Clinical trial NCT04098406
Conditions: Amyotrophic Lateral Sclerosis
Keywords: Gold Nanocrystal electromyography ALS Nanoparticle
Sponsor: Clene Nanomedicine
Start date: 2019-12-19; Completion date: 2021-07-13
Enrollment: 45 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
The objective of this trial was to assess the efficacy, safety, and PK/PD effects of CNM-Au8 as a disease-modifying agent for the treatment of ALS by utilizing electrophysiological measures to detect preservation of motor neuron function. The primary endpoint was the mean change in the average difference between active treatment and placebo from Baseline through Week 36 evaluated by electromyography.

Detailed description:
This was a multi-centre randomized, double-blind, parallel group, placebo-controlled study of the efficacy, safety, pharmacokinetics, and pharmacodynamics of CNM-Au8 in patients who are newly symptomatic within 24-months of Screening and with a clinically probable or possible or definite ALS diagnosis per the Awaji-Shima criteria.

Patients were screened over up to a 6-week period. Patients who met the inclusion criteria and none of the exclusionary criteria were enrolled into the clinical study. Patients were randomized 1:1 into one of two groups: either active treatment with CNM-Au8 30 mg or Placebo.

All patients received their randomized oral treatment daily over thirty-six (36) consecutive weeks during the Treatment Period.

There were up to four study periods:

1. Up to a six (6) week screening period (Screening Period);
2. A thirty-six (36) week blinded randomized treatment period (Treatment Period);
3. Up to a forty-eight (48) week optional open-label extension period (Open-Label Period);
4. A four (4) week safety follow-up period following completion of either the Treatment or Open-Label period or in the case of Early Termination (Safety Follow-Up Period).

Per protocol, all patients received their blinded and randomized oral treatment daily over at least 36 consecutive weeks during the Treatment Period.

For those patients not transitioning into the optional OLE period, patients completed a safety follow-up visit 4-weeks following study drug discontinuation.

An independent DSMB was responsible for monitoring the safety of the study on a quarterly basis and ad hoc at the request of the DSMB or the Sponsor (e.g., in the event of unexpected SAEs) to review data throughout the Treatment Period. The DSMB may make recommendations on the conduct of the study, including study termination. Appropriate procedures will be detailed in a DSMB Charter.

Arms: arm 1: The matched placebo used in this study consisted of water, sodium bicarbonate, and food coloring to match volume and color of the experimental treatment arm 2: 30mg suspension of clean-surfaced, faceted, gold nanocrystals in 60ml of sodium bicarbonate buffered water
Interventions: intervention 1: CNM-Au8 intervention 2: Placebo
Intervention descriptions: intervention 1: CNM-Au8 is a dark red/purple-colored liquid formulation consisting of a stable suspension of faceted clean surfaced elemental gold nanocrystals in buffered deionized water with a nominal concentration of 0.5 mg/mL of gold. The formulation is buffered by sodium bicarbonate present at a concentration of 0.546 mg/mL. There are no other excipients. The drug product is formulated to be taken orally and will be provided in single dose 60 mL HDPE containers. intervention 2: Placebo was liquid with identical color and taste

Protocol documents:
Prot_000.pdf: 
PROTOCOL TITLE PAGE 
 
 
 
 
STUDY NUMBER CNMAu8.205 
 
 
RESCUE ALS 
 
 
A Phase 2, Randomised, Double-Blind, Placebo-Controlled Study in Early 
Symptomatic Amyotrophic Lateral Sclerosis Patients on Stable Background 
Therapy to Assess Bioenergetic Catalysis with CNM-Au8 to Slow Disease 
Progression in ALS 
 
NCT04098406 
 
RELEASE DATE: 04OCT2021  
 


 
 
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` 
 
 
 
 
 
 
 
 
 
CLINICAL STUDY PROTOCOL 
 
 
 
 
 
 
RESCUE-ALS: 
A Phase 2, Randomised, Double-Blind, Placebo-Controlled Study in Early 
Symptomatic Amyotrophic Lateral Sclerosis Patients on Stable Background 
Therapy to Assess Bioenergetic Catalysis with CNM-Au8 to Slow Disease 
Progression in ALS 
 
 
 
 
 
 
U.S. IND Number:  
 
142,774 
Protocol Number:  
 
CNMAu8.205 
Clinical Phase: 
 
 
Phase 2 
Investigational Drug: 
 
CNM-Au8 
Protocol Version No.: 
 
7.0 (Amendment 6.0) 
Current Protocol Version Date: 
04-October-2021 
 
 
 
 
 
 
 
 
CONFIDENTIALITY STATEMENT 
The information contained in this document and all information provided to you related to CNM-
Au8 (“Study Drug”) or (“Investigational Product”) are the confidential and proprietary information 
of Clene Australia Pty Ltd. (Sponsor) and Clene Nanomedicine, Inc. and except as may be required 
by federal, state or local laws or regulations, may not be disclosed to others without prior written 
permission of the Sponsor. The Principal Investigator may, however, disclose such information to 
supervised individuals working on the Study Drug, provided such individuals agree to maintain the 
confidentiality of such information. 
 
 
 


 
 
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PROTOCOL APPROVAL PAGE 
 
 
Study Title: 
RESCUE-ALS: A Phase 2, Randomised, Double-Blind, Placebo-
Controlled Study in Early Symptomatic Amyotrophic Lateral Sclerosis 
Patients on Stable Background Therapy to Assess Bioenergetic Catalysis 
with CNM-Au8 to Slow Disease Progression in ALS 
Protocol Number: 
CNMAu8.205 
Current Protocol 
Date: 
  04-October-2021 
Sponsor Name and 
Address: 
Clene Australia Pty Ltd. 
C/- Prime Accounting & Business Advisory Pty Ltd.  
Floor 19, HWT Tower, 40 City Road  
SOUTHBANK, VIC 3006 
Australia  
 
A subsidiary of: 
Clene Nanomedicine, Inc. 
6550 South Millrock Drive, Suite G50 
Salt Lake City, UT 84121 
United States 
 
I, the undersigned, have read and approve this protocol and agree on its content. It is confirmed 
that the information and guidance given in this protocol complies with scientific principles, the 
guidelines of Good Clinical Practices, the Declaration of Helsinki in the latest relevant version, 
and the applicable legal and regulatory requirements. 
 
 
Sponsor 
Signature: 
 
 
 
 
 
 
 
 
 
Sponsor’s Medical Representative 
 
Robert Glanzman, MD FAAN 
 
 
 
Date 
 
 
 
 
 
 
 
 
 
 
 
 
10/4/2021


 
 
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INVESTIGATOR PROTOCOL AGREEMENT 
 
Protocol Title: 
RESCUE-ALS: A Phase 2, Randomised, Double-Blind, Placebo-
Controlled Study in Early Symptomatic Amyotrophic Lateral Sclerosis 
Patients on Stable Background Therapy to Assess Bioenergetic 
Catalysis with CNM-Au8 to Slow Disease Progression in ALS  
 
Protocol Number: 
CNMAu8.205 
 
Protocol Date: 
04-October-2021 
Version:  
7.0 (Amendment 6.0) 
 
 
 
By my signature, I: 
 
• 
Confirm that my staff and I have carefully read and understand this protocol and the 
Investigator’s Brochure (IB) and are thoroughly familiar with the appropriate use of the 
investigational drug described herein. 
 
• 
Agree to comply with the conduct and terms of the study specified herein and with any 
other study procedures provided by the Sponsor, Clene Nanomedicine, Inc. (herein 
referred to as “Clene”). 
 
• 
Agree to comply with US Food and Drug Administration (FDA), Health Canada, and 
Australian Therapeutic Goods Administration (TGA) regulations, as applicable; the 
International Conference on Harmonization (ICH) GCP guidelines, the Declaration of 
Helsinki, and all applicable rules, regulations, and federal, state, and local laws relating to the 
conduct of clinical studies and the protection of human subjects. 
 
• 
Agree not to implement changes to the protocol without agreement from the Sponsor and 
prior written approval (where required) from the Institutional Review Board (IRB) or 
Human Research Ethics Committee (HREC), except when necessary to eliminate an 
immediate hazard to the subjects. 
 
• 
Agree to onsite monitoring of the case report forms (CRFs) and source documents by Clene 
or designee and to audit by Clene or designee and appropriate regulatory authorities, 
including, but not limited to, the FDA and IRB/HREC inspectors. 
 
• 
Agree to supervise the conduct of the study and maintain responsibility for training and 
supervising all personnel who have delegated responsibilities under my leadership. The 
protocol and other important study materials will be available to study staff throughout the 
conduct of the study. 
 
 
 
 
 
 
Investigator’s Signature 
 
Date 
 
 
 
 
Print Name 
 
 
 
 
 


 
 
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PROTOCOL SYNOPSIS 
Category 
Description 
Sponsor 
Clene Australia Pty Ltd., a subsidiary of Clene Nanomedicine, Inc. 
Investigational 
Drug Product  
CNM-Au8 
Name of Active 
Ingredient 
Faceted clean-surfaced Au nanocrystals 
Phase of 
Development 
Phase 2 
Study Title 
A Phase 2, Randomised, Double-Blind, Placebo-Controlled Study in Early 
Symptomatic Amyotrophic Lateral Sclerosis Patients on Stable Background 
Therapy to Assess Bioenergetic Catalysis with CNM-Au8 to Slow Disease 
Progression in ALS  
(RESCUE-ALS) 
Study Center(s) 
Two study sites in Australia. 
Additional centres in Australia and/or the United States may be added at the 
discretion of the Sponsor based on patient recruitment rates. 
Chief 
Investigator(s)  
A/Professor Parvathi Menon PhD 
Consultant Neurologist, Associate Professor in the Faculty of Medicine 
University of Sydney 
 
Brain and Nerve Research Centre 
Concord Repatriation General Hospital 
Building 20, Hospital Road 
Concord  NSW  2139 
Australia  
Phone: +61 (2) 9767 8423 
Email: parmenon2010@gmail.com 
 
Dr. William Huynh 
Consultant Neurologist 
Brain and Mind Centre 
94 Mallet Street 
Camperdown NSW 2050 
Phone: +61 (2) 9114 4250 
Email: william.huynh@sydney.edu.au 
 
Study Objectives 
To assess the efficacy, safety, and PK/PD effects of CNM-Au8 as a disease-
modifying agent for the treatment of ALS by utilizing electrophysiological 
measures to detect preservation of motor neuron function. 
• Efficacy will be assessed as the difference in disease progression from 
baseline reflected by changes in motor neuron loss measured by 
electromyography (e.g., MUNIX, MUSIX, Split Hand Index, 
Neurophysiology Index, MScanFit), change in ALS Functional Rating 


 
 
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Category 
Description 
Score-Revised (ALSFRS-R) score, the mean rate of change (DFS) of the 
ALSFRS-R from symptom onset, survival status, respiratory functions, 
and composite disease progression. 
• Safety will be assessed up through the frequency of treatment emergent 
adverse events, serious adverse events, discontinuations due to adverse 
events, Falls Questionnaire, and the Columbia Suicide Severity Rating 
Scale (C-SSRS). 
Overall Study 
Design and Plan 
 
 
 
This is a multi-centre randomised, double-blind, parallel group, placebo-
controlled study of the efficacy, safety, pharmacokinetics, and 
pharmacodynamics of CNM-Au8 in patients who are newly symptomatic 
within 24-months of Screening and with a clinically probable or possible or 
definite ALS diagnosis per the Awaji-Shima criteria (de Carvalho et al., 
2008).  
Patients may be screened over up to a 6-week period. Patients who meet the 
inclusion criteria and none of the exclusionary criteria will be enrolled into 
the clinical study.   
Patients will be randomised 1:1 into one of two groups: either active 
treatment with CNM-Au8 30 mg or Placebo.  
All patients will receive their randomised oral treatment daily over thirty-six 
(36) consecutive weeks during the Treatment Period. 
There will be up to four study periods: 
1. Up to a six (6) week screening period (Screening Period); 
2. A thirty-six (36) week blinded randomised treatment period 
(Treatment Period); 
3. A forty-eight (48) week optional open-label extension period (Open-
Label Period), which may be extended by 12-week increments until 
discontinued by the Sponsor; 
4. A four (4) week safety follow-up period following completion of 
either the Treatment or Open-Label period or in the case of Early 
Termination (Safety Follow-Up Period). 
Per protocol all patients will receive their blinded and randomised oral 
treatment daily over at least 36 consecutive weeks during the Treatment 
Period.   
For those patients not transitioning into the optional OLE period, patients 
will complete a safety follow-up visit 4-weeks following study drug 
discontinuation. 
An independent DSMB will be responsible for monitoring the safety of the 
study on a trimester basis and ad hoc at the request of the DSMB or the 
Sponsor (e.g., in the event of unexpected SAEs) to review data throughout 
the Treatment Period and OLE period. The DSMB may make 
recommendations on the conduct of the study, including study termination.  
Appropriate procedures will be detailed in a DSMB Charter.  


 
 
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Category 
Description 
Estimated Study 
Duration 
The estimated study duration for the randomized placebo controlled period 
of the trial will be approximately 72-weeks from the first patient-first visit to 
the last patient-last visit. This duration assumes a 27-week recruitment 
period (e.g., 21-weeks, average of 1 enrolled patient per site per week (n=42) 
based on the site-specific projections from the recently enrolled TEALS 
study, plus a 6-week projected Christmas and New Year holiday recruitment 
pause), up to a 6-week screening period, the 36-week Treatment Period, and 
a 4-week safety follow-up period for those patients not transitioning to the 
optional OLE period of the trial. It is currently planned that the OLE period 
will run for up to an additional 48 weeks beyond the 36-week placebo 
controlled portion of the trial, which may be extended for additional 12-week 
increments until discontinued by the Sponsor.  
Number of 
Patients 
Approximately 42 randomised patients (1:1); 36 evaluable (assuming a 
~14% drop-out rate): 
• 
30 mg CNM-Au8 (n=21) 
• 
Placebo (n=21) 
Inclusion Criteria  
 
The patients to be enrolled in this study must meet the following inclusion 
criteria: 
1. Able to understand and give written informed consent. 
2. Male or female patients aged 30 years or greater (inclusive) and less 
than 80 years of age at the time of Screening. 
3. Patients whose conditions are defined as possible or probable or 
definite ALS per the diagnostic criteria by Awaji-Shima criteria as 
determined by a neurologist sub-specialising in ALS (e.g., the 
Principal Investigator by study site). 
4. For patients taking riluzole, stable dosing of riluzole over the prior 
30-days from Screening. 
5. At the time of Screening either disease duration less than or equal to 
24-months from symptom onset, or disease duration less than or 
equal to 12-months from diagnosis. 
6. Forced vital capacity (FVC) ³ 60% of predicted value as adjusted for 
gender, height, and age at the Screening Visit. 
7. Patient who has established care with a neurologist at one of the 
specialised ALS clinics involved in the study and will maintain this 
clinical care throughout the study.  If a patient is referred from a 
third party (neurologist or a State based ALS organisation) they must 
be willing to transfer care to the neurologist participating in the 
study.  
Following completion of the 36-week randomized placebo controlled 
treatment period, interested participants must meet the following inclusion 
criteria to enroll in the open-label extension: 
1. Participants must have completed the randomized placebo controlled 
Treatment Period without compliance issues 


 
 
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Category 
Description 
2. Able to understand and give written informed consent to participant 
in the open-label extension. 
3. If referred from a third party (neurologist or a State based ALS 
organisation), participant agrees to maintain transfer of care to a 
neurologist participating in the study. 
Exclusion Criteria 
 
1. Patients will be excluded from the study if they meet any of the 
following criteria: 
2. At Screening patients who utilize, or in the Investigator’s judgment 
will be imminently dependent upon: 
a. Non-invasive ventilation > 22 hours per day, or 
b. Tracheostomy 
Note: If the patient requires non-invasive ventilation post-
randomisation, they will be allowed to continue in the study. 
3. Patients with Familial ALS (e.g., 2 or more family members with 
ALS or motor neuron disease) 
4. Patients with a history of carpal tunnel syndrome, polyneuropathy, 
or in the investigators judgement diseases that could induce 
polyneuropathy and interfere with electromyography (EMG) 
recordings. 
5. Patients with too severe atrophy of the Abductor Digiti Minimi 
(ADM), Abductor Pollicis Brevis (APB), Biceps Brachii (BB), or 
Tibialis Anterior (TA) muscles in the least clinically affected hand 
and leg, respectively, to allow for reliable EMG recordings. 
6. Patient with a history of significant other major medical conditions 
based on the Investigator’s judgment. 
7. Based on the investigator’s judgment, patients who may have 
difficulty complying with the protocol and/or any study procedures. 
8. Patient with clinically significant abnormalities in haematology, 
blood chemistry, ECG, or physical examination not resolved by the 
Baseline visit which according to Investigator can interfere with 
study participation. 
9. Patients with clinically significant hepatic or renal dysfunction or 
clinical laboratory findings that would limit the interpretability of 
change in liver or kidney function, or those with low platelet counts 
(< 150 x 109 per liter) or eosinophilia (absolute eosinophil count of ≥ 
500 eosinophils per microliter) at Screening. 
10. Patient participating in any other investigational drug trial or using 
investigational drug (within 12 weeks prior to screening and 
thereafter). 
11. Females who are pregnant or nursing or who plan to get pregnant 
during the course of this clinical trial or within 6 months of the end 
of this trial. 
12. Females of child-bearing potential, or men, who are unwilling or 
unable to use accepted methods of birth control. 
13. Active inflammatory condition or autoimmune disorder.  
14. Positive screen for drugs of abuse. 


 
 
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Category 
Description 
15. History of gold allergy. 
16. Patient is considered a suicide risk in the opinion of the Investigator, 
has previously made a suicide attempt, or is currently demonstrating 
active suicidal ideation. Subjects with intermittent passive suicidal 
ideation are not necessarily excluded based on the assessment of the 
Investigator. 
Following completion of the 36-week randomized placebo controlled 
treatment period, interested participants will be excluded from participating 
in the open-label extension phase if they meet any of the following criteria: 
1. Lack of treatment compliance during the randomized placebo 
controlled Treatment Period. 
2. Positive pregnancy test at the Week 36 visit, or, females who plan to 
get pregnant during the course of this extension or within 6 months 
of the end of this extension. 
3. Based on the investigator’s judgment, patients who may have 
difficulty complying with the protocol and/or any study procedures. 
4. Patient with clinically significant abnormalities in haematology, 
blood chemistry, ECG, or physical examination identified during the 
W36 visit which according to Investigator may interfere with 
continued participation. 
5. Patients with clinically significant hepatic or renal dysfunction or 
clinical laboratory findings that would limit the interpretability of 
change in liver or kidney function, or those with low platelet counts 
(< 150 x 109 per liter) or eosinophilia (absolute eosinophil count of ≥ 
500 eosinophils per microliter) at the Week 36 visit. 
6. Patient is considered a suicide risk in the opinion of the Investigator, 
has previously made a suicide attempt, or is currently demonstrating 
active suicidal ideation. Subjects with intermittent passive suicidal 
ideation are not necessarily excluded based on the assessment of the 
Investigator. 
Concomitant 
Medications 
Disease-specific medications (e.g., riluzole) are allowed per the inclusion 
criteria. 
Except for disease specific medications (e.g., riluzole), acetaminophen 
(paracetamol), ibuprofen, naproxen, and 2nd generation antihistamines 
(including fexofenadine, loratadine, and cetirizine); patients may not take 
any new prescription medications, OTC, or dietary supplements from 14-
days prior to Baseline through the safety follow-up (including the optional 
OLE period) unless used to manage a treatment emergent adverse event, in 
which case the patient should report to his/her Study Physician as soon as 
possible, the occurrence of the adverse event and the medication(s) they are 
taking to treat the adverse event. 
The Investigator will make every effort to contact the Medical Monitor or 
Sponsor representative prior to administration of a new concomitant therapy 


 
 
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Category 
Description 
(prescription or OTC) after randomisation, unless the concomitant therapy is 
needed immediately for patient safety. 
Duration of 
Treatment 
Patients will receive 36 weeks of consecutive daily dosing per protocol. 
Following completion of the 36-week randomized, placebo controlled 
treatment period, participants may choose to participate in an open-label 
extension (OLE) period for up to an additional 48 weeks, which may be 
extended for additional 12-week increments until discontinued by the 
Sponsor.  
Test Product, 
Dose, and Mode of 
Administration 
CNM-Au8 is an aqueous suspension of clean surfaced faceted nanocrystals 
consisting of gold atoms self-organized into crystals of various geometrical 
shapes (hexagonal bi-pyramid, pentagonal bi-pyramid, tetrahedron, 
decahedron, planar spheroids).   
Highly pure elemental Au nanocrystals are suspended in USP purified 
deionized water buffered with 0.546 mg/mL (6.5 mM) sodium bicarbonate 
(NaHCO3) nominally concentrated up to 0.5 mg/L (500 ppm).  
Patients will orally receive 30 mg of CNM-Au8, or placebo, once daily. 
Those choosing to participate in the OLE period will orally receive 30 mg of 
CNM-Au8, once daily.  
CNM-Au8 or matching placebo will be administered orally in volumes of 60 
mL from single-dose HDPE containers. 
Primary Efficacy 
Endpoint  
Electromyography Measures of Disease Progression 
Mean change in the average difference between active treatment and placebo 
from Baseline through Week 36 for the MUNIXscore(4), which is the sum of 
the respective MUNIX values for the Abductor Digiti Minimi (ADM), 
Abductor Pollicis Brevis (APB), Biceps Brachii (BB), and Tibialis Anterior 
(TA). The average baseline summed values will be indexed to 100%.  
Changes will be calculated as the percent change from the Baseline index of 
100%. 
Secondary 
Efficacy 
Endpoints   
• 
Mean change of the average difference between active treatment and 
placebo from Baseline to Week 36 for respiratory function as measured 
by forced vital capacity (FVC). 
• 
Mean absolute change of the average difference between active 
treatment and placebo from Baseline through Week 36 for the 
MUNIXscore(4), which is the sum of the respective MUNIX values for 
the Abductor Digiti Minimi (ADM), Abductor Pollicis Brevis (APB), 
Biceps Brachii (BB), and Tibialis Anterior (TA).  
Exploratory 
Efficacy 
Endpoints 
 
The hierarchical assessment of exploratory endpoints will be detailed in the 
statistical analysis plan.  Exploratory endpoints include both 
electromyography and functional clinical endpoints, including: 


 
 
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Category 
Description 
• 
Mean change in the average difference between active treatment and 
placebo from Baseline through Week 36 (overall difference at all time 
points) as measured by MScanFit MUNE (Jacobsen et al., 2017) of the 
APB. The baseline average will be indexed to 100%, and changes at 
Week 12 and Week 36 will be calculated as the percent change from the 
Baseline index of 100%. 
• 
Mean change in the average difference between active treatment and 
placebo from Baseline through Week 36 for the MUSIXscore(4) 
(Neuwirth et al., 2015), which is the mean of the respective MUSIX 
values for the ADM, APB, BB, and TA. The average baseline mean 
values will be indexed to 100%.  Changes will be calculated as the 
percent change from the Baseline index of 100%. 
• 
Mean change in the average difference between active treatment and 
placebo from Baseline through Week 36 for the Neurophysiological 
Index (NPI) of the ADM (Cheah et al., 2011), defined as the ulnar nerve 
(ADMCMAP Peak Amplitude / ADMDistal Motor Latency) * ADMF-Wave (%). 
• 
Mean change in the average difference between active treatment and 
placebo from Baseline through Week 36 for the Split Hand Index (SI) 
(Menon et al., 2013), defined as the first dorsal interosseous (FDI)Peak 
CMAP Amplitude * APBPeak CMAP Amplitude/ADMPeak CMAP Amplitude. 
• 
Mean change between active treatment and placebo in the proportion of 
patients experiencing a > 6-point decline in the ALSFRS-R between 
active treatment and placebo from Baseline to Week 36. 
• 
Mean change in average ALSFRS-R score from Baseline to Week 36. 
• 
Mean change in slope of the decline of the ALSFRS-R from Baseline to 
Week 36. 
• 
Mean change between active treatment and placebo for the Combined 
Assessment of Function and Survival (CAFS), a joint-rank analysis of 
function (ALSFRS-R) and overall survival from Baseline to Week 36. 
• 
Mean change between active treatment and placebo from Baseline to 
Week 36 in the proportion of patients experiencing ALS clinical 
composite disease progression defined as the occurrence of death, 
tracheostomy, use of non-invasive ventilatory respiratory support, 
insertion of a gastrostomy tube, or a 6-point drop in the ALSFRS-R 
score. 
• 
Mean change in rate of disease progression defined as the average 
change in the DFS score ([Max ALSFRS-R minus current ALSFRS-R 
score]/symptom duration in months) from Baseline to Week 36. 
• 
Mean change in average difference between active treatment and 
placebo from Baseline to Week 36 for: 
o ALSSQOL-Short Form questionnaire (ALSSQOL-SF) 


 
 
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Category 
Description 
o Clinician’s Global Impression (CGI) 
o Patient’s Global Impression (PGI) 
• 
Difference in the proportion of patients utilizing health economic 
outcome measures from Baseline to Week 36. 
Open-Label 
Extension 
Endpoints 
The primary endpoint for the OLE is safety. Safety endpoints include 
incidence of treatment-emergent AEs, drug-related AEs, deaths, SAEs, and 
AEs leading to discontinuation from the study. Changes from baseline 
(Week 36 of the placebo controlled phase) in clinical laboratory results, 
physical examination findings, vital signs, ECGs, and C-SSRS will be 
summarized descriptively by group and timepoint.  
The primary efficacy endpoint for the OLE is the Electromyography 
Measures of Disease Progression defined as: 
• 
Mean change in the average difference between active treatment and 
placebo from Baseline through End of Study for the 
MUNIXscore(4), which is the sum of the respective MUNIX values 
for the Abductor Digiti Minimi (ADM), Abductor Pollicis Brevis 
(APB), Biceps Brachii (BB), and Tibialis Anterior (TA). 
Other secondary and exploratory endpoints will be described below in 
Section 6.  
Pharmacodynamic 
(PD) Endpoints  
Measures of Blood and Urine Biomarkers 
Blood, plasma, and urine will be collected at Baseline and at the Week 12, 
Week 24, and Week 36 visits and stored for subsequent pharmacodynamic 
analyses. During the OLE period, blood and urine for PD analyses will be 
collected at the Week 24 and every 24 weeks thereafter as long as the period 
is ongoing. The PD analyses may include blood metabolomic markers (e.g., 
redox coenzymes: NAD+, NADH, NADP+, NADPH; energetic coenzymes: 
ATP, ADP, AMP and antioxidants: GSSG and GSH), urinary neurotrophin 
receptor P75ECD levels, and serum neurofilament light chain (NfL).   
PD analyses will be specified in a separate PD analysis plan to be completed 
prior to database lock. 
Pharmacokinetic 
(PK) Endpoints 
A sample for the measurement of whole blood concentrations of Au will be 
collected before (pre-dose) administration of CNM-Au8 at Week 12 and 
Week 24. At the Week 36 Visit, samples for the measurement of whole 
blood concentrations of Au will be collected before (pre-dose) and at 1, 2, 4, 
and 6 hours, after administration of the last dose of the investigational drug 
product at the site. The study site will contact the patient and document the 
time at which the patient administered his/her prior day’s dose of study drug 
in order to impute a 24-hour trough value.  
The Week 36 data will be used to estimate an apparent Cmax and Tmax and 
area under the curve (AUC) over the 24-hour dosing interval [AUC(0-24)].   


 
 
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Category 
Description 
During the open-label extension phase, blood and urine for PK analyses will 
be collected at the Week 24 and every 24 weeks thereafter as long as the 
period is ongoing.  
PK data will be used to construct a composite whole blood concentration-
time profile for the Q12 week visits during the randomised treatment period. 
Statistical 
Methods 
 
The primary endpoint, the mean change in the MUNIXscore(4) summed 
value will be analysed using Mixed Model for Repeated Measures (MMRM) 
with treatment (Week 12, Week 24, and Week 36) as fixed effects and 
Baseline DFS, Baseline ALSFRS-R scores, and bulbar vs. limb onset as 
covariates. Estimates of least-square means, standard errors and 95% 
confidence intervals will be presented by treatment group. For the active 
treatment versus placebo comparisons, the least square mean difference, the 
standard error of the difference, and the 95% confidence interval of the 
difference will be presented.   
Sample size calculations were based on the following criteria:  
(i) 
Mean difference between the MUNIX(4)score indexed value in the 
change from baseline between active and placebo of 19.2% at Week 
36; 
(ii) common standard deviation (SD) of 19.8%;  
(iii) α value of 0.05;  
(iv) b power of 0.8; and 
(v) 12.5% dropout rate. 
Based on previously reported longitudinal studies of MUNIXscore(4) in 
ALS patients (Neuwirth et al., 2015); it is assumed the common standard 
deviation for the MUNIXscore(4) is 19.8% with a placebo deterioration of 
38.4% (e.g., 61.6% of the baseline index value) at Week 36.  The active 
treatment group deterioration is estimated at 19.2% (e.g., 80.8% of the 
baseline index value) at Week 36.  
At a 1:1 (CNM-Au8 30 mg: Placebo) allocation, 80% power and 5% 
statistical significance rate, an estimated 36 evaluable patients will be 
required for this study. With a 12.5% estimated non-evaluable rate, it is 
planned to assign 42 patients (21 active:21 placebo) to randomised treatment. 
Safety endpoints include incidence of treatment-emergent AEs, drug-related 
AEs, deaths, SAEs, and AEs leading to discontinuation from the study.  
Changes from baseline in clinical laboratory results and vital signs will be 
summarized by treatment group and time point.  Treatment-emergent 
adverse events will be coded using the Medical Dictionary for Regulatory 
Activities and will be tabulated in incidence tables by System Organ Class 
(SOC) and Preferred Term (PT).  Treatment-emergent adverse events will be 
summarised by SOC, PT, and treatment group. Treatment emergent adverse 
events will be further summarised by maximum severity and relationship to 
the investigational medicinal product.      


 
 
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Category 
Description 
All safety summaries will be descriptive; no statistical significance tests will 
be performed on safety data and will be based on the safety population. 
Gold (Au) concentration data in whole blood will be summarized with 
descriptive statistics by treatment group at each time point of collection. 
 
 


 
 
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Table 1: Time and Events Schedule 
Time and Events 
Schedule 
Visit 
-1 
0 
1 
2 
3 
4 
5 
6 
7 
8 
Phase 
Screening 
Baseline 
Treatment Period 
Safety 
Follow-Up b 
Week 
-6 
0 
3 
6 
12 
18 
24 
30 
36 
40 
Day  
-42 to -1 
1 
21 a 
42 a 
84 a 
126  a 
168 a 
210  a 
252 a 
280 c 
ICF Signed 
X 
 
 
 
 
 
 
 
 
 
Eligibility Review  
X 
X 
 
 
 
 
 
 
 
 
Medical History & Prior Med Assess. 
X 
 
 
 
 
 
 
 
 
 
Physical Examination  
X  
X  
 
 
X d 
 
X d 
 
X d 
X 
Brief Neurological Exam 
X 
X 
 
 
X 
 
X 
 
X 
X 
Anthropometrics (Height and Weight Assessment) 
X 
X e 
 
 
X e 
 
X e 
 
X e 
 
Urine Drug Test 
X 
 
 
 
 
 
 
 
 
 
HIV/Viral Hepatitis Screen  
X 
 
 
 
 
 
 
 
 
 
Serum Pregnancy Test  
X f 
 
 
 
 
 
 
 
 
 
Urine Pregnancy Test  
 
X f 
 
 
X f 
 
X f 
 
X f 
 
Vital Signs 
X 
X 
 
 
X 
 
X 
 
X 
X 
12-lead ECG  
X g 
X g 
 
 
X g 
 
X g 
 
X g 
 
Clinical Laboratory (Blood) 
X 
X 
 
 
X 
 
X 
 
X 
X 
Urinalysis 
X 
X 
 
 
X 
 
X 
 
X 
X 
Concomitant Medication  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Randomisation 
 
X 
 
 
 
 
 
 
 
 
Dispense/Return Drug 
 
X 
 
 
X 
 
X 
 
X 
 
Schedule Next Visit 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
PD Sampling (Blood, Urine) 
 
X h 
 
 
X h 
 
X h 
 
X h 
 
PK Sampling (Blood)  
 
 
 
 
X h 
 
X h 
 
X i 
 
Adverse Events 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
EMG: MUNIX, MUSIX, CMAP of the APB, ADM, 
BB, TA, FDI 
 
X j 
 
 
X j 
 
X j 
 
X j 
 
EMG: ADM, APB (F-Wave); Distal Motor Latency 
(APB, ADM, BB, TA, FDI) 
 
X j 
 
 
X j 
 
X j 
 
X j 
 
EMG: MScan for the APB 
 
X j 
 
 
X j 
 
X j 
 
X j 
 
ALSFRS-R 
X 
X 
 
 
X 
 
X 
 
X 
 
FVC 
X 
X 
 
 
X 
 
X 
 
X 
 
ALSSQOL-SF 
 
X 
 
 
X 
 
X 
 
X 
 
Health Utilisation Form (e.g., PEG, NIV, Wheel 
Chair) 
 
X 
 
 
X 
 
X 
 
X 
 
Falls Questionnaire 
 
 
 
 
X 
 
X 
 
X 
 
PGI (Patient Global Impression) 
 
X 
 
 
X 
 
X 
 
X 
 


 
 
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Time and Events 
Schedule 
Visit 
-1 
0 
1 
2 
3 
4 
5 
6 
7 
8 
Phase 
Screening 
Baseline 
Treatment Period 
Safety 
Follow-Up b 
Week 
-6 
0 
3 
6 
12 
18 
24 
30 
36 
40 
Day  
-42 to -1 
1 
21 a 
42 a 
84 a 
126  a 
168 a 
210  a 
252 a 
280 c 
CGI (Clinical Global Impression) 
 
X 
 
 
X 
 
X 
 
X 
 
Columbia-Suicide Severity Rating Scale  
(C-SSRS) 
X 
X 
 
 
X 
 
X 
 
X 
X 
Phone call 
 
 
X 
X 
 
X 
 
X 
 
 
 
Time and Events Schedule Notes: 
a. 
Scheduled Visit ± 5 days. 
b. For patients not transitioning to the optional Open-Label extension phase. 
c. 
Timing for the Safety Follow-Up visit should occur at four weeks (±5 days) following study early termination, or. following the patient’s final Week 36 visit if the 
participant chooses not to enter the optional OLE period. 
d. Brief physical exam only. 
e. 
Weight only 
f. 
For females of child bearing potential only. 
g. Electrocardiogram (ECG) intervals will be summarized and presented descriptively. ECG rhythm will be interpreted by the Investigator as normal (N), abnormal not-
clinically significant (aNCS), or abnormal clinically significant (aCS). Triplicate values will be collected at Baseline and averaged for comparison to single 
assessments at subsequent visits. 
h. Whole blood, plasma, and/or serum for PK and PD will be taken pre-dose only (e.g., within1 hour prior to the dose of study drug). 
i. 
Whole blood for PK will be taken at pre-dose (T0) and at 1, 2, 4, and 6 hours after dosing for the visit.  The exact time at which the patient took his/her previous day’s 
study drug dose must be recorded in order to impute a 24-hour trough value (T24-imputed).   
j. 
EMG to be conducted on the least clinically affected hand, leg, and arm identified at the Baseline visit. 
 
 


 
 
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Table 2: Time and Events Schedule (Optional Open-Label Extension) 
 
Time and Events 
Schedule 
Visit 
0 
1 
2, 4, 6, (n+2) 
3, 5, 7, (n+2) 
End of OLE 
Phase 
Baseline a 
Open-Label Extension Phase 
Safety Follow-Up c 
Week 
0 
6 
12, 36, 60, + every 24 weeks as 
applicable 
24, 48, 72, + every 24 weeks as 
applicable 
n+4 
Day  
0 
42 b 
84, 252, 420, n+168 b 
168, 336, 504, n+168 b 
Last visit +28 b 
ICF Signed 
X 
 
 
 
 
Eligibility Review and Confirmation 
X 
 
 
 
 
Brief Physical Examination  
X  
 
X 
X 
X 
Brief Neurological Exam 
X 
 
X 
X 
X 
Weight Assessment 
X 
 
 
X 
 
Urine Pregnancy Test d 
X 
 
X 
X 
 
Vital Signs 
X 
 
X 
X 
X 
12-lead ECG e 
X 
 
 
X 
 
Clinical Laboratory (Blood) 
X 
 
X 
X 
X 
Urinalysis 
X 
 
X 
X 
X 
Dispense/Return Drug 
X 
 
X 
X 
 
Schedule Next Visit 
X 
X 
X 
X 
 
PK/PD Sampling (Blood, Urine) 
X 
 
 
X f 
 
Adverse Events and Concomitant Medication Review 
X 
X 
X 
X 
X 
EMG: MUNIX, MUSIX, CMAP of the APB, ADM, 
BB, TA, FDI 
X g 
 
 
X g 
 
EMG: ADM, APB (F-Wave); Distal Motor Latency 
(APB, ADM, BB, TA, FDI) 
X g 
 
 
X g 
 
EMG: MScan for the APB 
X g 
 
 
X g 
 
ALSFRS-R 
X 
 
X 
X 
 
FVC 
X 
 
X 
X 
 
ALSSQOL-SF 
X 
 
X 
X 
 
Health Utilisation Form (e.g., PEG, NIV, Wheel 
Chair) 
X 
 
X 
X 
 
Falls Questionnaire 
 
 
X 
X 
 
PGI (Patient Global Impression) 
X 
 
X 
X 
 
CGI (Clinical Global Impression) 
X 
 
X 
X 
 
Columbia-Suicide Severity Rating Scale (C-SSRS) 
X 
 
X 
X 
X 
Phone call 
 
X 
 
 
 
 
 
 


 
 
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Optional Open-Label Extension Time and Events Schedule Notes: 
a. 
The Baseline Visit for the optional OLE study will correlate with the Week 36 visit of the randomized placebo controlled phase. For those participants who may enter 
this OLE phase 12 or more weeks after completing their Week 36 visit, Baseline assessment indicated in Table 2 will be completed and serve as the participants 
baseline for the OLE phase.  
b. Scheduled Visit ± 5 days. 
c. 
Timing for the Safety Follow-Up visit should occur at four weeks (±5 days) following early termination or the patient’s last OLE period visit.  
d. For females of child bearing potential only. 
e. 
Electrocardiogram (ECG) intervals will be summarized and presented descriptively. ECG rhythm will be interpreted by the Investigator as normal (N), abnormal not-
clinically significant (aNCS), or abnormal clinically significant (aCS).  
f. 
Whole blood, plasma,  serum, and/or urine for PK and PD will be taken pre-dose only (e.g., within1 hour prior to the dose of study drug). 
g. EMG to be conducted on the least clinically affected hand, leg, and arm identified at the randomized placebo controlled phase Baseline visit. 
 
 


 
 
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TABLE OF CONTENTS 
PROTOCOL APPROVAL PAGE ..................................................................................................... 2 
INVESTIGATOR PROTOCOL AGREEMENT ............................................................................. 3 
PROTOCOL SYNOPSIS .................................................................................................................... 4 
1 
BACKGROUND INFORMATION ......................................................................................... 29 
1.1 
DISEASE BACKGROUND AND PATHOPHYSIOLOGY .............................................................. 29 
1.2.1 
Investigational Product Background ........................................................................... 32 
1.2.2 
Investigational Product Characteristics ...................................................................... 33 
1.4.1 
In vitro ALS Neuroprotection Models ......................................................................... 38 
1.4.1.1 
CNM-Au8 Protects Primary Rodent Motor Neurons From Excitotoxicity ................. 38 
1.4.1.2 
CNM-Au8 Protects Normal iPSC Derived Human Motor Neurons From ALS-Patient-
Derived Toxic Astrocytes ............................................................................................................. 40 
1.4.2 
In vivo ALS Neuroprotection Models .......................................................................... 40 
1.4.3 
Summary ALS Treatment Rationale ............................................................................ 43 
2 
SUMMARY OF NONCLINICAL SAFETY & TOXICOLOGY STUDIES ....................... 44 
2.1 
SUMMARY OF SAFETY MUTAGENICITY STUDIES ................................................................ 44 
2.2 
SUMMARY OF SAFETY PHARMACOLOGY STUDIES .............................................................. 45 
2.3 
SUMMARY OF TOXICOLOGY AND TOXICOKINETIC STUDIES IN RODENTS AND MINIPIGS .. 45 
2.3.1 
Initial Toxicokinetic Studies in Rodents and Minipigs ................................................ 45 
2.3.1.1 
Study AB17834 (28-Day Repeat Dose Toxicity in Göttingen Minipig) .............................................. 47 
2.3.2 
Maximum Feasible Dose Study and High Dose Subchronic Toxicity Studies in Rodents 
and Minipigs ................................................................................................................................ 48 
2.3.3 
Chronic Rodent Toxicology (6-Month Dosing) ........................................................... 49 
2.4 
SUMMARY OF TOXICOLOGY AND TOXICOKINETIC STUDIES IN CANINES ........................... 50 
2.4.1 
Single Dose Canine Toxicokinetic Summary ............................................................... 52 
2.4.2 
Repeat Dose Canine Toxicokinetic Summary .............................................................. 54 
2.4.3 
Maximum Feasible Dose Canine Toxicokinetic Study ................................................ 55 
2.4.4 
Chronic Canine Toxicology (9-Month Dosing) ........................................................... 56 
3 
PRIOR HUMAN DOSING EXPERIENCE ............................................................................ 58 
3.1 
AU8.1000-14-01 DESIGN .................................................................................................... 58 
3.2 
AU8.1000-14-01 PHARMACOKINETIC RESULTS ................................................................. 58 
3.3 
AU8.1000-14-01 SAFETY RESULTS ..................................................................................... 59 
4 
INVESTIGATIONAL PLAN ................................................................................................... 62 
4.1 
RATIONALE FOR THE STUDY ............................................................................................... 62 
4.2 
STUDY OBJECTIVES ............................................................................................................. 62 
4.3 
OVERALL STUDY DESIGN AND PLAN .................................................................................. 62 
5 
INVESTIGATORS AND KEY STUDY PERSONNEL ........................................................ 64 
6 
STUDY ENDPOINTS ............................................................................................................... 66 
6.1 
EFFICACY ENDPOINTS (TREATMENT PERIOD) ..................................................................... 66 
6.1.1 
Primary Efficacy Endpoint .......................................................................................... 66 
6.1.2 
Secondary Efficacy Endpoint ...................................................................................... 66 
6.1.3 
Exploratory Efficacy Endpoints .................................................................................. 66 
6.1.3.1 
Exploratory Electromyography Endpoints ............................................................................................ 66 
6.1.3.2 
Exploratory Clinical Efficacy Endpoints .............................................................................................. 67 


 
 
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6.1.4 
Pharmacokinetic Endpoints ......................................................................................... 68 
6.1.5 
Pharmacodynamic Endpoints ...................................................................................... 68 
6.1.5.1 
Whole Blood Metabolomic Markers ..................................................................................................... 69 
6.2 
OPEN-LABEL EXTENSION ENDPOINTS ................................................................................. 69 
6.2.1 
Primary Safety Endpoint ............................................................................................. 69 
6.2.2 
Primary Efficacy Endpoint .......................................................................................... 69 
6.2.3 
Secondary and Exploratory Efficacy Endpoints .......................................................... 69 
7 
STUDY POPULATION ............................................................................................................ 70 
7.1 
STUDY INCLUSION CRITERIA ............................................................................................... 70 
7.2 
STUDY EXCLUSION CRITERIA .............................................................................................. 70 
7.3 
REPRODUCTIVE POTENTIAL ................................................................................................ 72 
7.4 
REMOVAL OF PATIENTS FROM THERAPY/PREMATURE DISCONTINUATION ....................... 73 
7.4.1 
Patient Replacement .................................................................................................... 74 
7.4.2 
Reasons for Discontinuation ....................................................................................... 74 
7.4.2.1 
Lost to Follow-Up ................................................................................................................................. 74 
7.5 
PATIENT IDENTIFICATION .................................................................................................... 74 
8 
INVESTIGATIONAL DRUG PRODUCT ............................................................................. 76 
8.1.1 
Treatments Administered ............................................................................................. 76 
8.1.2 
Identity of Investigational Products ............................................................................ 76 
8.1.2.1 
CNM-Au8 .............................................................................................................................................. 76 
8.1.2.2 
Placebo .................................................................................................................................................. 77 
8.1.3 
Labeling ....................................................................................................................... 78 
8.1.4 
Storage and Handling .................................................................................................. 79 
8.2 
METHOD OF ASSIGNING PATIENTS TO TREATMENT GROUPS AND DOSE SELECTION ......... 79 
8.2.1 
Treatment Assignment/Randomisation ........................................................................ 79 
8.2.2 
First In Human Dosing Experience ............................................................................. 79 
8.2.3 
Human Dosing Safety Margins vs. Nonclinical Toxicokinetic Data ........................... 80 
8.3 
PROCEDURES FOR BLINDING ............................................................................................... 82 
8.3.1 
Unblinding ................................................................................................................... 83 
8.3.1.1 
Unblinding by Sponsor’s Pharmacovigilance Representative .............................................................. 83 
8.3.1.2 
Emergency Unblinding By The Investigator ........................................................................................ 83 
8.3.1.3 
Unblinding For Ongoing Safety Monitoring ......................................................................................... 83 
8.4 
PRIOR AND CONCOMITANT THERAPY ................................................................................. 84 
8.5 
TREATMENT COMPLIANCE .................................................................................................. 84 
8.5.1 
Study Drug Accountability .......................................................................................... 85 
8.6 
DATA SAFETY MONITORING BOARD ................................................................................... 85 
9 
STUDY PROCEDURES ........................................................................................................... 86 
9.1 
STUDY SCHEDULE (TREATMENT PERIOD) ........................................................................... 86 
9.1.1 
Screening Phase (Day -42 through Day -1) – VISIT (-1) ............................................ 86 
9.1.2 
Baseline (Day 1) – VISIT 0 .......................................................................................... 87 
9.1.3 
Treatment Phase (VISIT 1 through VISIT 7) ............................................................... 88 
9.1.3.1 
Treatment Period – VISIT 1, 2, 4, and 6 (WEEK 3, 6, 18, and 30) ...................................................... 88 
9.1.3.2 
Treatment Period – VISITS 3, 5, and 7 ................................................................................................. 88 
9.1.3.3 
Safety Follow-up Visit – Week 40 ........................................................................................................ 89 
9.2 
STUDY SCHEDULE (OPEN-LABEL EXTENSION PERIOD) ...................................................... 90 
9.2.1 
OLE Baseline (Day 1) – Visit 0 ................................................................................... 90 
9.2.2 
OLE Period – Visit 1 (Week 6) .................................................................................... 91 
9.2.2.1 
OLE Period – Visits 2, 4, 6, and n+2 (Weeks 12, 36, 60, and n+24) .................................................... 92 
9.2.2.2 
OLE Period – Visits 3, 5, 7 and n+2 (Weeks 24, 48, 72 and n+24) ...................................................... 92 


 
 
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9.2.2.3 
Safety Follow-Up Visit – 4 weeks following last visit ......................................................................... 94 
9.3 
STUDY MEASUREMENTS AND ASSESSMENTS ...................................................................... 94 
9.3.1 
Demographic and Other Baseline Characteristics ..................................................... 94 
9.3.2 
Assessment of Efficacy ................................................................................................. 94 
9.3.2.1 
Electromyography Data Collection ....................................................................................................... 95 
9.3.2.2 
MUNIX ................................................................................................................................................. 95 
9.3.2.3 
MScan and MScan Fit ........................................................................................................................... 96 
9.3.2.4 
MUSIX .................................................................................................................................................. 96 
9.3.2.5 
Neurophysiological Index (NPI) ........................................................................................................... 96 
9.3.2.6 
Split Hand Index (SI) ............................................................................................................................ 97 
9.3.2.7 
ALSFRS-R ............................................................................................................................................ 97 
9.3.2.8 
FVC ....................................................................................................................................................... 97 
9.3.2.9 
CGI ........................................................................................................................................................ 98 
9.3.2.10 
PGI ........................................................................................................................................................ 98 
9.3.2.11 
Healthcare Utilisation ............................................................................................................................ 98 
9.3.3 
Assessment of Safety .................................................................................................... 98 
9.3.4 
PK and PD Assessments .............................................................................................. 99 
9.3.4.1 
Collecting, Processing, and Shipping of PK and PD Samples ............................................................ 100 
9.3.4.2 
Bioanalytical Methods ......................................................................................................................... 100 
9.3.5 
Clinical Laboratory Tests .......................................................................................... 101 
9.3.6 
Physical Examinations .............................................................................................. 102 
9.3.7 
Vital Signs .................................................................................................................. 102 
9.3.8 
12-Lead ECG ............................................................................................................. 102 
9.4 
ASSESSMENT WINDOWS .................................................................................................... 102 
10 
ADVERSE EVENTS ........................................................................................................... 103 
10.1 
SAFETY REPORTING GUIDELINES ...................................................................................... 103 
10.1.1 
Sponsor Guidance ..................................................................................................... 103 
10.1.2 
Investigator Guidance ............................................................................................... 103 
10.2 
ADVERSE EVENTS (AE OR ADVERSE EXPERIENCE) .......................................................... 103 
10.2.1 
Intensity of Adverse Events ........................................................................................ 105 
10.2.2 
Relationship and Attribution of the AE to Study Drug .............................................. 105 
10.2.2.1 
Relationship to Study Drug ................................................................................................................. 105 
10.2.2.2 
Attribution to The Study Drug ............................................................................................................ 106 
10.3 
SERIOUS ADVERSE EVENTS ............................................................................................... 106 
10.3.1 
Serious Adverse Events Related To Study-Mandated Procedures ............................ 107 
10.4 
REPORTING REQUIREMENTS FOR AES AND SAES ............................................................ 107 
10.4.1 
Reporting of Adverse Events ..................................................................................... 107 
10.4.2 
Reporting Abnormal Laboratory Test Values or Abnormal Clinical Findings ......... 108 
10.4.2.1 
Reporting of AE Intensity and Causality ............................................................................................ 108 
10.4.2.2 
Follow-up of AEs ................................................................................................................................ 108 
10.4.3 
Reporting Requirements For SAEs ............................................................................ 108 
10.4.3.1 
Reporting of SAEs .............................................................................................................................. 108 
10.4.3.2 
SAE Reporting Periods ....................................................................................................................... 109 
10.4.3.3 
SAE Reporting Procedures .................................................................................................................. 110 
10.4.3.4 
SAE Regulatory Reporting .................................................................................................................. 110 
10.5 
PREGNANCY ....................................................................................................................... 111 
10.5.1 
Prevention of Pregnancy During the Study ............................................................... 111 
10.5.2 
Reporting of Pregnancy ............................................................................................. 111 
10.5.3 
Pregnancy Follow-Up ............................................................................................... 112 
10.6 
STUDY HALTING RULES .................................................................................................... 112 
10.7 
CLINICAL MONITORING ..................................................................................................... 112 


 
 
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10.7.1 
Site Monitoring Plan ................................................................................................. 112 
11 
STATISTICS AND DATA MANAGEMENT .................................................................. 113 
11.1 
DETERMINATION OF SAMPLE SIZE AND ANALYSES .......................................................... 113 
11.2 
ANALYSIS POPULATIONS ................................................................................................... 113 
11.3 
BASELINE CHARACTERISTICS AND PATIENT DISPOSITION ............................................... 114 
11.4 
PRIOR AND CONCOMITANT MEDICATIONS ........................................................................ 114 
11.5 
PHARMACOKINETIC ANALYSES ......................................................................................... 114 
11.6 
SAFETY ANALYSES ............................................................................................................ 115 
11.7 
EFFICACY ANALYSES ........................................................................................................ 115 
11.8 
INTERIM ANALYSES ........................................................................................................... 116 
11.9 
DATA HANDLING AND QUALITY ASSURANCE .................................................................. 116 
11.9.1 
Data Recording ......................................................................................................... 116 
11.9.1.1 
Data Recorded From Screening Failures ............................................................................................ 116 
11.9.2 
Data Monitoring ........................................................................................................ 117 
11.9.3 
Data Collection and Management ............................................................................. 117 
11.9.4 
Data Audit and Inspection ......................................................................................... 118 
11.9.5 
Data Archiving .......................................................................................................... 118 
12 
RESPONSIBILITIES, ETHICS, AND LEGAL ASPECTS ............................................ 119 
12.1 
INVESTIGATOR RESPONSIBILITIES ..................................................................................... 119 
12.1.1 
Good Clinical Practice .............................................................................................. 119 
12.1.2 
Institutional Review Board (IRB)/Independent Ethics Committee (IEC) Approval .. 119 
12.1.3 
Informed Consent ...................................................................................................... 119 
12.1.4 
Adherence to Protocol ............................................................................................... 120 
12.1.5 
Confidentiality ........................................................................................................... 120 
12.1.6 
Study Files and Retention of Records ........................................................................ 120 
12.1.7 
Case Report Forms .................................................................................................... 121 
12.1.8 
Drug Accountability .................................................................................................. 121 
12.1.9 
Inspections ................................................................................................................. 122 
12.2 
SPONSOR RESPONSIBILITIES .............................................................................................. 122 
12.2.1 
Study Materials and Instructions ............................................................................... 122 
12.2.2 
Protocol Modifications .............................................................................................. 122 
12.2.3 
Insurance ................................................................................................................... 123 
12.2.4 
Premature Study Termination ................................................................................... 123 
12.3 
JOINT INVESTIGATOR/SPONSOR RESPONSIBILITIES ........................................................... 123 
12.3.1 
Access to Information for Monitoring ....................................................................... 123 
12.3.2 
Study Report and Publications .................................................................................. 124 
13 
PROTOCOL AMENDMENTS .......................................................................................... 125 
14 
APPENDICES ...................................................................................................................... 126 
15 
REFERENCES .................................................................................................................... 127 
 
 


 
 
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LIST OF IN-TEXT TABLES 
 
Table 1: Time and Events Schedule .................................................................................... 14 
Table 2: Time and Events Schedule (Optional Open-Label Extension) ............................. 16 
Table 3. Estimated Volume, Mass, and Particle Characteristics of CNM-Au8 .................. 33 
Table 4. Summary of Safety Mutagenicity Studies ............................................................. 44 
Table 5. Summary of Safety Pharmacology Studies ........................................................... 45 
Table 6. Initial Acute and Subchronic Dosing Studies in Rats and Minipigs ..................... 46 
Table 7: Study AB17834 Platelet Change from Day -12 to Day 27 in Select Animals ...... 47 
Table 8. Maximum Feasible Dose Study and High Dose Subchronic Toxicity Studies ..... 49 
Table 9. Chronic Rodent Toxicity Study ............................................................................. 50 
Table 10. Acute and Subchronic Dosing Studies in Canines .............................................. 52 
Table 11.  Summary of Cmax, AUC, T1/2, and Bioavailability Results Following Single 
Dose Administration of CNM-Au8 in Study CNAU-MPI-14-01 .................. 53 
Table 12.  Summary of CL, T1/2, Vz, and Vss after a Single 0.5 mg/kg IV Dose of CNM-
Au8 (Study CNAU-MPI-14-01) ................................................................... 54 
Table 13.  Summary of CL/F, T1/2, and Vz/F after a Single 10 mg/kg PO Dose of CNM-
Au8 (Study CNAU-MPI-14-01) ..................................................................... 54 
Table 14. Chronic Canine Toxicity Study ....................................................................... 57 
Table 15.  CNM-Au8 Investigational Product Dosing Administration ............................... 77 
Table 16.  CNM-Au8 Components and Quality Standards ........................................... 77 
Table 17. Matched Placebo Dosing Administration ............................................................ 77 
Table 18.  Matched Placebo Components and Quality Standards ....................................... 78 
Table 19. Summary of CNM-Au8 Conversion of Animal 21-Day Repeat Doses To Human 
Equivalent Dose (HED) Based On Body Surface Area (mg/m2) for 60 kg 
Human ............................................................................................................ 81 
Table 20. Summary of CNM-Au8 Exposure Safety Margin Based on End of Study AUC(0-
24) ng*hr/mL.  Ratio of Animal Toxicokinetic to Human Pharmacokinetic 
AUC Results From 21-Day Repeat Dose Studies. ......................................... 81 
Table 21.  Summary of CNM-Au8 Exposure Safety Margin Based on End of Study AUC(0-
24) ng*hr/mL Ratio of Chronic Animal Toxicokinetic 6 and 9-Month Rodent 
and Canine Repeat Dose Studies to Human 21-Day Pharmacokinetic Results
 ........................................................................................................................ 82 
Table 22. EMG Data Collection Plan .................................................................................. 95 
Table 23.  AE Attribution to the Study Drug ................................................................ 106 
Table 24.  Summary of Study Safety Reporting Periods ................................................... 111 
Table 25.  Summary of PK Parameters ......................................................................... 114 
 
 
 


 
 
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LIST OF IN-TEXT FIGURES 
 
Figure 1. CNM-Au8 NADH Catalysis Rates ................................................................... 35 
Figure 2.  Effects of CNM-Au8 on NAD Levels in Primary Rodent Mesencephalic 
Cultures ........................................................................................................... 36 
Figure 3.  Effects of CNM-Au8 on NADPH Oxidation ...................................................... 36 
Figure 4 . Effects of CNM-Au8 on SOD and ROS Generation .......................................... 37 
Figure 5. Effect of CNM-Au8 on OPC Differentiation and ATP Production ..................... 38 
Figure 6 . Neuroprotection of Motor Neurons From Glutamate Excitotoxicity by CNM-
Au8 ................................................................................................................. 39 
Figure 7. CNM-Au8 Protects Normal iPSC Derived Human Motor Neurons From ALS-
Patient-Derived Toxic Astrocytes .................................................................. 40 
Figure 8. Locomotor Functional Efficacy of CNM-Au8 in an SOD1G93A (C57Bl/6 
congenic strain) Murine Study .................................................................... 41 
Figure 9. Effect of CNM-Au8 on Survival in a Congenic Murine SOD1 G93A Model
 ........................................................................................................................ 42 
Figure 10. Whole Blood Concentrations by Day in 28-Day Repeat Dosing Canine Study 55 
Figure 11.  Study Scheme .................................................................................................... 63 
Figure 12.  21-Day AUC Exposure Ranges Between Rodent Toxicokinetic Studies, 
Preclinical Efficacy Models, and First-In-Human Dosing ............................. 82 
 
 
 


 
 
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ABBREVIATIONS 
 
Abbreviation Definition 
aCS 
Abnormal clinically significant 
AE 
Adverse event 
AESI 
Adverse events of special interest 
ALS 
Amytrophic Lateral Sclerosis 
ALSFRS-R 
Amytrophic Lateral Sclerosis Functional Rating Scale- Revised  
ALT 
Alanine aminotransferase 
ANCOVA 
Analysis of covariance 
aNCS 
Abnormal not clinically significant 
AST 
Aspartate aminotransaminase 
ASTM 
American Society for Testing and Materials 
ATP 
Adenosine Trinucleotide Phosphate 
Au 
Gold 
AUC 
Area under the curve 
AUC(0-24) 
Area under the curve for 24 hours  
βhCG 
Beta-human chorionic gonadotropin 
BID 
Twice a day (bis in die) 
BLQ 
Below the limit of quantification 
BMI 
Body mass index 
bpm 
Beats per minute 
BUN 
Blood urea nitrogen 
C0 
Initial or back-extrapolated plasma drug concentration at time zero following bolus 
intravenous injection 
CA 
Competent authority 
CFR 
Code of Federal Regulations 
CGI 
Clinician’s Global Impression  
CHDR 
Center for Human Drug Research 
CK 
Creatine kinase 
CL 
Apparent total body clearance of the drug 
CL/F 
Apparent total clearance of the drug from whole blood after oral administration 
CLr 
Renal clearance 
Cmax 
Peak plasma concentration, observed 
CNM-Au8 
Aqueous suspension of clean surfaced nanocrystals consisting of gold atoms self-organized
into crystals of various faceted, geometrical shapes  
CNS 
Central nervous system 
CRF 
Case report form 
CRO 
Contract research organization 
CRU 
Clinical research unit 
CSF 
Cerebrospinal fluid or cerebral spinal fluid 
CTA 
Clinical trial application 


 
 
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Abbreviation Definition 
CTAB 
Cetyl trimethylammonium bromide 
CTCAE 
Common terminology criteria for adverse events 
CV% 
Coefficient of variation 
λz 
Terminal phase rate constant (first-order) 
DE 
Differentially expressed 
DMT 
Disease modifying therapy 
DO 
Doctor of osteopathic medicine 
DTPA 
Diethylenetriaminepentacetate 
EC 
Ethics committee 
ECG 
Electrocardiogram 
eCRF 
Electronic case report form 
EDC 
Electronic data collection 
EEG 
Electroencephalogram 
EOS 
End of study 
F 
Bioavailability (systemic availability of the administered dose) 
fALS 
Familial Amytrophic Lateral Sclerosis 
FCS-AuNC 
Faceted clean surfaced Au nanocrystal 
FDA 
Food and Drug Administration 
GCP 
Good clinical practice 
GFR 
Glomerular filtration rate 
GGT 
Gamma-glutamyl transferase 
GMP 
Good manufacturing practices 
H202 
Hydrogen peroxide 
HAuCl4 
Chloroauric acid 
HepB 
Hepatitis B 
HepC 
Hepatitis C 
HED 
Human equivalent dose 
HDPE 
High density polyethylene 
HIV 
Human immunodeficiency virus 
hr 
Hour 
HREC 
Human Research Ethics Committee  
IB 
Investigator’s Brochure 
ICH 
International Conference on Harmonization 
ICH-GCP 
International Conference on Harmonization – Good Clinical Practice 
ICP-MS 
Inductively Coupled Plasma Mass Spectrometry 
IEC 
Independent Ethics Committee 
IND 
Investigational New Drug 
INR 
International normalised ratio 
IRB 
Institutional Review Board 
ISO 
International Organization for Standardization 


 
 
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Abbreviation Definition 
ITT 
Intent to treat 
IV 
Intravenous 
K2EDTA 
Dipotassium ethylenediaminetetraacetic acid 
kg 
Kilogram 
LDH 
Lactate dehydrogenase 
LGN 
Lateral geniculate nucleus 
LOQ/LLOQ 
Limit of quantitation or Lower limit of quantitation 
LPS 
Lipopolysaccharide 
m 
meter 
M:E 
Ratio of myeloid to erythroid precursors in bone marrow 
MAD 
Multiple ascending dose 
max 
Maximum 
MD 
Doctor of medicine 
MedDRA 
Medical Dictionary for Regulatory Activities 
MFD 
Maximum feasible dose 
mg 
Milligram 
min 
Minute(s) 
mL 
Milliliter 
mmHg 
Millimeters of mercury 
MRI 
Magnetic Resonance Imaging 
MRS 
Magnetic Resonance Spectroscopy 
mRNA 
Messenger Ribonucleic acid (RNA) 
ms 
Milliseconds 
MTD 
Maximum tolerated dose 
MWF 
Myelin water fraction 
N 
Normal 
NAD+ 
Oxidized form of nicotinamide adenine dinucleotide 
NADH 
Reduced form of nicotinamide adenine dinucleotide 
NADPH 
Reduced form of nicotinamide adenine dinucleotide phosphate 
NaHCO3 
Baking soda 
NCI 
National Cancer Institute 
NCS 
Not clinically significant 
ng 
nanogram 
nm 
nanometer 
NOAEL 
No observed adverse effect level 
OG 
Oral gavage 
OL 
Oligodendrocyte 
OLE 
Open Label Extension 
ON 
Optic neuritis 
OPC 
Oligodendrocyte progenitor cells 


 
 
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Abbreviation Definition 
OR 
Optic radiation 
OTC 
Over-the-counter 
PA 
Physician assistant 
PAS 
Partial analysis set 
PCE 
Polychromatic erythrocytes 
PD 
Pharmacodynamic 
PEG 
Polyethylene glycol 
PGI 
Participant Global Impression 
pH 
Potential hydrogen (relative acidity or alkalinity) 
PK 
Pharmacokinetic 
PO 
Oral administration (per os) 
PPP 
Pentose phosphate pathway 
PPS 
Per protocol set 
PT 
Preferred term 
QD 
Once daily (quaque die) 
QTc 
Corrected QT interval (measure of the time between the start of the Q wave and the end 
of the T wave) 
Rac 
Accumulation ratio 
SAD 
Single ascending dose 
SAE 
Serious adverse event 
sALS 
Sporadic Amyptrophic Lateral Sclerosis 
SAP 
Statistical analysis plan 
SAS 
Safety analysis set 
SC 
Subcutaneous 
SD 
Standard deviation 
SEM 
Standard error of the mean 
SGOT 
Serum glutamic oxaloacetic transaminase 
SGPT 
Serum glutamate-pyruvic transaminase 
SOC 
System organ class 
SOD1 
Superoxide dismutase  
SOP 
Standard operating procedure 
SRC 
Safety Review Committee 
SUSAR 
Suspected unexpected serious adverse reaction 
T½ 
Elimination half-life 
T1 
Time constant for the longitudinal relaxation time following an MRI radio-frequency 
pulse 
T2 
Time constant for the transverse relaxation time (perpendicular to the main field) following
an MRI radio-frequency pulse 
T3 
Triiodothyronine (thyroid hormone) 
TEAE 
Treatment emergent adverse event 
TEM 
Transmission electron microscopy 
TID 
 Three times daily (ter in die) 


 
 
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Abbreviation Definition 
TK 
Toxicokinetic 
Tmax 
Time to peak plasma concentration, observed 
Ue 
Urinary excretion 
μM 
Micrometer 
USP 
United States Pharmacopeia 
Vss 
Volume of distribution at steady state 
Vz 
Apparent volume of distribution (Vz) 
Vz/F 
Apparent volume of distribution during terminal phase after non-intravenous 
administration 
 
 


 
 
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1 
BACKGROUND INFORMATION 
1.1 
Disease Background and Pathophysiology 
Amyotrophic lateral sclerosis (ALS) is an adult-onset, progressive, and fatal neurodegenerative 
disorder of the neuromuscular system resulting in muscle weakness and paralysis that leads to death 
as early as three to five years after initial diagnosis. In 2015, there were an estimated 222,801 cases of 
ALS worldwide, which has been projected to increase by 69% to 376,674 cases by 2040, a gain 
largely attributable to an ageing population (Arthur et al., 2016).  ALS not only causes severe 
distress for patients and caregivers, but also results in a large economic burden on society 
(Gladman and Zinman, 2015). Despite these significant tolls and robust efforts to identify efficacious 
therapies for this disease, there have been limited clinical successes and no curative therapies 
approved to date (Mitsumoto et al., 2014). There are two FDA-approved therapeutic agents for the 
treatment of ALS: riluzole, an anti-glutamatergic agent, and edavarone, a free-radical scavenger. 
However, both of these treatments are acknowledged to have limited disease-modifying effects, as 
riluzole extends patient lifespans by an average of only two to three months, while edavarone slows 
the decline of the ALSFRS-R score only in a small subset of patients who are at an early stage of 
disease (Jaiswal, 2018). There is clearly an urgent unmet need for the development of safe and 
effective disease-modifying therapeutics for ALS. 
While most ALS cases are sporadic (sALS) in which the cause remains unknown, 5-10% of cases are 
familial forms of the disease (fALS). fALS cases arise from variants in single genes, including SOD1, 
TDP43, FUS, and C9ORF72 and are clinically indistinguishable from sporadic cases (sALS). The 
functions of these specific genetic fALS variants on balance involve RNA processing and 
metabolism, regulation of protein aggregation, maintenance of mitochondrial function, and protection 
against oxidative stress. During adult life, motor neurons that harbor specific genetic or epigenetic 
changes, or that have been exposed to unidentified environmental factors, may become exquisitely 
sensitive to dysregulation of these pathways, resulting in an imbalance between signals regulating 
neuron survival versus programmed cell death. In addition, there appear to be extrinsic factors related 
to astrocytes, oligodendrocytes, and cells involved in neuroinflammatory responses that can 
exacerbate or ameliorate the survival of motor neurons in patients with ALS. 
More recently, basic research has uncovered interconnections amongst the seemingly disparate 
functions of genes mutated in fALS.  Importantly, these emerging insights suggest impairment of 
pathways related to oxidative stress and mitochondrial function. These are represented by mutations 
in superoxide dismutase (SOD1) on one hand, and regulation of RNA processing and metabolism, 
represented by mutations in FUS, TDP43 and several more genes, on the other. Both oxidative stress 
and RNA dysregulation are indicative of an underlying unifying pathogenetic mechanism of 
bioenergetic failure in ALS. Bioenergetic affects not only the target cell type, the motor neurons, but 


 
 
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also the astrocytes and oligodendrocytes that provide crucial energetic support to the survival of 
motor neurons.  Postmortem analyses of brain tissues from both fALS and sALS patients exhibit 
evidence of widespread accumulation of oxidative damage to proteins, lipids, and DNA. Transgenic 
mice expressing mutant SOD1 forms have evidence of nerve and spinal cord tissue damage that 
recapitulates key aspects of ALS and demonstrates clear evidence of excessive protein and lipid 
oxidation (D’Amico et al. 2013)   . Oxidative stress also leads to the accumulation of protein 
aggregates such as TDP43 (Bozzo, Mirra, and Carrì 2017)(Bozzo et al., 2017) , which are invariably 
found in ALS motor neurons, and which indicate failures of protein degradation systems such as 
autophagy (Blokhuis et al., 2013). 
Importantly, elevated oxidative stress has been shown to impact the processing of gene transcripts 
important for motor neuron survival.  This observation connecting oxidative stress to RNA processing 
was demonstrated when paraquat, a well-known inducer of oxidative stress, was shown to induce 
striking changes in RNA splicing in neuroblastoma cells (Maracchioni et al., 2007). Two of the pre-
mRNAs whose splicing was shown to be altered in this study are transcripts of genes known to be 
important for motor neuron survival, Survival Motor Neuron (SMN) and Apoptotic Peptidase 
Activating Factor 1 (APAF1) (Maracchioni et al., 2007). The mislocalization of the RNA-binding 
protein TDP43 in ALS represents another link between oxidative stress and RNA dysmetabolism.  In 
general, TDP43 is involved in pre-RNA processing in the nucleus, where it functions in the 
transcriptional control of many genes including those involved in neural functions.  However, 
oxidative stress causes the TDP43 to translocate to the cytoplasm, where it accumulates in stress 
granules and forms protein aggregates. Sequestration of an RNA regulator such as TDP43 in the 
cytoplasm and away from the nucleus is thought to prevent it from carrying out its normal functions 
and thereby can lead to dysregulation of RNA processing and transcription.  The converse relationship 
has similarly been shown, namely that misregulation of RNA metabolism impacts and increases 
oxidative stress within the CNS. Mutations in RNA regulators FUS and TDP43 cause disruptions in 
the expression of key nuclear-encoded mitochondrial genes (Zhang et al., 2014) as well as in the 
expression of energy metabolism regulators such as PGC-1a and oxidative stress reducers such as 
MnSOD and catalase (Sanchez-Ramos et al., 2011). Therefore, the pathophysiologic disease 
mechanism of ALS appears to involve a positive feedback cycle of oxidative stress and protein 
aggregation impacting RNA regulation which in turn leads to a sustained increased oxidative stress 
disease state, ending in motor neuron death (Bozzo, Mirra, and Carrì 2017)(Bozzo et al., 2017) .  
Unifying both themes of RNA dysregulation and oxidative stress is the concept that ALS is a disease 
of energetic dysmetabolism (Dupuis et al., 2011; Tefera and Borges, 2016; Vandoorne et al., 2018). 
Motor neurons consume high amounts of energy in order to function, and are therefore exquisitely 
sensitive to apoptosis if their energetic demands cannot be met. The main energy-producing organelle 
of the cell, the mitochondria, exhibit dysfunction in ALS on multiple levels. For example, overall 


 
 
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there are fewer mitochondria, as measured by mitochondrial DNA, in the spinal cords of both fALS 
and sALS patients (Wiedemann et al., 2002). Presynaptic mitochondrial swelling in motor neurons 
has been observed in both ALS patients (Siklos et al., 1996), as well as in a SOD1 transgenic mouse 
model prior to disease onset (Manfredi and Xu, 2005). Swollen and vacuolarized mitochondria are 
indicative of impaired mitochondrial function (Siklos et al., 1996), which is corroborated by studies 
showing that there is decreased activity of the electron transport chain in spinal cord mitochondria of 
ALS patients (Wiedemann et al., 2002). Because reduced respiration and reduced ATP synthesis 
preceded clinical symptom onset in SOD1G93A mice (Jung et al., 2002; Mattiazzi et al., 2002; 
Szelechowski et al., 2018), energetic dysmetabolism appears to play an important role in the etiology 
of this disease. Overexpression of PGC1a, which stimulates mitochondrial biogenesis, improved 
survival, motor neuron function,  and motor neuron survival in mutant SOD1G93A mice (Zhao et al., 
2011), indicating that improving mitochondrial function and/or efficiency may be a successful 
therapeutic strategy for ALS (Vandoorne et al., 2018). 
Energetic dysmetabolism in ALS is further underscored by studies uncovering carbohydrate 
metabolism abnormalities and ATP deficits in ALS motor neurons (Vandoorne et al., 2018). FDG-
PET imaging has demonstrated a correlation between reduced ALS brain glucose uptake and  
cognitive impairment (Canosa et al., 2016) as well as overall disease severity (Dalakas et al., 1987). 
Some groups who conducted FDG-PET studies showing reduced glucose uptake in ALS patient 
brains suggested CNS hypometabolism can be used as an early diagnostic indication of ALS (Van 
Laere et al., 2014; Van Weehaeghe et al., 2016). While it is difficult to determine whether lowered 
glucose utilization detected in imaging studies is due to reduced neuronal catabolism of glucose or 
due to motor neuron loss, there are further lines of evidence to suggest energetic dysmetabolism in 
ALS cells. A proteomic study of ALS patient fibroblasts indicated a significant reduction in key 
enzymes involved in glycolysis (Szelechowski et al., 2018), and expression profiling of sALS patient 
motor cortexes showed downregulation of glycolytic genes (Lederer et al., 2007). A GWAS analysis 
involving 12577 cases and 23475 controls identified glycolysis/gluconeogenesis as among the top 
seven biological pathways represented by the genes identified as associated with ALS (Du et al., 
2018). Because glia preferentially utilize glycolysis, these results may indicate a dysfunction of glia in 
providing energetic support to motor neurons in ALS patients. Energetic stress on motor neurons may 
increase their levels of oxidative stress, as observed in post-mortem brain samples of ALS patients 
(Ferrante et al., 1997), and lead to motor neuron death.  
Given the clear involvement of cellular bioenergetic failure in the pathogenesis of ALS, the 
development of a disease modifying therapeutic that addresses the energetic dysregulation underlying 
the progressive accumulation of oxidative stress and dysregulated RNA processing is a rational 
therapeutic strategy.  


 
 
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1.2 
Investigational Product Rationale and Characteristics 
1.2.1 Investigational Product Background 
  
CNM-Au8 is an aqueous suspension of clean-surfaced nanocrystals consisting solely of Au atoms 
organized into crystals of highly faceted substantially uniform geometrical shapes. CNM-Au8 is 
supplied for dosing orally in sodium bicarbonate buffered USP purified water.   
Historically, monomolecular gold complexes (e.g., injectable sodium aurothiomalate, 
aurothioglucose; oral auranofin) have been widely used historically as immunomodulating therapies 
in the treatment of autoimmune disorders, predominantly rheumatoid arthritis (Dabrowiak, 2009).  
However, multiple forms of toxicity, including pruritus, dermatitis, stomatitis, diarrhea, proteinuria, 
and less frequently hematological effects compromised the clinical use of gold complexes 
(Dabrowiak, 2009; Menninger et al., 1998).  While the role of gold in the pattern of toxicity remains 
unclear, it is hypothesized that adverse events (AEs) related to gold complexes may be specifically 
related to the monomolecular covalent formulations of the gold complexes rather than from the 
activity of gold per se (Dabrowiak, 2009; Yei Ho and Tiekink, 2005).   
When functionalized as nanocrystals, gold adopts novel electrochemical characteristics unlike those 
of gold complexes.  In addition, as clean-faceted nanocrystals, CNM-Au8 has unique properties 
including an improved safety and tolerability profile as well as higher level of biocatalytic activity in 
cells unlike that of gold nanoparticles manufactured using traditional methods that require stabilizing 
or residual chemical modifications to the  surfaces of the particles. 
The faceted gold nanocrystals of CNM-Au8 generally consist of shapes including hexagonal bi-
pyramids, pentagonal bi-pyramids, tetrahedrons, and octahedrons.  These crystalline shapes, absent 
organic residues on their surfaces, are central to the biologic activity of CNM-Au8.  In contrast to 
molecular covalently bound gold compounds (e.g., historical gold salts), or colloidal gold 
nanoparticles containing surface residue or surfactants as a surface layer (e.g., polyethylene glycol 
(PEG), cetyl trimethylammonium bromide (CTAB), citrate, thiols, other surfactants), CNM-Au8 
consists solely of nanocrystals grown through an electro-crystal chemistry process, which produces 
consistently faceted catalytically active geometrical shapes (without utilizing surfactants such as those 
derived from the reduction of chloroauric acid (HAuCl4)).  
The characteristics of a nanoparticle’s size, shape, and surface chemistry impact, and define the 
biological activity of the nanoparticles.  Residual surface chemistry also affects the biological activity 
of nanoparticles and directly impacts cellular uptake.  Nanoparticle surfactants and residual chemical 
monolayers are also well-known to cause nanoparticle toxicity (Balasubramanian et al., 2010; Freese 
et al., 2012; Qiu et al., 2010). 


 
 
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In summary, CNM-Au8 was designed to promote biocatalytic activity on clean-surfaced, faceted 
nanocrystalline surfaces.     
1.2.2 Investigational Product Characteristics 
The median diameter of CNM-Au8 nanocrystals is approximately 13 nm, as determined by 
transmission electron microscopy (TEM).  Based upon the distributed range (Dn5 – Dn95: 6.5 – 15.8 
nm) of measured nanocrystal diameters and approximate geometrical shapes (e.g., low volume 
estimate: disc-like approximation, aspect ratio of 0.2; maximum volume estimate: spheroid, aspect 
ratio of 1.0), each Au nanocrystal has an approximate composition ranging from 13,000 – 66,000 Au 
atoms per nanocrystal at the 13 nm median diameter with a corresponding molar mass ranging 
between 2.7 x 103 kDA to 1.3 x 104 kDA. Summary estimates for CNM-Au8 mass, volume, and 
particle characteristics are described below in Table 3.  Each mL of CNM-Au8 suspension at 500 
μg/mL is estimated to contain between 100 - 500 trillion highly faceted Au nanocrystals. 
Table 3. Estimated Volume, Mass, and Particle Characteristics of CNM-Au8 
Metric 
(CNM-Au8 500 μg/mL, 60 mL Dose) 
Disc-Like 
Approximation 
Minimum 
(Aspect 0.2) 
Spherical 
Approximation 
Maximum 
(Aspect 1.0) 
Median Au Nanocrystal Diameter (nm) 
13 
Au Nanocrystal Volume (nm3) 
2.3 x 102 
1.2 x 103 
Au Nanocrystal Surface Area (nm2) 
3.2 x 102 
5.3 x 102 
Au Atoms per Nanocrystal (count) 
1.4 x 104 
6.8 x 104 
Au Nanocrystal Molecular Weight (kDa) 
2.7 x 103 
1.3 x 104 
Total Au Nanocrystal Surface Area per mL (cm2) 
3.6 x102 
1.2 x102 
Au Nanocrystals per mL CNM-Au8 (count) 
1.1 x 1014 
2.3 x 1013 
Au Nanocrystals per 60 mL Dose of  CNM-Au8 (count) 
3.4 x 1015 
6.8 x 1014 
 
1.3 
Preclinical Evidence of Mechanistic Rationale for CNM-Au8 Treatment of ALS  
CNM-Au8 passes into the systemic circulation via intestinal absorption.  Cellular uptake of CNM-
Au8 has been demonstrated in a variety of cells and tissue matrices including macrophages, 
oligodendrocytes, neurons, and brain tissue using Inductively Coupled Plasma Mass Spectrometry 
(ICP-MS) analyses and high resolution TEM visualization of nanocrystals.   
Preclinical characterization of the in vitro and in vivo properties of CNM-Au8 have demonstrated that 
it acts to protect neuronal populations from chemical, inflammatory, and hypoxic insults through a 


 
 
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series of unique catalytic mechanisms involving 1) the nicotine adenine dinucleotide redox couple 
(NAD+/NADH) to boost glycolytic energy production, 2) the nicotine adenine dinucleotide phosphate 
redox couple (NADP+/NADPH) to influence anabolic processes associated with differentiation, and 
3) the SOD-like inactivation of reactive oxygen species and nitric oxide to protect cells from oxidative 
damage and mitochondrial dysfunction.  
The nicotinamide adenine dinucleotide redox couple (NAD+, NADH) plays a central role in the 
energy metabolism of all living cells. NAD+, NADH and their relative intracellular ratio 
(NAD+/NADH) are linked to regulation of energy homeostasis, neuroprotection, immune function, 
chromosome stability, DNA repair mechanisms, sleep and circadian rhythms, and longevity (Canto et 
al., 2015; Imai, 2010a, b; Nikiforov et al., 2015; Ying, 2008).  Fundamentally, NAD+ and NADH are 
essential coenzymes in the adenosine triphosphate (ATP)-generating reactions driving both glycolysis 
and oxidative phosphorylation.  More specifically, in aerobic glycolysis, NAD+ availability is integral 
to the enzymatic cascade from glyceraldehyde 3-phosphate via glyceraldehyde phosphate 
dehydrogenase to 1,3-bisphosphoglyceric acid.  Similarly, two electrons are removed via NADH 
oxidation in Complex I of the electron transport chain during oxidative phosphorylation, resulting in 
NAD+, and ultimately these electrons are transferred to a lipid-soluble carrier, ubiquinone. 
In addition, NAD+ and its metabolites act as binding substrates for a wide range of proteins including 
the metabolic and transcription-regulating sirtuins, the poly-ADP-ribose polymerases (PARPs) 
involved in DNA repair, and the cyclic ADP-ribose synthases (cADPRs) such as CD38 that serve to 
regulate Ca2+ signaling involved in cell cycle control and insulin signaling (Canto et al., 2015). 
NAD+ and NADH are essential for life; dietary deficiency of vitamin B3, a NAD+ precursor,  gives 
rise to a life-threatening condition known as pellagra, which is characterized by a dark, pigmented 
skin rash, diarrhea, and dementia (Sydenstricker, 1958). Transgenic mice lacking both copies of the 
NAD+ salvage enzyme Nmnat1 resulting in NAD+ deficiency, do not live past embryonic stages 
(Conforti et al., 2011). Conversely, the heightened expression of NMNAT1, resulting in increased 
NAD+ in the Wallerian Degeneration Slow Dominant Mutant Mouse, has been attributed to neuronal 
protection against axon degeneration observed in these mice (Sasaki et al., 2009).   
Quantitative measurement of regional brain area NAD+ concentrations and redox states in healthy and 
diseased humans has recently been demonstrated using a novel 31P-Magnetic Resonance Spectroscopy 
(MRS) imaging technique (Chouinard et al., 2017; Lu et al., 2016). In humans, brain NAD+/NADH 
redox potential is inversely correlated with age. This age-related decrease in cerebral energy 
metabolism is believed to be intimately associated with the bioenergetic failure that may underpin the 
pathophysiology of all neurodegenerative diseases, because NAD+/NADH redox potential is essential 
for fundamental ATP-generating processes such as glycolysis and mitochondrial oxidative 
phosphorylation. These bioenergetic processes power all cellular processes including ‘housekeeping’ 


 
 
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functions that are responsible for maintaining overall cellular health including processes of autophagy, 
apoptosis, and the unfolded protein response (UPR) (Villanueva-Paz et al. 2016; Chua and Tang 
2013; Cantó, Menzies, and Auwerx 2015)  . Boosting brain NAD+ levels in a mouse model of AD 
reduced DNA damage, neuroinflammation, and apoptosis while improving cognitive function in 
multiple behavioral tests and restored hippocampal synaptic plasticity (Hou et al., 2018). In humans, 
31P-MRS of the visual cortex of young (21-26 year old), middle-aged (33-36 year old), and aged (59-
68 year old) healthy individuals has been show to demonstrate a measurable linear decline of NAD+ 
redox potential that occurs with increasing age (Zhu et al., 2015).  
The first demonstration of oxidation of NADH to NAD+ by gold nanoparticles was demonstrated by 
(Huang et al., 2005) using a simple cell-free assay. In order to compare the catalytic oxidation rate of 
clean-surfaced CNM-Au8 against similarly-sized gold nanoparticles made using citrate reduction, the 
same cell-free assay utilized by Huang et al. was repeated comparing gold nanoparticles sourced from 
the U.S. National Institutes of Standards and Technology (NIST).  The resulting change in the 339 nm 
NADH peak was assessed while investigating each of the gold nanoparticles at the same NADH and 
Au starting concentrations.  In all cases, CNM-Au8 nanocrystals consistently showed significantly 
superior catalytic activities regardless of size and/or method of preparation of the comparator gold 
nanoparticles (Figure 1). 
Figure 1. CNM-Au8 NADH Catalysis Rates 
Figure 1A.  CNM-Au8 Catalytic Effects vs. NIST 
Standard Citrated AuNP 
Figure 1B. Relative NADH Oxidation Rates vs. 
NIST Citrated AuNP 
CNM-Au8 treatment of rodent central nervous system cells in vitro also significantly increases levels 
of both NAD+ and NADH (Figure 2). 
 
 
0
5
10
15
20
25
30
0.10
0.12
0.14
0.16
0.18
0.20
0.22
0.24
NADH control, no GNPs
NIST 30nm
NIST 10nm
CNM-Au8
26 µM NADH in 5.7 mM NaHCO3 with 3.4 µg/mL Au
absorbance at 339nm, cm
-1
time, min
CNM-Au8
NIST 10nm
NIST 30nm
0
1
2
3
4
5
6
7
8
9
10
26 µM NADH in 5.7 mM NaHCO3
NADH oxidation rate, a.u.
GNPs at [Au] ~ 3.4 µg/mL


 
 
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Figure 2.  Effects of CNM-Au8 on NAD Levels in Primary Rodent Mesencephalic 
Cultures 
Figure 2A. Effect of CNM-Au8 on NAD+ Levels 
Figure 2B. Effect of CNM-Au8 on NADH Levels 
 
 
The redox couple NADP+/NADPH, similar  to NAD+/NADH, plays a fundamental role in energy 
homeostasis, anabolic processes, and protection against oxidative stress. NADP+ and NADPH 
function in the pentose phosphate pathway (PPP), serves to provide precursors for nucleotide and 
amino acid biosynthesis (Stincone et al., 2015). In addition, NADP+ and NADPH serve as the redox 
equivalents for both the thioredoxin and glutathione systems (Grant, 2008), which in turn serve as the 
cell’s primary defenses against oxidative stress.  
CNM-Au8 catalyzes the oxidation of NADPH to NADP+ (Figure 3). While the time course of 
catalysis of NADPH to NADP+ is longer than that observed for conversion of NADH to NAD+, the 
magnitude of the effect is similar. Thus, CNM-Au8 plays an important role in providing NADP+ to 
the enzyme glucose 6-phosphate dehydrogenase for the conversion of 6-phosphogluconate to ribulose 
5-phosphate and NADPH + CO2, which represents the rate-limiting step of the oxidative branch of the 
PPP. 
 Figure 3.  Effects of CNM-Au8 on NADPH Oxidation  
 
 
co n tro l
C N M -A u 8  (1 0  n g /m l)
C N M -A u 8  (1 0 0  n g /m l)
C N M -A u 8  (1  µ g /m l)
C N M -A u 8  (1 0  µ g /m l)
B D N F  (5 0  n g /m l)
0
10
20
30
40
50
60
70
80
90
Q u an tity  o f N A D +  (n M )
*
*
*
* p < 0 .0 5  v s c o n tro l c o n d itio n  O n e -W a y  A N O V A  fo llo w e d  b y  D u n n e tt's te st
co n tro l
C N M -A u 8  (1 0  n g /m l)
C N M -A u 8  (1 0 0  n g /m l)
C N M -A u 8  (1  µ g /m l)
C N M -A u 8  (1 0  µ g /m l)
B D N F  (5 0  n g /m l)
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
38
40
Q uantity of N A D H  (nM )
*
*
*
*p< 0.05 vs control condition O ne-W ay A N O V A  follow ed by D unnett's test
*


 
 
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Excessive reactive oxygen exposure disrupts cellular redox homeostasis, damages intracellular 
organelles as well as DNA and proteins, and may also underpin pathophysiologic mechanisms of 
ALS.  Super oxide dismutases (SODs) evolved as a component of the cell’s antioxidant defense 
system to regulate the levels of reactive oxygen species (ROS) and prevent damage from oxidative 
stress. SOD enzymes are found in the cytoplasm and mitochondria where they convert oxygen 
radicals to O2 or H2O2, which can in turn be converted to water and O2 by catalases.  A dose-
dependent reduction of ROS levels was observed in differentiating oligodendrocyte precursor cells in 
primary culture with CNM-Au8 treatment (Figure 4). 
Figure 4 . Effects of CNM-Au8 on SOD and ROS Generation 
Figure 4A. Effects on SOD Activity Assay  
 
Figure 4B.  Effects on ROS Generation in Purified 
Murine OPC cultures 
Figure 4C.  Effects on ROS Generation in 
Murine OPC Cultures Plus Rotenone 
Demonstration of SOD-like catalytic activity with CNM-Au8 treatment has several important 
implications. First, neurons and glial cells are energetically demanding and generate large amounts of 
ROS as byproducts of the energetic processes necessary for their function. Theories of aging and 
neurodegeneration suggest that as CNS cells age, they are less able to efficiently remove ROS and 
thereby succumb to the consequences of long-term ROS exposure. As CNS cells are exquisitely 
sensitive to ROS, they are among the first cell types to degenerate, leading to the cognitive, 
psychomotor, and movement impairments observed in diseases such as ALS, Alzheimer’s disease, 
and Parkinson’s disease (Angelova and Abramov, 2018). In addition, SOD1 may act not only as a 


 
 
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regulator of ROS but also as a part of a glucose-oxygen sensing mechanism of a cell to determine 
whether the cell utilizes oxidative phosphorylation or aerobic glycolysis for ATP production (Reddi 
and Culotta, 2013). A study of oligodendrocyte (OL) energetics showed that human OLs 
preferentially use aerobic glycolysis during differentiation and myelination (Rone et al., 2016).   Data 
with CNM-Au8 demonstrate that treatment switches OPCs from proliferation to differentiation, while 
simultaneously stimulating aerobic glycolysis production of ATP likely through NADH oxidation 
(Figure 5).  Stimulation of SOD-like activity therefore is consistent with a role for CNM-Au8 in 
regulating cellular bioenergetics.  
Figure 5. Effect of CNM-Au8 on OPC Differentiation and ATP Production 
 
 
Effect of CNM-Au8 on a) OPC differentiation (O4+ cells) in isoldated murine OPCs and b) ATP production 
in MO3.13 oligodendrocytes (72hr). Statistical analysis performed using one-way ANOVA (p < 0.05). 
1.4 
Nonclinical Summary of In Vitro and In Vivo ALS Neuroprotection Studies 
1.4.1 In vitro ALS Neuroprotection Models 
CNM-Au8 exhibits neuroprotective effects in a broad range of neural cell types in in vitro and in vivo 
preclinical models of ALS. 
1.4.1.1 CNM-Au8 Protects Primary Rodent Motor Neurons From Excitotoxicity 
Excitotoxicity is the pathological process by which neuronal death occurs as a result of excessive 
stimulation of receptors at excitatory synapses such as the NMDA receptor. Excitotoxicity has been 
implicated in acute neurological damage from ischemia and traumatic brain injury and in the chronic 
neurodegeneration in Huntington's disease. Glutamate excitoxicity is also believed to be a significant 
contributor to motor neuron death in ALS.  Excitotoxic neuronal death via over-activation of NMDA 
receptors contributes to excessive flux of calcium (Ca2+) into the cell. This triggers a range of 
responses resulting in cell death, including increased oxidative stress, inappropriate activation of 
proteases such as calpain, dysregulation of Ca2+-related pathways, mitochondrial damage, and the 
apoptotic cascade.  


 
 
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Determination of the neuroprotective effects of  CNM-Au8 on motor neurons in an in vitro glutamate 
challenge model was carried out in ventral spinal cord cultures from E14 rat embryos (Martinou et al., 
1992). On Day 11 after seeding, cultures were pre-treated with CNM-Au8 or vehicle. The positive 
control riluzole was added for 1 hour of pre-treatment before glutamate addition. On Day 13, 
glutamate was added to the cultures for 20 minutes, followed by treatment of riluzole or CNM-Au8 
for another 48 hours before cells were fixed and stained. Cultures were stained with anti-MAP-2 to 
assess motor neuron survival and neurite lengths, and also with TDP-43 and Hoechst stain to assess 
extranuclear TDP43. CNM-Au8 dose-dependently protects motor neurons from glutamate-induced 
cell death (Figure 6A) while also preserving neurite length (Figure 6B). CNM-Au8 also outperformed 
riluzole on neurite network preservation.  In addition, CNM-Au8 treatment prevented the 
accumulation of cytoplasmic TDP-43, a hallmark of ALS cytotoxicity (Figure 6D).  
Figure 6 . Neuroprotection of Motor Neurons From Glutamate Excitotoxicity by CNM-Au8 
Figure 6A. Motor Neuron Survival 
Figure 6B. Motor Neuron Neurtie Network Area 
 
Figure 6D. Reduction in Cytoplasmic TDP43 
 


 
 
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1.4.1.2 CNM-Au8 Protects Normal iPSC Derived Human Motor Neurons From ALS-
Patient-Derived Toxic Astrocytes 
Astrocytes from both sporadic and familial ALS patients display toxicity against normal human motor 
neurons (MN) in co-culture (Meyer et al., 2014a). Toxic ALS-patient-derived astrocytes appear to 
secrete an unidentified toxic factor; and when co-cultured with human MNs, the MNs die (Meyer et 
al., 2014a). Similar studies have shown that astrocytes from sporadic patients also exhibit toxicity 
against healthy MNs, likely by similar mechanisms (Haidet-Phillips et al., 2011; Meyer et al., 2014b; 
Qian et al., 2017). To determine whether CNM-Au8 protects MNs from toxic ALS-patient-derived 
astrocytes, healthy human iPSC-derived MNs were plated with SOD1A4V astrocytes for 14 days in the 
presence of various doses of CNM-Au8 or vehicle. Neuroprotection was assessed by quantification of 
the expression of neuronal markers (Tuj1, Isl1/2, and ChAT) compared to vehicle treated control. 
Measurement of primary neurite lengths and a neurite network complexity Sholl analysis was also 
conducted (Sholl, 1953). As shown in Figure 7, significant neuroprotective dose-dependent effects of 
CNM-Au8 treatment were consistently observed on survival in the presence of SOD1A4V patient-
derived toxic astrocytes.  
Figure 7. CNM-Au8 Protects Normal iPSC Derived Human Motor Neurons From ALS-Patient-
Derived Toxic Astrocytes 
 
 
 
 
1.4.2 In vivo ALS Neuroprotection Models 
To demonstrate the efficacy of CNM-Au8 treatment in an in vivo model of ALS, two studies were 
conducted in separate SOD1G93A mouse model strains. These included the rapidly progressive 
SOD1G93A transgenic line on a mixed SJL/C57BL6 background (Heiman-Patterson et al., 2005) and 
the more slowly progressive SOD1G93A transgenic line on a congenic C57Bl/6 background (Lutz, 
2018) with lifespans of ~157 days compared to ~129 days, respectively. The study using rapidly 
progressing SOD1G93A animals showed only minor improvement in clinical onset (p=0.13, Mantel-
Cox test), as well as significant lack of brainstem atrophy (p<0.05, unpaired t-test) in the CNM-Au8-
treated group (N=15 animals per group;); all other functional measures were not significant (data not 
shown).  In the study of the slower progressing SOD1G93A (N=20 female mice, 10 per group), four-


 
 
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week-old female SOD1 mice were randomly assigned one of two groups with each group balanced for 
weight.  
Beginning at four weeks of age, mice were provided either CNM-Au8 or vehicle ad libitum in their 
drinking water. Beginning at Week 8 of age each mouse was tested weekly for strength and motor 
coordination utilizing several measures including the triple horizontal bar hang time test, static rod 
orientation test, inverted screen hang time test, weight hold test, and home cage wheel activity 
(average speed) in addition to standard ALS clinical scoring (Deacon, 2013a, 2013b; Hatzipetros et 
al., 2015). The CNM-Au8-treated group significantly outperforms the vehicle treated group at 
virtually all timepoints across these tests (Figure 8).   In addition, survival benefits have been 
observed through Week 22 of the study (Figure 9). 
Taken together, these preliminary data from an ongoing study in a transgenic ALS mouse model 
demonstrate preservation of motor function following chronic treatment with CNM-Au8. 
Figure 8. Locomotor Functional Efficacy of CNM-Au8 in an SOD1G93A (C57Bl/6 congenic strain) 
Murine Study 
 
A. ALS Clinical Score 
B. ALS TDI Neuro Score 
 
 
 
 


 
 
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Figure 8. Locomotor Functional Efficacy of 
CNM-Au8 in an SOD1G93A (C57Bl/6 
congenic strain) Murine Study 
 
C. Weights Hold Test 
 
Figure 8. Locomotor Functional Efficacy of 
CNM-Au8 in an SOD1G93A (C57Bl/6 
congenic strain) Murine Study 
 
D. Static Rod Orientation Time 
 
 
E. Triple Horizontal Bar Hang Time 
F. Inverted Screen Hang Time 
 
 
Figure 9. Effect of CNM-Au8 on Survival in a Congenic Murine SOD1 G93A Model 
 


 
 
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1.4.3 Summary ALS Treatment Rationale 
CNM-Au8-treated motor neurons are protected against cell death by glutamate excitotoxicity in a 
dose-dependent manner in a primary rat neural-glial co-culture where cytoplasmic levels of TDP-43 
are significantly reduced. Aberrant cytoplasmic localization and aggregation of TDP-43 has been 
observed in over 90% of cases of ALS in humans (Neumann et al., 2006).  Further, results from these 
multiple iPSC human motor neuron studies derived from sporadic, familial, and healthy lines indicate 
that CNM-Au8 is neuroprotective to MNs challenged with multiple different ALS disease related 
stressors, namely, excitotoxic and toxic astrocytic stress.  Results from the SOD1 G93A-
overexpression mouse study demonstrate significant improvements in locomotor performance of 
CNM-Au8-treated mice with a significant survival benefit. 
In summary, CNM-Au8 has demonstrated neuroprotection across a range of neuronal cell types, anti-
oxidant activity to counteract the accumulation of ROS in ALS, and preservation of motor function in 
an ALS mouse model. CNM-Au8 therefore represents an important therapeutic candidate for ALS. 


 
 
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2 
SUMMARY OF NONCLINICAL SAFETY & TOXICOLOGY STUDIES 
The Sponsor has conducted multiple safety and toxicology studies with CNM-Au8 in accordance with 
ICH M3 (R2) guidelines across three species including rats, minipigs, and canines, in addition to 
standard in vitro mutagenicity studies.  Initial in vivo dosing levels were modeled on delivering 
comparable amounts of gold as the historical gold complex, auranofin, to a 50-kg patient on a 
milligram per kilogram basis without adjustments for body surface area variance between species.  
This resulted in target nonclinical daily doses of Au at an estimated 0.0348 mg/kg/day, which were 
increased 10-fold (0.348 mg/kg) and 100-fold (3.48 mg/kg) to provide an anticipated safety margin 
for planned human dosing. 
2.1 
Summary of Safety Mutagenicity Studies 
Three safety mutagenicity studies were conducted to address the mutagenic potential of CNM-Au8 
including in vivo Micronucleus testing, and the in vitro Mammalian Cell Gene Mutation Test and 
Bacterial Reverse Mutation Test.  These studies each demonstrated no effect of CNM-Au8 on 
cytotoxicity or mutation frequency as summarized below in Table 4. 
Table 4. Summary of Safety Mutagenicity Studies 
 
Study ID 
(Internal 
ID/ 
CRO ID) 
GLP  
Status 
Mutagenicity 
Model 
 
Brief Design 
[Route; 
Frequency] 
Effective 
Dose 
 
CNM-
Au8 
Conc. 
(μg/mL) 
Summary/Notes 
AB06525 
GLP 
L5178Y Mouse 
Lymphoma 
Cells 
(Thymidine 
Kinase+/-) 
Mammalian 
Cell Gene 
Mutation Test 
(In vitro) 
1.7, 3.5, 
5.2, 8.7 and 
17 μg/mL 
348 
No signs of cytotoxicity; no 
biologically significant 
increases in the mutant 
frequency  
AB05703 
GLP 
Salmonella 
typhimurium 
Bacterial 
Reverse 
Mutation Test  
(In vitro) 
17, 35, 70, 
104, 174 
μg/plate 
348 
No precipitate and no sign 
of cytotoxicity were noted 
in any strain and at any 
dose level, either with or 
without metabolic 
activation 
AB17832 
(sub-study) 
GLP 
Rat 
Micronucleus 
Test 
Bone Marrow 
Micronucleus 
Test after 4-
weeks of 
treatment  
(In vivo) 
N/A 
0.0348, 
0.348, 
3.48 
No significant increase in 
the frequency of 
micronucleated 
polychromatic erythrocytes; 
no decrease in the 
PCE/NCE ratio 
CNM-Au8-
MPI-17-01 
GLP 
Rat 
Micronucleus 
Test 
Bone Marrow 
Micronucleus 
Test after 2-
days of 
treatment  
(In vivo) 
N/A 
10, 20, 40 
mg/kg/d 
No significant increase in 
the incidence of 
micronuclei in the test 
article dosed animals 
compared to the vehicle 
control. The test article 
CNM-Au8 was evaluated as 
negative (non-clastogenic) 


 
 
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2.2 
Summary of Safety Pharmacology Studies 
Safety pharmacology assessments included testing of three doses of CNM-Au8 (0.0348, 0.348 and 
3.48 mg/kg) in rodents in the standard CNS Irwin test and the same dosing regimen for assessment of 
renal function following saline overload.  Cardiovascular safety was assessed by constant telemetry in 
minipigs.  The CNS Irwin testing protocol provided no evidence CNM-Au8 affected central and 
peripheral neurologic function.  Similarly, renal function was not affected in Han Wistar rats 
following saline overload.  Telemetry recording of cardiovascular responses in minipigs including 
heart rate, blood pressure, ECG, and body temperature demonstrated no negative effects of CNM-Au8 
on cardiovascular function.  These safety pharmacology results are summarized in Table 5. 
Table 5. Summary of Safety Pharmacology Studies 
2.3 
Summary of Toxicology and Toxicokinetic Studies in Rodents and Minipigs 
2.3.1 
Initial Toxicokinetic Studies in Rodents and Minipigs 
Two initial toxicokinetic studies were completed in the Göttingen Minipig and two initial studies were 
completed in rats as summarized in Table 6. 
Study ID 
(Internal ID/ 
CRO ID) 
GLP  
Status 
Species 
(N) 
Brief Design 
[Route; 
Frequency] 
 
Nominal 
Dose 
(mg/kg/day) 
CNM-Au8 
Conc. 
(μg/mL) 
Summary/Notes 
AB17835 
GLP 
Han 
Wistar Rat 
(N=24) 
CNS Irwin Test 
Following 
Single-Dose 
[OG, QD] 
0.0348 
3.3 
No relevant effect on a 
battery of behavioral and 
physiological parameters, 
covering the main central 
and peripheral nervous 
system functions, evaluated 
for 24 hours after dosing 
0.348 
36.6 
3.48 
346.5 
AB17836 
GLP 
Han 
Wistar Rat 
(N=40) 
Renal Function 
Following Saline 
Overload 
[OG, QD] 
0.0348 
3.3 
No mortality or clinical 
signs; no change in the 
serum concentrations of 
sodium, potassium, 
chloride or creatinine or in 
the serum osmolality; no 
changes in urine volume, 
pH, osmolality, 
electrolytes, or creatinine; 
no change in GF, free water 
clearance, or excretion 
fractions of electrolytes 
0.348 
36.6 
3.48 
346.5 
AB17837 
GLP 
Göttingen 
Minipig 
(N=6) 
Cardiovascular 
Telemetry (11-
Day + Washout + 
PK) 
[OG, QD] 
0.0348 
3.3 
No effect on general health 
status, body weight gain, or 
body temperature; no 
relevant effects on the 
arterial blood pressure, 
heart rate, or ECG 
parameters 
0.348 
36.6 
3.48 
346.5 
 


 
 
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These initial studies were conducted up to a maximum of 3.48 mg/kg or approximately 100-fold 
higher delivery of gold when compared to comparable doses of auranofin in humans.  These studies 
did not identify any treatment related toxicities, so a maximum tolerated dose was not defined.  The 
no-adverse-effect-level (NOAEL) was identified at 3.48 mg/kg in rats and minipigs.   
Table 6. Initial Acute and Subchronic Dosing Studies in Rats and Minipigs 
 
 
 
Study ID 
(Internal 
ID/ 
CRO ID) 
GLP  
Status 
Species 
(N) 
Brief Design 
[Route; 
Frequency] 
 
Nominal 
Dose 
(mg/kg/day) 
CNM-Au8 
Conc. 
(μg/mL) 
Safety Summary/ 
Toxicity Notes 
AB17839 
Non-
GLP 
Göttingen 
Minipig  
(N=2) 
1-Day & 5-Day 
Acute Toxicity;  
2-phases 
[OG; QD] 
0.0348 
3.7 
No mortality; no treatment 
related clinical signs; no 
related macroscopic 
abnormalities 
0.348 
35.3 
3.48 
343.3 
AB17834 
GLP 
Göttingen 
Minipig 
(N=24; 
6/group) 
28-Day Repeat 
Dose Toxicity  
[OG; QD] 
0.0348 
3.3 
No mortality; no treatment-
related clinical signs or 
ophthalmological findings; 
no treatment-related effects 
on hematology, serum 
clinical chemistry, and 
urine parameters; no 
treatment-related 
macroscopic or histological 
findings  
0.348 
36.6 
3.48 
346.5 
AB17831 
Non-
GLP 
Han-
Wistar Rat 
(N=40; 
10/group) 
7-Day Acute 
Toxicity  
 [OG; QD] 
0.0348 
3.7 
No mortality; no clinical 
signs; no treatment-related 
changes in body weight, 
body weight gain and food 
consumption; no effects on 
hematology and serum 
clinical chemistry; no 
treatment-related changes 
in organ weights; no 
macroscopic and 
histopathological changes  
0.348 
35.3 
3.48 
343.3 
AB17832 
GLP 
Han-
Wistar Rat 
(N=100; 
25/group) 
28-Day Repeat 
Dose Toxicity 
[OG; QD] 
0.0348 
3.3 
No mortality; no clinical 
signs; no treatment-related 
changes in body weight, 
body weight gain and food 
consumption; no effects on 
hematology, coagulation, 
serum clinical chemistry 
and urine parameters; no 
treatment-related 
ophthalmological findings 
at any dose level; no organ 
weight, macroscopic 
changes or histological 
findings 
0.348 
36.6 
3.48 
346.5 


 
 
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2.3.1.1 
Study AB17834 (28-Day Repeat Dose Toxicity in Göttingen Minipig) 
At the end of the treatment period in Study AB17834, a lower platelet count from the pretest baseline 
was noted in 3 animals as described in Table 7, below. One female in Group 2 (low dose) and one in 
Group 3 (intermediate dose) had very low levels of platelets counts, and one male in Group 4 (high 
dose) group had a significant reduction. 
Table 7: Study AB17834 Platelet Change from Day -12 to Day 27 in Select Animals  
Group 
Animal ID 
Platelets (Giga/L) 
Day -12 
Day 27 
Low Dose (0.0348 mg/kg) 
Female 310 
470 
16 
Intermediate Dose (0.348 mg/kg) 
Female 317 
401 
6 
High Dose (3.48 mg/kg) 
Male 321 
561 
109 
While the reduction in platelet counts were not attributed as related to the test article, given the history 
of hematological adverse events associated with gold complexes the Sponsor organized a series of 
measures to explore the potential relationship to test article, including: 
• 
Review of historical data from the minipig supplier and contact research organization (CRO) 
laboratory values for pre-dose and control minipigs to evaluate whether platelet reductions or 
low platelet counts had been previously observed. 
• 
Specialty hematological assessment of bone marrow sections from these animals and repeat 
examination of bone marrow smears taken at necropsy. 
Review of historical data sets revealed that the platelet count in the peripheral blood of the minipig is 
highly variable and low platelet counts have sporadically been observed in untreated minipigs at the 
CRO laboratory (Eurofins).  Further examination of bone marrow smears revealed no treatment-
related differences in group means or individual Myeloid:Erythroid (M:E) ratios.  Female no. 317 had 
a low M:E ratio due to higher proportion of erythroid precursors, which correlated with the 
histopathological observation of a high cellularity of the bone marrow.  These changes were 
consistent with a hyperplastic change of the erythroid compartment, not accompanied by any increase 
in reticulocyte count in the peripheral blood as might be expected.  There were no cytological 
abnormalities correlating with the severe decrease in platelet counts observed at necropsy in treated 
female nos. 310 and 317 and at lower severity in male no. 321.  It could not be excluded that the low 
platelet counts may be part of the background variation in this species or may have resulted from 
hemorrhage occurring accidentally at blood sampling.  There was no evidence of qualitative or 
quantitative treatment-related effects on lymphoid cells, monocytes, reticulum, mast cells, or 
megakaryocytes.  There were also no treatment-related differences in M:E ratio (group mean and 
individual values) or in absolute and relative counts of myeloid, erythroid, and lymphoid cell series. 


 
 
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To date, no significant platelet reductions have been observed in any of the toxicology studies 
conducted in rodents or canines. 
2.3.2 
Maximum Feasible Dose Study and High Dose Subchronic Toxicity Studies in 
Rodents and Minipigs 
Upon submission of the Investigational New Drug (IND) application to the U.S. FDA, the Agency 
requested additional higher dose studies to identify a maximum tolerated dose, or alternatively a 
maximum feasible dose.  Subsequently, a 7-day maximum feasible dose study was conducted in rats 
with subcutaneous (SC) dosing compared to 90 mg/kg oral gavage (OG) dosing.  The maximal 
feasible dose (MFD) represented the highest concentration of CNM-Au8 (3000 parts per million, 3 
mg/mL) that could be manufactured with currently available techniques dosed at the maximum 
permissible dosing volume delivered via gavage or SC administration.  Of note, the 3 mg/mL 
concentration used in the two MFD studies had deviations out of product specification (hydrodynamic 
radius of 54.38 nm, which exceeded the production specification range of 10 – 30 nm) likely 
indicating nanoparticle agglomeration.  
In rodents, doses of 5, 15, 30 and 90 mg/kg/day over seven consecutive days, were administered in a 
divided dose, i.e., twice daily subcutaneously (2.5, 7.5 and 15 mg/kg, BID) or, orally, three times 
daily (30 mg/kg TID; 90 mg/kg/day). The three times daily oral gavage administration was well 
tolerated by all rodents and not associated with any adverse findings. Test-article related findings that 
were not adverse, included discolored feces (black), decreased body weight gain and food 
consumption when compared to controls, and anatomic pathology findings of extramedullary 
hematopoiesis noted in the spleen and/or liver.  This study defined 90 mg/kg/day as the NOAEL with 
oral gavage administration.  
The daily subcutaneous administration was associated with adverse events related to subcutaneous 
administration of the test article.  The skin was thickened/leathery in all treatment groups with 
associated changes in clinical pathology, defined by increased neutrophils and fibrinogen levels and 
decreases in albumin; and anatomic pathology, defined by subacute/chronic inflammation, edema, and 
cavitation in the injection sites, which were considered adverse in their totality.  Systemic test article-
related changes not considered adverse were noted in body weights (decreased gain), food 
consumption (decreased), and anatomic pathology (increased spleen weights, and extramedullary 
hematopoiesis in the spleen and liver).  Accordingly, a NOAEL could not be established in the 
rodents receiving daily SC administration up to 30 mg/kg.   
With twice-daily SC administration of CNM-Au8, blood Au exposures increased proportionally or 
slightly greater than proportionally from 5 to 30 mg/kg/day on Day 1 and Day 7.  Blood Au exposures 
after SC administration were considerably higher than after oral gavage administration with the dose 
normalized AUC(0-Last) ratio (SC:OG) ranging from approximately 9x – 50x higher dose-normalized 


 
 
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AUC depending upon animal gender and the SC dose.  Despite substantially greater Au accumulation, 
no systemic toxicities were observed with SC administration.  
Table 8 below summarizes the design and results of the maximum feasible dose and subsequent high 
dose subchronic toxicity studies in rodents. 
Table 8. Maximum Feasible Dose Study and High Dose Subchronic Toxicity Studies 
 
2.3.3 Chronic Rodent Toxicology (6-Month Dosing) 
The objective of this study was to evaluate the toxicity of the test article in rats after administration 
for 13- and 26-weeks and to evaluate reversibility, progression, or delayed appearance of any 
observed changes following a 4-week postdose observation period after each dosing termination. 
Study ID 
(Internal ID/ 
CRO ID) 
GLP  
Status 
Species 
(N) 
Brief Design 
[Route; 
Frequency] 
Nominal 
Dose 
(mg/kg/day) 
CNM-Au8 
Conc. 
(μg/mL) 
Safety Summary/ 
Toxicity Notes 
CNAU-
MPI-14-04 
(2257-004) 
Non-
GLP 
Sprague-
Dawley 
Rat 
(N=60; 
12/group) 
7-Day Max 
Feasible Dose 
Study  
[SC; BID] 
[OG; TID] 
5 
[SC; 2.5 
mg/kg BID] 
500 
Discolored feces (black), 
decreased body weight gain 
and food consumption; 
non-adverse anatomic 
pathology findings 
consisting of 
extramedullary 
hematopoiesis noted in the 
spleen and/or liver. Skin 
thickened/leathery in SC 
injection groups associated 
with changes in clinical 
pathology (increased 
neutrophils and fibrinogen 
levels; decreases in 
albumin) and anatomic 
pathology (subacute/ 
chronic inflammation, 
edema, and cavitation in 
the injection sites). 
15 
[SC; 7.5 
mg/kg BID] 
1,500 
30 
[SC; 15 
mg/kg BID] 
3,000 
90 
[OG; 
30mg/kg, 
TID] 
3,000 
CNM-Au8-
MPI-16-01 
(2257-008) 
GLP 
CD Rat 
(N=146) 
21-Day Repeat 
Dose Toxicity 
[OG;  
QD/BID] 
10 
1,000 
No treatment-related signs 
of toxicity; no effects on 
body weights, food 
consumption or clinical 
pathology parameters; no 
treated related 
ophthalmologic effects; 
examinations; no organ 
weights changes; no 
treatment-related 
observations during 
necropsy and no 
histopathologic changes. 
20 
1,000 
40 
[20mg/kg, 
BID] 
1,000 


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


 
 
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Doses of CNM-Au8 up to 90 mg/kg by oral gavage have not demonstrated any acute or subchronic 
toxicity, and accordingly, a MTD has not been identified to date.   All dosing levels and all 
concentrations (ranging from 350 – 3,000 μg/mL) explored in canines have produced NOAELs.   
Table 10 below summarizes the design and results of the toxicokinetic studies conducted to date in 
Beagle dogs. 
 
 


 
 
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Table 10. Acute and Subchronic Dosing Studies in Canines 
2.4.1 Single Dose Canine Toxicokinetic Summary 
After intravenous (IV) administration, the mean CNM-Au8 whole blood estimated concentration at 
time zero (C0) was calculated as 9.39 ng/mL (range 4.97 to 18.4 ng/mL) extrapolated using a log-
Study ID 
(Internal 
ID/ 
CRO ID) 
GLP  
Status 
Species 
(N) 
Brief Design 
[Route; 
Frequency] 
Nominal 
Dose 
(mg/kg/day) 
CNM-Au8 
Conc. 
(μg/mL) 
Safety Summary/ 
Toxicity Notes 
CNAU-
MPI-14-01 
(2257-001) 
GLP 
Beagle 
Dog 
(N=18; 
6/group) 
Single Dose 
Toxicity and 
Toxicokinetics 
(With 9 Day 
Follow-Up) 
0.5 mg/kg 
IV 
100 
No mortality and no 
clinical observations noted 
during study. 
3.5 mg/kg 
[OG, QD] 
350 
10 mg/kg 
[OG, QD] 
1,000 
CNAU-
MPI-14-02 
(2257-003) 
GLP 
Beagle 
Dog  
(N=48; 
12/group) 
28-Day Repeat 
Dose Toxicity 
[OG, QD] 
0.35 
35 
No mortality; no 
treatment-related toxicity; 
no effects on body 
weights, food 
consumption or clinical 
pathology parameters; no 
treatment-related effects 
on ophthalmologic or 
physical examinations; no 
effects on organ weights 
or histopathologic changes 
3.5 
350 
10 
1,000 
CNAU-
MPI-14-03 
(2257-002) 
Non-
GLP 
Beagle 
Dog 
(N=8; 
2/group) 
Ascending Dose 
and 7-Day 
Repeat Dose 
Toxicity 
[OG, QD] 
10 
1,000 
No mortality and no 
clinical observations noted 
during study; discolored 
feces were observed in all 
treated animals; no related 
treatment effects on food 
consumption, body 
weight, or physical exam. 
20 
2,000 
30 
3,000 
CNAU-
MPI-14-05 
(2257-005) 
GLP 
Beagle 
Dog 
(N=24; 
6/group) 
21-Day Repeat 
Dose Toxicity 
(Maximum 
Feasible Dose) 
[OG; QD, BID, 
TID] 
30 
[30mg/kg 
QD] 
3,000 
No mortality; treatment-
related salivation and 
discolored feces at 60 and 
90 mg/kg/day. No 
treatment-related effects 
on body weights, food 
consumption, 
ophthalmology, 
electrocardiograms, 
clinical pathology 
parameters, organ weights 
or macroscopic 
examinations.  Non-
adverse changes in the 
kidneys in three animals at 
90 mg/kg/day with 
minimal bilateral tubular 
cell hypertrophy, 
characterized by a diffuse 
increase in the size of 
tubular epithelial cells. 
60 
[30mg/kg 
BID] 
3,000 
90 
[30mg/kg 
TID] 
3,000 


 
 
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linear regression from the first two measured concentrations.  The first blood sample after IV dosing 
was collected at 30 minutes postdose, so it is possible that the concentration at 30 minutes 
underestimates C0.  After oral administration, maximum CNM-Au8 plasma concentrations were 
observed at a Tmax range of 4 – 48 hours and 12 – 48 hours postdose for the 3.5 and 10 mg/kg cohorts, 
respectively.  
Due to limited interpretable data points above the lower limit of quantitation (LLOQ) in the IV dosing 
group, AUC∞ was not calculated, and absolute bioavailability (F) was therefore calculated using the 
mean values for AUC0-336 from two of six animals with quantifiable Au whole blood concentrations to 
336 hours.  As shown in Table 11, F was 30.5% for the 3.5 mg/kg group and 20.5% for the 10 mg/kg 
group.  The difference may be due to the use of different animals in the 3 cohorts rather than a true 
difference in bioavailability.  The mean Cmax value at 3.5 mg/kg includes two animals with CNM-Au8 
concentrations all below the lower limit of quantitation with subsequent Cmax values set to zero, so the 
reported Cmax value may be an underestimate in this dosing group. 
Table 11.  Summary of Cmax, AUC, T1/2, and Bioavailability Results Following Single Dose 
Administration of CNM-Au8 in Study CNAU-MPI-14-01 
CNM-
Au8 
Dose 
(mg/kg) 
Statistic 
Cmax or 
C0 
(ng/mL) 
AUC0-336hr 
(hr*ng/mL) 
AUC0-336/Dose 
(kg*hr*ng/mL/mg) 
T1/2 
(hr) 
Bioavailability 
(F%) 
(Dose Normalized 
AUC Ratio 
(PO/IV) 
0.5 
(IV) 
N 
6 
2 
2 
2 
N/A 
Mean 
9.39 
146 
291 
31.0 
SD 
5.25 
N/A 
N/A 
N/A 
CV% 
55.9 
N/A 
N/A 
N/A 
3.5 
(PO) 
N 
6 
4 
4 
N/A 
Insufficient 
Data) 
30.5% 
Mean 
1.80 
311 
88.8 
SD 
1.65 
234 
66.8 
CV% 
92% 
75% 
75% 
10.0 
(PO) 
N 
6 
5 
5 
4 
20.5% 
Mean 
4.04 
596 
59.6 
150 
SD 
2.99 
457 
45.7 
51.5 
CV% 
74% 
77% 
77% 
34% 
The urine volume and feces mass in each collection interval was not determined, therefore, 
comparisons among dosing groups were limited to urine and fecal concentration data.  In the IV 
dosing group, feces concentrations were all below the LLOQ (<150 ng/mL); however, identification 
of CNM-Au8 above the lower limit of detection (LLOD) in the feces over the 2-week period 
established the feces as a route of elimination.  Quantifiable urine concentrations were observed 
between 36 to 48 hours postdose in the 0.5 mg/kg IV dosing group, confirming urine as an elimination 
pathway.   Urinary excretion data were not collected at consistent intervals with whole blood 
concentration, so renal clearance could not be calculated.   Peak urine concentrations in the 3.5 and 10 


 
 
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mg/kg groups occurred between 12 – 24 hours and 36 – 48 hours, respectively, and exceeded whole 
blood concentrations. 
Mean values for half-life (T1/2), clearance (CL), volume of distribution (Vz), and volume of 
distribution at steady state (Vss), respectively, for the 0.5 mg/kg IV dosing group are shown in Table 
12. 
Table 12.  Summary of CL, T1/2, Vz, and Vss after a Single 0.5 mg/kg IV Dose of CNM-Au8 
(Study CNAU-MPI-14-01) 
CNM-Au8 Dose 
 
Statistic 
T1/2 
(hr) 
CL 
(L/hr/kg) 
Vz 
(L/hr/kg) 
Vss 
(L/hr/kg) 
0.5 mg/kg (IV) 
N 
2 
2 
2 
2 
Mean 
31.0 
5.64 
249 
242 
Animal102 
33.6 
4.72 
229 
224 
Animal105 
28.5 
6.57 
270 
261 
In the oral gavage dosing groups, dose normalized systemic exposure (AUC0-336hr/Dose) and Cmax values 
for CNM-Au8 showed less than proportional increases.  An approximate 1:3-fold increase in dose 
(3.5 mg/kg to 10 mg/kg) resulted in an approximate 1:1.5-fold decrease in mean dose normalized 
AUC0-336hr/Dose. Mean values for terminal half-life (T1/2), oral clearance (CL/F), and oral volume of 
distribution (Vz/F), for the 10 mg/kg dosing group are reported in Table 13.  
Table 13.  Summary of CL/F, T1/2, and Vz/F after a Single 10 mg/kg PO Dose of CNM-Au8 (Study 
CNAU-MPI-14-01) 
CNM-Au8 Dose 
 
Statistic 
T1/2 
(hr) 
CL/F 
(L/hr/kg) 
Vz/F 
(L/hr/kg) 
10 mg/kg (PO) 
N 
4 
4 
4 
Mean 
150 
13.1 
2,970 
SD 
51.5 
7.3 
2,080 
CV% 
34% 
56% 
70% 
2.4.2 
Repeat Dose Canine Toxicokinetic Summary 
In brief, in the subchronic toxicity study with a 4-week recovery period, 48 beagles were dosed for 
28-days to assess toxicity and toxicokinetics.  CNM-Au8 was well tolerated when administered at 
gold concentrations of 0.35, 3.5, and 10 mg/kg/day as a single daily dose of 1mg/mL CNM-Au8 via 
oral gavage, and the10 mg/kg/day dose was considered the NOAEL. There were no significant 
changes in serum chemistry or hematology measures or in the macroscopic or histologic assessments 
post-necropsy. In terms of toxicokinetics, systemic exposure appeared independent of gender. There 
was an increase in Cmax from 0.35 to 3.5 mg/kg, but no apparent change from 3.5 to 10 mg/kg, 
suggesting a plateau in exposure to 3.5 and 10 mg/kg. Mean systemic exposure AUC(0-24 hr) 
accumulated in whole blood following repeated administration over the first two weeks, with no 
significant change in accumulation ratio (Rac) after that time, indicating that steady-state was reached 


 
 
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within 2 weeks of dosing. Elimination half-life (T1/2) was long; 333 hours (13.9 days) in the 10 mg/kg 
dose group.  During the recovery elimination phase, gold levels were still quantifiable at 4-weeks 
post-dosing in both blood and tissue.  Whole blood Au concentrations are shown in Figure 10. 
Figure 10. Whole Blood Concentrations by Day in 28-Day Repeat Dosing Canine Study 
 
A noteworthy finding in the three-animal species studied was a disproportionate tissue concentration 
of gold measured in the kidney. This renal accumulation was not accompanied by changes in renal 
function, as measured by serum biochemistry, urinalysis, or structural changes identified in the 
histologic examination of the kidney. In the 4-week recovery period in the 28-day dog study, gold 
concentrations in the kidney decreased significantly over that recovery period, and continuing urinary 
excretion of gold was measured throughout the recovery period. 
2.4.3 Maximum Feasible Dose Canine Toxicokinetic Study 
In the canine maximum feasible dose study, the doses administered were 30 mg/kg/day (QD), 
60mg/kg/day (30 mg/kg BID), or 90 mg/kg/day (30 mg/kg TID) over three consecutive weeks 
(21-days). Dosing was well tolerated in the dogs over the 21 consecutive days of dosing. At the 
highest dose, 90mg/kg/day, minimal bilateral tubular cell hypertrophy was observed in the kidneys of 
males and females but was considered non-adverse by the MPI study pathologist-toxicologist.  
No deaths occurred. Treatment-related salivation and black discolored feces were observed at 60 and 
90 mg/kg/day. No treatment-related effects were observed on body weights, food consumption, 
ophthalmology, ECGs, clinical pathology parameters, organ weights or macroscopic examinations. 
There was slightly less than a proportional increase in gold exposure when the dose was increased 
from 30 to 60 mg/kg/day. Increasing the dose from 60 to 90 mg/kg/day was not generally 
accompanied by an increase in gold exposure. Thus, maximal systemic exposure in the dogs may 


 
 
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occur with a dose of 60mg/kg/day divided into two daily oral doses of 30 mg/kg. Accumulation 
appeared to plateau by Day 7, with no substantive increase in exposure on Days 14 and 21. Blood 
gold exposures at steady-state were approximately 1.1 to 3.3 times higher than on Day 1, and the 
extent of the accumulation tended to be lower with higher doses.  Systemic gold concentration 
appears to be approximately at steady state after 1 to 2 weeks of dosing. Systemic exposure appears to 
be higher in female dogs than in male dogs.  
2.4.4 Chronic Canine Toxicology (9-Month Dosing) 
The objective of this study was to evaluate the potential toxicity of the test article in beagle dogs when 
administered orally via gavage once daily for 13 and 39 weeks, and to evaluate reversibility, 
progression, or delayed appearance of any observed changes following a 4-week post dose 
observation period after each termination. 
Assessment of toxicity was based on mortality, clinical observations, body weight, and food 
consumption; ophthalmoscopic, and electrocardiographic examinations; and clinical and anatomic 
pathology. Blood, urine, CSF, and designated frozen tissues were analyzed for gold content. 
Toxicokinetic assessment for gold content in blood and urine was conducted. 
No early deaths occurred. There were no treatment-related clinical signs of toxicity observed, no 
effects on body weight or food consumption, or during ophthalmoscopic observations or 
electrocardiographic examinations. There were no test article-related effects among clinical pathology 
parameters noted during the interim dosing and recovery periods. No organ weight changes were 
observed and no test article related macroscopic or microscopic findings were observed at the interim 
or recovery necropsies. 
CNM-Au8 was well tolerated in dogs when administered at doses of 0.35, 3.5 and 10 mg/kg/day for 
39-weeks.  No adverse signs of toxicity were observed at any dose level. Therefore, the dose of 10 
mg/kg/day was considered the NOAEL in dogs following oral administration. 
 
 


 
 
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Table 14. Chronic Canine Toxicity Study 
 
 
 
Study ID 
(Internal ID/ 
CRO ID) 
GLP  
Status 
Species 
(N) 
Brief Design 
[Route; 
Frequency] 
Nominal 
Dose 
(mg/kg/day) 
CNM-Au8 
Conc. 
(μg/mL) 
Safety Summary/ 
Toxicity Notes 
CNM-AU8-
MPI-16-03 
(2257-007) 
GLP 
Beagle 
Dog 
(N=80; 8 
or 12 
(TK)/ 
group) 
39-Week Repeat 
Dose Toxicity 
with 4-Week 
Recovery  
[OG; QD] 
0.35 
[OG, QD] 
1,000 
No treatment-related 
clinical signs of toxicity 
observed, no effects on 
body weight or food 
consumption, or during 
ophthalmoscopic 
observations or 
electrocardiographic 
examinations. There were 
no test article-related 
effects among clinical 
pathology parameters noted 
during the interim dosing 
and recovery periods. No 
organ weight changes were 
observed and no test article 
related macroscopic or 
microscopic findings were 
observed at the interim or 
recovery necropsies. 
3.5 
[OG, QD] 
1,000 
 
10 
[OG, QD] 
1,000 


 
 
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3 
PRIOR HUMAN DOSING EXPERIENCE 
A Phase 1, First-Time-In-Human study was previously conducted under a clinical trial application 
(CTA) in the Netherlands (AU8.1000-14-01). The study was a 2-phase, randomised, placebo-
controlled, double˗blind, single- and multiple-dose escalating study to evaluate the safety, tolerability, 
and PK of CNM˗Au8 in healthy male and female volunteers. There were 2 phases to this study: a 
single ascending dose (SAD) Phase and a multiple ascending dose (MAD) Phase. The SAD Phase 
was conducted first, followed by the MAD Phase of the study. 
3.1 
AU8.1000-14-01 Design 
A total of 8 subjects per cohort were randomly assigned (3:1 ratio) to receive a single dose of either 
CNM˗Au8 (n = 6) or placebo (n = 2) at an initial dose level of 15 mg CNM-Au8. Additional cohorts 
of 8 subjects were enrolled to investigate single-escalating doses of CNM-Au8 at 30 mg, 60 mg, and 
90 mg. Cohorts were to be balanced by gender with no more than two-thirds of subjects being of one 
gender.  Safety parameters included findings from electrocardiograms (ECGs), vital signs, clinical 
laboratory panels, physical examinations, urinalysis, AEs, and concomitant medications. A follow-up 
visit was conducted for final safety assessments on Day 17 ± 1. 
After the SAD Phase was completed, a total of 12 subjects per cohort were randomly assigned (3:1 
ratio) to receive a multiple dose of either CNM-Au8 (n = 9) or placebo (n = 3) once daily for 21 days 
at an initial dose level of 15 mg CNM-Au8. Additional cohorts of 12 subjects were enrolled to 
investigate multiple escalating doses of CNM-Au8 at 30 mg, 60 mg, and 90 mg. Cohorts were 
balanced by gender, with no more than two-thirds of subjects being of one gender.  Following the 
final dose of study drug on Day 21, subjects entered a 28-Day follow-up phase and returned to the 
clinical research unit (CRU) for PK sampling on Days 23, 24, 25, 26, 27, 28, 32, 36, 40, and 49, 
which completed study participation.  Safety parameters included findings from ECGs, vital signs, 
clinical laboratory panels, physical examinations, urinalysis, AEs, and concomitant medications. 
3.2 
AU8.1000-14-01 Pharmacokinetic Results 
The PK Population included all randomised subjects who received CNM-Au8 study drug and had 
sufficient samples collected for estimation of PK parameters. 
• 
The PK Population for the SAD Phase included 24 subjects who received a single dose of 
CNM˗Au8 study drug at 15 mg, 30 mg, 60 mg, and 90 mg. 
 


 
 
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• 
The PK Population for the MAD Phase included a total of 35 subjects: 8 subjects in the 15 mg 
dosing group and 9 subjects each in the other 3 cohorts who received multiple doses of CNM-
Au8 study drug at 30 mg, 60 mg, and 90 mg (Cohorts 5–8). 
In the SAD Phase, PK analyses were not completed since the majority of whole blood Au 
concentrations were below the LLOQ. Since the lack of quantitation of Au concentrations may have 
been related to ICP-MS assay sensitivity, the Sponsor upgraded to an advanced, more sensitive, ICP-
MS instrument for the PK analyses in the MAD Phase. 
In the MAD Phase: 
• 
The geometric mean whole blood concentrations from 1 week onward increased in a 
dose˗related, but not a dose-proportional manner. Based on Days 14 and 21, the increases in 
both Cmax and AUC(0-24) were less than dose proportional. 
• 
Based on pre-specified fit criteria, the elimination t½ ranged from 277 to 628 hr (11.5 to 26.2 
days). 
• 
Steady-state for all cohorts, based on the geometric mean whole blood concentrations, was 
reached by the end of the second week of dosing (Day 14), which was substantially less than 
predicted by the t½ [range of 46 to 105 days (6.6 to 15 weeks)]. 
PK parameters related to urinary excretion (Ue, CLr) could not be calculated. Only 1 urine Au 
concentration ≥ LLOQ (3 ng/mL) was within limits of the assay. 
3.3 
AU8.1000-14-01 Safety Results 
The Safety Population included randomised subjects who received at least 1 dose of study drug and 
had at least 1 post-baseline safety assessment, and was used to perform all safety analyses. The Safety 
Population included 40 subjects in the SAD Phase, 46 subjects in the MAD Phase, and 86 subjects in 
the Pooled (SAD + MAD) group. 
All planned dose cohorts were completed, and the Safety Review Committee (SRC) agreed to escalate 
to each subsequent dose cohort per the protocol. An MTD was not identified. All subjects in the SAD 
Phase completed a single oral dose per protocol. In the MAD Phase, the mean duration of treatment 
was 21.0 days of consecutive oral dosing for the 15 mg, 30 mg, and 60 mg Cohorts and placebo. 
Subjects in the 90 mg Cohort received on average 20.1 days of consecutive dosing. One subject 
(subject 0085-MAD 90 mg) in the MAD Phase did not complete the 21 days of consecutive dosing 
per protocol due to a reported pregnancy after 13 days of consecutive dosing, and had a medically 
induced abortion 7 days later. 


 
 
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For the SAD and MAD Phases of the study, the overall incidence of TEAEs was comparable between 
treatments, including placebo; overall incidence of TEAEs considered related to study drug by the 
Investigator was also comparable between treatments, including placebo.  The most frequently 
reported TEAEs were in the classes of Nervous system disorders and Gastrointestinal disorders. The 
majority of TEAEs were Grade 1 severity (mild). There were no serious TEAEs, TEAEs leading to 
discontinuation of treatment, or TEAEs considered severe, life threatening, or resulting in death. 
Overall, no dose response relationship to TEAEs was observed in the SAD or MAD Phase of the 
study; however, the frequency of headache and gastrointestinal TEAEs was higher in the 90 mg MAD 
treated subjects. 
In the SAD Phase, TEAEs considered related to study drug by the Investigator were reported by 2 
(16.7%) out of 12 subjects in the 15 mg group, 2 (33.3%) out of 6 subjects in the 30 mg group, 4 
(66.7%) out of 6 subjects in the 60 mg group, and 5 (83.3%) out of 6 subjects in the 90 mg group 
compared with 7 (70.0%) out of 10 subjects in the placebo group. All related TEAEs were Grade 1 
severity (mild) in the SAD Phase, except for 2 related TEAEs (diarrhea and abdominal pain: both in 
Subject 0024-SAD 60 mg) that were considered Grade 2 severity (moderate). 
In the MAD Phase, TEAEs considered related to study drug by the Investigator were reported by 5 
(62.5%) out of 8 subjects in the 15 mg, 4 (44.4%) out of 9 subjects in the 30 mg, 3 (33.3%) out of 9 
subjects in the 60 mg, 8 (88.9%) out 9 subjects in the 90 mg, and 6 (54.5%) 11 subjects in the placebo 
group. All related TEAEs in the MAD Phase were Grade 1 severity (mild). 
Modified treatment emergent events were defined as a treatment emergent adverse event that started 
within 24 hours from first dose of study medication. Modified TEAEs for all CNM-Au8 doses were 
reported by 11 (36.7%) out of 30 subjects in the SAD Phase, 7 (20.0%) out of 35 subjects in the MAD 
Phase, and 18 (27.7%) out of 65 subjects in the Pooled (SAD + MAD) group. A total of 9 (42.9%) out 
of 21 placebo treated subjects reported modified TEAEs. The most frequently reported modified 
TEAEs included headache, blood creatinine increased, dizziness, diarrhea, and nausea. 
The Sponsor performed a pre-specified search of TEAE preferred terms potentially associated with 
gold complex compounds to determine adverse events of special interest (AESIs). All AESIs were 
considered Grade 1 severity (mild), except for 2 TEAEs of Grade 2 severity (moderate): diarrhea and 
abdominal pain in the same subject (Subject 0024-SAD 60 mg). Incidence rates were comparable 
between all dosing groups including placebo. 
Dosing with either a single dose or multiple doses of CNM-Au8 was generally well tolerated over the 
course of this study. The most frequently reported TEAEs in the pooled population were headache, 
somnolence, fatigue, abdominal pain upper, diarrhea, nausea, abdominal pain, and dizziness.  Overall 


 
 
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for both the SAD and MAD Phases, routine clinical laboratory assessments (hematology, serum 
chemistry, and urinalysis), vital signs, ECGs, and physical examinations did not reveal clinically 
notable findings; there were no serious TEAEs or TEAEs leading to discontinuation of treatment. No 
safety trends or safety signals were observed in this study. 
Oral administration of either a single (SAD) or repeated dose (MAD) of CNM-Au8 over 21 
consecutive days in healthy volunteers was safe and well tolerated. The TEAEs observed across the 4 
doses (15 mg, 30 mg, 60 mg, and 90 mg) of CNM-Au8 were mostly mild in severity. While no dose 
response relationship to TEAEs was observed overall in the SAD or MAD Phase of the study, 
increases in headache and gastrointestinal related TEAEs were observed in the 90 mg cohort of the 
MAD Phase. 
Overall, for both the SAD and MAD Phases, routine clinical laboratory assessments (hematology, 
serum chemistry, and urinalysis), vital signs, ECGs, and physical examinations did not reveal 
clinically notable findings or trends; none resulted in serious TEAEs or TEAEs leading to 
discontinuation of treatment. 
 
 


 
 
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4 
INVESTIGATIONAL PLAN 
4.1 
Rationale for the Study 
CNM-Au8 has been studied in several preclinical ALS rodent disease models and has demonstrated 
significant neuroprotection in human iPSC derived neuronal populations. Through a mechanism of 
action targeting restoration of cellular redox homeostasis, CNM-Au8 addresses pathophysiologic 
bioenergetic failure in neurons, which may underlie the pathogenesis of ALS and other 
neurodegenerative diseases. CNM-Au8 acts catalytically to affect cellular bioenergetics protecting 
sensitive neuronal populations through a unique mechanism promoting cellular redox homeostasis 
that involves the catalytic oxidation of NADH resulting in enhanced aerobic glycolytic energy 
production. 
4.2 
Study Objectives  
To assess the efficacy, safety, and PK/PD effects of CNM-Au8 as a disease-modifying agent for the 
treatment of ALS by utilizing electrophysiological measures to detect preservation of motor neuron 
function. 
• 
Efficacy will be assessed as the difference in disease progression from baseline reflected by 
changes in motor neuron loss measured by electromyography (e.g., MUNIX, MUSIX, Split 
Hand Index, Neurophysiology Index, MScanFit), change in ALS Functional Rating Score-
Revised (ALSFRS-R score), the mean rate of change (DFS) of the ALSFRS-R from symptom 
onset, survival status, respiratory functions, and composite disease progression. 
• 
Safety will be assessed up through the frequency of treatment emergent adverse events, 
serious adverse events, discontinuations due to adverse events, Falls Questionnaire and the 
Columbia Suicidality Severity Rating Scale (C-SSRS). 
• 
Pharmacodynamics and pharmacokinetics (PK/PD) will be assessed through blood and urine 
collection at Baseline and then every 12-weeks thereafter during the treatment period and 
every 24-weeks during the optional open-label extension period. PD analyses may include 
whole blood metabolomic markers (e.g., redox coenzymes: NAD+, NADH, NADP+, 
NADPH; energetic coenzymes: ATP, ADP, AMP and antioxidants: GSSG and GSH), urinary 
neurotrophin receptor P75ECD levels, and serum neurofilament light chain (NfL).     
4.3 
Overall Study Design and Plan 
This is a multi-centre randomised, double-blind, parallel group, placebo-controlled study of the 
efficacy, safety, pharmacokinetics, and pharmacodynamics of CNM-Au8 in patients who are newly 


 
 
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symptomatic within 24-months of Screening and with a clinically probable or possible or definite 
ALS diagnosis per the Awaji-Shima criteria (de Carvalho et al., 2008).  
Patients may be screened over up to a 6-week period. Patients who meet the inclusion criteria and 
none of the exclusionary criteria will be enrolled into the clinical study.   
Patients will be randomised 1:1 into one of two groups: either active treatment with CNM-Au8 30 mg 
or Placebo. All patients will receive their randomised oral treatment daily over thirty-six (36) 
consecutive weeks during the Treatment Period. For those who complete the Treatment Period and 
meet the required inclusion and exclusion criteria, an optional open-label extension period will be 
available for interested participants for up to and additional 48 weeks, which may be extended for 
additional 12-week increments until discontinued by the Sponsor. 
There will be four study periods: 
1. Up to a six (6) week screening period (Screening Period); 
2. A thirty-six (36) week blinded randomised treatment period (Treatment Period); 
3. An optional open-label extension period (Open-Label Period) that will remain active until 
discontinued by the Sponsor; 
4. A four (4) week safety follow-up period following completion of either the Treatment or Open-
Label period or in the case of Early Termination (Safety Follow-Up Period). 
Per protocol all patients will receive their blinded and randomised oral treatment daily over at least 36 
consecutive weeks during the Treatment Period.  Following the end of the Treatment Period patients 
may  elect to participate in the optional open-label extension (OLE) period. All participants will 
complete a Safety Follow-Up Visit four (4) weeks following their last dose of study medication. 
An independent DSMB will be responsible for monitoring the safety of the study on a periodic basis 
(e.g., Q16 weeks) and ad hoc at the request of the DSMB or the Sponsor (e.g., in the event of 
unexpected SAEs) to review data throughout the Treatment and OLE Periods. The DSMB may make 
recommendations on the conduct of the study, including study termination. Appropriate procedures 
will be detailed in a DSMB Charter. 
The study scheme is shown below in Figure 11. 
Figure 11.  Study Scheme 
 


 
 
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5 
INVESTIGATORS AND KEY STUDY PERSONNEL 
Key study personnel and investigators include the following:  
• 
Sponsor’s Medical Expert: 
Name: 
Robert Glanzman, MD, FAAN 
Title: 
Chief Medical Officer 
Address: 
6550 S. Millrock Drive 
Suite G50 
Salt Lake City, Utah 84121 
United States 
Email: 
robert@clene.com 
Telephone: +1  (801) 676 –9695 
• 
Chief Investigator 
Name: 
A/Professor Parvathi Menon PhD 
Title: 
Consultant Neurologist, Associate Professor in the Faculty of Medicine 
University of Sydney 
Address: 
Brain and Nerve Research Centre 
Concord Repatriation General Hospital 
Building 20, Hospital Road 
Concord  NSW 2139  
Australia 
Email: 
parmenon2010@gmail.com 
Telephone: +61 (2) 9767 8423 
• 
Chief Investigator 
Name: 
Dr. William Huynh 
Title: 
Consultant Neurologist 
Address: 
Brain and Mind Centre 
94 Mallet Street,  
Camperdown NSW  2050 
Australia 
Email: 
Email: william.huynh@sydney.edu.au 
Telephone: +61 (2) 9114 4250 
All other study personnel not included in this section are identified in a separate personnel list (not 
part of this clinical study protocol) as appropriate. This list will be updated as needed; an abbreviated 
version with personnel relevant for the centers will be available in each center’s Investigator site file. 
Whenever the term ‘Investigator’ is noted in the protocol text, it may refer to either the Principal 
Investigator at the site or an appropriately qualified, trained and delegated individual of the 
investigational site. 
The Principal Investigator of each site/study center must sign the protocol signature sheet before 


 
 
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patient recruitment may occur at the respective center. Similarly, all protocol amendments and/or 
revised integrated protocols must be signed and dated by the site’s Principal Investigator before 
coming into effect at the respective center. A complete list of all participating centers and their 
investigators, as well as all required signature documents, will be maintained in the Sponsor study 
file. 
Additional investigators and study sites may be added at the discretion of the Sponsor. 
 
 


 
 
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6 
STUDY ENDPOINTS 
6.1 
Efficacy Endpoints (Treatment Period) 
6.1.1 Primary Efficacy Endpoint 
The primary study endpoint is the change in the average difference between active treatment and 
placebo from Baseline through Week 36 for the summed MUNIXscore(4), which is the sum of the 
respective MUNIX values for the Abductor Digiti Minimi (ADM), Abductor Pollicis Brevis (APB), 
Biceps Brachii (BB), and Tibialis Anterior (TA).  The average baseline summed values will be 
indexed to 100% for each participant.  Changes will be calculated as the percent change from the 
Baseline index of 100%.     
Electromyography measurements for the MUNIX assessment will be taken in the least-clinically 
affected hand or limb, as applicable, identified at the Baseline visit.   
6.1.2 Secondary Efficacy Endpoint 
Key secondary efficacy endpoints include both a functional clinical endpoint and an 
electromyography endpoint as described below. The endpoints will be assessed hierarchically as 
follows: 
a. 
Mean change of the average difference between active treatment and placebo from Baseline 
to Week 36 for respiratory function as measured by Forced vital capacity (FVC). 
b. 
Mean absolute change of the difference between active treatment and placebo from Baseline 
through Week 36 for the MUNIXscore(4), which is the sum of the respective MUNIX values 
for the Abductor Digiti Minimi (ADM), Abductor Pollicis Brevis (APB), Biceps Brachii 
(BB), and Tibialis Anterior (TA). 
6.1.3 Exploratory Efficacy Endpoints 
Exploratory endpoints include both electromyography and functional clinical endpoints as described 
below. The hierarchical assessment and final exploratory endpoints will be detailed in the statistical 
analysis plan.  
6.1.3.1 
Exploratory Electromyography Endpoints 
Exploratory efficacy endpoints of electromyographic measurements of disease progression include 
assessment of Motor Unit Size Index (MUSIX), MScanMUNE, Split Hand Index (SI), and the 
Neurophysiological Index (NPI). 
6.1.3.1.1 MScanFit MUNE 
Mean change in the average difference between active treatment and placebo from Baseline through 


 
 
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Week 36 (overall difference at all time points) as measured by MScanFit MUNE (Jacobsen et al., 
2017) of the APB in the least clinically affected hand. The baseline average will be indexed to 100%, 
and changes at Week 12, 24 and Week 36 will be calculated as the percent change from the Baseline 
index of 100%. 
6.1.3.1.2 MUSIX 
Mean change in the average difference between active treatment and placebo from Baseline through 
Week 36 for the MUSIXscore(4) (Neuwirth et al., 2015), which is the mean of the respective MUSIX 
values for the ADM, APB, BB, and TA. The average baseline mean values will be indexed to 100%.  
Changes will be calculated as the percent change from the Baseline index of 100%. 
6.1.3.1.3 Split Hand Index 
Mean change in the average difference between active treatment and placebo from Baseline through 
Week 36 for the Split Hand Index (SI) (Menon et al., 2013), defined as the first dorsal interosseous 
(FDI)Peak CMAP Amplitude * APBPeak CMAP Amplitude/ADMPeak CMAP Amplitude. 
6.1.3.1.4 Neurophysiological Index 
Mean change in the average difference between active treatment and placebo from Baseline through 
Week 36 for the Neurophysiological Index (NPI) of the ADM (Cheah et al., 2011), defined as the 
ulnar nerve (ADMCMAP Peak Amplitude / ADMDistal Motor Latency) * ADMF-Wave (%). 
6.1.3.2 
Exploratory Clinical Efficacy Endpoints 
Exploratory clinical efficacy endpoints will include the following assessments: 
• 
Mean change between active treatment and placebo in the proportion of patients experiencing a > 
6-point decline in the ALSFRS-R between active treatment and placebo from Baseline to Week 
36. 
• 
Mean change in average ALSFRS-R score from Baseline to Week 36. 
• 
Mean change in slope of the decline of the ALSFRS-R from Baseline to Week 36. 
• 
Mean change between active treatment and placebo for the Combined Assessment of Function 
and Survival (CAFS) (Berry et al., 2013), a joint-rank analysis of function (ALSFRS-R) and 
overall survival from Baseline to Week 36. 
• 
Mean change between active treatment and placebo from Baseline to Week 36 in the proportion 
of patients experiencing ALS clinical composite disease progression defined as the occurrence of 


 
 
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death, tracheostomy, use of non-invasive ventilatory respiratory support, insertion of a 
gastrostomy tube, or a 6-point drop in the ALSFRS-R score. 
• 
Mean change in rate of disease progression defined as the average change in the DFS score ([Max 
ALSFRS-R minus current ALSFRS-R score]/symptom duration in months) from Baseline to 
Week 36. 
• 
Mean change in average difference between active treatment and placebo from Baseline to Week 
36 for: 
o ALSSQOL-Short Form questionnaire (ALSSQOL-SF) 
o Clinician’s Global Impression (CGI) 
o Patient’s Global Impression (PGI) 
• 
Difference in the proportion of patients utilizing health economic outcome measures from 
Baseline to Week 36. 
Additional exploratory efficacy parameters may be specified in the statistical analysis plan. 
6.1.4 Pharmacokinetic Endpoints 
Samples for the measurement of whole blood concentrations of Au will be collected every 12 weeks 
before (pre-dose) administration of the investigational drug product.  The data will be used to 
construct a composite whole blood concentration-time profile for the Q12 week visits over the 
randomised treatment period for the 30 mg QD dose.   
PK collection procedures are described in Section 9.3.4. 
Samples for the measurement of whole blood concentrations of Au will be collected before (pre-dose, 
and at 1, 2, 4, and 6 hours, after administration of the last dose of the investigational drug product at 
the Week 36 study visits.  The study site shall contact the patient and document the time at which the 
patient administered his/her prior day’s dose of study drug in order to impute a 24-hour trough value. 
The data will be used to estimate an apparent Cmax and Tmax and area under the curve (AUC) over 
the 24-hour dosing interval [AUC(0-24)]. 
6.1.5 Pharmacodynamic Endpoints 
Blood, plasma, and urine will be collected at Baseline and at the Week 12, Week 24, and Week 36 
visits per the schedule listed in Table 1.  Samples for the measurement of pharmacodynamic (PD) 
assays will be collected at baseline (pre-dose) and at each study visit, and stored for subsequent 
pharmacodynamic analyses.  PD collection procedures are detailed in Section 9.3.4.  PD analyses will 


 
 
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be specified in a separate PD analysis plan and may include additional assays not directly specified in 
Section 6.1.5. 
6.1.5.1 
Whole Blood Metabolomic Markers 
The PD analyses may include whole blood metabolomic markers for assessment of bioenergetic target 
engagement (e.g., redox coenzymes: NAD+, NADH, NADP+, NADPH; energetic coenzymes: ATP, 
ADP, AMP and antioxidants: GSSG and GSH).  Disease Progression Pharmacodynamic Markers in 
urine may include urinary neurotrophin receptor p75ECD levels (Shepheard et al., 2017) and plasma 
neurofilament light chain (NfL) levels (Poesen and Van Damme, 2018).   
6.2 
Open-Label Extension Endpoints 
6.2.1 Primary Safety Endpoint 
The primary endpoint for the OLE is safety. Safety endpoints include incidence of treatment-emergent 
AEs, drug-related AEs, deaths, SAEs, and AEs leading to discontinuation from the study. Changes 
from baseline (Week 36 of the placebo controlled phase) in clinical laboratory results, physical 
examination findings, vital signs, ECGs, and C-SSRS will be summarized descriptively by group and 
timepoint.  
6.2.2 Primary Efficacy Endpoint 
The primary efficacy endpoint for the OLE is the mean change from Baseline (Week 36 of the 
Treatment Period) through End of Study for the MUNIXscore(4), which is the mean of the respective 
MUNIX values for the Abductor Digiti Minimi (ADM), Abductor Pollicis Brevis (APB), Biceps 
Brachii (BB), and Tibialis Anterior (TA).  The average baseline mean values will be indexed to 100%.  
Changes will be calculated as the percent change from the Baseline index of 100%.   
Electromyography measurements for the MUNIX assessment will be taken in the same hand or limb, 
as applicable, identified during the Treatment Period.   
6.2.3 Secondary and Exploratory Efficacy Endpoints 
All secondary and exploratory efficacy endpoints described above in sections 6.1.2 through 6.1.6 will 
be included in the optional OLE. The data collected at the Week 36 visit of the Treatment Period will 
service and the participants Baseline value for the OLE Period. Mean change will be compared 
between the Baseline and End of Study visits.  
 


 
 
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7 
STUDY POPULATION 
The study selection criteria were chosen to exclude patients who may potentially be exposed to 
specific risks after administering the study drug as well as patients with conditions that may have an 
impact on assessing the objectives of the study. 
7.1 
Study Inclusion Criteria  
The patients to be enrolled in this study must meet the following inclusion criteria: 
1. Able to understand and give written informed consent. 
2. Male or female patients aged 30 years or greater (inclusive) and less than 80 years of age at 
the time of Screening. 
3. Patients whose conditions are defined as possible or probable or definite ALS per the 
diagnostic criteria by Awaji-Shima criteria as determined by a neurologist sub-specialising in 
ALS (e.g., the Principal Investigator by study site). 
4. For patients taking riluzole, stable dosing of riluzole over the prior 30-days from Screening. 
5. At the time of Screening either disease duration less than or equal to 24-months from 
symptom onset, or disease duration less than or equal to 12-months from diagnosis. 
6. Forced vital capacity (FVC) ³ 60% of predicted value as adjusted for gender, height, and age 
at the Screening Visit. 
7. Patient who has established care with a neurologist at one of the specialised ALS clinics 
involved in the study and will maintain this clinical care throughout the study.  If a patient is 
referred from a third party (neurologist or a State based ALS organisation) they must be 
willing to transfer care to the neurologist participating in the study. 
Following completion of the 36-week randomized placebo controlled phase of the trial, interested 
participants must meet the following inclusion criteria to enroll in the open-label extension: 
1. Participants must have completed the randomized placebo controlled Treatment Period 
without compliance issues. 
2. Able to understand and give written informed consent to participant in the open-label 
extension. 
3. If referred from a third party (neurologist or a State based ALS organisation), participant 
agrees to maintain transfer of care to a neurologist participating in the study. 
7.2 
Study Exclusion Criteria 
Patients will be excluded from the study if they meet any of the following criteria: 
1. At Screening patients who utilize, or in the Investigator’s judgment will be imminently 
dependent upon: 


 
 
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a. Non-invasive ventilation > 22 hours per day, or 
b. Tracheostomy 
Note: If the patient requires non-invasive ventilation post-randomisation, they will be allowed 
to continue in the study. 
2. Patients with Familial ALS (e.g., 2 or more family members with ALS or motor neuron 
disease) 
3. Patients with a history of carpal tunnel syndrome, polyneuropathy, or in the investigators 
judgement diseases that could induce polyneuropathy and interfere with electromyography 
(EMG) recordings. 
4. Patients with too severe atrophy of the Abductor Digiti Minimi (ADM), Abductor Pollicis 
Brevis (APB), Biceps Brachii (BB), or Tibialis Anterior (TA) muscles in the least clinically 
affected hand and leg, respectively, to allow for reliable EMG recordings. 
5. Patient with a history of significant other major medical conditions based on the 
Investigator’s judgment. 
6. Based on the investigator’s judgment, patients who may have difficulty complying with the 
protocol and/or any study procedures. 
7. Patient with clinically significant abnormalities in hematology, blood chemistry, ECG, or 
physical examination not resolved by the Baseline visit which according to Investigator can 
interfere with study participation. 
8. Patients with clinically significant hepatic or renal dysfunction or clinical laboratory findings 
that would limit the interpretability of change in liver or kidney function, or those with low 
platelet counts (< 150 x 109 per liter) or eosinophilia (absolute eosinophil count of ≥ 500 
eosinophils per microliter) at Screening. 
9. Patient participating in any other investigational drug trial or using investigational drug 
(within 12 weeks prior to screening and thereafter). 
10. Females who are pregnant or nursing or who plan to get pregnant during the course of this 
clinical trial or within 6 months of the end of this trial. 
11. Females of child-bearing potential, or men, who are unwilling or unable to use accepted 
methods of birth control. 
12. Active inflammatory condition or autoimmune disorder.  
13. Positive screen for drugs of abuse. 
14. History of gold allergy. 
15. Patient is considered a suicide risk in the opinion of the Investigator, has previously made a 
suicide attempt, or is currently demonstrating active suicidal ideation. Subjects with 
intermittent passive suicidal ideation are not necessarily excluded based on the assessment of 
the Investigator. 


 
 
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Following completion of the 36-week randomized placebo controlled phase of the trial, interested 
participants will be excluded from participating in the OLE phase if they meet any of the following 
criteria: 
1. Lack of treatment compliance during the randomized placebo controlled Treatment Period. 
2. Positive pregnancy test at the Week 36 visit, or, females who plan to get pregnant during the 
course of this extension or within 6 months of the end of this extension. 
3. Based on the investigator’s judgment, patients who may have difficulty complying with the 
protocol and/or any study procedures. 
4. Patient with clinically significant abnormalities in haematology, blood chemistry, ECG, or 
physical examination identified during the W36 visit which according to Investigator may 
interfere with continued participation. 
5. Patients with clinically significant hepatic or renal dysfunction or clinical laboratory findings 
that would limit the interpretability of change in liver or kidney function, or those with low 
platelet counts (< 150 x 109 per liter) or eosinophilia (absolute eosinophil count of ≥ 500 
eosinophils per microliter) at the Week 36 visit. 
6. Patient is considered a suicide risk in the opinion of the Investigator, has previously made a 
suicide attempt, or is currently demonstrating active suicidal ideation. Subjects with 
intermittent passive suicidal ideation are not necessarily excluded based on the assessment of 
the Investigator. 
7.3 
Reproductive Potential 
Female patients of child bearing potential should have a negative serum β-hCG pregnancy test at the 
Screening Visit (Visit -1) and a negative urine pregnancy test at the Baseline Visit (Visit 0) prior to 
randomization. Male and female patients must abstain from sexual activity that could result in 
pregnancy or agree to use acceptable methods of contraception during the study (both Treatment and 
OLE Periods) and for 6-months following their last dose. Condoms should be used with the following 
acceptable contraceptives: 
• 
Intrauterine devices 
• 
Hormonal contraceptives (oral, depot, patch, injectable, or vaginal ring). 
Other acceptable contraception methods are: 
• 
Double barrier methods (e.g., condoms and diaphragms with spermicidal gel or foam). 
All patients must be advised to use acceptable contraceptives throughout the study period(s) (both 
treatment and OLE) and for 180 days following the last dose of investigational product. If hormonal 
contraceptives are used, they should be administered according to the package insert. Male and female 
patients who are not currently sexually active must agree to use acceptable contraception, as defined 


 
 
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above, if they become sexually active during their participation and 180-days following the last dose 
of investigational product. 
7.4 
Removal of Patients from Therapy/Premature Discontinuation 
A patient may withdraw from the study at any time for any reason without prejudice to their future 
medical care by the physician or the institution. The Investigator or Sponsor may withdraw the patient 
at any time (e.g., in the interest of patient safety). The withdrawal of a patient from investigational 
product by the Investigator should be discussed where possible with the Medical Monitor before the 
patient stops the investigational product.  Any patient removed from the study will complete an end of 
treatment visit and remain under medical supervision until study discharge is medically acceptable.   
If the investigational product is prematurely discontinued, regardless of the reason, the final study 
evaluations are to be performed as completely as possible. The information should be collected in the 
eCRF until the safety follow-up visit 28 ± 5 days after the last intake of study drug. Adverse events 
that occur within 28 ± 5 days after the last dose of study drug will be followed up until resolution, if 
possible. 
All discontinued patients should also undergo the protocol-specified Safety Follow-Up Visit.  
Comments (spontaneous or elicited) or complaints made by the patient must be recorded in the 
appropriate source documents (e.g., an adverse event must be recorded and entered into the eCRF). 
The reason for termination, date of stopping investigational product, and the total amount of 
investigational product taken must be recorded on the electronic case report form (eCRF) and source 
documents for all discontinued patients. 
Patients will be encouraged to complete the study and all assessments.   
Patients will be discontinued from the study for the following medical and/or administrative reasons: 
• 
Patient request or at the request of the patient’s legally acceptable representative 
• 
Pregnancy, breast feeding, or repeat non-compliance with the scheduled pregnancy testing 
• 
The Investigator judges that continuation of the study would be harmful to the patient's well-
being 
• 
TEAE or SAE that limits the patient’s ability to continue the study 
• 
Treatment interruption for 35 days or more 
Patients may be discontinued from the study for the following medical and/or administrative reasons: 
• 
At the specific request of the Sponsor and in liaison with the Investigator (e.g., obvious non-
compliance, safety concerns) 
• 
If any exclusion criterion applies during the treatment periods 


 
 
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• 
Substantial non-compliance with planned study procedures 
• 
Use of illicit drugs or other substances that may, in the opinion of the Investigator have a 
reasonable chance of contributing to toxicity or otherwise confound the study results 
7.4.1 Patient Replacement 
Patients who withdraw or are withdrawn following administration of the investigational product will 
be replaced under this protocol at the discretion of the Sponsor and Investigator. 
7.4.2 Reasons for Discontinuation 
The reason for withdrawal must be determined by the Investigator and recorded in the patient’s 
medical record and on the eCRF. If a patient is withdrawn for more than one (1) reason, each reason 
should be documented in the source document and the most clinically relevant reason should be 
entered on the eCRF. 
If a TEAE is the reason for discontinuation, then TEAE must be recorded on the eCRF. 
Reasons for discontinuation include but are not limited to: 
• 
Adverse event 
• 
Protocol violation 
• 
Withdrawal by patient 
• 
Lost to follow-up 
• 
Lack of efficacy 
• 
Pregnancy 
• 
Other (must be specified) 
7.4.2.1 
Lost to Follow-Up 
At least 3 documented attempts must be made to contact any patient lost to follow-up at any time 
point prior to the last scheduled contact (office visit or telephone contact). One of these documented 
attempts must include a written communication sent to the patient’s last known address via courier or 
mail (with an acknowledgement of receipt request) asking that the patient return any unused 
investigational product and return to the site for final safety evaluations, as applicable. 
7.5 
Patient Identification 
After a patient has signed an informed consent form (ICF), the patient identification number for each 
patient will be assigned by site staff.  Patients will be identified by a unique number (e.g., 036-001-
001), which consists of: 


 
 
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• 
First three (3) digits: International Organization for Standardization (ISO) UN M49 Country 
code (e.g., Australia [036]) 
• 
Next three (3) digits:  Site code within the country (e.g., [001] Sydney Brain Mind Centre) 
• 
Last three (3) digits:  Current patient number within the center 
Patient identification numbers must be used in sequence and no number should be skipped, 
substituted, or re-used. Patients will retain their same identification number during the optional OLE 
Period.  
 
 


 
 
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8 
INVESTIGATIONAL DRUG PRODUCT 
8.1.1 Treatments Administered 
During the Treatment Period, patients will either receive CNM-Au8 30 mg or color-matched placebo 
in the study. Study drug will be self-administered by patients who will be directed to take the study 
drug each day in the morning (7:00 – 10:00 am) at approximately the same time (e.g., 8:00 a.m. ± 1 
hour), at least 30 minutes prior to planned food intake.  Patients will be instructed to hold their daily 
dose on days where they will report to the clinic for a study visit. The daily dose should be 
administered at the site following collection of the pre-dose PK/PD samples.  
The drug formulations will be identical in appearance (size, shape, volume, color) and smell. The 
packaging and labeling will be designed to maintain blinding to the Investigator’s team and to 
patients.  There are no visible differences between the 30 mg and placebo dosing units.   
During the OLE Period, all patients who choose to participate will receive open-label CNM-Au8 30 
mg for as long as the period is active. The dose for all patients may be adjusted once efficacy and 
safety data from the treatment period becomes available, which may occur after patients have already 
started this period. 
8.1.2 Identity of Investigational Products 
8.1.2.1 
CNM-Au8 
CNM-Au8 is a dark red/purple-colored liquid formulation consisting of a stable suspension of faceted 
clean surfaced elemental gold nanocrystals in buffered deionized water with a nominal concentration 
of 500 µg/mL of gold.  The formulation is buffered by sodium bicarbonate (NaHCO3), present at a 
concentration of 0.546 mg/mL.  The suspension is initially created as an in-process bulk suspension 
with a gold nanocrystal concentration of 5.5 – 8.5 mg/L, which is then further processed to increase 
the gold concentration up to 1000 mg/L.  The NaHCO3 is present to assist in the manufacturing 
process and the concentration of NaHCO3 remains nominally unchanged throughout processing.  The 
pH of the suspension is between 8.0 and 10.0.  There are no other excipients.  The drug product is 
formulated to be taken orally and will be provided in single dose HDPE containers. The study doses 
vary by the concentration of gold nanocrystals per milliliter in a volume of 60 mL as described in 
Table 15. 
The CNM-Au8 suspension is filtered using sterile, nonfiber-releasing 0.20 µm filters.  The filtration 
occurs in a clean room with either ISO 7 or ISO 8 standards (depending upon the specific room 
utilized).  The filtered solution is dispensed from the bulk container into clean, food-grade HDPE 
bottles. 


 
 
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The bottles will be labeled as described in Section 8.1.3. 
Manufacturing, testing, product characterization, release of CNM-Au8 will be carried out at the Clene 
Nanomedicine, Inc. facility at 500 Principio Parkway West, Suite 400, North East, MD 21901, USA.   
Table 15.  CNM-Au8 Investigational Product Dosing Administration 
CNM-Au8 
Dosage 
30 mg 
Nominal Concentration 
500 μg/mL 
Volume 
60 mL 
Route of Administration 
Oral 
Time and Frequency 
Once Daily; Same Time Each Day (± 1 hour) 
The investigational product components and quality standards are described in Table 16 below. 
Table 16.  CNM-Au8 Components and Quality Standards 
Description 
Quality Standard 
Concentration 
(mg/mL) 
Amount 
Per Liter 
NaHCO3 (mg/mL) 
USP 
0.546 
546 mg 
Au (mg/mL) 
Conforms with ASTM B562-95 and  
USP <232>  
0.5 
500 mg 
USP water 
USP for total organic carbon, and 
conductivity 
N/A 
1 L 
 
8.1.2.2 
Placebo 
The color matched placebo to be used in this study will consist of water, NaHCO3, and colorants.  
Manufacturing, testing, product characterization, and release of the investigational product will be 
carried out at the Clene Nanomedicine, Inc. facility at 500 Principio Parkway West, Suite 400, North 
East, Maryland 21901, USA  
Table 17. Matched Placebo Dosing Administration 
Placebo 
Dosage 
NA 
Au Concentration 
NA 
Volume 
60 mL 
Route of Administration 
Oral 
Time and Frequency 
Once Daily; Same Time Each Day (± 1 hour) 
 
The placebo components and quality standards are described below in Table 18. 
 
 


 
 
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Table 18.  Matched Placebo Components and Quality Standards 
Description 
Quality Standard 
Concentration 
(mg/mL) 
Amount 
Per Liter 
NaHCO3  
USP 
0.546 
546 mg 
FD&C Red 40 
Conforms with 21 CFR 74.340(a)(1) 
and (b) 
0.28 
280 mg 
FD&C Blue 1 
Conforms with 21 CFR 74.101(a)(1) 
and 74.101(b) 
0.03 
30 mg 
USP water 
USP for total organic carbon, and 
conductivity 
N/A 
1 L 
 
The placebo is made with the same process water that is used to make CNM-Au8.  The process water 
consists of deionized water supplemented with 0.546 mg/mL of NaHCO3.  The colors FD&C Red 40 
and FD&C Blue 1 are added to match the color profile of CNM-Au8. The placebo solution will be 
filtered using sterile, nonfiber-releasing 0.20 µm filters.  The filtration occurs in a clean room with 
either ISO 7 or ISO 8 standards (depending upon the specific room utilized).  The filtered solution 
will be dispensed from the bulk container into clean, food-grade HDPE bottles.  The bottles will be 
labeled as described below in Section 8.1.3. 
8.1.3 Labeling 
All investigational drug product will be labeled according to applicable local and legislative 
requirements. Label text will be approved according to the Sponsor’s agreed procedures, and a copy 
of the labels will be made available to the study site upon request. For all study drugs, a system of 
numbering in accordance with all requirements of Good Manufacturing Practice (GMP) will be used, 
ensuring that each dose of study drug can be traced back to the respective bulk ware of the 
ingredients. The Sponsor’s Quality Assurance group will maintain lists linking all numbering levels.  
A complete record of batch numbers and expiry dates of all study treatment as well as the labels will 
be maintained in the Sponsor study file. 
Study drug label may include, but is not limited to, the following information: 
• 
Batch number 
• 
Storage information 
• 
Site identification 
• 
Expiry date 
• 
Unique number/code 
• 
Study period 


 
 
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8.1.4 Storage and Handling 
Investigational product will be stored at the investigational site in accordance with Good Clinical 
Practice (GCP) and GMP requirements and will be inaccessible to unauthorized personnel. A 
complete record of batch numbers and expiry dates can be found in the Sponsor study file; the site-
relevant elements of this information will be available in the Investigator site file. The unblinded 
responsible site personnel (e.g., site study pharmacist) will confirm receipt of study drug to Sponsor’s 
designated production representative and will use the study drug only within the framework of this 
clinical study and in accordance with this protocol. Receipt, distribution, return and destruction (if 
any) of the study drug must be properly documented according to the Sponsor’s agreed and specified 
procedures. 
All study drug will be kept in a locked area with limited access and stored at 15°- 25°C (59°- 77°F). 
Mean kinetic temperature should not to exceed 25°C. Excursions between 15°C and 30°C (59° and 
86° F) that may be experienced in pharmacies, hospitals, or warehouses, and during shipping are 
allowed. 
8.2 
Method of Assigning Patients to Treatment Groups and Dose Selection 
8.2.1 Treatment Assignment/Randomisation 
Patients who complete all screening procedures and meet the eligibility criteria to enter the study will 
be randomised using a site specific pre-specified block randomisation scheme at a 1:1 allocation 
(CNM-Au8 30 mg:Placebo). Randomisation will be performed by an unblinded site designee (e.g., 
site study pharmacist) and kit dispensation will be facilitated by unblinded site personnel in a blinded 
manner to others who must remain blinded throughout the study (e.g. investigators, clinical 
coordinators and patients). Refer to the Pharmacy operations manual for additional details regarding 
stratification and site-level randomization. All patient who choose to participate in the optional open-
label extension period will received open-label CNM-Au8 30 mg regardless of their prior treatment 
assignment during the Treatment period.  
8.2.2 First In Human Dosing Experience 
The original planned CNM-Au8 dose levels in the first-time-in-human study were 15, 30, 60, and 90 
mg CNM-Au8. The initial dose level selected was calculated based on the FDA guidance document 
“Estimating the Maximum Safe Starting Dose in Clinical Trials for Therapeutics in Adult Healthy 
Volunteers”. The lowest NOAEL was in the rat and was 40 mg/kg. Based on this NOAEL, an 
equivalent human dose was determined to be approximately 6.4 mg/kg. In a 60-kg human patient, the 
selected starting dose of 15 mg CNM-Au8 represented a safety margin of approximately 26-fold. 


 
 
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The protocol for Study AU8.1000-14-01 was submitted to an Independent Ethics Committee and 
Competent Authority in the Netherlands and was subsequently approved for initiation under a Clinical 
Trial Application (CTA). The study was conducted in the Netherlands, at a Phase 1 facility, The 
Center for Human Drug Research (CHDR) and has been completed. 
A total of 40 patients were randomised in the SAD phase and 46 patients in the MAD phase. Oral 
administration of either a single (SAD) or repeated dose (MAD) of CNM-Au8 over 21 consecutive 
days in healthy volunteers was safe and well tolerated. The TEAEs observed across the 4 doses (15 
mg, 30 mg, 60 mg, and 90 mg) of CNM-Au8 were mostly mild in severity. While no dose response 
relationship to TEAEs was observed overall in the SAD or MAD Phase of the study, increases in 
headache and gastrointestinal related TEAEs were observed in the 90 mg cohort of the MAD Phase.  
No safety trends or safety signals were observed in the study.   
In the SAD phase, PK analyses were not completed because the majority of whole blood AU 
concentrations were below the LOQ.  However, a more sensitive ICP-MS instrument was employed 
for the MAD phase.  
In the MAD Phase:  
• 
The geometric mean whole blood concentrations from 1 week onward increased in a 
dose˗related, but not a dose-proportional manner. Based on PK results from Days 14 and 21, 
the increases in both Cmax and AUC(0-24) were less than dose proportional. 
• 
Based on pre-specified fit criteria, the elimination t½ ranged from 277 to 628 hr (11.5 to 26.2 
days). 
• 
Steady-state for all cohorts, based on the geometric mean whole blood concentrations, was 
reached by the end of the second week of dosing (Day 14), which was substantially less than 
predicted by the t½ [range of 46 to 105 days (6.6 to 15 weeks)]. 
• 
PK parameters related to urinary excretion (Ue, CLr) could not be calculated. Only one urine 
Au concentration ≥ LOQ (3 ng/mL) was within limits of the assay. 
8.2.3 
Human Dosing Safety Margins vs. Nonclinical Toxicokinetic Data 
Based upon the maximum doses (mg/kg/day) evaluated in the nonclinical GLP repeat-dose 21-day 
toxicokinetic studies, the completed first-time-in-human Phase 1 study (AU8.1000-14-01) doses of 
15, 30, 60, 90 mg provided a safety margin to the NOAEL based on dose ratios (mg/m2) ranging from 
26x – 4x in rodents, and 195x – 32x in canines, as described in the tables below.  Therefore, at the top 
dose of 90 mg tested in humans, there was a minimum 4x safety margin to the NOAEL in rats.  
 
 


 
 
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Table 19. Summary of CNM-Au8 Conversion of Animal 21-Day Repeat Doses To Human 
Equivalent Dose (HED) Based On Body Surface Area (mg/m2) for 60 kg Human 
Further, when evaluating Au exposure based on the end of study Day 21 AUC(0-24) (ng*hr/mL) in the 
canine, and rodent studies in comparison with the human 21-day MAD study, the human doses 
provided an exposure safety margin ranging from 3.3x – 1.6x  compared with rodents, and 18.5x – 
9.0x compared with canines, as described in Table 20 below. 
Table 20. Summary of CNM-Au8 Exposure Safety Margin Based on End of Study AUC(0-24) 
ng*hr/mL.  Ratio of Animal Toxicokinetic to Human Pharmacokinetic AUC Results From 21-
Day Repeat Dose Studies.  
CNM-Au8 exposure at the NOAEL at the end of the chronic toxicokinetic studies in the 9-Month 
canine and 6-Month rodent chronic dosing studies, provided an exposure safety margin ranging from 
6.5x – 3.2x, and 13.6x – 6.7x in rodents and canines, respectively in comparison with the human 
exposures in the 21-day MAD study, as described below in Table 21.  
 
 
Species 
21-Day 
NOAEL 
Dose 
(mg/kg/day) 
21-Day 
NOAEL 
Dose 
(mg/m2) 
Safety Margin Based on Dosing Ratios (mg/m2) 
(For 21-Day dosing Studies) 
15 mg 
(9.3 
mg/m2) 
30 mg 
(18.5 
mg/m2) 
60 mg 
(37.0 
mg/m2) 
90 mg 
(55.5 
mg/m2) 
Rat 
40 
240 
25.9 
13.0 
6.5 
4.3 
Canine 
90 
1800 
194.6 
97.3 
48.6 
32.4 
 
Species 
 
21-Day 
NOAEL 
Dose 
(mg/kg/day) 
Animal 
End of Study 
AUC(0-24) 
(ng*hr/mL)a 
Safety Margin Based on Animal/Human AUC(0-24) 
Ratio (For 21-Day Dosing Studies) 
Human 
15 mg 
AUC 
(32.3 
ng*hr/mL) 
Human 
30 mg 
AUC 
(41.4 
ng*hr/mL) 
Human 
60 mg 
AUC 
(50.3 
ng*hr/mL) 
Human 
90 mg 
AUC 
(66.0 
ng*hr/mL) 
Rat 
40 
106 
3.3 
2.6 
2.1 
1.6 
Canine 
90 
596 
18.5 
14.4 
11.8 
9.0 
Notes: a Average of Male and Female AUC(0-24) ng*hr/mL values at End of Study 


 
 
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Table 21.  Summary of CNM-Au8 Exposure Safety Margin Based on End of Study AUC(0-24) 
ng*hr/mL Ratio of Chronic Animal Toxicokinetic 6 and 9-Month Rodent and Canine Repeat 
Dose Studies to Human 21-Day Pharmacokinetic Results  
 
Based on CNM-Au8 exposures at the NOAELs in the chronic rodent and canine studies along with 
observed CNM-Au8 exposures in 21-day multiple dosing in humans while also considering safety and 
tolerability, doses chosen for this Phase 2 study in patients with ALS is 30 mg. This doses encompass 
the range of exposures from rodent toxicokinetic (TK) studies seen at the same dose used in the 
preclinical demyelination models at 10 mg/kg, where significant neuroprotection was observed per 
Figure 12.  
 
Figure 12.  21-Day AUC Exposure Ranges Between Rodent Toxicokinetic Studies, Preclinical 
Efficacy Models, and First-In-Human Dosing 
 
8.3 
Procedures for Blinding 
Patients will be randomised to receive CNM-Au8 or matching placebo in a double-blind fashion. The 
study data will remain blinded until database lock and authorisation of data release according to 
standard operating procedures (SOPs).  More specifically, the blinding of study medication will be 
maintained until the last visit has been completed and all study databases have been locked.  
30.6
32.3
41.4
50.3
66.0
0
25
50
75
100
TK Rat
10 mg/kg
Human
15 mg
Human
30 mg
Human
60 mg
Human
90 mg
AUC (0-24 hrs)
(hr*ng/mL)
AUC (0-24 hr) at End of Study (Day 21)
(hr*ng/mL; Geometric Mean)
Neuroprotection 
Efficacy at 
10 mg/kg
First-In-Human Study 
AU8.1000-14-01 
TK Study*
CNAU-MPI-15-01
*Average of Male and Female AUC(0-24) ng*hr/mL values
 
Species (Study) 
 
NOAEL  
Chronic 
Dosing 
(mg/kg/day) 
Animal 
End of 
Study 
AUC(0-24) 
(ng*hr/m
L)a 
Safety Margin Based on Chronic Animal End-of-Study/ 
Human 21-Day AUC(0-24) Ratio 
Human 
15 mg AUC 
(32.3 
ng*hr/mL) 
Human 
30 mg AUC 
(41.4 
ng*hr/mL) 
Human 
60 mg AUC 
(50.3 
ng*hr/mL) 
Human 
90 mg AUC 
(66.0 
ng*hr/mL) 
Rat (6-Month) 
40 
209 
6.5 
5.0 
4.2 
3.2 
Canine (9-Month) 
10 
440 
13.6 
10.6 
8.7 
6.7 
a Average of Male and Female AUC(0-24) ng*hr/mL values  at End of Study 


 
 
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The block randomisation code for each site will be generated by the study statistician and securely 
shared with the unblinded study site personnel (e.g., site study pharmacist).  The randomisation code 
will be kept under secure conditions to not reveal the treatment assignments to the Sponsor, 
Investigators, clinical staff, or patients.  The pharmacist at each site may maintain a secured copy of 
the randomisation code according to the site’s SOP and dispense medication based on the 
randomisation scheme for each patient, and for emergency unblinding in the case it is required. An 
unblinded clinical research associate or study monitor will reconcile study drug assignment and 
allocation during specified monitoring visits. 
8.3.1 Unblinding 
The treatment allocation of a patient will be made available to the Investigator in case of emergency 
and when knowledge of the treatment allocation is important in the medical management of AEs. All 
unblinding events must be reported to the IRB/HREC in accordance with IRB/HREC timelines.  
Unblinding may occur in the circumstances as specified within the sub-sections below. 
8.3.1.1 
Unblinding by Sponsor’s Pharmacovigilance Representative 
In compliance with applicable regulations, in the event of a suspected unexpected serious adverse 
reaction (SUSAR), which is deemed related to blinded treatment, the patient’s treatment code may be 
unblinded by the Sponsor before reporting to the health authorities, HRECs, IRBs, and investigators if 
the SUSAR is related to the blinded treatment. 
8.3.1.2 
Emergency Unblinding By The Investigator 
In case of emergency and where knowledge of assigned treatment allocation is required for the acute 
management of a TEAE, the Investigator may unblind the case via the unblinded site pharmacist. 
Investigators should note that the occurrence of an AE or SAE should not routinely precipitate the 
immediate unblinding. If possible, the Investigator should always consult with the Medical Monitor 
prior to breaking the blind.  The Investigator must contact the Medical Monitor in the event that the 
blind is broken and document the reason for unblinding. 
8.3.1.3 
Unblinding For Ongoing Safety Monitoring 
In order to allow an ongoing safety monitoring during the conduct of the study by an external DSMB, 
members of the Committee will receive unblinded safety data on a quarterly or ad hoc basis. The 
involvement of an external Statistical Analysis Center in this process will ensure that unblinded 
information is not available for third parties. Details of the process are described in the DSMB 
charter. 


 
 
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8.4 
Prior and Concomitant Therapy 
Disease-specific medications (e.g., riluzole) are allowed per the inclusion criteria. 
Except for disease specific medications (e.g., riluzole), acetaminophen (paracetamol), ibuprofen, 
naproxen, and 2nd generation antihistamines (including fexofenadine, loratadine, and cetirizine); 
patients may not take any new prescription medications, OTC, or dietary supplements from 14-days 
prior to Baseline through the safety follow-up (including the OLE) unless used to manage a treatment 
emergent adverse event, in which case the patient should report to his/her Study Physician as soon as 
possible, the occurrence of the adverse event and the medication(s) they are taking to treat the adverse 
event. 
The Investigator will make every effort to contact the Medical Monitor or Sponsor representative 
prior to administration of a new concomitant therapy (prescription or OTC) after randomisation, 
unless the concomitant therapy is needed immediately for patient safety. 
Any use of new prescription medicines, OTC medications, or dietary supplements during the study 
period must be reported on the eCRF. 
8.5 
Treatment Compliance 
Patients will receive study drug dispensed per visit schedule in Table 1 during the Treatment Period 
and Table 2 during the Open-Label Extension Period.  
To facilitate treatment compliance patients may be reminded daily to take their investigational 
medicine with automated email and/or mobile text message reminders.  The administration of the 
automated reminder program will be per the Investigator, authorized clinical site personnel, or the 
CRO.     
Patients will be requested to return any unused study drug including empty packaging and used bottles 
at each study visit.  Treatment compliance will be assessed at study visits through bottle counts and 
will be documented and summarized by a drug-dispensing log for each patient.  A web-based or 
mobile application compliance tool may also be utilized to collect supportive information regarding 
daily intake of the investigational medicine.  Overall treatment compliance with study drug intake for 
the per protocol analysis set should be between 80% and 120% of the planned dose and will be 
assessed at each study visit.  In the event patients are not compliant within this range, discontinuation 
may be considered by the Investigator in consultation with the Sponsor. 
The date of dispensing the study drug to the patient will be documented in the eCRF. 


 
 
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If a dose of study drug is missed, the patient should take the dose that day and continue with the 
planned dosing interval for the following day. The dose should not be doubled to make up for a 
missed dose within the same day. 
8.5.1 Study Drug Accountability 
Study drug will be administered in accordance with the procedures of this protocol.  Only authorized 
site personnel may supply study drug, and only patients enrolled in the study may receive study drug, 
in accordance with applicable regulatory requirements. 
Blinded CRO representatives will perform ongoing drug accountability assessments during planned 
interim study monitoring visits.  A different designated unblinded CRO representative who is not 
involved in routine study monitoring will reconcile study drug assignment and allocation by the site 
study pharmacist on a periodic basis.  Following the specific unblinded monitoring visits by the 
designated unblinded CRO representative, unused study drug and empty containers may be destroyed 
per Section 12.1.8.  Final reconciliation and full drug accountability will be completed by site 
personnel, pharmacy staff, and will be assessed by Sponsor or designee after the study blind is broken. 
8.6 
Data Safety Monitoring Board 
An independent Data Safety Monitoring Board (DSMB) will be responsible for monitoring the safety 
of the study on a trimester basis and ad hoc at the option of the DSMB or the Sponsor (e.g. in the 
event of unexpected SAEs) to review data throughout study. The DSMB may make recommendations 
on the conduct of the study, including study termination. Appropriate procedures will be detailed in a 
DSMB Charter that defines disclosure of any findings along with patient and study-stopping criteria. 
 
 


 
 
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9 
STUDY PROCEDURES 
9.1 
Study Schedule (Treatment Period) 
A Time and Events Schedule is provided in Table 1 for the blinded, randomized controlled Treatment 
Period. 
Screening may occur on Days -42 through -1. Of note, there is not a minimum required screening 
duration, so study subjects may be randomised into the study at any time within the 42-day screening 
window if they meet the study enrolment criteria. 
The Baseline visit will occur on Day 1. The treatment period will include Day 1 through the last dose 
of study medication. 
9.1.1 Screening Phase (Day -42 through Day -1) – VISIT (-1) 
The initial Screening Visit may be conducted up to 42 days prior to Baseline on Day 1.  The following 
procedures/assessments will be performed at Screening: 
• 
Informed consent (must be done prior to any of the following procedures) 
• 
Medical history and patient demographics (confirm ALS diagnosis) 
• 
Prior and current medication assessment 
• 
Physical examination 
• 
Brief neurological exam 
• 
Confirm patient meets all eligibility criteria  
• 
Height and weight assessment 
• 
Vital Signs 
• 
Urinalysis 
• 
Urine drug screen (cocaine, marijuana, opiates, benzodiazepines, amphetamines) 
• 
Venous blood for clinical laboratory tests 
• 
Venous blood for infectious disease screen (HIV, hepatitis B, and hepatitis C) 
• 
Serum pregnancy test (for females of childbearing potential) 
• 
12-Lead ECG  
• 
ALSFRS-R 


 
 
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• 
FVC 
• 
Adverse Events 
• 
C-SSRS (Baseline Version) 
• 
Schedule next study visit (Baseline Visit) 
9.1.2 Baseline (Day 1) – VISIT 0 
Prior to performing any Baseline assessment, all screening assessments and reports must be reviewed 
and signed by an Investigator. Patients will present to the study site for the Baseline assessments prior 
to dosing initiation, all Baseline assessments must be performed prior to administration of the first 
dose of study drug. The following assessments are to be completed at or by the Baseline visit: 
• 
Re-confirm patient meets all eligibility criteria 
• 
Physical exam 
• 
Brief neurological exam 
• 
Concomitant medication assessment 
• 
Vital signs 
• 
Weight 
• 
12-Lead ECG in triplicate  
• 
Urine pregnancy test (for females of childbearing potential) 
• 
Randomisation 
• 
Venous blood for clinical laboratory tests 
• 
PD whole blood, plasma, and urine collection 
• 
Urinalysis 
• 
Electromyography (Standard EMG: MUNIX, MUSIX, F-Wave, CMAP, DML) 
• 
Electromyography (MScan of APB) 
• 
ALSFRS-R 
• 
ALSSQOL-SF 
• 
FVC 


 
 
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• 
Health Utilisation 
• 
Patient’s Global Impression Scale (Severity) 
• 
Clinician’s Global Impression Scale (Severity) 
• 
C-SSRS (Since Last Visit Version) 
• 
Adverse events 
• 
Dispense Study Drug Package  
• 
Take First Study Dose at the Site from the dispensed supply (following all Baseline 
assessments) 
• 
Schedule next study visit 
9.1.3 Treatment Phase (VISIT 1 through VISIT 7) 
Following the Baseline Visit, patients will either be contacted via telephone or will return to the study 
site for evaluations of safety and efficacy as outlined in Table 1. 
9.1.3.1 
Treatment Period – VISIT 1, 2, 4, and 6 (WEEK 3, 6, 18, and 30) 
At Weeks 3, 6, 18, and 30, clinical site staff will contact patients by telephone and assess for the 
following items: 
• 
Adverse Events 
• 
Concomitant medication assessment 
• 
Treatment compliance assessment 
• 
Confirm scheduling of next visit 
9.1.3.2 
Treatment Period – VISITS 3, 5, and 7 
All patients will participate in the study for a minimum of 36-weeks per protocol. 
Study activities for Visits 2, 3, and 4 at Weeks 12, 24, and 36 include: 
• 
Brief physical exam 
• 
Brief neurological exam 
• 
Concomitant medication assessment 
• 
Vital signs 
• 
Weight 


 
 
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• 
12-Lead ECG 
• 
Urine pregnancy test (for females of childbearing potential) 
• 
Venous blood for clinical laboratory tests 
• 
PD blood, and urine collection 
• 
PK whole blood sample(s) 
• 
Urinalysis 
• 
Electromyography (Standard EMG: MUNIX, MUSIX, F-Wave, CMAP, DML) 
• 
Electromyography (MScan of APB) 
• 
ALSFRS-R 
• 
ALSSQOL-SF 
• 
FVC 
• 
Health Utilisation 
• 
Falls Questionnaire 
• 
Patient’s Global Impression Scale (Severity and Improvement) Clinician’s Global Impression 
Scale (Severity and Improvement)C-SSRS (Since Last Visit Version) 
• 
Adverse events 
• 
Dispense Study Drug Package  
• 
Take Study Dose at the Site from the dispensed supply (following all Baseline assessments) 
• 
Schedule next study visit  
9.1.3.3 
Safety Follow-up Visit – Week 40 
Timing for the safety follow-up visit should occur at 28-days (±5 days) following study 
discontinuation for: 1) patients who discontinue therapy prior to Week 36, or 2) who do not transition 
to the optional OLE period.   
Study activities during the follow-up visit include: 
• 
Brief physical exam 
• 
Brief neurological exam 


 
 
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• 
Vital signs 
• 
Venous blood and urine for clinical laboratory tests 
• 
Concomitant medication assessment 
• 
Adverse events 
• 
C-SSRS (Since Last Visit Version) 
• 
Return Study Drug Package (if discontinued prior to the Week 36 visit) 
Any AEs/SAEs occurring up to the time of the Follow-up visit will be recorded. Appropriate follow-
up should continue until all safety concerns, in the Investigator’s opinion, are resolved, or return to 
baseline. 
9.2 
Study Schedule (Open-Label Extension Period) 
A Time and Events Schedule is provided in Table 1 for the optional Open-Label Extension (OLE) 
Period. 
The assessments performed during the Week 36 visit of the Treatment Period will serve as the 
Baseline values for the optional OLE Period. The OLE Period is planned to run for up to 48 weeks 
beyond the 36-week treatment period, which may be extended for additional 12-week increments until 
until discontinued by the Sponsor. For patients who enter the OLE Period 12-weeks or more after 
completing their Treatment Period, the assessments indicated in Table 2 will be repeated to serve as 
their respective Baseline values.  
9.2.1 OLE Baseline (Day 1) – Visit 0 
Prior to dispensing open-label CNM-Au8, patients must provide consent to participate in the OLE 
period and eligibility should be confirmed. The following assessments are to be completed at or by the 
Baseline visit: 
• 
Obtain informed consent for OLE period 
• 
Confirm patient meets all eligibility criteria 
• 
Brief physical exam (collected during W36 visit) 
• 
Brief neurological exam (collected during W36 visit) 
• 
Concomitant medication assessment (collected during W36 visit) 
• 
Vital signs (collected during W36 visit) 


 
 
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• 
Weight (collected during W36 visit) 
• 
12-Lead ECG (collected during W36 visit) 
• 
Urine pregnancy test (for females of childbearing potential) (collected during W36 visit) 
• 
Venous blood for clinical laboratory tests (collected during W36 visit) 
• 
PD blood, and urine collection (collected during W36 visit) 
• 
PK whole blood sample(s) (collected during W36 visit) 
• 
Urinalysis (collected during W36 visit) 
• 
Electromyography (Standard EMG: MUNIX, MUSIX, F-Wave, CMAP, DML) (collected 
during W36 visit) 
• 
Electromyography (MScan of APB) (collected during W36 visit) 
• 
ALSFRS-R (collected during W36 visit) 
• 
ALSSQOL-SF (collected during W36 visit) 
• 
FVC (collected during W36 visit) 
• 
Health Utilisation (collected during W36 visit) 
• 
Falls Questionnaire (collected during W36 visit) 
• 
Patient’s Global Impression Scale (Severity and Improvement) Clinician’s Global Impression 
Scale (Severity and Improvement)C-SSRS (Since Last Visit Version) (collected during W36 
visit) 
• 
Adverse events (collected during W36 visit) 
• 
Dispense Study Drug Packages 
• 
Take Study Dose at the Site from the dispensed supply (following collection of informed 
consent) 
• 
Schedule next study visit  
9.2.2 OLE Period – Visit 1 (Week 6) 
At Week 6 of the OLE Period, clinical site staff will contact patients by telephone and assess for the 
following items: 
• 
Adverse Events 
• 
Concomitant medication assessment 


 
 
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• 
Treatment compliance assessment 
• 
Confirm scheduling of next visit 
9.2.2.1 
OLE Period – Visits 2, 4, 6, and n+2 (Weeks 12, 36, 60, and n+24) 
Study activities for Weeks 12, 36, 60 and every 24 weeks thereafter include: 
• 
Brief physical exam 
• 
Brief neurological exam 
• 
Concomitant medication assessment 
• 
Vital signs 
• 
Urine pregnancy test (for females of childbearing potential) 
• 
Venous blood for clinical laboratory tests 
• 
Urinalysis 
• 
ALSFRS-R 
• 
ALSSQOL-SF 
• 
FVC 
• 
Health Utilisation 
• 
Falls Questionnaire 
• 
Patient’s Global Impression Scale (Severity and Improvement) Clinician’s Global Impression 
Scale (Severity and Improvement) C-SSRS (Since Last Visit Version) 
• 
Adverse events 
• 
Drug Accountability  
• 
Dispense Study Drug Packages  
• 
Take Study Dose at the Site from the dispensed supply (following all assessments) 
• 
Schedule next study visit  
9.2.2.2 
OLE Period – Visits 3, 5, 7 and n+2 (Weeks 24, 48, 72 and n+24) 
Study activities for Weeks 24, 48, 72 and every 24 weeks thereafter include: 
• 
Brief physical exam 


 
 
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• 
Brief neurological exam 
• 
Concomitant medication assessment 
• 
Vital signs 
• 
Weight 
• 
12-Lead ECG 
• 
Urine pregnancy test (for females of childbearing potential) 
• 
Venous blood for clinical laboratory tests 
• 
PD blood, and urine collection 
• 
PK whole blood sample(s) 
• 
Urinalysis 
• 
Electromyography (Standard EMG: MUNIX, MUSIX, F-Wave, CMAP, DML) 
• 
Electromyography (MScan of APB) 
• 
ALSFRS-R 
• 
ALSSQOL-SF 
• 
FVC 
• 
Health Utilisation 
• 
Falls Questionnaire 
• 
Patient’s Global Impression Scale (Severity and Improvement) Clinician’s Global Impression 
Scale (Severity and Improvement) C-SSRS (Since Last Visit Version) 
• 
Adverse events 
• 
Drug Accountability 
• 
Dispense Study Drug Packages  
• 
Take Study Dose at the Site from the dispensed supply (following all assessments, excluding 
last visit) 
• 
Schedule next study visit  


 
 
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9.2.2.3 
Safety Follow-Up Visit – 4 weeks following last visit 
Timing for the safety follow-up assessment should occur at 28-days (±5 days) following last dose of 
study drug administer for those who participate in the optional OLE period.  
Study activities during the follow-up visit include: 
• 
Brief physical exam 
• 
Brief neurological exam 
• 
Vitals 
• 
Venous blood and urine for clinical laboratory tests 
• 
Concomitant medication assessment 
• 
Adverse events 
• 
C-SSRS (Since Last Visit Version) 
• 
Return Study Drug Package (if discontinuing prior to completion) 
9.3 
Study Measurements and Assessments 
Measurements and assessments are to be performed according to the schedule shown in Table 1 for 
the Treatment Period and Table 2 for the OLE Period. 
Measurements and assessments should only be performed by trained and qualified personnel and 
whenever possible, the same person at each site should perform each of these assessments for all 
Patient visits. 
If a patient terminates treatment prematurely, all assessments listed in Table 1 or Table 2 for the 
safety follow-up should be completed 28 days (±5 days) from date of last dose. 
9.3.1 Demographic and Other Baseline Characteristics 
Demographic characteristics such as age, sex, weight, height, ethnicity, and body mass index (BMI) 
will be collected during the study according to the schedule in Table 1. 
9.3.2 Assessment of Efficacy 
Efficacy will be assessed at each visit noted in the Study Schedules (Table 1 and Table 2) using the 
measures described below. All efficacy measurements are to be performed by a trained and qualified 
person. 


 
 
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To standardize acquisition data across study sites, healthy volunteers may participate during site 
training, data acquisition, and test transfer to the central reading centres for the electromyography 
assessments described below.  
9.3.2.1 
Electromyography Data Collection 
Electromyography data collection will occur in the least-clinically affected hand/limb identified at the 
Baseline visit in the Abductor Digiti Minimi (ADM), Abductor Pollicis Brevis (APB), Biceps Brachii 
(BB), Tibialis Anterior (TA), and the First Dorsal Interosseous per Table 22. 
Table 22. EMG Data Collection Plan 
Least Clinically Affected 
Hand/Limb 
EMG Sequence 
Muscle 
Abbr 
Standard EMG 
MScan  
MUNIX + 
MUSIX 
CMAP Peak 
Amplitude 
Distal Motor 
Latency 
F-
Wave/ 
Latency 
CMAP 
Stimulus 
Response  
Hand 
Abductor 
Pollicis Brevis 
APB 
X 
X  
X 
X 
X 
First Dorsal 
Interosseous 
FDI 
X 
X 
X 
 
 
Abductor 
Digiti Minimi 
ADM 
X 
X 
X 
X 
 
Arm 
Biceps  
Brachii 
BB 
X 
X 
X 
 
 
Leg 
Tibialis 
Anterior 
TA 
X 
X 
X 
X 
 
Est. Time per Visit 
~25-30 min 
~6-8 min 
9.3.2.2 
MUNIX 
The Motor Unit Number Index (MUNIX) is quantitative neurophysiological method that reflects loss 
of motor neurons in ALS in longitudinal studies (Neuwirth et al., 2018). MUNIX assessment employs 
an electromyography stimulation of compound muscle action potential (CMAP) and the surface 
electromyography interference pattern (SIP) and then uses a mathematical model to derives an index 
related to the number of motor units (Nandedkar et al., 2010). MUNIX requires minimal electrical 
stimulation, is highly reproducible in healthy volunteers and ALS patients, and is suitable for serial 
EMG investigations (Nandedkar et al., 2004; Neuwirth et al., 2010).   
EMG data collection for assessment of MUNIX will be conducted at the Baseline Visit and at the 
Week 12, Week 24, and Week 36 visits during the Treatment Period and every 24 weeks during the 
OLE Period.  The MUNIXscore(4), the mean of the MUNIX values for the APB, ADM, BB, and TA 
is the study primary efficacy endpoint. 


 
 
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9.3.2.3 
MScan and MScan Fit 
In MScan, after recording a maximal CMAP by stimulating the median nerve at the wrist, an 
electrical stimulus is applied and gradually reduced from supramaximal level to subthreshold in 0.2% 
steps to generate a detailed and inverted stimulus–response curve or CMAP scan (Bostock, 2016; 
Jacobsen et al., 2018). The stimulus–response curve describes the amplitude of the motor response as 
a function of stimulus current, due to recruitment of more and more motor units with increasing 
stimulus intensity. The stimulus–response curve describes the amplitude of the motor response as a 
function of stimulus current, due to recruitment of more and more motor units with increasing 
stimulus intensity. In MScanFit, a model is then fitted to the recorded stimulus response curve scan 
data to obtain an estimate of the number of motor units (motor nerves) in the specific nerve. The 
stimulus-response curves will be analysed in customized software [Qtrac software program, Institute 
of Neurology, University College, London), and from this model the number of motor units, mean 
amplitude of motor units and the amplitude of the largest motor unit (a biomarker of re-innervation) 
will be derived according to established methodology (Bostock, 2016; Jacobsen et al., 2017, 2019) 
MScan will be conducted at the Baseline Visit and at the Week 12, Week 24, and Week 36 visits 
during the Treatment Period and every 24 weeks during the OLE Period.  The MScanFit is a 
secondary efficacy endpoint. 
9.3.2.4 
MUSIX 
The Motor Unit Size Index (MUSIX) is obtained by dividing MUNIX into CMAP amplitude: 
CMAPamplitude/MUNIX. MUSIX is measured in microvolts (µV) and reflects the average amplitude of 
the surface-recorded motor unit potential (SMUP) (Nandedkar et al., 2010). Accordingly, MUSIX is 
an electromyographic index for size of motor units and not their absolute values. Since the rate of 
symptom progression in neuromuscular diseases such as ALS is determined by both the amount of 
axon loss and effective reinnervation, the MUSIX measurement therefore represents the 
compensatory reinnervation process in neuromuscular disorders, which may reveal important 
information on the natural course of such conditions and the response to new treatments (Alix et al., 
2019). 
EMG data collection for assessment of MUSIX will be conducted at the Baseline Visit and at the 
Week 12, Week 24, and Week 36 visits during the Treatment Period and every 24 weeks during the 
OLE Period.  The MUSIXscore(4), the mean of the MUSIX values for the APB, ADM, BB, and TA is 
a secondary efficacy endpoint. 
9.3.2.5 
Neurophysiological Index (NPI) 
The neurophysiological index (NPI) was developed to quantify peripheral disease burden in ALS 


 
 
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patients (Cheah et al., 2011). NPI has been shown to be more responsive to disease progression over a 
short measurement period than the ALSFR-S, together with moderate correlation with functional 
deterioration.  The NPI is defined as the ulnar nerve (ADMCMAP Peak Amplitude / ADMDistal Motor Latency) * 
ADMF-Wave (%). 
EMG data collection for assessment of NPI will be conducted at the Baseline Visit, and at the Week 
12, Week 24, and Week 36 visits during the Treatment Period and every 24 weeks during the OLE 
Period.  The NPI a secondary efficacy endpoint. 
9.3.2.6 
Split Hand Index (SI) 
Dissociated atrophy of intrinsic hand muscles, including the abductor pollicis brevis (APB) and first 
dorsal interosseous (FDI), with relative preservation of the hypothenar muscles, the split hand sign 
appears to be an early clinical feature of ALS (Menon et al., 2013). The clinical observation of 
dissociated hand muscle atrophy a simple neurophysiological biomarker for evaluating ALS. The 
split-hand index (SI) was derived by multiplying the compound muscle action potential (CMAP) 
amplitude recorded over the APB muscle by the CMAP amplitude recorded over the FDI muscle and 
dividing this product by the CMAP amplitude recorded over the abductor digiti minimi (ADM). 
EMG data collection for assessment of the SI will be conducted at the Baseline Visit, and at the Week 
12, Week 24, and Week 36 visits during the Treatment Period and every 24 weeks during the OLE 
Period.  The SI a secondary efficacy endpoint. 
9.3.2.7 
ALSFRS-R 
The ALS Functional Rating Scale-Revised (ALSFRS) is a validated rating instrument for monitoring 
the progression of disability in patients with amyotrophic lateral sclerosis (ALS). The revised version 
incorporates additional assessments of dyspnea, orthopnea, and the need for ventilatory support. The 
Revised ALSFRS (ALSFRS-R) retains the properties of the original scale and shows strong internal 
consistency and construct validity.  
The ALSFRS-R will be conducted at the Screening Visit, the Baseline Visit, and at the Week 12, 
Week 24, and Week 36 visits during the Treatment Period and every 12 weeks during the OLE 
Period.  Assessment of ALSFRS-R (e.g., mean change from baseline, change in slope, proportion of 
patients experiencing a > 6 point decline) are exploratory endpoints. 
9.3.2.8 
FVC 
The extent of respiratory involvement has been reported as a major prognostic factor in ALS patients.  
Forced vital capacity (FVC) is one index of respiratory function that may be used to indicate potential 
respiratory compromise in ALS.   


 
 
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FVC will be conducted at the Screening Visit, Baseline Visit, and at the Week 12, Week 24, and 
Week 36 visits during the Treatment Period and every 12 weeks during the OLE Period.  FVC mean 
change from Baseline is an exploratory endpoint. 
9.3.2.9 
CGI 
The CGI scales (assessing both severity [CGI-S] and improvement [CGI-I]) provides a brief 
assessment of the clinician’s view of the patient’s global functioning and severity of current disease 
state and can be utilized to assess for changes in disease progression over the course of a clinical trial. 
The CGI-S will be conducted at the Baseline Visit, and both the CGI-S and CGI-I at the Week 12, 
Week 24, and Week 36 visits during the Treatment Period and every 12 weeks during the OLE 
Period. CGI mean change from Baseline is an exploratory endpoint. 
9.3.2.10 PGI 
The PGI scales (assessing both severity [PGI-S] and improvement [PGI-I]) provides a brief 
assessment of the patient’s view global functioning and severity of current disease state and can be 
utilized to assess for changes in disease progression over the course of a clinical trial. 
The PGI-S will be conducted at the Baseline Visit, and both the PGI-S and PGI-I at the Week 12, 
Week 24, and Week 36 visits during the Treatment Period and every 12 weeks during the OLE 
Period.  PGI mean change from Baseline is an exploratory endpoint. 
9.3.2.11 Healthcare Utilisation 
A healthcare utilization questionnaire will document subject utilization of healthcare resources 
including manual wheelchair, power wheelchair, gastrostomy tube, non-invasive ventilation, and 
augmentative and alternative communication.    
The healthcare utilization form will be implemented at the Baseline Visit, and at the Week 12, Week 
24, and Week 36 visits during the Treatment Period and every 12 weeks during the OLE Period.  The 
mean change from Baseline in the proportion of subjects utilising healthcare resources is an 
exploratory endpoint. 
9.3.3 Assessment of Safety 
Safety assessments will include the following: 
• 
Treatment emergent AEs and SAEs, both reported and observed 
• 
Physical examination 


 
 
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• 
Vital sign measurements: Ear temperature, respiration, blood pressure, and heart rate (blood 
pressure and heart rate will be measured after the patient has been supine for 5 minutes) 
• 
12-Lead ECG will be conducted in triplicate at the Baseline Visit and averaged. A single 
ECG collection will occur at each additional scheduled time point 
• 
Venous blood for clinical laboratory tests will include hematology, and blood chemistry. 
Blood for analysis will be drawn after an overnight fast when possible 
• 
Falls Assessment will be conducted at each study visit following randomisation. 
• 
C-SSRS Columbia Suicide Severity Rating Scale (C-SSRS) 
The C-SSRS is a semi-structured interview that captures the occurrence, severity, and frequency of 
suicide-related thoughts and behaviors during the assessment period (Posner et al., 2011). The 
interview includes definitions and suggested questions to solicit the type of information needed to 
determine if a suicide-related thought or behavior occurred. 
The C-SSRS contains 2 required items pertaining to suicidal ideation, 4 required items pertaining to 
suicidal behavior, and 1 required item pertaining to non-suicidal self-injurious behavior. There are 8 
additional suicidal ideation items and 2 additional suicidal behavior items which are completed in 
cases of positive responses for other items, as well as 2 items for completed suicide and suicide 
behavior present during the interview. Thus, there is a maximum of 19 items to be completed. 
The C-SSRS must be performed by an individual who is medically responsible for the subject. 
Two versions of the C-SSRS are used in this study: 
o The “Baseline” version will be administered at the Screening Visit (Visit -1) and will be 
completed for all subjects. 
o The “Since Last Visit” version will be completed for all subjects at all in-clinic study 
visits after the Screening Visit (Visit -1).  
 
Outlier criteria for safety results including chemistry, urine, hematology, ECG, vital signs are based 
upon the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events 
(CTCAE) v5.0, November 27, 2017.  This outlier criteria document has been authored and approved 
by the Sponsor safety physician and the CRO physician to enhance review of safety data. The outlier 
criteria will be used as an additional review tool for TEAE reporting. 
9.3.4 PK and PD Assessments 
Blood samples for pharmacokinetic (PK) and pharmacodynamics (PD) analyses will be collected 
during the Treatment Period as outlined in the Time and Events Schedule in Table 1.  Blood samples 


 
 
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for pharmacokinetic (PK) and pharmacodynamics (PD) analyses will be collected during the OLE 
Period as outlined in the Time and Events Schedule in Table 2.   
During PK and PD study visits patients should present themselves to the clinical site or hospital 
without taking the morning dose of study medication. During these visits the PK and PD samples 
should always be taken at pre-dose trough before administration of the morning dose of the study 
medication.  Accurate time of blood sampling and administration times for PK and PD collection will 
be documented in the eCRF. 
An indwelling venous catheter may be inserted for the collection of blood samples if deemed 
necessary.  Appropriate flushing techniques should be applied to remove dead space blood prior to 
collecting a sample for PK and PD analyses.   
Pharmacokinetic analyses, and pharmacokinetic/pharmacodynamics (PK/PD) modeling as applicable, 
using population approaches to describe Au whole blood pharmacokinetics including potential 
influence of relevant patient co-variables (e.g. age, gender, body weight, etc.) or potentially to relate 
parameters of clinical safety and efficacy response with Au whole blood concentrations will be 
investigated under separate detailed PK and/or PD evaluation plan(s). 
9.3.4.1 
Collecting, Processing, and Shipping of PK and PD Samples 
For PK analyses, 4 mL of whole blood will be collected for each blood draw for bioanalytical 
analyses of Au content.  Blood samples for PK analyses will be collected in tubes with dipotassium 
ethylenediaminetetraacetic acid (K2EDTA), which should not exceed 1.6 mg K2EDTA per mL of 
whole blood).  PK samples must be placed on wet crushed ice immediately and stored at -70 °C or 
lower within 15 minutes and processed per the instructions described in the study’s Lab Manual.  
For PD analyses, additional whole blood and plasma will be collected following the collection of the 
PK.  Further, urine for PD analyses will be collected at the specified visits noted in Table 1 and Table 
2. PD sample collection and processing guidelines will be specified in the study’s Laboratory Manual.  
9.3.4.2 
Bioanalytical Methods 
Blood concentrations of gold (Au) will be determined by using validated Inductively Coupled Plasma 
Mass Spectrometer (ICP-MS) analytical methods.  The lower limit of quantification, deviation of 
calibration standards from the theoretical value, and precision have been established using standard 
methods.  Performance of the assay will be assessed by monitoring the analysis of spiked samples 
with known concentrations of CNM-Au8. 
Blood samples will be analyzed under the responsibility of the Sponsor’s bioanalytical laboratory at: 


 
 
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Clene Nanomedicine, Inc. 
Bioanalytics Laboratory 
500 Principio Parkway West, Suite 400 
North East, MD  21901-2912 
USA 
9.3.5 Clinical Laboratory Tests 
All routine safety samples will be analyzed by the local sites’ clinical laboratory unless otherwise 
specified in the study laboratory manual.  At the end of the study when all planned analyses are 
completed, all clinical laboratory blood samples will be destroyed per the central clinical laboratory 
SOPs.    
The clinical laboratory tests will include, but are not limited to: 
• 
Hematology:  hemoglobin, hematocrit, white   blood   cell   count   with differential, red blood 
cell count, and platelet count. 
• 
Serology (Screening Visit only): human immunodeficiency virus (HIV), hepatitis C (HepC), 
and hepatitis B (HepB). 
• 
Blood Chemistry: Alanine aminotransferase (ALT; SGPT) and Aspartate aminotransferase 
(AST; SGOT), total bilirubin, direct bilirubin, Gamma-Glutamyl transferase (GGT), blood 
urea nitrogen (BUN), creatinine, alkaline phosphatase, lactate dehydrogenase (LDH), sodium, 
potassium, calcium, chloride, albumin, uric acid, lipid profile/panel, creatine kinase (CK). 
• 
Serum and urine pregnancy test: Beta-human chorionic gonadotropin (βhCG) test for 
females of childbearing potential. 
• 
Urinalysis: Dipstick analyses will include: Leucocytes, blood, nitrite, protein, urobilinogen, 
bilirubin, pH, specific gravity, ketones, and glucose. Urinalysis will include macroscopic 
analysis and microscopic analysis only when indicated by dipstick. 
• 
Urine Drug Screen:  Cocaine, cannabinoids, amphetamines, benzodiazepines and opiates. 
Patients with positive urine drug screen test results will be excluded from the study. Urine 
Drug Screen kits will be supplied for sites to complete testing onsite.  Repeat urine drug 
screens for validation of initial findings may be conducted at the discretion of the site 
investigator. If a patient holds an active prescription for a medication that could return a 
positive result on the above urine drug analytes, the patient may be allowed to continue so 
long as elicit use is not suspected. 
The clinical sites local laboratory or core clinical laboratory will supply appropriate blood collection 
tubes for each study visit.  The Lab Manual will specify the blood collection volumes and specific 
collection tubes to be utilised. 


 
 
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9.3.6 Physical Examinations 
A full physical examination will consist of assessments of the following: skin, ears, nose, throat, head, 
eyes, lungs/chest, heart, abdomen, musculoskeletal, extremities, neurologic. Following randomisation, 
a symptom directed physical exam and brief neurological exam will be performed at each visit.  
9.3.7 Vital Signs 
Vital signs will include respiration rate (breaths per minute), temperature, blood pressure (mmHg) and 
heart rate (beats per minute [bpm]). Blood pressure and heart rate will be obtained after the patient has 
been resting in supine position for 5 minutes. If vitals are not able to be captured in a supine position, 
vitals may be collected in a sitting position.  The same arm must always be used for blood pressure 
and heart rate measurements. Noninvasive measurement should be conducted preferably with a 
mercury sphygmomanometer or a validated electronic device in accordance with published guidelines 
(e.g. American Heart Association: Recommendations for Blood Pressure Measurement in Humans 
and Experimental Animals) (Pickering et al., 2005).   
9.3.8 12-Lead ECG 
12-lead ECGs will be performed successively in triplicate after the patient has rested quietly for at 
least 5 minutes in a supine position at the Baseline Visit.  If the ECG is not able to be captured in a 
supine position, vitals may be collected in a sitting position. The average corrected QT interval 
(QTc) of the triplicate ECG measurements collected prior to Day 1 dosing will serve as that patient’s 
baseline for use in ongoing safety assessment.   At all other scheduled timepoints, a single ECG will 
be collected. When the timing of the measurement coincides with a blood collection, the ECG should 
be obtained prior to blood collection.  In some cases, it may be appropriate to repeat abnormal ECGs 
to rule out improper lead placement as contributing to the ECG abnormality. It is important that leads 
are placed in the same positions each time for consistency. 
ECG intervals will be summarized and presented descriptively. ECG rhythm will be interpreted by the 
Investigator as normal (N), abnormal not-clinically significant (aNCS), or abnormal clinically 
significant (aCS). 
9.4 
Assessment Windows 
Collection of PK samples should occur as close to the nominal timepoint as possible. The actual time 
of PK sample collection will be recorded.  All other assessments should be scheduled around the 
collection of PK samples at their nominal timepoints. 
 
 


 
 
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10 ADVERSE EVENTS 
Safety will be assessed up through the frequency of treatment emergent adverse events, serious 
adverse events, discontinuations due to adverse events, Falls Questionnaire, and the Columbia Suicide 
Severity Rating Scale (C-SSRS). 
10.1 Safety Reporting Guidelines 
AE monitoring and reporting is a routine part of every clinical study. All Investigators, clinical site 
staff, and the Sponsor’s employees share in the responsibility for reporting AEs and SAEs. 
10.1.1 Sponsor Guidance 
The Sponsor is required to notify all participating Investigators and FDA in a written Investigational 
New Drug (IND) safety report of any AE associated with the use of the investigational drug that is 
both serious and unexpected, and any finding from tests in laboratory animals that suggests a 
significant risk for human patients (21 CFR 312.32(c)(1)(i)(A),(B)).  The Sponsor is required to keep 
Investigators informed of new observations discovered by, or reported to the Sponsor regarding the 
study drug particularly with respect to AEs and safe use (21 CFR 312.55). 
10.1.2 Investigator Guidance 
The Investigator is required to promptly report to the Sponsor any AE that may reasonably be 
regarded as caused by or probably caused by the investigational drug.  If the AE is alarming, the 
Investigator shall report the adverse effect immediately to the Sponsor (21 CFR 312.64). Further, 
Investigators are required to promptly report to the Human Research Ethics Committee (HREC) 
and/or Institutional Review Board (IRB) as applicable all unanticipated problems involving risks to 
human patients or others including AEs that should be considered unanticipated problems (21 CFR 
56.108(B)(1), 21 CFR 312.53(c)(1)(vii), and 21 CFR 312.66). All Investigators and clinical site staff 
who learn about or are notified of a SAE must collect and promptly report to the Sponsor (within 24 
hours) data according to the study protocol and relevant regulations (21 CFR 312.64, 21 CFR 312.32). 
10.2 Adverse Events (AE or Adverse Experience) 
Adverse events include any untoward medical occurrence associated with the use of a drug in 
humans, whether or not considered drug related. Therefore, an AE can be any unfavorable and 
unintended sign (including an abnormal laboratory finding), symptom, or disease temporally 
associated with the use of the investigational drug, whether or not considered related to the study drug 
(attribution of ‘unrelated’, ‘unlikely’, ‘possible’, ‘probable’, or ‘definite’) (International Conference 
on Harmonization [ICH] E2A, E6).  Adverse events include: 


 
 
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• 
Exacerbation of a pre-existing disease. 
• 
Increase in frequency or intensity of a pre-existing episodic disease or medical condition. 
• 
Disease or medical condition detected or diagnosed after study drug administration even 
though it may have been present prior to the start of the study. 
• 
Continuous persistent disease or symptoms present at Baseline that worsen following the start 
of the study. 
• 
Lack of efficacy in the acute treatment of a life-threatening disease. 
• 
Events considered by the Investigator to be related to study-mandated procedures. 
• 
Abnormal assessments (e.g., change on physical examination, ECG findings), if they 
represent a clinically significant finding that were not present at Baseline or worsened during 
the course of the study. ALS related findings should not be documented as an AE if deemed 
by an Investigator as related to disease progression. Finding should be noted on exams as 
related.  
• 
Laboratory test abnormalities if they represent a clinically significant finding, symptomatic or 
not, which was not present at Baseline or worsened during the course of the study or led to 
dose reduction, interruption, or permanent discontinuation of the study drug. 
Adverse events do not include: 
• 
Medical or surgical procedure not mandated in the protocol (e.g., surgery, endoscopy, tooth 
extraction).  However, the event leading to the procedure is an AE. If this event is serious, the 
procedure must be described in the SAE narrative on the SAE eCRF. 
• 
Pre-existing disease or medical condition that does not worsen. However, if the condition 
deteriorates at any time during the study, it should be recorded as an AE. 
• 
Situations in which an adverse change did not occur (e.g., hospitalizations for cosmetic 
elective surgery or for social and/or convenience reasons). 
• 
Overdose of either study drug without any signs or symptoms. However, overdose of study 
drug must be reported in the Study Drug Log. 
The occurrence of an AE may come to the attention of study personnel during the study visits, during 
interviews of a study recipient presenting for medical care, or upon review by a study monitor. 
Information to be collected and recorded include: event description, time of onset, clinician’s 
assessment of severity, relationship to study product (assessed only by those with the training and 
authority to make a diagnosis, which would include MD, PA, Nurse Practitioner, DO, or Physician 
Assistant), and time of resolution/stabilization of the event. 


 
 
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All AEs occurring during the study including local and systemic reactions must be documented 
appropriately regardless of relationship and recorded on the relevant eCRF.  If there is any doubt as to 
whether a clinical observation is an AE, the event should be reported. 
10.2.1 Intensity of Adverse Events 
The intensity of all AEs will be graded for severity.  The investigating clinician will assess all AEs by 
grading the AE on a three-point scale of 1) mild, 2) moderate, and 3) severe; which are defined as 
follows: 
• 
Mild events: require minimal or no treatment and do not interfere with the patient’s daily 
activities. 
• 
Moderate events:  result in a low level of inconvenience or concern with the investigational 
drug. Moderate events may cause some interference with daily functioning. 
• 
Severe events: interrupt a patient’s usual daily activity and may require systemic drug 
therapy or other treatment. Severe events are usually incapacitating. 
If the intensity of an AE worsens during study drug administration, only the worst intensity should be 
reported on the relevant AE eCRF. If the AE lessens in intensity, no change in the severity is required.  
AEs characterized as intermittent require documentation of onset and duration of each episode. 
The AE intensity definitions do not apply to clinically significant and asymptomatic laboratory test 
abnormalities or abnormal assessments (e.g., ECG findings) considered as AEs. The Investigator 
should tick “non-applicable” on the AE page of the eCRF when identifying the intensity of the AE. 
Of note, mild, moderate, or severe AE classifications may or may not be serious (see SAE section).  
These terms are used to describe the intensity of a specific adverse event (as in mild, moderate, or 
severe nausea). For example, nausea lasting several hours may be rated as severe, but may not be 
clinically serious.  Alternatively, a fever of 39°C that is not considered severe, may however become 
serious, if it prolongs hospitalization.  Seriousness rather than severity serves as a guide for defining 
regulatory reporting requirements. 
10.2.2 Relationship and Attribution of the AE to Study Drug 
10.2.2.1 Relationship to Study Drug 
Each adverse event must be assessed by the Investigator as to whether or not there is a reasonable 
possibility of causal relationship to the study drug, and reported as either related or unrelated. The 
Investigators assessment of an AE's relationship to the study drug is part of the documentation 
process, but it is not a factor in determining what is or is not reported in the study. 
 


 
 
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• 
Related to Study Drug:  This category applies to any AE (whether serious or not) that 
appears to have a reasonable possibility of causal relationship to the use of the study drug 
(i.e., a relationship cannot be ruled out). Guidelines to determine whether an event might be 
considered related include but are not limited to the following: 
o The event occurred in close temporal relationship to study drug administration. 
o The event diminished or disappeared when treatment with the study drug was 
down titrated, interrupted, or discontinued. 
o The event reoccurred when treatment was reintroduced. 
o Environmental factors such as clinical state and other treatments could not equally 
have caused the event. 
• 
Unrelated to Study:  There is not a reasonable possibility that the administration of the 
study product caused the event (see above guidelines). 
10.2.2.2 Attribution to The Study Drug 
After identifying and grading the event, the clinical Investigator must assign an attribution to the AE 
using the following attribution categories described in the table below. AEs listed as ‘possibly, 
probably’ or definitely’ related to the investigational drug are considered to have a suspected 
‘reasonable causal relationship’ to the investigational agent (ICH E2A). 
Table 23.  AE Attribution to the Study Drug 
Relationship 
to Study Drug 
 
Attribution 
 
Description 
Unrelated 
Unrelated 
The AE is clearly NOT related to the study drug 
Unlikely 
The AE is doubtfully related to the study drug 
Related 
Possible 
The AE may be related to the study drug 
Probable 
The AE is likely related to the study drug 
Definite 
The AE is clearly related to the study drug 
 
10.3 Serious Adverse Events 
The International Conference on Harmonization (ICH) guidelines define a serious adverse event 
(SAE) as an AE or suspected adverse reaction that in the view of either the Investigator or Sponsor 
results in any of the following study patient outcomes: 
• 
Death, 
• 
A life-threatening AE, 
• 
Inpatient hospitalization or prolongation of existing hospitalization, 


 
 
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• 
A persistent or significant incapacity or substantial disruption of the ability to conduct normal 
life functions, 
• 
A congenital anomaly/birth defect, or 
• 
An important medical event, requiring medical or surgical intervention (treatment) to prevent 
at least one of the outcomes listed above. 
Life threatening refers to an event in which the patient was at risk of death at the time of the event. It 
does not refer to an event that hypothetically might have caused death had it been more severe. 
Important medical events that do not result in death, are not life threatening, or do not require 
hospitalizations may be considered serious when, based upon appropriate medical judgment, they may 
jeopardize the patient and may require medical or surgical intervention to prevent one of the outcomes 
listed in the SAE definition. Examples of such medical events include allergic bronchospasm 
requiring intensive treatment in an emergency room or at home, a blood dyscrasia or convulsion that 
does not result in inpatient hospitalization, or the development of drug dependency or drug abuse. 
Complications that occur during hospitalization may be AEs or SAEs depending upon Investigator 
judgment (i.e., if a complication prolongs hospitalization it would be considered an SAE). However, 
the following reasons for hospitalizations are not considered AEs, and are therefore also not SAEs: 
• 
Hospitalizations for cosmetic elective surgery, or social and/or convenience reasons. 
• 
Standard monitoring of a pre-existing disease or medical condition that did not worsen (e.g., 
hospitalization for coronary angiography in a patient with stable angina pectoris). 
• 
Elective treatment of a pre-existing disease or medical condition that did not worsen (e.g., 
elective hip replacement for arthritis). 
10.3.1 Serious Adverse Events Related To Study-Mandated Procedures 
A SAE is defined as related to study-mandated procedures if it appears to have a reasonable 
possibility of a causal relationship (i.e., a relationship cannot be ruled out) to procedures other than 
administration of the study drug. Examples of study-mandated procedures include blood sampling, car 
accident on the way to the study unit for a study visit, etc. 
10.4 Reporting Requirements for AEs and SAEs 
10.4.1 Reporting of Adverse Events 
All AEs are collected from the time the informed consent is signed up to 2 weeks after the last study 
drug dose, or leading to the premature discontinuation of study drug must be recorded on the 
appropriate AE pages of the eCRF. 


 
 
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Information to be collected includes event description, date of onset, Investigator assessment of 
severity, Investigator assessment of relationship to study product, date of resolution of the event, 
seriousness, and outcome. 
10.4.2 Reporting Abnormal Laboratory Test Values or Abnormal Clinical Findings 
Collection of specific safety laboratory data is outlined in the study visit schedule. Toxicity tables are 
based on the FDA toxicity tables developed for normal healthy adult volunteers. Laboratory values 
and abnormal clinical findings that are abnormal based on the toxicity tables must be reported on the 
appropriate AE eCRF. 
10.4.2.1 Reporting of AE Intensity and Causality 
Only licensed study clinicians (i.e., Medical Doctor, Doctor of Osteopathy, Nurse Practitioner, 
Physician’s Assistant) should assess the intensity of non-serious AEs. Similarly, only licensed study 
clinicians as identified on Form FDA 1572 or per ICH E6 standards should assess the causality of 
AEs. 
10.4.2.2 Follow-up of AEs 
All AEs occurring during the AE reporting period of the study will be documented appropriately 
regardless of relationship. All AEs occurring during the treatment period will be followed to adequate 
resolution or until the patient is considered stable. 
Adverse events still ongoing after study drug discontinuation for a given patient will be followed until 
28 days after study drug discontinuation or until AE resolution or patient stabilization. 
Resolution of an AE is defined as the return to pre-treatment status or stabilization of the condition to 
the Investigator and/or Sponsor’s satisfaction with the expectation that the condition or abnormality 
may remain chronic. Follow-up procedures, evaluations, and outcomes will be recorded on the 
patient's eCRF. 
10.4.3 Reporting Requirements For SAEs 
All SAEs occurring during the course of the study (e.g., signing of informed consent by patient to 28 
days following the last dose of the study drug) and any SAEs, considered causally related to study 
drug that occur following completion of the study, must be reported to the Sponsor. 
10.4.3.1 Reporting of SAEs 
All serious adverse events that occur during the course of study will be recorded on the appropriate 
eCRF (e.g., SAE eCRF) and will be reported to Sponsor’s drug safety physician. 


 
 
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Any AE that meets a protocol-defined criterion as serious must be submitted immediately (within 24 
hours of site or Investigator awareness) on an SAE form to the Sponsor’s drug safety physician at the 
following address: 
Chief Medical Officer  
Tel: +1 (801) 676-9695 
Email: safety@clene.com 
 
Information to be collected includes unique patient ID, event description, date of onset, Investigator 
assessment of severity, Investigator assessment of relationship to study product, date of resolution of 
the event, seriousness, and outcome. 
Other supporting documentation of the event may be requested by the Sponsor and should be 
provided as soon as possible. The Sponsor’s drug safety physician will review and assess the SAE for 
regulatory reporting and potential impact on study patient safety and protocol conduct. 
10.4.3.2 SAE Reporting Periods 
• 
Screening period: SAEs occurring between signing the Informed Consent Form and study 
drug initiation should be reported in the eCRF.  
• 
Treatment Period: All SAEs, regardless of causal relationship, must be reported, including 
those related to study-mandated procedures. Those SAEs occurring during study drug 
administration, i.e., between study drug initiation and 14 days after study drug 
discontinuation, are defined as treatment-emergent SAEs. These SAEs are reported on SAE 
forms and also on AE pages in the eCRF. They are therefore entered into both the drug safety 
and clinical databases, and must be reconciled before study closure. 
• 
Open-Label Extension Period: All SAEs, regardless of causal relationship, must be reported, 
including those related to study-mandated procedures. Those SAEs occurring during study 
drug administration, i.e., between study drug initiation and 14 days after study drug 
discontinuation, are defined as treatment-emergent SAEs. These SAEs are reported on SAE 
forms and also on AE pages in the eCRF. They are therefore entered into both the drug safety 
and clinical databases, and must be reconciled before study closure. 
• 
Follow-Up Period: All SAEs, regardless of causal relationship, occurring 14 days after study 
drug discontinuation until 28 days after study drug discontinuation must be reported. 
• 
Post Follow-Up Period: If the Investigator becomes aware of a new SAE that is suspected of 
being causally related to the study drug occurring after 28 days of follow-up or post-study 
completion, the Investigator will report the event within 24 hours to the Sponsor’s drug safety 


 
 
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physician. These SAEs are only entered in the drug safety pharmacovigilance database, and 
therefore will not affect study closure. 
10.4.3.3 SAE Reporting Procedures 
• 
All SAEs must be reported by the Investigator to drug safety physician within 24 hours of the 
Investigator’s first knowledge of the event. 
• 
All SAEs must be recorded on the appropriate SAE forms, irrespective of the study drug 
received by the patient, and whether this event is considered by the Investigator to be related 
to study drug. These SAE forms must be faxed and emailed to Clene’s drug safety physician. 
• 
The Investigator must complete the SAE form in English (unless otherwise specified), and 
must assess the relationship of the event to study drug.  Such reports will be followed by 
detailed descriptions that may include copies of hospital case reports, autopsy reports, 
hospital discharge summaries and other documents when requested and applicable. 
• 
Follow-up information about a previously reported SAE must also be reported within 24 
hours of receiving it. The drug safety physician may contact the Investigator to obtain further 
information. 
• 
The intensity of SAEs may only be assessed by a licensed study physician as described 
previously.  The causality of SAEs may only be assessed by a licensed physician identified on 
the Form FDA 1572 or per ICH E6 standards. 
10.4.3.4 SAE Regulatory Reporting 
Following notification from the Investigator, the Sponsor will expedite reporting any suspected 
adverse reaction that is both serious and unexpected to Health Authorities, HREC, IRBs, and other 
Investigators, as appropriate. 
The Sponsor will report an AE as a suspected adverse reaction only if there is evidence to suggest a 
causal relationship between the drug and the AE. Sponsor will notify FDA and all participating 
Investigators (i.e., all Investigators to whom the Sponsor is providing drug under its INDs or under 
any Investigator’s IND) in an IND safety report of potential serious risks from clinical trials or any 
other source, as soon as possible, but in no case later than 15 calendar days after the Sponsor 
determines that the information qualifies for reporting as specified in 21 CFR Part 312.32.  Further, 
Sponsor will notify FDA of any unexpected fatal or life-threatening suspected adverse reaction as 
soon as possible but in no case later than 7 calendar days after the Sponsor’s initial receipt of the 
information. Relevant follow-up information to an IND safety report will be submitted as soon as the 


 
 
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information is available. Upon request from FDA, Sponsor will submit to FDA any additional data or 
information that the agency deems necessary, as soon as possible, but in no case later than 15 calendar 
days after receiving the request. 
Un-blinding of serious and unexpected AEs will be performed as necessary and appropriate. 
All serious adverse events designated as “not related” to study product(s), will be reported to the FDA 
at least annually in a summary format. 
General study reporting periods and safety reporting requirements are summarized in the table below. 
Table 24.  Summary of Study Safety Reporting Periods 
Study Periods: 
Screening 
Treatment/OLE 
 
Post Follow-up 
Timeframe 
From signature of 
informed consent to study 
drug initiation 
During study drug 
administration plus 28 
days 
After 28 days 
AE/SAE 
Reporting on 
AE eCRF 
None 
All AEs/SAEs1 
None 
SAE 
Reporting on 
SAE eCRF 
Only if related to study- 
mandated procedures 
All SAEs  
If considered causally 
related to the study 
medication 
Reconciliation2 
Not applicable 
Yes 
Not applicable 
Clinical Study 
Report/Final 
Study Report 
AEs and SAEs may be 
described 
Analyzed 
AEs and SAEs may be 
described 
1Adverse events still ongoing after study drug discontinuation for a given patient must be followed 
until 28 days after study drug discontinuation or until resolution or stabilization or until the event is 
otherwise explained. 
2Reconciliation between clinical and drug safety databases. 
10.5 Pregnancy 
10.5.1 Prevention of Pregnancy During the Study 
Women should not become pregnant during the study and up to 6 months following study drug 
discontinuation. Accordingly, women of childbearing potential should take appropriate precautions to 
prevent pregnancy during the study. If a woman becomes pregnant while on study drug, no further 
treatment will be administered.  In the event of a pregnancy, all study-mandated blood samples will be 
obtained and the patient will continue in follow-up for safety events. 
10.5.2 Reporting of Pregnancy 
Irrespective of the treatment received by the patient, any pregnancy which occurs in a study patient or 
the partner of a male study patient, which occurs during study drug administration or 6 months 


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


 
 
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11 STATISTICS AND DATA MANAGEMENT 
A statistical analysis plan (SAP) will provide details of planned analyses and summary documents, 
such as tables, listings and figures.  All variables will be analyzed descriptively with appropriate 
statistical methods: categorical variables by frequency tables and continuous variables by sample 
statistics (i.e., mean, SD, minimum, median, quartiles and maximum).  An overview of the planned 
analyses is provided here.  However, final analyses are not limited to the summaries described herein 
but will be defined in the SAP prior to final database lock. 
11.1 Determination of Sample Size and Analyses 
Based on previously reported longitudinal studies of MUNIXscore(4) in ALS patients (Neuwirth et 
al., 2015); it is assumed the common standard deviation for the MUNIXscore(4) is 19.8% with a 
placebo deterioration of 38.4% (e.g., 61.6% of the baseline index value) at Week 36.  The active 
treatment group deterioration is estimated at 19.2% (e.g., 80.8% of the baseline index value) at Week 
36.  Accordingly, sample size calculations were based on the following criteria:  
a) Mean difference between the MUNIX(4)score indexed value in the change from baseline 
between active and placebo of 19.2% at Week 36; 
b) common standard deviation (SD) of 19.8%;  
c) α value of 0.05;  
d) b power of 0.8; and 
e) 12.5% dropout rate. 
At a 1:1 (CNM-Au8 30 mg: Placebo) allocation, 80% power and 5% statistical significance rate, an 
estimated 36 evaluable patients will be required for this study. With a 12.5% estimated non-evaluable 
rate, it is planned to assign 42 patients (21 active:21 placebo) to randomised treatment. 
11.2 Analysis Populations 
The following patient sets are applicable to this study: 
• 
Intent to Treat Analysis Set – The Intent To Treat Set (ITT) will consist of Screened patients for 
whom a randomisation number has been assigned at Visit 0. 
• 
Safety Analysis Set – The Safety Analysis Set (SAS) will consist of patients in the Randomised 
Set who receive at least 1 dose of investigational product. 
• 
Partial Analysis Set – The Partial Analysis Set (PAS) will consist of all patients in the Safety Set 
with at least 1 post-baseline EMG measurement. 


 
 
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• 
Per Protocol Set – The Per Protocol Set (PPS) will consist of all patients in the Safety Set who 
have completed 36-weeks of treatment and all of the Primary and Secondary endpoints and who 
are treatment adherent per Section 8.5. 
11.3 Baseline Characteristics and Patient Disposition 
Overall Baseline and demographic data will be summarized using descriptive statistics. Patient 
disposition (e.g., the number of patients enrolled, completed, and discontinued) will be summarized 
and medical history and physical examination findings will be listed. 
11.4 Prior and Concomitant Medications 
Medications taken after the patient receives study drug through Follow-Up will be listed by treatment, 
dose level and patient. 
11.5 Pharmacokinetic Analyses 
Pharmacokinetic parameters will be derived using noncompartmental analyses employing appropriate 
software and graphing tools (e.g. WinNonlin® Professional version 6.3 [Pharsight Corp], SAS® for 
Windows® Version 9.4, SigmaPlot for Windows Version 12.5; or higher versions).  
Au concentrations will be summarized using descriptive statistics (including N, mean, SD, coefficient 
of variation (CV%), median, minimum, and maximum) for each treatment. Concentrations below the 
limit of quantification (BLQ) will be treated as zero for the computation of descriptive statistics and 
for construction of mean concentration-time profiles. Concentrations assigned a value of missing will 
be omitted from the calculation of descriptive statistics. 
The following PK parameters will be estimated by noncompartmental methods from whole blood 
samples. Actual elapsed time from dosing will be used to estimate all individual PK parameters. 
Table 25.  Summary of PK Parameters 
 
Parameter 
Description 
Cmax 
Maximum observed plasma concentration 
Tmax 
Time of maximum concentration (h), obtained directly from 
the observed concentration versus time data. 
CL/F 
Apparent systemic clearance 
AUC(0-24) 
Area under the plasma concentration-time curve from time 
0 to the end of the 24-hour dosing interval 
 


 
 
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Derived PK descriptive statistics will be tabulated by dosing group and summary statistics.   
Descriptive statistics for PK parameters will include the arithmetic and geometric mean (for Cmax, 
Tmax, AUC(0-24), and CL/F), CV%, SD of the arithmetic mean, median, minimum, maximum, and N. 
Population PK and PK/PD models may be developed to address objectives that require an integrative 
interpretation of the study results. These include assessment of the dose proportionality, investigation 
of the nature of the PK/PD relationship, and the use of study results as part of a larger model-based 
data analysis. If population PK/PD models are developed, a separate Pharmacometric Analysis Plan 
will be written. 
11.6 Safety Analyses 
All safety summaries will be descriptive; no statistical significance tests will be performed on safety 
data and will be based on the safety population. 
Safety assessments include extent of exposure, incidence of treatment-emergent AEs, drug-related 
AEs, deaths, SAEs, AEs leading to discontinuation from the study, Falls Questionnaire, and the 
Columbia Suicidality Severity Rating Scale (C-SSRS).  Changes from baseline in clinical laboratory 
results, ECGs and vital signs will also be summarized by treatment group and time point.    
At each time point, absolute values and change from baseline of each safety endpoint will be 
summarized with n, mean, SD, standard error of the mean (SEM), median, Min, and Max values. The 
number of available observations and out-of-range values (absolute and in percentage) will be 
presented. Values outside the reference range will be flagged in the listing. ‘H’ and ‘L’, denoting 
values above or below the Investigator reference range (when present), will flag out-of-range results. 
The AE coding dictionary for this study will be Medical Dictionary for Regulatory Activities 
(MedDRA). It will be used to summarize AEs by primary system organ class (SOC) and preferred 
term (PT). 
11.7 Efficacy Analyses 
The primary endpoint, the mean change in the MUNIXscore(4) value will be analysed using Mixed 
Model for Repeated Measures (MMRM) with treatment (Week 12, Week 24, and Week 36) as fixed 
effects and Baseline DFS, Baseline ALSFRS-R scores, and bulbar vs. limb onset as covariates. 
Estimates of least-square means, standard errors and 95% confidence intervals will be presented by 
treatment group. For the active treatment versus placebo comparisons, the least square mean 
difference, the standard error of the difference, and the 95% confidence interval of the difference will 
be presented.   


 
 
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Descriptive summaries of the absolute and change from baseline mean scores by week will be 
presented for all efficacy measures. Specific analysis plans for the secondary and exploratory efficacy 
plans will be described in the SAP.  Primary and secondary efficacy analyses will be based on the 
intent to treat (ITT) population.  Additional exploratory analyses may examine different study 
population sets as described in Section 11.2. 
11.8 Interim analyses 
No pre-specified interim analyses are planned per protocol. 
The Independent Data Safety Monitoring Board (DSMB) will meet at regularly scheduled intervals as 
detailed in the DSMB Charter. The following un-blinded data may be reviewed by the DSMB based 
on the standards detailed in the DSMB charter (e.g., safety signals, trends warranting further un-
blinded review) and used to determine if study continuation may occur: 
• 
AEs and SAEs 
• 
Physical examination results  
• 
Clinical laboratory tests 
If un-blinded data are required, this data shall only be reviewed in a closed session of DSMB and not 
available to the Sponsor for review. 
11.9 Data Handling and Quality Assurance 
11.9.1 Data Recording 
Limited data may be entered solely into the eCRF (e.g., ethnic group). All other data must have source 
documentation available, which will be provided by the Sponsor. A source document checklist will be 
used at the site to identify the source data for all data points collected, and the study monitor will 
work with the site to complete the source documentation verification.  
11.9.1.1 Data Recorded From Screening Failures 
For patients who do not meet selection criteria (Screen Failures), source data will be recorded and 
entered into the eCRF, including the reason for the screen failure, and demographic information (e.g., 
patient number, date of birth/age, sex, height, weight, race and ethnicity), and the date of the study 
visit. 
For patients classified as Screen Failures with an SAE during the Screening visit (Visit -1), the 
following additional data should be collected in the eCRF: 


 
 
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• 
All information about the SAE 
• 
Other related including: 
o Concomitant medication 
o Medical history 
o Any other information needed to complete the SAE eCRF page 
11.9.2 Data Monitoring 
In accordance with applicable regulations, Good Clinical Practice (GCP), and the Sponsor’s and/or 
the Clinical Research Organization (CRO) procedures, study monitors will contact the site prior to the 
start of the study to review with the site staff the protocol, study requirements, and their 
responsibilities to satisfy regulatory, ethical, and Sponsor’s requirements. When reviewing data 
collection procedures, the discussion will also include identification and documentation of source data 
items. 
The Sponsor and/or CRO monitor will visit clinical sites periodically to monitor study activity to 
verify that the: 
• 
Data are authentic, accurate, and complete 
• 
Safety and rights of patients are being protected 
• 
Study is conducted in accordance with the currently approved protocol (including study 
treatment being used in accordance with the protocol) 
• 
All other study agreements, GCP, and all applicable regulatory requirements are being met. 
The site Investigator and the head of the medical institution, as applicable, agree to allow the Sponsor 
and/or CRO study monitor direct access to all relevant documents at the clinical site. 
11.9.3 Data Collection and Management 
Data collection will be conducted via a validated electronic data collection (EDC) system, which will 
be managed by the Sponsor’s biostatistics and data management CRO.  
Patient data necessary for analysis and reporting will be entered and/or transmitted into a validated 
database or data system. Clinical data management will be performed in accordance with applicable 
Sponsor and CRO standards for data cleaning procedures. This is applicable for data recorded on the 
eCRF as well as for data from other sources (e.g., IRT, laboratory, ECG). For data coding (e.g., AEs, 
medication), internationally recognized and accepted dictionaries will be used.  Data will be 
electronically verified through use of programmed edit checks specified by the clinical team. 
Discrepancies in the data will be brought to the attention of the clinical team, and investigational site 


 
 
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personnel, as applicable. Resolutions to these issues will be reflected in the database. An audit trail 
within the system will track all changes made to the data. 
11.9.4 Data Audit and Inspection 
To ensure compliance with GCP and regulatory requirements, a member of the Sponsor’s quality 
assurance unit, or designated CRO representative, may conduct an audit to assess the performance of 
the study at the study site and of the study documents originating there. The site Investigator and 
institution will be informed of the audit outcome.  In addition, inspections by regulatory health 
authority representatives and/or HREC(s)/IRB(s) are possible. The Investigator should notify the 
Sponsor immediately of any such inspection.  The Investigator/institution agrees to allow the auditor 
or inspector direct access to all relevant documents and to provide sufficient time and staff support to 
review any findings and any discuss any issues. Audits and inspections may occur at any time during 
or after completion of the study. 
11.9.5 Data Archiving 
Essential site documents shall be archived safely and securely in such a way that ensures that they are 
readily available upon regulatory authorities’ request.  Patient files will be archived according to local 
regulations and in accordance with the maximum period of time permitted by the hospital, institution 
or private practice associated with the study. Where the archiving procedures do not meet the 
minimum timelines required by the Sponsor, alternative arrangements must be made to ensure the 
availability of the source documents for the required period. The Investigator/institution shall notify 
the Sponsor if the archival arrangements change (e.g., relocation or transfer of ownership). 
The Investigator site file is not to be destroyed without the Sponsor’s written approval. 
 
 


 
 
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12 RESPONSIBILITIES, ETHICS, AND LEGAL ASPECTS 
12.1 Investigator Responsibilities 
12.1.1 Good Clinical Practice 
The Investigator will ensure that this study is conducted in full compliance with the principles of the 
“Declaration of Helsinki” (as amended in Edinburgh, Tokyo, Venice, Hong Kong, and South Africa), 
ICH guidelines, or with the laws and regulations of the country in which the research is conducted, 
whichever affords the greater protection to the study Patient. For studies conducted under a United 
States IND, the Investigator will ensure that the basic principles of “Good Clinical Practice,” as 
outlined in 21 CFR 312, subpart D, “Responsibilities of Sponsors and Investigators,” 21 CFR, Part 50, 
1998, and 21 CFR, Part 56, 1998, are adhered to. This study will be conducted in compliance with 21 
CFR, Part 320, 1993, “Retention of Bioavailability and Bioequivalence Testing Samples.” 
12.1.2 Institutional Review Board (IRB)/Independent Ethics Committee (IEC) 
Approval 
The Investigator will submit this protocol and any related documents to an IEC, Human Research 
Ethics Committee (HREC), and the Competent Authority (CA) as applicable. Approval from the EC 
and the statement of no objection from the CA must be obtained before starting the study, and should 
be documented in a dated letter/email to the Investigator, clearly identifying the study, the documents 
reviewed and the date of approval. A list of EC members must be provided, including the functions of 
these members. If study staff were present, it must be clear that none of these persons voted. 
Modifications made to the protocol after receipt of the EC approval must also be submitted as 
amendments by the Investigator to the EC in accordance with local procedures and regulations. 
12.1.3 Informed Consent 
It is the responsibility of the Investigator or designee to obtain written informed consent from each 
individual participating in this study after adequate explanation of the aims, methods, objectives, and 
potential hazards of the study and prior to undertaking any study-related procedures.   The 
Investigator or designee must utilize an HREC/IRB-approved informed consent form (ICF) for 
documenting written informed consent.  Each informed consent will be appropriately signed and 
dated by the patient and the person obtaining consent.  A patient may enter the study only if the 
patient or legal representative voluntarily agrees to sign the informed consent form.  A copy of the 
signed consent form will be provided to the patient. 
If informed consent is obtained on the date that Screening study procedures (Visit -1) are performed, 
the study record or patient’s clinical record must clearly show that informed consent was obtained 
prior to these procedures. 


 
 
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If the patient is not capable of providing a signature, a verbal statement of consent can also be given 
in the presence of an impartial witness (e.g., independent of the Sponsor and the Investigator). This is 
to be documented by a signature from the informing physician as well as by a signature from the 
witness. 
The ICF and any other written information provided to patients or the patient’s legal representative 
will be revised whenever important new information becomes available that may be relevant to the 
patient’s consent, or there is an amendment to the protocol that necessitates a change to the content of 
the patient information and/or the written ICF. The Investigator will inform the patient or legal 
representative in a timely manner and will ask patients to confirm their participation in the study by 
signing the revised informed consent form. Any revised written informed consent form and written 
information must receive the HREC/IEC/IRB’s approval prior to use. 
12.1.4 Adherence to Protocol 
The Investigator may not modify or alter the procedures described in this protocol and is required to 
strictly adherence to all specifications laid down in this protocol for all aspects of study conduct. 
Neither the Sponsor nor the Investigator will implement protocol amendments or modifications to the 
study protocol without agreement by both parties. However, the Investigator or the Sponsor may 
implement a deviation from, or a change to the protocol to eliminate an immediate hazard to patients 
without prior HREC/IEC/IRB/Sponsor approval. In this case, the implemented deviation or change, 
the reasons for it, and if appropriate, the proposed protocol amendment should be submitted to the 
IEC/IRB/head of medical institution and Sponsor as soon as possible.  
Any deviations from the protocol must be explained and documented by the Investigator. 
12.1.5 Confidentiality 
The Investigator must assure that patients’ anonymity will be strictly maintained and that their 
identities are protected from unauthorized parties. Only patient initials and an identification code (i.e., 
not names) should be recorded on any form submitted to the Sponsor and IRB/HREC.  The 
Investigator must keep a patient log showing codes, names, and addresses for all patients screened and 
for all patients enrolled in the study. 
12.1.6 Study Files and Retention of Records 
The Investigator must maintain adequate and accurate records to enable the conduct of the study to be 
fully documented and the study data to be subsequently verified.  These documents should be 


 
 
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classified into 2 separate categories (although not limited to) the following: (1) Investigator’s study 
file, and (2) Patient clinical source documents. 
The Investigator’s study file will contain the protocol/amendments, CRF and query forms, IRB/HREC 
approval with correspondence, informed consent, drug records, staff curriculum vitae and 
authorization forms, and other appropriate documents and correspondence. 
Patient clinical source documents would include (although is not limited to) the following: patient 
hospital/clinic records, physician’s and nurse’s notes, appointment book, original laboratory reports, 
ECG, electroencephalogram (EEG), EMG, X-ray, MRI, pathology and special assessment reports, 
consultant letters, screening and enrollment log, etc. 
All clinical study documents must be retained by the Investigator until at least two years after the last 
approval of a marketing application in an International Conference on Harmonization (ICH) region 
(i.e., United States, Europe, or Japan) and until there are no pending or contemplated marketing 
applications in an ICH region; or, until two years after the IND is discontinued and regulatory 
authorities have been notified. The Investigator must notify Sponsor prior to destroying any clinical 
study records. 
Should the Investigator wish to move study records to another location, arrangements must be made 
to store these in sealed containers so that they can be returned sealed to the Investigator in case of a 
regulatory audit.  Where source documents are required for the continued care of the Patient, 
appropriate copies should be made for storage outside of the site. 
12.1.7 Case Report Forms 
For each Patient who receives study drug, a CRF must be completed and signed (electronically signed 
if eCRF) by the Principal Investigator or sub-Investigator within a reasonable period after data 
collection.  This also applies to records for those patients who fail to complete the study.  If a patient 
withdraws from the study, the reason must be noted on the eCRF.  If a patient is withdrawn from the 
study because of a treatment-limiting adverse event, thorough efforts should be made to clearly 
document the outcome. 
12.1.8 Drug Accountability 
The Investigator or designee (i.e., pharmacist) is responsible for ensuring adequate accountability of 
all used and unused study drug. This includes acknowledgment of receipt of each shipment of study 
product (quantity and condition) and Patient dispensing records and returned or destroyed study 
product. Dispensing records will document quantities received and quantities dispensed to Patients, 


 
 
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including lot/batch number, date dispensed, Patient identifier number, Patient initials, and the initials 
of the person dispensing or witnessing dispensing of the study medication. 
At study initiation, the monitor will evaluate the site’s SOP for study drug disposal/destruction in 
order to ensure that it complies with study requirements.  Following unblinded study drug 
reconciliation by the unblinded monitor, the study site will be instructed by the Sponsor to destroy and 
unused or returned study drug. 
12.1.9 Inspections 
The Investigator will provide access to source documents and all study records for this study to 
appropriately qualified personnel from the Sponsor or its representatives, and to regulatory authority 
inspectors. 
12.2 Sponsor Responsibilities 
12.2.1 Study Materials and Instructions 
It is the Sponsor’s responsibility to ensure that the Investigator is provided with the documents and 
other study materials necessary to conduct the study.  Examples of those materials include, but are not 
limited to: protocol, Investigator’s Brochure, study drug, eCRF, SAE collection forms, logs, etc.  The 
Sponsor will also provide training and oversight through site and medical monitoring. 
12.2.2 Protocol Modifications 
Protocol modifications, except those intended to reduce immediate risk to study patients, will be made 
by Sponsor-initiated amendment.  IRB/HREC approval must be obtained before changes can be 
implemented except for non-substantial amendments (e.g., changes in study staff or contact details or 
minor changes in the packaging or labeling of the investigational product) as described below. 
Administrative or logistical minor changes will require a non-substantial amendment.  Non-
substantial amendments will be approved (signed) by the Investigator(s) and will be recorded and 
filed by the Investigator/Sponsor and the Ethics Committee (EC) and the Competent Authority (CA) 
may or may not be notified per local regulatory guidelines.  The implementation of a non-substantial 
amendment can be done without notification or approval to the appropriate EC or CA.  
The following amendments will be regarded as non-substantial: 
• 
Change in timing of the samples; 
• 
Changes in assay-type and/or institution where an assay will be performed, provided that 
validated assays will be used; 


 
 
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• 
Editorial changes to the patient information sheets; 
• 
Determination of additional parameters in already collected materials, which agree with the 
study objectives and do not provide prognostic or genetic information; 
• 
Other statistical analyses than described in the protocol. 
12.2.3 Insurance 
The Sponsor maintains clinical trial insurance coverage for this study in accordance with the laws and 
regulations of the country in which the study is performed. 
12.2.4 Premature Study Termination 
The Sponsor has the right to prematurely close this study or, if applicable, individual segments of the 
study, including but not limited to: treatment arms, study sites, titration steps, and study procedures; if 
at any time the risk-benefit profile of the investigational product, center conduct, or specific study 
treatment segment becomes unacceptable due to: 
• 
Safety findings from this study (e.g., SAEs) 
• 
Procedural issues or protocol violations from a study site that potentially affects patient 
safety 
• 
Safety findings from other parallel studies in different patient populations 
• 
Results from animal toxicology studies (e.g., toxicity, teratogenicity, carcinogenicity, or 
reproduction toxicity). 
Should premature termination be necessary, the Sponsor and Investigator will arrange discontinuation 
procedures and notify the appropriate regulatory authorities, IRBs and HRECs.  In terminating the 
study, the Sponsor and the Investigator will assure that adequate consideration is given to the 
protection of the Patients’ interests. 
12.3 Joint Investigator/Sponsor Responsibilities 
12.3.1 Access to Information for Monitoring 
In accordance with International Conference on Harmonization Good Clinical Practice (ICH-GCP) 
guidelines, the study monitor must have direct access to the Investigator’s source documentation in 
order to verify the data recorded in the CRFs for consistency. 
The monitor is responsible for routine review of the CRFs at regular intervals throughout the study, to 
verify adherence to the protocol, and the completeness, consistency and accuracy of the data being 
entered on them. The monitor should have access to any patient records needed to verify the entries 


 
 
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on the CRFs.  The Investigator agrees to cooperate with the monitor to ensure that any problems 
detected in the course of these monitoring visits are resolved. 
12.3.2 Study Report and Publications 
After conclusion of the study, Investigators in this study may communicate, orally present, or publish 
in scientific journals or other scholarly media only after the following conditions have been met: 
• 
The results of the study in their entirety have been publicly disclosed by or with the consent 
of Sponsor in an abstract, manuscript, or presentation form; or 
• 
The study has been completed for at least 2 years. 
No such communication, presentation, or publication will include Sponsor’s confidential information. 
Any information, inventions, or discoveries (whether patentable or not), innovations, suggestions, 
ideas, and reports, made or developed by the Investigator(s) as a result of conducting this study shall 
be promptly disclosed to the Sponsor and shall be the sole property of the Sponsor.  The Investigator 
agrees, upon the Sponsor’s request and at the Sponsor’s expense, to execute such documents and to 
take such other actions, as the Sponsor deems necessary or appropriate to obtain patents in the 
Sponsor’s name covering any of the foregoing. 
The Investigator will submit any proposed publication or presentation along with the respective 
scientific journal or presentation forum to the Sponsor at least 30 days prior to submission of the 
publication or presentation.  The Investigator will comply with Sponsor’s request to delete references 
to its confidential information (other than the study results) in any paper or presentation and agrees to 
withhold publication or presentation for an additional 60 days in order to obtain patent protection if 
deemed necessary. 
 
 


 
 
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13 PROTOCOL AMENDMENTS 
A protocol amendment to version 1.0 of clinical protocol CNMAu8.205 was performed on 
06September2019 to included added safety follow-up telephone calls as requested by the reviewing 
Human Research Ethics Committee (Sydney Local Health District). These changes will be noted in a 
supplementation summary of changes submitted alongside the revised protocol.  
A protocol amendment to version 2.0 of clinical protocol CNMAu8.205 was performed on 
27November2019 to remove the ENCALS inclusion criteria, stratification language, and clarification 
on inconsistencies between sections of the protocol and the PD analysis plan. These changes will be 
noted in a supplementation summary of changes submitted alongside the revised protocol. 
A protocol amendment to Version 3.0 of clinical protocol CNMAu8.205 was finalized on 
03March2020 to increase the age range of participation and provide additional clarity surrounding 
study parameters. These changes will be noted in a supplementation summary of changes submitted 
alongside the revised protocol. 
A protocol amendment to Version 4.0 of clinical protocol CNMAu8.205 was finalized on 
08September2020 to include the optional Open-Label Extension Period of the trial. These changes 
will be noted in a supplemententation summary of changes submitted alongside the revised protocol.  
A protocol amendment to Version 5.0 of clinical protocol CNMAu8.205 was finalized on 14May2021 
to clarify presentation of the primary endpoint as the summed MUNIX(4) change instead of the 
average MUNIX(4) change. Forced vital capacity was moved from an exploratory endpoint to 
secondary endpoint in order to include a clinical endpoint in the analysis hierarchy. Additionally, on 
27July2021 an administrative amendment was was finalized to correct the contact details for one of 
the participating Investigators. These changes will be noted in a supplemententation summary of 
changes submitted alongside the revised protocol.  
A protocol amendment to Version 6.1 of the clinical protocol CNMAu8.205 was finalized on 
04October2021 to extend the OLE phase beyond 48-weeks until discontinued by the Sponsor. These 
changes will be noted in a supplementation summary of changes submitted alongside the revised 
protocol. 
 


 
 
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14 APPENDICES 
Appendices to this version include: 
• 
American Heart Association: Recommendations for Blood Pressure Measurement in Humans 
and Experimental Animals (Pickering et al., 2005). 
• 
Sponsor Outlier Criteria based upon the CTCAE (v5.0; November 27, 2017).  
 
 


 
 
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