Conditions: Amyotrophic Lateral Sclerosis
Keywords: ALS Placebo-Controlled Double-Blind Regimen-Specific Appendix Lou Gehrig's Disease CNM-Au8 Clene Nanomedicine
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 161
Healthy volunteers: no

Brief summary:
The HEALEY ALS Platform Trial is a perpetual multi-center, multi-regimen clinical trial evaluating the safety and efficacy of investigational products for the treatment of ALS.

Regimen C will evaluate the safety and efficacy of a single study drug, CNM-Au8, in participants with ALS.

Detailed description:
The HEALEY ALS Platform Trial is a perpetual multi-center, multi-regimen clinical trial evaluating the safety and efficacy of investigational products for the treatment of ALS. This trial is designed as a perpetual platform trial. This means that there is a single Master Protocol dictating the conduct of the trial. The HEALEY ALS Platform Trial Master Protocol is registered as NCT04297683.

Once a participant enrolls into the Master Protocol and meets all eligibility criteria, the participant will be eligible to be randomized into any currently enrolling regimen. All participants will have an equal chance of being randomized to any currently enrolling regimen.

If a participant is randomized to Regimen C - CNM-Au8, the participant will complete a screening visit to assess additional Regimen C eligibility criteria. Once Regimen C eligibility criteria are confirmed, participants will complete a baseline assessment and be randomized in a 3:1 ratio to either active CNM-Au8 or matching placebo.

Regimen C will enroll by invitation, as participants may not choose to enroll in Regimen C. Participants must first enroll into the Master Protocol and be eligible to participate in the Master Protocol before being able to be randomly assigned to Regimen C.

For a list of enrolling sites, please see the HEALEY ALS Platform Trial Master Protocol under NCT04297683.

Arms:
arm 1: Drug: CNM-Au8

Administration: Oral

Dosage: 30 mg or 60 mg daily arm 2: Administration: Oral

Dosage: 2 bottles daily

Interventions: intervention 1: CNM-Au8 intervention 2: Matching Placebo
Intervention descriptions: intervention 1: Drug: CNM-Au8

Administration: Oral

Dosage: 30 mg or 60 mg daily intervention 2: Drug: Matching Placebo

Administration: Oral

Dosage: 2 bottles daily

Protocol document:
SAP_003.pdf: 
HEALEY ALS Platform Trial - Regimen C CNM-Au8 
NCT04414345 
Document Date: 22 Jul 2022 


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RGC REGIMEN-SPECIFIC STATISTICAL ANALYSIS PLAN (R-SAP) 
Master Protocol 
Platform Trial for the Treatment of Amyotrophic Lateral 
Sclerosis (ALS):  A perpetual multi-center, multi-regimen, 
clinical trial evaluating the safety and efficacy of 
investigational products for the treatment of ALS 
Regimen 
RGC: CNM-Au8 
Regimen Partner 
Clene Nanomedicine, Inc. 
Regulatory Sponsor 
Merit E. Cudkowicz, MD 
Master Protocol Version 
4.0, 31 Aug 2020 
RSA Version 
5.0, 22 Nov 2021 
Master SAP Version 
1.0, 24 Jun 2020 
R-SAP Version 
3.0, 22 Jul 2022 
 
SAP APPROVAL SIGNATURES 
 
 
Merit E. Cudkowicz, MD, MSc 
Principal Investigator and Regulatory Sponsor 
Date 
 
 
Sabrina Paganoni, MD, PhD 
Co-Principal Investigator 
Date 
 
 
Robert Glanzman, MD, FAAN 
Chief Medical Officer, Clene Nanomedicine, Inc. 
Date 
07/22/2022
07/22/2022
07/22/2022


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Michael Hotchkin 
Chief Development Officer, Clene Nanomedicine, Inc. 
 
 
 
Ben Saville, PhD 
Senior Statistical Scientist, Berry Consultants 
Date 
 
 
Eric A. Macklin, PhD 
Study Biostatistician 
Date 
07/23/2022
07/22/2022
07/22/2022


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SAP REVISION HISTORY 
Version 
Date 
Description of Changes 
1.0 
17 Mar 2022 Initial version 
2.0 
09 May 2022 Revision of Section 5.9 Survival to specify that both PAV-free 
survival and overall survival will be evaluated at both (i) the 
Week 24 Visit time point, and (ii) the last-participant-last-visit 
time point, and to specify that PAV-free survival to the Week 24 
Visit time point is the primary analysis of survival in this analysis 
plan. 
Revision of Section 6.5.2 CAFS to specify the following: 
1. A joint-rank analysis of PAV-free survival and SVC will be 
used as a supportive analysis for the secondary efficacy 
endpoint of SVC,  
2. The secondary endpoint joint-rank analyses will use multiple 
imputation to extend follow-up for participants who early 
terminate, withdraw consent, or are lost to follow-up as 
additional supportive analyses,  
3. The secondary joint-rank analyses will use time to death 
alone independent of any death equivalent as additional 
supportive analyses, and  
4. Primary inference from the joint-rank analyses will compare 
survival by time to death or death equivalent and will 
compare change in function to the last jointly observed time 
point. 
3.0 
22 Jul 2022 
Revision of Section 4.2 Exploratory Endpoints to (i) identify 
serum creatinine, serum and CSF neurofilament light chain 
(NfL), and urinary p75[ECD] as exploratory biomarkers of 
neurodegeneration and neuromuscular degeneration, and (ii) 
include ALSAQ-40 domain scores and symptom index (SI) as 
exploratory endpoints. 
Revision of Section 5.1 ALSFRS-R to specify details of the 
calculation of pre-baseline slope. 
Revision of Section 5.5 Quantitative Voice Characteristics to 
include predicted vital capacity as an additional metric at the 
Baseline Visit. 
Revision of Section 5.6 Biofluid Biomarkers of 
Neurodegeneration to specify assay techniques used to quantify 
serum creatinine, serum and CSF NfL, and urinary p75[ECD]. 


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Version 
Date 
Description of Changes 
3.0 
(continued) 
22 Jul 2022 
(continued) 
Revision of Section 5.7 ALSAQ-40 to specify calculation of 
domain scores and to revise calculation of overall ALSAQ-40 SI. 
Revision of Section 5.8 CNS-BFS to specify that the total score is 
referenced. 
Revision of Section 5.9 Survival to specify that time at risk 
begins at each participant's Baseline Visit and to specify that the 
date of PAV initiation, where applicable, will be imputed as the 
fifteenth day of a month if not specified more precisely. 
Revision of Section 6.1 Analysis Sets to add the Efficacy 
Common Mode of Administration (ECM) analysis set, to remove 
the restriction on protocol deviations that could be considered for 
exclusion from the Efficacy Per-protocol (EPP) analysis set must 
be classified as major protocol deviations, to specify the time 
point at which data is excluded from the EPP analysis set in the 
case of time-dependent exclusions, and to specify that data from 
placebo participants from other regimens would not be excluded 
from the EPP analysis set due to non-adherence to protocol-
specified dosing. 
Revision of Section 6.2 Baseline Characterization to include 
ALSAQ-40 domain scores and SI, urinary p75[ECD], and vital 
capacity predicted from quantitative voice characteristics. 
Revision of Section 6.5.2 CAFS to clarify that the primary CAFS 
analysis is specified in the ALS Master Protocol Recommended 
Statistical Analysis, Design and Simulation Report and is an 
adjusted analysis, to provide code for an adjusted analysis, and to 
add three additional sets of CAFS analyses, one set that adjusts 
rank scores in linear models for time from ALS symptom onset, 
delta-FRS, baseline use of riluzole, and baseline use of 
edaravone, one set that adjusts for the same set of covariates plus 
baseline serum NfL level, and one that makes no adjustment. 
Revision of Section 6.5.3 Repeated-measures Model to add a 
fixed term for treatment group (removing the shared-baseline 
assumption at the recommendation of the FDA) and to specify a 
separate supportive analysis that includes fixed terms for centered 
baseline serum NfL level, and centered baseline serum NfL level 
× visit interaction for analysis of clinical endpoints. 
Revision of Section 6.5.4 Survival to include ECM as an 
additional analysis set, to include baseline age as an additional 
covariate in all adjusted models, and to specify an additional 
adjusted analysis that includes baseline serum NfL level. 


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Version 
Date 
Description of Changes 
3.0 
(continued) 
22 Jul 2022 
(continued) 
Revision of Section 6.5.5 Random-slopes Model to add a fixed 
term for treatment group (removing the shared-baseline 
assumption) and to specify a separate supportive analysis that 
includes fixed terms for centered baseline serum NfL level, and 
centered baseline serum NfL level × study month interaction for 
analysis of clinical endpoints. 
Revision of Section 6.5.7 Composite of ALSFRS-R, SVC, and 
ALSAQ-40 Slopes to specify that one analysis will adjust for 
years since ALS symptom onset, delta-FRS, baseline riluzole use, 
and baseline edaravone use, and an additional analysis will adjust 
for the same covariates plus baseline serum NfL level. 
Revision of Section 6.5.8 HHD0 and HHD02 to remove reference 
to the shared-baseline assumption of the repeated-measures 
mixed model of Section 6.5.3 and to specify a separate analysis 
that adds baseline serum NfL level as an additional covariate. 
Revision of Section 6.5.9 Quantitative Voice Measures to remove 
reference to the shared-baseline assumption of the repeated-
measures and random-slopes mixed models and to add a fixed 
term for treatment group (removing the shared-baseline 
assumption) and to specify a separate analysis that includes fixed 
terms for centered baseline serum NfL level, and centered 
baseline serum NfL level × B-spline interaction. 
Revision of Section 6.5.10 Placebo Multiple Imputation to 
specify regression over sequential visits by the fully conditional 
specification method, to remove reference to the shared-baseline 
assumption of the repeated-measures mixed model of Section 
6.5.3, and to specify a separate analysis that adds baseline serum 
NfL level as an additional covariate. 
Revision of Section 6.5.13 Comparison of Controls across 
Regimens to specify separate analyses that add baseline serum 
NfL level as an additional covariate. 
 


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ABBREVIATIONS 
ALP 
Alkaline Phosphatase 
ALS 
Amyotrophic Lateral Sclerosis 
ALSAQ-40 
Amyotrophic Lateral Sclerosis Assessment Questionnaire, 40-item version 
ALSFRS-R 
Amyotrophic Lateral Sclerosis Functional Rating Scale, Revised 
ALT 
Alanine Transaminase 
AST 
Aspartate Transaminase 
ATC 
WHODrug Anatomical, Therapeutic, and Chemical class 
ATS 
American Thoracic Society 
BLQ 
Below the Limit of Quantitation 
BMI 
Body Mass Index 
C-SSRS 
Columbia Suicide Severity Rating Scale 
CAFS 
Combined Assessment of Function and Survival 
CBC 
Complete Blood Count 
CKD 
Chronic Kidney Disease 
COVID-19 
Coronavirus Disease 2019 
CNS-BFS 
Center for Neurologic Study Bulbar Function Scale 
CSF 
Cerebrospinal Fluid 
CSR 
Clinical Study Report 
CTCAE 
Common Terminology Criteria for Adverse Events  
delta-FRS 
Pre-baseline Slope in ALSFRS-R  
DAP 
Data Analysis Plan 
DILI 
Drug-induced Liver Injury 
DNA 
Deoxyribonucleic Acid 
DRR 
Disease Rate Ratio 
ECC 
Efficacy Concurrent Control 
ECD 
Extra-cellular Domain 
ECG 
Electrocardiography or Electrocardiogram 
eGFR 
Estimated Glomerular Filtration Rate 
EPP 
Efficacy Per-protocol 
ERO 
Efficacy Regimen-only 
ELISA 
Enzyme-linked Immunosorbent Assay 


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ABBREVIATIONS (continued) 
FAS 
Full Analysis Set 
FVC 
Forced Vital Capacity 
GLI 
Global Lung Initiative 
hCG 
Human Chorionic Gonadotropin 
HHD 
Hand-held Dynamometry 
HLT 
MedDRA High Level Term 
ICF 
Informed Consent Form 
ITT 
Intention-to-treat Principle 
M-SAP 
Master Statistical Analysis Plan 
MDRD 
Modification of Diet in Renal Disease  
MedDRA 
Medical Dictionary for Regulatory Activities 
MP 
Master Protocol 
MPRDR 
ALS Master Protocol Recommended Statistical Analysis, Design and 
Simulation Report 
NCI 
National Cancer Institute 
NEALS 
Northeast ALS 
NfL 
Neurofilament Light Chain 
NIV 
Noninvasive Ventilation 
OLE 
Open-label Extension 
p75[ECD] 
Neurotrophin Receptor p75 Protein Extracellular Domain 
PAV 
Permanent Assisted Ventilation 
PD 
Pharmacodynamics 
PK 
Pharmacokinetics 
PT 
MedDRA Preferred Term 
RBC 
Red Blood Cell 
RDW 
RBC Distribution Width 
RGC 
Regimen C (CNM-Au8, 30 mg/d and 60 mg/d) 
RSA 
Regimen-specific Appendix 
R-SAP 
Regimen-specific Statistical Analysis Plan 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
 


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ABBREVIATIONS (continued) 
SGOT 
Serum Glutamic Oxaloacetic Transaminase 
SGPT 
Serum Glutamic Pyruvic Transaminase 
SI 
Symptom Index 
SoA 
Schedule of Activities 
SOC 
MedDRA System Organ Class 
SRO 
Safety Regimen-only 
STF 
Safety and Tolerability Full 
STN 
Safety and Tolerability Narrow 
SVC 
Slow Vital Capacity 
TBL 
Total Bilirubin 
TEAE 
Treatment-emergent Adverse Event 
TSH 
Thyroid Stimulating Hormone 
ULN 
Upper Limit of Normal 
WBC 
White Blood Cell 
WHODrug 
World Health Organization Drug Dictionary Enhanced 
 


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Table of Contents 
1. 
Governing Documents ...................................................................................................................... 11 
2. 
Study Design ..................................................................................................................................... 11 
2.1 
Overview ....................................................................................................................................................... 11 
2.2 
Study Objectives ........................................................................................................................................... 12 
2.3 
Study Population ........................................................................................................................................... 12 
2.4 
Participant Flow ............................................................................................................................................ 12 
2.5 
Regimen Allocation ....................................................................................................................................... 12 
2.6 
Treatment Allocation ..................................................................................................................................... 12 
2.7 
Treatment Administration ............................................................................................................................. 12 
2.8 
Allocation Concealment ................................................................................................................................ 13 
2.9 
RGC Schedule of Activities (SoA) ................................................................................................................ 13 
3. 
General Considerations for Data Analysis ..................................................................................... 16 
3.1 
Statistical Software ........................................................................................................................................ 16 
3.2 
Summary Statistics ........................................................................................................................................ 16 
3.3 
Precision ........................................................................................................................................................ 16 
3.4 
Transformations ............................................................................................................................................ 16 
3.5 
Multiplicity Adjustments ............................................................................................................................... 16 
3.6 
Missing Data ................................................................................................................................................. 16 
4. 
Study Endpoints ............................................................................................................................... 16 
4.1 
Efficacy Endpoints ........................................................................................................................................ 16 
4.2 
Exploratory Endpoints ................................................................................................................................... 16 
4.3 
Safety Endpoints ........................................................................................................................................... 17 
5. 
Measurement Definitions ................................................................................................................. 18 
5.1 
ALSFRS-R .................................................................................................................................................... 18 
5.2 
SVC ............................................................................................................................................................... 18 
5.3 
Home Spirometry .......................................................................................................................................... 18 
5.4 
HHD and Grip Strength ................................................................................................................................. 19 
5.5 
Quantitative Voice Characteristics ................................................................................................................ 19 
5.6 
Biofluid Biomarkers of Neurodegeneration .................................................................................................. 19 
5.7 
ALSAQ-40 .................................................................................................................................................... 19 
5.8 
CNS-BFS ....................................................................................................................................................... 20 
5.9 
Survival ......................................................................................................................................................... 20 
5.10 
Pharmacokinetics of CNM-Au8 ............................................................................................................... 20 
5.11 
King's ALS Clinical Staging System ........................................................................................................ 20 
5.12 
Hospitalization and Other Clinical Events................................................................................................ 21 
5.13 
Pharmacodynamic Biomarkers ................................................................................................................. 21 
5.14 
Pharmacokinetics of Riluzole ................................................................................................................... 21 
5.15 
Clinical Safety Laboratory Tests .............................................................................................................. 21 
6. 
Statistical Methodology .................................................................................................................... 22 
6.1 
Analysis Sets ................................................................................................................................................. 22 
6.2 
Baseline Characterization .............................................................................................................................. 23 
6.3 
Primary Efficacy Analysis and Supportive Analyses .................................................................................... 23 
6.4 
Interim Analysis ............................................................................................................................................ 24 
6.5 
Secondary Efficacy Analyses ........................................................................................................................ 24 
6.5.1 
Hierarchical Testing ............................................................................................................................. 24 
6.5.2 
CAFS ................................................................................................................................................... 25 
6.5.3 
Repeated-measures Model ................................................................................................................... 26 
6.5.4 
Survival ................................................................................................................................................ 28 
6.5.5 
Random-slopes Model ......................................................................................................................... 29 
6.5.6 
Time to Clinical Events ....................................................................................................................... 30 
6.5.7 
Composite of ALSFRS-R, SVC, and ALSAQ-40 Slopes .................................................................... 31 
6.5.8 
HHD0 and HHD02 ............................................................................................................................... 31 
6.5.9 
Quantitative Voice Measures ............................................................................................................... 31 
6.5.10 
Placebo Multiple Imputation................................................................................................................ 32 


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6.5.11 
Additional Sensitivity Analyses of Primary and Key Secondary Outcomes ....................................... 32 
6.5.12 
Subgroup Analyses .............................................................................................................................. 32 
6.5.13 
Comparison of Controls across Regimens ........................................................................................... 33 
6.5.14 
Pharmacokinetic Analyses of CNM-Au8 ............................................................................................ 34 
6.5.15 
Pharmacodynamic Biomarker Analyses .............................................................................................. 34 
6.5.16 
Pharmacokinetics of Riluzole .............................................................................................................. 34 
6.6 
Safety Analyses ............................................................................................................................................. 34 
6.6.1 
Treatment-emergent Adverse Events ................................................................................................... 34 
6.6.2 
Safety Labs .......................................................................................................................................... 35 
6.6.3 
ECG Results......................................................................................................................................... 35 
6.6.4 
Vital Signs and Weight ........................................................................................................................ 35 
6.6.5 
Suicidality ............................................................................................................................................ 35 
6.7 
Other Analyses .............................................................................................................................................. 35 
6.7.1 
Participant Disposition ......................................................................................................................... 35 
6.7.2 
Study Drug Compliance and Tolerance ............................................................................................... 36 
6.7.3 
Concomitant Medication Use .............................................................................................................. 36 
6.7.4 
Medical History ................................................................................................................................... 37 
6.7.5 
Blindedness .......................................................................................................................................... 37 
6.7.6 
Protocol Deviations.............................................................................................................................. 37 
6.7.7 
Impact of COVID-19 Pandemic .......................................................................................................... 37 
7. 
Validation .......................................................................................................................................... 37 
7.1 
Primary Efficacy Analysis ............................................................................................................................. 37 
7.2 
Secondary, Exploratory, and Safety Analyses ............................................................................................... 37 
8. 
References ......................................................................................................................................... 37 


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1. Governing Documents 
This Regimen-specific Statistical Analysis Plan (R-SAP) for the CNM-Au8 regimen (RGC) 
specifies any modification from the default outcome measures, analysis samples, and planned 
analyses for the placebo-controlled period of the HEALEY ALS Platform Trial as specified in 
the Master SAP (M-SAP). The M-SAP and this R-SAP supplement the Master Protocol, the 
"ALS Master Protocol Recommended Statistical Analysis, Design and Simulation Report" 
(Appendix 1 to the Master Protocol), and the RGC Regimen-specific Appendix (RGC RSA). 
Please refer to the Master Protocol and the RGC RSA for details on the rationale for the study 
design, eligibility criteria, conduct of the trial, clinical assessments and schedule of assessments, 
definitions and reporting of adverse events, data management conventions, and regulatory 
oversight and compliance procedures. The "ALS Master Protocol Recommended Statistical 
Analysis, Design and Simulation Report" (MPRDR) and any regimen-specific deviations 
described in the RGC RSA, and this R-SAP are authoritative in defining the primary and interim 
analyses. In case of discrepancies between the RGC RSA and this R-SAP concerning use of 
shared placebos, this R-SAP is authoritative. In case of discrepancies between either SAP and the 
Master Protocol and the RGC RSA concerning matters of analysis other than the primary and 
interim analyses and use of shared placebos, the M-SAP and this R-SAP are authoritative. In 
case of discrepancies between the M-SAP and this R-SAP, this R-SAP is authoritative. On all 
matters not related to analysis, the Master Protocol and the RGC RSA are authoritative. The 
following table describes relationships among the relevant documents in adjudicating possible 
discrepancies with higher numbers indicating greater authority. 
Issues potentially requiring adjudication 
Master 
Protocol 
RGC RSA 
MPRDR 
M-SAP 
RGC  
R-SAP 
Use of shared placebos 
1 
4 
2 
3 
5 
Primary and interim analysis specifications not 
related to use of shared placebo 
1 
5 
4 
2 
3 
Statistical analysis specifications not related to use 
of shared placebo or primary and interim analyses 
1 
3 
2 
4 
5 
All matters not related to statistical analysis 
4 
5 
1 
2 
3 
2. Study Design 
2.1 
Overview 
The HEALEY ALS Platform Trial is a perpetual multi-center, multi-regimen clinical trial 
evaluating the safety and efficacy of investigational products for the treatment of ALS. RGC 
evaluates the safety and efficacy of CNM-Au8 administered orally at dosages of 30 mg/d and 60 
mg/d vs. placebo. The RGC RSA describes the nature of the intervention and its mechanism of 
action, the mode and frequency of administration, additional eligibility criteria beyond those 
specified in the Master Protocol, additional enrollment procedures, and additions and 
modifications of safety and efficacy assessments relative to those outlined in the Master 
Protocol. 


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2.2 
Study Objectives 
Primary Efficacy Objective: 
• To evaluate the efficacy of CNM-Au8 as compared to placebo on ALS disease 
progression. 
Secondary Efficacy Objectives: 
• To evaluate the effect of CNM-Au8 on selected secondary measures of disease 
progression, including survival. 
Safety Objectives: 
• To evaluate the safety of CNM-Au8 for ALS. 
Exploratory Efficacy Objectives: 
• To evaluate the effect of CNM-Au8 on selected biomarkers and endpoints. 
• To explore CNM-Au8 pharmacokinetics (PK) and pharmacodynamic (PD) effects. 
2.3 
Study Population 
In addition to eligibility criteria specified in the Master Protocol, participants in RGC must not 
have a history of allergy to gold, gold salts, or colloidal gold preparations. 
Participants will be recruited from approximately 60 centers located throughout the US that are 
part of the Northeast ALS (NEALS) Consortium. 
2.4 
Participant Flow 
Participants in RGC follow the consenting, Master screening, regimen assignment, regimen-
specific screening, randomization to active or placebo treatment, and follow-up procedures and 
timing described in the M-SAP. Detailed descriptions of study procedures and timing are 
specified in the Master Protocol and the RGC RSA. 
2.5 
Regimen Allocation 
Participants in RGC are those determined eligible for Master Protocol-level inclusion and 
exclusion criteria and randomly assigned to RGC, stratified by use of: (i) riluzole, (ii) edaravone, 
(iii) both, or (iv) neither at the time of screening for the Master Protocol. Details of regimen 
assignment are described in the Platform Trial Regimen Assignment Plan.  
2.6 
Treatment Allocation 
Participants in RGC are randomly allocated in a 3:3:2 ratio to 30 mg/d CNM-Au8, 60 mg/d 
CNM-Au8, or placebo treatment based on a pre-specified permuted-block randomization 
schedule, stratified by use of (i) riluzole, (ii) edaravone, (iii) both, or (iv) neither at the time of 
screening for the Master Protocol. 
2.7 
Treatment Administration 
CNM-Au8 and placebo are supplied as pairs of bottles each containing 60 mL of liquid. Bottles 
of active study drug at the 30 mg/d dosage contain CNM-Au8 at a concentration of 250 μg/mL 
(15 mg per bottle). Bottles of active study drug at the 60 mg/d dosage contain CNM-Au8 at a 


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concentration of 500 μg/mL (30 mg per bottle). All formulations contain 32.8 mg sodium 
bicarbonate and 60 mL USP purified water. 
A normal dosage is two (2) 60 mL bottles of study drug daily. If participants have difficulty 
tolerating study drug and with Site Investigator and Medical Monitor approval, participants may 
reduce the dosage to one (1) bottle daily. Participants who have down titrated may be 
rechallenged at full dosage with approval by the Site Investigator and Medical Monitor. 
Participants who cannot tolerate the rechallenge should remain at the dosage of one (1) bottle 
daily. Drug holidays (e.g., treatment-free periods) are not permitted.  
The first dose of study drug should be administered while in the office/clinic on the day of the 
Baseline Visit after all visit assessments are complete. Additional details of treatment 
administration are described in the RGC RSA. 
2.8 
Allocation Concealment 
Allocation concealment is the same as described in the M-SAP. All formations of study drug are 
identical in appearance (size, shape, volume, and color) and smell. 
2.9 
RGC Schedule of Activities (SoA) 
Activity 
MP 
Scrn1 
RGC 
Scrn2 
Base-
line 
Week 
2 
Week 
43 
Week 
83 
Week 
12 
Week 
16 
Week 
20 
Week 
243 
Final 
Call4 
Cln 
Cln 
Cln 
Phn 
Cln5 
Cln5 
Phn 
Cln5 
Phn 
Cln 
Phn 
-42d  
to -1d 
-41d  
to 0d 
Day  
0 
Day 
14±3 
Day 
28±7 
Day 
56±7 
Day 
84±3 
Day 
112±7 
Day 
140±3 
Day 
168±7 
28d ±3 
ALD 
Written Informed Consent6 
X 
X 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion Review7 
X 
X 
 
 
 
 
 
 
 
 
 
ALS & Medical History 
X 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
Physical Examination 
X 
 
 
 
 
 
 
 
 
 
 
Neurological Exam 
X 
 
 
 
 
 
 
 
 
 
 
Vital Signs8 
X 
 
X 
 
X 
X 
 
X 
 
X 
 
Slow Vital Capacity 
X9 
 
X 
 
 
C 
 
C 
 
X 
 
Home Spirometry 
X9 
 
X 
 
 
X 
 
X 
 
X 
 
Muscle Strength Assessment 
 
 
X 
 
 
C 
 
C 
 
X 
 
ALSFRS-R 
X 
 
X 
 
X 
X 
X 
X 
X 
X 
 
ALSAQ-40 
 
 
X 
 
 
 
 
 
 
X 
 
CNS-BFS  
 
 
X 
 
 
X 
 
X 
 
X 
 
12-Lead ECG 
X 
 
 
 
 
 
 
 
 
X 
 
Clinical Safety Labs10 
X 
 
X 
 
X 
X 
 
X 
 
X 
 
CNM-Au8 PK Samples11 
 
 
X 
 
C 
C 
 
 
 
X 
 
CNM-Au8 PD Samples11 
 
 
X 
 
C 
C 
 
 
 
X 
 
Biomarker Blood Collection11 
 
 
X 
 
 
C 
 
C 
 
X 
 
Biomarker Urine Collection11 
 
 
X 
 
 
C 
 
C 
 
X 
 
DNA Collection12 (optional) 
 
 
X 
 
 
 
 
 
 
 
 
CSF Collection (optional) 
 
 
X 
 
 
 
 
C13 
 
 
 
Concomitant Medication Review 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Adverse Event Review14 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Suicidality C-SSRS 
 
 
X 
 
X 
X 
 
X 
 
X 
 
Install Smartphone Apps15 
 
 
X 
 
 
 
 
 
 
 
 
Smartphone Voice Recording16 
 
 
X 
 
X 
X 
 
X 
 
X 
 
Uninstall Smartphone App 
 
 
 
 
 
 
 
 
 
X 
 
Regimen Assignment 
X 
 
 
 
 
 
 
 
 
 
 


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Activity 
MP 
Scrn1 
RGC 
Scrn2 
Base-
line 
Week 
2 
Week 
43 
Week 
83 
Week 
12 
Week 
16 
Week 
20 
Week 
243 
Final 
Call4 
Cln 
Cln 
Cln 
Phn 
Cln5 
Cln5 
Phn 
Cln5 
Phn 
Cln 
Phn 
-42d  
to -1d 
-41d  
to 0d 
Day  
0 
Day 
14±3 
Day 
28±7 
Day 
56±7 
Day 
84±3 
Day 
112±7 
Day 
140±3 
Day 
168±7 
28d ±3 
ALD 
Randomization within RGC 
 
 
X 
 
 
 
 
 
 
 
 
Administer/Dispense Study Drug 
 
 
X17 
 
 
X 
 
X 
 
 
 
Drug Accountability/Compliance 
 
 
 
X18 
X 
X 
X18 
X 
X18 
X 
 
Exit Questionnaire 
 
 
 
 
 
 
 
 
 
X 
 
Vital Status 
 
 
 
 
 
 
 
 
 
X19 
 
Abbreviations: ALD = after last dose, ALS = amyotrophic lateral sclerosis, ALSAQ-40 = ALS 
Assessment Questionnaire, ALSFRS-R = ALS Functional Rating Scale Revised, BP = blood 
pressure, C = completed only if the visit is conducted in-clinic, CBC = complete blood count, 
Cln = Clinic visit, CNS-BFS = Center for Neurologic Study Bulbar Function Scale, CSF = 
cerebrospinal fluid, C-SSRS = Columbia-Suicide Severity Rating Scale, d = day, DNA = 
deoxyribonucleic acid, ECG = electrocardiogram, LFTs = liver function tests, MP = Master 
Protocol, PD = pharmacodynamic, Phn = Phone visit, RGC = the CNM-Au8 regimen, Scrn = 
Screening Visit. 
1 Master Protocol (MP) screening procedures must be completed between 42 days and 1 day 
prior to the Baseline Visit. 
2 RGC regimen-specific screening procedures must be completed no more than 41 days prior to 
the Baseline Visit. RGC regimen-specific screening procedures may be completed on the same 
day as the Baseline Visit. 
3 Participants should be instructed to hold the morning dose of study drug on the day of the Week 
4, 8, and 24 study visits. Study drug should not be taken until after study visit procedures are 
complete. 
4 Participants who are participating into the Open-label Extension (OLE) at the time scheduled 
for the Follow-up Safety Call will not complete a Follow-up Safety Call. Participants who 
continue into the OLE and then terminate prior to the time scheduled for the Follow-up Safety 
Call should be asked to complete a Follow-Up Safety Call. 
5 The Week 4, 8, and 16 visits may be conducted via telemedicine (or via phone if telemedicine 
is not available) with remote services instead of in-clinic if this is needed to protect the safety of 
the participant due to a pandemic, or other reason. If a planned in-clinic visit is conducted via 
telemedicine (or via phone if telemedicine is not available) with remote services, only selected 
procedures will be performed: ALSFRS-R, home spirometry (Weeks 8 and 16 only), Center for 
Neurologic Study Bulbar Function Scale (CNS-BFS, Weeks 8 and 16 only), voice recording, 
adverse event review, Columbia Suicide Severity Rating Scale, concomitant medications, study 
drug accountability/compliance, and administer/dispense study drug. Additionally, selected vital 
signs (systolic and diastolic pressure, respiratory rate, heart rate, and temperature) and clinical 
safety labs will be performed by a home health agency. 
6 During the Master Protocol Screening Visit, participants will be consented using the Master 
Protocol informed consent form (ICF). After a participant is randomly assigned to RGC, he or 
she will be consented a second time using the RGC ICF. 


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7 At the MP Screening Visit, participants will have MP inclusion and exclusion criteria assessed. 
At the RGC Screening Visit, participants will have regimen-specific inclusion and exclusion 
criteria assessed. 
8 At all visits, whether conducted in-clinic or via telemedicine (or via phone if telemedicine is 
not available), vital signs include systolic and diastolic blood pressure, heart rate, respiratory 
rate, and temperature. At all in-clinic visits, vital signs include weight. At the MP Screening 
Visit only, vital signs include height measured in cm. 
9 If required due to pandemic-related restrictions, forced vital capacity (FVC) performed by a 
Pulmonary Function Laboratory evaluator or with a study-approved home spirometer or 
sustained phonation using a study-approved method may be used for eligibility (Master Protocol 
Screening ONLY). 
10 Clinical safety labs include hematology (CBC with differential), complete chemistry panel, 
liver function tests, thyroid function, and urinalysis. Serum pregnancy testing will occur in 
women of child-bearing potential at the Master Protocol Screening Visit and as necessary during 
participation. Pregnancy testing is only repeated as applicable if there is a concern for pregnancy. 
11 Whole blood samples for CNM-Au8 PK, plasma samples for riluzole PK, and whole blood, 
plasma, and urine samples for PD biomarkers should be obtained prior to the first daily dose of 
study drug at each applicable clinic visit. The time of the most recent dose of study drug, the 
most recent meal prior to sampling, and the time of sample collection should be reported. Whole 
blood and urine will be collected only at the Baseline and Week 24/Early Termination visits. 
12 If the participant consents to DNA sample collection but a DNA sample is not obtained at the 
Baseline Visit or if that sample is not usable, a DNA sample can be collected after the Baseline 
Visit. 
13 If the participant consents to CSF sample collection but a CSF sample is not obtained at the 
Week 16 Visit, a CSF sample can be collected at the Week 24 Visit. 
14 Adverse events that occur after signing the RGC ICF will be recorded. 
15 Two smartphone apps should be installed on the participant’s phone, one to collect home 
spirometry and one to collect voice recordings. 
16 In addition to study visits specified in the SoA for collection of voice recordings, participants 
should complete twice weekly voice recordings at home. During weeks when a participant 
completes a voice recording in-clinic, he or she should only complete one other voice recording 
at home. 
17 Administer first dose of study drug only after Baseline Visit procedures are completed. 
Participants should take the first dose of study drug while in the office/clinic on the day of the 
Baseline visit. 
18 Drug accountability will not be done at phone visits. A drug compliance check-in must be held 
during phone visits to ensure participant is taking drug per dose regimen and to note any report 
of missed doses. 
19 Vital status, a determination of date of death or death equivalent or date last known alive, will 
be made for each randomized participant at the end of their double-blind follow-up (generally the 
Week 24 Visit as indicated) and again, if previously alive, after the end of double-blind follow-


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up of all participants randomized to RGC. Vital status may also be ascertained at later time 
points by using publicly available data sources. 
3. General Considerations for Data Analysis 
3.1 
Statistical Software 
Statistical software use for analyses is the same as described in the M-SAP. 
3.2 
Summary Statistics 
Data summaries are the same as described in the M-SAP. 
3.3 
Precision 
Precision of reported results is the same as described in the M-SAP. 
3.4 
Transformations 
Data transformations are the same as described in the M-SAP. 
3.5 
Multiplicity Adjustments 
Handling of multiplicity adjustments is the same as described in the M-SAP with the addition 
that the primary contrast for any given analysis will be between all active arm participants (i.e., 
both 30 mg/d and 60 mg/d dosage groups) vs. placebo participants. Comparisons between the 
two dosage groups and between each dosage group and placebo will be exploratory. 
3.6 
Missing Data 
Handling of missing data is the same as described in the M-SAP. Clinic-based assessments that 
are missing due to COVID-19 restrictions or disruptions are considered missing at random. 
4. Study Endpoints 
4.1 
Efficacy Endpoints 
The primary endpoint is the same as described in the M-SAP. ALSFRS-R total score is 
considered the primary efficacy endpoint as described in the M-SAP.  Combined assessment of 
function and survival (CAFS), slow vital capacity (SVC) change, and survival (time to death or 
death equivalent) are considered key secondary efficacy endpoints in RGC. 
4.2 
Exploratory Endpoints 
The following categories of exploratory endpoints will be evaluated: 
• Change in ALSFRS-R domain scores, 
• Change in strength: hand-held dynamometry (HHD) global percentage, HHD upper 
extremity percentage, HHD lower extremity percentages, HHD0, and HHD02,  


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• Change in quantitative voice characteristics as measured by Aural Analytics: maximum 
phonation time, pause rate, breathy vocal quality, pitch instability, regulation of voicing, 
articulatory precision, speaking rate, articulation rate, and monotonicity,  
• Change in biofluid biomarkers of neurodegeneration and neuromuscular degeneration: serum 
creatinine, serum and cerebrospinal fluid (CSF) neurofilament light chain (NfL), and urinary 
neurotrophin receptor p75 protein extracellular domain (p75[ECD]) normalized to urinary 
creatinine,  
• Change in patient-reported outcomes: ALSAQ-40 physical mobility, independence in 
activities of daily living, eating and drinking, communications, and emotional reactions 
domain scores and ALSAQ-40 symptom index, CNS-BFS total score,  
• Change in plasma and whole blood concentrations of CNM-Au8,  
• Change in CNM-Au8 PD biomarkers,  
• Change in respiratory function as assessed by home spirometry,  
• Time to clinical events:  
o First hospitalization due to a serious adverse event (SAE),  
o First hospitalization due to an ALS-related SAE,  
o First use of assisted ventilation,  
o First placement of a feeding tube,  
o First time reaching King's stage 4a or 4b,  
o First instance of any of the following events: feeding tube placement, tracheostomy, 
initiation of permanent assisted ventilation (PAV), or death,  
o First instance of any of the following events: hospitalization for an SAE, feeding tube 
placement, tracheostomy, initiation of PAV, or death.  
• Time to first occurrence of a ≥ 6-point decline in ALSFRS-R total score 
• A composite of the standardized slope estimates for rate of change in ALSFRS-R total score, 
SVC percent-predicted, and ALSAQ-40 total score. 
4.3 
Safety Endpoints 
In addition to the safety endpoints described in the M-SAP, the following RGC regimen-specific 
safety endpoint will be evaluated: 
• Safety lab alerts: Proportion of participants with ALT >3x upper limit of normal (ULN), AST 
>3x ULN, creatinine >1.5x level at the Baseline Visit, and platelet count <75,000/mm3, and  
• Pharmacokinetics of riluzole. 


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5. Measurement Definitions 
5.1 
ALSFRS-R 
The definitions of ALSFRS-R scores are the same as described in the M-SAP. Pre-baseline slope 
in ALSFRS-R (delta-FRS) is defined as 48 minus the baseline ALSFRS-R total score then 
divided by the number of months from onset of symptomatic weakness to the Baseline Visit. The 
number of months will be calculated as the difference in days from onset of symptomatic 
weakness to the Baseline Visit multiplied by 12 / 365.25. The date of onset of symptomatic 
weakness will be imputed as the fifteenth day of a month if not specified more precisely. 
ALSFRS-R domain scores are exploratory measures of the primary efficacy endpoint ALSFRS-
R total score. 
Time to first occurrence of a ≥ 6-point decline in ALSFRS-R total score is a composite endpoint 
with death or death equivalent, whichever occurs first, and will be censored at the last date at 
which an ALSFRS-R assessment was performed up to the end of the Week 24 Visit window. 
5.2 
SVC 
The derivation of SVC percent-predicted of normal is the same as described in the M-SAP with 
age calculated as number of days from date of birth to the date of a given SVC assessment 
divided by 365.25 and with the following correspondence between self-identified race and race 
defined by Global Lung Initiative (GLI) classification: 
Self-identified Race 
GLI-defined Race 
American Indian or Alaska Native 
Mixed/Other 
Asian 
South East Asian 
Black or African American 
African American 
Native Hawaiian or Other Pacific Islander 
Mixed/Other 
White 
Caucasian 
Unknown 
Caucasian 
Not reported 
Caucasian 
More than one race indicated 
Mixed/Other 
5.3 
Home Spirometry 
Home spirometry assesses FVC remotely using a smartphone app (ZEPHYRx, Albany, NY) and 
a handheld spirometer (Spirobank Smart, Medical International Research, Rome, Italy). 
Coordinators guide participants through 3 to 8 maneuvers with live-video coaching using the 
ZEPHYRx platform. Flow loops are classified for acceptability and repeatability using American 
Thoracic Society (ATS) criteria and are manually reviewed by the NEALS Outcomes Center 
(Barrow Neurological Institute, Phoenix, AZ). The maximum FVC accepted by the NEALS 
Outcomes Center is converted to percent of predicted normal using GLI norms based on sex, age 
at time of assessment, height at time of screening, and race. Age is calculated as number of days 
from date of birth to the date of a given home spirometry assessment divided by 365.25. Higher 
values indicate greater respiratory function. 


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5.4 
HHD and Grip Strength 
The derivation of HHD upper and lower extremity scores and HHD0 are the same as described in 
the M-SAP with the revision that HHD0 is a composite endpoint with death or death equivalent. 
A second HHD time-to-event endpoint is defined as the time from the Baseline Visit to the 
second post-baseline occurrence of a muscle with a strength recording of 0 among those muscles 
that were non-zero at baseline, or time to death or death equivalent, whichever occurs first 
(HHD02).  
Time at risk for HHD0 and HHD02 will be censored at the last date at which an HHD assessment 
was performed up to the end of the Week 24 Visit window. 
HHD lower extremity average percentage, HHD upper extremity average percentage, HHD 
global average percentage, HHD0, and HHD02 are exploratory measures. 
5.5 
Quantitative Voice Characteristics 
Voice samples will be collected using the Aural Analytics app installed on either an Android or 
iOS-based smartphone. At each assessment, participants perform a set of speaking tasks: reading 
5 prespecified sentences, reading 5 sentences chosen at random from a large sentence bank, 
repeating a consonant-vowel sequence, producing a sustained phonation, and counting on a 
single breath. Speech analysis will be performed by Aural Analytics to derive the following 
quantitative voice characteristics: maximum phonation time, pause rate, breathy vocal quality, 
pitch instability, regulation of voicing, articulatory precision, speaking rate, articulation rate, and 
monotonicity. Aural Analytics will use data on quantitative voice characteristics and participant 
age, sex, race, height, and weight to derive a prediction of vital capacity at the Baseline Visit. 
5.6 
Biofluid Biomarkers of Neurodegeneration 
Biofluid biomarkers of neurodegeneration, including biomarkers of neuromuscular dysfunction, 
will be assayed. These will include serum creatinine, serum and CSF neurofilament light chain 
(NfL), and urinary p75[ECD]. Serum creatinine will be assayed by the kinetic Jaffe method (test 
001370, Labcorp, Burlington, NC). NfL will be assayed by single-molecule array (Simoa; 
Quanterix, Billerica, MA). Urinary p75[ECD] will be assayed by sandwich enzyme-linked 
immunoassay (Rogers lab, Flinders Univ, Adelaide, Australia) and normalized to urinary 
creatinine. Levels of serum and CSF NfL and urinary p75[ECD] that are reported to be below the 
limit of quantitation will be imputed at the limit of quantitation. Levels of serum and CSF NfL 
will be log-transformed in all analyses. 
5.7 
ALSAQ-40 
The description of the ALSAQ-40 instrument and item-level scores are the same as described in 
the M-SAP. Each of the five domains will be scored as the mean of all domain-specific items 
multiplied by 25 (range 0 to 100). An overall symptom index (SI) will be scored as the mean of 
the five domain scores. A domain score will be missing if more than 20% of the items are 
missing; otherwise, item non-response will be mean-imputed from other completed items from 
the same assessment. The ALSAQ-40 SI will be missing if any domain scores are missing. 
Higher scores indicate worse quality of life. 


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5.8 
CNS-BFS 
The definition of CNS-BFS total score is the same as described in the M-SAP. 
5.9 
Survival 
The primary definition of survival time is the same as described in the M-SAP with the 
clarification that PAV is defined as more than 22 hours per day of noninvasive or invasive 
mechanical ventilation for more than seven consecutive days. The date of PAV initiation, where 
applicable, will be imputed as the fifteenth day of a month if not specified more precisely. A 
secondary survival endpoint of death alone, independent of any death equivalent, is also defined. 
Time at risk for the composite endpoint of death or death equivalent and time at risk for the 
endpoint of death alone will be measured from each participant's Baseline Visit. Time at risk will 
be censored at two time points: (1) at the Week 24 Visit as defined in the M-SAP, and (2) at a 
subsequent assessment of death or death equivalent scheduled approximately at the end of 
placebo-controlled follow-up of the last RGC participant, with the latter effectively a comparison 
of either no-treatment or 24-week delayed treatment (for those participants who enter the open-
label extension). The primary analysis of survival will evaluate PAV-free survival to the Week 
24 Visit time point. 
5.10 Pharmacokinetics of CNM-Au8 
Whole blood and plasma samples collected at the Baseline and Week 24 visits will be analyzed 
to quantify the concentration of CNM-Au8. Details of the CNM-Au8 assay technique and 
analysis plan will be specified in a separate PK analysis plan. This plan will be finalized prior to 
database lock. 
5.11 King's ALS Clinical Staging System 
The King's ALS Clinical Staging System (Roche et al. 2012) is a 4-level ordinal scale with the 
first three levels indicating the number (1, 2, or 3) of distinct central nervous system regions 
(bulbar, upper limb, and lower limb) with neuromuscular dysfunction and levels 4a and 4b 
indicating nutritional or respiratory failure secondary to ALS, respectively. 
Participants will be classified to King's stage 1, 2, 3, 4a, or 4b based on scores from ALSFRS-R 
assessments according to a published derivation (Balendra et al. 2014). Bulbar involvement is 
defined as a score less than 4 on any of the ALSFRS-R questions in the bulbar domain (questions 
1, 2, and 3). Upper limb involvement is defined as a score less than 4 on either of the ALSFRS-R 
questions related to hand function (questions 4 and 5A). Lower limb involvement is defined as a 
score less than 4 on the ALSFRS-R question about walking (question 8). Nutritional failure is 
defined as responding that the participant uses gastrostomy for greater than 50% of their 
nutrition. Respiratory failure is defined as a score of 0 on the ALSFRS-R question addressing 
dyspnea (question 10 or R-1) or a score less than 4 on the ALSFRS-R question about use of 
mechanical ventilation (question 12 or R-3). Participants without evidence by ALSFRS-R scores 
of involvement of any of the three central nervous system regions will be scored as King's stage 
1 due to their confirmed diagnosis with ALS. Participants may meet criteria for both King's stage 
4a and 4b. 


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5.12 Hospitalization and Other Clinical Events 
Times to the following clinically relevant events are defined: 
• Time to first hospitalization due to a serious adverse event (SAE),  
• Time to first hospitalization due to an ALS-related SAE,  
• Time to first use of assisted ventilation,  
• Time to first placement of a feeding tube,  
• Time to King's stage 4a or 4b,  
• Time to first instance of feeding tube placement, tracheostomy, initiation of PAV, or death, 
and  
• Time to first instance of hospitalization for an SAE, feeding tube placement, tracheostomy, 
initiation of PAV, or death. 
Time at risk for each event will be measured from each participant's Baseline Visit. Time to first 
hospitalization excludes hospitalizations for elective procedures. ALS-related SAEs are those 
indicated as related to ALS disease progression by the site investigator. Participants will be 
excluded from respective analysis (as applicable) if: (i) they are already using assisted ventilation 
or have a feeding tube at the time of the Baseline Visit, (ii) they have answered Question 5B on 
the ALSFRS-R at the Baseline visit, or (iii) have scored 0 points on Question 10 or less than 4 
points on Question 12 of the ALSFRS-R at the Baseline visit. Death or death equivalent will be 
considered an outcome for each of the events listed, forming a composite endpoint. 
Time at risk for these events will be censored at the Week 24 Visit, if completed, the date of 
consent withdrawal, if withdrawn, or the last date at which the status of each endpoint is known 
prior to the end of the Week 24 Visit window for participants lost to follow-up. Time to King's 
stage 4a or 4b is interval censored between ALSFRS-R assessments. 
5.13 Pharmacodynamic Biomarkers 
Whole blood and urine PD samples collected at the Baseline and Week 24 visits and plasma PD 
samples collected at the Baseline, Week 4, Week 8, and Week 24 visits will be analyzed 
according to a separate PD analysis plan. The PD analysis plan will be finalized prior to database 
lock. 
5.14 Pharmacokinetics of Riluzole 
Plasma samples collected at the Baseline, Week 4, and Week 8 visits from the first forty (40) 
RGC participants taking riluzole who reach the Week 8 visit plus plasma samples collected at the 
Baseline Visit from an additional ten (10) RGC participants not taking riluzole will be analyzed 
to quantify riluzole concentration by high-performance liquid chromatography mass 
spectroscopy (LC/MS/MS) [Covance, Method ID: M10125, Study Number 8454-985]. 
5.15 Clinical Safety Laboratory Tests 
Clinical safety labs include hematology, blood chemistry panel, liver function tests, thyroid 
function, urinalysis, and pregnancy testing in women of childbearing potential as specified in 
Section 9.1.2 Clinical Safety Laboratory Tests of the Master Protocol: 


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• Hematology: hematocrit, hemoglobin, platelet count, red blood cell (RBC) count, mean 
corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin 
concentration, RBC distribution width (RDW), RBC morphology, white blood cell (WBC) 
count, and counts and percentages of basophils, eosinophils, lymphocytes, monocytes, and 
neutrophils; 
• Blood chemistry panel: bicarbonate, chloride, potassium, sodium, calcium, magnesium, 
phosphate, blood urea nitrogen, creatinine, estimated glomerular filtration rate (eGFR) 
calculated using the Modification of Diet in Renal Disease (MDRD) four-variable equation, 
creatinine clearance calculated using the Cockcroft-Gault equation, and glucose; 
• Liver function tests: alanine aminotransferase (ALT [SGPT]), aspartate aminotransferase 
(AST [SGOT]), alkaline phosphatase (ALP), albumin, total protein, total bilirubin (TBL); 
• Thyroid function tests: thyroid-stimulating hormone (TSH); 
• Urinalysis: clarity, color, specific gravity, pH, microalbumin, protein, glucose, ketones, 
bilirubin, urobilinogen, nitrite, leukocyte esterase, and blood; and  
• Pregnancy: qualitative and quantitative serum human chorionic gonadotropin (hCG). 
Clinical safety labs will also include derived measures of potential drug-induced liver injury 
(DILI), including those that potentially meet the Hy’s law criteria, as distinct safety lab 
outcomes. 
Three potential DILI criteria will be defined: 
• ALT or AST >3x ULN with TBL >1.5x ULN 
• AST or ALT >3x ULN with TBL >2x ULN 
• AST or ALT >3x ULN with TBL >2x ULN and ALP <2x ULN (potential Hy’s Law cases) 
where ULN is upper level of normal and all levels are measured on the same day. 
6. Statistical Methodology 
6.1 
Analysis Sets 
The ITT analysis set is henceforth referred to as the Full Analysis Set (FAS) and defined as 
follows: 
• 
Full Analysis Set (FAS): Participants who were randomized within RGC plus placebo 
participants from specified regimens, classified according to their randomized treatment 
assignment. Observations made after premature permanent discontinuation of study drug are 
included in this sample, should such participants remain on study. Observations completed 
after regimen data lock are excluded. Participants determined to not meet ALS diagnostic 
criteria are excluded. 
The definition of the STF analysis set is revised as follows: 
• 
Safety Full (STF) Set: Participants who initiated treatment within RGC plus placebo 
participants from specified regimens who are not known to be ineligible for RGC and who 
initiated treatment in their respective regimen, classified according to the treatment they 


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actually received. Observations made after premature permanent discontinuation of study 
drug are included in this sample, should such participants remain on study. Observations 
completed after regimen data lock are excluded. 
An analysis set restricting shared placebo participants to those regimens in which study drug is 
administered by the same route as RGC is defined as follows: 
• Efficacy Common Mode of Administration (ECM) Set: The subset of participants in the FAS 
analysis set who are in regimens in which study drug is administered by the same route as 
RGC (oral administration). 
The definitions of the ECC, ERO, STN, and SRO analysis sets are the same as described in the 
M-SAP with reference to the ITT analysis set now referencing the FAS analysis set. The 
following analysis set is specific to RGC: 
• 
Efficacy Per-protocol (EPP) Set: The subset of participants in the FAS analysis set who 
initiated study treatment and who were not involved in protocol deviations that affected the 
scientific integrity of the trial as documented prior to data lock, classified according to the 
treatment they actually received. Inclusion or exclusion from the EPP analysis set of any 
participant for whom treatment assignment was unblinded prior to data lock will be governed 
by the prespecified criteria above. If a participant's data is truncated for inclusion in the EPP 
analysis set due to non-adherence to protocol-specified dosing, clinical events observed up to 
28 days after the censoring event will be included in the EPP analysis set. For all other events 
leading to truncation of a participant's data, no events beyond that date will be included. Data 
from placebo participants shared from other regimens will not be truncated due to non-
adherence to protocol-specified dosing. 
Applicable analysis sets (FAS, ECM, EPP, STF, and STN) will include shared placebo 
participants from regimens A, B, and D. Data from shared placebo participants will include visits 
and events that occurred on or before the date of the final placebo-controlled period follow-up of 
an RGA, RGB, or RGC participant. As only concurrently enrolling regimens are contributing to 
efficacy analyses, the FAS and ECC analysis sets are synonymous and only the FAS analysis set 
will be referenced. As regimen A is administered by subcutaneous injection and regimens B and 
D are administered orally, only regimens B and D will contribute shared placebo participants for 
the ECM and STN analysis sets. 
6.2 
Baseline Characterization 
The baseline characteristics summarized for participants randomized within RGC are the same as 
specified in the M-SAP with the addition of ALSAQ-40 domain scores and SI, CNS-BFS total 
score, King's stage, weight, body mass index (BMI), serum urate concentration, serum creatinine 
concentration, serum NfL concentration, urinary p75[ECD], and vital capacity predicted from 
quantitative voice characteristics. 
6.3 
Primary Efficacy Analysis and Supportive Analyses 
The primary analysis for RGC is a Bayesian shared-parameter, repeated-measures model of 
ALSFRS-R that accounts for loss of follow-up due to mortality. Details of the model, including 
documentation of operating characteristics under a range of scenarios, are provided in the "ALS 
Master Protocol Recommended Statistical Analysis, Design and Simulation Report" (Appendix 1 
to the Master Protocol). The Bayesian shared-parameter, repeated-measures model will be 


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applied to the FAS analysis set as the primary analysis, to the ECM and ERO analysis sets as 
sensitivity analyses, and to the EPP analysis set as a supportive analysis. 
The estimand of the primary analysis is the relative rate of disease progression (the "disease rate 
ratio" or DRR) of the two active treatment groups relative to placebo in the FAS population 
under an assumption that active treatment slows mean time to death or death equivalent by the 
same proportion as treatment slows the mean rate of functional progression as measured by 
change in ALSFRS-R total score over time. The estimand is defined by the following attributes: 
• Treatment: CNM-Au8 administered orally at dosages of 30 mg/d and 60 mg/d vs. placebo. 
• Population: FAS population as defined in Section 6.1. 
• Variables: time to death or death equivalent and rate of change in ALSFRS-R total score 
from baseline to the Week 24 Visit. 
• Intercurrent event 1: treatment discontinuation due to death: no ALSFRS-R data from 
participants who reach the death or death equivalent endpoint are included in the analysis; 
instead, death or death equivalent are handled by a mortality component within the model, 
composite variable strategy approach. 
• Intercurrent event 2: treatment discontinuation not due to death: handled via treatment policy 
approach, all data will be used including data collected during the placebo-controlled period 
after treatment discontinuation regardless of concomitant medication, for those participants 
who have not been censored due to mortality. Missing data post-treatment will not be 
imputed, handled via missing at random assumption. 
• Population-level summary: mean ratio of hazard or progression rate of active treatment 
relative to placebo. 
6.4 
Interim Analysis 
RGC will be considered for early stopping for futility according to the interim analysis schedule 
and definition specified in the "ALS Master Protocol Recommended Statistical Analysis, Design 
and Simulation Report" (Appendix 1 to the Master Protocol). RGC will not be stopped early for 
success. 
6.5 
Secondary Efficacy Analyses 
6.5.1 Hierarchical Testing 
Primary inference for secondary efficacy endpoints will be based on analysis of the FAS analysis 
set using a joint-rank comparison for the combined assessment of function and survival (CAFS 
(Section 6.5.2 below), a repeated-measures linear mixed model for SVC (see Section 6.5.3 
below), and Kaplan-Meier product-limit estimates and log-rank test for the primary survival 
endpoint (see Section 6.5.4 below) with a comparison between all active arm participants (i.e., 
the average of both 30 mg/d and 60 mg/d dosage groups) vs. placebo participants. The sequence 
for testing secondary efficacy endpoints is the following: 
1. CAFS,  
2. SVC, 
3. Survival. 


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If the primary analysis indicates a significant slowing in disease progression from the Bayesian 
shared-parameter, repeated-measures model of ALSFRS-R and mortality, then each secondary 
efficacy endpoint in succession would be declared significant in the specified sequence using a 
comparison-wise criterion of two-tailed p < 0.05. After the first failure to declare significance, no 
endpoints lower in the hierarchy can be significant. This sequential closed-testing procedure 
controls the overall type 1 error rate at 5%. Nominal comparison-wise p-values for secondary 
efficacy endpoints will also be reported. 
6.5.2 CAFS 
The test consists of calculating a rank-sum score for each individual relative to pair-wise 
comparisons with all other participants. Participants are first ranked according to time to death or 
death equivalent when that is observed for both members of a pair or when one is censored after 
the observed event time for the other. Pairs that cannot be ranked by time to death or death 
equivalent are subsequently ranked by absolute change from baseline in ALSFRS-R total score 
at the maximum follow-up time at which both participants have an observation.  
The primary CAFS analysis is the same as specified in the MPRDR with the clarification that the 
active treatment group pools participants randomized to 30 mg/d CNM-Au8 and 60 mg/d CNM-
Au8. 
The estimand is the stochastic probability that a randomly selected active participant will rank 
higher than a randomly selected placebo participant based on time to death or death equivalent or 
change from baseline in ALSFRS-R. The estimand is defined by the following attributes: 
• Treatment: CNM-Au8 administered orally at dosages of 30 mg/d and 60 mg/d vs. placebo. 
• Population: FAS population as defined in Section 6.1. 
• Variables: ranksum for relative time to death or death equivalent up to the Week 24 Visit or 
absolute change from baseline in ALSFRS-R total score. 
• Intercurrent event: treatment discontinuation: handled via treatment policy approach, with 
pair ranked comparisons up at the maximum follow-up time at which both participants have 
an observation. 
• Population-level summary: difference in means of ranks of active treatment relative to 
placebo. 
Inference from this analysis is supportive of inference from the Bayesian shared-parameter, 
repeated-measures model for the primary endpoint and is the primary analysis for this secondary 
endpoint. 
The following SAS code specifies the analysis: 
proc mixed data=work.cafs; 
  class trtrnd(ref='0'); 
  model Rank = sx2bl dFRS rlz edv trtrnd / solution clparm; 
  estimate "Active vs. Placebo (one-sided)" Treat 1 -1 / cl upper; 
run; 
where trtrnd indicates treatment group (active = 1 or placebo = 0), Rank is the sum of the ranks 
(-1, 0, 1) of each participant vs. every other participant in the FAS analysis set, sx2bl is years 


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since ALS symptom onset, dFRS is pre-baseline slope, rlz is an indicator of riluzole use at 
baseline, and edv is an indicator of edaravone use at baseline. A significant difference requires 
interpretation based on estimates from the survival analysis described in Section 6.5.4 and the 
repeated-measures analysis of ALSFRS-R total score described in Section 6.5.3. 
In addition to the joint-rank CAFS analysis of PAV-free survival and change in ALSFRS-R total 
score including adjustment for covariates, the following additional joint-rank analyses will also 
be performed: 
1. SVC will be analyzed as a joint-rank test by substituting the change from baseline of 
SVC in place of ALSFRS-R total score as an additional supportive analysis,  
2. An additional set of joint-rank analyses will use multiple imputation to extend follow-up 
of (i) ALSFRS-R total score and (ii) SVC for participants who early terminate, withdraw 
consent, or are lost to follow-up as supportive analyses,  
3. An additional set of joint-rank analyses for (i) ALSFRS-R total score and (ii) SVC will 
use time to death independent of any death equivalent as supportive analyses,  
4. An additional set of joint-rank analyses for (i) ALSFRS-R total score and (ii) SVC will 
adjust rank scores in a linear model with the following covariates: time from ALS 
symptom onset, delta-FRS, baseline use of riluzole, baseline use of edaravone, and 
baseline serum NfL level, and  
5. An additional set of joint-rank analyses for (i) ALSFRS-R total score and (ii) SVC 
without adjustment and comparing pairs of participants at the last jointly observed time 
point as sensitivity analyses. 
The multiple imputation model referenced as method 2 above and used to extend follow-up of 
functional scores for participants who early terminate, withdraw consent, or are lost to follow-up 
will use linear regression with covariates of time since symptom onset, delta-FRS, baseline 
riluzole use, baseline edaravone use, and each observed functional score prior to a missing 
assessment. 
Inference from the joint-rank analyses of SVC are supportive of inference from the repeated-
measures model. Primary inference from the joint-rank CAFS analyses will compare survival by 
time to death or death equivalent, will compare change in function to the last jointly observed 
time point, and will adjust for the specified covariates. 
6.5.3 Repeated-measures Model 
The specification of the repeated-measures linear mixed model and the primary linear contrast 
for estimating differences in 24-week change from baseline in a given continuous efficacy 
endpoint (ALSFRS-R total and domain scores, HHD upper extremity, lower extremity, and 
global average percentages, SVC, FVC by home spirometry, serum creatinine, serum NfL, 
urinary p75[ECD], ALSAQ-40 domain scores and SI, and CNS-BFS total score) are revised 
from those specified in the M-SAP to include a main effect of treatment and with the 
modification that treatment group is a three-level variable (i.e., placebo, 30 mg/d CNM-Au8, and 
60 mg/d CNM-Au8). 
The model will include fixed terms for discrete visit, treatment group (3 levels), treatment group 
× visit interaction, centered time since symptom onset and centered time since symptom onset × 
visit interaction, centered delta-FRS and centered delta-FRS × visit interaction, centered baseline 
riluzole use and centered baseline riluzole × visit interaction, and centered baseline edaravone 


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use and centered baseline edaravone × visit interaction. The following equations describe the 
model with regimen random effects: 
𝑌𝑌𝑖𝑖𝑖𝑖= 𝑎𝑎𝑘𝑘(𝑖𝑖) + 𝛾𝛾1𝑡𝑡𝑖𝑖+ 𝛾𝛾2,𝑗𝑗𝑣𝑣𝑗𝑗+ 𝜸𝜸𝟑𝟑
′ 𝒛𝒛𝒊𝒊+ 𝛾𝛾4,𝑗𝑗 𝑡𝑡𝑖𝑖𝑣𝑣𝑗𝑗+ 𝜸𝜸𝟓𝟓,𝒋𝒋
′ 𝒛𝒛𝑖𝑖 𝑣𝑣𝑗𝑗+ 𝜖𝜖𝑖𝑖𝑖𝑖 
𝑎𝑎𝑘𝑘 ~ 𝑁𝑁(0, 𝜎𝜎𝑟𝑟
2), 𝝐𝝐𝒊𝒊∙ ~ 𝑁𝑁(𝟎𝟎, 𝑹𝑹), Cov൫𝑏𝑏𝑘𝑘(𝑖𝑖), 𝜖𝜖𝑖𝑖𝑖𝑖൯= 0 
(eqn. 1)
where Yij is a given efficacy endpoint measured in participant i at visit j, ak(i) is a random 
intercept for regimen k to which participant i was assigned, vj is an indicator variable for visit j, zi 
is the vector of covariates (centered time since onset, centered delta-FRS, centered baseline 
riluzole use, and centered baseline edaravone use) for participant i, ti is an indicator variable for 
treatment t to which participant i was assigned, γ1, γ2,j, γ3, γ4,j, and γ5,j are estimated parameters 
and vectors of parameters for the fixed effects, and ϵij is the residual for participant i at visit j. 
The regimen-specific random effects are normally distributed with mean 0 and variance σ2r. The 
vector of residuals for a given participant are normally distributed with mean 0 and an 
unstructured covariance matrix R. The regimen-specific random effect for a given participant 
and residuals for that participant are uncorrelated. 
The following SAS code specifies the model: 
proc mixed data=xxx method=reml; 
  class regimen id trtrnd visit; 
  model Value = trtrnd|visit  
                sx2bl|visit dFRS|visit rlz|visit edv|visit / solution cl; 
  random intercept / subject=regimen type=vc; 
  repeated visit / subject=id type=un; 
where id is a participant study identifier, trtrnd is the randomly assigned treatment group, 
visit is the visit identifier, Value is value of the efficacy endpoint being tested for a given 
participant at a given visit, sx2bl is years since ALS symptom onset centered at the sample 
median, dFRS is pre-baseline slope centered at the sample median, rlz is an indicator of riluzole 
use at baseline, and edv is an indicator of edaravone use at baseline. The primary estimate will 
be the treatment-dependent difference in change from baseline to the Week 24 Visit. The 
estimate and its 95% Wald confidence bounds will be obtained by a linear contrast of adjusted 
means. 
The estimand estimated by the primary linear contrast of the shared-baseline, repeated-measures 
linear mixed model is the mean difference in 24-week change from baseline of a given 
continuous efficacy endpoint in the two active treatment groups relative to the placebo group in 
the FAS population. The estimand is defined by the following attributes: 
• Treatment: CNM-Au8 administered orally at dosages of 30 mg/d and 60 mg/d vs. placebo. 
• Population: FAS population as defined in Section 6.1. 
• Variables: absolute change in endpoint from baseline to the Week 24 Visit. 
• Intercurrent event: treatment discontinuation: handled via treatment policy approach, all data 
will be used including data collected during the placebo-controlled period after treatment 
discontinuation. Missing data post-treatment, including data missing due to death, will not be 
imputed, handled via missing at random assumption. 


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• Population-level summary: difference in conditional means of active treatment relative to 
placebo. 
Inference from this analysis is supportive of inference from the Bayesian shared-parameter, 
repeated-measures model for the primary endpoint and is the primary analysis for the secondary 
SVC endpoint. 
The following SAS code specifies the linear contrast for an endpoint measured every 8 weeks 
and assuming that the sort order for treatment group is placebo, 30 mg/d CNM-Au8, and 60 mg/d 
CNM-Au8 and visits are sorted chronologically: 
  estimate "3|Act vs Plb|dWk 24"  
           post*trtrnd*visit 2 0 0 -2  -1 0 0 1  -1 0 0 1 / cl divisor=2; 
A significant difference in 24-week change in the direction of improved function would support 
inference that CNM-Au8 treatment reduced progression over 24 weeks for the efficacy endpoint 
being tested. 
A separate supportive analysis for clinical endpoints (ALSFRS-R total and domain scores, HHD 
upper extremity, lower extremity, and global average percentages, SVC, FVC by home 
spirometry, ALSAQ-40 domain scores and SI, and CNS-BFS total score) will include centered 
baseline serum NfL level and the interaction of centered baseline serum NfL level and visit as 
additional covariates. 
6.5.4 Survival 
The primary estimate of the effect of treatment on survival as an efficacy endpoint will include 
both death and death equivalent as components, will pool participants randomized to 30 mg/d 
CNM-Au8 and 60 mg/d CNM-Au8 in the FAS analysis set, and will include baseline age as an 
additional covariate in adjusted models. Otherwise, summaries and analyses of time to death or 
death equivalent are the same as specified in the M-SAP. 
The estimand estimated by the logrank test is the deviation in expected survival times in the FAS 
population. The estimand is defined by the following attributes: 
Treatment: CNM-Au8 administered orally at dosages of 30 mg/d and 60 mg/d vs. placebo. 
Population: FAS population as defined in Section 6.1. 
Variables: time to earlier of death or death equivalent. 
Intercurrent event: treatment discontinuation: handled via treatment policy approach, all data 
will be used including data collected during the placebo-controlled period after treatment 
discontinuation. Missing data post-treatment will not be imputed, handled via missing 
completely at random assumption. 
Population-level summary: difference in survival curves of active treatment and placebo. 
In the presence of a significant different by the logrank test, inference on whether active 
treatment extended survival will be based on the hazard ratio estimated from an unadjusted Cox 
proportional hazards regression. 
Survival to the end of the placebo-controlled period will also be analyzed in the ECM, ERO, 
EPP, STF, SFN, and SRO analysis sets. Survival analyses that include follow-up beyond the 
placebo-controlled period will be analyzed in the ERO analysis set. 


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Listings of all participants in the FAS, ECM, ERO, EPP, STF, and SRO analysis sets will 
document whether each participant had died, had reached a death equivalent endpoint, or was 
alive and free of a death equivalent and the study day of death, death equivalent, or last know 
alive and free of a death equivalent for each analysis timepoint. 
6.5.5 Random-slopes Model 
The specification of the random-slopes linear mixed model and the primary linear contrast for 
estimating differences in mean rate of progression in a given continuous efficacy endpoint 
(ALSFRS-R total and domain scores, HHD upper extremity, lower extremity, and global average 
percentages, SVC, FVC by home spirometry, quantitative voice characteristics, serum creatinine, 
serum NfL, urinary p75[ECD], ALSAQ-40 domain scores and SI, and CNS-BFS total score) are 
revised from those specified in the M-SAP  to include a main effect of treatment and with the 
modification that treatment group is a three-level variable (i.e., placebo, 30 mg/d CNM-Au8, and 
60 mg/d CNM-Au8). 
The model will include fixed terms for month since the Baseline Visit, treatment group, 
treatment group × month interaction, centered years since ALS symptom onset and centered 
years since ALS symptom onset × month interaction, centered delta-FRS and centered delta-FRS 
× month interaction, centered baseline riluzole use and centered baseline riluzole use × month 
interaction, and centered baseline edaravone use and centered baseline edaravone use × month 
interaction. The following equations describe the model with regimen random effects: 
𝑌𝑌𝑖𝑖𝑖𝑖= 𝛾𝛾1 + 𝑎𝑎𝑘𝑘(𝑖𝑖)
0
+ 𝑏𝑏𝑖𝑖
0 + 𝛾𝛾2𝑡𝑡𝑖𝑖+ 𝜸𝜸𝟑𝟑
′ 𝒛𝒛𝒊𝒊
+ ൫𝛾𝛾4 + 𝑎𝑎𝑘𝑘(𝑖𝑖)
1
+ 𝑏𝑏𝑖𝑖
1 + 𝛾𝛾5𝑡𝑡𝑖𝑖+ 𝜸𝜸𝟔𝟔
′ 𝒛𝒛𝒊𝒊൯ 𝑚𝑚𝑖𝑖𝑖𝑖+ 𝜖𝜖𝑖𝑖𝑖𝑖 
{𝑎𝑎𝑘𝑘
0, 𝑎𝑎𝑘𝑘
1} ~ 𝑁𝑁(𝟎𝟎, 𝚺𝚺𝒓𝒓), {𝑏𝑏𝑘𝑘
0, 𝑏𝑏𝑘𝑘
1} ~ 𝑁𝑁൫𝟎𝟎, 𝚺𝚺𝒑𝒑൯, 𝜖𝜖𝑖𝑖𝑖𝑖 ~ 𝑁𝑁(0, 𝜎𝜎𝜖𝜖
2) 
Cov(𝒂𝒂𝑘𝑘, 𝒃𝒃𝑘𝑘) = 𝟎𝟎, Cov(𝒂𝒂𝑘𝑘, 𝝐𝝐𝑖𝑖∙) = 𝟎𝟎, and Cov(𝒃𝒃𝑘𝑘, 𝝐𝝐𝑖𝑖∙) = 𝟎𝟎 
(eqn. 2)
where Yij is a given efficacy endpoint measured in participant i at visit j, a0k(i) and a1k(i) are 
random intercept and slope for regimen k to which participant i was assigned, b0i and b1i are 
random intercept and slope for participant i, zi is the vector of covariates (centered time since 
onset, centered delta-FRS, centered baseline riluzole use, and centered baseline edaravone use) 
for participant i, mij is the time from baseline to observation j for participant i in months 
calculated as days x 12 / 365.25, ti is an indicator variable for treatment t to which participant i 
was assigned, γ1, γ2, γ3, γ4, γ5, and γ6 are estimated parameters and vectors of parameters for the 
fixed effects, and ϵij is the residual for observation j for participant i. The regimen-specific 
random effects are normally distributed with mean 0 and unstructured covariance matrix Σr. The 
participant-specific random effects are normally distributed with mean 0 and unstructured 
covariance matrix Σp. The residuals for a given participant are normally distributed with mean 0 
and variance σ2ϵ. The regimen-specific random effects, participant-specific random effects, and 
residuals are uncorrelated. 
The following SAS code specifies the model: 
proc mixed data=xxx method=reml; 
  class regimen id trtrnd; 
  model Value = trtrnd|month  
                sx2bl|month dFRS|month rlz|month edv|month / solution cl; 
  random intercept month / subject=regimen type=un; 


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  random intercept month / subject=id type=un; 
where month is time in months from the Baseline Visit (assuming 12 months in an average of 
365.25 days per year) and other fields are the same as identified above in Section 6.5.3. The 
primary estimand will be the treatment-dependent difference in slopes. The estimate and its 95% 
Wald confidence bounds will be obtained by a linear contrast of adjusted means. 
The estimand estimated by the primary linear contrast of the random-slopes linear mixed model 
is the difference in mean rate of progression of a given continuous efficacy endpoint in the two 
active treatment groups relative to the placebo group in the FAS population. The estimand is 
defined by the following attributes: 
Treatment: CNM-Au8 administered orally at dosages of 30 mg/d and 60 mg/d vs. placebo. 
Population: FAS population as defined in Section 6.1. 
Variables: mean rate of change in endpoint from baseline to the Week 24 Visit. 
Intercurrent event: treatment discontinuation: handled via treatment policy approach, all data 
will be used including data collected during the placebo-controlled period after treatment 
discontinuation. Missing data post-treatment will not be imputed, handled via missing at 
random assumption. 
Population-level summary: difference in conditional mean slopes of active treatment relative 
to placebo. 
Inference from these analyses is supportive of inference from the Bayesian shared-parameter, 
repeated-measures model for the primary endpoint and inference from the repeated-measures 
linear mixed model for secondary endpoints. 
The following SAS code specifies the linear contrast assuming that the sort order for treatment 
group is placebo, 30 mg/d CNM-Au8, and 60 mg/d CNM-Au8: 
  estimate "3|Act vs Plb|Slope (/mn)"  
           month 0 trtrnd*month -2 1 1 / cl divisor=2; 
A significant difference in slopes in the direction of improved function would support inference 
that the treatment reduced rate of progression for the efficacy endpoint being tested. 
A separate supportive analysis for clinical endpoints (ALSFRS-R total and domain scores, HHD 
upper extremity, lower extremity, and global average percentages, SVC, FVC by home 
spirometry, quantitative voice characteristics, ALSAQ-40 domain scores and SI, and CNS-BFS 
total score) will include centered baseline serum NfL level and the interaction of centered 
baseline serum NfL level and study month as additional covariates. 
6.5.6 Time to Clinical Events 
Time to hospitalizations and clinical events will be analyzed in the FAS, ECM, ERO, and EPP 
analysis sets. The summaries and analyses will parallel the analyses described for survival 
described in Section 6.5.4. Analysis of time to King's stage 4a or 4b and time to a 6-point decline 
in ALSFRS-R total score will accommodate interval censoring between ALSFRS-R assessments. 
Analysis of time to King's stage 4a or 4b will be stratified by baseline King's stage. 


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6.5.7 Composite of ALSFRS-R, SVC, and ALSAQ-40 Slopes 
Participant-specific rates of change in ALSFRS-R total score, SVC percent-predicted, and 
ALSAQ-40 total score will be estimated in separate, endpoint-specific unadjusted random-slopes 
linear mixed models in the FAS, ECM, and ERO analysis sets. Participant-specific random 
slopes for each endpoint will be standardized to a mean of zero (0) and a variance of one (1) and 
then averaged for each participant. The composite average of standardized random slope 
estimates will be compared across treatment groups by one-way analysis of variance with 
adjustment for the following median-centered covariates: years since ALS symptom onset, delta-
FRS, baseline riluzole use, and baseline edaravone use. A separate analysis will include baseline 
serum NfL level as an additional covariate. Treatment comparison between all active arm 
participants (i.e., the average of both 30 mg/d and 60 mg/d dosage groups) vs. placebo 
participants and between each active treatment group separate vs. placebo will be estimated 
using contrasts of least-square means. 
6.5.8 HHD0 and HHD02 
Analyses of HHD0 are the same as specified in the M-SAP with the modification that treatment 
group is a three-level variable (i.e., placebo, 30 mg/d CNM-Au8, and 60 mg/d CNM-Au8), with 
addition of parallel analyses of HHD02, with a separate analysis that includes baseline serum 
NfL level as an additional covariate, and with the clarification that time to zero strength for both 
analyses is interval censored between HHD assessments. 
Inference from these analyses is supportive of inference from the repeated-measures linear mixed 
model for HHD upper and lower extremity scores. 
6.5.9 Quantitative Voice Measures 
Given the high frequency of voice recordings, a repeated-measures analysis with unstructured 
covariance is overly flexible but the assumption of linear change required by the random-slopes 
model may be overly rigid. To complement estimates from the random-slopes linear mixed 
model, quantitative voice characteristics will be analyzed in a linear mixed model in which the 
temporal profile for both fixed and random terms is modeled using cubic B-splines with knots at 
8 and 16 weeks. The model will include fixed terms for B-splines (4 terms), treatment group (3 
levels), treatment group × B-spline interaction, centered time since symptom onset and centered 
time since symptom onset × B-spline interaction, centered delta-FRS and centered delta-FRS × 
B-spline interaction, centered baseline riluzole use and centered baseline riluzole × B-spline 
interaction, and centered baseline edaravone use and centered baseline edaravone × B-spline 
interaction. The model will include random regimen-specific intercepts and slopes with 
unstructured covariance, random participant-specific B-splines (5 terms) with unstructured 
covariance, and a first-order autoregressive structure for residuals. A simplified covariance 
structure assuming no regimen-level covariance, heterogeneous compound symmetric covariance 
among the random B-splines, conditional independence of residuals, or a combination of the 
three simplifying assumptions will be used if the full model fails to converge. The primary 
estimand will be the active (i.e., the average of both 30 mg/d and 60 mg/d dosage groups) vs. 
placebo treatment-dependent difference in 24-week change from baseline. The estimate and its 
95% Wald confidence bounds will be obtained by a linear contrast of adjusted means. 
A separate supportive analysis will include centered baseline serum NfL level and the interaction 
of centered baseline serum NfL level and B-splines as additional covariates. 


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6.5.10 Placebo Multiple Imputation 
Placebo multiple imputation analyses are the same as specified in the M-SAP with the 
modification that treatment group is a three-level variable (i.e., placebo, 30 mg/d CNM-Au8, and 
60 mg/d CNM-Au8). Placebo multiple imputation analyses will be applied to ALSFRS-R total 
score, HHD upper and lower extremity percentages, and SVC. 
The following SAS code specifies the imputation for an endpoint measured every 8 weeks: 
proc mi data=work.outcomes seed=xxx nimpute=50 out=work.out_mi01  
        minimum=. . . . . x x x x maximum=. . . . . y y y y minmaxiter=1000; 
  class rlz edv trtrnd; 
  fcs reg(Wk08 = sx2bl dFRS rlz edv Wk00); 
  fcs reg(Wk16 = sx2bl dFRS rlz edv Wk00 Wk08); 
  fcs reg(Wk24 = sx2bl dFRS rlz edv Wk00 Wk08 Wk16); 
  mnar model( Wk08 Wk16 Wk24 / modelobs=(trtrnd="0")); 
  var sx2bl dFRS rlz edv Wk00 Wk08 Wk16 Wk24; 
run; 
where Wk00, Wk08, Wk16, and Wk24 are the values of a given efficacy endpoint at the Baseline, 
Week 8, Week 16, and Week 24 Visits, respectively, trtrnd has a value of zero (0) for 
participants randomized to placebo, and x and y take appropriate values to specify the range of a 
given outcome measure (i.e., 0 and 48 for ALSFRS-R total score; 0 and . for HHD upper and 
lower extremity percentages and SVC). 
Inference from these analyses is supportive of inference from the Bayesian shared-parameter, 
repeated-measures model for the primary endpoint and assess sensitivity to the missing data 
assumption of the repeated-measures linear mixed model for secondary endpoints in the FAS 
analysis set. A separate analysis will include centered baseline serum NfL level as an additional 
covariate in both imputation stages. 
6.5.11 Additional Sensitivity Analyses of Primary and Key Secondary Outcomes 
Sensitivity analyses of primary and key secondary efficacy outcomes are the same as specified in 
the M-SAP with the modification that treatment group is a three-level variable (i.e., placebo, 30 
mg/d CNM-Au8, and 60 mg/d CNM-Au8). 
6.5.12 Subgroup Analyses 
In addition to the subgroups specified in the M-SAP, the following additional subgroups will be 
analyzed in the random-slope model (see Section 6.5.5) for primary and secondary efficacy 
endpoints in the FAS analysis set: 
• Baseline use of riluzole and edaravone (neither, riluzole only, edaravone only, both),  
• Age (less than 65 years vs. 65 years or older),  
• Sex (female vs. male),  
• Race (white vs. any minority race with greater than 5% prevalence in the sample),  
• Ethnicity (Hispanic or Latino vs. non-Hispanic or Latino),  


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• Weight (less than 43 kg, 43 to less than 56 kg, 56 to less than 77 kg, 77 to less than 150 kg, 
150 kg or more),  
• BMI (less than 18.5 kg/m2, 18.5 to less than 25 kg/m2, 25 to less than 30 kg/m2, 30 to less 
than 40 kg/m2, 40 kg/m2 or more),  
• Chronic kidney disease (CKD) stage (stage 1 or better [eGFR 90 mL/min/1.73m2 or more], 
stage 2 [eGFR 60 to 89 mL/min/1.73m2], stage 3 [eGFR 30 to 59 mL/min/1.73m2], stage 4 
[eGFR 15 to 29 mL/min/1.73m2], stage 5 [eGFR less than 15 mL/min/1.73m2]),  
• Time since onset of weakness (less than 18 months vs. 18 months or longer),  
• El Escorial and time since onset of weakness (El Escorial definite and less than 18 months 
vs. not both),  
• Baseline symptom severity (all ALSFRS-R questions scored 2 or greater vs. any question 
scored 0 or 1),  
• Early disease state (all ALSFRS-R questions scored 2 or greater, SVC 80%-predicted or 
greater, and time since symptom onset less than 24 months vs. not meeting all three criteria),  
• Baseline serum urate concentration (less than 5.5 mg/dL vs. 5.5 mg/dL or greater),  
• Baseline serum NfL concentration (by median split),  
• Baseline delta-FRS score (less than 0.47 points/year, 0.47 to less than 1.11 points/year, 1.11 
points/year or greater),  
• Site of onset (any bulbar onset, no bulbar onset),  
• Site (individual sites with at least 5 participants per treatment group and all participants from 
sites with fewer than 5 participants per treatment group pooled). 
For each classification, unknown, not reported, and missing will be considered one group. All 
individuals not included in a specified subgroup will be combined into a mixed, "other" group. 
The "other" group will be included in analyses if its prevalence is greater than 5%; otherwise, the 
"other" group will be excluded. 
In cases where a model for a given subgroup and endpoint fails to converge, the covariance 
terms for the regimen-specific random effects will be simplified from unstructured covariance of 
intercepts and slopes to separate, uncorrelated variance components for intercepts and slopes. If 
convergence still fails, regimen-specific intercepts and slopes will be modeled as fixed effects. If 
convergence still fails, the participant-specific random effects will be simplified from 
unstructured covariance of intercepts and slopes to separate, uncorrelated variance components 
for intercepts and slopes. 
6.5.13 Comparison of Controls across Regimens 
Comparisons of placebo participants across regimens are the same as specified in the M-SAP 
with separate analyses that include baseline serum NfL level as an additional covariate plus 
applicable interaction terms as relevant to a given model. 


Cudkowicz (PI) HEALEY ALS Platform Trial: RGC Statistical Analysis Plan 
Version 3.0, 22 Jul 2022 
 
Page 34 of 35 
 
6.5.14 Pharmacokinetic Analyses of CNM-Au8 
Pre-dose concentrations of CNM-Au8 in whole blood and plasma will be summarized by 
treatment group and visit in the ERO sample. Concentrations below the limit of quantitation 
(BLQ) will be replaced with one half of the lower limit of quantitation. Summaries will include 
number of observations, number and percentage with concentrations BLQ, arithmetic mean, 
median, standard deviation, minimum, maximum, geometric mean, geometric coefficient of 
variation (calculated as sqrt(exp(variance of log-transformed concentrations) – 1)), and 95% 
confidence bounds for the geometric mean assuming log-normally distributed data. 
A concentration response relationship based on observed CNM-Au8 Cmax per active participant 
versus ALSFRS-R slope change will also be analyzed as an exploratory endpoint. 
Whole blood and plasma concentration data of CNM-Au8 may be subjected to population 
pharmacokinetic analysis to derive population estimates of pharmacokinetic parameters and test 
the effect of various covariates such as age, weight, and sex. Details of the analysis will be 
described in a separate data analysis plan (DAP). This analysis may be performed by combining 
data from the current study with data from other studies of CNM-Au8, if deemed appropriate. 
The tests of association with ALSFRS-R and the population pharmacokinetic analysis will be 
performed by Clene Nanomedicine or its designee and reported in a separate modelling report. 
6.5.15 Pharmacodynamic Biomarker Analyses 
Pharmacodynamic biomarkers other than serum creatinine, serum and CSF NfL, and urinary 
p75[ECD] will be analyzed by Clene Nanomedicine according to a separate pharmacodynamic 
DAP (Regimen C Pharmacodynamic Analysis Plan) and will be reported in a separate report. 
6.5.16 Pharmacokinetics of Riluzole 
Pharmacokinetic analysis of plasma riluzole concentrations will be analyzed according to a 
separate pharmacokinetic analysis plan authored and conducted by Dr. Charles Venuto, PharmD. 
6.6 
Safety Analyses 
6.6.1 Treatment-emergent Adverse Events 
Summaries and analyses of treatment-emergent adverse events (TEAE) are the same as specified 
in the M-SAP with the following revisions. 
TEAEs are defined as those adverse events with onset dates in the interval from double-blind 
treatment initiation to either the Final Safety Visit if completed, the date of death if the 
participant dies, 28 days after last dose of study drug if the participant early terminates or is lost 
to follow-up, or the date of first dose of study drug during participation in the OLE, if so 
exposed. Adverse events with onset on the day of double-blind treatment initiation and adverse 
events with incompletely specified onset date where the ambiguous date spans the day of double-
blind treatment initiation will be assumed to be treatment emergent except for those known to 
precede first exposure to study drug. 
In addition to summaries specified in the M-SAP, serious TEAEs will be summarized by 
MedDRA system organ class, high level term, and preferred term for all TEAEs. In addition, 
TEAEs will be summarized by Medical Dictionary for Regulatory Activities (MedDRA) system 
organ class and preferred term for fatal TEAEs, TEAEs that occurred during a participant's 
COVID-19 infection (defined as 5 days prior to symptom onset to end of COVID-19 symptoms 


Cudkowicz (PI) HEALEY ALS Platform Trial: RGC Statistical Analysis Plan 
Version 3.0, 22 Jul 2022 
 
Page 35 of 36 
 
or the earlier of 91 days after symptom onset or the end of double-blind follow-up, if ongoing), 
and TEAEs and serious TEAEs stratified by the following subgroups: baseline riluzole use, 
baseline edaravone use, age, sex, race, ethnicity, weight, BMI, and CKD stage. Subgroup 
classifications will be the same as described in Section 6.5.12 Subgroup Analyses except that the 
"other" group will be retained regardless of prevalence. 
TEAEs indicating COVID-19 infection are the following: Asymptomatic COVID-19, COVID-
19, COVID-19 pneumonia, COVID-19 treatment, Post-acute COVID-19 syndrome, SARS-CoV-
2 antibody test positive, SARS-CoV-2 RNA increased, SARS-CoV-2 sepsis, SARS-CoV-2 test 
false negative, SARS-CoV-2 test positive, SARS-CoV-2 viraemia, Suspected COVID-19. 
Treatment-dependent differences in the proportion of participants experiencing a given type of 
TEAE will not be tested. Treatment-dependent differences in TEAE incidence rates in units of 
number per 100 participant years will be estimated as differences rather than ratios and will 
include comparison-wise 95% confidence intervals with variance estimates obtained by the delta 
method. 
6.6.2 Safety Labs 
Summaries and analyses of clinical safety labs are the same as specified in the M-SAP with the 
revision that abnormal levels will be classified to a toxicity grade based on quantitative grading 
using National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events 
(CTCAE) version 5.0 and with the addition that maximum toxicity over all post-baseline visits 
will be included in shift tables along with visit-specific shifts. 
The proportion of participants with ALT >3x ULN, AST >3x ULN, creatinine >1.5x level at the 
Baseline Visit, and platelet count <75,000/mm3, or with any of the four will be presented as shift 
tables vs. the status of each participant at baseline for each visit by treatment group in all safety 
samples. The absolute level and the absolute change from baseline for ALT, AST, creatinine, and 
platelet count will be summarized as means, standard deviations, medians, and ranges at each 
visit by treatment group in all safety samples. 
6.6.3 ECG Results 
Summaries of ECG parameters and findings are the same as specified in the M-SAP. 
6.6.4 Vital Signs and Weight 
Summaries and analyses of vital signs and weight are the same as specified in the M-SAP. 
6.6.5 Suicidality 
Summaries of suicidality are the same as specified in the M-SAP. 
6.7 
Other Analyses 
6.7.1 Participant Disposition 
All participants consented to the Master Protocol between the time of the first and last consent of 
a participant assigned to a regimen included in the FAS analysis set will be summarized as a 
single set for the following events: consented to the Master Protocol, failed screening for the 
Master Protocol, other reasons not assigned to a regimen (including timing out of the screening 
window, death, withdrawal of consent, early termination, and administrative termination), and 
assigned to a regimen. Reasons for Master Protocol screen failure will be summarized. 


Cudkowicz (PI) HEALEY ALS Platform Trial: RGC Statistical Analysis Plan 
Version 3.0, 22 Jul 2022 
 
Page 36 of 37 
 
All participants in the above sample assigned to a regimen will be summarized as two sets (final 
screening for RGC vs. final screening for a non-RGC regimen) for the following events: 
consented to a regimen, failed screening for a regimen, other reasons not randomized within a 
regimen (including timing out of the screening window, death, withdrawal of consent, early 
termination, and administrative termination), and randomized within a regimen. If a given 
individual is screened multiple times prior to randomization within a regimen, then the final 
screening experience of that individual will be summarized. Reasons for RGC screen failure will 
be summarized separately for all participants screened for RGC whether that was their final 
screening experience or not. 
All participants in the FAS analysis set will be summarized as two sets (randomization to active 
study drug vs. randomization to placebo) for the following events: initiated regimen-specific 
study drug, prematurely terminated study participation due to death, withdrawal of consent, early 
termination, loss to follow-up, or administrative termination, completed 24-week follow up, and 
completed a safety follow-up visit vs. continued into the OLE. Reasons for withdrawal of 
consent or early termination after randomization will be summarized. 
Any randomized participants excluded from the FAS and EPP analysis sets or included in the 
FAS analysis set but not contributing to the primary analysis will be identified in a listing 
together with the reason for their exclusion. 
6.7.2 Study Drug Compliance and Tolerance 
Summaries of study drug compliance and tolerance are the same as specified in the M-SAP with 
the clarification that summaries will be reported for the ERO and SRO analysis sets and that date 
of permanent discontinuation of study drug is the date of last use of double-blind study drug 
among all participants in a given analysis set. 
The number of days of exposure to study drug will be calculated in three ways: 
• as the number of days from dose initiation to the final safety assessment during the placebo-
controlled period, inclusive,  
• as the number of days from dose initiation to drug withdrawal, inclusive, less any interval 
during which use of study drug was interrupted (individual missed doses will not be 
subtracted unless noted in the dosage management log), and  
• as the number of days from dose initiation to the earlier of final contact during the placebo-
controlled period or 28 days after last dose of study drug, inclusive. 
The proportion of participants who interrupted study drug or reduced study drug dosage and the 
time to first study drug interruption or dosage reduction will be summarized. The number of days 
of exposure to a reduced dosage of study drug will be summarized. 
6.7.3 Concomitant Medication Use 
Summaries of concomitant medication use are the same as specified in the M-SAP with the 
clarification that medications taken at baseline and those initiated after first dose of study drug 
will be separately summarized and will be classified by ATC Therapeutic class and WHODrug 
Preferred base name. 


Cudkowicz (PI) HEALEY ALS Platform Trial: RGC Statistical Analysis Plan 
Version 3.0, 22 Jul 2022 
 
Page 37 of 37 
 
6.7.4 Medical History 
Medical histories will be summarized by MedDRA system organ class, high level term, and 
preferred term in the STF and SRO analysis sets. 
6.7.5 Blindedness 
The proportions of participants and site investigators who report on the Exit Questionnaire a 
guess of active vs. placebo treatment assignment, each level of surety of that guess, and each of 
five pre-specified reasons for making a treatment assignment will be summarized by treatment 
group in the FAS and ERO analysis sets. Treatment-dependent differences in the proportion 
guessing active treatment assignment will be tested among all respondents and among those 
stating they are at least somewhat sure of their guess by Fisher's exact test and the difference in 
proportion guessing active treatment assignment will be estimated with confidence bounds. 
6.7.6 Protocol Deviations 
The number of major and minor protocol deviations will be summarized by type of deviation and 
treatment group in all analysis sets. Listings of all protocol deviations will be produced. 
6.7.7 Impact of COVID-19 Pandemic 
The proportions of planned assessments missed due to COVID-19 restrictions or disruptions will 
be summarized by treatment group, visit, and type of assessment in the FAS and ERO analysis 
sets. Protocol deviations that resulted from COVID-19 restrictions or disruptions will be 
summarized by treatment group and type of deviation in the FAS and ERO analysis sets and 
listed. 
7. Validation 
7.1 
Primary Efficacy Analysis 
Validation of the primary efficacy analysis is the same as specified in the M-SAP. 
7.2 
Secondary, Exploratory, and Safety Analyses 
Validation of secondary, exploratory, and safety analyses are the same as specified in the M-
SAP. 
8. References 
The following references are cited in addition to those specified in the M-SAP: 
Balendra R, Jones A, Jivraj N, Knights C, Ellis CM, Burman R, Turner MR, Leigh PN, Shaw 
CE, Al-Chalabi A. Estimating clinical stage of amyotrophic lateral sclerosis from the ALS 
Functional Rating Scale. Amyotroph Lateral Scler Frontotemporal Degener. 2014 Jun;15(3-
4):279-84. 
Roche JC, Rojas-Garcia R, Scott KM, Scotton W, Ellis CE, Burman R, Wijesekera L, Turner 
MR, Leigh PN, Shaw CE, Al-Chalabi A. A proposed staging system for amyotrophic lateral 
sclerosis. Brain. 2012 Mar;135(Pt 3):847-52. 


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Prot_000.pdf: 
HEALEY ALS Platform Trial - Regimen C CNM-Au8 
NCT04414345 
Document Date: 22 Nov 2021 


REGIMEN-SPECIFIC APPENDIX C 
 
FOR CNM-Au8  
 
 
Regimen-Specific Appendix Date: 
22 November 2021 
                            Version Number: 
5.0  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


HEALEY ALS Platform Trial  
Regimen-Specific Appendix C, CNM-Au8 
 
Version 5.0, 22-NOV-2021 
CONFIDENTIAL 
 
Page 2 of 73 
TABLE OF CONTENTS 
TABLE OF CONTENTS ---------------------------------------------------------------------------------------------------------- 2 
SIGNATURE PAGE -------------------------------------------------------------------------------------------------------------- 5 
LIST OF ABBREVIATIONS ---------------------------------------------------------------------------------------------------- 6 
REGIMEN-SPECIFIC APPENDIX SUMMARY --------------------------------------------------------------------------- 8 
SCHEDULE OF ACTIVITIES – --------------------------------------------------------------------------------------------- 10 
1. 
INTRODUCTION -------------------------------------------------------------------------------------------------------- 15 
1.1 CNM-Au8 Background Information ------------------------------------------------------------------------------------- 15 
1.2 CNM-Au8 Therapeutic Rationale --------------------------------------------------------------------------------------- 17 
1.2.1 Investigational Product Characteristics --------------------------------------------------------------------------- 17 
1.2.2 Preclinical Data Supporting CNM-Au8 in the Treatment of ALS --------------------------------------------- 18 
1.2.2.1 In vitro ALS Neuroprotection Models-------------------------------------------------------------------- 23 
1.2.2.1.1 CNM-Au8 Protects Primary Rodent Motor Neurons from Excitotoxicity ------------------------ 23 
1.2.2.1.2 CNM-Au8 Protects Normal iPSC Derived Human Motor Neurons From ALS-Participant-
Derived Toxic Astrocytes ------------------------------------------------------------------------------------------ 25 
1.2.2.2 In vivo ALS Neuroprotection Models -------------------------------------------------------------------- 26 
1.2.3 Summary CNM-Au8 Treatment Rationale for ALS ------------------------------------------------------------ 28 
2. 
OBJECTIVES ------------------------------------------------------------------------------------------------------------- 29 
2.1 Study Objectives and Endpoints ----------------------------------------------------------------------------------------- 29 
3. 
RSA DESIGN -------------------------------------------------------------------------------------------------------------- 31 
3.1 Scientific Rationale for RSA Design ------------------------------------------------------------------------------------ 31 
3.2 End of Participation Definition ------------------------------------------------------------------------------------------ 31 
3.3 
End of Regimen Definition ------------------------------------------------------------------------------------------- 31 
4. 
RSA Enrollment ----------------------------------------------------------------------------------------------------------- 33 
4.1 Number of Study Participants -------------------------------------------------------------------------------------------- 33 
4.2 Inclusion and Exclusion Criteria ---------------------------------------------------------------------------------------- 33 
4.2.1 RSA Inclusion Criteria ---------------------------------------------------------------------------------------------- 33 
4.2.2 RSA Exclusion Criteria --------------------------------------------------------------------------------------------- 33 
4.3 Treatment Assignment Procedures -------------------------------------------------------------------------------------- 33 
5. 
INVESTIGATIONAL PRODUCT ------------------------------------------------------------------------------------ 34 
5.1 Investigational Product Manufacturer ---------------------------------------------------------------------------------- 34 
5.2 Labeling, Packaging, and Resupply ------------------------------------------------------------------------------------- 34 
5.3 Acquisition, Storage, and Preparation---------------------------------------------------------------------------------- 35 


HEALEY ALS Platform Trial  
Regimen-Specific Appendix C, CNM-Au8 
 
Version 5.0, 22-NOV-2021 
CONFIDENTIAL 
 
Page 3 of 73 
5.4 Study Medication/Intervention, Administration, Escalation, and Duration ---------------------------------------- 35 
5.5 Dosage Adjustment -------------------------------------------------------------------------------------------------------- 36 
5.6 Justification for Dosage -------------------------------------------------------------------------------------------------- 37 
5.6.1. Human Dosing Safety Margins ----------------------------------------------------------------------------------- 37 
5.6.2 Neuroprotection Pharmacologic Exposure Data ----------------------------------------------------------------- 39 
5.7 Participant Compliance -------------------------------------------------------------------------------------------------- 40 
5.8 Overdose -------------------------------------------------------------------------------------------------------------------- 40 
5.9 CNM-Au8 Known Potential Risks and Benefits ----------------------------------------------------------------------- 40 
5.9.1 Known Potential Risks ---------------------------------------------------------------------------------------------- 40 
5.9.1.1 Immediate Risks ---------------------------------------------------------------------------------------------- 40 
5.9.1.2 Long Range Risks -------------------------------------------------------------------------------------------- 41 
5.9.1.3 Summary of Participant Risk ------------------------------------------------------------------------------ 41 
5.9.2 Known Potential Benefits------------------------------------------------------------------------------------------- 41 
5.10 Regimen-Specific Lab Alerts-------------------------------------------------------------------------------------------- 42 
6. 
REGIMEN SCHEDULE ------------------------------------------------------------------------------------------------ 43 
6.1 Regimen-Specific Screening Visit -------------------------------------------------------------------------------------- 44 
6.2 Baseline Visit --------------------------------------------------------------------------------------------------------------- 44 
6.3 Week 2 Telephone Visit -------------------------------------------------------------------------------------------------- 45 
6.4 Week 4 and 8 Visits -------------------------------------------------------------------------------------------------------- 45 
6.5 Week 12 Telephone Visit ------------------------------------------------------------------------------------------------- 45 
6.6 Week 16 Visit --------------------------------------------------------------------------------------------------------------- 45 
6.7 Week 20 Telephone Visit ------------------------------------------------------------------------------------------------- 46 
6.8 
Week 24 Visit or Early Termination Visit ---------------------------------------------------------------------------- 46 
6.9 
Follow-Up Safety Call ------------------------------------------------------------------------------------------------- 46 
6.10 Process for Early Terminations ---------------------------------------------------------------------------------------- 47 
6.11 Open Label Extension -------------------------------------------------------------------------------------------------- 47 
6.11.1 Week 2 OLE Telephone Visit ----------------------------------------------------------------------------------- 48 
6.11.2 
Week 4 OLE Visit ---------------------------------------------------------------------------------------------- 48 
6.11.3 
Week 8 OLE Visit ---------------------------------------------------------------------------------------------- 49 
6.11.4  Week 12 OLE Telephone Visit -------------------------------------------------------------------------------- 49 
6.11.5  Week 16 OLE Visit ---------------------------------------------------------------------------------------------- 49 
6.11.6  Week 20 OLE Telephone Visit -------------------------------------------------------------------------------- 50 
6.11.7  Week 24 OLE Telephone Visit -------------------------------------------------------------------------------- 50 
6.11.8  Week 28 OLE Visit ---------------------------------------------------------------------------------------------- 51 
6.11.9  Week 40 OLE Visit ----------------------------------------------------------- Error! Bookmark not defined. 
6.11.10  Week 52 OLE Visit ---------------------------------------------------------- Error! Bookmark not defined. 
7 
OUTCOME MEASURES AND ASSESSMENTS ------------------------------------------------------------------ 52 
7.1 Voice Analysis ------------------------------------------------------------------------------------------------------------- 52 


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7.2  ALSAQ-40 ----------------------------------------------------------------------------------------------------------------- 52 
7.3  Center for Neurologic Study Bulbar Function Scale --------------------------------------------------------------- 52 
8 
BIOFLUID COLLECTION -------------------------------------------------------------------------------------------- 54 
8.1 Pharmacokinetic (PK) Assessments ------------------------------------------------------------------------------------- 54 
8.1.1 Whole Blood PK Assessments of CNM-Au8 -------------------------------------------------------------------- 54 
8.1.2 Plasma PK Assessments of Riluzole ------------------------------------------------------------------------------ 54 
8.2 Pharmacodynamic (PD) Assessments ---------------------------------------------------------------------------------- 54 
9 
REGIMEN-SPECIFIC STATISTICAL CONSIDERATIONS -------------------------------------------------- 56 
Appendix I: The ALSAQ-40 --------------------------------------------------------------------------------------------------- 57 
Appendix II: The Bulbar Function Scale (CNS-BFS) --------------------------------------------------------------------- 66 
REFERENCES ------------------------------------------------------------------------------------------------------------------- 68 
 


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SIGNATURE PAGE 
 
I have read the attached Regimen-Specific Appendix (RSA) entitled, “REGIMEN C: CNM-Au8” 
dated October 15, 2021 (Version 5.0) and agree to abide by all described RSA procedures.  I 
agree to comply with the International Conference on Harmonisation Tripartite Guideline on 
Good Clinical Practice, applicable FDA regulations and guidelines identified in 21 CFR Parts 11, 
50, 54, and 312, central Institutional Review Board (IRB) guidelines and policies, and the Health 
Insurance Portability and Accountability Act (HIPAA). 
 
By signing the RSA, I agree to keep all information provided in strict confidence and to request 
the same from my staff. Study documents will be stored appropriately to ensure their 
confidentiality. I will not disclose such information to others without authorization, except to the 
extent necessary to conduct the study.  
 
 
 
 
Site Name: 
 
 
 
 
Site Investigator: 
 
 
 
 
Signed: 
 
 
 
 
 
Date: 
 
 


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LIST OF ABBREVIATIONS 
 
Abbreviation 
Definition 
ALSAQ-40 
Amyotrophic Lateral Sclerosis Assessment Questionnaire-40 
ASTM 
American Society for Testing and Materials 
ATP 
Adenosine Trinucleotide Phosphate 
Au 
Gold 
AUC 
Area under the curve 
AUC(0-24) 
Area under the curve for 24 hours  
CNM-Au8 
Aqueous suspension of clean surfaced nanocrystals consisting of gold atoms self-organized into 
crystals of various faceted, geometrical shapes  
CNS 
Central nervous system 
CNS-BFS 
Center for Neurologic Study Bulbar Function Scale 
CSF 
Cerebrospinal fluid or cerebral spinal fluid 
fALS 
Familial ALS 
FVC 
Forced Vital Capacity 
HED 
Human equivalent dose 
HDPE 
High density polyethylene 
hr 
Hour 
ICP-MS 
Inductively Coupled Plasma Mass Spectrometry 
IP 
Investigational Product 
K2EDTA 
Dipotassium ethylenediaminetetraacetic acid 
kg 
Kilogram 
m 
meter 
MAD 
Multiple ascending dose 
mg 
Milligram 
mL 
Milliliter 
MRS 
Magnetic Resonance Spectroscopy 
mRNA 
Messenger Ribonucleic acid (RNA) 
MTD 
Maximum tolerated dose 
NAD+ 
Oxidized form of nicotinamide adenine dinucleotide 
NADH 
Reduced form of nicotinamide adenine dinucleotide 
NADPH 
Reduced form of nicotinamide adenine dinucleotide phosphate 
NaHCO3 
Sodium bicarbonate (baking soda) 


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Abbreviation 
Definition 
ng 
nanogram 
nm 
nanometer 
NOAEL 
No observed adverse effect level 
OLE 
Open Label Extension 
PD 
Pharmacodynamic 
PPP 
Pentose phosphate pathway 
RSA 
Regimen-Specific Appendix 
SAE 
Serious adverse event 
SOD1 
Superoxide dismutase 
SVC 
Slow Vital Capacity 
TEM 
Transmission electron microscopy 
TK 
Toxicokinetic 
USP 
United States Pharmacopeia 
VC 
Vital Capacity 
 
 
 
 
 
 
 
 
 
 
 
 


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REGIMEN-SPECIFIC APPENDIX SUMMARY 
Regimen-Specific Appendix C 
For CNM-Au8  
 
Rationale and RSA Design 
 
CNM-Au8 is a suspension of clean-surfaced, faceted gold nanocrystals whose catalytic activity 
independently impacts energetic, metabolic, and redox pathways, resulting in significant 
neuroprotection from oxidative and excitotoxic insults.  
 
CNM-Au8 is a nanocatalyst that is administered orally, penetrates the blood brain barrier, and 
has a unique mechanism of action involving: (1) the catalytic production of nicotinamide adenine 
dinucleotide (NAD), a key co-factor in the ATP-generating pathways of all cells, (2) catalytic 
anti-oxidative activity resulting in cellular protection from oxidative stress, and (3) catalytic 
stimulation of the pentose phosphate pathway, influencing both anti-oxidative as well as anabolic 
processes. Importantly, CNM-Au8 demonstrated significant neuroprotection of healthy human 
motor neurons from cell death induced by toxic ALS-participant derived astrocytes, and of 
primary rat motor neurons from glutamatergic excitotoxicity. Oral delivery of CNM-Au8 to a 
mouse model of ALS resulted in the recovery of functional behaviors and significant extension 
of lifespan.  
 
Given the involvement of cellular bioenergetic failure in the pathogenesis of ALS, the 
development of a disease modifying therapeutic that addresses the energetic dysregulation 
underlying the progressive accumulation of oxidative stress and dysregulated RNA processing is 
a rational therapeutic strategy.  
 
This clinical protocol will test CNM-Au8 at doses of 30 mg and 60 mg versus placebo in a 
randomized, double-blind manner, to determine if CNM-Au8 can demonstrate sufficient efficacy 
and safety on accepted clinical and paraclinical outcomes for the treatment of ALS. The 
investigation of two doses of the study drug is based on counsel from the FDA recommending 
including a dose finding strategy in the study.  The 30 mg and 60 mg doses of CNM-Au8 
selected for the study achieve at least comparable AUC exposure in humans as those shown to 
demonstrate neuroprotection efficacy in nonclinical animals studies, and demonstrated minimal 
treatment emergent adverse events in the Phase 1 First-In-Human study in healthy volunteers. 
 
Allocation to Treatment Regimens 
Participants must first be screened under the Master Protocol before they are randomized to an 
RSA.  
 


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As soon as pre-defined criteria for futility for the RSA are met, or the target number of 
randomized participants has been reached, enrollment will stop in the RSA.   
 
Number of Planned Participants and Treatment Groups 
The number of planned participants for this regimen is approximately160.   
 
There are 2 treatment groups for this regimen, active and placebo. Participants will be 
randomized in a 3:1 ratio to active treatment or placebo (i.e., 120 active: 40 placebo).  Half of the 
active treatment group will receive CNM-Au8 30mg/day and the other half will receive 
60mg/day (i.e., 60 at 30mg/day: 60 at 60mg/day). 
 
Planned Number of Sites 
Research participants will be enrolled from approximately 60 centers in the US.   
 
Treatment Duration 
The maximum duration of the placebo-controlled treatment portion is 24 weeks.  
 
Follow-up Duration 
At the conclusion of the 24-week placebo-controlled Treatment Period of the study, all 
participants will either schedule a 28-day follow up phone call and end their participation in the 
regimen or have the option to receive CNM-Au8 in the Open Label Extension (OLE) phase of 
the study.  
In the OLE, CNM-Au8 will be provided by Clene Nanomedicine, until the primary results of the 
24 week double-blind portion of the study are available, or Clene or sponsor terminate support or 
development of CNM-Au8 for ALS. 
   
Total Planned Trial Duration 
For participants completing the placebo-controlled Treatment Period of the Study, the planned 
amount of time for a participant in the trial is up to 34 weeks, or about 8 months.  This duration 
assumes a 6-week screening window, a 24-week placebo-controlled treatment period, and a 4-
week safety follow-up period for those participants who do not enter the Open Label Extension. 
Participants will complete approximately 10 study visits during the placebo-controlled treatment 
period of the study.  
 
 


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SCHEDULE OF ACTIVITIES – PLACEBO-CONTROLLED PERIOD14  
 
As per the Schedule of Activities (SOA) below, visits must occur every 4 weeks and will be alternatively clinic-, phone-, or 
telemedicine-based, as applicable.  There is a maximum 24-week duration of placebo-controlled treatment for a Regimen. 
 
Activity (page 1 of 2) 
Master 
Protocol or 
Regimen-
Specific 
Master 
Protocol 
Screening1 
Regimen 
Specific 
Screening1 
Baseline 
Week 2 
Week 
416, 17 
Week 
816, 17 
Week 12 
Week 
1617 
Week 20 
Week 
24 or 
Early 
Term. 
Visit14, 
16 
Follow-Up 
Safety Call11, 
14 
Clinic 
Clinic 
Clinic 
Phone 
Clinic 
Clinic 
Phone 
Clinic 
Phone 
Clinic 
Phone 
-42 to -1 
Days 
-41 to 0 
Day 
Day 0 
Day 14 
±3 
Day 28 
±7 
Day 56 
±7 
Day 84 
±3 
Day 112 
±7 
Day 140 
±3 
Day 168 
±7 
28 days after 
last dose 3 
days 
Written Informed Consent2 
Master 
X 
X 
 
 
 
 
 
 
 
 
 
Written Informed Consent - OLE 
Master 
 
 
 
 
 
 
 
X 
 
 
 
Inclusion/Exclusion Review 
Master 
X 
X3 
 
 
 
 
 
 
 
 
 
ALS & Medical History 
Master 
X 
 
 
 
 
 
 
 
 
 
 
Demographics 
Master 
X 
 
 
 
 
 
 
 
 
 
 
Physical Examination 
Master 
X 
 
 
 
 
 
 
 
 
 
 
Neurological Exam 
Master 
X 
 
 
 
 
 
 
 
 
 
 
Vital Signs4 
Master 
X 
 
X 
 
X 
X 
 
X 
 
X 
 
Slow Vital Capacity 
Master 
X18 
 
X 
 
 
X 
 
X 
 
X 
 
Home Spirometry 
Regimen 
X18 
 
X 
 
 
X 
 
X 
 
X 
 
Muscle Strength Assessment  
Master 
 
 
X 
 
 
X 
 
X 
 
X 
 
ALSFRS-R 
Master 
X 
 
X 
 
X 
X 
X 
X 
X 
X 
 
ALSAQ-40 
Regimen 
 
 
X 
 
 
 
 
 
 
X 
 
CNS Bulbar Function Scale 
Regimen 
 
 
X 
 
 
X 
 
X 
 
X 
 
12-Lead ECG 
Master 
X 
 
 
 
 
 
 
 
 
X 
 
Clinical Safety Labs5 
Master 
X 
 
X 
 
X 
X 
 
X 
 
X 
 
PK/PD Biomarker Blood 
Collection12 
Regimen 
 
 
X 
 
X 
X 
 
 
 
X 
 
Biomarker PD Urine Collection 
Regimen 
 
 
X 
 
 
 
 
 
 
X 
 


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Biomarker Blood Collection 
Master 
 
 
X 
 
 
X 
 
X 
 
X 
 
 
 
Activity (page 2 of 2) 
Master 
Protocol or 
Regimen-
Specific 
Master 
Protocol 
Screening1 
Regimen 
Specific 
Screening1 
Baseline 
Week 2 
Week 
416, 17 
Week 
816, 17 
Week 12 
Week 
1617 
Week 20 
Week 
24 or 
Early 
Term. 
Visit14, 
16 
Follow-Up 
Safety Call11, 
14 
Clinic 
Clinic 
Clinic 
Phone 
Clinic 
Clinic 
Phone 
Clinic 
Phone 
Clinic 
Phone 
-42 to -1 
Days 
-41 to 0 
Day 
Day 0 
Day 14 
±3 
Day 28 
±7 
Day 56 
±7 
Day 84 
±3 
Day 112 
±7 
Day 140 
±3 
Day 168 
±7 
28 days after 
last dose 3 
days 
Biomarker Urine Collection 
Master 
 
 
X 
 
 
X 
 
X 
 
X 
 
DNA Collection7 (optional) 
Master 
 
 
X 
 
 
 
 
 
 
 
 
CSF Collection (optional) 
Master 
 
 
X 
 
 
 
 
X15 
 
 
 
Concomitant Medication 
Review 
Master 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Adverse Event Review6 
Master 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Columbia-Suicide Severity 
Rating Scale 
Master 
 
 
X 
 
X 
X 
 
X 
 
X 
 
Install Smartphone App19 
Regimen 
 
 
X 
 
 
 
 
 
 
 
 
Voice Recording9 
Regimen 
 
 
X 
 
X 
X 
 
X 
 
X 
 
Uninstall Smartphone App 
Regimen 
 
 
 
 
 
 
 
 
 
X 
 
Assignment to the Regimen 
Master 
X 
 
 
 
 
 
 
 
 
 
 
Randomization within the 
Regimen 
Master 
 
X 
 
 
 
 
 
 
 
 
Administer/Dispense 
Investigational product 
Master 
 
 
X8 
 
 
X 
 
X 
 
X10 
 
Study Drug 
Accountability/Compliance 
Master 
 
 
 
X20 
X 
X 
X20 
X 
X20 
X 
 
Exit Questionnaire 
Master 
 
 
 
 
 
 
 
 
 
X 
 
Vital Status Determination13 
Master 
 
 
 
 
 
 
 
 
 
X 
 
 
1 Master Protocol Screening procedures must be completed within 42 days to 1 day prior to the Baseline Visit. The Regimen-Specific Screening Visit and Baseline Visit should be 
combined, if possible.    


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2 During the Master Protocol Screening Visit, participants will be consented via the Master Protocol informed consent form (ICF). After a participant is randomized to a regimen, 
participants will be consented a second time via the regimen-specific ICF.  
3 At the Regimen Specific Screening Visit, participants will have regimen-specific eligibility criteria assessed.   
4 Vital signs include weight, systolic and diastolic pressure, respiratory rate, heart rate and temperature.  Height measured at Master Protocol Screening Visit only. 
5 Clinical safety labs include hematology (CBC with differential), complete chemistry panel, thyroid function and urinalysis. Serum pregnancy testing will occur in women of 
child-bearing potential at the Master Protocol Screening Visit and as necessary during the study. Pregnancy testing is only repeated as applicable if there is a concern for 
pregnancy. 
6 Adverse events that occur after signing the consent form will be recorded.  
7 The DNA sample can be collected after baseline if a baseline sample is not obtained or the sample is not usable. 
8 Administer first dose of investigational product only after Baseline Visit procedures are completed. 
9 In addition to study visits outlined in the SOA, participants will be asked to complete twice weekly voice recordings at home.  
10 Drug will only be dispensed at this visit if the participant continues in the OLE. 
11 Participants will only have a Follow-Up Safety Call at this time if they do not continue on in the OLE.  Participants who continue into OLE will have a Follow-Up Safety Call 
after their last dose of study drug during the OLE phase. 
12 Whole blood and plasma will be collected prior to administration of the daily dose at the Baseline and Week 24 visit.  Plasma will be collected prior to administration of the 
daily dose at the Week 4 and Week 8 visits.  Refer to the RSA laboratory manual for collection and processing parameters.  
13 Vital status, defined as a determination of date of death or death equivalent or date last known alive, will be determined for each randomized participant at the end of the 
placebo-controlled portion of their follow-up (generally the Week 24 visit, as indicated). If at that time the participant is alive, his or her vital status should be determined again at 
the time of the last patient last visit (LPLV) of the placebo-controlled portion of a given regimen. We may also ascertain vital status at later time points by using publicly available 
data sources as described in section 8.15 of the Master Protocol. 
14 The maximum window between study visits during the placebo-controlled period may not exceed 64 days.  
15 If the CSF collection is unable to be performed for logistical reasons, such as scheduling, at the Week 16 Visit, it may be performed at the Week 24 Visit. 
16 Participants should be instructed to hold the study drug on the day of the study visit. Study drug should not be taken until after study visit procedures are complete. 
17 Visit may be conducted via phone or telemedicine with remote services instead of in-person if this is needed to protect the safety of the participant due to a pandemic, or other 
reason.  
18 If required due to pandemic-related restrictions, Forced Vital Capacity (FVC) performed by a Pulmonary Function Laboratory evaluator or with a study-approved home 
spirometer, or sustained phonation using a study approved method may be used for eligibility (Master Protocol Screening ONLY).    
19 Two smartphone apps should be installed on the participant’s phone, one to collect the voice recordings and one to collect home spirometry.   
20 Drug accountability will not be done at phone visits. A drug compliance check-in must be held during phone visits to ensure participant is taking drug per dose regimen and to 
note any report of missed doses.  
 
 


 
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SCHEDULE OF ACTIVITIES – REGIMEN SPECIFIC OPEN LABEL EXTENSION PHASE (OPTIONAL) 
Activity (page 1 of 1) 
Master 
Protocol or 
Regimen-
Specific 
 
Open Label Extension (Optional)5 
Week 2 
Week 
49 
Week 
89 
Week 
12 
Week 
168,9 
Week 20 
 
Week 
24  
Week 28 and Q12 
Weeks8,9,11  
 
Follow-Up Safety Call6 
Phone 
Clinic 
Clinic 
Phone 
Clinic 
Phone 
Phone 
Clinic 
Phone 
Day 14 
+3 
 
 
 
Day 28 
±7 
 
 
 
Day 56 
±7 
Day 84 
±3 
Day 112 
±7 
Day 140 
±3 
 
 
 
Day168 
±3 
Day 196 ± 14  
 
 
 
28±7 days after last dose 
Vital Signs1 
Master 
 
X 
X 
 
X 
 
 
X 
 
Slow Vital Capacity 
Master 
 
X 
X 
 
X 
 
 
X 
 
Home Spirometry 
Regimen 
 
X 
X 
 
X 
 
 
X 
 
ALSFRS-R 
Master 
 
X 
X 
X 
X 
X 
X 
X 
 
ALSAQ-40 
Regimen 
 
 
 
 
 
 
 
X 
 
CNS Bulbar Function Scale 
Regimen 
 
 
X 
 
X 
 
 
X 
 
Clinical Safety Labs2 
Master 
 
X 
X 
 
X 
 
 
X 
 
PK/PD Biomarker Blood 
Collection11 
Regimen 
 
 
 
 
X 
 
 
X11 
 
Biomarker PD Urine 
Collection11 
Regimen 
 
 
 
 
X 
 
 
X11 
 
Biomarker Blood 
Collection11 
Master 
 
 
 
 
X 
 
 
X11 
 
Biomarker Urine 
Collection11 
Master 
 
 
 
 
X 
 
 
X11 
 
Concomitant Medication 
Review 
Master 
X 
X 
X 
X 
X 
X 
X 
X 
 
Adverse Event Review3 
Master 
X 
X 
X 
X 
X 
X 
X 
X 
X6 
Columbia-Suicide Severity 
Rating Scale 
Master 
 
X 
X 
 
X 
 
 
X 
 


 
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Administer/Dispense 
Investigational product 
Master 
 
 
X 
 
X 
 
 
X 
 
Drug 
Accountability/Compliance 
Master 
X10 
X 
X 
X10 
X 
X10 
X10 
X 
 
1 Vital signs include weight, systolic and diastolic pressure, respiratory rate, heart rate and temperature.  Height in cm measured at Master Protocol Screening Visit only. 
2 Clinical safety labs include hematology (CBC with differential), complete chemistry panel, liver function tests, thyroid function and urinalysis. Serum pregnancy testing will 
occur in women of child-bearing potential at the Master Protocol Screening Visit and as necessary during the study. Pregnancy testing is only repeated as applicable if there is a 
concern for pregnancy. 
3 Adverse events that occur after signing the consent form will be recorded.  
4 Participants who continue into OLE will have a Follow-Up Safety Call (as described in the body of this RSA) after their last dose of study drug during the OLE phase. 
5 The duration of the OLE is until the primary results of the 24 week double-blind portion of the study are available, or Clene or sponsor terminates support or development of 
CNM-Au8 for ALS. 
6 Participants who continue into the OLE and then withdraw consent or early terminate will be asked to complete an Early Termination Visit and Follow-Up Safety Call as 
described in the body of this RSA.  
7 The maximum window between study visits during the OLE may not exceed 64 days for the Week 8 and Week 16 visits; and 96 days for the Week 28, Week 40, and Week 52 
visits.  
8 Participants should be instructed to hold the study drug on the day of the study visit. Study drug should not be taken until after study visit procedures are complete. 
9 Visit may be conducted via phone or telemedicine with remote services instead of in-person if this is needed to protect the safety of the participant due to a pandemic or other 
reasons.  
10 Drug accountability will not be done at phone visits. A drug compliance check-in must be held during phone visits to ensure participant is taking drug per dose regimen and to 
note any report of missed doses 
11 Blood and urine biomarker collection in OLE phase will only occur at week 16, 28, and 52 
 
 


 
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1. INTRODUCTION 
Regimen C: CNM-Au8  
 
1.1 CNM-Au8 Background Information 
Amyotrophic lateral sclerosis (ALS) is a late-onset, fatal neurodegenerative disease affecting 
motor neurons with an incidence of approximately 1 in 100,000. Most ALS cases are sporadic, 
with 5–10% of cases being familial ALS (Zarei et al., 2015). Both sporadic and familial ALS are 
associated with degeneration and loss of cortical and spinal motor neurons, resulting in muscle 
wasting and weakness, eventually leading to respiratory failure and death. The etiology of ALS 
remains unknown. Emerging research has discovered interconnecting pathophysiological 
mechanisms amongst the seemingly disparate genetic mutations, implicated in both familial 
(fALS) and sporadic (sALS) ALS.  Importantly, these emerging data suggest that impairments 
related to oxidative stress and mitochondrial function appear to be common across many 
underlying genetic abnormalities. Genetic mutations in superoxide dismutase (SOD1), regulation 
of RNA processing and metabolism (represented by mutations in FUS, TDP43 and several more 
genes) all appear to result in both oxidative stress and RNA dysregulation, indicative of an 
underlying bioenergetic failure in ALS. Bioenergetic dysfunction affects not only motor neurons 
themselves but also astrocytes and oligodendrocytes that provide crucial energetic support to 
motor neuron survival.  Postmortem analyses of brain tissues from both fALS and sALS 
participants exhibit evidence of widespread accumulation of oxidative damage to proteins, lipids, 
and DNA. Transgenic mice expressing mutant SOD1 forms have evidence of nerve and spinal 
cord tissue damage that recapitulates key aspects of ALS and demonstrates clear evidence of 
excessive protein and lipid oxidation (D’Amico et al., 2013b). Oxidative stress also leads to the 
accumulation of protein aggregates such as TDP43 (Bozzo et al., 2017a), which are invariably 
found in ALS motor neurons, and which indicate failures of protein degradation systems such as 
autophagy (Blokhuis et al., 2013). 
 
Elevated oxidative stress has been shown to impact the processing of gene transcripts important 
for motor neuron survival.  This observation connecting oxidative stress to RNA processing was 
demonstrated when paraquat, a well-known inducer of oxidative stress, was shown to induce 
striking changes in RNA splicing in neuroblastoma cells (Maracchioni et al., 2007). Two of the 
pre-mRNAs whose splicing was shown to be altered in this study are transcripts of genes known 
to be important for motor neuron survival, Survival Motor Neuron (SMN) and Apoptotic 
Peptidase Activating Factor 1 (APAF1) (Maracchioni et al., 2007). The mis-localization of the 
RNA-binding protein TDP43 in ALS is further evidence of the connection between oxidative 
stress and RNA dysmetabolism.  In general, TDP43 is involved in pre-RNA processing in the 
nucleus, where it functions in transcriptional control.  However, oxidative stress causes the 


 
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TDP43 to translocate to the cytoplasm, where it accumulates in stress granules, as protein 
aggregates. Sequestration of an RNA regulator such as TDP43 in the cytoplasm and away from 
the nucleus is thought to prevent it from carrying out its normal functions and thereby can lead to 
dysregulation of RNA processing and transcription.  The converse relationship has similarly 
been shown, namely that mis-regulation of RNA metabolism increases oxidative stress within 
the CNS. Mutations in RNA regulators FUS and TDP43 cause disruptions in the expression of 
key nuclear-encoded mitochondrial genes (Zhang et al., 2014) as well as in the expression of 
energy metabolism regulators such as PGC-1 alpha and oxidative stress reducers such as 
MnSOD and catalase (Sanchez-Ramos et al., 2011). Therefore, the pathophysiologic disease 
mechanism of ALS appears to involve a positive feedback cycle of oxidative stress and protein 
aggregation impacting RNA regulation which in turn leads to a sustained increased oxidative 
stress disease state, ending in motor neuron death (Bozzo et al., 2017b).  
 
Unifying both themes of RNA dysregulation and oxidative stress is the concept that ALS is a 
disease of energetic dysmetabolism (Dupuis et al., 2011; Tefera and Borges, 2016; Vandoorne et 
al., 2018). Motor neurons consume high amounts of energy  to function and are therefore 
exquisitely sensitive to apoptosis if their energetic demands cannot be met. The main energy-
producing organelle of the cell, the mitochondria, exhibit dysfunction in ALS on multiple levels. 
For example, overall there are fewer mitochondria, as measured by mitochondrial DNA, in the 
spinal cords of both fALS and sALS participants (Wiedemann et al., 2002). Presynaptic 
mitochondrial swelling in motor neurons has been observed in both ALS participants (Siklos et 
al., 1996), as well as in a SOD1 transgenic mouse model prior to disease onset (Manfredi and 
Xu, 2005). Swollen and vacuolarized mitochondria are indicative of impaired mitochondrial 
function (Siklos et al., 1996), which is corroborated by studies showing that there is decreased 
activity of the electron transport chain in spinal cord mitochondria of ALS participants 
(Wiedemann et al., 2002). Because reduced respiration and reduced ATP synthesis preceded 
clinical symptom onset in SOD1G93A mice (Jung et al., 2002; Mattiazzi et al., 2002; 
Szelechowski et al., 2018), energetic dysmetabolism appears to play an important role in the 
etiology of this disease. Overexpression of PGC-1 alpha, which stimulates mitochondrial 
biogenesis, improved survival, motor neuron function and motor neuron survival in mutant 
SOD1G93A mice (Zhao et al., 2011), indicating that improving mitochondrial function and/or 
efficiency may be a successful therapeutic strategy for ALS (Vandoorne et al., 2018). 
 
Energetic dysmetabolism in ALS is further underscored by studies uncovering carbohydrate 
metabolism abnormalities and ATP deficits in ALS motor neurons (Vandoorne et al., 2018). 
FDG-PET imaging has demonstrated a correlation between reduced ALS brain glucose uptake 
and cognitive impairment (Canosa et al., 2016) as well as overall disease severity (Dalakas et al., 
1987). Some groups who conducted FDG-PET studies showing reduced glucose uptake in ALS 
participant brains suggested CNS hypometabolism can be used as an early diagnostic indication 


 
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of ALS (Van Laere et al., 2014; Van Weehaeghe et al., 2016). While it is difficult to determine 
whether lowered glucose utilization detected in imaging studies is due to reduced neuronal 
catabolism of glucose or due to motor neuron loss, there are further lines of evidence to suggest 
energetic dysmetabolism in ALS cells. A proteomic study of ALS participant fibroblasts 
indicated a significant reduction in key enzymes involved in glycolysis (Szelechowski et al., 
2018), and expression profiling of sALS participant motor cortexes showed downregulation of 
glycolytic genes (Lederer et al., 2007). A GWAS analysis involving 12577 cases and 23475 
controls identified glycolysis/gluconeogenesis as among the top seven biological pathways 
represented by the genes identified as associated with ALS (Du et al., 2018). Because glia 
preferentially utilize glycolysis, these results may indicate a dysfunction of glia in providing 
energetic support to motor neurons in ALS participants. Energetic stress on motor neurons may 
increase their levels of oxidative stress, as observed in post-mortem brain samples of ALS 
participants (Ferrante et al., 1997), and lead to motor neuron death.  
 
1.2 CNM-Au8 Therapeutic Rationale 
CNM-Au8 is a concentrated aqueous suspension of clean-surfaced nanocrystals consisting solely 
of Au atoms organized into clean surfaced crystals of highly faceted, substantially uniform 
geometrical shapes that act as nanocatalysts, supporting cellular bioenergetic reactions.  
 
CNM-Au8 is supplied for dosing orally in sodium bicarbonate buffered USP purified water. 
Each mL of CNM-Au8 suspension at 500 μg/mL is estimated to contain between 100 - 500 
trillion highly faceted Au nanocrystals. IP will consist of 60 mL high density polyethylene 
(HDPE) bottles containing CNM-Au8 at concentrations of 250 μg/mL (15 mg)  or 500 μg/mL 
(30 mg), or placebo, administered orally, once daily in the morning, at least 30 minutes prior to 
food intake.  Study participants will consume two (2) bottles of IP each morning for total daily 
intake of 120 mL equivalent to CNM-Au8 30mg or 60mg, or placebo. 
 
1.2.1 Investigational Product Characteristics 
The median diameter of CNM-Au8 nanocrystals is approximately 13 nm, as determined by 
transmission electron microscopy (TEM).  Based upon the distributed range (Dn5 – Dn95: 6.5 – 
15.8 nm) of measured nanocrystal diameters and approximate geometrical shapes (e.g., low 
volume estimate: disc-like approximation, aspect ratio of 0.2; maximum volume estimate: 
spheroid, aspect ratio of 1.0), each Au nanocrystal has an approximate composition ranging from 
13,000 – 66,000 Au atoms per nanocrystal at the 13 nm median diameter with a corresponding 
molar mass ranging between 2.7 x 103 kDA to 1.3 x 104 kDA. Summary estimates for CNM-Au8 
mass, volume, and particle characteristics are described below in Table 1.  Each mL of CNM-
Au8 suspension at 500 μg/mL is estimated to contain between 100 - 500 trillion highly faceted 
Au nanocrystals. 


 
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Table 1. Estimated Volume, Mass, and Particle Characteristics of CNM-Au8 
Metric 
(CNM-Au8 500 μg/mL, 60 mL Dose) 
Disc-Like 
Approximation 
Minimum 
(Aspect 0.2) 
Spherical 
Approximation 
Maximum 
(Aspect 1.0) 
Median Au Nanocrystal Diameter (nm) 
13 
Au Nanocrystal Volume (nm3) 
2.3 x 10^2 
1.2 x 10^3 
Au Nanocrystal Surface Area (nm2) 
3.2 x 10^2 
5.3 x 10^2 
Au Atoms per Nanocrystal (count) 
1.4 x 10^4 
6.8 x 10^4 
Au Nanocrystal Molecular Weight (kDa) 
2.7 x 10^3 
1.3 x 10^4 
Total Au Nanocrystal Surface Area per mL (cm2) 
3.6 x10^2 
1.2 x10^2 
Au Nanocrystals per mL CNM-Au8 (count) 
1.1 x 10^14 
2.3 x 10^13 
Au Nanocrystals per 60 mL Dose (count) 
3.4 x 10^15 
6.8 x 10^14 
 
1.2.2 Preclinical Data Supporting CNM-Au8 in the Treatment of ALS  
CNM-Au8 passes into the systemic circulation via intestinal absorption.  Cellular uptake of 
CNM-Au8, following oral administration, has been demonstrated in a variety of cells and tissue 
matrices including macrophages, oligodendrocytes, neurons, and brain tissue, utilizing 
Inductively Coupled Plasma Mass Spectrometry (ICP-MS) and high resolution TEM 
visualization of nanocrystals.   
 
Preclinical characterization of the in vitro and in vivo properties of CNM-Au8 demonstrated that 
it acts to protect neuronal populations from chemical, inflammatory, and hypoxic insults through 
a series of unique catalytic mechanisms involving 1) the nicotine adenine dinucleotide redox 
couple (NAD+/NADH) to boost glycolytic energy production, 2) the nicotine adenine 
dinucleotide phosphate redox couple (NADP+/NADPH) to influence anabolic processes 
associated with differentiation, and 3) the SOD-like inactivation of reactive oxygen species and 
nitric oxide to protect cells from oxidative damage and mitochondrial dysfunction.  
The nicotinamide adenine dinucleotide redox couple (NAD+, NADH) plays a central role in the 
energy metabolism of all living cells. NAD+, NADH and their relative intracellular ratio 
(NAD+/NADH) are linked to regulation of energy homeostasis, neuroprotection, immune 
function, chromosome stability, DNA repair mechanisms, sleep and circadian rhythms, and 
longevity (Canto et al., 2015; Imai, 2010a, b; Nikiforov et al., 2015; Ying, 2008).   


 
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Fundamentally, NAD+ and NADH are essential coenzymes in the adenosine triphosphate (ATP)-
generating reactions driving both glycolysis and oxidative phosphorylation.  More specifically, 
in aerobic glycolysis, NAD+ availability is integral to the enzymatic cascade from 
glyceraldehyde 3-phosphate via glyceraldehyde phosphate dehydrogenase to 1,3-
bisphosphoglyceric acid.  Similarly, two electrons are removed via NADH oxidation in Complex 
I of the electron transport chain during oxidative phosphorylation, resulting in NAD+, and 
ultimately these electrons are transferred to a lipid-soluble carrier, ubiquinone. 
In addition, NAD+ and its metabolites act as binding substrates for a wide range of proteins 
including the metabolic and transcription-regulating sirtuins, the poly-ADP-ribose polymerases 
(PARPs) involved in DNA repair, and the cyclic ADP-ribose synthases (cADPRs) such as CD38 
that serve to regulate Ca2+ signaling involved in cell cycle control and insulin signaling (Canto 
et al., 2015). In the Wallerian Degeneration Slow Dominant Mutant Mouse, heightened 
expression of NMNAT1, resulting in increased NAD+, has been attributed to protect against the 
axonal degeneration, otherwise observed in these mice (Sasaki et al., 2009).   
 
Quantitative measurement of regional brain area NAD+ concentrations and redox states in 
humans has recently been demonstrated using a novel 31P-Magnetic Resonance Spectroscopy 
(MRS) imaging technique (Chouinard et al., 2017; Lu et al., 2016). In people, brain 
NAD+/NADH redox potential is inversely correlated with age. 31P-MRS of the visual cortex of 
young (21-26 year old), middle-aged (33-36 year old), and aged (59-68 year old) healthy 
individuals demonstrated a linear decline of NAD+ redox potential with increasing age (Zhu et 
al., 2015). This age-related decrease in cerebral energy metabolism is believed to be associated 
with the bioenergetic failure underlying many neurodegenerative diseases, because 
NAD+/NADH redox potential is essential for fundamental ATP-generating processes such as 
glycolysis and mitochondrial oxidative phosphorylation. These bioenergetic processes power all 
cellular processes including ‘housekeeping’ functions that are responsible for maintaining overall 
cellular health including processes of autophagy, apoptosis, and the unfolded protein response 
(UPR) (Canto et al., 2015; Chua and Tang, 2013a; Villanueva-Paz et al., 2016). Boosting brain 
NAD+ levels in a mouse model of AD reduced DNA damage, neuroinflammation, and apoptosis 
while improving cognitive function in multiple behavioral tests and restored hippocampal 
synaptic plasticity (Hou et al., 2018).  
 
The first demonstration of catalyzed oxidation of NADH to NAD+ by gold nanoparticles was 
demonstrated by Huang et al. (2005) using a simple cell-free assay. In order to compare the 
catalytic oxidation rate of clean-surfaced CNM-Au8 against similarly-sized gold nanoparticles 
made using citrate reduction, the same cell-free assay utilized by Huang et al. was repeated 
comparing gold nanoparticles sourced from the U.S. National Institutes of Standards and 
Technology (NIST).  The resulting change in the 339 nm NADH absorbance peak was assessed 


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


 
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serve as the redox equivalents for both the thioredoxin and glutathione systems (Grant, 2008; 
Pollak et al., 2007), which in turn serve as the cell’s primary defenses against oxidative stress.  
CNM-Au8 catalyzes the oxidation of NADPH to NADP+ (Figure 3). While the time course of 
catalysis of NADPH to NADP+ is longer than that observed for conversion of NADH to NAD+, 
the magnitude of the effect is similar. Thus, CNM-Au8 plays an important role in providing 
NADP+ to the enzyme glucose 6-phosphate dehydrogenase for the conversion of 6-
phosphogluconate to ribulose 5-phosphate and NADPH + CO2, which represents the rate-
limiting step of the oxidative branch of the PPP. 
 
 Figure 3.  Effects of CNM-Au8 on NADPH Oxidation  
 
 
Excessive reactive oxygen exposure disrupts cellular redox homeostasis, damages intracellular 
organelles as well as DNA and proteins, and may also underpin pathophysiologic mechanisms of 
ALS.  Super oxide dismutases (SODs) evolved as a component of the cell’s antioxidant defense 
system to regulate the levels of reactive oxygen species (ROS) and prevent damage from 
oxidative stress. SOD enzymes are found in the cytoplasm and mitochondria where they convert 
oxygen radicals to O2 or H2O2, which can in turn be converted to water and O2 by catalases.  A 
dose-dependent reduction of ROS levels was observed in differentiating oligodendrocyte 
precursor cells in primary culture with CNM-Au8 treatment. 
 
 
 


 
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Figure 4 . Effects of CNM-Au8 on SOD and ROS Generation 
Figure 4A. Effects on SOD Activity Assay  
 
Figure 4B.  Effects on ROS Generation in Purified Murine OPC 
cultures 
Figure 4C.  Effects on ROS Generation in 
Murine OPC Cultures Plus Rotenone 
 
Demonstration of SOD-like catalytic activity with CNM-Au8 treatment has several important 
implications. First, neurons and glial cells are energetically demanding and generate large 
amounts of ROS as byproducts of the energetic processes necessary for their function. Theories 
of aging and neurodegeneration suggest that as CNS cells age, they are less able to efficiently 
remove ROS and thereby succumb to the consequences of long-term ROS exposure. As CNS 
cells are exquisitely sensitive to ROS, they are among the first cell types to degenerate, leading 
to the cognitive, psychomotor, and movement impairments observed in diseases such as ALS, 
Alzheimer’s disease, and Parkinson’s disease (Angelova and Abramov, 2018). In addition, 
SOD1 may act not only as a regulator of ROS but also as a part of a glucose-oxygen sensing 
mechanism of a cell to determine whether the cell utilizes oxidative phosphorylation or aerobic 
glycolysis for ATP production (Reddi and Culotta, 2013). A study of oligodendrocyte (OL) 
energetics showed that human OLs preferentially use aerobic glycolysis during differentiation 
and myelination (Rone et al., 2016).  Data with CNM-Au8 demonstrate that treatment switches 
OPCs from proliferation to differentiation, while simultaneously stimulating aerobic glycolysis 


 
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production of ATP likely through NADH oxidation. Stimulation of SOD-like activity therefore is 
consistent with a role for CNM-Au8 in regulating cellular bioenergetics.  
 
Figure 5. Effect of CNM-Au8 on OPC Differentiation and ATP Production 
 
 
Effect of CNM-Au8 on a) OPC differentiation (O4+ cells) in isolated murine OPCs and b) ATP production in 
MO3.13 oligodendrocytes (72hr). Statistical analysis performed using one-way ANOVA (p < 0.05). 
 
 
Nonclinical Summary of In Vitro and In Vivo ALS Neuroprotection Studies 
1.2.2.1 In vitro ALS Neuroprotection Models 
 
CNM-Au8 exhibits neuroprotective effects in a broad range of neural cell types in in vitro and in 
vivo preclinical models of ALS. 
1.2.2.1.1 CNM-Au8 Protects Primary Rodent Motor Neurons from Excitotoxicity 
Excitotoxicity is the pathological process by which neuronal death occurs as a result of excessive 
stimulation of receptors at excitatory synapses such as the NMDA receptor. Excitotoxicity has 
been implicated in acute neurological damage from ischemia and traumatic brain injury and in 
the chronic neurodegeneration in Huntington's disease. Glutamate excitoxicity is also believed to 
be a significant contributor to motor neuron death in ALS.  Excitotoxic neuronal death via over-
activation of NMDA receptors contributes to excessive flux of calcium (Ca2+) into the cell. This 
triggers a range of responses resulting in cell death, including increased oxidative stress, 
inappropriate activation of proteases such as calpain, dysregulation of Ca2+-related pathways, 
mitochondrial damage, and the apoptotic cascade.  
 
Determination of the neuroprotective effects of  CNM-Au8 on motor neurons in an in vitro 
glutamate challenge model was carried out in ventral spinal cord cultures from E14 rat embryos 
(Martinou et al., 1992). On Day 11 after seeding, cultures were pre-treated with CNM-Au8 or 


 
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vehicle. The positive control riluzole was added for 1 hour of pre-treatment before glutamate 
addition. On Day 13, glutamate was added to the cultures for 20 minutes, followed by treatment 
of riluzole or CNM-Au8 for another 48 hours before cells were fixed and stained. Cultures were 
stained with anti-MAP-2 to assess motor neuron survival and neurite lengths, and also with TDP-
43 and Hoechst stain to assess extranuclear TDP43. CNM-Au8 dose-dependently protects motor 
neurons from glutamate-induced cell death (Figure 6A) while also preserving neurite length 
(Figure 6B). CNM-Au8 also outperformed riluzole on neurite network preservation.  In addition, 
CNM-Au8 treatment prevented the accumulation of cytoplasmic TDP-43, a hallmark of ALS 
cytotoxicity (Figure 6D).  
 
Figure 6 . Neuroprotection of Motor Neurons from Glutamate Excitotoxicity by CNM-
Au8 
Figure 6A. Motor Neuron Survival 
Figure 6B. Motor Neuron Neurtie Network Area 
 
 
Figure 6B. Effect Of CNM-Au8 on MAP-2 Staining in Rat Hippocampal Neurons Following Glutamate 
Excitotoxicity Injury 


 
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Figure 6D. Reduction in Cytoplasmic TDP43 
 
1.2.2.1.2 CNM-Au8 Protects Normal iPSC Derived Human Motor Neurons From ALS-
Participant-Derived Toxic Astrocytes 
Astrocytes from both sporadic and familial ALS participants display toxicity against normal 
human motor neurons (MN) in co-culture (Meyer et al., 2014a). Toxic ALS-participant-derived 
astrocytes appear to secrete an unidentified toxic factor; and when co-cultured with human MNs, 
the MNs die (Meyer et al., 2014a). Similar studies have shown that astrocytes from sporadic 
participants also exhibit toxicity against healthy MNs, likely by similar mechanisms (Haidet-
Phillips et al., 2011; Meyer et al., 2014b; Qian et al., 2017). To determine whether CNM-Au8 
protects MNs from toxic ALS-participant-derived astrocytes, healthy human iPSC-derived MNs 
were plated with SOD1A4V astrocytes for 14 days in the presence of various doses of CNM-
Au8 or vehicle. Neuroprotection was assessed by quantification of the expression of neuronal 
markers (Tuj1, Isl1/2, and ChAT) compared to vehicle treated control. Measurement of primary 
neurite lengths and a neurite network complexity Sholl analysis was also conducted (Sholl, 
1953). As shown in Figure 7 below significant neuroprotective dose-dependent effects of CNM-
Au8 treatment were consistently observed on survival in the presence of SOD1A4V participant-
derived toxic astrocytes.  
 
 
 
 
 
 
 


 
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Figure 7. CNM-Au8 Protects Normal iPSC Derived Human Motor Neurons From ALS-
Participant-Derived Toxic Astrocytes 
 
 
 
 
1.2.2.2 In vivo ALS Neuroprotection Models 
 
To demonstrate the efficacy of CNM-Au8 treatment in an in vivo model of ALS, two studies 
were conducted in separate SOD1G93A mouse model strains. These included the rapidly 
progressive SOD1G93A transgenic line on a mixed SJL/C57BL6 background (Heiman-Patterson 
et al., 2005) and the more slowly progressive SOD1G93A transgenic line on a congenic C57Bl/6 
background (Lutz, 2018) with lifespans of ~157 days compared to ~129 days, respectively. The 
study using rapidly progressing SOD1G93A animals showed only minor improvement in clinical 
onset (p=0.13, Mantel-Cox test), as well as significant lack of brainstem atrophy (p<0.05, 
unpaired t-test) in the CNM-Au8-treated group (N=15 animals per group;); all other functional 
measures were not significant (data not shown).  In the study of the slower progressing 
SOD1G93A (N=20 female mice, 10 per group), four-week-old female SOD1 mice were randomly 
assigned one of two groups with each group balanced for weight.  
 
Beginning at four weeks of age, mice were provided either CNM-Au8 or vehicle ad libitum in 
their drinking water. Beginning at Week 8 of age each mouse was tested weekly for strength and 
motor coordination utilizing several measures including the triple horizontal bar hang time test, 
static rod orientation test, inverted screen hang time test, weight hold test, and home cage wheel 
activity (average speed) in addition to standard ALS clinical scoring (Deacon, 2013a, 2013b; 
Hatzipetros et al., 2015). The CNM-Au8-treated group significantly outperforms the vehicle 
treated group at virtually all timepoints across these tests (Figure 8).   In addition, survival 
benefits have been observed through Week 22 of the study (Figure 9). 
 
Taken together, these preliminary data from an ongoing study in a transgenic ALS mouse model 
demonstrate preservation of motor function following chronic treatment with CNM-Au8. 
 


 
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Figure 8. Locomotor Functional Efficacy of CNM-Au8 in an SOD1G93A (C57Bl/6 
congenic strain) Murine Study 
 
A. ALS TDI Neuro Score 
 
B. Weights Hold Test 
C. Horizontal Bar Test 
 
 
D. Home Wheel Velocity  
E. Home Wheel Velocity By Period 
 
 
 
 


 
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Figure 9. Effect of CNM-Au8 on Survival in a Murine SOD1G93A Model 
 
 
1.2.3 Summary CNM-Au8 Treatment Rationale for ALS 
 
CNM-Au8-treated motor neurons are protected against cell death by glutamate excitotoxicity in a 
dose-dependent manner in a primary rat neural-glial co-culture where cytoplasmic levels of 
TDP-43 are significantly reduced. Aberrant cytoplasmic localization and aggregation of TDP-43 
has been observed in over 90% of cases of ALS in humans (Neumann et al. 2006).  Further, 
results from these multiple iPSC human motor neuron studies derived from sporadic, familial, 
and healthy lines indicate that CNM-Au8 is neuroprotective to MNs challenged with multiple 
different ALS disease related stressors, namely, excitotoxic and toxic astrocytic stress.  Results 
from the SOD1G93A-overexpression mouse study demonstrate significant improvements in 
locomotor performance of CNM-Au8-treated mice with a significant survival benefit. 
In summary, CNM-Au8 has demonstrated neuroprotection across a range of neuronal cell types, 
antioxidant activity to counteract the accumulation of ROS in ALS, and preservation of motor 
function in an ALS mouse model. CNM-Au8 therefore represents an important therapeutic 
candidate for ALS. 
 
 


 
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2. OBJECTIVES 
2.1 Study Objectives and Endpoints  
Primary Efficacy Objective: 
To evaluate the efficacy CNM-Au8 as compared to placebo on ALS disease progression.  
 
Secondary Efficacy Objective: 
• To evaluate the effect of CNM-Au8 on selected secondary measures of disease 
progression, including survival. 
 
Safety Objective: 
• To evaluate the safety of CNM-Au8 for ALS. 
 
Exploratory Efficacy Objective: 
• To evaluate the effect of CNM-Au8 on selected biomarkers and endpoints. 
 
Primary Efficacy Endpoint: 
Change in disease severity as measured by the ALS Functional Rating Scale-Revised (ALSFRS-
R) total score using a Bayesian repeated measures model that accounts for loss to follow-up due 
to mortality.  
 
Secondary Efficacy Endpoints: 
• Change in respiratory function as assessed by slow vital capacity (SVC). 
• Change in muscle strength as measured isometrically using hand-held dynamometry 
(HHD) and grip strength. 
• Survival. 
 
Safety Endpoints: 
• Treatment-emergent adverse and serious adverse events. 
• Changes in laboratory values and treatment-emergent and clinically significant laboratory 
abnormalities. 
• Changes in ECG parameters and treatment-emergent and clinically significant ECG 
abnormalities. 
• Treatment-emergent suicidal ideation and suicidal behavior. 
 
Exploratory Efficacy Endpoints: 
• Changes in quantitative voice characteristics. 
• Difference in the proportion of patients experiencing a  6-point decline in the ALSFRS-
R between active treatment and placebo from Baseline to Week 24. 
• Changes in biofluid biomarkers of neurodegeneration. 


 
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• Changes in patient reported outcomes.  
• Change in respiratory function as assessed by home spirometry. 
 
 
 
 


 
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3. RSA DESIGN 
This study is a multi-center, randomized, placebo-controlled trial, testing two active doses of 
CNM-Au8 (30 mg, 60 mg), given orally daily versus color-matched placebo. Participants will be 
randomized 3:1 active (CNM-Au8): placebo.  Participants randomized to active will be equally 
allocated between the CNM-Au8 30 mg and 60 mg doses. 
  
3.1 Scientific Rationale for RSA Design 
The comparator for this study is placebo. Placebo will consist of a sodium bicarbonate solution 
in USP water, color matched to active CNM-Au8. Placebo was chosen as the comparator 
because there are no highly effective, disease-modifying therapies currently available for people 
with ALS. Both riluzole and edaravone, the only two therapies currently approved for ALS, are 
available to participants as concomitant therapy during this study. In this manner, participants are 
not sacrificing any potential benefit from currently approved therapies  to participate in this 
study. 
 
3.2 End of Participation Definition 
A participant is considered to have ended his or her participation in the placebo-controlled period 
of the Regimen if they: 
•  Complete planned placebo-controlled period visits, as described in the SOA, including 
participants on or off study drug 
• Early terminate from the study and complete the Early Termination Visit and Follow-Up 
Phone call as described in Section 6.1.11 
• Withdraw consent to continue participation in the study, or are lost to follow-up 
.  
If a participant initiates open-label study drug in the OLE period, he or she is considered to have 
completed his or her participation in the OLE period of the Regimen if they choose to 
discontinue participation or if all planned OLE period visits, including the last visit or the last 
scheduled procedure shown in the SOA, have been completed.  
3.3    End of Regimen Definition 
 
The end of the placebo-controlled period in a Regimen occurs when all randomized participants 
have completed their participation in the placebo-controlled period as defined in section 3.2. 


 
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The end of the OLE period in a Regimen occurs when all participants who initiated open-label 
study drug in the OLE period have completed their participation in the OLE period as defined in 
section 3.2. 
 
 
 


 
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4. RSA ENROLLMENT 
4.1 Number of Study Participants 
Approximately one hundred-sixty (160) participants will be randomized for this Regimen.   
 
4.2 Inclusion and Exclusion Criteria 
In order to be randomized to an RSA, participants must meet the Master Protocol eligibility 
criteria.  In addition, participants meeting all of the following inclusion and exclusion criteria 
will be allowed to enroll in this Regimen:  
 
4.2.1 RSA Inclusion Criteria 
Per the Master Protocol. 
 
4.2.2 RSA Exclusion Criteria  
1. History of allergy to gold, gold salts, or colloidal gold preparations.  
 
4.3 Treatment Assignment Procedures 
Each participant who meets all eligibility criteria for the RSA will be randomized to receive 
either CNM-Au8 or placebo for approximately 24-weeks of double-blind treatment.  An 
additional period of open-label treatment may be offered to participants following completion of 
the placebo-controlled portion of the study. 
 
 
 


 
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5. INVESTIGATIONAL PRODUCT  
5.1 Investigational Product Manufacturer 
Manufacturing, testing, product characterization, release of CNM-Au8 will be carried out at the 
Sponsor’s facility at 500 Principio Parkway West, Suite 400, North East, MD 21901, USA.  
 
Table 2.  CNM-Au8 Investigational Product Dosing Administration 
 
Description 
CNM-Au8 30 mg 
CNM-Au8 60 mg 
Matched Placebo 
Total Daily Dosage 
30 mg 
60mg 
NA 
Concentration 
250 μg/mL 
500 μg/mL 
NA 
Volume per Bottle 
60 mL 
60 mL 
60 mL 
Bottles per Day 
2 
2 
2 
Daily Volume 
120 mL 
120 mL 
120 mL 
Route of 
Administration 
Oral 
Oral 
Oral 
Time and 
Frequency 
Once Daily; Same 
Time Each Day  
(± 1 hour) 
Once Daily; Same 
Time Each Day  
(± 1 hour) 
Once Daily; Same 
Time Each Day  
(± 1 hour) 
 
The investigational product components and quality standards are described in Table 6 below. 
 
Table 3.  CNM-Au8 Components and Quality Standards 
 
Description 
Quality Standard 
CNM-
Au8 
30 mg 
CNM-
Au8 
60 mg 
Matched 
Placebo 
NaHCO3 (mg) per 
bottle 
ACS, USP identity 
32.8 mg 
32.8 mg 
32.8 mg 
Au (mg) per Bottle 
Conforms with ASTM B562-95 and USP 
<233>  
15 mg 
30 mg 
NA 
USP Purified Water 
USP for total organic carbon, and 
conductivity 
60 mL 
60 mL 
60 mL 
 
  
5.2 Labeling, Packaging, and Resupply 
All investigational drug products will be labeled according to applicable local and legislative 
requirements. Label text will be approved according to the Sponsor’s agreed procedures, and a 


 
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copy of the labels will be made available to the study site upon request. For all study drugs, a 
system of numbering in accordance with all requirements of Good Manufacturing Practice 
(GMP) will be used, ensuring that each dose of study drug can be traced back to the respective 
bulk ware of the ingredients. The Sponsor’s Quality Assurance group will maintain lists linking 
all numbering levels.  A complete record of batch numbers and expiry dates of all study 
treatment as well as the labels will be maintained in the Sponsor study file. 
 
Study drug label may include, but is not limited to, the following information: 
• Batch number 
• Storage information 
• Unique number/code 
  
5.3 Acquisition, Storage, and Preparation 
Investigational product will be stored at the investigational site in accordance with Good Clinical 
Practice (GCP) and GMP requirements and will be inaccessible to unauthorized personnel. A 
complete record of batch numbers and expiry dates can be found in the regimen industry partner 
study file; the site-relevant elements of this information will be available in the Investigator site 
file. The responsible site personnel will confirm receipt of IP via the interactive web response 
system (IWRS) and will use the IP only within the framework of this clinical study and in 
accordance with this protocol. Receipt, distribution, return and destruction (if any) of the IP must 
be properly documented according to the Sponsor’s agreed and specified procedures. 
 
All IP must be kept in a locked area with limited access and stored at 15°- 25°C (59°- 77°F). 
Mean kinetic temperature should not to exceed 25°C. Excursions between 15°C and 30°C (59° 
and 86° F) that may be experienced in pharmacies, hospitals, or warehouses, and during shipping 
are allowed. 
 
5.4 Study Medication/Intervention, Administration, Escalation, and Duration 
 
Participants will either receive CNM-Au8 30 mg, 60 mg, or color-matched placebo in the study.  
The Investigational Product (IP) will be self-administered by participants who will be directed to 
take the IP each day in the morning at approximately the same time, at home at least thirty (30) 
minutes prior to food intake. The drug formulations will be identical in appearance (size, shape, 
volume, color) and smell. The packaging and labeling will be designed to maintain blinding to 
the Site Investigator’s team and to participants. There are no visible differences between CNM-
Au8 30 mg, 60 mg, and placebo dosing units.  
 


 
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Participants may take the study drug by mouth or through a gastric tube.  Participants taking 
study drug by gastric tube should be directed to first flush the tube with approximately 20-30 mL 
of distilled water, administer study drug, and then flush the tube post-study drug administration 
with another 20-30 mL of distilled water. 
 
Based on the supply of the IP provided, the maximum window between in-clinic study visits 
during the placebo-controlled period may not exceed 64 days. The maximum window between 
in-clinic study visits during the Open Label Extension period may not exceed may not exceed 64 
days for the first 16 weeks, and may not exceed 96 days for the duration of the OLE study 
period. 
 
5.5 Drug Returns and Destruction  
At each in person visit the steps outlined in Manual of Procedures must be followed for study 
drug accountability and compliance, as well as study drug return and destruction.  
 
Prior to study drug destruction, all used and unused IP requires a second accountability 
verification to be completed by a different study team member, and both verifications should be 
documented on the study destruction logs. No study drug may be destroyed on-site until written 
approval is provided by the study monitoring team. Sites should follow their local drug 
destruction policies. 
 
 


 
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5.5 Dosage Adjustment 
 
No dosage adjustments are anticipated during the placebo-controlled period of the study. If 
participants have difficulty tolerating IP, the Investigator may permit the participants to reduce 
the daily dose by one (1) bottle. Potential tolerability issues may include gastrointestinal 
disturbances, headache, somnolence, or other treatment emergent adverse events are not 
otherwise explained.  
 
Down titration of IP to one (1) bottle daily will only be allowed to address tolerability issues and 
only with Medical Monitor approval. After a participant has been down titrated to, he/she may be 
allowed to retry two (2) bottle dose (re-challenge), after a discussion with and approval by the 
Site Investigator and Medical Monitor. Any dosing changes must be appropriately documented 
including start date(s) and re-challenge date(s). If the participant cannot tolerate the re-challenge, 
he/she may remain at the lower dose of one (1) bottle daily. Drug holidays (e.g., treatment-free 
periods) are not permitted. 
 
During the Open Label Extension, participants will maintain their current blinded dose. 
Participants previously randomized to placebo during the placebo-controlled period of the study 
will be re-randomized to receive CNM-Au8 30 mg or 60 mg for the Open Label Extension. All 
dosing assignments will remain blinded throughout the Open Label Extension. IP tolerability 
issues encountered during the Open Label Extension will be managed on a case-by-case basis by 
the Site Investigator in coordination with the Medical Monitor. 
 
5.6 Justification for Dosage  
Dosage selection has been made based on human safety margins from nonclinical toxicology 
studies and the exposure data from pharmacology studies that demonstrated neuroprotection 
benefits. 
 
5.6.1. Human Dosing Safety Margins 
Based upon the maximum doses (mg/kg/day) evaluated in the nonclinical GLP repeat-dose 21-
day toxicokinetic studies, the completed first-in-human Phase 1 study (AU8.1000-14-01) doses 
of 15, 30, 60, 90 mg provided a safety margin to the NOAEL based on dose ratios (mg/m2) 
ranging from 26x – 4x in rodents, and 195x – 32x in canines, as described in the tables below.  
Therefore, at the top dose of 90 mg tested in humans, there was a minimum 4x safety margin to 
the NOAEL in rats.  
 


 
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Table 4. Summary of CNM-Au8 Conversion of Animal 21-Day Repeat Doses To Human 
Equivalent Dose (HED) Based On Body Surface Area (mg/m2) for 60 kg Human 
 
Further, when evaluating Au exposure based on the end of study Day 21 AUC(0-24) (ng*hr/mL) 
in the canine, and rodent studies in comparison with the human 21-day MAD study, the human 
doses provided an exposure safety margin ranging from 3.3x – 1.6x  compared with rodents, and 
18.5x – 9.0x compared with canines, as described in the Table 3 below. 
 
Table 5. Summary of CNM-Au8 Exposure Safety Margin Based on End of Study AUC(0-
24) ng*hr/mL. Ratio of Animal Toxicokinetic to Human Pharmacokinetic AUC Results 
From 21-Day Repeat Dose Studies.  
 
CNM-Au8 exposure at the NOAEL at the end of the chronic toxicokinetic studies in the 9-Month 
canine and 6-Month rodent chronic dosing studies, provided an exposure safety margin ranging 
from 6.5x – 3.2x, and 13.6x – 6.7x in rodents and canines, respectively in comparison with the 
human exposures in the 21-day MAD study, as described below in Table 4. 
 
 
 
Species 
21-Day 
NOAEL 
Dose 
(mg/kg/day) 
21-Day 
NOAEL 
Dose 
(mg/m2) 
Safety Margin Based on Dosing Ratios (mg/m2) 
(For 21-Day dosing Studies) 
15 mg 
(9.3 
mg/m2) 
30 mg 
(18.5 
mg/m2) 
60 mg 
(37.0 
mg/m2) 
90 mg 
(55.5 
mg/m2) 
Rat 
40 
240 
25.9 
13.0 
6.5 
4.3 
Canine 
90 
1800 
194.6 
97.3 
48.6 
32.4 
 
Species 
 
21-Day 
NOAEL 
Dose 
(mg/kg/day) 
Animal 
End of 
Study 
AUC(0-24) 
(ng*hr/mL)a 
Safety Margin Based on Animal/Human  
AUC(0-24) Ratio (For 21-Day Dosing Studies) 
Human 
15 mg 
AUC 
(32.3 
ng*hr/mL) 
Human 
30 mg 
AUC 
(41.4 
ng*hr/mL) 
Human 
60 mg 
AUC 
(50.3 
ng*hr/mL) 
Human 
90 mg 
AUC 
(66.0 
ng*hr/mL) 
Rat 
40 
106 
3.3 
2.6 
2.1 
1.6 
Canine 
90 
596 
18.5 
14.4 
11.8 
9.0 
Notes: a Average of Male and Female AUC(0-24) ng*hr/mL values at End of Study 


 
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Table 6.  Summary of CNM-Au8 Exposure Safety Margin Based on End of Study AUC(0-
24) ng*hr/mL Ratio of Chronic Animal Toxicokinetic 6 and 9-Month Rodent and Canine 
Repeat Dose Studies to Human 21-Day Pharmacokinetic Results  
 
 
5.6.2 Neuroprotection Pharmacologic Exposure Data 
Based on the blood gold exposure observed in rodent toxicokinetic (TK) studies where 
significant remyelination and neuroprotection benefits were observed in preclinical 
neuroprotection models at mean AUC value of 30.6 (hr*ng/mL), which suggests a minimum 
human equivalent exposure to achieve a positive bioenergetic response to CNM-Au8 of 15 – 30 
mg.  Increased AUC exposure of 50.3 (hr*ng/mL) was observed at the CNM-Au8 60 mg dose.   
 
Figure 10. 21-Day AUC Exposure Ranges Between Rodent Toxicokinetic Studies, 
Preclinical Efficacy Models, and First-In-Human Dosing 
 
 
 
Species (Study) 
 
NOAEL  
Chronic 
Dosing 
(mg/kg/day) 
Animal 
End of 
Study 
AUC(0-
24) 
(ng*hr/m
L)a 
Safety Margin Based on Chronic Animal End-of-Study/ 
Human 21-Day AUC(0-24) Ratio 
Human 
15 mg AUC 
(32.3 
ng*hr/mL) 
Human 
30 mg AUC 
(41.4 
ng*hr/mL) 
Human 
60 mg AUC 
(50.3 
ng*hr/mL) 
Human 
90 mg AUC 
(66.0 
ng*hr/mL) 
Rat (6-Month) 
40 
209 
6.5 
5.0 
4.2 
3.2 
Canine  
(9-Month) 
10 
440 
13.6 
10.6 
8.7 
6.7 
a Average of Male and Female AUC(0-24) ng*hr/mL values  at End of Study 


 
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In conclusion, based on CNM-Au8 exposures at the NOAELs in the chronic rodent and canine 
studies along with observed CNM-Au8 exposures in 21-day multiple dosing in humans while 
also considering safety and tolerability, the dosage chosen for this study in participants with ALS 
will be CNM-Au8 30 mg/day and 60 mg/day.   
 
5.7 Participant Compliance 
Participants will be requested to return any unused IP including empty packaging and used 
bottles at each study visit. Treatment compliance will be assessed at in clinic study visits through 
bottle counts and will be documented and summarized by a drug-dispensing log for each 
participant. During phone visits, drug compliance check-in will be held to ensure participant is 
taking drug per dose regimen and to note any report of missed doses. Overall treatment 
compliance with IP intake for the per protocol analysis set should be between 80% and 120% of 
the planned dose and will be assessed at specified study visits. In the event participants are not 
compliant within this range, discontinuation may be considered by the Site Investigator in 
consultation with the Medical Monitor or designee. 
 
The date of dispensing the IP to the participant will be documented in the eCRF. Changes in IP 
dosing for tolerability issues will also be documented in the eCRF. 
 
If a dose of IP is missed, the participant should take the dose that day and continue with the 
planned dosing interval for the following day. The dose should not be doubled to make up for a 
missed dose within the same day.  
 
5.8 Overdose 
In the event of overdose, study staff should monitor the study participant and provide supportive 
care as needed. The SI should also contact the Medical Monitor within twenty-four (24) hours.  
No prior experience has been documented regarding overdosage in humans.  
5.9 Prohibited Medications 
There are no prohibited medications for this regimen.  
5.10 CNM-Au8 Known Potential Risks and Benefits 
5.10.1 Known Potential Risks 
5.10.1.1 Immediate Risks  
 
• There has been limited human exposure to clean-surfaced Au nanocrystals. There could be 
unexpected adverse effects from 24 weeks of exposure to 30 mg or 60 mg of CNM-Au8. 
These risks have been mitigated by an extensive preclinical toxicology program in multiple 


 
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species demonstrating No-Adverse-Effect-Levels (NOAEL) at the highest doses studied (up 
to 10 mg/kg/day in canines; 40 mg/kg/day in rats). Therefore, no Maximum Tolerated Dose 
(MTD) could be established in these nonclinical studies. In addition, single and multiple 
ascending dose studies have been performed in healthy human volunteers, which showed no 
significant adverse events (SAEs) or safety issues. CNM-Au8 was well tolerated at the doses 
studied up to 90 mg per day over twenty-one days of consecutive dosing. 
 
• There have been no clinical trials of CNM-Au8 in humans with ALS. There is a risk that 
CNM-Au8 may not be effective and a very small risk that CNM-Au8 could make participants 
worse. These risks have been mitigated by a robust preclinical program, demonstrating that 
CNM-Au8 is effective in multiple models of protection from neurodegeneration. 
 
5.10.1.2 Long Range Risks 
 
There has been limited human exposure to CNM-Au8. There could be unexpected adverse 
effects from chronic exposure to 30 mg or 60 mg of CNM-Au8. Based on rodent and canine 
toxicokinetic data, when taken orally with daily administration, CNM-Au8 can be expected to be 
absorbed, and eliminated, relatively slowly with increasing blood and tissue concentrations 
accumulating over time.  
 
The risks of long-term exposure to CNM-Au8 are mitigated by toxicology studies with chronic 
dosing, demonstrating no significant toxicities or maximum-tolerated dose. 
 
5.10.1.3 Summary of Participant Risk 
 
Given the potential benefits of CNM-Au8 demonstrated in pre-clinical models of ALS, the safety 
of CNM-Au8 demonstrated in preclinical toxicology studies and Phase 1 clinical trials in healthy 
controls, overall, the benefit-risk of CNM-Au8 is positive for participants with ALS.  
 
5.10.2 Known Potential Benefits 
As described previously, in preclinical models of ALS, CNM-Au8 has demonstrated efficacy in 
several relevant models of neurodegeneration.  CNM-Au8 has been shown to protect neuronal 
populations from chemical, inflammatory, and hypoxic insults through a series of unique 
catalytic mechanisms involving 1) the nicotine adenine dinucleotide redox couple 
(NAD+/NADH) to boost glycolytic energy production, 2) the nicotine adenine dinucleotide 
phosphate redox couple (NADP+/NADPH) to influence anabolic processes associated with 
differentiation, and 3) the SOD-like inactivation of reactive oxygen species and nitric oxide to 
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CNM-Au8 could improve participant functioning and/or prolong life in participants with ALS. 
The safety of CNM-Au8, at the doses to be tested in this study have been shown to be safe and 
well tolerated in preclinical toxicology and Phase 1 clinical trials in healthy controls. 
 
5.11 Regimen-Specific Lab Alerts 
Site Investigators and the Medical Monitor will receive an alert from the Central Lab for certain 
lab changes.  (See below.)  These alerts are informative only, and they do not mean a participant 
must reduce drug dosage or discontinue study drug. These alerts indicate that the Site 
Investigator and Medical Monitor should follow up with additional testing and management as 
clinically indicated. Discontinuation of any participant on the basis of abnormal laboratory 
findings will be at the discretion of the Site Investigator. 
 
Chemistry Panel Test 
Name 
Outlier Criteria Warranting Further 
Investigation 
ALT and AST 
>3x ULN 
Creatinine 
>1.5 x Baseline 
Hematology Panel Test 
Name 
Outlier Criteria Warranting Further 
Investigation 
Platelet count 
<75,000/mm3 
 


 
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6. REGIMEN SCHEDULE  
In addition to procedures in the Master Protocol, the following regimen-specific procedures will 
be conducted during the study: 
 
• Home Spirometry 
o Note: Home spirometry should be collected within the visit window but will occur 
while the participant is not in the clinic (at home or other remote location)e.  
• ALSAQ-40 
• CNS Bulbar Function Scale 
• Voice recording 
• Smartphone installation and removal 
• Whole blood collection for PK and PD analyses 
• Plasma collection for PK and PD analyses 
• Urine collection for PD analyses 
 
Modifications to Regimen Schedule  
 
Designated visits in the Schedule of Activities (i.e., Week 4, Week 8, and Week 16) may be 
conducted via telemedicine (or phone if telemedicine is not available) with remote services 
instead of in-person if needed to protect the safety of the participant due to a pandemic or other 
reason. If a planned in-clinic visit is conducted via telemedicine (or phone if telemedicine is not 
available) with remote services, only selected procedures will be performed. Instructions on how 
to document missed procedures are included in the MOP.  
 
In addition to the procedures in the Master Protocol that should be conducted during the phone or 
telemedicine and remote visits, the following regimen-specific procedures should be completed:  
 
• Home Spirometry (Week 8 and 16 only) 
• Voice Recording 
• CNS Bulbar Function Scale (Week 8 and 16 only)  
 
Details on collection of the CNS Bulbar Function Scale, dispensing IP during remote visits, and 
documenting participants’ willingness to participate in OLE are described in the MOP. 
 
Blood samples for PK and PD analyses are not collected during the remote visits by the home 
health agency and this should be recorded as such in the applicable source documentation and 
EDC.  


 
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6.1 Regimen-Specific Screening Visit 
This visit will take place in-person after the Master Protocol randomization to a regimen. There 
are no regimen-specific procedures for this visit. For this regimen, the Regimen-Specific 
Screening Visit and Baseline Visit should be combined, if possible. 
Participants may be required to reconsent to the regimen if new procedures or information is 
added in the future. Should a participant need to reconsent, this should occur during the 
participant’s next in-person visit. If the participant’s next in-clinic visit is conducted remotely, 
reconsent may also be completed remotely using the following procedures: 
 
1. The site staff sends copy of the informed consent form to the participant.  
2. The participant reads through the consent form but does not sign.  
3. The Site Investigator, or other study staff member approved and delegated to obtain informed 
consent, contacts the participant and reviews the informed consent form with the participant. 
4. The participant signs the informed consent form and returns the original signed consent form 
back to the site. 
5. Once received at the site, the individual who consented the participant signs the informed 
consent form. 
 
6.2 Baseline Visit 
This visit will take place on Day 0.  The following procedures will be performed for the regimen 
schedule: 
 
• ALSAQ-40 
• CNS Bulbar Function Scale 
• Install smartphone app 
• Home Spirometry 
• Voice recording 
• Whole blood collection for PK and PD analyses 
• Plasma collection for PK and PD analyses 
• Urine collection for PD analyses 
• Dispense IP 
• Administer first dose of IP in clinic after all Baseline procedures have been completed 
• Remind participant to bring in investigational product to the next visit 
 
 


 
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6.3 Week 2 Telephone Visit 
 
This visit will take place 14 ± 3 days after the Baseline Visit via telephone.  No regimen-specific 
procedures will be performed at this visit. 
 
6.4 Week 4 and 8 Visits 
Participants should be instructed to hold study drug on the day of the study visit. Study drug 
should not be taken until after study visit procedures are complete. 
 
These visits will take place on Days 28 ± 7 and 56 ± 7 days, respectively.  The following 
procedures will be performed for the regimen schedule: 
 
• Home Spirometry [Week 8 Only] 
• CNS Bulbar Function Scale [Week 8 only] 
• Voice recording 
• Plasma collection for PK analyses 
• Dispense IP (Week 8 only)  
• Remind participant to bring in investigational product to the next visit 
 
6.5 Week 12 Telephone Visit 
 
This visit will take place 84 ± 3 days after the Baseline Visit via telephone.  No regimen-specific 
procedures will be performed at this visit. 
 
6.6 Week 16 Visit  
This visit will take place on Day 112 ± 7 days.  The following procedures will be performed for 
the regimen schedule: 
• Home Spirometry 
• ALSAQ-40 
• CNS Bulbar Function Scale 
• Voice Recording 
• Dispense IP 
• Document participant’s willingness to participate in the OLE 
o 
If OLE consent is not obtained at Week 16, it may be obtained at Week 24. 
 
• Remind participant to bring in investigational product to the next visit 


 
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6.7 Week 20 Telephone Visit 
 
This visit will take place 140 ± 3 days after the Baseline Visit via telephone. No regimen-specific 
procedures will be performed at this visit. 
 
6.8 Week 24 Visit or Early Termination Visit 
Participants should be instructed to hold study drug on the day of the study visit. Study drug 
should not be taken until after study visit procedures are complete. 
 
This visit will take place on Day 168 ± 7 days.  The following procedures will be performed for 
the regimen schedule: 
• Home Spirometry 
• ALSAQ-40 
• CNS Bulbar Function Scale 
• Voice recording  
• Uninstall smartphone app 
• Whole blood collection for PK and PD analyses 
• Plasma collection for PD analyses 
• Urine collection for PD analyses 
• Dispense IP [See note below.] 
• Remind participant to bring investigational product to the next visit (only if continuing in 
OLE) 
 
Note: Drug is only dispensed at this visit if the participant is continuing in the Open Label 
Extension. 
 
6.9 Follow-Up Safety Call 
Participants will have a Follow-Up Safety Call 28±3 days after their last dose of study drug.  
Only those participants NOT continuing on in the Open Label Extension will have the Follow-
Up Safety Call at the end of their participation in the placebo-controlled portion of the trial.  The 
following procedures will be performed: 
 
• Assess and document AEs 
 


 
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6.10 Process for Early Terminations  
Participants who early terminate from the study and do not complete the protocol per ITT will be 
asked to be seen for an in-person Early Termination Visit and complete a Follow-Up Safety Call. 
If a participant is not able to be seen in-person, safety assessments and others that can be 
conducted remotely should be performed. 
 
 
The in-person Early Termination Visit should be scheduled as soon as possible after a participant 
early terminates. If the participant early terminates or withdraws consent during the placebo-
controlled portion of the Regimen, all assessments that are collected at the Week 24 in-clinic 
visit should be conducted. If the participant early terminates or withdraws consent during the 
OLE phase, all assessments that are collected at the OLE Week 52 in-clinic visit should be 
conducted. The Follow-Up Safety Call should be completed approximately 28 days after the last 
dose of study drug.   
 
If the Early Termination Visit occurs approximately 28±3 days after the last dose of study drug, 
the information for the Follow-Up Safety Call can be collected during the Early Termination 
Visit, and a separate Follow-Up Safety Call does not need to be completed. If the in-person Early 
Termination Visit does not occur within 28±3 days of the last dose of study drug, the Follow-Up 
Safety Call should occur approximately 28 days after the last dose of study drug and the Early 
Termination Visit will be completed after the Follow-Up Safety Call.  
 
If a participant decides to discontinue study drug, but will complete the protocol, an in-person 
Early Termination Visit and Follow-Up Safety Call is not necessary. 
 
6.11 Open Label Extension  
 
Participants who have completed the placebo-controlled portion of the trial on drug. will be 
eligible to continue in the Open Label Extension (OLE) as outlined in the SOA. Participants will 
first be asked about their desire to continue in the OLE at the Regimen-Specific Screening Visit.  
They will also be asked to re-confirm whether they want to continue in the OLE at the Week 16 
Visit of the placebo-controlled period. The OLE, CNM-Au8 will be provided by Clene 
Nanomedicine, until the primary results of the 24 week double-blind portion of the study are 
available, or Clene or sponsor terminate support or development of CNM-Au8 for ALS. 
 
Modifications to OLE Schedule  
Designated visits in the Schedule of Activities for the OLE (i.e. Week 4, Week 8, Week 16, 
Week 28, and Week 40) may be conducted via telemedicine (or phone if telemedicine is not 
available) with remote services instead of in-person if needed to protect the safety of the 


 
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participant due to a pandemic or other reason. If a planned in-clinic visit is conducted via 
telemedicine (or phone if telemedicine is not available) with remote services, only selected 
procedures will be performed. Instructions on how to document missed procedures are included 
in the Manual of Procedures.  
 
In addition to the procedures in the Master Protocol that should be conducted during the phone or 
telemedicine and remote visits, the following regimen-specific procedures should be completed:  
 
• Home Spirometry 
• CNS Bulbar Function Scale (Not done at OLE Week 4).  
 
Blood and urine samples for PK and PD analysis are not collected during the remote visits by the 
home health agency, and this should be recorded as such in the applicable source documentation 
and EDC.  
 
6.11.1 Week 2 OLE Telephone Visit 
 
This visit will take place via telephone 14 ± 3 days after the Week 24 Visit of the placebo-
controlled portion of the trial. The following procedures will be performed: 
 
• 
Review concomitant medications 
• 
Assess and document AEs, including Key Study Events (see section 10.3 of Master Protocol) 
• 
Drug Compliance Check-In 
• 
Remind participant to bring investigational product to the next visit 
 
6.11.2 Week 4 OLE Visit 
 
This visit will take place in-person 28 ± 10 days after the Week 24 Visit of the placebo-
controlled portion of the trial. The following procedures will be performed: 
 
• 
Collect vital signs including weight 
• 
Perform SVC 
• 
Collect Home Spirometry  
• 
Administer ALSFRS-R questionnaire 
• 
Collect blood samples for Clinical Safety Labs and, for WOCBP, for pregnancy test if 
applicable 
• 
Review concomitant medications 
• 
Assess and document AEs, including Key Study Events (see section 10.3 of Master Protocol) 
• 
Administer the C-SSRS Since Last Visit questionnaire  


 
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• 
Perform investigational product compliance 
• 
Remind participant to bring investigational product to the next visit 
 
6.11.3 Week 8 OLE Visit 
 
This visit will take place in-person at 56 ± 7 days after the Week 24 Visit of the placebo-
controlled portion of the trial. The following procedures will be performed: 
 
• 
Collect vital signs including weight 
• 
Perform SVC 
• 
Collect Home Spirometry 
• 
Administer ALSFRS-R questionnaire 
• 
CNS Bulbar Function Scale 
• 
Collect blood samples for Clinical Safety Labs and, for WOCBP, for pregnancy test if 
applicable 
• 
Review concomitant medications 
• 
Assess and document AEs, including Key Study Events (see section 10.3 of Master Protocol) 
• 
Administer the C-SSRS Since Last Visit questionnaire  
• 
Dispense investigational product to participant  
• 
Perform investigational product compliance 
• 
Remind participant to bring investigational product to the next visit 
 
6.11.4  Week 12 OLE Telephone Visit 
 
This visit will take place via telephone at 84 ± 3 days after the Week 24 Visit of the placebo-
controlled portion of the trial. The following procedures will be performed: 
 
• 
Administer ALSFRS-R questionnaire 
• 
Review concomitant medications 
• 
Assess and document AEs, including Key Study Events (see section 10.3 of Master Protocol) 
• 
Drug Compliance Check-In 
• 
Remind participant to bring investigational product to the next visit 
 
6.11.5  Week 16 OLE Visit 
 
Participants should be instructed to hold study drug on the day of the study visit. Study drug 
should not be taken until after study visit procedures are complete. 
 


 
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This visit will take place in-person at 112 ± 7 days after the Week 24 Visit of the placebo-
controlled portion of the trial. The following procedures will be performed: 
 
• 
Collect vital signs including weight 
• 
Perform SVC 
• 
Collect Home Spirometry 
• 
Administer ALSFRS-R questionnaire 
• 
CNS Bulbar Function Scale 
• 
Collect blood samples for Clinical Safety Labs and, for WOCBP, for pregnancy test if 
applicable 
• 
Review concomitant medications 
• 
Assess and document AEs, including Key Study Events (see section 10.3 of Master Protocol) 
• 
Administer the C-SSRS Since Last Visit questionnaire  
• 
Collect urine sample biomarker analyses 
• 
Collect blood sample for biomarker analyses 
• 
Whole blood PK and PD collection  
• 
Plasma PD collection 
• 
PD urine collection 
• Dispense investigational product to participant  
• 
Perform investigational product compliance 
• 
Remind participant to bring investigational product to the next visit 
 
6.11.6  Week 20 OLE Telephone Visit 
 
This visit will take place via telephone at 140 ± 3 days after the Week 24 Visit of the placebo-
controlled portion of the trial. The following procedures will be performed: 
 
• 
Administer ALSFRS-R questionnaire 
• 
Review concomitant medications 
• 
Assess and document AEs, including Key Study Events (see section 10.3 of Master Protocol) 
• 
Drug Compliance Check-In 
• 
Remind participant to bring investigational product to the next visit 
 
 
6.11.7  Week 24 OLE Telephone Visit 
 
This visit will take place via telephone at 168 ± 3 days after the Week 24 Visit of the placebo-
controlled portion of the trial. The following procedures will be performed: 
 
• 
Administer ALSFRS-R questionnaire 
• 
Review concomitant medications 


 
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• 
Assess and document AEs, including Key Study Events (see section 10.3 of Master Protocol) 
• 
Drug Compliance Check-In 
• 
Remind participant to bring investigational product to the next visit 
 
6.11.8  Week 28 and Q12 Week OLE Visits 
 
Participants should be instructed to hold study drug on the day of the study visit. Study drug 
should not be taken until after study visit procedures are complete. 
 
The Week 28 OLE Visit will take place in-person 196 ± 14 days after the Week 24 Visit of the 
placebo-controlled portion of the trial. The procedures listed in the SoA should be performed and 
participants should be provided with 8 weeks of drug and instructions for dosing. Following the 
Week 28 OLE Visit, visit will occur every 12 weeks ± 14 days. 


 
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7 OUTCOME MEASURES AND ASSESSMENTS 
For all assessments listed below, please refer to the Manual of Procedures for detailed 
instructions. 
 
7.1 Voice Analysis 
In addition to the scheduled in clinic voice recordings, voice samples will be collected twice per 
week, using an app installed on either an android or iOS based smartphone.  The app 
characterizes ambient noise, then asks patients to perform a set of speaking tasks: reading 
sentences -- 5 fixed and 5 chosen at random from a large sentence bank-- repeating a consonant-
vowel sequence, producing a sustained phonation, and counting on a single breath. Voice signals 
are uploaded to a HIPAA-compliant web server, where an AI-based analysis identifies relevant 
vocal attributes. Quality control (QC) of individual samples will occur by evaluation of voice 
records by trained personnel. 
 
The voice analysis app is only available in English, therefore participants who do not speak 
English should not complete the voice recording. Caregivers cannot provide language assistance 
when the participant is completing the voice recording. 
 
7.2  ALSAQ-40 
 
The Amyotrophic Lateral Sclerosis Assessment Questionnaire-40 (ALSAQ-40) is a patient self-
report health status patient-reported outcome. The ALSAQ-40 consists of forty questions that are 
specifically used to measure the subjective well-being of patients with ALS and motor neuron 
disease. 
 
Participants will be handed the questionnaire and asked to write their answers themselves.  
Caregivers can also help, if needed. 
 
7.3  Center for Neurologic Study Bulbar Function Scale 
 
The Center for Neurologic Study Bulbar Function Scale (CNS-BFS) is a patient self-report scale 
that has been developed for use as an endpoint in clinical trials and as a clinical measure for 
evaluating and following ALS patients. The CNS-BFS consists of three domains (swallowing, 
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Participants will be handed the questionnaire and asked to write their answers themselves.  
Caregivers can also help, if needed. 
 
Instructions on administering the questionnaire during a phone or telemedicine visit will be 
included in the MOP. 
 
7.4 Home Spirometry 
 
Remote/home-based forced vital capacity will be measured with the MIR Spirobank Smart 
spirometer. Instructions for use will be provided to the participant.  The participant will perform 
the vital capacity maneuver at home (or other remote location) with real time video coaching (or 
phone coaching, if video is not available) by the evaluator.  Three to five vital capacity 
maneuvers will be performed, consistent with the manner vital capacity is obtained in clinic.   
 
 
 


 
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8 BIOFLUID COLLECTION 
8.1 Pharmacokinetic (PK) Assessments 
8.1.1 Whole Blood PK Assessments of CNM-Au8 
Samples for the measurement of whole blood concentrations of Au will be collected before (pre-
dose) administration of investigational product per the Schedule of Assessments.  PK collection 
and processing parameters are specified in the RSA laboratory manual.   
 
PK analyses of CNM-Au8 will be specified in a separate PK analysis plan. 
 
PK blood samples will be shipped to and analyzed under the responsibility of the Clene 
Nanomedicine, Inc.’s bioanalytical laboratory at: 
 
Clene Nanomedicine, Inc. 
Bioanalytics Laboratory 
500 Principio Parkway West, Suite 400 North East, MD 21901-2912 
USA 
 
8.1.2 Plasma PK Assessments of Riluzole 
Samples for the measurement of plasma concentrations of riluzole will be collected before (pre-
dose) administration of both riluzole and the IP per the Schedule of Assessments.  Riluzole 
plasma PK collection and processing parameters are specified in the laboratory manual. 
 
Population PK analyses of riluzole will be specified in the separate PK analysis plan. The first 
forty (40) participants taking riluzole and randomized to Regimen C (CNM-Au8) to reach the 
Week 8 visit will be evaluated by the DSMB, or unblinded DSMB PK designee, to determine 
whether there are any changes in riluzole population PK parameters following treatment with 
CNM-Au8 versus placebo at the Week 4 and Week 8 timepoints.  The unblinded riluzole 
population PK analyses and designee will be implemented as per the DSMB charter. 
 
Riluzole PK plasma samples will be shipped to and analyzed under the responsibility of Covance 
Central Laboratory Services LP. 
 
8.2 Pharmacodynamic (PD) Assessments 
Plasma, whole blood, and urine samples for pharmacodynamic measurements will be collected 
before (pre-dose) administration of the investigational product per the Schedule of 
Assessments.  PD collection and processing parameters are specified in the laboratory manual. 


 
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PD plasma, whole blood, and urine samples will be shipped to the Clene Nanomedicine, Inc.’s 
bioanalytical laboratory at the address noted above for long-term storage. PD analyses will be 
conducted with external vendors and specified in a separate PD analysis plan. 
 
 


 
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9 
REGIMEN-SPECIFIC STATISTICAL CONSIDERATIONS 
9.1  Deviations from the Default Master Protocol Trial Design 
 
The statistical design for this regimen will be in accordance with the default statistical design 
described in Appendix I of the master protocol with only one deviation. This regimen will not 
include interim analyses for early success.  
 
9.2  Regimen Specific Operating Characteristics  
 
Clinical trial simulation is used to quantify operating characteristics for this regimen (refer to the 
regimen SAP for further details).   
 
9.3  Sharing of Controls from other Regimens 
 
The primary analysis of this regimen will include sharing of all controls from the other 
regimens.  This is justified by the minor differences in inclusion/exclusion criteria of the RSA, 
such that there are no expected systematic differences in the primary endpoint between the 
controls across regimens.   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
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APPENDIX I: THE ALSAQ-40


 
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APPENDIX II: THE BULBAR FUNCTION SCALE (CNS-BFS) 
BULBAR FUNCTION SCALE (CNS-BFS) 
SIALORRHEA 
Does 
Not 
Apply 
(1) 
Applies 
Rarely 
(2) 
   Applies 
Occasionally 
(3) 
Applies 
Frequently  
(4) 
Applies 
Most of 
the Time 
(5) 
 
1. Excessive saliva is a concern to 
me. 
 
 
 
 
 
2. I take medication to control 
drooling. 
 
 
 
 
 
3. Saliva causes me to gag or 
choke. 
 
 
 
 
 
4. Drooling causes me to be 
frustrated or embarrassed. 
 
 
 
 
 
5. In the morning I notice saliva on 
my pillow. 
 
 
 
 
 
6. My mouth needs to be dabbed to 
prevent drooling. 
 
 
 
 
 
7. My secretions are not 
manageable. 
 
 
 
 
 
  
TOTAL Sialorrhea Score: _____ 
SPEECH 
Does 
Not 
Apply 
(1) 
Applies 
Rarely 
(2) 
   Applies 
Occasionally 
(3) 
Applies 
Frequently  
(4) 
Applies 
Most of 
the Time 
(5) 
Unable to 
Communicate 
by Speaking 
(6) 
1. My speech is difficult to 
understand. 
 
 
 
 
 
 
2. To be understood I repeat myself. 
 
 
 
 
 
 
3. People who understand me tell 
other people what I said.  
 
 
 
 
 
 
4. To communicate I write things 
down or use devices such as a 
computer. 
 
 
 
 
 
 
5. I am talking less because it takes 
so much effort to speak. 
 
 
 
 
 
 


 
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6. My speech is slower than usual. 
 
 
 
 
 
 
7. It is hard for people to hear me. 
 
 
 
 
 
 
  
TOTAL Speech Score: _____ 
SWALLOWING 
Does 
Not 
Apply 
(1) 
Applies 
Rarely 
(2) 
   Applies 
Occasionally 
(3) 
Applies 
Frequently  
(4) 
Applies 
Most of 
the Time 
(5) 
  
    Feeding tube is in place 
1. Swallowing is a problem. 
 
 
 
 
 
2. Cutting my food makes it easier 
to chew and swallow. 
 
 
 
 
 
3. To get food down I have 
switched to a soft diet. 
 
 
 
 
 
4. After swallowing I gag or choke. 
 
 
 
 
 
5. It takes longer to eat. 
 
 
 
 
 
6. My weight is dropping because I 
can't eat normally. 
 
 
 
 
 
7. Food gets stuck in my throat. 
 
 
 
 
 
  
TOTAL Swallowing Score: _____ 
OVERALL SCORE: _____ 
 
 
 
 
 
 
 
 


 
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HEALEY ALS Platform Trial  
Regimen-Specific Appendix C, CNM-Au8 
 
Version 5.0, 22-NOV-2021 
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