Conditions: Cirrhosis Hepatic Encephalopathy
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 19
Healthy volunteers: no

Brief summary:
This research is studying the use of a new drug to learn about its safety and efficacy as a treatment for hepatic encephalopathy.

Eligible participants will be enrolled and given oral antibiotics followed by 14 days of the study drug (placebo vs.VE303). There will be visits as well as other procedures to collect blood and stool samples, and have tests of your cognition (thinking) for this research study.

The hypothesis is that VE303 will safely and effectively improve cognitive function in patients with a history of overt hepatic encephalopathy.

Detailed description:

Arms:
arm 1: None arm 2: VE303 is a live biotherapeutic product comprising 8 nonpathogenic commensal strains of Clostridia.

Interventions: intervention 1: Placebo intervention 2: VE303 intervention 3: oral vancomycin
Intervention descriptions: intervention 1: Starting the last day of oral vancomycin (Day 1), subjects randomized to this arm will take 5 capsules of placebo for 14 days taken once daily. intervention 2: Starting the last day of oral vancomycin (Day 1), subjects randomized to this arm will take 5 capsules of VE303 taken daily for 14 days.

The quantity of each strain is proportioned to assure a specific per-strain per-capsule titer. The 8 strains are blended together with a micro-crystalline cellulose flow agent and placed in enteric capsules. intervention 3: All enrolled subjects will receive 5 days of oral vancomycin 125 mg four times a day (q.i.d).

Protocol document:
Prot_SAP_000.pdf: 
Study Title: VE303 for Treatment of Hepatic Encephalopathy (HE)
PI: Patricia Pringle Bloom, MD
NCT: NCT04899115
Document Approval Date: 2/16/2023


A Randomized Controlled Trial of VE303 to Treat Hepatic 
Encephalopathy 
VE303 for Treatment of HE 
Protocol Number: HUM00194437 
IND Number: IND27324 
National Clinical Trial (NCT) Identified Number: NCT 04899115 
Principal Investigator: Patricia Pringle Bloom MD 
IND Holder: Patricia Pringle Bloom MD 
Funded by: ACG Junior Faculty Development Award 
And AASLD Advanced Hepatology Fellowship Award 
Vedanta Biosciences Inc 
University of Michigan 
Version Number: V6 
 November 14, 2022 


NIH-FDA Clinical Trial Protocol Template – v1.0 7 Apr 2017 
ii 
 
Table of Contents 
STATEMENT OF COMPLIANCE ............................................................................................................................. 1 
1 
PROTOCOL SUMMARY ............................................................................................................................... 1 
1.1 
Synopsis ................................................................................................................................................ 1 
1.2 
Schema ................................................................................................................................................. 2 
1.3 
Schedule of Activities (SoA) ............................................................................................................... 3 
2 
INTRODUCTION ............................................................................................................................................ 4 
2.1 
Study Rationale .................................................................................................................................... 4 
2.2 
Background........................................................................................................................................... 4 
2.3 
Risk/Benefit Assessment .................................................................................................................... 5 
2.3.1 
Known Potential Risks ..................................................................................................... 5 
2.3.2 
Known Potential Benefits ................................................................................................ 6 
2.3.3 
Assessment of Potential Risks and Benefits ................................................................ 6 
3 
OBJECTIVES AND ENDPOINTS ................................................................................................................ 6 
4 
STUDY DESIGN ............................................................................................................................................. 8 
4.1 
Overall Design ...................................................................................................................................... 8 
4.2 
Scientific Rationale for Study Design ................................................................................................ 9 
4.3 
Justification for Dose ........................................................................................................................... 9 
4.4 
End of Study Definition ..................................................................................................................... 10 
5 
STUDY POPULATION ................................................................................................................................ 10 
5.1 
Inclusion Criteria ................................................................................................................................ 10 
5.2 
Exclusion Criteria ............................................................................................................................... 10 
5.3 
Lifestyle Considerations .................................................................................................................... 11 
5.4 
Screen Failures .................................................................................................................................. 11 
5.5 
Strategies for Recruitment and Retention ...................................................................................... 12 
6 
STUDY INTERVENTION ............................................................................................................................ 12 
6.1 
Study Intervention(s) Administration ............................................................................................... 12 
6.1.1 
Study Intervention Description ..................................................................................... 12 
6.1.2 
Dosing and Administration ............................................................................................ 12 
6.2 
Preparation/Handling/Storage/Accountability ................................................................................ 13 
6.2.1 
Acquisition and accountability ...................................................................................... 13 
6.2.2 
Formulation, Appearance, Packaging, and Labeling ................................................ 13 
6.2.3 
Product Storage and Stability ....................................................................................... 13 
6.2.4 
Preparation ...................................................................................................................... 14 
6.3 
Measures to Minimize Bias: Randomization and Blinding ........................................................... 14 
6.4 
Study Intervention Compliance ........................................................................................................ 14 
6.5 
Concomitant Therapy ........................................................................................................................ 15 
6.5.1 
Rescue Medicine ............................................................................................................ 15 
7 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL .................................................................................................................... 16 
7.1 
Discontinuation of Study Intervention ............................................................................................. 16 
7.2 
Participant Discontinuation/Withdrawal from the Study ............................................................... 17 
7.3 
Lost to Follow-Up ............................................................................................................................... 17 
8 
STUDY ASSESSMENTS AND PROCEDURES ...................................................................................... 18 
8.1 
Efficacy Assessments ....................................................................................................................... 18 
8.2 
Safety and Other Assessments ....................................................................................................... 19 
8.3 
Adverse Events and Serious Adverse Events ............................................................................... 20 


NIH-FDA Clinical Trial Protocol Template – v1.0 7 Apr 2017 
iii 
 
8.3.1 
Definition of Adverse Events (AE) ............................................................................... 20 
8.3.2 
Definition of Serious Adverse Events (SAE) .............................................................. 21 
8.3.3 
Classification of an Adverse Event .............................................................................. 21 
8.3.4 
Time Period and Frequency for Event Assessment and Follow-Up ....................... 22 
8.3.5 
Adverse Event Reporting .............................................................................................. 23 
8.3.6 
Serious Adverse Event Reporting ............................................................................... 23 
8.3.7 
Reporting Events to Participants ................................................................................. 23 
8.3.8 
Events of Special Interest ............................................................................................. 24 
8.3.9 
Reporting of Pregnancy ................................................................................................ 24 
8.4 
Unanticipated Problems .................................................................................................................... 24 
8.4.1 
Definition of Unanticipated Problems (UP) ................................................................. 24 
8.4.2 
Unanticipated Problem Reporting ................................................................................ 24 
8.4.3 
Reporting Unanticipated Problems to Participants ................................................... 25 
9 
STATISTICAL CONSIDERATIONS ........................................................................................................... 25 
9.1 
Statistical Hypotheses ....................................................................................................................... 25 
9.2 
Sample Size Determination .............................................................................................................. 26 
9.3 
Populations for Analyses .................................................................................................................. 26 
9.4 
Statistical Analyses............................................................................................................................ 26 
9.4.1 
General Approach .......................................................................................................... 26 
9.4.2 
Analysis of the Primary Efficacy Endpoint(s) ............................................................. 26 
9.4.3 
Analysis of the Secondary Endpoint(s) ....................................................................... 26 
9.4.4 
Safety Analyses .............................................................................................................. 27 
9.4.5 
Baseline Descriptive Statistics ..................................................................................... 27 
9.4.6 
Planned Interim Analyses ............................................................................................. 27 
9.4.7 
Sub-Group Analyses ..................................................................................................... 27 
9.4.8 
Tabulation of Individual participant Data .................................................................... 27 
9.4.9 
Exploratory Analyses ..................................................................................................... 27 
10 
SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS............................... 27 
10.1 
Regulatory, Ethical, and Study Oversight Considerations ........................................................... 27 
10.1.1 
Informed Consent Process ........................................................................................... 27 
10.1.2 
Study Discontinuation and Closure ............................................................................. 28 
10.1.3 
Confidentiality and Privacy ........................................................................................... 29 
10.1.4 
Future Use of Stored Specimens and Data ............................................................... 29 
10.1.5 
Key Roles and Study Governance .............................................................................. 30 
10.1.6 
Safety Oversight ............................................................................................................. 30 
10.1.7 
Clinical Monitoring .......................................................................................................... 30 
10.1.8 
Quality Assurance and Quality Control ....................................................................... 31 
10.1.9 
Data Handling and Record Keeping ............................................................................ 31 
10.1.10 
Protocol Deviations ........................................................................................................ 32 
10.1.11 
Publication and Data Sharing Policy ........................................................................... 32 
10.1.12 
Conflict of Interest Policy .............................................................................................. 32 
10.2 
Additional Considerations ................................................................................................................. 32 
10.3 
Abbreviations ...................................................................................................................................... 33 
10.4 
Protocol Amendment History ........................................................................................................... 35 
11 
REFERENCES ............................................................................................................................................. 36 
12 
APPENDIX 1 ................................................................................................................................................. 38 


VE303 to Treat HE 
Protocol number: HUM00194437 
Version 6 
14 November 2022 
1 
 
 
  STATEMENT OF COMPLIANCE 
 
 
The trial will be carried out in accordance with International Conference on Harmonization Good 
Clinical Practice (ICH GCP) and the following: 
 
• 
United States (US) Code of Federal Regulations (CFR) applicable to clinical studies (45 CFR 
Part 46, 21 CFR Part 50, 21 CFR Part 56, 21 CFR Part 312, and/or 21 CFR Part 812) 
 
National Institutes of Health (NIH)-funded investigators and clinical trial site staff who are 
responsible for the conduct, management, or oversight of NIH-funded clinical trials have 
completed Human Subjects Protection and ICH GCP Training. 
 
The protocol, informed consent form(s), recruitment materials, and all participant materials will 
be submitted to the Institutional Review Board (IRB) for review and approval. Approval of both 
the protocol and the consent form must be obtained before any participant is enrolled. Any 
amendment to the protocol will require review and approval by the IRB before the changes are 
implemented to the study. In addition, all changes to the consent form will be IRB-approved; a 
determination will be made regarding whether a new consent needs to be obtained from 
participants who provided consent, using a previously approved consent form. 
 
 
 
 
Title: 
A Randomized Controlled Trial of VE303 to Treat Hepatic Encephalopathy 
Study Description: 
This is a randomized controlled trial of VE303 in patients with a history of 
overt hepatic encephalopathy (OHE). VE303 is a live biotherapeutic 
product comprising 8 nonpathogenic commensal strains of Clostridia. The 
duration of intervention is approximately 18 days and post-intervention 
follow-up is 6 months. This is the first trial to use VE303 for treating this 
condition. Our hypothesis is that VE303 will reduce the number of 
recurrent OHE episodes. A detailed schematic describing all visits and a 
schedule of assessments are in the Schema and Schedule of Activities, 
Sections 1.2 and 1.3, respectively. 
Objectives: 
Primary Objectives: 
Evaluate the safety and tolerability of VE303 in patients with cirrhosis. 
Determine if VE303 improves cognitive function as assessed by 
psychometric HE score (PHES). 
 
Secondary Objectives: 
Determine if VE303 reduces hospitalizations for OHE in the 6 months after 
administration. 
Determine if VE303 changes the microbiome composition in cirrhosis, 
including colonization of VE303 strains. 
Determine if VE303 changes serum and stool biomarkers including short- 
chain fatty acids, bile acids, ammonia, and inflammatory markers. 
1.1 
SYNOPSIS 
1 
PROTOCOL SUMMARY 


VE303 to Treat HE 
Protocol number: HUM00194437 
Version 6 
14 November 2022 
2 
 
 
 
Endpoints: 
Primary Safety Endpoint: Number of serious adverse events up to Week 6 
(4 weeks post VE303). 
 
Primary Efficacy Endpoint: Change in PHES as a measure of cognitive 
function from pre-vancomycin to Week 6 (4 weeks after VE303). 
 
Secondary Endpoints: 
- 
Number of hospitalizations for OHE up to Week 26. 
- 
Adverse events up to Week 26 
- 
Change in patient reported outcomes from pre-vancomycin to 
Week 26 
- 
Time to overt HE 
- 
Change in microbiome composition from pre-vancomycin to Week 
26 
- 
Change in serum and stool biomarkers from pre-vancomycin to 
Week 26 
- 
PHES from pre-vancomycin to Week 26 
- 
Stroop test at Week 4 and Week 26 
Study Population: 
The study sample will include 18 adult patients (aged 18-75 years old) with 
a history of cirrhosis and at least one prior episode of overt HE (OHE). 
Phase: 
Phase 2a trial 
Description of 
Sites/Facilities Enrolling 
Participants: 
Description of Study 
Intervention: 
This is a single-center blinded trial, enrolling only at the University of 
Michigan. 
Patients with cirrhosis and a history of OHE. 
All enrolled subjects will receive 5 days of oral vancomycin 125 mg QID. 
Starting the last day of oral vancomycin (Day 1), subjects will receive 5 
capsules of VE303 or placebo daily for 14 days. VE303 and placebo 
capsules will be provided by Vedanta. 
Study Duration: 
18 months 
Participant Duration: 
7 months 
 
 
 
1.2 
SCHEMA 


VE303 to Treat HE 
Protocol number: HUM00194437 
Version 6 
14 November 2022 
3 
 
 
 
 
1.3 
SCHEDULE OF ACTIVITIES (SOA) 
Pre- 
Screen 
Screening 
Treatment Assessments 
(O = Office, V = Virtual) 
Post-Treatment Assessments 
Day -40 to -4 
Day -25 to -4 
(0) 
Visit 1, Day -4 
(V) 
Visit 2, Day 1 
(O) 
Visit 3, Day 8 
± 2 days (V) 
Visit 4, Day 
14 (O) 
Visit 5, Week 
4 ± 2 days (V) 
Visit 6, Week 
6 ± 2 days (O) 
Visit 7-9, 
(Weeks 10, 
14, 18 ± 2 
weeks) (V) 
Visit 10, week 
26 ± 2 weeks 
(O) 
Clinical Assessments 
Informed 
Consent 
x 
Determine 
Eligibility 
(in part) 
x 
Randomize 
x 
Demographics 
x 
Medical History 
x 
x 
Symptom 
assessment, ER 
and hospital 
admissions 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Full Physical 
Exam 
x 
x 
x 
x 
x 
Height 
x 
Weight 
x 
x 
x 
x 
x 
Vital Signs1 
x 
x 
x 
x 
x 
Educational 
Session 
x 
Medication List 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Intervention 
adherence 
assessment2 
x 
x 
Lactulose/ 
Rifaximin 
Compliance 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Speech 
assessment 
x 
x 
x 
x 
x 
PROMIS QOL 
test 
10 min 
x 
x 
x 
x 
x 
Bristol Stool 
Scale 
x 
x 
x 
x 
PHES 
15-20 min 
x 
x 
x 
x 
x 
Stroop Test 
10-20 min 
x 
x 
x 
x 
x 
Collect solicited 
adverse events 
x 
x 
x 
x 
x 
Collect 
unsolicited AEs 
x 
x* 
x 
x 
x 
x 
x 
x 
Complete case 
report forms 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Laboratory Assessments 
CBC + platelet 
x 
x 
x 
x 
x 
Basic metabolic 
panel 
x 
x 
x 
x 
x 
Liver panel 
x 
x 
x 
x 
x 
PT/INR 
x 
x 
x 
x 
x 
Amylase and 
lipase level 
x 
x 
x 
Urine 
Pregnancy3 
x 
Venous 
Ammonia 
x 
x 
x 
x 
x 
C.difficile test4 
x 


VE303 to Treat HE 
Protocol number: HUM00194437 
Version 6 
14 November 2022 
4 
 
 
 
Stool 
Sequencing 
Sample 
x 
x 
x 
x 
x 
x 
Stool ammonia 
x 
x 
x 
x 
x 
Stool rifaximin 
level 
x 
x 
x 
Stool vanc level 
x 
Serum 
inflammatory 
biomarkers, 
LPS, SCFA 
x 
x 
x 
x 
x 
Stool bile acids 
x 
x 
x 
x 
x 
Stool SCFAs 
x 
x 
x 
x 
x 
Archive Stool 
x 
x 
x 
x 
x 
Archive Serum 
x 
x 
x 
x 
x 
Intervention 
Vancomycin 
For 5 days 
VE303 or 
placebo 
For 14 days 
x 
x 
1 We will collect temperature, heart rate, and blood pressure 
2 For virtual visit, ask subject to show # of pills remaining in study pill bottle. For in person day 14 visit, count remaining pills in study pill bottle 
3 Women of childbearing potential 
4 C.difficile testing is with EIA test for CDI antigen and toxin A and B. If EIA test is inconclusive, the PCR will be run. 
*For the time period between starting vancomycin and VE303 or placebo, subjects are instructed to contact the study team if they experience any adverse 
effects with taking vancomycin. Subjects will be asked about adverse events on day 1. 
**If a patient’s planned vancomycin start date is over 14 days after screening, an additional blood draw for a basic metabolic panel will be performed on 
Day -6 to check creatinine. Those with a serum creatinine 1.5 – 2.0 mg/dL at screening or on Day -6 will have an additional blood draw for basic metabolic 
panel obtained on Day -2 to check creatinine. 
 
 
  2.1   STUDY RATIONALE 
 
Hepatic encephalopathy (HE) is a complication of cirrhosis characterized by impaired cognition and 
abnormal psychomotor function. Up to 40% of patients with cirrhosis will develop HE, which leads to 
impaired quality of life, frequent hospital admissions, falls, and increased mortality.(1) First line HE 
treatment, lactulose, has limited efficacy with adverse effects that may include diarrhea, electrolyte 
disarray, dehydration, and patient discomfort.(2) Rifaximin, a second line treatment, is well tolerated but 
not accessible to many patients because of its costs and frequent insurance denial. The combination of 
lactulose and rifaximin is not completely effective at preventing recurrent HE episodes,(3) and both must 
be administered long-term after the onset of HE to prevent recurrence. More effective, less toxic and 
preferably finite therapies are needed to prevent overt HE episodes and treat minimal or subclinical HE 
that persists after overt HE (OHE) episodes. Manipulating the intestinal microbiome has been proposed 
to treat HE because of prior work demonstrating that HE develops through multiple mechanisms including 
from intestinal microbial products traversing the intestinal mucosa, crossing the blood-brain barrier, and 
affecting brain function. Indeed, lactulose and rifaximin as treatment of HE work in part through 
manipulation of the intestinal microbiome. 
We are performing a randomized, placebo-controlled, double-blind trial of VE303 to prevent recurrent 
OHE and improve cognition in patients with cirrhosis and a history of OHE. VE303 is a live biotherapeutic 
product composed of 8 nonpathogenic, nontoxigenic strains of Clostridia developed to prevent C. difficile 
infection, with characteristics that make it a promising treatment for HE. 
 
  2.2 
BACKGROUND 
 
Currently available HE treatments are flawed. There are two available FDA-approved therapies: lactulose 
and rifaximin. Lactulose frequently leads to side effects, including diarrhea, bloating, electrolyte disarray, 
2 
INTRODUCTION 


VE303 to Treat HE 
Protocol number: HUM00194437 
Version 6 
14 November 2022 
5 
 
 
 
and dehydration. Rifaximin, while causing fewer side effects, is costly and not covered by many insurance 
programs, thus limiting its accessibility to many patients. Finally, both these therapies are not perfect and 
many patients develop overt HE or experience ongoing mild HE symptoms despite treatment. 
 
Manipulating the intestinal microbiome has been proposed to treat HE because of prior work 
demonstrating that HE develops at least in part from intestinal microbial products traversing the intestinal 
mucosa, crossing the blood-brain barrier, and affecting brain function.(4, 5) Microbiome-directed therapy 
could plausibly treat HE for several reasons: first, lactulose and rifaximin, current standard-of-care 
treatments for HE, improve cirrhotic microbiome dysbiosis and function.(6-8) Second, replacing the gut 
microbiome with bacteria lacking urease in a mouse model led to reduced ammonia production and 
improved neurobehavioral function.(9) Third, a meta-analysis found that probiotics given to patients with 
HE decreased plasma ammonia.(10) Fourth, two trials of fecal microbiota transplant (FMT) have 
demonstrated improved cognition in patients with a history of OHE.(11, 12) 
 
Several plausible mechanisms link the intestinal microbiome to HE: 1) Intestinal dysbiosis in cirrhosis leads 
to increased ammonia production and therefore increased risk of HE. Evidence for this mechanism comes 
from cirrhotic patients with minimal HE who were found to have a significant linear correlation between 
intestinal concentrations of urease-containing Streptococcus salivarius and higher serum levels of 
ammonia.(13) Invasion of the distal intestine with oral commensals in cirrhosis perhaps explains the 
elevated abundance of these ammonia-producing Streptococcal species in the colons of these 
patients.(14) 2) Elevated circulating pro-inflammatory cytokines observed in cirrhosis increase the 
permeability of the blood-brain barrier to ammonia leading to poor cognition.(15-18) Investigators have 
found Faecalibacterium prausnitzi, a commensal with robust anti-inflammatory properties, is diminished 
in cirrhotic patients compared to healthy controls.(19-22) 3) Taxa with robust short-chain fatty acid 
(SCFA) production, essential to enterocyte health and maintenance of intestinal gap junctions, are 
diminished in cirrhotic patients, which may contribute to impaired intestinal permeability to neurotoxic 
bacterial products.(23) In a rat model, oral administration of SCFAs reduced enterotoxin-induced liver 
injury and TNF-α levels.(24) Based on this existing evidence, we hypothesize that manipulation of the gut 
microbiome could improve cognitive deficits in cirrhotic patients by influencing the pathways linking 
the gut to HE and prevent recurrent OHE. 
 
VE303 is a promising treatment for HE. First, VE303 is designed to treat C. difficile infection (CDI), and HE 
has previously been successfully treated with another microbiome therapy for CDI – FMT. Second, VE303 
contains organisms with robust SCFA production, one of the suspected pathways by which microbiome 
therapies could improve intestinal permeability and therefore HE. Third, VE303 strains induce conversion 
of primary bile acids into secondary bile acids, which has the potential downstream impact of reduced 
intestinal permeability. Fourth, VE303 strains induce T-regulatory cells, which play a critical role in 
maintaining intestinal homeostasis by controlling inflammation.(25, 26) 
 
  2.3 
RISK/BENEFIT ASSESSMENT 
 
 
Psychological Risk 
Participation in research may lead to undesired changes in thought process or emotion. Patients may 
experience discomfort when being asked questions about their medical history that they deem to be 
private. Cognitive testing may create stress or frustration for patients. Finally, stool sample collection is 
psychologically troubling to some. 
2.3.1 KNOWN POTENTIAL RISKS 


VE303 to Treat HE 
Protocol number: HUM00194437 
Version 6 
14 November 2022 
6 
 
 
 
 
Risks of VE303 
Thus far, VE303 has been given to approximately 100 people in clinical trials. The known or expected 
risks of the study medication are: 
• 
Common (happens in 10 or more patients out of 100): diarrhea, nausea, and belly pain 
• 
Uncommon (fewer than 10 patients out of 100): belly bloating, headache, elevated lipase (an 
enzyme from the pancreas), constipation, vomiting, and chills. 
Most cases of abdominal distension and nausea were attributed to oral vancomycin pretreatment 
rather than VE303. 
Please see the Investigator Brochure for further details regarding treatment emergent adverse events. 
Risks of oral Vancomycin 
From information obtained in the oral vancomycin capsule package insert, the most common adverse 
reactions (≥ 10%) were nausea (17%), abdominal pain (15%), and hypokalemia (13%). Nephrotoxicity has 
occurred following oral vancomycin capsule therapy, though not common, with those 65 years old and 
older at highest risk. This toxicity was reported in patients with colitis, which will be excluded in our 
cohort. We will monitor serum creatinine in all patients before and after vancomycin administration. 
Ototoxicity has also occurred in patients receiving oral vancomycin capsule, though not common. 
Finally, there is increased risk of the development of drug resistant bacteria. 
 
Risks Related to Study Procedures 
Subjects may develop a bruise, feel light-headed, faint or develop an infection related to study blood 
draws. 
 
This is the first study of VE303 in this patient population, so it is unclear if VE303 will provide any 
benefit. Potential benefits of VE303 include improvement in cognitive function and prevention of 
recurrence of OHE. 
 
HE is a common complication from cirrhosis, in desperate need of more effective and tolerable 
treatments. Discovery of one such novel treatment could benefit thousands of future patients. VE303 
has demonstrated a good safety profile in healthy volunteers and individuals with CDI. VE303 contains 
only known commensal bacterial strains, and therefore poses no known risk for harm to patients with 
cirrhosis. HE is a condition associated with considerable risk itself; therefore, we believe that the 
potential for benefit with this trial outweighs the potential risks. 
 
  3 
OBJECTIVES AND ENDPOINTS 
 
 
OBJECTIVES 
ENDPOINTS 
JUSTIFICATION FOR ENDPOINTS 
Primary 
Primary Safety Objective is 
to determine if VE303 
increases the rate of 
serious adverse events 
(SAEs). 
Primary Safety 
Endpoint: Number of 
SAEs up to Week 6. 
This is the first trial of VE303 in cirrhosis and 
safety assessment is a primary objective. 
2.3.2 KNOWN POTENTIAL BENEFITS 
2.3.3 ASSESSMENT OF POTENTIAL RISKS AND BENEFITS 


VE303 to Treat HE 
Protocol number: HUM00194437 
Version 6 
14 November 2022 
7 
 
 
Primary Efficacy Objective 
is to determine if VE303 
Primary Efficacy 
Endpoint: Change in 
The neurological impairment associated with 
HE involves deficits in several domains: 


VE303 to Treat HE 
Protocol number: HUM00194437 
Version 6 
14 November 2022 
8 
 
 
 
OBJECTIVES 
ENDPOINTS 
JUSTIFICATION FOR ENDPOINTS 
improves cognitive 
function. 
psychometric HE score 
(PHES) from pre- 
vancomycin to Week 6. 
attention, visuospatial, fine motor skills and 
memory. The ideal tool is a validated 
assessment that comprehensively assesses 
these domains for impairment.(27) The 
Psychometric Hepatic Encephalopathy Score 
(PHES): 
• 
Battery of 5 paper-pencil tests that 
evaluate cognitive and psychomotor 
processing speed and visuomotor 
coordination. 
• 
15-20 minutes to complete 
• 
Good external validity, endorsed by 
major specialty organization (ISHEN) 
and developed specifically to assess 
minimal HE. 
• 
Scores on each subtest are assigned 
values based on age-related norms 
Secondary 
Secondary Objective 1: 
Determine if VE303 
reduces OHE 
hospitalizations in the 6 
months post- 
administration. 
Secondary Objective 1: 
OHE hospitalizations in 
the 6 months post- 
administration (through 
Week 26). 
Recurrent OHE is associated with 
considerable morbidity and mortality, and 
therefore has significant clinical importance. 
Secondary Objective 2: 
Evaluate the durability of 
cognitive effect of VE303. 
Secondary Objective 2: 
Change in PHES from 
pre-vancomycin to 6 
months post-VE303 
(through Week 26). 
It is important to understand the durability of 
the intervention being studied. 
Secondary Objective 3: 
Evaluate the safety and 
tolerability of VE303 by 
cirrhotic patients. 
Secondary Objective 3: 
Difference between 
intervention and control 
arm in all adverse 
events 
Safety is critical to evaluate with an 
investigational drug. 
Secondary Objective 4: 
Determine if VE303 
changes the microbiome 
composition in cirrhosis. 
Secondary Objective 4: 
Change in microbiome 
composition. Calculate 
beta diversity between 
stool collection time 
In order to understand the mechanisms 
underpinning the (potential) therapeutic 
effect of VE303 in HE, the microbiome 
changes associated with VE303 and improved 
cognition must be evaluated. 


VE303 to Treat HE 
Protocol number: HUM00194437 
Version 6 
14 November 2022 
9 
 
 
 
OBJECTIVES 
ENDPOINTS 
JUSTIFICATION FOR ENDPOINTS 
points. We will perform 
metagenomic 
sequencing on stool to 
assess this. 
Secondary Objective 5: 
Determine if VE303 strains 
colonize cirrhotic patients. 
Secondary Objective 5: 
VE303 strain 
colonization, VE303 
strain-specific marker 
sequences will be 
detected in the stool 
over time. We will 
perform metagenomic 
sequencing on stool to 
assess this. 
The VE303 component strains have variable 
susceptibility to rifaximin. Monitoring VE303 
strain colonization in this study population is 
critical to understanding the associations 
between VE303 and improved cognition. 
Tertiary/Exploratory 
Determine if VE303 
changes serum and stool 
Change over time in: 
1. Venous and 
In order to better understand the mechanism 
underpinning the gut-liver-brain connection. 
biomarkers to explore the 
fecal ammonia 
mechanism behind the 
2. Inflammatory 
gut-liver-brain connection. 
cytokines 
including IL-1, 
IL-6, IL-18, CRP, 
fecal 
calprotectin, 
TNF-alpha 
3. Endotoxin (LPS) 
4. Serum and fecal 
short-chain fatty 
acids 
5. Fecal bile acids 
6. Speech 
assessment 
 
  4 
STUDY DESIGN 
 
 
  4.1 
OVERALL DESIGN 
 
 
We are performing a single-center randomized, placebo-controlled, double-blinded trial of VE303 to 
prevent OHE recurrence and improve cognition in patients with a history of overt hepatic encephalopathy 
(OHE). Our hypothesis is that VE303 will safely and effectively prevent OHE episodes and improve 
cognitive function, while changing the fecal microbiome in patients with a history of HE. Subjects will be 


VE303 to Treat HE 
Protocol number: HUM00194437 
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randomized 2:1 to VE303 vs placebo. There will be no stratification. Both study arms will receive 5 days of 
oral Vancomycin. The intervention arm will receive 5 VE303 capsules daily for 14 days and the placebo arm 
will receive 5 placebo capsules daily for 14 days. VE303 or placebo will start on the last day of Vancomycin 
(Day 1). Follow up will occur at Day 8, Day 14, and Weeks 4, 6, 10, 14, 18 and 26 after the start of VE303 
or placebo. Depending on results from the initial pilot study, further study of different dose, duration, and 
the necessity of pre-VE303 Vancomycin may be required. 
 
  4.2   SCIENTIFIC RATIONALE FOR STUDY DESIGN 
 
This study will be the first investigation of safety and efficacy of VE303 in patients with cirrhosis. As such, 
we plan to perform this phase 2a study. Placebo capsules for VE303 exist, and will provide an excellent 
control for our experiment. Performing a randomized placebo-controlled study will provide a high level of 
evidence concerning the safety and efficacy of VE303. 
 
In a study of healthy volunteers, pre-treatment with vancomycin was necessary for durable colonization 
of VE303 strains. In fact, VE303 strains were detected in recipients 1 year later when vancomycin pre- 
treatment was used. In order to optimize VE303 engraftment, VE303 must be administered as soon as 
possible after Vancomycin has been given. Delaying VE303 by even 1 or 2 days after Vancomycin 
completes can significantly reduce engraftment. For that reason, we plan to administer VE303 (or placebo) 
on the 5th day of Vancomycin; in other words, overlapping with Vancomycin for one day. If the patient 
unexpectedly requires rescheduling (for example due to a snow storm), we will allow for VE303 (or 
placebo) delivery on the day after Vancomycin completes, but will make strong efforts to dose VE303 (or 
placebo) exactly on Day 1 (last day of Vancomycin). 
 
If only the VE303-treatment arm received pre-treatment Vancomycin, two substantial study design 
problems would emerge: 1) the experiment would no longer be blinded as both patients and investigators 
would be aware of their grouping, introducing potential observer bias; 2) any comparison of outcomes 
between the placebo and treatment arms would be confounded by the use of vancomycin in only the 
treatment group. It would be impossible to disentangle which outcomes were related to vancomycin and 
which were related to VE303. Finally, oral vancomycin has very few side effects or risks. As such, we plan 
to administer pre-treatment vancomycin to all participants. 
 
All participants will remain on both lactulose and rifaximin at their prescribed dose and frequency 
throughout the study. First, maintaining both lactulose and rifaximin in all patients will prevent 
confounding or the need for stratification, which would have been necessary if there were heterogeneity 
in the active HE treatment of participants. Second, withdrawing lactulose and/or rifaximin prior to trial 
participation would risk precipitating an OHE event, which would pose too large a risk to participants. 
Third, rifaximin has weak anti-microbial properties and does not appear to impact microbial abundance 
in cirrhosis (rather impacts microbial function).(6) 
 
  4.3   JUSTIFICATION FOR DOSE 
 
In a Phase 1 study of healthy volunteers, 14 days of 10 daily VE303 capsules achieved the greatest number 
of VE303 strains at 1 year of follow up. Since the completion of that study, Vedanta now has capsules that 
contain double the quantity of the original capsules. Therefore, only 5 capsules are now needed to yield 
the same dose. This dosing regimen had a tolerable and benign safety profile. Patients with cirrhosis are 
more likely than individuals with no cirrhosis to require multiple doses of FMT to treat refractory CDI.(28) 
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As such, we suspect this 14-day dosing regimen is the most likely to overcome the dysbiosis of cirrhosis, 
safely, and lead to positive clinical outcomes. 
 
In the placebo arm, we will administer placebo capsules on the same schedule as the VE303 arm, in order 
to maintain blinding. 
 
Depending on results from the initial pilot study, further testing of different dose and duration, and need 
for vancomycin pre-treatment may be required. 
 
  4.4 
END OF STUDY DEFINITION 
 
 
A participant is considered to have completed the study if he or she has completed all phases of the 
study including the last visit or the last scheduled procedure shown in the Schedule of Activities (SoA), 
Section 1.3. The end of the study is defined as completion by the last participant of the last visit or 
procedure shown in the SoA section. 
 
  5     STUDY POPULATION 
 
Eligible patients have cirrhosis, at least one prior episode of OHE any time in the past and no current OHE. 
Only patients consistently taking lactulose and rifaximin are enrolled to limit confounding. Additional 
exclusion criteria include ongoing use of systemic antibiotics or immunosuppression. 
  5.1   INCLUSION CRITERIA 
 
In order to be eligible to participate in this study, an individual must meet all of the following criteria: 
1. Able to provide consent, with signed and dated informed consent form 
2. Stated willingness to comply with all study procedures and availability for the duration of the 
study, including ability to store VE303 or placebo in home fridge 
3. Male or female, aged 18 through 75 years old 
4. Diagnosis of cirrhosis based on liver biopsy, imaging, or evidence of clinical decompensation 
5. History of at least one episode of overt HE any time in the past 
• 
Defined by West Haven Criteria Grades II to IV 
• 
Can be precipitated HE episode 
6. Prescribed both lactulose and rifaximin, and compliant with this treatment 
a. Lactulose: At least one dose/day at least 5 days per week 
b. Rifaximin: At least one dose/day at least 5 days per week 
7. Sexually active women of childbearing potential enrolled in the study must agree to use a highly 
effective method of contraception, other than oral contraceptive pills (defined in Appendix 1) 
until 3 months after the last dose of the study product. 
 
  5.2 
EXCLUSION CRITERIA 
 
An individual who meets any of the following criteria will be excluded from participation in this study: 
 
1. Current episode of overt HE as defined by West Haven Criteria Grades II to IV 
2. Current infection including C difficile 
3. Variceal bleeding in the last 4 weeks 
4. Gut-absorbable or intravenous antibiotic therapy in the last 28 days 
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6. Fecal microbiota transplant in the last 6 months 
7. Use of probiotics in the last 2 weeks 
8. Alcohol or illicit drug intake in the last 4 weeks 
o By history 
o Alcohol use will be characterized as >1 alcoholic drink / week 
9. Primary sclerosing cholangitis as etiology of liver disease, as prior literature has suggested these 
individuals have a unique microbiome 
10. History of inflammatory bowel disease, short gut, gastrointestinal tract fistulas, intestinal 
ischemia, or any form of ongoing colitis 
11. Prior diagnosis of dementia or other primary neurocognitive disorder 
12. Known hypersensitivity/allergy/intolerance to Vancomycin and any ingredients of VE303: 
sucrose, histidine, yeast extract, cysteine, metabisulfite, and microcrystalline cellulose 
13. History of Roux-en-Y Gastric bypass 
14. Any gastrointestinal surgery in the last year 
15. Substantial immune compromise/deficiency (e.g., uncontrolled HIV, active immune suppressive 
therapy including high doses of corticosteroids or medications to prevent graft rejection, recent 
myeloablative therapy, sustained neutropenia) 
16. Pregnancy or breast feeding 
17. Use of oral contraceptive pills in the last month or planned use during the study period 
18. MELD > 20 
19. History of spontaneous bacterial peritonitis 
20. Hemodialysis in the last 28 days 
21. Other significant laboratory abnormalities: 
o Serum creatinine > 2.0 mg/dL 
o Hemoglobin < 8 g/dL 
o Serum sodium < 125 mmol/L 
o Serum potassium < 2.5 mmol/L 
22. Placement of a portosystemic shunt or transjugular intrahepatic portosystemic shunt in the last 
3 months (permissible if placed >3 months before enrollment) 
23. Unstable doses of opiates, benzodiazepines or other sedating medication 
o Chronic methadone or low dose benzodiazepines (for example) is acceptable 
 
  5.3 
LIFESTYLE CONSIDERATIONS 
 
Not applicable 
 
  5.4 
SCREEN FAILURES 
 
 
Screen failures are defined as participants who consent to participate in the clinical trial but do not 
receive any study drug, including vancomycin, VE303 or placebo. A minimal set of screen failure 
information is required to ensure transparent reporting of screen failure participants, to meet the 
Consolidated Standards of Reporting Trials (CONSORT) publishing requirements and to respond to 
queries from regulatory authorities. Minimal information includes demography, reasons for screen 
failure, and eligibility criteria. 
 
Individuals who do not meet the criteria for participation in this trial (screen failure) because of a recent 
clinical event on the list of exclusion criteria may be rescreened. Rescreened participants should be 


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assigned the same participant number as for the initial screening. Subjects will be limited to one re- 
screen. 
 
  5.5 
STRATEGIES FOR RECRUITMENT AND RETENTION 
 
Subjects will be identified through multiple mechanisms. First, University of Michigan hepatologists will 
be asked to review their patient panel for potential candidates. Second, the schedule of patients 
presenting to University of Michigan Liver Clinic will be reviewed in advance to screen for potential 
eligible patients. If an eligible patient is identified, the hepatology provider will be notified. If the 
hepatology provider agrees that the patient is an appropriate potential subject, the subject will be 
approached after their clinic visit. Finally, a flier will be posted in the University of Michigan Liver Clinic. 
Potential subjects’ hepatologist will be approached for permission to have study staff speak with the 
subjects. 
 
Subjects will receive a $50 check for each in-person screening or study visit. 
 
  6 
STUDY INTERVENTION 
 
 
  6.1 
STUDY INTERVENTION(S) ADMINISTRATION 
 
 
 
VE303 is a living biotherapeutic product (LBP) consisting of 8 well characterized, clonally-derived, 
nonpathogenic, nontoxigenic strains of Clostridia. The composition of VE303 was rationally selected 
based on strain and consortia-specific properties for their association with healthy human microbiomes, 
lack of C. difficile-related dysbiosis, and lack of overt pathogenic features. Each of the 8 bacterial strains 
in VE303 produce SCFAs, which are reduced in patients with cirrhosis and may influence intestinal 
barrier function and the development of HE. 
 
 
All enrolled participants will receive oral vancomycin 125 mg QID for 5 days prior to randomization. The 
purpose of this pretreatment is to reduce total bacterial biomass and allow for optimal VE303 strain 
colonization (see VE303 investigator brochure for further detail on rationale). 
 
The patients randomized to VE303 will receive 14 days of 5 oral VE303 capsules, taken once daily. The 
patients randomized to placebo will receive 14 days of 5 oral placebo capsules, identical in appearance 
to VE303, taken once daily. The VE303 or placebo regimens will start on the last day of Vancomycin (Day 
1), but could be given up to the day after Vancomycin stops if there are unavoidable schedule changes. 
Patients will be asked to take the study drug at approximately the same time each day. 
 
VE303 and placebo capsules will be administered orally once daily with a beverage of choice that 
contains no solid food substances – water is ideal, but any clear or carbonated beverage may be used. 
Beverages should be at room temperature, cool, or warm (not hot). 
 
In addition, patients cannot: 
6.1.1 STUDY INTERVENTION DESCRIPTION 
6.1.2 DOSING AND ADMINISTRATION 


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- 
Consume food or fast-acting antacids (calcium-, aluminum-, or magnesium-containing products 
such as Tums or Maalox) for at least 1 hour before or after study drug ingestion 
- 
Ingest histamine-2 receptor antagonist (ranitidine, famotidine, etc) within 12 hours before or 1 
hour after study drug ingestion 
- 
Ingest proton-pump inhibitor (omeprazole, pantoprazole, etc) within the 12 hours before or 1 
hour after study drug ingestion. 
 
  6.2 
PREPARATION/HANDLING/STORAGE/ACCOUNTABILITY 
 
 
 
Study intervention and placebo product will be shipped from PCI Pharma Services (Rockford IL), to the 
University of Michigan Research Pharmacy. The University of Michigan Research Pharmacy will confirm 
receipt of the study products with Vedanta. The University of Michigan Pharmacy will store the study 
products in a 5°C +/- 3°C fridge. This fridge will be in the locked premises of the Research Pharmacy, and 
only accessible by Pharmacy staff. A log will be kept detailing receipt, dispensing, and destruction or 
return to Vedanta of study product, by Pharmacy staff and according to University of Michigan Research 
Pharmacy standard operating procedure. 
 
Vancomycin will be supplied by the University of Michigan Research Pharmacy. Information on 
formulation, storage, and stability can be found in the package insert. 
 
 
VE303 consists of 8 different Clostridial strains, each manufactured separately. The quantity of each 
strain is proportioned to assure a specific per-strain per-capsule titer. The 8 strains are blended together 
with a micro-crystalline cellulose flow agent and placed in enteric capsules. The capsule also contains 
sucrose, histidine, yeast extract, cysteine, and sodium metabisulfite as excipients. The capsule will 
deliver 1.6x109 CFU per strain per capsule. The capsules are designed to pass through the stomach and 
then release the strains in the upper small intestine. Further details are provided in the Investigator 
Brochure and Pharmacy Manual. 
 
Placebo capsules contain micro-crystalline cellulose and are visually identical to VE303 capsules. 
However, placebo capsules will not contain any bacterial strains or formulation buffer used in the VE303 
drug product. 
 
 
VE303 is stable when stored in the sealed and capped bottle at 5°C ± 3°C. The University of Michigan 
Research Pharmacy will store both the VE303 and placebo capsules in a fridge under these conditions 
until dispensed to the patient. When dispensed to the patient, the study drug will be contained in the 
capped bottle, in a lunch box with freezer packs. The patient will ingest the VE303 or placebo capsules 
on Day 1 under the observation of study staff and then will be instructed to transport the study drug 
directly to their home. They will keep the capsules in a contained box within their fridge, clearly labeled 
with the statement “Caution: New Drug — Limited by Federal (or United States) law to investigational 
use.”, and only for the subject’s use. 
6.2.1 ACQUISITION AND ACCOUNTABILITY 
6.2.2 FORMULATION, APPEARANCE, PACKAGING, AND LABELING 
6.2.3 PRODUCT STORAGE AND STABILITY 


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The study product is produced to the point of capsule formation by the manufacturer. This study team 
at University of Michigan will not be involved in capsule creation. See the Pharmacy Manual for further 
detail regarding study drug preparation. 
 
  6.3 
MEASURES TO MINIMIZE BIAS: RANDOMIZATION AND BLINDING 
 
Subjects who have signed informed consent and meet enrollment criteria will be scheduled for a series 
of study visits. The first treatment study visit must take place within 3 weeks (or 21 days) of signing 
informed consent. If subjects are unable to present for the first treatment study visit within 21 days, we 
will re-verify eligibility including repeating lab testing and physical exam. Subjects will be randomized 
once they have signed informed consent and completed 4 days of oral vancomycin (5 days total of 
vancomycin but the 5th day overlaps with study drug initiation). Study staff will remain blinded to subject 
randomization until the final subject reaches the primary safety and efficacy endpoints (Visit 6). After 
this point, a portion of the study team will be unblinded to evaluate the primary outcome results. A 
portion of the study team, including the PI Dr. Bloom, will remain blinded until the end of the study. 
Only blinded study team members will be involved in evaluating adverse events, including with regards 
to possible relatedness to study drug. 
 
Randomization will be performed by the University of Michigan pharmacy. The study blind may be 
broken if a subject has received study drug and developed a serious adverse event that was potentially 
related to study drug. 
 
  6.4 
STUDY INTERVENTION COMPLIANCE 
 
To ensure drug accountability, subjects will be asked to show study staff their study drug pill bottle 
(virtually) on Day 8 and (in person) on Day 14. On Day 14, the subjects will be asked to bring the bottle 
of study drug to demonstrate it is empty (i.e. all of the study drug had been consumed). Subjects will 
also be asked about study drug compliance on Days 8 and 14. 
 
There will be an independent data safety monitoring board (DSMB) composed of a hepatologist, an 
infectious disease specialist and a statistician not involved in the study. That group will review AEs, SAEs, 
and enrollment. 
 
Safety monitoring will be ongoing throughout the protocol. Dr. Bloom or a co-investigator will evaluate 
the subjects at the Day 1 visit, Day 14 visit, Week 6 visit, and final study visit (Week 26). The PI will 
review all study visit documents, including labs, within 2 business days of the tests results. AEs will be 
thoroughly assessed after each treatment visit by study investigators and documented in the source. 
The PI and study staff will send blinded aggregate reports on safety events to co-investigators and the 
DSMB on a monthly basis. 
 
The PI will meet with study staff regularly to review study progress, subject status, and logistical issues. 
We will comply with the reporting of any IND safety reports according to FDA or other federal 
guidelines. The study coordinator will work with the physician investigators to process the report of 
these events as they happen. 
 
Study monitoring will be performed by the University of Michigan Institute of Clinical and Health 
Research (MICHR). Routine monitoring will be scheduled at appropriate intervals, with more frequent 
visits occurring at the beginning of the study. A site initiation visit will take place, followed by routine 
monitoring visits. 
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In addition to formal monitoring visits, Dr. Bloom will be regularly monitoring the study documents and 
meeting with study staff to review the status of the study. Dr. Bloom will ultimately be responsible for 


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protecting the rights, safety and welfare of all subjects enrolled in this study. In the case of Dr. Bloom’s 
absence, monitoring responsibilities will be delegated to one of the study sub-investigators listed in the 
IRB application. 
 
  6.5 
CONCOMITANT THERAPY 
 
For this protocol, a prescription medication is defined as a medication that can be prescribed only by a 
properly authorized/licensed clinician. Medications to be reported in the Case Report Form (CRF) are 
concomitant prescription medications, over-the-counter medications and supplements. 
 
To pass screening, subjects must report compliance with lactulose and rifaximin (at least one dose/day, 
5 days per week for each of these medications), no gut-absorbable or intravenous antibiotics in the last 
28 days, and antibiotic therapy cannot be anticipated in the coming 4 weeks. Subjects cannot be on 
immunosuppressive medications, or unstable doses of opiates, benzodiazepines or other sedating 
medications. These medications will be checked at each in-person study visit. 
 
In addition, patients cannot: 
- 
Consume food or fast-acting antacids (calcium-, aluminum-, or magnesium-containing products 
such as Tums or Maalox) for at least 1 hour before or after study drug ingestion 
- 
Ingest histamine-2 receptor antagonist (ranitidine, famotidine, etc) within 12 hours before or 1 
hour after study drug ingestion 
- 
Ingest proton-pump inhibitor (omeprazole, pantoprazole, etc) within the 12 hours before or 1 
hour after study drug ingestion. 
 
 
The study will not supply rescue medication for overt HE. Need for rescue would be triggered by an 
episode of overt HE necessitating emergency room visit or hospital admission. The need for rescue 
medication will not be made by study staff, rather by treating providers. The use of rescue medication is 
allowable at any time during the study and will not be delayed for study purposes. The date and time of 
rescue medication administration as well as the name and dosage regimen of the rescue medication 
must be recorded. 
 
If systemic antibiotics are deemed necessary during this study for a presumed infection, and VE303 
component bacteria may be implicated, consideration should be given to the use of one or more of the 
5 following broad-spectrum antibiotics, to which all of the bacteria contained in VE303 are susceptible 
(based on in vitro testing – refer to the VE303 Investigator Brochure for more details), according to 
institutional standard of care guidelines regarding antibiotic dose, route and frequency: 
- 
Piperacillin/tazobactam 
- 
Amoxicillin clavulanate 
- 
Imipenem 
- 
Metronidazole 
- 
Tigecycline 
 
This list of antibiotics will be reported to health care personnel if admission to the hospital or emergency 
department is warranted. Note: if VE303 component bacteria are implicated in an intestinal infection 
and an oral antibiotic is desired, oral metronidazole or amoxicillin clavulanate should be considered. 
6.5.1 RESCUE MEDICINE 


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  7.1 
DISCONTINUATION OF STUDY INTERVENTION 
 
We define temporary study-wide halting rules as follows: 
a. Any serious adverse event (SAE) assessed as probably or definitely related to study treatment. 
b. Any suspected or proven infection assessed as probably or definitely related to study treatment. 
c. Two or more subjects with the same, or similar, Grade 3 or higher adverse event considered at 
least possibly related to the oral vancomycin and/or study drug (VE303 or placebo). 
Temporary study-wide halt could entail: 
a. Stop new enrollment but allow enrolled patients to continue treatment 
b. Stop new enrollment and stop all dosing 
 
In the event of an SAE, suspected or proven infection, or two or more subjects with the same or similar 
Grade 3 or higher AE, Dr. Bloom will assess the relatedness to study treatment. If Dr. Bloom assesses the 
event as probably or definitely related to study treatment, she will report the event to the data safety 
monitoring board (DSMB). The DSMB will review the case, make its determination about relatedness, 
and if deemed necessary, recommend a temporary study-wide halt. This recommendation may apply to 
(a) new enrollment only, or (b) both new enrollment and participants already being treated in the study. 
This event will be reported to Vedanta as well as the IRB according to the IRB reporting guidelines. 
 
Study-wide halt will continue until relatedness to study treatment has been determined in consultation 
with (blinded) Vedanta personnel. Discontinuation from oral VE303 capsules does not mean 
discontinuation from the study, and remaining study procedures should be completed as indicated by 
the study protocol. 
 
Once relatedness is determined by the DSMB and a decision has been made regarding a study halt, next 
steps, including plans to lift a study halt, would be discussed and agreed upon by Dr. Bloom, DSMB, in 
consultation with (blinded) Vedanta representatives, and the University of Michigan IRB. If the decision 
is made to discontinue participation in the study, discontinuation from oral VE303 capsules does not 
mean discontinuation from the study, and remaining study procedures should be completed as 
indicated by the study protocol. 
 
The data to be collected at the time of study intervention discontinuation will include the following: 
• 
Stool sample for culture and sequencing 
• 
Routine blood tests, including CMP, CBC, INR 
• 
Cognitive testing by PHES 
 
In addition, an interval analysis will be performed when the 9th patient reaches Day 14 and has 
completed VE303 or placebo intervention. Specifically, the rate of SAEs, with a special focus on 
infection-related SAEs, will be compared between VE303 and placebo groups by the DSMB. If they deem 
the safety assessment to be satisfactory, the study will continue to complete enrollment of 18 subjects. 
We will briefly pause enrollment of the 10th patient, until this determination is made and restart 
enrollment immediately if there is no important safety concern related to VE303. 
7 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL 


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  7.2 
PARTICIPANT DISCONTINUATION/WITHDRAWAL FROM THE STUDY 
 
 
Participants are free to withdraw from participation in the study at any time upon request. 
An investigator may discontinue or withdraw a participant from the study for the following reasons: 
 
• 
Significant study intervention non-compliance 
• 
If any clinical adverse event (AE), laboratory abnormality, or other medical condition or situation 
occurs such that continued participation in the study would not be in the best interest of the 
participant. This includes, but is not limited to: 
o Single serious adverse event considered at least possibly related to the oral vancomycin 
and/or study drug (VE303 or placebo) treatment regimen 
o Grade 3 or higher adverse event considered at least possibly related to the oral 
vancomycin and/or study drug (VE303 or placebo) treatment regimen 
o Transmission of any infection from VE303 
o Pregnancy 
• 
Disease progression which requires discontinuation of the study intervention 
• 
If the participant meets an exclusion criterion (either newly developed or not previously 
recognized) that precludes further study participation 
• 
If there is an interruption in dosing: 
o If participants miss more than one day of vancomycin dosing, the investigator will 
withdraw them from participation and allow them to re-screen and re-enroll in the 
future. 
o If one day of vancomycin is missed on Day -4, -3, or -2, then the participant will resume 
vancomycin and continue the study schedule. 
o If one day of vancomycin is missed on Day -1, the participant will be asked to take one 
extra day of vancomycin before randomization (so the next day is vancomycin only, and 
the day thereafter is vancomycin + study drug) 
o If the participant misses 1-2 days of VE303 or placebo, they will be instructed to 
continue the intervention and add those doses to the end of their treatment course 
o If the participant misses 3 or more days of VE303 or placebo, including for 
hospitalization: 
■ 
If the interruption occurs on Days 12-14, continue the study as previously 
scheduled. Participants will not take the remaining capsules in this situation. 
■ 
If the interruption occurs before Day 12 and they miss 3 or more days of study 
capsules, study capsules will not be resumed after the pause. They will continue 
all subsequent visits. Additional subjects may be enrolled to replace this subject. 
 
The reason for participant discontinuation or withdrawal from the study will be recorded on the Study 
Withdrawal Case Report Form (CRF). Subjects who sign the informed consent form and are randomized 
but have not received the study intervention may be replaced. Subjects who sign the informed consent 
form, and are randomized and have received the study intervention, and subsequently withdraw from 
the study before the primary endpoint, not due to an SAE, may be replaced. Subjects who sign the 
informed consent form, and are randomized and have received the study intervention, and 
subsequently withdraw from the study due to an SAE, will not be replaced. 
 
  7.3 
LOST TO FOLLOW-UP 
 


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A participant will be considered lost to follow-up if he or she fails to return for 2 scheduled visits and is 
unable to be contacted by the study site staff. 
 
The following actions must be taken if a participant fails to return to the clinic for a required study visit: 
• 
The site will attempt to contact the participant and reschedule the missed visit within 2 weeks (1 
week for study visits during treatment phase) and counsel the participant on the importance of 
maintaining the assigned visit schedule and ascertain if the participant wishes to and/or should 
continue in the study. 
• 
Before a participant is deemed lost to follow-up, the investigator or designee will make every 
effort to regain contact with the participant (where possible, 3 telephone calls and, if necessary, 
a certified letter to the participant’s last known mailing address or local equivalent methods). 
These contact attempts should be documented in the participant’s medical record or study file. 
• 
Should the participant continue to be unreachable, he or she will be considered to have 
withdrawn from the study with a primary reason of lost to follow-up. 
 
  8 
STUDY ASSESSMENTS AND PROCEDURES 
 
 
  8.1 
EFFICACY ASSESSMENTS 
 
 
The primary efficacy assessment is change in the Psychometric Hepatic Encephalopathy Score (PHES) 
from baseline (before vancomycin) to Week 6. PHES is a validated tool to measure hepatic 
encephalopathy disease activity. 
 
The neurological impairment associated with HE involves deficits in several domains: attention, 
visuospatial, fine motor skills and memory. Therefore, we must use validated assessment tools that 
comprehensively assesses this impairment. The Psychometric Hepatic Encephalopathy Score (PHES) is 
the ideal tool to use. PHES is: 
• 
Battery of 5 paper-pencil tests that evaluate cognitive and psychomotor processing speed and 
visuomotor coordination. 
• 
Takes 15-20 minutes to complete. 
• 
Good external validity, endorsed by major specialist organization (ISHEN) and developed 
specifically to assess minimal HE.(27) 
• 
Scores on each subtest are assigned values based on age-related norms (1+ for scores better 
than 1 standard deviation (SD) above the normal mean to -3 for scores more than 3 SDs below 
the normal mean). 
• 
Combined scores vary from +6 to -18. 
 
The secondary efficacy assessment is number of OHE episodes up to Week 26 following study drug or 
placebo initiation. The presence of an OHE episode will be evaluated by the primary treating physician 
assessment during hospitalization, based on the West Haven Criteria. 
 
Another secondary efficacy endpoint of this study will be change in PHES from pre-intervention 
assessment (screening visit) to Week 26. 
 
As recommended by ISHEN, we will perform a second assessment of HE activity: the Stroop test. Stroop 
is also a well-validated test to screen and diagnose minimal HE.(29-31) The test involves identifying the 
color of the stimuli on the screen with three kinds of increasingly challenging stimuli. The test will be 


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performed on a study iPad, which will be maintained during the study period. The Stroop test sends an 
automatic email to study staff with results when the test has been completed. This email will be printed 
and saved as source documentation. 
 
  8.2 
SAFETY AND OTHER ASSESSMENTS 
 
 
The following assessments will be performed at screening and at several times during the study period to 
monitor safety (see SoA): 
• 
Physical examination including neurological examination and volume assessment (for hepatic 
hydrothorax, LE edema, and ascites). 
• 
Vital signs including body weight, temperature, pulse, and blood pressure. Study coordinator 
will be provided with a normal range of vital signs and will immediately notify a study physician 
of vital signs outside the normal range. 
• 
Laboratory evaluations. A series of routine blood tests will be performed at screening and at 4 
points throughout the study, as demonstrated in the SoA. These tests will include a BMP, LFTs, 
CBC, and INR. Amylase and lipase levels will be checked on Visits 2, 4, and 6. These test results 
will be sent to the PI’s (Dr. Bloom) clinical inbox for immediate response. These blood tests will 
all be performed by the University of Michigan core lab facilities, in compliance with CLIA. 
o There is the potential for systemic absorption of oral vancomycin, which can be 
nephrotoxic at higher levels. Therefore, the following additional monitoring will be 
performed: 
■ 
If a patient’s screening labs were more than 14 days prior to planned 
vancomycin initiation, we will recheck serum creatinine on Day -6 (2 days prior 
to vancomycin initiation). 
■ 
If at screening or on Day -6, the patient’s serum creatinine was 1.5 mg/dL to 2.0 
mg/dL (patients with serum creatinine > 2.0 mg/dL are excluded), these patients 
will undergo an additional blood draw on Day -2 to check serum creatinine. 
Vancomycin will be stopped if creatinine on Day -2 has increased to > 2.0 mg/dL 
or increased by 0.3 mg/dL since screening or Day -6. Vancomycin will not be 
resumed and the patient will not be randomized to study drug or placebo. The 
patient will continue to be monitored for nephrotoxicity but will be 
discontinued from the trial. 
• 
Assessment of adverse events. Adverse event reporting will be documented by an adverse 
event reporting form on Days 1, 8, 14, Week 4, 6, 10, 14, 18 and 26 follow up visits. Adverse 
events will be graded based on Common Terminology Criteria for Adverse Events (CTCAE) V.5.0. 
If an adverse event is identified and is at least possibly related to VE303, a more intensive 
monitoring schedule may be employed. The default will be a daily phone call (during weekdays) 
from study staff until the adverse event has resolved or the participant is removed from the 
study. Depending on the severity of the adverse event, the PI may determine that phone calls 
every 2 or 3 days is appropriate. Conversely, the PI may determine that an in-office study visit is 
required for further evaluation. 
o We will actively collect the following solicited AEs from patients: 
■ 
Diarrhea: This is challenging given that lactulose (a medication taken by all 
patients in the trial) purposefully creates loose and frequent stools. We will 
define diarrhea here as an increase in the number of bowel movements daily by 
2 or more, or a noticeable increase in looseness of stool. 


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■ 
Constipation: For this study, we will define constipation as no bowel movements 
for 2 days or more (if this is a change from baseline). 
■ 
Nausea 
■ 
Abdominal distension: This is challenging given that abdominal ascites and 
lactulose both cause abdominal distension in many of these patients at baseline. 
We will define this as a noticeable increase in abdominal distention from 
baseline or new abdominal distension. 
■ 
Abdominal pain 
■ 
Headache 
■ 
Chills 
■ 
Fever (temperature 100.4 or greater) 
o We will give patients a thermometer and a diary to record solicited AEs. We will ask 
patients to record this list of solicited AEs daily in their diary from Day 1 through Day 21 
(during 14 days of study drug and for 7 days thereafter). Study staff will specifically 
inquire about the solicited AEs during study visits 2, 3, 4, and 5 and collect the diary at 
visit 6. 
o We will collect solicited and unsolicited AEs on separate forms. Solicited AEs will be kept 
in one large solicited AE case report form which will include all of a patients’ solicited AE 
data from Day 1 through Day 21. Solicited AE data will be entered into this form on 
study visits 2, 3, 4, 5, and 6. 
o Unsolicited AEs will be captured on a different case report form. Unsolicited AEs could 
occur during days 1-21 (while solicited AE recording is taking place) if they are a 
symptom not on the solicited list. If a symptom on the solicited AE list occurs after day 
21 (when the patient is no longer being asked daily to record that symptom), that will be 
recorded as an unsolicited AE. 
o In analysis, we will present the two types of AEs separately. 
 
After the study screening visit, once all the screening assessments have been performed and resulted, a 
determination about screening failure or success will be made by the PI. The subject will be informed of 
the outcome and the remaining study visits will be scheduled if the subject was a screen success. 
 
If any of the above safety assessments are abnormal, the participant will be informed of the results in a 
timely manner. 
 
An interval analysis will be performed when the 9th patient reaches Day 14 and has completed VE303 or 
placebo intervention. Specifically, the rate of SAEs, with a special focus on infection-related SAEs, will be 
compared between VE303 and placebo groups by the DSMB. If the DSMB deems the safety assessment 
to be satisfactory, the study will continue to complete enrollment of 18 subjects. We will briefly pause 
enrollment of the 10th patient, until this determination is made and restart enrollment immediately if 
there is no important safety concern related to VE303. 
 
  8.3 
ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS 
 
 
8.3.1 DEFINITION OF ADVERSE EVENTS (AE) 


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Adverse event means any untoward medical occurrence associated with the use of an intervention in 
humans, whether or not considered intervention-related (21 CFR 312.32 (a)). 
 
An adverse event (AE) or suspected adverse reaction is considered "serious" if, in the view of the 
investigator, it results in any of the following outcomes: death, a life-threatening adverse event, 
inpatient hospitalization or prolongation of existing hospitalization, a persistent or significant incapacity 
or substantial disruption of the ability to conduct normal life functions, or a congenital anomaly/birth 
defect. An emergency room visit which does not lead to hospitalization will not qualify as an SAE unless 
other criteria are met. Important medical events that may not result in death, be life-threatening, or 
require hospitalization may be considered serious when, based upon appropriate medical judgment, 
they may jeopardize the participant and may require medical or surgical intervention to prevent one of 
the outcomes listed in this definition. 
 
 
For adverse events (AEs) not included in the protocol defined grading system, the following guidelines 
will be used to describe severity. 
 
• 
Grade 1: Mild – Events require minimal or no treatment and do not interfere with the 
participant’s daily activities. 
• 
Grade 2: Moderate – Events result in a low level of inconvenience or concern with the 
therapeutic measures. Moderate events may cause some interference with functioning. 
• 
Grade 3: Severe – Events interrupt a participant’s usual daily activity and may require systemic 
drug therapy or other treatment. Of note, the term “severe” does not necessarily equate to 
“serious”. 
• 
Grade 4: Life threatening 
• 
Grade 5: Death 
 
All adverse events (AEs) must have their relationship to study intervention assessed by the clinician who 
examines and evaluates the participant based on temporal relationship and his/her clinical judgment. 
The degree of certainty about causality will be graded using the categories below. In a clinical trial, the 
study product must always be suspect. 
 
• 
Definitely Related – There is clear evidence to suggest a causal relationship, and other possible 
contributing factors can be ruled out. The clinical event, including an abnormal laboratory test 
result, occurs in a plausible time relationship to study intervention administration and cannot be 
explained by concurrent disease or other drugs or chemicals. 
• 
Probably Related – There is evidence to suggest a causal relationship, and the influence of other 
factors is unlikely. The clinical event, including an abnormal laboratory test result, occurs within 
a reasonable time after administration of the study intervention, is unlikely to be attributed to 
concurrent disease or other drugs or chemicals, and follows a clinically reasonable response on 
withdrawal. 
• 
Possibly Related – There is some evidence to suggest a causal relationship (e.g., the event 
occurred within a reasonable time after administration of the trial medication). However, other 
8.3.2 DEFINITION OF SERIOUS ADVERSE EVENTS (SAE) 
8.3.3 CLASSIFICATION OF AN ADVERSE EVENT 
8.3.3.1     SEVERITY OF EVENT 
8.3.3.2      RELATIONSHIP TO STUDY INTERVENTION 


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factors may have contributed to the event (e.g., the participant’s clinical condition, other 
concomitant events). Although an AE may rate only as “possibly related” soon after discovery, it 
can be flagged as requiring more information and later be upgraded to “probably related” or 
“definitely related”, as appropriate. 
• 
Unlikely to be related – A clinical event, including an abnormal laboratory test result, whose 
temporal relationship to study intervention administration makes a causal relationship 
improbable (e.g., the event did not occur within a reasonable time after administration of the 
study intervention) and in which other drugs or chemicals or underlying disease provides 
plausible explanations (e.g., the participant’s clinical condition, other concomitant treatments). 
• 
Not Related – The AE is completely independent of study intervention administration, and/or 
evidence exists that the event is definitely related to another etiology. There must be an 
alternative, definitive etiology documented by the clinician. 
 
The causal relationship between study drug administration and adverse events will be assessed based 
on several factors: First, the temporal relationship between drug administration and the adverse event. 
Adverse events that take place within 3 days of drug administration are more likely to be definitely, 
probably or possibly related. Second, in case of infectious adverse events, the isolated pathogen will 
clarify the likelihood of a causal relationship. VE303 contains exclusively Clostridial species. Third, the 
expert opinions of Drs. Bloom, Lok, and Young. Dr. Lok is an international expert in hepatitis and end 
stage liver disease, and will be able to significantly contribute opinions on whether the AE represents 
progression of underlying disease or the intervention. Dr. Young is an international expert on the 
microbiome and infectious disease and will be able to contribute an opinion regarding the likelihood 
that the AE is related to VE303. We appreciate this may be a challenging determination. As questions of 
relatedness arise in real time, a physician discussion between Dr. Bloom (sponsor investigator) and co- 
investigators Drs. Lok and Young will take place. Dr. Bloom will make the ultimate determination of 
relatedness, with input from Drs. Lok and Young. We will err on the side of caution in assessing events as 
related. The DSMB will ultimately review AEs and SAEs and can request further investigation into 
determinations and change the ultimate relatedness determination. 
 
Dr. Bloom will be responsible for determining whether an adverse event (AE) is expected or unexpected. 
An AE will be considered unexpected if the nature, severity, or frequency of the event is not consistent 
with the risk information previously described for the study intervention based on the protocol, 
informed consent, vancomycin package insert, and the VE303 investigator brochure. 
 
The occurrence of an adverse event (AE) or serious adverse event (SAE) may come to the attention of 
study personnel during study visits and interviews of a study participant presenting for medical care, or 
upon review by a study monitor. 
 
All AEs including local and systemic reactions not meeting the criteria for SAEs will be captured on the 
appropriate case report form (CRF). Information to be collected includes event description, time of 
onset, clinician’s assessment of severity, relationship to study product (assessed by PI), and time of 
resolution/stabilization of the event. All AEs occurring while on study must be documented 
appropriately regardless of relationship. All AEs will be followed to adequate resolution. 
8.3.3.3      EXPECTEDNESS 
8.3.4 TIME PERIOD AND FREQUENCY FOR EVENT ASSESSMENT AND FOLLOW-UP 


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Any medical condition that is present at the time that the participant is screened will be considered as 
baseline and not reported as an AE. However, if the study participant’s condition deteriorates at any 
time during the study, it will be recorded as an AE. 
 
Changes in the severity of an AE will be documented to allow an assessment of the duration of the event 
at each level of severity to be performed. AEs characterized as intermittent require documentation of 
onset and duration of each episode. 
 
A clinical research coordinator will record all reportable events with start dates occurring any time after 
informed consent is obtained until the last day of study participation (Week 26). At each study visit, the 
research coordinator will inquire about the occurrence of AE/SAEs since the last visit. Events will be 
followed for outcome information until resolution or stabilization. 
 
All SAEs will be reported from a clinical research coordinator to Dr. Bloom, or Dr. Lok if Dr. Bloom is 
unavailable, within 24 hours. All non-serious AEs will be reported to Dr. Bloom within 5 business days. 
 
All SAEs will be reported from a clinical research coordinator to Dr. Bloom within 24 hours. Dr. Bloom 
will assess the relatedness to study treatment. If Dr. Bloom assesses the event as probably or definitely 
related to study treatment, she will report the event to the DSMB. The DSMB will review the case as 
outlined in the DSMB charter, make its determination about relatedness, and if deemed necessary, 
recommend a temporary study-wide halt. This event will be reported to Vedanta as well as the IRB. 
 
The PI and study staff will send blinded aggregate reports on safety events including all SAEs to co- 
investigators and the DSMB on a monthly basis. 
 
All serious adverse events (SAEs) will be followed until satisfactory resolution or until Dr. Bloom deems 
the event to be chronic or the participant is stable. 
 
All SAEs will be reported to the IRB per current institutional standards. 
 
Dr. Bloom, with assistance from the University of Michigan Institute of Clinical and Health Research 
IND/IDE Investigator Assistance Program will be responsible for the reporting of any and all IND safety 
reports to the FDA as per the requirements outlined in 21 CFR 312.32. This includes reporting of all 
Serious Adverse Events (SAEs) that are both unexpected and related to the drug as soon as possible, but 
in no case later than 15 calendar days after the sponsor determines that the information qualifies for 
reporting. If the unexpected and related SAE is either fatal or life-threatening, then the SAE must be 
reported as soon as possible but in no case later than 7 calendars days after Dr. Bloom’s initial receipt of 
the information. A summary of all non-expedited safety reports will be submitted in the annual report. 
In addition, Dr. Bloom must notify FDA and all participating investigators in this Investigational New 
Drug (IND) of any safety reports of potential serious risks, from clinical trials or any other source, as soon 
as possible, but in no case later than 15 calendar days after Dr. Bloom determines that the information 
qualifies for reporting. 
 
8.3.5 ADVERSE EVENT REPORTING 
8.3.6 SERIOUS ADVERSE EVENT REPORTING 
8.3.7 REPORTING EVENTS TO PARTICIPANTS 


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Participants will be informed of AEs and SAEs related to that participant as soon as they occur and will 
be updated as more information around relatedness becomes available. Any incidental findings, such as 
laboratory findings, will be disclosed to the participant, as well as their hepatology provider and primary 
care physician. Participants will not be informed of their cognitive testing results; only insofar as 
whether or not their score qualifies them to successfully screen into the study. 
 
NA 
 
If a woman becomes pregnant while in the study, the study drug will be discontinued and the team will 
request permission to follow the pregnant woman to her pregnancy outcome. The PI will notify the IRB 
and Vedanta within 24 hours. 
 
  8.4 
UNANTICIPATED PROBLEMS 
 
 
The Office for Human Research Protections (OHRP) considers unanticipated problems involving risks to 
participants or others to include, in general, any incident, experience, or outcome that meets all of the 
following criteria: 
 
• 
Unexpected in terms of nature, severity, or frequency given (a) the research procedures that are 
described in the protocol-related documents, such as the Institutional Review Board (IRB)- 
approved research protocol and informed consent document; and (b) the characteristics of the 
participant population being studied; 
• 
Related or possibly related to participation in the research (“possibly related” means there is a 
reasonable possibility that the incident, experience, or outcome may have been caused by the 
procedures involved in the research); and 
• 
Suggests that the research places participants or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or recognized. 
 
The investigator will report unanticipated problems (UPs) to the reviewing Institutional Review Board 
(IRB) per current institution guidelines. The UP report will include the following information: 
 
• 
Protocol identifying information: protocol title and number, PI’s name, and the IRB project 
number; 
• 
A detailed description of the event, incident, experience, or outcome; 
• 
An explanation of the basis for determining that the event, incident, experience, or outcome 
represents an UP; 
• 
A description of any changes to the protocol or other corrective actions that have been taken or 
are proposed in response to the UP. 
 
To satisfy the requirement for prompt reporting, UPs will be reported using the following timeline: 
 
• 
UPs that are serious adverse events (SAEs) will be reported to the IRB and to the sponsor 
investigator within 2 days of the investigator becoming aware of the event. 
8.3.8 EVENTS OF SPECIAL INTEREST 
8.3.9 REPORTING OF PREGNANCY 
8.4.1 DEFINITION OF UNANTICIPATED PROBLEMS (UP) 
8.4.2 
UNANTICIPATED PROBLEM REPORTING 


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• 
Any other UP will be reported to the IRB and to the study sponsor within 7 days of the 
investigator becoming aware of the problem. 
• 
All UPs should be reported to appropriate institutional officials (as required by an institution’s 
written reporting procedures), the supporting agency head (or designee), and the Office for 
Human Research Protections (OHRP) within 14 days of the IRB’s receipt of the report of the 
problem from the investigator. 
 
Participants will be informed of unanticipated problems as soon as they occur, and will be updated as 
more information around relatedness becomes available. 
 
  9 
STATISTICAL CONSIDERATIONS 
 
 
  9.1 
STATISTICAL HYPOTHESES 
 
 
 
• 
Primary Safety Endpoint: Number of SAEs from initiation of vancomycin up to Week 6. 
o Hypothesis: The intervention arm will not have a higher rate of serious adverse events. 
 
• 
Primary Efficacy Endpoint: Change in psychometric HE score (PHES) from pre-vancomycin to 
Week 6. 
o Null hypothesis: The change in psychometric HE score (PHES) from pre-vancomycin to 4 
weeks post-treatment (Week 6) is equal in the VE303/study drug and placebo/control 
arms. 
o Alternative hypothesis: The change in psychometric HE score (PHES) from pre- 
vancomycin to 4 weeks post-treatment (Week 6) will be greater (and beneficial) in the 
VE303/study drug arm than the placebo/control arm. 
 
• 
Secondary Efficacy Endpoint 1: number of OHE hospitalizations in the 6 months following study 
drug administration (up to Week 26) 
o Null hypothesis: Patients who undergo the study intervention (VE303) will have the 
same number episodes of OHE in the 6 months following drug administration compared 
to those who received placebo. 
o Alternative hypothesis: Patients who undergo the study intervention (VE303) will have 
fewer episodes of OHE in the 6 months following drug administration than those who 
received placebo. 
 
• 
Secondary Efficacy Endpoint 2: change in psychometric HE score (PHES) from pre-intervention to 
end of study follow-up (Week 26) 
o Null hypothesis: The change in psychometric HE score (PHES) from pre-intervention to 
the end of study follow up is equal in the VE303/study drug and placebo/control arms. 
o Alternative hypothesis: The change in psychometric HE score (PHES) from pre- 
intervention to the end of study follow up will be greater (and beneficial) in the 
VE303/study drug arm than the placebo/control arm. 
 
• 
Secondary Efficacy Endpoint 3: Diversity from pre-intervention to post-intervention (Week 6) 
8.4.3 REPORTING UNANTICIPATED PROBLEMS TO PARTICIPANTS 


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o Hypothesis: The administration of VE303 will be associated with a greater diversity in 
the microbiota (as assessed by metagenomics) between the two time points as 
compared to placebo. 
 
  9.2 
SAMPLE SIZE DETERMINATION 
 
Given the short duration of follow-up (6 weeks) until the primary safety outcome, we predict <10% 
patient drop out. 
 
This is a small pilot phase 2a study focused on safety as the primary outcome. Given 2:1 randomization, 
12 patients will receive VE303. This is similar to other safety studies in this population.(11, 12) 
 
  9.3 
POPULATIONS FOR ANALYSES 
 
We will analyze safety and efficacy data according to a modified Intention-to-Treat Analysis (i.e., all 
subjects who were randomized and received at least one dose of VE303 or placebo). 
 
  9.4 
STATISTICAL ANALYSES 
 
 
In this small pilot phase 2a study, the focus will be on evaluating safety. After enrollment of the first 9 
patients, we will perform interim analysis to evaluate safety of VE303 in this population. If there is no 
concern for a higher rate of SAEs in the VE303 group, enrollment will continue to reach a total of 18 
patients. Results from all 18 patients will be used together to evaluate safety and efficacy at trial 
completion. 
 
Demographic characteristics that are continuous variables with a normal distribution will be reported as 
a mean ± standard deviation. Continuous variables with a skewed distribution will be reported as 
median and interquartile range. Normality will be determined by the Shapiro-Wilk test. Demographic 
characteristics that are binary or categorical variables will be reported as a proportion in each category. 
If the continuous outcome is normally distributed, then we will perform a t-test and report the mean ± 
standard deviation as well as the confidence intervals. If the outcome is not normally distributed as 
determined by the Shapiro-Wilk test, we will perform a Wilcoxon Rank Sum test and report the median 
and interquartile range. 
 
If the continuous primary outcome is normally distributed, then we will perform a t-test and report the 
mean ± standard deviation as well as the confidence intervals. If the primary outcome is not normally 
distributed as determined by the Shapiro-Wilk test, we will perform a Wilcoxon Rank Sum test and 
report the median and interquartile range. 
 
If the continuous secondary endpoint is normally distributed, then we will perform a t-test and report 
the mean ± standard deviation as well as the confidence intervals. If the secondary endpoint is not 
normally distributed as determined by the Shapiro-Wilk test, we will perform a Wilcoxon Rank Sum test 
and report the median and interquartile range. If the secondary endpoint is categorical, we will perform 
a Fisher’s exact test. 
9.4.1 GENERAL APPROACH 
9.4.2 ANALYSIS OF THE PRIMARY EFFICACY ENDPOINT(S) 
9.4.3 ANALYSIS OF THE SECONDARY ENDPOINT(S) 


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We will compare the rate of serious adverse events per patient between the intervention and control 
arms. 
 
Laboratory data, including MELD score, if normally distributed will be tested by t-test and reported as 
mean ± standard deviation. If not normal, we will perform a Wilcoxon Rank Sum test and report the 
median and interquartile range. 
 
In this small population, we will not compare the overall incidence of adverse events between groups, 
but will report these descriptively. We will report the solicited and unsolicited AEs separately. 
 
Demographic characteristics that are continuous variables with a normal distribution will be reported as 
a mean ± standard deviation. Continuous variables with a skewed distribution will be reported as 
median and interquartile range. Normality will be determined by the Shapiro-Wilk test. Demographic 
characteristics that are binary or categorical variables will be reported as a proportion in each category. 
 
After the 9th patient reaches Day 14 of the study, an interim analysis will be completed. Safety events 
will be evaluated at the interim analysis. If there are no concerning findings in the safety outcome, the 
study will proceed to a total enrollment of 18 subjects. The interim analysis will be performed by the 
DSMB of 1 hepatologist, 1 infectious disease physician and 1 statistician. 
 
The primary analysis will be stratified by the presence of TIPS. No other sub-group analyses are planned. 
 
Individual participant PHES scores, Stroop test scores, ammonia levels, and microbiome data will be 
listed by time point. 
 
Computational analyses will assess VE303 strain penetration in the recipient microbiome by comparing 
single-nucleotide variants in strain level data between the donor and recipient, with the primary 
comparison being post-vancomycin/pre-VE303 (Day 1) compared to the final day of VE303 (Day 14). We 
will also calculate beta diversity between time points to assess change in microbial diversity before and 
after vancomycin, and over post-VE303 follow-up. We will examine taxa that differ significantly between 
pre- and post-VE303 administration, and test the degree to which changes in cognitive outcomes are 
explained by changes in the abundance of species and functional pathways. 
 
  10    SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS 
 
 
  10.1  REGULATORY, ETHICAL, AND STUDY OVERSIGHT CONSIDERATIONS 
 
 
9.4.4 SAFETY ANALYSES 
9.4.5 BASELINE DESCRIPTIVE STATISTICS 
9.4.6 PLANNED INTERIM ANALYSES 
9.4.7 SUB-GROUP ANALYSES 
9.4.8 TABULATION OF INDIVIDUAL PARTICIPANT DATA 
9.4.9 EXPLORATORY ANALYSES 
10.1.1 INFORMED CONSENT PROCESS 


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Consent forms describing in detail the study intervention, study procedures, and risks are given to the 
participant and written documentation of informed consent is required prior to starting 
intervention/administering study intervention. 
 
Informed consent is a process that is initiated prior to the individual’s agreeing to participate in the 
study and continues throughout the individual’s study participation. Consent forms will be Institutional 
Review Board (IRB)-approved and the participant will be asked to read and review the document. The 
investigator will explain the research study to the participant and answer any questions that may arise. 
A verbal explanation will be provided in terms suited to the participant’s comprehension of the 
purposes, procedures, and potential risks of the study and of their rights as research participants. 
Participants will have the opportunity to carefully review the written consent form and ask questions 
prior to signing. The participants should have the opportunity to discuss the study with their family or 
surrogates or think about it prior to agreeing to participate. The participant will sign the informed 
consent document prior to any procedures being done specifically for the study. Participants must be 
informed that participation is voluntary and that they may withdraw from the study at any time, without 
prejudice. A copy of the informed consent document will be given to the participants for their records. 
The informed consent process will be conducted and documented in the source document (including the 
date), and the form signed, before the participant undergoes any study-specific procedures. The rights 
and welfare of the participants will be protected by emphasizing to them that the quality of their 
medical care will not be adversely affected if they decline to participate in this study. 
 
A study physician investigator will obtain informed consent. In the case that a patient is in the medical 
practice of one of the investigators, the patient will have their information session and informed 
consent performed by another investigator. The consent form and protocol will be reviewed with the 
potential subject and any questions will be answered. Subjects will have the opportunity to take the 
consent form home and have 2 weeks to decide if they wish to participate. 
 
Ability to provide informed consent will be determined by study investigator assessment of capacity and 
a discussion with the subject’s primary hepatologist and, if needed, a mini-mental status exam. This 
study is designed to investigate a novel therapy for patients with a history of hepatic encephalopathy. 
Many patients with a history of hepatic encephalopathy have persistent cognitive deficits between overt 
episodes of encephalopathy. If ability to consent is in question, a mini-mental status exam will be 
performed. Subjects will require a score of 18 or greater in order to provide their own consent. A study 
physician investigator will review the consent form with each subject and perform a capacity 
assessment. Subjects will demonstrate capacity by being able to: 1) express an understanding of VE303 
and its risks and benefits, 2) express a choice about study participation, 3) describe how the study may 
have an impact on his or her life, 4) express a comparison between choosing to participate and not. 
 
This study may be temporarily suspended or prematurely terminated if there is sufficient reasonable 
cause. Written notification, documenting the reason for study suspension or termination, will be 
provided by the suspending or terminating party to study participants, investigator, funding agency, the 
Investigational New Drug (IND) sponsor and regulatory authorities. If the study is prematurely 
terminated or suspended, the Sponsor Investigator (SI) will promptly inform study participants, the 
10.1.1.1 CONSENT/ASSENT AND OTHER INFORMATIONAL DOCUMENTS PROVIDED TO 
PARTICIPANTS 
10.1.1.2 CONSENT PROCEDURES AND DOCUMENTATION 
10.1.2 STUDY DISCONTINUATION AND CLOSURE 


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Institutional Review Board (IRB), sponsor, and FDA and will provide the reason(s) for the termination or 
suspension. Study participants will be contacted, as applicable, and be informed of changes to study 
visit schedule. 
 
Circumstances that may warrant termination or suspension include, but are not limited to: 
• 
Determination of unexpected, significant, or unacceptable risk to participants 
• 
Demonstration of efficacy that would warrant stopping 
• 
Insufficient compliance to protocol requirements 
• 
Data that are not sufficiently complete and/or evaluable 
• 
Determination that the primary endpoint has been met 
• 
Determination of futility 
 
Study may resume once concerns about safety, protocol compliance, and data quality are addressed, 
and satisfy the sponsor investigator, IRB and/or Food and Drug Administration (FDA). 
 
Participant confidentiality and privacy is strictly held in trust by the participating investigators, their 
staff, and the sponsor(s) and their interventions. This confidentiality is extended to cover testing of 
biological samples and genetic tests in addition to the clinical information relating to participants. 
Therefore, the study protocol, documentation, data, and all other information generated will be held in 
strict confidence. No information concerning the study or the data will be released to any unauthorized 
third party without prior written approval of the sponsor. 
 
All research activities will be conducted in as private a setting as possible. 
 
The study monitor, representatives of the Institutional Review Board (IRB), regulatory agencies or 
pharmaceutical company supplying study product may inspect all documents and records required to be 
maintained by the investigator, including but not limited to, medical records (office, clinic, or hospital) 
and pharmacy records for the participants in this study. The clinical study site will permit access to such 
records. 
 
The study participant’s contact information will be securely stored the University of Michigan during the 
study. At the end of the study, all records will continue to be kept in a secure location for as long a 
period as dictated by the reviewing IRB, Institutional policies, or sponsor investigator requirements. 
 
Study participant research data, which is for purposes of statistical analysis and scientific reporting, will 
be transmitted to and stored on the University of Michigan server. This will not include the participant’s 
contact or identifying information. Rather, individual participants and their research data will be 
identified by a unique study identification number. The study data entry and study management 
systems used by research staff will be secured and password protected. At the end of the study, the 
data linking study identification number to participants identifying information will be destroyed. The 
deidentified database will be archived on the University of Michigan server. 
 
Data collected for this study will be analyzed and stored at the University of Michigan Gastroenterology 
and Hepatology Division and at Vedanta Biosciences, Inc., and may be used academically by the 
10.1.3 CONFIDENTIALITY AND PRIVACY 
10.1.4 FUTURE USE OF STORED SPECIMENS AND DATA 


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University of Michigan Gastroenterology and Hepatology Division and commercially by Vedanta 
Biosciences, Inc. 
 
With the participant’s approval, de-identified biological samples will be stored in the University of 
Michigan Gastroenterology and Hepatology Division and at Vedanta Biosciences, Inc. These samples 
could be used academically and commercially for purposes including, but not limited to, researching the 
causes of liver disease, hepatic encephalopathy, and other conditions for which individuals with chronic 
liver disease are at increased risk, and to improve treatment. 
 
During the conduct of the study, an individual participant can choose to withdraw consent to have 
biological specimens stored for future research. However, withdrawal of consent with regard to 
biosample storage may not be possible after the study is completed or after the samples have already 
been analyzed. 
 
 
Sponsor Investigator 
Patricia Bloom MD 
University of Michigan 
Taubman Center, 1500 E. Medical 
Center 
978-460-0538 
ppbloom@umich.med.edu 
 
 
 
An independent data safety monitoring board (DSMB) comprised of an independent hepatologist, 
infectious disease physician, and a statistician will monitor the study. 
 
In addition to formal monitoring visits by University of Michigan Institute of Clinical and Health Research 
(see 10.1.7), Dr. Bloom will be regularly monitoring the study documents and meeting with study staff to 
review the status of the study. Dr. Bloom will ultimately be responsible for protecting the rights, safety 
and welfare of all subjects enrolled in this study. In the case of Dr. Bloom’s absence, monitoring 
responsibilities will be delegated to one of the study sub-investigators listed in the IRB. 
 
 
To assure adequate protection of the rights of human subjects per 21 CFR part 312, this study will be 
monitored by the University of Michigan Institute of Clinical and Health Research (MICHR). Routine 
monitoring will be scheduled at appropriate intervals, with more frequent visits occurring at the 
beginning of the study. A site initiation visit will take place, followed by routine monitoring visits. 
Additional visits can be scheduled at the request of the Sponsor-Investigator. 
 
The established monitoring plan will ensure the quality and integrity of the data throughout the study 
conduct to verify adherence to the protocol, completeness and accuracy of study data and samples 
collected, dispensing and inventory of the study drug, and compliance with regulations. Monitoring 
10.1.5 KEY ROLES AND STUDY GOVERNANCE 
10.1.6 SAFETY OVERSIGHT 
10.1.7 CLINICAL MONITORING 


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visits can be conducted onsite or remotely with appropriate electronic documentation provided to the 
study monitors for review. 
 
Blinded aggregate data on safety events will be sent from the PI and study staff to co-investigators and 
the DSMB. 
 
We will perform internal quality management of study conduct, data and biological specimen collection, 
documentation and completion. 
 
Quality control (QC) procedures will be implemented beginning with the data entry system and data QC 
checks that will be run on the database. Any missing data or data anomalies will be communicated to 
the PI, Dr. Bloom, for clarification/resolution. 
 
Following written Standard Operating Procedures (SOPs), the monitors will verify that the clinical trial is 
conducted and data are generated and biological specimens are collected, documented (recorded), and 
reported in compliance with the protocol, International Conference on Harmonisation Good Clinical 
Practice (ICH GCP), and applicable regulatory requirements (e.g., Good Laboratory Practices (GLP), Good 
Manufacturing Practices (GMP)). 
 
The investigational site will provide direct access to all trial related sites, source data/documents, and 
reports for the purpose of monitoring and auditing by the sponsor, and inspection by local and 
regulatory authorities. 
 
 
Data collection is the responsibility of the clinical trial staff at the site under the supervision of the site 
investigator. The investigator is responsible for ensuring the accuracy, completeness, legibility, and 
timeliness of the data reported. 
 
All source documents should be completed in a neat, legible manner to ensure accurate interpretation 
of data. 
 
Hardcopies of the study visit worksheets will be provided for use as source document worksheets for 
recording data for each participant enrolled in the study. Data recorded in the electronic case report 
form (eCRF) derived from source documents should be consistent with the data recorded on the source 
documents. 
 
Clinical data (including adverse events (AEs), concomitant medications, and expected adverse reactions 
data) and clinical laboratory data will be entered into RedCap, a 21 CFR Part 11-capable data capture 
system provided by the University of Michigan. The data system includes password protection and 
internal quality checks, such as automatic range checks, to identify data that appear inconsistent, 
incomplete, or inaccurate. Clinical data will be entered directly from the source documents. 
 
10.1.8 QUALITY ASSURANCE AND QUALITY CONTROL 
10.1.9 DATA HANDLING AND RECORD KEEPING 
10.1.9.1 DATA COLLECTION AND MANAGEMENT RESPONSIBILITIES 
10.1.9.2 STUDY RECORDS RETENTION 


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Study documents will be retained until at least 2 years have elapsed since the formal discontinuation of 
clinical development of the study intervention. These documents should be retained for a longer period, 
however, if required by local regulations. No records will be destroyed without the written consent of 
the sponsor investigator, if applicable. 
 
A protocol deviation is any noncompliance with the clinical trial protocol or International Conference on 
Harmonisation Good Clinical Practice (ICH GCP). The noncompliance may be either on the part of the 
participant, the investigator, or the study site staff. As a result of deviations, corrective actions are to be 
developed by the site and implemented promptly. 
 
These practices are consistent with ICH GCP: 
• 
4.5 Compliance with Protocol, sections 4.5.1, 4.5.2, and 4.5.3 
• 
5.1 Quality Assurance and Quality Control, section 5.1.1 
• 
5.20 Noncompliance, sections 5.20.1, and 5.20.2. 
 
It is the responsibility of the investigator to use continuous vigilance to identify and report deviations 
within 7 working days of identification of the protocol deviation, or within 3 working days of the 
scheduled protocol-required activity. Protocol deviations must be sent to the Institutional Review Board 
(IRB) per their policies. 
 
This study will be conducted in accordance with the following publication and data sharing policies and 
regulations: 
 
National Institutes of Health (NIH) Public Access Policy, which ensures that the public has access to the 
published results of NIH funded research. It requires scientists to submit final peer-reviewed journal 
manuscripts that arise from NIH funds to the digital archive PubMed Central upon acceptance for 
publication. 
 
This study will comply with the NIH Data Sharing Policy and Policy on the Dissemination of NIH-Funded 
Clinical Trial Information and the Clinical Trials Registration and Results Information Submission rule. As 
such, this trial will be registered at ClinicalTrials.gov, and results information from this trial will be 
submitted to ClinicalTrials.gov. In addition, every attempt will be made to publish results in peer- 
reviewed journals. Data from this study may be requested from other researchers 2 years after the 
completion of the study by contacting Dr. Patricia Bloom. 
 
The independence of this study from any actual or perceived influence, such as by the pharmaceutical 
industry, is critical. Therefore, any actual conflict of interest of persons who have a role in the design, 
conduct, analysis, publication, or any aspect of this trial will be disclosed and managed. Furthermore, 
persons who have a perceived conflict of interest will be required to have such conflicts managed in a 
way that is appropriate to their participation in the design and conduct of this trial. 
 
  10.2 ADDITIONAL CONSIDERATIONS 
 
 
NA 
10.1.10 
PROTOCOL DEVIATIONS 
10.1.11 
PUBLICATION AND DATA SHARING POLICY 
10.1.12 
CONFLICT OF INTEREST POLICY 


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  10.3 ABBREVIATIONS 
 
 
AE 
Adverse Event 
CFR 
Code of Federal Regulations 
CLIA 
Clinical Laboratory Improvement Amendments 
CMP 
Clinical Monitoring Plan 
COC 
Certificate of Confidentiality 
CONSORT Consolidated Standards of Reporting Trials 
CRF 
Case Report Form 
DCC 
Data Coordinating Center 
DHHS 
Department of Health and Human Services 
DSMB 
Data Safety Monitoring Board 
DRE 
Disease-Related Event 
EC 
Ethics Committee 
eCRF 
Electronic Case Report Forms 
FDA 
Food and Drug Administration 
FDAAA 
Food and Drug Administration Amendments Act of 2007 
FFR 
Federal Financial Report 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practices 
GMP 
Good Manufacturing Practices 
GWAS 
Genome-Wide Association Studies 
HE 
Hepatic encephalopathy 
HIPAA 
Health Insurance Portability and Accountability Act 
IB 
Investigator’s Brochure 
ICH 
International Conference on Harmonisation 
ICMJE 
International Committee of Medical Journal Editors 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
ISM 
Independent Safety Monitor 
ISO 
International Organization for Standardization 
ITT 
Intention-To-Treat 
MedDRA 
Medical Dictionary for Regulatory Activities 
MSDS 
Material Safety Data Sheet 
NCT 
National Clinical Trial 
NIH 
National Institutes of Health 
OHE 
Overt hepatic encephalopathy 
OHRP 
Office for Human Research Protections 
PI 
Principal Investigator 
QA 
Quality Assurance 
QC 
Quality Control 
SAE 
Serious Adverse Event 


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SMC 
Safety Monitoring Committee 
SOA 
Schedule of Activities 
SOC 
System Organ Class 
SOP 
Standard Operating Procedure 
UP 
Unanticipated Problem 
US 
United States 


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  10.4 PROTOCOL AMENDMENT HISTORY 
 
The table below is intended to capture changes of IRB-approved versions of the protocol, including a 
description of the change and rationale. A Summary of Changes table for the current amendment is 
located in the Protocol Title Page. 
 
Version 
Date 
Description of Change 
Brief Rationale 
V2 
3/15/2021 
Addition of amylase and lipase 
monitoring. 
Enhanced creatinine monitoring with 
vancomycin. 
Addition of solicited AEs. 
Added detail to individual and study- 
wide halting rules. 
Response to FDA request. 
V3 
3/24/2021 
Addition of the following exclusion 
criteria: any GI surgery in the last 
year 
Revision of protocol number and 
addition of IND number 
Response to FDA request. 
Minor editorial changes 
V4 
5/16/2021 
Add exclusion criteria for oral 
contraceptive pills 
Response to IRB 
Minor editorial changes 
V4 
6/10/2021 
Add NCT number 
Response to clinicaltrial.gov team 
request. 
V5 
4/1/2022 
Fix discrepancy on page 16 and 27 of 
the protocol on when the interim 
analysis would occur. 
After the first 9 patients have 
completed treatment, an interim 
analysis will be completed. 
Investigator initiated edits. 
Discrepancy identified by PI.  
V6 
11/28/2022 
Updated for recent VE303 IB update and 
also to plan for unblinding for end of study 
analyses 
New VE303 IB. 
Planning for end of study analyses. 
 
 


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  11   REFERENCES 
 
 
1. 
Vilstrup H; Amodio P; Bajaj J; Cordoba J; Ferenci P; Mullen KD, et al. Hepatic encephalopathy in chronic 
liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the 
European Association for the Study of the Liver. Hepatology (Baltimore, Md). 2014;60(2):715-35. 
2. 
Gluud LL; Vilstrup H; Morgan MY. Nonabsorbable disaccharides for hepatic encephalopathy: A systematic 
review and meta-analysis. Hepatology (Baltimore, Md). 2016;64(3):908-22. 
3. 
Bass NM; Mullen KD; Sanyal A; Poordad F; Neff G; Leevy CB, et al. Rifaximin treatment in hepatic 
encephalopathy. The New England journal of medicine. 2010;362(12):1071-81. 
4. 
Kappus MR; Bajaj JS. Covert hepatic encephalopathy: not as minimal as you might think. Clinical 
gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological 
Association. 2012;10(11):1208-19. 
5. 
Wijdicks EF. Hepatic Encephalopathy. The New England journal of medicine. 2016;375(17):1660-70. 
6. 
Ponziani FR; Gerardi V; Pecere S; D'Aversa F; Lopetuso L; Zocco MA, et al. Effect of rifaximin on gut 
microbiota composition in advanced liver disease and its complications. World journal of gastroenterology. 
2015;21(43):12322-33. 
7. 
Riggio O; Varriale M; Testore GP; Di Rosa R; Di Rosa E; Merli M, et al. Effect of lactitol and lactulose 
administration on the fecal flora in cirrhotic patients. Journal of clinical gastroenterology. 1990;12(4):433-6. 
8. 
Bajaj JS; Heuman DM; Sanyal AJ; Hylemon PB; Sterling RK; Stravitz RT, et al. Modulation of the metabiome 
by rifaximin in patients with cirrhosis and minimal hepatic encephalopathy. PloS one. 2013;8(4):e60042. 
9. 
Shen TC; Albenberg L; Bittinger K; Chehoud C; Chen YY; Judge CA, et al. Engineering the gut microbiota to 
treat hyperammonemia. The Journal of clinical investigation. 2015;125(7):2841-50. 
10. 
Dalal R; McGee RG; Riordan SM; Webster AC. Probiotics for people with hepatic encephalopathy. The 
Cochrane database of systematic reviews. 2017;2:CD008716. 
11. 
Bajaj JS; Kassam Z; Fagan A; Gavis EA; Liu E; Cox IJ, et al. Fecal Microbiota Transplant from a Rational Stool 
Donor Improves Hepatic Encephalopathy: A Randomized Clinical Trial. Hepatology (Baltimore, Md). 2017. 
12. 
Bajaj JS; Salzman NH; Acharya C; Sterling RK; White MB; Gavis EA, et al. Fecal Microbial Transplant 
Capsules Are Safe in Hepatic Encephalopathy: A Phase 1, Randomized, Placebo-Controlled Trial. Hepatology 
(Baltimore, Md). 2019;70(5):1690-703. 
13. 
Zhang Z; Zhai H; Geng J; Yu R; Ren H; Fan H, et al. Large-scale survey of gut microbiota associated with 
MHE Via 16S rRNA-based pyrosequencing. The American Journal of Gastroenterology. 2013;108(10):1601-11. 
14. 
Qin N; Yang F; Li A; Prifti E; Chen Y; Shao L, et al. Alterations of the human gut microbiome in liver 
cirrhosis. Nature. 2014;513(7516):59-64. 
15. 
Montoliu C; Piedrafita B; Serra MA; del Olmo JA; Urios A; Rodrigo JM, et al. IL-6 and IL-18 in blood may 
discriminate cirrhotic patients with and without minimal hepatic encephalopathy. Journal of clinical 
gastroenterology. 2009;43(3):272-9. 


VE303 to Treat HE 
Protocol number: HUM00194437 
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39 
 
 
 
16. 
Luo M; Li L; Yang EN; Cao WK. Relationship between interleukin-6 and ammonia in patients with minimal 
hepatic encephalopathy due to liver cirrhosis. Hepatology research : the official journal of the Japan Society of 
Hepatology. 2012;42(12):1202-10. 
17. 
Shawcross DL; Davies NA; Williams R; Jalan R. Systemic inflammatory response exacerbates the 
neuropsychological effects of induced hyperammonemia in cirrhosis. Journal of hepatology. 2004;40(2):247-54. 
18. 
Odeh M; Sabo E; Srugo I; Oliven A. Relationship between tumor necrosis factor-alpha and ammonia in 
patients with hepatic encephalopathy due to chronic liver failure. Annals of Medicine. 2005;37(8):603-12. 
19. 
Breyner NM; Michon C; de Sousa CS; Vilas Boas PB; Chain F; Azevedo VA, et al. Microbial Anti- 
Inflammatory Molecule (MAM) from Faecalibacterium prausnitzii Shows a Protective Effect on DNBS and DSS- 
Induced Colitis Model in Mice through Inhibition of NF-kappaB Pathway. Frontiers in microbiology. 2017;8:114. 
20. 
Cao Y; Shen J; Ran ZH. Association between Faecalibacterium prausnitzii Reduction and Inflammatory 
Bowel Disease: A Meta-Analysis and Systematic Review of the Literature. Gastroenterology research and practice. 
2014;2014:872725. 
21. 
Martin R; Miquel S; Benevides L; Bridonneau C; Robert V; Hudault S, et al. Functional Characterization of 
Novel Faecalibacterium prausnitzii Strains Isolated from Healthy Volunteers: A Step Forward in the Use of F. 
prausnitzii as a Next-Generation Probiotic. Frontiers in microbiology. 2017;8:1226. 
22. 
Miquel S; Martin R; Rossi O; Bermudez-Humaran LG; Chatel JM; Sokol H, et al. Faecalibacterium prausnitzii 
and human intestinal health. Current opinion in microbiology. 2013;16(3):255-61. 
23. 
Usami M; Miyoshi M; Yamashita H. Gut microbiota and host metabolism in liver cirrhosis. World journal of 
gastroenterology. 2015;21(41):11597-608. 
24. 
Miyoshi M; Sakaki H; Usami M; Iizuka N; Shuno K; Aoyama M, et al. Oral administration of tributyrin 
increases concentration of butyrate in the portal vein and prevents lipopolysaccharide-induced liver injury in rats. 
Clinical nutrition (Edinburgh, Scotland). 2011;30(2):252-8. 
25. 
Atarashi K; Tanoue T; Oshima K; Suda W; Nagano Y; Nishikawa H, et al. Treg induction by a rationally 
selected mixture of Clostridia strains from the human microbiota. Nature. 2013;500(7461):232-6. 
26. 
Furusawa Y; Obata Y; Fukuda S; Endo TA; Nakato G; Takahashi D, et al. Commensal microbe-derived 
butyrate induces the differentiation of colonic regulatory T cells. Nature. 2013;504(7480):446-50. 
27. 
Randolph C; Hilsabeck R; Kato A; Kharbanda P; Li YY; Mapelli D, et al. Neuropsychological assessment of 
hepatic encephalopathy: ISHEN practice guidelines. Liver international : official journal of the International 
Association for the Study of the Liver. 2009;29(5):629-35. 
28. 
Pringle PL; Soto MT; Chung RT; Hohmann E. Patients With Cirrhosis Require More Fecal Microbiota 
Capsules to Cure Refractory and Recurrent Clostridium difficile Infections. Clinical gastroenterology and hepatology 
: the official clinical practice journal of the American Gastroenterological Association. 2018. 
29. 
Bajaj JS; Thacker LR; Heuman DM; Fuchs M; Sterling RK; Sanyal AJ, et al. The Stroop smartphone 
application is a short and valid method to screen for minimal hepatic encephalopathy. Hepatology (Baltimore, Md). 
2013;58(3):1122-32. 
30. 
Bajaj JS; Heuman DM; Sterling RK; Sanyal AJ; Siddiqui M; Matherly S, et al. Validation of EncephalApp, 
Smartphone-Based Stroop Test, for the Diagnosis of Covert Hepatic Encephalopathy. Clinical gastroenterology and 
hepatology : the official clinical practice journal of the American Gastroenterological Association. 
2015;13(10):1828-35.e1. 


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31. 
Allampati S; Duarte-Rojo A; Thacker LR; Patidar KR; White MB; Klair JS, et al. Diagnosis of Minimal Hepatic 
Encephalopathy Using Stroop EncephalApp: A Multicenter US-Based, Norm-Based Study. Am J Gastroenterol. 
2016;111(1):78-86. 
 
 
CONTRACEPTIVESa ALLOWED DURING THE STUDY INCLUDE: 
Highly Effective Methodsb That Have Low User Dependency Failure rate of < 1% per year when used 
consistently and correctly. 
• Implantable progestogen-only hormone contraception associated with inhibition of ovulationc 
• Intrauterine device (IUD) 
• Intrauterine hormone-releasing system (IUS)c 
• Bilateral tubal occlusion 
• Azoospermic partner (vasectomized or due to a medical cause) 
Azoospermia is a highly effective contraceptive method provided that the partner is the sole sexual partner 
of the woman of childbearing potential and the absence of sperm has been confirmed. If not, an additional 
highly effective method of contraception should be used. Spermatogenesis cycle is approximately 90 days. 
Note: documentation of azoospermia for a male participant can come from the site personnel’s review of 
the participant’s medical records, medical examination, or medical history interview. 
Highly Effective Methodsb That Are User Dependent Failure rate of <1% per year when used consistently and 
correctly. 
Sexual abstinence 
Sexual abstinence is considered a highly effective method only if defined as refraining from heterosexual 
intercourse during the entire period of risk associated with the study intervention. The reliability of sexual 
abstinence needs to be evaluated in relation to the duration of the study and the preferred and usual 
lifestyle of the participant. 
a) Contraceptive use by men or women should be consistent with local regulations regarding the use of 
contraceptive methods for those participating in clinical studies. 
b) Failure rate of < 1% per year when used consistently and correctly. Typical use failure rates differ from those 
when used consistently and correctly. 
c) Male condoms must be used in addition to hormonal contraception. If locally required, in accordance with 
Clinical Trial Facilitation Group (CTFG) guidelines, acceptable contraceptive methods are limited to those which 
inhibit ovulation as the primary mode of action. 
Note: Periodic abstinence (calendar, symptothermal, postovulation methods), withdrawal (coitus interruptus), 
spermicides only, and lactational amenorrhea method (LAM) are not acceptable methods of contraception. 
Male condom and female condom should not be used together (due to risk of failure from friction). 
 
Table obtained from the TransCelerate Protocol Library 
12   APPENDIX 1