Conditions: Diabetes Mellitus, Type 1
Keywords: Diamyd Diabetes Juvenile Diabetes Diabetes Type 1 Type 1 Diabetes Autoimmune Diabetes Insulin Dependent Diabetes Type 1 Diabetes MellitusType 1 Diabetes Mellitus rhGAD65 GAD65 GAD-Alum Diabetes Mellitus Diabetes mellitus Type 1 Glucose Metabolism Disorders Metabolic Diseases Vitamin D Etanercept
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 20
Healthy volunteers: no

Brief summary:
The objectives of this study is to:

* Evaluate the tolerability of a combination therapy with Diamyd, vitamin D and etanercept
* Evaluate how the above mentioned treatments influence the immune system and endogenous insulin secretion

Detailed description:

Arms:
arm 1: All patients will from Day 1 receive 2 000 IU vitamin D per os per day during 15 months, and from Days 1-90 receive etanercept (Enbrel) injected subcutaneously 0.8 mg/kg body weight (max 50 mg) once a week, and receive 2 subcutaneous injections of 20 μg Diamyd in a prime-and-boost regimen on Days 30 and 60.

Interventions: intervention 1: GAD-Alum intervention 2: Vitamin D intervention 3: Etanercept
Intervention descriptions: intervention 1: Recombinant Human Glutamic Acid Decarboxylase (rhGAD65) intervention 2: None intervention 3: None

Protocol document:
Prot_SAP_000.pdf: 
 
Clinical Study EDCR IIa   
Version 4.2: 2015-03-17 
 
Page 1 of 50 
 
Confidential 
CLINICAL STUDY PROTOCOL 
 
Open Label trial to evaluate the tolerability of a combination therapy 
consisting of GAD-alum (Diamyd®), etanercept and vitamin D in 
children and adolescents newly diagnosed with type 1 diabetes 
 
Acronym: EDCR (Etanercept Diamyd Combination Regimen)  
 
 
 
 
 
Study No. EDCR IIa 
EudraCT Number: 2014-001323-76   
Study Development Phase: II 
Version 4.2, 2015-03-17 
 
 
Sponsor: 
Johnny Ludvigsson 
 
Div of Pediatrics, Linköping university 
University Hospital, SE58185 Linköping, Sweden 
Phone: 
+ 46 13 286854 
Fax: 
+ 46 13 148265 
 
Coordinating Investigator: 
 
 
Professor Johnny Ludvigsson 
Linköping University Hospital 
Div of Pediatrics, Dept of Clinical and 
Experimental Medicine 
Faculty of Health Medicine, Linköping university 
SE-581 85 Linköping, Sweden 
 
Contract Research Organization: 
Linköping Academic Research Centre (LARC) 
Planned start date: 
Q1, 2015 
 
 
 
VERSION TABLE* 
Version 4.2: 
Final including Non-Substantial Information 
Amendment #0.2 
Mar 17, 2015 
Version 4.1: 
Final including Non-Substantial Information 
Amendment #0.1 
Mar 03, 2015 
Version 4:  
Final 
Nov 11, 2014 
 
*Version 1-3, prior to MPA approval, not applicable.


 
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STUDY ADMINISTRATION 
 
Name and address 
Telephone and fax numbers, e-mail 
address 
Sponsor 
Professor Johnny Ludvigsson 
Linköping University Hospital 
Div of Pediatrics,  
Dept of Clinical and 
Experimental  Medicine 
Faculty of Health Medicine, 
Linköping university, 
SE-581 85 Linköping, Sweden 
 
Phone: +46 13 286854 
E-mail: Johnny.Ludvigsson@liu.se 
 
Coordinating 
Investigator 
Professor Johnny Ludvigsson 
Linköping University Hospital 
Div of Pediatrics,  
Dept of Clinical and 
Experimental  Medicine 
Faculty of Health Medicine, 
Linköping university, 
SE-581 85 Linköping, Sweden 
 
Phone: +46 13 286854 
E-mail: Johnny.Ludvigsson@liu.se 
 
 
 
 
CONFIDENTIALITY STATEMENT 
This material is confidential and the property of Sponsor. Its contents must not be disclosed or used except as 
authorised in writing by Sponsor. 


 
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Table of Contents 
LIST OF ABBREVIATIONS AND DEFINITION OF STUDY SPECIFIC TERMINOLOGY ............ 8 
1 
INTRODUCTION ................................................................................................................................ 9 
1.1 BACKGROUND AND RATIONAL ............................................................................................................... 9 
1.1.1 Factors influencing the natural course ........................................................................................ 9 
1.1.2 Interventions ............................................................................................................................... 10 
1.1.3 Immune therapy with auto-antigens .......................................................................................... 10 
1.1.4 Previous clinical studies with GAD-Alum (Diamyd) ................................................................. 11 
1.1.5. Vitamin D and type 1 diabetes ................................................................................................... 12 
1.1.6 Etanercept and Type 1 diabetes .................................................................................................. 13 
1.1.7 Rationale for etanercept and GAD-alum (Diamyd) in type 1 diabetes ...................................... 13 
1.1.8 Rationale for Vitamin D supplementation ................................................................................. 14 
1.2 SUMMARY ............................................................................................................................................ 14 
2 
RISK-BENEFIT ANALYSIS ............................................................................................................. 15 
2.1 TYPE 1 DIABETES ................................................................................................................................. 15 
2.2 RISKS OF DIAMYD® .............................................................................................................................. 16 
2.3 RISKS OF ETANERCEPT (ENBREL®) ....................................................................................................... 16 
2.4 RISKS OF VITAMIN D SUPPLEMENTATION ............................................................................................ 17 
2.5 
RISKS OF COMBINING DIAMYD® AND ETANERCEPT AND VITAMIN D SUPPLEMENETATION ............ 17 
2.6 JUSTIFICATION ..................................................................................................................................... 17 
3 
AIM OF PRESENT STUDY .............................................................................................................. 18 
4 
OBJECTIVES AND ENDPOINTS ................................................................................................... 19 
4.1 OBJECTIVES ......................................................................................................................................... 19 
4.2 ENDPOINTS ........................................................................................................................................... 19 
4.2.1 Primary endpoints ....................................................................................................................... 19 
4.2.2 Secondary endpoints ................................................................................................................... 19 
5 
POPULATION .................................................................................................................................... 20 
5.1 INCLUSION CRITERIA ........................................................................................................................... 20 
5.2 EXCLUSION CRITERIA .......................................................................................................................... 21 
5.3 RECRUITMENT AND SCREENING ........................................................................................................... 22 
5.3.1 Screening for tuberculosis (exclusion criterion) ........................................................................ 22 
5.3.2 Screening for viral hepatitis liver disease and renal insufficiency ............................................ 22 
5.4 PATIENT WITHDRAWAL ....................................................................................................................... 23 
6 
TREATMENT PROCEDURES ........................................................................................................ 25 
6.1 STUDY DESIGN AND TREATMENT ......................................................................................................... 25 
6.2 ASSESSMENTS AND PROCEDURES ......................................................................................................... 26 
6.2.1 All Visits, Visit 1 through 9 ......................................................................................................... 26 
6.2.2 Injections with GAD-Alum (Diamyd), Visits 3 and 4 ................................................................. 26 
6.2.3 Mixed Meal Tolerance Test (MMTT), Visits 2, 6, 8 and 9 ........................................................ 27 
6.3 LABORATORY TESTS AND EXAMINATIONS: .......................................................................................... 27 
6.4 MEDICAL HISTORY .............................................................................................................................. 28 
6.5 PHYSICAL EXAMINATION AND NEUROLOGICAL EXAMINATION ........................................................... 28 
6.6 PATIENT DIARY .................................................................................................................................... 28 
6.7 SAFETY PLAN ....................................................................................................................................... 29 
6.7.1 General precautions during etanercept treatment (see Safety Plan for details) ....................... 29 
6.7.2 General precautions during Vitamin D treatment ..................................................................... 30 
6.8 DATA SAFETY MONITORING BOARD (DSMB) ..................................................................................... 31 


 
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6.9 ADVERSE EVENTS ................................................................................................................................ 31 
6.10 CONCOMITANT MEDICATION ............................................................................................................. 31 
7 
SCHEDULING OF PROCEDURES ................................................................................................. 32 
7.1 VISITS .................................................................................................................................................. 33 
8 
STUDY MEDICATION ..................................................................................................................... 34 
8.1 STUDY MEDICATIONS .......................................................................................................................... 34 
8.2 SUPPLY, PACKAGING, HANDLING AND STORAGE ................................................................................. 34 
8.3 DOSAGE AND ADMINISTRATION ........................................................................................................... 35 
8.4 DURATION OF TREATMENT .................................................................................................................. 35 
8.5 CONCOMITANT MEDICATION ............................................................................................................... 35 
8.6 STUDY MEDICATION ACCOUNTABILITY ............................................................................................... 35 
9 
RESPONSE VARIABLES AND OUTCOMES ............................................................................... 36 
9.1 ASSESSMENTS ...................................................................................................................................... 36 
9.1.1 Variables...................................................................................................................................... 36 
9.2 ADVERSE EVENTS, SERIOUS ADVERSE EVENTS AND PREGNANCY ....................................................... 36 
9.2.1 Definitions of Adverse Events (AE) ............................................................................................ 36 
9.2.2 Seriousness .................................................................................................................................. 37 
9.2.3 Intensity ....................................................................................................................................... 37 
9.2.4 Relationship to study medication ................................................................................................ 38 
9.2.5 Reporting of Adverse Events ....................................................................................................... 38 
9.2.6 Timelines and Reporting of SAE ................................................................................................ 39 
9.2.7 Unresolved Events ....................................................................................................................... 40 
9.2.8 Pregnancy Report Form ............................................................................................................. 40 
10 
STATISTICAL METHODOLOGY AND DATA MANAGEMENT ............................................. 40 
10.1 STUDY DESIGN ................................................................................................................................... 40 
10.2 ESTIMATION OF SAMPLE SIZE ............................................................................................................ 40 
10.3 STATISTICAL ANALYSIS PLAN ............................................................................................................ 40 
10.4 STUDY POPULATIONS ......................................................................................................................... 41 
10.5 DATA COLLECTION / CASE REPORT FORMS ....................................................................................... 41 
10.6 DATA MANAGEMENT ......................................................................................................................... 42 
11 
REGULATORY AND ADMINISTRATIVE PROCEDURES ....................................................... 42 
11.1 ETHICS COMMITTEE AND COMPETENT AUTHORITIES ......................................................................... 42 
11.2 PATIENT INFORMATION / INFORMED CONSENT .................................................................................. 43 
11.3 PATIENT CONFIDENTIALITY ............................................................................................................... 43 
11.4 PATIENT TREATMENT PLAN ............................................................................................................... 43 
11.5 GCP ................................................................................................................................................... 44 
11.6 RECORD RETENTION .......................................................................................................................... 44 
11.7 MONITORING / QUALITY CONTROL .................................................................................................... 44 
11.8 SOURCE DATA .................................................................................................................................... 44 
11.9 QUALITY ASSURANCE AND INSURANCE ............................................................................................. 44 
12 
END OF TRIAL .................................................................................................................................. 44 
12.1 STUDY REPORT .................................................................................................................................. 44 
12.2 STUDY STOPPING CRITERIA ............................................................................................................... 45 
12.3 PUBLICATION AND DATA RIGHTS....................................................................................................... 45 
13 
REFERENCES ................................................................................................................................... 46 
14 
INVESTIGATOR/SPONSOR SIGNATURES ................................................................................. 50 


 
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STUDY INFRASTRUCTURE  
 
The study will be conducted at approximately 9 clinical sites in Sweden. 
 
Principal Investigator and sponsor: 
- 
Johnny Ludvigsson. Professor of Pediatrics, Linköping university, Sweden 
 
Co-investigators  
- 
Mark Rigby, MD, Professor of Pediatrics, Indiana University and Riley Hospital for Children at 
Indiana University Health, Indianapolis, IN, USA 
- 
Teresa Quattrin, MD, Professor of Pediatrics, Diabetes Center, Women and Children’s Hospital of 
Buffalo, Buffalo, NY, USA  
- 
Bang Peter, Professor of Pediatrics, Linköping University Hospital 
- 
Carlsson Annelie; Ass prof of Pediatrics, Lund University Hospital 
- 
Hanås Ragnar MD,PhD, Pediatric Diabetologist, Uddevalla Hospital 
- 
Vigård Tore, MD, Pediatric diabetologist, Malmö University Hospital 
- 
Rathsman Björn, Pediatric Endocrinoligst, Södersjukhuset, Stockholm 
- 
Samuelsson Ulf, Ass Professor of Pediatrics, Linköping University Hospital 
- 
Särblad Stefan, MD, PhD, Ass prof of Pediatrics, Örebro University Hospital 
- 
Albin Anna-Karin, MD, Pediatric diabetologist, Helsingborg Hospital 
- 
Arvidsson Carl-Göran , MD, Pediatric diabetologist, Västerås Hospital 
- 
Söderström Ulf, MD, PhD, Pediatric diabetologist, Eskilstuna Hospital  
 
Study nurses:  
- 
AnneMarie Sandström, Diabetes Research Nurse, Div of Pediatrics, Linköping univ hospital 
- 
Eva Isacson, Diabetes Research Nurse, Div of Pediatrics, Linköping univ hospital 
 
Laboratory staff: 
- 
Rosaura Casas, Ass Prof of Pediatric Immunology, Clin Exp Centre, Div of Pediatrics, Linköping 
University 
- 
Ingela Johansson, MSC, Clin Exp Centre, Div of Pediatrics, Linköping university 
- 
Gosia Smolinska, Biomedical Assistant, Clin Exp Centre, Div of Pediatrics, Linköping university  
 
Facilities and Equipment 
 
- 
Laboratory: Clinical Experimental Research, Linköping university hospital, has localities with all 
necessary modern equipment. Div of Pediatrics has laboratory facilities, with an experienced and 
skilful staff  
- 
Clinical infrastructure: All participating clinics have experience from previous clinical studies, 
with experienced pediatric diabetologists, nurses with knowledge and experience of MMTT and 
collection of samples, how to fill in CRFs etc 
- 
Study Monitors: Clinical Study Monitors, are available at the Linköping Academic Research 
Centre ( LARC) 
- 
Computers, information technology: All necessary facilities are available at the Faculty of Health 
Sciences, Linköping university and at the involved hospitals.  
- 
Safety Reporting: A Contract Research Organization (CRO) will be assigned  
 
Data Safety Monitoring Board 
- 
Anders Fasth, MD, PhD, Dept of Pediatrics, University of Gothenburg 
- 
Ulf Smith, MD, PhD, Department of Internal Medicine, SU/Sahlgrenska 
- 
Jesper Peterson, MD, Department of Infectious Diseases, Malmo University Hospital, MAS 


 
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- 
SYNOPSIS OF THE PROPOSED PILOT STUDY 
 
Name of Sponsor 
Johnny Ludvigsson 
Individual Study Table Referring to 
Part of Dossier in Which the Individual 
Study or Study Table is Presented: 
 
 
 
 
Volume: 
Reference: 
 
(For National 
Authority Use Only) 
 
 
Name of Finished Product:  
DIAMYD® 
ETANERCEPT  
VITAMIN D 
 
Name of Active Ingredient:  
Recombinant Human Glutamic 
Acid Decarboxylase (rhGAD65) 
Calciferol (Vitamin D) 
Etanercept 
 
Title of  Study: Open Label trial to evaluate the tolerability of a combination therapy consisting of GAD-
alum (Diamyd®), etanercept and vitamin D in children and adolescents newly diagnosed with type 1 
diabetes 
 
Protocol Number:   
EDCR IIa 
Investigators and Study Centre:   
Approximately 9 sites in Sweden, including approximately 20 patients.   
 
Phase of Development:  Phase IIa 
 
Objectives:   
 
Evaluate the tolerability of a combination therapy with Diamyd, vitamin D and etanercept  
 
Evaluate how the above mentioned treatments influence the immune system and endogenous 
insulin secretion 
 
Study Design: 
The study is a multicenter, open-label, pilot clinical trial. All patients will from Day 1 receive 2 000 IU 
vitamin D per os per day during 15 months, and from Days 1-90 receive etanercept (Enbrel) injected 
subcutaneously 0.8 mg/kg body weight (max 50 mg) once a week, and receive 2 subcutaneous injections of 
20 µg Diamyd in a prime-and-boost regimen on Days 30 and 60. The patients will be evaluated for 
tolerability for 6 months (main study period, 6 visits) and followed for additionally 24 months (extension 
study period, 3 visits).  The total study period is 30 months. 
Selection of Subjects:  Patients must be age 8.00 to 17.99 years old, and diagnosed with type 1 diabetes 
(T1D) within the previous 100 days at the time of screening. Patients will be eligible for enrolment if fasting 
C-peptide is ≥0.12 nmol/L (0.36 ng/mL) and elevated levels of GAD65 antibodies are present. 
Number of Subjects Planned:  Approximately 20 patients will be enrolled.   
Description of Treatment Groups: 
There is one single treatment group. The patients will be assessed for eligibility at the screening visit (Visit 
1) 2 to 4 weeks prior to the start of the treatment. On Visit 2 (Day 1), patients eligible for the study will start 
the treatment as mentioned above. 


 
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Name of Sponsor 
Johnny Ludvigsson 
Individual Study Table Referring to 
Part of Dossier in Which the Individual 
Study or Study Table is Presented: 
 
 
 
 
Volume: 
Reference: 
 
(For National 
Authority Use Only) 
 
 
Name of Finished Product:  
DIAMYD® 
ETANERCEPT  
VITAMIN D 
 
Name of Active Ingredient:  
Recombinant Human Glutamic 
Acid Decarboxylase (rhGAD65) 
Calciferol (Vitamin D) 
Etanercept 
 
Endpoints 
 
Primary endpoints:  
To Evaluate the tolerability of a combination therapy with Diamyd, Vitamin D and etanercept at Month 6 
(main study Period), 9, 15 and 30 (extension study period) 
 
Variables to evaluate tolerability: 
   
 
Reactions at the injection site 
 
Infections 
 
Occurrence of Adverse Events (AEs) 
 
Occurrence of Serious Adverse Events 
 
Physiological and Neurology assessments 
 
Laboratory measurements (biochemistry and haematology), including Calcium and Vitamin D in 
serum 
 
GAD65AB titer (GADA) 
 
Secondary endpoints:  
To evaluate how the above mentioned treatments influence the immune system and endogenous insulin 
secretion at Month 6 (main study Period), 9, 15 and 30 (extension study period) 
 
Variables to evaluate the influence on the immune system: 
 
 
Inflammatory markers, especially TNF-alfa, IL-1 beta, IL-2, IL-17  
 
Th2-deviation of cell-mediated immune response seen e.g. as increased ratio of IL-5,10, 13 in 
comparison with IFN-gamma, TNF-alfa, IL-1 beta and IL-17 
 
Increase of T-regulatory cells  
 
Variables to evaluate the effect of endogenous insulin secretion: 
 
 
C-peptide (90 minute value and AUCmean 0-120 min) during an MMTT  
 
Proportion of patients with a stimulated maximum C-peptide level above 0.2 nmol/L  
 
Fasting C-peptide 
 
Hemoglobin A1c (HbA1c) 
 
Exogenous insulin dose per kg body weight and 24 hours 
 
 
Sample size:   
No real sample size calculation is done as this is an open-label pilot study just to see if the treatment is 
tolerable and does not cause negative effects on beta cell function and/or immune system.  
 
All variables  will be summarized descriptively 


 
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LIST OF ABBREVIATIONS AND DEFINITION OF STUDY SPECIFIC 
TERMINOLOGY 
 
 
 
ADA 
American Diabetes Association 
AE 
Adverse Event 
Alum 
Aluminum hydroxide 
AUC 
Area Under the Curve 
AUCmean 0-120 min 
AUC mean 0-120 minutes 
BMI 
Body Mass Index 
CRF 
Case Report Form 
CRA 
Clinical Research Associate 
CRO 
Contract Research Organization 
DCCT 
Diabetes Control and Complications Trial 
DCF 
Data Clarification Form 
DSMB 
Data Safety Monitoring Board 
EC 
Ethics Committee 
GAD 
Glutamic acid decarboxylase 
GADA 
Antibodies to GAD with molecular mass 65,000 
GAD65 
GAD with molecular mass 65,000 
GCP 
Good Clinical Practice 
HbA1c 
Hemoglobin A1c  
HLA 
Human Leukocyte Antigen 
IAA 
Insulin Autoantibody 
IA2 
Islet cell Antigen 512 
ICH 
International Conference on Harmonization 
ITT 
Intent-to-Treat 
LADA 
Latent Autoimmune Diabetes in Adults 
MMTT 
Mixed Meal Tolerance Test 
NOD 
Non-obese Diabetic  
PP 
Per-Protocol 
rhGAD65 
Recombinant Human GAD with molecular mass 65,000 
SAP 
Statistical Analysis Plan 
SAE 
Serious Adverse Event 
T1D 
Type 1 Diabetes 
T2D 
Type 2 Diabetes 


 
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1 
Introduction 
1.1 Background and Rational 
The incidence of Type 1 diabetes (T1D) in children is next to Finland highest in Sweden in the 
world, and is increasing rapidly. T1D is by far the most common chronic, serious, life-threatening 
disease in our country, and tends to become an extremely serious global problem. The disease is 
characterized by lack of insulin. Even though several patients at diagnosis have rather impressive 
residual beta cell function (1) the deficiency soon becomes very pronounced and finally complete 
(2,3). Residual insulin secretion is of crucial importance. In rare cases the beta cell function 
improves so much shortly after diagnosis that glucose metabolism normalizes and no insulin is 
required for some time, that is the patient goes into so called complete remission (4). As long as a 
the patient is in a complete remission there is no need of active treatment, more than perhaps 
some recommendation of sound life style regarding physical exercise and diet. There are no 
symptoms, no acute complications and if somebody stayed in complete remission it is unlikely 
that such an individual would ever develop late complications. Slight abnormality of glucose or 
lipid metabolism might increase the risk of macrovascular complications in the same way as for 
individuals with chemical diabetes or impaired glucose tolerance.  
 
Complete remission is rare, but partial remission it is not (4). During this period the child usually 
has near normal blood glucose values, not even mild hypoglycemia and no episodes of keto-
acidosis. The quality of life is very good as the child feels well, grows normally, needs few 
restrictions if any with regard to food, can exercise with great variation without getting 
hypoglycemia, and experiences very good home blood glucose tests. Only some residual insulin 
secretion is enough to diminish the risk of ketoacidosis (5). Furthermore, it has been shown in the 
DCCT trial that even quite modest residual insulin secretion, a response to a beta cell stimulation 
with serum C-peptide >0.20pmol/ml, plays an important role for prevention of complications (6). 
This effect may be due to the fact that residual insulin secretion should reasonably make it easier 
to reach good blood glucose balance, but it is also possible that C-peptide per se has a 
physiological function. It has in fact been reported that C-peptide influences vascular 
permeability, decreases leakage in retinal vessel, and not least has a positive effect on nerve 
function (7) although the effect of C-peptide per se still is under debate.  
1.1.1 Factors influencing the natural course 
At diagnosis of T1D it has been claimed that 70-90% of the beta cells in pancreas have been 
destroyed. However, the proof for this is scarce, and it may well be that the main problem is 
deterioration of function. Furthermore there is great difference between patients, as some have 
quite good residual insulin secretion and others have not. Shortly after diagnosis, especially when 
an active insulin treatment is given, there is an increase of C-peptide production, and at the same 
time an improvement of insulin sensitivity. Good metabolic control seems to improve the milieu 
and metabolism for the beta cells and the beta cell function is preserved, which in turn contributes 
to better metabolic control, and vice versa. The intensity of the autoimmune process plays a role, 
and it seems evident that children have a more aggressive immune process than adults with T1D, 
but it is still difficult to predict the course. Some studies have suggested that high concentrations 
of auto-antibodies are followed by a more rapid loss of insulin secretion, while others have not 
found such a relationship, or even the opposite. No special signs of cell-mediated immunity have 
so far been proven to predict beta cell loss but our own studies have shown that disease process is 
related to a T-helper-1 (Th-1) deviation of the immune system with increase of certain cytokines 
such as IFNg and decrease of IL-10, IL-13. 


 
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Interventions that may preserve beta cell function. 
Active insulin treatment during the first period of the disease prolonged the partial remission long 
time ago, and this finding could be confirmed and validated by improved residual insulin 
secretion (2). Intensified treatment seems to improve residual beta cell function at least for some 
time (8), but it may also have long-term positive effects (9). Active treatment has been shown not 
only to prevent or postpone diabetes in experimental animals, but studies have indicated that such 
treatment could prevent diabetes in high risk individuals (10). However, when tried at a larger 
scale in the Diabetes Prevention Trial, parenteral insulin treatment did not prevent diabetes (11). 
Oral treatment with insulin might have an effect (12) and therefore further studies are needed. 
1.1.2 Interventions 
In the 1970ies it became clear that T1D is an autoimmune disease and therefore immune 
interventions were tried. We performed the first immune intervention studies in the world on 
diabetic children when we already 30 years ago used plasmapheresis in newly-diagnosed children 
and adolescents with some positive effects (13). As a side effect of that treatment a new protein 
with the weight 64kD was found in plasma (14), which later showed to be Glutamic Acid 
Decarboxylase (GAD). The breakthrough, taken as a proof for the concept of immune 
intervention, was cyclosporin, which doubtlessly slowed down the autoimmune destructive 
process and gave improved residual insulin secretion, while other trials with immune suppression 
had minimal effect, especially so in children (15, 16,17), or showed too serious adverse events or 
risks (18, 19). In an effort to modulate the immune system we used photopheresis. Although clear 
effects on the immune system were demonstrated in a double blind placebo-controlled trial (20), 
the clinical effect was minimal and almost no improvement of residual beta cell function could be 
seen (21). Thus, with no successful immune intervention, our interest was directed to protective 
agents such as Nicotinamide and Diazoxide, with no or transient effect (22, 23, 24). With 
increasing knowledge of the immune process leading to beta cell destruction, it has become 
possible to direct more precisely the immune intervention to target the important T-cells. 
Promising studies using anti-CD3 antibodies in an attempt to block the destructive immune 
process have been performed. Result from both North-American and French trials with anti-CD3 
have shown that it is possible to block the destructive autoimmune process and thereby at least 
postpone the decline of the beta cell function (25,26). The decline of residual insulin secretion 
was significantly slowed down, but unfortunately it looks as if the decline was just delayed a 
year, and thereafter the declining C-peptide curve went parallel to the declining curve in the 
placebo group. Furthermore, a majority of the patients experience some Cytokine Release 
Syndrome (CRS), which may be quite serious, and in addition a number of side effects were seen 
in most of the patients. We have participated in one of two recent Phase III trials (Macrogenics 
trial), which failed to reach the primary endpoint, although the arm with the most intense 
treatment indeed showed some preservation of residual insulin secretion and lower exogenous 
insulin requirement to reach good HbA1c (27). New studies are needed but it is difficult to 
believe that this type of treatment alone will be the accepted solution for general clinical use. 
Even less likely is such a treatment accepted as a preventive treatment in otherwise healthy 
individuals of whom many never would develop diabetes. 
 
1.1.3 Immune therapy with auto-antigens 
In the treatment of allergic diseases, immunotherapy with small amount of disease specific 
antigen has been efficiently used during many years. The mechanism for this treatment remains 
unclear, although modulation of the immune responses and induction of regulatory cells have 
been suggested. In autoimmune diseases no such treatment has been successful, but should be 
tried (28). Experiments in diabetes prone animals have shown that treatment with a heat shock 
protein could delay or postpone development of diabetes. The use of Diapep277 peptide in a 


 
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study in adults showed significant preservation of insulin secretion without almost any adverse 
events (29). Later trials in children and adolescents with T1D (30), however, have shown no 
effect. Studies with Diapep277 treatment in so called LADA (Latent Autoimmune Diabetes in the 
Adult) are ongoing, and preliminary results (reported at IDF, Dubai dec 2011 and at ADA June 
2012) suggests that treatment with Diapep277 may preserve beta cell function in adults with mild 
T1D. However, the results are a bit unclear, as there was only a weak C-peptide preservation seen 
after Glucagon stimulation, but no effect at all after Mixed Meal Tolerance Test, and there was no 
differences whatsoever between the actively treated group and placebo in immune markers. 
 
Active treatment with insulin has been shown not only to prevent or postpone diabetes in 
experimental animals but preliminary open studies indicated that such treatment could prevent 
diabetes in high risk individuals (10). Insulin, clearly a beta cell specific auto-antigen, has been 
parentally administrated (DPT) to prevent diabetes in high risk individuals with no effect, while 
oral insulin administration with the same purpose may have some effect (12). 
 
1.1.4 Previous clinical studies with GAD-Alum (Diamyd) 
GAD (Glutamic Acid Decarboxylase), can be regarded as an auto-antigen, as it is produced in the 
islets with increased release as response to beta cell stimulation. This protein has been shown to 
deeply influence the autoimmune immune process (31,32,33,34). Several studies have shown that 
indeed GAD can prevent diabetes in experimental animals (35-42).The observed effect, even after 
the start of the immune process, suggests that it might be possible to expect the same effect in 
humans after the start of the immune process.  
 
1.1.4.1 GAD-Alum (Diamyd) vaccination 
GAD-alum (Diamyd) therapy aims at intervening in the autoimmune process in T1D in order to 
preserve beta cell function and endogenous insulin secretion by modulating the immune system in 
a discrete, antigen-specific fashion to stop the destruction of beta cells. Thus, the goal of Diamyd 
therapy would be to dramatically slow or halt the ongoing autoimmune destruction of pancreatic 
islet beta cells in order to preserve the largest possible amount of endogenous insulin production.   
 
In a phase II study in LADA patients the administration of one low dose, Diamyd 20 µg, led to 
improved beta cell function for up to 2 years compared to the placebo treated group, with no side 
effects. Also other doses were tried: 4 µg showed no effect, 100 µg showed a similar effect as 20 
µg , while 500 µg showed no effect. None of the doses showed any adverse events, still so after 
several years follow-up (43). Association with change in the ratio of CD4+CD25+/ CD4- CD25- 
cells was found, indicating a mechanism for the effect. With this promising background we 
started a Phase II study in T1D patients 10-18 years with recent onset. Based on the idea that the 
treatment earlier had effect in slowly progressive LADA patients we included patients with up to 
18 months duration of T1D at intervention. The patients were randomized to either 20 µg GAD-
alum (Diamyd) sc at Day 1 and 30, or placebo. The effect still after 30 months was remarkable, 
and clearly both statistically and clinically significant (44), with about half of the C-peptide 
decline in the GAD treated group compared with the placebo group. Patients with a diabetes 
duration < 3 months had a remarkably good effect with no or minimal decline of beta cell 
function during the follow-up of the first 15 months. Almost all effect was seen in patients with < 
6 months duration at vaccination. Even more, in contrast to other intervention treatments, this 
effect was gained with no adverse events at all, making the treatment very encouraging! Still after 
48 months the patients treated with < 6 months duration hade significantly preserved C-peptide 
and still no adverse events (45). So far GAD-treatment looked very promising. Two Phase III 
trials were performed, one European with Johnny Ludvigsson (JL) as PI, and one in USA with 
Jerry Palmer as PI and JL as co-investigator. In the European trial 334 patients were recruited into 


 
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three arms, one arm with GAD-alum (Diamyd) 20 µg at Day 1,30, 90 and 270, another arm with 
GAD-alum 20 µg at Day 1 and 30, and placebo at Day 90 and 270 and a third arm with Placebo at 
Day 1, 30, 90 and 270. Primary endpoint, serum C-peptide AUC after a Mixed Meal Tolerance 
Test (MMTT) at 15 months was not met! (C-peptide AUC (16.4% treatment effect; p=0.10); 
Fasting C-peptide p=0.07) (46). This prompted the company (Diamyd Medical + 
Johnson&Johnson) to close the Phase III program early. However, the Phase III trial did show 
several positive effects. Thus statistically significant efficacy was seen in several pre-specified 
subgroups. Furthermore, 45 Swedish patients had passed the 30 month visit when the study was 
stopped, and those 15 patients who had received two doses of GAD-alum (Diamyd) 20 µg 
showed a significant preservation of C-peptide after 30 months compared with placebo! (47) This 
is especially remarkable as the Swedish patients were the ones without efficacy after 15 months, 
while efficacy was found after 15 months in the non-Nordic countries. 
 
1.1.4.2 Possible Reasons to the different results Phase II and Phase III 
In Phase III randomization, patients receiving active drug were more often in the 10-11 year age 
group than in the 16-18 year age group whereas placebo was more frequent than active drug in 
the higher age group. This may have influenced the result. The Phase II patients were treated in 
March-April and those patients in Phase III who were treated in March-April had also significant 
effect of GAD-treatment. In the Phase II trial no vaccinations were accepted, but in Phase III 
Influenza-vaccination was allowed. Unfortunately an epidemic of H1N1-flu lead to that almost all 
patients were vaccinated, many of them in connection with the GAD-vaccinations. In Sweden and 
Finland the vaccine contained squalen, suspected to influence the immune system towards auto-
immunity, and in these two countries there was no efficacy of GAD-treatment, while the efficacy 
was significant in other European countries. Patients in Sweden, who did not get the influenza 
vaccination close to the GAD-treatment, had better efficacy of GAD-treatment (46). 
 
1.1.5. Vitamin D and type 1 diabetes 
Experimental evidence indicates that vitamin D may play a role in the defence against T1D as 
well as type 2 diabetes (T2D). Epidemiological data suggest that there is a link between vitamin 
D deficiency and an increased incidence of T1D. Thus a multinational case-control study and a 
birth cohort follow-up study from Finland with (48,49) have both concluded that vitamin D3 
supplementation at birth protects from T1D later in life, and a meta-analysis supports similar 
conclusions (50). Others report lower serum levels of 1α,25-dihydroxyvitamin D3 [1,25(OH)2D3, 
calcitriol] in patients with recently diagnosed T1D than in healthy control subjects (51) The 
protective effects of vitamin D are mediated through the regulation of several components such as 
the immune system and calcium homeostasis. Thus, mechanistic studies show that 1,25(OH)2D3 
modulates dendritic cell maturation in vitro and in vivo (52-55) and facilitates a shift from a Th1 
to a Th2 immune response (56). An increasing amount of evidence suggests that vitamin D also 
affects beta cells directly thereby rendering them more resistant to cellular stress (57), and there 
are results indicating that vitamin D may also improve insulin sensitivity (58), which in turn 
decrease beta cell stress. 
With this background vitamin D has been used in patients with recent onset T1D in an effort to 
preserve residual insulin secretion. However, so far Vitamin D alone has not been efficacious 
enough (59,60). Therefore there is reason to try Vitamin D, both in somewhat higher dose, and in 
combination with other therapy. 


 
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1.1.6 Etanercept and Type 1 diabetes 
Although T1D is regarded to be an autoimmune disease, there are several studies both in 
experimental animals and in humans suggesting that an existing inflammation when autoantigen 
are presented to T-cells play an important role for which response the immune system will take.  
 
We know that Tumor Necrosis Factor – α (TNFα) plays an important role for the destructive 
process in T1D. TNFα is involved in the autoimmune process leading to beta cell destruction 
(61,62). In the non-obese diabetic mouse, TNFα mRNA is produced by CD4+ T-cells within 
inflamed islets during the development of diabetes (63). In vitro models show that TNFα 
potentiates the direct functional inactivation and destruction of beta cells by other cytokines such 
as interleukin-1β and interferon-γ (64-68). Transgenic mice with increased beta cell expression of 
TNFα have significant lymphocytic insulitis (69).  
 
Etanercept is a recombinant soluble TNFα receptor fusion protein that binds to TNFα. It acts by 
clearing TNFα from the circulation, thereby blocking the biological activity of this inflammatory 
cytokine. Although etanercept is used in the treatment of many autoimmune diseases including 
ankylosing spondylitis, juvenile rheumatoid arthritis, psoriasis, psoriatic arthritis, and rheumatoid 
arthritis, (70,71) it has only been tested in young people with T1D (72). This was a 24-week 
double-blind, randomized, placebo-controlled study conducted at the Diabetes Center, Women 
and Children's Hospital of Buffalo. Eighteen subjects (11 male and 7 female, aged 7.8-18.2 years) 
were randomly assigned to receive either placebo or etanercept. The effect was quite impressive: 
The beta cell function was not only preserved but the percent change in C-peptide area under the 
curve from baseline to week 24 showed a 39% increase (!) in the etanercept group compared to a 
20% decrease in the placebo group (P < 0.05). From baseline to week 24 insulin dose decreased 
18% in the etanercept group compared with a 23% increase in the placebo group (P < 0.05). At 
the same time, with lower insulin dose, HbA1c at week 24 was lower in the etanercept group 
(5.91 +/- 0.5%) compared with that in the placebo group (6.98 +/- 1.2%; P < 0.05) with a higher 
percent decrease from baseline than in the placebo group (etanercept 0.41 +/- 0.1 vs. placebo 0.18 
+/- 0.21; P < 0.01). Seventeen patients completed the study, and none withdrew because of 
adverse events. In fact the adverse events were minimal in that study. 
 
1.1.7 Rationale for etanercept and GAD-alum (Diamyd) in type 1 diabetes 
There is consensus among diabetes researchers today that the key to curing T1D will be to 
simultaneously tackle the disease on several fronts by combining various therapeutics and that an 
autoantigen-specific treatment such as Diamyd will constitute an essential component in future 
combination therapies. 
 
In this EDCR IIa trial, we propose that etanercept and GAD-alum will synergize in a novel 
manner to produce extended beta cell function in those newly diagnosed with T1D. 
 
More specifically, although Phase III studies indicate GAD-alum alone does not preserve beta 
cell function enough, it does have a potent effect on the immune system. The data indicate that 
GAD-alum activates both TH2/immunoregulatory and TH1/proinflammatory components (73). 
Immunologically, TNFα plays an integral role in the initiation and progression of the innate and 
beta cell-specific autoimmunity (74). Blocking TNFα with etanercept in autoimmune patients has 
resulted in downregulation of Th1 and Th17 activation and an upregulation of Th2 and regulatory 
T-cell (Treg) subsets of immunocytes (75). If we can induce quiescence in the inflammatory 
immunologic milieu present in and around islets via combination treatment with etanercept, we 
could both enhance the TH2/immunoregulatory GAD-alum response and lessen the 
TH1/proinflammatory response. 


 
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Furthermore, metabolically, TNFα appears to inhibit insulin secretion, and acts in synergy with 
other cytokines such as IL1-β and IFNγ to enhance beta cell stress and destruction (74, 76, 77, 
64). Experience with etanercept and other TNFα blockers in T1D animal models and clinical 
patients with T1D suggests that beta cell destruction can be arrested leading to better metabolic 
control (78, 79, 80, 81). Because it is a potent proinflammatory cytokine (74) blocking soluble 
TNFα (sTNFα) reduces the activation state of immunocytes (75), but additionally, because 
Etanercept preferentially binds sTNFα over membrane bound TNFα (mTNFα) expressed on 
Dendritic Cells (DC) (unlike other anti-TNFα agents), a DC-mediated antigen specific Treg 
generation is preserved (82, 83). By uniquely blocking B-cell borne Lymphotoxin-α, disrupting 
Follicular Dendritic cells and Germinal Center architecture in lymphoid tissue, anti-TNFα reduces 
B cell numbers and impairs activation (84), and autoantibody production should be reduced.  
 
Preclinical data has shown that beta cell antigen delivered via quiescent DCs induce T-cell 
unresponsiveness and arrest beta cell destruction (85, 86). 
 
We believe, therefore, that when etanercept therapy is added to GAD-alum treatment, GAD-
specific autoantibody levels and effector T cell activity and number will be reduced while GAD-
specific Treg number and function will be maintained. Due to its acute beta-cell-protective and 
metabolic effects, etanercept will also preserve beta cells directly. This will produce a deviation 
of the diabetes autoimmune response towards a regulatory phenotype of sufficient critical mass to 
lead to a significant and prolonged effect on beta cell preservation. This is not unlike the original 
rationale for the GAD-alum monotherapy approach evaluated in a number of clinical studies, but 
with critical improvements based on the knowledge gained from those trials. 
 
1.1.8 Rationale for Vitamin D supplementation 
As explained in the rational above, experimental evidence indicates that vitamin D may play a 
role in the defence against T1D and epidemiological data suggest that there is a link between 
vitamin D deficiency and an increased incidence of T1D. Mechanistic studies show that 
1,25(OH)2D3 modulates dendritic cell maturation in vitro and in vivo (52-55) and facilitates a 
shift from a Th1 to a Th2 immune response (56). An increasing amount of evidence suggests that 
vitamin D also affects beta cells directly thereby rendering them more resistant to cellular stress 
(57), and there are results indicating that Vitamin D may also improve insulin sensitivity (58), 
which in turn decreases beta cell stress. Thus, there is reason to include Vitamin D in the 
combination with etanercept and Diamyd®. 
 
 
1.2 Summary 
 
 
The encouraging results of the Phase II GAD-alum trial and the partly positive results of 
the Phase III European Trial, support the concept that administration of GAD-alum 
(Diamyd) twice, at Day 1 and 30, may decrease the autoimmune process and contribute 
to preservation of residual insulin secretion 
 
Injection of GAD-alum (Diamyd) subcutaneously in the stomach area closer to pancreas 
and its neighbouring lymph nodes will likely increase the effect 
 
Addition of rather large doses of Vitamin D may improve the efficacy both via effects on 
the immune system and mechanism directly on the beta cells 


 
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 
Treatment with etanercept, before and/or during treatment with GAD-alum will decrease 
the ongoing inflammation and improve/maintain the effect of GAD-alum treatment 
enforced by vitamin D. 
 
With this background we believe that etanercept should be tried in combination with GAD-alum 
therapy and Vitamin D in rather large doses. Thus, we want to make an open pilot-trial where our 
first aim is to study safety, but then also elucidate efficacy and immunological mechanisms.  
 
2 
Risk-Benefit Analysis 
2.1 Type 1 diabetes 
The onset of human T1D is the clinical manifestation of beta-cell failure caused by T-cell 
mediated autoimmune destruction of the insulin producing pancreatic beta cells, a pathologic 
feature involving an inappropriate immunological recognition of the body’s own tissues. This 
results in a life-long dependence on daily insulin injections and exposure to both the acute and 
late complications of T1D. T1D is a particular burden to children and their families, representing 
by far the most common chronic, serious, life-threatening disease in our country, and tends to 
become an extremely serious global problem. 
 
By the time a T1D patient is diagnosed, up to 70-90% of pancreatic islet beta cell function has 
been lost due to autoimmune responses against specific beta cell antigens. Over time this 
autoimmune response persists and the amount of endogenous insulin that is produced is reduced. 
As this happens a T1D patient is reliant on exogenous insulin and is at greater risk for both short 
and long term complications of T1D. In the more acute manifestation of T1D, or in the absence of 
treatment, the lack of insulin can result in diabetic ketoacidosis (DKA), a potentially life-
threatening medical emergency. Insulin therapy can dramatically reduce the possibility of death 
from DKA but even patients adequately treated with insulin are still at increased risk to a number 
of acute and long-term (chronic) complications. Acute complications include DKA and severe 
hypoglycaemia. Long-term complications of T1D include microvascular, macrovascular and 
neurologic complications that increase morbidity as well as mortality. Studies have shown that 
retained residual insulin production is associated with a reduction in DKA and hypoglycemic risk 
as well as in the development of long-term complications (6).  
 
Although the use of insulin has dramatically improved the survival of patients with T1D, insulin 
does not represent a cure as individuals with the disorder, even if well managed, display marked 
increases in the frequency of debilitating and even life-threatening complications. The severity of 
these complications makes the development of a therapy allowing for beta cell preservation of 
great urgency for patients and caregivers. The world-wide incidence of T1D is increasing and 
despite the significant progress that has been made in its treatment, T1D still represents a severe 
burden on the individual and on society as well. Any intervention, which can stop or delay the 
complete loss of functional residual beta-cell mass would be significant as it would provide 
protection against hypoglycemia and provide improved metabolic control resulting in a delay and 
reduction in the micro and macro-vascular complications of diabetes. 
 
In summary, T1D without residual insulin secretion is a dangerous disease with increased 
mortality in spite of a lifetime of intense treatment. There is currently no approved method or 
medicament to halt or slow the immune destruction of remaining pancreatic islet beta cells. Such 
a treatment would be of great benefit for all newly diagnosed T1D patients in the world, as well 
for the society.  
 


 
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In this new pilot-trial (EDCR IIa) it is proposed to use a treatment period with the TNF-α 
inhibitor etanercept of three months at a dose of 0.8 mg/kg body weight (max 50 mg) per week 
(as for children with JIA), in combination with Diamyd® at a dose of 20µg administered as a 
prime dose with a booster dose of 20µg one month later (2 doses of 20µg in total), and 
Vitamin D at a dose of 2000 IU per day during 15 months. 
 
We argue that etanercept, Diamyd® and vitamin D in the proposed doses, and with the proposed 
exclusion and inclusion criteria, and careful follow-up are justified to try to stop the devastating 
progress of autoimmune beta cell destruction in new onset T1D, aiming to preserve blood glucose 
control and endogenous insulin secretion. 
 
2.2 Risks of Diamyd® 
Diamyd is an investigational experimental study drug (not marketed or approved) that has been 
studied in preclinical and clinical trials (Phase I through III). There are no risks of particular 
severity or seriousness anticipated based on the toxicological data in animals or prior studies in 
humans, except that patients have reported injection site reactions, such as e.g. itching, oedema, 
tenderness, bruises and pain. All patients recovered, and no patient was withdrawn from further 
treatment due to injection site reactions. 
 
Theoretical risks of Diamyd® such as acceleration of the autoimmune process, undesirable effects 
on the immune system and neurological disease have been discussed and also thoroughly 
evaluated during several clinical trials in both children and adults, and all clinical studies 
performed with Diamyd® to date indicate a favorable safety profile for Diamyd® and no 
neurological concerns have been identified (see section 1.1.4 above and the Investigator’s 
Brochure of Diamyd®). It is however possible that not yet detected side effects may be revealed in 
this or future clinical trials. 
 
The dose of 20 μg of Diamyd®, administered as a prime dose with a booster dose one month later 
or as a prime and boost on days 1 and 30 followed by one or two additional single doses (days 90 
and 270) have been shown to be safe in man (children and adolescents) with few and mild 
adverse reactions.  Recently approximately 60 patients have been randomized in the ongoing 
DIABGAD-1 trial and beside mild transient (a few hours) irritation at the injection site we have 
seen no adverse events related to the Diamyd treatment.  
 
2.3 Risks of Etanercept (Enbrel®) 
Etanercept (Enbrel®) is one of the clinically most well-used biologics in the world and is regarded 
as justified in the treatment of Juvenile Idiopathic Arthritis (JIA) also in children down to 2 years 
of age.  
 
Etanercept has documented side effects and the most commonly reported side effects are injection 
site reactions, infections (URI, bronchitis, cystitis and skin infections, reactivation of tuberculosis  
and other serious infections such as tuberculosis, and opportunistic infections, including invasive 
fungal infections, listeriosis and legionellosis), allergic reactions, development of autoantibodies, 
itching, pruritus and fever.  
 
TNF blockers such as etanercept affect the immune system and its use can affect the body’s 
immune response towards infections. Serious infections affect less than 1 of 100 patients that are 
treated with etanercept. Deadly and life-threatening infections as well as sepsis have been 
reported. Different kinds of malignancies have also been reported while treated with etanercept, 


 
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even if this AE has been questioned by Swedish researchers as the incidence of malignancy in 
children and adults with rheumatic disorders is increased even without treatment.  Additionally 
hematological, neurological and autoimmune reactions have been reported, including rare cases 
of pancytopenia (less than 1 of 1000) and very rare cases of aplastic anemia (less than one of 
10 000). Central and peripheral demyelination has been reported in both rare and very rare cases. 
Also, rare cases of lupus and lupus-like syndrome and vasculitis have been reported  
 
There are also reports that the risk for hypoglycemia may increase in patients with diabetes being 
treated with etanercept. 
 
2.4 Risks of Vitamin D supplementation 
There are no anticipated risks of vitamin D supplementation at the dose to be administered in this 
study, although toxic levels may induce hypercalcemia with symptoms such as tiredness, 
euphoria, nausea, drowsiness, weight loss, thirst, polyuria, nefrocalcinosis and renal failure. 
Additional symptoms of vitamin D toxicity include ECG changes, arrhythmia and pancreatitis.  
 
In DIABGAD-1 we give vitamin D 2000 IU per day for 15 months. This dose given to children 
and adolescents aged 10-18 years can be compared with the dose of 400 IU per day given to 
babies as a health recommendation to avoid vitamin D insufficiency. Approximately 60 patients 
in DIABGAD-1 have been randomized of whom ¾ should have received Vitamin D, and we have 
noticed no adverse event which can be regarded as related to Vitamin D. 
 
Vitamin D in a dose of 2000 IU/day in children has been reported safe (87). Additionally, a dose 
of up to 7000 IU/day to children from 5 years of age with HIV did not raise any safety concerns 
(88).  
 
However, as an extra safety measure, vitamin D serum levels and Calcium will be analyzed at 
most visits. Patients will only be included in the trial if their baseline Vitamin D is below 100 
nmol/L and the Vitamin D treatment will be dismissed  if Vitamin D levels are above 125 nmol/L 
or if the patient develops hypercalcemia. Vitamin D treatment will be started again if the levels 
fall <100 nmol/L.  
 
2.5 Risks of combining Diamyd® and etanercept and vitamin D supplemenetation 
We would not foresee that the addition of an anti-inflammatory treatment to the Diamyd® 
treatment would increase the theoretical risks of Diamyd®, such as acceleration of the 
autoimmune process, undesirable effects on the immune system, or neurological disease. We also 
do not believe that the risks of anti-TNFα therapy, which are mostly the side-effects of 
compromised immunity, should be increased by the presence of a native antigen. There are no 
anticipated risks supplementing with vitamin D in the proposed doses. 
 
 
2.6 Justification  
We argue that etanercept (Enbrel), Diamyd and vitamin D in the proposed doses, and with the 
proposed exclusion and inclusion criteria, and careful safety plan and follow-up are justified to try 
to stop the devastating progress of autoimmune beta cell destruction in those recently diagnosed 
with T1D, aiming to preserve blood glucose control and endogenous insulin secretion and thereby 
significantly reduce both acute and long-term complication of the disease.  
 


 
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We propose that etanercept and Diamyd will synergize in a novel manner to produce extended 
beta cell function in those newly diagnosed with T1D.  
 
As explained in the rational, we believe, that when etanercept therapy is added to GAD-alum 
treatment, GAD-specific autoantibody levels and effector T cell activity and number will be 
reduced while GAD-specific Treg number and function will be maintained. Due to its acute beta-
cell-protective and metabolic effects, etanercept will also preserve beta cells directly. This will 
produce a deviation of the diabetes autoimmune response towards a regulatory phenotype of 
sufficient critical mass to lead to a significant and prolonged effect on beta cell preservation.  
 
It is true that there is no documented pre-clinical data on the combination of etanercept and GAD 
immunotherapy in T1D. There are however positive results from the use of TNFα inhibitors in 
T1D models as well as positive clinical data on etanercept in both children and adults with T1D, 
suggesting that beta cell destruction can be arrested leading to better metabolic control (78-81). 
We do not expect the individual risks of GAD-alum and etanercept therapy to be increased by 
combining them. 
 
There are no anticipated risks with the proposed vitamin D supplementation. 
 
When summarizing the pros and cons, we argue that there is a clear possibility of therapeutic 
benefit of great importance whereas the adverse events and risks are reasonable as well as 
ethically and medically justified in the efforts to save residual insulin secretion at onset of T1D, 
as we know that T1D without residual insulin secretion is a dangerous disease in spite of very 
heavy and advanced treatment, during the whole life.  
 
3 
Aim of Present Study 
 
Our primary aim of the present pilot study is to ensure the combination of etanercept, Vitamin D 
and GAD-alum is tolerable in children newly diagnosed with T1D. Secondly we want to study 
how this regimen influences the immune system, block TFN-alfa, and other dangerous cytokines 
but rather cause the desired Th-2 deviation, increase of T-regulatory cells, and hopefully 
preservation of residual beta cell function although we do not expect to show statistically 
convincing proof with this small pilot group of patients in an open trial.  
 
A third aim is to receive more information on how GAD-alum could be combined with other 
types of treatment to improve efficacy without unacceptable non-justified risk of adverse events.  
 
Thus we want to evaluate the tolerability of a combination therapy of GAD-alum, vitamin D in 
rather large dose and etanercept given in the same dose as used in the treatment of arthritis also in 
children.  
 
Based on the results of this open pilot study we then want to use this knowledge for design of a 
larger Phase II trial to get more robust information. The main long-term goal is then to find a 
treatment at onset of T1D in young patients which is easy to administer at any clinical setting, 
tolerable for the patients, reasonably safe, and which can preserve residual insulin secretion and 
give the patients a better quality of life, with less acute complications and in the long run less risk 
of late complications.  
 


 
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4 
Objectives and Endpoints 
 
4.1 Objectives 
 
 
Evaluate the tolerability of a combination therapy with Diamyd, Vitamin D and 
etanercept  
 
Evaluate how the above mentioned treatments influence the immune system and 
endogenous insulin secretion 
 
4.2 Endpoints 
4.2.1 Primary endpoints  
 
Primary endpoints:  
To Evaluate the tolerability of a combination therapy with Diamyd, Vitamin D and etanercept at 
Month 6 (main study Period), 9, 15 and 30 (extension study period) 
 
Variables to evaluate tolerability: 
   
 
Reactions of the injection site 
 
Infections 
 
Occurrence of Adverse Events (AEs) 
 
Occurrence of Serious Adverse Events 
 
Physiological and Neurology assessments 
 
Laboratory measurments (biochemistry and haematology), including Calcium and 
Vitamin D in serum 
 
GAD65AB titer (GADA) 
 
4.2.2 Secondary endpoints 
 
Secondary endpoints:  
To evaluate how the above mentioned treatments influence the immune system and endogenous 
insulin secretion at at Month 6 (main study Period), 9, 15 and 30 (extension study period) 
 
Variables to evaluate the influence on the immune system: 
 
 
Inflammatory markers, especially TNF-alfa, IL-1 beta, IL-2, IL-17  
 
Th2-deviation of cell-mediated immune response seen e.g. as increased ratio of IL-5,10, 
13 in comparison with IFN-gamma, TNF-alfa, IL-1 beta and IL-17 
 
Increase of T-regulatory cells  
 
Variables to evaluate the effect of endogenous insulin secretion: 
 
 
C-peptide (90 minute value and AUCmean 0-120 min) during an MMTT  
 
Proportion of patients with a stimulated maximum C-peptide level above 0.2 nmol/L  
 
Fasting C-peptide 
 
Hemoglobin A1c (HbA1c) 


 
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 
Exogenous insulin dose per kg body weight and 24 hours 
 
5 
Population 
 
Consecutive patients with recent-onset T1D patients at Swedish pediatric clinics are given 
information about the study and they and their parents are asked to participate in the trial. 
 
5.1 Inclusion Criteria 
 
1. Informed consent given by patients and parent(s)/legal guardian(s) 
2. Type 1 diabetes according to the ADA classification, diagnosed within the previous 100 
days at the time of screening  
3. Age 8.00 -17.99 years at time of screening  
4. Fasting C-peptide at time of screening ≥0.12 nmol/L 
5. Positive for GADA but < 50 000 Units 
6. Menarchal females must agree to avoid pregnancy and have a negative urine pregnancy 
test 
7. Immunity against Varicella, either through previous infection or vaccination 
8. Patients must follow the Swedish vaccination programme 
9. Patients of childbearing potential must agree to using adequate contraception, if sexually 
active, until 1 year after the last administration of GAD-alum and etanercept. Adequate 
contraception is as follows:  
 
For females of childbearing potential: 
 
a. oral (except low-dose gestagen (lynestrenol and norestisteron), injectable, or 
implanted hormonal contraceptives (females) 
b. intrauterine device (females) 
c. intrauterine system (for example, progestin-releasing coil) (females) 
d. vasectomized male (with appropriate postvasectomy documentation of the 
absence of sperm in the ejaculate)  
 
For males of childbearing potential: 
 
a. Condom (male) 


 
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5.2 Exclusion Criteria 
 
1. Previous or current treatment with immunosuppressant therapy (although topical or 
inhaled steroids are accepted) 
2. Continuous treatment with anti-inflammatory drug (sporadic treatment e.g. because of 
headache or in connection with fever a few days will be accepted) 
3. Treatment with any oral or injected anti-diabetic medications (especially hypoglycemic 
agents) other than insulin  
4. Treatment with Vitamin D, marketed or not, or unwilling to abstain from such medication 
during the trial 
5. A history of hypercalcemia 
6. A history of anaemia or significantly abnormal haematology results at screening 
7. A history of epilepsy, head trauma or cerebro-vascular accident, or clinical features of 
continuous motor unit activity in proximal muscles 
8. Clinically significant history of acute reaction to vaccines or other drugs in the past 
9. Treatment with any vaccine within 4 months prior to planned first administration of 
GAD-Alum or planned treatment with vaccine up to 4 months after the last injection with 
GAD-Alum, including influenza vaccine   
10. Participation in other clinical trials with a new chemical entity within the previous 3 
months 
11. Inability or unwillingness to comply with the provisions of this protocol 
12. A history of alcohol or drug abuse 
13. A significant illness other than diabetes within 2 weeks prior to first dosing 
14. Known human immunodeficiency virus (HIV)  
15. Prior or active viral hepatitis B or C infection  
16. Females who are lactating or pregnant (for females who have started menstruating the 
possibility of pregnancy must be excluded by urine βHCG on-site within 24 hours prior 
to the GAD-Alum and etanercept administration, respectively) 
17. Males or females not willing to use adequate contraception, if sexually active, until 1 year 
after the last GAD-Alum and etanercept administration, respectively 
18. Presence of associated serious disease or condition, including active skin infections that 
preclude subcutaneous injection, which in the opinion of the investigator makes the 
patient non-eligible for the study. 
19. Deemed by the investigator not being able to follow instructions and/or follow the study 
protocol 
20. Active infection, including chronic and local infection or a history of previous tendency 
to serious infections, recent or ongoing uncontrolled bacterial, viral, fungal or other 
opportunistic infections, or known infection with active EBV or CMV  
21. Hypersensivity to the active substance in Enbrel (etanercept) or other ingredients in 
Enbrel 
22. Active or inactive (latent) tuberculosis (TBC) at screening 
23. History of malignancy or significant cardiovascular disease 
24. Current or history of leukopenia, anemia and/or thrombocytopeni 
25. Liver disease (clinical or hepatic enzymes >3 times the upper limit of normal (ULN)) 
26. Renal insufficiency (clinical or creatinine >3 times the upper limit of normal (ULN)) 
27. MS, undefined neurologic condition or known SLE, or anti-nuclear or known double-
stranded DNA antibody positivity 
28. Arrhythmia  
29. Pancreatitis 
30. Vitamin D serum levels >100 nmol/L at screening 


 
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5.3 Recruitment and Screening 
Eligible subjects and their parent(s) / legal guardian(s) will have the study explained to them, and 
will receive the written patient information. After having had the time to review the nature of the 
study, they will have the opportunity to ask questions to the investigational team. If, after this, the 
subjects agree to participate, they will personally sign and date the written informed consent 
form. Patients and their parent(s)/legal guardian(s) will provide written informed consent before 
any study-related procedures are performed.   
 
The patients and their parent(s)/legal guardian(s) will then receive a copy of the signed and dated 
patient information/informed consent form. 
 
5.3.1 Screening for tuberculosis (exclusion criterion) 
All patients will, at the screening visit, be screened for tuberculosis according to established 
Swedish and international guidelines. Patients with active or inactive (latent) tuberculosis cannot 
be included in the study.   
 
The evaluation will include  
 
 
detailed medical history 
 
previous potential exposure for tuberculosis  
 
recent travel to countries with possible high exposure to tuberculosis 
 
previous and/or current immunosuppressive treatments 
 
pulmonary X-ray 
 
QuantiFeron® test 
 
The investigator must be aware of the risk for a false negative tuberculin result in patients with 
serious disease or with impaired immune response.  
 
Any indication of active or latent tuberculosis will exclude the patient from the study.  These 
patients should be further investigated according to respective pediatric clinic’s standard routines 
for tuberculosis diagnosis and excluded from enrollment in this study. 
 
These patients cannot be enrolled in the study and cannot receive etanercept. 
 
5.3.2 Screening for viral hepatitis, liver disease and renal insufficiency 
 
All patients will be tested for Hepatitis B and C. Patients with prior or active hepatitis B and C 
will be excluded from the study. 
 
All patients will, at the screening visit, be tested for liver disease (clinical and/or hepatic enzymes 
≥3 times the upper limit of normal (ULN) and renal insufficiency (clinical and/or creatinine ≥3 
times the upper limit of normal (ULN)) 
 
Patients with liver disease, renal insufficiency or tested positive for hepatitis B and/or C cannot be 
included in the study.  


 
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5.4 Patient Withdrawal 
In accordance with the Declaration of Helsinki, the investigator must explain to the patient that 
they have the right to withdraw from the study at any time, and that this will in no way prejudice 
their future treatment. The reason for any kind of withdrawal must be recorded on the appropriate 
CRF. 
 
There will be two main categories for withdrawals from the study: 
 
Complete withdrawal (i.e. stopping investigational product and also continued efficacy and safety 
evaluations) 
 
Standard reasons for withdrawing from further participation in the study and from the follow-up 
visits (and <e.g. blood tests>) may be: 
 
Patient’s decision (withdrawal of consent to participate) 
 
Patient lost to follow-up  
 
Withdrawals from investigational product (i.e. stopping one or several investigational products, 
but continuing follow-up visits, including efficacy and safety evaluations) 
 
Standard reasons from withdrawing from taking further investigational product, but continuing 
follow-up visits and safety evaluations may be: 
 
 
Unacceptable adverse events 
 
Patient request 
 
Investigator's discretion 
 
Patient lost to follow-up/non-attendance 
 
Intercurrent illness 
 
The patient becomes pregnant 
 
Thus subcutaneous GAD-Alum should not be given to the patient if the patient after inclusion in 
the study develops/experiences  
 
‐ 
Brain damage, epilepsia, head trauma, neurological disease 
‐ 
Any active, serious hormonal disease other than T1D 
‐ 
Other severe autoimmune disease (except celiac disease which is accepted for inclusion.) 
‐ 
Immune-suppressive treatment 
‐ 
Cancer, cancer treatment 
‐ 
Any other diabetes drugs other than insulin 
‐ 
Any vaccination  
‐ 
Drug/alcohol abuse 
‐ 
Become pregnant or is no longer willing to use safe contraceptives during the study 
 
Etanercept should not be continued if the patient after inclusion in the study develops/experiences 
 
‐ 
Allergic reactions to etanercept or any of the excipients 
‐ 
Other severe reactions to etanercept injections 
‐ 
Sustained elevations of creatinine of liver function tests,  
‐ 
Evidence of cardiac disorder  
‐ 
Severe infections, such as sepsis, meningitis or osteomyelitis  


 
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‐ 
Suspected, latent or manifest tuberculosis 
‐ 
Suspected or manifest viral hepatitis 
‐ 
Severe lymphopenia 
‐ 
Anemia 
‐ 
Thrombocytopenia 
‐ 
Malignancy 
‐ 
Urticaria 
‐ 
Varicella Zoster virus exposure or infection 
‐ 
Live vaccines such as morbilli, parotitis, rubella, live polio, BCG and others 
‐ 
Alcohol abuse or alcohol induced hepatitis 
‐ 
Other autoimmune disease than T1D, such as SLE 
‐ 
Pancytopeni or aplastic anemia (cautiousness should be taken with patients that have 
previously experienced blood dyscrasias).  
‐ 
Become pregnant or is no longer willing to use safe contraceptives during the study 
‐ 
Heart disease  
‐ 
Impaired renal or liver function 
‐ 
Neurological disturbances 
 
Vitamin D treatment should not be continued if the patient after inclusion in the study 
develops/experiences 
 
‐ 
Symptoms of hypercalcemia such as tiredness, euphoria, drowsiness, nausea, weight loss, 
thirst, polyuria, nefrocalcinosis, renal failure  
‐ 
Arrhythmia  
‐ 
Pancreatitis 
‐ 
Vitamin D serum levels above 125 nmol/L.  
 
 
However, whenever a patient is withdrawn from a study, or for whatever reason is not coming to 
any further visits, a final study evaluation must be completed for that patient (visit <>) - stating 
the reason(s) why the patient was withdrawn from the study. All documentation concerning the 
patient must be as complete as possible. 
 
Withdrawals due to non-attendance must be followed up by the investigator to obtain the reason 
for non-attendance. Withdrawals due to intercurrent illnesses or adverse events must be fully 
documented in the case report form, with the addition of supplementary information if available 
and/or appropriate. 


 
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6 
Treatment Procedures 
6.1 Study Design and Treatment 
The trial is multicenter, open-label, pilot study in GADA positive T1D patients of either gender, 
8.00 to 17.99 years old, diagnosed with T1D within 100 days at time of screening (Visit 1) and 
fasting C-peptide levels equal to or above 0.12 nmol/L. In total, approximately 20 patients will be 
recruited at approximately 10 sites in Sweden. 
 
The patients will be assessed for eligibility at the screening visit (Visit 1) 10 to 21 days prior to 
the start of treatment. At each site, the screened patients will be assigned a sequential screening 
number (starting with 01) and this screening number together with the site number will be used as 
patient identification throughout the study (i.e. XX-XX).   
 
Patients who qualify for inclusion in the study will then be enrolled in the study to receive 
investigational study drug at the subsequent visits according to table 1 below.  
 
The patients will be followed for a total study period of 30 months which includes 9 visits to the 
site. 
 
See table 1 below for an overview of the study visits.  
 
Table 1. Study Visits 
 
 
EDCR IIa 
Screening 
Intervention – Main Study Period 
Follow-up – Extension Study 
Period 
 
Day  
-10 to -21  
Screening  
Day 1 
Base-
line 
Day 30 
Month 
1 
 
Day 60 
Month 2 
 
Day 90 
Month 3 
Day 180 
Month 6 
 Day 
270 
Month 9 
Day 450 
Month 15 
Day 900 
Month 30 
 
Visit 1 
 
Visit 2 
 
Visit 3  
± 3 
Visit 4 
± 3 
Visit 5 
± 7 
Visit 6 
± 7 
 Visit 7 
± 14 
Visit 8 
± 14 
Visit 9 
± 14 
Appr 20 
subjects 
 
Vitamin D 2 000 IU daily, from Day 1 to Day 450 
 
 
Etanercept injections once weekly from 
Day 1 to 90 
 
 
 
 
Prime 
injection 
GAD-
Alum 
20 µg 
 
Boost 
injection 
GAD-
Alum 
20 µg 
 
 
 
 
 


 
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6.2 Assessments and Procedures 
 
1. Standard insulin treatment, education and psychosocial support for newly diagnosed T1D 
patients. 
2. Normalization of fluid, electrolyte and acid-base balance. 
3. Thereafter information about the study.  
4. When the patients and parent(s) / legal guardian(s) have given their informed consent, at 
the latest 100 days after diagnosis, screening is performed with a fasting venous sample 
from patients who are eligible according to other criteria than C-peptide and GADA 
concentrations (Visit 1). Patients are also tested for tuberculosis, renal or liver disease at 
this visit (see section 5.3.1 and 5.3.2 above). 
5. At Visit 2 (Baseline), Visit 6 (6 months), Visit 8 (15 months) and Visit 9 (30 months), 
assessment of residual endogenous insulin secretion by MMTT.  
6. Blood sampling for Vitamin D in serum at Visit 1, and then after one month of treatment 
at Visit 3 (before the first GAD-alum treatment) and at Visit 8 (15 months)  
7. HbA1c, safety (haematology and chemistry), autoantibody titres (GAD65, IA-2), 
immunology are followed by blood samples at every visit. 
8. Exogenous insulin dose/24 hours, AEs and concomitant medication are registered at 
every visit. 
9. Self-reported hypoglycaemia (defined as needing help from others and/or seizures and/or 
unconscious) registered at every Study Visit.  
10. Any symptoms or signs of other medical problems should be treated at the discretion of 
the clinical doctor. Thus if a patient experiences symptoms and/or signs of infection that 
should be treated lege artis. 
 
Examinations will be performed according to table 2 in Section 7 below, and in the order outlined 
in the case report form (CRF).  
  
6.2.1 All Visits, Visit 1 through 9 
Note that the patient should attend all study visits in the morning following an 
overnight fast (> 10 hours, water allowed).  
 
For patients with evidence of an infection (including fever), the complete visit should be 
postponed for 5 days or until the patient has recovered. 
 
 
6.2.2 Injections with GAD-Alum (Diamyd), Visits 3 and 4 
Injections of GAD-alum (Diamyd) will be administered at Visits 3 and 4, subcutaneously in the 
stomach area.  
 
After the injection, the patient shall remain in the vicinity of the study site for the next hour, and 
the injection site will be examined by investigator/study nurse 1 hour post injection. 
 


 
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6.2.3 Mixed Meal Tolerance Test (MMTT), Visits 2, 6, 8 and 9 
 
The MMTT must be performed according to the instructions in the CRF. 
 
The patient should: 
 
 
Come to the study site following an overnight fast (>10hr), i.e. the patient may not eat but 
is permitted to drink water  
 
Not take short acting/direct acting insulin within 6 hours before the MMTT. The patient 
is allowed to take base-insulin day/night before, but not in the morning before the 
MMTT.  
 
Patients with CSII (insulin pump) must continue with their basal dose insulin, but not add 
bolus dose during the last 6 hours before the MMTT 
 
Have a fasting plasma glucose level in the range defined by 4-12 mmol/L on the patient’s 
home blood glucose meter in the morning of the test  
 
If the patient does not fulfill all of the above criteria, the MMTT should be rescheduled and the 
patient should return to the study site within 5 days if possible. 
 
If for safety reasons, subjects need to eat or take insulin, the visit should also be rescheduled. 
 
6.3 Laboratory Tests and Examinations: 
 
1. Immunological tests: 
a. Autoantibodies (Anti-GAD65, Anti-Insulin, Anti-IA-2, ZnT8) 
b. Relevant cytokines and chemokines are determined (see Table 2 and section 9.1.1 
below) 
c. T-cells are classified and studied (see Table 2 and section 9.1.1 below) 
2. Genetics: 
a. HLA determinations are done and genes related to diabetes development 
b. Array studies to elucidate the importance of diabetes-related genes 
3. Growth factors: 
a. IGF-1 and related binding proteins and growth factors possibly related to beta cell 
growth and regeneration 
 
4. Diabetes status:  
a. HbA1c 
b. Fasting glucose and fasting C-peptide 
c. Meal stimulated glucose and C-peptide 
 
5. Blood sampling for safety: 
a. Hematology  
b. Chemistry, including calcium 
 
6. Urinalysis 
a. Microalbuminuria 
b. Creatinine 
 
7. Other: 


 
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a. Vitamin D in serum 
 
6.4 Medical History  
A complete review of the subject’s past medical history will be undertaken by and documented on 
the Medical History CRF. 
 
All pre-existing conditions/diseases will be reported on the Medical History CRF page at the 
screening visit (Visit 1). 
 
The subject’s T1D diagnosis date and family history of T1D will also be documented. 
6.5 Physical Examination and Neurological Examination 
At the screening visit (Visit 1) the patient will undergo a general physical examination and a 
neurological examination and any findings will be reported as pre-existing conditions on the 
Medical History CRF page. 
 
During the subsequent study visits the patient will be examined for any new medical conditions or 
worsening of the pre-existing ones.  Any change in pre-existing conditions or new conditions 
must be entered on the AE page in the CRF and any medication given on the concomitant 
medication pages. 
 
The patients will, in addition to the physical examinations by the physician, undergo a 
standardized clinical neurological examination at 0, 6, 9, 15 and 30 months. The neurological 
tests are performed in order to detect possible mild signs of neuromuscular disease such as 
disturbance of strength, balance, and coordination. 
 
The neurological examination includes:   
 
 
Extremity reflexes 
 
Romberg (balance and coordination) 
 
Walk on a line, 2 meters (balance and coordination) 
 
Standing on 1 leg, left and right, 15 seconds per leg (balance and coordination) 
 
Finger-nose (coordination) 
 
Mimic (cranial nerves) 
 
Babinski reflex (central function) 
 
Muscle strength (shake hands) biceps, triceps, distal extensors, and flexors 
 
These examinations may also be repeated between scheduled visits at the discretion of the 
investigator. Screening for neurological disease with electroencephalogram (EEG) is not included 
due to low sensitivity and specificity. However, if any signs of neurological dysfunction are 
detected, the patient should be referred to a neurologist for further evaluation. 
 
6.6 Patient Diary 
The patients will be supplied with a diary at visit 2, 3, 4 and 5 respectively (during the Diamyd 
and etanercept treatment period).  
 
All patients and their parent(s)/legal guardian(s) will be informed, during etanercept treatment, to 
carefully follow the patient’s general condition, and if affected, to measure the patient’s morning 


 
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body temperature daily, and in case it is elevated also measure it at least once more that day. The 
body temperature should be documented in the patient diary.  
 
Since fever is one of the first signs of infection, all patients experiencing fever during the 
etanercept treatment period should, in addition to contacting medical health care and the study 
team, continue to measure the body temperature daily and document the temperature in the 
patient diary. 
 
Note: For safety reasons, during the etanercept treatment, this diary must be collected and 
reviewed by the investigator at every visit to detect potential side effects of etanercept. 
 
The patient will also be asked to use diary for documentation of injection site reactions from the 
Diamyd subcutaneous injections during the week following injection. 
 
The patient will carefully be instructed by study personnel on how to complete the diary and the 
investigator will review these together with the patient at the corresponding visit to sort out any 
inconsistencies and record any AE/SAE information onto the relevant CRF. 
 
6.7 Safety Plan 
To ensure subject safety a Safety Plan is in place describing the study specific safety measures 
that are to be taken during the study. This Safety Plan must be used in conjunction with this 
protocol. 
 
The purpose of the Safety Plan is to ensure: 
 
 
the safety of patients receiving etanercept, Diamyd and vitamin D treatment in the study. 
 
that appropriately qualified medical personnel are readily available to advise on trial 
related medical questions or problems regarding the study drug treatment in the above 
mentioned study. 
 
that study personnel are educated about know side effects of the study drug treatment and 
how to handle them. 
 
that patients and their parents/legal guardian(s) are given information about possible side 
effects.  
6.7.1 General precautions during etanercept treatment (see Safety Plan for details) 
 
To detect infections and other side effects as early as possible it is very important the 
investigator/study team cautiously collects symptoms and signs indicating any of the withdrawal 
criteria, as well as adverse events, and also be responsive to any spontaneous symptom/adverse 
event reporting in between study visits and at study visits. Patients who develop a new infection 
under etanercept treatment should be closely monitored. Fever is one of the first signs of 
infections. 
 
The Medical Adviser will be contacted and the etanercept treatment will be interrupted, until a 
decision is taken by the responsible physician to continue or withdraw, if a patient during 
etanercept treatment develops or experiences 
 
 
Fever, long-lasting and/or low-grade  
 
Infection with fever 


 
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 
Sore throat, especially with fever 
 
Fever with any kind of symptoms e.g. symptoms from a joint, red skin, difficulties to 
breath, abnormal tiredness 
 
Unexpected productive cough lasting two-three weeks or more 
 
Any abnormal signs such as pronounced tiredness, paleness, difficulties to breath, 
hematomas in the skin, bleedings, bruises, weight loss or any worrying symptom or sign 
 
Suspicion of exposure to tuberculosis or symptoms or signs of tuberculosis 
 
Suspicion of exposure to Varicella Zoster virus or symptoms or signs of 
chickenpox/shingles 
 
All patients and their parent(s)/legal guardian(s) must be informed by the investigator and study 
team that they should seek medical help immediately in case the patient treated with etanercept 
develops signs and/or symptoms of blood dyscrasia or infections (long-lasting low-grade fever, 
sore throat, bruises, bleedings, weight loss, unexpected productive cough lasting two-three weeks 
or more and/or paleness). 
 
Since fever is one of the first signs of infection, all patients and their parent(s)/legal guardian(s) 
will be informed to, during etanercept treatment, carefully follow the patient’s general condition, 
and if affected, to measure the patient’s morning body temperature daily, and in case it is elevated 
also measure it at least once more that day. The body temperature should be documented in the 
patient diary and the study team should be contacted.  
 
As there are reports that the risk for hypoglycemia may increase in patients with diabetes being 
treated with etanercept, there should be extra awareness among the diabetes team members and 
among patient and parent(s)/legal guardian(s) regarding the possible need to decrease insulin 
doses. 
 
It is desirable that patients that are to start with etanercept treatment have followed the national 
vaccination program. Live vaccines must not be given during etanercept treatment. 
 
6.7.2 General precautions during Vitamin D treatment  
 
Blood draws for Vitamin D will be taken at screening (Visit 1), month 1 (Visit 3), month 6 (Visit 
6), month 9 (Visit 7) and month 15 (Visit 8) and be analyzed continuously.  Blood draws for 
Calcium will be taken at every visit. Should the blood concentration during Vitamin D treatment 
exceed 125 nmol/L or if the child would develop hypercalcemia, the Vitamin D treatment will be 
stopped. The subject will however continue in the study and complete all the other study related 
evaluations, including sampling for Vitamin D and Calcium levels.  
 
Vitamin D treatment will be started again if the levels fall <100 nmol/L.  
 
Vitamin D treatment will be stopped and not started again if the subject develops 
hypercalcemia.  
 
 
 


 
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6.8 Data Safety Monitoring Board (DSMB) 
An independent Data Safety Monitoring Board (DSMB) will be appointed. A DSMB charter will 
be written to outline the working procedures and the duties of the DSMB. The DSMB will review 
the safety twice per year as long as patients are being treated with etanercept and thereafter 
annually. 
6.9 Adverse Events 
 
See section 9.2.2 below. 
 
6.10 Concomitant Medication 
Any concomitant medication used during the study, whether considered relevant for the study or 
not by the investigator must be reported on the concomitant medication log of the CRF. Please 
also see section 8.5, below. 
 


 
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7 
Scheduling of Procedures 
Table 2.     Pilot EDCR IIa Study, Schedule of Study Events, DIABETES patients 
Study Period 
Scree-
ning 
Intervention
Main Study Period 
Follow-up  
Extension Study Preiod 
Visit number 
1 
2
3
4
5
6
7 
8 
9
Day from Baseline (Visit 2) 
(Day/Month) 
D 
-10 to 
-21  
D1  
 
M1 
(D30 
± 3) 
 M2 
(D60 
± 3) 
 M3 
(D90  
± 7) 
M 6 
(D180
± 7) 
 M9 
(D270 
± 14) 
M 15 
(D450 
± 14) 
M30 
(D900
± 14) 
Informed Consent 
X 
 
 
Inclusion/Exclusion Criteria 
X 
 
 
 
 
 
 
 
 
Etanercept Administration starts 
 
Start 
Day 1 
 
 
Stop 
Day 90 
 
 
 
 
Vitamin D administration starts 
 
Start 
Day 1 
 
 
 
 
 
Stop 
Day 450 
 
GAD-Alum (Diamyd) injections 
 
 
X 
X 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
 
 
General Physical Examination 
X 
 
 
 
 
X 
X 
X 
X 
Brief Physical Examination 
 
X 
X 
X 
X 
 
 
 
 
Neurological Examination 
X 
 
 
 
 
X 
X 
X 
X 
Concomitant Medication 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Weight, height, BMI 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine pregnancy test (females) 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Injection site inspection 
a 
 
 
X 
X 
 
 
 
 
 
Insulin dose 
 
X 
X 
X 
X 
X 
X 
X 
X 
Self-Reported Severe 
Hypoglycemia 
b 
 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse Events 
 
X 
X 
X 
X 
X 
X 
X 
X 
Patient Diary review and 
collection 
 
 
X 
X 
X 
X 
 
 
 
Screening for tuberculosis, 
including blood tests, medical 
history and pulmonary X-ray 
X 
 
 
 
 
 
 
 
 
Screening for Hepatitis B and C 
(blood tests) 
X 
 
 
 
 
 
 
 
 
Blood sampling for safety 
Hematology 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Chemistry, including Calcium 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urinalysis 
Microalbuminuria 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Creatinine 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood sampling for Auto-antibodies 
GADA 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Other diabetes-related 
autoantibodies   
 
X 
X 
X 
X 
X 
X 
X 
X 
Blood sampling for Diabetes status 
HbA1c 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Fasting glucose/C-peptide 
X 
X 
X 
X 
X 
X 
X 
X 
X 
MMTT glucose/ C-peptide 
 
X 
 
 
 
X 
 
X 
X 
Blood sampling for genetics 
HLA 
 
X 
 
 
 
 
 
 
 
Blood sampling for immunology 
TNF-alfa, IL-1 beta, IL-2, IL-17, 
IL-5,10, 13  
IFN-gamma and T-regulatory 
cells 
 
X 
X 
X 
X 
X 
X 
X 
X 
Blood sampling for viruses 
Enteroviruses
c 
 
X 
X 
X 
X 
X 
X 
X 
X 
Blood sampling additional 
IGF-1 
 
X 
X 
X 
X 
X 
X 
X 
X 
Vitamin D in serum 
X 
 
X 
 
 
X 
X 
X 
 
Blood sampling for biobank 
 
X 
X 
X 
X 
X 
X 
X 
X 


 
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a Inspection of injection site before and 60 minutes after GAD-Alum injection by investigator or nurse 
b Severe Hypoglycemia is defined as needing help from others and/or seizures and/or unconscious  
c Especially certain types of Coxsackie virus may play a role for the beta cell destruction. Details will depend 
on results in the ongoing DIABGAD trial. 
 
7.1 Visits 
The first visit, the screening visit (Visit 1) should be performed 10 to 21 days before planned 
Visit 2 (Baseline). Visit 3 and 4 should then be scheduled with a visit window of ±3days (first and 
second injection with GAD-Alum) and of ±7 days for Visit 5 and 6. For Visit 7, 8 and 9 the visit 
window is extended to ± 14 days.  
 
Please note that all visits, except Visit 4 must be calculated from the baseline visit (Visit 2) 
according to the visit schedule. For Visit 4 (second GAD-Alum administration) the visit date must 
be set in accordance with Visit 3 (i.e. the first GAD-Alum administration) so that the first and 
second GAD-Alum doses will be 30 days apart (± 3 days). Please also note that the visits must be 
performed within the visit windows to comply with the study protocol. 


 
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8 
Study Medication 
8.1 Study Medications 
 
The following medication supplies will be used in the study: 
 
A. 
Study medication:  
GAD-Alum (Diamyd) subcutaneous injection 
Dosage and interval: 20 µg will be given subcutaneously at two 
occasions with one month interval (at Days 30 and 60). 
 
IMP supplier:  
Diamyd Medical AB, Stockholm, Sweden. 
 
B. 
Study Medication 
Etanercept (Enbrel) 
Dosage and interval: 0.8 mg/kg body weight, max 50 mg, given 
subcutaneously once per week from Day 1-90 
 
IMP supplier  
Commercially available 
 
C 
Study Medication 
Vitamin D (Calciferol) in oral solution 
Dosage and interval: 2 000 IU daily for 450 days  
 
 
IMP supplier  
Commercially available 
8.2 Supply, Packaging, Handling and Storage 
GAD-Alum (Diamyd) will be a subcutaneous formulation, supplied by Diamyd Medical. It will 
be supplied as pre-packed medication from Diamyd Medical to central pharmacy who will then 
distribute to the clinical site or local pharmacy. All dosing will take place in the hospital, and 
handled only by trained and authorised study personnel. 
 
GAD-alum must be stored in a refrigerator at 2-8 ºC in a secure area (e.g. a locked cabinet or drug 
storage room), protected from unintended use. 
 
Etanercept will be handled and distributed by Apoteket AB who will then distribute to the clinical 
site or local pharmacy.  
 
Vitamin D (Calciferol) will be handled and distributed by Apoteket AB, who will then distribute 
to the clinical site or local pharmacy.  
 
All study medication will be labelled with information according to local regulation. 


 
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8.3 Dosage and Administration 
 
Etanercept 
0.8 mg/kg body weight (max 50 mg) given subcutaneously once weekly from Day 
1-90 
 
Vitamin D 
2 000 IU per day, given per os from Day 1 to Day 450 
 
GAD-Alum:  20 µg given subcutaneously in the stomach area two times with one month 
interval.  
8.4 Duration of Treatment 
 
See 8.3 
8.5 Concomitant Medication 
No systemic immune modulating medication, no other diabetes medication than insulin, and no 
vitamin D, whether marketed or not, are allowed.  
8.6 Study medication Accountability 
All study medications supplied for this study must be retained in a safe place at all times of the 
study. Only personnel authorised by the investigator should dispense the study medication, and 
the accountability is the responsibility of investigator.  
 
A study medication inventory (dispensing records) for all medication dispensed must be 
maintained at all times and always kept current. Used and unused medication must be stored at 
the site or pharmacy throughout the study. The investigator/pharmacist must keep record of all 
study drugs received, used and returned. Both pharmacies and study sites are obliged to properly 
measure and record the storage temperature. 
 
When the study is completed all unused and used study medication containers must be returned to 
the drug supplier unless the drug supplier has approved other arrangements.   
 


 
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9 
Response Variables and Outcomes 
9.1 Assessments 
9.1.1 Variables 
The tolerability and safety assessments includes occurrence of adverse events (AEs), laboratory 
measurements, physical examinations and neurological assessments (See section 6.3-6.7) 
 
Adverse events will be recorded by the physician at every visit throughout the study. 
 
Blood tests for safety:   
 
Chemistry:  Creatinine, Calcium, Liver function tests (alanine aminotransferase 
[ALT], Aspartate Aminotransferase [AST], Alkaline Phosphatase, Bilirubin) 
 
Haematology (MHC, MCV, MCHC, Hemoglobin, Platelets, Leukocytes) 
 
Urinalysis for safety: 
 
 
Urine pregnancy test as appropriate 
 
Microalbuminuria 
 
Creatinine 
 
 
Other Variables which will be evaluated: 
 
 
Inflammatory markers, especially TNF-alfa, IL-1 beta, IL-2, IL-17  
 
Th2-deviation of cell-mediated immune response seen e.g. as increased ratio of IL-5,10, 
13 in comparison with IFN-gamma, TNF-alfa, IL-1 beta and IL-17, and increase of T-
regulatory cells  
 
C-peptide (90 minute value and AUCmean 0-120 min) during an MMTT  
 
Proportion of patients with a stimulated maximum C-peptide level above 0.2 nmol/L  
 
Fasting C-peptide 
 
Hemoglobin A1c (HbA1c)  
 
Exogenous insulin dose per kg body weight and 24 hours 
 
Vitamin D levels in serum 
 
Outcomes above are in agreement with the general Guidelines for Intervention Trials in subjects 
with newly diagnosed T1D defined by the Immunology of Diabetes Society (89). 
 
9.2 Adverse events, Serious Adverse Events and Pregnancy 
 
9.2.1 Definitions of Adverse Events (AE) 
An Adverse Event (AE) is defined as any untoward medical occurrence in a subject during a 
clinical study administered a medicinal product and which does not necessarily have a causal 
relationship with this treatment(s).  
 
An AE can therefore be any unfavorable and unintended clinical sign or symptom, any illness or 
disease, which develops or worsens in intensity during the course of the trial. It also includes an 


 
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abnormal laboratory finding, if e.g., the abnormality results in trial withdrawal, is serious, is 
associated with clinical signs or symptoms, or is considered being of clinical relevance. 
 
It could also include accidents and reasons for changes in medication (drug and/or dose), any 
medical/nursing/pharmacy consultation and admission to hospital/surgical operations. 
 
Any new findings, clinically significant laboratory values or worsening of pre-existing condition 
must be reported as an AE by the investigator, whether or not considered related to the medicinal 
product(s). 
 
Note that hospital admission and/or surgical operations for illness, which existed before the study 
drug was given or the subject was enrolled in the clinical trial and did not worsen during the 
study, are not AEs. 
 
9.2.2 Seriousness 
A Serious Adverse Events (SAE) is defined as: an Adverse Event that is fatal, life-threatening, 
significant or persistent disabling or requires hospitalisation or prolongation of exisiting 
hospitalisation, a congenital anomaly or birth defect. 
 
These characteristics/consequences have to be considered at the time of the event. For example, 
regarding a life- threatening event, this refers to an event in which the subject was at risk of death 
at the time of the event; it does not refer to an event which hypothetically might have caused 
death if it were more severe.  
 
Some medical events may jeopardise the subject or may require an intervention to prevent one of 
the above characteristics/consequences. Such events (referred to as important medical events) 
should also be considered as serious in accordance with the definition.  
 
9.2.3 Intensity 
Mild:  
the Adverse Event is transient and easily tolerated. 
Moderate:  
the Adverse Event causes the patient discomfort and interrupts the patient's usual 
activities. 
Severe: 
the Adverse Event causes considerable interference with the patient's usual 
activities, and may be incapacitating or life-threatening. 
 
Note: a distinction should be drawn between serious and severe AEs. The term severe is used to 
describe the intensity of the event and the event does not necessarily need to be considered 
serious. The term serious is based on the patient/event outcome or action and serves as a guide for 
defining regulatory reporting obligations. 


 
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9.2.4 Relationship to study medication 
Relationship to study medication will be assessed for the three treatments (GAD-Alum, 
etanercept and Vitamin D) separately. 
 
Unrelated:  
This category is applicable to those Adverse Events which, after careful medical consideration at 
the time they are evaluated, are judged to be clearly and incontrovertibly due to extraneous causes 
(disease, environment, etc.) and do not meet the criteria for study medication relationship listed 
under remote, plausible or probable. 
 
Remote:  
In general, this category is applicable to those Adverse Events which, after careful medical 
consideration at the time they are evaluated, are judged to be remotely related to the test study 
medication. An Adverse Event may be considered remote if, or when, for example: (i) it does not 
follow a reasonable temporal sequence from administration; (ii) it could readily have been 
produced by the patient's clinical state, environmental or toxic factors, or other modes of therapy 
administered to the patient; (iii) it does not follow a known response pattern to the suspected 
study medication; (iv) it does not reappear or worsen when the study medication is re-
administered. 
 
Plausible: 
This category is applicable to those Adverse Events which, after careful medical consideration at 
the time they are evaluated, the connection with the test study medication administration appears 
unlikely but cannot be ruled out with certainty. An Adverse Event may be considered plausible if, 
or when: (i) it follows a reasonable temporal sequence from administration; (ii) it could not 
readily have been produced by the patient's clinical state, environmental or toxic factors, or other 
modes of therapy administered to the patient; (iii) it follows a known response pattern to the 
suspected study medication; (iv) it does not reappear or worsen when the study medication is re-
administered. 
 
Probable: 
This category is applicable to those Adverse Events, which, after careful medical consideration at 
the time they are evaluated, the connection with the test study medication administration appears 
to, with a high degree of certainty, be related to the test study medication. An Adverse Event may 
be considered probable if: (i) it follows a reasonable temporal sequence from administration; (ii) 
it could not be reasonably explained by the known characteristics of the patient's clinical state, 
environmental or toxic factors, or other modes of therapy administered to the patient; (iii) it 
disappears or decreases on cessation or reduction in dose. There are important exceptions when 
an Adverse Event does not disappear upon discontinuation of the study medication, yet study 
medication-relatedness exists; e.g. bone marrow depression, fixed study medication eruptions, 
and tardive dyskinesias; (iv) it follows a known response pattern to the suspected study 
medication; (v) it reappears upon re-challenge. 
 
9.2.5 Reporting of Adverse Events  
All Adverse Events must be recorded in the CRF, defining relationship to study medication, 
severity and seriousness. Adverse Events should also be recorded by the investigator in the 
patient file/notes. 


 
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9.2.6 Timelines and Reporting of SAE 
All SAEs must be reported, whether or not considered attributable to the study drug on a separate 
SAE Report Form. 
An assigned CRO, contracted by Diamyd Medical AB, will be responsible for reporting all 
Serious Adverse Events (SAEs) in accordance with ICH Good Clinical Practice and local 
regulations. The sponsor, Diamyd Medical AB and the assigned CRO will complete and sign a 
“Pharmacovigilance Working Instructions” agreement covering the safety reporting 
responsibilities in the study. This agreement will also ensure the sponsor and Diamyd Medical 
AB is directly informed of each SAE reported by the Investigators. 
In order to meet the specified reporting requirements investigators should adhere to the following 
process for recording and reporting SAEs.  
 
It is the investigator’s responsibility to, as soon as he/she is aware of a potential Serious Adverse 
Event (SAE), he/she should contact the assigned CRO by fax or e-mail, and in any case no later 
than 24 hours after the knowledge of such a case.  
At the time of initial reporting, the investigator must provide as a minimum requirement, the 
patient number, birth date, nature of the SAE, and a preliminary assessment of causality. The 
investigator should follow-up the initial notification of the potential SAE by faxing or e-mailing a 
copy of the SAE reporting form to the assigned CRO at the numbers/e-mail address provided in 
the investigator Site File and on the SAE Report Form. The faxed/e-mailed SAE Reporting Form 
should be received by the assigned CRO within 24 hours of the initial notification of the event.  
 
It is the investigator’s responsibility to report to the CRO follow-up information on an existing 
SAE that is fatal or life-threatening within 5 days after the initial report. Where appropriate, 
hospitalisation or autopsy reports should be made available. All Serious Adverse Events will be 
followed up until resolution (i.e., asymptomatic, stabilisation or death).  
 
It is the CRO’s responsibility to receive e-mail or fax copies of the SAE report form and other 
relevant CRF pages from the Investigators. The Drug Safety unit at the CRO will review the 
information provided on the form and enter it into the safety data base. The SAE report will be 
assigned a unique number that will be entered on the SAE Report Form, and will be used to 
identify the report in all future communication. A notification of receipt of the report will be sent 
to the reporter, either by fax or e-mail within 48 hours. The CRO will contact the Investigator 
directly if there is any inconsistencies and missing information. 
The CRO is responsible for the timely submission of Suspected Unexpected Serious Adverse 
Reactions (SUSARs) to the Competent Authority and Ethics Committee according to appropriate 
Competent Authority and Ethical Committee requirements. It is the CRO’s respoinsibility to 
report SUSARs to investigators according to ICH Good Clinical Practice and to local regulations 
and to notify the Competent Authorities will be notified of all SUSARs through the 
Eudravigilance database.  
 
Fatal and life-threatening SUSARs should be reported by the assigned CRO as soon as possible to 
the Competent Authorities and Ethical Committees, and in any case no later than seven (7) 
calendar days, after knowledge by the Sponsor/assigned CRO of such a case. Relevant follow-up 
information on the case will be subsequently communicated within an additional eight (8) days. 
All other SUSARs shall be reported to the Competent Authorities concerned and to the Ethics 


 
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Committee concerned as soon as possible but within a maximum of fifteen (15) days of first 
knowledge by the assigned CRO/Sponsor.  
9.2.7 Unresolved Events 
If an AE/SAE is present when the patient has completed the study the course of the event must be 
followed until final outcome is known or the condition is stable. 
 
9.2.8 Pregnancy Report Form 
Pregnant and lactating women will not be included in the study. Menarchal females must have a 
negative urine pregnancy test prior to randomization and a negative urine pregnancy test at each 
study visit with study drug administration, prior to injection of study drug. Patients will be 
required to use an adequate form of birth control during the study. At Visit 2 the need for birth 
control will be re-assessed.  Patients and their partners will be strongly advised to avoid 
pregnancy for 1 year following the last dose and instructed to use adequate birth control. 
 
A pregnancy occurring during the trial must be recorded on the Pregnancy Report Form and no 
further drug doses will be given. If the pregnancy is verified prior to any of the injections, no 
further injection shall be given. 
 
The Pregnancy Report Form should be faxed or e-mailed within 24 hours of awareness to the 
assigned CRO. A copy of the report should be filed at the study site for follow-up until delivery. 
Any pregnancy must be followed until delivery or to the end of pregnancy. 
 
10 Statistical Methodology and Data Management  
10.1 Study Design 
The EDCR IIa study is an open controlled pilot intervention trial of the safety, and evaluation of 
the immune system response and residual insulin secretion, by a combined treatment with 
etanercept, Vitamin D and GAD-Alum (Diamyd). 
 
Study Participants: 
Newly diagnosed classic type 1 diabetes patients: N=20. Age 8.00-17.99 years. Recruited from 
approximately 10 pediatric clinics in Sweden 
 
10.2 Estimation of Sample Size 
Power analysis: 
 
No formal power analyses is done for this pilot study 
 
10.3 Statistical Analysis Plan 
In brief the following analysis is planned: 
 
All continuous variables will have the following descriptive statistics displayed: number of 
observations (n), mean value, standard deviation, minimum, median, and maximum. All variables 


 
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of a categorical nature will be displayed with frequencies and percentages. The tabulation of the 
descriptive statistics will be split by treatment group and visit. Where appropriate, baseline 
(screening) descriptive statistics will also be included.   
 
Demographic and other baseline characteristics 
 
Demographics such as age and gender will be described for Intention-to-treat and the 
Total population. Measures for other baseline characteristics are medical history, current 
medical conditions (at baseline), and current diabetes medication (at baseline). The 
baseline characteristics will be presented for the safety population. 
Demographics and baseline characteristics will be presented using descriptive statistics 
(summary tables).   
 
Variables: 
 
 
The AE/SAE data will be presented using a standardized tabulation of the frequency and 
incidence rate of all observed AEs/SAEs. The frequencies and incidence rates are calculated on a 
per patient basis. Adverse events will be summarized by body system, causality, and severity. 
Other safety data will be presented by descriptive statistics.  Data regarding C-peptide and 
immune system as well as Adverse events and other safety data will be summarized descriptively.    
 
10.4 Study Populations 
Intention-to-treat population 
Patients will be included in the primary intention-to-treat population for analysis of efficacy if 
they receive at least 1 dose of all study drugs, and are assessed at a later visit. 
 
Per protocol population 
In order to qualify for the stringent per protocol population, the subjects must have followed the 
study protocol without any major violations. Any examinations missed will be substituted with 
the last observation carried forward, but examinations from not more than 1 visit may be lost.  
 
Total population 
Any patient who withdraws from the study will be included in the safety analysis (adverse events 
and safety parameters). Data for all patients will be listed, and a list of withdrawn patients, with 
all reasons for withdrawal, will be given.  
 
10.5 Data Collection / Case Report Forms  
Case report forms (CRFs) will be supplied for recording data from each patient. Since it is 
important to have proper data collection in a timely manner, the investigator or assigned designee 
shall complete the CRFs promptly. When the monitor requests additional data or clarification of 
data for the CRF, the request must be answered satisfactorily in due time. 
 
It is the responsibility of the investigator to ensure that these case report forms are properly 
completed. The investigator will sign the designated signature pages to confirm that the case 
report form is accurate and complete. 
 
To ensure legibility the CRFs should be completed in block capitals with a black or blue ballpoint 
pen (not pencil, felt-tip or fountain pen). 


 
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Any corrections to the CRFs must be carried out by the investigator or his designate. A single 
stroke must be drawn through the original entry. The correction has to be dated and initialled. 
Incorrect entries must not be covered with correcting fluid, or obliterated, or made illegible in any 
way. 
 
Even if there are no changes from a previous examination, in the interests of completeness of data 
acquisition the questions, which are repeated in each section of the CRFs should be answered in 
full. A reasonable explanation must be given by the investigator for all missing data. 
 
10.6 Data Management 
Data will be coded and entered into a computer database. The handling of data, including data 
quality control, will comply with regulatory guidelines (e.g., International Conference on 
Harmonization [ICH] and Good Clinical Practice [GCP]). 
 
11 
Regulatory and Administrative Procedures  
11.1 Ethics Committee and Competent Authorities 
Any regulatory requirements must have been met before starting the study. The Sponsor will 
apply for the regulatory approval to the appropriate authorities. 
 
Study sites, facilities, laboratories and all data (including source data) and documentation must be 
made available for inspection by the authorities. 
 
The study will be conducted in accordance with the Brazil, (2013) amendment to the Declaration 
of Helsinki 1964. 
 
The Protocol and Patient Information and Informed Consent Form will be approved by the Ethics 
Committee before commencement. If a substantial protocol amendment is necessary, this will be 
signed and submitted by the Sponsor for ethical and regulatory approval. The approval from the 
Ethics Committee and Competent Authority should be obtained before any implementation of the 
amendment is done. When the change or deviation is to eliminate or reduce risk to human 
patients, the amendment may be implemented before review of approval by the Ethics Committee 
and Competent Authority. The sponsor should notify the Ethics Committee and Competent 
Authority of the change or deviation in writing within 10 working days after implementation. 
 
Minor amendments which do not affect the safety or conduct of the study from the patient 
viewpoint, and which do not significantly reduce the scientific value of the protocol, and which 
do not require a significant change to be made to the consent form and/or the information sheet, 
will not be submitted for formal ethics and regulatory review. These will be sent to the Ethics 
committee and Competent Authority on an ‘information only’ basis. 


 
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11.2 Patient Information / Informed Consent  
The investigator is responsible for giving the patients and his/her parents/caregivers full and 
adequate verbal and written information about the nature, purpose, possible risk and benefit of the 
study. Patients and his/her parents/caregivers must also be notified that they are free to withdraw 
from the study at any time. The patients and parents/caregivers should have reasonable time to 
read and understand the information before signing. The investigator is responsible for obtaining 
signed informed consent from all patients before including the patient in any study related 
procedures. 
 
Should there be any amendments to the final protocol, such that would directly affect the patient’s 
participation in the trial e.g., a change in any procedure, or if new data is obtained during the trial 
that may influence the standpoint to participate in the study, the patient information will be 
amended to incorporate this modification and the patient must agree to sign this amended form 
verifying that they re-consent to continue their participation in the trial. 
 
A copy of the Patient Information and of the Informed Consent Form will be given to the patients 
and parents/caregivers. 
 
11.3 Patient Confidentiality 
The investigator must ensure that patient's confidentiality will be maintained. CRFs or other 
documents submitted to the Sponsor should only identify patients by their initials and study 
number. The investigator should keep a separate log of patient codes and names. 
 
Documents not for submission to the Sponsor, e.g. patient's completed Consent Forms, should be 
retained by the investigator in strict confidence.  
 
The investigator is required to record safety data, concomitant medication and patient progress in 
the patient's file/notes/medical record. 
 
The patient's medical records will be reviewed by the study monitor to verify adequate source 
documentation, accuracy and completeness of Case Report Forms. The review will be conducted 
with strict adherence to professional standards of confidentiality. 
 
The investigator must keep a screening log, recording all patients who were screened, whether 
they were enrolled or not, and a separate Patient Identification List showing code numbers, 
names, and dates of birth to allow unambiguous identification of each patient included in the 
study. 
 
11.4 Patient Treatment Plan 
All patients will continue to receive standard care for Type 1 diabetes during the study. 
 
After the individual completion of the study, the patient will return to the standard treatment 
received prior to study participation. 
 


 
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11.5 GCP 
The study will be managed and conducted in compliance with the protocol and according to the 
latest international (ICH) guidelines for Good Clinical Practice (GCP) as well as the applicable 
regulatory requirement(s). 
 
11.6 Record Retention 
The CRFs and all medical records upon which the CRFs are based (source data) must be kept for 
at least 10 years after completion of the study.  
 
11.7 Monitoring / Quality Control 
Prior to the start of the study, the monitor will review the protocol and CRFs with the investigator 
and his/her staff. The investigator will be visited by the monitor, who will check study 
procedures, including safety assessments, study medication handling, data recording and source 
data verification (SDV). To assure the accuracy and completeness of the data recorded in the trial, 
the monitor will compare CRFs with medical records and other relevant documentation during the 
on-site monitoring visits. The monitor must therefore direct access to all source data according to 
ICH GCP to confirm that required protocol procedures are being followed and check consistency 
between patient record and CRF data. Incorrect or missing entries into the CRFs will be queried 
and must be corrected. Study monitoring will not jeopardise patient confidentiality.  
 
11.8 Source Data  
Source data is defined as any information in original records and certified copies of original 
records of clinical findings, observations or other activities necessary for reconstruction and 
evaluation for the study (e.g. CRFs, medical records (including EMRs) lab reports, patient 
information sheets, patient diaries, etc.).  
 
For this study, a separate Source Data Identification Agreement will be written for each site, 
defining the source data for this study. 
11.9 Quality Assurance and Insurance 
During or after the study is completed, regulatory authorities, Diamyd Medical, assigned CRO or 
other involved party may wish to carry out an audit. These representatives must have the same 
access to study data and patient source data as the monitor. 
 
Patients insurance is covered by the ordinary Patientskadeförsäkringen. 
12 End of Trial 
The end of the trial is defined as the last visit of the last patient included in the trial and all data 
have been collected.  
12.1 Study Report 
A clinical study report will be prepared covering clinical and statistical aspects and summarising 
all findings of the clinical study.  
 


 
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12.2 Study Stopping Criteria 
The Sponsor and the investigators reserve the right to discontinue the study at any time for safety 
reasons or other reasons jeopardizing the justification of the study. Such a termination will be 
implemented in a time frame that is compatible with the patient’s wellbeing. 
 
If the study is prematurely terminated or suspended, the investigator should promptly inform the 
patients and assure appropriate therapy and follow-up. The Sponsor will notify the Regulatory 
Authorities and the Ethics Committee of any plans to terminate the study. 
 
12.3 Publication and Data Rights 
It is envisaged that the findings of the study will, in due course and by mutual agreement, be 
published in a scientific journal and/or presented at a scientific meeting. The authorship of this 
publication/ will remain as specified below. 
 
The published international guidelines for authorship (International Committee of Medical 
Journal Editors, 1997) will be adhered to; i.e. ‘All persons designed as authors should qualify for 
authorship. Each author should have participated sufficiently in the work to take public 
responsibility for the content.’  Authorship credit will therefore be based only on substantial 
contributions to 1) conception and design, or analysis and interpretation of data; and to 2) drafting 
the article or revising it critically for important intellectual content; and on 3) final approval of the 
version to be published. Conditions 1), 2) and 3) must all be met. Participation solely in 
acquisition of funding or the collation of data does not justify authorship. General supervision of 
the research group is not sufficient for authorship. It is intended that information on what each 
author has contributed will be published. It is emphasised however, that only those who entirely 
meet the above mentioned criteria will be listed as authors. The principal investigator, who will 
be first or last author of publications based on this trial, has the final decision of the list of 
authors. 


 
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41. Jun et al (2002). Diabetologia 45:668-676 
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14 Investigator/Sponsor Signatures 
 
Investigator’s Statement: 
 
I have read and understand the foregoing protocol with the title: 
 
“Open Label trial to evaluate the tolerability of a combination therapy consisting of GAD-
alum (Diamyd®), etanercept and vitamin D in children and adolescents newly diagnosed 
with type 1 diabetes” 
 
with study number EDCR IIa and agree to conduct the trial, in compliance with ICH notes 
on Good Clinical Practice (CPMP/ICH/135/95), designated Standard Operating 
Procedures, National Laws and regulations and within the principles of the current 
revision of Declaration of Helsinki (Brazil 2013). 
 
 
Investigator’s Printed Name: 
 
 
…………..………………………………………… 
 
Investigator’s Signature: 
 
 
…………..………………………………………… 
 
 
Date: ………………………….. 
 
 
 
Sponsor and Coordinating Investigator’s signature: 
 
 
Name and function 
Signature 
Date 
 
Johnny Ludvigsson 
Coordinating Investigator 
and Sponsor