples for PK measurements.  
D 12-lead ECG will be performed at baseline and repeated 3 times, with an interval of at least 10 minutes between readings, on Day 0 or at least 1 hr prior to 
dosing on Day 1, and at 1 and 4 hr post-dose, just prior to taking blood samples for PK measurements. 
E Patients will be contacted 30 days after their final dose of study medication to follow up on the occurrence of any SAEs. 
F A pre-dose PK sample will be taken, and samples will be collected at 1 and 4 hr post dose (window ± 15 min).  
G Telephone contact with patient/caregiver will be done on Day 7 to assess tolerability of current dose of study medication, before the increase to Dose Level 3 
and Dose Level 4 on Days 8 and 9, respectively; adverse events and concomitant medication use will be assessed. 
H All Week 24 (Final) evaluations should be performed when a subject discontinues from the study prematurely. 
I Patients completing 168 days (+/- 7 days) of treatment will be considered to have completed the initial 6-month period of the study. 
J Safety follow-up assessments to be performed 14 days after the final dose of study medication, if the patient is not continuing in the open-label extension 
treatment period, or if the patient discontinues prematurely. 
K Record dosing from last 8-week period. Dose administration will be done only for patients continuing in the open-label extension treatment period. 
L Patient will be released from the hospital on Day 2 and Day 15, approximately 4 hr after the morning dose, if there are no tolerability issues. 
M During outpatient treatment, patients will undergo cardio-respiratory monitoring using a specialized ambulatory data acquisition system (BioRadio).  In 
addition, respiratory function will be assessed in the clinic using a similar device (SOMNOtouch). 
N During outpatient treatment, patients will undergo cardio-respiratory monitoring using a specialized ambulatory data acquisition system (BioRadio). 
Respiratory monitoring will be attempted at home for 6 hours each day during the time awake at Screening (three 3-day periods during the first, second and 
third week), and on any 3 days in the week preceding each subsequent scheduled office visit. Data recorded using this system will be downloaded from the 
device at home using the Internet/WiFi or a dedicated laptop provided by the Sponsor, if Internet access is not available; data collected during the screening test 
period will be verified for accuracy by Vivonoetics.  
O To be performed for all post-pubertal females.  
P MECP2 genetic mutation testing will be performed only if the patient has not had the test performed previously, or does not have adequate documentation of 
the test results from an accredited laboratory. 
 
 


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Table 6B.  Schedule of Evaluations: 24-Week Initial Open-label Extension Treatment Period (Weeks 24 - 48) 
Visit 
Assessment 
Week 24A/ 
Baseline 
Weeks 25 
Week 28 
Week 29 
Week 32 
Week 40 
Week 48B 
Safety  
follow-upC 
Study day(s) 
168 
175 
169-196 
203 
197-224 
225-280 
281-336 
337-350 
Informed consent (before any study procedure) 
X 
 
 
 
 
 
XM 
 
Inclusion/Exclusion Criteria 
X 
 
 
 
 
 
XM 
 
Vital Signs 
XI 
 
XI 
 
X 
X 
X 
X 
ECG (12-lead) 
XI 
 
XI 
 
X 
X 
X 
 
Physical Examination 
XI 
 
XI 
 
X 
X 
X 
 
Neurological Examination 
XI 
 
XI 
 
X 
X 
X 
 
Ophthalmological Examination 
 
 
 
 
 
 
X 
 
Laboratory Evaluation (Hematology, 
Biochemistry, Urinalysis) 
 
 
 
 
X 
X 
X 
 
Plasma ACTH/Cortisol 
 
 
 
 
 
 
X 
 
Serum prolactin 
 
 
 
 
 
 
X 
 
Serum pregnancy test J 
 
 
 
 
 
 
X 
 
Tanner Staging 
 
 
 
 
 
 
X 
 
Suicidality assessment 
 
 
 
 
 
 
X 
 
Dosage administration and drug label record  
XL 
X 
XL 
X 
X 
X 
XD 
 
Concomitant Medications and Significant  
Non-Drug Therapies 
X 
X 
X 
X 
X 
X 
X 
 
Adverse Events 
X 
X 
X 
X 
X 
X 
XE 
X 
Respiratory monitoring (in clinic) F 
 
 
X 
 
X 
X 
X 
 
CGI-C K 
 
 
X 
 
X 
X 
X 
 
CIC K 
 
 
X 
 
X 
X 
X 
 
RCSS 
 
 
 
 
 
 
X 
 
Motor-Behavioral Assessment Scale 
 
 
 
 
 
 
X 
 
Caregiver Top 3 Concerns 
 
 
 
 
 
 
X 
 
Telephone contact  
 
XG 
 
XG 
 
 
 
 
Study Completion 
 
 
 
 
 
 
XH 
X 
 
 
 


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Table 6C.  Schedule of Evaluations: Additional Open-label Extension Treatment Period – Part 1 (Weeks 49 – 96)  
Visit 
Assessment 
Week 54 
Week 60 
Week 66 
Week 72 
Week 78 
Week 84 
Week 90 
Final  
(Week 96) N 
Safety  
follow-upC 
Study day(s) 
337-378 
379-420 
421-462 
463-504 
505-546 
547-588 
589-630 
631-672 
673-686 
Informed consent (before any study procedure) 
 
 
 
 
 
 
 
XM 
 
Inclusion/Exclusion Criteria 
 
 
 
 
 
 
 
XM 
 
Vital Signs  
 
X 
 
X 
 
X 
 
X 
X 
ECG (12-lead) 
 
X 
 
X 
 
X 
 
X 
 
Physical Examination 
 
X 
 
X 
 
X 
 
X 
 
Neurological Examination 
 
X 
 
X 
 
X 
 
X 
 
Ophthalmological Examination 
 
 
 
X 
 
 
 
X 
 
Laboratory Evaluation (Hematology, 
Biochemistry, Urinalysis) 
 
X 
 
X 
 
X 
 
X 
 
Plasma ACTH/Cortisol 
 
 
 
X 
 
 
 
X 
 
Serum prolactin 
 
 
 
X 
 
 
 
X 
 
Serum pregnancy test J 
 
 
 
X 
 
 
 
X 
 
Tanner Staging 
 
 
 
X 
 
 
 
X 
 
Suicidality assessment 
 
 
 
X 
 
 
 
X 
 
Dosage administration and drug label record  
X 
X 
X 
X 
X 
X 
X 
XD 
 
Concomitant Medications and Significant  
Non-Drug Therapies 
X 
X 
X 
X 
X 
X 
X 
X 
 
Adverse Events 
X 
X 
X 
X 
X 
X 
X 
XE 
X 
Respiratory monitoring (in clinic) F 
 
X 
 
X 
 
X 
 
X 
 
CGI-C K 
 
X 
 
X 
 
X 
 
X 
 
CIC K 
 
X 
 
X 
 
X 
 
X 
 
RCSS 
 
 
 
X 
 
 
 
X 
 
Motor-Behavioral Assessment Scale 
 
 
 
X 
 
 
 
X 
 
Caregiver Top 3 Concerns 
 
 
 
X 
 
 
 
X 
 
Telephone contact  
XG 
 
XG 
 
XG 
 
XG 
 
 
Study Completion 
 
 
 
 
 
 
 
XO 
X 
 
 
 


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Table 6D.  Schedule of Evaluations: Additional Open-label Extension Treatment Period – Part 2 (Weeks 97 – 144)  
Visit 
Assessment 
Week 102 
Week 108 
Week 114 
Week 120 
Week 126 
Week 132 
Week 138 
Final  
(Week 144) P 
Safety  
follow-upC 
Study day(s) 
673-714 
715-756 
757-798 
799-840 
841-882 
883-924 
925-966 
967-1008 
1009-1022 
Informed consent (before any study procedure) 
 
 
 
 
 
 
 
XM 
 
Inclusion/Exclusion Criteria 
 
 
 
 
 
 
 
XM 
 
Vital Signs  
 
X 
 
X 
 
X 
 
X 
X 
ECG (12-lead) 
 
X 
 
X 
 
X 
 
X 
 
Physical Examination 
 
X 
 
X 
 
X 
 
X 
 
Neurological Examination 
 
X 
 
X 
 
X 
 
X 
 
Ophthalmological Examination 
 
 
 
X 
 
 
 
X 
 
Laboratory Evaluation (Hematology, 
Biochemistry, Urinalysis) 
 
X 
 
X 
 
X 
 
X 
 
Plasma ACTH/Cortisol 
 
 
 
X 
 
 
 
X 
 
Serum prolactin 
 
 
 
X 
 
 
 
X 
 
Serum pregnancy test J 
 
 
 
X 
 
 
 
X 
 
Tanner Staging 
 
 
 
X 
 
 
 
X 
 
Suicidality assessment 
 
 
 
X 
 
 
 
X 
 
Dosage administration and drug label record  
X 
X 
X 
X 
X 
X 
X 
XD 
 
Concomitant Medications and Significant  
Non-Drug Therapies 
X 
X 
X 
X 
X 
X 
X 
X 
 
Adverse Events 
X 
X 
X 
X 
X 
X 
X 
XE 
X 
Respiratory monitoring (in clinic) F 
 
X 
 
X 
 
X 
 
X 
 
CGI-C K 
 
X 
 
X 
 
X 
 
X 
 
CIC K 
 
X 
 
X 
 
X 
 
X 
 
RCSS 
 
 
 
X 
 
 
 
X 
 
Motor-Behavioral Assessment Scale 
 
 
 
X 
 
 
 
X 
 
Caregiver Top 3 Concerns 
 
 
 
X 
 
 
 
X 
 
Telephone contact  
XG 
 
XG 
 
XG 
 
XG 
 
 
Study Completion 
 
 
 
 
 
 
 
XQ 
X 
 
 
 


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Table 6E.  Schedule of Evaluations: Additional Open-label Extension Treatment Period – Part 3 (Weeks 145 – 192)  
Visit 
Assessment 
Week 150 
Week 156 
Week 162 
Week 168 
Week 174 
Week 180 
Week 186 
Final  
(Week 192) R 
Safety  
follow-upC 
Study day(s) 
1009-
1050 
1051-
1092 
1093-
1134 
1135-
1176 
1177-
1218 
1219-
1260 
1261-
1302 
1303-1344 
1345-1358 
Informed consent (before any study procedure) 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion Criteria 
 
 
 
 
 
 
 
 
 
Vital Signs  
 
X 
 
X 
 
X 
 
X 
X 
ECG (12-lead) 
 
X 
 
X 
 
X 
 
X 
 
Physical Examination 
 
X 
 
X 
 
X 
 
X 
 
Neurological Examination 
 
X 
 
X 
 
X 
 
X 
 
Ophthalmological Examination 
 
 
 
X 
 
 
 
X 
 
Laboratory Evaluation (Hematology, 
Biochemistry, Urinalysis) 
 
X 
 
X 
 
X 
 
X 
 
Plasma ACTH/Cortisol 
 
 
 
X 
 
 
 
X 
 
Serum prolactin 
 
 
 
X 
 
 
 
X 
 
Serum pregnancy test J 
 
 
 
X 
 
 
 
X 
 
Tanner Staging 
 
 
 
X 
 
 
 
X 
 
Suicidality assessment 
 
 
 
X 
 
 
 
X 
 
Dosage administration and drug label record  
X 
X 
X 
X 
X 
X 
X 
XD 
 
Concomitant Medications and Significant  
Non-Drug Therapies 
X 
X 
X 
X 
X 
X 
X 
X 
 
Adverse Events 
X 
X 
X 
X 
X 
X 
X 
XE 
X 
Respiratory monitoring (in clinic) F 
 
X 
 
X 
 
X 
 
X 
 
CGI-C K 
 
X 
 
X 
 
X 
 
X 
 
CIC K 
 
X 
 
X 
 
X 
 
X 
 
RCSS 
 
 
 
X 
 
 
 
X 
 
Motor-Behavioral Assessment Scale 
 
 
 
X 
 
 
 
X 
 
Caregiver Top 3 Concerns 
 
 
 
X 
 
 
 
X 
 
Telephone contact  
XG 
 
XG 
 
XG 
 
XG 
 
 
Study Completion 
 
 
 
 
 
 
 
XS 
X 
 
 
 


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Footnotes refer to Tables 6B, 6C, 6D and 6E 
A Week 24 (Day 168) safety and efficacy evaluations from the initial double-blind period will serve as the baseline evaluations for the open-label extension 
treatment period. All additional baseline assessments and administration of the first dose of the extension treatment period should be completed on Day 168, if 
possible, and the patient will be released from the hospital following the 4-hr post-dose safety assessments.  If necessary, the first dose administration and 4-hr 
safety follow-up in the clinic can be performed in the morning on the next day (Day 169).   
B The Week 48 evaluations should be performed for all subjects, and should be done when a subject discontinues from the study prematurely during the initial 
open-label extension period.  The Week 48 evaluations will be considered as the Final evaluation for subjects who discontinue prematurely between Week 24 
and Week 48, as well as for those who complete the initial 24-week open-label treatment period, but do not continue additional open-label treatment. 
C Safety follow-up to be performed 14 days after the final dose of study medication in the extension treatment period, or if the patient discontinues prematurely. 
D Recording of dosing for the final dosing period.   
E Patients will be contacted 30 days after their final dose of study medication to follow up on the occurrence of any SAEs. 
F Patients will undergo cardiorespiratory monitoring in the clinic at each scheduled visit using a specialized data acquisition system (SOMNOtouch).  
G Telephone contact with patient/caregiver will be done on Days 175 and 203 (± 1 day), and at Weeks 54, 66, 78, 90, 102, 114, 126, 138, 150, 162, 174 and 186 
(± 1 week), to assess tolerability of the current dose of study medication; adverse events and concomitant medication use will be assessed. 
H Patients completing 336 days (+/- 14 days) of treatment will be considered to have completed the initial 24-week extension treatment period of the study.  
I On Day 168 (first dose at 5 mg bid) and Day 196 (first dose at 10 mg bid), vital signs, ECG and physical/neurological examinations will be performed pre-dose 
and 1 and 4 hr post-dose.  At Baseline (Day 168), assessments performed as part of the final Week 24 evaluations in the preceding double-blind period of the 
study will serve as the pre-dose assessment.  
J To be performed for all post-pubertal females.  
K Ratings of the CGI-C and CIC for the open-label extension period should be based on the patient’s condition at the Week 24 visit.  
L The first dose (5 mg) at the starting dose (5 mg bid) on Day 168 (Week 24) and the first dose (10 mg) at the target dose (10 mg bid) on Day 196 (Week 28) will 
be administered in the clinic at least 6 hours after the previous dose.  
M Informed consent must be obtained at Week 48, at Week 96, and again at Week 144, for the patient to continue open-label treatment for an additional 48 
weeks. If in the Investigator’s opinion, the patient is benefitting from treatment with sarizotan and is not experiencing any significant adverse events, they will 
be eligible to continue open-label treatment.  
N All Week 96 (Final) evaluations should be performed for subjects who complete Part 1 of the additional open-label treatment period and do not continue open-
label treatment, or when a subject discontinues from the study prematurely after Week 48 and prior to Week 96. 
O Patients completing 672 days (+/- 14 days) of treatment will be considered to have completed Part 1 of the additional extension treatment period of the study.  
P All Week 144 (Final) evaluations should be performed for subjects who complete Part 2 of the additional open-label treatment period, or when a subject 
discontinues from the study prematurely after Week 96 and prior to Week 144. 
Q Patients completing 1008 days (+/- 28 days) of treatment will be considered to have completed Part 2 of the additional extension treatment period of the study.  
R All Week 192 (Final) evaluations should be performed for subjects who complete Part 3 of the additional open-label treatment period, or when a subject 
discontinues from the study prematurely after Week 144 and prior to Week 192. 
S Patients completing 1344 days (+/- 28 days) of treatment will be considered to have completed Part 3 of the additional extension treatment period of the study.  


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Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
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11.4 Visit Schedule and Assessments  
Initial 24-Week Double-blind Treatment Period 
11.4.1 Screening (Days -28 to -1) 
At Screening (Days -28 to -1) each patient will report to the clinic where the following procedures will be 
performed to establish eligibility for the study: 
a) Obtaining written informed consent (before any study procedures) 
b) Demography and background information 
c) MECP2 gene mutation test, if results not available from accredited laboratory  
d) Medical history and current medical conditions 
e) Physical examination  
f) Neurological examination 
g) Laboratory evaluations comprising the following tests: 
• 
hematology - RBC, WBC, hemoglobin, hematocrit, platelets, neutrophils, eosinophils, basophils, 
lymphocytes, monocytes;  
• 
biochemistry - total bilirubin, albumin, AST, ALT, GT, BUN, creatinine, sodium, potassium, 
chloride, bicarbonate, calcium, LDH, alkaline phosphatase, total cholesterol, HDL, LDL, VLDL, 
triglycerides, glucose, and CPK; 
• 
urinalysis – pH, glucose, ketones, specific gravity, nitrites, protein, bilirubin, hemoglobin and 
microscopic RBC, WBC and casts;  
• 
thyroid function*: TSH, Free T4, Triiodothyronine (T3);  
• 
virology tests* - hepatitis B antibody (core and surface) and surface antigen, and hepatitis C 
antibody screens, HIV; 
• 
serum pregnancy test for post-pubertal females; 
*screening only 
h) Vital signs – body weight, height, temperature, pulse, systolic and diastolic BP, and respiratory rate 
i) 12-lead standard ECG  
j) Prior (previous 4 weeks) and concomitant medications and therapies 
k) Adverse events (to be collected from the time of signing the consent form) 
l) Respiratory monitoring at home (BioRadio) in Weeks 1, 2 and 3 of screening period 
m) subject eligibility and inclusion/exclusion criteria checklist (all laboratory results must be available 
before the baseline visit) 
11.4.2 Baseline (Day 0 through Day 1 pre-dose) 
a) Overnight stay (hotel/hostel/housing) on Days 0 and 1; 
b) Physical examination* 


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c) Neurological examination* 
d) Ophthalmological examination (including visual acuity, lens, intraocular pressure and examination of 
the fundus, and OCT, if feasible for the patient) 
e) Laboratory evaluations comprising the following tests: 
• 
hematology*; 
• 
biochemistry*; 
• 
urinalysis*; 
• 
plasma ACTH and cortisol; 
• 
serum prolactin; 
• 
serum pregnancy test for post-pubertal females. 
f) Vital signs – body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic BP; 
to be done at least 1 hour prior to the first dose and repeated 3 times with an interval of at least 10 
minutes between readings;  
g) 12-lead standard ECG - to be done at least 1 hour prior to the first dose and repeated 3 times with an 
interval of at least 10 minutes between readings;  
h) Tanner Staging (see Appendix 7); 
i) Suicidality assessment 
j) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
k) Concomitant medication; 
l) Respiratory monitoring in clinic; 
m) Rett syndrome Clinical Severity Scale (RCSS);  
n) Motor-Behavioral Assessment Scale;  
o) Caregiver Top 3 Concerns; 
p) Confirmation of subject eligibility and inclusion/exclusion criteria checklist (all necessary test results 
must be available before randomization and administration of the first dose). 
*These tests do not need to be repeated if the screening assessment was done within 28 days of baseline. 
11.4.3 Day 1 (Dose Level 1)  
a) Randomization and first dose administration; 
b) Blood samples for PK (blank): 0 (within 10 minutes prior to dosing), and 1 and 4 hours post-dose 
(first dose; window ±15 min); 
c) Vital signs – body weight, temperature, respiratory rate, pulse, and systolic and diastolic BP at 1 and 
4 hr post-dose (first dose);  
d) 12-lead standard ECG – 1 and 4 hr post-dose (first dose);  
e) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
f) Concomitant medication;  


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Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
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g) Administration of the evening dose in the clinic. 
 
11.4.4 Day 2 (Dose Level 2)  
a) Physical and neurological examinations; 
b) Laboratory evaluations: 
• 
plasma ACTH and cortisol; 
c) Vital signs – body weight, temperature, pulse, systolic and diastolic BP, and respiratory rate;  
d) 12-lead standard ECG; 
e) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator; 
f) Concomitant medication; 
g) Leave hospital 4 hours after morning dose, if there are no safety issues.  
11.4.5 Day 7 - Telephone Contact 
A telephone contact will be made with the caregiver on Day 7 to inquire about the occurrence of any 
adverse events or use of concomitant medication; this information will be registered on the appropriate 
CRF page.  Based on the information gathered on this call, a decision will be made whether or not to 
increase the patient’s dose to Dose Level 3 on Day 8 and Dose Level 4 on Day 9, while the patient is 
residing at home.   
11.4.6 Day 14  
a) Respiratory monitoring at home (BioRadio) on any 3 days in the week preceding the scheduled 
visit; 
b) Overnight stay (hotel/hostel/housing); 
c) Physical and neurological examinations; 
d) Laboratory evaluations comprising the following tests: 
• 
hematology; 
• 
biochemistry; 
• 
urinalysis; 
e) Vital signs – body weight, temperature, respiratory rate, pulse, and systolic and diastolic BP;  
f) 12-lead standard ECG; 
g) CGI-C – performed by the Investigator; 
h) CIC – performed by the caregiver; 
i) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
j) Concomitant medication. 
11.4.7 Day 15 
a) Vital signs – body weight, temperature, respiratory rate, pulse, and systolic and diastolic BP;  


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Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
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b) 12-lead standard ECG; 
c) Blood samples for PK (Dose Level 4): 0 (within 10 minutes prior to morning dose – trough level), 
and 1 and 4 hours post-dose; 
d) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
e) Concomitant medication; 
f) Leave hospital 4 hours after morning dose, if there are no safety issues.   
11.4.8 Week 8 (Day 56)  
a) Respiratory monitoring at home (BioRadio) on any 3 days in the week preceding the scheduled 
visit; 
b) Physical and neurological examinations; 
c)  Laboratory evaluations comprising the following tests: 
• 
hematology; 
• 
biochemistry; 
• 
urinalysis; 
d) Vital signs – body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic BP;  
e) 12-lead standard ECG 
f) Suicidality assessment 
g) CGI-C – performed by the Investigator; 
h) CIC – performed by the caregiver; 
i) Motor-Behavioral Assessment Scale;  
j) Caregiver Top 3 Concerns;  
k) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
l) Concomitant medication. 
11.4.9 Week 16 (Day 112)  
a) Respiratory monitoring at home (BioRadio) on any 3 days in the week preceding the scheduled 
visit; 
b) Physical and neurological examinations; 
c) Ophthalmological examination; 
d) Laboratory evaluations comprising the following tests: 
• 
hematology; 
• 
biochemistry; 
• 
urinalysis; 
• 
plasma ACTH and cortisol; 


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Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
Confidential 
• 
serum prolactin; 
e) Vital signs – body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic BP;  
f) 12-lead standard ECG 
g) Respiratory monitoring in clinic; 
h) CGI-C – performed by the Investigator; 
i) CIC – performed by the caregiver; 
j) Motor-Behavioral Assessment Scale;  
k) Caregiver Top 3 Concerns;  
l) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
m) Concomitant medication. 
11.4.10 Week 24 (Day 168 or at early discontinuation) – Final Evaluation 
a) Respiratory monitoring at home (BioRadio) on any 3 days in the week preceding the scheduled 
visit; 
b) Physical and neurological examinations; 
c) Ophthalmological examination (including OCT, if feasible for the patient); 
d) Laboratory evaluations comprising the following tests: 
• 
hematology; 
• 
biochemistry; 
• 
urinalysis; 
• 
plasma ACTH and cortisol; 
• 
serum prolactin; 
• 
serum pregnancy test (post-pubertal females) 
e) Vital signs – body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic BP;  
f) 12-lead standard ECG; 
g) Tanner Staging; 
h) Suicidality assessment 
i) Respiratory monitoring in clinic; 
j) CGI-C – performed by the Investigator; 
k) CIC – performed by the caregiver; 
l) RCSS; 
m) Motor-Behavioral Assessment Scale;  
n) Caregiver Top 3 Concerns;  
o) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  


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Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
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p) Concomitant medication.  
11.4.11 Safety Follow-up (Day 182 or 14 days after last dose of study medication) 
For patients who complete the initial 24-week treatment period and do not continue treatment in the 
extension treatment period, as well as those patients who discontinue prematurely, the following 
assessments will be performed 14 days after the last dose of study medication:  
a) Vital signs – body weight, temperature, pulse, systolic and diastolic BP, and respiratory rate 
b) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator. 
 
168-Week Open-label Extension Treatment Period 
11.4.12 Week 24 (Day 168) – Baseline for open-label extension period 
a) Obtaining written informed consent for the initial 24-week open-label extension treatment period; 
b) Assessment of inclusion/exclusion criteria for the extension treatment period (see Section 9.2.7); 
c) Final (Week 24) evaluations for the initial double-blind treatment period will serve as the baseline 
evaluations for all safety and efficacy measures for the open-label extension treatment period (see 
Section 11.4.10);  
d) First dose (2 or 5 mg) at starting dose (2 or 5 mg bid), dependent on age and weight, given in clinic 
(minimally 6 hours after last dose in double-blind period); 
e) Physical examination - at 1 and 4 hr post-dose; 
f) Neurological examination - at 1 and 4 hr post-dose; 
g) Vital signs – body weight, temperature, respiratory rate, pulse, and systolic and diastolic BP - at 1 
and 4 hr post-dose;  
h) 12-lead standard ECG –at 1 and 4 hr post-dose;  
i) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
j) Concomitant medications and significant non-drug therapies;  
k) Patient will leave hospital ~4 hours after first dose, if there are no safety issues. 
11.4.13 Week 25 (Day 175) - Telephone Contact 
A telephone contact will be made with the caregiver on Day 175 to inquire about the occurrence of any 
adverse events or use of concomitant medication; this information will be registered on the appropriate 
CRF page.  If tolerability issues are noted, appropriate adjustment of the dose will be performed, and the 
patient may be asked to return to the clinic for an unscheduled visit, if necessary. 
11.4.14 Week 28 (Day 196) 
a) Respiratory monitoring in the clinic (SOMNOtouch); 
b) First dose (2, 5 or 10 mg) at target dose (2, 5 or 10 mg bid), dependent on age and weight, or lower 
dose if there are tolerability issues, given in clinic (minimally 6 hours after prior dose); 
c) Physical and neurological examinations – pre-dose and at 1 and 4 hr post-dose (AM dose); 


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Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
Confidential 
d) Vital signs – body weight, temperature, respiratory rate, pulse, and systolic and diastolic BP – pre-
dose and at 1 and 4 hr post-dose (AM dose); 
e) 12-lead standard ECG– pre-dose and at 1 and 4 hr post-dose (AM dose); 
f) CGI-C – performed by the Investigator;  
g) CIC – performed by the caregiver; 
h) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
i) Concomitant medications and significant non-drug therapies;  
j) Patient will leave hospital ~4 hours after dosing, if there are no safety issues.  
11.4.15 Week 29 (Day 203) - Telephone Contact  
A telephone contact will be made with the caregiver on Day 203 to inquire about the occurrence of any 
adverse events or use of concomitant medication; this information will be registered on the appropriate 
CRF page.  If tolerability issues are noted, appropriate adjustment of the dose will be performed, and the 
patient may be asked to return to the clinic for an unscheduled visit, if necessary.   
11.4.16 Week 32 (Day 224)  
a) Respiratory monitoring in the clinic (SOMNOtouch); 
b) Physical and neurological examinations; 
c) Laboratory evaluations comprising the following tests: 
• 
hematology; 
• 
biochemistry; 
• 
urinalysis; 
d) Vital signs – body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic BP;  
e) 12-lead standard ECG 
f) CGI-C – performed by the Investigator; 
g) CIC – performed by the caregiver; 
h) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
i) Concomitant medication.  
11.4.17 Week 40 (Day 280)  
a) Respiratory monitoring in the clinic (SOMNOtouch); 
b) Physical and neurological examinations; 
c) Laboratory evaluations comprising the following tests: 
• 
hematology; 
• 
biochemistry; 
• 
urinalysis; 
d) Vital signs – body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic BP;  


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Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
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e) 12-lead standard ECG 
f) CGI-C – performed by the Investigator; 
g) CIC – performed by the caregiver; 
h) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
i) Concomitant medication. 
11.4.18 Week 48 (Day 336 or early discontinuation)  
These assessments will serve as the final evaluations for patients who are not continuing treatment in 
Part 1 of the additional open-label extension period (through Week 96).  
a) Respiratory monitoring in the clinic (SOMNOtouch); 
b) Physical and neurological examinations; 
c) Ophthalmological examination (including OCT, if feasible for the patient); 
d) Laboratory evaluations comprising the following tests: 
• 
hematology; 
• 
biochemistry; 
• 
urinalysis; 
• 
plasma ACTH and cortisol; 
• 
serum prolactin; 
• 
serum pregnancy test (post-pubertal females); 
e) Vital signs – body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic BP;  
f) 12-lead standard ECG; 
g) Tanner Staging; 
h) Suicidality assessment 
i) CGI-C – performed by the Investigator; 
j) CIC – performed by the caregiver; 
k) RCSS; 
l) Motor-Behavioral Assessment Scale;  
m) Caregiver Top 3 Concerns;  
n) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
o) Concomitant medication.  
For patients continuing in Part 1 of the additional open-label extension treatment period: 
p) Obtaining written informed consent; 
q) Medication dispensing for the first 12-week period.  


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Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
Confidential 
11.4.19 Week 54 (Day 378) - Telephone Contact 
A telephone contact will be made with the caregiver at Week 54 to inquire about the occurrence of any 
adverse events or use of concomitant medication; this information will be registered on the appropriate 
CRF page. Overall compliance with the study medication will also be assessed by questioning the 
caregiver. If tolerability issues are noted, appropriate adjustment of the dose will be performed, and the 
patient may be asked to return to the clinic for an unscheduled visit, if necessary.   
11.4.20 Week 60 (Day 420) 
a) Respiratory monitoring in the clinic (SOMNOtouch); 
b) Physical and neurological examinations; 
c) Laboratory evaluations comprising the following tests: 
• 
hematology; 
• 
biochemistry; 
• 
urinalysis; 
d) Vital signs – body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic BP;  
e) 12-lead standard ECG 
f) CGI-C – performed by the Investigator; 
g) CIC – performed by the caregiver; 
h) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
i) Concomitant medication.  
11.4.21 Week 66 (Day 462) - Telephone Contact 
A telephone contact will be made with the caregiver at Week 66 to inquire about the occurrence of any 
adverse events or use of concomitant medication; this information will be registered on the appropriate 
CRF page. Overall compliance with the study medication will also be assessed by questioning the 
caregiver. If tolerability issues are noted, appropriate adjustment of the dose will be performed, and the 
patient may be asked to return to the clinic for an unscheduled visit, if necessary.   
11.4.22 Week 72 (Day 504) 
a) Respiratory monitoring in the clinic (SOMNOtouch); 
b) Physical and neurological examinations; 
c) Ophthalmological examination (including OCT, if feasible for the patient); 
d) Laboratory evaluations comprising the following tests: 
• 
hematology; 
• 
biochemistry; 
• 
urinalysis; 
• 
plasma ACTH and cortisol; 
• 
serum prolactin; 


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• 
serum pregnancy test (post-pubertal females); 
e) Vital signs – body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic BP;  
f) 12-lead standard ECG; 
g) Tanner Staging; 
h) Suicidality assessment 
i) CGI-C – performed by the Investigator; 
j) CIC – performed by the caregiver; 
k) RCSS; 
l) Motor-Behavioral Assessment Scale;  
m) Caregiver Top 3 Concerns;  
n) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
o) Concomitant medication.  
11.4.23 Week 78 (Day 546) - Telephone Contact 
A telephone contact will be made with the caregiver at Week 78 to inquire about the occurrence of any 
adverse events or use of concomitant medication; this information will be registered on the appropriate 
CRF page. Overall compliance with the study medication will also be assessed by questioning the 
caregiver. If tolerability issues are noted, appropriate adjustment of the dose will be performed, and the 
patient may be asked to return to the clinic for an unscheduled visit, if necessary.   
11.4.24 Week 84 (Day 588) 
a) Respiratory monitoring in the clinic (SOMNOtouch); 
b) Physical and neurological examinations; 
c) Laboratory evaluations comprising the following tests: 
• 
hematology; 
• 
biochemistry; 
• 
urinalysis; 
d) Vital signs – body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic BP;  
e) 12-lead standard ECG 
f) CGI-C – performed by the Investigator; 
g) CIC – performed by the caregiver; 
h) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
i) Concomitant medication.  
11.4.25 Week 90 (Day 630) - Telephone Contact 
A telephone contact will be made with the caregiver at Week 90 to inquire about the occurrence of any 
adverse events or use of concomitant medication; this information will be registered on the appropriate 


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CRF page. Overall compliance with the study medication will also be assessed by questioning the 
caregiver. If tolerability issues are noted, appropriate adjustment of the dose will be performed, and the 
patient may be asked to return to the clinic for an unscheduled visit, if necessary.   
11.4.26 Week 96 (Day 672 or early discontinuation)  
These assessments will serve as the final evaluations for patients who are not continuing treatment in 
Part 2 of the additional open-label extension period (through Week 144): 
a) Respiratory monitoring in the clinic (SOMNOtouch); 
b) Physical and neurological examinations; 
c) Ophthalmological examination (including OCT, if feasible for the patient); 
d) Laboratory evaluations comprising the following tests: 
• 
hematology; 
• 
biochemistry; 
• 
urinalysis; 
• 
plasma ACTH and cortisol; 
• 
serum prolactin; 
• 
serum pregnancy test (post-pubertal females); 
e) Vital signs – body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic BP;  
f) 12-lead standard ECG; 
g) Tanner Staging; 
h) Suicidality assessment 
i) CGI-C – performed by the Investigator; 
j) CIC – performed by the caregiver; 
k) RCSS; 
l) Motor-Behavioral Assessment Scale;  
m) Caregiver Top 3 Concerns;  
n) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
o) Concomitant medication.  
For patients continuing in Part 2 of the additional open-label extension treatment period: 
p) Obtaining written informed consent;  
q) Medication dispensing for the first 12-week period.  
11.4.27 Week 102 (Day 714) - Telephone Contact 
A telephone contact will be made with the caregiver at Week 102 to inquire about the occurrence of any 
adverse events or use of concomitant medication; this information will be registered on the appropriate 
CRF page. Overall compliance with the study medication will also be assessed by questioning the 


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Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
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caregiver. If tolerability issues are noted, appropriate adjustment of the dose will be performed, and the 
patient may be asked to return to the clinic for an unscheduled visit, if necessary.   
11.4.28 Week 108 (Day 756) 
a) Respiratory monitoring in the clinic (SOMNOtouch); 
b) Physical and neurological examinations; 
c) Laboratory evaluations comprising the following tests: 
• 
hematology; 
• 
biochemistry; 
• 
urinalysis; 
d) Vital signs – body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic BP;  
e) 12-lead standard ECG 
f) CGI-C – performed by the Investigator; 
g) CIC – performed by the caregiver; 
h) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
i) Concomitant medication.  
11.4.29 Week 114 (Day 798) - Telephone Contact 
A telephone contact will be made with the caregiver at Week 114 to inquire about the occurrence of any 
adverse events or use of concomitant medication; this information will be registered on the appropriate 
CRF page. Overall compliance with the study medication will also be assessed by questioning the 
caregiver. If tolerability issues are noted, appropriate adjustment of the dose will be performed, and the 
patient may be asked to return to the clinic for an unscheduled visit, if necessary.   
11.4.30 Week 120 (Day 840) 
a) Respiratory monitoring in the clinic (SOMNOtouch); 
b) Physical and neurological examinations; 
c) Ophthalmological examination (including OCT, if feasible for the patient); 
d) Laboratory evaluations comprising the following tests: 
• 
hematology; 
• 
biochemistry; 
• 
urinalysis; 
• 
plasma ACTH and cortisol; 
• 
serum prolactin; 
• 
serum pregnancy test (post-pubertal females); 
e) Vital signs – body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic BP;  
f) 12-lead standard ECG; 


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Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
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g) Tanner Staging; 
h) Suicidality assessment 
i) CGI-C – performed by the Investigator; 
j) CIC – performed by the caregiver; 
k) RCSS; 
l) Motor-Behavioral Assessment Scale;  
m) Caregiver Top 3 Concerns;  
n) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
o) Concomitant medication.  
11.4.31 Week 126 (Day 882) - Telephone Contact 
A telephone contact will be made with the caregiver at Week 126 to inquire about the occurrence of any 
adverse events or use of concomitant medication; this information will be registered on the appropriate 
CRF page. Overall compliance with the study medication will also be assessed by questioning the 
caregiver. If tolerability issues are noted, appropriate adjustment of the dose will be performed, and the 
patient may be asked to return to the clinic for an unscheduled visit, if necessary.   
11.4.32 Week 132 (Day 924) 
a) Respiratory monitoring in the clinic (SOMNOtouch); 
b) Physical and neurological examinations; 
c) Laboratory evaluations comprising the following tests: 
• 
hematology; 
• 
biochemistry; 
• 
urinalysis; 
d) Vital signs – body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic BP;  
e) 12-lead standard ECG 
f) CGI-C – performed by the Investigator; 
g) CIC – performed by the caregiver; 
h) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
i) Concomitant medication.  
11.4.33 Week 138 (Day 966) - Telephone Contact 
A telephone contact will be made with the caregiver at Week 138 to inquire about the occurrence of any 
adverse events or use of concomitant medication; this information will be registered on the appropriate 
CRF page. Overall compliance with the study medication will also be assessed by questioning the 
caregiver. If tolerability issues are noted, appropriate adjustment of the dose will be performed, and the 
patient may be asked to return to the clinic for an unscheduled visit, if necessary.   


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11.4.34 Week 144 (Day 1008 or early discontinuation)  
These assessments will serve as the final evaluation for patients who are not continuing treatment in 
Part 3 of the of the additional open-label extension period (through Week 192). 
a) Respiratory monitoring in the clinic (SOMNOtouch); 
b) Physical and neurological examinations; 
c) Ophthalmological examination (including OCT, if feasible for the patient); 
d) Laboratory evaluations comprising the following tests: 
• 
hematology; 
• 
biochemistry; 
• 
urinalysis; 
• 
plasma ACTH and cortisol; 
• 
serum prolactin; 
• 
serum pregnancy test (post-pubertal females); 
e) Vital signs – body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic BP;  
f) 12-lead standard ECG; 
g) Tanner Staging; 
h) Suicidality assessment 
i) CGI-C – performed by the Investigator; 
j) CIC – performed by the caregiver; 
k) RCSS; 
l) Motor-Behavioral Assessment Scale;  
m) Caregiver Top 3 Concerns;  
n) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
o) Concomitant medication.  
For patients continuing in Part 3 of the additional open-label extension treatment period: 
p) Obtaining written informed consent; 
q) Medication dispensing for the first 12-week period. 
11.4.35 Week 150 (Day 1050) - Telephone Contact 
A telephone contact will be made with the caregiver at Week 150 to inquire about the occurrence of any 
adverse events or use of concomitant medication; this information will be registered on the appropriate 
CRF page. Overall compliance with the study medication will also be assessed by questioning the 
caregiver. If tolerability issues are noted, appropriate adjustment of the dose will be performed, and the 
patient may be asked to return to the clinic for an unscheduled visit, if necessary.   
 


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11.4.36 Week 156 (Day 1092)  
a) Respiratory monitoring in the clinic (SOMNOtouch); 
b) Physical and neurological examinations; 
c) Laboratory evaluations comprising the following tests: 
• 
hematology; 
• 
biochemistry; 
• 
urinalysis; 
d) Vital signs – body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic BP;  
e) 12-lead standard ECG 
f) CGI-C – performed by the Investigator; 
g) CIC – performed by the caregiver; 
h) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
i) Concomitant medication.  
11.4.37 Week 162 (Day 1134) - Telephone Contact 
A telephone contact will be made with the caregiver at Week 162 to inquire about the occurrence of any 
adverse events or use of concomitant medication; this information will be registered on the appropriate 
CRF page. Overall compliance with the study medication will also be assessed by questioning the 
caregiver. If tolerability issues are noted, appropriate adjustment of the dose will be performed, and the 
patient may be asked to return to the clinic for an unscheduled visit, if necessary.   
11.4.38 Week 168 (Day 1176) 
a) Respiratory monitoring in the clinic (SOMNOtouch); 
b) Physical and neurological examinations; 
c) Ophthalmological examination (including OCT, if feasible for the patient); 
d) Laboratory evaluations comprising the following tests: 
• 
hematology; 
• 
biochemistry; 
• 
urinalysis; 
• 
plasma ACTH and cortisol; 
• 
serum prolactin; 
• 
serum pregnancy test (post-pubertal females); 
e) Vital signs – body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic BP;  
f) 12-lead standard ECG; 
g) Tanner Staging; 
h) Suicidality assessment 


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i) CGI-C – performed by the Investigator; 
j) CIC – performed by the caregiver; 
k) RCSS; 
l) Motor-Behavioral Assessment Scale;  
m) Caregiver Top 3 Concerns;  
n) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
o) Concomitant medication.  
11.4.39 Week 174 (Day 1218) - Telephone Contact 
A telephone contact will be made with the caregiver at Week 174 to inquire about the occurrence of any 
adverse events or use of concomitant medication; this information will be registered on the appropriate 
CRF page. Overall compliance with the study medication will also be assessed by questioning the 
caregiver. If tolerability issues are noted, appropriate adjustment of the dose will be performed, and the 
patient may be asked to return to the clinic for an unscheduled visit, if necessary.   
11.4.40 Week 180 (Day 1260) 
a) Respiratory monitoring in the clinic (SOMNOtouch); 
b) Physical and neurological examinations; 
c) Laboratory evaluations comprising the following tests: 
• 
hematology; 
• 
biochemistry; 
• 
urinalysis; 
d) Vital signs – body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic BP;  
e) 12-lead standard ECG 
f) CGI-C – performed by the Investigator; 
g) CIC – performed by the caregiver; 
h) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
i) Concomitant medication.  
11.4.41 Week 186 (Day 1302) - Telephone Contact 
A telephone contact will be made with the caregiver at Week 186 to inquire about the occurrence of any 
adverse events or use of concomitant medication; this information will be registered on the appropriate 
CRF page. Overall compliance with the study medication will also be assessed by questioning the 
caregiver. If tolerability issues are noted, appropriate adjustment of the dose will be performed, and the 
patient may be asked to return to the clinic for an unscheduled visit, if necessary.   
11.4.42 Week 192 (Day 1344 or early discontinuation) – Final Evaluation 
a) Respiratory monitoring in the clinic (SOMNOtouch); 
b) Physical and neurological examinations; 


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c) Ophthalmological examination (including OCT, if feasible for the patient); 
d) Laboratory evaluations comprising the following tests: 
• 
hematology; 
• 
biochemistry; 
• 
urinalysis; 
• 
plasma ACTH and cortisol; 
• 
serum prolactin; 
• 
serum pregnancy test (post-pubertal females); 
e) Vital signs – body weight, height, temperature, respiratory rate, pulse, and systolic and diastolic BP;  
f) 12-lead standard ECG; 
g) Tanner Staging; 
h) Suicidality assessment 
i) CGI-C – performed by the Investigator; 
j) CIC – performed by the caregiver; 
k) RCSS; 
l) Motor-Behavioral Assessment Scale;  
m) Caregiver Top 3 Concerns;  
n) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator;  
o) Concomitant medication.  
11.4.43 Safety Follow-up (14 days after last dose of study medication) 
For patients who discontinue treatment prematurely or complete the initial 24-week open-label extension 
treatment period (Week 48), but don’t continue open-label treatment, as well as those patients who complete 
the extension treatment period (Week 192), or discontinue treatment prematurely during open-label 
treatment, the following assessments will be performed 14 days after the last dose of study medication:  
a) Vital signs – body weight, temperature, respiratory rate, pulse, and systolic and diastolic BP; 
b) Adverse Events (AEs) – reported by the patient/caregiver or observed by the Investigator. 
All patients will be followed up for 30 days after the last dose of study medication regarding the occurrence 
of Serious Adverse Events. 
 
Visit Windows  
A window of ± 2 days will be allowed on the Day 14 visit; a window of ± 7 days will be permitted for each 
of the visits at Weeks 8, 16 and 24 during the initial treatment period, and the visits at Weeks 40, 48, 60, 
72, 84, 96, 108, 120, 132, 144, 156, 168, 180 and 192 during the extension treatment period; and a window 
of ± 3 days will be permitted for the visits at Weeks 28 and 32 during the extension treatment period.  
Telephone contacts in the extension treatment period on Days 175 and 203 should be made within ± 1 day 
of the scheduled date, while those scheduled for Weeks 54, 66, 78, 90, 102, 114, 126, 138, 150, 162, 174 


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and 186 should be performed within ± 7 days of the scheduled date.  The overall window for the completion 
of each part of the additional extension period of the study is ± 14 days for Week 96 (end of Part 1), ± 28 
days for Week 144 (end of Part 2), and ± 28 days for Week 192 (end of Part 3).  
 
11.5 Concomitant Medications 
Patients enrolled in the study must be on a stable medication regimen for 4 weeks prior to beginning the 
screening period (if receiving services - physical, occupational, or speech therapy - subjects must be on a 
stable regimen of these services for 3 months prior to beginning the study). Any medication (including 
over-the-counter medications), in addition to the study medication, that is administered during the study 
from the start of the screening period through to the final evaluations at Week 48, 96, 144 or 192 (Day 336, 
672, 1008 or 1344, or at early discontinuation) must be recorded in the CRF.  Patients/caregivers will be 
instructed to contact the Investigator for approval prior to taking any new medications, while residing at 
home and prior to their final evaluation.   
The following guidelines regarding use of concomitant medications must be followed:  
- 
Patients must not take any investigational agent within 2 months or 5 half-lives, whichever is 
longer, prior to screening; 
- 
Use of other 5-HT1a agonists, e.g. buspirone, is permitted during the study, provided the patient is 
on a stable dose for at least 4 weeks prior to screening.  However, addition of a 5-HT1a agonist 
during the treatment period is not permitted;  
- 
Care should be taken when sarizotan is administered in patients taking warfarin or other 
medications that are highly bound to plasma albumin; 
- 
Patients with a history of seizures who are receiving a stable dose of anti-seizure medication for at 
least 4 weeks prior to baseline will be eligible for the study, and will be allowed to continue on the 
medication.  
 


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12 SAFETY AND EFFICACY EVALUATIONS 
 
12.1 Safety Assessments  
The assessment of safety will be based on the following: 
a) laboratory tests (biochemistry, hematology, urinalysis, serum prolactin, and plasma ACTH and 
cortisol levels),  
b) 12-lead standard ECG, 
c) vital signs (body weight, height, temperature, pulse, systolic and diastolic BP, and respiratory rate), 
d) physical examinations, 
e) neurological examinations,  
f) routine ophthalmology examination (including OCT, if feasible for the patient); 
g) 12-lead standard ECG, 
h) subjective reporting of any AE by the patient/caregiver, 
i) objective observation of any AE by the Investigator, 
j) Tanner Staging,  
k) Suicidality assessment. 
The investigator will be asked to comment on any clinically significant abnormal test results. 
12.1.1 Physical and Neurological Examinations 
A physical examination will be performed according to the Schedule of Evaluations (Tables 6A, 6B, 6C, 
6D and 6E). The findings will be entered on the Physical Examination section of the Case Report Form. 
The physical examination will include an examination of general appearance, skin, neck (including 
thyroid), eyes and ears, nose, mouth, throat, lungs, heart, abdomen, back, lymph nodes, extremities and 
nervous system.  Genital, urinary tract and rectal examination will not be done on a routine basis.   
A neurological examination will be performed according to the Schedule of Evaluations (Tables 6A, 6B, 
6C, 6D and 6E). The findings will be entered on the Neurological Examination section of the Case Report 
Form. The neurological examination includes the following: evaluation of mental status, cranial nerves, 
muscle strength and tone, reflexes, the sensory system, coordination and gait.  
12.1.2 Vital Signs  
Vital signs assessments will be performed at all scheduled evaluations (Tables 6A, 6B, 6C, 6D and 6E).  
Vital signs will include, body weight, temperature, pulse, systolic and diastolic blood pressure, and 
respiratory rate.  Pulse and blood pressure will be measured after the subject has been resting for at least 5 
minutes. At the baseline visit, on Day 0 or at least 1 hour prior to the first dose of study medication on Day 
1, measurements of blood pressure and pulse will be repeated 3 times, at least 10 minutes apart, and the 
values will be averaged to obtain the baseline values.  In addition, height will be measured at Screening and 
Baseline, and at 8-week or 12-week intervals throughout the study.   
In the extension treatment period, vital signs assessments will be performed prior to the first dose of study 
medication on Day 168 (final Week 24 assessment from the double-blind period), and repeated at 1 and 4 
hours post-dose.  Similarly, pre- and post-dose assessments will be performed on Day 196 (Week 28) for 
the first administration of the target dose (10 mg bid). 


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If a change of clinical relevance from pre-dose to post-dose is observed, the vital signs assessment should 
be repeated as often as needed, at the discretion of the Investigator.  Findings should be documented on the 
Vital Signs section of the Case Report Form.   
12.1.3 Electrocardiogram (ECG) 
All subjects will have a standard 12-lead ECG performed as specified in the schedule of evaluations (see 
Tables 6A, 6B, 6C, 6D and 6E).  At baseline (Day 1), At the baseline visit, on Day 0 or at least 1 hour prior 
to the first dose of study medication on Day 1, the ECG evaluation will be repeated 3 times, at least 10 
minutes apart, and the values for the different parameters will be averaged to obtain the baseline values; the 
ECG will be repeated at 1 and 4 hours post-dose. Each ECG should be performed before collecting the 
scheduled blood sample for PK assessments.  
In the extension treatment period, ECG assessments will be performed prior to the first dose of study 
medication on Day 168 (final Week 24 assessment from the double-blind period), and repeated at 1 and 4 
hours post-dose.  Similarly, pre- and post-dose assessments will be performed on Day 196 (Week 28) for 
the first administration of the target dose (10 mg bid). 
To ensure consistency in the data analysis across subjects, all ECGs will be sent to a central ECG monitoring 
service (QECG) upon completion of each cohort; however, the ‘real-time’ review and interpretation of the 
12-lead ECGs that will be used for determination of a subject’s eligibility for enrollment in the trial, as well 
as post-dose safety monitoring, will be performed by a physician at the investigational site.  One copy of 
the ECG tracing will be retained in the subject’s records, one will be retrieved by the monitor, and a third 
will be provided to the central ECG reader for analysis.  The ECG read out must be reviewed by the 
investigator, initialed and dated, and copies inserted in the subject’s records and attached to the CRF.   
Each ECG tracing must have the following information entered on it: 
• 
Study number, 
• 
Subject’s number and initials, 
• 
Date and time ECG obtained. 
If clinically significant abnormalities are found, the subject’s ECG should be repeated at regular intervals 
until it returns to normal.   
Details of the procedures related to the centralized ECG monitoring service (QECG) will be provided in a 
separate manual prepared by the ECG Vendor. 
12.1.4 Drug levels and pharmacokinetic assessments 
Blood samples will be collected for PK evaluation at 0 min (before dosing), and 1 and 4 hours after the first 
dose of study drug is administered on Day 1. Additional blood samples for PK assessments will be taken 
on Day 15, just before the morning dose (steady state trough level) and at 1 and 4 hr after dosing.  Samples 
will be frozen and stored at < -70°C pending analysis. A window of ± 15 min will be allowed on the timing 
of these samples.   
12.1.5 Laboratory Evaluations 
Blood and urine samples for laboratory tests will be collected at the visits specified in the schedule of 
evaluations (see Tables 6A, 6B, 6C, 6D and 6E).  Evaluations of the hematology, biochemistry and 
urinalysis analytes listed in Table 7 will be performed at these scheduled visits.  In addition, virology tests 
(hepatitis B core and surface antibodies and surface antigen, and hepatitis C antibodies, and a HIV test) and 
tests of thyroid function (TSH, free thyroxine [T4] and triiodothyronine [T3]) will be performed at screening 
only.  Plasma ACTH and cortisol levels will be measured at Baseline and Day 2, and at Weeks 16 and 24 


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during the initial treatment period, and at Weeks 48, 72, 96, 120, 144, 168 and 192 in the extension treatment 
period.  Serum prolactin levels will be measured at Baseline and at Weeks 16 and 24 during the initial 
treatment period, and at Weeks 48, 72, 96, 120, 144, 168 and 192 in the extension treatment period.  A 
serum pregnancy test will be performed at Screening and Baseline and at Weeks 24, 48, 72, 96, 120, 144, 
168 and 192 (or at early discontinuation) for all post-pubertal females; a positive test result would exclude 
the patient from the study.   
 
 
Table 7. Summary of laboratory analytes 
Hematology 
Clinical Chemistry 
Urinalysis 
Hematocrit 
Sodium 
Triglycerides 
pH 
Hemoglobin 
Potassium 
AST 
Specific gravity 
RBC count 
Chloride 
ALT 
Protein 
WBC count 
Bicarbonate 
Alkaline phosphatase 
Glucose 
Differential WBC count 
Calcium 
GT  
Ketones 
Platelets 
Glucose 
LDH 
RBC, WBC, casts 
 
BUN 
Total cholesterol 
Nitrites 
 
Creatinine 
HDL, LDL, VLDL 
Bilirubin 
 
Total bilirubin 
CPK 
Hemoglobin 
 
Albumin 
Total protein 
 
Special Diagnostic Tests Thyroid function: TSH, free thyroxine (T4), and triiodothyronine (T3) 
(Screening only) 
Virology: Hepatitis B and C; HIV (Screening only) 
HPA axis: Plasma ACTH and cortisol levels (Baseline, Day 2 and Weeks 16, 24, 48, 72, 96, 120, 144, 
168 and 192)  
Prolactin: Serum prolactin (Baseline, and Weeks 16, 24, 48, 72, 96, 120, 144, 168 and 192) 
Serum pregnancy test: Post-pubertal females (Screening, Baseline, and Weeks 24, 48, 72, 96, 120, 144, 
168 and 192) 
MECP2 genetic mutation testing (optional): Only if prior test results from an accredited laboratory are 
not available (Screening) 
 
The Investigator must review screening laboratory values prior to the first administration of the study agent, 
to ensure that the subject meets the protocol’s inclusion/exclusion criteria.  The Investigator must review 
post-dose laboratory values within 24 hours of receipt of the laboratory report.  After the review is 
completed, the Investigator must sign and date each laboratory report. 
The laboratory will provide normal reference ranges for the laboratory tests on the laboratory results report.  
A value is normal when it falls on or within the upper and lower limits of the reference range.  A value is 
abnormal when it exceeds the upper or lower limit of the reference range.  The laboratory will flag all 
abnormal and clinically notable values (defined in Appendix 2) on the laboratory report, will provide the 
normal reference ranges for each parameter, and will verify that the result is not due to pre-analytical 
problems (e.g., sample taken improperly, sample stored incorrectly, sample labeled incorrectly) or to 
analytical problems (e.g., machine not accurately calibrated, technical problems with equipment or 
reagents, or deterioration of analyte). 


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In cases where a patient is unable to get to the clinic for a scheduled laboratory test, or when a follow-up 
laboratory test is required for safety reasons, the test may be performed by a local laboratory, rather than 
the central laboratory designated for the study. The results of the test(s) performed by the local laboratory 
will be reported to the Investigator, and a copy of the laboratory report will be included in the patient’s 
study file.  
The Investigator must evaluate any change of clinical relevance from pre-dose to post-dose in a laboratory 
test as to whether it meets the definition of an adverse event, and repeat, if needed, any clinically significant 
abnormal laboratory test.  Any laboratory abnormalities meeting the definition of an adverse event should 
be recorded on the Adverse Events CRF. 
Refer to Section 13.0, “Reporting Safety Information” for further directions. 
12.1.6 Routine Ophthalmological Examination  
A routine ophthalmological examination will be performed, preferably by a qualified ophthalmologist on 
each patient at Baseline and at Weeks 16 and 24 (or at early discontinuation) during the initial treatment 
period, and at Weeks 48, 72, 96, 120, 144, 168 and 192 (or at early discontinuation) in the extension 
treatment period.  Any newly emergent findings noted after initiation of treatment with the study medication 
should be commented on by the ophthalmologist, in particular, the potential relationship of the findings to 
the study medication.   
The battery of tests to be performed has been designed to ensure the patient’s safety, take the least amount 
of physician time and conform to regulatory requirements. The following evaluations should be performed, 
if possible: 
• 
Visual acuity: should be determined using tests appropriate for the patient’s disability; both eyes 
should be assessed, and abnormalities should be listed. 
• 
Lens 
• 
Intra-ocular pressure 
• 
Fundus: examination should be performed with dilation of the pupils and include determination of 
the presence of retinal pigmentation, changes in the vasculature, appearance of the fundus and the 
macula, as well as other adventitious changes. Each eye should be assessed as “normal” or 
“abnormal” and any abnormality should be listed. When possible, pictures of the fundus should be 
taken using 3 views (disc center, macula center and temporal to macula). 
• 
Optical Coherence Tomography (OCT): OCT is an optical signal acquisition and processing 
method that allows for high-quality, micrometer-resolution retinal images to be obtained. OCT 
should be performed only if feasible, based on the patient’s condition.  
If any part of the planned battery of tests cannot be performed due to the patient’s condition or inability to 
comply with the procedures, this should be documented in the CRF.  
12.1.7 Adverse Events 
All adverse events (AEs) experienced by the patient and observed by the caregiver while the patient is 
residing at home or observed by the Investigator during a hospital/clinic visit should be report on the AE 
CRF.  Many patients with RTT experience seizures as part of their illness; therefore, collection of 
information on seizures will be a focus of AE reporting in this study.  To ensure comprehensive collection 
of information related to seizures, the following questions should be asked of the caregiver at each visit:  


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At Screening:  
• 
Does the patient have a history of seizures? (If the answer is ‘No’, there is no need to ask the 
remaining questions) 
• 
Approximately how many seizures per day did the patient have over the last 2 weeks? 
• 
What type of seizure did the patient have (if known)? 
• 
Is the patient taking any medication to treat seizures? 
• 
If the patient is taking medication for seizures, what is the medication and what is the daily dose? 
At subsequent visits: 
• 
Has there been any change in the frequency or type of seizure the patient is experiencing since the 
last visit? 
• 
If the patient is taking medication for seizures, has there been any change in the medication (e.g. 
type of medication or dose) since the last visit?  
The information collected from this questioning should be reviewed with the Caregiver by the Investigator 
prior to entering it on the appropriate pages of the eCRF.  
12.1.8 Tanner Staging 
The sexual maturity of patients enrolled in the study will be evaluated at baseline and at Weeks 24, 48, 72, 
96, 120, 144, 168 and 192 (or at early discontinuation) during the treatment period using the Tanner scale 
(Marshall and Tanner, 1969; Marshall and Tanner, 1970; see Appendix 7).  The scale defines physical 
measurements of development in children, adolescents and adults based on external primary and 
secondary sex characteristics, such as the size of the breast, genitals, testicular volume and development 
of pubic hair. Due to natural variation, individuals pass through the Tanner stages at different rates, 
depending in particular on the timing of puberty. Tanner Staging will be used to assess potential effects of 
sarizotan on sexual development in the RTT patients.   
12.1.9 Suicidality Assessment  
An assessment of suicidality for patients enrolled in the study has been included, as requested by the 
FDA.  Because of the limited abilities of the RTT patient population, this assessment consists of a simple 
questionnaire to assess suicidality based largely on caregiver reports.  The Sponsor has created a 
structured suicidality assessment query, consisting of 10 questions requiring a Yes/No response, which 
will be administered to caregivers to assess the potential risk for suicide in each patient.  The core 
principles underlying assessment of suicidality are addressed and are mixed with core features/ behaviors 
of patients showing depressed mood prior to suicidal acts.  This assessment will be performed by the 
Investigator or other qualified staff at Baseline, and at scheduled visits at Weeks 8, 24, 48, 72, 96, 120, 
144, 168 and 192 (or at early discontinuation) and will be based on the behavior observed by the 
caregiver during the month prior to the visit.  For each question for which the caregiver has given a 
positive response, the frequency of the behavior (i.e. rarely, regularly), as well as whether it was observed 
recently, should be indicated, and a brief text description provided. 
The Investigator should carefully review the responses prior to deciding the next steps in the management 
of the patient. 
 


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12.2 Efficacy Assessments 
12.2.1 Number of Apnea Episodes (Primary Efficacy Outcome) 
Measurement of specific cardiorespiratory parameters for the assessment of primary and secondary efficacy 
outcomes during the initial 24-week treatment period will performed at home using respiratory inductive 
plethysmography (RIP) coupled with the BioRadioTM wireless physiological monitor (Great Lakes 
Neurotechnologies, Cleveland, Ohio). A brief description of RIP and use of the BioRadio is provided in 
Appendix 5.  The cardio-respiratory data collected using the BioRadio will be analysed and summarized by 
an external vendor, Vivonoetics.  A description of the analysis plan and procedures will be provided in a 
separate document.  
The primary efficacy measure to be used in assessing the efficacy of sarizotan in treating the respiratory 
symptoms associated with RTT will be the percent reduction (change) from baseline in the number of apnea 
episodes (each ≥10 seconds in duration) per hour, during awake time, from baseline to endpoint (Week 24 
or early discontinuation).  This will be calculated from the data obtained during home respiratory 
monitoring.  
Home cardiorespiratory monitoring will be performed during the screening period (three 3-day test periods 
during first 3 weeks) and for 3 days in the week prior to each scheduled clinic visit at Weeks 2, 8, 16 and 
24. Monitoring will be performed when the patient is awake for 6 hours on each of the 3 days. Data from 
all of the quality recording time (minimally 3 hours) in the Screening period and from the week prior to 
each of the visits at Weeks 2, 8, 16 and 24 will be averaged and used in calculating the value for the primary 
efficacy measure. If the patient meets the criterion for number of apnea episodes, as determined by 
Vivonoetics, in any week of the Screening period, home monitoring in the subsequent week(s) would not 
be required, and the screening data would be used to calculate the baseline value for the analyses.  
The caregiver should perform the home monitoring starting at approximately the same time each day.  If 
the patient attends school, the monitoring should be performed when the patients is at home, if at all 
possible; otherwise, it should be noted when the monitoring is performed at school.  
During home monitoring of respiratory function, caregivers should keep a diary and be instructed to record 
any problems that are encountered with the patient during the monitoring session, e.g., the patient is overly 
active or falls asleep, the RIP bands become loose or fall off, or the pulse oximeter becomes loose or falls 
off.  The date and starting time of onset for these problems should be noted.  The time at which the problem 
resolves should also be noted.  The diary should be brought to the hospital/clinic at each scheduled visit, 
and the information from the diary will be used in the analysis of the BioRadio data.  
Additional assessments of the respiratory outcomes will be performed at the hospital at Baseline and at the 
Week 16 and 24 visits, using the SOMNOtouch™ (SOMNOmedics GmBH, Randersacker, Germany), a 
stretch-sensitive resistance plethysmograph device similar to the BioRadio.  A period of approximately 1 
hour of cardiorespiratory monitoring using the SOMNOtouch will be performed at each of these visits.  
Data collected using the SOMNOtouch will be analysed and summarized by an external vendor, 
Vivonoetics. 
During the open-label extension phase of the study, patients will return for visits every 4, 8 or 12 weeks, 
and respiratory assessments will be performed in the clinic using the SOMNOtouch at Weeks 28, 32, 40, 
48, 60, 72, 84, 96, 108, 120, 132, 144, 156, 168, 180 and 192 (or at early discontinuation). Respiratory 
parameters derived from the SOMNOtouch data will be similar to those from the BioRadio, including apnea 
episodes. Efficacy data from the extension period from patients randomized to sarizotan at Baseline will be 
analysed to determine if there is any attenuation of the benefit noted during the first six months. In addition, 
a comparison will be made between patients who received sarizotan throughout both periods of the study 


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and those who were randomized to placebo in the double-blind period and switched to sarizotan in the open-
label extension period.  
12.2.2 Caregiver-rated Impression of Change (CIC) 
The key secondary efficacy outcome will be the difference between sarizotan and placebo on the Caregiver-
rated Impression of Change (CIC) from baseline, a 7-point Likert-type scale for which ratings range from 
1 = very much improved to 7 = very much worse, with 4 = no change. This caregiver-rated measure will 
take into account activities, behavior, mood and functioning.  This rating will be performed in consultation 
with the study Investigator, but should be based largely on the caregivers’ evaluation during the reporting 
period. The rating of the CIC would be based on changes in the following domains:  
• 
Activities (watching TV, interest in conversations around her, cooperation during toileting, 
dressing/bathing, etc.) 
• 
Communication (verbal or by eye movements, hand movements, or head movements) 
• 
Behavior (agitation, refusal to feed, scratching, social avoidance) 
• 
Participation in family/outdoor/social events, etc. 
The CIC assessment will be conducted on Day 14, and at Weeks 8, 16 and 24 (or at early discontinuation) 
during the initial double-blind treatment period, and will be based on the patient’s condition at the Baseline 
visit.  In the open-label extension treatment period, the CIC assessment will be performed at Weeks 28, 32, 
40, 48, 60, 72, 84, 96, 108, 120, 132, 144, 156, 168, 180 and 192 (or at early discontinuation), and will be 
based on the patient’s condition at the Week 24 visit.  
12.2.3 Clinical Global Impression of Change (CGI-C) 
The CGI (Guy 1976) is the general name for 2 scales: the CGI-Severity (CGI-S) measures global severity 
of illness at a given point in time, and the CGI-Change (CGI-C) measures change from the baseline state at 
each visit following the baseline visit. Whenever possible, the CGI scale must be completed by the same 
clinician for every assessment; if this is not possible, the rating clinician should review the subject’s 
presentation (along with review of clinical notes) with the rater who completed the initial evaluation. 
In the current study the CGI-C rating scale permits a global evaluation of the subject’s improvement or 
worsening over time. At each post-baseline visit, the rater will assess the change in the subject’s symptoms 
of RTT relative to the symptoms at baseline using a 7-point scale, ranging from 1 (very much improved) to 
7 (very much worse), with a score of 4 indicating no change. The CGI-C assessment will be conducted on 
Day 14, and at Weeks 8, 16 and 24 (or at early discontinuation) during the initial double-blind treatment 
period, and will be based on the patient’s condition at the Baseline visit. In the open-label extension 
treatment period, the CGI-C assessment will be performed at Weeks 28, 32, 40, 48, 60, 72, 84, 96, 108, 120, 
132, 144, 156, 168, 180 and 192 (or at early discontinuation), and will be based on the patient’s condition 
at the Week 24 visit. It is recommended that recently published guidelines for rating the CGI-C in RTT 
patients are followed for completing this assessment (Neul et al, 2015).  
12.2.4 Other Respiratory Symptoms of RTT 
The effect of sarizotan on the following respiratory symptoms of RTT will be evaluated:  
• 
Percent time spent with breathing dysrhythmia (% time apnea + % time hyperventilation) per hour; 
• 
Number of hyperventilation episodes (≥10 seconds each) per hour;  
• 
Oxygen saturation (number of episodes of oxygen desaturation below 90% per hour).  


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• 
Respiratory Distress Index - The sum of the following parameters calculated per hour of 
wakefulness: 1) number of breath-holding episodes, 2) number of episodes of hyperventilation [1 
and 2 are as defined in inclusion criteria; each would have to be ≥10 seconds in duration], and 3) 
number of drops in oxygen values to < 90%.  
Data for determination of these additional respiratory outcome parameters will be collected during home 
cardiorespiratory recording using the BioRadio.  
12.2.5 Motor-Behavioral Assessment Scale 
The Motor-Behavioral Assessment Scale (Fitzgerald, Jankovic and Percy, 1990) is comprised of three sub-
scales: 
I. 
Behavioral/Social Assessment (16 items): regression of motor skills; regression of 
communication skills; poor eye/social contact; lack of sustained interest; irritability, crying 
tantrums; overactive or over-passive; does not reach for objects or people; does not respond to 
spoken words when addressed by examiners or parents, acts as deaf even to loud noises; feeding 
difficulties; chewing difficulties; lack of toilet training; masturbation; self-mutilation/pulling 
hair or ears, scratching, etc.; aggressive behavior; seizures; apparent insensitivity to pain;  
II. 
Orofacial/Respiratory Assessment (7 items): speech disturbance; bruxism; breath holding; 
hyperventilation; air-saliva expulsion/drooling; mouthing of hands and objects; biting self and 
others; 
III. 
Motor Assessment/Physical Signs (14 items): hand clumsiness; stereotypic hand washing, 
rubbing, clapping, stroking, kneading; ataxia/apraxia (gait and trunk) or no gait; truncal 
rocking/shifting weight; oculogyric movements; bradykinesia; dystonia; hypomimia; scoliosis; 
myoclonus; dyskinesias including chorea/athetosis or oromotor; hypertonia/rigidity; 
hyperreflexia; vasomotor disturbance.  
Each item is rated on a scale from 0 to 4, with ‘0’ indicating normal or never, and ‘4’ indicating very severe 
or constant. This assessment will be performed at Baseline and at Weeks 8, 16, and 24 during the initial 
treatment period, and at Weeks 48, 72, 96, 120, 144, 168 and 192 (or at early discontinuation) in the 
extension treatment period.  
12.2.6 Caregiver Top 3 Concerns 
The severity of patient symptoms will be assessed using the Caregiver Top 3 Concerns scale, which uses a 
100-mm visual analogue scale (VAS).  The caregiver will select the 3 symptoms that are most problematic 
at baseline from a list of 12 possible concerns, and will rate each one using the VAS to indicate the severity 
on a scale of 0 to 100.  The same 3 symptoms will be rated using the VAS at the scheduled visits at Weeks 
8, 16, and 24 in the initial treatment period, and Weeks 48, 72, 96, 120, 144, 168 and 192 (or at early 
discontinuation) in the extension treatment period.  
The concerns from which the caregivers will select their top 3 are listed alphabetically below: 
• 
Aggression/frustration (head banging, screaming, spitting) 
• 
Anxiety 
• 
Difficulties with activities of daily living (toileting, feeding, grooming) 
• 
GI problems – constipation, bloating 
• 
Inappropriate social contact/avoids eye to eye contact, etc. 
• 
Involuntary/repetitive/non-purposeful hand movements, hand wringing, mouthing, etc. 


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• 
Lack of communication 
• 
Lack of hand use 
• 
Motor problems; difficulty with ambulation 
• 
Respiratory difficulties (breath holding - apnea, hyperventilation, air/saliva expulsion/ drooling) 
• 
Seizures 
• 
Self-mutilation.  
12.2.7 Rett Syndrome Clinical Severity Scale (RCSS) 
The RCSS is a scale specifically designed to assess the severity of symptoms of RTT (Neul et al, 2008).  
This 13-item measure provides a clinician rating of core symptoms of Rett syndrome on a Likert scale of 
either 0 to 4 or 0 to 5 with a maximum total score of 58.  The Investigator will use the scale to rate the 
following: frequency and manageability of seizures, respiratory irregularities, scoliosis, ability to walk (gait 
apraxia), hand use, speech and sleep.  A total score, as well as feature-specific scores will be calculated.  
This scale will be assessed at Baseline and Week 24 (or early discontinuation) in the initial treatment period, 
and Weeks 48, 72, 96, 120, 144, 168 and 192 (or early discontinuation) in the extension treatment period.  
12.2.8 Rater Training 
A multicenter Investigators’ Meeting will be held to standardize test procedures and consistency of ratings 
across centers for each of the rating scales, except the CIC and Caregiver Top 3 Concerns, which will be 
rated by the caregiver.  
To ensure the sensitivity and reliability of the assessments, it is requested that the same evaluator at the site 
conduct the CGI-C, and the same caregiver perform the rating of the Caregiver Top 3 Concerns and CIC, 
at every visit.  It is recognized that it will sometimes not be possible to meet this condition, but every 
reasonable effort should be made to ensure uniform conditions across evaluations.  
 


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13 REPORTING SAFETY INFORMATION 
13.1 Adverse Events 
Adverse Event evaluations will be performed during the screening period, at baseline and at each visit of 
the study.  Untoward medical events will be collected, from the time of signing of Informed Consent to the 
end of the safety follow-up period (14 days after last dose of study medication).  All Adverse Events will 
be recorded in the CRF.  In addition, all subjects will be followed up for 30 days after their last dose of 
study medication for the occurrence of any Serious AE.   
13.1.1 Glossary 
Adverse Drug Reaction (ADR) 
In the pre-approval clinical experience with a new medicinal product or its new usages, particularly as the 
therapeutic dose(s) may not be established, all noxious and unintended responses to a medicinal product 
related to any dose should be considered adverse drug reactions. The phrase “response to a medicinal 
product” means that a causal relationship between a medicinal product and an adverse event is at last a 
reasonable possibility, i.e., the relationship cannot be ruled out. 
Adverse Event (AE) 
An AE is any untoward medical occurrence in a patient or clinical investigation subject administered a 
pharmaceutical product and that does not necessarily have a causal relationship with this treatment. An AE 
can therefore be any unfavorable and unintended sign (including an abnormal laboratory finding), symptom, 
or disease temporally associated with the use of a medicinal (investigational) product, whether or not related 
to the medicinal (investigational) product. 
Serious Adverse Event (SAE) or Serious Adverse Drug Reaction (Serious ADR) 
Any untoward medical occurrence that at any dose: 
• 
Results in death, 
• 
Is life-threatening, i.e., an event which, in the view of the Investigator, places the subject at 
immediate risk of death from the event as it occurred (it does not include an event which 
hypothetically might have caused death if it were more severe) 
• 
Requires inpatient hospitalization or prolongation of existing hospitalization, 
• 
Results in persistent or significant disability/incapacity, 
• 
Is a congenital anomaly/birth defect (if exposure to product just before conception or during 
pregnancy resulted in an adverse outcome in the child), or  
• 
Is an important medical event that may jeopardize the subject or may require medical intervention 
to prevent one of the outcomes listed above.  
Symptoms or medically significant laboratory or instrumental (e.g., electrocardiographic) abnormalities of 
a pre-existing disease, such as cancer or other disease, should not be considered an adverse event.  However, 
occurrence of new symptoms, or laboratory or instrumental abnormalities, as well as worsening of pre-
existing ones, are considered adverse events. Planned procedures that require hospitalization will not be 
considered SAEs.   


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Unexpected Adverse Drug Reaction 
An Unexpected Adverse Drug Reaction is adverse event, the nature or severity of which is not consistent 
with the applicable product information (e.g., Investigator’s Brochure for an unapproved investigational 
product or package insert/summary of product characteristics for an approved product).  
Non-Serious Adverse Event 
A non-serious adverse event is any adverse event that does not meet the criteria listed above for a serious 
adverse event. 
Treatment-Emergent Adverse Events 
Adverse events that are newly occurring or worsened in severity after administration of the study 
medication are considered to be treatment-emergent AEs (TEAEs). In the open-label extension period, only 
newly occurring AEs and AEs that were ongoing at Week 24 and worsen in severity will be considered 
TEAEs.  
13.1.2 Data Collection 
For each event, record the following information on the Adverse Event section of the Case Report Form: 
• Classification of the Event: Classify the event as either serious or non-serious  
• Description of Signs or Symptoms: Whenever possible, record a specific diagnosis for the event.  
If a diagnosis cannot be made, then record each sign or symptom separately, e.g., record nausea 
and vomiting as two events.  If multiple episodes of an event occur, separated by an appropriate 
time interval to justify considering the subsequent episodes as a repeat occurrence, record each 
episode separately on the Case Report Form. 
• Onset Date and Time: Record the date and time the event started.  If a change from 
baseline/previous evaluation in a laboratory test is reported as an adverse event, record the start 
date as the date of collection of the first lab sample that shows the change. 
Stop Date and Time: Record the date and time the event resolved.  If a change from baseline/previous 
evaluation in a laboratory test is reported as an adverse event, record the stop date as the date of collection 
of the first sample that shows a return to the previous level. 
Intensity:  
1. Mild: Event not resulting in disability/incapacity, which resolves without treatment. 
2. Moderate: Event not resulting in disability/incapacity, which requires treatment. 
3. Severe: Event resulting in temporary and mild disability/incapacity, which requires treatment. 


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Relationship to the Study Agent: Every effort should be made to determine the cause of each adverse 
event.  The correlation between the study agent and the adverse event should be classified as follows:  
1. Probable  
a) The event follows a reasonable temporal sequence from administration of the 
study agent;  
b) The event follows a known response pattern to the study agent;  
c) The event cannot be reasonably explained by:  
• 
the known characteristics of subject’s clinical state, or  
• 
by other therapy administered, or 
• 
by the diagnostic/interventional procedure; 
d) There is evidence of partial or complete disappearance of the event after 
withdrawal of the product (positive de-challenge)  
 
  
2. Possible  
a) The event follows a reasonable temporal sequence from administration of the 
study agent; 
b) Causation of the event by the study agent cannot be excluded;  
c) The event follows a known response pattern to the study agent but the event could 
have been produced by:  
• 
the subject’s clinical state, or   
• 
other therapy administered, or 
• 
a diagnostic/interventional procedure. 
 
 
3. Unlikely  
 
a) The adverse event follows a reasonable temporal sequence from administration 
of the study agent; 
b) Other reasons are more likely to be the cause of the adverse event, based on the 
present knowledge of the  
• 
disease under treatment, or 
• 
other therapy administered, or 
• 
study drug; 
c) A causal relationship between the adverse event and the study drug can’t be ruled 
out with certainty. 
 
 
4. Not Related  The event is either a pre-dose event or is definitely due to causes separate from the 
administration of the study agent, i.e., 
• 
documented pre-existing condition 
• 
technical and manual procedural problems 
• 
concomitant medication 
• 
subject’s clinical state. 
 
 
5. Unknown  
The event does not meet any of the above criteria because of: 
• 
conflicting data and/or 
• 
dubious or insufficient/poor evidence  
• 
the event is not judged as related or not related. 


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Action Taken in Relation to the Adverse Event:  
1. None 
2. Drug treatment required (a medication was prescribed or changed; record on the 
Concomitant Medication section of the Case Report Form) 
3. Change in dose of concomitant medication 
4. Non-drug treatment required (a non-drug treatment was prescribed or changed, 
record under “Comments” in the Adverse Event section of the Case Report Form) 
5. Hospitalization or prolonged hospitalization 
6. Diagnostic or clinical test(s) conducted (attach a copy of the results to the Case 
Report Form)  
7. Subject discontinued from the study 
Action Taken with the Study Medication: 
1. Study medication dose interruption 
2. Study medication dose reduction 
3. Study medication discontinuation 
4. None 
Subject Outcome:   
1. Recovered without sequelae 
2. Recovered with sequelae (describe the sequelae under “Comments” in the Adverse 
Event section of the Case Report Form) 
3. Not Recovered, event on-going (follow the subject until a definite outcome can be 
determined.  When follow-up data are collected, report follow-up information under 
“Comments” in the Adverse Event section of the Case Report Form; if event is serious, 
fill in a follow-up Serious Adverse Event Report) 
4. Died (list primary cause of death under “Event Description” of the Adverse Event 
section of the Case Report Form; if available, attach a copy of the autopsy report to the 
Case Report Form and send a copy to the Sponsor) 
Comments: 
Provide other pertinent clinical information and observations under “Comments” in the Adverse 
Event section of the Case Report Form.  For example, record predisposing or contributing 
conditions, such as previous history, concomitant diseases or medications, and/or procedural 
risks. 
13.1.3 Subject Follow-up 
Every attempt should be made to follow the subject until the adverse event has resolved or until the 
Investigator determines the subject has returned to an acceptable state of health. 


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13.1.4 Reporting Serious Adverse Events  
The Investigator must report all serious adverse events within 24 hours, irrespective of the relationship 
to study medication, to the CRO, automatically through the eCRF or by telephone or fax.  The CRO will 
then forward this information to NEWRON within 24 hours of receipt.  The names of the CRO contact will 
be communicated to the investigators by the CRO prior to the start of subject enrollment.  
The minimum information required for an initial report of a Serious AE is as follows: 
• 
Sender of report (name, address of Investigator, site number), 
• 
Subject identification (screening/randomization number), 
• 
Protocol number, 
• 
Reportable event.  
In case of death, a comprehensive narrative report of the case should be prepared by the Investigator and 
sent to the CRO by mail together with the Serious AE Form, retaining a copy on-site.  If an autopsy is 
performed, a copy of the autopsy report should be actively sought by the Investigator and sent to the CRO 
as soon as available. A copy of the autopsy report will be retained on-site. 
A follow-up Serious Adverse Event Report will be completed by the Investigator if important follow-up 
information (i.e., diagnosis, outcome, causality assessment, results of specific investigations) are made 
available after submission of the initial form.  The follow-up form will be sent to the CRO as described 
above.  
If the Investigator becomes aware of any deaths or serious adverse events after the end of the 30-day follow-
up window established in the protocol following investigational product administration, they will be 
reported to the CRO as described above. 
13.1.5 Safety Reporting to Investigators, IRBs, IECs and Regulatory Authorities 
The Sponsor or their designee will be responsible for reporting all SAEs to regulatory authorities, 
investigators, Institutional Review Boards (IRBs) and Independent Ethics Committees (IECs), as 
applicable, in accordance with national regulations for the United States, Italy, India, the United Kingdom 
and Australia.  For all active investigators located in the United States, the Sponsor or their designee will 
prepare an expedited report for all SAEs that are unexpected and potentially related to the study drug, and 
copies will be distributed according to all applicable laws and regulations.  The investigational site also will 
forward a copy of all expedited reports to their IRB. 
13.1.6 Reporting of Overdose 
If the investigational site staff administering the study medication or the study Pharmacist reports that a 
subject took more than the requisite number of capsules or a higher dose than was assigned, this will be 
considered an overdose and must be reported immediately to the Investigator.  Any instance of overdose, 
whether symptomatic or not, must be communicated to the CRO within 24 hours and be fully documented 
as a Serious Adverse Event.  Details of any signs or symptoms and their management should be recorded 
including details of any antidote(s) administered. 
13.1.7 Breaking of the Study Blind by the Investigator 
The blind should be broken by the Investigator only in the case of emergency and if knowledge of the 
administered compound is deemed necessary for the medical treatment of the subject. Should it be 
necessary to break the blind, the Investigator will be able to do this using the IWRS.  If possible, the Sponsor 


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should be notified before the study drug blind is broken.  If the blind is broken the Investigator must 
immediately notify the CRO and provide the subject’s number. The reason for breaking the blind should 
be noted on the Adverse Event (or Serious Adverse Event) section of the Case Report Form. Newron will 
inform the Safety Monitoring Board of the unblinding. 
13.1.8 Pregnancy 
Females of childbearing potential who are not using a contraception method judged to be adequate by their 
Health Care Provider, will not be eligible for the study. [UK only: Adequate contraception is defined as the 
use of a hormonal contraceptive or an Intra Uterine Device (IUD), preferably in conjunction with a 
spermicidal substance.  Appropriate guidelines for use of the specific contraceptive should be followed.  
For patients whose illness is severe, i.e. advanced stage of physical and mental incapacitation, and are 
sexually inactive, the caregiver and the healthcare provider should discuss the most appropriate option, 
including abstinence. Adequate contraception should be continued until 4 weeks after stopping study 
medication.  
As a further precaution, a serum pregnancy test will be performed at screening and baseline for all post-
pubertal females. In addition, a serum pregnancy test will be performed at Weeks 24, 48, 72, 96, 120, 144, 
168 and 192 (or at early discontinuation) for post-pubertal females; additional serum pregnancy tests may 
be performed, based on local requirements.  
If a patient becomes pregnant during the study, she will be discontinued from the study immediately.  The 
Investigator must report all pregnancies, within 24 hours of notification by the patient, to the CRO by email 
or by fax using the Pregnancy Reporting form.  The timelines and other reporting requirements are the same 
as for a Serious AE.  The patient (or her parent or legal guardian/representative) should be instructed to 
notify the Investigator within 24 hours if it is determined, after completion of the study, that the patient has 
become pregnant, either during the treatment phase of the study or within 30 days of completing the study. 
Whenever possible, a pregnancy should be followed to term and for 1 year after delivery of the baby, and 
any premature terminations reported. The status of the mother and child should be reported to the CRO or 
NEWRON within 24 hours after delivery, and one year later.   
 
13.2 Safety Monitoring Board 
An Independent Safety Monitoring Board (ISMB) will be established by Newron to review the safety of all 
patients enrolled in the Sarizotan 001/II/2015 study.  It will be made up of at least 3 voting members.  All 
of these members will have taken part in other international safety monitoring boards.  Ravi Anand, MD, 
Newron’s Chief Medical Officer, will serve as the Sponsor’s primary contact for the ISMB.   
The ISMB will review data from all patients enrolled at specified intervals throughout the trial.  The ISMB 
will receive unblinded data; however, the blind will be maintained to the investigators, Sponsor, and CRO 
until after the final analysis has been completed.  The CRO and Sponsor will compile subject data by 
treatment group and provide to the ISMB.  The ISMB will have access to safety data, including adverse 
events, dropouts, SAEs, clinically significant abnormal laboratory tests, vital signs and ECGs,  The ISMB 
will be regularly notified of the occurrence of any fatal/life threatening event within 24 hours and other 
serious adverse events within 72 hours. The ISMB will also receive detailed information on any adverse 
dropouts occurring in the study.  
The ISMB is empowered to review all of the safety data on an ongoing basis, with special emphasis on 
serious AEs and deaths, in addition to the standard safety parameters. Based on their review of the safety 
data the ISMB will make a recommendation to Newron to (a) amend the ongoing study (e.g., increase safety 
monitoring), (b) terminate the study (e.g., the sarizotan safety profile is unacceptable), or (c) continue the 


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study as designed. The current study protocol will not be amended or changed (this includes the study 
design and entry criteria) unless mandated by the emerging (unblinded) safety profile of sarizotan.  
Details of the ISMB charter (separate document) will be submitted to regulatory authorities, and will be 
available to IECs/IRBs upon request.   


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14 SUBJECT COMPLETION AND DISCONTINUATION 
A subject will be considered to have completed the initial randomized treatment period of the study if the 
subject returns for the final visit at Week 24.  ‘Discontinuation’ will refer to any subject who does not 
complete the full 24 weeks (168 ± 7 days) of the initial treatment period of the study. A subject will be 
considered to have completed the initial 24-week open-label extension treatment period of the study if the 
subject returns for the final visit at Week 48 (336 ± 14 days).  A subject will be considered to have 
completed Part 1 of the additional extension treatment period of the study if the subject returns for the final 
visit at Week 96 (672 ± 14 days).  A subject will be considered to have completed Part 2 of the additional 
extension treatment period of the study if the subject returns for the final visit at Week 144 (1008 ± 28 
days). A subject will be considered to have completed Part 3 of the additional extension treatment period 
of the study if the subject returns for the final visit at Week 192 (1344 ± 28 days).  The end of the study for 
an individual patient is defined as completion of the Week 48 evaluation (for patients not entering the 
additional extension period), the Week 96 evaluation (end of Part 1; for patients not continuing open-label 
treatment after Week 96), the Week 144 evaluation (for patients enrolled in Part 2 of the open-label 
extension), or the Week 192 evaluation (for patients enrolled in Part 3 of the open-label extension), and the 
Safety Follow-up assessment 2 weeks after the last dose of study medication.  
In the absence of a medical contraindication or significant protocol deviation, every effort should be made 
by the investigator to keep the subject in the study; however, should the subject be withdrawn, all efforts 
will be made to complete and report the observations as thoroughly as possible, including post-treatment 
evaluation at the time of the subject’s withdrawal, with an explanation of why the subject is withdrawing 
from the study. 
The criteria for discharging a subject from the study prior to a post-study examination are listed below.  The 
reason and time of all discontinuations will be specified on the ‘final overall assessment’ form. 
A subject may be withdrawn from the study participation if: 
- 
Any hypersensitivity or allergic reaction, clearly linked to the study medication, has occurred; 
- 
Subject experiences an AE sufficiently severe, in the opinion of the investigator, that 
contraindicates continuing in the study; 
- 
Subject wishes to withdraw (e.g. subject refuses to have any more PK blood samples taken; in this 
instance a specific reason must be recorded by the investigator) 
- 
A subject is afflicted with a systemic illness, unrelated to the study medication but during the study 
period, for which a concomitant medication is required; 
- 
A major protocol deviation has occurred, e.g., the subject failed to meet protocol entry criteria or 
did not adhere to protocol requirements, and continued participation poses an unnecessary risk to 
the subject’s health. 
- 
The subject is lost to follow-up, i.e., the subject did not return to the clinic, and attempts to contact 
the subject were unsuccessful.  Attempts to contact the subject must be documented. 
- 
The Sponsor, Institutional Review Board / Independent Ethics Committee (IRB/IEC), or regulatory 
agency terminates the study. 
Dropouts will not be replaced.   
 
14.1 Procedures for handling withdrawals 
The Investigator may terminate a subject’s study participation at any time during the study if a subject 
meets the study termination criteria described in Section 14.  In addition, a subject may discontinue his/her 
participation without giving a reason at any time during the study.  Should a subject’s participation be 


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discontinued, the primary reason for termination must be recorded.  If a subject is withdrawn from the study 
after receiving a dose of study medication, he/she will not be replaced.  An attempt should be made to 
perform all final (Week 24 [double-blind period], Week 48 [initial 24-week open-label extension period], 
Week 96 [Part 1 of additional open-label extension period], Week 144 [Part 2 of additional open-label 
extension period], or Week 192 [Part 3 of additional open-label extension period]) assessments on the 
subject, and to follow up on any safety issues until resolution. Subjects who discontinue prematurely, as 
well as those subjects completing the study, should return to the clinic for a Safety Follow-up assessment 
2 weeks after the last dose of study medication, and must be followed up for 30 days after the last dose of 
study medication regarding the occurrence of Serious Adverse Events.  


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15 PHARMACOKINETIC AND STATISTICAL METHODS  
 
15.1 Pharmacokinetics and Determinants of Pharmacokinetic Variability  
The concentrations of sarizotan in plasma samples will be determined using a validated LC-MS/MS 
method (see Section 11.2).   
Appropriate pharmacokinetic parameters of sarizotan will be calculated for each dose level (Dose Levels 
1 and 4 only) using non-compartmental methods, e.g. Cmax, tmax, t1/2, AUC(0-t) and AUC(0-∞). The derived 
pharmacokinetic parameters will be listed and plotted by subject and summarized by treatment.  An 
analysis will be performed to evaluate the multiple-dose pharmacokinetics (PK) of sarizotan at the doses 
tested, and determine if the PK parameters are dose proportional. 
 
15.2 
Statistical methods 
This is a prospective, 24-week, randomized, double-blind, placebo-controlled study, with a 168-week open-
label extension, designed to evaluate the safety, tolerability, and efficacy of two oral doses of sarizotan in 
patients with RTT with respiratory abnormalities.  At least 129 patients will be randomized (approximately 
43/group) to receive 24 weeks of double-blind treatment with either low dose sarizotan [sarizotan 2 mg bid 
(age 4 to <13 years; or age ≥13 years, weight <25 kg) or 5 mg bid (age ≥13 years, weight ≥25 kg)], high 
dose sarizotan [sarizotan 5 mg bid (age 4 to <13 years; or age ≥13 years, weight <25 kg), or 10 mg bid (age 
≥13 years, weight ≥25 kg)], or placebo bid.   
At the start of the extension treatment period, all patients, including those previously randomized to 
placebo, will receive treatment with sarizotan and undergo dose titration, starting at a dose of 2 or 5 mg 
bid, dependent on age and body weight (see Section 10.2).  The dose will be maintained at 2 mg bid, 
increased to 5 mg bid, or increased to 10 mg bid after 4 weeks if there are no tolerability issues.  
Data from the initial 24-week double-blind period will be used for comparing the efficacy and safety of low 
dose sarizotan (2 and 5 mg bid) and high dose sarizotan (5 and 10 mg bid) vs. placebo.  The data from the 
open-label extension period, during which all patients will receive sarizotan, will be analyzed separately to 
evaluate long-term effects of treatment.  The Week 24 efficacy and safety assessments will serve as the 
baseline assessments for the extension treatment period.   
15.2.1 
Populations 
The safety population will consist of all subjects who took a dose of study medication.  The efficacy 
analyses will be performed on an Intent-to-Treat (ITT) population comprising all patients who were 
randomized to treatment.  
15.2.2 
Background and demographic characteristics 
The background and demographic characteristics (age, race, ethnicity, weight, height, education, past and 
current medical conditions, etc.), disease characteristics, and prior/concomitant medication use for 
randomized patients will be summarized by treatment group. Continuous variables will be summarized by 
minimum, maximum, mean, median, and standard deviation, and discrete variables will be summarized 
using frequencies and percentages. 
15.2.3 
Study medication 
The number of subjects receiving each dose level and the number of capsules taken will be reported.   


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15.2.4 
Concomitant therapy 
A listing of concomitant medications administered from the time of the first dose of the study medication 
through completion of the final (Week 192) evaluations will be summarized by treatment group for the 
double-blind period (Days 1-168), and overall for the open-label extension period (Days 169-1344).  
15.2.5 
Safety evaluations 
All subjects who receive a dose of study medication will be included in the safety analyses. All adverse 
events will be listed and summarized by body system and preferred term.  The incidence of AEs (%) and 
their relatedness to the study drug, as assessed by the Investigator, will be reported.  Serious adverse events 
(SAEs) and events which are newly occurring or worsening after administration of the study medication 
(TEAEs) will be summarized.  In addition, adverse events that result in death or discontinuation (ADOs) 
of the study medication will be listed separately. 
Results for other safety parameters such as vital signs, laboratory parameters, ECGs, physical, neurological 
and ophthalmological examinations, and the suicidality assessment, will be listed and summarized 
accordingly. Changes from baseline in vital signs, ECG and laboratory values, and physical, neurological 
and ophthalmological examination findings will be summarized, with abnormal and clinically notable 
values/findings being identified.  In the initial 24-week, double-blind, placebo-controlled period, a 
comparison will be made between the sarizotan and placebo groups in the proportion of subjects 
experiencing SAEs, ADOs, and TEAEs and any clinically significant abnormalities in other safety 
parameters.  Where feasible, mean changes from baseline will be examined using a paired t-test. Safety 
data for the open-label extension period will be analyzed separately and will use the Week 24 evaluations 
from the double-blind period as the baseline assessments. 
15.2.6 Efficacy evaluations 
Primary Efficacy Outcome 
The primary efficacy outcome will be the percent reduction (change) from baseline in the number of apnea 
episodes (each ≥10 seconds in duration) per hour, during awake time. This will be calculated from the data 
obtained during home respiratory monitoring by means of an ambulatory data acquisition system 
(BioRadioTM) designed to record specific respiratory and cardiac parameters. Assessment of the respiratory 
outcomes will be performed at home on any 3 days in each of the first 3 weeks of the Screening period, and 
in the week prior to each of the visits at Weeks 2, 8, 16, and 24. Monitoring will be performed when the 
patient is awake and should be attempted for 6 hours on each of the 3 days. Data from all of the quality 
recording time (minimally 3 hours) in the Screening period, and from the week prior to each of the visits at 
Weeks 2, 8, 16, and 24, will be averaged and used in calculating the value for the primary efficacy measure. 
If the patient meets the criterion for number of apnea episodes, as determined by Vivonoetics, in any week 
of the Screening period, home monitoring in the subsequent week(s) would not be required, and the 
screening data would be used to calculate the baseline value for the analyses. 
The primary efficacy analysis for the initial, 24-week, double-blind, treatment period will be performed on 
the Intent-to-Treat (ITT) population, consisting of all patients who were randomized to treatment. The 
percent reduction (change) from baseline in the number of apnea episodes (each ≥10 seconds in duration) 
per hour will be compared between treatment groups using a Mixed Model Repeated Measures (MMRM) 
analysis. The MMRM model will include percent change from baseline as response, the fixed, categorical 
effects of treatment group, visit, treatment group-by-visit interaction, and the continuous terms age and 
baseline value as covariate. A statistically significant difference between high dose sarizotan (5 or 10 mg 
bid) and placebo will be considered evidence of efficacy in reducing apnea.   


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Key Secondary Efficacy Outcome 
The mean rating of the caregiver-rated CIC at Week 24/endpoint will be compared between treatment 
groups using the Van Elteren test (a stratified Cochran Mantel Haenszel test with modified ridit scores). 
The following age strata will be considered in the analysis: <13 years and ≥ 13 years. In addition to the 
above analysis, comparisons between treatments for the proportion of patients rated improved at Week 24 
will be done using logistic regression.   
Other Secondary Efficacy Outcomes  
The analysis of the Caregiver Top 3 Concerns will be performed first, comparing the change from baseline 
in the total score on the VAS for each of the 3 symptoms identified as most concerning at baseline using an 
ANCOVA-LOCF analysis. The model will include treatment group and the baseline value along with age 
as covariates. Change will be estimated using the least-squares mean derived from the ANCOVA. 
Comparisons between treatment groups at Week 24 will be made using the difference in least-squares mean, 
95% confidence interval (CI) and p-values from the ANCOVA model. 
Descriptive statistics will be presented for the other secondary efficacy outcomes. The proportion of patients 
rated improved, as well as the mean score, on the Investigator-rated CGI-C at each of the scheduled visits 
will be presented.  Actual values and the change from baseline in other secondary efficacy variables (Motor 
Behavioral Assessment Scale and subscales, other respiratory parameters, and RCSS) at all scheduled visits 
will be presented. An additional analysis of efficacy will be performed for patients with a sarizotan plasma 
concentration of >400 ng/mL.  
Multiple Comparisons/ Multiplicity  
The study level error rate will be controlled by following a sequential multiple testing procedure, where 
testing will begin with the primary efficacy endpoint. The effects of the high dose sarizotan versus placebo 
will be analyzed first for all parameters in a pre-specified sequence.  
The sequence of testing will be as presented below:  
• 
Percentage change from baseline in the number of apnea episodes, 
• 
Mean rating of CIC, 
• 
Mean change from baseline in the Top Three Concerns Total Score. 
Initial 24-week Double-blind Treatment Period 
The primary efficacy assessment for the study will be performed using data from the initial 24-week double-
blind, placebo-controlled treatment period.  A statistical “Win” will be claimed if the following results are 
obtained in the primary and key secondary efficacy analyses: 
• 
Statistically significant difference between high dose sarizotan (5 or 10 mg bid) and placebo in the 
percent reduction (change) from baseline in the number of apnea episodes (each ≥10 seconds in 
duration) per hour, during awake time; 
• 
Directional change on the CIC in favor of high dose sarizotan (5 or 10 mg bid) group compared to 
placebo. 
168-week Open-label Extension Treatment Period 
Efficacy data from the extension period obtained from patients randomized to sarizotan at Baseline will be 
analyzed to determine if there is any attenuation of the benefit noted during the first six months. The 
response in placebo patients switched to sarizotan in the extension period will be compared with that in 
patients who were treated with sarizotan throughout the study. Data for the primary and secondary 


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respiratory parameters will be derived from data collected in the clinic using the SOMNOtouch. The 
statistical methodology to be used in the analyses conducted for the open-label extension treatment period 
will be described in detail in the Statistical Analysis Plan.  
15.2.7 
Interim analysis 
There will be no interim analysis in this study. 
15.2.8 
Sample size and power considerations 
A minimum of 129 patients with RTT will be included in this study, with approximately equal numbers of 
patients randomly assigned to each of the following three treatment groups:  
• 
low dose sarizotan [sarizotan 2 mg bid (age 4 to <13 years; or age ≥13 years, weight <25 kg) or 
5 mg bid (age ≥13 years, weight ≥25 kg)],  
• 
high dose sarizotan [sarizotan 5 mg bid (age 4 to <13 years; or age ≥13 years, weight <25 kg), or 
10 mg bid (age ≥13 years, weight ≥25 kg)], 
• 
or placebo bid.  
The sample size estimate was based on the following assumptions: 
• 
3 treatment groups (2 active + placebo)  
• 
Primary endpoint: Percent reduction in the number of apnea episodes (≥10 sec each) per hour 
• 
H0: Percent reduction in apnea episodes in placebo and active groups is the same 
• 
HA: There is a difference in the % reduction in apnea episodes between high dose sarizotan and 
placebo.  
The assumptions for the estimated standard deviation (SD) are based on limited data from a study by 
Khwaja et al. (2014), in RTT patients. There were only 5 patients with data reported for apnea index (for 
apnea episodes > 10 seconds). Pilot observational data collected using the BioRadio device in 26 patients 
with RTT indicated that the number of episodes of apnea may approach 60 per hour. Based on the range of 
10-60 episodes per hour, ranges of 10-30, 10-45 and 10-60 apnea episodes per hour indicate SDs of 5.0, 
8.75 and 12.5, respectively.  
Sample sizes were computed to determine the number of patients required to detect a minimum difference 
in mean percent reduction of 20% (high dose sarizotan 30%, placebo 10%; see Table 8) and 10% (high 
dose sarizotan 20%, placebo 10%; see Table 9), based on differences between high dose sarizotan and 
placebo. 
Table 8. Sample Size Estimates Assuming 90% Power and – 20% Difference  
 
Parameter 
1 
2 
3 
4 
Test significance level, α 
  0.050 
  0.050 
  0.050 
0.050 
1 or 2 sided test? 
   2 
   2 
   2 
2 
High Dose mean % Chg, µ1 
 -30.00 
 - 30.00 
 - 30.00 
-30.00 
Placebo mean % Chg, µ2 
 -10.00 
 -10.00 
 -10.00 
-10.00 
Difference, µ 1 - µ 2 
 -20.00 
 -20.00 
 -20.00 
-20.00 
Common St. Dev., σ  
   12.50 
   15.00 
   20.00 
25.00 
Effect size, δ = | µ 1 - µ 2| / σ 
    1.60 
    1.33 
    1.00 
0.80 
Power ( % ) 
     90 
     90 
     90 
90 
n per group 
 10 
 13 
 23 
34 


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Table 9. Sample Size Estimates Assuming 90% Power and – 10% Difference 
 
Parameter 
1 
2 
3 
4 
Test significance level, α 
  0.050 
  0.050 
  0.050 
0.050 
1 or 2 sided test? 
   2 
   2 
   2 
2 
High Dose mean % Chg, µ1 
   -20.00 
  - 20.00 
 - 20.00 
-20.00 
Placebo mean % Chg, µ2 
   -10.00 
   -10.00 
   -10.00 
-10.00 
Difference, µ 1 - µ 2 
   -10.00 
   -10.00 
   -10.00 
-10.00 
Common St. Dev., σ  
   20.00 
   12.50 
   8.75 
5.00 
Effect size, δ = | µ 1 - µ 2| / σ 
    0.50 
    0.80 
    1.14 
2.00 
Power ( % ) 
     90 
     90 
     90 
90 
n per group 
 86 
 34 
 18 
7 
Sample sizes of 23 or 34 in each treatment group will have 90% power to detect a difference in mean 
percent reduction of -20% or -10%, respectively, assuming a common SD of 20 (for the 20% reduction) 
and 12.5 (for the 10% reduction), using a two group t-test with a 0.050 two-sided significance level. 
Assuming an attrition rate of 25% (7 or 9 patients) per group, a total of 30 or 43 patients would need to be 
enrolled in each group to get 23 or 34 patients completing the study. As this is the first large-scale study 
evaluating the effect of sarizotan on respiratory symptoms in patients with RTT, a conservative estimate of 
10% reduction in apnea episodes was used to estimate the sample size required, i.e. approximately 43 
patients per group.  The sample size may be revised based on a prospective assessment of variability in the 
frequency of apnea episodes of 10 seconds or greater duration, from data collected from the first 20 patients 
who complete screening.   
Details of all statistical analyses will be provided in a separate Statistical Analysis Plan, which will be 
completed prior to unblinding of the data at the Week 24 endpoint.   
 
16   ETHICS 
16.1 Ethical Considerations 
The study will be carried out in accordance with the Declaration of Helsinki, as amended by the 64th World 
Medical Association General Assembly, Fortaleza, Brazil, October 2013 (Appendix 1A).  However, where 
applicable, the principles of the 1996 version of the Declaration of Helsinki will be adhered to (Appendix 
1B). 
Subject Information and Informed Consent 
The Informed Consent Form, as well as the Subject Information Sheet must be approved by the Ethics 
Committee together with the Study Protocol, before the start of the study.  
The subject’s parent, legal guardian, or representative must sign and personally date an approved Informed 
Consent Form after receiving detailed written and verbal information about the reason, the nature, the 
required procedures, the intended duration and the possible risks and benefits and any discomfort for the 
subject associated with the study. The subject may provide assent, if capable.  
He/She should be informed that the subject’s participation in the study is voluntary and that he/she may 
refuse to participate or withdraw from the trial, at any time, without penalty or loss of benefits to which the 
subject is otherwise entitled. 


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The language used in the oral and written information about the trial, including the written Informed 
Consent Form should be as non-technical as practical and should be understandable to the subject. 
The subject must be given ample time to read and to understand the Subject Information Sheet and 
opportunity to inquire and ask any clarification about the trial before signing the Informed Consent Form. 
No study procedure can be performed (including the screening visit) before the informed consent 
form has been signed. The informed consent procedure must be done according to the guidelines provided 
in the Declaration of Helsinki and the ICH E6 Guideline for Good Clinical Practice.  
The subject must be made aware and agree that personal information may be scrutinized during audit / 
inspection by competent authorities and properly authorized persons.  However, personal information will 
be treated as strictly confidential and will not be publicly available. 
By signing the Investigator Statement (Appendix 3), the Investigator assures NEWRON Pharmaceuticals 
that Informed Consent will be obtained.  
Original signed Informed Consent Forms will be filed with the Investigator’s File. 
 
16.2  Institutional Review Board / Independent Ethics Committee Approval 
The protocol, Investigator’s Brochure, Subject Information Sheet, Informed Consent Form and any 
advertisement for the recruitment of subjects must be reviewed and approved by an appropriately 
constituted IRB/IEC, as required in Chapter 3 of the ICH E6 Guideline. A copy of the Committee’s dated 
approval and a list of the members of the IRB/IEC will be given to the Sponsor for the Sponsor's files. A 
copy will be also included in the Final Report. Written IRB/IEC approval must be obtained by the Sponsor 
prior to shipment of study agent or subject enrollment.  Any substantial amendments to the protocol, 
Informed Consent Form or Subject Information Sheet, must be approved by this committee, [UK only: as 
well as the Competent Regulatory Authority,] prior to implementation.   
 
17 ADMINISTRATIVE CONSIDERATIONS 
17.1 Regulatory Requirements–Sponsor/Investigator Obligations 
This study will be conducted in accordance with the Declaration of Helsinki and the ICH E6 Guideline 
(Good Clinical Practice).  To ensure compliance the Investigator agrees, by written consent to this protocol, 
to fully cooperate with compliance checks by allowing access to all documentation, including subjects’ 
hospital files (the source documents), by authorized individuals. 
17.2 Curriculum Vitae 
The Investigator and any co-Investigator(s) must provide the Sponsor with current copies of their own 
curriculum vitae. 
17.3 Investigators and Study Administrative Structure 
The administrative structure of the study (e.g., Investigators, monitoring and evaluation personnel, 
laboratory facilities, clinical trial supply management) is presented in the Trial Master File. 
The listing should include: 
a) 
The Investigators. 


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b) 
Any other person carrying out observations of primary or other major efficacy variables, such 
as a nurse, physician's assistant, clinical psychologist, clinical pharmacist or house staff 
physician.   
17.4 Investigator’s Statement 
This document, signed and dated by the Principal Investigator, describes the Investigator’s obligations. The 
standard text is appended to the protocol (Appendix 3)  
17.5 Monitoring Procedures 
17.5.1 Study Monitoring 
A CRO will be selected by the Sponsor to oversee the conduct of the trial.  An appropriate representative 
of the CRO (Study Monitor) will maintain contact with the Investigator and will visit the study site for the 
purpose of discussing and/or reviewing data. An initiation visit will be made by the Study Monitor to discuss 
with the Investigator the protocol and the obligations of both the Sponsor and the Investigator.  The 
Investigator must allow the Study Monitor to perform periodic, interim monitoring visits.  The purposes of 
these visits are: 
• 
To verify that written Informed Consent was obtained prior to each subject’s participation in 
the trial. 
• 
To assess the progress of the study. 
• 
To review the compliance with the study protocol. 
• 
To determine whether all adverse events were appropriately reported. 
• 
To determine whether the Investigator is maintaining the essential documents. 
• 
To discuss any emergent problem. 
• 
To check the Case Report Forms for accuracy and completeness. 
• 
To validate the contents of the Case Report Forms against source documents. 
• 
To assess the status of drug storage, dispensing and retrieval. 
The Investigator will make available the source documents for inspection.  This information will be 
considered as confidential. Deviations from the protocol must be notified to the Study Monitor as soon as 
possible. 
The Study Monitor will perform a closeout visit at the time when all CRFs have been completed and all 
queries have been answered. 
17.5.2 Case Report Form 
All subject data generated during the study will be recorded on the electronic Case Report Form (eCRF). 
The eCRF must be completed for all subjects for whom signed Informed Consent has been obtained.  It is 
the Investigator’s responsibility to ensure the accuracy, completeness, and timeliness of the data reported 
in the subject’s source document/eCRF. The Investigator, or designated representative, should complete the 
source document/eCRF as soon as possible after information is collected, preferably on the same day that 
a study subject is seen for an examination, treatment, or any other study procedure. Any outstanding entries 
must be completed immediately after the final examination. An explanation should be given for all missing 
data. No section of the eCRF is to be left blank without an appropriate explanation by the Investigator, since 
the lack of such explanation may necessitate discarding an otherwise usable observation.  


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Paper copies of the eCRFs for the patient rating scales (e.g. CGI-C, CIC, RCSS) may be printed and used 
by the Investigator or designated staff during the assessment of the patient.  Data recorded on these paper 
forms must be transcribed into the eCRF, and the original forms stored in the patient’s file as source 
documents.  
If requested, copies of the Case Report Forms are to be made available to the appropriate regulatory 
agencies. 
The eCRFs will only be considered complete when each eCRF has been reviewed and electronically 
confirmed by the Investigator, indicating his/her assurance of the accuracy of all recorded data. It is 
expected that the Investigator and his/her staff will cooperate with the monitoring team and provide any 
missing data in a timely manner. 
17.5.3 Auditing/Inspecting 
The Investigator will make all pertinent records available, including source documentation, for inspection 
by regulatory authorities and for auditing by the Sponsor.  This information will be considered as 
confidential. Audits/Inspections may occur any time from start to after conclusion of the study. When an 
Investigator signs the protocol, he/she agrees to allow regulatory authorities and Newron auditors to inspect 
his/her study records. 
17.6 Archiving of Records 
Copies of the protocol, subject identification codes, Case Report Forms, source data, Informed Consent 
Forms and other documents pertaining to the study conduct must be kept for the maximum period of time 
as required by the study center.  This time period must be at least two years after the last approval of the 
marketing application of the study agent in an ICH region and until there are no pending or contemplated 
marketing applications in an ICH region, or at least two years have elapsed since the formal discontinuation 
of clinical development of the study agent. 
No study document should be destroyed without prior written agreement between the Sponsor and the 
Investigator. Originals of all documentation and copies of outgoing correspondence concerning the study 
will be stored and retained by the Sponsor in a safe area in the Trial Master File for the lifetime of the 
product.  In particular, the final report must be retained by the Sponsor, or the subsequent owner, for five 
years beyond the lifetime of the study agent. 
17.7 Final Report 
The Final Report will be written by the CRO, according to specifications to be defined by Newron.   
17.8 Study Documentation and Publication of Study Results 
Study Documentation 
All unpublished documentation (including the protocol, Case Report Form and Investigator's Brochure) 
given to the Investigator is strictly confidential.  All recipients must agree not to disclose the information 
herein contained to any person not connected with the study without the prior written authorization of 
NEWRON Pharmaceuticals.  The submission of these documents to the IRB/IEC is expressly permitted.  
The involved parties agree that the results of this study will be used in their original form and/or in a global 
report for submission to governmental and regulatory authorities of any country. 
All information communicated to the investigator(s) by Newron is the exclusive property of Newron 
Pharmaceuticals S.p.A. The Principal Investigator will ensure this information shall be kept strictly 
confidential by him/her or any other person connected with the study and shall not be disclosed to any third 
party without the prior written consent of Newron. 


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Publication of Results 
Any formal presentation or publication of the data from this trial will be considered as a joint publication 
by the Investigator(s) and Newron.  Authorship will be determined by a Publication Committee consisting 
of the lead investigator(s) from the trial, representatives from Newron, and an external consultant with 
expertise in the field. For multi-center studies, it is mandatory that the first publication is based on data 
from all centers, analyzed as stipulated in the protocol by a statistician designated by Newron.  Investigators 
participating in this study agree not to present or publish data gathered from a single center or sub-group of 
centers before the full initial publication, unless agreed to by all other investigators and Newron.  
Authorship of any publications resulting from pooled data will include members of each of the contributing 
centers, as well as Newron personnel. 
Newron will form a study publication committee to coordinate and develop a publication policy and help 
in its implementation.  The publication committee will be comprised of the Principal Investigator(s), a 
representative of Newron and an external consultant.  Members of the publication committee cannot serve 
as first authors of more than one primary publication.  
Any publication, abstract, or paper of any information or material relating to or arising out of the present 
clinical study shall be sent to Newron for review at least sixty (60) days before presentation at any congress, 
or publication of the final form(s) by any journal. Newron will inform the Investigator of any changes or 
deletions necessary to preserve Newron’s confidential and proprietary technical information. All rights and 
interests worldwide in any inventions, know-how or other intellectual or industrial property rights, which 
arise during the course and/or as a result of the present clinical study or which arise from the information 
or materials supplied under this Agreement, shall be assigned to, vest in and remain the property of Newron 
Pharmaceuticals S.p.A. 
17.9 Financial Agreement 
A financial agreement (separate from the protocol) will be made and signed by NEWRON Pharmaceuticals 
or their designee and by a representative of the Institution where the study will be conducted.  
17.10 Termination of the Study 
In the event that the Investigator is unable to continue the study, another suitable sub-Investigator at the site 
will be designated to serve as the Investigator in the interim, until a new Investigator can be identified.  This 
interim Investigator, if approved by the site IRB/IEC will carry out the responsibilities of the Investigator.  
Documentation testifying to this will be submitted to the Study Monitor within 10 days of the change.  
Within 6 months of the appointment of the interim Investigator, the new Principal Investigator must be 
identified and approved by both NEWRON Pharmaceuticals and the IRB/IEC for the study to continue at 
the site.  
If the Sponsor and/or the Investigator should discover conditions arising during the study that indicate it 
should be terminated, an appropriate schedule for termination will be instituted.  If the Investigator 
terminates the study, an explanatory letter will be provided to NEWRON Pharmaceuticals. Should the study 
be discontinued due to a decision by NEWRON Pharmaceuticals, the Investigator will be reimbursed for 
reasonable expenses incurred and for the subjects actually treated according to the study protocol. 
17.10.1 Study discontinuation by the Sponsor 
The Sponsor may terminate the entire study, or the study at an individual site, at any time, for any of the 
following reasons: 
• 
failure to enroll subjects; 
• 
protocol violations or deviations; 


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• 
inaccurate or incomplete data; 
• 
non GCP compliance; 
• 
completion of enrolment; 
• 
administrative reasons. 
17.10.2  Study discontinuation by the Clinical Investigator 
The Investigator may terminate his/her participation in the study in consultation with the Sponsor due to 
the occurrence of significant adverse events and/or adverse drug reactions endangering the health of 
subjects, which make it ethically unacceptable to continue. 
17.11 Insurance Policy  
NEWRON or its designee will provide insurance coverage for damages emerging from the trial and 
involving the subjects treated with the test compound, provided that the Investigator(s) have adhered to the 
terms and provisions of the protocol. The principal Investigator will be supplied with all data concerning 
the insurance company and policy number for a maximum sum insurable. 
17.12 Financial Disclosure 
The study will be performed under a US IND; therefore, all Investigators/sub-Investigators, contractors, 
etc., are expected to comply with the obligations as specified in the CFR (21 CFR part 54) by the US 
FDA, including requirements for full Financial Disclosure (Guidance for Clinical Investigators, Industry 
and FDA Staff: Financial Disclosure by Clinical Investigators, February 2013). 
The Principal Investigator and sub-Investigators will provide the Sponsor with adequate and accurate 
financial information (PD35) to ensure that the Sponsor can make complete and accurate financial 
certification of disclosure statements to concerned regulatory authorities.  It is the duty of the Investigator 
to promptly update previous information provided to the Sponsor if there are salient changes that occur 
during the course of the study, and for a period of one year following its completion (last patient last 
visit). 
 


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18 REFERENCES 
 
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2. Abdala et al. Pinpointing brainstem mechanisms responsible for autonomic dysfunction in Rett 
syndrome: therapeutic perspectives for 5-HT1A agonists. Frontiers in Physiology (May 2014) 
Volume 5, Article 205: 1-8.  
3. Abdala, et al. Effect of Sarizotan, a 5-HT1A and D2-Like Receptor Agonist, on Respiration in 
Three Mouse Models of Rett Syndrome. American Journal of Respiratory Cell and Molecular 
Biology (June 2014), Volume 50 Number 6: 1031-1039.  
4. Adams JA, Zabaleta IA, Stroh D, Sackner MA. Measurement of breath amplitudes: comparison 
of three noninvasive respiratory monitors to integrated pneumotachograph. Pediatr Pulmonology 
1993;16:254-258. 
5. Bloch KE, Li Y, Sackner MA, Russi EW. Breathing pattern during sleep disruptive snoring. Eur 
Respir J 1997;10:576-586.  
6. Brouillette RT, Morrow AS, Weese-Mayer DE, Hunt CE. Comparison of respiratory inductive 
plethysmography and thoracic impedance for apnea monitoring. J Pediatrics 1987;111:377-383.  
7. Buelke-Sam J. Comparative schedules of development in rats and humans: Implications for 
developmental neurotoxicity testing. Invited speaker and discussant: Workshop on Challenges of 
the Developmental Neurotoxicity Study, Society of Toxicology Annual Meeting, 2003. 
8. Byard RW. Forensic issues and possible mechanisms of sudden death in Rett syndrome. J Clin 
Forensic Med. 2006 Feb;13(2):96-9. 
9. Cantineau JP, Escourrou P, Sartene R, Gaultier C, Goldman M. Accuracy of respiratory 
inductive plethysmography during wakefulness and sleep in patients with obstructive sleep 
apnea. Chest 1992;102(4):1145-1151. 
10. Clarenbach CF, Senn O, Brack T, Kohler M, Bloch K. Monitoring of ventilation during exercise 
by a portable respiratory inductive plethysmograph. Chest 2005;128:1282-1290. 
11. Collop NA, et al. Portable Monitoring Task Force of the American Academy of Sleep Medicine. 
Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive 
sleep apnea in adult patients. J Clin Sleep Med 2007;3(7):737-747.  
12. Common Terminology Criteria for Adverse Events (CTCAE), Version 4.0, May 28, 2009 (v4.03 
June 14, 2010), U.S. Department of Health and Human Services.  
13. FitzGerald PM, Jankovic J, Percy AK. Rett syndrome and associated movement disorders. 
Movement Disorders 1990;3(5):195-202. 
14. Guy W (Ed). Clinical Global Impressions. In ECDEU Assessment Manual for 
Psychopharmacology, revised, U.S. Department of Health, Education and Welfare Pub. No. 
(ADM) 76-338. Rockville, MD: NIMH, 1976, 217-222. 
15. Hammer J, Newth CJL, Deakers TW. Validation of the phase angle technique as an objective 
measure of upper airway obstruction. Pediatr Pulmonol 1995;19:167-173.  
16. Julu et al. Immaturity of medullary cardiorespiratory neurones leading to inappropriate 
autonomic reactions as a likely cause of sudden death in Rett’s syndrome. Archives of Disease in 
Childhood 1997;77:463–469. 
17. Julu et al. Characterisation of breathing and associated central autonomic dysfunction in the Rett 
disorder Arch Dis Child 2001;85:29–37 29. 
18. Julu et al. Addressing the cardiorespiratory challenges posed by Rett Syndrome in Medicine. 
Lancet. 2008 Jun 14;371(9629):1981-3. 
19. Katz et al. (2009). Breathing Disorders in Rett Syndrome: Progressive Neurochemical 
Dysfunction in the respiratory network after birth. Respir Physiol Neurobiol. 2009 August 31; 
168(1-2): 101–108. 


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20. Kerr AM, et al. (1997). Rett syndrome: analysis of deaths in the British survey. Eur Child 
Adolesc Psychiatry 1997;6(suppl 1):71–4. 
21. Khwaja OS, et al. Safety, pharmacokinetics, and preliminary assessment of efficacy of 
mecasermin (recombinant IGF-1) for the treatment of Rett syndrome. Proc Nat Acad Sci 
2014;111(12):4596-4601. 
22. Konno K, Mead J. Measurement of the separate volume changes of rib cage and abdomen during 
breathing. J Appl Physiol 1967;22:407-422.  
23. Lalley PM, Bischoff AM, Richter DW. 5-HT-1A receptor-mediated modulation of medullary 
expiratory neurones in the cat. Journal of Physiology (1994), 476.1: 117-130. 
24. Landon C. Respiratory monitoring: Advantages of inductive plethysmography over impedance 
pneumograpy. VivoMetrics, VMLA-039-02, 2003.  
25. Leino K, Nunes S, Valta P, Takala J. Validation of a new respiratory inductive plethysmography. 
Acta Anesthiol Scand 2001;45:104-111.  
26. Loube DI, Andrada T, Howard RS. Accuracy of respiratory inductive plethysmography for the 
diagnosis of upper airway resistance syndrome. Chest 1999;115(5):1333-1337.   
27. Mackay J, Downs J, Wong K, et al. Autonomic breathing abnormalities in Rett syndrome: 
caregiver perspectives in an international database study. Journal of Neurodevelopmental 
Disorders 2017; 9:15.  
28. Marshall WA, Tanner JM. Variations in the pattern of pubertal changes in girls. Arch. Dis. 
Child. 1969;44(235):291–303. 
29. Marshall WA, Tanner JM. Variations in the pattern of pubertal changes in boys. Arch. Dis. 
Child. 1970;45(239):13–23.  
30. Neul JL, Fang P, Barrish J, et al. Specific mutations in methyl-CpG-binding protein 2 confer 
different severity in Rett syndrome. Neurology 2008;70:1313-1321.  
31. Neul JL, Kaufmann WE, Glaze DG, Christodoulou J, Clarke AJ, Bahi-Buisson N, et al. Rett 
syndrome: revised diagnostic criteria and nomenclature. Annals of Neurology 2010;68:944–950.  
32. Neul JL, Glaze DG, Percy AK, et al. Improving treatment trial outcomes for Rett syndrome: The 
development of Rett-specific anchors for the Clinical Global Impression scale. J Child Neurol 
2015 Apr 20 [ePublished ahead of print]. 
33. Neumann P, Zinserling J, Haase C, Sydow M, and Burchardi H. Evaluation of respiratory 
inductive plethysmography in controlled ventilation*. Measurement of tidal volume and PEEP-
induced changes of end-expiratory lung volume. Chest 1998; 113:443-51. 
34. Sackner MA, Watson H, Belsito AS, Feinerman D, Suarez M, Gonzalez G, Bizousky F, Krieger 
B. Calibration of respiratory inductive plethysmography during natural breathing. J Appl Physiol 
1989;66(1):410-20.  
35. Sarizotan Investigator’s Brochure, version 3 for Rett Syndrome, dated 14 September 2018. 
36. Tarquinio DC, Motil KJ, Hou W, et al. Growth failure and outcome in Rett syndrome: Specific 
references. Neurology 2012; 79:1653. 
37. Valta P, Takala J, Foster R, Weissman C, Kinney JM. Evaluation of respiratory inductive 
plethysmography in the measurement of breathing pattern and PEEP-induced changes in lung 
volume. Chest 1992; 102:234-238. 
38. Weng, SM, et al. (2011). Rett syndrome: from bed to bench. Pediatr. Neonatol. 52, 309–316, 
2011.  
39. Weese-Mayer DE, Lieske SP, Boothby CM, Kenny AS, Bennett HL, Silvestri JM, Ramirez JM. 
Autonomic nervous system dysregulation: Breathing and heart rate perturbation during 
wakefulness in young girls with Rett syndrome. Pediatric Research 2006;60(4): 443-9.  
 
 


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19 APPENDICES 
 
19.1 APPENDIX 1: Declaration of Helsinki 
Appendix 1A: 2013 Version of Declaration of Helsinki 
 
WORLD MEDICAL ASSOCIATION DECLARATION OF HELSINKI  
Ethical Principles for Medical Research Involving Human Subjects 
Adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964, and amended by the: 
29th WMA General Assembly, Tokyo, Japan, October 1975 
35th WMA General Assembly, Venice, Italy, October 1983 
41st WMA General Assembly, Hong Kong, September 1989 
48th WMA General Assembly, Somerset West, Republic of South Africa, October 1996 
52nd WMA General Assembly, Edinburgh, Scotland, October 2000 
53rd WMA General Assembly, Washington 2002 (Note of Clarification on paragraph 29 added) 
55th WMA General Assembly, Tokyo 2004 (Note of Clarification on Paragraph 30 added) 
59th WMA General Assembly, Seoul, October 2008 
64th WMA General Assembly, Fortaleza, Brazil, October 2013 
 
Preamble 
 
1. 
The World Medical Association (WMA) has developed the Declaration of Helsinki as a statement of 
ethical principles for medical research involving human subjects, including research on identiﬁable human material 
and data. 
 
The Declaration is intended to be read as a whole and each of its constituent paragraphs should be applied with 
consideration of all other relevant paragraphs. 
 
2. 
Consistent with the mandate of the WMA, the Declaration is addressed primarily to physicians. The WMA 
encourages others who are involved in medical research involving human subjects to adopt these principles. 
 
General Principles 
 
3. 
The Declaration of Geneva of the WMA binds the physician with the words, “The health of my patient will 
be my ﬁrst consideration,” and the International Code of Medical Ethics declares that, “A physician shall act in the 
patient's best interest when providing medical care.” 
 
4. 
It is the duty of the physician to promote and safeguard the health, well-being and rights of patients, 
including those who are involved in medical research. The physician's knowledge and conscience are dedicated to 
the fulﬁlment of this duty. 
 
5. 
Medical progress is based on research that ultimately must include studies involving human subjects. 
 
6. 
The primary purpose of medical research involving human subjects is to understand the causes, 
development and eﬀects of diseases and improve preventive, diagnostic and therapeutic interventions (methods, 
procedures and treatments). Even the best proven interventions must be evaluated continual y through research for 
their safety, eﬀectiveness, eﬃciency, accessibility and quality. 
 
7. 
Medical research is subject to ethical standards that promote and ensure respect for all human subjects and 
protect their health and rights. 
 


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8. 
While the primary purpose of medical research is to generate new knowledge, this goal can never take 
precedence over the rights and interests of individual research subjects. 
 
9. 
It is the duty of physicians who are involved in medical research to protect the life, health, dignity, 
integrity, right to self-determination, privacy, and conﬁdentiality of personal information of research subjects. The 
responsibility for the protection of research subjects must always rest with the physician or other health care 
professionals and never with the research subjects, even though they have given consent. 
 
10. 
Physicians must consider the ethical, legal and regulatory norms and standards for research involving 
human subjects in their own countries as well as applicable international norms and standards. No national or 
international ethical, legal or regulatory requirement should reduce or eliminate any of the protections for research 
subjects set forth in this Declaration. 
 
11. 
Medical research should be conducted in a manner that minimises possible harm to the environment. 
 
12. 
Medical research involving human subjects must be conducted only by individuals with the appropriate 
ethics and scientiﬁc education, training and qualiﬁcations. Research on patients or healthy volunteers requires the 
supervision of a competent and appropriately qualiﬁed physician or other health care professional. 
 
13. 
Groups that are underrepresented in medical research should be provided appropriate access to participation 
in research. 
 
14. 
Physicians who combine medical research with medical care should involve their patients in research only 
to the extent that this is justiﬁed by its potential preventive, diagnostic or therapeutic value and if the physician has 
good reason to believe that participation in the research study will not adversely aﬀect the health of the patients who 
serve as research subjects. 
 
15. 
Appropriate compensation and treatment for subjects who are harmed as a result of participating in research 
must be ensured. 
 
Risks, Burdens and Beneﬁts 
 
16. 
In medical practice and in medical research, most interventions involve risks and burdens. 
 
Medical research involving human subjects may only be conducted if the importance of the objective outweighs the 
risks and burdens to the research subjects. 
 
17. 
All medical research involving human subjects must be preceded by careful assessment of predictable risks 
and burdens to the individuals and groups involved in the research in comparison with foreseeable beneﬁts to them 
and to other individuals or groups aﬀected by the condition under investigation. 
 
Measures to minimise the risks must be implemented. The risks must be continuously monitored, assessed and 
documented by the researcher. 
 
18. 
Physicians may not be involved in a research study involving human subjects unless they are conﬁdent that 
the risks have been adequately assessed and can be satisfactorily managed. 
 
When the risks are found to outweigh the potential beneﬁts or when there is conclusive proof of deﬁnitive outcomes, 
physicians must assess whether to continue, modify or immediately stop the study. 
 
Vulnerable Groups and Individuals  
 
Some groups and individuals are particularly vulnerable and may have an increased likelihood of being wronged or 
of incurring additional harm. 


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All vulnerable groups and individuals should receive speciﬁcally considered protection. 
 
19. 
Medical research with a vulnerable group is only justiﬁed if the research is responsive to the health needs 
or priorities of this group and the research cannot be carried out in a non-vulnerable group. In addition, this group 
should stand to beneﬁt from the knowledge, practices or interventions that result from the research. 
 
Scientiﬁc Requirements and Research Protocols 
 
20. 
Medical research involving human subjects must conform to generally accepted scientiﬁc principles, be 
based on a thorough knowledge of the scientiﬁc literature, other relevant sources of information, and adequate 
laboratory and, as appropriate, animal experimentation. The welfare of animals used for research must be respected. 
 
21. 
The design and performance of each research study involving human subjects must be clearly described 
and justiﬁed in a research protocol. 
 
The protocol should contain a statement of the ethical considerations involved and should indicate how the 
principles in this Declaration have been addressed. The protocol should include information regarding funding, 
sponsors, institutional aﬃliations, potential conﬂicts of interest, incentives for subjects and information regarding 
provisions for treating and/or compensating subjects who are harmed as a consequence of participation in the 
research study. 
 
In clinical trials, the protocol must also describe appropriate arrangements for post-trial provisions. 
 
Research Ethics Committees 
 
22. 
The research protocol must be submitted for consideration, comment, guidance and approval to the 
concerned research ethics committee before the study begins. This committee must be transparent in its functioning, 
must be independent of the researcher, the sponsor and any other undue inﬂuence and must be duly qualiﬁed. It must 
take into consideration the laws and regulations of the country or countries in which the research is to be performed 
as well as applicable international norms and standards but these must not be allowed to reduce or eliminate any of 
the protections for research subjects set forth in this Declaration. 
 
The committee must have the right to monitor ongoing studies. The researcher must provide monitoring information 
to the committee, especially information about any serious adverse events. No amendment to the protocol may be 
made without consideration and approval by the committee. After the end of the study, the researchers must submit 
a ﬁnal report to the committee containing a summary of the study’s ﬁndings and conclusions. 
 
Privacy and Conﬁdentiality 
 
23. 
Every precaution must be taken to protect the privacy of research subjects and the conﬁdentiality of their 
personal information. 
 
Informed Consent 
 
24. 
Participation by individuals capable of giving informed consent as subjects in medical research must be 
voluntary. Although it may be appropriate to consult family members or community leaders, no individual capable 
of giving informed consent may be enrolled in a research study unless he or she freely agrees. 
 
25. 
In medical research involving human subjects capable of giving informed consent, each potential subject 
must be adequately informed of the aims, methods, sources of funding, any possible conﬂicts of interest, 
institutional aﬃliations of the researcher, the anticipated beneﬁts and potential risks of the study and the discomfort 
it may entail, post-study provisions and any other relevant aspects of the study. The potential subject must be 
informed of the right to refuse to participate in the study or to withdraw consent to participate at any time without 


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reprisal. Special attention should be given to the speciﬁc information needs of individual potential subjects as well 
as to the methods used to deliver the information. 
 
After ensuring that the potential subject has understood the information, the physician or another appropriately 
qualiﬁed individual must then seek the potential subject’s freely-given informed consent, preferably in writing. If the 
consent cannot be expressed in writing, the non-written consent must be formally documented and witnessed. 
 
All medical research subjects should be given the option of being informed about the general outcome and results of 
the study. 
 
26. 
When seeking informed consent for participation in a research study the physician must be particularly 
cautious if the potential subject is in a dependent relationship with the physician or may consent under duress. In 
such situations the informed consent must be sought by an appropriately qualiﬁed individual who is completely 
independent of this relationship. 
 
27. 
For a potential research subject who is incapable of giving informed consent, the physician must seek 
informed consent from the legally authorised representative. These individuals must not be included in a research 
study that has no likelihood of beneﬁt for them unless it is intended to promote the health of the group represented 
by the potential subject, the research cannot instead be performed with persons capable of providing informed 
consent, and the research entails only minimal risk and minimal burden. 
 
28. 
When a potential research subject who is deemed incapable of giving informed consent is able to give 
assent to decisions about participation in research, the physician must seek that assent in addition to the consent of 
the legally authorised representative. The potential subject’s dissent should be respected. 
 
29. 
Research involving subjects who are physically or mentally incapable of giving consent, for example, 
unconscious patients, may be done only if the physical or mental condition that prevents giving informed consent is 
a necessary characteristic of the research group. In such circumstances the physician must seek informed consent 
from the legally authorised representative. If no such representative is available and if the research cannot be 
delayed, the study may proceed without informed consent provided that the speciﬁc reasons for involving subjects 
with a condition that renders them unable to give informed consent have been stated in the research protocol and the 
study has been approved by a research ethics committee. Consent to remain in the research must be obtained as soon 
as possible from the subject or a legally authorised representative. 
 
30. 
The physician must fully inform the patient which aspects of their care are related to the research. The 
refusal of a patient to participate in a study or the patient’s decision to withdraw from the study must never 
adversely aﬀect the patient- physician relationship. 
 
31. 
For medical research using identiﬁable human material or data, such as research on material or data 
contained in biobanks or similar repositories, physicians must seek informed consent for its collection, storage 
and/or reuse. There may be exceptional situations where consent would be impossible or impracticable to obtain for 
such research. In such situations the research may be done only after consideration and approval of a research ethics 
committee. 
 
Use of Placebo 
 
32. 
The beneﬁts, risks, burdens and eﬀectiveness of a new intervention must be tested against those of the best 
proven intervention(s), except in the following circumstances: 
 
Where no proven intervention exists, the use of placebo, or no intervention, is acceptable; or 
 
Where for compelling and scientiﬁcally sound methodological reasons the use of any intervention less eﬀective than 
the best proven one, the use of placebo, or no intervention is necessary to determine the eﬃcacy or safety of an 
intervention and the patients who receive any intervention less eﬀective than the best proven one, placebo, or no 


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intervention will not be subject to additional risks of serious or irreversible harm as a result of not receiving the best 
proven intervention. 
 
Extreme care must be taken to avoid abuse of this option. 
 
Post-Trial Provisions 
 
33. 
In advance of a clinical trial, sponsors, researchers and host country governments should make provisions 
for post-trial access for all participants who still need an intervention identiﬁed as beneﬁcial in the trial. This 
information must also be disclosed to participants during the informed consent process. 
 
Research Registration and Publication and Dissemination of Results 
 
34. 
Every research study involving human subjects must be registered in a publicly accessible database before 
recruitment of the ﬁrst subject. 
 
35. 
Researchers, authors, sponsors, editors and publishers all have ethical obligations with regard to the 
publication and dissemination of the results of research. Researchers have a duty to make publicly available the 
results of their research on human subjects and are accountable for the completeness and accuracy of their reports. 
All parties should adhere to accepted guidelines for ethical reporting. Negative and inconclusive as well as positive 
results must be published or otherwise made publicly available. Sources of funding, institutional aﬃliations and 
conﬂicts of interest must be declared in the publication. Reports of research not in accordance with the principles of 
this Declaration should not be accepted for publication. 
 
Unproven Interventions in Clinical Practice 
 
36. 
In the treatment of an individual patient, where proven interventions do not exist or other known 
interventions have been ineﬀective, the physician, after seeking expert advice, with informed consent from the 
patient or a legally authorised representative, may use an unproven intervention if in the physician's judgement it 
oﬀers hope of saving life, re-establishing health or alleviating suﬀering. This intervention should subsequently be 
made the object of research, designed to evaluate its safety and eﬃcacy. In all cases, new information must be 
recorded and, where appropriate, made publicly available. 
 
 
© World Medical Association, Inc. - All Rights reserved. 
© Asociación médica mundial - Todos los derechos reservados. 
© L'Association Médicale Mondiale - Tous droits réservés. 
 


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Appendix 1B: 1996 Version of Declaration of Helsinki 
 
World Medical Association Declaration of Helsinki: 
Recommendations Guiding Medical Doctors in 
Biomedical Research Involving Human Subjects 
 
Adopted by the 18th World Medical Assembly, Helsinki, Finland, June 1964 and amended by the 29th World 
Medical Assembly, Tokyo, Japan, October 1975, 35th World Medical Assembly, Venice, Italy, October 1983, 
41st World Medical Assembly, Hong Kong, September 1989, and the 48th General Assembly, Somerset West, 
Republic of South Africa, October 1996 
 
INTRODUCTION 
It is the mission of the physician to safeguard the health of the people. His or her knowledge 
and conscience are dedicated the fulfilment of this mission. The Declaration of Geneva of 
the World Medical Assembly binds the physician with the words, "The health of my patient 
will be my first consideration," and the International Code of Medical Ethics declares that, 
"A physician shall act only in the patient's interest when providing medical care which might 
have the effect of weakening the physical and mental condition of the patient." 
 
The purpose of biomedical research involving human subjects must be to improve diagnostic, 
therapeutic and prophylactic procedures and the understanding of the aetiology and 
pathogenesis of disease. 
 
In current medical practice most diagnostic, therapeutic or prophylactic procedures involve 
hazards. This applies especially to biomedical research. Medical progress is based on 
research which ultimately must rest in part on experimentation involving human subjects. 
 
In the field of biomedical research a fundamental distinction must be recognized between 
medical research in which the aim is essentially diagnostic or therapeutic for a patient, and 
medical research, the essential object of which is purely scientific and without implying 
direct diagnostic or therapeutic value to the person subjected to the research. 
 
Special caution must be exercised in the conduct of research which may affect the 
environment, and the welfare of animals used for research must be respected. 
 
Because it is essential that the results of laboratory experiments be applied to human beings 
to further scientific knowledge and to help suffering humanity, the World Medical 
Association has prepared the following recommendations as a guide to every physician in 
biomedical research involving human subjects. They should be kept under review in the 
future. It must be stressed that the standards as drafted are only a guide to physicians all over 
the world. Physicians are not relieved from criminal, civic and ethical responsibilities under 
the laws of their own countries. 
 
I. BASIC PRINCIPLES 
 
1. Biomedical research involving human subjects must conform to generally accepted 
scientific principles and should be based on adequately performed laboratory and animal 
experimentation and on a thorough knowledge of the scientific literature. 


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2. The design and performance of each experimental procedure involving human subjects 
should be clearly formulated in an experimental protocol which should be transmitted for 
consideration, comment and guidance to a specially appointed committee independent of the 
investigator and the sponsor provided that this independent committee is in conformity with 
the laws and regulations of the country in which the research experiment is performed. 
 
3. Biomedical research involving human subjects should be conducted only by scientifically 
qualified persons and under the supervision of a clinically competent medical person. The 
responsibility for the human subject must always rest with a medically qualified person and 
never rest on the subject of the research, even though the subject has given his or her consent. 
 
4. Biomedical research involving human subjects cannot legitimately be carried out unless 
the importance of the objective is in proportion to the inherent risk to the subject. 
 
5. Every biomedical research involving human subjects should be preceded by careful 
assessment of predictable risks in comparison with foreseeable benefits to the subject or to 
others. Concern for the interest of the subject must always prevail over the interests of 
science and society. 
 
6. The right of the research subject to safeguard his or her integrity must always be respected. 
Every precaution should be taken to respect the privacy of the subject and to minimize the 
impact of the study on the subject's physical and mental integrity and on the personality of 
the subject. 
 
7. Physicians should abstain from engaging in research projects involving human subjects 
unless they are satisfied that the hazards involved are believed to be predictable. Physicians 
should cease any investigation if the hazards are found to outweigh the potential benefits. 
 
8. In publication of the results of his or her research, the physician is obliged to preserve the 
accuracy of the results. Reports of experimentation not in accordance with the principles laid 
down in this Declaration should not be accepted for publication. 
 
9. In any research on human beings, each potential subject must be adequately informed of 
the aims, methods, anticipated benefits and potential hazards of the study and the discomfort 
it may entail. He or she should be informed that he or she is a liberty to abstain from 
participation in the study and that he or she is free to withdraw his or her consent to 
participation at any time. The physician should then obtain the subject's freely-given 
informed consent, preferably in writing. 
 
10. When obtaining informed consent for the research project the physician should be 
particularly cautious if the subject is in a dependent relationship to him or her or may consent 
under duress. In that case the informed consent should be obtained by a physician who is not 
engaged in the investigation and who is completely independent of this official relationship. 
 
11. In case of legal incompetence, informed consent should be obtained from the legal 
guardian in accordance with national legislation. Where physical or mental incapacity makes 
it impossible to obtain informed consent, or when the subject is a minor, permission from the 
responsible relative replaces that of the subject in accordance with national legislation. 


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Whenever the minor child is in fact able to give consent, the minor's consent must be 
obtained in addition to the consent of the minor's legal guardian. 
 
12. The research protocol should always contain a statement of the ethical considerations 
involved and should indicate that the principles enunciated in the present Declaration are 
complied with. 
 
II. MEDICAL RESEARCH COMBINED WITH CLINICAL CARE 
(Clinical research) 
 
1. In the treatment of the sick person, the physician must be free to use a new diagnostic and 
therapeutic measure, if in his or her judgement it offers hope of saving life, reestablishing 
health or alleviating suffering. 
 
2. The potential benefits, hazards and discomfort of a new method should be weighed against 
the advantages of the best current diagnostic and therapeutic methods. 
 
3. In any medical study, every patient -- including those of a control group, if any -- should 
be assured of the best proven diagnostic and therapeutic method. This does not exclude the 
use of inert placebo in studies where no proven diagnostic or therapeutic method exists. 
 
4. The refusal of the patient to participate in a study must never interfere with the physician-patient 
relationship. 
 
5. If the physician considers it essential not to obtain informed consent, the specific reasons 
for this proposal should be stated in the experimental protocol for transmission to the 
independent committee (I,2). 
 
6. The physician can combine medical research with professional care, the objective being 
the acquisition of new medical knowledge, only to the extent that medical research is 
justified by its potential diagnostic or therapeutic value for the patient. 
 
III. NON-THERAPEUTIC BIOMEDICAL RESEARCH INVOLVING HUMAN 
SUBJECTS 
(Non-clinical biomedical research) 
 
1. In the purely scientific application of medical research carried out on a human being, it is 
the duty of the physician to remain the protector of the life and health of that person on 
whom biomedical research is being carried out. 
 
2. The subject should be volunteers - either healthy persons or patients for whom the 
experimental design is not related to the patient's illness. 
 
3. The investigator or the investigating team should discontinue the research if in his/her or 
their judgement it may, if continued, be harmful to the individual. 
 
4. In research on man, the interest of science and society should never take precedence over 
considerations related to the well being of the subject. 
 


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19.2 APPENDIX 2: Clinically Notable Values 
The following guidelines, originally established by the Division of Neuropharmacological Drug Products 
of the FDA, will be used for determining clinically notable values for laboratory and vital signs 
parameters.  
 
NOTABLE VALUES FOR LABORATORY PARAMETERS AND VITAL SIGNS  
 
CLINICALLY NOTABLE BLOOD CHEMISTRY VALUES  
Parameter 
Synonym 
S.I. units 
Other units 
Unit 
Lower 
Limit 
Upper 
Limit 
Unit 
Lower 
Limit 
Upper 
Limit 
Albumin 
 
g/L 
≤ 14 
≥ 62 
g/dL 
≤ 1.4 
≥ 6.2 
Alk. Phosphatase 
ALP 
U/L 
NA 
≥ 3.0*URL  
 
 
 
Amylase 
 
U/L 
≤ 15 
≥ 350 
 
 
 
ALAT, SGPT 
ALT,GPT 
U/L 
NA 
≥ 3.0*URL 
 
 
 
ASAT, SGOT 
AST,GOT 
U/L 
NA 
≥ 3.0*URL 
 
 
 
Bicarbonate 
 
mmol/L 
≤ 10 
NA 
 
 
 
Bilirubin total 
 
μmol/L 
NA 
≥ 34 
mg/dL 
 
≥ 2.0 
Calcium total 
 
mmol/L 
≤ 2.1 
≥ 3.0 
mg/dL 
≤ 8.2 
≥ 12 
Chloride 
 
mmol/L 
≤ 80 
≥ 125 
 
 
 
Cholesterol 
 
mmol/L 
NA 
≥ 141 
mg/dL 
 
≥ 500 
Creatinine kinase 
CPK 
U/L 
NA 
≥ 3.0*URL 
 
 
 
Creatinine 
 
μmol/L 
NA 
≥ 177 
mg/dL 
 
≥ 2.0 
Gamma-GT    Male 
 
U/L 
NA 
≥ 100 
 
 
 
Female 
 
U/L 
NA 
≥ 90 
 
 
 
Globulin total 
 
g/L 
≤ 10 
NA 
 
 
 
Glucose 
 
mmol/L 
≤ 1.7 
≥ 13.9 
mg/dL 
≤ 30 
≥ 250 
LDH 
 
U/L 
NA 
≥ 3.0*URL 
 
 
 
Phosphate 
 
mmol/l 
NA 
≥ 2 
 
 
 
Potassium 
 
mmol/L 
≤ 2.5 
≥ 6.5 
 
 
 
Protein total 
 
g/L 
≤ 45 
NA 
 
 
 
PTT 
 
sec 
NA 
≥ 80 
 
 
 
Sodium 
 
mmol/L 
≤ 120 
≥ 165 
 
 
 
Triglycerides 
 
mmol/L 
NA 
≥ 5.6 
mg/dL 
 
≥ 500 
Urea 
 
mmol/L 
NA 
≥ 16.6 
mg/dL 
 
≥ 100 
Urea nitrogen 
BUN 
mmol/L 
NA 
≥ 84.0 
mg/dL 
 
≥ 30 
Uric acid         Male 
 
μmol/L 
NA 
≥ 624 
mg/dL 
 
≥ 10.5 
Female 
 
μmol/L 
NA 
≥ 505 
mg/dL 
 
≥ 8.5 
 
 
 
 


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CLINICALLY NOTABLE HEMATOLOGY VALUES 
Parameter 
Synonym 
S.I. units 
Other units 
Unit 
Lower 
Limit 
Upper 
Limit 
Unit 
Lower 
Limit 
Upper 
Limit 
Basophils 
 
L/L 
NA 
≥ 0.15 
% 
 
≥ 15 
Eosinophils 
 
L/L 
NA 
≥ 0.10 
% 
 
≥ 10 
Erythocytes  Male 
RBC 
1012/L 
≤ 2.5 
NA 
 
 
 
Female 
 
1012/L 
≤ 2.0 
NA 
 
 
 
ESR                 Male 
 
Mm 
NA 
≥ 25 
 
 
 
Female 
 
Mm 
NA 
≥ 35 
 
 
 
Hematocrit      Male 
EVF 
L/L 
≤ 0.37 
NA 
% 
≤ 37 
 
 
Female 
 
L/L 
≤ 0.32 
NA 
% 
≤ 32 
 
Hemoglobin    Male 
 
g/L 
≤ 115 
NA 
g/dL 
≤ 11.5 
 
 
Female 
 
g/L 
≤ 95 
NA 
g/dL 
≤ 9.5 
 
Leukocytes 
WBC 
109/L 
≤ 2.8 
≥ 16.0 
 
 
 
Lymphocytes 
 
L/L 
NA 
≥ 0.80 
% 
 
≥ 80 
MCHC 
 
mmol/L 
≤ 12.4 
≥ 27.9 
g/dL 
≤ 20 
≥ 45 
MCV 
 
10-15L 
≤ 60 
≥ 120 
 
 
 
Monocytes 
 
L/L 
NA 
≥ 0.40 
% 
 
≥ 40 
Neutrophils 
 
L/L 
≤ 0.15 
NA 
% 
≤15 
 
Thrombocytes 
Platelets 
109/L 
≤ 75 
≥ 700 
 
 
 
 
CLINICALLY NOTABLE URINALYSIS VALUES 
Variable 
Clinically Notable Values 
Protein 
Increase of 2 units 
Glucose 
Increase of 2 units 
 
CLINICALLY NOTABLE VITAL SIGNS VALUES 
Parameter 
Unit 
Decrease 
Increase 
Sitting/Supine SBP 
mmHg 
Value ≤ 90 and ≥ 20 decrease from Baseline. 
Value ≥ 180 and ≥ 20 
increase from Baseline 
Sitting/Supine DBP 
mmHg 
Value ≤ 50 and ≥ 15 decrease from Baseline. 
Value ≥ 105 and ≥ 15 
increase from Baseline 
Orthostatic Hypotension 
(based on standing 
SBP/DBP) 
mmHg 
Decrease in SBP/DBP from Supine to 
Standing position exceeding > 30mmHg 
NA 
Sitting pulse rate 
bpm 
Value ≤ 50 and ≥ 15 decrease from Baseline 
Value ≥ 120 and ≥ 15 
increase from Baseline 
Weight 
kg 
≥ 7% decrease from Baseline. 
≥ 7% increase from 
Baseline. 
Respiration rates*  
Breaths/ 
minute 
< 12 
> 25 
Temperature 
oC 
NA 
Value ≥ 38.3 and ≥ 1.1 
increase from Baseline. 
Temperature 
˚F 
NA 
Value ≥ 101.0 and ≥ 2.0 
increase from baseline 
* For respiration rate values are relevant, not decrease/increase. 
 


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19.3 APPENDIX 3: Investigator Statement 
Investigator Statement 
 
Compound: 
Sarizotan  
Protocol Number: 
Sarizotan/001/II/2015 
Title: 
A Randomized, Double-Blind, Placebo-Controlled, Six-Month 
Study to Evaluate the Efficacy, Safety and Tolerability of Sarizotan 
in Patients with Rett Syndrome with Respiratory Symptoms 
Trial Center Number: 
 
Principle Investigator: 
Address: 
 
 
Telephone: 
Fax: 
Email: 
 
 
 
COMMITMENTS 
 
By signing this document, I agree to conduct the trial as outlined in the protocol and in accordance with (as 
applicable) the Declaration of Helsinki, the ICH GCP Guideline as well as all applicable government 
regulations. 
 
I declare: 
1. I am well qualified by scientific training and experience to conduct investigational studies in the clinical 
area of the proposed trial and I am affiliated with a recognized medical school or with an independent 
institution recognized for its excellence. 
2. I have received and understood the information about pharmacology, toxicology and possible risks and 
side effects of the investigational compound (e.g., as described in the Investigator's Brochure). 
3. I shall provide information to all staff members involved in the trial about their obligations as described 
in this document. 
4. I shall submit the protocol, Informed Consent form/subject information sheet and other required 
documentation to the IRB/IEC for review and approval. 


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5. I shall make no changes to the protocol without formal amendment (prepared in agreement with the 
Sponsor), except when necessary to protect the safety, the rights or welfare of subjects. In this last case 
I will inform the Sponsor of the change.  
6. I shall require Informed Consent from each subject prior to enrollment into the study.  The Informed 
Consent shall be documented by use of a written consent form approved by the Sponsor and the 
IRB/IEC. 
7. I shall use the investigational compound only in compliance with the trial protocol and I shall be 
responsible for the security and accountability of clinical study supplies. 
8. I shall notify NEWRON immediately or no later than 24 hours by telephone and/or by fax of serious 
or unexpected adverse events and submit written reports of adverse events, as outlined in the protocol, 
to NEWRON, the IRB/IEC and to Regulatory Authorities (when appropriate). 
9. I shall complete the Sponsor's Case Report Form (CRF) in a timely and legible manner. 
10. I shall maintain accurate source records (hospital or other institutional records), which will support the 
data entered into Case Report Forms and I shall maintain these as specified in the protocol. 
11. I shall allow monitoring visits by NEWRON's representatives at predetermined frequency. 
12. I shall allow the authorized Sponsor representative and any Regulatory Authorities to inspect the 
facilities and pertinent records at reasonable times and in a manner which ensure subject confidentiality. 
13. I shall maintain confidentiality about all information concerning the investigational compound, such as 
patent applications, formulas, manufacturing process, basic scientific data and formulation information 
supplied by the Sponsor and not previously published and I shall not disclose this information to a third 
party without the written consent of the Sponsor. 
14. I shall permit the information developed in the clinical trial to be used by the Sponsor in connection 
with the development of the compound and may be disclosed to the IRB/IEC and Regulatory 
Authorities. 
 
Following completion of the study, the data may be considered for reporting at a scientific meeting and/or 
for publication in a scientific journal.  A copy of the manuscript or abstract will be provided to the Sponsor 
for review before submission to a scientific journal for publication and/or a scientific meeting selection 
committee for oral or poster presentation.  Subgroup or individual Investigator publications must not 
interfere or compromise publication of the multi-center results of this clinical trial. 
 
 
 _______________________________  
 ___________________  
Investigator Signature 
Date 
 
 _______________________________  
 
Investigator (Printed Name) 
 


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19.4 APPENDIX 4: RTT Diagnostic Criteria 
Revised Diagnostic Criteria for Rett Syndrome (Neul et al, 2010) 
 


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Amend. 1, 19Jan2016; Amend. 2, 18May2016; Amend. 3, 21Oct2016; Amend. 4, 03Mar2017; Amend. 5, 29Mar2017; 
Amend. 6, 13Apr2017; Amend. 7, 02Oct2017; Amend. 8, 02Nov2017; Amend. 9, 11Feb2018; Amend. 10, 29Nov2018; 
Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
Confidential 
 
Revised Diagnostic Criteria for Rett Syndrome (continued) 
 
 


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Amend. 1, 19Jan2016; Amend. 2, 18May2016; Amend. 3, 21Oct2016; Amend. 4, 03Mar2017; Amend. 5, 29Mar2017; 
Amend. 6, 13Apr2017; Amend. 7, 02Oct2017; Amend. 8, 02Nov2017; Amend. 9, 11Feb2018; Amend. 10, 29Nov2018; 
Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
Confidential 
19.5 APPENDIX 5: Cardiorespiratory Measurements using the BioRadio 
Validation of the BioRadio System for Use in Remote Monitoring of Respiratory Function 
The BioRadio™ system will be used in the first sarizotan study in Rett syndrome patients (Study 
Sarizotan/001/II/2015) to assess respiratory function, including changes in the frequency of apnea episodes, 
which will be the primary efficacy parameter.  
What is the BioRadio? 
The BioRadio is a wireless data acquisition system developed by Great Lakes 
NeuroTechnologies (Cleveland, OH) that is capable of recording, displaying and 
analyzing physiological signals in real time, e.g. measuring electrocardiogram 
(ECG), respiratory, electro-encephalogram (EEG), electromyogram (EMG) and 
pulse oximetry parameters. Physiological signals are amplified, sampled and 
digitized, and can be wirelessly transmitted to a computer via Bluetooth receiver 
and/or recorded to onboard memory for post-analysis.  
What does it consist of? 
The BioRadio consists of a Primary Module, which has 4 (differential) or 8 (single-ended) channels, 
allowing measurement of multiple parameters simultaneously, and an optional Sensor Pod which has an 
input for a pulse oximeter and another sensor. A differential channel on the Primary Module can be 
configured for respiratory inductance plethysmography (RIP) using inductive bands.  This configuration 
will be used in the sarizotan study; an additional channel will be used for pulse oximetry. The BioRadio is 
worn by the patient and uses wireless technology to transfer data from sensors attached to the body, allowing 
the patient to move about freely during the recording process. 
How does it work? 
The BioRadio system employs RIP technology to measure 
respiratory functional parameters, including apnea index, 
hyperventilation index, epoch apnea, respiratory rate, respiratory 
cycle time, and respiratory irregularity. Dual-band RIP is a 
technique that uses two elastic bands containing inductive coils, 
which wrap around the chest and abdomen of the patient, to 
calculate chest and abdominal expansion, respiratory rate, 
respiratory pattern and tidal volume. An alternating current is 
passed through the belt, generating a magnetic field. The act of 
breathing changes the cross-sectional area of the patient’s body, 
which in turn changes the shape of the magnetic field generated by the belt, inducing an opposing current 
that can be measured.  The signal produced is linear and related to the change in cross-sectional area.  The 
utility of dual-band RIP in measuring respiratory function is based on the premise that volume changes at 
the orofacial orifices are equal to the sum of the volume changes of the rib cage and abdominal 
compartments (Konno and Mead, 1967), thus measurements done using RIP are equivalent to those made 
using spirometry, when the RIP system is properly calibrated (Sackner et al, 1989).   
How does it measure respiration? 
Impedance pneumography, using low amplitude, high frequency, alternating currents between two 
recording electrodes has been extensively used to record thoracic movements during respiration.  However 
impedance pneumography use is constrained by findings that indicate the electrical resistance of the rib 
cage tissues is less than air, and therefore the AC passing through the thoracic cavity reflects tissue 
impedance and provides an erroneous value for thoracic volume.  Impedance pneumography is affected by 


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Amend. 1, 19Jan2016; Amend. 2, 18May2016; Amend. 3, 21Oct2016; Amend. 4, 03Mar2017; Amend. 5, 29Mar2017; 
Amend. 6, 13Apr2017; Amend. 7, 02Oct2017; Amend. 8, 02Nov2017; Amend. 9, 11Feb2018; Amend. 10, 29Nov2018; 
Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
Confidential 
motion and cardiogenic artifacts, and as the rib cage (RC) signal is dependent on posture, tidal volumes are 
difficult to estimate and the polarity of signals changes suddenly.  This has led to increasing use of inductive 
plethysmography. 
Respiratory inductive plethysmography has been used extensively as a non-invasive method for measuring 
respiratory volumes, particularly in the diagnosis of sleep-related breathing disorders (Cantineau et al, 1992; 
Bloch et al, 1997) and upper airway resistance syndrome (Loube et al, 1999). RIP has a number of 
advantages over impedance pneumography, which employs alternating current between two surface 
electrodes to record thoracic movements or volume changes at the rib cage (Landon, 2003).  These 
advantages of RIP include greater accuracy and sensitivity, the ability to assess thoraco-abdominal 
coordination, and the minimization of motion artifact.  
Validation studies of the BioRadio 
The older RIP model was validated in patients and healthy volunteers for measurement of tidal volumes 
and respiratory lung volume by comparing it with data obtained with a pneumotachometer and spirometer 
as references (Valta et al 1992).  A series of validation studies were performed for newer models (Respitrace 
Plus™ ) of the RIP, where it was first calibrated using qualitative diagnostic calibration by comparison of 
signals obtained by the pneumotachometer and from the sum of the rib and abdominal cages (RC and AC).  
The newer model has also been validated by comparing its performance to the older RIP. 
The Respitrace Plus™ was evaluated both under clinical and laboratory conditions and compared with an 
earlier validated version (Respigraph™) in the measurement of tidal volume, long-term end-expiratory lung 
volume (EELV) and changes in EELV induced by positive end-expiratory pressure (PEEP) in a study done 
by Leino et al (2001).  In this study no significant differences were noted between RIP and the 
pneumotachometer with regard to measurements of tidal volume in spontaneously breathing volunteers and 
mechanically ventilated patients with acute lung injury, or in measurements of PEEP-induced changes in 
EELV in acute lung injury patients.   
A portable RIP has been tested in monitoring of ventilation during exercise in unrestrained subjects, 
including 20 healthy volunteers, 6 patients with COPD, and 5 patients with congestive heart failure 
(Clarenbach et al, 2005). An elastic body garment (LifeShirt™; VivoMetrics) containing the inductance 
sensors encircling the rib cage and abdomen was used and connected to a portable, battery-powered device 
which was connected to sensors measuring pulse oximetry, ECG and body movements, in addition to RIP.  
A comparison between measurements obtained with the portable RIP and a flowmeter (pneumotachograph) 
over the course of progressive exercise to exhaustion (treadmill) showed good agreement for respiratory 
cycle time, tidal volume, and minute ventilation for both healthy volunteers and patients with breathing 
difficulties.  The RIP monitor was able to identify differences in breathing patterns between healthy 
volunteers and patients with pulmonary or cardiac disease. 
The new RIP was also validated during controlled ventilation post operatively in patients with chronic 
obstructive pulmonary disease (COPD) and in acute lung injury, by comparing results with those obtained 
from a pneumotachometer (Neumann et al, 1998).  
Use of the BioRadio to measure respiratory indices in patients 
The guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea 
published by the Portable Monitoring Task Force of the American Academy of Sleep Medicine, recommend 
the use of RIP, as opposed to other non-invasive techniques, e.g. piezo sensors, strain gauges and thoracic 
impedance, for measuring respiratory effort, in particular for scoring hypopnea, in the laboratory setting 
(Collop et al, 2007).  
A study in newborn infants found that thoracic impedance monitors were less sensitive than RIP in 
monitoring respiratory events related to obstructive sleep apnea (Brouillette et al, 1987). Similarly, a study 


Protocol No. Sarizotan/001/II/2015  
 
 
 
 
 
 
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Amend. 1, 19Jan2016; Amend. 2, 18May2016; Amend. 3, 21Oct2016; Amend. 4, 03Mar2017; Amend. 5, 29Mar2017; 
Amend. 6, 13Apr2017; Amend. 7, 02Oct2017; Amend. 8, 02Nov2017; Amend. 9, 11Feb2018; Amend. 10, 29Nov2018; 
Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
Confidential 
performed comparing RIP and other methods, e.g. strain gauges and impedance pneumography, to a 
pneumotachograph in measuring breath amplitude and tidal volume in newborn infants demonstrated that 
RIP showed more accurate and consistent measurements in both the supine and prone positions, compared 
with the other methods (Adams et al, 1993).   
A non-calibrated RIP has been used in a study in monkeys to measure phase angle (relationship of thoracic 
to abdominal movements during breathing) to assess the effects of inspiratory load on thoraco-abdominal 
ansynchrony, as is observed in infants and small children with acute upper airway obstruction (Hammer et 
al, 1995). A good correlation was observed between the phase angle measurements, calculated based on 
data from the RIP, and inspiratory load, i.e., phase angle increased continuously with higher inspiratory 
loads.   
Use of the BioRadio in patients with Rett Syndrome 
Recently, a study was performed in 12 female patients with Rett syndrome, ages 3-10, to evaluate the safety, 
pharmacokinetics and efficacy of mecasermin (Khwaja et al, 2014). Eight of the 12 patients were diagnosed 
with breathing abnormalities (e.g. air expulsion, breath holding, hyperventilation, apnea) at baseline.  
Automated measurements of cardiorespiratory parameters were performed using RIP and ECG, and 
recorded using the BioRadio. Data collected with this system was used to calculate various respiratory 
parameters, including total respiratory cycle times (Ttot) and inspiratory peaks (amplitude >20% above the 
typical amplitude). Ttot was categorized as normal, apneic or tachypneic based on aged-defined norms. 
Clinically significant apnea was defined as a pause in inspiration ≥10 seconds, and the number of these 
events per hour (apnea index) was calculated for each patient at baseline (mean ± SE: 10.11 ± 19.34) and 
at subsequent visits. In addition, hyperventilation was defined as ≥5 consecutive tachypneic breaths, with 
amplitude greater than the typical amplitude, and the number of these events per hour (hyperventilation 
index) was calculated for each patients at baseline (mean ± SE: 3.55 ± 6.71) and at subsequent visits. These 
measurements, which were made using the BioRadio and RIP, showed good agreement with clinicians’ 
assessments using plethysmography.  
Regulatory status of the BioRadio 
The BioRadio complies with FCC Part 15 rules and conforms to FDA guidelines for use as a research tool 
in capturing electronic data in clinical trials. The Quality Management System for the device complies with 
the requirements of ISO13485:2003, and it is CE marked in Europe for research purposes. The BioRadio 
is not a medical device, but it complies with the Radio and Telecommunications Terminal Equipment 
(R&TTE) Directive 1999/5/EC and the Electromagnetic Compatibility (EMC) Directive 2004/108/EC, 
which are part of the product electrical safety requirements stated within IEC 60601-1.  
The BioRadio is available for sale in the US, Europe and Canada. The development of the device has been 
funded in part by the NIH and 25 collaborating institutions have been involved in its testing.  Results of 
studies using the BioRadio have been presented in over 65 peer-reviewed publications and presentations.   
Summary 
Respiratory inductive plethysmography has been used extensively over the past 25 years as a reliable 
method for non-invasive measurement of respiratory functional parameters.  Good agreement has been 
demonstrated in a large number of studies between measurements taken using RIP and direct measurements 
using spirometry or pneumotachography.  Coupling of RIP with a portable wireless data acquisition system 
such as the BioRadio allows respiratory measurements to be made in freely moving subjects.  The utility 
of this combination has been demonstrated in a recent study in Rett syndrome patients, where 
cardiorespiratory monitoring was performed using the BioRadio and RIP, including measurement of apnea 
and hyperventilation indexes (Khwaja et al, 2014).   


Protocol No. Sarizotan/001/II/2015  
 
 
 
 
 
 
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Amend. 1, 19Jan2016; Amend. 2, 18May2016; Amend. 3, 21Oct2016; Amend. 4, 03Mar2017; Amend. 5, 29Mar2017; 
Amend. 6, 13Apr2017; Amend. 7, 02Oct2017; Amend. 8, 02Nov2017; Amend. 9, 11Feb2018; Amend. 10, 29Nov2018; 
Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
Confidential 
19.6 APPENDIX 6: Procedure for Preparing and Administering Sarizotan as a Solution 
Administration of sarizotan as an oral solution  
If the patient has difficulty swallowing whole capsules, the whole capsule may be dissolved in apple 
juice, cranberry juice, orange juice, tea (with or without milk), or water.  Do not use a liquid other than 
one of these for mixing this medication. The procedure to prepare and administer a drinkable solution is 
as follows: 
• 
Place the capsule(s) into a cup.  
• 
Add 1 fluid ounce (2 tablespoons or 30 milliliters) of near boiling (800C or higher) hot apple 
juice, cranberry juice, orange juice, tea (with or without milk), or water to the cup.  
• 
Stir the mixture with a spoon for 5-10 minutes or until all parts of the capsule have dissolved. The 
solution may appear cloudy and have a pink to orange color.  
• 
Allow the solution to cool to room temperature. 
• 
The patient should drink all of the medication solution immediately. Use a straw to sip if 
necessary. 
• 
Add 1 more ounce (2 tablespoons or 30 milliliters) of warm or room temperature apple juice, 
cranberry juice, orange juice, tea, water or other liquid to the cup, swirl to rinse the walls of the 
cup, and have the patient drink immediately. This step is to make sure all of the medication is 
taken by the patient.  
• 
Add 1 more ounce (2 tablespoons or 30 milliliters) of warm or room temperature apple juice, 
cranberry juice, orange juice, tea, water or other liquid to the cup, swirl to rinse the walls of the 
cup, and have the patient drink immediately. This step is to make sure all of the medication is 
taken by the patient.  
• 
Discard any unused solution. Do not save solution or leftovers for later use. 
Patients following a ketogenic diet may use low sugar or no-added sugar apple juice or cranberry juice 
product.  
Dose differences are not anticipated between administering sarizotan in an oral capsule, or in a drinkable 
solution. The pharmacokinetics (PK) of sarizotan are linear in the dose range of 0.5 to 25 mg. Rapid 
absorption is indicated by Cmax occurring within 1 hour after administration. The absolute bioavailability 
is about 90%, so complete absorption is expected with both modes of administration. 
These procedures can be performed by the caregiver during outpatient treatment or by the Investigator 
when the patient is being dosed in the hospital. 
 
Administration of sarizotan as a solution through a gastrostomy tube (G-tube)  
To give the medication via an enteral feeding tube (such as gastrostomy tube): 
• 
Follow the standard procedures for enteral administration to ensure that the whole dose is given. Use 
aseptic techniques. Make sure to use a clean medicine cup, syringe, spoon and gauze. Follow this 
procedure to prepare and administer a solution via an enteral feeding tube: 
• 
Place the capsule into a cup. 


Protocol No. Sarizotan/001/II/2015  
 
 
 
 
 
 
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Amend. 1, 19Jan2016; Amend. 2, 18May2016; Amend. 3, 21Oct2016; Amend. 4, 03Mar2017; Amend. 5, 29Mar2017; 
Amend. 6, 13Apr2017; Amend. 7, 02Oct2017; Amend. 8, 02Nov2017; Amend. 9, 11Feb2018; Amend. 10, 29Nov2018; 
Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
Confidential 
• 
Add 1 fluid ounce (2 tablespoons or 30 milliliters) of near boiling (80°C or higher) hot water to the 
cup. 
• 
Stir the mixture with a spoon for 5‐10 minutes or until all parts of the capsule have dissolved. The 
solution may appear cloudy and have a pink to orange color. 
• 
Allow the solution to cool to room temperature. 
• 
Following proper techniques, administer the solution to the patient via the feeding tube using an 
appropriate syringe or other approved device. 
• 
Add 1 fluid ounce (2 tablespoons or 30 milliliters) of warm or room temperature water to the cup, 
swirl to rinse the walls of the cup, and use the syringe or approved device to administer the solution 
via the feeding tube immediately. This step is to make sure all of the medication is taken by the 
patient. 
• 
Add another 1 fluid ounce (2 tablespoons or 30 milliliters) of warm or room temperature water to the 
cup, swirl to rinse the walls of the cup, and use the syringe or approved device to administer the 
solution via the feeding tube immediately. 
• 
This additional step is to make sure all of the medication is taken by the patient. 
• 
Discard any unused solution. Do not save solution or leftovers for later use. 
 
 
 


Protocol No. Sarizotan/001/II/2015  
 
 
 
 
 
 
Page 135 of 136 
Amend. 1, 19Jan2016; Amend. 2, 18May2016; Amend. 3, 21Oct2016; Amend. 4, 03Mar2017; Amend. 5, 29Mar2017; 
Amend. 6, 13Apr2017; Amend. 7, 02Oct2017; Amend. 8, 02Nov2017; Amend. 9, 11Feb2018; Amend. 10, 29Nov2018; 
Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
Confidential 
19.7 APPENDIX 7: Tanner Staging 
SEXUAL MATURITY RATING (TANNER STAGING) IN ADOLESCENTS 
Stage 
Female 
Male 
Age 
range 
(years) 
Breast 
growth 
Pubic hair 
growth 
Other 
changes 
Age 
range 
(years) 
Testes 
growth 
Penis growth Pubic hair 
growth 
Other 
changes 
I 
0–15 
Pre-
adolescent 
None 
Pre-
adolescent 
0–15 
Pre-
adolescent 
testes 
(≤2.5 cm) 
Pre-
adolescent 
None 
Pre-
adolescent 
II 
8–15 
Breast 
budding 
(thelarche); 
areolar 
hyperplasia 
with small 
amount of 
breast tissue 
Long downy 
pubic hair 
near the 
labia, often 
appearing 
with breast 
budding or 
several weeks 
or months 
later 
Peak 
growth 
velocity 
often 
occurs 
soon after 
stage II 
10–15 
Enlargement 
of testes; 
pigmentation 
of scrotal sac 
Minimal or 
no 
enlargement 
Long 
downy hair, 
often 
appearing 
several 
months 
after 
testicular 
growth; 
variable 
pattern 
noted with 
pubarche 
Not applicable 
III 
10–15 Further 
enlargement 
of breast 
tissue and 
areola, with 
no 
separation 
of their 
contours 
Increase in 
amount and 
pigmentation 
of hair 
Menarche 
occurs in 
2% of girls 
late in 
stage III 
1½–16.5 
Further 
enlargement 
Significant 
enlargement, 
especially in 
diameter 
Increase in 
amount; 
curling 
Not applicable 
IV 
10–17 Separation 
of contours; 
areola and 
nipple form 
secondary 
mound 
above 
breasts 
tissue 
Adult in type 
but not in 
distribution 
Menarche 
occurs in 
most girls 
in stage 
IV, 1–3 
years after 
thelarche 
Variable: 
12–17 
Further 
enlargement 
Further 
enlargement, 
especially in 
diameter 
Adult in 
type but not 
in 
distribution 
Development 
of axillary 
hair and some 
facial hair 


Protocol No. Sarizotan/001/II/2015  
 
 
 
 
 
 
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Amend. 1, 19Jan2016; Amend. 2, 18May2016; Amend. 3, 21Oct2016; Amend. 4, 03Mar2017; Amend. 5, 29Mar2017; 
Amend. 6, 13Apr2017; Amend. 7, 02Oct2017; Amend. 8, 02Nov2017; Amend. 9, 11Feb2018; Amend. 10, 29Nov2018; 
Amend. 13, 10Dec2019; Amendment 14, 17 March 2020, Clean, Final 
 
Confidential 
Stage 
Female 
Male 
Age 
range 
(years) 
Breast 
growth 
Pubic hair 
growth 
Other 
changes 
Age 
range 
(years) 
Testes 
growth 
Penis growth Pubic hair 
growth 
Other 
changes 
V 
12.5–
18 
Large 
breast with 
single 
contour 
Adult in 
distribution 
Menarche 
occurs in 
10% of 
girls in 
stage V. 
13–18 
Adult in size 
Adult in size 
Adult in 
distribution 
(medial 
aspects of 
thighs; linea 
alba) 
Body hair 
continues to 
grow and 
muscles 
continue to 
increase in 
size for 
several 
months to 
years; 20% of 
boys reach 
peak growth 
velocity 
during this 
period 
Copyright © 2010, World Health Organization. 
 
 

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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 1 of 47 
  
 
 
 
 
STATISTICAL ANALYSIS PLAN 
 
 
SARIZOTAN/001/II/2015 
A RANDOMIZED, DOUBLE-BLIND, PLACEBO-
CONTROLLED, SIX-MONTH STUDY TO EVALUATE THE 
EFFICACY, SAFETY AND TOLERABILITY OF SARIZOTAN 
IN PATIENTS WITH RETT SYNDROME WITH 
RESPIRATORY SYMPTOMS 
 
 
 
AUTHOR: AYUSHI CHATURVEDI 
VERSION NUMBER AND DATE: V2, 30March2020 
 
 
 
 


 
 
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Version Date: 
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Effective Date: 01Apr2016 
 
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Newron Pharmaceuticals S.p.A. 
      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 2 of 47 
STATISTICAL ANALYSIS PLAN SIGNATURE PAGE 
Statistical Analysis Plan V2 (Dated 30March2020) for Protocol Sarizotan/001/II/2015, Version 
15.0. 
 
Name 
Signature 
Date 
Author: 
Ms. Ayushi Chaturvedi 
 
30March2020 
 
Position: 
Associate Biostatistician 
 
Company: 
IQVIA (Thane, India) 
 
Upon review of this document, the undersigned approves this version of the Statistical Analysis 
Plan, authorizing that the content is acceptable for the reporting of this study. 
 
Name 
Signature 
Date 
Reviewed By: 
Dr. Manoj Kumar 
Yadav 
 
30March2020 
 
Position: 
Senior Manager Biostatistics 
 
Company: 
IQVIA (Mumbai, India) 
 
Approved By: 
Dr. Ravi Anand 
 
 
 
Position: 
CMO 
 
Company: 
Newron Pharmaceuticals SpA 


 
 
Document: 
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Effective Date: 01Apr2016 
 
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MODIFICATION HISTORY 
Unique Identifier for 
this Version 
Date of the 
Document 
Version 
Author 
Significant Changes 
from Previous 
Authorized Version 
1.0 
26NOV2019 
Ayushi 
Chaturvedi 
Not Applicable – First 
Version 
2.0 
30March2020 
Ayushi 
Chaturvedi 
Analysis related to 
primary, key secondary 
and other secondary 
endpoints have been 
updated as per protocol 
amendment 14.0 
 
 
 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 4 of 47 
TABLE OF CONTENTS 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS ...........................................................................................8 
1. 
INTRODUCTION ...................................................................................................................... 10 
2. 
STUDY OBJECTIVES .............................................................................................................. 11 
2.1. 
Primary Objective ...................................................................................................................................... 11 
2.2. 
Secondary Objectives ................................................................................................................................ 11 
3. 
STUDY DESIGN ......................................................................................................................... 12 
3.1. 
General Description ................................................................................................................................... 12 
3.2. 
Schedule of Events..................................................................................................................................... 16 
3.3. 
Changes to Analysis from Protocol ............................................................................................................ 19 
4. 
PLANNED ANALYSES ............................................................................................................ 19 
4.1. 
Interim Analysis ......................................................................................................................................... 19 
4.2. 
Final Analysis ............................................................................................................................................. 19 
5. 
ANALYSIS POPULATIONS AND STUDY PERIOD ...................................................... 19 
5.1. 
ITT Population ........................................................................................................................................... 19 
5.2. 
Per Protocol Population ............................................................................................................................. 19 
5.3. 
Safety Population ...................................................................................................................................... 20 
5.4. 
24-Week Double-blind Treatment Period .................................................................................................. 20 
5.5. 
Initial 24-Week Open-label Extension Treatment Period ........................................................................... 20 
5.6. 
Three additional 48-Week Open-label Extension Treatment Periods ......................................................... 21 
6. 
GENERAL CONSIDERATIONS ........................................................................................... 21 
6.1. 
Reference Start Date and Study Day .......................................................................................................... 22 


 
 
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Page 5 of 47 
6.2. 
Baseline ..................................................................................................................................................... 22 
6.3. 
Retests, Unscheduled Visits and Early Termination Data ........................................................................... 22 
6.4. 
Statistical Tests .......................................................................................................................................... 22 
6.5. 
Common Calculations ................................................................................................................................ 23 
6.6. 
Software Version ....................................................................................................................................... 23 
7. 
STATISTICAL CONSIDERATIONS ................................................................................... 23 
7.1. 
Adjustments for Covariates and Factors to be Included in Analyses .......................................................... 23 
7.2. 
Multicenter Studies ................................................................................................................................... 23 
7.3. 
Missing data .............................................................................................................................................. 24 
7.4. 
Multiple Comparisons/ Multiplicity ........................................................................................................... 24 
7.5. 
Examination of Subgroups ......................................................................................................................... 24 
8. 
OUTPUT PRESENTATIONS ................................................................................................. 24 
8.1. 
data selection for double blind treatment period (24 Weeks) ................................................................... 26 
8.2. 
Visit windows: ........................................................................................................................................... 26 
9. 
DISPOSITION AND WITHDRAWALS .............................................................................. 27 
10. 
DEMOGRAPHIC AND OTHER BASELINE CHARACTERISTICS ......................... 27 
11. 
MEDICAL HISTORY ............................................................................................................... 27 
12. 
MEDICATIONS ......................................................................................................................... 28 
13. 
STUDY MEDICATION EXPOSURE ................................................................................... 28 
14. 
STUDY TREATMENT NON-COMPLIANCE ................................................................... 29 
15. 
EFFICACY OUTCOMES ........................................................................................................ 29 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 6 of 47 
15.1. 
Primary Efficacy ..................................................................................................................................... 29 
15.1.1 
Primary Efficacy Variable & Derivation .....................................................................................................29 
15.1.2 
Missing Data Methods for Primary Efficacy Variable ...............................................................................29 
15.1.3 
Analysis of Primary Efficacy Variable ........................................................................................................29 
15.1.4 
Key Secondary Efficacy Variable ...............................................................................................................30 
15.2. 
Secondary Efficacy ................................................................................................................................. 31 
15.2.1 
Secondary Efficacy Variables & Derivations .............................................................................................31 
15.2.1.1 
Change from Baseline in Total Score of Caregiver Top 3 Concerns at Week 24 ...............................31 
15.2.1.2 
Mean rating of Clinical Global Impression of Change (CGI-C) at Week 24 .......................................32 
15.2.1.3 
Change from baseline to Week 24 in Motor-Behavioral Assessment Scale (MBAS) ........................32 
15.2.1.4 
Change from baseline to Week 24 in other respiratory symptoms of RTT ......................................32 
15.2.1.5 
Change from baseline to Week 24 in Rett syndrome Clinical Severity Scale (RCSS) ........................33 
15.2.2 
Missing Data Methods for Secondary Efficacy Variables ..........................................................................33 
15.2.3 
Analysis of Secondary Efficacy Variables ..................................................................................................33 
15.2.3.1 
Analysis of Caregiver Top 3 Concerns Total Score at Week 24 .........................................................33 
15.2.3.2 
Analysis of mean rating of Clinical Global Impression of Change (CGI-C) at Week 24 .....................34 
15.2.3.3 
Analysis of change from baseline to Week 24 in Motor-Behavioral Assessment Scale (MBAS) ......34 
15.2.3.4 
Analysis of change from baseline to Week 24 in other respiratory symptoms of RTT .....................34 
15.2.3.5 
Analysis of change from baseline to Week 24 in Rett syndrome Clinical Severity Scale (RCSS) .......35 
15.2.4 
Exploratory Variables & Derivations .........................................................................................................35 
16. 
QUALITY OF LIFE ANALYSIS ........................................................................................... 35 
17. 
SAFETY OUTCOMES ............................................................................................................. 35 
17.1. 
Adverse Events ...................................................................................................................................... 35 
17.1.1 
All TEAEs ...................................................................................................................................................36 
17.1.2 
Intensity ....................................................................................................................................................36 
17.1.3 
Relationship to Study drug .......................................................................................................................36 
17.1.4 
AEs Leading to patient Discontinuation ....................................................................................................37 
17.1.5 
Serious Adverse Events .............................................................................................................................37 
17.1.6 
Adverse Drug reaction (ADR) ....................................................................................................................37 
17.1.7 
Summary of non-TEAEs ............................................................................................................................37 
17.2. 
Deaths ................................................................................................................................................... 37 
17.3. 
Laboratory Evaluations .......................................................................................................................... 37 
17.4. 
12-LEAD ECG .......................................................................................................................................... 38 
17.5. 
Vital Signs .............................................................................................................................................. 38 
17.6. 
Physical Examination ............................................................................................................................. 39 
17.7. 
NEUROLOGICAL EXAMINATION ............................................................................................................. 39 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 7 of 47 
17.8. 
OPHTHALMOLOGICAL EXAMINATION .................................................................................................... 39 
17.9. 
STRUCTURED SUICIDALITY ASSESSMENT ............................................................................................... 39 
17.10. 
Tanner Staging ....................................................................................................................................... 39 
18. 
DATA NOT SUMMARIZED OR PRESENTED ................................................................ 39 
19. 
REFERENCES ............................................................................................................................ 40 
APPENDIX 1. PARTIAL DATE CONVENTIONS ................................................................... 41 
Algorithm for Treatment Emergence of Adverse Events: ...................................................................................... 41 
Algorithm for Prior / Concomitant Medications: ................................................................................................... 42 
APPENDIX 2. CLINICALLY NOTABLE VALUES FOR LABORATORY 
PARAMETERS 44 
APPENDIX 3. CLINICALLY NOTABLE VITAL SIGNS VALUES ................................... 46 
APPENDIX 4. AGE CATEGORIZATION .................................................................................. 46 
APPENDIX 5. RANDOMIZATION OF PATIENTS ACCORDING TO AGE AND BODY 
WEIGHT CRITERIA........................................................................................................................... 47 
  


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 8 of 47 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS  
ADR  
adverse drug reaction  
AE  
adverse event  
ALT  
alanine-aminotransferase  
ANCOVA  
analysis of covariance  
AST  
aspartic-aminotransferase  
AUC  
area under the plasma drug concentration vs. time curve  
bid  
twice daily  
BUN  
blood urea nitrogen  
CGI-C  
Clinical Global Impression – Change from baseline  
CIC  
Caregiver-rated Impression of Change from baseline  
CI  
confidence intervals  
Cmax  
maximum post-dose plasma drug concentration  
CNS  
Central Nervous System  
CRF  
case report form  
CTCAE  
Common Terminology Criteria for Adverse Events  
DBP  
diastolic blood pressure  
ECG  
Electrocardiogram  
ESR  
Erythrocyte sedimentation rate  
GCP  
Good Clinical Practice  
GMP  
Good Manufacturing Practice  
γGT  
gamma-glutamyl transpeptidase  
GLP  
Good Laboratory Practice  
HDL  
high density lipoprotein  
HBV  
Hepatitis-B Virus  
HCV  
Hepatitis-C Virus  
hERG  
human Ether-a-go-go Related Gene  
HIV  
human immunodeficiency virus  
HR  
heart rate  
HPA  
hypothalamic – pituitary – adrenal  
 
 
 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 9 of 47 
IMP  
Investigational Medicinal Product  
ITT 
Intent-to-Treat 
IWRS  
Interactive Web Response System  
LC-MS/MS  
Liquid Chromatography/Mass Spectrometry/Mass 
Spectrometry  
LDL  
low density lipoprotein  
LOCF  
Last Observation Carried Forward  
LS Mean 
Least Squares Mean 
MTD  
Maximum tolerated dose  
Min 
Minimum 
Max 
Maximum 
MMRM 
Mixed Model Repeated Measures 
PK  
Pharmacokinetics  
PRL  
Prolactin  
RBC  
red blood cells  
RCSS  
Rett syndrome Clinical Severity Scale  
RTT  
Rett syndrome  
SAE  
Serious Adverse Event  
SBP  
systolic blood pressure  
SE 
Standard Error 
SD  
standard deviation  
T3  
Triiodothyronine  
T4  
Thyroxine  
TEAE  
Treatment-emergent adverse event  
TLFs 
Tables, listings and figures 
TSH  
Thyroid Stimulating Hormone  
VLDL  
very low-density lipoprotein  
WBC  
white blood cells  


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 10 of 47 
1. INTRODUCTION 
This document describes the rules and conventions to be used in the presentation and analysis 
of efficacy, safety and tolerability data for Protocol Sarizotan/001/II/2015. It describes the data 
to be summarized and analyzed, including the specifics of the statistical analyses to be 
performed.   
This statistical analysis plan (SAP) is based on protocol version 15.0, dated 17 March 2020. 
This statistical analysis plan is for the double-blind phase only. A separate SAP will be created 
for the open-label phase, Separate SAPs have been created  for both the ECG and PK analyses. 
The study was designed to demonstrate the efficacy of sarizotan 10 mg bid (“high” dose) 
compared to placebo on improvement in respiratory symptoms (primarily reduction of episodes 
of apnea) in patients with Rett syndrome (RTT) who were at least 13 years old and weighing at 
least 25 kg (protocol version 1.0, dated 27 October 2015). A lower dose of 5 mg bid was also 
evaluated to assess dose response. The 10 mg bid dose was selected, as it would be associated 
with plasma exposures (Cmax) exceeding 269 ng/mL (acute study) or 753 ng/mL (long-term 
study) that had been shown to be efficacious in reducing apnea episodes in a MeCP2 knockout 
mouse model of Rett syndrome (SN 0002, 7 May 2015). 
 
Subsequently, based on regulatory requests, toxicology studies to enable treatment of younger 
patients were completed and the protocol was amended (Amendment 5) to allow enrollment of 
patients at least 6 years of age who weighed 10 kg or more (protocol version 6.0, dated 29 March 
2017). As the body weight of these patients was lower than the originally envisaged population, 
the doses of sarizotan had to be reduced accordingly to ensure tolerability and achieve exposures 
comparable to the older patients. As a first step, data from the NIH Natural History study 
(Tarquinio et al, 2012) were reviewed to determine body weights that Rett patients between the 
ages of 6 and 13 years were likely to have. As a result the patients between the ages of 6 and 13 
received a “high” dose of 5 mg bid or a “low” dose of 2 mg bid, as these doses in these younger 
patients were expected to achieve the same exposures as older patients greater than 13 years who 
were receiving doses of 10 mg (“high”) bid or 5 mg (“low”) bid.  
Based on potential concerns for the safety of younger patients with low body weight (<18 kg) the 
randomization was amended to assign these patients only to the 2 mg bid or placebo groups, 
while younger patients with body weight of at least 18 kg were assigned to doses of 5 mg bid or 
placebo.  
 
Based on the emerging data that did not detect any signs of intolerance in the patients treated in 
this study, and the feedback from Health Authorities who identified that this amended 
randomization would create imbalance in the treatment groups, the randomization was readjusted 
to revert to the original plan and randomize all patients equally to the three treatment groups 
(protocol version 8.0, Amendment 7dated 02 October 2017). Based on this, all younger patients 
were randomized equally to doses of 5 mg bid, 2 mg bid or placebo.  
The protocol was further amended (Amendment 9) to allow inclusion of patients as young as 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 11 of 47 
4 years of age (protocol version 10.0, dated 11 February 2018). However, no further adjustments 
to the doses administered were required as a result of this amendment. 
 
Despite all these changes, the original intent of the study design to randomize patients equally 
(1:1:1) to “high” dose sarizotan, “low” dose sarizotan or placebo was maintained. In summary, 
the definition of the sarizotan “High Dose” group includes RTT patients whose dose was age-
weight adjusted to either 10 mg bid or 5 mg bid.  The sarizotan “Low Dose” group includes RTT 
patients whose dose was age-weight adjusted to either 5 mg bid or 2 mg bid. 
 
As a result, the patients who received “High Dose” sarizotan include: 
• 10 mg bid in patients > 13 years with weight > 25 kg, 
• 5 mg bid in patients >13 years with weight < 25 kg, 
• 5 mg bid in patients 4 to < 13 years with weight >10 kg.  
 
The patients who received “Low Dose” sarizotan include: 
• 5 mg bid in patients >13 years with weight > 25 kg, 
• 2 mg bid in patients >13 years with weight < 25 kg, 
• 2 mg bid in patients 4 to < 13 years with weight >10 kg. 
2. STUDY OBJECTIVES 
2.1. 
PRIMARY OBJECTIVE 
To evaluate the effect of sarizotan (high dose), compared to placebo, on reducing the number of 
apnea episodes, during awake time, in patients with RTT with respiratory abnormalities. 
2.2. 
SECONDARY OBJECTIVES 
• Key Secondary efficacy: To evaluate the effect of sarizotan (high dose), compared to 
placebo, on the Caregiver-rated Impression of Change (CIC) from baseline. 
• Safety: To evaluate the safety and tolerability of sarizotan  in patients with Rett syndrome 
(RTT) with respiratory abnormalities. 
• Efficacy: To evaluate the efficacy of sarizotan, compared to placebo, on the following: 
o Severity of patient symptoms based on evaluation of Caregiver Top 3 Concerns 
(Visual Analogue Scale [VAS]); Global change from baseline, assessed by the 
Clinical Global Impression of Change (CGI-C); 
o Motor behavior, assessed by the Motor-Behavioral Assessment Scale; 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 12 of 47 
o Other respiratory symptoms of Rett syndrome, assessed during awake time, 
including:  
▪ Percent time spent with breathing dysrhythmia (% time apnea + % time 
hyperventilation) per hour 
▪ Number of hyperventilation episodes (≥10 seconds each) per hour 
▪ Oxygen saturation (number of episodes of oxygen desaturation below 90% 
per hour).  
▪ Respiratory Distress Index - The sum of the following parameters calculated 
per hour of wakefulness: 1) number of breath-holding episodes, 2) number 
of episodes of hyperventilation [1 and 2 are as defined in inclusion criteria; 
each would have to be ≥10 seconds in duration], and 3) number of drops in 
oxygen values to < 90%. 
 
o Overall assessment of symptoms of RTT using the Rett syndrome Clinical Severity 
Scale (RCSS); 
• To determine the efficacy of sarizotan in patients who attain a minimum plasma exposure 
of 400 ng /ml on Day 15 (expected efficacious concentration based on the knockout mouse 
model);  
• To determine the PK profile of sarizotan at the doses tested and compare with the PK profile 
in adults. 
3. STUDY DESIGN 
3.1. 
GENERAL DESCRIPTION 
This is a Phase II/III, prospective, 24-week, randomized, double-blind, placebo-controlled study 
designed to evaluate the safety, tolerability, and efficacy of multiple oral doses of sarizotan in 
patients with RTT with respiratory abnormalities. This 24-week double-blind treatment period is 
followed by an open-label extension treatment period of up to 168 weeks, which is ongoing.  
Patients ≥ 4 years of age were randomized to the low or high dose groups of sarizotan or placebo, 
with the dose of sarizotan determined based on the patient’s age and body weight (refer to Appendix 
5).   
 
 
Trial Duration: 
 
The possible duration of the trial is up to 196 weeks, which includes: 
• 
Screening Period (4 Weeks) 
• 
Randomized, double blind treatment period (24 Weeks)  


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
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• 
Open-label extension period (168 Weeks)  
• 
Safety Follow-up Period after final dose of study medication (2 Weeks) 
 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 14 of 47 
Number of Subjects:  
A minimum of 129 patients with RTT were to be included in this study, with approximately equal 
numbers of patients randomly being assigned to each of the following three treatment groups:  
• low dose sarizotan [sarizotan 2 mg bid (age 4 to <13 years; or age ≥13 years, weight <25 
kg) or 5 mg bid (age ≥13 years, weight ≥25 kg)],  
• high dose sarizotan [sarizotan 5 mg bid (age 4 to <13 years; or age ≥13 years, weight <25 
kg), or 10 mg bid (age ≥13 years, weight ≥25 kg)], 
• or placebo bid.  
The sample size estimate was based on the following assumptions: 
• 3 treatment groups (2 active + placebo)  
• Primary endpoint: Percent reduction in the number of apnea episodes (≥10 sec each) per 
hour 
• H0: Percent reduction in apnea episodes in placebo and active groups is the same 
• 
HA: There is a difference in the percent reduction in apnea episodes between high dose 
sarizotan and placebo.  
The assumptions for the estimated standard deviation (SD) are based on limited data from a study 
by Khwaja et al. (2014), in RTT patients. There were only 5 patients with data reported for apnea 
index (for apnea episodes > 10 seconds). Pilot observational data collected using the BioRadio™ 
device in 26 patients with RTT indicated that the number of episodes of apnea may approach 60 
per hour. Based on the range of 10-60 episodes per hour, ranges of 10-30, 10-45 and 10-60 apnea 
episodes per hour indicate SDs of 5.0, 8.75 and 12.5, respectively.  
Sample sizes were computed to determine the number of patients required to detect a minimum 
difference in mean percent reduction of 20% (high dose sarizotan 30%, placebo 10%; see Table 1) 
and 10% (high dose sarizotan 20%, placebo 10%; see Table 2), based on differences between high 
dose sarizotan and placebo. 
Table 1. Sample Size Estimates Assuming 90% Power and – 20% Difference  
 
Parameter 
1 
2 
3 
4 
Test significance level, α 
  0.050 
  0.050 
  0.050 
0.050 
1 or 2 sided test? 
   2 
   2 
   2 
2 
High Dose mean % Chg, µ1 
 -30.00 
 - 30.00 
 - 30.00 
-30.00 
Placebo mean % Chg, µ2 
 -10.00 
 -10.00 
 -10.00 
-10.00 
Difference, µ 1 - µ 2 
 -20.00 
 -20.00 
 -20.00 
-20.00 
Common St. Dev., σ  
   12.50 
   15.00 
   20.00 
25.00 
Effect size, δ = | µ 1 - µ 2| / σ 
    1.60 
    1.33 
    1.00 
0.80 
Power ( % ) 
     90 
     90 
     90 
90 
n per group 
 10 
 13 
 23 
34 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 15 of 47 
Table 2. Sample Size Estimates Assuming 90% Power and – 10% Difference 
 
Parameter 
1 
2 
3 
4 
Test significance level, α 
  0.050 
  0.050 
  0.050 
0.050 
1 or 2 sided test? 
   2 
   2 
   2 
2 
High Dose mean % Chg, µ1 
   -20.00   - 20.00 
 - 20.00 
-20.00 
Placebo mean % Chg, µ2 
   -10.00    -10.00    -10.00 
-10.00 
Difference, µ 1 - µ 2 
   -10.00    -10.00    -10.00 
-10.00 
Common St. Dev., σ  
   20.00 
   12.50 
   8.75 
5.00 
Effect size, δ = | µ 1 - µ 2| / σ 
    0.50 
    0.80 
    1.14 
2.00 
Power ( % ) 
     90 
     90 
     90 
90 
n per group 
 86 
 34 
 18 
7 
 
Sample sizes of 23 or 34 in each treatment group would have 90% power to detect a difference in 
mean percent reduction of -20% or -10%, respectively, assuming a common SD of 20 (for the 
20% reduction) and 12.5 (for the 10% reduction), using a two group t-test with a 0.050 two-sided 
significance level. Assuming an attrition rate of 25% (7 or 9 patients) per group, a total of 30 or 
43 patients would need to be enrolled in each group to get 23 or 34 patients completing the study. 
As this is the first large-scale study evaluating the effect of sarizotan on respiratory symptoms in 
patients with RTT, a conservative estimate of 10% reduction in apnea episodes was used to 
estimate the sample size required, i.e. approximately 43 patients per group.   
 
 
Mode of dose: Oral (capsules), or as a solution either orally (for patients with swallowing 
difficulties) or through a gastrostomy tube (G-tube) 
 
 
Blinding:  
 
A randomization number corresponding to the treatment assignment was assigned to each 
randomized subject using an Interactive Web Response System (IWRS), and was registered in the 
subject’s files for identification.  If it was necessary to break the blind during the double-blind 
period for reasons of safety, the Investigator was able to break the blind using the IWRS. The 
Investigator was asked to inform the Sponsor and their representative of this as soon as possible 
and to provide a reason for the unblinding.  
 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 16 of 47 
 
3.2. 
SCHEDULE OF EVENTS 
The schedule of events for the 24-week, double-blind, treatment period can be found below, and in Section 11.3 of the study 
protocol.  
 
Visit 
Assessment 
Screening 
BaselineA 
Day 1 
Day 2 
Day 7 
Day 14 
Day 15 
Week 8 
Week 16 
Final  
(Week 24)H 
Safety 
follow-upJ 
Study day(s) 
-28 to -1 
0 
1 
2 
3-7 
8-14 
15 
16-56 
57-112 
113-168 
169-182 
Informed consent (before any study procedure) 
X 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
Demography/Background Information 
X 
 
 
 
 
 
 
 
 
 
 
MECP2 gene mutation confirmation  
XP 
 
 
 
 
 
 
 
 
 
 
Medical History and Current Medical 
Conditions 
X 
 
 
 
 
 
 
 
 
 
 
Vital Signs 
X 
XC 
XC 
X 
 
X 
X 
X 
X 
X 
X 
ECG (12-lead) 
X 
XD 
XD 
X 
 
X 
X 
X 
X 
X 
 
Physical Examination 
X 
XB 
 
X 
 
X 
 
X 
X 
X 
 
Neurological Examination 
X 
XB 
 
X 
 
X 
 
X 
X 
X 
 
Ophthalmological Examination 
 
X 
 
 
 
 
 
 
X 
X 
 
Laboratory Evaluation (Hematology, 
Biochemistry, Urinalysis) 
X 
XB 
 
 
 
X 
 
X 
X 
X 
 
Thyroid Function Tests (TSH, T3, T4) 
X 
 
 
 
 
 
 
 
 
 
 
Virology (Hepatitis B/C, HIV) 
X 
 
 
 
 
 
 
 
 
 
 
Plasma ACTH and cortisol 
 
X 
 
X 
 
 
 
 
X 
X 
 
Serum prolactin 
 
X 
 
 
 
 
 
 
X 
X 
 
Serum pregnancy test O 
X 
X 
 
 
 
 
 
 
 
X 
 
Tanner Staging 
 
X 
 
 
 
 
 
 
 
X 
 
Suicidality assessment 
 
X 
 
 
 
 
 
X 
 
X 
 
Dosage administration and drug label record  
 
 
X 
X 
X 
X 
X 
X 
X 
XK 
 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 17 of 47 
Visit 
Assessment 
Screening 
BaselineA 
Day 1 
Day 2 
Day 7 
Day 14 
Day 15 
Week 8 
Week 16 
Final  
(Week 24)H 
Safety 
follow-upJ 
Prior/Concomitant Medications and Significant 
Non-Drug Therapies 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Adverse Events 
X 
X 
X 
X 
X 
X 
X 
X 
X 
XE 
X 
Respiratory monitoring (in clinic) M 
 
X 
 
 
 
 
 
 
X 
X 
 
Respiratory monitoring (at home) N 
X 
 
 
 
 
X 
 
X 
X 
X 
 
CGI-C 
 
 
 
 
 
X 
 
X 
X 
X 
 
CIC 
 
 
 
 
 
X 
 
X 
X 
X 
 
RCSS 
 
X 
 
 
 
 
 
 
 
X 
 
Motor-Behavioral Assessment Scale 
 
X 
 
 
 
 
 
X 
X 
X 
 
Caregiver Top 3 Concerns 
 
X 
 
 
 
 
 
X 
X 
X 
 
Telephone contact G 
 
 
 
 
X 
 
 
 
 
 
 
Pharmacokinetic blood sample 
 
 
XF 
 
 
 
XF 
 
 
 
 
Overnight stay (hotel/housing) required  
 
X 
X 
XL 
 
X 
XL 
 
 
 
 
Study Completion 
 
 
 
 
 
 
 
 
 
XI 
X 
A Patients meeting all entry criteria will report to the hospital/clinic on Day 0.  Baseline evaluations may be started on Day 0 and continued on Day 1 pre-dose. 
Following completion of baseline evaluations, subjects will be randomized and dosed on Day 1.  
B This evaluation does not need to be performed at baseline unless the screening assessment was done more than 28 days beforehand or there were abnormalities 
noted that require follow-up. 
C Vital signs to be performed at baseline must be repeated 3 times, with an interval of at least 10 minutes between readings, on Day 0 or at least 1 hr prior to dosing 
on Day 1, and at 1 and 4 hr post-dose, just prior to taking blood samples for PK measurements.  
D 12-lead ECG will be performed at baseline and repeated 3 times, with an interval of at least 10 minutes between readings, on Day 0 or at least 1 hr prior to 
dosing on Day 1, and at 1 and 4 hr post-dose, just prior to taking blood samples for PK measurements. 
E Patients will be contacted 30 days after their final dose of study medication to follow up on the occurrence of any SAEs. 
F A pre-dose PK sample will be taken, and samples will be collected at 1 and 4 hr post dose (window ± 15 min).  
G Telephone contact with patient/caregiver will be done on Day 7 to assess tolerability of current dose of study medication, before the increase to Dose Level 3 
and Dose Level 4 on Days 8 and 9, respectively; adverse events and concomitant medication use will be assessed. 
H All Week 24 (Final) evaluations should be performed when a subject discontinues from the study prematurely. 
I Patients completing 168 days (+/- 7 days) of treatment will be considered to have completed the initial 6-month period of the study. 
J Safety follow-up assessments to be performed 14 days after the final dose of study medication, if the patient is not continuing in the open-label extension 


 
 
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Newron Pharmaceuticals S.p.A. 
      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 18 of 47 
treatment period, or if the patient discontinues prematurely. 
K Record dosing from last 8-week period. Dose administration will be done only for patients continuing in the open-label extension treatment period. 
L Patient will be released from the hospital on Day 2 and Day 15, approximately 4 hr after the morning dose, if there are no tolerability issues. 
M During outpatient treatment, patients will undergo cardio-respiratory monitoring using a specialized ambulatory data acquisition system (BioRadio).  In 
addition, respiratory function will be assessed in the clinic using a similar device (SOMNOtouch). 
N During outpatient treatment, patients will undergo cardio-respiratory monitoring using a specialized ambulatory data acquisition system (BioRadio). 
Respiratory monitoring will be attempted at home for 6 hours each day during the time awake at Screening (three 3-day periods during the first, second and 
third week), and on any 3 days in the week preceding each subsequent scheduled office visit. Data recorded using this system will be downloaded from the 
device at home using the Internet/WiFi or a dedicated laptop provided by the Sponsor, if Internet access is not available; data collected during the screening test 
period will be verified for accuracy by Vivonoetics.  
O To be performed for all post-pubertal females.  
P MECP2 genetic mutation testing will be performed only if the patient has not had the test performed previously, or does not have adequate documentation of 
the test results from an accredited laboratory. 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 19 of 47 
 
3.3. 
CHANGES TO ANALYSIS FROM PROTOCOL 
None.  
4. PLANNED ANALYSES 
One analysis is planned for the 24-week, double-blind treatment period, and a separate analysis 
will be performed for the open-label extension period, once it is completed. The analysis of the 
data from the open-label period will be described in a separate SAP. The analysis for PK 
parameters and analysis for ECG data will also be described in separate SAPs. 
4.1. 
INTERIM ANALYSIS  
No interim analysis was planned for this study. 
4.2. 
FINAL ANALYSIS  
All final, planned analyses identified in this SAP will be performed by IQVIA Biostatistics 
team following Sponsor authorization of this SAP and Database Lock.  
5. ANALYSIS POPULATIONS AND STUDY PERIOD 
Subjects to be included/excluded from each analysis population set will be determined before 
unblinding  
5.1. 
ITT POPULATION 
The Intent-to-Treat (ITT) population will include all patients who were randomized to 
treatment.,.  
This population will be used for all efficacy analyses. 
5.2. 
PER PROTOCOL POPULATION 
The Per Protocol population will include all patients in the ITT population who also meet the 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 20 of 47 
following criteria: 
• Have no critical protocol deviations during the study, including meeting critical study 
entry criteria. 
• Have been compliant with study medication administration, as evident from a “Yes” 
response to the CRF question “Was the IP taken Per Protocol (PP) (two times a day)?” 
on the drug accountability form at the Week 24 (final) visit. In patients with a “No” 
response, a further review of the compliance data at Week 24 was performed to identify 
those to be excluded from the Per Protocol population. 
• Have no major efficacy data missing. 
Patients who meet the above criteria will be identified prior to database lock and unblinding. 
This population will be used for supportive efficacy analyses. 
5.3. 
SAFETY POPULATION  
The Safety population will include all patients who took at least one dose of study medication. 
The safety analyses are based on the actual treatment received. 
This population will be used for all safety analyses. 
5.4. 
24-WEEK DOUBLE-BLIND TREATMENT PERIOD 
The 24-week, double-blind, treatment period included all patients who provided informed 
consent, or the patient’s parent, legal guardian, or representative provided written informed 
consent, prior to the patient’s participation in the trial, met all of the selection criteria, including 
diagnostic and respiratory criteria, for enrolment in the study, and were randomized to 
treatment.  
5.5. 
INITIAL 24-WEEK OPEN-LABEL EXTENSION TREATMENT 
PERIOD 
Patients were eligible for the 24-week Initial open-label treatment period if they  completed the 
final evaluations at Week 24 (Day 168), and met the following criteria: 
1. Had no safety or tolerability issues that would have precluded continuing the study 
medication. 
2. Had been compliant with the trial requirements. 
3. Had not worsened to the extent that they were considered at an increased risk for 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 21 of 47 
morbidity or mortality, as judged by the Investigator. 
5.6. 
THREE ADDITIONAL 48-WEEK OPEN-LABEL EXTENSION 
TREATMENT PERIODS 
Three additional 48-week open-label treatment periods were added to the study and will include 
all patients who provided informed consent at Weeks 48, 96 and 144, and for whom the 
investigators believe the patients are benefitting from treatment with sarizotan and are not 
experiencing any significant adverse events. 
6. GENERAL CONSIDERATIONS 
Descriptive statistics for continuous variables will be summarized by treatment group with n, 
mean, standard deviation (SD), median, minimum, and maximum, where appropriate.  
Descriptive statistics for categorical variables will be summarized by treatment group with 
count and percentages. All percentages should use the total number of subjects with data 
available in the relevant analysis set as the denominator, unless otherwise specified.  Categories 
for missing data will be presented as appropriate. 
Decimal places format 
In general, the number of decimal places displayed for each statistic will be determined as 
follows, unless otherwise specified: 
Descriptive Summaries 
 
Range (Min, Max) Recorded decimal places  
Mean, Median, Geometric Mean Recorded decimal places + 1 
Standard Deviation, Standard Error Recorded decimal places + 2 
Inferential Statistics 
 
LS Means, Difference in LS Means Recorded decimal places + 1 
CI’s corresponding to LS Means and  
Difference in LS Means 
Recorded decimal places + 2 
Odds Ratio Recorded decimal places + 3 
Listings 
Recorded decimal places 
Percentages: All percentages between 0 and 99 will be rounded to one decimal unless there is a 
need to report more than one decimal for percentages (e.g., AEs). 
P-values, if any, shall be reported to four decimal places or as <0.0001. 
Data from subjects excluded from an analysis set will be included in the data listings, but not in 
the summaries. 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 22 of 47 
6.1. 
REFERENCE START DATE AND STUDY DAY 
Study Day will be calculated from the reference start date, and will be used to show start/stop 
day of assessments and events.  
Reference start date is defined as the day of the first dose of study medication (Day 1 is the day 
of the first dose of study medication), and will appear in every listing where an assessment date 
or event date appears.  
If the date of the event is on or after the reference start date then:  
Study Day = (date of event – reference start date) + 1. 
If the date of the event is prior to the reference start date then:  
Study Day = (date of event – reference start date). 
In the situation where the event date is partial or missing, the date will appear partial or missing 
in the listings, and Study Day, and any corresponding durations will be presented based on the 
imputations specified in Appendix 1; Partial Date Conventions. 
6.2. 
BASELINE 
Unless otherwise specified, baseline is defined as the last non-missing measurement taken prior 
to reference start date (including unscheduled assessments).  In the case where the last non-
missing measurement and the reference start date coincide, that measurement will be 
considered pre-baseline, but Adverse Events (AEs) and medications commencing on the 
reference start date will be considered post-baseline. 
6.3. 
RETESTS, UNSCHEDULED VISITS AND EARLY 
TERMINATION DATA 
In general, for by-visit summaries, data will be reported by the protocol-defined nominal visit. 
For each nominal visit a pre-specified analysis window has been defined (Section 8). These 
analysis windows will define the visit at which the data are reported.  Listings will include 
scheduled, unscheduled, retest and early discontinuation data. 
6.4. 
STATISTICAL TESTS 
All statistical tests of treatment effects will be conducted to compare sarizotan (high dose group 
and low dose group) versus placebo at a two-sided alpha level of 0.05, unless otherwise 
specified.  


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 23 of 47 
6.5. 
COMMON CALCULATIONS 
For quantitative measurements, change from baseline at Visit X will be calculated as: 
 
Value at Post-baseline Visit X – Baseline Value 
For quantitative measurements, percentage change from baseline at Visit X will be calculated 
as: 
((Value at Post-baseline Visit X – Baseline Value)/Baseline value)*100 
Age will be calculated as following: 
Age = (Date of informed consent - Date of Birth + 1) / 365.25 
6.6. 
SOFTWARE VERSION 
All analyses will be conducted using SAS Enterprise Guide7.13 (64-bit).  
7. STATISTICAL CONSIDERATIONS 
7.1. 
ADJUSTMENTS FOR COVARIATES AND FACTORS TO BE 
INCLUDED IN ANALYSES 
Baseline value and age will be adjusted as covariates, and treatment as fixed factor will be 
included in the analyses wherever applicable.  
7.2. 
MULTICENTER STUDIES 
This study will be conducted by multiple investigators at multiple centers. Randomization to 
treatment arms was not stratified by country/ center. Centers will be grouped in regions for 
purposes of the analyses as follows: 
• Europe (United Kingdom and Italy) 
• India 
• US and Australia. 
 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 24 of 47 
7.3. 
MISSING DATA 
All data obtained for the ITT population will be used in the analysis.  Missing efficacy data for 
the primary endpoint will not be imputed. Last observation carried forward (LOCF) method 
will be adopted as imputation for the secondary quantitative endpoints (wherever required). 
Details of which endpoint will be imputed using LOCF approach can be found in the respective 
endpoint’s section description.  
7.4. 
MULTIPLE COMPARISONS/ MULTIPLICITY 
The study level error rate will be controlled by following a sequential multiple testing 
procedure, where testing will begin with the primary efficacy endpoint. The effects of the high 
dose sarizotan versus placebo will be analyzed first for all parameters in a pre-specified 
sequence.  
The sequence of testing will be as presented below:  
• Percentage reduction (change) from baseline in the number of apnea episodes, 
• Mean rating of CIC 
• Mean change from baseline in the Top Three Concerns Total Score. 
7.5. 
EXAMINATION OF SUBGROUPS 
Subgroup analyses will be performed for patients dichotomized by age groups of less than 13 
years of age, and 13 years of age and older.. No inferential statistics will be performed for these 
sub-groups. 
8. OUTPUT PRESENTATIONS 
In tables, the order and naming of the treatment groups will be as follows: 
• Sarizotan Low Dose 
• Sarizotan High Dose 
• Placebo 
In addition to the above treatment groups, the outputs will also be presented for Sarizotan 
threshold plasma concentration for the primary efficacy and demographics as follows 
• Sarizotan (>400 ng/ml) 
• Placebo  


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 25 of 47 
In addition to above treatment groups, the outputs will also be presented for Sarizotan pooled 
dose as follows: 
• Sarizotan (all doses) 
• Placebo 
In listings, the order and naming of the treatment groups will be as follows: 
• Sarizotan Low 2 mg dose 
• Sarizotan Low 5 mg dose 
• Sarizotan High 5 mg dose 
• Sarizotan High 10 mg dose 
Placebo 
For visit presentations, the naming of the visit will be as follows: 
 
Screening 
Day 0 (Baseline) 
Day 1 
Day 2 
Day 7 
Day 14  
Day 15   
Week 8 
Week 16 
Week 24 
Safety Follow-up 
 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 26 of 47 
8.1. 
DATA SELECTION FOR DOUBLE BLIND TREATMENT PERIOD 
(24 WEEKS) 
For patients who enter the open-label extension treatment period, all data up to and including the 
date of the first dose in the open-label extension phase will be considered as part of the double-
blind treatment period (24 weeks). For patients who do not enter the open-label extension, all 
data will be included in the double-blind treatment period (24 weeks). 
8.2. 
VISIT WINDOWS: 
The following visit windows will be used for analyses of efficacy endpoints: 
Visit 
Window 
Screening ( day - 28) 
Day - ∞ to day -1 
Baseline (day 0)  
Day -28  to day 0 (last value before first dose of study drug) 
[Baseline for the BioRadio™ data will be the last value prior to Day 1 (no cutoff at 
Day -28)] 
Day 1 
No window (day of the first dose taken) 
 
Day 2 
No window (immediately after day 1) 
Week 2 (day 14) 
Day 1 to day 35 
Day 15 
No window (immediately after day 14) 
Week 8 (day 56) 
Day 36 to  day 84 
Week 16 (day 112) 
Day 85 to day 140 
Week 24 (day 168) 
Day 141 to  day 196 
Safety follow - up 
Day 1 – Day 30 where Day 0 Is the day when the patient discontinues the study.  This 
Is likely to be a scheduled visit day – but possibly an unscheduled visit. Operationally 
it might be identified by being the previous day that a vital sign was measured (or any 
other measurement that is done when a patient either reaches Week 24 or discontinues 
prematurely – as per the protocol schedule of evaluations).  Importantly the patient is 
no longer on drug during this entire window.  
Note: Day 1 = first dosing day of study drug 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 27 of 47 
If there is more than one record within the same window, the non-missing value closest to the 
scheduled visit study day will be used for analyses. If two values are equidistant from the 
scheduled visit day, the earliest non-missing value will be used. 
9. DISPOSITION AND WITHDRAWALS 
All subjects who provide informed consent will be summarized.  
Disposition summary will be provided by study period separately for all randomized subjects.  
The frequency and percentage of randomized subjects who complete the study or discontinue 
early will be summarized by treatment group and overall.  Reasons for discontinuation from the 
study will also be summarized. 
The number of subjects in each population will be presented by treatment groups and overall. 
A list of critical protocol deviations will be provided for the randomized population.  A 
summary of critical or major protocol deviations with reason for the deviation will be provided 
as counts and percentages. 
10. DEMOGRAPHIC AND OTHER BASELINE CHARACTERISTICS 
Demographic data and other baseline characteristics will be presented and summarized for all 
randomized subjects. 
No statistical testing will be carried out for any demographic or baseline characteristics. Patient 
characteristics will be recorded at the screening visit and will be listed by patients and 
summarized by treatment groups. Overall summaries will include descriptive statistics for 
continuous measures (n, mean, SD, median, minimum, and maximum) and for categorical 
measures (n, count, and percent).  Missing categories will be represented as appropriate. 
Rett syndrome history will be summarized by treatment and overall for the following: 
• Duration of Rett syndrome (in months) defined as: 
(Date of Informed Consent – Date of Diagnosis of Rett syndrome)/30.25 
• Count and percentages of all responses for “Respiratory abnormalities”  
11. MEDICAL HISTORY 
Medical History information will be presented and summarized for the safety population and 
coded using Medical Dictionary for Regulatory Activities (MedDRA) dictionary Version 22.0.  
Medical History will be recorded at the Screening visit. 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 28 of 47 
Counts and percentages of Medical History conditions will be presented by treatment groups, 
SOC and preferred term.  Also a list of medical history findings will be provided. 
12. MEDICATIONS 
Medications will be presented and summarized for the safety population and coded using 
World Health Organization (WHO) DRUG dictionary of medical code.  
Prior and concomitant medications during the study will be summarized using ATC level 3 
coding. 
• ‘Prior’ medications are medications which started and stopped prior to first dose of 
study medication.  
• ‘Concomitant’ medications are medications which ended on or after first dose of 
randomized study medication or ongoing at the end of the study.  
The number of patients with concomitant medications will be summarized using count and 
percentages by therapeutic class, preferred term, treatment group and overall. Patients are 
counted only once in each therapeutic class category, and only once in each preferred term 
category. 
A list of prior and concomitant medications (includes procedures) will be provided separately. 
Concomitant medication (includes procedures) summary will be provided period-wise 
separately. 
See Appendix 1 for handling of partial dates for medications, in the case where it is not 
possible to define a medication as prior or concomitant, the medication will be classified by the 
worst case; i.e. concomitant. 
13. STUDY MEDICATION EXPOSURE 
Exposure to study medication in days will be summarized for the Safety Population. 
The total duration of study medication administration will be taken from the “Study medication 
administration” form of the eCRF.  
Duration of exposure (in Days) will be summarized descriptively. 
Duration of exposure (in Days) = Date of Last dose – Date of First Dose +1 
Interruptions and compliance are not taken into account for duration of exposure. 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 29 of 47 
14. STUDY TREATMENT NON-COMPLIANCE  
List of the treatment non-compliance (<80%) will be provided for the Safety population 
based on the data from DB period. 
15. EFFICACY OUTCOMES  
Summaries will include descriptive statistics for continuous measures (n, mean, SD, median, 
minimum and maximum) and for categorical measures (n, frequency and percentage). 
15.1. 
PRIMARY EFFICACY 
15.1.1 
PRIMARY EFFICACY VARIABLE & DERIVATION 
The primary efficacy outcome in the double-blind period will be the percent reduction (change) 
from baseline in the number of apnea episodes (each ≥10 seconds in duration) per hour, during 
awake time. The data was obtained from the vendor Vivonoetics. Assessment of the respiratory 
outcomes was performed at home on any 3 days in each of the first 3 weeks of the screening 
period, and in the week prior to each of the visits at Weeks 2, 8, 16, and 24.  
15.1.2 
MISSING DATA METHODS FOR PRIMARY EFFICACY VARIABLE 
Primary efficacy variable will not be imputed. 
15.1.3 
ANALYSIS OF PRIMARY EFFICACY VARIABLE 
The primary efficacy analysis for the 24-week, double-blind, treatment period will be 
performed on the Intent-to-Treat (ITT) population, consisting of all patients who were 
randomized to treatment.  
Primary efficacy variable is percent reduction (change) from baseline in the number of apnea 
episodes (each ≥10 seconds in duration) per hour, during awake time, obtained from the 
BioRadioTM. 
The primary efficacy test of hypothesis is as below:  
H0: There is no difference in mean percent reduction (change) from baseline in number of 
apnea episodes in placebo and Sarizotan high dose group.  
HA: There is a difference in the mean percent reduction (change) from baseline in number of 
apnea episodes in placebo and Sarizotan high dose group.. 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 30 of 47 
Descriptive statistics will be presented for actual value, change from baseline and percentage 
change from baseline in apnea episodes by visit and treatment groups. 
Prior to analyzing the primary efficacy data, a blinded data review will be performed to identify 
outliers. The potential outliers would be examined and determined if the value is clinically 
plausible and removed from the analysis if not. The primary inferential comparison between 
treatment groups will be done using a restricted maximum likelihood (REML)-based, mixed-
effects repeated measures model approach (MMRM) along with 95% confidence interval for 
the difference between treatment groups for percent change from baseline in the number of 
apnea episodes. The MMRM model will include percent change from baseline as response, the 
fixed, categorical effects of treatment group, visit, treatment group-by-visit interaction, and the 
continuous terms age and baseline value as covariate. The data collected at Baseline, Week 2, 
Week 8, Week 16 and Week 24 will be used in the MMRM model. 
An unstructured covariance matrix will be used to model the within-subject correlation. The 
Kenward-Roger approximation will be used to estimate denominator degrees of freedom.  If the 
model for unstructured covariance matrix fails to converge, other covariance structures will be 
considered using Akaike information criterion/Bayesian information criterion method to find 
appropriate covariance structure, for e.g. a heterogeneous autoregressive covariance structure. 
The differences in LS means will be calculated along with associated standard errors, 2-sided 
95% confidence intervals and p-values.  
The above analysis will also be repeated on the PP population. 
A sensitivity analysis will be performed for the ITT population to include all data (including 
outliers) to check the robustness of the primary analysis to potential outliers. 
 Additionally, graphical presentations will be provided. 
15.1.4 
KEY SECONDARY EFFICACY VARIABLE 
The key secondary efficacy outcome was the difference between sarizotan and placebo on the 
Caregiver-rated Impression of Change (CIC) from baseline, a 7-point Likert-type scale for 
which ratings range from 1 = very much improved to 7 = very much worse, with 4 = no change. 
The key secondary efficacy analysis will be performed for the ITT population. 
Summary statistics for CIC mean rating scores will be provided by visit and treatment group.  
The mean rating of the caregiver-rated CIC at Week 24 LOCF will be compared between 
treatment groups using the Van Elteren test (a stratified Cochran Mantel Haenszel test with 
modified ridit scores).  The following age strata will be considered in the analysis:  
<13 years 
>=13 years 
Improvement on the CIC (i.e. Responder) will be defined as a Likert scale score of 1 (very 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 31 of 47 
much improved), 2 (much improved) or 3 (minimally improved). The proportion of patients 
with a rating of improvement in the CIC (n, count, and percent) will be presented at post-
baseline visits by treatment group. 
In addition to the above analysis, comparisons between treatments for the proportion of 
responders at Week 24 LOCF will be done using logistic regression. The logistic regression 
model will include treatment group and age. For the treatment comparison, an estimate of the 
odds ratio, corresponding Wald 95% CI and chi-square p-value will be presented.  
Additionally, graphical presentation will be provided for the proportion of responders at Week 
24. 
In accordance with the original protocol (dated 27 October 2015, Section, page 70, Section 
15.2.6) and the amended protocol (version 11.0, incorporating protocol Amendment 10, dated 
29 November 2018, page 100, Section 15.2.6) as referred to in the FDA minutes of the meeting 
of February 5, 2020 issued by the FDA March 4, 2020, the Sponsor has reverted to using the 
“win” criteria referred to in these sections, as directed by FDA. A statistical “Win” will be 
claimed if the following results are obtained in the primary and key secondary efficacy 
analyses: 
• Statistically significant difference between high dose sarizotan (5 or 10 mg bid) and 
placebo in the percent reduction (change) from baseline in the number of apnea 
episodes (each ≥10 seconds in duration) per hour, during awake time; 
• Directional change on the CIC in favor of high dose sarizotan (5 or 10 mg bid) 
group compared to placebo. 
15.2. 
SECONDARY EFFICACY 
The secondary efficacy analyses described in SAP section 15.2.1.1 will be performed for the 
ITT population with LOCF imputation. Efficacy analyses described in SAP section 15.2.1.2, 
15.2.1.3, 15.2.1.4, 2 and 15.2.1.5 will be performed for the ITT population. 
15.2.1 
SECONDARY EFFICACY VARIABLES & DERIVATIONS 
Change from baseline calculation will be done as defined in section 6.5. 
15.2.1.1Change from Baseline in Total Score of Caregiver Top 3 Concerns at 
Week 24  
The severity of patient symptoms will be assessed using the Caregiver Top 3 Concerns 
scale, which uses a 100-mm visual analogue scale (VAS).  The caregiver will select the 
3 symptoms that are most problematic at baseline from a list of 12 possible concerns, 
and will rate each one using the VAS to indicate the severity on a scale of 0 to 100. The 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 32 of 47 
same 3 symptoms will be rated using the VAS at the scheduled visits at Weeks 8, 16, 
and 24 in the double-blind treatment period. The Top 3 Concerns Total Score for each 
patient is calculated as the sum of the score for the 3 concerns rated. This total score 
can range from 0 to 300.  
15.2.1.2Mean rating of Clinical Global Impression of Change (CGI-C) at Week 
24 
The CGI-C rating scale permits a global evaluation of the subject’s improvement or worsening 
over time. At each post-baseline visit, the rater will assess the change in the subject’s symptoms 
of RTT relative to the symptoms at baseline using a 7-point scale, ranging from 1 (very much 
improved) to 7 (very much worse), with a score of 4 indicating no change. The CGI-C 
assessment will be conducted on Day 14, and at Weeks 8, 16 and 24 (or at early 
discontinuation) during the initial double-blind treatment period, and will be based on the 
patient’s condition at the Baseline visit. 
Improvement on CGI-C (i.e. Responder) will be defined as a Likert scale score of 1 (very much 
improved) or 2 (much improved) or 3 (minimally improved). 
15.2.1.3Change from baseline to Week 24 in Motor-Behavioral Assessment Scale 
(MBAS) 
The MBAS is comprised of three sub-scales i.e. Behavioral/Social Assessment (included 16 
items), Orofacial/Respiratory Assessment (included 7 items) and Motor Assessment/Physical 
Signs (included 14 items). 
Each item is rated on a scale from 0 to 4, with ‘0’ indicating normal or never, and ‘4’ indicating 
very severe or constant.  
To see the change in Motor-Behavioral Assessment Scale, change from baseline will be 
calculated at Week 24, considering the grand total score (all 3 sub-scales), as well as the total 
score on each of the three sub-scales.  
Day 0 will be considered as baseline for this endpoint. 
15.2.1.4Change from baseline to Week 24 in other respiratory symptoms of RTT 
The following additional respiratory parameters will be analyzed:  
• Percent time spent with breathing dysrhythmia (% time apnea + % time 
hyperventilation) per hour; 
• Number of hyperventilation episodes (≥10 seconds each) per hour; 
• Oxygen saturation (# of episodes of oxygen desaturation below 90% per hour). 
• Respiratory Distress Index - The sum of the following parameters calculated per hour of 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 33 of 47 
wakefulness: 1) number of breath-holding episodes, 2) number of episodes of 
hyperventilation [1 and 2 are as defined in inclusion criteria; each would have to be ≥10 
seconds in duration], and 3) number of drops in oxygen values to < 90%. 
• Apnea episodes collected parallel at the hospital/clinic at Baseline and at Weeks 16 and 
24, using a stretch-sensitive resistance plethysmograph (SOMNOtouch)  
Data from the Bio-Radio and the SOMNOtouch will not be pooled and will be analyzed 
separately. 
Data for determination of these additional respiratory outcome parameters was collected during 
home cardiorespiratory recording using the BioRadioTM and in parallel at the hospital/clinic at 
Baseline and at Weeks 16 and 24, using a stretch-sensitive resistance plethysmograph  
(SOMNOtouch) and was obtained from the vendor Vivonoetics.  
To see the change in other respiratory symptoms of RTT, change from baseline will be 
calculated at Week 24. 
15.2.1.5Change from baseline to Week 24 in Rett syndrome Clinical Severity 
Scale (RCSS) 
The RCSS scale will assess the severity of symptoms of RTT. This scale contain 13 items 
which measure and provide a clinician rating of core symptoms of Rett syndrome on a Likert 
scale of either 0 to 4 or 0 to 5, with a maximum total score of 58.  
The change in RCSS, will be determined by calculating the difference between baseline and 
Week 24 for the total score of RCSS . Day 0 will be considered as baseline for this endpoint. 
15.2.2 
MISSING DATA METHODS FOR SECONDARY EFFICACY VARIABLES 
Last observation carried forward (LOCF) method will be adopted as imputation in the presence 
of at least one post-baseline observation if data is collected at multiple visits post baseline and 
is missing. Missing items in, Top 3 concerns score at baseline will be imputed with the mean 
baseline value of that item of all patients in the analysis population. There will be no imputation 
for MBAS, RCSS and Other Respiratory symptoms of RTT since only descriptive summary is 
presented. 
 
15.2.3 
ANALYSIS OF SECONDARY EFFICACY VARIABLES 
15.2.3.1 Analysis of Caregiver Top 3 Concerns Total Score at Week 24 
Descriptive statistics will be presented for actual value, change from baseline and percentage 
change from baseline in Top 3 Concerns total score by visit and treatment groups. 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 34 of 47 
 
Comparisons between treatments will be done using an ANCOVA model. The model will 
include treatment group and the baseline value along with age as covariates. Change will be 
estimated using the least-squares mean derived from the ANCOVA. Comparisons between 
treatment groups at Week 24 will be made using the difference in least-squares mean, 95% 
confidence interval (CI) and p-values from the ANCOVA model. 
Additional summaries of the Top 3 Concerns will be presented as follows: 
i. 
Frequency and percentage of all Top 3 Concerns reported. 
ii. 
Mean change and percent change from baseline for each Top 3 Concern 
reported. 
iii. 
The number and percentage of patients with at least a 20% improvement in the 
Top 3 Concerns Total Score. 
Additionally, graphical presentation will be provided. 
15.2.3.2 Analysis of mean rating of Clinical Global Impression of Change (CGI-C) at 
Week 24 
Summary statistics for the proportion of responders on the CGI - C (n, count, and percent) will 
be presented at all available scheduled visits for 24-week double-blind treatment period as per 
protocol. 
Summary statistics will also be presented for the CGI-C mean change score and summarized by 
visit. Additionally, graphical presentation will be provided. 
15.2.3.3 Analysis of change from baseline to Week 24 in Motor-Behavioral 
Assessment Scale (MBAS) 
Descriptive statistics will be presented by treatment group for actual and change from baseline 
in Motor-Behavioral Assessment scale, both for subtotals and grand total at all available 
scheduled visits for the 24-week double-blind treatment period, as per protocol. 
15.2.3.4 Analysis of change from baseline to Week 24 in other respiratory symptoms 
of RTT 
Descriptive statistics will be presented by treatment group for actual values and change (or 
percent change) from baseline in other respiratory symptoms of RTT for both BioRadio™ and 
SOMNOtouch (Refer to Section 15.2.1.4 for list of other respiratory symptoms) at all 
available scheduled visits for the 24-week double-blind treatment period, as per protocol. Data 
from the Bio-Radio and the SOMNOtouch will not be pooled and will be analyzed separately. 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 35 of 47 
15.2.3.5 Analysis of change from baseline to Week 24 in Rett syndrome Clinical 
Severity Scale (RCSS) 
Descriptive statistics will be presented by treatment group for actual score and change from 
baseline in the Rett syndrome Clinical Severity Scale (RCSS) at Week 24 of the double-blind 
treatment period, as per protocol. 
15.2.4 
EXPLORATORY VARIABLES & DERIVATIONS 
Primary efficacy endpoint will also be analyzed for the group of patients who have Sarizotan 
threshold plasma concentration (>400 ng/ml) vs placebo. The analysis will be analyzed as 
described in Section 15.1.3. Additional analyses based on exposure and response will be 
performed. 
16. QUALITY OF LIFE ANALYSIS  
Not applicable. 
17. 
SAFETY OUTCOMES 
All outputs for safety outcomes will be based on the Safety population.  
17.1. 
ADVERSE EVENTS 
Adverse Events (AEs) are be coded using MedDRA central coding dictionary version 22.0. 
An AE is defined as any untoward medical occurrence in a patient or clinical investigation patient 
administered a pharmaceutical product that does not necessarily have a causal relationship with the 
product.  An AE can therefore be any unfavorable and unintended sign (including a new, clinically 
important abnormal laboratory finding), symptom, or disease, temporally associated with drug 
administration, whether or not related to the product. 
The above definition covers also cases of  
• 
Exacerbation of pre-existing diseases or conditions. 
• 
Pre-existing diseases or conditions (reported at time of screening in medical history) 
will not be considered AEs unless there is an increase in the frequency or severity, or a 
change in the quality of the disease or condition.  
• Events occurring in subjects treated with matching placebo are also considered AEs.  
An AE will be defined as a treatment-emergent adverse event (TEAE) if the first onset (or 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 36 of 47 
worsening, in the case of pre-existing disease) is after the first administration of study treatment 
throughout the study.  In addition, any serious adverse events (SAEs) reported in the 30 days 
following last dose of IMP will be recorded and counted in the final clinical study report. 
See Appendix 1 for handling of partial dates for AEs.  In the case where it is not possible to 
define an AE as treatment emergent or not, the AE will be classified by the worst case; i.e. 
treatment emergent.  
An overall summary of number of subjects within each of the categories described in the sub-
section below, will be provided as specified in the templates. Listings will include TEAEs and 
Non-TEAEs. Listings will be provided for TEAEs, SAE and TEAEs leading to discontinuation 
from study for safety analysis set. 
17.1.1 
ALL TEAES  
Incidence of TEAEs will be presented by System Organ Class (SOC) and Preferred Term (PT) 
and also broken down further by maximum intensity,  and by relationship to study medication. 
An overview of AE’s will be provided with patients experiencing n (%) at least one SAEs, 
AEs, TEAE, treatment related TEAE,  treatment related SAE, Number of patients died and 
patients discontinuing the study due to AE. 
An overview of AE summary will be provided each period wise separately. 
17.1.2 
INTENSITY 
Intensity is classed as mild, moderate, severe.  TEAEs starting after the first dose of study 
medication with a missing intensity will be classified as severe.  If a subject reports a TEAE 
more than once within that SOC/PT, the AE with the greatest intensity will be used in the 
corresponding intensity summaries. 
17.1.3 
RELATIONSHIP TO STUDY DRUG 
Relationship, as indicated by the Investigator, is classed as “ Probable”, “Possible”, “Unlikely” 
, “Not related” and “Unknown”. A “related” TEAE is defined as a TEAE with a relationship to 
study medication as ” Probable”,  “Possible” and “Unknown” to study medication. TEAEs with 
a missing/Unknown relationship to study medication will be regarded as “probable” to study 
medication. The rest of the AEs will be considered as not related (“Unlikely” and “Not 
related”).   
If a subject reports the same AE more than once within that SOC/PT, the AE with the worst 
case relationship to study medication will be used in the corresponding relationship summaries.  


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 37 of 47 
17.1.4 
AES LEADING TO PATIENT DISCONTINUATION  
AEs leading to permanent discontinuation of patient will be identified.  
For AEs leading to discontinuation of patient, summaries of incidence rates (count and 
percentages) by SOC and PT will be prepared. 
17.1.5 
SERIOUS ADVERSE EVENTS 
Serious adverse events (SAEs) are those events recorded as “Serious” on the Adverse Events 
page of the eCRF.  A summary of serious TEAEs by SOC and PT will be prepared. 
17.1.6 
ADVERSE DRUG REACTION (ADR) 
All noxious and unintended responses to a medicinal product related to any dose should be 
considered as adverse drug reactions.  ADR is a related event, so it is a TEAE that is related as 
defined in Section 17.1.3 
A summary of ADR by SOC and PT will be prepared.  
Any ADR during the study will be presented in a data listing. 
17.1.7 
SUMMARY OF NON-TEAES 
Not applicable. Non-TEAEs will be in the data listing.  
17.2. 
DEATHS 
Any deaths during the study will be presented in a summary table and a data listing. 
17.3. 
LABORATORY EVALUATIONS 
Results from the central laboratory will be included in the reporting of this study for 
hematology, clinical chemistry, urinalysis, thyroid function tests, virology, serum pregnancy 
test for post-pubertal females, HPA axis and prolactin.  A list of laboratory assessments to be 
included in the outputs is included in the protocol.  
Quantitative laboratory measurements reported as “< X”, i.e. below the lower limit of 
quantification (BLQ), or “> X”, i.e. above the upper limit of quantification (ULQ), will be 
converted to X for the purpose of quantitative summaries, but will be presented as recorded, i.e. 
as “< X” or “> X” in the listings. 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 38 of 47 
The following summaries (descriptive statistics for quantitative measurements and count and 
percentage for qualitative measurements except urinalysis) will be provided for laboratory 
parameter (i.e. hematology, clinical chemistry, urinalysis, HPA axis, Serum Pregnancy Test and 
prolactin). 
• Actual and change from baseline by visit (for quantitative measurements). 
• Shift from baseline to Week 24 and End of Study visits according to standard 
normal range criteria (for quantitative measurements and categorical 
measurements). 
• Incidence table at Week 24 and End of Study visits  according to clinically notable 
values (for quantitative measurements and categorical measurements). 
• Listing of subjects’ laboratory evaluations with flagging of abnormal values. 
The descriptive statistics for actual measurement and change from baseline by treatment group 
will be performed at scheduled visits. 
17.4. 
12-LEAD ECG  
ECG analysis related details can be found in ECG SAP.  
17.5. 
VITAL SIGNS 
The following vital signs measurements will be reported for this study: 
• Systolic Blood Pressure (mmHg) 
• Diastolic Blood Pressure (mmHg) 
• Pulse (bpm) 
• Respiratory Rate (breaths/min) 
• Body Temperature (⁰C) 
The following summaries will be provided for vital signs data: 
• Actual values and change from baseline by visits and timepoints 
• Incidence of clinically notable vital signs values at Day 1, Day 15, Week 24 and 
End of Study visits as defined in Appendix 3 of the SAP 
• Listing of patients’ vital signs  
The descriptive statistics for actual measurement and change from baseline will be presented by 
treatment group and timepoints at scheduled visits. 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 39 of 47 
17.6. 
PHYSICAL EXAMINATION  
The count and percentage of patients with physical examination assessments will be 
summarized by body system and treatment group at schedule visit. 
A patient-wise listing of physical examination findings will be provided. 
17.7. 
NEUROLOGICAL EXAMINATION 
The count and percentage of patients with neurological examination assessments will be 
summarized by system and treatment group at schedule visit. 
A patient-wise listing of neurological examination findings will be provided. 
17.8. 
OPHTHALMOLOGICAL EXAMINATION 
The count and percentage of patients with ophthalmological examination assessments will be 
summarized by each type of assessment and treatment group at schedule visit.  
A patient-wise listing of ophthalmological examination findings will be provided. 
17.9. 
STRUCTURED SUICIDALITY ASSESSMENT 
The count and percentage of patients with suicidality assessments will be summarized by 
system and treatment group at schedule visit. 
A patient-wise listing of suicidality query will be provided. 
17.10. TANNER STAGING 
A patient-wise listing of Tanner staging will be provided. 
18. DATA NOT SUMMARIZED OR PRESENTED 
Not applicable. 


 
 
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      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 40 of 47 
19. REFERENCES  
Annotated CRF dated 23rd September 
Clinical Study Protocol Sarizotan/001/II/2015, V.15.0, dated 17 March 2020.  
Dobson, A. J. (2002). An introduction to generalized linear models, 2nd ed. Chapman & 
Hall/CRC. 
EMA. (n.d.). Guideline on Missing Data in Confirmatory Clinical Trials. Retrieved December 
15, 2011, from European Medicines Agency:  
Khwaja OS, Ho E, Barnes KV, O'Leary HM, Pereira LM, Finkelstein Y, Nelson CA 3rd, Vogel-
Farley V, DeGregorio G, Holm IA, Khatwa U, Kapur K, Alexander ME, Finnegan DM, Cantwell 
NG, Walco AC, Rappaport L, Gregas M, Fichorova RN, Shannon MW, Sur M, Kaufmann WE. 
Safety, pharmacokinetics, and preliminary assessment of efficacy of mecasermin (recombinant 
human IGF-1) for the treatment of Rett syndrome. PNAS 2014; 111(12):4596-4601.Little, R., & 
Yau, L. (1996). Intent-to-Treat Analysis for Longitudinal Studies with Drop-Outs. Biometrics , 
vol 52, 1324-1333. 
Tarquinio DC, Motil KJ, Hou W, Lee HS, Glaze DG, Skinner SA, Neul JL, Annese F, McNair L, 
Barrish JO, Geerts SP, Lane JB, Percy AK. Growth failure and outcome in Rett syndrome. 
Neurology 2012; 79(16):1653-1661. 
 
 
 


 
 
Document: 
\\ieedc-vnasc01\BIOSdata\Newron\Sarizotan\PXA76395\Biostatistics\Documentation\SAP 
Author: 
Ayushi Chaturvedi  
Version Number: 
V2 
 
 
Version Date: 
[30March2020] 
Template No:  CS_TP_BS016 – Revision 4 
Reference:  CS_WI_BS005 
Effective Date: 01Apr2016 
 
Copyright © 2009, 2010, 2012, 2016 Quintiles Transnational Corp. All rights reserved. 
The contents of this document are confidential and proprietary to Quintiles Transnational Corp. Unauthorized use, disclosure or reproduction is 
strictly prohibited. 
Newron Pharmaceuticals S.p.A. 
      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 41 of 47 
APPENDIX 1. PARTIAL DATE CONVENTIONS 
Imputed dates will NOT be presented in the listings. 
ALGORITHM FOR TREATMENT EMERGENCE OF ADVERSE EVENTS: 
START DATE 
STOP 
DATE 
ACTION 
Known 
Known 
If start date < study med start date, then not 
TEAE 
If start date >= study med start date, then TEAE 
 
Partial 
If start date < study med start date, then not 
TEAE 
If start date >= study med start date, then TEAE 
 
Missing 
If start date < study med start date, then not 
TEAE 
If start date >= study med start date, then TEAE 
 
 
 
Partial, but known 
components show that 
it cannot be on or after 
study med start date 
Known 
Not TEAE 
 
Partial 
Not TEAE 
 
Missing 
Not TEAE 
 
 
 
Partial, could be on or 
after study med start 
date 
Known 
If stop date < study med start date, then not TEAE 
If stop date >= study med start date, then TEAE 
 
Partial 
Impute stop date as latest possible date (i.e. last 
day of month if day unknown or 31st December if 
day and month are unknown), then: 
If stop date < study med start date, then not TEAE 
If stop date >= study med start date, then TEAE 


 
 
Document: 
\\ieedc-vnasc01\BIOSdata\Newron\Sarizotan\PXA76395\Biostatistics\Documentation\SAP 
Author: 
Ayushi Chaturvedi  
Version Number: 
V2 
 
 
Version Date: 
[30March2020] 
Template No:  CS_TP_BS016 – Revision 4 
Reference:  CS_WI_BS005 
Effective Date: 01Apr2016 
 
Copyright © 2009, 2010, 2012, 2016 Quintiles Transnational Corp. All rights reserved. 
The contents of this document are confidential and proprietary to Quintiles Transnational Corp. Unauthorized use, disclosure or reproduction is 
strictly prohibited. 
Newron Pharmaceuticals S.p.A. 
      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 42 of 47 
START DATE 
STOP 
DATE 
ACTION 
 
Missing 
Assumed TEAE 
 
 
 
Missing 
Known 
If stop date < study med start date, then not TEAE 
If stop date >= study med start date, then TEAE 
 
Partial 
Impute stop date as latest possible date (i.e. last 
day of month if day unknown or 31st December if 
day and month are unknown), then: 
If stop date < study med start date, then not TEAE 
If stop date >= study med start date, then TEAE 
 
Missing 
Assumed TEAE 
 
ALGORITHM FOR PRIOR / CONCOMITANT MEDICATIONS:  
START 
DATE 
STOP 
DATE 
ACTION 
Known 
Known 
If stop date < study med start date, assign as prior  
If stop date >= study med start date and start date <= end of 
treatment, assign as concomitant  
 
Partial 
Impute stop date as latest possible date (i.e. last day of month 
if day unknown or 31st December if day and month are 
unknown), then: 
If stop date < study med start date, assign as prior 
If stop date >= study med start date and start date <= end of 
treatment, assign as concomitant 
 
Missing 
If stop date is missing could never be assumed a prior 
medication 
If start date <= end of treatment, assign as concomitant 
 
 
 


 
 
Document: 
\\ieedc-vnasc01\BIOSdata\Newron\Sarizotan\PXA76395\Biostatistics\Documentation\SAP 
Author: 
Ayushi Chaturvedi  
Version Number: 
V2 
 
 
Version Date: 
[30March2020] 
Template No:  CS_TP_BS016 – Revision 4 
Reference:  CS_WI_BS005 
Effective Date: 01Apr2016 
 
Copyright © 2009, 2010, 2012, 2016 Quintiles Transnational Corp. All rights reserved. 
The contents of this document are confidential and proprietary to Quintiles Transnational Corp. Unauthorized use, disclosure or reproduction is 
strictly prohibited. 
Newron Pharmaceuticals S.p.A. 
      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 43 of 47 
START 
DATE 
STOP 
DATE 
ACTION 
Partial 
Known 
Impute start date as earliest possible date (i.e. first day of 
month if day unknown or 1st January if day and month are 
unknown), then: 
If stop date < study med start date, assign as prior 
If stop date >= study med start date and start date <= end of 
treatment, assign as concomitant 
 
Partial 
Impute start date as earliest possible date (i.e. first day of 
month if day unknown or 1st January if day and month are 
unknown) and impute stop date as latest possible date (i.e. 
last day of month if day unknown or 31st December if day 
and month are unknown), then: 
If stop date < study med start date, assign as prior 
If stop date >= study med start date and start date <= end of 
treatment, assign as concomitant 
 
Missing 
Impute start date as earliest possible date (i.e. first day of 
month if day unknown or 1st January if day and month are 
unknown), then: 
If stop date is missing could never be assumed a prior 
medication 
If start date <= end of treatment, assign as concomitant 
 
 
 
Missing 
Known 
If stop date < study med start date, assign as prior 
If stop date >= study med start date, assign as concomitant 
 
Partial 
Impute stop date as latest possible date (i.e. last day of month 
if day unknown or 31st December if day and month are 
unknown), then: 
If stop date < study med start date, assign as prior 
If stop date >= study med start date, assign as concomitant 
 
Missing 
Assign as concomitant 
 


 
 
Document: 
\\ieedc-vnasc01\BIOSdata\Newron\Sarizotan\PXA76395\Biostatistics\Documentation\SAP 
Author: 
Ayushi Chaturvedi  
Version Number: 
V2 
 
 
Version Date: 
[30March2020] 
Template No:  CS_TP_BS016 – Revision 4 
Reference:  CS_WI_BS005 
Effective Date: 01Apr2016 
 
Copyright © 2009, 2010, 2012, 2016 Quintiles Transnational Corp. All rights reserved. 
The contents of this document are confidential and proprietary to Quintiles Transnational Corp. Unauthorized use, disclosure or reproduction is 
strictly prohibited. 
Newron Pharmaceuticals S.p.A. 
      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 44 of 47 
APPENDIX 2. CLINICALLY NOTABLE VALUES FOR LABORATORY 
PARAMETERS 
 
Parameter 
Synonym 
S.I. units 
Other units 
Unit 
Lower 
Limit 
Upper 
Limit 
Unit 
Lower 
Limit 
Upper 
Limit 
Albumin 
 
g/L 
≤ 14 
≥ 62 
g/dL 
≤ 1.4 
≥ 6.2 
Alk. Phosphatase 
ALP 
U/L 
NA 
≥ 3.0*URL  
 
 
 
Amylase 
 
U/L 
≤ 15 
≥ 350 
 
 
 
ALAT, SGPT 
ALT,GPT 
U/L 
NA 
≥ 3.0*URL 
 
 
 
ASAT, SGOT 
AST,GOT 
U/L 
NA 
≥ 3.0*URL 
 
 
 
Bicarbonate 
 
mmol/L 
≤ 10 
NA 
 
 
 
Bilirubin total 
 
μmol/L 
NA 
≥ 34 
mg/dL 
 
≥ 2.0 
Calcium total 
 
mmol/L 
≤ 2.1 
≥ 3.0 
mg/dL 
≤ 8.2 
≥ 12 
Chloride 
 
mmol/L 
≤ 80 
≥ 125 
 
 
 
Cholesterol 
 
mmol/L 
NA 
≥ 7.25 
mg/dL 
 
≥ 280 
Creatinine kinase 
CPK 
U/L 
NA 
≥ 3.0*URL 
 
 
 
Creatinine 
 
μmol/L 
NA 
≥ 177 
mg/dL 
 
≥ 2.0 
Gamma-GT    Male 
 
U/L 
NA 
≥ 100 
 
 
 
Female 
 
U/L 
NA 
≥ 90 
 
 
 
Globulin total 
 
g/L 
≤ 10 
NA 
 
 
 
Glucose 
 
mmol/L 
≤ 1.7 
≥ 13.9 
mg/dL 
≤ 30 
≥ 250 
LDH 
 
U/L 
NA 
≥ 3.0*URL 
 
 
 
Phosphate 
 
mmol/l 
NA 
≥ 2 
 
 
 
Potassium 
 
mmol/L 
≤ 2.5 
≥ 6.5 
 
 
 
Protein total 
 
g/L 
≤ 45 
NA 
 
 
 
PTT 
 
sec 
NA 
≥ 80 
 
 
 
Sodium 
 
mmol/L 
≤ 120 
≥ 165 
 
 
 
Triglycerides 
 
mmol/L 
NA 
≥ 5.6 
mg/dL 
 
≥ 500 
Urea 
 
mmol/L 
NA 
≥ 16.6 
mg/dL 
 
≥ 100 
Urea nitrogen 
BUN 
mmol/L 
NA 
≥ 84.0 
mg/dL 
 
≥ 30 
Uric acid         Male 
 
μmol/L 
NA 
≥ 624 
mg/dL 
 
≥ 10.5 
Female 
 
μmol/L 
NA 
≥ 505 
mg/dL 
 
≥ 8.5 
 
 


 
 
Document: 
\\ieedc-vnasc01\BIOSdata\Newron\Sarizotan\PXA76395\Biostatistics\Documentation\SAP 
Author: 
Ayushi Chaturvedi  
Version Number: 
V2 
 
 
Version Date: 
[30March2020] 
Template No:  CS_TP_BS016 – Revision 4 
Reference:  CS_WI_BS005 
Effective Date: 01Apr2016 
 
Copyright © 2009, 2010, 2012, 2016 Quintiles Transnational Corp. All rights reserved. 
The contents of this document are confidential and proprietary to Quintiles Transnational Corp. Unauthorized use, disclosure or reproduction is 
strictly prohibited. 
Newron Pharmaceuticals S.p.A. 
      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 45 of 47 
 
Parameter 
Synonym 
S.I. units 
Other units 
Unit 
Lower 
Limit 
Upper 
Limit 
Unit 
Lower 
Limit 
Upper 
Limit 
Basophils 
 
L/L 
NA 
≥ 0.15 
% 
 
≥ 15 
Eosinophils 
 
L/L 
NA 
≥ 0.10 
% 
 
≥ 10 
Erythocytes  Male 
RBC 
1012/L 
≤ 2.5 
NA 
 
 
 
Female 
 
1012/L 
≤ 2.0 
NA 
 
 
 
ESR                 Male 
 
Mm 
NA 
≥ 25 
 
 
 
Female 
 
Mm 
NA 
≥ 35 
 
 
 
Hematocrit      Male 
EVF 
L/L 
≤ 0.37 
NA 
% 
≤ 37 
 
 
Female 
 
L/L 
≤ 0.32 
NA 
% 
≤ 32 
 
Hemoglobin    Male 
 
g/L 
≤ 115 
NA 
g/dL 
≤ 11.5 
 
 
Female 
 
g/L 
≤ 95 
NA 
g/dL 
≤ 9.5 
 
Leukocytes 
WBC 
109/L 
≤ 2.8 
≥ 16.0 
 
 
 
Lymphocytes 
 
L/L 
NA 
≥ 0.80 
% 
 
≥ 80 
MCHC 
 
mmol/L 
≤ 12.4 
≥ 27.9 
g/dL 
≤ 20 
≥ 45 
MCV 
 
10-15L 
≤ 60 
≥ 120 
 
 
 
Monocytes 
 
L/L 
NA 
≥ 0.40 
% 
 
≥ 40 
Neutrophils 
 
L/L 
≤ 0.15 
NA 
% 
≤15 
 
Thrombocytes 
Platelets 
109/L 
≤ 75 
≥ 700 
 
 
 
 
CLINICALLY NOTABLE URINALYSIS VALUES 
Variable 
Clinically Notable Values 
Protein 
Increase of 2 units 
Glucose 
Increase of 2 units 
 
 
 


 
 
Document: 
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Version Date: 
[30March2020] 
Template No:  CS_TP_BS016 – Revision 4 
Reference:  CS_WI_BS005 
Effective Date: 01Apr2016 
 
Copyright © 2009, 2010, 2012, 2016 Quintiles Transnational Corp. All rights reserved. 
The contents of this document are confidential and proprietary to Quintiles Transnational Corp. Unauthorized use, disclosure or reproduction is 
strictly prohibited. 
Newron Pharmaceuticals S.p.A. 
      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 46 of 47 
APPENDIX 3. CLINICALLY NOTABLE VITAL SIGNS VALUES 
 
Parameter 
Unit 
Decrease 
Increase 
Sitting/Supine SBP  
mmHg  
Value ≤ 90 and ≥ 20 
decrease from Baseline.  
Value ≥ 180 and ≥ 20 
increase from Baseline  
Sitting/Supine DBP  
mmHg  
Value ≤ 50 and ≥ 15 
decrease from Baseline.  
Value ≥ 105 and ≥ 15 
increase from Baseline  
Orthostatic Hypotension 
(based on standing 
SBP/DBP)  
mmHg  
Decrease in SBP/DBP from 
Supine to Standing position 
exceeding > 30mmHg  
NA  
Sitting pulse rate  
bpm  
Value ≤ 50 and ≥ 15 
decrease from Baseline  
Value ≥ 120 and ≥ 15 
increase from Baseline  
Weight  
kg  
≥ 7% decrease from 
Baseline.  
≥ 7% increase from Baseline.  
Respiration rates*  
Breaths/ minute  
< 12  
> 25  
Temperature  
oC  
NA  
Value ≥ 38.3 and ≥ 1.1 
increase from Baseline.  
Temperature  
˚F  
NA  
Value ≥ 101.0 and ≥ 2.0 
increase from baseline  
 
APPENDIX 4. AGE CATEGORIZATION 
Age Group 1 
< 13 years  
Age Group 2 
>= 13 years 
 


 
 
Document: 
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Author: 
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Version Number: 
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Version Date: 
[30March2020] 
Template No:  CS_TP_BS016 – Revision 4 
Reference:  CS_WI_BS005 
Effective Date: 01Apr2016 
 
Copyright © 2009, 2010, 2012, 2016 Quintiles Transnational Corp. All rights reserved. 
The contents of this document are confidential and proprietary to Quintiles Transnational Corp. Unauthorized use, disclosure or reproduction is 
strictly prohibited. 
Newron Pharmaceuticals S.p.A. 
      STATISTICAL ANALYSIS PLAN: PROTOCOL Sarizotan/001/II/2015 
Page 47 of 47 
APPENDIX 5. RANDOMIZATION OF PATIENTS ACCORDING TO AGE 
AND BODY WEIGHT CRITERIA