Clinical trial NCT03229252
Conditions: Cystic Fibrosis
Sponsor: Spyryx Biosciences, Inc.
Start date: 2017-08-01; Completion date: 2019-06-20
Enrollment: 91 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
28-Day double-blinded efficacy and safety trial of SPX-101 Inhalation Solution in adult subjects with cystic fibrosis.

Detailed description:

Arms: arm 1: Placebo Inhalation solution twice daily for 28 days. arm 2: Inhalation solution twice daily for 28 days. arm 3: Inhalation solution twice daily for 28 days.
Interventions: intervention 1: Placebo Inhalation Solution intervention 2: SPX-101
Intervention descriptions: intervention 1: Normal Saline Inhalation Solution intervention 2: SPX-101 Inhalation Solution

Protocol documents:
Prot_000.pdf: 
 
 
 
 
 
A RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED PHASE II STUDY 
TO EVALUATE THE EFFICACY AND SAFETY OF SPX-101 INHALATION 
SOLUTION IN SUBJECTS WITH CYSTIC FIBROSIS (HOPE-1 STUDY: 
HYDRATION FOR OPTIMAL PULMONARY EFFECTIVENESS) 
 
Test Drug: 
SPX-101 Inhalation Solution 
 
Protocol Number: 
SPX-101-CF-201 
 
EudraCT Number: 2016-005230-30 
Study Phase:  
II 
Global Amendment 3:  
 
14 May 2018; Version 4.0  
 
Original Global Protocol: 
 
09 March 2017; Version 1.0 
Global Amendment 1: 
 
19 April 2017; Version 2.0 
Global Amendment 2:  
 
14 November 2017; Version 3.0 
Country-Specific Amendments:  
14 June 2017; Version 2.0A (UK) 
 
 
 
 
 
20 July 2017; Version 2.0B (Portugal) 
 
 
 
 
 
14 November 2017; Version 3.0A (UK) 
Sponsor: 
Spyryx Biosciences, Inc. 
801-10 Capitola Drive 
Durham, NC 27713 
(919) 899-9399 
Contract Research Organization: 
PRA Health Sciences 
4130 ParkLake Avenue, Suite 400 
Raleigh, NC  
Phone: +1 (919) 786-8200 
Fax: +1 (919) 786-8201 
Spyryx Chief Medical Officer: 
Alistair Wheeler, MD, MFPM 
PRA Medical Monitors: 
Kirill Rudinskiy, MD, PhD  
Navreet Sindhwani, MD 
 
Safety Contacts (SAE reporting): 
Europe: MHGSafety@prahs.com 
Fax: +44 1792 525 720 
North America: CHOSafety@prahs.com 
Fax: 888-772-6919 or 434-951-3482 
 
This study will be conducted in compliance with the protocol, Good Clinical Practice (GCP) as set forth in the 
International Council for Harmonisation (ICH) guidelines on GCP (ICH E6), and applicable local regulatory 
requirements. 
CONFIDENTIAL 
 
This document is a confidential communication of Spyryx Biosciences, Inc. Acceptance of this document constitutes 
agreement by the recipient that no unpublished information contained herein shall be published or disclosed without 
prior written approval, except that this document may be disclosed to the appropriate Institutional Review 
Board(s)/Independent Ethics Committee(s) under the condition that they keep it confidential. 




 
 
 
 
Investigator 
 
I have read and agree to the protocol SPX-101-CF-201, entitled “A Randomized, Double-
Blind, Placebo-Controlled Phase II Study to Evaluate the Efficacy and Safety of SPX-101 
Inhalation Solution in Subjects with Cystic Fibrosis (HOPE-1 Study: Hydration for Optimal 
Pulmonary Effectiveness).” I have also read the Investigator’s Brochure. I am aware of my 
responsibilities as an Investigator under the guidelines of GCP, local regulations (as 
applicable) and the study protocol. I agree to conduct the study according to these 
responsibilities and to appropriately direct and assist the staff under my control, who will be 
involved in the study. 
 
Version 4.0 
14 May 2018 
Clinical Site:  
 
 
 
Site Number: 
 
Site Principal Investigator: 
 
 
 
Print Name 
 
Title 
 
 
 
 
Signature 
 
Date 
 
 


 
 
 
Page 4 of 76 
 
 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
2. 
SYNOPSIS 
NAME OF SPONSOR: Spyryx Biosciences, Inc. 
PROTOCOL No.: SPX-101-CF-201 
NAME OF STUDY TREATMENT: SPX-101 Inhalation Solution 
TITLE OF STUDY: A Randomized, Double-Blind, Placebo-Controlled Phase II Study to 
Evaluate the Efficacy and Safety of SPX-101 Inhalation Solution in Subjects with Cystic Fibrosis 
(HOPE-1 Study: Hydration for Optimal Pulmonary Effectiveness) 
STUDY CENTERS: Approximately 25 centers are planned internationally 
STUDY PERIOD: After a 3- to 28-day screening period, enrolled 
subjects will be in the study for approximately 30 days. 
PHASE OF 
DEVELOPMENT: Phase 
II 
PLANNED STUDY DATES: The study is expected to start in Q3 2017 and conclude in 2019 
OBJECTIVES:  
Primary Objective:  
 
To evaluate the efficacy of SPX-101 in subjects with cystic fibrosis (CF) 
Safety Objectives: 
 
To evaluate the safety and tolerability of SPX-101 in subjects with CF 
Pharmacokinetic Objective: 
 
To assess the extent of systemic exposure of SPX-101 in a subset of subjects 
STUDY DESIGN AND METHODOLOGY:  
This randomized, double-blind, placebo-controlled, Phase II study is designed to evaluate the 
efficacy and safety of SPX-101 inhalation solution, administered in different dose regimens, in a 
28-day treatment period in approximately 90 adults with CF. Two sequential cohorts are planned 
to compare the study drug SPX-101 with placebo. Each cohort will have its own baseline and will 
be analyzed separately.  
Cohort 1 
In Cohort 1, 46 subjects were randomized in a 1:1:1 ratio to 3 groups (2 treatment groups and 1 
placebo group); to achieve balance between treatment groups, randomization was stratified by 
baseline lung function (percent predicted forced expiratory volume in 1 second [ppFEV1] 40.0% 
to 55.0% or 55.1% to 80.0%). Cohort 1 treatment groups were the following: 
o Placebo twice daily (BID) x 28 days 
o SPX-101 60 mg BID x 28 days 
o SPX-101 120 mg BID x 28 days  
Cohort 2 
In Cohort 2, approximately 45 subjects will be randomized in a 2:1 ratio to either SPX-101 
120 mg BID or placebo BID. Subjects will be stratified according to concomitant hypertonic 
saline use, so that approximately 50% will be using hypertonic saline (defined as having used a 
constant regimen for 28 days prior to screening and planning to continue their usual concentration 
without change for 28 days post-randomization). The decision to use 120 mg BID in Cohort 2 
was based on the relatively greater improvements in the lung function at that dose in Cohort 1, 
and a need to define the variability in response within the population.  
For each cohort, there will be 5 clinic visits and 2 telephone calls: Visit 1 (Screening; Day -28 to 
Day -3); Visit 2 (Randomization; Day 1); Visit 3 (Day 8 -1); Visit 4 (Day 15 -2/+1); telephone 


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
call (Day 22 ± 3); Visit 5 (Day 29 ± 2; end-of-treatment); and a follow-up telephone call 2 days 
later (Day 31 ± 1; end-of-study). All study visits for an individual subject will be scheduled at 
approximately the same time of day to minimize the confounding effects of diurnal variation in 
lung function, background therapies, and daily chest physiotherapy regimens. Subjects will be 
screened at Visit 1 and then will enter a variable-length screening period of 3 to 28 days, to time 
the randomization so that the first dose of the investigational product will coincide, if applicable, 
to the first day of an inhaled antibiotic cycle. In Cohort 1, subjects who still met the 
randomization criteria on Day 1 (Visit 2) were randomized to 1 of the 3 treatment groups. In 
Cohort 2 subjects who still meet the randomization criteria on Day 1 (Visit 2) will be randomized 
either to the treatment or placebo group, as described. 
At Visits 2, 3, and 4, after completing spirometry and other assessments, subjects will self-
administer the study medication in the clinic. On Day 1 (Visit 2) only, subjects will be monitored 
for safety for the first 4 hours after completion of administration of the study drug. Monitoring 
will include spirometry, vital signs, and adverse event (AE) assessments as described in more 
detail in the protocol. After the 4-hour postdose assessments are complete, subjects who have 
tolerated the study medication will be discharged with a sufficient supply of medication to take 
BID on an outpatient basis until their next clinic visit. 
Subjects who regularly use a short-acting β-agonist (SABA) should administer this medication at 
least 4 hours before spirometry on clinic days, and they should use the SABA consistently 
throughout the study.  
STUDY POPULATION AND MAIN CRITERIA FOR INCLUSION/EXCLUSION:  
Subjects cannot be enrolled or randomized before all inclusion criteria (including test results) are 
confirmed. A subject may be re-screened once if they fail to meet randomization criteria for any 
reason. If this is the case, a new consent form must be signed, and a new screening number will 
be used. 
Inclusion Criteria:  
1. Ability to provide written, personally signed, and dated informed consent to participate in 
the study, in accordance with the ICH GCP Guideline E6 and applicable regulations, 
before completing any study-related procedures 
2. Ability and willingness (in the judgment of the Investigator) to attend study visits and 
fully comply with study procedures and restrictions; study visits will occur at 
approximately the same time of day throughout the study and under specified conditions 
with respect to daily respiratory clearance and medication regimens 
3. Ability to self-administer the investigational product 
4. Male or nonpregnant, nonlactating female subjects aged 18 to 50 years inclusive  
5. Diagnosis of cystic fibrosis as determined by the 2008 Cystic Fibrosis Foundation 
Consensus Guidelines for Diagnosis [1] defined as the presence of signs and symptoms of 
CF in conjunction with at least 1 of the following: 
a. Documented sweat chloride test ≥ 60 mEq/L by quantitative pilocarpine 
iontophoresis 
b. Two well-characterized, disease-causing genetic mutations in the CF 
transmembrane conductance regulator (CFTR) gene; the original documentation 
of genetic testing is not required if the specific mutations are documented in the 
subject’s medical record 
6. ppFEV1 as follows:  


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
a. Cohort 1: between 40.0% and 80.0%  
b. Cohort 2: between 50.0% and 80.0% 
Note: spirometry must be performed in accordance with American Thoracic 
Society/European Respiratory Society end-of-test criteria and the Global Lung 
Initiative predicted values [2, 3] 
7. Stable CF lung disease, defined as no pulmonary exacerbation or acute upper or lower 
respiratory illness other than CF within 28 days preceding screening, except for allergic 
or nonallergic rhinitis; in addition, subjects may not have had any of the following:  
a. Significant hemoptysis (at the discretion of the Investigator) within 28 days of 
screening 
b. Pneumothorax within 28 days of screening 
c. Diagnosis of active allergic bronchopulmonary aspergillosis (at the discretion of 
the Investigator) 
d. Documented colonization with Burkholderia cenocepacia or Mycobacterium 
abscessus within 6 months prior to screening; subjects with other infections in 
the Burkholderia or Mycobacterium genii are allowed at the discretion of the 
Investigator 
8. No significant changes (removal or addition of medications) to inhaled or oral CF 
medication regimen within 28 days preceding screening, and no anticipation of need to 
change this regimen during study participation; short courses of medications used to 
address an ongoing medical problem are allowed, provided the last dose of such 
medication was taken > 28 days before screening; subjects for whom a significant change 
in medication is anticipated during the study will be excluded. Specific requirements for 
ongoing concomitant medications are below: 
a. Inhaled antibiotic use: stable antibiotic medication, defined as at least 2 complete 
28-day cycles of intermittent monotherapy (if alternating month on and month 
off with a single inhaled antibiotic) or 2 full cycles if continuous alternating 
every 28 days between 2 inhaled antibiotics  
b. Dornase alfa: stable use of daily or intermittent dosing for at least 28 days before 
screening 
c. Inhaled bronchodilators: stable dose for at least 28 days before screening 
d. Inhaled hypertonic saline: stable dose for at least 28 days before screening 
9. Other concomitant medications may be taken during the study, provided the dose and 
regimen have been stable for at least 14 days before screening, and the regimen is 
expected to remain stable during the study  
10. Stable chest physiotherapy and clearance techniques for at least 28 days before screening, 
including chest percussion, use of vibrating vests, etc 
11. All female subjects of childbearing potential must be using a highly effective method of 
contraception through the duration of the study as follows:  
a. Female subjects of childbearing potential must not be pregnant, breastfeeding, or 
attempting to become pregnant for 28 days before screening, throughout the 
duration of the study, and for 28 days after the last study visit. Subjects must 
have a negative serum pregnancy test at screening, a negative urine pregnancy 
test at randomization, and be willing to commit to using a consistent and 


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
acceptable method of contraception for at least 28 days before screening and for 
the duration of the study, if they are (or become) sexually active. Female subjects 
of childbearing potential must meet at least 1 of the following:  
i. Consistent use of systemic contraception, including birth control pills, 
transdermal patch, vaginal ring, implants, and injectables 
ii. Consistent use of double barrier method, eg, condoms, cervical cap, 
diaphragm, vaginal contraceptive film with spermicide 
iii. Use of intrauterine device with a low failure rate (defined as < 1% risk of 
pregnancy per year) 
iv. Monogamous intercourse with a vasectomized man or has only same-sex 
partners 
v. Female subjects who are not sexually active but become so during the 
study must agree to follow the contraceptive requirements above 
b. Female subjects who are not of childbearing potential must meet at least 1 of the 
following criteria:  
i. At least 1 year since the last menstrual period 
ii. Surgically sterile (tubal ligation, bilateral oophorectomy, salpingectomy, 
or hysterectomy) 
iii. Congenitally sterile 
iv. Diagnosed as infertile and not undergoing treatment to reverse infertility 
Exclusion Criteria: 
1. BMI < 18 kg/m2 
2. Use of a CFTR corrector or potentiator during the study or within 60 days before 
screening 
3. The presence of significant and unstable comorbidities (based on the Investigator’s 
judgment) within 28 days before screening, including diabetes, significant renal or 
hepatic disease, significant respiratory disease other than CF, cardiac, neurological, or 
gastrointestinal disease other than those associated with CF. Subjects with stable co-
morbidities associated with CF (such as diabetes) may participate per the Investigator’s 
judgment unless specifically prohibited elsewhere. 
4. Subjects with either of the following:  
a. Hepatic impairment defined by elevation of bilirubin > 2 times the upper limit of 
normal (ULN) or aspartate aminotransferase, alanine aminotransferase, or 
alkaline phosphatase > 5 times the ULN 
b. Chronic hepatitis B and/or C 
5. History of malignancy in the previous 5 years; subjects who have been successfully 
treated for non-melanoma skin cancer, cervical cancer, or prostate cancer within the 
previous 5 years are allowed to enroll with the approval of the Medical Monitor 
6. Administration of another investigational drug within 28 days before screening 
7. Administration of a vaccination (including influenza) within 7 days before screening 
8. Requirement for supplemental oxygen of more than 2 L/min, and/or noninvasive 
ventilation for the management of respiratory failure; subjects must have been on a stable 
regimen for at least 60 days before screening (patients who have been using a stable 
regimen of oxygen ≤ 2 L/min for at least 60 days before screening are eligible to enroll) 
9. Current use of tobacco or tetrahydrocannabinol-containing products, delivered orally, by 


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
vaporizing, or by smoking; or a greater than 10 pack-year history of tobacco use 
10. Actively listed for lung transplantation  
11. Any history of organ transplantation 
12. Hospitalization for a respiratory event or CF-related condition within 28 days before 
screening or any plans for hospitalization for any reason during the study 
13. Current use of > 10 mg/day of prednisone/prednisolone (use of ≤ 10 mg/day is 
acceptable) 
14. Use of any of the following antihypertensive medications or combinations containing 
these medications: diuretics (eg, thiazides, loop diuretics, spironolactone, amiloride), 
angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or any other 
drugs known to affect the serum potassium concentration  
15. Hypersensitivity to the study drug or any of its excipients 
16. Subjects with significant electrocardiogram (ECG) abnormalities at screening or before 
the first dose on Day 1, including a QT interval corrected by the Fridericia correction 
formula (≥ 440 msec in men and ≥ 460 msec in women) 
Randomization Criteria: 
1. Continue to meet entrance criteria 
2. Negative serum (Visit 1) and urine (Visit 2, pre-randomization) pregnancy test result for 
all female subjects of childbearing potential 
3. Stable FEV1 at Visit 2, defined as FEV1 within ± 15% of the relative change between the 
Visit 1 and Visit 2 best FEV1. Relative change is defined as follows:  
 
FEV1 (Screening; Visit 1) ˗ FEV1 (Visit 2)  
FEV1 (Screening; Visit 1) 
 
4. No new intervening illnesses since Screening (Visit 1) and the subject’s CF is still stable 
in the judgment of the Investigator 
5. No clinically significant laboratory or ECG abnormalities that pose a significant risk to 
the subject, per the judgment of the Investigator  
Note: A subject may be re-screened once if they fail to meet randomization criteria for any 
reason. If this is the case, a new consent form must be signed, and a new screening number will 
be used. 
NUMBER OF SUBJECTS:  
In Cohort 1, 46 subjects were randomized in a 1:1:1 ratio to 1 of the 2 treatment groups or 
placebo. The sample size of 39 subjects was chosen to provide 70% power for the Analysis of 
Variance (ANOVA) to detect a difference range of 4.5% to 6% in the change from baseline in 
ppFEV1 and FEV1 between each of the 2 treatment groups versus placebo, with the alpha level of 
0.15 assuming a common standard deviation of 7%. The attrition rate was expected to be minimal 
given the 4 weeks’ treatment duration. 
In Cohort 2, a total of 45 subjects will be randomized in a 2:1 ratio to either SPX-101 120 mg 
BID or placebo BID. The sample size of 45 subjects will provide 88% to 97% power to detect a 
difference range of 6% to 8% in the change from baseline in ppFEV1 between the treatment group 
versus placebo, with the 1-sided alpha level of 0.1 assuming a common standard deviation of 
7.58%. 
× 100 


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
STUDY TREATMENT(S):  
Test Product, Dose and Mode of Administration: SPX-101 is a clear, sterile solution for 
inhalation consisting of 60 mg/mL SPX-101 drug substance in 0.9% sodium chloride adjusted to 
pH 7, intended for delivery as a nebulized aerosol by the investigational PARI eFlow nebulizer 
with PARI eTrack. 
Reference Therapy, Dose and Mode of Administration: 
The placebo for this study is sterile 0.9% saline adjusted to pH 7, free of preservatives and other 
excipients, suitable for inhalation via a nebulized aerosol by the investigational PARI eFlow 
nebulizer with PARI eTrack. 
All drug product manufacturing and labeling will be managed by Spyryx Biosciences, Inc., and 
shipment and management of the investigational product will be the responsibility of PRA. 
DURATION OF TREATMENT: 28 days 
STUDY EVALUATIONS: 
Efficacy Variables:  
Primary Efficacy Variable:  
 
Change from baseline in ppFEV1 at Week 4 
Secondary Efficacy Variables:  
 
Change from baseline in ppFEV1 at other study weeks  
 
Change from baseline in FEV1  
 
Change from baseline in forced vital capacity (FVC) and percent predicted FVC (ppFVC)  
 
Change from baseline in Cystic Fibrosis Questionnaire-Revised (CFQ-R) 
Safety Variables:  
 
Incidence of treatment-emergent AEs (TEAEs) 
 
Changes in vital signs 
 
Changes in clinical laboratory tests, including urine and blood electrolytes 
 
Changes in electrocardiograms 
Pharmacokinetic Variable (for Cohort 1 Only):  
 
Systemic exposure to SPX-101 (subset of subjects) 
Exploratory Variables 
 
Incidence of pulmonary exacerbation, as defined by Fuchs [4] (See Appendix 3, Section 
18.3 for details) 
STATISTICAL METHODS:  
Efficacy Analysis 
The primary endpoint is the change from baseline in ppFEV1 at Week 4 (Day 29).  
The change from baseline in ppFEV1 at Week 4 will be summarized and compared between each 
treatment group and placebo. The primary analysis will be based on an analysis of covariance 
(ANCOVA), incorporating the categorical stratification variable of baseline lung function in 
Cohort 1, and the stratification variable of concomitant hypertonic saline use in Cohort 2.  
Similar analysis will be performed for the change from baseline in ppFEV1 (Weeks 1 and 2), 
FEV1, ppFVC, and FVC at each visit (Week 1, 2, and 4). 
The change from baseline in ppFEV1 at each visit (week 1, 2, and 4) will also be considered 
based on a mixed effect model for repeated measure (MMRM). 


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
The change from baseline in CFQ-R respiratory domain score and physical domain score at 
Week 4 will be summarized and compared between each treatment group and placebo. 
The number and percentage of subjects with pulmonary exacerbation will be summarized.  
The effect of regular use of concomitant hypertonic saline will be explored across the primary 
and secondary endpoints. 
Safety Analysis 
Safety evaluations will include TEAEs, vital signs, clinical laboratory tests, ECGs, and physical 
examinations.  
Descriptive statistics will be provided. Continuous variables will be summarized using the 
number of observations, mean, standard deviation, median, the first quartile (Q1), the third 
quartile (Q3), minimum, and maximum. Categorical variables will be summarized using 
frequency and percentages. The changes from baseline for the continuous variables will be 
similarly summarized. 
Pharmacokinetic Analysis (for Cohort 1 only) 
The pharmacokinetic results will be summarized to assess systemic exposure to SPX-101.  
Data Safety Monitoring Board 
An independent DSMB will periodically review the accrued safety data in an unblinded manner 
to monitor the safety of subjects. Three DSMB meetings were scheduled at the following time 
points: midpoint of Cohorts 1 and 2 (after approximately 19 subjects have been randomized) and 
at the completion of Cohort 1. Additional meetings may be scheduled at the discretion of the 
DSMB members. The DSMB will be empowered to make any recommendations relevant to 
safety, but specifically will make recommendations to revise study procedures to increase subject 
safety or to stop the study based on periodic data reviews, and make recommendations on the 
dosage selection in Cohort 2. 
The DSMB charter, which defines the membership and organization of the DSMB, was finalized 
before the first subject in Cohort 1 was randomized to study drug. In addition, the DSMB charter 
defines the safety information that will be reviewed, the reporting obligations and responsibilities 
of the DSMB, and specifies what information, if any, may be shared with the Sponsor or 
investigators.  
DATE AND VERSION: 14 May 2018 (Version 4.0) 


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
3. 
TABLE OF CONTENTS 
1. 
SIGNATURES ........................................................................................................... 2 
2. 
SYNOPSIS .................................................................................................................. 4 
3. 
TABLE OF CONTENTS ........................................................................................ 11 
4. 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS ......................... 16 
5. 
ETHICS .................................................................................................................... 18 
5.1 
Ethics Committee ...................................................................................................... 18 
5.2 
Ethical Conduct of the Study ..................................................................................... 18 
5.3 
Subject Information and Consent .............................................................................. 18 
6. 
STUDY ADMINISTRATIVE STRUCTURE AND VENDORS ......................... 19 
7. 
INTRODUCTION ................................................................................................... 20 
7.1 
Disease Review .......................................................................................................... 20 
7.2 
Compound Review .................................................................................................... 21 
7.2.1 
Description of SPX-101 ............................................................................................ 21 
7.2.2 
Structural Formula and Physical Characteristics ....................................................... 21 
7.2.3 
Nonclinical and Pharmacology Studies ..................................................................... 21 
7.2.4 
Clinical Studies .......................................................................................................... 22 
7.3 
Clinical Study Rationale ............................................................................................ 23 
7.3.1 
Rationale for Cohort 1 Dosages ................................................................................. 23 
7.3.2 
Rationale for Cohort 2 Dosage .................................................................................. 23 
8. 
STUDY OBJECTIVES ........................................................................................... 25 
8.1 
Primary Objective ...................................................................................................... 25 
8.2 
Safety Objectives ....................................................................................................... 25 
8.3 
Pharmacokinetic Objective (Cohort 1 Only) ............................................................. 25 
9. 
INVESTIGATIONAL PLAN ................................................................................. 26 
9.1 
Overall Study Design and Plan .................................................................................. 26 
9.2 
Discussion of Study Design ....................................................................................... 32 
9.3 
Study Duration........................................................................................................... 32 
9.4 
Study Population ....................................................................................................... 32 
9.4.1 
Inclusion Criteria ....................................................................................................... 32 
9.4.2 
Exclusion Criteria ...................................................................................................... 34 
9.4.3 
Randomization Criteria (Assessed at Visit 2) ............................................................ 35 
9.4.4 
Withdrawal and Replacement of Subjects ................................................................. 36 
9.4.4.1 
Criteria for Subject Withdrawal ................................................................................ 36 
9.4.4.2 
Evaluations at Withdrawal ......................................................................................... 37 
9.4.4.3 
Termination of the Study by the Sponsor .................................................................. 37 


 
 
 
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Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
9.4.4.4 
Replacement of Subjects ........................................................................................... 37 
9.5 
Treatment ................................................................................................................... 37 
9.5.1 
Treatments Administered........................................................................................... 37 
9.5.2 
Study Treatment Formulation .................................................................................... 39 
9.5.3 
Study Treatment Labeling and Packaging ................................................................. 39 
9.5.4 
Blinding of Study Medication ................................................................................... 40 
9.5.5 
Study Treatment Storage and Accountability ............................................................ 40 
9.5.5.1 
Study Treatment Storage ........................................................................................... 40 
9.5.5.2 
Study Treatment Accountability ................................................................................ 40 
9.5.6 
Dose Adjustments and Dose Escalation .................................................................... 41 
9.5.7 
Prior and Concomitant Therapy ................................................................................ 41 
9.5.7.1 
Prohibited Medications .............................................................................................. 41 
9.5.8 
Treatment Compliance .............................................................................................. 42 
9.5.9 
Assignment to Treatment ........................................................................................... 42 
9.5.10 
Unblinding Procedures .............................................................................................. 42 
9.6 
Efficacy and Safety Variables ................................................................................... 43 
9.6.1 
Efficacy and Safety Measurements Assessed ............................................................ 43 
9.6.1.1 
Efficacy Variables ..................................................................................................... 43 
9.6.1.2 
Safety Variables ......................................................................................................... 43 
9.6.1.3 
Pharmacokinetic Variable (Cohort 1 Only) ............................................................... 43 
9.6.1.4 
Exploratory Variables ................................................................................................ 43 
10. 
STUDY EVALUATIONS BY VISIT ..................................................................... 44 
10.1 
Visit 1: Screening (Day -28 to -3) ............................................................................. 44 
10.2 
Visit 2: Day 1 (Randomization) ................................................................................. 44 
10.2.1 
Pre-Randomization Assessment ................................................................................ 44 
10.2.2 
Randomization and Study Procedures ....................................................................... 44 
10.2.3 
Post-Randomization Visit Schedule .......................................................................... 45 
10.3 
Visit 3: Day 8 (-1 Day) .............................................................................................. 45 
10.4 
Visit 4: Day 15 (-2/+1 Days) ..................................................................................... 46 
10.5 
Day 22 (± 3 Days): Telephone Contact ..................................................................... 46 
10.6 
Visit 5: Day 29 (± 2 Days) (Also the Early Termination Visit, If Applicable) ......... 46 
10.7 
Follow-up Telephone Call: Day 31 (± 1 Day) ........................................................... 47 
11. 
METHODS OF ASSESSMENT ............................................................................. 48 
11.1 
Cystic Fibrosis Questionnaire - Revised ................................................................... 48 
11.2 
Pregnancy Testing ..................................................................................................... 48 
11.3 
Pulmonary Function Tests ......................................................................................... 48 
11.4 
Vital Signs and Weight .............................................................................................. 48 


 
 
 
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Global Version 4.0; 14 May 2018 
11.5 
Physical Examination ................................................................................................ 48 
11.6 
Electrocardiogram ..................................................................................................... 49 
11.7 
Adverse Events and Pulmonary Exacerbation ........................................................... 49 
11.8 
Clinical Laboratory Testing ....................................................................................... 49 
11.9 
Blood Samples for Pharmacokinetic Testing (Cohort 1 Only) .................................. 50 
11.10 
Blood Samples for Antidrug Antibody Testing ......................................................... 50 
12. 
SAFETY MEASUREMENTS AND VARIABLES .............................................. 51 
12.1 
Adverse Events .......................................................................................................... 51 
12.2 
Serious Adverse Events ............................................................................................. 51 
12.3 
Reporting of Serious Adverse Events ........................................................................ 52 
12.4 
Monitoring of Subjects for Adverse Events .............................................................. 52 
12.4.1 
Abnormal Laboratory Test Results ............................................................................ 53 
12.4.2 
Abnormal Physical Examination Findings or ECG Changes .................................... 53 
12.5 
Overdose of Study Medication .................................................................................. 53 
12.6 
Pregnancy .................................................................................................................. 53 
13. 
DATA MANAGEMENT AND STATISTICAL ANALYSIS .............................. 54 
13.1 
Data Management ...................................................................................................... 54 
13.2 
Sample Size Estimation ............................................................................................. 54 
13.3 
Statistical Analysis Plan ............................................................................................ 54 
13.4 
Randomization ........................................................................................................... 54 
13.5 
Analysis Populations ................................................................................................. 55 
13.5.1 
Safety Population ....................................................................................................... 55 
13.5.2 
Intent-to-Treat Population ......................................................................................... 55 
13.5.3 
Per-Protocol Population ............................................................................................. 55 
13.6 
Statistical Methods .................................................................................................... 55 
13.6.1 
Missing Data .............................................................................................................. 55 
13.6.2 
Demographic, Cystic Fibrosis History, and Baseline Data ....................................... 55 
13.6.3 
Subject Disposition .................................................................................................... 55 
13.6.4 
Efficacy ...................................................................................................................... 55 
13.6.4.1 
Primary Efficacy Analysis ......................................................................................... 55 
13.6.4.2 
Secondary Efficacy Analysis ..................................................................................... 56 
13.6.4.3 
Exploratory Analyses ................................................................................................ 56 
13.6.5 
Pharmacokinetics – Cohort 1 Only ............................................................................ 56 
13.6.6 
Safety ......................................................................................................................... 56 
13.6.7 
Additional Data ......................................................................................................... 57 
13.6.8 
Interim Analysis ........................................................................................................ 57 
13.6.9 
Data Safety Monitoring Board .................................................................................. 57 


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
14. 
MONITORING PROCEDURES (QUALITY ASSURANCE) ............................ 58 
14.1 
Routine Monitoring ................................................................................................... 58 
14.2 
Inspections and Auditing Procedures ........................................................................ 58 
15. 
STUDY MANAGEMENT AND MATERIALS .................................................... 59 
15.1 
Electronic Case Report Forms ................................................................................... 59 
15.2 
Data Collection .......................................................................................................... 59 
15.3 
Source Documents Maintenance ............................................................................... 60 
15.4 
Record Maintenance .................................................................................................. 60 
15.5 
Confidentiality ........................................................................................................... 60 
16. 
ADMINISTRATION PROCEDURES .................................................................. 62 
16.1 
Regulatory Approval ................................................................................................. 62 
16.2 
Protocol Amendments ............................................................................................... 62 
16.3 
Protocol Adherence and Deviations .......................................................................... 62 
16.4 
Publication Policy ...................................................................................................... 63 
16.5 
Clinical Study Report ................................................................................................ 63 
16.6 
Contractual and Financial Details .............................................................................. 63 
16.7 
Insurance, Indemnity, and Compensation ................................................................. 63 
16.8 
Discontinuation of the Study ..................................................................................... 63 
16.9 
Study Center File Management ................................................................................. 63 
17. 
REFERENCE LIST ................................................................................................ 64 
18. 
APPENDICES .......................................................................................................... 66 
18.1 
Appendix 1: Declaration of Helsinki ......................................................................... 66 
18.2 
Appendix 2: Elements of Informed Consent ............................................................. 71 
18.3 
Appendix 3: Criteria for Pulmonary Exacerbation .................................................... 73 
18.4 
Appendix 4: Information for Subjects Enrolled in Study SPX-101-CF201 .............. 74 
18.5 
Appendix 5: Bioclinica Trident User Requirement Specifications for Unblinding ... 76 
 
 


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
LIST OF TABLES 
Table 1 
Selected Adverse Events from Cohort 1 .............................................................. 24 
Table 2 
Schedule of Events ............................................................................................... 28 
Table 3 
Visit 2 (Randomization Visit) Schedule of Events ............................................... 30 
Table 4 
Planned Study Medication Dosing for Cohort 1 and Cohort 2 ............................ 38 
Table 5 
Investigational Medicinal Products ...................................................................... 39 
 
LIST OF FIGURES 
 
Figure 1 
Study Diagram – Cohort 1 ................................................................................... 26 
Figure 2 
Study Diagram – Cohort 2 ................................................................................... 27 
 


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
4. LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
 
Term 
Definition 
ADA 
Antidrug antibody 
AE 
Adverse event  
ALP 
Alkaline phosphatase 
ALT 
Alanine aminotransferase 
ANCOVA 
Analysis of Covariance 
ANOVA 
Analysis of Variance 
AST 
Aspartate aminotransferase 
BID 
Twice daily 
BMI 
Body mass index 
CF 
Cystic fibrosis 
CFR 
Code of Federal Regulations 
CFTR 
Cystic fibrosis transmembrane conductance regulator 
CFQ-R 
Cystic Fibrosis Questionnaire-Revised 
CRO 
Contract research organization 
DSMB 
Data Safety Monitoring Board  
ECG 
Electrocardiogram 
eCRF 
Electronic case report form 
EDC 
Electronic data capture 
ENaC 
Epithelial sodium channel 
ET 
Early termination 
FDA 
Food and Drug Administration 
FEV1 
Forced expiratory volume in one second 
FVC 
Forced Vital Capacity 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practice 
HBE 
Human bronchial epithelial 
IB 
Investigator’s Brochure 
ICF 
Informed consent form 
ICH 
International Council for Harmonisation 
IEC 
Independent Ethics Committee 
IP 
Investigational product 
IRB 
Institutional Review Board 
ITT 
Intent-to-treat  
IXRS 
Interactive voice/web response system 


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
Term 
Definition 
LABA 
Long-acting β-agonist 
MAD 
Multiple ascending dose 
MedDRA 
Medical Dictionary for Regulatory Activities 
MMRM 
Mixed Effect Model for Repeated Measures 
PK 
Pharmacokinetic(s) 
PP 
Per protocol 
ppFEV1 
Percent predicted forced expiratory volume in 1 second 
ppFVC 
Percent predicted forced vital capacity 
QD 
Once daily 
QTcF 
QT Interval corrected by the Fridericia correction formula 
SABA 
Short-acting β-agonist 
SAD 
Single ascending dose 
SAE 
Serious adverse event 
SAP 
Statistical Analysis Plan 
SPLUNC1 
Short palate, lung, and nasal epithelial clone 1 
TEAE 
Treatment-emergent adverse event 
TC 
Telephone call 
TMV 
Tracheal mucus velocity 
ULN 
Upper limit of normal 
US/USA 
United States/United Sates of America 
WHO 
World Health Organization 
WMA 
World Medical Association 


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
5. 
ETHICS 
5.1 Ethics Committee 
This study will be conducted in compliance with independent ethics committee (IEC) and 
International Council for Harmonisation (ICH) Good Clinical Practice (GCP) Guidelines, in 
accordance with applicable regulations regarding clinical safety data management (E2A, 
E2B(R3)), European Community directives 2001/20, 2001/83, 2003/94 and 2005/28 as 
enacted into local law, and with ICH guidelines regarding scientific integrity (E4, E8, E9 and 
E10). In addition, this study will adhere to all local regulatory requirements, and 
requirements for data protection. 
Before initiating a trial/study, the Investigator/institution must have written and dated 
approval/favorable opinion from the IEC for the study protocol/amendment(s), written 
informed consent form, any consent form updates, subject recruitment procedures (eg, 
advertisements), and any written information to be provided to subjects and a statement from 
the IEC that they comply with GCP requirements. The IEC approval must identify the 
protocol version as well as the documents reviewed. 
5.2 Ethical Conduct of the Study 
This study will be conducted in accordance with the Note for Guidance on GCP (ICH 
Harmonized Tripartite Guideline E6 (R1); Food and Drug Administration (FDA) Code of 
Federal Regulations (CFR) (21 CFR § 50, 56, 312)), Declaration of Helsinki (Seoul 2008) 
(Appendix 1, Section 18.1) and all applicable regulatory requirements. 
5.3 Subject Information and Consent 
The Investigator will explain the benefits and risks of participation in the study to each 
subject, the subject’s legally acceptable representative or impartial witness and obtain written 
informed consent. Written informed consent must be obtained prior to the subject entering 
the study and before initiation of any study related procedure (including administration of 
study drug).  
The Sponsor will provide a sample informed consent form, based on the elements of 
informed consent in Appendix 2, Section 18.2. The final, version dated, form must be agreed 
to by the Sponsor and the IRB/IEC and will contain all elements in the sample form, in 
language readily understood by the subject. Each subject’s original consent form, personally 
signed and dated by the subject or by the subject’s legally acceptable representative, and by 
the person who conducted the informed consent discussion, will be retained by the 
Investigator. The Investigator will supply all enrolled subjects with a copy of their signed 
informed consent. 
The consent form may need to be revised during the study should important new information 
become available that may be relevant to the safety of the subject. In this instance approval 
should always be given by the IRB/IEC and existing subjects informed of the changes and 
reconsented. This is documented in the same way as previously described. 
The Investigator will, with the consent of the subject, inform the subject’s primary physician 
about participation in the clinical study. 


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
6. 
STUDY ADMINISTRATIVE STRUCTURE AND VENDORS 
 
Clinical Laboratories: 
Central Laboratory 
Eurofins Central Laboratory (North American sites) 
US:  
2430 New Holland Pike 
Lancaster, PA 17601, USA 
Eurofins Central Laboratory, B.V. (European sites)  
Bergschot 71 
4817 PA 
Breda 
The Netherlands 
Specialty Laboratory for Antidrug Antibody and PK Analyses 
QPS, LLC 
3 Innovation Way, Suite 240 
Newark, DE 19711, USA 
Contract Research Organization 
PRA Health Sciences 
4130 ParkLake Avenue, Suite 400 
Raleigh, NC, USA 27612 
Tel: +1 (919) 786-8200 
Fax: +1 (919) 786-8201 
PRA Study Medical Monitor/ Medical Expert 
Kirill Rudinskiy, MD, PhD (Europe) 
Navreet Sindhwani, MD (Canada) 
Central Spirometry Testing 
Biomedical Systems (BMS) 
77 Progress Parkway 
St. Louis, MO 63043 
Interactive Voice/Web Response System 
Bioclinica 
800 Adams Ave.  
Audubon, PA 19403, USA 


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
7. 
INTRODUCTION 
7.1 Disease Review 
Cystic fibrosis is the most common life-threatening disease among Caucasians, affecting 1 in 
every 2,000 to 3,500 newborn infants worldwide, depending on the region, and is severely 
underdiagnosed in Asia. Current therapies for CF focus on antibiotic treatment of airway 
infections or through targeted reduction of airway inflammation with correctors and 
potentiators of the mutated chloride and bicarbonate secretory channel, cystic fibrosis 
transmembrane conductance regulator (CFTR). Despite these advances as well as supportive 
therapies, lung function decline with respiratory failure continues to be a major cause of 
death in this patient population.  
Cystic fibrosis patients’ lack of functional CFTR leads to chronic lung disease. The loss of 
CFTR function also triggers abnormal upregulation of ENaC, which leads to Na+ and fluid 
hyperabsorption that is directly associated with dehydrated airway surface liquid/mucus 
[5;6;7]. The dehydration of airway surface liquid causes resident mucus to adhere to airway 
surfaces, preventing its clearance, and allowing concentrated mucus plaques to accumulate 
until the airways become occluded and colonized by bacteria [8;9;10]. In CF, there is also an 
abundance of neutrophil elastase, which has been shown to hyperactivate ENaC and further 
contribute to mucus dehydration [11].  
Although ENaC inhibition has been proven to help rehydrate CF mucus in preclinical models 
by retarding the hyperabsorption noted above, clinical trials of small molecule ENaC 
inhibitors for the treatment of CF have largely failed because these compounds are 
systemically absorbed and induce hyperkalemia from inhibition of ENaC in the kidney. For 
instance, amiloride is an ENaC inhibitor that is approved for human use as a diuretic. 
However, amiloride and its analogues are rapidly cleared from the lungs 
(half-life = 9 minutes) and failed to have any impact on CF lung disease at doses that did not 
adversely affect the kidney [12;13].  
Recently, a secreted protein, short palate lung and nasal epithelial clone 1 (SPLUNC1), was 
found to be a natural, allosteric inhibitor of ENaC that binds extracellularly to the ENaC 
subunits and reduces their concentration on the cell surface. Reduced ENaC protein in the 
plasma membrane diminishes the related channel activity and increases mucus transport. 
Importantly, the effects of SPLUNC1 are pH-dependent and are lost in the acidic CF airway. 
To address this deficiency, Spyryx has developed SPX-101, a pH-independent mimetic of 
SPLUNC1’s ENaC regulatory function, which acts via a novel mechanism of action to 
reduce the effects of ENaC in the airways that is fundamentally distinct from the mechanism 
of action of previously investigated ENaC receptor inhibitors.  
To translate these findings for clinical use, Spyryx has leveraged SPX-101’s novel 
mechanism of action, which durably reduces ENaC activity by promoting channel 
internalization, thereby reducing the density of ENaC on the cell surface in human bronchial 
epithelial (HBE) cultures. This unique and innovative approach of using a small peptide to 
reduce ENaC membrane concentration has several key advantages. Most importantly, the 
compound can be effectively delivered to the CF lung, a major site of disease in CF. 


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
Additionally, because a combination of low absorption and rapid clearance of small peptides 
from the circulation limits systemic exposure, there is reduced potential for systemic effects 
previously seen with small molecule ENaC inhibitors. Further, because the mechanism acts 
through ENaC instead of CFTR, SPX-101 may be effective for all patients with CF, 
independent of genetic mutation. 
7.2 Compound Review 
7.2.1 Description of SPX-101 
SPX-101 is a novel peptide being developed by Spyryx Biosciences, Inc for the treatment of 
lung associated pathologies in patients with CF. Specifically, SPX-101 will be developed as 
a genotype-independent treatment of the muco-obstructive pathology of the airways of 
pediatric and adult patients with CF. SPX-101 will be delivered via a high efficiency 
vibrating membrane nebulizer device. 
The SPX-101 drug product is an aqueous, sterile filled inhalation solution prepared by 
dissolving either 20 mg or 60 mg peptide in 1 mL of 0.9% sodium chloride, adjusting to pH 
7, and sterile filtering into sterile glass vials that are then stoppered, sealed, and labeled. 
SPX-101 contains no excipients. Drug product purity and nebulized droplet size distribution 
studies have been conducted at multiple concentrations and pH levels. Each vial of drug 
product will have a 1-mL fill in a 2-mL vial. 
The drug substance in SPX-101 is a linear, dodecapeptide containing 6 natural amino acids 
and 1 unnatural amino acid with a carboxamide group at the C-terminus. Additional 
information is provided in the Investigator’s Brochure (IB). 
7.2.2 Structural Formula and Physical Characteristics 
See the IB for details. 
7.2.3 Nonclinical and Pharmacology Studies 
SPX-101 acts as a mimetic of the ENaC regulatory domain of the endogenous protein, 
SPLUNC1. It reduces ENaC activity by internalization of the channel. This novel mechanism 
of action leads to a durable decrease in amiloride-sensitive current in cells from healthy and 
CF lungs. By restoring mucus transport to normal or near normal levels in animal models of 
CF, this activity provides a rationale for its use in the treatment of patients with CF, because 
airway dehydration leads to profound muco-obstructive pulmonary disease, morbidity, and 
mortality.  
Spyryx has completed a series of preclinical investigations with SPX-101, which include 
nonclinical pharmacology, PK, and toxicology studies. As part of these studies, assessments 
included primary and secondary pharmacodynamics, respiratory, cardiovascular, and central 
nervous system (CNS) safety pharmacology, absorption following inhalation exposure, 
inhalation toxicology of up to 28 days in duration, and in vitro and in vivo genotoxicity 
assessments.  
The effects of SPX-101 in vivo have been observed in a mouse model that develops CF-like 
lung disease manifested by goblet cell metaplasia, leukocyte infiltration, and mucus plugging 
of the airways. If untreated, approximately 50% of these mice die by 2 weeks of age. 


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
However, once daily intranasal administration of SPX-101 in these animals resulted in 
increased survival to > 90%.  
The ability of SPX-101 to increase mucus transport in large animals was investigated in a 
tracheal mucus velocity (TMV) sheep model. In this approach, both nebulized isotonic saline 
and an alphabetized control peptide (with the same molecular weight and amino acid 
composition as SPX-101 but in a pharmacologically inactive sequence) failed to demonstrate 
an increase in TMV. However, increasing doses of SPX-101 show a dose dependent increase 
in TMV sufficient to restore approximately 90% of TMV at a dose of 2 mg/kg and 100% 
recovery of TMV at a dose of 4 mg/kg. This increase was sustained over the course of the 
experiment (8 hours postdose). Notably, SPX-101 formulated in hypertonic saline showed a 
greater increase in TMV than the same dose in isotonic saline. In contrast, amiloride partially 
increased TMV, and this effect was short-lived (half-life of 4 hours), whether amiloride was 
formulated in isotonic or hypertonic saline. This important finding suggests that SPX-101 
can robustly and in a sustained manner, rescue the reduced inhibition of mucus movement 
caused by inhibition of CFTR function in the complex lung of this large animal. 
SPX-101 has not exhibited any test article-related respiratory, cardiovascular, or CNS 
effects, was well tolerated in two animal species (rats and dogs) when treated for 7-days and 
28-days with inhaled doses up to 9.4 and 12.4-times the starting human dose in the 
completed Phase I clinical study, and showed no evidence of mutagenic activity.  
Additional details on the nonclinical and pharmacology studies can be found in the IB. 
7.2.4 Clinical Studies 
The first human clinical study was a single-center, randomized, double-blind, placebo-
controlled Phase 1 trial to evaluate the safety and PK profile of inhaled SPX-101 
administered via nebulizer to 64 healthy adults in a domiciled clinic setting to ensure 
continuous monitoring of subject safety. The study was conducted in two parts, as a single 
ascending dose (SAD) phase comprising 4 escalating dose cohorts (Part 1) and as a multiple 
ascending dose (MAD) phase comprising 4 escalating dose cohorts (Part 2). In each part of 
the study, 32 subjects were randomized in a 3:1 ratio to SPX-101 or placebo. In the MAD 
portion of the study, subjects took SPX-101 or matching placebo twice daily for 14 days. 
The SAD portion of the trial demonstrated that SPX-101 at all doses tested (20 mg to 
240 mg) were safe and well-tolerated. All subjects completed the study, and there was no 
evidence of significant or adverse findings in any parameter. Observed plasma 
concentrations of SPX-101 were limited to the highest dose (240 mg) and detected in 4/6 
subjects and only at the 5-minute postdose timepoint.  
The MAD portion of the trial has also demonstrated that the range of doses taken, from 
10 mg twice daily (BID) for 14 days to 120 mg BID for 14 days, were safe and well 
tolerated. All 32 subjects completed the study as planned (no treatment withdrawals) and 
there have been no severe adverse events (AEs), serious adverse events (SAEs), or 
significant or notable changes in any safety parameters. There were no measurable plasma 
concentrations in any subject at any time point. 
Additional details of this study are provided in the IB.  


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
7.3 Clinical Study Rationale 
The unmet medical needs of patients with CF remain substantial with no available treatments 
that prevent the irreversible pulmonary damage associated with recurrent infections. 
Consequently, life expectancy remains limited to 30 to 40 years of age and quality of life 
decreases rapidly with advancing age. Although new treatments can be made available only 
through clinical trial data, the small population of patients with CF results in 
under-enrollment and delayed development of new treatments [14] Preclinical pharmacology 
data supported by the absence of dose-limiting toxicity in animal studies and good safety and 
tolerability in healthy adults indicate a high probability that SPX-101 will have an important 
impact on patients with CF, with the potential for disease-modifying effects on the lung. 
Therefore, this study has been designed to maximize scarce clinical research resources and 
optimize the availability of patients for clinical trials of other products that are currently in 
clinical development. Moreover, this study will avoid wasteful assessments of doses that are 
unlikely to be clinically important. This goal will be achieved by initially assessing dosing 
regimens in the middle of the dose range that has been shown to be safe and well tolerated in 
adults, as well as a higher dose. A cohort with lower doses will then be studied only if 
deemed appropriate to address regulatory requirements to describe the dose-response 
relationship prior to initiation of pivotal efficacy and safety studies.  
7.3.1 Rationale for Cohort 1 Dosages 
Specifically, the initial dose of 60 mg BID is at the midpoint of the dose range previously 
studied (20 to 120 mg BID) in adults. An additional dose of 120 mg BID was included in the 
first cohort to ensure that a scientifically sound decision could be made, driven by scientific 
data with regard to the future development of the drug. To optimize the opportunity to make 
this potential treatment available to patients, this protocol allows flexibility to adjust the 
dosing regimens in the second cohort to reflect the experience of the first cohort, but was not 
to exceed the total daily dose range approved for the first cohort (see Table 4). 
7.3.2 Rationale for Cohort 2 Dosage 
In Cohort 1, a total of 45 adult subjects with cystic fibrosis were treated with one of two 
doses of SPX-101 (60 mg BID and 120 mg BID) or matching placebo, and 40 subjects 
completed the study. 
The SPX-101 120 mg BID group demonstrated an improvement in the primary endpoint, 
trough ppFEV1 at day 28, (least squares mean difference from placebo ± standard error) of 
3.08 ± 2.411; p = 0.21 for the SPX-101 60 mg BID group and 5.19 ± 2.606; p = 0.05 for the 
SPX-101 120 mg BID group (source: Table 14.2.1.1). 
SPX-101 was well tolerated in both dose groups with no dose-limiting toxicity observed. 
There were no deaths in the study. Two subjects had serious adverse events (SAEs); one 
subject had tachycardia and one subject had cough and dyspnea, and both subjects were in 
the SPX-101 120 mg BID group. Treatment-emergent adverse events (TEAEs) were reported 
for 71.4%, 66.7%, and 75.0% of subjects in the placebo, SPX-101 60 mg BID, and SPX-101 
120 mg BID treatment groups, respectively. TEAEs that coded to the Medical Dictionary for 
Regulatory Activities (MedDRA) System Organ Class of Respiratory, Thoracic, and 


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
Mediastinal Disorders were reported for 35.7%, 53.3%, and 43.8% of subjects in the placebo, 
SPX-101 60 mg BID, and SPX-101 120 mg BID treatment groups, respectively. Although 
more respiratory TEAEs were reported for subjects on active treatment than placebo, the 
most commonly reported respiratory TEAEs were associated with the therapeutic effect of 
SPX-101: sputum increased was reported for 7.1%, 20%, and 12.5% of subjects in the 
placebo, SPX-101 60 mg BID, and SPX-101 120 mg BID treatment groups, respectively; and 
cough was reported for 0%, 26.7%, and 6.3% of subjects in the placebo, SPX-101 60 mg 
BID and SPX-101 120 mg BID treatment groups, respectively. The only pre-defined adverse 
event of special interest was hyperkalemia, which was not reported for subjects in any 
treatment group. Table 1 shows these results.  
Table 1 
Selected Adverse Events from Cohort 1 
 
Placebo BID 
SPX-101 60 mg 
BID 
SPX-101 120 mg 
BID 
All TEAEs 
71.4% 
66.7% 
75.0% 
 SOC: Respiratory, Thoracic, and 
Mediastinal Disorders 
35.7% 
53.3% 
43.8% 
 PT: Sputum Increased  
7.1% 
20% 
12.5% 
 PT: Cough 
0 
26.7% 
6.3% 
AESI (hyperkalemia) (n) 
0 
0 
0 
SAEs (n) 
0 
0 
2 
Fatal SAEs (n) 
0 
0 
0 
AESI = adverse event of special interest; BID = twice daily; PT = preferred term; SAE = serious adverse event; 
SOC = System Organ Class; TEAE = treatment-emergent adverse event 
Sources: Table 14.3.2.1, Table 14.3.2.8, Table 14.3.2.10 
In conclusion, the results of Cohort 1 showed evidence that the SPX-101 120 mg dose was 
associated with greater efficacy than the 60 mg BID. However, in view of the variability 
observed in the relatively small sample, it was decided that the second cohort should include 
additional subjects at the 120 mg BID dose level only. This decision is supported by the 
absence of dose-limiting safety concerns. 


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
8. 
STUDY OBJECTIVES  
8.1 Primary Objective 
 To evaluate the efficacy of SPX-101 in subjects with CF 
8.2 Safety Objectives 
 To evaluate the safety and tolerability of SPX-101 in subjects with CF 
8.3  Pharmacokinetic Objective (Cohort 1 Only) 
 To assess the extent of systemic exposure to SPX-101 in a subset of subjects 


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
9. 
INVESTIGATIONAL PLAN 
9.1 Overall Study Design and Plan  
Figure 1 shows the Cohort 1 design and Table 2 shows the schedule of events and 
assessments for both cohorts. Figure 2 shows Cohort 2, which is also a double-blind, 
placebo-controlled design to assess the safety and efficacy of SPX-101 120 mg BID as a 
regimen (see Table 4). 
 
Figure 1 
Study Diagram – Cohort 1 
 
 
BID = twice daily 


 
 
 
Page 27 of 76 
 
 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; 14 May 2018 
Figure 2 
Study Diagram – Cohort 2 
 
 
BID = twice daily


 
 
 
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 Protocol No. SPX-101-CF-201 
Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; xx May 2018 
Table 2 
Schedule of Events 
 
Screening  
Treatment Period 
FU 
Visit  
(Day) 
1 
 (-28 to -3) 
2 
(1) 
3 
(8-1) 
4 
(15 -2/+1)  
TC 
(22±3) 
5 
(29±2/ET) 
TC 
(31 ± 1) 
Informed consent 
X 
 
 
 
 
 
 
Eligibility 
X 
 
 
 
 
 
 
Randomizationa 
 
X 
 
 
 
 
 
Medical history and prior medications 
X 
 
 
 
 
 
 
Concomitant medications 
X 
X 
X 
X 
X 
X 
X 
Vital signsb 
X 
X 
X 
X 
 
X 
 
Weight, heightc, BMI 
X 
X 
 
 
 
X 
 
Physical examinationd 
X 
X 
X 
X 
 
X 
 
AE assessment 
 
X 
X 
X 
X 
X 
X 
Spirometrye 
X 
X 
X 
X 
 
X 
 
12-lead ECG 
X 
X 
 
 
 
X 
 
CFQ-R 
 
X 
 
 
 
Xf 
 
Hematology and serum chemistry including electrolytesg 
X 
X 
 
 
 
X 
 
ADA 
 
 
 
 
 
X 
 
Urinalysis 
 
X 
 
 
 
X 
 
Urine and blood electrolytes 
 
 
X 
X 
 
X 
 
Pregnancy testingh 
X 
X 
 
 
 
X 
 
Issue study nebulizer 
 
X 
 
 
 
 
 
IP administration in clinic  
 
X 
X 
X 
 
 
 
4-hr postdose monitoringi 
 
X 
 
 
 
 
 
Dispense IP 
 
X 
X 
X 
 
 
 
Cohort 1 only: Plasma PKj  
 
X 
 
 
 
 
 
Collect unused IP 
 
 
X 
X 
 
X 
 
Collect study nebulizer 
 
 
 
 
 
X 
 
ADA = antidrug antibodies; AE = adverse event; BMI = body mass index; CFQ-R = cystic fibrosis questionnaire revised; ECG = electrocardiogram; ET = 
early termination; FU = follow up; IP = investigational product; PK = pharmacokinetics; TC = telephone call 
a Only subjects who meet the randomization criteria at Visit 2 will be randomized (see Section 9.4.3).  
Footnotes continued on next page 


 
 
 
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Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; xx May 2018 
b Vital signs will include systolic and diastolic blood pressure, temperature, and heart rate. 
c Height will be measured only at the screening visit. 
d At Visit 1, a full physical examination of all body systems will be performed. At subsequent visits, an abbreviated physical examination (head, ears, eyes, nose, 
and throat; neck, respiratory, cardiovascular, and skin) may be performed. 
e At Visit 2, spirometry including forced expiratory volume in 1 second (FEV1), percent predicted FEV1, forced vital capacity (FVC) and percent predicted FVC 
will be evaluated pre-dose, and postdose at 30 minutes, 2 hours, and 4 hours. At all other visits, only pre-dose spirometry will be performed. 
f The CFQ-R will not be performed for subjects who are terminated early from the study 
g See Section 11.8 for specific laboratory tests to be performed.  
h At Screening (Visit 1), a serum pregnancy test will be performed; at Visits 2 and 5, a urine pregnancy test will be performed. 
i At Visit 2 only, the subject will be observed and monitored for at least 4 hours after completion of administration of the study drug. The subject may be 
discharged after 4 hours at the discretion of the Investigator (See Section 10.2).  
j For Cohort 1 only, at Visit 2, blood samples for PK testing will be collected pre-dose and at 5±2 minutes and 15±3 minutes after completion of administration 
of the study drug.  
Note: A subject may be re-screened once if they fail to meet randomization criteria for any reason. If this is the case, a new consent form must be signed, and a 
new screening number will be used.  


 
 
 
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Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; xx May 2018 
Table 3 shows the schedule and timing of events at Visit 2 (Randomization Visit; Day 1). 
The order of procedures in the table is the suggested approximate order in which the 
procedures should be carried out. 
Table 3 
Visit 2 (Randomization Visit) Schedule of Events 
 
Pre-Dose 
Dosing 
After Completion of Administration of Study Drug 
 
 
IP 
Dosing 
5 min  
(±2 m) 
15 min 
(±3 m) 
30 min 
(±15 m)  
1 hr 
(±15 m)  
2 hrs 
(±15 m) 
4 hours 
(±15 m)  
CFQ-R 
X 
 
 
 
 
 
 
 
Confirm 
randomization 
criteriaa are met, 
including the 
following: 
X 
 
 
 
 
 
 
-AE assessmentb 
X 
 
 
X 
X 
X 
X 
-Concomitant 
medications 
X 
 
 
 
 
 
 
-Spirometryc 
X 
 
 
X 
 
X 
X 
-Urine collected for 
electrolytes and 
pregnancy test 
X 
 
 
 
 
 
 
-Urine pregnancy test 
X 
 
 
 
 
 
 
Vital signsd 
X 
 
 
X 
X 
X 
X 
Brief physical exame, 
weight and BMI 
X 
 
 
 
 
 
 
12-lead ECG 
X 
 
 
 
 
 
 
Blood collected for 
hematology and 
serum chemistry 
including electrolytes 
X 
 
 
 
 
 
 
Randomization 
X 
 
 
 
 
 
 
Issue nebulizer 
X 
 
 
 
 
 
 
Administration of IPf 
 
X 
 
 
 
 
 
 
Cohort 1 only: Blood 
collected for PKg 
X 
 
X 
X 
 
 
 
 
Confirm subject may 
be discharged from 
clinic 
 
 
 
 
 
 
X 
Dispense IPh  
 
 
 
 
 
 
X 
AE = adverse event; BMI = body mass index; CFQ-R = Cystic Fibrosis Questionnaire – Revised; 
ECG = electrocardiogram; IP = investigational product; min/m = minutes; PK = pharmacokinetics 
a See Section 9.4.3 for a list of randomization criteria. 
b The Investigator or designee will ask the subject about any symptoms that could indicate an AE during the 
time vital signs are being collected postdose. Additional assessments are not required for the study but may be 
done at the discretion of the Investigator. 
Footnotes continued on next page 


 
 
 
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Global Version 4.0; xx May 2018 
c Spirometric parameters to be recorded include forced expiratory volume in 1 second (FEV1), percent predicted FEV1, 
forced vital capacity (FVC), and percent predicted FVC.  
d Vital signs include systolic and diastolic blood pressure, heart rate, and temperature. 
e The abbreviated physical examination should include at a minimum, the following organs or systems: head, ears, eyes, 
nose, and throat; respiratory; cardiovascular; and skin. Additional systems may be evaluated at the discretion of the 
Investigator. 
f The time of completion of administration of the study drug nebulizer treatment is defined as Time 0, and this time will be 
the reference for the timing of all postdose assessments and procedures.  
g PK analysis applies only to Cohort 1.  
h The Investigator or designee should issue a enough study drug to allow for BID administration until the date of the 
subject’s next clinic visit. 
Note: The Investigator or designee should provide education and instructions to the subject throughout the visit regarding 
study details, subject responsibilities, nebulizer use and care, timing of study drug and concomitant medications, study drug 
storage, procedures to be followed in case of a pulmonary exacerbation or emergency, and any other pertinent information


 
 
 
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Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; xx May 2018 
9.2 Discussion of Study Design 
This randomized, double-blind, placebo-controlled study is designed to evaluate the efficacy 
and safety of inhaled SPX-101 at a range of doses in adult subjects with CF in 2 cohorts.  
Randomization in the first cohort was stratified by the Baseline (Visit 2) ppFEV1 (40.0% to 
55.0% versus 55.1% to 80.0%).  
Randomization in the second cohort will be stratified according to the use of concomitant 
hypertonic saline (defined as having used a constant regimen for 28 days prior to screening 
and planning to continue their usual concentration without change for 28 days post-
randomization) so that approximately 50% of subjects will be using concomitant hypertonic 
saline.  
In Cohort 1, subjects were randomized to receive either placebo BID, SPX-101 60 mg BID, 
or SPX-101 120 mg BID for 28 days. After the Cohort 1 data were complete, unblinded, and 
analyzed, the DSMB evaluated the safety results, and Spyryx, in conjunction with the 
DSMB, reviewed the efficacy results to determine the appropriate dosage for Cohort 2.  
Cohort 2 will have the same design as Cohort 1; subjects will be randomized in a 2:1 ratio to 
either SPX-101 120 mg BID or placebo BID. 
9.3 Study Duration 
Subjects will enter a screening period of up to 28 days before randomization. Randomized 
subjects will be in the study for 28 days, with a follow-up phone call approximately 2 days 
later. The end of the study is defined as the date of the last data recorded, eg, the follow-up 
phone call at Day 31 or an unscheduled phone call, whichever is later.  
9.4 Study Population 
Subjects who satisfy eligibility criteria at the Screening Visit (Visit 1), and meet all the 
randomization criteria at Visit 2 will be eligible to enroll in the study. A subject may be re-
screened once if they fail to meet the screening or randomization criteria. If this occurs, a 
new consent form must be signed, and a new screening number will be used. 
9.4.1 Inclusion Criteria 
Subjects must satisfy all of the following inclusion criteria before they will be allowed to 
participate in the study: 
1. Ability to provide written, personally signed, and dated informed consent to 
participate in the study, in accordance with the ICH GCP Guideline E6 and applicable 
regulations, before completing any study-related procedures 
2. Ability and willingness (in the judgment of the Investigator) to attend study visits and 
fully comply with study procedures and restrictions; each subject’s study visits will 
occur at approximately the same time of day throughout the study and under specified 
conditions with respect to daily respiratory clearance and medication regimens 
3. Ability to self-administer the investigational product 
4. Male or nonpregnant, nonlactating female subjects aged 18 to 50 years inclusive  


 
 
 
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Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; xx May 2018 
5. Diagnosis of cystic fibrosis as determined by the 2008 Cystic Fibrosis Foundation 
Consensus Guidelines for Diagnosis [1], defined as the presence of clinical signs and 
symptoms of CF in conjunction with at least 1 of the following: 
a. Documented sweat chloride test result ≥ 60 mEq/L by quantitative pilocarpine 
iontophoresis 
b. Two well-characterized, disease-causing genetic mutations in the CFTR gene; 
the original documentation of genetic testing is not required if the specific 
mutations are documented in the subject’s medical record. 
6. ppFEV1 as follows:  
a. Cohort 1: between 40.0% and 80.0%  
b. Cohort 2: between 50.0% and 80.0% 
Note: spirometry must be performed in accordance with American Thoracic 
Society (ATS)/European Respiratory Society (ERS) end-of-test criteria and 
the Global Lung Initiative (GLI) predicted values [2; 3] 
7. Stable CF lung disease, defined as no pulmonary exacerbation or acute upper or 
lower respiratory illness other than CF within 28 days preceding screening, except for 
allergic or nonallergic rhinitis; in addition, subject must not have had any of the 
following:  
a. Significant hemoptysis (at the discretion of the Investigator) within 28 days of 
screening 
b. Pneumothorax within 28 days of screening 
c. Diagnosis of active allergic bronchopulmonary aspergillosis (at the discretion 
of the Investigator)  
d. Documented colonization with Burkholderia cenocepacia or Mycobacterium 
abscessus within 6 months prior to screening; subjects with other infections in 
the Burkholderia or Mycobacterium genii are allowed at the discretion of the 
Investigator. 
8. No significant changes (removal or addition of medications) to inhaled or oral CF 
medication regimen within 28 days preceding screening, and no anticipation of need 
to change this regimen during study participation; short courses of medications used 
to address an ongoing medical problem are allowed, provided the last dose of such 
medication was taken > 28 days before screening; subjects for whom a significant 
change in medication is anticipated during the study will be excluded. Specific 
requirements for ongoing concomitant medications are below: 
a. Inhaled antibiotic use: stable antibiotic medication, defined as at least 
2 complete 28-day cycles of intermittent monotherapy (if alternating month 
on and month off with a single inhaled antibiotic) or 2 full cycles if 
continuous alternating every 28 days between 2 inhaled antibiotics 
b. Dornase alfa: stable use of daily or intermittent dosing for at least 28 days 
before screening 
c. Inhaled bronchodilators: stable dose for at least 28 days before screening 
d. Inhaled hypertonic saline: stable dose for at least 28 days before screening 


 
 
 
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Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; xx May 2018 
9. Other concomitant medications may be taken during the study, provided the dose and 
regimen have been stable for at least 14 days before screening, and the regimen is 
expected to remain stable during the study.  
10. Stable chest physiotherapy and clearance techniques for at least 28 days before 
screening, including chest percussion, use of vibrating vests, etc 
11. All female subjects of childbearing potential must be using a highly effective method 
of contraception through the duration of the study as follows:  
a. Female subjects with childbearing potential must not be pregnant, 
breastfeeding, or attempting to become pregnant for 28 days before screening, 
throughout the duration of the study, and for 28 days after the last study visit. 
Subjects must have a negative serum pregnancy test at screening, a negative 
urine pregnancy test at randomization, and be willing to commit to using a 
consistent and acceptable method of contraception for at least 28 days before 
screening and for the duration of the study, if they are (or become) sexually 
active. Female subjects of childbearing potential must meet at least 1 of the 
following:  
i. Consistent use of systemic contraception, including birth control pills, 
transdermal patch, vaginal ring, implants, and injectables 
ii. Consistent use of double barrier method, eg, condoms, cervical cap, 
diaphragm, vaginal contraceptive film with spermicide 
iii. Use of intrauterine device with the low failure rate (defined as < 1% 
risk of pregnancy per year) 
iv. Monogamous intercourse with a vasectomized man or has only same-
sex partners 
v. Female subjects who are not sexually active but become so during the 
study must agree to follow the contraceptive requirements above 
b. Female subjects who are not of childbearing potential must meet at least 1 of 
the following criteria:  
i. At least 1 year since the last menstrual period 
ii. Surgically sterile (tubal ligation, bilateral oophorectomy, 
salpingectomy, or hysterectomy) 
iii. Congenitally sterile 
iv. Diagnosed as infertile and not undergoing treatment to reverse 
infertility 
9.4.2 Exclusion Criteria 
If any of the following apply, the subject must not enter the study: 
1. BMI < 18 kg/m2 
2. Use of a CFTR corrector or potentiator during the study or within 60 days before 
screening 
3. The presence of significant and unstable comorbidities (based on the Investigator’s 
judgment) within 28 days before screening, including diabetes, significant renal or 


 
 
 
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Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; xx May 2018 
hepatic disease, significant respiratory disease other than CF, cardiac, neurological, 
or gastrointestinal disease other than those associated with CF. Subjects with stable 
co-morbidities associated with CF (such as diabetes) may participate per the 
Investigator’s judgment unless specifically prohibited elsewhere. 
4. Subjects with either of the following:  
a. Hepatic impairment defined by elevation of bilirubin > 2 times the upper limit 
of normal (ULN) or aspartate aminotransferase, alanine aminotransferase, or 
alkaline phosphatase results > 5 times the ULN  
b. Chronic hepatitis B and/or C 
5. History of malignancy in the previous 5 years; subjects who have been successfully 
treated for non-melanoma skin cancer, cervical cancer, or prostate cancer within the 
previous 5 years are allowed to enroll with the approval of the Medical Monitor 
6. Administration of another investigational drug within 28 days before screening 
7. Administration of a vaccination (including influenza) within 7 days before screening 
8. Requirement for supplemental oxygen more than 2 L/min and/or noninvasive 
ventilation for the management of respiratory failure; subjects must have been on a 
stable regimen for at least 60 days before screening; (patients who have been using a 
stable regimen of oxygen ≤ 2 L/min for at least 60 days before screening are eligible 
to enroll) 
9. Current use of tobacco or tetrahydrocannabinol-containing products, delivered orally, 
by vaporizing, or by smoking; or a greater than 10 pack-year history of tobacco use 
10. Actively listed for lung transplantation  
11. Any history of organ transplantation 
12. Hospitalization for a respiratory event or CF-related condition within 28 days before 
screening or any plans for hospitalization for any reason during the study 
13. Current use of > 10 mg/day of prednisone/prednisolone (≤ 10 mg/day is acceptable) 
14. Use of any of the following antihypertensive medications or combinations containing 
these medications: diuretics (eg, thiazides, loop diuretics, spironolactone, and 
amiloride), angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, 
or any other drugs known to affect the serum potassium concentration 
15. Hypersensitivity to the study drug or any of its excipients 
16. Subjects with significant electrocardiogram (ECG) abnormalities at screening or 
before the first dose on Day 1, including a prolonged QT interval corrected by the 
Fridericia correction formula (QTcF; ≥ 440 msec in men and ≥ 460 msec in women) 
9.4.3 Randomization Criteria (Assessed at Visit 2) 
On Day 1 of the study, after completion of the screening period, the following criteria will be 
assessed to determine subject eligibility for randomization: 
1. Continue to meet the entrance criteria 
2. Negative serum (Visit 1) and urine (Visit 2 pre-randomization) pregnancy test result 
for all female subjects of childbearing potential 


 
 
 
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Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; xx May 2018 
3. Stable FEV1 at Visit 2 defined as FEV1 within ± 15% of the relative change between 
the Visit 1 and Visit 2 best FEV1. Relative change is defined as follows:  
 
FEV1 (Screening; Visit 1) ˗ FEV1 (Visit 2)  
FEV1 (Screening; Visit 1) 
 
4. No new intervening illnesses since Screening (Visit 1), and the subject’s CF is still 
stable in the judgment of the Investigator 
5. No clinically significant laboratory or ECG abnormalities that pose a significant risk 
to the subject, per the judgment of the Investigator  
Note: A subject may be re-screened once if they fail to meet randomization criteria for any 
reason. If this is the case, a new consent form must be signed, and a new screening number 
will be used. 
9.4.4 Withdrawal and Replacement of Subjects 
9.4.4.1 Criteria for Subject Withdrawal 
In accordance with the Declaration of Helsinki (see Appendix 1, Section 18.1) and other 
applicable regulations, a subject has the right to withdraw from the study at any time and for 
any reason without prejudice to his or her future medical care by the physician or at the 
institution. 
Subjects may also be withdrawn from the study for any of the following reasons: 
 A female subject becomes pregnant (See Section 12.6 for details on pregnancy 
reporting requirements) 
 The Investigator may decide that the subject should be withdrawn. If this decision is 
made because of an intolerable AE or a clinically significant abnormality of a 
laboratory value, the study medication is to be discontinued and appropriate measures 
are to be taken. The Sponsor or Sponsor designee is to be notified immediately. 
 The subject is unwilling to continue in the study. 
 The Investigator stops participating in the study or the Sponsor, for any reason, stops 
the study. 
 The subject or the Investigator decides it in the best interest of the subject to seek 
another treatment. 
 The subject fails to return to the clinic for scheduled visits and does not respond to 
attempts at communication. 
The reason for withdrawal will be recorded in the clinical records and the electronic case 
report form (eCRF). All subjects who prematurely discontinue the study treatment will 
undergo an early termination visit (see Section 10.6). Subjects who are withdrawn from the 
study will not be replaced. All subjects who are withdrawn or discontinue should be offered 
other approved medical care. 
× 100 


 
 
 
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Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; xx May 2018 
9.4.4.2 Evaluations at Withdrawal 
For any subject who is withdrawn before completing all study visits, the Investigator should: 
 Perform the procedures included in the early termination visit (see Section 10.6) 
These assessments should be performed as soon as possible after the last 
administration of the study drug, but in any case, will be performed no later than 
14 days after withdrawal or discontinuation of the study treatment. 
 Complete all appropriate eCRF pages, providing the date of and explanation for 
the subject’s withdrawal/discontinuation. 
 When indicated, arrange for appropriate medical follow-up care for the 
discontinued subject.  
If the subject fails to attend the scheduled early termination visit, the Investigator or designee 
will make at least 2 attempts to contact the subject by telephone. If the subject does not 
respond, s/he will be considered lost to follow up. 
9.4.4.3 Termination of the Study by the Sponsor 
The study may be prematurely terminated at any time at the discretion of Spyryx. Should 
premature termination be considered necessary, written notification documenting the reason 
for study termination will be provided to the appropriate Regulatory Authorities and 
IEC/IRBs, and procedures for termination of the study will be arranged. Circumstances that 
may warrant premature study termination include, but are not limited to, the following 
examples: 
 Determination of unexpected, significant, or unacceptable risk to subjects 
 Failure to accrue subjects at an acceptable rate 
 Insufficient adherence to the requirements of the protocol 
 Insufficient provision of complete and evaluable data 
 Plans to modify, suspend, or discontinue development of the study drug 
If the study is terminated prematurely, all study materials must be returned to Spyryx or its 
designee. 
9.4.4.4 Replacement of Subjects 
Subjects who are withdrawn will not be replaced. However, a sufficient number of subjects 
will be included to ensure the minimum sample size defined (see Section 13.2). 
9.5 Treatment 
9.5.1 Treatments Administered 
The Investigator must ensure that the study drug and investigational PARI eFlow nebulizer 
with PARI eTrack will be used in accordance with the protocol, and must instruct subjects 
that the study drug must be administered only with the study nebulizer and that all other 
inhaled medications must be administered with the subject’s regular nebulizer. 
Table 4 shows the planned dispensing of study medication for Cohort 1 and Cohort 2 .


 
 
 
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Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; xx May 2018 
Table 4 
Planned Study Medication Dosing for Cohort 1 and Cohort 2 
Cohort 
Placebo Group 
SPX-101 – Dose Group 1 
SPX-101 – Dose Group 2 
 
Dosage 
How each dose 
is supplied 
Total 
volume 
Dosage 
How each dose is 
supplied 
Total 
volume 
Dosage 
How each dose is 
supplied 
Total 
volume 
1 
Placebo BID 
2 vials placebo 
in the a.m. and 
the p.m. 
2 mL 
60 mg BID 
1 vial 60 mg/mL and  
1 vial placebo in the 
a.m. and the p.m. 
2 mL 
120 mg BID 
2 vials 60 mg/mL in 
the a.m. and the p.m. 
2 mL 
2 
Placebo BID 
2 vials placebo 
in the a.m. and 
the p.m. 
2 mL 
120 mg BID 
2 vials 60 mg/mL in 
the a.m. and the p.m. 
2 mL 
BID = twice daily 


 
 
 
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Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; xx May 2018 
9.5.2 Study Treatment Formulation 
The SPX-101 drug product is an aqueous, aseptically filled inhalation solution prepared by 
dissolving 20 mg or 60 mg peptide in 1 mL 0.9% sodium chloride, adjusting to pH 7, and 
sterile filtering into sterile glass vials that are then stoppered, sealed, and labeled. SPX-101 
contains no excipients. Drug product purity and nebulized droplet size distribution studies 
have been conducted at multiple concentrations and pH levels. Each vial of drug product will 
have a 1-mL fill in a 2-mL vial. The maximum anticipated dose is 240 mg/day, which could 
be achieved as a single 4-mL inhalation QD or a 2-mL inhalation BID. 
The placebo is 0.9% sodium chloride, pH adjusted to 7 and filtered for sterility into sterile 
glass vials that are then stoppered, sealed, and labeled, with a 1-mL fill in a 2-mL vial. Table 
5 shows some details about the study drug and placebo. 
Table 5 
Investigational Medicinal Products 
Product name 
SPX-101 
Placebo 
Dosage Form 
Solution for oral inhalation 
Solution for oral inhalation 
Unit Dose 
60 mg/mL  
(1 mL in a 2-mL vial) 
--- 
Route of 
Administration 
Oral inhalation by Investigational 
eTrack nebulization device 
Oral inhalation by Investigational 
eTrack nebulization device 
Physical Description 
Clear, sterile solution for 
inhalation consisting of 60 mg/mL 
of SPX-101 peptide in 0.9% 
sodium chloride adjusted to pH 7  
Clear, sterile solution for 
inhalation consisting of 0.9% 
sodium chloride adjusted to pH 7  
Storage Conditions 
Vials should be refrigerated at 2 -8º C 
Manufacturer of 
Drug Substance 
PolyPeptide Laboratories 
9395 Cabot Drive 
San Diego, CA 92126 
Manufacturer of 
Drug Product 
Ajinomoto Althea 
11040 Roselle Street 
San Diego, CA 92121 
 
9.5.3 Study Treatment Labeling and Packaging 
Both the investigational product and placebo will be supplied and labeled in accordance with 
the applicable regulatory requirements. The labeling will include the following information 
in the official language of the country in which the study drug is to be used: 
The primary packaging label (vials) will include at least the following information except as 
mandated by individual country requirements:  
 
Pharmaceutical dosage form, route of administration, and quantity of dosage units  
 
A blinded batch and/or code number that will link the contents and packaging operation  
 
Protocol number 
 
Kit number 
 
An expiration or “use by” date in a non-ambiguous format 


 
 
 
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Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; xx May 2018 
 
Subject ID number (write in) 
 
Site/Investigator name (write in) 
The secondary packaging label (container for the vials) should contain all the same 
information as on the primary packaging label plus at least the following information:  
 
Directions for use or reference to separate instructions to be provided to the subject 
 
“Investigational Product - For clinical trial use only” or similar wording 
 
Storage conditions (2° to 8° C or 35° to 45°F) 
 
An expiration or “use by” date in a non-ambiguous format 
 
“Keep out of reach of children” 
 
Name and address of the Sponsor 
 
EudraCT number (EU sites only) 
For Cohort 1, to reduce the risk of inadvertent unblinding, half the vials issued to each 
subject were labeled to indicate the morning dose, and half were labeled to indicate the 
evening dose. This strategy helped ensure that subjects, the Sponsor, Investigators, site staff 
members, and other study participants remained blinded to the study medication. 
9.5.4 Blinding of Study Medication 
This is a randomized, double-blind, placebo-controlled study. The investigational medicinal 
product and placebo will be identical in physical appearance. The treatment each subject will 
receive will not be disclosed to the Investigator, study center personnel, subject, or Sponsor. 
The treatment codes will be held according to the interactive web response system (IXRS). 
Bioclinica will provide the IXRS services and further instructions such emergency 
unblinding procedures will be provided in a separate IXRS manual. By logging into the 
IXRS system, Investigators will be able to unblind the treatment of any subject, should that 
be warranted. The Investigator is encouraged but not required to consult with the PRA 
Medical Monitor or the Sponsor prior to unblinding. 
9.5.5 Study Treatment Storage and Accountability 
The investigational drug and study supplies must not be used for purposes other than as 
defined in this protocol. 
9.5.5.1 Study Treatment Storage 
SPX-101 and the placebo are to be stored at 2° to 8°C. Investigators must store the study 
drug in a secure location, and must implement a temperature monitoring method for the 
refrigerator in which the study drugs are stored. The product remains stable with no 
significant increase in impurities for up to three months at 25°C, indicating that temporary 
excursions to room temperature will not alter the purity.  
9.5.5.2 Study Treatment Accountability 
All supplies of study medication and placebo will be accounted for in accordance with GCP. 
There will be an individual study drug accountability record for each subject and the 
Investigator will maintain accurate records of the disposition of all study medication supplies 
received during the study. These records will include the amounts and dates clinical drug 
supplies were received and then dispensed to the subject, and unused supplies returned by the 


 
 
 
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Phase II Study of SPX-101 in Subjects with Cystic Fibrosis 
Global Version 4.0; xx May 2018 
subject to the Sponsor. If errors or damages in the clinical drug supply shipments occur, the 
Investigator will contact the study monitor and the Sponsor immediately. Copies of the study 
medication accountability records will be provided by each Investigator for inclusion in the 
Trial Master File after database lock. The study monitor will periodically check the supplies 
of study medication held by the Investigator or pharmacist to verify accountability of all 
medication used. 
The Investigator will dispense the medication only to the identified subjects in this study, 
according to the procedures described in this study protocol. After the end of the study, all 
unused medication and all medication containers will be returned to Spyryx Biosciences, Inc. 
or its designee for destruction. The Sponsor will verify that a final report of drug 
accountability is prepared and maintained in the Investigator’s Study Center File. 
9.5.6 Dose Adjustments and Dose Escalation 
Not applicable to this study 
9.5.7 Prior and Concomitant Therapy 
Any treatment not explicitly excluded and considered necessary for the subject’s welfare 
may be given during the study at the discretion of the Investigator. Administration of 
concomitant medications must be reported in the appropriate eCRF with dosage information, 
dates of administration, and reasons for use. Generic names for concomitant medication 
should be used if possible. The total daily dose should be filled in whenever possible.  
Randomization (Day 1) and initiation of study drug should be scheduled to coincide with the 
first day of a cycle of inhaled antibiotics, if applicable. If simultaneous initiation of the study 
drug and inhaled antibiotics cannot be accommodated, the subject may be randomized, 
provided they start their 28-day cycle within ± 3 days of Visit 2.  
In general, the subject’s usual routine of medication and chest physiotherapy are to be 
continued unchanged throughout the study. The study drug should be added into the subject’s 
treatment regimen as the last mucolytic therapy inhaled (ie, after inhalation of dornase alfa, 
mannitol, and/or hypertonic saline) but before the inhalation of antibiotics or corticosteroids. 
The only exception to this rule is on the mornings of all clinic visits. The following 
procedures should be followed on clinic days only: 
 If a long-acting β-agonist (LABA) is taken regularly in the morning, instruct the 
subject to take it the evening prior to all clinic visits and not take it the morning until 
after all clinic assessments have been completed. 
 If a short-acting β-agonist (SABA) is taken regularly, the subject should ensure that it 
is taken at least 4 hours before the clinic visit. 
 The subject should be instructed not to take the morning dose of the study drug, but 
they should complete the regular routine of medications and chest physiotherapy at 
home (including inhaled antibiotics); the study drug will be administered during the 
clinic visit. 
9.5.7.1 Prohibited Medications 
Use of the following antihypertensive medications or combinations containing them is 


 
 
 
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prohibited within 28 days before screening and during the study:  
 Diuretics (eg, thiazides, loop diuretics, spironolactone, and amiloride) 
 Angiotensin-converting enzyme inhibitors 
 Angiotensin receptor blockers 
 Any other drugs known to affect the serum potassium concentration 
9.5.8 Treatment Compliance 
It is the Investigator’s responsibility to ensure that subjects are correctly instructed about 
how to take their study medication and use the PARI eFlow nebulizer with PARI eTrack, and 
understand the importance of being compliant with their assigned dose regimen. Records of 
study medication used and intervals between visits will be kept during the study. Drug 
accountability will be noted by the study monitor during site visits and at the completion of 
the study. Subjects will be asked to return all unused medication at the end of the study. 
Subjects should be instructed to discard used medication vials at home as the vials are used, 
to reduce the risk of infection. The study treatment should be dispensed by the Investigator, 
or by a qualified individual under the Investigator’s supervision. The Investigator must 
maintain an up-to-date treatment inventory and dispensing record (see Section 9.5.5.2). 
At each visit, the Investigator will collect previously dispensed, unused study medication and 
assess compliance. Subjects exhibiting poor compliance should be counseled on the 
importance of complying with study procedures. Subjects who are persistently noncompliant 
may be withdrawn from the study but only after consultation with the Medical Monitor. 
Where available, study drug compliance will be assessed electronically via a Bluetooth 
accessory called eTrack on the PARI eFlow investigational nebulizer. This monitor will 
capture the date and time of use of the investigational nebulizer. Subjects will be made aware 
of this feature and provided with the equipment and instructions to set this up for use in their 
home. Study coordinators will be expected to monitor study drug usage and intervene via 
phone call, etc. if there are any obvious problems (such as using the nebulizer too much, too 
little, etc). 
9.5.9 Assignment to Treatment 
The Investigator or designee will use IXRS to randomize eligible subjects. Randomization 
for Cohort 1 was stratified by the Visit 2 pre-dose ppFEV1 (between 40.0% and 55.0% vs 
between 55.1% and 80.0%). Randomization for Cohort 2 will be stratified by use of 
concomitant hypertonic saline (defined as having used a constant regimen for 28 days prior 
to screening and planning to continue with no change through 28 days post-randomization), 
so that approximately 50% of subjects will be using hypertonic saline. Only those subjects 
who have met the randomization criteria (Section 9.4.3) will be eligible for assignment to 
study treatment. Subjects who fail to meet the randomization criteria may have Visit 2 
repeated once, or they will be considered a screen failures. 
9.5.10 Unblinding Procedures 
Within the IXRS system, the Investigator may break the blind by clicking on the “Break 
Blind” button. The Investigator will then be prompted to enter either the Kit ID number or 


 
 
 
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Subject ID number and select “next.” The Investigator will then be prompted to confirm the 
blind should be broken. After selecting “Yes,” the Investigator will be prompted to enter a 
reason for breaking the blind. Once a reason has been properly entered, a warning will 
appear and once again the Investigator will select “confirm” and then will be prompted to 
enter the appropriate IXRS user password. The Investigator will then confirm this selection 
and the subject information with the unblinding data will be displayed. Additional 
procedures for unblinding in case of emergency will be detailed in the IXRS manual. See 
Appendix 5 (Section 18.5) for more details. 
9.6 Efficacy and Safety Variables 
9.6.1 Efficacy and Safety Measurements Assessed 
9.6.1.1 Efficacy Variables 
 Primary 
o Change from baseline in ppFEV1 at Week 4 
 Secondary 
o Change from baseline in ppFEV1 at other visits 
o Change from baseline in FEV1  
o Change from baseline in FVC and ppFVC  
o Change from baseline in CFQ-R 
9.6.1.2 Safety Variables 
 Incidence of treatment-emergent AEs 
 Changes in vital signs  
 Changes in clinical laboratory tests, including urine and blood electrolytes 
 Changes in ECGs 
9.6.1.3 Pharmacokinetic Variable (Cohort 1 Only) 
 Systemic exposure to SPX-101 (subset of subjects) 
9.6.1.4 Exploratory Variables 
 Incidence of pulmonary exacerbation, as defined by Fuchs [4] (See Appendix 3, 
Section 18.3 for details) 
 Incidence of antidrug antibodies (ADA) 


 
 
 
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10. 
STUDY EVALUATIONS BY VISIT 
10.1 
Visit 1: Screening (Day -28 to -3) 
There is a variable-length screening period of 3 to 28 days to the time of randomization so 
that the first dose of the study drug coincides, if applicable, to the first day of an inhaled 
antibiotic cycle. Additional information can be found in Section 9.5.7. 
At the Screening Visit, the following assessments/procedures will be performed in 
approximately the following general order: 
 Informed consent 
 Medical history 
 Previous and concomitant medications 
 Vital signs 
 Height, weight, BMI 
 Complete physical examination 
 Spirometry 
 12-lead ECG 
 Blood samples collected for hematology and serum chemistry tests and serum 
pregnancy test 
 Assessment of eligibility 
Note: Subjects may be re-tested once within 7 days to complete their eligibility assessments.  
10.2 
Visit 2: Day 1 (Randomization) 
10.2.1 Pre-Randomization Assessment 
 CFQ-R 
 AE assessment  
 Concomitant medications 
 Pre-dose spirometry 
 Urine collected for urinalysis, urine electrolytes, and urine pregnancy 
 Vital signs 
 Abbreviated physical examination 
 Weight and BMI 
 12-lead ECG 
 Blood collected for hematology and serum chemistry tests, including electrolytes and 
pre-dose sample for PK (Cohort 1 only) 
 Review randomization criteria to ensure eligibility  
Note: A subject may be re-screened once if they fail to meet the Randomization criteria for 
any reason. If this is the case, a new consent form must be signed, and a new screening 
number will be used.  
10.2.2 Randomization and Study Procedures 
 Randomization using IXRS 


 
 
 
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 The Investigator or designee will issue the eTrack study nebulizer and will train 
subjects on its use and all study procedures, and will review all instructional materials 
and ensure subjects understand all procedures and instructions 
 Study medication administration and postdose monitoring for at least 4 hours after 
completion of administration 
o Blood for PK analysis will be collected at 5 ± 2 minutes and 15 ± 3 minutes 
after completion of administration of the study drug (Cohort 1 only) 
o Post-dose spirometry at 30 (± 15) minutes, 2 hours (± 15 minutes), and 
4 hours (± 15 minutes) after completion of administration of the study drug 
o Vital signs at 30 (± 15) minutes, 1 hour (± 15 minutes), 2 hours 
(± 15 minutes), and 4 hours (± 15 minutes) after completion of administration 
of the study drug 
 Dispense study medication, nebulizer, and baby bottle sterilizer 
 Schedule the subject’s next visit and review instructions (See Appendix 4, Section 
18.4)  
If the subject experiences symptoms of acute bronchospasm following the first dose of 
study medication, the subject should be treated with SABAs or other treatment at the 
discretion of the Investigator and continued to be observed for at least 2 hours 
post-SABA or the 4-hour postdose timepoint, whichever is longer. If the subject’s 
bronchospasm has been relieved and the subject is stable for at least 30 minutes at the 
2-hour post-SABA or 4-hour postdose timepoint, the subject may continue in the trial at 
the discretion of the Investigator. If medically essential, the Investigator may elect to 
require that the subject be pre-treated with a SABA or other medication before every 
subsequent dose, or the PI may withdraw the subject from the study. If the subject 
requires pre-treatment with a SABA or other medication for subsequent doses, this drug 
will be recorded as a concomitant medication, and the bronchospasm will be reported as 
an AE. Additional follow-up procedures may be instituted at the discretion of the 
Investigator. 
10.2.3 Post-Randomization Visit Schedule 
Randomized subjects will return to the clinic after approximately 1, 2, and 4 weeks of 
treatment. Study drug consisting of an 8-day supply will be dispensed weekly to cover the 
period from Visit 2 to Visit 3 and again from Visit 3 to Visit 4. At Visit 4, a 2-week supply 
(2 boxes with an 8-day supply in each) will be dispensed to cover the period from Visit 4 to 
Visit 5. Sites must schedule subjects for Visit 3, 4, and 5 within the provided visit windows 
taking into account drug supply.  
10.3 
Visit 3: Day 8 (-1 Day) 
 Concomitant medications 
 AE assessment 
 Vital signs 
 Abbreviated physical examination 
 Pre-dose spirometry 
 Urine and blood samples collected for electrolytes 


 
 
 
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 Study drug administration  
 Dispense study drug 
 Collect unused study drug from previous visit 
 Schedule the subject’s next clinic visit and review instructions (Appendix 4, Section 
18.4) 
10.4 
Visit 4: Day 15 (-2/+1 Days) 
 Concomitant medications 
 AE assessment 
 Vital signs 
 Abbreviated physical examination 
 Pre-dose spirometry 
 Urine and blood samples collected for electrolytes 
 Study drug administration 
 Dispense study drug 
 Collect unused study drug from previous visit 
 Schedule the subject’s Week 3 telephone call and review instructions if needed 
(Appendix 4, Section 18.4) 
10.5 
Day 22 (± 3 Days): Telephone Contact 
 Concomitant medications 
 AE assessment 
 Schedule the subject’s next clinic visit and review instructions if needed (Appendix 4, 
Section 18.4) 
10.6 
Visit 5: Day 29 (± 2 Days) (Also the Early Termination Visit, If Applicable) 
 CFQ-R (not to be performed for subjects who discontinue early) 
 Concomitant medications 
 AE assessment 
 Vital signs 
 Weight and BMI 
 Abbreviated physical examination 
 Spirometry (the study drug will not be administered) 
 12-lead ECG 
 Blood samples collected for hematology and serum chemistry tests, including 
electrolytes  
 Blood sample collected for ADA testing 
 Urine samples collected for electrolytes, urinalysis, and urine pregnancy test 
 Urine pregnancy test performed 
 Collect study nebulizer and unused study drug from previous visit 
 Schedule the subject’s follow-up telephone call 


 
 
 
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10.7 
Follow-up Telephone Call: Day 31 (± 1 Day) 
 Concomitant medications 
 AE assessment 


 
 
 
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11. 
METHODS OF ASSESSMENT 
11.1 
Cystic Fibrosis Questionnaire - Revised 
At the Randomization Visit and at Week 4 (Visit 5) subjects will complete the respiratory 
and physical domains of the CFQ-R, and the Investigator or designee will record the data in 
the appropriate eCRF.  
11.2 
Pregnancy Testing 
Subjects who are pregnant will be excluded from the study. At the screening visit (Visit 1), 
blood will be collected for a serum pregnancy test. At the randomization visit (Visit 2) and at 
Visit 5, a urine pregnancy test will be performed. For more information about pregnancy-
related procedures and reporting, see Section 12.6. 
11.3 
Pulmonary Function Tests 
Spirometry will be performed at all clinic visits using equipment provided by the centralized 
spirometry vendor, Biomedical Systems (BMS). Spirometry will be performed in accordance 
with ATS/ERS guidelines and the GLI predictors of spirometric lung volume normal ranges 
[2; 3]. At Visit 2, spirometry will be performed pre-dose, and postdose at 30 minutes, 
2 hours, and 4 hours postdose after completion of administration of the study drug. At all 
other visits, only pre-dose spirometry will be performed. The following parameters will be 
recorded: 
 Absolute FEV1 and ppFEV1 
 Absolute FVC and ppFVC 
11.4 
Vital Signs and Weight  
Systolic blood pressure and diastolic blood pressure will be measured on the same arm 
(preferentially on the left arm) after the subject has been in a supine/sitting position for 
5 minutes. The heart rate will be recorded simultaneously with blood pressure measurements. 
The body temperature will also be recorded. On the first day of dosing, vital signs will be 
measured pre-dose, at 30 minutes and 1, 2, and 4 hours postdose.  
Body weight (kg) will be measured without shoes or jacket. Height will be measured at the 
Screening Visit to assess BMI. 
During the study, the measurement of vital signs may be repeated at the discretion of the 
Investigator for safety reasons. Clinically relevant abnormal findings will be reported as AEs. 
11.5 
Physical Examination 
Physical examinations will be performed by a physician or qualified designee and will 
include examination of the following: general appearance, head, ears, eyes, nose, throat 
(HEENT), neck, skin, cardiovascular system, respiratory system, abdomen, and nervous 
system (including a neurological examination; with an assessment of the reflexes, motor and 
sensory nerve assessment, sensory checks [extremities] and mental status assessment). At all 
visits after the Screening visit, the Investigator or qualified designee may perform an 
abbreviated physical examination, defined as a review of HEENT, neck, respiratory system, 
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For each body system, the Investigator will document any abnormalities and will provide an 
assessment of normal or abnormal on the eCRF. 
11.6 
Electrocardiogram 
Computerized 12-lead ECG recordings will be obtained, after the subject has been supine for 
5 minutes. Each lead will be recorded for at least 3-5 beats at a speed of 25 mm/sec paper 
speed and 10 mm/mV amplitude. At a minimum, heart rate and the P, PR, QRS, QT, and 
QTcF intervals will be obtained and entered into the eCRF. The Investigator will also 
evaluate whether the ECG is normal or abnormal, and if abnormal, whether the abnormality 
is clinically significant. A copy of all ECGs will be retained on site and may be collected for 
central review if required (ie, in case emerging ECG data necessitate expert evaluation). 
An ECG may be repeated for quality reasons and additional ECGs may be collected by the 
Investigator for safety reasons. Any clinically relevant abnormal findings noted at Screening 
will be exclusionary. Any clinically relevant abnormal findings after the first dose of the 
study drug will reported as AEs. Subjects with clinically relevant cardiovascular AEs (or 
clinically relevant ECG changes) must be withdrawn from the study (see Section 9.4.4). 
11.7 
Adverse Events and Pulmonary Exacerbation 
At each clinic visit, the Investigator or designee will ask the subject about any symptoms 
experienced since the previous contact to assess for AEs. The Investigator will also assess 
whether the subject had a pulmonary exacerbation since the previous visit, and if so, record it 
in the eCRF, complete the pulmonary exacerbation eCRF, and follow all procedures for 
reporting an AE or SAE. See Appendix 3, Section 18.3 for the Fuchs 1996 criteria for 
pulmonary exacerbation.  
On the first day of dosing, AEs will be assessed pre-dose, at 30 minutes, and 1, 2, and 
4 hours postdose. 
11.8 
Clinical Laboratory Testing 
Venous blood samples and urine samples will be collected for hematology and chemistry 
testing at study visits as outlined in Section 10.  
 Hematology: White blood cell count, red blood cell count, red blood cell indices, 
hemoglobin, hematocrit, platelet count, and a 5-part white blood cell differential 
(neutrophils, lymphocytes, monocytes, eosinophils, and basophils) 
 Clinical chemistry: Liver function tests (ALT, ALP, AST, and gamma 
glutamyltranspeptidase), electrolytes (sodium, potassium, chloride, and bicarbonate), 
total bilirubin, blood urea nitrogen, calcium, C-reactive protein, creatinine, glucose, 
lactate dehydrogenase, total protein, and albumin 
 Blood electrolytes: sodium, potassium, chloride, and bicarbonate 
 Urine electrolytes: sodium, potassium, and chloride 
 Urinalysis: pH, specific gravity, protein, glucose, and ketones 


 
 
 
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Routine laboratory tests will be performed by Eurofins Central Laboratories. Details about 
the procedures to be followed for sample collection, storage, and shipment will be provided 
in a Laboratory Manual.  
Additional and repeat laboratory testing may be performed at the discretion of the 
Investigator. 
11.9 
Blood Samples for Pharmacokinetic Testing (Cohort 1 Only) 
At Visit 2 only, venous blood samples were collected pre-dose and at 5 ± 2 minutes and 
15 ± 3 minutes after completion of administration of the study drug. Pharmacokinetic testing 
will be performed by QPS. Details about the procedures to be followed for sample collection, 
handling, storage, and shipment will be provided in a Laboratory Manual. 
11.10 
Blood Samples for Antidrug Antibody Testing 
At Visit 5 only, a venous blood sample will be collected for ADA testing, which will be 
performed by QPS. Details about the procedures to be followed for sample collection, 
handling, storage, and shipment will be provided in a Laboratory Manual. 


 
 
 
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12. 
SAFETY MEASUREMENTS AND VARIABLES 
12.1 
Adverse Events  
The definitions and reporting procedures provided in this protocol comply with the current 
CFR 21 Part 312. An AE is any untoward medical occurrence or worsening of a pre-existing 
condition, regardless of its relationship to the investigational medicinal product. An AE can 
therefore be any unfavorable or unintended sign, including an abnormal laboratory finding, 
symptom, or disease temporally associated with the use of an investigational medicinal 
product whether or not considered related to the product. Adverse events that are reported 
after signing the informed consent but prior to randomization, will be recorded in medical 
history. Adverse events that are reported after initiation of treatment up until the final study 
visit phone call on Day 31 will be considered TEAEs. Serious adverse events occurring at 
any time from informed consent to 28 days after the last dose of treatment with study drug 
will be reported. Subjects will be monitored for AEs throughout the entire study. 
Investigators will ask the subject at each visit if they have experienced any untoward effects 
since the last study visit. The Investigator or designee will record the following information 
about AEs on the eCRFs: an AE term or description of the event, severity, event start date, 
event end date (if known), any action (eg, treatment and follow-up tests), the outcome of the 
event, and the Investigator’s assessment of the relationship to the study treatment. 
Even if the Investigator feels there is no relationship to the study drug, all AEs must be 
recorded in the eCRF.  
12.2 
Serious Adverse Events  
An SAE is any untoward medical occurrence or effect that meets any of the following 
criteria: 
 
results in death; 
 
is life-threatening (refers to events during which a subject was actually at risk of death, 
and not to events that might have become life-threatening if they had occurred in a more 
severe form or if the subject had not received treatment); 
 
requires inpatient hospitalization (> 24 hours) or causes prolongation of existing inpatient 
hospitalization;  
 
results in a persistent or significant disability or incapacity; 
 
is a congenital abnormality/birth defect in the offspring of a study subject; 
 
is an important medical event that does not meet any of the above criteria but may require 
medical intervention to prevent one of the outcomes listed above, or is considered 
medically important by the Investigator; examples of important medical events include: 
o Bronchospasm requiring treatment in the emergency department or at 
home 
o Development of a blood dyscrasia 
o Diagnosis of a substance use disorder 


 
 
 
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12.3 
Reporting of Serious Adverse Events 
On behalf of Spyryx Biosciences, Inc, PRA Drug Safety will be managing SAE processing 
and reporting to regulatory authorities, as required by local regulations. 
In addition to completing all eCRFs related to SAEs, Investigators must report all SAEs to 
PRA Drug Safety within 24 hours after learning about the event. PRA Drug Safety contact 
information is provided below:  
PRA Drug Safety Contact Information:  
European Investigative Sites: 
 
Drug Safety Helpline: +49 621 878 2154 
 
Fax: +44 1792 525 720 
 
E-mail: MHGSafety@prahs.com 
North American Investigative Sites: 
Drug Safety Helpline: 1-800-772-2215 or 1-434-951-3482 
Fax: 1-888-772-6919 or 1-434-951-3482 
E-mail: CHOSafety@prahs.com  
To be valid, the initial SAE report must include the following minimal data:  
 A reporting source (the Investigator’s name and/or site number, and contact 
information) 
 A subject identifier 
 The identity of the investigational product 
 A SAE term, description, or outcome 
The following additional data should be provided as soon as possible, but are not required for 
the initial report if they are not immediately available:  
 Event start date  
 Event end date if known 
 Severity: mild, moderate, severe, life-threatening, or fatal 
 The Investigator’s assessment of causality: unrelated, unlikely related, possibly 
related, probably related, or definitely related  
 Any serious criteria that apply to the event (see Section 12.2) 
Investigators should submit follow-up reports for SAEs whenever additional pertinent 
information becomes available, and should provide copies of all pertinent documents such as 
hospital records, admission and discharge summaries, surgical records, laboratory reports, 
autopsy reports, and other documents when requested and applicable.  
12.4 
Monitoring of Subjects for Adverse Events 
Each subject must be carefully monitored for AEs, including clinically significant abnormal 
laboratory test results, physical examination findings, and ECG parameters. At each study 
visit or communication, the Investigator or designee will ask subjects about any new 
symptoms or worsening of baseline symptoms that could indicate an AE.  


 
 
 
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12.4.1 Abnormal Laboratory Test Results 
Changes or abnormalities in clinical laboratory results judged to be clinically significant by 
the Investigator will be recorded as AEs. If an unexplained abnormal laboratory test result 
occurs, the test should be repeated immediately, and the subject should be monitored until 
the result has returned to the normal range or an adequate explanation of the abnormality is 
found. 
12.4.2 Abnormal Physical Examination Findings or ECG Changes 
Changes or abnormalities in physical examination findings or ECGs judged to be clinically 
significant by the Investigator will be recorded as AEs. 
12.5 
Overdose of Study Medication 
No overdoses have occurred to date in any clinical studies with SPX-101. Any overdose of 
the study medication, with or without associated AEs, must be reported to PRA Drug Safety. 
Overdose will be reported in the eCRF. All reports of overdoses must be filed in the Study 
Center File. Any AEs associated with the overdose should be reported on relevant AE/SAE 
eCRFs. 
Investigators will instruct subjects regarding the management of their study medication, other 
medications including those for diabetes, and procedures to be followed if an overdose 
occurs. Subjects who experience an overdose of study medication should notify the 
Investigator as soon as feasible and seek appropriate supportive management if needed. 
12.6 
Pregnancy 
Pregnancy in itself is not regarded as an AE unless there is a suspicion that an investigational 
product may have interfered with the effectiveness of a contraceptive medication. However, 
any pregnancy during the study and the outcome of the pregnancy (eg, spontaneous 
miscarriage, elective termination, normal birth or congenital abnormality) must be reported 
to PRA. 
If a subject becomes pregnant after exposure to the study drug, she must stop the 
investigative drug and report the pregnancy to the Investigator immediately. The Investigator 
must then submit a completed Pregnancy Report Form to PRA Drug Safety and follow all 
procedures for early withdrawal from the study (Section 9.4.4.2). In the event of pregnancy, 
the Investigator should continue to monitor the subject through either childbirth or the end of 
pregnancy, and must submit a pregnancy follow-up form to PRA Drug Safety. Any 
congenital anomaly or birth defect in the offspring of the subject should be reported as an 
SAE. Investigators should contact the Medical Monitor through the Medical Monitoring 
Support Center if questions arise. 


 
 
 
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13. 
DATA MANAGEMENT AND STATISTICAL ANALYSIS 
13.1 
Data Management 
An eCRF will be used for the current study and a Data Management Plan will be prepared by 
PRA Health Sciences. 
Previous medications taken within 28 days of screening and all concomitant medications will 
be coded using the latest available WHO Drug Dictionary. Coexistent diseases and AEs will 
be coded using MedDRA. 
When the database for a given cohort has been declared to be complete and accurate, the 
database will be locked. Any changes to the database after that time can be made only by 
written agreement between Spyryx Biosciences, Inc, and the PRA project team. For further 
details, see the Data Management Plan. 
13.2 
Sample Size Estimation 
The study was planned for a minimum of 39 subjects per cohort to be enrolled. In Cohort 1, 
46 subjects were randomized in a 1:1:1 ratio to one of the two treatment groups or placebo. 
The sample size of 39 subjects was chosen to provide 70% power for the Analysis of 
Variance (ANOVA) to detect a difference range of 4.5% to 6% in the change from baseline 
in ppFEV1 and FEV1 between the 2 treatment groups versus placebo, with the alpha level of 
0.15 assuming a common standard deviation of 7%. The attrition rate is expected to be 
minimal given the 4 weeks’ treatment duration. 
 
In Cohort 2, a total of 45 subjects will be randomized in a 2:1 ratio to SPX-101 120 mg BID 
or placebo. The sample size of 45 subjects will provide 88% to 97% power to detect a 
difference range of 6% to 8% in the change from baseline in ppFEV1 between the treatment 
group versus placebo, with the 1-sided alpha level of 0.1 assuming a common standard 
deviation of 7.58%. 
13.3 
Statistical Analysis Plan 
The Statistical Analysis Plan (SAP) will be written and finalized prior to lock of the first 
cohort database. The SAP will provide a detailed description of the statistical methods and 
expand on the details provided in the protocol. Additional analyses may be added. A shell of 
the tables, listings, and figures will also be provided. 
13.4 
Randomization 
Two sequential, double-blind cohorts are planned to test the study drug SPX-101 at different 
dosages compared to placebo. Each cohort will have its own baseline. Cohort 1 had 3 groups: 
2 treatment groups with different dosages of SPX-101 and a placebo group, and Cohort 2 
will have 1 treatment group and a placebo group. Each cohort will be analyzed separately. In 
Cohort 1, randomization was stratified by whether the baseline (Visit 2) ppFEV1 was 
between 40.0% and 55.0% or between 55.1% and 80.0%. In Cohort 2, randomization will be 
stratified according to use of concomitant hypertonic saline so that approximately 50% of 
subjects will be using hypertonic saline (defined as having used a constant regimen of 
hypertonic saline for 28 days prior to screening, and planning to use their same concentration 


 
 
 
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without change through 28 days post-randomization. All randomized subjects must satisfy 
the randomization criteria in order to be eligible for study medication. 
13.5 
Analysis Populations 
13.5.1 Safety Population 
The Safety population will include all enrolled subjects who receive at least 1 dose of the 
study drug. 
13.5.2 Intent-to-Treat Population  
The Intent-to-Treat (ITT) population will include all randomized subjects. Subjects will be 
grouped according to their randomized study group assignment regardless of the actual 
treatment received. 
13.5.3 Per-Protocol Population 
The Per-Protocol (PP) population will include all subjects in the ITT population who did not 
have major protocol violations. Major protocol violations are defined as those that may have 
a substantial impact on efficacy assessments. The criteria to be used for excluding subjects 
from the PP population will be determined before database lock and will be documented. The 
PP analysis may be performed only for the primary and secondary efficacy endpoints, to 
provide supportive evidence for efficacy. 
13.6 
Statistical Methods 
13.6.1 Missing Data 
Missing data will not be imputed, with the exception of missing or partial dates. The 
imputation rules of missing or partial dates will be specified in the SAP. 
13.6.2 Demographic, Cystic Fibrosis History, and Baseline Data 
The demographic and baseline data, including CF history, will be summarized descriptively 
by study group. The continuous variables will be summarized including the number of 
observations, mean, standard deviation, median, the first quartile (Q1), the third quartile 
(Q3), and minimum and maximum values. The categorical variables will be summarized 
using frequency and percentage. All demographic and baseline data will be listed. 
Baseline will be defined as the last observation of an assessment prior to the first dose of 
study drug. 
13.6.3 Subject Disposition 
The number and percentage of subjects who complete the study treatment, who discontinue 
early, and the reasons for early discontinuation will be summarized. 
13.6.4 Efficacy 
13.6.4.1 
Primary Efficacy Analysis  
The primary endpoint is the change from baseline in ppFEV1 at Week 4 (Day 29). The 
change from baseline in ppFEV1 at each visit (Weeks 1, 2, and 4) will be summarized and 
compared between each treatment group and placebo. 
 


 
 
 
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The primary analysis for the change from baseline in ppFEV1 at Week 4 will be based on an 
analysis of covariance (ANCOVA). For Cohort 1, the model will also include the 
stratification variable baseline lung function categories (ppFEV1 40.0% to 55.0% or 55.1% to 
80.0%). For Cohort 2, the model will include the stratification variable of concomitant use of 
hypertonic saline.  
13.6.4.2 
Secondary Efficacy Analysis 
ppFEV1 
Similar analyses will be performed for the change from baseline in ppFEV1 at each of the 
remaining visits (Weeks 1, and 2). 
To support these analyses, the change from baseline in ppFEV1 at each visit (Weeks 1, 2, and 
4) will be considered based on a mixed effect model for repeated measure (MMRM). The 
model will include the change from baseline in ppFEV1 as the dependent variable; treatment, 
visit and treatment by visit interaction as fixed effects; and subject as a random effect. In this 
model, visits will be treated as a class variable. The structure of the covariance matrix will be 
investigated and the most appropriate will be assumed. This will be documented in the final 
Statistical Analysis Plan prior to unblinding. 
FEV1 
To investigate the robustness of the results, similar ANCOVA analyses will be performed for 
the change from baseline in FEV1 at each visit (Weeks 1, 2, and 4). 
 
FVC and Percent Predicted FVC  
Similar to the FEV1 analysis, FVC and ppFVC will be analyzed. 
 
CFQ-R 
The change from baseline in CFQ-R respiratory domain and physical domain at Week 4 will 
be summarized and compared between the treatment groups and the placebo. 
13.6.4.3 
Exploratory Analyses 
Pulmonary Exacerbation 
The number and percentage of subjects with pulmonary exacerbation (See Appendix 3, 
Section 18.3 for specific criteria) will be summarized.  
 
Concomitant Hypertonic Saline  
The effect of concomitant use of hypertonic saline will be explored. Each of the primary and 
secondary endpoints will be analyzed accounting for the use of hypertonic saline.  
13.6.5 Pharmacokinetics – Cohort 1 Only 
At Visit 2 only, blood samples were collected pre-dose and at 5 ± 2 minutes and 
15 ± 5 minutes after completion of administration of the study nebulizer treatment. The 
pharmacokinetic results will be listed.  
13.6.6 Safety 
Safety data will be summarized for the safety population. 


 
 
 
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Exposure to the study drug will be summarized. Summaries will include the number of doses 
received and dose compliance.  
 
All AEs reported after initiation of treatment, and pre-existing conditions that worsen or 
become more frequent after initiation of treatment will be considered TEAEs. Adverse events 
will be coded by system order class and preferred term using MedDRA. All recorded AEs 
will be included in the data listings.  
 
The number and percentage of subjects with TEAEs, SAEs, AEs leading to death, and AEs 
leading to discontinuation of the study drug will be summarized by preferred term, and where 
appropriate, system organ class. Deaths, SAEs, and AEs leading to discontinuation of the 
study drug will also be listed, and narratives will be written. 
 
Summary statistics for actual values and for change from baseline will be tabulated as 
appropriate for vital signs and clinical laboratory test results. Results of ECGs will be 
summarized and results of physical examinations will be listed. 
 
All non-study medications received during the treatment period will be considered 
concomitant medications. Previous and concomitant medications will be coded using the 
WHO Drug Dictionary and will be summarized.  
13.6.7 Additional Data 
Additional summaries and data listings may be defined in the SAP as appropriate. 
13.6.8 Interim Analysis 
There will be no interim analysis in this study. At the end of the Cohort 1 part of the study, 
all data was locked prior to review by the Sponsor to select the Cohort 2 dosing regimens. 
13.6.9 Data Safety Monitoring Board 
An independent DSMB will periodically review the accrued safety data in an unblinded 
manner to monitor the safety of subjects. There will be 3 scheduled DSMB meetings at the 
following time points: midpoint of Cohorts 1 and 2 (after approximately 19 subjects have 
been randomized) and at the completion of Cohort 1. Additional meetings may be scheduled 
at the discretion of the DSMB members. The DSMB will be empowered to make any 
recommendations relevant to safety, and specifically will make recommendations to revise 
study procedures to increase subject safety or to stop the study based on periodic data 
reviews. The DSMB may also make recommendations on the dosage selection in Cohort 2.  
The DSMB charter will be finalized before the first subject has been randomized to the study 
drug, and will define the membership and organization of the DSMB. In addition, the DSMB 
charter will define the safety information that will be reviewed, the reporting obligations and 
responsibilities of the DSMB, and will specify what information, if any, may be shared with 
the Sponsor or investigators. 


 
 
 
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14. 
MONITORING PROCEDURES (QUALITY ASSURANCE) 
The Sponsor has ethical, legal, and scientific obligations to conduct this study in accordance 
with established research principles and ICH GCP guidelines. As such, to fulfill these 
obligations and to maintain current of study progress, the Sponsor's monitors or 
representatives will visit the investigative sites during study conduct, in addition to 
maintaining telephone and written communication. On-site visits, telephone calls, and 
regular inspection of the CRFs will be conducted to assess subject enrollment, compliance 
with protocol procedures, completeness and accuracy of data entered on the CRFs, 
verification of CRF data against original source documents, and occurrence of AEs. The 
Investigator must provide the monitor with full access to all source and study documents. 
14.1 
Routine Monitoring 
PRA-assigned study monitors will conduct regular site visits to the investigational facilities 
to monitor various aspects of the study. The Investigator must agree to provide direct access 
for Sponsor- and PRA-authorized personnel to the clinical (or associated) files and clinical 
study supplies (dispensing and storage areas) for all study subjects considered for study 
entry, to verify entries made in the CRF, and they must assist the study monitors with their 
activities, if requested. Adequate time and space for monitoring visits should be made 
available by the Investigator. 
The site must complete the CRFs in a timely manner and on an ongoing basis to allow 
regular review by the study monitor. 
14.2 
Inspections and Auditing Procedures 
The Sponsor or its representative may conduct audits at the investigative sites including, but 
not limited to, drug supply, presence of required documents, the informed consent process, 
and comparison of eCRFs with source documents. All medical records (progress notes) must 
be available for audit. The Investigator agrees to participate with audits conducted at a 
convenient time in a reasonable manner. 
Government regulatory authorities may also inspect the Investigator during or after the study. 
The Investigator or designee should contact the Sponsor and PRA immediately if this occurs. 
The Investigator must cooperate fully with regulatory authorities or other audits conducted at 
a convenient time in a reasonable manner. 
The purpose of an audit is to assess whether ethics, regulatory, and quality requirements are 
fulfilled. 


 
 
 
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15. 
STUDY MANAGEMENT AND MATERIALS 
15.1 
Electronic Case Report Forms 
Electronic CRFs will be used to store and transmit subject information. The file structure and 
format for the eCRF will be provided by the Sponsor or their representative and should be 
handled in accordance with the instructions provided. 
The eCRF must be reviewed and electronically signed and dated by the Investigator. 
Access to the eCRF will be strictly password protected and limited to personnel directly 
participating in the study. Data should be entered into the eCRF completely by examining 
personnel or the study coordinator. The eCRF must be completed as soon as possible after 
any subject evaluation or communication. If data is to be changed due to erroneous input or 
other reason, an electronic audit trail will track these changes. The eCRFs and computers that 
store them must be accessible to study monitors and other regulatory auditors. 
15.2 
Data Collection 
During each study visit, a physician participating in the study will maintain progress notes, in 
ink, in the subject’s medical records to document all significant observations. At a minimum, 
these notes will contain: 
 
The date of the visit and the corresponding day or visit in the study schedule (e.g., 
screening, Day 1, Day 29, etc.) 
 
General condition and status remarks by the subject and any significant medical findings, 
including the severity, frequency, duration, and resolution of any reported AE, and the 
Investigator's assessment regarding whether or not the reported AE is study drug-related 
 
Changes in concomitant medications or dosages 
 
A general reference to the procedures completed 
 
The signature or initials of all physicians making an entry in the medical record (progress 
notes) 
In addition, any contact with the subject via telephone or other means that provides 
significant clinical information will also be documented in the medical record (progress 
notes), as described above.  
Information from the medical records (progress notes) and other source documents will be 
promptly transcribed to the appropriate section of the eCRF. 
Changes to information in the medical record (progress notes), eCRFs, and other source 
documents will be initialed and dated on the day the change is made by the Investigator or 
designee. If the reason for the change is not apparent, the Investigator or designee will write 
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15.3 
Source Documents Maintenance 
Source documents contain the results of original observations and activities of a clinical 
investigation. Source documents include, but are not limited to, medical records (progress 
notes), computer printouts, screening logs and recorded data from automated instruments.  
All source documents from this study will be maintained by the Investigator and made 
available for inspection by authorized persons. The original signed informed consent for each 
subject shall be filed with records kept by the Investigator and a copy shall be given to the 
subject. 
15.4 
Record Maintenance 
All data derived from the study will remain the property of Spyryx Biosciences, Inc.  
Records must be retained in accordance with the current ICH Guidelines on GCP. All 
essential study documents including records of subjects, source documents, CRFs and study 
drug inventory must be kept on file. 
Essential documents should be retained until at least two years after the last approval of a 
marketing application in an ICH region and until there are no pending or contemplated 
marketing applications in an ICH region, or until at least two years have elapsed since the 
formal discontinuation of clinical development of the investigational products. However, 
essential documents may be retained for a longer period if required by the applicable 
regulatory requirements or by agreement with the Sponsor. The Sponsor is responsible for 
informing the Investigator when these documents need no longer be retained. 
The Investigator will not dispose of any records relevant to this study without written 
permission from the Sponsor, and will provide the Sponsor the opportunity to collect such 
records. The Investigator shall take responsibility for maintaining adequate and accurate hard 
copy source documents of all observations and data generated during this study. Such 
documentation is subject to inspection by the Sponsor, its representatives and regulatory 
authorities. 
If an Investigator moves, withdraws from an investigation, or retires, the responsibility for 
maintaining the records may be transferred to another person who will accept responsibility. 
Notice of transfer must be made to and agreed by the Sponsor. 
15.5 
Confidentiality 
All information obtained during the conduct of the study with respect to the subject’s state of 
health will be regarded as confidential. For disclosure of any such information, an agreement 
will be obtained in writing.  
The Investigator must ensure that each subject’s anonymity is maintained. On CRFs and 
other documents submitted to the Sponsor or the CRO, subjects must not be identified by 
name. Instead, subjects will be known only by the unique subject number allocated to them 
to ensure confidentiality on all study documentation. Subjects will retain this unique number 
throughout the study. The Investigator will keep a separate log of these codes. 
To comply with government regulatory guidelines and to ensure subject safety, it may be 
necessary for the Sponsor and its representative, PRA personnel, the local research review 


 
 
 
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board, or regulatory authority to review subjects’ medical records as they relate to this study. 
Only the subject’s unique number on the eCRFs will identify him/her, but their full names 
may be made known to a drug regulatory authority or other authorized government or health 
care officials, if necessary, and to personnel designated by the Sponsor. 
Documents that are not for submission to the Sponsor or PRA (eg, consent forms) will be 
maintained by the Investigator in strict confidence, except to the extent necessary to allow 
monitoring by the Sponsor and PRA, and auditing by regulatory authorities. No documents 
identifying subjects by name will leave the investigative site, and subject identity will remain 
confidential in all publications related to the study. 


 
 
 
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16. 
ADMINISTRATION PROCEDURES 
16.1 
Regulatory Approval 
Spyryx Biosciences, Inc. or their appointed agents will be responsible for ensuring that 
appropriate regulatory authority approvals are obtained, according to local country 
requirements. 
No subject may enter the study until this approval has been obtained. A copy of the approval 
(where one is provided, according to local country requirements) will be provided to the 
Investigator and to the IRB(s)/IEC(s). 
16.2 
Protocol Amendments 
In accordance with ICH Topic E 6 (R1) Guideline for GCP the Investigator should not 
implement any deviation from, or changes to the protocol without agreement by the Sponsor 
and documented approval from the IRB/IECs of a protocol amendment, except where 
necessary to eliminate an immediate hazard(s) to study subjects, or when the change involves 
only logistical or administrative aspects of the study, eg, change in monitor or change of 
telephone numbers.  
Substantial amendments will be submitted to the IRB/IEC for written approval and where 
applicable, to National Competent Authorities. Written approval must be obtained before 
implementation of the amended version occurs unless the amendment is implemented to 
increase safety measures for the patients in the study. The written signed approval from the 
IRB/IEC should specifically reference the Principal Investigator’s name, protocol number, 
study title, and amendment number(s) that is/are applicable. The Investigator must await 
IRB/IEC approval of protocol amendments before implementing the changes, except where 
necessary to eliminate apparent immediate hazard to subjects. In these cases, the IRB/IEC 
must be notified within 5 days of the change. 
Once approved, the protocol amendment will be distributed to all recipients of the original 
protocol, with instructions to append the amendment to the protocol. 
If, in the judgment of the local IRB/IEC, the Investigator and/or Sponsor, the protocol 
amendment alters the study design, procedures and/or increases the potential risk to the 
subject, the currently approved written informed consent form will require modification. The 
modified informed consent form must also be reviewed and approved by the IEC and where 
applicable, National Competent Authorities as described above for protocol amendments. In 
such cases, repeat informed consent must be obtained from subjects enrolled in the study 
before participation continues. 
16.3 
Protocol Adherence and Deviations 
The protocol must be read thoroughly and the instructions must be followed. However, 
exceptions will be made in emergency situations when the protection, safety, and well-being 
of the subject requires immediate intervention based on the judgment of the Investigator or a 
responsible, appropriately trained, and credentialed professional(s) designated by the 
Investigator as a sub-investigator.  


 
 
 
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In the event of a significant protocol deviation due to an emergency, accident, or error, the 
Investigator or designee must contact the Medical Monitor as soon as possible by telephone. 
An early joint decision will be made regarding whether or not the subject should continue in 
the study. The Investigator, the Sponsor, and the Medical Monitor will document this 
decision. 
16.4 
Publication Policy 
After completion of the study, the Investigator(s) may prepare a joint publication with the 
Sponsor. The Investigator(s) must not undertake to submit any part of the data from this 
protocol for publication without the prior consent of Spyryx Biosciences, Inc.  
16.5 
Clinical Study Report 
A final clinical study report will be prepared according to the ICH guideline on Structure and 
Contents of Clinical Study Reports. A final clinical study report will be prepared regardless 
of whether the study is completed or prematurely terminated.  
16.6 
Contractual and Financial Details 
The Investigator (and/or, as appropriate, the hospital administrative representative) and the 
Sponsor will sign a clinical study agreement prior to the start of the study, outlining overall 
Sponsor and Investigator responsibilities in relation to the study. The contract should describe 
whether costs for pharmacy, laboratory and other protocol-required services are being paid 
directly or indirectly. Financial Disclosure Statements will need to be completed, as requested 
by FDA CFR 21 part 54. 
16.7 
Insurance, Indemnity, and Compensation 
Spyryx Biosciences, Inc. undertakes to maintain an appropriate clinical study insurance 
policy. 
Deviations from the study protocol - especially the prescription of a dose other than that 
scheduled in the study protocol, other modes of administration, other indications, and longer 
treatment periods - are not permitted and shall not be covered by the statutory subject 
insurance scheme. 
16.8 
Discontinuation of the Study 
This study may be terminated by the Sponsor. The study may also be terminated prematurely 
at any time when agreed to by both the Investigators and the Sponsor as being in the best 
interests of subjects, and justified on either medical or ethical grounds. In terminating the 
study, Spyryx Biosciences, Inc, PRA Health Sciences, and the Investigator will ensure that 
adequate consideration is given to the protection of the subjects’ interests. 
16.9 
Study Center File Management 
The Investigator is responsible for ensuring that the Study Center File is maintained in 
accordance with GCPs. 


 
 
 
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17. 
REFERENCE LIST 
1. Farrell PM, Rosenstein BJ, White TB, Accurso FJ, Castellani C, Cutting GR, et al. 
Guidelines for Diagnosis of Cystic Fibrosis in Newborns Through Older Adults: 
Cystic Fibrosis Foundation Consensus Report. J Pediatr.2008 August; 153(2):S4-
S14. 
2. Quanjer PH, Stanojevic S, Cole TJ, Baur, X, Hall GL, et al. Multi-ethnic reference 
values for spirometry for the 3-95-yr age range: the global lung function 2012 
equations. Eur Respir J. 2012;40:1324-1343. 
3. Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R, et al. Series “ATS/ERS 
Task Force: Standardisation of Lung Function Testing” – Standardisation of 
spirometry. Eur Respir J. 2005;26:319-338. 
4. Fuchs HJ, Borowitz DS, Christiansen DH, Morris EM, Nash ML, Ramsay BW, et al. 
Effect of aerosolized recombinant human DNAase on exacerbations of respiratory 
symptoms and on pulmonary function in patients with cystic fibrosis. N Engl J Med. 
1994;331:637-642 
5. Knowles MR, Boucher RC. Mucus clearance as a primary innate defense mechanism 
for mammalian airways. J Clin Invest. 2002;109(5):571-577. 
6. Gaillard EA, Kota P, Gentzsch M, Dokholyan NV, Stutts MJ, Tarran R. Regulation of 
the epithelial Na+ channel and airway surface liquid volume by serine proteases. 
Pflugers Arch. 2010;460(1):1-17Caldwell RA, Boucher RC, Stutts MJ. Serine 
protease activation of near-silent epithelial Na+ channels. Am J Physiol Cell Physiol. 
2004;286(1):C190-194.  
7. Mall M, Grubb BR, Harkema JR, O'Neal WK, Boucher RC. Increased airway 
epithelial Na+ absorption produces cystic fibrosis-like lung disease in mice. Nat Med. 
2004;10(5):487-493. 
8. Chmiel JF, Davis PB. State of the art: why do the lungs of patients with cystic 
fibrosis become infected and why can't they clear the infection? Respir Res. 2003;4:8. 
9. Gibson RL, Burns JL, Ramsey BW. Pathophysiology and management of pulmonary 
infections in cystic fibrosis. Am J Respir Crit Care Med. 2003;168(8):918-951 
10. .Worlitzsch D, Tarran R, Ulrich M, Schwab U, Cekici A, Meyer KC, et al. Effects of 
reduced mucus oxygen concentration in airway Pseudomonas infections of cystic 
fibrosis patients. J Clin Invest. 2002;109(3):317-325. 
11. Caldwell RA, Boucher RC, Stutts MJ. Serine protease activation of near-silent 
epithelial Na+ channels. Am J Physiol Cell Physiol. 2004;286(1):C190-194.  


 
 
 
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12. Knowles MR, Church NL, Waltner WE, Yankaskas JR, Gilligan P, King M, et al. A 
pilot study of aerosolized amiloride for the treatment of lung disease in cystic 
fibrosis. N Engl J Med. 1990 Apr 26;322(17):1189-1194. 
13. Tarran R, Grubb BR, Parsons D, Picher M, Hirsch AJ, Davis CW, et al. The CF salt 
controversy: in vivo observations and therapeutic approaches. Mol Cell. 
2001;Jul;8(1):149-158. 
14. Why Participate in a Clinical Trial? Cystic Fibrosis Foundation website. 
https://www.cff.org/Our-Research/Clinical-Trials/Clinical-Trials-101/Why-
Participate-in-a-Clinical-Trial/. Accessed January 5, 2017 


 
 
 
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18. 
APPENDICES 
18.1 
Appendix 1: 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 
53th 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 
A. INTRODUCTION 
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 not be applied without consideration of 
all other relevant paragraphs. 
2. Although the Declaration is addressed primarily to physicians, the WMA encourages other 
participants in medical research involving human subjects to adopt these principles. 
3. It is the duty of the physician to promote and safeguard the health of patients, including 
those who are involved in medical research. The physician's knowledge and conscience are 
dedicated to the fulfilment of this duty. 
4. 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.” 
5. Medical progress is based on research that ultimately must include studies involving 
human subjects. Populations that are underrepresented in medical research should be 
provided appropriate access to participation in research. 
6. In medical research involving human subjects, the well-being of the individual research 
subject must take precedence over all other interests. 
7. 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 current 
interventions must be evaluated continually through research for their safety, effectiveness, 
efficiency, accessibility and quality. 
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9. Medical research is subject to ethical standards that promote respect for all human subjects 
and protect their health and rights. Some research populations are particularly vulnerable and 
need special protection. These include those who cannot give or refuse consent for 
themselves and those who may be vulnerable to coercion or undue influence. 
10. Physicians should 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. 
B. PRINCIPLES FOR ALL MEDICAL RESEARCH 
11. It is the duty of physicians who participate in medical research to protect the life, health, 
dignity, integrity, right to self-determination, privacy, and confidentiality of personal 
information of research subjects. 
12. 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. 
13. Appropriate caution must be exercised in the conduct of medical research that may harm 
the environment. 
14. The design and performance of each research study involving human subjects must be 
clearly described 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, other potential conflicts of interest, incentives for subjects and 
provisions for treating and/or compensating subjects who are harmed as a consequence of 
participation in the research study. The protocol should describe arrangements for post-study 
access by study subjects to interventions identified as beneficial in the study or access to 
other appropriate care or benefits. 
15. The research protocol must be submitted for consideration, comment, guidance and 
approval to a research ethics committee before the study begins. This committee must be 
independent of the researcher, the sponsor and any other undue influence. 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 change to the protocol may be made without consideration and 
approval by the committee. 
16. Medical research involving human subjects must be conducted only by individuals with 
the appropriate scientific training and qualifications. Research on patients or healthy 


 
 
 
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volunteers requires the supervision of a competent and appropriately qualified physician or 
other health care professional. The responsibility for the protection of research subjects must 
always rest with the physician or other health care professional and never the research 
subjects, even though they have given consent. 
17. Medical research involving a disadvantaged or vulnerable population or community is 
only justified if the research is responsive to the health needs and priorities of this population 
or community and if there is a reasonable likelihood that this population or community 
stands to benefit from the results of the research. 
18. Every medical research study involving human subjects must be preceded by careful 
assessment of predictable risks and burdens to the individuals and communities involved in 
the research in comparison with foreseeable benefits to them and to other individuals or 
communities affected by the condition under investigation. 
19. Every clinical trial must be registered in a publicly accessible database before recruitment 
of the first subject. 
20. Physicians may not participate in a research study involving human subjects unless they 
are confident that the risks involved have been adequately assessed and can be satisfactorily 
managed. Physicians must immediately stop a study when the risks are found to outweigh the 
potential benefits or when there is conclusive proof of positive and beneficial results. 
21. Medical research involving human subjects may only be conducted if the importance of 
the objective outweighs the inherent risks and burdens to the research subjects. 
22. Participation by competent individuals as subjects in medical research must be voluntary. 
Although it may be appropriate to consult family members or community leaders, no 
competent individual may be enrolled in a research study unless he or she freely agrees. 
23. Every precaution must be taken to protect the privacy of research subjects and the 
confidentiality of their personal information and to minimize the impact of the study on their 
physical, mental and social integrity. 
24. In medical research involving competent human subjects, 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, 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 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. 
25. For medical research using identifiable human material or data, physicians must normally 
seek consent for the collection, analysis, storage and/or reuse. There may be situations where 


 
 
 
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consent would be impossible or impractical to obtain for such research or would pose a threat 
to the validity of the research. In such situations the research may be done only after 
consideration and approval of a research ethics committee. 
26. When seeking informed consent for participation in a research study the physician should 
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 should be 
sought by an appropriately qualified individual who is completely independent of this 
relationship. 
27. For a potential research subject who is incompetent, the physician must seek informed 
consent from the legally authorized 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 population represented by the potential subject, the research cannot instead be 
performed with competent persons, and the research entails only minimal risk and minimal 
burden. 
28. When a potential research subject who is deemed incompetent 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 authorized 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 population. In 
such circumstances the physician should seek informed consent from the legally authorized 
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 should be obtained as soon as possible from the 
subject or a legally authorized representative. 
30. Authors, editors and publishers all have ethical obligations with regard to the publication 
of the results of research. Authors 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. They should adhere to accepted guidelines for ethical reporting. Negative and 
inconclusive as well as positive results should be published or otherwise made publicly 
available. Sources of funding, institutional affiliations and conflicts of interest should be 
declared in the publication. Reports of research not in accordance with the principles of this 
Declaration should not be accepted for publication. 
C. ADDITIONAL PRINCIPLES FOR MEDICAL RESEARCH COMBINED WITH 
MEDICAL CARE 
31. The physician may combine medical research with medical care only to the extent that 
the research is justified by its potential preventive, diagnostic or therapeutic value and if the 


 
 
 
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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. 
32. The benefits, risks, burdens and effectiveness of a new intervention must be tested 
against those of the best current proven intervention, except in the following circumstances: 
 The use of placebo, or no treatment, is acceptable in studies where no current proven 
intervention exists; or 
 Where for compelling and scientifically sound methodological reasons the use of 
placebo is necessary to determine the efficacy or safety of an intervention and the 
patients who receive placebo or no treatment will not be subject to any risk of serious 
or irreversible harm. Extreme care must be taken to avoid abuse of this option. 
33. At the conclusion of the study, patients entered into the study are entitled to be informed 
about the outcome of the study and to share any benefits that result from it, for example, 
access to interventions identified as beneficial in the study or to other appropriate care or 
benefits. 
34. The physician must fully inform the patient which aspects of the 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 interfere with the patient-physician relationship. 
35. In the treatment of a patient, where proven interventions do not exist or have been 
ineffective, the physician, after seeking expert advice, with informed consent from the patient 
or a legally authorized representative, may use an unproven intervention if in the physician's 
judgment it offers hope of saving life, re-establishing health or alleviating suffering. Where 
possible, this intervention should be made the object of research, designed to evaluate its 
safety and efficacy. In all cases, new information should be recorded and, where appropriate, 
made publicly available.


 
 
 
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18.2 
Appendix 2: Elements of Informed Consent 
 
ELEMENTS OF INFORMED CONSENT 
 
Both the informed consent discussion and the written informed consent form and any other 
written information to be provided to subjects should include explanations of the following: 
 
 That the study involves research. 
 The purpose of the study 
 The study treatment(s) and the probability for random assignment to each treatment 
 The study procedures to be followed including all invasive procedures 
 The subject’s responsibilities 
 Those aspects of the study that are experimental 
 The reasonably foreseeable risks or inconveniences to the subject and, when applicable, 
to an embryo, fetus, or nursing infant 
 The reasonably expected benefits; when there is no intended clinical benefit to the 
subject, the subject should be made aware of this. 
 The other approved procedure(s) or course(s) of treatment that may be available to the 
subject, and their important potential benefits and risks 
 The compensation and/or treatment available to the subject in the event of study-related 
injury 
 The anticipated prorated payment, if any, to the subject for participating in the study 
 The anticipated expenses, if any, to the subject for participating in the study 
 That the subject’s participation in the study is voluntary and that the subject may refuse 
to participate or withdraw from the study, at any time, without penalty or loss of benefits 
to which the subject is otherwise entitled 
 That the monitor(s), the auditor(s), the IRB/IEC, and the regulatory authority(ies) will be 
granted direct access to the subject’s original medical records for verification of clinical 
study procedures and/or data, without violating the confidentiality of the subject, to the 
extent permitted by the applicable laws and regulations and that, by signing a written 
informed consent form, the subject or the subject’s legally acceptable representative is 
authorizing such access. 
 That records identifying the subject will be kept confidential and, to the extent permitted 
by the applicable laws and/or regulations, will not be made publicly available. If the 
results of the study are published, the subject’s identity will remain confidential. 
 That the subject or the subject’s legally acceptable representative will be informed in a 
timely manner if information becomes available that may be relevant to the subject’s 
willingness to continue participation in the study. 


 
 
 
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 The person(s) to contact for further information regarding the study and the rights of 
study subjects, and whom to contact in the event of study-related injury 
 The foreseeable circumstances and/or reasons under which the subject’s participation in 
the study may be terminated 
 The expected duration of the subject’s participation in the study 
 The approximate number of subjects involved in the study


 
 
 
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18.3 
Appendix 3: Criteria for Pulmonary Exacerbation 
For the purpose of this study, the following criteria will be used to define pulmonary 
exacerbation: 
Treatment with parenteral antibiotics for at least 4 of the following 12 signs or symptoms:  
 Change in sputum 
 New or increased hemoptysis 
 Increased cough 
 Increased dyspnea 
 Malaise, fatigue, or lethargy 
 Temperature higher than 38°C 
 Anorexia or weight loss 
 Sinus pain or tenderness 
 Change in sinus discharge 
 Change in physical examination of the chest 
 Decrease in pulmonary function by 10% or more from a previously recorded value 
 Radiographic changes indicative of pulmonary infection 
Fuchs HJ, Borowitz DS, Christiansen DH, Morris EM, Nash ML, Ramsay BW, et al. Effect 
of aerosolized recombinant human DNAase on exacerbations of respiratory symptoms and 
on pulmonary function in patients with cystic fibrosis. N Engl J Med. 1994;331:637-642.  


 
 
 
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Global Version 4.0; xx May 2018 
18.4 
Appendix 4: Information for Subjects Enrolled in Study SPX-101-CF201 
General 
 Call your doctor if you have any questions about the study, the study medication or 
nebulizer, or anything else related to the study. 
 During the study, call your doctor as soon as possible if you notice any of the 
following symptoms or worsening of symptoms:  
o Shortness of breath 
o Wheezing 
o Cough 
o Fever 
eFlow Nebulizer with eTrack 
 Remember that the eFlow study nebulizer with eTrack must be used only with the 
study drug, and you must use your regular nebulizer for all other medications. 
 Always bring your eTrack study nebulizer to clinic visits.  
 The study nebulizer should be cleaned after each use and sterilized once per day. 
Follow the instructions given to you for this process. 
Study Medication 
 Keep the study drug vials in the original container in the refrigerator between 2° and 
8°C. The study drug is stable at room temperature for short periods of time, but 
should be refrigerated whenever possible. 
 The study medication should be taken as instructed (ie, twice each day, 
approximately 12 hours apart. Study medication, should be inhaled only with the 
study nebulizer.  
 You should take the last dose of study medication as instructed. For Cohorts 1 and 2, 
this will be the evening before your final clinic visit (Visit 5 [Day 29]).  
 Discard used study drug vials at home after use.  
Order of Medications and Other Treatments 
 In general:  
o You should follow your usual routine of medication and chest physiotherapy, 
unchanged, throughout the study. 
o The study drug is added into your usual treatment regimen as the last 
mucolytic therapy inhaled: 
 The study drug should be used after inhalation of dornase alfa, 
mannitol, and/or hypertonic saline 


 
 
 
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 The study drug should be used before inhalation of antibiotics or 
corticosteroids 
 Long-acting β-agonist (LABA) like salmeterol or formoterol (if used):  
o If normally used in the morning, use the evening before the day of a clinic 
visit, and do not take the morning of the clinic visit. 
 Short-acting β-agonist (SABA) like albuterol (if used):  
o On clinic days: take this at home, at least 4 hours before your clinic visit. 
o On non-clinic days: take this at the normal time. 
 Other medications: If you have any questions about other medications and when or 
how to take them during this study, please ask your doctor. 
 Preparing for Clinic Visit Days: 
o If you use a LABA, use it the evening before, and not on the morning of a 
clinic visit. 
o If you use a SABA, use it at least 4 hours before your clinic visit. 
o Do not take the study drug the morning before a clinic visit. 
o Take your routine medications, including oral antibiotics, and perform chest 
physiotherapy in the morning. 
o Remember to bring your study nebulizer and all unused study medication 
vials to the clinic. 


 
 
 
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Global Version 4.0; xx May 2018 
18.5 
Appendix 5: Bioclinica Trident User Requirement Specifications for 
Unblinding 
 
 
 
Source: Bioclinica Trident User Requirement Specifications, v3.0, pp 35-36 

SAP_001.pdf: 
Statistical Analysis Plan 
Version 2.0 
Version Date: TBD  
Sponsor: SPYRYX Biosciences 
Protocol no: SPX-101-CF-201 
  
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Statistical Analysis Plan 
 
Sponsor: 
 SPYRYX Biosciences, Inc.  
 
Protocol No: 
 SPX-101-CF-201  
 
PRA Project ID: 
 SPYPX101-SPX101  
 
Protocol Version 
Date: 
 14-May-2018  
 
Protocol Version No.: 
    4.0 (including Versions 4.0A and 4.0B) 
 
Title: 
A Randomized, Double-Blind, Placebo-Controlled Phase II Study to Evaluate 
the Efficacy and Safety of SPX-101 Inhalation Solution in Subjects with 
Cystic Fibrosis (HOPE-1 Study: Hydration for Optimal Pulmonary 
Effectiveness)  
CRF Version 
No./Date: 
3.0/17-Jul-2018  
 
SAP Version Date:  
July 9, 2019 
SAP Version No. 
  2.1 
 
1.0 Approvals 
Sponsor 
Sponsor Name: 
Spyryx Biosciences 
Representative/ Title: 
Christie Hudson / Senior Program Manager 
Signature /Date: 
 
PRA 
Project Manager/Title: 
Amy Henley / Senior Project Manager 
Signature /Date: 
 
Biostatistician / Title 
(Owner): 
Sheila Quinn / Senior Principal Biostatistician  
Signature /Date: 
 


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Table of Contents 
1.0 Approvals ............................................................................................................................................................................ 1 
Table of Contents ..................................................................................................................................................................... 2 
2.0 Purpose ................................................................................................................................................................................ 4 
3.0 Scope ..................................................................................................................................................................................... 4 
4.0 Introduction ....................................................................................................................................................................... 4 
4.1 Changes from Protocol .............................................................................................................................................. 4 
5.0 Study Objectives ............................................................................................................................................................... 5 
6.0 Study Design ....................................................................................................................................................................... 5 
6.1 Sample Size Considerations .................................................................................................................................. 11 
6.2 Randomization ........................................................................................................................................................... 11 
7.0 Study Variables and Covariates ................................................................................................................................ 11 
7.1 Primary Efficacy Variables ..................................................................................................................................... 11 
7.2 Secondary Efficacy Variables ................................................................................................................................ 11 
7.3 Safety Variables .......................................................................................................................................................... 12 
7.4 Pharmacokinetic Variable: .................................................................................................................................... 12 
7.5 Exploratory Variables: ............................................................................................................................................ 12 
7.6 Predetermined Covariates and Prognostic Factors .................................................................................... 12 
8.0 Definitions and Data Derivations ............................................................................................................................ 12 
9.0 Analysis Sets ..................................................................................................................................................................... 15 
9.1 Intention-to-Treat Analysis Set ........................................................................................................................... 15 
9.2 Per Protocol Analysis Set ....................................................................................................................................... 15 
9.3 Safety Analysis Set .................................................................................................................................................... 15 
10.0 Interim Analyses .......................................................................................................................................................... 15 
11.0 Data Review ................................................................................................................................................................... 16 
11.1 Data Handling and Transfer ............................................................................................................................... 16 
11.2 Data Screening ......................................................................................................................................................... 16 
12.0 Statistical Methods ...................................................................................................................................................... 16 
12.1 Subject Disposition ................................................................................................................................................ 17 
12.2 Demographic and Baseline Characteristics ................................................................................................. 17 
12.3 Important Protocol Deviations ......................................................................................................................... 17 
12.4 Treatment Exposure .............................................................................................................................................. 17 
12.5 Prior and Concomitant Medications ............................................................................................................... 18 
12.6 Efficacy Analyses ..................................................................................................................................................... 18 
12.6.1 Primary Variable ............................................................................................................................................ 18 
12.6.2 Secondary Variables ...................................................................................................................................... 20 
12.6.3 Exploratory Analyses .................................................................................................................................... 21 
12.6.4 Additional Analyses ....................................................................................................................................... 21 
12.6.5 Methods for Handling Dropouts and Missing Data .......................................................................... 22 


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12.6.6 Multiplicity ........................................................................................................................................................ 23 
12.6.7 Pooling of Sites ................................................................................................................................................ 23 
12.7 Pharmacokinetics (PK) ......................................................................................................................................... 23 
12.8 Safety Analyses ........................................................................................................................................................ 23 
12.8.1 Adverse Events ................................................................................................................................................ 23 
12.8.2 Laboratory Data .............................................................................................................................................. 24 
12.8.3 Vital Signs .......................................................................................................................................................... 25 
12.8.4 Electrocardiograms (ECGs) ........................................................................................................................ 25 
12.8.5 Physical Examinations and Other Observations Related to Safety ............................................ 25 
12.8.6 Antidrug Antibodies (ADA) ........................................................................................................................ 25 
12.8.7 Post-Dose FEV1 (Day 1 only) .................................................................................................................... 25 
13.0 Pooled Analyses Across Cohorts ........................................................................................................................... 26 
14.0 Validation ........................................................................................................................................................................ 26 
15.0 References ...................................................................................................................................................................... 26 
Appendix 1 Glossary of Abbreviations ......................................................................................................................... 26 
Appendix 2 Tables, Figures, Listings, and Supportive SAS Output Appendices .......................................... 29 
 


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2.0 Purpose 
The statistical analysis plan (SAP) describes the statistical methods to be used during the 
reporting and analyses of data collected under SPYRYX Biosciences Protocol SPX-101-CF-201. 
3.0 Scope 
This plan is a living document that will be created during the trial start-up.  The Statistical 
Analysis Plan will be finalized prior to database lock. SAP will require sign off from the Project 
Manager and the sponsor.   
The Statistical Analysis Plan outlines the following: 
• Study objectives 
• Study design 
• Variables analyzed and analysis sets 
• Applicable study definitions 
• Statistical methods regarding important protocol deviations, study drug exposure, 
efficacy analysis, concomitant medications, adverse events handling, laboratory data and 
physical examinations  
4.0 Introduction 
The Statistical Analysis Plan (SAP) Version 1.0 was written and finalized prior to database lock 
of the first cohort.  Version 2.1 of the SAP was revised and finalized prior to the database lock of 
Cohort 2. 
This statistical analysis plan (SAP) describes the methods to be used during the reporting and 
analyses of data collected under SPYRYX Biosciences Protocol SPX-101-CF-201. 
This SAP should be read in conjunction with the study protocol and CRF. For Cohort 1, Version 
1.0 of the plan was developed using the protocol dated 14Nov2017 and CRF dated 11MAY2017. 
For Cohort 2, Version 2.1 of the plan was developed using the protocol dated 14May2018 and 
CRF dated 17Jul2018. Any further changes to the protocol or CRF may necessitate updates to 
the SAP. 
4.1 Changes from Protocol 
Cohort 1 was analyzed per Version 1 of this SAP which covered Protocol Versions 1.0, 2.0 and 
3.0).    
Version 2 of this SAP covers changes associated with Protocol Version 4.0.  The primary 
changes associated with Protocol Version 4.0 are summarized in Section 6.0. 
Protocol Version 4.0 lists “Incidence of antidrug antibodies (ADA)” as an exploratory variable, 
but this version of the SAP will not include this as an exploratory variable. Instead, ADA will be 
explored as a safety variable and presented as such. 


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5.0 Study Objectives 
5.1 Primary Objective  
• To evaluate the efficacy of SPX-101 in subjects with Cystic Fibrosis (CF)  
 
5.2 Safety Objective  
• To evaluate the safety and tolerability of SPX-101 in subjects with CF  
 
5.3 Pharmacokinetic Objective  
• To assess the extent of systemic exposure to SPX-101 in a subset of subjects  
6.0 Study Design 
This randomized, double-blind, placebo-controlled, Phase II study is designed to evaluate the 
efficacy and safety of SPX-101 inhalation solution in a 28-day treatment period in approximately 
90 adults with CF. Two sequential cohorts were planned to compare the study drug SPX-101 (2 
groups) with placebo (1 group) in Cohort 1 (1:1:1 ratio).  Cohort 2 compares the study drug 
SPX-101 (120 mg BID) to placebo in a 2:1 randomization ratio. Each cohort will have its own 
baseline and will be analyzed separately. To achieve balance between treatment groups, 
randomization will be stratified by baseline lung function (percent predicted forced expiratory 
volume in 1 second [ppFEV1] 40.0% to 55.0% or 55.1% to 80.0%) in Cohort 1 and stratified by 
concomitant hypertonic saline use in Cohort 2.  
 
Cohort 1 treatment groups were the following:  
• Placebo twice daily (BID) x 28 days  
• SPX-101 60 mg BID x 28 days  
• SPX-101 120 mg BID x 28 days  
 
Cohort 2 SPX-101 daily doses were anticipated to not exceed those studied in Cohort 1 and may 
have included 240 mg once daily (QD), 120 mg QD, 60 mg QD, or 30 mg BID. The actual dose 
regimens used in the 2 active treatment groups in Cohort 2 were determined by the Sponsor in 
consultation with the Data Safety Monitoring Board (DSMB) based on the efficacy and safety 
results of Cohort 1.  
 
Cohort 2 treatment groups are the following: 
• Placebo twice daily (BID) x 28 days  
• SPX-101 120 mg BID x 28 days  
 
For each cohort, there will be 5 clinic visits and 2 telephone calls: Visit 1 (Screening; Day -28 to 
Day -3); Visit 2 (Randomization; Day 1); Visit 3 (Day 8 -1); Visit 4 (Day 15 -2/+1); telephone 
call (Day 22 ± 3); Visit 5 (Day 29 ± 2; end-of-treatment); and a follow-up telephone call 2 days 
later (Day 31 ± 1; end-of-study). All study visits for an individual subject will be scheduled at 
approximately the same time of day to minimize the confounding effects of diurnal variation in 
lung function, background therapies, and daily chest physiotherapy regimens. Subjects will be 
screened at Visit 1 and then will enter a variable-length screening period of 3 to 28 days to time 


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the randomization so that the first dose of the investigational product will coincide, if applicable, 
to the first day (± 3 days) of an inhaled antibiotic cycle. If subjects still meet the randomization 
criteria on Day 1 (Visit 2), they will be randomized to the treatment groups as described. At 
Visits 2, 3, and 4, after completing spirometry and other assessments, subjects will 
self-administer the study medication in the clinic. On Day 1 (Visit 2) only, subjects will be 
monitored for safety for the first 4 hours after completion of administration of the study drug. 
Monitoring will include spirometry, vital signs, and adverse event (AE) assessments as described 
in more detail in the protocol. After the 4-hour post dose assessments are complete, subjects who 
have tolerated the study medication will be discharged with a sufficient supply of medication to 
take BID on an outpatient basis, until their next clinic visit.  
 
The duration of the study from first subject first visit to last subject last visit will be dependent 
on the ability of the sites to identify and enroll eligible subjects.  
 
Figures 1 and 2 show the design for Cohort 1 and Cohort 2, respectively.  Table 1 shows the 
schedule of events and assessments.  
 


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Figure 1 
Study Diagram – Cohort 1 
 
 
 
 


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Figure 2 
Study Diagram – Cohort 2 
 
 
 
 
 


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Table 1 Schedule of Events 
 
Screening 
Treatment Period 
FU 
Visit  
(Day) 
1 
 (-28 to -3) 
2 
(1) 
3 
(8-1) 
4 
(15 -2/+1)  
TC 
(22±3) 
5 
(29±2/ET) 
TC 
(31 ± 1) 
Informed consent 
X 
 
 
 
 
 
 
Eligibility 
X 
 
 
 
 
 
 
Randomizationa 
 
X 
 
 
 
 
 
Medical history and prior medications 
X 
 
 
 
 
 
 
Concomitant medications 
X 
X 
X 
X 
X 
X 
X 
Vital signsb 
X 
X 
X 
X 
 
X 
 
Weight, heightc, BMI 
X 
X 
 
 
 
X 
 
Physical examinationd 
X 
X 
X 
X 
 
X 
 
AE assessment 
 
X 
X 
X 
X 
X 
X 
Spirometrye 
X 
X 
X 
X 
 
X 
 
12-lead ECG 
X 
X 
 
 
 
X 
 
CFQ-R 
 
X 
 
 
 
Xf 
 
Hematology and serum chemistry including electrolytesg 
X 
X 
 
 
 
X 
 
ADA 
 
 
 
 
 
X 
 
Urinalysis 
 
X 
 
 
 
X 
 
Urine and blood electrolytes 
 
 
X 
X 
 
X 
 
Pregnancy testingh 
X 
X 
 
 
 
X 
 
Issue study nebulizer 
 
X 
 
 
 
 
 
IP administration in clinic 
 
X 
X 
X 
 
 
 
4-hr postdose monitoringi 
 
X 
 
 
 
 
 
Dispense IP 
 
X 
X 
X 
 
 
 
Cohort 1 only: Plasma PKj  
 
X 
 
 
 
 
 
Collect unused IP 
 
 
X 
X 
 
X 
 
Collect study nebulizer 
 
 
 
 
 
X 
 
ADA = antidrug antibodies; AE = adverse event; BMI = body mass index; CFQ-R = cystic fibrosis questionnaire revised; ECG = electrocardiogram; ET = 
early termination; FU = follow up; IP = investigational product; PK = pharmacokinetics; TC = telephone call 
a Only subjects who meet the randomization criteria at Visit 2 will be randomized (see Section 9.4.3 of the protocol). 
b Vital signs will include systolic and diastolic blood pressure, temperature, and heart rate. 


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c Height will be measured only at the screening visit. 
d At Visit 1, a full physical examination of all body systems will be performed. At subsequent visits, an abbreviated physical examination (head, ears, 
eyes, nose, and throat; neck, respiratory, cardiovascular, and skin) may be performed. 
e At Visit 2, spirometry including forced expiratory volume in 1 second (FEV1), percent predicted FEV1, forced vital capacity (FVC) and percent predicted 
FVC will be evaluated pre-dose, and postdose at 30 minutes, 2 hours, and 4 hours. At all other visits, only pre-dose spirometry will be performed. 
f The CFQ-R will not be performed for subjects who are terminated early from the study. 
g See Section 11.8 of the protocol for specific laboratory tests to be performed.  
h At Screening (Visit 1), a serum pregnancy test will be performed; at Visits 2 and 5, a urine pregnancy test will be performed. 
i At Visit 2 only, the subject will be observed and monitored for at least 4 hours after completion of administration of the study drug. The subject may be 
discharged after 4 hours at the discretion of the Investigator (See Section 10.2 of the protocol).  
j For Cohort 1 only, at Visit 2, blood samples for PK testing will be collected pre-dose and at 5±2 minutes and 15±5 minutes after completion of 
administration of the study drug.  
Note: A subject may be re-screened once if they fail to meet randomization criteria for any reason. If this is the case, a new consent form must be signed 
and a new screening number will be used. 
 
 
 
 
 
 
 


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6.1 Sample Size Considerations 
In Cohort 1, the study was planned for a minimum of 39 subjects per cohort to be enrolled. The 
subjects will be randomized in a 1:1:1 ratio to one of the two treatment groups or placebo. The 
sample size of 39 subjects provided 70% power for the Analysis of Variance (ANOVA) to detect 
a difference range of 4.5% to 6% in the change from baseline in ppFEV1 and FEV1 between the 
2 treatment groups versus placebo, with the two-sided alpha level of 0.15 assuming a common 
standard deviation of 7%. The attrition rate is expected to be minimal given the 4 week treatment 
duration. 
In Cohort 2, a total of 45 subjects will be randomized in a 2:1 ratio to SPX-101 120 mg BID or 
placebo. The sample size of 45 subjects will provide 88% to 97% power to detect a difference 
range of 6% to 8% in the change from baseline in ppFEV1 between the treatment group versus 
placebo, with the 1-sided alpha level of 0.1 assuming a common standard deviation of 7.58%.  
The estimated treatment difference and standard deviation are based on the Cohort 1 results from 
the 120 mg SPX-101 dose group and placebo, among subjects with baseline ppFEV1 between 
50.0% and 80.0%, since this reflects the subjects enrolled in Cohort 2.     
6.2 Randomization 
The Investigator or designee will use an Interactive Voice/Web Response System to randomize 
eligible subjects for each cohort. In Cohort 1, randomization was stratified by the Visit 2 pre-
dose ppFEV1 (between 40.0% and 55.0% vs between 55.1% and 80.0%). Only those subjects 
who met the randomization criteria were eligible for assignment to study treatment. Subjects who 
failed to meet the randomization criteria could have had Visit 2 repeated once, or they were 
considered screen failures. In Cohort 2, randomization was stratified by concomitant use of 
hypertonic saline.  NOTE: The Cohort 2 FEV1 entrance criterion was modified to require a 
screening ppFEV1 between 50 – 80% of predicted normal thus no stratification by baseline 
ppFEV1 was undertaken. 
7.0 Study Variables and Covariates 
7.1 Primary Efficacy Variables 
• Change from baseline in ppFEV1 at visit 5 (week 4)  
7.2 Secondary Efficacy Variables 
• Change from baseline in ppFEV1 at visits 3 and 4 (weeks 1 and 2) 
• Change from baseline in FEV1 at visits 3, 4 and 5 
• Change from baseline in forced vital capacity (FVC) and percent predicted FVC (ppFVC) 
at visits 3, 4 and 5 
• Change from baseline in 25-75% forced expiratory Flow (FEF25-75) at visits 3, 4 and 5 
• Change from baseline in Cystic Fibrosis Questionnaire-Revised (CFQ-R) (respiratory and 
physical domains) at visit 5. 


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7.3 Safety Variables 
• Incidence of treatment-emergent AEs (TEAEs)  
• Changes in vital signs  
• Changes in clinical laboratory tests, including urine and blood electrolytes  
• Changes in electrocardiograms  
7.4 Pharmacokinetic Variable:  
• Systemic exposure to SPX-101 (Cohort 1 only)  
7.5 Exploratory Variables:  
• Incidence of pulmonary exacerbation, as defined by Fuchs (1994)  
• Incidence of concomitant hypertonic saline use 
 
7.6 Predetermined Covariates and Prognostic Factors 
In Cohort 1, baseline lung function ppFEV1 categories (percent predicted forced expiratory 
volume in 1 second between 40.0% and 55.0% vs between 55.1% and 80.0%) will be included as 
a covariate in the model of the analysis of covariance (ANCOVA).  
In Cohort 2, the use (yes/no) of concomitant hypertonic saline and baseline ppFEV1 will be 
covariates in the ANCOVA model.  
8.0 Definitions and Data Derivations 
Baseline  
For two sequential cohorts, each cohort will have its own baseline. Unless otherwise specified, 
baseline is defined as the last non-missing value before the first dose of study drug (SPX-101 or 
placebo). Baseline values will be assessed at Visit 2 (Day 1) in this study. If Visit 2 measures are 
missing, corresponding variables at screening visit will be used as baseline.  
 
For spirometry endpoints, the baseline is defined as the last non-missing value before the first 
dose of study drug (SPX-101 or placebo) at Visit 2 (Day 1) for primary analysis. The average of 
screening and Visit 2 (Day 1) values will also be derived for exploratory purpose.   
 
Change from Baseline  
Change from baseline (CFB) will be calculated as (value at post-baseline visit – value at 
baseline). CFB will be calculated for subjects with both a baseline and post-baseline value as 
applicable. Percent CFB will be calculated as (CFB/baseline)*100, where applicable. If a 
baseline or post-baseline value has not been recorded for a parameter, then CFB will not be 
calculated for that parameter. Subjects with missing CFB values will be excluded from analyses 
in which CFB is the endpoint unless otherwise noted. 
 
Study Day 1 
The first day of study product administered. 


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Study Day 
Study day is defined as the number of days from Study Day 1. 
• Before Study Day 1: Study Day = (Date of Interest – Date of Study Day 1) 
• On or After Study Day 1: Study Day = (Date of Interest – Date of Study Day 1) + 1 
Therefore, the day prior to Study Day 1 is -1. 
 
Study Completion  
A subject is considered completed the study if a subject is not terminated early and completes 
Visit 5 (Day 29). 
Prior and Concomitant Medications  
Prior medications will be any medication with a start date before the first day of treatment that 
has been discontinued prior to the first dose of study treatment. 
Concomitant medications are defined as any medications ongoing at the start of treatment or with 
a start date on or after the first dose date but on or prior to the last dose of treatment date.  
Treatment-emergent Adverse Event (TEAE) 
A TEAE is defined as an AE which begins or an aspect of medical history that increases in 
severity after the first dose of study drug until the final study visit phone call on Day 31. Adverse 
Events will be considered treatment-emergent if they have missing or partial start dates for which 
it cannot be determined whether the AE started before or after the first dose of study medication. 
Adverse Events with Outcome of Death 
Any AE with an outcome of “fatal” will be considered as AE with an outcome of death.  
 
Imputation of AE (for determination of TEAE only) and concomitant medication start and 
stop dates: 
Start Date:   
If only ‘day’ is missing, and the month and year are not the same as the month of first dose, 
then impute day with ‘01’.  Otherwise, if the month and year are the same as the first dose 
date, use the first dose date.  
 If ‘day’ and ‘month’ are missing, and ‘year’ is not missing, then impute month and day with 
month and day of the first dose date (assuming same ‘year’).  
 If ‘day’ and ‘month’ are missing and ‘year’ is not missing and is not the same year as first 
dose date, then impute with ‘01’ for both ‘day’ and ‘month’.  If the start date is completely 
missing, it will be set to the first dose date. 
Stop Date:   
If only ‘day’ is missing, impute day with last day of the month.  


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If ‘day’ and ‘month’ are missing, and ‘year’ is not missing, then impute month with ‘12’ and 
day with ‘31’ (or date of study discontinuation/completion if earlier than 12-31 and year is 
the same as the year of discontinuation). 
 If the stop date is completely missing, it will be set to the date of study 
discontinuation/completion. A stop date will not be applied to ongoing AEs. 
The imputed dates will be used to assess whether AEs should be considered as treatment-
emergent and if medications should be included in the safety summaries as prior or concomitant, 
however the original, partial dates will be included in data listings.  The duration of AEs will be 
derived as the AE end date (including imputation date for incomplete AE end date) –AE onset 
date (imputed date for incomplete AE onset date) +1. 
Treatment-related Adverse Events 
Any AE with a relationship to study treatment of “Possibly Related” or “Definitely Related” or 
missing will be considered a treatment-related AE as determined by the Investigator. 
Analysis Visit window  
Since the actual visit for a subject may not exactly coincide with the scheduled visit date, the 
actual visit date is mapped to the study analysis visit as follows: 
Study Analysis Visit 
Target Day 
Study Day 
Interval (days) 
Visit 1, Screening 
Varies 
<= -1 
NA 
Visit 2, Baseline  
1 
1 
NA 
Visit 3, Week 1 
7 
2 – 11 
10 
Visit 4, Week 2 
14 
12 – 21 
10 
Visit 5, Week 4 
28 
≥22  
NA 
 
For lab assessment and spirometry assessment, if more than one actual visit falls within the same 
defined window, the visit closest to the target day with non-missing data will be considered for 
analysis. If two actual visit dates are at the same distance from the target day, the latest visit with 
non-missing data will be considered for analysis.  
All summaries and analyses will utilize analysis visits, where appropriate.  Data listings will 
present actual visit names as recorded in the clinical database. Tabulations will not include rows 
for unscheduled visits, however, unscheduled visits will be included in listings.  
 
Cystic Fibrosis Questionnaire – Revised (CFQ-R) Domain Scores 
 
The recall period for this instrument is within the past 2 weeks. The domain scores are calculated 
as follows, as per University of Miami’s scoring guidelines: 
 
First, item scores are assigned as values between 1 and 4.  Next, items #6, #10, #13, #15, #17, 
#18, #23, #28, #30, #32, #34, #35, and #43 are reverse scored, where the new score is (5 – old 
score). If an item response is missing, the median value of scores for other items within that 
domain (e.g., #1 - #5, #13, #19, #20 for physical domain, and #40 – #42, #44 – #46 for 
respiratory domain) will be imputed, if no more than half of the responses for that domain are 


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missing.  If more than half of the answers for a specific domain are missing, that domain score 
will be missing. 
The respiratory domain score is calculated as (#40 + #41 + #42 + #44 + #45 + #46 – 6)/18 * 100.  
The physical domain score is calculated as (#1 + #2 + #3 + #4 + #5 + #13 + #19 + #20 – 8)/24 * 
100.   
Concomitant Hypertonic Saline 
For Cohort 1, concomitant hypertonic saline use will be identified by a review of all concomitant 
medication terms by ATC, preferred name, and verbatim term.  The Medical Monitor or 
designee will review all concomitant medications (while blinded to treatment information) prior 
to database lock, and identify which medications are inhaled hypertonic saline.  This information 
will be recorded on a spreadsheet, finalized prior to database lock, and incorporated into analysis 
datasets for use in summaries and analyses. 
For Cohort 2, concomitant hypertonic saline use will be identified prior to randomization by the 
investigator or designee and will be entered into the Interactive Voice/Web Response System. 
9.0 Analysis Sets 
9.1 Intention-to-Treat Analysis Set 
The Intent-to-Treat (ITT) Analysis Set will include all enrolled (randomized) subjects. Subjects 
will be grouped according to their randomized study group assignment regardless of the actual 
treatment received. The ITT population will be the primary population for all efficacy analyses. 
9.2 Per Protocol Analysis Set 
The Per-Protocol (PP) Analysis set will include all subjects in the ITT population who did not 
have important protocol violations. Important protocol violations are defined as those that may 
have a substantial impact on efficacy assessments. The criteria to be used for excluding subjects 
from the PP population will be determined before database lock and will be documented. The PP 
analysis may be performed for the primary and secondary efficacy endpoints, to provide 
supportive evidence for efficacy. 
9.3 Safety Analysis Set  
The Safety Analysis Set will include all enrolled subjects who receive at least 1 dose of the 
study drug.  This analysis set will be used for all safety analyses. 
10.0 Interim Analyses 
There was no interim analysis in this study. At the end of the Cohort 1 part of the study, all 
data was locked prior to review by the Sponsor which enabled selection of the Cohort 2 dosing 
regimens. 
An independent DSMB will periodically review the accrued safety data in an unblinded 
manner to monitor the safety of subjects. There will be 3 scheduled DSMB meetings at the 


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following time points: the approximate midpoint of Cohorts 1 and 2 (after approximately 19 
subjects have been randomized or at the discretion of the DSMB) and at the completion of 
Cohort 1.  
11.0 Data Review 
11.1 Data Handling and Transfer 
Data will be entered into the clinical database and exported as SAS® datasets. Subsequent 
datasets will be created using SAS and following standard Clinical Data Interchange Standards 
Consortium Standard Data Tabulation Model (CDISC SDTM, version 1.3, Implementation 
Guide version v3.1.3) conventions. Analysis datasets will be created using SAS and following 
CDISC Analysis Data Model (ADaM, version 2.1, Implementation Guide 1.0) standards. 
Medical history and AEs will be coded using the Medical Dictionary for Regulatory Activities 
(MedDRA), version 20.0 at the time of the analysis to assign a system organ class (SOC) and 
preferred term (PT) to each event. Prior and concomitant medications will be coded using the 
World Health Organization Drug Dictionary WHODRUG 2017SEP01 DDE+HD B2 at the time 
of the analysis. 
Additional details can be found in the PRA Data Management Plan and the Data Quality Plan for 
this study. 
11.2 Data Screening 
Beyond the data screening built into the PRA Data Management Plan, the PRA programming of 
analysis datasets, tables, figures, and listings (TFL) provides additional data screening. Presumed 
data issues will be output into SAS logs identified by the word “Problem” and extracted from the 
logs by a SAS macro and sent to Data Management. 
The PRA statistician and the SPYRYX Biosciences signatory must approve database lock. 
12.0 Statistical Methods 
All statistical programming will use SAS® version 9.4 or higher.  
All statistical analyses will be performed using a two-sided alpha = 0.05, unless otherwise 
specified. 
For two sequential cohorts, each cohort will be analyzed separately based on its own baseline.  
Unless otherwise specified, descriptive summaries will be tabulated by treatment groups and 
overall. Categorical data will be presented using counts and percentages, with the number of 
subjects in each category as the denominator for percentages. Percentages will be rounded to one 
decimal place except 100% will be displayed without any decimal places and percentages will 
not be displayed for zero counts.  
All continuous data will be summarized using the number of observations (n), mean, standard 
deviation (SD), median, first quartile, third quartile, minimum, and maximum. Minimum and 
maximum will be rounded to the precision of the original value. Mean and median will be 


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rounded to one decimal place greater than the precision of the original value. The SD will be 
rounded to two decimal places greater than the precision of the original value. 
12.1 Subject Disposition 
The number of subjects screened will be tabulated.  In addition, the number and percentage of 
enrolled (randomized), and the number of subjects in each defined analysis set (ITT, PP, safety) 
will be summarized by treatment group and total for all enrolled subjects.  
Subject disposition will be summarized by treatment group and overall using the ITT analysis 
set. The table will present the number and percentage of subjects who completed study. The 
number and percentage of subjects who discontinued from the study will be summarized by the 
reason for study discontinuation collected in the CRF.   
Disposition data will be listed by subject using the ITT analysis set. 
12.2 Demographic and Baseline Characteristics 
Demographic and baseline characteristics, including age (years and categories of <30, ≥30-<40, 
≥40, sex, ethnicity, race, baseline height [cm], weight [kg], BMI and smoking tobacco history 
will be summarized descriptively by treatment group and total using the ITT analysis set.    
Cystic Fibrosis (CF) history, including CF diagnosis, time from diagnosis to first dose date in 
years, the number of CF related hospitalization within past year and the number of pulmonary 
exacerbations within the past year will be summarized by treatment group and total using the 
ITT analysis set. In addition, the number of subjects who were concomitantly taking inhaled 
hypertonic saline and inhaled antibiotics during the treatment period will be summarized as 
above (Cohort 2 only). A listing of Cystic Fibrosis history will also be presented by treatment 
group and total using the ITT analysis set.  
Baseline Spirometry, including absolute FEV1, ppFEV1, absolute FVC and ppFVC, will be 
summarized and listed by treatment group and total and by timepoints using the ITT analysis set. 
12.3 Important Protocol Deviations 
Per PRA processes, protocol deviations (PDV) data will be entered into our Clinical Trials 
Management System (CTMS). The study team and the sponsor will conduct on-going reviews of 
the deviation data from CTMS and the resulting set of evaluable subjects throughout the study, 
finalizing the PDV criteria as seems appropriate. The evaluable subjects set must be finalized at 
the post-freeze data review meeting (or earlier), prior to database lock. 
Important protocol deviations (IPD) are a subset of protocol deviations that might significantly 
affect the completeness, accuracy, and/or reliability of the study data or that might significantly 
affect a subject's rights, safety, or well-being. IPDs will be summarized by category. The sponsor 
and study team will review and categorize IPDs. A list of subjects with IPDs will be presented.  
12.4 Treatment Exposure 
The investigational PARI eFlow nebulizer with PARI eTrack will be used for the dose 
administration. The ‘Adherence Report’ will be generated by the eTrack controller in the 
PARItrack web portal by the vendor.  


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The variables from PARI’s ‘adherence report’ are the following: 
• Start date and time 
• Day of this subject´s therapy  
• Status of each nebulization  
• Device serial number 
There will be no additional summary of drug exposure and drug compliance in this SAP.  A data 
transfer from PARI to PRA is not intended.  An “adherence report” in PDF-file format through 
the PARItrack web portal will be available for inclusion in the eTMF. 
12.5 Prior and Concomitant Medications 
Prior/concomitant medications will be coded by World Health Organization Drug Dictionary (as 
per Section 8) and will be summarized by Anatomic Therapeutic Classification (ATC) class and 
preferred name. The analysis will be performed using the ITT population. 
The numbers and percentages of subjects using each medication will be displayed. Subjects 
taking more than one medication in the same ATC class or preferred name will be counted once 
per ATC and once per preferred name. 
Prior and concomitant medications will be listed, including start and stop dates, dose, unit, 
frequency, route of administration, indication and reason for administration.  
12.6 Efficacy Analyses 
The primary analysis, secondary efficacy endpoints and exploratory efficacy endpoints will be 
performed on the ITT analysis set. The primary and secondary efficacy endpoints will be 
repeated on the PP analysis set, to provide supportive evidence for efficacy, only if there are 
substantial differences from ITT.  
12.6.1 Primary Variable 
Primary Efficacy Analysis 
The primary efficacy endpoint is the change from baseline in ppFEV1 at visit 5 (week 4). The 
change from baseline in ppFEV1 at each visit (Weeks 1, 2, and 4) will be summarized and 
compared between each treatment group and placebo. No imputation of missing data will be 
done for this analysis. 
The comparison between each treatment group and placebo will be evaluated by using an 
analysis of covariance (ANCOVA) model, which will include treatment as the factor, and the 
stratification factor as a covariate (i.e., baseline lung function categories [ppFEV1 40.0% to 
55.0% or 55.1% to 80.0% for Cohort 1] and the concomitant use of hypertonic saline for Cohort 
2). Also included in the ANCOVA model for Cohort 2 is baseline ppFEV1. Descriptive statistics 
will include the number of observations, unadjusted mean, standard deviation, median, first 
quartile, third quartile, minimum and maximum, and least squares mean. Treatment differences 
from placebo will be presented and estimated by least squares means from the analysis model 
along with 95% confidence intervals and associated 2-sided p-values, which are presented for 
descriptive purposes. 


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As described in the power and sample size calculations in Section 6.1, Cohort 1 will be evaluated 
for success using a two-sided 0.15 significance level. Cohort 2 will be evaluated for success 
using a one-sided (upper) 0.10 significance level.  For Cohort 2, both the one-sided p-value and 
the lower bound (i.e. one-sided 90% confidence interval) will be presented. 
The assumption of homogeneity of variance will be evaluated using Levene’s test, on an 
ANOVA model with treatment as a factor, since Levene’s test cannot be performed with an 
additional covariate in the model (i.e., the ANCOVA model).  The assumption of normality will 
be evaluated using the Shapiro-Wilk test, applied to the raw residuals from the ANCOVA model.  
Both will be tested at the 0.05 level of significance. If Levene’s test has p > 0.05 but the Shapiro-
Wilk test is significant, the ANOVA model with treatment as a factor will be evaluated for the 
assumption of normality.  If that model meets criteria, it will be used as the primary efficacy 
analysis.  If either Levene’s test is significant, or the Shapiro-Wilk test is significant for both the 
ANCOVA and ANOVA models, a non-parametric Kruskal-Wallis test (for Cohort 1) or 
Wilcoxon-Mann-Whitney test (for Cohort 2) will be used to compare ppFEV1 between treatment 
arms. Note that both the Kruskal-Wallis and Wilcoxon-Mann-Whitney tests do not allow for 
covariates, so baseline lung function category will be excluded from the analysis. 
In Cohort 1 only, the primary efficacy analysis will also be repeated comparing the combined 
SPX-101 treatment groups with the placebo group. 
Analyses of ppFEV1 at Additional Timepoints 
The above approach will be repeated for testing treatment differences from placebo in the other 
timepoints, with a two-sided significance level of 0.05: 
• Change from baseline in ppFEV1 at visit 3 (week 1)  
• Change from baseline in ppFEV1 at visit 4 (week 2). 
Mixed Model for Repeated Measures 
The change from baseline in ppFEV1 at each visit (week 1, 2, and 4) will also be evaluated using 
a mixed effect model for repeated measure (MMRM).  
For Cohort 1, to evaluate treatment differences of ppFEV1 change from baseline across time 
points (week 1, 2 and 4), a likelihood-based mixed effect model repeated measures (MMRM) 
analysis will be run on ITT analysis set. The model will include the change from baseline in 
ppFEV1 as the dependent variable; the treatment, visit and treatment by visit interaction term will 
be treated as fixed effects, and covariates of baseline lung function category (ppFEV1 40.0% to 
55.0% or 55.1% to 80.0% for Cohort 1).  Subject will be treated as a random effect. 
For Cohort 2, the MMRM analysis will be performed for the change from baseline in ppFEV1 to 
estimate the treatment difference at Week 4. The model will include all participants in the ITT 
population, and the dependent variable will be the observed change from baseline in ppFEV1 at 
each post-randomization visit. Covariates in the model will include the fixed categorical effects 
of treatment, concomitant use of hypertonic saline, visit and treatment by visit interaction, as 
well as the continuous fixed covariates of baseline ppFEV1 and baseline ppFEV1 by visit 
interaction. 


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Descriptive statistics will be presented for Visit 5 (week 4), and for all visits for Cohort 2, and 
will include number of observations, unadjusted mean, standard deviation, median, first quartile, 
third quartile, minimum and maximum, and adjusted mean from the mixed model. Treatment 
differences from placebo will be presented and estimated via least squares means from the 
analysis model along with 95% confidence intervals. The 2-sided p-value of the overall analysis 
at Week 4 will be presented. These models will be performed using an unstructured correlation 
matrix to model the within-subject errors and the Kenward-Rogers correction to degrees of 
freedom will be applied.  If the unstructured covariance matrix does not converge when fitting 
the mixed model, further investigation into the most appropriate correlation matrix will be 
conducted.  The final selection of the correlation matrix to be used in fitting the mixed model 
will be noted in the footnote and fully documented in the results section of the clinical study 
report. 
ANCOVA with Multiple Imputation of ppFEV1 
Multiple imputation will be used to explore the effect of missing data on the primary endpoint in 
Cohort 2 only. All missing ppFEV1 data at baseline and Visit 5 (week 4) will be imputed for all 
enrolled subjects, utilizing the full conditional specification method (FCS). Missing values will 
be imputed using treatment, hypertonic saline use, sex, age group, and the ppFEV1 recorded at 
each time point (including baseline). For this analysis, CFB will be calculated for all subjects 
following imputation. 
An ANCOVA model with treatment as a factor, and concomitant use of hypertonic saline and 
baseline ppFEV1 as covariates, will be run on the imputed data from PROC MI and results will 
be combined using PROC MIANALYZE. Further details of the multiple imputation are 
described in section 12.6.5. 
Descriptive statistics of the imputed data combined with observed data will include the number 
of observations, unadjusted mean, standard deviation, median, first quartile, third quartile, 
minimum and maximum, and least squares mean. Treatment differences from placebo will be 
presented and estimated by least squares means from the analysis model along with 95% 
confidence intervals and associated 2-sided p-value. 
12.6.2 Secondary Variables 
FEV1,  
Similar ANCOVA analyses as the primary analysis, using a two-sided significance level of 0.05,  
will be repeated for testing treatment differences from placebo in the endpoints: 
• Change from baseline in FEV1 at visit 3 (week 1) 
• Change from baseline in FEV1visit 4 (week 2)  
• Change from baseline in FEV1 visit 5 (week 4) 
 
FVC and ppFVC  
Similar ANCOVA analyses as the primary analysis, using a two-sided significance level of 0.05,  
will be repeated for testing group differences in the endpoints: 


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• Change from baseline in FVC at visit 3 (week 1) 
• Change from baseline in FVC at visit 4 (week 2)  
• Change from baseline in FVC at visit 5 (week 4)  
• Change from baseline in ppFVC at visit 3 (week 1) 
• Change from baseline in ppFVC at visit 4 (week 2)  
• Change from baseline in ppFVC at visit 5 (week 4)  
 
FEF25-75  
Similar ANCOVA analyses as the primary analysis, using a two-sided significance level of 0.05,  
will be repeated for testing group differences in the endpoints: 
• Change from baseline in FEF25-75 at visit 3 (week 1) 
• Change from baseline in FEF25-75 at visit 4 (week 2)  
• Change from baseline in FEF25-75 at visit 5 (week 4)  
 
Cystic Fibrosis Questionnaire – Revised (CFQ-R) 
The respiratory and physical domain scores will be calculated as described in Section 8.  The 
observed scores at Visit 1, Visit 5 (week 4), and change-from baseline at Visit 5 (week 4) will be 
summarized for each domain. Scores from the respiratory and physical domains will be listed. 
12.6.3 Exploratory Analyses 
Pulmonary Exacerbation 
The number and percentage of subjects with pulmonary exacerbation will be tabulated using the 
ITT analysis set, by treatment groups and total and by visit. A subject listing will be provided. 
Further analysis may be explored. 
Concomitant Hypertonic Saline 
The number and percentage of subjects using concomitant hypertonic saline will be tabulated 
using the ITT analysis set, by treatment groups and total. A subject listing will be provided. 
Further analysis may be explored. 
12.6.4 Additional Analyses 
Others 
The change from baseline in the ppFEV1, FEV1, FVC, and ppFVC (at Weeks 1, 2 and 4, as 
described for the primary efficacy analysis) will be summarized and analyzed separately by 
subgroup (using concomitant hypertonic saline vs no concomitant hypertonic saline usage), 
utilizing the ITT analysis set. 
  


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The change from baseline in ppFEV1 by strata (baseline ppFEV1 <= 55%, baseline ppFEV1 
>55%) will be explored by treatment groups and by visit, also by combined active group and 
placebo group (Cohort 1 only).  
 
The change from baseline in ppFEV1 by treatment groups, by visit and by category (≤ -10%, 
> -10% – ≤ -5%, > -5% - ≤ 0%, > 0% - ≤ 5%, > 5% - ≤ 10%, > 10% - ≤ 15%, > 15%) will be 
explored.  
 
The change from baseline in the ppFEV1, FEV1, FVC, and ppFVC (at Weeks 1, 2 and 4, as 
described for the primary efficacy analysis) may be summarized and analyzed separately by 
subgroup (CFTR Modulator Response vs No Response) , utilizing the ITT analysis set. This will 
be done only if there is a sufficient sample size to warrant this analysis.  This population cannot 
be defined programmatically, therefore the sponsor will review the genetic mutations for each 
subject, and will identify those that have class 1 or other CFTR modulator non-responsive 
mutations, and will provide this information to PRA. 
 
The change from baseline in the ppFEV1 (at Weeks 1, 2 and 4, as described for the primary 
efficacy analysis) will be summarized and analyzed separately by subgroup based on starting a 
new cycle of concomitant inhaled antibiotics within +/- 3 days of start of study drug vs not 
starting a new cycle of inhaled antibiotics within +/- 3 days of start of study drug use in the ITT 
analysis set.  The first data set will include patients taking inhaled antibiotics defined as those 
who start a cycle of inhaled antibiotics with study drug (patients who are on an on-month of an 
alternating month on/month off cycle with a single inhaled antibiotic and those that alternate 
monthly between 2 inhaled antibiotics).  The second data set will include all the patients that do 
not begin a new inhaled antibiotic with study drug (patients who are off-cycle of an alternating 
month on/month off cycle, patients who are taking continuous inhaled antibiotics, or patients 
who are not taking inhaled antibiotics.  Due to data capture limitations, these populations cannot 
be defined programmatically with certainty.  Therefore, the sponsor will review the inhaled 
antibiotic usage and will identify the patients to be included in each data set.   
 
The change from baseline in the ppFEV1 (at Weeks 1, 2 and 4, as described for the primary 
efficacy analysis) will be summarized and analyzed separately by subgroup (using dornase alfa 
and not using dornase alfa), utilizing the ITT analysis set.   
 
12.6.5 Methods for Handling Dropouts and Missing Data 
Missing data will not be imputed, with the exception of missing or partial dates, missing item 
responses on the CFQ-R, and missing baseline and Visit 4 (week 5) ppFEV1.  
 
Missing or partial dates will be imputed if dates are missing or incomplete for an AE (including 
death event) or concomitant medication as described in Section 8.0. 
 
Partial dates for the date of CF diagnosis will be imputed. If only ‘day’ is missing, then impute 
day with ‘01’. If ‘day’ and ‘month’ are missing, and ‘year’ is not missing, then impute both 
month and day with ‘01’.  


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Missing item responses will be imputed using the median of item responses within that domain, 
when no more than half the item responses are missing, for CFQ-R domain scores.  See Section 
8 for more details.  
 
Missing ppFEV1 data will be imputed only for use in the sensitivity analysis described in section 
12.6.1.  The FCS multiple imputation method will be used. The multiple imputation will be 
carried out in SAS using PROC MI. Twenty sets of imputed data will be generated and the 
default maximum of 100 iterations will be used to attempt to impute values within the 
appropriate range for each variable, though this may be increased to impute appropriate values.  
 
12.6.6 Multiplicity 
There will be no multiplicity adjustments for this study. 
12.6.7 Pooling of Sites 
All sites will be pooled together for the analyses.    
12.7 Pharmacokinetics (PK) 
At Visit 2, blood samples for PK testing will be collected pre-dose and at 5±2 minutes and 15±5 
minutes after completion of administration of the study drug, for Cohort 1 only. 
There will be no additional summary of PK in this SAP.  A data transfer from QPS to PRA is not 
intended.  QPS will send a listing of PK results for inclusion in the eTMF 
12.8 Safety Analyses 
The Safety Analysis set will be used to summarize all safety endpoints. 
12.8.1 Adverse Events   
Any condition, event and/or signs and symptoms occurring after signing the informed consent 
form and before starting study drug treatment should be recorded as medical history in the eCRF.  
Medical conditions/diseases are considered AEs only if they start or worsen after starting study 
drug treatment (first application of study drug).   
Therefore, an AE includes any condition (including a pre-existing condition) that: 1) was not 
present prior to study treatment, but appeared or reappeared following initiation of study 
treatment, or 2) was present prior to study treatment, but worsened during study treatment. 
A Treatment Emergent Adverse Event (TEAE) is defined as per Section 8. 
Subject incidence of adverse events (AEs) will be summarized by MedDRA system organ class 
(SOC) and preferred term (PT), severity and relationship to study drug for each treatment group 
and total. For incidence reporting, subjects will be counted only once within same SOC or PT. 
All AEs, TEAEs and pertinent subject information will be presented in data listings. Serious 
adverse events (SAEs), AEs leading to death, and AEs leading to withdrawal from study will be 
presented in separate listings respectively. An overall summary of AEs will be provided by 
treatment groups and total.    


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Missing values for severity will be assigned as ‘severe’ and missing values for relationship to 
treatment will be considered as ‘related’ in the summary. 
A summary of AEs by SOC and PT will be tabulated in descending order of frequency by 
treatment groups and total for the following: 
• AEs leading to study discontinuation  
• AEs leading to death 
• All serious adverse events (SAEs) 
• SAEs related to study treatment 
• All treatment-emergent AEs (TEAEs) 
• Treatment-related TEAEs  
• TEAEs by maximum severity. For each system organ class or preferred term, multiple 
occurrences of events within a subject are counted only once at the highest severity 
12.8.1.1 Adverse Events of Special Interest (AESI) 
For those adverse events considered as TEAEs of special interest (hyperkalemia/increased 
potassium) classification will be final before final database lock (DBL).  
The total number of AESIs will be summarized for each treatment group and total.  
12.8.2 Laboratory Data 
All laboratory test results will be reported in International System of Units (SI). 
Descriptive summaries of changes from baseline for each laboratory test listed below will be 
provided for numerical laboratory assessments by visit.  
Each laboratory value will be assessed as low, normal or high based on the normal ranges 
provided by the laboratory.  Laboratory shift tables from baseline to each post-baseline visit for 
lab values evaluation of ‘High’ ‘Low’ or ‘Normal’, when available, will be planned when the 
baseline results are available. 
The categorical lab results will be summarized by frequency and percentage and by visit. 
The clinical safety laboratory tests will include the following parameters: 
• Hematology: White blood cell count, red blood cell count, red blood cell indices, 
hemoglobin, hematocrit, platelet count, and a 5-part white blood cell differential 
(neutrophils, lymphocytes, monocytes, eosinophils, and basophils) 
• Clinical chemistry: Liver function tests (ALT, ALP, AST, and gamma 
glutamyltranspeptidase), electrolytes (sodium, potassium, chloride, and bicarbonate), 
total bilirubin, blood urea nitrogen, calcium, C-reactive protein, creatinine, glucose, 
lactate dehydrogenase, total protein, and albumin 


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• Blood and urine electrolytes: sodium, potassium, chloride, and bicarbonate  
• Urinalysis: pH, specific gravity, protein, glucose, and ketones 
Pregnancy test results for females of childbearing potential only will be listed by visit for each 
treatment group.  
If multiple assessments per lab test are done on the same date, then the average value will be 
used. The denominator for the percentages will be the total number of subjects in the treatment 
group with a baseline and post-baseline value. Laboratory parameters with abnormal clinically 
significant results will be identified and listed, where available.   
12.8.3 Vital Signs 
Vital signs (systolic and diastolic blood pressure, heart rate, and body temperature) will be 
measured at each visit during screening and treatment period.   
Observed values and changes from baseline in vital signs will be summarized by vital sign 
parameter and visit. Descriptive statistics will be shown for baseline, each post-baseline time 
point, and the change from baseline to each post-baseline time point. 
12.8.4 Electrocardiograms (ECGs) 
At a minimum, heart rate and the P, PR, QRS, QT, and QTcF intervals will be obtained and 
entered into the eCRF. The Investigator will also evaluate whether the ECG is normal or 
abnormal, and if abnormal, whether the abnormality is clinically significant. 
The number and percentage of subjects for each category of ECG evaluation will be presented by 
treatment group and total. ECG shift tables from baseline to visit 5 for clinical interpretation of 
normal, abnormal, clinically significant abnormal will be presented.   
A listing of subjects with ECG assessments, including the clinical evaluation results, will be 
provided. 
12.8.5 Physical Examinations and Other Observations Related to Safety 
Physical examination results for all body systems examined will be summarized and listed by 
visit for each treatment group.  
12.8.6  Antidrug Antibodies (ADA) 
Anti-Drug Antibody (ADA) response to the study drug will be listed. A summarization of ADA 
may be considered based on the frequency of ADA detected. 
12.8.7  Post-Dose FEV1 (Day 1 only) 
 
A summary of Day 1 change from baseline from pre-dose at each post-dose time point on Day 1 
(ie, 30 min, 2 hrs and 4 hours post-dose).  Only descriptive statistics will be presented.  


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13.0 Pooled Analyses Across Cohorts 
The analyses specified in Sections 12 will be performed separately for each cohort, where 
applicable.  In addition, the following summaries and analyses may be performed on the pooled 
cohorts for exploratory purposes.  If performed, summaries and analyses will be presented by 
dose level (60 mg SPX-101 Cohort 1, 120 mg SPX-101 Cohort 1 and 2, and pooled placebo) and 
overall. 
• Summary of subject disposition 
• Summary of subject demographics 
• Summary of CF history 
• An ANCOVA as described in Section 12.6.1, using baseline ppFEV1  use as a covariate. 
 
14.0 Validation 
PRA's goal is to ensure that each TFL delivery is submitted to the highest level of quality. Our 
quality control procedures will be documented separately in the study specific quality control 
plan.  
15.0 References 
Fuchs HJ, Borowitz DS, Christiansen DH, Morris EM, Nash ML, Ramsay BW, et al. Effect of 
aerosolized recombinant human DNAase on exacerbations of respiratory symptoms and on 
pulmonary function in patients with cystic fibrosis. N Engl J Med. 1994;331:637-642 
 
CFQ-R Scoring guidelines: Handscoring instructions. University of Miami, copyright 2008. 
http://www.psy.miami.edu/cfq_QLab/scoring.html accessed 31Oct2018. 
 
 
 
 
 
 
 
 
 
Appendix 1 Glossary of Abbreviations 
Glossary of Abbreviations: 


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ADaM 
Analysis Data Model 
AE 
Adverse event 
AESI 
Adverse event of special interest 
AR1 
First order autoregressive 
ALT 
Alanine aminotransferase test 
ALP 
Alkaline phosphatase test 
ANOVA 
Analysis of variance 
ANCOVA 
Analysis of covariance 
AST 
Aspartate aminotransferase test 
BID 
Twice daily 
BMI 
Body mass index 
CF 
Cystic Fibrosis 
CFB 
Change from baseline 
CFQ-R 
Cystic fibrosis questionnaire revised 
CRF 
Case Report Form 
CS 
Compound symmetry 
CSR 
Clinical Study Report 
CTMS 
Clinical trials management system 
DSMB 
Data Safety Monitoring Board 
ECG 
Electrocardiogram 
ET 
Early termination 
FEF 
Forced Expiratory Flow 
FEV1 
Forced expiratory volume in 1 second 
FVC 
Forced vital capacity 
FU  
Follow up  
HE 
Health Economics 
IP 
Investigational product  
IPD 
Important protocol deviations 
ITT 
Intention-to-treat 
IVRS 
Interactive Voice Response System 
MedDRA 
Medical Dictionary for Regulatory Activities 
MMRM 
Mixed effect model repeated measures 
PDV 
Protocol deviation  
PK 
Pharmacokinetic 


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PP 
Per Protocol 
ppFEV1 
Percent Predicted forced expiratory volume in 1 second  
ppFVC 
Percent Predicted forced vital capacity 
QD 
Once daily 
QoL 
Quality of Life 
SAP 
Statistical Analysis Plan 
SAE 
Serious Adverse Event 
SAS 
Statistical analysis system 
SDTM 
Standard Data Tabulation Model 
TC 
Telephone call 
TEAE 
Treatment-emergent adverse event 
TFL 
Table, figures and listings 
WHO 
World Health Organization 


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 Appendix 2 Tables, Figures, Listings, and Supportive SAS Output 
Appendices 
 
The TFL shells and table of contents are provided in a separate document titled “SPYPX101 
TFL Shells Version 2_0”.