Conditions: Duchenne Muscular Dystrophy
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 77
Healthy volunteers: no

Brief summary:
The main objective of this study is to evaluate the efficacy of Viltolarsen compared to placebo in Duchenne muscular dystrophy (DMD) patients amenable to exon 53 skipping.

Detailed description:
This is a Phase 3 randomized, double-blind, placebo-controlled, multi-center study to assess the efficacy and safety of Viltolarsen in ambulant boys with Duchenne muscular dystrophy. Eligible patients with out-of-frame deletion mutations amenable to exon 53 skipping will be randomized to receive once weekly intravenous (IV) infusions of 80 mg/kg Viltolarsen or placebo for up to 48 weeks.

The study will enroll approximately 74 patients amenable to exon 53 skipping. Clinical efficacy will be assessed at regularly scheduled study visits, including functional tests such as Time to Stand Test (TTSTAND), Time to Run/Walk 10 Meters Test (TTRW), Six-minute Walk Test (6MWT), North Star Ambulatory Assessment (NSAA), Time to Climb 4 Steps Test (TTCLIMB) and Hand-held dynamometer (elbow extension, elbow flexion, knee extension and knee flexion on the dominant side only).

Safety will be assessed through the collection of adverse events (AEs), laboratory tests, electrocardiograms (ECGs), vital signs, and physical examinations throughout the study.

Blood samples will be taken periodically throughout the study to assess the pharmacokinetics of study drug.

Arms:
arm 1: Patients amenable to exon 53 skipping will receive viltolarsen intravenous (IV) infusions, weekly, at 80 mg/kg for up to 48 weeks. arm 2: Patients amenable to exon 53 skipping will receive placebo intravenous (IV) infusions, weekly, for up to 48 weeks.

Interventions: intervention 1: Viltolarsen intervention 2: Placebo
Intervention descriptions: intervention 1: IV infusion intervention 2: IV infusion

Protocol document:
Prot_SAP_000.pdf: 
NCT04060199 
NS-065/NCNP-01 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
v4.0 08Dec2022 
 
 
 
 
NS Pharma, Inc. – CONFIDENTIAL  
 
Page 1 of 114 
Clinical Study Protocol: NS-065/NCNP-01-301 
Study Title: 
A Phase 3 Randomized, Double-blind, Placebo-controlled, 
Multi-center Study to Assess the Efficacy and Safety of Viltolarsen in 
Ambulant Boys with Duchenne Muscular Dystrophy (DMD) 
Protocol Number: 
NS-065/NCNP-01-301 
Study Phase: 
Phase 3 
Product Name: 
Viltolarsen 
IND Number: 
127474 
EudraCT Number: 
2019-002076-13 
Sponsor: 
NS Pharma, Inc. 
Original Protocol 
Date: 
 
12 June 2019 
 
Amendment 1 
Global Date: 
 
 
04 September 2019 
 
Amendment 2 
US-AUS Specific 
Date: 
 
 
 
23 September 2019 
 
Amendment 2 
Global Date: 
 
Amendment 3 
US-AUS Specific 
Date: 
 
Amendment 4  
US-AUS Specific 
Date: 
 
Amendment 4 
Global Date: 
 
Amendment 5 
China Specific 
Date: 
 
Amendment 5 
Global Date: 
 
 
21 February 2020 
 
 
 
02 March 2020 
 
 
 
15 December 2020 
 
 
08 January 2021 
 
 
 
14 July 2021 
 
 
08 December 2022 


NCT04060199 
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Clinical Study Protocol: NS-065/NCNP-01-301 
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Confidentiality Statement 
This protocol contains confidential, proprietary information which is the property of NS Pharma, Inc. 
No information contained herein may be published or disclosed without written approval from 
NS Pharma, Inc. 


NCT04060199 
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Clinical Study Protocol: NS-065/NCNP-01-301 
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STUDY SYNOPSIS 
Study Title 
A Phase 3 Randomized, Double-blind, Placebo-controlled, 
Multi-center Study to Assess the Efficacy and Safety of 
Viltolarsen in Ambulant Boys with Duchenne Muscular 
Dystrophy (DMD) 
Protocol Number 
NS-065/NCNP-01-301 
Investigative Product 
Viltolarsen 
Study Phase 
Phase 3 
Indication 
Treatment of Duchenne Muscular Dystrophy (DMD) with 
dystrophin deletion amenable to exon 53 skipping 
Number of Participants 
74 
Study Centers 
Approximately 53 clinical sites in approximately 19 countries, 
predominantly in Europe, Asia, North America, Oceania, and 
South America. 
Objectives/Endpoints 
Primary Objective(s) 
Primary Endpoint(s) 
• 
To compare the 
efficacy of viltolarsen 
administered 
intravenously (IV) at 
weekly doses of 80 mg/kg 
over a 48-week treatment 
period vs. placebo 
controls in ambulant boys 
ages 4 to <8 years with 
DMD using the Time to 
Stand Test (TTSTAND) 
as a measure of strength 
and function. 
• 
TTSTAND at 
48 weeks of treatment 
Secondary Objective(s) 
Secondary Endpoint(s) 
• 
To compare the 
efficacy of viltolarsen 
administered IV at 
weekly doses of 80 mg/kg 
in ambulant boys ages 
4 to <8 years with DMD 
over a 48-week treatment 
period vs. placebo 
controls using 
• 
Hierarchical analysis 
at 48 weeks treatment of 
the following strength 
and endurance measures: 
o Time to 
Run/Walk 
10 Meters Test 
(TTRW) 
o Six-minute Walk 
Test (6MWT) 


NCT04060199 
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Clinical Study Protocol: NS-065/NCNP-01-301 
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hierarchical strength and 
endurance outcomes; and 
o North Star 
Ambulatory 
Assessment 
(NSAA) 
o Time to Climb 
4 Stairs Test 
(TTCLIMB) 
o Quantitative 
muscle strength 
measured by 
hand-held 
dynamometer 
(elbow extension, 
elbow flexion, 
knee extension, 
and knee flexion 
on the dominant 
side only) 
• 
To evaluate the 
safety and tolerability of 
viltolarsen administered 
IV at weekly doses of 
80 mg/kg in ambulant 
boys ages 4 to <8 years 
with DMD. 
• 
Vital signs (blood 
pressure, heart rate, 
respiratory rate, and body 
temperature [modality for 
determining temperature 
should be consistent for 
each participant at all 
assessment time points 
throughout the study]) 
• 
Physical 
examination 
• 
Clinical laboratory 
tests: 
o Hematology and 
clinical chemistry 
o Urinalysis 
o Urine cytology 
o Exogenous tracer 
glomerular 
filtration rate 
(GFR) 
• Antibodies to 
dystrophin and viltolarsen 
• 
12-lead 
electrocardiogram (ECG) 


NCT04060199 
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Clinical Study Protocol: NS-065/NCNP-01-301 
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• 
Clinical signs and 
symptoms (adverse 
events [AEs] and serious 
adverse events [SAEs]) 
• 
Grading of clinical 
and clinical laboratory 
AEs will be according to 
the Common 
Terminology Criteria for 
Adverse Events 
(CTCAE) v.4.03 
Exploratory 
Objective(s) 
Exploratory 
Endpoint(s) 
• 
To evaluate 
health-related quality of 
life impact of viltolarsen 
treatment on participant’s 
DMD. 
• 
Pediatric Outcome 
Data Collection 
Instrument (PODCI)  
• 
Personal Adjustment 
and Role Skills Scale, 
3rd edition (PARS III) 
Questionnaire 
Study Design 
This Phase 3 study is a randomized, double-blind, 
placebo-controlled, multi-center study in ambulant boys ages 4 to 
<8 years with DMD receiving 80 mg/kg viltolarsen administered 
IV weekly over a 48-week treatment period.  Participants are 
randomly assigned to either 80 mg/kg/week viltolarsen or 
placebo in a 1:1 ratio. 
Group 
Number of 
Participants 
Investigational Product 
1 
37 
Viltolarsen 80 mg/kg/week  
2 
37 
Placebo 
Study Population 
Inclusion Criteria: 
1. Participant’s parent(s) or legal guardian(s) has (have) 
provided written informed consent and Health Insurance 
Portability and Accountability Act (HIPAA) authorization, 
where applicable, prior to any study-related procedures; 
participants will be asked to give written or verbal assent 
according to local requirements; 
2. Participant has a confirmed diagnosis of DMD defined as: 
a. Participant is male with clinical signs compatible with 
DMD; and 


NCT04060199 
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b. Participant has a confirmed DMD mutation(s) in the 
dystrophin gene that is amenable to skipping of 
exon 53 to restore the dystrophin mRNA reading 
frame including determination of unambiguously 
defined exon boundaries (using techniques such as 
Multiplex Ligation-dependent Probe Amplification 
[MLPA], comparative genomic hybridization [CGH] 
array or other techniques with similar capability); 
3. Participant is ≥4 years and <8 years of age at time of first 
infusion in the study; 
4. Participant is able to walk independently without assistive 
devices; 
5. Participant is able to complete the TTSTAND without 
assistance in <10 seconds, as assessed at the Screening Visit 
and the Pre-infusion Visit.  (Note: The TTSTAND performed 
independently from the NSAA should be used to determine 
eligibility.); 
6. Participant and parent(s)/guardian(s) are willing and able to 
comply with scheduled visits, study drug administration plan, 
and study procedures; 
7. Participant must be on a stable dose of glucocorticoid (GC) 
for at least 3 months prior to first dose of study drug and is 
expected to remain on the stable dose of GC treatment for the 
duration of the study. 
Exclusion Criteria: 
1. Participant has current or history of chronic systemic fungal 
or viral infections; 
2. Participant has had an acute illness within 4 weeks prior to 
the first dose of study drug based on the Principal 
Investigator’s judgment/discretion; 
3. Participant has evidence of symptomatic cardiomyopathy.  
(Note: Asymptomatic cardiac abnormality on investigation 
would not be exclusionary.); 
4. Participant has an allergy or hypersensitivity to the study drug 
or to any of its constituents; 
5. Participant has severe behavioral or cognitive problems that 
preclude participation in the study, in the opinion of the 
investigator; 
6. Participant has a previous or ongoing medical condition, 
medical history, physical findings, or laboratory 
abnormalities that could affect participant safety, make it 
unlikely that treatment and follow-up will be correctly 
completed, or impair the assessment of study results, in the 
opinion of the investigator; 


NCT04060199 
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Clinical Study Protocol: NS-065/NCNP-01-301 
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7. Participant has had surgery within the 3 months prior to the 
first anticipated administration of study drug or surgery is 
planned for anytime during the duration of the study; 
8. Participant has positive test results for hepatitis B antigen, 
hepatitis C antibody, or human immunodeficiency virus 
(HIV) antibody at screening.  (Note: A positive hepatitis C 
antibody result is acceptable if accompanied by a negative 
hepatitis C RNA test and normal bilirubin and 
gamma-glutamyl transferase results.); 
9. Participant is currently taking any other investigational drug 
or has taken any other investigational drug within 3 months 
prior to the first dose of study drug or within 5 times the 
half-life of a medication, whichever is longer; 
10. Participant was previously enrolled in an interventional study 
of viltolarsen; 
11. Participant is currently taking any other exon skipping agent 
or has taken any other exon skipping agent within 3 months 
prior to the first dose of study drug; 
12. Participant has taken any gene therapy; 
13. Participant is currently taking idebenone, anabolic steroids 
(e.g., oxandrolone), or products containing resveratrol or 
adenosine triphosphate, or has taken such within 3 months 
prior to first dose of study drug.  Coenzyme Q10 or creatine 
are permitted only if the participant is receiving a stable dose 
for at least 3 months prior to the first dose of study drug and 
for the duration of the study; 
14. Note: There is no exclusion criterion #14.  This criterion was 
removed from the protocol with Amendment 4 (version 3.0, 
dated 08 January 2021); however, the numbering was 
maintained to avoid documentation errors; 
15. Participant has hydronephrosis, hydroureter, renal or urinary 
tract calculi, or ureteral stenosis by medical history or renal 
ultrasound. 
Note: Any parameter/test may be repeated at the investigator’s 
discretion during screening to determine sustainability and 
reproducibility. 
Test Product, Dose, and 
Mode of Administration 
Viltolarsen injection 250 mg aqueous solution will be supplied as 
a 5 mL glass vial containing 50 mg/mL of drug substance 
solution in saline.   
Participants randomized to viltolarsen will receive IV infusions 
of viltolarsen injection administered once weekly over a 48-week 
period.  Participants will be dosed at 80 mg/kg/week. 


NCT04060199 
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Clinical Study Protocol: NS-065/NCNP-01-301 
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Comparator, Dose, and 
Mode of Administration 
Placebo will be supplied as a 5 mL matching glass vial of saline 
without the drug substance solution. 
Participants randomized to placebo will receive IV infusions of 
placebo administered once weekly over a 48-week period.   
Safety Measures 
• Vital signs (blood pressure, heart rate, respiratory rate, and 
body temperature [modality for determining temperature 
should be consistent for each participant at all assessment 
time points throughout the study]) 
• Physical examination 
• Clinical laboratory tests: 
o Hematology and clinical chemistry 
o Urinalysis 
o Urine cytology 
o Exogenous tracer GFR 
• 12-lead ECG 
• Antibodies to dystrophin and viltolarsen 
• Clinical signs and symptoms (AEs and SAEs) 
• Grading of clinical and clinical laboratory AEs will be 
according to CTCAE v.4.03 
Clinical Efficacy 
Measures 
 
Primary Outcome: 
• TTSTAND at 48 weeks of treatment 
Secondary Outcomes:   
Hierarchical analysis at 48 weeks treatment of the following 
strength and endurance measures: 
• TTRW  
• 6MWT 
• NSAA  
• TTCLIMB 
• Quantitative muscle strength measured by hand-held 
dynamometer (elbow extension, elbow flexion, knee 
extension, and knee flexion on the dominant side only) 
Exploratory Measures 
• PODCI 
• PARS III Questionnaire 
Pharmacokinetic 
Measures 
Viltolarsen levels in plasma will be assessed at predose and 1, 3, 
and 6 hours after initiation of infusion at Day 1.  Viltolarsen 
levels in plasma will be assessed at predose and 2 hours after 
initiation of infusion at Weeks 13, 25, 37, and 48 as well as at 
6 hours after initiation of infusion at Week 48. 


NCT04060199 
NS-065/NCNP-01 
 
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Clinical Study Protocol: NS-065/NCNP-01-301 
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Statistical Methods 
Sample Size:  
A total of approximately 74 participants: 
Viltolarsen 80 mg/kg/week (n=37) 
Placebo (n=37) 
Analysis Populations:  
The safety population will consist of all randomized participants 
who received at least 1 dose of investigational product.  
Participants will be analyzed as treated.  This will be the primary 
analysis population for the evaluation of exposure and safety.  
The modified Intent-to-Treat (mITT) population will consist of 
all randomized participants who received at least 1 dose of 
investigational product and have a baseline assessment and at 
least 1 post baseline efficacy assessment.  Participants will be 
analyzed as randomized.  This will be the primary analysis 
population for the evaluation of efficacy. 
General Statistical Considerations:  
For TTSTAND (calculated as a velocity, defined as rise per 
second), the sample size of 74 participants has been calculated 
using the following values:  
• Mean difference = 0.05 
• Standard deviation = 0.075 
• Type I error level (two-sided) = 0.05 
• Power level = 0.8 
• Allocation ratio (N1: viltolarsen/N2: placebo) = 1 
The mean difference and the SD were set based on the result of 
comparison between viltolarsen group and natural history control 
group at 25 weeks in the Phase 2 Study NS-065/NCNP-01-201 
(mean difference between 2 groups: 0.0395, SD: 0.07545 and 
0.07377).  As the mean difference between the 2 groups at 
48 weeks is expected to be larger than at 25 weeks, the mean 
difference was estimated to be 0.05. 
An unpaired t-test for analysis was used instead of mixed effect 
model repeat measurement for the calculation method due to lack 
of prior information. 
When approximately 90% of participants are enrolled in the 
study, an unblinded review will be conducted and sample size 
re-estimation will be considered.  An additional unblinded review 
and re-estimation will be performed when approximately 
50 participants have completed the Week 49 evaluations for the 
primary outcome measure. 


NCT04060199 
NS-065/NCNP-01 
 
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Clinical Study Protocol: NS-065/NCNP-01-301 
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Efficacy Evaluation:   
The primary efficacy outcome of TTSTAND will be summarized 
descriptively at each visit using actual values and change from 
baseline values.  The time measured for TTSTAND will be 
converted to a velocity expressed as rise per second. 
The primary efficacy outcome measure of TTSTAND velocity 
will be compared between participants treated with viltolarsen or 
placebo using mixed-effects linear models.   
Secondary and exploratory outcomes are detailed in the protocol 
and statistical analysis plan. 
Safety Evaluation: 
Safety analyses will be performed using the safety population.  
All safety assessments will be based on actual treatments 
received by participants and are detailed in the protocol and 
statistical analysis plan. 
Pharmacokinetic Evaluation: 
Population PK analysis will be presented in a separate report. 


NCT04060199 
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Clinical Study Protocol: NS-065/NCNP-01-301 
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1 
STUDY SCHEMA AND SCHEDULE OF ASSESSMENTS 
1.1 
Study Schema 
Figure 1 
Study Design 
 
 
Screening
Pre Treatment  
Visit
Randomization
Viltolarsen 80 mg/kg/week
N = 37
Placebo
N = 37
Week 
49
Week 
49
30 Day 
Follow 
up
30 Day 
Follow 
up
Day -28
Day -7
Day -1
Day 1
Week 48
Pre Treatment Phase
Treatment Phase
End of Treatment Phase


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1.2 
Schedule of Assessments 
Table 1. Schedule of Study Assessments for Pretreatment Phase to Treatment Phase Week 24 
Assessment * 
Pretreatment Phase 
Treatment Phase (Day 1 to Week 24) ** 
Screening 
Visita 
Day -28  
to Day -8 
Pre-Infusion 
Visit 
Day -7  
to Day -1 
First 
Infusion 
Day 1  
2 
3 
4 
5 
6 to 
8 
9 
10 to 
12 
13 
14 to 
16 
17 
18 to 
20 
21 
22 to 
24 
± 3 days for each weekly visit 
General Procedures 
Informed consent/assent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/exclusion criteriab 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Confirmed diagnosis of 
DMD 
X 
 
Xc 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographicsd 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical and surgical historye 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medication and treatment 
historyf 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical and surgical 
procedure reviewg 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Concomitant medication and 
treatmenth 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Heighti and weightj 
X 
X 
X 
 
 
 
 
 
 
 
X 
 
 
 
 
 
Vital signsk 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Physical and neurological 
examinationl 
X 
X 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
12-lead ECGm 
X 
 
X 
 
 
 
 
 
 
 
X 
 
 
 
 
 
Renal ultrasoundn 
X 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
Laboratory Assessments 
Hematologyo 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
Chemistryo 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
First morning void 
urinalysiso,p  
Xq 
X 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
Urine cytologyr 
 
X 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
Postdose urinalysiso,s  
 
 
X 
 
 
 
 
 
 
 
X 
 
 
 
 
 


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Assessment * 
Pretreatment Phase 
Treatment Phase (Day 1 to Week 24) ** 
Screening 
Visita 
Day -28  
to Day -8 
Pre-Infusion 
Visit 
Day -7  
to Day -1 
First 
Infusion 
Day 1  
2 
3 
4 
5 
6 to 
8 
9 
10 to 
12 
13 
14 to 
16 
17 
18 to 
20 
21 
22 to 
24 
± 3 days for each weekly visit 
Exogenous tracer GFRt 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antigen and antibody 
testingu 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anti-dystrophin antibodyv 
 
 
X 
 
 
 
 
 
 
 
X 
 
 
 
 
 
Anti-viltolarsen antibodyv 
 
 
X 
 
 
 
 
 
 
 
X 
 
 
 
 
 
Pharmacokinetic Assessment 
PK (blood)w 
 
 
X 
 
 
 
 
 
 
 
X 
 
 
 
 
 
Other Assessments 
Function and strengthx 
X 
X 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
Patient reported outcomey 
X 
X 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
Adverse events 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Investigational Product Administration 
Study drug administrationz 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Abbreviations: DMD = Duchenne muscular dystrophy; ECG = electrocardiogram; GFR = glomerular filtration rate; IV = intravenous; 
PARS III = Personal Adjustment and Role Skills Scale, 3rd edition; PK = pharmacokinetics; PODCI = Pediatric Outcome Data Collection Instrument. 
Note: Whenever vital signs, 12-lead ECGs, and blood draws are scheduled for the same nominal time, the assessments should occur in the following 
order: 12-lead ECG, vital signs, blood draws, with vital signs obtained without repositioning. 
a. 
The informed consent/assent must be obtained prior to any study related procedures being conducted.  Request for randomization will be made after 
all screening procedures are performed and prior to the first treatment. 
b. The Time to Stand Test (TTSTAND) is performed independently and as part of the North Star Ambulatory Assessment (NSAA).  The TTSTAND 
performed independently from the NSAA should be used to determine eligibility to satisfy inclusion criterion #5. 
c. 
A DMD genetic test at Day 1 will be conducted in order to obtain uniform DMD mutation information for the exact intronic boundaries to be 
analyzed by a central laboratory. 
d. Demographics will include date of birth, race, ethnicity, and hand dominance.  
e. 
Medical history will include the following: medical and surgical history. 
f. 
Includes prior and concomitant medication, treatment history.  
g. Medical and surgical procedures will be reviewed. 
h. Concomitant medication and treatments will be reviewed.  
i. 
Height will be collected without shoes.  The participant’s legs should be kept as close as possible and the participant’s heels should be placed back as 
close to the wall as possible.  Participant may hold on to an object to facilitate balance.  
j. 
Weight will be collected with the participant wearing no shoes and light-weight clothes. 
k. For each visit that includes a study drug administration, vital signs will be measured at predose as well as 1 hour (up to 20 minutes following 
completion of the infusion) and 2 hours (± 20 minutes) after initiation of infusion.  If a clinically significant change from predose is observed at 


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2 hours after initiation of infusion, the parameter will be measured again at 6 hours (± 20 minutes) after initiation of infusion.  Vital signs will be 
measured prior to any blood collection scheduled at the same time point and will include systolic and diastolic blood pressure, heart rate, respiratory 
rate, and temperature.  
l. 
Physical and neurological examinations will include an assessment of the following: general appearance, head, ears, eyes, nose, and throat (HEENT), 
skin, lymph nodes, heart, including rhythm, heart sounds and presence of cardiac abnormalities, lungs, abdomen, extremities/joints, nervous system, 
and any additional assessments necessary to establish baseline status or evaluate symptoms or adverse experiences as detailed in Section 9.11. 
m. ECGs will be performed with the participant having rested for at least 5 minutes, and the participant should remain in the supine or semi-recumbent 
position.  A consistent position should be maintained for each individual participant.  On Day 1, triplicate ECGs, each approximately 1 to 2 minutes 
apart, will be collected at predose as well as 1 hour (up to 20 minutes following completion of the infusion) and 3 hours (± 20 minutes) after initiation 
of infusion.  At the Screening Visit and Week 13, single ECGs will be collected (predose is recommended at Week 13). 
n. Renal ultrasound will include imaging of the kidneys, ureters, and bladder.  Except for the screening assessment, renal ultrasound can occur up to 
2 weeks prior to or after the scheduled week, as needed for scheduling purposes. 
o. Refer to Table 3 for additional details on the clinical laboratory tests, including the laboratory analytes that will be measured for hematology, serum 
chemistry, and urinalysis.   
p. Patients will collect a first morning void urine sample on the date of the specified visit and bring it to the site.  Analysis of the sample will include 
urine dipstick protein to be performed at the site.  An aliquot will also be sent to the central laboratory for urinalysis.  Refer to Section 11.11.1 for 
details on monitoring of renal function and urine analyses. 
q. First morning void urine sample collection and dipstick protein are not required at screening. 
r. 
To be performed on a predose urine sample collected on-site. 
s. 
To be performed on a urine sample collected within 5 hours after completion of infusion. 
t. 
GFR will be determined using an exogenous tracer test, if available.  This should be done per standard of care at the institution. 
u. To include hepatitis B antigen, hepatitis C antibody, and HIV antibody. 
v. To be collected predose and will be performed on serum blood samples.  
w. Viltolarsen levels in plasma will be assessed at predose (within 60 minutes prior to dose) as well as 1 hour (up to 20 minutes following completion of 
the infusion), 3 hours (± 20 minutes), and 6 hours (± 20 minutes) after initiation of infusion at Day 1.  Viltolarsen levels in plasma will be assessed at 
predose (within 60 minutes prior to dose) and 2 hours (± 20 minutes) after initiation of infusion at Week 13.  Postdose PK should not be drawn from 
the cannula that was used for the infusion.  These samples can be drawn from the arm opposite the infusion or can be from a separate distal access 
point in the same arm as the infusion.  This postdose PK draw requirement is in place to prevent any contamination with viltolarsen derived from the 
dosing cannula. 
x. Function and strength test will include the following: Time to Stand Test (TTSTAND), Time to Run/Walk 10 Meters Test (TTRW), North Star 
Ambulatory Assessment (NSAA), Time to Climb 4 Stairs Test (TTCLIMB), Six-minute Walk Test (6MWT), and hand-held dynamometer.  The 
NSAA and hand-held dynamometer should be administered before the 6MWT at each visit. 
y. Patient reported outcomes will include PODCI and PARS III. 
z. 
Investigational product solution is administered every week within a ± 3-day window.  A minimum of 3 days (72 hours) should elapse between 
treatments.  
* 
If a participant returns to the clinic for a visit outside of the protocol evaluation time points, the visit and any assessments and/or tests performed will 
be recorded in the source documents and the eCRF as an Unscheduled Visit. 
** If allowed per local regulations, Weeks 6 to 8, 10 to 12, 14 to 16, 18 to 20, and 22 to 24 can be completed at a non-site location via the home health 
vendor.  NS Pharma reserves the right to require visits to be completed at the site, if needed.  
 


NCT04060199 
NS-065/NCNP-01 
 
 
 
 
 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
 
 
 
 
      v4.0 08Dec2022 
NS Pharma, Inc. – CONFIDENTIAL  
 
 
 
 
 
 
 
Page 15 of 114 
Table 2. Schedule of Study Assessments for Treatment Phase from Week 25 to End-of-Treatment Phase 
 Assessment * 
Treatment Phase 
(Week 25 to Week 48) ** 
± 3 days for each weekly visit 
End-of-Treatment Phasea 
Week 
25 
26 to 
28 
29 
30 to 
32 
33 
34 to 
36 
37 
38 to 
40 
41 
42 
to 
44 
45 
46 to 
47 
48 
49  
Follow-Up 
Telephone Calla 
30 days  
(± 3 days) 
postdose 
ETb 
General Procedures 
Medical and surgical procedure 
reviewc 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Concomitant medication and 
treatmentd 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Height and weighte 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
X 
 
X 
Vital signsf 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
Physical and neurological 
examinationg 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
X 
 
X 
12-lead ECGh 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
X 
 
X 
Renal ultrasoundi 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
X 
 
X 
Laboratory Assessments 
Hematologyj 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
X 
 
X 
Chemistryj 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
X 
 
X 
First morning void urinalysisj,k  
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
X 
 
X 
Urine cytologyl 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
X 
 
X 
Postdose urinalysisj,m 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
Exogenous tracer GFRn 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
X 
Anti-dystrophin antibodyo 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
Anti-viltolarsen antibodyo 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
Pharmacokinetic Assessment 
PK (blood)p 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
Other Assessments 
Function and strengthq 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
X 
 
X 
Patient reported outcomer 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
X 
 
X 
Adverse events 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 


NCT04060199 
NS-065/NCNP-01 
 
 
 
 
 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
 
 
 
 
      v4.0 08Dec2022 
NS Pharma, Inc. – CONFIDENTIAL  
 
 
 
 
 
 
 
Page 16 of 114 
 Assessment * 
Treatment Phase 
(Week 25 to Week 48) ** 
± 3 days for each weekly visit 
End-of-Treatment Phasea 
Week 
25 
26 to 
28 
29 
30 to 
32 
33 
34 to 
36 
37 
38 to 
40 
41 
42 
to 
44 
45 
46 to 
47 
48 
49  
Follow-Up 
Telephone Calla 
30 days  
(± 3 days) 
postdose 
ETb 
Investigational Product Administration 
Study drug administrations 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
Abbreviations: ECG = electrocardiogram; ET = early termination; GFR = glomerular filtration rate; IV = intravenous; PARS III = Personal 
Adjustment and Role Skills Scale, 3rd edition; PK = pharmacokinetics; PODCI = Pediatric Outcome Data Collection Instrument.  
Note: Whenever vital signs, 12-lead ECGs, and blood draws are scheduled for the same nominal time, the assessments should occur in the 
following order: 12-lead ECG, vital signs, blood draws, with vital signs obtained without repositioning. 
a. 
Participants will have a telephone call conducted by the site study staff, 30 days (± 3 days) following the last study drug administration.  
b. If a participant returns to the clinic for a visit outside of the protocol evaluation time points, the visit and any assessments and/or tests performed 
will be recorded in the source documents and the eCRF as an Unscheduled Visit. 
c. 
Medical and surgical procedures will be reviewed. 
d. Concomitant medication and treatments will be reviewed.  
e. 
Height will be collected without shoes.  The participant’s legs should be kept as close as possible and the participant’s heels should be placed 
back as close to the wall as possible.  Participant may hold on to an object to facilitate balance.  Weight will be collected with the participant 
wearing no shoes and light-weight clothes. 
f. 
For each visit that includes a study drug administration, vital signs will be measured at predose as well as 1 hour (up to 20 minutes following 
completion of the infusion) and 2 hours (± 20 minutes) after initiation of infusion.  If a clinically significant change from predose is observed at 
2 hours after initiation of infusion, the parameter will be measured again at 6 hours (± 20 minutes) after initiation of infusion.  Vital signs will be 
measured prior to any blood collection scheduled at the same time point and will include: systolic and diastolic blood pressure, heart rate, 
respiratory rate, and temperature.  
g. Physical and neurological examinations will include an assessment of the following: general appearance, head, ears, eyes, nose, and throat 
(HEENT), skin, lymph nodes, heart, including rhythm, heart sounds and presence of cardiac abnormalities, lungs, abdomen, extremities/joints, 
nervous system, and any additional assessments necessary to establish baseline status or evaluate symptoms or adverse experiences as detailed in 
Section 9.11. 
h. ECGs will be performed with the participant having rested for at least 5 minutes, and the participant should remain in the supine or 
semi-recumbent position.  A consistent position should be maintained for each individual participant.  At Weeks 25, 37, 49, and ET, single ECGs 
will be collected (predose is recommended at Weeks 25 and 37). 
i. 
Renal ultrasound will include imaging of the kidneys, ureters, and bladder.  Except for the screening assessment, renal ultrasound can occur up to 
2 weeks prior to or after the scheduled week, as needed for scheduling purposes. 
j. 
Refer to Table 3 for additional details on the clinical laboratory tests, including the laboratory analytes that will be measured for hematology, 
serum chemistry, and urinalysis. 


NCT04060199 
NS-065/NCNP-01 
 
 
 
 
 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
 
 
 
 
      v4.0 08Dec2022 
NS Pharma, Inc. – CONFIDENTIAL  
 
 
 
 
 
 
 
Page 17 of 114 
k. Patients will collect a first morning void urine sample on the date of the specified visit and bring it to the site.  Analysis of the sample will include 
urine dipstick protein to be performed at the site.  An aliquot will also be sent to the central laboratory for urinalysis.  Refer to Section 11.11.1 for 
details on monitoring of renal function and urine analyses. 
l. 
To be performed on a predose urine sample collected on-site. 
m. To be performed on a urine sample collected within 5 hours after completion of infusion. 
n. GFR will be determined using an exogenous tracer test, if available.  This should be done per standard of care at the institution. 
o. To be collected predose and will be performed on serum blood samples.  
p. Viltolarsen levels in plasma will be assessed at predose (within 60 minutes prior to dose) and 2 hours (± 20 minutes) after initiation of infusion at 
Week 25, Week 37, and Week 48 as well as at 6 hours (± 20 minutes) after initiation of infusion at Week 48.  Postdose PK should not be drawn 
from the cannula that was used for the infusion.  These samples can be drawn from the arm opposite the infusion or can be from a separate distal 
access point in the same arm as the infusion.  This postdose PK draw requirement is in place to prevent any contamination with viltolarsen 
derived from the dosing cannula. 
q. Function and strength test will include the following: Time to Stand Test (TTSTAND), Time to Run/Walk 10 Meters Test (TTRW), North Star 
Ambulatory Assessment (NSAA), Time to Climb 4 Stairs Test (TTCLIMB), Six-minute Walk Test (6MWT), and hand-held dynamometer.  The 
NSAA and hand-held dynamometer should be administered before the 6MWT at each visit. 
r. 
Patient reported outcomes will include PODCI and PARS III. 
s. 
Investigational product solution is administered every week within a ± 3-day window.  A minimum of 3 days (72 hours) should elapse between 
treatments.  
* 
If a participant returns to the clinic for a visit outside of the protocol evaluation time points, the visit and any assessments and/or tests performed 
will be recorded in the source documents and the eCRF as an Unscheduled Visit. 
** If allowed per local regulations, Weeks 26 to 36 and 38 to 47 can be completed at a non-site location via the home health vendor.  NS Pharma 
reserves the right to require visits to be completed at the site, if needed. 
 


NCT04060199 
NS-065/NCNP-01 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
v4.0 08Dec2022 
 
 
 
 
NS Pharma, Inc. – CONFIDENTIAL  
 
Page 18 of 114 
TABLE OF CONTENTS 
STUDY SYNOPSIS ..................................................................................................................3 
1 
STUDY SCHEMA AND SCHEDULE OF ASSESSMENTS ........................................11 
1.1 
Study Schema.........................................................................................................11 
1.2 
Schedule of Assessments .......................................................................................12 
TABLE OF CONTENTS .........................................................................................................18 
LIST OF IN-TEXT TABLES ..................................................................................................23 
LIST OF IN-TEXT FIGURES.................................................................................................23 
LIST OF APPENDICES ..........................................................................................................23 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS ..........................................24 
2 
INTRODUCTION ...........................................................................................................27 
2.1 
Rationale for Study Design, Control Group, and Dose Selection .........................27 
2.1.1 
Rationale for Dose Selection .......................................................................27 
2.1.2 
Rationale for Study Design and Control Group ...........................................28 
2.1.3 
Rationale for the Primary Endpoint and Age Range ...................................28 
2.1.4 
Rationale for Study Duration of 48 Weeks ..................................................29 
2.2 
Disease and Treatment ...........................................................................................29 
2.2.1 
Duchenne Muscular Dystrophy– Epidemiology and Genetic/Biochemical 
Basis .............................................................................................................29 
2.2.2 
Current Natural History, Disease Management, and Treatment 
Recommendations ........................................................................................30 
2.2.3 
Glucocorticoid Treatment ............................................................................30 
2.2.4 
Dystrophin Restoring Interventions .............................................................31 
2.3 
Background on Viltolarsen ....................................................................................31 
2.3.1 
Mechanism of Action ...................................................................................32 
2.3.2 
Summary of Non-Clinical Findings .............................................................32 
2.3.2.1 
Pharmacology ....................................................................................32 
2.3.2.2 
Pharmacokinetics ...............................................................................33 
2.3.2.3 
Toxicology .........................................................................................34 
2.3.3 
Summary of Clinical Findings .....................................................................36 
2.4 
Risk/Benefit Assessment .......................................................................................39 
2.4.1 
Viltolarsen ....................................................................................................39 
2.4.2 
Procedures ....................................................................................................40 
3 
STUDY OBJECTIVES AND ENDPOINTS ...................................................................41 
4 
HYPOTHESIS .................................................................................................................43 
5 
INVESTIGATIONAL PLAN ..........................................................................................44 
5.1 
Overall Study Design and Plan ..............................................................................44 


NCT04060199 
NS-065/NCNP-01 
 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
v4.0 08Dec2022 
NS Pharma, Inc. – CONFIDENTIAL  
 
Page 19 of 114 
5.1.1 
Number of Centers .......................................................................................44 
5.2 
Design Implementation ..........................................................................................44 
5.2.1 
Randomization .............................................................................................44 
5.2.2 
Investigational Product Dosing ....................................................................44 
5.2.3 
Potential Design Modifications Due to Toxicities .......................................45 
5.2.4 
Infusion Interruptions...................................................................................45 
5.3 
Study Duration and Dates ......................................................................................45 
5.3.1 
Open-Label Extension .................................................................................45 
5.3.2 
End of Study Definition ...............................................................................45 
5.3.3 
End of Treatment .........................................................................................46 
6 
STUDY POPULATION SELECTION ...........................................................................47 
6.1 
Study Population ....................................................................................................47 
6.2 
Inclusion Criteria ...................................................................................................47 
6.3 
Exclusion Criteria ..................................................................................................48 
6.4 
Lifestyle Restrictions .............................................................................................49 
6.4.1 
Meals and Dietary Restrictions ....................................................................49 
6.4.2 
Caffeine, Alcohol, and Tobacco ..................................................................49 
6.4.3 
Activity ........................................................................................................49 
7 
INVESTIGATIONAL PRODUCT ..................................................................................50 
7.1 
Description of Viltolarsen and Placebo .................................................................50 
7.2 
Dispensing Investigational Product .......................................................................50 
7.3 
Instructions for Administration of Investigational Product ...................................50 
7.4 
Blinding..................................................................................................................51 
7.5 
Emergency Unblinding ..........................................................................................51 
7.6 
Treatment Compliance ...........................................................................................51 
7.7 
Overdose ................................................................................................................51 
7.8 
Packaging and Labeling .........................................................................................51 
7.9 
Storage and Accountability ....................................................................................52 
8 
PRIOR AND CONCOMITANT MEDICATIONS AND TREATMENTS ....................53 
8.1 
Prohibited Medications ..........................................................................................53 
8.2 
Allowable Medications ..........................................................................................54 
9 
STUDY PROCEDURES .................................................................................................55 
9.1 
Time and Events Schedule .....................................................................................55 
9.2 
Informed Consent...................................................................................................55 
9.3 
Assignment of Participant Identification Number .................................................56 
9.3.1 
Screen Failures .............................................................................................57 
9.4 
Genetic Confirmation of Diagnosis .......................................................................57 
9.5 
Demographics ........................................................................................................57 


NCT04060199 
NS-065/NCNP-01 
 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
v4.0 08Dec2022 
NS Pharma, Inc. – CONFIDENTIAL  
 
Page 20 of 114 
9.6 
Medical History .....................................................................................................58 
9.7 
Prior and Concomitant Treatment ..........................................................................58 
9.8 
Weight and Height .................................................................................................58 
9.9 
12-Lead Electrocardiograms ..................................................................................58 
9.10 
Vital Signs ..............................................................................................................59 
9.11 
Physical and Neurological Examination ................................................................60 
9.12 
Renal Ultrasound ...................................................................................................60 
9.13 
Adverse Events and Serious Adverse Events ........................................................60 
9.14 
Clinical Laboratory Tests .......................................................................................61 
9.14.1 
Sample Collection, Storage, and Shipping ..................................................61 
9.14.2 
Anti-Dystrophin Antibody ...........................................................................64 
9.14.3 
Anti-Viltolarsen Antibody ...........................................................................64 
9.14.4 
Antigen and Antibody Testing .....................................................................64 
9.15 
Pharmacodynamics and Efficacy Assessments .....................................................64 
9.15.1 
Function and Strength ..................................................................................64 
9.15.1.1 
Time to Stand Test .............................................................................64 
9.15.1.2 
Time to Run/Walk 10 Meters Test.....................................................65 
9.15.1.3 
Six-Minute Walk Test ........................................................................65 
9.15.1.4 
North Star Ambulatory Assessment...................................................65 
9.15.1.5 
Time to Climb 4 Stairs Test ...............................................................66 
9.15.1.6 
Muscle Strength Measured with Hand-Held Dynamometer ..............66 
9.16 
Pharmacokinetic Assessments ...............................................................................66 
9.16.1 
Collection and Assessment of Pharmacokinetic Samples ...........................66 
9.16.2 
Shipment of Pharmacokinetic Samples .......................................................67 
9.17 
Patient Reported Outcomes....................................................................................67 
9.17.1 
Pediatric Outcome Data Collection Instrument (PODCI) ...........................67 
9.17.2 
Personal Adjustment and Role Skills Scale, 3rd Edition (PARS III) 
Questionnaire ...............................................................................................67 
10 STUDY ACTIVITIES .....................................................................................................68 
10.1 
Pretreatment Phase .................................................................................................68 
10.1.1 
Screening Visit (Days -28 to -8) ..................................................................68 
10.1.2 
Pre-Infusion Visit (Days -7 to -1) ................................................................69 
10.1.3 
Randomization .............................................................................................70 
10.2 
Treatment Phase .....................................................................................................70 
10.2.1 
Day 1 Dosing Visit (First Infusion) .............................................................70 
10.2.2 
Week 2 .........................................................................................................71 
10.2.3 
Week 3 .........................................................................................................71 
10.2.4 
Week 4 .........................................................................................................71 
10.2.5 
Week 5 .........................................................................................................72 


NCT04060199 
NS-065/NCNP-01 
 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
v4.0 08Dec2022 
NS Pharma, Inc. – CONFIDENTIAL  
 
Page 21 of 114 
10.2.6 
Weeks 6 to 8.................................................................................................72 
10.2.7 
Week 9 .........................................................................................................72 
10.2.8 
Weeks 10 to 12.............................................................................................73 
10.2.9 
Week 13 .......................................................................................................73 
10.2.10 Weeks 14 to 24.............................................................................................74 
10.2.11 Week 25 .......................................................................................................75 
10.2.12 Weeks 26 to 36.............................................................................................76 
10.2.13 Week 37 .......................................................................................................76 
10.2.14 Weeks 38 to 47.............................................................................................77 
10.2.15 Week 48 .......................................................................................................77 
10.3 
End-of-Treatment Phase ........................................................................................78 
10.3.1 
Week 49 .......................................................................................................78 
10.3.2 
Follow-Up Phone Call .................................................................................79 
10.3.3 
Unscheduled Visit ........................................................................................79 
10.3.4 
Early Termination or Withdrawal from the Study .......................................79 
10.3.5 
Procedures for Early Termination ................................................................81 
10.4 
Participant Replacement ........................................................................................81 
10.5 
Suspension or Termination of Study......................................................................82 
11 SAFETY PROCEDURES AND PROCESSES ...............................................................83 
11.1 
Definition of an Adverse Event .............................................................................83 
11.2 
Definition of a Serious Adverse Event ..................................................................84 
11.3 
Severity ..................................................................................................................85 
11.4 
Relationship ...........................................................................................................86 
11.5 
Adverse Events of Special Interest ........................................................................86 
11.6 
Disease-Related Signs and Symptoms ...................................................................87 
11.7 
Reporting................................................................................................................87 
11.7.1 
Adverse Event Reporting .............................................................................87 
11.7.2 
Adverse Events of Special Interest Reporting .............................................88 
11.7.3 
Serious Adverse Event Reporting ................................................................88 
11.8 
Serious Adverse Event Follow-Up ........................................................................88 
11.9 
Expedited Reporting to Regulatory Authorities ....................................................88 
11.10 Monitoring and Follow-Up of Adverse Events .....................................................89 
11.11 General Monitoring and Management of Abnormal Clinical Laboratory 
Findings..................................................................................................................90 
11.11.1 Monitoring of Renal Function and Urine Analyses .....................................90 
11.12 Monitoring and Management of Abnormal Electrocardiograms ...........................91 
11.13 Intravenous (IV) Access Considerations ...............................................................91 
11.14 Data and Safety Monitoring Board ........................................................................92 


NCT04060199 
NS-065/NCNP-01 
 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
v4.0 08Dec2022 
NS Pharma, Inc. – CONFIDENTIAL  
 
Page 22 of 114 
12 PLANNED STATISTICAL METHODS ........................................................................93 
12.1 
General Considerations ..........................................................................................93 
12.2 
Determination of Sample Size ...............................................................................93 
12.3 
Analysis Populations ..............................................................................................94 
12.4 
Demographics and Baseline Characteristics ..........................................................94 
12.5 
Efficacy Endpoints .................................................................................................94 
12.5.1 
Efficacy Objective .......................................................................................94 
12.5.2 
Secondary Objectives...................................................................................95 
12.5.2.1 
Function and Strength ........................................................................95 
12.5.2.2 
Analysis Comparing Viltolarsen to Placebo ......................................95 
12.6 
Safety Assessments ................................................................................................95 
12.6.1 
Anthropometrics, Vital Signs, Laboratory Assessments, and ECG .............95 
12.6.2 
Physical Examination and Adverse Events ..................................................95 
12.6.3 
Concomitant Medications and/or Other Treatments ....................................96 
12.6.3.1 
Antibodies and Pharmacokinetics ......................................................96 
12.7 
Pharmacokinetic Endpoints and Analysis ..............................................................97 
12.8 
Interim Analyses ....................................................................................................97 
12.9 
Handling of Missing Data ......................................................................................98 
13 REFERENCE LIST .........................................................................................................99 
14 APPENDICES ...............................................................................................................102 
Investigators .....................................................................................................................105 
Informed Consent, Protected Health Information (PHI) and Confidentiality ..................106 
Informed Consent.......................................................................................................106 
Confidentiality ...........................................................................................................106 
Protected Health Information (PHI) ...........................................................................107 
Study Administrative Structure........................................................................................107 
Institutional Review Board/Independent Ethics Committee Approval ...........................108 
Protocol Amendments ......................................................................................................109 
Ethical Conduct of the Study ...........................................................................................109 
Study Monitoring .............................................................................................................110 
On-Site Audits .................................................................................................................111 
Case Report Forms ...........................................................................................................111 
Source Documents ...........................................................................................................112 
Record Retention .............................................................................................................113 
Publication and Disclosure Policy ...................................................................................113 
 


NCT04060199 
NS-065/NCNP-01 
 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
v4.0 08Dec2022 
NS Pharma, Inc. – CONFIDENTIAL  
 
Page 23 of 114 
LIST OF IN-TEXT TABLES 
Table 1. 
Schedule of Study Assessments for Pretreatment Phase to Treatment 
Phase Week 24 ...........................................................................................12 
Table 2. 
Schedule of Study Assessments for Treatment Phase from Week 25 to 
End-of-Treatment Phase ............................................................................15 
Table 3. 
Clinical Laboratory Tests ...........................................................................62 
 
LIST OF IN-TEXT FIGURES 
Figure 1 
 Study Design .............................................................................................11 
 
LIST OF APPENDICES 
Appendix 1 
Sponsor Signatures...................................................................................103 
Appendix 2 
Investigator’s Signature ...........................................................................104 
Appendix 3 
Administrative Considerations.................................................................105 
 
 
 


NCT04060199 
NS-065/NCNP-01 
 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
v4.0 08Dec2022 
NS Pharma, Inc. – CONFIDENTIAL  
 
Page 24 of 114 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
2’O-Me 
6MWT  
2’O-methyl phosphorothioate 
Six-minute Walk Test  
ADL 
AE 
Activities of Daily Living 
Adverse Event 
ATC 
Anatomical Therapeutic Chemical classification 
AUC  
Area under the curve  
BMD 
Becker muscular dystrophy 
Ca 
cDNA 
CGH 
Cl 
CE 
Calcium 
Complementary DNA 
Comparative genomic hybridization 
Chloride 
Clinical evaluator 
CINRG 
Cmax 
CMO 
CRO 
Cooperative International Neuromuscular Research Group  
Maximum Drug Concentration 
Contract manufacturing organization 
Clinical Research Organization 
CSR 
CK  
Clinical Study Report 
Creatine kinase  
cm 
Centimeter 
CTCAE 
Common Terminology Criteria for Adverse Events v4.03 
CVA 
Central venous access 
CYP 
DNA 
Cytochrome P450 
Deoxyribonucleic acid 
DMD  
Duchenne muscular dystrophy  
DNHS  
Duchenne Natural History Study  
DSMB 
DSUR 
ECG 
eCRF 
EU 
FDA 
GC 
GCP 
GFR 
HB 
HCV 
HEENT 
HIPAA 
HIV 
IB 
ICF  
Data and Safety Monitoring Board 
Drug Safety Update Reports 
Electrocardiogram 
Electronic case report form 
European Union 
Food and Drug Administration 
Glucocorticoid 
Good Clinical Practice 
Glomerular filtration rate 
Hepatitis B 
Hepatitis C Virus 
Head, ears, eyes, nose, and throat 
Health Insurance Portability and Accountability Act 
Human Immunodeficiency Virus 
Investigator’s Brochure 
Informed consent form 
ICH 
International Council for Harmonisation 
IEC 
Independent Ethics Committee 
IND  
Investigational New Drug  


NCT04060199 
NS-065/NCNP-01 
 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
v4.0 08Dec2022 
NS Pharma, Inc. – CONFIDENTIAL  
 
Page 25 of 114 
IPIM 
Investigational Product Information Manual 
IRB 
IV 
K 
kg 
Institutional Review Board 
Intravenous(ly) 
Potassium 
Kilogram 
LC-MS/MS 
LLOQ 
Liquid Chromatography Tandem Mass Spectrometry 
Lower limit of quantification 
MedDRA 
Medical Dictionary for Regulatory Activities 
mITT 
MLPA 
Modified intention to treat 
Multiplex Ligation-dependent Probe Amplification 
MMRM 
Mixed effect model repeat measurement 
mRNA 
Messenger ribonucleic acid 
MS  
Mass spectrometry  
Na 
Sodium 
NCNP  
National Center of Neurology and Psychiatry, Japan 
N/D 
Not done 
NOAEL  
No observed adverse effect level  
NSAA 
NSP  
North Star Ambulatory Assessment 
NS Pharma, Inc. 
NS-065/NCNP-01  
NS-065/NCNP-01 drug substance  
NS-065/NCNP-01 
Injection 250 mg 
NS-065/NCNP-01 investigational drug substance solution (250 mg 
vial strength) 
PARS III 
Questionnaire 
Personal Adjustment and Role Skills Scale, 3rd edition 
PCR 
Polymerase chain reaction 
PHI 
PK  
Protected Health Information  
Pharmacokinetic 
PMO  
Phosphorodiamidate morpholino oligomer  
PODCI 
Pediatric Outcome Data Collection Instrument 
PT-INR 
QMT 
QWBA  
Prothrombin Time – International Normalized Ratio 
Quantitative Muscle Testing 
Quantitative whole-body autoradiography 
RT-PCR 
RBC 
Ret 
RIPA 
RNA 
RT-PCR 
SAE  
SAP 
SD 
SRM 
SUSAR 
t1/2 
Tmax 
TEAEs 
Reverse transcriptase polymerase chain reaction 
Red blood cell count 
Reticulocyte 
Radioimmunoprecipitation assay 
Ribonucleic acid 
Reverse transcriptase polymerase chain reaction 
Serious Adverse Event 
Statistical analysis plan 
Standard deviation 
Study Reference Manual 
Suspected unexpected serious adverse reaction 
Terminal Elimination Half-Life 
Time of Maximum Drug Concentration 
Treatment-emergent AEs 


NCT04060199 
NS-065/NCNP-01 
 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
v4.0 08Dec2022 
NS Pharma, Inc. – CONFIDENTIAL  
 
Page 26 of 114 
TICVAD 
Totally implantable central venous access device 
TK 
TNF-α 
Toxicokinetic 
Tumor necrosis factor-alpha 
TTCLIMB  
Time to Climb 4 Stairs Test 
TTRW  
Time to Run/Walk 10 Meters Test 
TTSTAND  
Time to Stand Test 
UPCR 
Urine protein to creatinine ratio 
US 
United States 
WBC 
White blood cell count 


NCT04060199 
NS-065/NCNP-01 
 
 
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Clinical Study Protocol: NS-065/NCNP-01-301 
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2 
INTRODUCTION 
2.1 
Rationale for Study Design, Control Group, and Dose Selection 
2.1.1 Rationale for Dose Selection 
The dose (80 mg/kg/week for 48 weeks) for this study was based on the successful treatment of 
participants at 80 mg/kg/week in Study NS-065/NCNP-01-201 for up to a total of 24 weeks of 
treatment, as well as in the Phase 1/2 Study NS-065/NCNP-01-P1/2 conducted in Japan 
(Japan P1/2).  Results are detailed below.   
Viltolarsen dystrophin levels and exon skipping ratio were assessed in Japan P1/2 
(Study NS065/NCNP01-P1/2) and Study NS-065/NCNP-01-201.  The results are summarized 
below: 
1. Highest dystrophin production measured by Western Blot at 20 to 24 weeks in both 
Japan P1/2 (Study NS065/NCNP01-P1/2 [n = 4]) and Study NS-065/NCNP-01-201 
(n = 8) studies were observed at 80 mg/kg. 
2. Average dystrophin production by group measured by Western Blot at 24 weeks in 
Japan P1/2 (Study NS065/NCNP01-P1/2) was higher at 80 mg/kg (n = 4). 
3. Average dystrophin production by group excluding exon 45-52 mutation measured by 
Western Blot at 20 to 24 weeks in both Japan P1/2 (Study NS065/NCNP01-P1/2) and 
Study NS-065/NCNP-01-201 (n = 3) were higher at 80 mg/kg. 
a) Dystrophin production by patients with exon 45-52 mutation were lower than 
those with other mutation types in both Japan P1/2 (Study NS065/NCNP01-P1/2) 
(n = 4) and Study NS-065/NCNP-01-201 (n = 8) at both 40 and 80 mg/kg. 
4. Average % of dystrophin positive fiber by group measured by immunofluorescence in 
Study NS-065/NCNP-01-201was higher at 80 mg/kg (n = 8). 
5. Average exon skipping ratio by group measured by RT-PCR in both Japan P1/2 
(NS065/NCNP01-P1/2) and Study NS-065/NCNP-01-201were higher at 80 mg/kg. 
6. Safety profiles were comparable in both Japan P1/2 (NS065/NCNP01-P1/2) and 
Study NS-065/NCNP-01-201 studies between 40 and 80 mg/kg. 


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Study NS-065/NCNP-01-201 and Study NS-065/NCNP-01-202 (extension study for 
Study NS-065/NCNP-01-201) have enrolled a total of 16 participants.  As of 28 February 2018, 
there have been no apparent drug-related serious adverse events (SAEs) reported, and no adverse 
events (AEs) led to study drug discontinuation.  One SAE (left tibia/fibula fracture required 
hospitalization for surgery, not-related to drug) was reported in June 2018.  Safety profiles were 
comparable for both studies at 40 mg/kg and 80 mg/kg. 
In summary, the dose of 80 mg/kg/week for 48 weeks is supported, based on dystrophin 
production at 80 mg/kg/week and safety profile (well-tolerated for 168 weeks) in the 2 studies 
(Japan P1/2 (NS065/NCNP01-P1/2) and Study NS-065/NCNP-01-201) conducted to date. 
2.1.2 Rationale for Study Design and Control Group 
The sponsor indicated its preference to conduct a single global confirmatory trial and expressed 
concerns about the impact on enrolling for a placebo-controlled trial after an accelerated 
approval is granted in the United States (US) and Japan.  The Food and Drug Administration 
(FDA) explained the complexity in interpreting a study with natural history as a control group 
due to the heterogeneity of the disease progression in Duchenne muscular dystrophy (DMD), 
unless the drug effect is very large.  Therefore, the FDA reiterated their position that a placebo 
controlled study would be required. 
2.1.3 Rationale for the Primary Endpoint and Age Range 
The primary endpoint for this study is the Time to Stand Test (TTSTAND).  The rationale for 
using TTSTAND as the primary endpoint is:  
• TTSTAND is an objective endpoint that can be measured in a standardized way,  
• TTSTAND is well validated,  
• TTSTAND is clinically meaningful as a measure of patient function, and  
• TTSTAND is an important prognostic factor and more generally can predict disease 
progression.  
TTSTAND is the first functional milestone lost in DMD disease progression (McDonald et al, 
2018; Arora et al, in press).  The sponsor intends to use velocity rather than time (seconds) 


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because the velocity measure is superior to the time (seconds) measure in handling large values 
as patients begin to lose the ability to stand.  
In consideration of boys with DMD who could perform functional tests (Arora et al, in press), 
age range with 4 to <8 years is selected. 
2.1.4 Rationale for Study Duration of 48 Weeks 
Individual participant study duration is 48 weeks, which takes into consideration the feasibility 
of patient enrollment and retention in the proposed placebo-controlled study. 
2.2 
Disease and Treatment 
2.2.1 Duchenne Muscular Dystrophy– Epidemiology and Genetic/Biochemical Basis 
DMD is a disorder of progressive weakness leading to severe disability and ultimately death 
caused by a deficiency of the dystrophin protein.  The reported prevalence of DMD is 15.9 cases 
per 100,000 live male births in the US and 19.5 cases per 100,000 live male births in the UK 
(Ryder et al, 2017; Mendell et al, 2012; Moat et al, 2013).  The symptoms of DMD are often first 
noted at about 3 to 5 years of age, although clinical manifestations may be present as early as the 
first year of life.  Proximal leg weakness impairs mobility and precludes the ability to run or to 
rise from a squatting position.  Complete loss of ambulation follows, with a progressive decline 
of upper extremity strength and function.  Declines in respiratory and cardiac function contribute 
to morbidity later in the disease, ultimately culminating in early lethality (Bushby et al [Part 1], 
2018; Birnkrant et al, 2018.)  The impact of this debilitating condition on those affected by it and 
their families is significant.  
The biochemical basis of DMD is the absence of a functional dystrophin protein in striated 
muscle tissue that is essential for healthy muscle function and muscle fiber integrity.  In normal 
striated muscle the cytoplasmic dystrophin protein links intracellular actin with the extracellular 
matrix to provide structural stability of the muscle cell membrane.  In the majority of patients 
with DMD, dystrophin protein is not produced because of out-of-frame mutations characterized 
by a deletion of one or more exons from the dystrophin gene, which is located on the short arm 
of the X chromosome.  Dystrophin mutations in which some dystrophin protein function remains 
are associated with a similar, but often milder phenotype, classified as Becker muscular 
dystrophy (BMD).  DMD and BMD exhibit X-linked recessive inheritance. 


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2.2.2 Current Natural History, Disease Management, and Treatment Recommendations 
The Cooperative International Neuromuscular Research Group (CINRG) conducted the largest 
prospective multi-center natural history study to date in DMD, the CINRG Duchenne Natural 
History Study (DNHS) (McDonald et al, 2013; Henricson et al, 2013; McDonald et al, 2018).  
The study includes >400 boys and men with DMD, with variable amounts of longitudinal 
follow-up over the course of a decade (2006 to 2016).  The study has annual follow-up visits that 
include timed function tests, muscle strength, questionnaire functional assessments, pulmonary 
function tests, and quality of life assessments.   
Since there is currently no cure for DMD, the goal of care is to provide the best quality of life 
through all stages of the disease.  To date, treatments focus on optimizing strength and function 
through the use of pharmacological interventions, physical therapy, and assistive and adaptive 
devices. 
2.2.3 Glucocorticoid Treatment 
At present, treatment with glucocorticoid (GC) medication is the only pharmacological 
intervention that has been shown to slow the decline of strength and function in DMD patients.  
The two main GCs used in DMD are prednisone and deflazacort (EMFLAZA™).  Daily oral 
administration of prednisone or deflazacort stabilizes or improves strength and prolongs 
ambulation (Drachman et al, 1974; Brooke et al, 1987; Griggs et al, 1993; Mendell et al, 1989; 
Griggs et al, 1991; Fenichel et al, 1991).  The mechanism by which GCs are beneficial in 
dystrophin deficiency is likely multifactorial, including anti-inflammatory actions.  The 
immunosuppressive effects of GCs may not be beneficial, and other immunosuppressants have 
not shown benefit (Griggs et al, 1993).  On February 9, 2017, the US FDA approved 
EMFLAZA™ for the treatment of patients 5 years of age and older with DMD.   
In 2005, the American Academy of Neurology issued a practice parameter regarding GC 
treatment in DMD and recommended that GC should be offered as treatment, despite known side 
effects (Moxley et al, 2005).  The significant side effects of GCs include Cushingoid features, 
adverse behavioral changes, obesity, growth retardation, increased risk for bone fractures, 
gastritis, delayed puberty, cataracts, hypertension, glucose intolerance, susceptibility to infection, 
and masking of response to stress (Matthews et al, 2016). 


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2.2.4 Dystrophin Restoring Interventions 
New therapies based on specific genotypes are in development.  Small molecules that can read 
through nonsense mutations could potentially treat approximately 13% of DMD patients 
(Bushby et al, 2014).  Exon skipping, which uses antisense oligonucleotides to alter the splicing 
pattern of the genes is designed to bring out-of-frame deletions into frame.  The technology of 
exon skipping utilizes antisense oligonucleotides that bind to a specific sequence in the 
messenger ribonucleic acid (mRNA) to alter splicing of exons.  By this means, specific exons 
can be excluded from the final transcript that is exported to the cytoplasm from the nucleus; 
hence the term ‘exon skipping’.  By the design of the oligonucleotide, the out-of-frame deletion 
can be enlarged to include the adjacent exon such that the resulting deletion is in-frame 
(Kole and Krieg, 2015).  
This new type of treatment could potentially treat 80% of DMD patients who have large-scale 
deletion or duplication mutations in the dystrophin gene (Aartsma et al, 2009).  The full 
characterization of DMD patient mutations and further development of the technology will be 
crucial to fully realize these novel therapies as they are developed. 
To date, 2 oligonucleotide chemistries have been brought to the stage of human clinical trial: 
2’O-methyl phosphorothioate (2’O-Me) antisense oligonucleotides (Voit et al, 2014) and 
phosphorodiamidate morpholino oligomers (PMO) for skipping of exon 51 in the dystrophin 
gene (Mendell et al, 2013; Cirak et al, 2012; Cirak et al, 2011). 
A 48-week study of the 2’O-Me compound drisapersen did not reach significance in the 
Six-minute Walk Test (6MWT), which was its primary outcome measure for this Phase 2 study 
(Voit et al, 2014).  The PMO compound eteplirsen was tested in a 48-week study, with the 
number of muscle fibers showing restored dystrophin as its primary outcome measure 
(Mendell et al, 2013).  Eteplirsen (Exondys 51®) was approved by the FDA under the accelerated 
approval pathway on September 19, 2016. 
2.3 
Background on Viltolarsen 
Viltolarsen is a novel antisense oligonucleotide for the treatment of DMD, which has been 
discovered jointly by National Center of Neurology and Psychiatry (NCNP) which is a National 
Research and Development Agency in Japan and Nippon Shinyaku Co., Ltd.  Details of data 
summarized in the following sections can be found in the Investigator’s Brochure. 


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2.3.1 Mechanism of Action 
Viltolarsen is designed to interact with the dystrophin gene ribonucleic acid (RNA) and alter the 
exon/intron splicing patterns.  The mechanism of action is for viltolarsen to bind to a specific 
sequence in or near exon 53 of the dystrophin pre-RNA transcript and block the exon/intron 
splicing of exon 53, leading to mature mRNA transcripts that lack exon 53.  Viltolarsen is 
thought to be effective on DMD patients with exon deletions amenable to skipping of exon 53 
such as 43-52, 45-52, 47-52, 48-52, 49-52, 50-52, or 52.  The loss of exon 53 restores the mRNA 
reading frame, thus converting a DMD (out-of-frame) deletion mutation to a Becker-like 
(in-frame) deletion mutation.  In-frame deletion mutations are typically compatible with 
production of a shortened dystrophin protein, although the resulting Becker-like dystrophin 
protein will be smaller in molecular weight compared to the normal dystrophin protein, and 
likely lower in abundance (quantity) compared to normal muscle, and thus may have lower 
function than normal amounts of wild-type dystrophin protein. 
2.3.2 Summary of Non-Clinical Findings 
2.3.2.1 
Pharmacology 
Viltolarsen (0 to 10 μmol/L) demonstrated sustained exon 53 skipping and dystrophin protein 
expression for at least 2 weeks in cells from a DMD patient with deletion of exons 45–52 and in 
cells from a DMD patient with deletion of exons 48–52.  In cynomolgus monkeys, a dose of 
60 mg/kg viltolarsen resulted in exon 53 skipping in the right gastrocnemius muscles and the 
cardiac muscle in a 12-week intermittent intravenous (IV) toxicity study. 
The potential off-target effect of viltolarsen and its n ± 1 mers among all human mRNA 
sequences was assessed by in silico and in vitro approaches.  Taken together, while CX3CL1, 
APCDD1, FUT1, CNTNAP2 and MYT1 showed some predicted and statistically-significant 
changes on mRNA expression, the clinical relevance for these moderate differences in terms of 
protein expression or predicted effects on physiology in vivo is questionable. 
Viltolarsen did not display any adverse effects in in vitro and in vivo cardiovascular, in vivo 
central nervous system, or in vivo respiratory safety pharmacology studies.  


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2.3.2.2 
Pharmacokinetics 
Pharmacokinetic (PK) and toxicokinetic (TK) analyses revealed no apparent species differences 
for viltolarsen.  None of the in vitro or in vivo metabolism studies showed any distinct evidence 
of metabolism of viltolarsen.  After IV administration, time of maximum plasma concentration 
(Tmax) occurred at the first sampling time after the injection or at the end of the infusion for mice, 
rats, and monkeys.  Maximum plasma concentration (Cmax) and area under the curve (AUC) 
increased with dose, and most increases were approximately proportional to dose, with some 
increases being greater than dose proportional.  For rats, the mean values for t1/2 were 1.19, 1.19, 
and 10.5 hours for 6, 20, and 60 mg/kg.  For monkeys, the mean values for t1/2 ranged from 
1.7 to 3.5 hours.  For mice and monkeys, exposure did not change with 12 or 13 weeks of repeat 
dosing. 
The fraction of viltolarsen bound to rat, monkey, and human serum proteins was low, ≤40%, for 
all species and was independent of concentration.  The distribution of viltolarsen into red blood 
cells was ≤2.5%, ≤6.7%, and ≤3.5% for rat, monkey, and human, respectively, indicating low 
distribution of viltolarsen to red blood cells.  Quantitative whole-body autoradiography (QWBA) 
studies showed wide tissue distribution of [14C] viltolarsen in both mice and monkeys, with the 
highest concentrations observed in the kidney, and general distribution to muscle tissues.  For 
both rats and monkeys, renal excretion was the major route of elimination, with less than 10% in 
the feces.  No radioactivity was in the expired air from the rats.  Most of the radioactivity was 
excreted within the first 24 hours.  However, small measurable amounts continued to be excreted 
in the urine and feces throughout the seven-day collection periods.  
Viltolarsen showed weak inhibition to cytochrome (CYP) 3A4 (Ki value: 1.44 mmol/L), while 
no inhibitory effects were observed to other CYPs (CYP1A2, CYP2B6, CYP2C8, CYP2C9, 
CYP2C19 and CYP2D6).  Viltolarsen did not induce CYP1A2, CYP2B6 and CYP3A4.  
Viltolarsen showed weak inhibition to UGT1A1 (Ki value: 0.642 mmol/L), while no inhibitory 
effects were observed to UGT2B7.  Viltolarsen was not a substrate of transporters (P-gp, BCRP, 
OAT1, OAT3, OCT2, MATE1 and MATE2-K).  Viltolarsen showed weak inhibition to 
OATP1B1, OATP1B3, OAT3 and BCRP (respective IC50 value: 0.485, 0.448, 0.176 and 
1.97 mmol/L), while no inhibitory effects were observed to other transporters (P-gp, OAT1, 
OCT1, OCT2, MATE1, MATE2-K and BSEP). 


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2.3.2.3 
Toxicology 
Histopathological evaluations following a single IV dose of 600 mg/kg in monkeys resulted in 
vacuolation of the epithelium of the proximal renal tubules.  No other renal changes were noted.  
Repeated administration of viltolarsen via the clinically relevant route of administration (weekly 
IV injections) in mice, rats and monkeys resulted in decreases in red blood cell parameters, 
increased values for cytokines and histopathological effects in the kidney and urinary bladder.  
The kidney is the primary target organ in mice, rats and monkeys, as shown by increased values 
in clinical chemistry parameters indicative of renal effects (1000 mg/kg in 4-, 13- and 26-week 
mouse studies, ≥500 mg/kg in 4- and 13-week rat studies, and 600 mg/kg in a 12-week monkey 
study) and by histopathological findings of effects in renal tubules (≥240 mg/kg in 4-, 13- and 
26-week mouse studies, ≥250 mg/kg in 4-week and 13-week rat studies ≥200 mg/kg in 12- and 
39-week monkey studies) accompanied by increased kidney weight at necropsy.  An additional 
histopathological finding in a 26-week mouse study was the presence of cytoplasmic 
eosinophilic material in the transitional epithelium of the urinary bladder at 60 mg/kg and above.  
An increase in blood urea nitrogen (BUN) was observed in all toxicity studies with all species 
mainly at the higher doses.  The main causes of an increase in BUN are high protein diet, 
decrease in glomerular filtration rate (GFR) (suggestive of renal failure) and in blood volume 
(hypovolemia), congestive heart failure, gastrointestinal hemorrhage, fever, and increased 
catabolism.  In the toxicity studies with viltolarsen, BUN increases were considered to be 
attributable to a decrease in GFR.  Based on these data, the no observed adverse effect levels 
(NOAELs) were concluded to be 60 and 15 mg/kg in 13-week and 26-week mouse studies 
respectively and 60 mg/kg in 12-week and 39-week monkey studies respectively. 
Results from in vitro and in vivo genotoxicity studies were negative, and studies showed no 
evidence of chromosomal aberrations. 
In a study of the effects of viltolarsen on fertility and early embryonic development to 
implantation by intermittent IV administration, no toxicologically significant changes were noted 
in copulation rate, copulatory interval, fertility rate, necropsy, organ weights (testes or 
epididymis), sperm examinations, number of corpora lutea, number of implantations, 
implantation rate, preimplantation loss rate, number of live embryos, embryonic viability rate, 
number of postimplantation losses, or postimplantation loss rate.  The NOAELs of viltolarsen 
were 240 mg/kg for general toxicity (based on increases in BUN) and 1000 mg/kg for 


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reproductive function and early embryonic development (no changes observed at the highest 
tested dose). 
Viltolarsen administered to juvenile male mice (from postnatal day 7) at (SC or IV) doses up to 
2000 mg/kg once-weekly (up to 4 weeks) or up to 1200 mg/kg once-weekly (up to 10 weeks) 
suggested tolerability up to 240 mg/kg, after which evidence of toxic effects to the kidney were 
observed (tubular degeneration, basophilia, and vacuolation and chronic progressive nephropathy 
in the kidneys at ≥ 240 mg/kg).  The NOAEL for general toxicity of viltolarsen is 60 mg/kg, and 
for bone growth/geometry and juvenile neurotoxicity of viltolarsen is 1200 mg/kg.  No toxicity 
specific to juvenile animals were noted. 
IV injections of 200 mg/kg showed acceptable local tolerances in cynomolgus monkeys, but 
600 mg/kg IV injections induced signs of inflammation at the injection site in to SC tissue.  
Similarly, IM injections of 100 mg/kg were not suitable for administration of viltolarsen, 
showing inflammation of the injection site. 
No anti-viltolarsen antibodies were detected in the 4-week, 13-week or 26-week mouse studies, 
or in a 39-week monkey study.  Anti-viltolarsen antibodies were detected in 1 male at 200 mg/kg 
in a 12-week monkey study and 1 male at 500 mg/kg in a 13-week rat study.  However, antibody 
detection was not considered to affect the toxicological evaluation in this study, since skipping 
efficiency was confirmed in the muscle of this monkey at the end of the treatment period or no 
remarkable alteration in exposure to viltolarsen was observed after repeated dosing. 
No toxicological differences were noted between lots of viltolarsen produced from an initial 
solid (SP) phase and the new liquid phase (LP2, LP2) synthetic process. 
Viltolarsen was administered once weekly for 26 weeks at dose levels of 
0 (vehicle: physiological saline), 50, 150, and 500 mg/kg (51 mice per group) in male 
CByB6F1-Tg(HRAS)2Jic mice via IV administration with a bolus injection.  After the terminal 
necropsy, macroscopic examinations showed a mass and/or thickening in 1 side of the ureter in 
1 mouse at 50 mg/kg, and in 2 mice at 150 mg/kg, and no findings at 500 mg/kg dose group.  In 
subsequent histopathological examinations on these 3 mice, transitional cell carcinomas were 
noted.  Histopathological examination of the ureters for the other mice was conducted and no 
further tumorigenic changes were identified.  Additionally, no treatment-related tumors were 
noted in any other organs.   


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The blood concentration of viltolarsen in mice who received 50 mg/kg/week was lower than the 
blood concentration of viltolarsen expected in human patients who will receive 80 mg/kg/week. 
2.3.3 Summary of Clinical Findings 
A Phase 1 investigator-initiated study (Study NCNP/DMT01) (ClinicalTrials.gov 
NCT02081625) of viltolarsen injection was conducted in DMD patients (aged 5 to 18 years) to 
investigate the overall usefulness of viltolarsen injection in the treatment of DMD, based on 
evaluations of safety, exploration of predictive markers of treatment response, and assessment of 
PK.  A total of 10 DMD patients were enrolled and randomized.  IV administration of viltolarsen 
injection in doses of 1.25 mg/kg, 5 mg/kg and 20 mg/kg to DMD patients once weekly for 
12 weeks was well tolerated, and no dose-limiting toxicity was observed, although all patients 
had at least one AE.  Moreover, neither SAEs nor incidences of Common Terminology Criteria 
for Adverse Events (CTCAE) v4.0-JCOG (Japanese translation, published by the Japan Clinical 
Oncology Group [JCOG]) Grade 3 (severe) or worse were reported.  
Among the mild and moderate AEs, an increase in beta-N-acetyl-D-glucosaminidase (Grade 1) 
was found in all patients in both cohorts 1 and 2 [Cohort 1 (n = 3) Cohort 2 (n = 3)] and in all but 
one patient in Cohort 3 [Cohort 3 (n = 4)].  
Initially, testing appeared to reveal proteinuria in 8 of 10 patients.  However, it was subsequently 
determined that there was a cross reaction between viltolarsen and the pyrogallol red dye-binding 
method, which was used for urinary protein measurement resulting in a false positive result for 
protein in the 24-hour pooled urine samples.  To evaluate the 24-hour pooled urine samples for 
protein, the Coomassie brilliant blue method was used to re-measure urinary protein in the frozen 
urine samples.  None of the retested samples showed urinary protein levels exceeding the normal 
range of the institution (i.e., 31.2 to 120 mg/day).  Current studies utilize a urine protein 
benzethonium chloride method, using reagents that do not cross react with viltolarsen.  
Viltolarsen exhibited no cross reactivity with the benzethonium chloride method up to 
500 mg/dL.  
The 24-hour pooled urine samples did not show increased levels of albumin.  Spot measurements 
of urinary albumin were positive in 7 patients (Grade 1).  


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Interleukin levels were increased (Grade 1) in the serum in 6 out of 10 patients (high IL-6 level 
in 4 subjects, high IL-1β level in 1 subject, and high IL-2 level in 1 subject), and some level of 
anemia (Grade 1) was observed in 7 out of 10 patients.  
Increased levels of brain natriuretic peptide (Grade 1) in serum were present in 4 patients.  White 
blood cell count (WBC) was increased in 3 patients (Grade 1).  All other mild and moderate AEs 
occurred in 2 or fewer patients. 
The maximum plasma concentration and area under the curve (AUC0-t) values increased in a 
dose-dependent manner, and the t1/2 value was between 1.52 and 1.84 hours. 
Distinct exon 53 skipping efficiency by reverse transcriptase polymerase chain reaction 
(RT-PCR), positive dystrophin fibers by immunofluorescent staining, and dystrophin protein 
expression by Western blot were detected in one patient in Cohort 3, who was the largest patient 
enrolled in the cohort and hence received a largest absolute dose of viltolarsen injection that was 
administered in the study.  
Phase 2 Trials 
Study NS065/NCNP01-P1/2, Study NS-065/NCNP-01-201, and Study NS-065/NCNP-01-202 of 
viltolarsen were completed.  Results for all studies are detailed below. 
Study NS065/NCNP01-P1/2 
Study NS065/NCNP01-P1/2 is a Phase 1/2 study of viltolarsen injection conducted in Japan.  
This was a multi-center, parallel-group, open-label, 24-week study.  Participants received weekly 
IV administration of viltolarsen injection 250 mg (40 mg/kg and 80 mg/kg) over 24 weeks.  The 
primary efficacy endpoint of this study is dystrophin protein expression as measured by Western 
blot, immunofluorescence staining, and RT-PCR.  Sixteen DMD patients amenable to exon 53 
skipping, aged 5 to <18 years were enrolled.   
Viltolarsen injection was well tolerated in up to the highest administered dose of 80 mg/kg; no 
SAEs were observed, one SAE (upper respiratory tract infection, Grade 2, not-related to drug) 
was reported, and no patients discontinued study drug administration as a result of an AE.  
Adverse events included 84 Grade 1 AEs in 10 patients, 11 Grade 2 AEs in 5 patients, and no 
Grade 3 AEs.  The Grade 2 AEs included nasopharyngitis, and eczema, each in 2 patients, and 
miliaria (a common disorder of eccrine sweat glands), pharyngitis, ejection fraction decreased, 
ligament sprain, and urine protein present, each in 1 patient.  No evidence for immunogenicity 


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was found in any Phase 1/2 study participants, as no anti-viltolarsen or anti-dystrophin antibodies 
were detected in DMD patients receiving 40 or 80 mg/kg viltolarsen injection in this study.  
Under the conditions of this clinical trial, viltolarsen injection was safe and well tolerated up to 
80 mg/kg, the highest dose in this study. 
Study NS-065/NCNP-01-201 
Study NS-065/NCNP-01-201 is a Phase 2 study conducted in the US and Canada.   
This was a multi-center, 24-week dose finding study to assess the safety, tolerability, PK, and 
pharmacodynamics of viltolarsen in boys with DMD.  Participants received weekly IV 
administration of viltolarsen injection 250 mg (40 mg/kg and 80 mg/kg) or placebo for the first 
4 weeks, followed by weekly IV administration of viltolarsen injection 250 mg (40 mg/kg and 
80 mg/kg) over the remaining 20 weeks.  The primary efficacy endpoint of this study is 
dystrophin protein expression as measured by Western blot.  Sixteen DMD patients amenable to 
exon 53 skipping, aged 4 to <10 years were enrolled.  There were no apparent drug-related SAEs 
reported, and no AEs led to study drug discontinuation.  There were 59 treatment-emergent 
adverse events (TEAEs) with 23 TEAEs from participants in the low dose cohort and 36 TEAEs 
from participants in the high dose cohort.  Fifty-four of the 59 TEAEs were reported as mild in 
severity, with 5 from the high dose cohort reported as moderate in severity.  There were 55 AEs 
deemed unrelated to study drug and 7 as unlikely related. 
Study NS-065/NCNP-01-202 
Study NS-065/NCNP-01-202 was the extension study for Study NS-065/NCNP-01-201 and was 
conducted in the US and Canada.  There were 16 DMD participants enrolled.  No participants 
died, and no participants discontinued the study or study drug as the result of an AE (or for any 
other reason).  No TEAEs required NS-065/NCNP-01 dose reduction or interruption.  
Three participants had treatment-emergent SAEs.  However, these events were assessed as not 
related to viltolarsen by the investigator.  The most common TEAEs were cough, followed by 
nasopharyngitis, vomiting, pyrexia, arthropod bite, and rash.  Adverse events of special interest, 
added in Protocol Amendment 9, were assessed upon completion of the treatment phase and did 
not raise drug-related safety concerns.  There was no indication of treatment-related kidney 
toxicity.  Of participants who experienced TEAEs, most experienced events of mild severity 
(6 participants, 37.5%) or moderate severity (8 participants, 50.0%).  Two participants (12.5%) 
had TEAEs of maximum severity Grade 3, which were 3 of the SAEs mentioned above: lower 


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limb fracture, rhabdomyolysis, and lower limb fracture.  No TEAEs were assessed by the 
investigator as CTCAE Grades 4 (life-threatening) or 5 (death).  One TEAE (injection site 
extravasation) was assessed as drug-related by the investigator.  There were no treatment-related 
clinically meaningful trends in laboratory parameters, vital signs, or electrocardiograms (ECGs) 
over time or among treatment groups.  Anti-dystrophin antibodies were detected in 2 of the 
16 participants (273104 at Week 145 and 273106 at Week 121).  All other samples were judged 
anti-dystrophin antibody negative.  No participants had anti-NS-065/NCNP-01 antibody results 
at any time.  Treatment with NS-065/NCNP-01 was safe and well tolerated under the conditions 
of this study, for an additional 192-week time period.  Preliminary evidence for clinical benefit 
of viltolarsen-treated participants in comparison with the CINRG DNHS population, matched for 
study criteria, was observed.  Generally, extended improvement in performance on timed 
function tests was confirmed in the viltolarsen-treated participants whereas the CINRG DNHS 
historical control group showed deterioration.  The safety profile in Study NS-065/NCNP-01-202 
confirmed what was seen in the previous 24-week Study NS-065/NCNP-01-201, further 
supporting that viltolarsen was well tolerated.  The results of this study appear to be fully aligned 
with the current, FDA-approved viltolarsen product labeling and prescribing information. 
2.4 
Risk/Benefit Assessment  
2.4.1 Viltolarsen 
There were no important identified risks of viltolarsen in the current clinical development 
program.  Identified important potential risks from non-clinical studies were renal disorder, 
hepatic dysfunction, anemia, drug allergy, immune activation, and transitional cell carcinoma.  
No serious adverse reactions were recognized in the reporting period of the current Drug Safety 
Update Report (DSUR) (May 14, 2017 to May 13, 2018), and there were no actions taken for 
safety reasons, or any significant changes in the Investigator's Brochure (IB). 
At present, none of the safety risks identified during the current reporting period were considered 
to be important risks.  Further, nonclinical adverse effects previously identified as important 
potential risks have not been observed in any of the human studies conducted to date. 


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2.4.2 Procedures 
Risks due to study-related procedures are detailed below. 
Blood sample collection for hematology, chemistry, and PK is associated with the usual risks of 
a blood draw which include pain, bruising at the point where the blood is taken, redness and 
swelling of the vein, infection, and a rare risk of fainting.  In order to decrease any of these 
possible risks the sites will employ pediatric trained staff and will use a numbing cream, if 
desired by the participant, to reduce the risk of pain. 
Function and strength tests will be performed during this study.  These include the TTSTAND, 
Time to Run/Walk 10 Meters Test (TTRW), Six-minute Walk Test (6MWT), North Star 
Ambulatory Assessment (NSAA), and Time to Climb 4 Stairs Test (TTCLIMB).  All tests 
associated with muscle soreness, fatigue, and falls. 
The 6MWT may also cause feelings of pressure or pain in the participant’s chest, difficulty 
breathing, and shortness of breath.  The 6MWT may also cause an increased risk of muscle 
cramping. 
Quantitative muscle strength by hand-held dynamometer may cause fatigue and muscle soreness. 


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3 
STUDY OBJECTIVES AND ENDPOINTS 
Primary Objective(s) 
Primary Endpoint(s) 
• 
To compare the efficacy of viltolarsen 
administered IV at weekly doses of 80 mg/kg 
over a 48-week treatment period vs. placebo 
controls in ambulant boys ages 4 to <8 years 
with DMD using the TTSTAND as a measure 
of strength and function. 
• 
TTSTAND at 48 weeks of treatment 
Secondary Objective(s) 
Secondary Endpoint(s) 
• 
To compare the efficacy of viltolarsen 
administered IV at weekly doses of 80 mg/kg 
in ambulant boys ages 4 to <8 years with 
DMD over a 48-week treatment period vs. 
placebo controls using hierarchical strength 
and endurance outcomes; and 
• 
Hierarchical analysis at 48 weeks 
treatment of the following strength and 
endurance measures: 
o TTRW 
o 6MWT 
o NSAA 
o TTCLIMB 
o Quantitative muscle strength 
measured by hand-held dynamometer 
(elbow extension, elbow flexion, knee 
extension, and knee flexion on the 
dominant side only) 
• 
To evaluate the safety and tolerability of 
viltolarsen administered IV at weekly doses of 
80 mg/kg in ambulant boys ages 4 to <8 years 
with DMD. 
• 
Vital signs (blood pressure, heart rate, 
respiratory rate, and body temperature 
[modality for determining temperature should 
be consistent for each participant at all 
assessment time points throughout the study]) 
• 
Physical examination 
• 
Clinical laboratory tests: 
o Hematology and clinical chemistry 
o Urinalysis 
o Urine cytology 
o Exogenous tracer GFR 
• 
Antibodies to dystrophin and viltolarsen 
• 
12-lead ECG 
• 
Clinical signs and symptoms (AEs and 
SAEs) 
• 
Grading of clinical and clinical laboratory 
AEs will be according to CTCAE v.4.03 
 


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Exploratory Objective(s) 
Exploratory Endpoint(s) 
• 
To evaluate health-related quality of life 
impact of viltolarsen treatment on 
participant’s DMD. 
• 
Pediatric Outcome Data Collection 
Instrument (PODCI) 
• 
Personal Adjustment and Role Skills 
Scale, 3rd edition (PARS III) Questionnaire 
 
 
 


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4 
HYPOTHESIS 
Viltolarsen administered at 80 mg/kg/week, in comparison to placebo, ameliorates the clinical 
course of ambulant boys with DMD as assessed by a muscle functional measure.  The 
improvement in function is due to an increase in muscle tissue dystrophin expression. 
 


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5 
INVESTIGATIONAL PLAN 
5.1 
Overall Study Design and Plan 
This Phase 3 study is a randomized, double-blind, placebo-controlled, multi-center study in 
ambulant boys ages 4 to <8 years with DMD receiving 80 mg/kg viltolarsen administered IV 
weekly over a 48-week treatment period.  See Section 1.1 for study schema. 
5.1.1 Number of Centers 
The study will be conducted at approximately 53 clinical sites in approximately 19 countries, 
predominantly in Europe, Asia, North America, Oceania, and South America. 
5.2 
Design Implementation 
5.2.1 Randomization 
Participants are randomly assigned to either 80 mg/kg/week viltolarsen or placebo in a 1:1 ratio.  
Randomization is carried out with dynamic allocation by minimization method with the 
biased-coin method.  The allocation factors are gene mutation and baseline values for 
TTSTAND, and region (North America, South America, European Union [EU], and Asia).  Once 
randomized, participants will be stratified to the exon 45-52 deletion group or the group of all 
other exon 53-amenable deletions that are not an exon 45-52 deletion.   
The randomization schedule will be generated by an unblinded statistician and maintained by the 
contract manufacturing organization (CMO).  All other parties will be blinded to the 
randomization. 
5.2.2 Investigational Product Dosing 
The dose per participant (in mg) will be calculated based on body weight (in kg) collected per 
the protocol.  Details of dose preparation can be found in the study Investigational Product 
Information Manual (IPIM).  Doses will be administered by an IV infusion over a 1 hour period.  
All missed or incomplete doses will be documented.  The dispensed study drug vials will be 
stored at the research site until drug accountability is verified by the pharmacy monitor. 
In the event it becomes necessary, or at the discretion of the parents/guardian, in consultation 
with the investigator and consulting surgeon and following adequately informed and voluntary 
parent/guardian consent and child assent, a totally implantable central venous access device 
(TICVAD) may be used, contingent upon approval by local and/or country-specific regulatory 


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body(ies). Implantable central venous access (CVA) ports will be considered on a case-by-case 
basis for participants who experience difficulty with peripheral venous access.  Discussions 
regarding implantable ports for participants will include the study site investigator, medical 
monitor, and sponsor.  Before final decision, NS Pharma will obtain documentation from the 
investigator that the consulting surgeon who will place the port holds hospital privileges as a 
board eligible/board certified surgeon.  Implantation should not proceed without sponsor 
approval. Care of the TICVAD (including aseptic access and flushing) and patient monitoring 
must be performed by qualified personnel according to the site’s standard operating procedure. 
An alternative method of CVA may only be considered in the case of a documented 
contraindication to the placement of a TICVAD.  
5.2.3 Potential Design Modifications Due to Toxicities 
Dose reductions or omissions may be necessary for individual participants.  The dose level will 
be determined jointly by the investigator and medical monitor in consultation with the sponsor.   
5.2.4 Infusion Interruptions 
Infusion interruptions may be necessary for individual participants.  Infusion interruptions should 
be handled in accordance with standard procedures should an acute reaction occur during an 
infusion.  Sites should notify the medical monitor in the event of an infusion interruption due to 
an acute reaction. 
5.3 
Study Duration and Dates 
The expected study duration for each participant is approximately 48 weeks.  The Pretreatment 
Phase will last approximately 28 days (inclusive of Screening Visit and Pre-Infusion Visit).  The 
Treatment Phase will last approximately 48 weeks.  The follow-up phase is 30 days. 
5.3.1 Open-Label Extension  
Participants completing the 301 study will have the option to enter an open-label extension study 
in which all participants will receive active study drug.  Participants directly entering the extension 
study will not have the 30 day follow-up telephone call.  
5.3.2 End of Study Definition 
Primary Completion:  The primary completion date is the same as the end of study date and is 
the date when the last participant has completed the study (i.e., last participant last visit). 


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If the study concludes prior to the primary completion date originally planned in the protocol 
(i.e., early termination of the study), then the primary completion date will be the date when the 
last participant is assessed or receives an intervention for evaluation in the study (i.e., last 
participant last visit). 
End of Study:  The end of study date is defined as the date when the last participant at the site is 
assessed or receives an intervention for evaluation in the study (i.e., last participant last visit). 
5.3.3 End of Treatment 
End of treatment is defined as the last assessment for the protocol specified treatment phase of 
the study for an individual participant. 


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6 
STUDY POPULATION SELECTION 
6.1 
Study Population 
Approximately 74 participants (ambulant boys, 4 to <8 years of age) with DMD that meet the 
eligibility criteria below will be enrolled.   
6.2 
Inclusion Criteria 
1. Participant’s parent(s) or legal guardian(s) has (have) provided written informed 
consent and Health Insurance Portability and Accountability Act (HIPAA) 
authorization, where applicable, prior to any study-related procedures; participants 
will be asked to give written or verbal assent according to local requirements; 
2. Participant has a confirmed diagnosis of DMD defined as: 
a. Participant is male with clinical signs compatible with DMD; and 
b. Participant has a confirmed DMD mutation(s) in the dystrophin gene that is 
amenable to skipping of exon 53 to restore the dystrophin mRNA reading 
frame including determination of unambiguously defined exon boundaries 
(using techniques such as Multiplex Ligation-dependent Probe Amplification 
[MLPA], comparative genomic hybridization [CGH] array or other techniques 
with similar capability); 
3. Participant is ≥4 years and <8 years of age at time of first infusion in the study; 
4. Participant is able to walk independently without assistive devices; 
5. Participant is able to complete the TTSTAND without assistance in <10 seconds, as 
assessed at the Screening Visit and the Pre-infusion Visit.  (Note: The TTSTAND 
performed independently from the NSAA should be used to determine eligibility.); 
6. Participant and parent(s)/guardian(s) are willing and able to comply with scheduled 
visits, study drug administration plan, and study procedures; 
7. Participant must be on a stable dose of GC for at least 3 months prior to first dose of 
study drug and is expected to remain on the stable dose of GC treatment for the 
duration of the study. 


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6.3 
Exclusion Criteria 
1. Participant has current or history of chronic systemic fungal or viral infections; 
2. Participant has had an acute illness within 4 weeks prior to the first dose of study drug 
based on the Principal Investigator’s judgment/discretion; 
3. Participant has evidence of symptomatic cardiomyopathy.  (Note: Asymptomatic 
cardiac abnormality on investigation would not be exclusionary.); 
4. Participant has an allergy or hypersensitivity to the study drug or to any of its 
constituents;  
5. Participant has severe behavioral or cognitive problems that preclude participation in 
the study, in the opinion of the investigator; 
6. Participant has a previous or ongoing medical condition, medical history, physical 
findings, or laboratory abnormalities that could affect participant safety, make it 
unlikely that treatment and follow-up will be correctly completed, or impair the 
assessment of study results, in the opinion of the investigator; 
7. Participant has had surgery within the 3 months prior to the first anticipated 
administration of study drug or surgery is planned for anytime during the duration of 
the study; 
8. Participant has positive test results for hepatitis B antigen, hepatitis C antibody, or 
human immunodeficiency virus (HIV) antibody at screening.  (Note: A positive 
hepatitis C antibody result is acceptable if accompanied by a negative hepatitis C 
RNA test and normal bilirubin and gamma-glutamyl transferase results.); 
9. Participant is currently taking any other investigational drug or has taken any other 
investigational drug within 3 months prior to the first dose of study drug or within 
5 times the half-life of a medication, whichever is longer; 
10. Participant was previously enrolled in an interventional study of viltolarsen; 
11. Participant is currently taking any other exon skipping agent or has taken any other 
exon skipping agent within 3 months prior to the first dose of study drug; 
12. Participant has taken any gene therapy; 


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13. Participant is currently taking idebenone, anabolic steroids (e.g., oxandrolone), or 
products containing resveratrol or adenosine triphosphate, or has taken such within 
3 months prior to first dose of study drug.  Coenzyme Q10 or creatine are permitted 
only if the participant is receiving a stable dose for at least 3 months prior to the first 
dose of study drug and for the duration of the study; 
14. Note: There is no exclusion criterion #14.  This criterion was removed from the 
protocol with Amendment 4 (version 3.0, dated 08 January 2021); however, the 
numbering was maintained to avoid documentation errors; 
15. Participant has hydronephrosis, hydroureter, renal or urinary tract calculi, or ureteral 
stenosis by medical history or renal ultrasound. 
Note: Any parameter/test may be repeated at the investigator’s discretion during 
screening to determine sustainability and reproducibility.   
6.4 
Lifestyle Restrictions 
6.4.1 Meals and Dietary Restrictions 
Not applicable. 
6.4.2 Caffeine, Alcohol, and Tobacco 
Not applicable. 
6.4.3 Activity 
Participants are to maintain regular activities. 
 


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7 
INVESTIGATIONAL PRODUCT 
7.1 
Description of Viltolarsen and Placebo 
In this study, investigational product is defined as viltolarsen injection and placebo. 
Investigational product is provided in 5 mL glass vials for dilution and IV administration.  
• Viltolarsen injection 250 mg aqueous solution: 5 mL glass vial containing 50 mg/mL of 
drug substance solution in saline 
• Placebo: 5 mL glass vial of saline without the drug substance solution 
Description:  
• Viltolarsen: Clear, colorless to pale yellow solution  
• Placebo: Matching in clarity and color to viltolarsen 
Stability: Viltolarsen injection 250 mg is stable at 5 ± 3°C.  Additional stability details can be 
found in the IPIM. 
Storage conditions: Store refrigerated at 2° to 8°C. 
Investigational product will be packaged, labeled, and distributed to clinical sites by CMO.  
Additional details for ordering the investigational product can be found in the IPIM and the 
Study Reference Manual (SRM).  
7.2 
Dispensing Investigational Product 
Participants will receive either viltolarsen injection or placebo, based on randomization. 
Participants randomized to viltolarsen will receive IV infusions of viltolarsen injection 
administered once weekly over a 48-week period.  Participants will be dosed at 80 mg/kg/week.  
Participants randomized to placebo will receive IV infusions of placebo administered once 
weekly over a 48-week period.  Participants will be dosed in an equivalent volume to viltolarsen. 
Investigational products will be prepared in accordance with the IPIM by the study site pharmacy 
and administered by IV infusion over a 1-hour period.  
7.3 
Instructions for Administration of Investigational Product 
Administration of prepared investigational product (diluted solution) should be completed within 
6 hours of preparation and may be stored at room temperature during this time.  Additional 


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stability details can be found in the IPIM.  A minimum of 3 days (72 hours) should elapse 
between treatments. 
7.4 
Blinding 
Both the investigational product and the placebo will be of equal volume and equal appearance, 
thus maintaining the blind.  
All site investigators, coordinators, and pharmacists as well as the contract research organization 
(CRO) will remain blinded to treatment assignment.  
7.5 
Emergency Unblinding 
Study sites are provided with an unblinding envelope that contains the code necessary to unblind 
the patient within the study IRT system.  Should sites need to unblind the participant, they will 
follow the instructions within the envelope to log into the study IRT system, enter the code, and 
receive information regarding the participant’s treatment assignment.  Whenever possible, first 
contact the medical monitor to discuss. 
7.6 
Treatment Compliance 
The participant’s compliance with the treatment regimen will be monitored in terms of the 
participant receiving the investigational product infusion every week within a ± 3-day window.  
A minimum of 3 days (72 hours) should elapse between treatments.  Weekly study drug 
treatments for this study should be calculated from the first infusion, not from the previous 
week’s infusion.  If an infusion day is rescheduled, the original scheme should be reinstated as 
soon as possible.  Missed, delayed, or incomplete infusions will be clearly documented and 
considered in the analysis.  The amount of solution received should be documented for all 
infusions.  
7.7 
Overdose 
There is currently no experience with overdose for viltolarsen and no antidote.  The investigator 
should treat the participant’s symptoms as medically appropriate. 
7.8 
Packaging and Labeling 
Investigational product will be packaged and shipped from CMO directly to the investigative site 
as a participant kit.  Each participant kit consists of a single carton of 10 vials.  Ancillary 
supplies will be provided by CMO with each participant kit.  The labeling requirements comply 


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with Annex 13 of the EU Guideline to Good Manufacturing Practice and are in compliance with 
the requirements of Directive 2003/94/EC. 
7.9 
Storage and Accountability 
Investigational Product Storage:  Refrigerated (2° to 8°C), store in original packaging (10 vials in 
light resistant paperboard carton). 
An identified, appropriate, and secure storage location will be defined at each site’s pharmacy for 
the investigational product. 
Additional details regarding proper handling of the investigational product can be found in the 
IPIM. 
The investigator’s or site’s designated investigational product manager is required to maintain 
accurate investigational product accountability records.  All unused investigational product will 
be returned or disposed of as defined in the IPIM.  This information will be included as part of 
the investigational product accountability record. 


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8 
PRIOR AND CONCOMITANT MEDICATIONS AND TREATMENTS 
Glucocorticoid steroids and other pharmacological medications including over the counter 
medications, herbal remedies, supplements, and vitamins used within 3 months prior to the first 
dose of study drug will be recorded in source documents and in the electronic case report form 
(eCRF).  The date of first glucocorticoid steroid use will also be captured.  All medications taken 
throughout the study will be recorded in source documents and in the eCRF.  The following 
information will be collected: the medication name, dose, unit, frequency, route, indication, start 
and stop dates.  
Any non-pharmacological treatment the participant has received within 3 months prior to the 
first dose of study drug will be collected.  The following information will be collected: name of 
treatment, indication, and start and stop date.  Prior non-pharmacologic treatment will be 
recorded in source documents and captured in the relevant eCRF.  Physical therapy schedule 
should not change, and no new physical therapy should be started during the study.  The need for 
changes to physical therapy should be discussed with the medical monitor prior to 
implementation. 
8.1 
Prohibited Medications 
Investigators are reminded to minimize concomitant medication or supplement use or changes to 
GC steroid use unless necessary for medical management. 
The use of idebenone, anabolic steroids (e.g., oxandrolone), and products containing resveratrol 
or adenosine triphosphate is prohibited from 3 months prior to first dose of study drug and 
through the duration of the study.  If growth hormones or supplements with a potential effect on 
muscle strength or function (e.g., coenzyme Q10 or creatine) are used, these should be kept 
stable from 3 months prior to the first dose of study drug through the duration of the study.  
Adjustments based on changes in body habitus are permitted.  Any other 
experimental/investigational products are prohibited from 3 months prior to first dose of study 
drug or within 5 times the half-life of a medication, whichever is longer.  Any other exon 
skipping agents and any gene therapies are prohibited.  Participants who begin another 
investigational product will be withdrawn from the study. 


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8.2 
Allowable Medications 
Investigators may prescribe concomitant medications or treatments deemed necessary to provide 
adequate therapeutic and supportive care.  Specifically, participants should receive full medical 
care during the study, including transfusions of blood and blood products, treatments with 
antibiotics, anti-emetics, anti-diarrheals, analgesics, topical or inhaled steroids, and other care as 
usual.  All concomitant blood products, medications, and supplements will be recorded in source 
documents and in the relevant eCRF.  For a stable dose of glucocorticoid, a stable dose permits 
weight-based adjustments (stable mg/kg). 


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9 
STUDY PROCEDURES 
9.1 
Time and Events Schedule 
The schedule of study assessments is described in Table 1 and Table 2; however, a participant 
can be seen at any time for reasons of safety.  Study events are divided into the following phases: 
• Pretreatment Phase:  
o From execution of the Informed Consent/HIPAA authorization/Assent until 
Day 1 (first infusion). 
• Treatment Phase:   
o From Day 1 (first infusion) until Week 48 (last infusion). 
• Post-treatment Phase:  
o The 30-day interval (including Week 49) beginning after completion of the 
48-week Treatment Phase and ending after a final phone call for collection of 
any information about AEs and concomitant medications for all participants.   
9.2 
Informed Consent 
Each participant’s parent or legal guardian will receive an explanation of the nature and purposes 
of the study from the investigator or designee.  The investigator or designee will ensure the study 
is appropriate for the participant.  Consent must be obtained in accordance with the principles 
outlined in the current version of the Declaration of Helsinki.  The participant’s parent or 
guardian will confirm that s/he understands that the study is for research purposes only and that it 
may not provide any therapeutic benefit to the individual.  Each participant’s parent or guardian 
will confirm that s/he understands that the participant is free to withdraw from the study at any 
time without prejudice.  The investigator or designee will review the elements of the HIPAA and 
Protected Health Information (PHI) with each participant’s parent or guardian and each 
participant’s parent or guardian will confirm that s/he understands HIPAA authorization and 
PHI.  The investigator (or designated staff) will obtain the written informed consent and HIPAA 
authorization on the approved informed consent form (ICF) by the appropriate Institutional 
Review Board/Independent Ethics Committee (IRB/IEC) at each site, from the participant’s 
parent or guardian prior to any study-related procedures, including agreement to discontinuation 


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of any prohibited medications, prior to the start of the study.  The written assent of children will 
be obtained per individual site guidelines.  
The ICF must be dated and signed by the investigator or designee and the participant’s legal 
representative and the original signed consent form must be kept by the investigator in the study 
participant’s file.  “Legal representative” means an individual or judicial or other body 
authorized under applicable law to consent on behalf of a prospective study participant to the 
participant’s participation in the procedure(s) involved in the research.  The study participant’s 
legal representative will receive a copy of the signed consent form. 
If the ICF is amended during the study, the investigator must follow all applicable regulatory 
requirements pertaining to all new participants and repeat the consent process with the amended 
ICF for any ongoing participants. 
9.3 
Assignment of Participant Identification Number 
Study NS-065/NCNP-01-301 participation begins once written informed consent/assent is 
obtained from the parent/legal guardian for a participant before any study-specific procedures are 
performed.  
Following the signing of the written ICF/Assent Form, participants will be assigned a unique, 
site-specific, 6-digit participant identification number in sequential order of screening into the 
study.  The participant identification number will be assigned by the site at the time of 
submission of the de-identified genetic test report to the central genetic counselor to confirm that 
the participant meets the genetic diagnostic eligibility criteria.  If the de-identified genetic test 
report is submitted to the central genetic counselor prior to signing of the ICF (only if acceptable 
per local IRB/IEC), then the report will have personal health information removed prior to 
sending for review.  
All data will be identified using the unique participant identification number.  The assigned 
participant identification number will be retained through enrollment and throughout 
participation in the study.  Participant identification numbers assigned to participants who fail 
screening may not be used again.   


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Each investigator will keep a Participant Identification log relating the names of the participants 
to their participant identification numbers to permit efficient verification of patient files, when 
required.   
9.3.1 Screen Failures 
Participants who fail to meet inclusion criteria are considered to be screen failures and are not 
required to return for additional visits (although a participant can be seen by the investigator at 
any time for safety reasons).  Participants who have failed screening may be rescreened if 
ineligible due to a transient condition.  Rescreening may be performed twice between Day -28 to 
Day -8.  Once the rescreening has failed, the participant should repeat all screening procedures.  
This full re-screening may be performed up to two times, after which the participant is no longer 
eligible for the study. 
If rescreening is more than 90 days since a current ICF/Assent form has been signed and/or the 
consent form has been modified from their original consent, participants should be re-consented 
prior to rescreening procedures. 
9.4 
Genetic Confirmation of Diagnosis 
As part of the screening assessments the central genetic counselor will review the de-identified 
genetic report to confirm the participant’s DMD diagnosis and presence of a mutation that is 
eligible for skipping of exon 53.  The date of diagnosis, method of diagnosis, diagnosis results 
will be documented in source documents and captured in the relevant eCRF.   
A DMD genetic test at Day 1 will be conducted in order to obtain uniform DMD mutation 
information for the exact intronic boundaries and will be analyzed by a central laboratory. 
9.5 
Demographics 
The following information will be collected: date of birth (if allowed by local regulations), race, 
ethnicity, and hand dominance and documented in source documents and captured in the relevant 
eCRF.  If local regulations do not allow collection of full date of birth, then year of birth should 
be collected. 


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9.6 
Medical History 
The investigator or designee will obtain detailed information regarding all past medical and 
surgical events.  The dates and descriptions of past events will be documented in source 
documents and captured in the relevant eCRF. 
9.7 
Prior and Concomitant Treatment 
The investigator or designee will review prior and concomitant treatment as indicated in Table 1 
and Table 2.  See Section 8 for additional details. 
9.8 
Weight and Height 
Standing height, and weight will be collected at the visits specified in Table 1 and Table 2.  
Standing height will be collected with the participant barefoot (without shoes).  The participant’s 
legs should be kept as close as possible and the participant’s heels should be placed back as close 
to the wall as possible.  Participant may hold on to an object to facilitate balance.  Weight will be 
collected with the participant wearing no shoes and light-weight clothes.  Height and weight 
should take approximately 2 minutes.  These measurements are routinely performed during 
standard clinical examinations of participants with DMD.  Weight in kilograms (kg) and height 
in centimeters (cm) will be documented in source documents and captured in the relevant eCRF. 
9.9 
12-Lead Electrocardiograms 
12-lead ECGs will be collected at the times specified in the schedule of study assessments 
(Table 1 and Table 2) and will be centrally read.   
ECGs will be performed with the participant having rested for at least 5 minutes, and the 
participant should remain in the supine or semi-recumbent position.  A consistent position should 
be maintained for each individual participant.  Skin preparation should be thorough and 
electrodes should be placed according to standard 12-lead ECG placement.  Digital ECGs will be 
submitted to the ECG core laboratory, which will perform the digital ECG analysis and 
interpretation in this study. 
On Day 1, triplicate ECGs, each approximately 1 to 2 minutes apart, will be collected at predose 
as well as 1 hour (up to 20 minutes following completion of the infusion) and 
3 hours (± 20 minutes) after initiation of infusion.  At the Screening Visit; Weeks 13, 25, 37, and 


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49; and early termination, single ECGs will be collected (predose is recommended at Weeks 13, 
25, and 37). 
9.10 
Vital Signs 
Vital signs will be measured at each study visit as specified in Table 1 and Table 2.   
Vital signs can be measured in the supine, semi-recumbent, or sitting position.  A consistent 
position should be maintained for each individual participant.  Whenever vital signs, 12-lead 
ECGs, and blood draws are scheduled for the same nominal time, the assessments should occur 
in the following order: 12-lead ECG, vital signs, blood draws, with vital signs obtained without 
repositioning.  If the participant changes position during or after the ECG assessment, then a 
5-minute rest would need to occur in the new position prior to measuring vital signs.  Otherwise, 
vital signs can be measured immediately after the ECG is completed, and blood draws can occur 
immediately after vital signs.  At time points after infusion when vital signs are measured but 
ECGs are not performed, participants should maintain the position in which they were infused.  
At all other times when vital signs are measured but ECGs are not performed, vital signs will be 
measured after a 5-minute rest.   
Vital signs will be measured at predose as well as 1 hour (up to 20 minutes following completion 
of the infusion) and 2 hours (± 20 minutes) after initiation of infusion.  If a clinically significant 
change from predose is observed at 2 hours after initiation of infusion, the parameter will be 
measured again at 6 hours (± 20 minutes) after initiation of infusion.  Vital signs will be 
measured prior to any blood collection scheduled at the same time point and will include the 
following: 
• Systolic blood pressure, 
• Diastolic blood pressure,  
• Heart rate,  
• Respiratory rate, 
• Temperature. 
Vital signs will be documented in source documents and captured in the relevant eCRF.  Any 
clinically significant changes noted by the investigator should be reported as an AE. 


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9.11 
Physical and Neurological Examination 
The physical and neurological examinations will be performed at the visits specified in the 
schedule of study assessments (Table 1 and Table 2) to assess any changes in physical 
presentation and symptoms. 
Physical and neurological examinations will include an assessment of the following: 
• General appearance; 
• HEENT (head, ears, eyes, nose, and throat); 
• Skin; 
• Lymph nodes; 
• Heart, including rhythm, heart sounds and presence of cardiac abnormalities; 
• Lungs; 
• Abdomen; 
• Extremities/joints; 
• Nervous system; 
• Any additional assessments necessary to establish baseline status or evaluate symptoms or 
adverse experiences. 
Abnormal findings will be assessed for clinical significance and details provided in the eCRF.  
Documentation of the physical and neurological examination findings will be included in the 
source documentation at the clinical site.   
9.12 
Renal Ultrasound 
Renal ultrasound will include imaging of the kidneys, ureters, and bladder and be performed at 
visits specified in the schedule of study assessments (Table 1 and Table 2).  Except for the 
screening assessment, renal ultrasound can occur up to 2 weeks prior to or after the scheduled 
week, as needed for scheduling purposes.  Renal ultrasound will be assessed by local urologists 
or other appropriately trained medical professionals. 
9.13 
Adverse Events and Serious Adverse Events 
Investigators will assess the occurrence of AEs and SAEs each study visit, or participant contact 
during the study.  AEs and SAEs may be reported by the participant/parent, discovered upon 
questioning, detected during examinations or review of test and lab results.  AEs and SAEs 
should be documented in the source documents and the relevant eCRF with a full description 


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including the nature, date and time of onset and resolution, determination of seriousness, 
severity, causality, corrective treatment, and outcome.  Refer to Section 11 for safety procedures 
and reporting. 
9.14 
Clinical Laboratory Tests 
Clinical laboratory assessments will be performed at visits specified in the schedule of study 
assessments (Table 1 and Table 2).  Any blood sampling that occurs during the investigational 
product infusion should be collected from a location away from the investigational product 
infusion placement (i.e., opposite arm). 
9.14.1 Sample Collection, Storage, and Shipping 
Each participant will have blood drawn and urine collected for the blood and urine laboratory 
safety assessments as listed/described in the sections below and the schedule of study 
assessments (Table 1 and Table 2), including hematology, chemistry, urinalysis, 24-hour urine 
analysis, urine cytology, exogenous tracer GFR, anti-dystrophin antibody, anti-viltolarsen 
antibody, and viral antigen and antibody testing. 
Blood draw volumes will be 8.5 to 24.0 mL per day at screening, Day 1, Weeks 3, 5, 9, 13, 17, 
21, 25, 37, 49, and EOT, totaling up to approximately 163.5 mL over the course of the study.  No 
more than 47.0 mL will be drawn in a 4-week period. 
For post screening urinalyses, patients will collect a first morning void urine sample on the date 
of the specified visit and bring it to the site according to the schedule of study assessments 
(Table 1 and Table 2).  Analysis of the sample will include urine dipstick protein to be performed 
at the site.  An aliquot will also be sent to the central laboratory for urinalysis (see Table 3 for a 
list of the laboratory analytes that will be measured for all urinalyses, including the first morning 
void urinalysis). 
If first morning void urine dipstick protein 2+, urine protein to creatinine ratio (UPCR) 
0.5 mg/mg, or UPCR 2  baseline, a first morning void urine dipstick protein will be repeated 
within 1 week.  If 1 or more of these criteria are met again on the repeat test, a 24-hour urine 
sample will be collected within 1 week of the results to assess protein and creatinine.  Caregivers 
will be provided a diary to enter void times during the 24-hour collection period.  When 
obtaining this 24-hour urine, the patient will be asked to urinate in the toilet immediately after 


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waking up on the day of the test.  This time will be recorded in the diary as the start time.  
Directions will be provided for collection throughout the test, and documentation of all 
subsequent voids will be recorded in the diary through the first sample immediately after 
awakening on the following morning, as close to 24-hours later as possible.  Refer to 
Section 11.11.1 for additional details on monitoring of renal function and urine analyses. 
If serum cystatin C 1.5  baseline, or if serum creatinine 2  baseline and 0.3 mg/dL, the test 
will be repeated within 1 week of the results.  Refer to Section 11.11.1 for additional details on 
monitoring of renal function and urine analyses. 
GFR will be determined using an exogenous tracer test, if available, at the Pre-Infusion Visit and 
Week 49 (or at early termination, if applicable).  This should be done per standard of care at the 
institution. 
Samples will be collected by a trained member of the study team unless otherwise noted.   
All blood and urine samples will be sent to the designated central laboratory for testing unless 
otherwise noted.  The urine cytology samples will be collected predose at the site and sent to a 
local laboratory for analysis.  The procedures for the collection, handling, and shipping of central 
laboratory samples will be specified in the Laboratory Manual.  Clinical laboratory tests are 
listed in Table 3. 
Table 3. Clinical Laboratory Tests 
Hematology, Chemistry, Urinalysis (Screening, First Morning Void, and Postdose), 24-Hour Urine 
Analysis, Urine Cytology, and Glomerular Filtration Rate – Safety Labs 
• Hematology 
o Red blood cell count 
o Hemoglobin 
o Hematocrit 
o Reticulocyte count 
o Mean corpuscular volume 
o Mean corpuscular hemoglobin 
o Mean corpuscular hemoglobin concentration 
o White blood cell count 
o White blood cell differential 
o Platelet count 
o Fibrinogen  
o Activated partial thromboplastin time 
o Prothrombin international normalization ratio 
• Blood Chemistry 


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o Sodium 
o Potassium 
o Chloride 
o Calcium 
o Inorganic phosphorus 
o Blood urea nitrogen 
o Creatinine 
o Cystatin C  
o Aspartate aminotransferase  
o Alanine aminotransferase   
o Gamma-glutamyl transferase 
o Alkaline phosphatase 
o Haptoglobin  
o Lactate dehydrogenase/lactate dehydrogenase isozyme 
o Creatine kinase 
o Total bilirubin (Direct/Indirect)  
o Total protein 
o Albumin 
o Albumin to globulin ratio 
o Total cholesterol  
o Triglyceride  
o Blood glucose   
o C-reactive protein 
• Urinalysis (Screening, First Morning Void, and Postdose) 
o Glucose 
o Blood 
o Urobilinogen 
o Specific gravity 
o Osmolality 
o Urinary sediment (erythrocytes, white blood cells, casts, epithelial cells, crystals)  
o Protein (benzethonium chloride method) 
o Microalbumin 
o N-acetyl-beta-D-glucosaminidase 
o α1-microglobulin 
o 2-microglobulin 
o Creatinine 
o Protein to creatinine ratio 
o Protein to osmolality ratio 
o Dipstick protein (to be performed by the site on the first morning void urine 
samples) 
• 24-Hour Urine Analysis 
o Protein (benzethonium chloride method) 
o Creatinine 
• Urine Cytology 
• Glomerular Filtration Rate (via Exogenous Tracer Test) 


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9.14.2 Anti-Dystrophin Antibody 
Anti-dystrophin antibody testing will be performed on serum samples collected predose during 
the visits specified in the schedule of study assessments (Table 1 and Table 2).  Samples will be 
analyzed by Shin Nippon Biomedical Laboratories, Ltd. (Japan). 
9.14.3 Anti-Viltolarsen Antibody 
Anti-viltolarsen antibody testing will be performed on serum samples collected predose during 
the visits specified in the schedule of study assessments (Table 1 and Table 2).  Samples will be 
analyzed by Shin Nippon Biomedical Laboratories, Ltd. (Japan).  
9.14.4 Antigen and Antibody Testing 
Antigen and antibody testing will be performed during the screening assessment.  The following 
tests will be performed: hepatitis B antigen, hepatitis C antibody, and HIV antibody.  
9.15 
Pharmacodynamics and Efficacy Assessments 
9.15.1 Function and Strength 
All function and strength testing will be performed by a trained site clinical evaluator (CE).  The 
same CE should perform testing on the same participant throughout the study when possible.  
Instructions and further details on these tests can be found within the CE Manual. 
The function and strength measures will be videotaped to ensure that they are being conducted 
properly and consistently by the CE, where possible and upon consent.  The videotaping will 
only be used to standardize the assessment in the tests.  The videos will be reviewed centrally by 
an experienced physiotherapist reviewed and will be compiled and stored confidentially in the 
video review portal in compliance with all ISO requirements and in compliance with data 
protection requirements.  The video review does not affect the assessment results and adoption of 
the test data.  The patient will be allowed to participate in the study if they meet all other criteria 
even if they do not agree to the recording or recording is not permitted at the site.  
9.15.1.1 
Time to Stand Test 
TTSTAND will be performed by a CE at visits specified in the schedule of study assessments 
(Table 1 and Table 2).  This test will assess the time it takes the participant to go from lying flat 
on the floor to standing and is administered as an independent test in addition to as part of the 
NSAA (see Section 9.15.1.4).  The number of seconds required to perform the test and the 


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assessment of a 6-point rating scale of how the participant attains the standing position will be 
documented in source documents and captured in the relevant eCRF.  The TTSTAND is 
performed independently and as part of the NSAA.  The TTSTAND performed independently 
from the NSAA should be used to determine eligibility to satisfy inclusion criterion #5. 
9.15.1.2 
Time to Run/Walk 10 Meters Test 
TTRW will be performed by a CE at visits specified in the schedule of study assessments 
(Table 1 and Table 2).  This test will assess the time it takes the participant to walk/run 10 meters 
including a 6-point rating scale for quality of the run/walk and is administered as an independent 
test in addition to as part of the NSAA (see Section 9.15.1.4).  The number of seconds required 
to perform the test will be documented in source documents and captured in the relevant eCRF.  
The TTRW is performed independently and as part of the NSAA. 
9.15.1.3 
Six-Minute Walk Test  
The 6MWT will be performed by a CE at visits specified in the schedule of study assessments 
(Table 1 and Table 2).  The 6MWT is a widely used and accepted test.  The version of the 
6MWT adapted for use in DMD will be used (McDonald et al, 2010).  To perform the test, 
2 points (cones) are set 25 meters apart and participants are asked to walk back and forth, 
between the cones quickly and safely for 6 minutes.  The total distance in meters that the 
participant walks in 6 minutes is recorded.  This test is considered a simple, standardized, 
low-technology and cost-effective means of clinically assessing 1) functional motor status and 
2) integrated and global responses to exercise.  The CE will measure the number of steps taken 
by the participant for the first 50 meters and total meters walked in 6 minutes.  This test should 
take approximately 30 minutes.  
9.15.1.4 
North Star Ambulatory Assessment  
NSAA will be performed by a CE at visits specified in the schedule of study assessments 
(Table 1 and Table 2).  The NSAA is a clinician rated, 17-item, functional scale originally 
designed for ambulant boys with DMD who are able to ambulate at least 10 meters 
(Mazzone et al, 2009).  This evaluation tool assesses functional activities including standing, 
getting up from the floor, negotiating steps, hopping, and running.  The assessment is based on a 
3-point rating scale of 2 = ability to perform the test normally, 1 = modified method or assistance 


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to perform test, 0 = unable to perform the test.  Thus, total score can range from 0 (completely 
non-ambulant) to 34 no impairment on these assessments.  Individual test item scores and total 
score will be recorded in source documents and in the relevant eCRF.  This test should take 
approximately 20 minutes. 
9.15.1.5 
Time to Climb 4 Stairs Test 
TTCLIMB will be performed by a CE at visits specified in the schedule of study assessments 
(Table 1 and Table 2).  This test will assess the time it takes the participant to climb 4 stairs 
(Brooke et al, 1981) and will assess a 6-point rating scale to assess how the participant negotiates 
the stairs (see Section 9.15.1.4).  This test should take approximately 5 minutes.  The number of 
seconds required to perform the test will be documented in source documents and captured in the 
relevant eCRF. 
9.15.1.6 
Muscle Strength Measured with Hand-Held Dynamometer 
Muscle strength will be measured for elbow extension, elbow flexion, knee extension, and knee 
flexion on the dominant side only using a hand-held dynamometer at visits specified in the 
schedule of study assessments (Table 1 and Table 2).  This test should take approximately 
15 minutes.  The force generated for each muscle strength measure will be documented in source 
documents and captured in the relevant eCRF. 
9.16 
Pharmacokinetic Assessments 
9.16.1 Collection and Assessment of Pharmacokinetic Samples 
PK assessments will be performed at visits specified in the schedule of study assessments 
(Table 1 and Table 2).  PK sampling post infusion times are measured from the start of infusion.  
Infusion is expected to take 1 hour to complete.  Postdose PK should not be drawn from the 
cannula that was used for the infusion.  These samples can be drawn from the arm opposite the 
infusion or can be from a separate distal access point in the same arm as the infusion.  This 
postdose PK draw requirement is in place to prevent any contamination with viltolarsen derived 
from the dosing cannula.  Blood will be drawn from participants for PK analysis at the following 
sampling times: 
• Day 1 (first dose):  
- 
Predose (within 60 minutes prior to dose) 
- 
1 hour (up to 20 minutes following completion of the infusion) 


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- 
3 hours (± 20 minutes) 
- 
6 hours (± 20 minutes)   
• Week 13: 
- 
Predose (within 60 minutes prior to dose) 
- 
2 hours (± 20 minutes)  
• Week 25: 
- 
Predose (within 60 minutes prior to dose) 
- 
2 hours (± 20 minutes)  
• Week 37: 
- 
Predose (within 60 minutes prior to dose) 
- 
2 hours (± 20 minutes)  
• Week 48: 
- 
Predose (within 60 minutes prior to dose) 
- 
2 hours (± 20 minutes) 
- 
6 hours (± 20 minutes) 
 
Appropriate PK samples will be collected and processed by a trained member of the study team 
for shipment to the central laboratory who will forward to BML, Inc. (Japan) for analysis.  
Procedures for the collection, handling, and shipping of laboratory samples will be specified in 
the Laboratory Manual. 
9.16.2 Shipment of Pharmacokinetic Samples 
Plasma PK samples will be shipped frozen on dry ice according to instructions provided in the 
Laboratory Manual. 
9.17 
Patient Reported Outcomes 
9.17.1 Pediatric Outcome Data Collection Instrument (PODCI) 
The questionnaire to document health related quality of life is the Pediatric Outcomes Data 
Collection Instrument (PODCI).  It is designed to be completed by the parent/guardian of the 
children aged 10 or younger.  Please refer to the SRM for further details on how to administer 
the PODCI questionnaire. 
9.17.2 Personal Adjustment and Role Skills Scale, 3rd Edition (PARS III) Questionnaire 
Personal Adjustment and Role Skills Scale, 3rd edition (PARS-III) is a questionnaire designed for 
Duchenne muscular dystrophy young men that asks parents/guardians about their child’s 
well-being and psychosocial adjustment (https://www.ncbi.nlm.nih.gov/pubmed/18650207).  
Please refer to the SRM for further details on how to administer the PARS-III Questionnaire. 


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10 
STUDY ACTIVITIES 
10.1 
Pretreatment Phase 
The pretreatment phase will be comprised of a minimum of 2 visits; a Screening Visit to allow 
the investigator to assess the participant’s eligibility, and a Pre-Infusion Visit.  The SRM and CE 
manual provides additional details on order of testing and data collection information. 
10.1.1 Screening Visit (Days -28 to -8) 
The ICF/assent must be obtained prior to any study related procedures being conducted.  
Screening will include assessments to confirm eligibility (review of inclusion/exclusion criteria 
and review to confirm the DMD diagnosis and appropriate mutations).   
Screening activities: 
• Informed consent/assent  
• Review of inclusion/exclusion criteria 
• Confirm DMD diagnosis 
• Demographics 
• Medical and surgical history 
• Concomitant medication and treatment history 
• Height and weight 
• 12-lead ECG 
• Vital signs 
• Physical and neurological examination 
• Renal ultrasound of kidneys, ureters, and bladder 
• Function and strength 
o TTSTAND 
o TTRW 
o NSAA  
o TTCLIMB 
o Hand-held dynamometer 
o 6MWT 


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• Patient reported outcomes 
o PODCI 
o PARS III Questionnaire 
• Antigen and antibody testing: HBs antigen, HCV antibody, HIV antibody 
• Hematology 
• Chemistry 
• Urinalysis (random urine) 
• AE review 
10.1.2 Pre-Infusion Visit (Days -7 to -1) 
• Review of inclusion/exclusion criteria 
• Concomitant medications and treatment history; any changes will be noted 
• Height and weight 
• Vital signs  
• Physical and neurological examination 
• First morning void urinalysis 
Note: Analysis of the first morning void urine sample will include urine dipstick protein 
to be performed at the site. 
• Urine cytology (utilizing a urine sample collected on-site) 
• Exogenous tracer GFR 
Note: This should be done, if possible, per standard of care at the institution. 
• Function and strength 
o TTSTAND 
o TTRW 
o NSAA  
o TTCLIMB  
o Hand-held dynamometer 
o 6MWT 


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• Patient reported outcomes 
o PODCI 
o PARS III Questionnaire 
• AE review 
10.1.3 Randomization 
Randomization request will be submitted to the designated CRO and a copy to NS Pharma as 
described in the SRM.  Request for randomization will be made after all screening procedures 
are performed and prior to the first treatment. 
10.2 
Treatment Phase 
If allowed per local regulations, Weeks 6 to 8, 10 to 12, 14 to 16, 18 to 20, 22 to 24, 26 to 36, 
and 38 to 47 can be completed at a non-site location via the home health vendor.  NS Pharma 
reserves the right to require visits to be completed at the site, if needed. 
A ± 3 day window is permitted for each weekly visit from Weeks 2 to 48, inclusive. 
10.2.1 Day 1 Dosing Visit (First Infusion) 
The following assessments will occur: 
• Confirmed diagnosis of DMD 
• Concomitant medications and treatment history; any changes will be noted 
• Height and weight 
• 12-lead ECG 
• Vital signs 
• Physical and neurological examination  
• Hematology 
• Chemistry 
• Postdose urinalysis (utilizing a urine sample collected within 5 hours after completion of 
the infusion)  
• Anti-dystrophin antibody (predose) 
• Anti-viltolarsen antibody (predose) 
• PK blood sample (pre and postdose) 
• Investigational product administration 


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• AE review  
10.2.2 Week 2 
The following assessments will occur: 
• Review of medical and surgical procedures, concomitant medications, and other 
treatments; any changes will be noted  
• Vital signs 
• Investigational product administration  
• AE review 
10.2.3 Week 3  
The following assessments will occur: 
• Review of medical and, surgical procedures, concomitant medications, and other 
treatments; any changes will be noted  
• Vital signs 
• Hematology 
• Chemistry 
• First morning void urinalysis 
Note: Analysis of the first morning void urine sample will include urine dipstick protein 
to be performed at the site. 
• Investigational product administration  
• AE review 
10.2.4 Week 4 
The following assessments will occur: 
• Review of medical and surgical procedures, concomitant medications, and other 
treatments; any changes will be noted  
• Vital signs 
• Investigational product administration  
• AE review 


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10.2.5 Week 5 
The following assessments will occur: 
• Review of medical and surgical procedures, concomitant medications, and other 
treatments; any changes will be noted 
• Vital signs  
• Physical and neurological examination 
• Hematology  
• Chemistry  
• First morning void urinalysis 
Note: Analysis of the first morning void urine sample will include urine dipstick protein 
to be performed at the site. 
• Investigational product administration  
• AE review 
10.2.6 Weeks 6 to 8 
The following assessments will occur: 
• Review of medical and surgical procedures, concomitant medications, and other 
treatments; any changes will be noted  
• Vital signs  
• Investigational product administration  
• AE review 
10.2.7 Week 9 
The following assessments will occur: 
• Review of medical and surgical procedures, concomitant medications, and other 
treatments; any changes will be noted  
• Vital signs  
• Physical and neurological examination  
• Hematology  
• Chemistry  


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• First morning void urinalysis 
Note: Analysis of the first morning void urine sample will include urine dipstick protein 
to be performed at the site. 
• Investigational product administration  
• AE review 
10.2.8 Weeks 10 to 12 
The following assessments will occur: 
• Review of medical and surgical procedures, concomitant medications, and other 
treatments; any changes will be noted  
• Vital signs  
• Investigational product administration  
• AE review 
10.2.9 Week 13 
The following assessments will occur: 
• Review of medical and surgical procedures, concomitant medications, and other 
treatments; any changes will be noted  
• Height and weight 
• 12-lead ECG 
• Vital signs 
• Physical and neurological examination 
• Renal ultrasound of kidneys, ureters, and bladder 
• Hematology  
• Chemistry  
• First morning void urinalysis  
Note: Analysis of the first morning void urine sample will include urine dipstick protein 
to be performed at the site. 
• Urine cytology (utilizing a predose urine sample collected on-site) 
• Postdose urinalysis (utilizing a urine sample collected within 5 hours after completion of 
the infusion) 
• Anti-dystrophin antibody (predose) 


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• Anti-viltolarsen antibody (predose) 
• PK blood sample (pre and postdose) 
• Function and strength  
o TTSTAND 
o TTRW 
o NSAA 
o TTCLIMB  
o Hand-held dynamometer 
o 6MWT 
• Patient reported outcomes 
o PODCI 
o PARS III Questionnaire 
• Investigational product administration 
• AE review 
10.2.10 Weeks 14 to 24 
The following assessments will occur: 
• Review of medical and surgical procedures, concomitant medications, and other 
treatments; any changes will be noted 
• Vital signs  
• Physical and neurological examination (Week 17 and Week 21 only) 
• Hematology (Week 17 and Week 21 only) 
• Chemistry (Week 17 and Week 21 only) 
• First morning void urinalysis (Week 17 and Week 21 only) 
Note: Analysis of the first morning void urine sample will include urine dipstick protein 
to be performed at the site. 
• Investigational product administration  
• AE review 


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10.2.11 Week 25 
The following assessments will occur: 
• Review of medical and surgical procedures, concomitant medications, and other 
treatments; any changes will be noted 
• Height and weight 
• 12-lead ECG 
• Vital signs 
• Physical and neurological examination 
• Renal ultrasound of kidneys, ureters, and bladder 
• Hematology  
• Chemistry  
• First morning void urinalysis  
Note: Analysis of the first morning void urine sample will include urine dipstick protein 
to be performed at the site. 
• Urine cytology (utilizing a predose urine sample collected on-site) 
• Postdose urinalysis (utilizing a urine sample collected within 5 hours after completion of 
the infusion) 
• Anti-dystrophin antibody (predose) 
• Anti-viltolarsen antibody (predose) 
• PK blood sample (pre and postdose) 
• Function and strength   
o TTSTAND 
o TTRW 
o NSAA 
o TTCLIMB  
o Hand-held dynamometer 
o 6MWT 
• Patient reported outcomes 
o PODCI 
o PARS III Questionnaire 


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• Investigational product administration 
• AE review 
10.2.12 Weeks 26 to 36 
The following assessments will occur: 
• Review of medical and surgical procedures, concomitant medications, and other 
treatments; any changes will be noted 
• Vital signs 
• Investigational product administration 
• AE review 
• First morning void urinalysis (Week 29 and Week 33 only) 
Note: Analysis of the first morning void urine sample will include urine dipstick protein 
to be performed at the site. 
10.2.13 Week 37 
The following assessments will occur: 
• Review of medical and surgical procedures, concomitant medications, and other 
treatments; any changes will be noted  
• Height and weight 
• 12-lead ECG 
• Vital signs 
• Physical and neurological examination 
• Renal ultrasound of kidneys, ureters, and bladder 
• Hematology  
• Chemistry  
• First morning void urinalysis  
Note: Analysis of the first morning void urine sample will include urine dipstick protein 
to be performed at the site. 
• Urine cytology (utilizing a predose urine sample collected on-site) 
• Postdose urinalysis (utilizing a urine sample collected within 5 hours after completion of 
the infusion) 
• Anti-dystrophin antibody (predose) 


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• Anti-viltolarsen antibody (predose) 
• PK blood sample (pre and postdose) 
• Function and strength   
o TTSTAND 
o TTRW 
o NSAA 
o TTCLIMB  
o Hand-held dynamometer 
o 6MWT 
• Patient reported outcomes 
o PODCI 
o PARS III Questionnaire 
• Investigational product administration 
• AE review 
10.2.14 Weeks 38 to 47 
The following assessments will occur: 
• Review of medical and surgical procedures, concomitant medications, and other 
treatments; any changes will be noted 
• Vital signs 
• Investigational product administration 
• AE review 
• First morning void urinalysis (Week 41 and Week 45 only) 
Note: Analysis of the first morning void urine sample will include urine dipstick protein 
to be performed at the site. 
10.2.15 Week 48 
The following assessments will occur: 
• Review of medical and surgical procedures, concomitant medications, and other 
treatments; any changes will be noted  
• Vital signs  
• Anti-dystrophin antibody (predose) 


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• Anti-viltolarsen antibody (predose) 
• PK blood sample (pre and postdose) 
• Investigational product administration 
• AE review 
10.3 
End-of-Treatment Phase 
10.3.1 Week 49 
The following assessments will occur at the end of treatment (± 3 days) after the Week 48 dose 
for all participants or for a participant: 
• Review of medical and surgical procedures, concomitant medications, and other 
treatments; any changes will be noted  
• Height and weight 
• 12-lead ECG 
• Vital signs 
• Physical and neurological examination 
• Renal ultrasound of kidneys, ureters, and bladder 
• Hematology  
• Chemistry  
• First morning void urinalysis 
Note: Analysis of the first morning void urine sample will include urine dipstick protein 
to be performed at the site. 
• Urine cytology (utilizing a urine sample collected on-site) 
• Exogenous tracer GFR 
Note: This should be done, if possible, per standard of care at the institution. 
• Function and strength  
o TTSTAND 
o TTRW 
o NSAA  
o TTCLIMB 
o Hand-held dynamometer 
o 6MWT 


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• Patient reported outcomes 
o PODCI 
o PARS III Questionnaire 
• AE review 
10.3.2 Follow-Up Phone Call 
Participants will have a phone call conducted with a member of the site study staff, 30 days 
(± 3 days) following the last investigational product infusion, to assess adverse events and 
medical, surgical, medication, and treatment review.  Any AE(s) that is unresolved will be 
followed up by the site (investigator or designee) for as long as medically indicated.  The CRO 
retains the right to request additional information for any participant with ongoing AEs at the end 
of the study, if judged necessary. 
10.3.3 Unscheduled Visit 
If a participant returns to the clinic for a visit outside of the protocol evaluation time points, the 
visit and any assessments and/or tests performed will be recorded in the source documents and 
the eCRF as an Unscheduled Visit.   
10.3.4 Early Termination or Withdrawal from the Study 
A participant (or the legal guardian acting on behalf of the participant) is free to withdraw 
consent and discontinue participation in the study at any time, without prejudice to further 
treatment according to standard clinical practice.  Study participation may be discontinued at any 
time at the discretion of the investigator or sponsor.  Study participation must be discontinued 
under the following circumstances: 
• Withdrawal of consent by the participant/legal guardian; 
• Failure to comply with the protocol; 
• Lost-to-follow-up; 
• Illness, condition, or procedural complication (including adverse events) affecting the 
participant’s ability to participate or requiring prohibited medication; 
• In the Investigator’s judgment, it is deemed in the best interest of the participant to 
discontinue his/her participation in the study; 


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• The Investigator, sponsor, Data and Safety Monitoring Board (DSMB), and/or regulatory 
authority terminates the study; or 
• Any other reason. 
A Participant Completion/Discontinuation eCRF, describing the reason for discontinuation must 
be completed, for any discontinued or withdrawn participant regardless of reason.  If a 
participant withdraws from the study or if the study is prematurely terminated, the investigator or 
designee will contact the participant or the participant’s legal guardian within 30 days after 
withdrawal or termination to assess any AEs.  The investigator will be asked to follow all SAEs 
until the event returns to baseline or until the investigator determines that follow-up is no longer 
medically necessary. 
Participants who are withdrawn from the study may not re-enter.  
The following assessments should be performed at the time of early termination: 
• Review of medical and surgical procedures, concomitant medications, and other 
treatments; any changes will be noted  
• Height and weight 
• 12-lead ECG 
• Vital signs 
• Physical and neurological examination 
• Renal ultrasound of kidneys, ureters, and bladder 
• Urine cytology (utilizing a urine sample collected on-site) 
• Anti-dystrophin antibody 
• Anti-viltolarsen antibody 
• Hematology  
• Chemistry  
• First morning void urinalysis 
Note: Analysis of the first morning void urine sample will include urine dipstick protein 
to be performed at the site. 
• Exogenous tracer GFR 
Note: This should be done, if possible, per standard of care at the institution. 


NCT04060199 
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• Function and strength  
o TTSTAND 
o TTRW 
o NSAA 
o TTCLIMB 
o Hand-held dynamometer 
o 6MWT 
• Patient reported outcomes 
o PODCI 
o PARS III Questionnaire 
• AE review 
If a participant is lost to follow-up, every reasonable effort must be made by the clinical site 
personnel to contact the participant and determine the reason for discontinuation/withdrawal 
(including assessment of any AEs reported by the participant/caregiver).  The measures taken to 
follow-up must be documented in source documents. 
10.3.5 Procedures for Early Termination 
If a participant withdraws or is removed from the study for any reason, all early termination 
procedures should be completed per Table 2.  Reason for withdrawal, date of the discontinuation, 
and date of the last dose of investigational product should be recorded in source documents and 
in the appropriate section of the eCRF.  Investigational product assigned to the withdrawn 
participant may not be assigned to another participant. 
The medical monitor should be consulted prior to the withdrawal of the study participant, except 
in the case of a medical emergency.  Written notice (regardless of cause) is to be provided to the 
medical monitor within 48 hours of the withdrawal.  At the time of discontinuation, every effort 
should be made to ensure all relevant procedures and evaluations scheduled for the final study 
visit are performed.   
10.4 
Participant Replacement 
Participants will not be replaced. 


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10.5 
Suspension or Termination of Study 
If, in the opinion of the medical monitor, clinical observations in the study suggest that it may be 
unwise to continue, the study may be suspended.  The medical monitor will request a DSMB 
meeting and consult with the sponsor.  If the medical monitor, DSMB and sponsor agree that 
safety concerns warrant termination of the study, the sponsor will terminate the study.  A written 
statement fully documenting the reasons for such a termination will be provided to investigators, 
IRBs/IECs and regulatory authorities, if required.  
NS Pharma has the right to terminate an Investigator’s participation in the study and remove all 
study materials from a clinical site.  A written statement will be provided to the investigator, the 
IRB/IEC, and regulatory authorities, if required.   
Possible reasons for termination of the study at a clinical site include, but are not limited to: 
• Unsatisfactory enrollment with respect to quantity or quality, 
• Inaccurate or incomplete data collection on an ongoing basis, 
• Falsification of records, or 
• Failure to adhere to the protocol. 
If any serious or non-serious adverse events have occurred at such a clinical site, all 
documentation relating to the event(s) must be obtained. 


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11 
SAFETY PROCEDURES AND PROCESSES 
11.1 
Definition of an Adverse Event 
An AE is any untoward medical occurrence in a participant or clinical investigation participant 
administered a pharmaceutical product, including control, and which does not necessarily have a 
causal relationship with treatment.  This includes any untoward signs or symptoms experienced 
by the participant from the time of consent until completion of the study. 
AEs may include, but are not limited to: 
• Any unfavorable and unintended sign (including an abnormal laboratory finding), 
symptom, or disease temporally associated with the use of a medicinal product, whether 
or not considered related to the medicinal product. 
• Any new disease or exacerbation of an existing disease. 
• Any deterioration in non-protocol-required measurements of laboratory value or other 
clinical test (e.g., ECG) that results in symptoms, a change in treatment, or 
discontinuation from investigational product. 
Disease signs, symptoms, and/or laboratory abnormalities already existing prior to the use of the 
product are not considered AEs after treatment, unless they reoccur after the participant has 
recovered from the preexisting condition or in the opinion of the investigator, they represent a 
clinically significant exacerbation in intensity or frequency.  If clinically significant worsening 
from baseline is noted, the changes will be documented in the AE source document and the 
eCRF.   
TEAEs are defined as any AE or worsening of an existing condition after initiation of the 
investigational product and through 30 days after completion of study participation. 
Suspected adverse reaction means any AE for which there is a reasonable possibility that the 
drug caused the AE.  For the purposes of investigational new drug (IND) safety reporting, 
‘reasonable possibility’ means there is evidence to suggest a causal relationship between the drug 
and the AE.  A suspected adverse reaction implies a lesser degree of certainty about causality 
than adverse reaction, which means any AE caused by a drug.  
An AE or suspected adverse reaction is considered “unexpected” if it is not listed in the 
investigator’s drug brochure or is not listed at the specificity or severity that has been previously 


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observed.  During the course of the study, the investigator brochure should be updated on an 
ongoing basis with new important safety information.  
11.2 
Definition of a Serious Adverse Event 
An adverse event is serious when the participant outcome is: 
• Death, 
• Life-threatening (see below for expanded definition), 
• Hospitalization (initial or prolonged), 
• Disability or permanent damage (see below for expanded definition), 
• Congenital anomaly/birth defect, 
• Important medical events that, based upon appropriate medical judgment, may jeopardize 
the participant and may require medical or surgical intervention to prevent one of the 
outcomes listed above. 
Life-threatening Experience: Any AE that places the participant, in the view of the site 
investigator, at immediate risk of death from the AE as it occurred, i.e., does not include an AE 
that, had it occurred in a more severe form, might have caused death. 
Any hospital admission with at least one overnight stay will be considered an inpatient 
hospitalization.  However, emergency room visits that do not result in admission to the hospital 
should be evaluated for one of the other serious outcomes (e.g., life-threatening; required 
intervention to prevent permanent impairment or damage; other serious medically important 
event). 
Hospitalization for an elective or outpatient procedure will not be considered to be an SAE.  
However, unexpected complications and/or prolongation of hospitalization that occur during 
elective or outpatient surgery should be recorded as AEs and assessed for seriousness.  
Admission to the hospital for social or situational reasons (e.g., no place to stay, live too far 
away to come for hospital visits) will not be considered inpatient hospitalizations.  
Disability or permanent damage: Any AE that results in a substantial disruption of a participant’s 
ability to conduct normal life functions, i.e., the AE resulted in a significant, persistent or 
permanent change, impairment, damage or disruption in the participant's body function/structure, 
physical activities and/or quality of life. 


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Important medical events that may jeopardize the participant and may require medical or surgical 
intervention to prevent one of the outcomes listed above: an AE that may not result in death, be 
life-threatening, or require hospitalization may be considered an SAE when, based upon 
appropriate medical judgment, it may jeopardize the participant and may require medical or 
surgical intervention to prevent one of the outcomes listed above. 
11.3 
Severity 
It is the investigator’s responsibility to assess the intensity (severity) of an AE.   
The severity of the AE will be characterized and recorded as “mild, moderate, severe, 
life-threatening or death” according to the following definitions:  The CTCAE v4.03 guidelines 
for severity assessments will be used to grade AEs for this trial (available at 
evs.nci.nih.gov/ftp1/CTCAE/About.html).  The CTCAE v4.03 listed guidelines for severity 
assessment are: 
• Mild: Asymptomatic or mild symptoms; clinical or diagnostic observations only or 
intervention not indicated 
• Moderate: Minimal, local or noninvasive intervention indicated or limited 
age-appropriate instrumental activities of daily living (ADL)  
• Severe: Severe or medically significant but not immediately life-threatening; or 
hospitalization or prolongation of hospitalization indicated; or disabling; or limiting 
self-care ADL  
• Life-threatening: Life-threatening consequences or urgent intervention indicated 
• Death: Death related to AE 
Note:  A severe AE need not be serious, and an SAE need not be severe. 


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11.4 
Relationship 
It is the investigator’s responsibility to assess the relationship between the investigational 
product and the adverse event.  The degree of “relatedness” of the AE to the investigational 
product may be described using the following scale: 
Not Related 
• Not Related: No temporal association and other etiologies are likely the cause.  
• Unlikely: Event or laboratory test abnormality, with a time to drug that makes a 
relationship improbable (but not impossible).  Diseases or other drugs provide plausible 
explanations. 
Related 
• Possible: Temporal association, but other etiologies are likely the cause.  However, 
involvement of the investigational product cannot be excluded. 
• Probable: Temporal association, other etiologies are possible but unlikely.  The event 
may respond if the investigational product is discontinued. 
• Definite: Established temporal association with administration of the investigational 
product with no other more probable cause.  The event should resolve when the 
investigational product is discontinued and recur on re-challenge. 
11.5 
Adverse Events of Special Interest 
The following events are considered adverse events of special interest based on the route of 
administration and toxicology profile for viltolarsen: 
• Access device complication (for participants with indwelling access devices); 
• Urinary protein excretion 300 mg/day based on a 24-hour urine collection; 
• Serum cystatin C 1.5  baseline, or serum creatinine 2  baseline and 0.3 mg/dL, 
confirmed with a repeat test within 1 week of the original results (i.e., meets the 
cystatin C or creatinine criteria for referral to a pediatric nephrologist described in 
Section 11.11.1); 
• Any confirmed instances of hematuria or other potentially clinically significant 
abnormalities on urinalysis. 


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11.6 
Disease-Related Signs and Symptoms 
Reporting of disease related or DMD-related signs and symptoms as AEs are based on the 
investigator’s clinical judgment.  However, progression of symptoms and signs associated with 
DMD that is inconsistent to the usual course of the disease should be reported as an AE in the 
eCRF and source documentation. 
11.7 
Reporting 
11.7.1 Adverse Event Reporting 
All AEs occurring during the course of the study (starting from signing informed consent to 
study completion) will be collected on the AE eCRF.  Each AE is to be evaluated for duration, 
severity, seriousness, and causal relationship to the investigational product.  For each AE, the 
following information will be recorded: 
• Description of the event (e.g., headache), 
• Date of onset, 
• Date of resolution (or that the event is continuing), 
• Action taken as a result of the event, 
• Seriousness of the event, 
• Severity of the event, 
• Outcome of the event, and 
• Investigator’s assessment of relationship to investigational product. 
A cluster of signs and symptoms that results from a single cause should be reported as a single 
AE (e.g., fever, elevated WBC, cough, abnormal chest x-ray, etc., can all be reported as 
“pneumonia”). 
The investigator will carefully evaluate the comments of the participant and the response to 
treatment in order that he/she may judge the true nature and severity of the AE.  The question of 
the relationship of AE to investigational product administration should be determined by the 
Investigator or study physician after thorough consideration of all facts that are available. 
Clinically significant changes from time of ICF will be documented as AEs on the AE eCRF.  
Clinically significant changes are physical findings that have medical relevance and may result 
in an alteration in medical care. 


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11.7.2 Adverse Events of Special Interest Reporting 
Adverse events of special interest should be promptly recorded in the eCRF so that the DSMB 
and medical monitor are notified.  Such events will be reviewed by the DSMB and medical 
monitor to enable consideration of implications for other participants. 
11.7.3 Serious Adverse Event Reporting 
All SAEs occurring from the time of informed consent until the follow-up telephone call, 
30 days following the last administration of study drug must be reported to the designated CRO 
and the sponsor within 24 hours of the knowledge of the occurrence.  This includes death due to 
any cause and whether or not the SAE is deemed drug-related or expected.  After the 30-day 
reporting window, any SAE that the investigator considers related to study drug must also be 
reported.  
To report the SAE, the investigator is to complete the SAE form electronically in the electronic 
data capture (EDC) system for the study.  If the event meets serious criteria and it is not possible 
to access the EDC system, the investigator is to send an email, phone or fax the event to the 
designated CRO within 24 hours of awareness.  When the EDC system becomes available, the 
SAE information must then be entered within 24 hours of the system becoming available. 
The investigator is required to submit SAE reports to the IRB or IEC in accordance with local 
requirements.   
11.8 
Serious Adverse Event Follow-Up 
SAEs will be followed by the site investigator until resolution or until the investigator determines 
that follow-up is no longer medically necessary. 
Follow-up information, or new information regarding an ongoing SAE, must be provided 
promptly to the CRO within 24 hours of knowledge of the new or follow-up information.  The 
CRO will forward the information to the sponsor, and the medical monitor. 
11.9 
Expedited Reporting to Regulatory Authorities 
The NS Pharma designated CRO is responsible for reporting all relevant information about 
suspected unexpected serious adverse reactions (SUSARs) that are fatal or life-threatening as 
soon as possible to the applicable regulatory authorities in all the Member States concerned, and 
to the Central Ethics Committee, and in any case no later than 7 days after knowledge by the 


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CRO of such a case.  All other SUSARs will be reported to the applicable regulatory authorities 
concerned and to the Central Ethics Committee concerned as soon as possible but within a 
maximum of 15 days of first knowledge by the sponsor/designee. 
The NS Pharma designated CRO will also report any additional expedited safety reports required 
in accordance with the timelines outlined in country-specific legislation. 
The NS Pharma designated CRO will also inform all investigators as required per local 
regulation.  Reports of all applicable SUSARs must be communicated as soon as possible to the 
appropriate IRB/IEC and/or reported in accordance with local laws and regulations.  
Investigators should file written documentation of IRB/IEC notification for each report to the 
designated CRO as applicable. 
The sponsor must report any suspected adverse reaction to the study drug, that is both serious 
and unexpected, or any SAEs suspected to be related to the CVA port, to the US FDA, Health 
Canada (21 CFR 312.32(c)(1)(i) and C.05.014, respectively), and other national and local health 
authorities. 
11.10 Monitoring and Follow-Up of Adverse Events 
Participants who experience AEs will be monitored with relevant clinical assessments and 
laboratory tests, as determined by the investigator.  All follow-up results are to be reported to the 
medical monitor.  Any actions taken and follow-up results must be recorded either on the 
appropriate page of the eCRF or in appropriate follow-up written correspondence, as well as in 
the participant’s source documentation.  Follow-up laboratory results should be filed with the 
participant’s source documentation. 
For all AEs that require the participant to be discontinued from the study, relevant clinical 
assessments and laboratory tests must be repeated at appropriate intervals until final resolution or 
stabilization of the event(s). 
Any AEs that are unresolved at the participant’s last AE assessment in the study are followed up 
by the investigator or designee for as long as medically indicated, but without further recording 
in the eCRF.  The sponsor and designated CRO retain the right to request additional information 
for any participant with ongoing AEs/SAEs at the end of the study, if judged necessary. 


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11.11 General Monitoring and Management of Abnormal Clinical Laboratory Findings 
It is the investigator’s responsibility to review the results of all laboratory tests as they become 
available and to sign and date the results indicating review.  For each laboratory test outside of 
the laboratory normal range, the investigator must ascertain if this represents a clinically 
significant change from baseline for the individual participant.  The investigator may repeat a 
laboratory test or request additional tests to verify results of the original laboratory test. 
If a laboratory value is determined to be an abnormal and clinically significant change from 
baseline for the participant, the investigator should determine if it qualifies as an AE, and if so, 
an appropriate eCRF will be completed.  All clinically significant laboratory abnormalities 
occurring during the study and that were not present at baseline should be followed and 
evaluated with additional tests if necessary, until diagnosis of the underlying cause, or resolution.  
11.11.1 Monitoring of Renal Function and Urine Analyses 
All scheduled first morning void urinalyses will include urine dipstick protein to be performed at 
the site.  If first morning void urine dipstick protein 2+, UPCR 0.5 mg/mg, or 
UPCR 2  baseline, a first morning void urine dipstick protein will be repeated within 1 week.  
If 1 or more of these criteria are met again on the repeat test, a 24-hour urine sample will be 
collected within 1 week of the results to assess protein and creatinine.  If proteinuria on a 
24-hour urine sample is 300 mg/day, the patient will be referred to a pediatric nephrologist. 
In addition, any instances of hematuria or other potentially clinically significant abnormalities on 
urinalysis will be confirmed at the following week’s visit, or sooner at discretion of the 
investigator.  Confirmed clinically significant treatment-emergent abnormalities will be recorded 
as AEs and discussed with the medical monitor.  Abnormalities will be monitored and evaluated 
with additional tests or consultations, if necessary, until the underlying cause is determined, or 
the event is brought to an acceptable resolution.  Additional clinical and laboratory information 
may be collected and documented in order to better characterize abnormalities and identify 
etiology and appropriate management.  Potential need for interruption or discontinuation of study 
drug should be discussed with the medical monitor and sponsor. 
If serum cystatin C 1.5  baseline, or if serum creatinine 2  baseline and 0.3 mg/dL, the test 
will be repeated within 1 week of the results.  If either of these criteria are met again on the 
repeat test, the patient will be referred to a pediatric nephrologist. 


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To help relate creatinine and cystatin C measurements to GFR in patients with DMD, GFR will 
be determined using an exogenous tracer test, if available, at the Pre-Infusion Visit and Week 49 
(or at early termination, if applicable).  This should be done per standard of care at the 
institution. 
11.12 Monitoring and Management of Abnormal Electrocardiograms 
If a clinically significant ECG abnormality occurs that was not present at baseline (screening) 
and the investigator determines that the abnormality is related to investigational product, the 
abnormality will be discussed with the medical monitor.  The ECG abnormality will be 
monitored and evaluated with additional tests (if necessary) until the underlying cause is 
determined or the event is brought to an acceptable resolution.  Additional clinical and laboratory 
information will be collected and carefully documented in order to better characterize the ECG 
abnormality and rule out alternative causes.  ECG findings determined to be a clinically 
significant change from baseline should be reported as an adverse event regardless of causality. 
Unscheduled ECG assessments will be completed at the discretion of the investigator. 
11.13 Intravenous (IV) Access Considerations 
Investigational product dosing will be administered through IV infusion.  Peripheral venous 
access (IV catheter that empties into a peripheral vein in the arms, hands, legs or feet) is the 
preferred route of investigational product administration for this study.   
A CVA (IV catheter that empties into a large central vein) will be considered on a case-by-case 
basis for participants who have difficulty with peripheral venous access.  A TICVAD is the 
preferred option of CVA, if necessary, for this study.  The sponsor will decide whether or not to 
approve this option after discussions with the investigator and medical monitor have ensured 
mutual agreement that CVA will still maintain a positive benefit/risk ratio for the participant in 
this study.  Before final decision, NS Pharma will obtain documentation from the investigator 
that the consulting surgeon who will place the port holds hospital privileges as a board 
eligible/board certified surgeon.  The decision, rationale and conclusion regarding the maintained 
positive benefit/risk ratio will be detailed in writing and sent to the requesting site.  CVA should 
not be implemented without sponsor approval. 


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An alternative method of CVA may only be considered in the case of a contraindication, in the 
opinion of the consulting surgeon for the placement of a TICVAD (port).  
11.14 Data and Safety Monitoring Board 
It is the responsibility of the DSMB to review data quality, relevant safety data, and AEs for all 
participants enrolled in the study and to make recommendations to the medical monitor, and 
sponsor regarding the ongoing conduct and monitoring of the study.  Details are provided in the 
DSMB charter. 


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12 
PLANNED STATISTICAL METHODS 
12.1 
General Considerations 
The statistical analyses described in this section will be performed as further outlined in the 
statistical analysis plan (SAP), which will be finalized prior to database lock.  The SAP will 
supersede the protocol if there are any differences between the two documents in the plans for 
data analysis and the differences will be noted in the SAP.  The SAP will be included as an 
appendix in the clinical study report for this protocol.  Statistical analyses will be performed 
using SAS 9.2 or higher.  
12.2 
Determination of Sample Size 
For TTSTAND (calculated as a velocity, defined as rise per second), the sample size of 
74 participants has been calculated using the following values:  
• Mean difference = 0.05 
• Standard deviation = 0.075 
• Type I error level (two-sided) = 0.05 
• Power level = 0.8 
• Allocation ratio (N1: viltolarsen/N2: placebo) = 1 
The mean difference and the SD were set based on the result of comparison between viltolarsen 
group and natural history control group at 25 weeks in the Phase 2 Study NS-065/NCNP-01-201 
(mean difference between 2 groups: 0.0395, SD: 0.07545 and 0.07377).  As the mean difference 
between the 2 groups at 48 weeks is expected to be larger than at 25 weeks, the mean difference 
was estimated to be 0.05. 
An unpaired t-test for analysis was used instead of mixed effect model repeat measurement 
(MMRM) for the calculation method due to lack of prior information. 
When approximately 90% of participants are enrolled in the study, an unblinded review will be 
conducted and sample size re-estimation will be considered.  An additional unblinded review and 
re-estimation will be performed when approximately 50 participants have completed the 
Week 49 evaluations for the primary outcome measure.  See Section 12.8 for details. 


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12.3 
Analysis Populations 
The safety population will consist of all randomized participants who received at least 1 dose of 
investigational product.  Participants will be analyzed as treated.  This will be the primary 
analysis population for the evaluation of exposure and safety. 
The modified Intent-to-Treat (mITT) population will consist of all randomized participants who 
received at least 1 dose of investigational product and have a baseline assessment and at least 
1 post baseline efficacy assessment.  Participants will be analyzed as randomized.  This will be 
the primary analysis population for the evaluation of efficacy. 
12.4 
Demographics and Baseline Characteristics 
Summaries of participant demographics (age, race, ethnicity and dominant hand), baseline safety 
characteristics (anthropometrics, vital signs, physical examination, hematology, chemistry, 
urinalysis, ECG, and antibodies), and baseline efficacy parameters will be done. 
12.5 
Efficacy Endpoints 
All efficacy analyses will be performed using the modified intent to treat (mITT) population.  In 
addition, additional analyses will utilize the placebo treatment group. 
A hierarchical analysis, following a fixed-sequence hypothesis testing method, is used to first 
test TTSTAND and then TTRW, 6MWT, NSAA, TTCLIMB, and hand-held dynamometer, if 
the former was statistically significant. 
12.5.1 Efficacy Objective  
The primary efficacy outcome measure (TTSTAND) will be summarized by treatment group 
over time using descriptive statistics. 
The TTSTAND times to perform the test will also be converted to velocities.  Note that a test 
result that is to be converted to velocity that the participant could not perform due to disease 
progression will have velocity set to zero only at the first visit where this occurs.  After that visit, 
missing observations due to disease progression will be left as missing. 
The TTSTAND will be compared between the viltolarsen treated participants and the placebo 
treated participants using MMRM analysis with treatment group, week of the visit, and the 
treatment-by-week interaction as factors, and age as one covariate, and baseline performance as a 
second covariate.  The TTSTAND times to perform the test will be converted to velocities.  


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The treatment comparisons of most interest will be the LS means contrasts between the 
viltolarsen treated participants and the placebo treated participants at Week 49. 
12.5.2 Secondary Objectives  
12.5.2.1 
Function and Strength 
TTRW, 6MWT, NSAA, TTCLIMB, and hand-held dynamometer will be summarized by 
treatment group over time using descriptive statistics. 
The TTRW and TTCLIMB times to perform the test will also be converted to velocities.  For a 
test that the participant could not perform, the velocity will be set to zero. 
12.5.2.2 
Analysis Comparing Viltolarsen to Placebo 
TTSTAND, TTRW, 6MWT, NSAA, TTCLIMB, and hand-held dynamometer results will be 
compared between the viltolarsen treated participants and the placebo treated participants using 
MMRM analysis with treatment group, week of the visit, and the treatment-by-week interaction 
as factors, and age as one covariate, and baseline performance as a second covariate.  The TTRW 
and TTCLIMB times to perform the test will be converted to velocities.  For a test that the 
participant could not perform, the velocity will be set to zero. 
12.6 
Safety Assessments 
Safety analyses will be performed using the safety population.  All safety assessments will be 
based on actual treatments received by participants and are detailed in the protocol and statistical 
analysis plan.   
12.6.1 Anthropometrics, Vital Signs, Laboratory Assessments, and ECG 
Anthropometrics, vital signs, hematology, chemistry, urinalysis, and ECG results will be 
summarized by treatment over time using descriptive statistics for continuous outcomes.  Actual 
values and change from Day 1 will be presented.  Further, all laboratory abnormalities will be 
listed. 
12.6.2 Physical Examination and Adverse Events 
Physical examination results will be summarized by frequency of presence of abnormalities in 
body system (beyond the DMD diagnosis) and in particular any changes in the physical 
examination over time. 


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TEAEs will be summarized by treatment group.  Coding will be done by system organ class and 
preferred term (using the Medical Dictionary for Regulatory Activities [MedDRA]).  Level of 
severity will be assessed using the CTCAE grading system.  
Summaries will include: 
• Summaries at the participant level 
o How many participants had any TEAE, any SAE, highest severity of TEAE 
within a participant across all infusions, highest relationship level of TEAE within 
a participant across all infusions, highest intervention level regarding 
investigational product (e.g., discontinued, vs. infusion interruption vs. no 
interruption in infusions), and worst outcome within a participant (e.g., AE did 
not resolve and has a permanent effect). 
• Summary at the event level 
o Summaries will be done using the MedDRA coding by events and overall, 
summarizing by system organ class and preferred term, by relationship to 
investigational product, severity, intervention, and outcome. 
Listings tables will be provided for all AEs. 
12.6.3 Concomitant Medications and/or Other Treatments 
Glucocorticoids, which are required as part of the inclusion criteria, will be summarized by type 
of GC (prednisone vs. deflazacort), by schedule (daily vs. any other), and by treatment.  
Participants are required not to change the GC dose while on study.  Any changes in doses or 
schedule will be listed. 
Other concomitant medications will be summarized by ATC class and preferred term.  Each 
medication will be counted once within a participant using it, regardless of the number of times it 
was reported on the eCRFs.  The summaries will note new medications or supplements vs. those 
already given at baseline and study entry.  Any other treatment, surgeries, will be listed and 
described; however, those are expected to be few without a need to be summarized using tables. 
12.6.3.1 
Antibodies and Pharmacokinetics 
Antibodies and PK concentrations will be summarized by treatment group over time.  PK 
concentrations may be summarized at a later date.   


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12.7 
Pharmacokinetic Endpoints and Analysis 
Population PK analysis will be presented in a separate report. 
12.8 
Interim Analyses 
Interim analysis is planned when approximately 90% of participants are enrolled in the study.  
An additional unblinded review and re-estimation will be performed when approximately 
50 participants have completed the Week 49 evaluations for the primary outcome measure.  At 
these 2 time points, an unblinded data review will be conducted, which will include review by 
the DSMB.  Based on this review, the DSMB will make a recommendation to the sponsor for 
possible sample size re-estimation, i.e., the additional number of participants to be enrolled to 
increase the conditional power to an acceptable level.   
Denne (Denne, 2001) described the sample size re-estimation procedure for the group sequential 
test by using the conditional power without inflating the type I error rate for the interim analyses.  
At the point at which the sample size re-estimation is being made for the interim analyses, the 
test statistic 𝑧1 is observed.  The conditional power is the probability of rejection 𝐻0 on the basis 
that 𝑍2 ≥𝑐2 given 𝑍1 = 𝑧1, which is denoted by 𝐶𝑃𝜃(𝑛2, 𝑐2|𝑧1).  The conditional power is given 
by: 
𝐶𝑃𝜃(𝑛2, 𝑐2|𝑧1) = 1 −𝛷[
𝑐2√𝑛2 −𝑧1√𝑛1 −
(𝑛2−𝑛1)
√2𝜎2 𝜃
√𝑛2 −𝑛1
] 
where 𝑛1 is the sample size per treatment group at the interim analyses, the true difference in 
mean response 𝜃 is estimated by the current sample mean difference 𝛿, and 𝜎2 is estimated by 
the current sample within group variance 𝑠2.  The re-estimated sample size per treatment group 
𝑛2 is obtained by solving the conditional power be at least 80% power as defined in the sample 
size determination.  The re-estimated total sample size is given by 𝑛∗= 2𝑛2. 
To preserve study integrity, a small alpha of 0.001 will be spent at the second re-estimation 
resulting in the overall significance level to be 0.049 at the final stage. 
If the re-estimated total sample size from the interim analyses is smaller than the planned total 
sample size of 74, the sample size adjustment will not be needed.  If the re-estimated total 


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sample size is larger than the planned total sample size, the sample size may be increased up to a 
maximum target sample size of 100. 
12.9 
Handling of Missing Data 
Every effort will be made to collect all data.  However, despite best efforts, missing or 
incomplete data may be reported.  All missing or partial data will be presented in the participant 
data listing, as they are recorded on the eCRF. 
Participants lost to follow-up or withdrawn will be included in statistical analyses up to the point 
of their last evaluation.  Unless otherwise specified, no imputation of values for missing data will 
be performed.  Of note, since participants with DMD are expected to decline over time, imputing 
efficacy parameters by last value carried forward mostly biases towards participants appearing 
stronger or faster than they are, since it carries forward potentially a better value than the value at 
the time of the missed observation.  Therefore, for this study, we will summarize how much data 
are missing, but do not expect to need to impute any data to accomplish the analyses as 
described.  Details of handling missing data will be described in the SAP. 


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13 
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14 
APPENDICES 
 
 
 
 
 
 
 


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Appendix 1 
Sponsor Signatures 
 
Study Title: 
A Phase 3 Randomized, Double-blind, Placebo-controlled, Multi-center 
Study to Assess the Efficacy and Safety of Viltolarsen in Ambulant 
Boys with Duchenne Muscular Dystrophy (DMD) 
Study Number: 
NS-065/NCNP-01-301 
Final Date: 
08 December 2022 
 
This clinical study protocol was subject to critical review and has been approved by the sponsor. 
The following personnel contributed to writing and/or approving this protocol: 
Reviewed by: 
 
 
Signed: ___________________________________  
Date: __________________  
 
Shinya Hiramatsu 
Associate Director, Clinical Research 
NS Pharma, Inc. 
 
 
 
 
Signed: ___________________________________  
Date: __________________  
 
Richard Scheyer, MD 
Medical Monitor 
Vice President, Medical Department 
Medpace 
 
 
Approved by: 
 
 
Signed: ___________________________________  
Date: __________________  
 
Takeshi Seita 
Vice President of R&D  
NS Pharma, Inc. 
 
 
 


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Appendix 2 
Investigator’s Signature 
Study Title: 
A Phase 3 Randomized, Double-blind, Placebo-controlled, Multi-center 
Study to Assess the Efficacy and Safety of Viltolarsen in Ambulant 
Boys with Duchenne Muscular Dystrophy (DMD) 
Study Number: 
NS-065/NCNP-01-301 
Final Date: 
08 December 2022 
 
I have read the protocol described above.  I agree to comply with all applicable regulations and 
to conduct the study as described in the protocol.  
Prior to the start of the study, I agree to release sufficient and accurate financial information that 
permits NS Pharma to demonstrate that as an investigator and all study personnel listed on the 
FDA Form 1572, the Health Canada Qualified Investigator Undertaking form, or similar as 
required by other national/local health authorities, I have no personal or professional financial 
incentive regarding the future approval or disapproval of the investigational product such that my 
research might be biased by such incentive. 
 
 
Signed: 
 
 
Date:  
 
 
Name and credentials  
 
 
 
Title  
 
 
 
Affiliation  
 
 
 
Address  
 
 
 
Telephone number  
 
 
 
 
 
 
 
 
 


NCT04060199 
NS-065/NCNP-01 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
v4.0 08Dec2022 
 
 
 
 
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Appendix 3 
Administrative Considerations 
Investigators 
The investigator must agree to the responsibilities and obligations listed below, as specified by 
the appropriate FDA/Health Canada regulatory requirements or International Council for 
Harmonisation/Good Clinical Practices (ICH/GCP) guidelines: 
• Agree to conduct the study in accordance with the relevant current protocol; 
• Agree to personally conduct or supervise the described investigation(s); 
• Agree to inform any participants, or persons used as controls, that the investigational 
products are being used for investigational purposes and ensure that the requirements relating 
to obtaining informed consent and IRB/IEC review and approval are met; 
• Agree to report adverse experiences that occur during the course of the investigation(s); 
• Read and understand the information in the Investigator’s Brochure, including the potential 
risks and side effects of the investigational product; 
• Ensure that all associates, colleagues, and employees assisting in the conduct of the study are 
informed about their obligations in meeting the above commitments; 
• Maintain adequate and accurate records and make those records available for inspection; 
• Ensure that an IRB/IEC will be responsible for the initial and continuing review and approval 
of the clinical investigation; 
• Agree to promptly report to the IRB/IEC all changes in the research activity and all 
unanticipated problems involving risks to participants or others; 
• Agree to not make changes in the research without IRB/IEC approval, except where 
necessary to eliminate apparent hazards to participants; and 
• Comply with all other requirements regarding the obligations of clinical investigators and all 
other pertinent requirements. 
Refer also to: 
• FDA Regulations Related to Good Clinical Practice (GCP) and Clinical Trials: 
http://www.fda.gov/oc/gcp/regulations.html 
• Guidance and Information Sheets on GCP in FDA-Regulated Clinical Trials: 
http://www.fda.gov/oc/gcp/guidance.html 


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NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
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• Guidance for IRBs and Clinical Investigators:  
http://www.fda.gov/oc/ohrt/irbs/default.htm 
• Guidance for Industry - E6 Good Clinical Practice:  Consolidated Guidance 
http://www.fda.gov/cder/guidance/959fnl.pdf 
Informed Consent, Protected Health Information (PHI) and Confidentiality 
Informed Consent 
The ICF, assent form, and consent process must comply with US 21CFR Part 50 and local laws.  
The ICF/Assent Form will document the study-specific information provided to the participant 
by the investigator or designee and the participant’s/legal guardian’s agreement to participate in 
the study.  
The investigator, or designee (as described on Delegation of Authority log), must explain in 
terms understandable to the participant, the purpose and nature of the study, the study 
procedures, anticipated benefits, potential risks, the possible adverse effects and any discomfort 
participation in the study may involve.  Each participant must provide a signed and dated ICF 
before any study related procedures are performed.  In the case of a participant who is incapable 
of providing informed consent, the investigator or designee must obtain a signed and dated ICF 
from the participant’s legal guardian.  
Minors, who are not legally capable of giving informed consent, may possess the ability to assent 
or dissent to participation in the study.  The investigator, or designee should explain the study 
and study procedures to the minor in as much detail as the minor is able to comprehend.  
IRB/IEC-approved, age-appropriate Assent Forms must be obtained from minor participants as 
required by local laws and governing IRBs/IECs. 
Confidentiality 
Authority regulations (FDA, Health Canada, or other national and local health authorities) 
require the sponsor or the sponsor’s authorized representative to inspect all study documents and 
records maintained by the investigator, including but not limited to medical records (office, 
clinic, or hospital) for the participants in this study.  These regulations also allow the sponsor’s 
records to be inspected by authorized representatives of the regulatory authorities.  The names 
and identities of all research participants will be kept in strict confidence and will not appear on 


NCT04060199 
NS-065/NCNP-01 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
v4.0 08Dec2022 
 
 
 
 
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eCRFs or other records provided to or retained by the sponsor or the sponsor’s authorized 
representative.  Participant confidentiality will be respected during review of source documents 
by monitors, auditors and other sponsor representatives.  Review procedures will adhere to 
regulatory requirements and professional standards for confidentiality.  Names and identities of 
participants can be protected by de-identifying (i.e., “blacking-out”) participant’s name and 
replacing the name with the participant’s study identification number.  The ICF must include 
appropriate statements explaining these requirements. 
Protected Health Information (PHI) 
Information on maintaining participant confidentiality in accordance with US and local patient 
privacy regulations must be provided to each participant/legal guardian as part of the informed 
consent process, either as part of the ICF or as a separate signed HIPAA consent.  The 
investigator or designee must explain to each participant that for the evaluation of study results, 
the participant’s PHI obtained during the study may be shared with NS Pharma and its designees, 
regulatory agencies and IRBs/IECs.  As the study sponsor, NS Pharma will not use the 
participant’s PHI or disclose it to a third party without applicable participant authorization.  It is 
the investigator’s responsibility to obtain written permission to use PHI from each 
participant/legal guardian.  If a participant or participant’s legal guardian withdraws permission 
to use PHI, it is the investigator’s responsibility to obtain the request in writing and ensure that 
no further data is collected on the participant.  Any data collected up to the point of HIPAA 
consent withdrawal may be used in analysis of the study results. 
Study Administrative Structure 
 
Medical Monitor 
Richard Scheyer, MD 
Medpace 
5375 Medpace Way 
Cincinnati, Ohio 45227 
Phone: 513-579-9911 ext. 11868 
Email: r.scheyer@medpace.com 
 


NCT04060199 
NS-065/NCNP-01 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
v4.0 08Dec2022 
 
 
 
 
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Institutional Review Board/Independent Ethics Committee Approval 
Before initiation of the study, the investigator must obtain approval or favorable opinion of the 
research protocol, informed consent form, and any material related to participant recruitment 
from an IRB or IEC complying with the provisions specified in 21 CFR Part 56 and applicable 
pertinent state and federal requirements of each participating location, including ICH and GCP 
guidelines. 
Institutional Review Boards and IECs must be constituted according to the applicable laws.  It is 
the responsibility of each clinical site to submit the protocol, Investigator’s Brochure, participant 
informed consent, participant recruitment materials (if applicable), and other documentation as 
required by the IRB/IEC for review and approval.  A copy of the written approval must be 
provided to NS Pharma.  
The documentation should clearly mention the approval/favorable opinion of the protocol, the 
participant informed consent form, and participant recruitment materials (if applicable), 
including respective version dates.  The written approval and a list of the voting members, their 
titles or occupations, and their institutional affiliations must be obtained from the IRBs/IECs and 
provided to NS Pharma (or its authorized CRO) prior to the release of clinical study supplies to 
the clinical site and commencement of the study.  If any member of the IRB/IEC has direct 
participation in this study, written notification regarding his or her abstinence from voting must 
also be obtained. 
Clinical sites must adhere to all requirements stipulated by their respective IRB/IEC.  This 
includes notification to the IRB/IEC regarding: protocol amendments, updates to the participant 
informed consent, recruitment materials intended for viewing by participants, IND Safety 
Reports, serious and unexpected adverse events, reports and updates regarding the ongoing 
review of the study at intervals specified by the respective IRB/ IEC, and submission of final 
study reports and summaries to the IRB/ IEC. 
It is the responsibility of each clinical site to submit information to the appropriate IRB/IEC for 
annual review and annual re-approval. 


NCT04060199 
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NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
v4.0 08Dec2022 
 
 
 
 
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The investigator must promptly inform their IRB/IEC of all SAEs or other safety information 
reported from the participant or NS Pharma or its authorized CRO. 
Protocol Amendments 
Any changes to the study that arise after approval of the protocol must be documented as 
protocol amendments.  Protocol amendments that are deemed substantial (e.g., affecting the 
safety of the participant, the scope of the study, and/or the scientific quality) will be submitted to 
regulatory authorities and/or to the IEC/IRB as appropriate.  For substantial amendments, the 
changes will become effective only after approval by the Sponsor, the responsible Investigator, 
IEC/IRB, and competent authorities.  All other amendments (i.e., non-substantial or 
administrative amendment) will be documented in the Trial Master File. 
Ethical Conduct of the Study 
The investigator agrees, when signing the protocol, to adhere to the instructions and procedures 
described in the protocol and conduct the study in accordance with the CFRs (21 CFR Parts 11, 
50, 54, 56, 312, 314, and 320) and local regulations, which originate from the ethical principles 
laid down in the current revision of the Declaration of Helsinki, GCPs, and policies and 
procedures as outlined by the ethical requirements for IRB/IEC review and informed consent 
forms.  
The investigator agrees to allow monitoring and auditing of all essential clinical study documents 
by NS Pharma or its authorized representatives and inspection by the FDA or other appropriate 
regulatory authorities.  Monitoring and auditing visits by NS Pharma or authorized designee will 
be scheduled with the appropriate staff at mutually agreeable times periodically throughout the 
study. 
The investigator will assure proper implementation and conduct of the study, including those 
study-related duties delegated to other appropriately qualified individuals.  The investigator will 
assure that study staff cooperates with monitoring and audits and will demonstrate due diligence 
in recruiting and screening study participants.  The investigator must sign and return to NS 
Pharma (or its authorized CRO) the “Study Acknowledgment” page and provide a copy of 
current curriculum vitae.   


NCT04060199 
NS-065/NCNP-01 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
v4.0 08Dec2022 
 
 
 
 
NS Pharma, Inc. – CONFIDENTIAL  
 
Page 110 of 114 
Study Monitoring 
The investigator agrees to allow direct access to all essential clinical study documents for the 
purpose of monitoring and/or auditing by NS Pharma or its authorized representatives and 
inspection by the appropriate regulatory authorities. 
NS Pharma (or its authorized CRO) has the obligation to follow this study closely to ensure that 
the study is conducted in accordance with the protocol, ICH and GCP regulatory requirements, 
the CFRs, FDA, and the current Declaration of Helsinki throughout its duration by means of 
personal visits to the investigator’s facilities and other communications.  
These visits will be conducted to evaluate the progress of the study, verify the rights and 
well-being of the participants are protected, and verify the reported clinical study data are 
accurate, complete, and verifiable from source documents.  This includes review of informed 
consent forms, results of tests performed as a requirement for participation in this study, and any 
other medical records (e.g., laboratory reports, clinic notes, investigational product disbursement 
log, pharmacy records, participant sign-in sheets, participant-completed questionnaires, 
telephone logs, ECGs) required to confirm information contained in the eCRFs. 
A monitoring visit should include a review of the essential clinical study documents (regulatory 
documents, case report forms, medical records and source documents, investigational product 
disposition records, participant informed consent forms, etc.) as well as discussion on the 
conduct of the study with the investigator and staff. 
The monitor should conduct these visits as frequently as appropriate for the clinical study.  The 
investigator and staff should be available during these visits for discussion of the conduct of the 
study as well as to facilitate the review of the clinical study records and resolve/document any 
discrepancies found during the visit.  
All monitoring activities will be reported and archived.  In addition, monitoring visits will be 
documented at the clinical site by signature and date on the study-specific monitoring log. 
Details of monitoring procedures will be described in the study monitoring plan. 


NCT04060199 
NS-065/NCNP-01 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
v4.0 08Dec2022 
 
 
 
 
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On-Site Audits 
Representatives of NS Pharma or its authorized clinical quality assurance group may visit a 
clinical site at any time during the study to conduct an audit of the study in compliance with 
regulatory guidelines and company policy.  These audits will require access to all study records, 
including source documents, for inspection and comparison with the eCRFs.  Participant privacy 
must be respected.  The investigator and clinical site personnel are responsible for being present 
and available for consultation during routinely scheduled site audit visits conducted by 
NS Pharma or its authorized representative.   
The clinical study may also be inspected by the FDA (or other regulatory authorities) to verify 
that the study was conducted in accordance with protocol requirements, as well as the applicable 
regulations and guidelines. 
In the event the investigator is contacted by regulatory authorities who wish to conduct an 
inspection of the clinical site, the investigator will promptly notify NS Pharma (or its authorized 
CRO) of all such requests and will promptly forward a copy of all such inspection reports. 
Case Report Forms  
Access to eCRFs will be provided to the clinical site.  As part of the responsibilities assumed by 
participating in the study, the investigator agrees to maintain adequate case histories for the 
participants treated as part of the research under this protocol.  The investigator agrees to 
maintain accurate source documentation and eCRFs as part of the case histories.  
Study records are comprised of source documents, eCRFs, and all other administrative 
documents (e.g., IRB/IEC correspondence, clinical study materials and supplies shipment 
manifests, monitoring logs, and correspondence).  A study-specific binder will be provided with 
instructions for the maintenance of study records. 
A completed eCRF must be submitted for each participant who receives investigational product, 
regardless of duration.  All supportive documentation submitted with the eCRF, such as 
laboratory or hospital records, should be clearly identified with the study and participant number.  
Any personal information, including participant name, should be removed or rendered illegible 


NCT04060199 
NS-065/NCNP-01 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
v4.0 08Dec2022 
 
 
 
 
NS Pharma, Inc. – CONFIDENTIAL  
 
Page 112 of 114 
to preserve individual confidentiality.  The eCRF should not be used as a source document unless 
otherwise specified by NS Pharma.  
It is essential that all dates appearing on NS Pharma participant data collection forms for 
laboratory tests, cultures, etc., be the dates on which the specimens were obtained, or the 
procedures performed.  The eCRFs will be electronically signed by the investigator and dated as 
verification of the accuracy of the recorded data.  All data collection forms should be completed 
within 48 hours following the evaluation.  
Data reflecting the participant’s participation with the investigational product under investigation 
are to be reported to NS Pharma.  The data are to be recorded on the eCRFs and/or other media 
provided or approved by NS Pharma.  
Details for completing the eCRF are provided in the eCRF completion manual for this study. 
Source Documents 
Source documentation is defined as any hand written or computer-generated document that 
contains medical information or test results that have been collected for or in support of the 
protocol specifications (e.g., laboratory reports, clinic notes, investigational product 
disbursement log, pharmacy records, participant sign-in sheets, participant completed 
questionnaires, telephone logs, x-rays, and ECGs).  All draft, preliminary, and pre/final iterations 
of a final report are also considered to be source documents (e.g., faxed and hard copy of 
laboratory reports, faxed and hard copy of initial results, and final report).   
Authority regulations require the sponsor (or the sponsor’s authorized representative) to inspect 
all documents and records to be maintained by the investigator, including but not limited to, 
medical records (office, clinic, or hospital) for the participants in this study.  These regulations 
also allow the sponsor’s records to be inspected by authorized representatives of regulatory 
authorities.  The investigator will permit study-related monitoring, audits, IRB/IEC review, and 
regulatory inspections by providing direct access to source data/documents.  Direct access 
includes permission to examine, analyze, verify, and reproduce any records and reports that are 
important to the evaluation of a clinical study. 


NCT04060199 
NS-065/NCNP-01 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
v4.0 08Dec2022 
 
 
 
 
NS Pharma, Inc. – CONFIDENTIAL  
 
Page 113 of 114 
Record Retention 
In compliance with the ICH/GCP guidelines, the investigator/institution agrees to retain and 
maintain all study records that support the data collected from each participant, as well as all 
study documents as specified in ICH/GCP, Section 8 Essential Documents for the Conduct of a 
Clinical Trial.  Retention of study documents will be governed by the Clinical Study Agreement 
between the sponsor and Institution. 
Study documents (including eCRFs, source documents, clinical drug disposition records, signed 
participant informed consent forms, adverse event reports, and other regulatory documents) as 
required by the applicable regulations, must be maintained for 15 years after a marketing 
application is approved for the drug for the indication for which it is being investigated; or, if no 
application is to be filed or if the application is not approved for such indication, until 2 years 
after the investigation is discontinued and the FDA is notified. 
It is the responsibility of NS Pharma or authorized CRO to inform the investigator/institution as 
to when these documents no longer need to be retained. 
Publication and Disclosure Policy 
All information derived from this clinical study will be used by NS Pharma (or designee) and 
therefore, may be disclosed by NS Pharma (or designee) as required to other clinical 
investigators, to the FDA, and to other government agencies, or in connection with intellectual 
property filings or publications.  Details of disclosure of study information are provided in the 
investigator’s written clinical study agreement with NS Pharma. 
The results of the study will be reported in a clinical study report (CSR) prepared by NS Pharma 
(or designee), which will contain eCRF data from all clinical sites that conducted the study. 
NS Pharma shall have the right to publish data from the study without approval from the 
investigator.  All publications (e.g., manuscripts, abstracts, oral/slide presentations, book 
chapters) may only be prepared through cooperation between NS Pharma (or designee) and the 
study investigator(s).  If an investigator wishes to publish information from the study, a copy of 
the manuscript must be provided to NS Pharma for review in accordance with the provisions of 
such investigator’s written agreement with NS Pharma (or designee) before submission for 


NCT04060199 
NS-065/NCNP-01 
 
NS Pharma, Inc. 
Clinical Study Protocol: NS-065/NCNP-01-301 
v4.0 08Dec2022 
 
 
 
 
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publication or presentation.  If requested by NS Pharma in writing, the investigator will withhold 
such publication in accordance with the provisions of such agreement. 
Authorship of any publications resulting from this study will be determined on the basis of the 
Uniform Requirement for Manuscripts Submitted to Biomedical Journals International 
Committee of Medical Journal Editors (ICMJE) Recommendations for the Conduct of Reporting, 
Editing, and Publications of Scholarly Work in Medical Journals, which states: 
Authorship credit is to be based on: (1) substantial contributions to conception and design, 
acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it 
critically for important intellectual content; (3) final approval of the version to be published; and 
(4) agreement to be accountable for all aspects of the work in ensuring that questions related to 
the accuracy or integrity of any part of the work are appropriately investigated and resolved.  
Authors need to meet conditions 1, 2, 3, and 4. 
When a large, multi-center group has conducted the work, the group is to identify the individuals 
who accept direct responsibility for the manuscript.  These individuals must fully meet the 
criteria for authorship defined above.