Conditions: Alcoholic Hepatitis
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 147
Healthy volunteers: no

Brief summary:
This multicenter, randomized, double blinded, placebo-controlled clinical trial is focused on novel treatments for severe alcoholic hepatitis (AH), a life-threatening stage of alcoholic liver injury that has a short-term mortality rate much higher than that of other liver diseases.

The primary objective of the study is to determine the clinical efficacy and safety of Anakinra (plus zinc) compared to the current standard medical treatment consisting of prednisone in participants with clinically severe AH. Key secondary objectives broadly are as follows: (a) to evaluate the use of biomarkers to assess disease severity and treatment response; and (b) to develop novel endpoints to overcome the limitations of current assessment strategies for severe AH.

Detailed description:

Arms:
arm 1: Standard of care plus prednisone 40 mg orally once daily on Days 1-30 and matching placebos for Anakinra (1 syringe s.c. once daily on Days 1-14), and zinc (matched pill once daily on Days 1-90). arm 2: Standard of care plus Anakinra (100 mg s.c.) once daily on Days 1-14 zinc sulfate 220 mg once daily on Days 1-90, and placebo for prednisone (matched pill once daily on Days 1-30).

Interventions: intervention 1: Anakinra and Zinc intervention 2: Prednisone intervention 3: Placebos
Intervention descriptions: intervention 1: Anakinra is indicated for reduction in signs and symptoms and slowing the progression of structural damage in moderately to severely active rheumatoid arthritis. It has been previously studied in AH. Zinc is a nutritional supplement. Zinc supplementation reverses the clinical signs of zinc deficiency in participants with alcoholic liver disease. intervention 2: Prednisone is indicated for numerous conditions including inflammatory disease. Corticosteroids, such as prednisolone, are considered standard of care in alcoholic liver disease. intervention 3: Matching placebo

Protocol document:
Prot_SAP_000.pdf: 
1 
 
ALCHEPNET CONSORTIUM CLINICAL STUDY PROTOCOL 
 
Protocol Title 
A multicenter, randomized, double blinded, placebo-controlled 
clinical trial of Anakinra (plus zinc), or prednisone in patients 
with severe alcoholic hepatitis by the AlcHepNet Consortium 
 
Protocol Number: AlcHepNet – 02 IRB: 20190963  
IND: 144031 
Version 6: January 25, 2022 
 
Primary Investigators at each site: Indiana University in Indianapolis, Indiana, (PI: Dr. Samer 
Gawrieh (IND holder) and Dr.Kavish Patidar), University of Louisville in Louisville, Kentucky (PI: Dr. 
Craig McClain and Dr.Vatsalya Vatsalya), Beth Israel Deaconess Medical Center in Boston 
Massachusetts (PI: Dr. Gyongyi Szabo), Mayo Clinic in Rochester, Minnesota (PI: Dr. Vijay Shah and Dr. 
Patrick Kamath), Cleveland Clinic Foundation in Cleveland, Ohio (PI: Dr. Srinivasan Dasarathy), 
University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania (PI: Dr. Ramon Bataller), 
University of Texas Southwestern Medical Center in Dallas, Texas (PI: Dr. Mack Mitchell), and 
Virginia Commonwealth University in Richmond, Virginia (PI: Dr. 
Arun Sanyal). 
 
 
 
 
 
Disclosure 
 
This study is conducted by the AlcHepNet consortium which is funded by the National Institute of Alcohol Abuse and 
Alcoholism (NIAAA) to pursue translational investigations in Alcoholic hepatitis (AH). The AlcHepNet Consortium is 
made up of investigators from Indiana University (Indianapolis, IN), Mayo Clinic (Rochester, MN), Virginia 
Commonwealth University (Richmond, VA), University of Pittsburgh (Pittsburgh, PA), University of Louisville (Louisville, 
KY), Beth Israel Deaconess Medical Center (Boston MA), Cleveland Clinic Foundation (Cleveland, OH), and University 
of Texas Southwestern (Dallas, TX).  
 
Some of the information contained herein is the property of and may not be reproduced, published, or disclosed to 
others without written authorization from SOBI. 


2 
 
 
 
SPONSOR’S approval of the protocol reviewed and approved by: 
 
 
  
 
 
 
1/31/2022 
______________________________________ 
 
____________________ 
 
Samer Gawrieh, MD 
 
 
 
 
Date 
Primary Investigator (Indiana University) 
 
 
 
 
 
 
 
 
 
 
 
_____________________________________ 
 
____________________ 
 
 
 
 
Institutional Signing Official (If Applicable) 
 
Date        


3 
 
Table of Contents 
 
 
Page number 
Ethical Conduct of Study and Regulatory Requirements 
5 
Executive Summary 
6 
Investigator’s Affirmation 
19 
Abbreviations 
20 
Introduction & Rationale 
22 
Rationale for Trial Design and Dose for Study Medicine 
23 
Clinical Experience with Study Medicine 
24 
Summary of Known Risks of Study Medicine 
27 
Trial Objectives 
29 
Investigational Plan 
30 
Schedule of Study Procedures 
33 
Participant Selection (Inclusion & Exclusion Criteria) 
35 
Participant Mandatory Hold 
38 
Participant Discontinuation from the Trial 
40 
Investigational Product/ Study Medication 
41 
Dose, Administration and Blinding 
44 
Randomization 
46 
Holding and Unblinding Procedures 
47 
Treatment Compliance 
51 
Trial Procedures 
52 
Efficacy Evaluations 
61 
Safety Evaluations 
62 
Adverse Events 
64 
Serious Adverse Event (SAE) 
66 
Reporting of AEs 
68 
Statistical Methods 
71 
Data and Safety Monitoring Board 
74 
Administrative and Regulatory Considerations 
76 


4 
 
Trial Monitoring & Auditing 
78 
List of Planned Laboratory Values 
80 
Exploratory Evaluations 
81 
References 
82 
 
 
 
Tables 
 
Table 1: Schedule of Trial Procedures 
Table 2: Severity of AEs 
Table 3: Relationship of AEs to Study Medicine 
Table 4: Requirements for Reporting AEs to Various Stakeholders 
Table 5: Total Blood Volumes 


5 
 
1. 
ETHICAL CONDUCT OF THE STUDY AND REGULATORY REQUIREMENTS 
1.1 
Institutional Review Board (IRB) 
The study protocol and any amendments will be reviewed by the Western Institutional Review 
Board (WIRB). The IRB will review the participant safety, informed consent form (ICF), their 
updates (if any), and any written materials given to the participants. 
1.2 
Ethical Conduct of the Study 
This study will be conducted in accordance with the ethical principles that have their origins in the 
Declaration of Helsinki, in compliance with the approved protocol, Good Clinical Practice (GCP) 
and applicable regulatory requirements. 
1.3 
Participant Information and Consent 
The investigator will obtain a freely given written consent from each participant after an appropriate 
explanation of the aims, methods, anticipated benefits, potential hazards, and any other aspects of 
the study that are relevant to the participant's decision to participate. In appropriate language, the 
consent form must be signed and dated by the participant before he/she is exposed to any protocol- 
specific procedure. 
The investigator will explain that the participants are completely free to refuse to enter the study or to 
withdraw from it at any time, without any consequences for their further care and without the need 
to justify. 
The participant will receive a copy of the signed informed consent. 
The participant will be told if information becomes available that may be relevant to his/her 
willingness to continue participation in the study. 
Each participant will be informed that a monitor or a health authority inspector, in accordance with 
applicable regulatory requirements, may review the portions of their source records and source data 
related to the study. Data protection and confidentiality will be handled in compliance with federal, 
state, local and university guidelines.


6 
 
2. 
EXECUTIVE SUMMARY 
Title of Trial 
A multicenter, randomized, double blinded, placebo-controlled clinical trial of Anakinra (plus zinc) 
or prednisone in participants with severe alcoholic hepatitis by the AlcHepNet Consortium. 
 
Name of Active Ingredient(s) 
a. Anakinra 
b. Prednisone 
c. Zinc-Sulfate 
 
Pharmacological Class of the Drugs 
a. Anakinra is immunological agent, an inhibitor of the Interleukin-1 receptor (IL-1). 
b. Prednisone is an adrenal glucocorticoid. 
c. Zinc-sulfate is a nutritional supplement. 
Indication 
 
Severe alcoholic hepatitis. 
 
Study Type 
 
Phase 2B multicenter randomized, 2-arm, double blinded, placebo controlled clinical trial. 
 
Investigational Sites 
Indiana University, Mayo Clinic, Virginia Commonwealth University, Cleveland Clinic Foundation, 
University of Louisville, Beth Israel Deaconess Medical Center, University of Pittsburgh Medical 
Center, and University of Texas Southwestern Medical Center 
 
Planned Number of Participants 
Approximately 258 participants will be randomized in a 1:1 ratio into 1 of 2 treatment arms (129 
participants per arm): (1) Prednisone + Placebo for Anakinra/Zinc (2) Anakinra + Zinc + Placebo 
for Prednisone.  


7 
 
Objectives 
 
This multicenter, randomized, double blinded, placebo-controlled clinical trial is focused on novel 
treatments for severe alcoholic hepatitis (AH), a life-threatening stage of alcoholic liver injury that has 
a short-term mortality rate much higher than that of other liver diseases. 
 
The primary objective of the study is to determine the clinical efficacy and safety of Anakinra (plus 
zinc) compared to the current standard medical treatment consisting of prednisone in participants 
with clinically severe AH. Key secondary objectives broadly are as follows: (a) to evaluate the use of 
biomarkers to assess disease severity and treatment response; and (b) to develop novel endpoints to 
overcome the limitations of current assessment strategies for severe AH. 
 
Overview of Study Design and Conduct 
 
The proposed study is a Phase 2b, multicenter, prospective, randomized, 2-arm, double blinded, 
placebo-controlled clinical trial to assess the efficacy of Anakinra, an interleukin (IL)-1 receptor 
antagonist plus zinc compared to prednisone for the treatment of severe AH (Model for End Stage 
Liver Disease (MELD) score ≥ 20). All participants will receive standard care for treatment of 
severe AH as described in recent guidelines endorsed by American Association for the Study of 
Liver Diseases (AASLD) and American Gastroenterological Association (AGA). The study will be 
conducted at 8 clinical sites across the United Stated selected by the National Institute of Alcoholic 
Abuse and Alcoholism (NIAAA) and will be supported by a Data Coordinating Center at Indiana 
University (DCC-IU). The biorepository will be managed by University of Massachusetts. 
 
The study will be conducted according to Good Clinical Practice (GCP) and in compliance with 
local, state, and federal regulatory requirements. Adverse events during the course of the trial will 
be identified, recorded, assessed for causality, and reported in accordance with FDA guidance. In 
addition to general assessment, we will specifically focus on (1) rates and types of infection as well as 
their severity, (2) potential development of drug-induced liver injury, (3) injection site reactions, and 
(4) hematological adverse events. 
 
This study will be approved by an appropriately convened single IRB, Western Institutional Review 
Board (WIRB), and will be monitored by an NIAAA appointed Data and Safety Monitoring Board 
(DSMB). We will conduct this study under an Investigational New Drug (IND) application from the 
United States Food and Drug Administration (FDA). 


8 
 
It is anticipated that a centrally located 
investigational pharmacy located at Indiana 
University will dispense the study medications to 
all participating sites under close coordination 
from the DCC-IU. Anakinra plus zinc, prednisone 
and matching placebos will be provided by the 
study to the participants. 
 
Interventions to be tested 
Concomitant treatments in this trial include standard 
care for severe AH for all participants as 
recommended in recent guidelines1. The standard of 
care for severe AH includes attention to early 
diagnosis and treatment of bacterial and fungal infections, portal hypertension and its complications 
including acute kidney injury, gastrointestinal bleeding, fluid overload (ascites and edema) and hepatic 
encephalopathy. 
In addition, all participants will be offered as part of the standard of care, non- pharmacologic 
intervention for treatment of alcohol use disorders, such as cognitive behavioral therapy and 12-step 
programs intervention as aligned with the best practices at the participating study site. 
 
Participants with severe AH are very sick and often have multiple active medical problems requiring 
intervention. The use of specific interventions during this time has the potential to modify treatment 
response. Ideally, these interventions would be completely standardized. However, the standard of 
care varies by region, institution and the specialties involved in the care of the participant. The 
decision regarding treatments for these complications will be delegated to the primary physicians 
caring for the participants during hospitalizations and to the investigators during the ambulatory 
follow-up of the participants. Other than the general guidelines noted, no specific treatments for 
specific complications such as those noted are required. However, such treatments might include, but 
are not limited to, the administration of IV fluids, intravenous human serum albumin, antibiotics 
including antifungal medications, renal replacement therapy, supplemental oxygen, assisted 
ventilation and intravenous pressors. Diagnostic procedures such as paracentesis, upper endoscopy, 
colonoscopy, endoscopic ultrasound, and liver biopsy will be permitted as required to provide 
standard care. 
 
During the initial six months of trial, the investigators will develop a “manual of clinical operations” 
that will include best practices on the use of vasopressors, albumin, ICU care, mechanical ventilation 
and renal replacement therapy using Surviving Sepsis Campaign, International Guidelines for 
Management of Severe Sepsis and Septic Shock. The investigators will also provide best practices for 
management of nutrition and alcohol counseling and minimization of recidivism. Although the 
management of these complications will not be mandated by protocol, the care provided will be 
recorded to develop novel designs for future trials and for practice guidance and quality improvement 
programs. 
 
After informed consent has been obtained and all of the inclusion are met and none of the 
exclusion, participants will be randomized to receive one of the following interventions in addition to 
standard care. 


9 
 
Group 1: Standard of care plus prednisone 40 mg orally once daily on Days 1-30 and matching 
placebos for Anakinra (1 syringe s.c. once daily on Days 1-14), and zinc (matched pill once daily on 
Days 1-90). 
Group 2: Standard of care plus Anakinra (100 mg s.c.) once daily on Days 1-14 zinc sulfate 220 mg once 
daily on Days 1-90, and placebo for prednisone (matched pill once daily on Days 1-30). 
Lille score will be calculated from day 7 labs, participants will stop prednisone or prednisone 
placebo if Lille score >0.45.  
 
Figure 1. Distribution of study drug and placebo 
 
 
Participants or guardian will be instructed in subcutaneous injection technique to continue self- 
administration of these experimental treatments after discharge from the hospital. Study personnel will 
ensure participants and guardian are proficient in the technique before the end of study visit and an 
instructional document will be provided. 


10 
 
Primary and Important Secondary Endpoints 
 
Primary Endpoints Survival at 90 days 
 
 
Secondary Endpoints 
• Changes in score(s): Changes in Lille score, change in MELD score, development of 
AKI, multi-organ failure, SIRS, transfer to ICU, changes in liver function will all be 
evaluated at 7, 30 and 90 days. 
• Organ dysfunction: Measure of changes in Sequential Organ Failure Assessment 
(SOFA) scores and proportions requiring hemodynamic support for MAP < 65 mm Hg 
and lactate > 2 mmol/l, renal replacement therapy or mechanical ventilation. The 
SOFA score will be modified and re-evaluated without platelet counts given that these 
are usually low in AH. 
• Infections and Sepsis: The endpoints and case definitions related to sepsis may vary 
depending on what will be used (clinical care, research, surveillance or quality 
improvement). Given the central role of sepsis as a driver of outcomes, measuring the 
types of infection will occur but also identify the proportions of those with sepsis, septic 
shock or quick-SOFA (qSOFA) criteria based on SEPSIS-3 guidance2,3. Key parameters 
will be captured and needed for various sepsis related endpoint construction aligned by 
the recent guidance from the European Drug Development Hub (http://eddh- 
cro.wixsite.com/fdtsfv). 
• Renal dysfunction: In alignment with guidance from the acute disease quality initiative, 
the AKI development will be quantified and its progression through persistent AKI, acute 
kidney disease to chronic kidney disease. 
• Need for care escalation: Proportion of participants requiring transfer to ICU for care, 
intubation for airway control, need for ventilator support or RRT. 
• Indicators of gut permeability: (endotoxin and bacterial 18S DNA) and pro- 
inflammatory cytokine/chemokines (TNFa, MCP1, IL-6, IL-1ß) will be assessed in 
serum/plasma samples. 
• Survival at 30 days and 180 days 
Limitations of mortality as an endpoint in AH and plans to overcome these 
All-cause mortality is most relevant when mortality is substantial and attributable to a single 
mechanism in a homogeneous population. Participants with severe AH are highly heterogeneous with 
respect to disease severity, end organ involvement and the care they receive. Moreover, as in sepsis and 
heart failure, death involves failure of multiple organs (liver, heart, kidney, lungs) making it difficult to 
ascertain which one is the primary cause of death. This has led to development and regulatory 
acceptance of composite endpoints including mortality and key parameters driving mortality for acute 
heart failure trials. These guiding principles to construct a novel and innovative key secondary 
composite endpoint which will include death or worsening of the modified SOFA score4,5 by ≥2 points 
and worsening of MELD score by ≥2 points. These are associated with mortality and capture the organ 
recruitment that marks progression of AH towards death. This endpoint will also be validated with 
respect to reliability, construct-, criterion- and content validity to establish this as a primary endpoint 
in future trials. Model changes in SOFA scores and MELD scores against mortality to further optimize 
this endpoint and cross-validate it in the observation cohort will occur. 


11 
 
 
Novel (experimental) endpoints to overcome limitations of conventional endpoints Efficacy 
endpoints must capture “clinically meaningful benefit”. While traditional endpoints such as mortality 
are meaningful, they also have multiple shortcomings in the context of AH as noted below. 
Innovation will be used to construct, measure, and validate novel additional endpoints to overcome 
the limitations of currently used endpoints and cross-validate them in the observational cohort. The 
combined expertise in endpoint development and the use of harmonized measurements will make 
this feasible. These will provide novel assessments in AH and provide the scientific evidence-base to 
use these as primary endpoints in future trials. 
 
Inclusion Criteria 
1. AH, as defined by the NIAAA pan-consortia for AH6: 
a) Onset of jaundice (defined as serum total bilirubin >3 mg/dL) within the prior 8 
weeks to screening visit 
b) Regular consumption of alcohol with an intake of > 40 gm daily or >280gm weekly on 
average for women and > 60 gm daily or >420gm weekly on average for men for 6 months 
or more, with less than 8 weeks of abstinence before onset of jaundice 
c) AST > 50 IU/l 
d) AST: ALT > 1.5 and both values < 400 IU/l 
e) and/or histological evidence of AH* 
 
2. MELD 20-35 on day of randomization. 
3. Ages ≥ 21 
 
* In patients with possible AH or AH with confounding factors such as possible ischemic 
hepatitis, possible DILI, uncertain history of alcohol use (e.g., patient denies excessive 
alcohol use), and atypical/abnormal laboratory tests (e.g., AST < 50 IU/L or > 400 
IU/L, AST/ALT ratio < 1.5), antinuclear antibody > 1:160 or SMA > 1:80, a standard of care 
liver biopsy may be performed during current hospital admission to confirm AH and 
exclude competing etiologies 17 


12 
 
Exclusion Criteria 
1. MELD SCORE <20 or > 35 
2. Active sepsis (positive blood or ascitic cultures) with Systemic Inflammatory Response 
Syndrome (SIRS) or hemodynamic compromise requiring intravenous pressors to maintain 
tissue perfusion 
3. Pneumonia as evidenced by radiological exam 
4. Multi-organ failure 
5. Renal failure defined by GFR <35 mL/min by CKD- EPI. 
6. Clinically active C. diff infection 
7. History of imaging of the liver (ultrasound, computerized tomography, or magnetic 
resonance) showing other causes of jaundice 
8. History of other liver diseases including hepatitis B (positive HBsAg or HBV DNA), 
hepatitis C (positive HCV RNA), autoimmune hepatitis, Wilson disease, genetic 
\hemochromatosis, alpha1-antitrypsin deficiency, or strong suspicion of Drug Induced 
Liver Injury (DILI). Previously treated hepatitis C that was cured (sustained virological 
response with negative RNA ≥24 weeks following treatment) is not an exclusion. 
9. History of HIV infection (positive HIV RNA or on treatment for HIV infection) 
10. History or presence of cancer (including hepatocellular carcinoma) other than non- 
melanoma skin cancer 
11. History of other significant medical problems such as autoimmune diseases, severe asthma, 
psoriasis, Inflammatory Bowel Disease (IBD), etc. that might require immunosuppressive 
treatments 
12. Pregnancy or breastfeeding 
13. Prior exposure to experimental therapies in last 3 months 
14. Prior exposure to systemic corticosteroid (glucocorticoid) or immunosuppressive therapy 
for more than 4 days within previous 30 days 
15. Need for inotropic pressor support to maintain perfusion to critical organs within prior 48 
hours before randomization and initiation of experimental treatment 
16. Clinically significant pancreatitis- abdominal pain, elevated lipase (> 3 X ULN) and at least 
edema of pancreas with fat-stranding on CT scan 
17. Total WBC count > 30,000/mm3 
18. Known allergy or intolerance to therapeutic agents to be tested 
19. Inability to voluntarily obtain informed consent from participant or guardian 
20. Perceived inability to follow study procedures and comply with protocol 
21. Platelet count < 40,000 k/cumm. 
22. Positive PCR test for COVID -19 within 7 days prior to the baseline day 0 visit* 
23. Active gastrointestinal bleeding defined as hematemesis or melena with a decrease in 
hemoglobin more than 2 g/dl in 24 hrs. Due to gastrointestinal bleeding, or with a 
decrease in mean arterial BP to < 65 mmHg 
*Positive PCR test for COVID-19 is exclusionary only during screening period. If a patient tests 
positive any time after baseline randomization, a positive PCR test for COVID-19 will be 
considered as a SAE.  
The participants for this study will be recruited from a hospitalized population of participants 
meeting the eligibility criteria outlined above who live within one day travel from one of the 


13 
 
participating clinical centers and who have provided informed consent to participate in this clinical 
trial and who are willing to continue their participation for the anticipated follow-up period of the 
trial. Although the primary endpoint is survival at 90 days, follow-up visits will be continued up to 6 
months. 


14 
 
Study Visits and Data Collection Schedule***** 
 
Screening 
Treatment Phase 
Follow-up 
phase 
D0 
D3 
D7 
D14 D28 
D60 
D90 
D180 
Window (days)
±2 
±2 
±2 
±2 
±7 
±7 
±7 
±7 
Informed consent 
x 
History and physical 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Vital signs, weight 
*** 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Alcohol 
consumption history 
x 
x 
x 
x 
x 
x 
x 
Randomization 
x 
Concomitant 
medicines 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Dispense Study 
Drug 
x 
 
* 
 
Adverse events 
x 
x 
x 
x 
x 
x 
x 
Electrocardiogram**
**** 
x 
Evaluation of 
compliance 
x 
x 
x 
x 
x 
x 
CBC, PT/INR, 
Hepatic Function 
Panel, BMP 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Test for COVID-
19**** 
x 
 
 
 
 
 
 
 
 
Sepsis studies, as 
indicated 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Pregnancy test, 
serum** 
x 
Pregnancy test, 
urine** 
x 
x 
x 
x 
x 
x 
Blood collection for 
trough Anakinra 
levels 
x 
x 
x 
x 
Specimen Banking¶ 
x 
x 
x 
x 
x 
x 
x 
Saliva Banking+ 
x 
x 
Questionnaires δ 
x 
 
 
x 
x 
x 
x 


15 
 
¶Specimen banking includes blood and stool (when possible) D0, D7, D14, D28, D60, D90, D180, 
and, when available, urine and liver biopsy/tissue. Blood will be used to extract germline DNA at 
baseline and at Day 180 as well as to extract serum/plasma/PBMC at all visits. Type of specimen 
collection is site specific. 
+ Saliva collection at D0 and D90. Collected until an adequate number of samples are collected. 
δ Questionnaires include Alcohol Use Disorders Identification Test (AUDIT), Alcohol Timeline 
Follow Back (TLFB), and Chronic Liver Disease Questionnaire (CLDQ). The timeline follow back 
questionnaire will be the only questionnaire administered at days 28, 60, 90, and 180. All are given 
at screening. 
*Day 7 study drug dispensation will be unscheduled and only on an as-needed basis, based on safety 
lab evaluations (outpatient only.) 
** if applicable 
*** height at screening only. 
**** Test for COVID-19 PCR only if not done as SOC with 7 days prior to the baseline Day 0 
visit.  
***** In response to COVID-19, we are lessening restrictions if applicable or necessary such as: 
allowing wider windows D14, D28, D60 to +/- 10 days. Allowing replacement of protocol 
mandated in-person study visits with one or more of the following, phone calls, telemedicine virtual 
visits, implement digital technology to record responses to questionnaires. Lastly, allowing blood 
draws at remote or commercial laboratories 
******ECG can be done as standard of care within 7 days of screening 
 
Abbreviations: CBC: Complete blood count, BMP: Basic metabolic, INR: International normalized 
ratio and PT: Prothrombin Time. 
Data Collection 
Clin= clinical (relevant elements of history, physical exam), Biosamples: whole blood, plasma, 
serum, PBMC, DNA, and stool (when possible) at all time-points, liver biopsy/tissue and urine 
(20ml) if available, Questionnaires= AUDIT, alcohol timeline follow back, CLDQ, SOC (standard 
of care) labs= CBC, Hepatic Function Panel, BMP: Basic Metabolic Panel,  PT/INR, Sepsis 
studies at baseline and during trial duration, as indicated (blood cultures, chest X ray, stool for 
WBC and C. Diff as indicated, ascites tap, UA with culture, liver ultrasound or other imaging, 
endoscopy if available within 6 months). 
 
Relevant clinical care parameters will be recorded on days specified. As noted above, attention will be 
paid to recording concomitant care provided to treat complications related to AH and/or portal 
hypertension including those treatments not specified by protocol, including but not limited to 
antibiotics, IV fluids, albumin, pressors, renal replacement, etc. 
 
Standardizing study conduct and good clinical practice (GCP) 
 
Variations in protocol implementation and clinical care can have a major impact on trial outcomes. 
This will be optimized by: (1) GCP training and certification of all study personnel, (2) 
investigator/coordinator training and certification prior to site activation, (3) monthly performance 
reports, (4) development of manual of operations that provide best practices, and (5) annual 
investigator meeting to review developments and clinical and trial practice patterns. (6) DSMB will 
convene every 6 months to ensure relevant study procedures are followed. 
 
Study Population 


16 
 
The study population will be comprised of men and women of all races, ethnic groups and 
socioeconomic status of the ages of 21 and greater admitted to the hospital with a clinical diagnosis 
of AH. A full description of the statistical analysis and calculation of sample size is recorded below. 
The definition of AH is established by the NIAAA pan-consortia for AH. A conscious decision not 
to require a liver biopsy for inclusion was made based on the current low rate of liver biopsy used 
to establish this diagnosis in the US and the ability to diagnose the condition with relative accuracy 
based on the experience in the first cycle of funding. Eligible participants will be identified based 
on inclusion/exclusion criteria as defined above. 
 
 
 
Enrollment sites 
 
Enrollment sites will be limited to the 8 clinical sites selected during the competitive renewal of the 
U01 study for treatment of acute AH. These enrollment sites include: Indiana University School of 
Medicine affiliated hospitals in Indianapolis, Indiana (PI: Dr. Kavish Patidar), University of 
Louisville affiliated hospitals in Louisville, Kentucky (PI: Dr. Craig McClain), Beth Israel Deaconess 
Medical Center in Boston, Massachusetts (PI: Dr. Gyongyi Szabo), Mayo Clinic in Rochester, 
Minnesota (PI: Dr. Vijay Shah and Patrick Kamath), Cleveland Clinic Foundation in Cleveland, 
Ohio (PI: Dr. Srinivasan Dasarathy), University of Pittsburgh Medical Center in Pittsburgh, 
Pennsylvania (PI: Dr. Ramon Bataller), University of Texas Southwestern Medical Center in Dallas, 
Texas (PI: Dr. Mack Mitchell), and Virginia Commonwealth University in Richmond, Virginia (PI: 
Dr. Arun Sanyal). Each site will be permitted to use more than one hospital or other healthcare 
facility to recruit participants based on the inclusion/exclusion criteria. 
 
Expected enrollment per site: 32-33 severe AH participants 
 
Central IRB: The DCC-IU with WIRB as the central IRB for this study. This will require that IRBs 
from all 8 participating centers establish the contractual agreements with WIRB. 
 
Statistical Design and Power 
 
The primary analysis will be comparisons of 90-day mortality of Anakinra plus zinc vs Prednisone 
using survival analysis. Mortality event times greater than 90 days will be censored at 90 days or at 
time of liver transplant, whichever comes first. The experiment-wise significance level will be 5%. 
The most recent data from the AlcHepNet consortium suggest a 90-day mortality rate for 
prednisone is approximately 20%. We estimate that with a total of 258 participants (129 per 
treatment arm), we will be able to detect a clinically significant hazards ratio of 0.325, which 
translates to a 13% reduction in 90-day mortality, i.e., 80% survival in prednisone vs 93% in 
anakinra plus zinc groups with 85% power by using two-sided logrank tests. We use O’Brien and 
Fleming α-spending function to determine the efficacy stopping boundaries for the sequential tests. 
Specifically, if the test statistics of the log-rank test is greater than 2.963 or less than -2.963, we will 
claim a significant difference between the two treatments and stop the trial. Otherwise, we will 
continue enrolling more patients until the full sample size is reached and then the final analysis will 
be performed. For the final analysis, if the test statistic value is greater than 1.969 or less than -1.969, 
we will claim a significant difference between the treatments. Otherwise, we will declare that no 
statistically significant difference is detected. 
 
Besides the group sequential tests, we have in place an early stopping rule for futility based on 
conditional power. At the time of interim analysis, we will calculate the conditional power, i.e., the 
probability of claiming difference at the end of the trial given the data at the interim analysis. We will 
stop the trial for futility when the conditional power is less than 0.1. In other words, based on data 
that become available at the interim analysis, assuming that the current trend continues, we should 


17 
 
early stop the trial if the probability of declaring anakinra + zinc superior in the final analysis is low 
(e.g., less than 10%). We use this early stopping rule to limit patient exposure to a potentially 
inefficacious treatment. 
 
 
Group Assignment 
Participants will be randomized to the two treatment groups with matching placebos for drugs in 
the other arm, in equal proportions. Randomization will be stratified by site and MELD score. 
Random blocks of size 4 will be generated to ensure treatment assignments are balanced between 
the two treatment arms within each block. Both participants, coordinators, and investigators will be 
blinded to the randomization plans. 
 
Statistical Analyses 
The primary analyses of 90-day mortality will be performed in an Intention-to-Treat (ITT) 
framework using survival analysis. Specifically, 
 
(1) we will use all-cause mortality in the first 90-days as the primary outcome event of interest. We 
will compare the distributions of time to mortality between the two treatment arms. In the 
primary analysis, mortality event times greater than 90 days will be censored at the 90 days or at 
the time of liver transplant, whichever comes first. We will use the Logrank test to compare the 
survival functions of the two treatment groups. Cox regression analysis can be performed if it is 
necessary to control for the influences of unbalanced patient characteristics, such as MELD 
score, between the treatment groups. If evidence suggests a violation of the hazard function 
proportionality, we will conduct an analysis of the restricted mean survival time (RMST) of the 
first 90 days. 
(2) as a secondary analysis, we will compare transplant-free survival in the first 90 days of treatment 
initiation as between the two treatment arms, as done in other clinical trials. We will perform 
logrank test, Cox regression, and RMST analyses as appropriate. 
(3) we plan to conduct one interim analysis and one final analysis for this trial. The interim analysis 
will be conducted when 129 patients, half of the enrollment number, complete the 90-day 
follow-up. We use the group sequential method to control the type 1 error rate of the trial. 
(4)  as another secondary analysis, we will examine the treatment effects in patients with baseline 
MELD scores ≤25 and >25 by assessing the equality of treatment effects of the anakinra in high 
and low MELD groups, we will test the interaction between the intervention indicator and 
baseline MELD score in the Cox regression model.  
  
Subject Participation Duration 
 
180 days 
Recruitment and Retention Plan 
 
Sources of participants: 
Identification of participants with severe AH requires collaboration with those physicians who 
manage these participants within the hospital and the emergency department. Almost 100% of 
participants are admitted to hospital based on the severity of their liver disease. Occasionally 
participants are seen in free-standing urgent care centers, free-standing emergency rooms or in 
office/clinic practices. Since the standard of care is to admit these participants for further evaluation 
to exclude infections as a precipitating cause of decompensated liver disease, most will ultimately be 
identified in a hospital setting. Letters will also be sent to referring MDs and referring hospitals. 


18 
 
 
Some sites in the current U01 have found that screening laboratory results for elevated AST and 
total bilirubin is a useful way to identify potential participants. In accordance with Institutional 
Review Board Policies, once identified the primary team caring for these participants must be 
contacted by the investigators and agree to ask the participant about their interest in participating in 
a clinical trial as part of the treatment of the underlying AH. Once the participant expresses 
willingness to be contacted the investigators may discuss details of the study and obtain informed 
consent prior to beginning treatment. 
 
Management of barriers for recruitment: 
Special conferences with medicine, ICU and ER staff will increase awareness of the trial, and its 
significance. Contact information for study personnel will be made available so that they can meet 
with participants and their family to educate them about AH and the trial. For those who live at a 
distance, travel costs will be budgeted in alignment with local practices for other trials. 
 
Contingency plans: 
Recruitment will be tracked with monthly review of expected versus actual enrollment. Screen fail 
rates will also be assessed. There will be direct communication between DCC-IU, NIAAA and study 
leadership with site-PI and staff to better understand the barriers for recruitment and 
develop/implement solutions. Best practices from high-performing sites will be shared with the 
under-performing sites. For continued failure, the site budgets will be cut, and funds redirected 
towards supporting enrollment at high performing sites after discussion with NIAAA project 
officer. 
 
 


19 
 
 
Retention plan: 
It is anticipated that some participants will drop out after the initial hospitalization. This will be 
minimized by participant education, frequent communication by study coordinator and provision of 
ways for participants and their family to communicate with the study team. Travel support will be 
provided when needed. 
 
Competition from other trials: 
The participating clinical centers will not engage in other trials for AH that have similar eligibility 
criteria for the duration of the trial. 
Safeguards: 
Each clinical center will establish safeguards for vulnerable populations, especially institutional 
employees, and their families, in close collaboration with their institutional review boards. 
 
Investigator’s Affirmation 
 
I have received and read the current version of the Investigator’s Brochure (IB) for Anakinra, 
zinc, and prednisone and this protocol AlcHepNet - 02. Having fully considered all the 
information available, I agree that it is ethically justifiable to give Anakinra, zinc, and prednisone 
to selected participants/participants according to this protocol. 
 
I understand that all information concerning Anakinra, zinc, and prednisone supplied to me by the 
AlcHepNet Consortium and from SOBI Pharmaceuticals and not previously published is 
confidential. This includes the IB, Clinical Trial Protocol, Case Report Forms (CRF) and any other 
preclinical and clinical data. 
 
I understand that no data are to be made public or published without prior knowledge and written 
approval by the AlcHepNet Steering Committee. 
 
By my signature below, I hereby attest that I have read, understood and agreed to abide by all the 
conditions, instructions and restrictions contained in protocol AlcHepNet - 02 and in accordance 
with Good Clinical Practice (CPMP/ICH/135/95), 21CFR Part 312 and all applicable regulatory 
requirements. 
 
I acknowledge that the Steering Committee of the AlcHepNet Consortium has the right to 
discontinue this trial at any time. 
 
 
 
 
 
 
 
 
Investigator’s Name (Printed) 
Investigator’s Signature 
Date 


20 
 
Abbreviations 
 
Abbreviation 
Definition 
6-ECDCA 
6α-ethyl chenodeoxycholic acid 
AASLD 
American Association for the Study of Liver Disease 
AAH 
AE(s) 
acute alcoholic hepatitis 
adverse event(s) 
AGA 
American Gastroenterological Association 
AH 
alcoholic hepatitis 
AKI 
acute kidney injury 
ALT 
alanine aminotransferase 
ALP 
alkaline phosphatase 
ANR 
anakinra 
AST 
aspartate aminotransferase 
AUDIT 
alcohol use disorders identification test 
BL 
baseline 
BP 
blood pressure 
BAS 
bile acid sequestrants 
BUN 
blood urea nitrogen 
CBC 
complete blood count 
CDCA 
chenodeoxycholic acid 
C.Diff 
clostridium difficile 
CFR 
CLDQ 
code of federal regulations 
chronic liver disease questionnaire 
CMP 
complete metabolic panel 
Cmax 
maximum concentration 
CRA 
clinical research associate 
COVID-19 
Coronavirus disease 2019 
CRF 
case report form 
CT 
computerized tomography 
DCC 
data coordinating center 
DCA 
deoxycholic acid 
DCC-IU 
data coordinating center-Indiana University 
DILI 
drug induced liver injury 
dL 
deciliter(s) 
DSMB 
data and safety monitoring board 


20 
 
ECG 
electrocardiogram 
ER 
emergency room 
FDA 
Food and Drug Administration 
FGF-19 
fibroblast growth factor-19 
FXR 
farnesoid X receptor 
GGT 
gamma-glutamyltransferase 
GMP 
good manufacturing practice 
GCP 
good clinical practice 
HBsAg 
hepatitis B surface antigen 
HBV DNA 
hepatitis B Virus deoxyribonucleic acid 
HCV RNA 
hepatitis C virus ribonucleic acid 
HDPE 
high-density polyethylene 
HIV 
human immunodeficiency virus 
HIV RNA 
human immunodeficiency virus ribonucleic acid 
IB 
investigator’s brochure 
IBD 
inflammatory bowel disease 
ICF 
informed consent form 
ICH 
International Conference on Harmonization 
ICU 
intensive care unit 
IgM 
immunoglobulin M 
IL-1 
interleukin-1 
IL-1β 
interleukin-1beta 
IL-6 
interleukin-6 
IND 
investigational new drug 
INR 
international normalized ratio 
IRB 
institutional review board 
ISF 
investigator site file 
ITT 
intention to treat 
IU/L 
international units per liter 
IV 
intravenous 
LTSE 
long term safety extension 
MAP 
mean arterial pressure 
MCP1 
monocyte chemoattractant protein-1 
MELD 
model for end stage liver disease 
mg 
milligram(s) 


21 
 
mL 
milliliter(s) 
mm Hg 
millimeter of mercury 
mmol/l 
millimoles per liter 
NAFLD 
nonalcoholic fatty liver disease 
NASH 
nonalcoholic steatohepatitis 
NDB 
nutrition database 
NIAAA 
National Institute on Alcohol Abuse and Alcoholism 
NIH 
National Institute of Health 
PBC 
primary biliary cirrhosis 
PI 
principal investigator 
PLB 
placebo 
PK 
pharmacokinetic(s) 
PROMIS 
patient reported outcomes measurement system 
qSOFA 
quick-sequential organ failure assessment 
SAE 
serious adverse event 
SIRS 
systemic inflammatory response syndrome 
SOC 
standard of care 
SOFA 
sequential organ failure assessment 
SUSAR 
suspected, unexpected serious adverse reaction 
SAP 
statistical analysis plan 
TEAE(s) 
treatment-emergent adverse event(s) 
TIPS 
transjugular intrahepatic portosystemic shunt 
TNF-α 
tumor necrosis factor-alpha 
TNF-β 
tumor necrosis factor-beta 
UA 
urinary analysis 
UDCA 
ursodeoxycholic acid 
U/L 
units per liter 
ULN 
upper limit(s) of normal 
US 
United States (of America) 
vs 
versus 
WBC 
white blood cell 
WIRB 
Western Institutional Review Board 


22 
 
2.1 
Introduction and Rationale- Anakinra, Prednisone and Zinc in Severe AH 
2.1.1 Clinical Experience 
Anakinra, prednisone and zinc used in this trial have FDA-approved labeling for other 
indications. FDA-approved labeling is included in the Investigator’s Brochure. 
1. Anakinra is indicated for reduction in signs and symptoms and slowing the progression of 
structural damage in moderately to severely active rheumatoid arthritis. It has been previously 
studied in AH7. 
2. Zinc-sulfate is a nutritional supplement. Zinc supplementation reverses the clinical signs of zinc 
deficiency in participants with alcoholic liver disease. 
3. Prednisone is indicated for numerous conditions including inflammatory disease. Corticosteroids, 
such as prednisolone, are considered standard of care in alcoholic liver disease. 
 
2.1.2 
Status of Drugs in Other Countries 
Anakinra, zinc sulfate, and prednisone are licensed in numerous other countries and have not 
been withdrawn. 
 
2.1.3 
Pharmacology and Toxicology Information 
Drug Interactions: 
 
There are no drug interactions listed in MicroMedex or PubMed with the other agents given 
concurrently in the protocol –Anakinra + zinc sulfate (current as of 23 Jan 2019). Prednisone is 
given as the single study agent in arm 1. The investigator at each site will check for drug 
interactions between study drugs and other concurrent medications for each participant. 


23 
 
2.2 
Rationale for Trial Design and Dose for Study Medication 
2.2.1 
Study Rationale: 
Severe AH continues to be associated with a high mortality and represents a significant public health 
burden8-13. Prednisone is the standard of care but is associated with a modest and transient survival 
benefit at best and increased risk of severe bacterial and fungal infections14-16. A recent large study 
indicated that pentoxifylline is not significantly superior to placebo15. While several new targets are 
being evaluated, they are not sufficiently powered to provide definitive data. There is therefore a 
need for well-designed, appropriately powered efficacy (phase 2B or 3) trials to define the utility of 
newer therapies for severe AH against prednisone. 
 
2.2.2 
Rationale for Prednisone in Severe AH, current standard of care for severe Acute Alcoholic 
Hepatitis (AAH): 
 
Corticosteroid therapy is recommended by the American Association for the Study of Liver 
Diseases as primary treatment for participants with severe AAH, defined by the Maddrey DF > 32 
based on Class I, level A evidence1. Participants with DF < 32 have six-month survival of > 85% 
whereas those with DF > 32 have a survival of only 60%. Almost all trials of corticosteroids have 
treated participants for 28 days. Although short-term mortality is reduced by 28 days of 
corticosteroids, 6-month survival is similar to standard care. Many reasons account for late 
deterioration in steroid treated participants. Infections develop after the first 30 days in some 
participants treated with steroids. Tapering the dose of steroids (median of 15 days) after 50% 
improvement in total bilirubin and prothrombin time combined with enteral nutrition reduced the 
risk of late infections17. The investigators postulated that the benefit of enteral nutrition was 
mediated through improvement in integrity of the gut mucosal barrier and reduced gut bacterial 
translocation and endotoxemia. 
 
Early improvement in bilirubin within the first week is predictive of a good response to 
corticosteroids at 28 days18. Although corticosteroids improve survival in a subset of participants 
with severe AAH, some participants do not respond, either because of steroid “resistance” or due to 
the underlying severity of the disease. Steroids are not well tolerated in participants with active GI 
bleeding or systemic infections. 
 
Corticosteroids represent a clinically tested treatment for severe AH and will be offered to a third of 
the participants in this randomized clinical trial. 
 
2.2.3 
Rationale for testing anakinra plus zinc as novel drugs for severe AH against the standard 
treatment (Prednisone in Arm 2): 
 
There are currently no new drugs formally approved by the FDA for severe AH. The rationale to 
repurpose already available agents for AH treatment is to generate evidence to support moving to 
pivotal trials by the drug manufacturers or support the off-label use of these compounds and thus 
provide much needed benefit to those with severe AH. 


24 
 
2.2.4 
Clinical applications of anakinra: 
Preliminary data from the interim analysis of the ongoing clinical trial from the Defeat Alcoholic 
Steatohepatitis (DASH) UO1 consortium suggests that the treatment arm with anakinra plus 
pentoxiphylline plus zinc may provide better survival at day 90 and 180 compared to the steroid 
treated group. Side effects including infection rates were comparable between the anakinra and 
steroid arms. 
 
Anakinra blocks the effects of IL-1 by inhibiting the binding of IL-1ß and IL-1α to the IL-1 
receptor. It is FDA-approved for treatment of moderate to severe rheumatoid arthritis (RA) since 
2001, and is used also in patients with Still's disease, and in familial cold autoinflammatory and 
Muckle-Wells syndromes20-22. 
 
Anakinra has an excellent safety profile compared to other biological therapies. The rate of serious 
infections was 3.2 per 100 participant-years in participants exposed to Anakinra23. A meta-analysis of 
trials evaluating anakinra in RA reported a 1.4% incidence of serious infections with anakinra, 
compared with 0.5% with placebo, although this difference was not significant after adjustment for 
underlying comorbidities24. This is important given that participants with severe AH are prone to 
bacterial infections. No adverse reactions or microbial superinfections were attributable to anakinra 
treatment in participants with severe sepsis25. Other FDA approved drug candidates for inhibiting 
IL- 1 are canakinumab and rilonacept26,27, that are human monoclonal antibodies and both target IL- 
1ß (and not IL-1α). The advantage of anakinra is that it prevents both IL-1ß and IL-1α effects. An 
additional advantage of the anakinra is its short half-life for participants with alcoholic liver disease 
given the concern of susceptibility to infections in this participant population. 
Anakinra, a human recombinant IL-1 receptor antagonist, prevents IL-1 receptor signaling 28-30. IL- 
1ß, that activates the IL-1receptor, is a unique therapeutic target in AH because unlike other pro- 
inflammatory cytokines, IL-1ß secretion is under control of two cytokines, IL-1ß secretion is under 
control of two signals31. This dual regulation suggests that accumulation of multiple danger signals 
will trigger IL-1ß secretion28. We have recently identified that gut-derived LPS and sterile danger 
signals such as ATP and uric acid from alcohol-damaged hepatocytes act in concert to activate the 
multiprotein complex, NLRP3 inflammasome, that results in activation for IL-1ß secretion via 
caspase-1/pro-IL-1ß cleavage32,33. The biological significance of increased IL-1ß production extends 
beyond the direct pro-inflammatory effects of IL-1ß29. IL1ß, after engaging the IL-1 receptor, 
amplifies pro-inflammatory cytokine production including IL-1, TNF, MCP-1, and IL-634. In 
addition, IL-1ß mediates biological effects that contribute to salient pathological features of ALD 
and AH. Specifically, IL-1ß promotes steatosis, hepatocyte death, liver fibrosis and inhibits liver 
regeneration19,30,35. All of these biological effects of IL-1ß and IL-1receptor activation are blocked by 
the naturally occurring IL1receptor antagonist (IL-1ra). Testing of the IL-1 receptor antagonist, 
anakinra, in mice fed with the Lieber-DeCarli alcohol or control diet for 4 weeks revealed that 
alcohol-induced increase in serum ALT, liver steatosis and upregulated inflammatory cytokine 
production (TNFα, pro-IL-1β, mature IL-1β) were all significantly reduced by IL-1ra administration. 


25 
 
(Fig 1)30. 
 
 
 
2.2.5 Clinical applications of Zinc supplementation: 
Zinc is an essential trace element required for normal cell growth, development, and 
differentiation36. It is a critical component of many proteins/enzymes, including zinc- dependent 
transcription factors. Importantly, oxidative stress (e.g., resulting from ethanol metabolism) may 
cause release of zinc from critical zinc-finger proteins and subsequent loss of DNA-binding activity 
and function36. Zinc deficiency/altered zinc metabolism is regularly observed in people with AH and 
may result from decreased dietary intake, increased urinary excretion, abnormal activation of certain 
zinc transporters, and induction of hepatic metallothionein37. Zinc deficiency has been shown to 
cause/exacerbate gut barrier dysfunction, endotoxemia, increased proinflammatory cytokine 
production, oxidative stress, decreased zinc finger function, and hepatocyte steatosis/injury/death in 
experimental ALD36,38-51. Similarly, zinc supplementation improved experimental ALD, in part, by 
stabilizing tight junctions, reducing endotoxemia, lowering levels of metabolic toxins such as 
ammonia, decreasing production of pro-inflammatory cytokines, reducing oxidative stress, and 
attenuating hepatocyte steatosis/injury/death. (Figure 2) 36,38-51. 


26 
 
Moreover, limited studies in human ALD have generally shown similar mechanistic beneficial effects 
of zinc (Figure 2-unpublished data). The dose of zinc used for treatment of ALD usually is 50 mg of 
elemental zinc taken with a meal to decrease the potential side effect of nausea. This clinical trial will 
use zinc supplementation to inhibit multiple mechanisms involved in the pathogenesis/progression 
of AAH and possibly other organ failure, beginning with intestinal barrier dysfunction (Figure 2). 
 
2.2.5 Impact Statement: 
The proposed trial will provide definitive evidence of the safety and efficacy of Anakinra plus zinc 
vs prednisone in severe AH; if positive, it will change the standard of care for severe AH and, if 
negative, it will discourage their off label use thereby saving cost and potential exposure to an 
ineffective drug in afflicted participants. In either case, the proposed study will alter how 
participants with severe AH are managed. 


27 
 
2.3 
Summary of Known Potential Risks with Study Medication 
Corticosteroids (including prednisone) are the standard medical care for severe acute AH and 
have anti-inflammatory effects that can alter the body’s reaction to other injuries. Prednisone 
may cause some, all or none of the side-effects listed below at the dose and duration used in the 
study. 
 
Side effects 
Frequent 
>20% of 
participants 
Occasional 
2 - 20% of 
participants 
Rare 
Less than 2% of 
participants 
Serious 
Infection 
Psychosis, 
Pancreatitis, 
Ulcerative 
esophagitis, 
Cushing’s 
syndrome 
Anaphylaxis, 
Hypersensitivity 
reaction, Peptic 
ulcer, Bone 
necrosis, Blood 
clot in a deep 
vein 
Less Serious 
Weight gain 
High blood 
sugar, High 
blood pressure, 
Wound healing 
impairment, 
Increased 
intraocular 
pressure, 
Increased liver 
enzymes 
Muscle weakness 
Minor 
Facial swelling 
Fluid retention 
Indigestion 
Increased 
appetite 
Difficulty 
sleeping, Mood 
changes, 
Euphoria, 
Headache, 
Bruising 


28 
 
Anakinra (study drug) is another anti-inflammatory treatment. It can alter the body’s 
reaction to other injuries. Anakinra may cause some, all or none of the side-effects listed 
below at the dose and duration used in the study. 
 
 
Side Effects 
Frequent 
>20% of participants 
Occasional 
2 - 20% of 
participants 
Rare 
Less than 2% of 
participants 
Serious 
Infection, including 
cellulitis, pneumonia 
and bone and joint 
infections) 
Anaphylaxis, 
hypersensitivity 
reactions, 
Angioedema, 
Malignancy 
Less Serious 
Low blood count, 
(Neutropenia), Joint 
pain 
Low blood count 
(Eosinophilia, 
Platelets), Nausea, 
Diarrhea 
Minor 
Injection site redness 
Fever, 
Nasopharyngitis, Skin 
rash 
 
 
Zinc is an essential nutrient found in highest quantities in oysters, shellfish, meat, chicken, 
and fish. It is essential for the body’s cells to function. When given in tablets, zinc may 
cause some, all or none of the side-effects listed below at the dose and duration used in 
the study. 
 
 
Side effects 
Frequent 
>20% of participants 
Occasional 
2 - 20% of 
participants 
Rare 
Less than 2% of 
participants 
Serious 
Less Serious 
Nausea, Vomiting, 
Dizziness, Headache, 
Abdominal cramps, 
Diarrhea 
Minor 
Indigestion 


29 
 
3. 
TRIAL OBJECTIVES 
The primary purpose of this study is to determine whether Anakinra plus zinc is superior to 
standard treatment with Prednisone in the treatment of severe AH. 
 
Primary Endpoint 
• Survival at 90 days. 
Secondary Endpoints 
• Change in Lille score, change in MELD score, development of AKI, multi-organ failure, SIRS, 
transfer to ICU, changes in liver function will all be evaluated at 7, 30 and 90 days. 
• Organ dysfunction: Changes in Sequential Organ Failure Assessment (SOFA) scores and 
proportions requiring hemodynamic support for MAP < 65 mm Hg and lactate > 2 mmol/l, 
renal replacement therapy or mechanical ventilation. We will also modify and re-evaluate the 
SOFA score without platelet counts given that these are usually low in AH. 
• Infections and Sepsis: It is now recognized that the endpoints and case definitions related to 
sepsis may vary depending on what these will be used for (clinical care, research, surveillance, or 
quality improvement). Given the central role of sepsis as a driver of outcomes, we will not only 
measure the types of infection but also identify the proportions of those with sepsis, septic shock 
or quick-SOFA (qSOFA) criteria based on SEPSIS-3 guidance2,3. Capturing the key parameters 
needed for various sepsis related endpoint construction aligned by the recent guidance from the 
European Drug Development Hub (http://eddh-cro.wixsite.com/fdtsfv). 
• Renal dysfunction: In alignment with guidance from the acute disease quality initiative, we will 
quantify AKI development and its progression through persistent AKI, acute kidney disease to 
chronic kidney disease. 
• Need for care escalation: Proportion of participants requiring transfer to ICU for care. 
• Indicators of gut: Permeability (endotoxin and bacterial 18S DNA) and pro- inflammatory 
cytokine/chemokines (TNFa, MCP1, IL-6, IL-1ß) will be assessed in serum/plasma samples. 
• Survival at 30 and 180 days. 
 
Limitations of mortality as an endpoint in AH and plans to overcome these: 
All-cause mortality is most relevant when mortality is substantial and attributable to a single 
mechanism in a homogeneous population. Participants with severe AH are highly heterogeneous 
with respect to disease severity, end organ involvement and the care they receive. Moreover, as in 
sepsis and heart failure, death involves failure of multiple organs (liver, heart, kidney, lungs) making 
it difficult to ascertain which one is the primary cause of death. This has led to development and 
regulatory acceptance of composite endpoints including mortality and key parameters driving 
mortality for acute heart failure trials. We will leverage these guiding principles to construct a novel 
and innovative key secondary composite endpoint which will include death or worsening of the 
SOFA score4,5 by ≥2 points and worsening of MELD score by ≥2 points. These are associated with 
mortality and capture the organ recruitment that marks progression of AH towards death. This 
endpoint will also be validated with respect to reliability, construct-, criterion- and content validity to 


30 
 
establish this as a primary endpoint in future trials. We will also model changes in SOFA scores and 
MELD scores against mortality to further optimize this endpoint and cross-validate it in the 
observation cohort. 
 
Novel (experimental) endpoints to overcome limitations of conventional endpoints Efficacy 
endpoints must capture “clinically meaningful benefit”. While traditional endpoints such as mortality 
are meaningful, they also have multiple shortcomings in the context of AH as noted below. We will 
therefore innovate to construct, measure and validate novel additional endpoints to overcome the 
limitations of currently used endpoints and cross-validate them in the observational cohort. Our 
combined expertise in endpoint development and the use of harmonized measurements will make 
this feasible. These will provide novel assessments in AH and provide the scientific evidence-base to 
use these as primary endpoints in future trials. 
4. 
INVESTIGATIONAL PLAN 
4.1 
Overall Trial Design and Plan 
Overview of Study Design and Conduct 
The proposed study is a Phase 2b, multicenter, prospective, randomized, 2-arm, double blinded, 
placebo-controlled clinical trial to assess the efficacy of Anakinra, an IL-1 receptor antagonist plus 
zinc compared to prednisone for the treatment of severe AH (Model for End Stage Liver Disease 
(MELD) score ≥ 20). All participants will receive standard care for treatment of severe AH as 
described in recent guidelines endorsed by AASLD and AGA1. The study will be conducted at 8 
clinical sites across the United Stated selected by the NIAAA and will be spearheaded by a Data 
Coordinating Center (DCC-IU) at Indiana University. 
 
The study will be conducted according to good clinical practice (GCP) and in compliance with local, 
state, and federal regulatory requirements. Adverse events during the course of the trial will be 
identified, recorded, assessed for causality, and reported in accordance with FDA guidance. In 
addition to general assessment, we will specifically focus on (1) rates and types of infection as well as 
their severity, (2) potential development of drug-induced liver injury, (3) injection site reactions, and 
(4) hematological adverse events. These are related to the mechanisms of action of the drugs to be 
tested. 
 
It is anticipated that this study will be approved by an appropriately convened single IRB and will be 
monitored by an NIAAA appointed data and safety monitoring board. We will conduct this study 
under an Investigational New Drug (IND) application from the United States Food and Drug 
Administration (FDA). 
 
It is anticipated that a centrally located investigational pharmacy located at Indiana University will 
dispense the study medications to all participating sites under close coordination from the DCC- IU. 
Anakinra plus zinc and prednisone and matching placebos will be provided by the study to the 
participants. 
 
Interventions to be tested 
 
Concomitant treatments in this trial include standard care for severe AH for all participants as 
recommended in recent guidelines. The standard of care for severe AH includes attention to early 
diagnosis and treatment of bacterial and fungal infections, portal hypertension and its complications 
including acute kidney injury, gastrointestinal bleeding, fluid overload (ascites and edema) and 
hepatic encephalopathy. As part of the standard of care, all participants will be offered non- 


31 
 
pharmacologic intervention for treatment of alcohol use disorders, such as cognitive behavioral 
therapy and 12-step programs intervention as aligned with the best practices at the participating 
study site. 
 
Participants with severe AH are very sick and often have multiple active medical problems requiring 
intervention. The use of specific interventions during this time has the potential to modify treatment 
response. Ideally, these interventions would be completely standardized. However, the standard of 
care varies by region, institution and the specialties involved in the care of the participant. The 
decision regarding treatments for these complications will be delegated to the primary physicians 
caring for the participants during hospitalizations and to the investigators during the ambulatory 
follow-up of the participants. Other than the general guidelines noted, no specific treatments for 
specific complications such as those noted are required. However, such treatments might include, but 
are not limited to the administration of IV fluids, intravenous human serum albumin, antibiotics 
including antifungal medications, renal replacement therapy, supplemental oxygen, assisted 
ventilation and intravenous pressors. Diagnostic procedures such as paracentesis, upper endoscopy, 
colonoscopy, endoscopic ultrasound, and liver biopsy will be permitted as required to provide 
standard care. 
 
During the initial six months of trial, the investigators will develop a “manual of clinical operations” 
that will include best practices on the use of vasopressors, albumin, ICU care, mechanical ventilation 
and renal replacement therapy using Surviving Sepsis Campaign, International Guidelines for 
Management of Severe Sepsis and Septic Shock. The investigators will also provide best practices for 
management of nutrition and alcohol counseling and minimization of recidivism. Although the 
management of these complications will not be mandated by protocol, the care provided will be 
recorded to develop novel designs for future trials and for practice guidance and quality improvement 
programs. 
 
After ensuring that participants meet all of the inclusion criteria and none of the exclusion criteria, and 
after the informed consent has been obtained participants will be randomized to receive one of the 
following interventions in addition to standard care. 
 
Group 1: Standard of care plus prednisone (40 mg orally) once daily on Days 1-30 and matching 
placebos for Anakinra (1 syringe s.c. once daily on Days 1-14) and zinc (matched pill once daily on 
Days 1-90). 
Group 2: Standard of care plus Anakinra (100 mg s.c.) once daily on Days 1-14, zinc sulfate 220 mg 
once daily on Days 1-90, and placebo for prednisone (matched pill once daily on Days 1-30).  
Lille score will be calculated from day 7 labs, participants will stop prednisone or prednisone 
placebo if Lille score >0.45.  
 
 


32 
 
 
 
Figure 1. Distribution of study drugs and placebo 
 
Participants or guardian will be instructed in subcutaneous injection technique to continue self- 
administration of these experimental treatments after discharge from the hospital. Study personnel will 
ensure participants and guardian are proficient in the technique before the end of study visit. 
 
Relevant clinical care parameters will be recorded on days specified. As noted above, attention will be 
paid to recording concomitant care provided to treat complications related to AH or portal 
hypertension including those treatments not specified by protocol, including, but not limited to, 
antibiotics, IV fluids, albumin, pressors, renal replacement, etc. 
 
Standardizing study conduct and good clinical practice (GCP) 
 
Variations in protocol implementation and clinical care can have a major impact on trial outcomes. 
This will be optimized by: (1) GCP training and certification of all study personnel, (2) 
investigator/coordinator training and certification prior to site activation, (3) monthly performance 
reports, (4) development of manual of operations that provide best practices and study procedures 
to follow, and (5) annual investigator meeting to review developments and clinical and trial practice 
patterns. 


33 
 
4.2 
Schedule of Trial Procedures 
Table 1. Study Visits and Data Collection Schedule***** 
 
Screening 
Treatment Phase 
Follow-up 
phase 
D0 
D3 
D7 
D14 D28 
D60 
D90 
D180 
Window (days)
±2 
±2 
±2 
±2 
±7 
±7 
±7 
±7 
Informed consent 
x 
History and physical 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Vital signs, weight 
*** 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Alcohol 
consumption history 
x 
x 
x 
x 
x 
x 
x 
Randomization 
x 
Concomitant 
medicines 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Dispense Study 
Drug 
x 
 
* 
 
Adverse events 
x 
x 
x 
x 
x 
x 
x 
Electrocardiogram*
***** 
x 
Evaluation of 
compliance 
x 
x 
x 
x 
x 
x 
CBC, PT/INR, 
Hepatic Function 
Panel, BMP 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Test for COVID-
19**** 
x 
 
 
 
 
 
 
 
 
Sepsis studies, as 
indicated 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Pregnancy test, 
serum** 
x 
Pregnancy test, 
urine** 
x 
x 
x 
x 
x 
x 
Blood collection for 
trough Anakinra 
levels 
x 
x 
x 
x 
Specimen Banking¶ 
x 
x 
x 
x 
x 
x 
x 
Saliva Banking+ 
x 
x 
Questionnaires δ 
x 
 
 
x 
x 
x 
x 


34 
 
¶Specimen banking includes blood and stool (when possible) D0, D7, D14, D28, D60, D90, D180, 
and, when available, urine and liver biopsy/tissue. Blood will be used to extract germline DNA at 
baseline and at Day 180 as well as to extract serum/plasma/PBMC at all visits. Type of specimen 
collection is site specific. 
+ Saliva banking at D0 and D90. Collected until an adequate number of samples are collected. 
δ Questionnaires include Alcohol Use Disorders Identification Test (AUDIT), Alcohol Timeline 
Follow Back (TLFB), and Chronic Liver Disease Questionnaire (CLDQ). The timeline follow back 
questionnaire will be the only questionnaire administered at days 28, 60, 90, and 180. All are given 
at screening. 
*Day 7 study drug dispensation will be unscheduled and only on an as-needed basis, based on safety 
lab evaluations (outpatient only.) 
** If applicable 
*** Height at screening only. 
**** Test for COVID-19 PCR only if not done as SOC with 7 days prior to the baseline Day 0 
visit.  
***** In response to COVID-19, we are lessening restrictions if applicable or necessary such as: 
allowing wider windows D14, D28, D60 to +/- 10 days. Allowing replacement of protocol 
mandated in-person study visits with one or more of the following, phone calls, telemedicine virtual 
visits, implement digital technology to record responses to questionnaires. Lastly, allowing blood 
draws at remote or commercial laboratories. 
******ECG can be done as standard of care within 7 days of screening 
 
 
Abbreviations: CBC: Complete blood count, BMP: Basic metabolic panel, INR: International 
normalized ratio and PT: Prothrombin Time. 
Data Collection 
Clin= clinical (relevant elements of history, physical exam), Biosamples: whole blood, plasma, serum, 
PBMC, DNA, (and stool (when possible) at all time-points, Liver biopsy/tissue and urine (20ml) if 
available, Questionnaires= AUDIT, alcohol timeline follow back, CLDQ. SOC (standard of care) 
labs= CBC, Hepatic Function Panel, BMP, PT/ INR, Sepsis studies at baseline and during trial 
duration, as indicated (blood cultures, chest X ray, stool for WBC and C. Diff, as indicated, ascites 
tap, UA with culture, liver ultrasound or other imaging, endoscopy if available within 6 months). 
 
4.3 
Duration of Trial by Phase 
 
 
Time expected for all participants to be 
enrolled: 
5 years 
Duration of individual participant 
participation: 
90 days during the treatment phase 
90 days during the follow up phase 
180 days total participation 
Total duration of trial (excluding data 
collection and analysis): 
5 years 


35 
 
5. 
PARTICIPANT SELECTION 
5.1 
Participant Population 
The study population will be comprised of men and women of all races, ethnic groups and 
socioeconomic status of the ages of 21 and greater admitted to the hospital with a clinical diagnosis 
of AH. The definition of AH is based on criteria established by NIAAA. A conscious decision not 
to require a liver biopsy for inclusion was made based on the current low rate of liver biopsy used to 
establish this diagnosis in the US and the ability to diagnose the condition with relative accuracy based 
on the experience in the first cycle of funding. Eligible participants will be identified based on 
inclusion/exclusion criteria as defined below. 
Inclusion Criteria/ Exclusion Criteria  
Inclusion Criteria 
 
1. AH, as defined by the NIAAA pan-consortia for AH: 
a) Onset of jaundice (defined as serum total bilirubin >3 mg/dL) within the prior 
8 weeks 
b) Regular consumption of alcohol with an intake of > 40 gm daily or >280gm weekly on 
average for women and > 60 gm daily or >420gm weekly on average for men for 6 months 
or more, with less than 8 weeks of abstinence before onset of jaundice 
c) AST > 50 IU/l 
d) AST: ALT > 1.5 and both values < 400 IU/l 
e) and/or histological evidence of AH* 
 
 
2. MELD 20-35 on day of randomization. 
 
3. Ages ≥ 21 
 
* In patients with possible AH or AH with confounding factors such as possible ischemic 
hepatitis, possible DILI, uncertain history of alcohol use (e.g., patient denies excessive 
alcohol use), and atypical/abnormal laboratory tests (e.g., AST < 50 IU/IU/L or > 400 
IU/IU/L, AST/ALT ratio < 1.5), antinuclear antibody > 1:160 or SMA > 1:80,  
standard of care liver biopsy may be performed during current hospital admission to 
confirm AH and exclude competing etiologies 17. 


36 
 
Exclusion Criteria 
1. MELD SCORE <20 or > 35 
2. Active sepsis (positive blood or ascitic cultures) with Systemic Inflammatory Response 
Syndrome (SIRS) or hemodynamic compromise requiring intravenous pressors to maintain 
tissue perfusion 
3. Pneumonia as evidenced by radiological exam 
4. Multi-organ failure 
5. Renal failure defined by GFR <35 mL/min by CKD EPI. 
6. Clinically active C. diff infection 
7. History of imaging of the liver (ultrasound, computerized tomography, or magnetic 
resonance) showing other causes of jaundice 
8. History of other liver diseases including hepatitis B (positive HBsAg or HBV DNA), 
hepatitis C (positive HCV RNA), autoimmune hepatitis, Wilson disease, genetic 
\hemochromatosis, alpha1-antitrypsin deficiency, or strong suspicion of Drug Induced 
Liver Injury (DILI). Previously treated hepatitis C that was cured (sustained virological 
response with negative RNA ≥24 weeks following treatment) is not an exclusion. 
9. History of HIV infection (positive HIV RNA or on treatment for HIV infection) 
10. History or presence of cancer (including hepatocellular carcinoma) other than non- 
melanoma skin cancer 
11. History of other significant medical problems such as autoimmune diseases, severe asthma, 
psoriasis, Inflammatory Bowel Disease (IBD), etc. that might require immunosuppressive 
treatments 
12. Pregnancy or breastfeeding 
13. Prior exposure to experimental therapies in last 3 months 
14. Prior exposure to systemic corticosteroid (glucocorticoid) or immunosuppressive therapy 
for more than 4 days within previous 30 days 
15. Need for inotropic pressor support to maintain perfusion to critical organs within prior 48 
hours before randomization and initiation of experimental treatment 
16. Clinically significant pancreatitis- abdominal pain, elevated lipase (> 3 X ULN) and at least 
edema of pancreas with fat-stranding on CT scan 
17. Total WBC count > 30,000/mm3 
18. Known allergy or intolerance to therapeutic agents to be tested 
19. Inability to voluntarily obtain informed consent from participant or guardian 
20. Perceived inability to follow study procedures and comply with protocol 
21. Platelet count < 40,000 k/cumm. 
22. Positive PCR test for COVID -19 within 7 days prior to the baseline day 0 visit* 
23. Active gastrointestinal bleeding defined as hematemesis or melena with a decrease in 
hemoglobin more than 2 g/dl in 24 hrs. Due to gastrointestinal bleeding, or with a 
decrease in mean arterial BP to < 65 mmHg.    
*Positive PCR test for COVID-19 is exclusionary only during screening period. If a patient tests 
positive any time after baseline randomization, a positive PCR test for COVID-19 will be considered 
as a SAE.  
The participants for this study will be recruited from a hospitalized population of participants 
meeting the eligibility criteria outlined above who live within one day travel from one of the 


37 
 
participating clinical centers and who have provided informed consent to participate in this clinical 
trial and who are willing to continue their participation for the anticipated follow-up period of the 
trial. Although the primary endpoint is survival at 90 days, follow-up visits will be continued up to 6 
months. 
 


38 
 
5.2 
Participant Compensation and Recruitment 
5.3.1 Participant Compensation 
Participant compensation is site specific. 
 
5.3.2 Participant Recruitment 
Sources of participants: 
Identification of participants with severe AH requires collaboration with those physicians who 
manage these participants within the hospital and the emergency department. Almost 100% of 
participants are admitted to hospital based on the severity of their liver disease. Occasionally 
participants are seen in free-standing urgent care centers, free-standing emergency rooms or in 
office/clinic practices. Since the standard of care is to admit these participants for further evaluation 
to exclude infections as a precipitating cause of decompensated liver disease, most will ultimately be 
identified in a hospital setting. Letters will also be sent to referring MDs and referring hospitals. 
 
Some sites in the current U01 have found that screening laboratory results for elevated AST and 
total bilirubin is a useful way to identify potential participants. In accordance with Institutional 
Review Board Policies, once identified the primary team caring for these participants must be 
contacted by the investigators and agree to ask the participant about their interest in participating in 
a clinical trial as part of the treatment of the underlying AH. Once the participant expresses 
willingness to be contacted the investigators may discuss details of the study and obtain informed 
consent prior to beginning treatment. 
 
5.4.1 Individual Drug Discontinuation Criteria Reasons for Mandatory Trial Hold – Infection 
If one of the following criteria is met, the study drugs should be held for 3 days: 
1. Documented Infection 
• Pneumonia defined as new infiltrate by CXR or chest CT scan 
• Positive cultures (blood, ascites) for bacteria or fungus 
• Positive fungal cultures in urine (> 50,000 colonies/ml)  
• CNS infection defined as positive cultures or WBC > 5 in CSF 
• Severe soft tissue or bone infections including clinical diagnosis of cellulitis 
 
2. SIRS (defined as two or more abnormalities in temperature, increased heart rate, 
respiration, or white blood cell count) with increase in SOFA score ≥2 points 
 
Participants will be reassessed on the third day of the study drugs hold: If infection clears and 
participant stabilizes, study drugs will be resumed. 
 
For participants with documented infection: If infection is responsive to antibiotics and 
participant is stabilized or improved, study drugs may be resumed at the discretion of the 
clinical care team. If there is no improvement after 3 days, study drugs will be stopped 


39 
 
For participants meeting only SOFA+SIRS (#2 above) criteria for stopping: if cultures of urine, 
blood, ascites, stool (including C. diff) are negative and CXR is unchanged, study drugs may be 
resumed at the discretion of the clinical care team.  
If the participant has a second hold of study drugs due to infection/SIRS+SOFA criteria, study 
drugs will be stopped. 
 
5.4.2 Reasons for Mandatory Trial Discontinuation 
1. Persistent infection: a) Participants with documented infection will be reassessed on 3rd day of 
the study drugs hold. If infection is responsive to antibiotics and participant is stabilized or 
improved, study drugs may be resumed at the discretion of the clinical care team. If there is no 
improvement after 3 days, study drugs will be stopped. b) For participants meeting only 
SOFA+SIRS criteria for stopping: if cultures of urine, blood, ascites, stool (including C. diff) are 
negative and CXR is unchanged, study drugs may be resumed at the discretion of the clinical 
care team. c) If the participant has a 2nd hold of study drugs due to infection/SOFA +SIRS 
criteria, study drugs will be stopped.  
 
2. Pregnancy: If a female participant becomes pregnant, she must stop taking study 
medication and must be withdrawn from the trial. The participant must be followed by the 
investigator through the end of her pregnancy. The mother (and infant) will be followed as 
considered appropriate by the investigator and the study designated physician (Dr. Gawrieh or 
his designee). For reporting purposes, pregnancy is not considered a serious adverse event (SAE). 
 
3. Clinical deterioration: During the trial, if Maddrey’s Discriminant Factor (DF) increases by 5 
points and also exceeds 32, or MELD scores increases by 5 points and also exceeds 20, the study 
medication should be stopped, however the participant will remain in the trial, completing 
procedures as detailed in the Schedule of Procedures (Table 1). The study drugs will also be 
stopped if severe leukocytosis (≥100,000/mm3) develops. Treating physicians may offer any other 
treatment that is considered as medically indicated and appropriate. 
 
4. Suspected drug induced liver injury (DILI): Hold the study drug if MELD increases by 5 
from baseline or Child’s score increases by 3 points from baseline plus >3-fold increase in ALT 
from baseline on two consecutive occasions. These instances may represent either lack of 
therapeutic efficacy or DILI or some other etiology. If there is a competing etiology and DILI 
can be excluded, study drug can be resumed within 3-4 days. However, if DILI cannot be 
excluded, then the study drug will be permanently discontinued. Additional reasons for study 
drug discontinuation include unexplained elevation in ALT > 5 x baseline or > 500 U/L on two 
consecutive occasions or unexplained elevation in Alk P > 3 x baseline or >500 U/L on two 
consecutive occasions. It should be noted that cholestatic DILI may have a devastating impact on 
participant survival in individuals with advanced liver disease. 
 
5. Lille score: Participants in either arm who have a Lille score of >0.45 on day 7 will stop bottle 
1(prednisone/ placebo) and will continue with bottle 2 (zinc/zinc placebo.) 
 


40 
 
a) Other Reasons for Trial or Treatment Discontinuation 
The following events are considered appropriate reasons for a participant to discontinue from the 
trial: 
• The participant withdraws consent or requests to be withdrawn from the trial. It is fully 
understood that all participants volunteer for the trial and that they may withdraw their 
consent at any time. 
• The participant experiences an adverse event that in the opinion of the site investigator or 
the primary investigator of the trial (i.e., study designated physician, Dr. Gawrieh) is caused 
by or exacerbated by any of the trial procedures or study medication, of sufficient intensity 
to warrant discontinuation. 
• The participant refuses to comply with the requirements for trial participation. 
• Termination of the trial due to DILI concerns: The Data Safety and Monitoring Board 
(DSMB) should carefully monitor the number of discontinuations due to MELD/Child’s Score 
worsening in three treatment groups. Since this trial is not powered for rare adverse events, 
one should not look for statistically significant imbalance among treatment groups, but the 
DSMB should consider numerical imbalances that its members deem clinically significant. 
While it may be straight forward in some instances (for example, 2 discontinuations in groups 
A but 5 discontinuations in group B) but in other instances it may not be as clear cut and one 
may continue the trial for a growing trend. In any case, the DSMB is advisory in nature, and it 
makes a recommendation to the Sponsor, NIAAA. In addition to seeking the AlcHepNet 
Steering Committee input, the NIAAA may seek external input to assist in its deliberation if 
the DSMB recommends that the clinical trial must be terminated due to safety concerns. 
 
When possible, the investigator should discuss the potential discontinuation of a participant with the 
study designated physician (Dr. Gawrieh or his designee) in advance. 
 
b) Participant Discontinuation Notification 
 
The investigator must notify the study designated physician (Dr. Gawrieh or his designee) as soon as 
possible if any participant prematurely discontinues from the trial. The date when the participant is 
withdrawn and the primary reason for discontinuation must be recorded in the CRF; additional 
information may be requested to complete a discontinuation narrative. Participants will be 
considered “lost to follow up” only after reasonable, documented attempts to reach the participant 
prove unsuccessful. In all cases, a reasonable effort must be made to determine the reason(s) that a 
participant fails to return for required trial visits or discontinues from the trial. 
 
If a participant stays in the study but discontinues study medication (either by participant’s choice, or 
by the investigator’s decision), then study measurements should be performed according to the 
Schedule of Trial Procedures, Table 1 (rather than expediting study visits, or measurements). 
Patients will be followed until the final evolution (stability, worsening, or resolution) of the event 
that invoked drug discontinuation and followed until the end of the trial, if they are willing to do so. 


41 
 
6. 
INVESTIGATIONAL PRODUCT (IP)/ STUDY MEDICATION 
6.1 
Description of IP/ Study Medication 
For the purpose of this protocol, the term ‘investigational product (IP)’ is interchangeable with the 
term ‘study medication’. Descriptions of the drugs, physical and chemical characteristics, and 
biological effects are included in the Labeling Information filed the Investigator’s Brochure. 
 
6.1.1 Study Medication 
A. 
Prednisone, Zinc Sulfate and Placebo Oral Therapy 
 
1. The University of Iowa Pharmaceuticals (UIP) will over-encapsulate the active 
prednisone and zinc sulfate tablets and manufacture placebo capsules. 
 
a. The UIP will purchase commercially available prednisone and zinc sulfate. 
 
1. Prednisone 20 mg tablets (Westward Pharmaceuticals) 
 
2. Zinc Sulfate 220 mg tablets 
 
3. The UIP will use stock excipients to manufacture placebo capsules. 
 
2. Prednisone, Zinc Sulfate and Placebo capsules will be identical, encapsulated in a size 
AAA empty capsule shell 
 
3. UIP will package study medications as 
 
a. Prednisone 40 mg capsules, 50 capsules per bottle 
 
b. Zinc Sulfate 220 mg capsules, 50 capsules per bottle 
 
c. Placebo for Prednisone 40 mg/Zinc Sulfate 220 mg Capsules, 100 capsules per 
bottle 
B. 
Anakinra and Placebo Subcutaneous Therapy 
 
1. Anakinra 100 mg/0.67 mL Prefilled Syringes will be procured by IU Health 
Investigational Drug Service through wholesaler Cardinal Health (NDC 66658-0234-07, 
SOBI Pharmaceuticals) 
 
2. Placebo for Anakinra 100 mg) will be prefilled syringes purchased directly from SOBI 
Pharmaceuticals and distributed by IU Health Investigational Drug Service. Each 
syringe is labeled by Sobi Pharmaceuticals as “Placebo for Kineret.” Each 1 mL syringe 
is filled to 0.67 mL. 


42 
 
6.1.2 Treatment Phase 
Study medication will be provided to each site (pharmacy) as unblinded product, over labeled at each 
site and blinded based on the randomization scheduled, and then provided to participants in a 
blinded manner (i.e., pharmacy, investigator, site staff and participant will be unable to distinguish 
treatment assignment). Study medication will consist of either 
1. Group 1: Standard of care plus prednisone (40 mg orally) once daily on Days 1-30 and 
matching placebos for Anakinra (1 syringe s.c. once daily on Days 1-14) and zinc 
(matched pill once daily on Days 1-90). 
2. Group 2: Standard of care plus Anakinra (100 mg s.c.) once daily on Days 1-14, zinc sulfate 
220 mg once daily on Days 1-90, and placebo for prednisone (matched pill once daily on 
Days 1-30).  
 
6.2 
Packaging, Labeling, and Storage 
The packaging and labeling of study medication for provision to the clinical trial sites will be 
performed according to GMP standards by designated qualified vendors. 
 
The designated IP distribution vendor will be responsible for the distribution of the study medication 
to the clinical trial sites. Prednisone, Zinc Sulfate and Placebo capsules should be stored at controlled 
room temperature (15°C to 30°C) and protected from excess humidity. Anakinra and Placebo prefilled 
syringes should be stored in the refrigerator (2°C to 8 °C) and protected from light. Avoid shaking 
and protect from freezing. 
 
Study medication will be packaged for the trial as described below. 
 
 


43 
 
6.3 
Labels for Study Drugs and Study Drug Dispensing Units: 
Study medication will be packaged for the trial as described below. 
 
Anakinra Prefilled Syringes, and the Placebo Prefilled Syringes provided by SOBI will have the 
manufacturers label on the study drug. Prednisone, Zinc Sulfate and Placebo Capsules will be labeled 
by the University of Iowa Pharmaceuticals. 
 
 
 
 
 
 
 
 
 
 
Over-Encapsulation of Prednisone (2 x 20 mg Tablets) 40 
mg C 
   Lot #: XXXXXXXXX 
50 Capsules per Bottle 
Store at Controlled Room Temperature  
Caution: New Drug – Limited by Federal Law to 
Investigational Use Only. 
The University of Iowa Pharmaceuticals – College of 
Pharmacy – The University of Iowa – Iowa City, Iowa 
52242 
Over-Encapsulation of Zinc Sulfate 220 mg Capsules 
Lot #: XXXXXX  
Store at Controlled Room Temperature  
Caution: New Drug – Limited by Federal Law to 
Investigational Use Only. 
The University of Iowa Pharmaceuticals – College of 
Pharmacy – The University of Iowa – Iowa City, Iowa 
52242 
Placebo Capsules for Prednisone and Zinc Sulfate  
50 Capsules Lot #: 
XXXXXX 
Store at Controlled Room Temperature  
Caution: New Drug – Limited by Federal Law to 
Investigational Use Only. 
The University of Iowa Pharmaceuticals – College of 
Pharmacy – The University of Iowa – Iowa City, Iowa 
52242 


44 
 
6.4 
Dose, Administration and Blinding 
Two treatment groups will be evaluated in the trial: 1) Prednisone, and 2) Anakinra plus zinc 
 
Participants will be instructed to begin dosing on day 1.  Oral study medication should be taken with 
water as instructed on study drug label. Patients will receive two oral medications. Bottle 1 will be 
Prednisone or Placebo and will be taken daily on Days 1-30 per protocol. Bottle 2 will be Zinc 
Sulfate or Placebo and will be taken daily on Day 1-90 per protocol. 
Participants must be instructed to swallow the capsule whole; they must not open capsule. 
Subcutaneous study medication should also begin on Day 1 and be administered daily on Days 1 to 
14. 
 
6.4.1 Dispensing Procedures 
On Day 0, after confirmation of participant eligibility and randomization, the investigator or 
designee will dispense study medication to the participant. Before leaving the clinic/hospital, the 
study staff will ensure that the participant fully understands the dosing instructions. We will dispense 
a sharps container for each subject discharged before day 14. The clinical trial site investigator may 
adjust the number of study medication dispensed to the participant based on clinical judgment and 
visit scheduling to ensure an adequate supply of study medication is available for dosing between 
clinic visits. An unscheduled distribution of study medication Anakinra/ Placebo may occur on Day 
7 if needed to comply with medication changes necessitated by safety lab results. 
 
 


45 
 
6.4.2 Blinding 
Study medication bottles will be labeled in a blinded manner to ensure that neither participant nor 
investigator is unblinded. Examples of labels for the initial dispense: 
 
BOTTLE 1, DAY 0 
BOTTLE 2, DAY 0 
 
 
SYRINGE BAG, DAY 0 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pharmacy Name, Address, Phone Number 
Caution: Federal law prohibits transfer of this drug to any person other than the patient 
for whom prescribed. 
 
Rx: Number                               Prescriber: 
Patient Name                             MRN: 
 
Take 1 capsule by mouth daily on Days 1 through 30. 
 
STUDY Prednisone / Placebo 40 mg Capsule 
Quantity: 30 Capsules                IRB: 1904-650121/AlcHepNet-02 
Date Filled: 
Do Not Use After: Date 
 
Pharmacy Name, Address, Phone Number 
Caution: Federal law prohibits transfer of this drug to any person other than the patient 
for whom prescribed. 
 
Rx: Number                               Prescriber: 
Patient Name                             MRN: 
 
Take 1 capsule by mouth daily on Days 1 through 90. 
 
STUDY Zinc Sulfate / Placebo 220 mg Capsule 
Quantity: 90 Capsules                IRB: 1904-650121/AlcHepNet-02 
Date Filled: 
Do Not Use After: Date 
 
Pharmacy Name, Address, Phone Number 
Caution: Federal law prohibits transfer of this drug to any person other than the patient 
for whom prescribed. 
 
Rx: Number                               Prescriber: 
Patient Name                             MRN: 
 
Inject 1 syringe subcutaneously every morning daily on Days 1 
through 14. 
 
STUDY Anakinra / Placebo 100 mg/0.67 mL Prefilled Syringe 
Quantity: 90 Capsules                IRB: 1904-650121/AlcHepNet-02 
Date Filled: 
Do Not Use After: Date 
 


46 
 
6.4.3 Missed Doses 
Participants who miss a dose of study medication should be instructed to take it later the same day, 
as soon as they remember, but no more than 12 hours past normal dosing time for the injectable 
study medications. ‘Missed’ doses should not be taken on a subsequent day (i.e., the participant 
should not take more than the prescribed daily dose). Participants will make note of missed dose on 
medication compliance log. 
 
6.4.4 Environmental Assessment 
Is requested for categorical exclusion for this proposed clinical trial as provided for in 21 
CFR.25.31(e) in that the drug shipped under this notice is intended to be used in clinical trials in 
which the amount of waste expected to enter the environment may reasonably be expected to be 
non-toxic. 
 
6.5 
Randomization 
6.5.1 Method of Assigning Participants to Treatment Groups 
The trial will be conducted in a double-blind, placebo-controlled manner. Participants will be 
randomized to the two treatment groups in equal proportions. The randomization plan will be 
stratified by site and MELD score. Blocks of size 4 will be generated randomly based on a 
predefined randomization code generated by the AlcHepNet IU data coordinating unit (DCC- IU). 
Both participants and investigators will be blinded to the randomization plans. 
 
The investigator or designee will be required to register the participant into the REDCap system 
(AlcHepNet’s data management system) and will provide participant data to properly randomize and 
allocate the participant to treatment. A randomization number will be assigned and study medication 
dispensing information (e.g., arm assignment) will be provided. 
 
In the unlikely event of a system failure, the randomization will occur outside of REDCap according 
to the back-up emergency plan detailed in the Manual of Operations. IU DCC will maintain at all 
times a current, off-line randomization list and will be able to act as the Emergency Support team 
until the system is restored to its full capacity. 
 
6.5.2 Site Numbers 
Each trial site selected to participate in this trial will be assigned a Site Number by the AlcHepNet 
consortium. The Site Number will be used to categorize participant data and to identify the site and 
or investigator within trial documents. 
 
6.5.3 Screening Numbers 
At the Screening Visit, after the participant has provided written informed consent, the participant will 
be assigned a unique 5-digit participant ID number. 
 
 


47 
 
6.6 
Holding and Unblinding Procedures 
The site pharmacist will be unblinded to randomization codes and corresponding treatment 
assignment. Additionally, the randomization codes and corresponding treatment assignment will be 
maintained by the AlcHepNet DCC-IU. The biostatisticians performing the analyses will also be 
blinded. The study designated physician (Dr. Gawrieh or his designee), or the individual 
investigators will not have access to this information. In the event that a medical emergency 
necessitates unblinding (i.e., in situations where knowledge of the blinded treatment is necessary for 
further medical management of the participant), the site investigator (or his/her designee) will 
contact the designated study physician to discuss the rationale for unblinding. If there is a difference 
of opinion between the designated study physician and the site investigator, then the site investigator 
will defer to the sub-investigator who retains the final right to seek unblinding. The designated sub-
investigator will communicate with the DCC-IU about the decision to unblind the participant and 
then the DCC-IU will unblind the participant by interacting directly with the sub- investigator. 
 
The Data and Safety Monitoring Board (DSMB) will be able to unblind participants. Cases of 
premature unblinding (as noted above) will be reviewed by the DSMB. 
 
Access to randomization codes and corresponding treatment assignment will also be made available 
to the designated study physician who is responsible for reporting SAEs and suspected unexpected 
serious adverse reactions (SUSARs) to the Regulatory Authorities and should be accessed only in the 
event that reporting necessitates unblinding. Aside from the IU IDS pharmacist who conducts the 
drug over labeling, site pharmacy staff will be unblinded to the subject’s treatment. Treatment will be 
assigned through REDCap. Pharmacy staff will be responsible for blinding the subject’s treatment before 
dispensing. Pharmacy will be trained to maintain the blind. No other site personnel will have direct 
access to blinded participant treatment codes until all trial data have been entered onto the trial 
database and validated and the database locked. 
6.6.1 Treatment and holding/stopping rules for infection and sepsis 
Leukocytosis is common in AH and may be further exacerbated by administration of prednisone. 
Such iatrogenic rise in leukocytosis may alarm participant care teams who are blinded to the 
treatment arm and may raise concern for development of infection or sepsis. 
 
While many AH participants may develop the systemic inflammatory response syndrome (SIRS) 
(defined as two or more abnormalities in temperature, increased heart rate, respiration, or white 
blood cell count), SIRS may not always be indicative of infection in participants with AH and may 
be reflective of the dysregulated inflammatory state with AH. 
 
 


48 
 
Drug Holding Rules (Day 0-Day 30): 
If one of the following criteria met, the study drugs should be held for 3 days: 
1. Documented Infection 
• Pneumonia defined as new infiltrate by CXR or chest CT scan 
• Positive cultures (blood, ascites) for bacteria or fungus 
• Positive fungal cultures in urine (> 50,000 colonies/ml)  
• CNS infection defined as positive cultures or WBC > 5 in CSF 
• Severe soft tissue or bone infections including clinical diagnosis of cellulitis 
2. SIRS (defined as two or more abnormalities in temperature, increased heartrate, 
respiration, or white blood cell count) with increase in SOFA score ≥2 points. 
Participants will be reassessed on 3rd day to determine if study drugs could be resumed or 
should be stopped. 
Drug Stopping rules (Day 0-Day 30): 
 
Participants will be reassessed on third day of the study drugs hold: If infection clears and 
participant stabilizes, study drugs will be resumed. 
 
1. For participants with documented infection: If infection is responsive to antibiotics and 
participant is stabilized or improved, study drugs may be resumed at the discretion of the 
clinical care team. If there is no improvement after 3 days, study drugs will be stopped. 
2. For participants meeting only SOFA+SIRS criteria for stopping: if cultures of urine, 
blood, ascites, stool (including C. diff) are negative and CXR is unchanged, study drugs 
may be resumed at the discretion of the clinical care team. 
3. If the participant has a second hold of study drugs due to infection/SOFA+SIRS criteria, 
study drugs will be stopped. 
4. Participants in either arm who have a Lille score of >0.45 on day 7 will stop bottle 1 
(prednisone/ placebo) and will continue with bottle 2 (zinc/zinc placebo.) 
 
Drug stopping Rules (Day 0-Day 30): 
• No improvement or stabilization after holding study drugs for 3 days 
• 2nd hold of study drugs due to infection/SOFA+SIRS criteria 
• Development of severe leukocytosis (≥100,000/mm3). 
 
Treatment holding and stopping rules for Drug Induced Liver Injury (DILI) 
 
Identifying the instances of suspected drug induced liver injury (DILI) in individuals with underlying 
liver disease with abnormal liver biochemistries is difficult and this issue becomes far more 
challenging in individuals with severe alcoholic hepatitis because (a) aminotransferases and alkaline 
phosphatase may not reliably increase due to burnt out hepatocytes in this population and (b) liver 
test worsening may be due to myriad of other reasons including worsening of underlying alcoholic 
hepatitis or sepsis. 
 


49 
 
Therefore, we propose the following: 
 
1) When to hold or discontinue the study medicine in a participant? In individuals with 
severe alcoholic hepatitis participating in our RCT, we will hold the study medicine if 
MELD increases by 5 from baseline or Child’s score increases by 3 points from baseline 
plus >3-fold increase in ALT from baseline on two consecutive occasions. These 
instances may represent either lack of therapeutic efficacy or DILI or some other 
etiology. If there is a competing etiology and DILI can be excluded, study drug can be 
resumed within 3-4 days. However, if DILI cannot be excluded, then the study drug will 
be permanently discontinued. Additional reasons for study drug discontinuation include 
unexplained elevation in ALT > 5 x baseline or > 500 U/L on two consecutive occasions 
or unexplained elevation in Alk P > 3 x baseline or >500 U/L on two consecutive 
occasions. It should be noted that cholestatic DILI may have a devastating impact on 
participant survival in individuals with advanced liver disease. 
2) When to terminate the trial due to DILI concerns? The Data Safety Monitoring 
Committee (DSMB) should carefully monitor the number of discontinuations due to 
MELD/Child’s Score worsening in the three treatment groups. Since this trial is not 
powered for rare adverse events, one should not look for statistically significant 
imbalance among treatment groups, but the DSMB should consider numerical 
imbalances that its members deem clinically significant. While it may be straight forward 
in some instances (for example, 2 discontinuations in groups A but 5 discontinuations in 
group B) but in other instances it may not be as clear cut and one may continue the trial 
for a growing trend. In any case, the DSMB is advisory in nature and it makes a 
recommendation to the Sponsor which is the NIAAA for this trial. In addition to seeking 
the AlcHepNet Steering Committee input, the NIAAA may seek external input to assist 
in its deliberation if the DSMB recommends that the clinical trial must be terminated due 
to safety concerns. 
Treatment holding/stopping rules for laboratory abnormalities 
 
• If platelet counts drop to < 40,000 while on injectable study drugs, injectable study drugs 
will be held and resumed when platelet count is ≥40,000. 
 
• Worsening renal function 
As all patients are randomized to treatment arms while hospitalized, the site’s dispensing pharmacy 
will check the GFR before dispensing the study drugs for the day. Pharmacy will enter the daily lab 
values into a REDCap-based decision support form, which will aid the pharmacy by providing 
guidance on daily dispensation. This REDCap form is in addition to the pharmacy manual of 
procedures, which also provides guidance on daily dispensation. For weekend coverage, the GFR 
and platelet values from the Friday labs may be used to generate the dispensation schedule at some 
sites. If the subject’s GFR has dropped to <30 but ≥20 and the subject is in the anakinra group, 
Redcap will provide instructions for pharmacy to dose reduce to every other day by providing 
anakinra placebo one day, alternating with active anakinra the following day. If the GFR drops to < 
20 mL/min, the instructions from REDCap will hold active anakinra and substitute with anakinra 
placebo 
 
When the patient is discharged and now outpatient, all injectable drugs will be dose reduced and 
administered every other day when the GFR drops to <30 but ≥20 mL/min. All injectable drugs 


50 
 
will be stopped if GFR drops to <20 mL/min. 
 
6.6.2 Unscheduled, Emergency Unblinding 
6.6.2.1 Rules for unblinding participants for leukocytosis and concern for infection/sepsis (Day 0- 
Day 30): 
In this placebo- controlled, blinded and randomized trial, Principal Investigators, enrolled 
participants, and any study team member who will/is interpreting data will remain blinded. 
1. If the participant develops leukocytosis >) WBC > 30 x 109/L or WBC > 30,000/mm3, the clinical 
care team may request unblinding if the team believes that knowing the treatment would impact care 
decisions such as starting antibiotics. 
2. If the participant develops hypotension (systolic BP < 90) and/or requires transfer to an ICU, the 
clinical care team may request unblinding if the team believes that knowing the treatment would 
impact care decisions such as administration of pressors, fluids or other supportive therapy. 
3. If the participant develops any other serious adverse event that is, in the opinion of the investigator, 
probably related to one of the study drugs, the clinical care team may request unblinding if it would 
impact care decisions. 
 
Who to unblind? 
• Only sub-investigator 
• Clinical care team 
• DCC contact 
Unblinding procedure: 
1. Each site will designate a sub-investigator who can be contacted if the participant care team has 
concerns about rising leukocytosis 
2. The contacted sub-investigator will communicate with IU DCC to unblind the participant then 
inform participant care team of the study drug/s participant is receiving 
3. IU DCC will build this into the database system and keep track of unblinded participants 
4. The decision to begin antibiotics for possible infection is left to the judgment of the clinical care 
team. 
 
6.7 
Prior and Concomitant Medications or Procedures 
Relevant information about all concomitant drugs (including prescribed, over the counter, or herbal 
preparations) taken prior to 30 days of screening and during the trial must be recorded in the source 
documents and CRF, as well as any dose or dose regimen changes that occur during the trial. The 
clinical care team should be advised not to give supplemental zinc to subjects in the trial as that 
could result in an excessive dosing particularly in subject with renal dysfunction. No interaction 
between zinc and anakinra is reported. Zinc may interfere with absorption of certain oral antibiotics 
such as quinolones and tetracyclines. To avoid potential interference with concomitant medications, 
we will administer the morning blinded capsules (zinc/zinc placebo or prednisone/prednisone 
placebo) at least 3 hours apart from other medications the participant will take. 
 


51 
 
6.8 
Treatment Compliance 
The investigator should assess the participant’s compliance with dosing of study medication on an 
ongoing basis, at least at each visit, and confirm by conducting drug accountability (i.e., count of 
returned capsules, syringes). 
Participants should be instructed to retain all study medication, even if empty, and to return them to 
the investigator at the subsequent visit. The investigator or designee should perform drug 
accountability and, if applicable, follow up with the participant to retrieve any study medication that 
has not been returned. 
If the investigator has concerns about a participant’s dosing compliance s/he should discuss this 
with the participant, assess the reasons for noncompliance and the likelihood that the participant 
will remain noncompliant, and notify the designated study physician accordingly. Continued trial 
eligibility should be assessed based on the participant’s compliance with study medication dosing 
and clinic visits. 
 
6.9 
Study Medication Accountability and Retention 
IU Health Investigational Drug Services representative will send study medication to the trial sites 
under appropriate storage conditions. All shipments of study medication should be unpacked, and the 
contents reviewed immediately upon receipt. The pharmacist or designee should verify the study 
medication against the shipment documentation. The pharmacist or designee should contact the 
designee of IU Health Investigational Drug Services immediately to report any concerns regarding 
the shipment. 
All study medication will be provided for use only in this trial and is not to be used for any other 
purpose. The investigator or designee will maintain a full record of study medication accountability, 
including records of individual participant dispensing and final return or disposition. 
 
The monitor from DCC-IU, will review accountability records against study medication dispensed and 
that remaining in stock, during on-site monitoring visits and when the trial is completed, or if it is 
prematurely terminated. The CRA will retrieve documentation detailing and confirming the return 
or destruction of the study medication. 
 
 


52 
 
6.10 
Trial or Site Termination 
The AlcHepNet consortium reserves the right to terminate the trial at any time. It is normal 
procedure to review the emerging clinical and safety data. As a result of such a review or a 
recommendation by the DSMB, it may be necessary to stop the trial before all participants have 
completed the trial. 
 
It is the responsibility of the individual site’s PI to report to the Western Institutional Review Board 
(WIRB) of discontinuation of the trial and the reason for doing so in a timely fashion according to 
institutional policies. 
 
7. 
TRIAL PROCEDURES 
7.1 
Screening 
7.1.1 Informed Consent 
The investigator or designee will explain the nature, purpose and risks of the trial to the participant or 
legally authorized representative (LAR/guardian) and will provide him/her with a copy of the 
written information and informed consent form (ICF). The participant or LAR will be given 
sufficient time to consider the trial before deciding whether or not to participate. The participant or 
LAR will be informed that participation is voluntary and that her/his future medical treatment will 
not be compromised by participation in the trial and that s/he can withdraw from the trial at any 
time. The participant or LAR must be willing and able to provide written informed consent before 
entering the trial. The investigator or a medically qualified designee is responsible for administering 
and documenting the written informed consent of the participant. 
7.1.2 Participant Identification Assignment 
After the participant has met eligibility criteria and enrolls into the study, the participant will be 
assigned a unique 5-digit ID number. This 5-digit number will be used to identify the participant 
throughout the trial and during the data analysis. 
 
7.2 
Visit Procedures 
Participants should be instructed to fast, when possible, overnight (at least 8 hours) immediately prior 
to all at- clinic visits, Screening Visit. While fasting, water is permitted. 
 
 


53 
 
 
7.2.1 Screening Period – Fasting for at least 8 hours, when possible 
The screening period will consist of ≤ 7 days prior to the randomization visit (Day 0). During the 
screening period, participants’ eligibility criteria must be confirmed. Patients with clinical suspicion 
of sepsis will have an initial run-in period of 48 hours while being screened for eligibility for 
enrollment. Patients with evidence of sepsis at the end of this run-period will be excluded from 
participation. Participants or LAR must sign an informed consent prior to initiating any of the 
screening procedures. Participants who do not fulfill all eligibility criteria cannot continue in the 
protocol (screening failures). 
Screening period procedures are as follows: 
 
• The participant or LAR is to review and sign the informed consent document. Informed consent 
must be obtained from the participant or LAR before performing any trial related procedures, 
including screening procedures 
• Verify inclusion and exclusion criteria for eligibility 
• Assess MELD score. 
• Physical exam 
• Collect medical history including the alcohol consumption specifics  
• Have participants completed the TLFB questionnaire, CLDQ, and AUDIT 
• Record vital signs, including height and weight 
• Record prior (within 30 days of Day 0) and current concomitant medications 
• Perform a baseline standard 12-lead electrocardiogram (ECG), if not already done as standard of 
care within 7 days of screening 
• Assess availability of liver biopsy samples (if applicable) which may have been obtained as part of 
standard of care 
• Obtain blood samples for hematology, hepatic function panel, BMP, and coagulation tests 
• Perform a serum pregnancy test in females of childbearing potential 
• Perform a PCR test for COVID-19, if not done as SOC. 
**The participant should be reminded that fasting (8 hours) is requested, when possible, prior to 
his/her next visit. 
 
 


54 
 
7.2.2 Day 0 Procedures (Randomization) – Fasting for at least 8 hours, when possible 
 
• Collect medical history including the alcohol consumption specifics 
• Perform a physical examination 
• Record vital signs, including weight 
• Assess and record any pretreatment emergent AEs 
• Record prior (within 30 days of Day 0) and current concomitant medications, noting any changes 
from screening, if applicable. Perform a urine pregnancy test in females of childbearing potential, 
if greater than one day has elapsed since screening pregnancy test. 
• Confirm inclusion and exclusion criteria for eligibility 
• Assess MELD scores 
• Randomize the participant only if s/he meets all inclusion criteria and no exclusion criteria 
• Obtain blood samples for hematology, hepatic function panel, BMP, and coagulation tests, if 
greater than one day has passed since screening. 
• Obtain biospecimens for specimen banking and measuring anakinra trough levels as outlined in 
Table 1. 
• Dispense study medication and instruct the participant on medication dosing and administration. 
Instruct the participant to swallow the capsules whole; s/he must not open, chew, divide, open 
or crush the capsule. Verbally instruct participant and caregiver (if applicable) on subcutaneous 
injection procedures and provide IRB-approved instruction handout 
• The participant should be reminded that fasting (8 hours) is requested, when possible, prior to 
his/her next visit. 
 
 


55 
 
 
7.2.3 D3 Procedures (± 2 days) -– Fasting for at least 8 hours, when possible  
• Perform a physical examination 
• Record vital signs, including weight 
• Assess and record any emergent AEs 
• Record any changes to concomitant medications 
• Assess MELD scores 
• Obtain blood samples for hematology, hepatic function panel, BMP, and coagulation tests  
• Obtain biospecimens for specimen banking and measuring anakinra trough levels as outlined in 
Table 1. 
• The participant should be reminded that fasting (8 hours) is requested, when possible, prior to 
his/her next visit. 
• Assess medication compliance form 
7.2.4 D7 Procedures (± 2 days) – Fasting for at least 8 hours, when possible  
• Perform a physical examination 
• Record vital signs, including weight 
• Assess and record any emergent AEs 
• Record any changes to concomitant medications 
• Assess MELD and Lille scores. 
• Obtain blood samples for hematology, hepatic function panel, BMP, and coagulation tests 
• Obtain biospecimens for specimen banking and measuring anakinra trough levels as outlined in 
Table 1. 
• The participant should be reminded that fasting (8 hours) is requested, when possible, prior to 
his/her next visit. 
• Assess medication compliance. 
• Calculate Lille score. If >0.45, participant should stop the bottle Prednisone/placebo. 
• Dispense study medication if required by safety lab results (outpatient only.) 
7.2.5 Day 14 procedures (± 2 days) -– Fasting for at least 8 hours, when possible  
• Collect medical history including the alcohol consumption specifics 
• Perform a physical examination, including a urine pregnancy test 
• Record vital signs, including weight 
• Assess and record any emergent AEs 
• Record any changes to concomitant medications 
• Assess MELD scores 
• Obtain blood samples for hematology, hepatic function panel, BMP, and coagulation tests. 


56 
 
• Obtain biospecimens for specimen banking and measuring anakinra trough levels as outlined in 
Table 1. 
• The participant should be reminded that fasting (8 hours) is requested, when possible, prior to 
his/her next visit. 
• Assess medication compliance. 
7.2.6 D28, D60 and D 90 Procedures (± 7 days) -– Fasting for at least 8 hours, when possible 
 
• Collect medical history including the alcohol consumption specifics 
• Perform a physical examination 
• Record vital signs, including weight 
• The participant is to complete the Alcohol Timeline Follow back 
• Assess and record any emergent AEs 
• Record any changes to concomitant medications 
• Assess MELD scores. 
• Obtain blood samples for hematology, hepatic function panel, BMP, and coagulation tests. 
• Obtain biospecimens for specimen banking as outlined in Table 1. 
• The participant should be reminded that fasting (8 hours) is requested, if possible, prior to 
his/her next visit. 
• Assess medication compliance 
7.2.7 Follow up phase D180 (± 7 days) – Fasting for at least 8 hours, when possible  
 
• Collect medical history including the alcohol consumption specifics 
• Perform a physical examination 
• Record vital signs, including weight 
• The participant is to complete the Alcohol Timeline Follow back 
• Assess and record any emergent AEs 
• Record any changes to concomitant medications 
• Assess Liver Scores: MELD 
• Obtain blood samples for hematology, hepatic function panel, BMP, and coagulation tests. 
• Obtain biospecimens for specimen banking as outlined in Table 1.  


60 
 
7.2.8 Missed Visits 
Participants who miss a visit will receive a phone call from the coordinator who will read and collect 
information from the phone script. If a person is unable to be reached by phone, a medical record 
review will take place. 
 
7.2.9 Early Termination Procedures 
Participants who withdraw consent or discontinue treatment prematurely during the Treatment 
Phase should complete the assessments required on Day 60, if patient is willing. Participants who 
discontinue prematurely during the Follow-up Phase should complete the assessments required on 
Day 180. 
 
7.2.10 Unscheduled Safety Visits 
The investigator may schedule an at-clinic Unscheduled/Safety Visit at any time if clinically warranted. 
Unscheduled and/or repeat assessments may be conducted. As appropriate, the designated study 
physician should be contacted. 
 
7.2.11 Specimen Banking 
Specimens to be banked include genomic DNA, blood mononuclear cells, blood (PBMC, serum and 
plasma), saliva (only until an adequate number of samples are collected determined by PIs), stool 
(when possible), urine, and liver biopsy when available.  
 Type specimen collection is site specific.


61 
 
8. 
EFFICACY EVALUATIONS Primary Endpoint Survival at 90 days Secondary Endpoints 
• Change in Lille score, change in MELD score, development of AKI, multi-organ failure, SIRS, 
transfer to ICU, changes in liver function will all be evaluated at 7, 30 and 90 days. 
 
• Organ dysfunction: We will measure changes in Sequential Organ Failure Assessment (SOFA) 
scores and proportions requiring hemodynamic support for MAP < 65 mm Hg and lactate > 2 
mmol/l, renal replacement therapy or mechanical ventilation. We will also modify and re-evaluate 
the SOFA score without platelet counts given that these are usually low in AH. 
 
• Infections and Sepsis: It is now recognized that the endpoints and case definitions related to 
sepsis may vary depending on what these will be used for (clinical care, research, surveillance, or 
quality improvement). Given the central role of sepsis as a driver of outcomes, we will not only 
measure the types of infection but also identify the proportions of those with sepsis, septic shock 
or quick-SOFA (qSOFA) criteria based on SEPSIS-3 guidance2,39. We will also capture the key 
parameters needed for various sepsis related endpoint construction aligned by the recent 
guidance from the European Drug Development Hub (http://eddh-cro.wixsite.com/fdtsfv). 
 
• Renal dysfunction: In alignment with guidance from the acute disease quality initiative56, we will 
quantify AKI development and its progression through persistent AKI, acute kidney disease to 
chronic kidney disease. 
• Need for care escalation: Proportion of participants requiring transfer to ICU for care 
• Indicators of gut permeability (endotoxin and bacterial 18S DNA) and pro- inflammatory 
cytokine/chemokines (TNFa, MCP1, IL-6, IL-1ß) will be assessed in serum/plasma samples. 
• Survival at day 30 and 180. 
Limitations of mortality as an endpoint in AH and plans to overcome these 
All-cause mortality is most relevant when mortality is substantial and attributable to a single 
mechanism in a homogeneous population. Participants with severe AH are highly heterogeneous 
with respect to disease severity, end organ involvement and the care they receive. Moreover, as in 
sepsis and heart failure, death involves failure of multiple organs (liver, heart, kidney, lungs) making 
it hard to ascertain which one is the primary cause of death. This has led to development and 
regulatory acceptance of composite endpoints including mortality and key parameters driving 
mortality for acute heart failure trials. We will leverage these guiding principles to construct a novel 
and innovative key secondary composite endpoint which will include death or worsening of the 
SOFA score4,5 by ≥ 2 points and worsening of modified MELD score by ≥ 2 points. These are 
associated with mortality and capture the organ recruitment that marks progression of AH towards 
death. This endpoint will also be validated with respect to reliability, construct-, criterion- and 
content validity to establish this as a primary endpoint in future trials. We will also model changes in 
SOFA scores and MELD scores against mortality to further optimize this endpoint and cross- 
validate it in the observation cohort. 
 


62 
 
9. 
SAFETY EVALUATIONS 
9.1 
Adverse Events 
Adverse event (AE) data will be collected from Day 0 through the double-blind phase, until the 
participant fully completes her/his trial participation at the Follow Up visit. 
 
9.2 
Physical Examination and Vital Signs 
To assess for clinical findings, the investigator or designee will perform a physical examination at the 
time points specified in the Schedule of Trial Procedures (Table 1). All above physical exams may be 
extracted from medical records if patient is inpatient. This includes height only at Screening. The 
physical examination must include the following: 
 
9.2.1 Physical Examination 
• General appearance 
• Weight 
• Eyes 
• Ears, nose, and throat 
• Neck 
• Respiratory system 
• Cardiovascular system 
• Abdominal region 
• Mental status 
• Neurological system 
9.2.2 Vital signs 
The following vital signs will be assessed at indicated visits: body temperature, sitting heart rate, sitting 
blood pressure (BP), respiratory rate, body weight in kilograms without shoes, and height in 
centimeters (screening only). When taking heart rate and BP readings, participants should be seated 
quietly for a minimum of 3 minutes before the reading is taken. 
 
9.3 
Clinical Laboratory 
Blood samples for serum chemistry, hematology, and coagulation will be collected at every visit as 
detailed in the Schedule of Trial Procedures. The number and volume of samples to be collected at 
each visit will be detailed in a separate document. These tests will be conducted at local laboratories 
at 8 participating sites. 
 
All participants with laboratory tests containing clinically significant abnormal values should be 
followed regularly until the values return to normal ranges, until a valid reason for the AE (other 
than study medication related AE) is identified, or until further follow up is deemed medically 
unnecessary. 
 


63 
 
9.4 
Other Safety Related Clinical Outcomes 
The following clinical outcomes will be assessed: 
 
• Death (from hepatic and non-hepatic related causes) 
• Complications of portal hypertension including gastroesophageal bleeding, interventions to 
manage variceal bleeding (e.g., variceal banding/sclerotherapy or TIPS placement) and diuretic 
resistant ascites 
• Complications of Cirrhosis: new-onset ascites, hepatic encephalopathy, hepatorenal 
syndrome (type I or II), and spontaneous bacterial peritonitis). 
• Hospitalization 
• Change to a higher level of care (i.e., floor to ICU) is an SAE 
Each of these events including hospitalizations will be adjudicated by the site investigator as 
expected as part of the natural history of severe AH, or unexpected (e.g., suicide, motor vehicle 
accident, or myocardial infarction).


64 
 
10. 
ADVERSE EVENTS 
10.1 
Definition of Adverse Events & Reporting Period for Adverse Events 
Safety will be assessed in terms of AEs. All AEs, whether observed by the investigator, reported by 
the participant, noted from laboratory findings, or identified by other means, will be recorded from 
Day 0 until the participant completes trial participation (D-180). 
 
AEs are defined as any untoward medical occurrence associated with the use of the study 
medication in humans, whether or not considered related to study medication. An AE (also referred 
to as an adverse experience) can be any unfavorable and unintended sign (e.g., an abnormal 
laboratory finding), symptom, or disease temporally associated with any use of the study medication, 
without any judgment about causality and irrespective of route of administration, formulation, or 
dose, including an overdose. For this trial, study medication refers to Anakinra, zinc, Prednisone, or 
placebo in the double-blind phase. 
 
AEs include but are not limited to: (1) a worsening or change in nature, severity, or frequency of 
condition(s) present at the start of the trial; (2) participant deterioration due to primary illness; (3) 
intercurrent illness; and (4) drug interaction. 
 
Participants should be questioned in a general way, without leading the participant or asking about the 
occurrence of any specific symptom. The investigator should attempt to establish a diagnosis of the 
event based on signs, symptoms, and/or other clinical information. The diagnosis and not the 
individual signs/symptoms should be documented as the AE. For example, if the underlying disease 
process is a stroke, it would not be appropriate to record the AE by describing the symptoms 
“sudden numbness, dizziness, and difficulty speaking.” The AE medical term of “stroke or 
cerebrovascular accident” should be recorded as it more accurately describes the AE. Following 
questioning and evaluation, all AEs, whether believed by the investigator to be related or unrelated 
to the study medication, must be documented in the participant’s medical records, in accordance with 
the investigator’s normal clinical practice and on the AE source Document. Each AE is to be 
evaluated for duration, intensity, frequency, seriousness, outcome, other actions taken, and 
relationship to the study medication. 
 
10.1.1.1 Pretreatment Event(s) 
Untoward events that occur during screening phase (prior to randomization) should be recorded as 
medical history. 
10.1.2 Severity of AEs 
AEs must be graded for severity (i.e., intensity). A severity category of mild, moderate, or severe, as 
defined in Table 2, must be entered on the AE source document. It should be noted that the term 
“severe” used to grade intensity is not synonymous with the term “serious.” For example, severe 
headache is a severe AE, but may not be a serious AE. The assessment of severity is made 
regardless of study medication relationship or of the seriousness of the AE. 
 
 


65 
 
Table 2: Clinical Description of Adverse Event Severity 
 
Grade 
Clinical Description of Severity 
1 = Mild 
Causing no limitation of usual activities; the participant may experience 
slight discomfort. 
2 = 
Moderate 
Causing some limitation of usual activities; the participant may experience 
annoying discomfort. 
3 = 
Severe 
Causing inability to carry out usual activities; the participant may 
experience intolerable discomfort or pain. 
 
10.1.3 Relationship of AEs to Study Medication 
The investigator will document her/his opinion of the relationship of the AE to treatment with study 
medication using the criteria outlined in Table 3 An AE for which there is a ‘reasonable possibility’ 
that the study medication caused the AE is otherwise referred to as suspected adverse reaction 
(SAR). ‘Reasonable possibility’ means there is evidence to suggest a causal relationship between the 
study medication and the AE. 
Table 3. Relationship of AEs to Study Medication 
 
Relationship Description 
Definite 
A reaction that follows a reasonable temporal sequence from administration of the 
drug or in which the study medication level has been established in body fluids or 
tissue; that follows a known or expected response pattern to the suspected drug; and 
that is confirmed by improvement on stopping or reducing the dosage of the study 
medication, and reappearance of the reaction on repeated exposure. 
Probable 
A reaction that follows a reasonable temporal sequence from administration of the 
study medication; that follows a known or expected response pattern to the suspected 
study medication; that is confirmed by stopping or reducing the dosage of the study 
medication; and that could not be reasonably explained by other factors. 
Possible 
A reaction that follows a reasonable temporal sequence from administration of the 
study medication; that follows a known or expected response pattern to the suspected 
study medication; but that could readily be produced by a number of other factors. 
Unlikely 
A reaction that does not follow a reasonable temporal sequence from administration 
of the study medication; that does not follow a known or suspected response pattern 
to the suspected study medication; and that could reasonably be explained by known 
characteristics of the participant’s clinical state. 
Not Related 
Any event that does not meet the above criteria. 


66 
 
10.2 Serious Adverse Events 
10.2.1 Definition of a Serious Adverse Event 
An adverse event or suspected adverse reaction is considered ‘serious’ if, in the view of the 
investigator, it results in any of the following outcomes: 
 
(a) Death; 
(b) Is life threatening; 
(c) Results in persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions; 
(d) A congenital anomaly/birth defect; 
(e) Requires in-participant hospitalization or prolongs an existing hospitalization; 
(f) An important medical event that may jeopardize the participant or participant and may require 
medical or surgical intervention to prevent one of the outcomes listed above. 
10.2.2 Serious Adverse Events (SAE) Classifications Common in Severe AH 
Acute kidney injury: 
• Increase in creatinine of 50% above baseline over a period of 7 days 
• Increase in creatinine of 0.3 mg/dl within a period of 48 hrs. 
• Onset of renal failure requiring dialysis 
Sepsis: 
• Life-threatening organ dysfunction caused by a dysregulated host response to infection 
• An increase in SOFA score of 2 points of more 
• Note: most participants with severe AH have 4 points based on bilirubin only 
Infection: 
• Pneumonia defined as new infiltrate by CXR or Chest CT scan not explained by “fluid overload” 
• Positive blood cultures for bacteria or fungus, not suspected as contaminant 
• Positive urine fungal culture > 50,000 colonies/ml 
• Positive urine bacterial culture > 100,000 colonies/ml (mixed flora is excluded) 
• Soft tissue or bone infections including cellulitis or abscess documented by exam or scan 
• CNS infection defined as positive culture of CSF or > 5 WBC/ml 
• Ascitic fluid white cell count >500/ml or neutrophils>250/ml. with or without positive bacterial 
or fungal cultures 
 
Decompensation of liver disease: 
• New onset of ascites if not present on admission to study 
• New onset of variceal hemorrhage 
• New onset of hepatic encephalopathy (HE). 


67 
 
Hepatic failure defined as increase in MELD score ≥ 5 on two consecutive occasions 
 
Cerebral failure defined as worsening HE ≥ Grade 3 if hepatic encephalopathy present on admission 
 
Renal failure defined as serum creatinine ≥3 milligrams per liter or requirement for renal replacement therapy 
despite adequate volume replacement 
 
Respiratory failure defined as need for BIPAP therapy or ventilation 
 
Circulatory failure defined as shock or requirement of vasopressor support to maintain mean arterial pressure ≥ 
60 mm Hg despite adequate volume replacement 
 
Multiple organ failure defined as failure ≥2 organs 
 
Note: Sepsis will often be an SAE that precedes documented infection by 1-5 days. If sepsis is 
reported as an SAE and infection is never documented, then it should be classified separately, 
i.e., sepsis with documented infection or sepsis without documented infection. 
 
Sepsis can be diagnosed by minor changes in lab parameters such as decrease in platelet count from 
160,000 to 90,000 or increase in creatinine to 1.3 and drop in platelet count to 100-150,000 from 
normal on admission. However, these changes may also occur due to worsening liver disease 
without infection as a cause. 
 


68 
 
10.2.3 Reporting SAEs 
In agreeing to the provisions of this protocol, the investigator accepts all legal responsibilities for 
immediate reporting of SAEs to the study designated physician (Dr. Gawrieh or his designee) as 
described below. 
Table 4: Requirements for Reporting AEs to Various Stakeholders 
 
 
WIRB and 
Local IRB 
 
NIAAA 
 
DSMB 
 
Other 
centers 
 
Drug 
Company 
FDA 
AEs 
 
Continuing 
Review 
 
Annual 
Report 
 
Every 6 
months 
DSMB 
reports (every 
6 months) 
DSMB 
reports (every 
6 months) 
Annual 
Report 
TEAEs 
 
Continuing 
Review 
 
Annual 
Report 
 
Every 6 
months 
DSMB 
reports (every 
6 months) 
DSMB 
reports (every 
6 months) 
Annual 
Report 
SAEs 
Continuing 
Review 
2 
working 
days 
Every 6 
months 
DSMB 
reports (every 
6 months) 
DSMB 
reports (every 
6 months) 
Annual 
Report 
SUSAR 
5 days 
2 
working 
days 
2 
working 
days 
2 working 
days 
2 working 
days 
7 days if 
death  
15 days if 
other 
Fatality 
If unrelated Follow SAE timeline  
If related follow SUSAR timeline 
AE: Adverse Event; TEAS: Treatment Emergent Adverse Event; SAE: Serious Adverse Event; 
SUSAR: Serious Unsuspected Adverse Reaction; DSMB: Data and Safety Monitoring Board 
 
The study designated physician for AlcHepNet - 02 is Samer Gawrieh, MD, who as the IND holder 
will assume the responsibility of monitoring safety concerns internally and serve as the liaison 
between the AlcHepNet and the DSMB. 
 
All SAEs must be reported to the DCC-IU (i.e., within 2 working days) after the investigator 
identifies the SAE. SAEs should be entered into the REDCap system within 2 working days of the 
investigator becoming aware of the event. An initial report by telephone should then be followed, as 
soon as possible, by completion of the SAE CRF. Any supporting source documentation should be 
emailed to the assigned contact information as soon as possible. At a minimum the following 
information should be provided at the time of the initial report: 5-digit Study ID, a description of 
the event, at least one criterion classifying the event as Serious and the name and title of the 
reporting individual. Additionally, judgment of causality by the investigator must be provided as 
soon as possible to ensure timely reporting to regulatory authorities. 
 


69 
 
Following the initial report, any additional information obtained by the investigator about the SAE 
must be reported promptly to the DCC-IU. 
The site investigator will assess whether the event is causally related to the study medication. The 
study designated physician (Dr. Gawrieh) will consider the investigator’s assessment, however, since 
Dr. Gawrieh holds the IND and is primarily responsible for the overall safety of the participants, his 
causality assessment will take precedence over that of the site investigator. The study designated 
physician will determine if an SAE meets the criteria for an IND safety report (suspected, 
unexpected serious adverse reaction (SUSAR) in accordance with the FDA regulations, 
312.32(c)(1)(i). 
 
We will monitor safety closely, including all SAEs, AKI, and infection. We will provide unblinded 
data on SAEs including infections and AKI to the DSMB on monthly basis and hold the first 
DSMB after 3 months from the start of enrollment. We also propose a risk-based monitoring 
(RBM) approach which will create a more efficient and timely monitoring of accumulating data on 
the adverse events of interest, namely AKI and infections. The FDA has issued a final guidance in 
2013 (Guidance for Industry. Oversight of Clinical Investigations — A Risk-Based Approach to 
Monitoring. August 2013) with a follow-up draft guidance in March 2019 (A Risk-Based Approach 
to Monitoring of Clinical Investigations. Questions and Answers. Guidance for Industry) that 
indicated the acceptability of RBM in studies with FDA oversight. While the details and 
implementation are left to the trial investigators, the overall concepts are included in these two 
documents – and in the Transcelerate RBM Position Paper (available at 
https://www.transceleratebiopharmainc.com/wp-content/uploads/2013/10/TransCelerate-RBM- 
Position-Paper-FINAL-30MAY2013.pdf). The essential elements of the study-specific AE/SAE 
monitoring plan would be for the RBM tools to interface with the main REDCap database so that 
any new AEs or SAEs would be immediately passed to the data driven RBM tools to determine if a 
trigger threshold has been reached. This interaction between receipt of data by REDCap and the 
comparison of the data to the triggers (and reporting of it on study dashboards) by the RBM tools 
will be virtually instantaneous. In addition, levels of thresholds can be set so that data trends of 
SAEs accumulating within treatment groups can be identified before significance is reached. A 
complete monitoring plan, including RBM details, will be developed for review by the FDA 
and the DSMB within three months of study initiation. We will also include Statistical Process 
Control (SPC) techniques in the monitoring plan to ensure that appropriate statistical controls are 
also utilized during the study. 
 
10.2.3.1 Additional Principal Investigator Responsibilities for SAEs 
The safety data recorded in the source document represent the official record of all AEs and SAEs 
reported in the trial. The investigator should comply with requests by the designated study physician 
to record the SAE on the participant’s AE source document and, if necessary, provide a copy of this 
source document to the DCC-IU. Other supporting documents such as radiology reports, hospital 
discharge summaries and autopsy reports should also be provided, when appropriate, in anonymized 
fashion. Additionally, upon request by the designated study physician, the investigator should provide 
input into the SAE narrative and provide timely information to ensure prompt follow up and 
closure of the SAE report. 
 
The investigator and supporting personnel responsible for participant care should discuss with the 
designated study physician any need for supplemental investigations of SAE(s). The results of these 
additional assessments must be reported to the designated study physician. 
 
10.3 
SAEs that are Anticipated to Occur in the Study Population (Expected SAEs) 
Certain SAEs are anticipated to occur in this study population at some frequency independent of 


70 
 
drug exposure. Examples of these expected SAEs include variceal bleeding, ascites, spontaneous 
bacterial peritonitis, jaundice, hepatorenal syndrome, or hepatic encephalopathy. These expected 
SAEs as well as any related hospitalization will not be expeditiously reported as IND safety reports 
but will be reported in the manner described above (Table 4.). However, if an aggregate analysis 
indicates that these events are occurring more frequently in the drug treatment group than in a 
concurrent or historical control group, the SAEs will be reported as an IND safety report (21 CRF 
312.32(c)(1)(c)). Follow up of AEs 
All AEs, including clinically significant laboratory values or physical examination findings relative to 
pretreatment assessments, must be followed during the trial until the AE resolves, is no longer of 
clinical concern, has stabilized or is otherwise explained, or the participant is lost to follow up. 
 
AEs ongoing at the final visit that are deemed to be ‘possibly, probably, or definitely” related or of 
other clinical significance must be followed for as long as necessary to adequately evaluate the safety 
of the participant or until the event stabilizes, resolves, or is no longer of clinical concern. If 
resolved, a resolution date for the AE should be documented on the CRF. The investigator must 
ensure that follow up includes any supplemental investigations indicated to elucidate the nature 
and/or causality of the AE. This may include additional laboratory tests or investigations, or 
consultation with other healthcare professionals, as considered clinically appropriate by the 
investigator. 
 
Note: Some SAEs like AKI, GI bleeding, infections, etc. can be both expected and common


71 
 
11. STATISTICAL METHODS 
11.1 
Analysis Sets 
The primary analyses of 90-day mortality will be performed in an Intention-to-Treat (ITT) 
framework using survival analysis. Specifically, 
 
(1) we will use all-cause mortality in the first 90-days as the primary outcome event of interest. We 
will compare the distributions of time to mortality between the two treatment arms. In the 
primary analysis, mortality event times greater than 90 days will be censored at the 90 days or at 
the time of liver transplant, whichever comes first. We will use the Logrank test to compare the 
survival functions of the two treatment groups. Cox regression analysis can be performed if it is 
necessary to control for the influences of unbalanced patient characteristics, such as MELD 
score, between the treatment groups. If evidence suggests a violation of the hazard function 
proportionality, we will conduct an analysis of the restricted mean survival time (RMST) of the 
first 90 days. 
(2) as a secondary analysis, we will compare transplant-free survival in the first 90 days of treatment 
initiation as between the two treatment arms, as done in other clinical trials. We will perform 
logrank test, Cox regression model, and RMST analyses as appropriate. 
(3) we plan to conduct one interim analysis and one final analysis for this trial. The interim analysis 
will be conducted when 129 patients, half of the enrollment number, complete the 90-day 
follow-up. We use the group sequential method to control the type 1 error rate of the trial. 
(4)  as another secondary analysis, we will examine the treatment effects in patients with baseline 
MELD scores ≤25 and >25 by assessing the equality of treatment effects of the anakinra in high 
and low MELD groups, we will test the interaction between the intervention indicator and 
baseline MELD score in the Cox regression model.  
 
Complete details of the proposed statistical analyses, including a single interim analysis, can be 
found in the Revised Statistical Analysis Plan (SAP). 
 
11.2 
Determination of Sample Size 
The primary analysis will be comparisons of 90-day mortality of Anakinra plus zinc vs Prednisone 
using survival analysis. Mortality event times greater than 90 days will be censored at 90 days or at 
time of liver transplant, whichever comes first. The experiment-wise significance level will be 5%. 
The most recent data from the AlcHepNet consortium suggest a 90-day mortality rate for 
prednisone is approximately 20%. We estimate that with a total of 258 participants (129 per 
treatment arm), we will be able to detect a clinically significant hazards ratio of 0.325, which 
translates to a 13% reduction in 90-day mortality, i.e., 80% survival in prednisone vs 93% in 
anakinra plus zinc groups with 85% power by using two-sided logrank tests. We use O’Brien and 
Fleming α-spending function to determine the efficacy stopping boundaries for the sequential tests. 
Specifically, if the test statistics of the log-rank test is greater than 2.963 or less than -2.963, we will 
claim a significant difference between the two treatments and stop the trial. Otherwise, we will 
continue enrolling more patients until the full sample size is reached and then the final analysis will 
be performed. For the final analysis, if the test statistic value is greater than 1.969 or less than -1.969, 
we will claim a significant difference between the treatments. Otherwise, we will declare that no 
statistically significant difference is detected. 
 
Besides the group sequential tests, we have in place an early stopping rule for futility based on 
conditional power. At the time of interim analysis, we will calculate the conditional power, i.e., the 
probability of claiming difference at the end of the trial given the data at the interim analysis. We will 
stop the trial for futility when the conditional power is less than 0.1. In other words, based on data 
that become available at the interim analysis, assuming that the current trend continues, we should 
early stop the trial if the probability of declaring anakinra + zinc superior in the final analysis is low 


72 
 
(e.g., less than 10%). We use this early stopping rule to limit patient exposure to a potentially 
inefficacious treatment. 
 
11.3 
Safety Analysis 
Descriptive statistics will be used to summarize safety data to allow a comparison between groups. 
Safety data, including AEs, clinical and laboratory observations and physical examination findings, and 
other safety related outcomes will be summarized by treatment group. 
11.3.1 AEs 
AEs will be labeled according to standard medical terminology using the case report forms provided. 
Summary tables of treatment-emergent AEs will be provided. A TEAE is any AE that newly 
appeared, increased in frequency, or worsened in severity following initiation of study medication. 
The incidence of TEAEs will be tabulated by system organ class and preferred term for each 
treatment group, and by severity and relationship to treatment. Tables of TEAEs leading to study 
medication discontinuation and SAEs will be provided. 
 
11.3.2 Clinical Laboratory Evaluations 
Descriptive statistics summarizing central laboratory data (hematology, chemistry, and coagulation) 
will be presented for all trial visits. Changes from pretreatment to each trial visit will also be 
summarized by treatment group/arm. 
 
a. The primary analyses of 90-day mortality will be carried out in an ITT framework using the 
logrank test or Cox regression. Time-to-death will be censored at 90 days or at liver transplant, 
whichever comes first. In addition to the logrank test, we will perform Cox regression analyses. 
The models will include baseline MELD score as well as other covariates deemed to be 
unbalanced or to effect survival. Tests will be performed at a two-sided nominal significance level 
of 5%. If the proportional hazard assumption is not met, we will compare the restricted mean 
survival time at 90 days. 
 
Comparisons of binary survival indicators will be performed as alternative analyses, by using 
either chi-square tests or logistic regression models. In the logistic regression analysis, MELD 
score as well as other covariates deemed to be unbalanced or to effect survival will be included as 
covariates.  
b. We will also compare the transplant-free survival functions of the two treatment groups, at 30, 90 
and 180 days.  
c. We will also secondarily compare the occurrence of events such as sepsis and renal dysfunction 
by using survival analysis (logrank test and Cox regression). 
 
 
Before the groups are compared on these instruments, the baseline data will be examined to look for 
group imbalance among the survivors. Comparisons will be made using linear regression models that 
include baseline MELD score and other relevant and/or unbalanced covariates. 
 
11.3.3 Additional Safety and Clinical Findings 
Additional safety assessments include vital signs, lab results, and physical examinations. Descriptive 
statistics of the vital sign and lab measures will be provided; comparisons between the two treatment 


73 
 
groups will be made using mixed effects models. Changes of these variables from baseline at each 
visit will be analyzed similarly.  
  
 


74 
 
11.3.4 Other Safety Related Clinical Outcomes 
The following clinical outcomes will be assessed: 
 
• Death (from hepatic and non-hepatic related causes) 
• Complications of portal hypertension including gastroesophageal bleeding, interventions to 
manage variceal bleeding (e.g., variceal banding/sclerotherapy or TIPS placement) and diuretic 
resistant ascites 
• Complications of Cirrhosis: new-onset ascites, hepatic encephalopathy, hepatorenal syndrome 
(type I or II), and spontaneous bacterial peritonitis). 
• Hospitalization 
• Liver transplantation 
11.4 
Interim Analyses 
Interim analyses for efficacy or futility to determine if the study may be terminated prior to 
completion will be conducted once after the cohort associated with at least 50% of the participants 
have been in the study for 90 days. Formal efficacy analyses will be based on the Lan-Demets 
version of the O’Brien-Fleming boundary to provide an overall two-sided P = 0.05 test. Futility will 
be assessed based on conditional power.57,58 . For example, termination due to futility may be 
considered if conditional power is very low (e.g. less than 0.10), under the assumption that the 
hypothesized treatment difference is correct. In other words, based on data that become available at 
the interim analysis, assuming that the current trend continues, we should early stop the trial if the 
probability of declaring anakinra + zinc superior in the final analysis is low (e.g., less than 10%). We 
use this early stopping rule to limit patient exposure to a potentially inefficacious treatment. 
The efficacy interim analyses will be performed on unblinded data. Additional data that will be 
included in the interim analyses are: 
 
• Tables of laboratory data by group 
• Tabulated safety data by group 
• Listings of adverse events and serious adverse events by group 
 
11.5 
Handling of Missing Data 
Missing values will not be imputed and only observed values will be used in data analyses and 
presentations. 
 
11.6 
Data and Safety Monitoring Board (DSMB) 
An independent DSMB will be formed to review safety data at periodic intervals from this and all 
other AlcHepNet studies. Members of the DSMB will not be allowed to participate as investigators 
in this trial. 
 
The DSMB will review blinded safety data and unblinded safety data (as necessary in their opinion) 
to ensure the safe and property treatment of participants. The frequency of their standard meetings 
will be according to the agreed upon DSMB charter. In addition, Chair of the DSMB or the 
designated study physician may call for an ad-hoc DSMB if deemed necessary by either party. Based 
on review of these data, the DSMB will send a written report to the designated study physician and to 
the DCC-IU. It is the responsibility of the designated study physician and the DCC-IU to distribute 


75 
 
these reports to all other stakeholders (NIAAA, FDA, and individual sites) 
 
The DSMB will operate under an appropriate charter (in compliance with relevant regulatory 
guidance) that will define its organization and operation. The DSMB will prepare written minutes of 
both its open and closed sessions. The closed minutes will be made available to the investigators only 
after the database is locked and the blind for the trial has been broken. All investigators and 
responsible IRBs will be informed of any decisions made which alter the conduct of this trial based on 
recommendations from the DSMB relating to participant safety. The investigators will inform the 
participants of such actions and the protocol and ICF will be revised, as appropriate. 
 
Changes to the protocol or to the ICS may be initiated by any investigator, but it is the final 
responsibility of the designated study physician as the IND holder to approve/finalize any such 
changes and to communicate to other stakeholder. 


76 
 
12. 
ADMINISTRATIVE AND REGULATORY CONSIDERATIONS 
12.1 
Ethical Conduct of the Trial 
This trial will be conducted in accordance with 21CFR Part 312, Good Clinical Practice 
(CPMP/ICH/135/95), and with the ethical principles laid down in the Declaration of Helsinki and 
applicable regulatory requirements. 
 
12.2 
Institutional Review Board (IRB) 
Western Institutional Review Board (WIRB) will review and approve this study prior to its initiation. 
Amendments can be implemented only following the IRB approval unless the amendment is 
necessary to reduce immediate risk to trial participants. The IRB will be informed of any new safety 
information that negatively affects the risk assessment of the trial as soon as it becomes available. 
Investigators will report various categories of the AEs to the IRB according to the schedule 
described in Table 4. 
 
12.3 
Patient Confidentiality and Data Protection 
All information obtained during the conduct of the trial with respect to the participant will be 
regarded as confidential and confidentiality of all participants will be maintained. Clinical monitors 
(e.g., CRAs), auditors and inspectors will require access to a participant’s medical notes for the 
purpose of source document verification, but the participant’s confidentiality will be maintained at all 
times. An agreement for disclosure of any such information will be obtained in writing and is 
included in the statement of informed consent. The trial data shall not be disclosed to a third party 
(with the exception of auditors and/or regulatory authorities) without the written consent of the 
AlcHepNet consortium. All data shall be secured against unauthorized access. 
 
Apart from the site investigators, no one will have access to participant’s identity. Each site will 
securely maintain the code that links participants’ identity to their study numbers to prevent access to 
unauthorized third parties. Participants will be identified according to their study numbers in the 
data management system (REDCap) and by the investigators during any communications. 
 
The written ICF will explain that, for data verification purposes, authorized representatives of the 
funding agency, IRB or drug companies which are supplying the study medicine may require direct 
access to parts of the hospital or practice records relevant to the trial, including participant’s medical 
history. 
 
 


77 
 
12.4 
Access to Source Documents and Data 
12.4.1 Source documents 
Source documents may include, but are not limited to, medical records, charts, appointment books, 
participant questionnaires, original laboratory records, equipment print-outs. All source documents 
must be made available to the CRA. The following data must be included in the source data: 
a) Consent to Participate in Trial 
b) Letter to Primary Care Physician, if applicable 
c) Participants visit dates 
d) Screening and Randomization Numbers 
e) Demographic information 
f) Medical history 
g) Disease history 
h) Physical examination 
i) Vital signs 
j) Laboratory assessments (copy of laboratory reports) 
k) AEs and concomitant medications 
l) Dates of dispensing study medication 
m) ECGs 
n) Liver biopsy reports (if applicable) 
o) Participant questionnaires 
p) Drug accountability 
q) Issues with protocol compliance 
r) Completion of, or withdrawal from, trial 
 
12.5 
Investigator Obligations 
The investigator or a medically trained designee will be responsible for obtaining written informed 
consent and for the care of the participants for the duration of the trial. If the investigator is not 
present in the clinical research facility during the assessment, he or she will leave instructions for the 
trial site staff and a telephone number where he or she can be reached. 
 
12.5.1 AE Reporting 
The investigator is responsible for recording AEs reported by the participant or discovered by any 
other means during the trial. In agreeing to the provisions of this protocol, the investigator accepts all 
legal responsibilities for immediate reporting of SAEs to the designated study physician. 
 
12.5.2 Protocol Deviations 
The investigator is not permitted to deviate from the protocol in any significant way without proper 
notification to the DCC-IU and the study designated physician (Dr. Samer Gawrieh). Changes to the 
protocol or to the informed consent (ICF) may be initiated by any investigator, but it is the final 
responsibility of the designated study physician, Dr. Samer Gawrieh, as the IND holder to 
approve/finalize any such changes and to communicate to other stakeholder Although protocol 
amendments can be initiated by any study personnel, it is the final responsibility of the designated 


78 
 
study physician as the IND holder to approve/finalize any protocol amendments. Any protocol 
amendments can be implemented at each site only after WIRB approval. The only exception is when 
the investigator considers a participant’s safety to be compromised if immediate action is not taken. 
 
12.5.3 Regulatory Documentation 
The following regulatory documentation must be completed or provided, and maintained: 
 
(a) Approved ICF 
(b) IRB approvals (of protocol/amendments, participant questionnaires, etc.) 
(c) Form FDA 1572 equivalent 
(d) Current medical license of the primary site investigator and sub investigators 
(e) Financial disclosure forms 
(f) GCP CITI Certificate 
(g) Delegation of Authority Log 
(h) Protocol Training Log 
(i) Sponsor Master Trial Files 
 
12.6 
Data Quality Assurance and Quality Control 
Logic and consistency checks will be performed on all data entered into the source document to 
ensure accuracy and completeness. 
 
Training sessions, regular monitoring of the trial at the trial sites, instruction manuals, data 
verification, cross-checking and data audits will be performed to ensure quality of all trial data. 
Investigators’ meetings and/or on-site trial initiations will be performed to prepare investigators and 
other trial site personnel for appropriate collection of trial data. 
12.7 
Site monitoring & auditing 
12.7.1 Trial Monitoring 
Trial records at each site will be monitored at regular intervals by a clinical research associate (CRA). 
The role of the CRA is to aid the investigator in the maintenance and documentation of complete, 
accurate, legible, well organized, and easily retrievable data. In addition, the CRA will ensure the 
investigator’s understanding of all applicable regulations concerning the clinical evaluation of the 
study medication and will ensure an understanding of the protocol, reporting responsibilities and the 
validity of the data. This will include ensuring that full and appropriate essential documentation is 
available. Responsibility for properly implementing the protocol and maintaining complete trial 
records remain with each investigator. 
 
In order to perform this role, the CRA must perform source data verification (SDV) and as such 
must be given access to the participant’s primary source documentation (e.g., paper or electronic 
medical records) that support data entries in the CRF. The investigator may exercise judgment in 
allowing the CRA access to particular sections of the participant’s medical records if these are 
deemed irrelevant to the performance, observations or conduct of this trial. 
 
 


79 
 
 
12.7.2 Trial Auditing 
The investigator should understand that it may be necessary for the IRB and / or a regulatory 
agency to conduct one or more site audits during or after the trial and agrees to allow access to all 
trial related documentation and information and be available for discussion about the trial. 
12.8 
Archiving and Record Retention 
The investigator should retain all correspondence relating to this trial in the Investigator Site File 
(ISF). Any trial documents stored elsewhere should have their location referenced in the ISF. 
 
All documents relating to the trial including the ISF itself, source documents and participant medical 
files), completed trial participant log and confidential participant identification list will be retained by 
the investigator for a minimum period of 15 years, in accordance with regulations. In the event that 
storage of records becomes a problem at any time during this period, the Sponsor should be 
consulted for assistance. At the end of the minimum period, the investigator should obtain written 
authorization from the Sponsor prior to the destruction of any records. The investigator will notify 
the Sponsor if ownership of documents or responsibility for the trial site is transferred. The Sponsor 
will inform investigators should it become aware of any changes in storage requirements. 
 
12.9 
Publication Policy 
No data are to be made public or published without prior knowledge and written approval by the 
AlcHepNet Consortium Steering Committee. 
 
The AlcHepNet consortium publication policies will be applied. 


80 
 
LIST OF PLANNED LABORATORY ANALYTES 
 
 
Serum Chemistry 
sodium 
potassium 
calcium 
chloride 
bicarbonate 
albumin 
BUN 
creatinine 
total bilirubin 
unconjugated (indirect) bilirubin 
conjugated (direct) bilirubin 
aspartate aminotransferase (AST; SGOT) 
alanine transaminase (ALT; SGPT) 
alkaline phosphatase (ALP) 
glucose 
total protein 
MELD Score Calculation 
http://www.mayoclinic.org/meld/mayomodel6.html 
Lille Score Calculation 
https://www.mdcalc.com/lille-model-alcoholic-hepatitis 


81 
 
Hematology 
hemoglobin 
hematocrit 
WBC with differential 
 
platelets 
RBC count (incl. MCV, HBE [MCH], MCHC) 
prothrombin time (PT and INR) 
Urine and/or Serum pregnancy test 
 
 
 
The following are the analyses that might be analyzed in the serum/plasma and peripheral blood 
mononuclear cells (PBMC): Cytokines/chemokines, NK cells, Cytotoxic T cells, Dendritic Cells (DC), 
Complement activation. 
 
Table 5: Total Blood Volumes¶ 
 
Sample Blood Volume (ml) 
Sample Type 
Screen 
Day 0 Day 3 Day 7 Day 
14 
Day 28 Day 60 Day 
90 
Day 180 
Total 
Volume 
(ml) 
Chemistry 
5 
5 
5 
5 
5 
5 
5 
5 
5 
40 
Hematology 
3 
3 
3 
3 
3 
3 
3 
3 
3 
24 
Coagulation 
3 
3 
3 
3 
3 
3 
3 
3 
3 
24 
Serum Pregnancy 
3 
 
 
 
 
 
 
 
 
3 
Biospecimen 
Banking1 
60 
 
60 
60 
60 
60 
60 
60 
420 
Total 
14 
71 
11 
71 
71 
71 
71 
71 
71 
522 
 
¶These are estimated volume and may vary from center to center, depending on local laboratory 
requirements. 
Special investigations 
Pro-inflammatory cytokine/chemokines measurements (serum TNF-α, MCP1, IL-6, and IL-1β) 
Indicators of gut permeability (endotoxin and bacterial 18S DNA) and pro-inflammatory 
cytokine/chemokines (TNFa, MCP1, IL-6, IL-1ß) 
EXPLORATORY EVALUATIONS 


82 
 
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