Clinical trial NCT03094416
Conditions: Hypothyroidism;Postablative
Sponsor: IBSA Institut Biochimique SA
Start date: 2018-07-30; Completion date: 2020-06-15
Enrollment: 66 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
This is an open-label therapeutic efficacy study of Tirosint (levothyroxine sodium) capsules in thyroidectomized patients taking proton pump inhibitors and levothyroxine, evaluating changes in serum levels of Thyroid Stimulating Hormone (TSH) upon switch to Tirosint with respect to baseline.

Detailed description:

Arms: arm 1: levothyroxine sodium capsules 88 to 250 mcg/day (depending on individual needs) for 3 months
Interventions: intervention 1: levothyroxine sodium capsule intervention 2: Proton pump inhibitor (PPI) intervention 3: Levothyroxine Sodium (LT4) Tablets
Intervention descriptions: intervention 1: after the run-in period, patients will be switched to levothyroxine sodium capsule at the same dose used during run-in intervention 2: for the whole study duration all subjects will keep taking their proton pump inhibitor medication, as per prescription and as before inclusion intervention 3: during the run-in period, subjects will continue taking their levothyroxine sodium tablet medication as per prescription and as before inclusion

Protocol documents:
Prot_000.pdf: 



























































































































































SAP_001.pdf: 


Sponsor: IBSA Institut Biochimique SA 
 
CONFIDENTIAL 
 
Statistical Analysis Plan                                                                                           Study Protocol N. 13US-T404 
 
Final v. 2.0, 23/12/2021 
2 
 
 
 
 
SIGNATURES 
 
 
Protocol number: 13US-T404 
 
Title: An open-label therapeutic efficacy study of Tirosint® (levothyroxine sodium) capsules in 
thyroidectomized patients taking proton pump inhibitors. 
 
 
Document: Statistical Analysis Plan 
 
Date: 23/12/2021 
 
Author 
 
 
__________________________________________________                  ___________________ 
 
       Date (dd/mm/yyyy) 
 
 
Approver 
 
 
__________________________________________________  
      ___________________ 
        Date (dd/mm/yyyy) 
 


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Statistical Analysis Plan                                                                                           Study Protocol N. 13US-T404 
 
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TABLE OF CONTENTS 
SIGNATURES ......................................................................................................................... 2 
TABLE OF CONTENTS ........................................................................................................ 3 
LIST OF ABBREVIATIONS ................................................................................................ 4 
1 
INTRODUCTION ........................................................................................................... 5 
2 
VERSION HISTORY ...................................................................................................... 5 
3 
STUDY OBJECTIVES HYPOTHESIS TESTING ...................................................... 6 
3.1 
STUDY OBJECTIVES ............................................................................................ 6 
3.2 
HYPOTHESES TO BE TESTED ............................................................................ 6 
4 
STUDY DESIGN ............................................................................................................. 6 
4.1 
SAMPLE SIZE ......................................................................................................... 9 
4.2 
RANDOMISATION ................................................................................................. 9 
5 
DEFINITIONS AND DATA CONVENTIONS ............................................................ 9 
6 
ANALYSIS SETS .......................................................................................................... 12 
6.1 
INTENTION-TO-TREAT POPULATION (ITT)/ FULL ANALYSIS SET 
(FAS)  .................................................................................................................................. 12 
6.2 
PER-PROTOCOL POPULATION (PP) .............................................................. 12 
6.3 
SAFETY POPULATION (SP) ............................................................................... 12 
6.4 
OTHER ANALYSIS SET ...................................................................................... 12 
6.5 
TREATMENT MISALLOCATIONS .................................................................. 12 
6.6 
PROTOCOL DEVIATIONS ................................................................................. 12 
7 
VARIABLES OF INTEREST ...................................................................................... 13 
7.1 
EFFICACY VARIABLES ..................................................................................... 13 
7.1.1 
PRIMARY EFFICACY VARIABLES .......................................................................... 13 
7.1.2 
SECONDARY EFFICACY VARIABLES ..................................................................... 13 
7.2 
SAFETY AND TOLERABILITY VARIABLES ................................................. 13 
7.3 
CONCOMITANT MEDICATIONS ..................................................................... 14 
7.4 
LABORATORY DATA ......................................................................................... 14 
8 
HANDLING OF MISSING AND INCOMPLETE DATA ........................................ 14 
9 
STATISTICAL METHODOLOGY ............................................................................ 16 
9.1 
GENERAL METHODOLOGY ............................................................................ 16 
9.2 
PATIENT DISPOSITION ..................................................................................... 16 
9.3 
DEMOGRAPHIC AND SCREENING/BASELINE CHARACTERISTICS .... 16 
9.4 
ANALYSIS OF EFFICACY .................................................................................. 17 
9.4.1 
PRIMARY EFFICACY ANALYSIS ............................................................................. 17 
9.4.2 
SECONDARY EFFICACY ANALYSIS ........................................................................ 17 
9.5 
ANALYSIS OF SAFETY ....................................................................................... 19 
9.5.1 
TOLERABILITY PARAMETERS .............................................................................. 19 


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9.5.2 
ADVERSE EVENTS ................................................................................................. 19 
9.5.3 
VITAL SIGNS ......................................................................................................... 20 
9.5.4 
OTHER TOLERABILITY PARAMETERS .................................................................. 20 
9.6 
INTERIM ANALYSIS ........................................................................................... 21 
10 
GENERAL CONSIDERATIONS ............................................................................ 23 
10.1 SOFTWARE TO BE USED ................................................................................... 23 
10.2 CODING DICTIONARIES ................................................................................... 23 
10.3 PROGRAMS QUALITY CONTROL .................................................................. 23 
11 
REFERENCES ........................................................................................................... 24 
12 
PROGRAMMING SPECIFICATIONS .................................................................. 24 
13 
APPENDIX 1: LIST OF TABLES, LISTINGS AND FIGURES .......................... 24 
14 
APPENDIX 2: SHELL TABLES.............................................................................. 25 
 
 








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Statistical Analysis Plan                                                                                           Study Protocol N. 13US-T404 
 
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3 
STUDY OBJECTIVES HYPOTHESIS TESTING 
 
3.1 
STUDY OBJECTIVES 
 
The objective of this study is to evaluate the therapeutic efficacy of Tirosint® capsules in 
patients with a history of hypothyroidism and on proton pump inhibitors. 
 
3.2 
HYPOTHESES TO BE TESTED 
 
Primary objective 
 
The primary objective of this study is to evaluate the therapeutic efficacy of Tirosint® capsules in 
patients with a history of hypothyroidism and on PPIs. 
The hypothesis is that PPIs may have less of an effect on the absorption, as assessed by alteration in 
serum TSH, of Tirosint® capsules when compared to standard tablets therapy in this patients’ 
population. 
 
Secondary objective 
 
The secondary objectives of this study are to evaluate any biochemical changes in creatine 
phosphokinase (CPK), sex hormone binding globulin (SHBG), ferritin, angiotensin converting enzyme 
(ACE) level, and lipid panel, as well as the change in daily LT4 dose in the same population upon 
switch from conventional tablets to Tirosint® capsules. 
 
 
 
4 
STUDY DESIGN 
 
This was an open-label, phase IV study. 
Enrolment was to be stopped as soon as 48 patients were completed or 60 patients included in the 
Tirosint treatment phase, whatever came first. 
Adult patients with a history of hypothyroidism due to total thyroidectomy, who were on stable doses 
of levothyroxine tablets (between 88 and 250 mcg daily) for at least 6 weeks before screening visit and 
with a history of gastroesophageal reflux disease (GERD) or associated gastrointestinal issues on 
prescription (Rx) PPIs (i.e. omeprazole ≥ 20 mg daily, or esomeprazole ≥ 20 mg daily, or lansoprazole 
≥ 15 mg daily, or dexlansoprazole ≥ 30 mg daily, or pantoprazole ≥ 40 mg daily, or rabeprazole ≥ 20 
mg daily) for at least 8 weeks before screening visit were included in the study. 
 
During the screening visit, subjects (holding their morning dose of LT4) underwent screening serum 
measurements for TFTs (TSH, FT4, free T3 [FT3], total T3 [TT3]), along with a physical examination. 
Subjects complying with inclusion/exclusion criteria entered a run-in period, in which they continued 
taking their levothyroxine and PPI medications as per prescription, at their current dose. Should the 
patient require LT4 dose adjustment at screening visit, it was possible to re-screen the patient until TSH 
normalization under the new dose. 




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Statistical Analysis Plan                                                                                           Study Protocol N. 13US-T404 
 
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Drug return 
 
 
X 
X 
Outcomes: 
 
 
 
 
Thyroid function tests 
 
X4 
X3 
X4 
Serum lab tests5 
 
X 
 
X 
Pill count (compliance) 
 
 
X 
X 
AEs and concomitant 
medications monitoring 
 
X 
X 
X 
 
1 Vital signs, height (V1 only), weight, neck exam, cardiac exam, and respiratory exam 
2 Weight 
3 TSH, FT4, FT3 and TT3 (sample to be collected pre-dose) (same tests in case of re-screening) 
4 TSH, FT4, TT4, FT3 and TT3 (sample to be collected pre-dose) 
5 CPK, SHBG, ferritin, ACE level, and lipid panel (TC, LDL-C, HDL-C, VLDL-C, and TG) (sample 
to be collected pre-dose and in fasting conditions)  
6 Day 1 of treatment period was the first day of Tirosint® intake and should be the day of V2. 
7 In case re-screening is necessary, this time period may be extended, provided that time interval 
between re-screening and V2 is kept within -28/-42 days, and that the overall screening period does 
not exceed 4 months. 
 
 
 


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Changes from study protocol 
Treatment compliance 
 
Study protocol states that treatment compliance will be evaluated separately over run-in and treatment 
periods. To have a more accurate compliance evaluation it will also be computed by visit both from 
the Study Diary and Drug accountability.  
Compliance from the Drug accountability will be computed on the amount of drug to be taken among 
visits rather than on the number of capsules, as the number of capsules differs according to the 
prescribed dosages. 
 
Analysis Sets 
 
In order to assess sensitivity on efficacy analysis an additional analysis population will be defined. 
Modified Intention-To-Treat population will be defined as: all included patients who received at least 
one dose of the study medication and performed at least Visit 2 and Visit 3 laboratory assessments 
under the same LT4 dose with a valid TSH value. 
 
Baseline covariates 
 
Since the repeated measures analysis will be performed only on two time points (one baseline and one 
post baseline), the models will not include the basal value also as additional covariate for the analysis. 
 
 
4.1 
SAMPLE SIZE 
 
A sample size of 48 subjects had 70% power to detect a difference in means of TSH of 0.7, assuming 
a standard deviation of differences of 1.9, using a paired t-test with a 0.050 two-sided significance level. 
To account for a drop-out and dose adjustment rate of about 20%, a maximum number of 60 subjects 
were to be included in the study (Tirosint® treatment phase).  
The study was early terminated with 47 patients included in the Tirosint ® treatment phase and 45 
patients completed, due to the COVID-19 pandemic outbreak. 
 
4.2 
RANDOMISATION 
Not applicable. This is an open label non-randomized study. 
 
5 
DEFINITIONS AND DATA CONVENTIONS 
 
Age  
 
Age will be calculated in decimal form as portion of the date of screening visit minus the date of birth, 
divided by 365.25 days per year, and then rounded down, that is: 
 
Age (years) =  Floor((date of screening visit – date of birth) /365.25). 


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Body Mass Index (BMI) 
 
BMI will be computed using the following formula: 
 
BMI =  Body Weight (kg) / (Height (m))ଶ 
 
Daily dosage 
Daily dosage (mcg) will be computed for each patient as:  
𝐷𝑎𝑖𝑙𝑦 𝐷𝑜𝑠𝑎𝑔𝑒= ቆ
∑
(𝑑𝑎𝑖𝑙𝑦 𝑑𝑜𝑠𝑎𝑔𝑒௜ [𝑚𝑐𝑔])
଻
௜ୀଵ
7
ቇ 
where “i” is the day of the week.  
 
Daily dosage/Body Weight  
Daily dosage/Body Weight (mcg / kg) will be computed for each patient as:  
𝐷𝑎𝑖𝑙𝑦 𝐷𝑜𝑠𝑎𝑔𝑒/𝐵𝑜𝑑𝑦 𝑊𝑒𝑖𝑔ℎ𝑡= 
ቆ∑
(𝑑𝑎𝑖𝑙𝑦 𝑑𝑜𝑠𝑎𝑔𝑒௜ [𝑚𝑐𝑔])
଻
௜ୀଵ
7
ቇ 
𝑊𝑒𝑖𝑔ℎ𝑡 [𝑘𝑔] 
 
where “i” is the day of the week.  
 
Prior medications 
 
Medications reported with an end date before the first study treatment administration (end date < date 
of first study treatment administration). As prior medication will be also indicated all medications 
reported by patients who didn’t took the study treatment. 
 
Concomitant medications 
 
Medications reported as ongoing or with an end date after the first study treatment administration 
(ongoing or end date ≥ date of first study treatment administration). 
 
Treatment-Emergent Adverse Events (TEAEs) 
 
Adverse events who started after the start of the study treatment, adverse events without start date and 
with an end date after the start of the study treatment or adverse events without start date reported as 
ongoing (for patients who take at least one dose of study treatment). 
 
Pre-Treatment Adverse Events (PTAEs) 


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Adverse events started after the subject’s inclusion into the study but before the effective study 
treatment period (start date < date of first study treatment administration). 
 
Serious Adverse Events (SAEs) 
  
Adverse Event judged as serious. 
 
Drug related Adverse Events 
 
Adverse Events with a relationship to treatment reported as "Certain", "Probable" or "Possible". 
 
Adverse events leading to discontinuation 
 
Adverse Events leading to discontinuation is an AE with action taken equal to “Drug withdrawn”. 
 
Adverse events leading to death 
 
Adverse Events leading to death is an AE with outcome equal to “Fatal”. 
 
 


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6 
ANALYSIS SETS 
 
6.1 
INTENTION-TO-TREAT POPULATION (ITT)/ FULL ANALYSIS SET (FAS) 
 
All included patients who received at least one dose of the study medication. 
 
 
6.2 
PER-PROTOCOL POPULATION (PP) 
 
All patients in the ITT population who completed the study and who did not have any major protocol 
violations (e.g. use of prohibited concomitant medications, violation of major inclusion/exclusion 
criteria). 
 
 
6.3 
SAFETY POPULATION (SP) 
 
All included patients. 
 
6.4 
OTHER ANALYSIS SET 
 
MODIFIED INTENTION-TO-TREAT POPULATION (ITT) 
 
All included patients who received at least one dose of the study medication and performed at least 
Visit 2 and Visit 3 laboratory assessments under the same LT4 dose with a valid TSH value. 
 
6.5 
TREATMENT MISALLOCATIONS 
 
Not applicable. 
 
6.6 
PROTOCOL DEVIATIONS 
 
Any protocol violation or deviation (i.e., wrong inclusion, poor compliance, forbidden concomitant 
medications etc.) will be discussed by case before statistical analysis with the clinical team and 
described in the statistical report. 
Violations will be classified as major violation or minor violation according to the impact on subject 
safety, the effect on completeness, accuracy and reliability of the data collected for the study, and the 
influence on the efficacy assessments. Protocol deviations related to COVID-19 will also be identified. 
 


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Statistical Analysis Plan                                                                                           Study Protocol N. 13US-T404 
 
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7 
VARIABLES OF INTEREST 
 
7.1 
EFFICACY VARIABLES 
7.1.1 
Primary efficacy variables 
 
The primary efficacy variable is the serum levels of TSH. 
Serum levels of TSH will be measured at screening visit(s), at baseline, halfway 
through the treatment period and at the final visit.  
The serum levels of TSH recorded after changes in LT4 dose will not be considered 
for the analysis. 
 
7.1.2 
Secondary efficacy variables 
The secondary efficacy variables are the serum levels of FT4, TT4, FT3, TT3, CPK, 
SHBG, ferritin, ACE level, and lipid panel; and the LT4 dose adjustment. 
 
Serum levels of FT4, FT3 and TT3 will be measured at screening visit(s), at baseline, 
halfway through the treatment period and at the final visit. In addition, serum levels of 
TT4, CPK, SHBG, ferritin, ACE level, and lipid panel (TC, HDL-C, LDL-C, VLDL-
C, TG) will be measured at baseline and at the end of the 12-week treatment period 
(Final visit).  
The change in serum levels of TSH, FT4, FT3, TT3 at Visit 3 vs baseline will also be 
analysed as secondary efficacy endpoint. 
The serum levels of TSH, FT4, TT4, FT3, TT3, CPK, SHBG, ferritin, ACE level, and 
lipid panel recorded after changes in LT4 dose will not be considered for the analysis. 
 
LT4 dose adjustment will be evaluated both in terms of number of patients requiring 
changes in daily dose during the treatment period and as mean change in daily LT4 
dose at the end of the treatment period versus baseline. 
 
 
7.2 
SAFETY AND TOLERABILITY VARIABLES 
Safety and tolerability will include Adverse Events, physical examination, body weight, vital signs and 
compliance. 
- 
Adverse events will be recorded throughout the study. 
- 
Physical examination including neck exam, cardiac exam and respiratory exam will be 
performed at screening and final visits. Body weight will also be recorded at screening, 
baseline, and final visit. 


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- 
Vital signs including heart rate, systolic and diastolic blood pressure will be performed at 
screening and final visits. 
- 
Patients’ compliance with Tirosint® and with the prescribed treatments (levothyroxine as per 
prescription during the run-in and PPI during the run-in and throughout the whole treatment 
period) will be assessed by visit based on data reported in the Subject’s Diary; Tirosint® 
compliance will also be assessed by visit based on the Drug Administration. 
 
7.3 
CONCOMITANT MEDICATIONS 
Prior and concomitant medications will be summarized by Anatomical Therapeutic Chemical (ATC) 
level 2 and Preferred Term (PT) assigned from the WHO drug terms and procedures dictionary for 
treatments and surgical and medical procedures, showing the number and percentage of subjects from 
the Safety Population taking each medication. Prior and concomitant LT4/PPI treatments will be 
summarized separately. 
 
7.4 
LABORATORY DATA 
Laboratory data will include: 
- 
blood sampling for thyroid function tests: TSH, FT4, TT4, FT3, TT3;  
- 
serum laboratory tests: CPK, SHBG, ferritin, ACE, and lipid panel (TC, HDL-C, LDL-C, 
VLDL-C, TG); 
 
8 
HANDLING OF MISSING AND INCOMPLETE DATA 
 
Cases of withdrawal from the study, for any reasons, after inclusion will not be replaced. However, the 
withdrawn cases will be analyzed in the ITT analysis. 
TSH, FT4, TT4, FT3, TT3, CPK, SHBG, ferritin, ACE level, and lipid panel (TC, HDL-C, LDL-C, 
VLDL-C, TG) values recorded after changes in LT4 dose will not be considered for the statistical 
analysis. 
For analyses that require complete patient data, missing values during the treatment period will be 
replaced, for all primary and secondary variables, with the Last Observation Carried Forward (LOCF) 
technique. Imputed values will be included in the analysis set(s), but will not change the original clinical 
database. 
 
Partial dates imputation: 
 
Prior and Concomitant Medications 
 
Partial start dates will be computed as follow: 
- 
If day is missing the first day of the reported month will be imputed. 
- 
If month and day are missing the 1st January will be imputed. 
- 
If month, day and year are missing no imputation will be applied. 


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Statistical Analysis Plan                                                                                           Study Protocol N. 13US-T404 
 
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Partial end dates will be computed as follow: 
- 
If day is missing the last day of the reported month will be imputed. 
- 
If month and day are missing the 31st December will be imputed. 
- 
If month, day and year are missing no imputation will be applied. 
 
Prior and concomitant medications without an end date will be considered as ongoing. 
 
Adverse Events 
 
Partial start dates will be computed as follow: 
- 
If day is missing the first day of the reported month will be imputed. 
- 
If month and day are missing the 1st January will be imputed. 
- 
If month, day and year are missing no imputation will be applied. 
 
 
Partial end dates will be computed as follow: 
- 
If day is missing the last day of the reported month will be imputed. 
- 
If month and day are missing the 31st December will be imputed. 
- 
If month, day and year are missing no imputation will be applied. 
 
Adverse events without an end date will be considered as ongoing. 
 
 
 
 


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Statistical Analysis Plan                                                                                           Study Protocol N. 13US-T404 
 
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9 
STATISTICAL METHODOLOGY 
 
9.1 
GENERAL METHODOLOGY 
Descriptive statistics 
- 
Continuous variables will be summarized by mean, standard deviation, median, 1st 
quartile, 3rd quartile, minimum and maximum.  
- 
Discrete variables will be summarized by frequencies and percentages. 
All p-values will be rounded to four decimal places. Statistical significance will be declared if 
the two tailed p-value is less than 0.050. 
 
Baseline definition 
 
As baseline will be considered the last assessment before the first dose of study treatment. (i.e. date of 
assessment previous or equal to the start date of study treatment) 
 
 
9.2 
PATIENT DISPOSITION 
 
A complete screening disposition on screened patients including the number of enrolled 
patients, the number of screening failure, the number of patients rescreened and the reason for 
screening failure will be provided. 
A study disposition will also be provided, it will include number of patients who completed or 
discontinued the study and the reason for discontinuation. 
Disposition of patients who performed each visit, patients included in each analysis population 
and protocol deviations will be provided. To evaluate the COVID-19 impact on the study a 
summary of protocol deviations related to it will be provided. 
 
9.3 
DEMOGRAPHIC AND SCREENING/BASELINE CHARACTERISTICS 
Demographic data will include age, height, weight, BMI: those will be analyzed as summary 
of means. Gender and race will also be analyzed as summary of frequencies and percentages. 
Patients baseline characteristics will include: 
 


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- 
Prior medications: those will be summarized by Anatomical Therapeutic Chemical 
(ATC) level 2 and Preferred Term (PT). Prior LT4/PPI treatments will be summarized 
separately.  
 
- 
Medical and surgical history information: those will be summarized by System Organ 
Class (SOC) and Preferred Term (PT). 
 
- 
Childbearing potential and urine pregnancy test information that will be summarized 
by frequencies and percentages on female patients of the following variables: 
childbearing potential and information about lactating, using reliable contraception, 
pregnancy in the next months and pregnancy test. 
 
9.4 
ANALYSIS OF EFFICACY 
 
All efficacy variables will be analyzed in the ITT, mITT and PP populations. 
 
9.4.1 
Primary efficacy analysis 
The primary efficacy endpoint is the change in serum levels of TSH at the end of the 
12-week treatment period with Tirosint® capsules vs baseline. 
 
A mixed model ANCOVA repeated measures model will be used to test differences in 
means of TSH level at Visit 4 vs baseline visit. As covariates will be considered the 
following baseline variables: Age, Sex, BMI and the prescribed Tirosint® dosage 
(dose/Kg). Unstructured covariance structure will be used (If a different type of 
covariance structure will be used details will be provided). 
 
Normal distribution for the TSH data will be tested with Shapiro Wilks. 
If TSH data results not to be distributed as a normal distribution the following methods 
will be applied: 
 
- 
Data will be log transformed and analyzed with the ANCOVA repeated measures 
model described above. 
 
 
The TSH level at each time point will also be summarized as continuous variable. 
 
The primary efficacy analysis will be performed on data with missing values replaced 
with LOCF method and on original data (values recorded after changes in LT4 dose 
will not be considered in either case). 
 
9.4.2 
Secondary efficacy analysis 


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- 
Serum levels of FT4, FT3, TT4, TT3, CPK, SHBG, ferritin, ACE level, and lipid 
panel (TC, HDL-C, LDL-C, VLDL-C, TG) at the end of each 12-week treatment 
period vs baseline 
 
The secondary efficacy endpoints are the changes in serum levels of FT4, FT3, 
TT4, TT3, CPK, SHBG, ferritin, ACE level, and lipid panel (TC, HDL-C, LDL-C, 
VLDL-C, TG) at the end of each 12-week treatment period with Tirosint® capsules 
vs baseline.  
Mixed model ANCOVA repeated measures models will be used to test differences 
in means of serum levels of FT4, FT3, TT4, TT3, CPK, SHBG, ferritin, ACE level, 
at Visit 4 vs baseline visit. As covariates will be considered the following baseline 
variables: Age, Sex, BMI and the prescribed Tirosint® dosage (dose/Kg). 
Unstructured covariance structure will be used (If a different type of covariance 
structure will be used details will be provided). 
 
Normal distributions for each serum level data will be tested with Shapiro Wilks. 
If data results not to be distributed as a normal distribution the following methods 
will be applied: 
 
- 
Data will be log transformed and analyzed with the ANCOVA repeated 
measures models described above. 
 
- 
The change in serum levels of TSH, FT4, FT3, TT3 at Visit 3 vs baseline 
 
Mixed model ANCOVA repeated measures models will be used to test differences 
in means of serum levels of TSH, FT4, FT3, and TT3 at Visit 3 vs baseline visit. 
As covariates will be considered the following baseline variables: Age, Sex, BMI 
and the prescribed Tirosint® dosage (dose/Kg). Unstructured covariance structure 
will be used (If a different type of covariance structure will be used details will be 
provided). 
 
Normal distributions for each serum level data will be tested with Shapiro Wilks. 
If data results not to be distributed as a normal distribution the following methods 
will be applied: 
 
- 
Data will be log transformed and analyzed with the ANCOVA repeated 
measures models described above. 
 
The serum levels of TSH, FT4, FT3, TT4, TT3, CPK, SHBG, ferritin, ACE level, 
and lipid panel at each time point will also be summarized as continuous variables. 
 
- 
LT4 dose adjustment  
 
Frequencies and percentages of patients requiring changes in LT4 daily dose 
during the treatment period will be provided.  
 


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Changes in mean LT4 daily dose/kg at the end of the treatment period versus 
baseline will be analyzed by a mixed model ANCOVA repeated measures model 
with LT4 daily dose/kg at each time point as dependent variable. Unstructured 
covariance structure will be used (If a different type of covariance structure will be 
used details will be provided). 
Normal distribution for the LT4 daily dose/kg data will be tested with Shapiro 
Wilks. 
If LT4 daily dose/kg data results not to be distributed as a normal distribution the 
following methods will be applied: 
 
- 
Data will be log transformed and analyzed with the ANCOVA repeated 
measures model described above. 
 
The secondary efficacy analysis will be performed on data with missing values 
replaced with LOCF method and on original data (values recorded after changes 
in LT4 dose will not be considered in either case). 
 
 
 
9.5 
ANALYSIS OF SAFETY 
The safety analyses will be carried out in the safety population. 
 
9.5.1 
Tolerability parameters 
Laboratory parameters will be summarized for each visit by means of descriptive 
statistics. Changes from baseline and 95% confidence interval on mean change will 
also be provided. Frequencies and percentages of low, normal and high values for each 
parameter at each time point will also be provided. Laboratory data will also be listed 
with clinically significant information. 
Physical examinations will be summarized as frequency and percentages of normal and 
abnormal body system at each time point. Weight and BMI will be summarized by 
means of descriptive statistics and changes from baseline. 
 
9.5.2 
Adverse Events 
Adverse events (AEs) intensity and frequency will be analysed during the pre-treatment 
phase and in the treatment phase until End of Study Visit. 
The following summary tables will be provided: 
- 
Adverse Events by SOC and PT; 
- 
Serious Adverse Events by SOC and PT; 


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- 
Drug related Adverse Events by SOC and PT; 
- 
Pre-Treatment Adverse Events by SOC and PT; 
- 
Serious Pre-Treatment Adverse Events by SOC and PT; 
- 
Treatment-Emergent Adverse Events by SOC and PT; 
- 
Serious Treatment-Emergent Adverse Events by SOC and PT; 
- 
Drug related Treatment-Emergent Adverse Events by SOC and PT; 
 
Serious adverse events and fatal adverse events will also be listed. 
 
9.5.3 
Vital signs 
Vital signs (including heart rate, systolic and diastolic blood pressure) and body weight 
will be analyzed by means of descriptive statistics. Moreover mean change from 
baseline and 95% confidence interval on mean change will also be provided.  
 
9.5.4 
Other tolerability parameters 
Treatment compliance 
- 
Patients’ compliance with Tirosint® and with the prescribed treatments 
(levothyroxine as per prescription during the run-in and PPI during the run-in and 
throughout the whole treatment period) will be assessed based on data reported in 
the Subject’s Diary, calculating the percentage of medication taken in relation to 
the actual period of treatment (number of doses reported to be taken during the 
period / number of doses envisaged to be taken during the period x 100). 
 
o Number of doses reported to be taken during the period will be computed 
as number of days through the visits reported with dose taken = “Yes” in 
the Subject’s Diary. 
 
o Number of doses envisaged to be taken during the period will be computed 
as number of days from the previous visit to the next one. 
 
Patient who didn’t fill in Subject’s Diary for at least one visit will not be considered 
for this analysis and compliance will be considered not evaluable. 
 
- 
Patients’ compliance with Tirosint® will also be assessed on the Drug 
Administration, calculating the percentage of medication taken in relation to the 
recommended dose and the actual period of treatment (total amount of drug 
actually taken during the period / total amount of drug envisaged to be taken during 
the period x 100).  
 


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o Amount of drug actually taken will be computed from the drug 
accountability as sum of used amount of drug returned and used amount 
of drug not returned x related drug dosages. 
 
o Amount of drug envisaged to be taken will be computed as prescribed 
dosage x period time.   
 
Compliance will be defined as: 
 excellent for consumption of study drug ≥ 95% of the amount 
envisaged. 
 good for consumption ≥ 90 and < 95%;  
 poor for values lower than 90%. 
Compliance will be evaluated separately by visit. 
 
Treatment compliance will be analyzed by means of descriptive statistics for: 
- 
Tirosint® compliance from Subject Diary 
- 
Tirosint® compliance by visit from Subject Diary 
- 
LT4 compliance from Subject Diary 
- 
LT4 compliance by visit from Subject Diary 
- 
Tirosint® compliance from Drug accountability 
- 
Tirosint® compliance by visit from Drug accountability 
- 
PPI compliance from Subject Diary 
- 
PPI compliance by visit from Subject Diary 
Frequencies and percentages of patients’ compliance classification (excellent, good 
or poor) will be provided for Tirosint® compliance from drug accountability data.  
Drug dosage 
Tirosint® mean Daily dosage and mean Daily dosage/Body Weight will be 
analyzed by means of descriptive statistics at each time point. 
 
 
9.6 
INTERIM ANALYSIS 


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No interim analyses were planned. 
 
 


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10 
GENERAL CONSIDERATIONS 
 
10.1 
SOFTWARE TO BE USED 
All statistical analyses will be performed using SAS® Software (release 9.4) on a
 
Operating system. Data-Entry and Data Management were performed using
. 
 
10.2 
CODING DICTIONARIES 
Adverse events and previous/concomitant pathologies will be coded using the Medical Dictionary for 
Regulatory Activities (MedDRATM 21.1 Version), while prior and concomitant medications will be 
coded using WHO-Drug Dictionary (Version of 2018 September). 
 
10.3 
PROGRAMS QUALITY CONTROL 
The Study Statistician – programmer of the tables and listings will perform checks to ensure that the 
output of the statistical analysis process, including both analysis programs (e.g. the log files should be 
free from error messages or unexpected warnings) and results, is accurate and bias are minimised. 
A second Statistician, not involved in the trial analysis, will thoroughly check and test all analysis 
programs, in particular for code obtained from external sources. 
He will ensure that the outputs created by each program are clear and contain correct data, that the 
programs are executed on the latest version of the clinical database and that the analyses are carried out 
in accordance with the SAP. 
 
 
 


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11 
REFERENCES 
 
13US-T404 Study Protocol (Version 6.0, 17 June 2019). 
13US-T404 Case Report Form (Version 3.0 – 05 November 2018). 
 
13US-T404 Patient’s Diary (Version 2.0 – 20 July 2018). 
ICH Harmonised Guideline, Statistical Principles for Clinical trials; 
IBSA Standard Operating Procedure 
 
Colucci, P., P. D'Angelo, et al. (2011). "Pharmacokinetic equivalence of a levothyroxine sodium soft 
capsule manufactured using the new food and drug administration potency guidelines in 
healthy volunteers under fasting conditions." Ther Drug Monit 33(3): 355-61. 
IBSA Pharma Inc (2018). “Tirosint (levothyroxine sodium) capsule, Label Information [online]." 
Version revised on June 2018. Available at: 
https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=7a7ade79-0165-4e31-b84e-
667416c00c7e. 
Pabla, D., F. Akhlaghi, et al. (2009). "A comparative pH-dissolution profile study of selected 
commercial levothyroxine products using inductively coupled plasma mass spectrometry." 
Eur J Pharm Biopharm. 72(1): 105-10. doi: 10.1016/j.ejpb.2008.10.008. Epub 2008 Nov 1. 
Seng Yue C, Benvenga S, Scarsi C, Loprete L, Ducharme M. (2015) When Bioequivalence in 
Healthy Volunteers May not Translate to Bioequivalence in Patients: Differential Effects of 
Increased Gastric pH on the Pharmacokinetics of Levothyroxine Capsules and Tablets. J 
Pharm Pharm Sci. 18(5):844-55.  
Takeda Pharmaceuticals America, Inc. (2017). " Prevacid (lansoprazole) capsule, delayed release, 
Label Information [online]." Version revised on October 2017. Available at: 
https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=71ba78cb-7e46-43eb-9425-
fa130f537f84. 
 
 
12 
PROGRAMMING SPECIFICATIONS 
 
Not applicable. 
 
13 
APPENDIX 1: LIST OF TABLES, LISTINGS AND FIGURES 
 
Not applicable. 
 
 


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14 
APPENDIX 2: SHELL TABLES 
 
Not applicable.