Conditions: Hemorrhagic Hereditary Telangiectasia (HHT)
Keywords: Hemorrhagic Hereditary Telangiectasia (HHT) Antiangiogenic therapy Tacrolimus
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 50
Healthy volunteers: no

Brief summary:
The recognized manifestations of HHT are all due to abnormalities in vascular structure. Epistaxis due to telangiectases formation is spontaneous, very variable, recurrent in 90% of patients, and associated with severe anemia in 2-10%. They also significantly reduce quality of life.

Improvement in epistaxis has been shown in HHT patients after a liver transplantation. It was hypothesized that the immunosuppressive treatment (FK506) used to prevent rejection may have an anti-angiogenic effect.

The results of Albiñana et al suggest that the mechanism of action of FK506 involves a partial correction of endoglin and ALK1 haplosufficiency, genes responsible for 90% of HHT case.

Tacrolimus ointment is available on the market for the treatment of eczema and can therefore readily be used as it is for nasal administration. Topical nasal administration of tacrolimus may be an easy local ENT treatment that is non-aggressive and results in little trauma for the patient in relation to other first line treatment possibilities.

The main objective of this trial is to evaluate, at 6 weeks after the end of the treatment, the efficacy on the duration of nosebleeds, of 6 weeks tacrolimus nasal ointment application, in patients with HHT complicated by nosebleeds (30 min/6 weeks). Secondary objectives are to evaluate the tolerance throughout the study, the efficacy on anemia and on clinical parameters (nosebleeds, quality of life, epistaxis severity score questionnaire and blood transfusions) and the systemic absorption of nasal administration.

This is a multicenter prospective and double blinded phase I/II trial. A total of 48 patients will be randomized versus placebo using an allocation ratio of 1:1. The ointment (Protopic® at 0.1% or placebo) will be self-administered by the patient with one administration in each nostril twice a day for 6 consecutive weeks.

Detailed description:

Arms:
arm 1: Protopic® 0.1% ointment, packed in blinded tube of 30g. arm 2: Same formulation as the Protopic® 0.1% ointment but without tacrolimus, packed in blinded tube of 30g.

Interventions: intervention 1: Protopic® (Tacrolimus) 0.1% ointment intervention 2: Placebo
Intervention descriptions: intervention 1: About 0,1g of ointment is administered by the patient on nasal mucosa of each nostril twice a day for 6 weeks. intervention 2: About 0,1g of ointment is administered by the patient on nasal mucosa of each nostril twice a day for 6 weeks.

Protocol document:
Prot_SAP_000.pdf: 
 
Page 1 of 64 
 
 
 
 
 
 
TACRO 
Efficacy and safety of a 0.1% tacrolimus nasal ointment as 
a treatment for epistaxis in Hemorrhagic Hereditary 
Telangiectasia (HHT) 
A double blind, randomized, placebo-controlled, 
multicenter trial 
 
 
 
 
EUDRACT N° 2017-000085-30 
ClinicalTrials.gov Identifier: NCT03152019 
Version 4 dated: 21 june 2017 
 
 
 
Main investigator 
 
Name:     Dr Sophie DUPUIS-GIROD 
Address: Hospices Civils de Lyon 
Service de Génétique Clinique 
Hôpital Femme Mère Enfant  
59, Bd Pinel 
69677 BRON cedex  
Tel.:  
04 27 85 65 22 
E-mail:     sophie.dupuis-girod@chu-lyon.fr 
Centre for the Methodology, Management and 
Analysis of data 
 
Name:  
Dr Evelyne DECULLIER 
                  Under the responsibility of Dr François 
CHAPUIS 
Address:  Unité de Recherche Clinique, Pôle IMER 
                 162, Avenue Lacassagne 
                 69424 Lyon Cedex 03 
 
Tel.:  
04 72 11 57 06 
Fax: 
04 72 11 57 11 
E-mail:       evelyne.decullier@chu-lyon.fr  
Sponsor 
Hospices Civils de Lyon 
3, quai des Célestins 
69229 LYON CEDEX 02 
 
Person authorized to sign the protocol and any possible modifications on behalf of the sponsor: 
Ms Muriel MALBEZIN 
Direction de la Recherche Clinique – Hospices Civils de Lyon 
3 quai des Célestins 
69229 Lyon cedex 02 
 
Name and job title of the person responsible for research on behalf of the sponsor: 
Dr Valérie PLATTNER 
Direction de la Recherche Clinique – Hospices Civils de Lyon 
3 quai des Célestins 
69229 Lyon cedex 02 
Tel.: 04 72 40 68 40 / Fax: 04 72 11 51 90 
E-mail: valerie.plattner@chu-lyon.fr 
 
 


 
Page 2 of 64 
ASSOCIATED INVESTIGATORS 
Investigators  
Address of the Center 
Telephone, E-mail 
Dr Frédéric FAURE 
 
Service ORL 
Hôpital Edouard Herriot 
5, place d’Arsonval 
69437 LYON cedex 03 
04 72 11 05 40 
frederic.faure@chu-lyon.fr  
Dr Pierre PHILOUZE 
Service ORL 
Hôpital de la Croix Rousse 
103, grande rue de la Croix Rousse 
69317 LYON cedex 04 
04 72 00 90 08 
pierre.philouze@chu-lyon.fr 
Dr Vincent GROBOST 
CHU Estaing 
Service de médecine interne 
63100 CLERMONT-FERRAND 
04 73 75 00 85 
vincent.grobost@gmail.com 
Dr Nicolas SAROUL 
CHU  Gabriel-Montpied 
Service ORL 
63100 CLERMONT-FERRAND 
04 73 75 16 85 
nsaroul@chu-clermontferrand.fr 
Dr Sophie RIVIERE 
CHU de Montpellier 
Hôpital St Eloi – Av Augustin Fliche 
Service de médecine Interne A 
34295 MONTPELLIER Cedex 
04 67 33 73 37 
s-riviere@chu-montpellier.fr 
 
Dr César CARTIER 
Pr Louis CRAMPETTE 
CHU de Montpellier 
Hôpital Gui de Chauliac 
Service ORL - Av. Augustin Fliche 
34295 MONTPELLIER Cedex 
04 67 33 68 95 
c-cartier@chu-montpellier.fr 
l-crampette@chu-montpellier.fr 
 
 
OTHER PARTICIPANTS  
Name 
Address  
Telephone, E-mail 
Anne-Emmanuelle 
FARGETON 
Chargée d’études 
Service de Génétique Clinique 
Hôpital Femme Mère Enfant  
59, Bd Pinel - 69677 BRON cedex 
04 27 85 65 23 
anne-emmanuelle.fargeton 
@chu-lyon.fr  
Marjolaine BEAUDOIN 
Attachée de Recherche 
Clinique 
Service de Génétique Clinique 
Hôpital Femme Mère Enfant  
59, Bd Pinel - 69677 BRON cedex 
04 27 85 61 83 
marjolaine.beaudoin@chu-
lyon.fr 
Adeline ROUX 
DataManager 
 
Unité de Recherche Clinique, Pôle 
IMER 
162, Avenue Lacassagne 
69424 LYON Cedex 03 
04 72 11 54 24 
adeline.roux@chu-lyon.fr 
 
Bettina COLLOMBET 
Pharmacienne 
Pharmacie à Usage Intérieur 
Groupement Hospitalier Est 
59, Bd Pinel - 69677 BRON cedex 
04 72 35 95 23 
bettina.colombet@chu-lyon.fr 
 
Valentine BREANT 
Pharmacienne 
Pharmacie à Usage Intérieur 
Groupement Hospitalier Est 
59, Bd Pinel - 69677 BRON cedex 
04 72 68 49 11 
valentine.breant@chu-lyon.fr 
 
 
UPDATE HISTORY 
Version 
Date 
Update reason 
01 
02/02/2017 
First version – CPP & ANSM submission 
02 
22/03/2017 
Second version – Further to ANSM request 
Addition of a phone call to patient at Day 15, ophthalmic 
safety data (§1.3.3.), exclusion criteria “women of child 
bearing potential without reliable contraception”, arguments 
on rationale (§2.2).  


 
Page 3 of 64 
03 
04/04/2017 
Third version – Further to ANSM request 
Changes in duration: 6 weeks treatment and 6 weeks follow 
up, inclusion criteria adapted: epistaxis>30 mn for 6 weeks. 
Addition of blood samples at day 8 & 22 for tacrolimus 
dosage. Addition of in vivo demonstration for ointment 
administration. 
04 
21/06/2017 
Fourth version 
Further to the request of the independent monitoring and 
safety committee, review of the rules for discontinuation of 
the study in case of imbalance between the randomization 
arms §2.3.  


 
Page 4 of 64 
CONTENTS 
 
Synopsis ............................................................................................................................... 9 
The State of the Matter .........................................................................................................13 
1.1 
Hereditary Hemorrhagic Telangiectasia (HHT) ......................................................13 
1.1.1 
Introduction .......................................................................................................13 
1.1.2 
The disease ......................................................................................................13 
1.1.2.1 
Clinical picture ...........................................................................................13 
1.1.2.2 
Genetics and physiopathology ...................................................................14 
1.1.3 
Nosebleeds .......................................................................................................14 
1.1.4 
Treating nosebleeds in HHT ..............................................................................15 
1.2 
Angiogenesis and its regulation ............................................................................16 
1.2.1 
Angiogenesis and HHT .....................................................................................16 
1.3 
Tacrolimus ............................................................................................................18 
1.3.1 
Mechanism of action .........................................................................................18 
1.3.2 
Current indications ............................................................................................19 
1.3.3 
Safety: Ointment safety  ....................................................................................19 
1.3.3.1 
Skin ...........................................................................................................19 
1.3.3.2 
Mucosae ....................................................................................................20 
1.3.3.3 
Ophtalmic ..................................................................................................21 
1.3.4 
Pharmacokinetic and systemic absorption ........................................................21 
1.4 
Tacrolimus and HHT .............................................................................................21 
2 
Justification for the study ..............................................................................................22 
2.1 
Rationale for the study ..........................................................................................22 
2.2 
Safety and rationale for the pharmaceutical form, means of administration and 
doses used .......................................................................................................................23 
2.3 
Rationale for the methodology ..............................................................................24 
3 
Objectives .....................................................................................................................27 
3.1 
Main objective .......................................................................................................27 
3.2 
Secondary objectives ............................................................................................28 
4 
Methodology .................................................................................................................28 
4.1 
Outline of the experiment ......................................................................................28 
4.1.1 
Monitoring the patients ......................................................................................28 
4.1.2 
Patient selection ................................................................................................28 
4.1.3 
Duration of the study .........................................................................................28 
4.2 
Patients .................................................................................................................29 
4.2.1 
Recruitment and feasibility ................................................................................29 
4.2.2 
Number of patients ............................................................................................29 
4.2.3 
Modalities for recruitment, inclusion and follow-up ............................................30 
4.2.4 
Inclusion criteria ................................................................................................30 
4.2.5 
Exclusion criteria ...............................................................................................30 
4.3 
Assessment criteria for the study product..............................................................31 
4.3.1 
Main judgement criterion ...................................................................................31 
4.3.2 
Secondary judgement criteria ............................................................................31 
4.4 
Randomization, blinding and lifting the blind .........................................................32 
4.5 
Modalities for premature termination of the treatment and withdrawal from the study
 
33 
4.6 
Rules for definitive termination ..............................................................................33 
4.6.1 
A research person terminates his or her participation in the study .....................33 
4.6.2 
Termination of all or part of the research ...........................................................33 
5 
Description, supply and management of the drugs .......................................................34 
5.1 
General modalities of preparation and administration ...........................................34 
5.2 
Treatment tested ...................................................................................................34 
5.2.1 
Modalities for the preparation ............................................................................34 
5.2.2 
Storage and conservation .................................................................................34 
5.2.3 
Return and destruction ......................................................................................34 


 
Page 5 of 64 
5.3 
Placebo .................................................................................................................34 
5.3.1 
Modalities for preparing .....................................................................................34 
5.3.2 
Storage and conservation of the placebo ..........................................................35 
5.3.3 
Return and destruction ......................................................................................35 
5.4 
Associated treatments...........................................................................................35 
5.5 
Drug circuit ............................................................................................................35 
5.5.1 
Supply ...............................................................................................................35 
5.5.2 
Dispensing the study products by the hospital pharmacy in the centers 
participating in the study ...............................................................................................35 
5.6 
Ointment tubes: presentation and supplier ............................................................36 
6 
Practical running of the study ........................................................................................36 
6.1 
General organization and study sites ....................................................................36 
6.2 
Inclusion visit (V1) .................................................................................................37 
6.2.1 
Ointment administration ....................................................................................38 
6.2.2 
Recommendations ............................................................................................38 
6.3 
Phone calls on day 15, 14 days after the beginning of the treatment (up to day 18 
tolerated) ..........................................................................................................................39 
6.4 
Phone calls on day 31, 30 days after the beginning of the treatment (up to day 37 
tolerated) ..........................................................................................................................39 
6.5 
Visit at the end of the treatment, V2 = at day 43 (up to day 50 tolerated) ..............40 
6.6 
Visit after 6 weeks follow-up, V3 = at day 85 (up to day 100 tolerated)..................40 
6.7 
Synopsis of the study per patient ..........................................................................42 
7 
Intercurrent events ........................................................................................................43 
7.1 
Definitions .............................................................................................................43 
7.1.1 
Adverse event ...................................................................................................43 
7.1.2 
Serious adverse event (SAE) ............................................................................43 
7.1.3 
Intensity ............................................................................................................43 
7.1.4 
Adverse reaction ...............................................................................................44 
7.1.5 
Reference document for the experimental drug .................................................44 
7.2 
Responsabilities of the investigator .......................................................................44 
7.2.1 
Adverse Events reporting ..................................................................................44 
7.2.2 
General AE/SAE reporting rules: .......................................................................44 
7.2.3 
SAE declaration ................................................................................................44 
7.2.4 
Follow up of Adverse Events and Serious Adverse events ................................45 
7.3 
Sponsor’s responsibilities ......................................................................................45 
7.4 
Specific management of complications .................................................................45 
7.4.1 
Nosebleeds .......................................................................................................45 
7.4.2 
Perforation of the nasal septum .........................................................................46 
7.4.3 
Other complications associated with adverse events linked to topical tacrolimus
 
46 
7.4.4 
Tacrolimus systemic absorption ........................................................................46 
8 
Data management ........................................................................................................46 
8.1 
Electronic case report forms..................................................................................46 
8.2 
Source documents ................................................................................................47 
8.3 
Archiving ...............................................................................................................47 
8.4 
Electronic data management.................................................................................47 
9 
Statistics .......................................................................................................................48 
9.1 
Number of participants ..........................................................................................48 
9.2 
Statistical analysis plan .........................................................................................48 
9.2.1 
Analysis populations .........................................................................................48 
9.2.1.1 
“Efficacy” population in intention to treat ....................................................48 
9.2.1.2 
“Efficacy” population per protocol ..............................................................48 
9.2.1.3 
“Safety” population ....................................................................................48 
9.2.2 
Statistical methods ............................................................................................49 
9.2.2.1 
Populations ...............................................................................................49 
9.2.2.2 
Deviation from the protocol ........................................................................49 


 
Page 6 of 64 
9.2.2.3 
Initial characteristics ..................................................................................49 
9.2.2.4 
Analysis of the main judgement criterion ...................................................49 
9.2.2.5 
Analysis of the secondary judgement criteria .............................................49 
9.2.2.6 
Handling of missing values/censoring/discontinuations .............................50 
10 
Quality assurance .........................................................................................................51 
11 
Ethical and regulatory aspects ......................................................................................51 
11.1 
Qualification of the research and patient information .............................................52 
11.1.1 
Information sheet ..........................................................................................52 
11.1.2 
Enlightened consent ......................................................................................52 
11.2 
Benefit / risk ratio ..................................................................................................52 
11.3 
Confidentiality of the data ......................................................................................53 
11.4 
Confidentiality and Good Clinical Practices ...........................................................53 
11.5 
Submitting the protocol to the CPP and ANSM .....................................................53 
11.6 
Amendments to the protocol .................................................................................53 
11.7 
Computerization of the data ..................................................................................54 
11.8 
Curriculum vitae and signature of the protocol ......................................................54 
11.9 
Insurance ..............................................................................................................54 
11.10 
Study report and publications ............................................................................54 
12 
Organization of the study ..............................................................................................55 
12.1 
Scientific committee ..............................................................................................55 
12.2 
Independent monitoring and safety committee for the study .................................55 
13 
Medium and long term perspectives .............................................................................55 
14 
References ...................................................................................................................57 
15 
Appendices ...................................................................................................................61 
15.1 
Appendix 1: Nosebleed monitoring sheet ..............................................................61 
15.2 
Appendix 2: ESS questionnaire .............................................................................62 
15.3 
Appendix 3: ENT monitoring examination .............................................................63 
15.4 
Appendix 4: Epistaxis emergency .........................................................................64 
 


 
Page 7 of 64 
LIST OF ABBREVIATIONS 
 
ALK ............................ Activin-like-receptor-type 1 
ANSM ........................ Agence Nationale de Sécurité du Médicament et des Produits de Santé 
 
(French National Agency for Drug Safety) 
AVF ............................ Arteriovenous Fistula  
BMP ........................... Body Morphogenetic Proteins 
BMPR2 ...................... Body Morphogenetic Protein Receptor, type II 
CHU  .......................... Centre Hospitalier Universitaire (University Teaching Hospital)  
CNIL ........................... French Commission for Data Protection and Liberties 
CNV ........................... Corneal NeoVascularization 
CPP ........................... Comités de Protection des Personnes (French Ethics Committee) 
CRF ........................... Case Report Form (Cahier d’observation) 
DSMB ........................ Data and Safety Monitoring Board 
EC .............................. Endothelial Cells 
ENG ........................... Endogline 
ENT ............................ Ear, Nose and Throat Specialist 
ESS ............................ Epistaxis Severity Score 
FKBP ......................... FK-Binding Protein 
Flt-1 ............................ Fms-like tyrosine kinase 
HAS ........................... Haute Autorité de Santé (French National Authority for Health) 
HHT ........................... Hereditary Hemorrhagic Telangiectasia 
IMER .......................... Information Médicale Evaluation Recherche 
 
(Medical Information Research Assessment) 
IV ............................... Intra venous 
IWRS ......................... Interactive Web Response System 
KO .............................. Knock Out 
MAPK ......................... Mitogen-activated protein kinases 
MCP ........................... Monocyte Chemoattractant Protein 
mRNA ........................ messenger Ribonucleic Acid 
OLP ............................ Oral Lichen Planus 
PAH ........................... Pulmonary Arterial Hypertension 
PNDS ......................... Protocoles Nationaux de Diagnostic et de Soins  
 
(French National Protocol for Diagnosis and Healthcare) 
SAE ............................ Serious Adverse Events 
SAS ............................ Statistical Analysis System  
SMAD ........................ Mothers Against Dpp homologue 4 
SPC ........................... Summary of Product Characteristics 
TGF-β ........................ Transforming Growth Factor-β 
TNF ............................ Tumor Necrosis Factor 
VEGF ......................... Vascular Endothelial Growth Factor 
VEGFR ...................... Vascular Endothelial Growth Factor Receptor. 
 


 
Page 8 of 64 
LIST OF FIGURES 
 
 
Figure 1: Angiogenesis results from an activation phase and a maturation phase. (Taken 
from David L. 28) ...........................................................................................................16 
Figure 2: Involvement of the BMP9/ALK1/endoglin pathway in HHT (taken from S. Bailly31) 17 
Figure 3: Angiogenic balance in HHT (taken from S. Bailly31) ...............................................17 
Figure 4 General diagram of the study .................................................................................24 
Figure 5: Inclusions flow chart ..............................................................................................27 
Figure 6: Schedule ...............................................................................................................29 
Figure 7: Diagram of the running of the study .......................................................................30 
Figure 8: Diagram of the running of the study .......................................................................37 
 
 
 
 
LIST OF TABLES 
 
 
Table 1: Synopsis of the study per patient ............................................................................42 


 
Page 9 of 64 
Synopsis 
Title of the study:  
TACRO: Efficacy and safety of a 0.1% tacrolimus nasal ointment as a treatment for epistaxis in Hemorrhagic 
Hereditary Telangiectasia (HHT) - A double blind, randomized, placebo-controlled, multicenter trial. 
Context:  
HHT is a rare but ubiquitous hereditary vascular disease, with estimated prevalence of 1/6000. It is related to 
disequilibrium in the angiogenic balance, resulting from abnormal homeostasis between the factors involved 
in the activation phase and those involved in the maturation phase of angiogenesis. ENG (Endoglin) and 
ACVRL1 encoding ALK1 (Activine receptor like kinase 1) genes are responsible for 90% of cases of HHT. 
These genes both intervene in the signaling pathway of the Transforming growth factor beta (TGFbeta) family 
in endothelial cells. 
The recognized manifestations of HHT are all due to abnormalities in vascular structure. Lesions may be 
small (telangiectases) or large arteriovenous malformations (AVMs). Telangiectases and AVMs vary widely 
between individuals and even within the same family. Epistaxes are spontaneous, very variable, recurrent in 
90% of patients, and associated with severe anemia in 2-10%. They also significantly reduce quality of life. 
Nosebleeds are the most frequent complication in HHT and may occur as often as several times every day. 
Blood transfusions are sometimes required in 10-30% of patients, but are regularly required (every 2 or 3 
weeks) in 2-5% of patients. The incomplete and transient efficacy of surgical therapies has inspired a new 
search for adjuvant medical treatments which would greatly diminish daily iron loss.  
Intra-venous anti-VEGF treatment is efficient on epistaxis1, but its use is limited to severe forms of the 
disease, and local administration (nasal spray) recently evaluated in a phase 2 study is not efficient (Dupuis-
Girod S et al., in press – clinical trial identifier: NCT02106520).  
Improvement in epistaxis has been shown in HHT patients after a liver transplantation. It was hypothesized 
that the immunosuppressive treatment (FK506) used to prevent rejection may have an anti-angiogenic effect. 
Albiñana et al. found that the immunosuppressor FK506 increases the protein and mRNA expression of ENG 
and ALK1 in cultured endothelial cells, and enhances the TGF-β1/ALK1 signaling pathway and endothelial 
cell functions such as tubulogenesis and migration. These results suggest that the mechanism of action of 
FK506 involves a partial correction of endoglin and ALK1 haplosufficiency and may therefore be an interesting 
drug for use in patients with HHT. 
Topical nasal administration of tacrolimus may be an easy local ENT treatment that is non-aggressive and 
results in little trauma for the patient in relation to other first line treatment possibilities. In addition, tacrolimus 
ointment is available on the market for the treatement of eczema and can therefore readily be used as it is 
for nasal administration. 
 
Objectives  
Main objective: To evaluate, at 6 weeks after the end of the treatment, the efficacy on the duration of 
nosebleeds, of tacrolimus nasal ointment, administered for 6 weeks in patients with HHT complicated by 
nosebleeds. 
Secondary objectives are to evaluate: 
1. Tolerance of tacrolimus nasal administration for 6 weeks, throughout the study. 
2. Efficacy of the treatment on progress in the  
 
clinical parameters:  
 
Nosebleed duration 
 
Number of nosebleeds  
 
Number of transfusions of red blood cells 
 
Quality of life 
 
ESS = Epistaxis Severity Score 
 
biological parameters: hemoglobin and serum ferritin concentrations 
These parameters will be evaluated at the end of the 6 weeks of treatment (V2) and at the end of 6 
weeks’ follow-up (V3). 
3. Systemic absorption after 1, 3 and 6 weeks of nasal administration. 


 
Page 10 of 64 
Methodology  
This is a phase II multicenter, randomized study carried out in double blind.  
Number of patients: 48 patients will be randomized with an active/placebo ratio = 1:1. 
For all patients, monitoring will be for 84 days (6 weeks’ treatment + 6 weeks’ follow-up). 
 
 
 For safety reasons, as no tolerance data are available with a nasal administration, we decided to include 
patients sequentially. We designed an inclusion scheme in 3 or 4 steps. An independent safety 
committee will give its rcommandations on the continuation of the study.  
 
Product tested:  
The treatment tested is Tacrolimus, manufactured by the laboratories Astellas and marketed under the name 
of Protopic® (tacrolimus at 0.1%). For the study, the ointment will be used as is. 
The comparative treatment, placebo, is the same formulation as the active product but without tacrolimus. 
One tube of product is delivered to patients, for administrations twice daily for 6 weeks. 
Patients:  
Inclusion criteria:  
- 
Age ≥ 18 years. 
- 
Patients who have given their free informed and signed consent.  
- 
Patients affiliated to a social security scheme or similar. 
- 
Patients monitored for clinically confirmed HHT (presence of at least 3 Curaçao criteria) and/or 
confirmed by molecular biology. 
- 
Patients presenting nosebleeds with total duration > 30 minutes for 6 weeks prior to the time of inclusion 
justified by completed follow-up grids. 
Exclusion criteria:  
- 
Women who are pregnant or nursing (lactating), women of child-bearing potential without reliable 
contraception. 
- 
Patients not affiliated to a social security scheme. 
- 
Patients who are protected adults under the terms of the law (French Public Health Code). 
- 
Refusal to consent.  
- 
Patients for whom the diagnosis of HHT has not been confirmed clinically and/or by molecular biology. 
- 
Participation in another clinical trial wich may interfere with the proposed trial (judgment of the 
investigator). 
- 
Patients who have undergone nasal surgery in the 6 weeks prior to inclusion. 
- 
Known hypersensitivity to macrolides in general, to tacrolimus or to any of the excipients. 
- 
Patient with an inherited skin barrier disease such as Netherton’s syndrome, lamellar ichtyosis, 
generalized erythroderma, graft-versus-host skin disease, or suffering from generalized erythroderma. 
.  
- 
Patient with CYP3A4 inhibitors treatment, e.g. erythromycin, itraconazole, ketoconazole and diltiazem. 
- 
Patients who have incompletely filled in the nosebleed grids in the 6 weeks preceding the treatment. If 
there is missing data for more than 7 days (10%), the patient cannot be included. 
- 
Patients who do not present nosebleeds with total duration > 30 minutes for 6 weeks prior to the time 
of inclusion. 
- 
Patients with ongoing immunosuppressive treatment 
- 
Patients with known and symptomatic immune deficiency 
 
Main judgement criterion: The main judgement criterion is the percentage of patients experiencing an 
improvement in their nosebleeds. An improvement is defined as a 30% reduction in the total duration of 


 
Page 11 of 64 
nosebleeds over 6 weeks after treatment, compared with duration of the nosebleeds in the 6 weeks before 
treatment. 
Secondary judgement criteria 
1. 
Adverse events (AE) and Severe Adverse Events (SAE) observed throughout the study (clinical 
examination, epistaxis grids, ENT examination at each visit before and after the treatment). Additionally, 
all patients are contacted by phone after 14 and 30 days of treatment in order to collect data on tolerance 
and observance of the treatment. 
2. 
Clinical efficacy criteria: 
- 
Nosebleed duration will be evaluated by the nosebleed monitoring grids completed by the patients 
(Appendix 1). The grids will be collected at inclusion (V1): observation of nosebleeds in the 6 weeks 
prior to inclusion, at the end of the treatment (V2): observation of nosebleeds in the 6 weeks of 
treatment, and at the end of the study (V3): observation of nosebleeds in the 6 weeks after the end 
of treatment. 
- 
Progress in the number of nosebleeds. This criterion will be evaluated by the nosebleed monitoring 
grids completed by the patients (Appendix 1) and collected at inclusion (V1): observation of 
nosebleeds in the 6 weeks prior to inclusion, at the end of treatment (V2): observation of nosebleeds 
in the 6 weeks of treatment, and at the end of the study (V3): observation of nosebleeds in the 6 
weeks after the end of treatment. 
- 
Comparison of the number of red blood cell transfusions between inclusion (V1) (collected over 6 
weeks before treatment), end of treatment (V2) (collected over the 6 weeks of treatment) and end of 
the study (V3) (collected over 6 weeks after the end of treatment). 
- 
Progress in the scores obtained in the SF36 quality of life questionnaire completed at inclusion (V1), 
at the end of treatment (V2) and at the end of the study (V3).  
- 
Progress in the Epistaxis Severity Score (ESS) using data from the specific questionnaire (Appendix 
2) completed at inclusion (V1), at the end of treatment (V2) and at the end of the study (V3). 
Biological efficacy criteria: progress in hemoglobin and serum ferritin concentrations between inclusion 
(V1) and end of treatment (V2) and the end of the study (V3). 
3. 
Systemic absorption, after 1, 3 and 6 weeks of nasal administration, will be evaluated by blood tacrolimus 
dosage at the end of treatment. 
 
Benefit/risk ratio: 
All the surgical treatments currently on offer are aggressive for the nasal mucosa and present a risk of 
perforation of the nasal septum.  
Patients’ participation in this study will not compromise their possibility for future medical or surgical treatment. 
The expected adverse events in this study are: 
 
Skin burning or irritation at the application site (approximately half of the patients). These symptoms 
are usually mild to moderate and generally go away within one week of using Protopic. Administration 
could easily be stopped in case of an adverse reaction. 
 
The risk of systemic adverse events related to tacrolimus is low given the very low doses of tacrolimus 
administered to the patients. Tacrolimus in blood is monitored and the treatment will be stopped in 
case of absorption. 
 
The risk at the blood test may be of the hematoma type at the puncture point or fainting.  
If the efficacy of the treatment is shown, the treatment will be proposed to all the patients who have received 
the placebo.  
The benefit/risk ratio for a patient participating in this study is thus perfectly acceptable. 
Total maximum duration of the study: 21 months 
Inclusion period: 18 months. 
Participation duration per patient: 12 weeks 
Expected outcomes:  
In case of efficacy, a topical nasal administration of tacrolimus could be an easy local ENT treatment that is 
non-aggressive and results in little trauma for the patient in relation to other first line treatment possibilities. 
Moreover, a galenic ointment with tacrolimus is available on the market. 
Conduct of the study and research sites:  


 
Page 12 of 64 
Selection and recruitment modalities: Patients for the study will be recruited and given all the necessary 
information during a standard ENT consultation or in the Reference Center or Skill center for HHT. 
Inclusion and prescription of the treatment: Inclusion and treatment prescription will take place in the skill 
centers in Montpellier or Clermont-Ferrand or the reference center for HHT in Lyon.  
Treatment: The ointment tube is delivered by the pharmacies in the hospital centers involved. Treatment 
(active or placebo) is self-administered by patients, twice daily in each nostril, for 6 weeks. 
Follow-up: Throughout the study, patients will be required to complete epistaxis grids. 
Follow-up is scheduled by the center which has carried out the inclusion as follows: 
- 
Tacrolimus dosage in blood at 1, 3 and 6  weeks after the beginning of the treatment. 
- 
Two phones questionnaire on day 15 and 31, 14 and 30 days after the start of the treatment to collect 
data on the tolerance and observance of the treatment. 
- 
Two follow-up visits: after 6 weeks of treatment and 6 weeks after the end of treatment. There will be a 
consultation in the skill center or the reference center for HHT, an ENT examination and a blood sample 
These consultations and examinations are in addition to usual patient care to ensure follow-up of these 
patients and the collection of data during the study. 
Sponsor: Hospices Civils de Lyon 
3 Quai des Célestins, 69229 Lyon cedex 02 
Tel.: 04 72 40 68 40           E-mail: valerie.plattner@chu-lyon.fr  
Main investigator: Dr Sophie DUPUIS-GIROD  
Hospices Civils de Lyon, Hôpital Edouard Herriot, Service ORL, Lyon 
Tel: 33 4 72 11 05 40         E-mail: sophie.dupuis-girod@chu-lyon.fr 
Data analysis:  
Unité de Recherche Clinique (Pôle IMER) – Hospices Civils de Lyon 
162 avenue Lacassagne, 69424 Lyon cedex 03 
Tél.: 04 72 11 57 06           E-mail: evelyne.decullier@chu-lyon.fr  
Favorable decision issed by the Ethics Committee (CPP), on 03/04/2017 
Authorization by the Competent Authorities, on 07/04/2017 
EUDRACT n°: N° 2017-000085-30 
 


 
Page 13 of 64 
The State of the Matter 
1.1 Hereditary Hemorrhagic Telangiectasia (HHT) 
1.1.1 
Introduction 
Hereditary Hemorrhagic Telangiectasia (HHT) is a rare but ubiquitous hereditary 
vascular disease that concerns between 1/6,000 and 1/10,000 patients.  
The French HHT National reference center received its label in 2004. With 12 skill 
centers, it has a cohort of more than 2,000 patients managed both clinically and 
genetically.  
 
1.1.2 
The disease 
1.1.2.1 
Clinical picture 
The diagnosis of Hereditary Hemorrhagic Telangiectasia is based on several criteria, 
known as the Curaçao criteria2: 
 
 
The hereditary element. Transmission is dominant autosomal (50% to each 
child). 
 
 
Telangiectasias. These are lesions that are characteristic of the disease and are 
cutaneous (lips, fingers, face, hands and feet) and mucosal (inside of the lips, 
tongue, palate, nasal and digestive mucosae).  
 
 
Epistaxis (nosebleeds). These are the main form of expression of these 
telangiectasias, both in terms of their frequency and the handicap that they 
provoke. Chronic disabling anemia is an unannullable and predominant 
consequence in these patients.  
 
 
Visceral arteriovenous fistulae (AVF). These are vascular lesions whose impact 
is always aggravated in cases of anemia. Visceral involvement can replace one 
of the three main external signs in a positive diagnosis. The localization of these 
AVF can be: 
 
- pulmonary (6 to 60% of patients 3-9). The treatment has now been codified and 
is based on radiological vaso-occlusion. Annulling hemorrhagic ruptures, 
cerebral complications (abscesses and transitory ischemic attacks) and 
pulmonary signs (dyspnea, cyanosis and polyglobulitis, consequences of 
hypoxia) is a major issue.  
 
 
- neurological, cerebral or medullary 10,11. Prevention of these lesions is 
problematic during the asymptomatic phase. Once their existence becomes 
evident, the sequellae of the possible treatments are serious. Scanning for 
these lesions is controversial 12-16 and their presence is evaluated at between 5 
and 23% of patients with neurologically asymptomatic HHT 2,17,18. 
 
 
- hepatic 19,20. Their definition is based on several radiological criteria. Their 
progress leads certain patients to a liver transplant 21-24. 
 


 
Page 14 of 64 
The clinical diagnosis is 
- certain if at least 3 of the criteria are present, 
- suspected or possible if 2 of the criteria are present, 
- unlikely if only 1 of the criteria is present. 
 
Every typical visceral complication can form one of the three criteria required for the 
diagnosis, thus replacing the nosebleeds, telangiectasias or the hereditary nature2. 
Certain patients can have 4 or 5 signs of the disease, with several forms of visceral 
involvement.  
 
1.1.2.2 
Genetics and physiopathology 
There are three genes known to be responsible for HHT: 
- 
Endoglin (ENG), responsible for the HHT1 phenotype of the disease.  
- 
Activin-like-receptor-type 1 (ALK-1), responsible for the HHT2 phenotype of the 
disease. 
- 
SMAD 4, responsible for a rarer phenotype that associates HHT and chronic 
juvenile polyposis.  
A fourth gene has been localized but not yet identified and is responsible for the HHT3 
phenotype.  
 
ENG and ALK1 are responsible for 90% of cases of HHT. These genes both intervene 
in the signaling pathway of the TGFβ family in endothelial cells. 
 
 
1.1.3 
Nosebleeds 
These are the main expression of HHT and are often the most disabling complication 
of the disease in terms of quality of life and morbidity.  
Nosebleeds affect more than 95% of patients. They are spontaneous, repeated, 
irregular, diurnal and nocturnal; they lead to anemia and are both disabling and socially 
embarrassing. They are also the motivation for repeated periods of sick leave and even 
on occasion a classification of disability 25. The duration of the nosebleeds may be 
greater than 24 hours per month in certain patients, and may require repeated blood 
transfusions and hospitalizations. As a result, the anemia may be severe, and the 
repeated ENT treatments have a risk of complication (perforation of the nasal septum, 
infections after packing). 
Their objective assessment is achieved by means of a grid that contains the number 
of nosebleeds per month and the duration of the bleeding (Appendix 1: Nosebleed 
monitoring grid).  
Furthermore, a validated scoring index, the Epistaxis Severity Score (ESS), was 
developed as a standardized measurement of patient-reported epistaxis severity. This 
score summarizes the severity of epistaxis symptoms along multiple domains, 
including frequency and intensity of nosebleeds, duration of epistaxis episodes, and 
the medical consequences of recurrent epistaxis such as anemia and dependence on 
blood transfusions. An increase in the ESS is significantly correlated to a decline in 
health-related quality of life, as measured by the Medical Outcomes Study 36-Item 
Short Form (SF-36).26 


 
Page 15 of 64 
1.1.4 
Treating nosebleeds in HHT 
 
There is currently no surgical treatment that makes it possible to cure nosebleeds 
definitively. The repetition of ENT treatments is often the source of significant 
iatrogenic conditions, including the perforation of the nasal septum, resulting in 
worsening of the nosebleeds. No studies with a “high level of proof” have shown the 
efficacy of any medical or surgical treatments. 
The French national protocol for the diagnosis and care (PNDS) of patients with HHT, 
drawn up by the reference center(s) that have been labelized with the support of the 
French national authority for health (HAS), contains the following information and 
recommendations regarding the treatment of nosebleeds. 
The PNDS groups together the various medical and surgical treatments available.  
 platelet agents such as ethamsylate are indicated in the treatment of bleeding by 
means of capillary fragility. Nevertheless, no specific studies have been carried 
out in the context of HHT; 
 other treatments are being discussed or studied: 
- 
tranexamic acid (antifibrinolytic) has a moderately positive effect on anemia 
and nosebleeds27; 
- 
aminocaproic acid and estrogens. The use of estrogens is limited by the 
existence of their thromboembolic risk and should only be envisaged in the 
context of clinical trials. 
 As first line treatments the following are proposed: 
- 
laser photocoagulation,  
- 
injections of biological glue, 
- 
injections of sclerosing agents (Ethibloc®, Aetoxisclérol®). 
 As second line treatments: 
- 
selective arterial embolization, either isolated or associated with the previous 
techniques, 
- 
arterial ligature of the sphenopalatine and/or ethmoidal arteries, 
- 
the Saunders surgical technique (suppression of the nasal mucosa), 
dermoplasty or septodermoplasty with or without graft (amniotic cells, jugal 
mucosal cells or skin flap), 
- 
Young’s nasal obstruction (surgical closure of the nasal cavities), either uni- 
or bi-lateral. 
In addition to the treatments already mentioned, regular (several times a day) 
humidification of the nasal mucosa by the patient by means of an association of 
pomades and physiological serum makes it possible to partially improve the 
nosebleeds. 
 
Iron supplementation is recommended for all patients whose repeated nosebleeds 
result in long term iron deficiency anemia. Patients with poor tolerance of oral iron 
supplementation may benefit from intravenous iron injections every 3 weeks. Blood 
transfusions are carried out in accordance with the recommendations of the ANSM. 
 
 
 


 
Page 16 of 64 
1.2 Angiogenesis and its regulation  
 
1.2.1 
Angiogenesis and HHT 
Angiogenesis is the formation of new blood vessels from an existing vascular network. 
There are two phases in angiogenesis: an activation phase, in which the extracellular 
matrix is degraded and the endothelial cells migrate and proliferate (Figure 1). VEGF 
is one of the key factors in this activation phase. This phase is followed by a maturation 
phase, in which the endothelial cells stop migrating and proliferating, the cellular matrix 
is reconstituted and there is recruitment of mesenchymatous cells which differentiate 
into pericytes or smooth muscle cells, depending on the type of vessel. Angiogenesis 
is generally quiescent in adults.  
 
 
 
 
Figure 1: Angiogenesis results from an activation phase and a maturation phase. (Taken from David L. 
28) 
(NO: nitric oxide, VEGF: vascular endothelial growth factor, Ang2: angiopoietin 2, Ang1: angiopoietin 1, 
MMPs: matrix metalloproteinases, EGF: epidermal growth factor, FGF: fibroblast growth factor, TGFb: 
transforming growth factor beta, PDGF: platelet-derived growth factor and TNFa: tumour necrosis factor 
alpha.) 
 
What is known as angiogenic balance results from homeostasis between the factors 
involved in the activation phase and those involved in the maturation phase of 
angiogenesis. The receptor ALK1 plays a key role in inhibiting the proliferation, 
migration and budding of endothelial cells in vitro, as well as neo-angiogenesis in 
vivo28,29. The ligand for ALK1, BMP9, may thus be a key factor in the maturation phase 


 
Page 17 of 64 
of angiogenesis (Figure 2) and its presence in the blood suggests it plays a role in 
maintaining vascular quiescence in adults30. When the BMP9/ALK1/endoglin pathway 
is disturbed, the quiescence decreases, resulting in the dysregulation of this 
angiogenic balance, and thus neo-activation of angiogenesis (Figure 3). 
 
 
 
 
Inhibition of proliferation and  
migration of endothelial cells. 
BMP9/ALK1/Endoglin: Maturation phase 
 
Figure 2: Involvement of the BMP9/ALK1/endoglin pathway in HHT (taken from S. Bailly31) 
BMP9 binds on to a heterocomplex composed of two ALK1 receptors and two type 2 receptors (BMPR2 
or ActR2). The type 2 phosphoryl ALK1 receptor in turn phosphorylates the Smad1/5/8 transcription 
factors. Adding BMP9 results in inhibition of the migration and proliferation of endothelial cells, 
suggesting that this signaling pathway plays a role in the maturation phase of angiogenesis. 
 
 
 
 
Figure 3: Angiogenic balance in HHT (taken from S. Bailly31) 


 
Page 18 of 64 
A. In healthy adults, angiogenic balance is equal between the activation phase and the maturation phase, 
and the vascular network is quiescent.  
B. In HHT patients, the BMP9/ALK1/endoglin signaling pathway is deficient, which results in a decrease 
in the maturation phase and thus an imbalance in the angiogenic balance in favor of the activation phase 
(VEGF).  
In HHT, the mechanisms leading to a predisposition to, and the formation of AVMs, the 
direct connections between arteries and veins, are yet to be determined. One proposed 
mechanism is defective arteriovenous differentiation, observed in Eng and Alk1 null 
embryos that develop AVMs 32 but absent in the endothelial-targeted Eng (Eng-iKOe) 
and Alk1 inducible knockout (Alk1-iKOe) mice 33. Moreover, focal regression of 
capillaries leading to the formation of AVMs has also been postulated in HHT, although 
supporting data for this model are still lacking. Recently, it was shown that wound injury 
was necessary for development of AVMs in adult Alk1-iKOe 34 and Eng1-iKOe mice. 
In addition, intracerebral injection of an adenovirus expressing VEGF contributed to 
pathogenesis of cerebral AVMs in several transgenic Eng KO mice. Angiogenesis is 
the de novo formation of vessels from the pre-existent vascular tree, in response to a 
stimulus. This biological process is controlled by pro-angiogenic factors that promote 
vascular growth and angiostatic factors that induce vascular regression. Physiological 
angiogenesis occurs during development and in healthy individuals, in wound injury 
and repair, menstruation, and pregnancy. 
1.3 Tacrolimus  
Tacrolimus (FK506) is a macrolide antibiotic with immunosuppressive and anti-
angiogenic properties.   
1.3.1 
Mechanism of action  
FK506 (tacrolimus), via a dual mechanism of action, is a calcineurin inhibitor that also 
binds FK-binding protein-12 (FKBP12), a repressor of BMP signaling. FK506 released 
FKBP12 from the type I receptors activin receptor-like kinase 1 (ALK1), ALK2, and 
ALK3, and activated both downstream SMAD1/5 and MAPK signaling and ID1 gene 
regulation in a manner superior to the calcineurin inhibitor cyclosporine and the 
FKBP12 ligand rapamycin.35  
Via its binding to a specific cytoplasmic immunophilin (FKBP12), tacrolimus inhibits 
calcium-dependent signal transduction pathways in cells. In particular, tacrolimus 
inhibits the formation of cytotoxic lymphocytes, which are mainly responsible for graft 
rejection. 
 
The mechanism of action of tacrolimus in atopic dermatitis is not fully understood. 
In vitro, in Langerhans cells isolated from normal human skin, tacrolimus reduced the 
stimulatory activity towards T cells. Tacrolimus has also been shown to inhibit the 
release of inflammatory mediators from skin mast cells, basophils and eosinophils. 
In animals, tacrolimus ointment suppressed inflammatory reactions in experimental 
and spontaneous dermatitis models that ressemble human atopic dermatitis. 
Tacrolimus ointment did not reduce skin thickness and did not cause skin atrophy in 
animals. 
In patients with atopic dermatitis, improved skin lesions during treatment with 
tacrolimus ointment was associated with reduced Fc receptor expression on 
Langerhans cells, as well as reducing their hyperstimulatory activity toward T cells. 
Tacrolimus ointment does not affect collagen synthesis in humans. 36  
 


 
Page 19 of 64 
1.3.2 
Current indications 
At present, when administered either intravenously or orally, tacrolimus is used to 
prevent rejection following organ transplant.  Tacrolimus (FK-506) is a strong 
immunosuppressant neutral macrolide isolated from streptomyces tsukubaensis. It has 
been used to prevent allograft rejections in the liver, kidney, lungs, and heart. 37,38  
 
Tacrolimus ointment has been developed in dermatology and provides physicians with 
an 
alternative 
to 
conventional 
topical 
corticosteroid 
therapy 
for 
atopic 
dermatitis39.Monotherapy is rapidly effective, resulting in clinical improvements within 
three days of starting therapy, and produces a progressive increase in efficacy that is 
sustained throughout long-term treatment. Tacrolimus treats the signs and symptoms 
of atopic dermatitis, reduces the incidence of flares, and offers the potential for long-
term disease control.  
 
1.3.3 Safety: Ointment safety  
1.3.3.1 Skin 
No major safety concerns have been reported to date. Tacrolimus ointment is generally 
well-tolerated, the primary adverse events being mild to moderate and transient 
application-site reactions: skin burning, pruritus and erythema.36 40 
Approximately 50% of patients experienced some type of skin irritation adverse 
reaction at the site of application. Burning sensation, pruritus, and erythema were very 
common, usually mild to moderate in severity and tended to resolve within one week 
of starting treatment. Increased skin sensitivity and skin tingling were also common 
skin irritation adverse reactions. Alcohol intolerance (facial flushing) was common. 
Patients may be at an increased risk of folliculitis, acne, and herpes simplex. 36 
 
Three published observational studies have assessed the carcinogenic risk on large 
cohorts of patients: 
- 
The retrospective Arana study (2010)41 compared the incidence of cancer in the 
general population and in patients with atopic dermatitis. It focused on a cohort of 
4,456,008 patients with no history of cancer from "The Health Improvement 
Network" database, representative of the population of the United Kingdom. This 
study showed a higher incidence of skin cancer in atopic patients, but it did not 
make it possible to establish a link between skin cancer and treatment for atopic 
dermatitis.  
 
- 
Hui (2009)42 studied safety in a retrospective cohort. Of the 11,961 cancer cases 
reported between 2001 and 2005, no difference was observed for all forms of 
cancer combined between patients exposed or not exposed to calcineurin inhibitors 
after adjustment according to age and sex.  
 
- 
Schneeweiss 43 studied a cohort of 1,252,300 patients, to assess the risk of 
lymphoma during treatment with tacrolimus, pimecrolimus or corticosteroids. 
Compared to the general population, these three treatments were associated with 
an increased risk of occurrence of lymphoma. Compared to patients with untreated 


 
Page 20 of 64 
atopic dermatitis, however, the three treatments were not associated with an 
increased risk of lymphoma. 
 
An open-label multicenter trial in children has been performed to evaluate safety. Skin 
infections occurred in 26% of patients. A burning sensation with product application, 
reported by 38% of patients, was transient and of mild-to-moderate severity in most 
cases. They concluded that Tacrolimus 0.1% ointment was safe, well-tolerated, and 
efficacious in the treatment of atopic dermatitis in children over the age of six months 
and adults 44. 
 
Long-term safety was studied in a systematic review of published trials with long term 
treatments (at least 12 weeks)45 . Data from 9 trials using tacrolimus were collected 
i.e. 1370 patients, treatment duration varied from 12 weeks to 5 years. This review 
supports the long-term safety with no evidence of cutaneous atrophy or cumulative 
systemic exposure and no reports of lymphoma45. 
 
1.3.3.2 Mucosae 
To evaluate the tolerability of tacrolimus on mucosae (tacrolimus 0.3 mg g(-1) 
ointment), in the treatment of chronic plaque psoriasis affecting facial and 
genitofemoral regions, a double-blind, parallel, 6-week study was carried out on 50 
patients who were randomized in a 1 : 1 ratio to apply calcitriol or tacrolimus twice 
daily. The authors concluded that both calcitriol 3 microg g(-1) and tacrolimus 0.3 mg 
g(-1) are safe and well-tolerated therapeutic agents in the treatment of psoriasis in 
sensitive areas. Tacrolimus demonstrated a more effective clinical outcome compared 
with calcitriol. 46 
 
Tolerability has been evaluated in the treatment of oral lichen planus (OLP). Corrocher 
reported in the group treated with tacrolimus, nine of 16 patients (56.3%) who had an 
initial worsening of burning sensation during the first 2 days of treatment. However, it 
resolved rapidly within 4–5 days as OLP improved47, Vohra et al reported a transient 
burning sensation by seven patients (six in the tacrolimus and one in the pimecrolimus 
group), and two patients complained of dysgeusia following tacrolimus application. No 
serious adverse effects necessitating stopping treatment were recorded in the two 
groups.48. More recently, Arduino et al published a randomized study treated with 
tacrolimus or piperolimus. Among them, in the tacrolimus group, two patients reported 
mucosal burning sensation during the first days of the therapy and one reported a 
transient sialorrhoea. In the pimecrolimus group, two patients reported xerostomia, two 
experienced episodes of gastroesophageal reflux and one the recurrence of two 
lesions of herpes labialis. None of these adverse effects was severe enough to require 
discontinuation of therapy. There were no statistically significant differences between 
the two groups in the incidence of adverse effects49 and Sonthalia et al compared the 
efficacy of clobetasol propionate (0.05%) ointment or tacrolimus (0.1%) ointment for 
eight weeks in 40 patients. None of the patients in either group showed any abnormality 
in hematological or biochemical parameters at eight weeks of treatment and no severe 
adverse events were reported. The majority of patients in both treatment groups 
reported good local tolerance to the topical drugs. Three patients in the tacrolimus 
group (15%) and three in the clobetasol group (15%) complained of a transient burning 
sensation following the application of the ointment, which lasted for a few seconds to 
a few minutes and did not necessitate the discontinuation of therapy. No patient 


 
Page 21 of 64 
developed any clinically detectable atrophy, pigmentation, telangiectasia, or any type 
of allergic reaction.50 
1.3.3.3 Ophtalmic 
Tacrolimus ointment can be used by ophtalmic route for ocular diseases treatments, 
several studies were published:  
Barot RK 51 studied effect 0.1% tacrolimus ointment in allergic ocular diseases on 36 
patients. 
Fukushima A52 investigated efficacy of topical 0.1% tacrolimus eye drops for allergic 
ocular diseases on a cohort of 1436 patients.  
Chatterjee S53 in an open-label study enrolled 30 patiens with  vernal 
keratoconjunctivitis, they were treated with 0.03% tacrolimus eye ointment for at least 
4 weeks. 
Shoughy S54 studied efficacy and safety of topical tacrolimus 0.01% solution on 62 
patients with vernal keratoconjunctivitis.  
In all cases the treatment was well tolerated, no serious adverse event was observed, 
the most common adverse reaction was a transient burning sensation, rare corneal 
infections were described, one bacterial corneal ulcer and one trachoma. 
1.3.4 Pharmacokinetic and systemic absorption 
Data from healthy human subjects indicate that there is little or no systemic exposure 
to tacrolimus following repeated topical application of tacrolimus ointment. As systemic 
exposure is low with tacrolimus ointment, the high binding of tacrolimus to plasma 
proteins is not considered to be clinically relevant. The metabolism of tacrolimus by 
human skin was not detectable. Systemically-available tacrolimus is extensively 
metabolized in the liver via CYP3A4. Following repeated topical application of the 
ointment, the average half-life of tacrolimus was estimated to be 75 hours for adults 
and 65 hours for children.36  
Several studies in infants55,56 on the pharmacokinetics of tacrolimus after first and 
repeated application showed minimal systemic exposure. 92% of blood samples 
contained tacrolimus concentrations of less than 1 ng per mL and 17% of samples 
were less than 0.025 ng per mL (lower limit of quantification). These values are minimal 
compared with an oral dose after a liver transplant. Systemic exposure to tacrolimus 
increased in proportion to the size of the body surface treated, and decreased with 
time as the skin lesions healed. There was no evidence of systemic accumulation. 
Further to an administration on mucosae, pharmacokinetic was evaluated in two 
clinical trials and no systemic absorption was detected47,49. 
 
1.4 Tacrolimus and HHT 
In vitro, Albinana et al.57 reported the efficacy of tacrolimus (FK506) in increasing ENG 
and ALK1 protein levels at the surface of endothelial cells; it also increases the 
expression of ENG and ALK1 mRNA and ENG and ALK1 promoter activity in cultured 
endothelial cells, and enhances the TGF-β1/ALK1 signaling pathway and endothelial 
cell functions such as tubulogenesis and migration. 


 
Page 22 of 64 
Furthermore, we know that after HHT patients have had a liver transplant for hepatic 
AVMs and high-output cardiac failure, their epistaxes improve dramatically 58 and 
mucosal bleeding stops. Their hemoglobin levels normalize and cutaneous and 
gastrointestinal telangiectases disappear.  
This suggests that the immunosuppressive therapy might have had anti-angiogenic 
effects on the telangiectases 59, and that the mechanism of action of FK506 involves a 
partial correction of endoglin and ALK1 haploinsufficiency. It may therefore be an 
interesting drug for use in HHT patients. 
 
It has recently been reported (HHT Meeting, Florida 2015) by Feige et al., in the 
HHTreat project that aims to identify new drugs that could be of interest in the treatment 
of HHT patients, that tacrolimus would be a good candidate.  
 
The antiangiogenic effect of tacrolimus has been demonstrated in other vascular 
diseases. In vitro, in pulmonary artery endothelial cells (ECs) from patients with 
idiopathic pulmonary arterial hypertension (PAH), low-dose FK506 reversed 
dysfunctional BMPR2 signaling. In mice with conditional Bmpr2 deletion in ECs, low-
dose FK506 prevented exaggerated chronic hypoxic PAH associated with the 
induction of the EC targets of BMP signaling, such as apelin. Low-dose FK506 also 
reversed severe PAH in rats with medial hypertrophy following monocrotaline and in 
rats with neointima formation following VEGF receptor blockade and chronic hypoxia. 
These data indicate that low-dose FK506 could be useful in the treatment of PAH. 35.  
More recently, sirolimus (rapamycine), which also binds FK-binding protein-12 
(FKBP12), is safe and efficient in the treatment of Blue rubber bleb nevus syndrome, 
a rare multifocal venous malformation syndrome involving predominantly the skin and 
gastrointestinal tract60 or other vascular malformations61.  
A recent study on corneal neovascularization in rabbits compares the antiangiogenic 
effects of tacrolimus and bevacizumab. They conclude that topical or subconjunctival 
administration of tacrolimus reduces experimental CNV, shown by the decreased 
levels of VEGF, macrophages, TNF-, IL-1β and MCP-1.62 
 
2 
Justification for the study 
2.1 Rationale for the study  
To date, no surgical treatment has made it possible to significantly decrease 
nosebleeds – the most common complication of the disease, responsible for significant 
morbidity – in the medium to long term in patients with HHT. Moreover, surgical 
treatments are aggressive for the nasal mucosa and risk perforating the nasal septum. 
Intra-venous anti-VEGF treatment is efficient on epistaxis 1, but its use is limited to 
severe forms of the disease, and local administration (nasal spray) recently evaluated 
in a phase 2 study is not efficient (NCT02106520)63.  
Improved epistaxes have been observed in HHT patients after a liver transplant. It was 
hypothesized that the immunosuppressive treatment (FK506) used to prevent rejection 
may have an anti-angiogenic effect. 
A topical nasal administration of tacrolimus could be an easy local ENT treatment that 
is non-aggressive and results in little trauma for the patient in relation to other first line 
treatment possibilities. Moreover, a galenic ointment with tacrolimus is available on the 
market. 


 
Page 23 of 64 
 
2.2 Safety and rationale for the pharmaceutical form, means of 
administration and doses used 
The pharmaceutical form retained for this phase II study is an ointment: Protopic® 
0.1%, packaged in tubes of 30 g. This marketed product (market authorization 
EU/1/02/201/003) is precribed to treat severe atopic dermatitis. 
In the study, this ointment can be use as is in the nose. 
 
Nasal administration of tacrolimus ointment and its safety is unknown. Nevertheless 
data published on mucosae and ophtalmic route are encouraging, tacrolimus ointment 
is generally well tolerated including long-term treatments. Burning sensation is the 
most common reaction but it is transient and usally without treatment interruption. 
 
As safety and pharmacokinetics have been extensively studied in dermatitis, we 
decided to use the same posology, i.e. twice daily. 
For a nasal administration, the quantity applied will be about 0.1 g in each nostril; it 
represents 0.4 g of ointment per day i.e. 0.4 mg of tacrolimus. 
In order to show efficiency, the treatment period has to be long enough to heal lesions 
responsible for epistaxis and to decrease vascularization. The longer period treatment 
recommended on SmPC has been chosen, that is to say 6 weeks.  
 
The risk of systemic effect is limited because of the low doses prescribed. The 
administered dose is 0,4 g of ointment per day, that is to say 0,4 mg of tacrolimus per 
day.   
Transplant patients treated with tacrolimus by oral route receive a dose from 0,1 to 0,2 
mg / kg / day (i.e. 5 to 10 mg per day for a 50 kg person). The dose on IV route is 0,01 
to 0,05 mg/kg/day (i.e. 0,5 to 3 mg per day for a 50 kg person). 
Although systemic absorption was not observed after administration on mucosae47,49, 
if a systemic absorption occurs, no adverse reactions are expected given the low doses 
and the good tolerance of tacrolimus per os. 
 
It should be noted that the risk of surdosage is very low in this study, since the 
application of ointment in the nose can cause discomfort for the patient, it is unlikely 
that the patient will increase the doses to be administered. 
 
Tacrolimus systemic absorption will be monitored in this study. FK506 dosages in 
blood are scheduled at Day 8, 22 and 43. Analysis will be centralized in “Hospices 
Civils de Lyon”.  
After transplantation , the optimal trough blood concentrations are generally between 
5.0 and 15.0 ng/mL64 and should be maintained below 20 ng/mL. 
In the present study, no systemic absorption and effect are expected. However in case 
of positive dosage, from 5 ng/mL and above, the laboratory will immediately inform the 
investigator who will ask the patient to stop treatment.  
In case of dosage higher than 20 ng/mL, the laboratory will immediately inform the 
investigator who will ask the patient to stop treatment and the patient will be 
hospitalized. 
 
The placebo formulation is strictly identical to Protopic: it contains all the ingredients 
except tacrolimus. The packaging is similar. The posology is also twice daily.  
 


 
Page 24 of 64 
2.3 Rationale for the methodology 
The methodology retained for this efficacy (phase II) study is a randomized trial, which 
is the design presenting the highest level of evidence.  
 
We started to assess parameters by comparing data collected at 3 visits: 
 
Visit 1: inclusion, data collected for 6 weeks before treatment and during the 
visit 
 
Visit 2: end of treatment, data collected during the 6 weeks preceding the 
visit (i.e. 6 weeks of treatment) and during the visit 
 
Visit 3: end of study, data collected during the 6 weeks preceding the visit 
(i.e. 6 weeks following the end of treatment) and during the visit. 
 
In addition, data are collected on pharmacokinetic at Day 8 and Day 22 
(blood sample) and on safety at Day 15 and Day 31 (phone call). 
 
 
 
  
Figure 4 General diagram of the study 
 
For safety reasons, as no tolerance data are available with a nasal administration, we 
decided to include patients sequentially. We designed an inclusion scheme in 3 or 4 
steps. An independent safety committee will give its recommandations on the 
continuation of the study. 
 
The theoretical inclusion scheme is described as follows. It was established 
pragmatically based on our sample size. 
We consider that a cessation of treatment for at least 8 consecutive days, for safety 
concern, that is to say adverse reaction due to the ointment, is a major issue.  
 
 STEP 1-  8 patients will be included in Lyon. 
On day 31 (phone call): information regarding adverse events (AE), severe adverse 
events (SAE) and observance of the treatment for the first 30 days of treatment are 
collected for these 8 patients. 
Based on these data, a DSMB meeting (#1) will be consulted and will give its 
recommandations on the continuation of the study according to the following 
theoretical scheme: 
 


 
Page 25 of 64 
 
 
 
 
If there is no imbalance between arms (difference < 1), the total number of patient who 
stop treatment at least 8 consecutive days will be consider (semi-blind data transmitted 
to DSMB): 
 
   < 4 patients in both arms  inclusion of 16 new patients (Step 2A) 
   > 4 patients in both arms  inclusion of  8 new patients (Step 2B) 
 
Note: if a large number of patients stopped the treatment for at least 8 consecutive 
days, the hypothesis will be that the ointment form is not well accepted. Then we 
consider it is worthwhile to check this point by including 8 additionnal patients. 
 
If there is an imbalance between arms (difference > 1), (unblinded data will be 
transmitted to DSMB): 
 
- 
 The number of “stops” is higher in the placebo arm 
    If “0” or “1” patients in active arm stop treatment  inclusion of 16 new 
patients (Step 2A) 
    If “2” patients in active arm stop treatment  inclusion of 8 new patients 
(Step 2B) 
 
- 
The number of “stops” is higher in the active arm 
   If difference between arms is 2  inclusion of 8 new patients (Step 2B) 
   If difference between arms is over 2  inclusions may be discontinued 
(Step 2C). 
 
 
The first 8 patients will be included in the Lyon center. Further inclusions will take place 
in all centers. 
 
0
1
2
3
4
0
0
1
2
3
4
1
1
2
3
4
5
2
2
3
4
5
6
3
3
4
5
6
7
4
4
5
6
7
8
ARM PLACEBO
ARM 
ACTIV
Number of patient who 
stop treatment for 8 
consecutive days
No imbalance between arms
Imbalance between arms active>placebo
Imbalance between arms placebo>active
0
+ 16 patients
0
+ 8 patients
0
Stop
The numbers inside 
the table 
= 
total number of 
events in both arms 


 
Page 26 of 64 
For the following steps, we consider the total number of patients who have a cessation 
of treatment for at least 8 consecutive days for safety concerns. Indeed, if 50% or more 
of patients are “in failure”, the continuation of the study may be called into question and 
the analysis on the main judgement criteria will then not be relevant. 
 
 STEP2 – Following inclusions, all centers 
 
STEP 2A- In case of inclusion of 16 new patients. 
For these 16 patients, on day 31 (phone call): information regarding adverse events 
(AE), severe adverse events (SAE) and observance of the treatment for the first 30 
days of treatment are collected. Additionally, safety assessment is carried out on the 
data collected at the visit after the end of treatment for the first 8 patients. 
Based on these data, a DSMB meeting (#2) will be consulted and will give its 
recommandations on the continuation of the study according to the following 
theoretical equations: 
 
 If less than 12 of the 24 patients stop treatment for 8 consecutive days due to 
safety concerns, 24 new patients will be included (Step 3A). Total number of 
patients included: 8 + 16 + 24 = 48. 
 If 12 or more patients stop treatment for at least 8 consecutive days due to 
safety concerns,  depending on the group imbalance, the DSMB may request 
the lifting of the blind and inclusions may be discontinued (Step 3B). Total 
number of patients included: 8 + 16 = 24. 
 
STEP 2B- In case of inclusion of 8 new patients. 
For these 8 patients, on day 31 (phone call): information regarding adverse events 
(AE), severe adverse events (SAE) and observance of the treatment for the first 30 
days of treatment are collected. Additionally, safety assessment is carried out on data 
collected at the visit after the end of treatment for the first 8 patients. 
Based on these data, a DSMB meeting (#2) will be consulted and will give its 
recommandations on the continuation of the study according to the following 
theoretical equations: 
 If less than 8 patients stop treatment for 8 consecutive days due to safety 
concerns, 16 new patients will be included (Step 3C). 
 If 8 or more patients stop treatment for at least 8 consecutive days due to safety 
concerns, depending on the group imbalance, the DSMB may request the lifting 
of the blind and inclusions may be discontinued (Step 3D). Total number of 
patients included: 8 + 8 = 16. 
 
 STEP3 – Following inclusions, all centers 
 
STEP 3A- Inclusion of 24 new patients, total number of patients included = 48 
 
STEP 3C- In case of inclusion of 16 new patients. 
For these 16 patients, on day 31 (phone call): information regarding adverse events 
(AE), severe adverse events (SAE) and observance of the treatment for the first 30 
days of treatment are collected. Additionally, safety assessment is carried out on data 
collected at the visit after the end of treatment for the first 16 patients. 
Based on these data, a DSMB meeting (#3) will be consulted and will give its 
recommandations on the continuation of the study according to the following 
theoretical equations: 


 
Page 27 of 64 
 If less than 16 patients stop treatment for 8 consecutive days due to safety 
concerns, 16 new patients will be included (Step 4A). 
 If 16 or more patients stop treatment for at least 8 consecutive days due to 
safety concerns, depending on the group imbalance, the DSMB may request 
the lifting of the blind and inclusions may be discontinued (Step 4B). Total 
number of patients included: 8 + 8 + 16 = 32. 
 
 STEP4 – Following inclusions, all centers 
 
STEP 4A- Inclusion of 16 new patients, total number of patients included = 48 
 
 
 
 
 
 
 
Figure 5: Inclusions flow chart 
 
3 
Objectives  
3.1 Main objective 
To evaluate, at 6 weeks after the end of the treatment, the efficacy of tacrolimus nasal 
ointment on the duration of nosebleeds when administered for 6 weeks in patients with 
HHT complicated by nosebleeds. 
 
Inclusion
8 patients
2A
inclusion 
+16 patients
total : 8+16=24
3A
inclusion 
+24 patients
total: 8+16+24=48
3B
inclusion 
discontinuation
2B
inclusion
+8 patients
total: 8+8=16
3C
inclusion 
+ 16 patients
total: 8+8+16= 32
4A
inclusion 
+16 patients
total: 8+8+16+16= 48
4B
inclusion
discontinuation
3D
inclusion 
discontinuation
2C
inclusion 
discontunation
STEP 1 
STEP 2 
STEP 3 
STEP 4 
D
S
M
B
1 
D
S
M
B
2 
D
S
M
B
3 


 
Page 28 of 64 
3.2 Secondary objectives 
The secondary objectives are to evaluate: 
4. Tolerance of tacrolimus nasal administration for 6 weeks, throughout the study. 
5. Efficacy of the treatment on progress in the  
  clinical parameters:  
 Nosebleed duration, 
 Number of nosebleeds,  
 Number of transfusions of red blood cells. 
 Quality of life 
 ESS = Epistaxis Severity Score 
  biological parameters: hemoglobin and serum ferritin concentrations 
These parameters will be evaluated at the end of the 6 weeks of treatment (V2) 
and at the end of 6 weeks of follow-up (V3). 
6. Systemic absorption after nasal administration. 
 
4 
Methodology 
4.1 Outline of the experiment 
This is a multicenter, randomized study carried out in double blind. For all patients, 
monitoring will be for 12 weeks (6 weeks’ treatment + 6 weeks’ follow-up). 
 
 
4.1.1 
Monitoring the patients  
The tacrolimus ointment will be delivered at the centers participating in the study during 
the first visit after verifying the inclusion criteria. A phone call is scheduled on day 31, 
i.e. 30 days after the beginning of the treatment, to monitor the safety of the treatment. 
Patients will have two medical visits: at the end of the treatment and after 6 weeks of 
follow-up. 
A scientific committee and an independent monitoring committee will be set up (see 
paragraph 12.1 & 12.2). 
A specific management procedure is envisaged for each expected complication (see 
paragraph 7.3). 
 
4.1.2 
Patient selection 
Patients in the HHT network will thus be informed of the study in progress during a 
standard ENT consultation or in the Reference Center or Skill Center.  
Patients will be included (the consent form will be signed) on the day of the treatment 
is prescribed. 
Subjects will be attributed a number in relation to their chronological inclusion. 
 
4.1.3 
Duration of the study 
The duration of the inclusion period will be maximum 18 months. 


 
Page 29 of 64 
The duration of participation per patient will be 12 weeks (6 weeks’ treatment + 6 
weeks’ of follow-up). 
The total duration of the study will thus be maximum 21 months. 
 
Figure 6: Schedule 
4.2 Patients 
4.2.1 
Recruitment and feasibility 
Aspects to ensure the feasibility of the project 
 Network coordinated by the reference center (over 2000 patients followed 
regularly). The cohort of patients followed for HHT in the Lyon reference center 
is around 1,000 patients. At the national level, more than 2,000 patient files are 
currently included in the database. Of these patients, at least 25% present with 
nosebleeds that justify ENT management. 
 The complication targeted by the treatment (epistaxis) is frequent, present in 
95% of patients over the age of 50. 
 Previous studies conducted by the Reference center, including Metafore 
published in 2012,1 Ellipse published in 201465 and Alegori published in 201663. 
 The support of the patients’ association (AMRO) and the high expectations of 
the patients. 
 
4.2.2 
Number of patients 
We intend to randomize 48 patients. 
 
M1
M2
M3
M4
M5
M6
M7
M8
M9 M10 11M M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22
1 - Inclusion
Follow up 
8D31
)
D85
Monitoring
M
2A
J

16D31
)
D85
M
3A
J

24
D31
)
D85
DSMB 2
M
Analysis
3B
L

2B
K

8D31
)
D85
M
3C
J

16
D31
)
D85
M
DSMB 2
4A
J

16
D31
)
D85
DSMB 3
M
Analysis
4B
L

3D
L

2C L

STOP N=24 (8+16)
N=48 (8+16+24)
Year 1
Year 2
DSMB 1
N=number of 
patients 
included
STOP N=32 (8+8+16)
STOP N=16 (8+8)
STOP N=8
N=48 (8+8+16+16)


 
Page 30 of 64 
4.2.3 
Modalities for recruitment, inclusion and follow-up 
Recruiting and informing the patients of the study in progress will take place during a 
standard ENT consultation or in the Reference Center or Skill Center for HHT. 
Patients will be included on the day the treatment is prescribed. 
The treatment is self-administered by patients, twice daily, for 6 weeks. 
The follow-up period will be scheduled as follows: 
- 
at each consultation, an ENT examination and a clinical examination including 
measurement of heart rate and blood pressure will be performed 
 
 
 
Figure 7: Diagram of the running of the study 
 
4.2.4 
 Inclusion criteria 
- Age ≥ 18 years. 
- Patients who have given their free, informed and signed consent.  
- Patients affiliated to a social security scheme or similar. 
- Patients monitored for clinically confirmed HHT (presence of at least 3 Curaçao 
criteria) and/or confirmed by molecular biology. 
- Patient presenting nosebleeds with total duration > 30 minutes for 6 weeks prior to 
the time of inclusion justified by completed follow-up grids. 
4.2.5 
Exclusion criteria 
- Women who are pregnant or nursing (lactating),  women of child-bearing potential 
without reliable contraception. 
- Patients not affiliated to a social security scheme. 
- Patients who are protected adults under the terms of the law (French Public Health 
Code). 
- Refusal to consent.  
- Patients for whom the diagnosis of HHT has not been confirmed clinically and/or by 
molecular biology. 
- Participation in another clinical trial wich may interfere with the proposed trial 
(judgment of the investigator). 


 
Page 31 of 64 
- Patients who have undergone nasal surgery in the 6 weeks prior to inclusion. 
- Known hypersensitivity to macrolides in general, to tacrolimus or to any of the 
excipients. 
- Patient with an inherited skin barrier disease such as Netherton’s syndrome, lamellar 
ichtyosis, generalized erythroderma, graft-versus-host skin disease, or suffering from 
generalized erythroderma. 
- Patient with CYP3A4 inhibotors treatment, e.g. erythromycin, itraconazole, 
ketoconazole and diltiazem. 
- Patients who have incompletely filled in the nosebleed grids in the 6 weeks preceding 
the treatment. If there is missing data for more than 7 days (10%), the patient cannot 
be included. 
- Patients who do not present nosebleeds with a total duration of > 30 minutes for 6 
weeks prior to the time of inclusion. 
- Patients with ongoing immunosuppressive treatment 
- Patients with known and symptomatic immune deficiency. 
 
4.3 Assessment criteria for the study product 
4.3.1 
Main judgement criterion 
The main judgement criterion is the percentage of patients experiencing an 
improvement in their nosebleeds. An improvement is defined as a 30% reduction in 
the total duration of nosebleeds over 6 weeks after treatment, compared with the 
duration of the nosebleeds in the 6 weeks before the treatment. 
 
4.3.2 
Secondary judgement criteria 
1. Adverse Events (AE) and Severe Adverse Events (SAE) observed throughout the 
study (clinical examination, epistaxis grids, ENT examination at each visit before 
and after the treatment). Additionally, all patients are contacted by phone after 15 
and 30 days of treatment in order to collect data on tolerance and observance of 
the treatment. 
2. Clinical efficacy criteria: 
- 
Nosebleed duration will be evaluated by the nosebleed monitoring grids 
completed by the patient (Appendix 1), collected at inclusion (V1): observation 
of the nosebleeds in the 6 weeks prior to inclusion, at the end of the treatment 
(V2): observation of the nosebleeds in the 6 weeks during treatment, and at the 
end of the study (V3): observation of the nosebleeds in the 6 weeks after the 
end of the treatment. 
- 
Progress in the number of nosebleeds. This criterion will be evaluated by the 
nosebleed monitoring grids completed by the patient (Appendix 1) collected at 
inclusion (V1): observation of the nosebleeds in the 6 weeks prior to inclusion, 
at the end of the treatment (V2): observation of the nosebleeds in the 6 weeks 
during treatment, and at the end of the study (V3): observation of the 
nosebleeds in the 6 weeks after the end of the treatment. 
- 
Comparison of the number of red blood cell transfusions between inclusion (V1) 
(collected over 6 weeks before treatment), the end of the treatment (V2) 
(collected over 6 weeks of treatment) and at the end of the study (V3) (collected 
over 6 weeks after the end of the treatment). 
- 
Progress in the scores obtained in the SF36 quality of life questionnaire 


 
Page 32 of 64 
completed at inclusion (V1), at the end of the treatment (V2) and at the end of 
the study (V3).  
- 
Progress in the ESS (Epistaxis Severity Score) using data from the specific 
questionnaire (Appendix 2) completed at inclusion (V1), at the end of the 
treatment (V2) and at the end of the study (V3). 
Biological efficacy criteria: progress in hemoglobin and serum ferritin 
concentrations between inclusion (V1) and the end of the treatment (V2) and at the 
end of the study (V3). 
3. Systemic absorption, after 1, 3 and 6 weeks of nasal administration, will be 
evaluated by a tacrolimus dosage in the blood at the end of the treatment. 
Blood samples on EDTA are sent to the laboratory for a centralized analysis. A 
specific procedure is established to maintain the blind: the analysis results will not 
be transmitted as the study is ongoing, but may be provided on request at the end. 
Investigator will be informed in case of dosage above 5 ng/mL. 
 
If convenient, patients can connect to the Clinsight platform (Ennov Clinical), with a 
personal identification number, and complete on-line questionnaires (ESS and SF36) 
and epistaxis grids. Otherwise they will complete a paper form. 
4.4 Randomization, blinding and lifting the blind 
The randomization process will be centralized. Allocation of a randomization arm to a 
patient included will be made by IWRS (Interactive Web Response System), on the 
basis of a unique randomization list for all investigation centers.  
The lists of randomization will be pre-established, by the “Pole IMER” at the Hospices 
Civils de Lyon – Clinical Research Unit. 
 
Clinsight (Ennov clinical) software will be used to manage this study. 
During the inclusion visit, after verifying the inclusion criteria, the investigator connects 
to the platform to include the patients in the eCRF. This will assign an identification 
number. When inclusion is validated, the patient is randomized and a treatment code 
is allocated by the system. The treatment is then dispensed by the pharmacy at the 
Hospital Center.  
This will be a double blind study in which neither the patient nor the investigator will be 
aware of the nature of the treatment administered so as to annul any bias in the follow-
up and measurements.  
Tubes of Tacrolimus 0.1% or placebo will be identical and will have appropriate 
labeling.  
Should a serious adverse event occur, the main investigator, the co-investigators or 
the sponsor may request that the Anti-Poison Center in Lyon lift the blind 24h/24h (the 
phone number is written on the clinical trial participation card). The written detailed 
procedures for lifting the blind will be given to the investigators and the Anti-Poison 
Center in Lyon. 
All requests for unblinding must be justified. Most often, study drug discontinuation and 
knowledge of the possible treatment assignments are enough to treat a study patient 
who presents with an emergency condition. When the investigator asks for unblinding, 
he/she must provide patient identifying information, the date, and the reason for 
unblinding. The investigator will be informed of the details of the drug treatment.  


 
Page 33 of 64 
 
4.5 Modalities for premature termination of the treatment and 
withdrawal from the study 
If the treatment is prematurely or temporary stopped by the patient:  
 Due to complications linked to the product: intolerance or discomfort, the patient 
will not be replaced and will be followed-up as initially planned for the study. 
 Due to intercurrent events such as high temperature, rhinitis, etc. the patient 
may start ointment administrations again when the event turns out favorably and 
will be followed-up as initially planned for the study. 
 Due to reasons other than the onset of complications linked to the drug, such 
as for logistical reasons (for example, a patient’s work-related trips), the patient 
will not be replaced and will be followed-up as initially planned for the study. 
If a visit following treatment is not attended by the patient and cannot be rescheduled, 
this visit will be considered as absent and the next post-treatment follow-up visit will be 
scheduled according to the original timetable initially devised for this patient. There is 
no maximum number of post-treatment follow-up visits missed after which the patient 
will be withdrawn from the study, particularly in the case of complications. 
 
4.6 Rules for definitive termination 
4.6.1 
A research person terminates his or her participation in the study  
A patient’s participation in the study will be terminated should the patient withdraw his 
or her consent. Patients may withdraw their consent at any time in the course of the 
study. Their withdrawal from the research does not in any way change their relationship 
with the investigating doctor, who will propose medical follow-up that is adapted to their 
clinical condition. 
 
Patients will also stop the study treatment if they undergo nasal surgery or other 
procedures (such as local hemostatic matrix), as this may modify interpretation of the 
results. However, their follow-up will be maintained. 
 
4.6.2 
Termination of all or part of the research 
The research may be terminated either temporarily or definitively: 
- 
by decision of the main investigator, the sponsor or the Competent Authority; 
- 
in case of knowledge of data that could compromise the study for reasons 
concerning the safety of the patients; 
- 
in case of publication of new scientific data that bring the research into question. 
 


 
Page 34 of 64 
5 
Description, supply and management of the drugs 
5.1 General modalities of preparation and administration 
Marketed Protopic® 0.1% tubes of 30 g are used for this study. For the placebo, the 
manufacturing and filling is managed by an external pharmaceutical laboratory with 
GMP agreement. The placebo formulation is similar to the active ointment; it contains 
all the ingredients except the active one: tacrolimus. The product is provided in strictly 
identical tubes. The same masked label is placed on both batches in order to respect 
the blind. 
The ointment is self-administered by patient, twice daily, for 6 weeks. 
5.2 Treatment tested 
The treatment tested is tacrolimus, manufactured by the laboratories Astellas and 
commercialized as Protopic® (tube of 30 g) at 0.1% of tacrolimus. 
5.2.1 
Modalities for the preparation  
Commercialized tubes (30 g) of Protopic® 0.1% are used. Tubes are completely 
masked by a specific label. This process will be carried out by Unither pharmaceuticals, 
a Contract Manufacturing Organization located in Bordeaux (France). 
An additional label is attached with suitable information regarding the clinical trial, 
including the treatment code allocated. This labeling will be carried out by the 
Pharmacy at the Hospices Civils de Lyon. The tubes will be weighed before delivery 
to the patient. 
5.2.2 
Storage and conservation  
The shelf life of the product is two years. 
Tubes should be stored at room temperature, not above 25°C. 
5.2.3 
Return and destruction 
After the end of the administration period, the tubes will be returned to the pharmacy 
at the hospital center and will once again be weighed “after administration” so as to 
determine the exact quantity administered. The tubes will be conserved for the 
monitoring visits and destroyed in accordance with the procedures in force after 
sponsor authorization. 
 
5.3 Placebo 
The comparative treatment is the same formulation as the active product but without 
tacrolimus. 
5.3.1 
Modalities for preparing 
This product is manufactured for this study by Unither pharmaceuticals, a Contract 
Manufacturing Organization located in Bordeaux (France). The ointment is packed in 
strictly identical tubes to those of Protopic®, and covered by the masking label. 
An additional label is attached with suitable informations regarding the clinical trial, 
including the treatment code allocated. This labeling will be carried out by the 
pharmacy at the Hospices Civils de Lyon. The tubes will be weighed before delivery to 
the patients. 


 
Page 35 of 64 
 
 
5.3.2 
Storage and conservation of the placebo 
The shelf life of the product is two years. 
A certificate is provided by Unither pharmaceuticals, according to stability study results. 
The tubes should be stored at room temperature, not above 25°C. 
5.3.3 
Return and destruction 
After the end of the administration period, the tubes will be returned to the pharmacy 
and will once again be weighed “after administration” so as to determine the exact 
quantity administered. The tubes will be conserved for the monitoring visits and 
destroyed in accordance with the procedures in force after authorization. 
 
5.4 Associated treatments 
No other experimental drug for nosebleeds may be used during the study. If nasal 
surgery becomes necessary during the study, the patient will be withdrawn from the 
study. 
Systemically available tacrolimus is metabolized via hepatic Cytochrome P450 3A4 
(CYP3A4).The possibility of interactions cannot be ruled out and patients with ongoing 
treatment of CYP3A4 inhibitors (e.g. erythromycin, itraconazole, ketoconazole and 
diltiazem) will not be included in the study. 
All other concomitant treatments necessary for management of the patient will be 
authorized during the study and will be documented in the study’s data collection 
sheets. Recommendations will be given to patients in case of administration of another 
nasal treatment (see paragraph 6.2.1). 
5.5 Drug circuit 
5.5.1 
Supply 
Protopic® 0.1% tubes are ordered by the subcontractor: Unither pharmaceuticals, to 
carry out the blinding operation. 
For the manufacture of the placebo, all operations are managed by the subcontractor: 
Unither pharmaceuticals, supply of raw materials, manufacturing, filling, masking, and  
analytic control. 
Tubes of Protopic® and placebo are sent to the Central Pharmacy at the Hospices 
Civils de Lyon. They will be labeled, released and stored on their premises. 
The pharmacies in the centers participating in the study are supplied by the Central 
Pharmacy at the Hospices Civils de Lyon.  
5.5.2 
Dispensing the study products by the hospital pharmacy in the 
centers participating in the study 
The doctor investigator prescribes Protopic® 0.1% or placebo on the specific 
prescription sheet for the study. The information provided by the doctor will be:  
- 
date of the prescription; 
- 
surname, forenames and date of birth of the patient using a patient sticker; 


 
Page 36 of 64 
- 
The patient’s identification number. 
- 
The treatment code. 
The original of the prescription will be taken to the hospital pharmacy of the Hospital 
Center. The product allocated is then dispensed. 
Before delivery, the tube is weighed. It will be weighed again after its return to calculate 
the total quantity administered. These data processed by the pharmacies will be 
available if necessary. 
One tube is delivered to each patient; a specific leaflet is included with 
recommendations and application modalities. 
All the traceability of the treatments used will be consigned to the prescription register 
specific to the trial at the HOSPITAL PHARMACY at the Hospital Center. 
 
5.6 Ointment tubes: presentation and supplier 
The primary packaging is a laminate tube with an inner lining of low-density-
polyethylene fitted with a polypropylene screw cap. 
Protopic® 0.1% is manufactured by Astellas pharma. 
The placebo formulation is manufactured by Unither Pharmaceuticals. 
6 
Practical running of the study 
6.1 General organization and study sites 
Patients will be recruited and informed during a standard consultation with the ENT 
doctor or doctor responsible in the reference center or skill center for HHT. Patients 
will be informed of the study and the need to complete nosebleed grids for ENT 
monitoring for the 6 weeks prior to the start of the treatment (Appendix 1: Nosebleed 
monitoring grid, a grid completed daily by patients). 
The inclusion of the patients will take place when they come for a consultation for 
prescription of the treatment.  
The treatment will be self-administered by the patient, twice daily, for 6 weeks. 
Two follow-up visits are organized, at the end of the 6 weeks of treatment, and 6 weeks 
after the end of the treatment, with medical consultations in the department responsible 
for coordinating HHT (Reference or skill center) and in the ENT department of each 
center. 
FK-506 dosage in blood are scheduled on Day 8, 22 and 43.  
A phone call is scheduled on day 15 and 31 (i.e. 14 and 30 days after the beginning of 
the treatment) in order to collect information regarding tolerance and observance. 


 
Page 37 of 64 
 
 
Figure 8: Diagram of the running of the study 
 
6.2 Inclusion visit (V1)  
Patients will be seen at a consultation for the treatment by a doctor and a clinical 
research assistant from the center if possible.  
At this visit: 
 The investigator will once again inform the patients about the study. 
 The nosebleed grids completed by the patient in the 6 weeks prior to the 
treatment will be collected (Appendix 1: Nosebleed monitoring grid). 
 The inclusion and exclusion criteria will be verified and the consent form will be 
signed. The investigator connects to the platform, includes the patient and an 
identification number will be assigned to the patient. 
 The patient will undergo a clinical examination, including blood pressure and 
heart rate.  
 A urinary pregnancy test will be performed for all female patients of child-bearing 
age. The investigator will inform these patients that there is no data available in 
pregnant women and they must use an effective contraceptive method 
(combined hormonal contraceptive, implant, intra-uterine device). The use of 
any other means, such as condom, will be left to the judgment of the 
investigator; the patient will have to give her commitment which will be recorded 
in the medical file. 
 The number of red blood cell transfusions in the 6 weeks prior to administration 
of the treatment will be noted (as noted by the patient on the nosebleed grids). 
 Any concomitant treatments will be noted. 
 
If all the criteria are validated:  
 The examination will be completed by a set of biological blood samples (2 x 5 
mL tubes) for hemoglobinemia and serum ferritin.  


 
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 An ENT examination will be carried out (Appendix 3: Monitoring ENT 
examination).  
 The ESS questionnaire is completed by patient (Appendix 2). 
 An SF36 quality of life questionnaire will be given to the patient for completion. 
 The nosebleed grids will be given to the patient for ENT monitoring during the 6 
weeks of treatment (Appendix 1: Nosebleed monitoring grid). Specific boxes are 
provided to mark the two daily administrations, in order to verify observance of 
the treatment. If convenient for the patient a connexion code can be provided to 
allow them to complete these grids online on eCRF. 
 Drug dispensation: The prescription for the drug will be made, and the product 
will be delivered by the pharmacist at the hospital. Patients are carefully 
instructed how to apply the medication throught an in vivo demonstration and a 
written description is provided with the product in which the modalities of 
application are reported. 
 A clinical trial participation card will be given to the patient. It will include phone 
numbers if needed and in case of emergency. Recommendations are given in 
case of the onset adverse events. 
 A specific prescription will be given to the patient for the dosage of FK506 in 
blood, one week and three weeks after the beginning of the treatment (i.e. on 
Day 8 and Day 22). Blood sample will be taken in a laboratory selected by the 
patient; the latter will send the tube in the biological laboratory for a centralized 
analysis. 
 
If the criteria are not validated, the patient may be asked to return at a later date if the 
inclusion criteria can be normalized. 
 
6.2.1 
Ointment administration 
The ointment is self-administered by the patient twice daily.  
About 0.1 g of product should be administered in each nostril. The tube is gently 
squeezed to extract an amount roughly equivalent to the size of the head of a cotton 
swab. 
 
The ointment is introduced into each nostril with a finger or a cotton swab. Patients can 
choose the most convenient way for them to administer the product. The product is 
extended inside the nostril with a cotton swab or/and by external pressure on the 
nostril. 
 
Should other nasal product be used, such as physiologic serum or gelositin for 
example, we recommend that the other product not be applied simultaneously but at a 
different time, for example two hours before or after the tested product. 
 
6.2.2 
Recommendations 
 
Patients will receive recommendations on how to contact the doctor in case of the 
onset of adverse events.  


 
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A burning sensation is frequently observed at the administration site; usually this 
sensation is acceptable and disappears after a few days of administration. 
In case of an adverse event probably due to the product: skin irritation, an 
unacceptable burning sensation, pruritus, and erythema, at the application site: 
 The patient must stop the treatment. 
 He or she must inform the investigator as soon as possible. 
 Based on symptoms, a medical consultation can be carried out by a general 
practitioner, a specialist or an investigator involved in the study. 
 The treatment can be reintroduced, or not, after clinical normalization. 
 It is up to the investigator to make the decision in the interest of the patient, on 
the basis of the balance between the risk of a new event and the risk of 
aggravation of the disease. 
The modalities for managing nosebleeds will be given to the patients to inform all 
doctors of the treatment of the nosebleeds specific to this disease. 
6.3 Phone calls on day 15, 14 days after the beginning of the 
treatment (up to day 18 tolerated) 
Patients will be contacted by phone, 14 days after the beginning of the treatment, to 
collect intermediate data regarding tolerance and observance. 
The following data will be collected: 
 Treatment observance: any interruption to the treatment interruption will be 
noted precisely (date, duration), as will the reason for the interruption. 
 Occurrence of adverse events: nature, date of onset, and whether or not a 
symptomatic treatment was given. 
 Any change in the concomitant treatments. 
 The date of the blood sample planned at day 8 (FK506 dosage). 
 
6.4 Phone calls on day 31, 30 days after the beginning of the 
treatment (up to day 37 tolerated) 
Patients will be contacted by phone, 30 days after the beginning of the treatment, to 
collect intermediate data regarding tolerance and observance. 
The following data will be collected: 
 Treatment observance: any interruption to the treatment interruption will be 
noted precisely (date, duration), as will the reason for the interruption. 
 Occurrence of adverse events: nature, date of onset, and whether or not a 
symptomatic treatment was given. 
 Any change in the concomitant treatments. 
 The date of the blood sample planned at day 22 (FK506 dosage). 


 
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6.5 Visit at the end of the treatment, V2 = at day 43 (up to day 50 
tolerated) 
The patients will be seen in consultation, in the Reference center or skill center for 
HHT. 
The following examinations/consultations will take place: 
 Clinical examination including blood pressure and heart rate. 
 Collection of the nosebleed grids completed by the patients during the 6 weeks 
of treatment (Appendix 1: Nosebleed monitoring grid), if not completed on line. 
These grids include monitoring of treatment administrations. 
 The ESS questionnaire is completed by patient (Appendix 2). 
 New nosebleed grids will be given to the patients for ENT monitoring during the 
next 6 weeks (Appendix 1: Nosebleed monitoring grid), if not completed online. 
 The number of red blood cell transfusions received by the patient in the last 6 
weeks will be noted.  
 Patients will return the product, it will be transmitted to the hospital pharmacy. 
 A set of biological blood samples (2 x 5 mL tubes) is collected: hemoglobinemia 
and serum ferritin.   
 A blood sample is collected (4 mL on EDTA) for tacrolimus dosage. 
 An SF36 quality of life questionnaire will be given to patients for completion. 
 Monitoring and collection of any adverse events. 
 Concomitant treatments will be noted. 
 
6.6 Visit after 6 weeks follow-up, V3 = at day 85 (up to day 100 
tolerated) 
The patients will be seen in consultation, in the Reference center or skill center for 
HHT. 
The following examinations/consultations will take place: 
 Clinical examination including blood pressure and heart rate. 
 Collection of the nosebleed grids completed by the patients during the 6 weeks’ 
follow-up after the treatment (Appendix 1: Nosebleed monitoring grid), if not 
completed online. 
 The ESS questionnaire is completed by the patient (Appendix 2). 
 The number of red blood cell transfusions received by the patient in the last 6 
weeks will be noted (as noted by the patient on the nosebleed grids). 
 A set of biological blood samples (2 x 5 mL tubes) is collected: hemoglobinemia 
and serum ferritin.   
 An SF36 quality of life questionnaire will be given to patients for completion. 
 Monitoring and collection of any adverse events. 


 
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 Concomitant treatments will be noted. 


 
Page 42 of 64 
 
6.7 Synopsis of the study per patient 
 
Inclusion 
V1 J0 
Blood sample 
D8 (to 10) 
Phone Call 
D15 (to 18) 
Blood sample 
D22 (to 24) 
Phone Call 
D31 (to 37) 
V2 
D43 (to 50) 
V3 
D85 (to 100) 
Inclusion / exclusion criteria 
x 
 
 
 
 
 
 
Epistaxis grids surrender 
x 
 
x 
 
x 
x 
 
Epistaxis grids collection 
x 
 
 
 
 
x 
x 
Consent Form signature 
x 
 
 
 
 
 
 
Pregnancy Test  
x 
 
 
 
 
 
 
Clinical examination (HR, BP) 
x 
 
 
 
 
x 
x 
ENT examination 
x 
 
 
 
 
x 
x 
Hémoglobinemia, serum ferrritin 
x 
 
 
 
 
x 
x 
FK 506 dosage 
 
x 
 
x 
 
x 
 
Treatment : protopic/placebo dispensation 
x 
 
 
 
 
 
 
Product return 
 
 
 
 
 
x 
 
Blood Cell transfusions collection 
x 
 
 
 
 
x 
x 
ESS questionnaire 
x 
 
 
 
 
x 
x 
SF36 Quality of life questionnaire  
x 
 
 
 
 
x 
x 
Concomitant treatment collection 
x 
 
x 
 
x 
x 
x 
Adverse events collection 
x 
 
x 
 
x 
x 
x 
 
Legend: D = dayV = visit 
Table 1: Synopsis of the study per patient


 
Page 43 of 64 
 
7 
Intercurrent events 
7.1 Definitions 
7.1.1 
Adverse event 
An adverse event (AE) is any untoward medical occurrence in a patient or clinical 
investigation patient administered a pharmaceutical product and which does not 
necessarily have to have a causal relationship with this treatment. 
An adverse event can therefore be any unfavourable and unintended sign (including 
an abnormal laboratory finding, for example), symptom, or disease temporally 
associated with the use of a medicinal product, whether or not considered related to 
the medicinal product. 
7.1.2 
Serious adverse event (SAE) 
A serious adverse event (SAE) is any untoward medical occurrence that at any dose: 
 Results in death  
 Is life-threatening (the term "life-threatening" in the definition of "serious" refers 
to an event in which the patient 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)  
 Requires in-patient hospitalization or prolongation of existing hospitalization  
 Results in persistent or significant disability/incapacity  
 Is a congenital anomaly/birth defect  
 Is a medically significant event: 
Medical and scientific judgment should be exercised in deciding whether expedited 
reporting is appropriated in situations, such as important medical events that may not 
be immediately life-threatening or result in death or hospitalization but may jeopardize 
the patient or may require intervention to prevent one of the outcomes listed in the 
definition above. 
The term “severe” is a measure of intensity, thus a severe adverse event is not 
necessarily serious. For example, “nausea of several hours” duration may be severe 
but may not be clinically serious. 
For “TACRO” study, any tacrolimus blood concentration resulting > 5ng/ml and 
any sign of infection under treatment should be considered as medically 
significant event and reported immediately by the investigator to the sponsor as 
a SAE. 
 
7.1.3 
Intensity 
The intensity of the event will be graded according to the following classification:  
 Mild (grade 1): Discomfort noticed but no disruption of normal daily activity 
 Moderate (grade 2): Discomfort sufficient to reduce or affect normal daily 
activity 
 Severe (grade 3): Incapacitating with inability to work or perform normal daily 
activity 
 Life-threatening (grade 4): Substantial risk of dying at time of event 
 Death: (grade 5) 
 


 
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7.1.4 
Adverse reaction 
An adverse reaction implies at least a reasonable possibility of a causal relationship 
between a suspected medicinal product and an adverse event. An adverse reaction, 
in contrast to an adverse event, is characterised by the fact that a causal relationship 
between a medicinal product and an occurrence is suspected.  
7.1.5 
Reference document for the experimental drug 
Reference document for the experimental drug n°1: Summary of Product 
Characteristics (SPC) for PROTOPIC 0.1% (tacrolimus). 
 
7.2 Responsabilities of the investigator 
7.2.1 
Adverse Events reporting  
All adverse events (AE) regardless of seriousness or relationship to Investigational 
Product that occurred after the informed consent up to 30 days after the last study 
drug administration are to be recorded in the AE pages of the Case Report Form 
(CRF). After this delay only fatal AE and adverse event related to the IMP must be 
recorded.  
Whenever possible, symptoms should be grouped as a single syndrome or diagnosis. 
The investigator should specify the date of onset, intensity, action taken regarding trial 
medication, corrective therapy given, outcome of all adverse events and his opinion as 
to whether the adverse event can be related to the study drugs and/or to concomitant 
drugs.  
All events that meet one or more criteria of seriousness will be reported as Serious 
Adverse Event. 
7.2.2 
General AE/SAE reporting rules:  
Any episode of any grade of toxicities, related to a Serious Adverse Event must be 
reported as “Adverse Event” in the appropriate CRF pages. 
Adverse events (serious or not) will not be recorded after the start of a new out-of-
study treatment or after disease progression. 
Planned hospital admissions or surgical procedures for an illness or disease which 
existed before the patient was enrolled in the study or before study drug was given are 
not to be considered SAEs unless the condition deteriorated in an unexpected manner 
during the study (eg surgery was performed earlier than planned). 
All adverse events which meet grade 3, 4 and 5 criteria must be reported immediately 
to the sponsor. 
7.2.3 
SAE declaration 
All defined Serious Adverse Events (SAEs) occurred after the informed consent 
up to 30 days after the last study drug administration, whether or not ascribed to 
the study, will be recorded in the Serious Adverse Event pages. After this delay only 
fatal SAE and SAE related to the IMP must be recorded.  
Serious Adverse Event (serious or not) will not be recorded after the start of a new out-
of-study treatment or after disease progression (fatal event excluded) 
All Serious Adverse Events must also be reported on the Adverse Event page of the 
CRF. 
In a case of Serious Adverse event The Investigator must immediately: 
 SEND, by fax, the SAE pages to  


 
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SAFETY DESK: 
FAX: +33 (0) 4 72 11 51 90 
All SAE forms must be dated and signed by the responsible Investigator 
or one of his/her authorized staff Members. 
 Attach the photocopy of all examinations carried out and the dates on which these 
examinations were performed. Care should be taken to ensure that the patient’s 
identity is protected and the patient’s identifiers in the Clinical study are properly 
mentioned on any copy of source document. For laboratory results, include the 
laboratory normal ranges. 
 Follow up of any Serious Adverse Event that is fatal or life threatening should be 
provided within one calendar week. 
For serious adverse events, the following must be assessed: relationship to test 
substance, action taken, and outcome to date. The relatedness with concomitant 
treatment must also be evaluated. The Causality is initially assessed by the 
investigator. For serious adverse events, causality can be one of two possibilities: 
 Unrelated  
 Related  
7.2.4 
Follow up of Adverse Events and Serious Adverse events  
 Any SAEs should be monitored until they are resolved or are clearly determined 
to be due to a patient’s stable or chronic condition or underlying condition. Any 
additional information known after the event has been initially reported should 
be sent to the SAFETY DESK as soon as information becomes available. 
 All adverse events must be documented and the outcome must be followed up 
until the return to normal or consolidation of the patient’s condition.  
  
7.3 Sponsor’s responsibilities 
During the course of the study, the Sponsor will report in an expedited manner all SAEs 
that are both unexpected and at least reasonably related to study drug, to the Health 
Authorities in each country in accordance with the law of March 5, 2012 international 
and local regulations, Ethics Committees, Clinical Trial Eudravigilance database and 
to the Investigators. 
The expectedness of an adverse reaction will be determined by the Sponsor according 
to the Summary Product Characteristics of PROTOPIC 0,1%®. 
The sponsor will report all safety information from the trial in the Annual Safety Reports 
and will notify the reports to the Health Authorities and Ethics Committees in 
accordance with international and local regulations. 
 
7.4 Specific management of complications 
7.4.1 
Nosebleeds 
Patients will have access to the standard management techniques for nosebleeds in 
HHT. ENT monitoring will be ensured before the start of administration, after 6 weeks 
of treatment and 6 weeks after the end of the treatment so as to note any modification 
to the nasal mucosa during the treatment (Appendix 3: ENT monitoring examination). 
The modalities for the management of nosebleeds will be given to the patients, as 
described in the “PNDS” (Protocole National de Diagnostic et de Soin), so that they 
may inform any doctor of the treatment modalities for the nosebleeds specific to this 


 
Page 46 of 64 
pathology. Emergency document (see Appendix 4), accessible on the internet 
http://www.favamulti.fr/wp-content/uploads/2016/05/37_RO-Epistaxis.pdf, is given to 
the patients. 
 
7.4.2 
Perforation of the nasal septum 
ENT monitoring will take place at each visit so as to note any modification to the nasal 
mucosa. Should there be any perforation of the nasal septum, the ENT monitoring will 
be prolonged until the perforation closes, as it generally does spontaneously.  
 
7.4.3 
Other complications associated with adverse events linked to 
topical tacrolimus 
Common complications linked to topical administration described in the Summary of 
Product Characteristics are burning skin, pruritus, skin erythema, skin tingling, 
folliculitis, acne, herpes simplex, hyperesthesia (increased skin sensitivity, especially 
to hot and cold) and alcohol intolerance (facial flushing or skin irritation after 
consumption of an alcoholic beverage). 
In case of the onset of a severe reaction, patients should stop product administration 
immediately. They must inform the investigator of the study as soon as possible and, 
if necessary, consult a doctor. 
Adapted management of the complication will be administered. 
 
7.4.4 
Tacrolimus systemic absorption 
Tacrolimus systemic absorption will be monitored in this study. FK506 dosages in 
blood are scheduled at Day 8, 22 and 43. Analysis will be centralized in “Hospices 
Civils de Lyon”.  
After transplantation , the optimal trough blood concentrations are generally between 
5.0 and 15.0 ng/mL64 and should be maintained below 20 ng/mL. 
In the present study, no systemic absorption and effect are expected. However in case 
of positive dosage, from 5 ng/mL and above, the laboratory will immediately inform the 
investigator who will ask the patient to stop treatment.  
In case of dosage higher than 20 ng/mL, the laboratory will immediately inform the 
investigator who will ask the patient to stop treatment and the patient will be 
hospitalized. 
Any sign of infection due to immunosuppressive action should be reported immediately 
to the sponsor as SAE. 
 
 
8 
Data management 
8.1 Electronic case report forms 
All the information required by the protocol must be provided on the eCRF and an 
explanation is given for any missing data. All clinical or paraclinical data have to be 
transferred to the electronic case report forms as soon as they are obtained. The form 


 
Page 47 of 64 
at the end of each visit must be dated and signed by the investigator thus indicating 
his or her approval of the data in the case report forms.  
 
The database (items defined on the basis of the electronic case report forms) will be 
put together in collaboration with the Clinical Research Unit at the Pole IMER (Dr F. 
Chapuis). 
 
8.2 Source documents 
The source documents are the original documents, the data and dossiers from which 
the data concerning the patients will be reported in an electronic case report forms 
(Clinsight). These data include, amongst other things, the results of examinations, 
monitoring of the patient at the hospital and/or medical notes, self-monitoring forms, 
dispensation notes and medical correspondence. 
The investigator must undertake to authorize direct access to the source data for the 
study during control visits, audits or inspections. 
 
8.3 Archiving 
The following documents concerning this research will be archived in the appropriate 
premises and locked in accordance with Good Clinical Practices for a period of 15 
years following the end of the research by those responsible for the study: 
- 
the original version of the consent forms signed by the participants, 
- 
the protocol and its appendices and any amendments made to the protocol, 
- 
electronic case report forms, 
- 
all the other documents and letters concerning the research. 
 
8.4 Electronic data management 
The Clinical Research Unit at the Pole IMER will develop an electronic Case Report 
Form to collect data for the study.  
The study data will be computerized in conformity with the law concerning electronic 
data, files and civil liberties (law 78-17 of January 6, 1978 modified by law 2004-801 
of August 6, 2004). Data access will be restricted. 
 
Electronic report forms will be available for each participating center. Electronic case 
report forms will be filled in via internet by the investigator. A user guide and online 
training will be available to investigators.  
The investigator is responsible for the accuracy, quality and relevance of all data 
captured. As such, any changes in value must be validated in the eCRF. Data changes 
will be drawn in an audit trail. 
Patients’ eCRF will be printed at the end of the study and will be archived by the 
investigator. 
 
When entering data, the system will immediately run consistency checks. 
Coherence controls will also be carried out using SAS software. 
 


 
Page 48 of 64 
9 
Statistics 
9.1 Number of participants 
 
We hypothesize that 60 % of patients will be improved in the treatment group against 
15 % in the placebo group. It is therefore necessary to include 22 patients in each 
group to reach an 80% power with a 5% alpha (bilateral), leading to 44 patients 
overall (Fisher exact test).  
Taking into account early withdrawal and patients who may be lost to follow-up, we 
are going to include 24 patients in each group, that is to say, a total of 48 patients. 
 
9.2 Statistical analysis plan 
The following section includes the main elements of the statistical analysis plan. This 
plan may be revised to take into account any amendments to the protocol and to make 
changes in order to adapt to the occurrence of unexpected events in the course of the 
study and which may have an impact on the analysis of the data. 
These possible revisions will be carried out before the database is frozen. 
 
At the end of the study, the data analysis will be carried out by the Clinical Research 
Unit at the Pole IMER (Department of Dr François Chapuis, Hospices Civils de Lyon), 
who will have the randomization codes. 
 
In case of scattered numbers of ointments across patients, the analyses would be 
repeated with an adjustment for the number of ointments or would be broken into 
subgroup analysis. 
 
9.2.1 
Analysis populations 
9.2.1.1 
“Efficacy” population in intention to treat 
This population will be composed of all the randomized patients. If patients stop the 
study treatment, their follow-up will be maintained in order to obtain the epistaxis grids. 
 
9.2.1.2 
“Efficacy” population per protocol 
This population will be composed of all the patients who have received all the 
treatments set out in the protocol. A treatment will be considered complete if the patient 
received at least a total of 60 administrations out of 84 (twice a day for 42 days) 
envisaged by the protocol. 
 
9.2.1.3 
“Safety” population 
This population will be composed of all the patients who have received at least one 
ointment. 
 


 
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9.2.2 
Statistical methods 
9.2.2.1 
Populations 
All the populations in the study will be presented with their numbers. 
 
9.2.2.2 
Deviation from the protocol 
Any deviation from the protocol that may have an impact on the results of the study will 
be listed. 
 
9.2.2.3 
Initial characteristics 
All the initial characteristics of the patients will be summarized by means of descriptive 
statistics (number, average, standard deviation, median, minimum and maximum for 
the quantitative variables and numbers and percentages for the qualitative variables).  
 
9.2.2.4 
Analysis of the main judgement criterion 
 
The percentage of patients experiencing improvement in their nosebleeds will be 
computed in each group. An improvement is defined as a 30% reduction in the total 
duration of nosebleeds over 6 weeks after treatment, compared with the duration of 
the nosebleeds in the 6 weeks before the treatment. 
The percentage of the two groups will be compared using a Fisher exact test, and the 
analysis will be performed on the intention to treat population.  
Patients who stopped the treatment but who have epistaxis grids will be analyzed using 
their data. Patients who withdraw from the study before completing the follow-up will 
be considered as failures. 
A descriptive listing will present for each patient: the duration of nosebleeds before 
treatment, during treatment, after treatment, the treatment group, the number of 
consecutive days of treatment, the total number of days of treatment. 
 
9.2.2.5 
Analysis of the secondary judgement criteria 
 
All AE and SAE will be coded with MedDRA. Each adverse event observed between 
inclusion and the end of follow-up will be listed by frequency in each group. Then, the 
percentage of patients with at least one adverse event, or at least one severe adverse 
event will be computed and compared between the 2 groups. A list and verbatim of 
severe adverse events will be provided. All analyses will be performed on the safety 
population. 
 
Efficacy criteria: 
- 
The total duration of nosebleeds will be presented in each group for the 3 
periods (6 weeks before treatment, 6 weeks of treatment, 6 weeks’ follow-up 
after treatment). The relative evolution in duration of nosebleeds will be 
computed by subtracting the baseline value from the V2 value (end of treatment) 
and the V3 value (end of study). The delta from inclusion (V3/V1 & V2/V1) in 
total duration will be compared between the 2 groups using student t-tests (or 


 
Page 50 of 64 
Mann-Withney tests in case of non normality).  Mixed models will be produced 
to compare evolution between the groups. 
- 
The number of nosebleeds will be presented in each group for the 3 periods (6 
weeks before treatment, 6 weeks of treatment and 6 weeks’ follow up after the 
end of treatment). The relative evolution in duration of nosebleeds will be 
computed by subtracting the baseline value from the V2 value (end of treatment) 
and the V3 value (end of study). The delta (V3/V1 & V2/V1) in number will be 
compared between the 2 groups using student t-tests (or Mann-Withney tests 
in case of non normality). Mixed models will be produced to compare evolution 
between the groups. 
- 
The number of red blood cell transfusions will be presented in each group for 
the 3 periods (6 weeks before treatment, 6 weeks of treatment, 6 weeks’ follow-
up after treatment). The relative evolution in the number of red blood cell 
transfusions will be computed by subtracting the baseline value from the V2 
value (end of treatment) and the V3 value (end of study). The delta (V3/V1 & 
V2/V1) in number of red blood cell transfusions will be compared between 
groups using student t-tests (or Mann-Withney tests in case of non normality). 
Mixed models will be produced to compare the evolution between groups. 
- 
The physical component and mental component of the SF36 and its domains 
will be presented in each group at inclusion, at the end of the treatment and at 
the end of the study. The relative evolution in SF36 (overall and per item) will 
be computed by subtracting the baseline value from the V2 value (end of the 
treatment) and the V3 value (end of the study). The delta (V3/V1 & V2/V1) in 
components and in each SF36 domain will be compared between groups using 
student t-tests (or Mann-Withney tests in case of non normality). Mixed models 
will be produced to compare evolution between the groups. 
- 
The ESS will be presented for each group at inclusion, at the end of the 
treatment, and at the end of the study. The relative evolution in ESS will be 
computed by subtracting the baseline value from the V2 value (end of treatment) 
and the V3 value (end of study). The delta (V3/V1 & V2/V1) in ESS will be 
compared between groups using student t-tests (or Mann-Withney tests in case 
of non normality). Mixed models will be produced to compare evolution between 
the groups. 
- 
The biological values (hemoglobin and serum ferritin) will be presented in each 
group at inclusion, the end of the treatment and the end of the study. The relative 
evolution in hemoglobin and ferritine levels will be computed by subtracting the 
baseline value from the V2 value (end of treatment) and the V3 value (end of 
study). The delta (V3/V1 & V2/V1) in biological measures will be compared 
between groups using student t-tests (or Mann-Withney tests in case of non 
normality). Mixed models will be produced to compare the evolution. 
 
Systemic tacrolimusTacrolimus systemic absorption: the percentage of patients who 
present with systemic absorption of KK506 will be calculated. If tacrolimus is detected 
in the blood the level of exposure will be listed. 
 
9.2.2.6 Handling of missing values/censoring/discontinuations 
 


 
Page 51 of 64 
Follow-up of patients will be pursued regardless of the situation, except if the patient 
withdraws his or her consent. In the case of nasal surgery during the study period or 
any other treatment that is a substitute to the studied treatment, the patient will be 
followed up but his or her results will be considered as a failure. 
 
The main judgement criterion is based on grids that are filled in daily. Patients are used 
to these grids and fill them in carefully; the daily durations are summarized over 6 
weeks. However if one day is missing, the value will be replaced by an average of the 
4 values before and the 4 values after the missing value. This strategy will be applied 
up to 7 missing values over 6 weeks (i.e. 10%). 
If more than 7 days and less than 21 days (included) are missing, a daily average will 
be computed from the data available (from the 6-week period evaluated) and will be 
multiplied by 42 to obtain the overall estimated duration. 
 
If a patient is lost to follow-up or refuses to communicate his nosebleed grids or has 
more than 21 days missing on his grids, the result for the concerned patient will be 
considered as a failure. 
10 
Quality assurance 
The Clinical research associate mandated by the sponsor is responsible for inspecting 
the case report forms in conformity with the monitoring schedule for the study, 
throughout the study, verifying that the protocol is being respected, as well as the 
totality and the conformity of the source documents, the coherence of the data and that 
the regulations governing good clinical practices are being respected. The Clinical 
research associate mandated must have access to the medical files of the patients and 
other files in relation to the study needed to verify the data entered in the study’s 
electronic case report forms.  
The controls of presence, verisimilitude, and coherence will be carried out 
electronically in accordance with the rules defined in advance. Requests for 
information will be generated when possible errors are detected. 
The health authorities and/or an independent auditor mandated by the sponsor may 
audit any investigation site, or the sponsor, throughout the duration of the study or after 
the end of the study so as to control how the study is being conducted and the quality 
of the data. The investigator must provide direct access to the source documents, and 
the sponsor to the regulatory documents. 
 
11 
Ethical and regulatory aspects 
 
The study will be conducted in conformity with the protocol, the guidelines from the 
French and European Good Clinical Practices, the Helsinki declaration in its most 
recent version (Seoul 2008), as well as the recommendations of the ICH (International 
Conference on Harmonization), and in conformity with the law covering research 
involving the human person in the French Public Health Code (Law 2012-300 of March 
5, 2012). 
 


 
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11.1 Qualification of the research and patient information  
In accordance with Law n°2012-300 of March 5, 2012 of the French Public Health 
Code, this is considered as research involving the human person. The study effectively 
concerns a drug, called tacrolimus. This drug is not generally used locally in 
nosebleeds in patients with HHT, but is instead administered topically in the treatment 
of dermatitis. 
11.1.1 Information sheet 
Patients may only participate in this study if they have given their written informed 
consent. To do so, they will first receive spoken and written information from their 
doctor on: the aim of the study, the duration of their participation, the procedures that 
will be followed, the benefits, the predictable risks, the disadvantages that may result 
from the treatments administered or examinations undergone, the confidentiality of the 
data, insurance cover, and management of the costs associated with this study. 
All this information will be summarized in an information sheet that will be given to each 
patient.  
11.1.2 Enlightened consent 
Patients may only participate in this study if they have given their written informed 
consent. Two copies of the consent form will be signed by the subject and the 
investigating doctor. One copy of this document will be given to the person participating 
in the study, and the investigator must keep the second copy in his or her archives for 
a minimum period of 15 years. 
 
11.2 Benefit / risk ratio 
All the surgical treatments currently on offer are aggressive for the nasal mucosa and 
present a risk of perforation of the nasal septum.  
Patients’ participation in this study will not compromise their possibility for future 
medical or surgical treatment. 
The expected adverse events in this study are: 
 Skin burning or irritation at the application site (approximately half of the 
patients). These symptoms are usually mild to moderate and generally go away 
within one week of using Protopic. Administration could be easily stopped in 
case of adverse reaction. 
 The risk of systemic adverse events related to tacrolimus is low given the very 
low doses of tacrolimus administered to the patients. Tacrolimus in blood is 
monitored and the treatment will be stopped in case of absorption. 
 Risk for the blood test may be of the hematoma type at the puncture point or 
fainting.  
 
If the efficacy of the treatment is shown, the treatment will be proposed to all the 
patients who have received the placebo.  
The risk / benefit ratio for a patient participating in this study is thus perfectly 
acceptable. 
 


 
Page 53 of 64 
11.3 Confidentiality of the data 
Everyone taking part in the study will be bound by the confidentiality agreement 
regarding the protocol, and linked by professional confidentiality with regard to the 
participants. 
The information sheet will summarize the rights of access of the participants to the 
nominative information concerning them either directly or indirectly. 
All the data collected will be processed anonymously and will be covered by the laws 
of medical confidentiality.  
On the case report forms, or on all other documents, the patients must be identified by 
their initials and their study number only. 
We request that the investigator allow the representatives of the sponsor and/or legal 
authorities to have direct access to the patients’ original medical files for verification of 
the procedures of the study and the data. The investigator must inform the patient that 
the files concerning him or her and in relation to the study will be reviewed by the 
aforementioned representatives without any breach of confidentiality. 
 
11.4 Confidentiality and Good Clinical Practices 
In conformity with the dispositions regarding the confidentiality of the data to which the 
people in charge of controlling the quality of the biomedical research will have access 
(article L.1121-3 of the French public health code), those people with direct access will 
take all the precautions necessary with a view to ensuring the confidentiality of the 
information concerning the people participating in the study and in particular with 
regards to their identity and the results obtained. 
These people, as well as the investigators themselves, are subject to professional 
confidentiality restrictions (in accordance with the conditions defined by articles 226-
13 and 226-14 of the French penal code).  
During the biomedical research, or after its termination, the data collected on the 
people taking part will be rendered anonymous by the investigators (or any other 
specialized people). 
These data must not under any circumstances reveal the names of the participants or 
their addresses. Only the initials of the subjects will be recorded, accompanied by a 
code number specific to the study and that indicates the chronological order of 
inclusion of the subjects. 
Every person agreeing to participate in the research will have given his or her written 
agreement to have access to the individual data concerning him or her and which is 
strictly necessary for controlling the quality of the research. 
 
11.5 Submitting the protocol to the CPP and ANSM 
A request for authorization will be sent by the sponsor of the study to the ANSM. The 
protocol will be submitted to a randomly selected French CPP for assessment. 
 
 
11.6 Amendments to the protocol 
Any modifications to the protocol will be validated by the Scientific Committee and the 
sponsor of the study and submitted to the selected CPP and the ANSM for 
authorization if applicable. 


 
Page 54 of 64 
 
11.7 Computerization of the data 
The information collected during this study will be the subject of data processing. The 
file will be declared at the CNIL and will be put together in conformity with the law 
governing information technology, files and personal rights (law 78-17 of January 6, 
1978, modified by law 2004-801 of August 6, 2004): commitment to conformity with the 
MR-001 (deliberation n°2016-262 of July 21, 2016). 
 
In conformity with the Information Technology and Freedom law currently in force, 
patients have the right to access, communicate, oppose and rectify any nominative 
information. This right can be exercised directly by the patient or by the doctor of his 
or her choice from the doctor investigators participating in the study.  
 
11.8 Curriculum vitae and signature of the protocol 
Before starting the study, the main investigator will provide the representatives of the 
sponsor with a copy of his or her signed and dated personal curriculum vitae, as well 
as that of his or her co-investigators, and a signed and dated (signature page) copy of 
the final protocol of the study. 
 
11.9  Insurance 
The Hospices Civils de Lyon (3 Quai des Célestins, BP 2251, 69229 Lyon Cedex 02) 
will be the sponsors of the study and will take out an insurance policy in their name 
and at their expense (Compagnie SHAM, 18 rue Edouard Rochet, 69008 Lyon, contrat 
n°XXXX). 
 
11.10 Study report and publications 
The final report of the study will be written in collaboration with the investigator, co-
investigators and person responsible for analyzing the data. 
This report will be submitted to each of the investigators for approval and once a 
concensus has been obtained, the final version will be officially approved by the 
signature of each of the investigators. 
 
The results, regardless of their nature, will be submitted for publication in the 
international journals with peer review committees interested in this disease.  
One main publication is planned, and will focus on the efficacy of nasal administration 
of tacrolimus on the population studied. The main investigator will write and sign the 
article as the leading author, providing the main results from the study. The other 
authors will include the co-investigators, and a representative of the department having 
carried out the statistical analysis. The ranking of the authors will be decided by 
concensus, validated ultimately by the main investigator. 
Indication of the sponsorship by the Hospices Civils de Lyon will be made in all or any 
publication. 
 


 
Page 55 of 64 
12 
Organization of the study 
12.1 Scientific committee 
The Scientific Committee for the study, presided over by the study’s main investigator, 
will be composed of investigators (one ENT specialist, one geneticist), the 
methodologist and the sponsor of the study. The committee will be responsible for 
validating the definitive version of the protocol, supervising the implementation and 
running of the study, and for writing the reports and publications resulting from the 
study.  
 
12.2 Independent monitoring and safety committee for the study  
Monitoring the safety of administration of the product, motivated by the iatrogenic risks, 
justifies the setting up of a specific independent monitoring and safety committee. 
This committee will meet as defined in paragraph 2.3. The first meeting will occur after 
collection of adverse events and observance of the treatment after 30 days for the 8 
first patients included. 
The committee will give its recommandations on the continuation of the study. 
DSMB recommendations will be forwarded to ANSM for information. 
There will be two or three meetings depending on the tolerance of the product. 
It will be composed of: 
 a specialist of the disease not involved in the study, 
 a ENT specialist,  
 a statistician specializing in the methodology of clinical trials. 
 
 
 
13 
Medium and long term perspectives 
Nosebleeds are a significant morbidity factor in HHT, not solely because of the anemia 
they provoke, but also because of the handicap that they represent in the daily lives of 
active patients.  
In total, around 95% of the patients followed for HHT are concerned by nosebleeds. 
Although the mortality rate for the patients followed for this disease is low, the morbidity 
rate is severe and the psychosocial impact of HHT is almost constant in adults. 
 
For most patients with severe nosebleeds, a regular nasal administration of tacrolimus 
should make it possible in terms of clinical development to: 
- 
obtain a significant reduction in nosebleed duration.  
- 
decrease the monthly number of nosebleeds, 
- 
increase hemoglobin and serum ferritin concentrations, 
- 
decrease the number of local surgical and packing treatments, as well as the 
intravenous perfusions of iron, 
- 
decrease the number of blood transfusions sometimes needed in case of a too 
great loss of blood, 
- 
improve air flow and decrease nasal obstructions, 


 
Page 56 of 64 
- 
improve patient quality of life (possibility of going shopping, going to a 
restaurant, enjoying meals with family, having a professional activity, etc.), 
- 
decrease the number of consultations and/or hospitalizations, 
- 
decrease the cost of management of severe nosebleeds given their current 
costs (transfusions, iron supplementation, etc.). 
 
The possible efficacy of a nasal administration of tacrolimus on nosebleeds would be 
extremely interesting and would constitute significant progress to the extent that no 
current treatments, either medical or surgical, have made it possible to significantly 
decrease nosebleeds in the long term, with the exception of the closure of the nasal 
cavities which remains an aggressive, last resort act.  
 
In the long term, and should the product prove to be effective, it would be possible to 
imagine regular nasal administrations of tacrolimus.   
 


 
Page 57 of 64 
14 
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David L, Feige JJ, Bailly S. Emerging role of bone morphogenetic proteins in 
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David L, Mallet C, Mazerbourg S, Feige JJ, Bailly S. Identification of BMP9 and BMP10 
as functional activators of the orphan activin receptor-like kinase 1 (ALK1) in 
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vascular quiescence factor. Circ Res. Apr 25 2008;102(8):914-922. 
31. 
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update]. Med Sci (Paris). Oct 2010;26(10):855-860. 
32. 
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American Society of Health-System Pharmacists. Jul 15 1995;52(14):1521-1535. 


 
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38. 
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39. 
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Dupuis-Girod S, Ambrun A, Decullier E, et al. ELLIPSE Study: A Phase 1 study 
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15 
Appendices 
15.1 Appendix 1: Nosebleed monitoring sheet 
 


 
Page 62 of 64 
15.2 Appendix 2: ESS questionnaire 
 
 
 
 
 
 
 
Epistaxis Severity Score (ESS) for Hereditary Hemorrhagic Telangiectasia 
The purpose of these questions is to calculate a severity score of epistaxis (nose bleeding) 
for patients with Hereditary Hemorrhagic Telangiectasia who are involved in a Research 
Study. For more information regarding the meaning of this score, please discuss this with 
you health care provider. 
Please answer each of the following questions as they pertain to your TYPICAL nosebleed 
symptoms DURING THE PAST 6 WEEKS.  
Please answer all questions. 
How often do you TYPICALLY have nose bleeding? 
0 — Less than monthly  
1 — Once per month  
2 — Once per week  
3 — Several per week 
4 — Once per day 
5 — Several each day 
How long do your TYPICAL nose bleeds last?  
0 — <1 minute  
1 — 1–5 minutes  
2 — 6–15 minutes 
3 — 16–30 minutes 
4 — >30 minutes 
How would you describe your TYPICAL nose bleeding intensity? 
0 — Not typically gushing  
1 — Typically gushing or pouring 
Have you every sought medical attention for nose bleeding? 
0 — No  
1 — Yes 
Are you anemic (low blood count) currently?  
0 — No  
1 — Yes 
Have you ever received a red blood cell transfusion specifically because of nose bleeding?  
0 — No 
1 — Yes 


 
Page 63 of 64 
15.3 Appendix 3: ENT monitoring examination 
 
ENT: NASAL examination 
 
 
Visit ____Date ____  ____  ____ 
 
 
Septal perforationYes □No □  
DysosmiaYes □No □ 
Nasal obstructionYes □No □ If yes, give details……………. 
 
 
Lesions 
 
Comments:………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………. 
 
Scabs 
Right nasal cavity:Left nasal cavity: 
Number:□ None□ None 
□ <50% of the visible surface□ <50% of the visible surface 
□ >50% of the visible surface□ >50% of the visible surface 
Comments:………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………… 
 
 
 
 
 
Name of the doctor: …………………………………….. 
 
Signature: 
 
 


 
Page 64 of 64 
15.4 Appendix 4: Epistaxis emergency