Clinical trial NCT03488524
Conditions: Amyotrophic Lateral Sclerosis ALS
Sponsor: Amylyx Pharmaceuticals Inc.
Start date: 2018-03-29; Completion date: 2021-03-01
Enrollment: 90 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
This extension study, in which all participants received active treatment (AMX0035), was designed to assess the longer-term safety and therapeutic potential of AMX0035 for participants who have completed the Main Study (AMX3500, also known as CENTAUR).

Detailed description:
The Centaur Open Label Extension Study (CENTAUR-OLE) is an extension study for patients with ALS who participated in the CENTAUR study (Study AMX3500). During the OLE, all participants received active treatment (AMX0035), and the investigators, evaluators, and participants remained blinded to the randomized treatment assigned at the beginning of the double-blind main study. The study was designed to assess the longer term safety and therapeutic potential of AMX0035.

Arms: arm 1: AMX0035 twice daily--a combination of Sodium Phenylbutyrate (3g) and Taurursodiol (1g)
Interventions: intervention 1: AMX0035
Intervention descriptions: intervention 1: Combination therapy of PB and TURSO

Protocol documents:
SAP_002.pdf: 
CONFIDENTIAL 
Amylyx Pharmaceuticals, Inc. 
Integrated Analysis of Protocols # AMX3500 and AMX3500-OLE 
Evaluation of the Safety, Tolerability, Efficacy and Activity of AMX0035,  
a Fixed Combination of Phenylbutyrate (PB) and Taurursodiol (TURSO), 
for Treatment of Amyotrophic Lateral Sclerosis (ALS)  
Version 1
Statistical Analysis Plan for Survival 
March 27, 2020 
Prepared by: 
© 2020 
 
 


CONFIDENTIAL 
Amylyx Pharmaceuticals, Inc. 
Integrated Analysis of Protocols # AMX3500 and AMX3500-OLE 
Statistical Analysis Plan for Survival 
March 27, 2020 
Version 1
Prepared by: 
 
Author: 
 
Date: 
 
 
 
 
 
Author: 
Date: 
 
 
 
 
 
Approved by: Amylyx Pharmaceuticals, Inc. 
 
 
 
Date: 
 
 
 
 
 
 
 


AMYLYX PROTOCOL #AMX3500-OLE: STATISTICAL ANALYSIS PLAN FOR SURVIVAL 
March 27, 2020 
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CONFIDENTIAL 
Contents
1. Introduction ....................................................................................................................................... 1
2. Summary of study design and treatment ...................................................................................... 1
3. Objectives of the Statistical Analysis Plan..................................................................................... 2
4. Randomization and masking considerations ............................................................................... 2
4.1.
Randomization ........................................................................................................................ 2
4.2.
Masking ................................................................................................................................... 3
5. General conventions and statistical considerations ..................................................................... 3
5.1.
Baseline .................................................................................................................................... 3
5.2.
Data sources ............................................................................................................................ 4
5.3.
Changes to planned analyses ................................................................................................ 4
6. Survival analyses .............................................................................................................................. 4
6.1.
Survival outcomes .................................................................................................................. 5
6.1.1.
Main analysis: Death ................................................................................................ 5
6.1.2.
Supportive analysis: Death or death equivalent ................................................... 7
6.2.
Covariates ................................................................................................................................ 8
6.3.
Details of the Cox proportional hazard model ................................................................... 9
6.4.
Sensitivity analyses .............................................................................................................. 10
7. References ........................................................................................................................................ 11


AMYLYX #AMX3500: STATISTICAL ANALYSIS PLAN FOR SURVIVAL 
March 27, 2020 
Page ii 
CONFIDENTIAL 
Abbreviations
ALS 
Amyotrophic Lateral Sclerosis 
ALSFRS-R 
ALS Functional Rating Scale - Revised
CRF
case report form 
CSR 
clinical study report
FS 
functional score
del-FS
delta-FS 
HR 
hazard ratio
ICH 
International Conference on Harmonization 
ITT
intent-to-treat 
OLE 
open label extension 
PAV 
permanent assisted ventilation 
PB
Phenylbutyrate 
SAP 
statistical analysis plan 
 
 
TURSO 
Taurursodiol 
 
 


AMYLYX PROTOCOL #AMX3500-OLE: STATISTICAL ANALYSIS PLAN FOR SURVIVAL 
March 27, 2020 
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1. 
Introduction 
This statistical analysis plan (SAP) is based on Amylyx Pharmaceutical’s Protocols AMX3500 
and AMX3500-OLE, “Evaluation of the Safety, Tolerability, Efficacy and Activity of AMX0035, 
a Fixed Combination of Phenylbutyrate (PB) and Taurursodiol (TURSO), for Treatment of 
Amyotrophic Lateral Sclerosis (ALS)”, dated January 11, 2019. This SAP focuses specifically on 
analyses of survival from the time of randomization in Protocol AMX3500 (“main study”, also 
referred to as “CENTAUR”) through the open label extension (“OLE”) period up to a cutoff 
date of February 29, 2020. This document is complementary to the main OLE SAP [1].  
The statistical principles applied in the design and planned analyses of this study are 
consistent with the ICH guidelines E9 (Statistical Principles for Clinical Trials) [2]. 
This document will focus on the outcomes and specifications relevant to analyses of survival 
through the cutoff date of February 29, 2020. Detailed descriptions of study design and other 
analyses appear in the main study SAP [3] and the OLE SAP. If there are discrepancies for 
survival analyses between this SAP and previously written analysis plans, the analyses in this 
SAP supersede those in previous documents.  
2. 
Summary of study design and treatment 
ALS is a progressive neurodegenerative disease that has no cure. The disease exacts a 
significant economic burden. There are only two medications approved specifically for 
treating ALS: Rilutek (riluzole), which only provides a modest benefit for subjects, and 
Radicava (edaravone).  
AMX3500 was a Phase II, multicenter, randomized, double-blind, placebo-controlled 
evaluating the safety, tolerability, efficacy, pharmacokinetics and biological activity of 
AMX3500 in subjects with Amyotrophic Lateral Sclerosis (ALS).  
Subjects were randomly assigned in a 2:1 ratio to oral (or feeding tube) AMX0035 treatment (1 
sachet= 3g PB and 1g TURSO plus excipients) or matching placebo. For the first three weeks of 


AMYLYX PROTOCOL #AMX3500-OLE: STATISTICAL ANALYSIS PLAN FOR SURVIVAL 
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CONFIDENTIAL 
dosing, subjects were to take one sachet daily (i.e. half-dose) which, if tolerated, increased to 
two sachets daily. Subjects were to remain on treatment until the Week 24 visit. An Open 
Label Extension (OLE) study was available to those subjects who completed the randomized, 
double-blind study. The duration of the OLE is 132 weeks. In the open label extension study 
all subjects received active therapy.  
If a subject did not enroll in the extension, they were requested to complete a Final Telephone 
Interview 28 days (+ 5 days) after last dose of study drug to assess for adverse events (AEs), 
changes in concomitant medications and to administer the ALSFRS-R. 
3. 
Objectives of the Statistical Analysis Plan 
The analyses in this SAP are meant to support the objectives of the protocol through a 
comparison of the survival of the two treatment groups from the time of randomization in the 
main study until February 29, 2020. Survival is defined in two ways:  
 
Death alone – all cause mortality 
 
Death or death equivalent, also referred to as the “combined survival” outcome. The 
“death equivalent” outcome is comprised of: 
 
Tracheostomy 
 
Permanent assisted ventilation (PAV), defined as more than 22 hours daily of 
non-invasive mechanical ventilation for more than one week (7 days).  
4. 
Randomization and masking considerations 
4.1. 
Randomization 
The randomization assignments for this analysis were the same as for the main CENTAUR 
study: 
 
Original Placebo group, defined as those patients who were randomized to placebo 
in the main study whether or not they continue into the extension 
 
Original Active group, defined as those patients who were randomized to AMX0035 
in the main study whether or not they continue into the extension. 


AMYLYX PROTOCOL #AMX3500-OLE: STATISTICAL ANALYSIS PLAN FOR SURVIVAL 
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A status table and/or by-subject listing will summarize subjects who withdrew during the 
main study and those who did not enter OLE, as well as their status as of February 29, 2020. 
4.2. 
Masking 
The authors of this complementary SAP do not have any access to the raw study data, analysis 
datasets, or the study database. Furthermore, although the subjects who have entered the OLE 
are all receiving active treatment, the authors are masked to the originally assigned treatment 
groups in the main study and have no access to any individual-level treatment group data. 
The SAP authors will continue to remain masked until the document is finalized.  
5. 
General conventions and statistical considerations 
General statistical procedures will follow those in the main SAPs. All analyses described in 
this plan are considered a priori analyses in that they have been defined prior to the authors of 
the SAP being unblinded to any raw data and to individual treatment assignments. All other 
analyses, if any, defined subsequent locking the survival database will be considered post-hoc 
analyses and will be applied using exploratory methodology. The Clinical Study Report will 
identify all post-hoc analyses as such. 
Throughout this analysis plan, the phrase “by treatment regimen” will be understood to mean 
the two originally assigned groups from the main study protocol. 
All significance testing will be two-tailed using  = 0.05. Tests will be declared statistically 
significant if the calculated p-value is  0.05.  
5.1. 
Baseline 
Two baselines are used in the OLE: the baseline from the randomized phase of the trial, and 
the baseline from the OLE portion of the study. The applicable baseline for survival analyses is 
the former: the baseline from the randomized phase of the trial, or “study baseline”. Unless 
otherwise noted, baseline is defined as the last non-missing measurement before 
randomization. 


AMYLYX PROTOCOL #AMX3500-OLE: STATISTICAL ANALYSIS PLAN FOR SURVIVAL 
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Baseline age, baseline ALSRS-R, and del-FS, the rate of disease progression prior to entering 
the study, will be covariates in the survival analysis. 
5.2. 
Data sources 
Three sources of data will contribute to the analyses. 
1. Main study data: a cleaned, locked CRF database from the main CENTAUR study. 
2. OLE data: An interim snapshot of the OLE’s database; data collection and monitoring will 
be ongoing. 
3. Survival sweep data: an independent assessment of vital status which will capture updated 
data on deaths and corresponding death dates through February 29, 2020. 
5.3. 
Changes to planned analyses 
Changes to the analyses described in this plan will be fully documented in a revised version of 
the plan prior to locking the study database and conducting the survival analyses. Changes 
made after locking both the OLE snapshot and survival sweep databases will be described in 
the clinical study report and characterized as “exploratory”. 
6. 
Survival analyses 
Survival analyses will use the intent-to-treat population, i.e. all 137 randomized subjects. 
The analysis will include all events captured in the three data sources from study start through 
February 29, 2020. 
The analysis will include all subjects, i.e., those who, up through February 29, 2020: 
 
Died during the main study period 
 
Died during the OLE up to and including February 29, 2020 
 
Withdrew or were lost to follow-up 
 
Did not enroll in the OLE. 
Outside of the vital status follow-up activities listed in the protocol, which included searches 
of public records for vital status, Amylyx is currently conducting a separate, comprehensive 


AMYLYX PROTOCOL #AMX3500-OLE: STATISTICAL ANALYSIS PLAN FOR SURVIVAL 
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CONFIDENTIAL 
vital status “sweep” assessment for each randomized subject through February 29, 2020. The 
assessment will include those subjects who withdrew or were lost to follow-up at any time 
prior to this date, as well as those who did not enroll in the OLE. The organization conducting 
the assessment estimates identifying the vital status of 95% subjects in a trial, meaning the 
survival sweep will likewise identify the updated vital status (alive or dead) for approximately 
95% of the original study population. As a result, the analysis for survival outcomes will adopt 
an administrative censoring approach with a cutoff date of February 29, 2020. Amylyx chose 
this date because it is Rare Disease Day [4] and prior to the rapid increase in cases of COVID-
19 in the United States. 
A table will show the concordance between deaths identified in the CRF databases and those 
identified in the survival sweep. 
6.1. 
Survival outcomes 
6.1.1. 
Main analysis: Death 
The main analysis will compare time to death between the two treatment regimens. The date 
of death will initially be recorded on the CRF. The vital status sweep may capture additional 
deaths and associated death dates through the cut-off date of February 29, 2020. Some of these 
additional deaths may have previously been recorded as alive or lost to follow-up. For the 
analysis of survival defined by death alone, the following conventions will apply: 
 
The vital status sweep may capture additional deaths for those who were previously 
recorded as alive or lost to follow-up on the CRF. The analysis will use the updated 
death status and dates of death from the survival sweep if they occur before 
February 29, 2020. 
 
If a date of death from the vital status sweep and a death from either CRF database 
conflict, the date of death from the survival sweep will be used as the definitive date 
if occurs before February 29, 2020. 
 
The OLE snapshot may capture death dates that are later than February 29, 2020. In 
these cases, subjects will be considered alive for the analysis and censored on 
February 29, 2020. 


AMYLYX PROTOCOL #AMX3500-OLE: STATISTICAL ANALYSIS PLAN FOR SURVIVAL 
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CONFIDENTIAL 
 
Otherwise, surviving subjects who were not recorded as having died during the 
analysis period will be censored on February 29, 2020  
 
Survival time = (earliest date of death or censoring -randomization date) + 1. 
The median duration of survival and the associated 95% confidence interval will be estimated 
overall using the Kaplan-Meier method.  
The hazard ratio of death comparing the Original Active group to the Original Placebo group 
will be estimated using a Cox proportional hazards model (proc phreg in SAS and coxph() in 
R) with treatment and covariates of del-FS, baseline ALSFRS-R, and age at baseline. Inference 
for treatment effect adjusted for the model covariates will use the likelihood ratio test, which 
has been shown to be more stable for smaller sample sizes and extreme data situations and 
was referenced in the previous main study and open label extension SAP [5]. When the sample 
size is large, the likelihood ratio test will give results similar to those of the Wald test, which is 
the proc phreg default. Because the likelihood ratio test is not produced by default in SAS or R 
for model estimates, the analysis will need to run two models to calculate the likelihood ( ) 
for: 
 
A full model with treatment and the three covariates 
 
A reduced model with del-FS, baseline ALSFRS-R, and age at baseline (no 
treatment). 
If the coefficient for treatment in the full model is , then the hypothesis 
: 
= 0 can be tested 
by comparing the likelihoods of the full and reduced models, which are considered nested 
models. The likelihood ratio test statistic for the treatment effect adjusted for the model 
covariates is the difference between -2×log likelihood for the reduced model and -2×log 
likelihood for the full model, or 2[log (  
)
log (  
)]. Under 
, this test statistic is 
2 with 1 degree of freedom.  
The analysis will use the Efron likelihood for handling ties, which is the default method in R’s 
coxph(). The Breslow likelihood, which is the default in SAS’s proc phreg, may be biased in the 
presence of heavy ties. 


AMYLYX PROTOCOL #AMX3500-OLE: STATISTICAL ANALYSIS PLAN FOR SURVIVAL 
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Figures for the Kaplan-Meier estimates and the hazard function will be presented showing the 
survival of Original Active and Original Placebo subjects, in addition to hazard ratios and 
Wald p-values for each covariate.  
6.1.2. 
Supportive analysis: Death or death equivalent 
A supportive analysis will compare time to death or death equivalent between the two 
treatment regimens. Death and death equivalent events will be tabulated by treatment 
regimens. As mentioned in Section 5.2, the data for death equivalent events will be recorded in 
the locked CENTAUR database and an interim snapshot of the OLE’s database. The OLE 
database will still be undergoing data collection at the time of the data snapshot for analysis. 
For death equivalent events: 
 
Tracheostomy: analyses will use the recorded date of tracheostomy as the event date. 
 
PAV: defined as more than 22 hours daily of non-invasive mechanical ventilation for 
more than one week (7 days). The date of onset of PAV is the first day of the seven 
days. 
For the analysis of the combined survival defined by death or equivalent, the following 
conventions will apply: 
 
The vital status sweep may capture additional deaths for those who were previously 
recorded as alive or lost to follow-up. The analysis will use the updated death status 
and dates of death from the survival sweep. 
 
If a date of death from the vital status sweep and a death from either CRF database 
conflict, the date of death from the survival sweep will be used as the definitive date. 
 
The OLE snapshot may capture death dates or death equivalent dates that are later 
than February 29, 2020. In these cases, subjects will be considered alive for the 
analysis and censored on February 29, 2020.  
 
It is possible that some of the participants who were lost to follow-up or who did not 
enter the OLE experienced a death equivalent event after they were no longer being 
followed. Such events will likely not appear in any of the data sources; the analysis 


AMYLYX PROTOCOL #AMX3500-OLE: STATISTICAL ANALYSIS PLAN FOR SURVIVAL 
March 27, 2020 
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CONFIDENTIAL 
will assume that these subjects did not have a death equivalent event in this period 
and will assume a censoring date of February 29, 2020. 
 
Subjects who are determined to be alive from the survival sweep, but who are 
recorded as having a death equivalent event in either CRF database prior to February 
29, 2020, will be considered as having a death equivalent event in the analysis. 
 
Surviving subjects who were not recorded as experiencing death, tracheostomy, or 
PAV during the analysis period will be censored on February 29, 2020.  
 
Survival time = (earliest of death date, tracheostomy date, or PAV date as defined 
above – randomization date) + 1. 
The median duration of the combined survival endpoint and the associated 95% confidence 
interval will be estimated overall using the Kaplan-Meier method.  
The hazard ratio of death or equivalent comparing the Original Active group to the Original 
Placebo group will be estimated using a Cox proportional hazards model (proc phreg in SAS 
or coxph() in R) with treatment and covariates of del-FS, baseline ALSFRS-R, and age at 
baseline. Inference for treatment effect adjusted for the model covariates will use the 
likelihood ratio test as described above in section 6.1.1. 
Figures for the Kaplan-Meier estimates and the hazard function will be presented showing the 
survival of Original Active and Original Placebo subjects in addition to hazard ratios and p-
values for each covariate.  
6.2. 
Covariates 
The covariates of baseline ALSFRS-R, baseline age, and del-FS will enter the Cox models as 
covariates.  
“Del-FS”, short for “delta-FS”, is the rate of disease progression prior to entering the trial. As a 
measure of decline in the subject since symptom onset, del-FS is measured at the baseline visit. 
Del-FS = (48 – ALSFRS-R at first available visit)/ time in months from symptom onset to first 
available visit.  


AMYLYX PROTOCOL #AMX3500-OLE: STATISTICAL ANALYSIS PLAN FOR SURVIVAL 
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6.3. 
Details of the Cox proportional hazard model 
Details of the Cox model are adapted from the main AMX3500 SAP. 
The Cox model is expressed by the hazard function denoted by h(t). The hazard function can 
be interpreted as the risk of dying at time t, which can be estimated as follows: 
( ) =
( ) × exp (
+
+
+
). 
 
t represents the survival time; 
 
h(t) is the hazard function determined by a set of covariates (x1, x2, x3, and x4); 
 
the coefficients (b1, b2, b3, and b4) measure the impact (i.e., the effect size) of the 
covariates; 
 
x1 represents treatment (active-active or placebo-active); 
 
x2 represents del-FS; 
 
x3 represents age at baseline; 
 
x4 represents ALSFRS-R at baseline 
 
the term ho(t), which is called the baseline hazard, corresponds to the value of the 
hazard function if all x values are equal to zero. 
The quantiles exp(bi) are called hazard ratios (HR). A value of bi greater than zero, or 
equivalently a hazard ratio greater than one, indicates that as the value of the ith covariate 
increases, the event hazard increases and the length of survival decreases. A hazard ratio 
above 1 indicates a covariate that is positively associated with the event probability and 
therefore negatively associated with the length of survival. 
The hazard ratio will be examined to determine how the active treatment influenced the 
hazard. 
 
HR=1: No effect; 
 
HR<1: Active treatment reduces the hazard  
 
HR>1: Active treatment increases the hazard 


AMYLYX PROTOCOL #AMX3500-OLE: STATISTICAL ANALYSIS PLAN FOR SURVIVAL 
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6.4. 
Sensitivity analyses 
Sensitivity analyses will include the following models for the outcomes of death and combined 
survival (death and equivalent): 
 
Analysis using a Cox proportional hazards model with treatment and covariates of 
del-FS and baseline age (as specified in the original main study SAP). 
 
Analysis using a Cox proportional hazards model with only treatment (no covariate).  


AMYLYX PROTOCOL #AMX3500-OLE: STATISTICAL ANALYSIS PLAN FOR SURVIVAL 
March 27, 2020 
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CONFIDENTIAL 
7. 
References 
1. 
Statistical Analysis Plan, AMX3500-OLE, Amylyx Pharmaceuticals, Inc.; October 2019 v3. 
2. 
International Conference on Harmonization of Technical Requirements for Registration 
of Pharmaceuticals for Human Use. Statistical principles for clinical trials (E9). 
International Conference on Harmonization; 1998. 
3. 
Statistical Analysis Plan, AMX3500, Amylyx Pharmaceuticals, Inc.; October 2019 v3. 
4. 
https://www.rarediseaseday.org/article/about-rare-disease-day
5. 
Hsieh, FY. A Cautionary Note on the Analysis of Extreme Data with Cox Regression. 
The American Statistician, May 1995, Vol. 49, No. 2, 1995. 
 

SAP_003.pdf: 
Protocols: AMX3500 (includes AMX3500-0LE) 
Protocol Date and Version: Mar 2020 v7 
Amylyx Pharmaceuticals, Inc 
Survival SAP Addendum 
Page 1 of 4 
Amylyx Pharmaceuticals, Inc. 
Integrated Analysis of Protocols # AMX3500 and AMX3500-
0LE Evaluation of the Safety, Tolerability, Efficacy and 
Activity of AMX0035, a Fixed Combination of 
Phenylbutyrate (PG) and Taurursodiol (TURSO), for 
Treatment of Amyotrophic Lateral Sclerosis (ALS) 
Version 1.0 
Addendum to Statistical Analysis Plan for Survival 
August 26, 2020 
Prepared by: 


Protocols: AMX3500 (includes AMX3500-0LE) 
Protocol Date and Version: Mar 2020 v7 
Amylyx Pharmaceuticals, Inc 
Survival SAP Addendum 
Page 2 of 4 
Integrated Analysis of Protocols # AMX3500 and AMX3500-
0LE Evaluation of the Safety, Tolerability, Efficacy and 
Activity of AMX0035, a Fixed Combination of 
Phenylbutyrate (PG) and Taurursodiol (TURSO), for 
Treatment of Amyotrophic Lateral Sclerosis (ALS) 
By signing below, all parties accept that the analysis methods and data 
presentations are acceptable and that this document is final. 
Prepared By: 
Reviewed/ Approved By: 
Reviewed/ Approved By: 
Date 
August 28, 2020 
Date 
16:00:17 04'00' 


Protocols: AMX3500 (includes AMX3500-0LE) 
Protocol Date and Version: Mar 2020 v7 
1. Introduction 
Amylyx Pharmaceuticals, Inc 
Survival SAP Addendum 
Page 4 of4 
This addendum to the survival statistical analysis plan (SAP) contains details of differences 
between the initial interim survival analysis (interim analysis 1) and the present analysis 
(interim analysis 2). The initial interim analysis was designed to provide the FDA with survival 
information in support of the initial data generated from AMX3500. The second interim 
analysis, of which relevant differences are outlined below, is required to provide survival data 
corresponding to the first 24 weeks of the AMX open label extension (OLE) data 
(AMX35000LE). We anticipate a final follow-up analysis (described at a later date) will be 
required once the last patient completes the OLE. This is not a stand-alone document but should 
be read together with the protocol (AMX3500 v7) and the AMX3500 survival SAP (v1.0). 
2. Analysis Addendum 
The survival analysis outlined in AMX3500 survival SAP (v1.0) will be performed with the 
following changes. 
1) The cutoff date for the present analysis will be changed from February 29, 2020 
(AMX3500 interim analysis 1) to July 20, 2020 (AMX3500 OLE interim analysis 2). 
2) The 
 data at the cut-off outlined above will be used for all individuals in 
the study, with the exception of two individuals. These individuals were identified to 
be out of the country and do not have 
 data available, thus EDC data will 
be used for these individuals and the last EDC date available will be used as the 
censoring cutoff date. 


Protocols: AMX3500 (includes AMX3500-0LE) 
Protocol Date and Version: Mar 2020 v7 
Modification History 
Unique Identifier 
Date ofthe 
Document 
for this Version 
Version 
1.0 
26 August 2020 
Author 
Amylyx Pharmaceuticals, Inc 
Survival SAP Addendum 
Page 3 of4 
Significant 
Changes from 
Previous 
Authorized 
Version 
Not Applicable-
First Version 

Prot_000.pdf: 
AMX-0035 in ALS 
Protocol Number: AMX3500 
Version 7.0 
Version date 30Mar2020 
Page 1 of 102 
Evaluation of the Safety, Tolerability, Efficacy and Activity of AMX0035, a Fixed 
Combination of Phenylbutyrate (PB) and Tauroursodeoxycholic Acid (TUDCA), for 
Treatment of Amyotrophic Lateral Sclerosis (ALS) 
Regulatory Sponsor: 
Amylyx Pharmaceuticals Inc. 
Funding Sponsor: 
Amylyx Pharmaceuticals Inc. 
Study Product: 
AMX0035 
Protocol Number: 
AMX3500 
IND Number: 
129563 
Draft or Version Number: 
7.0 
30 Mar 2020 
The information contained herein is confidential and proprietary in nature, and will not be 
disclosed to any third party without written approval of authorized designee. 
This document may be disclosed to the appropriate institutional review boards or to duly 
authorized representatives of the US Food and Drug Administration or a national 
regulatory authority under the condition that they maintain confidentiality.  
. 


AMX-0035 in ALS 
Protocol Number: AMX3500 
Version 7.0 
Version date 30Mar2020 
Page 2 of 102 
STATEMENT OF COMPLIANCE 
This study will be conducted in compliance with the protocol, International Conference on 
Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use 
(ICH), Good Clinical Practice (GCP), and the applicable regulatory requirements, United States 
Code of Federal Regulations (CFR) Title 45 CFR Part 46 and Title 21 CFR Parts 50, 56, and 
312.


AMX-0035 in ALS 
Protocol Number: AMX3500 
Version 7.0 
Version date 30Mar2020 
Page 3 of 102 
SIGNATURE PAGE 
I have read the attached protocol entitled, Evaluation of the Safety, Tolerability, Efficacy and 
Activity 
of 
AMX0035, 
a 
Fixed 
Combination 
of 
Phenylbutyrate 
(PB) 
and 
Tauroursodeoxycholic Acid (TUDCA), for Treatment of Amyotrophic Lateral Sclerosis 
(ALS) dated March 30, 2020 (Version 7.0) and agree to abide by all described protocol 
procedures.  I agree to comply with the International Conference on Harmonisation Tripartite 
Guideline on Good Clinical Practice, applicable FDA regulations and guidelines identified in 21 
CFR Parts 11, 50, 54, and 312, Institutional Review Board (IRB) and local institutional 
guidelines and policies, and the Health Insurance Portability and Accountability Act (HIPAA). 
Site Investigator: 
Signed: 
Date: 


AMX-0035 in ALS 
Protocol Number: AMX3500 
Version 7.0 
Version date 30Mar2020 
Page 4 of 102 
TABLE OF CONTENTS 
STATEMENT OF COMPLIANCE ···························································································· 2 
SIGNATURE PAGE ·············································································································· 3 
LIST OF ABBREVIATIONS ···································································································· 8 
PROTOCOL SUMMARY ····································································································· 10 
SCHEDULE OF ACTIVITIES ································································································ 13 
STUDY WORKFLOW ········································································································· 15 
1 
ETHICS/PROTECTION OF HUMAN SUBJECTS ······························································· 16 
1.1 
INSTITUTIONAL REVIEW BOARD (IRB) ··············································································· 16 
1.2 
ETHICAL CONDUCT OF STUDY ························································································· 16 
1.3 
SUBJECT INFORMATION AND CONSENT ··············································································· 16 
2 
INTRODUCTION: BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE ·············· 17 
2.1 
BACKGROUND INFORMATION ·························································································· 17 
2.1.1 
ALS Overview ············································································································· 17 
2.1.2 
AMX0035 Rationale ······································································································ 17 
2.1.3    Prior Clinical Use of PB and TUDCA in Subjects with ALS ··························································· 18 
2.1.4 
Additional Previous Clinical Experience with Phenylbutyrate ······················································ 21 
2.1.5 
Additional Previous Clinical Experience with TUDCA ······························································ 25 
2.1.6   Previous Clinical Experience with Ursodiol (UDCA) ···································································· 30 
2.2 
POTENTIAL RISKS AND BENEFITS ····················································································· 31 
2.2.1 
Potential Risks ············································································································· 31 
2.2.2 
Known Potential Benefits ································································································· 33 
3 
OBJECTIVES ············································································································· 34 
3.1 
STUDY OBJECTIVES ····································································································· 34 
3.2 
STUDY OUTCOME MEASURES ························································································· 34 
3.2.1 
Primary Outcome Measures ······························································································ 34 
3.2.2 
Secondary Outcome Measures ··························································································· 35 
4 
STUDY DESIGN ·········································································································· 36 
4.1 
OVERALL STUDY DESIGN AND PLAN ················································································ 36 
4.2 
STUDY CENTERS ········································································································ 36 
4.3 
STUDY DURATION ······································································································ 36 
4.4 
PROTOCOL ADHERENCE ······························································································ 36 
5 
STUDY ENROLLMENT AND WITHDRAWAL ·································································· 37 
5.1 
NUMBER OF STUDY SUBJECTS ······················································································· 37 
5.2 
INCLUSION AND EXCLUSION CRITERIA ············································································· 37 
5.2.1 
Inclusion Criteria ········································································································· 37 
5.2.2 
Exclusion Criteria ·········································································································· 38 
5.3 
TREATMENT ASSIGNMENT PROCEDURES ············································································· 41 


 
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Version 7.0 
Version date 30Mar2020 
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5.3.1 
Randomization Procedures ······························································································· 41 
5.4. 
REASONS FOR WITHDRAWAL······················································································· 41 
5.4.1 
Handling of Withdrawals ······························································································· 42 
5.5 
TERMINATION OF STUDY ······························································································· 43 
6 
TREATMENTS ADMINISTERED ··················································································· 44 
6.1 
TREATMENTS ············································································································ 44 
6.1.1 
Study Product Description ································································································ 44 
6.1.2 
Placebo ······················································································································ 45 
6.2 
ACQUISITION ············································································································· 46 
6.2.1 
Formulation, Packaging, and Labeling ·············································································· 46 
6.2.2 
Product Storage and Stability ························································································· 46 
6.2.3 
Dispensing Product ······································································································ 46 
6.3 
DOSAGE, PREPARATION AND ADMINISTRATION OF STUDY INTERVENTION/INVESTIGATIONAL PRODUCT
 
47 
6.3.1  
Feeding Tube Study Drug Administration ············································································· 48 
6.4 
MODIFICATION OF STUDY INTERVENTION/INVESTIGATIONAL PRODUCT FOR A SUBJECT ················ 48 
6.4.1. 
Dosage Discontinuation ································································································· 48 
6.5 
STUDY DRUG ACCOUNTABILITY PROCEDURES ··································································· 49 
6.6 
ASSESSMENT OF SUBJECT COMPLIANCE ··········································································· 49 
6.7 
PRIOR AND CONCOMITANT THERAPY ······································ ERROR! BOOKMARK NOT DEFINED. 
6.7.1 
Prohibited Medications and Contraindications ···································································· 50 
7 
STUDY SCHEDULE ····································································································· 52 
7.1 
MR-PET SCHEDULING CALL ························································································ 52 
7.2 
SCREENING VISIT ······································································································ 52 
7.2.1 
Screen Failures ············································································································ 53 
7.3 
MR-PET VISIT 1 (ONLY FOR PATIENTS IN MR-PET SUBSTUDY) ·············································· 53 
7.4 
BASELINE VISIT ········································································································ 54 
7.5 
WEEK 3 CLINIC VISIT ································································································· 55 
7.6 
WEEK 6 CLINIC VISIT ································································································· 55 
7.7 
WEEK 9 TELEPHONE VISIT ··························································································· 55 
7.8 
WEEK 12 CLINIC VISIT ································································································ 56 
7.9 
WEEK 15 PHONE VISIT ································································································ 56 
7.10 
WEEK 18 CLINIC VISIT ······························································································ 57 
7.11 
WEEK 21 PHONE VISIT ······························································································ 57 
7.12 
MR-PET VISIT 2 (ONLY FOR PATIENTS IN MR-PET SUBSTUDY) ·········································· 57 
7.13 
FINAL STUDY VISIT (WEEK 24) ·················································································· 58 
7.14 
FINAL FOLLOW-UP TELEPHONE CALL (WEEK 28) ···························································· 58 
7.15 
WITHDRAWAL OF CONSENT FINAL SAFETY VISIT & FINAL FOLLOW-UP TELEPHONE CALL ········· 59 
7.16 
PROTOCOL DEVIATIONS ··························································································· 59 
7.16.1 
Missed Visits and Procedures ···························································································· 59 
7.17 
RECORDING DEATHS ······························································································· 60 
8 
CLINICAL ASSESSMENTS AND OUTCOME MEASURES ·················································· 61 
8.1 
CLINICAL VARIABLES ································································································· 61 


 
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Protocol Number: AMX3500 
Version 7.0 
Version date 30Mar2020 
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8.1.1 
Vital Signs, Height & Weight ·························································································· 61 
8.1.2 
Clinical Laboratory Assessments ····················································································· 61 
8.1.3 
Biomarkers and Pharmacokinetic Analysis ········································································· 62 
8.1.4  
Blood Samples for Future Research Use ··············································································· 62 
8.1.5  12-Lead Electrocardiogram (ECG) ·························································································· 63 
8.1.6 
Physical Examination ···································································································· 63 
8.1.7 
Neurological Examination ······························································································ 63 
8.1.8 
Upper Motor Neuron-Burden (UMN-B) ··············································································· 63 
8.1.9 
Columbia Suicide Severity Rating Scale (C-SSRS) ································································ 63 
8.1.10 
 Exit Questionnaire······································································································· 64 
8.1.11  Adverse Events ··············································································································· 64 
8.2 
OUTCOME MEASURES ································································································· 64 
8.2.1 
ALSFRS-R (Amyotrophic Lateral Sclerosis Functional Rating Scale – Revised) ··························· 64 
8.2.2 
Pulmonary Function Testing - Slow Vital Capacity (SVC) ······················································ 64 
8.2.3 
Isometric Strength Testing (ATLIS) ················································································· 65 
8.2.4 
Neuroimaging MR-PET Sub-Study ·················································································· 65 
8.2.5 Survival Assessment ············································································································ 65 
8.2.6 
Training and Validation ································································································ 65 
9 
SAFETY AND ADVERSE EVENTS ················································································· 66 
9.1 
DEFINITIONS OF AES, SUSPECTED ADVERSE DRUG REACTIONS & SAES ···································· 66 
9.1.1 
Adverse Event and Suspected Adverse Drug Reactions ·························································· 66 
9.1.2 
Serious Adverse Events ································································································· 67 
9.2 
ASSESSMENT AND RECORDING OF ADVERSE EVENTS ···························································· 68 
9.2.1 
Assessment of Adverse Events ························································································· 68 
9.2.2 
Relatedness of Adverse Event to Investigational Product························································ 69 
9.2.3  Adverse Events in Prior Human Experience with Each Individual Component ······································· 70 
9.2.4 
Recording of Adverse Events ·························································································· 70 
9.3 
ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS - REPORTABLE EVENTS ································ 70 
10 
DATA AND SAFETY MONITORING AND STATISTICAL ANALYSIS PLAN ·························· 72 
10.1 
DATA AND SAFETY MONITORING BOARD ······································································ 72 
10.2 
STATISTICAL CONSIDERATIONS ·················································································· 72 
10.2.1 
Statistical Methods ······································································································· 72 
10.2.2 
Analysis for Safety ········································································································ 73 
10.2.3 
Analysis for Efficacy ······································································································ 74 
10.2.4 
Analysis Populations ······································································································ 74 
10.3 
MISSING DATA ······································································································ 74 
11 
DATA COLLECTION, MANAGEMENT AND MONITORING ·············································· 75 
11.1 
ROLE OF DATA MANAGEMENT ··················································································· 75 
11.1.1 
Data Entry and Checks ································································································· 75 
11.1.2 
Data Lock Process ········································································································ 75 
11.1.3 
Quality Assurance ········································································································ 75 
11.2 
CLINICAL MONITORING ··························································································· 76 
11.3 
DATA HANDLING AND RECORD KEEPING ······································································ 76 
11.3.1 
Confidentiality ············································································································ 76 
11.3.2 
Study Discontinuation ··································································································· 76 


 
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Protocol Number: AMX3500 
Version 7.0 
Version date 30Mar2020 
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11.3.3 
Retention of Records····································································································· 77 
11.3.4 
Publications ················································································································ 77 
12 
LITERATURE REFERENCES························································································ 78 
13 
APPENDICES ············································································································· 80 
13.1 APPENDIX I: EL ESCORIAL WORLD FEDERATION OF NEUROLOGY CRITERIA FOR THE DIAGNOSIS OF ALS ··· 80 
13.2   APPENDIX II: ALS FUNCTIONAL RATING SCALE – REVISED (ALSFRS-R) ······································ 82 
13.3   APPENDIX III: COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS) BASELINE VERSION ················ 85 
13.4   APPENDIX IV: COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS) SINCE LAST VISIT VERSION ······· 88 
13.5   APPENDIX V: CENTER FOR NEUROLOGICAL STUDY – LABILITY SCALE ·········································· 91 
13.6   APPENDIX VI: INSTRUCTIONS TO PATIENTS ·································································· 92 
13.7   APPENDIX VII: AMX-0035 IN ALS OPEN LABEL EXTENSION (OLE): ········································· 93 


 
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Protocol Number: AMX3500 
Version 7.0 
Version date 30Mar2020 
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LIST OF ABBREVIATIONS 
 
 
ADR 
Adverse Drug Reaction 
AE 
Adverse Event/Adverse Experience 
b.i.d 
Twice a Day 
CFR 
Code of Federal Regulations 
CIB 
Clinical Investigator’s Brochure 
cIRB 
Central Institutional Review Board 
CRF 
Case Report Form 
DSMB 
Data and Safety Monitoring Board 
eCRF 
Electronic Case Report Form 
ER 
Endoplasmic Reticulum 
FDA 
Food and Drug Administration 
FWA 
Federal-wide Assurance 
g 
Gram 
GCP 
Good Clinical Practice 
GUID 
Globally Unique Identifier 
HIPAA 
Health Insurance Portability and Accountability Act 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
IDE 
Investigational Device Exemption 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
ITT 
Modified Intent to Treat 
MOP 
Manual of Procedures 
MPRAGE 
Magnetization Prepared Rapid Gradient Echo 
N 
Number (typically refers to subjects) 
NDA 
New Drug Application 
NYGC 
New York Genome Center 
NIH 
National Institutes of Health 
OHRP 
Office for Human Research Protections 
OHSR 
Office of Human Subjects Research 
OLE 
Open Label Extension 
PAA 
Phenylacetate (metabolite of PB) 
PB 
Sodium Phenylbutyrate 
PET 
Positron Emission Tomography 
PCP 
Primary Care Provider 
PHI 
Protected Health Information 
PI 
Principal Investigator 
QA 
Quality Assurance 
QC 
Quality Control 


 
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Protocol Number: AMX3500 
Version 7.0 
Version date 30Mar2020 
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ROI 
Region of Interest 
SAE 
Serious Adverse Event/Serious Adverse Experience 
SAP 
Statistical Analysis Plan 
SI 
Site Investigator 
SMC 
Safety Monitoring Committee 
SOP 
Standard Operating Procedure 
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
t.i.d 
Three Times a Day 
UDCA 
Ursodeoxycholic Acid (ursodiol) 
TUDCA 
Tauroursodeoxycholic Acid 
US 
United States 


 
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Protocol Number: AMX3500 
Version 7.0 
Version date 30Mar2020 
Page 10 of 102 
 
PROTOCOL SUMMARY 
Study Title 
Evaluation of the Safety, Tolerability, Efficacy and Activity of AMX0035, a Fixed Combination 
of Phenylbutyrate (PB) and Tauroursodeoxycholic Acid (TUDCA), for Treatment of 
Amyotrophic Lateral Sclerosis (ALS) 
 
Version Number 
4.0 
 
Study Indication 
Amyotrophic Lateral Sclerosis (ALS) 
 
Phase of Development 
II 
 
Rationale for the Study 
The objective of this study is to determine the safety and efficacy of AMX0035 in subjects with 
Amyotrophic Lateral Sclerosis (ALS). ALS is a progressive neurodegenerative disease for which 
there is no cure. There are only two medications approved specifically for treating ALS.  This 
includes Rilutek (riluzole), which only provides a modest benefit for subjects, and Radicava 
(edaravone). ALS also exacts a significant economic burden. 
 
AMX0035 has demonstrated efficacy in models of neurodegeneration, classical activation of 
neuroinflammation, and bioenergetics deficits. The individual components of AMX0035, PB and 
TUDCA have demonstrated efficacy in in vivo models of ALS, Parkinson’s, Alzheimer’s, 
ischemia, and many others. Each individual component has also been tested in small clinical 
trials of ALS subjects and was found to be safe and well-tolerated, and hit primary endpoints of 
efficacy. 
 
The first trial under this IND will be a randomized double-blind placebo-controlled Phase II trial 
to evaluate the safety and efficacy of AMX0035 for treatment of ALS. The program is designed 
to demonstrate that treatment is safe, can slow the decline in function, muscle strength, and vital 
capacity, and to assess the impact of AMX0035 therapy on biomarkers of ALS including blood 
levels of phosphorylated axonal neurofilament H subunit and 18 kDa translocator protein PET 
tracer uptake. This Phase II trial would also serve as the basis for the design of a pivotal trial in 
this subject population. 
 
Study Design 
This is a multicenter, randomized, double-blind, placebo-controlled 28-week study evaluating 
the safety, tolerability, efficacy, pharmacokinetics and biological activity of AMX0035. 


 
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Study Objectives and Endpoints  
The primary objective of the study is to assess safety, tolerability, and efficacy of oral (or feeding 
tube) administration of AMX0035 via sachet (3g PB and 1g TUDCA) twice daily vs. matched 
placebo administered via sachet twice daily.  
 
The primary outcome measures will be: 
1. To confirm the safety and tolerability of AMX0035 in subjects with ALS over a 24-week 
period 
2. To measure the impact of treatment on disease progression using the slope of the revised 
Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R) 
 
The secondary objectives of the study will be:  
1. To assess the impact of AMX0035 on the rate of decline of isometric muscle strength, as 
measured by the Accurate Test of Limb Isometric Strength (ATLIS) 
2. To assess the impact of AMX0035 on disease progression as measured by Slow Vital 
Capacity (SVC) decline, time to tracheostomy, and survival 
3. To assess the impact of AMX0035 on biomarkers including blood levels of 
phosphorylated axonal neurofilament H subunit (pNF-H) and 18 kDa translocator protein 
(TSPO) PET tracer uptake 
4. To determine the population pharmacokinetics parameters of PB and TUDCA at steady 
state during treatment with AMX0035 
5. To measure the impact of the treatment on survival. 
 
Study Locations 
Up to 25 Northeast ALS Consortium (NEALS) centers in the United States will participate in the 
study.  
 
Number of Planned Subjects 
Approximately 132 subjects will be randomized in the study. 
 
Study Population 
This study will be conducted in subjects who have sporadic or familial ALS diagnosed as 
definite as defined by revised El Escorial criteria (Appendix 1).  Subjects must provide written 
informed consent prior to screening.  At screening, eligible subjects must be at least 18 years old 
and less than 80 years old, and have a VC ≥ 60% of predicted capacity for age, height and 
gender.  Subjects must have had onset of ALS symptoms less than or equal to 18 months prior to 
the screening visit, defined as first onset of weakness. Subjects on a stable dose of riluzole and 
those not taking riluzole, and women of child-bearing age at screening are eligible for inclusion 
as long as they meet specific protocol requirements. There will be no restrictions for subjects 
taking Radicava (edaravone) at the time of screening, or if started while enrolled in the study. 
Detailed criteria are described in the body of the protocol. 
 


 
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Treatment Groups 
Subjects will be randomly assigned in a 2:1 ratio to oral (or feeding tube) AMX0035 treatment (1 
sachet= 3g PB and 1g TUDCA plus excipients) or matching placebo. For the first three weeks of 
dosing, subjects will take one sachet daily (i.e. half-dose) and if tolerated will increase to two 
sachets daily.  
 
Duration of Treatment and Follow-up 
Subjects will remain on treatment until the Week 24 visit.  Each randomized subject will also 
have a Final Telephone Interview 28 days (+ 5 days) after last dose of study drug to assess for 
adverse events (AEs), changes in concomitant medications and to administer the ALSFRS-R.


 
 
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SCHEDULE OF ACTIVITIES  
ACTIVITY 
Screening 
Visit 
Study Drug Administration (weeks) 
Final Follow-
up Telephone 
Call2 
 
MR-PET Sub-
Study Subjects 
Only 
Baseline 
Visit1 
Week 3 
Week 6 
Week 9 
Week 
12 
Week 
15 
Week 
18 
Week 21 
Week 24 OR 
Early 
Discontinuation/ 
Final Safety Visit 
Clinic 
Clinic 
Clinic 
Clinic 
Phone 
Clinic 
Phone 
Clinic 
Phone 
Clinic 
Phone 
At MGH 
-42 Days 
Day 0 
Day 21 
±5 
Day 42 
±5 
Day 63 
±5 
Day 84 
±5 
Day 105 
±5 
Day 
126 ±5 
Day 147 
±5 
Day 168 ±5 
28 +5 days 
 
Written Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
X 
Inclusion/Exclusion Review 
X 
X 
 
 
 
 
 
 
 
 
 
X 
Medical History 
History/Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
ALS Diagnosis/ALS History 
X 
 
 
 
 
 
 
 
 
 
 
 
Vital Signs3 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
 
Neurological Exam4  
X 
 
 
 
 
X 
 
 
 
X 
 
X4 
Physical Exam5  
X 
 
 
 
 
X 
 
 
 
X 
 
 
Blood Draw for Safety Labs6 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
 
Blood Draw for Serum Pregnancy 
Test for WOCB6 
X 
 
 
 
 
 
 
 
 
 
 
 
Urine Sample for Urinalysis6 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
 
12-Lead ECG 
X 
 
 
 
 
X 
 
 
 
X 
 
 
ALSFRS-R  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Slow Vital Capacity  
X 
X 
 
X 
 
X 
 
X 
 
X 
 
 
ATLIS Testing 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
 
Columbia-Suicide Severity Scale7 
 
X7 
X 
X 
 
X 
 
X 
 
X 
 
 
Exit Questionnaire 
 
 
 
 
 
 
 
 
 
X 
 
 
MR-PET Scan8 
 
X 
 
 
 
X 
 
 
X8 
Blood draw for Biomarker Testing9 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
Blood draw for PK Analysis10 
 
X 
 
 
 
X 
 
 
 
X11 
 
 
Blood draw for optional DNA 
collection12 
 
X 
X 
X 
 
X 
 
X 
 
X 
 
 
Adverse Events13 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood draw for TSPO affinity 
testing14 
X 
 
 
 
 
 
 
 
 
 
 
 
Concomitant Medications 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Randomization15 
 
X 
 
 
 
 
 
 
 
 
 
 
Dispense Study Drug16 
 
X 
 
X 
 
X 
 
X 
 
 
 
 
Drug Accountability/ Compliance 
 
 
X17 
X 
X 
X 
X 
X 
X 
X 
 
 
 


 
 
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1The Baseline Visit should occur no more than 42 days after the Screening Visit. 
2A Final Safety Telephone Call will be conducted 28 (+5 days) after the subject takes their last dose of study drug (whether or not the subject has 
discontinued from the study) to assess for adverse events (AEs), changes in concomitant medications and to administer the ALSFRS-R. This call will 
only be required for subjects who do NOT enroll in the OLE. 
3Vital signs include systolic and diastolic pressure in mmHg, respiratory rate/minute, heart rate/minute and temperature.  
4 The standard Neurological Exam will be used for all patients. The Upper Motor Neuron Burden Scale (UMN-B) will be included for the MR-PET 
Sub-Study only and administered at the time of the scan. 
5Physical Exam will include height and weight.  Height will be collected at Screening Visit ONLY. 
6Safety labs include Hematology (CBC with differential), Complete Chemistry Panel, Liver Function Tests and Urinalysis. Serum pregnancy testing 
will occur in women of child bearing potential (WOCBP) at the Screening Visit and as necessary during the course of the study. 
7C-SSRS Baseline version to be completed at Baseline Visit only. C-SSRS Since Last Visit version to be completed at all other visits.  
8Approximately 20 subjects will receive MR-PET (Magnetic Resonance-Positron Emission Tomography) scanning completed at selected sites.  First 
scan will occur PRIOR to the Baseline Visit (pre-dose) and the second scan will occur between the Week 12 and Week 21 study visits.  MR-PET 
subjects will also provide blood samples for peripheral blood mononuclear cell (PBMC) extraction prior to each MR-PET scan.  
9Subjects will provide a blood sample for biomarker testing and storage in a biorepository.  
10All subjects will provide a blood sample for pharmacokinetic (PK) testing at the Baseline Visit (pre-dose).  Subjects will also provide a blood 
sample either 1 hour or 4 hours post-dose (±10 minute window per time point) at the Week 12 and Week 24 Visits.  PK times will be randomized 
such that every subject has a 1-hour draw at one visit and a 4-hour draw at the other. 
11PK should not be drawn for early termination subjects 
12 If Baseline visit has already occurred or the sample was not collected, DNA should be obtained at next available visit. This is a one-time collection. 
13Adverse events that occur AFTER signing the consent form will be recorded.  
14For MR-PET Sub-Study subjects only, blood will be drawn for TSPO testing at the subject’s site during the Screening Visit. 
15Randomization should occur at the Baseline Visit. Randomization will entail entering a subject’s kit number into the data capture system. 
16First dose of study drug will be administered in clinic after ALL Baseline Visit procedures are completed. 
17Notify subjects of increase from one sachet per day to two sachets per day 
 


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STUDY WORKFLOW
~176 patients screened
~132 Randomized
Screening Period
On Active Treatment
88 Subjects on AMX0035 (administered as 4g Sachet) 
    
           
 
21 Days
Screening
Baseline
Week 3
Week 6
Week 9
Week 15
Week 18
Week 12
Week 21
Week 24
     44 Subjects on Placebo (administered as 4g Sachet) 
Subjects who discontinue from the study early will be asked to return to the study site for Final Safety Assessments
42 Days Maximum


 
 
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1 
ETHICS/PROTECTION OF HUMAN SUBJECTS 
1.1 
Institutional Review Board (IRB) 
This study will be conducted in compliance with current Good Clinical Practices (GCP) and 
Title 21 Part 56 of the United States of America Code of Federal Regulations (CFR) relating to 
IRBs.  
1.2 
Ethical Conduct of Study 
The study will be conducted in accordance with GCP defined by the International Conference on 
Harmonization (ICH) and the ethical principles of the Declaration of Helsinki. 
1.3 
Subject Information and Consent 
This study will be conducted in compliance with Title 21 Part 50 of the United States of America 
Code of Federal Regulations (CFR), Federal Regulations and ICH Guidance Documents 
pertaining to informed consent.  At the first visit, prior to initiation of any study-related 
procedures, subjects will be informed about the nature and purpose of the study, 
participation/termination conditions, and risks and benefits. Subjects will be given adequate time 
to ask questions and become familiar with the study prior to providing consent to participate. 
Subjects will give their written consent to participate in the study and will be provided with a 
copy of the fully executed consent form for their records. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
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2 
Introduction: Background Information and Scientific Rationale 
2.1 
Background Information 
2.1.1  ALS Overview 
ALS is the most prevalent, adult-onset, progressive motor neuron disease, affecting more than 
20,000 subjects in the US and an estimated 450,000 people worldwide, according to the ALS 
Association. ALS causes the progressive degeneration of motor neurons, resulting in rapidly 
progressing muscle weakness and atrophy that eventually leads to partial or total paralysis; on 
average, the disease is fatal within just 3-5 years. There are two FDA-approved medications for 
ALS, riluzole, which only extends survival modestly, and Radicava (edaravone).  ALS also 
exacts a significant economic burden. 
 
Although the precise cause of ALS is unknown, ALS and other neurodegenerative diseases such 
as Alzheimer’s are strongly characterized by nerve cell death and inflammation. Together these 
processes form a toxic cycle that is a key driver of progressive neurological decline. Recent 
research has highlighted mitochondrial stress and endoplasmic reticulum (ER) stress as key 
mediators of both the nerve cell death and neuroinflammatory processes1. The mitochondrion is 
the energy production center of the cell, while the ER is the quality control center. These two 
organelles are in constant communication, and are in fact physically connected by a membrane, 
and their health is vital to cell survival. When either of these cellular processes goes awry, the 
resulting stress can either kill the cell and/or create inflammation. The brain is extremely 
sensitive to both mitochondrial stress and ER stress, and both of these pathways have been 
strongly implicated in causing neurodegenerative disease. We believe that only therapeutically 
targeting both organelles simultaneously will enact a significant and lasting benefit. 
2.1.2 AMX0035 Rationale 
AMX0035 is a proprietary combination of two small molecules, phenylbutyrate (PB) and 
tauroursodeoxycholic acid (TUDCA), designed to block neuronal death and neurotoxic 
inflammation through simultaneous inhibition of endoplasmic reticulum (ER) stress and 
mitochondrial stress.  
 
Both PB and TUDCA have been evaluated individually in many disease-specific models of ALS 
and other neurodegenerative diseases, and in many nonspecific models of ER Stress and 
bioenergetic stress, respectively.  
 
PB is a pan-HDAC inhibitor and ameliorates ER stress through upregulation of the master 
chaperone regulator DJ-1 and through recruitment of other chaperone proteins2,3. The large 
increase in chaperone production reduces activation of canonical ER stress pathways, folds 
misfolded proteins, and has been shown to increase survival in many in vivo models including 


 
 
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the G93A SOD1 mouse model of ALS4. Phenylbutyrate has also been effective in additional in 
vivo models of Huntington’s Disease, Alzheimer’s, and Parkinson’s5,6,7. 
 
TUDCA recovers mitochondrial bioenergetic deficits through incorporating into the 
mitochondrial membrane, reducing Bax translocation to the mitochondrial membrane, reducing 
mitochondrial permeability, and increasing the apoptotic threshold of the cell8. TUDCA has 
exhibited efficacy in many in vivo oxidative insult models, including mouse models of stroke, 
retinal disease, cardiac disease, brain lipopolysaccharide insult, the MPTP mouse model of 
Parkinson’s, and ALS in vitro models of poly(GA)-induced toxicity9,10,11. 
 
Either ER stress or bioenergetic stress can result in neuronal death and a cytotoxic immune 
response. We therefore combined PB and TUDCA and have since demonstrated that they have 
synergistic efficacy when dosed in particular ratios. The combination of agents demonstrated a 
mathematically synergistic increase in neuronal viability in a strong oxidative insult model 
(H2O2-mediated toxicity) by linear modeling.   
 
Cytotoxic neuroinflammation has been found to be a major part of neurodegeneration12,13,14. 
Different ratios of AMX0035 reduced classical activation of cytotoxic cytokines and increased 
phagocytic cytokines in an LPS-insult, glial model of inflammation.  
2.1.3    Prior Clinical Use of PB and TUDCA in Subjects with ALS 
Both PB and TUDCA have been evaluated in subjects with ALS and were found to be safe, well-
tolerated, and exhibited preliminary signs of efficacy. PB was evaluated in a 20-week safety and 
biomarker study in ALS subjects15. This was a Phase I dose escalation trial and each subject was 
scheduled to receive PB at increasing dose from 9 to 21 g/day. A total of 40 subjects were 
recruited at 8 sites in the US. Twenty-six subjects completed the 20-week treatment phase. 
Histone acetylation was decreased by approximately 50% in blood buffy-coat specimens at 
screening and was significantly increased after PB administration. Blood levels of PB and the 
primary metabolite, phenylacetate, increased with dosage (Figure 1) with a plateau between the 3 
and 6 gram t.i.d. regimen. While the majority of subjects tolerated higher dosages of PB, the 
lowest dose (9 g/day), was the most effective at increasing histone acetylation levels in blood 
(Figure 2). Treatment with PB did not alter blood riluzole levels. Adverse events in subjects 
taking riluzole and NaPB together did not occur more frequently, compared to those on PB 
alone. 


 
 
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Figure 1: Histone acetylation levels with PB dose. Blood histone 
acetylation levels are shown compared with dose taken prior to blood 
draw. The error bars represent standard error. (Doses are repeated 
t.i.d in this study) 
 
Figure 2: Phenylbutyrate and phenylacetate levels. Blood 
phenylbutyrate and phenylacetate levels are shown compared with 
dose taken prior to blood draw. The error bars represent standard 
error (doses are repeated t.i.d in this study). 


 
 
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It is not clear why acetylation levels were highest at 9 g/day. However, the author noted that in a 
study of PB in Huntington’s disease, the effects of PB on mRNA expression levels of a 12-gene 
biomarker set were greatest at lowest dosages (4 g t.i.d.) with an inverse dose response16. 
 
For the planned Phase II trial of PB in combination with TUDCA, we therefore selected a dose 
of 3 grams of PB twice a day (6 grams per day) as a target dose with the desired pharmacologic 
effect. 
 
Recently, TUDCA at 1g b.i.d. demonstrated a statistically significant slowing of ALSFRS-R 
progression rate in a year-long, multi-site, placebo-controlled clinical trial of ALS17.  In this 
proof-of-principle trial, 34 ALS subjects under treatment with riluzole were randomized to 
placebo or TUDCA (1 gram b.i.d.) for 54 weeks.  The proportion of responders (defined as 
subjects with >15% improvement in ALSFRS-R slope) was higher under TUDCA (87%) than 
under placebo (P = 0.021; 43%). At study end, baseline-adjusted ALSFRS-R was signiﬁcantly 
higher (P = 0.007) in TUDCA than in placebo groups. Comparison of the slopes of regression 
analysis showed slower progression in the TUDCA than in the placebo group (P < 0.01) (Figure 
3). 
 
Figure 3: Linear regression analysis of ALSFRS-R mean scores 
over time for the TUDCA (circles, slope -0.388) and placebo 
groups (triangles, slope -0.262). 
 
For the planned Phase II trial of PB in combination with TUDCA, we therefore selected a dose 
of 1 gram of TUDCA twice a day (2 grams per day) as a target dose. 
 
Ursodiol (UDCA), the non-taurine conjugated form of TUDCA, was also found to be safe and 
well-tolerated in a crossover study subjects with ALS18. Subjects who received UDCA treatment 
also showed significant benefit as measured by the Appel ALS rating scale.  


 
 
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Subjects randomized to active therapy in the Phase II trial will receive 3g PB and 1g TUDCA 
twice a day orally (or by feeding tube). AMX0035 will be presented as a 4 gram sachet to be 
suspended in water and taken with a glass of water before a meal. Single agent TUDCA or PB 
treatment in subjects with ALS was very well tolerated. 
 
In the TUDCA study from Elia et al., the AE profile and laboratory anomalies were not different 
between the TUDCA and placebo cohort. In the small group of 15 subjects treated with TUDCA, 
the adverse events were limited to diarrhea.  
 
In the PB study from Cudkowicz et al., tolerability was similar to that reported in other trials of 
PB in other indications.  There were no changes in safety laboratory tests, EKG or vital signs. 
The most common AEs were those previously reported with PB, including falls, dizziness, 
diarrhea, edema, dry mouth, headache, nausea and rash. A single subject interrupted treatment 
with PB at the 9 gram per day dose (i.e. a dose higher than that planned in the proposed Phase II) 
for the occurrence of edema on the foot and under the eye. 
2.1.4 Additional Previous Clinical Experience with Phenylbutyrate 
Sodium phenylbutyrate (PB) is generally well tolerated. It is FDA approved for subjects with 
urea cycle disorders including deficiencies of carbamylphosphate synthetase, ornithine 
transcarbamylase, or argininosuccinic acid synthetase. It is indicated in patients with either 
neonatal-onset deficiency or late-onset disease. The usual total daily dose is 450-600 mg/kg/day 
in patients weighing less than 20kg, or 9.9-13.0 g/m2/day in larger patients. Detailed information 
can be found on the package insert for PB19. 
 
Sodium phenylbutyrate is also under development as an anticancer agent. In a dose escalation 
study in subjects with refractory solid tumor malignancies doses of up to 45g/day were 
administered20. Due to dose-limiting toxicities, the study concluded that 27g/day was the 
maximally tolerated dose. Nausea, vomiting, hypocalcemia and fatigue occurred at the 36g/day 
and 45g/day doses. Gastrointestinal upset (nausea, dyspepsia and vomiting) occurred at the 
lowest dose of 9g/day and was seen within 30 minutes of drug ingestion. However, 82% of 
subjects completed the study despite these side effects. Other frequently reported side effects 
include a "sweat"-like odor, usually noticeable only to the caregiver. Mild neurotoxicity 
(confusion, lethargy) has been noted at higher doses of close to 30g/day, but resolved with dose 
reduction.  
 
A dose-escalation study of intravenous PB in subjects with myelodysplastic syndromes and acute 
myelogenous leukemia found a maximally tolerated dose at 375 mg/kg/day (26.3g/day for a 
70kg individual) with no serious toxicities detected in subjects receiving doses between 125 and 
375 mg/kg/day (8.8 and 26.3g/day for a 70kg individual) 21. Dose-limiting toxicities (lethargy, 
confusion, slurred speech) were detected at 440 and 500 mg/kg/day PB (30.8 and 35g/day 
respectively, for a 70kg individual). Reports of edema have been blamed on the high sodium 


 
 
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load associated with the drug. Phase I/II studies in subjects with sickle cell anemia (see table 1 
below) and beta thalassemia report similar side effects.  
 
Another phase I study in subjects with refractory solid tumors tested IV PB doses between 150 to  
515 mg/kg/day (up to 36g/day for a 70kg individual) with dose-limiting toxicities (excessive 
somnolence, confusion) and electrolyte abnormalities resulting at a dose of 515 mg/kg/day (36.0 
g/day for a 70kg individual). The maximally tolerated dose of PB was determined to be 410 
mg/kg/day (28.7 grams/day for a 70kg individual) as there were no dose-limiting toxicities at this 
dose and no subjects required dose reductions or escalations (see table 1).  
 
The most common side effects of PB include: menstrual irregularities, decreased appetite, sweat-
like body odor, and bad taste. Less common side effects include: nausea, vomiting, stomach 
upset, stomach pain, gastritis, headache, and skin rash. Rarely, cases of peptic ulcers, rectal 
bleeding, constipation, pancreatitis and renal tubular acidosis have been reported. 
Hypoalbuminemia, metabolic acidosis, alkalosis, hyperchloremia, hyperuricemia, hypokalemia, 
hypophosphatemia, hyperphosphatemia and hypernatremia have been observed. At higher doses, 
some subjects experienced confusion and fatigue, both of which resolved with dose reductions. 
Rarely, the following may occur, but have not been directly linked to sodium phenylbutyrate 
therapy: anemia, leukopenia, leukocytosis, thrombocytopenia, thrombocytosis, arrhythmia, 
syncope and depression.  
 
Table 1: Prior Clinical Experience with Phenylbutyrate 
Dose 
Durati
on 
Patient 
Population 
# of 
patients 
AE summary 
Location 
Status 
Reference 
NCT # (if ref 
unavailable) 
9-21g/day 
5 
months 
Amyotrophic 
Lateral 
Sclerosis 
40 
Well tolerated at 
9 g 
US 
Completed 
Amyotrophic 
Lateral 
Sclerosis. 
2009; 10: 
99106 
12-18g/day 
28 days 
per 
dose 
level 
Huntington's 
24 
Table included, 
Nausea, 
Headache, gain 
instability, were 
most common. 
Most side effects 
uncommon at 
12g/day 
US 
Completed 
Hogarth et al. 
Sodium 
phenylbutyrat
e in 
Huntington's 
disease: a 
dose-finding 
study. Mov. 
Disord. 2007.  
15g/day 
12 
months 
SCA3 
20 
NA 
Ex-US 
Withdrawn 
NA 
NCT01096095 
500mg/kg/day 
14 days 
Maple Syrup 
Urine Disease 
40 
NA 
US 
Complete 
Brunetti-Pieri, 
et al. 
NCT01529060 


 
 
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Dose 
Durati
on 
Patient 
Population 
# of 
patients 
AE summary 
Location 
Status 
Reference 
NCT # (if ref 
unavailable) 
Phenylbutyrat
e therapy for 
maple syrup 
urine disease. 
Hum. Mol. 
Gen. 2010.  
20g/day 
4 days 
Urea Cycle 
Disorders 
9 
NA 
US 
Active 
NA 
NCT02111200 
IV 
Phenylbutyrate 
7 years 
Advanced 
Colorectal 
Cancer 
46 
NA 
US 
Cancelled 
NA 
NCT00002796 
12.4g/day 
(mean dose, 
198mg/kg-
476mg/kg 
range) 
12 
months 
Urea Cycle 
Disorders 
11 
One case of 
vomiting, see 
horizon package 
insert 
US 
Completed 
Lichter-
Konecki, U. et 
al. Mol Genet 
Metab. 2011 
Aug;103(4) 
<20g/day 
10 
weeks 
Urea Cycle 
Disorders 
14 
See Horizon 
package insert 
US 
Completed 
See Horizon 
Package Insert 
1g/day 
16 
weeks 
HIV 
279 
NA 
Ex-US 
Completed 
NA 
NCT01702974 
9-36g/day 
28 days 
recurrent 
malignant 
glioma 
23 
No AE's at 
9g/day, 1 
headache, 1 
lightheadedness 
at 18g/day, 1 
fatigue at 
27g/day, 2 
fatigue at 
36g/day 
US 
Completed 
Neuro-oncol. 
2005 Apr 
 
1g/day 
16 
weeks 
Tuberculosis 
390 
NA 
Ex-US 
Completed 
BMC 
Pulmonary 
MedicineBM
C series 2013 
Effective dose 
for UCD 
28 days 
UCD 
46 
1 patient 
experienced 
Hyperammonaem
ia 
US 
Completed 
NA 
NCT00992459 
450-
600mg/kg/day 
18-24 
months 
SMA 
14 
infants 
NA 
US 
Completed 
NA 
NCT00528268 
19g p.o./day 
divided into 
three doses 
1 week 
F(del)508 CF 
18 
Minimal and 
comparable side 
effects 
US 
Completed 
Am J Respir 
Crit Care 
Med. 1998  


 
 
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Dose 
Durati
on 
Patient 
Population 
# of 
patients 
AE summary 
Location 
Status 
Reference 
NCT # (if ref 
unavailable) 
500mg/kg/day 
12 
weeks 
SMA1 
5 
Terminated for 
slow enrollment 
US 
Cancelled 
NA 
NCT00439218 
500mg/kg/day 
12 
weeks 
SMA2/SMA3 
9 
Terminated for 
poor compliance 
US 
Cancelled 
NA 
NCT00439569 
500mg/kg/day 
1 week 
Argininosucci
nic Aciduria 
12 
NA 
US 
Completed 
NA 
NCT00345605 
200mg/kg IV 
5 days 
Acute 
Myeloid 
Leukemia 
10 
Well tolerated, 
fatigue observed 
US 
Completed 
Leukemia (20
06) 20, 212–
217 
7.5g/day 
2 
weeks 
BMI>27 
10 
NA 
Canada 
Completed 
NA 
NCT00533559 
IV 
Phenylbutyrate 
NA 
Multiple 
Cancers 
20 
NA 
US 
Completed 
NA 
NCT00006019 
IV 
Phenylbutyrate 
up to 
4yrs 
AML 
9 to 24 
NA 
US 
Completed 
NA 
NCT00006240 
IV/Oral 
Phenylbutyrate 
Escalating top 
dose: 45g/day 
4 
weeks 
Refractory 
Solid Tumor 
malignancies 
28 
Generally well 
tolerated 
<27g/day. 
Nausea, 
Hypocalemia 
observed 
US 
Completed 
Clin Cancer 
Res August 
2001 7;2292 
7.5g, 15g/day 
14 day 
Protinuric 
Nephropathy 
26 
NA 
Ex-US 
Completed 
NA 
NCT02343094 
IV 
Phenylbutyrate 
Ascend
ing 
Dose 
Hematologic 
Cancer 
3 to 24 
NA 
US 
Completed 
NA 
NCT00006239 
20g/day 
41 to 
460 
days 
Thalessemia 
Major 
11 
Weight gain 
and/or edema 
caused by 
increase salt load 
in 2/12, transient 
epigastric 
discomfort in 
7/12, and 
abnormal body 
odor in 3/12 
subjects 
US 
Completed 
AF Collins et 
al., 1995; 
Blood: 85 (1) 


 
 
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Dose 
Durati
on 
Patient 
Population 
# of 
patients 
AE summary 
Location 
Status 
Reference 
NCT # (if ref 
unavailable) 
20g/day 
41 to 
460 
days 
Thalessemia 
Major 
11 
Weight gain 
and/or edema 
caused by 
increase salt load 
in 2/12, transient 
epigastric 
discomfort in 
7/12, and 
abnormal body 
odor in 3/12 
subjects 
US 
Completed 
January 1, 
1995; Blood: 
85 (1) 
20g/day 
4 
weeks 
Healthy, BMI 
30-45 
101 
Not yet posted 
US 
Completed 
NA 
NCT00771901 
30-40g/day 
10 days 
ATT 
deficiency 
12 
NA 
US 
Completed  
NA 
NCT00067756 
2.1.5 Additional Previous Clinical Experience with TUDCA 
Tauroursodeoxycholic acid is currently marketed in Italy under the brand name Tudcabil 
(
). It is exported to China and Turkey under the brand name Taurolite. It is 
used for the treatment of cholesterol gallstones. It has been used for the treatment of cholestatic 
liver diseases including primary cirrhosis, pediatric familial intrahepatic cholestasis and primary 
sclerosing cholangitis and cholestasis due to cystic fibrosis. To our knowledge there are no other 
off label uses of tauroursodeoxycholic acid.  
 
Ursodeoxycholic acid (UDCA), which is widely used in the United States for treating gallstones, 
is produced and secreted endogenously by the liver as a taurine (TUDCA) or glycine (GUDCA) 
conjugate. Taurine conjugation increases the solubility of UDCA by making it more hydrophilic. 
TUDCA is taken up in the distal ileum under active transport and therefore likely has a slightly a 
longer dwell time within the intestine than UDCA which is taken up more proximally in the 
ileum (IND 
).  
 
TUDCA is widely used for the dissolution of cholesterol gallstones. This generally requires long 
periods of treatment often 1 to 2 years to obtain complete dissolution (IND 
).  
 
Between 1997 and 2007, 898,000 Tudcabil tablets were sold in Italy (taken from product profile 
contained in referenced IND 
). There were no reported cases of toxicity related to 
Tudcabil capsules. There were no reports of overdose or drug abuse during this period. There 
were no reports related to the use of pregnancy (all pregnant subjects, and those planning to 
become pregnant, are excluded from this trial).  Common adverse events include mild abdominal 
pain and diarrhea. There are some cases of pruritus and a very limited number of cases of 
elevated liver enzymes. It should be noted that most of the studies are conducted in subjects with 
chronic liver disease. 
 


 
 
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TUDCA is contraindicated in subjects with biliary tree infections, frequent biliary colic, or in 
subjects who have trouble absorbing bile acids (e.g. ileal disease or resection).  The only known 
or theoretical drug interactions are with substances that inhibit the absorption of bile acids such 
as cholestyramine and with drugs that increase the elimination of cholesterol in the bile (TUDCA 
reduces biliary cholesterol content). Based on similar physicochemical characteristics, it is likely 
that drug toxicity and interactions are very similar to those of ursodeoxycholic acid which are 
summarized below.  
 
TUDCA has been and is being evaluated in multiple other studies as well. A study at Columbia 
of 20 subjects with new onset type 1 diabetes in which subjects are administered 1.75g TUDCA 
for 12 months is ongoing (see table 2). A study at Washington University assessing the effect of 
TUDCA on lipid markers and ER stress has been completed in 101 subjects at 1.75g daily for 4 
weeks; an additional study arm in this study assessed PB at 20g/day (see table 2). We have 
included in the IND package a signed right to reference to the IND for a study at Washington 
University assessing subjects with HIV receiving 1.75g daily TUDCA for 30 days.  
 
Table 2: Prior Clinical Experience with TUDCA 
TUDC
A Dose 
Duration 
Patient 
Population 
# of 
patients 
AE summary 
Location 
Status 
Reference 
NCT # 
1g b.i.d. 
1 year 
Amyotrophic 
Lateral 
Sclerosis 
29 
Mild diarrhea 
occurred in two 
patients treated with 
TUDCA and in two 
treated with placebo; 
anorexia was 
reported in a 
placebo-treated 
patient.  
ex-US 
Complete
d 
Elia et al. 
European J. 
Neurology 
NCT00877604 
1.75g/d
ay 
1 year 
Type 1 Diabetes 
20 
NA 
US 
Ongoing 
NA 
NCT02218619 
1.75g/d
ay 
4 weeks 
Healthy, BMI 
30-45 
101 
Not yet posted 
US 
Complete
d 
NA 
NCT00771901 
750mg/
day 
24 weeks 
Chronic 
Cholestatic 
Liver Disease 
199 
NA 
Ex-US 
Complete
d 
NA 
NCT01829698 
750mg/
day 
18 
months 
Transthyretin 
Amyloid 
Cardiomyopath
y 
40 
NA 
US 
Active 
NA 
NCT01855360 
1.75g 
once 
30 days 
Protease-
48 
NA 
US 
Recruiting 
NA 
NCT01877551 


 
 
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TUDC
A Dose 
Duration 
Patient 
Population 
# of 
patients 
AE summary 
Location 
Status 
Reference 
NCT # 
daily 
inhibitor 
Associated 
Insulin 
Resistance 
750mg/
day 
12 
months 
PBC 
216 
NA 
Ex-US 
Complete
d 
NA 
NCT01857284 
750mg/
day 
1 year 
Transthyretin 
Amyloidosis 
40 
NA 
Ex-US 
Complete
d 
NA 
NCT01171859 
UNK 
3 months 
Hepatobiliary 
Disease in 
Cystic Fibrosis 
39 
NA 
US 
Complete
d 
NA 
NCT00004441 
500mg/
day 
60-80 
days 
Biliary 
Dyspepsia 
30 
Safe and well 
tolerated 
Ex-US 
Complete
d 
Rivista di 
Patologia e 
Clinica, 1985, 
34:3370-380 
750mg/
day 
254 days 
mean 
Cholelithiasis 
93 
Minor side effects 
were observed in 4 
patients treated with 
TUDCA (2 g.i. and 2 
unspecified skin 
cases) none of which 
required suspension 
of treatment. 
Ex-US 
Complete
d 
Acta 
Toxicologica et 
Therapeutica, 
Vol. 5, Oct-
Dec. 1986, 
Vaccari ed., 
Parma 
1.0 
g/day 
10 days 
Patients with 
Gallstones 
7 
NA 
US 
Complete
d 
Batta, et al. 
Hepatology, 
1982, 2(6):811-
816 
.5g, 1g, 
1.5g/da
y 
6 months 
Primary Biliary 
Cirrhosis 
24 
Diahrrea only 
observed AE 
Ex-US 
Complete
d 
Crosignani, et 
al. Digestive 
Diseases and 
Sciences. 1996, 
41(4):809-815 
.5g, 1g, 
1.5g/da
y 
6 months 
Primary Biliary 
Cirrhosis 
24 
NA 
Ex-US 
Complete
d 
Setchell et al. 
GUT, 1996; 
38:439-446 
 
3.5-
16.6mg
/kg/day 
4-6 weeks 
Gallstones 
33 
NA 
Ex-US 
Complete
d 
Muraca et al. 
International J. 
Clin. 
Pharmacol. 
Therapeuticcs, 
1995; 
33(7):391-393, 


 
 
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TUDC
A Dose 
Duration 
Patient 
Population 
# of 
patients 
AE summary 
Location 
Status 
Reference 
NCT # 
3.5-
16.6mg
/kg/day 
4-6 weeks 
Biliary Lipid 
Composition 
33 
NA 
Ex-US 
Complete
d 
Muraca et al. 
Ital J. 
Gastroenterol 
1995, 27:439-
440 
 
10mg/k
g/day 
1 month 
Gallstones 
29 
NA 
Ex-US 
Complete
d 
Portincasa, et 
al. Ital. J. 
Gastroenterol. 
1996, 28:111-
113 
10-
13mg/k
g/day 
3 months 
chronic hepatitis 
5 
NA 
Ex-US 
Complete
d 
Panella, et al. 
Ital. J. 
Gastroenterolog
y 1995; 27:256-
258; 
10mg/k
g/day 
6 months 
Gallstones 
12 
No side effects 
observed 
Ex-US 
Complete
d 
La Clinica 
Terapeutica, 
1986; 117:475-
479 
10mg/k
g/day 
6 months 
Gallstones 
31 
NA 
Ex-US 
Complete
d 
The American 
Journal of 
Gastroenterolog
y 1995; 
90(6):978-981 
500mg/
day 
3 months 
Biliary 
Dyspepsia 
133 
NA 
Ex-US 
Complete
d 
Advances in 
Therapy - 1994; 
11 (1):34-41, 
500mg/
day 
3 months 
chronic active 
hepatitis 
53 
No side effects 
observed 
Ex-US 
Complete
d 
Portincasa et al. 
Current 
Therapeutic 
Research. 1993; 
53(5):521-531 
 
500mg/
day 
3 months 
Patients post 
cholecystectom
y  
203 
1 patient  vomited, 
and 1 had abdominal 
pain in active, 1 
abdominal pain, 1 
rash cutaneous, 1 
lipotinemia in 
placebo 
Ex-US 
Complete
d 
Annali Italiani 
di Chirurgia, 
1993, 
64(5):533-537 
.5g, 1g, 
1.5g/da
y 
6 months 
asymptomatic/m
ildly 
symptomatic 
PBC 
24 
NA 
Ex-US 
Complete
d 
Hepatology, 
1994, 130A. 


 
 
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TUDC
A Dose 
Duration 
Patient 
Population 
# of 
patients 
AE summary 
Location 
Status 
Reference 
NCT # 
.5g, 1g, 
1.5g/da
y 
6 months 
asymptomatic/m
ildly 
symptomatic 
PBC 
24 
TUDCA was well 
tolerated (rarely 
diarrhoea dose 
dependent 
reversible). 
Ex-US 
Complete
d 
Hepatology, 
1993, 10; 176A 
 
500mg/
day 
6 months 
PBC 
23 
Well tolerated and 
no patient 
complained of side 
effects. 
Ex-US 
Complete
d 
Aliment. 
Pharmacol. 
Ther. 1997; 
11:409-414 
750mg/
day 
2 month 
with 
crossover 
PBC 
12 
females 
NA 
US 
Complete
d 
Hepatology. 
1999; 29:320-
327 
 
675mg/
day 
2 months 
PBC 
15 
Two patients 
experienced burning 
discomfort in the 
epigastrium during 
the TUDCA 
treatment period. 
Ex-US 
Complete
d 
Clin. Res. 1986, 
34(1):181 
13mg/k
g/day 
3 months 
Chronic liver 
disease 
hystologically 
determined 
69 
NA 
Ex-US 
Complete
d 
J of 
Hepatology. 
1993; 18 
(Suppl. 1) S157 
500mg/
day 
3 months 
chronic hepatitis 
c  
134 
2.2% cases of 
diarrhoea solved 
promptly without 
suspension of 
therapy 
Ex-US 
Complete
d 
Advances in 
therapy. 1994, 
11(5):262-268 
500mg/
day 
3 months 
patients with 
biopsy proved 
CAH due to 
HCV or HBV 
infections 
162 
1 patient developed 
abdominal 
discomfort, 1 patient 
had mild pruritus, 3 
patients developed 
mild diarrhoea 
without wirthdrawal 
Ex-US 
Complete
d 
Current 
Therapeutic 
Research 1995; 
56(6):626-634, 
500mg/
day 
6 months 
compensated 
liver cirrhosis 
associated with 
hepatitis B or C 
of Child’s group 
A or B 
(histological 
tests) 
30 
No side effects and 
no treatment 
withdrawals 
occurred 
Ex-US 
Complete
d 
Current 
Therapeutic 
Research 1994; 
55 (11):1355-
1362, 


 
 
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TUDC
A Dose 
Duration 
Patient 
Population 
# of 
patients 
AE summary 
Location 
Status 
Reference 
NCT # 
Phase 
1: 
TUDC
A 10 
mg/kg/
day + 
lympho
blastoid 
IFNα 
3MU/m
2 ter in 
week; 
Phase 
2: 
TUDC
A idem 
+ IFNα 
tapering 
dose 
down to 
the 
minimu
m 
effectiv
e 
6 month 
phase 1, 6 
months 
phase 2 
Patients with 
CHC 
120 
NA 
Ex-US 
Complete
d 
Gastroenterolog
y 1996; 110(4) 
A1296. 
 
.25, .5, 
1 g/day 
6 months 
Chronic 
Hepatitis 
155 
Two patients were 
withdrawn for minor 
side effects (one for 
diarrhea and one for 
dyspepsia). 
Ex-US 
Complete
d 
Hepatology. 
1995, 
23(4):120A - 53 
500mg/
day 
12 
months 
Liver transplant 
33 
Safe and well 
tolerated 
Ex-US 
Complete
d 
Ital J. Gastro 
and Hepatology 
1999; P/C 
13/37:154 
2.1.6   Previous Clinical Experience with Ursodiol (UDCA) 
Ursodiol therapy has not been associated with liver damage. Lithocholic acid, a naturally 
occurring bile acid, is known to be a liver-toxic metabolite. This bile acid is formed in the gut 
from ursodiol less efficiently and in smaller amounts than that seen from chenodiol. Lithocholic 
acid is detoxified in the liver by sulfation and, although man appears to be an efficient sulfater, it 
is possible that some subjects may have a congenital or acquired deficiency in sulfation, thereby 
predisposing them to lithocholate-induced liver damage (IND 
). 
 
Abnormalities in liver enzymes have not been associated with Actigall® (Ursodiol USP 
capsules) therapy and, in fact, Actigall® has been shown to decrease liver enzyme levels in liver 
disease. However, subjects given Actigall® should have SGOT (AST) and SGPT (ALT) 


 
 
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measured at the initiation of therapy and thereafter as indicated by the particular clinical 
circumstances.  
 
Bile acid sequestering agents such as cholestyramine and colestipol may interfere with the action 
of ursodiol by reducing its absorption. Aluminum-based antacids have been shown to adsorb bile 
acids in vitro and may be expected to interfere with ursodiol in the same manner as the bile acid 
sequestering agents (IND 
). Estrogens, oral contraceptives, and clofibrate (and perhaps 
other lipid-lowering drugs) increase hepatic cholesterol secretion, and encourage cholesterol 
gallstone formation and hence may counteract the effectiveness of ursodiol. 
 
Ursodeoxycholic acid was tested in 2-year oral carcinogenicity studies in CD-1 mice and 
Sprague-Dawley rats at daily doses of 50, 250, and 1000 mg/kg/day. It was not tumorigenic in 
mice. In the rat study, it produced statistically significant dose-related increased incidences of 
pheochromocytomas of adrenal medulla in males (p=0.014, Peto trend test) and females 
(p=0.004, Peto trend test). A 78-week rat study employing intrarectal instillation of lithocholic 
acid and tauro-deoxycholic acid, metabolites of ursodiol and chenodiol, has been conducted. 
These bile acids alone did not produce any tumors. A tumor-promoting effect of both metabolites 
was observed when they were co-administered with a carcinogenic agent. Ursodiol is not 
mutagenic in the Ames test (IND 
).  
 
Reproduction studies have been performed in rats and rabbits with ursodiol doses up to 200-fold 
the therapeutic dose and have revealed no evidence of impaired fertility or harm to the fetus at 
doses of 20- to 100-fold the human dose in rats and at 5-fold the human dose (highest dose 
tested) in rabbits. Studies employing 100- to 200-fold the human dose in rats have shown some 
reduction in fertility rate and litter size. (IND 
) There have been no adequate and well-
controlled studies of the use of ursodiol in pregnant women, but inadvertent exposure of 4 
women to therapeutic doses of the drug in the first trimester of pregnancy during the Actigall 
trials led to no evidence of effects on the fetus or newborn baby. Although it seems unlikely, the 
possibility that ursodiol can cause fetal harm cannot be ruled out; hence, the drug is not 
recommended for use during pregnancy. 
 
2.2 
Potential Risks and Benefits 
2.2.1 Potential Risks 
The safety profile with PB administration is in large part derived from studies of subjects with 
urea cycle disorders.  Refer to the phenylbutyrate tablet label (Buphenyl®). 
 
In female subjects, the most common clinical adverse event reported was amenorrhea/menstrual 
dysfunction (irregular menstrual cycles), which occurred in 23% of the menstruating subjects. 
Decreased appetite occurred in 4% of all subjects. Body odor (probably caused by the 
metabolite, phenylacetate [PAA]) and bad taste or taste aversion were each reported in 3% of 
subjects.  


 
 
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Other adverse events reported in 2% or fewer subjects were:  
• 
Gastrointestinal: abdominal pain, gastritis, nausea and vomiting; constipation, rectal 
bleeding, peptic ulcer disease, and pancreatitis each occurred in one subject.  
• 
Hematologic: aplastic anemia and ecchymoses each occurred in one subject.  
• 
Cardiovascular: arrhythmia and edema each occurred in one subject.  
• 
Renal: renal tubular acidosis  
• 
Psychiatric: depression  
• 
Skin: rash  
• 
Miscellaneous: headache, syncope, and weight gain  
 
Phenylbutyrate has been evaluated in a dose-escalating study in ALS subjects over the course of 
20-weeks and was found to be generally safe and tolerable15. Specifically, the most common 
adverse events included falls or other accidental injury, dizziness, diarrhea, edema, dry mouth, 
headache, nausea, and rash. With the exception of headache, these adverse events occurred at a 
higher rate compared to the comparison placebo cohort. These events are expected side effects 
from PB. There were no clinically significant changes in laboratory values, EKGs or vital signs. 
No deaths or unexpected and related serious adverse events occurred. Significant adverse events 
did not occur more frequently with subjects who were taking riluzole in addition to NPB, 
compared to subjects taking PB alone. Importantly, this study evaluated daily dosages of 
phenylbutyrate between 9 and 21 grams while our study will be limited to 6 grams daily. 
 
Neurotoxicity was reported in cancer subjects receiving intravenous phenylacetate, 250–300 
mg/kg/day for 14 days, repeated at 4-week intervals. Manifestations were predominately 
somnolence, fatigue, and lightheadedness; with less frequent headache, dysgeusia, hypoacusis, 
disorientation, impaired memory, and exacerbation of a pre-existing neuropathy.  
 
These adverse events were mainly mild in severity. The acute onset and reversibility when the 
phenylacetate infusion was discontinued suggest a drug effect. 
 
The most common adverse reactions reported with the use of TUDCA (≥1%) are: abdominal 
discomfort, abdominal pain, diarrhea, nausea, pruritus, and rash. 
 
TUDCA is generally well tolerated. A derivative, UDCA or ursodiol, is approved for subjects 
with primary biliary cirrhosis. Common adverse events with TUDCA include mild abdominal 
pain and diarrhea. There are some cases of pruritus and a very limited number of cases of 
elevated liver enzymes.  
 
TUDCA has been evaluated over a year-long placebo controlled study in ALS subjects at 1g 
b.i.d17. The population for safety analysis consisted of 15 subjects who took TUDCA and 14 
subjects who took placebo. The treatment was well tolerated in all subjects. Laboratory 
parameters did not change in either treatment group during the course of the study. Except for 


 
 
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the expected complications related to ALS, no changes in vital signs and laboratory values that 
could possibly be attributed to the study drug or placebo were recorded. Overall, five adverse 
events were considered by the Investigators to be study related based on the subjects’ 
descriptions. Two events were reported in the 15 TUDCA-treated subjects (13.3%); three events 
occurred in the 14 placebo-treated subjects (21.4%). The events were as follows: mild diarrhea 
occurred in two subjects treated with TUDCA and in two treated with placebo; anorexia was 
reported in a placebo-treated subject. Four subjects died during the study period, one in the 
TUDCA group and three in the placebo group. The one death in the treated group was not 
considered drug related—TUDCA trended towards a survival benefit.   
 
The risks and side effects of muscle strength testing include fatigue and/or muscle cramping.  
 
2.2.2 Known Potential Benefits 
This study is designed to assess the safety, tolerability and biological activity of AMX0035 
therapy. TUDCA and PB have both been tested individually in ALS clinical trials and met their 
primary endpoints of safety and tolerability. TUDCA also met its efficacy endpoint of slowing 
ALSFRS-R decline, and PB was therapeutically efficient in improving histone acetylation levels. 
If successful, this trial will allow further clinical development of this therapy to potentially slow 
ALS progression. The trial is also assessing multiple biomarkers in concert with clinical 
endpoints, which will allow both a more detailed understanding of drug activity as well as serve 
as a data set for the field as a whole to help understand how these biomarkers might track ALS 
progression.  


 
 
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3 
OBJECTIVES 
3.1 
Study Objectives 
This Phase II protocol is intended as a proof of concept of AMX0035 as a safe and effective 
treatment of adult subjects with ALS. The main strategic objectives of this protocol are below.  
 
The primary outcome measures will be: 
1. To confirm the safety and tolerability of a fixed-dose combination of PB and TUDCA in 
subjects with ALS over a 6-month period; 
2. To measure the impact of the treatment using the slope of progression with the revised 
Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R); 
 
The secondary objectives of the study will be:  
1. To assess the impact of AMX0035 on the rate of decline of isometric muscle strength, as 
measured by the Accurate Test of Limb Isometric Strength (ATLIS); 
2. To assess the impact of AMX0035 on disease progression as measured by Slow Vital 
Capacity (SVC) decline, time to tracheostomy and survival; 
3. To assess the impact of AMX0035 on biomarkers including phosphorylated axonal 
neurofilament H subunit (pNF-H) levels and 18 kDa translocator protein (TSPO) uptake;  
4. To develop concentration-response models of TUDCA and phenylbutyrate at steady-state 
after administration of AMX0035 sachet twice-daily. 
5. To measure the impact of AMX0035 on survival. 
 
3.2 
Study Outcome Measures 
3.2.1 Primary Outcome Measures 
The primary outcome measures for the study will include: 
• Safety and tolerability as defined as the proportion of subjects able to remain on study 
drug until planned discontinuation. 
• The rate of decline (slope of decline) in the ALS functional rating scale (ALSFRS-R).   
 
Safety and tolerability will be assessed by the procedures outlined in Section 9. 
 
The revised version of the ALSFRS was created to add assessments of respiratory dysfunction, 
including dyspnea, orthopnea, and the need for ventilatory support. The revised ALSFRS 
(ALSFRS-R) has been demonstrated to retain the properties of the original scale and show strong 
internal consistency and construct validity. 
 
Survival endpoint will be defined as death, tracheostomy or permanent assisted ventilation (>22 
hours a day). 
 


 
 
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3.2.2 Secondary Outcome Measures 
The secondary outcome measures include:  
• Assessing the impact of AMX0035 on the rate of decline of isometric muscle strength, as 
measured by the Accurate Test of Limb Isometric Strength (ATLIS); 
• Assessing the impact of AMX0035 on disease progression as measured by Slow Vital 
Capacity (SVC) decline;  
• Assessing the impact of AMX0035 on survival, hospitalization and tracheostomies; 
• Assessing the impact of AMX0035 on biomarkers including phosphorylated axonal 
neurofilament H subunit (pNF-H) levels and 18 kDa translocator protein (TSPO) uptake; 
• Assessing the concentration-response model of TUDCA and phenylbutyrate at steady-
state after administration of AMX0035 4 grams twice daily.  
 


 
 
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4 
STUDY DESIGN 
4.1 
Overall Study Design and Plan 
During the enrollment period approximately 176 subjects will be screened from approximately 
25 Northeast ALS Consortium (NEALS) centers in the US.  One hundred thirty-two (132) of 
these subjects will be randomly assigned in a 2:1 ratio to oral (or feeding tube) twice daily sachet 
of active therapy or matching placebo.  Treatment duration will be twenty-four (24) weeks. For 
the first three weeks study drug will be administered once daily. If tolerated, the dose will then 
be increased to twice a day. Clinic visits will occur at Screening, Baseline, Week 3 (day 21), 
Week 6 (day 42), Week 12 (day 84), Week 18 (Day 126), and Week 24 (Day 168). Phone calls 
will be conducted at Week 9, Week 15, Week 21 and Week 28 (4 weeks after completion of 
treatment).  
 
All visit windows are consecutive calendar days and are calculated from the day the subject 
starts study treatment (Day 0, the day of the Baseline Visit).  Any change from this visit window 
will be considered an out of window visit deviation. 
An one thirty-two (132) week Open Label Extension (OLE) study will be available to those 
subjects who complete the randomized, double-blind study.  Please refer to 13.7 Appendix VII 
for all the details on the OLE. 
4.2 
Study Centers 
This study will be conducted at up to 25 NEALS Centers in the US.  Sites will be selected based 
on recruitment record from prior trials, compliance with prior study protocols and regulations, 
clinical research expertise and availability of necessary resources. 
4.3 
Study Duration 
Subjects will remain on randomized, placebo-controlled, double-blind treatment until the Week 
24 visit.  Each randomized subject will also have a Follow-up Telephone Interview 28 days after 
the completion of dosing to assess for adverse events (AEs), changes in concomitant medications 
and to administer the ALSFRS-R. Including the Screening and Follow-up Visits, each subject 
will be in the study for approximately 8 months. We expect the study to take up to 18 months to 
meet enrollment goals.  
4.4 
Protocol Adherence 
Each Site Investigator must adhere to the protocol detailed in this document and agree that any 
changes to the protocol must be approved by the NCRI Coordination Center (CC) or their 
Central Institutional Review Board (cIRB). Each Site Investigator (SI) will be responsible for 
enrolling only those study subjects who have met protocol eligibility criteria. 


 
 
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5 
STUDY ENROLLMENT AND WITHDRAWAL 
5.1 
Number of Study Subjects 
Approximately 132 ALS subjects will be randomized.  
5.2 
Inclusion and Exclusion Criteria 
5.2.1 Inclusion Criteria 
Inclusion Criteria 
1. Male or female, aged 18-80 years of age 
2. Sporadic or familial ALS diagnosed as definite as defined by the World 
Federation of Neurology revised El Escorial criteria 
3. Less than or equal to 18 months since ALS symptom onset 
4. Capable of providing informed consent and following trial procedures 
5. Geographically accessible to the site 
6. Slow Vital Capacity (SVC) >60% of predicted value for gender, height, and age 
at the Screening Visit 
7. Subjects must either not take riluzole or be on a stable dose of riluzole for at least 
30 days prior to the Screening Visit.  Riluzole-naïve subjects are permitted in the 
study. 
8. Women of child bearing potential (e.g. not post-menopausal for at least one year 
or surgically sterile) must agree to use adequate birth control for the duration of 
the study and 3 months after last dose of study drug 
a. Women must not be planning to become pregnant for the duration of the 
study and 3 months after last dose of study drug 
9. Men must agree to practice contraception for the duration of the study and 3 
months after last dose of study drug 
a. Men must not plan to father a child or provide sperm for donation for the 
duration of the study and 3 months after last dose of study drug 
 
Acceptable birth control methods for use in this study are: 
• Hormonal methods, such as birth control pills, patches, injections, vaginal ring, or 
implants 
• Barrier methods (such as a condom or diaphragm) used with a spermicide (a foam, 
cream, or gel that kills sperm) 
• Intrauterine device (IUD) 
• Abstinence (no heterosexual sex) 
• Unique partner who is surgically sterile (men) or not of child bearing potential (female) 
 
Date of ALS Symptom Onset. For the purposes of this study, the date of symptom onset will be 
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for this study, the date of symptom onset must be no greater than exactly 18 months prior to the 
Screening Visit date. 
 
MR-PET Sub-Study 
A subset of study subjects will undergo MR-PET and will need to meet the following additional 
inclusion criteria: 
 
1. Ability to safely lie flat for 90 min for MR-PET procedures in the opinion of the 
Site Investigator 
2. High or mixed affinity to bind TSPO protein (Genotype Ala/Ala or Ala/Thr) 
 
TSPO affinity test: Venous blood for the TSPO affinity test will be drawn from all subjects who 
have indicated their interest in participating in the MR-PET sub-study.  (This will be indicated 
via a checkbox on the consent form.) The blood will be drawn at Screening in order to have the 
subjects genotyped for the Ala147Thr TSPO polymorphism in the TSPO gene (rs6971).  About 
10% of humans show low binding affinity to PBR2821.  
 
Note: High or Mixed affinity binders (Ala/Ala or Ala/Thr) will be considered eligible, whereas 
the low affinity binders (Thr/Thr) will be considered ineligible for the MR-PET sub-study. 
Note: A subject may be eligible for the main study but ineligible for the MR-PET sub-study. 
However, if a subject is found to be ineligible for the main study, he or she is automatically 
ineligible for the MR-PET sub-study as well.  
5.2.2 Exclusion Criteria  
Study subjects meeting any of the following criteria during screening evaluations will be 
excluded from entry into the study: 
 
Exclusion Criteria 
1. Presence of tracheostomy  
2. Exposure to PB, TUDCA or UDCA within 3 months prior to the Screening Visit 
or planning to use these medications during the course of the study 
3. History of known allergy to PB or bile salts 
4. Abnormal liver function defined as AST and/or ALT > 3 times the upper limit of 
the normal 
5. Renal insufficiency as defined by eGFR < 60 mL/min/1.73m2. 
6. Poorly controlled arterial hypertension (SBP>160mmHg or DBP>100mmHg) at 
the Screening Visit 
7. Pregnant women or women currently breastfeeding 
8. History of cholecystectomy  


 
 
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9. Biliary disease which impedes biliary flow including active cholecystitis, primary 
biliary cirrhosis, sclerosing cholangitis, gallbladder cancer, gallbladder polyps, 
gangrene of the gallbladder, abscess of the gallbladder.  
10. History of Class III/IV heart failure (per New York Heart Association – NYHA) 
11. Severe pancreatic or intestinal disorders that may alter the enterohepatic 
circulation and absorption of TUDCA including biliary infections, pancreatitis 
and ileal resection 
12. The presence of unstable psychiatric disease, cognitive impairment, dementia or 
substance abuse that would impair ability of the subject to provide informed 
consent, according to Site Investigator judgment 
13. Patients who have cancer with the exception of the following: basal cell 
carcinoma or successfully treated squamous cell carcinoma of the skin; cervical 
carcinoma in situ; prostatic carcinoma in situ; or other malignancies curatively 
treated and with no evidence of disease recurrence for at least 3 years. 
14. Clinically significant unstable medical condition (other than ALS) that would 
pose a risk to the subject if they were to participate in the study 
15. Active participation in an ALS clinical trial evaluating an experimental small 
molecule within 30 days of the Screening Visit. (Please refer to MOP section E. 
Protocol Compliance for current list of experimental small molecules).  
16. Exposure at any time to any cell therapies and gene therapies  under investigation 
for the treatment of subjects with ALS (off-label use or investigational)  
17. Exposure to monoclonal antibodies under investigation for the treatment of ALS 
(off-label use or investigational) within 90 days from screening. If previously 
exposed to monoclonal antibodies under investigation for the treatment of ALS, a 
90-day wash-out period will be required prior to screening. 
18. Implantation of Diaphragm Pacing System (DPS) 
19. Anything that, in the opinion of the Site Investigator, would place the subject at 
increased risk or preclude the subject’s full compliance with or completion of the 
study 
20. Exposure to any disallowed medications listed below  
 
MR-PET Sub-Study 
A subset of study subjects will undergo MR-PET. The following additional exclusion criteria 
apply to this subset: 
1. Exposure to immunomodulatory medications within 30 days of the Screening 
Visit 
2. Any contraindication to undergo MRI studies such as: 
a. History of a cardiac pacemaker or pacemaker wires 
b. 
 Metallic particles in the body 
c. Vascular clips in the head 
d. 
 Prosthetic heart valves 
e. Severe claustrophobia impeding ability to participate in an imaging study 


 
 
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3. Low affinity binders (Thr/Thr) on the TSPO Affinity Test 
4. Radiation exposure that exceeds the site’s current guidelines 
 
Note: A subject may be eligible for the main study but ineligible for the MR-PET sub-study. 
However, if a subject is found to be ineligible for the main study, he or she is automatically 
ineligible for the MR-PET sub-study as well.  
Note on Benzodiazepines for MR-PET Sub-Study Subjects: If an MR-PET subject is taking a 
benzodiazepine, he or she should not take the benzodiazepine for at least 1 day before his or her 
scans with the exception of lorazepam and clonazepam that do not need to be discontinued.  
 
Disallowed medications for all subjects include 
• HDAC Inhibitors including: 
o Valproate 
o Vorinostat (Zolinza) 
o Romidepsin 
o Chidamide 
o Panobinostat 
o Lithium 
o Butyrate  
o Suramin 
 
• Probenecid  
 
• Bile Acid Sequestrants including:  
o Cholestyramine and Cholestyramine Light 
o Questran and Questran Light 
o Welchol  
o Colestid and Colestid Flavored 
o Prevalite 
 
 
Note on Antacids Within Two Hours of AMX0035 Administration: 
Antacids containing Aluminum hydroxide or smectite (aluminum oxide) may not be taken 
within two hours of administration of AMX0035 as they inhibit absorption of TUDCA. These 
include: 
o Alamag 
o Alumina and Magnesia 
o Antacid, Antacid M and Antacid Suspension 
o Gen-Alox 
o Kudrox 
o M.A.H. 


 
 
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o Maalox HRF and Maalox TC  
o Magnalox 
o Madroxal 
o Mylanta and Mylanta Ultimate 
o Ri-Mox 
o Rulox 
 
Cautionary Note on Mexiletine  
Subjects who participated in the Mexiletine trial within the last 30 days will be excluded from 
the trial. However, subjects who are using Mexiletine at a dosage less than or equal to 
300mg/day for cramps and fasciculations will not be excluded.  
 
There is a potential for an interaction between AMX0035 and Mexiletine; at 20 times the 
intended clinical concentration (Cmax), the principal metabolite of Phenylbutyrate, 
Phenylacetylacetate has been shown to be inhibitory to CYP 1A2 and CYP 2D6 which are the 
major enzymes responsible for the breakdown of Mexiletine. Therefore, it is possible the co-
administration of Phenylbutyrate and Mexiletine will increase the subject’s exposure to 
Mexiletine. 
 
Subjects who are co-administered AMX0035 and Mexiletine should therefore be monitored for 
Mexiletine-associated adverse events, and if these events present, the Site Investigator should 
consider stopping or reducing the dosage of Mexiletine. Adverse events associated with 
Mexiletine include but are not limited to cardiac arrhythmias, liver injury, and blood dyscrasias. 
5.3 
Treatment Assignment Procedures 
Each subject who meets all eligibility criteria will be randomized to receive either therapy by 
twice daily sachet of AMX0035 (3g PB and 1g TUDCA) or matching placebo for 24 weeks of 
treatment. For the first three weeks of the study subjects will only take a single sachet daily and 
will be instructed to increase to 2 sachets daily at the Week 3 Visit.  
5.3.1 Randomization Procedures 
The randomization scheme will be independently developed and will indicate the treatment 
assignment and the subject numbers to be used by each site. The randomization scheme will be 
managed by the manufacturer.  
5.4. 
Reasons for Withdrawal 
A study subject will be discontinued from participation in the study if: 
• Any clinical adverse event (AE), laboratory abnormality, requirement for a concomitant 
medication, concurrent illness, or other medical condition or situation occurs such that, in 
the opinion of the Investigator, continued participation in the study would not be in the 
best interest of the subject. 
• The subject is non-compliant or is lost-to-follow-up. 


 
 
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Subjects are free to withdraw from participation in the study at any time upon request. 
5.4.1 Handling of Withdrawals 
A subject may choose to discontinue participation in the study at any time.  However, the Site 
Investigator (SI) or designee will encourage subjects to continue with follow-up, regardless of 
their compliance with the study drug.  If the SI or designee is concerned about the use of a 
prohibited medication or other safety issues, then the study drug may have to be reduced to 
single dose or discontinued.  If a subject permanently discontinues study drug, the SI or designee 
should still encourage subjects to follow the study protocol under the modified intent-to-treat 
principle (ITT). These subjects will be encouraged to follow the study visits, off drug. Loss to 
follow-up should be prevented whenever possible. 
 
Any subject who is on study drug and needs to begin the use of any prohibited medication, must 
immediately discontinue use of the study drug and should not begin use of the prohibited 
medication before an appropriate wash-out period of at least 30 days occurs.  Subjects who must 
permanently discontinue study drug may continue in the ITT portion of the study, per protocol. 
 
Subjects who permanently discontinue study drug and will not continue monitoring per the study 
schedule should complete early study drug termination procedures per protocol.  Subjects who 
discontinue treatment should not be unblinded unless there is a specific reason to do so.  
 
If a subject wishes to withdraw consent, i.e., withdraw his or her participation in future study 
procedures, the subject will be asked to delay consent withdrawal to allow for a Final Safety 
Visit and Final Safety Telephone Call. The subject will be asked to return to the study site for a 
Final Safety Visit as soon as possible after stopping study drug, if possible within 28 days of 
asking to withdraw consent. The subject will also be asked to have a Follow-Up Telephone Call 
no sooner than 28 days (+5 days) after taking their last dose of study drug to monitor their safety 
and to permit review of their medical records at the end of the study to document their vital 
status.  
 
Subjects who withdraw from the study due to adverse events will be followed for outcome 
measures under the ITT protocol as noted above. The DSMB will review these events promptly 
and make recommendations about potential changes to the study, including possible changes to 
protocol, updates to the informed consent form, or even ending the study early.   
 
In the event a subject wishes to no longer have their personal health information used for the 
analysis of this study, he or she will notify the site through an authorized letter and future data 
will not be included in analysis; however, all data up to this letter will still be included.  


 
 
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5.5 
Termination of Study  
This study may be prematurely terminated if, in the opinion of the DSMB or sponsor, there is 
sufficient reasonable cause.  Written notification, documenting the reason for study termination, 
will be provided to the Principal Investigator or Sponsor by the terminating party. 
 
Circumstances that may warrant termination include, but are not limited to: 
• Determination of unexpected, significant, or unacceptable risk to subjects. 
• Enrollment is unsatisfactory. 
• Insufficient adherence to protocol requirements. 
• Data that are not sufficiently complete and/or evaluable.  
• Plans to modify, suspend or discontinue the development of the study drug. 
 
If the study is prematurely terminated or suspended, the Sponsor will promptly inform the Site 
Investigators/institutions, and the regulatory authority(ies) of the termination or suspension and 
the reason(s) for the termination or suspension. The Central IRB (cIRB) will also be informed 
promptly and provided the reason(s) for the termination or suspension by the Sponsor or by the 
Site Investigator/institution, as specified by the applicable regulatory requirement(s). 
 


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6 
TREATMENTS ADMINISTERED
6.1 
Treatments
6.1.1 Study Product Description
AMX0035 is a combination therapy comprised of two active pharmaceutical ingredients, sodium 
phenylbutyrate (PB and tauroursodeoxycholic acid (TUDCA). 
Phenylbutyrate is an approved compound in the United States for urea cycle disorders and is 
marketed in the US as Buphenyl®. There is an existing USP monograph for this material.
The chemical structure for PB is provided below. 
Chemical Structure PB
The drug substance PB is produced by 
. under cGMP 
conditions. The manufacture and controls for PBA are described in Drug Master File 
No. 
.  
The specifications for PB are identical to those of the Ph.Eur.
The drug substance TUDCA is currently marketed in Italy under the brand name Tudcabil. It is 
exported to China and Turkey under the brand name Taurolite. It is used for the indications of 
treatment of cholesterol gallstones. It has been used for the treatment of cholestatic liver diseases 
including primary cirrhosis, pediatric familial intrahepatic cholestasis and primary sclerosing 
cholangitis and cholestasis due to cystic fibrosis. To our knowledge, there are no other uses of 
tauroursodeoxycholic acid. It is marketed by some companies in the United States on websites 
such as Amazon as a dietary supplement to “promote liver health”. 
The chemical structure for TUDCA is provided below. 


 
 
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Chemical Structure TUDCA 
 
 
 
The drug substance TUDCA is produced by 
  
 
The specifications for TUDCA are identical to those used by the supplier. 
 
A powder filled sachet will be used as the AMX0035 drug product. The drug product will be 
filled under cGMP conditions in an aluminum foil lined sachet. 
 
The sachet containing active ingredients will include: 
o Active Ingredients: 
• 1g TUDCA 
• 3g PB 
 
o Excipients 
• Sodium Phosphate Dibasic, Anhydrous 
• Dextrates, Hydrates 
• Sorbitol 
• Syloid 63FP (colloidal silica) 
• Sucralose 
• Sodium Stearyl Fumarate 
• Weber Mixed Berry Flavoring 
• Kleptose Linecaps (maltodextrin) 
6.1.2 Placebo 
A matched placebo will be used to maintain the dosage-blind.  The placebo sachets for this study 
will match the corresponding AMX0035 sachets in size, color, and presentation. 
 
The placebo sachets contain: 
 
o Excipients 
• Sodium Phosphate Dibasic, Anhydrous 
• Dextrates, Hydrates 


 
 
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• Sorbitol 
• Syloid 63FP (colloidal silica) 
• Sucralose 
• Sodium Stearyl Fumarate 
• Weber Mixed Berry Flavoring 
• Kleptose Linecaps (maltodextrin) 
• Denatonium Benzoate Granules 
 
Administration of matching placebo will be the same as for subjects in the treatment group. 
6.2 
Acquisition 
Upon receipt of the study treatment supplies, an inventory must be performed and a drug receipt 
log filled out and signed by the person accepting the shipment.  It is important that the designated 
study staff counts and verifies that the shipment contains all the items noted in the shipment 
inventory.  Any damaged or unusable study drug in a given shipment will be documented in the 
study files. The Site Investigator must notify the study Sponsor or their designee of any damaged 
or unusable study treatments that were supplied to the Site Investigator’s site. 
6.2.1 Formulation, Packaging, and Labeling 
The study drug is prepackaged in kits containing 98 sachets and ready for oral (or feeding tube) 
administration. The Site Investigator (SI) has the responsibility to ensure that the integrity of 
packaged study drug is not jeopardized prior to dispensing.  Each individual subject kit must be 
dispensed as provided with no further repackaging or labeling done at the investigational site, 
unless required by the institution per institutional polices. 
6.2.2 Product Storage and Stability 
The SI must ensure that all investigational drug supplies are kept in a locked, safe area at 
ambient temperature 15-25°C with access limited to authorized study staff. Investigational drug 
supplies should not be repackaged in any way.  
Once subjects have access to kits containing the sachets, they will be asked to store them away 
from moisture at room temperature. Stability has been assessed both at ICH standard and 
accelerated conditions for each of the individual active ingredients and they were found to be 
stable over five years. Drug product will receive regular stability testing over the course of the 
study to ensure product does not degrade. At least one month stability will be verified prior to 
initiation of the proposed trial. Subjects should contact the SI or their designee in the case of 
damaged goods; the SI or designee will coordinate with the Sponsor or their designee to 
determine the most appropriate remediation.  
6.2.3 Dispensing Product 
Drug product will be dispensed to subjects only after the SI has reviewed the necessary safety 
procedures for the subject to continue taking the study drug.  Safety procedures must be 


 
 
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performed every six (6) months to monitor safety.  Interim safety procedures can be done at each 
study visit, at the discretion of the SI.   
Drug product can be dispensed from the site to the subject using the following options:  
1. The drug product will be dispensed to the subject at the clinic visit. 
2. The drug product will be delivered to the subject’s home of residence through the use of a 
clinical supply chain courier company. 
3. Other options may be approved by the Sponsor on an ad hoc basis. 
  
6.3 
Dosage, Preparation and Administration of Study Intervention/Investigational 
Product 
 
It is recommended that the study drug be taken prior to a meal. Subjects should rip open the 
sachet of study drug and add it to a cup or other container and add approximately 8 oz. (1 cup) of 
room temperature water and stir vigorously. The study drug mixture should be consumed 
completely and within one hour of combining the contents of the sachet with water. The site 
personnel will provide oral instructions to the patients and will assist the patient through the first 
oral administration (Appendix VI).  
 
Subjects may resume normal eating and drinking after taking the study drug. 
 
Note on Antacids Within Two Hours of Study Drug Administration 
Antacids containing Aluminum hydroxide or smectite (aluminum oxide) may not be taken 
within two hours of administration of the study drug as they inhibit absorption of TUDCA.  
 
These include: 
o Alamag 
o Alumina and Magnesia 
o Antacid, Antacid M and Antacid Suspension 
o Gen-Alox 
o Kudrox 
o M.A.H. 
o Maalox HRF and Maalox TC  
o Magnalox 
o Madroxal 
o Mylanta and Mylanta Ultimate 
o Ri-Mox 


 
 
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o Rulox 
6.3.1  Feeding Tube Study Drug Administration 
For subjects with a gastrostomy or nasogastric (feeding) tube, the study drug may be dissolved in 
water as per the procedures outlined above in Section 6.3 and the study drug may be 
administered via the feeding tube.    
6.4 
Modification of Study Intervention/Investigational Product For A Subject 
Any dosage adjustment, including the reason for and dates of adjustment, will be documented in 
the CRF for each subject requiring this manipulation. The SI or designated licensed physician 
Sub-Investigator may reduce the dosage of study drug or discontinue the study drug in its 
entirety for adverse events (AEs) thought to be related to the study drug or for other reasons 
during the trial (the reason for, and dates of suspension or dose reduction must be documented). 
All dose modifications need to be discussed with the study Medical Monitor.  If the AE is mild 
or moderate, the dosage may be reduced until the event improves.  The SI or designated licensed 
physician Sub-Investigator may then choose to resume the higher dosage or maintain the subject 
at a reduced dosage.  
 
If the event is serious or life threatening, and deemed to be definitely drug related, the study drug 
will be discontinued immediately. Study subjects must remain off the study drug permanently. 
Subjects may not resume study drug.  All AEs will be followed to resolution within the study for 
28 days (+ 5 days) after a subject’s last dose of study drug.  
6.4.1. Dosage Discontinuation 
Reasons for discontinuation of study drug may include an AE, Medical Monitor or Site 
Investigator recommendation, Sponsor termination, protocol deviation, lost-to-follow-up, subject 
request, or death.  All serious adverse events (SAEs) that occur in a subject who has discontinued 
early must be recorded and reported within 24-hours of awareness.   
 
Study subjects who discontinue study drug prematurely (early termination from study) and 
decide to not remain in the modified intent-to-treat (ITT) portion of the study will be encouraged 
to return for a Final Safety/Early Termination Visit and participate in a Follow-Up Telephone 
Call 28 days (+ 5 days) after the last dose of study drug.  
 
All subjects who discontinue study drug early and choose to remain in the ITT portion of the 
study will be encouraged to follow the study visits, off drug, up to the time of the last visit 
(Follow-Up Telephone Call).   
 
SAEs will be followed for resolution for 28 days (+5 days) after a subject’s last dose of study 
drug, regardless of whether they prematurely discontinued study drug or completed 24 weeks of 
treatment.  


 
 
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6.5 
Study Drug Accountability Procedures  
At the completion of the study, there will be a final reconciliation of study drug shipped, drug 
consumed, and drug remaining. This reconciliation will be logged on the study drug 
reconciliation form, signed and dated.  Any discrepancies noted will be investigated, resolved, 
and documented prior to return or destruction of unused study drug.  Drug destroyed on site will 
be documented in the study files. 
6.6 
Assessment of Subject Compliance  
Subjects will be instructed to return empty and unused study drug containers at each clinic Visit 
(Weeks 6, 12, 18, and 24) or the Final Safety Visit (whichever occurs first). In the event that a 
remote study visit occurs, the subject will be instructed to return empty and unused study drug 
containers from previous study drug kits at the next clinic visit.  
Site staff will count returned and unused sachets to determine compliance.  
 
Non-compliance will be otherwise defined as taking less than 80% or more than 125% of study 
drug as determined by sachet counts.  If a study subject is non-compliant with study drug, the 
Site Investigator (SI) or designee should re-educate and train the subject in administration of 
study drug.  Data indicating non-compliance will be used in the end of study analysis.  
 
6.7 
Prior and Concomitant Therapy 
Throughout the study, Site Investigators (SIs) may prescribe concomitant medications or 
treatments deemed necessary to provide adequate supportive care provided that the medications 
are licensed in the United States. Study subjects should not receive other experimental agents 
during the study.  This includes marketed agents at experimental dosages that are being tested for 
the treatment of ALS.  All concomitant medications and/or treatments and significant non-drug 
therapies including supplements and assistive devices, received by a subject should be recorded 
on the appropriate source document and eCRF. 
 
Any investigational small molecule therapy being used or evaluated for the treatment of ALS is 
prohibited beginning 30 days prior to the Screening Visit and throughout the study. This 
includes, but is not limited to, the following:  
• Pioglitazone 
• Arimoclomol 
• Olanzapine 
• Tamoxifen 
• NP001 
• Mexiletine 
• Rasagiline 
• Masitinib 
• Dexpramipexole 
• Tirasemtiv 


 
 
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• Ibudilast 
• TW001 
• Inosine 
• RNS60 
• Acetyl-L-Carnitine 
• Methylcobalamine (if administered at doses equal to or greater than 25 mg per week) 
 
Use of any biologic therapy prior to this study excludes subjects from enrollment. This includes 
any cell or gene therapy under evaluation for the treatment of ALS and includes but is not 
limited to, the following:  
•  ISIS 333611 
•  Ionis SOD1R 
•  NurOwn 
•  Q-Cells 
•  NSI-566 
•  GM604 
•  GSK 1223249 
•  Treg cell therapies 
 
6.7.1 Prohibited Medications and Contraindications 
 
Prohibited Medications 
Throughout the course of the trial, study subjects should not be treated with the following 
medications.  If a Site Investigator learns that a subject has begun therapy with any of these 
medications, this should be reported to the Medical Monitor and Coordination Center 
immediately and the SI should make the determination whether to stop the study drug or the 
prohibited medication immediately, taking into account the health, safety and preference of the 
study subject.  
 
Agents which might impair bile acid processing or renal function are contraindicated with 
AMX0035. Prohibited medications include but are not limited to: 
 
• HDAC Inhibitors including: 
o Valproate 
o Vorinostat (Zolinza) 
o Romidepsin 
o Chidamide 
o Panobinostat 
o Lithium 


 
 
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o Butyrate  
o Suramin 
 
• Probenecid for potential kidney interaction 
 
• Antacids containing aluminum hydroxide or smectite (aluminum oxide) within two 
hours of administration of AMX0035. These inhibit absorption of TUDCA. These 
include: 
o Alamag 
o Alumina and Magnesia 
o Antacid, Antacid M and Antacid Suspension 
o Gen-Alox 
o Kudrox 
o M.A.H. 
o Maalox HRF and Maalox TC  
o Magnalox 
o Madroxal 
o Mylanta and Mylanta Ultimate 
o Ri-Mox 
o Rulox 
 
• Bile Acid Sequestrants including:  
o Cholestyramine and Cholestyramine Light 
o Questran and Questran Light 
o Welchol  
o Colestid and Colestid Flavored 
o Prevalite 
 
Pregnancy & Nursing Mothers 
There are no adequate and well-controlled studies in pregnant women.   Female subjects or 
female partners of male subjects should not become pregnant during the study or 3 months after 
stopping study drug.  
 
If a female subject becomes pregnant, study treatment must be discontinued immediately. If a 
female subject becomes pregnant during the course of the study, the Medical Monitor and 
Coordination Center should be contacted immediately. 
 
It is not known whether AMX0035 is excreted in human milk.  Caution should be exercised; 
therefore, no subject should nurse an infant while participating in this study. 
 


 
 
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7 
STUDY SCHEDULE 
No study procedures should be performed prior to the signing of the informed consent form 
(ICF). All subjects will sign an ICF prior to undergoing any study tests or procedures. It is 
recommended that the ALSFRS-R be completed first at every visit. After the ALSFRS-R it is 
recommended that SVC and ATLIS measurements are performed so as not to fatigue the subject 
with other testing.  Blood samples are recommended to be taken at the end of the study visits. 
The order of testing, however, will be at the discretion of each Site Investigator (SI). 
 
Visit windows are consecutive calendar days and the target visit dates are calculated from the 
Baseline Visit.   
 
Subjects who withdraw consent or early terminate from the study (i.e., discontinue study drug) 
will be asked to come in for a Final Safety Visit and have a Final Follow-up Telephone Call 28 
days (+5 days) after stopping study drug. 
7.1 
MR-PET Scheduling Call  
Subjects from all sites will be considered to participate in the MR-PET Sub-Study. The MR-PET 
Sub-Study procedures will be conducted at Massachusetts General Hospital (MGH) in Boston, 
MA. However, blood will be drawn for TSPO testing at the subject’s site during the Screening 
Visit. 
 
Subjects participating in the MR-PET Sub-Study may be consented over the phone by a 
medically licensed professional MGH study staff member to determine subject eligibility and to 
ensure the subject is safe to undergo the MR-PET scan.  These procedures include: 
o Obtain verbal pre-screening informed consent from subject 
o Assess MR-PET inclusion and exclusion criteria 
o Complete MR-PET safety questionnaire  
 
During this call, MR-PET Sub-Study procedures will be discussed in detail and the subject 
should be given the opportunity to ask questions about the MR-PET Sub-Study.  The MGH study 
staff will write a consent note to document the consenting process over the phone.  The written 
informed consent will be signed by the subject and the MGH Study Investigator at the MR-PET 
in-person visit.    
 
7.2 
Screening Visit 
The following procedures will be performed at an office visit to determine the subject’s 
eligibility for the study.  
o Obtain written informed consent from subject 
o Create Globally Unique Identifier (GUID) 
o Assess inclusion and exclusion criteria 
o Obtain medical history and demographics 
o Review and document concomitant medications and therapies 


 
 
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o Obtain ALS diagnosis history 
o Administer ALSFRS-R questionnaire 
o Perform pulmonary function testing including slow vital capacity (SVC)  
o Measure isometric strength using ATLIS machine 
o Assess and document adverse events (AEs) that occur after subject signs informed 
consent form (ICF) 
o Measure vital signs (blood pressure, heart and breathing rates, temperature) 
o Perform neurological examination  
o Perform comprehensive physical examination including height and weight 
o Perform 12-lead ECG (Electrocardiogram) 
o  [After other tests] Collect blood samples for clinical laboratory assessments including 
Hematology (CBC with differential), Complete Chemistry Panel, Liver Function Tests, 
and serum pregnancy test (for women of child-bearing potential [WOCBP]) 
o MR-PET SCAN SUBJECTS ONLY: TSPO Affinity Testing  
o Collect urine sample for urinalysis 
o Schedule the Baseline Visit  
 
MR-PET Scan:  For those subjects that consent to participate in the MR-PET scan sub-study, 
the scan will be scheduled/performed before the Baseline Visit at the MGH in Boston, MA.  At 
that time, blood will also be collected for peripheral blood mononuclear cell (PBMC) storage and 
analysis. 
7.2.1 Screen Failures 
Any subject who signs consent will be considered enrolled in the study.  If a subject fails 
screening, at a minimum, the following information should be captured and entered in the 
Electronic Data Capture (EDC) System: 
o Inclusion/Exclusion Criteria 
o Demographics 
o Reason for screen failure 
7.3 
MR-PET Visit 1 (Only for patients in MR-PET substudy) 
The following procedures will be performed at an office visit to determine the subject’s 
eligibility for the MR-PET sub-study.  
o Obtain written informed consent 
o Assess MR-PET inclusion and exclusion criteria 
o Complete MR-PET safety questionnaire  
o Perform the MR-PET Scan 
o Perform the Upper Motor Neuron-Burden (UMN-B) Scale  
o Measure vital signs (blood pressure, heart and breathing rates, temperature), and weight 
o Administer ALSFRS-R questionnaire 
o Collect blood for  
o Biomarker (PBMC) testing  


 
 
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o Pregnancy testing (for women of child bearing potential) 
o Review and document concomitant medications and therapies 
o Assess and document adverse events (AEs) that occur after subject signs informed 
consent form (ICF) 
 
MR-PET Follow-Up Call 
This visit will take place 24-48 hours after the MR-PET Visit 1.  The following procedures will 
be performed.  
o Assess and document AEs directly related to the MR-PET procedures 
 
7.4 
Baseline Visit 
This visit will take place a maximum of 42 days after the Screening Visit. The 42-day window 
allows those subjects participating in the MR-PET portion of the study to have their scans 
scheduled. Site staff are advised to schedule the baseline visit as soon as possible after 
determining eligibility.  The following procedures will be performed.  
o Confirm eligibility criteria are still met 
o Randomize subject using kit number from the study drug 
o Administer the C-SSRS baseline questionnaire 
o Administer ALSFRS-R questionnaire  
o Perform pulmonary function testing, including slow vital capacity (SVC)  
o Measure isometric strength using ATLIS machine 
o Review and document concomitant medications and therapies 
o Review and document Adverse Events since last visit and following study drug 
administration 
o Measure vital signs 
o [After other tests] Collect blood samples for clinical laboratory assessments including 
Hematology (CBC with differential), Complete Chemistry Panel, Liver Function Tests. 
o Collect blood sample for biomarkers 
o Collect pre-dose blood sample for pharmacokinetic analysis 
o Collect blood sample for optional DNA collection (Note: if Baseline visit has passed or 
blood sample for DNA was not collected, the blood sample should be collected at the 
next available visit) 
o Collect urine sample for urinalysis 
 
After all other visit activities are completed: 
o Dispense 6 weeks of study drug 
o Administer first dose of study drug. The healthcare staff member will advise the subject 
on appropriate administration (Appendix VI). The subject will be observed at the site for 
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site’s institutional/state regulations to assess medical status and any immediate reaction to 
the study drug. 
o Review and document any Adverse Events after first dose of study drug 
 
7.5 
Week 3 Clinic Visit  
This visit will take place 21±5 days after the Baseline Visit.  The following procedures will be 
performed.  
o Administer ALSFRS-R questionnaire  
o Review and document concomitant medications and therapies 
o Review and assess Adverse Events  
o Measure vital signs 
o Administer the C-SSRS questionnaire 
o Collect blood samples for clinical laboratory assessments including Hematology (CBC 
with differential), Complete Chemistry Panel, Liver Function Tests 
o Collect urine sample for urinalysis 
o Perform study drug accountability  
o Unless drug is not tolerated, advise subject to increase dosage level from one sachet to 
two sachets daily.  
o Schedule next study visit 
 
7.6 
Week 6 Clinic Visit  
This visit will take place 42±5 days after the Baseline Visit.  The following procedures will be 
performed.  
o Administer ALSFRS-R questionnaire  
o Perform pulmonary function testing, including slow vital capacity (SVC)  
o Measure isometric strength using ATLIS machine 
o Review and document concomitant medications and therapies 
o Review and assess Adverse Events  
o Measure vital signs 
o Administer the C-SSRS questionnaire 
o [After other tests] Collect blood samples for clinical laboratory assessments including 
Hematology (CBC with differential), Complete Chemistry Panel, Liver Function Tests 
o Collect blood sample for biomarkers 
o Collect urine sample for urinalysis 
o Perform study drug accountability and collect all unused study drug and empty containers 
o Dispense next 6 weeks of study drug 
o Schedule next study visit 
 
7.7 
Week 9 Telephone Visit  
This visit will take place 63±5 days after the Baseline Visit.  The following procedures will be 
performed.  
o Administer ALSFRS-R questionnaire  


 
 
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o Review and document concomitant medications and therapies 
o Assess and document AEs  
o Enquire about tolerance and compliance 
o Schedule next study visit 
o Remind subject to bring study drug to the Week 12 Visit  
 
7.8 
Week 12 Clinic Visit 
This visit will take place 84±5 days after the Baseline Visit. Subject must take study drug at 
the site upon beginning this visit due to the PK analysis.  It is recommended that this visit 
happens earlier in the day since the drug is administered in clinic. The following procedures will 
be performed: 
o Record day/time of previous study drug dose, including if the subject missed a dose.  
o Note time of last meal 
o Administer study drug and record time of administration 
o Collect blood sample for PK (i.e. at 1-hour or 4-hours post-dose) as indicated at the time 
of randomization 
o Administer ALSFRS-R questionnaire 
o Perform pulmonary function testing including slow vital capacity (SVC)  
o Measure isometric strength using ATLIS machine 
o Review and document concomitant medications and therapies 
o Review and assess Adverse Events  
o Measure vital signs 
o Perform neurological examination  
o Perform comprehensive physical examination including weight 
o Perform 12-lead ECG (Electrocardiogram) 
o Administer the C-SSRS questionnaire 
o  [After other tests] Collect blood samples for clinical laboratory assessments including 
Hematology (CBC with differential), Complete Chemistry Panel, Liver Function Tests 
o Collect blood sample for biomarkers 
o Collect urine sample for urinalysis 
o Perform study drug accountability and collect all unused study drug and empty containers 
o Dispense next 6 weeks of study drug 
o Schedule next study visit 
 
7.9 
Week 15 Phone Visit 
This visit will take place 105±5 days after the Baseline Visit.  The following procedures will be 
performed.  
o Administer ALSFRS-R questionnaire  
o Review and document concomitant medications and therapies 
o Assess and document AEs  
o Enquire about tolerance and compliance 
o Schedule next study visit 


 
 
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7.10 
Week 18 Clinic Visit  
This visit will take place 126±5 days after the Baseline Visit.  The following procedures will be 
performed.  
o Administer ALSFRS-R questionnaire  
o Perform pulmonary function testing including slow vital capacity (SVC)  
o Measure isometric strength using ATLIS machine 
o Review and document concomitant medications and therapies 
o Review and assess Adverse Events  
o Measure vital signs 
o Administer the C-SSRS questionnaire 
o [After other tests] Collect blood samples for clinical laboratory assessments including 
Hematology (CBC with differential), Complete Chemistry Panel, Liver Function Tests 
o Collect blood sample for biomarkers 
o Collect urine sample for urinalysis 
o Perform study drug accountability and collect all unused study drug and empty containers 
o Dispense next 6 weeks of study drug 
o Schedule next study visit 
7.11 
Week 21 Phone Visit  
This visit will take place 147±5 days after the Baseline Visit.  The following procedures will be 
performed.  
o Administer ALSFRS-R questionnaire  
o Review and document concomitant medications and therapies 
o Assess and document AEs  
o Enquire about tolerance and compliance 
o Schedule next study visit  
o Remind subject to bring study drug to clinic for the Week 24 Visit  
o Schedule MR-PET scan for those subjects participating in the MR-PET Sub-Study  
7.12 
MR-PET Visit 2 (Only for patients in MR-PET Substudy) 
This visit will take place between the Week 12 and Week 20 study visits. 
o Complete MR-PET safety questionnaire  
o Perform the MR-PET Scan 
o Perform the Upper Motor Neuron-Burden (UMN-B) Scale  
o Measure vital signs (blood pressure, heart and breathing rates, temperature), height, and 
weight 
o Administer ALSFRS-R questionnaire 
o Collect blood for  
o Biomarker (PBMC) testing  
o Pregnancy testing (for women of child bearing potential) 


 
 
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o Review and document concomitant medications and therapies 
o Assess and document adverse events (AEs)  
 
MR-PET Follow-Up Call 
This visit will take place 24-48 hours after the MR-PET Visit 2.  The following procedures will 
be performed.  
o Assess and document AEs directly related to the MR-PET procedures 
7.13 
Final Study Visit (Week 24)  
This visit will take place 168±5 days after the Baseline Visit.  Subject must take study drug 
upon beginning this visit due to the PK analysis.  It is recommended that this visit happens 
earlier in the day since the drug is administered in clinic. The following procedures will be 
performed: 
o Record day/time of previous study drug dose, including if the subject missed a dose 
o Record time of last meal   
o Administer study drug and record time of administration 
o Collect a single blood sample for PK (i.e. at 1 hour or 4 hours post-dose) as indicated at 
the time of randomization (Week 24 only, not Early Termination Subjects) 
o Administer ALSFRS-R questionnaire  
o Perform pulmonary function testing, including slow vital capacity (SVC) 
o Measure isometric strength using ATLIS machine 
o Review and document concomitant medications and therapies 
o Review Adverse Events  
o Measure vital signs 
o Perform neurological examination 
o Perform physical examination including weight 
o Perform 12-lead ECG (Electrocardiogram) 
o Administer the C-SSRS questionnaire 
o Exit questionnaire 
o [After other tests] Collect blood samples for clinical laboratory assessments including 
Hematology (CBC with differential), Complete Chemistry Panel, Liver Function Tests 
o Collect blood sample for biomarkers 
o Collect urine sample for urinalysis 
o Perform study drug accountability and collect all unused study drug and empty containers 
 
7.14 
Final Follow-up Telephone Call (Week 28) 
A follow-up phone call will take place 28 + 5 days (no earlier than 28 days) after the subject’s 
last dose of study drug. Subjects who enroll in the open label extension will not be required to 
complete this telephone call. The following will be performed.  
o Complete ALSFRS-R Questionnaire 
o Review and document concomitant medications and therapies 
o Assess and document AEs 
 


 
 
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7.15 
Withdrawal of Consent Final Safety Visit & Final Follow-up Telephone Call 
Subjects who withdraw consent will be asked to come in for a Final Safety Visit as soon as 
possible after consent withdrawal and to have a final Follow-Up Telephone Call 28 + 5 days (no 
earlier than 28 days) after the last dose of study drug.  
 
The following will be performed at the Final Safety Visit: 
o Administer ALSFRS-R questionnaire  
o Perform pulmonary function testing, including slow vital capacity (SVC)  
o Measure isometric strength using ATLIS machine 
o Review and document concomitant medications and therapies 
o Review Adverse Events  
o Measure vital signs 
o Perform physical examination including weight 
o Perform neurological examination  
o Perform 12-lead ECG (Electrocardiogram) 
o Administer the C-SSRS questionnaire 
o [After other tests] Collect blood samples for clinical laboratory assessments including 
Hematology (CBC with differential), Complete Chemistry Panel, Liver Function Tests 
o Collect blood sample for biomarkers 
o Collect urine sample for urinalysis 
o Perform study drug accountability and collect all unused study drug and empty containers 
 
The following procedures will be performed via telephone 28 +5 days after the last 
administration of study drug: 
o Administer ALSFRS-R questionnaire 
o Review and document concomitant medications and therapies 
o Assess and document AEs 
 
7.16 
Protocol Deviations 
A protocol deviation is any noncompliance with the clinical trial protocol.  The noncompliance 
may be either on the part of the subject, the Site Investigator, or the study site staff.  As a result 
of deviations, corrective actions are to be developed by the site and implemented promptly. 
 
 
All deviations from the protocol must be addressed in the subject’s source documents.  All major 
protocol deviations will be sent to the central IRB and entered in the Protocol Deviations Log in 
the Electronic Data Capture (EDC) System.  
7.16.1 Missed Visits and Procedures  
Missed visits and any procedures not performed (not attempted) for reasons other than illness, 
injury or progressive disability (i.e. subject is physically unable to perform test) will be reported 
as protocol deviations.   
 


 
 
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Procedures or visits not performed due to illness, injury or disability, including procedures that 
were attempted but failed (i.e. blood samples unable to be drawn after multiple attempts, or 
weight unable to be obtained due to subject immobility) will not be reported as protocol 
deviations.   
 
Study drug compliance that is outside the limits set in the study operations manual will be 
reported as a protocol deviation.   
 
In the event that a remote study visit occurs, the following procedures should be completed in the 
suggested order: ALSFRS-R, AE Review, Key Study Events, Concomitant Medications, 
Columbia-Suicide Severity Scale. Missed procedures during these remote visits will not be 
considered protocol deviations. 
 
Details and specific instructions regarding protocol deviations, including any exceptions to this 
standard procedure, are found in the Site Manual of Procedures. 
 
7.17 
Recording Deaths 
Information on whether a subject has died may be obtained by the subject’s family, clinic notes, 
or utilizing public means such as a reliable internet source such as the Centers for Disease 
Control and Prevention (CDC) National Death Index (http://www.cdc.gov/nchs/ndi.htm) or the 
Social Security Death Index (http://ssdmf.info/). 
 


 
 
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8 
CLINICAL ASSESSMENTS AND OUTCOME MEASURES 
8.1 
Clinical Variables 
Assessments will be performed at designated time-points throughout the study for clinical 
evaluation.  In addition to the assessments evaluated below, subjects will provide information on 
their demographics, past medical history, including ALS and cardiac history, as well as 
concomitant medication usage. 
8.1.1 Vital Signs, Height & Weight 
Vital signs will be obtained after the subject has been in a seated position for several minutes.  
Vital signs, including systolic and diastolic blood pressure, pulse rate (radial artery)/minute, 
respiratory rate/minute, temperature and weight will be assessed at specified visits.  Height will 
be measured and recorded at the Screening Visit only.   
8.1.2 Clinical Laboratory Assessments 
The following laboratory tests will be performed for safety: 
 
o Hematology with differential panel: complete blood count with differential (hematocrit, 
hemoglobin, platelet count, RBC indices, Total RBC, Total WBC, and WBC & 
differential)  
 
o Blood chemistry panel/Liver function tests (LFTs): alanine aminotransferase (ALT 
(SGPT)), aspartate aminotransferase  (AST (SGOT)), albumin, alkaline phosphatase, 
bicarbonate, blood urea nitrogen, calcium, chloride, creatinine, glucose, magnesium, 
phosphate, potassium, sodium, total bilirubin and total protein 
 
o Urinalysis: albumin, bilirubin, blood, clarity, color, glucose, ketones, nitrate, pH, protein, 
specific gravity, urobilinogen and WBC screen  
 
o Serum human chorionic gonadotrophin (hCG) for women of childbearing potential 
(WOCBP) (collected only at Screening Visit, and as necessary throughout course of 
study) 
 
All subjects will have safety laboratory tests at the designated visits outlined in the protocol. 
These samples will be analyzed at a central laboratory.  The Site Investigator (SI) may order 
additional testing, if needed, to further assess an adverse event (AE), or if there is any suspicion 
that a subject may be pregnant, throughout the course of the study. 
 
Specific instructions regarding the collection, processing, storage and shipment of these samples 
will be provided in the Site Manual of Procedures (MOP). 
 


 
 
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8.1.3 Biomarkers and Pharmacokinetic Analysis 
Subjects will have blood drawn to assess AMX0035 concentrations for pharmacokinetics (PK)  
pre-dose at the Baseline Visit and then again at either 1 hour or 4 hours (± 10 minutes) post-dose 
at the Week 12 and 24 visits. Every attempt should be made to collect samples within the allotted 
timeframes; however, all samples should be analyzed regardless of actual collection time. The 
time of administration will be noted.  The time of the last meal prior to administration and the 
time of the drug administration(s) in the previous 24 hours will also be noted.   
 
Additionally, blood will be collected for biomarker analysis, including light and heavy 
neurofilament testing (NF-L and pNF-H, respectively). Neurofilaments will be used as a 
mechanistic measure of neuronal death. These proteins are greatly elevated in ALS subjects and 
promising results from multiple trials suggest this marker may be prognostic of clinical decline. 
NF-L and pNF-H will be tested over multiple time points with the intention of generating a 
longitudinal dataset correlating neurofilament levels to observed clinical outcomes. This dataset 
will help to validate AMX0035 therapeutic mechanism and provide a dataset for the ALS field.  
 
All samples will be labeled with a code.  The code will not include any identifiable information.  
Coded blood samples will be stored at a central laboratory prior to PK and biomarker analysis 
and other research use. 
 
Specific instructions regarding the collection, processing, storage and shipment of these samples 
will be provided in the Site Manual of Procedures (MOP). 
8.1.4  Blood Samples for Future Research Use 
Subjects will provide an additional blood sample for storage in a biofluid biorepository at 
Barrow Neurological Institute.  Any research performed on the samples is for research purposes 
only. These samples will be used for broad future research use in motor neuron diseases.  All 
samples will be labeled with a code.  The code will not include any identifiable information.  
Results of future research will not be provided to the subject or his/her physician. 
 
There is no scheduled date on which the samples will be destroyed.  Samples may be stored for 
research until they are used, damaged, decayed or otherwise unfit for analysis. If a subject no 
longer wishes to participate in the study and withdraws consent, it will not be possible to destroy 
samples that may have already been used.  
Specific instructions regarding the collection, processing, storage and shipment of these samples 
will be provided in the Site Manual of Procedures (MOP). 
Subjects will have the opportunity to provide an additional optional blood sample for 
deoxyribonucleic acid (DNA) extraction for genome sequencing at the Baseline Visit.  
Deidentified blood samples will be sent to the New York Genome Center (NYGC) in New York 
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DNA may be stored, used in genome-wide association studies (GWAS), whole genome 
sequencing, exome sequencing, or for any other known or as yet undiscovered DNA analysis 
applicable to understanding or targeting disease, with a particular emphasis on ALS.  The 
information from these genetic studies may be made available to collaborators in academia, not-
for-profit settings, or industry for appropriate research.   Results of DNA testing from this study 
will not go into the participant’s medical record.   
 
The NYGC will be conducting the sequencing of the coded samples, doing the analysis of the 
sequencing and sharing the results of such sequencing and analysis with researchers pursuant to 
this protocol, as well as uploading the data to data repositories such as the National Institutes of 
Health (NIH) Database of Genotypes and Phenotypes (dbGaP).  
 
8.1.5  12-Lead Electrocardiogram (ECG) 
A standard 12-lead ECG will be performed.  Tracings will be reviewed by a central ECG reader 
and a copy of the tracings will be kept on site as part of the source documents. The central ECG 
vendor will provide standard ECG devices for every site and provide training as necessary.  
8.1.6 Physical Examination 
A comprehensive physical examination will be performed and recorded.   
8.1.7 Neurological Examination  
A neurological examination will be performed and recorded. Examination will include 
assessment of mental status, cranial nerves, motor and sensory function, reflexes, coordination, 
and stance/gait.   
 
8.1.8 Upper Motor Neuron-Burden (UMN-B) 
The Penn Upper Motor Neuron-Burden (UMN-B) is the total number of pathological UMN signs 
on examination including pathologically brisk biceps, supinator, triceps, finger, knee and ankle 
reflexes, and extensor plantar responses assessed bilaterally and brisk facial and jaw jerks.  The 
scale is a combination of Ashworth, Reflexes, and Pseudobulbar Affect scale (Range score: 0-
32). 
 
The UMN also includes scoring of the Center for Neurologic Study-Lability Scale (CNS-LS), a 
7-item self-report scale that assesses pseudobulbar affect (PBA) by measuring the perceived 
frequency of PBA episodes (laughing or crying).  Data is generated from the clinical exam and 
scored from 1-5, the lowest score indicating normal tone and the highest extreme spasticity. 
 
8.1.9 Columbia Suicide Severity Rating Scale (C-SSRS) 
The US FDA recommends the use of a suicidality assessment instrument that maps to the 
Columbia Classification Algorithm for Suicide Assessment (C-CASA)22. The C-CASA was 
developed to assist the FDA in coding suicidality data accumulated during the conduct of clinical 
trials of antidepressant drugs. One such assessment instrument is the Columbia Suicide Severity 


 
 
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Rating Scale (C-SSRS)23. The C-SSRS involves a series of probing questions to inquire about 
possible suicidal thinking and behavior. 
 
At the Baseline Visit, the C-SSRS Baseline version will be administered.  This version is used to 
assess suicidality over the subject’s lifetime. 
 
At all clinic visits after the Baseline Visit, the Since Last Visit version of the C-SSRS will be 
administered. This version of the scale assesses suicidality since the subject’s last visit. 
8.1.10  Exit Questionnaire 
An exit questionnaire will be completed by subjects and Site Investigators at the Final Study 
Visit (Week 24). This will include questions regarding blindedness and overall experience with 
the trial.  
 
8.1.11  Adverse Events 
Adverse events (AEs) will be documented at each study visit, including the Screening Visit once 
the informed consent form has been signed by the subject, and at all study visits, including the 
Final Telephone Call 28 days (+ 5 days) after the last dose of study drug.  Information on 
adverse effects of study drug and on inter-current events will be determined at each visit by 
direct questioning of the subjects, review of concomitant medications, and vital sign results.  
8.2 
Outcome Measures 
8.2.1 ALSFRS-R (Amyotrophic Lateral Sclerosis Functional Rating Scale – Revised) 
The ALSFRS-R is a quickly administered (5 minutes) ordinal rating scale (ratings 0-4) used to 
determine subjects' assessment of their capability and independence in 12 functional activities.  
All 12 activities are relevant in ALS. Initial validity was established by documenting that in ALS 
subjects, change in ALSFRS-R scores correlated with change in strength over time, was closely 
associated with quality of life measures, and predicted survival. The test-retest reliability is 
greater than 0.88 for all test items. The advantages of the ALSFRS-R are that the categories are 
relevant to ALS, it is a sensitive and reliable tool for assessing activities of daily living function 
in those with ALS, and it is quickly administered.  With appropriate training the ALSFRS-R can 
be administered with high inter-rater reliability and test-retest reliability.  The ALSFRS-R can be 
administered by phone with good inter-rater and test-retest reliability.  The equivalency of phone 
versus in-person testing, and the equivalency of study subject versus caregiver responses have 
also recently been established.  The ALSFRS-R will therefore also be given to the study subject 
over the phone.  All ALSFRS-R evaluators must be NEALS certified. 
8.2.2 Pulmonary Function Testing - Slow Vital Capacity (SVC) 
Slow Vital Capacity (SVC): The vital capacity (VC) (percent of predicted normal) will be 
determined, using the upright slow VC method. The VC can be measured using conventional 
spirometers that have had a calibration check prior to subject testing.  A printout from the 


 
 
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spirometer of all VC trials will be retained. All VC evaluators must be NEALS certified. Three 
VC trials are required for each testing session, however up to 5 trials may be performed if the 
variability between the highest and second highest VC is 10% or greater for the first 3 trials. 
Only the 3 best trials are recorded on the CRF. The highest VC recorded is utilized for eligibility.  
8.2.3 Isometric Strength Testing (ATLIS) 
Accurate Testing of Limb Isometric Strength: We are measuring isometric strength using the 
Accurate Testing of Limb Isometric Strength device (ATLIS) developed by Dr. Patricia Andres 
of Massachusetts General Hospital. The device was specifically designed to alleviate the 
reproducibility concerns that exist for prior strength measurements such as hand held 
dynamometry (HHD). ATLIS does not depend on experimenter strength, and has measurement 
settings to ensure that subjects are in the same position each time they are tested.  All ATLIS 
evaluators must be trained and certified. ATLIS may detect functional decline before the 
ALSFRS-R, which may have a ceiling effect, and may be able to detect changes in function with 
greater sensitivity to ALSFRS-R. The measure does show a small training effect, so we will 
include measurement at initial screening visit to allow subjects to become acquainted with the 
device. 
8.2.4 Neuroimaging MR-PET Sub-Study 
A subset of subjects will undergo MR-PET scans at the Baseline Visit and again between the 
Week 12 and 21 Visits.  Prior to the scan, every MR-PET sub-study subject will complete the 
MR-PET Safety Questionnaire.  Scanning procedures and subject instructions will be provided in 
the Site Manual of Procedures (MOP).  
8.2.5 Survival Assessment  
Survival endpoint will be considered as mortality, tracheostomy or permanent assisted 
ventilation.  
 
8.2.6 Training and Validation 
All evaluators must be NEALS certified to perform the ALSFRS-R, SVC and ATLIS; specific 
certification requirements are outlined in the study operations manual. Repeat NEALS 
certification will be required every two years for all NEALS certified outcome measures. It is 
strongly preferred that a single evaluator performs all measures throughout the study, if possible. 
NEALS certification is required for all evaluators prior to performing any study tests. 
 


 
 
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9 
SAFETY AND ADVERSE EVENTS 
The adverse event (AE) definitions and reporting procedures provided in this protocol comply 
with all applicable United States Food and Drug Administration (FDA) regulations and 
International Conference on Harmonization (ICH) guidelines.  The Site Investigator will 
carefully monitor each subject throughout the study for possible adverse events.  All AEs will be 
documented on CRFs designed specifically for this purpose.  It is also important to report all 
AEs, especially those that result in permanent discontinuation of the investigational product 
being studied, whether serious or non-serious. 
9.1 
Definitions of AEs, Suspected Adverse Drug Reactions & SAEs 
9.1.1 Adverse Event and Suspected Adverse Drug Reactions 
An adverse event (AE) is any unfavorable and unintended sign (including a clinically significant 
abnormal laboratory finding, for example), symptom, or disease temporally associated with a 
study, use of a drug product or device whether or not considered related to the drug product or 
device.  
 
Adverse drug reactions (ADR) are all noxious and unintended responses to a medicinal product 
related to any dose.  The phrase “responses to a medicinal product” means that a causal 
relationship between a medicinal product and an adverse event is at least a reasonable possibility, 
i.e., the relationship cannot be ruled out.  Therefore, a subset of AEs can be classified as 
suspected ADRs, if there is a causal relationship to the medicinal product. 
 
Examples of adverse events include: new conditions, worsening of pre-existing conditions, 
clinically significant abnormal physical examination signs (i.e. skin rash, peripheral edema, etc), 
or clinically significant abnormal test results (i.e. lab values or vital signs), with the exception of 
outcome measure results, which are not being recorded as adverse events in this trial (they are 
being collected, but analyzed separately). Stable chronic conditions (i.e., diabetes, arthritis) that 
are present prior to the start of the study and do not worsen during the trial are NOT considered 
adverse events.  Chronic conditions that occur more frequently (for intermittent conditions) or 
with greater severity, would be considered as worsened and therefore would be recorded as 
adverse events. 
 
Adverse events are generally detected in two ways: 
 
 
Clinical  symptoms reported by the subject or signs detected on examination. 
 
Ancillary Tests  abnormalities of vital signs, laboratory tests, and other diagnostic 
procedures (other than the outcome measures, the results of which are not being captured 
as AEs). 
 


 
 
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For the purposes of this study, symptoms of progression/worsening of ALS, including ‘normal’ 
progression, will be recorded as adverse events.     
 
The following measures of disease progression will not be recorded as adverse events even if 
they worsen (they are being recorded and analyzed separately): vital capacity results, ALSFRS-
R, and ATLIS results. 
 
If discernible at the time of completing the AE log, a specific disease or syndrome rather than 
individual associated signs and symptoms should be identified by the Site Investigator and 
recorded on the AE log.  However, if an observed or reported sign, symptom, or clinically 
significant laboratory anomaly is not considered by the Site Investigator to be a component of a 
specific disease or syndrome, then it should be recorded as a separate AE on the AE log.  
Clinically significant laboratory abnormalities, such as those that require intervention, are those 
that are identified as such by the Site Investigator. 
 
Subjects will be monitored for adverse events from the time they sign consent until completion 
of their participation in the study (defined as death, consent withdrawal, loss to follow up, early 
study termination for other reasons or following completion of the entire study).   
 
An unexpected adverse event is any adverse event, the specificity or severity of which is not 
consistent with the current Investigator’s Brochure.  An unexpected, suspected adverse drug 
reaction is any unexpected adverse event for which, in the opinion of the Site Investigator or 
Sponsor (or their designee), there is a reasonable possibility that the investigational product 
caused the event. 
9.1.2 Serious Adverse Events 
A serious adverse event (SAE) is defined as an adverse event that meets any of the following 
criteria: 
1. Results in death. 
2. Is life threatening: that is, poses an immediate risk of death as the event occurred. 
a. This serious criterion applies if the study subject, in the view of the Site 
Investigator or Sponsor, is at immediate risk of death from the AE as it occurs.  It 
does not apply if an AE hypothetically might have caused death if it were more 
severe. 
3. Requires in-patient hospitalization or prolongation of existing hospitalization. 
a. Hospitalization for an elective procedure (including elective PEG tube/g-
tube/feeding tube placement) or a routinely scheduled treatment is not an SAE by 
this criterion because an elective or scheduled “procedure” or a “treatment” is not 
an untoward medical occurrence. 
4. Results in persistent or significant disability or incapacity. 


 
 
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a. This serious criterion applies if the “disability” caused by the reported AE results 
in a substantial disruption of the subject’s ability to carry out normal life 
functions. 
5. Results in congenital anomaly or birth defect in the offspring of the subject (whether the 
subject is male or female).   
6. Necessitates medical or surgical intervention to preclude permanent impairment of a 
body function or permanent damage to a body structure. 
7. Important medical events that may not result in death, are not life-threatening, or do not 
require hospitalization may also be considered SAEs when, based upon appropriate 
medical judgment, they may jeopardize the subject and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition.  Examples of such 
medical events include blood dyscrasias or convulsions that do not result in in-patient 
hospitalization, or the development of drug dependency or drug abuse. 
 
An in-patient hospital admission in the absence of a precipitating, treatment-emergent, clinical 
adverse event may meet criteria for "seriousness" but is not an adverse experience, and will 
therefore, not be considered an SAE.  An example of this would include a social admission 
(subject admitted for other reasons than medical, e.g., lives far from the hospital, has no place to 
sleep). 
 
A serious, suspected adverse drug reaction (SUSAR) is an SAE for which, in the opinion of the 
Site Investigator or Sponsor, there is a reasonable possibility that the investigational product 
caused the event. 
 
The Site Investigator is responsible for classifying adverse events as serious or non-serious. 
9.2 
Assessment and Recording of Adverse Events 
The Site Investigator will carefully monitor each subject throughout the study for possible AEs.  
All AEs will be documented on source document templates and eCRFs designed specifically for 
this purpose.  All AEs will be collected and reported in the electronic data capture (EDC) system 
and compiled into reports for periodic reviewing by the Medical Monitor. The Medical Monitor 
shall promptly review all information relevant to the safety of the investigational product, 
including all serious adverse events (SAEs).  Special attention will be paid to those that result in 
permanent discontinuation of the investigational product being studied, whether serious or non-
serious. 
 
9.2.1 Assessment of Adverse Events 
At each visit (including telephone interviews), the subject will be asked if they have had any 
problems or symptoms since their last visit in order to determine the occurrence of adverse 
events.   If the subject reports an adverse event, the Investigator will probe further to determine: 
1. Type of event 
2. Date of onset and resolution (duration) 


 
 
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3. Severity (mild, moderate, severe) 
4. Seriousness (does the event meet the above definition for an SAE) 
5. Causality, relation to investigational product and disease 
6. Action taken regarding investigational product 
7. Outcome 
9.2.2 Relatedness of Adverse Event to Investigational Product 
 
The relationship of the AE to the investigational product should be specified by the Site 
Investigator, using the following definitions: 
 
1.  Not Related:          
Concomitant illness, accident or event with no reasonable 
association with treatment. 
 
2.  Unlikely: 
The reaction has little or no temporal sequence from administration 
of the investigational product, and/or a more likely alternative 
etiology exists. 
 
3.  Possibly Related: 
The reaction follows a reasonably temporal sequence from 
administration of the investigational product and follows a known 
response pattern to the suspected investigational product; the 
reaction could have been produced by the investigational product 
or could have been produced by the subject’s clinical state or by 
other modes of therapy administered to the subject. (Suspected 
ADR) 
 
4.  Probably Related: 
The reaction follows a reasonably temporal sequence from 
administration of investigational product; is confirmed by 
discontinuation of the investigational product or by re-challenge; 
and cannot be reasonably explained by the known characteristics 
of the subject’s clinical state. (Suspected ADR) 
 
5.  Definitely Related: 
The reaction follows a reasonable temporal sequence from 
administration of investigational product; that follows a known or 
expected response pattern to the investigational product; and that is 
confirmed by improvement on stopping or reducing the dosage of 
the investigational product, and reappearance of the reaction on 
repeated exposure. (Suspected ADR) 
 
 


 
 
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9.2.3  Adverse Events in Prior Human Experience with Each Individual Component 
 
TUDCA 
o A small number of subjects (>1%) receiving TUDCA have presented with abdominal 
discomfort, abdominal pain, diarrhea, nausea, emesis, pruritus, and rash. 
 
PB 
o Common adverse events include: menstrual irregularities (23%), decreased appetite (4%), 
sweat-like body odor (3%), and bad taste (3%) 
o Rare effects (<2%) have included Gastrointestinal: abdominal pain, gastritis, nausea and 
vomiting; constipation, rectal bleeding, peptic ulcer disease, and pancreatitis each 
occurred in one subject.  
o Hematologic: aplastic anemia and ecchymoses each occurred in one 
subject.  
o Cardiovascular: arrhythmia and edema each occurred in one subject.  
o Renal: renal tubular acidosis  
o Psychiatric: depression  
o Skin: rash  
o Miscellaneous: headache, syncope, and weight gain 
 
o Hypoalbuminemia, metabolic acidosis, alkalosis, hyperchloremia, hyperuricemia, 
hypokalemia, hypophosphatemia, hyperphosphatemia and hypernatremia have been 
observed. 
 
9.2.4 Recording of Adverse Events 
All clinical adverse events are recorded in the Adverse Event (AE) Log in the subject’s study 
binder. The site should fill out the AE Log and enter the AE information into the Electronic Data 
Capture (EDC) system within 48 hours of the site learning of a new AE or receiving an update 
on an existing AE.   
 
Please Note: Serious Adverse Events (SAEs) must be reported to the Medical Monitor and 
Coordination Center within 24 hours of the site learning of the SAE.  
 
Entries on the AE Log (and into the EDC) will include the following: name and severity of the 
event, the date of onset, the date of resolution, relationship to investigational product, action 
taken, and primary outcome of event.   
 
9.3 
Adverse Events and Serious Adverse Events - Reportable Events 
The following are considered reportable events and must be reported to the Medical Monitor and 
Coordination Center within 24 hours of the site being notified of the event.  
 
o All events that meet the above criteria for Serious Adverse Events (SAEs) 


 
 
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o Dosage Changes (Dose Management) 
o Investigational Product Suspension, Reduction or Re-challenge 
o Investigational Product Discontinuation 
 
o Key Study Events: 
o Subject Final Disposition 
o Feeding Tube Placement 
o Permanent Assisted Ventilation (PAV)* 
o Tracheostomy 
o Mortality 
o Pregnancy 
o Diaphragm Pacing System (DPS) device implantation 
o Emergency or Accidental Unblinding Events 
 
* Permanent Assisted Ventilation (PAV) is defined as more than 22 hours daily of non-invasive 
mechanical ventilation for more than one week (7 days).  The date of onset of PAV is the first 
day of the seven days. 
 


 
 
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10 
DATA AND SAFETY MONITORING AND STATISTICAL ANALYSIS PLAN 
10.1 
Data and Safety Monitoring Board 
An independent Data and Safety Monitoring Board (DSMB) will be assembled for the trial. The 
DSMB receives the blinded and unblinded summary reports of the frequency of all clinical 
adverse events and safety laboratory tests for planned periodic meetings as specified in the 
DSMB charter. In addition, the DSMB Chair may call ad hoc meetings. Meetings will be held 
via teleconference. A DSMB Charter will detail the processes of this group.   
 
Summaries of serious adverse events and enrollment will be provided approximately monthly to 
the DSMB by the Study Biostatisticians. Any possibly, probably or definitely study drug related,  
serious adverse events (i.e. serious adverse drug reactions, or SUSARs) are considered events of 
interest and will be reported in real-time (within 1 business day of Coordination Center (CC) 
awareness) to the DSMB. All adverse events and abnormal laboratory values results will be 
listed and will be completely identified (using MedDRA adverse reaction codes) by subject and 
center. The DSMB can ask to receive the SAE reports more frequently.  As necessary, the 
DSMB can review the frequencies of clinical and laboratory abnormalities.  Recommendations 
for modification or termination of the trial based on safety data will be made by the DSMB to the 
PIs and Steering Committee.  The DSMB will review safety data throughout the trial and may 
stop the trial for safety if they determine that there is a significant difference in the rate of a 
particular adverse event that would indicate a risk that is greater than the possible benefit of the 
study drug.  A notable increase in the frequency of any adverse event should be examined by the 
DSMB although it may not lead to a recommendation by the DSMB.  
 
Prior to each DSMB meeting, the CC will provide an update to the DSMB on enrollment, data 
quality (missing data) and protocol adherence.  The CC will be responsible for communication 
with the DSMB.   
 
Complete information can be found in the Data and Safety Monitoring Board Charter. 
 
10.2 
Statistical Considerations 
10.2.1 Statistical Methods 
A challenge in ALS is generating robust data on treatment effects without running prohibitively 
large studies. Our analysis of the PROACT and ceftriaxone de-identified subject databases 
suggests that statistical powering can be significantly improved by enrolling subjects who are 
<1.5 years from symptom onset and have a definite diagnosis of ALS according to El Escorial 
Criteria . Mixed-effects modeling was used to account for both the variance between subjects 
and the deviation within subjects from their average rate of decline. We plan to recruit subjects at 
a rate of at least 10/month to allow for complete enrollment of the study population within 14 
months. 
 


 
 
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Power for safety and tolerability was considered in three ways: incidence of adverse events 
(AEs), change in ALFSR-R and ATLIS, and change in biomarker such as pNF-H. 
 
With 88 treated subjects, we will have an 80% probability of detecting any adverse event 
expected to occur in at least 2% of treated subjects. We will have 80% power to detect a 28 
percentage point elevation in the rate of any adverse event relative to placebo based on a one-
tailed test at alpha = 0.05. We will consider a dose tolerable if the proportion of treatment 
failures (discontinuation of study drug due to an adverse event) is less than 40% with 80% 
confidence, one-tailed. With 88 treated subjects this would occur if 30 or fewer subjects on 
AMX0035 fail to complete the 6-month study. By this criterion, we will have 80% power for 
declaring AMX0035 tolerable at the tested dose if the true treatment failure rate is 30%. 
 
A shared-baseline, mixed-effects analysis will be used for primary analysis. A covariate of 
bulbar onset or onset elsewhere and a second covariate of age at enrollment will be included in 
the analysis. The mixed-effects model accounts for both the variance between subjects and the 
deviation within subjects from their average rate of decline. We will use the same analysis for 
clinical outcomes in this trial. We propose to test at an alpha of 0.05. 
 
Further detail on primary analysis and analysis rationale for secondary endpoints will be 
included in the Statistical Analysis Plan (SAP). 
10.2.2 Analysis for Safety 
The safety data will be summarized by treatment group. Treatment AEs will be coded and graded 
using MedDRA grading criteria.  The treatment groups will be compared with respect to 
occurrence of each adverse event and incidence of Grade III/IV adverse events. Total number of 
serious adverse events and abnormal laboratory tests will be compared between groups using 
Fisher's exact test. Withdrawal, abnormal laboratory tests, vital signs and use of concomitant 
medications will be assessed to characterize the safety profile of the combination of PB and 
TUDCA. Compliance data will be determined for each visit and by treatment group. The time to 
subject refusal will be compared between treatment groups to better determine tolerability. This 
will be accomplished using a method of survival analysis that allows informative censoring due 
to death. Descriptive statistics denoting the changes from baseline to the final assessment visit 
with respect to key laboratory parameters and vital signs will also be provided.  
 
Further detail will be provided in a statistical analysis plan.  
 
 
 


 
 
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10.2.3 Analysis for Efficacy 
Modified intention-to-treat analysis will be performed, including all randomized subjects 
receiving at least one dose of the study medication and having at least one primary efficacy 
assessment after randomization. Slope will be imputed from available data and time points. 
Homogeneity of clinical characteristics and efficacy variables at baseline between the two 
randomization groups (between-group baseline differences) will be assessed by analysis of 
variance for continuous variables and by a chi-squared test for discrete variables. All efficacy 
endpoints will compared between the two randomization groups at study end (between-group 
differences at study end) by means of analysis of covariance for continuous variables, adjusting 
for baseline value and for center effect, and by a chi-squared test for discrete variables. Survival 
time will compared between treatments by a Kaplan–Meier survival analysis.  
 
The primary analysis strategy will use a shared-baseline, mixed-effects model of ALSFRS-R 
progression rate. The mixed-effects model accounts for both the variance between subjects and 
the deviation within subjects from their average rate of decline. We will use the same analysis 
for clinical outcomes in this trial. We propose to test at an alpha of 0.05. We are targeting an 
effect size (slowing of ALSFRS-R slope) greater than 30% based on the trial by Elia et al17. In 
the Phase I/II trial of TUDCA that analyzed a total of 29 subjects, the ALSFRS-R score declined 
32.5% more slowly in the TUDCA group: the slopes of the two regression lines were 
significantly different (-0.262/week for the TUDCA group, -0.388/week for the placebo group; P 
< 0.01). 
10.2.4 Analysis Populations 
The modified intent to treat (ITT) population will include all study subjects who are randomized 
and receive at least one dose of study drug. The ITT population will be considered for primary 
analyses. For ITT analyses, subjects will be grouped based on randomized treatment, regardless 
of treatment actually received.  
 
10.3 
Missing Data 
The trial will be modified intent to treat (ITT). Every effort will be made to obtain follow-up 
information for all subjects whether or not they continue on treatment.  


 
 
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11 
DATA COLLECTION, MANAGEMENT AND MONITORING 
11.1 
Role of Data Management 
Data Management (DM) is the development, execution and supervision of plans, policies, 
programs, and practices that control, protect, deliver, and enhance the value of data and 
information assets. 
 
All data will be managed in compliance with applicable Sponsor (or their designee) policies and 
regulatory requirements. Site personnel will collect, transcribe, correct, and transmit the data 
onto source documents, Case Report Forms (CRFs), and other forms used to report, track and 
record clinical research data.  Clinical sites will be monitored to ensure compliance with data 
management requirements and Good Clinical Practices.  DM is responsible for developing, 
testing, and managing clinical data management activities. 
11.1.1 Data Entry and Checks 
The site personnel are encouraged to enter information into the Electronic Data Capture (EDC) 
System within 5 days of a visit.  Please Note: Serious Adverse Events (SAEs) must be reported 
to the Coordination Center within 24 hours of the site learning of the SAE.  Data collection is the 
responsibility of the staff at the site under the supervision of the Site Investigator (SI).  During 
the study, the Site Investigator must maintain complete and accurate documentation for the 
study. 
 
The EDC includes password protection.  An edit checking and data clarification process will be 
put in place to ensure accuracy and completeness of the database.  Logic and range checks as 
well as more sophisticated rules will be built into the EDC to provide immediate error checking 
of the data entered.  The system has the capability to automatically create electronic queries for 
forms that contain data that are out of range, out of window, missing or not calculated correctly.  
The sites will only have access to the queries concerning their subjects.   
11.1.2 Data Lock Process 
The application will have the ability to lock the database to prevent any modification of data 
once the study is closed.  Once this option is activated, every user will have Read-Only access to 
the data. The database can only be locked after each Site Investigator (SI) has signed off on their 
subjects and all queries have been resolved.   
11.1.3 Quality Assurance 
Protocol procedures are reviewed with the Site Investigator (SI) and associated personnel prior to 
the study to ensure the accuracy and reliability of data. Each SI must adhere to the protocol 
detailed in this document and agree that any changes to the protocol must be approved by the 
Coordination Center prior to seeking approval from the central IRB.  Each Site Investigator will 
be responsible for enrolling only those study subjects who have met protocol eligibility criteria. 


 
 
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11.2 
Clinical Monitoring 
Study Monitors will visit each study site to review source documentation materials, informed 
consent forms, and confirm entered data and that data queries have been accurately completed, 
and again at a study close-out visit.  Study Monitors will also verify that SAEs and protocol 
deviations have been reported appropriately, as required.  The Study Monitors will also review 
clinical facilities, resources and procedures for evaluating study subjects and study drug 
dispensing.  Subsequently, the Study Monitors will provide monitoring reports to the Project 
Manager and, if requested, will provide reports of protocol compliance to the Study Principal 
Investigator and the Steering Committee.  Completed informed consent forms from each subject 
must be available in the subject’s file and verified for proper documentation.  A document 
outlining the monitoring plan is provided to each Study Monitor. 
11.3 
Data Handling and Record Keeping 
The Site Investigator (SI) is responsible to ensure the accuracy, completeness, legibility, and 
timeliness of the data reported. All source documents should be completed in a neat, legible 
manner to ensure accurate interpretation of data. Dark ink is required to ensure clarity of 
reproduced copies.  When making changes or corrections, cross out the original entry with a 
single line, and initial and date the change. Do not erase, overwrite, or use correction fluid or 
tape on the original.  
 
Source document templates (SDTs) will be provided for use and maintained for recording data 
for each subject enrolled in the study. Data reported in the eCRF derived from source documents 
should be consistent with the source documents and discrepancies should be explained.  The 
Coordination Center will provide guidance to SIs on making corrections to the source documents 
and eCRFs. 
11.3.1 Confidentiality 
Study subject medical information obtained by this study is confidential, and disclosure to third 
parties other than those noted below is prohibited. Upon the subject’s permission, medical 
information may be given to his or her personal physician or other appropriate medical personnel 
responsible for his or her welfare. All local and federal guidelines and regulations regarding 
maintaining study subject confidentiality of data will be adhered to. 
 
Data generated by this study must be available for inspection by representatives of the US FDA, 
the Office for Human Research Protections (OHRP), the Sponsor, all pertinent national and local 
health and regulatory authorities, the Coordination Center or their representative, Study 
Monitoring personnel, and the central IRB. 
11.3.2 Study Discontinuation  
The study can be terminated at any time by the Sponsor, DSMB, or FDA.  Reasons for 
terminating the study may include the following: 
• The incidence or severity of AEs in this or other studies indicates a potential health 
hazard to study subjects. 


 
 
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• Study subject enrollment is unsatisfactory. 
• Data recording is inaccurate or incomplete. 
• Sponsor withdraws funding. 
11.3.3 Retention of Records 
US FDA regulations (21 CFR 312.62[c]) require that records and documents pertaining to the 
conduct of this study and the distribution of investigational drug, including CRFs (if applicable), 
consent forms, laboratory test results, and medical inventory records, must be retained by the 
Site Investigator (SI) for two years after marketing application approval.  If no application is 
filed, these records must be kept for two years after the investigation is discontinued and the US 
FDA and the applicable national and local health authorities are notified.  The Coordination 
Center or their representative will notify the Site Investigators of these events. The Site 
Investigators should retain all study documents and records until they are notified in writing by 
the Sponsor or their representative.  
11.3.4 Publications 
The Study Principal Investigator, 
, along with the Sponsor, Amylyx 
Pharmaceuticals, Inc., will be responsible for publications of results from this trial. Their 
responsibilities will include the following: 
• Analyze and interpret data gathered in this study, and write publications from these data. 
• Submit manuscripts to selected journals and address peer reviewers’ comments. 
• Submit abstracts to selected meetings and present data at the meetings. 
• Determine authorship on the basis of the Uniform Requirements for Manuscripts. 
 
 


 
 
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12 
LITERATURE REFERENCES 
1. Manfredi, G and Kawamata, H Mitochondria and endoplasmic reticulum crosstalk in 
amyotrophic lateral sclerosis. Neurobiology of Disease. 2015. 
2. Zhou, W et al. Phenylbutyrate up-regulates the DJ-1 protein and protects neurons in cell 
culture and in animal models of Parkinson disease. J Biol Chem. 2011. 
3. Suaud, L et Al. ERp29 Regulates F508 and Wild-type Cystic Fibrosis Transmembrane 
Conductance Regulator (CFTR) Trafficking to the Plasma Membrane in Cystic Fibrosis 
(CF) and Non-CF Epithelial Cells. JBC. 2011 
4. Ryu, H et al. Sodium phenylbutyrate prolongs survival and regulates expression of 
antiapoptotic genes in transgenic amyotrophic lateral sclerosis mice. J Neurochem. 2005. 
5. Gardian G, Browne SE, Choi DK, Klivenyi P, Gregorio J, Kubilus JK, Ryu H, Langley 
B, Ratan RR, Ferrante RJ, et al. Neuroprotective effects of phenylbutyrate in the N171- 
82Q transgenic mouse model of Huntington’s disease. J Biol Chem. 2005 
6. Ricobaraza A, Cuadrado-Tejedor M, Pérez-Mediavilla A, Frechilla D, Del Río J, García- 
Osta A. Phenylbutyrate ameliorates cognitive deficit and reduces tau pathology in an 
Alzheimer's disease mouse model. Neuropsychopharmacology. 2009 
7. Roy, A, et al. Sodium Phenylbutyrate Controls Neuroinflammatory and Antioxidant 
Activities and Protects Dopaminergic Neurons in Mouse Models of Parkinson’s Disease. 
PLoS ONE. 2012. 
8. Rodrigues, CM. et al. Tauroursodeoxycholic acid prevents Bax-induced membrane 
perturbation and cytochrome C release in isolated mitochondria. Biochemistry. 2003.  
9. Zhang et al. Aggregation-prone c9FTD/ALS poly(GA) RAN-translated proteins cause 
neurotoxicity by inducing ER stress. Acta Neuropath 2014 
10. Rodrigues et al. Tauroursodeoxycholic acid reduces apoptosis and protects against 
neurological injury after acute hemorrhagic stroke in rats. PNAS. 2003. 
11. Castro-Caldas et al. Tauroursodeoxycholic acid prevents MPTP-induced dopaminergic 
cell death in a mouse model of Parkinson's disease. J. Mol. Neurobiol. 2012 
12. Lewis CA, Manning J, Rossi F, Krieger C. The Neuroinflammatory Response in ALS: 
The Roles of Microglia and T Cells. Neurol Res Int 2012;2012:803701. 
13. Huang Y, Henry CJ, Dantzer R, Johnson RW, Godbout JP. Exaggerated sickness 
behavior and brain proinflammatory cytokine expression in aged mice in response to 
intracerebroventricular lipopolysaccharide. Neurobiol Aging 2008;29:1744-53. 
14. Berger A. Th1 and Th2 responses: what are they? BMJ 2000;321:424. 
15. Cudkowicz, ME et al. Phase 2 study of sodium phenylbutyrate in ALS. Amyotrophic 
Lateral Sclerosis. 2009. 
16. Hogarth, P. et al. Sodium Phenylbutyrate in Huntington’s Disease: A Dose-Finding 
Study. Movement Disorders. 2007.  
17. Elia, AE et al. Tauroursodeoxycholic acid in the treatment of subjects with amyotrophic 
lateral sclerosis. Eur J. Neurol. 2015. 


 
 
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18. Min, JH et al. Oral Solubilized Ursodeoxycholic Acid Therapy in Amyotrophic Lateral 
Sclerosis: A Randomized Cross-Over Trial. J. Korean Medical Science. 2012. 
19. Buphenyl 
Package 
Insert
 
 
20. Gilbert, J. et al. A phase I dose escalation and bioavailability study of oral sodium 
phenylbutyrate in patients with refractory solid tumor malignancies. Clin Cancer Res. 
2001. 
Gore, SD et al. Impact of the putative differentiating agent sodium phenylbutyrate on 
myelodysplastic syndromes and acute myeloid leukemia. Clin Cancer Res. 2001. 
21. Zurcher et al. Increased in vivo glial activation in subjects with amyotrophic lateral 
sclerosis: Assessed with [11C]-PBR28. Neuroimage Clin. 2015. 
22. Posner K, (et.al), Columbia Classification Algorithm of Suicide Assessment (C-CASA): 
Classification of Suicidal Events in the FDA’s Pediatric Suicidal Risk Analysis of 
Antidepressants, Am J Psychiatry, 2007, 164:1035-1043. 
23. September 2010 US FDA Draft Guidance for Industry Suicidality: Prospective 
Assessment of Occurrence in Clinical Trials 
 


 
 
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13 
APPENDICES 
13.1 APPENDIX I: EL ESCORIAL WORLD FEDERATION OF NEUROLOGY 
CRITERIA FOR THE DIAGNOSIS OF ALS 
 
Information obtained from the web site: www.wfnals.org. 
 
The diagnosis of Amyotrophic Lateral Sclerosis [ALS] requires:  
 
A - The presence of: 
 
(A:1) evidence of lower motor neuron (LMN) degeneration by clinical, electrophysiology
 
or neuropathologic examination,  
 
(A:2) evidence of upper motor neuron (UMN) degeneration by clinical examination, and  
 
(A:3) progressive spread of symptoms or signs within a region or to other regions, as 
determined by history or examination, together with 
 
B - The absence of: 
 
(B:1) electrophysiological and pathological evidence of other disease processes that 
might explain the signs of LMN and/or UMN degeneration, and  
 
(B:2) neuroimaging evidence of other disease processes that might explain the observed 
 
clinical and electrophysiological signs.  
 
CLINICAL STUDIES IN THE DIAGNOSIS OF ALS 
 
A careful history, physical and neurological examination must search for clinical evidence of 
UMN and LMN signs in four regions [brainstem, cervical, thoracic, or lumbosacral spinal cord] 
(see Table 1) of the central nervous system [CNS]. Ancillary tests should be reasonably applied, 
as clinically indicated, to exclude other disease processes. These should include 
electrodiagnostic, neurophysiological, neuroimaging and clinical laboratory studies.  Clinical 
evidence of LMN and UMN degeneration is required for the diagnosis of ALS.  The clinical 
diagnosis of ALS, without pathological confirmation, may be categorized into various levels of 
certainty by clinical assessment alone depending on the presence of UMN and LMN signs 
together in the same topographical anatomic region in either the brainstem [bulbar cranial motor 
neurons], cervical, thoracic, or lumbosacral spinal cord [anterior horn motor neurons]. The terms 
Clinical Definite ALS and Clinically Probable ALS are used to describe these categories of 
clinical diagnostic certainty on clinical criteria alone: 
 
A. Clinically Definite ALS is defined on clinical evidence alone by the presence of UMN, as 
well as LMN signs, in three regions.  
 
B. Clinically Probable ALS is defined on clinical evidence alone by UMN and LMN signs in at 
least two regions with some UMN signs necessarily rostral to (above) the LMN signs. 


 
 
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C. Clinically Probable ALS - Laboratory-supported is defined when clinical signs of UMN and 
LMN dysfunction are in only one region, or when UMN signs alone are present in one region, 
and LMN signs defined by EMG criteria are present in at least two limbs, with proper 
application of neuroimaging and clinical laboratory protocols to exclude other causes. 
 
D. Clinically Possible ALS is defined when clinical signs of UMN and LMN dysfunction are 
found together in only one region or UMN signs are found alone in two or more regions; or 
LMN signs are found rostral to UMN signs and the diagnosis of Clinically Probable - 
Laboratory-supported ALS cannot be proven by evidence on clinical grounds in conjunction with 
electrodiagnostic, neurophysiologic, neuroimaging or clinical laboratory studies. Other diagnoses 
must have been excluded to accept a diagnosis of Clinically Possible ALS. 
 
Table 1 
 
Brainstem  
Cervical  
Thoracic  
Lumbosacral  
Lower motor 
neuron signs 
weakness, 
atrophy, 
fasciculations  
jaw, face, 
palate, 
tongue, larynx  
neck, arm, hand, 
diaphragm  
back, 
abdomen  
back, abdomen, 
leg, foot  
Upper motor 
neuron signs 
pathologic spread 
of reflexes, clonus, 
etc.  
clonic jaw 
gag reflex 
exaggerated 
snout reflex 
pseudobulbar 
features 
forced yawning 
pathologic 
DTRs 
spastic tone  
clonic DTRs  
Hoffman reflex 
pathologic 
DTRs 
spastic tone 
 
preserved reflex 
in weak wasted 
limb  
loss of 
superficial 
abdominal 
reflexes 
pathologic 
DTRs 
spastic tone  
clonic DTRs - 
extensor plantar 
response 
pathologic DTRs 
spastic tone 
 
preserved reflex in 
weak wasted limb  
 


 
 
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13.2   APPENDIX II: ALS FUNCTIONAL RATING SCALE – REVISED (ALSFRS-R) 
ALSFRS-R 
 
QUESTIONS: 
 
 
 
 
 
 
 
SCORE: 
    
1. Speech 
4 = Normal speech processes 
3 = Detectable speech disturbances 
2 = Intelligible with repeating 
1 = Speech combined with nonvocal communication 
0 = Loss of useful speech 
 
2. Salivation 
4 = Normal 
3 = Slight but definite excess of saliva in mouth; may have nighttime drooling 
2 = Moderately excessive saliva; may have minimal drooling 
1 = Marked excess of saliva with some drooling 
0 = Marked drooling; requires constant tissue or handkerchief 
 
3. Swallowing 
4 = Normal eating habits 
3 = Early eating problems – occasional choking 
2 = Dietary consistency changes 
1 = Needs supplemental tube feeding 
0 = NPO (exclusively parenteral or enteral feeding) 
 
4. Handwriting 
4 = Normal 
3 = Slow or sloppy; all words are legible 
2 = Not all words are legible 
1 = No words are legible but can still grip a pen  
0 = Unable to grip pen 
 
5a. Cutting Food and Handling Utensils (subjects without gastrostomy) 
 
 
 
4 = Normal 
3 = Somewhat slow and clumsy, but no help needed 
2 = Can cut most foods, although clumsy and slow; some help needed 
1 = Food must be cut by someone, but can still feed slowly 
0 = Needs to be fed 
 


 
 
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5b. Cutting Food and Handling Utensils (alternate scale for subjects with gastrostomy) 
4 = Normal 
3 = Clumsy, but able to perform all manipulations independently 
2 = Some help needed with closures and fasteners 
1 = Provides minimal assistance to caregivers 
0 = Unable to perform any aspect of task 
 
6. Dressing and Hygiene 
4 = Normal function 
3 = Independent, can complete self-care with effort or decreased efficiency 
2 = Intermittent assistance or substitute methods 
1 = Needs attendant for self-care 
0 = Total dependence 
 
7. Turning in Bed and Adjusting Bed Clothes 
4 = Normal function 
3 = Somewhat slow and clumsy, but no help needed 
2 = Can turn alone, or adjust sheets, but with great difficulty 
1 = Can initiate, but not turn or adjust sheets alone 
0 = Helpless 
 
8. Walking 
4 = Normal 
3 = Early ambulation difficulties 
2 = Walks with assistance 
1 = Nonambulatory functional movement only 
0 = No purposeful leg movement 
 
9. Climbing Stairs 
4 = Normal 
3 = Slow 
2 = Mild unsteadiness or fatigue 
1 = Needs assistance 
0 = Cannot do 
 


 
 
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R-1. Dyspnea  
 
 
 
4 = None 
3 = Occurs when walking 
2 = Occurs with one or more of the following: eating, bathing, dressing 
1 = Occurs at rest, difficulty breathing when either sitting or lying 
0 = Significant difficulty, considering using mechanical respiratory support 
 
R-2 Orthopnea 
 
 
 
4 = None 
3 = Some difficulty sleeping at night due to shortness of breath, does not routinely use more than 
two pillows 
2 = Needs extra pillow in order to sleep (more than two) 
1 = Can only sleep sitting up 
0 = Unable to sleep without mechanical assistance 
 
R-3 Respiratory Insufficiency 
 
4 = None 
3 = Intermittent use of BiPAP 
2 = Continuous use of BiPAP during the night 
1 = Continuous use of BiPAP during the night and day 
0 = Invasive mechanical ventilation by intubation or tracheostomy 
  
 
Evaluator’s Initials: _____ _____ ______ 
 


 
 
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13.3   APPENDIX III: COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS) 
BASELINE VERSION  
 
Information obtained from: http://www.cssrs.columbia.edu/ 
 
SUICIDAL IDEATION  
Ask questions 1 and 2. If both are negative, proceed to “Suicidal Behavior” section. If the 
answer to question 2 is “yes”, ask questions 3, 4 and 5. If the answer to question 1 
and/or 2 is “yes”, complete “Intensity of Ideation” section below.  
Lifetime:  
Time 
He/She 
Felt Most 
Suicidal  
1. Wish to be Dead  
Subject endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake 
up.  
Have you wished you were dead or wished you could go to sleep and not wake up?  
If yes, describe:  
Yes No  
□ □  
2. Non-Specific Active Suicidal Thoughts  
General, non-specific thoughts of wanting to end one’s life/commit suicide (e.g., “I’ve thought about killing 
myself”) without thoughts of ways to kill oneself/associated methods, intent, or plan.  
Have you actually had any thoughts of killing yourself?  
If yes, describe:  
Yes No  
 □ □  
3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act  
Subject endorses thoughts of suicide and has thought of at least one method during the assessment period. 
This is different than a specific plan with time, place or method details worked out (e.g., thought of method to 
kill self but not a specific plan). Includes person who would say, “I thought about taking an overdose but I 
never made a specific plan as to when, where or how I would actually do it…and I would never go through with 
it.”  
Have you been thinking about how you might do this?  
If yes, describe:  
Yes No  
 □ □  
4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan  
Active suicidal thoughts of killing oneself and subject reports having some intent to act on such thoughts, as 
opposed to “I have the thoughts but I definitely will not do anything about them.”  
Have you had these thoughts and had some intention of acting on them?  
If yes, describe:  
Yes No  
 □ □  
5. Active Suicidal Ideation with Specific Plan and Intent  
Thoughts of killing oneself with details of plan fully or partially worked out and subject has some intent to carry 
it out.  
Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry 
out this plan?  
If yes, describe:  
Yes No  
 □ □  
INTENSITY OF IDEATION  
The following features should be rated with respect to the most severe type of ideation (i.e., 1-5 
from above, with 1 being the least severe and 5 being the most severe). Ask about time he/she 
was feeling the most suicidal.  
_____ _________________________________________________  
Most Severe Ideation:  
Type # (1-5) Description of Ideation  
Most 
Severe  
Frequency  
How many times have you had these thoughts?  
(1) Less than once a week (2) Once a week (3) 2-5 times in week (4) Daily or almost daily (5) Many times 
each day  
____  


 
 
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Duration  
When you have the thoughts, how long do they last?  
(1) Fleeting - few seconds or minutes (4) 4-8 hours/most of day  
(2) Less than 1 hour/some of the time (5) More than 8 hours/persistent or continuous  
(3) 1-4 hours/a lot of time  
____  
Controllability  
Could/can you stop thinking about killing yourself or wanting to die if you want to?  
(1) Easily able to control thoughts (4) Can control thoughts with a lot of difficulty  
(2) Can control thoughts with little difficulty (5) Unable to control thoughts  
(3) Can control thoughts with some difficulty (0) Does not attempt to control thoughts  
____  
Deterrents  
Are there things - anyone or anything (e.g., family, religion, pain of death) - that 
stopped you from wanting to die or acting on thoughts of committing suicide?  
(1) Deterrents definitely stopped you from attempting suicide (4) Deterrents most likely did not stop you  
(2) Deterrents probably stopped you (5) Deterrents definitely did not stop you  
(3) Uncertain that deterrents stopped you (0) Does not apply  
____  
Reasons for Ideation  
What sort of reasons did you have for thinking about wanting to die or killing 
yourself? Was it to end the pain or stop the way you were feeling (in other words you 
couldn’t go on living with this pain or how you were feeling) or was it to get attention, 
revenge or a reaction from others? Or both?  
(1) Completely to get attention, revenge or a reaction from others (4) Mostly to end or stop the pain (you 
couldn’t go on  
(2) Mostly to get attention, revenge or a reaction from others living with the pain or how you were feeling)  
(3) Equally to get attention, revenge or a reaction from others (5) Completely to end or stop the pain (you 
couldn’t go on  
and to end/stop the pain. living with the pain or how you were feeling)  
(0) Does not apply  
____  
 
SUICIDAL BEHAVIOR  
(Check all that apply, so long as these are separate events; must ask about all types)  
Lifetime  
Actual Attempt:  
A potentially self-injurious act committed with at least some wish to die, as a result of act. Behavior was in 
part thought of as method to kill oneself. Intent does not have to be 100%. If there is any intent/desire to die 
associated with the act, then it can be considered an actual suicide attempt. There does not have to be 
any injury or harm, just the potential for injury or harm. If person pulls trigger while gun is in mouth but 
gun is broken so no injury results, this is considered an attempt.  
Inferring Intent: Even if an individual denies intent/wish to die, it may be inferred clinically from the behavior or 
circumstances. For example, a highly lethal act that is clearly not an accident so no other intent but suicide 
can be inferred (e.g., gunshot to head, jumping from window of a high floor/story). Also, if someone denies 
intent to die, but they thought that what they did could be lethal, intent may be inferred.  
Have you made a suicide attempt?  
Have you done anything to harm yourself?  
Have you done anything dangerous where you could have died?  
What did you do?  
Did you______ as a way to end your life?  
Did you want to die (even a little) when you_____?  
Were you trying to end your life when you _____?  
Or did you think it was possible you could have died from_____?  
Or did you do it purely for other reasons / without ANY intention of killing yourself (like 
to relieve stress, feel better, get sympathy, or get something else to happen)? (Self-
Injurious Behavior without suicidal intent)  
If yes, describe:  
Has subject engaged in Non-Suicidal Self-Injurious Behavior?  
Yes No  
□ □  
 
Total # of  
Attempts  
______  
 
Yes No  
□ □  


 
 
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Interrupted Attempt:  
When the person is interrupted (by an outside circumstance) from starting the potentially self-injurious act (if 
not for that, actual attempt would have occurred).  
Overdose: Person has pills in hand but is stopped from ingesting. Once they ingest any pills, this becomes an 
attempt rather than an interrupted attempt. Shooting: Person has gun pointed toward self, gun is taken away 
by someone else, or is somehow prevented from pulling trigger. Once they pull the trigger, even if the gun 
fails to fire, it is an attempt. Jumping: Person is poised to jump, is grabbed and taken down from ledge. 
Hanging: Person has noose around neck but has not yet started to hang - is stopped from doing so.  
Has there been a time when you started to do something to end your life but someone 
or something stopped you before you actually did anything?  
If yes, describe:  
Yes No  
□ □  
 
Total # of 
interrupted  
______  
Aborted Attempt:  
When person begins to take steps toward making a suicide attempt, but stops themselves before they 
actually have engaged in any self-destructive behavior. Examples are similar to interrupted attempts, except 
that the individual stops him/herself, instead of being stopped by something else.  
Has there been a time when you started to do something to try to end your life but 
you stopped yourself before you actually did anything?  
If yes, describe:  
Yes No  
□ □  
 
Total # of  
aborted  
______  
Preparatory Acts or Behavior:  
Acts or preparation towards imminently making a suicide attempt. This can include anything beyond a 
verbalization or thought, such as assembling a specific method (e.g., buying pills, purchasing a gun) or 
preparing for one’s death by suicide (e.g., giving things away, writing a suicide note).  
Have you taken any steps towards making a suicide attempt or preparing to kill 
yourself (such as collecting pills, getting a gun, giving valuables away or writing a 
suicide note)?  
If yes, describe:  
Yes No  
□ □  
Suicidal Behavior:  
Suicidal behavior was present during the assessment period?  
Yes No  
□ □  
Answer for Actual Attempts Only  
Most 
Recent  
Attempt  
Date:  
Most 
Lethal  
Attempt  
Date:  
Initial/First  
Attempt  
Date:  
Actual Lethality/Medical Damage:  
0. No physical damage or very minor physical damage (e.g., surface scratches).  
1. Minor physical damage (e.g., lethargic speech; first-degree burns; mild bleeding; 
sprains).  
2. Moderate physical damage; medical attention needed (e.g., conscious but 
sleepy, somewhat responsive; second-degree burns; bleeding of major 
vessel).  
3. Moderately severe physical damage; medical hospitalization and likely intensive 
care required (e.g., comatose with reflexes intact; third-degree burns less 
than 20% of body; extensive blood loss but can recover; major fractures).  
4. Severe physical damage; medical hospitalization with intensive care required 
(e.g., comatose without reflexes; third-degree burns over 20% of body; 
extensive blood loss with unstable vital signs; major damage to a vital area).  
5. Death  
Enter 
Code  
______  
Enter 
Code  
______  
Enter Code  
______  
Potential Lethality: Only Answer if Actual Lethality=0  
Likely lethality of actual attempt if no medical damage (the following examples, 
while having no actual medical damage, had potential for very serious lethality: put 
gun in mouth and pulled the trigger but gun fails to fire so no medical damage; 
laying on train tracks with oncoming train but pulled away before run over).  
0 = Behavior not likely to result in injury  
1 = Behavior likely to result in injury but not likely to cause death  
2 = Behavior likely to result in death despite available medical care  
Enter 
Code  
______  
Enter 
Code  
______  
Enter Code  
______  
 
 


 
 
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13.4   APPENDIX IV: COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS) 
SINCE LAST VISIT VERSION 
 
Information obtained from: http://www.cssrs.columbia.edu/ 
 
SUICIDAL IDEATION  
Ask questions 1 and 2. If both are negative, proceed to “Suicidal Behavior” section. If the 
answer to question 2 is “yes”, ask questions 3, 4 and 5. If the answer to question 1 and/or 2 is 
“yes”, complete “Intensity of Ideation” section below.  
Since 
Last 
Visit  
1. Wish to be Dead  
Subject endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up.  
Have you wished you were dead or wished you could go to sleep and not wake up?  
If yes, describe:  
Yes No  
□     □  
2. Non-Specific Active Suicidal Thoughts  
General, non-specific thoughts of wanting to end one’s life/commit suicide (e.g., “I’ve thought about killing myself”) 
without thoughts of ways to kill oneself/associated methods, intent, or plan during the assessment period.  
Have you actually had any thoughts of killing yourself?  
If yes, describe:  
Yes No  
□     □ 
3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act  
Subject endorses thoughts of suicide and has thought of at least one method during the assessment period. This is 
different than a specific plan with time, place or method details worked out (e.g., thought of method to kill self but not a 
specific plan). Includes person who would say, “I thought about taking an overdose but I never made a specific plan as 
to when, where or how I would actually do it…and I would never go through with it.”  
Have you been thinking about how you might do this?  
If yes, describe:  
Yes No  
□     □ 
4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan  
Active suicidal thoughts of killing oneself and subject reports having some intent to act on such thoughts, as opposed 
to “I have the thoughts but I definitely will not do anything about them.”  
Have you had these thoughts and had some intention of acting on them?  
If yes, describe:  
Yes No  
□     □  
5. Active Suicidal Ideation with Specific Plan and Intent  
Thoughts of killing oneself with details of plan fully or partially worked out and subject has some intent to carry it out.  
Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this 
plan?  
If yes, describe:  
Yes No  
□     □   
INTENSITY OF IDEATION  
The following features should be rated with respect to the most severe type of ideation (i.e., 1-5 from 
above, with 1 being the least severe and 5 being the most severe).  
Most Severe Ideation: _____ _________________________________________________  
Type # (1-5) Description of Ideation  
Most 
Severe  
Frequency  
How many times have you had these thoughts?  
(1) Less than once a week (2) Once a week (3) 2-5 times in week (4) Daily or almost daily (5) Many times each day  
____  
Duration  
When you have the thoughts, how long do they last?  
(1) Fleeting - few seconds or minutes (4) 4-8 hours/most of day  
(2) Less than 1 hour/some of the time (5) More than 8 hours/persistent or continuous  
(3) 1-4 hours/a lot of time  
____  
Controllability  
Could/can you stop thinking about killing yourself or wanting to die if you want to?  
(1) Easily able to control thoughts (4) Can control thoughts with a lot of difficulty  
(2) Can control thoughts with little difficulty (5) Unable to control thoughts  
(3) Can control thoughts with some difficulty (0) Does not attempt to control thoughts  
____  


 
 
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Deterrents  
Are there things - anyone or anything (e.g., family, religion, pain of death) - that stopped you 
from wanting to die or acting on thoughts of committing suicide?  
(1) Deterrents definitely stopped you from attempting suicide (4) Deterrents most likely did not stop you  
(2) Deterrents probably stopped you (5) Deterrents definitely did not stop you  
(3) Uncertain that deterrents stopped you (0) Does not apply  
____  
Reasons for Ideation  
What sort of reasons did you have for thinking about wanting to die or killing yourself? Was 
it to end the pain or stop the way you were feeling (in other words you couldn’t go on living 
with this pain or how you were feeling) or was it to get attention, revenge or a reaction from 
others? Or both?  
(1) Completely to get attention, revenge or a reaction from others (4) Mostly to end or stop the pain (you couldn’t go on  
(2) Mostly to get attention, revenge or a reaction from others living with the pain or how you were feeling)  
(3) Equally to get attention, revenge or a reaction from others (5) Completely to end or stop the pain (you couldn’t go 
on  
and to end/stop the pain living with the pain or how you were feeling)  
(0) Does not apply  
____  
 
SUICIDAL BEHAVIOR  
(Check all that apply, so long as these are separate events; must ask about all types)  
Since 
Last Visit  
Actual Attempt:  
A potentially self-injurious act committed with at least some wish to die, as a result of act. Behavior was in part 
thought of as method to kill oneself. Intent does not have to be 100%. If there is any intent/desire to die associated 
with the act, then it can be considered an actual suicide attempt. There does not have to be any injury or 
harm, just the potential for injury or harm. If person pulls trigger while gun is in mouth but gun is broken so no 
injury results, this is considered an attempt.  
Inferring Intent: Even if an individual denies intent/wish to die, it may be inferred clinically from the behavior or 
circumstances. For example, a highly lethal act that is clearly not an accident so no other intent but suicide can be 
inferred (e.g., gunshot to head, jumping from window of a high floor/story). Also, if someone denies intent to die, but 
they thought that what they did could be lethal, intent may be inferred.  
Have you made a suicide attempt?  
Have you done anything to harm yourself?  
Have you done anything dangerous where you could have died?  
What did you do?  
Did you______ as a way to end your life?  
Did you want to die (even a little) when you_____?  
Were you trying to end your life when you _____?  
Or did you think it was possible you could have died from_____?  
Or did you do it purely for other reasons / without ANY intention of killing yourself (like to 
relieve stress, feel better, get sympathy, or get something else to happen)? (Self-Injurious 
Behavior without suicidal intent)  
If yes, describe:  
Has subject engaged in Non-Suicidal Self-Injurious Behavior?  
Yes No  
□  □  
 
Total # of  
Attempts  
______  
 
Yes No  
□  □  
Interrupted Attempt:  
When the person is interrupted (by an outside circumstance) from starting the potentially self-injurious act (if not for 
that, actual attempt would have occurred).  
Overdose: Person has pills in hand but is stopped from ingesting. Once they ingest any pills, this becomes an 
attempt rather than an interrupted attempt. Shooting: Person has gun pointed toward self, gun is taken away by 
someone else, or is somehow prevented from pulling trigger. Once they pull the trigger, even if the gun fails to fire, it 
is an attempt. Jumping: Person is poised to jump, is grabbed and taken down from ledge. Hanging: Person has 
noose around neck but has not yet started to hang - is stopped from doing so.  
Has there been a time when you started to do something to end your life but someone or 
something stopped you before you actually did anything?  
If yes, describe:  
Yes No  
□  □  
 
Total # of 
interrupted  
______  


 
 
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Aborted Attempt:  
When person begins to take steps toward making a suicide attempt, but stops themselves before they actually have 
engaged in any self-destructive behavior. Examples are similar to interrupted attempts, except that the individual 
stops him/herself, instead of being stopped by something else.  
Has there been a time when you started to do something to try to end your life but you 
stopped yourself before you actually did anything?  
If yes, describe:  
Yes No  
□  □  
 
Total # of  
aborted  
______  
Preparatory Acts or Behavior:  
Acts or preparation towards imminently making a suicide attempt. This can include anything beyond a verbalization 
or thought, such as assembling a specific method (e.g., buying pills, purchasing a gun) or preparing for one’s death 
by suicide (e.g., giving things away, writing a suicide note).  
Have you taken any steps towards making a suicide attempt or preparing to kill yourself 
(such as collecting pills, getting a gun, giving valuables away or writing a suicide note)?  
If yes, describe:  
Yes No  
□  □  
Suicidal Behavior:  
Suicidal behavior was present during the assessment period?  
Yes No  
□  □  
Suicide:  
Yes No  
□  □ 
Answer for Actual Attempts Only  
Most Lethal 
Attempt  
Date:  
Actual Lethality/Medical Damage:  
0. No physical damage or very minor physical damage (e.g., surface scratches).  
1. Minor physical damage (e.g., lethargic speech; first-degree burns; mild bleeding; sprains).  
2. Moderate physical damage; medical attention needed (e.g., conscious but sleepy, somewhat responsive; second-
degree burns; bleeding of major vessel).  
3. Moderately severe physical damage; medical hospitalization and likely intensive care required (e.g., comatose 
with reflexes intact; third-degree burns less than 20% of body; extensive blood loss but can recover; major 
fractures).  
4. Severe physical damage; medical hospitalization with intensive care required (e.g., comatose without reflexes; 
third-degree burns over 20% of body; extensive blood loss with unstable vital signs; major damage to a vital area).  
5. Death  
 
Enter Code  
______  
Potential Lethality: Only Answer if Actual Lethality=0  
Likely lethality of actual attempt if no medical damage (the following examples, while having no actual medical 
damage, had potential for very serious lethality: put gun in mouth and pulled the trigger but gun fails to fire so no 
medical damage; laying on train tracks with oncoming train but pulled away before run over).  
0 = Behavior not likely to result in injury  
1 = Behavior likely to result in injury but not likely to cause death  
2 = Behavior likely to result in death despite available medical care  
 
Enter Code  
______  
 
 
 


 
 
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13.5   APPENDIX V: CENTER FOR NEUROLOGICAL STUDY – LABILITY SCALE 
INSTRUCTIONS  
 
 
 
 
 
 
 
 
 
 
The purpose of this questionnaire is to help us better understand your neurologic problems.  Please read each statement, and using the scale below, determine the 
degree to which it has applied to you DURING THE PAST WEEK.  Circle the appropriate answer, or if you need help in marking your responses, tell the 
interviewer the number of the best response.   Please choose only one response for each item. 
 
Evaluator’s Initials: _____ ______ ______   
 
 
 
 
 
 
 
Total: __________________ 
Please select the number that describes the degree to which each item has applied to you DURING THE PAST WEEK. 
 
Does not 
Apply 
1 
Rarely 
Applies 
2 
Occasionally   
Applies 
3 
Frequently  
Applies 
4 
Applies 
Most  
of the Time 
5 
1. There are times when I feel fine 1 minute, and then I’ll become tearful 
the next over something small or for no reason at all. 
  
  
  
  
  
2. Others have told me that I seem to become amused very easily or that I 
seem to become amused about things that aren’t funny. 
  
  
  
  
  
3. I find myself crying very easily. 
  
  
  
  
  
4. I find that even when I try to control my laughter, I am often unable to do 
so.  
  
  
  
  
  
5. There are times when I won’t be thinking of anything happy or funny at 
all, but then I’ll suddenly be overcome by funny or happy thoughts.  
  
  
  
  
  
6. I find that even when I try to control my crying, I am often unable to do 
so. 
  
  
  
  
  
7. I find that I am easily overcome by laughter. 
  
  
  
  
  


 
 
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13.6   APPENDIX VI: INSTRUCTIONS TO PATIENTS 
The following instructions will be provided orally to the patient at the Baseline Visit by a 
healthcare staff member. Please have the Listerine® products (Pocketpaks® and Pocketmist®) 
available for demonstration. 
 
- Alert the patient that the study drug has a strong bitter taste, but that there are ways to make it 
more palatable (see below). 
 
- Rip open the sachet of study drug and add it to a cup or other container and add approximately 
8 oz. (1 cup) of room temperature water and stir vigorously. Study drug may require significant 
stirring or gentle crushing to dissolve.  
 
- The treatment should be taken within one hour of mixing into water. 
 
- Several things may be done to reduce the bad taste and make the drug more palatable: 
 
1) Use Listerine Pocket Packs® (strips) or a Listerine PocketMist® (spray) immediately 
before and/or immediately after taking the drug. Use liberally to coat the mouth. This has 
been found to significantly mask the bitter taste. 
 
2) Take a snack or a meal after taking your treatment. 
 
3) Follow drug immediately with milk to remove taste from the mouth. 
 
4) Avoid drinking fruit juice at the same time as the drug as this may make flavor worse. 
 
- Mixing the study drug with a liquid other than water should be avoided. 
              
 
 


 
 
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13.7   APPENDIX VII: AMX-0035 IN ALS OPEN LABEL EXTENSION (OLE): 
OPEN LABEL EXTENSION SCHEDULE OF ACTIVITIES 
ACTIVITY 
Screenin
g/ 
Baseline 
Visit 
 
 
Study Drug Administration 
(weeks) 
 
 
 
 
 
Wee
k 6 
Wee
k 12 
Wee
k 24 
Week 
36 
Week 
52 
 
Week 
68* 
 
Week 
84* 
Week 
100 
Week 
116 
Week 
132* 
OR 
Early 
Discon
tinuati
on/ 
Final 
Safety 
Visit 
Clinic 
Clinic** 
Day 08 
Day 
42 
±10 
Day 
84 
±10 
Day 
168 
±28 
Day 
252 
±28 
Day 
364 
±28 
Day  
476 
 ±28 
Day  
588  
±28 
Day  
700 
 ±28 
Day 
812 
±28 
Day 
924 
±28 
Written Informed 
Consent 
X 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion 
Review 
X 
 
 
 
 
 
 
 
 
 
 
Vital Signs1*** 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood Draw for 
Safety Labs2*** 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood Draw for 
Serum Pregnancy 
Test for WOCB2 
X 
 
 
 
 
 
 
 
 
 
 
Blood draw for 
optional DNA 
collection 
X3 
X3 
X3 
X3 
X3 
X3 
X3 
X3 
X3 
X3 
X3 
Urine Sample for 
Urinalysis2*** 
X 
X 
X 
X 
X 
X 
      X 
X 
X 
X 
X 
12-Lead ECG4*** 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
ALSFRS-R 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Slow Vital Capacity 
X 
X 
X 
X 
X 
X 
      X 
X 
X 
X 
X 
ATLIS 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Columbia-Suicide 
Severity Scale5 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse Events6 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Concomitant 
Medications 
X 
 
 
 
 
 
 
 
 
 
 
Dispense Study 
Drug7 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Key Study Events 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Drug Accountability/ 
Compliance 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
1 Vital signs include systolic and diastolic pressure in mmHg, respiratory rate/minute, heart rate/minute, temperature and weight. 
Vital signs only need to be taken if they were not already recorded as part of a standard of care visit that occurred within the 
study visit window. 
2 Safety labs include Hematology (CBC with differential), Complete Chemistry Panel, Liver Function Tests and Urinalysis. Serum 
pregnancy testing will occur in women of child bearing potential (WOCBP) at the Screening Visit and as necessary during the 
course of the study. Blood draws and urine samples will only be taken if they were not already recorded as part of a standard of 
care visit that occurred within the study visit window. 


 
 
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3 Optional one-time blood draw for DNA analysis can be completed during the OLE, if not completed during main study.  
4    12-Lead ECG only needs to be completed if it was not already recorded as part of a standard of care visit that occurred within the 
study visit window. 
5 C-SSRS Since Last Visit version to be completed at all visits.  
6 Adverse events that are ongoing from the main study should be recorded and followed during the OLE. Any new adverse events 
that occur AFTER start of OLE treatment will be recorded.  
7 First dose of study drug will be administered in clinic after ALL Screening/Baseline Visit procedures are completed.  
8 Day 0 Visit of the open label extension sub-study may be the same as Week 24 Visit of the main study – so that exams and tests 
do not need to be duplicated if the Day 0 visit occurs within 7 days of the Week 24 visit.  If the subject enrolls day 8-28 then all 
assessments for the Day 0 visit should be completed.  Subjects must enroll in the OLE within 28 days of the Week 24 visit of the 
main study. 
*   If subject is unable to complete all procedures, minimal procedures should be completed in the following    
suggested order: ALSFRS-R, AE Review, Safety labs, ECG, Concomitant Medication. 
** Study visits may occur remotely. If possible, remote visits should be conducted using a HIPAA-compliant video conferencing      
    platform. If video conferencing is not available or not feasible, remote visits may be conducted by phone. If the visit is not     
    conducted in person, the following procedures should be completed in the following suggested order: ALSFRS-R, AE Review,  
    Key Study Event, Concomitant Medications, Columbia-Suicide Severity Scale, and Dispense Study Drug. Drug product will be  
    dispensed to subjects only after the SI has reviewed the necessary safety procedures for the subject to take the study drug. 
*** In order for subject to remain on study drug, these procedures must be performed every six (6) months to monitory safety. These  
      procedures can be done during a clinic visit at the study site or done remotely using a local health facility or home nurse service.  
    Interim safety procedures can be done at each study visit, at the discretion of the SI.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
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OPEN LABEL EXTENSION PLAN 
 
Study Indication 
Amyotrophic Lateral Sclerosis (ALS) 
 
Phase of Development 
II 
Rationale for the Study 
The objective of this study is to determine the long-term safety of AMX0035 in subjects with Amyotrophic 
Lateral Sclerosis (ALS). ALS is a progressive neurodegenerative disease for which there is no cure. There are 
only two medicines approved specifically for treating ALS, Rilutek (riluzole) and Radicava (edaravone). ALS 
also exacts a significant economic burden. 
 
AMX0035 has demonstrated efficacy in models of neurodegeneration, classical activation of 
neuroinflammation, and bioenergetics deficits. The individual components of AMX0035, PB and TUDCA 
have demonstrated efficacy in in vivo models of ALS, Parkinson’s, Alzheimer’s, ischemia, and many others. 
Each individual component has also been tested in small clinical trials of ALS subjects and was found to be 
safe and well-tolerated, and hit primary endpoints of efficacy. 
 
Study Design and Plan 
This is a multicenter, open label extension, up to 132-week study evaluating the long-term safety of 
AMX0035. Up to one hundred thirty-two (132) subjects will be given oral (or feeding tube) twice daily sachet 
of active therapy.  Treatment duration will be up to one thirty-two (132) weeks starting at the 
Screening/Baseline visit.  Clinic visits will occur at Screening/Baseline, Week 6 (day 42), Week 12 (day 84), 
Week 24 (day 168), Week 36 (day 252), and Week 52 (Day 364), Week 68 (Day 476), Week 84 (Day 588), 
Week 100 (Day 700), Week 116 (Day 812), Week 132 (Day 924). Study visits may occur remotely, as needed.  
If possible, remote visits should be conducted using a HIPAA-compliant video conferencing platform. If video 
conferencing is not available or not feasible, remote visits may be conducted by phone. If the visit is not 
conducted in person, the following procedures should be completed in the following suggested order: 
ALSFRS-R, AE Review, Key Study Event, Concomitant Medications, Columbia-Suicide Severity Scale. 
 
All visit windows are consecutive calendar days and are calculated from the day the subject starts study 
treatment (Day 0, the day of the Screening/Baseline Visit). The screening/Baseline visit must occur within 28 
days of the Week 24 visit of the main study.  If the Screening/Baseline visit occurs on the day of the Week 24 
visit or within 7 days of that visit then it is not necessary to complete the assessments, labs and outcomes.  If 
the Screening/Baseline visit occurs Day 8 – Day 28 then all assessments, labs and outcomes need to be 
completed.  Visit windows will be +/- 10 days for the Week 6 and Week 12 visits and +/- 28 days for the Week 
24, Week 36, Week 52, Week 68, Week 84, Week 100, Week 116 and Week 132 visits. Any change from this 
visit window will be considered an out of window visit deviation. 
 
 


 
 
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Study Objectives 
The primary objective of the study is to assess long-term safety of oral (or feeding tube) administration of 
AMX0035 via sachet (3g PB and 1g TUDCA) twice daily for compassionate use. 
The primary outcome measure is: 
1. To confirm the long-term safety of AMX0035 in subjects with ALS over a 132-week period 
Secondary outcome measures will include: 
1. The rate of key study events including tracheostomy, hospitalization, and death 
2. Rate of progression on the ALSFRS-R scale  
3. ATLIS rate of progression 
4. Rate of progression of slow vital capacity  
 
Study Locations 
Up to 25 Northeast ALS Consortium (NEALS) centers in the United States that participated in the randomized, 
double-blind trial will participate in this study. 
 
Number of Planned Subjects 
Up to 132 subjects that participated in the randomized, double-blind trial will be able to enroll in this study. 
 
Study Population 
This study will be conducted in subjects who have sporadic or familial ALS diagnosed as definite as defined 
by revised El Escorial criteria (Appendix 1).  Subjects must provide written informed consent prior to 
screening. At screening/baseline subjects must have completed participation in the randomized, double-blind 
trial. 
 
Study Enrollment 
Inclusion Criteria: 
1. Completion of all visits in the randomized, double blind AMX0035 study. Subjects that receive 
tracheostomy or PAV during the course of the main study will still be followed as ITT until the week 
24 visit before enrollment in the OLE. 
2. Must enroll in the OLE within 28 days of the Week 24 visit of the main study. 
3. Signed informed consent to enter the open label extension phase. 
 
Exclusion Criteria: 
1. Discontinued study drug prematurely in the double-blind phase of the study for reasons other than 
tracheostomy or PAV. 
2. Exposure to or anticipated requirement for any disallowed medication listed below. 
3. Any ongoing adverse events that in the opinion of the Site Investigator are clear contraindications to the 
study drug. 
4. Unstable cardiac or other life-threatening disease emergent during the randomized, double blind study 


 
 
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5. Any major medical condition that in the opinion of the Site Investigator would interfere with the study 
and place the subject at increased risk. 
Subjects who receive tracheostomy or PAV while in the randomized, double-blind trial can elect to enroll in 
the OLE so long as they complete all visits in the main study. 
Disallowed medications for all subjects include: 
• HDAC Inhibitors including: 
o Valproate 
o Vorinostat (Zolinza) 
o Romidepsin 
o Chidamide 
o Panobinostat 
o Lithium 
o Butyrate  
o Suramin 
 
• Probenecid  
 
• Bile Acid Sequestrants including:  
o Cholestyramine and Cholestyramine Light 
o Questran and Questran Light 
o Welchol  
o Colestid and Colestid Flavored 
o Prevalite 
 
Note on Antacids Within Two Hours of Study Drug Administration 
Antacids containing Aluminum hydroxide or smectite (aluminum oxide) may not be taken within two 
hours of administration of the study drug as they inhibit absorption of TUDCA.  
 
These include: 
o Alamag 
o Alumina and Magnesia 
o Antacid, Antacid M and Antacid Suspension 
o Gen-Alox 
o Kudrox 
o M.A.H. 
o Maalox HRF and Maalox TC  
o Magnalox 
o Madroxal 
o Mylanta and Mylanta Ultimate 
o Ri-Mox 


 
 
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o Rulox 
 
Please refer to section 6.7 and 6.7.1 of the main protocol for all medication information. 
 
Study Drug and Treatment Administration 
There will be a new formulation for the open label extension that has been optimized for better taste.   
 
A powder filled sachet will be used as the AMX0035 drug product. The drug product will be filled under 
cGMP conditions in an aluminum foil lined sachet. 
 
The sachet containing active ingredients will include: 
o Active Ingredients: 
• 1g TUDCA 
• 3g PB (Phenylbutyrate) 
 
o Excipients 
• Dextrates 
• Sorbitol 
• Sucralose 
• Syloid 63FP (colloidal silica) 
• Kleptose Linecaps (maltodextrin) 
• Firmenich Flavor Masking Flavorant 
• Firmenich Mixed Berry Flavorant 
• Sodium Phosphate Dibasic 
• Sodium Stearyl Fumarate 
 
Changes from the batch used in the randomized, double blind study include a different level of sucralose, the 
mixed berry flavor being provided by a new company and the addition of a flavor masking agent. 
 
Please see section 6 of the main protocol for more information on the description, packaging, storage, dosage, 
administration, concomitant therapies and prohibited medications of the study drug. 
 
Study drug will be provided in clinic on the day of the screening/baseline visit and re-supplied at each 
subsequent visit. 
 
Subjects should bring in unused sachets so that the site may check compliance. Any unused sachets should be 
re-dispensed to the subject during the visit. Please refer to the site MOP for a detailed description of study drug 
dispensing. 
 
Subjects will take 2 sachets daily, 1 sachet in the morning and 1 sachet in the afternoon, throughout the study. 


 
 
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In order for subjects to remain on study drug, the following safety procedures must continue to be performed 
every six (6) months to monitor safety. Interim safety procedures can be done at each study visit, at the 
discretion of the SI. These procedures can be done during the clinic visit or remotely using a local health 
facility or home nurse service: 
1. Vital signs including blood pressure, body weight, and temperature 
2. 12-lead ECG (Electrocardiogram) 
3. Laboratory assessments including Hematology (CBC with differential), Complete Chemistry Panel, Liver 
Function Tests 
4. Urinalysis 
 
Duration of Treatment and Follow-up 
Subjects will remain on treatment until the Week 132 or early discontinuation visit.   
 
Study Schedule 
No study procedures should be performed prior to the signing of the informed consent form (ICF). All subjects 
will sign an ICF prior to undergoing any study tests or procedures. To the extent possible, the Schedule of 
Activities for each study visit should be performed. It is recommended that the ALSFRS-R and ATLIS are 
completed first at each study visit and Blood Samples are drawn at the end of the study visit. If subject is 
unable to complete all procedures during the in-person clinic study visits, minimal procedures should be 
completed in the following suggested order: ALSFRS-R, AE Review, Safety Labs, ECG, and Concomitant 
Medications.  
 
Study visits may occur remotely as needed.  If possible, remote visits should be conducted using a HIPAA-
compliant video conferencing platform. If video conferencing is not available or not feasible, remote visits may 
be conducted by phone. If the visit is not conducted in person, the following procedures should be completed 
in the suggested order: ALSFRS-R, AE Review, Key Study Event, Concomitant Medications, Columbia-
Suicide Severity Scale. 
 
Visit windows are consecutive calendar days and the target visit dates are calculated from the 
Screening/Baseline Visit.   
 
Subjects who withdraw consent or early terminate from the study (i.e., discontinue study drug) will be asked to 
come in for a Final Safety Visit. 
 
Screening/Baseline Clinic Visit: 
 
Day 0 Visit of the open label extension sub-study may be the same as Week 24 Visit of the main study – so 
that exams and tests do not need to be duplicated if they were previously completed. 
The following procedures will be performed: 
o Obtain written informed consent from subject 
o Assess inclusion and exclusion criteria 
o Review and document concomitant medications and therapies 


 
 
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o Administer C-SSRS (Baseline Version) 
o Administer ALSFRS-R questionnaire 
o Measure isometric strength using ATLIS machine 
o Assess and document adverse events (AEs) that occur after subject signs informed 
consent form (ICF) 
o Measure vital signs (blood pressure, heart and breathing rates, temperature, and weight) 
o Perform 12-lead ECG (Electrocardiogram) 
o  [After other tests] Collect blood samples for clinical laboratory assessments including 
Hematology (CBC with differential), Complete Chemistry Panel, Liver Function Tests, 
serum pregnancy test (for women of child-bearing potential [WOCBP]), optional DNA 
analysis if not completed during main study 
o Collect urine sample for urinalysis 
o Dispense 2 kits of study drug (12 weeks + 2 weeks extra) 
o Capture key study events 
o Schedule the Week 6 Visit  
 
Week 6, Week 12, Week 24, Week 36, Week 52, Week 68, Week 84, Week 100, Week 116, Week 132 or Early 
Discontinuation/Final Safety Clinic Visit:   
 
The Week 6 and Week 12 visits will take place +/- 10 days and the Week 24, Week 36, Week 52, Week 68, 
Week 84, Week 100, Week 116 and Week 132 visits will take place +/- 28 days from the time specified in the 
schedule of activities (table as beginning of this section).   
The following procedures will be performed:  
o Review and assess Adverse Events  
o Measure vital signs 
o Administer the C-SSRS questionnaire (Since Last Visit) 
o Administer ALSFRS-R questionnaire 
o Measure isometric strength using ATLIS machine 
o Perform 12-lead ECG (Electrocardiogram) 
o Collect blood samples for clinical laboratory assessments including Hematology (CBC 
with differential), Complete Chemistry Panel, Liver Function Tests, optional DNA 
analysis if not completed during main study 
o Collect urine sample for urinalysis 
o Perform study drug accountability  
o Dispense study drug (Except at Week 132/Early Discontinuation) 
o Capture key study events 
o Schedule next study visit (Except Week 132/Early Discontinuation) 
 
 
Please note – safety labs, urine collection for urinalysis, pregnancy test, and 12-lead ECG do not need to be 
repeated if they were completed as part of clinical or SOC visit within the approved study visit window. 
 


 
 
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Laboratory Testing: 
 
The following laboratory tests will be performed for safety: 
 
o Hematology with differential panel: complete blood count with differential (hematocrit, 
hemoglobin, platelet count, RBC indices, Total RBC, Total WBC, and WBC & 
differential)  
 
o Blood chemistry panel/Liver function tests (LFTs): alanine aminotransferase (ALT 
(SGPT)), aspartate aminotransferase  (AST (SGOT)), albumin, alkaline phosphatase, 
bicarbonate, blood urea nitrogen, calcium, chloride, creatinine, glucose, potassium, 
sodium, total bilirubin and total protein 
 
o Urinalysis:, bilirubin, blood, clarity, color, glucose, ketones, nitrate, pH, protein, specific 
gravity, urobilinogen and WBC screen  
 
o Serum human chorionic gonadotrophin (hCG) for women of childbearing potential 
(WOCBP) (collected only at Screening Visit, and as necessary throughout course of 
study) 
Please note: for the OLE portion of the study, local laboratories will be used. 
 
In order for subjects to remain on study drug, laboratory testing must continue to be performed every six (6) 
months to monitor safety. Interim laboratory testing can be done at each study visit, at the discretion of the SI. 
This laboratory testing can be done remotely using a local health facility or home nurse service, if clinic visit is 
not feasible.  
 
Safety and Adverse Events 
For the purposes of this study, an adverse event (AE) will be defined as any unfavorable and unintended sign, 
symptom, or disease that the Site Investigator deems to be definitely, probably, possibly, unlikely or not related 
to the conduct of the study procedures or study drug. 
 
Please refer to section 9 of the main protocol for more information on adverse events. 
 
Data Safety and Monitoring and Statistical Analysis Plan 
Please refer to section 7.16 and 7.17 regarding protocol deviations, missed visits and deaths. Please refer to 
section 9 of this protocol regarding safety management. The safety management plan contains additional 
details regarding safety management. Please refer to section 11 regarding data capture. A separate statistical 
analysis plan will be prepared for this study.   
 
Statistical analysis will mainly entail analysis of types and frequencies of adverse events. Measures of SVC, 
ATLIS, ALSFRS-R and study events in the open label extension study will be compared to the double-blind 


 
 
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section of this study and to historical data. A detailed description of the statistical plan is contained in the 
section titled, “Open Label Extension Statistical Analysis Plan.” 
 
While the blinded study is ongoing, the DSMB will review safety events in this study during its regular 
meeting, as detailed in the DSMB charter. When the main study is concluded (last patient out), the independent 
Medical Monitor will review ongoing safety for the remainder of the extension. 

SAP_001.pdf: 
Protocol: AMX3500-OLE 
  Amylyx Pharmaceuticals Inc. 
   Page 1 
STATISTICAL ANALYSIS PLAN 
Protocol: 
Evaluation of the Safety, Tolerability, Efficacy and Activity of AMX0035, a Fixed Combination 
of Phenylbutyrate (PB) and Taurursodiol (TURSO), for Treatment of Amyotrophic Lateral 
Sclerosis (ALS) Open Label Extension (OLE) 
Amylyx Pharmaceuticals Inc. 
Date/Version: October 2019 V3 


Protocol: AMX3500-OLE 
  Amylyx Pharmaceuticals Inc. 
   Page 2 
Evaluation of the Safety, Tolerability, Efficacy and Activity of AMX0035, a Fixed Combination 
of Phenylbutyrate (PB) and Taurursodiol (TURSO), for Treatment of Amyotrophic Lateral 
Sclerosis (ALS) Open Label Extension (OLE) 
By signing below, all parties accept that the analysis methods and data presentations are 
acceptable and that this document is final. 
Prepared By:  
Date 
Reviewed/Approved By: 
Date 
Date 
Date 
01 Nov. 2019
01 Nov 2019
01 Nov 2019
01 Nov 2019


Protocol: AMX3500-OLE 
 
  Amylyx Pharmaceuticals Inc. 
 
 
   Page 3 
 
 
Table of Contents 
Definitions....................................................................................................................................... 8 
1 
Introduction ............................................................................................................................. 9 
1.1 
Amyotrophic Lateral Sclerosis ............................................................................... 9 
1.2 
AMX3500 ............................................................................................................... 9 
2 
Objectives .............................................................................................................................. 12 
2.1 
Primary Objectives................................................................................................ 12 
2.2 
Secondary Objectives............................................................................................ 12 
3 
Study Design ......................................................................................................................... 13 
3.1 
Number of Subjects............................................................................................... 13 
3.2 
Sample Size Considerations .................................................................................. 13 
3.3 
Study Design ......................................................................................................... 13 
4 
Randomization and Unblinding Procedures .......................................................................... 16 
4.1 
Randomization ...................................................................................................... 16 
5 
Efficacy/Safety Assessments ................................................................................................. 17 
5.1 
Efficacy Endpoints ................................................................................................ 17 
5.1.1 
ALSFRS-R ............................................................................................................ 17 
5.1.2 
ATLIS ................................................................................................................... 18 
5.1.3 
SVC ....................................................................................................................... 18 
5.1.4 
Survival, Hospitalization and Tracheostomies ......................................................21 
5.2 
Safety Assessments ............................................................................................... 21 
5.2.1 
Adverse Events ..................................................................................................... 22 
5.2.2 
Vital Signs ............................................................................................................. 23 
5.2.3 
ECG....................................................................................................................... 24 
5.2.4 
Clinical Laboratory Assessments .......................................................................... 24 
5.2.5 
C-SSRS ................................................................................................................. 25 
5.3 
Other Evaluations.................................................................................................. 25 
5.4 
Interim of Analysis ............................................................................................... 25 
6 
Analysis Populations and General Statistical Procedures ..................................................... 26 
6.1 
Definition of OLE Analysis Populations .............................................................. 26 
6.2 
Application of Analysis Populations .................................................................... 26 
6.3 
General Statistical Procedures .............................................................................. 26 
7 
Subject Disposition, demographics and Baseline characteristics Evaluations ...................... 29 
7.1 
Subject Enrollment................................................................................................ 29 
7.2 
Subject Disposition ............................................................................................... 29 
7.3 
Drug Exposure ...................................................................................................... 29 
7.4 
Subject Demographic and Baseline Data .............................................................. 29 
7.5 
Medical History .................................................................................................... 30 
7.6 
Medications ........................................................................................................... 30 


Protocol: AMX3500-OLE 
 
  Amylyx Pharmaceuticals Inc. 
 
 
   Page 4 
 
 
7.7 
Protocol Deviations ............................................................................................... 30 
8 
Efficacy Evaluations .............................................................................................................. 31 
8.1  
Efficacy Analyses………………………………………………………………...31 
8.2 
Survival Analyses ................................................................................................. 32 
 
 
8.4 
Sensitivity Analysis for MAR Assumption .......................................................... 32 
8.5 
Subject Discontinuation Rate ................................................................................ 33 
8.6 
Additional Analyses .............................................................................................. 33 
9 
Safety Evaluations ................................................................................................................. 34 
9.1 
Adverse Events ..................................................................................................... 34 
9.2 
Vital Signs ............................................................................................................. 35 
9.3 
Electrocardiogram ................................................................................................. 35 
9.4 
Clinical Laboratory Evaluations ........................................................................... 35 
9.5 
C-SSRS ................................................................................................................. 36 
9.6 
Days Hospitalized ................................................................................................. 36 
10 
Other Listings........................................................................................................ 37 
 
 
 


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List of Abbreviations 
∆FS 
Del-FS Score 
AA 
Those patients on active in the main study who continue into the 
extension 
AE 
Adverse Event 
ALP 
Alkaline phosphatase 
ALS 
Amyotrophic Lateral Sclerosis 
ALSFRS-R 
Amyotrophic Lateral Sclerosis Functional Rating Scale Revised 
ALT 
Alanine aminotransferase 
AST 
Aspartate aminotransferase 
ATLIS 
Accurate Testing of Limb Isometric Strength 
BUN 
Blood Urea Nitrogen 
CFB 
Change from Baseline 
CSF 
Cerebro-spinal fluid 
C-CASA 
Columbia Classification Algorithm for Suicide Assessment 
C-SSRS 
Columbia Suicidality Severity Rating Scale 
eCRF 
Electronic Case Report Form 
ECG 
Electrocardiogram 
EDC 
Electronic Data Capture system 
ER 
Endoplasmic Reticulum 
hCG 
Human Chorionic Gonadotropin  
HDL 
High-density Lipoprotein 
HHD 
Hand-held Dynamometry  
LDL 
Low-density Lipoprotein 
LDH 
Lactate dehydrogenase 


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LFT 
Liver Function Test 
LS 
Least-squares 
LSMEANS 
Least-squares Means 
mITT 
Modified Intent-to-treat 
MMRM 
Mixed model with repeated measures 
MAR 
Missing at Random 
MNAR 
Missing Not at Random 
MOP 
Site Manual of Procedures 
MRI 
Magnetic resonance imaging 
N 
Number of subjects 
NEALS 
Northeast Amyotrophic Lateral Sclerosis Consortium 
NFL 
Neurofilament Light Chain 
OLE 
Open Label Extension 
PA 
Those patients who were on placebo in the main study who 
continue into the extension 
PAV 
Permanent Assisted Ventilation 
PB 
Phenylbutyrate 
PBMC 
Peripheral Blood Mononuclear Cell 
PET 
Positron Emission Tomography 
PK 
Pharmacokinetic 
PMM 
Pattern Mixture Model 
pNF-H 
Phosphorylated Neurofilament Heavy Chain 
PP 
Per Protocol 
PPK 
Population pharmacokinetics 


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RBC 
Red blood cell 
SAE 
Serious Adverse Event 
SVC 
Slow Vital Capacity 
SD 
Standard Deviation 
SDTM 
Study Data Tabulation Model 
SI 
Site Investigator 
TC 
Total cholesterol 
TEAE 
Treatment Emergent Adverse Events 
TG 
Triglyceride 
TSH 
Thyroid stimulating hormone 
TSPO 
18 kDa translocator protein 
TURSO 
Taurursodiol 
WBC 
White Blood Cell 
WOCBP 
Women of Child Bear Potential 
 
 
 


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DEFINITIONS 
Safety Population 
All subjects who receive at least one dose of study medication in 
the OLE. 
Modified Intent-to-Treat 
Population (mITT) 
All subjects who receive at least one dose of study medication and 
have at least one ALSFRS-R score recorded after their OLE 
baseline visit   
Treatment 
 
 
Two groups will be 
defined in the open label 
extension 
In the OLE, all patients will receive AMX0035 via sachet (3g PB and 
1g TURSO) once daily for the first three weeks and increased to 
two sachets daily if tolerated. 
 
PA defined as those patients who were on placebo in the main 
study who continue into the extension 
AA defined as those patients who were on active in the main study 
who continue into the extension 
 
 
 


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1 
INTRODUCTION 
The objective of the Statistical Analysis Plan (SAP) is to ensure the credibility of all study 
findings by means of a predefined data analysis plan. This plan assumes familiarity with the 
study protocol and will provide further details of the summaries and analyses planned therein. 
This Statistical Analysis Plan was finalized via signatory prior to the treatment unblinding.   
1.1 
Amyotrophic Lateral Sclerosis 
ALS is a progressive neurodegenerative disease for which there is no cure. There are only two 
medications approved specifically for treating ALS. This includes Rilutek (riluzole), which only 
provides a modest benefit for subjects, and Radicava (edaravone). ALS also exacts a significant 
economic burden. ALS is the most prevalent, adult-onset, progressive motor neuron disease, 
affecting more than 20,000 subjects in the US and an estimated 450,000 people worldwide, 
according to the ALS Association. ALS causes the progressive degeneration of motor neurons, 
resulting in rapidly progressing muscle weakness and atrophy that eventually leads to partial or 
total paralysis; on average, the disease is fatal within 18-24 months from diagnosis. There are 
two FDA-approved medications for ALS, riluzole, which only extends survival modestly, and 
Radicava (edaravone). ALS also exacts a significant economic burden. 
Although the precise cause of ALS is unknown, ALS and other neurodegenerative diseases such 
as Alzheimer’s are characterized by nerve cell death and inflammation. Together these processes 
form a toxic cycle that is a key driver of progressive neurological decline. Recent research has 
highlighted mitochondrial stress and endoplasmic reticulum (ER) stress as key mediators of 
nerve cell death [Manfredi, G 2015]. The mitochondrion is the energy production center of the 
cell, while the ER is the quality control center. These two organelles are in constant 
communication, and are in fact physically connected by a membrane, and their health is vital to 
cell survival. When either of these cellular processes goes awry, the resulting stress can either 
kill the cell and/or create inflammation. The brain is extremely sensitive to both mitochondrial 
stress and ER stress, and both of these pathways have been strongly implicated in causing 
neurodegenerative disease. We believe that only therapeutically targeting both organelles 
simultaneously will enact a significant and lasting benefit. 
1.2 
AMX3500 
AMX0035 is a proprietary combination of two small molecules, phenylbutyrate (PB) and 
Taurursodiol (TURSO), designed to block neuronal death and neurotoxic inflammation through 
simultaneous inhibition of endoplasmic reticulum (ER) stress and mitochondrial stress.  
The individual components of AMX0035, PB and TURSO have demonstrated efficacy in in vivo 
models of ALS, Parkinson’s, Alzheimer’s, ischemia, and many others [Ryu 2005, Del Signore 
2009, Ricobarza 2009, Wiley 2011, Ricobarza 2012, Rodrigues 2003, Castro-Caldas 2012, 


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Zhang 2014]. Each individual component has also been tested in small clinical trials of ALS 
subjects and was found to be safe and well-tolerated, and achieved intended results on efficacy 
endpoints. 
Both PB and TURSO have also been evaluated in subjects with ALS and were found to be safe, 
well-tolerated, and exhibited preliminary signs of efficacy. Adverse events in subjects taking 
riluzole and NaPB together did not occur more frequently, compared to those on PB alone. 
Recently, TURSO (called “TUDCA” in the publication) at 1g b.i.d. demonstrated a statistically 
significant slowing of ALSFRS-R progression rate in a year-long, multi-site, placebo-controlled 
clinical trial of ALS [Elia et al, 2016]. In this proof-of-principle trial, 34 ALS subjects under 
treatment with riluzole were randomized to placebo or TURSO (1 gram b.i.d.) for 54 weeks. The 
proportion of responders (defined as subjects with >15% improvement in ALSFRS-R slope) was 
higher under TURSO (87%) than under placebo (P = 0.021; 43%). At study end, baseline-
adjusted ALSFRS-R was signiﬁcantly higher (P = 0.007) in TURSO than in placebo groups. 
Comparison of the slopes of regression analysis showed slower progression in the TURSO than 
in the placebo group (P < 0.01) (Figure 3). 
 
Figure 3: Linear regression analysis of ALSFRS-R mean scores over time for the TURSO 
(TUDCA in the publication) (circles, slope -0.388) and placebo groups (triangles, slope -0.262). 
 
For the planned Phase II trial of PB in combination with TURSO, a dose of 1 gram of TURSO 
twice a day (2 grams per day) as a target dose was selected.  
Sodium phenylbutyrate (PB) is generally well tolerated. It is FDA approved for subjects with 
urea cycle disorders including deficiencies of carbamylphosphate synthetase, ornithine 
transcarbamylase, or argininosuccinic acid synthetase. It is indicated in subjects with either 


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neonatal-onset deficiency or late-onset disease. The usual total daily dose is 450-600 mg/kg/day 
in subjects weighing less than 20kg, or 9.9-13.0 g/m2/day in larger subjects. Detailed information 
can be found on the package insert for PB [Buphenyl, Package Insert].  
PB has also been studied in pre-clinical ALS models and in subjects with ALS. In mice it was 
shown to reduce neuronal death and increase survival through mechanisms thought to be related 
to its HDAC inhibition activity. In a small Phase 2a trial in subjects with ALS it was also shown 
to affect HDAC activity in human and to be safe and well tolerated [Cudkowicz, 2009].  
Across models of oxidative stress, mitochondrial deficits, endoplasmic reticulum stress, 
glutamate toxicity and protein misfolding, and multiple sclerosis the combination has been 
shown to be effective in improving neuronal viability and function. In most of these models, the 
combination had significant benefit over either drug alone and furthermore in all models the 
combination showed efficacy whereas the individual drugs did not always show efficacy.  
The program is designed to demonstrate that treatment is safe and can slow the decline in 
function for subjects with ALS. The study is additionally looking at muscle strength, and vital 
capacity, and the impact of AMX0035 therapy on biomarkers of ALS including blood levels of 
phosphorylated axonal neurofilament H subunit. This study is expected to provide a robust 
dataset which could support the efficacy and safety of AMX0035.  


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2 
OBJECTIVES 
2.1 
Primary Objectives 
The primary outcome measure will be: 
1. To confirm the long-term safety of AMX0035 in subjects with ALS over a 132-week 
period 
2.2 
Secondary Objectives 
The secondary objectives will be to measure:  
1. Rate of progression on the ALSFRS-R scale  
2. The rate of key study events including tracheostomy, hospitalization, and death 
3. ATLIS rate of progression 
4. Rate of progression of slow vital capacity  
 


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3 
STUDY DESIGN 
3.1 
Number of Subjects 
This study will be conducted in subjects who complete the CENTAUR main study and opt into 
the extension study. Detailed inclusion exclusion criteria can be found in Appendix VII of the 
clinical protocol.  
All but one site from the CENTAUR main study participated in the open label extension study. 
Subjects will be assigned to oral (or feeding tube) AMX0035 treatment (1 sachet= 3g PB and 1g 
TURSO plus excipients) at two sachets daily.  
3.2 
Sample Size Considerations 
Detailed powering calculations were not conducted for the open label extension study.  
3.3 
Study Design 
This is a multicenter, open label extension, up to 132-week study evaluating the long-term safety 
of AMX0035. Up to one hundred thirty-two (132) subjects who completed the 24 weeks placebo 
controlled randomized phase of the trial and elect to continue treatment in this trial extension 
will be given oral (or feeding tube) twice daily sachets of AMX-0035 (verum) therapy.  Patients 
previously randomized to placebo in the randomized placebo-controlled phase of the trial will be 
crossed over to AMX0035 therapy.  Treatment duration will be up to one hundred and thirty-two 
(132) weeks starting upon completion of the randomized phase of the trial.  Clinic visits will 
occur at Screening/Baseline (entry in the OLE), Week 6 (day 42), Week 12 (day 84), Week 24 
(day 168), Week 36 (day 252), and Week 52 (Day 364), Week 68 (Day 476), Week 84 (Day 
588), Week 100 (Day 700), Week 116 (Day 812), Week 132 (Day 924). 
All visit windows are consecutive calendar days and are calculated from the day the subject 
starts study treatment (Day 0, the day of the Screening/Baseline Visit). The Screening/Baseline 
visit must occur within 28 days of the Week 24 visit of the main study.  If the Screening/Baseline 
visit occurs on the day of the Week 24 visit in the randomized phase of the trial or within 7 days 
of that visit then it is not necessary to complete the assessments, labs and outcomes.  If the 
Screening/Baseline visit occurs Day 8 – Day 28 then all assessments, labs and outcomes need to 
be completed.  Visit windows will be +/- 10 days for the Week 6 and Week 12 visits and +/- 28 
days for the Week 24, Week 36, Week 52, Week 68, Week 84, Week 100, Week 116 and Week 
132 visits. Any change from this visit window will be considered an out of window visit 
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Table 1: Schedule of Activities 
ACTIVITY 
Screening/ 
Baseline 
Visit 
Study Drug Administration (weeks) 
 
 
 
 
 
Week 
6 
Week 
12 
Week 
24 
Week 
36 
Week 
52 
Week 
68* 
Week 
84* 
Week 
100 
Week 
116 
Week 132* OR Early 
Discontinuation/ Final 
Safety Visit 
Clinic 
Clinic 
Clinic 
Clinic 
Clinic 
Clinic 
Clinic 
Clinic 
Clinic 
Clinic 
Clinic 
Day 08 
Day 
42 
±10 
Day 
84 
±10 
Day 
168 
±28 
Day 
252 
±28 
Day 
364 
±28 
Day  
476 
 ±28 
Day  
588  
±28 
Day  
700 
 ±28 
Day 812 
±28 
Day 924 
±28 
Written Informed 
Consent 
X 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion 
Review 
X 
 
 
 
 
 
 
 
 
 
 
Vital Signs1 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood Draw for Safety 
Labs2 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood Draw for Serum 
Pregnancy Test for 
WOCB2 
X 
 
 
 
 
 
 
 
 
 
 
Blood draw for optional 
DNA collection 
X3 
X3 
X3 
X3 
X3 
X3 
X3 
X3 
X3 
X3 
X3 
Urine Sample for 
Urinalysis2 
X 
X 
X 
X 
X 
X 
      X 
X 
X 
X 
X 
12-Lead ECG4 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
ALSFRS-R 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Slow Vital Capacity 
X 
X 
X 
X 
X 
X 
      X 
X 
X 
X 
X 
ATLIS 
X 
X 
X 
X 
X 
X 
 
 
X 
X 
X 
Columbia-Suicide 
Severity Scale5 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse Events6 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Concomitant 
Medications 
X 
 
 
 
 
 
 
 
 
 
 
Dispense Study Drug7 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Key Study Events 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Drug Accountability/ 
Compliance 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 


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1 
Vital signs include systolic and diastolic pressure in mmHg, respiratory rate/minute, heart rate/minute, temperature and weight. Vital signs only need to 
be taken if they were not already recorded as part of a standard of care visit that occurred within the study visit window. 
2 
Safety labs include Hematology (CBC with differential), Complete Chemistry Panel, Liver Function Tests and Urinalysis. Serum pregnancy testing will 
occur in women of child bearing potential (WOCBP) at the Screening Visit and as necessary during the course of the study. Blood draws and urine 
samples will only be taken if they were not already recorded as part of a standard of care visit that occurred within the study visit window.  During the 
OLE, safety laboratory tests will be performed by local laboratories. 
3 
Optional one-time blood draw for DNA analysis can be completed during the OLE, if not completed during main study.  
4     
12-Lead ECG only needs to be completed if it was not already recorded as part of a standard of care visit that occurred within the study visit window. 
5 
C-SSRS Since Last Visit version to be completed at all visits.  
6 
Adverse events that are ongoing from the main study should be recorded and followed during the OLE. Any new adverse events that occur AFTER start 
of OLE treatment will be recorded.  
7 
First dose of study drug will be administered in clinic after ALL Screening/Baseline Visit procedures are completed. 
8 
Day 0 Visit of the open label extension sub-study may be the same as Week 24 Visit of the main study – so that exams and tests do not need to be 
duplicated if the Day 0 visit occurs within 7 days of the Week 24 visit.  If the patient enrolls day 8-28 then all assessments for the Day 0 visit should be 
completed.  Patients must enroll in the OLE within 28 days of the Week 24 visit of the main study. 
 
*   If subject is unable to complete all procedures, minimal procedures should be completed in the following suggested order: AE Review, Safety labs, ECG, 
Concomitant Medication, ALSFRS-R. 
 
 
 
 
 


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4 
RANDOMIZATION AND UNBLINDING PROCEDURES 
4.1 
Randomization 
This is an open label extension so subjects will all be on active therapy. However, two groups 
will be defined in the OLE: 
o PA group defined as those patients who were randomized to placebo in the main study 
who continue into the extension 
o AA group defined as those patients who were randomized to AMX-0035 verum  in the 
main study who continue into the extension 
  


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5 
EFFICACY/SAFETY ASSESSMENTS  
5.1 
Efficacy Endpoints 
The efficacy outcome measures are listed below in hierarchical order:  
• 
Rate of progression on the ALSFRS-R total score;  
• 
The rate of key study events including tracheostomy, hospitalization, and death; 
• 
Rate of progression in upper and lower ATLIS scores; 
• 
Rate of progression of slow vital capacity; 
• 
Rate of progression on ALSFRS-R domains; 
• 
Rate of progression on total ATLIS score. 
5.1.1 
ALSFRS-R 
The primary efficacy outcome measure for the study is the rate of decline (slope of decline) in the 
ALS functional rating scale (ALSFRS-R). The revised version of the ALSFRS was created to 
add assessments of respiratory dysfunction, including dyspnea, orthopnea, and the need for 
ventilatory support. The revised ALSFRS (ALSFRS-R) has been demonstrated to retain the 
properties of the original scale and show strong internal consistency and construct validity.  
Initial validity was established by documenting that in ALS subjects, change in ALSFRS-R 
scores correlated with change in strength over time, was closely associated with quality of life 
measures, and predicted survival. The test-retest reliability is greater than 0.88 for all test items. 
The advantages of the ALSFRS-R are that the categories are relevant to ALS, it is a sensitive and 
reliable tool for assessing activities of daily living function in those with ALS, and it is quickly 
administered. With appropriate training the ALSFRS-R can be administered with high inter-rater 
reliability and test-retest reliability. The ALSFRS-R can be administered by phone with good 
inter-rater and test-retest reliability. The equivalency of phone versus in-person testing, and the 
equivalency of study subject versus caregiver responses have also recently been established. The 
ALSFRS-R will therefore also be given to the study subject over the phone. All ALSFRS-R 
evaluators must be NEALS certified. 
The ALSFRS-R is a quickly administered (5 minutes) ordinal rating scale (ratings 0-4) used to 
determine subjects' assessment of their capability and independence in 12 functional activities. 
Higher scores indicate better performance. The maximum score is 48 points. All 12 activities are 
relevant in ALS. The ALSFRS-R can be broken down into four domains as described below: 
1. Bulbar 
a. Speech 
b. Salivation 
c. Swallowing 


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2. Fine Motor 
a. Handwriting 
b. Cutting Food/Handling Utensils 
c. Dressing and Hygiene 
3. Gross Motor 
a. Turning in Bed 
b. Walking 
c. Climbing Stairs 
4. Breathing 
a. Dyspnea 
b. Orthopnea 
c. Respiratory Insufficiency 
The total ALSFRS-R scale will be the primary efficacy outcome 
 
. 
5.1.2 
Survival, Hospitalization and Tracheostomies 
Survival endpoint will be defined as death, tracheostomy or permanent assisted ventilation 
(PAV). PAV is defined as more than 22 hours daily of non-invasive mechanical ventilation for 
more than one week (7 days). The date of onset of PAV is the first day of the seven days. 
5.1.3 
ATLIS 
We will measure isometric strength using the ATLIS device developed by Dr. Patricia Andres of 
Massachusetts General Hospital. The device was specifically designed to alleviate the 
reproducibility concerns that exist for prior strength measurements such as hand-held 
dynamometry (HHD). ATLIS does not depend on experimenter strength and has measurement 
settings to ensure that subjects are in the same position each time they are tested. All ATLIS 
evaluators must be trained and certified. ATLIS may detect functional decline before the 
ALSFRS-R, which may have a ceiling effect, and may be able to detect changes in function with 
greater sensitivity to ALSFRS-R. The measure does show a small training effect, so we will 
conduct the test at initial screening visit to allow subjects to become acquainted with the device.  
ATLIS is an isometric strength measurement device. Each subject’s absolute strength in twelve 
muscle areas will be measured at screening by ATLIS and then normalized to standard values 
based on Patricia Andres per predicted normal dataset (Andres, P. et al. Developing normalized 
strength scores for neuromuscular research. Muscle and Nerve. 2013.). Of the twelve muscle 
areas, 6 are considered lower and the other 6 are considered upper. Average standardized ATLIS 
scores will be used in the analysis. The coefficients and intercept that will be used to obtain the 
predicted value for each of the 12 muscle group areas measured in ATLIS is shown in Table 2 
below. Two ATLIS trials will be conducted generally, but a third may be conducted if the first 


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two trials vary by over 15%. The highest score of all trials at a time point will be used for 
analysis. 
 


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Table 2: Coefficient and Intercept for ATLIS Standardization 
Gender 
Maneuver 
Age (years) 
Coefficient 
Weight (lbs) 
Coefficient 
Height (in) 
Coefficient 
Intercept 
Female 
Left Grip 
-0.15 
0.16 
1.18 
-28.91 
Right Grip 
-0.21 
0.18 
1.05 
-14.01 
Left Elbow Flexion 
-0.04 
0.14 
0.44 
-6.03 
Right Elbow Flexion 
-0.07 
0.13 
0.49 
-6.95 
Left Elbow Extension -0.09 
0.1 
0.09 
12.14 
Right Elbow 
Extension 
-0.09 
0.08 
0.13 
13.37 
Left Knee Extension 
-0.231 
0.231 
0.352 
21.263 
Right Knee Extension -0.231 
0.165 
0.319 
32.604 
Left Knee Flexion 
-0.14 
0.08 
0.62 
-12.64 
Right Knee Flexion 
-0.19 
0.09 
0.65 
-14.23 
Left Ankle 
Dorsiflexion 
-0.13 
0.1 
0.06 
23.63 
Right Ankle 
Dorsiflexion 
-0.08 
0.11 
0.03 
23.28 
Male 
Left Grip 
-0.28 
0.17 
1.41 
-20.59 
Right Grip 
-0.27 
0.19 
1.65 
-32.94 
Left Elbow Flexion 
-0.14 
0.15 
0.24 
26.61 
Right Elbow Flexion 
-0.17 
0.16 
0.53 
5.89 
Left Elbow Extension -0.26 
0.14 
-0.21 
50.13 
Right Elbow 
Extension 
-0.29 
0.13 
-0.24 
55.17 
Left Knee Extension 
-0.011 
0.297 
-0.594 
74.789 
Right Knee Extension 0.022 
0.33 
-1.056 
101.992 
Left Knee Flexion 
-0.19 
0.18 
0.27 
-1.07 
Right Knee Flexion 
-0.22 
0.16 
0.15 
14.26 
Left Ankle 
Dorsiflexion 
-0.06 
0.11 
0.06 
26.03 
Right Ankle 
Dorsiflexion 
-0.04 
0.13 
0.02 
26.62 
 
For example, the predicted value for left grip maneuver for a 41-year-old female who is 62 
inches tall and weighs 126 pounds would be 58.26, see formulas below. 
𝑃𝑟𝑒𝑑𝑖𝑐𝑡𝑒𝑑= −28.91 −0.15 ∗𝐴𝑔𝑒+ 0.16 ∗𝑊𝑒𝑖𝑔ℎ𝑡+ 1.18 ∗𝐻𝑒𝑖𝑔ℎ𝑡 
𝑃𝑟𝑒𝑑𝑖𝑐𝑡𝑒𝑑= −28.91 −0.15 ∗41 + 0.16 ∗126 + 1.18 ∗62 
𝑃𝑟𝑒𝑑𝑖𝑐𝑡𝑒𝑑= 58.26 


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ATLIS scores for each subject and visit will go through the following steps in order to be used in 
analyses: 
1. Obtain predicted value for each of the 12 muscle groups using each subject’s baseline 
information (age, height and weight) and the coefficient and intercept estimates provided 
in Table 2; 
2. For each of the 12 muscle groups, divide the maximum observed score for each subject 
and visit combination by the predicted score. These are the standardized ATLIS scores. If 
a subject has no motion in a limb and is therefore not tested, his/her score will be 
recorded as a zero. If he/she had motion, but are for other reasons unable to complete the 
testing this data will be considered missing. A zero score divided by the predicted score 
will still be zero, so the zeros are considered “standardized ATLIS scores” in the 
following calculation steps. 
3. Average the 6 standardized upper muscle groups (left grip, right grip, left elbow flexion, 
right elbow flexion, left elbow extension, right elbow extension) to obtain the “Upper 
Extremity (Arm) ATLIS” score. Only calculate the average score if at least 4 of the 6 
items are observed; 
4. Average the 6 standardized lower muscle groups (left knee extension, right knee 
extension, left knee flexion, right knee flexion, left ankle dorsiflexion, right ankle 
dorsiflexion) to obtain the “Lower Extremity (Leg) ATLIS” score. Only calculate the 
average score if at least 4 of the 6 items are observed; 
5. Average the lower and upper ATLIS scores (numbers 3 and 4 above) to obtain the “Total 
ATLIS” score. Only calculate the average score if both averaged standardized muscle 
groups are observed. 
5.1.4 
SVC 
The vital capacity (VC) (percent of predicted normal) will be determined, using the upright slow 
VC method. The VC can be measured using conventional spirometers that have had a calibration 
check prior to subject testing. A printout from the spirometer of all VC trials will be retained. All 
VC evaluators must be NEALS certified. Three VC trials are required for each testing session, 
however up to 5 trials may be performed if the variability between the highest and second 
highest VC is 10% or greater for the first 3 trials. Only the 3 best trials are recorded on the CRF. 
The highest VC recorded is utilized for analysis, regardless of the number of trials performed.  
5.2 
Safety Assessments 
Safety assessments include the following: 
• 
Adverse events (AEs); 
• 
Vital signs; 
• 
12-lead ECG; 
• 
Hematology, chemistry and urinalysis; 
• 
Physical and neurological examinations; 


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• 
Columbia Suicide Severity Rating Scale (C-SSRS). 
5.2.1 
Adverse Events 
An adverse event (AE) or adverse experience is any untoward medical occurrence in a subject or 
clinical investigation subject who is administered a medicinal product that does not necessarily 
have a causal relationship with this treatment that occur after informed consent for the extension 
study is signed and started more than 33 days after the last treatment was received in the main 
study up to 28 days (+5 days) after the study drug has been discontinued in the extension study. 
AEs starting within 28 days (+5 days), i.e. 33 days, after the last treatment was received in the 
main study were included and summarized as part of the main study. For the purposes of this 
study, symptoms of progression/worsening of ALS, including ‘normal’ progression, will be 
recorded as adverse events.   
At each visit (including telephone interviews), the subject will be asked if they have had any 
problems or symptoms since their last visit in order to determine the occurrence of adverse 
events.  If the subject reports an adverse event, the Investigator will probe further to determine: 
1. Type of event; 
2. Date of onset and resolution (duration); 
3. Severity (mild, moderate, severe); 
4. Seriousness (does the event meet the above definition for an SAE); 
5. Causality, relation to investigational product and disease; 
6. Action taken regarding investigational product; 
7. Outcome. 
The relationship of the AE to the investigational product should be specified by the Site 
Investigator, using the following definitions: 
1.  Not Related: Concomitant illness, accident or event with no reasonable association with 
treatment. 
2.   Unlikely: The reaction has little or no temporal sequence from administration of the 
investigational product, and/or a more likely alternative etiology exists. 
3.   Possibly Related: The reaction follows a reasonably temporal sequence from 
administration of the investigational product and follows a known response pattern to 
the suspected investigational product; the reaction could have been produced by the 
investigational product or could have been produced by the subject’s clinical state or by 
other modes of therapy administered to the subject. (Suspected adverse drug reaction 
[ADR]) 


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4.   Probably Related: The reaction follows a reasonably temporal sequence from 
administration of investigational product; is confirmed by discontinuation of the 
investigational product or by re-challenge; and cannot be reasonably explained by the 
known characteristics of the subject’s clinical state. (Suspected ADR) 
5.   Definitely Related: The reaction follows a reasonable temporal sequence from 
administration of investigational product; that follows a known or expected response 
pattern to the investigational product; and that is confirmed by improvement on stopping 
or reducing the dosage of the investigational product, and reappearance of the reaction 
on repeated exposure. (Suspected ADR) 
A serious adverse event (SAE) is defined as an adverse event that meets any of the following 
criteria: 
1. Results in death. 
2. Is life threatening: that is, poses an immediate risk of death as the event occurred. 
This serious criterion applies if the study subject, in the view of the Site 
Investigator or Sponsor, is at immediate risk of death from the AE as it occurs. It 
does not apply if an AE hypothetically might have caused death if it were more 
severe. 
3. Requires in-subject hospitalization or prolongation of existing hospitalization. 
Hospitalization for an elective procedure (including elective PEG tube/g-
tube/feeding tube placement) or a routinely scheduled treatment is not an SAE by 
this criterion because an elective or scheduled “procedure” or a “treatment” is not 
an untoward medical occurrence. 
4. Results in persistent or significant disability or incapacity. 
This serious criterion applies if the “disability” caused by the reported AE results 
in a substantial disruption of the subject’s ability to carry out normal life 
functions. 
5. Results in congenital anomaly or birth defect in the offspring of the subject (whether the 
subject is male or female).  
6. Necessitates medical or surgical intervention to preclude permanent impairment of a 
body function or permanent damage to a body structure. 
7. Important medical events that may not result in death, are not life-threatening, or do not 
require hospitalization may also be considered SAEs when, based upon appropriate 
medical judgment, they may jeopardize the subject and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition. Examples of such 
medical events include blood dyscrasias or convulsions that do not result in in-subject 
hospitalization, or the development of drug dependency or drug abuse. 
5.2.2 
Vital Signs 


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Vital signs will be obtained after the subject has been in a seated position for several minutes. 
Vital signs, including systolic and diastolic blood pressure, pulse rate (radial artery)/minute, 
respiratory rate/minute, temperature and weight will be assessed at specified visits. Height will 
be measured and recorded at the Screening Visit only.  
5.2.3 
ECG 
A standard 12-lead ECG will be performed. Tracings will be reviewed by a central ECG reader 
and a copy of the tracings will be kept on site as part of the source documents. The central ECG 
vendor will provide standard ECG devices for every site and provide training as necessary.  
5.2.4 
Clinical Laboratory Assessments 
The following laboratory tests will be performed for safety:  
o Hematology with differential panel: complete blood count with differential (hematocrit, 
hemoglobin, platelet count, RBC indices, Total RBC, Total WBC, and WBC & 
differential) 
o Blood chemistry panel/Liver function tests (LFTs): alanine aminotransferase (ALT 
(SGPT)), aspartate aminotransferase (AST (SGOT)), albumin, alkaline phosphatase, 
bicarbonate, blood urea nitrogen, calcium, chloride, creatinine, glucose, magnesium, 
phosphate, potassium, sodium, total bilirubin and total protein 
o Urinalysis: albumin, bilirubin, blood, clarity, color, glucose, ketones, nitrate, pH, protein, 
specific gravity, urobilinogen and WBC screen  
o Serum human chorionic gonadotrophin (hCG) for women of childbearing potential 
(WOCBP) (collected only at Screening Visit, and as necessary throughout course of 
study) 
All subjects will have safety laboratory tests at the designated visits outlined in the protocol. 
These samples will be analyzed at a central laboratory. The Site Investigator (SI) may order 
additional testing, if needed, to further assess an adverse event (AE), or if there is any suspicion 
that a subject may be pregnant, throughout the course of the study. 
Specific instructions regarding the collection, processing, storage and shipment of these samples 
will be provided in the Site Manual of Procedures (MOP). 
 
 


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5.2.5 
C-SSRS 
The US FDA recommends the use of a suicidality assessment instrument that maps to the 
Columbia Classification Algorithm for Suicide Assessment (C-CASA). The C-CASA was 
developed to assist the FDA in coding suicidality data accumulated during the conduct of clinical 
trials of antidepressant drugs. One such assessment instrument is the Columbia Suicide Severity 
Rating Scale (C-SSRS) [Posner K, 2007]. The C-SSRS involves a series of probing questions to 
inquire about possible suicidal thinking and behavior. 
At the Baseline Visit, the C-SSRS Baseline version will be administered. This version is used to 
assess suicidality over the subject’s lifetime.  
At all clinic visits after the Baseline Visit, the Since Last Visit version of the C-SSRS will be 
administered. This version of the scale assesses suicidality since the subject’s last visit. 
5.3 
Other Evaluations 
Additional evaluations include the following: 
1.  Demographics;  
2. Baseline disease characteristics;  
3. Medical history;  
4. Days hospitalized;  
5. Prior medications. 
5.4 
Interim of Analysis 
An interim analysis of the OLE will occur using data collected up to the time of the last-patient 
last-visit (LPLV) in the randomized phase of the trial.   


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6 
ANALYSIS POPULATIONS AND GENERAL STATISTICAL 
PROCEDURES 
6.1 
Definition of OLE Analysis Populations 
Note: All definitions below refer to OLE study period and the baseline is the last visit of the randomized phase of 
the study.  Statistical analysis and data tabulation will be performed using the following subject populations unless 
specified otherwise: 
1. Safety Population; 
2. Modified Intent-to-Treat (mITT) Population; 
3. Per Protocol (PP) Population. 
The safety population will include all subjects who received at least one dose of study 
medication in the OLE. Subjects in this population are analyzed based on the actual treatment 
they received.  
The mITT population will include all subjects who receive at least one dose of study medication 
and have at least one post-OLE baseline total ALSFRS-R score available. Subjects in this 
population will be analyzed based on the treatment they were assigned to.  
The PP population will include all mITT subjects up until the point they did not take study drug 
for 30 days or had a major protocol violation which will exclude subsequent visits from PP 
analysis. PP assignments will be based on a by-visit basis, removing visits that could have been 
affected by major protocol deviations and all visits thereafter. Subjects will remain in the 
analysis up until the time that they had a major protocol violation or have not taken study 
medication for 30 days. The date of the major protocol deviation or month drug interruption 
(whichever comes first) for each subject will be used to filter the data collected after these events 
and exclude it from the PP population. 
6.2 
Application of Analysis Populations 
The primary population for efficacy analysis is the mITT population. Analysis of efficacy 
endpoints will be performed in the mITT and PP populations. The safety population will be used 
for analyses of safety endpoints.  
Subject enrollment, disposition, drug exposure, demographics and baseline disease 
characteristics will be shown for all populations. 
6.3 
General Statistical Procedures 
All analyses described in this plan are considered a priori analyses in that they have been defined 
prior to breaking the study blind. All other analyses, if any, defined subsequent to breaking the 
study blind will be considered post hoc analyses and will be applied using exploratory 
methodology. All post hoc analyses will be identified as such in the Clinical Study Report.  


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Descriptive statistics for continuous variables will include number of subjects (N), arithmetic 
mean, standard deviation (SD), median, minimum, maximum and first and third quartile limits 
unless otherwise noted. Frequency and percentage will be calculated for categorical variables. 
Unless stated otherwise, all summary tables will present descriptive statistics and/or frequencies 
either by treatment or overall, and all data listings will be sorted by subject number. 
Unless otherwise specified, all significance testing will be 2-tailed using α = 0.05. Tests will be 
declared statistically significant if the calculated p-value is ≤ 0.05.  
As applicable, two baselines will be used for analysis: the baseline from the randomized phase of 
the trial and the baseline from the OLE portion of the study.  Change from baseline is calculated 
by subtracting the baseline score from the observed value at any subsequent visit. For safety 
summaries, the last pre-randomization measurement or the last pre-OLE measure is defined as 
the baseline value. For efficacy measures baseline is defined as the last pre-randomization 
measurement or the last pre-OLE measure as applicable.   
Visit windowing will be applied for analyses which use visit categories instead of actual number 
of days relative to dosing for each assessment. For categorical visit summaries, all visits 
including early termination assessments and unscheduled visits will be included with the closest 
scheduled post-baseline visit that includes the efficacy or safety assessment, based on number of 
days since Day 0 (first dose in OLE). If an early termination visit and a regular visit (other than 
baseline) both fall within the same visit window, any non-missing efficacy assessments will be 
averaged and a worst-case approach will be used for safety data.  
Safety analyses will be used based on visit category as recorded. In the case that there is more 
than one result at the same visit, a worst-case approach will be used and the “worst” value will 
be used for summary statistics and analyses.  
Percentages are based on the number of subjects in each treatment group and overall in the given 
population for medical history, prior and concomitant medications and AE summary tables. For 
all other tables, percentages are based on the number of subjects with non-missing data in each 
treatment group and overall for the given population. 
If partial dates are recorded for efficacy outcomes then partially missing start/beginning date 
(e.g. AE/Concomitant medication start date) will fill in the missing month with January and 
missing day with 1. For example, if month and day were both missing, then the date would be 
filled in with January 1st. Partially missing end/finishing date (e.g. AE/Concomitant medication 
end date) will be filled in with December and missing day with the last day of the month. For 
example, if month and day were both missing, then the date would be filled in with December 
31st. For other outcomes (e.g. date of vital signs collection) fill in missing month with June 


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(middle month) and missing day with the middle day of the month. For example, if month and 
day were both missing, then the value would be filled in with June 15th. 
Days will be converted to weeks by dividing by seven. Days will be converted to months by 
dividing by 30.417. Days will be converted to years by dividing by 365.25. All analyses will be 
conducted with R v3.3.1 or SAS v9.4 or later using procedures appropriate for the particular 
analysis. All data collected during the study will be analyzed and reported unless stated 
otherwise. 
There are two groups in the OLE study which will be referred to as “Treatment” and they are: 
1. PA group defined as those patients who were randomized to placebo in the main study 
who continue into the extension; 
2. AA group defined as those patients who were randomized to AMX-0035 verum  in the 
main study who continue into the extension. 
Sensitivity analyses similar to in the main study may be performed.  
 


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7 
SUBJECT DISPOSITION, DEMOGRAPHICS AND BASELINE 
CHARACTERISTICS EVALUATIONS 
7.1 
Subject Enrollment 
Subject enrollment in the OLE will be summarized by treatment group (AA and PA) and center 
for all populations. The number of subjects overall and at each center for each analysis 
population will be presented. 
Study timelines will also be summarized by treatment and overall for all subjects in the OLE.  
Enrollment information will be provided in a data listing by subject. 
7.2 
Subject Disposition 
Subject disposition will be summarized overall and by treatment group (AA and PA) for all 
populations. The number and percentage of subjects who remain in the study at the time of data 
freeze (same time as last patient last visit of main study) and discontinuing from the study will be 
presented by treatment (AA and PA) and overall and by reason for termination. 
Subject disposition will be provided in a data listing by subject. 
7.3 
Drug Exposure  
Duration of exposure is defined as the total time a subject is exposed to any study drug. The 
duration of exposure in weeks will be calculated by dividing the total number of days from the 
first dose date (Day 0) to the last dose date by 7 days/week. If the last dose date is missing or a 
subject is lost to follow-up, but the study medication administration log confirms that the subject 
has taken study drug, the date of the last completed study medication administration will be used.  
Extent of exposure to study drug will also be characterized by calculating the cumulative number 
of grams taken by subjects. The duration and extent of exposure to study drug will be 
summarized by treatment group for both the safety and mITT populations. N and percentage of 
subjects in each population will be displayed. The duration and extent of exposure to study drug 
will be summarized using descriptive statistics.  
7.4 
Subject Demographic and Baseline Data 
Subjects will be described using demographic information and baseline characteristics. Baseline 
disease characteristics and demographics at both baselines (randomized phase and OLE) will be 
provided in separate summary tables. 
Demographic information to be assessed is age, gender, ethnicity, racial group, height and 
weight. Subject demographics will be summarized by treatment (AA and PA) for the safety, 
mITT and PP populations. 


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Racial group, ethnicity, gender and other categorical questions will be summarized using the 
number and percentage of subjects with a particular attribute. The denominators for calculating 
the percentages will be the number of subjects in each treatment for the safety, mITT, and PP 
populations. Age, weight, height and other numeric responses will be summarized using 
descriptive statistics.  
Prior/current ALS therapy, length of time on specified ALS therapy (edaravone and riluzole), 
time since diagnosis, time since symptom onset, and baseline efficacy variables will be 
summarized using descriptive statistics by treatment for the safety, mITT and PP populations. 
Demographics and baseline disease characteristics will be provided in a data listing by subject. 
7.5 
Medical History 
Medical history will be summarized by treatment (AA and PA) for each System/Category for the 
safety population. The number and percentage of subjects with significant medical history will 
be presented for each system organ class and preferred term. The denominators for calculating 
the percentages will be based on the number of subjects in each treatment group in the mITT 
population. 
Medical history will be provided in a data listing by subject. 
7.6 
Medications 
Medication summaries will present the number and percentage of subjects taking medications for 
the safety population. Summaries will be presented for prior (prior to OLE baseline) medication 
use and concomitant (after OLE baseline) medication use, if applicable.  
All summaries will present the number and percentage of subjects by treatment. Prior, 
concomitant and ALS medication will be provided in a data listing by subject. 
7.7 
Protocol Deviations 
Major protocol deviations are defined to be those deviations that could potentially bias the 
conclusions of the study. Minor deviations are defined to be those deviations not deemed major. 
The protocol deviations summary will present the number and percentage of subjects with each 
deviation category and specific deviation term within each treatment group (AA and PA) and 
overall.  
Protocol deviations will be provided in a data listing by subject. 


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8 
EFFICACY EVALUATIONS 
Overall efficacy evaluation for the OLE will follow the methods outlined in the SAP for the main 
study. Two sets of analyses will be performed: one using the original baseline and following 
patients through to the end of the observation time in the OLE, and a second analysis using only 
data from the OLE phase corrected for the new baseline at the beginning of the OLE phase of the 
study. 
Specifically, all continuous efficacy measures will use the same statistical model (ALSFRS-R 
total, ATLIS lower, ATLIS upper, ATLIS total, SVC, and 4 ALSFRS-R domains) and will be 
presented in hierarchical order. Covariates of age, rate of disease progression prior to entering 
trial ∆FS (del-FS) and del- of the efficacy outcome being measured (if other than ALSFRS-R 
total) interacting with time will be included in the analysis. Del-FS from the original baseline 
will be included as a covariate in the OLE phase model in addition to rate of disease progression 
from the double-blind phase. It is acknowledged that any model that corrects for a post-
randomization covariate may interfere with assessment of the treatment effect since the covariate 
would likely have been influenced by the treatment effect in the double-blind phase.  
8.1 
Efficacy Analyses 
All analyses defined in the original SAP for the main study will also be performed for the OLE 
study. Two groups of patients will be compared, those who have previously been in the placebo 
group of the main study (PA group) and those who received AMX-0035 in the main study (AA 
group). The following evaluations will be done:  
1. Slope during the extension will be compared to slope during the main study to 
determine whether the change from the double-blind phase to the OLE phase differs 
between treatment groups.  
2. Within group comparisons of the difference in slope between the extension phase and 
the main study will be performed for patients who received placebo to determine 
whether initiation of treatment influenced the placebo slope and for patients who 
received AMX0035 during the main study to determine robustness and extent of 
duration of effect.  
3. Slope over the entire duration of the main and extension study periods will be 
assessed using the original model from the main study SAP, but extended throughout 
the observation time of the OLE study. 
4. The first 6 months of active treatment will be pooled for patients in the PA and AA 
groups and received treatment during the OLE phase. This pooled group will be 
compared to the placebo arm from the main study. An assessment of the relationship 
between the covariates and the slope over time will be performed to make sure that 
the range of covariate values for the two active groups overlap sufficiently to allow 


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inclusion of both groups in the same model. The second phase of the active arm may 
also be included in this model as a third treatment arm resulting in a comparison of 
these 3 arms: placebo, first 6 months of treatment and second 6 months of treatment. 
 
 
8.2 
Survival Analyses 
Survival analyses will be performed using a Cox proportional hazards model with covariates of 
del-FS and age at baseline. There are 3 survival outcomes: 1) death, 2) tracheostomy and 3) 
PAV.   
The original analysis will be continued out to the end of the OLE study observation, and the 
analysis will also be performed beginning at the initiation of the OLE study.  For the analysis 
beginning at the initiation of the OLE study, only events occurring more than 28 weeks after the 
main study (24 weeks + 28 days) will be included since events which occurred within 28 weeks 
are addressed in the main study analysis.  An additional analysis including 2 treatment arms will 
also be performed: a pooled active arm including the time from initiation of active treatment and 
a placebo arm from baseline out to 6 months. 
Figures for the hazard function will be presented showing the survival of AA subjects vs. PA 
subjects in addition to hazard ratios and p-values for each covariate. A separate survival analysis 
will be performed for each of the 3 survival outcomes listed above and the combined analysis of 
“Death or Equivalent.”  This analysis will be performed for the entire study population of the 
main study (mITT and PP) using as baseline the initiation of treatment in the randomized phase 
of the trial, and will be repeated for the OLE population (OLE mITT and OLE PP) using as 
baseline the first day of treatment in the OLE. 
 
 
 
 
8.4 
Sensitivity Analysis for MAR Assumption 
A MMRM, using multiple imputation from the control arm to complete assessments missing 
after discontinuation of study drug may be performed.  This analysis assumes subjects who 
discontinue medication and are no longer assessed immediately become similar to subjects who 
never took any medication, and so provides a lower bound on efficacy, again under the MAR 
assumption that the time of stopping study medication depends only on past history and 
covariates.  The parameters for subjects who never took any medication will be taken from the 


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placebo arm of the double-blind treatment phase of the study.  Subjects with outcomes that are 
more extreme than all measurements in the placebo arm of the double-blind treatment phase may 
be excluded. 
8.5 
Subject Discontinuation Rate 
Counts of subjects who discontinue from the OLE study early will be compared between 
treatment groups for the safety, mITT and PP populations using Fisher’s Exact tests. In addition, 
time to discontinuation will be displayed. These same analyses will be repeated for any of the 
following discontinuation reasons with sufficient numbers of subjects: 
• Death; 
• Subject early terminated; 
• Subject withdrew consent prior to end of study; 
• Subject lost to follow-up; 
• Other. 
Time to discontinuation overall and by reason will be analyzed with a Gehan-Wilcoxon test and 
the corresponding Kaplan-Meier Plots will be displayed. Subjects discontinuing for one of the 
other reasons will be censored and “time to event” will be used. 
8.6 
Additional Analyses 
Additional efficacy analyses may include: comparison of the full open label extension population 
to appropriate historical or virtual controls or a crossover analysis of the PA patients.  
 
 


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9 
SAFETY EVALUATIONS  
9.1 
Adverse Events 
AEs reported on CRFs will be coded into system organ classes and preferred terms using 
the Medical Dictionary for Regulatory Activities (MedDRA v16.1). A treatment-emergent 
adverse event (TEAE) is defined as an AE with an onset date on or after the start of dosing. The 
adverse event summary will include only TEAEs. Any AEs that are not considered treatment-
emergent will be provided in data listings only.  
The incidence of AEs will be summarized for the safety population. Although a preferred term or 
system organ class may be reported more than once for a subject, each subject will only be 
counted once in the incidence count for each category. If a subject has the same AE on multiple 
occasions, the highest severity (severe > moderate > mild) or drug relationship (definite > 
probable > possible > unlikely > not related) recorded for the event will be presented.  
Severity levels include: mild, moderate and severe. Relationships will be grouped into two 
categories for analysis: related and unrelated. Not related and unlikely will be categorized as 
“unrelated.” Possible, probable and definite will be categorized as “related.” If severity or drug 
relationship is missing no data imputation will be performed and no category of missing will be 
presented.  
Summary tables showing the number of subjects and percent within each category will be 
generated for each of the following types of adverse events: 
• All AEs; 
• Fatal Adverse Events; 
• AEs for Subjects who Died. 
In addition, the event rate per 100 person years will also be summarized to allow comparison of 
event rates between the placebo group and the active treatment periods which will have much 
longer exposure time.  
These summaries will present the number and percentage of subjects reporting an adverse event 
for each classification level. The denominators for calculating the percentages overall will be 
based on the number of subjects in the safety population. The denominators for calculating the 
percentages by treatment will be based on the number and duration of treatment of subjects 
exposed to each treatment in the safety population. In addition to these summaries, all AEs will 
be summarized by action taken, seriousness, severity, and relationship to study drug. 


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All AEs that occurred in 5% or more of all subjects will be tabulated for the safety population. 
These results will be analyzed descriptively and their incidence rate and two-sided 95% 
confidence intervals will be summarized.  
All SAEs, AEs leading to premature discontinuation from the study, AEs with fatal outcome, and 
AEs for subjects who died will also be provided in data listings by subject and preferred term. 
9.2 
Vital Signs  
Each vital sign will be summarized by treatment and overall by visit, using descriptive statistics 
(mean, median, SD, minimum, maximum, and number of subjects) for the safety population. 
Additionally, descriptive summaries will be provided for CFB values for each treatment by visit 
for vital sign measurements collected during the study.  
The latest non-missing vital sign value collected prior to dosing will be used as the baseline 
values. The baseline values will usually be the vital signs recorded at the baseline visit. In the 
case of repeated vital signs, the last collected values within that visit will be used for the 
summary tables. 
Vital signs will be provided in a data listing by subject, visit, and parameter.   
9.3 
Electrocardiogram 
ECG values and change from baseline values will be summarized by visit using descriptive 
statistics. ECG abnormalities will be summarized as the count and percentage of subjects in each 
treatment group. CFB will be summarized in a shift table crossing baseline and each visit result. 
The denominators for calculating the percentages will be the number of subjects in each 
treatment group who have an evaluation for both the screening and each visit in the safety 
population. These results will be analyzed descriptively and their incidence rate and two-sided 
95% confidence intervals will be summarized. 
9.4 
Clinical Laboratory Evaluations 
Continuous clinical laboratory analytes absolute values and change from baseline values will be 
summarized by analyte and visit using descriptive statistics (mean, median, SD, minimum, 
maximum, and number of subjects). Mean line plots over time will be displayed for each analyte 
with separate lines for each treatment. Categorical laboratory analytes, classified as normal or 
abnormal, will be summarized by analyte and visit using the number and percentage of subjects 
in each category. The denominators for calculating the percentages will be based on the number 
of subjects with non-missing assessments at a particular visit for the safety population. The latest 
non-missing clinical laboratory tests collected prior to dosing will be used as the baseline values. 
 


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Shifts to values outside of the normal range will be presented by analyte and will be summarized 
by the number and percentage of subjects with shifts. Shifts will be determined for analytes in 
which both the baseline value and the termination value are recorded. The denominators for 
calculating the percentages will be based on the number of subjects with non-missing 
assessments for a particular analyte. 
Clinical laboratory results will be provided in data listings by subject, visit and analyte. 
Abnormal lab results will be provided in a separate listing by subject, center, analyte and visit. 
9.5 
C-SSRS 
The C-SSRS responses will be tabulated by visit, treatment group, question and response. All C-
SSRS responses will also be provided in a data listing. 
9.6 
Days Hospitalized 
The number of days hospitalized will be calculated using the start and stop date of a severe or 
serious AE that resulted in hospitalization. The total number of days each subject was 
hospitalized over the course of the trial will be calculated by summing all periods of 
hospitalization. An analysis of covariance (ANCOVA) will be performed to analyze the total 
days of hospitalization. The model will have total days of hospitalization as the response variable 
and del-FS and treatment as the explanatory variables. 
LSMEANs and standard errors will be estimated for PA treatment and AA at the mean level of 
del-FS across all subjects. The least-squares difference and standard error in predicted values 
between treatments will also be presented. In addition, treatment differences, p-values, 95% 
confidence intervals for the difference, and effect size will be displayed for treatment 
comparisons. The number of subjects included in the analysis, mean, standard deviation, median, 
25th percentile (Q1), 75th percentile (Q3), minimum and maximum total number of days 
hospitalized will all be reported and accompany the estimates from the ANCOVA outlined in 
this section.  
  
 


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10 
OTHER LISTINGS  
The following additional listings will be provided: 
• Subjects excluded from the safety, mITT, and PP populations; 
• Clinical laboratory results for hematology, blood chemistry and urinalysis;  
• Abnormal laboratory results; 
• Concomitant medications;