Clinical trial NCT03662789
Conditions: Heart Transplant Recipients
Keywords: Heart transplant Iron deficiency Intravenous iron supplement Peak oxygen consumption Cardiopulmonary exercise test Cognitive function Muscle strength
Sponsor: Oslo University Hospital
Start date: 2018-04-25; Completion date: 2020-02-27
Enrollment: 102 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
Iron deficiency is prevalent in heart transplant recipients, and may be associated with reduced functional capacity. The IronIC trial is designed to assess the effect of intravenous iron isomaltoside on exercise capacity, muscle strength, cognition and quality of life in iron-deficient heart transplant recipients

Detailed description:
Iron deficiency is prevalent in patients with heart failure. Iron deficiency is associated with a worse prognosis, and randomised controlled trials have shown that correction of iron deficiency with intravenous iron therapy improves functional capacity, quality of life, and 6-minute walk distance. Current guidelines therefore recommend intravenous iron substitution in patients with heart failure with reduced ejection fraction and iron deficiency. Intravenous iron is more effective, better tolerated, and improves quality of life to a greater extent than oral iron supplements. In the IRONOUT HF trial, in which 225 patients with systolic heart failure were randomised to oral iron supplement or placebo, there was no effect on oxygen uptake, 6-minute walk distance, or quality of life. The authors attributed the negative results to the minimal effect on iron stores, suggesting that oral iron does not adequately replenish iron stores in patients with heart failure.

Cardiac allograft recipients resemble patients with heart failure in many respects. Prior to transplantation, and in some instances after heart transplantation, they have had overt heart failure. Moreover, due to the immunologic challenge posed by the allograft, and their susceptibility to infection due to immunosuppressive treatment, cardiac allograft recipients have low-grade inflammation. This low-grade inflammation makes it difficult to interpret iron stores, and results in dysregulated iron metabolism.

There have been no studies to assess the effect of intravenous iron therapy in heart transplant recipients who have iron deficiency. There is reason to believe that a liberal definition of iron deficiency should be used in cardiac allograft recipients, and the investigators have elected to use the well-established definition used in patients with heart failure: serum ferritin \< 100 µg/l or ferritin between 100 and 300 µg/l in combination with a transferrin saturation \< 20 %. Because oral iron supplement is less effective then intravenous iron in general, and in patients with heart failure in particular, the investigators assume that oral iron supplement is inadequate in heart transplant recipients. the investigators have designed the IronIC trial to assess the effect of intravenous iron isomaltoside on exercise capacity, muscle strength, cognition and quality of life in iron-deficient heart transplant recipients.

Arms: arm 1: The active drug, iron isomaltoside 1000 will be administered as a single, intravenous infusion of 20 mg/kg body weight (rounded off to the nearest 100 mg) dissolved in 100 ml NaCl as recommended by the drug manufacturer ("on-label" treatment). arm 2: Patients allocated to placebo will receive an intravenous infusion of 100 ml NaCl 0.9%
Interventions: intervention 1: Iron Isomaltoside 1000 intervention 2: Placebo: NaCl 0,9%
Intervention descriptions: intervention 1: Intravenous infusion intervention 2: Intravenous infusion

Protocol documents:
Prot_000.pdf: 
IronIC Protocol version 1.41 March 20tieth 2018 
Page 1 
 
 
 
Intravenous Iron 
supplement for Iron 
deficiency in Cardiac 
transplant recipients:  
The IronIC trial 
 
 
 
 
 
Protocol Identification Number: IronIC 1.41 
EudraCT Number: 2017-004871-30   
NCT03662789  
 
SPONSOR: 
Oslo University Hospital 
Address: Postboks 4590 Nydalen 
0424 Oslo, Norway 
E-mail: post@oslo-universitetssykehus.no 
 
PRINCIPAL INVESTIGATOR: 
Professor Lars Gullestad 
Address: OUS-Rikshospitalet 
Postboks 4590 Nydalen 
0424 Oslo, Norway 
Tel : 23070000 
E-mail: lars.gullestad@medisin.uio.no 
 
PROTOCOL VERSION NO. 1.41 
March 20tieth 2018 
Kaspar Broch 
 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 2 
 
 
1 
CONTACT DETAILS 
 
Sponsor: 
Oslo University Hospital (OUS) 
Address: Postboks 4590 Nydalen 
0424 Oslo, Norway 
E-mail: post@oslo-universitetssykehus.no 
Coordinating Investigator  
Professor Lars Gullestad 
Address: OUS-Rikshospitalet 
Postboks 4590 Nydalen 
0424 Oslo, Norway 
Tel : 23070000 
E-mail: lars.gullestad@medisin.uio.no 
 
Investigators  
Kristine Brautaset 
E-mail: brautaset@hotmail.com  
  
Professor Lars Gullestad 
E-mail: lars.gullestad@medisin.uio.no 
 
Kaspar Broch 
E-mail: sbbrok@ous-hf.no 
 
Arne K Andreassen 
E-mail: aandreas@ous-hf.no  
 
Einar Gude 
E-mail: egude@ous-hf.no 
 
Trond Vartdal 
E-mail: tvartdal@ous-hf.no 
 
Participating Department: 
Dept of Cardiology, OUS  
Visiting address: Sognsvannsveien 20 
0372 Oslo, Norway 
 
 
 
  


IronIC Protocol version 1.41 March 20tieth 2018 
Page 3 
 
Monitor: 
Clinical Research Support  
Research Support Unit  
Oslo Hospital Services  
Oslo University Hospital  
 
 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 4 
 
Signature page 
Intravenous Iron supplement for Iron deficiency in 
Cardiac transplant recipients: The IronIC trial 
 
I hereby declare that I will conduct the study in compliance with the Protocol, 
ICH GCP and the applicable regulatory requirements: 
Name 
Title 
Role 
Signature 
Date 
Lars Gullestad 
Professor, MD, 
PhD 
Coordinating 
investigator 
 
 
Kaspar Broch 
MD, PhD  
Investigator 
 
 
Arne K Andreassen 
MD, PhD 
Investigator 
 
 
Einar Gude  
MD, PhD  
Investigator 
 
 
Trond Vartdal 
MD, PhD 
Investigator 
 
 
Kristine Brautaset 
MD 
Investigator 
 
 
Thor Ueland 
PhD 
Biochemistry, 
statistics 
 
 
Kathrine Rolid 
PT 
Physical testing 
 
 
Richard J Massey 
BSc 
Echocardiography 
 
 
Pål Aukrust 
MD, PhD 
Inflammation 
 
 
Charlotte Myrdal 
Østby 
Study nurse 
Patient recruitment, 
assessment 
 
 
Ingelin Grov 
Nurse 
Patient recruitment 
 
 
Anne Relbo 
Nurse 
Patient recruitment 
 
 
 
 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 5 
 
Protocol Synopsis 
Intravenous Iron supplement for Iron deficiency in 
Cardiac transplant recipients: The IronIC trial 
 
Sponsor 
Oslo University Hospital 
Phase and study type 
Phase II, interventional, randomised controlled trial 
Investigational Medical 
Product (including active 
comparator and placebo) :       
Intravenous iron isomaltoside or matching placebo (NaCl 0.9 %) 
Centres: 
Oslo University Hospital, Rikshospitalet, Oslo, Norway 
Study Period: 
 
Estimated date of first patient enrolled (study start): February 1st  2018 
Anticipated recruitment period: February 1st 2018 – January 31st 2019 
Estimated date of last patient completed (last patient, last visit: Study 
end): July 30tieth 2019 
Treatment Duration: 
1 day 
Follow-up: 
6 months 
Objectives  
The main goal of this study is to evaluate the effect of a single dose of 
intravenous iron isomaltoside on exercise capacity in cardiac allograft 
recipients with iron deficiency.  
Secondary objectives are to assess the impact of treatment on: (i) iron 
stores, (ii) muscle strength, (iii) body composition, (iv) cognitive 
function, (v) quality of life, (vi) markers of myocardial disease and 
inflammation, and (vii) safety and tolerability. 
Endpoints: 
Primary endpoint: The primary endpoint will be the between-group 
difference in the baseline-adjusted peak oxygen consumption 
measured 6 months after trial intervention. 
 
Secondary endpoints:  
• 
The number of patients with absolute or functional iron 
deficiency 
• 
Muscle strength as measured by a hand-grip (device) 
• 
Body composition 
• 
Quality of life as assessed by the SF-36 and EQ 5D 3L EuroQoL 
questionnaires 
• 
Cognitive function 
• 
N-terminal pro-B-type natriuretic peptide (NT-proBNP) 
• 
Cardiac troponin T (TnT) 
• 
C-reactive protein (CRP) 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 6 
 
• 
Inflammatory and vasoactive peptides 
Study Design: 
This is a single site, dual arm, double blind, randomised, placebo 
controlled trial. 
Main Inclusion Criteria:    
Heart transplant recipient.  
Iron deficiency defined as serum ferritin < 100 µg/l or ferritin between 
100 and 300 µg/l in combination with a transferrin saturation < 20 %.  
Age between 18 and 80 years. 
Signed informed consent and expected compliance with protocol. 
Main Exclusion Criteria 
  
Contraindications to study medication. 
Failure to obtain written informed consent 
Sample Size: 
100 patients 
Efficacy Assessments: 
Assessment of peak oxygen consumption; biomarkers reflecting iron 
stores and metabolism, myocardial stress, and inflammation; muscle 
strength, cognitive function and quality of life 
Safety Assessments: 
Physical examination. In-hospital observation for at least two hours 
after study drug administration. Safety visit at general practitioner 3 
months after study drug administration. A 24-hour contact number will 
be provided. Repeat assessment after six months. 
 
 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 7 
 
List of abbreviations and definition of terms 
Abbreviation or special term 
Explanation 
AE 
Adverse event  
CANTAB 
Cambridge Neuropsychological Test Automated Battery 
CRF 
Case report form (electronic/paper) 
CRP 
C-reactive protein 
DMC 
Data monitoring committee 
GCP 
Good clinical practice 
ICH 
International Conference on Harmonisation 
NT-proBNP 
N-terminal pro-B-type natriuretic peptide 
SAE 
Serious adverse event   
SUSAR 
Suspected unexpected serious adverse reaction 
TnT 
Cardiac troponin T 
 
 
 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 8 
 
Table of contents 
1 
CONTACT DETAILS 
2 
Signature page 
4 
Protocol Synopsis 
5 
List of abbreviations and definition of terms 
7 
Table of contents 
8 
1 
Introduction 
11 
1.1 
Iron metabolism 
11 
1.2 
Iron deficiency in heart failure 
12 
1.3 
Therapeutic information 
13 
 
Pre-Clinical & Clinical Experience with iron isomaltoside 
13 
1.3.1
 
Known and potential risks and benefits 
13 
1.3.2
1.4 
Rationale for the study and purpose 
14 
1.5 
Rationale for study endpoint 
14 
2 
Study objectives and related endpoints 
14 
2.1 
Primary endpoint 
14 
2.2 
Secondary endpoints 
14 
3 
Overall study design 
15 
4 
Study population 
15 
4.1 
Selection of study population 
15 
4.2 
Number of patients 
15 
4.3 
Inclusion criteria 
16 
4.4 
Exclusion criteria 
16 
5 
Treatment 
16 
5.1 
Drug identity, supply and storage 
16 
5.2 
Dosage and administration 
17 
5.3 
Duration of therapy 
17 
5.4 
Monitoring during drug administration 
17 
5.5 
Concomitant medication 
17 
 
Prohibited treatments during study period 
18 
5.5.1
5.6 
Drug accountability 
18 
5.7 
Drug labelling 
18 
5.8 
Subject identification 
19 
6 
Study procedures 
19 
6.1 
Table 
19 
6.2 
By visit 
19 
 
Before treatment starts 
20 
6.2.1
 
3-month safety visit 
20 
6.2.2
 
End of study visit 
21 
6.2.3


IronIC Protocol version 1.41 March 20tieth 2018 
Page 9 
 
 
After end of treatment 
21 
6.2.4
6.3 
Criteria for patient discontinuation 
21 
6.4 
Procedures for discontinuation 
22 
 
Patient discontinuation 
22 
6.4.1
 
Trial discontinuation 
22 
6.4.2
7 
Assessments 
22 
7.1 
Assessments of efficacy 
22 
 
Peak oxygen consumption 
22 
7.1.1
 
Hand grip strength 
23 
7.1.2
 
Body composition 
23 
7.1.3
 
Quality of life 
23 
7.1.4
 
Cognitive function 
23 
7.1.5
 
Blood samples 
24 
7.1.6
7.2 
Safety and tolerability 
24 
8 
Safety monitoring and reporting 
24 
8.1 
Definitions 
25 
 
Adverse event (AE) 
25 
8.1.1
 
Adverse events of special interest (AESI) 
25 
8.1.2
 
Serious adverse event (SAE) 
25 
8.1.3
 
Suspected unexpected serious adverse reaction (SUSAR) 
25 
8.1.4
8.2 
Time period for reporting adverse events and serious adverse events 
26 
8.3 
Recording of adverse events 
26 
8.4 
Reporting procedure 
27 
 
Adverse events, adverse events of special interest and serious adverse events 
27 
8.4.1
 
Suspected unexpected serious adverse reactions 
27 
8.4.2
 
Annual safety report 
27 
8.4.3
 
Clinical study report 
27 
8.4.4
8.5 
Procedures in case of emergency 
27 
8.6 
Safety monitoring 
28 
9 
Data management and monitoring 
28 
9.1 
Case report forms (CRFs) 
28 
9.2 
Source data 
28 
9.3 
Study monitoring 
28 
9.4 
Confidentiality 
29 
9.5 
Database management 
29 
9.6 
Biobanking 
29 
10 
Statistical methods and data analysis 
29 
10.1 
Determination of sample size 
29 
10.2 
Randomisation 
29 
 
Allocation- sequence generation 
29 
10.2.1


IronIC Protocol version 1.41 March 20tieth 2018 
Page 10 
 
 
Allocation- procedure to randomise a patient 
30 
10.2.2
 
Blinding and emergency un-blinding 
30 
10.2.3
10.3 
Population for Analysis 
30 
10.4 
Planned analyses 
30 
10.5 
Statistical analysis 
30 
11 
Study management 
31 
11.1 
Investigator delegation procedure 
31 
11.2 
Protocol adherence 
31 
11.3 
Study amendments 
31 
11.4 
Audit and inspections 
31 
12 
Ethical and regulatory requirements 
32 
12.1 
Ethics committee approval 
32 
12.2 
Other regulatory approvals 
32 
12.3 
Informed consent procedure 
32 
12.4 
Subject identification 
32 
13 
Trial sponsorship and financing 
32 
14 
Trial insurance 
33 
15 
Publication policy 
33 
16 
References 
34 
 
 
 
 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 11 
 
1 
Introduction 
Heart transplantation is the treatment of choice for selected patients with end-stage heart 
failure.1 World-wide, the median survival after transplantation is approximately 11 years.2 Early 
survival is limited by early graft failure and acute rejections,3 whereas complications to 
immunosuppressive therapy, such as infections and cancers, are among the most important causes 
of death in long-term survivors.3 On the other hand, a major impediment to long-term survival is 
cardiac allograft vasculopathy caused by smouldering rejection.4, 5 Long-term success in heart 
transplantation is therefore dependent on compromising between detrimental immunosuppression 
and low-grade inflammation. 
Iron is an essential nutrient and co-factor not only in haemoglobin, but in several key respiratory 
reactions. It readily engages in one-electron oxidation-reduction reactions between its ferric (3+) and 
ferrous (2+) states. We exploit this property in oxidative phosphorylation, where iron acts as an 
intermediate in the electron transport chain. However, the same chemical quality explains why an 
excess of free, reactive iron is toxic. Ferrous iron can participate in redox chemistry known as the 
Fenton reaction, where it reacts with hydrogen peroxide or lipid peroxides to generate ferric iron, 
OH−, and highly reactive radicals. These compounds damage lipid membranes, proteins, and nucleic 
acids. Since cellular iron overload as well as iron deficiency are detrimental, the levels of reactive iron 
must be carefully controlled and limited.6 
Exercise capacity and health-related quality of life are reduced in cardiac allograft recipients 
despite good over-all results regarding graft function.7, 8 We have shown exercise capacity after heart 
transplantation depends mainly on peripheral factors rather than on allograft function.9, 10 Numerous 
mechanisms unrelated to haemodynamic dysfunction may underlie the impaired exercise tolerance 
in heart transplant recipients, one of which may be iron deficiency. Iron plays a key role in oxygen 
uptake, transport, storage, and metabolism in skeletal muscle.11  Heart transplant recipients have 
multiple reasons for having iron deficiency, including previous heart failure, perioperative blood loss, 
frequent blood sampling, renal failure, and polypharmacy. Among our heart transplant survivors, 48 
% have iron deficiency (defined as serum ferritin < 100 µg/l or ferritin between 100 and 300 µg/l in 
combination with a transferrin saturation < 20 %) [Abstract submitted to ISHLT congress, Nice 2018]. 
We hypothesise that intravenous iron therapy will improve peak oxygen consumption, muscle 
strength, functional capacity and quality of life in these patients. The IronIC trial is designed to test 
this hypothesis. 
1.1 
Iron metabolism 
Dietary iron is absorbed in the small intestine and transferred to the circulation. Before 
absorption, ferric iron in the diet must be reduced to ferrous iron at the apical surface of 
enterocytes. Iron is then transported into the cell by the divalent metal transporter-1, an energy-
dependent symporter that is essential for intestinal uptake of inorganic sources of dietary iron. 
Heme, another source of dietary iron, is internalised through receptor-mediated endocytosis. This 
process seems to be regulated by iron stores.12 Ferrous iron is exported through the basolateral 
membrane of the enterocyte to the interstitial space by the exporter ferroportin and oxidised by the 
ferroxidase hephaestin. Ferroportin is negatively regulated by the iron-regulatory hormone 
hepcidin.13  
The major transport protein for circulating iron is transferrin. Once extracellular, iron is bound 
with high affinity by this protein. The cellular uptake of iron occurs through receptor-mediated 
endocytosis of the iron/transferrin complex through transferrin receptor-1. Iron is then exported 
from the endosomal vesicle by the divalent metal transporter-1, suggesting that a ferrireductase 
must exist within the endosomal vesicle.  Ferrous iron is thought to enter a labile intracellular iron 
pool, from where it can be utilised for intracellular functions.11 
The portion of intracellular iron that is not needed for immediate use is stored by ferritin. 
Twenty-four ferritin subunits assemble to form the apoferritin molecule, each of which can sequester 
up to approximately 4500 iron atoms. Ferritin also possesses enzymatic properties, and oxidises 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 12 
 
ferrous iron to its ferric form.14 Small amounts of iron-poor ferritin are present in the serum, where it 
can be measured and quantified. Serum ferritin is elevated in iron overload, but also in inflammatory 
conditions.  
The content of cytoplasmic ferritin is regulated by the availability of intracellular free iron. This 
regulatory response is posttranscriptional. When intracellular iron stores are depleted, iron 
regulatory proteins 1 and 2 bind to the iron responsive element of the ferritin mRNA and prohibit 
translation. Conversely, when iron levels are high, ferritin synthesis increases.14 On the contrary, the 
binding of iron regulatory proteins to an iron regulatory element in transferrin receptor 1 mRNA 
lengthens its half-life, ultimately leading to increased transferrin receptor display on the cell surface 
in situations of iron depletion. 
Ferritin and transferrin, established markers of iron availability, are regulated not only by iron 
stores, but also by inflammation. Ferritin is an “acute phase” protein, the serum concentrations of 
which increase in inflammatory conditions.14 In fact, ferritin can be viewed not only as an iron 
regulatory protein, but also as a protein that takes part in the cellular defence against stress and 
inflammation. Transferrin receptor-1 and transferrin, on the other hand, are down-regulated in 
inflammatory states. These responses contribute to low available iron in states of inflammation, 
presumably to deprive invading microorganisms of an essential nutrient.15 
The major regulator of systemic iron metabolism is the peptide hormone hepcidin. Full iron 
stores induce hepcidin transcription through the bone morphogenetic protein signalling pathway. 
However, hepcidin expression is also up-regulated in inflammation.16 Its mode of action is to bind to, 
and induce degradation of, ferroportin.13  Hepcidin thus exerts its control over systemic iron 
metabolism by regulating the transfer of dietary, recycled, and stored iron from intracellular 
compartments to the extracellular fluid, regulating the amount of iron available for iron-demanding 
tissues.15 This gate-keeping mechanism reduces the effect of oral iron in patients with inflammation, 
and can be partially circumvented by intravenous administration of iron. 
1.2 
Iron deficiency in heart failure 
Iron deficiency is prevalent in patients with heart failure.17, 18 Iron deficiency is associated with a 
worse prognosis, and randomised controlled trials have shown that correction of iron deficiency with 
intravenous iron therapy improves functional capacity, quality of life, and 6-minute walk distance.19, 
20  Current guidelines therefore recommend intravenous iron substitution in patients with heart 
failure with reduced ejection fraction and iron deficiency.21 Intravenous iron is more effective, better 
tolerated, and improves quality of life to a greater extent than oral iron supplements.22-24 In the 
IRONOUT HF trial, in which 225 patients with systolic heart failure were randomised to oral iron 
supplement or placebo, there was no effect on oxygen uptake, 6-minute walk distance, or quality of 
life. The authors attributed the negative results to the minimal effect on iron stores, suggesting that 
oral iron does not adequately replenish iron stores in patients with heart failure.25 
Cardiac allograft recipients resemble patients with heart failure in many respects. Prior to 
transplantation, and in some instances after heart transplantation, they have had overt heart failure. 
Moreover, due to the immunologic challenge posed by the allograft, and their susceptibility to 
infection due to immunosuppressive treatment, cardiac allograft recipients have low-grade 
inflammation. This low-grade inflammation makes it difficult to interpret iron stores, and results in 
dysregulated iron metabolism.  
To our knowledge, there have been no studies to assess the effect of intravenous iron therapy in 
heart transplant recipients who have iron deficiency. There is reason to believe that a liberal 
definition of iron deficiency should be used in cardiac allograft recipients, and we have elected to use 
the well-established definition used in patients with heart failure: serum ferritin < 100 µg/l or ferritin 
between 100 and 300 µg/l in combination with a transferrin saturation < 20 %. Because oral iron 
supplement is less effective then intravenous iron in general, and in patients with heart failure in 
particular,25  we assume that oral iron supplement is inadequate in heart transplant recipients. We 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 13 
 
have designed the IronIC trial to assess the effect of intravenous iron isomaltoside on exercise 
capacity, muscle strength, cognition and quality of life in iron-deficient heart transplant recipients. 
1.3 
Therapeutic information 
Isomaltoside 1000 is an oligosaccharide with a mean molecular weight of 1,000 Da, which 
consists predominantly of unbranched chains corresponding to 3–5 glucose units.26 The iron in 
Monofer® is tightly bound to isomaltoside in a matrix containing approximately 10 iron molecules per 
one isomaltoside pentamer. This structure releases iron to iron-binding proteins in a controlled 
manner with little risk of free iron toxicity.27   
 
Pre-Clinical & Clinical Experience with iron isomaltoside  
1.3.1
According to the Summary of Product Characteristics (SPC), available at www.medicines.org.uk, 
iron complexes have been reported to be teratogenic and embryocidal in non-anaemic pregnant 
animals at high single doses above 125 mg iron/kg body weight. The highest recommended dose in 
clinical use is 20 mg iron/kg body weight. In a murine fertility study with Monofer®, there were no 
effects on male reproductive performance and spermatogenic parameters. There have been no 
adequately sized and controlled trials to assess the safety of iron isomaltoside in pregnancy, and 
Monofer® should not be used in pregnancy unless clearly necessary. Iron does not transfer easily to 
human milk, and no adverse effects on breastfed infants are anticipated. In patients with chronic 
kidney disease, the plasma iron half-life is approximately 30 hours after intravenous administration, 
regardless of the infused dose.28 After infusion, the iron in iron isomaltoside follows first-order 
kinetics.29 
Clinical experience with Monofer® has been reviewed by Kalra and Bhandari.30 In short, the 
efficacy and safety of intravenous iron isomaltoside has been investigated in patients with chronic 
kidney disease,31-34 inflammatory bowel disease,35, 36  and postpartum haemorrhage.37 In general, the 
treatment has been efficacious and associated with few adverse events.  In a double-blind trial, 60 
patients undergoing coronary bypass surgery were randomised to receive 1000 mg iron isomaltoside 
(up to 20 mg/kg body weight) or saline. The fall in haemoglobin was significantly less pronounced in 
patients allocated to iron. No adverse events were observed. In 20 patients with congestive heart 
disease and iron deficiency anaemia who received on average 868 mg (range 650–1000 mg) of iron 
isomaltoside, there was a significant improvement in health-related quality of life and no serious 
adverse events. Specifically, there were no acute or delayed hypersensitivity reactions.38 
 
Known and potential risks and benefits 
1.3.2
Intravenous iron transfusion carries a very low,30 but clinically significant risk of hypersensitivity 
reactions. This risk is increased in patients with known allergies, an allergic diathesis, or autoimmune 
diseases. Heart transplant recipients are treated with immunosuppressants and possibly less prone 
to experiencing these reactions. To prevent serious consequences of a hypersensitivity reaction, the 
patients will be monitored in-hospital during the study drug infusion and for at least two hours 
afterwards. The Monofer® SPC specifically recommends at least 30 minutes of observation. The 
infusions will be administered at the cardiology ward at Rikshospitalet. This ward is well-staffed and 
equipped to deal with acute hypotension/cardiac arrest/respiratory failure. Hypersensitivity-
reactions should be treated with immediate stop in transfusion, volume resuscitation, and supportive 
care and cardiopulmonary resuscitation as required. The investigator and the responsible physician 
must decide whether reintroduction of the study drug infusion is safe after the episode has been 
resolved, depending on the severity of the episode. Nominal hypotension without symptoms and 
without threatening organ function is acceptable and should not result in study drug withdrawal. 
Subcutaneous/extravenous infusions can lead to skin reactions and prolonged discolouration of 
the skin. Vigilant assessment of the infusion side is therefore necessary during drug infusion, and 
careful testing of the peripheral cannula with infusion of a test dose of isotonic saline should be 
performed prior to study drug infusion. 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 14 
 
The benefit of intravenous iron supplement in iron-deficient heart transplant recipients is 
unknown. Experience from other populations,23, 24 and from patients with heart failure in particular, 
suggests that intravenous iron can replete iron stores and improve exercise capacity and health-
related quality of life in patients with iron deficiency. This trial is designed to assess if similar results 
can be obtained in iron-deficient heart transplant recipients.   
1.4 
Rationale for the study and purpose 
Iron deficiency is associated with poor exercise capacity, lethargy and reduced quality of life. Our 
results show that iron deficiency is prevalent in heart transplant recipients. Cardiac allograft 
recipients have reduced exercise capacity and quality of life compared with the age and gender 
matched general population.  We assume that some of these symptoms are due to iron deficiency, 
and hypothesise that intravenous iron supplement will improve peak oxygen consumption, muscle 
strength, functional capacity, cognition, and health-related quality of life in heart transplant 
recipients with iron deficiency.  
1.5 
Rationale for study endpoint 
Measurement of peak oxygen capacity is the gold standard for assessing exercise capacity.39 
Exercise capacity is an established surrogate endpoint in patients who are evaluated for heart 
transplantation.40 Exercise capacity is associated with mortality before41 and after42 heart 
transplantation, and is tightly associated with quality of life in these patients. We have extensive 
experience in measuring peak oxygen uptake in heart transplant recipients.42, 43 Moreover, the 
accuracy of this measurement is good, resulting in low intra-individual variability in repeated 
measurements. 
2 
Study objectives and related endpoints 
The main goal of this study is to evaluate the ability of a single administration of intravenous iron 
isomaltoside to increase peak oxygen consumption in cardiac allograft recipients who have iron 
deficiency defined as serum ferritin < 100 µg/l or ferritin between 100 and 300 µg/l in combination 
with a transferrin saturation < 20 %.  
Secondary objectives are to assess the impact of treatment on: (i) iron stores, (ii) muscle 
strength, (iii) body composition, (iv) cognitive function, (v) quality of life, (vi) markers of myocardial 
disease and inflammation, and (vii) safety and tolerability. 
2.1 
Primary endpoint  
The primary endpoint will be the baseline-adjusted between-group difference in peak oxygen 
consumption as measured on a treadmill exercise test 6 months after study drug administration. 
2.2 
Secondary endpoints 
Secondary endpoints: 
• 
The number of patients with absolute or functional iron deficiency 
• 
Muscle strength as measured by a hand-grip dynamometer 
• 
Body composition 
• 
Cognitive function as assessed by the Cambridge Neuropsychological Test Automated 
Battery 
• 
Quality of life as assessed by the SF-36 and 5D EuroQoL questionnaires 
• 
N-terminal pro-B-type natriuretic peptide (NT-proBNP) 
• 
Cardiac troponin T (TnT) 
• 
C-reactive protein (CRP) 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 15 
 
• 
Inflammatory and vasoactive peptides 
 
3 
Overall study design 
This is a phase 2, double blind, randomised, placebo-controlled trial. Participants will be 
randomised in a 1:1 fashion to receive a single intravenous dose of iron isomaltoside or matching 
placebo. The study is designed to show superiority with regard to the primary endpoint in patients 
assigned to active treatment versus patients allocated to the placebo arm. 
 
 
Study Period 
 
Estimated date of first patient enrolled (study start): February 1st 2018. 
Anticipated recruitment period: February 1st 2018 – January 31th 2019. 
Estimated date of last patient completed (last patient, last visit: Study end): 
August 1st 2019. 
Treatment Duration: 
One day (single iv dose drug administration) 
Follow-up: 
6 months 
4 
Study population 
4.1 
Selection of study population 
The IronIC trial will be conducted at Oslo University Hospital, Rikshospitalet, in Oslo, Norway. 
Oslo University Hospital Rikshospitalet is the only centre in Norway to perform transplantations. We 
perform approximately 35 heart transplantations per year. With a median survival of more than 12 
years, we have a population of approximately 500 cardiac allograft recipients who attend regular 
follow-ups twice per year. Per routine, we measure ferritin and transferrin saturation in all of these 
patients. We plan to recruit patients who are admitted for their yearly control, and who have iron 
deficiency defined as serum ferritin < 100 µg/l or ferritin between 100 and 300 µg/l in combination 
with a transferrin saturation < 20 %. A dedicated study nurse will send a written invitation to 
participate in the trial prior to the patient’s routine control at our centre. 
4.2 
Number of patients 
We aim to enrol 100 patients in this trial. 
Patients 
screened 
Start 
infusion 
Efficacy and safety 
assessment 
Baseline 
assessment 
Efficacy and safety 
assessment 
Start 
infusion  
Patients 
excluded 
Randomisation 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 16 
 
4.3 
Inclusion criteria 
Patients will be screened for eligibility upon admittance for routine follow-up at least one year 
after heart transplantation. 
All of the following conditions must apply prior to administering the investigational medicinal 
product: 
• 
Cardiac allograft.  
• 
Presentation at least one year after heart transplantation.  
• 
Iron deficiency defined as serum ferritin < 100 µg/l or ferritin between 100 and 300 µg/l in 
combination with a transferrin saturation < 20 %.  
• 
Age between 18 and 80 years. 
• 
Informed consent obtained and documented according to Good Clinical Practice (GCP), and 
national/regional regulations. 
4.4 
Exclusion criteria 
Patients will be excluded from the study if they meet any of the following criteria: 
• 
Anaemia (Haemoglobin < 100 mg/l) 
• 
Haemochromatosis 
• 
Haemosiderosis 
• 
Porphyria cutanea tarda 
• 
Blood dyscrasias or any disorders causing haemolysis or unstable red blood cells  
• 
Decompensated liver disease (Child-Pugh score  7 or higher) 
• 
End-stage renal failure, i.e. eGFR < 15 ml/min or on renal replacement therapy  
• 
Planned cardiac surgery or angioplasty within 6 months 
• 
Planned major surgery within 6 months  
• 
Medical history of unresolved cancer (except for basal cell carcinoma)  
• 
Treatment with systemic steroids more than the equivalent of 10 mg Prednisone/day at the 
time of informed consent or change in dosage of thyroid hormones within 6 weeks prior to 
informed consent   
• 
Any uncontrolled endocrine disorder except type 2 diabetes  
• 
Pregnancy 
• 
On erythropoietin analogues 
• 
Known sensitivity or intolerance to iron isomaltoside or other parenteral iron preparations 
• 
Intravenous iron supplement within 6 months prior to inclusion 
• 
On oral iron substitution (unless the subject agrees to stop treatment prior to randomisation) 
• 
Ongoing rejections or infections 
• 
Alcohol or drug abuse within 3 months of informed consent that would interfere with trial 
participation or any ongoing condition leading to decreased compliance with study 
procedures or study drug intake 
• 
Intake of an investigational drug in another trial within 30 days prior to intake of study 
medication in this trial or participating in another trial involving an investigational drug and/or 
follow-up 
5 
Treatment 
For this study, intravenous iron isomaltoside (Monofer®) and matching placebo are defined as 
investigational medicinal products.  
5.1 
Drug identity, supply and storage 
Medication and comparator 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 17 
 
Active drug: Intravenous iron isomaltoside dissolved in 100 ml NaCl 0.9 %. 
Placebo: Intravenous sodium chloride 0.9%; 100 ml. 
 
Supply, packaging, labelling, handling, storage and accountability 
The manufacturer supplies study medication to the investigators on site. It is labelled with 
information according to local regulation. The study medication will be stored in a locked refrigerator 
(2-8°C), protected from unintended use. All study medications supplied for this trial will be retained 
in a safe place at all times of the study. Only personnel authorised by the principal investigator 
should dispense the study medication, and the accountability is the responsibility of investigator. An 
up to date study medication inventory (dispensing records) will be maintained at all times. 
5.2 
Dosage and administration 
After the participant has provided informed consent, he or she will be randomised to receive a 
single intravenous administration of iron isomaltoside (Monofer®) or matching placebo. The active 
drug, iron isomaltoside, will be administered as a single, intravenous infusion of 20 mg/kg body 
weight (rounded off to the nearest 100 mg) dissolved in 100 ml NaCl as recommended by the drug 
manufacturer (“on-label” treatment). Patients allocated to placebo will receive an intravenous 
infusion of 100 ml NaCl 0.9% administered in the same manner. Because iron isomaltoside is a dark-
brown solution that is easily distinguishable from the saline placebo, study personnel responsible for 
the preparation and administration of the study drug will be aware of the group assignments and will 
therefore not be involved in any study assessments. To ensure that patients are unaware of 
treatment allocation, we will cover the injection site, syringes and intravenous lines with sheets to 
shield the injection site from the patient's view 
The active drug dilution/placebo will be prepared and administered, according to the 
randomisation code, by nurses who do not participate in the trial. The investigational medicinal 
products will only be administered when staff trained to evaluate and manage anaphylactic reactions 
is immediately available, in an environment where full resuscitation facilities can be assured. The 
patients will be observed for adverse effects for at least two hours following the injections. 
5.3 
Duration of therapy 
The investigational medicinal products (iron isomaltoside or placebo) will be administered as a 
single intravenous infusion over 30 minutes only (1,67 ml/min). No other study-specific intervention 
will be provided. For intravenous iron, a single dose of 20 mg/kg is expected to provide adequate iron 
supplement in patients with haemoglobin above 100 mg/l. 
5.4 
Monitoring during drug administration 
The study drug will be administered in a hospital setting, with frequent attendance by 
experienced nurses. Vital signs are observed and documented prior to study drug infusion. The 
patients will be hospitalised for at least two hours after the study drug infusion, and thereafter for as 
long as deemed necessary by the responsible physician. 
5.5 
Concomitant medication 
All concomitant medication (incl. vitamins, herbal preparation and other “over-the-counter” 
drugs) used by the patient will be recorded in the patient’s file and CRF. Study participation does not 
preclude administration of drugs that are provided on clinical indication. On the contrary, study 
participants will receive standard-of-care treatment as recommended in prevailing guidelines. 
Concurrent treatment with steroids other than low doses of corticosteroids (equivalent to 10 mg 
prednisone or less) at the time of randomisation is an exclusion criterion. New immunosuppressants 
should not be introduced within the first month after randomisation unless necessary as deemed by 
the treating physician. 
 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 18 
 
 
Prohibited treatments during study period   
5.5.1
The following treatments are not permitted during the study:  
• 
parenteral iron supplement (other than the initial study drug infusion) 
• 
oral iron substitution 
5.6 
Drug accountability 
The responsible site personnel will confirm receipt of study drug and will use the study drug only 
within the framework of this clinical study and in accordance with this protocol. The manufacturer 
(Pharmacosmos®) provides the active study drug. The study drug or matching placebo will be 
administered by trained hospital personnel. The manufacturer supplies study medication to the 
investigators on site. It will be labelled with information according to local regulation. The study 
medication will be stored in a locked refrigerator (2-8°C), protected from unintended use. All study 
medications supplied for this study must be retained in a safe place at all times of the study. Only 
personnel authorised by the principal investigator should dispense the study medication, and the 
accountability is the responsibility of investigator. A study medication inventory (dispensing records) 
for all medication dispensed must be maintained at all times. A unique, three-digit number will be 
assigned to each study drug dose (iron isomaltoside or placebo) by an independent nurse. The study 
drug number and drug dose (sham dose if placebo) will be available in the patient file. A list linking 
study drug numbers and batch-numbers and expiry dates will be kept in a sealed envelope in a 
locked closet, but can be opened if unblinding is necessary (see paragraph 10.2.3). The study drug 
inventory must contain information on Monofer® vial batch numbers and expiration dates. A study 
nurse will be responsible for drug storage, including keeping a temperature log, and the study drug 
inventory.  
5.7 
Drug labelling 
The investigational product will have a label permanently affixed to the outside and will be 
labelled according with ICH/GCP and national regulations, stating that the material is for clinical trial 
/ investigational use only and should be kept out of reach of children.  
 
The bag with the dissolved solution will have an affixed label stating (in Norwegian) 
 
This bag contains … mg iron isomaltoside or placebo (Study drug number …) dissolved in 100 ml 
NaCl 0.9 % for the IronIC trial. The drug is meant for intravenous administration over 30 minutes 
(1.67 ml/min). The content of this bag was prepared by … .  
 
Labels will also include blank lines (in Norwegian) for:  
 
Patient’s initials 
Patient’s study number 
Date dispensed 
Name of prescribing doctor 
 
“Denne posen inneholder … mg jernisomaltosid eller placebo (studiemedikamentnummer …) i 
100 ml 0,9 % NaCl til bruk i IronIC-studien. Posen skal gis intravenøst ila 30 minutter (1,67 ml/min). 
Denne posen ble tilberedt av _________________.  
Pasientens initialer:_____________  
Studienummer:_______________ 
Dato:___________  
Forskrevet av dr:________________  
» 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 19 
 
5.8 
Subject identification 
Each study participant is identified by a unique subject number that is assigned after the subject 
signs the informed consent form. This number is generated through the randomisation process. Once 
assigned, the subject number cannot be reused for any other subject. The same primary identifier 
will be used throughout the study.  
 
6 
Study procedures 
6.1 
Table 
 
 
Baseline 
3 months 
6 months 
Informed consent 
x 
Study drug infusion 
 
 
Clinical 
examination 
x 
x 
x 
ECG 
x 
 
x 
Echocardiography 
x 
 
 
Safety samples1 
x 
x 
x 
Serum hCG2 
x 
 
 
Randomisation 
x 
 
 
Biobank samples3 
x 
 
x 
6-minute walk test 
x 
 
x 
Measurement of 
peak oxygen 
consumption 
x 
 
x 
Hand grip strength 
x 
 
x 
Body mass 
composition 
x 
 
x 
Cognitive function 
x 
 
x 
Quality of life 
x 
 
x 
Adverse events 
 
ßxà 
 
 1Haematological parameters, renal function, serum electrolytes, tests of liver damage, TnT, NT-proBNP 
and CRP are measured routinely in our transplant recipients. 2In pre-menopausal women only 3Secondary 
endpoints (i.e, NT-proBNP, markers of iron metabolism and inflammation). 
6.2 
By visit 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 20 
 
Study participants will be recruited from the pool of heart transplant recipients who attend 
regular follow-up at Oslo University Hospital, Rikshospitalet. A dedicated study nurse not responsible 
for the routine treatment of the patients, will ask eligible patients to participate when clinical 
assessment, ferritin/transferrin and safety blood samples (routine blood samples in heart transplant 
recipients) have been performed and analysed. 
 
Before treatment starts  
6.2.1
Informed consent 
Written informed consent (Appendix A) must have been provided voluntarily by each subject before 
any study specific procedure is initiated.  
The following tests will be performed at baseline: 
Physical examination 
A physical examination (including examination of heart, lungs, abdomen, neck and assessment of 
peripheral circulation and oedema) must be performed; vital signs (blood pressure, and heart rate); 
and height and weight must be recorded. 
Medical history 
A medical history must be obtained, and age; gender; NYHA functional status; risk factors 
(hypertension, smoking, and diabetes); reason for and time since heart transplantation; and 
concomitant disease must be recorded.  
Concomitant medication 
All concomitant medication (incl. vitamins, herbal preparation and other “over-the-counter” drugs) 
used by the participant within 28 days of treatment start must be recorded in the CRF by generic 
name and dose. 
Laboratory analyses 
Blood samples will be obtained to determine: Haemoglobin; white blood cell count, platelet count;  
serum potassium; serum sodium; glucose, glycosylated haemoglobin (HbA1c); creatinine; ALT; 
bilirubin; albumin; INR; CRP; N-terminal pro-B-type natriuretic peptide (NT-proBNP); total 
cholesterol; ferritin; transferrin, serum iron and total iron binding capacity. Serum hCG must be 
evaluated to exclude pregnancy in pre-menopausal females, and repeated prior to study drug 
infusion if more than 72 hours have passed between screening and study drug administration. Blood 
for efficacy analyses must be drawn and appropriately labelled and stored for later analysis. 
Treadmill test 
A treadmill test for the assessment of peak oxygen consumption is performed at baseline. The 
results of this test will be used for adjustment of the test-result six months after study drug infusion. 
The latter result, with adjustment for the baseline result, constitutes the primary endpoint of the 
IronIC trial. 
Hand grip strength 
Right and left hand grip strengths will be measured by a hand-held dynamometer. 
Body composition 
Body composition (weight, total water, total fat, percent fat, the ratio of extracellular water to 
intracellular water [measuring oedema], and visceral fat) will be measured at baseline and after 6 
months with the InBody 770 body composition analyser. 
Quality of life 
Self-reported, health-related quality of life will be gauged with the SF-36 and EQ 5D 3L 
questionnaires. 
Cognitive function 
Cognitive function will be assessed with the Cambridge Neuropsychological Test Automated 
Battery (CANTAB). 
 
3-month safety visit 
6.2.2


IronIC Protocol version 1.41 March 20tieth 2018 
Page 21 
 
The study participants will be asked to visit their general practitioner for a clinical examination 
and blood sampling 3 months after study drug infusion. The blood samples will be sent to the 
laboratory at Oslo University Hospital, Rikshospitalet, for delayed (after end-of-study) assessment of 
haemoglobin, serum ferritin, serum iron, serum transferrin, and transferrin saturation.  
 
End of study visit 
6.2.3
This study visit six months after study drug administration is designed to assess efficacy and 
safety. 
Medical history 
A medical history must be repeated, and NYHA functional status; any change in risk factors 
(hypertension, smoking, diabetes mellitus), and concomitant disease must be recorded. Any medical 
events since inclusion in trial must be evaluated. Current well-being, symptoms, potential side effects 
and physical capacity must be assessed. 
Physical examination 
A physical examination must be performed, and results (including examination of heart, lungs, 
abdomen, neck and assessment of peripheral circulation and oedema); vital signs (blood pressure, 
and heart rate); and height and weight must be recorded. 
Concomitant medication 
All concomitant medication (incl. vitamins, herbal preparation and other “over-the-counter” drugs) 
used by the participant within 28 days of treatment start must be recorded in the CRF by generic 
name and dose. 
Laboratory analyses 
Blood samples will be obtained to determine: Haemoglobin; white blood cell count, platelet count;  
serum potassium; serum sodium; glucose, glycosylated haemoglobin (HbA1c); creatinine; ALT; 
bilirubin; albumin; INR; CRP; N-terminal pro-B-type natriuretic peptide (NT-proBNP); total 
cholesterol; ferritin; transferrin, serum iron and total iron binding capacity. Blood for efficacy 
analyses must be drawn and appropriately labelled and stored for later analysis. 
Treadmill test 
A treadmill test for the assessment of peak oxygen consumption is performed after six months. 
The results of this test, with adjustment for the baseline result, constitute the primary endpoint of 
the IronIC trial. 
Hand grip strength 
Right and left hand grip strengths will be measured by a hand-held dynamometer. 
Body composition 
Body composition (weight, total water, total fat, percent fat, the ratio of extracellular water to 
intracellular water [measuring oedema], and visceral fat) will be measured at baseline and after 6 
months with the InBody 770 body composition analyser. 
Quality of life 
Self-reported, health-related quality of life will be gauged with the SF-36 and EQ 5D 3L 
questionnaires. 
Cognitive function 
Cognitive function will be assessed with CANTAB. 
Safety assessment 
Any untoward medical event (i.e. any AE, SAE or SUSAR) since the last visit must be recorded in 
the case report form (CRF) and the patient medical record. 
 
 
After end of treatment 
6.2.4
We do not plan to perform study visits after the six-month follow-up.  
6.3 
Criteria for patient discontinuation  


IronIC Protocol version 1.41 March 20tieth 2018 
Page 22 
 
Patients may be discontinued from study treatment and assessments at any time. Specific 
reasons for discontinuing a patient for this study are: 
• 
Voluntary discontinuation: participating patients are free to discontinue his/her participation 
in the study at any point in time, without prejudice to further treatment. 
• 
Major protocol deviation 
• 
Incorrect randomisation, i.e. the patient does not meet the required inclusion/exclusion 
criteria for the study 
• 
Patient lost to follow-up 
• 
Patient’s non-compliance to study treatment and/or procedures 
6.4 
Procedures for discontinuation 
 
Patient discontinuation 
6.4.1
Patient withdrawal must be documented in the CRF as well as in hospital records. If possible, a 
final assessment should be obtained (end of study visit). The reason for discontinuation is recorded. 
The investigator is obliged to follow up any significant adverse events until the outcome either is 
recovered or resolved, recovering/resolving, not recovered/not resolved, recovered/resolved with 
sequelae, fatal or unknown. Patients who withdraw will be included in the intention-to treat analysis. 
 
Trial discontinuation 
6.4.2
The whole trial may be discontinued at the discretion of the primary investigator or the sponsor 
in the event of any of the following: 
• 
Occurrence of AEs unknown to date in respect of their nature, severity and duration 
• 
Medical or ethical reasons affecting the continued performance of the trial 
• 
Difficulties in the recruitment of patients 
• 
Cancellation of drug development  
The sponsor and principal investigator will inform all investigators, the relevant Competent 
Authorities and Ethics Committees of the termination of the trial along with the reasons for such 
action. If the study is terminated early on grounds of safety, the Competent Authorities and Ethics 
Committees will be informed within 15 days. 
7 
Assessments  
7.1 
Assessments of efficacy  
Efficacy will be evaluated through a comprehensive assessment of peak oxygen uptake, hand-
grip strength, self-assessed quality of life, assessment of cognitive function, and biochemistry. All 
efficacy assessments will be made prior to study drug infusion and at the end-of-study visit after six 
months. The results will be reported as baseline-adjusted between-group differences. 
 
Peak oxygen consumption 
7.1.1
Peak oxygen consumption will be measured on a treadmill according to a protocol that we have 
successfully employed in heart transplant recipients.43 The protocol employs a modified treadmill 
walk test in compliance with the European Society of Cardiology recommendations for 
cardiopulmonary exercise testing in patients with chronic heart failure.44 The test begins with warm-
up period of 10 min on a Runrace Treadmill (Technogym, Cesena, Italy), during which the individual 
walk speed is determined. The inclination of the treadmill is then increased by 2% every 2 min until 
volitional fatigue. Test termination criteria are a respiratory exchange ratio (RER) >1.05 and/or a 
rated perceived exertion (Borg 6–20 scale) >18.45 Lung function and breath gas exchange will be 
measured using the Sensormedics Vmax (Yorba Linda, CA, USA). ECG and HR will be monitored 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 23 
 
before, during and after exercise. Peak oxygen consumption, carbon dioxide production, maximum 
ventilation and respiratory exchange rate will be continuously monitored. Blood pressure will be 
measured automatically (Tango; Sun Tech Medical Instruments, NC, USA) before exercise, every 2 
min during exercise, and after exercise. After termination of the test, the treadmill will be stopped 
and the patients rest in an upright position for a recovery period of 2 min. VO2peak will be calculated 
as the mean of the three highest ten-second measurements before volitional fatigue prior to the end 
of exercise. A Borg score >18 and/or a respiratory exchange ratio > 1.05 will be used as criteria for an 
adequate maximal exercise test.  
Summary of parameters to be recorded: 
Before start: Heart rate, oxygen saturation and blood pressure. At peak exercise: treadmill 
inclination, heart rate, blood pressure, Borg score, oxygen saturation, peak oxygen consumption, 
expiratory exchange ratio, and peak ventilation volume. 
 
Hand grip strength 
7.1.2
As an estimate of muscle strength, we will measure peak hand grip strength using a hand grip 
strength dynamometer. 
 
Body composition 
7.1.3
We will use the InBody 770 Body Composition Analyzer to assess patients’ body composition. The 
patients steps onto the apparatus and holds on to the hand grips. The InBody 770 scanner uses six 
different electromagnetic frequencies to obtain 30 impedance measurements and three frequencies 
to obtain 15 resistance measures. The results can be integrated to yield body total water content, 
total fat content, percent fat, the ratio of extracellular water to intracellular water [measuring 
oedema], and visceral fat. 
 
Quality of life 
7.1.4
Quality of life will be examined at baseline and at the end of the study using two validated 
questionnaires; the SF3646 and the EQ 5D 3L EuroQoL questionnaire.47 The SF-36v2 is a 36-item 
general health-related quality of life instrument that has 36 questions that contribute to 8 domains 
or scale scores of physical functioning, role-physical, bodily pain, general health, vitality, social 
functioning, and role-emotional and mental health.46 The EQ 5D 3L EuroQoL questionnaire consists of 
2 pages, the EQ-5D descriptive system and the EQ visual analogue scale. The quality of life 
questionnaires (in Norwegian) can be found in appendix B. 
 
 
Cognitive function 
7.1.5
Cognitive function will be assessed with the Cambridge Neuropsychological Test Automated 
Battery (CANTAB).48, 49 The CANTAB test battery is performed electronically on a dedicated tablet. 
CANTAB is language-independent, culturally neutral, and requires no technical knowledge or prior 
familiarity with computers. It helps to determine an individual’s cognitive health across five key 
domains and includes an integrated depression scale to assess the current mood of the person taking 
the test. 
The cognitive domains assessed are: 
•Executive function - Central control, planning, strategy, and flexible thinking 
•Processing speed - The ability to perform mental tasks quickly and efficiently 
•Attention - The ability to concentrate and actively process information 
•Working memory - How we hold information while processing or acting on it 
•Episodic memory - Memory of events and experiences: what happened, where and when? 
 
Benefits of using the CANTAB platform includes dedicated courses for the staff administering the 
test, the highly accurate and validated evaluation of cognitive performance, the good discriminatory 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 24 
 
ability, even in high-functioning individuals, and the dedicated technical support. CANTAB is already 
accepted for use in research at Oslo University Hospital, and was used in the world-wide 
Ebbinghausen study49 that assessed cognitive function in patients treated with evolocumab vs 
placebo. 
 
Blood samples 
7.1.6
We will draw blood samples for biobanking at baseline, prior to study drug infusion, and at 6 
months. For biobanking, 18 ml blood should be drawn into tubes containing EDTA as the 
anticoagulant, 6 ml into tubes with citrate as the anticoagulant and 6 ml into tubes without additives. 
The tubes with EDTA and citrate should be put on ice immediately and be centrifuged at 3700 
rotations/min for 20 minutes. The tubes without additives should be left at room temperature for 1-
2 hours prior to centrifugation at 3500 rotations/min for 15 minutes. The tubes containing citrate as 
the anticoagulant should be put on ice immediately. The resulting plasma and serum, respectively, 
should be stored in multiple aliquots (at least four aliquots of serum and six aliquots of plasma per 
patient per visit), and labelled with the unique trial subject number, and the letter A signifying 
baseline, and the letter B signifying the end-of-treatment visit. The samples should be stored at -80 
degrees Celsius until analysis.  
 
Blood samples for safety will be collected at baseline, and 6 months after randomisation (end-of-
study). These blood samples will be drawn and analysed at the study sites as per clinical routine. 
Troponin values will be used for endpoint analyses. 
 
NT-proBNP will be assayed on a MODULAR platform (Roche Diagnostics, Basel, Switzerland). 
Plasma levels of CRP will be determined by a high-sensitivity particle-enhanced immunoturbidimetric 
assay (Tina-quant CRP [Latex] HS, Roche Diagnostic, Basel, Switzerland). TnT will be assessed using a 
high-sensitive immunoassay (Roche hs-TnT). 
7.2 
Safety and tolerability  
Safety will be monitored by the assessments described below as well as the collection of AEs at 
every visit. Significant findings that are present prior to the signing of informed consent must be 
included in the relevant medical history/ current medical condition page of the CRF. For details on AE 
collection and reporting, refer to Section 8.  
For the assessment schedule, refer to Flow chart in Section 6.1.  
Physical examinations will be performed at baseline and after 6 months. Vital signs including 
heart rate and blood pressure will be recorded before, during, and after study drug infusion. 
Monitoring must be especially vigilant with regard to signs of acute hypersensitivity reactions/abrupt 
hypotension.  
Blood samples for safety analyses will be drawn at baseline and after 3 and 6 months. Local 
laboratory cut-points for normal values will be used for safety analyses. Haemoglobin; white blood 
cell count, platelet count;  serum potassium; serum sodium; glucose, glycosylated haemoglobin 
(HbA1c); creatinine; ALT; bilirubin; albumin; INR; CRP; N-terminal pro-B-type natriuretic peptide (NT-
proBNP); total cholesterol; ferritin; transferrin, serum iron and total iron binding capacity will be 
evaluated at each visit. In addition, blood samples for the measurement of iron stores will be drawn 
3 months after study drug administration. 
8 
Safety monitoring and reporting 
The investigator is responsible for the detection and documentation of events meeting the 
criteria and definition of an adverse event (AE) or serious adverse event (SAE). Each patient will be 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 25 
 
instructed to contact the investigator immediately should they manifest any signs or symptoms they 
perceive as serious. 
The methods for collection of safety data are described below. 
8.1 
Definitions 
 
Adverse event (AE) 
8.1.1
An AE is any untoward medical occurrence in a patient administered a pharmaceutical product 
and which does not necessarily have a causal relationship with this treatment.  
An adverse event (AE) can therefore be any unfavourable and unintended sign (including an 
abnormal laboratory finding), symptom, or disease temporally associated with the use of a medicinal 
(investigational) product, whether or not related to the medicinal (investigational) product.  
The term AE is used to include both serious and non-serious AEs. 
If an abnormal laboratory value/vital sign are associated with clinical signs and symptoms, the 
sign/symptom should be reported as an AE and the associated laboratory result/vital sign should be 
considered additional information that must be collected on the relevant CRF. 
 
Adverse events of special interest (AESI) 
8.1.2
In general, AESIs are AEs that occur in categories of special interest with regard to determining 
the benefit/risk profile and overall safety of a drug. Two kinds of AEs are of particular concern 
regarding intravenous iron infusions: 
• 
Hypersensitivity/anaphylactic reactions: Infusion with Monofer® can result in acute 
hypersensitivity reactions characterised by hypotension and signs of anaphylaxis. These 
reactions may occur even in patients who have had previous, uneventful iron infusions, and 
are more common in patients with allergic diatheses or autoimmune diseases. 
• 
Skin discolouration: Paravenous leakage may cause skin irritation and long-lasting 
discolouration. 
 
 
Serious adverse event (SAE) 
8.1.3
Any untoward medical occurrence that at any dose:  
• 
Results in death 
• 
Is immediately life-threatening 
• 
Requires in-patient hospitalisation or prolongation of existing hospitalisation  
• 
Results in persistent or significant disability or incapacity 
• 
Is a congenital abnormality or birth defect 
• 
Is an important medical event that may jeopardise the subject or may require medical 
intervention to prevent one of the outcomes listed above. 
Medical and scientific judgment is to be exercised in deciding on the seriousness of a case. 
Important medical events may not be immediately life-threatening or result in death or 
hospitalisation, but may jeopardise the subject or may require intervention to prevent one of the 
listed outcomes in the definitions above. In such situations, or in doubtful cases, the case should be 
considered as serious. Hospitalisation for administrative reason (for observation or social reasons) is 
allowed at the investigator’s discretion and will not qualify as serious unless there is an associated 
adverse event warranting hospitalisation. 
 
Suspected unexpected serious adverse reaction (SUSAR)  
8.1.4
Adverse Reaction: all untoward and unintended responses to an investigational medicinal 
product related to any dose administered;  
Unexpected Adverse Reaction: an adverse reaction, the nature or severity of which is not 
consistent with the applicable product information as provided in the Monofer® SPC. 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 26 
 
Suspected Unexpected Serious Adverse Reaction: SAE (see section 8.1.3) that is unexpected and 
possibly related to the investigational medicinal products. Any SAE not mentioned in the 
investigational medicinal product SPC, paragraph 4.8, is to be considered a suspected unexpected 
serious adverse reaction (SUSAR). 
8.2 
Time period for reporting adverse events and serious adverse events  
For each patient the he standard time period for collecting and recording AE and SAEs will begin 
at the start of study treatment and will continue for half a year subsequent to study drug 
administration (until the end-of-study visit). We will proactively follow up all AEs and SAEs for each 
patient during the course of the study; events will be followed up to resolution, unless the event is 
considered to be unlikely to resolve due to the underlying disease. Every effort should be made to 
obtain a resolution for all events, even if the events continue after discontinuation/study completion. 
Mandatory reporting of new AEs ends after the end-of-study visit 6 months after study drug infusion. 
8.3 
Recording of adverse events 
If the patient has experienced adverse event(s), the investigator will record the following 
information in the CRF: 
The nature of the event(s) will be described by the investigator in precise standard medical 
terminology (i.e. not necessarily the exact words used by the patient). 
The duration of the event will be described in terms of event onset date and event ended data. 
The intensity of the adverse event will be categorised as mild / moderate / severe / life-
threatening / death according to Common Terminology Criteria for Adverse Events version 4.0: 
• 
Mild: asymptomatic or mild symptoms; clinical or diagnostic observations only; intervention 
not indicated;  
• 
Moderate; minimal, local or non-invasive intervention indicated; limiting age-appropriate 
instrumental activities of daily life;  
• 
Severe: Severe or medically significant but not immediately life-threatening; hospitalisation or 
prolongation of hospitalisation indicated; disabling; limiting self-care activities of daily life;  
• 
Life-threatening consequences: urgent intervention indicated.  
The causal relationship of the event to the study medication will be assessed as one of the 
following: 
• 
Unrelated: There is not a temporal relationship to investigational product administration (too 
early, or late, or investigational product not taken), or there is a reasonable causal relationship 
between non-investigational product, concurrent disease, or circumstance and the AE. 
• 
Unlikely: There is a temporal relationship to investigational product administration, but there 
is not a reasonable causal relationship between the investigational product and the AE. 
• 
Possible: There is reasonable causal relationship between the investigational product and the 
AE. Dechallenge information is lacking or unclear. 
• 
Probable: There is a reasonable causal relationship between the investigational product and 
the AE. The event responds to dechallenge. Rechallenge is not required. 
• 
Definite: There is a reasonable causal relationship between the investigational product and 
the AE.  
Action taken: Which investigations/medical procedures/treatments that are initiated as a 
result of the adverse event. 
The outcome of the adverse event – whether the event is resolved or still ongoing. 
 
It is important to distinguish between seriousness and severity of AEs. Severity is a measure of 
intensity whereas seriousness is defined by the criteria in Section 8.1. An AE of severe intensity need 
not necessarily be considered serious. For example, nausea that persists for several hours may be 
considered severe nausea, but is not an SAE. On the other hand, a stroke that results in only a limited 
degree of disability may be considered a mild stroke, but would be an SAE. 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 27 
 
8.4 
Reporting procedure 
 
Adverse events, adverse events of special interest and serious adverse 
8.4.1
events 
All adverse events and serious adverse events that should be reported as defined in section 8.1.1 
will be recorded in the patient's CRF. SAEs must be reported by the investigator to the sponsor, Oslo 
University Hospital, within 24 hours after the site has gained knowledge of the SAE. The Serious 
Adverse Event Report Form must be completed, documented in the CRF, signed and sent to Lars 
Gullestad. The initial report shall promptly be followed by detailed, written reports if necessary. The 
initial and follow-up reports shall identify the trial subjects by unique trial code numbers assigned to 
the latter. The sponsor keeps detailed records of all SAEs reported by the investigators and performs 
an evaluation with respect to seriousness, causality and expectedness. Adverse events of specific 
interest and any SAEs as defined above must be reported to the study drug manufacturer 
(Pharmacosmos®) within 24 hours after the site has gained knowledge of the event in question. 
 
Suspected unexpected serious adverse reactions 
8.4.2
SUSARs will be reported to the Norwegian Medicines Agency and the Ethics Committee 
according to national regulation. The following timelines should be followed: 
The sponsor will ensure that all relevant information about suspected serious unexpected 
adverse reactions that are fatal or life-threatening is recorded and reported as soon as possible to 
the Norwegian Medicines Agency and the Regional Committee for Medical and Health Research 
Ethics in any case no later than seven (7) days after knowledge by the sponsor of such a case, and 
that relevant follow-up information is subsequently communicated within an additional eight (8) 
days. The sponsor shall ensure that suspected adverse reactions that are serious and unexpected are 
reported to the Norwegian Medicines Agency and to the Regional Committee for Medical and Health 
Research Ethics within 15 days of the sponsor after knowledge of the event. The sponsor shall inform 
all investigators of the trial substance in question of suspected adverse reactions that are serious and 
unexpected. An account of any interruption in treatment or any breaking of the treatment code, the 
investigator’s assessment of the causal relationship, and consequences for further testing shall 
accompany the notification of suspected adverse reactions pursuant to the first and second 
paragraphs. 
The Norwegian Medicines Agency may require that individual reports of adverse events 
described in collective reports should also be submitted. The sponsor shall keep detailed records of 
all adverse events that are reported to him by the investigator. The records shall be submitted to the 
Norwegian Medicines Agency on request. 
 
Annual safety report 
8.4.3
Once a year throughout the clinical trial, the sponsor will provide the Norwegian Medicines 
Agency with an annual safety report. The format will comply with national requirements.  
 
Clinical study report 
8.4.4
The adverse events and serious adverse events occurring during the study will be discussed in the 
safety evaluation part of the Clinical Study Report. 
8.5 
Procedures in case of emergency 
The investigator is responsible for assuring that there are procedures and expertise available to 
cope with emergencies during the study.  
Provide information regarding code break, if applicable (see also section 10.2.3). 
 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 28 
 
8.6 
Safety monitoring  
An experienced specialist in internal medicine will be appointed to assess trial safety. This 
clinician will receive reports summarising patient recruitment and the number of AEs / SAEs after the 
first 20 patients have been randomised, and again after 50 % and 100 % of patient enrolment.. The 
clinician responsible for safety monitoring will receive additional information on demand, and can 
advise temporary or permanent stop in patient enrolment. He or she will have access to the 
randomisation code. The clinician responsible for safety monitoring is independent from the sponsor 
and will have no competing interest with regard to the study investigational products or study 
outcome. 
9 
Data management and monitoring 
9.1 
Case report forms (CRFs) 
The designated investigator staff will enter the data required by the protocol into the case report 
form (CRF). The Principal Investigator is responsible for assuring that data entered into the CRF are 
complete, accurate, and that entry is performed in a timely manner. If any assessments are omitted, 
the reason for such omissions will be noted in the CRFs. Corrections, with the reason for the 
corrections will also be recorded. After database lock, the investigator will receive a digital copy of 
the subject data for archiving at the investigational site.  
9.2 
Source data  
Data will be recorded directly into the CRF, which, along with the patients’ medical record is to 
be considered the source data. Data important for patient safety and continued care must be 
duplicated in the patient’s medical record as described below. Study-specific imaging data and blood 
analyses are independent source data.  
The medical records of each patient should clearly describe at least: 
• 
That the patient is participating in the study 
• 
Date when the informed consent was obtained from the patient;  
• 
Results of all assessments confirming a patient’s eligibility for the study; 
• 
Diseases (past and current; both the disease studied and others, as relevant); 
• 
Surgical history, as relevant; 
• 
Treatments withdrawn/withheld due to participation in the study; 
• 
Results of assessments performed during the study; 
• 
Treatments provided, changes in treatments during the study and the time points for the 
changes;  
• 
Visits to the clinic / telephone contacts during the study, including those for study purposes 
only; 
• 
Non-Serious Adverse Events and Serious Adverse Events (if any) including causality 
assessments;  
• 
Date of, and reason for, discontinuation from study treatment;  
• 
Date of, and reason for, withdrawal from study; 
• 
Date of death and cause of death, if available. 
9.3 
Study monitoring  
The investigator will be visited on a regular basis by the Clinical Study Monitor, who will check 
that the study is conducted as approved by the Ethics committee and adheres to GCP guidelines. 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 29 
 
Sponsor’s representatives (e.g. monitors, auditors) and/or competent authorities will be allowed 
access to source data for source data verification in which case a review of those parts of the hospital 
records relevant to the study may be required.  
9.4 
Confidentiality 
The investigator shall arrange for the secure retention of the patient identification and the code 
list. Patient files shall be kept for the maximum period of time permitted by each hospital. The study 
documentation (CRFs, Site File etc.) shall be retained and stored during the study and for 15 years 
after study closure. All information concerning the study will be stored in a safe place inaccessible to 
unauthorised personnel. 
9.5 
Database management 
Data will be entered into the CRF without delay and stored in a dedicated and secured area at 
OUS. Data will be stored in a de-identified manner, where each study participant is recognisable by 
his/her unique trial subject number. The data will be stored until Dec 31st 2034, or until the patient 
requires that his/her data are deleted. Data in the CRF will be handled according to GCP. Only the 
personnel authorised to enter and/or analyse data (i.e. investigators) will have access to the 
database.  
9.6 
Biobanking 
A biobank will be established at the Dept. of Cardiology, Oslo University Hospital, Rikshospitalet 
for the analysis of serum and plasma. The samples will be stored in multiple aliquots and labelled 
with the unique trial subject number, and the letter A signifying baseline, and the letter B signifying 
the end-of-study visit after 6 months. The samples will be stored at -80 degrees Celsius in a dedicated 
research freezer. The material is scheduled for destruction by Dec 31st 2034. Professor Lars Gullestad 
at Oslo University Hospital, Rikshospitalet will be responsible for the biobank. 
10 
Statistical methods and data analysis 
10.1 
Determination of sample size 
This trial is designed to assess the effect of intravenous iron on peak oxygen consumption in 
heart transplant recipients with iron deficiency. We consider an increase in peak oxygen 
consumption of 1.5 ml/kg/min, equivalent to approximately half a Metabolic Equivalent of Task 
(MET), to represent a clinically meaningful improvement. An increase in O2 consumption of 1.5 
ml/kg/min is approximately 6 % of the baseline maximal oxygen consumption in our heart transplant 
recipients.43 Data from the ACTION HF trial showed that a 6 % increase in peak oxygen consumption 
translated to an improved outcome in patients with heart failure.50 With a mean difference between 
the groups of 1.5 ml/kg/min and an expected repeat-measurement standard deviation of 2.5 
ml/kg/min,43 a power of 80% and an α of 5 %, we will need at least 44 patients in each group.  
 To allow for drop-out and to improve the chances of obtaining significance for secondary 
endpoints, we aim to include 100 patients. 
10.2 
Randomisation  
 Allocation- sequence generation 
10.2.1
Balanced, permuted block randomisation (in a 1:1: ratio for the two study arms) using random 
block sizes will be generated by the Research Support Unit at Oslo University Hospital using a 
computerised procedure. A complete, sealed randomisation list containing details of all patient 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 30 
 
numbers and study group will be stored as essential documentation with the Trial Master File in a 
locked office. 
 Allocation- procedure to randomise a patient 
10.2.2
We will use a computerised randomisation procedure for treatment allocation. Patient 
randomisation will be performed by random draw of sealed, opaque envelopes containing cards with 
the words “iron, 20 mg/kg” or “placebo (study drug no. …)” once eligibility has been confirmed and 
the informed consent form has been signed. The study drug numbers will be assigned to each drug 
vial (or placebo card) by a nurse who does not participate in the trial or have competing interest 
regarding study outcome. This nurse will have exclusive access to the list linking study drug numbers, 
and batch numbers and expiry dates. According to the randomisation list, unique cards marked “iron, 
20 mg/kg” or “placebo (study drug no. …)” will be placed in sealed, opaque envelopes by a nurse not 
participating in the trial. A copy of the randomisation list will be stored in a sealed, opaque envelope 
in a locked cupboard along with the study drugs, a mechanism employed to minimise the possibility 
that those enrolling and assigning patients will obtain access to the list.   
 Blinding and emergency un-blinding 
10.2.3
The study participants (patients) and all study personnel, including investigators, personnel 
assessing outcomes, study nurses, data analysts and treating physicians and nurses, will be blinded to 
allocation to study drug. Only the non-investigating nurse(s) preparing and administering the study 
drug at randomisation will be aware of treatment allocation.  
Un-blinding will be performed in the event of AEs where knowledge of the type of drug might be 
of importance to the personnel treating the patients, and in the event of SUSARS.  Un-blinding will be 
performed by non-investigating personnel without competing interest, and the result will 
immediately be reported to the primary investigator, who will then take the required action(s). 
Unless unavoidable, other investigators and personnel assessing outcomes should not be made 
aware of treatment allocation.  
10.3 
Population for Analysis 
 The following populations will be considered for the analyses:  
• 
Intention to treat (ITT) population: All randomised participants, regardless of protocol 
adherence.   
• 
Per-protocol population (PP): Includes all subjects who have received study drug 
10.4 
Planned analyses 
The main statistical analysis is planned when the last patient has completed the end-of-study 
visit 6 months after randomisation. Safety analyses will be performed biannually.  
Deviation from the original statistical plan will be described and justified in the Clinical Study 
Report. Amendments to plan can be done until day of database lock. 
10.5 
Statistical analysis 
All statistical tests will be performed using a two-sided 5 % level of significance. Continuous 
efficacy variables will be analysed using independent T-tests for comparisons between the treatment 
arms and baseline-adjusted ANCOVA for difference in changes. If necessary, values will be log-
transformed to meet the assumptions of the tests. All analyses will primarily be analysed according 
to the intention-to-treat principle.  Between-group differences in ordinal categorical variables, such 
as NYHA class, will be analysed using ordinal logistic regression, whereas the count variables will be 
assessed by Poisson regression. Demographic, efficacy and safety data will be summarised by 
treatment group using means, minimums, medians, maximums, interquartile ranges and standard 
deviations for continuous variables and frequency counts and percentages for categorical variables. 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 31 
 
Per protocol analyses will be performed using the same methods as for the intention-to-treat 
analyses. 
  
The primary endpoint, the baseline-adjusted between-group difference in peak oxygen 
consumption, will be calculated by ANCOVA according to the intention-to-treat principle, the 
statistical null-hypothesis being that the baseline-adjusted oxygen uptake does not differ between 
the two treatment arms. Secondary analyses will be made according to the per-protocol-principle. 
 
Key, secondary endpoints: 
The baseline-adjusted between-group difference in the change in i) hand grip strength, ii) 
normally distributed body composition data, and iii) other normally distributed data will be 
calculated by ANCOVA. The statistical null-hypotheses are that the changes in these characteristics 
do not differ between patients allocated to iron isomaltoside and patients allocated to placebo. 
NT-proBNP, TnT and CRP at six months will be analysed using Mann Whitney U-tests, the 
statistical null-hypothesis being that the levels of these biomarkers do not differ between the 
treatment arms. Regarding quality of life, we specifically plan to assess the between-group number 
of patients with a minimal clinical difference in the SF36 score. 
Secondary per protocol analyses will be performed using the same methods as for the intention-
to-treat analyses. Exploratory analyses will be made for efficacy variables stratified by centre.  
Safety analyses will include tabulation of type and frequency of all adverse events. Any serious 
adverse events will be reported with comprehensive narratives. Any value of safety laboratory 
parameters outside normal ranges will be identified. 
Missing data will be omitted from analyses, i.e. there will be no imputation or estimation of 
missing values. Statistical analyses will be performed in IBM SPSS Statistics version 21 or later. 
11 
Study management 
11.1 
Investigator delegation procedure 
The principal investigator is responsible for making and updating a “delegation of tasks” listing all 
the involved co-workers and their role in the project. He will ensure that appropriate training 
relevant to the study is given to all of these staff, and that any new information of relevance to the 
performance of this study is forwarded to the staff involved. 
11.2 
Protocol adherence 
Investigators ascertain they will apply due diligence to avoid protocol deviations. All significant 
protocol deviations will be recorded and reported in the Clinical Study Report (CSR). 
11.3 
Study amendments 
If it is necessary for the study protocol to be amended, the amendment and/or a new version of 
the study protocol (Amended Protocol) must be notified to and approved by the Competent 
Authority and the Ethics Committee according to EU and national regulations. 
11.4 
Audit and inspections 
Authorised representatives of a Competent Authority and Ethics Committee may visit the centre 
to perform inspections, including source data verification. Likewise the representatives from sponsor 
may visit the centre to perform an audit. The purpose of an audit or inspection is to systematically 
and independently examine all study-related activities and documents to determine whether these 
activities were conducted, and data were recorded, analysed, and accurately reported according to 
the protocol, Good Clinical Practice (ICH/GCP), and any applicable regulatory requirements. The 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 32 
 
principal investigator will ensure that the inspectors and auditors will be provided with access to 
source data/documents. 
12 
Ethical and regulatory requirements 
The study will be conducted in accordance with ethical principles that have their origin in the 
Declaration of Helsinki and are consistent with ICH/GCP and applicable regulatory requirements. 
Registration of patient data will be carried out in accordance with national personal data laws. 
12.1 
Ethics committee approval 
The study protocol, including the patient information and informed consent form to be used, 
must be approved by the regional ethics committee before enrolment of any patients. 
The investigator is responsible for informing the ethics committee of any serious and unexpected 
adverse events and/or major amendments to the protocol as per national requirements. 
12.2 
Other regulatory approvals 
The protocol will be submitted and approved by The Norwegian Medicines Agency and the Data 
Protection Officer (Personvernombudet) at Oslo University Hospital before commencement of the 
study. The protocol will also be registered in www.clinicaltrials.gov before the inclusion of the first 
patient. 
12.3 
Informed consent procedure 
The investigator is responsible for giving the patients full and adequate verbal and written 
information about the nature, purpose, and potential risks and benefits of the study. Study 
participants will be informed as to the strict confidentiality of their patient data, but that their 
medical records may be reviewed for trial purposes by authorised individuals other than their 
treating physician.  
It will be emphasised that study participation is voluntary and that the patient is allowed to 
refuse further participation in the protocol whenever she/he wants. This will not prejudice the 
patient’s subsequent care. Written informed consent must be obtained for all study participants 
before enrolment in the study. This will be done in accordance with the national and local regulatory 
requirements. The investigator is responsible for obtaining signed informed consent. 
A copy of the patient information and consent form will be given to the patients. The signed and 
dated consent forms will be filed in the Investigator Site File binder. 
12.4 
Subject identification 
The investigator is responsible for keeping a list of all patients (who have received study 
treatment or undergone any study specific procedure) including patient’s date of birth and personal 
number, full names and last known addresses.  
The patients will be identified in the CRFs by a study-specific, unique identification number. 
13 
Trial sponsorship and financing 
The IronIC trial is an investigator-initiated study supported by an unrestricted grant provided by 
Pharmacosmos®, who have also provided the study drug. The funding sources have had no role in 
the design of the study; neither will they participate in the implementation of the trial, in the 
analyses of the results, or in the decision to publish. The investigators take sole responsibility for the 
integrity of the data, the writing of the manuscript and the dissemination of the results. 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 33 
 
14 
Trial insurance 
The Principal investigator has insurance coverage for this study through membership of the Drug 
Liability Association.  
15 
Publication policy 
Upon study completion and finalisation of the study report the results of this study will either be 
submitted for publication and/or posted in a publicly assessable database of clinical study results.  
The results of this study will also be submitted to the Competent Authority and the Ethics 
Committee according to EU and national regulations. All personnel who have contributed 
significantly with the planning and performance of the study (Vancouver convention 1988) may be 
included in the list of authors. The funding sources have had no role in the design of the study; 
neither will they participate in the implementation of the trial, in the analyses of the results, or in the 
decision to publish. 
 
 
 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 34 
 
16 
References 
 
References 
 
1. 
Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S, Fedson S, Fisher P, 
Gonzales-Stawinski G, Martinelli L, McGiffin D, Smith J, Taylor D, Meiser B, Webber S, Baran D, 
Carboni M, Dengler T, Feldman D, Frigerio M, Kfoury A, Kim D, Kobashigawa J, Shullo M, Stehlik J, 
Teuteberg J, Uber P, Zuckermann A, Hunt S, Burch M, Bhat G, Canter C, Chinnock R, Crespo-Leiro M, 
Delgado R, Dobbels F, Grady K, Kao W, Lamour J, Parry G, Patel J, Pini D, Towbin J, Wolfel G, Delgado 
D, Eisen H, Goldberg L, Hosenpud J, Johnson M, Keogh A, Lewis C, O'Connell J, Rogers J, Ross H, 
Russell S, Vanhaecke J. The International Society of Heart and Lung Transplantation Guidelines for 
the care of heart transplant recipients. JHeart Lung Transplant 2010;29(8):914-956. 
2. 
Lund LH, Edwards LB, Dipchand AI, Goldfarb S, Kucheryavaya AY, Levvey BJ, Meiser B, 
Rossano JW, Yusen RD, Stehlik J. The Registry of the International Society for Heart and Lung 
Transplantation: Thirty-third Adult Heart Transplantation Report-2016; Focus Theme: Primary 
Diagnostic Indications for Transplant. J Heart Lung Transplant 2016;35(10):1158-1169. 
3. 
Lund LH, Edwards LB, Kucheryavaya AY, Benden C, Dipchand AI, Goldfarb S, Levvey BJ, Meiser 
B, Rossano JW, Yusen RD, Stehlik J. The Registry of the International Society for Heart and Lung 
Transplantation: Thirty-second Official Adult Heart Transplantation Report--2015; Focus Theme: Early 
Graft Failure. J Heart Lung Transplant 2015;34(10):1244-54. 
4. 
Michaels PJ, Espejo ML, Kobashigawa J, Alejos JC, Burch C, Takemoto S, Reed EF, Fishbein 
MC. Humoral rejection in cardiac transplantation: risk factors, hemodynamic consequences and 
relationship to transplant coronary artery disease. J Heart Lung Transplant 2003;22(1):58-69. 
5. 
Kfoury AG, Renlund DG, Snow GL, Stehlik J, Folsom JW, Fisher PW, Reid BB, Clayson SE, 
Gilbert EM, Everitt MD, Bader FM, Singhal AK, Hammond ME. A clinical correlation study of severity 
of antibody-mediated rejection and cardiovascular mortality in heart transplantation. J Heart Lung 
Transplant 2009;28(1):51-7. 
6. 
Hentze MW, Muckenthaler MU, Andrews NC. Balancing acts: molecular control of 
mammalian iron metabolism. Cell 2004;117(3):285-97. 
7. 
Saeed I, Rogers C, Murday A. Health-related quality of life after cardiac transplantation: 
results of a UK National Survey with Norm-based Comparisons. J Heart Lung Transplant 
2008;27(6):675-81. 
8. 
Mettauer B, Levy F, Richard R, Roth O, Zoll J, Lampert E, Lonsdorfer J, Geny B. Exercising with 
a denervated heart after cardiac transplantation. Ann Transplant 2005;10(4):35-42. 
9. 
Nytroen K, Rustad LA, Gude E, Hallen J, Fiane AE, Rolid K, Holm I, Aakhus S, Gullestad L. 
Muscular exercise capacity and body fat predict VO(2peak) in heart transplant recipients. European 
journal of preventive cardiology 2014;21(1):21-9. 
10. 
Rustad LA, Nytroen K, Amundsen BH, Gullestad L, Aakhus S. One year of high-intensity 
interval training improves exercise capacity, but not left ventricular function in stable heart 
transplant recipients: a randomised controlled trial. European journal of preventive cardiology 
2014;21(2):181-91. 
11. 
Dunn LL, Suryo Rahmanto Y, Richardson DR. Iron uptake and metabolism in the new 
millennium. Trends Cell Biol 2007;17(2):93-100. 
12. 
Shayeghi M, Latunde-Dada GO, Oakhill JS, Laftah AH, Takeuchi K, Halliday N, Khan Y, Warley 
A, McCann FE, Hider RC, Frazer DM, Anderson GJ, Vulpe CD, Simpson RJ, McKie AT. Identification of 
an intestinal heme transporter. Cell 2005;122(5):789-801. 
13. 
Nemeth E, Tuttle MS, Powelson J, Vaughn MB, Donovan A, Ward DM, Ganz T, Kaplan J. 
Hepcidin regulates cellular iron efflux by binding to ferroportin and inducing its internalization. 
Science 2004;306(5704):2090-3. 
14. 
Torti FM, Torti SV. Regulation of ferritin genes and protein. Blood 2002;99(10):3505-16. 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 35 
 
15. 
Drakesmith H, Prentice AM. Hepcidin and the iron-infection axis. Science 
2012;338(6108):768-72. 
16. 
Nicolas G, Chauvet C, Viatte L, Danan JL, Bigard X, Devaux I, Beaumont C, Kahn A, Vaulont S. 
The gene encoding the iron regulatory peptide hepcidin is regulated by anemia, hypoxia, and 
inflammation. J Clin Invest 2002;110(7):1037-44. 
17. 
Klip IT, Comin-Colet J, Voors AA, Ponikowski P, Enjuanes C, Banasiak W, Lok DJ, Rosentryt P, 
Torrens A, Polonski L, van Veldhuisen DJ, van der Meer P, Jankowska EA. Iron deficiency in chronic 
heart failure: an international pooled analysis. Am Heart J 2013;165(4):575-582.e3. 
18. 
Okonko DO, Mandal AK, Missouris CG, Poole-Wilson PA. Disordered iron homeostasis in 
chronic heart failure: prevalence, predictors, and relation to anemia, exercise capacity, and survival. J 
Am Coll Cardiol 2011;58(12):1241-51. 
19. 
Anker SD, Comin Colet J, Filippatos G, Willenheimer R, Dickstein K, Drexler H, Luscher TF, Bart 
B, Banasiak W, Niegowska J, Kirwan BA, Mori C, von Eisenhart Rothe B, Pocock SJ, Poole-Wilson PA, 
Ponikowski P. Ferric carboxymaltose in patients with heart failure and iron deficiency. N Engl J Med 
2009;361(25):2436-48. 
20. 
Ponikowski P, van Veldhuisen DJ, Comin-Colet J, Ertl G, Komajda M, Mareev V, McDonagh T, 
Parkhomenko A, Tavazzi L, Levesque V, Mori C, Roubert B, Filippatos G, Ruschitzka F, Anker SD. 
Beneficial effects of long-term intravenous iron therapy with ferric carboxymaltose in patients with 
symptomatic heart failure and iron deficiencydagger. Eur Heart J 2015;36(11):657-68. 
21. 
Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, Falk V, Gonzalez-Juanatey 
JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, 
Rosano GM, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the 
diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and 
treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed 
with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016. 
22. 
Henry DH. The role of intravenous iron in cancer-related anemia. Oncology (Williston Park) 
2006;20(8 Suppl 6):21-4. 
23. 
Ratcliffe LE, Thomas W, Glen J, Padhi S, Pordes BA, Wonderling D, Connell R, Stephens S, 
Mikhail AI, Fogarty DG, Cooper JK, Dring B, Devonald MA, Brown C, Thomas ME. Diagnosis and 
Management of Iron Deficiency in CKD: A Summary of the NICE Guideline Recommendations and 
Their Rationale. Am J Kidney Dis 2016;67(4):548-58. 
24. 
Dignass AU, Gasche C, Bettenworth D, Birgegard G, Danese S, Gisbert JP, Gomollon F, Iqbal T, 
Katsanos K, Koutroubakis I, Magro F, Savoye G, Stein J, Vavricka S. European consensus on the 
diagnosis and management of iron deficiency and anaemia in inflammatory bowel diseases. Journal 
of Crohn's & colitis 2015;9(3):211-22. 
25. 
Lewis GD, Malhotra R, Hernandez AF, McNulty SE, Smith A, Felker GM, Tang WHW, LaRue SJ, 
Redfield MM, Semigran MJ, Givertz MM, Van Buren P, Whellan D, Anstrom KJ, Shah MR, Desvigne-
Nickens P, Butler J, Braunwald E. Effect of Oral Iron Repletion on Exercise Capacity in Patients With 
Heart Failure With Reduced Ejection Fraction and Iron Deficiency: The IRONOUT HF Randomized 
Clinical Trial. JAMA 2017;317(19):1958-1966. 
26. 
Jahn MR, Andreasen HB, Futterer S, Nawroth T, Schunemann V, Kolb U, Hofmeister W, 
Munoz M, Bock K, Meldal M, Langguth P. A comparative study of the physicochemical properties of 
iron isomaltoside 1000 (Monofer), a new intravenous iron preparation and its clinical implications. 
Eur J Pharm Biopharm 2011;78(3):480-91. 
27. 
Zager RA, Johnson AC, Hanson SY, Wasse H. Parenteral iron formulations: a comparative 
toxicologic analysis and mechanisms of cell injury. Am J Kidney Dis 2002;40(1):90-103. 
28. 
Gupta DR, Larson DS, Thomsen LL, Coyne DW. Pharmacokinetics of iron isomaltoside 1000 in 
patients with stage 5 chronic kidney disease on dialysis therapy. J Drug Metab Toxicol 2013;4(3):152. 
29. 
Nordfjeld K, Andreasen H, Thomsen LL. Pharmacokinetics of iron isomaltoside 1000 in 
patients with inflammatory bowel disease. Drug Des Devel Ther 2012;6:43-51. 
30. 
Kalra PA, Bhandari S. Efficacy and safety of iron isomaltoside (Monofer((R))) in the 
management of patients with iron deficiency anemia. Int J Nephrol Renovasc Dis 2016;9:53-64. 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 36 
 
31. 
Wikstrom B, Bhandari S, Barany P, Kalra PA, Ladefoged S, Wilske J, Thomsen LL. Iron 
isomaltoside 1000: a new intravenous iron for treating iron deficiency in chronic kidney disease. 
Journal of nephrology 2011;24(5):589-96. 
32. 
Bhandari S, Kalra PA, Kothari J, Ambuhl PM, Christensen JH, Essaian AM, Thomsen LL, 
Macdougall IC, Coyne DW. A randomized, open-label trial of iron isomaltoside 1000 (Monofer(R)) 
compared with iron sucrose (Venofer(R)) as maintenance therapy in haemodialysis patients. Nephrol 
Dial Transplant 2015;30(9):1577-89. 
33. 
Kalra PA, Bhandari S, Saxena S, Agarwal D, Wirtz G, Kletzmayr J, Thomsen LL, Coyne DW. A 
randomized trial of iron isomaltoside 1000 versus oral iron in non-dialysis-dependent chronic kidney 
disease patients with anaemia. Nephrol Dial Transplant 2016;31(4):646-55. 
34. 
Biggar P, Leistikow F, Walper A. A prospective observational study of effectiveness and safety 
of iron isomaltoside in patients with chronic renal failure and iron deficiency anemia. Clin Nephrol 
2016;86 (2016)(12):310-318. 
35. 
Reinisch W, Staun M, Tandon RK, Altorjay I, Thillainayagam AV, Gratzer C, Nijhawan S, 
Thomsen LL. A randomized, open-label, non-inferiority study of intravenous iron isomaltoside 1,000 
(Monofer) compared with oral iron for treatment of anemia in IBD (PROCEED). Am J Gastroenterol 
2013;108(12):1877-88. 
36. 
Reinisch W, Altorjay I, Zsigmond F, Primas C, Vogelsang H, Novacek G, Reinisch S, Thomsen 
LL. A 1-year trial of repeated high-dose intravenous iron isomaltoside 1000 to maintain stable 
hemoglobin levels in inflammatory bowel disease. Scand J Gastroenterol 2015;50(10):1226-33. 
37. 
Holm C, Thomsen LL, Norgaard A, Langhoff-Roos J. Single-dose intravenous iron infusion or 
oral iron for treatment of fatigue after postpartum haemorrhage: a randomized controlled trial. Vox 
Sang 2017;112(3):219-228. 
38. 
Hildebrandt PR, Bruun NE, Nielsen OW, Pantev E, Shiva F, Videbæk L, Wikström G, Thomsen 
LL. Effects of administration of iron isomaltoside 1000 in patients with chronic heart failure. A pilot 
study. Transfus Altern Transfus Med 2010;11(4):131–137  
39. 
Wasserman K, Hansen JE, Sue DY, Stringer WW, Whipp BJ. Normal Values. In: Wasserman K, 
Hansen JE, Sue DY, Stringer WW, Whipp BJ, eds. Principles of exercise testing and interpretation: 
including pathophysiology and clinical applications. Philadelphia, PA: Lippincott Williams & Wilkins; 
2005, p 160-182. 
40. 
Mehra MR, Canter CE, Hannan MM, Semigran MJ, Uber PA, Baran DA, Danziger-Isakov L, 
Kirklin JK, Kirk R, Kushwaha SS, Lund LH, Potena L, Ross HJ, Taylor DO, Verschuuren EA, Zuckermann 
A. The 2016 International Society for Heart Lung Transplantation listing criteria for heart 
transplantation: A 10-year update. J Heart Lung Transplant 2016;35(1):1-23. 
41. 
Mancini DM, Eisen H, Kussmaul W, Mull R, Edmunds LH, Jr., Wilson JR. Value of peak exercise 
oxygen consumption for optimal timing of cardiac transplantation in ambulatory patients with heart 
failure. Circulation 1991;83(3):778-786. 
42. 
Yardley M, Havik OE, Grov I, Relbo A, Gullestad L, Nytroen K. Peak oxygen uptake and self-
reported physical health are strong predictors of long-term survival after heart transplantation. Clin 
Transplant 2016;30(2):161-9. 
43. 
Nytroen K, Rustad LA, Aukrust P, Ueland T, Hallen J, Holm I, Rolid K, Lekva T, Fiane AE, Amlie 
JP, Aakhus S, Gullestad L. High-intensity interval training improves peak oxygen uptake and muscular 
exercise capacity in heart transplant recipients. Am J Transplant 2012;12(11):3134-42. 
44. 
Recommendations for exercise testing in chronic heart failure patients. Eur Heart J 
2001;22(1):37-45. 
45. 
Borg G. Psychophysical scaling with applications in physical work and the perception of 
exertion. ScandJWork EnvironHealth 1990;16 Suppl 1:55-58. 
46. 
Ware JE, Kosinski M, Bjorner JB, Turner-Bowker DM, Gandek B, Maruish ME. User’s Manual 
for the SF-36v2® Health Survey , 2nd edn. Lincoln, RI: Qual. Inc., 2007. 2. ed. Lincoln, RI: Qual. Inc.; 
2007. 
47. 
Brooks R. EuroQol: the current state of play. Health Policy 1996;37(1):53-72. 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 37 
 
48. 
Chamberlain SR, Robbins TW, Winder-Rhodes S, Muller U, Sahakian BJ, Blackwell AD, Barnett 
JH. Translational approaches to frontostriatal dysfunction in attention-deficit/hyperactivity disorder 
using a computerized neuropsychological battery. Biol Psychiatry 2011;69(12):1192-203. 
49. 
Giugliano RP, Mach F, Zavitz K, Kurtz C, Im K, Kanevsky E, Schneider J, Wang H, Keech A, 
Pedersen TR, Sabatine MS, Sever PS, Robinson JG, Honarpour N, Wasserman SM, Ott BR. Cognitive 
Function in a Randomized Trial of Evolocumab. N Engl J Med 2017;377(7):633-643. 
50. 
Swank AM, Horton J, Fleg JL, Fonarow GC, Keteyian S, Goldberg L, Wolfel G, Handberg EM, 
Bensimhon D, Illiou MC, Vest M, Ewald G, Blackburn G, Leifer E, Cooper L, Kraus WE. Modest increase 
in peak VO2 is related to better clinical outcomes in chronic heart failure patients: results from heart 
failure and a controlled trial to investigate outcomes of exercise training. Circ Heart Fail 
2012;5(5):579-85. 
 
 
 
 
 


IronIC Protocol version 1.41 March 20tieth 2018 
Page 38 
 
 
 

SAP_001.pdf: 
 
IronIC Statistical Analysis Plan 
SAP version 1.0: IronIC 29 Feb 2020 
Page 1 of 14 
 
 
 
Intravenous Iron supplement for Iron 
deficiency in Cardiac transplant 
recipients (IronIC): A randomized 
clinical trial  
 
NCT03662789  
 
Date 29.02.2020


 
IronIC Statistical Analysis Plan 
SAP version 1.0: IronIC 29 Feb 2020 
Page 2 of 14 
 
Statistical Analysis Plan 
 
TRIAL FULL TITLE 
Intravenous Iron supplement for Iron deficiency in Cardiac 
transplant recipients (IronIC) 
EUDRACT NUMBER 
2017-004871-30 
SAP VERSION 
1.0 
SAP VERSION DATE 
29 Feb, 2020 
TRIAL STATISTICIAN 
Kristine Victoria Brautaset Englund 
TRIAL CHIEF INVESTIGATOR 
Kaspar Broch 
SAP AUTHOR 
Kaspar Broch 
1 
SAP Signatures 
I give my approval for the attached SAP entitled IronIC dated 29 Feb, 2020 
Chief Investigator 
Name: Kaspar Broch 
 
Signature: _________________                                                 
 
Date: 
 
                                                 
Statistician 
Name: Kristina Victoria Brautaset 
 
Signature: ____________________  
                                                
 
Date: 
 
                              
 


 
IronIC Statistical Analysis Plan 
SAP version 1.0: IronIC 29 Feb 2020 
Page 3 of 14 
 
2 
Contents 
1 
SAP Signatures ................................................................................................................................ 2 
3 
Introduction .................................................................................................................................... 4 
3.1 
Preface ................................................................................................................................... 4 
3.2 
Purpose of the analyses ......................................................................................................... 4 
4 
Study Objectives and Endpoints ..................................................................................................... 5 
4.1 
Study Objectives ..................................................................................................................... 5 
4.2 
Endpoints ................................................................................................................................ 5 
5 
Study Methods ............................................................................................................................... 5 
5.1 
General Study Design and Plan .............................................................................................. 5 
5.2 
Study plan and assessments ................................................................................................... 6 
5.3 
Inclusion-Exclusion Criteria .................................................................................................... 7 
5.3.1 
Inclusion criteria ............................................................................................................. 7 
5.3.2 
Exclusion criteria ............................................................................................................. 7 
5.4 
Randomisation and Blinding ................................................................................................... 8 
5.5 
Study Variables ....................................................................................................................... 8 
6 
Sample Size ..................................................................................................................................... 8 
7 
General Considerations .................................................................................................................. 9 
7.1 
Timing of Analyses .................................................................................................................. 9 
7.2 
Analysis Populations ............................................................................................................... 9 
7.2.1 
Intention-to-treat Population (Primary analyses) .......................................................... 9 
7.2.2 
Per Protocol Population ................................................................................................. 9 
7.2.3 
Safety Population ........................................................................................................... 9 
7.3 
Covariates and Subgroups ...................................................................................................... 9 
7.4 
Missing Data ......................................................................................................................... 10 
8 
Summary of Study Data ................................................................................................................ 10 
8.1 
Subject Disposition ............................................................................................................... 12 
8.2 
Demographic and Baseline Variables ................................................................................... 13 
8.3 
Treatment Compliance ......................................................................................................... 13 
9 
Efficacy Analyses .......................................................................................................................... 13 
9.1 
Primary Efficacy Analysis ...................................................................................................... 13 
9.2 
Secondary Efficacy Analyses ................................................................................................. 13 
9.2.1 
Secondary endpoints .................................................................................................... 13 
9.3 
Exploratory Efficacy Analyses ............................................................................................... 14 


 
IronIC Statistical Analysis Plan 
SAP version 1.0: IronIC 29 Feb 2020 
Page 4 of 14 
 
10 
Safety Analyses ......................................................................................................................... 14 
10.1 
Adverse Events ..................................................................................................................... 14 
11 
Technical Details ....................................................................................................................... 14 
12 
Summary of Changes to the Protocol ....................................................................................... 14 
 
 
3 
Introduction 
 
3.1 
Preface 
Iron deficiency is associated with poor exercise capacity, lethargy and reduced quality of life. Our 
results show that iron deficiency is prevalent in heart transplant recipients. Cardiac allograft 
recipients have reduced exercise capacity and quality of life compared with the age and gender 
matched general population.  We assume that some of these symptoms are due to iron deficiency, 
and hypothesise that intravenous iron supplement will improve peak oxygen consumption, muscle 
strength, functional capacity, cognition, and health-related quality of life in heart transplant 
recipients with iron deficiency.  
3.2 
Purpose of the analyses 
These analyses will assess the efficacy and safety of iron isomaltoside in comparison with placebo 
and will be included in the clinical study report 


 
IronIC Statistical Analysis Plan 
SAP version 1.0: IronIC 29 Feb 2020 
Page 5 of 14 
 
4 
Study Objectives and Endpoints 
4.1 
Study Objectives 
The main goal of this study is to evaluate the ability of a single administration of intravenous iron 
isomaltoside to increase peak oxygen consumption in cardiac allograft recipients who have iron 
deficiency defined as serum ferritin < 100 µg/l or ferritin between 100 and 300 µg/l in combination 
with a transferrin saturation < 20 %.  
Secondary objectives are to assess the impact of treatment on: (i) iron stores, (ii) muscle strength, 
(iii) body composition, (iv) cognitive function, (v) quality of life, (vi) markers of myocardial disease 
and inflammation, and (vii) safety and tolerability. 
4.2 
Endpoints 
The primary endpoint is the baseline-adjusted peak oxygen consumption as measured on a treadmill 
exercise test 6 months after study drug administration. 
Secondary endpoints: 
• 
The number of patients with absolute or functional iron deficiency 
• 
Muscle strength as measured by a dynamometer hand-grip device 
• 
Body composition 
• 
Cognitive function as assessed by the Cambridge Neuropsychological Test Automated 
Battery 
• 
Quality of life as assessed by the SF-36 and 5D EuroQoL questionnaires 
• 
N-terminal pro-B-type natriuretic peptide (NT-proBNP) 
• 
Cardiac troponin T (TnT) 
• 
C-reactive protein (CRP) 
• 
Inflammatory and vasoactive peptides.   
5 
Study Methods 
5.1 
General Study Design and Plan 
This is a balanced, randomised, placebo controlled, double blind, parallel group trial. Eligible patients 
are randomised 1:1 and allocated to intravenous iron supplement or matching placebo at baseline, 
after providing written informed consent and performing baseline exams. The patients receive the 
study intervention immediately after randomisation, and no more than 3 days after performing the 
baseline tests. The patients then return for efficacy tests 6 months ± 2 weeks after the study 
intervention.   
 


 
IronIC Statistical Analysis Plan 
SAP version 1.0: IronIC 29 Feb 2020 
Page 6 of 14 
 
5.2 
Study plan and assessments 
Phases 
Screening 
Baseline 
Follow-up 
3 months 
6 months 
Informed consent 
x 
 
Study drug infusion 
 
 
Confirmation of 
eligibility 
x 
 
 
 
ECG 
 
x 
 
x 
Echocardiography 
 
x 
 
 
Safety samples1 
 
x 
x 
x 
Serum hCG2 
x 
 
 
 
Randomisation 
 
x 
 
 
Biobank samples3 
 
x 
 
x 
Measurement of 
peak oxygen 
consumption 
 
x 
 
x 
Hand grip 
strength 
 
x 
 
x 
Body mass 
composition 
 
x 
 
x 
Cognitive function 
 
x 
 
x 
Quality of life 
 
x 
 
x 
Registration of 
adverse events 
 
x 
x 
x 
x 
 
 


 
IronIC Statistical Analysis Plan 
SAP version 1.0: IronIC 29 Feb 2020 
Page 7 of 14 
 
5.3 
Inclusion-Exclusion Criteria  
Patients will be screened for eligibility upon admittance for routine follow-up at least one year after 
heart transplantation. 
5.3.1 
Inclusion criteria 
The following conditions must apply prior to administering the investigational medicinal product: 
• 
Cardiac allograft.  
• 
Presentation at least one year after heart transplantation.  
• 
Iron deficiency defined as serum ferritin < 100 µg/l or ferritin between 100 and 300 µg/l in 
combination with a transferrin saturation < 20 %.  
• 
Age between 18 and 80 years. 
• 
Informed consent obtained and documented according to Good Clinical Practice (GCP), and 
national/regional regulations. 
5.3.2 
Exclusion criteria 
Patients will be excluded from the study if they meet any of the following criteria: 
• 
Anaemia (Haemoglobin < 100 mg/l) 
• 
Haemochromatosis 
• 
Haemosiderosis 
• 
Porphyria cutanea tarda 
• 
Blood dyscrasias or any disorders causing haemolysis or unstable red blood cells  
• 
Decompensated liver disease (Child-Pugh score 7 or higher) 
• 
End-stage renal failure, i.e. eGFR < 15 ml/min or on renal replacement therapy  
• 
Planned cardiac surgery or angioplasty within 6 months 
• 
Planned major surgery within 6 months  
• 
Medical history of unresolved cancer (except for basal cell carcinoma)  
• 
Treatment with systemic steroids more than the equivalent of 10 mg Prednisone/day at the 
time of informed consent or change in dosage of thyroid hormones within 6 weeks prior to 
informed consent   
• 
Any uncontrolled endocrine disorder except type 2 diabetes  
• 
Pregnancy 
• 
On erythropoietin analogues 
• 
Known sensitivity or intolerance to iron isomaltoside or other parenteral iron preparations 
• 
Intravenous iron supplement within 6 months prior to inclusion 
• 
On oral iron substitution (unless the subject agrees to stop treatment prior to 
randomisation) 
• 
Ongoing rejections or infections 
• 
Alcohol or drug abuse within 3 months of informed consent that would interfere with trial 
participation or any ongoing condition leading to decreased compliance with study 
procedures or study drug intake 
• 
Intake of an investigational drug in another trial within 30 days prior to intake of study 
medication in this trial or participating in another trial involving an investigational drug 
and/or follow-up 


 
IronIC Statistical Analysis Plan 
SAP version 1.0: IronIC 29 Feb 2020 
Page 8 of 14 
 
5.4 
Randomisation and Blinding 
Balanced, permuted block randomisation (in a 1:1: ratio for the two study arms) using random block 
sizes was computed by the Research Support Unit at Oslo University Hospital. A complete, sealed 
randomisation list containing details of all patient numbers and study group is stored as essential 
documentation within the Trial Master File in a locked office. Treatment allocation is performed by 
random draw of sealed, opaque envelopes containing cards marked “iron isomaltoside 20 mg/kg” or 
“placebo”. A nurse who does not participate in the trial or has competing interest regarding study 
outcomes prepared the envelopes and has exclusive access to the list linking study drug numbers, 
and batch numbers and expiry dates. The administration of the study drug is performed by nurses 
who are not part of the study team. The study participants (patients) and all study personnel, 
including investigators, personnel assessing outcomes, study nurses, data analysts and treating 
physicians and nurses, are blinded to allocation to study drug. 
5.5 
Study Variables 
Primary endpoint: The primary endpoint, the peak oxygen consumption, will be measured as the 
three highest ten-second averaged measurements before the termination of exercise. The oxygen 
consumption is measured in ml/kg/min, meaning that the absolute oxygen uptake (in ml/minute) 
divided by the patient’s weight (in kg) as measured on the day of the test procedure. 
Secondary endpoints: 
The muscle strength is measured in KG. The baseline-adjusted between-group values will be 
analysed by ANCOVA, if necessary after log.-transformation of the data. 
Quality of life as assessed by the EuroQoL 5D 3L will be assessed as the sum of scores (1-3) for the 
five questions. The between-group difference will be assessed with the Mann Whitney U-test. Forms 
with more than one missing value will be discarded, whereas an average value will be imputed for 
forms with one missing variable. The between-group results of visual analogue scale data, on a scale 
from 1-100, will be assessed with baseline-adjusted ANCOVA. The scores for the SF-36v2 will be 
summed up and transformed to norm a based score of (mean ± standard deviation) 50 ± 10 as 
recommended for this version. The between-group difference in the physical and mental score 
components, as well as the sum of the components, will be analysed with baseline-adjusted 
ANCOVA analyses. If more than 20 % of values are missing, the forms will be regarded as invalid, and 
the patients with these forms will be excluded from the intention to treat analysis. If 20 % or fewer 
variables are missing, we will impute mean values derived from the existing values in the same 
subscore (mental of physical) 
6 
Sample Size  
This trial is designed to assess the effect of intravenous iron on peak oxygen consumption in heart 
transplant recipients with iron deficiency. We consider an increase in peak oxygen consumption of 
1.5 ml/kg/min, equivalent to approximately half a Metabolic Equivalent of Task (MET), to represent a 
clinically meaningful improvement. An increase in O2 consumption of 1.5 ml/kg/min is 
approximately 6 % of the baseline maximal oxygen consumption in our heart transplant recipients. 


 
IronIC Statistical Analysis Plan 
SAP version 1.0: IronIC 29 Feb 2020 
Page 9 of 14 
 
Forty-four patients in each group provides the trial with an 80 % power at an α of 5 % to show a 
difference between the groups of 1.5 ml/kg/min at an expected repeat-measurement standard 
deviation of 2.5 ml/kg/min. To allow for drop-out and to improve the chances of obtaining 
significance for secondary endpoints, we aim to include 100 patients. 
7 
General Considerations 
7.1 
Timing of Analyses 
The final analysis will be performed after the last patient has completed the last (6-month) follow-up 
visit, and all data have been transferred to a separate file on having been documented as meeting 
the cleaning and approval requirements of the primary investigator and after the finalisation and 
approval of this Statistical Analysis Plan. Only when these requirements have been met, will 
database lock occur, and the randomisation code be opened. 
7.2 
Analysis Populations 
7.2.1 
Intention-to-treat Population (Primary analyses) 
All subjects who were randomised. For the primary endpoint, only patients who (irrespective 
of receipt of actual treatment) performed an adequate cardiopulmonary exercise test at 
baseline and follow-up can be analysed. The adequacy of the cardiopulmonary exercise test 
must be determined before database lock and the randomisation code is opened. 
7.2.2 
Per Protocol Population 
All subjects actually received the study drug and who performed baseline and follow-up 
tests. 
7.2.3 
Safety Population 
All subjects who received any study treatment (including control) but excluding subjects who 
drop out prior to receiving any treatment. 
 
Each subject’s inclusion or exclusion status regarding each analysis population must be determined 
prior to breaking the blind. The statuses must be documented in the final database prior to breaking 
the blind. 
7.3 
Covariates and Subgroups 
The primary analyses (intention-to-treat population) will not be adjusted for baseline demographics. 
However, the primary endpoint and key secondary endpoints are calculated as the baseline-adjusted 
values (i.e. the follow-up result is adjusted for the baseline result of the same assessment in 
ANCOVA analyses) as specified for each endpoint. 
We will perform binary subgroup analyses of the primary endpoint stratified by gender; age 
(median); whether the baseline transferrin saturation is < or ≥ 20 %; by whether or not the patient 
has anaemia (defined according to World Health Organization criteria of < 12 g/l for women and < 13 
g/l for men); C-reactive protein (median) and whether or not iron parameters have normalised (to 
values no longer defined as iron deficiency as defined in “study objectives”. A forest plot will be used 


 
IronIC Statistical Analysis Plan 
SAP version 1.0: IronIC 29 Feb 2020 
Page 10 of 14 
 
to communicate the results. The subgroup analyses are exploratory only, as the trial is not powered 
to show differences across subgroups. 
7.4 
Missing Data 
Because the efficacy data are collected twice only, and the endpoint analyses will be baseline 
adjusted ANCOVA or single point assessments only, there will be no imputation of missing data. 
However, to elucidate possible biases this method entails, baseline data for patients for whom 
endpoint data exist will be compared with baseline data for patients who for some reason drop out 
or are unable to complete both sets of tests. We will also explore if the dropout rate differs between 
the treatment arms.  The extent of missing data will be quantified for each endpoint variable.  
We expect few missing baseline covariates and will not employ a strategy to impute missing baseline 
covariates.  
8 
Summary of Study Data 
The baseline, intention-to-treat population demographics will be presented by columns for each 
treatment (Placebo, Intravenous iron isomaltoside). All continuous variables will be summarised 
using the following descriptive statistics: mean ± standard deviation; median (interquartile range). 
The frequency and percentages (based on the non-missing sample size) of observed levels will be 
reported for all categorical measures. All summary tables will be structured with a column for each 
treatment in the order (Control, Experimental) and will be annotated with the total population size 
relevant to that table/treatment, including any missing observations. 
The sample size of non-missing values for univariable summary statistics may be larger than the 
sample size of non-missing values in a complete-case analysis used in the primary regression 
(ANCOVA) analysis. 
 
Table 1 
Demographics  
Placebo  
Intravenous iron 
Age  – years  
 
 
Male gender – no (%) 
 
 
Time since HTx – years (IQR) 
 
 
Reason for HTx, no (%) 
 
 
Ischemic  
 
 
DCMP  
 
 
GUCH no  
 
 
Other no  
 
 
Left ventricular ejection fraction 
 
 
NYHA functional class, no (%) 
I 
 
 
II 
 
 
III  
 
 
IV 
 
 
Body mass index – kg/m2  
 
 


 
IronIC Statistical Analysis Plan 
SAP version 1.0: IronIC 29 Feb 2020 
Page 11 of 14 
 
 
Systolic blood pressure – mmHg  
 
 
Heart rate – beats per minute 
 
 
Treatment 
Cyclosporine/Tacrolimus 
 
 
Everolimus 
 
 
Mycophenolic acid/Azathioprine 
 
 
Prednisolone  
 
 
Angiotensin converting enzyme inhibitor 
 
 
Angiotensin II-receptor antagonist 
 
 
Loop diuretic 
 
 
Thiazide 
 
 
Beta-blocker 
 
 
Calcium antagonist  
 
 
Platelet inhibitors 
 
 
Oral anticoagulants 
 
 
Proton pump inhibitors 
 
 
Biochemistry 
Haemoglobin – g/l 
 
 
Creatinine - µmol/L 
 
 
Estimated glomerular filtration rate – ml/min/1.73m2 
 
 
Ferritin – µg/l (IQR) 
 
 
Transferrin saturation – % (IQR) 
 
 
Transferrin receptor (mg/l) % (IQR) 
 
 
Sedimentation Rate – mm (IQR) 
 
 
C-reactive protein – µg/l (IQR)  
 
 
Total plasma protein – g/l 
 
 
Troponin T – ng/l (IQR) 
 
 
N-terminal pro B-type natriuretic peptide-ng/l (IQR) 
 
 
Ferritin < 30 µg/ - no (%) 
 
 
Transferrin saturation < 20% - no (%) 
 
 
Ferritin 100-300 µg/l +Transferrin sat. <20% -no (%) 
 
 


 
IronIC Statistical Analysis Plan 
SAP version 1.0: IronIC 29 Feb 2020 
Page 12 of 14 
 
8.1 
Subject Disposition 
We will document how many subjects reached the various stages of the trial (the number screened, 
randomised, reached the 6-month follow-up visit and could be analysed for the primary endpoint), 
and how many dropped out and for what reasons (death, withdrew consent, failed to show up) 
according to the following CONSORT diagram: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patients screened:  
n= 
Patients randomized: 
n= 
Patients not included: 
 
 
 
Iron intervention:  
n= 
 
Placebo: 
n= 
Follow up at 6 months:  
n= 
Follow up at 6 months: 
n= 
Lost to follow up: 
n= 
Lost to follow up:  
n= 


 
IronIC Statistical Analysis Plan 
SAP version 1.0: IronIC 29 Feb 2020 
Page 13 of 14 
 
8.2 
 Demographic and Baseline Variables 
The following baseline variables will be presented:  
The summary statistics will be produced in accordance with section 8. 
8.3 
Treatment Compliance 
Because the study intervention consists of a single, intravenous infusion, there is no issue with 
treatment compliance. The intention-to-treat primary analyses will be performed regardless of 
whether or not the study drug infusion was completed, but the number of patients who did not 
receive the intervention will be reported for each group. 
9 
Efficacy Analyses 
9.1 
 Primary Efficacy Analysis 
The primary endpoint, the baseline-adjusted peak oxygen consumption 6 months after the 
intervention, will be calculated by ANCOVA with treatment allocation and the baseline peak oxygen 
consumption as covariates according to the intention-to-treat principle, the statistical null-
hypothesis being that the baseline-adjusted oxygen uptake does not differ between the two 
treatment arms. If the primary endpoint is met at a significance level of 0.05, the result will be 
considered confirmatory of the main research hypothesis. 
9.2 
 Secondary Efficacy Analyses 
Secondary, per protocol analysis will be performed for the primary endpoint. Exploratory subgroup 
analyses will be performed for the six subgroup categories mentioned in the section “Covariates and 
subgroups. The latter results will be communicated as a forest plot, and the interaction value of the 
covariates “treatment allocation” and the binary subgroup identifier in question will be reported at a 
significance level of 0.05.  
9.2.1 
Secondary endpoints 
The baseline-adjusted between-group difference in the change in i) hand grip strength, ii) normally 
distributed body composition data, and iii) the SF36 score and the visual analogue scale data from 
the EuroQoL 5D 3L form will be calculated by ANCOVA. The statistical null-hypotheses are that the 
changes in these characteristics do not differ between patients allocated to iron isomaltoside and 
patients allocated to placebo. 
NT-proBNP, TnT and CRP at six months will be analysed using Mann Whitney U-tests, the statistical 
null-hypothesis being that the levels of these biomarkers do not differ between the treatment arms. 
The between-group difference in the proportion of patients with a minimum clinically important 
improvement, defined as an improvement of 4 points, and the between-group difference in the 
proportion of patients with a minimum clinically important deterioration, defined as a decrease of 4 
points, will be calculated by Chi square tests. 
Secondary per protocol analyses will be performed using the same methods as for the intention-to-
treat analyses. 


 
IronIC Statistical Analysis Plan 
SAP version 1.0: IronIC 29 Feb 2020 
Page 14 of 14 
 
9.3 
 Exploratory Efficacy Analyses 
Exploratory analyses of between-group differences in inflammatory parameters and parameters 
pertaining to iron metabolism, such as Hepcidin, Interleukin 6 and the ferritin index will be 
performed by ANCOVA or repeated test t-tests, if necessary after log-transformation to meet the 
requirements of the test.  
10 
Safety Analyses 
Safety analyses will include tabulation of type and frequency of all adverse events. Any value of 
safety laboratory parameters outside normal ranges will be identified. The final report will include 
the absolute number of adverse and severe adverse events in each group. The results will be 
reported for the Safety Population only. The summary statistics will be produced in accordance with 
section 8. 
10.1 
 Adverse Events 
Serious adverse events and adverse events of special interest; pregnancies and adverse reactions to 
the investigational medicinal products will be reported with comprehensive narratives.  
11 
Technical Details 
Statistical analyses will be performed in IBM SPSS Statistics version 21 or later.  
12 
Summary of Changes to the Protocol 
This Statistical Analysis Plan differs from the protocol (Version 1.4) only with regard to the detail 
with which the statistical methods and plans for how results are communicated are presented, and 
the specification of exploratory subgroup analyses of the primary endpoint.