Conditions: Barrett's Esophagus
Keywords: Barrett's Esophagus Esophageal Adenocarcinoma GERD Acid Reflux
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 27
Healthy volunteers: no

Brief summary:
The purpose of this study is to determine whether treatment with an experimental drug called YF476 in patients with Barrett's esophagus reduces the expression of tissue markers that are associated with an increased risk of developing esophageal cancer.

Detailed description:
The association between gastro-esophageal reflux disease (GERD) and cancer of the esophagus is well-established. Barrett's esophagus (BE) is a condition in which the lining of the part of the esophagus changes to look like small intestine, and this change occurs in the setting of GERD. Patients with BE are at increased risk for developing esophageal cancer. It is recommended that all patients with BE take medicines called proton pump inhibitors (PPIs), which greatly reduce the acid produced by the stomach, in the hopes of reducing the risk of esophageal cancer. However, by reducing the acid level in the stomach, levels of a hormone called gastrin are increased. There is laboratory data to suggest that gastrin may have effects that actually promote the development of cancer, including esophageal cancer. The investigators previously showed that BE patients with very high gastrin levels are more likely to have either advanced precancerous changes (also called high grade dysplasia) or cancer of the esophagus. As such, the obvious question is raised: does gastrin promote the development of cancer in BE? YF476 is a new drug that blocks the effects of gastrin. Trials in healthy subjects have demonstrated that the drug is safe and well-tolerated. The investigators therefore propose to conduct a randomized placebo-controlled trial of YF476 in patients with Barrett's esophagus. The primary hypothesis is that treatment with YF476 will reduce the expression of tissue markers that are associated with an increased risk of developing esophageal cancer.

Arms:
arm 1: YF476 (gastrin-receptor antagonist) arm 2: Placebo pill (identical in appearance to YF476 pills)

Interventions: intervention 1: YF476 intervention 2: Placebo
Intervention descriptions: intervention 1: 25 mg: one capsule to be taken by mouth once daily for 12 weeks. intervention 2: Matching placebo: one capsule to be taken by mouth once daily for 12 weeks.

Protocol document:
Prot_SAP_000.pdf: 
YF476 in Barrett’s esophagus  
  
Trial code: 10-505 (T-016)  
Protocol Version 23  
13 May 2016  
Page 1 of 65  
NCT01298999 
 Trio 
Medicines Limited  
TRIO 
Trial protocol  
  
Confidential  
  
Trial title  
Randomized, placebo-controlled trial of YF476, a gastrin  
receptor antagonist, in Barrett’s esophagus  
Short title  
YF476 and Barrett’s esophagus  
Version and date of protocol  
Version 23, 13 May 2016  
HMR code   
10-505  
Sponsor code   
T-016  
IND#  
IND 107354  
EudraCT number  
2014-002418-22  
Trial medication  
YF476  
Phase of trial  
Phase II  
Place of trial  
Columbia University  
  
Division of Digestive & Liver Diseases  
622 W 168th Street  
PH 7W-318  
New York, NY  10032  
USA  
  
  
National Institute for Health Research  
Clinical Investigation Ward  
  
Cambridge University Hospitals NHS Foundation Trust  
Cambridge Biomedical Campus  


YF476 in Barrett’s esophagus  
  
Trial code: 10-505 (T-016)  
Protocol Version 23  
13 May 2016  
Page 2 of 65  
Hills Road  
Cambridge  CB2 0QQ  
  
UK  
  
  
Sponsor  
 
Chief investigator, and  principal 
investigator at   
TRIO Medicines Ltd  
PO Box 53346  
London, NW10 7XU  
England  
Columbia University  
Julian A. Abrams  MD  MS Columbia 
University  
 
Division of Digestive & Liver Diseases 
622 W 168th St  
 
PH 7W-318  
New York, NY   10032  
 
USA  
 
Co-investigator at  
Tel: +1 (212) 342-0476  
Fax: +1 (212) 342-5759  
E-mail: ja660@columbia.edu  
Columbia University  
Charles J Lightdale  MD  
Columbia University  
Division of Digestive & Liver Diseases 
180 Ft. Washington Avenue  
Harkness Pavilion, 7th Floor  
New York, NY  10032  
USA  
 
Co-investigator at  
Tel: +1 (212) 305-4398  
E-mail: cjl18@columbia.edu  


YF476 in Barrett’s esophagus  
  
Trial code: 10-505 (T-016)  
Protocol Version 23  
13 May 2016  
Page 3 of 65  
Columbia University  
John M. Poneros  MD  
Columbia University  
Division of Digestive & Liver Diseases 
622 W 168th Street  
PH 7W-318  
New York, NY  10032  
USA  
 
Tel: +1 (212) 342-3171  
E-mail: jmp14@columbia.edu  
Co-investigator at  
Columbia University  
Timothy Wang  MD  
Columbia University  
Division of Digestive & Liver Diseases  
1130 St. Nicholas Avenue  
Herbert Irving Cancer Center, Room 923  
New York, NY  10032 USA  
 
Co-investigator at  
Tel: +1 (212) 851-4581  
E-mail: tcw21@columbia.edu  
Columbia University  
Antonia Sepulveda  MD  
Columbia University  
Department of Pathology  
630 W 168th Street  
Vanderbilt Clinic, 14-212  
New York, NY  10032  
USA  
 
Principal investigator at   
Tel: +1 (212) 305-3623  
E-mail: as4400@columbia.edu  
University of Cambridge  
Professor Rebecca Fitzgerald  
 
MRC Cancer Unit  
University of Cambridge  
Hutchison/MRC Research Centre (Box 197) 
Cambridge Biomedical Campus  
Cambridge  
United Kingdom  
CB2 0XZ  


YF476 in Barrett’s esophagus  
  
Trial code: 10-505 (T-016)  
Protocol Version 23  
13 May 2016  
Page 4 of 65  
Study biostatistician  
Bin Cheng, PhD  
Columbia University  
722 W 168th Street  
Room 631  
New York, NY  10032  
 
Tel: +1 (212) 342-1238  
Fax: +1 (212) 342-1232  
E-mail: bc2159@columbia.edu  
Sponsor’s medical representative  
Malcolm Boyce  BSc  FRCP  FFPM  FBPharmacolS  
Hammersmith Medicines Research (HMR)  
Cumberland  Avenue  
London, NW10 7EW  
England  
  
Tel:  +44 (0) 20 8961 4130  
  
Mobile: +44 (0) 7850 510 572  
Fax: +44 (0) 20 8961 8665  
Email:  mboyce@hmrlondon.com  
Sponsor’s statistician  
Toni Mitchell   BSc  MSc  CStat  
Head of Statistics and Data Management  
HMR  
  
Tel:  +44 (0) 20 8961 4130  
Fax: +44 (0) 20 8961 8665  
Email:  tmitchell@hmrlondon.com  
Planned dates of trial  
February 2012 – December 2016 


 
 
1.1 
Background  
Barrett’s Esophagus (BE) is the precursor lesion for the development of esophageal 
adenocarcinoma (EAC).  BE is defined as the presence of intestinal metaplasia in the distal 
esophagus, and is associated with a 25-30 times increased risk of EAC.1    Unfortunately, the 
prognosis of esophageal cancer is poor, with 5-year survival rates of  
16.5% in the US.2  
The development of BE is thought to be caused in part by acid reflux.  The change in 
esophageal lining presumably develops as a result of chronic exposure to refluxed stomach 
acid and bile, leading to recurrent mucosal injury.3  
Current management of BE patients consists of endoscopic surveillance and acid 
suppression.4  In theory, gastric acid suppression reduces chronic inflammation within the 
BE segment, which in turn may reduce the risk of progression to EAC. By inhibiting acid 
secretion and increasing intragastric pH, proton pump inhibitors (PPIs) at therapeutic 
doses can cause secondary hypergastrinemia.  Gastrin exerts trophic effects in BE via 
cholecystokinin-2 receptor (CCK2R) activation5, and there is some evidence that 
hypergastrinemia is associated with an increased risk of progression to high grade 
dysplasia and cancer.6   
YF476 is a potent, orally active, highly selective, competitive antagonist of CCK2 
receptors.7  The primary hypothesis for this study is that administration of YF476 to 
patients with BE will result in a significant decrease in cellular proliferation in the Barrett’s 
mucosa.  
1.2 
Trial medication  
YF476 (25 mg) or matching placebo: one capsule to be taken by mouth once daily for 12 
weeks.  Study medication will be taken with breakfast except on clinic visit days, when 
patients will fast overnight and take study medication after completion of study procedures.  
1.3 
Objectives  
Primary:  
The primary objective of this study is to determine if administration of YF476 (a CCK2R 
antagonist) to patients with Barrett’s esophagus (BE) decreases tissue Ki67 expression, a 
marker of cellular proliferation.  
 
Secondary:  
  
The secondary objectives are to assess the effects of YF476 on:   
• 
biomarkers associated with esophageal adenocarcinoma, in particular, cyclooxygease-2 
(COX-2), p53, CCK2R and DCAMKL1; and  
• 
fasting serum gastrin, a marker of gastric acid suppression, and plasma chromogranin A 
(CgA), a marker of ECL cell hyperplasia.  


 
 
We also aim to determine whether YF476 is safe in patients with BE.  
1.4 
Type of trial  
Phase II, randomised, double-blind, out-patient trial.  
1.5 
Trial population  
a 
Total  20 patients completing the trial.   
b 
Inclusion criteria  
1. 
Aged ≥18 years, with histologically confirmed diagnosis of BE without dysplasia.  A 
prior endoscopy with biopsies read as indefinite for dysplasia is permitted if biopsies 
from the most recent endoscopy prior to study entry demonstrated BE without 
dysplasia.  
2. 
Minimum of 1 cm circumferential Barrett’s mucosa on endoscopy or at least 2 cm 
maximal contiguous extent of Barrett’s mucosa. (Prague criteria C≥1, any M or any 
C, M≥2).  
3. 
Proton pump inhibitor use at least once daily, for at least twelve months prior to 
enrollment, and stable dose of PPI for the three months before enrollment. Any PPI, 
dose, and frequency are allowable.  
4. 
ECOG performance status ≤2 and Karnofsky ≥60%; see Appendix A. 5.  Normal 
organ and marrow function, defined as white blood cells (WBC) ≥3 x 109/L, absolute 
neutrophil count ≥1.5 x 109/L, platelets ≥100 x 109/L, creatinine ≤1.5 mg/dL, total 
bilirubin ≤1.5 mg/dL, AST ≤100 U/L, ALT ≤100 U/L.  
 
6.  
Use of adequate contraception during the study as follows.    
• Pre-menopausal women must use a highly effective method of contraception  
(≤1% failure/year when used correctly), including:  o 
intrauterine device (IUD); o bilateral tubal 
occlusion;  
o vasectomised partner – must have had medical assessment of successful 
surgery; o intrauterine hormone-releasing system (IUS);  
o progestogen-only hormonal contraception implants associated with 
inhibition of ovulation; or  
o hormonal contraception associated with inhibition of ovulation (combined 
or progestogen-only – includes oral, intravaginal, transdermal and 
injections).   
• 
To prevent pregnancy, men with partners of childbearing potential must use a 
condom or have had a vasectomy (with a medical assessment of successful 


 
 
surgery).  Partners who are not of childbearing potential are defined as:  men; 
post-menopausal women (no menstrual periods for at least 1 year); or women 
who have no uterus, ovaries or fallopian tubes.    
• 
Women classed as post-menopausal (no menstrual periods for at least 1 year) are 
not required to use contraception.  
7. 
Willingness to comply with all treatment and follow-up procedures.  
8. 
Ability to understand and the willingness to sign a written informed consent 
document.  
9. 
Up to date with all age-appropriate cancer screening tests (based on national 
guidelines.  
 
d  
Exclusion criteria  
1. 
Histologically confirmed BE with high-grade dysplasia.  
2. 
Histologically confirmed diagnosis of invasive carcinoma of the esophagus.  
3. 
Histologically confirmed BE with low-grade dysplasia that has been diagnosed by at 
least two expert gastrointestinal pathologists.   
4. 
Prior endoscopic therapy for Barrett’s esophagus.  
5. 
A relevant history of esophageal or gastric surgery that, in the investigator’s opinion, 
could compromise the objectives of the trial.  
6. 
History of atrophic gastritis, pernicious anemia, or Zollinger-Ellison syndrome.  
7. 
Participation in a trial of an IMP within the previous 28 days.  
8. 
Prolonged QTc interval >450 msec   
9. 
History of allergic reactions attributed to compounds of similar chemical composition 
to YF476.  
10. 
History or baseline findings of:  
• 
diabetes mellitus requiring insulin therapy;  
• 
pancreatitis (baseline amylase and/or lipase ≥ 2.0 x ULN);  
• 
hepatitis B or hepatitis C;  
• 
HIV, unless, at the discretion of the PI, with at least 120 days on stable 
antiretroviral therapy (ART) with undetectable HIV viral load and CD4 >350 
cells/mm3;  
• 
malabsorption syndrome or inability to swallow or retain oral medicine;  
• 
major surgery ≤28 days prior to enrollment;  
• 
ECOG performance status ≥2; or  
• 
another cancer within 3 years except for basal carcinoma of the skin or cervical 
carcinoma in-situ.  


 
 
• 
Also, any clinically significant and uncontrolled major morbidity including but 
not limited to: serious cardiac disease (unstable angina, s/p myocardial  
infarction ≤1 month); respiratory disease (advanced COPD or pulmonary 
fibrosis); uncontrolled hypertension; active systemic infection; or psychiatric 
illness/social situations that would limit compliance with study requirements.  
11. 
Certain medicines and herbal remedies (see Appendix B) taken during the 7 days 
before the start of study drug.  
12. 
A history of cancer >3 years from the time of enrollment, and the patient is not up to 
date with surveillance for that cancer (based on national guidelines), or has evidence 
of cancer at the time of enrollment.  
1.6 
Trial design and methods  
Patients will be randomised (1:1 ratio) to receive either 25 mg YF476  or matching placebo.  
They will attend the clinic 4 or 5 times, and will take up to 18 weeks to complete the trial.  
At Visit 1, patients will sign the Informed Consent form. Patients will undergo assessment 
of eligibility, physical examinations, ECG, urine pregnancy test (premenopausal women 
only) and safety tests of blood and urine.  
Visit 2 can take place on the same day as visit 1, or up to 2 weeks later.  At Visit 2, patients 
will undergo ECG, safety tests of blood and urine, including urine pregnancy test (pre-
menopausal women only), unless Visit 2 is on the same day as Visit 1.  All patients will 
have baseline biomarker assessments, baseline  
esophagogastroduodenoscopy (EGD) and biopsies.  If they meet all the eligibility criteria, 
they will be given a bottle of study medication (25 mg YF476 or placebo) capsules to take 
once daily, with breakfast, starting the next day.  Patients will complete a diary card 
throughout the treatment period.  
The Week 6 visit will be 6 weeks after starting study treatment.  Patients will fast before 
the visit, and will bring their dose of study medication to the clinic, to take after fasting 
blood tests.  First, patients will have safety tests of blood and urine, ECG, and blood taken 
for biomarkers and trough YF476 concentration.  Patients will then take their study 
medication, and 1 h afterwards will have blood taken for peak YF476 concentration.  
Patients will be asked about any adverse events and concomitant medications, and will 
return their study medication bottle for assessment of compliance.  They will receive their 
next bottle of study medication.  
The Week 12 visit will be 12 weeks after starting study treatment.  Patients will fast before 
the visit, and will bring their dose of study medication to the clinic, to take after fasting 
blood tests.  First, patients will have safety tests of blood and urine, ECG, and blood taken 
for biomarkers and trough YF476 concentration, before undergoing EGD assessments and 
biopsies.  Patients will then take their study medication, and 1 h afterwards will have blood 
taken for peak YF476 concentration.   
Follow-up visit will be 4 weeks after the patients have stopped taking study medication.   


 
 
Patients will have safety tests of blood and urine, ECG, and blood tests for biomarkers.  
Patients will be asked about any adverse events.      
1.7 
Methods  
• 
Esophagogastroduodenoscopy (EGD), to enable taking of biopsies for assessment of the 
primary endpoint, Ki67 expression levels;  
• 
blood sampling for assay of biomarkers and serum for storage;  
• 
diary card for patients to record adverse events, concomitant medication and 
compliance; and  
• 
physical examination, ECG and safety tests of blood and urine.  
1.8 
Primary variable  
Efficacy:  
change in Ki67 expression between baseline (Visit 2) and the Week 12 
visit  
1.9 
Secondary variables  
Biomarkers:    
change from baseline at Week 12 in biomarkers associated with 
esophageal adenocarcinoma, in particular, cyclooxygenase-2 (COX-
2), P53, CCK2R and DCAMKL1, and in fasting serum gastrin and 
plasma CgA   
 
Safety:  
vital signs, ECG, physical examination, laboratory safety tests:  
blood tests: red blood cells (RBC), haemoglobin, haematocrit, 
platelets, white blood cells (WBC, differential: neutrophils, bands, 
lymphocytes, monocytes, eosinophils, basophils), sodium, potassium, 
magnesium, chloride, bicarbonate, creatinine, serum glucose, blood 
urea nitrogen (BUN), alkaline phosphatase, lactate dehydrogenase 
(LDH), serum glutamic-oxaloacetic transaminase/aspartate amino 
transferase (SGOT/AST), serum glutamic-pyruvic transaminase/ 
alanine aminotransferase (SGPT/ALT), total bilirubin, total protein, 
albumin, calcium, amylase, lipase; and urine tests: pH, specific 
gravity, protein, glucose, ketones, blood, and change in histology.  
 
Tolerability:  
adverse events  
 
Pharmacokinetics:  trough and peak concentrations of YF476  
 


 
 
STUDY DIAGRAM  
  
Randomized, placebo-controlled trial of a gastrin  receptor 
antagonist, YF476, in Barrett’s esophagus  
  
  
Barrett’s esophagus without dysplasia  
Proton pump inhibitor use at least once daily, for at least 12 months prior to enrollment, and stable 
dose of PPI for the 3 months before enrollment  
  
Informed consent  
 
 
Baseline data collection [history + physical, endoscopy + biopsy, blood (safety tests, pregnancy test 
(pre-menopausal women only) biomarkers), urine]  
 
 
Randomization: 1:1 ratio between patients on 25 mg YF476 daily and patients on placebo daily, for 
12 weeks  
 
  
 
 
Follow-up data collection [endoscopy + biopsy, blood (safety tests, biomarkers, YF476 PK), urine, 
compliance, AEs, SAEs]  
 
  
 
  
Primary Endpoint – Ki67 expression  
Secondary endpoints – expression of other biomarkers (including COX-2, p53, CCK2R, DCAMKL1), 
serum gastrin, plasma CgA and safety.  
 
 
 
 
 
 
 
 


 
 
Table of contents  
 
Signatures  
5  
1  Summary 
Error! Bookmark not defined. 
1.1  Background 
5 
1.2  Trial medication 
5 
1.3 Objectives 
5 
1.4 Type of trial 
6 
1.5 Trial population 
6 
1.6  Trial design and methods 
8 
1.7  Methods 
9 
1.8  Primary variable 
9 
1.9  Secondary variables 
9 
Table of contents 
11 
List of Abbreviations 
13 
2  Objectives 
16 
2.1  Primary objective 
16 
2.2  Secondary objectives 
16 
3  Background 
16 
3.1  Barrett’s esophagus 
16 
3.2  YF476 
17 
3.2.1  Non-clinical studies 
17 
3.2.2  Phase 1 studies 
18 
3.3  Rationale 
19 
4 Summary of study plan 
20 
4.1 Study design 
20 
4.2  Discussion of study design 
21 
4.3  Risk-benefit analysis 
22 
5 Patient selection 
23 
5.1 Inclusion criteria 
23 
5.2 Exclusion criteria 
24 
5.3  Inclusion of women and minorities 
25 
5.4  Recruitment and retention plan 
25 
6 Administration of study medication 
26 
6.1 Dose regimen and dose groups 
26 
6.2 YF476 administration 
26 
6.3 Run-in procedures 
26 
6.4 Contraindications 
26 
6.5 Concomitant medications 
26 
6.6 Dose modification 
27 
6.7  Compliance 
27 
7  Pharmaceutical information 
28 
7.1  Active pharmaceutical ingredient (API):  YF476 
28 
7.2  Formulated intermediate:  spray-dried YF476 
28 


 
 
7.3  Final formulation 
29 
7.4  Packaging and labelling 
29 
7.5  Storage, accountability and dispensing of study medication 
29 
7.6 Registration and randomization 
30 
7.7 Blinding and unblinding methods 
30 
7.8  YF476 destruction/disposal 
31 
8  Clinical evaluations and procedures 
32 
8.1  Schedule of events 
32 
8.2  Baseline testing and pre-study evaluation 
33 
8.3  Evaluations during study treatment 
34 
8.4  Evaluations at completion of study treatment 
34 
8.5 Post-treatment follow-up period 
35 
8.6 Flexibility of study days 
35 
8.7  Withdrawal of patients from the trial 
35 
8.7.1  Termination of study medication 
35 
8.7.2  Termination of study participation 
35 
8.8  Study termination 
36 
9  Criteria for evaluation and endpoint definition 
36 
9.1  Primary endpoint 
36 
9.2  Secondary endpoints 
36 
10  Methods 
37 
10.1  Methods for clinical procedures 
37 
10.2  Rationale for laboratory methods 
37 
10.3  Laboratory methods 
38 
10.3.1 Laboratories 
38 
10.3.2 Collection and handling procedures 
38 
11  Reporting adverse events 
40 
11.1  Adverse events (AEs) 
41 
11.2  Serious adverse events (SAEs) 
42 
11.2.1 Definition 
42 
11.2.2 Reporting SAEs 
42 
12  Data management and quality assurance 
43 
12.1  Data and safety monitoring plan 
44 
12.2  Sponsor or regulatory monitoring 
44 
12.3  Record retention 
44 
12.4  Clinical Trial Agreement 
44 
13 Statistical methods 
45 
13.1 Analysis Sets 
45 
13.2  General Statistical Considerations 
45 
13.3  Study Population Data 
45 
13.4  Efficacy Analyses 
45 
13.5  Pharmacokinetic Analyses 
46 
13.6  Safety Analyses 
47 
13.6.1 Adverse Event Analyses 
47 
13.6.2 Analyses of Clinical Laboratory Tests 
47 


 
 
13.6.3 Electrocardiogram Analyses 
47 
13.7  Determination of sample size 
47 
14  Ethical and regulatory considerations 
48 
14.1  Columbia University Medical Center, New York, US 
48 
14.1.1 Form FDA 1572 
48 
14.1.2 Other required documents 
48 
14.1.3 Institutional Review Board (IRB) approval 
48 
14.2  National Institute for Health Research Clinical Investigation Ward, Cambridge,  
49 
UK 
49 
14.3  Informed consent 
49 
15  Financing, expenses, and/or insurance 
50 
16  Obligations of the sponsor and investigator 
50 
16.1 Publication 
50 
16.2 Archiving 
50 
16.3  Premature termination of the trial 
51 
17  References 
51 
Appendix A – performance status criteria 
Error! Bookmark not defined. 
Appendix B – drug interactions 
Error! Bookmark not defined. 
Appendix C – medications card (CUMC) 
Error! Bookmark not defined. 
 
List of Abbreviations  
 
 
ACG  
American College of Gastroenterology  
 
ADL  
activities of daily living  
 
AE  
adverse event  
 
API  
active pharmaceutical ingredient  
 
ART  
antiretroviral therapy  
 
AUC  
area under the curve  
 
BE  
Barrett’s esophagus  
 
CAP  
College of American Pathologists  
 
CCK2R  
cholecystokinin 2 receptor  
 
CDE  
Common Data Elements  
 
CgA  
chromogranin A  
 
CI  
confidence interval  
 
CIW  
Clinical Investigation Ward  
 
CLIA  
Clinical Laboratory Improvement Amendments  
 
cm  
centimetre  


 
 
 
Cmax  
peak concentration  
 
COX-2  
cyclooxygenase-2  
 
CRF  
case report form  
 
CTA  
clinical trial authorisation  
 
CTCAE  
Common Terminology Criteria for Adverse Events  
 
CUMC  
Columbia University Medical Centre  
 
CV  
Curriculum Vitae  
 
CYP  
cytochrome P450 enzyme  
 
DCAMKL-1  
doublecortin- and Ca2+/calmodulin-dependent protein kinase-like  
protein 1  
 
DCP  
Division of Cancer Prevention  
 
DSMB  
Data Safety Monitoring Board  
 
EAC  
esophageal adenocarcinoma  
 
ECL  
enterochromaffin-like  
EGD  
esophagogastroduodenoscopy  
FDA  
Food and Drug Administration  
FWA  
Federal-wide assurance  
g  
gram  
GCP  
Good Clinical Practice  
GERD  
gastro-esophageal reflux disesase  
GI  
gastrointestinal  
GMP  
Good Manufacturing Practice  
GRA  
gastrin receptor antagonist   
h  
hour  
H2RA  
histamine-2 receptor antagonist  
hERG  
human ether-à-go-go related gene  
HGD  
high grade dysplasia  
HIPAA  
health insurance portability and accountability act  
HMR  
Hammersmith Medicines Research  
HPMC  
hydroxypropylmethylcellulose  


 
 
IC50  
concentration of a drug causing 50% inhibition of a response  
ICH  
International Conference on Harmonisation of Technical  
Requirements for Registration of Pharmaceuticals for Human Use   
IHC  
immunohistochemistry  
IMP  
investigational medicinal product  
IND  
Investigational New Drug  
IRB  
Institutional Review Board  
LGD  
low grade dysplasia  
mg  
milligram  
MHRA  
Medicines and Healthcare products Regulatory Agency  
mL  
millilitre  
mm Hg  
millimetres of mercury  
NCI  
National Cancer Institute  
NDA  
new drug application  
NIHR  
National Institute for Health Research  
NOAEL  
no observable adverse effect level  
NSAID  
non-steroidal anti-inflammatory drug  
ºC  
degrees celsius  
OHRP  
office for human research protections  
OR  
odds ratio  
p53  
tumour protein 53  
PCR  
polymerase chain reaction  
PD  
pharmacodynamic  
pH  
negative logarithm to base 10 of the hydrogen ion concentration 
PI  
principal investigator  
PK  
pharmacokinetic  
PPI  
proton pump inhibitor  
QA  
quality assurance  
qRT-PCR  
quantitative RT-PCR  
QTc  
interval of the ECG corrected for heart rate  
REC  
Research ethics committee  


 
 
RT-PCR  
reverse transcriptase polymerase chain reaction  
SAB  
SAE  
Scientific Advisory Board 
serious adverse event  
SAS  
statistical analysis software  
SD  
standard deviation  
SUSAR  
serious unexpected serious adverse reaction  
T1/2  
half-life  
Tmax  
time of peak concentration  
ΔKi67  
change in Ki67 expression  
μg  
microgram  
μmol  
micromole  
 
2 
Objectives  
2.1 
Primary objective  
The primary objective of this study is to determine if administration of YF476 (a CCK2R 
antagonist) to patients with Barrett’s esophagus (BE) decreases tissue Ki67 expression, a 
marker of cellular proliferation.  
2.2 
Secondary objectives   
The secondary objectives are to assess the effects of YF476 on:   
• 
biomarkers associated with esophageal adenocarcinoma, in particular, cyclooxygease-2 
(COX-2), p53, CCK2R and DCAMKL1; and  
• 
fasting serum gastrin, a marker of gastric acid suppression, and plasma chromogranin A 
(CgA), a marker of ECL cell hyperplasia.  
We also aim to determine whether YF476 is safe in patients with BE.  
3 
Background  
3.1 
Barrett’s esophagus  
Barrett’s esophagus (BE) is the precursor lesion for the development of esophageal 
adenocarcinoma (EAC).  BE is defined as the presence of intestinal metaplasia in the distal 
esophagus, and is associated with a 25–30 fold increased risk of EAC.1  The incidence of 
EAC has increased five-fold in the past three decades in the United States (US), with 
similar patterns of incidence observed in most developed western countries.8  
Unfortunately, the prognosis of esophageal cancer is poor, with 5-year survival rates of 
16% in the US.2  


 
 
The development of BE is thought to be caused in part by acid reflux.  The change in 
esophageal lining presumably develops as a result of chronic exposure to refluxed acid and 
bile from the stomach leading to recurrent mucosal injury.3  The esophageal injury is 
accompanied by inflammation and, ultimately, a cellular change (metaplasia) to a 
specialized columnar epithelium.  BE-associated intestinal metaplasia can ultimately 
progress to low grade (LGD) and high grade dysplasia (HGD), states that are associated 
with elevated risk of progressing to EAC.  
Current management of BE patients consists of endoscopic surveillance and acid 
suppression.4  For example, current American College of Gastroenterology (ACG) 
guidelines recommend periodic upper endoscopy with random biopsies of the Barrett’s 
segment in order to assess for the presence of LGD, HGD, or EAC.  The purpose of 
surveillance is to allow for early detection, which may lead to improved patient outcomes.  
ACG guidelines for the management of BE also recommend gastric acid suppression with 
proton pump inhibitors (PPIs).  In theory, gastric acid suppression reduces chronic 
inflammation within the BE segment, which in turn may reduce the risk of progression to 
EAC.    
3.2 
YF476  
Details of YF476 are in the Investigator’s Brochure (Trio Medicines Ltd)7, so only a 
summary is provided here.  
3.2.1 
Non-clinical studies  
Non-clinical studies have shown YF476 to be a potent, highly selective, and competitive 
antagonist of gastrin receptors in vitro and in vivo.9-11  
Toxicology studies of YF476 consisted of: single- and/or repeat-dose toxicity studies in rats 
and dogs; toxicokinetics in rats and dogs; and embryo-foetal toxicity studies in rats and 
rabbits.  Other non-clinical studies consisted of: safety pharmacology studies in rats, mice 
and dogs; genotoxicity studies in vivo and in vitro; studies of metabolism by cytochrome 
P450 in human liver microsomes in vitro; a study to determine the extent of YF476 protein 
binding in normal human serum in vitro; a study of the effect of YF476 on the hERG ion 
channel in human embryonic kidney cells in vitro: and a study to compare the metabolism 
of 14C-YF476 in rat, dog and human cells in vitro.  
In acute toxicity studies in beagle dogs, 100 and 500 mg/kg/day resulted in similar plasma 
concentrations of YF476, and caused no adverse effects.  Therefore, 10, 30 and 100 
mg/kg/day were tested in a 13-week toxicity study.  Changes in pancreas weight and 
histopathology were observed in some animals, and serum amylase was elevated in one 
low-dose male.  Although the histological findings resemble nesidioblastosis, a 
spontaneous finding in laboratory beagles, an effect of YF476 cannot be excluded, so the 
study did not clearly establish a NOAEL.  
A 13-week toxicity study of YF476 doses 100, 300 and 1000 mg/kg/day was done in rats.  
At 300 and 1000 mg/kg/day, some animals had minor, reversible changes in enzyme 
activities and heart weight, and discoloured urine and pale faeces.  Also, there were minor 


 
 
histopathological lesions in the heart and pancreas of four treated animals and one control 
animal.  The NOAEL was deemed 100 mg/kg/day.    
In the 13-week study in dogs, YF476 had no effect on the ECG, and no effect on the ECG 
intervals, including QTc.  A concentration of YF476 about four times the highest Cmax in a 
human subject to date did not affect the hERG channel in vitro.  Because ∼84% of YF476 
is bound to serum protein in vivo, that represents 25-fold safety cover.    
Embryo-foetal studies were done in the rat and rabbit, using YF476 doses of 100, 300 and 
1000 mg/kg/day.  YF476 had no effect on embryo-foetal survival, growth or development 
in rabbits.  There was slight delay in foetal development in rats given 1000 mg/kg/day, so 
the NOAEL was deemed 300 mg/kg/day.  
The metabolism of parent 14C-YF476 was most efficiently catalysed by human > dog > rat 
hepatocytes in vitro.  Phase I and II metabolites were formed.  There was no evidence for 
formation of unique major human metabolites, although the main metabolite was different 
from that formed by rat and dog.  Thus, the rat and dog are appropriate species to assess the 
potential toxicity of YF476 in humans.  
YF476 caused some reversible inhibition of CYP2C8 and CYP3A4 in vitro.  The likelihood 
of a drug-drug interaction via those enzymes in trials in patients is remote or possible, 
respectively, at the proposed doses of YF476.  
Non-clinical studies support administration of YF476 to humans for up to 13 weeks.  The 
treatment period for this clinical trial will be 12 weeks.  
3.2.2 
Phase 1 studies  
Trio has completed 11 studies of YF476 in healthy men and women.7  184 subjects 
received YF476: single doses up to 400 mg; up to 25 mg daily for 14 days; 100 mg twice 
daily for 7 days; 100 mg YF476 daily, either alone or with 20 mg rabeprazole, for 6 weeks; 
and 25 mg YF476 daily for 14 days either alone or with 40 mg esomeprazole.  The 
outcome measures were: safety; tolerability; pharmacokinetics; and  
pharmacodynamics (24-h gastric pH; pentagastrin-induced gastric acid secretion; serum 
gastrin; and markers of ECL-cell hyperplasia).  The comparators were placebo, ranitidine, 
omeprazole and rabeprazole.  
Safety and tolerability  
In all studies, YF476 was well tolerated.  Adverse events were minor, transient, occurred in 
subjects given placebo or comparators as well as YF476, and were not YF476-dose 
dependent.  YF476 affected neither vital signs, ECG, nor safety tests of blood and urine.    
Pharmacodynamics   
Single doses caused dose-dependent increases in 24-h gastric pH.  The effect lasted much 
longer than that of a single dose of ranitidine.  However, the effect of YF476 on 24-h 
gastric pH was mostly lost after repeated doses, whereas that of omeprazole persisted.  
Single doses of YF476 also caused dose-dependent inhibition of pentagastrininduced falls 
in gastric pH and increases in gastric volume and H+ output.  Again, the effect on gastric 
pH was mostly lost after repeated doses of YF476.  But, the effects on volume and H+ 


 
 
output persisted.  So, gastrin receptors must still be blocked after repeated doses of YF476.  
In a study of YF476 and rabeprazole, alone and in combination for 6 weeks, YF476:   
• 
was as effective as the PPI in reducing gastric volume and H+ activity;   
• 
was as effective as the PPI in increasing serum gastrin;   
• 
did not increase plasma chromogranin A (CgA), a biomarker for ECL-cell 
activity, whereas the PPI increased it;   
• 
abolished the PPI-induced increase in CgA;   
• 
augmented gastric acid suppression by the PPI without reducing the increase in 
gastric pH induced by the PPI; and   
• 
prevented the rebound increase in H+ activity induced by the PPI.    
In conclusion, the combination was more effective than either the PPI or YF476 alone in 
suppressing gastric acid production.  YF476 prevented stimulation of ECL cells and 
rebound hyperacidity, both of which are caused by PPI-induced hypergastrinaemia.  
Overall, the effects of YF476 are consistent with antagonism of gastrin receptors.  
Pharmacokinetics  
The pharmacokinetic profile of YF476 varied among the 1996, 2001, 2005 and 2009 
capsule formulations.  The 2001 and 2005 formulations were crystalline, and the 1996 and 
2009 formulations were spray-dried. The spray-dried formulations had the most favourable 
profile.  In a single-dose study of 50–400 mg of the current (2009) formulation of YF476, 
absorption was rapid, Tmax was 1.5–2 h, T½ varied with dose, and Cmax and AUC0-24 were 
not proportional to dose.  T½ after 100 mg YF476 was about 7 h.  Food increased Cmax and 
AUC0–24 by 1.9 and 1.6-fold, respectively.  The absolute bioavailability was about 16% in a 
study of 100 mg ‘cold’ YF476 by mouth after fasting and 15 µg 14C-YF476 intravenously.  
Protein binding in human serum was about 84%.  In a 7-day study of 100 mg YF476 twice 
daily of the 1996 formulation, YF476 reached steady state by Day 3 and did not accumulate 
by Day 7.  Even though the crystalline formulations were much less bioavailable than the 
spray-dried formulations, the pharmacodynamic results were still favourable, which 
suggests that YF476 is a potent gastrin antagonist in man.    
3.3 
Rationale  
As described above, clinical guidelines for the management of BE include gastric acid 
suppression with chronic PPI therapy.  Acid reflux appears to have an important causal role 
in the development of BE, and a history of reflux symptoms is associated with EAC.12  
However, data are inconclusive with regard to acid suppression and EAC risk.  In a 
retrospective study of veterans with BE, PPI compared with histamine-H2 antagonists or no 
acid suppression was associated with a lower risk of progression to dysplasia.13  In contrast, 
other studies suggest that PPIs may be associated with an increased risk for developing 
EAC,14 and Feagins et al reported anti-proliferative effects of acid exposure in non-
dysplastic BE cells.15  


 
 
By inhibiting acid secretion, PPIs at therapeutic doses can cause secondary 
hypergastrinemia.  Gastrin exerts trophic effects in BE via CCK2R activation.5 There is 
increased expression of CCK2R in BE compared to squamous epithelium, and gastrin can 
stimulate proliferation, anti-apoptosis, COX-2 expression, and loss of cell-cell adhesion in 
BE cells.5, 16  The chief investigator’s group recently reported that BE patients with high 
serum gastrin levels had significantly increased odds of a history of high grade dysplasia 
(HGD) or EAC.6  In that cross-sectional study, they enrolled 95 patients with BE (with and 
without dysplasia or EAC) and GERD controls on chronic PPI therapy.  Subjects in the 
highest serum gastrin quartile had significantly increased odds of a history of advanced 
neoplasia (adjusted OR 5.46, 95% CI 1.20–24.8).  The group also analyzed 19 samples 
from non-dysplastic Barrett’s epithelium, and found marked elevations in Ki67 expression, 
with a mean Ki67 index of 48.3% (SD 16.0%).  They also found a moderate correlation 
between serum gastrin and tissue Ki67 index (r=0.64, p=0.05) in a subset of ten patients 17.  
Those studies support the notion that gastrin may promote carcinogenesis in BE, and that 
these potentially pro-neoplastic effects occur via activation of the CCK2 receptor.  We 
therefore propose the following clinical trial to analyze the effects of a CCK2 receptor 
antagonist in patients with BE.  The primary hypothesis is that administration of YF476, a 
CCK2 receptor antagonist, in patients with BE will result in a significant decrease in 
cellular proliferation in the Barrett’s mucosa.  
4 
Summary of study plan  
4.1 
Study design  
We propose a randomized, double-blind, placebo-controlled pilot study of YF476, a 
cholecystokinin-2 receptor antagonist, in patients with Barrett’s esophagus without 
dysplasia.  Patients will take YF476 or placebo for 12 weeks.    
There are 2 research sites, Columbia University and the University of Cambridge.  We aim 
for 20 patients to complete the study.  Patients will be randomized (1:1 ratio) to treatment 
with YF476 or placebo.    
Patients will make up to 5 visits to the research site (Visits 1 and 2 may be combined, or up 
to 2 weeks apart.  See schedule of events in Section 8.1.):  
• 
Registration (Visit 1)  
• 
Baseline (Visit 2 – start of treatment phase)  
• 
Study treatment (6 weeks after the start of the treatment phase). • End of 
study treatment (after 12 weeks’ treatment)  
• 
Follow-up (4 weeks after the end of treatment).  
After giving informed consent (Visit 1) and after the initial endoscopy (Visit 2), patients 
will be given one bottle of YF476 or placebo. They will be given a study bottle again at the 
Week 6 visit.    


 
 
The primary endpoint of the study (Ki67 expression) will be assessed using endoscopic 
biopsies taken at baseline and at 12 weeks.   
Esophageal tissue from endoscopic biopsies will be evaluated for Ki67 expression  
(primary endpoint) and expression of additional markers potentially associated with  
esophageal neoplasia (secondary endpoints).   Expression of these markers will be assessed 
by immunohistochemistry (IHC) and reverse transcriptase-PCR (RT-PCR), as appropriate.  
Blood samples will be taken at Visit 2, the Week 6 visit and the Week 12 visit for 
measurement of serum gastrin and plasma CgA, and at the Week 6 and Week 12 visits for 
trough and peak YF476 concentrations.  
Safety tests and pregnancy tests (pre-menopausal women only) will be done at each visit.  
Patients will complete a diary card daily to record study drug, concomitant medication and 
adverse events.  Adverse events will be assessed 6 and 12 weeks after starting study 
medication, and 4 weeks after finishing study medication.  Blood and urine samples will 
also be collected at these visits to assess for hematologic, metabolic, or other disturbances 
that may be due to study drug.  The duration of the study for each individual patient will be 
between 16 and 18 weeks.  
4.2 
Discussion of study design  
Patient population  
In this first trial of YF476 in patients with BE, we will study only those without dysplasia.  
BE patients without dysplasia are all placed on PPIs for acid suppression and undergo 
lifelong endoscopic surveillance.  Therefore, this population will be most vulnerable to any 
long-term adverse effects of increased gastrin exposure, and represents the group of 
patients who could potentially benefit the most from a gastrin receptor antagonist. The 
standard of care for patients with high grade dysplasia (HGD) at the study institutions 
consists of endoscopic ablative therapy and not continued endoscopic surveillance. The 
diagnosis of low grade dysplasia (LGD) is confounded by extremely poor interobserver 
reliability, even among expert pathologists.  Additionally, ablative therapy is also 
frequently recommended for LGD patients. Therefore, BE patients with LGD and HGD are 
not ideal candidates for chemoprevention studies in BE.  Dose regimen  
The dose regimen of 25 mg YF476 or matching placebo once daily has been chosen based 
on a previous study of YF476 (T-013), which showed that a dose as low as 5 mg YF476 
suppressed the increase in CgA, a marker of ECL-cell activity, induced by PPI treatment, in 
healthy subjects.  The patients in the proposed T-016 study will have had prolonged 
hypergastrinaemia, so a dose of 25 mg YF476 is appropriate.  A placebocontrolled design 
is appropriate for this study as there is no alternative treatment known to reduce the levels 
of Ki67 expression in patients with BE.  
Efficacy tests  
We will use Ki67 index as the primary endpoint, as it is a reliable and reproducible marker 
of ongoing cellular proliferation.  Quantitative assessment of the number of proliferating 


 
 
(Ki67+) epithelial cells is easiest and most reliable in immunohistochemistry (IHC).  We 
will also take blood samples to assay fasting serum gastrin and plasma CgA, and trough 
and peak YF476 concentrations.  
4.3 
Risk-benefit analysis  
What are the potential risks of harm to the trials patients from YF476 and from the trial 
procedures, and how might they be mitigated?  
Reported adverse events and potential risks  
In all studies in healthy volunteers, YF476 was well tolerated.  Adverse events were minor, 
transient, occurred in subjects given placebo or comparators as well as YF476, and were 
not YF476-dose dependent.  YF476 did not affect:  vital signs; ECG; or safety tests of 
blood and urine.  There was no evidence of effect on QT interval in human studies, but in 
vitro studies showed that YF476 has a low potential for prolonging QT interval (See 
Section 3.2.1).  So, until we have more information about YF476, patients with prolonged 
QT interval are excluded from clinical trials.  
The adverse effects that occurred at a frequency of 10% or greater were:  abdominal 
distention, diarrhea, abdominal pain, nausea, and headache.  None of these adverse effects 
were observed with greater frequency as compared to placebo or comparators. Because of 
the pancreatic findings in the 13-week toxicology study of dogs (Section 3.2.1), serum 
amylase and lipase will be monitored at each visit.  Also, any patient who complains of 
abdominal discomfort at any time during the study will be seen immediately by the 
investigator or delegate and evaluated with history, physical examination, and laboratory 
tests, including serum amylase and lipase, and other appropriate tests, including 
radiological investigations. Risk from concomitant medications  
In vitro studies have shown that the likelihood of a drug-drug interaction in patients in vivo 
is:  
• 
CYP2C8:  possible for 50–400 mg YF476   
• 
CYP3A4 (testosterone):  remote for 50 & 100 mg YF476, and possible for 200 & 400 
mg  
• 
CYP3A4 (midazolam):  remote for 50 mg YF476, and possible for 100–400 mg. 
Although YF476 caused some irreversible inhibition of CYP3A4, the degree of 
inhibition makes a drug-drug interaction in patients in vivo unlikely.  And, a clinical 
study (T-007) of YF476 and midazolam (a substrate of CYP3A4) alone and in 
combination showed that neither medicine affects the pharmacokinetics of the other 
(see YF476 Investigator’s brochure for further details).  
Many medicines are metabolised via CYP3A4/5. Very few are metabolised via  
CYP2C8.  Examples of the main types of medicine that are metabolised by CYP3A4/5  
and CYP2C8 are listed in Appendix B.  Guidance about assessing the risk and managing 
drug-drug interactions is also provided in Appendix B.  All medications (prescription and 
over-the-counter), vitamin and mineral supplements, and/or herbs taken by the patient will 


 
 
be documented in the CRF at baseline, and the patient will record any new concomitant 
medications in the diary card, which will be checked at each visit. Risk from study 
procedures: endoscopy  
Patients who take part in the trial must undergo endoscopy at baseline and at the Week 12 
visit.  All patients in the study will have had at least one endoscopy before the trial.  Most 
gastroscopies are done without any problem.  Some people have a sore throat for a day or 
so afterwards.  Patients may feel tired or drowsy for several hours after sedation.  There is a 
slightly increased risk of developing a chest infection after endoscopy.  Rarely, the 
endoscope damages the esophagus, causing bleeding or infection.  Patients will be given 
information on how to prepare for their endoscopy according to local procedures.  
Overall, the potential benefits to the trial patients of taking part in the trial greatly outweigh 
the risks of any harm.  
5 
Patient selection  
5.1 
Inclusion criteria  
1. Aged ≥ 18 years, with histologically confirmed diagnosis of BE, defined as 
endoscopically-suspected BE with intestinal metaplasia present on esophageal biopsies, 
without dysplasia.  A prior endoscopy with biopsies read as indefinite for dysplasia is 
permitted if biopsies from the most recent endoscopy prior to study entry demonstrated 
BE without dysplasia.  The most recent endoscopy documenting BE must have been 
performed no more than three (3) years from the time of enrollment.  
2. Minimum of 1 cm circumferential Barrett’s mucosa on endoscopy or at least 2 cm 
maximal contiguous extent of Barrett’s mucosa. (Prague criteria C≥1, any M or any C, 
M≥2).  
3. Proton pump inhibitor use at least once daily, for at least twelve months prior to 
enrollment, and stable dose of PPI for the three months before enrollment. Any PPI, 
dose, and frequency are allowable.  
4. ECOG performance status ≤2 and Karnofsky  ≥60%; see Appendix A.  
5. Participants must have normal organ and marrow function, defined as white blood cells 
(WBC) ≥3 x 109/L, absolute neutrophil count  ≥1.5 x 109/L, platelets ≥100 x 109/L, 
creatinine ≤1.5 mg/dL, total bilirubin ≤1.5 mg/dL, AST ≤100 U/L, ALT ≤100 U/L.  
6. The effects of YF476 on the developing human fetus at the recommended therapeutic 
dose are unknown.  All patients must agree to use adequate contraception for the 
duration of study participation as follows.       
• 
Pre-menopausal women must use a highly effective method of contraception  
(≤1% failure/year when used correctly), including:   
o intrauterine device (IUD); o bilateral tubal occlusion;  


 
 
o vasectomised partner – must have had medical assessment of successful 
surgery;  
o intrauterine hormone-releasing system (IUS);  
o progestogen-only hormonal contraception implants associated with 
inhibition of ovulation; or  
o hormonal contraception associated with inhibition of ovulation  
(combined or progestogen-only – includes oral, intravaginal, transdermal 
and injections).   
• 
To prevent pregnancy, men with partners of childbearing potential must use a 
condom or have had a vasectomy.  Partners who are not of childbearing potential 
are defined as:  men; post-menopausal women (no menstrual periods for at least 
1 year); or women who have no uterus, ovaries or fallopian tubes.    
• 
Women classed as post-menopausal (no menstrual periods for at least 1 year) are 
not required to use contraception.  
7. Willingness to comply with all treatment and follow-up procedures.  
8. Ability to understand, and the willingness to sign, a written informed consent 
document.  
9. Up to date with all age-appropriate cancer screening tests (based on national guidelines.  
5.2 
Exclusion criteria  
1. 
Histologically confirmed BE with high-grade dysplasia.  
2. 
Histologically confirmed diagnosis of invasive carcinoma of the esophagus.  
3. 
Histologically confirmed BE with low-grade dysplasia that has been diagnosed by at 
least two expert gastrointestinal pathologists.   
4. 
Prior endoscopic therapy for Barrett’s esophagus, including (but not limited to) 
mucosal resection, radiofrequency ablation, and photodynamic therapy.  
5. 
A relevant history of esophageal or gastric surgery that, in the investigator’s opinion, 
could compromise the objectives of the trial.  
6. 
History of atrophic gastritis, pernicious anemia, or Zollinger-Ellison syndrome.  
7. 
Participation in a trial of an IMP within the previous 28 days.  
8. 
Prolonged QTc interval (>450 msec)   
9. 
History of allergic reactions attributed to compounds of similar chemical composition 
to YF476.  
10. 
History or baseline findings of:  
• 
diabetes mellitus requiring insulin therapy;  
• 
pancreatitis (baseline amylase and/or lipase ≥ 2.0 x ULN);  
• 
hepatitis B or hepatitis C;  


 
 
• 
HIV, unless, at the discretion of the PI, with at least 120 days on stable ART 
with undetectable HIV viral load and CD4 >350 cells/mm3;  
• 
malabsorption syndrome or inability to swallow or retain oral medicine;  
• 
major surgery ≤28 days prior to enrollment;  
• 
ECOG performance status ≥2; or  
• 
cancer within 3 years except for basal carcinoma of the skin or cervical 
carcinoma in-situ.  
• 
Also, any clinically significant and uncontrolled major morbidity including but 
not limited to: serious cardiac disease (unstable angina, s/p myocardial 
infarction ≤1 month); respiratory disease (advanced COPD or pulmonary 
fibrosis); uncontrolled hypertension; active systemic infection; or psychiatric 
illness/social situations that would limit compliance with study requirements.  
11. 
Certain medicines and herbal remedies (see Appendix B) taken during the 7 days 
before the start of study drug.  
12. 
A history of cancer >3 years from the time of enrollment, and the patient is not up to 
date with surveillance for that cancer (based on national guidelines), or has evidence 
of cancer at the time of enrollment.  
5.3 
Inclusion of women and minorities  
Men and women of all races and ethnic groups are eligible for this trial.  However, the 
described epidemiology of Barrett’s esophagus is such that the majority of study patients 
are likely to be white males.  
5.4 
Recruitment and retention plan  
There will be 2 study sites: Columbia University Medical Center (CUMC), New York,  
US, and the National Institute for Health Research (NIHR) Clinical Investigation Ward 
(CIW), Cambridge University Hospitals, Cambridge, UK.  Eligible patients will be 
recruited from the clinical practices of the study investigators (JAA, CJL, JMP, RF). All of 
the study investigators see a large volume of patients referred for management and 
treatment of Barrett’s esophagus.  We aim for 20 patients to complete the trial.  
Recruitment progress will be assessed on an ongoing basis.  Screening and enrollment logs 
will be regularly reviewed by the investigators.  Patient withdrawals will be carefully 
monitored. Methods for patient retention will be implemented, including the maintenance 
of regular contact with study patients.  The study staff will meet regularly to review issues 
related to recruitment and retention, identify areas of improvement, and implement 
appropriate strategies to address any deficiencies.  Additional recruitment methods such as 
advertising may be performed by each individual site with the approval of that site’s 
Institutional Review Board or REC.  
Withdrawals will be replaced at the discretion of the investigator.   


 
 
6 
Administration of study medication  
Study medication will be dispensed on an outpatient basis, and self-administered by 
patients.  Reported adverse events and potential risks are described in Section 4.3.    
6.1 
Dose regimen and dose groups  
• 
Patients will take 25 mg YF476 (1 x 25 mg capsule) or matching placebo capsules, by 
mouth once daily.  
• 
The treatment period for this trial will be 12 weeks.  
6.2 
YF476 administration  
• 
Each study patient will self-administer the YF476 or placebo.   
• 
The study medication will be dispensed into bottles: 46 capsules of 25 mg YF476 or 
placebo per bottle.  1 bottle will be dispensed to participants at the baseline visit 
(Visit 2) and at the Week 6 visit.  
• 
Study medication should be taken once daily, in the morning, with breakfast. But, if a 
patient takes the study medication without food, or at a different time of the day, it 
will not be recorded as a protocol deviation.  Missed doses will be recorded as 
protocol deviations.  
6.3 
Run-in procedures  
No run-in phase is planned for this study.    
6.4 
Contraindications  
Contraindications to taking YF476 include prolonged QTc interval, pregnancy or 
breastfeeding.  Patients with prolonged QTc interval (>450 msec) are excluded.  Women of 
childbearing potential will be included in the study only if they are using adequate 
contraception and will be advised by the recruiting physician and in the information and 
consent form about the risks of becoming pregnant while taking part in the study.   
Pregnancy tests will be done at each visit.  
6.5 
Concomitant medications  
All study patients will take proton pump inhibitors at least once daily.  Any formulation of 
PPI is permitted during the study period.  
All medications (prescription and over-the-counter), vitamin and mineral supplements, 
and/or herbs taken by the participant will be documented on the concomitant medication 
CRF and will include: 1) start and stop date, dose and route of administration, and 
indication. Medications taken for a procedure (eg: biopsy) should also be included.  
CYP 450 enzymes  
Studies were done to assess the potential of YF476 to inhibit cytochrome P450 enzymes in 
vitro.  For details, see Appendix B – drug interactions, and the YF476 Investigator’s 
Brochure. The likelihood of a drug-drug interaction in patients in vivo is:  
• 
CYP2C8:  possible for 50–400 mg YF476   


 
 
• 
CYP3A4 (testosterone):  remote for 50 & 100 mg YF476, and possible for 200 & 400 
mg  
• 
CYP3A4 (midazolam):  remote for 50 mg YF476, and possible for 100–400 mg.  
Although YF476 caused some irreversible inhibition of CYP3A4 in vitro, the degree of 
inhibition makes a drug-drug interaction in patients in vivo unlikely.  And, a clinical study 
(T-007) of YF476 and midazolam (a substrate of CYP3A4) alone and in combination 
showed that neither medicine affects the pharmacokinetics of the other.  For details, see the 
Netazepide (YF476) Investigator’s Brochure.  
Many medicines are metabolised via CYP3A4/5. Very few are metabolised via CYP2C8.  
Examples of the main types of medicine that are metabolised by CYP3A4/5 and CYP2C8 
are listed in Appendix B.  Guidance about assessing the risk and managing drug-drug 
interactions is also provided in Appendix B.  
Drugs that are substrates for, or inhibitors or inducers of CYP3A4/5 and CYP2C8 are not 
prohibited, but the patients must be monitored carefully, and the investigator must be 
informed of any new concomitant medications via the patient’s diary card.  Midazolam 
may be used during endoscopy.  It was used safely before gastroscopy in a study of YF476 
in healthy subjects.  
6.6 
Dose modification  
Dose modifications of study drug will not be performed.  If drug-related toxicity is 
suspected, then treatment will be discontinued.  
6.7 
Compliance  
• 
All randomized patients will be eligible for statistical analysis.  Patients will be 
analyzed on an intent-to-treat basis, and also per protocol.  
• 
Compliance will be measured by capsule counts at the Week 6 and Week 12 visits, 
and by review of patient diary cards.  
 


 
 
7 
Pharmaceutical information  
YF476 (IND # 107354, IND Sponsor: Trio Medicines Ltd)    
7.1 
Active pharmaceutical ingredient (API):  YF476  
International non-proprietary name (INN):  netazepide Structural 
formula:  
  
Chemical formula: (R)-1-[2,3-dihydro-2-oxo-1-pivaloylmethyl-5- (2-pyridyl)-1H -
1,4-benzodiazepin-3-yl]-3-(3-methylaminophenyl)urea    
Molecular formula:  C28H30N6O3 Molecular 
weight:  498.58  
Description: white crystalline powder  
Purity: 99.9%  
Optical rotation: [α]D20 = +124 ° (Acetone, 0.5%)  
Acid dissociation constant (pKa): 2.53, 4.59  
Hygroscopicity: <0.3% at room temperature, and 93% relative humidity (7 days) 
Stability: Chemically stable for at least 9.5 years at room temperature, protected from 
light.   
7.2 
Formulated intermediate:  spray-dried YF476   
YF476 and hydroxypropylmethylcellulose (HPMC) (YF476:HPMC ratio 1:3.5) were 
dissolved in dichloromethane/isopropanol (7:2 v/v).  The solution was spray-dried, and at 
all stages of production, the solution and resulting spray-dried powder were shielded from 
light.  The formulated intermediate was characterised as follows.  
Description: white to off-white powder  
Structural configuration:  amorphous by x-ray powder diffraction  
YF476 purity:  ≥95% of the theoretical purity (adjusted for water)  
Water content:  ≤7.5%  


 
 
Residual dichloromethane:  ≤2000 ppm  
Residual isopropanol:  ≤10000 ppm  
Stability:  Chemically and physically stable at 2–8 °C for at least 4 years.  Stability studies 
are ongoing.    
7.3 
Final formulation  
The co-formulation of spray-dried YF476 and HPMC is blended with starch, and placed 
into hard gelatine capsules at the Hammersmith Medicines Research (HMR) Pharmacy.  
Each capsule contains 25 mg YF476.  Matching placebo capsules, containing starch only, 
will also be prepared.  The sponsor will provide a certificate of analysis for the test product.   
7.4 
Packaging and labelling  
For the CUMC, HMR Pharmacy will provide bulk supplies of investigational medicinal 
product (IMP) in accordance with The Rules Governing Medicinal Products in the 
European Union, Volume 4:  Good Manufacturing Practice (GMP) 19, and with HMR’s 
Manufacturing Authorisation for IMPs (MIA(IMP)).  The trial medication will be 
dispensed and labelled by the site pharmacy in accordance with United States Code of 
Federal Regulations governing labelling of investigational new drugs (21CFR 312.6).    
For NIHR CIW, the trial medication will be packaged and labelled by the HMR  
Pharmacy, in accordance with The Rules Governing Medicinal Products in the European 
Union, Volume 4:  Good Manufacturing Practice (GMP)19], and with HMR’s 
Manufacturing Authorisation for IMPs (MIA(IMP)).  The IMP labels will include the 
information required by Annex 13 to GMP.   
7.5 
Storage, accountability and dispensing of study medication  
The HMR Pharmacy will dispatch the study medication to the site Pharmacy by secure 
temperature-controlled courier after ethical and regulatory approvals of the trial have been 
obtained.  The site Pharmacy will record and acknowledge in writing the receipt of all 
supplies of study medication.  The study medication will be stored securely at 2 to 8°C, 
protected from moisture and light, accessible only to those individuals authorised by the 
investigator to dispense the IMP.    
Each site pharmacy will dispense study drug (or placebo) for trial patients in accordance 
with the randomization code.  The labels on bottles given to trial patients will not indicate 
whether the capsules are study drug or placebo, so as to maintain blindness among the 
study investigators and study patients.    
The site Pharmacy will maintain a careful record of the inventory and disposition of all 
medication received from the HMR Pharmacy. The site Pharmacy will maintain adequate 
records of receipt, dispensing and final disposition of YF476 and placebo. The receipt 
record will include from whom the study medication was received and to whom study 
medication was distributed, date, quantity and batch or lot number. The dispensing record 
will be blinded, and will include quantities and the dates YF476 or placebo was dispensed 


 
 
to and returned by each participant. Dr. Julian A. Abrams will be responsible for study 
medication accountability for participants at CUMC and Prof. Rebecca Fitzgerald will be 
responsible for study medication accountability for participants at  
NIHR CIW.  
At the end of the trial, all unused study medication supplies will be returned to the HMR 
Pharmacy.  
7.6 
Registration and randomization  
• 
A member of the HMR Statistics and Data Management Department will generate a 
randomization list for each site.  Patient numbers will be allocated to eligible patients 
immediately before the EGD and biopsy at Visit 2 (Baseline).  Patients enrolled at 
CUMC will be allocated patient numbers 01–24.  Patients enrolled at NIHR CIW will 
be allocated patient numbers 1001–1024.  The lists are independent of each other.  At 
both sites, patients on PPI once daily will be given the next available number from 
the top of the list, and patients on PPI twice daily will be given the next available 
number from the bottom of the list.    
• 
At each site, the site coordinators will maintain a site-specific list of participants, 
including patient codes, start date, and duration of treatment.  Every time a patient is 
recruited at one of the sites, the coordinator for that site will inform the chief 
investigator (if applicable) and the coordinator for the other site.  It is the chief 
investigator’s responsibility to ensure that the total number of study patients does not 
exceed the target.  
The randomization list will specify whether the patient receives a dose of YF476 or 
placebo.  Fixed allocation randomization will be performed, with equal allocation (1:1) 
between the 25 mg YF476 and placebo groups. Blocked randomization will be used. 
Randomization will be stratified by PPI dose and by site.  The site pharmacy will dispense 
YF476 or placebo according to the randomization list.  The study investigators and the 
study patients will remain blinded.   
7.7 
Blinding and unblinding methods  
• 
Bottles containing study medication for individual patients will not be labelled with 
any information to indicate whether the capsules are YF476 or placebo.  
• 
Patients will be blinded to study treatment.   
• 
One member of the HMR Statistics and Data Management Department will not be 
blinded.  That person will generate the randomization code. The Columbia University 
biostatistician will be blinded.  
• 
All Investigators will be blinded to study treatment.   
• 
For each site, there will be a blinded monitor and an unblinded monitor.  The 
unblinded monitor will review dispensing records at the site Pharmacy.  
• 
Pharmacy staff will not be blinded.  
• 
The Data and Safety Monitoring Board will not be blinded.  


 
 
• 
The blind will be broken by the investigator or delegate in the following 
circumstances:  
o 
If unblinding is required in the interest of the safety of a subject, an investigator 
will discuss the matter with the sponsor before opening the individual code-
break envelope for that subject.  In a medical emergency, the principal 
investigator or delegate may open the individual code-break envelope for that 
subject without prior consultation with the sponsor.  In that event, the principal 
investigator or delegate will notify the sponsor as soon as possible that the 
randomisation code has been broken for the subject.  
o 
The blind will be broken for the entire study population at the completion of the 
study, after the statistical analysis plan (SAP) has been signed and the database 
has been locked.  
7.8 
YF476 destruction/disposal  
At the completion of investigation, the site Pharmacy will return all unused YF476 and 
placebo capsules to the HMR Pharmacy.   
 


 
 
8 
Clinical evaluations and procedures  
8.1 
Schedule of events  
  
Baseline Testing/ 
Prestudy Evaluation  
Study treatment  
Follow-up period  
  
Visit 11  
Visit 2  
Week 6 
visit   
Week 12 
visit   
Follow–up  
Evaluation/ Procedure  
Registration  
Randomization, 
& Endoscopy  
Week 6  
Week 12  
Follow Up Visit 4 weeks after 
stopping treatment  
Informed consent  
X  
  
  
  
  
Assess eligibility  
X  
  
  
  
  
Central pathology review2  
X  
  
  
  
  
Medical history  
X  
  
  
  
  
Physical exam  
X  
  
  
  
  
Vital signs  
X  
X5  
X  
X  
X  
Height and weight/ waist 
circumference  
X  
  
  
  
  
Smoking history  
X  
  
  
  
  
Medication history  
X  
  
  
  
  
Blood and urine collection 
for safety tests  
X  
X5  
X  
X  
X  
Urine pregnancy test4  
X  
X5  
X  
X  
X  
ECG  
X  
X5  
X  
X  
X  
Blood for YF476 assay3  
  
  
X  
X  
  
Blood for assay of fasting 
serum gastrin and plasma 
CgA, and serum for storage  
  
X  
X  
X  
X  
EGD (Upper GI endoscopy)  
  
X  
  
X  
  
Biopsies  
  
X  
  
X  
  
Concomitant medication 
assessment  
  
X  
X  
X  
  
Dispense study medication  
  
X  
X  
  
  
Collect study medication  
  
  
X  
X  
  
Compliance assessment  
  
  
X  
X  
  
AE assessment  
  
X  
X  
X  
X  
1. There may be up to a 2-week gap between Visits 1 and 2.  
2. Review of patient’s history to obtain histological confirmation of the patient’s eligibility to participate in the trial.  
3. Plasma YF476 assay: patients fast overnight.  For the Week 6 and 12 visits, patients bring their container of study medication 
with them, and take study medication only after collection of blood samples for trough YF476, fasting serum gastrin and CgA 
levels, and endoscopy (if applicable).  Patients stay for 1 h after dosing for collection of a blood sample for peak YF476 level.   
4. Pre-menopausal women only.  
5. These tests may be omitted if Visit 2 occurs on the same day as Visit 1.  


 
 
8.2 
Baseline testing and pre-study evaluation  
Visit 1: registration  
Patients will attend the clinic and complete the informed consent form.   The investigator 
will complete the following evaluation for each patient, and enter the data from this visit, 
and all subsequent visits, on the appropriate page of the CRF:  
• 
review of most recent endoscopy (within 3 years) to confirm diagnosis of Barrett’s 
esophagus with no dysplasia;  
• 
review of medication history to determine that participants meet the inclusion criteria 
(daily PPI use for at least the most recent 12 months before study entry, and stable PPI 
dose for at least the most recent 3 months before study entry);  
• 
medical history, physical examination, ECG and vital signs; • blood and urine samples 
for laboratory safety tests; and  
• 
urine pregnancy test (pre-menopausal women only).   
Visit 2: baseline  
Visit 2 may occur on the same day or up to 2 weeks after Visit 1.  The patient will fast for 6 
hours before the study visit.  The investigator will complete the following evaluation for 
each patient, and enter the data from this visit, and all subsequent visits, on the appropriate 
page of the CRF.  If Visits 1 and 2 are combined, only 1 blood sample (safety tests, fasting 
serum gastrin, plasma CgA and serum for storage) and 1 urine sample will be taken, and 
ECG, vital signs and pregnancy tests will be done only once.  
• 
blood and urine samples for laboratory safety tests, urine pregnancy test 
(premenopausal women only), ECG and vital signs;  
• 
blood samples for fasting serum gastrin, plasma CgA and serum for storage;  
• 
endoscopy and biopsies; and  
• 
randomization to 25 mg YF476 or placebo, and dispensing of study medication (a 42-
day supply, plus overage: 1 bottle of 25 mg YF476 or placebo containing 46 capsules).  
The investigator will then:  
• 
give the patient a diary card;  
• 
tell the patient to start taking their study medication the day after Visit 2;  
• 
remind the patient to fast before the Week 6 visit (6 weeks after starting study 
medication); and  
• 
remind the patient not to take their study medication at home on the day of the Week 6 
visit, but instead to bring their container of study medication with them to the visit, and 
take their dose at the clinic, after the fasting blood tests.   


 
 
8.3 
Evaluations during study treatment  
Week 6 visit: after 6 weeks of study treatment The 
investigator will:  
• 
check that the patient has fasted;  
• 
collect the diary card, and issue a new one;  
• 
check the diary card for compliance with treatment, and for adverse events and 
concomitant medication;  
• 
collect the study medication bottle and assess compliance;  
• 
do an ECG and vital signs;  
• 
take blood and urine for laboratory safety tests and urine pregnancy testing (pre-
menopausal women only);  
• 
take blood samples for fasting serum gastrin, plasma CgA, trough YF476 concentration 
and serum for storage;  
• 
after taking the fasting blood samples, give the patient their dose of study medication, 
wait 1 h, then collect blood for assay of peak concentration of YF476;  
• 
issue a new container of study medication, to be taken as before;  
• 
remind the patient to fast before the next visit; and  
• 
remind the patient not to take their study medication at home on the day of the Week 12 
visit, but instead to bring their container of study medication with them to the visit, and 
take their dose at the clinic, after the fasting blood tests and endoscopy.   
8.4 
Evaluations at completion of study treatment  
Week 12 visit: after 12 weeks of study treatment   The 
investigator will:  
• 
check that the patient has fasted;  
• 
collect the diary card;  
• 
check the diary card for compliance with treatment, and for adverse events and 
concomitant medication;  
• 
collect the study medication bottle and assess compliance;  
• 
do an ECG and vital signs;  
• 
take blood and urine for laboratory safety tests and urine pregnancy testing 
(premenopausal women only);  
• 
take blood samples for fasting serum gastrin, plasma CgA, trough YF476 concentration 
and serum for storage;  
• 
do an endoscopy and biopsies; and  


 
 
• 
after the endoscopy, give the patient their dose of study medication, wait 1 h, then 
collect blood for assay of peak concentration of YF476.   
8.5 
Post-treatment follow-up period  
Follow-up: 4 weeks after stopping study treatment   
The patient will return 4 weeks after the end of the treatment period.  The investigator will:  
• 
assess the patient for any delayed adverse events;  
• 
do an ECG and vital signs;  
• 
take blood and urine for laboratory safety tests and urine pregnancy testing 
(premenopausal women only); and  
• 
take blood samples for fasting serum gastrin, plasma CgA, and serum for storage.  
8.6 
Flexibility of study days  
There will be a ±4 day window for clinic visits.    
8.7 
Withdrawal of patients from the trial  
8.7.1 
Termination of study medication  
Patients may stop taking study medication for the following reasons.   
• 
When a patient has completed the protocol-prescribed treatment, we will not provide 
any further study medication.  
• 
If a patient has an adverse event, grade 2 or greater (see section 11.1), the patient or 
investigator may choose to terminate study treatment.  
• 
A patient might be non-compliant and stop taking the protocol-prescribed treatment; 
or the investigator may choose to terminate study treatment.   
• 
The investigator may terminate study treatment because of a medical 
contraindication.  
• 
The investigator may terminate study treatment because of evidence of serious 
interactions with medications metabolized by CYP3A4/5 or CYP2C8, (see Appendix 
B for list of relevant medications).   
In all cases listed above, patients will continue to be followed, if possible, for safety 
reasons and in order to collect endpoint data according to the schedule of events.   
8.7.2 
Termination of study participation  
Patients may go ‘off-study’ (ie leave the study with no follow-up possible) for the following 
reasons.   
• 
The protocol treatment and any protocol-required follow-up period is completed.   
• 
If a patient has an adverse event, grade 2 or greater (see section 11.1), the patient may 
choose to terminate study participation.   


 
 
• 
A patient might be lost to follow-up, if the investigator is unable to establish contact 
with him or her.  
• 
A patient might be non-compliant and not attend the clinic visits (including the 
follow-up visit).   
• 
The investigator may terminate study participation because of a medical 
contraindication.  
• 
A patient may withdraw his or her consent to participate in the study.   
• 
Determination of ineligibility, not discovered before enrollment.  In particular; 
patients will be withdrawn from the study if their baseline endoscopy (Visit 2): o 
does not show any intestinal metaplasia; or  
o biopsies are read as indefinite for dysplasia, low grade dysplasia, high grade 
dysplasia, or adenocarcinoma.  
• 
Death.   
8.8 
Study termination  
Enrollment of patients onto the study will be terminated when at least 20 participants have 
completed 12 weeks of treatment, undergone a post-treatment endoscopy, and returned for 
the follow-up visit (4 weeks after stopping study medication).  The study will end when the 
analysis of all biopsy samples is complete.   
9 
Criteria for evaluation and endpoint definition  
9.1 
Primary endpoint  
 
•  
Change in Ki67 expression (∆Ki67) between baseline (Visit 2) and the Week 12  
visit  
9.2 
Secondary endpoints  
• 
Biomarkers  
o 
Change from baseline at Week 12 in biomarkers associated with esophageal 
adenocarcinoma, in particular:    
 Change in CCK2R mRNA levels (measured by qRT-PCR)  
 Change in DCAMKL1 expression (measured by IHC)  
 Change in DCAMKL1 mRNA levels (qRT-PCR)  
 Change in COX-2 mRNA levels (qRT-PCR)  
 Change in p53 expression (IHC) o  Reduction in PPI-induced 
increase in plasma CgA o  
Increase in PPI-induced hypergastrinaemia  
• 
Safety  
o 
Vital signs, ECG, physical examination, laboratory safety tests: blood tests:  
red blood cells (RBC), haemoglobin, haematocrit, platelets, white blood cells  


 
 
(WBC, differential: neutrophils, bands, lymphocytes, monocytes, eosinophils, 
basophils), sodium, potassium, magnesium, chloride, bicarbonate, creatinine, 
serum glucose, blood urea nitrogen (BUN), alkaline phosphatase, lactate 
dehydrogenase (LDH), serum glutamic-oxaloacetic transaminase/aspartate 
amino transferase (SGOT/AST), serum glutamicpyruvic transaminase/ alanine 
aminotransferase (SGPT/ALT), total bilirubin, total protein, albumin, calcium, 
amylase, lipase; and urine tests: pH, specific gravity, protein, glucose, ketones, 
blood.  
o 
Change in histology  
• 
Tolerability:  assessment of adverse events.  
• 
Pharmacokinetics:  through and peak concentration of YF476  
10 
Methods  
10.1 
Methods for clinical procedures  
Upper endoscopy with biopsies will be performed at baseline (Visit 2) and at the Week 12 
visit, after 12 weeks’ treatment with study medication.  Patients will fast before the 
endoscopy, and will need to come accompanied to the site endoscopy suite, according to 
hospital practice and regulations.  Upon arrival at the endoscopy suite, a peripheral 
intravenous line will be inserted.  Informed consent will be obtained for the endoscopy 
prior to starting the procedure.  In the procedure room, a local anaesthetic (xylocaine) will 
be sprayed in the back of the mouth to diminish the gag reflex.  Subsequently, intravenous 
medication (specifically, midazolam, fentanyl, and/or propofol) will be administered in 
order to achieve moderate sedation.  Once the patient has been sedated, the upper 
endoscope will be inserted into the esophagus and advanced to the second portion of the 
duodenum.  The following represents standard clinical care for Barrett’s esophagus: 1) the 
area of Barrett’s esophagus will be carefully inspected for any focal nodules or mucosal 
irregularities that could represent the presence of dysplasia; 2) if any such abnormalities are 
noted, then targeted biopsies of these areas will be taken; 3) irrespective of the presence of 
such abnormalities, random 4-quadrant biopsies will be taken every 1–2 cm along the 
length of BE.  For study purposes, 6 additional biopsies will be taken and snap frozen for 
qRT-PCR analyses: GE junction (top of the gastric folds; 2 biopsies); mid-Barrett’s 
segment (2 biopsies); normalappearing esophageal mucosa (2 cm above the maximal extent 
of BE; 2 biopsies).   
10.2 
Rationale for laboratory methods  
In general, it is desirable to perform quantitative analyses of biomarkers, as achieved by 
using quantitative real-time PCR (qRT-PCR), in contrast to qualitative or  
semi-quantitative immunhistochemical analyses (IHC).  Quantitative analysis allows for 
detection of small differences between different tissue samples.  However, qRT-PCR does 
not discriminate between different cell types within a particular tissue sample, whereas IHC 
allows for visual assessment of the type and location of cells that express a biomarker of 
interest.  


 
 
• 
IHC for Ki67 is a robust marker of ongoing proliferation, and has been reliably and 
reproducibly used to evaluate cell type-specific evaluation.  Quantitative assessment 
of the number of proliferating (Ki67+) epithelial cells is easiest and most reliable in 
IHC.  
• 
For the assessment of CCK2R expression in human esophageal tissue, qRT-PCR 
seems to be the best method, as IHC with various antibodies has proven to be 
unreliable and non-specific.   
• 
Biologically relevant COX-2 expression can be quantitatively assessed using qRT-
PCR, but cannot be detected by IHC.   
• 
DCAMKL-1 is a putative marker of intestinal stem cells.  In order to analyze 
expansion of these putative stem cells in the development of Barrett’s esophagus, it is 
important to get an impression of the precise location of these cells.  Therefore, both 
qRT-PCR and IHC will be used to analyze DCAMKL-1 expression.  
• 
Changes in the levels of p53 protein expression can be detected best with IHC, as 
mRNA levels of p53 do not differ very much despite altered protein expression.  The 
function of p53 is more likely determined by protein stability.   
All the above described methods have been performed in previously published studies (by 
the chief investigator’s group and others) as well as in Dr. Timothy Wang’s laboratory in a 
new mouse model of Barrett’s esophagus and adenocarcinoma.  Therefore, the investigators 
will be able to compare the achieved data with previously published and unpublished 
results from the chief investigator’s laboratory and other groups.   
10.3 
Laboratory methods  
10.3.1 Laboratories  
All tissue biomarker analyses will be performed in the laboratory of Dr. Timothy Wang 
(Columbia University, New York, NY).  Histological review of specimens, including IHC 
assessment of Ki67, p53, and DCAMKL1 expression, will be performed by Dr.  
Antonia Sepulveda (Columbia University, New York, NY).  Routine testing of blood and 
urine specimens will be performed locally.  
10.3.2 Collection and handling procedures  
• 
Collection and analysis of tissue for IHC and qRT-PCR qRT-PCR.  Routine 
endoscopic biopsies (4 quadrant biopsies every 2 cm along the length of BE) will be taken 
for clinical purposes and placed in formalin.  The formalin-fixed biopsies taken at CUMC 
will be submitted to the Columbia University Department of Pathology (CUDP).  The 
formalin-fixed biopsies taken at NIHR CIW will be stored there; slides of the biopsies will 
be sent by courier to CUDP at the end of the study, or as agreed between the investigators 
and sponsor.  The respective Departments of Pathology will store the paraffin-embedded 
samples as per usual practice. Histologic analysis of biopsies from both study sites will be 


 
 
done at CUDP.  As per clinical practice, these biopsies will be reviewed to assess the 
presence of dysplasia.  Six additional biopsies (from each endoscopy; 2 biopsies each from 
GE junction, mid-Barrett’s segment, and normal esophagus) will be taken for study 
purposes, placed in Qiagen Allprotect™ tissue reagent, and then stored at –80°C for future 
qRT-PCR analysis. The freezers for storing these samples are located in the laboratory of 
Dr. Timothy Wang at Columbia University.  Samples taken at Cambridge University will be 
stored in freezers in Prof. Rebecca Fitzgerald’s laboratory at the MRC Cancer Unit, 
University of Cambridge, until dispatch to Columbia University.  
IHC analyses.  Additional sections will be cut from paraffin-embedded endoscopic biopsies 
for study purposes.  Slides from NIHR CIW will be sent by courier to Columbia University 
at the end of the study, or as agreed between the investigators and sponsor. Ki67 expression 
will be assessed by IHC from esophageal biopsies of Barrett’s esophagus.  Paraffin-
embedded biopsies from the most distal esophageal biopsies containing intestinal metaplasia 
will be immunostained for Ki67.  Ki67 index will be calculated as:  (# crypt epithelial cells 
with positive nuclear staining for Ki67) / (# BE crypt cells counted).  Five representative 
crypts with goblet cells will be evaluated from five separate fields at 100x magnification.  
∆Ki67 for YF476 and placebo arms will be compared.  The pathologist evaluating Ki67 
staining will be blinded to both treatment arm and timing of endoscopy (ie pre- or post-
treatment).  
• 
Collection and processing of blood samples for laboratory safety tests:  
20 mL of blood will be collected.  10 mL (one purple top, one gold top tube) will be used 
for routine measurements.  The other 10 mL (one purple top, one gold top tube) will be 
processed for separate storage of serum, plasma, and Buffy coats at –80°C.   
 
o  
Safety tests:  
 haematology:  Hb, RBC, haematocrit, WBC and differential, and platelets;    
 biochemistry: creatinine,  total bilirubin, BUN, LDH,  total protein, albumin, 
alkaline phosphatase, AST, ALT, glucose, potassium, sodium, calcium, 
magnesium, chloride, amylase and lipase.  
Blood specimens will be collected when the patient is fasting.  If the blood collection occurs 
on the day of the endoscopy, the blood will be collected prior to the endoscopy.    
 
•  
Collection of urine for laboratory safety tests  
A routine urine sample will be collected for standard urinalysis: dipstick test:  protein, 
blood, ketones, glucose, specific gravity, pH; microscopy if the result of the dipstick test 
for protein or blood is abnormal; and pregnancy test (pre-menopausal women only).  • 
 
Collection and processing of blood samples for serum gastrin and stored serum 
Venous blood for serum gastrin assay and stored serum (2 × 2.5 mL) will be collected into 
polypropylene tubes and will be allowed to clot at room temperature for at least 20 min.  
After clotting, the tubes will be centrifuged at about 1500 G for 10 min at 4°C, and the 
serum transferred to smaller tubes in equal aliquots then stored at –80°C before shipment to 
the HMR Analytical Laboratory, Cumberland Avenue, Park Royal, London, NW10 7EW.  


 
 
Shipment of serum samples for gastrin assay and storage will be agreed between the 
investigator and sponsor.  Serum will be stored by the HMR laboratory for assay of trial-
related markers only, which will be decided on at a later date.    
 
•  
Collection and processing of plasma for CgA assays  
4 mL venous blood will be collected into an EDTA tube and centrifuged at about 1500 G 
for 10 minutes at 4°C.  2 equal aliquots of plasma will be transferred to polypropylene 
tubes, and stored at –80°C, before shipment to the HMR Analytical Laboratory, 
Cumberland Avenue, Park Royal, London, NW10 7EW.  Shipment of plasma samples for 
CgA assay will be agreed between the investigator and sponsor.  All sample handling 
materials will be provided by the HMR Analytical Laboratory.  
 
•  
Gastrin and CgA assays    
Serum gastrin and plasma CgA will be measured by the HMR Analytical Laboratory using 
commercially available assays.  The analytical laboratory may not analyse samples 
collected from patients with HIV.   
 
•  
Collection and processing of blood samples for YF476 PK  
YF476 is light sensitive, so blood samples (4 mL) will be taken into foil-wrapped or amber 
lithium heparin tubes and immediately placed on ice.  Samples will be centrifuged at about 
1500 G for 10 minutes at 4°C.  Plasma will be transferred to foilwrapped or amber 
polypropylene storage tubes.  Plasma samples will be stored at –80°C within 90 minutes 
after collection, and stored in darkness until dispatch.  Samples will be sent to the HMR 
laboratory, Cumberland Avenue, London, NW10 7EW for reconciliation before being sent 
to Analytical Services, St George’s Hospital for analysis of YF476 by the method of 
Redrup et al 2002.18  
• 
All specimens will be labelled with a code assigned to the study patient.   
• 
A separate tracking sheet will be maintained for each study patient.  All specimens 
will be logged on these sheets, including date and time of collection.  
• 
Samples will be kept in storage for the duration of the study.  Unused samples will be 
kept in storage for an additional three years prior to disposal.  
The analytical laboratory may not analyse samples collected from patients with HIV.  
11 
Reporting adverse events  
Definition:  an adverse event (AE) is any untoward medical occurrence in a study 
participant.  An AE does not necessarily have a causal relationship with the treatment or 
study participant.  An AE can therefore be any unfavourable and unintended sign 
(including an abnormal laboratory finding), symptom, or disease temporally associated 
with participation in a study, whether or not related to that participation.  This includes any 
deaths that occur while a participant is on a study.  
A list of adverse events that have occurred or might occur can be found in Section 4.3, and 
in the Investigator Brochure.    


 
 
11.1 
Adverse events (AEs)  
• 
Reportable adverse events  
All adverse events that occur after the informed consent is signed will be recorded on 
the adverse event CRF whether or not related to study medication.  
• 
AE data elements  o  AE reported date o  AE Verbatim Term  
o 
SOC (System Organ Class from MedDRA)  
o 
Common Terminology for Adverse Events v4.0 (CTCAE) AE term o 
 Event onset date and event ended date o  
Severity grade  
o 
Attribution to study medication (relatedness)  
o 
Whether or not the event was reported as a Serious Adverse Event (SAE) o 
 Whether or not the patient dropped due to the event o  
Action taken with the 
study medication o  
Outcome of the event o  
Comments  
• 
Severity of AEs  
Adverse events will be identified using the NCI Common Terminology Criteria for 
Adverse Events (CTCAE) version 4.0.  The CTCAE provides descriptive 
terminology and a grading scale for each adverse event listed.  A copy of the CTCAE 
can be found at 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm#ctc_4 0  
AEs will be assessed according to the CTCAE grade associated with the AE term.  
AEs that do not have a corresponding CTCAE term will be assessed according to the 
general guidelines for grading used in the CTCAE v4.0. as stated below.   
• 
CTCAE v4.0 general severity guidelines   
(from http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.02_2009-09- 
15_QuickReference_8.5x11.pdf)  
Grade  
Severity  
Description   
1  
Mild  
Mild; asymptomatic or mild symptoms; clinical or 
diagnostic observations only; intervention not 
indicated.  
2  
Moderate  
Moderate; minimal, local or noninvasive intervention 
indicated; limiting age-appropriate instrumental 
ADL*.  
3  
Severe  
Severe or medically significant but not immediately 
life-threatening; hospitalization or prolongation of 
hospitalization indicated; disabling; limiting self-care  
ADL**.  
4  
Lifethreatening  Life-threatening consequences; urgent intervention 
indicated.  
5  
Fatal  
Death related to AE.  


 
 
• 
Activities of Daily Living (ADL)  
*Instrumental ADL refer to preparing meals, shopping for groceries or clothes, using 
the telephone, managing money, etc.  
**Self care ADL refer to bathing, dressing and undressing, feeding self, using the 
toilet, taking medications, and not bedridden.  
• 
Assessment of relationship of AE to treatment  
The possibility that the adverse event is related to study medication will be classified 
as one of the following:  not related, unlikely, possible, probable, definite.   
• 
Follow-up of AEs  
All AEs, including abnormalities that in the opinion of the investigator are clinically 
significant, will be followed according to good medical practices and documented as 
such.  
11.2 
Serious adverse events (SAEs)  
11.2.1 Definition  
ICH Guideline E2A and Fed. Reg. 62, Oct. 7, 1997 define serious adverse events as those 
events, occurring at any dose, which meet any of the following criteria:  
• 
Results in death.   
• 
Is life threatening (Note: the term life-threatening 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 inpatient hospitalization or prolongation of existing hospitalization.   
• 
Results in persistent or significant disability/incapacity.   
• 
Is a congenital abnormality/birth defect.   
• 
Events that may not meet these criteria, but which the investigator finds very unusual 
and/or potentially serious, will also be reported in the same manner.  
11.2.2 Reporting SAEs  
• 
The investigators will report SAEs on the SAE form.   
• 
The Sponsor representative and the Data Safety Monitoring Board (DSMB) 
representative will be contacted within 24 hours of knowledge of the event.    
• 
The following information will be included when informing the Sponsor and the 
DSMB representative:  
o 
when the SAE occurred o  
when the SAE report will 
be available  
o 
Name of reporter o  Call back phone number (if 
primary contact is by phone) o  
Protocol number  


 
 
o 
Description of the SAE, including attribution to drug   
• 
The investigators will FAX (or email a scan of) written SAE reports to the Sponsor 
and DSMB within 48 hours of learning of the event using the paper SAE form.  
• 
The Sponsor will determine which SAEs require submission to the competent 
authorities.  
• 
The Lead Organization and all Participating Organizations will comply with 
applicable regulatory requirements related to reporting SAEs to the IRB and/or REC.   
• 
Follow-up of SAE:  site staff will send follow-up reports as requested when 
additional information is available.  Additional information will be entered on the  
SAE form in the appropriate format.  Follow-up information will be sent to the 
Sponsor and DSMB as soon as available. SAEs will be followed by the study staff 
until resolved.  
12 
Data management and quality assurance  
Patient data will be collected using protocol-specific case report forms (CRF).  These will 
be designed and produced by HMR.  The final version will be approved by the sponsor.  
All data will be entered legibly in black or blue ink with a ball-point pen.  If an error is 
made, the error will be crossed through with a single line in such a way that the original 
entry can still be read.  The correct entry will then be clearly inserted and the alterations 
will be initialled and dated by the person making the alteration.  Overwriting or use of 
correction fluid is not permitted.  
To preserve confidentiality, the CRFs will not bear the subject’s name.  The subject’s 
initials, date of birth, and subject number will be used for identification.  
It will be the responsibility of the investigator to ensure the accuracy of all data entered in 
the CRFs.  
The data will be securely stored by the investigator.  After the CRFs have been signed off 
by the principal investigator, the original NCR copies will be sent to the Data Management 
department at HMR, where they will be securely stored on behalf of the sponsor.  
Data will be double-entered into a clinical database management system (ClinPlus Version 
3.3), which is based on SAS® Version 9.2.  Edit checks and generation of queries will be 
done in ClinPlus.  Tabulations and listings will be produced using validated, trial-specific 
SAS® programs.  
Data will be checked by the HMR Quality Assurance (QA) Department.  In addition, the 
HMR QA Department will audit the trial report; that audit will include checks to ensure 
that statistical output is correctly reproduced in the report.  
Source documents.  Before the start of the study, the sponsor and investigator(s) will sign 
an agreement listing the source documents to be used in this trial.  The CRF will be source 
for the following datapoints: heart rate and blood pressure.  


 
 
12.1 
Data and safety monitoring plan  
The Data Safety Monitoring Board (DSMB) will review all SAE forms as well as all AEs.  
If additional information is required, the DSMB will request that information from the PI.  
The DSMB will review reported AEs at regular meetings and provide written reports to the 
PI.  The reports will contain written information regarding findings for the trial as a whole 
related to cumulative toxicities observed and any relevant recommendations related to 
continuing, changing, or terminating the trial.   
Members of the DSMB are as follows:  
Benjamin Lebwohl (Columbia University, Division of Digestive & Liver Diseases) Lorna 
Dove (Columbia University, Division of Digestive & Liver Diseases)  
Zhezhen Jin (Columbia University, Department of Biostatistics)  
Hugo Ford (Cambridge University, Cancer Services)  
12.2 
Sponsor or regulatory monitoring  
Trio Medicines, Ltd. (or their designee) or the relevant regulatory authorities may 
monitor/audit various aspects of the study. These monitors will be given access to facilities, 
databases, supplies and records to review and verify data pertinent to the study.   
12.3 
Record retention  
The sponsor and both principal investigators will keep the following in a trial master file.  
• 
All the essential documents required by GCP  
• 
All data generated during the study  
All documents will be stored such that they are readily available for inspection at the 
request of the sponsor or a regulatory authority.  Any transfer of ownership of the 
investigator’s data or documents will be documented, and the sponsor will be informed.  
For at least 15 years after the end of the study, and at least 2 years after the last approval of 
a marketing application in an ICH region and until there are no pending or contemplated 
marketing applications in an ICH region or at least two years have elapsed since the formal 
discontinuation of clinical development of the study medication:  
• 
HMR will ensure that the sponsor’s master file and original copies of CRFs will be 
archived in a secure place; and  
• 
the investigators will ensure that the investigator’s master file, and original source 
documents (other than CRFs) will be archived in a secure place.    
12.4 
Clinical Trial Agreement   
The sponsor and the investigators will sign an agreement outlining each party’s obligations 
with respect to the trial.  
Each party will allow the other 30 days to comment before any results are submitted for 
publication, or 10 days prior to an abstract presentation.  Authorship should reflect work 
done by the investigators and personnel of the sponsor, in accordance with generally 
recognized principles of scientific collaboration.  


 
 
13 
Statistical methods  
13.1 
Analysis Sets  
The safety analysis set will include all patients who are randomized and receive at least one 
dose of study medication.  In this population, treatment will be assigned based upon the 
treatment patients actually receive regardless of the treatment to which they were 
randomized.  
The pharmacokinetic analysis set will include all patients who receive at least one dose of 
study medication, and yield at least one plasma concentration for YF476.  
The Intent-to-Treat (ITT) analysis set will include all randomized patients who receive at 
least one dose of study medication and have at least one post-baseline assessment.  In this 
population, treatment will be assigned based upon the treatment to which patients were 
randomized regardless of which treatment they actually received. A per-protocol analysis 
will also be completed.  
13.2 
General Statistical Considerations  
The null hypothesis is that there is no difference between YF476 and placebo in the 
treatment of patients with Barrett’s esophagus, the alternative hypothesis is that there is a 
difference between the treatments.  Statistical significance will be defined as p≤0.05.  
Statistical analysis will be done by HMR.  The statistical package SAS (version 9.2) will be 
used to produce all summary tables and data listings.  
For the data analysis, missing or dropout data will not be imputed; analyses will be 
performed only on observed data.  In this study, there will be no significance level 
adjustment for multiplicity.  
Quantitative data will be tabulated with descriptive summary statistics: arithmetic mean,  
standard deviation, median, minimum and maximum values, and number of observations.  
Geometric mean and geometric CV% will be provided for Cmax and Ctrough.   For categorical 
data, frequency tables will be provided.  
A detailed Statistical Analysis Plan (SAP) describing the methodology to be used in the 
final analysis will be prepared by the HMR Statistics and Data Management Department 
after completion of the final protocol.  Any deviations from the planned statistical analyses 
in the protocol will be fully described in the SAP.  
13.3 
Study Population Data  
The safety population will be summarized for demographic characteristics, and will be 
presented.  Continuous demographic variables (age, weight, height, and BMI) will be 
summarised with descriptive statistics.  Categorical demographic variables (gender, race, 
and ethnicity) will be summarised with frequency counts and corresponding percentages.  
13.4 
Efficacy Analyses  
All efficacy analyses, summaries and listings will be generated using the efficacy analysis 
set.  


 
 
Primary efficacy variables are:  
• 
Change in Ki67 expression (∆Ki67) Secondary efficacy variables are:   
• 
Change in CCK2R mRNA levels (measured by qRT-PCR)  
• 
Change in DCAMKL1 expression (measured by IHC)  
• 
Change in DCAMKL1 mRNA levels (measured by qRT-PCR)  
• 
Change in COX-2 mRNA levels (measured by qRT-PCR)  
• 
Change in p53 expression (measured by IHC)  
• 
Change in serum gastrin and plasma CgA between baseline and Visit 
5 For all efficacy variables listed above, individual values will be presented by 
patient and summarised by visit.    
The primary endpoint (Change from baseline (Visit 2) in Ki67 expression (∆Ki67)) will be 
summarised using descriptive statistics.  The primary analysis for the primary endpoint will 
use two sample t-tests comparing between treatment groups.  Nominal p-value and 95% 
confidence intervals for treatment difference will be reported.   To evaluate the robustness 
of the primary analysis, the following sensitivity analysis will also be performed:   
Baseline Adjusted Analysis: this sensitivity analysis will use an analysis of covariance 
model with the primary endpoint as the dependent variable, treatment group as a factor and 
baseline (Visit 2) as a covariate.  Adjusted least square means and corresponding 95% 
confidence interval will be reported.  
Serum gastrin and chromogranin A (CgA) will be measured at baseline (Visit 2) and at 
Weeks 6 and 12.  Analyses will be performed to determine whether there is a correlation 
between baseline gastrin and subsequent ∆Ki67.  YF476 assays will be performed at Weeks 
6 and 12.  
Analysis of the secondary endpoints will be similar to the primary analysis. No sensitivity 
analysis is planned for these endpoints.   
13.5 
Pharmacokinetic Analyses  
The statistical analysis of pharmacokinetic parameters will be done by the HMR Statistics 
and Data Management Department.  
All pharmacokinetic analyses, summaries, and listings will be generated using the 
pharmacokinetic analysis set.  
The pharmacokinetic parameters will be listed in tables of individual values and aggregated 
in summary tables.  Descriptive statistics (sample size, mean, standard deviation, 
coefficient of variation [%CV], standard error of the mean, minimum, maximum, and 
median) will be calculated at each evaluation timepoint for plasma concentrations of 
YF476.  
Individual, mean and median plasma concentration-time data will be presented graphically.  
The relationship between PK concentrations and plasma CgA concentration or serum 
gastrin concentration will be examined using a graphical approach.  


 
 
13.6 
Safety Analyses  
Summaries and listings of safety data will be generated using the safety analysis set.  
13.6.1 Adverse Event Analyses  
Adverse events (AEs) will be coded using the version of the Medical Dictionary for 
Regulatory Activities (MedDRA) that is current when the database is locked.  All AEs 
including serious AEs will be mapped to system organ class and preferred term, and will be 
listed in the data listing.  
A treatment-emergent adverse event (TEAE) is defined as an AE that emerges during 
treatment, having been absent pre-treatment, or that worsens relative to the pre-treatment 
state.    
The number and percentage of patients reporting TEAEs will be tabulated for the safety 
analysis set by MedDRA preferred term and system organ class, and further by relationship 
to study drug administered and by severity.    
Listings of deaths, SAEs, and AEs that lead to discontinuation of a patient will be 
presented.  
13.6.2 Analyses of Clinical Laboratory Tests  
Standard haematology, biochemistry and urinalysis at each planned assessment, and change 
from baseline at each planned post-baseline assessment, will be summarized.     
13.6.3 Electrocardiogram Analyses  
The ECG variables (PR, RR, QRS, QT, QTcB, and QTcF) and heart rate (HR) at each 
planned assessment will be summarised.  The QT intervals will be corrected for heart rate 
by the Bazett’s and Fridericia’s formula (QTcB = QT/[RR]1/2 and QTcF =  
QT/[RR]1/3).  The incidence of outliers in absolute QT, QTcF and QTcB intervals (>450, 
>480, and >500 msec), and the change from time-matched baseline in QT, QTcF and QTcB 
intervals (>30 and >60 msec) will be summarised.  
13.7 
Determination of sample size  
Based on our preliminary data, we estimate a mean baseline Ki67 index of 45–50%, with a 
common SD of 14–18%. Assuming a two-sided type I error rate of 0.05, a sample size of 
20 (10 per arm) has 98% power to detect a 30% absolute difference in ΔKi67 between the 
two arms if the common SD is 16%, and 97% power for a 25% difference with a 14% 
common SD (see Table 1).    
Table 1.  Power calculations based on 20 patients (10 per arm)  
  
ΔKi67YF – ΔKi67pl  
SD  
0.25  
0.30  
0.35  
0.14  
97%  
99%  
>99%  
0.16  
91%  
98%  
>99%  


 
 
0.18  
84%  
94%  
98%  
14 
Ethical and regulatory considerations  
This trial will be conducted in compliance with the protocol, Good Clinical Practice (GCP), 
and the applicable regulatory requirements.  
14.1 
Columbia University Medical Center, New York, US  
14.1.1 Form FDA 1572  
Prior to initiating this study, the Chief Investigator and the Principal Investigator at the 
Participating Organization(s) will provide a signed Form FDA 1572 stating that the study 
will be conducted in compliance with regulations for clinical investigations and listing the 
investigators that will participate in the protocol.  
14.1.2 Other required documents  
• 
Signed and dated current (within two years) CV or short biography for all 
investigators listed on the Form FDA 1572 for the Lead Organization and all 
Participating Organizations.   
• 
Current medical licenses for all investigators listed on Form FDA 1572 for the Lead 
Organization and all Participating Organizations.  
• 
Laboratory certification (eg, CLIA, CAP) and laboratory normal ranges for all labs 
listed on Form FDA 1572 for the Lead Organization and all Participating 
Organizations.  
• 
IRB Membership list/letter from IRB for the Lead Organization and all Participating 
Organizations.  
• 
Documentation of training in “Protection of Human Research Subjects” for all 
investigators listed on the FDA Form 1572 for the Lead Organization and all 
Participating Organizations.  
• 
Documentation of Federal-wide Assurance (FWA) number for the Lead Organization 
and all Participating Organizations.  
• 
Signed receipt of Investigator Brochure  
• 
Delegation of Responsibility form  
• 
FDA Form 3455 Financial Disclosure Form  
• 
Evidence of submission of this protocol to the FDA  
14.1.3 Institutional Review Board (IRB) approval  
Prior to initiating the study and receiving study medication, the Investigators at the Lead 
Organization and the Participating Organization(s) will obtain written approval to conduct 


 
 
the study from the appropriate IRB. Should changes to the study become necessary, 
protocol amendments will be submitted to the respective institutional IRBs.   
14.2 
National Institute for Health Research Clinical Investigation Ward,  
Cambridge, UK   
The trial protocol will be reviewed by a recognised REC, the Scientific Advisory Board 
(SAB) at Addenbrooke’s Clinical Research Centre, and by the MHRA.  The trial will not 
proceed in the UK unless the sponsor obtains from the MHRA a clinical trial authorisation 
(CTA), and the main REC and SAB approves the trial.  The trial will not proceed until the 
local National Health Service Trust has approved it.  
The trial will be done in compliance with EU Directives 2001/20/EC and 2005/28/EC, The 
Medicines for Human Use (Clinical Trials) Regulations 2004 and current amendments, the 
Declaration of Helsinki (South Africa Revision, 1996), GMP, the standard operating 
procedures issued by NRES for RECs in the UK, and Good Clinical Practice.  
The sponsor will ensure that the MHRA and the REC are informed promptly of suspected 
serious adverse reaction (SUSARs), and that any new reports of SUSARs from other 
ongoing trials of the IMP under investigation in this trial are notified to the MHRA, and to 
the REC, if applicable.  The sponsor will provide the investigator, the REC and the MHRA 
with annual safety reports of each IMP under investigation, and listings of all SSAR 
reports.    
The investigator will promptly inform the sponsor and chief investigator of any SAE that 
occurs during this trial.  The principal investigator will in turn inform the REC, if 
applicable.  The principal investigator will provide the REC with annual progress reports of 
the trial, if it lasts longer than a year.  
The principal investigator will report to the sponsor and chief investigator any protocol 
deviation that is, in his or her opinion, of clinical significance.  The principal investigator 
will also inform the sponsor and chief investigator in the event of several deviations which, 
although of no clinical significance, cause inconvenience and/or discomfort to the 
volunteers.  The principal investigator will in turn promptly inform the REC.  
The sponsor will notify the MHRA and REC of any serious breach of Good Clinical 
Practice (for example, the investigator puts subjects’ safety at risk, falsifies data, or 
persistently fails to comply with this protocol or Good Clinical Practice).   
Within 90 days after the end of the trial, the sponsor will ensure that the REC and the 
MHRA are notified that the trial has finished.  If the trial is terminated prematurely, those 
reports will be made within 15 days after the end of the trial.  
The sponsor will supply a summary report of the clinical trial to the MHRA and REC 
within 1 year after the end of the trial.   
14.3 
Informed consent  
All potential study participants will be given a copy of the IRB- or REC-approved 
information and consent form (ICF) to review. The investigator will explain all aspects of 


 
 
the study in lay language and answer all questions regarding the study. If the patient 
decides to participate in the study, he/she will be asked to sign and date the ICF. The study 
medication will not be released to a patient who has not signed the Informed Consent 
document. Patients who refuse to participate or who withdraw from the study will be 
treated without prejudice.  
Prior to study initiation, the site-specific ICFs will be reviewed and approved by the IRB or 
REC, as appropriate.  Prior to implementation, any changes to the ICF for Columbia 
University will be approved by the IRB, and any substantial changes to the ICF for 
Cambridge University will be approved by the REC.  
15 
Financing, expenses, and/or insurance  
The baseline endoscopy and biopsies are considered standard of care for eligible study 
patients, so the cost of those procedures will not be covered by the trial.  At CUMC, the 
baseline endoscopy and biopsies will be billed to the study patients’ insurance.  All 
additional tests and procedures, including the endoscopies and biopsies at the Week 12 
visit, will be covered by the trial. The YF476 and placebo capsules will be provided free of 
charge. If the participant is injured and requires medical treatment as a direct result of 
taking part in this study, the study sponsor will pay reasonable medical costs (doctor’s fees 
and medical expenses) needed to treat the injury.  The treatment must be authorized by the 
investigator except in the event of an emergency in which case the investigator should be 
notified as soon as possible.   
16 
Obligations of the sponsor and investigator  
16.1 
Publication  
Each party will allow the other 30 days to comment before any results are submitted for 
publication, or 10 days prior to an abstract presentation.  Authorship should reflect work 
done by the investigators and personnel of the sponsor, in accordance with generally 
recognized principles of scientific collaboration.  
16.2 
Archiving  
The sponsor and both principal investigators will keep the following in a trial master file.  
• 
All the essential documents required by GCP  
• 
All data generated during the study  
All documents will be stored such that they are readily available for inspection at the 
request of the sponsor or a regulatory authority.  Any transfer of ownership of the 
investigator’s data or documents will be documented, and the sponsor will be informed.  
For at least 15 years after the end of the study, and at least 2 years after the last approval of 
a marketing application in an ICH region and until there are no pending or contemplated 
marketing applications in an ICH region or at least two years have elapsed since the formal 
discontinuation of clinical development of the study medication:  


 
 
• 
HMR will ensure that the sponsor’s master file and original copies of CRFs will be 
archived in a secure place; and  
• 
the investigators will ensure that the investigator’s master file, and original source 
documents (other than CRFs) will be archived in a secure place.     
16.3 
Premature termination of the trial  
The sponsor and investigator reserve the right to terminate this trial should serious or 
severe AEs or any other safety issue occur during the trial.  In addition, the sponsor may, at 
any time for any reason, terminate the trial by halting further recruitment of patients.  If the 
trial is terminated prematurely, the investigator will return all CRFs to the sponsor, and the 
sponsor or investigator, as appropriate, will provide a written statement of the reasons for 
termination.  The sponsor will ensure that the IRB, REC and competent authorities are 
notified.  
17 
References  
1. 
Shaheen NJ. Advances in Barrett's esophagus and esophageal adenocarcinoma. 
Gastroenterology 2005;128:1554-66.  
2. 
Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin 2008;58:71-96.  
3. 
Shaheen N, Ransohoff DF. Gastroesophageal reflux, barrett esophagus, and esophageal 
cancer: scientific review. JAMA 2002;287:1972-81.  
4. 
Wang KK, Sampliner RE. Updated guidelines 2008 for the diagnosis, surveillance and 
therapy of Barrett's esophagus. Am J Gastroenterol 2008;103:788-97.  
5. 
Haigh CR, Attwood SE, Thompson DG, et al. Gastrin induces proliferation in Barrett's 
metaplasia through activation of the CCK2 receptor. Gastroenterology 2003;124:615-25.  
6. 
Wang JS, Varro A, Lightdale CJ, et al. Elevated serum gastrin is associated with a history of 
advanced neoplasia in Barrett's esophagus. Am J Gastroenterol 2010;105:1039-45.  
7. 
Boyce M. Investigator's Brochure: YF476. In: Trio Medicines, Ltd.; 2009.  
8. 
Brown LM, Devesa SS, Chow WH. Incidence of adenocarcinoma of the esophagus among 
white Americans by sex, stage, and age. J Natl Cancer Inst 2008;100:1184-7.  
9. 
Semple G, Ryder H, Rooker DP, et al. (3R)-N-(1-(tert-butylcarbonylmethyl)-2,3-dihydro-
2oxo-5-(2-pyridyl)-1H-1, 4-benzodiazepin-3-yl)-N'-(3-(methylamino)phenyl)urea (YF476): a potent 
and orally active gastrin/CCK-B antagonist. J Med Chem 1997;40:331-41.  
10. 
Takemoto Y, Yuki H, Nishida A, et al. Effects of YF476, a potent and selective 
gastrin/cholecystokinin-B receptor antagonist, on gastric acid secretion in beagle dogs with gastric 
fistula. Arzneimittelforschung 1998;48:403-7.  
11. 
Takinami Y, Yuki H, Nishida A, et al. YF476 is a new potent and selective 
gastrin/cholecystokinin-B receptor antagonist in vitro and in vivo. Aliment Pharmacol Ther 
1997;11:113-20.  
12. 
Lagergren J, Bergstrom R, Lindgren A, Nyren O. Symptomatic gastroesophageal reflux as a 
risk factor for esophageal adenocarcinoma. N Engl J Med 1999;340:825-31.  


 
 
13. 
El-Serag HB, Aguirre TV, Davis S, Kuebeler M, Bhattacharyya A, Sampliner RE. Proton 
pump inhibitors are associated with reduced incidence of dysplasia in Barrett's esophagus. Am J 
Gastroenterol 2004;99:1877-83.  
14. 
Garcia Rodriguez LA, Lagergren J, Lindblad M. Gastric acid suppression and risk of 
oesophageal and gastric adenocarcinoma: a nested case control study in the UK. Gut 2006;55:1538-
44.  
15. 
Feagins LA, Zhang HY, Hormi-Carver K, et al. Acid has antiproliferative effects in 
nonneoplastic Barrett's epithelial cells. Am J Gastroenterol 2007;102:10-20.  
16. 
Ferrand A, Wang TC. Gastrin and cancer: a review. Cancer Lett 2006;238:15-29.  
17. 
Green DA, Mlynarczyk CM, Vaccaro BJ, et al. Correlation between serum gastrin and 
cellular proliferation in Barrett's esophagus. Therap Adv Gastroenterol 2011 (in press).  
18. 
Redrup MJ, Leaf FC, Miyashita A, et al. Validation of a liquid chromatographic-tandem 
mass spectrometric method for the measurement of (R)-1-[2,3-dihydro-2-oxo-1-pivaloylmethyl-5-
(2pyridyl)-1H-1,4-benzodiazep in-3-yl]-3-(3-methylaminophenyl)urea (YF476) in human plasma. J 
Chromatogr B Analyt Technol Biomed Life Sci 2002;772:317-25.  
19. 
The Rules Governing Medicinal Products in the European Union, Volume 4 – Good 
Manufacturing Practice, incorporating Directive 2003/94/EC.