Clinical trial NCT03815916
Conditions: Parkinson's Disease
Keywords: neurodegeneration gold nanocrystal NAD+ redox 31P-MRS Parkinson's Disease magnetic resonance spectroscopy nanoparticle nanomedicine NADH
Sponsor: Clene Nanomedicine
Start date: 2019-12-19; Completion date: 2021-06-07
Enrollment: 13 participants; Allocation: NON_RANDOMIZED; Intervention model: SEQUENTIAL

Brief summary:
REPAIR-PD is a single-center open label pilot, sequential group, investigator and patient blinded study to assess the CNS metabolic effects, safety, pharmacokinetics, and pharmacodynamics of CNM-Au8 in patients who have been diagnosed with Parkinson's Disease (PD) within three (3) years of Screening. The primary endpoint is the ratio of the oxidized to reduced form of nicotinamide adenine dinucleotide (NAD+:NADH) measured non-invasively by 31phosphorous magnetic resonance spectroscopy (31P-MRS).

Detailed description:
This is a single-center open label pilot, sequential group, investigator blinded study of the CNS metabolic effects, safety, pharmacokinetics, and pharmacodynamics of CNM-Au8 in patients who have been diagnosed with Parkinson's Disease within three years of Screening. The Sponsor will select a starting treatment dose of CNM-Au8 for the initial treatment. Investigators and patients will be blinded to each cohort's study dose. Upon completion of the first treatment cohort, the Sponsor will select a single dose or two different doses for the subsequent second cohort from a pre-specified dosing selection plan based on the evaluation of the 31P-Magnetic Resonance Spectroscopy (31P-MRS) changes versus baseline in the first cohort. Up to a total of two treatment cohorts may be studied (n=15 patients/cohort, total n=30 patients). All patients will receive daily oral treatment over twelve consecutive weeks during each cohort's Treatment Period.

There will be three study periods per treatment cohort:

1. A six-week screening period (Screening Period);
2. A twelve-week treatment period (Treatment Period);
3. A four-week follow-up period (End-of-Study Assessment).

The primary study outcome, CNS metabolic changes, will be assessed based upon each patient's Week 12 study visit versus the pre-treatment baseline. The primary endpoint is the brain metabolic effects of treatment with CNM-Au8 as assessed by an improvement of 31P-MRS assessment of Brain Tissue Cellular Redox Potential defined by the measured tissue ratio of NAD+:NADH concentrations following 12 weeks of once daily treatment.

Arms: arm 1: 7.5mg suspension of clean-surfaced, faceted, gold nanocrystals in 120ml of sodium bicarbonate buffered water arm 2: 15mg suspension of clean-surfaced, faceted, gold nanocrystals in 120ml of sodium bicarbonate buffered water arm 3: 30mg suspension of clean-surfaced, faceted, gold nanocrystals in 120ml of sodium bicarbonate buffered water arm 4: 60mg suspension of clean-surfaced, faceted, gold nanocrystals in 120ml of sodium bicarbonate buffered water
Interventions: intervention 1: Gold Nanocrystals
Intervention descriptions: intervention 1: CNM-Au8 is a dark red/purple-colored liquid formulation consisting of a stable suspension of faceted clean surfaced elemental gold nanocrystals in buffered deionized water with a concentration of up to 0.5 mg/mL of gold. The formulation is buffered by sodium bicarbonate present at a concentration of 0.546 mg/mL. There are no other excipients. The drug product is formulated to be taken orally and will be provided in single dose HDPE containers. The study doses vary by the concentration of gold nanocrystals per milliliter in a volume of 60 mL.

Protocol documents:
Prot_000.pdf: 
PROTOCOL TITLE PAGE 
 
 
 
 
STUDY NUMBER CNMAu8.202 
 
 
REPAIR-PD 
 
 
A PHASE 2, OPEN LABEL, SEQUENTIAL GROUP, INVESTIGATOR 
BLINDED STUDY OF MAGNETIC RESONANCE SPECTROSCOPY (31P-
MRS) TO ASSESS THE EFFECTS OF CNM-Au8 FOR THE BIOENERGETIC 
IMPROVEMENT OF IMPAIRED NEURONAL REDOX STATE IN 
PARKINSON’S DISEASE (PD) 
 
 
NCT:03815916 
 
 
RELEASE DATE: 09SEP2020  
 


 
 
 
 
 
 
 
 
 
 
 
 
CLINICAL STUDY PROTOCOL 
      
REPAIR-PD: 
A Phase 2, Pilot Open Label, Sequential Group, Investigator Blinded Study 
of Magnetic Resonance Spectroscopy (31P-MRS) to Assess the Effects of 
CNM-Au8 for the Bioenergetic Improvement of Impaired Neuronal Redox 
State in Parkinson’s Disease (PD)  
  
 
 
 
 
U.S. IND Number:  
 
142,773 
Protocol Number:  
 
CNMAu8.202 
Clinical Phase: 
 
 
Phase 2 
Investigational Drug: 
 
CNM-Au8 
Protocol Version No.: 
 
6.0 (Amendment 5.0) 
Current Protocol Version Date: 
09-September-2020 
 
 
 
 
 
 
 
 
CONFIDENTIALITY STATEMENT 
The information contained in this document and all information provided to you related to CNM-Au8 
(“Study Drug”) or (“Investigational Product”) are the confidential and proprietary information of Clene 
Nanomedicine, Inc. (“Sponsor”) and its affiliates, and except as may be required by federal, state, or 
local laws or regulations, may not be disclosed to others without prior written permission of the Sponsor. 
The Principal Investigator may, however, disclose such information to supervised individuals working 
on the Study Drug, provided such individuals agree to maintain the confidentiality of such information. 
 
 




 
 
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INVESTIGATOR PROTOCOL AGREEMENT 
 
Protocol Title: 
REPAIR-PD:  A Phase 2, Pilot Open Label, Sequential Group, 
Investigator Blinded Study of Magnetic Resonance Spectroscopy (31P-
MRS) to Assess the Effects of CNM-Au8 for the Bioenergetic 
Improvement of Impaired Neuronal Redox State in Parkinson’s Disease 
(PD)  
 
Protocol Number: 
CNMAu8.202 
Version:  
6.0 (Amendment 5.0) 
Version Date: 
09-September-2020 
 
 
 
By my signature, I: 
 
• 
Confirm that my staff and I have carefully read and understand this protocol and the 
Investigator’s Brochure (IB) and are thoroughly familiar with the appropriate use of the 
investigational drug described herein. 
 
• 
Agree to comply with the conduct and terms of the study specified herein and with any other 
study procedures provided by the Sponsor, Clene Nanomedicine, Inc. (herein referred to as 
“Clene”). 
 
• 
Agree to comply with US Food and Drug Administration (FDA), as applicable, the 
International Conference on Harmonization (ICH) GCP guidelines, the Declaration of Helsinki, 
and all applicable rules, regulations, and federal, state, and local laws relating to the conduct of 
clinical studies and the protection of human subjects. 
 
• 
Agree not to implement changes to the protocol without agreement from the Sponsor and prior 
written approval (where required) from the Institutional Review Board (IRB) except when 
necessary to eliminate an immediate hazard to the subjects. 
 
• 
Agree to onsite monitoring of the case report forms (CRFs) and source documents by Clene or 
designee and to audit by Clene or designee and appropriate regulatory authorities, including, 
but not limited to, the FDA and IRB/HREC inspectors. 
 
• 
Agree to supervise the conduct of the study and maintain responsibility for training and 
supervising all personnel who have delegated responsibilities under my leadership. The 
protocol and other important study materials will be available to study staff throughout the 
conduct of the study. 
 
 
 
 
 
Investigator’s Signature 
 
Date 
 
 
 
 
Print Name 
 
 


 
 
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PROTOCOL SYNOPSIS 
Category 
Description 
Sponsor 
Clene Nanomedicine, Inc.  
Investigational 
Drug Product  
CNM-Au8 
Name of Active 
Ingredient 
Faceted clean-surfaced Au nanocrystals 
Phase of 
Development 
Phase 2 
Study Title 
A Phase 2, Pilot Open Label, Sequential Group, Investigator  
Blinded Study of Magnetic Resonance Spectroscopy (31P-MRS) to Assess the 
Effects of CNM-Au8 for the Bioenergetic Improvement of Impaired Neuronal 
Redox State In Parkinson’s Disease (PD) 
(REPAIR-PD) 
Protocol Version 
6.0 
Study Center(s) 
UT Southwestern Medical Center 
Dallas, Texas 
Principal 
Investigator(s) & 
Sub-investigators 
Principal Investigator 
Richard B. Dewey, Jr., MD 
Professor 
Director of the Clinical Center for Movement Disorders. 
Department of Neurology and Neurotherapeutics 
UT Southwestern Medical Center 
Sub-investigators 
Jimin Ren, PhD (Imaging) 
Associate Professor 
Advanced Imaging Research Center 
Department of Radiology 
UT Southwestern Medical Center 
Ben Greenberg, MD (Biomarkers) 
Professor, Cain Denius Scholar in Mobility Disorders 
Department of Neurology and Neurotherapeutics 
UT Southwestern Medical Center 
 
 
 


 
 
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Study Objectives 
To assess the CNS metabolic biomarker profile and safety of CNM-Au8 for the 
treatment of Parkinson’s Disease (PD):  
• 
Metabolic effects will be assessed as an improvement of 31P Magnetic 
Resonance Spectroscopic (31P-MRS) assessment of brain tissue cellular 
Redox potential defined by the measured tissue ratio of NAD+:NADH 
concentrations and various bioenergetic markers. Safety will be assessed 
via adverse events, serious adverse events, discontinuations due to 
adverse events,  and the Columbia Suicide Severity Rating Scale (C-
SSRS). 
Overall Study 
Design and Plan 
 
 
 
This is a single-center open label pilot, sequential group, investigator blinded 
study of the CNS metabolic effects, safety, pharmacokinetics, and 
pharmacodynamics of CNM-Au8 in patients who have been diagnosed with 
Parkinson’s Disease (PD) within three (3) years of Screening. Patients will be 
screened over a 6-week period.  Patients who meet the inclusion criteria and 
none of the exclusion criteria will be enrolled into the clinical study.   
The Sponsor will select a starting treatment dose of 15mg or 30mg CNM-Au8 
for the initial treatment.  Investigators and patients will be blinded to each 
cohort’s study dose.  Upon completion of the first treatment cohort, the Sponsor 
will select a single dose or two different doses for the subsequent second cohort 
from a prespecified dosing selection plan based on the evaluation of the 31P-
MRS changes versus baseline in the first cohort.  Up to a total of two treatment 
cohorts may be studied. 
All patients will receive daily oral treatment over twelve (12) consecutive weeks 
during each cohort’s Treatment Period. 
There will be three study periods per treatment cohort: 
1. A (6) six week screening period (Screening Period); 
2. A (12) twelve week treatment period (Treatment Period); 
3. A (4) four-week follow-up period (End-of-Study Assessment). 
The primary study outcome, CNS metabolic changes, will be assessed based 
upon each patient’s Week 12 study visit versus the pre-treatment baseline. The 
study investigators and patients will remain blinded until the study database is 
formally locked. 
Patients will be contacted by phone to assess safety and tolerability at Week 2. 
At Weeks 4, 8, and 12 patients will return to the clinic to complete 31P-MRS 
imaging (Week 12 only), PK, PD, and safety assessments.  At the end of the 
Treatment Period, patients will complete an end-of-study (EOS) visit.  All 
patients who are discontinued from treatment will complete the end-of-study 
visit.  


 
 
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Imaging Plan 
 
MRI/MRS scans will be conducted on a Philips Achieva 7 Tesla human MRI 
scanner located in the Advanced Imaging Research Center at UTSW. Patients 
will undergo 31P MRS scans to measure brain phosphorous metabolites and 
redox state.  
Whole Brain Metabolite Measurements:  
Preparation: A cylinder bird-cage shaped 31P T/R volume coil insert (into a 1H 
T/R volume coil) will be used for imaging the brain stem. The head of the 
patient will be positioned in the center of the coil with soft cushion pads placed 
under and on the sides of the head to secure the positioning of the head and 
reduce potential movement during the scans.  
After a scout image scan, axial, sagittal and coronal T2-weighted spin-echo 
multi-slice brain images will be collected using the typical parameters: TR 3.5 
sec, TE 80 ms, slice thickness 8 mm, gap 2 mm. A 2nd-order volume-based 
shimming will be conducted prior to 31P MRS data acquisition. 
31P MRS scans: Whole brain 31P spectra will be acquired using three-
dimensional chemical shift imaging (3D CSI) approach.  Typical MRS 
parameters will be TR = 0.5 sec, NP 2 k, BW 8 kHz, NA = 4 (short scan) and 16 
(long scan), with spatial resolution of 2x2x2 cm3. If subjects are able to complete 
both short and long scans without movement artifact, the data will be combined. 
Otherwise, only the completed dataset without movement artefacts will be used 
for data analysis.  Voxel-based 31P spectra will be pooled together based on the 
functional regions (frontal, temporal, parietal and occipital) to evaluate the 
spatial distributions of metabolites.  Data analysis will be performed by 
lineshape fitting of the 31P resonances of all phosphorous metabolites using a 
previously developed Matlab program.   
Partial Volume Coil Measurement: 
Preparation: A half-cylinder-shaped 1H/31P dual-tuned T/R partial volume coil 
will be used to image the posterior brain (occipital and parietal lobes) for 
evaluation of the brain redox state based on the measurement of NAD+/NADH 
ratio.  
Axial, sagittal and coronal T2-weighted spin-echo multi-slice images will be 
collected from the posterior head using the typical parameters TR 3.5 sec and TE 
80 ms, slice thickness 8 mm, gap 2 mm. A 2nd-order volume-based shimming 
will be conducted over the posterior brain region prior to 31P MRS data 
acquisition. 
31P MRS scans: To obtain 31P spectra with resolved NAD from overlapping a-
ATP signals, an inversion-recovery-based NAD spectral editing technique will 
be used.  Briefly, acquisition of a reference 31P spectrum using pulse-acquire 
sequence is conducted plus the acquisition of an additional spectrum using a 
sequence containing an adiabatic inversion pre-pulse followed by a short delay is 


 
 
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done to selectively nullify the NAD signal. A spectral subtraction will be 
performed to obtain an NAD-edited spectrum with resolved NAD signal from 
the reference spectrum.  The contribution of NAD+ and NADH to the resolved 
NAD signal will be quantified by lineshape fitting based on prior knowledge of 
the NADH signal being a singlet and the NAD+ signal being a quartet (as 
defined by 31P coupled AB-spin system resonance pattern). The brain redox state 
will be calculated by the NAD+/NADH ratio. Typical 31P MRS parameters for 
data acquisition will be TR 1.0 sec, TD 0.17 ms, NP 4k and zero filled to 8k, 
BW 8 kHz, data accumulated in blocks of NA 256 or 512. For quantitative 
comparison of different metabolites in the posterior brain region, an additional 
scan will be performed, using the partial volume coil, under the fully relaxed T1 
condition with long TR of 15 sec and 16 acquisition averages. 
Estimated 
Participant Study 
Duration 
The planned study duration for each participant will be approximately twenty-
two (22) weeks from the start of Screening.  This assumes up to a 6-week 
Screening period; a 12-week Treatment Period; and a 4-week Follow-Up Safety 
Period.   
Number of 
Patients 
Up to 30 patients planned between both cohorts; Up to 15 patients per cohort 
with 13 patients evaluable (assuming a ~20% drop-out rate): 
• 
Cohort Dose 1 (n = 15) 
• 
Cohort Dose 2 (n = 15) 
The Cohort 2 sample size may be re-calculated based on the mean change from 
baseline in NAD+/NADH Redox Ratio to Week 12 and standard deviation of the 
change from Cohort 1. 
Inclusion Criteria  
 
The patients to be enrolled in this study must meet the following inclusion 
criteria: 
1. Able to understand and give written informed consent and follow study 
procedures. 
2. Male or female, aged 30 – 80 years or age (inclusive) at the time of PD 
diagnosis. 
3. PD subjects will be recruited in accordance with the MDS Clinical 
Diagnostic Criteria for PD: 
a. Parkinsonism present (bradykinesia + either rest tremor or rigidity) 
b. 2 of the following 4 supportive criteria: 
i. Clear and dramatic beneficial response to dopaminergic 
medication 
ii. Presence of levodopa induced dyskinesias 
iii. Rest tremor of a limb 
iv. Olfactory loss or cardiac sympathetic denervation seen on prior 
MIBG SPECT 
4. Duration of PD since diagnosis is < 3 years (inclusive) 


 
 
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5. Modified Hoehn and Yahr stage < 3 
6. Treatment with dopaminergic therapy for at least 12-weeks and with no 
change in current medications within the prior 6-weeks 
Exclusion Criteria 
 
Patients will be excluded from the study if they meet any of the following 
criteria: 
1. Atypical parkinsonism, including that due to drugs, metabolic disorders, 
encephalitis, cerebrovascular disease, normal pressure hydrocephalus, or 
other neurodegenerative disease. 
2. The presence of any of the following: 
a. Unequivocal cerebellar abnormalities 
b. Downward vertical gaze limitation or slowing of downward saccades 
c. Diagnosis of behavioral variant frontotemporal dementia or primary 
progressive aphasia 
d. Parkinsonian features restricted to the lower limbs for > 3 years 
e. Treatment with dopamine blockers or depleters in a time course 
consistent with drug induced parkinsonism 
f. Absence of an observable response to high dose levodopa despite 
moderate disease severity 
g. Expert considers a diagnosis of alternative syndrome more likely than 
PD 
h. Rapid progression of gait impairment requiring wheelchair within 5 
years of onset 
i. 
Complete absence of progression of motor symptoms over 3 years 
unless due to treatment 
j. 
Early bulbar dysfunction within the first 5 years since diagnosis 
k. Inspiratory respiratory dysfunction (stridor or frequent sighs) 
l. 
Severe autonomic failure in the first 5 years 
m. Recurrent falls (>1 per year) because of impaired balance in the first 3 
years 
n. Disproportionate dystonic anterocollis or hand contractures of hands or 
feet within 10 years 
o. Absence of any of the common non-motor features of PD despite 5 
years of disease 
p. Otherwise unexplained pyramidal tract signs (weakness, hyperreflexia, 
or extensor toe signs) 
q.  Bilateral symmetric parkinsonism 
3. Mini-Mental State Examination (MMSE) score of less than 19. 
4. Patient with a history of any clinically significant or unstable medical 
condition based on the Investigator’s judgment. 
5. History of human immunodeficiency virus (HIV), hepatitis C (HepC) virus 
antibody, or hepatitis B (HepB) virus antibody.   


 
 
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6. Based on the investigator’s judgment, patients who may have difficulty 
complying with the protocol and/or study procedures. 
7. Patient with clinically significant abnormalities in hematology, blood 
chemistry, ECG, or physical examination not resolved by the Baseline visit 
which according to Investigator may interfere with study participation. 
8. Patients with clinically significant hepatic or renal dysfunction or clinical 
laboratory findings that would limit the interpretability of change in liver or 
kidney function, or those with low platelet counts (<150 x 109 per liter) or 
eosinophilia (absolute eosinophil count of ≥500 eosinophils per microliter) 
at Screening. 
9. Patient participating in any other investigational drug trial or using 
investigational drug (within 12 weeks prior to screening and thereafter) 
10. Positive screen for drugs of abuse or known history of alcohol abuse. 
11. Women of child-bearing potential, or men, who are unwilling or unable to 
use accepted methods of birth control during the study and for 6 months 
following completion of study participation. 
12. Women with a positive pregnancy test, are lactating, or are planning to 
become pregnant during the study or within 6 months of the end of this trial. 
13. Patients with implanted metal objects in their body that may be affected by 
an MRI procedure. 
14. Patients who are claustrophobic or otherwise unlikely to be able to complete 
the MRI scanning procedures. 
15. History of allergy to gold in any form.  
16. Patient is considered a suicide risk in the opinion of the Investigator, has 
previously made a suicide attempt, or is currently demonstrating active 
suicidal ideation. Subjects with intermittent passive suicidal ideation are not 
necessarily excluded based on the assessment of the Investigator. 
Concomitant 
Medications 
Disease-specific medications allowed per the inclusion/exclusion criteria.   
To ameliorate procedure-related anxiety, all patients will receive 5 mg of 
diazepam, PO, 45-60 minutes prior to planned 31P-MRS scan at the Baseline and 
Week 12 Visits. 
Otherwise, except for acetaminophen, ibuprofen, naproxen, and 2nd generation 
antihistamines (including fexofenadine, loratadine, and cetirizine); patients may 
not take any new prescription medications, OTC, or dietary supplements from 
14-days prior to Baseline through the end of study follow-up unless used to 
manage a treatment emergent adverse event, in which case the patient should 
report to his/her Study Physician as soon as possible, the occurrence of the 
adverse event and the medication(s) they are taking to treat the adverse event. 
The Investigator will make every effort to contact the Sponsor’s Medical 
Monitor prior to administration of a new concomitant therapy (prescription or 
OTC) after treatment assignment, unless the concomitant therapy is needed 
immediately for patient safety. 


 
 
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Duration of 
Treatment 
Each treatment cohort will receive twelve (12) weeks of consecutive once daily 
dosing. In the event that collection of the 31P-MRS at the Week 12 visit is 
delayed due to imaging issues or COVID-19 pandemic related concerns, 
participants may remain on study drug beyond the Week 12 visit, so long as the 
extension is agreeable to both the study PI and Sponsor’s Medical Monitor, until 
it is deemed safe to return for collection of the Week 12 efficacy assessments. 
Safety assessments that are able to be captured should be completed every 4 
weeks beyond the planned Week 12 visits prior to dispensation of unscheduled 
study drug.  
Test Product, 
Dose, and Mode of 
Administration 
CNM-Au8 is an aqueous suspension of clean surfaced faceted nanocrystals 
consisting of gold atoms self-organized into crystals of various geometrical 
shapes (hexagonal bi-pyramid, pentagonal bi-pyramid, tetrahedron, decahedron, 
planar spheroids).   
Highly pure elemental Au nanocrystals are suspended in USP purified water 
buffered with 0.546 mg/mL (6.5 mM) sodium bicarbonate (NaHCO3) nominally 
concentrated to 0.0625 mg/L (62.5 ppm) for the 7.5 mg CNM-Au8 dose, 0.125 
mg/L (125 ppm) for the 15 mg CNM-Au8 dose, 0.25 mg/L (250 ppm) for 30 mg 
CNM-Au8, or 0.5 mg/L (500 ppm) for 60 mg CNM-Au8.  
CNM-Au8 will be administered orally in a total volume of 120 mL from two 
single-unit sterile 60 mL HDPE containers.   
Primary Outcome 
Brain Redox 
Potential 
Measure of Brain Bioenergetic Changes 
Change in 31P-MRS Redox Ratio (NAD+/NADH): 
• 
Mean change in average NAD+/NADH measured brain Redox Ratio per 
treatment cohort from Baseline to Week 12. 
Exploratory 
Outcomes 
31P-MRS CNS 
Bioenergetic 
Metabolites and 
Membrane Markers 
Other Measures of Brain Bioenergetic Changes 
Change in 31P-MRS Bioenergetic Metabolites  
• 
Regression of baseline values versus mean percentage change of the average 
tissue concentration by subject per dosing group from Baseline to Week 12 
for: 
o ATP (a, b, g) 
o NAD+/NADH pool 
o Phosphocreatine (PCr) 
o Intracellular inorganic phosphate (Pi(in))  
o Extracellular inorganic phosphate (Pi(ex)) 
 


 
 
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Change in 31P-MRS Membrane Components 
• 
Regression of baseline values versus mean percentage change of the average 
tissue concentration by subject per dosing group from Baseline to Week 12 
for: 
o Phosphoethanolamine (PE) 
o Phosphocholine (PC) 
o Glycerolphosphoethanolamine (GPE) 
o Glycerophosphocholine (GPC) 
Functional 
Exploratory 
Outcomes 
 
Exploratory Efficacy Measures of Gait, Balance, and Mobility 
• 
Mean change in average difference between Baseline to Week 12 for: 
o APDM Instrumented Timed Up and Go (TUG) Test 
o APDM Instrumented Postural Sway Test 
o APDM Instrumented Walk Test 
Exploratory Efficacy Measurements of Global Impression of Disease 
Severity and Improvement 
• 
Mean change in average difference between Baseline to Week 12 for: 
o Clinical Global Impression Scale (CGI) 
o Patient Global Impression Scale (PGI) 
Exploratory Efficacy Measurements of Disease Progression  
• 
Mean change in total score and sub-scales between Baseline to Week 12 for: 
o Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) 
Safety Endpoints 
 
• 
Columbia Suicide Severity Rating Scale (C-SSRS) 
Pharmacodynamic 
(PD) Endpoints  
Measures of Blood and Cerebrospinal Fluid Biomarkers (CSF optional) 
Whole blood and plasma will be collected at baseline and at Weeks 4, 8, and 12 
and stored for subsequent pharmacodynamic analyses. CSF will be collected on 
a voluntary basis only at baseline and at Week 12 and stored for subsequent 
pharmacodynamic analyses.  
PD analyses will be specified in a separate PD Analysis Plan.   
Pharmacokinetic 
(PK) Endpoints 
A sample for the measurement of whole blood concentrations of Au will be 
collected before (pre-dose) administration of CNM-Au8 at Weeks 4, 8, and the 
end of study follow-up Week 16 visit.  At the Week 12 visit, whole blood samples 
for the measurement of whole blood concentrations of Au will be collected before 


 
 
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(pre-dose) and at 1, 2, 4, and 6 hours, after administration of the last dose of the 
study drug. The study site shall contact the patient and document the time at which 
the patient administered his/her prior day’s dose of study drug in order to impute 
a 24-hour trough value. 
The data will be used to estimate an apparent Cmax and Tmax and area under the 
curve (AUC) over the 24-hour dosing interval [AUC(0-24)].   
Statistical 
Methods 
 
The primary efficacy endpoint is mean change in NAD Redox Ratio from 
Baseline to Week 12. 
Redox Ratio is defined as: 
NAD Redox Ratio = mean NAD+/NADH  
The statistical significance, comparing the result in each CNM-Au8 treatment to 
Baseline, will be reported. Statistical significance will be determined by two-
sided paired t-tests assessed at the p ≤ 0.05 significance level.   
The Cohort 2 sample size may be re-calculated based on the mean change from 
baseline in NAD+/NADH Redox Ratio to Week 12 and standard deviation of the 
change from Cohort 1.  
Safety endpoints include incidence of treatment-emergent AEs, deaths, SAEs, 
AEs leading to discontinuation from the study and changes in the C-SSRS.  
Changes from baseline in clinical laboratory results and vital signs will be 
summarized by treatment group and time point.    
All safety summaries will be descriptive; no statistical significance tests will be 
performed on safety data and will be based on the safety population. 
Gold (Au) concentration data in whole blood will be summarized with 
descriptive statistics by treatment group at each time point of collection. 


 
 
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Table 1: Time and Events Schedule 
 
Time and 
Events 
Schedule 
Visit 
-1 
0 
1 
2 
3 
4 
5 
Phase 
Screening 
Baseline 
Treatment Period 
EOS 
Week 
-6 
0 
2 
4 
8 
12 
16 
Day  
-42 to -1 
1a 
14 a 
28 a 
56 a 
84 a 
112 b 
ICF Signed 
X 
 
 
 
 
 
 
Eligibility Review  
X 
X 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
ConMed/Prior Med Assessment  
X 
X 
X 
X 
X 
X 
X 
Physical Examination 
X 
X 
 
X 
X 
X 
X 
Height Assessment 
X 
 
 
 
 
 
 
Weight Assessment 
X 
X 
 
 
 
X 
 
Urine Drug Test 
X 
 
 
 
 
 
 
HIV/Viral Hepatitis Screen  
X 
 
 
 
 
 
 
Serum Pregnancy Test c 
X 
 
 
 
 
 
 
Urine Pregnancy Test c 
 
X 
 
X 
X 
X 
 
Vital Signs 
X 
X 
 
X 
X 
X 
X 
12-lead ECG d 
X 
X 
 
X 
X 
X 
X 
Clinical Laboratory (Blood) 
X 
X 
 
X 
X 
X 
X 
Urinalysis 
X 
X 
 
X 
X 
X 
X 
MMSE 
X 
 
 
 
 
 
 
Treatment Assignment 
 
X 
 
 
 
 
 
Dispense/Return Drug 
 
X 
 
X 
X 
X 
 
PK Sampling (Whole Blood)  
 
 
 
Xe 
Xe 
Xf 
Xe 
PD Sampling (Whole Blood, Plasma) 
 
Xe  
 
Xe 
Xe 
Xe 
 
CSF Sampling (optional) 
 
X 
 
 
 
X 
 
Adverse Events 
X 
X 
X 
X 
X 
X 
X 
Anxiolytic Administration 
 
X 
 
 
 
X 
 
31P-MRS 
 
X 
 
 
 
X 
 
MDS-UPDRS 
 
X 
 
X 
X 
X 
 
PGI 
 
X 
 
X 
X 
X 
 
CGI  
 
X 
 
X 
X 
X 
 
C-SSRS 
X 
X 
X 
X 
X 
X 
X 
APDM Instrumented Tests 
 
X 
 
 
 
X 
 
Phone call 
 
 
X 
 
 
 
 


 
 
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Time and Events Schedule Footnotes: 
a. 
Scheduled Visit ± 4 days for Visit 1-4. For Visit 0 (Baseline), the 31P-MRS and PD CSF assessments may be 
completed over a -7 day window prior to Day 1. All assessments must be completed prior to administration 
of first study drug dose. 
b. Timing for the EOS assessment should occur at four weeks (±3 days) from last dose regardless of early 
termination or completion of the trial. 
c. 
For females of child bearing potential only. 
d. Electrocardiogram (ECG) intervals will be summarized and presented descriptively. ECG rhythm will be 
interpreted by the Investigator as normal (N), abnormal not-clinically significant (aNCS), or abnormal 
clinically significant (aCS). Triplicate values will be collected at Baseline and averaged for comparison to 
single assessments at subsequent visits. 
e. 
Whole blood for PK and PD will be taken pre-dose only (~1 hour prior to the dose of study drug).  
f. 
Whole blood for PK will be taken at pre-dose (T0) and at 1, 2, 4, and 6 hours after dosing for the visit.  The 
exact time at which the patient took his/her previous day’s study drug dose must be recorded in order to 
impute a 24-hour trough value (T24-imputed). 
 
 
 
 


 
 
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TABLE OF CONTENTS 
PROTOCOL APPROVAL PAGE ............................................................................................... 2 
INVESTIGATOR PROTOCOL AGREEMENT ....................................................................... 3 
PROTOCOL SYNOPSIS .............................................................................................................. 4 
1 
BACKGROUND INFORMATION .................................................................................... 26 
1.1 
DISEASE BACKGROUND AND PATHOPHYSIOLOGY ........................................................... 26 
1.2 
INVESTIGATIONAL PRODUCT RATIONALE AND CHARACTERISTICS .................................. 28 
1.2.1 
Investigational Product Background ....................................................................... 28 
1.2.2 
Investigational Product Characteristics .................................................................. 29 
1.3 
CNM-AU8 BIOENERGETIC MECHANISM OF ACTION ....................................................... 30 
1.4 
CNM-AU8 PARKINSON’S DISEASE NEUROPROTECTION MODELS ................................... 36 
1.4.1 
In vitro Dopaminergic Neuroprotection Models ..................................................... 36 
1.4.2 
In vivo Dopaminergic Neuroprotection Models ...................................................... 39 
2 
SUMMARY OF NONCLINICAL SAFETY & TOXICOLOGY STUDIES .................. 41 
2.1 
SUMMARY OF SAFETY MUTAGENICITY STUDIES .............................................................. 41 
2.2 
SUMMARY OF SAFETY PHARMACOLOGY STUDIES ........................................................... 42 
2.3 
SUMMARY OF TOXICOLOGY AND TOXICOKINETIC STUDIES IN RODENTS AND MINIPIGS .. 43 
2.3.1 
Initial Toxicokinetic Studies in Rodents and Minipigs ............................................ 43 
2.3.1.1 
Study AB17834 (28-Day Repeat Dose Toxicity in Göttingen Minipig) ........................................................ 45 
2.3.2 
Maximum Feasible Dose Study and High Dose Subchronic Toxicity Studies in 
Rodents and Minipigs ............................................................................................................. 46 
2.3.3 
Chronic Rodent Toxicology (6-Month Dosing) ....................................................... 48 
2.4 
SUMMARY OF TOXICOLOGY AND TOXICOKINETIC STUDIES IN CANINES .......................... 49 
2.4.1 
Single Dose Canine Toxicokinetic Summary ........................................................... 52 
2.4.2 
Repeat Dose Canine Toxicokinetic Summary .......................................................... 54 
2.4.3 
Maximum Feasible Dose Canine Toxicokinetic Study ............................................ 55 
2.4.4 
Chronic Canine Toxicology (9-Month Dosing) ....................................................... 56 
3 
PRIOR HUMAN DOSING EXPERIENCE ...................................................................... 58 
3.1 
AU8.1000-14-01 DESIGN ................................................................................................ 58 
3.2 
AU8.1000-14-01 PHARMACOKINETIC RESULTS .............................................................. 59 
3.3 
AU8.1000-14-01 SAFETY RESULTS ................................................................................. 59 
4 
INVESTIGATIONAL PLAN .............................................................................................. 62 
4.1 
STUDY RATIONAL ............................................................................................................ 62 
4.2 
STUDY OBJECTIVES ......................................................................................................... 63 
4.3 
OVERALL STUDY DESIGN AND PLAN ............................................................................... 64 
5 
INVESTIGATORS AND KEY STUDY PERSONNEL ................................................... 67 
6 
STUDY ENDPOINTS .......................................................................................................... 69 
6.1 
EFFICACY ENDPOINTS ...................................................................................................... 69 


 
 
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6.1.1 
Primary Efficacy Endpoint ...................................................................................... 69 
6.1.2 
Exploratory Efficacy Endpoints .............................................................................. 69 
6.1.3 
Pharmacokinetic Endpoints ..................................................................................... 70 
6.1.4 
Pharmacodynamic Endpoints .................................................................................. 70 
7 
STUDY POPULATION ....................................................................................................... 72 
7.1 
STUDY INCLUSION CRITERIA ........................................................................................... 72 
7.2 
STUDY EXCLUSION CRITERIA .......................................................................................... 72 
7.3 
REPRODUCTIVE POTENTIAL ............................................................................................. 74 
7.4 
REMOVAL OF PATIENTS FROM THERAPY/PREMATURE DISCONTINUATION ...................... 75 
7.4.1 
Patient Replacement ................................................................................................ 76 
7.4.2 
Reasons for Discontinuation ................................................................................... 77 
7.4.2.1 
Lost to Follow-Up ........................................................................................................................................... 77 
7.5 
PATIENT IDENTIFICATION ................................................................................................ 77 
8 
INVESTIGATIONAL DRUG PRODUCT ........................................................................ 79 
8.1 
TREATMENTS ADMINISTERED .......................................................................................... 79 
8.2 
IDENTITY OF INVESTIGATIONAL PRODUCTS ..................................................................... 79 
8.2.1 
CNM-Au8 ................................................................................................................. 79 
8.2.2 
Labeling ................................................................................................................... 80 
8.2.3 
Storage and Handling .............................................................................................. 81 
8.3 
METHOD OF ASSIGNING PATIENTS TO TREATMENT GROUPS AND DOSE SELECTION ....... 81 
8.3.1 
Treatment Assignment ............................................................................................. 81 
8.3.2 
Selection of Doses in the Study ................................................................................ 82 
8.4 
PROCEDURES FOR BLINDING ............................................................................................ 85 
8.5 
UNBLINDING .................................................................................................................... 85 
8.5.1 
Unblinding by Sponsor’s Pharmacovigilance Representative ................................ 86 
8.5.2 
Emergency Unblinding By The Investigator ........................................................... 86 
8.6 
PRIOR AND CONCOMITANT THERAPY .............................................................................. 86 
8.7 
TREATMENT COMPLIANCE ............................................................................................... 87 
8.7.1 
Study Drug Accountability ...................................................................................... 87 
9 
STUDY PROCEDURES ...................................................................................................... 89 
9.1 
STUDY SCHEDULE ............................................................................................................ 89 
9.1.1 
Screening Phase (Day -42 through Day -1) – VISIT (-1) ........................................ 89 
9.1.2 
Baseline (Day 1) – VISIT 0 ...................................................................................... 90 
9.1.3 
Treatment Phase (Day 1 through EOS) ................................................................... 91 
9.1.3.1 
VISIT 1 (Week 2) ........................................................................................................................................... 91 
9.1.3.2 
VISIT 2, 3 (Week 4 and 8) ............................................................................................................................. 92 
9.1.3.3 
VISIT 4 (Week 12) ......................................................................................................................................... 92 
9.1.3.4 
VISIT 5 (Week 16/EOS) ................................................................................................................................. 94 
9.1.4 
End of Study Visit – Follow Up Period (Period 3) .................................................. 94 
9.2 
STUDY MEASUREMENTS AND ASSESSMENTS ................................................................... 95 


 
 
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9.2.1 
Demographic and Other Baseline Characteristics ................................................. 95 
9.2.2 
Assessment of Imaging Biomarkers ......................................................................... 95 
9.2.3 
Imaging Procedures ................................................................................................ 96 
9.2.3.1 
Whole Brain Metabolite Measurements: ........................................................................................................ 96 
9.2.3.2 
Partial Volume Coil Measurement: ................................................................................................................ 97 
9.2.4 
APDM Gait and Postural Analysis .......................................................................... 97 
9.2.5 
Assessment of Safety ................................................................................................ 98 
9.2.6 
Assessment of Disease Improvement ....................................................................... 99 
9.2.6.1 
Clinical Global Impression Scale (CGI) ......................................................................................................... 99 
9.2.6.2 
Patients Global Impression Scale (PGI) ......................................................................................................... 99 
9.2.6.3 
Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) ........................................................................... 99 
9.2.7 
Assessment of Disease Related Safety ................................................................... 100 
9.2.7.1 
Columbia Suicide Severity Rating Scale (C-SSRS) ..................................................................................... 100 
9.2.8 
PK and PD Assessments ........................................................................................ 100 
9.2.8.1 
Collecting, Processing, and Shipping of PK and PD Samples ..................................................................... 101 
9.2.8.2 
Bioanalytical Methods .................................................................................................................................. 101 
9.2.9 
Clinical Laboratory Tests ...................................................................................... 102 
9.2.10 
Physical Examinations .......................................................................................... 103 
9.2.11 
Vital Signs .............................................................................................................. 103 
9.2.12 
12-Lead ECG ......................................................................................................... 103 
9.2.13 
Assessment Windows ............................................................................................. 104 
10 
ADVERSE EVENTS ...................................................................................................... 105 
10.1 
SAFETY REPORTING GUIDELINES ............................................................................... 105 
10.1.1 
Sponsor Guidance ................................................................................................. 105 
10.1.2 
Investigator Guidance ........................................................................................... 105 
10.2 
ADVERSE EVENTS (AE OR ADVERSE EXPERIENCE) .................................................... 106 
10.2.1 
Intensity of Adverse Events .................................................................................... 107 
10.2.2 
Relationship and Attribution of the AE to Study Drug .......................................... 108 
10.2.2.1 
Relationship to Study Drug ........................................................................................................................... 108 
10.2.2.2 
Attribution to The Study Drug ...................................................................................................................... 109 
10.2.3 
Serious Adverse Events .......................................................................................... 109 
10.2.4 
Serious Adverse Events Related To Study-Mandated Procedures ........................ 110 
10.3 
REPORTING REQUIREMENTS FOR AES AND SAES ...................................................... 111 
10.3.1 
Reporting of Adverse Events ................................................................................. 111 
10.3.2 
Reporting Abnormal Laboratory Test Values or Abnormal Clinical Findings ..... 111 
10.3.3 
Reporting of AE Intensity and Causality ............................................................... 111 
10.3.4 
Follow-up of AEs ................................................................................................... 111 
10.3.5 
Reporting Requirements For SAEs ........................................................................ 112 
10.3.5.1 
Reporting of SAEs ........................................................................................................................................ 112 
10.3.5.2 
SAE Reporting Periods ................................................................................................................................. 113 
10.3.5.3 
SAE Reporting Procedures ........................................................................................................................... 113 
10.3.5.4 
SAE Regulatory Reporting ........................................................................................................................... 114 
10.4 
PREGNANCY ............................................................................................................... 115 


 
 
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10.4.1 
Prevention of Pregnancy During the Study ........................................................... 115 
10.4.2 
Reporting of Pregnancy ......................................................................................... 115 
10.4.3 
Pregnancy Follow-Up ........................................................................................... 116 
10.5 
CLINICAL MONITORING .............................................................................................. 116 
10.5.1 
Site Monitoring Plan ............................................................................................. 116 
11 
STATISTICS AND DATA MANAGEMENT ............................................................. 117 
11.1 
DETERMINATION OF SAMPLE SIZE ............................................................................. 117 
11.2 
ANALYSIS POPULATIONS ............................................................................................ 117 
11.3 
TREATMENT COHORT – A TREATMENT COHORT WILL BE DEFINED AS ALL PATIENTS 
WHO RECEIVE THE SAME DOSE OF CNM-AU8. BASELINE CHARACTERISTICS AND PATIENT 
DISPOSITION ............................................................................................................................. 117 
11.4 
PRIOR AND CONCOMITANT MEDICATIONS ................................................................. 118 
11.5 
PHARMACOKINETIC ANALYSES .................................................................................. 118 
11.6 
SAFETY ANALYSES .................................................................................................... 119 
11.7 
EFFICACY ANALYSES ................................................................................................. 119 
11.7.1 
Primary Efficacy Endpoint .................................................................................... 119 
11.7.2 
Exploratory Efficacy Endpoints ............................................................................ 120 
11.7.3 
Functional Exploratory Endpoints ........................................................................ 120 
11.8 
INTERIM ANALYSES .................................................................................................... 121 
11.9 
DATA HANDLING AND QUALITY ASSURANCE ............................................................ 121 
11.9.1 
Data Recording ..................................................................................................... 121 
11.9.2 
Data Recorded From Screening Failures ............................................................. 121 
11.9.3 
Data Monitoring .................................................................................................... 122 
11.9.4 
Data Collection and Management ......................................................................... 123 
11.9.5 
Data Audit and Inspection ..................................................................................... 123 
11.9.6 
Data Archiving ...................................................................................................... 123 
12 
RESPONSIBILITIES, ETHICS, AND LEGAL ASPECTS ....................................... 125 
12.1 
INVESTIGATOR RESPONSIBILITIES .............................................................................. 125 
12.1.1 
Good Clinical Practice .......................................................................................... 125 
12.1.2 
Institutional Review Board (IRB)Approval ........................................................... 125 
12.1.3 
Informed Consent .................................................................................................. 125 
12.1.4 
Adherence to Protocol ........................................................................................... 126 
12.1.5 
Confidentiality ....................................................................................................... 127 
12.1.6 
Study Files and Retention of Records .................................................................... 127 
12.1.7 
Case Report Forms ................................................................................................ 128 
12.1.8 
Drug Accountability .............................................................................................. 128 
12.1.9 
Inspections ............................................................................................................. 128 
12.2 
SPONSOR RESPONSIBILITIES ....................................................................................... 129 
12.2.1 
Study Materials and Instructions ........................................................................... 129 


 
 
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12.2.2 
Protocol Modifications .......................................................................................... 129 
12.2.3 
Insurance ............................................................................................................... 130 
12.2.4 
Premature Study Termination ............................................................................... 130 
12.3 
JOINT INVESTIGATOR/SPONSOR RESPONSIBILITIES .................................................... 130 
12.3.1 
Access to Information for Monitoring ................................................................... 130 
12.3.2 
Study Discontinuation ........................................................................................... 131 
12.3.3 
Study Report and Publications .............................................................................. 131 
13 
PROTOCOL AMENDMENTS ..................................................................................... 132 
14 
REFERENCES ............................................................................................................... 134 
 
 


 
 
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LIST OF IN-TEXT TABLES 
 
Table 1: Time and Events Schedule .......................................................................................... 13 
Table 2. Estimated Volume, Mass, and Particle Characteristics of CNM-Au8 ........................ 30 
Table 3. Summary of Safety Mutagenicity Studies ................................................................... 42 
Table 4. Summary of Safety Pharmacology Studies ................................................................. 43 
Table 5. Initial Acute and Subchronic Dosing Studies in Rats and Minipigs ........................... 44 
Table 6: Study AB17834 Platelet Change from Day -12 to Day 27 in Select Animals ............ 45 
Table 7. Maximum Feasible Dose Study and High Dose Subchronic Toxicity Studies ........... 48 
Table 8. Chronic Rodent Toxicity Study ................................................................................... 49 
Table 9. Acute and Subchronic Dosing Studies in Canines ...................................................... 51 
Table 10.  Summary of Cmax, AUC, T1/2, and Bioavailability Results Following Single Dose 
Administration of CNM-Au8 in Study CNAU-MPI-14-01 ................................. 53 
Table 11.  Summary of CL, T1/2, Vz, and Vss after a Single 0.5 mg/kg IV Dose of CNM-Au8 
(Study CNAU-MPI-14-01) ................................................................................... 54 
Table 12.  Summary of CL/F, T1/2, and Vz/F after a Single 10 mg/kg PO Dose of CNM-Au8 
(Study CNAU-MPI-14-01) ................................................................................... 54 
2.4.4.1 
Table 13. Chronic Canine Toxicity Study ............................................................ 57 
Table 14.  CNM-Au8 Investigational Product Dosing Administration ..................................... 80 
Table 15.  CNM-Au8 Components and Quality Standards ....................................................... 80 
Table 16. Summary of CNM-Au8 Conversion of Animal 21-Day Repeat Doses To Human 
Equivalent Dose (HED) Based On Body Surface Area (mg/m2) for 60 kg Human
 .............................................................................................................................. 83 
Table 17. Summary of CNM-Au8 Exposure Safety Margin Based on End of Study AUC(0-24) 
ng*hr/mL.  Ratio of Animal Toxicokinetic to Human Pharmacokinetic AUC 
Results From 21-Day Repeat Dose Studies. ......................................................... 84 
Table 18.  Summary of CNM-Au8 Exposure Safety Margin Based on End of Study AUC(0-24) 
ng*hr/mL Ratio of Chronic Animal Toxicokinetic 6 and 9-Month Rodent and 
Canine Repeat Dose Studies to Human 21-Day Pharmacokinetic Results .......... 84 
Table 19.  AE Attribution to the Study Drug .......................................................................... 109 
Table 20.  Summary of Study Safety Reporting Periods ......................................................... 115 
Table 21.  Summary of PK Parameters ................................................................................... 118 
 
 
 


 
 
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LIST OF IN-TEXT FIGURES 
 
Figure 1. CNM-Au8 NADH Catalysis Rates ............................................................................ 33 
Figure 2.  Effects of CNM-Au8 on NAD Levels in Primary Rodent Mesencephalic Cultures 33 
Figure 3.  Effects of CNM-Au8 on NADPH Oxidation & Long-Chain Fatty Acid Synthesis . 34 
Figure 4 . Effects of CNM-Au8 on SOD and ROS Generation ................................................ 35 
Figure 5. Effect of CNM-Au8 on OPC Differentiation and ATP Production ........................... 36 
Figure 6. Effect of CNM-Au8 on TH+ Neuron Survival and Neuron Network Area Following 
MPP+ Injury ......................................................................................................... 37 
Figure 7. Effect Of CNM-Au8 On Mitochondria Level (Mitotracker) In TH Positive Neuron 
After  MPP+ Injury ............................................................................................... 38 
Figure 8. Effect Of CNM-Au8 On TH+ Neuron Survival And Neurite Network Following 6-
OHDA Injury ........................................................................................................ 38 
Figure 9. Effect Of CNM-Au8 On α-Synuclein Presence In TH+ Neurons and α-Syn 
Aggregates Following 6-OHDA Injury ................................................................ 39 
Figure 10. CNM-Au8 Efficacy in Reducing Apomorphine-Induced Rotations and Contralateral 
Paw Placements in 6-OHDA Unilaterally Lesioned Rats .................................... 40 
Figure 11. Whole Blood Concentrations by Day in 28-Day Repeat Dosing Canine Study ...... 55 
Figure 12.  NAD Redox Potentential In Adult Humans ............................................................ 63 
Figure 13. Dose Selection Plan ................................................................................................. 65 
Figure 14. Study Scheme ........................................................................................................... 65 
Figure 15. 21-Day AUC Exposure Ranges Between Rodent Toxicokinetic Studies, Preclinical 
Efficacy Models, and First-In-Human Dosing ..................................................... 85 
 
 
 


 
 
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ABBREVIATIONS 
 
 
Abbreviation 
Definition 
31P-MRS 
Phosphrus-31 magnetic resonance spectroscopy  
6-OHDA 
Oxidopamine 
α -SYN 
Alpha-synuclein 
aCS 
Abnormal clinically significant 
AD 
Alzheimer’s Disease 
AE 
Adverse event 
AESI 
Adverse events of special interest 
aNCS 
Abnormal not clinically significant 
ASTM 
American Society for Testing and Materials 
ATP 
Adenosine Trinucleotide Phosphate 
Au 
Gold 
AUC 
Area under the curve 
AUC(0-24) 
Area under the curve for 24 hours  
βhCG 
Beta-human chorionic gonadotropin 
BID 
Twice a day (bis in die) 
C0 
Initial or back-extrapolated plasma drug concentration at time zero following bolus 
intravenous injection 
CA 
Competent authority 
CFR 
Code of Federal Regulations 
CGI 
Clinical Global Impression 
CL 
Apparent total body clearance of the drug 
CL/F 
Apparent total clearance of the drug from whole blood after oral administration 
CLr 
Renal clearance 
Cmax 
Peak plasma concentration, observed 
CNM-Au8 
Aqueous suspension of clean surfaced nanocrystals consisting of gold atoms self-organized 
into crystals of various faceted, geometrical shapes  
CNS 
Central nervous system 
CRF 
Case report form 
CRO 
Contract research organization 
CRU 
Clinical research unit 
CSF 
Cerebrospinal fluid or cerebral spinal fluid 
CTCAE 
Common terminology criteria for adverse events 
CV% 
Coefficient of variation 


 
 
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Abbreviation 
Definition 
DNA 
Deoxyribonucleic acid 
DO 
Doctor of osteopathic medicine 
EC 
Ethics committee 
ECG 
Electrocardiogram 
eCRF 
Electronic case report form 
EOS 
End of study 
F 
Bioavailability (systemic availability of the administered dose) 
FDA 
Food and Drug Administration 
GCP 
Good clinical practice 
GLP 
Good laboratory practice 
GMP 
Good manufacturing practices 
HepB 
Hepatitis B 
HepC 
Hepatitis C 
HDPE 
High density polyethylene 
HIV 
Human immunodeficiency virus 
hr 
Hour 
HREC 
Human Research Ethics Committee  
IB 
Investigator’s Brochure 
ICF 
Informed consent form 
ICH 
International Conference on Harmonization 
ICH-GCP 
International Conference on Harmonization – Good Clinical Practice 
ICP-MS 
Inductively Coupled Plasma Mass Spectrometry 
IEC 
Independent Ethics Committee 
IND 
Investigational New Drug 
IRB 
Institutional Review Board 
ISO 
International Organization for Standardization 
IV 
Intravenous 
K2EDTA 
Dipotassium ethylenediaminetetraacetic acid 
kg 
Kilogram 
LOQ/LLOQ 
Limit of quantitation or Lower limit of quantitation 
m 
meter 
M:E 
Ratio of myeloid to erythroid precursors in bone marrow 
MAD 
Multiple ascending dose 
max 
Maximum 
MD 
Doctor of medicine 


 
 
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Abbreviation 
Definition 
MDS-UPDRS 
Movement Disorders Society – Unified Parkinson’s Disease Rating Scale 
MFD 
Maximum feasible dose 
mg 
Milligram 
MIBG-SPECT 
Metaiodobenzylguanidine scintigraphy 
min 
Minute(s) 
mL 
Milliliter 
mmHg 
Millimeters of mercury 
MMSE 
Mini-Mental State Examination  
MPTP 
Methyl-4-phenyl-1,2,3,6 tetrahydropyridine 
MRI 
Magnetic Resonance Imaging 
MRS 
Magnetic Resonance Spectroscopy 
ms 
Milliseconds 
MTD 
Maximum tolerated dose 
N 
Normal 
NAD+ 
Oxidized form of nicotinamide adenine dinucleotide 
NADH 
Reduced form of nicotinamide adenine dinucleotide 
NADP+ 
Oxidized form of nicotinamide adenine dinucleotide phosphate  
NADPH 
Reduced form of nicotinamide adenine dinucleotide phosphate 
NaHCO3 
Baking soda (Sodium Bicarbonate)  
NIST 
National Institutes of Standards and Technology 
ng 
nanogram 
nm 
nanometer 
NOAEL 
No observed adverse effect level 
O2 
Oxygen 
OG 
Oral gavage 
OL 
Oligodendrocyte 
OPC 
Oligodendrocyte progenitor cells 
OTC 
Over-the-counter 
PA 
Physician assistant 
PD 
Pharmacodynamic 
PGI 
Patient Global Impression  
pH 
Potential hydrogen (relative acidity or alkalinity) 
PK 
Pharmacokinetic 
PO 
Oral administration (per os) 
QD 
Once daily (quaque die) 


 
 
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Abbreviation 
Definition 
ROS 
Reactive oxygen species  
SAD 
Single ascending dose 
SAE 
Serious adverse event 
SAP 
Statistical analysis plan 
SC 
Subcutaneous 
SD 
Standard deviation 
SEM 
Standard error of the mean 
SGOT 
Serum glutamic oxaloacetic transaminase 
SGPT 
Serum glutamate-pyruvic transaminase 
SOD 
  Superoxide dismutase 
SOP 
Standard operating procedure 
SUSAR 
Suspected unexpected serious adverse reaction 
T½ 
Elimination half-life 
T1 
Time constant for the longitudinal relaxation time following an MRI radio-frequency pulse 
T2 
Time constant for the transverse relaxation time (perpendicular to the main field) following 
an MRI radio-frequency pulse 
TEAE 
Treatment emergent adverse event 
TEM 
Transmission electron microscopy 
TID 
 Three times daily (ter in die) 
TK 
Toxicokinetic 
Tmax 
Time to peak plasma concentration, observed 
Ue 
Urinary excretion 
USP 
United States Pharmacopeia 
Vss 
Volume of distribution at steady state 
Vz 
Apparent volume of distribution (Vz) 
Vz/F 
Apparent volume of distribution during terminal phase after non-intravenous administration 


 
 
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1 
BACKGROUND INFORMATION 
1.1 
Disease Background and Pathophysiology 
Parkinson’s disease (PD) is a chronic, progressive neurodegenerative disorder characterized by 
tremors, bradykinesia, limb rigidity and gait and balance problems. Approximately one in one 
hundred individuals over the age of 60 is affected by PD. Both genetic and environmental factors 
are thought to contribute to the development of PD, and a combination of factors results in the 
progressive loss of dopaminergic neurons in the substantia nigra area of the midbrain. 
PD is currently incurable; existing treatments for PD, such as dopamine agonists, COMT and 
MAO-B inhibitors, and deep brain stimulation, produce only a modest and temporary 
amelioration of symptoms. Specifically, long-term use of levodopa, a commonly-prescribed 
dopamine precursor used to treat Parkinsonian symptoms, results in dyskinesia that in itself 
becomes disabling. The global burden of PD is expected to further increase owing to 
population ageing (GBD 2016 Parkinson’s Disease Collaborators 2018). PD results in a large 
economic burden on society. Current major challenges in PD drug development include the 
lack of reliable biomarkers for its early diagnosis and for disease progression, the lack of a 
clear understanding of pathophysiologic mechanism(s) of PD, and lack of well-validated 
clinical trial tools to demonstrate neuroprotection (Arnerić, Kern, and Stephenson 2018; 
Olanow, Kieburtz, and Katz 2017).   
Despite an enormous effort over the past several decades, no disease-modifying or 
neuroprotective therapeutic for PD has been developed. A therapeutic that alters or slows the 
clinical progression, and thus improves PD patient quality of life and lifespan, represents a 
huge unmet need (Olanow, Kieburtz, and Katz 2017).  
The pathophysiology of genetic and sporadic variants of PD, though multifactorial, appear to 
share common pathogenetic mechanisms, including impaired mitochondrial and lysosomal 
functions, neural sensitivity to glutamate toxicity, accumulation of oxidative stress, autophagic 
failure in clearing misfolded proteins, and loss of synapse integrity (Plotegher and Duchen 
2017). These pathogenetic mechanisms all together are representative of processes of neuronal 
bioenergetic failure (Camandola and Mattson 2017). As such, improvement of cellular 


 
 
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bioenergetic efficiency represents an important and previously unaddressed therapeutic target for 
this disease.   
Several published studies suggest that elevating brain NAD+ levels and improving cellular redox 
may be therapeutic for the treatment of PD and other neurodegenerative diseases (De Jesus-
Cortes et al., 2012; Gong et al., 2013; Kim et al., 2017; Tesla et al., 2012; Zhou et al., 2015). As 
cells age, energy production capabilities decrease, mitochondria become damaged, and the redox 
potential of energy-producing molecules such as nicotine adenine dinucleotide (NAD/NADH) 
declines. NAD/NADH serve as a key redox couple in energy-producing pathways of the cell, 
including glycolysis and oxidative phosphorylation.  
An age-dependent decline of NAD/NADH redox has been previously demonstrated by 31P 
magnetic resonance spectroscopy of the visual cortex in young, middle-aged, and aged healthy 
humans (Zhu et al. 2015).  In other studies, increasing intracellular levels of NADH and NAD+ 
have been demonstrated following administration of the precursor, nicotinamide, in cell and 
animal models of PD resulting in improvements in mitochondrial function and resistance to 
oxidative stress (Jia et al. 2008; Delgado-Camprubi et al. 2017; S. Lehmann et al. 2016; Susann 
Lehmann, Loh, and Martins 2017; Thirtamara-Rajamani et al. 2017; Schwab et al. 2017; Sison 
and Ebert 2018; Ocampo, Liu, and Barrientos 2013). Similarly, nicotinamide supplementation of 
culture media improved SK-N-MC neuroblastoma cell viability in response to the dopaminergic 
neural toxin MPTP, and feeding nicotinamide to transgenic alpha-synuclein (a-syn) 
overexpressing Drosophila improved climbing behavior (Jia et al. 2008). More recently, 
Schöndorf et al. demonstrated that increasing intracellular NAD+ using nicotinamide riboside 
supplementation rescued mitochondrial ultrastructure, reduced ROS levels, restored 
mitochondrial membrane potential, and increased the potential for mitophagy in PD iPSC-
derived neurons (Schondorf et al. 2018). Taken together, these data all suggest that bioenergetic 
failure plays an important role in the pathophysiology of PD  and that agents that improve 
NAD/NADH redox states have the potential to treat this neurodegenerative disease. 


 
 
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1.2 
Investigational Product Rationale and Characteristics 
1.2.1 Investigational Product Background 
  
CNM-Au8 is an aqueous suspension of clean-surfaced nanocrystals consisting solely of Au 
atoms organized into crystals of highly faceted substantially uniform geometrical shapes. CNM-
Au8 is supplied for dosing orally in sodium bicarbonate buffered USP purified water.   
Historically, monomolecular gold complexes (e.g., injectable sodium aurothiomalate, 
aurothioglucose; oral auranofin) have been widely used historically as immunomodulating 
therapies in the treatment of autoimmune disorders, predominantly rheumatoid arthritis 
(Dabrowiak, 2009).  However, multiple forms of toxicity, including pruritus, dermatitis, 
stomatitis, diarrhea, proteinuria, and less frequently hematological effects compromised the 
clinical use of gold complexes (Dabrowiak, 2009; Menninger et al., 1998).  While the role of 
gold in the pattern of toxicity remains unclear, it is hypothesized that adverse events (AEs) 
related to gold complexes may be specifically related to the monomolecular covalent 
formulations of the gold complexes rather than from the activity of gold per se (Dabrowiak, 
2009; Yei Ho and Tiekink, 2005).   
When functionalized as nanocrystals, gold adopts novel electrochemical characteristics unlike 
those of gold complexes.  In addition, as clean-faceted nanocrystals CNM-Au8 has unique 
properties including a clean safety and tolerability profile as well as high level of biocatalytic 
activity in cells that is unlike that of gold nanoparticles manufactured using traditional methods 
that require stabilizing or residual chemical modifications to the particles’ surfaces. 
The faceted gold nanocrystals of CNM-Au8 generally consist of shapes including hexagonal bi-
pyramids, pentagonal bi-pyramids, tetrahedrons, and octahedrons.  These crystalline shapes, 
absent organic residues on their surfaces, are central to the biologic activity of CNM-Au8.  In 
contrast to molecular covalently bound gold compounds (e.g., historical gold salts), or colloidal 
gold nanoparticles containing surface residue or surfactants as a surface layer (e.g., polyethylene 
glycol (PEG), cetyl trimethylammonium bromide (CTAB), citrate, thiols, other surfactants), 
CNM-Au8 consists solely of nanocrystals grown through an electro-crystal chemistry process, 
which produces consistently faceted catalytically active geometrical shapes (without utilizing 
surfactants such as those derived from the reduction of chloroauric acid (HAuCl4)).  


 
 
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The characteristics of a nanoparticle’s size, shape, and surface chemistry impact, and can define, 
the biological activity of the nanoparticles.  Residual surface chemistry also affects the biological 
activity of nanoparticles and directly impacts cellular uptake.  Nanoparticle surfactants and 
residual chemical monolayers are also well-known to cause nanoparticle toxicity 
(Balasubramanian et al., 2010; Freese et al., 2012; Qiu et al., 2010). 
In summary, CNM-Au8 was rationally designed to eliminate the need for residual surface 
chemistry, and to promote biocatalytic activity on it’s clean-surfaced, faceted nanocrystalline 
surfaces.  CNM-Au8 is a novel therapeutic paradigm as a suspension of non-covalently bound 
faceted clean-surfaced Au nanocrystals.   
1.2.2 Investigational Product Characteristics 
The median diameter of CNM-Au8 nanocrystals is approximately 13 nm, as determined by 
transmission electron microscopy (TEM).  Based upon the distributed range (Dn5 – Dn95: 6.5 – 
15.8 nm) of measured nanocrystal diameters and approximate geometrical shapes (e.g., low 
volume estimate: disc-like approximation, aspect ratio of 0.2; maximum volume estimate: 
spheroid, aspect ratio of 1.0), each Au nanocrystal has an approximate composition ranging from 
13,000 – 66,000 Au atoms per nanocrystal at the 13 nm median diameter with a corresponding 
molar mass ranging between 2.7 x 103 kDA to 1.3 x 104 kDA. Summary estimates for CNM-Au8 
mass, volume, and particle characteristics are described below in Table 2.  Each mL of CNM-
Au8 suspension at 500 μg/mL is estimated to contain between 100 - 500 trillion highly faceted 
Au nanocrystals. 
 
 


 
 
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Table 2. Estimated Volume, Mass, and Particle Characteristics of CNM-Au8 
Metric 
(CNM-Au8 500 μg/mL, 60 mL Dose) 
Disc-Like 
Approximation 
Minimum 
(Aspect 0.2) 
Spherical 
Approximation 
Maximum 
(Aspect 1.0) 
Median Au Nanocrystal Diameter (nm) 
13 
Au Nanocrystal Volume (nm3) 
2.3 x 102 
1.2 x 103 
Au Nanocrystal Surface Area (nm2) 
3.2 x 102 
5.3 x 102 
Au Atoms per Nanocrystal (count) 
1.4 x 104 
6.8 x 104 
Au Nanocrystal Molecular Weight (kDa) 
2.7 x 103 
1.3 x 104 
Total Au Nanocrystal Surface Area per mL (cm2) 
3.6 x102 
1.2 x102 
Au Nanocrystals per mL CNM-Au8 (count) 
1.1 x 1014 
2.3 x 1013 
Au Nanocrystals per 60 mL Dose of  CNM-Au8 (count) 
3.4 x 1015 
6.8 x 1014 
 
1.3 
CNM-Au8 Bioenergetic Mechanism of Action 
CNM-Au8 passes into the systemic circulation via intestinal absorption.  Cellular uptake of 
CNM-Au8 has been demonstrated in a variety of cells and tissue matrices including 
macrophages, oligodendrocytes, neurons, and brain tissue using Inductively Coupled Plasma 
Mass Spectrometry (ICP-MS) analyses and high resolution TEM visualization of nanocrystals.   
Preclinical characterization of the in vitro and in vivo properties of CNM-Au8 have demonstrated 
that it acts to protect neuronal populations from chemical, inflammatory, and hypoxic insults 
through a series of unique catalytic mechanisms involving 1) the nicotine adenine dinucleotide 
redox couple (NAD+/NADH) to boost glycolytic energy production, 2) the nicotine adenine 
dinucleotide phosphate redox couple (NADP+/NADPH) to influence anabolic processes 
associated with differentiation, and 3) the SOD-like inactivation of reactive oxygen species and 
nitric oxide to protect cells from oxidative damage and mitochondrial dysfunction.  
The nicotinamide adenine dinucleotide redox couple (NAD+, NADH) plays a central role in the 
energy metabolism of all living cells. NAD+, NADH and their relative intracellular ratio 
(NAD+/NADH) are linked to regulation of energy homeostasis, neuroprotection, immune 


 
 
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function, chromosome stability, DNA repair mechanisms, sleep and circadian rhythms, and 
longevity (Canto et al., 2015; Imai, 2010a, b; Nikiforov et al., 2015; Ying, 2008).  
Fundamentally, NAD+ and NADH are essential coenzymes in the adenosine triphosphate (ATP)-
generating reactions driving both glycolysis and oxidative phosphorylation.  More specifically, 
in aerobic glycolysis, NAD+ availability is integral to the enzymatic cascade from 
glyceraldehyde 3-phosphate via glyceraldehyde phosphate dehydrogenase to 1,3-
bisphosphoglyceric acid.  Similarly, two electrons are removed via NADH oxidation in Complex 
I of the electron transport chain during oxidative phosphorylation, resulting in NAD+, and 
ultimately these electrons are transferred to a lipid-soluble carrier, ubiquinone. 
In addition, NAD+ and its metabolites act as binding substrates for a wide range of proteins 
including the metabolic and transcription-regulating sirtuins, the poly-ADP-ribose polymerases 
(PARPs) involved in DNA repair, and the cyclic ADP-ribose synthases (cADPRs) such as CD38 
that serve to regulate Ca2+ signaling involved in cell cycle control and insulin signaling (Canto et 
al., 2015). 
NAD+ and NADH are essential for life; dietary deficiency of vitamin B3, a NAD+ precursor,  
gives rise to a life-threatening condition known as pellagra, which is characterized by a dark, 
pigmented skin rash, diarrhea, and dementia (Sydenstricker, 1958). Transgenic mice lacking both 
copies of the NAD+ salvage enzyme Nmnat1 resulting in NAD+ deficiency, do not live past 
embryonic stages (Conforti et al., 2011). Conversely, the heightened expression of NMNAT1, 
resulting in increased NAD+ in the Wallerian Degeneration Slow Dominant Mutant Mouse, has 
been attributed to neuronal protection against axon degeneration observed in these mice (Sasaki 
et al., 2009).   
Quantitative measurement of regional brain area NAD+ concentrations and redox states in 
healthy and diseased humans has recently been demonstrated using a novel 31P-Magnetic 
Resonance Spectroscopy (MRS) imaging technique (Chouinard et al., 2017; Lu et al., 2016). In 
humans, brain NAD+/NADH redox potential is inversely correlated with age. This age-related 
decrease in cerebral energy metabolism is believed to be intimately associated with the 
bioenergetic failure that may underpin the pathophysiology of all neurodegenerative diseases, 
because NAD+/NADH redox potential is essential for fundamental ATP-generating processes 


 
 
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such as glycolysis and mitochondrial oxidative phosphorylation. These bioenergetic processes 
power all cellular processes including ‘housekeeping’ functions that are responsible for 
maintaining overall cellular health including processes of autophagy, apoptosis, and the unfolded 
protein response (UPR) (Villanueva-Paz et al. 2016; Chua and Tang 2013; Cantó, Menzies, and 
Auwerx 2015). Boosting brain NAD+ levels in a mouse model of AD reduced DNA damage, 
neuroinflammation, and apoptosis while improving cognitive function in multiple behavioral 
tests and restored hippocampal synaptic plasticity (Hou et al., 2018). In humans, 31P-MRS of the 
visual cortex of young (21-26 year old), middle-aged (33-36 year old), and aged (59-68 year old) 
healthy individuals has been show to demonstrate a measurable linear decline of NAD+ redox 
potential that occurs with increasing age (Zhu et al., 2015). 
The first demonstration of oxidation of NADH to NAD+ by gold nanoparticles was 
demonstrated by Huang et al. (2005) using a simple cell-free assay. In order to compare the 
catalytic oxidation rate of clean-surfaced CNM-Au8 against similarly-sized gold nanoparticles 
made using citrate reduction, the same cell-free assay utilized by Huang et al. was repeated 
comparing gold nanoparticles sourced from the U.S. National Institutes of Standards and 
Technology (NIST).  The resulting change in the 339 nm NADH peak was assessed while 
investigating each of the gold nanoparticles at the same NADH and Au starting concentrations.  
In all cases, CNM-Au8 nanocrystals consistently showed significantly superior catalytic 
activities regardless of size and/or method of preparation of the comparator gold nanoparticles, 
(Figure 1). 
 
 


 
 
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Figure 1. CNM-Au8 NADH Catalysis Rates 
Figure 1A.  CNM-Au8 Catalytic Effects vs. NIST 
Standard Citrated AuNP 
Figure 1B. Relative NADH Oxidation Rates vs. 
NIST Citrated AuNP 
 
 
CNM-Au8 treatment of rodent central nervous system cells in vitro also significantly increases 
levels of both NAD+ and NADH (Figure 2). 
 
Figure 2.  Effects of CNM-Au8 on NAD Levels in Primary Rodent Mesencephalic 
Cultures 
Figure 2A. Effect of CNM-Au8 on NAD+ Levels 
Figure 2B. Effect of CNM-Au8 on NADH Levels 
 
 
The redox couple NADP+/NADPH, similar  to NAD+/NADH, plays a fundamental role in 
energy homeostasis, anabolic processes, and protection against oxidative stress. NADP+ and 
NADPH function in the pentose phosphate pathway (PPP), serves to provide precursors for 
nucleotide and amino acid biosynthesis (Stincone et al., 2015). In addition, NADP+ and NADPH 
serve as the redox equivalents for both the thioredoxin and glutathione systems (Grant, 2008; 
Pollak et al., 2007), which in turn serve as the cell’s primary defenses against oxidative stress.  
0
5
10
15
20
25
30
0.10
0.12
0.14
0.16
0.18
0.20
0.22
0.24
NADH control, no GNPs
NIST 30nm
NIST 10nm
CNM-Au8
26 µM NADH in 5.7 mM NaHCO3 with 3.4 µg/mL Au
absorbance at 339nm, cm
-1
time, min
CNM-Au8
NIST 10nm
NIST 30nm
0
1
2
3
4
5
6
7
8
9
10
26 µM NADH in 5.7 mM NaHCO3
NADH oxidation rate, a.u.
GNPs at [Au] ~ 3.4 µg/mL
co n tro l
C N M -A u 8  (1 0  n g /m l)
C N M -A u 8  (1 0 0  n g /m l)
C N M -A u 8  (1  µ g /m l)
C N M -A u 8  (1 0  µ g /m l)
B D N F  (5 0  n g /m l)
0
10
20
30
40
50
60
70
80
90
Q u an tity  o f N A D +  (n M )
*
*
*
* p < 0 .0 5  v s c o n tro l c o n d itio n  O n e -W a y  A N O V A  fo llo w e d  b y  D u n n e tt's te st
co n tro l
C N M -A u 8  (1 0  n g /m l)
C N M -A u 8  (1 0 0  n g /m l)
C N M -A u 8  (1  µ g /m l)
C N M -A u 8  (1 0  µ g /m l)
B D N F  (5 0  n g /m l)
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
38
40
Q uantity of N A D H  (nM )
*
*
*
*p< 0.05 vs control condition O ne-W ay A N O V A  follow ed by D unnett's test
*


 
 
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CNM-Au8 catalyzes the oxidation of NADPH to NADP+ (Figure 3). While the time course of 
catalysis of NADPH to NADP+ is longer than that observed for conversion of NADH to NAD+, 
the magnitude of the effect is similar. Thus, CNM-Au8 plays an important role in providing 
NADP+ to the enzyme glucose 6-phosphate dehydrogenase for the conversion of 6-
phosphogluconate to ribulose 5-phosphate and NADPH + CO2, which represents the rate-
limiting step of the oxidative branch of the PPP.  
 
 Figure 3.  Effects of CNM-Au8 on NADPH Oxidation  
Figure 3. NADPH Oxidation Rates  
 
Excessive reactive oxygen exposure disrupts cellular redox homeostasis, damages intracellular 
organelles as well as DNA and proteins, and may also underpin pathophysiologic mechanisms of 
PD (Puspita, Chung, and Shim 2017).  Super oxide dismutases (SODs) evolved as a component 
of the cell’s antioxidant defense system to regulate the levels of reactive oxygen species (ROS) 
and prevent damage from oxidative stress. SOD enzymes are found in the cytoplasm and 
mitochondria where they convert oxygen radicals to O2 or H2O2, which can in turn be converted 
to water and O2 by catalases.  A dose-dependent reduction of ROS levels was observed in 
differentiating oligodendrocyte precursor cells in primary culture with CNM-Au8 treatment 
(Figure 4). 
 
 


 
 
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Figure 4 . Effects of CNM-Au8 on SOD and ROS Generation 
Figure 4A. Effects on SOD Activity Assay  
 
Figure 4B.  Effects on ROS Generation in Purified 
Murine OPC cultures 
Figure 4C.  Effects on ROS Generation in 
Murine OPC Cultures Plus Rotenone 
 
Demonstration of SOD-like catalytic activity with CNM-Au8 treatment has several important 
implications. First, neurons and glial cells are energetically demanding and generate large 
amounts of ROS as byproducts of the energetic processes necessary for their function. Theories 
of aging and neurodegeneration suggest that as CNS cells age, they are less able to efficiently 
remove ROS and thereby succumb to the consequences of long-term ROS exposure. As CNS 
cells are exquisitely sensitive to ROS, they are among the first cell types to degenerate, leading 
to the cognitive, psychomotor, and movement impairments observed in diseases such as 
Alzheimer’s disease and Parkinson’s disease (Angelova and Abramov, 2018). In addition, SOD1 
may act not only as a regulator of ROS but also as a part of a glucose-oxygen sensing mechanism 
of a cell to determine whether the cell utilizes oxidative phosphorylation or aerobic glycolysis for 
ATP production (Reddi and Culotta, 2013). A study of oligodendrocyte (OL) energetics showed 
that human OLs preferentially use aerobic glycolysis during differentiation and myelination 


 
 
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(Rone et al., 2016).  Data with CNM-Au8 demonstrate that treatment switches OPCs from 
proliferation to differentiation, while simultaneously stimulating aerobic glycolysis production of 
ATP likely through NADH oxidation (Figure 5).  Stimulation of SOD-like activity therefore is 
consistent with a role for CNM-Au8 in regulating cellular bioenergetics.  
Figure 5. Effect of CNM-Au8 on OPC Differentiation and ATP Production 
 
 
Effect of CNM-Au8 on a) OPC differentiation (O4+ cells) in isoldated murine OPCs and b) ATP production in 
MO3.13 oligodendrocytes (72hr). Statistical analysis performed using one-way ANOVA (p < 0.05). 
1.4 
CNM-Au8 Parkinson’s Disease Neuroprotection Models  
1.4.1 In vitro Dopaminergic Neuroprotection Models 
In vitro models of neuroprotection were conducted to assess the neuroprotective role of CNM-
Au8’s bioenergetic mechanism of action.  Treatment with the neurotoxins: methyl-4-phenyl-
1,2,3,6 tetrahydropyridine (MPTP) and 6-hydroxydopamine (6-OHDA) results in oxidative stress 
and impairment of neuronal mitochondrial function  (Dauer and Przedborski 2003).   
CNM-Au8 was studied in rat primary mesencephalic neurons injured with MPP+ or 6-OHDA.  
The primary assessment was protection of tyrosine hydroxylase (TH)-expressing neurons and 
neurite network preservation. In addition, impairment of mitochondria function induced by these 
neurotoxins was studied including measures of energy production (ATP pool), oxidative stress 
(ROS), and mitochondria function.   
MPP+ (4 µM, 48 h) induced significant TH+ neuronal death (~35 %) and loss of the neurite 
network (~40 %) in primary rat dopaminergic neurons. In the presence of CNM-Au8 (pre-
incubated 48 hours before MPP+), a significant dose-dependent neuroprotective effect was 


 
 
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observed (Figure 6) . A dose-dependent neuroprotective effect on neurite network area was also 
observed. Furthermore, addition of the neurotoxin MPP+ induced a significant decrease of 
number of mitochondria in the cytoplasm of TH+ neurons. Pretreatment with CNM-Au8 for 48 
hours significantly protected neurons from depletion of mitochondria (Figure 7). 
Consistent with the MPP+ results, 6-OHDA (20 µM, 48h) also induced a significant TH+ 
neuronal death (~30 %) and a large loss of the neurite network (~40%). The presence of CNM-
Au8 (pre-incubated 48 hours before 6-OHDA), also showed a significant dose-dependent 
protective effect on neuronal survival (Figure 8).  
Figure 6. Effect of CNM-Au8 on TH+ Neuron Survival and Neuron Network Area 
Following MPP+ Injury 
 
 
Effect of CNM-Au8 on a) TH positive neuron survival and b) neurite network of primary rat dopaminergic neurons 
injured with MPP+ (48h, 4 µM). Data expressed as percentage of control show the mean ± SEM (100% = no 
MPP+, no compound). One-way ANOVA followed by Dunnett’s test, n=6. * p< 0.05 was considered significant (vs 
MPP+ condition).  
 
 
 
 


 
 
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Figure 7. Effect Of CNM-Au8 On Mitochondria Level (Mitotracker) In TH Positive 
Neuron After  MPP+ Injury 
 
Effect of CNM-Au8 on mitochondria level in primary rat dopaminergic neurons injured with MPP+ (48h, 4 µM). 
Data expressed as percentage of control show the mean ± SEM (100% = no MPP+, no compound). One-way 
ANOVA followed by Dunnett’s test, n=6. * p< 0.05 was considered significant (vs MPP+ condition). 
Figure 8. Effect Of CNM-Au8 On TH+ Neuron Survival And Neurite Network Following 
6-OHDA Injury 
 
 
Effect of CNM-Au8 on a) TH positive neuron survival,  and b) neurite network, in primary rat dopaminergic 
neurons injured with 6OHDA (48h, 20 µM). Data expressed as percentage of control show the mean ± SEM 
(100% = no 6OHDA, no compound). One-way ANOVA followed by Dunnett’s test, n=6. * p< 0.05 was considered 
significant (vs 6-OHDA condition). 


 
 
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TH positive neurons demonstrated α-syn aggregates in their cytoplasm after 6-OHDA treatment 
and treatment with CNM-Au8 significantly and dose-dependently prevented intracellular α-
synuclein aggregation. CNM-Au8 also significantly reduced the size of the α-synuclein 
aggregates (Figure 9). 
Figure 9. Effect Of CNM-Au8 On α-Synuclein Presence In TH+ Neurons and α-Syn 
Aggregates Following 6-OHDA Injury 
 
 
Effect of CNM-AU 8 on a) ratio of TH positive neuron showing α-syn aggregates and b) size of the α-syn 
aggregates in primary rat dopaminergic neurons injured with 6OHDA (48h, 20 µM). Data expressed as 
percentage of control show the mean ± SEM (100% = no 6-OHDA, no compound). One-way ANOVA followed by 
Dunnett’s test, n=6. * p< 0.05 was considered significant (vs 6-OHDA condition). 
Taken together, these in vitro data demonstrate a significant neuroprotective effect of CNM-Au8 
on dopaminergic neurons in neurotoxin models of Parkinson’s Disease. 
1.4.2 In vivo Dopaminergic Neuroprotection Models 
CNM-Au8’s was studied in a behavioral model of Parkinson’s Disease Rats were unilaterally 
lesioned by stereotactic injection of 6-OHDA into the right striatum on Day 1. Apomorphine-
induced rotations were quantified during a 30-minute window on a weekly basis starting on Day 
15.  Cylinder paw placement was quantified on Day -1 (baseline), and then weekly.  In the 
apomorphine-induced rotation study (Figure 10A), early treatment (D1+) with CNM-Au8 
resulted in a trend of reduced number of apomorphine-induced rotations by 42% compared to 
vehicle, numerically outperforming the reduction seen with the positive control L-
Dopa/Carbidopa (CNM-Au8 early treatment vs. vehicle; p=0.06, unpaired t-test).  In the 
C o n tro l
6 O H D A  (2 0  µ M )
+  C N M -A u  8  (1 0  n g /m l)
+  C N M -A u  8  (3 2  n g /m l)
+  C N M -A u  8  (1 0 0  n g /m l)
+  C N M -A u  8  (3 1 6  n g /m l)
+  C N M -A u  8  (1  µ g /m l)
+  C N M -A u  8  (3 ,1 6 2  µ g /m l)
+  C N M -A u  8  (1 0  µ g /m l)
+  B D N F  (5 0  n g /m l)
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
0.50
0.55
0.60
0.65
0.70
E ffect of C N M -A u 8 on the ratio of a -syn positive T H  neuron
after 6O H D A  injury
num ber of a -syn positive T H  neuron on the num ber of T H  neuron
(overlapping T H  and a -syn, ratio)
*
*
*
*
*
* p <  0.05 vs 6O H D A  condition, one-w ay A N O V A  follow ed by D unnett's test
*
*
*
*
C o n tro l
6 O H D A  (2 0  µ M )
+  C N M -A u  8  (1 0  n g /m l)
+  C N M -A u  8  (3 2  n g /m l)
+  C N M -A u  8  (1 0 0  n g /m l)
+  C N M -A u  8  (3 1 6  n g /m l)
+  C N M -A u  8  (1  µ g /m l)
+  C N M -A u  8  (3 ,1 6 2  µ g /m l)
+  C N M -A u  8  (1 0  µ g /m l)
+  B D N F  (5 0  n g /m l)
0
20
40
60
80
100
120
140
160
180
200
220
240
E ffect of C N M -A u 8 on a -syn aggregates into T H  positive neuron
after 6O H D A  injury
a -syn area into T H  positive neurons
(%  of control)
*
*
*
*
*
* p <  0.05 vs 6O H D A  condition, one-w ay A N O V A  follow ed by D unnett's test
*


 
 
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functional paw placement test (Figure 10B), both early treatment demonstrated a trend and late 
treatment with CNM-Au8 showed a statistically significant contralateral paw placement 
improvement over vehicle (Early: p=0.08; late: p=0.009, unpaired t-tests). 
Figure 10. CNM-Au8 Efficacy in Reducing Apomorphine-Induced Rotations and 
Contralateral Paw Placements in 6-OHDA Unilaterally Lesioned Rats 
 
Taken together, these in vivo data demonstrate a significant neuroprotective effect of CNM-Au8 
in behavioral models of Parkinson’s Disease. 
In summary, CNM-Au8 has demonstrated neuroprotective effects in both in vitro and in vivo 
dopaminergic toxin-induced models of PD. Treatment with CNM-Au8 significantly increases 
cell viability while significantly reducing detectable intracellular alpha-synuclein (a-syn) 
aggregates within dopaminergic neurons exposed to the toxins MPTP and 6-OHDA. Functional 
in vivo studies using a standard 6-OHDA unilateral lesion rat model have further demonstrated 
CNM-Au8’s efficacy.  The unique intracellular catalytic mechanism of action, positions CNM-
Au8 as a promising therapeutic for the treatment of PD. 


 
 
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2 
SUMMARY OF NONCLINICAL SAFETY & TOXICOLOGY STUDIES 
The Sponsor has conducted multiple safety and toxicology studies with CNM-Au8 in accordance 
with ICH M3 (R2) guidelines across three species including rats, minipigs, and canines, in 
addition to standard in vitro mutagenicity studies.  Initial in vivo dosing levels were modeled on 
delivering comparable amounts of gold as the historical gold complex, auranofin, to a 50-kg 
patient on a milligram per kilogram basis without adjustments for body surface area variance 
between species.  This resulted in target nonclinical daily doses of Au at an estimated 0.0348 
mg/kg/day, which were increased 10-fold (0.348 mg/kg) and 100-fold (3.48 mg/kg) to provide an 
anticipated safety margin for planned human dosing. 
2.1 
Summary of Safety Mutagenicity Studies 
Three safety mutagenicity studies were conducted to address the mutagenic potential of CNM-
Au8 including in vivo Micronucleus testing, and the in vitro Mammalian Cell Gene Mutation 
Test and Bacterial Reverse Mutation Test.  These studies each demonstrated no effect of CNM-
Au8 on cytotoxicity or mutation frequency as summarized below in Table 3.  
 
 


 
 
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Table 3. Summary of Safety Mutagenicity Studies 
 
2.2 
Summary of Safety Pharmacology Studies 
Safety pharmacology assessments included testing of three doses of CNM-Au8 (0.0348, 0.348 
and 3.48 mg/kg) in rodents in the standard CNS Irwin test and the same dosing regimen for 
assessment of renal function following saline overload.  Cardiovascular safety was assessed by 
constant telemetry in minipigs.  The CNS Irwin testing protocol provided no evidence CNM-Au8 
affected central and peripheral neurologic function.  Similarly, renal function was not affected in 
Han Wistar rats following saline overload.  Telemetry recording of cardiovascular responses in 
minipigs including heart rate, blood pressure, ECG, and body temperature demonstrated no 
negative effects of CNM-Au8 on cardiovascular function.  These safety pharmacology results are 
summarized in Table 4. 
 
 
Study ID 
(Internal 
ID/ 
CRO ID) 
GLP  
Status 
Mutagenicity 
Model 
 
Brief Design 
[Route; 
Frequency] 
Effective 
Dose 
 
CNM-
Au8 
Conc. 
(μg/mL) 
Summary/Notes 
AB06525 
GLP 
L5178Y Mouse 
Lymphoma 
Cells 
(Thymidine 
Kinase+/-) 
Mammalian 
Cell Gene 
Mutation Test 
(In vitro) 
1.7, 3.5, 
5.2, 8.7 and 
17 μg/mL 
348 
No signs of cytotoxicity; no 
biologically significant 
increases in the mutant 
frequency  
AB05703 
GLP 
Salmonella 
typhimurium 
Bacterial 
Reverse 
Mutation Test  
(In vitro) 
17, 35, 70, 
104, 174 
μg/plate 
348 
No precipitate and no sign 
of cytotoxicity were noted 
in any strain and at any 
dose level, either with or 
without metabolic 
activation 
AB17832 
(sub-study) 
GLP 
Rat 
Micronucleus 
Test 
Bone Marrow 
Micronucleus 
Test after 4-
weeks of 
treatment  
(In vivo) 
N/A 
0.0348, 
0.348, 
3.48 
No significant increase in 
the frequency of 
micronucleated 
polychromatic erythrocytes; 
no decrease in the 
PCE/NCE ratio 
CNM-Au8-
MPI-17-01 
GLP 
Rat 
Micronucleus 
Test 
Bone Marrow 
Micronucleus 
Test after 2-
days of 
treatment  
(In vivo) 
N/A 
10, 20, 40 
mg/kg/d 
No significant increase in 
the incidence of 
micronuclei in the test 
article dosed animals 
compared to the vehicle 
control. The test article 
CNM-Au8 was evaluated as 
negative (non-clastogenic) 


 
 
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Table 4. Summary of Safety Pharmacology Studies 
2.3 
Summary of Toxicology and Toxicokinetic Studies in Rodents and Minipigs 
2.3.1 Initial Toxicokinetic Studies in Rodents and Minipigs 
Two initial toxicokinetic studies were completed in the Göttingen Minipig and two initial studies 
were completed in rats as summarized in Table 5. 
These initial studies were conducted up to a maximum of 3.48 mg/kg or approximately 100-fold 
higher delivery of gold when compared to comparable doses of auranofin in humans.  These 
studies did not identify any treatment related toxicities, so a maximum tolerated dose was not 
defined.  The no-adverse-effect-level (NOAEL) was identified at 3.48 mg/kg in rats and 
minipigs.   
Study ID 
(Internal ID/ 
CRO ID) 
GLP  
Status 
Species 
(N) 
Brief Design 
[Route; 
Frequency] 
 
Nominal 
Dose 
(mg/kg/day) 
CNM-Au8 
Conc. 
(μg/mL) 
Summary/Notes 
AB17835 
GLP 
Han 
Wistar Rat 
(N=24) 
CNS Irwin Test 
Following 
Single-Dose 
[OG, QD] 
0.0348 
3.3 
No relevant effect on a 
battery of behavioral and 
physiological parameters, 
covering the main central 
and peripheral nervous 
system functions, evaluated 
for 24 hours after dosing 
0.348 
36.6 
3.48 
346.5 
AB17836 
GLP 
Han 
Wistar Rat 
(N=40) 
Renal Function 
Following Saline 
Overload 
[OG, QD] 
0.0348 
3.3 
No mortality or clinical 
signs; no change in the 
serum concentrations of 
sodium, potassium, 
chloride or creatinine or in 
the serum osmolality; no 
changes in urine volume, 
pH, osmolality, 
electrolytes, or creatinine; 
no change in GF, free water 
clearance, or excretion 
fractions of electrolytes 
0.348 
36.6 
3.48 
346.5 
AB17837 
GLP 
Göttingen 
Minipig 
(N=6) 
Cardiovascular 
Telemetry (11-
Day + Washout + 
PK) 
[OG, QD] 
0.0348 
3.3 
No effect on general health 
status, body weight gain, or 
body temperature; no 
relevant effects on the 
arterial blood pressure, 
heart rate, or ECG 
parameters 
0.348 
36.6 
3.48 
346.5 
 


 
 
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Table 5. Initial Acute and Subchronic Dosing Studies in Rats and Minipigs 
Study ID 
(Internal 
ID/ 
CRO ID) 
GLP  
Status 
Species 
(N) 
Brief Design 
[Route; 
Frequency] 
 
Nominal 
Dose 
(mg/kg/day) 
CNM-Au8 
Conc. 
(μg/mL) 
Safety Summary/ 
Toxicity Notes 
AB17839 
Non-
GLP 
Göttingen 
Minipig  
(N=2) 
1-Day & 5-Day 
Acute Toxicity;  
2-phases 
[OG; QD] 
0.0348 
3.7 
No mortality; no treatment 
related clinical signs; no 
related macroscopic 
abnormalities 
0.348 
35.3 
3.48 
343.3 
AB17834 
GLP 
Göttingen 
Minipig 
(N=24; 
6/group) 
28-Day Repeat 
Dose Toxicity  
[OG; QD] 
0.0348 
3.3 
No mortality; no treatment-
related clinical signs or 
ophthalmological findings; 
no treatment-related effects 
on hematology, serum 
clinical chemistry, and 
urine parameters; no 
treatment-related 
macroscopic or histological 
findings  
0.348 
36.6 
3.48 
346.5 
AB17831 
Non-
GLP 
Han-
Wistar Rat 
(N=40; 
10/group) 
7-Day Acute 
Toxicity  
 [OG; QD] 
0.0348 
3.7 
No mortality; no clinical 
signs; no treatment-related 
changes in body weight, 
body weight gain and food 
consumption; no effects on 
hematology and serum 
clinical chemistry; no 
treatment-related changes 
in organ weights; no 
macroscopic and 
histopathological changes  
0.348 
35.3 
3.48 
343.3 
AB17832 
GLP 
Han-
Wistar Rat 
(N=100; 
25/group) 
28-Day Repeat 
Dose Toxicity 
[OG; QD] 
0.0348 
3.3 
No mortality; no clinical 
signs; no treatment-related 
changes in body weight, 
body weight gain and food 
consumption; no effects on 
hematology, coagulation, 
serum clinical chemistry 
and urine parameters; no 
treatment-related 
ophthalmological findings 
at any dose level; no organ 
weight, macroscopic 
changes or histological 
findings 
0.348 
36.6 
3.48 
346.5 


 
 
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2.3.1.1 Study AB17834 (28-Day Repeat Dose Toxicity in Göttingen Minipig) 
At the end of the treatment period in Study AB17834, a lower platelet count from the pretest 
baseline was noted in 3 animals as described in Table 6, below. One female in Group 2 (low 
dose) and one in Group 3 (intermediate dose) had very low levels of platelets counts, and one 
male in Group 4 (high dose) group had a significant reduction. 
Table 6: Study AB17834 Platelet Change from Day -12 to Day 27 in Select Animals  
Group 
Animal ID 
Platelets (Giga/L) 
Day -12 
Day 27 
Low Dose (0.0348 mg/kg) 
Female 310 
470 
16 
Intermediate Dose (0.348 mg/kg) 
Female 317 
401 
6 
High Dose (3.48 mg/kg) 
Male 321 
561 
109 
While the reduction in platelet counts were not attributed as related to the test article, given the 
history of hematological adverse events associated with gold complexes the Sponsor organized a 
series of measures to explore the potential relationship to test article, including: 
• Review of historical data from the minipig supplier and contact research organization 
(CRO) laboratory values for pre-dose and control minipigs to evaluate whether platelet 
reductions or low platelet counts had been previously observed. 
• Specialty hematological assessment of bone marrow sections from these animals and 
repeat examination of bone marrow smears taken at necropsy. 
Review of historical data sets revealed that the platelet count in the peripheral blood of the 
minipig is highly variable and low platelet counts have sporadically been observed in untreated 
minipigs at the CRO laboratory (Eurofins).  Further examination of bone marrow smears 
revealed no treatment-related differences in group means or individual Myeloid:Erythroid (M:E) 
ratios.  Female no. 317 had a low M:E ratio due to higher proportion of erythroid precursors, 
which correlated with the histopathological observation of a high cellularity of the bone marrow.  
These changes were consistent with a hyperplastic change of the erythroid compartment, not 
accompanied by any increase in reticulocyte count in the peripheral blood as might be expected.  
There were no cytological abnormalities correlating with the severe decrease in platelet counts 
observed at necropsy in treated female nos. 310 and 317 and at lower severity in male no. 321.  It 


 
 
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could not be excluded that the low platelet counts may be part of the background variation in this 
species or may have resulted from hemorrhage occurring accidentally at blood sampling.  There 
was no evidence of qualitative or quantitative treatment-related effects on lymphoid cells, 
monocytes, reticulum, mast cells, or megakaryocytes.  There were also no treatment-related 
differences in M:E ratio (group mean and individual values) or in absolute and relative counts of 
myeloid, erythroid, and lymphoid cell series. 
To date, no significant platelet reductions have been observed in any of the toxicology studies 
conducted in rodents or canines. 
2.3.2 Maximum Feasible Dose Study and High Dose Subchronic Toxicity Studies in 
Rodents and Minipigs 
Upon submission of the Investigational New Drug (IND) application to the U.S. FDA, the 
Agency requested additional higher dose studies to identify a maximum tolerated dose, or 
alternatively a maximum feasible dose.  Subsequently, a 7-day maximum feasible dose study 
was conducted in rats with subcutaneous (SC) dosing compared to 90 mg/kg oral gavage (OG) 
dosing.  The maximal feasible dose (MFD) represented the highest concentration of CNM-Au8 
(3000 parts per million, 3 mg/mL) that could be manufactured with currently available 
techniques dosed at the maximum permissible dosing volume delivered via gavage or SC 
administration.  Of note, the 3 mg/mL concentration used in the two MFD studies had deviations 
out of product specification (hydrodynamic radius of 54.38 nm, which exceeded the production 
specification range of 10 – 30 nm) likely indicating nanoparticle agglomeration.  
In rodents, doses of 5, 15, 30 and 90 mg/kg/day over seven consecutive days, were administered 
in a divided dose, i.e., twice daily subcutaneously (2.5, 7.5 and 15 mg/kg, BID) or, orally, three 
times daily (30 mg/kg TID; 90 mg/kg/day). The three times daily oral gavage administration was 
well tolerated by all rodents and not associated with any adverse findings. Test-article related 
findings that were not adverse, included discolored feces (black), decreased body weight gain 
and food consumption when compared to controls, and anatomic pathology findings of 
extramedullary hematopoiesis noted in the spleen and/or liver.  This study defined 90 mg/kg/day 
as the NOAEL with oral gavage administration.  


 
 
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The daily subcutaneous administration was associated with adverse events related to 
subcutaneous administration of the test article.  The skin was thickened/leathery in all treatment 
groups with associated changes in clinical pathology, defined by increased neutrophils and 
fibrinogen levels and decreases in albumin; and anatomic pathology, defined by subacute/chronic 
inflammation, edema, and cavitation in the injection sites, which were considered adverse in 
their totality.  Systemic test article-related changes not considered adverse were noted in body 
weights (decreased gain), food consumption (decreased), and anatomic pathology (increased 
spleen weights, and extramedullary hematopoiesis in the spleen and liver).  Accordingly, a 
NOAEL could not be established in the rodents receiving daily SC administration up to 30 
mg/kg.   
With twice-daily SC administration of CNM-Au8, blood Au exposures increased proportionally 
or slightly greater than proportionally from 5 to 30 mg/kg/day on Day 1 and Day 7.  Blood Au 
exposures after SC administration were considerably higher than after oral gavage administration 
with the dose normalized AUC(0-Last) ratio (SC:OG) ranging from approximately 9x – 50x higher 
dose-normalized AUC depending upon animal gender and the SC dose.  Despite substantially 
greater Au accumulation, no systemic toxicities were observed with SC administration.  
Table 7 below summarizes the design and results of the maximum feasible dose and subsequent 
high dose subchronic toxicity studies in rodents. 
 
 


 
 
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Table 7. Maximum Feasible Dose Study and High Dose Subchronic Toxicity Studies 
2.3.3 Chronic Rodent Toxicology (6-Month Dosing) 
The objective of this study was to evaluate the toxicity of the test article in rats after 
administration for 13- and 26-weeks and to evaluate reversibility, progression, or delayed 
appearance of any observed changes following a 4-week postdose observation period after each 
dosing termination. 
Assessment of toxicity was based on mortality, clinical observations, body weight, and food 
consumption; ophthalmoscopic examinations; and clinical and anatomic pathology. 
Study ID 
(Internal ID/ 
CRO ID) 
GLP  
Status 
Species 
(N) 
Brief Design 
[Route; 
Frequency] 
Nominal 
Dose 
(mg/kg/day) 
CNM-Au8 
Conc. 
(μg/mL) 
Safety Summary/ 
Toxicity Notes 
CNAU-
MPI-14-04 
(2257-004) 
Non-
GLP 
Sprague-
Dawley 
Rat 
(N=60; 
12/group) 
7-Day Max 
Feasible Dose 
Study  
[SC; BID] 
[OG; TID] 
5 
[SC; 2.5 
mg/kg BID] 
500 
Discolored feces (black), 
decreased body weight gain 
and food consumption; 
non-adverse anatomic 
pathology findings 
consisting of 
extramedullary 
hematopoiesis noted in the 
spleen and/or liver. Skin 
thickened/leathery in SC 
injection groups associated 
with changes in clinical 
pathology (increased 
neutrophils and fibrinogen 
levels; decreases in 
albumin) and anatomic 
pathology (subacute/ 
chronic inflammation, 
edema, and cavitation in 
the injection sites). 
15 
[SC; 7.5 
mg/kg BID] 
1,500 
30 
[SC; 15 
mg/kg BID] 
3,000 
90 
[OG; 
30mg/kg, 
TID] 
3,000 
CNM-Au8-
MPI-16-01 
(2257-008) 
GLP 
CD Rat 
(N=146) 
21-Day Repeat 
Dose Toxicity 
[OG;  
QD/BID] 
10 
1,000 
No treatment-related signs 
of toxicity; no effects on 
body weights, food 
consumption or clinical 
pathology parameters; no 
treated related 
ophthalmologic effects; 
examinations; no organ 
weights changes; no 
treatment-related 
observations during 
necropsy and no 
histopathologic changes. 
20 
1,000 
40 
[20mg/kg, 
BID] 
1,000 


 
 
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Toxicokinetic (TK) assessment [whole blood, urine, cerebral spinal fluid (CSF), and designated 
frozen tissues] was conducted for gold content.  
 
There were no definitive test article-related mortalities and no test article-related effects on body 
weight, food consumption, ophthalmoscopic examinations; clinical pathology, macroscopic 
examinations and organ weights. Based on the data from the detailed clinical observations, body 
weight, food consumption, clinical and anatomical pathology, oral doses of CNM-Au8 at 10, 20, 
and 40 mg/kg/day resulted in no adverse findings of these rats. Therefore, the NOAEL for this 
study was considered to be 40 mg/kg/day, the highest dose tested.  
Table 8. Chronic Rodent Toxicity Study 
 
2.4 
Summary of Toxicology and Toxicokinetic Studies in Canines 
Five toxicokinetic studies have been conducted in Beagle dogs including:   
• Single Dose Toxicokinetic Study 
• Maximum Tolerated Dose study (7-Day) 
• 28-Day Subchronic Repeat Dose Toxicokinetic Study 
• 21-Day Maximum Feasible Dose Study 
• 9-Month Chronic Toxicity Study 
Study ID 
(Internal ID/ 
CRO ID) 
GLP  
Status 
Species 
(N) 
Brief Design 
[Route; 
Frequency] 
Nominal 
Dose 
(mg/kg/day) 
CNM-Au8 
Conc. 
(μg/mL) 
Safety Summary/ 
Toxicity Notes 
CNM-Au8-
MPI-16-04 
(2257-006) 
GLP 
CD Rat 
(N=306) 
26-Week Repeat 
Dose Toxicity 
with 4-Week 
Recovery  
[OG; QD] 
[OG; BID] 
10 
[OG QD] 
1,000 
There were no definitive 
test article-related 
mortalities.  No test article-
related effects on body 
weight, food consumption, 
ophthalmoscopic 
examinations; clinical 
pathology, organ weights 
macroscopic and 
microscopic examinations. 
20 
[OG QD] 
1,000 
40 
[OG; 20 
mg/kg BID] 
1,000 


 
 
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Doses of CNM-Au8 up to 90 mg/kg by oral gavage have not demonstrated any acute or 
subchronic toxicity, and accordingly, a MTD has not been identified to date.   All dosing levels 
and all concentrations (ranging from 350 – 3,000 μg/mL) explored in canines have produced 
NOAELs.   
Table 9 below summarizes the design and results of the toxicokinetic studies conducted to date 
in Beagle dogs. 
 


 
 
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Table 9. Acute and Subchronic Dosing Studies in Canines 
Study ID 
(Internal 
ID/ 
CRO ID) 
GLP  
Status 
Species 
(N) 
Brief Design 
[Route; 
Frequency] 
Nominal 
Dose 
(mg/kg/day) 
CNM-Au8 
Conc. 
(μg/mL) 
Safety Summary/ 
Toxicity Notes 
CNAU-
MPI-14-01 
(2257-001) 
GLP 
Beagle 
Dog 
(N=18; 
6/group) 
Single Dose 
Toxicity and 
Toxicokinetics 
(With 9 Day 
Follow-Up) 
0.5 mg/kg 
IV 
100 
No mortality and no clinical 
observations noted during 
study. 
3.5 mg/kg 
[OG, QD] 
350 
10 mg/kg 
[OG, QD] 
1,000 
CNAU-
MPI-14-02 
(2257-003) 
GLP 
Beagle 
Dog  
(N=48; 
12/group) 
28-Day Repeat 
Dose Toxicity 
[OG, QD] 
0.35 
35 
No mortality; no treatment-
related toxicity; no effects on 
body weights, food 
consumption or clinical 
pathology parameters; no 
treatment-related effects on 
ophthalmologic or physical 
examinations; no effects on 
organ weights or 
histopathologic changes 
3.5 
350 
10 
1,000 
CNAU-
MPI-14-03 
(2257-002) 
Non-
GLP 
Beagle 
Dog 
(N=8; 
2/group) 
Ascending Dose 
and 7-Day 
Repeat Dose 
Toxicity 
[OG, QD] 
10 
1,000 
No mortality and no clinical 
observations noted during 
study; discolored feces were 
observed in all treated 
animals; no related treatment 
effects on food consumption, 
body weight, or physical 
exam. 
20 
2,000 
30 
3,000 
CNAU-
MPI-14-05 
(2257-005) 
GLP 
Beagle 
Dog 
(N=24; 
6/group) 
21-Day Repeat 
Dose Toxicity 
(Maximum 
Feasible Dose) 
[OG; QD, BID, 
TID] 
30 
[30mg/kg 
QD] 
3,000 
No mortality; treatment-
related salivation and 
discolored feces at 60 and 90 
mg/kg/day. No treatment-
related effects on body 
weights, food consumption, 
ophthalmology, 
electrocardiograms, clinical 
pathology parameters, organ 
weights or macroscopic 
examinations.  Non-adverse 
changes in the kidneys in 
three animals at 90 mg/kg/day 
with minimal bilateral tubular 
cell hypertrophy, 
characterized by a diffuse 
increase in the size of tubular 
epithelial cells. 
60 
[30mg/kg 
BID] 
3,000 
90 
[30mg/kg 
TID] 
3,000 


 
 
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2.4.1 Single Dose Canine Toxicokinetic Summary 
After intravenous (IV) administration, the mean CNM-Au8 whole blood estimated concentration 
at time zero (C0) was calculated as 9.39 ng/mL (range 4.97 to 18.4 ng/mL) extrapolated using a 
log-linear regression from the first two measured concentrations.  The first blood sample after IV 
dosing was collected at 30 minutes postdose, so it is possible that the concentration at 30 minutes 
underestimates C0.  After oral administration, maximum CNM-Au8 plasma concentrations were 
observed at a Tmax range of 4 – 48 hours and 12 – 48 hours postdose for the 3.5 and 10 mg/kg 
cohorts, respectively.  
Due to limited interpretable data points above the lower limit of quantitation (LLOQ) in the IV 
dosing group, AUC∞ was not calculated, and absolute bioavailability (F) was therefore calculated 
using the mean values for AUC0-336 from two of six animals with quantifiable Au whole blood 
concentrations to 336 hours.  As shown in Table 10 was 30.5% for the 3.5 mg/kg group and 
20.5% for the 10 mg/kg group.  The difference may be due to the use of different animals in the 
3 cohorts rather than a true difference in bioavailability.  The mean Cmax value at 3.5 mg/kg 
includes two animals with CNM-Au8 concentrations all below the lower limit of quantitation 
with subsequent Cmax values set to zero, so the reported Cmax value may be an underestimate in 
this dosing group. 
 


 
 
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Table 10.  Summary of Cmax, AUC, T1/2, and Bioavailability Results Following Single Dose 
Administration of CNM-Au8 in Study CNAU-MPI-14-01 
CNM-
Au8 Dose 
(mg/kg) 
Statistic 
Cmax or 
C0 
(ng/mL) 
AUC0-336hr 
(hr*ng/mL) 
AUC0-336/Dose 
(kg*hr*ng/mL/mg) 
T1/2 
(hr) 
Bioavailability 
(F%) 
(Dose Normalized 
AUC Ratio 
(PO/IV) 
0.5 
(IV) 
N 
6 
2 
2 
2 
N/A 
Mean 
9.39 
146 
291 
31.0 
SD 
5.25 
N/A 
N/A 
N/A 
CV% 
55.9 
N/A 
N/A 
N/A 
3.5 
(PO) 
N 
6 
4 
4 
N/A 
Insufficient 
Data) 
30.5% 
Mean 
1.80 
311 
88.8 
SD 
1.65 
234 
66.8 
CV% 
92% 
75% 
75% 
10.0 
(PO) 
N 
6 
5 
5 
4 
20.5% 
Mean 
4.04 
596 
59.6 
150 
SD 
2.99 
457 
45.7 
51.5 
CV% 
74% 
77% 
77% 
34% 
The urine volume and feces mass in each collection interval was not determined, therefore, 
comparisons among dosing groups were limited to urine and fecal concentration data.  In the IV 
dosing group, feces concentrations were all below the LLOQ (<150 ng/mL); however, 
identification of CNM-Au8 above the lower limit of detection (LLOD) in the feces over the 2-
week period established the feces as a route of elimination.  Quantifiable urine concentrations 
were observed between 36 to 48 hours postdose in the 0.5 mg/kg IV dosing group, confirming 
urine as an elimination pathway.   Urinary excretion data were not collected at consistent 
intervals with whole blood concentration, so renal clearance could not be calculated.   Peak urine 
concentrations in the 3.5 and 10 mg/kg groups occurred between 12 – 24 hours and 36 – 48 
hours, respectively, and exceeded whole blood concentrations. 
Mean values for half-life (T1/2), clearance (CL), volume of distribution (Vz), and volume of 
distribution at steady state (Vss), respectively, for the 0.5 mg/kg IV dosing group are shown in 
Table 11. 
 
 
 


 
 
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Table 11.  Summary of CL, T1/2, Vz, and Vss after a Single 0.5 mg/kg IV Dose of CNM-Au8 
(Study CNAU-MPI-14-01) 
CNM-Au8 Dose 
 
Statistic 
T1/2 
(hr) 
CL 
(L/hr/kg) 
Vz 
(L/hr/kg) 
Vss 
(L/hr/kg) 
0.5 mg/kg (IV) 
N 
2 
2 
2 
2 
Mean 
31.0 
5.64 
249 
242 
Animal102 
33.6 
4.72 
229 
224 
Animal105 
28.5 
6.57 
270 
261 
In the oral gavage dosing groups, dose normalized systemic exposure (AUC0-336hr/Dose) and Cmax 
values for CNM-Au8 showed less than proportional increases.  An approximate 1:3-fold increase 
in dose (3.5 mg/kg to 10 mg/kg) resulted in an approximate 1:1.5-fold decrease in mean dose 
normalized AUC0-336hr/Dose. Mean values for terminal half-life (T1/2), oral clearance (CL/F), and 
oral volume of distribution (Vz/F), for the 10 mg/kg dosing group are reported in Table 12.  
Table 12.  Summary of CL/F, T1/2, and Vz/F after a Single 10 mg/kg PO Dose of 
CNM-Au8 (Study CNAU-MPI-14-01) 
CNM-Au8 Dose 
 
Statistic 
T1/2 
(hr) 
CL/F 
(L/hr/kg) 
Vz/F 
(L/hr/kg) 
10 mg/kg (PO) 
N 
4 
4 
4 
Mean 
150 
13.1 
2,970 
SD 
51.5 
7.3 
2,080 
CV% 
34% 
56% 
70% 
2.4.2 Repeat Dose Canine Toxicokinetic Summary 
In brief, in the subchronic toxicity study with a 4-week recovery period, 48 beagles were dosed 
for 28-days to assess toxicity and toxicokinetics.  CNM-Au8 was well tolerated when 
administered at gold concentrations of 0.35, 3.5, and 10 mg/kg/day as a single daily dose of 
1mg/mL CNM-Au8 via oral gavage, and the10 mg/kg/day dose was considered the NOAEL. 
There were no significant changes in serum chemistry or hematology measures or in the 
macroscopic or histologic assessments post-necropsy. In terms of toxicokinetics, systemic 
exposure appeared independent of gender. There was an increase in Cmax from 0.35 to 3.5 mg/kg, 
but no apparent change from 3.5 to 10 mg/kg, suggesting a plateau in exposure to 3.5 and 
10 mg/kg. Mean systemic exposure AUC(0-24 hr) accumulated in whole blood following repeated 
administration over the first two weeks, with no significant change in accumulation ratio (Rac) 
after that time, indicating that steady-state was reached within 2 weeks of dosing. Elimination 


 
 
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half-life (T1/2) was long; 333 hours (13.9 days) in the 10 mg/kg dose group.  During the recovery 
elimination phase, gold levels were still quantifiable at 4-weeks post-dosing in both blood and 
tissue.  Whole blood Au concentrations are shown in Figure 11. 
Figure 11. Whole Blood Concentrations by Day in 28-Day Repeat Dosing Canine Study 
 
A noteworthy finding in the three-animal species studied was a disproportionate tissue 
concentration of gold measured in the kidney. This renal accumulation was not accompanied by 
changes in renal function, as measured by serum biochemistry, urinalysis, or structural changes 
identified in the histologic examination of the kidney. In the 4-week recovery period in the 28-
day dog study, gold concentrations in the kidney decreased significantly over that recovery 
period, and continuing urinary excretion of gold was measured throughout the recovery period. 
2.4.3 Maximum Feasible Dose Canine Toxicokinetic Study 
In the canine maximum feasible dose study, the doses administered were 30 mg/kg/day (QD), 
60mg/kg/day (30 mg/kg BID), or 90 mg/kg/day (30 mg/kg TID) over three consecutive weeks 
(21-days). Dosing was well tolerated in the dogs over the 21 consecutive days of dosing. At the 
highest dose, 90mg/kg/day, minimal bilateral tubular cell hypertrophy was observed in the 
kidneys of males and females but was considered non-adverse by the MPI study pathologist-
toxicologist.  


 
 
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No deaths occurred. Treatment-related salivation and black discolored feces were observed at 60 
and 90 mg/kg/day. No treatment-related effects were observed on body weights, food 
consumption, ophthalmology, ECGs, clinical pathology parameters, organ weights or 
macroscopic examinations. There was slightly less than a proportional increase in gold exposure 
when the dose was increased from 30 to 60 mg/kg/day. Increasing the dose from 60 to 
90 mg/kg/day was not generally accompanied by an increase in gold exposure. Thus, maximal 
systemic exposure in the dogs may occur with a dose of 60mg/kg/day divided into two daily oral 
doses of 30 mg/kg. Accumulation appeared to plateau by Day 7, with no substantive increase in 
exposure on Days 14 and 21. Blood gold exposures at steady-state were approximately 1.1 to 3.3 
times higher than on Day 1, and the extent of the accumulation tended to be lower with higher 
doses.  Systemic gold concentration appears to be approximately at steady state after 1 to 2 
weeks of dosing. Systemic exposure appears to be higher in female dogs than in male dogs.  
2.4.4 Chronic Canine Toxicology (9-Month Dosing) 
The objective of this study was to evaluate the potential toxicity of the test article in beagle dogs 
when administered orally via gavage once daily for 13 and 39 weeks, and to evaluate 
reversibility, progression, or delayed appearance of any observed changes following a 4-week 
post dose observation period after each termination. 
Assessment of toxicity was based on mortality, clinical observations, body weight, and food 
consumption; ophthalmoscopic, and electrocardiographic examinations; and clinical and 
anatomic pathology. Blood, urine, CSF, and designated frozen tissues were analyzed for gold 
content. Toxicokinetic assessment for gold content in blood and urine was conducted. Results are 
summarized in Table 13. 
No early deaths occurred. There were no treatment-related clinical signs of toxicity observed, no 
effects on body weight or food consumption, or during ophthalmoscopic observations or 
electrocardiographic examinations. There were no test article-related effects among clinical 
pathology parameters noted during the interim dosing and recovery periods. No organ weight 
changes were observed and no test article related macroscopic or microscopic findings were 
observed at the interim or recovery necropsies. 


 
 
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CNM-Au8 was well tolerated in dogs when administered at doses of 0.35, 3.5 and 10 mg/kg/day 
for 39-weeks.  No adverse signs of toxicity were observed at any dose level. Therefore, the dose 
of 10 mg/kg/day was considered the NOAEL in dogs following oral administration. 
Table 13. Chronic Canine Toxicity Study 
 
 
 
Study ID 
(Internal ID/ 
CRO ID) 
GLP  
Status 
Species 
(N) 
Brief Design 
[Route; 
Frequency] 
Nominal 
Dose 
(mg/kg/day) 
CNM-Au8 
Conc. 
(μg/mL) 
Safety Summary/ 
Toxicity Notes 
CNM-AU8-
MPI-16-03 
(2257-007) 
GLP 
Beagle 
Dog 
(N=80; 8 
or 12 
(TK)/ 
group) 
39-Week Repeat 
Dose Toxicity 
with 4-Week 
Recovery  
[OG; QD] 
0.35 
[OG, QD] 
1,000 
No treatment-related 
clinical signs of toxicity 
observed, no effects on 
body weight or food 
consumption, or during 
ophthalmoscopic 
observations or 
electrocardiographic 
examinations. There were 
no test article-related 
effects among clinical 
pathology parameters noted 
during the interim dosing 
and recovery periods. No 
organ weight changes were 
observed and no test article 
related macroscopic or 
microscopic findings were 
observed at the interim or 
recovery necropsies. 
3.5 
[OG, QD] 
1,000 
 
10 
[OG, QD] 
1,000 


 
 
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3 
PRIOR HUMAN DOSING EXPERIENCE 
A Phase 1, First-Time-In-Human study was previously conducted under a clinical trial 
application (CTA) in the Netherlands (AU8.1000-14-01). The study was a 2-phase, randomized, 
double˗blind, single- and multiple-dose escalating study to evaluate the safety, tolerability, and 
PK of CNM˗Au8 in healthy male and female volunteers. There were 2 phases to this study: a 
single ascending dose (SAD) Phase and a multiple ascending dose (MAD) Phase. The SAD 
Phase was conducted first, followed by the MAD Phase of the study. 
3.1 
AU8.1000-14-01 Design 
A total of 8 subjects per cohort were randomly assigned (3:1 ratio) to receive a single dose of 
either CNM˗Au8 (n = 6) or placebo (n = 2) at an initial dose level of 15 mg CNM-Au8. 
Additional cohorts of 8 subjects were enrolled to investigate single-escalating doses of CNM-
Au8 at 30 mg, 60 mg, and 90 mg. Cohorts were to be balanced by gender with no more than two-
thirds of subjects being of one gender.  Safety parameters included findings from 
electrocardiograms (ECGs), vital signs, clinical laboratory panels, physical examinations, 
urinalysis, AEs, and concomitant medications. A follow-up visit was conducted for final safety 
assessments on Day 17 ± 1. 
After the SAD Phase was completed, a total of 12 subjects per cohort were randomly assigned 
(3:1 ratio) to receive a multiple dose of either CNM-Au8 (n = 9) or placebo (n = 3) once daily for 
21 days at an initial dose level of 15 mg CNM-Au8. Additional cohorts of 12 subjects were 
enrolled to investigate multiple escalating doses of CNM-Au8 at 30 mg, 60 mg, and 90 mg. 
Cohorts were balanced by gender, with no more than two-thirds of subjects being of one gender.  
Following the final dose of study drug on Day 21, subjects entered a 28-Day follow-up phase 
and returned to the clinical research unit (CRU) for PK sampling on Days 23, 24, 25, 26, 27, 28, 
32, 36, 40, and 49, which completed study participation.  Safety parameters included findings 
from ECGs, vital signs, clinical laboratory panels, physical examinations, urinalysis, AEs, and 
concomitant medications. 


 
 
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3.2 
AU8.1000-14-01 Pharmacokinetic Results 
The PK Population included all randomized subjects who received CNM-Au8 study drug and 
had sufficient samples collected for estimation of PK parameters. 
• The PK Population for the SAD Phase included 24 subjects who received a single dose of 
CNM˗Au8 study drug at 15 mg, 30 mg, 60 mg, and 90 mg. 
• The PK Population for the MAD Phase included a total of 35 subjects: 8 subjects in the 
15 mg dosing group and 9 subjects each in the other 3 cohorts who received multiple 
doses of CNM-Au8 study drug at 30 mg, 60 mg, and 90 mg (Cohorts 5–8). 
In the SAD Phase, PK analyses were not completed since the majority of whole blood Au 
concentrations were below the LLOQ. Since the lack of quantitation of Au concentrations may 
have been related to ICP-MS assay sensitivity, the Sponsor upgraded to an advanced, more 
sensitive, ICP-MS instrument for the PK analyses in the MAD Phase. 
In the MAD Phase: 
• The geometric mean whole blood concentrations from 1 week onward increased in a dose 
related, but not a dose-proportional manner. Based on Days 14 and 21, the increases in 
both Cmax and AUC(0-24) were less than dose proportional. 
• Based on pre-specified fit criteria, the elimination t½ ranged from 277 to 628 hr (11.5 to 
26.2 days). 
• Steady-state for all cohorts, based on the geometric mean whole blood concentrations, 
was reached by the end of the second week of dosing (Day 14), which was substantially 
less than predicted by the t½ [range of 46 to 105 days (6.6 to 15 weeks)]. 
PK parameters related to urinary excretion (Ue, CLr) could not be calculated. Only 1 urine Au 
concentration ≥ LLOQ (3 ng/mL) was within limits of the assay. 
3.3 
AU8.1000-14-01 Safety Results 
The Safety Population included randomized subjects who received at least 1 dose of study drug 
and had at least 1 post-baseline safety assessment, and was used to perform all safety analyses. 


 
 
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The Safety Population included 40 subjects in the SAD Phase, 46 subjects in the MAD Phase, 
and 86 subjects in the Pooled (SAD + MAD) group. 
All planned dose cohorts were completed, and the Safety Review Committee (SRC) agreed to 
escalate to each subsequent dose cohort per the protocol. An MTD was not identified. All 
subjects in the SAD Phase completed a single oral dose per protocol. In the MAD Phase, the 
mean duration of treatment was 21.0 days of consecutive oral dosing for the 15 mg, 30 mg, and 
60 mg Cohorts and placebo. Subjects in the 90 mg Cohort received on average 20.1 days of 
consecutive dosing. One subject (subject 0085-MAD 90 mg) in the MAD Phase did not complete 
the 21 days of consecutive dosing per protocol due to a reported pregnancy after 13 days of 
consecutive dosing, and had a medically induced abortion 7 days later. 
For the SAD and MAD Phases of the study, the overall incidence of TEAEs was comparable 
between treatments, including placebo; overall incidence of TEAEs considered related to study 
drug by the Investigator was also comparable between treatments, including placebo.  The most 
frequently reported TEAEs were in the classes of Nervous system disorders and Gastrointestinal 
disorders. The majority of TEAEs were Grade 1 severity (mild). There were no serious TEAEs, 
TEAEs leading to discontinuation of treatment, or TEAEs considered severe, life threatening, or 
resulting in death. Overall, no dose response relationship to TEAEs was observed in the SAD or 
MAD Phase of the study; however, the frequency of headache and gastrointestinal TEAEs was 
higher in the 90 mg MAD treated subjects. 
In the SAD Phase, TEAEs considered related to study drug by the Investigator were reported by 
2 (16.7%) out of 12 subjects in the 15 mg group, 2 (33.3%) out of 6 subjects in the 30 mg group, 
4 (66.7%) out of 6 subjects in the 60 mg group, and 5 (83.3%) out of 6 subjects in the 90 mg 
group compared with 7 (70.0%) out of 10 subjects in the placebo group. All related TEAEs were 
Grade 1 severity (mild) in the SAD Phase, except for 2 related TEAEs (diarrhea and abdominal 
pain: both in Subject 0024-SAD 60 mg) that were considered Grade 2 severity (moderate). 
In the MAD Phase, TEAEs considered related to study drug by the Investigator were reported by 
5 (62.5%) out of 8 subjects in the 15 mg, 4 (44.4%) out of 9 subjects in the 30 mg, 3 (33.3%) out 


 
 
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of 9 subjects in the 60 mg, 8 (88.9%) out 9 subjects in the 90 mg, and 6 (54.5%) 11 subjects in 
the placebo group. All related TEAEs in the MAD Phase were Grade 1 severity (mild). 
Modified treatment emergent events were defined as a treatment emergent adverse event that 
started within 24 hours from first dose of study medication. Modified TEAEs for all CNM-Au8 
doses were reported by 11 (36.7%) out of 30 subjects in the SAD Phase, 7 (20.0%) out of 35 
subjects in the MAD Phase, and 18 (27.7%) out of 65 subjects in the Pooled (SAD + MAD) 
group. A total of 9 (42.9%) out of 21 placebo treated subjects reported modified TEAEs. The 
most frequently reported modified TEAEs included headache, blood creatinine increased, 
dizziness, diarrhea, and nausea. 
The Sponsor performed a pre-specified search of TEAE preferred terms potentially associated 
with gold complex compounds to determine adverse events of special interest (AESIs). All 
AESIs were considered Grade 1 severity (mild), except for 2 TEAEs of Grade 2 severity 
(moderate): diarrhea and abdominal pain in the same subject (Subject 0024-SAD 60 mg). 
Incidence rates were comparable between all dosing groups including placebo. 
Dosing with either a single dose or multiple doses of CNM-Au8 was generally well tolerated 
over the course of this study. The most frequently reported TEAEs in the pooled population were 
headache, somnolence, fatigue, abdominal pain upper, diarrhea, nausea, abdominal pain, and 
dizziness.   
Oral administration of either a single (SAD) or repeated dose (MAD) of CNM-Au8 over 21 
consecutive days in healthy volunteers was safe and well tolerated. The TEAEs observed across 
the 4 doses (15 mg, 30 mg, 60 mg, and 90 mg) of CNM-Au8 were mostly mild in severity. While 
no dose response relationship to TEAEs was observed overall in the SAD or MAD Phase of the 
study, increases in headache and gastrointestinal related TEAEs were observed in the 90 mg 
cohort of the MAD Phase. 
Overall, for both the SAD and MAD Phases, routine clinical laboratory assessments 
(hematology, serum chemistry, and urinalysis), vital signs, ECGs, and physical examinations did 
not reveal clinically notable findings or trends; none resulted in serious TEAEs or TEAEs 
leading to discontinuation of treatment. 


 
 
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4 
INVESTIGATIONAL PLAN 
4.1 
Study Rational  
CNM-Au8 has been studied in several preclinical Parkinson’s Disease Models and has 
demonstrated significant neuroprotection in these models. Through a mechanism of action 
targeting restoration of cellular redox homeostasis, CNM-Au8 addresses pathophysiologic 
bioenergetic failure in neurons that may underlie the pathogenesis of Parkinson’s Disease and 
other neurodegenerative diseases. CNM-Au8 acts on bioenergetics to protect sensitive neuronal 
populations from chemical, inflammatory, and hypoxic insults through a unique mechanism 
promoting cellular redox homeostasis that involves the catalytic oxidation of NADH resulting in 
enhanced aerobic glycolytic energy production. 
The primary objective of this investigator-blinded, open labeled, randomized, Clinical Phase 2 
trial is to study the effects on brain NAD+/NADH redox potential of 12-weeks of treatment with 
CNM-Au8 using 31P-Magnetic Resonance Spectroscopy in patients with Parkinson’s Disease.  
Measurement of regional brain NAD+/NADH concentrations in healthy human subjects and in 
patients with schizophrenia has been demonstrated using 31P-MRS (Chouinard et al., 2017; Lu et 
al., 2016). In humans, brain NAD/NADH redox potential is inversely correlated with age and has 
been shown to decrease linearly with advancing age in healthy human subjects (Zhu et al. 2015) 
shown in Figure 12 below.  
 
 


 
 
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Figure 12.  NAD Redox Potential In Adult Humans 
 
Age dependences of NAD+/NADH redox potential observed in healthy human brains. The open symbols 
represent individual subject data, and the filled symbols display the average data from three age groups of 
younger (21–26 y old; n = 7), middle (33–36 y old; n = 4), and older (59–68 y old; n = 6) subjects. 
This age-related decrease in brain cellular redox potential is believed to be associated with the 
bioenergetic failure that underpins neurodegenerative diseases such as PD in susceptible people. 
NAD+/NADH redox potential is essential for fundamental ATP-energy-generating bioenergetic 
processes such as glycolysis and mitochondrial oxidative phosphorylation. Proper bioenergetic 
functioning is required for normal cellular activities including many ‘cellular housekeeping’ 
processes such as autophagy, apoptosis and the unfolded protein response (UPR) that have been 
shown to be abnormal in neurodegenerative diseases (Villanueva-Paz et al. 2016; Chua and Tang 
2013; Cantó, Menzies, and Auwerx 2015). Improvement  of brain NAD+/NADH redox potential 
demonstrated via 31P-MRS will provide Proof of Concept for the ability of CNM-Au8 treatment 
to potentially treat bioenergetic failure associated with the neurodegeneration observed in 
patients with Parkinson’s Disease.  
4.2 
Study Objectives  
To assess the CNS metabolic biomarker profile and safety of CNM-Au8 for the treatment of 
Parkinson’s Disease (PD):  
• Metabolic effects will be assessed as an improvement of 31P Magnetic Resonance 
Spectroscopic (31P-MRS) assessment of brain tissue cellular Redox potential defined by 


 
 
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the measured tissue ratio of NAD+:NADH concentrations and various bioenergetic 
markers. 
• Safety will be assessed via adverse events, serious adverse events, discontinuations due to 
adverse events, and the Columbia Suicide Severity Rating Scale (C-SSRS). 
4.3 
Overall Study Design and Plan 
This is a single-center open label pilot, sequential group, investigator-blinded study of the CNS 
metabolic effects, safety, pharmacokinetics, and pharmacodynamics of CNM-Au8 in patients 
who have been diagnosed with Parkinson’s Disease (PD) within three (3) years of Screening. 
Patients will be screened over a 6-week period.  Patients who meet the inclusion criteria and 
none of the exclusion criteria will be enrolled into the clinical study.   
The Sponsor will select a starting treatment dose for the initial treatment cohort of 15 mg or 30 
mg CNM-Au8.  Investigators and patients will remain blinded to each cohort’s study dose.  
Upon completion of a treatment cohort, the Sponsor will select a single dose or two doses from 
the prespecified dosing selection plan for the next treatment cohort based on the evaluation of the 
31P-MRS changes versus baseline in NAD+/NADH (Figure 13).  Up to a total of two treatment 
cohorts may be initiated. 
 
 


 
 
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Figure 13. Dose Selection Plan 
 
All patients will receive daily oral treatment over twelve (12) consecutive weeks during each 
cohort Treatment Period according the study schematic in Figure 14. 
Figure 14. Study Scheme 
  


 
 
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The primary efficacy outcome measure will be assessed based upon each patient’s Week 12 
study visit. All patients who are discontinued from treatment will complete the EOS assessment.  
At the end of the study, patients will complete an EOS Visit 4-weeks following their last study 
visit before exiting the study. 
All patients will receive once daily oral treatment over twelve (12) consecutive weeks during 
each cohort Treatment Period. In the event that collection of the 31P-MRS at the Week 12 visit is 
delayed due to imaging issues or COVID-19 pandemic related concerns, participants may remain 
on study drug beyond the Week 12 visit, so long as the extension is agreeable to both the study 
PI and Sponsor’s Medical Monitor, until it is deemed safe to return for collection of the Week 12 
efficacy assessments. Safety assessments that are able to be captured should be completed every 
4 weeks beyond the planned Week 12 visits prior to dispensation of unscheduled study drug. 
There will be three study periods per treatment cohort: 
1. A (6) six-week screening period (Screening Period); 
2. A (12) twelve-week treatment period (Treatment Period); 
3. A (4) four-week follow-up period (End-of-Study Assessment). 
The study investigators and patients will remain blinded for the duration of the study. 
 
 


 
 
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5 
INVESTIGATORS AND KEY STUDY PERSONNEL 
Key study personnel and investigators include the following:  
• Sponsor’s Medical Monitor: 
Name: 
Robert Glanzman, MD, FAAN 
Title: 
Chief Medical Officer 
Address: 
3165 E. Millrock Drive 
Suite 325 
Salt Lake City, Utah 84121 
United States 
Email: 
Robert@clene.com or mm@clene.com 
Telephone: 
+1  (801) 676 –9695 
• Principal Investigator 
Name: 
Richard Dewey, Jr., MD 
Title: 
Professor, Neurology and Neurotherapeutics 
Director, Clinical Center for Movement Disorders 
Address: 
UT Southwestern Medical Center 
Dallas, Texas 
Email: 
Richard.Dewey@UTSouthwestern.edu 
Telephone: +1 (817) 424-5567 
• Coordinating Core Biomarkers Investigator; Sub-investigator 
Name: 
Ben Greenberg, MD 
Title: 
Professor, Cain Denius Scholar in Mobility Disorders 
Department of Neurology and Neurotherapeutics 
Address: 
UT Southwestern Medical Center 
Dallas, Texas 
Email: 
Benjamin.Greenberg@UTSouthwestern.edu 
Telephone: +1 (214) 645-0555 
• Coordinating Core Imaging (MRS) Investigator; Sub-investigator 
Name: 
Jimin Ren, PhD 
Title: 
Associate Professor 
Advanced Imaging Research Center, Department of Radiology 
Address: 
UT Southwestern Medical Center 
Dallas, Texas 
Email: 
Jimin.Ren@UTSouthwestern.edu 
 


 
 
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All other study personnel not included in this section are identified in a separate personnel list 
(not part of this clinical study protocol) as appropriate. This list will be updated as needed; an 
abbreviated version with personnel relevant for the centers will be available in each center’s 
Investigator site file. 
Whenever the term ‘Investigator’ is noted in the protocol text, it may refer to either the Principal 
Investigator at the site or an appropriately qualified, trained and delegated individual of the 
investigational site. 
The Principal Investigator of each site/study center must sign the protocol signature sheet before 
patient recruitment may occur at the respective center. Similarly, all protocol amendments and/or 
revised integrated protocols must be signed and dated by the site’s Principal Investigator before 
coming into effect at the respective center. A complete list of all participating centers and their 
investigators, as well as all required signature documents, will be maintained in the Sponsor 
study file. 
 
 


 
 
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6 
STUDY ENDPOINTS 
6.1 
Efficacy Endpoints 
6.1.1 Primary Efficacy Endpoint 
Measure of Brain Bioenergetic Improvement 
Change in 31P-MRS Redox Ratio (NAD+/NADH): 
• Mean change in average NAD+/NADH  measured brain Redox Ratio by treatment group 
from Baseline to Week 12 
6.1.2 Exploratory Efficacy Endpoints 
Measures of Brain Bioenergetic Improvement 
Change in 31P-MRS Bioenergetic Metabolites: 
• Regression of baseline values versus mean percentage change in of the average tissue 
concentration by subject per dosing group from Baseline to Week 12 for: 
o ATP (a, b, g) 
o NAD+/NADH pool 
o Phosphocreatine (PCr) 
o Intracellular inorganic phosphate (Pi(in)) 
o Extracellular inorganic phosphate (Pi(ex)) 
Change in 31P-MRS Membrane Components: 
o Phosphoethanolamine (PE) 
o Phosphocholine (PC) 
o Glycerolphosphoethanolamine (GPE) 
o Glycerophosphocholine (GPC) 
Exploratory Functional Measures 
Change in APDM Instrumental Tests of Gait, Balance, and Mobility 
• Mean change in average difference between Baseline to Week 12 for: 
o APDM Instrumented Timed Up and Go (TUG) Test 
o APDM Instrumented Postural Sway Test 
o APDM Instrumented Walk Test 


 
 
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Change in Global Impression of Disease Severity and Improvement 
• Mean change between Baseline to Week 12 for: 
o Clinician Global Impression Scale (CGI) 
o Patient Global Impression Scale (PGI) 
Change in Disease Severity and Progression 
• Mean change in total score and sub-scales between Baseline to Week 12 for: 
o Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) 
6.1.3 Pharmacokinetic Endpoints 
Samples for the measurement of whole blood concentrations of Au will be collected before (pre-
dose) administration of the investigational drug product during the Week 4, 8, and Week 12 
Visit.   
At the Week 12 Visit, whole blood for PK will be taken at pre-dose (T0) and at 1, 2, 4, and 6 
hours after dosing for the visit.  The exact time at which the patient took his/her previous day’s 
study drug dose must be recorded in order to impute a 24-hour trough value (T24-imputed). 
The data will be used to construct a composite whole blood concentration-time profile for the 
Week 12 visit over the assigned treatment period.  The Week 12 data will be used to estimate an 
apparent Cmax and Tmax and area under the curve (AUC) over the 24-hour dosing interval [AUC(0-
24)].   
PK collection procedures are described in Section 9.2.8. 
6.1.4 Pharmacodynamic Endpoints 
Blood samples for the measurement of pharmacodynamic (PD) assays will be collected at 
Baseline (pre-dose) and following the PK collection during the Weeks 4, 8, and 12 Visits. An 
optional CSF collection for PD analysis will occur at the Baseline Visit (pre-dose) and Week 12 
for subjects who consent to the procedure. PD samples will be stored for future analyses to be 
defined in a separate PD analysis plan. 
PD blood and CSF collection procedures are detailed in Section 9.2.8 


 
 
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Blood and CSF collection for PD assays will be collected according to the schedule listed in 
Table 1. 
 


 
 
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7 
STUDY POPULATION 
The study selection criteria were chosen to exclude patients who may potentially be exposed to 
specific risks after administering the study drug as well as patients with conditions that may have 
an impact on assessing the objectives of the study. 
7.1 
Study Inclusion Criteria  
The patients to be enrolled in this study must meet the following inclusion criteria at the time of 
screening: 
1. Able to understand and give written informed consent and follow study procedures. 
2. Male or female, aged 30 – 80 years or age (inclusive) at the time of PD diagnosis. 
3. PD subjects will be recruited in accordance with the MDS Clinical Diagnostic Criteria for 
PD:  
a. Parkinsonism present (bradykinesia + either rest tremor or rigidity) 
b. 2 of the following 4 supportive criteria: 
i. Clear and dramatic beneficial response to dopaminergic medication 
ii. Presence of levodopa induced dyskinesias 
iii. Rest tremor of a limb 
iv. Olfactory loss or cardiac sympathetic denervation seen on prior MIBG SPECT 
4. Duration of PD since diagnosis is < 3 years (inclusive) 
5. Modified Hoehn and Yahr stage < 3 
6. Treatment with dopaminergic therapy for at least 12-weeks and with no change in current 
medications within the prior 6-weeks 
7.2 
Study Exclusion Criteria 
Patients will be excluded from the study if they meet any of the following criteria: 
1. Atypical parkinsonism, including that due to drugs, metabolic disorders, encephalitis, 
cerebrovascular disease, normal pressure hydrocephalus, or other neurodegenerative 
disease. 
2. The presence of any of the following: 
a. Unequivocal cerebellar abnormalities 


 
 
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b.  Downward vertical gaze limitation or slowing of downward saccades 
c.  Diagnosis of behavioral variant frontotemporal dementia or primary progressive 
aphasia 
d.  Parkinsonian features restricted to the lower limbs for > 3 years 
e.  Treatment with dopamine blockers or depleters in a time course consistent with drug 
induced parkinsonism 
f.  Absence of an observable response to high dose levodopa despite moderate disease 
severity 
g.  Expert considers a diagnosis of alternative syndrome more likely than PD 
h.  Rapid progression of gait impairment requiring wheelchair within 5 years of onset 
i.  Complete absence of progression of motor symptoms over 5 years unless due to 
treatment 
j.  Early bulbar dysfunction within the first 5 years since diagnosis 
k.  Inspiratory respiratory dysfunction (stridor or frequent sighs) 
l.  Severe autonomic failure in the first 5 years 
m.  Recurrent falls (>1 per year) because of impaired balance in the first 3 years 
n.  Disproportionate dystonic anterocollis or hand contractures of hands or feet within 
10 years 
o.  Absence of any of the common non-motor features of PD despite 5 years of disease 
p.  Otherwise unexplained pyramidal tract signs (weakness, hyperreflexia, or extensor 
toe signs) 
q.  Bilateral symmetric parkinsonism 
3. Mini-Mental State Examination (MMSE) score of less than 19. 
4. Patient with a history of any clinically significant or unstable medical condition based on 
the Investigator’s judgment. 
5. History of human immunodeficiency virus (HIV), hepatitis C (HepC) virus antibody, or 
hepatitis B (HepB) virus antibody.   
6. Based on the investigator’s judgment, patients who may have difficulty complying with 
the protocol and/or study procedures. 


 
 
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7. Patient with clinically significant abnormalities in hematology, blood chemistry, ECG, or 
physical examination not resolved by the Baseline visit which according to Investigator 
may interfere with study participation. 
8. Patients with clinically significant hepatic or renal dysfunction or clinical laboratory 
findings that would limit the interpretability of change in liver or kidney function, or 
those with low platelet counts (<150 x 109 per liter) or eosinophilia (absolute eosinophil 
count of ≥500 eosinophils per microliter) at Screening. 
9. Patient participating in any other investigational drug trial or using investigational drug 
(within 12 weeks prior to screening and thereafter) 
10. Positive screen for drugs of abuse or known history of alcohol abuse. 
11. Women of child-bearing potential, or men, who are unwilling or unable to use accepted 
methods of birth control during the study and for 6 months following completion of study 
participation. 
12. Women with a positive pregnancy test, are lactating, or are planning to become pregnant 
during the study or within 6 months of the end of this trial. 
13. Patients with implanted metal objects in their body that may be affected by an MRI 
procedure. 
14. Patients who are claustrophobic or otherwise unlikely to be able to complete the MRI 
scanning procedures. 
15. History of allergy to gold in any form.  
16. Patient is considered a suicide risk in the opinion of the Investigator, has previously made 
a suicide attempt, or is currently demonstrating active suicidal ideation. Subjects with 
intermittent passive suicidal ideation are not necessarily excluded based on the 
assessment of the Investigator.  
A patient who, for any reason (e.g., failure to satisfy the selection criteria), terminates the study 
before treatment assignment at the Baseline Visit (Visit 0) will be regarded as a Screen Failure.  
Screen Failures may be rescreened on a case by case basis after discussion and Sponsor approval. 
7.3 
Reproductive Potential 
Female patients of child bearing potential must have a negative serum β-hCG pregnancy test at 
the Screening Visit (Visit -1) and a negative urine pregnancy test at the Baseline Visit (Visit 0) 


 
 
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prior to treatment assignment. Male and female patients must abstain from sexual activity that 
could result in pregnancy or agree to use acceptable methods of contraception during the study 
and or 6-months following their last dose. Condoms should be used with the following 
acceptable contraceptives: 
• Intrauterine devices 
• Hormonal contraceptives (oral, depot, patch, injectable, or vaginal ring). 
Other acceptable contraception methods are: 
• Double barrier methods (e.g., condoms and diaphragms with spermicidal gel or foam). 
All patients must be advised to use acceptable contraceptives throughout the study period and for 
180 days following the last dose of investigational product. If hormonal contraceptives are used, 
they should be administered according to the package insert. Male and female patients who are 
not currently sexually active must agree to use acceptable contraception, as defined above, if 
they become sexually active during the period of the study and 180-days following the last dose 
of investigational product. 
7.4 
Removal of Patients from Therapy/Premature Discontinuation 
A patient may withdraw from the study at any time for any reason without prejudice to their 
future medical care by the physician or the institution. The Investigator or Sponsor may 
withdraw the patient at any time (e.g., in the interest of patient safety). The withdrawal of a 
patient from investigational product by the Investigator should be discussed where possible with 
the Sponsor’s Medical Monitor before the patient stops the investigational product.  Any patient 
removed from the study will complete an end of treatment visit and remain under medical 
supervision until study discharge is medically acceptable.   
If the investigational product is prematurely discontinued, regardless of the reason, the final 
study evaluations are to be performed as completely as possible. The information should be 
collected in the eCRF until the safety follow-up visit 28 ± 3 days after the last intake of study 
drug. Adverse events that occur within 28 ± 3 days after the last dose of study drug will be 
followed up until resolution, if possible. 


 
 
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All discontinued patients should also undergo the protocol-specified follow-up and should 
complete the end of study assessments.  Comments (spontaneous or elicited) or complaints made 
by the patient must be recorded in the appropriate source documents (e.g., an adverse event must 
be recorded and entered into the eCRF). The reason for termination, date of stopping 
investigational product, and the total amount of investigational product taken must be recorded 
on the electronic case report form (eCRF) and source documents for all discontinued patients. 
Patients will be encouraged to complete the study and all assessments.   
Patients will be discontinued from the study for the following medical and/or administrative 
reasons: 
• Patient request or at the request of the patient’s legally acceptable representative 
• Pregnancy, breast feeding, or repeat non-compliance with the scheduled pregnancy 
testing 
• The Investigator judges that continuation of the study would be harmful to the patient's 
well-being 
• TEAE or SAE that limits the patient’s ability to continue the study 
• Treatment interruption for 7 days or more 
Patients may be discontinued from the study for the following medical and/or administrative 
reasons: 
• At the specific request of the Sponsor and in liaison with the Investigator (e.g., obvious 
non-compliance, safety concerns) 
• If any exclusion criterion applies during the treatment periods 
• Substantial non-compliance with planned study procedures 
• Use of illicit drugs or other substances that may, in the opinion of the Investigator have a 
reasonable chance of contributing to toxicity or otherwise confound the study results 
7.4.1 Patient Replacement 
Patients who withdraw or are withdrawn following administration of the investigational product 
will be replaced under this protocol at the discretion of the Sponsor and Investigator. 


 
 
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7.4.2 Reasons for Discontinuation 
The reason for withdrawal must be determined by the Investigator and recorded in the patient’s 
medical record and on the eCRF. If a patient is withdrawn for more than one (1) reason, each 
reason should be documented in the source document and the most clinically relevant reason 
should be entered on the eCRF. 
If a TEAE is the reason for discontinuation, then TEAE must be recorded on the eCRF. 
Reasons for discontinuation include but are not limited to: 
• Adverse event 
• Protocol violation 
• Withdrawal by patient 
• Lost to follow-up 
• Pregnancy 
• Other (must be specified) 
7.4.2.1 Lost to Follow-Up 
At least 3 documented attempts must be made to contact any patient lost to follow-up at any time 
point prior to the last scheduled contact (office visit or telephone contact). One of these 
documented attempts must include a written communication sent to the patient’s last known 
address via courier or mail (with an acknowledgement of receipt request) asking that the patient 
return any unused investigational product and return to the site for final safety evaluations, as 
applicable. 
7.5 
Patient Identification 
After a patient has signed an informed consent form (ICF), the patient identification number for 
each patient will be assigned by site staff.  Patients will be identified by a unique number (e.g., 
840-001-001), which consists of: 
• First three (3) digits: International Organization for Standardization (ISO) UN M49 
Country code (e.g., United States [840]) 
• Second three (3) digits:  Site code (e.g., [001] UTSW) 


 
 
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• Last three (3) digits:  Current sequential patient number within the center 
Patient identification numbers must be used in sequence and no number should be skipped, 
substituted, or re-used. 


 
 
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8 
INVESTIGATIONAL DRUG PRODUCT 
8.1 
Treatments Administered 
Patients will either receive CNM-Au8 at doses of 7.5 mg, 15 mg, 30 mg, or 60 mg during the 
study. Study drug will be self-administered by patients who will be directed to take the study 
drug each day in the morning (7:00 – 10:00 am) at approximately the same time (e.g., 8:00 a.m. 
± 1 hour) at least 30 minutes before planned food intake.   
The drug formulations will be identical in appearance (size, shape, volume, color) and smell. The 
packaging and labeling will be designed to maintain blinding to the Investigator’s team and to 
patients.  There are no visible differences between the 7.5 mg, 15 mg, 30 mg, and 60 mg CNM-
Au8 dosing units.   
8.2 
Identity of Investigational Products 
8.2.1 CNM-Au8 
CNM-Au8 is a dark red/purple-colored liquid formulation consisting of a stable suspension of 
faceted clean surfaced elemental gold nanocrystals in buffered deionized water with a 
concentration of up to 1 mg/mL of gold.  The formulation is buffered by sodium bicarbonate 
(NaHCO3), present at a concentration of 0.546 mg/mL.  The suspension is initially created as an 
in-process bulk suspension with a gold nanocrystal concentration of 5.5 – 8.5 mg/L, which is 
then further processed to increase the gold concentration up to 1000 mg/L.  The NaHCO3 is 
present to assist in the manufacturing process and the concentration of NaHCO3 remains 
nominally unchanged throughout processing.  The pH of the suspension is between 7.5 and 10.0.  
There are no other excipients.  The drug product is formulated to be taken orally and will be 
provided in single dose HDPE containers. The study doses vary by the concentration of gold 
nanocrystals per milliliter in a volume of 60 mL as described in Table 14. 
The CNM-Au8 suspension is filtered using sterile, nonfiber-releasing 0.20 µm filters.  The 
filtration occurs in a clean room with either ISO 7 or ISO 8 standards (depending upon the 
specific room utilized).  The filtered solution is dispensed from the bulk container into clean, 
food-grade HDPE bottles. 
The bottles will be labeled as described in Section 8.2.2. 


 
 
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Manufacturing, testing, product characterization, release of CNM-Au8 will be carried out at the 
Sponsor’s facility at 500 Principio Parkway West, Suite 400, North East, MD 21901, USA.  
Table 14.  CNM-Au8 Investigational Product Dosing Administration 
Description 
CNM-Au8 
Daily Dosage 
7.5 mg 
15 mg 
30 mg 
60 mg 
Concentration 
62.5 μg/mL 
125 μg/mL 
250 μg/mL 
500 μg/mL 
Volume per Bottle 
60 mL 
60 mL 
60 mL 
60 mL 
Bottles per Day 
2 
2 
2 
2 
Daily Volume 
120 mL 
120 mL 
120 mL 
120 mL 
Route of 
Administration 
Oral 
Oral 
Oral 
Oral 
Time and 
Frequency 
Once Daily; Same 
Time Each Day  
(± 1 hour) 
Once Daily; Same 
Time Each Day  
(± 1 hour) 
Once Daily; Same 
Time Each Day  
(± 1 hour) 
Once Daily; Same 
Time Each Day  
(± 1 hour) 
The investigational product components and quality standards are described in Table 15 below. 
Table 15.  CNM-Au8 Components and Quality Standards 
Description 
Quality Standard 
CNM-
Au8 
7.5 mg 
CNM-
Au8 
15 mg 
CNM-
Au8 
30 mg 
CNM-
Au8 
60 mg 
NaHCO3 (mg) 
per bottle 
ACS, USP identity 
32.8 mg 
32.8 mg 
32.8 mg 
32.8 mg 
Au (mg) per 
Bottle 
Conforms with ASTM B562-
95 and USP <233>  
3.75 mg 
7.5 mg 
15 mg 
30 mg 
USP Purified 
Water 
USP for total organic 
carbon, and conductivity 
60 mL 
60 mL 
60 mL 
60 mL 
 
 
8.2.2 Labeling 
All investigational drug product will be labeled according to applicable local and legislative 
requirements. Label text will be approved according to the Sponsor’s agreed procedures, and a 
copy of the labels will be made available to the study site upon request. For all study drugs, a 
system of numbering in accordance with all requirements of Good Manufacturing Practice 
(GMP) will be used, ensuring that each dose of study drug can be traced back to the respective 
bulk ware of the ingredients. The Sponsor’s Quality Assurance group will maintain lists linking 


 
 
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all numbering levels.  A complete record of batch numbers and expiry dates of all study 
treatment as well as the labels will be maintained in the Sponsor study file. 
Study drug label may include, but is not limited to, the following information: 
• Batch number 
• Storage information 
• Site identification 
• Expiry date 
• Unique number/code 
8.2.3 Storage and Handling 
Investigational product will be stored at the investigational site in accordance with Good Clinical 
Practice (GCP) and GMP requirements and will be inaccessible to unauthorized personnel. A 
complete record of batch numbers and expiry dates can be found in the Sponsor study file; the 
site-relevant elements of this information will be available in the Investigator site file. 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. Receipt, 
distribution, return and destruction (if any) of the study drug must be properly documented 
according to the Sponsor’s agreed and specified procedures. 
All study drug will be kept in a locked area with limited access and stored at 15°- 25°C (59°- 
77°F). Mean kinetic temperature should not to exceed 25°C. Excursions between 15°C and 30°C 
(59° and 86° F) that may be experienced in pharmacies, hospitals, or warehouses, and during 
shipping are allowed. 
8.3 
Method of Assigning Patients to Treatment Groups and Dose Selection 
8.3.1 Treatment Assignment 
Patients who complete all screening procedures and meet the eligibility criteria to enter the study 
will be allocated by an unblinded study pharmacist to treatment per the pre-specified dosing 
schedule (Figure 13).  


 
 
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8.3.2 Selection of Doses in the Study 
The original planned CNM-Au8 dose levels in the first-time-in-human study were 15, 30, 60, 
and 90 mg CNM-Au8. The initial dose level selected was calculated based on the FDA guidance 
document “Estimating the Maximum Safe Starting Dose in Clinical Trials for Therapeutics in 
Adult Healthy Volunteers”. The lowest NOAEL was in the rat and was 40 mg/kg. Based on this 
NOAEL, an equivalent human dose was determined to be approximately 6.4 mg/kg. In a 60-kg 
human patient, the selected starting dose of 15 mg CNM-Au8 represented a safety margin of 
approximately 26-fold. 
The protocol for Study AU8.1000-14-01 was submitted to an Independent Ethics Committee and 
Competent Authority in the Netherlands and was subsequently approved for initiation under a 
Clinical Trial Application (CTA). The study was conducted in the Netherlands, at a Phase 1 
facility, The Center for Human Drug Research (CHDR) and has been completed. 
A total of 40 patients were randomized in the SAD phase and 46 patients in the MAD phase. 
Oral administration of either a single (SAD) or repeated dose (MAD) of CNM-Au8 over 21 
consecutive days in healthy volunteers was safe and well tolerated. The TEAEs observed across 
the 4 doses (15 mg, 30 mg, 60 mg, and 90 mg) of CNM-Au8 were mostly mild in severity. While 
no dose response relationship to TEAEs was observed overall in the SAD or MAD Phase of the 
study, increases in headache and gastrointestinal related TEAEs were observed in the 90 mg 
cohort of the MAD Phase.  No safety trends or safety signals were observed in the study.   
In the SAD phase, PK analyses were not completed because the majority of whole blood Au 
concentrations were below the LOQ.  However, a more sensitive ICP-MS instrument was 
employed for the MAD phase.  
In the MAD Phase:  
• The geometric mean whole blood concentrations from 1 week onward increased in a dose 
related, but not a dose-proportional manner. Based on PK results from Days 14 and 21, 
the increases in both Cmax and AUC(0-24) were less than dose proportional. 
• Based on pre-specified fit criteria, the elimination t½ ranged from 277 to 628 hr (11.5 to 
26.2 days). 


 
 
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• Steady-state for all cohorts, based on the geometric mean whole blood concentrations, 
was reached by the end of the second week of dosing (Day 14), which was substantially 
less than predicted by the t½ [range of 46 to 105 days (6.6 to 15 weeks)]. 
• PK parameters related to urinary excretion (Ue, CLr) could not be calculated. Only one 
urine Au concentration ≥ LOQ (3 ng/mL) was within limits of the assay. 
Based upon the maximum doses (mg/kg/day) evaluated in the nonclinical GLP repeat-dose 21-
day toxicokinetic studies, the completed first-time-in-human Phase 1 study (AU8.1000-14-01) 
doses of 15, 30, 60, 90 mg provided a safety margin to the NOAEL based on dose ratios (mg/m2) 
ranging from 26x – 4x in rodents, and 195x – 32x in canines, as described in the tables below.  
Therefore, at the top dose of 90 mg tested in humans, there was a minimum 4x safety margin to 
the NOAEL in rats.  
Table 16. Summary of CNM-Au8 Conversion of Animal 21-Day Repeat Doses To 
Human Equivalent Dose (HED) Based On Body Surface Area (mg/m2) for 60 kg Human 
 
Further, when evaluating Au exposure based on the end of study Day 21 AUC(0-24) (ng*hr/mL) in 
the canine, and rodent studies in comparison with the human 21-day MAD study, the human 
doses provided an exposure safety margin ranging from 3.3x – 1.6x  compared with rodents, and 
18.5x – 9.0x compared with canines, as described in Table 17 below. 
 
 
Species 
21-Day 
NOAEL 
Dose 
(mg/kg/day) 
21-Day 
NOAEL 
Dose 
(mg/m2) 
Safety Margin Based on Dosing Ratios (mg/m2) 
(For 21-Day dosing Studies) 
15 mg 
(9.3 mg/m2) 
30 mg 
(18.5 
mg/m2) 
60 mg 
(37.0 
mg/m2) 
90 mg 
(55.5 
mg/m2) 
Rat 
40 
240 
25.9 
13.0 
6.5 
4.3 
Canine 
90 
1800 
194.6 
97.3 
48.6 
32.4 


 
 
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Table 17. Summary of CNM-Au8 Exposure Safety Margin Based on End of Study 
AUC(0-24) ng*hr/mL.  Ratio of Animal Toxicokinetic to Human Pharmacokinetic AUC 
Results From 21-Day Repeat Dose Studies.  
CNM-Au8 exposure at the NOAEL at the end of the chronic toxicokinetic studies in the 9-Month 
canine and 6-Month rodent chronic dosing studies, provided an exposure safety margin ranging 
from 6.5x – 3.2x, and 13.6x – 6.7x in rodents and canines, respectively in comparison with the 
human exposures in the 21-day MAD study, as described below in Table 18. 
Table 18.  Summary of CNM-Au8 Exposure Safety Margin Based on End of Study 
AUC(0-24) ng*hr/mL Ratio of Chronic Animal Toxicokinetic 6 and 9-Month Rodent and 
Canine Repeat Dose Studies to Human 21-Day Pharmacokinetic Results  
 
Based on CNM-Au8 exposures at the NOAELs in the chronic rodent and canine studies along 
with observed CNM-Au8 exposures in 21-day multiple dosing in humans while also considering 
safety and tolerability, the doses chosen for this Phase 2 study in patients with Parkinson’s 
Disease will be up to 60 mg. Furthermore, the blood gold exposure observed at this dose in 
humans, is similar to the exposure observed in rodent toxicokinetic (TK) studies where 
significant remyelination and neuroprotection benefits were observed in preclinical 
neuroprotection models at 10 mg/kg, thus suggesting a positive bioenergetic response to CNM-
Au8 at this relative dose (e.g. 15 – 60 mg). 
 
Species 
 
21-Day 
NOAEL 
Dose 
(mg/kg/day) 
Animal 
End of Study 
AUC(0-24) 
(ng*hr/mL)a 
Safety Margin Based on Animal/Human AUC(0-24) 
Ratio (For 21-Day Dosing Studies) 
Human 
15 mg 
AUC 
(32.3 
ng*hr/mL) 
Human 
30 mg 
AUC 
(41.4 
ng*hr/mL) 
Human 
60 mg 
AUC 
(50.3 
ng*hr/mL) 
Human 
90 mg 
AUC 
(66.0 
ng*hr/mL) 
Rat 
40 
106 
3.3 
2.6 
2.1 
1.6 
Canine 
90 
596 
18.5 
14.4 
11.8 
9.0 
Notes: a Average of Male and Female AUC(0-24) ng*hr/mL values at End of Study 
 
Species (Study) 
 
NOAEL  
Chronic 
Dosing 
(mg/kg/day) 
Animal 
End of 
Study 
AUC(0-24) 
(ng*hr/m
L)a 
Safety Margin Based on Chronic Animal End-of-Study/ 
Human 21-Day AUC(0-24) Ratio 
Human 
15 mg AUC 
(32.3 
ng*hr/mL) 
Human 
30 mg AUC 
(41.4 
ng*hr/mL) 
Human 
60 mg AUC 
(50.3 
ng*hr/mL) 
Human 
90 mg AUC 
(66.0 
ng*hr/mL) 
Rat (6-Month) 
40 
209 
6.5 
5.0 
4.2 
3.2 
Canine (9-Month) 
10 
440 
13.6 
10.6 
8.7 
6.7 
a Average of Male and Female AUC(0-24) ng*hr/mL values  at End of Study 


 
 
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Figure 15. 21-Day AUC Exposure Ranges Between Rodent Toxicokinetic Studies, 
Preclinical Efficacy Models, and First-In-Human Dosing 
 
 
8.4 
Procedures for Blinding 
Patients and investigators will remain blinded to the study dose through the duration of the study.  
An unblinded study pharmacist at the clinical site will allocate patients to a dose of study 
medication per the pre-specified dosing schedule in Figure 13. The initial starting dose will be 
communicated to the sites unblinded representative prior to treatment assignment, and 
subsequent doses as outlined in Figure 13 will be only communicated to unblinded staff in order 
to maintain the single blind.  
The pharmacist at each site will maintain a secured copy of the pre-specified dosing scheme 
according to the site’s SOP and dispense medication based on the scheme for each patient. In the 
event the PI requires knowledge of the assigned dose for immediate care, the site’s unblinded 
pharmacist or Sponsor’s Medical Monitor can be contacted.  
8.5 
Unblinding 
The treatment allocation of a patient will be made available to the Investigator in case of 
emergency and when knowledge of the treatment allocation is important in the medical 
30.6
32.3
41.4
50.3
66.0
0
25
50
75
100
TK Rat
10 mg/kg
Human
15 mg
Human
30 mg
Human
60 mg
Human
90 mg
AUC (0-24 hrs)
(hr*ng/mL)
AUC (0-24 hr) at End of Study (Day 21)
(hr*ng/mL; Geometric Mean)
Neuroprotection 
Efficacy at 
10 mg/kg
First-In-Human Study 
AU8.1000-14-01 
TK Study*
CNAU-MPI-15-01
*Average of Male and Female AUC(0-24) ng*hr/mL values


 
 
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management of AEs. All unblinding events must be reported to the IRB/HREC in accordance 
with IRB/HREC timelines.  Unblinding may occur in the following circumstances: 
8.5.1 Unblinding by Sponsor’s Pharmacovigilance Representative 
In compliance with applicable regulations, in the event of a suspected unexpected serious 
adverse reaction (SUSAR), which is deemed related to blinded treatment, the patient’s treatment 
code may be unblinded by the Sponsor before reporting to the health authorities, HRECs, IRBs, 
and investigators if the SUSAR is related to the blinded treatment. 
8.5.2 Emergency Unblinding By The Investigator 
In case of emergency and where knowledge of assigned treatment allocation is required for the 
acute management of a TEAE, the Investigator may unblind the case by contacting the site’s 
unblinded pharmacist or Sponsor’s Medical Monitor. Investigators should note that the 
occurrence of an AE or SAE should not routinely precipitate the immediate unblinding. If 
possible, the Investigator should always consult with the Sponsor’s Medical Monitor prior to 
breaking the blind.  The Investigator must contact the Sponsor’s Medical Monitor in the event 
that the blind is broken and document the reason for unblinding. 
8.6 
Prior and Concomitant Therapy 
Disease-specific medications allowed per the inclusion/exclusion criteria.   
To ameliorate procedure-related anxiety, all patients will receive 5 mg of diazepam, PO, 45-60 
minutes prior to planned 31P-MRS scan at the Baseline and Week 12 Visits. 
Otherwise, except for acetaminophen, ibuprofen, naproxen, and 2nd generation antihistamines 
including fexofenadine, loratadine, and cetirizine; patients may not take any new prescription or 
OTC medications or dietary supplements from 14 days prior to Baseline through the end of study 
follow-up unless used to manage a TEAE.   
Patients must be on a stable dose of any chronic medications for at least six weeks prior to 
Screening. Any changes in dose or newly prescribed medications started during the study must 
be brought to the attention of the Investigator and reported immediately to the Sponsor’s Medical 
Monitor. 


 
 
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The Investigator will make every effort to contact the Sponsor’s Medical Monitor prior to 
administration of a new concomitant therapy (prescription or OTC) after treatment assignment, 
unless the concomitant therapy is needed immediately for patient safety. 
Any use of new prescription medicines, OTC medications, or dietary supplements during the 
study period must be reported on the eCRF. 
8.7 
Treatment Compliance 
Patients will receive study drug dispensed per visit schedule in Table 1.   
Patients will be requested to return any unused study drug including empty packaging and used 
bottles at the Week 4, 8 and 12 Visits.  Treatment compliance will be assessed at study visits 
through bottle counts and will be documented and summarized by a drug-dispensing log for each 
patient.  Overall treatment compliance with study drug intake for the per protocol analysis set 
should be between 80% and 120% of the planned dose and will be assessed at each study visit.  
In the event patients are not compliant within this range, discontinuation may be considered by 
the Investigator in consultation with the Sponsor. In the event of site logistical issues or safety 
concerns due to global pandemics, study participants may remain on study drug beyond the 
Week 12 visit if agreeable to both the PI and Sponsor’s Medical Monitor. Treatment compliance 
will be assessed for each 4-week extension beyond the Week 12 visit. The date of dispensing the 
study drug to the patient will be documented in the CRF. 
If a dose of study drug is missed, the patient should take the dose that day and continue with the 
planned dosing interval for the following day. The dose should not be doubled to make up for a 
missed dose within the same day. 
8.7.1 Study Drug Accountability 
Study drug will be administered in accordance with the procedures of this protocol.  Only 
authorized site personnel may supply study drug, and only patients enrolled in the study may 
receive study drug, in accordance with applicable regulatory requirements. 
A sponsor representative will perform ongoing drug accountability assessments during interim 
study monitoring visits.  Following completion of the trial, unused study drug and empty 


 
 
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containers may be returned to the sponsor or upon request from the sponsor, destroyed per site 
process.  


 
 
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9 
STUDY PROCEDURES 
9.1 
Study Schedule 
A Time and Events Schedule is provided in Table 1. Assessments should be conducted at each 
visit indicated in Table 1, unless the collection is unable to occur due to logistical or safety 
concerns associated with the COVID-19 pandemic. In these unique cases, missed assessments 
should be attributed to COVID-19 on the respective CRFs. 
Screening will occur on Days -42 through -1.  The Baseline visit will occur on Day 1. The 
treatment period will include Day 1 through the last dose of study medication. 
9.1.1 Screening Phase (Day -42 through Day -1) – VISIT (-1) 
The initial Screening Visit may be conducted up to 42 days prior to Baseline on Day 1.  The 
following procedures/assessments will be performed at Screening: 
• Informed consent (must be done prior to any of the following procedures) 
• Medical history and patient demographics (confirm PD diagnosis) 
• Prior medication assessment 
• Physical examination 
• Confirm patient meets all eligibility criteria  
• Height and weight 
• Vital Signs 
• Urinalysis 
• Urine drug screen (cocaine, marijuana, opiates, benzodiazepines, methamphetamines) 
• Venous blood for clinical laboratory tests 
• Venous blood for infectious disease screen (HIV, hepatitis B, and hepatitis C) 
• Serum pregnancy test (for females of childbearing potential) 
• Mini Mental State Exam (MMSE) 


 
 
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• 12-Lead ECG  
• Columbia Suicide Severity Rating Scale (C-SSRS) 
• Adverse Events 
• Schedule next study visit (Baseline Visit) 
9.1.2 Baseline (Day 1) – VISIT 0 
Patients will present to the study site for the Baseline assessments prior to dosing initiation. All 
Baseline assessments should be completed prior to the subject receiving their first dose of study 
medication. Magnetic resonance spectroscopy and/or  PD CSF collection may be performed 
within a -7 day window from Day 1. The following assessments are to be completed for the 
Baseline visit: 
• Physical exam 
• Concomitant medication assessment 
• Vital signs 
• Weight 
• 12-Lead ECG in triplicate  
• Urine pregnancy test (for females of childbearing potential) 
• Re-confirm patient meets all eligibility criteria 
• Venous blood for clinical laboratory tests 
• PD blood collection 
• PD CSF collection (optional) 
• Urinalysis 
• Adverse events 
• Anxiolytic Administration 


 
 
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• Magnetic Resonance Spectroscopy (MRS) 
• Unified Parkinson's Disease Rating Scale (MDS-UPDRS) 
• Clinical Global Impression Scale (CGI) 
• Patient Global Impression Scale (PGI) 
• Columbia Suicide Severity Rating Scale (C-SSRS) 
• APDM Instrumented Timed Up and GO (TUG) Test 
• APDM Instrumented Postural Sway Test 
• APDM Instrumented Walk Test 
• Treatment Assignment 
• Dispense Study Drug Package  
• Take First Study Dose at the Site from the dispensed supply (following all Baseline 
assessments) 
• Schedule next study visit 
9.1.3 Treatment Phase (Day 1 through EOS) 
During this period, patients will return to the study site for evaluations of safety and efficacy as 
outlined in Table 1. 
9.1.3.1 VISIT 1 (Week 2) 
At Week 2, clinical site staff will contact patients by telephone and assess for the following 
items: 
• Adverse Events 
• Concomitant medication assessment 
• Treatment compliance assessment 
• Columbia Suicide Severity Rating Scale (C-SSRS) 
• Schedule next visit 


 
 
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9.1.3.2 VISIT 2, 3 (Week 4 and 8) 
Study activities include: 
• Physical exam 
• Concomitant medication assessment 
• Vital signs 
• 12-Lead ECG 
• Urine pregnancy test (for females of childbearing potential) 
• Venous blood for clinical laboratory tests 
• PK blood collection 
• PD blood collection 
• Urinalysis 
• Adverse events 
• Unified Parkinson's Disease Rating Scale (MDS-UPDRS) 
• Clinical Global Impression Scale (CGI) 
• Patient Global Impression Scale (PGI) 
• Columbia Suicide Severity Rating Scale (C-SSRS) 
• Return/Dispense Study Drug Package  
• Take Study Dose at the Site from the dispensed supply  
• Schedule next study visit 
9.1.3.3 VISIT 4 (Week 12) 
Study activities include: 
• Physical exam 
• Concomitant medication assessment 


 
 
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• Vital signs 
• 12-Lead ECG 
• Urine pregnancy test (for females of childbearing potential) 
• Venous blood for clinical laboratory tests 
• PK blood collection 
• PD blood collection 
• PD CSF collection (optional) 
• Urinalysis 
• Adverse events 
• Anxiolytic Administration 
• Magnetic Resonance Spectroscopy (MRS) 
• Unified Parkinson's Disease Rating Scale (MDS-UPDRS) 
• Clinical Global Impression Scale (CGI) 
• Patient Global Impression Scale (PGI) 
• Columbia Suicide Severity Rating Scale (C-SSRS) 
• APDM Instrumented Timed Up and GO (TUG) Test 
• APDM Instrumented Postural Sway Test 
• APDM Instrumented Walk Test 
• Return Study Drug Package  
• Take Last Study Dose at the Site from the dispensed supply (at least 1 hour prior to 
MRS) 
• Schedule next study visit 


 
 
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9.1.3.4 VISIT 5 (Week 16/EOS) 
• Physical exam 
• Concomitant medication assessment 
• Vital signs 
• 12-Lead ECG 
• Venous blood for clinical laboratory tests 
• PK blood collection 
• Urinalysis 
• Adverse events 
• Columbia Suicide Severity Rating Scale (C-SSRS) 
9.1.4 End of Study Visit – Follow Up Period (Period 3) 
Timing for the end-of-study assessment (Visit 5) should occur at 28-days (±3 days) following 
study discontinuation for: 1) patients who discontinue therapy prior to the end of study, or 2) 
who complete the study. 
Any AEs/SAEs occurring up to the time of the follow-up visit will be recorded. Appropriate 
follow-up should continue until all safety concerns, in the Investigator’s opinion, are resolved, or 
return to baseline. 
9.1.5 Unscheduled Safety Assessments 
In the event that collection of the 31P-MRS at the Week 12 visit is delayed due to imaging issues 
or COVID-19 pandemic related concerns, participants may remain on study drug beyond the 
Week 12 visit, so long as the extension is agreeable to both the study PI and Sponsor’s Medical 
Monitor, until it is deemed safe to return for collection of the Week 12 efficacy assessments. 
Safety assessments that are able to be captured should be completed every 4 weeks beyond the 
planned Week 12 visits prior to dispensation of unscheduled study drug. These safety 
assessments include: 


 
 
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• Adverse Events 
• Concomitant Medications 
• ECG (if able to collect) 
• Vitals (if able to collect) 
• Physical Exam (if able to collect via remote visit) 
• Clinical Laboratory Tests (if able to collect via remote visit) 
• Patient Global Impression Scale (PGI) 
• Columbia Suicide Severity Rating Scale (C-SSRS) 
9.2 
Study Measurements and Assessments 
Measurements and assessments are to be performed according to the schedule shown in Table 1. 
Measurements and assessments should only be performed by trained and qualified personnel and 
whenever possible, the same person at each site should perform each of these assessments for all 
Patient visits. 
If a patient terminates treatment prematurely, all assessments listed in Table 1 for the End-of-
Study Assessment should be completed and dispensed study drug should be returned to the 
clinical site. 
9.2.1 Demographic and Other Baseline Characteristics 
Demographic characteristics such as age, sex, weight, height, ethnicity, and body mass index 
(BMI) will be collected during the study according to the schedule in Table 1. 
9.2.2 Assessment of Imaging Biomarkers 
Imaging of metabolic biomarkers will be assessed at each visit noted in the Study Schedule 
(Table 1) using the measures described below. All efficacy measurements are to be performed by 
a trained and qualified person. 


 
 
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In vivo 31P Magnetic Resonance Spectroscopy (MRS) measures phosphorus-containing 
metabolites such as NADH and ATP that are key molecules in cellular bioenergetic processes. 
By measuring the ratios of NAD+/NADH and ATP, neuronal redox potential can be assessed 
and the effects of CNM-Au8 on redox homeostasis can be studied. Patients will have two 31P-
MRS studies: at Baseline (Visit 0) and at Week 12 (Visit 4).  
9.2.3 Imaging Procedures 
MRI/MRS scans will be conducted on a Philips Achieva 7 Tesla human MRI scanner located in 
the Advanced Imaging Research Center, at UTSW. Patients will undergo 31P MRS scans to 
measure brain phosphorous metabolites and redox state. 45-60 minutes prior to 31P-MRS scans, a 
standard anxiolytic dose will be administered to ameliorate procedure related anxiety. The 
patient will remain under medical supervision until deemed safe for discharge by the 
Investigator. 
9.2.3.1 Whole Brain Metabolite Measurements:  
Preparation: A cylinder bird-cage shaped 31P T/R volume coil insert (into a 1H T/R volume coil) 
will be used for imaging the brain stem. The head of the patient will be positioned in the center 
of the coil with soft cushion pads placed under and on the sides of the head to secure the 
positioning of the head and reduce potential movement during the scans.  
After a scout image scan, axial, sagittal and coronal T2-weighted spin-echo multi-slice brain 
images will be collected using the typical parameters: TR 3.5 sec, TE 80 ms, slice thickness 8 
mm, gap 2 mm. A 2nd-order volume-based shimming will be conducted prior to 31P MRS data 
acquisition. 
31P MRS scans: Whole brain 31P spectra will be acquired using three-dimensional chemical shift 
imaging (3D CSI) approach.  Typical MRS parameters will be TR = 0.5 sec, NP 2 k, BW 8 kHz, 
NA = 4 (short scan) and 16 (long scan), with spatial resolution of 2x2x2 cm3. If subjects are able 
to complete both short and long scans without movement artifact, the data will be combined. 
Otherwise, only the completed dataset without movement artefacts will be used for data analysis. 
Voxel-based 31P spectra will be pooled together based on the functional regions (frontal, 
temporal, parietal and occipital) to evaluate the spatial distributions of metabolites.  Data 


 
 
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analysis will be performed by lineshape fitting of the 31P resonances of all phosphorous 
metabolites using a previously developed Matlab program.   
9.2.3.2 Partial Volume Coil Measurement: 
Preparation: A half-cylinder-shaped 1H/31P dual-tuned T/R partial volume coil will be used to 
image the posterior brain (occipital and parietal lobes) for evaluation of the brain redox state 
based on the measurement of NAD+/NADH ratio.  
Axial, sagittal and coronal T2-weighted spin-echo multi-slice images will be collected from the 
posterior head using the typical parameters TR 3.5 sec and TE 80 ms, slice thickness 8 mm, gap 
2 mm. A 2nd-order volume-based shimming will be conducted over the posterior brain region 
prior to 31P MRS data acquisition. 
31P MRS scans: To obtain 31P spectra with resolved NAD from overlapping a-ATP signals, an 
inversion-recovery-based NAD spectral editing technique will be used.  Briefly, acquisition of a 
reference 31P spectrum using pulse-acquire sequence is conducted plus the acquisition of an 
additional spectrum using a sequence containing an adiabatic inversion pre-pulse followed by a 
short delay is done to selectively nullify the NAD signal. A spectral subtraction will be 
performed to obtain an NAD-edited spectrum with resolved NAD signal from the reference 
spectrum.  The contribution of NAD+ and NADH to the resolved NAD signal will be quantified 
by lineshape fitting based on prior knowledge of the NADH signal being a singlet and the NAD+ 
signal being a quartet (as defined by 31P coupled AB-spin system resonance pattern). The brain 
redox state will be calculated by the NAD+/NADH ratio. Typical 31P MRS parameters for data 
acquisition will be TR 1.0 sec, TD 0.17 ms, NP 4k and zero filled to 8k, BW 8 kHz, NA 512x2. 
For quantitative comparison of different metabolites in the posterior brain region, an additional 
scan will be performed, using the partial volume coil, under the fully relaxed T1 condition with 
long TR of 15 sec and 16 acquisition averages. 
9.2.4 APDM Gait and Postural Analysis 
Gait abnormalities and postural instability are features of PD that worsen with disease severity 
and can both be used as indicators of fall risk. Gait abnormalities and postural instability will be 
assessed using the APDM Mobility Lab and wearable Opal sensors. 


 
 
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Measurements of gait abnormality will be collected by conducting two instrumented tests. A 
Timed Up and Go (TUG) test will be performed, which involves standing from a seated position, 
walking six meters, turning 180°, walking back to the chair and sitting. The time it takes to 
complete this action will be recorded, and the wearable Opal sensors will provide multiple 
measures pertaining to gait analysis (e.g., lean angle, duration, velocity, steps, speed, etc.).  Gait 
abnormality will also be measured by the Instrumented 2-Minute Walk test, which involves 
walking back and forth on a 7-meter course for a period of two minutes. Multiple variables will 
be measured by the Opal sensors, and the distance walked recorded.  
Measurements of postural instability will be collected by performing an Instrumented Postural 
Sway test in which the subject will be instructed to stand still for a period of time while the 
wearable sensors measure parameters such as mean sway area, path length, jerk, and sway 
distance in the mediolateral and anteroposterior directions. This assessment will be conducted 
while the subject remains standing with their eyes open, and repeated standing with their eyes 
closed, both when standing on a firm surface (e.g., a laminate floor).  
Both the TUG, Postural Sway and 2-Minute Walk assessments will be conducted at the Baseline 
and Week 12 Visits.  
9.2.5 Assessment of Safety 
Safety assessments will include the following: 
• Treatment emergent AEs and SAEs, both reported and observed 
• Physical examination 
• Vital sign measurements: Ear temperature, respiration, blood pressure, and heart rate 
(blood pressure and heart rate will be measured after the patient has been supine for 5 
minutes) 
• 12-Lead ECG will be conducted in triplicate at the Baseline Visit and averaged. A single 
ECG collection will occur at each additional scheduled time point 
• Venous blood for clinical laboratory tests will include hematology, coagulation, and 
blood chemistry. Blood for analysis will be drawn after an overnight fast when possible 
• C-SSRS 


 
 
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Outlier criteria for safety results including chemistry, urine, hematology, ECG, vital signs are 
based upon the National Cancer Institute (NCI) Common Terminology Criteria for Adverse 
Events (CTCAE ) v5.0, November 27, 2017.  This outlier criteria document has been authored 
and approved by the Sponsor safety physician to enhance review of safety data. The outlier 
criteria will be used as an additional review tool for TEAE reporting. 
9.2.6 Assessment of Disease Improvement 
9.2.6.1 Clinical Global Impression Scale (CGI) 
The CGI scale provides a brief assessment of the clinician’s view of the patient’s global 
functioning and severity of current disease state and can be utilized to assess for changes in 
disease progression over the course of a clinical trial. The CGI scale assessing disease severity 
(CGI-S) will be performed at the Baseline Visit and at Weeks 4, 8, and 12. A second CGI scale 
assessing improvement (CGI-I) will be performed at the Weeks 4, 8, and 12 visits.   
9.2.6.2 Patients Global Impression Scale (PGI) 
The PGI scale provides a brief assessment of the patient’s view global functioning and severity 
of current disease state and can be utilized to assess for changes in disease progression over the 
course of a clinical trial. The PGI scale assessing disease severity (PGI-S) will be performed at 
the Baseline Visit and at Weeks 4, 8, and 12. A second PGI scale assessing improvement (PGI-I) 
will be performed at the Weeks 4, 8, and 12 visits.   
9.2.6.3 Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) 
The Unified Parkinson's Disease Rating Scale (UPDRS) is a rating tool used to gauge the course 
of Parkinson’s disease in patients.  The UPDRS is composed of four parts: part I assesses 
behavioral problems such as intellectual decline, hallucinations, and depression; part II assesses 
patients' perceptions of their ability to carry out activities of daily living, including dressing, 
walking, and eating; part III covers the motor evaluation of disability and includes ratings for 
tremor, slowness (bradykinesia), stiffness (rigidity), and balance; part IV covers a number of 
treatment complications including ratings of involuntary movements (dyskinesias), painful 
cramps (dystonia), and irregular medication responses (motor fluctuations).  


 
 
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The UDPRS will be performed at the Baseline Visit and Weeks 4, 8 and 12. 
9.2.7 Assessment of Disease Related Safety 
9.2.7.1 Columbia Suicide Severity Rating Scale (C-SSRS) 
The C-SSRS is a semi-structured interview that captures the occurrence, severity, and frequency 
of suicide-related thoughts and behaviors during the assessment period (Posner et al. 2011). The 
interview includes definitions and suggested questions to solicit the type of information needed 
to determine if a suicide-related thought or behavior occurred. 
The C-SSRS contains 2 required items pertaining to suicidal ideation, 4 required items pertaining 
to suicidal behavior, and 1 required item pertaining to non-suicidal self-injurious behavior. There 
are 8 additional suicidal ideation items and 2 additional suicidal behavior items which are 
completed in cases of positive responses for other items, as well as 2 items for completed suicide 
and suicide behavior present during the interview. Thus, there is a maximum of 19 items to be 
completed. 
The C-SSRS must be performed by an individual who is medically responsible for the subject. 
Two versions of the C-SSRS are used in this study: 
• The “Baseline” version will be administered at the Screening Visit (Visit 0) and will be 
completed for all subjects. 
• The “Since Last Visit” version will be completed for all subjects at all study visits after 
the Screening Visit (Visit 0).  
9.2.8 PK and PD Assessments 
Blood samples for pharmacokinetic (PK) and pharmacodynamics (PD) analyses and the optional 
CSF samples for PD analyses will be collected during the Treatment Phases as outlined in the 
Time and Events Schedule in Table 1.   
During PK and PD study visits patients should present themselves to the clinical site or hospital 
without taking the morning dose of study medication. During these visits the PK and PD blood 
samples should always be collected before administration of the morning dose of the study 


 
 
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medication.  Accurate time of blood sampling and administration times for PK and PD collection 
will be documented in the eCRF. 
For patients participating in the optional CSF collection, CSF will be sampled by via lumbar 
puncture by a board certified clinician. Following sterile collection, the CSF sample should 
immediately be transported to the laboratory and processed per the study’s Lab Manual. CSF 
sampling should occur after the subject has performed all other assessments associated with the 
visit.   
Pharmacokinetic analyses, and pharmacokinetic/pharmacodynamics (PK/PD) modeling as 
applicable, using population approaches to describe Au whole blood pharmacokinetics including 
potential influence of relevant patient co-variables (e.g. age, gender, body weight, etc.) or 
potentially to relate parameters of clinical safety and efficacy response with Au whole blood 
concentrations will be investigated under separate detailed PK and/or PD evaluation plan(s). 
9.2.8.1 Collecting, Processing, and Shipping of PK and PD Samples 
For PK analyses, 4 mL of whole blood will be collected for each blood draw for bioanalytical 
analyses of Au content.  Blood samples for PK analyses will be collected in tubes with 
dipotassium ethylenediaminetetraacetic acid (K2EDTA), which should not exceed 1.6 mg 
K2EDTA per mL of whole blood).  PK samples must be placed on wet crushed ice immediately 
and stored at -70 °C or lower within 15 minutes.  
For PD analyses, up to an additional 20 mL of whole blood will be collected following the 
collection of the PK in two divided samples.  PD samples will be collected in citric acid tubes, 
placed on wet crushed ice immediately, and stored at -70 °C or lower, as quickly as feasible.  
Additional processes surrounding collection, processing and shipment of collected samples will 
be defined in the study’s Lab Manual.  
9.2.8.2 Bioanalytical Methods 
Blood concentrations of gold (Au) will be determined by using validated Inductively Coupled 
Plasma Mass Spectrometer (ICP-MS) analytical methods.  The lower limit of quantification, 
deviation of calibration standards from the theoretical value, and precision have been established 


 
 
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using standard methods.  Performance of the assay will be assessed by monitoring the analysis of 
spiked samples with known concentrations of CNM-Au8. 
Blood samples will be analyzed under the responsibility of the Sponsor’s bioanalytical laboratory 
at: 
Clene Nanomedicine, Inc. 
Bioanalytics Laboratory 
500 Principio Parkway West, Suite 400 
North East, MD  21901-2912 
9.2.9 Clinical Laboratory Tests 
All routine samples will be analyzed by a central licensed clinical laboratory unless otherwise 
specified below.  At the end of the study when all planned analyses are completed, all clinical 
laboratory blood samples will be destroyed per the central clinical laboratory SOPs.    
The clinical laboratory tests should include, but are not limited to: 
• Hematology:  hemoglobin, hematocrit, white blood cell count with differential, red blood 
cell count, platelet count. 
• Serology (Screening Visit only): human immunodeficiency virus (HIV), hepatitis C 
(HepC), and hepatitis B (HepB). 
• Blood Chemistry: Alanine aminotransferase (ALT; SGPT) and Aspartate 
aminotransferase (AST; SGOT), total bilirubin, direct bilirubin, Gamma-Glutamyl 
transferase (GGT), blood urea nitrogen (BUN), creatinine, alkaline phosphatase, lactate 
dehydrogenase (LDH), sodium, potassium, calcium, chloride, glucose, albumin, 
bicarbonate, uric acid, total protein, creatine kinase (CK). 
• Serum and urine pregnancy test: Beta-human chorionic gonadotropin (βhCG) test for 
females of childbearing potential. 
• Urinalysis: Dipstick analyses will include: Leucocytes, blood, nitrite, protein, 
urobilinogen, bilirubin, pH, specific gravity, ketones, and glucose. Urinalysis will include 
macroscopic analysis and microscopic analysis only when indicated by dipstick. 
• Urine Drug Screen:  Cocaine, cannabinoids, methamphetamines, benzodiazepines, and 
opiates. Patients with positive urine drug screen test results, without an active 


 
 
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prescription, will be excluded from the study. Urine Drug Screen kits will be supplied for 
sites to complete testing onsite.  Repeat urine drug screens for validation of initial 
findings may be conducted at the discretion of the site investigator. 
The core clinical laboratory will supply appropriate blood collection tubes for each study visit as 
specified in the study’s Lab Manual.   
9.2.10 Physical Examinations 
A full physical examination will consist of assessments of the following: skin, ears, nose, throat, 
head, eyes, lungs/chest, heart, abdomen, musculoskeletal, extremities, neurologic.  
9.2.11 Vital Signs 
Vital signs will include respiration rate (breaths per minute), temperature, blood pressure 
(mmHg) and heart rate (beats per minute [bpm]). Blood pressure and heart rate will be obtained 
after the patient has been resting in supine position for 5 minutes.  The same arm must always be 
used for blood pressure and heart rate measurements. Noninvasive measurement should be 
conducted preferably with a mercury sphygmomanometer or a validated electronic device in 
accordance with published guidelines (e.g. American Heart Association: Recommendations for 
Blood Pressure Measurement in Humans and Experimental Animals) (Pickering et al., 2005).  
9.2.12 12-Lead ECG 
12-lead ECGs will be performed successively in triplicate after the patient has rested quietly for 
at least 5 minutes in a supine position at the Baseline Visit.   The average corrected QT interval 
(QTc) of the triplicate ECG measurements collected prior to Day 1 dosing will serve as that 
patient’s baseline for use in ongoing safety assessment.  At all other scheduled timepoints, a 
single ECG will be collected after the patient has rested quietly for at least 5 minutes in a supine 
position. When the timing of the measurement coincides with a blood collection, the ECG should 
be obtained prior to blood collection.  In some cases, it may be appropriate to repeat abnormal 
ECGs to rule out improper lead placement as contributing to the ECG abnormality. It is 
important that leads are placed in the same positions each time for consistency. 


 
 
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ECG intervals will be summarized and presented descriptively. ECG rhythm will be interpreted 
by the Investigator as normal (N), abnormal not-clinically significant (aNCS), or abnormal 
clinically significant (aCS). 
9.2.13 Assessment Windows 
The MRS scan should occur as close to the same time per patient for the Baseline and Week 12 
Visit, within a +/- 2 hours window. Collection of blood samples should occur as close to the 
nominal timepoint as possible. The actual collection time of blood samples will be recorded.  


 
 
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10 ADVERSE EVENTS 
Safety will be assessed via adverse events, serious adverse events, discontinuations due to 
adverse events, and changes in the Columbia Suicide Severity Rating Scale (C-SSRS). 
10.1 Safety Reporting Guidelines 
AE monitoring and reporting is a routine part of every clinical study.  All Investigators, clinical 
site staff, and the Sponsor’s employees share in the responsibility for reporting AEs and SAEs. 
10.1.1 Sponsor Guidance 
The Sponsor is required to notify all participating Investigators and FDA in a written 
Investigational New Drug (IND) safety report of any AE associated with the use of the 
investigational drug that is both serious and unexpected, and any finding from tests in laboratory 
animals that suggests a significant risk for human patients (21 CFR 312.32(c)(1)(i)(A),(B)).  The 
Sponsor is required to keep Investigators informed of new observations discovered by, or 
reported to the Sponsor regarding the study drug particularly with respect to AEs and safe use 
(21 CFR 312.55). 
10.1.2 Investigator Guidance 
The Investigator is required to promptly report to the Sponsor any AE that may reasonably be 
regarded as caused by or probably caused by the investigational drug.  If the AE is alarming, the 
Investigator shall report the adverse effect immediately to the Sponsor (21 CFR 312.64). Further, 
Investigators are required to promptly report to the Human Research Ethics Committee (HREC) 
and/or Institutional Review Board (IRB) as applicable all unanticipated problems involving risks 
to human patients or others including AEs that should be considered unanticipated problems (21 
CFR 56.108(B)(1), 21 CFR 312.53(c)(1)(vii), and 21 CFR 312.66). All Investigators and clinical 
site staff who learn about or are notified of a SAE must collect and promptly report to the 
Sponsor (within 24 hours) data according to the study protocol and relevant regulations (21 CFR 
312.64, 21 CFR 312. 32). 


 
 
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10.2 Adverse Events (AE or Adverse Experience) 
Adverse events include any untoward medical occurrence associated with the use of a drug in 
humans, whether or not considered drug related. Therefore, an AE can be any unfavorable and 
unintended sign (including an abnormal laboratory finding), symptom, or disease temporally 
associated with the use of the investigational drug, whether or not considered related to the study 
drug (attribution of ‘unrelated’, ‘unlikely’, ‘possible’, ‘probable’, or ‘definite’) (International 
Conference on Harmonization [ICH] E2A, E6).  Adverse events include: 
• Exacerbation of a pre-existing disease. 
• Increase in frequency or intensity of a pre-existing episodic disease or medical condition. 
• Disease or medical condition detected or diagnosed after study drug administration even 
though it may have been present prior to the start of the study. 
• Continuous persistent disease or symptoms present at Baseline that worsen following the 
start of the study. 
• Lack of efficacy in the acute treatment of a life-threatening disease. 
• Events considered by the Investigator to be related to study-mandated procedures. 
• Abnormal assessments (e.g., change on physical examination, ECG findings), if they 
represent a clinically significant finding that were not present at Baseline or worsened 
during the course of the study. 
• Laboratory test abnormalities if they represent a clinically significant finding, 
symptomatic or not, which was not present at Baseline or worsened during the course of 
the study or led to dose reduction, interruption, or permanent discontinuation of the study 
drug. 
Adverse events do not include: 
• Medical or surgical procedure not mandated in the protocol (e.g., surgery, endoscopy, 
tooth extraction).  However, the event leading to the procedure is an AE. If this event is 
serious, the procedure must be described in the SAE narrative on the SAE eCRF. 
• Pre-existing disease or medical condition that does not worsen. However, if the condition 
deteriorates at any time during the study, it should be recorded as an AE. 


 
 
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• Situations in which an adverse change did not occur (e.g., hospitalizations for cosmetic 
elective surgery or for social and/or convenience reasons). 
• Overdose of either study drug without any signs or symptoms. However, overdose of 
study drug must be reported in the Study Drug Log. 
The occurrence of an AE may come to the attention of study personnel during the study visits, 
during interviews of a study recipient presenting for medical care, or upon review by a study 
monitor. Information to be collected and recorded include: event description, time of onset, 
clinician’s assessment of severity, relationship to study product (assessed only by those with the 
training and authority to make a diagnosis, which would include MD, PA, Nurse Practitioner, 
DO, or Physician Assistant), and time of resolution/stabilization of the event. 
All AEs occurring during the study including local and systemic reactions must be documented 
appropriately regardless of relationship and recorded on the relevant eCRF.  If there is any doubt 
as to whether a clinical observation is an AE, the event should be reported. 
10.2.1 Intensity of Adverse Events 
The intensity of all AEs will be graded for severity.  The investigating clinician will assess all 
AEs by grading the AE on a three-point scale of 1) mild, 2) moderate, and 3) severe; which are 
defined as follows: 
• Mild events: require minimal or no treatment and do not interfere with the patient’s daily 
activities. 
• Moderate events:  result in a low level of inconvenience or concern with the 
investigational drug. Moderate events may cause some interference with daily 
functioning. 
• Severe events: interrupt a patient’s usual daily activity and may require systemic drug 
therapy or other treatment. Severe events are usually incapacitating. 
If the intensity of an AE worsens during study drug administration, only the worst intensity 
should be reported on the relevant AE eCRF. If the AE lessens in intensity, no change in the 
severity is required.  AEs characterized as intermittent require documentation of onset and 
duration of each episode. 


 
 
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The AE intensity definitions do not apply to clinically significant and asymptomatic laboratory 
test abnormalities or abnormal assessments (e.g., ECG findings) considered as AEs. The 
Investigator should tick “non-applicable” on the AE page of the eCRF when identifying the 
intensity of the AE. 
Of note, mild, moderate, or severe AE classifications may or may not be serious (see SAE 
section).  These terms are used to describe the intensity of a specific adverse event (as in mild, 
moderate, or severe nausea). For example, nausea lasting several hours may be rated as severe, 
but may not be clinically serious.  Alternatively, a fever of 39°C that is not considered severe, 
may however become serious, if it prolongs hospitalization.  Seriousness rather than severity 
serves as a guide for defining regulatory reporting requirements. 
10.2.2 Relationship and Attribution of the AE to Study Drug 
10.2.2.1 Relationship to Study Drug 
Each adverse event must be assessed by the Investigator as to whether or not there is a 
reasonable possibility of causal relationship to the study drug, and reported as either related or 
unrelated. The Investigators assessment of an AE's relationship to the study drug is part of the 
documentation process, but it is not a factor in determining what is or is not reported in the study. 
 
• Related to Study Drug:  This category applies to any AE (whether serious or not) that 
appears to have a reasonable possibility of causal relationship to the use of the study 
drug (i.e., a relationship cannot be ruled out). Guidelines to determine whether an event 
might be considered related include but are not limited to the following: 
o The event occurred in close temporal relationship to study drug administration. 
o The event diminished or disappeared when treatment with the study drug was 
down titrated, interrupted, or discontinued. 
o The event reoccurred when treatment was reintroduced. 
o Environmental factors such as clinical state and other treatments could not 
equally have caused the event. 
• Unrelated to Study:  There is not a reasonable possibility that the administration of the 
study product caused the event (see above guidelines). 


 
 
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10.2.2.2 Attribution to The Study Drug 
After identifying and grading the event, the clinical Investigator must assign an attribution to the 
AE using the following attribution categories described in the table below. AEs listed as 
‘possibly, probably’ or definitely’ related to the investigational drug are considered to have a 
suspected ‘reasonable causal relationship’ to the investigational agent (ICH E2A). 
Table 19.  AE Attribution to the Study Drug 
Relationship 
to Study Drug 
 
Attribution 
 
Description 
Unrelated 
Unrelated 
The AE is clearly NOT related to the study drug 
Unlikely 
The AE is doubtfully related to the study drug 
Related 
Possible 
The AE may be related to the study drug 
Probable 
The AE is likely related to the study drug 
Definite 
The AE is clearly related to the study drug 
 
10.2.3 Serious Adverse Events 
The International Conference on Harmonization (ICH) guidelines define a serious adverse event 
(SAE) as an AE or suspected adverse reaction that in the view of either the Investigator or 
Sponsor results in any of the following study patient outcomes: 
• Death, 
• A life-threatening AE, 
• Inpatient hospitalization or prolongation of existing hospitalization, 
• A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions, 
• A congenital anomaly/birth defect, or 
• An important medical event, requiring medical or surgical intervention (treatment) to 
prevent at least one of the outcomes listed above. 


 
 
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Life threatening refers to an event in which the patient was at risk of death at the time of the 
event. It does not refer to an event that hypothetically might have caused death had it been more 
severe. 
Important medical events that do not result in death, are not life threatening, or do not require 
hospitalizations may be considered serious when, based upon appropriate medical judgment, 
they may jeopardize the patient and may require medical or surgical intervention to prevent one 
of the outcomes listed in the SAE definition. Examples of such medical events include allergic 
bronchospasm requiring intensive treatment in an emergency room or at home, a blood dyscrasia 
or convulsion that does not result in inpatient hospitalization, or the development of drug 
dependency or drug abuse. 
Complications that occur during hospitalization may be AEs or SAEs depending upon 
Investigator judgment (i.e., if a complication prolongs hospitalization it would be considered an 
SAE). However, the following reasons for hospitalizations are not considered AEs, and are 
therefore also not SAEs: 
• Hospitalizations for cosmetic elective surgery, or social and/or convenience reasons. 
• Standard monitoring of a pre-existing disease or medical condition that did not worsen 
(e.g., hospitalization for coronary angiography in a patient with stable angina pectoris). 
• 
Elective treatment of a pre-existing disease or medical condition that did not worsen (e.g., 
elective hip replacement for arthritis). 
10.2.4 Serious Adverse Events Related To Study-Mandated Procedures 
A SAE is defined as related to study-mandated procedures if it appears to have a reasonable 
possibility of a causal relationship (i.e., a relationship cannot be ruled out) to procedures other 
than administration of the study drug. Examples of study-mandated procedures include blood 
sampling, car accident on the way to the study unit for a study visit, etc. 


 
 
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10.3 Reporting Requirements for AEs and SAEs 
10.3.1 Reporting of Adverse Events 
All AEs collected from the time of treatment initiation up to the last IP dose, or leading to the 
premature discontinuation of IP must be recorded on the appropriate AE pages of the eCRF. AEs 
documented between signing of the Informed Consent and treatment initiation, and from last 
dose to 28 days after study drug discontinuation will be recorded on the appropriate AE source 
page but will not be entered as an eCRF. 
Information to be collected includes event description, date of onset, Investigator assessment of 
severity, Investigator assessment of relationship to study product, date of resolution of the event, 
seriousness, and outcome. 
10.3.2 Reporting Abnormal Laboratory Test Values or Abnormal Clinical Findings 
Collection of specific safety laboratory data is outlined in the study visit schedule. Toxicity 
tables are based on the FDA toxicity tables developed for normal healthy adult volunteers. 
Laboratory values and abnormal clinical findings that are abnormal based on the toxicity tables 
must be reported on the appropriate AE eCRF. 
10.3.3  Reporting of AE Intensity and Causality 
Only licensed study clinicians (i.e., Medical Doctor, Doctor of Osteopathy, Nurse Practitioner, 
Physician’s Assistant) should assess the intensity of non-serious AEs. Similarly, only licensed 
study clinicians as identified on Form FDA 1572 or per ICH E6 standards should assess the 
causality of AEs. 
10.3.4  Follow-up of AEs 
All AEs occurring during the AE reporting period of the study will be documented appropriately 
regardless of relationship. All AEs occurring during the treatment period will be followed to 
adequate resolution or until the patient is considered stable. 
Adverse events still ongoing after study drug discontinuation for a given patient will be followed 
until 28 days after study drug discontinuation or until AE resolution or patient stabilization. 


 
 
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Resolution of an AE is defined as the return to pretreatment status or stabilization of the 
condition to the Investigator and/or Sponsor’s satisfaction with the expectation that the condition 
or abnormality may remain chronic. Follow-up procedures, evaluations, and outcomes will be 
recorded on the patient's CRF. 
10.3.5 Reporting Requirements For SAEs 
All SAEs occurring during the course of the study (e.g., signing of informed consent by patient 
to 28 days following the last dose of the study drug) and any SAEs, considered causally related 
to study drug that occur following completion of the study, must be reported to the Sponsor. 
10.3.5.1  Reporting of SAEs 
All serious adverse events that occur during the course of study will be recorded on the 
appropriate eCRF (e.g., SAE eCRF) and will be reported to Sponsor’s drug safety physician. 
Any AE that meets a protocol-defined criterion as serious must be submitted immediately 
(within 24 hours of site or Investigator awareness) on an SAE form to the Sponsor’s drug safety 
physician at the following address: 
Robert Glanzman, MD, FAAN 
Sponsor’s Medical Monitor 
Clene Nanomedicine, Inc. 
3165 East Millrock Drive, Suite 325 
Salt Lake City, Utah 84121 
United States 
Tel: +1 (801) 676-9695 
Email: safety@clene.com  
 
Information to be collected includes unique patient ID, event description, date of onset, 
Investigator assessment of severity, Investigator assessment of relationship to study product, date 
of resolution of the event, seriousness, and outcome. 
Other supporting documentation of the event may be requested by the Sponsor and should be 
provided as soon as possible. The Sponsor’s drug safety physician will review and assess the 
SAE for regulatory reporting and potential impact on study patient safety and protocol conduct. 


 
 
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10.3.5.2  SAE Reporting Periods 
• Screening period: SAEs occurring between signing the Informed Consent Form and study 
drug initiation should be reported in the eCRF.  
• Treatment Period: All SAEs, regardless of causal relationship, must be reported, 
including those related to study-mandated procedures. Those SAEs occurring during 
study drug administration, i.e., between study drug initiation and 28 days after study drug 
discontinuation, are defined as treatment-emergent SAEs. These SAEs are reported on 
SAE forms and also on AE pages in the eCRF. They are therefore entered into both the 
drug safety and clinical databases, and must be reconciled before study closure. 
• Follow-Up Period: All SAEs, regardless of causal relationship, occurring after study drug 
discontinuation until 28 days after study drug discontinuation must be reported. 
• Post Follow-Up Period: If the Investigator becomes aware of a new SAE that is suspected 
of being causally related to the study drug occurring after 28 days of follow-up or post-
study completion, the Investigator will report the event within 24 hours to the Sponsor’s 
drug safety physician. These SAEs are only entered in the drug safety database, and 
therefore will not affect study closure. 
10.3.5.3  SAE Reporting Procedures 
• All SAEs must be reported by the Investigator to drug safety physician within 24 hours of 
the Investigator’s first knowledge of the event. 
• All SAEs must be recorded on the appropriate SAE forms, irrespective of the study drug 
received by the patient, and whether this event is considered by the Investigator to be 
related to study drug. These SAE forms must be faxed and emailed to the Clene 
Nanomedicine, Inc. drug safety physician. 
• The Investigator must complete the SAE form in English (unless otherwise specified), 
and must assess the relationship of the event to study drug.  Such reports will be followed 


 
 
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by detailed descriptions that may include copies of hospital case reports, autopsy reports, 
hospital discharge summaries and other documents when requested and applicable. 
• Follow-up information about a previously reported SAE must also be reported within 24 
hours of receiving it. The drug safety physician may contact the Investigator to obtain 
further information. 
• The intensity of SAEs may only be assessed by a licensed study physician as described 
previously.  The causality of SAEs may only be assessed by a licensed physician 
identified on the Form FDA 1572 or per ICH E6 standards. 
10.3.5.4  SAE Regulatory Reporting 
Following notification from the Investigator, the Sponsor will expedite reporting any suspected 
adverse reaction that is both serious and unexpected to Health Authorities, HREC, IRBs, and 
other Investigators, as appropriate. 
The Sponsor will report an AE as a suspected adverse reaction only if there is evidence to 
suggest a causal relationship between the drug and the AE. Sponsor will notify FDA and all 
participating Investigators (i.e., all Investigators to whom the Sponsor is providing drug under its 
INDs or under any Investigator’s IND) in an IND safety report of potential serious risks from 
clinical trials or any other source, as soon as possible, but in no case later than 15 calendar days 
after the Sponsor determines that the information qualifies for reporting as specified in 21 CFR 
Part 312.32.  Further, Sponsor will notify FDA of any unexpected fatal or life-threatening 
suspected adverse reaction as soon as possible but in no case later than 7 calendar days after the 
Sponsor’s initial receipt of the information. Relevant follow-up information to an IND safety 
report will be submitted as soon as the information is available. Upon request from FDA, 
Sponsor will submit to FDA any additional data or information that the agency deems necessary, 
as soon as possible, but in no case later than 15 calendar days after receiving the request. 
Un-blinding of serious and unexpected AEs will be performed as necessary and appropriate. 
All serious adverse events designated as “not related” to study product(s), will be reported to the 
FDA at least annually in a summary format. 


 
 
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General study reporting periods and safety reporting requirements are summarized in the table 
below. 
 
Table 20.  Summary of Study Safety Reporting Periods 
 
Study Periods: 
Screening 
Treatment 
Follow-Up 
Post Follow-up 
Timeframe 
From signature of 
informed consent to 
study drug initiation 
During study drug 
administration  
From immediately 
after study drug 
discontinuation until 
28 days after study 
drug discontinuation 
After 28 days 
AE Reporting 
on AE eCRF 
None 
All AEs 
None1 
None 
SAE 
Reporting on 
AE eCRF 
Only if related to 
study- mandated 
procedures 
All SAEs 
(treatment- 
emergent) 
All SAEs 
If considered 
causally related to 
the study 
medication 
Reconciliation2 
Not applicable 
Yes 
Not applicable 
Not applicable 
Clinical Study 
Report/Final 
Study Report 
AEs and SAEs may 
be described 
Analyzed 
Reported 
AEs and SAEs may 
be described 
1Adverse events still ongoing after study drug discontinuation for a given patient must be followed until 
28 days after study drug discontinuation or until resolution or stabilization or until the event is otherwise 
explained. 
2Reconciliation between clinical and drug safety databases. 
10.4 Pregnancy 
10.4.1 Prevention of Pregnancy During the Study 
Women should not become pregnant during the study and up to 6 months following study drug 
discontinuation. Accordingly, women of childbearing potential should take appropriate 
precautions to prevent pregnancy during the study. If a woman becomes pregnant while on study 
drug, no further treatment will be administered.  In the event of a pregnancy, all study-mandated 
blood samples will be obtained and the patient will continue in follow-up for safety events. 
10.4.2 Reporting of Pregnancy 
Irrespective of the treatment received by the patient, any pregnancy which occurs in a study 
patient or the partner of a male study patient, which occurs during study drug administration or 6 


 
 
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months following study drug discontinuation must be reported within 24 hours of the 
Investigator’s knowledge of the event. 
Pregnancies must be reported to the Sponsor's drug safety physician and on the AE page of the 
eCRF, as applicable. 
10.4.3 Pregnancy Follow-Up 
Pregnancies will be followed to pregnancy outcome pending the patient’s permission and 
reported to the Sponsor's drug safety physician. Follow-up information will only be entered in 
the drug safety database, and hence will not affect study closure. 
10.5 Clinical Monitoring 
10.5.1  Site Monitoring Plan 
Site monitoring will be conducted to ensure that human patient protection, study procedures, 
laboratory procedures, study intervention administration, and data collection processes are of 
high quality and meet Sponsor, International Conference on Harmonization (ICH)/Good Clinical 
Practice (GCP) guidelines and applicable regulatory requirements, and that the study is 
conducted in accordance with the protocol and Sponsor’s SOPs. The Sponsor or its designee will 
conduct site-monitoring visits as specified in the monitoring plan. 
Monitoring visits will include, but are not limited to, review of regulatory files, accountability 
records, eCRFs, patient source records (i.e., electronic medical records), informed consent forms 
(ICFs), medical and laboratory reports, and protocol compliance. Study monitors will meet with 
Investigators to discuss any problems and actions to be taken and document visit findings and 
discussions. 


 
 
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11 STATISTICS AND DATA MANAGEMENT 
Separate PK and statistical analysis plans (SAP) will provide details of planned analyses and 
summary documents, such as tables, listings and figures.  All variables will be analyzed 
descriptively with appropriate statistical methods: categorical variables by frequency tables and 
continuous variables by sample statistics (i.e., mean, SD, minimum, median, quartiles and 
maximum).  An overview of the planned analyses is provided here.  However, final analyses are 
not limited to the summaries described herein but will be defined in the SAP prior to final 
database lock. 
11.1 Determination of Sample Size 
As an open label pilot study, no formal sample size calculations have been conducted. 
11.2 Analysis Populations 
The following patient sets are applicable to this study: 
• Intent to Treat Analysis Set – The Intent To Treat Set (ITT) will consist of Screened 
patients for whom a treatment assignment number has been assigned at Visit 0. 
• Safety Analysis Set – The Safety Analysis Set (SAS) will consist of patients in the 
Treatment Assignment Set who receive at least 1 dose of investigational product. 
• Partial Analysis Set – The Partial Analysis Set (PAS) will consist of all patients in the 
Safety Set with at least 1 post-baseline measurement of MDS-UPDRS. 
• Per Protocol Set – The Per Protocol Set (PPS) will consist of all patients in the Safety Set 
who have completed at least 12-weeks of treatment, the Week 12 31P-MRS scan, and who are 
treatment adherent per Section 8.7. 
• Treatment Cohort – A Treatment Cohort will be defined as all patients who receive the 
same dose of CNM-Au8. 
11.3 Baseline Characteristics and Patient Disposition 
Overall Baseline and demographic data will be summarized using descriptive statistics. Patient 
disposition (e.g., the number of patients enrolled, completed, and discontinued) will be 
summarized and medical history and physical examination findings will be listed. 


 
 
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11.4 Prior and Concomitant Medications 
Medications taken after the patient receives study drug through Follow-Up will be listed by 
treatment, dose level and patient. 
11.5 Pharmacokinetic Analyses 
Pharmacokinetic parameters will be derived using noncompartmental analyses employing 
appropriate software and graphing tools (e.g. WinNonlin® Professional version 6.3 [Pharsight 
Corp], SAS® for Windows® Version 9.4, SigmaPlot for Windows Version 12.5; or higher 
versions).  
Au concentrations will be summarized using descriptive statistics (including N, mean, SD, 
coefficient of variation (CV%), median, minimum, and maximum) for each treatment. 
Concentrations below the limit of quantification (BLQ) will be treated as zero for the 
computation of descriptive statistics and for construction of mean concentration-time profiles. 
Concentrations assigned a value of missing will be omitted from the calculation of descriptive 
statistics. 
The following PK parameters will be estimated by noncompartmental methods from whole blood 
samples. Actual elapsed time from dosing will be used to estimate all individual PK parameters. 
Table 21.  Summary of PK Parameters 
 
Parameter 
Description 
Cmax 
Maximum observed plasma concentration 
Tmax 
Time of maximum concentration (h), obtained directly from 
the observed concentration versus time data. 
CL/F 
Apparent systemic clearance 
AUC(0-24) 
Area under the plasma concentration-time curve from time 
0 to the end of the 24-hour dosing interval 
 
Derived PK descriptive statistics will be tabulated by dosing group and summary statistics.   
Descriptive statistics for PK parameters will include the arithmetic and geometric mean (for 
Cmax, Tmax, AUC(0-24), and CL/F), CV%, SD of the arithmetic mean, median, minimum, 
maximum, and N. 


 
 
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Population PK and PK/PD models may be developed to address objectives that require an 
integrative interpretation of the study results. These include assessment of the dose 
proportionality, investigation of the nature of the PK/PD relationship, and the use of study results 
as part of a larger model-based data analysis. If population PK/PD models are developed, a 
separate Pharmacometric Analysis Plan will be written. 
11.6 Safety Analyses 
All safety summaries will be descriptive; no statistical significance tests will be performed on 
safety data and will be based on the safety population. 
Safety assessments include extent of exposure, incidence of treatment-emergent AEs, drug-
related AEs, deaths, SAEs, AEs leading to discontinuation from the study and changes in the C-
SSRS.  Changes from baseline in clinical laboratory results, ECGs and vital signs will also be 
summarized by treatment group and time point.    
At each time point, absolute values and change from baseline of each safety endpoint will be 
summarized with n, mean, SD, standard error of the mean (SEM), median, Min, and Max values. 
The number of available observations and out-of-range values (absolute and in percentage) will 
be presented. Values outside the reference range will be flagged in the listing. ‘H’ and ‘L’, 
denoting values above or below the Investigator reference range (when present), will flag out-of-
range results. 
The AE coding dictionary for this study will be Medical Dictionary for Regulatory Activities 
(MedDRA). It will be used to summarize AEs by primary system organ class (SOC) and 
preferred term (PT). 
11.7 Efficacy Analyses 
11.7.1 Primary Efficacy Endpoint 
The primary efficacy endpoint is the mean change in NAD Redox Ratio measured by 31P-MRS 
from Baseline to Week 12. 
Redox Ratio is defined as: 
• NAD Redox Ratio = mean NAD+/NADH 


 
 
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11.7.2 Exploratory Efficacy Endpoints 
Exploratory 31P-MRS imaging endpoints are as follows: 
• Regression of baseline values versus mean percentage change of the average tissue 
concentration by subject per dosing group from Baseline to Week 12 for: 
o ATP (a, b, g) 
o NAD+/NADH pool 
o Phosphocreatine (PCr) 
o Intracellular inorganic phosphate (Pi(in))  
o Extracellular inorganic phosphate (Pi(ex)) 
o Phosphoethanolamine (PE) 
o Phosphocholine (PC) 
o Glycerolphosphoethanolamine (GPE) 
o Glycerophosphocholine (GPC) 
11.7.3 Functional Exploratory Endpoints 
Exploratory analyses of Gait, Postural Stability, and Mobility are: 
• Mean change by treatment group from Baseline to Week 12 for: 
o APDM Instrumented Timed Up and Go (TUG) Test 
o APDM Instrumented Postural Sway Test 
o APDM Instrumented Walk Test 
Exploratory Measurements of Global Impression of Disease Severity and Improvement are: 
• Mean change in average difference between Baseline to Week 12 for: 
o Clinical Global Impression Scale (CGI) 
o Patient Global Impression Scale (PGI) 
Exploratory Efficacy Measurements of Disease Progression  
• Mean change in total score and sub-scales between Baseline to Week 12 for: 
o Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) 
 


 
 
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For primary and exploratory endpoints, the statistical significance comparing the result of each 
CNM-Au8 treatment versus baseline, will be reported. Statistical significance will be determined 
by two-sided paired t-tests assessed at the p ≤ 0.05 significance level.  Instrumented APDM tests 
will be performed at the Baseline and Week 12 study visits to determine the change from 
Baseline.  All analyses will be specified in the Statistical Analyses Plan. 
The Cohort 2 sample size may be re-calculated based on the mean change from baseline in 
NAD+/NADH Redox Ratio to Week 12 and standard deviation of the change from Cohort 1.  
The proportion of patients with improvement of additional secondary bioenergetic metabolites 
will be compared between treatment groups using exact test procedures.  
Primary, and exploratory efficacy analyses will be based on the intent to treat (ITT) population.  
Changes in primary and secondary efficacy parameters (e.g., 31P-MRS Redox Ratio 
[NAD+/NADH ratio], bioenergetic metabolites) will also be compared to historical age-matched 
healthy controls. 
11.8 Interim analyses 
Cohort 1 data will be analyzed prior to initiation of Cohort 2.  No other pre-specified interim 
analyses are planned per protocol. 
11.9 Data Handling and Quality Assurance 
11.9.1 Data Recording 
Limited data may be entered solely into the eCRF (e.g., ethnic group). All other data must have 
source documentation available. A source document checklist will be used at the site to identify 
the source data for all data points collected, and the study monitor will work with the site to 
complete the source documentation verification.  
11.9.2  Data Recorded From Screening Failures 
For patients who do not meet selection criteria (Screen Failures), source data will be recorded 
and entered into the eCRF, including the reason for the screen failure, and demographic 
information (e.g., patient number, date of birth/age, sex, height, weight, race and ethnicity), and 
the date of the study visit. 


 
 
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For patients classified as Screen Failures with an SAE during the Screening visit (Visit -1), the 
following additional data should be collected in the eCRF: 
• All information about the SAE 
• Other related including: 
o Concomitant medication 
o Medical history 
o Any other information needed to complete the SAE eCRF page 
11.9.3 Data Monitoring 
In accordance with applicable regulations, Good Clinical Practice (GCP), and the Sponsor’s 
and/or the Clinical Research Organization (CRO) procedures, study monitors will contact the site 
prior to the start of the study to review with the site staff the protocol, study requirements, and 
their responsibilities to satisfy regulatory, ethical, and Sponsor’s requirements. When reviewing 
data collection procedures, the discussion will also include identification and documentation of 
source data items. 
The Sponsor or its designee will visit clinical sites periodically to monitor study activity to verify 
that the: 
• Data are authentic, accurate, and complete 
• Safety and rights of patients are being protected 
• Study is conducted in accordance with the currently approved protocol (including study 
treatment being used in accordance with the protocol) 
• All other study agreements, GCP, and all applicable regulatory requirements are being 
met. 
The site Investigator and the head of the medical institution, as applicable, agree to allow the 
Sponsor and/or designated study monitors direct access to all relevant documents at the clinical 
site. 


 
 
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11.9.4 Data Collection and Management 
Data collection will be conducted via a validated electronic data collection (EDC) system, which 
will be managed by the Sponsor’s biostatistics and data management CRO.  
Patient data necessary for analysis and reporting will be entered and/or transmitted into a 
validated database or data system. Clinical data management will be performed in accordance 
with applicable Sponsor and CRO standards for data cleaning procedures. This is applicable for 
data recorded on the eCRF as well as for data from other sources (e.g., laboratory, ECG). For 
data coding (e.g., AEs, medication), internationally recognized and accepted dictionaries will be 
used.  Data will be electronically verified through use of programmed edit checks specified by 
the clinical team. Discrepancies in the data will be brought to the attention of the clinical team, 
and investigational site personnel, as applicable. Resolutions to these issues will be reflected in 
the database. An audit trail within the system will track all changes made to the data. 
11.9.5 Data Audit and Inspection 
To ensure compliance with GCP and regulatory requirements, a member of the Sponsor’s quality 
assurance unit, or designated representative, may conduct an audit to assess the performance of 
the study at the study site and of the study documents originating there. The site Investigator and 
institution will be informed of the audit outcome.  In addition, inspections by regulatory health 
authority representatives and/or IRB(s) are possible. The Investigator should notify the Sponsor 
immediately of any such inspection.  The Investigator/institution agrees to allow the auditor or 
inspector direct access to all relevant documents and to provide sufficient time and staff support 
to review any findings and any discuss any issues. Audits and inspections may occur at any time 
during or after completion of the study. 
11.9.6 Data Archiving 
Essential site documents shall be archived safely and securely in such a way that ensures that 
they are readily available upon regulatory authorities’ request.  Patient files will be archived 
according to local regulations and in accordance with the maximum period of time permitted by 
the hospital, institution or private practice associated with the study. Where the archiving 
procedures do not meet the minimum timelines required by the Sponsor, alternative 


 
 
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arrangements must be made to ensure the availability of the source documents for the required 
period. The Investigator/institution shall notify the Sponsor if the archival arrangements change 
(e.g., relocation or transfer of ownership). 
The Investigator site file is not to be destroyed without the Sponsor’s written approval. 
 
 


 
 
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12 RESPONSIBILITIES, ETHICS, AND LEGAL ASPECTS 
12.1 Investigator Responsibilities 
12.1.1 Good Clinical Practice 
The Investigator will ensure that this study is conducted in full compliance with the principles of 
the “Declaration of Helsinki” (as amended in Edinburgh, Tokyo, Venice, Hong Kong, and South 
Africa), ICH guidelines, or with the laws and regulations of the country in which the research is 
conducted, whichever affords the greater protection to the study Patient. For studies conducted 
under a United States IND, the Investigator will ensure that the basic principles of “Good 
Clinical Practice,” as outlined in 21 CFR 312, subpart D, “Responsibilities of Sponsors and 
Investigators,” 21 CFR, Part 50, 1998, and 21 CFR, Part 56, 1998, are adhered to. This study will 
be conducted in compliance with 21 CFR, Part 320, 1993, “Retention of Bioavailability and 
Bioequivalence Testing Samples.” 
12.1.2 Institutional Review Board (IRB)Approval 
The Investigator will submit this protocol and any related documents to an IRB, and the 
Competent Authority (CA) as applicable. Approval from the IRB and the statement of no 
objection from the CA must be obtained before starting the study, and should be documented in a 
dated letter/email to the Investigator, clearly identifying the study, the documents reviewed and 
the date of approval. A list of IRB members must be provided, including the functions of these 
members. If study staff were present, it must be clear that none of these persons voted. 
Modifications made to the protocol after receipt of the IRB approval must also be submitted as 
amendments by the Investigator to the IRB in accordance with local procedures and regulations. 
12.1.3 Informed Consent 
It is the responsibility of the Investigator or designee to obtain written informed consent from 
each individual participating in this study after adequate explanation of the aims, methods, 
objectives, and potential hazards of the study and prior to undertaking any study-related 
procedures.   The Investigator or designee must utilize an IRB-approved informed consent form 
(ICF) for documenting written informed consent.  Each informed consent will be appropriately 
signed and dated by the patient and the person obtaining consent.  A patient may enter the study 


 
 
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only if the patient or legal representative voluntarily agrees to sign the informed consent form.  A 
copy of the signed consent form will be provided to the patient. 
If informed consent is obtained on the date that Screening study procedures (Visit -1) are 
performed, the study record or patient’s clinical record must clearly show that informed consent 
was obtained prior to these procedures. 
If the patient is not capable of providing a signature, a verbal statement of consent can also be 
given in the presence of an impartial witness (e.g., independent of the Sponsor and the 
Investigator). This is to be documented by a signature from the informing physician as well as by 
a signature from the witness. 
The ICF and any other written information provided to patients or the patient’s legal 
representative will be revised whenever important new information becomes available that may 
be relevant to the patient’s consent, or there is an amendment to the protocol that necessitates a 
change to the content of the patient information and/or the written ICF. The Investigator will 
inform the patient or legal representative in a timely manner and will ask patients to confirm 
their participation in the study by signing the revised informed consent form. Any revised written 
informed consent form and written information must receive the IRB’s approval prior to use. 
12.1.4 Adherence to Protocol 
The Investigator may not modify or alter the procedures described in this protocol and is 
required to strictly adherence to all specifications laid down in this protocol for all aspects of 
study conduct. 
Neither the Sponsor nor the Investigator will implement protocol amendments or modifications 
to the study protocol without agreement by both parties. However, the Investigator or the 
Sponsor may implement a deviation from, or a change to the protocol to eliminate an immediate 
hazard to patients without prior IRB/Sponsor approval. In this case, the implemented deviation 
or change, the reasons for it, and if appropriate, the proposed protocol amendment should be 
submitted to the IRB/head of medical institution and Sponsor as soon as possible.  
Any deviations from the protocol must be explained and documented by the Investigator. 


 
 
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12.1.5 Confidentiality 
The Investigator must assure that patients’ anonymity will be strictly maintained and that their 
identities are protected from unauthorized parties. Only patient initials and an identification code 
(i.e., not names) should be recorded on any form submitted to the Sponsor and IRB.  The 
Investigator must keep a patient log showing codes, names, and addresses for all patients 
screened and for all patients enrolled in the study. 
12.1.6 Study Files and Retention of Records 
The Investigator must maintain adequate and accurate records to enable the conduct of the study 
to be fully documented and the study data to be subsequently verified.  These documents should 
be classified into 2 separate categories (although not limited to) the following: (1) Investigator’s 
study file, and (2) Patient clinical source documents. 
The Investigator’s study file will contain the protocol/amendments, CRF and query forms, IRB 
approval with correspondence, informed consent, drug records, staff curriculum vitae and 
authorization forms, and other appropriate documents and correspondence. 
Patient clinical source documents would include (although is not limited to) the following: 
patient hospital/clinic records, physician’s and nurse’s notes, appointment book, original 
laboratory reports, ECG, electroencephalogram (EEG), X-ray, MRI, pathology and special 
assessment reports, consultant letters, screening and enrollment log, etc. 
All clinical study documents must be retained by the Investigator until at least two years after the 
last approval of a marketing application in an International Conference on Harmonization (ICH) 
region (i.e., United States, Europe, or Japan) and until there are no pending or contemplated 
marketing applications in an ICH region; or, until two years after the IND is discontinued and 
regulatory authorities have been notified. The Investigator must notify Sponsor prior to 
destroying any clinical study records. 
Should the Investigator wish to move study records to another location, arrangements must be 
made to store these in sealed containers so that they can be returned sealed to the Investigator in 


 
 
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case of a regulatory audit.  Where source documents are required for the continued care of the 
Patient, appropriate copies should be made for storage outside of the site. 
12.1.7 Case Report Forms 
For each Patient who receives study drug, a CRF must be completed and signed (electronically 
signed if eCRF) by the Principal Investigator or sub-Investigator within a reasonable period after 
data collection.  This also applies to records for those patients who fail to complete the study.  If 
a patient withdraws from the study, the reason must be noted on the eCRF.  If a patient is 
withdrawn from the study because of a treatment-limiting adverse event, thorough efforts should 
be made to clearly document the outcome. 
12.1.8 Drug Accountability 
The Investigator or designee (i.e., pharmacist) is responsible for ensuring adequate accountability 
of all used and unused study drug. This includes acknowledgment of receipt of each shipment of 
study product (quantity and condition) and Patient dispensing records and returned or destroyed 
study product. Dispensing records will document quantities received and quantities dispensed to 
Patients, including lot/batch number, date dispensed, Patient identifier number, Patient initials, 
and the initials of the person dispensing or witnessing dispensing of the study medication. 
At study initiation, the monitor will evaluate the site’s SOP for study drug disposal/destruction in 
order to ensure that it complies with study requirements.  Following blinded study drug 
reconciliation by the monitor, the study site will be instructed by the Sponsor to return any 
unused study drug supplies returned by patients including empty containers to the investigational 
product central supply depot for storage or destruction. 
12.1.9 Inspections 
The Investigator will provide access to source documents and all study records for this study to 
appropriately qualified personnel from the Sponsor or its representatives, and to regulatory 
authority inspectors. 


 
 
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12.2 Sponsor Responsibilities 
12.2.1 Study Materials and Instructions 
It is the Sponsor’s responsibility to ensure that the Investigator is provided with the documents 
and other study materials necessary to conduct the study.  Examples of those materials include, 
but are not limited to: protocol, Investigator’s Brochure, study drug, eCRF, SAE collection 
forms, logs, etc.  The Sponsor will also provide training and oversight through site and medical 
monitoring. 
12.2.2 Protocol Modifications 
Protocol modifications, except those intended to reduce immediate risk to study patients, will be 
made by Sponsor-initiated amendment.  IRB approval must be obtained before changes can be 
implemented except for non-substantial amendments (e.g., changes in study staff or contact 
details or minor changes in the packaging or labeling of the investigational product) as described 
below. 
Administrative or logistical minor changes will require a non-substantial amendment.  Non-
substantial amendments will be approved (signed) by the Investigator(s) and will be recorded 
and filed by the Investigator/Sponsor and the Institutional Review Board (IRB) and the 
Competent Authority (CA) may or may not be notified per local regulatory guidelines.  The 
implementation of a non-substantial amendment can be done without notification or approval to 
the appropriate IRB or CA.  
The following amendments will be regarded as non-substantial: 
• Change in timing of the samples; 
• Changes in assay-type and/or institution where an assay will be performed, provided that 
validated assays will be used; 
• Editorial changes to the patient information sheets; 
• Determination of additional parameters in already collected materials, which agree with 
the study objectives and do not provide prognostic or genetic information; 
• Other statistical analyses than described in the protocol. 


 
 
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12.2.3 Insurance 
The Sponsor maintains clinical trial insurance coverage for this study in accordance with the 
laws and regulations of the country in which the study is performed. 
12.2.4 Premature Study Termination 
The Sponsor has the right to prematurely close this study or, if applicable, individual segments of 
the study, including but not limited to: treatment arms, study sites, titration steps, and study 
procedures; if at any time the risk-benefit profile of the investigational product, center conduct, 
or specific study treatment segment becomes unacceptable due to: 
• Safety findings from this study (e.g., SAEs) 
• Procedural issues or protocol violations from a study site that potentially affects patient 
safety 
• Safety findings from other parallel studies in different patient populations 
• Results from animal toxicology studies (e.g., toxicity, teratogenicity, carcinogenicity, or 
reproduction toxicity). 
12.3 Joint Investigator/Sponsor Responsibilities 
12.3.1 Access to Information for Monitoring 
In accordance with International Conference on Harmonization Good Clinical Practice (ICH-
GCP) guidelines, the study monitor must have direct access to the Investigator’s source 
documentation in order to verify the data recorded in the CRFs for consistency. 
The monitor is responsible for routine review of the CRFs at regular intervals throughout the 
study, to verify adherence to the protocol, and the completeness, consistency and accuracy of the 
data being entered on them. The monitor should have access to any patient records needed to 
verify the entries on the CRFs.  The Investigator agrees to cooperate with the monitor to ensure 
that any problems detected in the course of these monitoring visits are resolved. 


 
 
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12.3.2 Study Discontinuation 
Both the Sponsor and the Investigator reserve the right to terminate the study at any time for 
safety or medical reasons. Should this be necessary, both parties will arrange discontinuation 
procedures and notify the appropriate regulatory authorities, IRBs and HRECs.  In terminating 
the study, the Sponsor and the Investigator will assure that adequate consideration is given to the 
protection of the Patients’ interests. 
12.3.3 Study Report and Publications 
After conclusion of the study, Investigators in this study may communicate, orally present, or 
publish in scientific journals or other scholarly media only after the following conditions have 
been met: 
• The results of the study in their entirety have been publicly disclosed by or with the 
consent of Sponsor in an abstract, manuscript, or presentation form; or 
• The study has been completed for at least 2 years. 
No such communication, presentation, or publication will include Sponsor’s confidential 
information. 
Any information, inventions, or discoveries (whether patentable or not), innovations, 
suggestions, ideas, and reports, made or developed by the Investigator(s) as a result of 
conducting this study shall be promptly disclosed to the Sponsor and shall be the sole property of 
the Sponsor.  The Investigator agrees, upon the Sponsor’s request and at the Sponsor’s expense, 
to execute such documents and to take such other actions, as the Sponsor deems necessary or 
appropriate to obtain patents in the Sponsor’s name covering any of the foregoing. 
The Investigator will submit any proposed publication or presentation along with the respective 
scientific journal or presentation forum to the Sponsor at least 30 days prior to submission of the 
publication or presentation.  The Investigator will comply with Sponsor’s request to delete 
references to its confidential information (other than the study results) in any paper or 
presentation and agrees to withhold publication or presentation for an additional 60 days in order 
to obtain patent protection if deemed necessary. 
 


 
 
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13 PROTOCOL AMENDMENTS 
Summary of changes will be noted in a supplemental document submitted with the amended 
protocol to the appropriate IRB.   
 
Amendment to version 1.0 of the Protocol dated 12-February-2019 occurred on 06-March-2019 
(version 2.0). Summary of changes will be noted in a supplemental document submitted with the 
amended protocol to the appropriate IRB/HREC. These changes were implemented based off 
FDA comments and feedback issued upon their review of the clinical protocol.  
 
Amendment to version 2.0 of the protocol dated 06-March-2019 occurred on 29-March-2019 
(version 2.1). Summary of changes were noted alongside changes associated with version 2.0. 
These changes were implemented to clarify that randomization will not occur, rather, a treatment 
assignment will be assigned to each subject who qualifies for participation.  
 
 
Amendment to version 2.1 of the protocol dated 29-March-2019 occurred on 21-May-2019 
resulting in version 3.0 of the protocol. Summary of changes will be noted in a supplemental 
document submitted with the amended protocol to the appropriate IRB. Minor modifications 
were made to the imaging plan, food restriction language added surrounding drug administration, 
and updates to exploratory endpoints. A window was incorporated for specific Baseline Visit 
assessments. 
 
Amendment to version 3.0 of the protocol dated 21-May-2019 occurred on 08-July-2019 
resulting in version 4.0 of the protocol. Summary of changes will be noted in a supplemental 
document submitted with the amended protocol to the appropriate IRB. Additional assessments 
and exploratory outcomes were added surrounding patient mobility. Medical Monitor contact 
information was updated and minor changes were included throughout.  
 
Amendment to version 4.0 of the protocol dated 08-Jul-2019 occurred on 07-Aug-2019 resulting 
in version 5.0 of the protocol. Summary of changes will be noted in a supplemental document 
submitted with the amended protocol to the appropriate IRB. Changes under this amendment 


 
 
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include anxiolytic administration for all subjects undergoing 31P-MRS assessments, 
modifications to exploratory and safety endpoints, and clarifying language surrounding AE 
documentation. 
 
Amendment to version 5.0 of the protocol dated 09-Aug-2019 occurred on 09-September-2020 
resulting in version 6.0 of the protocol. Summary of changes will be noted in a supplemental 
document submitted with the amended protocol to the appropriate IRB. Changes under this 
amendment include modifications to the collection volume of PD samples, reporting of safety 
analytes and allowance for participants to remain on study drug beyond Week 12 in the event of 
site logistical issues or safety concerns surrounding the COVID-19 pandemic and allowing for 
the inclusion of up to 15 participants per cohort to be enrolled.  
 


 
 
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14 REFERENCES 
Arnerić, Stephen P., Volker D. Kern, and Diane T. Stephenson. 2018. “Regulatory-Accepted 
Drug Development Tools Are Needed to Accelerate Innovative CNS Disease 
Treatments.” Biochemical Pharmacology 151 (May): 291–306. 
https://doi.org/10.1016/j.bcp.2018.01.043. 
Camandola, Simonetta, and Mark P. Mattson. 2017. “Brain Metabolism in Health, Aging, 
and Neurodegeneration.” The EMBO Journal 36 (11): 1474–92. 
https://doi.org/10.15252/embj.201695810. 
Cantó, Carles, Keir J. Menzies, and Johan Auwerx. 2015. “NAD(+) Metabolism and the Control 
of Energy Homeostasis: A Balancing Act between Mitochondria and the Nucleus.” Cell 
Metabolism 22 (1): 31–53. https://doi.org/10.1016/j.cmet.2015.05.023. 
Chua, Christelle En Lin, and Bor Luen Tang. 2013. “Linking Membrane Dynamics and 
Trafficking to Autophagy and the Unfolded Protein Response.” Journal of Cellular 
Physiology 228 (8): 1638–40. https://doi.org/10.1002/jcp.24341. 
Dauer, William, and Serge Przedborski. 2003. “Parkinson’s Disease: Mechanisms and Models.” 
Neuron 39 (6): 889–909. 
Delgado-Camprubi, Marta, Noemi Esteras, Marc Pm Soutar, Helene Plun-Favreau, and Andrey 
Y. Abramov. 2017. “Deficiency of Parkinson’s Disease-Related Gene Fbxo7 Is 
Associated with Impaired Mitochondrial Metabolism by PARP Activation.” Cell Death 
and Differentiation 24 (12): 2210. https://doi.org/10.1038/cdd.2017.175. 
GBD 2016 Parkinson’s Disease Collaborators. 2018. “Global, Regional, and National Burden of 
Parkinson’s Disease, 1990-2016: A Systematic Analysis for the Global Burden of 
Disease Study 2016.” The Lancet. Neurology 17 (11): 939–53. 
https://doi.org/10.1016/S1474-4422(18)30295-3. 
Jia, Haiqun, Xin Li, Hongxiang Gao, Zhihui Feng, Xuesen Li, Lei Zhao, Xu Jia, Hongyu Zhang, 
and Jiankang Liu. 2008. “High Doses of Nicotinamide Prevent Oxidative Mitochondrial 
Dysfunction in a Cellular Model and Improve Motor Deficit in a Drosophila Model of 
Parkinson’s Disease.” Journal of Neuroscience Research 86 (9): 2083–90. 
https://doi.org/10.1002/jnr.21650. 
Lehmann, S., A. C. Costa, I. Celardo, S. H. Y. Loh, and L. M. Martins. 2016. “Parp Mutations 
Protect against Mitochondrial Dysfunction and Neurodegeneration in a PARKIN Model 
of Parkinson’s Disease.” Cell Death & Disease 7 (March): e2166. 
https://doi.org/10.1038/cddis.2016.72. 
Lehmann, Susann, Samantha H. Y. Loh, and L. Miguel Martins. 2017. “Enhancing NAD+ 
Salvage Metabolism Is Neuroprotective in a PINK1 Model of Parkinson’s Disease.” 
Biology Open 6 (2): 141–47. https://doi.org/10.1242/bio.022186. 
Ocampo, Alejandro, Jingjing Liu, and Antoni Barrientos. 2013. “NAD+ Salvage Pathway 
Proteins Suppress Proteotoxicity in Yeast Models of Neurodegeneration by Promoting 
the Clearance of Misfolded/Oligomerized Proteins.” Human Molecular Genetics 22 (9): 
1699–1708. https://doi.org/10.1093/hmg/ddt016. 
Olanow, C. W., K. Kieburtz, and R. Katz. 2017. “Clinical Approaches to the Development of a 
Neuroprotective Therapy for PD.” Experimental Neurology 298 (Pt B): 246–51. 
https://doi.org/10.1016/j.expneurol.2017.06.018. 


 
 
CNMAu8.202 Protocol (6.0) 
09-Sep-2020 
 
Clene Nanomedicine, Inc. 
- Confidential & Proprietary - 
Page 135 of 135 
 
Plotegher, Nicoletta, and Michael R. Duchen. 2017. “Crosstalk between Lysosomes and 
Mitochondria in Parkinson’s Disease.” Frontiers in Cell and Developmental Biology 5: 
110. https://doi.org/10.3389/fcell.2017.00110. 
Plotegher, Nicoletta, Chiara Stringari, Sohail Jahid, Marina Veronesi, Stefania Girotto, Enrico 
Gratton, and Luigi Bubacco. 2015. “NADH Fluorescence Lifetime Is an Endogenous 
Reporter of α-Synuclein Aggregation in Live Cells.” FASEB Journal: Official 
Publication of the Federation of American Societies for Experimental Biology 29 (6): 
2484–94. https://doi.org/10.1096/fj.14-260281. 
Posner, Kelly, Gregory K. Brown, Barbara Stanley, David A. Brent, Kseniya V. Yershova, Maria 
A. Oquendo, Glenn W. Currier, et al. 2011. “The Columbia-Suicide Severity Rating 
Scale: Initial Validity and Internal Consistency Findings from Three Multisite Studies 
with Adolescents and Adults.” The American Journal of Psychiatry 168 (12): 1266–77. 
https://doi.org/10.1176/appi.ajp.2011.10111704. 
Puspita, Lesly, Sun Young Chung, and Jae-Won Shim. 2017. “Oxidative Stress and Cellular 
Pathologies in Parkinson’s Disease.” Molecular Brain 10 (1): 53. 
https://doi.org/10.1186/s13041-017-0340-9. 
Schöndorf, David C., Dina Ivanyuk, Pascale Baden, Alvaro Sanchez-Martinez, Silvia De Cicco, 
Cong Yu, Ivana Giunta, et al. 2018. “The NAD+ Precursor Nicotinamide Riboside 
Rescues Mitochondrial Defects and Neuronal Loss in IPSC and Fly Models of 
Parkinson’s Disease.” Cell Reports 23 (10): 2976–88. 
https://doi.org/10.1016/j.celrep.2018.05.009. 
Schwab, Andrew J., Samantha L. Sison, Michael R. Meade, Katarzyna A. Broniowska, John A. 
Corbett, and Allison D. Ebert. 2017. “Decreased Sirtuin Deacetylase Activity in LRRK2 
G2019S IPSC-Derived Dopaminergic Neurons.” Stem Cell Reports 9 (6): 1839–52. 
https://doi.org/10.1016/j.stemcr.2017.10.010. 
Sison, Samantha L., and Allison D. Ebert. 2018. “Decreased NAD+ in Dopaminergic Neurons.” 
Aging 10 (4): 526–27. https://doi.org/10.18632/aging.101433. 
Thirtamara-Rajamani, Keerthi, Peipei Li, Martha L. Escobar Galvis, Viviane Labrie, Patrik 
Brundin, and Lena Brundin. 2017. “Is the Enzyme ACMSD a Novel Therapeutic Target 
in Parkinson’s Disease?” Journal of Parkinson’s Disease 7 (4): 577–87. 
https://doi.org/10.3233/JPD-171240. 
Villanueva-Paz, Marina, David Cotán, Juan Garrido-Maraver, Manuel Oropesa-Ávila, Mario de 
la Mata, Ana Delgado-Pavón, Isabel de Lavera, Elizabet Alcocer-Gómez, Mónica 
Álvarez-Córdoba, and José A. Sánchez-Alcázar. 2016. “AMPK Regulation of Cell 
Growth, Apoptosis, Autophagy, and Bioenergetics.” EXS 107: 45–71. 
https://doi.org/10.1007/978-3-319-43589-3_3. 
Zhu, Xiao-Hong, Ming Lu, Byeong-Yeul Lee, Kamil Ugurbil, and Wei Chen. 2015. “In Vivo 
NAD Assay Reveals the Intracellular NAD Contents and Redox State in Healthy Human 
Brain and Their Age Dependences.” Proceedings of the National Academy of Sciences of 
the United States of America 112 (9): 2876–81. https://doi.org/10.1073/pnas.1417921112. 
 

SAP_001.pdf: 
TITLE PAGE 
 
 
 
 
STUDY NUMBER CNMAu8.202 
 
 
REPAIR-PD 
 
 
A PHASE 2, OPEN LABEL, SEQUENTIAL GROUP, INVESTIGATOR 
BLINDED STUDY OF MAGNETIC RESONANCE SPECTROSCOPY (31P-
MRS) TO ASSESS THE EFFECTS OF CNM-Au8 FOR THE BIOENERGETIC 
IMPROVEMENT OF IMPAIRED NEURONAL REDOX STATE IN 
PARKINSON’S DISEASE (PD) 
 
 
NCT:03815916 
 
 
RELEASE DATE: 19MAY2021  
 


 
STATISTICAL ANALYSIS PLAN 
 
STUDY NUMBER CNMAu8.202 
 
 
REPAIR-PD 
A PHASE 2, OPEN LABEL, SEQUENTIAL GROUP, INVESTIGATOR BLINDED 
STUDY OF MAGNETIC RESONANCE SPECTROSCOPY (31P-MRS) TO ASSESS 
THE EFFECTS OF CNM-Au8 FOR THE BIOENERGETIC IMPROVEMENT OF 
IMPAIRED NEURONAL REDOX STATE IN PARKINSON’S DISEASE (PD) 
 
 
 
 
 
Document version: 
Final v1 
Release date: 
19May2021 
Protocol: 
CNMAu8.202 
Prepared by: 
 
Instat Clinical Research 
Shelia Ligozio 
Principal Biostatistician 
 
 
DocuSign Envelope ID: 5A70C948-E7BB-4EA7-8820-393EA1B54E36


Clene Nanomedicine, Inc. 
 
Statistical Analysis Plan 
Protocol CNMAu8.202 
 
Final 19May2021 
This study will be conducted in compliance with the Protocol, Good Clinical Practice and all other 
applicable regulatory requirements, including the archiving of essential documents. 
DOCUMENT HISTORY 
 
Version 
Number 
Author 
Date  
Change 
V0.1 
S. Ligozio 
04May2021 
new 
V1 
S.Ligozio 
19May2021 
Final, incorporating sponsor 
comments from 207 SAP, added 
descriptive statistical testing to 
PGI/CGI 
 
 
 
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Statistical Analysis Plan 
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Signature Page 
 
STUDY NUMBER CNMAu8.202 
 
REPAIR-PD 
A PHASE 2, OPEN LABEL, SEQUENTIAL GROUP, INVESTIGATOR BLINDED 
STUDY OF MAGNETIC RESONANCE SPECTROSCOPY (31P-MRS) TO ASSESS 
THE EFFECTS OF CNM-Au8 FOR THE BIOENERGETIC IMPROVEMENT OF 
IMPAIRED NEURONAL REDOX STATE IN PARKINSON’S DISEASE (PD) 
 
Author: 
Shelia Ligozio 
Principal Statistician 
Instat Clinical Research 
 
Signature:___________________________ 
 
Date:_______________________________ 
 
Sponsor Representatives: 
Austin Rynders 
Senior Director, Clinical Operations  
Clene Nanomedicine, Inc. 
Signature:__________________________ 
 
Date:______________________________ 
Robert Glanzman 
Chief Medical Officer 
Clene Nanomedicine, Inc.  
Signature:__________________________ 
 
Date:______________________________ 
Michael Hotchkin 
Chief Development Officer 
Clene Nanomedicine, Inc. 
Signature:__________________________ 
 
Date:______________________________ 
 
 
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Clene Nanomedicine, Inc. 
 
Statistical Analysis Plan 
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Final 19May2021 
TABLE OF CONTENTS 
 
1. 
Introduction ........................................................................................................................................7 
1.1 Study Design ......................................................................................................................................... 7 
1.2 Study Objectives .................................................................................................................................. 9 
2. 
Study Populations..............................................................................................................................9 
3. 
Statistical Methodology ....................................................................................................................9 
3.1 Determination of Sample Size ..................................................................................................... 10 
3.2 Handling of Missing Data .............................................................................................................. 10 
3.3 Subject Characteristics .................................................................................................................. 11 
3.3.1 Disposition ................................................................................................................................................................... 11 
3.3.2 Demographics and Baseline Characteristics .................................................................................................... 11 
3.3.3 Parkinson’s Disease History and Medical History ......................................................................................... 11 
3.3.4 Prior and Concomitant Medications .................................................................................................................... 12 
3.4 Efficacy Analyses .............................................................................................................................. 12 
3.4.1 Primary Efficacy Endpoint ..................................................................................................................................... 13 
3.4.2 Secondary Efficacy Endpoints .............................................................................................................................. 13 
3.4.3 Exploratory Efficacy Endpoints ........................................................................................................................... 13 
3.5 Pharmacokinetic and Pharmacodynamic Endpoints ......................................................... 16 
3.6 Safety Analyses ................................................................................................................................. 16 
3.6.1 Extent of Exposure .................................................................................................................................................... 17 
3.6.2 Adverse Events ........................................................................................................................................................... 17 
3.6.3 Clinical Laboratory Tests ........................................................................................................................................ 18 
3.6.4 Physical Examinations ............................................................................................................................................. 18 
3.6.5 Vital Signs .................................................................................................................................................................... 18 
3.6.6 Electrocardiogram ..................................................................................................................................................... 18 
3.6.7 Columbia Suicide Severity Rating Scale ........................................................................................................... 19 
4. 
Interim Analysis ............................................................................................................................. 19 
5. 
Tables, Listings, Figures ............................................................................................................... 19 
6. 
REFERENCES............................................................................................................................... 20 
 
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GLOSSARY AND ABBREVIATIONS 
Abbreviation 
Definition 
31P-MRS 
31P Magnetic Resonance Spectroscopy 
ACS 
Abnormal clinically significant 
ADP 
Adenosine Diphosphate 
AE 
Adverse event 
APDM 
Ambulatory Parkinson’s Disease Monitoring 
ANCS 
Abnormal not clinically significant 
ATP 
Adenosine Trinucleotide Phosphate 
ATP (avg) 
ATP average 
Au 
Gold 
AUC [0-24] 
Area under the plasma concentration-time curve for 24 hours 
BL 
Baseline 
BMI 
Body Mass Index 
C-SSRS 
Columbia Suicide Severity Rating Scale 
Cmax 
Maximum observed plasma concentration 
CGI 
Clinician Global Impression 
CNS 
Central Nervous System 
CSF 
Cerebral spinal fluid 
CSR 
Clinical Study Report 
ECG 
Electrocardiogram 
EOS 
End of study 
GPC 
Glycerophosphocholine 
GPE 
Glycerolphosphoethanolamine 
ITT 
Intent-to-treat 
MDS-UPDRS 
Movement Disorders Society – Unified Parkinson’s Disease Rating Scale  
MedDRA 
Medical Dictionary for Regulatory Activities 
NAD 
Nicotinamide adenine dinucleotide 
NAD+ 
Oxidized form of nicotinamide adenine dinucleotide 
NADH 
Reduced form of nicotinamide adenine dinucleotide 
PC 
Phosphocholine 
PCr 
Phosphocreatine 
PD 
Parkinson’s Disease 
PDE 
Phosphodiesters 
PDF 
Portable document file 
PE 
Phosphoethanolamine 
PGI 
Patient Global Impression 
PME 
Phosphomonoesters 
PI(t) 
Total Inorganic phosphate 
PI(in) 
Intracellular inorganic phosphate 
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Statistical Analysis Plan 
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Abbreviation 
Definition 
PI(ex) 
Extracellular inorganic phosphate 
PK 
Pharmacokinetic 
SAE 
Serious adverse event 
SAP  
Statistical analysis plan 
SD 
Standard deviation 
SEM 
Standard error of the mean 
TEAE 
Treatment-emergent adverse event 
Tmax 
Time to reach Cmax 
TUG 
Timed Up and Go 
UDPG 
Uridine diphosphate glucose 
UPDRS 
Unified Parkinson’s Disease Rating Scale 
WHO 
World Health Organization 
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Statistical Analysis Plan 
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1. 
Introduction 
The purpose of this statistical analysis plan (SAP) is to ensure that the statistical methodologies 
implemented in Protocol CNMAu8.202 (Repair-PD) are complete and appropriate, allowing for 
valid conclusions regarding the study objectives. Results obtained from the analyses outlined in 
this document will be included in the final clinical study report (CSR) for this protocol.  Any 
deviations from this SAP will be documented in the final CSR. 
The pharmacokinetic (PK), pharmacodynamic, and ambulatory Parkinson’s Disease monitoring 
(APDM) data will be analyzed outside of this SAP. Therefore, analyses planned for these data will 
be described in a separate analysis plan.    
1.1 
Study Design 
This is a single-center open label, sequential group, investigator-blinded study of the central 
nervous system (CNS) metabolic effects, safety, pharmacokinetics, and pharmacodynamics of 
CNM-Au8 in subjects who have been diagnosed with Parkinson’s Disease (PD) within three years 
of their screening visit. Subjects will be screened over a 6-week period. Subjects who meet the 
inclusion criteria and none of the exclusion criteria will be enrolled into the clinical study. 
This study will consist of up to two treatment cohorts, with each cohort consisting of up to fifteen 
subjects. Both cohorts will share identical study schedules (See Table 1).  Investigators and 
subjects will remain blinded to the study dose. The Sponsor may choose to discontinue the study 
following the completion of the first cohort. In the case that two cohorts are conducted, each will 
be analyzed separately following the completion of each respective cohort.  
The primary efficacy outcome measure will be assessed based upon data obtained at each subject’s 
final treatment period study visit (originally planned as the Visit 4, Week 12 study visit). Due to 
the ongoing COVID-19 pandemic, some participants may remain on study treatment for greater 
than 12 weeks, if Institutional restrictions or safety concerns prevent the completion of the planned 
visits per the study schedule (see Table 1). At the end of the study, subjects will complete an end 
of study (EOS) visit four weeks following their last study visit before exiting the study. All subjects 
who are discontinued from treatment will be asked to complete an EOS assessment. Participants 
who electively terminate their participation prior to completion of the 12-week visit will be asked 
to return for an abbreviated EOS visit 4-weeks following their last dose of study medication.  All 
subjects will receive once daily oral treatment over twelve consecutive weeks during the treatment 
period.  
There will be three study periods per treatment cohort: 
(1) A 6-week screening period (Screening Period); 
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(2) A 12-week treatment period (Treatment Period); 
(3) A 4-week follow-up period (End-of-Study Assessment). 
The visit schedule is shown in Table 1 below. 
Table 1. Time and Events Schedule 
Time 
and 
Events 
Schedule 
Visit 
-1 
0 
1 
2 
3 
4 
5 
Phase 
Screening 
Baseline 
Treatment Period 
EOS 
Week 
-6 
0 
2 
4 
8 
12 
16 
Day  
-42 to -1 
1a 
14 a 
28 a 
56 a 
84 a 
112 b 
ICF Signed 
X 
 
 
 
 
 
 
Eligibility Review  
X 
X 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
ConMed/Prior Med Assessment  
X 
X 
X 
X 
X 
X 
X 
Physical Examination 
X 
X 
 
X 
X 
X 
X 
Height Assessment 
X 
 
 
 
 
 
 
Weight Assessment 
X 
X 
 
 
 
X 
 
Urine Drug Test 
X 
 
 
 
 
 
 
HIV/Viral Hepatitis Screen  
X 
 
 
 
 
 
 
Serum Pregnancy Test c 
X 
 
 
 
 
 
 
Urine Pregnancy Test c 
 
X 
 
X 
X 
X 
 
Vital Signs 
X 
X 
 
X 
X 
X 
X 
12-lead ECG d 
X 
X 
 
X 
X 
X 
X 
Clinical Laboratory (Blood) 
X 
X 
 
X 
X 
X 
X 
Urinalysis 
X 
X 
 
X 
X 
X 
X 
MMSE 
X 
 
 
 
 
 
 
Treatment Assignment 
 
X 
 
 
 
 
 
Dispense/Return Drug 
 
X 
 
X 
X 
X 
 
PK Sampling (Whole Blood)  
 
 
 
Xe 
Xe 
Xf 
Xe 
PD Sampling (Whole Blood, Plasma) 
 
Xe  
 
Xe 
Xe 
Xe 
 
CSF Sampling (optional) 
 
X 
 
 
 
X 
 
Adverse Events 
X 
X 
X 
X 
X 
X 
X 
Anxiolytic Administration 
 
X 
 
 
 
X 
 
31P-MRS 
 
X 
 
 
 
X 
 
MDS-UPDRS 
 
X 
 
X 
X 
X 
 
PGI 
 
X 
 
X 
X 
X 
 
CGI  
 
X 
 
X 
X 
X 
 
C-SSRS 
X 
X 
X 
X 
X 
X 
X 
APDM Instrumented Tests 
 
X 
 
 
 
X 
 
Phone call 
 
 
X 
 
 
 
 
a. 
Scheduled Visit ± 4 days for Visit 1-4. For Visit 0 (Baseline), the 31P-MRS and PD CSF assessments may be 
completed over a -7 day window prior to Day 1. All assessments must be completed prior to administration of 
first study drug dose. 
b. Timing for the EOS assessment should occur at four weeks (±3 days) from last dose regardless of early 
termination or completion of the trial. 
c. 
For females of child bearing potential only. 
d. Electrocardiogram (ECG) intervals will be summarized and presented descriptively. ECG rhythm will be 
interpreted by the Investigator as normal (N), abnormal not-clinically significant (aNCS), or abnormal clinically 
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significant (aCS). Triplicate values will be collected at Baseline and averaged for comparison to single 
assessments at subsequent visits. 
e. 
Whole blood for PK and PD will be taken pre-dose only (~1 hour prior to the dose of study drug).  
f. 
Whole blood for PK will be taken at pre-dose (T0) and at 1, 2, 4, and 6 hours after dosing for the visit.  The 
exact time at which the patient took his/her previous day’s study drug dose must be recorded in order to impute 
a 24-hour trough value (T24-imputed). 
1.2 
Study Objectives 
To assess the CNS metabolic profile and safety of CNM-Au8 for the treatment of PD: 
 Metabolic effects will be assessed as an improvement of 31P-MRS assessment of brain 
tissue ratio of oxidized form of nicotinamide adenine dinucleotide/reduced form of 
nicotinamide adenine dinucleotide (NAD+/NADH) concentrations and various additional 
bioenergetic and phospholipid membrane markers. 
 Safety will be assessed via adverse events, serious adverse events, discontinuations due to 
adverse events, and changes in the Columbia Suicide Severity Rating Scale (C-SSRS), 
clinical laboratory results, and vital signs.  
2. 
Study Populations 
The following analysis populations are to be used for this study:  
 Intent to Treat Population (ITT) – The Intent to Treat population will consist of all screened 
subjects who were assigned a treatment assignment number.  
 Safety Population – The Safety population will consist of subjects in the ITT population 
who received at least one dose of study drug.  
 Per Protocol Treatment Population – The Per Protocol Treatment population will consist 
of subjects in the Safety population who have completed at least 12 weeks of treatment, 
have Week 12 31P-MRS measurements, and who have an overall treatment compliance 
between 80-120%. Participants remaining on treatment longer than 12 weeks due to the 
COVID-19 pandemic who return to the Institution for completion of the Week 12 visit 
outside the specified visit window will be included in this population.  
3. 
Statistical Methodology 
All study data will be presented in listings, tables and/or figures.  Continuous variables will be 
summarized using descriptive statistics (i.e., mean, standard deviation (SD), minimum, median, 
and maximum).  Categorical variables will be summarized using frequency counts and 
percentages. 
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Statistical Analysis Plan 
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All summaries, statistical analyses, and individual subject data listings described below will be 
performed using Version 9.3 or later of the SAS Statistical Analysis System (SAS Institute, Inc. 
Cary, NC).  A study-wise Type I error (alpha) of 0.05 will be used for the study. P-values will be 
2-sided and descriptive in nature.  
Reporting precision in the tables will be to one decimal place for percentages and typically one 
decimal place more than the precision of the variable when collected/reported for the mean and 
median. The SD will be presented to one decimal place more than the mean, and the minimum and 
maximum will be presented to the same precision as the reported value or follow the mean/median 
precision if derived. Missing values will not be considered in percentage calculations, unless stated 
otherwise.  In these cases, footnotes will specify the percentage denominator definition, or the 
denominator used will be presented with the summary. P-values will be presented to 4 decimal 
points. If a p-value is less than or equal to 0.0001, it will be reported as <0.0001. The table shells 
will specify if there is a deviation from the precision noted here. Data listings will be sorted by 
subject, dose level, and visit (if applicable). Tables, listings, and figures will be in portable 
document format (PDF) files.  
Baseline will be defined as the last non-missing measurement prior to dosing. Repeated or 
unscheduled assessments will not be summarized in the tables unless they are part of a baseline 
derivation, a worst value summary, or the scheduled assessment is missing/invalid, in which case 
the first non-missing post-baseline value after the scheduled assessment will be used for data 
analysis.  
3.1 
Determination of Sample Size 
Ren et. al. assessed the feasibility of repeated 31P-MRS scans in a cohort of 7 healthy volunteers 
(aged 55.7 ± 6.2 years) at UT Southwestern with scans approximately two weeks apart 
(unpublished data, Ren et al. 2019). The ratio of the NAD+/NADH baseline average value for the 
healthy volunteer cohort was 4.09 ± 0.78, while the repeat 31P-MRS assessment was 4.11 ± 0.79. 
The standard deviation of the difference from baseline to week 2 was 0.28, while the coefficient 
of variation was 5.8% ± 4.8%, demonstrating consistent 31P-MRS NAD+/NADH reproducibility.  
For sample size estimates, assuming a common SD of 0.42 for the change from Baseline to Week 
12, an evaluable sample size of 11 patients per cohort will have 80% power to detect a mean 
difference of 0.41 (e.g., approximately 10% change versus baseline).  Allowing for up to two drop-
out per cohort (~15%) brings the planned sample size to at least 13 participants per cohort.  
3.2 
Handling of Missing Data 
Incomplete dates will be imputed as follows:  
If the incomplete date is a start/onset date:  
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(1) if the month and year are present, then the first day of the month will be used for day.  
(2) if only the year is present, then the first day of January will be used for month and day.  
If the incomplete date is an end date:  
(1) if the month and year are present, then the last day of the month will be used for day.  
(2) if only the year is present, then the last day of December will be used for month and day.  
If the reported year is the same as the informed consent year and the imputed date is invalid using 
the rules above (no day or month), then the informed consent date will be used.  
Missing dates will not be imputed. 
Missing data will not be imputed for endpoints, and data will be summarized at the visits reported 
in the database. Drop-outs (i.e., those participants without post-baseline 31P-MRS scan data) will 
not be imputed and will not be included in the 31P-MRS efficacy analyses for the Per Protocol 
Treatment population. 
3.3 
Subject Characteristics 
3.3.1 Disposition 
Subject disposition will be summarized by treatment on all subjects. The number of screen failures, 
assigned treatment, included in each population, completing the study and discontinuing from the 
study as well as the reasons for discontinuation will be presented. Disposition will be presented in 
data listings.  
3.3.2 Demographics and Baseline Characteristics 
Demographic data such as age, gender, race, ethnicity, height, weight, body mass index (BMI), 
and childbearing potential, will be summarized by treatment and presented in data listings. 
Demographic summaries will be presented for ITT, Per Protocol Treatment, and Safety 
populations.  
3.3.3 Parkinson’s Disease History and Medical History 
Parkinson’s Disease and medical history are collected during the screening visit.  
The age at diagnosis of PD, the number of years since onset of symptoms, the diagnostic criteria 
(presence of resting tremor, bradykinesia, rigidity, and response to dopaminergic therapy), length 
of dopaminergic therapy and whether the dopaminergic therapy was stable in the last 6 weeks will 
be summarized on the ITT, Per Protocol Treatment, and Safety populations. 
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Medical history will be coded using Medical Dictionary of Regulatory Activities (MedDRA) 
version 21.0. Medical history will be presented in a data listing. 
3.3.4 Prior and Concomitant Medications 
Medications taken before and during the study will be coded using the World Health Organization 
(WHO) Drug Dictionary Global B3 March 2021. Incomplete dates will be imputed (See Section 
3.2). If a medication started and ended before the first dose of study drug, then it is considered a 
prior medication. Medications that are ongoing at or started after the first dose of study drug are 
considered concomitant medications. All medications will be presented in a data listing.  
3.4 
Efficacy Analyses 
31P-MRS scans will be performed at the baseline and Week 12 visits. Because Week 12 31P-MRS 
scans may have been delayed due to COVID-19 related research restrictions, they will be 
considered for the Week 12 primary endpoint regardless of the actual timing.   
The 31P-MRS NAD+/NADH ratio is measured by a partial volume coil that images the parietal and 
occipital lobes as a single value with respect to the fraction (%) of the nicotinamide adenine 
dinucleotide (NAD) signal measured as either the oxidized (NAD+) or reduced form (NADH).  All 
other 31P-MRS reported data are measured by a full volume coil (e.g., whole brain coil, bird cage 
coil) with reported values consisting of the means for all evaluable voxels (approximately 600 
voxels at 2 cm3).  
The primary endpoint is the mean change from baseline to Week 12 in the ratio of NAD+ to NADH 
(NAD+/NADH) on the Per Protocol Treatment population. Secondary endpoints include the mean 
change from baseline to Week 12 from the partial volume coil for the fraction (%) of NAD+, and 
the fraction (%) of NADH. 
The exploratory endpoints include additional measures of brain bioenergetics and brain membrane 
component precursors as measured by 31P-MRS, the Movement Disorders Society Unified 
Parkinson’s Disease Rating Scale (MDS-UPDRS), APDM measurements of gait, balance, and 
mobility, and patient and clinician reported outcomes will be assessed by global impression (CGI 
and PGI).  
All efficacy analyses will be conducted on the Intent to Treat and Per Protocol Treatment 
populations. All efficacy parameters will be presented in data listings. 
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3.4.1 Primary Efficacy Endpoint  
The primary efficacy endpoint is the mean change in the average NAD+/NADH brain ratio from 
baseline to Week 12 using the partial volume coil 31P-MRS data on the Per Protocol Treatment 
Population. A paired t-test will be used to analyze the mean change from baseline.  
3.4.2 Secondary Efficacy Endpoints 
The secondary efficacy endpoints using the partial volume coil 31P-MRS data are the mean change 
in the NAD+ brain fraction (%) from baseline to Week 12 and the mean change in the NADH 
brain fraction (%) from baseline to Week 12. A paired t-test will be used to analyze the mean 
change from baseline for each endpoint. Secondary Efficacy Endpoints will be assessed heirchially 
with NAD+ brain fraction (%) followed by NADH brain fraction (%). 
3.4.3 Exploratory Efficacy Endpoints 
3.4.3.1 
31P-MRS Markers of Brain Bioenergetics and Membrane Component Precursors 
Exploratory analyses will include:  (i) regression of the percent changes at the end of study 
compared to the baseline values, and (ii) mean change from baseline (BL) to end of treatment 
(Week 12), as follows: 
 
Regression of the mean change in average tissue concentration as measured by 31P-MRS 
(a) full volume coil and (b) partial volume coil peak area (integral of peak signal area) by 
metric for the treatment group, for the percent (%) change from BL to Week 12 (end of 
treatment) compared to the BL subject values.  
 
Mean change in average tissue concentration as measured by 31P-MRS (a) full volume coil 
and (b) partial volume coil peak area (integral of peak signal area) by metric for the 
treatment group for the mean change from baseline and percent (%) change from baseline 
to Week 12.  
The regression analyses, along with percent changes from baseline to Week 12, will be presented 
for the following phosphorous metabolites and phosphorous indices: 
 NAD(u) (i.e., combined NAD+, NADH pool, including uridine diphosphate glucose 
(UDPG) overlap)  
 Alpha () adenosine trinucleotide phosphate (ATP)  
 Gamma () ATP  
 Beta () ATP  
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 Intracellular inorganic phosphate (Pi (in)) 
 Extracellular inorganic phosphate (Pi (ex)) 
 Phosphoethanolamine (PE) 
 Phosphocholine (PC) 
 Glycerolphosphoethanolamine (GPE) 
 Glycerophosphocholine (GPC) 
 Uridine diphosphate glucose 
Phosphocreatine (PCr) is used as a normalization factor for each 31P-MRS imaged voxel and will 
be reported as a value of one (1) for all participants and not analyzed. 
The following variables will be calculated programmatically based on the 31P-MRS coil reported 
metrics described above: 
 NAD(only): NAD signal only, defined as NAD(u) less UDPG 
 Phosphomonoesters (PME): defined as the sum of PC + PE 
 Phosphodiesters (PDE): defined as the sum of GPE + GPC 
 Average ATP (ATP(avg)): defined as the average of alpha, beta, and gamma ATP 
 PC/PE ratio: defined as the ratio of PC to PE 
 Pi(in)/Pi(ex) ratio: defined as the ratio of Pi(in) to Pi(ex) 
 Total inorganic phosphorous (Pi(t)): defined as the sum of Pi(in) + Pi(ex) 
 Energy Consumption Index1: defined as Pi(t) divided by ATP(avg) 
 Energy Consumption Index2: defined as Pi(ex) divided by ATP(avg) 
 Membrane Phospholipid Index: defined as PME divided by PDE 
 pH will be calculated as pkA + log10 [(Pi(in) [for the PPM value only] – Da)/(Db - Pi(in))], 
where the constants pKA = 6.75, Da=3.27, Db = 5.63  
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 Adenosine diphosphate (ADP) (M) will be calculated as 0.15085/ ((1.66*10^9) * 
(1*10^(0-pH)))*1000*2.8 
Values will also be reported and analyzed for each phosphorous metabolite described above for:  
 Average mean change and percent change from Baseline to Week 12 for the Magnitude of 
each phosphorous peak (e.g., the maximum height of the phosphorous peak)  
 Average mean change and percent change from Baseline to Week 12 for the PPM shift 
3.4.3.2 MDS-UPDRS 
The MDS-UPDRS will be collected at baseline and Weeks 4, 8, and 12. The Unified Parkinson's 
Disease Rating Scale (UPDRS) is a rating tool used to gauge the course of Parkinson’s disease in 
patients.  The UPDRS is composed of four parts: part I assesses behavioral problems; part II 
assesses patients' perceptions of their ability to carry out activities of daily living; part III covers 
the motor evaluation of disability; part IV covers treatment complications.  
The change from baseline for the total score and each part of the MDS-UPDRS will be 
summarized. A paired t-test will be used to test for differences. 
3.4.3.3 APDM Measurements of Gait, Balance, and Mobility 
APDM Mobility Lab and wearable Opal sensors will be utilized to assess for gait abnormalities 
and postural instability, conditions that worsen with disease severity and can both be used as 
indicators of fall risk. Assessments include a Timed Up and Go (TUG) test, a 2-Minute Walk test, 
and in Instrumented Postural Sway test conducted with both eyes open and eyes closed.  
APDM assessments are performed at baseline and Week 12. Changes from baseline will be 
summarized post-hoc in a separate statistical analysis plan.  
3.4.3.4 Patient Global Impression Scale 
The PGI of severity will be performed at baseline, Weeks 4, 8, and 12.  Subjects will mark the 
response that best describes their symptoms at each visit and their change from baseline.  
Frequencies and percentages will be used to summarize the responses for each visit by dose. 
Additionally, the change from baseline will be summarized. The severity responses will be 
numbered sequentially: 0=Normal, 1=Mild, 2=Moderate, 3=Severe. The change responses will be 
numbered such that any positive or negative change will be evident: 3=Very much better, 2=Much 
better, 1=A little better, 0=No change, -1=A little worse, -2=Much worse, -3=Very much worse. 
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The PGI severity responses will be analyzed using a paired t-test. The PGI change responses will 
be analyzed using a one sample t-test. 
3.4.3.5 Clinical Global Impression Scale 
The CGI severity will be performed at baseline, Weeks 4, 8, and 12, and the CGI of change will 
be performed on the post-baseline visits. The severity scale is a measure of the subject against the 
clinician’s patient population.  
The results will be presented using frequencies and percentages by visit. Additionally, the change 
from baseline will be summarized. The severity responses will be numbered sequentially: 
0=Normal, not at all, 1=Borderline ill, 2=Mildly ill, 3=Moderately ill, 4=Markedly ill, 5=Severely 
ill, 6=Among the most extremely ill patients. The change responses will be numbered such that 
any positive or negative change will be evident: 3=Very much improved, 2=Much improved, 
1=Minimally improved, 0=No change, -1=Minimally worse, -2=Much worse, -3=Very much 
worse. The CGI severity responses will be analyzed using a paired t-test. The CGI change 
responses will be analyzed using a one sample t-test. 
3.5 
Pharmacokinetic and Pharmacodynamic Endpoints 
Samples for the measurement of whole blood concentrations of gold (Au) will be collected before 
(pre-dose) administration of the investigational drug product during the Week 4, 8, 12, and EOS 
visits.  At the Week 12 visit, whole blood for PK will be taken at 1, 2, 4, and 6 hours after dosing 
as well. The data will be used to construct a composite whole blood concentration-time profile for 
the Week 12 visit over the treatment period. The Week 12 data will be used to estimate the 
maximum observed plasma concentration (Cmax) of Au and time (Tmax) and the area under the 
curve over the 24-hour dosing interval (AUC [0-24]). The 24-hour trough value will be imputed.  
Samples for the measurement of pharmacodynamic data will be collected before (pre-dose) study 
drug administration at the baseline visit and following the PK collection during the Week 4, 8, and 
12. An optional cerebrospinal fluid or cerebral spinal fluid (CSF) collection at the baseline (pre-
dose) and Week 12 visit. 
Summaries and analyses on these data will be described in a separate analysis plan. 
3.6 
Safety Analyses 
Safety summaries will be descriptive and performed on the Safety population. No statistical 
comparisons will be performed.  
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Safety assessments include extent of exposure, incidence of adverse events (AE), clinical 
laboratory results, physical examinations, vital signs, electrocardiogram results (ECG), and 
Columbia Suicide Severity Rating Scale. All safety parameters will be presented in data listings. 
3.6.1 Extent of Exposure 
The duration of treatment will be summarized by dose. Treatment duration will be derived as 
follows:  Date of Last Dose – Date of First Dose +1. 
If the date of last dose is missing, then it will be imputed to the last available date of study visit.  
Study duration will also be summarized and is defined as the total number of days in the study 
(date of last visit – date of informed consent +1). 
Compliance will also be summarized at each visit and overall by dose. Drug accountability will be 
collected at Weeks 4, 8, and 12. Subjects are expected to consume 2 bottles per day. Therefore, 
the expected number of used bottles will be calculated for each subject based on the number of 
days between each visit (current visit date - previous visit date + 1). Compliance at each visit will 
be derived as follows: (Number of Used Bottles/2 x number of days between each visit) x 100. 
The overall compliance will be the total number of used bottles divided by the total number of 
expected used bottles multiplied by 100. For participants who remain on their assigned treatment 
longer than 12-weeks due to ongoing safety or Institutional restrictions related to COVID-19, 
overall compliance will include all unscheduled study drug dispensations.  
3.6.2 Adverse Events 
Adverse events will be collected throughout the study and coded using MedDRA version 21.0. A 
treatment emergent adverse event (TEAE) is defined as any event that starts on or after the first 
dose of study drug.  
An overall summary of adverse events will be tabulated for:   
 the number of subjects with an adverse event 
 the total number of adverse events 
 the number of subjects with TEAEs 
 the number of subjects with TEAEs related to study drug 
 the number of subjects with deaths due to a TEAE 
 the number of subjects with serious adverse events (SAE) that are treatment emergent 
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 the number of subjects with a TEAE leading to discontinuation of study drug 
Treatment emergent adverse events will be summarized by system organ class and preferred term 
for each dose. Related TEAEs, SAEs, TEAEs leading to discontinuation, and TEAEs by severity 
(mild, moderate, severe) will also be summarized by system organ class and preferred term.  
Subjects with more than one event in a system organ class will be counted once within the class 
and once for each preferred term. Subjects with more than one event with the same preferred term 
will be counted once, and if the summary is by severity, the subject’s most severe event will be 
counted.   
3.6.3 Clinical Laboratory Tests 
Laboratory tests will be assessed at screening, baseline, and Weeks 4, 8, 12, and 16 (EOS). Tests 
with numeric results for hematology, chemistry, and urinalysis will be summarized using 
descriptive statistics (number of subjects, mean, SD, standard error of the mean (SEM), median, 
minimum, and maximum) for each visit by dose. Tests with subjective results will be displayed in 
data listings only.   
Table summaries will be presented for observed and change from baseline values. Values flagged 
as Low, Normal, Abnormal, or High using the laboratory reference ranges will be summarized 
using shift tables comparing the Week 4 – 12 and EOS values to baseline.  
3.6.4 Physical Examinations 
A full physical examination will be performed at screening, baseline, and Weeks 4, 8, 12, and 16 
(EOS). Clinically significant findings during a physical examination after the baseline visit will be 
reported as adverse events. Results from the physical examinations will be presented in a data 
listing. 
3.6.5 Vital Signs 
Vital signs will be measured at screening, baseline, and Weeks 4, 8, 12, and 16 (EOS). Observed 
and change from baseline values for systolic and diastolic blood pressure, pulse rate, respiration 
rate, and temperature will be summarized using descriptive statistics (n, mean, SD, median, 
minimum, and maximum) for each visit by dose. 
3.6.6 Electrocardiogram 
12-Lead ECG will be measured at screening, baseline, and Weeks 4, 8, 12, and 16 (EOS). The 
baseline measurements will be performed in triplicate and the values averaged for summary. The 
worst response for the Investigator’s interpretation of the ECG will be used in the baseline 
summary, and a shift table will be used to present the changes from baseline to each post baseline 
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visit. Observed and change from baseline values for the numeric parameters will be summarized 
using descriptive statistics (n, mean, SD, median, minimum, and maximum) by dose for each visit.  
3.6.7 Columbia Suicide Severity Rating Scale 
The C-SSRS will be given at baseline, Weeks 4, 8, 12 and 16 (EOS). The post screening 
assessments will be in relation to how they feel in comparison to their last visit. The results will 
be listed.   
4. 
Interim Analysis 
No formal interim analysis will be performed. In the case that two cohorts are conducted, each will 
be analyzed separately following the completion of each respective cohort. 
5. 
 Tables, Listings, Figures 
A table of contents for the tables, listings, and figures will be presented in a separate document as 
the list of summaries or numbering may change after finalization of this document. If additional 
summaries are added that are not described in this document, then this SAP will be amended, or 
an addendum will be created. 
  
 
 
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Statistical Analysis Plan 
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6. 
REFERENCES 
There are no references for this document.  
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