Clinical trial NCT03843541
Conditions: Respiratory Tract Diseases Abnormal Mucus Secretions
Keywords: N-acetylcysteine (NAC) ambroxol hydrochloride bronchitis cystic fibrosis fibrosis bronchiectasis increased sputum viscosity cough Chronic Obstructive Pulmonary Disease (COPD)
Sponsor: Zambon SpA
Start date: 2019-06-25; Completion date: 2021-02-05
Enrollment: 333 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
This is a phase 3, multicenter, randomized, rater- and patient-blind, placebo- and active-controlled, 3-arm parallel group clinical trial. Patients will be randomized to N-acetylcysteine (NAC) or ambroxol or placebo in a 1:1:1 ratio. A total of approximately 333 patients in China will be randomized. The total study duration will be approximately 8 months including the enrolment period of approximately 7 months and the patient participation duration of 1 month or 4 weeks. Each patient will undergo a screening period of up to 1 week, a 1-week treatment period and a 2-week follow-up period. This study will be conducted in approximately 15-25 sites in China.

Detailed description:

Arms: arm 1: NAC 600mg will be administered by slow intravenous infusion twice daily for the 1-week treatment period. arm 2: Ambroxol hydrochloride 30 mg will be administered by slow intravenous infusion twice daily for the 1-week treatment period. arm 3: Placebo will be administered by slow intravenous infusion twice daily for the 1-week treatment period.
Interventions: intervention 1: N-acetylcysteine (NAC) 600 mg intervention 2: Ambroxol hydrochloride 30 mg intervention 3: placebo
Intervention descriptions: intervention 1: NAC will be administered twice a day, morning and evening, during treatment period. intervention 2: Ambroxol hydrochloride will be administered twice a day, morning and evening, during treatment period. intervention 3: Placebo will be administered twice a day, morning and evening, during treatment period.

Protocol documents:
Prot_000.pdf: 
• Protocol number: Z7244L01
• Document title: A Phase III, multi-centre, randomized, rater- and patient blind, placebo- and active-
controlled, parallel group clinical trial to compare the safety and efficacy of 1-week treatment with
intravenous N-acetylcysteine (NAC) 600 mg twice daily (active test treatment), ambroxol hydrochloride
30 mg twice daily (active control treatment) and placebo as expectorant therapies in adult Chinese
Patients with respiratory tract diseases and abnormal mucus secretions
• NCT number: NCT03843541
• Version number: 2.0
• Date of the document: 19 Dec 2018


Final Version 1.0 - 29 August 2018 
Page 1 of 65 
CLINICAL TRIAL PROTOCOL
INTRAVENOUS NAC PHASE III CHINA CLINICAL TRIAL 
(IVNAC-3C) 
A PHASE III, MULTI-CENTRE, RANDOMIZED, RATER- AND PATIENT-BLIND, 
PLACEBO- AND ACTIVE-CONTROLLED, PARALLEL GROUP CLINICAL TRIAL 
TO COMPARE THE EFFICACY AND SAFETY OF 1-WEEK TREATMENT WITH 
INTRAVENOUS N-ACETYLCYSTEINE (NAC) 600 MG TWICE DAILY (ACTIVE 
TEST TREATMENT), AMBROXOL HYDROCHLORIDE 30 MG TWICE DAILY 
(ACTIVE CONTROL TREATMENT) AND PLACEBO AS EXPECTORANT 
THERAPIES IN ADULT CHINESE PATIENTS WITHRESPIRATORY TRACT 
DISEASES AND ABNORMAL MUCUS SECRETIONS 
Protocol Code 
Z7244L01 
Protocol Name 
IVNAC-3C (IntraVenous NAC – Phase 3 China Trial) 
Final Date: 29 August 2018 
Version: Version 1.0 
Zambon SpA 
Via Lillo del Duca 10 
20091 Bresso - Milan – Italy 
THIS DOCUMENT IS ZAMBON'S SOLE PROPERTY AND OWNERSHIP. THIS DOCUMENT, AND ALL 
INFORMATION AND DATA CONTAINED HEREIN HAS TO BE CONSIDERED AND TREATED AS 
STRICTLY CONFIDENTIAL. THIS DOCUMENT SHALL BE USED ONLY FOR THE PURPOSE OF THE 
DISCLOSURE HEREIN PROVIDED. NO DISCLOSURE OR PUBLICATION SHALL BE MADE WITHOUT 
THE PRIOR WRITTEN CONSENT i1OF ZAMBON.  








 
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1. TABLE OF CONTENTS 
 
APPROVAL PAGE .............................................................................................................2 
ZAMBON CONTACT DETAILS ..........................................................................................3 
CONTRACT RESEARCH ORGANISATION CONTACT DETAILS .....................................3 
OTHER INSTITUTIONS .....................................................................................................3 
LIST OF COMMITTEES .....................................................................................................4 
1. 
Table of Contents .....................................................................................................5 
2. 
Abbreviations ............................................................................................................8 
3. 
Summary ................................................................................................................ 10 
4. 
Introduction and Rationale ...................................................................................... 18 
5. 
Evaluation of the Anticipated Risks/Benefit Ratio ................................................... 19 
6. 
Objectives ............................................................................................................... 20 
7. 
Ethics Requirements .............................................................................................. 21 
8. 
Design and Duration of the Clinical Trial ................................................................ 21 
8.1. 
Clinical Trial Design ......................................................................................... 21 
8.2. 
Duration of Clinical Trial ................................................................................... 22 
9. 
Clinical Trial Population .......................................................................................... 22 
9.1. 
Number of Subjects ......................................................................................... 22 
9.2. 
Selection of Subjects ....................................................................................... 22 
9.2.1. Inclusion Criteria ....................................................................................................... 22 
9.2.2. Exclusion Criteria ...................................................................................................... 22 
10. 
Overall Clinical Trial Schedule ................................................................................ 23 
10.1. 
Visit 1 - Screening Visit .................................................................................... 23 
10.2. 
Visit 2 - Randomisation Visit (Day 1)- (WITHIN 7 DAYS OF VISIT 1) .............. 24 
10.3. 
DAY 2 .............................................................................................................. 24 
10.4. 
Visit 3 (Day 3) .................................................................................................. 25 
10.5. 
DAY 4 .............................................................................................................. 25 
10.6. 
DAYS 5 and 6 .................................................................................................. 25 
10.7. 
Visit 4 (day 7) ................................................................................................... 25 
10.8. 
DAY 8 .............................................................................................................. 26 
10.9. 
Follow-up Phone Call or Visit (2 weeks ± 3 days after THE LAST ADMINISTRATION OF 
imp) .................................................................................................................. 26 
10.10. unscheduled DETERIORATION Visit .............................................................. 26 
10.11. premaTURE DISCONTINUATION VISIT ......................................................... 27 
11. 
Methodology ........................................................................................................... 27 
11.1. 
Methods of Assessment ................................................................................... 27 


 
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11.1.1. 
Demography and Medical History ......................................................................... 27 
11.1.2. 
Physical Examination ............................................................................................ 27 
11.1.3. 
Vital Signs ............................................................................................................. 27 
11.1.4. 
Laboratory Evaluations .......................................................................................... 28 
11.1.5. 
Efficacy Evaluations .............................................................................................. 28 
11.1.6. 
Safety Evaluations ................................................................................................. 29 
11.2. 
ADHERENCE WITH IMP DOSING REGIMEN ................................................ 30 
11.3. 
Pharmacodynamics ......................................................................................... 30 
11.4. 
Pharmacokinetics ............................................................................................. 30 
12. 
PRIOR AND Concomitant Treatments ................................................................... 30 
13. 
Investigational Medicinal Product ........................................................................... 31 
13.1. 
Investigational Medicinal Product Supplies and Packaging ............................. 31 
13.2. 
Investigational Medicinal Product Dispensing and Administration ................... 31 
13.3. 
Randomisation ................................................................................................. 32 
13.4. 
Investigational Medicinal Product Accountability ............................................. 32 
14. 
Clinical Trial Amendments ...................................................................................... 33 
15. 
Deviations from the Clinical Trial Protocol .............................................................. 33 
15.1. 
Code Breaking ................................................................................................. 33 
16. 
Clinical Trial Withdrawals/Drop-outs ....................................................................... 33 
17. 
Stopping and Discontinuation Criteria for the Trial ................................................. 34 
18. 
Reporting Safety Information .................................................................................. 34 
18.1. 
Definition of Adverse Event .............................................................................. 34 
18.2. 
Definition of Adverse Event of Special Interest ................................................ 35 
18.3. 
Definition of Adverse Drug Reaction ................................................................ 35 
18.3.1. 
Definition of Unexpected Adverse Drug Reaction ................................................. 35 
18.3.2. 
Definition of Medical Device Malfunction and Incident .......................................... 35 
18.4. 
Definition of Serious Adverse Events or Serious Adverse Drug ReactionS ..... 36 
18.4.1. 
Definition of Serious Adverse Event OR Serious Adverse Reaction ..................... 36 
18.4.2. 
Definition of Suspected Unexpected Serious Adverse Reactions ......................... 36 
18.5. 
Definition of Severity of Adverse Events .......................................................... 36 
18.6. 
Definition of Adverse Event Causality .............................................................. 37 
18.7. 
Adverse Event Recording ................................................................................ 37 
18.8. 
Adverse Event monitoring window ................................................................... 37 
18.9. 
Adverse Event Reporting ................................................................................. 37 
18.9.1. 
Reporting Serious Adverse Events ........................................................................ 37 
18.9.2. 
Reporting Adverse Events of Special Interest ....................................................... 38 
18.10. Follow-up for Adverse Events .......................................................................... 38 
18.11. Pregnancy ........................................................................................................ 38 


 
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19. 
Records .................................................................................................................. 39 
19.1. 
Case Report Forms, SOURCE DATA AND QUERY RESOLUTION ............... 39 
19.2. 
Records Maintained by the Investigator ........................................................... 39 
19.3. 
Trial Master File ............................................................................................... 39 
19.4. 
Trial Monitoring ................................................................................................ 40 
19.5. 
Confidentiality of Subject’s Information ............................................................ 40 
20. 
Biometrics ............................................................................................................... 40 
20.1. 
Data MANAGEMENT ....................................................................................... 40 
20.2. 
STUDY END-POINTS ...................................................................................... 41 
20.3. 
Sample Size ..................................................................................................... 41 
20.4. 
Statistical Analyses .......................................................................................... 42 
20.4.1. 
General Statistical Considerations ........................................................................ 42 
20.4.2. 
Trial Populations .................................................................................................... 43 
20.4.3. 
Efficacy Data ......................................................................................................... 44 
20.4.4. 
HANDLING OF MISSING DATA ........................................................................... 45 
20.4.5. 
multiplicity .............................................................................................................. 45 
20.4.6. 
multicenter study ................................................................................................... 46 
20.4.7. 
Interim Analyses .................................................................................................... 46 
20.4.8. 
Safety Data ........................................................................................................... 46 
21. 
Informed Consent ................................................................................................... 47 
22. 
Ethics Committee Approval .................................................................................... 47 
23. 
Regulatory Requirements ....................................................................................... 47 
24. 
Quality Assurance .................................................................................................. 48 
25. 
Insurance ................................................................................................................ 48 
26. 
Clinical Trial Report ................................................................................................ 48 
27. 
Use of Information and Publication ......................................................................... 48 
28. 
References ............................................................................................................. 50 
29. 
Appendices ............................................................................................................. 51 
 
 
 


 
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2. ABBREVIATIONS 
ADR 
Adverse Drug Reaction 
AE 
Adverse Event 
AH  
Ambroxol hydrochloride 
ALP                     Alkaline phosphatase 
ALT                     Alanine aminotransferase 
AST 
Aspartate aminotransferase 
BUN 
Blood Urea Nitrogen 
CA 
Competent Authority 
C-FDA 
Chinese Food and Drug Administration 
COPD 
Chronic Obstructive Pulmonary Disease 
CRO 
Contract Research Organisation 
CTP 
Clinical Trial Protocol 
CTR 
Clinical Trial Report 
DV 
Deterioration Visit 
EC 
Ethics Committee 
ECG 
Electrocardiogram 
eCRF 
Electronic case report form 
EM 
Expectation-Maximization 
EMA 
European Medicines Agency 
EoT 
End of Treatment 
EU 
European Union 
GCP 
Good Clinical Practice 
γGT 
gamma glutamyl transferase 
GSH  
Glutathione 
HOCl 
Hypochorous acid 
IB 
Investigator Brochure 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
IMP 
Investigational Medicinal Product  
IMPD                   Investigational Medicinal Product Dossier 
ITT 
Intention-to-treat 
IV 
Intravenous 
IUD 
Intrauterine Device 
IUS 
Intrauterine hormone-releasing system 
IWRS 
Interactive Web Response System 
Kg 
Kilograms 
LOCF 
Last Observation Carried Forward 
MC 
Monte Carlo 
MedDRA  
Medical dictionary for regulatory activities 
mg 
 
 
Milligram 
mITT 
Modified Intention to Treat 
ml 
 
 
Milliliter 
MVTF                  Missing Value Treatment Failure  


 
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NAC 
N-acetylcysteine 
NaCl 
Sodium chloride 
PI 
Package Insert 
PP 
Per-protocol population 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SAR 
Serious Adverse Reaction 
SmPC 
Summary of Product Characteristics  
SOPs 
Standard Operating Procedures 
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
TCM 
Traditional Chinese Medicine 
TEAE 
Treatment Emergent Adverse Event 
TMF 
Trial Master File 
US-FDA  
United States Food and Drug Administration 
WHO-DD  
World Health Organization-drug dictionary  
WOCF 
Worst Observation Carried Forward 
 
 
 


 
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3. SUMMARY 
 
Title: 
Intravenous NAC Phase III China Trial 
A phase III, multi-centre, randomized, rater- and patient-blind, 
placebo- and active-controlled, parallel group clinical trial to 
compare the efficacy and safety of 1-week treatment of 
intravenous N-acetylcysteine (NAC) 600 mg twice daily (active test 
treatment), ambroxol hydrochloride 30 mg twice daily (active 
control treatment) and placebo as expectorant therapies in adult 
Chinese patients with respiratory tract diseases and abnormal 
mucus secretions  
Protocol 
Code/ 
Protocol Name: 
 
 
 
Z7244L01  
IVNAC-3C (IntraVenous NAC – Phase 3 China Trial) 
Phase:  
III 
 
Treatments 
  
Active test treatment 
Ampoule containing 300 mg N-acetylcysteine (NAC) in 3 ml 
(Zambon Spa, Vicenza, Italy). 
Two ampoules (NAC 600 mg) in 10 ml NaCl 0.9% saline solution, 
administered by slow (at least 5 minutes) intravenous infusion 
twice a day, morning before 9 am and afternoon/evening 
approximately 12 hours apart for 1 week (7 days). Total daily NAC 
dose: 1200 mg/day.   
 
Active control treatment 
Vial containing 15 mg Ambroxol Hydrochloride (AH) in 2 ml 
(Boehringer Ingelheim, Shanghai, China). 
Two vials (AH 30 mg) in 10 ml NaCl 0.9% saline solution
administered by slow (at least 5 minutes) intravenous infusion 
twice a day, morning before 9 am and afternoon/evening 
approximately 12 hours apart for 1 week (7 days). Total daily AH
dose: 60 mg.  
 
Placebo treatment 
Vial containing 10ml NaCl 0.9% saline solution (China Otsuka 
Pharmaceutical Co., Ltd.) 
One vial of 10 ml NaCl 0.9% saline solution administered by slow
(at least 5 minutes) intravenous infusion twice a day, morning 
before 9 am and afternoon/evening approximately 12 hours apart
for 1 week (7 days). 
 
 
 


 
Final Version 1.0 - 29 August 2018 
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Objectives: 
 
Efficacy objectives 
Primary objective 
Demonstrate that slow (at least 5 minutes) intravenous infusion of 
NAC 600 mg twice daily is superior to placebo in change from 
baseline to the end of 1-week treatment of sputum viscosity score 
or expectoration difficulty score in adult Chinese hospitalized 
patients with respiratory tract diseases and abnormal mucus 
secretions 
 
 
Secondary objectives 
Efficacy objectives 
Demonstrate in the same patient population that: 
- slow (at least 5 minutes) intravenous infusion of NAC 600 mg 
twice daily is superior to placebo in change from baseline to day 3 
and end of 1-week treatment of other indicators of mucolytic 
activity (individual sputum viscosity and expectoration difficulty 
scores, cough score, mucous color score and mucous volume);  
- slow (at least 5 minutes) intravenous infusion of NAC 600 mg 
twice daily is non-inferior to slow intravenous infusion of ambroxol
hydrochloride 30 mg twice daily in change from baseline to the end 
of 1-week treatment of sputum viscosity score or expectoration 
difficulty score; 
- slow (at least 5 minutes) intravenous infusion of ambroxol
hydrochloride 30 mg twice daily is superior to placebo in change 
from baseline to day 3 and to the end of 1-week treatment of 
sputum viscosity score or expectoration difficulty score and of 
other indicators of mucolytic activity: individual sputum viscosity 
and expectoration difficulty scores, cough score, mucous color 
score and mucous volume. 
Safety objectives 
- 
Confirm that 1-week treatment with iv NAC 600 mg twice 
daily is safe and well tolerated. 
 
Design: 
Multicenter, randomized, rater- and patient-blind, placebo- and 
active-controlled, 3-arm parallel group clinical trial. 
Subjects will be randomized to NAC or ambroxol or placebo in a 
1:1:1 ratio. 
The study will consist of a total of 4 core hospital visits and a follow-
up call 2 weeks after end of treatment. If the patient is still 
hospitalized or if more convenient for the patient, the follow-up 
phone call can be replaced by a follow-up hospital visit. 
 
 
Number of patients: 
 
 
 
 
 
 
 
A total of 333 patients will be randomized. This number includes 
10% overage to allow for patients who discontinue the trial 
prematurely (“drop-outs”) without contributing to the primary end-
point. 
 
 


 
Final Version 1.0 - 29 August 2018 
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Trial duration: 
 
 
Duration of patient 
participation: 
 
Participating Countries:        
 
 
Number of Sites: 
Approximately 8 months. The enrolment period will be 
approximately 7 months.  
 
 
Up to 4 weeks. Each patient will undergo a screening period of up 
to 1 week, a 1-week treatment period and a 2-week follow-up 
period. 
China 
 
 
Approximately in the range of 15-25  
 
Population: 
Inclusion criteria 
Patients will be enrolled in the trial if all of the following criteria 
are met:  
1. Male or female adult (≥18 years old) hospitalized patients 
with respiratory tract diseases and abnormal mucus 
secretions such as : acute bronchitis, chronic bronchitis 
and exacerbations, emphysema, mucoviscidosis and 
bronchiectasis Chinese ethnicity and/or Chinese  
2. Signed the informed consent form before any study-
related procedure 
3. Sputum viscosity score ≥ 2 at randomization visit 
4. Expectoration difficulty score ≥ 2 at randomization visit  
5. Willingness and ability to comply with study procedures 
 
Exclusion criteria 
Patients will not be enrolled if one or more of the following criteria 
are met: 
1. Intolerance or contra-indication to treatment with NAC or 
ambroxol or allergy to any component of the study 
treatments 
2. (For female patients) ongoing pregnancy or lactation, or 
childbearing potential but unwillingness to adopt 
abstinence or contraception measures during the study 
3. Intake of an investigational drug within 1 month before the 
screening visit 
4. Use of expectorants or drugs with expectorant effect 
within 3 days before randomization visit 
5. Medical history of and/or illness (including laboratory 
abnormality) and/or treatment that in the investigator’s 
opinion may interfere with the patient’s safety, compliance, 
or study evaluations 
6. Serum ALT and/or AST more than 3 times above the 
upper limit of normal at screening visit 
7. Serum creatinine more than 3 times above the upper limit 
of normal at screening visit 


 
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8. Addiction to alcohol or drugs 
9. Mental illness, or other reasons for non-cooperation in the 
investigator’s opinion 
 
Outcome measures: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
End-points: 
      Efficacy variables 
 Sputum viscosity, expectoration difficulty, sputum color and 
cough are assessed by means of ordinal categorical 4-point 
scales with 0 = best and 3= worst.  
For each patient the assessment is to be carried out by the 
blinded rater on treatment days 1 (baseline), 3 and 7 in the 
morning between 7 am and 9 am before administration of 
study drug. Should a patient discontinue prematurely from 
the trial (including discharge from the hospital before day 7) 
an assessment should be conducted on the day of 
discharge whenever possible.  
Scoring criteria are as follows: 
 
 
0 
1 
2 
3 
Sputum 
viscosity 
Liquid 
(normal 
viscosity)
 
Fluid  
(mildly 
increased 
viscosity) 
Viscous  
(moderately 
increased 
viscosity) 
Sticky 
(severely 
increased 
viscosity) 
Expectoration 
difficulty 
No 
difficulty 
Mild 
difficulty 
Moderate 
difficulty 
Marked 
difficulty 
 
Sputum  
Color 
Mostly 
white 
Mostly 
pale 
yellow 
Mostly dark 
yellow 
Very dark 
yellow 
/green 
Cough 
 
No 
cough 
Sporadic 
and mild 
cough 
Moderate 
cough 
Severe 
Cough 
Adapted from [12]. 
 Sputum volume: patients will collect 24-hour sputum 
(morning to same time of the following morning) in a 
graduated cup on treatment days 1 (Baseline), 3 and 7. 
Volume will be expressed as mL/24h. 
 
Safety variables 
 Adverse events assessed for severity and seriousness. 
 Laboratory measurements including hematology, liver 
enzymes, serum creatinine. 
 12-lead electrocardiogram 
 
Primary efficacy end-point 
Superiority of NAC over placebo in change from baseline to end 
of 1-week treatment of mean sputum viscosity score or mean 
expectoration difficulty score.


 
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The study will be declared success if at least one of two 
components of the primary end-point will show superiority over 
placebo.  
 
Secondary efficacy end-points 
A. Superiority of NAC over placebo: 
 in change from baseline to day 3 of mean sputum viscosity 
score OR mean expectoration difficulty score;  
 in change from baseline to day 3 and to end of 1-week 
treatment of individual scores:  
 mean sputum viscosity score 
 mean expectoration difficulty score 
 mean sputum color score 
 mean cough score 
 in change from baseline to day 3 and to end of 1-week 
treatment of mean sputum volume  
  
B. Non-inferiority of NAC vs. ambroxol in change from baseline 
to end of 1-week treatment of mean sputum viscosity score or 
change of mean expectoration difficulty score. 
 
C. Superiority of ambroxol vs. placebo in change from baseline 
to day 3 and to end of 1-week treatment of  
 mean sputum viscosity score OR mean 
expectoration difficulty score;  
 mean sputum viscosity score (individual score) 
 mean expectoration difficulty score (individual 
score) 
 mean sputum color score 
 mean cough score 
 mean sputum volume 
 
Safety end-points 
Counts and frequency distributions of 
 all, mild/moderate/severe, non-serious/serious adverse 
events  
 vital signs  
 Laboratory tests  
 12-lead ECG (normal, abnormal clinically non- significant, 
abnormal clinically significant) 
 
 
 


 
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Statistical Analysis: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sample size justification 
This study has been powered to reach statistical significance for 
the superiority comparisons of N-acetyl-cysteine (NAC) vs. 
placebo (primary study objective), and for the non-inferiority 
comparisons of NAC vs. ambroxol hydrochloride (secondary 
study objective) in at least one of the two co-primary endpoints at 
the end of the 1-week treatment. To control the overall type I 
family-wise error rate at the one-tailed 0.025 significance level, a 
multiple-sequence gatekeeping procedure was implemented in a 
Monte Carlo study with 1000 runs and with the Bonferroni 
correction applied to the set of superiority comparisons (first 
gatekeeper) and the Hochberg correction applied to the set of 
non-inferiority comparisons (second gatekeeper). 
For the superiority tests, and with group sample sizes of 100 
patients in placebo group and 100 patients in NAC group, the 
Monte Carlo study estimated an overall power (“disjunctive” 
power) close to 93% to reach statistical significance in at least 
one co-primary end-point. These calculations are based on a one-
sided Mann-Whitney test and assuming a minimal clinically 
relevant difference of 0.35 points between placebo and NAC on a 
0-3-point scale, standard deviation equal to 0,79 and 0,77 for 
sputum viscosity and expectoration difficulty scores (change from 
baseline to the 1-week treatment) respectively and a correlation 
between the two end-points equal to 0.31. 
For the non-inferiority tests, a sample of 100 patients per each 
active treatment group ensures sufficient disjunctive power 
(Monte Carlo disjunctive power = 82%) to detect non-inferiority 
between NAC and ambroxol in at least one co-primary end-point. 
These calculations are based on a one-sided non-inferiority t-test 
assuming a margin of non-inferiority equal to 0.30, standard 
deviation equal to 0,79 and 0,77 for sputum viscosity and 
expectoration difficulty scores (change from baseline to the 1-
week treatment) respectively and a correlation between the two 
endpoints equal to 0.31. 
Assuming a drop-out rate of about 10% over one week of entry, a 
total of 333 patients will be randomized (i.e. 111 patients in the 
placebo group, 111 patients in the NAC group and 111 patients 
in the ambroxol group). 
 
Statistical methods 
All efficacy analyses will be performed on the Modified Intention 
to Treat (mITT) population. Analysis of the primary and secondary 
efficacy variables will be also carried out on the Per Protocol (PP) 
population to assess the robustness of the findings. Safety 
outcomes will be analysed on the Safety population.  
The primary efficacy end-points “change from baseline to the 1-
week treatment in sputum viscosity score and change from 
baseline to the 1-week treatment in expectoration difficulty score” 
will be analysed by means of conventional Mann-Whitney U 
Statistic for testing the hypotheses of superiority of NAC versus 
placebo and by means of the non-inferiority variant of the Mann-
Whitney U Statistic for testing the hypotheses of non-inferiority of 


 
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Concomitant Treatments 
NAC versus ambroxol. Statistical significant results will be 
needed on both mITT and PP populations to accept the 
hypothesis of non-inferiority of NAC versus ambroxol. Point 
estimates of treatment differences together with associated two-
sided 95% confidence intervals will be computed using 
nonparametric bootstrap. 
The overall type I family-wise error rate for testing the co-primary 
endpoints in superiority and non-inferiority assessments will be 
controlled at the one-tailed 0.025 significance level using a 
multiple-sequence gatekeeping procedure. This procedure will be 
fully described in the protocol. 
The same approach will be taken for the supportive secondary 
end-point “superiority of NAC over placebo in change from 
baseline to day 3 of mean sputum viscosity score or mean 
expectoration difficulty score”. 
As for the supportive secondary efficacy end-points concerning 
individual scores (sputum viscosity, expectoration difficulty, 
sputum colour, cough) or measured on continuous scale (sputum 
volume), the hypothesis of superiority of NAC compared to 
placebo will be assessed using the same nonparametric test 
(Mann-Whitney U Statistic), whilst point estimates of treatment 
differences together with associated two-sided 95% confidence 
intervals will be computed using nonparametric bootstrap.  
 
The same statistical analysis (Mann-Whitney Test) will be carried 
out for testing superiority of ambroxol vs placebo on the same 
efficacy endpoints. Results will be used for the purpose of 
verifying study’s assay sensitivity. 
 
For the analyses of supportive secondary efficacy end-points no 
adjustment of significance level will be made to account for 
multiple comparisons. 
 
Missing data on the primary and secondary efficacy endpoints will 
be imputed as treatment failures (MVTF) by replacing missing 
values using the worst observation carried forward (WOCF) as 
primary imputation method (namely baseline or follow-up 
measurement, whichever is worse, and using expectation-
maximization (EM) algorithm and last observation carried forward 
(LOCF) as sensitivity analyses. 
 
 
 
Permitted  
 Appropriate treatment(s) for any respiratory tract 
disease, that in the investigator’s opinion will not interfere 
with the measurements contributing to the efficacy 
outcomes, such as: corticosteroids (inhaled or systemic), 


 
Final Version 1.0 - 29 August 2018 
Page 17 of 65 
bronchodilators, antibiotics (in case of co-administration, 
the i.v. antibiotic should be administered separately). 
 Appropriate treatment(s) for any other underlying 
disease, that in the investigator’s opinion will not interfere 
with the measurements contributing to the efficacy 
outcomes 
 If co-treatment with parenteral nitroglycerin is needed the 
patients should be monitored for potential hypotension, 
which may be severe and may be indicated by the 
presence of headache  
   
 If one or more treatments interfering with the 
measurements contributing to the primary efficacy 
outcomes are deemed necessary, the patient should not 
be randomized or should be discontinued from the study.
Not permitted  
 Expectorants 
 Antitussive agents  
 Sedatives  
 Traditional Chinese Medicine (TCM) treatments. 
 
 
 
 
 
 
 
 
 
 
 


 
Final Version 1.0 - 29 August 2018 
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4. INTRODUCTION AND RATIONALE 
Background  
Numerous respiratory diseases, including acute and chronic bronchitis, COPD, cystic fibrosis and 
non-cystic fibrosis bronchiectasis are characterized by increased sputum viscosity and difficult 
expectoration, often associated with cough (1- 4).  
Furthermore, acute and chronic bronchitis and COPD are commonly associated with of many non-
respiratory chronic conditions in both outpatients and hospitalized patients, especially in smokers, 
elderly patients and patients living in heavily polluted environments. 
In China, cigarette smoking, and high environmental pollution have a high prevalence and morbidity 
(5). Hence, abnormalities of mucus and expectoration are frequent in patients with primary 
respiratory diseases and with respiratory complications of chronic non-respiratory conditions (6). 
Treatment 
Mucolytic agents are used worldwide for symptomatic treatment of abnormalities of mucus viscosity 
and expectoration. These include N-acetyl cysteine, also referred to as NAC (Fluimucil®, Zambon) 
and ambroxol hydrochloride (Mucosolvan®, Boehringer Ingelheim; Fluibron®, Chiesi Farmaceutici 
S.a.s.). 
NAC exerts an intense mucolytic-fluidifying action on mucous and mucopurulent secretions by 
depolymerizing mucoproteic complexes and nucleic acids which contribute to the viscosity of 
sputum and other secretions. In addition, NAC exerts a direct antioxidant action, thanks to its free 
thiol (-SH) nucleophilic group which can interact with the electrophilic groups of oxidant radicals. 
Of interest is the finding that NAC protects α1-antitrypsin, an elastase-inhibiting enzyme, from 
inactivation by hypochlorous acid (HClO), a potent oxidant agent produced by the myeloperoxidase 
enzyme of activated phagocytes. Moreover, NAC can easily cross the cellular membranes; inside 
the cell NAC is deacetylated to L-cysteine, an amino acid indispensable for glutathione (GSH) 
synthesis.  GSH, a highly reactive tripeptide found in many animal tissues, is the most important 
endo-cellular protective agent against oxidant radicals, exogenous and endogenous, as well as 
against several cytotoxic substances (7)   
NAC is approved in China for aerosol administration (8) and broadly used by this route of 
administration as mucolytic agent. However, especially in hospital settings, in China there is a 
preference to use mucolytic agents by intravenous administration in patients with moderate to 
severe abnormalities of mucus viscosity and expectoration: intravenous administration is 
considered by hospital staff more convenient due to common use of other intravenous treatments 
and is preferred by patients. Hence, the lack of approved NAC for intravenous administration in 
China is an important gap in medical practice. 
Intravenous administration of NAC is approved in most countries at very high doses as an antidote 
against liver injury due to paracetamol intoxication (see Section 5) (9) and in several countries, 
namely as mucolytic agent (10). More detail is provided in the Investigator Brochure (IB).  
The efficacy and safety of iv infusion of NAC as mucolytic was investigated in seven clinical trials, 
3 of which randomized and controlled (11-13) and 4 uncontrolled (14-17). 
 
Trial Rationale  
This trial is intended to provide pivotal (phase III) evidence of efficacy and safety for registration in 
China of slow intravenous infusion of NAC in adult hospitalised patients with with respiratory tract 
diseases and abnormal mucus secretions.NAC, the active test treatment, will be compared to 
placebo and to ambroxol hydrochloride. The inclusion of a placebo arm is deemed ethically and 
scientifically sound for the following reasons: 1) the selection criteria used in this study ensure that 
condition being studied is not serious or life threatening at the time of enrolment; 2) immediate 
discontinuation from the trial and rescue use of mucolytics is envisaged in the protocol; 3) the true 
value of iv intervention in the target population is not fully established. The use of placebo was 


 
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requested by the Chinese FDA (C-FDA) reviewers in their feedback to an earlier version of this 
protocol. Ambroxol hydrochloride is included as the third treatment arm of the study as it is the only 
mucolytic agent approved in China for iv administration. The inclusion of an active control arm, also 
requested by C-FDA reviewers, will allow to test internal validity of the trial.  
This trial is designed as rater- and patient-blind. i.e. whereas the staff administering the study drugs 
will know what each patient is receiving, neither the staff evaluating the patient, nor the patients 
themselves will know. The trial cannot be fully blinded (double-blind) because the appearance of 
NAC ampoules and ambroxol vials is different and more importantly because the NAC formulation 
releases a harmless but immediately distinguishable sulfuric smell. Rater- and patient-blinded 
designs are accepted for pivotal registration trials by the US-FDA, EMA and Regulatory Authorities 
worldwide in situations where full blinding is impossible. 
The selected doses of iv NAC and ambroxol are within the limits of relevant SmPCs (10,18); dose 
justification is provided in Section 5 below.  
The treatment duration of 1 week has been selected after consultation with Chinese experts, as 
only a small minority of patients receive iv mucolytics for more than 1 week.  
5. EVALUATION OF THE ANTICIPATED RISKS/BENEFIT RATIO 
 
NAC has been available to patients as a mucolytic agent for many years and has a well-established 
and satisfactory safety and tolerability profile (see IB).  
Independently of route of administration (inhalation, oral, intravenous) adverse events are reported 
rarely following NAC administration and are usually mild and transient.  
 
The most frequent adverse events associated with NAC oral administration are gastrointestinal 
(e.g., vomiting, diarrhoea, stomatitis, abdominal pain and nausea). Hypersensitivity reactions (e.g. 
anaphylactoid reactions, urticaria, rash, pruritus, and bronchospasm) have been reported less 
frequently after oral administration, while with the IV administration they were reported more 
frequently compared to gastrointestinal symptoms. Some of the hypersensitivity reactions were 
associated to higher infusion rate. Most anaphylactoid reactions can be managed by temporarily 
suspending the acetylcysteine infusion, administering appropriate supportive care. A cumulative 
analysis of all safety reports received by the Sponsor up to September 2017 for NAC IV, confirmed 
the nature and severity of the events were in line with the above profile of the product. 
 
Intravenous NAC has been studied in clinical trials and published case series both as mucolytic 
agent and as an antidote against intoxication by paracetamol and other toxic agents including 
amanita phalloides and chlorinated hydrocarbons. Overall, in published studies in humans, a total 
of 745 patients were exposed to iv NAC at doses ranging from 500 mg/day to 980mg/kg/day for a 
duration of 1 to 18 days.  Details of safety results are included in the IB. 
 
In published studies, whereas iv NAC as mucolytic agent typically was given at doses up to 1000 
mg/day, much higher iv doses of NAC as antidote were given over multiple days, maintaining a 
satisfactory safety profile. 
Locatelli and colleagues (19) published two case series, one of 86 patients with acute intoxication 
from amanita phalloides and the other of 35 patients with acute intoxication from chlorinated 
hydrocarbons. Patients received iv NAC 300 mg/kg/day for 3 to 14 days and 3 to 18 days 
respectively. The safety and tolerability profile were overall benign, with 4 out of 121 exposed 
patients suffering from anaphylactoid reaction or rash (due to the rapid administration of the bolus 


 
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according to the authors), none of which caused discontinuation of treatment. No other AEs were 
reported. 
Keays and colleagues (20) randomized 50 patients suffering from paracetamol intoxication and 
admitted to the liver failure unit to NAC in addition to conventional intensive liver care (N=25) or 
conventional intensive liver care alone (N=25) with maintenance dose of 100 mg/kg/day for several 
days, until recovery from encephalopathy or death (the average number and range of treatment 
days is not reported but in survivors appears to be at least 4 days). No AEs were reported in the 
patients treated with NAC. 
From the data summarized above and the full dataset summarized in the IB, a daily intravenous 
dose NAC of 1200 mg/day given in a hospital setting for 7 days is likely to be associated with a 
small safety risk.   
The safety profile of the active comparator ambroxol hydrochloride given intravenously as is also 
favourable, as outlined in the Chinese PI. The product is well tolerated, and mild upper 
gastrointestinal adverse reactions have been occasionally reported, mainly including stomach 
burning, indigestion and occasional nausea and vomiting, occurring mostly after parenteral 
administration. Allergic reactions are rare, mainly including rash. Few cases have reported severe 
acute allergic reactions, but the correlation with ambroxol hydrochloride is not known. The dose 
chosen for this trial (60 mg/day) is within the range allowed by the Chinese SmPC (18). 
Anticipated benefits to the patients with respiratory tract diseases and abnormal mucus secretions 
randomised to NAC and ambroxol hydrochloride include reduction in mucus viscosity and improved 
expectoration.  
In conclusion, for both active treatments, in this trial the benefit risk ratio is anticipated to be 
positive. 
Patients randomized to placebo will be monitored very closely by experienced investigators and 
study staff. Should expectoration difficulty increase during the trial, the investigator and/or the 
patient may choose to discontinue the study treatment and immediately administer/receive rescue 
mucolytic, as described in Sections 8.1 and 10.10. Hence, also for the patients randomized to 
placebo no clinically meaningfully negative benefit/risk ratio is anticipated.   
6. OBJECTIVES 
The primary objective of this trial is to demonstrate that slow (at least 5 minutes) intravenous 
infusion of NAC 600 mg twice daily is superior to placebo in change from baseline to the end of 1-
week treatment of sputum viscosity score or expectoration difficulty score in adult Chinese 
hospitalized patients with respiratory tract diseases and abnormal mucus secretions . 
 
Secondary objectives are as follows:  
Efficacy 
Demonstrate in the same patient population that: 
- slow (at least 5 minutes) intravenous infusion of NAC 600 mg twice daily is superior to placebo in 
change from baseline to day 3 and end of 1-week treatment of other indicators of mucolytic activity: 
individual sputum viscosity and expectoration difficulty scores, cough score, mucous color score 
and mucous volume;  
- slow (at least 5 minutes) intravenous infusion of NAC 600 mg twice daily is non-inferior to slow 
intravenous infusion of ambroxol hydrochloride 30 mg twice daily in change from baseline to the 
end of 1-week treatment of sputum viscosity score or expectoration difficulty score; 
- slow (at least 5 minutes) intravenous infusion of ambroxol hydrochloride 30 mg twice daily is 
superior to placebo in change from baseline to day 3 and to the end of 1-week treatment of sputum 
viscosity score or expectoration difficulty score and of other indicators of mucolytic activity: 


 
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individual sputum viscosity and expectoration difficulty scores, cough score, mucous color score 
and mucous volume. 
Safety 
Confirm that 1-week treatment with iv NAC 600 mg twice daily is safe and well tolerated 
 
 
The trial endpoints are described in Section 20.2. 
7. ETHICS REQUIREMENTS 
This trial will be conducted in compliance with last version of Declaration of Helsinki 
(http://www.wma.net/en/30publications/10policies/b3/index.html), with International Council for 
Harmonisation (ICH) Good Clinical Practice (GCP), in particular E6(R2), with the applicable 
regulatory requirements and with Zambon and contract research organisation (CRO) standard 
operating procedures (SOPs). 
8. DESIGN AND DURATION OF THE CLINICAL TRIAL 
8.1. CLINICAL TRIAL DESIGN 
This is a multicenter, randomized, rater- and patient-blind, placebo- and active-controlled, 3-arm 
parallel group clinical trial.  
The trial will be conducted in approximately 15 -25 sites in China.  
Please refer to Appendix 1 for a trial flow chart.  
The study will consist of a total of 4 core hospital visits (screening, baseline, treatment day 3, 
treatment day 7, see Section 9) and of one follow-up phone call 2 weeks after discontinuation of 
treatment; if the patient is still hospitalized or if more convenient for the patient, the follow-up phone 
call can be replaced by a follow-up hospital visit. 
At screening visit (Visit 1), patients will be asked to provide Informed Consent prior to any trial 
related procedure and will be checked against inclusion and exclusion criteria. Their medical history 
will be recorded. Furthermore, patients will undergo a 12-lead ECG and laboratory assessments. 
Results must be available before Visit 2.  
At randomization visit (Visit 2), to occur within 7 days after Visit 1, female patients will undergo a 
pregnancy test; all patients will be checked again against the full set of inclusion and exclusion 
criteria and eligible subjects will be randomised with a 1:1:1 ratio to receive NAC or ambroxol 
hydrochloride or placebo.  
A total of 111 patients are to be randomized in each treatment group.  
Procedures performed at each core hospital visit will include documentation of concomitant 
medications and treatment emergent adverse events (TEAEs), 24-hour sputum collection and 
assessment on a 4-point ordinal scale of expectoration difficulty, sputum viscosity, sputum colour 
and cough.  
In case a patient experiences a deterioration of expectoration capacity and related symptoms, 
and/or of an underlying condition, he/she should contact a study investigator immediately and 
undergo an unscheduled deterioration visit. If the patient and/or the investigator believe that it is in 
the patient’s best interest to receive a rescue mucolytic, the patient will be discontinued from the 
study and rescue mucolytic will be administered, with any additional treatment the investigator 
deems appropriate.  


 
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8.2. DURATION OF CLINICAL TRIAL 
The overall study duration (from first patient first visit to last patient last visit) is expected to be of 
approximately 8 months.  
The maximum expected duration of participation in this trial for an individual subject, from Visit 1 
(Screening) to the follow-up phone call or visit is 4 weeks. Treatment duration will be 1 week 
(7days). 
The start of the trial is defined as first subject in, i.e. Visit 1 for the first subject. 
The end of the trial is defined as the last subject out, i.e. when the last subject had the follow-up 
phone call or follow-up visit or unscheduled Deterioration visit. 
If the trial is prematurely stopped, please refer to Section 16. 
9. CLINICAL TRIAL POPULATION 
9.1. NUMBER OF SUBJECTS 
A total of 333 subjects (111 in each treatment group) is planned to be enrolled into the trial. The 
enrolment is competitive among sites.  
For a description of sample size calculation, please refer to Section 20.3. 
9.2. SELECTION OF SUBJECTS 
9.2.1. 
INCLUSION CRITERIA 
Subjects can be enrolled in the trial if they meet all inclusion criteria listed below: 
1. Male or female adult (≥18 years old) hospitalized patients with respiratory tract  diseases 
and abnormal mucus secretions such as : acute bronchitis , chronic bronchitis and 
exacerbations, emphysema, mucoviscidosis and bronchiectasis   Chinese ethnicity and/or 
Chinese  
2. Signed the informed consent form before any study-related procedure 
3. Sputum viscosity score ≥ 2 at randomization visit 
4. Expectoration difficulty score ≥ 2 at randomization visit  
5. Willingness and ability to comply with study procedures 
9.2.2. 
EXCLUSION CRITERIA 
Subjects are not eligible for the trial if they meet one or more of the exclusion criteria listed below: 
1. Intolerance or contra-indication to treatment with NAC or ambroxol or allergy to any 
component of the study treatments 
2. (For female patients) ongoing pregnancy or lactation, or childbearing potential but 
unwillingness to adopt abstinence or contraception measures during the study 
3. Intake of an investigational drug within 1 month before the screening visit 
4. Use of expectorants or drugs with expectorant effect within 3 days before 
randomization visit 


 
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5. Medical history of and/or illness (including laboratory abnormalities) and/or treatment 
that in the investigator’s opinion may interfere with the patient’s safety, compliance, or 
study evaluations 
6. Serum ALT and/or AST more than 3 times above the upper limit of normal at screening 
visit 
7. Serum creatinine more than 3 times above the upper limit of normal at screening visit 
8. Addiction to alcohol or drugs 
9. Mental illness, or other reasons for non-cooperation in the investigator’s opinion 
 
Contraceptive methods 
Although teratology studies carried out in animals evidenced no teratogenic effects of NAC (ref 
IB) or ambroxol hydrochloride (ref SmPC Italy), safety in human pregnancy has not been 
established with iv administration.  
Female subjects can be enrolled if they are either post-menopausal for at least 2 years, or 
surgically sterilized or have undergone hysterectomy.  
Female subjects of child-bearing potential must be willing to avoid pregnancy. They are required 
to have a negative pregnancy test at inclusion (see Section 10.2), and should use a highly 
effective method of birth control for 1 month prior to randomisation, throughout the trial duration 
and up to 1 month after the last dose of IMP, which include:  
 combined (estrogen and progestogen containing) hormonal contraception associated with 
inhibition of ovulation (oral, intravaginal or transdermal) 
 progestogen-only hormonal contraception associated with inhibition of ovulation (oral, 
injectable or implantable) 
 intrauterine device (IUD)  
 intrauterine hormone-releasing system (IUS)  
 surgical sterilization (e.g. bilateral tubal ligation or occlusion)  
 male sterilization (vasectomised partner)  
 sexual abstinence  
 a male sexual partner who agrees to use a male condom with spermicide  
 
Throughout the course of the study male participants with female partners of child bearing 
potential must abstain from sexual intercourse or use condoms or use effective contraceptive 
precautions (female partners should follow the same birth control of female patients).  
Male participants must also not take part in the donation of sperm whilst enrolled on the study. 
10. 
OVERALL CLINICAL TRIAL SCHEDULE 
The current trial will include 4 planned core clinical visits at the investigational site and 1 follow-up 
telephone call or visit. Unscheduled Deterioration visit(s) will be conducted as necessary. A 
detailed flow chart showing the procedures performed is given in Appendix 1. The following 
sections outline the procedures to be performed at the individual visits.  
10.1. 
VISIT 1 - SCREENING VISIT  
At Visit 1 (Screening), the following procedures will be performed: 
 obtain written Informed Consent before any study-related procedure; 


 
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 document medical history and subject’s demographic data; 
 document concomitant medications; 
 assess vital signs (Section 11.1.3); 
 conduct physical examination (including chest auscultation); 
 conduct 12-lead ECG in the supine position after 5 minutes of rest (Section 11.1.6); 
 check inclusion/exclusion criteria: not all criteria can be assessed at screening, but do not 
proceed further if the patient is not eligible based on the criteria that can be checked; 
 collect blood samples for clinical laboratory assessments (haematology and clinical 
chemistry). (Section 11.1.4); 
 Instruct patients on actions to be taken in case of worsening of symptoms related to 
expectoration. 
 Record details of any AEs since the Inform Consent signature  
The Investigator will arrange an appointment for Visit 2 within 7 days. 
10.2. 
VISIT 2 - RANDOMISATION VISIT (DAY 1)- (WITHIN 7 DAYS OF VISIT 
1) 
At Visit 2 (Randomisation), the following procedures will be performed: 
 conduct dip-stick urine pregnancy test for females of childbearing potential. 
 check complete set of inclusion and exclusion criteria; 
 document concomitant medications; 
 record details of any AEs since the Screening Visit (Visit 1); 
 assess of vital signs (Section 11.1.3); 
 conduct physical examination (including chest auscultation); 
 give to patient the container for 24-hour sputum collection and instruct patient to collect all 
sputum until the same time of the following day; 
 conduct assessment of expectoration difficulty, sputum viscosity, sputum color and cough 
by means of the 4-point ordinal scales provided;  
 randomise the eligible patient by IWRS; 
 administer first dose of study medication in the morning and the second dose in the 
afternoon/evening. The two daily doses must be administered  approximately 12 hours apart 
from each other.  
Warning: Study staff responsible for administration of study medication, patient care and 
routine assessments (unblinded) should be different from study staff responsible for rating 
of expectoration difficulty, sputum viscosity, sputum color and cough (rater). No disclosure 
of the identity of study medication from the former to the latter is to occur unless required 
for safety reasons; 
 remind patients on actions to be taken in case of worsening of symptoms related to 
expectoration.  
 To assess adherence with IMP dosing regimen  
The Investigator will arrange an appointment for Visit 3 (on day 3 after Visit 2) and will instruct the 
subjects to report any AEs occurring during this period at the next visit.  
10.3. 
DAY 2 
On day 2 the following procedures will be performed: 
 collect 24-hour sputum sample and report volume (mL) in eCRF; 
 administer study medication at the same times as on Day 1 (see Warning in section 10.2. 
above). 


 
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10.4. 
VISIT 3 (DAY 3) 
At Visit 3 (day 3), the following procedures will be performed: 
 document concomitant medications; 
 record details of any AEs since the Randomization Visit (Visit 2); 
 assess of vital signs (Section 11.1.3); 
 conduct physical examination (including chest auscultation); 
 give to patient the container for 24-hour sputum collection and instruct patient to collect all 
sputum until the same time of the following day; 
 conduct assessment of expectoration difficulty, sputum viscosity, sputum color and cough 
by means of the 4-point ordinal scales provided 
 administer study medication at the same times as on Day 1 (see Warning in section 10.2. 
above); 
 remind patients on actions to be taken in case of worsening of symptoms related to 
expectoration. To assess adherence with IMP dosing regimen  
The Investigator will arrange an appointment for Visit 4 (on day 7 after Visit 2) and will instruct 
the subjects to report any AEs occurring during this period at the next visit.  
10.5. 
DAY 4 
On day 4 the following procedures will be performed: 
 collect 24-hour sputum sample and report volume (mL) in eCRF; 
 administer study medication at the same times as on Day 1 (see Warning in section 10.2. 
above). 
10.6. 
DAYS 5 AND 6 
On days 5 and 6 the following procedure will be performed: 
 administer study medication at the same times as on Day 1 (see Warning in section 10.2. 
above). 
10.7. 
VISIT 4 (DAY 7)  
At Visit 4 (day 7), the following procedures will be performed: 
 conduct dip-stick urine pregnancy test for females of childbearing potential. 
 document concomitant medications; 
 record details of any AEs since Visit 3 (day 3); 
 assess of vital signs (Section 11.1.3); 
 conduct physical examination (including chest auscultation); 
 give to patient the container for 24-hour sputum collection and instruct patient to collect all 
sputum until the same time of the following day; 
 conduct assessment of expectoration difficulty, sputum viscosity, sputum color and cough 
by means of the 4-point ordinal scales provided. 
 conduct 12-lead ECG in the supine position after 5 minutes of rest (Section 11.1.6); 
 collect blood samples for clinical laboratory assessments (haematology and clinical 
chemistry). 
 to assess adherence with IMP dosing regimen  
 administer study medication at the same times as on Day 1 (see Warning in section 10.2. 
above). 


 
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The Investigator will arrange an appointment for the follow-up call or visit 2 weeks ± 3 days after 
the last administration of IMP 
10.8. 
DAY 8 
On day 8 the following procedure will be performed: 
 collect 24-hour sputum sample and report volume (mL) in eCRF; 
 
10.9. 
FOLLOW-UP PHONE CALL OR VISIT (2 WEEKS ± 3 DAYS AFTER 
THE LAST ADMINISTRATION OF IMP) 
A follow-up phone call will be performed at 2 weeks ± 3 days after the last administration of IMP. If 
the patient is still hospitalized or it is more convenient for the patient, the follow-up call can be 
replaced by a follow-up visit  
The following procedures will be performed during the follow-up call or visit:  
 record details of any AEs since Visit 4 (day 7); 
 record concomitant medications since Visit 4. 
 
 
10.10. 
UNSCHEDULED DETERIORATION VISIT 
Patients will be trained by the Investigator to recognise worsening of expectoration and related 
symptoms.  
 
If the patient and/or the investigator believe that it is in the patient’s best interest to receive a rescue 
mucolytic, the patient will be discontinued from the study and rescue mucolytic will be administered, 
with any additional treatment the investigator deems appropriate and an unscheduled Deterioration 
Visit should be conducted whenever possible.  
An unscheduled Deterioration Visit should be conducted also in case of worsening of the underlying 
condition. In particular, in case of bronchospasm in asthmatic patients the treatment must be 
discontinued and adequate therapeutic measures taken. 
 
In case of unscheduled Deterioration Visit the following procedures will be performed: 
 record details of any AEs since previous visit 
 conduct dip-stick urine pregnancy test for females of childbearing potential. 
 assess of vital signs (Section 11.1.3); 
 conduct physical examination (including chest auscultation); 
 conduct 12-lead ECG in the supine position after 5 minutes of rest (Section 11.1.6); 
 conduct assessment of expectoration difficulty, sputum viscosity, sputum colour and cough 
by means of the 4-point ordinal scales provided 
 
In case during the unscheduled deterioration visit the patient and/or the investigator deem 
appropriate the discontinuation from the trial, all evaluations requested at Visit 4 should be 
performed (Section 10.11).    


 
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10.11.   PREMATURE DISCONTINUATION VISIT 
In case of premature discontinuation for any other reasons than those listed in 10.10 all evaluations 
requested at Visit 4 should be performed, excluding study medication administration.    
A premature discontinuation visit must also be conducted in case of unexpected pregnancy.  
 
 
 
11. 
METHODOLOGY 
11.1. 
METHODS OF ASSESSMENT 
11.1.1. 
DEMOGRAPHY AND MEDICAL HISTORY 
At Visit 1 (Screening) the subjects’ demographic data will be documented, including age, ethnicity, 
gender, height, weight as well as smoking history and alcohol use.  
Further, the reason for hospitalization and medical history will be documented.  
Any relevant worsening in ongoing conditions during the trial (i.e. since Visit 1) is required to be 
recorded as AEs in the eCRF (see Section 18). 
11.1.2. 
PHYSICAL EXAMINATION 
At Visit 1, Visit 2, Visit 3 and Visit 4, and/or at the unscheduled deterioration Visit/premature 
discontinuation, a physical examination of general body systems will be performed according to 
current medical standards and site practice. The examination is to include a chest auscultation. 
Any relevant worsening regarding physical examination results of a subject since Visit 1 should be 
recorded as AE in the eCRF (see Section 18). 
11.1.3. 
VITAL SIGNS 
At Visit 1, Visit 2, Visit 3 and Visit 4 and/or at the unscheduled deterioration visit/premature 
discontinuation, vital signs will be recorded according to site practice. Vital signs include: 
 heart rate, 
 systolic and diastolic blood pressure, measured after at least 5 minutes in the supine 
position,  
 respiratory rate, 
 body temperature, measured under the arm pit. 
Automatic or manual devices may be used, but the same device should be used for any given 
subject throughout the trial. The same arm should be used for all measurements. 
Any relevant clinically significant worsening of vital signs of a subject since the previous visit should 
be recorded as AE in the eCRF (see Section 18). 


 
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11.1.4. 
LABORATORY EVALUATIONS 
Routine laboratory evaluations will be performed at Screening Visit (Visit 1) and Visit 4 and in case 
of premature discontinuation.  
The blood samples must be collected after the 12-lead ECG has been performed.  
The haematology and clinical chemistry parameters detailed in Table 1 will be analysed by the 
local hospital laboratory.  
Subjects with clinically relevant impaired renal function, as defined by serum creatinine levels ≥3.0x 
upper limit of normal at Visit 1 will not be randomized. 
Subjects with clinically relevant impaired liver function, as defined by serum ALT and/or AST ≥3.0x 
upper limit of normal at Visit 1 will not be randomized. 
A dipstick urine pregnancy test for women of childbearing potential will be performed at 
Randomization Visit (Visit 2) and at Visit 4 and/or at unscheduled deterioration visit/premature 
discontinuation visit.  
Female subjects who become pregnant during the trial must be withdrawn from the trial without 
delay and undergo the premature discontinuation visit; these patients are to be followed up to 
determine the outcome of the pregnancy. The Investigator is required to inform the Sponsor of a 
subject’s pregnancy and the estimated date of delivery. Reporting requirements are outlined in 
Section 18.10.  
Clinical laboratory tests will be reviewed for results of potential clinical significance before Visit 2 
to confirm patient’s eligibility and during the trial, as appropriate. Clinically significant laboratory 
abnormalities arising at Visit 4 (or at premature discontinuation visit) are considered AEs. Where 
possible, a diagnosis should be ascribed to the abnormal lab test. 
 
 
Table 1 CLINICAL LABORATORY EVALUATIONS 
Hematology: at Screening Visit (Visit 1) and Visit 4 or premature discontinuation visit 
Hematocrit 
Hemoglobin 
Platelet count 
Red blood cell count 
White blood cell count and differential (neutrophils, lymphocytes, monocytes, eosinophils and basophils) 
Clinical Chemistry: at Screening Visit (Visit 1) and visit 4 or premature discontinuation visit 
BUN or UREA 
Chloride  
AST 
Creatinine 
Uric acid 
ALT 
Sodium 
Amylase 
γGT 
Potassium 
ALP 
Bilirubin (direct and total) 
Calcium 
 
 
 
 
 
Pregnancy Test: at Screening Visit (Visit 1), Visit 4 or premature discontinuation visit 
Urine β-hCG (dipstick)  
11.1.5. 
EFFICACY EVALUATIONS 
Sputum viscosity, expectoration difficulty, sputum color, cough 
Sputum viscosity, expectoration difficulty, sputum color and cough are assessed by means of 
ordinal categorical 4-point scales with 0 = best and 3 = worst.  
For each patient the assessment is to be carried out by the blinded rater on treatment days 1 
(baseline), 3 and 7 in the morning before 9 am before administration of study drug. Should a patient 
discontinue prematurely from the trial (including discharge from the hospital before day 7) an 


 
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assessment should be conducted on the day of discontinuation whenever possible (see 
unscheduled Deterioration Visit, Section 10.10).  
 
 
 
 
 
 
 
 
Scoring criteria are as follows (adapted from [12]) 
 
0 
1 
2 
3 
Sputum 
viscosity 
Liquid 
(normal 
viscosity)
 
Fluid  
(mildly 
increased 
viscosity) 
Viscous  
(moderately 
increased 
viscosity) 
Sticky 
(severely 
increased 
viscosity) 
Expectoration 
difficulty 
No 
difficulty 
Mild 
difficulty 
Moderate 
difficulty 
Marked 
difficulty 
 
Sputum  color
Mostly 
white 
Mostly 
pale 
yellow 
Mostly dark 
yellow 
Very dark 
yellow 
/green 
Cough 
 
No 
cough 
Sporadic 
and mild 
cough 
Moderate 
cough 
Severe 
Cough 
 
Sputum Volume 
At Randomization Visit (Visit 2), Visit 3 and Visit 4 the patients will be given a graduated container 
and instructed to use it to collect all sputum generated in the following 24 hours (i.e. same time of 
the following day). The day the container will be collected, and the 24-hour sputum volume 
measured in ml. 
11.1.6. 
SAFETY EVALUATIONS 
Adverse Events  
AEs will be recorded by Investigator in the appropriate eCRF Section from Visit 1 (date of informed 
consent) to the follow-up phone all or visit occurring 2 weeks (±3 days) after the last administration 
of the investigational medicinal product (IMP). At each contact (i.e. clinical visit or phone call), 
subjects will be asked in a non-leading manner if they experienced any AEs.  
All AEs occurring from the day of the first IMP administration, i.e. Visit 2, until the end of the trial, 
i.e. follow-up phone call, will be considered as treatment emergent TEAEs.  
For definitions and reporting of AEs and SAEs, see Section 18. 
 
12-lead electrocardiogram (ECG)  


 
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12-lead ECG recordings will be obtained at each study centre using site machines at the Screening 
Visit (Visit 1) to verify the eligibility of the subject, and at Visit 4 or unscheduled Deterioration visit. 
ECG will be performed after obtaining vital signs. Prior to recording, the subject should be at rest 
for at least 5 mins.  
ECG will be evaluated by the investigator/local medical staff and the recording will be reported in 
the eCRF as “normal”, “abnormal clinically significant” or “abnormal not clinically significant”.  
Abnormalities of clinical significance recorded at V1, Visit 4 or unscheduled deterioration 
visit/premature discontinuation visit which are not related to pre-exist medical condition before ICF 
signature will be reported as AEs. Repeat measurements will be performed if needed. 
11.2. 
ADHERENCE WITH IMP DOSING REGIMEN 
As the administration of the IMP will be carried out by the study staff in a hospital setting, it is 
anticipated that adherence with IMP dosing regimen will be high.   
Nevertheless, the Investigator will assess adherence with IMP dosing regimen on an ongoing basis 
by determining the amount of IMP dispensed, used (i.e. returned open ampoules/vials) and the 
amount of IMP returned (i.e. returned, unopened ampoules/vials) at Visit 2 (first dose), Visit 3 and 
Visit 4 (end of treatment) or unscheduled Deterioration Visit/premature discontinuation visit.  
The evaluation of compliance will be done using the following formula: 
% of administered drug = 100 x  
Total number of administered doses 
Total number of scheduled doses 
 
11.3. 
PHARMACODYNAMICS 
Not applicable.  
11.4. 
PHARMACOKINETICS 
Not applicable.  
12. 
PRIOR AND CONCOMITANT TREATMENTS 
At Visit 1 (Screening), all prior and concomitant medications, including antibiotics, and over-the-
counter products used by an individual subject within 1 month prior to Screening Visit (Visit 1) will 
be documented in the eCRF.  
During all subsequent clinical visits, the Investigator will document any changes in concomitant 
medications.  
The following concomitant treatments are permitted from Visit 1 to Visit 4 (end of IMP treatment) 
or unscheduled Deterioration Visit: 
 Appropriate treatment(s) for any underlying disease, that in the investigator’s opinion will not 
interfere with the measurements contributing to the primary efficacy outcomes. If one or more 
treatments interfering with the measurements contributing to the primary efficacy outcomes are 
deemed necessary, the patient should not be randomized or should be discontinued from the 
study. 


 
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The following concomitant treatments are not permitted from Visit 1 to Visit 4 (end of IMP 
treatment) or unscheduled Deterioration Visit:  
 Expectorants 
 Antitussive agents  
 Sedatives  
 Traditional Chinese Medicine (TCM) treatments. 
13. 
INVESTIGATIONAL MEDICINAL PRODUCT 
13.1. 
INVESTIGATIONAL MEDICINAL PRODUCT SUPPLIES AND 
PACKAGING 
NAC will be supplied in boxes containing 2 ampoules each. 
NAC is formulated in yellow glass ampoules as a solution of 300 mg NAC in 3 ml water for injection; 
other excipients are: sodium hydroxide and disodium edetate. The product is manufactured by 
Zambon SpA, Vicenza, Italy. 
Ambroxol hydrochloride will be supplied in boxes containing 2 vials each. 
Ambroxol hydrochloride is formulated in yellow glass vials as a solution of 15 mg ambroxol 
hydrochloride in 2 ml water for injection; other excipients are: citric acid monohydrate, sodium 
hydrogen phosphate dihydrate, sodium chloride. The product is manufactured by Boehringer 
Ingelheim. 
Placebo will be supplied in boxes containing 1 vial each. 
Placebo is formulated in vials as 10 ml NaCl 0.9% saline solution. The product is manufactured by 
China Otsuka Pharmaceutical Co., Ltd. 
13.2. 
INVESTIGATIONAL MEDICINAL PRODUCT DISPENSING AND 
ADMINISTRATION 
All IMPs will be administered at the hospital investigational sites by study staff otherwise not 
involved with the assessment and care of study patients. The study staff members administering 
the IMP will be aware of its identity but will not disclose it to patients or to other study staff members 
(patient and rater-blind design, see Section 4).  
 
NAC (Active test treatment) 
Two ampoules (NAC 600 mg) will be diluted in 10 ml NaCl 0.9% saline solution and administered 
by slow (at least 5 minutes) intravenous infusion twice a day, morning before 9 am and 
afternoon/evening approximately 12 ± 1 hours apart for 1 week (7 days). Total daily NAC dose: 
1200 mg/day.   
 
Ambroxol hydrochloride (active control treatment) 
Two vials (ambroxol 30 mg) will be diluted in 10 ml NaCl 0.9% saline solution and administered by 
slow (at least 5 minutes) intravenous infusion twice a day, morning before 9 am and 
afternoon/evening approximately 12 ± 1 hours apart for 1 week (7 days). Total daily ambroxol dose: 
60 mg.  
 
Placebo 


 
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One vial of 10 ml NaCl 0.9% saline solution will be administered by slow (at least 5 minutes) 
intravenous infusion twice a day, morning before 9 am and afternoon/evening approximately 12  ± 
1 hours apart for 1 week (7 days). 
Study staff administering the IMP will be instructed to store the empty used and the unused 
ampoules/vials for IMP accountability. 
 
13.3. 
RANDOMISATION 
 
Each subject will receive a screening number as soon as site staff enters the IWRS, after they have 
signed the ICF (Visit 1).  
The screening number will consist of country number (3 digits), a site number (3 digits) and a 
continuous number for a subject at an individual site (3 digits), e.g. 001001-001. Every subject who 
signs the ICF must be entered into the IWRS system regardless of eligibility. 
At Visit 2, eligible subjects will be randomised using the IWRS according to a pre-specified 
randomisation scheme such that they either receive NAC or ambroxol hydrochloride or placebo.  
The randomisation within each site will be done with blocks sized of unequal length to guarantee 
a good balance among NAC, ambroxol hydrochloride and placebo at any stage of the enrolment 
minimizing the procedure selection bias. 
The allocation to the treatment will be stored within the IWRS database until unblinding of the trial 
is requested. Unblinding may be performed directly by the Investigators only in case of SAE of life-
threating significance where knowledge of treatment assignment is essential for the future 
management of patient care (see Section 15.1).  
13.4. 
INVESTIGATIONAL MEDICINAL PRODUCT ACCOUNTABILITY 
IMP inventory and accountability records will be maintained within IWRS. The following rules are 
to be followed: 
a) 
The Investigator will keep IMPs in a pharmacy, or a locked and secure storage facility, 
accessible only to those individuals authorised by the Investigator to dispense the IMPs. 
b) 
The inventory will be maintained by the Investigator or pharmacist or other nominated 
individual. The inventory will be done by means of a specific “Subject/Study Investigational 
Product Accountability Record & Investigational Product Reconciliation Log” and will include 
details of IMPs received and a clear record of when they were dispensed. 
c) 
At the conclusion or termination of the clinical trial, the Investigator will conduct a final IMP 
inventory and to record the results of the inventory on an Investigational Product Return Form. 
The monitor will check that IMP accountability was correctly performed. The Investigator will 
return all original IMP containers, whether empty or full, to the CRO for final reconciliation and 
destruction. 
d) 
The Investigator/pharmacist agree not to supply IMP to any person except those named as 
Investigators/Co-Investigators as detailed in the Site Signature/Delegation Log, and to 
subjects in this trial. 
For instructions to maintain the study patient and rater-blind, see Section 4. 


 
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14. 
CLINICAL TRIAL AMENDMENTS 
Changes to the CTP can be made preparing written amendments to be agreed and signed by the 
Principal Investigator and Sponsor. No substantial amendment can be implemented without a 
favourable opinion of the Ethics Committee (EC) and Competent Authority (CA) and CA, unless 
the changes consist of urgent safety measures to protect trial subjects. 
Amendments which are non-substantial amendments as defined by current regulations can be sent 
to EC/CA for notification as applicable per local requirements and may be implemented at the site 
before EC notification according to local rules.  
15. 
DEVIATIONS FROM THE CLINICAL TRIAL PROTOCOL 
Any major or critical deviation which may have an impact on study results and/or the safety of the 
subjects should be immediately reported to the CRO and a decision will be taken together with the 
Sponsor whether or not the patient for whom the deviation from the CTP took place is to continue 
in the trial. A deviation log will be maintained to track actual deviations and decisions taken. All 
deviations will be reported to the EC and CA according to ICH-GCP and local requirements. 
In case of an emergency deviation from the CTP has to be implemented for a give patient, this 
deviation will be only applied to that individual. 
In such an emergency the Investigator must contact the CRO by telephone as soon as possible.  
15.1. 
CODE BREAKING 
The code for any individual subject will not be broken by the Investigator/rater during course of the 
trial except in the circumstance of an SAE where knowledge of treatment assignment is essential 
for the future management of patient care. 
Despite the fact that this study is not double-blind, in order to ensure proper documentation, in case 
of emergency, unblinding of the treatment is to be done through IWRS. The IWRS will be designed 
to send a confirmation (by fax and/or notification email) to the site for every transaction performed 
by the site users. Site users will be provided with usernames and passwords to access the IWRS. 
Unblinding of the study treatment must be done in case of an emergency situation, where the 
Investigator/rater considers it essential to know what treatment the subject was taking. Access to 
the unblinding option will be granted only to the Investigators and sub-Investigators at the sites. 
The IWRS will promptly notify the Sponsor and the Clinical Trial Monitor whenever a treatment 
code is unblinded. If the treatment code has been opened, this must be recorded in the eCRF.  
Users from PAREXEL and Sponsor Pharmacovigilance will have their own passwords to unblind 
subjects in case of suspected unexpected serious adverse reactions (SUSARs) to be reported to 
the CA and ECs. 
16. 
CLINICAL TRIAL WITHDRAWALS/DROP-OUTS 
Patients will be withdrawn from the trial for one of the following reasons: 
 patient may withdraw from the study at any time at his/her own request;  
 patient may withdraw from the study due to an AE;  
 patient may be withdrawn at any time at the discretion of the Investigator for safety, 
behavioural, compliance or administrative reasons; 
 patient may be withdrawn due to lack of adherence to study medication regimen. 


 
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 Female patient who becomes pregnant should be withdrawn from the trial and followed-up in 
accordance with Section 18.8; 
 Patient should be withdrawn from the trial once rescue mucolytic is received; 
 non-emergency unblinding of study treatment allocation;  
 lost to follow up: before a subject is deemed lost to follow up, the Investigator or designee 
must make every effort to regain contact with the participant (where possible, 3 telephone 
calls and, if necessary, a certified letter to the participant’s last known mailing address or local 
equivalent methods). These contact attempts should be documented in the participant’s 
medical record. Should the participant continue to be unreachable, he/she will be considered 
to have withdrawn from the study;  
The sponsor, CA, or EC/IRB(s), can terminate the trial or participation of an individual site. 
The reason for removal of a subject from the trial or premature discontinuation of treatment must be 
fully documented in the eCRF as well as in respective source documents. Follow-up for withdrawn 
subjects follows the procedures described in Section 18.8 and Section 18.9.  
17. 
STOPPING AND DISCONTINUATION CRITERIA FOR THE 
TRIAL 
The trial may be prematurely terminated or placed on temporary hold for the following reasons: 
 the Sponsor feels that the number and/or severity of AEs justifies discontinuation of the trial; 
 the Sponsor considers the applied doses of one or more IMPs to be no longer relevant; 
 data not known before, become available and raise concern about the safety of one or more 
IMPs so that continuation would pose potential risks to the subjects; 
Premature termination of the trial must be reported to the EC and CA according to applicable laws 
generally within 30 days. A detailed written explanation of the reason should be given and 
alternative procedures for subjects under treatment specified.  
However, trial results have to be reported according to the requirements outlined in this CTP as far 
as applicable. 
If, after the termination of the trial, the risk/benefit analyses have changed, the new evaluation 
should be provided in case it will have an impact on the planned follow-up of the patients who have 
participated in the trial. If possible, the patients should return to the clinic for an early End of 
Treatment Visit. 
18. 
REPORTING SAFETY INFORMATION 
18.1. 
DEFINITION OF ADVERSE EVENT 
An AE is "any untoward medical occurrence in a patient or clinical trial subject administered a 
medicinal product and which does not necessarily have a causal relationship with this treatment". 
AEs include: 
 worsening (change in nature, severity or frequency) of conditions present at the onset of the 
trial; 
o worsening of expectoration difficulties and related symptoms may prompt 
discontinuation of the patient and immediate administration of rescue mucolytic if 


 
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judged to be in the patient’s best interest by the investigator and/or the patient 
him/herself 
 subject deterioration due to the primary illness; 
 intercurrent illnesses; 
 drug interactions; 
 events related or possibly related to concomitant medications; 
 abnormal laboratory values, as well as significant shifts from baseline within the range of 
normal, which the Investigator considers to be clinically significant. 
An AE can therefore be any unfavourable and unintended sign (including an abnormal laboratory 
finding), symptom, or disease temporally associated with the use of an investigational medicinal 
product, whether or not considered related to the IMP. 
An unscheduled Deterioration Visit should be conducted whenever possible (Section 10.10). 
 
18.2. 
DEFINITION OF ADVERSE EVENT OF SPECIAL INTEREST  
No AEs of special interest are defined for this trial.  
18.3. 
DEFINITION OF ADVERSE DRUG REACTION 
An adverse drug reaction (ADR) is “any untoward and unintended response to an IMP related to 
any dose administered and which implies an AE with at least a reasonable possibility of a causal 
relationship with the use of the product (i.e. there is evidence or arguments to suggest a causal 
relationship). 
The definition covers also medication error and uses outside what is foreseen in the CTP, including 
misuse and abuse of the IMP. 
All AEs judged by either the reporting Investigator or the Sponsor as having a reasonable causal 
relationship to a medicinal product qualify as ADRs. 
18.3.1. 
DEFINITION OF UNEXPECTED ADVERSE DRUG REACTION 
An unexpected ADR is: “An adverse reaction, the nature, or severity of which is not consistent with 
the applicable product information (e.g. Investigator's Brochure [IB] for an unapproved 
investigational product or SmPC, for approved product)”. The reference safety information for 
evaluation of AE expectedness in this trial will be the Investigator Brochure for NAC and the 
Chinese Package Insert for ambroxol hydrochloride. 
18.3.2. 
DEFINITION OF MEDICAL DEVICE MALFUNCTION AND INCIDENT 
A medical device malfunction is the failure of a device to meet performance specifications or to 
perform as intended. 
A medical device incident is any malfunction or deterioration in the characteristics and/or 
performance of a device, as well as any inadequacy in the labelling or instructions for use which, 
directly or indirectly, might lead to or might have led to the death of a patient, a user, or other 
persons, or to a serious deterioration in their state of health.  
A medical device complaint meeting the criteria of a potential medical device incident is reportable.  
Subjects will also be monitored for any medical device malfunction or incident and, if these occur, 
details will be recorded as for ADRs. 


 
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18.4. 
DEFINITION OF SERIOUS ADVERSE EVENTS OR SERIOUS 
ADVERSE DRUG REACTIONS 
18.4.1. 
DEFINITION OF SERIOUS ADVERSE EVENT OR SERIOUS ADVERSE REACTION 
A Serious Adverse Event (SAE) or Serious Adverse Reaction (SAR) is any untoward medical 
occurrence or effect that at any dose: 
 results in death; 
 is life-threatening (i.e. the subject was at risk of death at the time of the event/reaction; it does 
not refer to an event/reaction which hypothetically might have caused death if it were more 
severe); 
 requires inpatient hospitalisation or prolongation of existing hospitalisation; 
 results in persistent or significant disability/incapacity (where disability is defined as a 
permanent or substantial disruption of ability to carry out normal life functions, either reported 
or defined as per clinical judgement); 
 is a congenital anomaly/birth defect; 
 is an important medical event that may not result in death, be life-threatening, or require 
hospitalisation but, according to appropriate medical judgment, it may jeopardise the subject 
and may require medical or surgical intervention to prevent any of the outcomes listed in the 
definition above. Examples of such events include allergic bronchospasm requiring intensive 
treatment in an emergency room or at home, and blood dyscrasias or convulsions that do not 
result in hospitalisation, or development of drug dependency or drug abuse.  
Any suspected transmission via a medicinal product of an infectious agent is also considered an 
SAE. 
A Serious Adverse Reaction (SAR) is any SAE judged by either the reporting Investigator or the 
Sponsor as having a reasonable causal relationship to a medicinal product. 
18.4.2. 
DEFINITION OF SUSPECTED UNEXPECTED SERIOUS ADVERSE REACTIONS 
 
A SUSAR (Suspected, Unexpected Serious Adverse Reaction) is a subset of SAEs/SARs that, 
although foreseeable, are potentially related to the IMP and not identified in the reference safety 
information and will be reported to the appropriate regulatory authorities and investigators following 
local and global guidelines and requirements. 
 
18.5. 
DEFINITION OF SEVERITY OF ADVERSE EVENTS 
The term “severe” is used to describe the intensity (severity) of a specific event: 
 Mild: causing no limitation of usual activities; the subject may experience slight discomfort; 
 Moderate: causing some limitation of usual activities; the subject may experience annoying 
discomfort; 
 Severe: causing inability to carry out usual activities; the subject may experience intolerable 
discomfort or pain. 


 
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18.6. 
DEFINITION OF ADVERSE EVENT CAUSALITY 
Causality shall be determined according to the definition of ADRs as given in Section 18.3. 
All AEs judged by either the Investigator or the Sponsor as having a reasonable suspected causal 
relationship to an IMP qualify as ADRs. The causality assessment given by the Investigator should 
not be downgraded by the Sponsor. 
The following binary decision for causality will be used: 
 reasonable possibility that the IMP caused the event; 
 no reasonable possibility that the IMP caused the event. 
Features supportive of an association include: 
 temporal plausibility; 
 pharmacological properties of the drug or of the substance class; 
 course of the AE after de-challenge and, if applicable, after re-challenge; 
 specific tests indicating involvement of the drug in the occurrence/worsening of the AE;  
 alternative explanations. 
18.7. 
ADVERSE EVENT RECORDING 
Each AE occurring to a subject, either spontaneously revealed by the subject or observed by the 
Investigator, whether believed by the Investigator to be related or unrelated to the IMP, must be 
recorded by the Investigator on the AE information page of the eCRF. Also, for SAEs, information 
must be recorded in the eCRF (see Section 19.1).  
The Investigator performs an evaluation with respect to seriousness and causality of the AEs and 
records it on the appropriate section of the eCRF. 
18.8. 
ADVERSE EVENT MONITORING WINDOW 
- 
Start of monitoring: from immediately after the signature of the informed consent 
- 
End of monitoring: final study visit/ETV (observation window) 
An AE occurring after the final visit/ETV and coming to knowledge of the investigator (e.g. during a 
follow-up assessment or by spontaneous reporting by study subjects) must be recorded only if it is 
an ADR, according to the investigator’s judgment. 
18.9. 
ADVERSE EVENT REPORTING 
The Investigator must report to the CRO all AEs which occur during the trial, regardless of their 
relationship to IMP. All AEs are recorded by the Investigator on the AE information page of the eCRF. 
In addition, any SAE will have to be reported according to the following detailed procedure. 
18.9.1. 
REPORTING SERIOUS ADVERSE EVENTS 
Investigators must report SAEs within 24 hours of first awareness of the event. 
The SAE must be reported through the eCRF to the CRO’s Pharmacovigilance group as per contact 
details provided in the "List of CRO personnel" at the beginning of this CTP. 
If there is any issue with the electronic reporting process, such as internet failure or database 
issues, this must not delay SAE reporting. The back-up procedure is to send the back-up paper 


 
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Serious Adverse Event Form to the CRO’s Pharmacovigilance group by email or fax using the 
contact details specified in the SAE guidelines. 
Note: Any reports submitted on paper must be retrospectively added to the eCRF as soon as 
possible. 
The national and local standards of confidentiality must always be maintained and any relevant 
national legislation on data protection must be followed. 
SAEs are reportable from the time a patient signs the informed consent to the follow-up phone call 
or visit occurring 2 weeks (± 3 days) after the last dose of IMP. 
If the Investigator becomes aware of any SAE occurring to a subject within the follow-up window 
established in this CTP, he/she will report the SAE as above. The SAE will be also reported in the 
eCRF. 
If the Investigator becomes aware of any SAE outside the follow-up window established in this 
CTP, it is the Investigator’s responsibility to report the SAE to the CRO. The Investigator might use 
the eCRF, as described above. However, the SAE is not an event occurred within the trial period. 
18.9.2. 
REPORTING ADVERSE EVENTS OF SPECIAL INTEREST  
No specific provisions relate to reporting of AEs of special interest in this trial.  
18.10. 
FOLLOW-UP FOR ADVERSE EVENTS 
All AEs requiring the subject’s discontinuation and SAEs will be followed up until they are resolved 
or closed. 
Resolution of an AE is defined as the return to pre-treatment status or stabilisation of the condition 
with the expectation that it will remain chronic.  
The Investigator must respond to any request for follow-up information (e.g. additional information, 
outcome and final evaluation, specific records where needed) and answer any question that the 
Sponsor or designee may have regarding the AE.  
Regarding SAEs, the timelines and procedure for follow-up reports are the same as those for the 
initial reports for SAEs. 
This is necessary to permit a prompt assessment of the event by the Sponsor or designee and (as 
applicable) to allow the Sponsor to meet strict regulatory timelines associated with expedited safety 
reporting obligations. 
If follow-up information on SAEs is available, a follow-up eCRF form will be filled-in by the 
Investigator and sent to the CRO as above-described, under Section 18.8.1.  
18.11. 
PREGNANCY 
Subjects must be instructed that known or suspected pregnancy occurring during the trial should 
be confirmed and reported to the Investigator, who must then withdraw the subject from the trial 
without delay (Section 10.10). The Investigator should also be notified in case the partner of a male 
study subject becomes pregnant at any time during the course of the study (in this event a specific 
ICF for the subject’s partner will be obtained). 
In the event that a subject or a female partner  is found to be pregnant after inclusion in the trial, 
then pregnancy will be actively followed up to term and the status of mother and child will be 
reported by the Investigator to the CRO through the appropriate pregnancy report provided by the 
CRO.  
The Investigator will send pregnancy reports within the timeframes of SAEs.  


 
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If pregnancy results in abnormal outcome that the Investigator and/or the Sponsor considers to be 
due to the IMP, this will be treated as an expedited ADR report. 
19. 
RECORDS 
19.1. 
CASE REPORT FORMS, SOURCE DATA AND QUERY RESOLUTION 
The Investigator must ensure that the clinical data required by the CTP are carefully reported in 
the eCRF. He/she must also check that the data reported in the eCRF correspond to those in the 
official files (source documentation).  
Data entered directly into the eCRF comprises all data raised via the 4-point ordinal scales for the 
assessment of expectoration difficulty, sputum viscosity, sputum color and cough and the 24-hour 
sputum volume.  
ECG and laboratory results must be printed and signed by the Investigator and kept as source data 
on site after entering outcome into the eCRF. 
All other data has to be documented in the subject file as source data first and then entered into 
the eCRF.  
Data must be entered into eCRFs in English by the designated site personnel as soon as possible 
after a subject visit, and monitors will have access to data recorded. These data will be reviewed 
versus source documents by trial monitors for completeness and acceptability during monitoring 
visits.  
If data correction is required for an eCRF after initial entry, the site personnel can make necessary 
corrections on their own or as a response to an automated query by the eCRF system. Monitor 
and Clinical Data Manager review the eCRF for accuracy and can also generate queries to the 
investigational staff for resolution.  
Any correction to the eCRFs' entries must be carried out by the Investigator or a designated 
member of staff. Corrections are recorded in an audit trail that records the old information, the new 
information, and identification of the person making the changes, date of correction made and 
reason for change. In the interests of completeness of data acquisition, the questions which are 
repeated in each section of the eCRFs should be answered in full, even if there are no changes 
from a previous examination. A reasonable explanation must be given by the Investigator for all 
missing data. The Investigator or his/her designees named in the clinical staff list will review the 
eCRF for accuracy and completeness. The Investigator must electronically sign and date the eCRF 
pages as indicated. 
19.2. 
RECORDS MAINTAINED BY THE INVESTIGATOR 
A copy of all trial records (any documents sent or received from the Sponsor/CRO, correspondence 
with EC and any other institution or authority and relevant approvals, subjects' source data and 
subjects' identification documentation) must be maintained by the Investigator for at least 5 years, 
or for a longer period, where so required by other applicable requirements or by an agreement 
between the Sponsor and the Investigator. 
19.3. 
TRIAL MASTER FILE 
The Trial Master File (TMF) will be maintained by the CRO according to the respective CRO SOPs 
with direct access for all study participants.  


 
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At the end of the trial, the TMF will be transferred to the Sponsor, where it will be archived according 
to specific Sponsor SOPs. A copy of the Investigator files will be left on site after trial end. 
19.4. 
TRIAL MONITORING 
The trial will be monitored by means of regular visits and telephone calls according to specific and 
pre-defined SOPs and trial specific monitoring guidelines. Details of the visits will be recorded in 
appropriate Monitoring Report forms to be submitted regularly to Sponsor. Any relevant protocol 
deviation must be promptly communicated to designated Sponsor’s personnel 
Monitoring will be performed by personnel of the CRO, Parexel.  
19.5. 
CONFIDENTIALITY OF SUBJECT’S INFORMATION 
The Investigator has the responsibility to maintain the pseudonymity of subjects in compliance with 
the Chinese and Italian data protection laws. In all trial documents, subjects are associated to a 
code which does not reveal subject’s identity. Only at the site, the Investigator holds the subject’s 
identity on a Subject Identification Log under his/her responsibility. The Investigator will maintain 
this for the longest period allowed by his/her own institution and, in any case, until further 
communication from the Sponsor. 
The site and the Sponsor shall process personal data of subjects involved in the clinical trial as 
data controllers and in compliance with the Italian data protection law, each of them in its area of 
competence and in accordance with the responsibilities provided by GCP, only in relation to the 
trial performance and for pharmacovigilance purposes. 
Any contracted organisation as data processor including Parexel, the local laboratories, and IWRS 
provider, will act in compliance with the terms and conditions agreed with the Sponsor. 
20. 
BIOMETRICS 
20.1. 
DATA MANAGEMENT 
A data management plan specifying all relevant aspects of data processing for the study (including 
data validation, cleaning, correcting, and releasing) will be maintained and stored at Parexel. 
Electronic systems that may be used to process and/or collect data in this study will include the 
following: 
 IWRS system – randomization, study drug supply 
 eCRF and Electronic Data Capture (EDC) system – data capture 
 Statistical Analysis System (SAS®) – statistical review and analysis 
 Pharmacovigilance safety database 
Subject data will be captured in an eCRF system and reviewed by the Clinical Research Associate 
in order to check CTP adherence and to detect any data inconsistency or discrepancy (data 
validation step). 
Medical/surgical history and underlying diseases and AEs will be coded using the Medical 
Dictionary for Regulatory Activities (MedDRA) latest version current at trial start and which will be 
maintained during the trial. 


 
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Previous and concomitant medications will be coded using the World Health Organization-Drug 
Dictionary (WHO-DD). Actual versions of coding dictionaries used will be stated in the CTR.  
The final data file will be transferred to the Sponsor in the agreed format as soon as possible after 
the trial is completed. 
20.2. 
STUDY END-POINTS  
 
Primary efficacy end-point 
Superiority of NAC over placebo in change from baseline to end of 1-week treatment of mean 
sputum viscosity score or mean expectoration difficulty score. 
The study will be declared success if at least one of two components of the primary end-point will 
show superiority over placebo.  
 
Secondary efficacy end-points 
A. Superiority of NAC over placebo 
 in change from baseline to day 3 of mean sputum viscosity score OR mean expectoration 
difficulty score;  
 in change from baseline to day 3 and to end of 1-week treatment of individual scores:  
 mean sputum viscosity score 
 mean expectoration difficulty score 
 mean sputum color score 
 mean cough score 
 in change from baseline to day 3 and to end of 1-week treatment of mean sputum volume  
  
D. Non-inferiority of NAC vs. ambroxol in change from baseline to end of 1-week treatment of 
mean sputum viscosity score or change of mean expectoration difficulty score. 
 
E. Superiority of ambroxol vs. placebo in change from baseline to day 3 and to end of 1-week 
treatment of  
 mean sputum viscosity score OR mean expectoration difficulty score;  
 mean sputum viscosity score (individual score) 
 mean expectoration difficulty score (individual score) 
 mean sputum color score 
 mean cough score 
 mean sputum volume 
 
Safety end-points 
Counts and frequency distributions of 
 all, mild/moderate/severe, non-serious/serious adverse events  
 vital signs  
 Laboratory tests  
 12-lead ECG (normal, abnormal clinically non-significant, abnormal clinically significant) 
20.3. 
SAMPLE SIZE 
This study has been powered to reach statistical significance for the superiority comparisons of N-
acetyl cysteine (NAC) vs. placebo (primary study objective), and for the non-inferiority comparisons 
of NAC vs. ambroxol hydrochloride (key secondary study objective) in at least one of the two co-


 
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primary endpoints at the end of the 1-week treatment. This implies that sample size computation 
must account for the type I error inflation caused by the multiplicity over the two co-primary 
endpoints and by the multiplicity over the study targets (superiority and non-inferiority 
assessments) as well as the logical relationships among the two family of hypotheses with the non-
inferiority testable only provided that the superiority contrast, assessed on the same endpoint, is 
statistical significant. To accomplish this, a multiple-sequence gatekeeping procedure [21] was 
implemented in a Monte Carlo (MC) study with 1000 runs and with the Bonferroni correction applied 
to the set of superiority comparisons (first gatekeeper) and the Hochberg correction applied to the 
set of non-inferiority comparisons (second gatekeeper) in order to control the overall type I family-
wise error rate at the one-tailed 0.025 significance level. Details on the adopted gatekeeping 
strategy are reported further on.  
For the superiority tests, and with group sample sizes of 100 patients in placebo group and 100 
patients in NAC group, the Monte Carlo study estimated an overall power (“disjunctive” power) 
close to 93% to reach statistical significance in at least one co-primary end-point. These 
calculations are based on a one-sided Mann-Whitney test and assuming a minimal clinically 
relevant difference of 0,35 points between placebo and NAC on a 0-3-point scale, standard 
deviation equal to 0,79 and 0,77 for sputum viscosity and expectoration difficulty scores (change 
from baseline to the 1-week treatment) respectively and a correlation between the two end-points 
equal to 0.31. 
For the non-inferiority tests, a sample of 100 patients per each active treatment group ensures 
sufficient disjunctive power (Monte Carlo disjunctive power = 82%) to detect non-inferiority between 
NAC and ambroxol in at least one co-primary end-point. These calculations are based on a one-
sided non-inferiority t-test assuming a margin of non-inferiority equal to 0.30, standard deviation 
equal to 0,79 and 0,77 for sputum viscosity and expectoration difficulty scores (change from 
baseline to the 1-week treatment) respectively and a correlation between the two endpoints equal 
to 0.31. 
Assuming a drop-out rate of about 10% over one week of entry, a total of 333 patients will be 
randomized (i.e. 111 patients in the placebo group, 111 patients in the NAC group and 111 patients 
in the ambroxol group. The sample size calculations were performed using the Mediana package 
[22]. 
20.4. 
STATISTICAL ANALYSES 
20.4.1. 
GENERAL STATISTICAL CONSIDERATIONS 
All data captured on eCRFs will be available as listings. 
The statistical analysis will be performed by the CRO and it will be carried out according to ICH 
guidelines ICH E9: “Statistical Principles for Clinical Trials” (CPMP/ICH/363/96). If not otherwise 
stated all statistical analyses and data tabulations will be produced using SAS® for Windows 
release 9.4 (64-bit) or later (SAS Institute Inc., Cary, NC, USA). 
The data from all sites will be pooled. Unless stated otherwise, all available data from withdrawn 
subjects will be included in the analysis up to the time of withdrawal. 
The primary study objective will be assessed by testing superiority of NAC compared to placebo 
and will be achieved if at least one of the two co-primary end-points will be found statistically 
significant. The key secondary objective will be assessed through the analysis of non-inferiority of 
NAC compared to ambroxol and, similarly, will be reached if at least one of the two co-primary end-
points will be found statistically significant. Conversely, the analyses on the remaining secondary 


 
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efficacy endpoints will be treated as non-key secondary objectives since they will be performed 
only to support primary endpoints findings. 
All tests will be one-sided and performed at the significance nominal level of α = 0.025. Details are 
reported in Section 20.4.5. 
More detail about the statistical analysis will be provided in the SAP. The SAP will be released 
before the start of the study. Any change in the SAP occurred after release will be documented as 
an amendment. Any deviation from the SAP occurring after breaking the blind will be documented 
and justified in the final CTR and deviations will be clearly marked as ‘post hoc’ analyses. 
20.4.2. 
TRIAL POPULATIONS 
There will be 4 analysis populations defined for the trial analyses: 
Intention-To-Treat (ITT) Population The Intention-To-Treat Population will include all subjects who 
provided informed consent and received a patient number (randomisation number) whether or not 
they receive IMP. 
Modified Intention-To-Treat Population The Modified ITT (mITT) Population will comprise all 
subjects who provided informed consent, were randomised and received at least 1 dose or partial 
dose of the IMP.  
Primary analyses will be performed on the mITT population with exclusions from the ITT defined 
and justified in the SAP.  
Following the ITT principle, subjects will be analysed according to the treatment they have been 
assigned to at randomisation. 
The mITT will be used to produce summaries of baseline subject characteristics and for the 
analysis of all efficacy endpoints. 
Safety Population 
The Safety Population will comprise all subjects who provide Informed Consent and received at 
least 1 dose or partial dose of IMP.  
Subjects will be analysed according to the treatment they actually received.  
The Safety Population will be used to produce summaries of all safety related endpoints and 
demography. 
Per-protocol Population 
The Per-protocol Population (PP) will include all mITT subjects who were compliant with study drug 
administration (i.e. had a compliance of at least 80%) and who had no major protocol deviations 
that were considered as potentially impacting the efficacy results. Major protocol deviations might 
include, but are not be limited to, subjects taking a not-permitted concomitant medication, the IMP 
not being administered during the trial as defined in the protocol, subjects receiving a treatment 
different than the one assigned by randomisation; others will be defined in the SAP.  
With the exclusion of non-inferiority comparisons, results of the primary and secondary efficacy 
endpoints analyses conducted in the PP will be considered as supportive. 
Exclusion of subjects from the PP analyses will be decided jointly by the CRO and Sponsor’s 
Medical Monitor, Clinical Trial Manager and Statistician prior to unblinding of the randomisation 
code and database release.  
The subjects or observations to be excluded, and the reasons for their exclusion will be 
documented and approved by the above-mentioned persons prior to database release. The 
documentation will be filed together with the remaining trial documentation. 
The number of subjects in each analysis population will be reported. Violations excluding subjects 
from any particular population will be described, reporting the number of protocol violators per each 
criterion. All protocol violations, minor ones included, will be listed. 


 
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20.4.3. 
EFFICACY DATA 
If not otherwise stated the mITT population will be used for the primary analyses of each of the 
efficacy endpoints whilst results from supplemental analyses using the Per Protocol Population will 
be compared to those based on the mITT population to assess the effects of dropouts, missing 
data and exclusions for protocol violations. 
The distributions of all the efficacy endpoints listed in Section 20.2 will be summarized by treatment 
group and time point. Counts and percentages will be reported with the latest computed based on 
the numbers of patients with non-missing observations. The percentages will be suppressed when 
the count is zero in order to draw attention to the non-zero counts.  Furthermore, efficacy endpoints 
will be further summarized by arithmetic means, standard deviations, medians quartiles, minima 
and maxima. 
 
20.4.3.1. 
ANALYSIS OF PRIMARY END-POINTS 
The co-primary efficacy endpoints are: “the change from baseline to the 1-week treatment in 
sputum viscosity score” and “the change from baseline to the 1-week treatment in expectoration 
difficulty score” and will be analyzed on the mITT and PP populations by means of conventional 
Mann-Whitney U Statistics for testing the hypotheses of superiority of NAC versus placebo (primary 
objective)) and by means of a modified Mann-Whitney U Statistics [23] for testing the hypotheses 
of non-inferiority of NAC versus ambroxol (key secondary objective) assuming a margin of non-
inferiority equal to 0.30. Statistical significant results will be needed on both mITT and PP 
populations to accept the hypothesis of non-inferiority of NAC versus ambroxol. Point estimates of 
treatment differences together with associated two-sided 95% confidence intervals will be 
computed using nonparametric bootstrap.     
20.4.3.2. 
ANALYSIS OF SECONDARY ENDPOINTS 
 Change from baseline to day 3 in sputum viscosity score: the hypothesis of superiority of 
NAC compared to placebo will be assessed using the same nonparametric test (Mann-
Whitney U Statistics), whilst point estimates of treatment differences together with 
associated two-sided 95% confidence intervals will be computed using nonparametric 
bootstrap. 
 Change from baseline to day 3 in expectoration difficulty score: the hypothesis of superiority 
of NAC compared to placebo will be assessed using the same nonparametric test (Mann-
Whitney U Statistics), whilst point estimates of treatment differences together with 
associated two-sided 95% confidence intervals will be computed using nonparametric 
bootstrap. 
 Change from baseline to day 3 and to the end of the 1-week treatment period in sputum 
color score: the hypothesis of superiority of NAC compared to placebo will be assessed 
using the same nonparametric test (Mann-Whitney U Statistics), whilst point estimates of 
treatment differences together with associated two-sided 95% confidence intervals will be 
computed using nonparametric bootstrap. 
 Change from baseline to day 3 and to the end of the 1-week treatment period in cough 
severity score: the hypothesis of superiority of NAC compared to placebo will be assessed 
using the same nonparametric test (Mann-Whitney U Statistics), whilst point estimates of 
treatment differences together with associated two-sided 95% confidence intervals will be 
computed using nonparametric bootstrap. 


 
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 Change from baseline to day 3 and to the end of the 1-week treatment period in sputum 
volume: the hypothesis of superiority of NAC compared to placebo will be assessed using 
the same nonparametric test (Mann-Whitney U Statistics), whilst point estimates of 
treatment differences together with associated two-sided 95% confidence intervals will be 
computed using nonparametric bootstrap. 
 
The same statistical analysis (Mann-Whitney Test) will be carried out for testing superiority of 
ambroxol vs. placebo on the same efficacy endpoints. Results will be used for the purpose of 
verifying study’s assay sensitivity.    
20.4.4. 
HANDLING OF MISSING DATA 
Missing data on the primary and secondary efficacy endpoints will be imputed as treatment failures 
(MVTF) by replacing missing values with the scores recorded at baseline or last measurement, 
whichever is worse as primary imputation method. Expectation-maximization (EM) algorithm and 
last observation carried forward (LOCF) will also be used as sensitivity analyses. Details regarding 
the EM algorithm (i.e. the randomization seed and the SAS code that will be used) will be reported 
in the SAP. 
 
20.4.5. 
MULTIPLICITY 
The overall type I family-wise error rate will be preserved at the one-tailed 0,025 nominal level (i.e. 
α = 0,025) by controlling multiplicity over the two co-primary endpoints and over the two study 
targets (superiority and non-inferiority) using a multiple-sequence gatekeeping procedure [20]. To 
achieve this, the analyses on primary endpoints will be grouped into two family of comparisons 
(gatekeepers) and processed as follows:  
1. The first gatekeeper includes the superiority contrasts “NAC vs placebo” with the adjustment 
for multiple comparisons across the two co-primary endpoints performed according to 
Bonferroni. This implies that a difference will be considered statistically significant for a one-
tailed p-value ≤ 0.0125 (i.e. α/2 = 0.0125). The transition to the second gatekeeper requires 
that at least one of the two co-primary endpoints is statistically significant.   
2. The second gatekeeper includes the family of non-inferiority contrasts “NAC vs ambroxol”. The 
analyses in the second gatekeeper will be performed depending upon the results obtained in 
the first gatekeeper as shown below: 
a. If both superiority contrasts will be found statistically significant, non-inferiority will be 
tested on both co-primary endpoints with an overall probability α set to 0,025 (one-tailed) 
and with the adjustment for multiple comparisons across the two co-primary endpoints 
performed according to Hochberg. 
b. If only one of the two superiority contrasts will be found statistically significant, non-
inferiority will be tested only for that co-primary endpoint and will be considered achieved 
if the associated one-tailed p-value will be  ≤ 0.0125. 
Consistent with the hypothesis testing process performed on the co-primary endpoints, the strategy 
described above will also be applied to control the coverage of confidence intervals at the two-
tailed 95% nominal level (i.e. 1 - 2α = 0,95). 
The analyses on secondary efficacy endpoints (not key) will be performed only to support primary 
endpoints findings and/or for explorative reasons, therefore no adjustment of significance level will 
be made to account for multiple comparisons. 


 
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20.4.6. 
MULTICENTER STUDY 
As additional analysis, a test of site-by-treatment interaction will be carried-out using a two-way 
nonparametric ANOVA performed by resorting to the “Aligned Rank Transform” (ART) procedure 
[24]. The interaction will be considered statistically significant for a two-tailed α=0.1. Also, in order 
to graphically assess the possible heterogeneity of the treatment effect across centres, forest plots 
will be generated to display the results at each center. In case that the number of patients in each 
site were scarce, sites will be gathered into “region”. Upon completion of the study and prior to 
unblinding, study statisticians in consultation with the clinical team will determine the pooling based 
on enrolment numbers and geographical proximity. 
20.4.7. 
INTERIM ANALYSES 
No interim analyses are planned. 
20.4.8. 
SAFETY DATA 
All safety endpoints will be summarised and analysed using the Safety Population. 
Incidence of Treatment Emergent Adverse Events 
The number and the percentage of subjects reporting TEAEs, treatment emergent SAEs, severe 
TEAEs, TEAEs leading to discontinuation and TEAEs leading to death will be presented by 
treatment group, along with the number of events occurring.  
TEAEs will be summarised also by System Organ Class and Preferred Term according to 
MedDRA; they will be additionally summarised by severity and relationship to treatment. A separate 
summary table will be provided for SAEs. 
Only TEAEs, i.e. events with an onset date on or after the date of IMP start, will be included in the 
summary tables. Individual data listings will include all AEs recorded; a separate listing will be 
provided for treatment-emergent SAEs. 
Vital Signs 
Descriptive statistics for vital signs will be presented overall and by treatment.  
Physical examination data. 
Descriptive statistics for physical examination data will be presented overall and by treatment.  
Haematology and clinical chemistry  
Haematology and clinical chemistry tests results will be converted to standard international units 
and summarised by treatment group using descriptive statistics for continuous variables. 
Summaries for change from Visit 1 will be also provided. Frequency of subjects with values 
appearing outside the central laboratory normal range will be reported by visit for each treatment 
group. All values appearing outside the laboratory normal range will be highlighted in listings. 
 
12-lead Electrocardiogram 
Descriptive statistics for ECG results will be presented overall and by treatment (normal, abnormal 
clinically non-significant, abnormal clinically significant). 
Adherence and Exposure 
Subject adherence will be summarised by treatment group presenting descriptive statistics and 
percentages of adherent subjects, i.e. with a least 80% of compliance.  
The total number of doses of IMP taken by each subject, will be summarised as well. 
If an AE has a partial or fully missing date, and it is unclear whether the AE is treatment-emergent, 
it will be assumed that it is. In the AEs analysis, when relationship to study drug is missing for a 


 
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treatment-emergent adverse event it will be imputed to be drug related. More detail will be provided 
in the Statistical Analysis Plan (SAP). 
21. 
INFORMED CONSENT 
Written informed consent will be obtained by the Investigator or other authorized person from all 
subjects or their legally acceptable representative.  
The Investigator is responsible for correctly obtaining the informed consent in accordance with the 
applicable regulatory requirement(s), GCP and the ethical principles that have their origin in the 
Declaration of Helsinki. 
Prior to the beginning of the trial, the Investigator should have received the EC written approval of 
the ICF. 
Informed consent must be obtained prior to the initiation of any procedures specific to the trial. The 
record of the informed consent must be available to be audited/inspected by the Sponsor/CRO 
designees and by CA(s), whenever requested.  
The informed consent documentation must be personally dated and signed by the trial subjects, to 
confirm that consent is based on information that has been understood, and by the Investigator. 
Neither the Investigator, nor the trial staff, should coerce or unduly influence a subject to participate 
or to continue to participate in a trial. 
Before informed consent may be obtained, the Investigator or other authorised person, should 
provide the subject ample time and opportunity to inquire about details of the trial and to decide 
whether or not to participate in the trial. All questions about the trial should be answered to the 
satisfaction of the subject. 
The subject should receive a copy of the signed and dated ICF and any other written information 
provided to him/her, and updates. 
 
If the subject is not able to write, a verbal consent can be obtained.  For illiterate patients, at least 
1 impartial witness must be invited to join in the consent process, who would sign off ICF. 
Further, in case the subject and his/her legal representative are unable to read, informed consent 
will be obtained in the presence of an impartial witness, i.e. a person independent of the trial who 
will read the ICF and the written information for the subject. 
22. 
ETHICS COMMITTEE APPROVAL 
This trial will be undertaken only after written and dated approval from EC has been received by 
the Investigator and by the Sponsor for CTP, all its appendices, ICF, and subjects recruitment 
procedures (i.e. advertisement) if applicable. 
In addition to the above-mentioned documents, the EC will be provided with an updated 
Investigator Brochure, SmPc and IMPD (where applicable), the Investigator’s up-to-date 
Curriculum Vitae and/or other documentation evidencing qualifications, and any other documents 
that the EC may need to fulfil its responsibilities. 
During the trial, on regular basis, the Investigator will have to submit written summaries of the trial 
status (i.e. recruitment rate) to the EC, if requested. 
23. 
REGULATORY REQUIREMENTS 
The trial is to be conducted in compliance with the Chinese legislation and ICH-GCP E6 Rev2.  


 
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. 
Selection of subjects will not start prior to the approval of the EC has been obtained and the trial 
notified to or authorised by CAs as per national and local requirements.  
24. 
QUALITY ASSURANCE 
This CTP has been audited by the Sponsor’s Quality Assurance. The Audit Plan for the study 
includes site audits. Audits will be planned and conducted according to the Sponsor’s SOPs. 
25. 
INSURANCE 
The Sponsor is concerned with the safety of the subjects in the clinical trial and wishes to protect 
the Investigator (and as applicable per local regulations, the site, the monitor and all the 
Investigator’s staff involved in the trial) in the event of claims or lawsuits alleging injury as a result 
of administration of a study drug. 
In consideration of undertaking a human trial in subjects according to this CTP the Sponsor will:  
 indemnify the Investigator and hold him without liability for claims for damages arising out 
of the above described investigation in excess to those covered by his/her own professional 
liability insurance; 
 defend the Investigator against any claims or lawsuits initiated by, or on behalf of, subjects 
who seek damages for bodily injury alleged to have been sustained as a result of 
administration of the study drug; 
 pay any settlements of judgement resulting therefrom, providing that for all of the 
aforementioned cases, the study drug was administered under the Investigator's supervision 
and in strict accordance with accepted medical practice, the CTP, and the precautions, 
indications, and other instructions, provided by the Sponsor; 
Indemnification is not valid for claims for damages arising from malpractice and/or negligence on 
the part of the Investigator or those under the Investigator's supervision. 
The protection afforded by this policy does not take the place of the Investigator's professional liability 
insurance but covers damages in excess of such insurance protection. Further, this indemnity is 
conditional upon the Investigator giving the Sponsor information as soon as reasonably practicable 
and upon the Investigator assisting the Sponsor and its authorised representatives in the 
investigation and defence of any suit for which coverage is provided. 
26. 
CLINICAL TRIAL REPORT 
A CTR of the trial will be prepared and written by the CRO according to ICH topic E3 
(CPMP/ICH/137/95). A summary of the report will be sent to Investigators/EC/Regulatory 
Authorities according to current regulations. 
27. 
USE OF INFORMATION AND PUBLICATION 
Investigator agrees to inform in advance Zambon about his/her intention to divulge any data, results 
concerning the Confidential Information and/or the trial subject to this agreement. As a 
consequence hereof, Investigator hereby undertakes to submit to Zambon, at least with a 60 days 
(30 in case of abstracts) prior written notice, the text and or the content of the concerned 
publication, divulgation as to allow Zambon to assess properly that such proposed publication 
respects and/or is not in conflict with Zambon’s rights to preserve and protect its intellectual 


 
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property rights and any confidentiality imposed to Zambon by the prevailing rules of the country 
where the trial is conducted . 
Further, without any prejudice to Investigator’s right to divulge and save for what stated 
hereinabove, Investigator intends to seek Zambon opinion and advice on and prior to the intended 
publication and/or disclosure, in consideration also of the contractual relationship in force between 
Zambon and Investigator and the nature of the trial hereto. 
 


 
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28. 
REFERENCES 
1. Global Strategy for the diagnosis, management, and prevention of Chronic Obstructive 
Pulmonary Disease (GOLD) guidelines, update 2018. 
2. Polverino E, et al. European Respiratory Society guidelines for the management of adult 
bronchiectasis. Eur Respir J 2017; 50: 1700629. 
3. Wenzel RP, et al. Acute Bronchitis. N Engl J Med 2006;355:2125-30. 
4. ERS White Book. Cystic fibrosis, Chapter 14:160-175. 
5. Chen R, et al. Fine Particulate Air Pollution and Daily Mortality. A Nationwide Analysis in 
272 Chinese Cities. AJCCM 2017; 196:73-81. 
6. Zhang T, et al. Clinical application of expectorant therapy in chronic inflammatory airway 
diseases. Exp Ther Med 2014;7: 763-767. 
7. Sadowska AM. N-Acetylcysteine mucolysis in the management of chronic obstructive 
pulmonary disease. Ther Adv Respir Dis 2012;6:127-35.  
8. Fluimucil Vials for Aerosol – Chinese SmPC. 
9. Fluimucil Vials for Aerosol – Italian SmPC. 
10. Fluimucil Vials for Aerosol – Switzerland SmPC. 
11. Grassi C, et al. Clinical Evaluation of systemic acetylcysteine by different routes of 
administration. Curr Ther Res 1973;15:165-179. 
12. Henneghien C, et al. Study of the N-acetylcysteine (NAC) by oral or intravenous 
administration in chronic bronchitis. Curr Ther Res 1983;34:750-756. 
13. Porsio A, et al. Sull’impiego dell’acetilcisteina per via endovenosa: esperienze cliniche di 
tollerabilità e di attività. Clin Terap 1970; 55:123-132. 
14. Balestra L, et al. L’acetilcisteina per via venosa in rianimazione. Min Anest 1971; 37:394-
398.  
15. Gunella G, et al. Effetti dell’acetilcisteina per via endovenosa, associata ad altre terapie, in 
broncopneumopatici cronici portatori di insufficienza ventilatoria globale o parziale. Min 
Pneum 1973; 12:142-149.  
16. Domenichini E, et al. Effetto mucolitico e terapeutico dell’acetilcisteina per via endovenosa. 
Min Anest 1973; 39:7-12.  
17. Gambini A, et al. Valutazione biochimica ed elettrocardiografica dell’acetilcisteina per via 
endovenosa. Clin Terap 1971; 57:357-369. 
18. Ambroxol Vials for Aerosol – Chinese SmPC.  
19. Locatelli C, et al.  N-acetilcisteina in tossicologia clinica. Terapia protratta nelle 
intossicazionii da Amanita phalloides e da idrocarburi clorurati.  Atti II FIMUPS, 1995. 
20. Keays r, et al. Intravenous acetylcysteine in paracetamol induced fulminant hepatic failure: 
a prospective controlled trial. BMJ 1991;303:1026-9.  
21. Dmitrienko, A., Kordzakhia, G., Brechenmacher, T. (2016). Mixture-based gatekeeping 
procedures for multiplicity problems with multiple sequences of hypotheses. Journal of 
Biopharmaceutical Statistics. 26, 758-780. 
22. Dmitrienko, A., Pulkstenis, E. (2017). Clinical Trial Optimization Using R. Chapman & 
Hall/CRC Biostatistics Series, 4-28. 
23. Rothmann, M.D., Wiens, B.L., Chan, I.S.F. (2012). Design and Analysis of Non-Inferiority 
Trials. Chapman & Hall/CRC Biostatistics Series, 350-351. 
24. Wobbrock, J.O., Findlater L., Gergle D., Higgins J.J. (2011). The Aligned Rank Transform 
for Nonparametric Factorial Analyses Using Only ANOVA Procedures. Proceedings of the 


 
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ACM Conference on Human Factors in Computing Systems (CHI '11). Vancouver, British 
Columbia (May 7-12, 2011). New York: ACM Press, pp. 143-146. 
29. 
APPENDICES 
Appendix 1: Trial Flow Chart  
Appendix 2: SmPC of NAC 
Appendix 3: PI of ambroxol hydrochloride 
Appendix 4: Investigator Signature Page 
 
Appendix 1 
Trial Flow Chart 
 
ACTIVITIES 
(See sections 9 & 10 
for details) 
Visit 1 
Screening 
Visit 2 
Randomisa
tion 
 
Visit 3
 
 
 
Visit 4 
End of 
treatment 
(EoT) 
 
Follow-
up 
phone 
call or 
Visit
 
Unschedu
led 
deteriorati
on visit 
Premature 
discotinuati
on visit) 
 
Within 7 days  
of Visit 2 
Day 1 
 
Day 2 
Day 3 
Day 4 
Day 5 & 6
Day 7 
2 weeks
± 3 days 
after 
EoT or 
DV
 
 
 
Informed consent
X
Verification of 
eligibility for 
randomization
X 
X 
 
 
 
 
 
 
 
 
Medical 
history/demography
X 
 
 
 
 
 
 
 
 
 
Pregnancy test
X
X
x
X
Vital signs
X
X
X
X
x
X
Physical examination
X
X
X
X
x
X
Previous/concomitan
medications
X 
X 
 
X 
 
 
X 
X 
 
X 
12-lead ECG
X
X
x
X
Blood sample for 
haematology and 
clinical chemistry
X 
 
 
 
 
 
X 
 
 
X 
Assessment of 
expectoration 
difficulty, sputum 
viscosity, sputum 
colour and cough by 
means of the 4-point 
ordinal scales 
provided
 
x 
 
x 
 
 
x 
 
 
X 
X 
24-h sputum 
collection (to be 
collected and 
measured the 
following day)
 
X 
 
X 
 
 
X 
 
 
X 
IMP dispensation 
 
X 
X 
X 
X 
X 
X 
 
 
 
Accountability of IMP
 
X 
X 
X 
X 
X 
X 
 
X 
X 


 
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AE monitoring
X
X
X
X
X
x
X


 
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Appendix 2 
Summary of Product Characteristics – N-Acetyl cysteine (NAC) 
Switzerland 
 


 
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Appendix 3 
Package Insert – Ambroxol hydrochloride  
China 
 
[Drug Name] 
Generic name: Ambroxal Hydrochloride Injection 
English name: Ambroxal Hydrochloride Injection 
Trade name: Mucosolvan 
[Composition] 
Ambroxol hydrochloride (also known as bromocyclohexylaminealcohol hydrochloride)  
Excipients: Citric acid monohydrate, sodium hydrogen phosphate dihydrate, sodium chloride, water 
for injection, nitrogen. 
[Description] 
Colorless clear liquid. 
[Indication] 
1. Indicated for expectorant therapy in the following patients with acute and chronic respiratory 
diseases accompanied by abnormal sputum secretion and poor expectoration, such as acute 
exacerbation of chronic bronchitis, asthmatic bronchitis, bronchiectasis, bronchial asthma and 
pneumonia.  
2. Prophylactic treatment of postoperative pulmonary complications. 
3. Treatment of infant respiratory distress syndrome (IRDS) in premature infants and newborns. 
[Dosage and Administration] 
Adults and children above the age of 12 years: 2-3 times a day, 15 mg each time, slow intravenous 
injection; the dose can be increased to 30 mg each time for severe cases. 
Children aged 6-12 years: 2-3 times a day, 15 mg each time. 
Children aged 2-6 years: 3 times a day, 7.5 mg each time. 
Children below the age of 2 years:  2 times a day, 7.5 mg each time. 
All for slow intravenous injection. 
Or add the drug to glucose injection (or normal saline) for intravenous drip. 
Treatment of infant respiratory distress syndrome (IRDS): The total daily dose is calculated based 
on the infant’s weight, 30 mg/kg, divided into 4 injections per day. An infusomat should be used for 
administration, and the duration of intravenous injection should be at least 5 minutes. 
[Dosage Form] 


 
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Page 63 of 65 
  
Injection 
[Adverse Reactions] 
The product is well tolerated, and mild upper gastrointestinal adverse reactions have been 
occasionally reported, mainly including stomach burning, indigestion and occasional nausea and 
vomiting, occurring mostly after parenteral administration. Allergic reactions are rare, mainly 
including rash. Few cases have reported severe acute allergic reactions, but the correlation with 
ambroxol hydrochloride is not yet known, and such patients are often allergic to other substances. 
[Contraindication] 
Those who are known to be allergic to ambroxol hydrochloride or other ingredients shall not use the 
product. 
[Precautions] 
1. Pregnant and breastfeeding women should use the product with caution.  
2. It is prohibited to mix the product with other solutions having a pH greater than 6.3, as the increase 
in pH will lead to free base precipitation of ambroxol. 
[Ingredient] 
Ambroxol hydrochloride 
[Use in Pregnant and Breastfeeding Women] 
Pre-clinical trials and a great deal of clinical experience in women after pregnancy for 28 weeks 
have shown that the product has no adverse effect on pregnancy. However, during pregnancy, 
especially in the first three months of pregnancy, the drug should be used with caution. The drug 
may enter breast milk, but is supposed to have no effect on infants at the therapeutic dose. 
[Pediatric 
Use] 
Keep observing during medication.  
[Geriatric Use] 
The safety and efficacy of medication in the elderly and young patients have been assessed, and the 
results have shown no difference.  
[Drug Interactions] 
Co-administration of the product and antibiotics (amoxicillin, cefuroxime, erythromycin, 
doxycycline) may increase the concentration of antibiotics in the lung tissue. There has been no 
report on relevant clinical adverse reactions when the product is used in combination with other 
drugs. 
[Pharmacological Action] 


 
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The product is a mucolytic agent, which can increase respiratory mucosal serous gland secretion, 
and reduce mucus gland secretion, thereby reducing the viscosity of sputum; it can also promote the 
secretion of pulmonary surfactants, and increase bronchial cilia movement, so that sputum can easily 
be coughed up. 
[Manufacturer] 
Boehringer Ingelheim Shanghai Pharmaceutical Co., Ltd. 
 
 
 
 
 
 
 
 
 
 
 






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Protocol Code Z7244L01 Amendment 1
– App. 3 Page 1 of 13
PROTOCOL AMENDMENT
NUMBER: 1
INTRAVENOUS NAC PHASE III CHINA CLINICAL TRIAL
(IVNAC-3C)
A PHASE III, MULTI-CENTRE, RANDOMIZED, RATER- AND PATIENT-BLIND, PLACEBO-
AND ACTIVE-CONTROLLED, PARALLEL GROUP CLINICAL TRIAL TO COMPARE THE
EFFICACY AND SAFETY OF 1-WEEK TREATMENT WITH INTRAVENOUS N-
ACETYLCYSTEINE (NAC) 600 MG TWICE DAILY (ACTIVE TEST TREATMENT),
AMBROXOL HYDROCHLORIDE 30 MG TWICE DAILY (ACTIVE CONTROL TREATMENT)
AND PLACEBO AS EXPECTORANT THERAPIES IN ADULT CHINESE PATIENTS WITH
RESPIRATORY TRACT DISEASES AND ABNORMAL MUCUS SECRETIONS
Protocol Code
Z7244L01
DATE OF THE AMENDMENT: 19 December 2018
Zambon Spa
Via Lillo del Duca 10
20091 Bresso - Milan - Italy
THIS DOCUMENT IS ZAMBON'S SOLE PROPERTY AND OWNERSHIP. THIS DOCUMENT, AND ALL
INFORMATION AND DATA CONTAINED HEREIN HAS TO BE CONSIDERED AND TREATED AS STRICTLY
CONFIDENTIAL. THIS DOCUMENT SHALL BE USED ONLY FOR THE PURPOSE OF THE DISCLOSURE
HEREIN PROVIDED. NO DISCLOSURE OR PUBLICATION SHALL BE MADE WITHOUT THE PRIOR WRITTEN
CONSENT OF ZAMBON.
CCI




Protocol Code Z7244L01 Amendment 1
– App. 3 Page 3 of 13
PROTOCOL AMENDMENT n.1
This amendment is considered not substantial because the introduced changes do not impact
the subject’s safety and efficacy or quality of the investigational drug. In detail:
Protocol section
Text of the protocol
version 1.0
Amended text of
the protocol
version 2.0
Rational for the
change
4. INTRODUCTION
AND RATIONALE
This trial is intended to
provide pivotal (phase
III) evidence of efficacy
and safety for
registration in China of
slow intravenous
infusion of NAC in
adult hospitalised
patients with with
respiratory tract
diseases and abnormal
mucus secretions.
This trial is intended
to provide pivotal
(phase III) evidence
of efficacy and safety
for registration in
China of slow
intravenous infusion
of NAC in adult
hospitalised patients
with respiratory tract
diseases and
abnormal mucus
secretions.
Typing error
Exclusion criteria
number 4
Use of expectorants or
drugs with expectorant
effect within 3 days
before randomization
visit
Use of expectorants
or drugs with
expectorant effect
within 2 days before
randomization visit
A period of 48 hours
is sufficient to ensure
the washout from
expectorants or
drugs with
expectorant effect
and to ensure the
validity of efficacy
assessment.
8.1.
CLINICAL
TRIAL DESIGN
The trial will be
conducted in
approximately 15 -25
sites in China.
The trial will be
conducted in
approximately 25
sites in China.
Administrative
change
8.1.
CLINICAL
TRIAL DESIGN
The study will consist
of a total of 4 core
hospital visits
(screening, baseline,
treatment day 3,
treatment day 7, see
Section 9)
The study will consist
of a total of 4 core
hospital visits
(screening, baseline,
treatment day 3,
treatment day 7, see
Section 10)
Typing error
8.2.
DURATION
OF CLINICAL TRIAL
If the trial is
prematurely stopped,
please refer to Section
16
If the trial is
prematurely stopped,
please refer to
Section 17
Typing error
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Protocol Code Z7244L01 Amendment 1
– App. 3 Page 4 of 13
9.2.1. INCLUSION
CRITERIA
1.
Male or female
adult (≥18 years old) 
hospitalized patients
with respiratory tract
diseases and abnormal
mucus secretions such
as: acute bronchitis,
chronic bronchitis and
exacerbations,
emphysema,
mucoviscidosis and
bronchiectasis
1.
Male or female
adult (≥18 years old)
hospitalized patients
with respiratory tract
diseases and
abnormal mucus
secretions such as:
acute bronchitis,
chronic bronchitis
and exacerbations,
emphysema,
mucoviscidosis and
bronchiectasis.
Diagnostic criteria for
these conditions are
provided in Annex 1
Added following an
NMPA suggestion
9.2.1. INCLUSION
CRITERIA
1.
Male or female
adult (≥18 years old) 
hospitalized patients
with respiratory tract
diseases and abnormal
mucus secretions such
as: acute bronchitis,
chronic bronchitis and
exacerbations,
emphysema,
mucoviscidosis and
bronchiectasis.Chinese
ethnicity and/or
Chinese
2.
Chinese
ethnicity and/or
Chinese
Typing error
9.2.2. EXCLUSION
CRITERIA
5.
Diagnosis of
active tuberculosis,
lung cancer,
pulmonary fibrosis,
acute pulmonary
thromboembolism or
any other respiratory
condition that might,
in the opinion of the
investigator,
compromise the
safety of the patient
or affect the
interpretation of the
results
Added following an
NMPA suggestion
9.2.
SELECTION
OF SUBJECTS
Although teratology
studies carried out in
Although teratology
studies carried out in
Administrative
change
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Protocol Code Z7244L01 Amendment 1
– App. 3 Page 5 of 13
Contraceptive
methods
animals evidenced no
teratogenic effects of
NAC (ref IB) or
ambroxol
hydrochloride (ref
SmPC Italy), safety in
human pregnancy has
not been established
with iv administration.
animals evidenced
no teratogenic effects
of NAC (ref IB) or
ambroxol
hydrochloride (ref
Package Insert
China), safety in
human pregnancy
has not been
established with iv
administration.
Several sections
sputum colour
sputum color
Typing error
11.1.6
Abnormalities of
clinical significance
recorded at V1, Visit 4
or unscheduled
deterioration
visit/premature
discontinuation visit
which are not related
to pre-exist medical
condition before ICF
signature will be
reported as AEs.
Abnormalities of
clinical significance
recorded at Visit 1,
Visit 4 or
unscheduled
deterioration
visit/premature
discontinuation visit
which are not related
to pre-exist medical
condition before ICF
signature will be
reported as AEs.
Typing error
12.
PRIOR AND
CONCOMITANT
TREATMENTS
•
Appropriate
treatment(s) for any
underlying disease,
that in the
investigator’s opinion
will not interfere with
the measurements
contributing to the
primary efficacy
outcomes. If one or
more treatments
interfering with the
measurements
contributing to the
primary efficacy
outcomes are deemed
necessary, the patient
should not be
randomized or should
be discontinued from
the study.
•
Appropriate
treatment(s) for any
respiratory tract
disease, that in the
investigator’s opinion
will not interfere with
the measurements
contributing to the
efficacy outcomes,
such as:
corticosteroids
(inhaled or systemic),
bronchodilators,
antibiotics (in case of
co-administration, the
i.v. antibiotic should
be administered
separately).
•
Appropriate
treatment(s) for any
other underlying
disease, that in the
investigator’s opinion
Administrative
change (the section
has been aligned to
the synopsis)
CCI


Protocol Code Z7244L01 Amendment 1
– App. 3 Page 6 of 13
will not interfere with
the measurements
contributing to the
efficacy outcomes
•
If co-treatment
with parenteral
nitroglycerin is
needed the patients
should be monitored
for potential
hypotension, which
may be severe and
may be indicated by
the presence of
headache
•
If one or more
treatments interfering
with the
measurements
contributing to the
primary efficacy
outcomes are
deemed necessary,
the patient should not
be randomized or
should be
discontinued from the
study
All concomitant
medications will be
recorded and
analysed as
described in Section
20.4.3.3.
13.1.
INVESTIGATIONAL
MEDICINAL
PRODUCT
SUPPLIES AND
PACKAGING
NAC will be supplied in
boxes containing 2
ampoules each.
NAC will be supplied
in boxes containing 4
ampoules each.
Administrative
change
13.1.
INVESTIGATIONAL
MEDICINAL
PRODUCT
SUPPLIES AND
PACKAGING
Ambroxol
hydrochloride will be
supplied in boxes
containing 2 vials
each.
Ambroxol
hydrochloride will be
supplied in boxes
containing 4 vials
each.
Administrative
change
13.1.
Placebo will be
Placebo will be
Administrative
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Protocol Code Z7244L01 Amendment 1
– App. 3 Page 7 of 13
INVESTIGATIONAL
MEDICINAL
PRODUCT
SUPPLIES AND
PACKAGING
supplied in boxes
containing 1 vial each.
supplied in boxes
containing 2 vials
each.
change
13.2.
INVESTIGATIONAL
MEDICINAL
PRODUCT
DISPENSING AND
ADMINISTRATION
All IMPs will be
administered at the
hospital investigational
sites by study staff
otherwise not involved
with the assessment
and care of study
patients. The study
staff members
administering the IMP
will be aware of its
identity but will not
disclose it to patients
or to other study staff
members (patient and
rater-blind design, see
Section 4).
All IMPs will be
dispensed twice daily
as one in the
morning and another
is in the
afternoon/evening for
a week of treatment
period at hospital
investigational sites
by study staff. All
IMP will be
administered at the
hospital
investigational sites
by study staff
otherwise not
involved with the
efficacy assessment
and care of study
patients. The study
staff members
administering the
IMP will be aware of
its identity but will not
disclose it to patients
or to other study staff
members who are
involved in efficacy
assessment (patient
and rater-blind
design, see Section
4).
To further guide the
IMP dispensing and
administration
procedure.
13.3.
RANDOMISATION
The screening number
will consist of country
number (3 digits), a
site number (3 digits)
and a continuous
number for a subject at
an individual site (3
digits), e.g.
001001001. Every
subject who signs the
ICF must be entered
The screening
number will consist of
country number (1
digit), a site number
(3 digits) and a
continuous number
for a subject at an
individual site (3
digits), e.g. 1001-
001. Every subject
who signs the ICF
Administrative
change
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Protocol Code Z7244L01 Amendment 1
– App. 3 Page 8 of 13
into the IWRS system
regardless of eligibility.
must be entered into
the IWRS system
regardless of
eligibility.
18.3.2. DEFINITION
OF MEDICAL
DEVICE
MALFUNCTION AND
INCIDENT
A medical device
malfunction is the
failure of a device to
meet performance
specifications or to
perform as intended.
A medical device
incident is any
malfunction or
deterioration in the
characteristics and/or
performance of a
device, as well as any
inadequacy in the
labelling or instructions
for use which, directly
or indirectly, might lead
to or might have led to
the death of a patient,
a user, or other
persons, or to a
serious deterioration in
their state of health.
A medical device
complaint meeting the
criteria of a potential
medical device incident
is reportable.
Subjects will also be
monitored for any
medical device
malfunction or incident
and, if these occur,
details will be recorded
as for ADRs.
Not applicable
section, therefore
has been removed
18.4.1. DEFINITION
OF SERIOUS
ADVERSE EVENT
OR SERIOUS
ADVERSE
REACTION
A Serious Adverse
Event (SAE) or Serious
Adverse Reaction
(SAR) is any untoward
medical occurrence or
effect that at any dose:
A Serious Adverse
Event (SAE) is any
untoward medical
occurrence or effect
that at any dose:
Typing error
18.4.1. DEFINITION
OF SERIOUS
ADVERSE EVENT
• requires inpatient
hospitalisation or
prolongation of existing
• requires inpatient
hospitalisation or
prolongation of
Administrative
change
(hospitalization
CCI


Protocol Code Z7244L01 Amendment 1
– App. 3 Page 9 of 13
OR SERIOUS
ADVERSE
REACTION
hospitalisation;
existing
hospitalisation
considering that
hospitalization is not
a SAE in itself,
planned or selective
hospitalization,
hospitalization for
underlying disease
which did not worsen
during the study, as
well as
hospitalizations for
social reasons
should not be
reported as SAEs;
definition added)
18.7. ADVERSE
EVENT
RECORDING
The Investigator
performs an evaluation
with respect to
seriousness and
causality of the AEs
and records it on the
appropriate section of
the eCRF.
The Investigator
performs an
evaluation with
respect to
seriousness and
causality of the AEs
and records it on the
appropriate section
of the eCRF and on
the “Serious Adverse
Event Form” (if
appropriate).
Administrative
change
18.9.1. REPORTING
SERIOUS ADVERSE
EVENTS
The back-up procedure
is to send the back-up
paper Serious Adverse
Event Form to the
CRO’s
Pharmacovigilance
group by email or fax
using the contact
details specified in the
SAE guidelines.
The back-up
procedure is to send
the back-up paper
Serious Adverse
Event Form to the
CRO’s
Pharmacovigilance
group by email using
the contact details
specified in the SAE
guidelines.
Administrative
change (fax deleted)
18.9.1. REPORTING
SERIOUS ADVERSE
EVENTS
If the Investigator
becomes aware of any
SAE outside the follow-
up window established
in this CTP, it is the
Investigator’s
responsibility to report
the SAE to the CRO.
The Investigator might
If the Investigator
becomes aware of
any SAE is related to
the study drug
outside the follow-up
window established
in this CTP, it is the
Investigator’s
responsibility to
Administrative
change
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Protocol Code Z7244L01 Amendment 1
– App. 3 Page 10 of 13
use the eCRF, as
described above.
However, the SAE is
not an event occurred
within the trial period.
report the SAE to the
Sponsor. The
Investigator might
use the “Serious
Adverse Event Form”
via email, but the
SAE must not to be
reported in the CRF,
the SAE is not an
event occurred within
the trial period.
18.10. FOLLOW-UP
FOR ADVERSE
EVENTS
All AEs requiring the
subject’s
discontinuation and
SAEs will be followed
up until they are
resolved or closed.
All AEs requiring the
subject’s
discontinuation and
SAEs will be followed
up until they are
resolved or closed or
when the subject is
lost to follow up or
uncontactable.
Administrative
change
18.10. FOLLOW-UP
FOR ADVERSE
EVENTS
If follow-up information
on SAEs is available, a
follow-up eCRF form
will be filled-in by the
Investigator and sent
to the CRO as above-
described, under
Section 18.8.1.
If follow-up
information on SAEs
is available, a follow-
up information will be
filled-in eCRF by the
Investigator and sent
to the CRO as
above-described,
under Section 18.9.1.
Administrative
change
18.11. PREGNANCY
In the event that a
subject or a female
partner is found to be
pregnant after
inclusion in the trial,
then pregnancy will be
actively followed up to
term and the status of
mother and child will
be reported by the
Investigator to the
CRO through the
appropriate pregnancy
report provided by the
CRO.
The Investigator will
send pregnancy
In the event that a
subject or a female
partner is found to be
pregnant after
inclusion in the trial,
then pregnancy will
be actively followed
up to term or
pregnancy
termination and the
status of mother and
child will be reported
by the Investigator to
the CRO through the
appropriate
pregnancy report
provided by the
Administrative
change
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Protocol Code Z7244L01 Amendment 1
– App. 3 Page 11 of 13
reports within the
timeframes of SAEs.
If pregnancy results in
abnormal outcome, the
Investigator and/or the
Sponsor considers this
to be due to the IMP,
will be treated as an
expedited ADR report.
CRO.
The Investigator will
send pregnancy
reports using
pregnancy Reporting
and Outcome form to
CRO within the
timeframes of SAEs.
If pregnancy results
in abnormal
outcome, it will be
considered as SAE.
If the Investigator
and/or the Sponsor
considers this to be
due to the IMP, this
will be treated as an
expedited ADR
report.
20.4.3.1.
ANALYSIS OF
PRIMARY END-
POINTS
Statistical significant
results will be needed
on both mITT and PP
populations to accept
the hypothesis of non-
inferiority of NAC
versus ambroxol.
Statistically
significant results will
be needed on both
mITT and PP
populations to accept
the hypothesis of
non-inferiority of NAC
versus ambroxol.
Typing error
20.4.3.1.
ANALYSIS OF
PRIMARY END-
POINTS
The co-primary
efficacy endpoints are:
“the change from
baseline to the 1-week
treatment in sputum
viscosity score” and
“the change from
baseline to the 1-week
treatment in
expectoration difficulty
score” and will be
analyzed on the mITT
and PP populations by
means of conventional
Mann-Whitney U
Statistics for testing the
hypotheses of
superiority of NAC
versus placebo
(primary objective))
The co-primary
efficacy endpoints
are: “the change from
baseline to the 1-
week treatment in
sputum viscosity
score” and “the
change from baseline
to the 1-week
treatment in
expectoration
difficulty score” and
will be analyzed on
the mITT and PP
populations by
means of stratified
Mann-Whitney U
Statistics for testing
the hypotheses of
superiority of NAC
Added following an
NMPA suggestion
CCI


Protocol Code Z7244L01 Amendment 1
– App. 3 Page 12 of 13
and by means of a
modified Mann-
Whitney U Statistics
[23]
versus placebo
(primary objective)
after blocking for
baseline score and
by means of a
modified Mann-
Whitney U Statistics
[23]
20.4.3.2. ANALYSIS
OF SECONDARY
ENDPOINTS
(Mann-Whitney U
Statistics)
(stratified Mann-
Whitney U Statistics
blocking for baseline
score)
Added following an
NMPA suggestion
20.4.3.3.
SUBGROUP
ANALYSES
Upon completion of
the study, the study
statistician in
consultation with
Zambon’s Clinical
Team will determine
the proportion of
concomitant
medications between
the treatment groups
and will decide
whether to perform
subgroup efficacy
analyses if deemed
appropriate. The
analyses described
for the primary and
secondary efficacy
endpoints will be
performed separately
for each of the
identified stratums.
Added following an
NMPA suggestion
22.
ETHICS
COMMITTEE
APPROVAL
This trial will be
undertaken only after
written and dated
approval from EC has
been received by the
Investigator and by the
Sponsor for CTP, all its
appendices, ICF, and
subjects recruitment
procedures (i.e.
advertisement) if
applicable.
This trial will be
undertaken only after
written and dated
approval from EC
has been received by
the Investigator and
by the Sponsor for
CTP, all its
appendices, ICF, and
subject’s recruitment
procedures (i.e.
advertisement) if
applicable.
Typing error
29.
ANNEX
Annex 1: Diagnostic
Added following an
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Protocol Code Z7244L01 Amendment 1
– App. 3 Page 13 of 13
criteria for the
underlying
respiratory disease at
baseline
NMPA suggestion
Annex 1
Diagnostic criteria for
the underlying
respiratory disease at
baseline table and
references
Added following an
NMPA suggestion
Appendix 1
Premature
discotinuation visit
Premature
discontinuation visit
Typing error
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Final Version 2.0 - 19 December 2018 
Page 1 of 65 
 
 
 
 
CLINICAL TRIAL PROTOCOL 
 
 
INTRAVENOUS NAC PHASE III CHINA CLINICAL TRIAL 
(IVNAC-3C) 
 
A PHASE III, MULTI-CENTRE, RANDOMIZED, RATER- AND PATIENT-BLIND, 
PLACEBO- AND ACTIVE-CONTROLLED, PARALLEL GROUP CLINICAL TRIAL 
TO COMPARE THE EFFICACY AND SAFETY OF 1-WEEK TREATMENT WITH 
INTRAVENOUS N-ACETYLCYSTEINE (NAC) 600 MG TWICE DAILY (ACTIVE 
TEST TREATMENT), AMBROXOL HYDROCHLORIDE 30 MG TWICE DAILY 
(ACTIVE CONTROL TREATMENT) AND PLACEBO AS EXPECTORANT 
THERAPIES IN ADULT CHINESE PATIENTS WITH RESPIRATORY TRACT 
DISEASES AND ABNORMAL MUCUS SECRETIONS 
 
Protocol Code 
Z7244L01 
 
Protocol Name 
IVNAC-3C (IntraVenous NAC – Phase 3 China Trial) 
 
Final Date: 19 December 2018  
 
Version: Version 2.0 
 
Zambon SpA 
Via Lillo del Duca 10 
20091 Bresso - Milan – Italy 
 
THIS DOCUMENT IS ZAMBON'S SOLE PROPERTY AND OWNERSHIP. THIS DOCUMENT, AND ALL 
INFORMATION AND DATA CONTAINED HEREIN HAS TO BE CONSIDERED AND TREATED AS 
STRICTLY CONFIDENTIAL. THIS DOCUMENT SHALL BE USED ONLY FOR THE PURPOSE OF THE 
DISCLOSURE HEREIN PROVIDED. NO DISCLOSURE OR PUBLICATION SHALL BE MADE WITHOUT 
THE PRIOR WRITTEN CONSENT i1OF ZAMBON.  
                                            
 








 
Final Version 2.0 - 19 December 2018 
Page 5 of 65 
1. TABLE OF CONTENTS 
 
APPROVAL PAGE .............................................................................................................2 
ZAMBON CONTACT DETAILS ..........................................................................................3 
CONTRACT RESEARCH ORGANISATION CONTACT DETAILS .....................................3 
OTHER INSTITUTIONS .....................................................................................................3 
LIST OF COMMITTEES .....................................................................................................4 
1. 
Table of Contents .....................................................................................................5 
2. 
Abbreviations ............................................................................................................8 
3. 
Summary ................................................................................................................ 10 
4. 
Introduction and Rationale ...................................................................................... 18 
5. 
Evaluation of the Anticipated Risks/Benefit Ratio ................................................... 19 
6. 
Objectives ............................................................................................................... 20 
7. 
Ethics Requirements .............................................................................................. 21 
8. 
Design and Duration of the Clinical Trial ................................................................ 21 
8.1. 
Clinical Trial Design ......................................................................................... 21 
8.2. 
Duration of Clinical Trial ................................................................................... 22 
9. 
Clinical Trial Population .......................................................................................... 22 
9.1. 
Number of Subjects ......................................................................................... 22 
9.2. 
Selection of Subjects ....................................................................................... 22 
9.2.1. Inclusion Criteria ....................................................................................................... 22 
9.2.2. Exclusion Criteria ...................................................................................................... 22 
10. 
Overall Clinical Trial Schedule ................................................................................ 23 
10.1. 
Visit 1 - Screening Visit .................................................................................... 24 
10.2. 
Visit 2 - Randomisation Visit (Day 1) - (WITHIN 7 DAYS OF VISIT 1) ............. 24 
10.3. 
DAY 2 .............................................................................................................. 25 
10.4. 
Visit 3 (Day 3) .................................................................................................. 25 
10.5. 
DAY 4 .............................................................................................................. 25 
10.6. 
DAYS 5 and 6 .................................................................................................. 25 
10.7. 
Visit 4 (day 7) ................................................................................................... 25 
10.8. 
DAY 8 .............................................................................................................. 26 
10.9. 
Follow-up Phone Call or Visit (2 weeks ± 3 days after THE LAST ADMINISTRATION OF 
imp) .................................................................................................................. 26 
10.10. unscheduled DETERIORATION Visit .............................................................. 26 
10.11. premaTURE DISCONTINUATION VISIT ......................................................... 27 
11. 
Methodology ........................................................................................................... 27 
11.1. 
Methods of Assessment ................................................................................... 27 


 
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11.1.1. 
Demography and Medical History ......................................................................... 27 
11.1.2. 
Physical Examination ............................................................................................ 27 
11.1.3. 
Vital Signs ............................................................................................................. 27 
11.1.4. 
Laboratory Evaluations .......................................................................................... 27 
11.1.5. 
Efficacy Evaluations .............................................................................................. 28 
11.1.6. 
Safety Evaluations ................................................................................................. 29 
11.2. 
ADHERENCE WITH IMP DOSING REGIMEN ................................................ 29 
11.3. 
Pharmacodynamics ......................................................................................... 30 
11.4. 
Pharmacokinetics ............................................................................................. 30 
12. 
PRIOR AND Concomitant Treatments ................................................................... 30 
13. 
Investigational Medicinal Product ........................................................................... 31 
13.1. 
Investigational Medicinal Product Supplies and Packaging ............................. 31 
13.2. 
Investigational Medicinal Product Dispensing and Administration ................... 31 
13.3. 
Randomisation ................................................................................................. 32 
13.4. 
Investigational Medicinal Product Accountability ............................................. 32 
14. 
Clinical Trial Amendments ...................................................................................... 32 
15. 
Deviations from the Clinical Trial Protocol .............................................................. 33 
15.1. 
Code Breaking ................................................................................................. 33 
16. 
Clinical Trial Withdrawals/Drop-outs ....................................................................... 33 
17. 
Stopping and Discontinuation Criteria for the Trial ................................................. 34 
18. 
Reporting Safety Information .................................................................................. 34 
18.1. 
Definition of Adverse Event .............................................................................. 34 
18.2. 
Definition of Adverse Event of Special Interest ................................................ 35 
18.3. 
Definition of Adverse Drug Reaction ................................................................ 35 
18.3.1. 
Definition of Unexpected Adverse Drug Reaction ................................................. 35 
18.4. 
Definition of Serious Adverse Events or Serious Adverse Drug ReactionS ..... 35 
18.4.1. 
Definition of Serious Adverse Event OR Serious Adverse Reaction ..................... 35 
18.4.2. 
Definition of Suspected Unexpected Serious Adverse Reactions ......................... 36 
18.5. 
Definition of Severity of Adverse Events .......................................................... 36 
18.6. 
Definition of Adverse Event Causality .............................................................. 36 
18.7. 
Adverse Event Recording ................................................................................ 36 
18.8. 
Adverse Event monitoring window ................................................................... 37 
18.9. 
Adverse Event Reporting ................................................................................. 37 
18.9.1. 
Reporting Serious Adverse Events ........................................................................ 37 
18.9.2. 
Reporting Adverse Events of Special Interest ....................................................... 37 
18.10. Follow-up for Adverse Events .......................................................................... 38 
18.11. Pregnancy ........................................................................................................ 38 
19. 
Records .................................................................................................................. 38 


 
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19.1. 
Case Report Forms, SOURCE DATA AND QUERY RESOLUTION ............... 38 
19.2. 
Records Maintained by the Investigator ........................................................... 39 
19.3. 
Trial Master File ............................................................................................... 39 
19.4. 
Trial Monitoring ................................................................................................ 39 
19.5. 
Confidentiality of Subject’s Information ............................................................ 39 
20. 
Biometrics ............................................................................................................... 40 
20.1. 
Data MANAGEMENT ....................................................................................... 40 
20.2. 
STUDY END-POINTS ...................................................................................... 40 
20.3. 
Sample Size ..................................................................................................... 41 
20.4. 
Statistical Analyses .......................................................................................... 42 
20.4.1. 
General Statistical Considerations ........................................................................ 42 
20.4.2. 
Trial Populations .................................................................................................... 42 
20.4.3. 
Efficacy Data ......................................................................................................... 43 
20.4.4. 
HANDLING OF MISSING DATA ........................................................................... 44 
20.4.5. 
multiplicity .............................................................................................................. 45 
20.4.6. 
multicenter study ................................................................................................... 45 
20.4.7. 
Interim Analyses .................................................................................................... 45 
20.4.8. 
Safety Data ........................................................................................................... 46 
21. 
Informed Consent ................................................................................................... 46 
22. 
Ethics Committee Approval .................................................................................... 47 
23. 
Regulatory Requirements ....................................................................................... 47 
24. 
Quality Assurance .................................................................................................. 47 
25. 
Insurance ................................................................................................................ 47 
26. 
Clinical Trial Report ................................................................................................ 48 
27. 
Use of Information and Publication ......................................................................... 48 
28. 
References ............................................................................................................. 49 
29. 
ANNEX ................................................................................................................... 50 
30. 
Appendices ............................................................................................................. 50 
 
 
 


 
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2. ABBREVIATIONS 
ADR 
Adverse Drug Reaction 
AE 
Adverse Event 
AH  
Ambroxol hydrochloride 
ALP 
Alkaline phosphatase 
ALT 
Alanine aminotransferase 
AST 
Aspartate aminotransferase 
BUN 
Blood Urea Nitrogen 
CA 
Competent Authority 
C-FDA 
Chinese Food and Drug Administration 
COPD 
Chronic Obstructive Pulmonary Disease 
CRO 
Contract Research Organisation 
CTP 
Clinical Trial Protocol 
CTR 
Clinical Trial Report 
DV 
Deterioration Visit 
EC 
Ethics Committee 
ECG 
Electrocardiogram 
eCRF 
Electronic case report form 
EM 
Expectation-Maximization 
EMA 
European Medicines Agency 
EoT 
End of Treatment 
EU 
European Union 
GCP 
Good Clinical Practice 
γGT 
gamma glutamyl transferase 
GSH  
Glutathione 
HOCl 
Hypochorous acid 
IB 
Investigator Brochure 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
IMP 
Investigational Medicinal Product  
IMPD                   Investigational Medicinal Product Dossier 
ITT 
Intention-to-treat 
IV 
Intravenous 
IUD 
Intrauterine Device 
IUS 
Intrauterine hormone-releasing system 
IWRS 
Interactive Web Response System 
Kg 
Kilograms 
LOCF 
Last Observation Carried Forward 
MC 
Monte Carlo 
MedDRA  
Medical dictionary for regulatory activities 
mg 
 
 
Milligram 
mITT 
Modified Intention to Treat 
ml 
 
 
Milliliter 
MVTF 
 
Missing Value Treatment Failure  


 
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NAC 
N-acetylcysteine 
NaCl 
Sodium chloride 
PI 
Package Insert 
PP 
Per-protocol population 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SAR 
Serious Adverse Reaction 
SmPC 
Summary of Product Characteristics  
SOPs 
Standard Operating Procedures 
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
TCM 
Traditional Chinese Medicine 
TEAE 
Treatment Emergent Adverse Event 
TMF 
Trial Master File 
US-FDA  
United States Food and Drug Administration 
WHO-DD  
World Health Organization-drug dictionary  
WOCF 
Worst Observation Carried Forward 
 
 
 


 
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3. SUMMARY 
 
Title: 
Intravenous NAC Phase III China Trial 
A phase III, multi-centre, randomized, rater- and patient-blind, 
placebo- and active-controlled, parallel group clinical trial to 
compare the efficacy and safety of 1-week treatment of 
intravenous N-acetylcysteine (NAC) 600 mg twice daily (active test 
treatment), ambroxol hydrochloride 30 mg twice daily (active 
control treatment) and placebo as expectorant therapies in adult 
Chinese patients with respiratory tract diseases and abnormal 
mucus secretions  
Protocol 
Code/ 
Protocol Name: 
 
 
Z7244L01  
IVNAC-3C (IntraVenous NAC – Phase 3 China Trial) 
Phase:  
III 
 
Treatments 
  
Active test treatment 
Ampoule containing 300 mg N-acetylcysteine (NAC) in 3 ml 
(Zambon Spa, Vicenza, Italy). 
Two ampoules (NAC 600 mg) in 10 ml NaCl 0.9% saline solution, 
administered by slow (at least 5 minutes) intravenous infusion 
twice a day, morning before 9 am and afternoon/evening 
approximately 12 hours apart for 1 week (7 days). Total daily NAC 
dose: 1200 mg/day.   
 
Active control treatment 
Vial containing 15 mg Ambroxol Hydrochloride (AH) in 2 ml 
(Boehringer Ingelheim, Shanghai, China). 
Two vials (AH 30 mg) in 10 ml NaCl 0.9% saline solution
administered by slow (at least 5 minutes) intravenous infusion 
twice a day, morning before 9 am and afternoon/evening 
approximately 12 hours apart for 1 week (7 days). Total daily AH
dose: 60 mg.  
 
Placebo treatment 
Vial containing 10ml NaCl 0.9% saline solution (China Otsuka 
Pharmaceutical Co., Ltd.) 
One vial of 10 ml NaCl 0.9% saline solution administered by slow
(at least 5 minutes) intravenous infusion twice a day, morning 
before 9 am and afternoon/evening approximately 12 hours apart
for 1 week (7 days). 
 
 
 


 
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Objectives: 
 
Efficacy objectives 
Primary objective 
Demonstrate that slow (at least 5 minutes) intravenous infusion of 
NAC 600 mg twice daily is superior to placebo in change from 
baseline to the end of 1-week treatment of sputum viscosity score 
or expectoration difficulty score in adult Chinese hospitalized 
patients with respiratory tract diseases and abnormal mucus 
secretions 
 
Secondary objectives 
Efficacy objectives 
Demonstrate in the same patient population that: 
- 
slow (at least 5 minutes) intravenous infusion of NAC 600 
mg twice daily is superior to placebo in change from 
baseline to day 3 and end of 1-week treatment of other 
indicators of mucolytic activity (individual sputum viscosity 
and expectoration difficulty scores, cough score, mucous 
color score and mucous volume);  
- 
slow (at least 5 minutes) intravenous infusion of NAC 600 
mg twice daily is non-inferior to slow intravenous infusion of 
ambroxol hydrochloride 30 mg twice daily in change from 
baseline to the end of 1-week treatment of sputum viscosity 
score or expectoration difficulty score; 
- 
slow (at least 5 minutes) intravenous infusion of ambroxol
hydrochloride 30 mg twice daily is superior to placebo in 
change from baseline to day 3 and to the end of 1-week 
treatment of sputum viscosity score or expectoration 
difficulty score and of other indicators of mucolytic activity: 
individual sputum viscosity and expectoration difficulty 
scores, cough score, mucous color score and mucous 
volume. 
Safety objectives 
- 
Confirm that 1-week treatment with iv NAC 600 mg twice 
daily is safe and well tolerated. 
 
Design: 
Multicenter, randomized, rater- and patient-blind, placebo- and 
active-controlled, 3-arm parallel group clinical trial. 
Subjects will be randomized to NAC or ambroxol or placebo in a 
1:1:1 ratio. 
The study will consist of a total of 4 core hospital visits and a follow-
up call 2 weeks after end of treatment. If the patient is still 
hospitalized or if more convenient for the patient, the follow-up 
phone call can be replaced by a follow-up hospital visit. 
 
 


 
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Number of patients: 
 
 
 
 
Trial duration: 
 
 
 
Duration of patient 
participation: 
 
                        
Participating Countries: 
 
 
Number of Sites: 
A total of 333 patients will be randomized. This number includes 
10% overage to allow for patients who discontinue the trial 
prematurely (“drop-outs”) without contributing to the primary end-
point. 
 
Approximately 8 months. The enrolment period will be 
approximately 7 months.  
 
 
Up to 4 weeks. Each patient will undergo a screening period of up 
to 1 week, a 1-week treatment period and a 2-week follow-up 
period. 
 
China 
 
 
Approximately 25  
 
Population: 
Inclusion criteria 
Patients will be enrolled in the trial if all of the following criteria are 
met:  
1. Male or female adult (≥18 years old) hospitalized patients 
with respiratory tract diseases and abnormal mucus 
secretions such as: acute bronchitis, chronic bronchitis and
exacerbations, 
emphysema, 
mucoviscidosis 
and 
bronchiectasis. Diagnostic criteria for these conditions are 
provided in Annex 1  
2. Chinese ethnicity and/or Chinese  
3. Signed the informed consent form before any study-related 
procedure 
4. Sputum viscosity score ≥ 2 at randomization visit 
5. Expectoration difficulty score ≥ 2 at randomization visit  
6. Willingness and ability to comply with study procedures 
 
Exclusion criteria 
Patients will not be enrolled if one or more of the following criteria 
are met: 
1. Intolerance or contra-indication to treatment with NAC or 
ambroxol or allergy to any component of the study 
treatments 
2. (For female patients) ongoing pregnancy or lactation, or 
childbearing potential but unwillingness to adopt abstinence 
or contraception measures during the study 
3. Intake of an investigational drug within 1 month before the 
screening visit 
4. Use of expectorants or drugs with expectorant effect within 
2 days before randomization visit 


 
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5. Diagnosis of active tuberculosis, lung cancer, pulmonary 
fibrosis, acute pulmonary thromboembolism or any other 
respiratory condition that might, in the opinion of the 
investigator, compromise the safety of the patient or affect 
the interpretation of the results 
6. Medical history of and/or illness (including laboratory 
abnormality) and/or treatment that in the investigator’s 
opinion may interfere with the patient’s safety, compliance, 
or study evaluations 
7. Serum ALT and/or AST more than 3 times above the upper 
limit of normal at screening visit 
8. Serum creatinine more than 3 times above the upper limit 
of normal at screening visit 
9. Addiction to alcohol or drugs 
10. Mental illness, or other reasons for non-cooperation in the 
investigator’s opinion 
 
Outcome measures: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Efficacy variables 
 Sputum viscosity, expectoration difficulty, sputum color and 
cough are assessed by means of ordinal categorical 4-point 
scales with 0 = best and 3= worst.  
For each patient the assessment is to be carried out by the 
blinded rater on treatment days 1 (baseline), 3 and 7 in the 
morning between 7 am and 9 am before administration of 
study drug. Should a patient discontinue prematurely from 
the trial (including discharge from the hospital before day 7) 
an assessment should be conducted on the day of 
discharge whenever possible.  
Scoring criteria are as follows: 
 
 
0 
1 
2 
3 
Sputum 
viscosity 
Liquid 
(normal 
viscosity)
 
Fluid  
(mildly 
increased 
viscosity) 
Viscous  
(moderately 
increased 
viscosity) 
Sticky 
(severely 
increased 
viscosity) 
Expectoration 
difficulty 
No 
difficulty 
Mild 
difficulty 
Moderate 
difficulty 
Marked 
difficulty 
 
Sputum  
Color 
Mostly 
white 
Mostly 
pale 
yellow 
Mostly dark 
yellow 
Very dark 
yellow 
/green 
Cough 
 
No 
cough 
Sporadic 
and mild 
cough 
Moderate 
cough 
Severe 
Cough 
Adapted from [12]. 
 Sputum volume: patients will collect 24-hour sputum 
(morning to same time of the following morning) in a 


 
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End-points: 
graduated cup on treatment days 1 (Baseline), 3 and 7. 
Volume will be expressed as mL/24h. 
 
Safety variables 
 Adverse events assessed for severity and seriousness. 
 Laboratory measurements including hematology, liver 
enzymes, serum creatinine. 
 12-lead electrocardiogram 
 
Primary efficacy end-point 
Superiority of NAC over placebo in change from baseline to end 
of 1-week treatment of mean sputum viscosity score or mean 
expectoration difficulty score. 
The study will be declared success if at least one of two 
components of the primary end-point will show superiority over 
placebo. 
 
Secondary efficacy end-points 
A. Superiority of NAC over placebo: 
 in change from baseline to day 3 of mean sputum viscosity 
score OR mean expectoration difficulty score;  
 in change from baseline to day 3 and to end of 1-week 
treatment of individual scores:  
 mean sputum viscosity score 
 mean expectoration difficulty score 
 mean sputum color score 
 mean cough score 
 in change from baseline to day 3 and to end of 1-week 
treatment of mean sputum volume  
  
B. Non-inferiority of NAC vs. ambroxol in change from baseline to 
end of 1-week treatment of mean sputum viscosity score or 
change of mean expectoration difficulty score. 
 
C. Superiority of ambroxol vs. placebo in change from baseline to 
day 3 and to end of 1-week treatment of  
 mean 
sputum 
viscosity 
score 
OR 
mean 
expectoration difficulty score;  
 mean sputum viscosity score (individual score) 
 mean expectoration difficulty score (individual score)
 mean sputum color score 
 mean cough score 
 mean sputum volume 
 
Safety end-points 
Counts and frequency distributions of 
 all, mild/moderate/severe, non-serious/serious adverse 
events  
 vital signs  
 Laboratory tests  


 
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 12-lead ECG (normal, abnormal clinically non- significant, 
abnormal clinically significant) 
 
Statistical Analysis: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sample size justification 
This study has been powered to reach statistical significance for 
the superiority comparisons of N-acetyl-cysteine (NAC) vs. 
placebo (primary study objective), and for the non-inferiority 
comparisons of NAC vs. ambroxol hydrochloride (secondary 
study objective) in at least one of the two co-primary endpoints at 
the end of the 1-week treatment. To control the overall type I 
family-wise error rate at the one-tailed 0.025 significance level, a 
multiple-sequence gatekeeping procedure was implemented in a 
Monte Carlo study with 1000 runs and with the Bonferroni 
correction applied to the set of superiority comparisons (first 
gatekeeper) and the Hochberg correction applied to the set of 
non-inferiority comparisons (second gatekeeper). 
For the superiority tests, and with group sample sizes of 100 
patients in placebo group and 100 patients in NAC group, the 
Monte Carlo study estimated an overall power (“disjunctive” 
power) close to 93% to reach statistical significance in at least 
one co-primary end-point. These calculations are based on a one-
sided Mann-Whitney test and assuming a minimal clinically 
relevant difference of 0.35 points between placebo and NAC on a 
0-3-point scale, standard deviation equal to 0,79 and 0,77 for 
sputum viscosity and expectoration difficulty scores (change from 
baseline to the 1-week treatment) respectively and a correlation 
between the two end-points equal to 0.31. 
For the non-inferiority tests, a sample of 100 patients per each 
active treatment group ensures sufficient disjunctive power 
(Monte Carlo disjunctive power = 82%) to detect non-inferiority 
between NAC and ambroxol in at least one co-primary end-point. 
These calculations are based on a one-sided non-inferiority t-test 
assuming a margin of non-inferiority equal to 0.30, standard 
deviation equal to 0,79 and 0,77 for sputum viscosity and 
expectoration difficulty scores (change from baseline to the 1-
week treatment) respectively and a correlation between the two 
endpoints equal to 0.31. 
Assuming a drop-out rate of about 10% over one week of entry, a 
total of 333 patients will be randomized (i.e. 111 patients in the 
placebo group, 111 patients in the NAC group and 111 patients 
in the ambroxol group). 
 
Statistical methods 
All efficacy analyses will be performed on the Modified Intention 
to Treat (mITT) population. Analysis of the primary and secondary 
efficacy variables will be also carried out on the Per Protocol (PP) 
population to assess the robustness of the findings. Safety 
outcomes will be analysed on the Safety population.  
The primary efficacy end-points “change from baseline to the 1-
week treatment in sputum viscosity score and change from 
baseline to the 1-week treatment in expectoration difficulty score” 


 
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will be analysed by means of stratified Mann-Whitney U Statistic 
for testing the hypotheses of superiority of NAC versus placebo
after blocking for baseline score and by means of the non-
inferiority variant of the Mann-Whitney U Statistic for testing the 
hypotheses of non-inferiority of NAC versus ambroxol. Statistical 
significant results will be needed on both mITT and PP 
populations to accept the hypothesis of non-inferiority of NAC 
versus ambroxol. Point estimates of treatment differences 
together with associated two-sided 95% confidence intervals will 
be computed using nonparametric bootstrap. 
The overall type I family-wise error rate for testing the co-primary 
endpoints in superiority and non-inferiority assessments will be 
controlled at the one-tailed 0.025 significance level using a 
multiple-sequence gatekeeping procedure. This procedure will be 
fully described in the protocol. 
The same approach will be taken for the supportive secondary 
end-point “superiority of NAC over placebo in change from 
baseline to day 3 of mean sputum viscosity score or mean 
expectoration difficulty score”. 
As for the supportive secondary efficacy end-points concerning 
individual scores (sputum viscosity, expectoration difficulty, 
sputum color, cough) or measured on continuous scale (sputum 
volume), the hypothesis of superiority of NAC compared to 
placebo will be assessed using the same nonparametric test 
(stratified Mann-Whitney U Statistics blocking for baseline score), 
whilst point estimates of treatment differences together with 
associated two-sided 95% confidence intervals will be computed 
using nonparametric bootstrap.  
 
The same statistical analysis (stratified Mann-Whitney U 
Statistics blocking for baseline score) will be carried out for testing 
superiority of ambroxol vs placebo on the same efficacy 
endpoints. Results will be used for the purpose of verifying study’s 
assay sensitivity. 
 
For the analyses of supportive secondary efficacy end-points no 
adjustment of significance level will be made to account for 
multiple comparisons. 
 
Missing data on the primary and secondary efficacy endpoints will 
be imputed as treatment failures (MVTF) by replacing missing 
values using the worst observation carried forward (WOCF) as 
primary imputation method (namely baseline or follow-up 
measurement, whichever is worse, and using expectation-
maximization (EM) algorithm and last observation carried forward 
(LOCF) as sensitivity analyses. 
 
 


 
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Concomitant Treatments 
Permitted  
 Appropriate treatment(s) for any respiratory tract 
disease, that in the investigator’s opinion will not interfere 
with the measurements contributing to the efficacy 
outcomes, such as: corticosteroids (inhaled or systemic), 
bronchodilators, antibiotics (in case of co-administration, 
the i.v. antibiotic should be administered separately). 
 Appropriate treatment(s) for any other underlying 
disease, that in the investigator’s opinion will not interfere 
with the measurements contributing to the efficacy 
outcomes 
 If co-treatment with parenteral nitroglycerin is needed the 
patients should be monitored for potential hypotension, 
which may be severe and may be indicated by the 
presence of headache  
 If one or more treatments interfering with the 
measurements contributing to the primary efficacy 
outcomes are deemed necessary, the patient should not 
be randomized or should be discontinued from the study.
All concomitant medications will be recorded and analysed as 
described in Section 20.4.3.3. 
 
Not permitted  
 Expectorants 
 Antitussive agents  
 Sedatives  
 Traditional Chinese Medicine (TCM) treatments. 
 
 
 
 
 
 
 
 
 
 
 


 
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4. INTRODUCTION AND RATIONALE 
Background  
Numerous respiratory diseases, including acute and chronic bronchitis, COPD, cystic fibrosis and 
non-cystic fibrosis bronchiectasis are characterized by increased sputum viscosity and difficult 
expectoration, often associated with cough (1- 4).  
Furthermore, acute and chronic bronchitis and COPD are commonly associated with of many non-
respiratory chronic conditions in both outpatients and hospitalized patients, especially in smokers, 
elderly patients and patients living in heavily polluted environments. 
In China, cigarette smoking, and high environmental pollution have a high prevalence and morbidity 
(5). Hence, abnormalities of mucus and expectoration are frequent in patients with primary 
respiratory diseases and with respiratory complications of chronic non-respiratory conditions (6). 
 
Treatment 
Mucolytic agents are used worldwide for symptomatic treatment of abnormalities of mucus viscosity 
and expectoration. These include N-acetyl cysteine, also referred to as NAC (Fluimucil®, Zambon) 
and ambroxol hydrochloride (Mucosolvan®, Boehringer Ingelheim; Fluibron®, Chiesi Farmaceutici 
S.a.s.). 
NAC exerts an intense mucolytic-fluidifying action on mucous and mucopurulent secretions by 
depolymerizing mucoproteic complexes and nucleic acids which contribute to the viscosity of 
sputum and other secretions. In addition, NAC exerts a direct antioxidant action, thanks to its free 
thiol (-SH) nucleophilic group which can interact with the electrophilic groups of oxidant radicals. 
Of interest is the finding that NAC protects α1-antitrypsin, an elastase-inhibiting enzyme, from 
inactivation by hypochlorous acid (HClO), a potent oxidant agent produced by the myeloperoxidase 
enzyme of activated phagocytes. Moreover, NAC can easily cross the cellular membranes; inside 
the cell NAC is deacetylated to L-cysteine, an amino acid indispensable for glutathione (GSH) 
synthesis.  GSH, a highly reactive tripeptide found in many animal tissues, is the most important 
endo-cellular protective agent against oxidant radicals, exogenous and endogenous, as well as 
against several cytotoxic substances (7)   
NAC is approved in China for aerosol administration (8) and broadly used by this route of 
administration as mucolytic agent. However, especially in hospital settings, in China there is a 
preference to use mucolytic agents by intravenous administration in patients with moderate to 
severe abnormalities of mucus viscosity and expectoration: intravenous administration is 
considered by hospital staff more convenient due to common use of other intravenous treatments 
and is preferred by patients. Hence, the lack of approved NAC for intravenous administration in 
China is an important gap in medical practice. 
Intravenous administration of NAC is approved in most countries at very high doses as an antidote 
against liver injury due to paracetamol intoxication (see Section 5) (9) and in several countries, 
namely as mucolytic agent (10). More detail is provided in the Investigator Brochure (IB).  
The efficacy and safety of iv infusion of NAC as mucolytic was investigated in seven clinical trials, 
3 of which randomized and controlled (11-13) and 4 uncontrolled (14-17). 
 
Trial Rationale  
This trial is intended to provide pivotal (phase III) evidence of efficacy and safety for registration in 
China of slow intravenous infusion of NAC in adult hospitalised patients with respiratory tract 
diseases and abnormal mucus secretions. NAC, the active test treatment, will be compared to 
placebo and to ambroxol hydrochloride. The inclusion of a placebo arm is deemed ethically and 
scientifically sound for the following reasons: 1) the selection criteria used in this study ensure that 
condition being studied is not serious or life threatening at the time of enrolment; 2) immediate 
discontinuation from the trial and rescue use of mucolytics is envisaged in the protocol; 3) the true 


 
Final Version 2.0 - 19 December 2018 
Page 19 of 65 
value of iv intervention in the target population is not fully established. The use of placebo was 
requested by the Chinese FDA (C-FDA) reviewers in their feedback to an earlier version of this 
protocol. Ambroxol hydrochloride is included as the third treatment arm of the study as it is the only 
mucolytic agent approved in China for iv administration. The inclusion of an active control arm, also 
requested by C-FDA reviewers, will allow to test internal validity of the trial.  
This trial is designed as rater- and patient-blind. i.e. whereas the staff administering the study drugs 
will know what each patient is receiving, neither the staff evaluating the patient, nor the patients 
themselves will know. The trial cannot be fully blinded (double-blind) because the appearance of 
NAC ampoules and ambroxol vials is different and more importantly because the NAC formulation 
releases a harmless but immediately distinguishable sulfuric smell. Rater- and patient-blinded 
designs are accepted for pivotal registration trials by the US-FDA, EMA and Regulatory Authorities 
worldwide in situations where full blinding is impossible. 
The selected doses of iv NAC and ambroxol are within the limits of relevant SmPCs (10,18); dose 
justification is provided in Section 5 below.  
The treatment duration of 1 week has been selected after consultation with Chinese experts, as 
only a small minority of patients receive iv mucolytics for more than 1 week.  
5. EVALUATION OF THE ANTICIPATED RISKS/BENEFIT RATIO 
NAC has been available to patients as a mucolytic agent for many years and has a well-established 
and satisfactory safety and tolerability profile (see IB).  
Independently of route of administration (inhalation, oral, intravenous) adverse events are reported 
rarely following NAC administration and are usually mild and transient.  
 
The most frequent adverse events associated with NAC oral administration are gastrointestinal 
(e.g., vomiting, diarrhoea, stomatitis, abdominal pain and nausea). Hypersensitivity reactions (e.g. 
anaphylactoid reactions, urticaria, rash, pruritus, and bronchospasm) have been reported less 
frequently after oral administration, while with the IV administration they were reported more 
frequently compared to gastrointestinal symptoms. Some of the hypersensitivity reactions were 
associated to higher infusion rate. Most anaphylactoid reactions can be managed by temporarily 
suspending the acetylcysteine infusion, administering appropriate supportive care. A cumulative 
analysis of all safety reports received by the Sponsor up to September 2017 for NAC IV, confirmed 
the nature and severity of the events were in line with the above profile of the product. 
 
Intravenous NAC has been studied in clinical trials and published case series both as mucolytic 
agent and as an antidote against intoxication by paracetamol and other toxic agents including 
amanita phalloides and chlorinated hydrocarbons. Overall, in published studies in humans, a total 
of 745 patients were exposed to iv NAC at doses ranging from 500 mg/day to 980mg/kg/day for a 
duration of 1 to 18 days.  Details of safety results are included in the IB. 
 
In published studies, whereas iv NAC as mucolytic agent typically was given at doses up to 1000 
mg/day, much higher iv doses of NAC as antidote were given over multiple days, maintaining a 
satisfactory safety profile. 
Locatelli and colleagues (19) published two case series, one of 86 patients with acute intoxication 
from amanita phalloides and the other of 35 patients with acute intoxication from chlorinated 
hydrocarbons. Patients received iv NAC 300 mg/kg/day for 3 to 14 days and 3 to 18 days 
respectively. The safety and tolerability profile were overall benign, with 4 out of 121 exposed 
patients suffering from anaphylactoid reaction or rash (due to the rapid administration of the bolus 


 
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according to the authors), none of which caused discontinuation of treatment. No other AEs were 
reported. 
Keays and colleagues (20) randomized 50 patients suffering from paracetamol intoxication and 
admitted to the liver failure unit to NAC in addition to conventional intensive liver care (N=25) or 
conventional intensive liver care alone (N=25) with maintenance dose of 100 mg/kg/day for several 
days, until recovery from encephalopathy or death (the average number and range of treatment 
days is not reported but in survivors appears to be at least 4 days). No AEs were reported in the 
patients treated with NAC. 
From the data summarized above and the full dataset summarized in the IB, a daily intravenous 
dose NAC of 1200 mg/day given in a hospital setting for 7 days is likely to be associated with a 
small safety risk.   
The safety profile of the active comparator ambroxol hydrochloride given intravenously as is also 
favourable, as outlined in the Chinese PI. The product is well tolerated, and mild upper 
gastrointestinal adverse reactions have been occasionally reported, mainly including stomach 
burning, indigestion and occasional nausea and vomiting, occurring mostly after parenteral 
administration. Allergic reactions are rare, mainly including rash. Few cases have reported severe 
acute allergic reactions, but the correlation with ambroxol hydrochloride is not known. The dose 
chosen for this trial (60 mg/day) is within the range allowed by the Chinese SmPC (18). 
Anticipated benefits to the patients with respiratory tract diseases and abnormal mucus secretions 
randomised to NAC and ambroxol hydrochloride include reduction in mucus viscosity and improved 
expectoration.  
In conclusion, for both active treatments, in this trial the benefit risk ratio is anticipated to be 
positive. 
Patients randomized to placebo will be monitored very closely by experienced investigators and 
study staff. Should expectoration difficulty increase during the trial, the investigator and/or the 
patient may choose to discontinue the study treatment and immediately administer/receive rescue 
mucolytic, as described in Sections 8.1 and 10.10. Hence, also for the patients randomized to 
placebo no clinically meaningfully negative benefit/risk ratio is anticipated.   
6. OBJECTIVES 
The primary objective of this trial is to demonstrate that slow (at least 5 minutes) intravenous 
infusion of NAC 600 mg twice daily is superior to placebo in change from baseline to the end of 1-
week treatment of sputum viscosity score or expectoration difficulty score in adult Chinese 
hospitalized patients with respiratory tract diseases and abnormal mucus secretions. 
 
Secondary objectives are as follows:  
Efficacy 
Demonstrate in the same patient population that: 
- 
slow (at least 5 minutes) intravenous infusion of NAC 600 mg twice daily is superior to 
placebo in change from baseline to day 3 and end of 1-week treatment of other indicators 
of mucolytic activity: individual sputum viscosity and expectoration difficulty scores, cough 
score, mucous color score and mucous volume;  
- 
slow (at least 5 minutes) intravenous infusion of NAC 600 mg twice daily is non-inferior to 
slow intravenous infusion of ambroxol hydrochloride 30 mg twice daily in change from 
baseline to the end of 1-week treatment of sputum viscosity score or expectoration difficulty 
score; 
- 
slow (at least 5 minutes) intravenous infusion of ambroxol hydrochloride 30 mg twice daily 
is superior to placebo in change from baseline to day 3 and to the end of 1-week treatment 
of sputum viscosity score or expectoration difficulty score and of other indicators of mucolytic 


 
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activity: individual sputum viscosity and expectoration difficulty scores, cough score, mucous 
color score and mucous volume. 
Safety 
Confirm that 1-week treatment with iv NAC 600 mg twice daily is safe and well tolerated. 
 
 
The trial endpoints are described in Section 20.2. 
7. ETHICS REQUIREMENTS 
This trial will be conducted in compliance with last version of Declaration of Helsinki 
(http://www.wma.net/en/30publications/10policies/b3/index.html), with International Council for 
Harmonisation (ICH) Good Clinical Practice (GCP), in particular E6(R2), with the applicable 
regulatory requirements and with Zambon and contract research organisation (CRO) standard 
operating procedures (SOPs). 
8. DESIGN AND DURATION OF THE CLINICAL TRIAL 
8.1. CLINICAL TRIAL DESIGN 
This is a multicenter, randomized, rater- and patient-blind, placebo- and active-controlled, 3-arm 
parallel group clinical trial.  
The trial will be conducted in approximately 25 sites in China.  
Please refer to Appendix 1 for a trial flow chart.  
The study will consist of a total of 4 core hospital visits (screening, baseline, treatment day 3, 
treatment day 7, see Section 10) and of one follow-up phone call 2 weeks after discontinuation of 
treatment; if the patient is still hospitalized or if more convenient for the patient, the follow-up phone 
call can be replaced by a follow-up hospital visit. 
At screening visit (Visit 1), patients will be asked to provide Informed Consent prior to any trial 
related procedure and will be checked against inclusion and exclusion criteria. Their medical history 
will be recorded. Furthermore, patients will undergo a 12-lead ECG and laboratory assessments. 
Results must be available before Visit 2.  
At randomization visit (Visit 2), to occur within 7 days after Visit 1, female patients will undergo a 
pregnancy test; all patients will be checked again against the full set of inclusion and exclusion 
criteria and eligible subjects will be randomised with a 1:1:1 ratio to receive NAC or ambroxol 
hydrochloride or placebo.  
A total of 111 patients are to be randomized in each treatment group.  
Procedures performed at each core hospital visit will include documentation of concomitant 
medications and treatment emergent adverse events (TEAEs), 24-hour sputum collection and 
assessment on a 4-point ordinal scale of expectoration difficulty, sputum viscosity, sputum color 
and cough.  
In case a patient experiences a deterioration of expectoration capacity and related symptoms, 
and/or of an underlying condition, he/she should contact a study investigator immediately and 
undergo an unscheduled deterioration visit. If the patient and/or the investigator believe that it is in 
the patient’s best interest to receive a rescue mucolytic, the patient will be discontinued from the 
study and rescue mucolytic will be administered, with any additional treatment the investigator 
deems appropriate.  


 
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8.2. DURATION OF CLINICAL TRIAL 
The overall study duration (from first patient first visit to last patient last visit) is expected to be of 
approximately 8 months.  
The maximum expected duration of participation in this trial for an individual subject, from Visit 1 
(Screening) to the follow-up phone call or visit is 4 weeks. Treatment duration will be 1 week 
(7days). 
The start of the trial is defined as first subject in, i.e. Visit 1 for the first subject. 
The end of the trial is defined as the last subject out, i.e. when the last subject had the follow-up 
phone call or follow-up visit or unscheduled Deterioration visit. 
If the trial is prematurely stopped, please refer to Section 17. 
9. CLINICAL TRIAL POPULATION 
9.1. NUMBER OF SUBJECTS 
A total of 333 subjects (111 in each treatment group) is planned to be enrolled into the trial. The 
enrolment is competitive among sites.  
For a description of sample size calculation, please refer to Section 20.3. 
9.2. SELECTION OF SUBJECTS 
9.2.1. 
INCLUSION CRITERIA 
Subjects can be enrolled in the trial if they meet all inclusion criteria listed below: 
1. Male or female adult (≥18 years old) hospitalized patients with respiratory tract diseases 
and abnormal mucus secretions such as: acute bronchitis, chronic bronchitis and 
exacerbations, emphysema, mucoviscidosis and bronchiectasis. Diagnostic criteria for 
these conditions are provided in Annex 1  
2. Chinese ethnicity and/or Chinese  
3. Signed the informed consent form before any study-related procedure 
4. Sputum viscosity score ≥ 2 at randomization visit 
5. Expectoration difficulty score ≥ 2 at randomization visit  
6. Willingness and ability to comply with study procedures 
9.2.2. 
EXCLUSION CRITERIA 
Subjects are not eligible for the trial if they meet one or more of the exclusion criteria listed below: 
1. Intolerance or contra-indication to treatment with NAC or ambroxol or allergy to any 
component of the study treatments 
2. (For female patients) ongoing pregnancy or lactation, or childbearing potential but 
unwillingness to adopt abstinence or contraception measures during the study 
3. Intake of an investigational drug within 1 month before the screening visit 
4. Use of expectorants or drugs with expectorant effect within 2 days before randomization 
visit 


 
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5. Diagnosis of active tuberculosis, lung cancer, pulmonary fibrosis, acute pulmonary 
thromboembolism or any other respiratory condition that might, in the opinion of the 
investigator, compromise the safety of the patient or affect the interpretation of the results 
6. Medical history of and/or illness (including laboratory abnormalities) and/or treatment 
that in the investigator’s opinion may interfere with the patient’s safety, compliance, or 
study evaluations 
7. Serum ALT and/or AST more than 3 times above the upper limit of normal at screening 
visit 
8. Serum creatinine more than 3 times above the upper limit of normal at screening visit 
9. Addiction to alcohol or drugs 
10. Mental illness, or other reasons for non-cooperation in the investigator’s opinion 
 
Contraceptive methods 
Although teratology studies carried out in animals evidenced no teratogenic effects of NAC (ref IB) 
or ambroxol hydrochloride (ref Package Insert China), safety in human pregnancy has not been 
established with iv administration.  
Female subjects can be enrolled if they are either post-menopausal for at least 2 years, or surgically 
sterilized or have undergone hysterectomy.  
Female subjects of child-bearing potential must be willing to avoid pregnancy. They are required 
to have a negative pregnancy test at inclusion (see Section 10.2), and should use a highly effective 
method of birth control for 1 month prior to randomisation, throughout the trial duration and up to 1 
month after the last dose of IMP, which include:  
 combined (estrogen and progestogen containing) hormonal contraception associated with 
inhibition of ovulation (oral, intravaginal or transdermal) 
 progestogen-only hormonal contraception associated with inhibition of ovulation (oral, 
injectable or implantable) 
 intrauterine device (IUD)  
 intrauterine hormone-releasing system (IUS)  
 surgical sterilization (e.g. bilateral tubal ligation or occlusion)  
 male sterilization (vasectomised partner)  
 sexual abstinence  
 a male sexual partner who agrees to use a male condom with spermicide  
 
Throughout the course of the study male participants with female partners of child bearing potential 
must abstain from sexual intercourse or use condoms or use effective contraceptive precautions 
(female partners should follow the same birth control of female patients).  
Male participants must also not take part in the donation of sperm whilst enrolled on the study. 
10. 
OVERALL CLINICAL TRIAL SCHEDULE 
The current trial will include 4 planned core clinical visits at the investigational site and 1 follow-up 
telephone call or visit. Unscheduled Deterioration visit(s) will be conducted as necessary. A 
detailed flow chart showing the procedures performed is given in Appendix 1. The following 
sections outline the procedures to be performed at the individual visits.  


 
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10.1. 
VISIT 1 - SCREENING VISIT  
At Visit 1 (Screening), the following procedures will be performed: 
 obtain written Informed Consent before any study-related procedure; 
 document medical history and subject’s demographic data; 
 document concomitant medications; 
 assess vital signs (Section 11.1.3); 
 conduct physical examination (including chest auscultation); 
 conduct 12-lead ECG in the supine position after 5 minutes of rest (Section 11.1.6); 
 check inclusion/exclusion criteria: not all criteria can be assessed at screening, but do not 
proceed further if the patient is not eligible based on the criteria that can be checked; 
 collect blood samples for clinical laboratory assessments (haematology and clinical 
chemistry). (Section 11.1.4); 
 Instruct patients on actions to be taken in case of worsening of symptoms related to 
expectoration. 
 Record details of any AEs since the Inform Consent signature  
The Investigator will arrange an appointment for Visit 2 within 7 days. 
10.2. 
VISIT 2 - RANDOMISATION VISIT (DAY 1) - (WITHIN 7 DAYS OF VISIT 
1) 
At Visit 2 (Randomisation), the following procedures will be performed: 
 conduct dip-stick urine pregnancy test for females of childbearing potential. 
 check complete set of inclusion and exclusion criteria; 
 document concomitant medications; 
 record details of any AEs since the Screening Visit (Visit 1); 
 assess of vital signs (Section 11.1.3); 
 conduct physical examination (including chest auscultation); 
 give to patient the container for 24-hour sputum collection and instruct patient to collect all 
sputum until the same time of the following day; 
 conduct assessment of expectoration difficulty, sputum viscosity, sputum color and cough 
by means of the 4-point ordinal scales provided;  
 randomise the eligible patient by IWRS; 
 administer first dose of study medication in the morning and the second dose in the 
afternoon/evening. The two daily doses must be administered approximately 12 hours apart 
from each other.  
 Warning: Study staff responsible for administration of study medication, patient care and 
routine assessments (unblinded) should be different from study staff responsible for rating 
of expectoration difficulty, sputum viscosity, sputum color and cough (rater). No disclosure 
of the identity of study medication from the former to the latter is to occur unless required 
for safety reasons; 
 remind patients on actions to be taken in case of worsening of symptoms related to 
expectoration.  
 To assess adherence with IMP dosing regimen  
The Investigator will arrange an appointment for Visit 3 (on day 3 after Visit 2) and will instruct the 
subjects to report any AEs occurring during this period at the next visit.  


 
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10.3. 
DAY 2 
On day 2 the following procedures will be performed: 
 collect 24-hour sputum sample and report volume (mL) in eCRF; 
 administer study medication at the same times as on Day 1 (see Warning in section 10.2. 
above). 
10.4. 
VISIT 3 (DAY 3) 
At Visit 3 (day 3), the following procedures will be performed: 
 document concomitant medications; 
 record details of any AEs since the Randomization Visit (Visit 2); 
 assess of vital signs (Section 11.1.3); 
 conduct physical examination (including chest auscultation); 
 give to patient the container for 24-hour sputum collection and instruct patient to collect all 
sputum until the same time of the following day; 
 conduct assessment of expectoration difficulty, sputum viscosity, sputum color and cough 
by means of the 4-point ordinal scales provided 
 administer study medication at the same times as on Day 1 (see Warning in section 10.2. 
above); 
 remind patients on actions to be taken in case of worsening of symptoms related to 
expectoration. To assess adherence with IMP dosing regimen  
The Investigator will arrange an appointment for Visit 4 (on day 7 after Visit 2) and will instruct the 
subjects to report any AEs occurring during this period at the next visit.  
10.5. 
DAY 4 
On day 4 the following procedures will be performed: 
 collect 24-hour sputum sample and report volume (mL) in eCRF; 
 administer study medication at the same times as on Day 1 (see Warning in section 10.2. 
above). 
10.6. 
DAYS 5 AND 6 
On days 5 and 6 the following procedure will be performed: 
 administer study medication at the same times as on Day 1 (see Warning in section 10.2. 
above). 
10.7. 
VISIT 4 (DAY 7)  
At Visit 4 (day 7), the following procedures will be performed: 
 conduct dip-stick urine pregnancy test for females of childbearing potential. 
 document concomitant medications; 
 record details of any AEs since Visit 3 (day 3); 
 assess of vital signs (Section 11.1.3); 
 conduct physical examination (including chest auscultation); 
 give to patient the container for 24-hour sputum collection and instruct patient to collect all 
sputum until the same time of the following day; 


 
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 conduct assessment of expectoration difficulty, sputum viscosity, sputum color and cough 
by means of the 4-point ordinal scales provided. 
 conduct 12-lead ECG in the supine position after 5 minutes of rest (Section 11.1.6); 
 collect blood samples for clinical laboratory assessments (haematology and clinical 
chemistry). 
 to assess adherence with IMP dosing regimen  
 administer study medication at the same times as on Day 1 (see Warning in section 10.2. 
above). 
The Investigator will arrange an appointment for the follow-up call or visit 2 weeks ± 3 days after 
the last administration of IMP 
10.8. 
DAY 8 
On day 8 the following procedure will be performed: 
 collect 24-hour sputum sample and report volume (mL) in eCRF; 
10.9. 
FOLLOW-UP PHONE CALL OR VISIT (2 WEEKS ± 3 DAYS AFTER 
THE LAST ADMINISTRATION OF IMP) 
A follow-up phone call will be performed at 2 weeks ± 3 days after the last administration of IMP. If 
the patient is still hospitalized or it is more convenient for the patient, the follow-up call can be 
replaced by a follow-up visit  
The following procedures will be performed during the follow-up call or visit:  
 record details of any AEs since Visit 4 (day 7); 
 record concomitant medications since Visit 4. 
10.10. 
UNSCHEDULED DETERIORATION VISIT 
Patients will be trained by the Investigator to recognise worsening of expectoration and related 
symptoms.  
 
If the patient and/or the investigator believe that it is in the patient’s best interest to receive a rescue 
mucolytic, the patient will be discontinued from the study and rescue mucolytic will be administered, 
with any additional treatment the investigator deems appropriate and an unscheduled Deterioration 
Visit should be conducted whenever possible.  
An unscheduled Deterioration Visit should be conducted also in case of worsening of the underlying 
condition. In particular, in case of bronchospasm in asthmatic patients the treatment must be 
discontinued and adequate therapeutic measures taken. 
 
In case of unscheduled Deterioration Visit the following procedures will be performed: 
 record details of any AEs since previous visit 
 conduct dip-stick urine pregnancy test for females of childbearing potential. 
 assess of vital signs (Section 11.1.3); 
 conduct physical examination (including chest auscultation); 
 conduct 12-lead ECG in the supine position after 5 minutes of rest (Section 11.1.6); 
 conduct assessment of expectoration difficulty, sputum viscosity, sputum color and cough 
by means of the 4-point ordinal scales provided 
 


 
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In case during the unscheduled deterioration visit the patient and/or the investigator deem 
appropriate the discontinuation from the trial, all evaluations requested at Visit 4 should be 
performed (Section 10.11).    
10.11.   PREMATURE DISCONTINUATION VISIT 
In case of premature discontinuation for any other reasons than those listed in 10.10 all evaluations 
requested at Visit 4 should be performed, excluding study medication administration.    
A premature discontinuation visit must also be conducted in case of unexpected pregnancy.  
11. 
METHODOLOGY 
11.1. 
METHODS OF ASSESSMENT 
11.1.1. 
DEMOGRAPHY AND MEDICAL HISTORY 
At Visit 1 (Screening) the subjects’ demographic data will be documented, including age, ethnicity, 
gender, height, weight as well as smoking history and alcohol use.  
Further, the reason for hospitalization and medical history will be documented.  
Any relevant worsening in ongoing conditions during the trial (i.e. since Visit 1) is required to be 
recorded as AEs in the eCRF (see Section 18). 
11.1.2. 
PHYSICAL EXAMINATION 
At Visit 1, Visit 2, Visit 3 and Visit 4, and/or at the unscheduled deterioration Visit/premature 
discontinuation, a physical examination of general body systems will be performed according to 
current medical standards and site practice. The examination is to include a chest auscultation. 
Any relevant worsening regarding physical examination results of a subject since Visit 1 should be 
recorded as AE in the eCRF (see Section 18). 
11.1.3. 
VITAL SIGNS 
At Visit 1, Visit 2, Visit 3 and Visit 4 and/or at the unscheduled deterioration visit/premature 
discontinuation, vital signs will be recorded according to site practice. Vital signs include: 
 heart rate, 
 systolic and diastolic blood pressure, measured after at least 5 minutes in the supine 
position,  
 respiratory rate, 
 body temperature, measured under the arm pit. 
Automatic or manual devices may be used, but the same device should be used for any given 
subject throughout the trial. The same arm should be used for all measurements. 
Any relevant clinically significant worsening of vital signs of a subject since the previous visit should 
be recorded as AE in the eCRF (see Section 18). 
11.1.4. 
LABORATORY EVALUATIONS 
Routine laboratory evaluations will be performed at Screening Visit (Visit 1) and Visit 4 and in case 
of premature discontinuation.  


 
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The blood samples must be collected after the 12-lead ECG has been performed.  
The haematology and clinical chemistry parameters detailed in Table 1 will be analysed by the 
local hospital laboratory.  
Subjects with clinically relevant impaired renal function, as defined by serum creatinine levels ≥3.0x 
upper limit of normal at Visit 1 will not be randomized. 
Subjects with clinically relevant impaired liver function, as defined by serum ALT and/or AST ≥3.0x 
upper limit of normal at Visit 1 will not be randomized. 
A dipstick urine pregnancy test for women of childbearing potential will be performed at 
Randomization Visit (Visit 2) and at Visit 4 and/or at unscheduled deterioration visit/premature 
discontinuation visit.  
Female subjects who become pregnant during the trial must be withdrawn from the trial without 
delay and undergo the premature discontinuation visit; these patients are to be followed up to 
determine the outcome of the pregnancy. The Investigator is required to inform the Sponsor of a 
subject’s pregnancy and the estimated date of delivery. Reporting requirements are outlined in 
Section 18.10.  
Clinical laboratory tests will be reviewed for results of potential clinical significance before Visit 2 
to confirm patient’s eligibility and during the trial, as appropriate. Clinically significant laboratory 
abnormalities arising at Visit 4 (or at premature discontinuation visit) are considered AEs. Where 
possible, a diagnosis should be ascribed to the abnormal lab test. 
 
Table 1 CLINICAL LABORATORY EVALUATIONS 
Hematology: at Screening Visit (Visit 1) and Visit 4 or premature discontinuation visit 
Hematocrit 
Hemoglobin 
Platelet count 
Red blood cell count 
White blood cell count and differential (neutrophils, lymphocytes, monocytes, eosinophils and basophils) 
Clinical Chemistry: at Screening Visit (Visit 1) and visit 4 or premature discontinuation visit 
BUN or UREA 
Chloride  
AST 
Creatinine 
Uric acid 
ALT 
Sodium 
Amylase 
γGT 
Potassium 
ALP 
Bilirubin (direct and total) 
Calcium 
 
 
 
 
 
Pregnancy Test: at Screening Visit (Visit 1), Visit 4 or premature discontinuation visit 
Urine β-hCG (dipstick)  
11.1.5. 
EFFICACY EVALUATIONS 
Sputum viscosity, expectoration difficulty, sputum color, cough 
Sputum viscosity, expectoration difficulty, sputum color and cough are assessed by means of 
ordinal categorical 4-point scales with 0 = best and 3 = worst.  
For each patient the assessment is to be carried out by the blinded rater on treatment days 1 
(baseline), 3 and 7 in the morning before 9 am before administration of study drug. Should a patient 
discontinue prematurely from the trial (including discharge from the hospital before day 7) an 
assessment should be conducted on the day of discontinuation whenever possible (see 
unscheduled Deterioration Visit, Section 10.10).  
 
 
 


 
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Scoring criteria are as follows (adapted from [12]) 
 
0 
1 
2 
3 
Sputum viscosity 
Liquid 
(normal 
viscosity) 
Fluid  
(mildly 
increased 
viscosity) 
Viscous  
(moderately 
increased 
viscosity) 
Sticky 
(severely increased 
viscosity) 
Expectoration 
difficulty 
No difficulty 
Mild difficulty 
Moderate 
difficulty 
Marked difficulty 
Sputum color 
Mostly white 
Mostly pale 
yellow 
Mostly dark 
yellow 
Very dark yellow 
/green 
Cough 
 
No cough 
Sporadic and 
mild cough 
Moderate cough 
Severe Cough 
 
Sputum Volume 
At Randomization Visit (Visit 2), Visit 3 and Visit 4 the patients will be given a graduated container 
and instructed to use it to collect all sputum generated in the following 24 hours (i.e. same time of 
the following day). The day the container will be collected, and the 24-hour sputum volume 
measured in ml. 
11.1.6. 
SAFETY EVALUATIONS 
Adverse Events  
AEs will be recorded by Investigator in the appropriate eCRF Section from Visit 1 (date of informed 
consent) to the follow-up phone all or visit occurring 2 weeks (±3 days) after the last administration 
of the investigational medicinal product (IMP). At each contact (i.e. clinical visit or phone call), 
subjects will be asked in a non-leading manner if they experienced any AEs.  
All AEs occurring from the day of the first IMP administration, i.e. Visit 2, until the end of the trial, 
i.e. follow-up phone call, will be considered as treatment emergent TEAEs.  
For definitions and reporting of AEs and SAEs, see Section 18. 
 
12-lead electrocardiogram (ECG)  
12-lead ECG recordings will be obtained at each study centre using site machines at the Screening 
Visit (Visit 1) to verify the eligibility of the subject, and at Visit 4 or unscheduled Deterioration visit. 
ECG will be performed after obtaining vital signs. Prior to recording, the subject should be at rest 
for at least 5 mins.  
ECG will be evaluated by the investigator/local medical staff and the recording will be reported in 
the eCRF as “normal”, “abnormal clinically significant” or “abnormal not clinically significant”.  
Abnormalities of clinical significance recorded at Visit 1, Visit 4 or unscheduled deterioration 
visit/premature discontinuation visit which are not related to pre-exist medical condition before ICF 
signature will be reported as AEs. Repeat measurements will be performed if needed. 
11.2. 
ADHERENCE WITH IMP DOSING REGIMEN 
As the administration of the IMP will be carried out by the study staff in a hospital setting, it is 
anticipated that adherence with IMP dosing regimen will be high.   


 
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Nevertheless, the Investigator will assess adherence with IMP dosing regimen on an ongoing basis 
by determining the amount of IMP dispensed, used (i.e. returned open ampoules/vials) and the 
amount of IMP returned (i.e. returned, unopened ampoules/vials) at Visit 2 (first dose), Visit 3 and 
Visit 4 (end of treatment) or unscheduled Deterioration Visit/premature discontinuation visit.  
The evaluation of compliance will be done using the following formula: 
% of administered drug = 100 x  
Total number of administered doses 
Total number of scheduled doses 
11.3. 
PHARMACODYNAMICS 
Not applicable.  
11.4. 
PHARMACOKINETICS 
Not applicable.  
12. 
PRIOR AND CONCOMITANT TREATMENTS 
At Visit 1 (Screening), all prior and concomitant medications, including antibiotics, and over-the-
counter products used by an individual subject within 1 month prior to Screening Visit (Visit 1) will 
be documented in the eCRF.  
During all subsequent clinical visits, the Investigator will document any changes in concomitant 
medications.  
The following concomitant treatments are permitted from Visit 1 to Visit 4 (end of IMP treatment) 
or unscheduled Deterioration Visit: 
 Appropriate treatment(s) for any respiratory tract disease, that in the investigator’s opinion 
will not interfere with the measurements contributing to the efficacy outcomes, such as: 
corticosteroids (inhaled or systemic), bronchodilators, antibiotics (in case of co-
administration, the i.v. antibiotic should be administered separately). 
 Appropriate treatment(s) for any other underlying disease, that in the investigator’s opinion 
will not interfere with the measurements contributing to the efficacy outcomes 
 If co-treatment with parenteral nitroglycerin is needed the patients should be monitored for 
potential hypotension, which may be severe and may be indicated by the presence of 
headache  
 If one or more treatments interfering with the measurements contributing to the primary 
efficacy outcomes are deemed necessary, the patient should not be randomized or should 
be discontinued from the study 
The following concomitant treatments are not permitted from Visit 1 to Visit 4 (end of IMP 
treatment) or unscheduled Deterioration Visit:  
 Expectorants 
 Antitussive agents  
 Sedatives  
 Traditional Chinese Medicine (TCM) treatments. 
 
All concomitant medications will be recorded and analysed as described in Section 20.4.3.3. 


 
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13. 
INVESTIGATIONAL MEDICINAL PRODUCT 
13.1. 
INVESTIGATIONAL MEDICINAL PRODUCT SUPPLIES AND 
PACKAGING 
NAC will be supplied in boxes containing 4 ampoules each. 
NAC is formulated in yellow glass ampoules as a solution of 300 mg NAC in 3 ml water for injection; 
other excipients are: sodium hydroxide and disodium edetate. The product is manufactured by 
Zambon SpA, Vicenza, Italy. 
Ambroxol hydrochloride will be supplied in boxes containing 4 vials each. 
Ambroxol hydrochloride is formulated in yellow glass vials as a solution of 15 mg ambroxol 
hydrochloride in 2 ml water for injection; other excipients are: citric acid monohydrate, sodium 
hydrogen phosphate dihydrate, sodium chloride. The product is manufactured by Boehringer 
Ingelheim. 
Placebo will be supplied in boxes containing 2 vials each. 
Placebo is formulated in vials as 10 ml NaCl 0.9% saline solution. The product is manufactured by 
China Otsuka Pharmaceutical Co., Ltd. 
13.2. 
INVESTIGATIONAL MEDICINAL PRODUCT DISPENSING AND 
ADMINISTRATION 
All IMPs will be dispensed twice daily as one in the morning and another is in the afternoon/evening 
for a week of treatment period at hospital investigational sites by study staff. All IMP will be 
administered at the hospital investigational sites by study staff otherwise not involved with the 
efficacy assessment and care of study patients. The study staff members administering the IMP 
will be aware of its identity but will not disclose it to patients or to other study staff members who 
are involved in efficacy assessment (patient and rater-blind design, see Section 4).  
 
NAC (Active test treatment) 
Two ampoules (NAC 600 mg) will be diluted in 10 ml NaCl 0.9% saline solution and administered 
by slow (at least 5 minutes) intravenous infusion twice a day, morning before 9 am and 
afternoon/evening approximately 12 ± 1 hours apart for 1 week (7 days). Total daily NAC dose: 
1200 mg/day.   
 
Ambroxol hydrochloride (active control treatment) 
Two vials (ambroxol 30 mg) will be diluted in 10 ml NaCl 0.9% saline solution and administered by 
slow (at least 5 minutes) intravenous infusion twice a day, morning before 9 am and 
afternoon/evening approximately 12 ± 1 hours apart for 1 week (7 days). Total daily ambroxol dose: 
60 mg.  
 
Placebo 
One vial of 10 ml NaCl 0.9% saline solution will be administered by slow (at least 5 minutes) 
intravenous infusion twice a day, morning before 9 am and afternoon/evening approximately 12 ± 
1 hours apart for 1 week (7 days). 
Study staff administering the IMP will be instructed to store the empty used and the unused 
ampoules/vials for IMP accountability. 
 


 
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13.3. 
RANDOMISATION 
Each subject will receive a screening number as soon as site staff enters the IWRS, after they have 
signed the ICF (Visit 1).  
The screening number will consist of country number (1 digit), a site number (3 digits) and a 
continuous number for a subject at an individual site (3 digits), e.g. 1001001. Every subject who 
signs the ICF must be entered into the IWRS system regardless of eligibility. 
At Visit 2, eligible subjects will be randomised using the IWRS according to a pre-specified 
randomisation scheme such that they either receive NAC or ambroxol hydrochloride or placebo.  
The randomisation within each site will be done with blocks sized of unequal length to guarantee 
a good balance among NAC, ambroxol hydrochloride and placebo at any stage of the enrolment 
minimizing the procedure selection bias. 
The allocation to the treatment will be stored within the IWRS database until unblinding of the trial 
is requested. Unblinding may be performed directly by the Investigators only in case of SAE of life-
threating significance where knowledge of treatment assignment is essential for the future 
management of patient care (see Section 15.1).  
13.4. 
INVESTIGATIONAL MEDICINAL PRODUCT ACCOUNTABILITY 
IMP inventory and accountability records will be maintained within IWRS. The following rules are 
to be followed: 
a) 
The Investigator will keep IMPs in a pharmacy, or a locked and secure storage facility, 
accessible only to those individuals authorised by the Investigator to dispense the IMPs. 
b) 
The inventory will be maintained by the Investigator or pharmacist or other nominated 
individual. The inventory will be done by means of a specific “Subject/Study Investigational 
Product Accountability Record & Investigational Product Reconciliation Log” and will include 
details of IMPs received and a clear record of when they were dispensed. 
c) 
At the conclusion or termination of the clinical trial, the Investigator will conduct a final IMP 
inventory and to record the results of the inventory on an Investigational Product Return Form. 
The monitor will check that IMP accountability was correctly performed. The Investigator will 
return all original IMP containers, whether empty or full, to the CRO for final reconciliation and 
destruction. 
d) 
The Investigator/pharmacist agree not to supply IMP to any person except those named as 
Investigators/Co-Investigators as detailed in the Site Signature/Delegation Log, and to 
subjects in this trial. 
For instructions to maintain the study patient and rater-blind, see Section 4. 
14. 
CLINICAL TRIAL AMENDMENTS 
Changes to the CTP can be made preparing written amendments to be agreed and signed by the 
Principal Investigator and Sponsor. No substantial amendment can be implemented without a 
favourable opinion of the Ethics Committee (EC) and Competent Authority (CA) and CA, unless 
the changes consist of urgent safety measures to protect trial subjects. 
Amendments which are non-substantial amendments as defined by current regulations can be sent 
to EC/CA for notification as applicable per local requirements and may be implemented at the site 
before EC notification according to local rules.  


 
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15. 
DEVIATIONS FROM THE CLINICAL TRIAL PROTOCOL 
Any major or critical deviation which may have an impact on study results and/or the safety of the 
subjects should be immediately reported to the CRO and a decision will be taken together with the 
Sponsor whether or not the patient for whom the deviation from the CTP took place is to continue 
in the trial. A deviation log will be maintained to track actual deviations and decisions taken. All 
deviations will be reported to the EC and CA according to ICH-GCP and local requirements. 
In case of an emergency deviation from the CTP has to be implemented for a give patient, this 
deviation will be only applied to that individual. 
In such an emergency the Investigator must contact the CRO by telephone as soon as possible.  
15.1. 
CODE BREAKING 
The code for any individual subject will not be broken by the Investigator/rater during course of the 
trial except in the circumstance of an SAE where knowledge of treatment assignment is essential 
for the future management of patient care. 
Despite the fact that this study is not double-blind, in order to ensure proper documentation, in case 
of emergency, unblinding of the treatment is to be done through IWRS. The IWRS will be designed 
to send a confirmation (by fax and/or notification email) to the site for every transaction performed 
by the site users. Site users will be provided with usernames and passwords to access the IWRS. 
Unblinding of the study treatment must be done in case of an emergency situation, where the 
Investigator/rater considers it essential to know what treatment the subject was taking. Access to 
the unblinding option will be granted only to the Investigators and sub-Investigators at the sites. 
The IWRS will promptly notify the Sponsor and the Clinical Trial Monitor whenever a treatment 
code is unblinded. If the treatment code has been opened, this must be recorded in the eCRF.  
Users from PAREXEL and Sponsor Pharmacovigilance will have their own passwords to unblind 
subjects in case of suspected unexpected serious adverse reactions (SUSARs) to be reported to 
the CA and ECs. 
16. 
CLINICAL TRIAL WITHDRAWALS/DROP-OUTS 
Patients will be withdrawn from the trial for one of the following reasons: 
 patient may withdraw from the study at any time at his/her own request;  
 patient may withdraw from the study due to an AE;  
 patient may be withdrawn at any time at the discretion of the Investigator for safety, 
behavioural, compliance or administrative reasons; 
 patient may be withdrawn due to lack of adherence to study medication regimen. 
 Female patient who becomes pregnant should be withdrawn from the trial and followed-up in 
accordance with Section 18.8; 
 Patient should be withdrawn from the trial once rescue mucolytic is received; 
 non-emergency unblinding of study treatment allocation;  
 lost to follow up: before a subject is deemed lost to follow up, the Investigator or designee 
must make every effort to regain contact with the participant (where possible, 3 telephone 
calls and, if necessary, a certified letter to the participant’s last known mailing address or local 
equivalent methods). These contact attempts should be documented in the participant’s 
medical record. Should the participant continue to be unreachable, he/she will be considered 
to have withdrawn from the study;  


 
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The sponsor, CA, or EC/IRB(s), can terminate the trial or participation of an individual site. 
The reason for removal of a subject from the trial or premature discontinuation of treatment must be 
fully documented in the eCRF as well as in respective source documents. Follow-up for withdrawn 
subjects follows the procedures described in Section 18.8 and Section 18.9.  
17. 
STOPPING AND DISCONTINUATION CRITERIA FOR THE 
TRIAL 
The trial may be prematurely terminated or placed on temporary hold for the following reasons: 
 the Sponsor feels that the number and/or severity of AEs justifies discontinuation of the trial; 
 the Sponsor considers the applied doses of one or more IMPs to be no longer relevant; 
 data not known before, become available and raise concern about the safety of one or more 
IMPs so that continuation would pose potential risks to the subjects; 
Premature termination of the trial must be reported to the EC and CA according to applicable laws 
generally within 30 days. A detailed written explanation of the reason should be given and 
alternative procedures for subjects under treatment specified.  
However, trial results have to be reported according to the requirements outlined in this CTP as far 
as applicable. 
If, after the termination of the trial, the risk/benefit analyses have changed, the new evaluation 
should be provided in case it will have an impact on the planned follow-up of the patients who have 
participated in the trial. If possible, the patients should return to the clinic for an early End of 
Treatment Visit. 
18. 
REPORTING SAFETY INFORMATION 
18.1. 
DEFINITION OF ADVERSE EVENT 
An AE is "any untoward medical occurrence in a patient or clinical trial subject administered a 
medicinal product and which does not necessarily have a causal relationship with this treatment". 
AEs include: 
 worsening (change in nature, severity or frequency) of conditions present at the onset of the 
trial; 
o worsening of expectoration difficulties and related symptoms may prompt 
discontinuation of the patient and immediate administration of rescue mucolytic if 
judged to be in the patient’s best interest by the investigator and/or the patient 
him/herself 
 subject deterioration due to the primary illness; 
 intercurrent illnesses; 
 drug interactions; 
 events related or possibly related to concomitant medications; 
 abnormal laboratory values, as well as significant shifts from baseline within the range of 
normal, which the Investigator considers to be clinically significant. 
An AE can therefore be any unfavourable and unintended sign (including an abnormal laboratory 
finding), symptom, or disease temporally associated with the use of an investigational medicinal 
product, whether or not considered related to the IMP. 


 
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An unscheduled Deterioration Visit should be conducted whenever possible (Section 10.10). 
18.2. 
DEFINITION OF ADVERSE EVENT OF SPECIAL INTEREST  
No AEs of special interest are defined for this trial.  
18.3. 
DEFINITION OF ADVERSE DRUG REACTION 
An adverse drug reaction (ADR) is “any untoward and unintended response to an IMP related to 
any dose administered and which implies an AE with at least a reasonable possibility of a causal 
relationship with the use of the product (i.e. there is evidence or arguments to suggest a causal 
relationship). 
The definition covers also medication error and uses outside what is foreseen in the CTP, including 
misuse and abuse of the IMP. 
All AEs judged by either the reporting Investigator or the Sponsor as having a reasonable causal 
relationship to a medicinal product qualify as ADRs. 
18.3.1. 
DEFINITION OF UNEXPECTED ADVERSE DRUG REACTION 
An unexpected ADR is: “An adverse reaction, the nature, or severity of which is not consistent with 
the applicable product information (e.g. Investigator's Brochure [IB] for an unapproved 
investigational product or SmPC, for approved product)”. The reference safety information for 
evaluation of AE expectedness in this trial will be the Investigator Brochure for NAC and the 
Chinese Package Insert for ambroxol hydrochloride. 
18.4. 
DEFINITION OF SERIOUS ADVERSE EVENTS OR SERIOUS 
ADVERSE DRUG REACTIONS 
18.4.1. 
DEFINITION OF SERIOUS ADVERSE EVENT OR SERIOUS ADVERSE REACTION 
A Serious Adverse Event (SAE) is any untoward medical occurrence or effect that at any dose: 
 results in death; 
 is life-threatening (i.e. the subject was at risk of death at the time of the event/reaction; it does 
not refer to an event/reaction which hypothetically might have caused death if it were more 
severe); 
 requires inpatient hospitalisation or prolongation of existing hospitalisation considering that 
hospitalization is not a SAE in itself, planned or selective hospitalization, hospitalization for 
underlying disease which did not worsen during the study, as well as hospitalizations for social 
reasons should not be reported as SAEs; 
 results in persistent or significant disability/incapacity (where disability is defined as a 
permanent or substantial disruption of ability to carry out normal life functions, either reported 
or defined as per clinical judgement); 
 is a congenital anomaly/birth defect; 
 is an important medical event that may not result in death, be life-threatening, or require 
hospitalisation but, according to appropriate medical judgment, it may jeopardise the subject 
and may require medical or surgical intervention to prevent any of the outcomes listed in the 
definition above. Examples of such events include allergic bronchospasm requiring intensive 


 
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treatment in an emergency room or at home, and blood dyscrasias or convulsions that do not 
result in hospitalisation, or development of drug dependency or drug abuse.  
Any suspected transmission via a medicinal product of an infectious agent is also considered an 
SAE. 
A Serious Adverse Reaction (SAR) is any SAE judged by either the reporting Investigator or the 
Sponsor as having a reasonable causal relationship to a medicinal product. 
18.4.2. 
DEFINITION OF SUSPECTED UNEXPECTED SERIOUS ADVERSE REACTIONS 
A SUSAR (Suspected, Unexpected Serious Adverse Reaction) is a subset of SAEs/SARs that, 
although foreseeable, are potentially related to the IMP and not identified in the reference safety 
information and will be reported to the appropriate regulatory authorities and investigators following 
local and global guidelines and requirements. 
18.5. 
DEFINITION OF SEVERITY OF ADVERSE EVENTS 
The term “severe” is used to describe the intensity (severity) of a specific event: 
 Mild: causing no limitation of usual activities; the subject may experience slight discomfort; 
 Moderate: causing some limitation of usual activities; the subject may experience annoying 
discomfort; 
 Severe: causing inability to carry out usual activities; the subject may experience intolerable 
discomfort or pain. 
18.6. 
DEFINITION OF ADVERSE EVENT CAUSALITY 
Causality shall be determined according to the definition of ADRs as given in Section 18.3. 
All AEs judged by either the Investigator or the Sponsor as having a reasonable suspected causal 
relationship to an IMP qualify as ADRs. The causality assessment given by the Investigator should 
not be downgraded by the Sponsor. 
The following binary decision for causality will be used: 
 reasonable possibility that the IMP caused the event; 
 no reasonable possibility that the IMP caused the event. 
Features supportive of an association include: 
 temporal plausibility; 
 pharmacological properties of the drug or of the substance class; 
 course of the AE after de-challenge and, if applicable, after re-challenge; 
 specific tests indicating involvement of the drug in the occurrence/worsening of the AE;  
 alternative explanations. 
18.7. 
ADVERSE EVENT RECORDING 
Each AE occurring to a subject, either spontaneously revealed by the subject or observed by the 
Investigator, whether believed by the Investigator to be related or unrelated to the IMP, must be 
recorded by the Investigator on the AE information page of the eCRF. Also, for SAEs, information 
must be recorded in the eCRF (see Section 19.1).  


 
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The Investigator performs an evaluation with respect to seriousness and causality of the AEs and 
records it on the appropriate section of the eCRF and on the “Serious Adverse Event Form” (if 
appropriate). 
18.8. 
ADVERSE EVENT MONITORING WINDOW 
- 
Start of monitoring: from immediately after the signature of the informed consent 
- 
End of monitoring: final study visit/ETV (observation window) 
An AE occurring after the final visit/ETV and coming to knowledge of the investigator (e.g. during a 
follow-up assessment or by spontaneous reporting by study subjects) must be recorded only if it is 
an ADR, according to the investigator’s judgment. 
18.9. 
ADVERSE EVENT REPORTING 
The Investigator must report to the CRO all AEs which occur during the trial, regardless of their 
relationship to IMP. All AEs are recorded by the Investigator on the AE information page of the eCRF. 
In addition, any SAE will have to be reported according to the following detailed procedure. 
18.9.1. 
REPORTING SERIOUS ADVERSE EVENTS 
Investigators must report SAEs within 24 hours of first awareness of the event. 
The SAE must be reported through the eCRF to the CRO’s Pharmacovigilance group as per contact 
details provided in the "List of CRO personnel" at the beginning of this CTP. 
If there is any issue with the electronic reporting process, such as internet failure or database 
issues, this must not delay SAE reporting. The back-up procedure is to send the back-up paper 
Serious Adverse Event Form to the CRO’s Pharmacovigilance group by email using the contact 
details specified in the SAE guidelines. 
Note: Any reports submitted on paper must be retrospectively added to the eCRF as soon as 
possible. 
The national and local standards of confidentiality must always be maintained and any relevant 
national legislation on data protection must be followed. 
SAEs are reportable from the time a patient signs the informed consent to the follow-up phone call 
or visit occurring 2 weeks (± 3 days) after the last dose of IMP. 
If the Investigator becomes aware of any SAE occurring to a subject within the follow-up window 
established in this CTP, he/she will report the SAE as above. The SAE will be also reported in the 
eCRF. 
If the Investigator becomes aware of any SAE is related to the study drug outside the follow-up 
window established in this CTP, it is the Investigator’s responsibility to report the SAE to the 
Sponsor. The Investigator might use the “Serious Adverse Event Form” via email, but the SAE 
must not to be reported in the CRF, the SAE is not an event occurred within the trial period. 
18.9.2. 
REPORTING ADVERSE EVENTS OF SPECIAL INTEREST  
No specific provisions relate to reporting of AEs of special interest in this trial.  


 
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18.10. 
FOLLOW-UP FOR ADVERSE EVENTS 
All AEs requiring the subject’s discontinuation and SAEs will be followed up until they are resolved 
or closed or when the subject is lost to follow up or uncontactable. 
Resolution of an AE is defined as the return to pre-treatment status or stabilisation of the condition 
with the expectation that it will remain chronic.  
The Investigator must respond to any request for follow-up information (e.g. additional information, 
outcome and final evaluation, specific records where needed) and answer any question that the 
Sponsor or designee may have regarding the AE.  
Regarding SAEs, the timelines and procedure for follow-up reports are the same as those for the 
initial reports for SAEs. 
This is necessary to permit a prompt assessment of the event by the Sponsor or designee and (as 
applicable) to allow the Sponsor to meet strict regulatory timelines associated with expedited safety 
reporting obligations. 
If follow-up information on SAEs is available, a follow-up information will be filled-in eCRF by the 
Investigator and sent to the CRO as above-described, under Section 18.9.1.  
18.11. 
PREGNANCY 
Subjects must be instructed that known or suspected pregnancy occurring during the trial should 
be confirmed and reported to the Investigator, who must then withdraw the subject from the trial 
without delay (Section 10.10). The Investigator should also be notified in case the partner of a male 
study subject becomes pregnant at any time during the course of the study (in this event a specific 
ICF for the subject’s partner will be obtained). 
In the event that a subject or a female partner is found to be pregnant after inclusion in the trial, 
then pregnancy will be actively followed up to term or pregnancy termination and the status of 
mother and child will be reported by the Investigator to the CRO through the appropriate pregnancy 
report provided by the CRO.  
The Investigator will send pregnancy reports using pregnancy Reporting and Outcome form to 
CRO within the timeframes of SAEs.  
If pregnancy results in abnormal outcome, it will be considered as SAE. If the Investigator and/or 
the Sponsor considers this to be due to the IMP, this will be treated as an expedited ADR report. 
19. 
RECORDS 
19.1. 
CASE REPORT FORMS, SOURCE DATA AND QUERY RESOLUTION 
The Investigator must ensure that the clinical data required by the CTP are carefully reported in 
the eCRF. He/she must also check that the data reported in the eCRF correspond to those in the 
official files (source documentation).  
Data entered directly into the eCRF comprises all data raised via the 4-point ordinal scales for the 
assessment of expectoration difficulty, sputum viscosity, sputum color and cough and the 24-hour 
sputum volume.  
ECG and laboratory results must be printed and signed by the Investigator and kept as source data 
on site after entering outcome into the eCRF. 
All other data has to be documented in the subject file as source data first and then entered into 
the eCRF.  


 
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Data must be entered into eCRFs in English by the designated site personnel as soon as possible 
after a subject visit, and monitors will have access to data recorded. These data will be reviewed 
versus source documents by trial monitors for completeness and acceptability during monitoring 
visits.  
If data correction is required for an eCRF after initial entry, the site personnel can make necessary 
corrections on their own or as a response to an automated query by the eCRF system. Monitor 
and Clinical Data Manager review the eCRF for accuracy and can also generate queries to the 
investigational staff for resolution.  
Any correction to the eCRFs' entries must be carried out by the Investigator or a designated 
member of staff. Corrections are recorded in an audit trail that records the old information, the new 
information, and identification of the person making the changes, date of correction made and 
reason for change. In the interests of completeness of data acquisition, the questions which are 
repeated in each section of the eCRFs should be answered in full, even if there are no changes 
from a previous examination. A reasonable explanation must be given by the Investigator for all 
missing data. The Investigator or his/her designees named in the clinical staff list will review the 
eCRF for accuracy and completeness. The Investigator must electronically sign and date the eCRF 
pages as indicated. 
19.2. 
RECORDS MAINTAINED BY THE INVESTIGATOR 
A copy of all trial records (any documents sent or received from the Sponsor/CRO, correspondence 
with EC and any other institution or authority and relevant approvals, subjects' source data and 
subjects' identification documentation) must be maintained by the Investigator for at least 5 years, 
or for a longer period, where so required by other applicable requirements or by an agreement 
between the Sponsor and the Investigator. 
19.3. 
TRIAL MASTER FILE 
The Trial Master File (TMF) will be maintained by the CRO according to the respective CRO SOPs 
with direct access for all study participants.  
At the end of the trial, the TMF will be transferred to the Sponsor, where it will be archived according 
to specific Sponsor SOPs. A copy of the Investigator files will be left on site after trial end. 
19.4. 
TRIAL MONITORING 
The trial will be monitored by means of regular visits and telephone calls according to specific and 
pre-defined SOPs and trial specific monitoring guidelines. Details of the visits will be recorded in 
appropriate Monitoring Report forms to be submitted regularly to Sponsor. Any relevant protocol 
deviation must be promptly communicated to designated Sponsor’s personnel 
Monitoring will be performed by personnel of the CRO, Parexel.  
19.5. 
CONFIDENTIALITY OF SUBJECT’S INFORMATION 
The Investigator has the responsibility to maintain the pseudonymity of subjects in compliance with 
the Chinese and Italian data protection laws. In all trial documents, subjects are associated to a 
code which does not reveal subject’s identity. Only at the site, the Investigator holds the subject’s 
identity on a Subject Identification Log under his/her responsibility. The Investigator will maintain 
this for the longest period allowed by his/her own institution and, in any case, until further 
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The site and the Sponsor shall process personal data of subjects involved in the clinical trial as 
data controllers and in compliance with the Italian data protection law, each of them in its area of 
competence and in accordance with the responsibilities provided by GCP, only in relation to the 
trial performance and for pharmacovigilance purposes. 
Any contracted organisation as data processor including Parexel, the local laboratories, and IWRS 
provider, will act in compliance with the terms and conditions agreed with the Sponsor. 
20. 
BIOMETRICS 
20.1. 
DATA MANAGEMENT 
A data management plan specifying all relevant aspects of data processing for the study (including 
data validation, cleaning, correcting, and releasing) will be maintained and stored at Parexel. 
Electronic systems that may be used to process and/or collect data in this study will include the 
following: 
 IWRS system – randomization, study drug supply 
 eCRF and Electronic Data Capture (EDC) system – data capture 
 Statistical Analysis System (SAS®) – statistical review and analysis 
 Pharmacovigilance safety database 
Subject data will be captured in an eCRF system and reviewed by the Clinical Research Associate 
in order to check CTP adherence and to detect any data inconsistency or discrepancy (data 
validation step). 
Medical/surgical history and underlying diseases and AEs will be coded using the Medical 
Dictionary for Regulatory Activities (MedDRA) latest version current at trial start and which will be 
maintained during the trial. 
Previous and concomitant medications will be coded using the World Health Organization-Drug 
Dictionary (WHO-DD). Actual versions of coding dictionaries used will be stated in the CTR.  
The final data file will be transferred to the Sponsor in the agreed format as soon as possible after 
the trial is completed. 
20.2. 
STUDY END-POINTS  
 
Primary efficacy end-point 
Superiority of NAC over placebo in change from baseline to end of 1-week treatment of mean 
sputum viscosity score or mean expectoration difficulty score. 
The study will be declared success if at least one of two components of the primary end-point will 
show superiority over placebo.  
 
Secondary efficacy end-points 
A. Superiority of NAC over placebo 
 in change from baseline to day 3 of mean sputum viscosity score OR mean expectoration 
difficulty score;  
 in change from baseline to day 3 and to end of 1-week treatment of individual scores:  
o mean sputum viscosity score 
o mean expectoration difficulty score 


 
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o mean sputum color score 
o mean cough score 
 in change from baseline to day 3 and to end of 1-week treatment of mean sputum volume  
  
B. Non-inferiority of NAC vs. ambroxol in change from baseline to end of 1-week treatment of 
mean sputum viscosity score or change of mean expectoration difficulty score. 
 
C. Superiority of ambroxol vs. placebo in change from baseline to day 3 and to end of 1-week 
treatment of  
o mean sputum viscosity score OR mean expectoration difficulty score;  
o mean sputum viscosity score (individual score) 
o mean expectoration difficulty score (individual score) 
o mean sputum color score 
o mean cough score 
o mean sputum volume 
 
Safety end-points 
Counts and frequency distributions of: 
 All, mild/moderate/severe, non-serious/serious adverse events  
 Vital signs  
 Laboratory tests  
 12-lead ECG (normal, abnormal clinically non-significant, abnormal clinically significant) 
20.3. 
SAMPLE SIZE 
This study has been powered to reach statistical significance for the superiority comparisons of N-
acetyl cysteine (NAC) vs. placebo (primary study objective), and for the non-inferiority comparisons 
of NAC vs. ambroxol hydrochloride (key secondary study objective) in at least one of the two co-
primary endpoints at the end of the 1-week treatment. This implies that sample size computation 
must account for the type I error inflation caused by the multiplicity over the two co-primary 
endpoints and by the multiplicity over the study targets (superiority and non-inferiority 
assessments) as well as the logical relationships among the two family of hypotheses with the non-
inferiority testable only provided that the superiority contrast, assessed on the same endpoint, is 
statistical significant. To accomplish this, a multiple-sequence gatekeeping procedure [21] was 
implemented in a Monte Carlo (MC) study with 1000 runs and with the Bonferroni correction applied 
to the set of superiority comparisons (first gatekeeper) and the Hochberg correction applied to the 
set of non-inferiority comparisons (second gatekeeper) in order to control the overall type I family-
wise error rate at the one-tailed 0.025 significance level. Details on the adopted gatekeeping 
strategy are reported further on.  
For the superiority tests, and with group sample sizes of 100 patients in placebo group and 100 
patients in NAC group, the Monte Carlo study estimated an overall power (“disjunctive” power) 
close to 93% to reach statistical significance in at least one co-primary end-point. These 
calculations are based on a one-sided Mann-Whitney test and assuming a minimal clinically 
relevant difference of 0,35 points between placebo and NAC on a 0-3-point scale, standard 
deviation equal to 0,79 and 0,77 for sputum viscosity and expectoration difficulty scores (change 
from baseline to the 1-week treatment) respectively and a correlation between the two end-points 
equal to 0.31. 
For the non-inferiority tests, a sample of 100 patients per each active treatment group ensures 
sufficient disjunctive power (Monte Carlo disjunctive power = 82%) to detect non-inferiority between 
NAC and ambroxol in at least one co-primary end-point. These calculations are based on a one-
sided non-inferiority t-test assuming a margin of non-inferiority equal to 0.30, standard deviation 


 
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equal to 0,79 and 0,77 for sputum viscosity and expectoration difficulty scores (change from 
baseline to the 1-week treatment) respectively and a correlation between the two endpoints equal 
to 0.31. 
Assuming a drop-out rate of about 10% over one week of entry, a total of 333 patients will be 
randomized (i.e. 111 patients in the placebo group, 111 patients in the NAC group and 111 patients 
in the ambroxol group. The sample size calculations were performed using the Mediana package 
[22]. 
20.4. 
STATISTICAL ANALYSES 
20.4.1. 
GENERAL STATISTICAL CONSIDERATIONS 
All data captured on eCRFs will be available as listings. 
The statistical analysis will be performed by the CRO and it will be carried out according to ICH 
guidelines ICH E9: “Statistical Principles for Clinical Trials” (CPMP/ICH/363/96). If not otherwise 
stated all statistical analyses and data tabulations will be produced using SAS® for Windows 
release 9.4 (64-bit) or later (SAS Institute Inc., Cary, NC, USA). 
The data from all sites will be pooled. Unless stated otherwise, all available data from withdrawn 
subjects will be included in the analysis up to the time of withdrawal. 
The primary study objective will be assessed by testing superiority of NAC compared to placebo 
and will be achieved if at least one of the two co-primary end-points will be found statistically 
significant. The key secondary objective will be assessed through the analysis of non-inferiority of 
NAC compared to ambroxol and, similarly, will be reached if at least one of the two co-primary end-
points will be found statistically significant. Conversely, the analyses on the remaining secondary 
efficacy endpoints will be treated as non-key secondary objectives since they will be performed 
only to support primary endpoints findings. 
All tests will be one-sided and performed at the significance nominal level of α = 0.025. Details are 
reported in Section 20.4.5. 
More detail about the statistical analysis will be provided in the SAP. The SAP will be released 
before the start of the study. Any change in the SAP occurred after release will be documented as 
an amendment. Any deviation from the SAP occurring after breaking the blind will be documented 
and justified in the final CTR and deviations will be clearly marked as ‘post hoc’ analyses. 
20.4.2. 
TRIAL POPULATIONS 
There will be 4 analysis populations defined for the trial analyses: 
Intention-To-Treat (ITT) Population: The Intention-To-Treat Population will include all subjects who 
provided informed consent and received a patient number (randomisation number) whether or not 
they receive IMP. 
Modified Intention-To-Treat Population: The Modified ITT (mITT) Population will comprise all 
subjects who provided informed consent, were randomised and received at least 1 dose or partial 
dose of the IMP.  
Primary analyses will be performed on the mITT population with exclusions from the ITT defined 
and justified in the SAP.  
Following the ITT principle, subjects will be analysed according to the treatment they have been 
assigned to at randomisation. 


 
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The mITT will be used to produce summaries of baseline subject characteristics and for the 
analysis of all efficacy endpoints. 
Safety Population 
The Safety Population will comprise all subjects who provide Informed Consent and received at 
least 1 dose or partial dose of IMP.  
Subjects will be analysed according to the treatment they actually received.  
The Safety Population will be used to produce summaries of all safety related endpoints and 
demography. 
Per-protocol Population 
The Per-protocol Population (PP) will include all mITT subjects who were compliant with study drug 
administration (i.e. had a compliance of at least 80%) and who had no major protocol deviations 
that were considered as potentially impacting the efficacy results. Major protocol deviations might 
include, but are not be limited to, subjects taking a not-permitted concomitant medication, the IMP 
not being administered during the trial as defined in the protocol, subjects receiving a treatment 
different than the one assigned by randomisation; others will be defined in the SAP.  
With the exclusion of non-inferiority comparisons, results of the primary and secondary efficacy 
endpoints analyses conducted in the PP will be considered as supportive. 
Exclusion of subjects from the PP analyses will be decided jointly by the CRO and Sponsor’s 
Medical Monitor, Clinical Trial Manager and Statistician prior to unblinding of the randomisation 
code and database release.  
The subjects or observations to be excluded, and the reasons for their exclusion will be 
documented and approved by the above-mentioned persons prior to database release. The 
documentation will be filed together with the remaining trial documentation. 
The number of subjects in each analysis population will be reported. Violations excluding subjects 
from any particular population will be described, reporting the number of protocol violators per each 
criterion. All protocol violations, minor ones included, will be listed. 
20.4.3. 
EFFICACY DATA 
If not otherwise stated the mITT population will be used for the primary analyses of each of the 
efficacy endpoints whilst results from supplemental analyses using the Per Protocol Population will 
be compared to those based on the mITT population to assess the effects of dropouts, missing 
data and exclusions for protocol violations. 
The distributions of all the efficacy endpoints listed in Section 20.2 will be summarized by treatment 
group and time point. Counts and percentages will be reported with the latest computed based on 
the numbers of patients with non-missing observations. The percentages will be suppressed when 
the count is zero in order to draw attention to the non-zero counts.  Furthermore, efficacy endpoints 
will be further summarized by arithmetic means, standard deviations, medians quartiles, minima 
and maxima. 
20.4.3.1. 
ANALYSIS OF PRIMARY END-POINTS 
The co-primary efficacy endpoints are: “the change from baseline to the 1-week treatment in 
sputum viscosity score” and “the change from baseline to the 1-week treatment in expectoration 
difficulty score” and will be analyzed on the mITT and PP populations by means of stratified Mann-
Whitney U Statistics for testing the hypotheses of superiority of NAC versus placebo (primary 
objective) after blocking for baseline score and by means of a modified Mann-Whitney U Statistics 
[23] for testing the hypotheses of non-inferiority of NAC versus ambroxol (key secondary objective) 
assuming a margin of non-inferiority equal to 0.30. Statistically significant results will be needed on 


 
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both mITT and PP populations to accept the hypothesis of non-inferiority of NAC versus ambroxol. 
Point estimates of treatment differences together with associated two-sided 95% confidence 
intervals will be computed using nonparametric bootstrap.     
20.4.3.2. 
ANALYSIS OF SECONDARY ENDPOINTS 
 Change from baseline to day 3 in sputum viscosity score: the hypothesis of superiority of 
NAC compared to placebo will be assessed using the same nonparametric test (stratified 
Mann-Whitney U Statistics blocking for baseline score), whilst point estimates of treatment 
differences together with associated two-sided 95% confidence intervals will be computed 
using nonparametric bootstrap. 
 Change from baseline to day 3 in expectoration difficulty score: the hypothesis of superiority 
of NAC compared to placebo will be assessed using the same nonparametric test (stratified 
Mann-Whitney U Statistics blocking for baseline score), whilst point estimates of treatment 
differences together with associated two-sided 95% confidence intervals will be computed 
using nonparametric bootstrap. 
 Change from baseline to day 3 and to the end of the 1-week treatment period in sputum 
color score: the hypothesis of superiority of NAC compared to placebo will be assessed 
using the same nonparametric test (stratified Mann-Whitney U Statistics blocking for 
baseline score), whilst point estimates of treatment differences together with associated two-
sided 95% confidence intervals will be computed using nonparametric bootstrap. 
 Change from baseline to day 3 and to the end of the 1-week treatment period in cough 
severity score: the hypothesis of superiority of NAC compared to placebo will be assessed 
using the same nonparametric test (stratified Mann-Whitney U Statistics blocking for 
baseline score), whilst point estimates of treatment differences together with associated two-
sided 95% confidence intervals will be computed using nonparametric bootstrap. 
 Change from baseline to day 3 and to the end of the 1-week treatment period in sputum 
volume: the hypothesis of superiority of NAC compared to placebo will be assessed using 
the same nonparametric test (stratified Mann-Whitney U Statistics blocking for baseline 
score), whilst point estimates of treatment differences together with associated two-sided 
95% confidence intervals will be computed using nonparametric bootstrap. 
 
The same statistical analysis (stratified Mann-Whitney U Statistics blocking for baseline score) will 
be carried out for testing superiority of ambroxol vs. placebo on the same efficacy endpoints. 
Results will be used for the purpose of verifying study’s assay sensitivity. 
20.4.3.3. 
SUBGROUP ANALYSES 
Upon completion of the study, the study statistician in consultation with Zambon’s Clinical Team 
will determine the proportion of concomitant medications between the treatment groups and will 
decide whether to perform subgroup efficacy analyses if deemed appropriate. The analyses 
described for the primary and secondary efficacy endpoints will be performed separately for each 
of the identified stratums. 
20.4.4. 
HANDLING OF MISSING DATA 
Missing data on the primary and secondary efficacy endpoints will be imputed as treatment failures 
(MVTF) by replacing missing values with the scores recorded at baseline or last measurement, 
whichever is worse as primary imputation method. Expectation-maximization (EM) algorithm and 


 
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last observation carried forward (LOCF) will also be used as sensitivity analyses. Details regarding 
the EM algorithm (i.e. the randomization seed and the SAS code that will be used) will be reported 
in the SAP. 
20.4.5. 
MULTIPLICITY 
The overall type I family-wise error rate will be preserved at the one-tailed 0,025 nominal level (i.e. 
α = 0,025) by controlling multiplicity over the two co-primary endpoints and over the two study 
targets (superiority and non-inferiority) using a multiple-sequence gatekeeping procedure [20]. To 
achieve this, the analyses on primary endpoints will be grouped into two family of comparisons 
(gatekeepers) and processed as follows:  
1. The first gatekeeper includes the superiority contrasts “NAC vs placebo” with the adjustment 
for multiple comparisons across the two co-primary endpoints performed according to 
Bonferroni. This implies that a difference will be considered statistically significant for a one-
tailed p-value ≤ 0.0125 (i.e. α/2 = 0.0125). The transition to the second gatekeeper requires 
that at least one of the two co-primary endpoints is statistically significant.   
2. The second gatekeeper includes the family of non-inferiority contrasts “NAC vs ambroxol”. The 
analyses in the second gatekeeper will be performed depending upon the results obtained in 
the first gatekeeper as shown below: 
a. If both superiority contrasts will be found statistically significant, non-inferiority will be 
tested on both co-primary endpoints with an overall probability α set to 0,025 (one-tailed) 
and with the adjustment for multiple comparisons across the two co-primary endpoints 
performed according to Hochberg. 
b. If only one of the two superiority contrasts will be found statistically significant, non-
inferiority will be tested only for that co-primary endpoint and will be considered achieved 
if the associated one-tailed p-value will be ≤ 0.0125. 
Consistent with the hypothesis testing process performed on the co-primary endpoints, the strategy 
described above will also be applied to control the coverage of confidence intervals at the two-
tailed 95% nominal level (i.e. 1 - 2α = 0,95). 
The analyses on secondary efficacy endpoints (not key) will be performed only to support primary 
endpoints findings and/or for explorative reasons, therefore no adjustment of significance level will 
be made to account for multiple comparisons. 
20.4.6. 
MULTICENTER STUDY 
As additional analysis, a test of site-by-treatment interaction will be carried-out using a two-way 
nonparametric ANOVA performed by resorting to the “Aligned Rank Transform” (ART) procedure 
[24]. The interaction will be considered statistically significant for a two-tailed α=0.1. Also, in order 
to graphically assess the possible heterogeneity of the treatment effect across centres, forest plots 
will be generated to display the results at each center. In case that the number of patients in each 
site were scarce, sites will be gathered into “region”. Upon completion of the study and prior to 
unblinding, study statisticians in consultation with the clinical team will determine the pooling based 
on enrolment numbers and geographical proximity. 
20.4.7. 
INTERIM ANALYSES 
No interim analyses are planned. 


 
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20.4.8. 
SAFETY DATA 
All safety endpoints will be summarised and analysed using the Safety Population. 
Incidence of Treatment Emergent Adverse Events 
The number and the percentage of subjects reporting TEAEs, treatment emergent SAEs, severe 
TEAEs, TEAEs leading to discontinuation and TEAEs leading to death will be presented by 
treatment group, along with the number of events occurring.  
TEAEs will be summarised also by System Organ Class and Preferred Term according to 
MedDRA; they will be additionally summarised by severity and relationship to treatment. A separate 
summary table will be provided for SAEs. 
Only TEAEs, i.e. events with an onset date on or after the date of IMP start, will be included in the 
summary tables. Individual data listings will include all AEs recorded; a separate listing will be 
provided for treatment-emergent SAEs. 
Vital Signs 
Descriptive statistics for vital signs will be presented overall and by treatment.  
Physical examination data. 
Descriptive statistics for physical examination data will be presented overall and by treatment.  
Haematology and clinical chemistry  
Haematology and clinical chemistry tests results will be converted to standard international units 
and summarised by treatment group using descriptive statistics for continuous variables. 
Summaries for change from Visit 1 will be also provided. Frequency of subjects with values 
appearing outside the central laboratory normal range will be reported by visit for each treatment 
group. All values appearing outside the laboratory normal range will be highlighted in listings. 
12-lead Electrocardiogram 
Descriptive statistics for ECG results will be presented overall and by treatment (normal, abnormal 
clinically non-significant, abnormal clinically significant). 
Adherence and Exposure 
Subject adherence will be summarised by treatment group presenting descriptive statistics and 
percentages of adherent subjects, i.e. with a least 80% of compliance.  
The total number of doses of IMP taken by each subject, will be summarised as well. 
If an AE has a partial or fully missing date, and it is unclear whether the AE is treatment-emergent, 
it will be assumed that it is. In the AEs analysis, when relationship to study drug is missing for a 
treatment-emergent adverse event it will be imputed to be drug related. More detail will be provided 
in the Statistical Analysis Plan (SAP). 
21. 
INFORMED CONSENT 
Written informed consent will be obtained by the Investigator or other authorized person from all 
subjects or their legally acceptable representative.  
The Investigator is responsible for correctly obtaining the informed consent in accordance with the 
applicable regulatory requirement(s), GCP and the ethical principles that have their origin in the 
Declaration of Helsinki. 
Prior to the beginning of the trial, the Investigator should have received the EC written approval of 
the ICF. 
Informed consent must be obtained prior to the initiation of any procedures specific to the trial. The 
record of the informed consent must be available to be audited/inspected by the Sponsor/CRO 
designees and by CA(s), whenever requested.  


 
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The informed consent documentation must be personally dated and signed by the trial subjects, to 
confirm that consent is based on information that has been understood, and by the Investigator. 
Neither the Investigator, nor the trial staff, should coerce or unduly influence a subject to participate 
or to continue to participate in a trial. 
Before informed consent may be obtained, the Investigator or other authorised person, should 
provide the subject ample time and opportunity to inquire about details of the trial and to decide 
whether or not to participate in the trial. All questions about the trial should be answered to the 
satisfaction of the subject. 
The subject should receive a copy of the signed and dated ICF and any other written information 
provided to him/her, and updates. 
 
If the subject is not able to write, a verbal consent can be obtained. For illiterate patients, at least 
1 impartial witness must be invited to join in the consent process, who would sign off ICF. 
Further, in case the subject and his/her legal representative are unable to read, informed consent 
will be obtained in the presence of an impartial witness, i.e. a person independent of the trial who 
will read the ICF and the written information for the subject. 
22. 
ETHICS COMMITTEE APPROVAL 
This trial will be undertaken only after written and dated approval from EC has been received by 
the Investigator and by the Sponsor for CTP, all its appendices, ICF, and subject’s recruitment 
procedures (i.e. advertisement) if applicable. 
In addition to the above-mentioned documents, the EC will be provided with an updated 
Investigator Brochure, SmPc and IMPD (where applicable), the Investigator’s up-to-date 
Curriculum Vitae and/or other documentation evidencing qualifications, and any other documents 
that the EC may need to fulfil its responsibilities. 
During the trial, on regular basis, the Investigator will have to submit written summaries of the trial 
status (i.e. recruitment rate) to the EC, if requested. 
23. 
REGULATORY REQUIREMENTS 
The trial is to be conducted in compliance with the Chinese legislation and ICH-GCP E6 Rev2.  
 
Selection of subjects will not start prior to the approval of the EC has been obtained and the trial 
notified to or authorised by CAs as per national and local requirements.  
24. 
QUALITY ASSURANCE 
This CTP has been audited by the Sponsor’s Quality Assurance. The Audit Plan for the study 
includes site audits. Audits will be planned and conducted according to the Sponsor’s SOPs. 
25. 
INSURANCE 
The Sponsor is concerned with the safety of the subjects in the clinical trial and wishes to protect 
the Investigator (and as applicable per local regulations, the site, the monitor and all the 
Investigator’s staff involved in the trial) in the event of claims or lawsuits alleging injury as a result 
of administration of a study drug. 


 
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In consideration of undertaking a human trial in subjects according to this CTP the Sponsor will:  
 indemnify the Investigator and hold him without liability for claims for damages arising out 
of the above described investigation in excess to those covered by his/her own professional 
liability insurance; 
 defend the Investigator against any claims or lawsuits initiated by, or on behalf of, subjects 
who seek damages for bodily injury alleged to have been sustained as a result of 
administration of the study drug; 
 pay any settlements of judgement resulting therefrom, providing that for all of the 
aforementioned cases, the study drug was administered under the Investigator's supervision 
and in strict accordance with accepted medical practice, the CTP, and the precautions, 
indications, and other instructions, provided by the Sponsor; 
Indemnification is not valid for claims for damages arising from malpractice and/or negligence on 
the part of the Investigator or those under the Investigator's supervision. 
The protection afforded by this policy does not take the place of the Investigator's professional liability 
insurance but covers damages in excess of such insurance protection. Further, this indemnity is 
conditional upon the Investigator giving the Sponsor information as soon as reasonably practicable 
and upon the Investigator assisting the Sponsor and its authorised representatives in the 
investigation and defence of any suit for which coverage is provided. 
26. 
CLINICAL TRIAL REPORT 
A CTR of the trial will be prepared and written by the CRO according to ICH topic E3 
(CPMP/ICH/137/95). A summary of the report will be sent to Investigators/EC/Regulatory 
Authorities according to current regulations. 
27. 
USE OF INFORMATION AND PUBLICATION 
Investigator agrees to inform in advance Zambon about his/her intention to divulge any data, results 
concerning the Confidential Information and/or the trial subject to this agreement. As a 
consequence hereof, Investigator hereby undertakes to submit to Zambon, at least with a 60 days 
(30 in case of abstracts) prior written notice, the text and or the content of the concerned publication, 
divulgation as to allow Zambon to assess properly that such proposed publication respects and/or 
is not in conflict with Zambon’s rights to preserve and protect its intellectual property rights and any 
confidentiality imposed to Zambon by the prevailing rules of the country where the trial is 
conducted . 
Further, without any prejudice to Investigator’s right to divulge and save for what stated 
hereinabove, Investigator intends to seek Zambon opinion and advice on and prior to the intended 
publication and/or disclosure, in consideration also of the contractual relationship in force between 
Zambon and Investigator and the nature of the trial hereto. 
 


 
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28. 
REFERENCES 
1. Global Strategy for the diagnosis, management, and prevention of Chronic Obstructive 
Pulmonary Disease (GOLD) guidelines, update 2018. 
2. Polverino E, et al. European Respiratory Society guidelines for the management of adult 
bronchiectasis. Eur Respir J 2017; 50: 1700629. 
3. Wenzel RP, et al. Acute Bronchitis. N Engl J Med 2006;355:2125-30. 
4. ERS White Book. Cystic fibrosis, Chapter 14:160-175. 
5. Chen R, et al. Fine Particulate Air Pollution and Daily Mortality. A Nationwide Analysis in 
272 Chinese Cities. AJCCM 2017; 196:73-81. 
6. Zhang T, et al. Clinical application of expectorant therapy in chronic inflammatory airway 
diseases. Exp Ther Med 2014;7: 763-767. 
7. Sadowska AM. N-Acetylcysteine mucolysis in the management of chronic obstructive 
pulmonary disease. Ther Adv Respir Dis 2012;6:127-35.  
8. Fluimucil Vials for Aerosol – Chinese SmPC. 
9. Fluimucil Vials for Aerosol – Italian SmPC. 
10. Fluimucil Vials for Aerosol – Switzerland SmPC. 
11. Grassi C, et al. Clinical Evaluation of systemic acetylcysteine by different routes of 
administration. Curr Ther Res 1973;15:165-179. 
12. Henneghien C, et al. Study of the N-acetylcysteine (NAC) by oral or intravenous 
administration in chronic bronchitis. Curr Ther Res 1983;34:750-756. 
13. Porsio A, et al. Sull’impiego dell’acetilcisteina per via endovenosa: esperienze cliniche di 
tollerabilità e di attività. Clin Terap 1970; 55:123-132. 
14. Balestra L, et al. L’acetilcisteina per via venosa in rianimazione. Min Anest 1971; 37:394-
398.  
15. Gunella G, et al. Effetti dell’acetilcisteina per via endovenosa, associata ad altre terapie, in 
broncopneumopatici cronici portatori di insufficienza ventilatoria globale o parziale. Min 
Pneum 1973; 12:142-149.  
16. Domenichini E, et al. Effetto mucolitico e terapeutico dell’acetilcisteina per via endovenosa. 
Min Anest 1973; 39:7-12.  
17. Gambini A, et al. Valutazione biochimica ed elettrocardiografica dell’acetilcisteina per via 
endovenosa. Clin Terap 1971; 57:357-369. 
18. Ambroxol Vials for Aerosol – Chinese SmPC.  
19. Locatelli C, et al.  N-acetilcisteina in tossicologia clinica. Terapia protratta nelle 
intossicazionii da Amanita phalloides e da idrocarburi clorurati.  Atti II FIMUPS, 1995. 
20. Keays r, et al. Intravenous acetylcysteine in paracetamol induced fulminant hepatic failure: 
a prospective controlled trial. BMJ 1991;303:1026-9.  
21. Dmitrienko, A., Kordzakhia, G., Brechenmacher, T. (2016). Mixture-based gatekeeping 
procedures for multiplicity problems with multiple sequences of hypotheses. Journal of 
Biopharmaceutical Statistics. 26, 758-780. 
22. Dmitrienko, A., Pulkstenis, E. (2017). Clinical Trial Optimization Using R. Chapman & 
Hall/CRC Biostatistics Series, 4-28. 
23. Rothmann, M.D., Wiens, B.L., Chan, I.S.F. (2012). Design and Analysis of Non-Inferiority 
Trials. Chapman & Hall/CRC Biostatistics Series, 350-351. 
24. Wobbrock, J.O., Findlater L., Gergle D., Higgins J.J. (2011). The Aligned Rank Transform 
for Nonparametric Factorial Analyses Using Only ANOVA Procedures. Proceedings of the 


 
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ACM Conference on Human Factors in Computing Systems (CHI '11). Vancouver, British 
Columbia (May 7-12, 2011). New York: ACM Press, pp. 143-146. 
29. 
ANNEX 
Annex 1: Diagnostic criteria for the underlying respiratory disease at baseline 
30. 
APPENDICES 
Appendix 1: Trial Flow Chart  
Appendix 2: SmPC of NAC 
Appendix 3: PI of ambroxol hydrochloride 
Appendix 4: Investigator Signature Page 


 
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Annex 1 
 
Diagnostic criteria for the underlying respiratory disease at baseline 
Disease 
 
Main Diagnostic criteria 
International/national 
reference  
Acute Bronchitis 
Cough (clear, yellowish, purulent) malaise, 
difficult breathing, and wheezing. The 
symptoms may have been preceded by upper 
respiratory infection symptoms of runny nose, 
sore throat, fever, and malaise 
ERS guidelines 
Chronic 
Bronchitis/Emphysema 
and Acute 
exacerbations 
breathing difficulty, cough, mucus (sputum) 
production and wheezing 
GOLD 2018  
Mucoviscidosis  
progressive decline of lung function with 
episodes of acute worsening of respiratory 
symptoms such as cough, increased sputum 
production, shortness of breath, chest pain  
ECFS guidelines  
Bronchiectasis  
Cough, tenacious sputum, one or more 
exacerbations/year, radiographical presence of 
bronchial wall thickening and airway dilatation 
on chest computed tomographic (CT) scans. 
British Thoracic 
2019/Chinese Expert 
Consensus  
 
 
References 
 Acute Bronchitis  https://www.sciencedirect.com/science/article/pii/S1198743X1461404X 
 
 Chronic Bronchitis/Emphysema and Acute exacerbations https://goldcopd.org/wp-
content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov WMS.pdf 
 
 Mucoviscidosis https://www.cysticfibrosisjournal.com/article/S1569-1993(18)30029-
8/fulltext 
 
 Bronchiectasis 
a) https://www.brit-thoracic.org.uk/document-library/clinical-information/bronchiectasis/bts-
guideline-for-bronchiectasis-in-adults/ 
 
b) Xiao BQ, He QY, Gao ZC, et al. Expert consensus on diagnosis and treatment of adult 
bronchiectasis [article in Chinese]. Zhonghua Jie He He Hu Xi Za Zhi 2012;35:485–492. 
 
 


 
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Appendix 1 
Trial Flow Chart 
 
ACTIVITIES 
(See sections 9 & 10 
for details) 
Visit 1 
Screening 
Visit 2 
Randomisa
tion 
 
Visit 3
 
 
 
Visit 4 
End of 
treatment 
(EoT) 
 
Follow-
up 
phone 
call or 
Visit
 
Unscheduled 
deterioration 
visit 
Premature 
discontinuatio
n visit) 
 
Within 7 days 
of Visit 2 
Day 1 
 
Day 2 
Day 3 
Day 4 
Day 5 & 6
Day 7 
2 weeks
± 3 days 
after 
EoT or 
DV
 
 
 
Informed consent
X
Verification of 
eligibility for 
randomization
X 
X 
 
 
 
 
 
 
 
 
Medical 
history/demography
X 
 
 
 
 
 
 
 
 
 
Pregnancy test
X
X
x
X
Vital signs
X
X
X
X
x
X
Physical 
examination
X 
X 
 
X 
 
 
X 
 
x 
X 
Previous/concomita
nt medications
X 
X 
 
X 
 
 
X 
X 
 
X 
12-lead ECG
X
X
x
X
Blood sample for 
haematology and 
clinical chemistry
X 
 
 
 
 
 
X 
 
 
X 
Assessment of 
expectoration 
difficulty, sputum 
viscosity, sputum 
color and cough by 
means of the 4-point 
ordinal scales 
provided
 
x 
 
x 
 
 
x 
 
 
X 
X 
24-h sputum 
collection (to be 
collected and 
measured the 
following day)
 
X 
 
X 
 
 
X 
 
 
X 
IMP dispensation 
 
X 
X 
X 
X 
X 
X 
 
 
 
Accountability of 
IMP 
 
X 
X 
X 
X 
X 
X 
 
X 
X 
AE monitoring
X 
X 
 
X 
 
 
X 
X 
x 
X 


 
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Appendix 2 
Summary of Product Characteristics – N-Acetyl cysteine (NAC) 
Switzerland 
 
 
 


 
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Appendix 3 
Package Insert – Ambroxol hydrochloride  
China 
 
[Drug Name] 
Generic name: Ambroxal Hydrochloride Injection 
English name: Ambroxal Hydrochloride Injection 
Trade name: Mucosolvan 
[Composition] 
Ambroxol hydrochloride (also known as bromocyclohexylaminealcohol hydrochloride)  
Excipients: Citric acid monohydrate, sodium hydrogen phosphate dihydrate, sodium chloride, water 
for injection, nitrogen. 
[Description] 
Colorless clear liquid. 
[Indication] 
1. Indicated for expectorant therapy in the following patients with acute and chronic respiratory 
diseases accompanied by abnormal sputum secretion and poor expectoration, such as acute 
exacerbation of chronic bronchitis, asthmatic bronchitis, bronchiectasis, bronchial asthma and 
pneumonia.  
2. Prophylactic treatment of postoperative pulmonary complications. 
3. Treatment of infant respiratory distress syndrome (IRDS) in premature infants and newborns. 
[Dosage and Administration] 
Adults and children above the age of 12 years: 2-3 times a day, 15 mg each time, slow intravenous 
injection; the dose can be increased to 30 mg each time for severe cases. 
Children aged 6-12 years: 2-3 times a day, 15 mg each time. 
Children aged 2-6 years: 3 times a day, 7.5 mg each time. 
Children below the age of 2 years:  2 times a day, 7.5 mg each time. 
All for slow intravenous injection. 
Or add the drug to glucose injection (or normal saline) for intravenous drip. 
Treatment of infant respiratory distress syndrome (IRDS): The total daily dose is calculated based 
on the infant’s weight, 30 mg/kg, divided into 4 injections per day. An infusomat should be used for 
administration, and the duration of intravenous injection should be at least 5 minutes. 
[Dosage Form] 
Injection 


 
Final Version 2.0 – 19 December 2018 
Page 63 of 65 
[Adverse Reactions] 
The product is well tolerated, and mild upper gastrointestinal adverse reactions have been 
occasionally reported, mainly including stomach burning, indigestion and occasional nausea and 
vomiting, occurring mostly after parenteral administration. Allergic reactions are rare, mainly 
including rash. Few cases have reported severe acute allergic reactions, but the correlation with 
ambroxol hydrochloride is not yet known, and such patients are often allergic to other substances. 
[Contraindication] 
Those who are known to be allergic to ambroxol hydrochloride or other ingredients shall not use the 
product. 
[Precautions] 
1. Pregnant and breastfeeding women should use the product with caution.  
2. It is prohibited to mix the product with other solutions having a pH greater than 6.3, as the increase 
in pH will lead to free base precipitation of ambroxol. 
[Ingredient] 
Ambroxol hydrochloride 
[Use in Pregnant and Breastfeeding Women] 
Pre-clinical trials and a great deal of clinical experience in women after pregnancy for 28 weeks 
have shown that the product has no adverse effect on pregnancy. However, during pregnancy, 
especially in the first three months of pregnancy, the drug should be used with caution. The drug 
may enter breast milk, but is supposed to have no effect on infants at the therapeutic dose. 
[Pediatric 
Use] 
Keep observing during medication.  
[Geriatric Use] 
The safety and efficacy of medication in the elderly and young patients have been assessed, and the 
results have shown no difference.  
[Drug Interactions] 
Co-administration of the product and antibiotics (amoxicillin, cefuroxime, erythromycin, 
doxycycline) may increase the concentration of antibiotics in the lung tissue. There has been no 
report on relevant clinical adverse reactions when the product is used in combination with other 
drugs. 
[Pharmacological Action] 
The product is a mucolytic agent, which can increase respiratory mucosal serous gland secretion, 
and reduce mucus gland secretion, thereby reducing the viscosity of sputum; it can also promote the 


 
Final Version 2.0 – 19 December 2018 
Page 64 of 65 
secretion of pulmonary surfactants, and increase bronchial cilia movement, so that sputum can easily 
be coughed up. 
[Manufacturer] 
Boehringer Ingelheim Shanghai Pharmaceutical Co., Ltd. 
 
 
 
 
 
 
 
 
 
 
 



SAP_001.pdf: 
• Protocol number: Z7244L01
• Document title: A Phase III, multi-centre, randomized, rater- and patient blind, 
placebo- and active-controlled, parallel group clinical trial to compare the safety and 
efficacy of 1-week treatment with intravenous N-acetylcysteine (NAC) 600 mg twice 
daily (active test treatment), ambroxol hydrochloride 30 mg twice daily (active 
control treatment) and placebo as expectorant therapies in adult Chinese Patients with 
respiratory tract diseases and abnormal mucus secretions
• NCT number: NCT03843541
• Version number: 2.0
• Date of the document: 14 Apr 2021 


Zambon S.p.A. 
Z7244L01 
Statistical Analysis Plan 
TP-GDO-WW-016-06 
CONFIDENTIAL 
Project Document Version No. V2.0 
Effective Date:  28 Jun 17 
Project Document Effective Date: Date of last signature 
Related to:  
 
Page 1 of 45 
 PAREXEL International  
Zambon S.p.A. 
Z7244L01 
A PHASE III, MULTI-CENTRE, RANDOMIZED, RATER- AND PATIENT-BLIND, 
PLACEBO- AND ACTIVE-CONTROLLED, PARALLEL GROUP CLINICAL TRIAL 
TO COMPARE THE EFFICACY AND SAFETY OF 1-WEEK TREATMENT WITH 
INTRAVENOUS N-ACETYLCYSTEINE (NAC) 600 MG TWICE DAILY (ACTIVE 
TEST TREATMENT), AMBROXOL HYDROCHLORIDE 30 MG TWICE DAILY 
(ACTIVE CONTROL TREATMENT) AND PLACEBO AS EXPECTORANT 
THERAPIES IN ADULT CHINESE PATIENTS WITHRESPIRATORY TRACT 
DISEASES AND ABNORMAL MUCUS SECRETIONS 
Statistical Analysis Plan 
PAREXEL Project Number: 
CCI
CCI








Zambon S.p.A. 
Z7244L01 
Statistical Analysis Plan 
TP-GDO-WW-016-06 
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Project Document Version No. V2.0 
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Project Document Effective Date: Date of last signature 
Related to:  
 
Page 5 of 45 
V2.0 
April 13 2021 
 
Adjusted “change from baseline to 1-week treatment” to “change from baseline to day 
7” for viscosity score, expectoration difficulty score sputum color score, cough severity 
score and sputum volume  
Modified the partial date conventions for prior and concomitant medication. 
Added summaries of Covid-19 to disposition, protocol deviations and adverse events 
sections.  
Added definition and explanation of minor protocol deviations for morning dose 
between 9am and 11am, and efficacy assessments occurring within 2 hours after 
morning dose of study medication.  
Added summary of major protocol deviations leading to exclusion from the Per-
Protocol Population. 
Defined prior prohibited medications and prohibited concomitant medications.  
As sputum volume is a continuous measure, added new variable (sputum volume in 
quartiles) for the stratified Mann-Whitney U tests.  
Adjusted the replicate number of bootstraps from 5000 to 1000. 
Adjusted the code of two-way nonparametric ANOVA procedure in 4.14.3. 
Adjusted the code of EM algorithm in 4.14.4. 
Specified that assessments for the premature discontinuation visit are to be included for 
data imputation. 
 
Clarified that missing baseline data will not be imputed. 
Clarified that the the decision to proceed or not proceed to the second gate for the non-
inferiority comparison (for both the mITT and PP Population) only depends on the 
superiority results for the mITT Population). 
Explained the process for reporting Suspected, Unexpected Serious Adverse Reactions 
(SUSARs). 
Added description of the baseline definition to allow efficacy assessments after and 
within 2h of first IMP to be used. 
To further specify the number of multiple imputation of EM to 0 in SAS code as EM 
algorithms does not involve multiple imputation. 
Clarified that fiberoptic bronchoscopies are collected as concomitant procedures, 
regardless of relationship to AEs and SAEs. 
CCI
PPD
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Page 6 of 45 
TABLE OF CONTENTS 
1
INTRODUCTION ....................................................................................................... 9
2
STUDY OBJECTIVES ............................................................................................... 9
2.1 Primary objective .................................................................................................. 9
2.2 Secondary objectives ............................................................................................ 9
2.2.1 Efficacy objectives ...................................................................................... 9
2.2.2 Safety objectives ....................................................................................... 10
3
INVESTIGATIONAL PLAN ................................................................................... 10
3.1 Overall Study Design and Plan ........................................................................... 10
3.2 Efficacy and Safety Variables ............................................................................ 11
3.2.1 Efficacy Variables ..................................................................................... 11
3.2.2 Safety Variables ........................................................................................ 11
4
STATISTICAL METHODS ..................................................................................... 12
4.1 Data Quality Assurance ...................................................................................... 12
4.2 General Presentation Considerations .................................................................. 12
4.3 Study Subjects .................................................................................................... 13
4.3.1 Disposition of Subjects ............................................................................. 13
4.3.2 Protocol Deviations ................................................................................... 14
4.4 Analysis Populations .......................................................................................... 14
4.4.1 Enrolled Population .................................................................................. 14
4.4.2 Intention-To-Treat (ITT) Population ........................................................ 14
4.4.3 Modified Intention-To-Treat (mITT) Population ..................................... 15
4.4.4 Safety Population ...................................................................................... 15
4.4.5 Per-protocol Population ............................................................................ 15
4.5 Demographic and Other Baseline Characteristics .............................................. 15
4.6 Medical and Surgical History ............................................................................. 16
4.7 Prior and Concomitant Medication ..................................................................... 16
4.8 Concomitant Procedures ..................................................................................... 17
4.9 Efficacy Evaluation ............................................................................................ 17
4.9.1 Analysis and Data Conventions ................................................................ 18
4.9.1.1 Multi-center Studies .................................................................... 18
4.9.1.2 Adjustments for Covariates ......................................................... 18
4.9.1.3 Handling of Dropouts or Missing Data ....................................... 18
4.9.1.4 Multiple Comparisons/Multiplicity ............................................. 19
4.9.1.5 Interim Analyses .......................................................................... 20
4.9.1.6 Examination of Subgroups .......................................................... 20
4.9.2 Primary Efficacy Analysis ........................................................................ 20
4.9.3 Secondary Efficacy Analysis .................................................................... 21
4.9.4 Multi-center Analysis................................................................................ 22
4.10
Safety Evaluation ...................................................................................... 23
4.10.1
Extent of Exposure ............................................................................ 23
4.10.2
Adverse Events ................................................................................. 24
4.10.3
Deaths and Serious Adverse Events ................................................. 25
4.10.4
Laboratory Evaluations ..................................................................... 26
4.10.5
Vital Signs and Physical Examination .............................................. 27
CCI


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Page 7 of 45 
4.10.6
12-Lead Electrocardiogram .............................................................. 28
4.10.7
Suspected Unexpected Serious Adverse Reactions .......................... 29
4.11
Determination of Sample Size .................................................................. 29
4.12
Changes to protocol-defined analyses ...................................................... 30
4.13
Reference .................................................................................................. 30
4.14
Appendix ................................................................................................... 32
4.14.1
Hochberg procedure .......................................................................... 32
4.14.2
Bootstrap Sampling Algorithm ......................................................... 32
4.14.3
Two-way nonparametric ANOVA procedure ................................... 33
4.14.4
EM Algorithm ................................................................................... 34
4.14.5
The Stratified Wilcoxon-Mann-Whitney Test Statistic .................... 35
4.14.6
The Modified Wilcoxon-Mann-Whitney Test Statistic .................... 36
4.14.7
Partial Date Conventions .................................................................. 41
4.14.7.1Algorithm for Prior/Concomitant Medications ........................... 41
4.14.7.2Algorithm for Adverse Events (include TEAE and pre-treatment 
AE) 44
CCI


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Page 8 of 45 
LIST OF ABBREVIATIONS 
AE
Adverse Event
ALP
Alkaline phosphatase
ALT 
Alanine aminotransferase
AST
Aspartate aminotransferase
ATC 
Anatomical Therapeutic Chemical
BUN
Blood Urea Nitrogen
CTR 
Clinical Trial Report
ECG 
Electrocardiogram
eCRF
Electronic Case Report Form
EM 
Expectation-Maximization 
GT
gamma glutamyl transferase
GSH 
Glutathione
HOCl
Hypochorous acid
ICF 
Informed Consent Form
IMP
Investigational Medicinal Product
ITT 
Intention-to-treat
Kg 
Kilograms
LOCF 
Last Observation Carried Forward 
MC 
Monte Carlo 
MedDRA 
Medical Dictionary for Regulatory Activities
mg
Milligram
mITT
Modified Intention to Treat
ml
Milliliter
MVTF
Missing Value Treatment Failure
NAC
N-acetylcysteine
PD
Protocol Deviation
PP
Per-Protocol Population 
PT 
Preferred Term 
SAE
Serious Adverse Event
SAP
Statistical Analysis Plan
SD
Standard Deviation
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
SOC 
System Organ Class
TEAE 
Treatment Emergent Adverse Event
TESAE
Treatment Emergent Serious Adverse Event
WHO-DD 
World Health Organization-Drug Dictionary 
WOCF
Worst Observation Carried Forward 
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Page 9 of 45 
1
INTRODUCTION 
The study is intended to provide pivotal evidence of efficacy and safety for registration in 
China of slow intravenous infusion of N-acetylcysteine (NAC) in adult hospitalised 
patients with respiratory tract diseases and abnormal mucus secretions.  The study is 
designed in rater and patient-blind fashion because of the distinguishable appearance and 
sulfuric smell of NAC.   
This document presents the statistical analysis plan (SAP) for the study: A phase III, multi-
centre, randomized, rater- and patient-blind, placebo- and active-controlled, parallel group 
clinical trial to compare the efficacy and safety of 1-week treatment of intravenous N-
acetylcysteine (NAC) 600 mg twice daily (active test treatment), ambroxol hydrochloride 
30 mg twice daily (active control treatment) and placebo as expectorant therapies in adult 
Chinese patients with respiratory tract diseases and abnormal mucus secretions. This SAP 
contains definitions of analysis populations, derived variables, and statistical analysis 
methods for the analysis of efficacy and safety parameters. 
This SAP is based upon the following study documents: 
Study Protocol, Version 2.0 (Dec 19, 2018) 
Electronic Case Report Form (eCRF), Version 4.0 (May 19, 2020) 
Protocol Deviation Specification, Version 8.0 (Jan 15, 2021) 
All report outputs will be produced using SAS® version 9.4 in a secure and validated 
environment.  All report outputs will be provided to the Sponsor in a single Microsoft Word 
document.   
2
STUDY OBJECTIVES 
2.1
Primary objective 
Demonstrate that slow (at least 5 minutes) intravenous infusion of NAC 600 mg twice daily 
is superior to placebo in change from baseline to the end of 1-week treatment of sputum 
viscosity score or expectoration difficulty score in adult Chinese hospitalized patients with 
respiratory tract diseases and abnormal mucus secretions 
2.2
Secondary objectives 
2.2.1
Efficacy objectives 
Demonstrate in the same patient population that: 
slow (at least 5 minutes) intravenous infusion of NAC 600 mg twice daily is 
superior to placebo in change from baseline to day 3 and end of 1-week treatment 
of other indicators of mucolytic activity (individual sputum viscosity and 
expectoration difficulty scores, cough score, mucous color score and mucous 
volume); 
CCI


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Page 10 of 45 
slow (at least 5 minutes) intravenous infusion of NAC 600 mg twice daily is non-
inferior to slow intravenous infusion of ambroxol hydrochloride 30 mg twice daily 
in change from baseline to the end of 1-week treatment of sputum viscosity score 
or expectoration difficulty score; 
slow (at least 5 minutes) intravenous infusion of ambroxol hydrochloride 30 mg 
twice daily is superior to placebo in change from baseline to day 3 and to the end 
of 1-week treatment of sputum viscosity score or expectoration difficulty score and 
of other indicators of mucolytic activity: individual sputum viscosity and 
expectoration difficulty scores, cough score, mucous color score and mucous 
volume. 
2.2.2
Safety objectives 
Confirm that 1-week treatment with iv NAC 600 mg twice daily is safe and well 
tolerated. 
3
INVESTIGATIONAL PLAN 
3.1
Overall Study Design and Plan 
This is a phase 3, multicenter, randomized, rater- and patient-blind, placebo- and active-
controlled, 3-arm parallel group clinical trial. 
The trial will be conducted in approximately 25 sites in China, and a total of 333 patients 
with respiratory tract diseases and abnormal mucus secretions will be enrolled. 
The study will consist of a total of 4 core hospital visits (screening, baseline, treatment day 
3, treatment day 7) and of one follow-up phone call (or follow-up hospital visit, at the 
patient’s convenience ) 2 weeks after discontinuation of treatment; if the patient is still 
hospitalized or if more convenient for the patient, the follow-up phone call can be replaced 
by a follow-up hospital visit. 
At screening visit (Visit 1), patients will be asked to provide Informed Consent prior to any 
trial related procedure and will be checked against inclusion and exclusion criteria. Their 
medical history will be recorded. Furthermore, patients will undergo a 12-lead 
electrocardiogram (ECG) and laboratory assessments. Results must be available before 
Visit 2. 
At randomization visit (Visit 2), to occur within 7 days after Visit 1, female patients will 
undergo a pregnancy test; all patients will be checked again against the full set of inclusion 
and exclusion criteria and eligible subjects will be randomized with a 1:1:1 ratio to receive 
NAC or ambroxol hydrochloride or placebo. 
Procedures performed at each core hospital visit will include documentation of 
concomitant medications and treatment emergent adverse events (TEAEs), 24-hour sputum 
collection and assessment on a 4-point ordinal scale of expectoration difficulty, sputum 
viscosity, sputum color and cough. 
In case a patient experiences a deterioration of expectoration capacity and related 
symptoms, and/or of an underlying condition, he/she should contact a study investigator 
immediately and undergo an unscheduled deterioration visit. If the patient and/or the 
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Page 11 of 45 
investigator believe that it is in the patient’s best interest to receive a rescue mucolytic, the 
patient will be discontinued from the study and rescue mucolytic will be administered, with 
any additional treatment the investigator deems appropriate. 
3.2
Efficacy and Safety Variables 
3.2.1
Efficacy Variables 
Sputum viscosity, expectoration difficulty, sputum color and cough are assessed 
by means of ordinal categorical 4-point scales with 0 = best and 3= worst.  
For each patient the assessment is to be carried out by the blinded rater on treatment 
days 1, 3 and 7 in the morning before 9 am before administration of study drug. Should 
a patient discontinue prematurely from the trial (including discharge from the hospital 
before day 7) an assessment should be conducted on the day of discharge whenever 
possible. 
Scoring criteria are as follows: 
0 
1 
2 
3 
Sputum 
viscosity 
Liquid 
(normal 
viscosity)
Fluid  
(mildly 
increased 
viscosity) 
Viscous  
(moderately 
increased 
viscosity) 
Sticky 
(severely 
increased 
viscosity)
Expectoration 
difficulty 
No 
difficulty 
Mild 
difficulty 
Moderate 
difficulty 
Marked 
difficulty 
Sputum  
Color 
Mostly 
white 
Mostly pale 
yellow 
Mostly 
dark yellow 
Very 
dark 
yellow 
/green 
Cough 
No 
cough 
Sporadic 
and mild 
cough 
Moderate 
cough 
Severe 
Cough 
Sputum volume  
At Randomization Visit (Visit 2), Visit 3 and Visit 4 the patients will be given a 
graduated container and instructed to use it to collect all sputum generated in the 
following 24 hours (i.e. same time of the following day). The day the container will be 
collected, and the 24-hour sputum volume measured in mL/24h. 
3.2.2
Safety Variables 
Adverse events assessed for severity and seriousness. 
12-lead electrocardiogram 
Laboratory measurements including hematology, liver enzymes, serum creatinine. 
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Page 12 of 45 
Vital signs 
4
STATISTICAL METHODS 
4.1
Data Quality Assurance 
All tables, figures and data listings to be included in the report will be independently 
checked for consistency, integrity and in accordance with standard PAREXEL procedures. 
4.2
General Presentation Considerations 
Continuous data will be summarized in terms of the mean, standard deviation (SD), 
median, minimum, maximum and number of observations, unless otherwise stated.  The 
minimum and maximum will be reported to the same number of decimal places as the raw 
data recorded in the database.  The mean, median, lower quartile and upper quartile will be 
reported to one more decimal place than the raw data recorded in the database.  The SD 
will be reported to two more decimal places than the raw data recorded in the database.  In 
general, the maximum number of decimal places reported shall be four for any summary 
statistic. 
Categorical data will be summarized in terms of the number of subjects providing data at 
the relevant time point (n), frequency counts and percentages.  Any planned collapsing of 
categories will be detailed in the SAP text and the data displays.   
Percentages will be presented to one decimal place. Percentages will not be presented for 
zero counts.  Percentages will be calculated using n as the denominator.  If sample sizes 
are small, the data displays will show the percentages, but any textual report will describe 
frequencies only.   
Changes from baseline in categorical data will be summarized using shift tables where 
appropriate. 
P-values greater than or equal to 0.001, in general, will be presented to three decimal 
places.  p-values less than 0.001 will be presented as “<0.001”. 
Confidence intervals will be presented to one more decimal place than the raw data. 
The data from all sites will be pooled. Unless stated otherwise, all available data from 
withdrawn subjects will be included in the analysis up to the time of withdrawal. 
Baseline for Efficacy and safety 
Generally, baseline measurements are the last available data obtained prior to the first 
administration of investigational medicinal product (IMP) at Visit 2.  
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Page 13 of 45 
For sputum viscosity, expectoration difficulty, sputum color and cough, the last available 
data at Visit 2 (Day 1) within 2 hours after the first dose of IMP can be used for baseline if 
no data was obtained prior to the first dose of IMP. 
For 24-hour sputum collection, the baseline measurement will be the last available data 
captured on Visit 2 (Day 1) or the next day (Day 2). This is because the collection of sputum 
is to begin on Day 1 and lasts for 24 hours up until the same time the next day (Day 2). 
Therefore, the baseline sputum volume measurement may be after the first dose of IMP.  
Scheduled and Unscheduled Assessments 
The by-visit tables will only include the scheduled assessments, unless specifically stated 
otherwise. If more than one value is available for a given visit, the first valid observation 
will be used in summary tables, unless specifically stated otherwise, and all observations 
will be presented in listings. 
Unscheduled assessments will be included in listings, but not in summary tables. 
Detection of Outliers 
Any outliers that are detected during the review of the data before database lock will be 
investigated. If necessary, queries will be issued to Investigators, to either correct or 
confirm the outlier. 
4.3
Study Subjects 
4.3.1
Disposition of Subjects 
A clear accounting of the disposition of all subjects who enter the study will be provided, 
from screening to study completion. 
The following summaries will be provided: 
A summary of the number and percentage of subjects who were screened, 
randomized, and subjects who are excluded prior to randomization by major reason 
and overall, using the Enrolled population (Section 4.4.1). 
A summary of the number and percentage of patients treated (with at least one dose 
or partial dose of IMP) and discontinued from treatment, and the number and 
percentage of major reason of patient discontinuation from treatment (including due 
to Covid-19) by treatment group and overall, using the Intention-To-Treat (ITT) 
population (Section 4.4.2). 
A summary of the number and percentage of patients who completed the study and 
discontinued from the study, and the number and percentage of major reasons for 
discontinuation from the study (including withdrawn due to Covid-19), by 
treatment group and overall, using the ITT population (Section 4.4.2). 
A by-subject listing of disposition data will be provided, using the Enrolled Population 
(Section 4.4.1). 
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Page 14 of 45 
4.3.2
Protocol Deviations 
Protocol Deviations (PDs) will be classified as “major” or “minor”, and any action to be 
taken regarding the exclusion of subjects or affected data from specific analyses will be 
defined in the project-specific Protocol Deviation Specification. Exclusion of subjects from 
the PP analyses will be decided jointly by the CRO and Sponsor’s Medical Monitor, 
Clinical Trial Manager and Biostatistician prior to database lock. The subjects or 
observations to be excluded, and the reasons for their exclusion will be documented and 
approved by the above-mentioned persons prior to database release. The documentation 
will be filed together with the remaining trial documentation. 
Major PDs are defined as those deviations from the protocol likely to have an impact on 
the subject’s rights, safety, well-being, and/or on the validity of the data for analysis. Major 
PDs that have impact on the efficacy assessment will lead to the exclusion of a subject from 
the PP population. PDs will be assessed prior to final database lock. 
Note that per the Protocol, morning study drug administration is meant to occur prior to 
9am. In addition, efficacy assessments are meant to occur before the morning study drug 
administration for sputum viscosity, expectoration difficulty, sputum color and cough. 
Following medical discussion, it was decided that morning study drug administration 
between 9am and 11am would be considered minor protocol deviations. In addition, 
efficacy assessments occurring within 2 hours after the morning dose of study medication 
would also be classified as minor deviations. Efficacy assessments occurring after 2 hours 
of the morning dose of study medication will be classified as a major deviation.  
The PD summaries will include: 
the number and percentage of subjects with a major PD by treatment group and 
overall, and by type of major deviation, based on the ITT population (Section 
4.4.2). 
the number and percentage of subjects with a major PD leading to exclusion from 
the Per- Protocol Population by treatment group and overall, and by type of major 
deviation leading to exclusion, based on the ITT Population (Section 4.4.2). 
A by-subject listing of PDs should be provided based on the ITT population (Section 4.4.2). 
4.4
Analysis Populations 
4.4.1
Enrolled Population 
Enrolled population is defined as all patients who provided informed consent for this study. 
4.4.2
Intention-To-Treat (ITT) Population 
The Intention-To-Treat Population will include all subjects who provided informed consent 
and received a patient number (randomization number) whether or not they receive IMP. 
Following the ITT principle, subjects will be analyzed according to the treatment they have 
been assigned to at randomization. 
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Page 15 of 45 
4.4.3
Modified Intention-To-Treat (mITT) Population 
The Modified ITT (mITT) Population will comprise all subjects in the ITT population who 
received at least 1 dose or partial dose of the IMP. 
4.4.4
Safety Population 
The Safety Population will comprise all subjects who provide Informed Consent and 
received at least 1 dose or partial dose of IMP. Subjects will be analyzed according to the 
treatment they actually received. 
4.4.5
Per-protocol Population 
The Per-protocol (PP) Population will include all mITT subjects who were compliant with 
study drug administration (i.e. had a compliance of at least 80%) and who had no major 
protocol deviations that were considered as potentially impacting the efficacy results. 
Major protocol deviations might include, but are not be limited to, subjects taking a not-
permitted concomitant medication, the IMP not being administered during the trial as 
defined in the protocol, subjects receiving a treatment different than the one assigned by 
randomization, major PDs related to Covid-19. With the exclusion of non-inferiority 
comparisons, results of the primary and secondary efficacy endpoints analyses conducted 
in the PP will be considered as supportive. 
A summary of analysis populations will be provided using the ITT population. 
A by-subject listing of analysis populations will be provided using the ITT population. 
If not otherwise stated, the mITT population will be used for the primary analyses of each 
of the efficacy endpoints whilst results from supplemental analyses using the Per Protocol 
Population will be compared to those based on the mITT population to assess the effects 
of dropouts, missing data and exclusions for major protocol violations. 
4.5
Demographic and Other Baseline Characteristics 
At Visit 1 (Screening) the subjects’ demographic data will be documented, including age, 
ethnicity, gender, height, weight as well as smoking history and alcohol use.  
The following summaries will be provided: 
A summary of the demographic data, baseline height (cm), and baseline weight (kg) 
will be provided using the mITT population (Section 4.4.3). 
A summary of the demographic data, baseline height (cm), and baseline weight (kg) 
will be provided using the PP population (Section 4.4.5). 
Age will be calculated as the number of complete years between a patient's date of birth 
and the date of informed consent. Age (in years) will be calculated as: 
(Date of informed consent – date of birth + 1)/365.25 
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If date of birth is a partial date missing month only, month will be assumed to be June. If 
date of birth is a partial date missing day only, day will be assumed to be 15th of the month. 
If date of birth is a partial date missing both month and day, it will be assumed to be Jun 
30 of the year. 
A by-subject listing of the demographic data and the baseline characteristics will be 
provided using the ITT population (Section 4.4.2). 
4.6
Medical and Surgical History 
Medical and surgical history will be summarized separately using the ITT population 
(Section 4.4.2). Frequency table will be provided by treatment group and total group, 
system organ class (SOC) and preferred term (PT), where SOC and PT are coded by 
Medical Dictionary for Regulatory Activities (MedDRA) Version 23.1. 
The following listings will be provided using the ITT population (Section 4.4.2): 
A by-subject listing of medical history, including the reported term, the coded term, 
the start date, and the end date. 
A by-subject listing of surgical history, including the reported term, the coded term, 
the start date, and the end date. 
4.7
Prior and Concomitant Medication 
Medication start and stop dates will be compared to the date of first dose of study 
medication to allow medications to be classified as either Prior, or Concomitant.  
Medications that start and stop prior to the date of first dose of study medication will be 
classified as Prior medication. If a medication stops on or after the date of first dose of 
study medication up to the last dose of study medication, then the medication will be 
classified as a Concomitant medication. 
If medication start and/or stop dates are missing or partial, the dates will be compared as 
far as possible with the date of first dose of study medication. Medications will be assumed 
to be Concomitant, unless there is clear evidence (through comparison of partial dates) to 
suggest that the medication stopped prior to the first dose of study medication. If there is 
clear evidence to suggest that the medication stopped prior to the first dose of study 
medication, the medication will be assumed to be Prior. 
Imputation of partial dates of prior and concomitant medications is described in Appendix 
4.14 (section 4.14.7). 
Prior and concomitant medication will be summarized using the ITT population (Section 
4.4.2) separately. Frequency table will be provided by treatment group, anatomical 
therapeutic chemical (ATC) drug class and preferred term (PT), where ATC and PT will 
be coded using the World Health Organization-Drug Dictionary Enhanced (WHO-DDE) 
September 2020 B3.  
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Zambon S.p.A. 
Z7244L01 
Statistical Analysis Plan 
TP-GDO-WW-016-06 
CONFIDENTIAL 
Project Document Version No. V2.0 
Effective Date:  28 Jun 17 
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A by-subject listing of prior and concomitant medications will be provided using the ITT 
population. 
In addition, the following treatments are not permitted from Visit 1 to Visit 4 (end of IMP 
treatment) or unscheduled Deterioration Visit:  
Expectorants 
Antitussive agents  
Sedatives  
Traditional Chinese Medicine (TCM) treatments. 
Prior prohibited medications are defined as those prohibited medications with a stop date 
on or after the Visit 1 date, and prior to the first dose of study medication date. Prohibited 
concomitant medications are defined above as for concomitant medications for those 
treatments not permitted.  
Prior prohibited medications and prohibited concomitant medications will be summarized 
for the ITT population. Frequency tables will be provided following the same structure as 
for prior and concomitant medications.   
A by-subject listing of prohibited medications will be provided using the ITT population. 
4.8
Concomitant Procedures 
Concomitant procedures are defined as any procedures starting after the first dose of study 
drug up to the last dose date of study drug. 
Concomitant procedures will be collected only if they are related to AEs and SAEs, with 
the exception of fiberoptic bronchoscopies, which will be captured regardless of 
relationship to AEs and SAEs. Concomitant procedures will be summarized using the 
Safety population (Section 4.4.4). Frequency table will be provided by treatment group, 
system organ class (SOC) and preferred term (PT), where SOC and PT are coded by 
Medical Dictionary for Regulatory Activities (MedDRA) Version 23.1. 
A by-subject listing of concomitant procedures will be provided using the Safety 
population. 
4.9
Efficacy Evaluation 
The co-primary efficacy endpoints are: “the change from baseline to the 1-week treatment 
in sputum viscosity score” and “the change from baseline to the 1-week treatment in 
expectoration difficulty score” and will be analyzed using the mITT and PP populations.  
The primary study objective will be assessed by testing superiority of NAC compared to 
placebo and will be achieved if at least one of the two co-primary end-points will be found 
statistically significant.  
The key secondary objective will be assessed through the analysis of non-inferiority of 
NAC compared to ambroxol and, similarly, will be reached if at least one of the two co-
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Page 19 of 45 
(WOCF) with the worst scores recorded at baseline or post baseline (follow up) (including 
measurements from the premature discontinuation visit) imputed to missing visits. MVTF 
is the primary imputation method. The Expectation-Maximization (EM) algorithm and last 
observation carried forward (LOCF) will be used as sensitivity analyses.  
Data missing at baseline will not be imputed.  
4.9.1.4
Multiple Comparisons/Multiplicity 
The overall type I family-wise error rate will be preserved at the one-tailed 0.025 nominal 
over the two study targets (superiority and non-inferiority) using a multiple-sequence 
gatekeeping procedure (Keays et al., 1991). To achieve this, the analyses on primary 
endpoints will be grouped into two family of comparisons (gatekeepers) and processed as 
follows: 
1. The first gatekeeper includes the superiority contrasts “NAC vs placebo” with the 
adjustment for multiple comparisons across the two co-primary endpoints performed 
according to Bonferroni. This implies that a difference will be considered statistically 
significant for a one-tailed p-value  0.0125 (i.e. /2 = 0.0125).  
The transition to the second gatekeeper requires that at least one of the two co-primary 
endpoints is statistically significant in the mITT population. 
2. The second gatekeeper includes the family of non-inferiority contrasts “NAC vs 
ambroxol” conducted for both the mITT population and PP population.  
The analyses in the second gatekeeper will be performed depending upon the results 
obtained in the first gatekeeper as shown below: 
a.
If both superiority contrasts are found statistically significant in the mITT 
population, non-inferiority will be tested on both co-primary endpoints for both the 
with the adjustment for multiple comparisons across the two co-primary endpoints 
performed according to Hochberg. Details of the Hochberg procedure can be found 
in Appendix (Section 4.14.1). 
b. If only one of the two superiority contrasts are found statistically significant in the 
mITT population, non-inferiority will be tested for that co-primary endpoint only 
for both the mITT and PP populations and will be considered achieved if the 
associated one-tailed p-values are  0.0125. 
Statistically significant results will be needed in both the mITT and PP populations to 
accept the hypothesis of non-inferiority of NAC versus ambroxol. 
Consistent with the hypothesis testing process performed on the co-primary endpoints, the 
strategy described above will also be applied to control the coverage of confidence intervals 
The analyses on secondary efficacy endpoints (not key) will be performed only to support 
primary endpoints findings and/or for explorative reasons, therefore no adjustment of 
significance level will be made to account for multiple comparisons. 
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4.9.1.5
Interim Analyses 
No interim analysis will be performed. 
4.9.1.6
Examination of Subgroups 
Upon completion of the study, the study statistician in consultation with Zambon’s Clinical 
Team will determine the proportion of concomitant medications between the treatment 
groups and will decide whether to perform subgroup efficacy analyses if deemed 
appropriate. The analyses described for the primary and secondary efficacy endpoints will 
be performed separately for each of the identified stratums. 
4.9.2
Primary Efficacy Analysis 
The co-primary efficacy endpoints are: “the change from baseline to day 7 in sputum 
viscosity score” and “the change from baseline to day 7 in expectoration difficulty score” 
and they will be analyzed on the mITT and PP populations by means of stratified Mann-
Whitney U Statistics for testing the hypotheses of superiority of NAC versus placebo 
(primary objective) and by means of a modified Mann-Whitney U Statistics (Rothmann, et 
al., 2012) for testing the hypotheses of non-inferiority of NAC versus ambroxol (key 
secondary objective) assuming a margin (i.e. 
) of non-inferiority equal to 0.30. 
Statistically significant results will be needed on both mITT and PP populations to accept 
the hypothesis of non-inferiority of NAC versus ambroxol. Non-inferiority will be declared 
if the one-sided confidence interval will be within the interval [1/2-
, 1) so, equivalently, 
the lower limit of the confidence interval will be greater than 1/2-
, where 
 is the non-
inferiority margin converted on a probability scale from a point scale
. Details of the 
converting margin can be found in Appendix 4.14.6. Note that the one-sided confidence 
interval will be conducted depending on the outcome of the first gatekeeper procedure for 
the superiority contrasts.  
In addition, for all superiority test in efficacy analysis, Hodges Lehmann point estimate of 
the median treatment differences together with associated two-sided 95% confidence 
intervals will be computed using nonparametric bootstrap; For all non-inferiority tests in 
the efficacy analysis, point estimates of treatment differences in probability scale together 
with associated one-side confidence interval will be provided. Nonparametric bootstrap
point estimates of treatment differences in probability scale together with two-sided 95% 
confidence intervals will also be computed. Details of bootstrap can be found in Appendix 
(Section 4.14.2). 
The following summaries of testing the hypotheses of superiority of NAC versus placebo 
and non-inferiority of NAC versus ambroxol will be provided: 
A summary of the change from baseline to day 7 in sputum viscosity score using 
the mITT population, in which the missing data will be handled using the MVTF 
A summary of the change from baseline to day 7 in expectoration difficulty score 
using the mITT population, in which the missing data will be handled using the 
MVTF 
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Page 21 of 45 
A summary of the change from baseline to day 7 in sputum viscosity score using 
the PP population, in which the missing data will be handled using the MVTF 
A summary of the change from baseline to day 7 in expectoration difficulty score 
using the PP population, in which the missing data will be handled using the MVTF 
The following sensitivity analyses will be provided: 
A summary of p-value of the superiority and non-inferiority tests for the change 
from baseline to day 7 in sputum viscosity score using the mITT population and PP 
population, in which the missing data will be handled using the EM algorithm 
A summary of p-value of the superiority and non-inferiority tests for the change 
from baseline to day 7 in expectoration difficulty score using the mITT population 
and PP population, in which the missing data will be handled using the EM 
algorithm 
A summary of p-value of the superiority and non-inferiority tests for the change 
from baseline to day 7 in sputum viscosity score using the mITT population and PP 
population, in which the missing data will be handled using the LOCF 
A summary of p-value of the superiority and non-inferiority tests for the change 
from baseline to day 7 in expectoration difficulty score using the mITT population 
and PP population, in which the missing data will be handled using the LOCF 
The test statistics for the superiority and non-inferiority tests can be found in the Appendix 
(Section 4.14.5 and 4.14.6). 
4.9.3
Secondary Efficacy Analysis 
The secondary efficacy variables will be analyzed using the mITT, and the missing data 
will be handled using the MVTF, EM and LOCF methods: 
Change from baseline to day 3 in sputum viscosity score: the hypothesis of 
superiority of NAC compared to placebo will be assessed using the same 
nonparametric test (stratified Mann-Whitney U Statistics blocking for baseline 
score), whilst Hodges Lehmann point estimate of the median treatment differences 
together with associated two-sided 95% confidence intervals will be computed 
using nonparametric bootstrap. 
Change from baseline to day 3 in expectoration difficulty score: the hypothesis of 
superiority of NAC compared to placebo will be assessed using the same 
nonparametric test (stratified Mann-Whitney U Statistics blocking the baseline 
score), whilst Hodges Lehmann point estimate of the median treatment differences 
together with associated two-sided 95% confidence intervals will be computed 
using nonparametric bootstrap. 
Change from baseline to day 3 and to day 7 period in sputum color score: the 
hypothesis of superiority of NAC compared to placebo will be assessed using the 
same nonparametric test (stratified Mann-Whitney U Statistics blocking for 
baseline score), whilst Hodges Lehmann point estimate of the median treatment 
differences together with associated two-sided 95% confidence intervals will be 
computed using nonparametric bootstrap. 
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Change from baseline to day 3 and to day 7 period in cough severity score: the 
hypothesis of superiority of NAC compared to placebo will be assessed using the 
same nonparametric test (stratified Mann-Whitney U Statistics blocking for 
baseline score), whilst Hodges Lehmann point estimates of the median treatment 
differences together with associated two-sided 95% confidence intervals will be 
computed using nonparametric bootstrap. 
Change from baseline to day 3 and to day 7 in sputum volume: the hypothesis of 
superiority of NAC compared to placebo will be assessed using the same 
nonparametric test (stratified Mann-Whitney U Statistics blocking for baseline 
score), whilst Hodges Lehmann point estimate of 
the median  treatment 
differences together with associated two-sided 95% confidence intervals will be 
computed using nonparametric bootstrap. 
The same statistical analysis (stratified Mann-Whitney U Statistics blocking for baseline 
score) will be carried out for testing superiority of ambroxol vs. placebo on the same 
efficacy endpoints. Results will be used for the purpose of verifying study’s assay 
sensitivity. 
The following summaries will be provided using the mITT population (Section 4.4.3): 
A summary of comparing ambroxol and placebo for the change from baseline to 
day 3 and to day 7 in sputum viscosity score, in which the missing data will be 
handled using the MVTF, expectation-maximization (EM) algorithm and last 
observation carried forward (LOCF) as sensitivity analyses. 
A summary of comparing ambroxol and placebo for the change from baseline to 
day 3 and to day 7 in expectoration difficulty score, in which the missing data will 
be handled using the MVTF, expectation-maximization (EM) algorithm and last 
observation carried forward (LOCF) as sensitivity analyses. 
A summary of comparing ambroxol and placebo for the change from baseline to 
day 3 and to day 7 in sputum color score, in which the missing data will be handled 
using the MVTF, expectation-maximization (EM) algorithm and last observation 
carried forward (LOCF) as sensitivity analyses. 
A summary of comparing ambroxol and placebo for the change from baseline to 
day 3 and to day 7 in cough severity score, in which the missing data will be handled 
using the MVTF, expectation-maximization (EM) algorithm and last observation 
carried forward (LOCF) as sensitivity analyses. 
A summary of comparing ambroxol and placebo for the change from baseline to 
day 3 and to day 7 in sputum volume, in which the missing data will be handled 
using the MVTF, expectation-maximization (EM) algorithm and last observation 
carried forward (LOCF) as sensitivity analyses. 
The stratified Mann-Whitney U test statistic can be seen in the Appendix (Section 4.14.5). 
4.9.4
Multi-center Analysis 
 In the first instance, since the 
aim of the analysis is to examine sites, the analysis will be performed using individual 
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sites (i.e. no pooling of sites). If the situation occurs where there are convergence issues 
or SAS errors/warnings due to some sites with small numbers of subjects, sites with 8 or 
fewer randomized subjects will be grouped for the multi-center analysis.  
The following summaries will be provided for each co-primary efficacy endpoint: 
A summary of the change from baseline to day 7 in sputum viscosity score using 
the mITT population, in which the missing data will be handled using the MVTF. 
Two-way non-parametric ANOVA will be performed by including treatment, site, 
and site-by-treatment interaction terms in the model.  
A summary of the change from baseline to day 7 in expectoration difficulty score 
using the mITT population, in which the missing data will be handled using the 
MVTF. Two-way non-parametric ANOVA will be performed by including 
treatment, site, and site-by-treatment interaction terms in the model. 
Forest plots will be generated to display the results at each center. Note that the Forest plots 
utilize a GLM fit to the ranked datasets used by the two-way non-parametric ANOVA. 
This is because it is not possible to include an interaction term (site-by-treatment) into the 
stratified Mann-Whitney U Statistic test utilized for analysis of the co-primary endpoints. 
Caution must be taken in interpreting the results of the multi-center analysis owing to 
difference in statistical methodology compared to the primary and secondary endpoints 
analysis as well as a lack of appropriate stratification for the randomization.  
4.10 Safety Evaluation 
All safety summaries and listings will be based upon the Safety Population (Section 4.4.4). 
4.10.1 Extent of Exposure  
Exposure will be summarized both in terms of the treatment duration (in days) and the total 
dose administered up to the end of the last administration of IMP, as recorded on the eCRF. 
The duration of treatment will be calculated from the first administration date to the last 
administration date at the end of the last administration of treatment arm (duration = the 
last administration date - the first administration date +1). The total dose of the treatment 
arm will be the summation of actual administration dose at every administration. 
Investigator will assess adherence with IMP dosing regimen on an ongoing basis by 
determining the amount of IMP dispensed, used (i.e. returned open ampoules/vials) and the 
amount of IMP returned (i.e. returned, unopened ampoules/vials) at Visit 2 (first dose), 
Visit 3 and Visit 4 (end of treatment) or unscheduled Deterioration Visit/premature 
discontinuation visit. 
The evaluation of compliance will be done using the following formula: 
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The compliance calculation will be based on visit basis. For example, if subject takes IMP 
only in the morning but withdraws in the afternoon without taking IMP as planned, then 
the total number of scheduled doses at this visit will count two doses in the denominator. 
A subject would be considered as compliant if % of administered drug is at least 80%. 
The following summaries will be provided: 
A summary of the duration and the actual total dose by treatment group 
A summary of number and percentage of subjects with treatment compliance by 
treatment group and visit. 
The following listings will be provided: 
A by-subject listing of administration of IMP 
A by-subject listing of treatment compliance 
4.10.2 Adverse Events 
An AE is "any untoward medical occurrence in a patient or clinical trial subject 
administered a medicinal product and which does not necessarily have a causal relationship 
with this treatment". 
Adverse events will be coded using Medical Dictionary for Regulatory Activities 
(MedDRA) Version 23.1.   
Any AE occurring onset date on or after the date of the first IMP administration, i.e. Visit 
2, until the end of the trial, i.e. follow-up phone call, will be considered as a treatment 
emergent AE (TEAE). AEs which are already present before the first IP and increase in 
severity after the first IP will be considered as TEAEs. Pre-existing AEs before the first IP 
with no increase in severity after the first IP will not be considered as TEAEs. A Pre-
treatment AE will be defined as any AE with an onset date before the date of first 
administration of IMP.
Imputation of partial dates of AE record is described in Appendix 4.14 (section 4.14.7). 
Following summaries will be provided: 
An overview of all TEAEs including any TEAEs with relationship to IMP, any 
TEAEs leading to drug withdrawn, any TEAEs leading to drug interrupted, any 
TEAEs leading to fatal, any TEAEs of Covid-19, by treatment group.   
A summary of Pre-treatment Adverse Events by SOC, PT and CTCAE Grade (Safety 
Set)
A summary of the number and percentage of subjects reporting an TEAE and the 
number of TEAEs, by treatment group, SOC, and PT 
A summary of the number and percentage of subjects reporting a TEAE with 
Incidence 
 5% of Patients by treatment group, SOC, and PT 
A summary of the number and percentage of subjects reporting Other adverse 
events with Incidence 
 5% of Patients by treatment group, SOC, and PT 
A summary of the number and percentage of subjects reporting a TEAE Related to 
IMP by treatment group, SOC, and PT 
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A summary of the number and percentage of subjects reporting an TEAE and the 
number of TEAEs, by treatment group, relationship, SOC, and PT 
A summary of the number and percentage of subjects reporting an TEAE and the 
number of TEAEs, by treatment group, severity, SOC, and PT 
A summary of the number and percentage of subjects reporting a TEAE Leading to 
Study Discontinuation by treatment group, SOC, and PT 
A summary of the number and percentage of subjects reporting a TEAE Leading to 
Drug withdrawal of IMP by treatment group, SOC, and PT 
For the summarization of number of subjects, a subject will be counted only once for each 
SOC and each PT, even if the subject reported one or more event under each subcategory; 
for the summarization of number of events, the number of TEAEs will count all TEAEs of 
each subject under each SOC and each PT.  
For each TEAE, the most extreme grade recorded in eCRF will be attributed and used in 
the by-severity summaries. If the severity is missing, it will be imputed as the most extreme 
case, i.e., Severe. If relationship to study treatment is missing, the relationship will be 
imputed as Related. 
Unless specified otherwise, the table of a summary will be ordered in terms of decreasing 
number of subjects for system organ class and then preferred term within system organ 
class in the overall group, and then alphabetically for SOC and PT within SOC if the 
frequency is tied. 
A by-subject listing of all AEs will be provided. 
4.10.3 Deaths and Serious Adverse Events 
Any SAE occurring from the day of the first IMP administration, i.e. Visit 2, until the end 
of the trial, i.e. follow-up phone call, will be considered as a treatment-emergent SAE. 
Following summaries will be provided: 
An overview of all treatment-emergent SAEs including any treatment-emergent 
SAEs with relationship to IMP, any treatment-emergent SAEs leading to drug 
withdrawn, any treatment-emergent SAEs leading to drug interrupted, any 
treatment-emergent SAEs leading to death, any treatment-emergent SAEs of 
Covid-19, by treatment arm.   
A Summary of Death
A summary of the TEAE Leading to Death by System Organ Class, Preferred Term 
A summary of the number and percentage of subjects reporting a SAE and the 
number of SAEs, by treatment group, SOC and PT 
A summary of the number and percentage of subjects reporting a treatment-
emergent SAE and the number of treatment-emergent SAEs, by treatment group, 
SOC and PT 
A summary of the number and percentage of subjects reporting a treatment-
emergent SAE Related to IMP, by treatment group, SOC, and PT 
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Zambon S.p.A. 
Z7244L01 
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A summary of the number and percentage of subjects reporting a treatment-
emergent SAE and the number of treatment-emergent SAEs, by treatment group, 
severity (mild, moderate, severe), SOC, and PT 
A summary of the number and percentage of subjects reporting a treatment-
emergent SAE and the number of treatment-emergent SAEs, by treatment group, 
relationship, SOC, and PT 
A summary of the number and percentage of subjects reporting a treatment-
emergent SAE leading to drug withdrawal, by treatment group, SOC and PT 
A summary of the number and percentage of subjects reporting a treatment-
emergent SAE leading to Study discontinuation, by treatment group, SOC and PT 
Tables should follow the similar format described for TEAEs if appropriate.
A by-subject listing of all SAEs will be provided. 
4.10.4 Laboratory Evaluations 
Laboratory evaluations will include Hematology, Clinical Chemistry (biochemistry), and 
Pregnancy test. Lab value will be converted to standard unit. 
Quantitative laboratory measurements reported as ‘< X’, i.e. below the lower limit of 
quantification (BLQ), or ‘> X’, i.e. above the upper limit of quantification (ULQ), will be 
converted to X for the purpose of quantitative summaries, but will be presented as 
recorded, i.e. as ‘< X’ or ‘> X’ in the listings. 
The evaluations of hematology and clinical chemistry (biochemistry) will be performed at 
Screening Visit (Visit 1) and Visit 4 and in case of premature discontinuation.  
A dipstick urine pregnancy test for women of childbearing potential will be performed at 
Randomization Visit (Visit 2) and at Visit 4 and/or at unscheduled deterioration 
visit/premature discontinuation visit. 
The parameters of hematology, clinical chemistry(biochemistry) and pregnancy test are 
presented in the following table. 
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systolic and diastolic blood pressure, measured after at least 5 minutes in the supine 
position (mmHg) 
respiration rate (breaths/min) 
body temperature, measured under the arm pit (°C) 
A summary of the observed values and changes from Visit 1 for each vital sign by treatment 
group and overall at each visit will be provided. Both raw values and changes from Visit 1 
will be summarized using descriptive statistics. 
A by-subject listing of vital signs will be provided. 
Physical Examination  
At Visit 1, Visit 2, Visit 3 and Visit 4, and/or at the unscheduled deterioration 
Visit/premature discontinuation, a physical examination of general body systems will be 
performed according to current medical standards and site practice. The general body 
systems include: 
Respiratory System 
Cardiovascular System 
Abdomen 
General Appearance 
Head and Neck 
Lymph Nodes 
Musculoskeletal System 
Nervous System 
Skin 
Endocrine System 
Ears, nose and throat 
Hematopoietic System 
Reproductive System 
Urinary System 
The examination is to include a chest auscultation. 
A summary of the number and percentage of subjects for each body system by category 
(normal, abnormal not clinically significant, and abnormal clinically significant), treatment 
group and overall at each visit will be provided. 
A by-subject listing of physical examination will be provided. 
4.10.6 12-Lead Electrocardiogram 
12-lead electrocardiogram (ECG) recordings will be obtained at each study center using 
site machines at the Screening Visit (Visit 1) to verify the eligibility of the subject, and at 
Visit 4 or unscheduled deterioration visit. 
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ECG will be performed after obtaining vital signs. Prior to recording, the subject should be 
at rest for at least 5 mins.  
ECG will be evaluated by the investigator/local medical staff and the recording will be 
reported in the eCRF as “normal”, “abnormal clinically significant” or “abnormal not 
clinically significant”. 
A shift table of the ECG assessments at Visit 4 compared to the ECG assessments at Visit 
1 by treatment group will be provided. When there are multiple assessments of ECG taken 
at a visit, the worst ECG finding will be used. 
A by-subject listing of 12-lead ECG will be provided. 
4.10.7 Suspected Unexpected Serious Adverse Reactions 
A Suspected, Unexpected Serious Adverse Reaction (SUSAR) is a subset of SAEs that, 
although foreseeable, are potentially related to the IMP and not identified in the reference 
safety information and will be reported to the appropriate regulatory authorities and 
investigators following local and global guidelines and requirements. The identification 
and reporting of SUSARs is the responsibility of Zambon’s Pharmacovigilance 
department. Following database lock, a listing of SUSARs will be requested from Zambon. 
If any occurred during the study, they will be incorporated in the TLFs.  
The following summaries will be provided: 
A summary of number and proportion of subjects reporting at least one SUSAR. 
The corresponding two-sided 95% CI of the proportion for each treatment group 
using the Clopper-Pearson method 
A summary of number and percentage of subjects reporting at least one SUSAR, 
and the number of SUSARs presented by System Organ Class, and Preferred Term. 
A by-subject listing of SUSARs will be provided. 
4.11 Determination of Sample Size 
This study has been powered to reach statistical significance for the superiority 
comparisons of N-acetyl cysteine (NAC) vs. placebo (primary study objective), and for the 
non-inferiority comparisons of NAC vs. ambroxol hydrochloride (key secondary study 
objective) in at least one of the two co-primary endpoints at the end of the 1-week 
treatment. This implies that sample size computation must account for the type I error 
inflation caused by the multiplicity over the two co-primary endpoints and by the 
multiplicity over the study targets (superiority and non-inferiority assessments) as well as 
the logical relationships among the two family of hypotheses with the non-inferiority 
testable only provided that the superiority contrast, assessed on the same endpoint, is 
statistically significant. To accomplish this, a multiple-sequence gatekeeping procedure 
[21] was implemented in a Monte Carlo (MC) study with 1000 runs and with the 
Bonferroni correction applied to the set of superiority comparisons (first gatekeeper) and 
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the Hochberg correction applied to the set of non-inferiority comparisons (second 
gatekeeper) in order to control the overall type I family-wise error rate at the one-tailed 
0.025 significance level. Details on the adopted gatekeeping strategy are reported further 
on. 
For the superiority tests, and with group sample sizes of 100 patients in placebo group and 
100 patients in NAC group, the Monte Carlo study estimated an overall power 
(“disjunctive” power) close to 93% to reach statistical significance in at least one co-
primary end-point. These calculations are based on a one-sided Mann-Whitney test and 
assuming a minimal clinically relevant difference of 0.35 points between placebo and NAC 
on a 0-3-point scale, standard deviation equal to 0.79 and 0.77 for sputum viscosity and 
expectoration difficulty scores (change from baseline to the 1-week treatment) respectively 
and a correlation between the two end-points equal to 0.31. 
For the non-inferiority tests, a sample of 100 patients per each active treatment group 
ensures sufficient disjunctive power (Monte Carlo disjunctive power = 82%) to detect non-
inferiority between NAC and ambroxol in at least one co-primary end-point. These 
calculations are based on a one-sided non-inferiority t-test assuming a margin of non-
inferiority equal to 0.30, standard deviation equal to 0.79 and 0.77 for sputum viscosity 
and expectoration difficulty scores (change from baseline to the 1-week treatment) 
respectively and a correlation between the two endpoints equal to 0.31. 
Assuming a drop-out rate of about 10% over one week of entry, a total of 333 patients will 
be randomized (i.e. 111 patients in the placebo group, 111 patients in the NAC group and 
111 patients in the ambroxol group. 
4.12 Changes to protocol-defined analyses 
The following changes from protocol defined analyses were made:  
In protocol, a test of site-by-treatment interaction was planned to be carried-out using 
a two-way nonparametric ANOVA performed by resorting to the “Aligned Rank 
Transform” (ART) procedure. However, this ART procedure will not be performed in 
final analysis. The main reason is due to the program limitation for implementing in 
the SAS 9.4 and no existing and validated procedure to perform this ART analysis. 
From the program maintenance and quality control perspective, the study team 
decides to use canonical two-way nonparametric ANOVA procedure instead. 
4.13 Reference 
1. Wobbrock, J. O., Findlater L., Gergle D., Higgins J. J. (2011). The Aligned Rank 
Transform for Nonparametric Factorial Analyses Using Only ANOVA Procedures. 
Proceedings of the ACM Conference on Human Factors in Computing Systems (CHI 
'11). Vancouver, British Columbia (May 7-12, 2011). New York: ACM Press, pp. 
143-146. 
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2. Keays, et al. (1991). Intravenous acetylcysteine in paracetamol induced fulminant 
hepatic failure: a prospective controlled trial. BMJ; 303: 1026-9.  
3. Rothmann, M. D., Wiens, B. L., and Chan, I. S. F. (2012). Design and Analysis of Non-
Inferiority Trials. Chapman & Hall/CRC Biostatistics Series, 350-351. 
4. Qu Y., Zhao Y. D., and Rahardia D. (2008). Wilcoxon-Mann-Whitney test: stratify or 
not? Journal of Biopharmaceutical Statistics; 18: 1103-1111.  
5. Munzel U. and Hauschke D. (2003). A nonparametric test for proving noninferiority in 
clinical trials with ordered categorical data. Pharmaceutical Statistics; 2:31-37. 
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4.14 Appendix 
4.14.1 Hochberg procedure 
In the case the co-primary endpoints for the superiority of NAC versus placebo are 
statistically significant (first gatekeeper), in the second gatekeeper for the family of non-
inferiority tests the Hochberg procedure for adjustment of multiple comparisons across the 
two co-primary endpoints will be performed. The Hochberg procedure assumes p-values 
are independent and uniformly distributed under respective null hypotheses and control the 
familywise error rate calculated in step-up fashion. 
Suppose test  null hypotheses and denote the ordered p-values as  
 , the 
Hochberg-adjusted p-values
 are obtained from: 
(
), (
)
The SAS syntax of Hochberg procedure is specified as follows: 
PROC MULTTEST INPVALUES=<input_raw_pvalue>  OUT= <output_adjust_pvalue> 
HOCHBERG; 
RUN; 
Where input_raw_pvalue= “the raw p-value calculated”.  
output_adjust_pvalue= “the adjusted p-value output”. 
The procedure of MULTTEST will compute the adjusted p-value and can be tested on 
4.14.2 Bootstrap Sampling Algorithm 
The algorithm to generate bootstrap samples is by using the procedure of PROC 
SURVEYSELECT to perform the random sampling with replacement stratified by 
treatment group. And the following statements will generate 1000 bootstrap samples by 
repeatedly drawing 333 random observations from the original data. 
The SAS syntax of Bootstrap Sampling Algorithm is specified as follows: 
%let rep = 1000; /* number of bootstrap resamples */ 
PROC SURVEYSELECT DATA= <input_dataset> OUT=<output_dataset>  
(rename=(Replicate=SampleID)) SEED =<seed number>  OUTHITS
METHOD = urs  /* resample with replacement */ 
SAMPRATE = 1 /* sample rate */ 
REP = &rep; /* generate NumSamples bootstrap resamples */ 
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STRATA trt01pn ; /*stratified by treatment group*/ 
RUN; 
After resampling 1000 times from the data to form 333 bootstrap samples, the efficacy 
analysis based on both mITT and PP populations will be performed by using either the 
stratified WMW test or modified WMW test on each bootstrap sample. The stratified and 
modified WMW syntax can be referenced in 0 and  4.14.6.
Then bootstrap distribution will be used to obtain bootstrap estimates including the point 
estimates of treatment differences together with associated two-sided 95% confidence 
intervals. Here nonparametric confidence interval can be estimated by percentiles of the 
bootstrap distribution. The 95% bootstrap confidence interval of SAS syntax can be 
referred as follow: 
PROC UNIVARIATE DATA= <input_stats>; 
VAR stats; 
OUTPUT OUT=Pctl  PCTLPRE =CI95_ 
MEAN=BootMean STD=BootStdErr /* compute bootstrap mean and standard error */ 
PCTLPTS =2.5  97.5       /* compute 95% bootstrap confidence interval */ 
PCTLNAME=Lower Upper; 
RUN; 
where  input_dataset = “individual efficacy data of changing from baseline” 
input_stat= “Bootstrap distribution of stratified WMW statistics or modified 
WMW statistics”. 
stats= “Computed point estimates of stratified WMW statistics or modified 
WMW statistics”. 
trt01pn = “treatment group, 1 stands for test group; 2 stands for control group”.
4.14.3 Two-way nonparametric ANOVA procedure 
A test of site-by-treatment interaction will be carried-out using a two-way nonparametric 
ANOVA and modelling adjustment for covariates will be performed and tested at two-
model. SAS syntax can be referred as follow:
  PROC RANK DATA=<input_dataset>  OUT= <ranked_dataset>; 
BY SITE; 
VAR response; 
RANKS ranked_response; 
RUN; 
PROC ANOVA DATA=<ranked_dataset>; 
CLASS site trt01pn; 
MODEL ranked_response = site trt01pn site* trt01pn; 
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RUN; 
To obtain the treatment difference by site for the forest plot, SAS syntax can be referred as 
below: 
PROC GLM DATA=<ranked_dataset>; 
CLASS site trt01pn ; 
MODEL ranked_response = site trt01pn site* trt01pn; 
LSMEANS site*trt01pn /cl PDIFF STDERR; 
RUN; 
Where trt01pn = “treatment group, 1 stands for test group; 2 stands for control group”.
response = “change from baseline to day 7 in Sputum viscosity” or “change from 
baseline to day 7 in Expectoration difficulty” 
4.14.4 EM Algorithm 
The expectation-maximization (EM) algorithm is a technique for maximum likelihood 
estimation in parametric models for incomplete data. The EM algorithm computes the MLE 
for the means and covariance matrix, of a multivariate normal distribution from the input 
data set with missing values.  
The SAS syntax of EM algorithm is specified as follows: 
PROC MI DATA=<input_dataset> SEED= <Seed number> NIMPUTE=0; 
EM OUTEM=out_data; 
VAR spv epd spc cough sv; 
RUN; 
Please note that the imputed values will round to the nearest integer. For value range of 
sputum viscosity, expectoration difficulty, sputum color and cough severity score will be 
integer from 0 to 3. The range of Sputum volume imputed value can be non-negative 
number. 
Where input_data= “Individual efficacy data” 
Seed number= “Random Seed” 
spv=“Sputum viscosity” 
epd=“Expectoration difficulty” 
spc=“Sputum  Color” 
cough = “Cough severity score”  
sv=“sputum volume” 
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4.14.5 The Stratified Wilcoxon-Mann-Whitney Test Statistic 
Let 
 and 
, 
, be the  pairs (strata) of 
independent random samples from distribution 
 and 
, respectively, where  is the 
number of blocks of baseline score. The -values are from the active test group, and the -
values are from the placebo group.  
The null hypotheses of superiority test can be expressed as 
where 
(
), 
 and 
 are random variables with distribution 
 and 
, respectively, and 
(
+ 1)
. 
The stratified WMW test statistic (van Elteren statistic) is computed as 
where  
= (
)
and 
(
)
(
+ 1).
The detail can be seen in Qu et al. (2008). 
The SAS syntax of stratified WMW test (Van Elteren test) is specified as follows: 
PROC NPAR1WAY DATA = <input_dataset> ; 
CLASS trt01pn ;  
STRATA  baseline_score;  
VAR Change_from_baseline;  
RUN; 
where input_data  = “Individual efficacy data of changing from baseline” 
trt01pn  = “treatment group, 1 stands for test group; 2 stands for control group” 
baseline_score = “The following Baseline score will be implemented separately,  
including sputum viscosity score, expectoration difficulty score, sputum color 
score, cough severity score and sputum volume” 
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Change_from_baseline= “The response will consider : (1) Change from baseline 
to day 3 (2) Change from baseline to day7. For each condition, the following 
change from baseline score will be considered: sputum viscosity score, 
expectoration difficulty score, sputum color score, cough severity score, sputum 
volume.” 
4.14.6 The Modified Wilcoxon-Mann-Whitney Test Statistic 
Let 
 and 
 denote the independent random samples from 
distribution 
 and 
, respectively. The -values are from the active test group, and the 
-values are from the active control group.  
The null hypotheses of non-inferiority test are expressed as 
where 
(
)
(
), and the value for 
 is the non-inferiority 
margin. 
The unbiased estimator of  is given by  
(
(
+ 1) 2
where 
 is the arithmetic average of the rank of the observation in the active control 
group among all observations. That is 
=
¸where 
 is the rank of 
 in ordering of the combined sample. Define also 
=
, where 
 is 
the rank of 
 in the ordering of the combined sample. When ties occur, 
 is the 
midrank, as well as 
. Let 
( )
 denote the rank of 
 among 
, and let 
( )
 denote the rank of 
 among 
. Define  
( )
+ (
+ 1) 2
(
),
and 
( )
+ (
+ 1) 2
(
).
Furthermore, for 
, define 
(
) , where 
. The test 
statistics is given by 
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(
)
+
.
The detail can be seen in (Munzel and Hauschke, 2003) as well. 
Since for using Munzel and Hauschke approach, a non-inferiority margin expressed on a 
probability scale is needed, the non-inferiority margin (as used in the sample size 
estimation) needs to be converted from a point scale (since it is expressed in the same 
scale of data) to a probability scale.  
The converted non-inferiority margin can be derived as below. 
To derive 
(probability scale margin) from  
(point scale margin) we apply the 
following formula of Cohen D effect size by assuming normality between two effect size: 
×
)
)
Where 
= 0.30  ; 
(
) =
 ; 
(
) =
SD is the term used here to indicate the standard deviation associated to statistic 
based on   
 and  
 and 
 are the standard deviation of the changes from baseline of the original 
scores for control group and test group respectively 
 and 
 are estimated according to the formula as shown above. 
The SAS syntax of obtaining the probability margin converting from point scales and 
modified Wilcoxon-Mann Whitney test are specified as follows. 
/*R(x j ) and R(y j )*/
proc rank data= input_data  out=out1 ties=mean; 
var chg; 
ranks r_chg; 
run; 
data out1t; 
set out1; 
where trt01pn=1; 
run; 
data out1c; 
set out1; 
where trt01pn=2;  
run; 
/*R^((T) ) (x_j )*/
proc rank data=input_data (where=(trt01pn=1)) out=out_rt ties=mean; 
var chg; 
ranks r_chg_rt; 
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run; 
/*R^((C) ) (y j )*/
proc rank data=input_data (where=(trt01pn=2)) out=out_rc ties=mean; 
var chg; 
ranks r_chg_rc; 
run; 
/*R mean T and  n_T*/
proc sql; 
select mean(r chg), count(r chg) into: avg_rt, :n_t 
from out1(where=(trt01pn=1));  
quit; 
%put &avg_rt &n_t; 
/* R_mean C and  n_C*/
proc sql; 
select mean(r_chg), count(r_chg) into: avg_rc, :n_c 
from out1(where=(trt01pn=2));  
quit; 
%put &avg_rc &n_c; 
/*JT2*/
proc sql noprint; 
select sum(((r_chg - r_chg_rt - &avg_RT + (&n_T+1)/2)**2)/(&n_T-1)) 
into :JT2 
from out1t as a 
left join out rt as b 
 on a.usubjid = b.usubjid; 
quit; 
%put &JT2; 
/*JC2*/
proc sql noprint; 
select sum(((r_chg - r_chg_rc - &avg_RC + (&n_C+1)/2)**2)/(&n_C-1)) 
into :JC2 
from out1c as a 
left join out_rc as b 
 on a.usubjid = b.usubjid; 
quit; 
%put &JC2; 
/*UT2 and UC2*/
%let UT2=%sysevalf(&JT2/(&n_C**2)); 
%let UC2=%sysevalf(&JC2/(&n_T**2)); 
%put &UT2; %put &UC2; 
/*Std_RC and Std_RT*/
proc sql; 
select std(chg) into : std_rc 
from out_rc; 
quit; 
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%put &std_rc; 
proc sql; 
select std(chg)  into : std_rt 
from out_rt; 
quit; 
%put &std_rt; 
All above calculated variables will be used to calculate the 
to implement the following 
modified Wilcoxon-Mann-Whitney tests.  
The SAS syntax of modified Wilcoxon-Mann-Whitney test to compute test statistics and 
one side confidence intervals are specified as follows: 
proc freq data= input_data;  /*somers d statistics*/
table trt01pn*chg /measures;  
test smdcr; 
output smdcr out=smd_out; 
run; 
data outf; 
set smd_out; 
p 1=(1+ smdcr )/2; /* unbiased estimator of p */
e_p1=e_smdcr/2; 
keep _smdcr_ e_smdcr p_1 e_p1; 
run; 
data test; 
set outF; 
 
delta1=0.3; 
 
delta2= delta1*sqrt(&UT2+&UC2)/sqrt(&Std_RT**2+&Std_RC**2) ; 
 
p 10=0.5- delta2 ; /* defined margin*/
 
Z p1=(p_1-p_10)/e_p1; /* modified Wilcoxon-Mann-Whitney test 
statistics*/ 
 
p_p1=1-probnorm(Z_p1); /*p value for P_1*/ 
 
lower limit 1=p 1-1.96* e p1; /* Depends on results of primary 
endpoint, here is the sample code of one side 97.5% lower CI of 
modified Wilcoxon-Mann-Whitney test statistics */
upper limit_1=1;  /* Upper CI of modified Wilcoxon-Mann-Whitney 
test statistics*/ 
lower limit 2=p 1-2.24* e p1; /* Depends on results of primary 
endpoint, here is the sample code of one side 98.75% lower CI of 
modified Wilcoxon-Mann-Whitney test statistics  */
upper limit_2=1;  /* Upper CI of modified Wilcoxon-Mann-Whitney 
test statistics*/ 
run;
where input_data  = “individual efficacy data of changing from baseline” 
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trt01pn = “treatment group, 1 stands for test group; 2 stands for control group” 
chg = “change from baseline score of ordinal categorical 4-point scales starting from 
0(normal) to 3(worst) of sputum viscosity score, expectoration difficulty score, sputum 
color score, and cough severity score” 
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