Conditions: Paroxysmal Nocturnal Haemoglobinuria (PNH)
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 1
Healthy volunteers: no

Brief summary:
Coversin in Paroxysmal Nocturnal Haemoglobinuria (PNH) in patients with resistance to Eculizumab due to complement C5 polymorphisms.

Detailed description:
Coversin, a small protein complement C5 inhibitor which prevents the cleavage of C5 by C5 convertase into C5a and C5b, will be used in an open label, non-comparative clinical trial in patients with PNH and proven resistance to eculizumab due to C5 polymorphisms. Patients will be treated with Coversin by daily subcutaneous injection for 6 months in order to determine the safety and efficacy of the drug in these circumstances. If satisfactory control of the PNH is achieved, and at the discretion of the Principal Investigator (PI), patients will have the option of remaining on Coversin and being entered into the long term follow-up study for 2 years.

Please note, 'Coversin' is used throughout, but Nomacopan is the official name/INN.

Please note, the end points were assessed for 6 months, but the adverse events were measured over the 2 year period.

Arms:
arm 1: This is an open label, non-comparator study.

Patient will be given a single ablating dose of 0.57mg/kg per subject followed by daily repeat maintenance doses. The initial repeat dose will be 25% of the ablating dose. If this is insufficient to maintain complement inhibition at ≤10% of baseline (pre-treatment) level after 5 days of treatment the daily dose will be increased by doubling until that level of inhibition is achieved. In the event of 100% inhibition being achieved the dose may be titrated downwards at the PI's discretion until a satisfactory clinical result is obtained. If at any point in treatment complement inhibition falls to less than 50% of baseline a further ablating dose of 0.57mg/kg should be given. Coversin lyophilised powder in each vial was diluted with 0.6 mL water for injection prior to use.

Interventions: intervention 1: Coversin
Intervention descriptions: intervention 1: Patients enrolled in this protocol will initially be treated with an ablating dose of Coversin and daily repeat maintenance doses calculated according to body weight, the ablating dose to be 0.57mg/kg. Thereafter the daily repeat dose will be titrated according to clinical response and complement inhibition determined by CH50 ELISA. The initial repeat dose will be 25% of the ablating dose and this will be adjusted up or down if necessary once steady state is reached (5 days).

Protocol document:
Prot_SAP_000.pdf: 
 
 
 
 
CONFIDENTIAL 
 
 
 
Page 1 of 43 
  
Protocol AK-Study-578 - version 2.0 
 
© Akari Therapeutics Plc 
11 november 2015 
 CONFIDENTIAL 
 
 
 
 
 
 
 
Coversin in paroxysmal nocturnal haemoglobinuria (PNH) 
in patients with resistance to eculizumab due to complement 
C5 polymorphisms  
 
 
 
 
 
PROTOCOL NUMBER:  
AK Study 578 
 
DATE:  
 
 
11 November 2015 
 
VERSION NUMBER: 
2.0 
 
SPONSOR:   
 
Akari Therapeutics Plc 
 
 


 
 
 
 
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11 november 2015 
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SPONSOR ADDRESS: 
 75-76 Wimpole Street  
 London W1G 9RT, UK 
 
AUTHORISED SIGNATORY:  
 
Dr Wynne H Weston-Davies MB FRCS 
 
SPONSOR’S MEDICAL EXPERT:  
Dr Wynne H Weston-Davies MB FRCS 
Rosebank, Salperton, Cheltenham, GL54 
4EF, UK 
 
 
 
 
 
Tel: +44 (0)1451 850128 
 
             Mobile: +44(0)7801 281283 
 
PRINCIPAL PIs 
Dr. Saskia Langemeijer 
 
Dr. Petra Muus 
Radboud University Medical Centre 
Department of Haematology 
Geert Grooteplein Zuid 8 
6525 GA  Nijmegen 
Netherlands 
 
TRIAL SITE: 
Radboud University Medical Centre 
Nijmegen 
Netherlands 
 
CLINICAL LABORATORIES: 
 
 
Safety (chemistry, haematology, urinalysis and serology): 
 
 
 
 
 
 
 
Radboud University Medical Centre 
Nijmegen 
Netherlands 
 
 
 
 
Complement activity (CH50, drug levels, anti-drug antibodies): 
 
The Haemostasis Research Laboratory 
UCL Department of Haematology 
51 Chenies Mews 
London WC1E 6HX 
UK 
 


 
 
 
 
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Table of contents 
 
List of Abbreviations ................................................................................................................. 6 
Protocol Signature Page ............................................................................................................ 8 
List of prohibited medications: ................................................................................................ 11 
1.0  
INTRODUCTION ....................................................................................................... 12 
1.1 
Investigational Product ......................................................................................... 12 
1.2 
Summary of Nonclinical and Clinical Studies Relevant to the Clinical Trial .. 13 
1.3 
Summary of Known and Potential Risks and Benefits to Human Subjects ..... 17 
1.4 
Description of/and Justification for the Route of Administration, Dosage 
Regimen and Treatment Period(s) ................................................................................... 18 
1.5  
Compliance Statement .......................................................................................... 20 
1.6 
Description of the Trial Population ..................................................................... 20 
2.0 
TRIAL OBJECTIVE AND PURPOSE ....................................................................... 21 
3.0 
TRIAL DESIGN .......................................................................................................... 21 
3.1 
Endpoints ............................................................................................................... 21 
4.0 
CONTRACEPTION.............................................................................................. 22 
4.1 
Exposure to Partners During the Study ............................................................... 22 
4.2 
Sperm Donation ................................................................................................... 22 
5.0 
SUBJECT WITHDRAWAL CRITERIA ............................................................ 22 
7.0 
STOPPING RULES AND DISCONTINUATION CRITERIA ........................ 29 
7.1 
Management of individual patients who experience clinically significant toxicity
 
29 
7.2 
Toxicity occurring in two or more patients ......................................................... 29 
8.0  
ACCOUNTABILITY PROCEDURES................................................................ 30 
9.0 
SELECTION AND WITHDRAWAL OF SUBJECTS ............................................... 30 
9.1 
Inclusion Criteria................................................................................................... 30 
9.2 
Exclusion Criteria .................................................................................................. 30 


 
 
 
 
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10.0 
NEISSERIA IMMUNISATION AND ANTIBIOTIC PROPHYLAXIS ............. 31 
11.0 
COMPLIANCE ..................................................................................................... 31 
11.1 
Assessment of pharmacokinetics and complement activity ............................... 32 
12.0 
ADVERSE EVENTS ............................................................................................. 32 
12.1 
Adverse Events .................................................................................................... 32 
12.2 
Definition ............................................................................................................. 32 
12.3 
Relationship to study medication ........................................................................ 32 
12.4 
Serious Adverse Events ....................................................................................... 33 
12.5 
Severity ................................................................................................................ 34 
12.6 
Adverse event reporting ...................................................................................... 34 
12.7 
Follow-up after Adverse Events .......................................................................... 35 
13 
STATISTICS ............................................................................................................... 36 
13.1 
Statistical Methods ................................................................................................ 36 
13.2 
Number of Subjects ............................................................................................... 36 
13.3 
Significance Level .................................................................................................. 36 
13.4 
Missing, Unused or Spurious Data ....................................................................... 36 
13.5 
Deviations from the Statistical Plan ..................................................................... 37 
13.6 
Subjects to be Included in the Analysis ............................................................... 37 
14 
DIRECT ACCESS TO SOURCE DOCUMENTS ...................................................... 37 
15 
QUALITY CONTROL AND QUALITY ASSURANCE .......................................... 37 
16 
ETHICAL CONSIDERATIONS ................................................................................ 37 
17 
DATA HANDLING, RECORD KEEPING AND SAMPLE COLLECTION ........... 37 
18 
FINANCING AND INSURANCE .............................................................................. 38 
19 
PUBLICATION POLICY ........................................................................................... 38 
20.0 
SUPPLEMENTS ......................................................................................................... 38 
20.1 
CH50 Eq ELISA Assay ......................................................................................... 38 
1. Equipment .......................................................................................................................... 39 


 
 
 
 
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2. Blood Collection ................................................................................................................. 40 
3. Centrifugation and Separation of Serum and Plasma for Complement Tests ............ 40 
4. Storage of Serum and Plasma Samples ........................................................................... 41 
21.0  
 REFERENCES ....................................................................................................... 42 
 
 


 
 
 
 
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List of Abbreviations 
Abbreviation Definition/Term 
ACh 
Acetylcholine 
AChR 
Acetylcholine Receptor 
ADR 
Adverse Drug Reaction 
AE 
Adverse Event 
ANOVA 
Analysis of Variance 
BP 
Blood Pressure 
CRF 
Case Report Form 
CRO 
Contract Research Organisation 
CT 
Computerised Tomography 
DLT 
Dose Limiting Toxicity 
DSMB 
Drug Safety Monitoring Board 
EAMG 
Experimental Autoimmune Myasthenia Gravis 
EC 
Ethics Committee 
ECG 
Electrocardiogram 
ED 
Effective Dose 
EMA 
European Medicines Agency 
ELISA 
Enzyme-Linked Immunosorbent Assay 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
HAHA 
Human Antihuman Antibodies  
HED 
Human Equivalent Dose 
ICH 
International Committee on Harmonisation 
IRB 
Institutional Review Board (or equivalent, e.g. Ethics Committee) 
ITT 
Intention to Treat 
i.v. 
Intravenous 
MAC 
Membrane Attack Complex 
MedDRA 
Medical Dictionary of Regulatory Activities 
MG 
Myasthenia Gravis 
MGFA 
Myasthenia Gravis Foundation of America 
MHRA 
Medcines and Healthcare Regulatory Agency 
MTD 
Maximum Tolerated Dose 
MW 
Molecular Weight 
NOAEL 
No Observable Adverse Event Level 
OmCI 
Ornithodoros moubata Complement Inhibitor 
PAD 
Pharmacologically Active Dose 
PBS 
Phosphate Buffered Saline 
PI 
Principal Investigator 
PNH 
Paroxysmal Nocturnal Haemoglobinuria 
POM 
Prescription Only Medicine 


 
 
 
 
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Abbreviation Definition/Term 
PP 
Per Protocol 
p.r.n 
pro re nata (as necessary) 
QA 
Quality Assurance 
QC 
Quality Control 
QMG 
Quantitative Myasthenia Gravis (score) 
SAD 
Single Ascending Dose 
SAE 
Serious Adverse Event 
s.c. 
Subcutaneous 
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
TSC 
Trial Steering Committee 
ULN 
Upper Limit of Normal 




 
 
 
 
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Protocol synopsis 
Protocol Title: 
 
Coversin in paroxysmal nocturnal haemoglobinuria (PNH) in patients 
with resistance to eculizumab due to complement C5 polymorphisms.  
Protocol Number: 
AK Study 578 
Sponsor: 
 
Akari Therapeutics Plc 
76 Wimpole Street 
London W1G 9RT 
UK 
Investigational Product(s): 
 
Coversin (rVA576) sterile solution for subcutaneous injection 7.2  
mg/mL 
Phase of Development: 
II 
Indication: 
Paroxysmal nocturnal haemoglobinuria 
PI(s): 
 
Dr Saskia Langemeijer 
Dr Petra Muus 
Department of  Haematology  
Radboud University Medical Centre 
Nijmegen 
Netherlands 
Study Center(s): 
 
Radboud University Medical Centre 
Nijmegen 
Netherlands 
Objectives: 
 
Primary Objective: Safety of Coversin (rVA576).  
 
Secondary Objectives: Efficacy of Coversin in the treatment of 
patients with PNH resistant to eculizumab. 
Study Design: 
Open label, non-comparative 
Planned Number of 
Subjects: 
Minimally 1 and maximally 6  
Subject Population: 
 
Patients with PNH, male or female, 18 years or older with proven 
resistance to eculizumab due to complement C5 polymorphisms 
Diagnosis and Main  
Criteria for Inclusion and 
Exclusion: 
Inclusion Criteria: 
 Patients with known paroxysmal nocturnal haemoglobinuria (PNH) 
 LDH ≥1.5 ULN 
 Resistance to eculizumab proven by both a recognised C5 
polymorphism on genetic screening and complement inhibition on 
CH50 ELISA of <100% at concentrations of eculizumab in excess 
of 50µg/mL 
 Willing to give informed consent to treatment with Coversin 
 Willing to self-inject Coversin daily or to receive daily 
subcutaneous injections by a home nurse or in a doctor’s office or 
hospital clinic 
 Willing to receive appropriate prophylaxis against Neisseria 
infection by both immunisation and continuous or intermittent 
antibiotics 


 
 
 
 
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Exclusion Criteria: 
 Pregnancy (females) 
 Known allergy to ticks or severe reaction to arthropod venom (e.g. 
bee or wasp venom) 
 Failure to satisfy the PI of fitness to participate for any other reason 
Treatment Regimen: 
 
Single ablating dose of 0.57mg/kg per subject followed by daily  
maintenance doses. The initial maintenance dose will be 25% of the 
ablating dose. If this is insufficient to maintain complement activity at 
≤10% of baseline (pre-treatment) level after 5 days of treatment the 
daily maintenance  dose will be increased by doubling until that level 
of inhibition is achieved. In the event of 100% inhibition being 
achieved the dose may be titrated downwards at the PI’s discretion 
until a satisfactory clinical result is obtained. If at any point in 
treatment complement activity (CH50)   is  50% of baseline or more  a 
further ablating dose of 0.57mg/kg should be given. An increased 
daily maintenance dose may be required in the event of intercurrent 
infection or illness. CH50 level should be checked in the event of 
deteriorating clinical response manifested by rising serum LDH. 
Duration of Treatment: 
Patients will undergo an initial period of 6 months treatment according 
to this protocol. At the expiry of this period, and on the 
recommendation of the PI, patients will have the option of remaining 
on long-term Coversin therapy and will enter the long term follow-up 
study. 
Endpoints: 
 
Efficacy Endpoints:  
Primary:  Reduction in serum LDH  from day 0 – Day 28 
Secondary: Hb, haptoglobin, Fatigue (FACIT), Quality of Life 
(EORTC QL-C30), PNH RBC clone size, Transfusion requirement 
 
Safety Endpoints:  
Adverse events, ECG, Laboratory results, Vital signs. 
Statistical Methods: 
Descriptive statistics  
 


 
 
 
 
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List of prohibited medications: 
 
1. Tizanidine (if on ciprofloxacin) 
 
2. Eculizumab (Soliris®) should be discontinued before Coversin therapy is 
commenced. Ideally this should be 2 or more weeks before commencing Coversin 
unless, in the opinion of the investigator, it would not be in the best interests of the 
patient to do so. 
 


 
 
 
 
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1.0  
INTRODUCTION 
Coversin is a small protein complement C5 inhibitor which prevents the cleavage of 
C5 by C5 convertase into C5a and C5b. It is effective in inhibiting terminal 
complement activity irrespective of the activating pathway. In in vitro experiments it 
has been found to be as effective as eculizumab (Soliris®) at a molar equivalent dose 
in preventing the haemolysis of affected clones of red blood cells taken from patients 
with paroxysmal nocturnal haemoglobinuria (PNH). Following an initial successful 
Phase Ia clinical trial in healthy human volunteers it is now being developed for the 
treatment of patients with PNH and other complement mediated diseases. Its small 
molecular size relative to the monoclonal antibody Soliris® makes it suitable for small 
volume subcutaneous injection with the advantage that patients can self-administer 
the drug and are not tied to bi-monthly intravenous infusions which necessitate either 
attendance at a hospital clinic or a home visit by a suitably qualified nurse. 
 
Under this protocol named patients with PNH and proven resistance to eculizumab 
will be treated with Coversin for 6 months in order to determine the safety and 
efficacy of the drug in these circumstances. If satisfactory control of the PNH is 
achieved, and at the discretion of the PI, patients will have the option of remaining on 
Coversin and being entered into the long term follow-up study. 
 
1.1 
Investigational Product 
Coversin sterile solution for subcutaneous injection  7.2 mg/ml [NB This is the 
concentration of the drug product (DP) to be used for the initial treatment of the first 
patient treated under this protocol. Coversin is still in development and this 
concentration may change. It is intended that fixed dosing for all patients between 50 
and 100kg in weight will be introduced following Phase Ib clinical trials] 
 
Coversin is a compact small protein molecule with a lipocalin-like structure 
consisting of alpha helices and a beta barrel. There is a surface active site which binds 
to the complement C5 molecule with a high affinity (KD 1.85 x 10-8) and an 
internalised active site which appears capable of binding small eicosinoid molecules 
such as leukotriene B4 [1]. The importance or otherwise of the latter site in the 
pharmacological and presumed therapeutic activity of Coversin has not been fully 
determined.  
 
The molecular mass of Coversin as predicted by molecular modelling and confirmed 
by mass spectrometry is 16.7855 kDa. 
The amino acid sequence of Coversin showing disulphide bridges is shown below: 
 
 
 
 


 
 
 
 
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DSESDCTGSEPVDAFQAFSEGKEAYVLVRSTDPKARDCLKGEPAG 
 
EKQDNTLPVMMTFKNGTDWASTDWTFTLDGAKVTATLGNLTQN 
 
REVVYDSQSHHCHVDKVEKEVPDYEMWMLDAGGLEVEVECCR 
 
QKLEELASGRNQMYPHLKDC 
 
Coversin drug substance is presented as a colourless aqueous solution stored frozen at 
-20oC. Coversin drug product is presented as a colourless aqueous sterile-filtered 
solution for injection in 2ml vials filled to 0.5ml at a concentration of 8.9mg/ml. It 
will be prepared for s.c. administration by drawing up the requisite volume to deliver 
the desired dose in one or more syringes. No more than 1.0ml will be administered to 
a single injection site because of potential discomfort. Doses will be adjusted to the 
subject’s weight. 
 
1.2 
Summary of Nonclinical and Clinical Studies Relevant to the Clinical 
Trial  
Coversin is a recombinant small protein (MW 16.8kDa) which is derived from a 
native protein discovered in the saliva of the Ornithodoros moubata tick [2]. Its 
function in tick saliva is to assist the parasite in feeding by suppressing the host 
immune reactions that would otherwise alert the host to the presence of the parasite 
which could then be removed by scratching or grooming. It has been known for some 
time that all species of ticks, which can feed undisturbed on their hosts including 
rodents, cattle, dogs and man, for periods of 14 days or more, secrete an array of  
immunomodulatory peptides and proteins in their saliva in order to take control of 
their hosts’ local and systemic immune and inflammatory  responses [3].  
 
The complement system is an important part of the innate immune system in many 
animal species including all mammals. There are three known pathways in the 
cascade: the classical, the alternative and the lectin but all converge on a final 
common pathway. At this point complement C5, a product of the classical pathway is 
acted upon by the enzyme C5 convertase, a product of the alternative pathway, to 
form C5a and a cluster of proteins (C5b, C6, C7, C8, and C9) which are collectively 
known as the membrane attack complex (MAC). It is known that many human 
autoimmune diseases are associated with inappropriate reactions to products of the 
final common pathway of the complement system. In particular myasthenia gravis, in 
which individuals form antibodies to their own acetyl choline receptors 
(approximately 70% of all MG patients) is associated with either inappropriate 
reaction to or over-production of MAC proteins [4].  


 
 
 
 
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Coversin binds to the C5 molecule, preventing any C5 convertase from acting on it 
and cleaving it to form C5a and the MAC. It appears to do this by interfering with the 
interaction of C5 convertases rather than by blocking the actual cleavage site on the 
C5 molecule [5]. The binding to C5 is high affinity (KD 1.85 x 10-8) and appears to be 
irreversible in physiological conditions [6]. Other studies including X-ray 
crystallography have confirmed that Coversin complexes with human complement C5 
[5]. 
 
Inhibition of the C5 complement system is a therapeutic target in a wide range of 
autoimmune and inflammatory diseases including rheumatoid arthritis, Crohn’s 
disease, hypersensitivity pneumonitis, ischaemia reperfusion injury, sepsis, 
myasthenia gravis, paroxysmal nocturnal haemoglobinuria (PNH) and age related 
macular degeneration [7-14]. 
 
The initial proposed clinical indication is PNH in patients known to be resistant to 
eculizumab because of polymorphisms occurring in the complement C5 molecule. 
The humanised monoclonal antibody eculizumab (Soliris®) was approved in Europe 
and the USA for the treatment of PNH in 2007 and is now the standard of care in this 
condition. Since Coversin acts in exactly the same way as Soliris® it is believed that it 
will be effective as a therapeutic agent in the treatment of PNH but may offer patient 
benefits in terms of convenience since it can be self-administered by sub cutaneous 
injection rather than having to be administered by a health-care professional by 
intravenous infusion at two weekly intervals and in addition can be used in patients 
resistant to eculizumab. 
 
There are no satisfactory animal models of PNH and the presumed efficacy of 
Coversin in this condition relies on the fact that, since its mode of action is identical 
to that of Soliris® with the exception that it binds to a different epitope on the C5 
molecule, the clinical effects on patients with PNH are likely to be the same. In 
addition Coversin has been tested in an in vitro flow cytometry model using blood 
from patients with  PNH with a large clone of Type III PNH cells . In this model the 
blood was either complement inactivated through heat treatment (negative control) or 
not and complement activation was achieved by acidification and the addition of 
magnesium chloride (MgCl). Blood so treated was first spiked with either Coversin or 
Soliris® in ascending concentrations and the effect of complement activation on the 
relative populations of Clone III to Clone I RBCs was observed. These results are 
shown in Figs 1and 2 below. They show that Coversin 10µg/mL and Soliris® 
50µg/mL (molar equivalent concentrations) are equally effective in preventing 
haemolysis in blood from a patient with Type III red blood cells These results are 
illustrated below in Figs 1 and 2. 


 
 
 
 
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Fig 1 Effect of ascending concentrations of Coversin on complement activation 
in blood from a patient with PNH and type III PNH erythrocytes only.  
 
 
Fig 2   Comparison of Coversin 10µg/mL and Soliris® 50µg/mL on Type III PNH 
erythrocytes. 
 
A single ascending dose (SAD) clinical trial in healthy volunteers, of Coversin 
administered by subcutaneous injection has been carried out in order to validate this 
route of administration and to confirm the dose needed to totally inhibit all C5 in the 


 
 
 
 
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vascular compartment. The starting dose was one eighth of the dose found to induce 
total C5 blockade in rodent and non-human primate (NHP) PK studies (0.57mg/kg) 
and doubled in each succeeding cohort of subjects until the target dose was reached. 
This dose was found to produce complete terminal complement blockade as 
determined by CH50 Equivalent assay in all four subjects and the result is shown in 
Figure 3 below. In this study there were no serious or dose related adverse events and 
the drug was well tolerated. There were three mild adverse reaction reported in two 
subjects who received active drug (intolerance to light, pain in the armunrelated to the 
injection site and light headedness). These adverse events were transient and self-
limiting and were not dose related. 
 
An immunogenicity study in BALBc mice given Coversin by daily subcutaneous 
injection showed that approximately 70% formed anti-Coversin antibodies by Day 28 
but that these IgG antibodies were non-neutralising. There were no clinical or 
injection site reactions indicative of immuno- or allergenicity. 
 
Figure 3   Phase I SAD clinical trial in normal volunteers. CH50 activity (% of 
baseline) in 4 active and 2 placebo treated subjects 
 
A single human patient, a 4 year old child with a thrombotic microangiopathy (TMA) 
secondary to stem cell transplantation for chronic granulomatous disease has been 
treated with Coversin on a named patient basis for 58 days. The patient had 
previously been treated with eculizumab for 3 months with no apparent clinical 
benefit and was then found to have a polymorphism of C5 which prevented proper 
binding of the antibody to the complement protein. This polymorphism had 
previously only been reported in patients of Japanese origin although this patient was 


 
 
 
 
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Caucasian.[REF] Akari Therapeutics Plc has shown in vitro that when complement is 
activated in serum from this patient and from another non-Japanese PNH patient with 
resistance to eculizumab due to the same polymorphism it can be blocked with 
Coversin but not eculizumab and it was decided on that basis to attempt to treat the 
patient with Coversin. 
 
The patient initially responded well to Coversin but the drug supply was limited and 
the patient died 10 days after the drug was withdrawn. During treatment there were no 
adverse events attributable to Coversin, no injection site reactions and no evidence of 
drug neutralisation. This patient represents the longest human exposure to date of 
Coversin.  
 
1.3 
Summary of Known and Potential Risks and Benefits to Human Subjects 
Although there has been limited clinical experience with Coversin to date the clinical 
implications of complement C5 blockade can be deduced from a combination of 
genetic and epidemiological studies, animal studies and experience with eculizumab 
(Soliris®), an anti-complement C5 monoclonal antibody. Complement C5 deficiency 
in humans is a rare, familial condition caused by a variety of genetic defects including 
mutations in the C5 exons. Those affected have a predisposition to gram negative 
infections, particularly meningococcal meningitis, herpetic infections and seborrhoeic 
dermatitis. [17] 
 
 In clinical trials of eculizumab in paroxysmal nocturnal haemoglobinuria (PNH) 2 of 
96 patients developed meningococcal meningitis and currently all subjects taking the 
drug are advised to maintain Neisseria meningitidis immunization with booster shots 
at recommended intervals. [18] In limited duration toxicological studies with both 
eculizumab and Coversin no adverse events or findings attributable to C5 blockade 
have been reported but PIs are advised to be alert for possible infectious events even 
in subjects who have received meningococcal immunisation. All subjects screened for 
entry into this trial will have pre-trial throat and nasal swabs taken within 5 days of 
entry and any positive Neisseria sp. results will be grounds for excluding that subject 
from the trial irrespective of immunisation status until the bacteria have been 
eliminated.  
 
In long term studies and post marketing surveillance of eculizumab patients for 
periods in excess of three years, apart from the increased risk of meningococcal 
infection referred to above, the most commonly reported side effects were headache, 
runny nose (nasopharyngitis), back pain, nausea and tiredness (fatigue). However 
these are all known to be associated with the use of antibodies rather than any known 
association with complement inhibition and, in any case, in trials the incidence was 
not significantly different from symptoms experienced by placebo treated patients. 
 


 
 
 
 
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There have been no adverse events in single or repeat dose animal toxicology studies 
of Coversin in doses up to 100 times the anticipated human dose. It is not anticipated 
that there will be any difference in the risk or adverse event profile of Coversin compared to 
eculizumab. 
 
Because Coversin is a xenologous protein (derived from a tick salivary protein) there 
is always a possibility that its chronic use may be associated with the formation of 
antibodies which could neutralise the effect of the drug or cause untoward adverse 
reactions. The immunogenicity study mentioned above has gone some way to 
mitigating this possibility and experience with other parasite derived therapeutic 
molecules such as the leech-derived anticoagulant lepirudan suggest that parasite 
derived therapeutic molecules are not usulally associated with neutralising activity.  
  
Potential benefits to patients with autoimmune disease remain to be evaluated but it is 
anticipated on the basis of results in animal models considered to be predictive of 
human disease that patients with autoimmune neurological conditions in which one or 
more specific antibodies to target tissues have been identified and which are known to 
be associated with complement activation will benefit from C5 inhibition. Such 
conditions include myasthenia gravis, Guillain Barré syndrome and varieties of 
multiple sclerosis associated with the MOG16 antibody. 
 
1.4 
Description of/and Justification for the Route of Administration, Dosage 
Regimen and Treatment Period(s) 
The human complement C5 standing pool is about 200mg in a 70kg individual. Given 
the molecular weight of C5 (190kDa), the molecular weight of Coversin (16.8kDa) 
and the fact that it is a 1:1 binding, it would be expected that 1mg of Coversin would 
bind 11.3mg of C5. However, it has been shown that a 2.26:1 excess of Coversin is 
necessary to produce optimal binding conditions to C5 [19]. This means that it would 
take 40.0mg of Coversin to completely neutralise the standing pool of C5 in a 70kg 
human. 
 
Pharmacokinetic studies in rats have shown that unbound Coversin is rapidly excreted 
by the renal route and that the serum half-life is ~30minutes whereas Coversin 
complexed with C5 has a circulating half-life of ~30 hours [6]. The rate of production 
of C5 by humans is not known precisely. Sissons et al. using the Fick Principle and 
125I labelled C5 injected intravenously calculated a daily turnover in normal humans 
of between 65 and 196µg/kg/24hrs (mean 90µg/kg/24hrs) [20]. It is generally 
believed that turnover in autoimmune disease is not substantially different to that in 
normal subjects. On this basis the mean amount of C5 produced daily is 151.2mg and, 
using the calculation explained above, it would take 30.0mg of Coversin to 
completely ablate it. These figures indicate that a loading ablation dose for a human is 
0.57mg/kg and a maintenance dose is 0.018mg/kg/hr.  
 


 
 
 
 
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In preclinical models of myasthenia gravis in rats doses of 0.5, 5.0 and 50mg/kg were 
all found to be significantly more effective than control (vehicle) in mitigating the 
signs of experimental autoimmune myasthenia gravis (EAMG) in a dose dependent 
fashion [16]. The Pharmacologically Active Dose (PAD) in laboratory animals 
(rodents) is therefore estimated at ≤0.5mg/kg. In a human in vitro model using whole 
blood from patients with paroxysmal nocturnal haemoglobinuria (PNH), an 
autoimmune complement dependent condition, it was found that the maximal effect in 
preventing red cell haemolysis was achieved by a dose equivalent to between 0.3 and 
0.7 mg/kg.  Above 0.7 mg/kg no additional benefit was seen. 
 
In pharmacokinetic studies in mice it was found that when a single loading dose was 
administered by the subcutaneous injection route serum complement activity as 
determined by the CH50 Eq ELISA was totally suppressed and did not return to 
normal levels until 24 hours later. At 12 hours there was still 45% or more inhibition 
of terminal complement activity compared to baseline. This level of inhibition was 
significantly longer than when the drug was administered intravenously and is 
believed to be because of a reservoir effect combined with relatively slower renal 
clearance. These observations have yet to be fully confirmed by more extensive 
metabolic studies but are considered to be a reasonable basis for selecting 
administration by subcutaneous rather than intravenous injection. 
 
Toxicokinetic samples were taken at intervals following first dose in the cynomolgus 
monkey repeat dose toxicology study. As the only dose used in this study was 50x the 
expected human therapeutic dose interpretation must be guarded. Serum complement 
activity at 15 minutes, 1, 3, 6, 9 and 12 hours was measured using the CH50 ELISA. 
The results showed that complement activity fell to about 50% of baseline after 15 
minutes and to zero at one hour and it remained at that level for the whole of the 12 
hour period. Since it is known that any circulating unbound Coversin would have 
been excreted by the renal route within 2 – 3 hours it may be assumed that the 
prolonged effect was due to some depot effect associated with the subcutaneous route 
of administration. 
 
Single and repeat dose toxicology studies in rat and cynomolgus monkey have been 
performed using doses of up to 200 times (single dose) and 50 times (repeat dose) the 
expected human dose. In these studies no signs of toxicity were observed, no 
haematological or biochemical observations fell outside the range of normal and no 
gross or microscopic signs of pathology were found in any organ or tissue. It has 
therefore not been possible to set a No Observable Adverse Effect Level (NOAEL) 
and so a Human Equivalent Dose (HED) has not been established.  
 
In pharmacology studies no toxicity has been observed to date in any species at any 
dose by any route of administration. These have included up to 50mg/kg 
intraperitoneally and up to 20mg/kg intravenously and by inhalation. The current 


 
 
 
 
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toxicology studies include single and repeat doses of up to 100 fold the likely HED 
(i.e. 57.0mg/kg in rats and primates). 
 
The Phase I single ascending dose SAD study showed a maximum onset of action 
between 6 and 12 hours after injection and a slow recovery due to replenishment of 
C5 by the liver and other tissues so that at 96 hours post-dose CH50 had only returned 
to about 75% of baseline. This result was unexpected since both onset and duration of 
action in animals including NHP was substantially faster and it is considered likely 
that it is due to both a depot effect since humans generally have more subcutaneous 
adipose tissue than laboratory animals and because the production of C5 by the liver 
appears to be slower in humans. 
 
The result suggests that, following a single ablating dose of Coversin, it should be 
possible to dose once a day using a maintenance dose between 25 and 50% of the 
ablating dose and keep terminal complement activity totally inhibited which is 
considered necessary in diseases such as PNH. If a fixed dose of 60mg, 50% higher 
than the 40mg needed to completely ablate C5 in a 70kg individual, is used it should 
provide adequate initial ablation in all subjects up to 100kg in weight. Similarly a 
daily maintenance dose of between 25 and 50% of this should be sufficient to provide 
24 hour complement inhibition. Paediatric patients and patients of 50kg or less could 
be treated using a half dose.  
 
In the first patient in the current study however, because the drug supply will be 
limited for the first 3 – 6 months it is proposed that a dose tailored the patient’s actual 
weight will be used. When lyophilised drug product becomes available and when the 
supply situation is improved this and other patients may be switched to a fixed dosing 
regimen.  
 
1.5  
Compliance Statement 
This Phase II clinical trial will adhere to the trial protocol and will be conducted in 
compliance with current ICH Good Clinical Practice (GCP) guidelines and all 
applicable regulatory requirements. 
 
1.6 
Description of the Trial Population 
The study population will be minimally 1 patient  and maximally 6 patients above the 
age of 18with PNH and known  resistance to eculizumab. Patients may be male or 
non-pregnant females using adequate methods of contraception if of childbearing 
potential. 
 
 
 


 
 
 
 
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2.0 
TRIAL OBJECTIVE AND PURPOSE 
The trial objectives of this study are to demonstrate the safety and efficacy of 
Coversin when given to patients with PNH and known resistance to eculizumab.  
 
1) To assess the safety and tolerability of Coversin at a single ablating dose 
followed by repeat daily maintenance doses calculated by body weight. 
 
2) To assess whether this dosage regimen is sufficient to control the signs and 
symptoms of PNH (see Endpoints below). 
 
 
3.0 
TRIAL DESIGN 
 
Treatment with Coversin comprises an ablating dose on day 1 and  daily maintenance 
treatment from day 2 onwards.  Calculated according to body weight, the ablating 
dose will be 0.57mg/kg. Thereafter the daily repeat maintenance dose will be titrated 
according to clinical response and complement inhibition as determined by CH50 
ELISA. The initial daily  maintenance dose will be 25% of the ablating dose (0.14 
mg/kg)  and this will be adjusted up or down  if necessary once steady state is reached 
(5 days). This is further explained in chapter 6, TRIAL PROCEDURE .  
 
In order to mitigate the risk of infection by Neisseria sp all subjects or patients taking 
part in the trial will be carefully instructed about precautions to be taken in case of 
actual or suspected infection. Patients may either be given permanent antibiotic 
prophylaxis (oral penicillin daily) or be provided with high dose ciprofloxacin and  
instructed to immediately commence taking it in the event of a suspected infection. In 
the latter case they will also be told to make immediate contact with the PI or her 
deputy. In addition all patients will receive immunisation with quadrivalent 
meningoccal  vaccine  Anti meningococcal B vaccine has recently been developed 
and will be given once approved in the country where the patient is treated. 
Vaccination against meningococci typ ACW135Y is required at the start of the study. 
Vaccination against meningococci typ B is not mandatory for inclusion in the study. 
Should the first vaccination take place < 14 days of commencement of Coversin, then 
the patient must take high dose antibiotic for the first 2 weeks. This will generally be 
ciprofloxacin daily (2x 750mg orally, until 2 weeks have elapsed since first 
vaccination) or alternative antibiotic treatment directed against meningococci.   
 
3.1 
Endpoints 
Safety: 
 
 Frequency, type and relationship to treatment of AEs and SAEs 
 Out of range laboratory parameters (haematology and chemistry) 
 Vital signs 
 ECG abnormalities Day 0 – Day 90 


 
 
 
 
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Primary efficacy endpoint: 
 
 
Serum lactic dehydrogenase (LDH) AUC from Day 0 to Day 28 compared 
with 28 days pre-treatment 
 
Secondary efficacy endpoints: 
 
 
Haemoglobin at Day 28 and day 90 and Day 180, absolute and change from 
baseline 
 
LDH at days 90 and 180 
 
Haptoglobin at day 28, day 90  and day 180, absolute and change from 
baseline 
 
Dependency on blood transfusion 
 
Quality of Life at days assessed by the FACIT and EORTC QL-C30 
instruments compared to Day 0, day 28, 90 and 180  
 
 
4.0 
CONTRACEPTION 
At this point in time the reproductive safety of  Coversin is unknown. Female patients 
entered into this study should not be pregnant at the time of commencing Coversin 
therapy and should observe suitable contraceptive methods until such time as 
reproductive toxicity data become available. Should inadvertent pregnancy occur this 
should be discussed with the PI in order to decide how to proceed. It is anticipated 
that reproductive toxicity data will become available by early 2017. 
 
4.1 
Exposure to Partners During the Study 
There is a unknown risk of drug exposure through the ejaculate (which also applies to 
vasectomised males) that might be harmful to the sexual partners, including pregnant 
partners, of male subjects. Although the risks of this are at present unknown this 
should be carefully explained to all male patients taking Coversin and they should be 
advised to use  barrier contraception until reproductive toxicity data become available.  
 
4.2 
Sperm Donation 
Male subjects should not donate sperm for the duration of the study and for at least 
90 days after the last day of Coversin administration. 
 
 
5.0 
SUBJECT WITHDRAWAL CRITERIA 
Subjects may be withdrawn from the trial in the following circumstances: 
 
 
An adverse event graded serious or severe which in the opinion of the PI is 
possibly, probably or definitely related to administration of the trial drug. 


 
 
 
 
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 
Any other reason for which, in the opinion of the PI it would not be in the best 
interests of the subject to remain in the trial. 
 
 
At the request of the subject for any reason. 
 
 
Non-compliance or behaviour not compatible with the proper conduct of the 
trial. 
 
Appropriate clinical and serological data will be entered in the CRFs. In addition the 
Subject Withdrawal page of the CRFs will be completed. All data that would 
normally have been entered on the final day of dosing will be collected and entered 
together with such additional data as the PI considers clinically necessary to ensure 
the subject’s safety or to elucidate the nature of the AE (e.g. special tests, X Rays, 
scans, photographs etc.) 
 
 
6.0 
TRIAL PROCEDURE 
The trial will comprise an open label, non-comparative study of minimally 1 patient 
and maximally 6 patients with PNH and known resistance to Eculizumab, who meet 
the inclusion and exclusion criteria (see below). Patients agreeing to participate in the 
trial will be admitted to the hospital for a minimum of 2 days for initiation of 
Coversin treatment, for clinical observation and for bloodsampling (PK/PD). 
Treatment will be continued on an out-patient basis with  daily visits until 
stabilization or adjustment of dose.  
 
Patients deemed capable of self-administration will be taught how to calculate and 
draw up the appropriate volume of solution for injection and how to inject 
subcutaneously. They will also be taught how to store and thaw Coversin prior to 
injection..  
 
For Patients deemed not capable of self administration, alternative facilities for 
administration at home will be sought (General Physician or suitably qualified home 
care  nurse).  
 
Only if, in the opinion of the PI, the patient is capable of self injecting the correct 
dose of Coversin or adequate alternative facilities existfor safety monitoring and 
dosing supervision,  treatment will be transferred  to admisitration at home.  
 
If not already immunised against Neisseria sp. immunisation and prophylactic 
antibiotics will be administered as set out in Section 10 below. Nose and throat swabs 
will be taken although growth of Neisseria species will not be grounds for exclusion 
but will prompt particular vigilance on the part of the PI. 


 
 
 
 
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The ablating dose will be divided between as many injection sites as are necessary to 
avoid injection of  >1.2mL of Coversin solution for injection. These sites may be 
chosen from the deltoid regions, the anterior abdominal region or the anterior femoral 
regions. The injection sites used will be recorded in the patient notes and will be 
inspected at 24 hour intervals for 5 days for injection site reactions. 
 
Doses of Coversin will be given at the same time each day, preferably between 6 and 
8am. The time of each dose will be recorded in the CRFs. Patients self-administering 
Coversin will use suitable sites on the anterior femoral and anterior abdominal regions 
and the site, date and  time of injection will be entered on the appropriate CRF sheet 
(patient diary) and be initialled by the supervising nurse.  
 
All patients will return to the hospital out patient clinic for follow-up  at a minimum 
of monthly intervals according to the schedule in appendix 1. 
 
Blood and urine samples will be taken from all patients according the schedule on 
appendix 1. 
 
Patients who have satisfactorily mastered the technique of self-administration of 
Coversin may be discharged home when considered appropriate to do so by the PI 
providing that adequate arrangements for daily pre-dose blood sampling and sample 
handling for CH50 samples have been arranged (see below). 
 
All patients will be followed up at a minimum of monthly intervals by the PI. If at the 
6 month follow-up the patient wishes to continue Coversin treatment and if the PI is 
satisfied as to the suitability of Coversin treatment, the patient may be transferred to 
the long-term follow-up protocol. 
 
It is expected that the majority of patients will respond to an ablating dose of 
0.57mg/kg  followed by a daily maintenance dose of 25% of the ablating dose. 
 
On a per patient basis this will be adjusted as necessary on the basis of clinical 
response and CH50 assay. The protocol allows for a flexible, tailored dose adaptation  
on day 7 and any subsequent follow-up. in patients who are not adequately controlled  
as  is outlined below .. 
 
If patients are not adequately controlled at the first (7 day) or subsequent follow up 
either of three  options may be followed: 
 
Patient will be reinduced with an identical ablating dose (0.57 mg/kg) and /or the 
maintenance dose may be increased  with one step at the time for a maximum of 2 


 
 
 
 
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times according to the below schedule of increments . Each incremental dose level 
must be given for a minimum of 4 days.   
  
The definition of adequately controlled coversin treatment is: 
 
LDH  <1.5xULN   
AND 
CH50 <10% of baseline.  
 
It is expected that this adequate control is achieved at day 5.  
 
If a recent CH50 result is not available at the time of assessment then the PI will make 
a decision on clinical grounds alone on the adequacy or otherwise of disease control. 
 
If adequate control is not achieved on day 5 of  maintenance therapy at the standard 
dose level  (and day 5 of  increment dose levels if applicable)  the following dose 
adaptation  will take place: 
 
 If  CH50 <10% and LDH is reducing but still >1.5xULN,  treatment at the 
same maintenance dose level is continued for another week.  
 
 If LDH is decreasing and if CH50 is between 50 and 10% of baseline, the 
maintenance dose may be increased according to the schedule of increments of 
maintenance dose shown below. 
 
  If LDH is not reducing and CH50  is >50% of baseline the patient must either 
be discontinued from the trial and switched to alternative therapy or must be 
readmitted  to hospital for dose stabilisation following another ablating dose 
(0.57mg/kg) of Coversin. In either case the findings and course of action  must 
be discussed by a Trial Steering Committee comprised of, at minimum, the PI, 
and the Medical Director of the Sponsor company. 
 
The schedule of increments for the maintenance dose is as follows: 
 
Ablating dose 
First maintenance 
dose level 
Second mainte-
nance  dose level 
Third mainte-
nance dose level 
0.57 mg/kg 
0.14 mg/kg 
0.29 mg/kg 
0.57 mg/kg 
 
Within each patient the first incremeneted maintenance dose should be given at 24 
hour intervals for at least 4 days until steady state is reached and at that point a CH50 
assay should be performed. If the CH50 is not ≤10% of baseline (adjusted to 100%) 
then the next incremental dose (Second  maintenance dose level  should be given for 
at least another 4 days before switching to the Third maintenance  dose level. If at any 


 
 
 
 
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stage the CH50 is >50% of baseline another ablating dose should be given before 
using the next incremental dose. 
 
Blood samples and timing is shown in Appendix 1. Samples for CH50, antibodies and 
drug level should be processed as shown in Section 20 and sent to the Akari 
Therapeutics Plc complement laboratory for assaying. All other laboratory tests 
should be done locally in the PI’s hospital laboratory. 
 
 If an ablating dose is repeated , PK/PD and other assessment will be performed as 
indicated in Appendix 1 at 1hr, day 2 and day 5. 
At increments of the maintenance dose PK and PD and other assessments are repeated 
at day 5 as indicated in Appendix 1.  
Extra samples for PK/PD may be taken at the discretion of the investigators during 
illness or infection.   


 
 
 
 
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Flow chart: Schedule of Procedures and Visits 
 
 
 
Ist fixed maintenance dose of Coversin at 25% of ablating dose. 
Bloods taken as in Table 1.  
Patient may return home and continue daily self-injection if 
deemed appropriate by the PI and if arrangements for out-
patient clinics visits and scheduled blood sampling are in place 
(see Table 1).  
Out-patient Clinic visit if not still in hospital. PI to review results 
and take action as below. 
Day 1 
 
 
 
Day 2 
 
 
Day 3 - 5 
 
 
Day 7±1 day  At 7 days 
intervals 
until 
adequate 
control at/before day 28.  
 
LDH reducing < 1.5 xULN 
OR CH50 ≤10% of 
baseline 
LDH  reducing AND CH50  
≤50% .and >10% of 
baseline 
LDH not reducing OR 
CH50 >50% of baseline. 
Continue 
on 
current 
regimen until next clinic 
visit 
Patient(s) admitted to hospital for full assessment, screening 
for eligibility to participate and informed consent. If all entry 
criteria are fulfilled, first dose of 0.57mg/kg given. Patient 
trained to self-inject Coversin. 
Discuss 
with 
Trial 
Steering 
Committee. 
Increase 
maintenance 
dose of Coversin to next 
increment or consider 
readmission to hospital 
for dose adjustment 
Discuss 
with 
Trial 
Steering 
Committee. 
Either terminate trial for 
this patient or readmit to 
hospital 
for 
dose 
stabilisation 
(repeat 
ablating dose)  


 
 
 
 
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The trial will continue for 6 months or until it has been decided by the PI in consultation with 
the Sponsor Company that further Coversin treatment is futile or not in the patient’s best 
interests. If the patient is satisfactorily controlled and wishes to continue on Coversin he/she 
will be permitted to enter the long-term follow-up study. Drug will, if necessary, be supplied 
free of charge by the Sponsor until it is approved for this indication and reimbursed through 
the normal channels. 
 
6.1 
Endpoints 
 
Primary Efficacy Endpoint: 
 
 Significant reduction in mean serum LDH from Day 0 (pre-dose) to Day 28 (AUC) 
 
Secondary Efficacy Endpoints:  
 
 Change in LDH from Day 0 (pre-dose) at monthly intervals after Day 28 
 Change in proportion of PNH clone Day 0 – Day 90 
 Change in mean Hb Day 0 – Day 90 
 Change in mean Hp Day 0 – Day 90 
 Change in FACIT score Day 0 – day 28- Day 90 - Day 180  
 Change in EORTC QLQ C30 score Day 0 – -Day 28-Day 90 – Day 180 
 
Safety Endpoints: 
 
 Frequency, type and relationship to treatment of AEs and SAEs 
 Out of range laboratory parameters (haematology and chemistry) 
 Vital signs 
 ECG abnormalities Day 0 – Day 90 
 
6.2 
Description of Trial Treatments, Dosage and Dosage Regimens 
Coversin for subcutaneous injection will be supplied initially as vials of frozen solution, each 
2mL vial containing 1.2mL of 7.2mg/mL solution. Vials should be stored frozen at -20oC 
until between 12 and 24 hours of use when they should be allowed to thaw at ambient or 
refrigerated (2 – 6oC) temperature. Ideally they should be thawed overnight in refrigerated 
conditions. 
 
Following the initial batch for use in the first patient treated under this protocol it is likely 
that all future batches will be supplied  as lyophilised powder 15mg in 5mL glass vials. Until 
reconstituted it can be stored at ambient temperature for the duration allowed by the expiry 
date printed on the label. It will be reconstituted within 6 hours of administration with 0.5mL 
of sterile water for injection to form a solution of 30mg/mL concentration. After injection of 


 
 
 
 
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sterile water into the Coversin vial it should be shaken a few times until no particulate matter 
remains. After reconstitution vials should be stored between 2 and 6oC until used and in any 
case for no longer than 24 hours.  
 
Following the switch to lyophilised powder the maintenance dose will be changed to a fixed 
multiple of 15mg (ie 15, 30 or 60mg) which will be the next dose above the dose that the 
patient is being maintained on. Thereafter the first ablating dose in all future patients treated 
under this protocol will be 60mg (2mL) which will divided between two injection sites.  
 
After the first, ablating, dose all subjects will receive fixed daily maintenance doses for the 
remainder of the trial. The size of the fixed maintenance dose will be determined by the 
results achieved in the first patient treated under this protocol. As mentioned above there will 
be some flexibility to allow for adjustment of dose in individual patients if they do not appear 
to be responding adequately but the overall aim will be to find a fixed dose that will maintain 
full complement inhibition in all patients treated. 
 
All doses should be given at the same time each day, ideally between 6 and 8 am. Blood 
samples should be taken immediately pre-dose or as shown in appendix 1. 
 
 
7.0 
STOPPING RULES AND DISCONTINUATION CRITERIA 
 
7.1 
Management of individual patients who experience clinically significant toxicity   
 In the event of a patient experiencing significant toxicity the PI and the Sponsor Medical 
Director will examine the circumstances. If this is not possible the Principal PI or any other 
physician having direct responsibility for the patient’s treatment may take appropriate action. 
The patient will be withdrawn from the trial and offered alternative treatment in the event of 
any of the following: 
 
 An adverse event graded serious or severe which in the opinion of the TSC is probably 
or definitely related to administration of the trial drug and which would prejudice the 
patient’s well-being if it was to continue or recur. 
 
 Any other reason for which, in the opinion of the Principal PI or the TSC, it would not 
be in the best interests of the patient to remain in the trial. 
 
 At the request of the patient for any reason. 
 
7.2 
Toxicity occurring in two or more patients  
In the event of the same or a similar severe adverse event occurring in two or more patients in 
the trial and which, in the opinion of the PI, is possibly, probably or definitely related to 
administration of Coversin consideration will be given to halting the trial. A serious adverse 
event (SAE) occurring in two or more patients which is probably or definitely drug related is 


 
 
 
 
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an absolute indication to terminate the trial. Adverse events which are not SAEs but which 
appear to affect more than one patient will be assessed for their severity, threat to the 
patients’ health and drug relationship and a decision on whether to halt the trial or allow it to 
continue while keeping the situation under review will be made by the PI and the Sponsor 
Medical Director.  
 
 
8.0  
ACCOUNTABILITY PROCEDURES 
The PI and the hospital pharmacist are responsible for study medication accountability, 
reconciliation, and record maintenance.  Drug accountability records will be maintained 
during the study, including the amount of study medication received from the Sponsor, the 
amount distributed to each subject, and the amount of unused drug returned to the Sponsor or 
destroyed at Sponsors request.  In addition, in the event of necessary disposal of opened but 
wasted medication, the disposal should be documented appropriately (ie, witnessed) in 
accordance with applicable local regulations, and “Good Clinical Practice” (GCP) 
procedures. 
 
 
9.0 
SELECTION AND WITHDRAWAL OF SUBJECTS 
 
Trialists will be patients with PNH and known genetically determined resistance to 
eculizumab who are willing to give informed consent to participate in the trial. 
 
9.1 
Inclusion Criteria 
 
 Males or females taking adequate contraceptive precautions if of childbearing 
potential, 18 – 80 years of age 
 Body weight ≥50kg and  ≤ 100kg  
 The patient has provided written informed consent. 
 Willing to avoid prohibited medications for duration of study (see Exclusion Criteria) 
 Must agree to take appropriate prophylactic precautions against Neisseria  infection 
 
Must be counselled regarding the possible reproductive risks of using Coversin and be 
advised to use an adequate method of contraception pending further data on 
reproductive toxicology. 
 
9.2 
Exclusion Criteria 
 
 
Body weight <50kg or > 100kg  
 
Pregnancy 
 
 


 
 
 
 
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10.0 
NEISSERIA IMMUNISATION AND ANTIBIOTIC PROPHYLAXIS 
It is known that the products of C5 complement activation are important in protection against 
infection by Neisseria species (15). This is believed to be the only known hazard of blocking 
this stage of the complement cascade and patients taking part in previous trials of 
complement C5 inhibitors were found to be at greater risk of Neisseria infection, particularly 
meningococcal infection (16). For this reason all patients entering the trial should where 
possible have received immunization against Neisseria meningitidis infection in the past, or 
must receive a booster shot of quadrivalent vaccine (against meningococci type ACW135Y) ) 
at the time of recruitment into the trial and at least prior to receiving the first dose of 
medication. In addition all patients should be immunised against Meningitis B using the 
Bexsero® vaccine as soon as this vaccine is available in the country where the patient is 
treated.  This vaccine requires an initial dose followed by a booster 1 month later.  
 
All patients will in addition have throat and nasal swabs taken after entry to the trial and prior 
to receiving the first dose. Cultures positive for any Neisseria species will not be grounds for 
excluding that subject from the trial but will alert the PI to use extra vigilance during and 
after induction of complement inhibition. Any patient having positive nasal swabs will be re-
tested 7 days later to ensure that the pathogen has been eliminated by ciprofloxacin. 
 
Patients will preferably receive a 5 day course of oral ciprofloxacin commencing the day 
before the first dose of Coversin and this will either be followed by oral penicillin 
prophylactic treatment or, at the discretion of the PI and in accordance with local custom, the 
patient may be provided with high dose ciprofloxacin to be started in the event of an actual or 
suspected infection. Patients will be instructed to make urgent contact with the PI or her 
deputy in that event.  
 
Because of the known drug interaction between tizanidine and ciprofloxacin the former drug 
will be prohibited during this trial. In addition patients will be given a medication leaflet for 
ciprofloxacin in their native language in which other possible drug interactions (e.g. with 
antacids) and precautions regarding known or suspected sensitivity to fluoroquinolones will 
be pointed out. It is the responsibility of the PI and her deputies to make the patient(s) aware 
of these precautions.   
 
 
11.0 
COMPLIANCE 
Whilst patients are in a hospital setting responsibility for compliance will rest with the 
medical, pharmacy, pharmaceutical science and nursing/technical staff who will be 
responsible for administering the trial medication. When patients return home, for the first 
month compliance will be assured by retrieval and counting of all used vials and syringes and 
completion of a diary to record the time and date of each dose. All empty and unused 
Coversin vials will be returned to the Sponsor as an additional compliance check. 
 
 


 
 
 
 
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11.1 
Assessment of pharmacokinetics and complement activity 
Blood (5ml) samples for CH50 assays and Coversin levels will be collected according to the 
time schedule presented in Appendix 1.  These blood samples will take precedence over all 
other procedures. Samples will be processed in accordance with Paragraph 20.2. 
 
 
12.0 
ADVERSE EVENTS 
12.1 
Adverse Events 
All adverse events, whether or not considered to be related to the study drug, will be 
monitored and reported on at all stages of the study. Adverse events occurring between 
discharge from hospital and the 1 week follow up visit will be reported at that visit and 
entered on the adverse event form of the case report forms. 
12.2 
Definition 
An adverse event is any untoward medical occurrence in a patient or clinical investigation 
subject administered a pharmaceutical product whether or not it is caused by this treatment.  
An adverse event can therefore be any unfavourable and unintended sign (including an 
abnormal laboratory finding), symptom, or disease temporally associated with the use of a 
medicinal product, whether or not considered related to the medicinal product. 
 
Worsening of a medical condition that was present prior to the administration of the study 
medication will also be considered a new adverse event and reported.  Any medical condition 
present prior to the administration of the study medication which remains unchanged or 
improved will not be recorded as an adverse event at subsequent visits. 
 
Documentation regarding the adverse event will include the nature, time and date of onset, 
time and date of resolution, severity, presumed relationship to study medication, action(s) 
taken, and outcome of any sign or symptom observed by the physician or reported by the 
subject upon indirect questioning. 
 
12.3 
Relationship to study medication 
The relationship between the AE and the investigational product will be determined by the PI 
or Sub-PI on the basis of his/her clinical judgement and the following definitions: 
 
Unrelated: 
Clinical event with an incompatible time relationship to IMP 
administration, and that could be explained by underlying disease or 
other drugs or chemicals or is incontrovertibly not related to the IMP 
 
Possibly related: 
Clinical event with a reasonable time relationship to IMP 
administration, and that is unlikely to be attributed to concurrent 
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Related: 
Clinical event with plausible time relationship to IMP administration 
and that cannot be explained by concurrent disease or other drugs or 
chemicals 
 
The degree of certainty with which an AE is attributed to IMP administration (or alternative 
causes, e.g. natural history of the underlying disease, concomitant therapy, etc) will be 
determined by how well the experience can be understood in terms of one or more of the 
following: 
 
• 
known pharmacology of the IMP 
• 
reactions of a similar nature have been previously observed with the IMP or this class 
of drug 
• 
the experience being related by time to IMP administration, terminating with IMP 
withdrawal or recurring on re challenge 
• 
alternative cause 
12.4 
Serious Adverse Events 
 
A serious adverse event (SAE) is defined as any untoward medical occurrence at any dose 
that: 
 
 
Results in death 
 
 
Is life threatening (Note:  The term “life threatening” refers to an event in which the 
subject was actually at risk of death at the time of the event;  it does not refer to an 
event which hypothetically might have caused death if it was more severe). 
 
 
Requires in-patient hospitalisation or prolongation of existing hospitalisation. (Note: 
Complications that occur during hospitalization are AEs. If a complication prolongs 
hospitalization or fulfils any other serious criteria, the event is serious.  
Hospitalization for elective treatment of a pre-existing condition that did not worsen 
from Baseline is not considered to be an AE.) 
 
 
Results in persistent or significant disability/incapacity. (Note:  The term disability 
means a substantial disruption of a person’s ability to conduct normal life functions.  
This definition is not intended to include experiences of relatively minor medical 
significance such as uncomplicated headache, nausea, vomiting, diarrhoea, influenza, 
or accidental trauma (e.g. sprained ankle) that may interfere or prevent everyday life 
functions but do not constitute a substantial disruption.)  
 
 
Is a congenital abnormality. 
 


 
 
 
 
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Important medical events that may not be immediately life-threatening or result in death or 
hospitalization but may jeopardize the patient or may require intervention to prevent one of 
the outcomes listed in the definition above should also usually be considered serious.  
Examples of such events are intensive treatment in an emergency room or at home for 
allergic bronchospasm, blood dyscrasias, or convulsions that do not result in hospitalization; 
or development of drug dependency or drug abuse.   
 
All serious adverse events will be reported to the PI, and the Sponsor within 24 hours of 
learning of its occurrence. The Sponsor will be responsible for reporting the adverse event to 
the appropriate regulatory authority and the IRB within the legally specified period. It is 
important to distinguish between SAEs and severe AEs.  Severity is a measure of intensity 
whereas seriousness is defined by the criteria above.  An AE of severe intensity need not 
necessarily be considered serious.  For example, a migraine headache that incapacitates a 
patient for many hours may be considered a severe AE, whereas a stroke that results in a 
limited degree of disability may be considered mild, but should be reported as an SAE). 
12.5 
Severity 
The following definitions will apply: 
 
Mild: 
Event is noticeable to the patient, but is easily tolerated, requires no additional 
therapy and does not interfere with the subject’s daily activities. 
 
 
Moderate:Event causes discomfort or inconvenience, possibly requiring additional 
therapy, and may interfere with the subject’s daily activities. 
 
Severe: 
Event is intolerable, necessitates additional therapy or alteration of therapy and 
interferes with the subject’s daily activities. 
12.6 
Adverse event reporting 
All Serious or Severe adverse events, whether or not considered to be drug related, will be 
reported immediately to the PI and the Sponsor who will be responsible for reporting it/them 
to the regulatory authority (MHRA) and the Ethics Committee within 24 hours of learning of 
its occurrence.. They will be recorded on the appropriate CRF with a description of the 
outcome. Non-serious moderate or mild adverse events will be recorded in the CRFs but need 
not be reported to the Sponsor at the time unless there are unusual circumstances (e.g. the 
adverse event was of a completely unexpected nature); they should be reported to the Safety 
Monitoring Committee within sufficient time for decisions regarding dose escalation to be 
made. 
 
Procedures for reporting a serious adverse event: 
Any serious adverse event occurring during the study period should be reported < 24 hours of 
learning of its occurrence  to the Sponsor or its representative listed on the personnel page 


 
 
 
 
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and recorded on the appropriate case report forms.  All patients experiencing a serious 
adverse event must be followed up and the outcome reported.  
 
Procedures for reporting a suspected unexpected serious adverse reaction (SUSAR) 
 
It is the responsibility of the Sponsor to determine whether a reported SAE fits the 
classification of a SUSAR and to notify the PI of their decision as soon as possible. 
 
Expedited Reporting of Events 
 
It is the responsibility of the Sponsor to determine whether an event requires expedited 
reporting and to notify the PI of their decision as soon as possible. 
Where expedited reporting is required, the following procedures should be followed. 
 
Fatal or life-threatening SUSARs 
 
It is the responsibility of the Sponsor to report fatal or life-threatening SUSARs to the MHRA 
and EMA as soon as possible, but no later than 7 calendar days after they first became aware 
of the reaction.in accordance with Directive.. or per national reg requeirements in particular 
countries. 
 
The PI is required to notify the EC of any SUSAR as soon as possible, but no later than 7 
calendar days after they first became aware of the reaction. Any additional relevant 
information should be sent within 8 days of the report. 
 
Other SUSARs 
It is the responsibility of the Sponsor to report other SUSARs to the MHRA and EMA as 
soon as possible, but no later than 15 calendar days after they first became aware of the 
reaction. 
 
The PI is required to notify the EC of any other SUSAR as soon as possible, but no later than 
15 calendar days after they first became aware of the reaction. 
 
12.7 
Follow-up after Adverse Events 
Adverse events which have not resolved by the time of anticipated discharge from the clinical 
unit will be followed up until resolution. If, in the opinion of the PI, they are sufficiently 
clinically important to necessitate continued observation in a hospital or clinic setting the 
Sponsor will be informed and arrangements made for continued in-patient care in a suitable 
facility or referred to their GP. If the subject is able to be discharged they will be followed up 
in the same way as other subjects in the study or more frequently at the discretion of the PI. 
All AEs will be recorded in the appropriate pages of the CRFs until there has been full 
resolution. Any medications (e.g. analgesics) that may be required at the time of discharge 
will be supplied. Subjects who are discharged from the clinical unit but who have not had full 


 
 
 
 
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resolution of the AE (e.g. a skin rash) will continue their own observations at home and make 
daily records in the diary card, including any worsening or resolution of the AE. Diary cards 
on which AEs are recorded will be signed by the subject and the PI and will subsequently 
become part of the CRF record. 
 
 
13 
STATISTICS 
 
13.1 
Statistical Methods 
The statistical approach taken will depend on the number of patients recruited. 
 
If less than 4 patients are recruited, each patient will be analysed separately. Changes in the 
primary efficacy outcome during the period Day 0 to Day 28 will be analysed using linear 
regression using all measurements in the analysis. Secondary efficacy outcomes measured 
multiple times will be analysed in an equivalent manner. 
 
If 4 or more patients are recruited, the patients will be analysed as a single group. Differences 
between specific timepoints (e.g. Day 0 and Day 28) for the primary and secondary efficacy 
endpoints will be performed using the paired t-test.  
 
Additionally the change in the primary efficacy outcome over time will also be examined 
using all measurements. Mixed model will be used to allow for repeat measurements from the 
same patients, with the patient considered as a random effect. 
 
13.2 
Number of Subjects 
A total of 6 patients may be enrolled under this protocol if they present. 
 
13.3 
Significance Level 
For all comparisons p<0.05 will be considered significant. 
 
13.4 
Missing, Unused or Spurious Data 
Missing data that cannot be retrieved from source records or other repositories will be 
recorded as such in the CRFs and will not be entered into the statistical analysis. Spurious 
data will be examined by the Sponsor’s monitor, medical or statistical advisors and a decision 
made as to how it should be handled. If there is an obvious transcription or data entry error 
such as a misplaced decimal point in a biochemical parameter this will be discussed with the 
CRO or the laboratory and, if all parties agree, it will be corrected and endorsed by both the 
PI and the Sponsor. Outlying data may be treated appropriately after consultation with the 
Sponsor’s statistical advisors (e.g. isolated, out of range biochemical parameters where there 
may have been a recording error may be treated by removal of highest and lowest 
observations and re-analysis. In such an event both the fact will be recorded in the statistical 
report and data will be presented showing the full data set and after removal of paired 
outliers). 


 
 
 
 
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Unused data (e.g. superfluous blood pressure recordings or haematological results in addition 
to those required by the protocol will remain part of the source documentation and only be 
incorporated into the trial documents and analysis if there is reason for them to be (e.g. an 
unexpected fall in blood pressure that might constitute an AE). 
 
13.5 
Deviations from the Statistical Plan 
It is not envisaged that there should be any deviations from the statistical plan since this is 
primarily a safety study. Any unexpected deviations (eg a requirement for a trend analysis not 
foreseen in planning the trial) will be discussed with the PI and the statistical advisor and the 
rationale for such an analysis will be included in the trial report. 
 
13.6 
Subjects to be Included in the Analysis 
All patients in the study will be included in the safety analysis whether completing the trial 
according to the protocol or not. The efficacy analysis will include all measurements made 
whilst the patient(s) correctly followed the trial protocol.  
 
 
14 
DIRECT ACCESS TO SOURCE DOCUMENTS 
The CRO, hospitals and PIs carrying out this study will allow the Sponsor direct access to all 
source documents and will permit trial-related auditing of clinical, pharmacy and laboratory 
facilities.  
 
 
15 
QUALITY CONTROL AND QUALITY ASSURANCE 
Hospitals/departments taking part in the trial are responsible for maintaining their own SOPs 
and QA/QC procedures. The Sponsor will also maintain its SOPs, QA and QC procedures 
and will, at its discretion, carry out a full or partial audit of the trial site facilities and SOPs. 
The Sponsor will be responsible for monitoring the trial and carrying out full or 
representative source data verification. 
 
 
16 
ETHICAL CONSIDERATIONS 
The application will be reviewed and approved by appropriate Ethics Committees prior to the 
trial commencing. All ethical aspects of the study will be in accordance with ICH Good 
Clinical Practice (GCP) guidelines and the requirements of the Declaration of Helsinki. 
 
 
17 
DATA HANDLING, RECORD KEEPING AND SAMPLE COLLECTION 
The CRO and hospitals will supply and complete the source documentation and all related 
documentation (eg ECG traces, laboratory data) and at the conclusion of the trial will transfer 
these to the CRO who will be responsible for data entry and analysis. The original 
documentation will be returned to the hospitals for archiving (at least 20 years after 
completing of the trial) and the Sponsor will also keep duplicates for the same purpose.  


 
 
 
 
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Biological samples may only be stored indefinitely for the purpose of additional research 
related to this protocol  if the patient has given informed consent for additional scientific 
research (directly related to this protocol).  If no informed consent was obtained, samples 
must  be destroyed after the patient has completed all protocol treatment and procedures. 
 
Storage of biological samples on site is subject to the site’s guidelines. When samples are 
shipped to another facility (e.g. a central laboratory), they should be stripped from any 
identifying information and labeled with a code (trialname, patient study number, date and 
time of collection).  
 
 
18 
FINANCING AND INSURANCE 
The Sponsor will have a commercial contract in place with the hospital and the PI and the 
hospitals/universities who will be responsible for any payments to subjects and for payment 
of travel and other expenses. 
 
The Sponsor has a clinical trials insurance policy in place, underwritten by AON Limited. A 
copy of the policy/certificate of insurance will be supplied separately. 
 
 
19 
PUBLICATION POLICY 
The trial will be registered with the U.S. National Institutes of Health  ClinicalTrials.gov 
website and the results will be posted there when available.  
 
The PI of the clinical units has independent rights of publication but will agree to discuss any 
intended publications or presentations with the Sponsor and to allow the Sponsor reasonable 
time to make comments, file or add to patent applications or request changes to the 
manuscript.  
 
 
20.0 
SUPPLEMENTS 
 
20.1 
CH50 Eq ELISA Assay 
Coversin acts as an inhibitor of the terminal common pathway of complement activation by 
binding to C5 in a 1:1 ratio and preventing its cleavage to C5a and the Membrane Attack 
Complex proteins. The Quidel CH50 Eq ELISA provides a direct measure of the total 
complement activity in serum by quantifying the amount of MAC generated under standard 
conditions. The MAC present in the sample binds to the monoclonal antibodies coating the 
surface of the microassay wells. The microassay plate is then loaded with a Horseradish 
Peroxidase (HRP) conjugate which binds to the bound MAC. After washing, the microplate 
is loaded with a chromogenic enzyme substrate. The chromophore building reaction is then 
halted by addition of a stop solution. 


 
 
 
 
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The amount of chromophore, which will be detected at λ = 405nm, correlates with the 
concentration of MAC. An increased amount of Coversin in the sample is accompanied by a 
corresponding decrease in MAC formation which can therefore be detected by a reduced 
absorption at λ = 405nm. 
 
This analysis will be performed by the Sponsor at the Haemostasis Research Laboratory (see 
Page 1) and the results will be relayed to the PI and to the CRO for entry into the subject 
records as soon as they are available. 
 
20.2 
 Handling of samples for complement (CH50) analysis 
 
1. Equipment 
 
For Blood Collection:  
Butterfly Cannula, needles (Abbott), Vacutainer Collection set (Becton Dickinson), luer 
adaptors, as appropriate. Alternative, equivalent, collection equipment may be used, as 
available at site. 
 
CH50 Complement Pathway Assays:  
5-6ml plain glass, or plastic tubes containing silica clot additive (e.g. Vacutainer Ref 367837, 
Red tube), or SST type tubes with plastic block (e.g. Vacutainer SST II, Ref 367954, Gold 
tube), suitable for serum preparation, should be used. 
 
Complement Proteins and Complement Activation Markers (e.g. C3, C5, C3a, C5a, 
SC5b9):  
4-5ml EDTA tube (e.g. Vacutainer K2E tubes, Ref 367839, Lavender tubes), for plasma 
preparation. 
 
For Sample Separation:  
Plastic Transfer Pipettes - disposable polypropylene pipettes with a bulb at the end (e.g. 
Elkay 1ml Liquipettes, product No. 127-P511-000). 
 
Intermediate Plastic Tubes for Sample Handling – Polypropylene 75x12mm test tubes 
capable of withstanding centrifugation and suitable push fit stoppers (e.g. Sarstedt, Cat No.  
55.526.005 & 65.719). Alternatively, cryotubes as specified below may also be used as 
intermediate tubes.  
 
Cryotubes for Sample Storage – 1.8ml screw-cap polypropylene tubes suitable for low 
temperatures, with an ‘o’ ring in the lid (e.g. Sarstedt Cat. No. 72/694.007, Micro tube SC 
2ml SP). 
 


 
 
 
 
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Indelible Marker - Water insoluble permanent marking pen with fine tip, for labelling 
cryotubes, or suitable, water resistant labels (e.g. Brady THT Freezerbondz B492 25mm x 
12.7mm labels). 
 
2. Blood Collection 
 
Blood should be collected from a single, clean venepuncture with minimal stasis, using a 19 
or 21 gauge Butterfly needle. Where the Vacutainer system, or other evacuated containers are 
used, a luer adaptor may be required. 
The first tube of blood that is drawn should not be used for markers of complement 
activation; where appropriate, it is usually convenient to collect a plain tube for CH50 or 
other tests. The blood for complement activation markers should be collected into an EDTA 
tube. The anticoagulated blood must be immediately mixed by gentle inversion 5-6 times. 
The samples should be maintained upright, at room temperature (18-22°C) until 
centrifugation. 
 
 
3. Centrifugation and Separation of Serum and Plasma for Complement Tests 
 
Plain Tubes for Serum (CH50 samples):  
Maintain at ambient temperature (18-20°C) for 1 hour to allow clot formation. Centrifuge at 
1500g for 10 minutes to separate serum. Carefully remove the supernatant serum, avoiding 
disturbance of any cells, with a polypropylene transfer pipette, and deliver into at least 2 x 
0.5ml aliquots using screw-cap cryotubes.  
 
Store at –80°C (temporary storage at –20°C for 24 hours is possible, with subsequent transfer 
to –80°C, or shipment on dry ice).  
 
EDTA Tubes (Complement Activation samples):  
Centrifuge EDTA tubes at 2000g (approximately 3800 rpm in a typical laboratory bench-top 
centrifuge), at room temperature (18-20°C), for 15 minutes, within 2 hours of collection. 
Carefully remove the supernatant plasma, avoiding disturbance of the buffy coat, with a 
plastic transfer pipette, and deliver into intermediate plastic tubes. Repeat the centrifugation 
step above, to remove any residual platelets. Save at least 2 x 0.5ml aliquots of EDTA plasma 
in screw-cap cryotubes.  
 
Ensure that the tubes are labelled throughout the separation process and clearly identified 
during freezing! 
 


 
 
 
 
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4. Storage of Serum and Plasma Samples 
 
The aliquots of serum, EDTA and citrate plasma must be frozen rapidly at below –40°C (dry 
ice or freezer), and transferred to a -80°C freezer as soon as possible, where they should be 
maintained until shipping for assay. When placed in the freezer, the samples must be allowed 
to freeze rapidly, preferably in a metal rack (they must not be placed in polystyrene racks). 
 


 
 
 
 
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21.0   
REFERENCES 
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the complement system. Journal of molecular biology 369:784-793. 
2. 
Nunn, M. A., A. Sharma, G. C. Paesen, S. Adamson, O. Lissina, A. C. Willis, and P. 
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Ornithodoros moubata. J Immunol 174:2084-2091. 
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Francischetti, I. M., A. Sa-Nunes, B. J. Mans, I. M. Santos, and J. M. Ribeiro. 2009. 
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21 
Nishimura J et al. Genetic Variants in C5 and Poor Response to Eculizumab. 
N Engl J Med 2014;370:632-9