Conditions: Irritable Bowel Syndrome Characterized by Constipation
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 20
Healthy volunteers: no

Brief summary:
The objective of this trial is to determine the effect of linaclotide on abdominal girth in IBS-C participants with the baseline symptoms of abdominal bloating and an increased abdominal girth.

Detailed description:

Arms:
arm 1: Linaclotide Oral, once daily arm 2: Matching Placebo Oral, once daily

Interventions: intervention 1: Linaclotide intervention 2: Placebo
Intervention descriptions: intervention 1: Oral, once daily intervention 2: Oral, one daily

Protocol document:
Prot_000.pdf: 
 
 
 
Clinical Study Protocol: MCP-103-403-P-04 
Final Version, 25 April 2017 
 
Study Title: 
A Phase 4, Single-centre, Randomised, Double-blind, Placebo-
controlled, Parallel-group, Fixed-dose Study of the Effect of 
Linaclotide on Abdominal Girth in Participants with Irritable 
Bowel Syndrome with Constipation 
Study Number: 
MCP-103-403 
Study Phase: 
4 
Product Name: 
Linaclotide 
Sponsor: 
Ironwood Pharmaceuticals, Inc. 
301 Binney Street 
Cambridge, Massachusetts 02142 
Sponsor Contact: 
 
 
Original Protocol Date: 
14 October 2015 
Protocol Amendment #1: 
24 February 2016 
Protocol Amendment #2: 
26 July 2016 
Protocol Amendment #3: 
25 April 2017 
 
 
This document is the property of Ironwood Pharmaceuticals, Allergan and the University 
Hospital of South Manchester and may not—in full or part—be passed on, reproduced, 
published, distributed, or submitted to any regulatory authority or any other person or 
organisation without the express written permission of Ironwood Pharmaceuticals, Allergan, 
and the University Hospital of South Manchester. 
Document Date: 25-Apr-2017 9:50 / Version 4






Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
Page 4 of 79 
SYNOPSIS 
Study Number: MCP-103-403 
Title of Study:  A Phase 4, Single-centre, Randomised, Double-blind, Placebo-controlled, 
Parallel-group, Fixed-dose Study of the Effect of Linaclotide on Abdominal Girth in 
Participants with Irritable Bowel Syndrome with Constipation 
Investigator:  
 
Study Centre:  University of Manchester, Manchester, UK 
Development Phase: Phase 4 (Collaborative Study) 
Objective: 
To determine the effect of linaclotide on abdominal girth in irritable bowel syndrome with 
constipation (IBS-C) participants with the baseline symptoms of abdominal bloating and an 
increased abdominal girth. 
Methodology: 
This protocol describes a single-centre, randomised, double-blind, placebo-controlled, 
parallel-group, fixed-dose, 4-week study, consisting of 4 distinct periods. Participants 
attending the IBS clinic at the University Hospital of South Manchester or those held in the 
database of the Neurogastroenterology Unit should be eligible for the study as long as they 
have no concomitant exclusionary disease. 
Figure S1. Study Design 
 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
Page 5 of 79 
Study Periods: 
Screening Period (Day -21 through Day -8):  The Screening Period starts with the signature of 
the informed consent form (ICF) and lasts for up to 14 calendar days. During this period, 
participant eligibility for entry into the Pretreatment Period will be determined. The end of the 
Screening Period coincides with the start of the Pretreatment Period, and the Screening Visit 
can occur on the same day as the Pretreatment Visit. 
Pretreatment Period (Day -7 through Day -1):  The Pretreatment Period is defined as the 
7 calendar days immediately before randomisation. During this period, participants will record 
(via paper diary) Daily Bowel Habits, Daily Participant Symptom Severity Assessments 
scored on an 11-point numerical rating scale (NRS), and per protocol Rescue Medicine 
(bisacodyl tablets or suppositories) or any other laxative, suppository, or enema use. At the 
end of the Pretreatment Period, participants will be fitted with the abdominal inductance 
plethysmography (AIP) belt and their abdominal girth measured over the next 24 hours. 
During this time they will be asked to record their subjective symptoms of abdominal pain, 
discomfort, bloating, and distension on an hourly basis (during waking hours) via a Digestive 
Sensations Questionnaire. In addition, they will also be asked to empty their bladder on an 
hourly basis (during waking hours), or more frequently if they have the desire to go, to avoid 
confounding between symptoms of bladder fullness and IBS-C abdominal symptoms. 
Treatment Period (Day 1 through Day 29):  The Treatment Period begins with randomisation 
and lasts for 4 weeks. On return to the study centre for the Randomisation Visit (Day 1), the 
data from the AIP belt will be downloaded immediately and those exhibiting an increase in 
girth during the course of the previous day of >4 cm are eligible for the study. A participant 
whose girth does not increase by >4 cm will be refitted with the belt for another 24 hours. The 
abdominal girth requirement will not be disclosed to the participant. If they still do not reach 
the required girth measurement, they will be excluded from the study. Participants who meet 
all other entry criteria will be randomised (1:1) to once daily oral capsules containing 290 ug 
linaclotide or matching placebo. Participants will take their initial dose of study drug in the 
study centre during the Randomisation Visit; thereafter, study drug is to be taken once daily, 
in the morning, ≥ 30 minutes before breakfast. Participants will continue to record their daily 
diary assessments throughout the Treatment Period. Abdominal girth will be measured by the 
AIP belt, and the Digestive Sensations Questionnaire will be administered, for another 24 
hours at the mid-point of the Treatment Period (Day 13 Visit) and again at the end of 
treatment (Day 27 Visit) to assess the effect of the treatment on abdominal girth and IBS-C 
symptoms. 
Follow-up Period (Day 30 through Day 36): The Follow-up Period starts at the End of 
Treatment Visit (Visit 8) and finishes with the Follow-up Telephone Call on Day 36, one 
week after the End of Treatment Visit (Visit 8). During this call, participants will be asked to 
report any adverse events (AEs) since the End of Treatment Visit (Visit 8) and detail any other 
symptoms or comments they may have. 
Note: End of Study will be defined as the last participant Follow-up Telephone Call (Day 36 ± 
2). 
For details regarding assessments during each study period, see the Schedule of Evaluations. 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
Page 6 of 79 
Ethical Considerations: 
The study will be submitted to the Greater Manchester Research Ethics Committee (REC) for 
approval. 
Concomitant and Rescue Medicine: 
At the Screening Visit, all ongoing medicines taken by the participant will be recorded. Any 
over-the-counter or prescription laxatives, suppositories, or enemas used to treat IBS-C may 
not be used on the calendar day before the Pretreatment Visit. Other prohibited medicines may 
not be used during the 14 calendar days before the Pretreatment Visit. 
A complete list of drugs that are conditionally allowed as concomitant medicines for either 
episodic or chronic use or as Rescue Medicine is provided in Appendix 1. Prohibited 
concomitant medicines are also included in Appendix 1.  
During the Pretreatment and Treatment Periods, participants may use dispensed, protocol-
defined laxatives (bisacodyl tablets or suppositories) as Rescue Medicine when at least 72 
hours have passed since their previous BM or when their symptoms become intolerable. In 
order to qualify for randomisation into the Treatment Period, participants must not have used 
Rescue Medicine on the calendar day before the Randomisation Visit and on the day of the 
Randomisation Visit up until the time of the clinic visit. Participants must agree to refrain 
from using Rescue Medicine from the time of the clinic visit through the calendar day after 
randomisation. Furthermore, participants will be asked to refrain from using Rescue Medicine 
on the day before, day of, and day after each AIP measurement. 
Any changes in concomitant medicines or new medicines added from the Screening Period 
through the Follow-up Period will be recorded on the CRF. Concomitant medicines will be 
recorded at all study visits throughout the entire study. Rescue Medicine will be documented 
by the participant on the Rescue Medicine record form. 
Planned Number of Participants: 
In order to ensure that 40 participants have completed the study as planned, up to 120 
participants may need to be screened. 
Diagnosis and Main Criteria for Inclusion: 
Inclusion Criteria: 
To be eligible to participate in the study, participants must meet all of the following criteria: 
1. Participant has provided written informed consent before participating in the study after 
being given a full description of the study and prior to any study-specific procedures being 
performed. 
2. Participant is a male or non-pregnant, non-breastfeeding female, and is age 18 years or 
older (no upper age limit). 
3. Female participants of childbearing potential must complete a urine pregnancy test with 
negative results at the Screening Visit (Visit 1) and again at the Randomisation Visit (Visit 
4) prior to dosing. 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
Page 7 of 79 
4. Female participants who are pre-menopausal should be enrolled between days 7 and 21 of 
their menstrual cycle.   
5. Sexually active female participants of childbearing potential must agree to use one of the 
following methods of contraception from the date that they sign the ICF until the end of 
study:  
a) Hormonal contraception (i.e., oral contraceptive, contraceptive implant, or 
injectable hormonal contraceptive); 
b) Intra-uterine device (IUD); 
c) A barrier birth control (such as condoms or occlusive cap with spermicidal 
foam/gel/film/cream/suppository); 
d) Surgical sterilisation (i.e., bilateral oophorectomy, hysterectomy, or tubal ligation); 
e) Abstinence, when in the opinion of the Investigator, the participant’s occupation or 
lifestyle gives sufficient evidence that abstinence will be maintained throughout the 
study and for 1 month thereafter.  
6. Participant meets Rome III criteria for IBS-C, as well as abdominal pain score (average of 
≥3 on 0-10 point numerical rating scale [NRS]) and abdominal bloating score (average of 
≥5 on 0-10 point NRS) during the PreTreatment Period, and criterion for abdominal girth 
measurement (AIP increase of >4 cm) criteria over a 24-hour period. 
7. Participant agrees to refrain from strenuous physical activity for 24 hours prior to each 
study visit and for all periods of AIP belt recordings from the time of fitting until belt 
removal. 
8. Participant agrees to refrain from initiating any lifestyle or dietary changes. 
9. Participant agrees to refrain from taking any probiotics from 14 days prior to enrollment in 
the study throughout the Treatment Period.  
10. Participant is able to communicate well with the Investigator and to comply with the 
requirements for the entire study. 
11. Participant has a body mass index (BMI) between 18.5 and 34.9 kg/m2 (bounds included) 
at the Screening Visit. 
Exclusion Criteria: 
Participants who meet any of the following criteria will not be eligible to participate in the 
study: 
1. Participant reports loose (mushy) or watery stools (BSFS score of 6 or 7) in the absence of 
any laxative, suppository, enema, or prohibited medicine (as described in Appendix 1) for 
>25% of BMs during the 12 weeks before the Screening Visit. 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
Page 8 of 79 
2.  Participant has ever had a diagnosis of familial adenomatous polyposis, hereditary 
nonpolyposis colorectal cancer, or any other form of familial colorectal cancer, or 
inflammatory bowel disease. 
3. Participant currently has both unexplained and clinically significant alarm symptoms 
(lower GI bleeding, iron-deficiency anaemia or any unexplained anaemia, or weight loss) 
or systemic signs of infection or colitis. 
4. Participant currently has active peptic ulcer disease (i.e., disease that is not adequately 
treated or stable with therapy). 
5. Participant has a history of any chronic GI condition (e.g., diverticulitis) that can be 
associated with abdominal pain or discomfort. 
6. Participant has CNS disease or any organic condition associated with constipation. 
7. Participant has had surgery that meets any of the following criteria:  
a. Has undergone any surgery within 6 months prior to the Screening Visit;  
b. Has had previous abdominal surgery except appendectomy, cholecystectomy, or 
hysterectomy. 
8. Participant has diabetes. 
9. Participant reports using a Prohibited Medicine (excluding laxatives, suppositories, and 
enemas) during the Pretreatment Period or is not willing or able to abide by the restrictions 
regarding use of Prohibited Medicines defined in Appendix 1. (Note: the use of fibre, bulk 
laxatives, or stool softeners [such as docusate] is acceptable provided that the participant 
has been on a stable dose during the 30 days before the Screening Visit and plans to 
continue on a stable dose throughout the study.) 
10. Participant has taken commercially available linaclotide during the 30 days prior to the 
Screening Visit. 
11. Participant is drinking alcohol above the recommended safe alcohol limit (< 21 
units/week) or abusing drugs. In addition, participants will be asked to refrain from 
drinking alcohol for 24 hours before plethysmography recordings and until belt removal. 
12. Participant has an acute or chronic condition that, in the Investigator’s opinion, would 
limit the participant’s ability to complete or participate in this clinical study. 
13. Participant has lactose intolerance.  
14. Participant is involved in this study as an Investigator, sub-Investigator, study coordinator, 
other study staff, or Sponsor member. 
15. Participant has a known or suspected mechanical gastrointestinal obstruction. 
16. Participant has a history of hypersensitivity to linaclotide or to any of the excipients 
contained in the study drug (active or placebo). 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
Page 9 of 79 
Test Product, Planned Doses, and Mode of Administration: 
Linaclotide 290 ug once daily, oral administration. Should diarrhoea occur while taking the 
290 ug dose, the daily dose may be temporarily suspended by the Investigator until resolution 
of the diarrhea, but participants must be taking study drug for 24 hours before AIP belt 
fittings.  
Reference Therapy, Planned Dose, and Mode of Administration: 
Placebo to match linaclotide 290 ug once daily, oral administration. Should diarrhoea occur 
while taking the 290 ug dose, the daily dose may be temporarily suspended by the Investigator 
until resolution of the diarrhea, but participants must be taking study drug for 24 hours before 
AIP belt fittings. 
Duration of Treatment: 
Total participation is expected to last for up to 57 days. There will be a Screening Period of up 
to 14 days, followed by a Pretreatment Period of 7 days, followed by a 29-day double-blind 
Treatment Period and a 7-day Follow-up Period.  
Criteria for Evaluation: 
Primary Outcome Measure: 
Mean change from randomisation (Visit 4) to the end of the study (Visit 8) in abdominal girth 
(as measured by AUC) determined by 24-hour AIP between the linaclotide and placebo 
groups. 
Secondary Outcome Measures: 
Diary questions that determine the following: 
• Daily participant assessment of abdominal pain, discomfort, bloating, and distension; 
• Whether a BM is an SBM; 
• Whether an SBM is a CSBM; 
• Stool consistency (Bristol Stool Form Scale [BSFS]) with each BM. 
Safety Measures:  Adverse event recording, clinical laboratory measures, vital sign 
parameters, and physical examinations. 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
Page 10 of 79 
Statistical Methods: 
Sample Size Determination: 
To achieve 80% power to detect a difference of 2.2 cm or more (using a simple 2-sided t-test 
with estimated SD = 2.4 cm and the conventional 5% significance level) in the mean change 
in abdominal girth (as measured by AIP AUC) from the start to the end of the day, between 
the active and placebo groups, 20 participants per group (40 participants in all) are required. 
Assuming a 15% dropout rate, 47 participants would need to be randomised to yield 40 
evaluable participants. Estimating a 60% screen/pretreatment failure rate (mostly from failure 
to meet distension criteria, but also pretreatment abdominal pain and abdominal bloating 
criteria), 120 participants would need to enter screening to achieve 40 randomised 
participants. 
Analysis Populations: 
ITT Population (all who were randomised to a treatment group at the randomisation visit), 
Safety Population (all randomised participants who received at least one dose of study drug) 
and Evaluable Population (all participants included in the Safety Population presenting no 
major protocol deviations with the potential to bias the criteria for evaluation and with full 
follow-up). 
Efficacy Analyses: 
Changes from Baseline in abdominal girth at 4 weeks (primary outcome) using analysis of 
covariance on AUC measures (24-hour AIP) and at 2 weeks as well as changes in maximal 
abdominal girth at both 2 and 4 weeks.  
Change from Baseline in symptom severity and Bristol Stool Form Scale (diary data) using 
longitudinal regression analysis on weekly average scores. 
Change from Baseline in digestive sensation at 2 and 4 weeks as measured by hourly scores, 
using analyses of covariance on AUC measures. 
Safety Analyses: 
Adverse events will be summarised by system organ class (SOC), preferred term (PT), and 
treatment group. Listings will be provided for severe AEs, drug-related AEs, SAEs, and AEs 
leading to study discontinuation. Descriptive statistics will be calculated on vital signs and 
clinical laboratory tests by treatment group. 
 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 11 of 79 
Schedule of Evaluations 
 
Screening 
Period 
(14 days) 
Pretreatment Period 
(7 days) 
Treatment Period 
(29±2 days) 
Follow-up 
Period (7± 
2 days) 
Visit Name → 
Screening 
Visit 
Pretreatment 
Visit 
Baseline 
Visit 
Randomisation 
Visit 
Day 13 
Visit 
Day 15 
Visit 
Day 27 
Visit 
EOT 
Visita 
Follow-up 
Visit Number → 
Visit 1 
Visit 2 
Visit 3 
Visit 4 
Visit 5 
Visit 6 
Visit 7 
Visit 8 
Telephone 
Call 
Visit Day → 
Day -21 
Day -7 
Day -2 
Day 1 
Day 
13±2 
Day 
15±2 
Day 
27±2 
Day 
28±2 
Day 36 ± 2 
Study Procedure ↓ 
 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
Inclusion and exclusion criteria 
verification 
X 
 
 
X 
 
 
 
 
 
Medical and surgical history 
X 
 
 
X 
 
 
 
 
 
Rome III status for IBS-C 
X 
 
 
 
 
 
 
 
 
Physical examinationb 
X 
 
 
X 
 
 
 
X 
 
Body weight and heightc 
X 
 
 
X 
 
X 
 
X 
 
Seated vital signsd 
X 
 
 
X 
 
X 
 
X 
 
Prior and concomitant medicines 
X 
X 
X 
X 
X 
X 
X 
X 
 
Clinical laboratory determinationse 
X 
 
 
 
 
 
 
 
 
Pregnancy testf 
X 
 
 
X 
 
 
 
X 
 
Completion of HADs and IBS-SSS 
X 
 
 
 
 
 
 
X 
 
Laxative, suppository, and enema 
washout instructions 
X 
 
 
 
 
 
 
 
 
AE evaluationsg 
 
X 
X 
X 
X 
X 
X 
X 
X 
Rescue Medicine dispensedh 
 
X 
 
X 
 
X 
 
 
 
Diary training, compliance 
verification, and reminderi 
 
X 
X 
 
X 
 
X 
 
 
Daily diary recording 
 
X 
X 
X 
X 
X 
X 
X 
 
Daily diary collection 
 
 
 
X 
 
X 
 
X 
 
Digestive Sensations questionnaire 
given 
 
 
X 
 
X 
 
X 
 
 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 12 of 79 
Schedule of Evaluations 
 
Screening 
Period 
(14 days) 
Pretreatment Period 
(7 days) 
Treatment Period 
(29±2 days) 
Follow-up 
Period (7± 
2 days) 
Visit Name → 
Screening 
Visit 
Pretreatment 
Visit 
Baseline 
Visit 
Randomisation 
Visit 
Day 13 
Visit 
Day 15 
Visit 
Day 27 
Visit 
EOT 
Visita 
Follow-up 
Visit Number → 
Visit 1 
Visit 2 
Visit 3 
Visit 4 
Visit 5 
Visit 6 
Visit 7 
Visit 8 
Telephone 
Call 
Visit Day → 
Day -21 
Day -7 
Day -2 
Day 1 
Day 
13±2 
Day 
15±2 
Day 
27±2 
Day 
28±2 
Day 36 ± 2 
Study Procedure ↓ 
 
 
 
 
 
 
 
 
 
Digestive Sensations questionnaire 
collected 
 
 
 
X 
 
X 
 
X 
 
AIP fittedj 
 
 
X 
 
X 
 
X 
 
 
AIP Assessment 
 
 
 
X 
 
X 
 
X 
 
Randomisation 
 
 
 
X 
 
 
 
 
 
Study drug dispensedk 
 
 
 
X 
 
 
 
 
 
Study drug accountability 
 
 
 
 
 
X 
 
X 
 
Follow-up phone call 
 
 
 
 
 
 
 
 
X 
a. 
Participants who are randomised but do not complete the Treatment Period (withdraw consent or are discontinued before they have completed 4 weeks of 
treatment) shall be considered Treatment-Period withdrawals and should complete the procedures required at the EOT Visit (even if out of window). 
b. A physical examination should include the following: general appearance, HEENT (head, ears, eyes, nose, and throat), neck, cardiovascular, thorax/lungs, 
abdomen, musculoskeletal, lymph nodes, skin, neurologic, and mental status. Rectal examination is not required; however, sigmoidoscopy/colonoscopy may 
be performed at the discretion of the Investigator. 
c. 
Height will only be measured at the Screening Visit (Visit 1) 
d. Vital signs (oral temperature, respiratory rate, systolic and diastolic blood pressure, and pulse rate) must be obtained from participants who are in the seated 
position. 
e. 
Complete hematology and chemistry will be required at the Screening Visit (Visit 1) if lab results obtained within the prior 30 days are not available.  
f. 
To be eligible for the study, a negative urine pregnancy test must be documented at the Screening Visit (Visit 1) and Randomisation Visit (Visit 4); another 
urine pregnancy test will be performed at the EOT Visit (Visit 8).  
g. All AEs occurring after the participant signs the ICF will be documented.  
h. Rescue Medicine (bisacodyl tablets) will be supplied to participants at the Pretreatment Visit (Visit 2) and, if needed, at subsequent visits. 
i. 
At the Pretreatment Visit (Visit 2) the Study Coordinator will instruct the participants about the use of the Daily Diary. At subsequent visits, the Study 
Coordinator will review the Daily Diary to verify participant compliance. After determining the participant’s compliance, the Study Coordinator will remind 
participants to record their diary assessments daily. 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 13 of 79 
j. 
Women who are actively menstruating during AIP belt placement should have their visits delayed for 48 hours. Participants who have taken Rescue 
Medicines within 24 hours of AIP belt placement should have their visits delayed until 24 hours have passed since the use of Rescue Medicine. Participants 
who have had study drug suspended due to diarrhea should have their AIP belt placement visits delayed until study drug has been resumed for 24 hours.   
k. Study drug will be administered in the clinic at the Randomisation Visit (Visit 4). At this visit, study drug does not need to be taken in the morning before 
breakfast. On all other days, study drug will be taken once daily in the morning at least 30 minutes before breakfast. 
AE = adverse event; AIP = abdominal inductance plethysmography; IBS-C = irritable bowel syndrome with constipation; EOT = end of treatment; 
HADs = Hospital Anxiety and Depression Scale; IBS-SSS= Irritable Bowel Syndrome Symptom Severity Score 
 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 14 of 79 
SAFETY/MEDICAL MONITORING AND STUDY CONTACTS 
A summary of key study participants is provided in Table 1. 
Table 1. 
Key Study Participants 
Role 
Contact Information 
Principal Investigator and Study Centre: 
 
University Hospital of South Manchester 
Southmoor Road 
Wythenshawe 
Manchester, UK 
M23 9LT 
 
 
Ironwood Contact: 
 
Ironwood Pharmaceuticals, Inc. 
301 Binney Street 
Cambridge, MA  02142 
 
 
 
Medical Monitor: 
 
Ironwood Pharmaceuticals, Inc. 
301 Binney Street 
Cambridge, MA  02142 
 
 
 
Safety Officer: 
 
Ironwood Pharmaceuticals, Inc. 
301 Binney Street 
Cambridge, MA  02142 
 
 
Serious Adverse Event (SAE) E-mail: 
clinicalsafety@ironwoodpharma.com 
Dedicated SAE Facsimile Number: 
1-617-933-7688 
 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
l 
Page 15 of 79 
TABLE OF CONTENTS 
SPONSOR SIGNATURE ................................................................................................................2 
INVESTIGATOR’S SIGNATURE .................................................................................................3 
SYNOPSIS .......................................................................................................................................4 
SAFETY/MEDICAL MONITORING AND STUDY CONTACTS ............................................14 
LIST OF ABBREVIATIONS ........................................................................................................21 
1. 
ETHICAL CONSIDERATIONS ...........................................................................................23 
1.1 
INSTITUTIONAL REVIEW BOARD/ETHICS COMMITTEES .............................23 
1.2 
PARTICIPANT INFORMATION AND INFORMED CONSENT............................23 
2. 
INVESTIGATORS AND STUDY ADMINISTRATIVE STRUCTURE ............................25 
3. 
INTRODUCTION .................................................................................................................26 
3.1 
BACKGROUND .........................................................................................................26 
3.2 
INVESTIGATIONAL PRODUCT ..............................................................................28 
4. 
STUDY OBJECTIVES ..........................................................................................................31 
5. 
STUDY DESIGN...................................................................................................................32 
5.1 
OVERALL STUDY DESIGN AND PLAN: DESCRIPTION ....................................32 
5.1.1 
Study Periods .....................................................................................................33 
5.1.1.1 
Screening Period ......................................................................................33 
5.1.1.2 
Pretreatment Period ..................................................................................33 
5.1.1.3 
Treatment Period ......................................................................................33 
5.1.1.4 
Follow-up Period .....................................................................................34 
5.2 
DISCUSSION OF STUDY DESIGN, INCLUDING THE CHOICE OF 
CONTROL GROUPS ..................................................................................................34 
6. 
STUDY POPULATION ........................................................................................................35 
6.1 
SELECTION OF STUDY POPULATION .................................................................35 
6.2 
INCLUSION CRITERIA .............................................................................................35 
6.3 
EXCLUSION CRITERIA ...........................................................................................36 
7. 
STUDY TREATMENTS .......................................................................................................38 
7.1 
TREATMENTS ADMINISTERED ............................................................................38 
7.2 
IDENTITY OF INVESTIGATIONAL PRODUCT ....................................................38 
7.3 
METHOD OF ASSIGNING PARTICIPANT TO TREATMENT GROUPS ............38 
7.4 
SELECTION AND TIMING OF DOSE FOR EACH PARTICIPANT .....................39 
7.5 
BLINDING ..................................................................................................................39 
7.6 
CONCOMITANT MEDICINES .................................................................................39 
7.7 
TREATMENT COMPLIANCE ..................................................................................40 
8. 
PROCEDURES......................................................................................................................41 
8.1 
SCREENING PERIOD (DAY -21 TO DAY -8) .........................................................41 
8.1.1 
Screening Visit (Visit 1) ....................................................................................41 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 16 of 79 
8.2 
PRETREATMENT PERIOD (DAY -7 TO DAY -1) ..................................................42 
8.2.1 
Pretreatment Visit (Visit 2) ................................................................................42 
8.2.2 
Baseline Visit (Visit 3) .......................................................................................42 
8.3 
TREATMENT PERIOD (DAY 1 TO DAY 29) ..........................................................43 
8.3.1 
Randomisation Visit (Visit 4) ............................................................................43 
8.3.2 
Day 13 Visit (Visit 5) .........................................................................................44 
8.3.3 
Day 15 Visit (Visit 6) .........................................................................................44 
8.3.4 
Day 27 Visit (Visit 7) .........................................................................................45 
8.3.5 
End of Treatment Visit (Visit 8) ........................................................................45 
8.4 
FOLLOW-UP PERIOD (DAY 29 TO DAY 35) .........................................................46 
8.4.1 
Follow-up (Telephone Call) ...............................................................................46 
9. 
STUDY OUTCOME ASSESSMENTS .................................................................................47 
9.1 
EFFICACY MEASUREMENTS ................................................................................47 
9.1.1 
Primary Efficacy Assessment ............................................................................47 
9.1.2 
Secondary Efficacy Assessments and Additional Efficacy Assessments ..........47 
9.2 
SAFETY OUTCOME ASSESSMENTS .....................................................................50 
9.2.1 
Adverse Events ..................................................................................................50 
9.2.2 
Clinical Laboratory Determinations ..................................................................50 
9.2.3 
Vital Signs ..........................................................................................................50 
9.2.4 
Physical Examination.........................................................................................51 
9.2.5 
Medical History .................................................................................................51 
9.2.6 
Appropriateness of Measurements .....................................................................51 
9.3 
CONCOMITANT MEDICINES .................................................................................51 
10. ADVERSE EVENTS .............................................................................................................52 
10.1 
DEFINITIONS .............................................................................................................52 
10.1.1 
Adverse Event ....................................................................................................52 
10.1.2 
Serious Adverse Event .......................................................................................52 
10.2 
PROCEDURES FOR RECORDING ADVERSE EVENTS .......................................53 
10.3 
PROCEDURES FOR REPORTING SERIOUS ADVERSE EVENTS ......................54 
10.4 
RECORDING REQUIREMENTS ..............................................................................56 
10.4.1 
Severity ..............................................................................................................56 
10.4.2 
Causality ............................................................................................................56 
10.4.3 
Laboratory Abnormalities ..................................................................................56 
10.5 
UNBLINDING ............................................................................................................57 
10.6 
TERMINATION OF PARTICIPANTS ......................................................................57 
11. STATISTICAL METHODS ..................................................................................................59 
11.1 
DETERMINATION OF SAMPLE SIZE ....................................................................59 
11.2 
ANALYSIS POPULATIONS .....................................................................................59 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 17 of 79 
11.2.1 
ITT Population ...................................................................................................59 
11.2.2 
Safety Population ...............................................................................................59 
11.2.3 
Evaluable Population .........................................................................................59 
11.3 
STATISTICAL ANALYSES ......................................................................................60 
11.3.1 
General Considerations ......................................................................................60 
11.3.2 
Disposition, Demographics, and Baseline Characteristics ................................60 
11.3.3 
Efficacy Analyses ..............................................................................................61 
11.3.3.1 
Primary Efficacy Endpoint ......................................................................61 
11.3.3.2 
Primary Efficacy Analysis .......................................................................61 
11.3.3.3 
Secondary Efficacy Endpoints .................................................................62 
11.3.3.4 
Secondary Efficacy Analyses ..................................................................63 
11.3.3.5 
Additional Analysis .................................................................................64 
11.3.4 
Safety Analyses ..................................................................................................65 
11.4 
COMPUTER METHODS ...........................................................................................65 
12. STUDY OPERATIONS ........................................................................................................66 
12.1 
GOOD CLINICAL PRACTICE ..................................................................................66 
12.2 
FINANCIAL DISCLOSURE ......................................................................................66 
12.3 
ESSENTIAL DOCUMENTS ......................................................................................66 
12.4 
GENERATION OF STUDY RECORDS ....................................................................67 
12.5 
CASE REPORT FORMS AND DATA MANAGEMENT .........................................68 
12.6 
STUDY MONITORING .............................................................................................68 
12.7 
CHANGE IN INVESTIGATOR .................................................................................69 
12.8 
RECORD RETENTION AND ARCHIVING .............................................................69 
12.9 
REPORTING AND PUBLICATION POLICY ..........................................................69 
13. REFERENCE LIST ...............................................................................................................70 
14. APPENDICES .......................................................................................................................73 
 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 18 of 79 
LIST OF IN-TEXT TABLES 
Table 1. 
Key Study Participants .......................................................................................14 
 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 19 of 79 
LIST OF IN-TEXT FIGURES 
Figure 1. 
Abdominal Inductance Plethysmography Belt ..................................................27 
Figure 2. 
Study Schedule and Chronology ........................................................................32 
 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 20 of 79 
LIST OF APPENDICES 
Appendix 1 
Concomitant Medicines .....................................................................................74 
Appendix 2 
Digestive Sensations Questionnaire ...................................................................77 
Appendix 3 
Hospital Anxiety and Depression Scale (HADS) ..............................................78 
Appendix 4 
Irritable Bowel Syndrome Symptom Severity Score (IBS-SSS) .......................79 
 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 21 of 79 
LIST OF ABBREVIATIONS 
Abbreviation 
Term 
AE 
adverse event 
AIP 
abdominal inductance plesthymography 
AUC 
area under the curve 
BM 
bowel movement 
BMI 
body mass index 
BP 
blood pressure 
BSFS 
Bristol Stool Form Scale 
CFR 
Code of Federal Regulations 
cGMP 
cyclic guanosine 3’, 5’-monophosphate 
CIC 
Chronic idiopathic constipation 
CNS 
Central nervous system 
CSBM 
Complete spontaneous bowel movement 
CT 
Computed tomography 
EOT 
End of Treatment 
FDA 
Food and Drug Administration 
GC-C 
Guanylate cyclase-c 
GCP 
good clinical practice 
GGT 
gamma glutamyl transferase   
IBS-C 
Irritable Bowel Syndrome with Constipation 
IBS-D 
Irritable Bowel Syndrome with Diarrhoea 
IBS-SSS 
Irritable Bowel Syndrome – Syndrome Symptom Severity 
ICF  
informed consent form 
ICH 
International Conference on Harmonisation 
IRB 
Institutional Review Board 
ITT 
Intent to Treat 
kg 
kilogram 
kg/m2 
kilograms/meters squared (body mass index) 
MedDRA 
Medical Dictionary for Regulatory Activities 
mg 
milligram 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 22 of 79 
Abbreviation 
Term 
NRS 
Numerical Rating Scale 
PT 
Preferred Term 
REC 
Research Ethics Committee  
RW 
Randomized Withdrawal 
SAE 
serious adverse event 
SAP 
Statistical Analysis Plan 
SAS® 
Statistical Analysis System 
SBM 
Spontaneous Bowel Movement 
SD 
Standard Deviation 
SOC 
system organ class 
TEAE 
treatment emergent adverse event 
ug 
microgram 
 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 23 of 79 
1. 
ETHICAL CONSIDERATIONS 
This clinical study is designed to comply with the International Conference on Harmonisation 
(ICH) Guidance on General Considerations for Clinical Trials (62 Code of Federal Regulations 
[CFR] 66113, December 17, 1997) and Good Clinical Practice (GCP): Consolidated Guidance 
(62 CFR 25692, May 9, 1997). The study will be conducted in full compliance with the UK 
guidelines on GCP and in accordance with the ethical principles that have their origins in the 
Declaration of Helsinki and 21 CFR § 312.120. 
1.1 
INSTITUTIONAL REVIEW BOARD/ETHICS COMMITTEES 
Obtaining approval by the Research Ethics Committee (REC) prior to the start of the study will 
be the responsibility of the Investigator. A copy of the approval letter will be transmitted to the 
Sponsor or designee. During the course of the study, the Investigator will provide timely and 
accurate reports to the REC on the progress of the study, and will notify the REC and Sponsor of 
SAEs or other significant safety findings in a manner consistent with REC policies and ICH and 
GCP requirements. The study protocol (and any amendments), Informed Consent Form (ICF), 
and associated documentation will be approved by the REC prior to study initiation, in 
compliance with CFR, Title 21, Part 56.  
1.2 
PARTICIPANT INFORMATION AND INFORMED CONSENT 
It is the responsibility of the Investigator (or qualified designee) to give each participant full and 
adequate information regarding the objectives and procedures of the study and the possible risks 
involved. The participants must be informed about their right to withdraw from the study at any 
time. Furthermore, it is the responsibility of the Investigator to obtain signed and dated written 
informed consent from all participants, and a dated signature from the persons conducting the 
informed consent discussion, before undertaking any study-related procedure. The written ICF 
must be approved by the REC for the purposes of obtaining and documenting consent. The 
Investigator must be available to answer all participants’ questions regarding the study. The 
participant should receive a copy of the signed and dated ICF. The Investigator must retain each 
participant’s original signed ICF. If the protocol is amended and the modifications necessitate a 
change to the ICF, then the ICF must be submitted to the REC for review and approval before 
initiation. 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 24 of 79 
If new information becomes available that may be relevant to a participant’s consent and 
willingness to participate in the study, the ICF will be revised. The revised consent form will be 
submitted to the REC for review and approval prior to its use. 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 25 of 79 
2. 
INVESTIGATORS AND STUDY ADMINISTRATIVE 
STRUCTURE 
The Investigator at the study centre will be responsible for ensuring that the study is conducted 
according to the signed Clinical Trial Agreement, the protocol, REC requirements, and GCP 
guidelines. The Investigator will be responsible for the oversight of the study centre’s conduct of 
the study, which will consist of completing all protocol assessments, maintaining the study file 
and the participant records, drug accountability, corresponding with the REC, and completing the 
CRFs. 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 26 of 79 
3. 
INTRODUCTION 
3.1 
BACKGROUND 
Abdominal bloating is an extremely common feature of irritable bowel syndrome (IBS) which 
many patients rank as their most intrusive symptom (1, 2). The exact pathophysiology of this 
problem is not fully understood, but its understanding has improved with the advent of various 
investigational techniques, such as abdominal inductance plethysmography (AIP), the gas 
infusion technique, and computed tomography (CT) scanning (3, 4). As a result of studies using 
these investigations, it is now appreciated that bloating can sometimes be accompanied by an 
actual increase in girth which, subjectively may be felt by the patient as abdominal distension. 
However, patients usually use the term bloating when describing this symptom, whether they 
feel bloated and/or whether it is accompanied by an actual increase in girth or neither.  
In addition, it is now apparent that abdominal bloating and change in abdominal girth have 
somewhat different, but overlapping, underlying pathophysiologies. Bloating appears to be more 
common in patients with IBS with diarrhoea (IBS-D) and those who exhibit hypersensitivity of 
the rectal mucosa (5, 6). In contrast, an increase in abdominal girth appears to be more common 
in IBS with constipation (IBS-C) patients and those with slow transit (5, 7). Consequently, when 
contemplating the treatment of increased abdominal girth, relieving constipation or accelerating 
transit should lead to some improvement in patients with IBS-C. However, there has been little 
research on the possibility that relieving constipation brings about a reduction in abdominal girth.  
One placebo-controlled trial (8) utilised AIP, which measures abdominal girth over a 24-hour 
period in an ambulatory fashion (see Figure 1) (9) and, therefore, offers the opportunity to assess 
whether a drug that relieves constipation also leads to a reduction in abdominal girth (9). This 
trial used a yoghurt containing bifidobacterium lactis DN-173 010, which has previously been 
shown to accelerate transit and improve the subjective feeling of bloating in patients with IBS-C 
(10, 11). A total of 34 IBS-C patients were randomised to ingest either an active yoghurt or a 
matching placebo yoghurt for 4 weeks. The active yoghurt led to an acceleration of both small 
and large bowel transit and a significant reduction in maximum abdominal girth compared with 
placebo (8). 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 27 of 79 
Figure 1. 
Abdominal Inductance Plethysmography Belt 
 
 
In addition, in recent years there have been a number of studies assessing the efficacy of 
potential new pharmacological treatments for constipation (12-16). In all of these studies, there 
has been evidence that the symptom of bloating has been improved, but girth was not objectively 
measured in any of these studies. However, it seems reasonable to assume that, as patients often 
describe an increase in abdominal girth as ‘bloating,’ that the latter may have been reduced in at 
least a proportion of these patients. 
This study is designed to establish whether linaclotide reduces abdominal bloating and 
abdominal girth in patients with IBS-C.  
 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 28 of 79 
3.2 
INVESTIGATIONAL PRODUCT 
Linaclotide is a minimally absorbed 14-amino-acid peptide, which binds to and activates 
guanylate cyclase C (GC-C) on the luminal surface of the intestinal epithelium. Activation of 
intestinal GC-C results in increased cyclic guanosine monophosphate (cGMP) production, which 
in turn causes chloride and bicarbonate to be secreted into the gastrointestinal lumen, with 
consequent increased fluid secretion and accelerated intestinal transit (17-19). Linaclotide 
reduces visceral hypersensitivity in animal models, and improves abdominal pain in patients with 
IBS-C; this effect may be related to cGMP modulation of afferent nerve activity (15, 20-24). 
The clinical development program for linaclotide included 4 large double-blind, placebo-
controlled registration trials and 2 large open-label safety studies. Two Phase 3 trials (LIN-MD-
31 and MCP-103-302) were conducted in IBS-C patients (15, 23, 24) and two (LIN-MD-01 and 
MCP-103-303) were conducted in patients with chronic idiopathic constipation (CIC) (17). Two 
long-term safety studies (LIN-MD-02 and MCP-103-305), each with 78-week Treatment 
Periods, have also been completed. Linaclotide is approved in the US, Canada, and Mexico for 
the treatment of adults with IBS-C and CIC and approved in the EU and Switzerland for the 
treatment of adults with IBS-C. 
The two Phase 3 IBS-C trials evaluated the safety and efficacy of 290 ug linaclotide 
administered as an oral capsule (15, 23, 24). The overall design of these two Phase 3 trials was 
identical through the first 12 weeks of the Treatment Period. One of the Phase 3 trials (LIN-MD-
31) included a 4-week double-blind, Randomised Withdrawal (RW) Period immediately 
following the 12-week Treatment Period to assess the potential for rebound worsening of 
constipation or abdominal symptoms following discontinuation of linaclotide. The other trial 
(MCP-103-302) extended the double-blind Treatment Period an additional 14 weeks (26 weeks 
total treatment). 
A total of 1606 patients were randomised to either to linaclotide 290 ug or matching placebo 
once daily. In both trials, linaclotide met all prespecified primary and secondary endpoints. For 
the FDA responder definition (one of 4 primary efficacy endpoints), a patient was required to 
have an increase of at least 1 complete spontaneous bowel movement (CSBM) from baseline, 
and a decrease of at least 30% in the mean abdominal pain score, during the same week, for at 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 29 of 79 
least 6 of the first 12 weeks of the Treatment Period. For the MCP-103-302 trial, 33.7% of 
linaclotide-treated patients met this primary endpoint, compared with 13.9% of patients who 
received placebo. Similarly, in the LIN-MD-31 trial, 33.6% of linaclotide-treated patients met 
this primary endpoint, compared with 21.0% of patients who received placebo (for both trials, 
p < 0.0001 for linaclotide versus placebo). 
Statistically significant improvements were demonstrated in patients’ abdominal symptoms 
(including abdominal pain, discomfort and bloating) and bowel symptoms (including CSBM 
frequency, spontaneous bowel movement (SBM) frequency, stool consistency and straining). 
These improvements were sustained throughout 12 weeks of the Treatment Period of each of the 
two trials and for 26 weeks in Trial MCP-103-302. The results from the RW Period showed that 
there was no evidence of development of tolerance, nor was there evidence of rebound 
worsening of bowel or abdominal symptoms relative to baseline once linaclotide was 
discontinued. 
Linaclotide was well tolerated in the IBS-C Phase 3 efficacy trials. Treatment-emergent adverse 
events (TEAEs) occurred in 54.9% of placebo-treated and 60.8% linaclotide-treated patients. 
Diarrhoea was the most frequent TEAE and was reported in 3.0% of placebo-treated patients and 
19.8% of linaclotide-treated patients. Diarrhoea was generally mild to moderate in severity. 
Diarrhoea resulted in the discontinuation of 0.4% of patients treated with placebo and 5.3% 
treated with linaclotide. There were 9 (1.1%) SAEs in placebo-treated patients and 6 (0.7%) in 
linaclotide-treated patients. The SAEs were judged to be unlikely or unrelated to treatment by the 
Investigator, with the exception of 2 SAEs (pericarditis and pericardial effusion occurring in 1 
patient treated with linaclotide) that were judged by the Investigator to be possibly related to 
treatment. There were no deaths. One patient died in the Screening Period but never received 
either linaclotide or placebo. Overall, there was no obvious pattern in the types of SAEs 
experienced in either the placebo or linaclotide group. There were no SAEs of diarrhoea. 
Refer to Section 6 of the United States Package Insert (USPI) for a more detailed description of 
the safety of linaclotide, as it will serve as the Reference Safety Information for this study. Refer 
to the Investigator’s Brochure for a more detailed description of the IBS-C and CIC clinical 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 30 of 79 
trials, as well as the chemistry, pharmacology, and efficacy of linaclotide, based on studies 
conducted in animals, healthy volunteers, and in patients with CIC and IBS-C. 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 31 of 79 
4. 
STUDY OBJECTIVES 
To determine the effect of linaclotide on abdominal girth in irritable bowel syndrome with 
constipation (IBS-C) participants with baseline symptoms of abdominal bloating and an 
increased abdominal girth. 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 32 of 79 
5. 
STUDY DESIGN 
5.1 
OVERALL STUDY DESIGN AND PLAN: DESCRIPTION 
The study will be a single-centre, randomised, double-blind, placebo-controlled, parallel-group 
study comparing linaclotide to placebo. Approximately 40 participants with a diagnosis of IBS-C 
(Rome III criteria), who are shown to distend >4 cm over 24 hours during the Pretreatment 
Period, will be randomised. 
The study will consist of up to 14 days of screening, 7 days of pretreatment, 29 (± 2) days of 
double-blind treatment, and 7 (± 2) days of follow-up. At the end of the Pretreatment Period, 
participants meeting the entry criteria for this study will be randomised (1:1) to one of two 
double-blind treatment groups: 290 ug linaclotide or matching placebo. 
Figure 2. 
Study Schedule and Chronology 
 
 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 33 of 79 
5.1.1 
Study Periods 
5.1.1.1 
Screening Period 
The Screening Period starts with the signature of the ICF and lasts for up to 14 calendar days. 
During this period, participant eligibility for entry into the Pretreatment Period will be 
determined. 
At the Screening Visit, all ongoing medicines taken by the participant will be recorded. Any 
over-the-counter or prescription laxatives, suppositories, or enemas used to treat IBS-C may not 
be used on the calendar day before the Pretreatment Visit; other prohibited medicines may not be 
used during the 14 calendar days before the Pretreatment Visit. The end of the Screening Period 
coincides with the start of the Pretreatment Period. 
5.1.1.2 
Pretreatment Period 
The Pretreatment Period is defined as the 7 calendar days immediately before randomisation. 
During this period, participants will record (via paper diary) Daily Bowel Habits, Daily 
Participant Symptom Severity Assessments scored on an 11-point numerical rating scale (NRS), 
and per protocol Rescue Medicine (bisacodyl tablets or suppositories) or any other laxative, 
suppository, or enema use. At the end of the Pretreatment Period, participants will be fitted with 
the AIP belt in the morning and their abdominal girth measured over the next 24 hours. The AIP 
belt will be fitted prior to the dose of linaclotide and participants will be asked to record their 
subjective symptoms of abdominal pain, discomfort, bloating, and distension on an hourly basis 
(during waking hours) via a Digestive Sensations Questionnaire. In addition, they will also be 
asked to empty their bladder on an hourly basis (during waking hours), or more frequently if they 
have the desire to go, to avoid confounding between symptoms of bladder fullness and IBS-C 
abdominal symptoms.  
5.1.1.3 
Treatment Period 
The Treatment Period begins with randomisation and lasts for 4 weeks. On return to the study 
centre for the Randomisation Visit (Day 1), the data from the AIP belt will be downloaded 
immediately and those exhibiting an increase in girth during the course of the previous day of >4 
cm are eligible for the study. A participant whose girth does not increase by >4 cm will be 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 34 of 79 
refitted with the belt for a further 24 hours. The abdominal girth requirement will not be 
disclosed to the participant. If they still do not reach the required girth measurement, they will be 
excluded from the study. Participants who meet all other entry criteria will be randomised (1:1) 
to once daily oral capsules containing 290 ug linaclotide or placebo. Participants will take their 
initial dose of study drug in the study centre during the Randomisation Visit; thereafter, study 
drug is to be taken once daily, in the morning, ≥30 minutes before breakfast. Participants will 
continue to record their daily diary assessments throughout the Treatment Period. Abdominal 
girth will be measured by the AIP belt, and the Digestive Sensations Questionnaire will be 
administered for another 24 hours at the mid-point of the Treatment Period (Day 13 Visit) and 
again at the end of the study (Day 27 Visit) to assess the effect of the treatment on abdominal 
girth and IBS-C symptoms. 
5.1.1.4 
Follow-up Period 
The Follow-up Period starts at the End of Treatment Visit (Visit 8) and finishes with the Follow-
up Telephone Call on Day 36 (± 2), one week after the End of Treatment Visit (Visit 8). During 
this call, participants will be asked to report any adverse events (AEs) since the End of 
Treatment Visit (Visit 8) and detail any other symptoms or comments they may have. 
Note: End of Study will be defined as the last participant Follow-up Telephone Call (Day 36 ± 
2). 
5.2 
DISCUSSION OF STUDY DESIGN, INCLUDING THE CHOICE OF 
CONTROL GROUPS 
A double-blind, placebo-controlled, parallel-group study design was chosen in accordance with 
the concepts in ICH E10, Choice of Control Groups and Related Issues in Clinical Trials 
(International Conference on Harmonisation of Technical Requirements for Registration of 
Pharmaceuticals for Human Use, 2001), in order to provide comparable treatment groups and 
minimal chance of selection or investigator bias. This study has a 7-day Pretreatment Period to 
establish baseline without therapy, followed by randomisation and a 29-day Treatment Period, 
and a 7-day Follow-up Period. 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 35 of 79 
6. 
STUDY POPULATION 
6.1 
SELECTION OF STUDY POPULATION 
Participants attending the IBS clinic at the study centre or those held in the database of 
Neurogastroenterology Unit will be recruited for participation in the study. The study centre 
must have a full medical history from each subject’s GP within the last 12 months, prior to 
enrollment in the study and to ensure that the participant does not have any concomitant 
exclusionary disease. Each subject’s GP will be informed of their participation in the study.  
6.2 
INCLUSION CRITERIA 
To be eligible to participate in the study, participants must meet all of the following criteria: 
1. Participant has provided written informed consent before participating in the study after 
being given a full description of the study and prior to any study-specific procedures being 
performed. 
2. Participant is a male or non-pregnant, non-breastfeeding female, and is age 18 years or older 
(no upper age limit). 
3. Female participants of childbearing potential must complete a urine pregnancy test with 
negative results at the Screening Visit (Visit 1) and again at the Randomisation Visit (Visit 4) 
prior to dosing. 
4. Female participants who are pre-menopausal should be enrolled between days 7 and 21 of 
their menstrual cycle. 
5. Sexually active female participants of childbearing potential must agree to use one of the 
following methods of contraception from the date that they sign the ICF until the end of 
study:  
a. Hormonal contraception (i.e., oral contraceptive, contraceptive implant, or injectable 
hormonal contraceptive); 
b. Intra-uterine device (IUD); 
c. A barrier birth control (such as condoms or occlusive cap with spermicidal 
foam/gel/film/cream/suppository); 
d. Surgical sterilisation (i.e., bilateral oophorectomy, hysterectomy, or tubal ligation); 
e. Abstinence, when in the opinion of the Investigator, the participant’s occupation or 
lifestyle gives sufficient evidence that abstinence will be maintained throughout the study 
and for 1 month thereafter. 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 36 of 79 
6. Participant meets Rome III criteria for IBS-C, as well as abdominal pain score (average of ≥ 
3 on 0-10 point numerical rating scale [NRS]), abdominal bloating score (average of ≥ 5 on 
0-10 point NRS), and abdominal girth measurement (AIP increase of > 4 cm) criteria during 
the Pretreatment Period. 
7. Participant agrees to refrain from strenuous physical activity for 24 hours prior to each study 
visit. 
8. Participant agrees to refrain from initiating any lifestyle or dietary changes. 
9. Participant agrees to refrain from taking any probiotics from 14 days prior to enrolment in 
the study throughout the Treatment Period.  
10. Participant is able to communicate well with the Investigator and to comply with the 
requirements for the entire study. 
11. Participant has a body mass index (BMI) between 18.5 and 34.9 kg/m2 (bounds included) at 
the Screening Visit. 
 
6.3 
EXCLUSION CRITERIA 
Participants who meet any of the following criteria will not be eligible to participate in the study:  
1. Participant reports loose (mushy) or watery stools (BSFS score of 6 or 7) in the absence of 
any laxative, suppository, enema, or prohibited medicine (as described in Appendix 1) for 
> 25% of BMs during the 12 weeks before the Screening Visit. 
2. Participant has ever had a diagnosis of familial adenomatous polyposis, hereditary 
nonpolyposis colorectal cancer, or any other form of familial colorectal cancer, or 
inflammatory bowel disease. 
3. Participant currently has both unexplained and clinically significant alarm symptoms (lower 
GI bleeding, iron-deficiency anaemia or any unexplained anaemia, or weight loss) or 
systemic signs of infection or colitis. 
4. Participant currently has active peptic ulcer disease (i.e., disease that is not adequately treated 
or stable with therapy). 
5. Participant has a history of any chronic GI condition (e.g., diverticulitis) that can be 
associated with abdominal pain or discomfort. 
6. Participant has CNS disease or any organic condition associated with constipation. 
7. Participant has had surgery that meets any of the following criteria:  
a. Has undergone any surgery within 6 months prior to the Screening Visit;  
b. Has had previous abdominal surgery except appendectomy, cholecystectomy, or 
hysterectomy. 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 37 of 79 
8. Participant has diabetes. 
9. Participant reports using a Prohibited Medicine (excluding laxatives, suppositories, and 
enemas) during the Pretreatment Period or is not willing or able to abide by the restrictions 
regarding use of Prohibited Medicines defined in Appendix 1. (Note: the use of fibre, bulk 
laxatives, or stool softeners [such as docusate] is acceptable provided that the participant has 
been on a stable dose during the 30 days before the Screening Visit and plans to continue on 
a stable dose throughout the study.) 
10. Participant has taken commercially available linaclotide during the 30 days prior to the 
Screening Visit. 
11. Participant is drinking alcohol above the recommended safe alcohol limit (< 21 units/week) 
or abusing drugs. In addition, participants will be asked to refrain from drinking alcohol for 
24 hours before plethysmography recordings until belt removal. 
12. Participant has lactose intolerance.  
13. Participant has an acute or chronic condition that, in the Investigator’s opinion, would limit 
the participant’s ability to complete or participate in this clinical study. 
14. Participant is involved in this study as an Investigator, sub-Investigator, study coordinator, 
other study staff, or Sponsor member. 
15. Participant has a known or suspected mechanical gastrointestinal obstruction. 
16. Participant has a history of hypersensitivity to linaclotide or to any of the excipients 
contained in the study drug (active or placebo). 
 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 38 of 79 
7. 
STUDY TREATMENTS 
7.1 
TREATMENTS ADMINISTERED 
Study drug in the form of oral capsules will be provided by Ironwood or designee. For the 
double-blind Treatment Period, participants will be supplied with identically appearing capsules 
containing 290 ug linaclotide, or matching placebo. 
7.2 
IDENTITY OF INVESTIGATIONAL PRODUCT 
All study drug will be supplied in bottles containing thirty-five (35) capsules of linaclotide 
290 ug or matching placebo. Bottles will be uniquely numbered and labelled in a double-blind 
fashion that conforms to Regulatory requirements. 
All study drug will be provided by Ironwood or designee. Study drug will be stored at the study 
centre in an appropriate secure, temperature controlled area at 77°F (25°C), excursions permitted 
to 59-86°F (15-30°C). Any deviations from the storage conditions must be reported to Ironwood 
and use of the study drug suspended until authorisation for its continued use has been provided 
by Ironwood. 
The Investigator must ensure that the receipt and use of all study drug supplied is recorded and 
supervise the storage and allocation of these supplies. All study drug supplies must be retained in 
a locked room that may only be accessed by the Investigator or other duly designated persons. 
Study drug must not be used outside the context of this protocol and under no circumstances 
should the Investigator or study centre personnel allow the supplies to be used other than as 
directed by this protocol without prior authorisation from Ironwood. All unused study drug must 
be returned to Ironwood’s designee. Whenever study drug is returned, unit counts must be 
performed by study centre staff to ensure reliable drug accountability. Drug unit counts are 
documented on the appropriate CRF form. Prior to the end of the study, instructions for the 
return of all unused capsules and study drug bottles will be provided. 
7.3 
METHOD OF ASSIGNING PARTICIPANT TO TREATMENT GROUPS 
Participants will be allocated to treatment using a computer-generated simple block 
randomisation method (with block sizes randomly varying between 2 and 8). The randomisation 
list will be derived prior to the start of the study and held by a person who will be independent of 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 39 of 79 
the main study research group. Consecutively numbered opaque envelopes containing the 
appropriate allocation will be prepared in advance and used by the researcher in charge of 
recruitment. 
7.4 
SELECTION AND TIMING OF DOSE FOR EACH PARTICIPANT 
All study drug will be administered orally as a single daily dose. Participants who meet all 
eligibility criteria at screening and pretreatment will be randomised to treatment at the 
Randomisation Visit and dispensed one bottle containing 35 capsules. Participants will be 
instructed to take one capsule in the morning at least 30 minutes before breakfast. Participants 
will take their initial dose of study drug (either one capsule of 290 ug linaclotide, or matching 
placebo) at the study centre during the Randomisation Visit. Should intolerable diarrhoea occur 
while taking study drug, the daily dose may be temporarily suspended until such time as the 
diarrhea resolves.  
7.5 
BLINDING 
Both the participants and the research team will be blinded to randomisation and allocation of 
study drug/placebo. 
In the scenario that the Investigator must unblind a participant, the Investigator will have access 
to individual sealed unblinding envelopes, which can be opened to identify the treatment 
assignment for an individual participant in an emergency. The reason for breaking the blind must 
be documented in the participant’s CRF. 
The Investigator, all other study personnel not previously noted, and the participant will remain 
blinded to the participant’s treatment assignment throughout the study. 
7.6 
CONCOMITANT MEDICINES 
At the Screening Visit, all ongoing medicines taken by the participant will be recorded. Any 
over-the-counter or prescription laxatives, suppositories, or enemas used to treat IBS-C may not 
be used on the calendar day before the Pretreatment Visit. Other prohibited medicines may not 
be used during the 14 calendar days before the Pretreatment Visit (refer to Appendix 1). 
Document Date: 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 40 of 79 
A complete list of drugs that are conditionally allowed as concomitant medicines for either 
episodic or chronic use or as Rescue Medicine is provided in Appendix 1. Prohibited 
concomitant medicines are also included in Appendix 1. 
During the Pretreatment and Treatment Periods, participants may only use dispensed, protocol-
defined laxatives (bisacodyl tablets or suppositories) as Rescue Medicine when at least 72 hours 
have passed since their previous BM or when their symptoms become intolerable. In order to 
qualify for randomisation into the Treatment Period, participants must not have used Rescue 
Medicine on the calendar day before the Randomisation Visit and on the day of the 
Randomisation Visit up until the time of the clinic arrival. Participants must agree to refrain from 
using Rescue Medicine from the time of the clinic arrival through the calendar day after 
randomisation. Furthermore, participants will be asked to refrain from using Rescue Medicine on 
the day before, day of, and day after each AIP measurement. 
Any changes in concomitant medicines or new medicines added from the Screening Period 
through the Follow-up Period will be recorded on the CRF. Concomitant medicines will be 
recorded at all study visits throughout the entire study. Rescue Medicine will be documented by 
the participant on the Rescue Medicine record form. 
7.7 
TREATMENT COMPLIANCE 
Study drug will be administered to the participant by study centre staff at the Randomisation 
Visit. For the other days in the Treatment Period, study drug will be taken by the participant once 
daily in the morning at least 30 minutes before breakfast. Study drug compliance by the 
participant will be closely monitored during the Treatment Period by counting the number of 
capsules returned and recording that information on the CRF. Every effort will be made to 
collect all unused study drug. 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 41 of 79 
8. 
PROCEDURES 
8.1 
SCREENING PERIOD (DAY -21 TO DAY -8) 
The Screening Period will begin with the signature of the ICF and will last for up to 14 calendar 
days. The end of the Screening Period will coincide with the beginning of the Pretreatment 
Period. 
8.1.1 
Screening Visit (Visit 1) 
The Screening Visit will occur on Day -21. Participants will undergo the following assessments: 
• Informed consent 
• Check of inclusion and exclusion criteria 
• Medical and surgical history 
• Rome III status for IBS-C 
• Physical examination 
- 
A physical examination should include the following: general appearance, HEENT (head, 
ears, eyes, nose and throat), neck, cardiovascular, thorax/lungs, abdomen, 
musculoskeletal, lymph nodes, skin, neurologic, and mental status). Rectal examination is 
not required; however, sigmoidoscopy/colonoscopy may be performed at the discretion 
of the Investigator. 
• Body weight and height 
• Seated vital signs 
• Documentation of prior and concomitant medicines 
• Collection of blood samples for clinical laboratory determinations (complete blood count, 
chemistry), if lab results obtained within 30 days prior to Visit 1 are not available.  
• Urine pregnancy test (result must be confirmed as negative in order to qualify for study 
participation) 
• Completion of the HADS (Appendix 3) and IBS-SSS (Appendix 4) 
• Instructions for participants to discontinue use of all laxatives, suppositories, and/or enemas 
at least one calendar day before the first day of the Pretreatment Period, and all other 
restriction and prohibited medicines as defined in Appendix 1 
 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 42 of 79 
8.2 
PRETREATMENT PERIOD (DAY -7 TO DAY -1) 
The Pretreatment Period will be the 7 days immediately before the Randomisation Visit. The 
purposes of this period are to collect data to determine whether the participant is eligible to 
continue into the Treatment Period of the study, to provide the participant with experience using 
the data collection methods employed during the study (e.g., daily diary, Digestive Sensations 
Questionnaire), and to provide baseline data for comparison with data collected during the 
Treatment Period. 
8.2.1 
Pretreatment Visit (Visit 2) 
The Pretreatment Visit will occur on Day -7. Participants will undergo the following 
assessments: 
• Documentation of concomitant medicines 
• Review of AEs, from the signing of the ICF to Visit 2 
• Rescue Medicine dispensed; review with participant how Rescue Medicine should be used 
• Delivery of daily diary (vol. 1); diary training and start of daily recording 
 
8.2.2 
Baseline Visit (Visit 3) 
The Baseline Visit will occur on Day -1. Participants will undergo the following assessments: 
• Documentation of concomitant medicines 
• Review of AEs 
• Diary compliance check and continued daily recording 
• Distribution of Digestive Sensations Questionnaire and instructions for completion 
• Participants fitted with the AIP belt (the schedule of this visit should be adjusted in the 
following instances): 
• Women who are actively menstruating during AIP belt placement should have their visits 
delayed for 48 hours.  
• Participants who have taken Rescue Medicines within 24 hours of AIP belt placement 
should have their visits delayed until 24 hours have passed since the use of Rescue 
Medicine.  
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 43 of 79 
• Participants who have had study drug suspended due to diarrhea should have their AIP 
belt placement visits delayed until study drug has been resumed for 24 hours.  
 
8.3 
TREATMENT PERIOD (DAY 1 TO DAY 29) 
The Treatment Period begins with randomisation on Day 1 and lasts for 29 (±2) days, through 
the End of Treatment Visit (Visit 8) on Day 27 (±2). The end of the Treatment Period will 
coincide with the beginning of the Follow-up Period. 
8.3.1 
Randomisation Visit (Visit 4) 
The Randomisation Visit will occur on Day 1. Participants will undergo the following 
assessments: 
• Verification of inclusion and exclusion criteria 
• Medical and surgical history 
• Physical examination: 
• A physical examination should include all assessments: general appearance, HEENT, 
neck, cardiovascular, thorax/lungs, abdomen, musculoskeletal, lymph nodes, skin, 
neurologic, and mental status. Rectal examination is not required; however, 
sigmoidoscopy/colonoscopy may be performed at the discretion of the Investigator. 
• Body weight 
• Seated vital signs 
• Documentation of concomitant medicines 
• Urine pregnancy test (result must be confirmed as negative in order to qualify for study 
participation) 
• Review of AEs 
• Rescue Medicine dispensed, as needed; review with participant how Rescue Medicine should 
be used 
• Diary collection (vol. 1), delivery of daily diary (vol. 2), and continued daily recording 
• Collection of Digestive Sensations Questionnaire 
• Data from the AIP belt downloaded 
• Randomisation 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 44 of 79 
• Delivery and administration of study drug 
 
8.3.2 
Day 13 Visit (Visit 5) 
The Day 13 Visit will occur on Day 13 (± 2 days). Participants will undergo the following 
assessments: 
• Documentation of concomitant medicines 
• Review of AEs 
• Diary compliance check and continued daily recording 
• Distribution of Digestive Sensations Questionnaire and instructions for completion 
• Participants fitted with the AIP belt: (the schedule of this visit should be adjusted in the 
following instances): 
• Women who are actively menstruating during AIP belt placement should have their visits 
delayed for 48 hours.  
• Participants who have taken Rescue Medicines within 24 hours of AIP belt placement 
should have their visits delayed until 24 hours have passed since the use of Rescue 
Medicine.  
 
8.3.3 
Day 15 Visit (Visit 6) 
The Day 15 Visit will occur on Day 15 (± 2 days). Participants will undergo the following 
assessments: 
• Body weight 
• Seated vital signs 
• Documentation of concomitant medicines 
• Review of AEs 
• Rescue Medicine dispensed, as needed; review with participant how Rescue Medicine should 
be used 
• Diary collection (vol. 2), delivery of daily diary (vol. 3), and continued daily recording 
• Collection of Digestive Sensations Questionnaire 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 45 of 79 
• Data from the AIP belt downloaded 
• Study drug accountability 
 
8.3.4 
Day 27 Visit (Visit 7) 
The Day 27 Visit (Visit 7) will occur on Day 27 (± 2 days). Participants will undergo the 
following assessments: 
• Documentation of concomitant medicines 
• Review of AEs 
• Diary compliance check and continued daily recording 
• Distribution of Digestive Sensations Questionnaire and instructions for completion 
• Participants fitted with the AIP belt: (the schedule of this visit should be adjusted in the 
following instances): 
• Women who are actively menstruating during AIP belt placement should have their visits 
delayed for 48 hours.  
• Participants who have taken Rescue Medicines within 24 hours of AIP belt placement 
should have their visits delayed until 24 hours have passed since the use of Rescue 
Medicine.  
 
8.3.5 
End of Treatment Visit (Visit 8) 
The End of Treatment Visit (Visit 8) will occur on Day 28 (± 2 days). Participants will undergo 
the following assessments: 
• Physical examination 
• A physical examination should include all assessments: general appearance, HEENT, 
neck, cardiovascular, thorax/lungs, abdomen, musculoskeletal, lymph nodes, skin, 
neurologic, and mental status. Rectal examination is not required; however, 
sigmoidoscopy/colonoscopy may be performed at the discretion of the Investigator. 
• Body weight 
• Seated vital signs 
• Documentation of concomitant medicines 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 46 of 79 
• Urine pregnancy test 
• Review of AEs 
• Diary daily recording and collection (vol. 3) 
• Collection of Digestive Sensations Questionnaire 
• Data from the AIP belt downloaded 
• Study drug accountability 
 
8.4 
FOLLOW-UP PERIOD (DAY 29 TO DAY 35) 
The Follow-up Period starts at the end of the End of Treatment Visit (Visit 8) and finishes on 
Day 36 (± 2), one week after the End of Treatment Visit. 
8.4.1 
Follow-up (Telephone Call) 
The Follow-up Telephone Call will occur on Day 36 (± 2). During this call, participants will be 
asked to report any AEs since the End of Treatment Visit (Visit 8) and detail any other 
symptoms or comments they may have. 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 47 of 79 
9. 
STUDY OUTCOME ASSESSMENTS 
9.1 
EFFICACY MEASUREMENTS 
9.1.1 
Primary Efficacy Assessment 
Mean change from randomisation (Visit 4) to the end of the study (Visit 8) in abdominal girth (as 
measured by AUC) determined by 24-hour AIP between the linaclotide and placebo groups.  
Data on abdominal girth will be downloaded and analysed from the data logger by a blinded 
member of the research team when participants return with the belt at the Randomisation, Day 
15, and End of Treatment Visits.  
Comparisons of the mean change in abdominal girth over 24 hours (as measured by AUC) will 
be made between the baseline and mid-study, and baseline and end-of-treatment assessments.  
9.1.2 
Secondary Efficacy Assessments and Additional Efficacy Assessments 
Daily Diary 
The secondary efficacy assessments are the diary questions that determine the following: 
• Daily participant assessment of abdominal pain, discomfort, bloating, and distension; 
• Whether a BM is an SBM; 
• Whether an SBM is a CSBM; 
• Stool consistency (Bristol Stool Form Scale [BSFS]) with each BM. 
 
To determine these secondary outcome measures, participants will be asked to complete paper 
daily diaries in the evening (or approximately the same time each day) recording: 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 48 of 79 
• Daily Participant Assessment of Bowel Habits: 
“Have you taken any laxatives, suppositories, or enemas since yesterday?” 
1=Yes 
2=No 
“If yes, which rescue medicine did you take?” 
1=Oral Bisacodyl 
2=Bisacodyl suppository 
3=Other laxatives, suppositories, or enemas 
 “How many bowel movements did you have since yesterday?” 
“Did you feel like you completely emptied your bowels?” 
1=Yes 
2=No 
“Please refer to the laminated Bristol Stool Form Scale given to you. Please describe the 
consistency of the bowel movement using the following scale where:” 
1=Separate hard lumps like nuts (difficult to pass) 
2=Sausage shaped but lumpy 
3=Like a sausage but with cracks on surface 
4=Like a sausage or snake, smooth and soft 
5=Soft blobs with clear-cut edges (passed easily) 
6=Fluffy pieces with ragged edges, a mushy stool 
7=Watery, no solid pieces (entirely liquid) 
• Daily Participant Symptom Severity Assessments 
“How would you rate your abdominal pain at its worst over the last 24 hours? Enter a 
number from 0 to 10, where 0 represents no abdominal pain and 10 represents very severe 
abdominal pain.” 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 49 of 79 
 “How would you rate your abdominal discomfort at its worst over the last 24 hours? Enter a 
number from 0 to 10, where 0 represents no abdominal discomfort and 10 represents very 
severe abdominal discomfort.” 
“How would you rate your abdominal bloating at its worst over the last 24 hours? Enter a 
number from 0 to 10, where 0 represents no abdominal bloating and 10 represents very 
severe abdominal bloating.” 
“How would you rate your abdominal distension at its worst over the last 24 hours? Enter a 
number from 0 to 10, where 0 represents no abdominal distension and 10 represents very 
severe abdominal distension.” 
Digestive Sensations Questionnaire 
A Digestive Sensations Questionnaire (Appendix 2) will be used to record abdominal pain, 
discomfort, bloating, distension, and overall IBS symptoms on an hourly basis (waking hours 
only) during the 24 hours the participants are fitted with the AIP belt, using an 11-point NRS. 
Participants will be asked to record the following: 
“How would you rate your abdominal pain over the last hour? Circle a number from 0 to 10, 
where 0 represents no abdominal pain and 10 represents very severe abdominal pain.” 
 “How would you rate your abdominal discomfort over the last hour? Circle a number from 
0 to 10, where 0 represents no abdominal discomfort and 10 represents very severe 
abdominal discomfort.” 
“How would you rate your abdominal bloating over the last hour? Circle a number from 0 to 
10, where 0 represents no abdominal bloating and 10 represents very severe abdominal 
bloating.” 
“How would you rate your abdominal distension over the last hour? Circle a number from 0 
to 10, where 0 represents no abdominal distension and 10 represents very severe abdominal 
distension.” 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 50 of 79 
“How would you rate your overall IBS symptoms over the last hour? Circle a number from 0 
to 10, where 0 represents no IBS symptoms and 10 represents very severe IBS symptoms.” 
9.2 
SAFETY OUTCOME ASSESSMENTS 
9.2.1 
Adverse Events 
All participants will be monitored for AEs and use of concomitant medicines throughout the 
study. All AEs and concomitant medicines will be recorded in accordance with the procedures 
outlined in Section 10. 
9.2.2 
Clinical Laboratory Determinations 
Clinical laboratory tests will be performed at the Screening Visit if lab results obtained within 
the prior 30 days are not available. 
The following clinical laboratory tests will be performed: 
• Haematology: Absolute white blood cell count, erythrocyte count, haemoglobin, 
haematocrit, platelet count, and red blood cell indices (mean corpuscular volume, mean 
corpuscular haemoglobin, and mean corpuscular haemoglobin concentration) 
• Chemistry: Sodium, magnesium, potassium, calcium, chloride, glucose, blood urea nitrogen, 
creatinine, total protein, alkaline phosphatase, albumin, total bilirubin, aspartate 
aminotransferase, alanine aminotransferase, bicarbonate, phosphate, and cholesterol  
• Pregnancy test: Urine human chorionic gonadotropin pregnancy test will be conducted for 
all females at the Screening Visit and other visits specified in the Schedule of Evaluations. A 
negative urine pregnancy test for females of childbearing potential must be documented at 
the Randomisation Visit for the participant to be eligible for randomisation and dosing with 
study drug. Positive results on the pregnancy test will exclude a participant from participating 
or continuing in the study. 
 
9.2.3 
Vital Signs 
Vital sign measurements will be performed at the Screening Visit and other visits defined in the 
Schedule of Evaluations with the participants in the seated position and documented. The 
parameters are oral temperature, pulse rate, respiratory rate, and systolic and diastolic blood 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 51 of 79 
pressure (BP). Pulse and BP readings will be taken after the participant has been sitting for five 
minutes. 
9.2.4 
Physical Examination 
A complete physical examination will be performed at the Screening Visit and other visits 
defined in the Schedule of Evaluations by the Investigator or a licensed health professional. Any 
physical examination abnormality that the Investigator considers to be potentially clinically 
significant and changed from the baseline will be reported as an AE. 
9.2.5 
Medical History 
A complete medical history will be provided by the participant at the Screening Visit and the 
Randomisation Visit.  
9.2.6 
Appropriateness of Measurements 
The safety assessments to be conducted during this study, including monitoring for AEs, 
physical examination findings, vital signs parameters, and clinical laboratory measures, are 
widely used and generally recognised as reliable, accurate, and relevant. 
9.3 
CONCOMITANT MEDICINES 
Restrictions regarding concomitant medicines are described in Section 6.3. All concomitant 
medicines taken from the time of informed consent at the Screening Visit through the End of 
Treatment Visit will be recorded on the appropriate concomitant medicine page of the 
participant’s CRF. 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 52 of 79 
10. 
ADVERSE EVENTS 
10.1 
DEFINITIONS 
10.1.1 
Adverse Event 
An AE is any untoward medical occurrence in a patient or clinical investigational subject 
administered a pharmaceutical product and which does not necessarily have to have a causal 
relationship with this treatment. 
An AE, therefore, can be any unfavourable and unintended sign (including a clinically 
significant abnormal laboratory finding, for example), symptom, or disease temporally 
associated with the use of a medicinal product, whether or not considered related to the 
medicinal product. 
An AE includes, but is not limited to, the following: 
• Any unfavourable changes in general condition; 
• Any clinically significant worsening of a preexisting condition; 
• Any intercurrent diseases and accidents. 
 
NOTE:  A procedure is not an AE, but rather the reason for the procedure is the AE. 
10.1.2 
Serious Adverse Event 
An SAE is defined as any AE occurring at any dose that results in any of the following 
outcomes: 
• Death; 
• Life-threatening: the patient was at immediate risk of death from the reaction as it occurred 
(i.e., it does not include a reaction that hypothetically might have caused death if it had 
occurred in a more severe form); 
• Hospitalisation or prolongation of existing hospitalisation; 
• Persistent or significant disability/incapacity: a substantial disruption of a person’s ability to 
conduct normal daily functions; 
• Congenital anomaly/birth defect; 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 53 of 79 
• Important medical events: events that may not result in death, be life threatening, or require 
hospitalisation. Such an event may be considered serious when, based on appropriate medical 
judgement, it may jeopardise the patient and may require medical or surgical intervention to 
prevent 1 of the outcomes listed in this definition. Examples of such medical events include 
allergic bronchospasm requiring intensive treatment in an emergency department or at home, 
blood dyscrasias or convulsions that do not result in inpatient hospitalisation, or the 
development of drug dependency or drug abuse. 
 
Clarification should be made between the terms “serious” and “severe” since these 2 terms ARE 
NOT synonymous. The term “severe” is used to describe the intensity (severity) of a specific 
event (as in mild, moderate, or severe myocardial infarction) (see Section 10.4.1); the event 
itself, however, may be of relatively minor medical significance (such as a severe headache). 
“Serious” is based on the patient/event outcome or action criteria described above and is usually 
associated with events that pose a threat to a patient’s life or functioning. A severe AE does not 
necessarily need to be considered serious. For example, persistent nausea of several hours 
duration may be considered severe nausea but not an SAE. On the other hand, a stroke resulting 
in only a minor degree of disability may be considered mild but would be defined as an SAE 
based on the above noted criteria. Seriousness (not severity) serves as a guide for defining 
regulatory reporting obligations. 
10.2 
PROCEDURES FOR RECORDING ADVERSE EVENTS 
Adverse events will be collected and recorded from the time the participant signs the ICF at the 
Screening Visit through completion of the Follow-up Telephone Call. All AEs, regardless of the 
assumption of a causal relationship with study procedures or study drug, must be recorded on the 
appropriate AE page of the participant’s CRF. This record includes AEs the participant reports 
spontaneously, those observed by the Investigator, and those elicited by the Investigator in 
response to open-ended questions such as, “Have you had any unusual signs or symptoms since 
your last visit?” during the study. 
Any medical condition that is present when a participant is screened and does not deteriorate in 
severity and/or frequency should be reported as Medical History and not as an AE. However, if 
the condition does deteriorate in severity and/or frequency at any time during the study, it should 
be reported as an AE. 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 54 of 79 
All AEs will be followed until resolution, until the event has stabilised, or until the participant is 
lost to follow-up. 
10.3 
PROCEDURES FOR REPORTING SERIOUS ADVERSE EVENTS 
An AE that meets any of the serious criteria must be reported to Ironwood within 24 hours from 
the time that study centre personnel first learn of the event, using the SAE Report form provided 
for the study. Regardless of causality, all SAEs must be reported and will be collected and 
recorded from the time the participant signs ICF at the Screening Visit until the Follow-up 
Telephone Call. All SAEs must also be recorded on the AE page of the participant’s CRF. 
The initial report should include at least the following information: 
• Participant’s study number; 
• Description and onset of the event; 
• Serious criteria; 
• Causality assessment to study drug. 
 
Special Situation: Exposure to Study Drug during Pregnancy 
In the event that a pregnancy occurs in a participant, the study drug must be stopped at once, and 
study personnel must report the pregnancy as soon as possible (within 24 hours after notification) 
on the pregnancy notification form provided for this study. The study personnel must follow the 
pregnancy until the end and report the pregnancy outcome on the pregnancy outcome form 
provided for this study. If the pregnancy is associated with an SAE (e.g., if the mother is 
hospitalised for dehydration), a separate SAE form must be completed. 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 55 of 79 
All relevant SAE or pregnancy information should be emailed to Ironwood Drug Safety and 
Pharmacovigilance. 
All SAE Report Forms should be emailed to: 
 
Clinical Drug Safety & Pharmacovigilance 
Ironwood Pharmaceuticals, Inc. 
clinicalsafety@ironwoodpharma.com 
Fax: 1-617-933-7688 
 
If follow-up is obtained, or requested by Ironwood, the additional information should be emailed 
on a SAE Report Form to Ironwood, in a timely manner according to the procedures outlined 
above. Copies of discharge summaries, consultant reports, autopsy reports, and any other 
relevant documents may also be requested. 
Appropriate remedial measures should be taken by the Investigator using his/her best medical 
judgement to treat the SAE. These measures and the participant’s response to these measures 
should be recorded. All SAEs regardless of relationship to study drug will be followed by the 
Investigator until satisfactory resolution, until the Investigator deems the SAE to be chronic or 
stable, or until the participant is lost to follow-up. Clinical, laboratory, and diagnostic measures 
should be employed by the Investigator as needed to adequately determine the etiology of the 
event. 
The Investigator will be responsible for reporting all SAEs to Ironwood within 24 hours of 
learning of the event. The Investigator will provide timely and accurate reports to the REC on the 
progress of the study, and will notify the REC and the Sponsor of SAEs or other significant 
safety findings in a manner consistent with REC policies and ICH and GCP requirements. 
Ironwood shall keep detailed records of all SAEs that are reported by the investigator for future 
queries, if requested. Ironwood will also be responsible for reporting any suspected unexpected 
serious adverse reactions as soon as possible (but within a maximum of 7 days for suspected 
unexpected serious adverse reactions that are fatal or life-threatening, and 15 days for all other 
suspected unexpected serious adverse reactions) to the regulatory authorities and ensuring all 
SAEs are reported to the REC. 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 56 of 79 
10.4 
RECORDING REQUIREMENTS 
10.4.1 
Severity 
The Investigator will provide an assessment of the severity of each AE by recording a severity 
rating on the AE page of the participant’s CRF. Severity, which is a description of the intensity 
of manifestation of the AE, is distinct from seriousness, which implies a participant outcome or 
AE-required treatment measure associated with a threat to life or functionality. Severity will be 
assessed according to the following scale: 
Mild: 
A type of AE that is usually transient and may require only minimal treatment or 
therapeutic intervention. The event does not generally interfere with usual 
activities of daily living. 
Moderate: 
A type of AE that is usually alleviated with additional specific therapeutic 
intervention. The event interferes with usual activities of daily living, causing 
discomfort but poses no significant or permanent risk of harm to the research 
participant. 
Severe: 
A type of AE that interrupts usual activities of daily living, or significantly affects 
clinical status, or may require intensive therapeutic intervention. 
 
10.4.2 
Causality 
For all AEs, the Investigator must provide an assessment of causal relationship to study drug. 
The causality assessment must be recorded on the AE page of the participant’s CRF. Causal 
relationship must be assessed according to the following: 
• Related: An event where there is a reasonable possibility of a causal relationship between the 
event and the study drug; 
• Unrelated: Any other event. 
 
10.4.3 
Laboratory Abnormalities 
All of the following laboratory abnormalities should be captured as AEs: 
• Any laboratory test result that meets criteria for an SAE; 
• Any laboratory abnormality that resulted in study discontinuation; 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 57 of 79 
• Any laboratory abnormality that required the participant to receive specific corrective 
therapy; 
• Any laboratory abnormality that the Investigator considers to be clinically significant. 
 
Ongoing abnormal laboratory values/conditions that are being treated at baseline will be captured 
as an AE if the abnormality increases in severity and/or frequency while on study or if the 
abnormality requires more frequent treatment. If a participant is treated for an abnormal 
laboratory value just before the Screening Visit, then the medical history should reflect the 
severity of the abnormality before treatment. 
10.5 
UNBLINDING 
In the scenario that the Investigator must unblind a participant, the Investigator will have access 
to individual sealed unblinding envelopes, which can be opened to identify the treatment 
assignment for an individual participant in an emergency. The reason for breaking the blind must 
be documented in the participant’s CRF. 
The Investigator, all other study personnel not previously noted, and the participant will remain 
blinded to the participant’s treatment assignment throughout the study. 
10.6 
TERMINATION OF PARTICIPANTS 
Participants will be informed that they have the right to withdraw from the study at any time for 
any reason, without prejudice to their medical care. The Investigator will make reasonable efforts 
to keep each participant in the study. However, if the Investigator removes a participant from the 
study or if the participant declines further participation, the evaluations required at the EOT 
Visits should be performed if possible. All evaluations and observations, together with the 
description of the reason(s) for study withdrawal, must be recorded on the appropriate page of 
the participant’s CRF. 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 58 of 79 
The following are justifiable reasons for the Investigator to withdraw a participant from the 
study: 
• The occurrence of an AE; 
• Withdrawal of consent; 
• Unforeseen events: any event that, based on the Investigator’s judgement, makes further 
treatment inadvisable; 
• Serious violation of the study (including persistent participant attendance failure and 
non-compliance). 
 
An effort must be made to determine why a participant fails to return for the necessary visits or is 
dropped from the study. Regardless of the reason for termination, all data available for the 
participant at the time of discontinuation of follow-up should be recorded where applicable on 
the CRF. All reasons for discontinuation of treatment should be documented. 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 59 of 79 
11. 
STATISTICAL METHODS 
Details regarding the statistical methods will be provided in the Statistical Analysis Plan (SAP), 
to be finalised before unblinding of the study. 
11.1 
DETERMINATION OF SAMPLE SIZE 
A power calculation was used to determine how many participants will be required, as can be 
seen below. A total of 40 (20 in each group) participants are required to complete the study, with 
120 needed to enter screening to account for ineligible participants and dropouts. 
To achieve 80% power to detect a difference of 2.2 cm or more (using a simple 2-sided t-test 
with estimated SD = 2.4 cm and the conventional 5% significance level) in the mean change in 
abdominal girth (as measured by AIP AUC) from the start to the end of the day, between the 
active and placebo groups, 20 participants per group (40 participants in all) are required. 
Assuming a 15% dropout rate, 47 participants would need to be randomised to yield 40 evaluable 
participants. Estimating a 60% screen/pretreatment failure rate (mostly from failure to meet 
abdominal girth criteria, but also pretreatment abdominal pain and abdominal bloating criteria), 
120 participants may need to enter screening to achieve 40 randomised participants. 
11.2 
ANALYSIS POPULATIONS 
11.2.1 
ITT Population 
The Intent-to-treat (ITT) Population will consist of all participants randomised to a treatment 
group at the Randomisation visit (visit 4). 
11.2.2 
Safety Population 
The Safety Population will consist of all randomised participants who received at least one dose 
of study drug. 
11.2.3 
Evaluable Population 
The Evaluable Population will consist of all participants included in the Safety population 
presenting no major protocol deviations with the potential to bias the criteria for evaluation and 
with full follow-up. 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 60 of 79 
11.3 
STATISTICAL ANALYSES 
11.3.1 
General Considerations 
A more detailed description of the statistical methodology will be given in the Statistical 
Analayis Plan which will be finalised before unblinding of data. 
Distribution of study parameters and covariates will be summarised depending on the type of 
variable with the number of subjects and the number of missing data  (where relevant).  
Verification of the normality of the distribution for continuous data will be carried out by 
graphical inspection and consideration of skewness and kurtosis measures. 
Descriptive statistics will be presented as; 
 Qualitative data: number and percentage of participants in each category 
 Ordinal qualitative data: number and percentage of participants in each category, median, 
interquartiles, range 
 Continuous normally distributed data: number, mean, standard deviation, range 
 Continuous non-normally distributed data: number, median, interquartiles, range 
All statistical comparison tests will be performed using the conventional two-sided significance 
level of 5%. 
11.3.2 
Disposition, Demographics, and Baseline Characteristics 
The number of screen failures (i.e., participants who entered the Screening Period but not the 
Pretreatment Period) and the number of pretreatment failures (i.e., participants who entered the 
Pretreatment Period but were not randomised) will be tabulated by reason for failure. 
The overall number of participants screened and the number of participants randomised to each 
treatment group will be presented. The number and percentage of participants included in each of 
the analysis populations (ITT, Safety, and Evaluable) will be presented by treatment group and 
overall. The number and percentage of participants who completed the study or discontinued 
early, including the reason for discontinuation, will be presented by treatment group and overall. 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 61 of 79 
Participant demographics (age, sex, race, ethnicity, weight, height, and BMI [defined as weight 
in kg divided by height in meters squared]) and other relevant baseline characteristics will be 
summarised by treatment group for the ITT Population. 
11.3.3 
Efficacy Analyses 
Assessment of efficacy of treatment will be based on changes between baseline data provided at 
the Randomisation Visit (Visit 4) and subsequent study visits. Linear interpolation (for the 24 hr 
recorded girth data) or multiple imputation methods will be used to account for missing outcome 
data where appropriate . All analyses will be carried out on the ITT, Safety and Evaluable 
Populations.   
11.3.3.1 
Primary Efficacy Endpoint 
Change from Baseline in Abdominal Girth at Week 4 
The mean change from randomisation (Visit 4) to the end of the study (Visit 8) in abdominal 
girth (as measured by AUC) determined by 24-hour AIP (with hourly averages), between the 
linaclotide and placebo groups. 
The AUC will be calculated using the Trapezoidal method from the first reliable hour of 
measurement to last measurement (bedtime). The AUC for each patient will then be individually 
standardised by dividing the total AUC over the period by that patient’s number of hours of 
measurement included in the AUC. 
In case of missing data in the middle of the valid period of measurement, AUC is calculated with 
linear interpolation.  
11.3.3.2 
Primary Efficacy Analysis 
Changes in girth from the first hour of the 24-hour AIP at Visit 8 will be compared between the 
linaclotide and placebo groups with the AUC measure, adjusting for the corresponding changes 
in girth at Visit 4 and any other important confounding factors (such as age and BMI), using 
analyses of covariance. 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
C
 
Page 62 of 79 
11.3.3.3 
Secondary Efficacy Endpoints 
The secondary efficacy endpoints are as follows: 
Change from Baseline in Abdominal Distension at Week 2 
The mean change from randomisation (Visit 4) to (Visit 6) in abdominal girth (as measured by 
AUC) determined by 24-hour AIP, between the linaclotide and placebo groups. 
Change from Baseline in Maximal Abdominal Distension at Week 4 
The maximum change in girth from the first hour, over the period from the 2nd hour to bedtime. 
The percentage change in maximum distension from baseline to 4 weeks will also be calculated. 
Change from Baseline of symptom severity (abdominal pain, discomfort, bloating, and 
distension) 
Daily diary scores for each of the digestive symptoms and a composite score of these parameters 
will be averaged to obtain ‘weekly’ scores as follows; 
Baseline = mean (day -7 to day -1) 
Week 1 = mean (day 1 to day 7) 
Week 2 = mean (day 8 to day 14) 
Week 3 = mean (day 15 to day 21) 
Week 4 = mean (day 22 to day 28) 
 
Change from Baseline in Digestive sensations (subjective bloating, abdominal discomfort, 
abdominal distension and abdominal pain) at Weeks 4 and 8 
The mean change from randomisation (Visit 4) to Visit 6 and from randomisation to Visit 8 in  
each of the hourly measures of digestive sensations (as measured by AUC), between the 
linaclotide and placebo groups. 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 63 of 79 
Change from Baseline of Bristol Stool Form Scale at Weeks 4 and 8 
Daily diary BSFS scores will be recoded to represent discrepancies from a ‘normal’ stool type 4 
as follows: 
 Type 1 – coded 3 
 Type 2 – coded 2 
 Type 3 – coded 1 
 Type 4 – coded 0 
 Type 5 – coded 1 
 Type 6 – coded 2 
 Type 7 – coded 3 
 
Hence a higher score represents greater discrepancy from a ‘normal’ stool consistency. 
Daily average recoded BSFS scores for each subject will be computed by averaging over the first 
1, 2 or 3 stools as appropriate. For a subject with no stools on a particular day then their BSFS 
daily average BSS for that day is denoted as ‘missing’. 
The following means will be calculated for each subject: 
 Baseline = mean (day -7 to day -1) 
 Week 1 = mean (day 1 to day 7) 
 Week 2 = mean (day 8 to day 14) 
 Week 3 = mean (day 15 to day 21) 
 Week 4 = mean (day 22 to day 28) 
 
11.3.3.4 
Secondary Efficacy Analyses 
Change from Baseline in Abdominal Distension at Week 2 
Changes in girth from the first hour of the 24-hour AIP at Visit 6 will be compared between the 
linaclotide and placebo groups with the AUC measure, adjusting for the corresponding changes 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 64 of 79 
in girth at Visit 4 and any other important confounding factors (such as age and BMI), using 
analyses of covariance. 
Change from Baseline in Maximal Abdominal Distension at Week 4 
Changes in maximal abdominal girth will be compared between the linaclotide and placebo 
groups, adjusting for the corresponding changes in girth at Visit 4 and any other important 
confounding factors (such as age and BMI), using analyses of covariance. 
The percentage change in maximal distension will be compared using a simple t-test or Mann-
Whitney U-test as appropriate. 
Change from Baseline of symptom severity (abdominal pain, discomfort, bloating, and  
distension) 
Each of the digestive symptoms and the composite score will be compared between the 
linaclotide and placebo groups over the study period using longitudinal regression analysis with 
generalised estimating equations on the weekly scores. 
Change from Baseline in Digestive sensations at Weeks 4 and 8 
Changes in each of the digestive sensation scores at Visit 6 and Visit 8 separately, will be 
compared between the linaclotide and placebo groups with the AUC measure over the period 
hour 1 to bedtime, adjusting for the corresponding measures at Visit 4 and any other important 
confounding factors (such as age and BMI), using analyses of covariance. 
Change from Baseline of Bristol Stool Form Scale at Weeks 4 and 8 
The weekly average BSS recoded scores will be compared between the linaclotide and placebo 
groups over the study period using longitudinal regression analysis with generalised estimating 
equations on the weekly scores. 
11.3.3.5 
Additional Analysis 
The relationship between the hourly digestive sensation scores for bloating and the 
corresponding hourly difference in girth measures from hour 1 over the relevant time period 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 65 of 79 
during each of the two 24-hour periods at visit 4 and visit 8 will be assessed using longitudinal 
regression analysis. 
11.3.4 
Safety Analyses 
Adverse events will be coded using the latest version of Medical Dictionary for Regulatory 
Activities (MedDRA) available at the start of the study. TEAEs are those AEs that started or 
worsened in severity after the administration of study drug. TEAEs will be summarised by 
system organ class (SOC) and preferred term (PT) for each treatment group. In addition, listings 
of severe TEAEs, drug-related AEs, SAEs, AEs leading to study discontinuation, and AEs 
leading to death (if any) will be provided. 
Vital signs and clinical laboratory evaluations at each assessment time point and the change from 
baseline at each post-dose time point will be summarised for each treatment group. 
11.4 
COMPUTER METHODS 
Statistical analyses will be performed using SPSS, version 22.0 and STATA version 13 (or 
newer). 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 66 of 79 
12. 
STUDY OPERATIONS 
12.1 
GOOD CLINICAL PRACTICE 
This study will be conducted according to the protocol and in compliance with ICH GCP, the 
ethical principles stated in the Declaration of Helsinki, and other applicable regulatory 
requirements. 
The Investigator confirms the above by signing the protocol. 
12.2 
FINANCIAL DISCLOSURE 
Relevant financial disclosures will be included in the submission to the ethical committee. 
12.3 
ESSENTIAL DOCUMENTS 
1. Current, signed curricula vitae of the Investigator and all sub-Investigators; 
2. Copy of current medical license of the Investigator and all sub-Investigators (as applicable); 
3. Copy of REC approved Participant information sheet; 
4. Evidence of Sponsor insurance or indemnity; 
5. Copy of the REC approval letter for the protocol and informed consent; 
6. Copy of the REC-approved informed consent document to be used; 
7. Copy of the REC approval of recruitment advertising (if applicable); 
8. A list of REC members and their qualifications, and a description of the committee’s 
working procedures. 
 
During the study, the Investigator must maintain the following essential/administrative 
documents related to the study: 
1. Copy of the signed Protocol Signature Page; 
2. Copy of financial disclosure form(s) for the Investigator and all sub-Investigators; 
3. Curricula vitae of any new Investigator(s) and/or sub-Investigators involved in the study; 
4. SAE Reports; 
5. Drug Inventory Forms (drug receipts, drug dispensing and inventory forms); 
6. Name and address of local or central laboratory, list of normal laboratory values and units of 
measurements, as well as laboratory certification or hospital accreditation; 
7. Updates of medical/laboratory/technical procedures/tests: 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 67 of 79 
c. Normal value(s)/range(s), 
d. Certification, 
e. Accreditation, 
f. Established quality control and/or external quality assessment, 
g. Other validation (where required); 
8. Record of retained body fluids/tissue samples (if any); 
9. Correspondence with the Sponsor; 
10. Responsibility Log; 
11. Other logs (screening, enrolment, etc.); 
12. Signed ICFs; 
13. Participant diaries; 
14. Validated questionnaires;  
15. CRFs; 
16. Master randomisation list. 
 
12.4 
GENERATION OF STUDY RECORDS 
Ironwood, or its designated representative, will oversee the conduct of a Study Centre visit to 
verify the qualifications of each Investigator, inspect study centre facilities, and inform the 
Investigator of responsibilities and procedures for ensuring adequate and correct study 
documentation. 
The Investigator is required to prepare and maintain adequate and accurate case histories 
designed to record all observations and other data pertinent to the study for each study 
participant. For this study, information recorded on the CRFs is considered to be the participant’s 
source documentation. 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 68 of 79 
12.5 
CASE REPORT FORMS AND DATA MANAGEMENT 
All data relating to the study will be recorded in the participant’s CRF. The CRFs are to be 
completed at the time of the participant’s visit, except for results of tests performed outside the 
Investigator’s office. CRF data should indicate the participant’s participation in the study and 
should document the dates and details of study procedures, AEs, all observations, and participant 
status. The Investigator is responsible for verifying that all data entries on the CRFs are accurate 
and correct and ensure that all data are entered in a timely manner, as soon as possible after 
information is collected. An explanation should be provided for all missing data. The 
Investigator must provide his or her formal approval of all the information on the CRFs and 
changes to the CRFs to endorse the final submitted data for the participants for which he or she is 
responsible. 
The CRFs will be in the form of paper and will be stored initially in locked filing cabinets in the 
Neurogastoenterology unit and subsequently archived. A paper copy will be made of each CRF 
for retention by Ironwood.  
A record of participant screen failures will be maintained for participants who do not qualify for 
enrolment, including the reason for the failure. 
12.6 
STUDY MONITORING 
Ironwood, or its designee, may perform quality control and assurance checks as per the study 
monitoring plan. Before enrolling any participants into this study, Ironwood personnel, and/or a 
trained designated representative, will review the following with the Investigator: the protocol, 
the Investigator’s Brochure, the United States Package Insert (USPI), the CRFs and instructions 
for their completion, the procedure for obtaining informed consent, and the procedure for 
reporting AEs and SAEs. The Clinical Site Monitor will ensure that the investigation is 
conducted according to the protocol and regulatory requirements and will maintain current 
personal knowledge of the study through observation, review of study records, and discussion of 
the conduct of the study with the Investigator, sub-Investigators, and staff. 
All aspects of the study will be overseen by Ironwood, or its designee for compliance with 
applicable government regulations in respect to GCP and current standard operating procedures. 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 69 of 79 
12.7 
CHANGE IN INVESTIGATOR 
If any Investigator retires, relocates, or otherwise withdraws from conducting the study, the 
responsibility for maintaining records may be transferred to another person (Ironwood, REC, or 
other Investigators) who will accept the responsibility. Ironwood must be notified of and agree to 
the change. 
12.8 
RECORD RETENTION AND ARCHIVING 
Records and documents pertaining to the conduct of this study, including CRFs, consent forms, 
laboratory test results, and study drug inventory records, will be retained until Ironwood no 
longer need the data for any commercial purposes. No study records shall be destroyed without 
notifying Ironwood and giving Ironwood the opportunity to take such study records or 
authorising in writing the destruction of records after the required retention period. 
12.9 
REPORTING AND PUBLICATION POLICY 
All data generated in this study will be the property of Ironwood. An integrated clinical and 
statistical report will be prepared at the completion of the study. 
Publication of the results by the Investigator will be subject to mutual agreement between the 
Investigator and Ironwood. 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 70 of 79 
13. 
REFERENCE LIST 
References: 
1. Lembo T, Naliboff B, Munakata J, Fullerton S, Saba L, Tung S, et al. Symptoms and visceral 
perception in patients with pain-predominant irritable bowel syndrome. Am J Gastroenterol. 
1999; 94:1320-6. 
2. Ringel Y, Williams RE, Kalilani L, Cook SF. Prevalence, characteristics, and impact of 
bloating symptoms in patients with irritable bowel syndrome. Clin Gastroenterol Hepatol. 
2009;7:68-72. 
3. Agrawal A, Whorwell PJ. Review article: abdominal bloating and distension in functional 
gastrointestinal disorders--epidemiology and exploration of possible mechanisms. Aliment 
Pharmacol Ther. 2008;27:2-10. 
4. Whorwell PJ. Unraveling functional abdominal bloating and distension: the role of thoraco-
abdominal accommodation and a physical sign to aid its detection. Neurogastroenterol Motil. 
2012 Apr;24:301-4. 
5. Houghton LA, Lea R, Agrawal A, Reilly B, Whorwell PJ. Relationship of abdominal 
bloating to distention in irritable bowel syndrome and effect of bowel habit. 
Gastroenterology. 2006;131:1003-10. 
6. Agrawal A, Houghton LA, Lea R, Morris J, Reilly B, Whorwell PJ. Bloating and distention 
in irritable bowel syndrome: the role of visceral sensation. Gastroenterology. 2008;7:1882-9. 
7. Agrawal A, Houghton LA, Reilly B, Morris J, Whorwell PJ. Bloating and distension in 
irritable bowel syndrome: the role of gastrointestinal transit. Am J Gastroenterol. 
2009;104:1998-2004. 
8. Agrawal A, Houghton LA, Morris J, Reilly B, Guyonnet D, Goupil Feuillerat N, et al. 
Clinical trial: the effects of a fermented milk product containing Bifidobacterium lactis DN-
173-010 on abdominal distension and gastrointestinal transit in irritable bowel syndrome 
with constipation. Aliment Pharmacol Ther. 2008;29:104-14. 
9. Reilly BP, Bolton MP, Lewis MJ, Houghton LA, Whorwell PJ. A device for 24 hour 
ambulatory monitoring of abdominal girth using inductive plethysmography. Physiol Meas. 
2002;23:661-70. 
10. Marteau P, Cuillerier E, Meance S, Gerhardt MF, Myara A, Bouvier M, et al. 
Bifidobacterium animalis strain DN-173 010 shortens the colonic transit time in healthy 
women: a double-blind, randomized, controlled study. Aliment Pharmacol Ther. 
2002;16:587-93. 
11. Guyonnet D, Chassany O, Ducrotte P, Picard C, Mouret M, Mercier CH, et al. Effect of a 
fermented milk containing Bifidobacterium animalis DN-173 010 on the health-related 
quality of life and symptoms in irritable bowel syndrome in adults in ;primary care: a 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 71 of 79 
multicentre, randomized, double-blind, controlled trial. Aliment Pharmacol Ther. 
2007;26:475-86. 
12. Drossman DA, Chey WD, Johanson JF, Fass R, Scott C, Panas R, et al. Clinical trial: 
lubiprostone in patients with constipation associated irritable bowel syndrome-results of two 
randomized, placebo-controlled studies. Aliment Pharmacol Ther 2009;29:329-41. 
13. Nyhlin H, Bang C, Elsborg L, Silvennoinen J, Holme I, Ruegg P, et al. A double-blind, 
placebo-controlled, randomized study to evaluate the efficacy, safety and tolerability of 
tegaserod in patients with irritable bowel syndrome. Scand J Gastroenterol 2004; 39: 119-
26.Scand J Gastroenterol 2004;39:119-26. 
14. Quigley EM, Vandeplassche L, Kerstens R, Ausma J. Clinical trial: the efficacy, impact on 
quality of life, and safety and tolerability of prucalopride in severe chronic constipation – a 
12-week, randomized, double-blind, placebo-controlled study. Aliment Pharmacol Ther 
2009;29:315–28. 
15. Quigley EM, Tack J, Chey WD, Rao SS, Fortea J, Falques M, et al. Randomised clinical 
trials: Linaclotide phase 3 studies in IBS-C - a prespecified further analysis based on 
European Medicines Agency-specified endpoints. Aliment Pharmacol Ther 2012;37:49-61. 
16. Lembo AJ, Schneier HA, Shiff SJ, Kurtz CB, MacDougall JE, Jia XD, et al. Two randomized 
trials of linaclotide for chronic constipation. N Engl J Med 2011;365:527-36. 
17. Bryant AP, Busby RW, Bartolini WP, Cordero EA, Hannig G, Kessler MM, et al. 
Linaclotide is a potent and selective guanylate cyclase C agonist that elicits pharmacological 
effects locally in the gastrointestinal tract. Life Sci 2010;86:760-5. 
18. Busby RW, Bryant AP, Bartolini WP, Cordero EA, Hannig G, Kessler MM, et al. 
Linaclotide, through activation of guanylate cyclase C, acts locally in the gastrointestinal 
tract to elicit enhanced intestinal secretion and transit. Eur J Pharmacol 2010;649:328-35. 
19. Busby RW, Kessler MM, Bartolini WP, Bryant AP, Hannig G, Higgins CS, et al. 
Pharmacological properties, metabolism and disposition of linaclotide, a novel therapeutic 
peptide approved for the treatment of irritable bowel syndrome with constipation and chronic 
idiopathic constipation. J Pharmacol Exp Ther 2013;344:196-206. 
20. Castro J, Harrington AM, Hughes PA, Martin CM, Ge P, Shea CM, et al. Linaclotide inhibits 
colonic nociceptors and relieves abdominal pain via guanylate cyclase-C and extracellular 
cyclic GMP. Gastroenterology 2013;145:1334-46. 
21. Eutamene H, Bradesi S, Larauche M, Theodorou V, Beaufrand C, Ohning G, et al. Guanylate 
cyclase C-mediated antinociceptive effects of linaclotide in rodent models of visceral pain. 
Neurogastroenterol Motil 2010;22:312-22. 
22. Silos-Santiago I, Hannig G, Eutamene H, Ustinova EE, Bernier SG, Ge P, et al. 
Gastrointestinal pain: Unraveling a novel endogenous pathway through 
uroguanylin/guanylate cyclase-C/cGMP activation. Pain 2013;154:1820-30. 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 72 of 79 
23. Chey WD, Lembo AJ, Lavins BJ, Shiff SJ, Kurtz CB, Currie MG, et al. Linaclotide for 
irritable bowel syndrome with constipation: a 26-week, randomized, double-blind, placebo-
controlled trial to evaluate efficacy and safety. Am J Gastroenterol 2012;107:1702-12. 
24. Rao S, Lembo AJ, Shiff SJ, Lavins BJ, Currie MG, Jia XD, et al. A 12-week, randomized, 
controlled trial with a 4-week randomized withdrawal period to evaluate the efficacy and 
safety of linaclotide in irritable bowel syndrome with constipation. Am J Gastroenterol 
2012;107:1714-25. 
 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 73 of 79 
14. 
APPENDICES 
 
 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 74 of 79 
APPENDIX 1 
CONCOMITANT MEDICINES 
Rescue Medicine 
Rescue Medicine, which will be selected by the Investigator and dispensed to participants, will 
be a choice of 5-mg bisacodyl tablets or 10-mg bisacodyl suppositories. During the Pretreatment 
and Treatment Periods, participants may use dispensed, protocol-permitted laxatives (bisacodyl 
tablets or suppositories) as Rescue Medicine when at least 72 hours have passed since their 
previous BM or when their symptoms become intolerable. In order to qualify for randomisation 
into the Treatment Period, participants must have refrained from using Rescue Medicine on the 
calendar day before the Randomisation Visit and on the day of the Randomisation Visit up until 
the time of the clinic visit. Participants must agree to refrain from using Rescue Medicine from 
the time of the clinic visit through the calendar day after the Randomisation Visit and 24 hours 
prior to any visit where participants will be fitted with the AIP belt (Visit 3, Visit 5, and Visit 7). 
If a Rescue Medicine has been used within 24 hours of a scheduled AIP belt placement visit, the 
visit should be postponed until 24 hours after the administration of the rescue medicine.  
Prohibited Medicines 
All medicine listed in the sections below are excluded from the Screening Visit for the duration 
of the study. Please note the specific restriction windows for detailed instructions. 
1. Drugs with known pharmacological activity at 5-hydroxytryptophan (HT)4, 5-HT2b or 
5-HT3 receptors (e.g., cisapride, tegaserod, ondansetron, tropisetron, granisetron, dolasetron, 
and mirtazapine). 
2. Any treatment specifically taken for IBS-C or CIC alone or in combination, including 
lubiprostone, an approved chloride channel activator that enhances intestinal fluid secretion, 
colchicine, and misoprostol. 
3. Prokinetic agents (e.g., metoclopramide, itopride, and domperidone). 
4. Anti-cholinergic agents (e.g., dicyclomine, flavoxate, scopolamine, hyoscyamine, 
propantheline, oxybutynin, tolterodine, solefenacin, darifenacin, and trospium). Note: inhaled 
ipratropium and tiotropium are permitted. 
5. Bile acid sequestrants (e.g., cholestyramine and colestipol). 
6. Cholinomimetic agents (e.g., bethanechol, pyridostigmine, tacrine, and physostigmine). 
Note: intraocular cholinomimetic agents (e.g., pilocarpine) are permitted. 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 75 of 79 
7. Antipsychotic agents (e.g., risperidone, haloperidol, droperidol, chlorpromazine, 
perphenazine, all phenothiazines, quetiapine, olanzapine, and clozapine) unless the 
participant has been on a stable dose for 30 days before the Screening Visit and there is no 
plan to change the dose after the Screening Visit. Note: paliperidone is permitted without 
restriction. 
8. Antidepressants unless the participant has been on a stable dose for at least 3 months before 
the Screening Visit and there is no plan to change the dose after the Screening Visit. 
Specifically included are the following: 
- 
Tricyclic antidepressants (e.g., amitriptyline, imipramine, and nortriptyline) 
- 
Monoamine oxidase inhibitors (e.g., furazolidone, isocarboxazid, pargyline, phenelzine, 
and selegiline tranylcypromine) 
- 
Selective serotonin reuptake inhibitors (e.g., fluoxetine, sertraline, paroxetine, and 
citalopram) 
- 
Serotonin and norepinephrine reuptake inhibitors (e.g., venlafaxine and desvenlafaxine 
succinate) 
- 
Others (e.g., trazodone, and bupropion) 
9. Calcium channel blocker verapamil, unless the participant has been on a stable dose for 30 
days before the Screening Visit and there is no plan to change the dose after the Screening 
Visit. Note: all other calcium channel blockers (e.g., nifedipine, diltiazem, amlodipine, 
felodipine, nicardipine, nimodipine, nisoldipine, etc.) are permitted and may be used without 
restriction. 
10. Oral and parenteral antibiotics within 60 days of the Screening Visit. 
11. Any investigational drugs. 
12. All narcotics either alone or in combination (e.g., tramadol, codeine, morphine, 
propoxyphene, loperamide, diphenoxylate, and paregoric). Note: narcotics used as 
anaesthesia for a colonoscopy require a 5 calendar day wash-out prior to the participant 
entering into the Pretreatment Period. 
13. Any medicine taken for the purpose of losing weight (e.g., orlistat, phentermine, 
phendimetrazine, diethylpropion, benzphetamine, and sibutramine). 
14. Any medicine that is known to cause diarrhoea (e.g., acarbose). 
15. Proton pump inhibitors (e.g., omeprazole, lansoprazole, esomeprazole, pantoprazole, 
rabeprazole) unless the participant has been on a stable dose for at least 3 months before the 
Screening Visit and there is no plan to change the dose after the Screening Visit. 
16. Others: barbiturates (e.g., butalbital and phenobarbital) and chronic oral or parenteral 
glucocorticoids (which must be discontinued at least 3 months before the Screening Visit; 
however, one 10-day course of oral or 1 injection of parenteral glucocorticoids is permitted). 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 76 of 79 
Pregabalin is acceptable, provided the participant has been on a stable dose during the 30 
days before the Screening Visit and plans to continue stable dosing throughout the study. 
17. Thyroxin, unless the participant has been on a stable dose for at least three months before the 
Screening Visit and there is no plan to change the dose after the screening visit.  
18. Participant is taking analgesic drugs, except paracetamol. 
19. Long-term oral iron preparations. 
 
1 Day Prior to the Pretreatment Visit and Visits 3, 5, and 7 
1. Any over-the-counter or prescription laxative, suppository, or enema (e.g., polyethylene 
glycol, lactulose, Fleet’s). Note: The use of fibre, bulk laxatives, stool softeners (surfactants 
such as docusate), and probiotics is acceptable, provided the participant has been on a stable 
dose during the 30 days before the Screening Visit and plans to continue stable dosing 
throughout the study. 
2. Any medicine used to treat diarrhoea (e.g., bismuth subsalicylate, kaolin). 
3. NSAIDs if taken for abdominal pain or discomfort. 
 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 77 of 79 
APPENDIX 2 
DIGESTIVE SENSATIONS QUESTIONNAIRE 
 
 
 
  
   
                                        
 
 
                                                                                   
 
                                                                                        
 
 
 
 
 
   
                                        
 
 
                                                                                   
 
                                                                                        
 
 
 
 
 
   
                                        
 
 
                                                                                   
 
                                                                                        
 
 
 
 
 
   
                                        
  
 
                                                                                   
 
                                                                                        
 
 
 
 
 
   
                                        
 
 
                                                                                   
 
                                                                                        
 
 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 78 of 79 
APPENDIX 3 
HOSPITAL ANXIETY AND DEPRESSION SCALE 
(HADS) 
 
 
 25-Apr-2017 9:50 / Version 4


Linaclotide 
 
Ironwood Pharmaceuticals, Inc. 
Clinical Study Protocol: MCP-103-403-P-04 
 
25 April 2017 
 
 
Page 79 of 79 
APPENDIX 4 
IRRITABLE BOWEL SYNDROME SYMPTOM 
SEVERITY SCORE (IBS-SSS) 
 
 
 
 25-Apr-2017 9:50 / Version 4

SAP_001.pdf: 
STATISTICAL ANALYSIS PLAN: MCP-103-403-SAP-01 
Final Version 
 
Study Title: 
A Phase 4, Single-centre, Randomised, Double-blind, Placebo-
controlled, Parallel-group, Fixed-dose Study of the Effect of 
Linaclotide on Abdominal Girth in Participants with Irritable Bowel 
Syndrome with Constipation 
Protocol Number: 
MCP-103-403-P-04 
Product Name: 
Linaclotide 
Sponsor: 
Ironwood Pharmaceuticals, Inc. 
301 Binney Street 
Cambridge, MA 02142 
Final Date: 
March 11, 2019 
 
 
The contents of this document are confidential and belong to Ironwood Pharmaceuticals, Inc. 
Except as may be otherwise agreed to in writing, by accepting or reviewing these materials, 
you (including any colleagues or subordinates) agree to hold such information in confidence 
and not to disclose it to others (except where required by applicable law), nor to use it for 
unauthorized purposes. In the event of actual or suspected breach of this obligation, 
Ironwood should be promptly notified. 
 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 2 of 29 
1. 
TABLE OF CONTENTS 
STATISTICAL ANALYSIS PLAN: MCP-103-403-SAP-01 .........................................................1 
1. 
TABLE OF CONTENTS .........................................................................................................2 
2. 
LIST OF ABBREVIATIONS ..................................................................................................5 
3. 
INTRODUCTION ...................................................................................................................7 
3.1 
STUDY DESIGN SUMMARY .....................................................................................7 
3.2 
STUDY OBJECTIVES AND ENDPOINTS .................................................................8 
3.3 
SCHEDULE OF EVALUATIONS ...............................................................................9 
4. 
STATISTICAL METHODS, STUDY ENDPOINTS, AND DETERMINATION OF 
SAMPLE SIZE ......................................................................................................................12 
4.1 
STATISTICAL AND ANALYTICAL PLAN ............................................................12 
4.1.1 
General Methods ................................................................................................12 
4.1.1.1 
Analysis Populations ................................................................................12 
4.1.1.2 
Study Medication .....................................................................................13 
4.1.1.3 
Statistical Methods ...................................................................................13 
4.1.1.4 
Missing Data ............................................................................................14 
4.1.1.5 
Study Periods ...........................................................................................14 
4.1.2 
Demographics ....................................................................................................14 
4.1.2.1 
Disposition of Subjects ............................................................................14 
4.1.2.2 
Protocol Deviations ..................................................................................15 
4.1.2.3 
Demographics and Baseline Characteristics ............................................16 
4.1.2.4 
Medical History .......................................................................................17 
4.1.2.5 
Prior and Concomitant Medication ..........................................................18 
4.1.2.6 
Drug compliance ......................................................................................18 
4.1.2.7 
Diary Compliance ....................................................................................19 
4.1.3 
Efficacy ..............................................................................................................19 
4.1.3.1 
Analysis of Primary Efficacy Endpoint ...................................................19 
4.1.3.2 
Secondary and Additional Efficacy Analyses ..........................................20 
4.2 
SAMPLE SIZE JUSTIFICATION ..............................................................................23 
4.3 
SAFETY ANALYSIS ..................................................................................................23 
4.3.1 
Adverse Events ..................................................................................................23 
4.3.2 
Clinical Laboratory Data....................................................................................25 
4.3.3 
Vital Signs Parameters .......................................................................................25 
4.3.4 
Physical Examination.........................................................................................26 
5. 
CHANGES FROM ANALYSES PLANNED IN THE PROTOCOL ...................................27 
6. 
REFERENCES ......................................................................................................................29 
 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 3 of 29 
LIST OF IN-TEXT TABLES 
Table 1. 
Schedule of Evaluations .......................................................................................9 
Table 2. 
Statistical Methods .............................................................................................13 
Table 3. 
Missing data handling conventions ....................................................................14 
Table 4. 
Study Periods .....................................................................................................14 
Table 5. 
Disposition Analyses .........................................................................................14 
Table 6. 
Important Protocol Deviations ...........................................................................16 
Table 7. 
Demographics ....................................................................................................17 
Table 8. 
Baseline Characteristics .....................................................................................17 
Table 9. 
Medical History .................................................................................................18 
Table 10. 
Prior and Concomitant Medication ....................................................................18 
Table 11. 
Study Drug Compliance .....................................................................................19 
Table 12. 
Diary Compliance ..............................................................................................19 
Table 13. 
Primary Efficacy Analysis .................................................................................20 
Table 14. 
Secondary and Additional Efficacy Endpoints ..................................................21 
Table 15. 
AE classification ................................................................................................24 
Table 16. 
Adverse Events ..................................................................................................25 
Table 17. 
Clinical Laboratory Summaries .........................................................................25 
Table 18. 
Vital Signs Summaries .......................................................................................26 
 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 4 of 29 
LIST OF IN-TEXT FIGURES 
Figure 1. 
Study Schedule and Chronology ..........................................................................7 
 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 5 of 29 
2. 
LIST OF ABBREVIATIONS 
Abbreviation/Term Definition 
ADO 
adverse event leading to drop out 
AE 
adverse event 
AIP 
abdominal inductance plesthymography 
ANCOVA 
analysis of covariance 
BM 
bowel movement 
BMI 
body mass index 
BSFS 
Bristol Stool Form Scale 
CMH 
Cochran-Mantel-Haenszel 
CSBM 
complete spontaneous bowel movement 
EOT 
End-of-Treatment Period 
HADs 
Hospital Anxiety and Depression Scale 
IBS-C 
Irritable Bowel Syndrome with Constipation 
IBS-SSS 
Irritable Bowel Syndrome – Symptom Severity Scale 
IPD 
Important Protocol Deviations 
ITT 
Intent-to-Treat 
LOCF 
last observation carried forward 
LS 
least-squares 
MedDRA 
Medical Dictionary for Regulatory Activities 
MI 
multiple imputation 
NRS 
numerical rating scale 
OC 
observed case 
PCS 
potentially clinically significant 
PT 
preferred term 
RM 
rescue medication 
SAE 
serious adverse event 
SAP 
statistical analysis plan 
SBM 
spontaneous bowel movement  
SD 
standard deviation 
SI 
International System of Units 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 6 of 29 
Abbreviation/Term Definition 
SOC 
system organ class 
TEAE 
treatment emergent adverse event 
ug 
microgram 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 7 of 29 
3. 
INTRODUCTION 
This statistical analysis plan (SAP) provides a more technical and detailed elaboration of the 
statistical analyses of the efficacy and safety data as outlined and/or specified in the final 
protocol of Study MCP-103-403-P-04 (Amendment 3, dated April 25, 2017).  Specifications for 
the tables, figures, and data listings are contained in a separate document. 
3.1 
STUDY DESIGN SUMMARY 
The study will be a single-centre, randomised, double-blind, placebo-controlled, parallel-group 
study comparing linaclotide to placebo. Approximately 40 participants with a diagnosis of IBS-C 
(Rome III criteria), who are shown to distend >4 cm over 24 hours during the Pretreatment Period, 
will be randomised. 
The study will consist of up to 14 days of screening, 7 days of pretreatment, 29 (± 2) days of 
double-blind treatment, and 7 (± 2) days of follow-up. At the end of the Pretreatment Period, 
participants meeting the entry criteria for this study will be randomised (1:1) to one of two double-
blind treatment groups: 290 ug linaclotide or matching placebo. 
Figure 1. 
Study Schedule and Chronology 
 
 
Screening
Period
Pre-treatment
Period
Treatment
Period
Follow-up
Period
14 days
7 days
29 (±2) days
7 (±2 days)
**
**
**
Screening
Visit
(Day -21)
Pretreatment
Visit
(Day -7)
Randomization
Visit**
(Day 1)
Baseline
Visit
(Day -1)
Day 13
Visit
(Day 13 to 15)
Day 15
Visit
(Day 15 to 17)
Day 27
Visit
(Day 27 to 29)
EOT
Visit**
(Day 28 to 30)
Follow-up
Phone Call
(Day 36 to 39)
No Treatment
No Treatment
Note: There is no Day 0
** AIP Belt Measurement
Linaclotide 290 ug
OR
Matching Placebo


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 8 of 29 
3.2 
STUDY OBJECTIVES AND ENDPOINTS 
To determine the effect of linaclotide on abdominal girth in irritable bowel syndrome with 
constipation (IBS-C) participants with baseline symptoms of abdominal bloating and an increased 
abdominal girth. 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 9 of 29 
3.3 
SCHEDULE OF EVALUATIONS 
Table 1. 
Schedule of Evaluations 
Schedule of Evaluations 
 
Screening 
Period 
(14 days) 
Pretreatment Period 
(7 days) 
Treatment Period 
(29±2 days) 
Follow-up 
Period (7± 
2 days) 
Visit Name → 
Screening 
Visit 
Pretreatment 
Visit 
Baseline 
Visit 
Randomisation 
Visit 
Day 13 
Visit 
Day 15 
Visit 
Day 27 
Visit 
EOT 
Visita 
Follow-up 
Visit Number → 
Visit 1 
Visit 2 
Visit 3 
Visit 4 
Visit 5 
Visit 6 
Visit 7 
Visit 8 
Telephone 
Call 
Visit Day → 
Day -21 
Day -7 
Day -2 
Day 1 
Day 
13±2 
Day 
15±2 
Day 
27±2 
Day 
28±2 
Day 36 ± 2 
Study Procedure ↓ 
 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
Inclusion and exclusion criteria 
verification 
X 
 
 
X 
 
 
 
 
 
Medical and surgical history 
X 
 
 
X 
 
 
 
 
 
Rome III status for IBS-C 
X 
 
 
 
 
 
 
 
 
Physical examinationb 
X 
 
 
X 
 
 
 
X 
 
Body weight and heightc 
X 
 
 
X 
 
X 
 
X 
 
Seated vital signsd 
X 
 
 
X 
 
X 
 
X 
 
Prior and concomitant medicines 
X 
X 
X 
X 
X 
X 
X 
X 
 
Clinical laboratory determinationse 
X 
 
 
 
 
 
 
 
 
Pregnancy testf 
X 
 
 
X 
 
 
 
X 
 
Completion of HADs and IBS-SSS 
X 
 
 
 
 
 
 
X 
 
Laxative, suppository, and enema 
washout instructions 
X 
 
 
 
 
 
 
 
 
AE evaluationsg 
 
X 
X 
X 
X 
X 
X 
X 
X 
Rescue Medicine dispensedh 
 
X 
 
X 
 
X 
 
 
 
Diary training, compliance 
verification, and reminderi 
 
X 
X 
 
X 
 
X 
 
 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 10 of 29 
Schedule of Evaluations 
 
Screening 
Period 
(14 days) 
Pretreatment Period 
(7 days) 
Treatment Period 
(29±2 days) 
Follow-up 
Period (7± 
2 days) 
Visit Name → 
Screening 
Visit 
Pretreatment 
Visit 
Baseline 
Visit 
Randomisation 
Visit 
Day 13 
Visit 
Day 15 
Visit 
Day 27 
Visit 
EOT 
Visita 
Follow-up 
Visit Number → 
Visit 1 
Visit 2 
Visit 3 
Visit 4 
Visit 5 
Visit 6 
Visit 7 
Visit 8 
Telephone 
Call 
Visit Day → 
Day -21 
Day -7 
Day -2 
Day 1 
Day 
13±2 
Day 
15±2 
Day 
27±2 
Day 
28±2 
Day 36 ± 2 
Study Procedure ↓ 
 
 
 
 
 
 
 
 
 
Daily diary recording 
 
X 
X 
X 
X 
X 
X 
X 
 
Daily diary collection 
 
 
 
X 
 
X 
 
X 
 
Digestive Sensations questionnaire 
given 
 
 
X 
 
X 
 
X 
 
 
Digestive Sensations questionnaire 
collected 
 
 
 
X 
 
X 
 
X 
 
AIP fittedj 
 
 
X 
 
X 
 
X 
 
 
AIP Assessment 
 
 
 
X 
 
X 
 
X 
 
Randomisation 
 
 
 
X 
 
 
 
 
 
Study drug dispensedk 
 
 
 
X 
 
 
 
 
 
Study drug accountability 
 
 
 
 
 
X 
 
X 
 
Follow-up phone call 
 
 
 
 
 
 
 
 
X 
a. 
Participants who are randomised but do not complete the Treatment Period (withdraw consent or are discontinued before they have completed 4 weeks of 
treatment) shall be considered Treatment-Period withdrawals and should complete the procedures required at the EOT Visit (even if out of window). 
b. A physical examination should include the following: general appearance, HEENT (head, ears, eyes, nose, and throat), neck, cardiovascular, thorax/lungs, 
abdomen, musculoskeletal, lymph nodes, skin, neurologic, and mental status. Rectal examination is not required; however, sigmoidoscopy/colonoscopy may 
be performed at the discretion of the Investigator. 
c. 
Height will only be measured at the Screening Visit (Visit 1) 
d. Vital signs (oral temperature, respiratory rate, systolic and diastolic blood pressure, and pulse rate) must be obtained from participants who are in the seated 
position. 
e. 
Complete hematology and chemistry will be required at the Screening Visit (Visit 1) if lab results obtained within the prior 30 days are not available.  
f. 
To be eligible for the study, a negative urine pregnancy test must be documented at the Screening Visit (Visit 1) and Randomisation Visit (Visit 4); another 
urine pregnancy test will be performed at the EOT Visit (Visit 8).  
g. All AEs occurring after the participant signs the ICF will be documented.  
h. Rescue Medicine (bisacodyl tablets) will be supplied to participants at the Pretreatment Visit (Visit 2) and, if needed, at subsequent visits. 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 11 of 29 
i. 
At the Pretreatment Visit (Visit 2) the Study Coordinator will instruct the participants about the use of the Daily Diary. At subsequent visits, the Study 
Coordinator will review the Daily Diary to verify participant compliance. After determining the participant’s compliance, the Study Coordinator will remind 
participants to record their diary assessments daily. 
j. 
Women who are actively menstruating during AIP belt placement should have their visits delayed for 48 hours. Participants who have taken Rescue 
Medicines within 24 hours of AIP belt placement should have their visits delayed until 24 hours have passed since the use of Rescue Medicine. Participants 
who have had study drug suspended due to diarrhea should have their AIP belt placement visits delayed until study drug has been resumed for 24 hours.   
k. Study drug will be administered in the clinic at the Randomisation Visit (Visit 4). At this visit, study drug does not need to be taken in the morning before 
breakfast. On all other days, study drug will be taken once daily in the morning at least 30 minutes before breakfast. 
AE = adverse event; AIP = abdominal inductance plethysmography; IBS-C = irritable bowel syndrome with constipation; EOT = end of treatment; 
HADs = Hospital Anxiety and Depression Scale; IBS-SSS= Irritable Bowel Syndrome Symptom Severity Score 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 12 of 29 
4. 
STATISTICAL METHODS, STUDY ENDPOINTS, AND 
DETERMINATION OF SAMPLE SIZE 
4.1 
STATISTICAL AND ANALYTICAL PLAN 
Statistical analyses defined in the SAP will be performed using STATA Version 13 or newer, 
Rv3.2.4 or newer, and SAS version 9.4 or newer. 
4.1.1 
General Methods 
Distribution of study parameters and covariates will be summarised depending on the type of 
variable with the number of subjects and the number of missing data (where relevant). 
Verification of the normality of the distribution for continuous data will be carried out by graphical 
inspection and consideration of skewness and kurtosis measures. 
Percentages will be based on the total number of non-missing values. The number missing will be 
presented, but without a percentage.  
Descriptive statistics will be presented as; 
• Discrete data: number and percentage of participants in each category 
• Ordinal categorical data: number and percentage of participants in each category, median, 
interquartiles, range 
• Continuous data: number, mean, median, standard deviation, minimum, maximum 
 
All confidence intervals reported will be two-sided and at the 95% confidence level. There is no 
adjustment for multiplicity. 
If not otherwise specified, the baseline value is defined as the last nonmissing value measured 
before administration of study drug on Day 1. 
4.1.1.1 
Analysis Populations 
Screening population: All participants who signed the consent form and had a Screening Visit. 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 13 of 29 
Intent-to-Treat (ITT):  All participants who were randomised to a treatment group at the 
randomisation visit (visit 4). 
Safety Population: All randomised participants who received at least one dose of study drug. 
Evaluable Population: All participants included in the Safety Population presenting no major 
protocol deviations with the potential to bias the criteria for evaluation and with full follow-up. 
In the event a subject receives multiple randomization assignments, the subject will be analyzed 
in the ITT Population according to the first assignment they received; the subject will be analysed 
according to what they actually received in the Safety Population; the subject will not be included 
in the Evaluable Population as this is a major protocol deviation. 
4.1.1.2 
Study Medication 
For the double-blind Treatment Period, participants will be supplied with identically appearing 
capsules containing 290 ug linaclotide, or matching placebo. 
4.1.1.3 
Statistical Methods 
For descriptive summaries, N will represent the total number of patients within the summarized 
population and n will represent the number of non-missing patients for the summarized endpoint.  
All summary statistics will be presented by treatment and based on non-missing endpoint values, 
unless otherwise specified. 
Table 2. 
Statistical Methods  
Method 
Definition 
Categorical Summaries 
• Number and percent of patients in each 
category 
• Percent based on number of non-missing  
values 
• Number of missing patients in each category; 
percent not presented. 
Continuous Summaries 
• Number of non-missing patients, mean, 
median, standard deviation, minimum, 
maximum 
 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 14 of 29 
4.1.1.4 
Missing Data 
Table 3. 
Missing data handling conventions 
Endpoint Type 
Descriptions 
24 hour recorded girth data 
Linear interpolation 
 
4.1.1.5 
Study Periods 
Table 4. 
Study Periods 
Period 
Start Date 
End Date 
Screening 
Date of Signed ICF 
PreTreatment Visit Date - 7 
Pretreatment 
PreTreatment Visit Date 
Randomization Date (up to time 
of randomization) 
Treatment 
Date of Randomization 
End of Treatment Visit Date 
Follow-up Period 
End of Treatment Visit Date 
Follow-up Phone Call 
 
4.1.2 
Demographics  
4.1.2.1 
Disposition of Subjects 
Table 5. 
Disposition Analyses 
Analysis Population 
Description 
Summary Method 
Screening, ITT, Safety, 
Evaluable 
Overall 
Counts 
Screening 
Reason for Screening and 
Pretreatment Failure 
Categorical Summary  
ITT, Safety 
Premature Discontinuation 
• Completed Study 
• Discontinued Study 
• Reason for Discontinuation 
 
Categorical Summary  
ITT 
Discontinuation by Time 
(Week) 
Time to D/C = 1 + <date of 
d/c> - <date of first dose> 
Categorical Summary 
 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 15 of 29 
The number of screen failures (i.e., participants who entered the Screening Period but not the 
Pretreatment Period) and the number of pretreatment failures (i.e., participants who entered the 
Pretreatment Period but were not randomised) will be tabulated by reason for failure. 
The overall number of participants screened and the number of participants randomised to each 
treatment group will be presented. The number and percentage of participants included in each of 
the analysis populations (ITT, Safety, and Evaluable) will be presented by treatment group and 
overall. The number and percentage of participants who completed the study or discontinued early, 
including the reason for discontinuation, will be presented by treatment group and overall. 
4.1.2.2 
Protocol Deviations 
Protocol deviations and Important Protocol Deviations (IPD) will be identified and documented 
for all randomized patients prior to unblinding through programmatic checks of the study data and 
select individual data reviews. IPDs will be determined based on review of all protocol deviations 
and protocol deviation categories (i.e., Use of Disallowed Medication)  performed by members of 
the Ironwood Clinical Trials team, including but not limited to the Clinical Medical Researcher 
and study Biostatistician. 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 16 of 29 
Table 6. 
Important Protocol Deviations 
Analysis Population 
Description 
Summary Method 
ITT 
Important Protocol Deviations 
• those who entered the study 
even though they did not 
satisfy the entry criteria;  
• those who developed 
withdrawal criteria during 
the study but were not 
withdrawn;  
• those who received the 
wrong treatment or incorrect 
dose;  
• those who received an 
excluded concomitant 
treatment.  
• Other 
Listing 
 
4.1.2.3 
Demographics and Baseline Characteristics 
Participant demographics (age, sex, race, ethnicity, weight, height, and BMI [defined as weight 
in kg divided by height in meters squared]) and other relevant baseline characteristics will be 
summarized by treatment group for the ITT population. 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 17 of 29 
Table 7. 
Demographics  
Endpoint 
Description 
Summary Method 
Age 
Age at informed consent date 
Continuous Summary 
Sex 
Male 
Female 
Categorical Summary 
Race 
Caucasian 
Non-Caucasian 
Black or African American 
Asian 
American Indian or Alaska 
Native 
Native Hawaiian or Pacific 
Islander 
Other 
Ethnicity 
Hispanic or Latino 
Not Hispanic or Latino  
 
Table 8. 
Baseline Characteristics 
Endpoint 
Description 
Summary Method 
Weight 
 
Weight (kg) 
Continuous Summary 
Height 
Height (m) 
BMI 
BMI (kg/m2) 
Baseline Efficacy Endpoints 
Abdominal girth (measured by 
AUC) 
CSBMs (standardized weekly 
rate) 
SBMs (standardized weekly 
rate)  
Abdominal pain 
Abdominal discomfort 
Abdominal bloating 
Abdominal distension 
BSFS 
Note:  include any measure that 
will be used as a baseline 
covariate in endpoint analyses 
 
4.1.2.4 
Medical History 
Medical History, abnormalities and surgeries, reported prior to screening occurring prior to 
screening will be coded using MedDRA version 19.1 or newer.  Summaries will be presented by 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 18 of 29 
MedDRA system organ class (SOC) and preferred term by treatment arm and overall for the safety 
population.  Patients will be counted once per SOC and PT. 
Table 9. 
Medical History 
Parameter 
Description 
Summary Method 
Medical History 
Surgeries and Abnormalities 
reported at Screening 
SOC 
    PT 
Categorical Summaries 
 
4.1.2.5 
Prior and Concomitant Medication 
Reported medication will be coded using the World Health Organization (WHO) Drug Dictionary 
Enhanced B2, version dated December 2016 or newer to their Anatomical Therapeutical Chemical 
(ATC) class and PT.  Summaries will be presented by ATC and PT for the Safety Population.  
Patients will be counted once per ATC and PT. 
Table 10. 
Prior and Concomitant Medication 
Parameter 
Description 
Summary 
Prior Medications 
Medication taken prior to first 
dose of study medication 
Categorical Summary 
Concomitant Medication 
Medication taken on or after 
first dose of study medication. 
 
4.1.2.6 
Drug compliance 
Patient drug compliance over the double-blind treatment period will be calculated for each patient. 
Dosing compliance for the Treatment Period is defined as the number of capsules actually taken 
by a patient during the Treatment Period divided by the number of capsules that were expected to 
be taken during the Treatment Period, multiplied by 100. The total number of capsules actually 
taken will be calculated as the total number of capsules dispensed minus the total number of 
capsules returned. The total number of capsules expected to be taken during the Treatment Period 
is the number of days between the date of first dose taken and the date of last dose taken, inclusive 
(i.e., last dose date – first dose date + 1). Summaries will be presented by treatment arm and overall 
for the Safety Population. 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 19 of 29 
Table 11. 
Study Drug Compliance 
Parameter 
Description 
Summary Method 
Overall Drug Compliance 
Percent of drug actually taken 
relative to amount expected to 
be taken in defined interval 
Continuous Summary 
 
4.1.2.7 
Diary Compliance 
Diary compliance will be calculated for each patient. Summaries will be presented by treatment 
arm over the baseline and double-blind treatment periods, and weekly, for the ITT Population.  A 
complete Diary is defined as having responses to each of the daily Diary questions asked during 
the daily report. 
Table 12. 
Diary Compliance 
Parameter 
Description 
Summary Method 
Diary Compliance 
Baseline (Pretreatment 
Period) 
DB Treatment Period 
(Weeks 1-4) 
Week 1 
Week 2 
Week 3 
Week 4 
Percent of completed Diary days 
relative to number of days in 
reporting interval 
Continuous Summary 
 
4.1.3 
Efficacy 
4.1.3.1 
Analysis of Primary Efficacy Endpoint 
Baseline abdominal girth (as measured by AIP AUC) will be calculated using the first 24 hours of 
measurements from the belt following the Baseline Visit. If an AIP increase of >4 cm is not 
observed over the first 24-hour period, then baseline will be defined as the 24 hours leading up to 
the Randomization Visit on day 1. For subjects with an AIP increase of >4 cm in both 24 hour 
periods, the first 24-hour period will be used.  


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 20 of 29 
Table 13. 
Primary Efficacy Analysis 
Endpoint 
Description 
Timing 
Summary Method 
Change from baseline 
in abdominal girth at 
Week 4 
The mean change from 
randomization (Visit 4) to the end of 
the study (Visit 8) in abdominal girth 
(as measured by AUC) determined 
by 24-hour AIP (with hourly 
averages), between the linaclotide 
and placebo groups. 
 
The AUC will be calculated using 
the Trapezoidal method from the 
first reliable hour of measurement to 
last measurement (bedtime). The 
AUC for each patient will be then 
individually standardised by dividing 
the total AUC over the period by that 
patient’s number of hours of 
measurement included in the AUC. 
 
In case of missing data in the middle 
of the valid period of measurement, 
AUC is calculated with linear 
interpolation.  
Day -1 to 
Day 27 
Continuous summary, 
95% CI 
 
 
4.1.3.2 
Secondary and Additional Efficacy Analyses 
Baseline score for abdominal symptoms will be calculated as the average of daily values reported 
over the Pretreatment Period. 
A patient’s daily Abdominal Score is calculated as the average of the daily abdominal pain, 
abdominal bloating, and abdominal discomfort assessments. If two or more of these individual 
daily abdominal symptoms are missing, then the Abdominal Score for that day will be missing. 
A patient’s daily Abdominal Score plus Distension is calculated as the average of the daily 
abdominal pain, abdominal bloating, abdominal discomfort, and abdominal distension 
assessments. If three or more of these individual daily abdominal symptoms are missing, then the 
Abdominal Score plus Distension for the day will be missing. 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 21 of 29 
Table 14. 
Secondary and Additional Efficacy Endpoints 
Endpoint 
Description 
Timing 
Summary 
Method 
Change from baseline in 
abdominal girth at Week 2 
The mean change from baseline 
to the midpoint of treatment in 
abdominal girth (as measured by 
AUC) determined by 24-hour 
AIP (with hourly averages), 
between the linaclotide and 
placebo groups. 
 
The AUC will be calculated using 
the Trapezoidal method from the 
first reliable hour of measurement 
to last measurement (bedtime). 
The AUC for each patient will be 
then individually standardised by 
dividing the total AUC over the 
period by that patient’s number of 
hours of measurement included in 
the AUC. 
Day -1 to Day 15 
Continuous 
summary, 95% 
CI 
Change from Baseline in 
Maximal Abdominal Girth 
at Week 4 
The maximum change in girth 
from the first hour, over the 
period from the 2nd hour to 
bedtime. The percentage change 
in maximum distension from 
baseline to 4 weeks will also be 
calculated. 
1st hour, 2 hour to 
bedtime 
Continuous 
summary, 95% 
CI 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 22 of 29 
Table 14. 
Secondary and Additional Efficacy Endpoints 
Endpoint 
Description 
Timing 
Summary 
Method 
Symptom Severity (weekly 
averages and change from 
baseline) 
Abdominal pain 
Abdominal discomfort 
Abdominal bloating 
Abdominal distension 
 
Multicomponent scores: 
  Abdominal Score 
  Abdominal Score  + 
Distension 
Each item assessed daily on 11-
point NRS 
 
Weekly average scores (pain, 
discomfort, bloating, distension): 
Baseline = mean (day -7 to day -
1) 
Week 1=mean (day 1 to day 7) 
Week 2= mean (day 8 to day 14) 
Week 3= mean (day 15 to day 21) 
Week 4= mean (day 22 to day 28) 
 
Abdominal Score: calculated 
weekly; the daily average of the 
following individual items (pain, 
discomfort, bloating) will be 
calculated, then the weekly 
average will be calculated as the 
mean of day 1 to day 7. 
 
Abdominal Score plus 
Distension: calculated weekly; 
the daily average of the following 
individual items (pain, 
discomfort, bloating, distension) 
will be calculated, then the 
weekly average will be calculated 
as the mean of day 1 to day 7. 
 
Change from baseline each post-
baseline timepoint 
Baseline, Week 1, 
Week 2, Week 3, 
Week 4; change from 
baseline at each post- 
baseline timepoint 
Continuous 
summary, 95% 
CI 
Change from Baseline in 
Digestive sensations 
Change from baseline in 
digestive sensations (abdominal 
pain, discomfort, bloating and 
distension) at end of treatment (as 
measured by AUC of hourly 
digestive sensations)  
Baseline, Week 2 
(Visit 6), Week 4 
(Visit 8) 
Continuous 
summary, 95% 
CI 
Weekly averages change 
from baseline in Bristol 
Stool Form Scale (BSFS) 
Baseline= mean (day -7 to day -
1) 
Week 1= mean (day 1 to day 7) 
Week 2=mean (day 8 to day 14) 
Week 3=mean (day 15 to day 2) 
Week 4=mean (day 22 to day 28) 
Change from baseline 
Baseline, Week 1, 
Week 2, Week 3, 
Week 4, Change from 
baseline at each 
postbaseline timepoint 
Continuous 
summary, 95% 
CI  


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 23 of 29 
4.2 
SAMPLE SIZE JUSTIFICATION 
A total of 40 (20 in each group) participants are required to complete the study, with 120 needed 
to enter screening to account for ineligible participants and dropouts. 
To achieve 80% power to detect a difference of 2.2 cm or more (using a simple 2-sided t-test with 
estimated SD = 2.4 cm and the conventional 5% significance level) in the mean change in 
abdominal girth (as measured by AIP AUC) from the start to the end of the day, between the active 
and placebo groups, 20 participants per group (40 participants in all) are required. Assuming a 
15% dropout rate, 47 participants would need to be randomised to yield 40 evaluable participants. 
Estimating a 60% screen/pretreatment failure rate (mostly from failure to meet distension criteria, 
but also pretreatment abdominal pain, abdominal bloating, and bowel movement criteria), 120 
participants would need to enter screening to achieve 40 randomised participants. 
Note: for a previous yogurt study, a mean difference in girth of 1.6 cm (SD = 2.4 cm) was observed 
Sample size calculated using nQuery Advisor 3.0. 
Note: Due to difficulties with enrollment, the study was terminated by the sponsor after 20 subjects 
were randomized. 
4.3 
SAFETY ANALYSIS 
All safety analyses will be performed using the Safety Population. 
4.3.1 
Adverse Events 
All adverse event reported during the study will be coded using MedDRA version 19.1.  All 
summaries and listings will be presented of the safety population. 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 24 of 29 
Table 15. 
AE classification 
AE classification 
Definition 
Treatment Emergent 
Adverse Event (TEAE) 
TEAE if: 
• Treatment Start date/time <= AE Start Date/Time <=Date of Last 
Treatment +1 
And 
• PT not previously reported prior to Treatment 
• PT reported prior to Treatment however increased in severity after start 
of treatment 
Serious Adverse Event 
(SAE) 
Any event meeting the following criteria: 
• Results in death 
• Is life-threatening 
• Requires inpatient hospitalization or prolongation of an existing 
hospitalization 
• Results in persistent or significant disability or incapacity 
• Results in a congenital anomaly or birth defect 
 
These criteria will identified by AE Serious criteria = Yes 
 
Patients reporting multiple incidence of an adverse event mapping to the same PT will be 
counted only once overall, at the most severe severity level, and at the closest relationship to 
treatment. AEs will be summarized as described in Table 6. 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 25 of 29 
Table 16. 
Adverse Events 
Summaries 
Description 
Summary Method 
Overall Summary 
• TEAEs 
• Deaths 
• On-Therapy SAEs 
• Withdrawals Due to TEAEs 
(ADOs)  
 
Categorical Summary 
 
TEAEs 
• At Least One AE  
• By SOC 
• By PT within SOC 
 
TEAEs By Severity 
TEAEs By Relationship 
Listings of All Adverse Event 
for Patients with: 
1. SAEs 
2. ADOs 
3. Fatal 
For Patients meeting the defined 
criteria, list all all the pateints 
Adverse Events  
Data Listing – See Table Shell 
for variables to include 
 
4.3.2 
Clinical Laboratory Data 
Clinical laboratory measure recorded over the course of the study will be summarized as defined 
in Table 17. 
Table 17. 
Clinical Laboratory Summaries  
Endpoint 
Description 
Timing 
Summary Method 
Descriptive 
Summary of Laboratory Category 
and Parameter (SI Units) at  
Screening Visit 
Screening 
Continuous Summary 
 
4.3.3 
Vital Signs Parameters 
Vital signs endpoints will be defined and summarized as described in Table 18. 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 26 of 29 
Table 18. 
Vital Signs Summaries 
Endpoint 
Description 
Timing 
Summary Method 
Descriptive 
Summary Vital Sign 
measures at each 
timepoint measured 
plus Change from 
baseline 
Day 1, Day 15, Day 28 
(EOT) 
Continuous Summary 
 
4.3.4 
Physical Examination 
Clinically significant physical examination results for all subjects will be presented in a data 
listing for the Safety Population. 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 27 of 29 
5. 
CHANGES FROM ANALYSES PLANNED IN THE 
PROTOCOL 
The following analyses differ compared to those specified in the study protocol:  
• All continuous data, regardless of normality, will be presented as number, mean, standard 
deviation, and range. Protocol had stated continuous, non-normally distributed data 
would be presented as number, median, interquartiles, and range. 
• Section 11.3.4 of the Protocol states that change from baseline will be calculated for 
clinical laboratory evaluations. Clinical labs were only taken at screening and therefore, 
no change values will be calculated. 
• The following secondary efficacy endpoints have been renamed: 
o ‘Change from baseline in abdominal distension at week 2’ will now be referred to 
as ‘change from baseline in abdominal girth at week 2’ 
o ‘Change from baseline in maximal abdominal distension at week 4’ will now be 
referred to as ‘change from baseline in maximal abdominal girth at week 4’ 
o ‘Change from Baseline in digestive sensations at weeks 4 and 8’ was an error as 
the study is only 4 weeks in duration. This should have been ‘Change from 
baseline in digestive sensations at week 2 (Visit 6) and week 4 (Visit 8)’. 
o ‘Change from baseline in Bristol Stool Form Scale at weeks 4 and 8’ was an error 
as the study is only 4 weeks in duration. This should have been ‘Change from 
baseline in Bristol stool form scale at week 2 (Visit 6) and week 4 (Visit 8)’. 
o Change from baseline in Bristol Stool Form Scale at Weekk 2 and 4 will be 
analyzed using linear mixed models with appropriate contrasts. The Protocol had 
previously specified generalized estimating equations (GEE) would be used for 
analysis. 
• The HADS and IBS-SSS were assessed at Screening and EOT. These values will not be 
analyzed. 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 28 of 29 
• Section 11.3.3.5 of the Protocol reports additional analysis that will be conducted. 
Specifically, it states, “The relationship between the hourly digestive sensation scores for 
bloating and the corresponding hourly difference in girth measures from hour 1 over the 
relevant time period during each of the two 24-hour periods at visit 4 and visit 8 will be 
assessed using longitudinal regression analysis.” This analysis will no longer be 
conducted. 
• Given that the study was terminated by the sponsor after only 20 patients were 
randomized, there will be no formal statistical modeling (ANCOVA, MMRM) and 
descriptive statistics and confidence intervals will be presented only. 


Linaclotide 
Ironwood Pharmaceuticals, Inc. 
Statistical Analysis Plan: MCP-103-403-SAP-01 
March 11, 2019 
 
Page 29 of 29 
6. 
REFERENCES 
1. nQuery (2017). Sample Size and Power Calculation. “Statsols” (Statistical Solutions 
Ltd). Cork, Ireland